[Reprinted from the American Gynecological and Obstetrical Journal for July, 1895.] PUERPERAL ECLAMPSIA.* By A. D. Price, M. D., Harrodsburg, Ky. Eclampsia is the most serious and fatal trouble to which the preg- nant woman is liable. It is well, therefore, to occasionally review the subject and learn, by an interchange of views, what is of doubtful utility, and thus to formulate rules of practice, founded on sound pathological principles, for the management of this dangerous disease. The importance of such reviews and interchange of opinions is recognized when it is remembered that eclampsia develops only in about one in every three hundred cases of labor, and that conse- quently the opportunity for large clinical observation comes but to the favored few. The one essential thing in the management of this disease is a correct knowledge of its aetiology. The following declaration, as enunciated by another, may be accepted as approaching correctness : First, that eclampsia " is a condition of toxaemia due to functional in- sufficiency of the kidneys ; second, that the convulsions are depend- ent upon an abnormally irritable condition of the central nervous system, produced by the hydraemia of pregnancy. While either may be the sole cause in some cases, yet we must recognize the presence of both, the one or the other predominating, in the vast majority of cases." Puerperal convulsions may occur during pregnancy, while labor is in progress, or after its completion. The cases developing after labor rarely supervene later than the second or third day, while those coming on before do so after the fourth month, their liability in- creasing with the advance of gestation. Their relative frequency has been pretty accurately determined. Of Shrbder's 316 cases, 62 oc- curred during pregnancy, 190 during labor, and 64 in the puerperium. Wieger reports 455 cases-109 during pregnancy, 236 during labor, * Read before the Tri-State Medical Society, at St. Louis, April 4, 1895. Copyright, 1895, by J. D. Emmet, M. D. 2 A. D. Price, M. D. no in the puerperium. The experience of other observers approxi- mates these statements. » The mortality has been estimated to be from thirty to forty per cent.; this, I am led to believe from the recent literature on the subject, has been greatly diminished, and will continue to grow less as the correct principles of treatment become more definitely defined. The convulsion may come without previous indications, but this is rare. It is generally preceded by premonitory symptoms, and these should always engage the physician's serious attention. For this, were there no other reason, the patient should be under medical supervision from the earliest months of pregnancy. To the accept- ance of this dictum the public should be educated; and those who do obstetrical work should, in season and out of season, avail themselves of every opportunity to make its great importance known. Here is a field where we may labor wisely and successfully, and by earnest, persistent effort, so instruct the laity that this class of patients will be saved much suffering and many dangers. Were it the rule to carefully examine these patients during the early months of pregnancy and keep them under strict supervision, there would be found the fewest number of cases without prodromic symptoms. The probability is that all would present, in some form or other, more or less indications of the impending danger. Careful observation would be very apt to detect some of the premonitory symptoms-as headache, excessive nervousness or marked irritability, impaired vision, disturbance of the sense of hearing, severe epigastric pain sudden in its appearance and of short duration, nausea and vomiting during the latter months of pregnancy, general oedema, diminished quantity of urine with a low specific gravity and with or without albumin or casts. The treatment of eclampsia resolves itself into preventive and curative. And the physician whose great and chief mission is to pre- vent disease and save life has here the opportunity to accomplish much and add many jewels to his crown of glory. The pregnant woman should be under constant supervision, that preventive treatment may be instituted on the first appearance of the premonitory symptoms. The urine, being an index to the activity of the treatment, should claim special attention. The authorities tell us that albumin occurs in twenty per cent, in the urine of pregnant women, and that these women are four times more liable to convulsions than an equal num- Puerperal Eclampsia. 3 ber without it. The urine should be frequently examined, and the amount passed in twenty-four hours ascertained once a week. The quantity and quality, specific gravity, amount of albumin and urea, character of epithelia and casts being known, the danger signal would rarely be unobserved and the patient put in a condition favorable for a safe confinement. However desperate the threatened condition may appear, hope should never be abandoned, as, by persistent and well directed efforts, the danger is often averted. By rest, quiet, and freedom from mental worry and physical overexertion; by diaphoresis, diuresis, and catharsis ; by the milk diet and the administration of the tinc- ture of chloride of iron in large doses ; by the knee-chest position as- sumed several times a day to take the pressure off the ureters and kidneys ; and by proper hygiene-the toxaemia is diminished, and the nervous system so stayed as to greatly lessen the liability to an eclamptic seizure. A case in point is that of a primipara the subject of chronic parenchymatous nephritis. Early in gestation she manifested head- ache, disturbance of vision, tinnitis aurium, marked and persistent nausea, anaemia, general cedema, renal insufficiency with a large amount of albumin and numerous renal epithelial and granular casts. The twenty-four hours' urine was frequently less than eight ounces ; yet, by the management above indicated, she went safely through her pregnancy and gave birth to a healthy child, and I was saved the necessity of producing premature labor, which I was ready, and ex- pected, to do at any moment. Such risks as were taken in this case are justifiable only in the primipara ; and it should be remembered that in assuming them the life of the patient is jeopardized. The induction of labor is often imperative. If convulsions are threatened in spite of the treatment already outlined, the welfare of the patient and of the child, if viable, demands its prompt accom- plishment. No time should be wasted in doubtful expedients; delay is fraught with the gravest dangers. When one convulsion occurs you may expect another, and another. The first one compromises the life of the patient and the foetus, and each succeeding seizure makes death more certain. The only ques- tion that can now be entertained is emptying the uterus at once with the forceps or by turning, the patient having been completely an- aesthetized and the cervix, if necessary, fully dilated. The curative treatment embraces many remedial agents, and much valuable time is often lost in flitting from one to another. Hence 4 A. D. Price, M. J). the necessity of always expecting an eclamptic seizure, and going to the bedside with well-defined and fixed rules of procedure. There are, doubtless, cases that require bloodletting to relieve vascular tension of the brain and congestion of the lungs, to subdue the laboring heart, and to remove urea from the system, but it has not been my fortune to observe them. Chloroform to ward off the attack and morphine hypodermatically in doses sufficient to subdue and control the nervous excitability, in conjunction with free catharsis and diaphoresis, are remedies that will be successful in the majority of cases. The most unpromising cases are sometimes saved, as exemplified by the following : A primipara, aged thirty years, whom I saw in con- sultation. During the four hours previous to my visit she had had eight convulsions, remaining unconscious from the first seizure. She had the ninth one soon after I entered the room, and the tenth in fifteen minutes. She was pale and anaemic, and there was present general oedema. The cervix was slightly dilated ; the head engaged ; the bladder empty. Chloroform was administered, the cervix rapidly dilated, and a living child delivered with the forceps. The eleventh convulsion occurred while the perinaeum was being repaired. The patient was ordered two grains of calomel on the tongue every hour till five doses were given. She had sulphate of morphine, one half grain hypodermatically, with instructions to repeat every two hours till convulsions ceased. During the next five hours she had five seizures, and three hypodermatic injections of sulphate of mor- phine, one half grain each. She remained unconscious the succeed- ing ten hours, at which time she awoke in a dazed condition, her bowels having acted copiously and her kidneys freely. She made a good recovery. In conclusion, I would impress upon all the necessity of having constant supervision of the patient from the earliest months of preg- nancy until the completion of the lying-in. To this end spare no pains to educate the public.