The use of chloroform once granted, how should it be administered ? It should be inhaled and carried to complete narcosis, but the use of chloroform must not cease when once. it has been employed. Inhalation should begin the momentthe nervous excitement commences before the attack; it should be given rapidly in order to get complete anEethesia as soon as possible. This once obtained, the inhalations should not be given up, but should be continued for several hours, six, eight, twelve, fifteen hours or even more if necessary. If the attacks are far apart, the amount of chloroform may be diminished or suspended altogether during the in terval. Do not allow the patient to come out of the chloroform and regain consciousness; at the least sign of a return of an attack give the chloroform again to complete antesthesia. Tarnier, in one case which he cured, kept the patient under chloroform all night, and 6000 grains of chloroform were used. When once complete atuesthesia is produced, keep it up without regard to time. This is well in theory, but it cannot always be done in practice; for there are cases in which the use of chloro form must be suspended after a certain time, although it need not be given up altogether, as in our patient.
It is well then, to resort to other means; but in general, it is astonish ing to see with what ea,se patients will endure a long-continued amesthe sia, and the length of time that they can be kept under its influences without inconvenience. There is still one other difficulty, i.e., how is one to know the exact time when it will be safe to give up chloroform ? This cannot be fixed ex.actly. It is not rare to have the interval between the attacks last for several hours, and we seem to have mastered it, when in reality there has been a short suspension. The question cannot possi bly be answered absolutely. When the patient has gone several hours without an attack, it is best to withdraw the chloroform a little without giving it up altogether. We would keep the patient in a half-sleepy con dition, so that, if necessary, we may produce by a few inhalations com plete anEesthesia if there are any other symptoms of the attack. But it is only after some time that the chloroform can be entirely given up. Bailly goes still further, and advises in cases in which the attacks con tinue, and with greater obstinacy, not to keep up the chloroform more than twelve hours at once, but to stop it at the end of this time, to allow the blood to become purified, and to make use of chloroform again in case of a relapse. We do not accept this view, because we think that chloro form acts only on condition that its influence is prolonged, and therefore it must be given continuously. Admitting the action of chloroform on the nerve centres, we believe that, in acting as Bailly would have us, patients would be exposed to all the dangers of chloroform without deriv ing any advantage from it.
But there is another agent, little known, or better, little used until 1872, which has since taken a prominent place in the treatment of eclamp ail', and we have reported already some marvellous cases in which it has been employed. This is chloral-hydrate. The use of chloral-hydrate in
the treatment of eclampsia either by the mouth, rectum or subcutane• onsly, only dates back a few years. It is only since 1869 that chloral has really taken its place in practice in the treatment of eclampsia.
Employed for the first time, in 1869, by Saint Germain, it was not 4 slow in taking its place in obstetric practice, and we limit ourselves to the following works on the subject: Lecacheur, 1870; Alexander, Sedywick, Demarquay, 1870; Campbell, Milne, Flok, Mackintosch, 1870-71; Ray mond, Furley, Stearly, Mac Rae, Bookley, 1871-72; Windhorn, Mawsell, Phillips, Tarnier, Bourdon, Charpentier, 1872; Franco-y-Mazora,Paissier, 1873; Fanny, 1874; Beliere, Chouppe, 1876; Testut, 1877; Troquart, 1877, Delaunay, 1877; Wlissier, 1878; Tucoulat, Froger, 1879. Fanny, in 1874; collected 36 cases, 16 of which had been given chloral after other treat ment, and 20 had received chloral alone. The following results aro given: Chouppe has had good results from chloral, and adds one cure. Legroux, always a partisan, reports some cases of death by art over-dose of chloral. Depaul reports 3 deaths, alhd, without giving up chloral, is but little in favor of it. Lissonde rejects it entirely; but the best and most interest ing papers on the subject are those of Delaunay and Testut, 1877, and a paper by Froger in 1879.
Testut admits two kinds of eclampsia; the one from reflex irritation, and the other from cerebral cedema. "In the first, chloral is all powerful; (a) in quieting the spiiial nerve-centres in which arises all the muscular and motor excitement; (b) in paralyzing the vaso-motor centre in the medulla, it thus renders the contraction of the vessels impossible, and also the ap pearance of aniemia of the convulsive areas, and opposes at the same time outward manifestations of eolampsia." In eclampsia due to cerebral cedema, chloral would be powerless.
Delaunay admits that chloral acts on the nerve-centres themselves: " The blood being unable to stimulate the centres regularly, produces, in some way or other, a general irritation, which leads to an eclamptic attack more or less long, which may or may not be repeated. Is this central-nerv ous irritation due to cerebral congestion, to serous exudation into the ventricles and meninges of the brain, to cedema of the brain substance, or to an alteration in the nerve tissue itself ? We do not know. In any event, if other lesions do exist, it is not on these that the influence of chloral is exerted. Its action must, of necessity, be exerted on the nerve cells themselves, particularly on the nerve-cells of the spinal cord, which all regard as the seat and origin of all convulsive attacks of whatever kind. Chloral acts first as an hypnotic, and then stupifies the cerebral nerve-cen tres, and makes them insensible to the cauke of the attack." Froger has collected all the cases since 1879, i.e., 110 cases, in 51 of which chloral was alone used, with 49 cures and 2 deaths-4 per cent. Finally Testut, who has taken the statistics from our table and observa tions, gives the following table, which comprises the results obtained from different methods of treatment.