Puerperal Eclampsia. BY F. W. RITTER, M. D., Moyock, N. C. REPRINTED FROM THE North Carolina Medical Journal. AUGUST 1887. Puerperal Eclampsia. BY F. W, RITTER, M. D, Moyock, Currituck County, N. C [Reprinted from the North Carolina Medical Journal, August, 1887.] Among the most dangerous complications of pregnancy, and probably only secondary to post-partum haemorrhage, are those cases of puerperal eclampsia, taxing the resources of the physi- cian to the utmost and rendering it an imperative duty on every one who practices midwifery to make himself thoroughly acquain- ted with its preventive and curative treatment. Tne reprehensible practice of parturient women in this sec- tion of trusting themselves during labor in the hands of ignorant and incompetent midwives, debars the physician from seeing eclampsic patients in time to take advantage of the precursory symptoms that are occasionally present, and too frequently he is only called in after the supervention of coma ; and the life of the foetus, and often of the mother, is the sacrifice. Normal, physiological labor is a process that ordinarily needs, or tolerates, no interference; but owing to the present modes of living, and what is ostensibly termed refinement, by which the physical development of the female sex is prostituted to the die- 2 turn of fashion, truly natural labors are not common, and scien- tific midwifery is becoming more and more a necessity. It is not my aim in this article to suggest any new treatment for puerperal eclampsia, but to urge upon the profession the ne- cessity of attending to those states of the system presented by pregnant patients indicating albuminous urine. Although Imbert Goubeyre has deduced evidence showing that every case of albuminuria is not necessarily accompanied by convulsions, still it does so in a sufficient number of cases and renders it exceedingly irrational practice to allow a patient, when albuminuria is diagnosed, to go to confinement without making strenuous efforts to restore the balance of circulation, rid it of noxious elements, and, by placing the body in as nearly as pos- sible a physiological condition, pave the way to a safe and pleas- ant confinement. Since Luer, Braun, Frerich and Tyson have shown the in- timate association of puerperal eclampsia with albuminuria, wc have in most cases a key to the treatment, and it is my humble opinion that if women would place themselves under competent medical advice two or three months before confinement, a great many cases might be averted. I have seen women in confinement suffering from scanty urine, anasarca dizziness, spots before the eyes, etc., pointing unmistaka- bly to a renal complication, and have been informed by them that these symptoms, with greater or less intensity, had existed a month or more prior to their parturition, and I have yet to see 3 the case presenting the foregoing symptoms that did not eventu- ate in eclampsia more or less severe. The presence of albumen in the urine of pregnant women does not have nearly the same significance as in the non-pregnant state, and often depends up- on temporary causes, still the presence of this foreign element in the urine should speed us to action and warn us not to remain inactive until a permanent and fatal effect is produced. In the present uncertainty of the pathology of puerperal eclampsia it is important to scan closely the literature and clini- cal history of a disease so fraught with danger. A great many hypotheses have been advanced purporting to explain its etiology, and each of them with some truth, but no one hypothesis has explained all the phenomena, while some are diametrically op- posed by philosophical laws. W. R. Playfair, in his admirable treatise upon “Obstetrics,5' gives a succinct account of the pathological condition of peur- peral eclampsia as advanced by Braxton Hicks, Kussmaul, Tur- ner and other writers, and discriminates very nicely between apoplexy, epilepsy and hysteria, each of which occasionally com- plicates parturition, but touches very lightly upon the preventive treatment. The state of the bowels and bladder ought in every instance to be attended to, as a loaded rectum or a distended bladder will, in many instances, keep up the convulsions and baf- fle the efforts of the physician, who relies solely upon the admin- istration of drugs. A simple enema, bringing away large masses of impacted faeces or catheterization, relieving the bladder ot a 4 quantity of dark, ammoniacal urine, has in numerous instances cut short an attack of convulsions that threatened to terminate fatally. In patients presenting evident symptoms of albuminuria, as a preventive treatment I generally prescribe the benzo-salicy- late of Lithia in conjunction with fresh hydrangea, which is pre- pared by the Lambert Pharmacal Company, of St. Louis (under the name, Lambert’s Lithiated Hydrangea), in teaspoonful doses, representing 3 grains of the former and 30 grains of the latter every four hours, or increased according to the severity of the symptoms, and order the bowels moved twice or thrice daily with confection of senna, which is a mild and very efficient laxative, when, as is frequently the case in the seaboard counties, malaria is present as a complication. Podophyllin and extract taraxaci will be found excellent cholagogues, and if the patient is at all anaemic, the administration of dilute mtro muriatic acid, com- bined with the tincture of the chloride of iron and compound tincture of cinchona, will give excellent results. A steady and persistent use of the lithia, and, where there is a ack of tenacity in the patient, the free use of tincture of iron combined with glycerine to counteract its astringency, while it will not cure a chronic case of Bright’s disease, will in nearly every instance relieve the urgent symptoms and give the woman abetter chance of a safe recovery. As a useful adjuvant to the above treatment dry friction with a coarse towel or flesh brush, or a Turkish bath twice a week to equalize the cutaneous circulation and open the emunctories of the skin, and passive exercise will be found really beneficial. In multipara, with lax abdominal walls, allowing the uterus to antevert and compress the bladder, a well-fitting flannel abdominal supporter is quite a desideratum, for if the contractile power of the bladder is interfered with by pressure from the gravid uterus, vesical irritation will result. I give below four selected cases of puerperal eclampsia occur- ring in practice, with treatment and results: Case i.—January 28th, 1887, at 1 o’clock P. M , I was called to Mrs. C. Found her lying on the floor ; upon making inquiry learned that while sitting before the fire she remarked to those in the room, “I have a funny, queer feeling,” and in a few seconds pitched head-long out of her chair, bruising her head badly upon the hearth and burning one hand slightly. The con- vulsive seizure lasted only a few moments, and when I arrived she was slightly dazed, but answered questions intelligently. She was not expecting confinement under two or three weeks. I had the bed prepared and put the patient on it, and in about fifteen minutes a severe convulsion came on, during which I adminis- tered chloroform. After the paroxysm a digital examination re- vealed a dilated and patulous os, ample pelvic diameters and the condition of the soft parts good. Having administered a dose of chloral hyd. and pot. brom., which was immediately vomited, I ordered an enema of warm water, which brought away quite a large amount of hard faeces. I followed the simple enema with one of chloral and pot. brom. There being no pains, the os be- ing sufficiently dilated and the membranes ruptured, % grain of 5 ergotine was given subcutaneously every hour At the end of three hours slight expulsive efforts began to be made, and at io o’clock P. M. she gave birth to a small, but well and fully formed male child, which was asphyxiated, but was resuscitated and cried lustily at the end of one hour. This patient had only six convul- sions in all, but entered a profound coma after the second attack. She revived in about three hours after the birth of the child, and made a good rec jvery in three weeks. Mrs. C. presented very evident symptoms of albuminuria when I saw her, and I was in- formed that she had suffered from scanty urine, anasarca, dizzi- ness, etc., for a month or so prior to confinement. The acetate of potash and spts. nit. dulc. acted like a charm in this case and the anasarca was speedily dissipated. Case 2.—On March 6th, 1887, at 4 o’clock P. M., I was called by Dr. K., of our village, to assist him in a case of puer- peral eclampsia. Upon arrival I found the patient profoundly comatose, having had prior to my arrival forty or more convul- sions, unable to swallow, face livid, pulse somewhat feeble. Up- on examination found a roomy pelvis, labor in first stage, vertex presentation, os rigid and dilated to about the size of a crown piece, with no expulsive pains. Upon auscultation could detect no foetal heart-sounds. Chloral and bromide of potash having been given before my arrival, I had extract of belladonna freely applied to the rigid os and began the subcutaneous injection of yL[ grain Bonjeau’s ergotin every hour to stimulate the natural expulsive efforts, and in four hours under this treatment the 6 uterus began to contract and the os to dilate and lose its rigidity. The membranes were then ruptured, ergotin suspended, and in two hours more we had the satisfaction of relieving our patient of a medium size foetus, which was dead. She remained comatose over twenty-four hours before rousing, but never had another convulsion after delivery, and under the administration of diure- tics and alteratives made a rapid recovery. Case 3.—September 21st, 1886, at 9 o’clock P. M., I was sent tor in haste to see Mrs. H., aged 17 years, primapara. When I arrived the patient was in a deep coma, the cheeks being drawn in and distended with each respiration, face turgid, carotids throbbing, no expulsive efforts, the abdomen enormously distend- ed, bladder and rectum both empty. Upon inquiry learned that she had been in labor twelve or fourteen hours, and had em- ployed a physician who had left her without making any efforts to subdue the convulsions or to deliver her. She had some forty or fifty seizures before I saw her and two afterwards Examina- tion discovered the os dilated, membranes ruptured, the foetal head presenting, and as there was no effort at expulsion and the mother evidently passing to the spirit land, I applied the forceps and had no difficulty in delivering her of male twins weighing, respectively, 8 and 9 pounds, which, however, had evidently been dead sometime. The mother died in a few hours after delivery, having never recovered consciousness. Case 4.—Primapara, single aged 13 years, poorly developed for age, had been under a colored midwife for thirty hours and 7 8 the membranes had been ruptured eighteen hours. The head of the foetus had impacted the enterior lip of the cervix. The pelvis was very small. The antero-posterior diameter being too short to ow ot the passage of the foetal head by the natural efforts, and these being absent, I applied the forceps, and, after several attempts, delivered her of a very large male child, which ceased to breathe in one hour or so. I could not learn how many con- vulsions this patient had It was six hours after delivery before she regained consciousness, and, after suffering from a severe diarrhoea, in about two months she was discharged The history of each of the above cases of puerperal eclamp- sia presented similar features before parturition, none applied for medical advice, and all went to term with anasarca, which had existed in conjunction with the other symptoms of albuminuria for a month or two prior to confinement, and it is the object of this paper to show the general, although not universal, depend- ence of puerperal eclampsia upon albuminuria, and open a discus- sion among the fraternity in the hope of finding some treatment prior to parturition that will be an effectual preventive. FORMULA.—Each fluid drachm of “Lambert’s Lithiated Hydrangea” represents thirty grains of Fresh Hydrangea and three grains of chemically pure Benzo-Salicy- late of Lithia. Prepared by our improved process of osmosis, it is invariably of dbeinite and unikorm therapeutic strength, and hence can be depended upon in clinical practice. DOSE.—One or two teaspoonfuls four times a day (preferably between meals.)