Re-published from the Tr insactions of the Connecticut Medical Society, 1872. 
THE TREATMENT 
OF 
PUERPERAL CONVULSIONS. 
BY W. LOCKWOOD BRADLEY, M.D.y 
DEMONSTRATOR OF ANATOMY IN YALE COLLEGE. 
NEW HAVEN: 
TUTTLE, MOREHOUSE & TAYLOR, PRINTERS. 
1872. [From Proceedings of Connecticut Medical Society, May, 1872.] 
ARTICLE V. 
THE TREATMENT OF PUERPERAL CONVULSIONS. 
BY W. LOCKWOOD BRADLEY, M.D., OF NEW HAVEN. 
The occurrence of Puerperal Eclampsia is justly regarded as one 
of the most dangerous conditions to which the pregnant woman 
is liable; and in none does the practitioner more require the aid of 
settled principles of practice. No apology, therefore, seems 
necessary for a paper upon the treatment of Puerperal Con- 
vulsions. I am led to confine myself almost entirely to this 
department of the general subject, because the symptomatology 
of the disease is well known, and because our present knowl- 
edge regarding the etiology and pathology of the disease is vague 
and unsatisfactory. By the term puerperal convulsions is under- 
stood an affection especially characterized by a variable number of 
convulsive fits, and always accompanied by a complete suspension 
of intelligence. In order to show the kind of treatment which is 
most worthy of our confidence, it will be necessary to make slight 
references to the supposed causes and the pathology of the dis- 
ease ; also to direct attention to the opinions of various obstetric 
authorities and to statistics of results following particular methods 
of treatment. 
The treatment of puerperal convulsions may be divided into 
the preventive and the curative ; both must be founded on clinical 
facts and reduced to set rules for practice, but regulated by the 
peculiarities of each case. 
The premonitory signs which precede an invasion of the disease 
are similar to those observed in Bright's disease of the kidney. 
They have been described by Dr. J. Hall Davis, of London 
(Trans. Lond. Obstet. Soc., vol. xi, p. 270), in the following 
language: " Dropsical effusions, especially in the form of oedema of 
the face and upper extremities, associated with albuminuria and 
deficient urea in the urine, accompanied, in some instances, by the 2 
presence of cylindrical blood-clots, casts of the uriniferous tubes, 
with fatty epithelium." A knowledge of these signs is necessary 
to an early and successful adoption of preventive treatment; con- 
sequently, the urine of the pregnant woman should be examined 
chemically and microscopically, at least once in two weeks, during 
the last two months of pregnancy. This is especially important 
in primiparte, in those in whom there is oedema of the face, or in 
whose urine albumen has been present or suspected, in a previous 
labor or at any other time. 
Having detected the presence of these signs or of well-known 
premonitory symptoms, we must vary our treatment according to 
the constitution of the individual. Moderate exercise should be 
enjoined, but all mental excitement should be avoided. If the 
patient is strong and plethoric, we must seek to overcome any 
tendency to congestion of the nervous centres by giving an active 
saline carthartic, ordering an unstimulating diet, and, in rare 
cases, bleeding from the arm. If, on the contrary, the patient is 
anaemic and weak, a mild laxative and a nutritious diet should be 
ordered. In both sthenic and asthenic cases we are liable to have 
oedema and albuminuria. These conditions should be treated by 
cupping or counter-irritation over the renal region, and the pro- 
duction of free diaphoresis. In such cases, Prof. Wm. II. Byford, 
of Chicago (Treatise on Obstetrics, p. 444, 1870), considers the 
wine of colchicum an invaluable remedy, and advises its adminis- 
tration in as full doses as the patient can bear. 
With rare exceptions, albuminuria, as a sign of renal disease in 
cases of puerperal eclampsia, disappears entirely in a few days, 
or at least within a month after delivery; for this reason, Prof. 
Carl Braun, of Vienna, and others, advise the induction or 
acceleration of labor in cases where the life of the woman is placed 
in imminent danger by the increasing gravity of the albuminuria, 
and the extent of the dropsical swellings accompanied, it may be, 
by functional troubles of the heart and lungs. Dr. Geo. T. Elliot, 
in his Obstetric. Clinic, gives two cases in which this operation 
was performed at the seventh month of pregnancy. In both cases 
the urine was almost solidified by heat and nitric acid; one woman 
was universally dropsical, and the other was not; both were 
anaemic and very weak; both improved after the delivery of the 
child. In one case the child was still-born ; in the other, it died 
three weeks after delivery. As in all elective operations, imperil- 
ing the life of the mother and the child, a decision should only be 3 
made after deliberate consultation. In making such a decision, 
we shall be assisted by the same considerations which, further on, 
will be offered for and against the induction of labor, as a method 
of treating the actual occurrence of convulsions. The reality of 
the danger, and the success of the preventive treatment, has 
repeatedly been proved by the occurrence of cases in which the 
threatening symptoms, properly treated, disappeared, but after- 
ward, at the dnset of labor, reappeared and were followed by con- 
vulsions. 
The curative treatment of puerperal convulsions should be intro- 
duced by the adoption of certain precautionary measures; injury to 
the tongue should be prevented by interposing between the teeth 
a piece of soft pine wood, cork, or other suitable substance; the 
clothing should be loosened to prevent any obstacle to free cir- 
culation and respiration; the room should have a full supply of 
fresh air, and the movements of the patient should, as far as 
possible, be unrestrained. After these precautionary measures, 
we should adopt such of the following methods of treatment as 
may seem best adapted to each case. 
In order to remedy any possible irritation from the accumulation 
of excretions in the bowels, it is recommended that a powder of 
calomel and jalap should be administered; or, if the patient is 
unable to swallow, a drop or two of croton oil placed upon the 
tongue is preferable. To hasten the movement of the bowels, an 
enema, rendered purgative by an ounce and a half or two ounces 
of castor oil, may be given. If necessary, which it very rarely is, 
the bladder should be emptied by means of a catheter. Through 
fear of exciting a convulsive paroxysm, all unnecessary irritation 
of the skin or mucous passages should be avoided. For this reason, 
and because of their comparative inefficiency, the application of 
sinapisms to the feet, and of cold to the head, are rarely employed. 
Passing now to the consideration of methods of treatment which 
are more or less debatable, we find that nearly all obstetric 
authorities are agreed as to the value of bleeding when employed 
locally. M. Cazeaux would confine its employment to cases where 
the convulsions have followed a profuse hemorrhage. Some value it 
because it acts as a counter-irritant, and, also, because the quan- 
tity of blood can be accurately measured. 
Regarding the employment of general bleeding there is great 
diversity of opinion. We find the late Sir James Simpson, Dr. 
Barnes, Dr. Carl Braun and others expressing themselves unfav- 4 
orable to its employment; on the contrary, Drs. Churchill, 
Cazeaux, Pajot, Tyler Smith, J. Hall Davis and others are favora- 
ble to general bleeding. Dr. Davis says (Trans. Lond. Obstet. 
Soc., vol. xi, p. 277): "We must resort to it freely among robust 
plethoric subjects. Generally, one full bleeding will suffice; 
rarely, when required to be repeated, is more than a second 
smaller bleeding called for." The opinion thus stated, is, I think, 
the one more generally adopted by the profession in this country 
and Great Britain. It is believed that bleeding relieves the circu- 
lation, lessens secondary congestion and prevents injury to the 
nervous centres, especially to the brain and spinal cord. If it does 
not immediately arrest the paroxysm, it relieves cerebral conges- 
tion, and thus shortens the period of unconsciousness which ordi- 
narily follows the cessation of the convulsions. 
It should, however, be remembered that convulsions may arise 
from, or be accompanied by, an anaemic condition of the brain 
and spinal cord; in fact, Elliot claims (Obstetric Clinic, p. 76) 
that a majority of the severe cases of eclampsia occur in patients 
who are anaemic, and whose subsequent histories display tenden- 
cies to hydraemia. Prof. Kussmaul, of the University of Heidel- 
berg, and Dr. Tenner have investigated the nature and origin of 
epileptiform convulsions by numerous experiments upon the lower 
animals. While declaring (Publication New Sydenham Soc., Lon- 
don, 18f>9) that a strong flow of arterial blood into the head never 
produces, but rather arrests, the more frightful convulsions, they 
do not absolutely reject venesection ; on the contrary, they say 
that " cases but too frequently happen where a rapid abstraction 
of blood, especially from the external jugular vein, becomes im- 
perative, in order to relieve the brain from congestion of venous 
blood with which it is surcharged, to facilitate the access of arter- 
ial blood, and to arrest an attack of apoplexy." 
When, therefore, bleeding is absolutely indicated, we should 
guard ourselves against carrying it beyond what the case requires; 
at the same time remembering that, if blood-letting be timidly 
employed or too long delayed, the nervous centres may suffer 
serious injury. Of thirty-one cases reported by Dr. J. Hall Davis, 
eighteen were treated by blood letting with a result of only two 
deaths, and one of these was by apoplexy. When venesection is 
to be performed, the patient should be placed in a sitting posture 
and the blood should be allowed to flow in a full stream, until 
syncope is apprehended. If the patient is feeble, and the pulse 5 
weak and quick, we must place our reliance upon other remedies. 
Prof. T. Gaillard Thomas of New York, at one of his recent lec- 
tures, related a case, seen by him in consultation, where an attempt 
was made to diminish the flow of blood to the head by passing a 
bandage around the leg; the patient had previously been bled as 
much as seemed advisable. 
In the year 1848, Dr. Richet of France first employed chloro- 
form with success in the treatment of puerperal convulsions ; in 
the same year, Simpson of Edinburgh experimented with it, and, 
at the present time its utility, at least in a large proportion of 
cases, is well established. It has been claimed that the necessity 
for bleeding will be diminished in proportion to the frequency of 
the administration of chloroform at an early period of the attack. 
On the other- hand, the advocates for blood-letting, who employ 
chloroform as an adjuvant, argue that, in the majority of cases, 
the patient is not seen until several convulsions have occurred, 
and that frequently pulmonary congestion (indicated by lividity 
of face and quickened respiration) must be relieved by blood-let- 
ting before chloroform can be safely administered. The employ- 
ment of chloroform will be successful for the amelioration or pre- 
vention of the convulsive paroxysms in proportion as its inhalation 
is commenced at an early stage of the disease. Dr. Carl Braun 
(The Uraemic Convulsions of Pregnancy, Parturition and Child- 
bed) reports sixteen cases treated by chloroform, all of which 
recovered. This is a degree of success which is certainly unparal- 
leled, and the repetition of which can scarcely be expected ; for 
this reason, the recommendation made by him as to the manner of 
administering choroform is especially worthy of remembrance ; he 
says that, if chloroform be not administered in time to cut short a 
paroxysm, as much atmospheric air as possible should be allowed 
to enter the lungs during the convulsive attack and the coma 
immediately succeeding. Under such circumstances, the respira- 
tion and the circulation are very much impeded, and we can under- 
stand how the administration of an anaesthetic would be apt to in- 
crease the difficulty to a dangerous degree. As soon, however, as 
the respiration becomes easy, the inhalation of chloroform should 
be commenced and carried to the production of complete narcosis; 
nothing short of this will completely arrest the convulsive mani- 
festations. It is impossible to lay down any rule regarding the 
proper duration and intensity of the anaesthetic sleep. In severe 
cases, where the paroxysms tend to increase in force and frequency, 6 
it should be continued for three or four hours, then suspended for 
a time, only to be recommenced, if convulsions are threatened. 
By a judicious interruption in its employment, it can be continued 
for twenty-four hours or longer. In certain cases bleeding is inad- 
missible or insufficient, and chloroform faithfully administered 
either does not prevent the recurrence of the convulsions, or its 
use is counter-indicated on principles which govern its general 
employment. Dr. Elliot (op. cit.) reports a case in which he was 
obliged to suspend its use, because the breathing suddenly stopped 
and the pulse ran down in a most alarming way. In such cases 
other remedies have been employed as adjuvants or substitutes. 
During the past three years a few cases have been reported in 
the journals showing successful results from the employment of 
the hydrate of chloral. The bromide of potassium has been given 
in doses of a half to four drachms, both before and after delivery, 
and, in mild cases, with good results. The late Dr. N. B. Ives of 
New Haven was accustomed, in his treatment of convulsions after 
delivery, to rely upon the administration by enema of one drachm 
of tincture of stramonium ; and his practice has been endorsed by 
the experience of other practitioners in the same place. When 
the attack is somewhat subsiding, it has been recommended by 
the highest authorities to give an opiate. Dr. Collins of Dublin 
would restrict its employment to cases where the paroxysms con- 
tinue after delivery. Believing that opium increases cerebral con- 
gestion, Tyler Smith and Cazeaux, in common with the majority 
of French accoucheurs, are opposed to its employment, except in 
cases of anaemia or where a large amount of blood has been lost. 
When the administration of opium is indicated, it should be given 
in doses sufficient to produce a positive soporific effect. 
Sometimes the comatose condition of the patient, or the rapid 
succession of paroxysms, prevents the administration by the 
mouth of opium or other remedies. These obstacles to medica- 
tion are overcome by the hypodermic injection of a solution of 
morphia. Unlike opiutn, it does not produce cerebral conges- 
tion ; and, as in the case of one full bleeding, we gain an addi- 
tional advantage from the rapidity of its action. Since this 
method of treatment is comparatively new, and is not even men- 
tioned in the leading text-books, I will give several illustrative 
cases. 
In the year 1860, Prof. Scanzoni, of Wurtzburg, Germany, re- 
ported a case which he had successfully treated by this method : 
His patient, aged 21, a primipara, strong and robust, was seized 7 
with puerperal convulsions at the commencement of labor. Four at- 
tacks occurred in two hours and three-quarters; she was then bled 
to about eight ounces, an enema of twenty-five drops of laudanum 
was given, the body was put in a warm bath, while cold irrigation 
was applied to the head. As opium could not be administered by 
the mouth, a solution of the meconate of morphia was, at three 
different times, injected under the skin, the whole quantity given 
being equivalent to ten grains of opium. Two hours after she bad 
another attack and again one in six hours, after which there was 
no recurrence of the paroxysms for sixteen hours. Toward the 
end of this time she was delivered of a living child by means of 
the forceps; she then had a slight and short convulsion, after 
which they did not recur, and she made a good recovery. 
Dr. Bossi of Germany (Spitals Zeitung, 1862) reports four cases 
treated by this method at the Lying-in Hospital at Gratz, Austria; 
two died and two recovered. 
During the past year, three cases, in which this remedy was 
successfully employed, have been reported to the New Haven 
Medical Association. In the first case, the patient, aged twenty- 
two, a primipara, with feeble pulse, was delivered of a stillborn 
child at the seventh month of pregnancy; she was then taken 
with convulsions, which continued to recur with undiminished 
force and frequency until fourteen paroxysms had occurred, not- 
withstanding the administration of full doses of bromide of potas- 
sium, hydrate of chloral and chloroform by inhalation. Dr. F. L. 
Dibble then injected hypodermically about one sixth of a grain of 
morphia, after which the convulsions ceased ;* in the second case, 
the injection was made by Dr. S. G. Hubbard ; and in the third case 
by myself. To show what may be expected from this remedy, 
even in cases where all other treatment has failed, I will give a 
condensed statement of the last mentioned case. 
The patient was aged eighteen, married, a primipara, strong and 
robust, with slight oedema of the face and hands, and the urine al- 
buminous. Having arrived at the full term of pregnancy, she was 
seized in the night with vomiting, and, at about eight o'clock the 
next morning, I found her in a state of unconciousness. As she 
was unable to swallow, a purgative enema was ordered. Three 
hours after she had her first convulsion. The following methods 
of treatment were practiced in the order mentioned: Bromide of 
* One slight convulsion followed the injection, after which she went into a 
peaceful slumber, from which she did not awake for eight hours, and then made a 
good recovery. 8 
potassium in dose of a half drachm, chloroform by inhalation, 
bleeding from the arm about half a pint; a powder of calomel and 
jalap was with great difficulty administered by the mouth. At 
five o'clock in the afternoon, the treatment pursued was seen to be 
ineffectual, and the convulsions, then twelve in number, were in- 
creasing in force and frequency; it was therefore determined to 
hasten delivery. In the course of an hour, the os was sufficiently 
dilated to admit of the application of forceps, and a stillborn child 
was delivered. During the two hours occupied in manual dilata- 
tion, the delivery of the child and the after-birth, she was kept 
under the influence of chloroform, and there was no convulsion ; 
but, as soon as the womb was evacuated, she had two convulsions, 
one occurring soon after the other. During the following six 
hours she had six convulsions, making twenty in all, and this not- 
withstanding the administration of chloroform. She was then 
bled about a pint, and, as she then had two more convulsions, a 
sixth of a grain of sulphate of morphia in solution was injected 
hypodermically; she immediately became quiet, slept for three 
hours, had no more convulsions, and made a rapid recovery. 
Of the eight cases which I have collected as having been 
treated by the hypodermic injection of a solution of morphia, six 
resulted in recovery. In one of the cases the injection was made 
before and in three other cases after delivery. In the remaining 
four the time of injection was not stated. 
In two cases reported in the London Lancet (May 29, 1869, p. 
747) the convulsions came on after delivery, and were arrested 
almost instantaneously by an injection hypodermically of two 
minims of Fleming's tincture of aconite and one-third of a grain of 
acetate of morphia. In both cases the patient made a rapid recovery. 
As the result of clinical observation, some obstetric authori- 
ties claim that opium and other narcoties have an effect to 
retard labor; for this reason, those who believe that the condition 
of pregnancy is the first cause of the convulsions, and therefore, 
that its early termination is desirable, think that such remedies 
should not be employed until after delivery has been completed. 
When, notwithstanding the employment of the methods before 
spoken of, the convulsions continue and increase in violence, we 
are brought to consider what other treatment is necessary. 
The great majority of practitioners are, in a general way, favor- 
able to an evacuation of the uterus. They say that the principal 
cause of eclampsia is to be sought for in a general alteration of the 
economy, that this alteration is due to renal congestion, which, in 9 
turn, is caused by " the weight and pressure of the gravid uterus 
upon the kidneys and venous circulation, interfering with the 
free return of venous blood from that organ." In substantiation 
of this view, they claim that the convulsions usually occur in the 
latter part of pregnancy, when the weight and pressure is 
greatest; and more frequently in primiparse, with whom the pres- 
sure of the uterus is especially great on account of the unimpaired 
tonicity of the abdominal walls. To this theory it has been 
objected, that cases have occurred where the abdomen was 
largely distended by a fibrous tumor of the uterus, and yet no 
albuminuria has resulted. In reply, it may be said, that the 
growth, in the case supposed, is more gradual, and, therefore, that 
the tonicity of the abdominal walls is more readily overcome. 
That the evacuation of the uterus relieves renal congestion, is 
also inferred from a fact already stated, namely, that the albumi- 
nuria usually entirely disappears in a few days or at most a month 
after delivery. This belief is based not only on theoretical 
grounds, but also upon the results of clinical observation. Ac- 
cording to Prof. Carl Braun (op. cit.), the completion of labor 
causes an amelioration of the convulsions in thirty-one per cent, of 
the cases, their cessation in thirty-seven per cent., while in only 
thirty-two per cent, do they continue unchanged. It is claimed 
that the last mentioned percentage will be further reduced by the 
earlier adoption of measures to accelerate delivery. M. Cazeaux 
(Treatise on Midwifery, 1855, Am. edition, p. 746) says, "in no 
case in which eclampsia had existed a long time before we were 
called to the patient, have we found the termination of labor to 
put an end to the symptoms, and very rarely did it ever lessen 
their intensity." 
Allowing, then, that there is a presumption in favor of evacuat- 
ing the uterus, or, as M. Cazeaux expresses it-" in a general way, 
regarding the termination of labor as a favorable condition," we 
are led to consider the following questions. The cervix being 
dilated or dilatable, ought delivery to be accelerated? or, suppos- 
ing it to be neither dilated nor dilatable, what measures should be 
adopted ? 
In all cases of convulsions, even where we have no evidence 
that labor has commenced, a vaginal examination should be made, 
for cases have occurred where it was supposed the labor had not 
commenced, and yet the practitioner, on his first examination, has 
found the first stage of labor completed; or in still other cases, 
has discovered the child lying dead outside the vulva. 10 
Supposing that the cervix is dilated or dilatable, ought delivery 
to be accelerated? If the convulsive attacks are mild and are 
separated by long intervals, accompanied by a return of conscious- 
ness ; if the dilatation is complete and the head of the child has 
descended deeply into the excavation; if the uterus contracts 
powerfully and the perineum is yielding, it is proper to wait for a 
natural delivery. If, on the other hand, the same conditions are 
present, but the uterine contractions are weak and the convulsions 
are increasing in force and frequency, it is better that the delivery 
should be accelerated by means of the forceps. Should this be 
an impossibility, because of the smallness of the pelvis or the 
large size of the child's head, we may practice turning or even 
craniotomy. Breech presentations are to be advanced in the usual 
way by manual aid, followed by a prompt application of forceps. 
In all the operations just spoken of, and in those to be mentioned 
hereafter, chloroform should be employed. It is useful in relaxing 
the tissues and also as a remedy for the eclampsia. By its aid we 
are enabled to safely practice manual dilatation in cases where 
the cervix is yielding, but not fully dilated, and also with safety 
to adopt early instrumental interference. Dr. Cappie of Edin- 
burgh (Edinburgh Med. Jour., Oct., 1868) has published three cases 
illustrating the truthfulness of this statement. He says, "in not 
one of the cases was either the frequency or the severity of the 
paroxysms in the least affected by the attempts to dilate the os 
with the finger, or by the still more severe process of dragging 
the head against its inner surface, and, at the same time, pushing 
back its edges with some degree of force." Prof. Brickell, of the 
New Orleans School of Medicine, writing on this subject (New 
Orleans Journal of Medicine, Jan., 1868), says " I have performed 
manual dilatation again and again, and have never seen the least 
evil result." 
Again, supposing that the cervix is not dilated, and that we 
have tried manual dilatation without success, and that the con- 
vulsions continue, notwithstanding the remedial treatment, what 
further measures should be adopted ? Under the circumstances 
suggested, cases have occurred where the escape of the amniotic 
water has diminished the force and frequency of the convulsions; 
for this reason, M. Cazeaux, Tyler Smith, J. Hall Davis, and others, 
advise the rupture of the membranes in cases where it is believed 
the womb is abnormally distended; "otherwise," says Davis 
(Trans. Loud. Obstet. Soc., vol. xi, p. 280), rupture of the mem- 11 
branes should be avoided as a first measure, as being calculated 
to interfere with the easy progress of labor, and certainly to 
render turning more difficult, should it become necessary." If it 
is decided not to rupture the membranes, or if the escape of the 
water has not alleviated the convulsions, M. Cazeaux (Treatise on 
Midwifery, p. 746) would recommend a forced delivery, provided 
the uterine contractions are naturally present, or have been devel- 
oped prematurely or spontaneously, under the influence of the 
general convulsions ; but if the womb is inert, he is opposed to 
the operation on the ground " that the time required for the 
abortive (or premature) measures to act, and for the expulsion of 
the product of conception, exceeds by far the ordinary duration 
of eclampsia, and the woman would be either dead or cured before 
the influence could be felt." Since M. Cazeaux wrote, nearly 
seventeen years have elapsed, and the objection which he offered 
has lost nearly all its weight, for, by means of Barnes' dilator, we 
are allowed to anticipate a very rapid dilatation of the cervix 
within a few hours. Dr. Robert Barnes, of London, after whom 
the dilator was named, says (Lectures on Obstetric Operations, 
Lond., 1871, p. 373): "By its (the dilator's) aid it is very possible, 
in many cases, to expand the cervix sufficiently to admit of 
delivery within an hour, although generally it is necessary to 
expend more time. I have completed delivery in five hours, in 
four hours, and even in one hour from the commencement of any 
proceeding. In many cases of placenta praevia, when there was 
scarcely any cervical dilatation, I have effected full dilatation in 
half an hour." Dr. J. Hall Davis (Trans. Lond. Obstet. Soc., 
vol. xi, p. 280), writing fourteen years later than Cazeaux, ex- 
presses the opinion that, under the circumstances now being con- 
sidered, parturition should be induced and furthered by means of 
Barnes' dilator; and he gives a case in which, by this method, 
he induced labor at the sixth and a half months of pregnancy. In 
the course of twelve hours the labor was completed, and the 
patient quickly recovered her former state of health. Dr. Geo. T. 
Elliot, of New York, writing a year earlier than Davis, says in his 
Obstetric Clinic (p. 39) that " when the foetus is not viable, we 
must wait until the mother's life is actually endangered by suc- 
cessive attacks of eclampsia." In the same book, but entirely dis- 
connected with the opinion just quoted, he has published two 
cases in which labor was induced between the sixth and seventh 
months of pregnancy. In neither case did the patient recover. 12 
Scattered through the same publication, I have found ten othei- 
cases, in which labor was induced between the seventh month and 
the full term of pregnancy. In thirty-three per cent, of these 
cases the patient recovered. If the Barnes' dilator, which was 
used in only four out of ten instances, had been employed in a 
larger proportion of the cases, the result would probably have been 
more favorable. Taking the percentage of successful cases as it 
stands, I think it justifies the induction of labor as a last resort in 
cases where the life of the woman is greatly imperilled by the 
occurrence of puerperal eclampsia. It is true that Prof. Hodge, 
of Philadelphia (The Principles and Practice of Obstetrics, Phil., 
1864), informs us that he " has had many cases where the mother has 
been preserved and the infant born alive some days or months 
after severe and continued convulsions; " but it is equally true 
that many women have died undelivered. If a fatal termination 
has followed procrastination in inducing labor, it has also resulted 
from over haste or want of precaution in the mode of proceeding. 
In a word, there is no common rule; but we must be guided in 
each case by a careful consideration of the circumstances. If 
labor is to be induced, Dr. Barnes advises that it be done slowly 
and deliberately, and by a method involving the least manual or 
other operative interference. Such a mode of procedure is de- 
scribed by him (op. cit.) in the following language : " It is better 
to puncture the membranes. This at once lessens the bulk of the 
uterus, and diminishes the pressure upon the abdominal vessels. 
If the convulsions remit, we may leave the labor to nature. If 
urgent symptoms persist, we may dilate the cervix carefully by 
the cervical dilators." 
The evacuation of the uterus may be accelerated by forceps, by 
turning, or even by craniotomy. Elliot (op. cit., p. 55) gives a 
case in which the os was so rigid that he was unable to dilate it 
by means of Barnes' dilator and the warm douche further than to 
admit the points of three fingers, and was obliged to perform 
craniotomy; the patient recovered. In a second case (op. cit., 
p. 125) the child was dead, and he performed the operation to 
give a slight chance of life to the mother. Dr. Churchill, of 
Dublin (Theory and Practice of Midwifery, Lond., 1860, p. 505), 
reported a case in which he felt that the patient would probably 
die before the completion of labor naturally, and he therefore per- 
forated and extracted the child, and the patient recovered, after 
an insensibility lasting nearly three days. Prof. Hodge (op. cit., 
p. 448) believes that perforation should be " restricted to cases of 13 
deformity of the pelvis, or of the child, and, perhaps, to a few 
instances where the child is dead." 
Incision of the cervix may be required in certain cases where 
there is rigidity from alteration of the tissue, as oedema, hyper- 
trophy, and cicatrix. M. Cazeaux would limit their employment 
to cases where the internal orifice and upper part of the cervix 
have been dilated either by the progress of gestation or prema- 
ture contraction. 
After delivery, the accoucheur should take special pains to 
assure himself that the womb is well contracted, and that it con- 
tains no coagula, or portions of the membrane or placenta. 
Finally, in anticipation of returning consciousness, the room 
should be darkened, and perfect rest should be enjoined. This is 
especially important, because the cessation of the convulsions is 
peculiarly liable to be followed by mania, pulmonary congestion, 
and various forms of pelvic and abdominal inflammation. 
It will, perhaps, be noticed that in the course of my paper I 
have not referred to the child, and for this reason: Knowing that 
half the children born during or after puerperal convulsions are 
dead, I believe that there will be a better chance for the life of 
the child the sooner it is removed from the influence of uraemic 
poisoning, or the convulsive action of the uterus; but I am also of 
the opinion that, when the life of the mother is in such imminent 
danger, considerations for the child should not be allowed to 
influence our treatment. 
In concluding this paper, I would say that I have endeavored 
to give a comprehensive statement of the treatment which, at the 
present time, experience has proved most efficient in puerperal 
convulsions. When narcotics were the best remedies in the 
possession of the practitioner, the mortality was at least fifty per 
cent. Since the introduction of free bleeding, chloroform, and 
other remedies, the mortality has gradually diminished, and in 
1863 was estimated by Prof. Hodge (op. cit.) to be twenty-five 
per cent. In the year 1870, Dr. J. Hall Davis, of London 
(op. cit.), published thirty-five cases of puerperal eclampsia, which 
showed a mortality of only one in eleven. What we need at the 
present time is not so much the introduction of new remedies as 
a better understanding of the principles which should govern us 
in the proper employment of those now in our possession. When 
these principles are more fully elucidated and judiciously carried 
out, we may hope for even more favorable results both for the 
mother and the child.