A CASE -OF- Puerperal Eclampsia, WITH REMARKS. A. CASE OF PUERPERAL ECLAMPSIA,, WITH REMARKS. JOSEPH EVE ALLEN, M.D., Augusta, Ga. REPRINT FROM ATLANTA MEDICAL AND SURGICAL JOURNAL. (Read before the Augusta Medical Society.) The following clinical history of a case of puerperal eclampsia is worthy of record, for the reason that it pre- sents symptoms which are unusual and peculiar, and illus- trates fully the great value of certain remedial agents whose place in the therapeutics of this affection is at present unsettled in the opinion of the profession. Jane S., mulatto, aged 20 years, came under my care in the latter part of August, 1879, when about seven and a, half months gone in her second pregnancy. She then suffered from nausea and vomiting, which was greatly in- creased by the ingestion of food, a burning sensation referred to the epigastric region which, though always- present, was so much increased at night that it prevented! sleep, and dyspnoea, which was also worse at night, and! made rest in the recumbent posture impossible. With the exception of an occasional slight rush of blood to the head,, there was no cerebral disturbance. She was extremely thin and anaemic; there was, however, no edema, either of the face or extremities; the urine was secreted in small quantity, highly colored, and loaded with albumen.. This- 2 patient had been affected thus for about a month previous, •during which time she was subjected to treatment for dys- pepsia. I prescribed acetate potash with infusion of digitalis and sub-nitrate bismuth with saccharated pepsin. This treatment was of such apparent benefit that in a short time the case was discharged. After the lapse of about fifteen days this patient came again under observation, now suffering from the usual cer- ebral disorders attendant on uraemic poisoning of the blood; the dyspnoea and gastric troubles had returned, but not so ■severe as before ; there was great irritability of the bladder, and the urine passed was scanty, thick, dark and highly albumenous, yet there was no edema of the face or limbs perceptible. The diuretic mixture was continued and bro- mide potassium and hydrate chloral prescribed in addition; flip baths and sinapism to the lumbar region were also or- dered ; the advisability of venisection was considered, but deferred in consequence of the extremely anaemic condition •of the patient. There was no appreciable change in this patient’s state until labor commenced at one o’clock in the morning of September 15th, one month before the calculated time for her confinement. On arrival I found her nervous and ex- cited, complaining greatly of pain in the lumbar and hy- pogastric regions which was not intermittent, cutting or grinding, like pains usual to the first stage, but was dull, aching, constant and increasing in severity. Vaginal ex- amination revealed the os high up and just beginning to •dilate, the vertex was presenting in the first position; there was marked vesical irritation, and the urine voided was so dark and thick that it was at first mistaken by the nurse for the “ show.” I administered one drachm of hy- drate of chloral in doses of fifteen grains, repeated every quarter of an hour. This had the effect of quieting some- what the nervous excitement and decidedly diminishing the intensity of the pain. About six a.m., while sitting up in bed, she was seized with a violent convulsion, which was promptly controlled by the inhalation of chloroform. I)r. Jos. A. Eve was then called in consultation. On his 3 arrival the patient was in an unconscious condition, blit could be partially aroused, and when aroused was rational, and stated that she was free from pain. She remained in this condition for aboutfan hour, during which time forty- five grains of hydrate chloral was given in doses of fifteen grains every fifteen minutes; another convulsion then came on; after this had been controlled by chloroform at Dr. Eve’s suggestion, she was bled; the blood flowed freely,, was thin and clotted slowly, and was stopped only with the greatest difficulty after over a pint had been taken* After the venisection the patient became perfectly con- scious and remained so, sleeping occasionally from the ef- fect of the hydrate chloral and chloroform until near ten o’clock a.m., when there was a recurrence of a slight con- vulsion; consciousness was soon regained, however, and at twelve o’clock, the os being completely dilated, the mem- branes were ruptured and in less than ten minutes a fully- developed eight months’ child was born, the mother being* perfectly sensible during the time of delivery. Very little blood was lost in the third stage, for the placenta being delivered by Crede’s method, the womb contracted firmly. Two slight convulsions, both of which readily yielded to chloroform, occurred immediately after the birth of the child; a quarter of a grain of sulphate morphia was then, given by hypodermic puncture, and an hour afterward the patient was left sleeping quietly. On my return at four p.m. she was awake and talking rationally; while talking she was taken with a violent convulsion. The convulsions then recurred at intervals of about two hours, during which time the patient was in a semi-conscious condition until half past nine o’clock p.m., when deep coma supervened. From the time of delivery until the occurrence of the last convulsion a drachm and a half of hydrate chloral, two punctures of sulphate morphia (a fourth of a grain each,) and over eight ounces of chloroform were administered. At eleven o’clock the patient was deeply comatose, the breathing was stertorous and irregular, and in rate only about eight inspirations to the minute; a puncture of the sixtieth of a grain of sulphate atropia was then given, which had the effect of rendering the respirations regular. 4 and increasing the rate to about sixteen in the minute. About an hour after the atropia had been given, and while the woman was still in this state of coma, the vein which had been opened in the morning began to bleed again and was permitted to do so until several ounces had been ab- stracted. The patient remained unconscious for about twenty- four hours, but took nourishment freely. During this time ten grains of calomel, twenty grains sulphate quinia and citrate potash, in doses of thirty grains every two hours, 'were given. On the morning of the third day after deliv- ery she waked up and remained sensible all day, talking -almost incessantly in a quick, cross, irritable manner, but complained of no pain except that usually attendant on ■the establishment of lactation. The urine, which was drawn by the catheter, was clear and normal in quantity, and the bowels moved frequently from the action of the calomel. The sulphate quinia and citrate potash was continued, but no hydrate chloral or sulphate morphia was taken. At ten o’clock p.m. a teaspoonful of “Dugas’ astringent mixture” was given to check the bowels; after this the patient went to sleep and slept until about one o’clock the next morning, when she awoke with a -slight convulsion which was immediately followed by deep coma. When I reached her, about half an hour after the convulsive seizure, she was perfectly comatose and her breathing was irregular, stertorous and between six and eight inspirations to the minute; a puncture of the forty- eighth of a grain of sulphate atropia was given, which in- creased the rate of respiration to eighteen per minute; after this mustard was applied to the chest and extrem- ities, cold water to the head and a blister to the back of the neck. In about two hours, or as soon as the blister began to draw, the patient Commenced to arouse and had no return of the eclampsia. She convalesced slowly, but is now almost restored to health ; there exists, however, almost complete atrophy of the muscles of the hands and forearms. The infant died of spasms, probably caused by indiges- tion, on the sixth day after its birth. 5 The points of interest in the clinical history of this case are :— 1. The continuance of nausea and vomiting during the latter months of pregnancy.—In the American Journal of Obstetrics, Jan. 1879, Dr. Richardson, of Boston, calls attention to the fact that the continuance of nausea and vomiting during the latter months of pregnancy is often indicative of ne- phritic disease with consquent uraemia, and he rightly urges the necessity, in all such cases, of first examining the urine chemically before attempting to treat this symp- tom as dyspepsia or a return of the reflex disorders of the earlier months. in the present state of our knowledge it is impossible to say positively whether this nausea and vomiting is due to the circulation through the brain of blood poisoned by the accumulation of excrementitious material or whether it is a morbid reflex action anteceding or becoming devel- oped at the same time with the disturbance of the renal function, and having with it as a common cause, some hidden source of puerperal irritation. It is probable that the last is the true explanation, for if closely observed it will be found that cases of puerperal eclampsia frequently occur in which, as in the case above reported, the gastric disorder precedes for weeks the headache, blindness, dizzi- ness and aedema symptoms characteristic of uraemic blood poisoning. The persistence of nausea and vomiting dur- ing the latter months of pregnancy is therefore a condi- tion of great pathological significance, being highly in- dicative of acute nephritis and prognostic of puerperal eclampsia. 2. The recurrence of the eclampsia on the third day after delivery.—The recurrence of the eclampsia on the third day after delivery, at a time when the urinary organs were acting normally and the woman had been perfectly con- scious for over twelve hours, was doubtless due to the sys- temic excitement attendant on the establishment of the _ _ # 1 i r* , •'Cp A lacteal secretion, and worthy of note in convul- sive seizures may be induced in women whose nervous systems are morbidly impressible by various causes of di- tfux.t~ rect or indirect irritation, orAas Rosenthal states,* puerpe- ral eclampsia is really a reflex epilepsy. 6 3. The therapeutic value of hydrate chloral in the treatment of puerperal eclampsia.—Attention is called to the benefit derived from the use of hydrate chloral in this case espe- cially for the reason that although now the use of this drug is advised in almost every standard work on obstet- rics, and'the current medical literature of the day is full of reports of the good results obtained from its employ- ment, still Dr. Fordyce Barker has recently expressed him- self adversely to it,f stating that he has found that in puerperal|eclampsia hydrate chloral does not, like chloro- form, allay,|but that he is strongly suspicious that it ex- cites nervous irritability. This opinion coming, as it does, from one of the highest authorities in this country, and based, as it is, on such a vast amount of clinical observa- tion and research, demands most careful consideration and is justly entitled to the highest respect, and therefore the place of hydrate chloral among our resources for the treat ment of this’affeetion is at present a matter which is only to be determined by the study and comparison of individ- ual experiences. Dr. Wm. Goodell, in remarks before the Obstetrical Society of Philadelphia,! advocates the use of hydrate chlo- ral in puerperal eclampsia, and reports several cases in which the convulsions were absolutely controlled by the drug; and again, at the last meeting of the same society, he said|| that he considered it the best single remedy for the treatment of this disease, and that he had never lost a case to which hydrate chloral had been administered. Dr. Jos. A. Eve has used hydrate chloral in his practice ever since its first introduction into obstetric medicine. In the treatment of puerperal eclampsia he regards this drug as one of the most valuable of remedial agents. Its administration has, in his experience, always been attend- ed with the most satisfactory results. In several cases *Diseases of the Nervous System. tPuerperal Diseases, page 120. tAmerican Journal of Obstetrics,[Veil. IX., page 495.. || American Journal of Obstetrics, April, 1880. 7 where puerperal eclampsia was threatened, Dr. Eve believes that he has prevented its occurrence by giving hydrate chloral during the first stage of labor until its hypnotic effect was produced. It has been his observa- tion that the use of this drug during labor calms nervous excitement, lengthens the intervals, and induces rest be- tween the pains, and thus strengthens and renders more efficient the uterine contractions, while at the same time the woman is saved much suffering and exhaustion. As an anaesthetic during delivery it will of course never take the place of sulphuric ether or chloroform, but he consid- ers hydrate chloral peculiarly applicable at a period when th)\se agents cannot be used to advantage, viz., during the first stage when a drug is required which is continuous in its action and does not necessitate the constant personal supervision of the medical attendant. Dr. Richardson, of Boston, in a paper read at the first meeting of the American Gynecological Society,* has recorded his views on the use of hydrate chloral in obstet- rics, and especially as to its good effect in the treatment of puerperal eclampsia. If the systemic action of hydrate chloral be studied in connection with any one of the many theories which have been advanced to explain the etiology of puerperal eclamp- sia, it will be seen that, in accordance with each, its use is rationally indicated; but as it is impossible here to con- sider these opposite and contradictory theories held by different pathologists, the following synopsis of the views of Dr. H. F. Campbell, drawn from his paper on “ Blood- letting in Puerperal Eclampsia,’’f is taken as expressing concisely and completely, and interpreting most reason- ably, all that is now known of the pathology of this affec- tion—that is, that puerperal eclampsia is induced by sev- eral widely different morbid processes, all culminating in the one overruling proximate cause, the pathological con- dition of nervous irritation. Now, as hydrate of chloral is proved by physiological experimentation! and clinical American Gynecological Society—Vol. 1. tAmeriean Journal of Obstetrics, Yol. IX. JSee the researches of Labbee, Rayewsky, H. C. Wood and other physiologists, H. C. Wood’s Therapeutics, Materia Medica and Toxicology. 8 observations to be, when given in full doses, a most cer- tain depresso-motor, acting as a depressant upon the cen- tres of the base of the brain and spinal cord, thus allaying reflex excitability and subduing nervous irritation, it is manifest that its use is indicated in puerperal eclampsia as a most certain remedial agent, secondary in importance only to the more prompt cerebro-spinal sedatives, vene- section and chloroform. 4. The great value of blood-letting in puerperal eclampsiay and especially in apparently anemic cases of the affection.— This case illustrates the good effect of blood-letting, espe- cially in apparently anemic cases of puerperal eclampsia,, for the woman was thin, emaciated and seemingly almost exsanguined; in fact, her condition was such that Dr. Eve, who has long regarded venesection as one of the most prompt and efficient means at our command for the con- trol of puerperal eclampsia,* hesitated before advising in her case a resort to this measure. The abstraction of blood was, however, followed by the most marked and immediate benefit, the explanation of which is found in the fact that, as Barker says,f “ In hydrsemia there may be an excess in the quantity of blood—a kind of serous plethora, result- ing in great disturbance of the circulation and local con- gestions, which will be overcome by moderate venesection, followed by more nutritious animal diet and the use of iron and other tonics.” /pr In the same article, referring to this subject, very forcibly remarks, “ It has seemed to me there is some lia- bility to err in the neglect of blood-letting, from the feel- ing that this measure should never be resorted to unless the patient was in a sthenic condition. But some of the most striking instances of its usefulness have occurred, under my observation where the patient was extremely ansemic.” Dr. H. F. Campbell has demonstrated the rationale of therapeutic action of vensection in puerperal eclampsia. In his article above referred to, he has proved that blood- letting, by reducing vascular pressure, relieves congestion Medical and Surgical Journal—Vol. III. IBlood-letting as a Therapeutic Resource in Ohatetric Medicine. 9 of the brain and spinal column, thus acting as a cerebro- spinal sedative, while at the same time, by lessening turgescense of the kidney, it aids most materially in the elimination of the poison from the blood. Observation of cases, not only of puerperal but of non-puerperal uremic eclampsia, has led me to believe that although this seda- tive action on the nervous system is most strikingly appa- rent and of great importance in the prompt control of the convulsive seizures, still that the abstraction of blood is frequently of as much, if not of more, permanent benefit in re-establishing the renal functions. 5 The use of sulphate atropia in puerperal eclampsia.— The good results obtained from the hypodermic adminis- tration of sulphate atropia in this case, proves its value as a respiratory stimulant during the comatose state su- pervening after puerperal convulsions. It may be urged that when first employed it acted simply as a physiologi- cal antidote to the hydrate chloral and other drugs which had been taken. This I am not prepared wholly to deny ; but the coma on the third night after delivery was, with- out doubt, due to the eclampsia, for it could not possibly have been caused by the small quantity of opium given four hours previous in the Dugas mixture; and it was in this last instance that the great benefit of sulphate atropia was most evident.