Admitting even that a certain number of fatal cases have not been pub lished, the results given by chloral differ so much from those given by other methods, that they cannot be but striking, and Beliere was right in saying, in 1876, when speaking of our work d'f 1872, that perhaps later we would give a more decided opinion. Since that time, indeed, cases have increased and are multiplying every day, and, in our opinion, the treatment of eclampsia to-day may be summed up in two great classes: 1. To bleed the patient moderately; 2. To give chloral in large doses, as we shall show.
Before studying the different methods of giving chloral, let us say that Bourdon is not satisfied with giving chloral when the eclamptic attack is in full force, but he has employed it as a prophylactic agent in an albu minuric condition. In these cases chloral was given in doses of 60 grains at the time of confinement, and the labor has ended without eclampsia.
How and in what dose should chloral be given? Chloral may be given by the mouth, by the rectum, subcutaneously, or by intravenous injec tion. Of these four ways, there are two which we discard at once, i.e., lst. the intravenous injections, because they are dangerous, and therefore should not be employed except as a last resort. 2d. Subcutaneous injec tions, because they expose the patient to abscesses, phleginon, gangrene. There remains then the mouth and rectum. But eclamptic cases, besides that they swallow with difficulty, vomit often all that they take. This would leave the rectum for the administration of chloral.
Bourdon begins with 60 grains of chloral, then he gives 15 to 30 grains every quarter of an hour, until 150 grains have been given. If the attacks do not cease, he waits some time before continuing the treatment. Chouppe goes as high as 180 grains. Testut at first gives 60 grains, then 15 grains every hour until the enema is used up. The enema is made of 150 grains of chloral and 5000 gmins of distilled water.
Our method differs slightly. At first we give 60 gmins to our patient; if this is not retained or only partially, we give immediately a second, and if necessary a third until the medicine is borne. Whether the at tacks continue or cease, we do nothing for a few hours, say five or six if necessary, and it is only at the end of this time that we give another 60 grains of chloral.
It is rare that we have to pass this limit, which represents -80 grains of chloral, to be taken in eighteen or twenty-four hours. We do not fear to give a still larger dose, and in one case we have given as high as 240 gmins in twenty-foar hours. If the attacks become farther apart, we make the interval between giving the medicine longer; if, on the contrary, the attacks persist, we do not wait as long. In one case which was cured, (by bleeding and chloml) we gave without inconvenience, 180 grains of chloral in 10 hours. We never stop the medicine suddenly, but we give the patient always, even when cured, 60 grains of chloral at the end of the first twenty-four hours after the attack. By separating the doses, and giving them in large quantities, we obtain greater quiet with less trouble and worry to our patients. We have never had to exceed this dose, but we would not hesitate to do so if necessary, even to go as high as 300 grains, as Delaunay and Froger have done.
Does disturbance of cardiac innervation and organic heart-trouble con tra-indicate the administmtion of chloral, as Gubler would have us be lieve? The cases of Liebreich, of Davreux, of Waters, of Dunlap, of Meldola, of Smalmann, seem to justify this view. But Waters, Ogles, Foyers, Westrangle have, in spite of cardiac trouble, had good results from chloral. The cases of Lucas ChampionniAre seem to justify these authors, for not only does he not fear to use chloral in patients who have cardiac disease, but he does not even see any contra-indication to chloroform in cardiac disease.
In all of his surgical operations, Lucas Championniere uses chloroform, whatever be the state of the patient's heart, and he has never had anacrei dent,. It is true, that in these cases the prolonged action of chloroform is less than that of chloral. These facts, nevertheless, are very encourag ing, but we will still resort to chloral only in these cases, although, per haps in smaller doses.
2. Obstetrical Treatment. —All accoucheurs are agreed on this one point, that,whenever one can terminate the labor either by the use of forceps or by turning without injury to the mother, it will be best to do so, as well for the mother as the child, i.e., whenever the cervix is dilated or dilatable.