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“ (Uræmic eclampsia occurs in every period of pregnancy, as well as at other times, and even in males.) It is distinguished by quick repetition of the fits and complete insensibility during the fit, as well as generally during the interval. The face and neck appear swollen and injected during a paroxysm.
“ The eyelids are prominent, and open or closed; the eyeballs exhibit quick rolling motions in the most different directions, or are fixed in an upward stare.” (The latter was the case with Mrs. C.; the upward stare was well marked.) “ The vessels of the conjunctiva are mostly injected; the mouth is at first widely opened and distorted; the tongue is protruded; then trismus follows, in which, if proper care be not taken, the protruded tongue is often bitten through, and hence a bloody foam flows from the mouth. In the muscles of the face, lively distorting convulsions are observed, whereupon the upper extremities get bent, the trunk is twisted to one side, and then all the extremities are thrown into jerking motions. Respiration often altogether ceases for many seconds. The carotids show strong pulsation ; the veins of the neck and face swell on account of stoppage of the blood from muscular spasms. The colour of the face is cyanotic.
"All the muscles of respiration, especially the diaphragm, are in a state of contraction ; and, in consequence of this, asphyxia may occur. The urine and fæces are involuntarily excreted. Vomiting rarely precedes the first fit. The skin remains dry, or may be covered with perspiration, and its temperature is either increased or diminished.
“ The reflex sensibility is suspended during the fit. The pulse is frequent or slow; the arteries small or large. After this group of symptoms, , there follows a soporose condition, in which the patient continues for a shorter or longer time, and lies motionless; the extremities stretched out and stiff; the respiration frequent and difficult, and at first stertorous, afterwards slower and snoring. Generally there is absence of consciousness and sensation.
"After awaking, patients generally complain of a confused, dull headache, and of great languor, which continue till a renewal of restlessness, stretching, extending, slow, tremulous bending of the upper extremities, jerking of the facial muscles, with reddening of the face, announce a new paroxysm. The fits may be repeated several times in a day - sometimes as much as seventy times. Generally after a few fits complete unconsciousness supervenes, and this continues till recovery or death."
In cases where such a train of symptoms is observed, Dr. Braun (and others) maintain that acute Bright's disease is almost invariably present, that it " is the first link of a chain of morbid changes leading on to
puerperal.convulsions" (Braun on Puerperal Convulsions, translated by Dr. J. Matthews Duncan, page 32). We cannot, at present, attempt to follow Dr. Braun through all the arguments which he advances in support of his position. There can be no doubt that the weight of evidence is in his favour; at the same time, the opinions of such men as Marchal, Liebert, Depaul, Legroux, L'Huillier, Stolltz, and Scanzoni are not to be lightly laid aside. Cases such as the one above related, in which there is eclampsia, without any evidence of renal disease, may be rare; nevertheless they do occur, and they go far to lessen the importance of Bright's disease as a cause of puerperal eclampsia. Moreover, it is admitted by Dr. Braun himself that, “ As regards the proximate cause of the uræmic · intoxication in Bright's disease, conjectures only can, at present, be expressed; for acute Bright's disease is not always accompanied by uræmia and eclampsia. Of 100 cases of acute Bright's disease only from -sixty to seventy are seized with uræmic eclampsia.
"Of cases of eclampsia eighty per cent. occur in first pregnancies, in which, on account of the greater resistance of the abdominal walls, a powerful counter pressure on the kidneys is generally produced.
In cases of repeated pregnancy the pressure connected with a pleural pregnancy, with depressed pelvis, hydraminos, large size of the fætus and a high position of the womb are frequently met with where eclampsia. occurs.” (Duncan's translation, pp. 22 and 24.)
Dr. Braun’s researches have undoubtedly thrown great light upon this intricate and most important subject, nevertheless much remains to be done before the pathology of puerperal eclampsia is thoroughly understood.
In conclusion, with regard to the question of treatment, I wish to make a few observations.
In the case of Mrs. C., the chief means resorted to were chloroform inhalation and the artificial induction of labour.
The medical treatment recommended by Dr. Braun is the same, whether the eclampsia occurs in pregnancy during labour or in child-bed. He says, “ The chief object to be attained is to diminish, as much as possible, the reflex excitability, to weaken the paroxysms, in order to diminish the dangers and to gain time for entering upon rational treatment. In this respect we have observed results from chloroform-narcotism which have surpassed all expectations. In uræmic eclampsia, the chloroform-narcotism is to be induced instantly when indications of an impending paroxysm, show. themselves-as great restlessness, increasing rigidity of the muscles of the arms, expiry of the intervals between former paroxysms,, fixity of expression, or tossing hither and thither,
The narcotism is to be kept up until the premonitory symptoms of the paroxysm disappear and quiet sleep follows—a result generally attained in one minute.
“ But, if it be not possible to cut short the paroxysm, then the chloroform inhalation is not to be kept up during the convulsive attacks and the comatose condition, in order to let an abundant supply of fresh atmospheric air reach the lungs. The chloroform inhalation moderates the imminently dangerous cramps of the muscles of the neck, epiglottis, and tongue, and may be continued even during a persistent trismus, when other medicines cannot be introduced into the stomach, and when loud mucous rôles indicate the development of ædema of the lungs.
“To moderate the secondary congestions of the head, which come on during and after the paroxysms, the application of ice is useful, and also smart sprinkling with cold water; and, better still, the cold douche on the head, during which operation the head of the patient is held over the side of the bed, and the ice-water falls into a basin held beneath it.
“ Sponging the skin with tepid vinegar produces a most desirable diaphoresis and is easily accomplished. General depletion of blood easily produces an injurious effect in uræmic eclampsia, because, by bleeding the hydroæmia is further increased, the nervous fits are not improved, puerperal thrombosis and pyæmia in child-bed are much to be feared ; and, because not unfrequently the paroxysms are aggravated by it, and exhaustion, fainting, and very slow convalescence are thereby produced.
“ A great number of physicians consider prompt, careful evacuation of the uterus as the main point in the treatment of eclampsia. Artificial premature labour is to be resorted to only when there is some probability of the mother being thereby saved, and so much the more if death of the fætus has already occurred.
“Colpeurysis and uterine catheterization we consider in this case the most secure method."
The efficiency of the method of treatment recommended by Dr. Braun was well illustrated in the case of Mrs. C. The same principles of treatment apply to all cases of true puerperal convulsions, whether connected with Bright's disease or not. The undue length to which this paper has extended, and for which I beg to apologize, has prevented the quotation, in full, of Dr. Braun's observations on the subject of treatment. For having restricted myself to quoting his words in reference to this part of the subject, I am sure no apology need be offered.
Quinine and Iodide of Potassium in Acute Rheumatism. By E. LEMIRE,
M.D., attending Physician to the Grey Nuns and Providence
Dispensaries. The use of quinine and iodide of potassium in the treatment of acute rheumatism is not a novelty, nor an unknown fact, as almost every author mentions it, although they have employed those agents separately. There is not perhaps any disease so frequent, so suffering, and for which no giren mode of cure has yet been discovered. Why is this? Is it because the disease is unknown ? No, as Aritie mentions it, since the highest antiquity; after him Sydenham, and many others since that time. Is the nature of the affection so obscure that no appropriated treatment can be discovered ? I should think not, as almost all authors agree in considering the affection as a special inflammatory disease a phlegmasia sui generis whose manifestations symptoms are so well defined that any mistake in the diagnosis is rather impossible. The reason of this is perhaps, in the fact that every author thinks his own way of curing a disease better than any other, or would be hurt in his self-love in giving credit to another for his innovations. Some of them, as Chomel, would treat the affection with few bleedings and mercury; Bouillaud says, bleeding (saignée coup-sur-coup) is sufficient. Others will prescribe only the alkalies, Valleix quinine. I think that in medicine more than in any other science, it is rather difficult to be positive; and to heal an affection with a treatment always the same is impossible. First, because the disease varies often according to the idiosyncrasy of the patient, and sometimes on the sickly conditions under which he stands. Then rheumatism being a special disease, no mode of cure having yet been discovered, wisdom tells us to have no invariable treatment, but to choose amongst them all, or combine them to obtain our design, that is cure. Every one knows the ordinary duration of the disease. Some say nine days, as Bouillaud : Pinel—six to sixty ; Chomel says that he has seen it continue for three months; but the general opinion, I think is from the twentieth to the thirtieth day. This long duration of the disease is perhaps the cause of the numerous and various treatments practised. The physician, bearing in mind to save suffering to his patient, varies his treatment until he produces the effect he desires. It is known that quinine given in large doses, as M. M. Briquet and Monneret prescribe it, shortens very much its duration. Some years past Dr. Levins of Liverpool has combined quinine with iodide of potassium, and this, he says, with the best result. He never prescribes more than two grains of the former with five grains of the latter.
Parting from this fact, I have tried the treatment, varying a little in the dose, and far from claiming any credit for myself in the success, but only with the view of corroborating facts, I give you the following case of acute rheumatism treated by the combination of quinine and iodide of potassium, thinking it my duty, as every forward step made to shorten the duration of such a suffering disease is worthy of notice.
The fifth of May last Mr. W., a stone cutter, was seized with acute rheumatism, the disease affecting the ankles, the knee joints, wrists, and one shoulder-strong odourous perspirations, and tongue white coated. I immediately opened the bowels with five grains of calomel and twenty grains of jalap and ordered the following mixture, sulph. quinine 3j., iod. potassium 3 ij., acid sulp. dil. 3 ss. aquæ 5 viij., a tablespoonful to be taken every four hours. Six days after—that is the elevenththe patient left his bed, walked on the twelfth about his room, and two days after was out and perfectly cured. Two other cases that I have had last winter went on very near as well, the patients being out ten days after the beginning of the treatment. As I have said, I do not claim any credit for the success, knowing that perhaps at the next occasion the same treatment will fail; but I thought I did right in mentioning it, as the result is as good as by any other mode of treatment.
Case of Traumatic Inflammation of the Knee-joint. Recovery without
anchylosis. By HERBERT H. READ, M.D., L.R.C.S., Edinburgh. On August 2nd., 1864, I was called to Leonard R., aged 12, whose right knee-joint had been opened three days previously, by a transverse incision on the inside of the joint. The cut was an inch and a half in length, and part of it was in the line of articulation. Synovia had escaped, and his uncle, who carried him into the house, could see into the cavity of the joint through the gaping wound. An attempt was made to keep the edges together by strips of plaster, but it was ineffectual, and when I saw him, they were three-fourths of an inch apart, and the wound was filled with healthy granulation. There was neither pain, swelling nor redness about it, and I drew the edges of the cut together, and maintained them in opposition by long strips of plaster, afterwards applying the long splint.
August 10th, severe pain suddenly seized the knee, followed in a day or two by a great swelling. I saw him on the 13th, found him suffering intense pain, the knee greatly swollen, the wound gaping widely, and filled by a dense slough which I divided.