If convulsions have already occurred when the practitioner first sees the case, he should carry out the measures just advised—stomach lavage with the administration of a purgative, preferably Croton Oil as the most potent, rectal lavage, and the application of external warmth. It is questionable whether Chloral per rectum should be given. The alternative is a hypodermic of Morphine ( gr.), which has the advantage of being quicker and more certain in its action. It is fairly certain that the morphine, especially if it be followed up by .-gr. doses every 2 hours up to 2 grs., as many authorities recommend, will kill the child, but this is not a valid objection, as in most cases of severe eclampsia the child is stillborn no matter what treatment is adopted. A more serious objection is that the morphine is not eliminated in the disabled condition of the kidneys, and may produce poisonous effects, slowing the respirations and conducing to cyanosis and coma. These symptoms may have to be met by artificial respiration and the administration of oxygen, so that I think the practi tioner who has not the resources of a hospital behind him will be well advised not to increase the total dose of morphine above a grs. in the 24 hours unless he has skilled assistance at hand. With this limitation he may safely employ it. The next question that faces him is how to deal with the fits as they arise. Practically the only thing that can be clone is to treat each fit as an epileptic fit, have a piece of stick or a spoon wrapped around with linen to place between the teeth as the fit comes on in order to prevent the patient biting her tongue, see that all clothes are loose at the neck, and take care that she cannot injure herself in the clonic contractions. Chloroform has been recommended, but it may, I think, be unhesitatingly condemned, unless as administered between the fits for some procedure, such as passing the stomach-tube. The post mortem in fatal cases shows a condition of the liver identical with that found in acid intoxication, and a precisely similar condition is found in cases of delayed chloroform-poisoning. Full chloroform anaesthesia is therefore inadmissible on account of the danger of producing or assisting in a degeneration of the liver which will lead directly to a fatal result. The partial chloroform anaesthesia often recommended, which consists in clapping on the mask at the beginning of a paroxysm, is useless for the reason that the initial stage of the fit consists of a tonic spasm in which the respiratory muscles share, so that the chloroform vapour is not inspired, and therefore cannot be absorbed until the fit is already half over. It is therefore practically without effect in the duration of the seizure. I may say that I have witnessed the onset of repeated convulsions in a patient who was ansthetised with chloroform for the performance of an operation, so that even full surgical anesthesia is not always capable of inhibiting them.
The methods recommended by Stroganoff have been so successful over a long series of cases that I add his own summary of his procedure: r. Avoidance of all external irritation. Room to be kept quiet and dark; all examination limited to what is absolutely necessary. All manipulations, catheterisation, rectal injections, hypodermics, etc.. to be carried out under slight chloroform anesthesia (15 to 3o mins.).
2. Control of fits by morphine and chloral hydrate, given as follows: rst hour: Morphine (I gr.) hypodermic.
2nd hour: Chloral Hydrate (3o grs.) by mouth or rectum.
3rd hour: Morphine (i gr.) hypodermic.
7th hour: Chloral (3o grs.). i3th hour: Chloral (25 grs.). 2rst hour: Chloral (25 grs.).
3. Labour is assisted, but not forced.
4. Watching and stimulating the vital processes.
(t) Respiration.—Posture; cleansing of nose and throat; pure warm air; oxygen after fits.
(2) Ileart.—Milk and saline infusion per us and rectum; digitalis for weak pulse.
(3) Kidneys and Skin.—Warmth and saline infusions.
Another point which the practitioner will consider is the propriety of inducing labour or of rapidly emptying the uterus. Although it is true that eclampsia occurs in quite as severe a form intra- or postpartum as ante partum, I think that the experience of most obstetricians is that when fits occur before labour they usually cease as soon as it is completed, and that, prima facie, the evidence would be in favour of the emptying of the uterus at once. In deciding this point we must recollect that labour comes on in nearly every case of eclampsia of its own accord, and that it usually progresses rapidly, so that a wait of a very few hours is certain in most cases to put us in possession of any therapeutic advantage that the completion of labour confers. We have to consider further the risks
that are run in an accouchement force—laceration of the cervix with great probability of sepsis, to which eclamptic patients fall an easy prey. and in any case a considerable amount of shock. The interests of the patient will best, in my opinion, be consulted by confining interference to the application of forceps when the os is fully dilated if delivery is slow.
I have come to this conclusion after an experience which includes all the methods of rapidly emptying the uterus, such as Cxsarean section, accouchement force, and the use of Bossi's dilator. I am now satisfied that if the modern methods of elimination are faithfully carried out the patient's chance of recovery is quite as good undelivered as delivered, and there is nothing to he gained by taking the risk unavoidable in an attempt to deliver before labour has set in.
It is at least possible that the improvement sometimes following artificial delivery or other operative procedures is partly due to the coincident loss of blood. Bleeding was formerly a routine method of procedure, and it seems to he indicated when the patient is plethoric and cyanotic. The vein at the bend of the elbow or one of the veins on the back of the hand may be opened and 12 to 20 oz. of blood taken.
The principle of saline transfusion for the purpose of increasing the volume of fluid in the circulation and so both diluting the toxins and stimulating excretion by the kidneys is almost universally admitted to he sound. The only drawback alleged to its use is the possibility of encouraging the onset of pulmonary (edema. So long as large volumes of fluid are not rapidly added to the blood this danger is probably a negligible one. The technique of saline transfusion is fully described under Shock and Collapse and Operations, Treatment of. It is sufficient to say here that the most satisfactory method in eclampsia is to use the submammary method. The breast should be lifted up and the needle thrust in at the lower margin of the gland into the loose suhmammary tissue to avoid the risk of producing abscess or gangrene of the gland. k pint to a pint and a half should he injected, and the same quantity may be given again at the end of 2 hours. Normal Saline solution (drachm of common salt to the pint) is commonly used, but some authori ties recommend a solution of sodium bicarbonate (drachm to the pint) with the object of combating the acid intoxication.
In the worst cases, in spite of all forms of treatment and in spite of delivery being completed, the patient grows steadily worse, and finally sinks into a state of coma which ultimately ends in death. In cases of this kind it is proposed to attempt to resuscitate the kidney functions by the operation of decapsulation. The kidney is exposed, but need not be raised from its bed. it is steadied by grasping the capsule with toothed forceps, and an incision is then made through the capsule with knife or scissors. The finger is then introduced through the incision and sweeps round between the capsule and kidney substance, the two being very easily separated. The wound is then sutured with a small gauze or tube drain. The operation is neither severe nor difficult, and 'n view of the numerous good results which have been recorded it seems worth while to give it a trial when delivery has taken place and other treatment is of no avail to control the condition.
Veratrone has been highly recommended, hut should be used with caution, as the drug is a dangerous one.
Tweedy has pointed out that many fatal cases die of suffocation during a fit. I fe urges the importance of skilled assistance being at hand, and advises that when symptoms of suffocation are noted the patient should be seized by one arm and by the hair of the head and dragged across the bed, the body being turned over, so that she is thrown on her face with the head over the edge of the bed. He says that this manoeuvre is followed by the discharge of a quantity of bloody mucus and fluid from the mouth and nose, and claims that patients may in this way be saved from imminent danger of suffocation. He also deprecates very strongly the giving of any food, including milk. until convalescence is well established.
R. J. J.