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IN THE CONVULSIONS OF PREGNANT AND PARTURIENT WOMEN.
By DARWIN COLVIN, M. D., of Wayne County.
In the practice of medicine, fashions change as they do in wearing apparel. Medicinal agents in use a few years ago, in the majority of instances, not because better have been discovered, are now rarely prescribed. So is it with the lancet; for phlebototomy, as the revered Gross said, is one of the "lost arts." Seldom will one be found in the pocket of a physician of not more than ten or fifteen years experience; and if, perchance, one should be found, it is there as a matter of form, for in all probability it has never been used. So will it be, perhaps, with the aconite, veratrum, chloral, and jaborandi of to-day. They, in their turn, may soon be known no more.
My remarks on the subject of this paper will be based upon the experience of a revered father, who, for more than fifty years, was largely engaged in the practice of midwifery. Notes of his cases are now in my possession; and I feel that I have a right to make use of them, as, for the last thirty years of his practice, five of which were during a copartnership, I was associated with him in the treatment of the patients. I shall also draw upon my own experience, now covering a period of forty years. In presenting my experience and conclusions relative to the use of the lancet in puerperal convulsions, I shall not attempt to discuss the causes of this formidable malady, but shall give "a plain, unvarnished tale" by reporting a few cases occurring
either before, during, or after parturition, which cases are typical of many others found in our note-book. The greater number of my father's cases, as well as a few of my own, occurred before chloroform, chloral, the bromides, morphia hypodermically, or albuminous urine were thought of. Throughout my father's midwifery-book, especially the records of the first thirty years of his practice, I find frequent mention of cases like the following:
I saw Mrs. A., who was seven months advanced in pregnancy. I found her œdematous, with much headache, and complaining of an inability to see distinctly.
She was bled to the extent of sixteen ounces, and I ordered a saline cathartic, with directions that the diet should be less nutritious, and that the bowels be kept in a soluble condition.
As confinement approaches, unless the symptoms, except œdema of the ankles, should subside, I am to be informed, so that I may take more blood. Mrs. A. was safely delivered at full term.
Quite frequently the second venesection was practiced. There are between three and four hundred such cases recorded during the first thirty years of my father's practice, none being followed by eclampsia at the time of parturition.
During this period of thirty years, there are recorded many cases like the following:
I was called to attend Mrs. B., a primipara. She was quite ædematous and had severe headache. The pains seemed to be inefficient. After waiting a reasonable time and not making much progress, I opened a vein and allowed ounces of blood to flow, which relieved her. The pains soon began to improve, and inhours labor was completed.
Then, again, many cases of the following character are recorded:
While attending Mrs. C. in her first labor, matters not progressing to suit me, and as I was about to take some blood, she had a convulsion. Not waiting for the convulsive movements to cease, I bled her to the extent of ounces. Soon the muscles be
came relaxed, and after a short time she became conscious. Labor progressed satisfactorily, and she was soon delivered.
I could spend a great deal of time in giving reports of similar cases found in my father's book, but shall hasten on. It must be remembered that, during the period referred to, chloroform, chloral, morphia hypodermically, and albuminuria, were not thought of; and yet, as was subsequently proven, the results of his cases of puerperal eclampsia were more satisfactory then than after these agents were introduced, for, as a consequence, the lancet was not used at the proper time.
About the close of the first thirty years of my father's professional work, I obtained my degree, and immediately a copartnership was formed. It was at about this time that much was written on anæsthesia, referring especially to ether and chloroform. Chloroform was used in midwifery practice, as well as in convulsions, whether infantile or in the lying-in woman, and, when applied to the latter, it was asserted that it would supersede the use of the lancet. Its use in the place of the lancet was frequently the subject of our conversation by night as well as by day. I urged the propriety of its use in the first case of puerperal eclampsia which should come under our care. However, I had not long to wait before an opportunity presented itself, when I could urge its use instead of the lancet, in a case where labor was ushered in by a convulsion.
About 5 o'clock one cold, November morning, I found my father at the door, desiring me to accompany him to a case of labor which, the messenger informed him, "had produced a fit." Notwithstanding that some time would elapse before we could reach the patient, she being in the country, I determined, if possible, to test the effects of chloroform.
Upon arriving at the bedside, we found a primipara, aged twenty-eight, at the completion of term. Her general health had been good. Decided uterine contraction began three hours before our arrival, and, when the friends were about to dispatch a messenger for my father, a severe convulsion occurred, with bitten tongue, bloody saliva being upon her lips and clothing. Con
sciousness had returned. She was plethoric, without much odema, and complained of cephalalgia. The pulse was 90, full and hard. After much opposition, I obtained consent to use the chloroform, should another convulsion occur, not, however, without my father saying, sotto voce, "You will regret it, as she will have another convulsion. If I bleed her, she will not."
While an examination per vaginam was being made, another convulsive seizure occurred, and I began to administer chloroform. A good impression was produced, and, while the patient was under the influence of the anaesthetic, another examination was made, to determine the condition of the os. But little progress in dilatation had been made. I withdrew the chloroform, being anxious to know whether consciousness would return before the occurrence of another convulsion. After waiting for a longer time than that which followed the first seizure, the brain seeming to be overpowered, there were noticed some slight muscular twitchings of the muscles of the face, when I again resorted to the chloroform. These movements seemed to increase for a short time, when the patient became quiet. The breathing began to be more labored, and the objective symptoms became more formidable, when my father, without further consultation, said: "Your chloroform will not do. This woman will never become conscious unless the brain is relieved by loss of blood. I shall not sit here and see her die for want of this relief. I shall bleed her, and then, if you choose, you can use the chloroform." I confess that my courage in continuing the chloroform had nearly oozed out. A vein was opened, with the remark, "Let the blood run until her complexion changes, even though she is in a recumbent posture." I did as directed, and, when about twenty-four ounces of blood had been taken, the breathing became more quiet and the cyanosed appearance disappeared. The pulse became fuller and more easily compressed after thirty ounces had been taken. The patient then began to moan, the eyelids opened, and she was evidently sensitive to uterine contraction. A slight twitching of the facial muscles was again observed, the chloroform was again applied, and no more convulsions occurred. Pains began to increase. Chloroform was occasionally, though moderately, used. Consciousness returned, and at 11 A. M., the first stage of labor was completed. The patient became conscious and was quite free from nervous irritation. At 1 P. M., labor was
completed. Accidentally it was learned that the urinary secretion had been scanty for some days prior to parturition; but at that time this had no more significance than constipation.
On the 5th of January following, at 9 A. M., my father and I were asked to see Mrs. P., who was said to be "in a fit." We soon reached the house and found the patient between seven and eight months advanced in pregnancy with her first child. She was twenty-four years of age, of medium muscular development, and her health was usually good. Consciousness had not fully returned. The pulse was 88, and the breathing hurried though not labored. No imprudence on the part of the patient could be ascertained. We learned that, upon rising that morning, she made the remark that she "could not see." This soon passed off, however, to again return just before the convulsion.
No perceptible uterine contractions had occurred, as an examination disclosed; but scarcely had the examination been completed, when there was another convulsion. I immediately began the use of chloroform, with no satisfactory effect, as the spasmodic movements were very severe and protracted. Consciousness was so long in returning, that venesection was imperatively urged by my father. I suggested a saline cathartic as soon as deglutition would permit, and to continue the chloroform should convulsive movements recur. My entreaties were unheeded, and
venesection was resorted to.
The loss of twenty-seven ounces of blood, followed by a saline cathartic, brought a return of happiness to the sick-room, as I used the chloroform but once after the venesection. With a careful diet and a soluble condition of the bowels enjoined, the patient was left, after we had urged upon the husband the importance of reporting her condition to us from time to time.
On the 5th of February, my father was asked to see this patient on account of headache. His note states "that, confinement being near, and the pulse hard, I bled her to the extent of a pint, with immediate relief to her head. She was confined, with no intercurrent difficulties, on the 16th of February, at 2 a. M., after a labor of seven hours."
I believe the lives of these two patients were saved by the taking of blood; and it is idle talk, not argument, for those