230 Puerperal Convulsions.

articles of food are used in a fashionably "h igh" condition ? In other words, what determines the formation of these deadly ptomaines, for it is clear they are not always present in commencing septic changes ? Can it be a question of the temperature at which these changes take place, or, of exposure, or non-exposure to the atmosphere? And are they formed in all cases, if only those changes proceed far enough ? Again--can the existence of' disease at the time of the animal's death have any influence ?

Doubtless, in this case the patient was rendered a more easy prey to those poisonous principles by the fact that he was~ at the time, both mentally and physicaUy depressed.

ART. XIII.--Puerperal Convulsions, with Atbuminuria, Coma, and Prolonged Insensibility, treated by Local a~d GeTteral Bleed- ing, ~'c. ; Recovery. By RICHARD RYAN, M.D., Medical OMcer, Bailieborough Union Hospitals.

:PUERPERAL eclampsia is a disease so alarming in its onset and so frequently fatal in its termination that it has received much attention from the most eminent members of our profession, yet its treatment is far from settled. The usual division into hysterical, epileptic, and apoplectic is satisfactory as far as the first and third are concerned, but I consider the second defective as implying too close a relation to epilepsy and withdrawing our attention from the acute albuminuria and the urmmic nature of the attack. If we compare the very little danger attending an epileptic attack uncomplicated with albuminuria with one in which this symptom with its attendant phenomena is present, the importance of bearing the condition of the kidneys in mind becomes manifest with a view to prognosis and treatment. As the cases which I intend describing in this communication were attended with acute albumi- nuria and occurred before delivery, the remarks which I am about to make will apply to such cases. The treatment laid down in text-books of the present day may be thus summed up--Chloroform inhalations, bromide of potassium, hydrate of chloral, morphia, and other antispasmodics, cold effusion to the head, counter- irritants and purgatives; venesection is but tentatively recom- mended or condemned, a

Now let us take a typically severe case of puerperal convulsions

�9 See Playfair's Midwifery. Vol. II., p. 808-9.

By DR. R. RYA~. 231

with albuminuria, and see which of those remedies ought we to have recourse to on theoretical grounds, and then give the results as faras we have been able to put these & priori reasons to the test of practice.

The patient is in the last months of pregnancy, and with or without some trivial premonitory symptoms is seized with con- vulsions, which after some time become more frequent, and there is no recovery of consciousness in the intervals : the breathing is stertorous, the pulse is slow and labouring or rapid and feeble, and now she is in deep coma. The coma in such case is produced by paralysis of the higher nerve-centres from an impure blood cir- culating in them, or from serous effusion, or from h~morrhage.

Such a patient can hardly swallow, so that we cannot properly administer a good calomel and jalap purge, or if we get it into her stomach it will probably remain there inert, for absorption is suspended with the other functions except respiration and circula- tion. The same objection applies to bromide of potassium and hydrate of chloral. Morphia aggravates the suppression of urine, hinders the elimination of the morbid material circulating in the blood, increases the stertor, and if it stops the convulsions will probably deepen the coma into death. To give such a patient chloroform is, I believe, to extinguish the faint chance of life she has. I t may control the convulsions, which in such a case as I have pictured can hardly be regarded as the worst symptom, but what of the already dangerously embarrassed respiration, the flagging overwrought heart, and the c o m a ? These will all be intensified and the transition to death made easy. Of the counter- irritants, cantharides is contraindicated by the albuminuria and renal congestion. Venesection, I believe, is the remedy which best meets the causal and symptomatic indications, which is quickest in its action--and in such a case as I have sketched minutes are of consequence--and which in critical cases will give the best results. What we have to contend against is acute congestion of the kidneys, partial or complete suppression of urine, retention of some morbid material in the blood, which, circulating in the nervous centres, produces the convulsions, and our efforts ought to be directed to relieve the renal congestion, to promote the action of the kidneys, skin, intestinal tract, and other excretory organs, and combat the tendency to death by coma or asphyxia. Venesection fulfils these indications when aided by warmth to the surface and extremities, sinapisms and hot poultices to the loins,

232 Puerperal Convulsions.

enemata mad purgatives by the month as soon as the patient can swallow. The following advantages are claimed for it : - -

1. Venesection lowers the vascular tension, and thereby (a) permits the renal capillaries to discharge themselves into the veins ; (b) promotes absorption of any serum which may have been poured into the nerve-eentres and produced anaemia therein; (c) dimi- nishes the quantity of venous blood and increases the quantity of arterial blood in the nerve-centres and muscles of respiration and circulation, thus increasing their "irri tabili ty; ' '" (d)favours the absorption and special action of remedies administered by the mouth or otherwise, such as purgatives, bromide of potassium, chloral, &c. ; (e) lessens the risk of cerebral hsemorrhage; ( f ) relieves the distended right heart of the venous blood which it is unable to propel through the pulmonary capillaries during the arrest of respiration which takes place in the paroxysms.

2. By means of venesection we immediately withdraw from the system a certain quantity of the morbid material which has pro- duced all the misetllef, whether this be urea, b carbonate of ammonia, ~ or ereatlne and ereatinine, a

3. I f labour be imminent or have commenced, veneseetion relaxes the os uteri and favours the early expulsion of the rectus, thereby relieving the erethism of the nervous system and the pressure on the abdominal veins, which are present in a variable degree during pregnancy.

The objection to venesection in ur~emie convulsions occurring in the progress of chronic Bright's disease--viz., that it increases the poverty of the blood a~ld tends to the usual cause of death by asthenia--does not apply to such eases as I am about to record, where there has been no previous renal disease and no failure of the vital powers, and where once the immediate danger of death by coma or asphyxia is removed and the kidneys resume their function, the patient rapidly returns to a state of perfect health.

The principles of treatment laid down above have been adopted with the happiest results in the following eases : -

CASE I.----June 4th, 1879.--Called to attend Mrs. A. On arrival I was informed that she was in the eighth month of gestation. For about two months she was complaining of pain in the head and loins, vomiting, and lassitude, and latterly her friends noticed (edema of the feet and puffiness of the face. This was her second pregnancy. I attended her in tmr first

a See ~ 'os ter ' s Phys io logy . P . 95. b t I a m m o n d , c F re r i chs . a Opple r a n d Schot t in .

B y D m R. RyA~. 233

confinement, which ended favourably about four years previously. She had become fat in the interval. About six hours before I saw her she had a severe attack of epileptic convulsions, after which her mind was confused, and having slept for half an hour, she had another similar fit.

On examination, pulse 84, moderately full; throbbing of cervical vessels ; face congested, but cold ; general surface cool. About an ounce of dark-coloured urine, which I drew off by catheter, became semi-solid on the applieation of heat. Her bowels had not been moved for thirty- six hours. Her manner was drowsy and heedless.

Gave a soap and water injection, which brought away some hard f~eces ; then twenty grains of calomel and twenty grains of rhubarb, which her stomach immediately rejected. Another and a severer at tack of convul- sions supervened~ lasting about ten minutes. When the convulsive movements ceased, and whilst she was yet unconscious, I took about thirty-five ounces of blood from the arm. She now became conscious. I repeated the calomel and rhubarb draught, to he followed by a senna draught in three hours; applied a large mustard blister to the loins, followed by large, very hot, linseed poultices every four hours; and prescribed a mixture containing spirit of nitrous ether, and spirit of juniper, to be taken every three hours. A warm jar was applied to the feet, and I ordered them to supply her freely with hot whey and flaxseed tea, and, if the fits returned, to put twelve leeches over the kidneys.

5th.--Bowels well moved. Had a slight attack just before they were moved, but none since. Urine copious; contains only a trace of albumen. Has no remembrance of my attending her on yesterday. Cautioned her to attend to her bowels, to avoid cold, and to send for me at once should the fits return, or any sign o[ labour make its appearance.

18th . - -Labour has come on, head and funis presenting; delivered by podalic version; foetus apparently dead since sixth month; skin dark- coloured; cuticle peels off. She had no return of the convulsions. She complains of a slight numbness and want of perfect power of left arm and leg, but this is only noticeable to herself. Hardly a trace of albumen in the urine. Some (edema of feet continues.

August 4 t h . - - ~ o albumen in urine ; no (edema of feet. I saw her again in about a year. She was complaining of occasional

fulness and pain in head, and some numbness in left arm and leg. She said her head felt as it had been before the convulsions, and asked to be bled. She had become fat and florid. There was no albumeu in urine. I took about twenty ounces of blood from the arm. She enjoys excellent health since, but has had no family.

There was, probably, some slight cerebral hremorrhage or serous effusion in this case, as indicated by the impairment of nervous power on the left side. I t is in this way that the epileptic may pass into the apopletie variety of puerperal convulsions. I think I may fairly claim

234 Puerperal Convulsions.

that the free venesection, by diminishing the vascular tension, besides its immediate effect on the convulsions, prevented a severe, and perhaps irremediable attack of apoplexy.

CASE II .---November 15th, 1883.--Called to attend Mrs. B., in consul- tation with Dr. M~Kenna, of Carrickmacross. She was in the eighth month of her third pregnancy. She thought she caught cold a few days previously, and her face became a little swollen. Had first attack of convulsions at six o'clock a.m., before getting up ; had another about two hem's after. From that up to the time I saw her the fits increased in frequency and intensity. She was unconscious since the third at tack; and now, at my visit~ ten o'clock p.m.~ she was getting the fits almos~ every half hour. Her breathing was stertorous ; her face much congested and cedematous ; the bed was wet, as if she had passed urine during the convulsions. A little urine drawn off by the catheter was dark-coloured, and became semi-solid on boiling. Pulse 90, very small and weak. She lay in a state of profound coma, alternating with epileptic attacks, in which so great became the dyspncea as the fit reached its climax, that we feared each attack would end in total asphyxia ; and when the fit ceased, it was only to leave her in the even more dangerous state of coma. She could not swallow.

Having agreed that venesection afforded the only chance, we hastily prepared to adopt i L fearing that she might die before we could give her any assistance. On opening the vein in her arm, the blood for the first five minutes came in a mere trickle, but, when about ten ounces had been abstracted, it came in full stream, and the pulse increased in volume and strength. We bled her to forty-five ounces. Applied sinapisms to loins, back of neck, and calves of feet~ followed by hot poultices to loins ; gave

a soap and water enem% and a calomel and jalap purge by the mouth with difficulty, followed in an hour with thir ty grains of bromide of potassium. On examination~ the os was soft and dilatable~ but no other appearance of labour pains. Ordered a diaphoretic mixture, combined with bromid% warm jars to the feet, and warm whey if she could be got to swallow. The fits and coma still continue.

16th . - -The bowels were moved. The foetus was expelled about four o'clock a .m , during a convulsion. The fits continued, as before, up to eight o'clock a.m.~ when they became less frequent, and ceased about eleven o'clock a.m. The breathing is still stertorous; she is in deep coma. They could not get her to swallow any of the medicine or drink ordered. Passed some urine involuntarily.

17 th . - -Had no return of the convulsions; the breathing only slightly stertorous~ and the coma not quite so profound, but she is quite uncon- scious ; cannot be roused or got to take any drink, and only manifests some indications of pain. Some urine drawn off by the catheter did not show quite so much albumen. Pulse, 90 ; temperature, 98"8 ~ We wet-

By DR. R. RYAN. 235

cupped over the kidneys to eight ounces ; ordered hot poultices, lotinns, and warm jars to be continued to feet ; enemata of beef-tea every four hours~ until such time as she can be got to swallow. The skin is acting slightly.

18th.--She drank the beef-tea since nightfall yesterday, slept a heavy sleep ~luring the night, but breathing not stertorous, and she could be roused to answer questions. She passed no water for past twenty hours, but on examining the bed we found she had done so in large quantity whilst the nurse was informing us about the case. A little urine, drawn off by catheter, contained no albumen. Her recovery was henceforth rapid, except for some diarrhoea, which, I am informed, she suffered from subsequently during some weeks. She does not remember that I attended her at all, although she recognised me when I spoke to her on the 18th. She was seventy-two hours unconscious, and sixty hours in a state of coma, during which she neither ate nor drank. She had convulsions for thirty hours, and for eighteen hours of these she had them almost every half-hour. There was a peculiarly disagreeable odour from her breath on the 15th, 16th, and to a less degree on the 17'th ; it resembled some- what the smell given off from her urine when boiling it. This smell was not observable on the 18th. For some weeks before the onset of the convulsions she was suffering from dlarrhc~a, which, as well as the subsequent diarrhea, was probably caused, as pointed out by Treitz, by the urea, not excreted by the kidneys, being poured into the intestines, where it set up irritation. For this she had been using pretty freely the highly-popular remedy, brandy. And I think we may infer that it increased the renal congestion, diminished the excretory action, already deficient, of the kidneys, impeded the vicarious action of the other excretory organs, and perhaps precipitated the convulsions.

The continuance of epileptic convulsions after dclivery, as in my second case, their subsidence for many days before delivery when the albumen has disappeared from the urine and the renal function is restored, as in my first case, and their occurrence in acute and chronic Bright 's disease, totally unconnected with chi ld-bearing-- all go to prove that pregnancy is merely a predisposing condition, and that what we have really to combat in these cases is ur~emic convulsions induced by the accumulation in the blood and tissues of something which is not eliminated by the acutely congested kidneys. Were this more prominently insisted on, and the urmmic nature of these epileptiform convulsions more generally reeognised, the danger of giving chloroform, or opium in any fbrm, or blistering with cantharides where the patient is semi-asl~hyxiated, comatose, and suffering from arrest of the renal function, would be obvious~

236 Pae~Teral Convulsions.

however harmless or even useful such remedies may be in less severe cases where the eminently dangerous symptoms just men- tioned are not present. I t is generally conceded tha t the causes which produce convulsions and coma--viz. , an impure or a deficient blood supply to the nerve-cells, are precisely those which, by affect- ing the glomerulal epithelium cells of the kidneys and impairing their functions, render them incapable of retaining the albumen of the blood. Venesectior~ offers a quick, easy, and safe means by which these causes and their dangerous results may be overcome in suitable cases.

MACROGI.OSSA TRE&TED BY PAQUELIN~S CAUTERY.

t]ELF~RICH, in 1879, employed ignipuncture with successful results in the treatment of maeroglossa, aud now Dr. Weizs~cker relates an equally successful case which occurred in Brun's clinic at Tiibingen. The greatly enlarged tongue of a girl, five years of age, projected constantly out of the mouth, and greatly embarrassed respiration. Fourteen punc- tures were made with a Paquelln, from above downward, at about a centimetre from each other, and five in a transverse direction, without a drop of blood being lost. On the third day, secondary h~emorrhage occurred from the intercommunication of three of the punctures, but this was arrested by chloride of iron. The tongue gradually diminished in size, was withdrawn within the mouth, and all embarrassment of respi- ration ceased.--~led, and ,_%rg. ~ep. and T)te Analeatic.

SPASM OF THE TONGUE.

E. GANGHOFI~'NER ( Cenlralbl. f~r die reed. Wiss.) describes the following case : - -A youth~ aged nineteen, had from infancy suffered under a spasmodic affection of the muscles of the tongue, which~ when he began to speak~ protruded from his mouth. Simultaneously with this move- ment he experienced jerking of the right lower extremity. In repeating by heart a poem, in singing, or in rapid speaking, the spasm of the tongue would pass off. The patient was anaemic, but otherwise in good health. When not speaking, he seemed to have nothing about him abnormal. His mother had suffered from deafness from her childhood; a brother also had presented a similar defect of speech; a sister was epileptic. Treatment by bromide of potassium had no influence over the spasms. Doubtless this was a case of chorea, the spasm of the tongue being a local manifestation of this neurosis.--Med. Record and The A nalectic.