anæmia is one of the actual conditions of the nerve-centres- -a fact of much practical importance in reference to treatment. Treatment. The management of cases in which the occurrence of suspicious symptoms has led to the detection of albuminuria has already been fully discussed (p. 215). We shall therefore, here, only consider the treatment of cases in which convulsions have actually occurred. Until quite recently venesection was regarded as the sheet-anchor in the treatment, and blood was always removed copiously, and, there is sufficient reason to believe, with occasional remarkable benefit. Many cases are recorded in which a patient, in apparently profound coma, rapidly regained her consciousness when blood was extracted in sufficient quantity. The improvement, however, was often transient, the convulsions subsequently recurring with increased vigor. There are good theoretical grounds for believing that bloodletting can only be of merely temporary use, and may even increase the tendency to convulsion. These are so well put by Schroeder, that I cannot do better than quote his observations on this point: "If," he says, "the theory of Traube and Rosenstein be correct, a sudden depletion of the vascular system, by which the pressure is diminished, must stop the attacks. From experience it is known that after venesection the quantity of blood soon becomes the same through the serum taken from all the tissues, while the quality is greatly deteriorated by the abstraction of blood. A short time after venesection we shall expect to find the former blood-pressure in the arterial system, but the blood far more watery than previously. From this theoretical consideration, it follows that abstraction of blood, if the above-mentioned conditions really cause convulsions, must be attended by an immediate favorable result, and, under certain circumstances, the whole disease may surely be cut short by it. But, if all other conditions remain the same, the blood-pressure will after some time again reach its former height. The quality of blood has in the meantime been greatly deteriorated, and consequently the danger of the disease will be increased." These views sufficiently well explain the varying opinions held with regard to this remedy, and enable us to understand why, while the effects of venesection have been so lauded by certain authors, the mortality has admittedly been much lessened since its indiscriminate use has been abandoned. It does not follow because a remedy, when carried to excess, is apt to be hurtful that it should be discarded altogether; and I have no doubt that in properly selected cases and judiciously employed, venesection is a valuable aid in the treatment of eclampsia, and that it is specially likely to be useful in mitigating the first violence of the attack and in giving time for other remedies to come into action. Care should, however, be taken to select the cases properly, and it will be specially indicated when there is marked evidence of great cerebral congestion and vascular tension, such as a livid face, a full bounding pulse, and strong pulsation in the carotids.. The general constitution of the patient may also serve as a guide in determining its use, and we shall be the more disposed to resort to it if the patient be a strong and healthy woman; while on the other hand, if she be feeble and weak, we may wisely discard it and trust entirely to other means. In any case it must be looked upon as a temporary expedient only, useful in warding off immediate danger to the cerebral tissues, but never as the main agent in treatment. Nor can it be permissible to bleed in the heroic manner frequently recommended. A single bleeding, the amount regulated by the effect produced, is all that is ever likely to be of service. As a temporary expedient, having the same object in view, compression of the carotids during the paroxysms is worthy of trial. This was proposed by Trousseau in the eclampsia of infants, and in the single case of eclampsia in which I have tried it, it seemed decidedly beneficial. It is simple, and it offers the advantage of not leading to any permanent deterioration of the blood, as in venesection. As a subsidiary means of diminishing vascular tension the administration of a strong purgative is desirable, and has the further effect of removing any irritant matter that may be lodged in the intestinal tract. If the patient be conscious, a full dose of the compound jalap powder may be given, or a few grains of calomel combined with jalap; if comatose and unable to swallow, a drop of croton oil or a quarter of a grain of elaterium may be placed on the back of the tongue. The great indication in the management of eclampsia is the controlling of convulsive action by means of sedatives. Foremost amongst them must be placed the inhalation of chloroform, a remedy which is frequently remarkably useful, and which has the advantage of being applicable at all stages of the disease, and whether the patient be comatose or not. Theoretical objections have been raised against its employment, as being likely to increase cerebral congestion of this there is no satisfactory proof; on the contrary there is reason to think that chloroform inhalation has rather the effect of lessening arterial tension, while it certainly controls the violent muscular action by which the hyperæmia is so much increased. Practically no one who has used it can doubt its great value in diminishing the force and frequency of the convulsive paroxysms. Statistically its usefulness is shown by Charpentier in his thesis on the effects of various methods of treatment in eclampsia, since out of sixty-three cases in which it was used, in forty-eight it had the effect of diminishing or arresting the attacks, one only proving fatal. The mode of administration has varied. Some have given it almost continuously, keeping the patient in a more or less profound state of anaesthesia. Others have contented themselves with carefully watching the patient, and exhibiting the chloroform as soon as there were any indications of a recurring paroxysm, with the view of controlling its intensity. The latter is the plan I have myself adopted, and of the value of which in most cases I have no doubt. Every now and again cases will occur in which chloroform inhalation is insufficient to control the paroxysm, or in which, from the very cyanosed state of the patient, its administration seems contra-indicated. Moreover, it is advisable to have, if possible, some remedy more continuous in its action and requiring less constant personal supervision. Latterly the internal administra tion of chloral has been recommended for this purpose. My own experience is decidedly in its favor, and I have used, with, as I believe, marked advantage, a combination of chloral with bromide of potassium, in the proportion of twenty grains of the former to half a drachm of the latter, repeated at intervals of from four to six hours. If the patient be unable to swallow, the chloral may be given in an enema or hypodermically, six grains being diluted in 5j of water, and injected under the skin. The remarkable influence of bromide of potassium in controlling the eclampsia of infants would seem to be an indication for its use in puerperal cases. Fordyce Barker was opposed to the use of chloral, which he thought excited instead of lessening reflex irritability. Another remedy, not entirely free from theoretical objections, but strongly recommended, is the subcutaneous injection of morphia, which has the advantage of being applicable when the patient is quite unable to swallow. It may be given in doses of one-third of a grain, repeated in a few hours, so as to keep the patient well under its influence. It is to be remembered that the object is to control muscular action, so as to prevent as much as possible the violent convulsive paroxysm, and, therefore, it is necessary that the narcosis, however produced, should be continuous. It is rational, therefore, to combine the intermittent action of chloroform with the more continuous action of other remedies, so that the former should supplement the latter when insufficient. Inhalation of the nitrite of amyl has been recommended on physiological grounds as likely to be useful, and is well worthy of trial; but of its action I have, as yet, no personal experience. Several very successful cases of treatment by the inhalation of oxygen have been recorded by Schmidt, of St. Petersburg. Pilocarpine has recently been tried, in the hope that the diaphoresis and salivation it produces might diminish arterial tension and free the blood of toxic matters. Braun administered three centigrammes of the muriate of pilocarpine hypodermically, and reports favorably of the result; Fordyce Barker,* however, was of opinion that it produced so much depression as to be dangerous. 3 Other remedies, supposed to act in the way of antidotes to uræmic poisoning, have been advised, such as acetic or benzoic acid, but they are far too uncertain to have any reliance placed on them, and they distract attention from more useful measures. Precautions during the Paroxysm.-Precautions are necessary during the fits to prevent the patient injuring herself, especially to obviate laceration of the tongue; the latter can be best done by placing something between the teeth as the paroxysm comes on, such as the handle of a teaspoon enveloped in several folds of flannel. Obstetric Management.-The obstetric management of eclampsia will naturally give rise to much anxiety, and on this point there has been considerable difference of opinion. On the one hand, we have practitioners who advise the immediate emptying of the uterus, even when labor has commenced; on the other, those who would leave the labor entirely alone. Thus Gooch said: "Attend to the convulsions, 1 The Puerperal Diseases, p. 120. 2 London Med. Record, 1886, vol. xiv. p. 75. a Berl. klin. Wochenschr., June 16, 1879. (Extr. from Russkaia Meditz., 1885, No. 32, p. 595.) 4 New York Med. Record, March 1, 1879. and leave the labor to take care of itself;" and Schroeder said: "Especially no kind of obstetric manipulation is required for the safety of the mother," but he admitted that it is sometimes advisable to hasten the labor to insure the safety of the child. In cases in which the convulsions come on during labor, the pains are often strong and regular, the labor progresses satisfactorily, and no interference is needful. In others we cannot but feel that emptying the uterus would be decidedly beneficial. We have to reflect, however, that any active interference might, of itself, prove very irritating and excite fresh attacks. The influence of uterine irritation is apparent by the frequency with which the paroxysms recur with the pains. If, therefore, the os be undilated and labor have not begun, no active means to induce it should be adopted, although the membranes may be ruptured with advantage, since that procedure produces no irritation. Forcible dilatation of the os, and especially turning, are strongly contra-indicated. The rule laid down by Tyler Smith seems that which is most advisable to follow--that we should adopt the course which seems least likely to prove a source of irritation to the mother. Thus, if the fits seem evidently induced and kept up by the pressure of the foetus, and the head be within reach, the forceps may be resorted to. But if, on the other hand, there be reason to think that the operation necessary to complete delivery is likely per se to prove a greater source of irritation than leaving the case to Nature, then we should not interfere. [If called to a case of convulsions followed by coma in a primipara near term, but not in labor, draw off a little urine and examine it, as the patient may be far advanced in Bright's disease and the coma purely uræmic. In such a case little can be gained by bringing on labor and delivering the foetus. Eclampsia is sometimes purely reflex, and not at all dangerous, although it may be alarming. The convulsive movements may arise from nerve-disturbance due to the foetal head distending the cervix in the last stage of dilatation in primipare. When the head begins to distend the perineum the convulsive seizure often ceases. Such patients are safer without the forceps.-ED.] CHAPTER IV. PUERPERAL INSANITY. Classification.-Under the head of "Puerperal Mania," writers on obstetrics have indiscriminately classed all cases of mental disease connected with pregnancy and parturition. The result has been unfortunate, for the distinction between the various types of mental disorder has, in consequence, been very generally lost sight of. But little study of the subject suffices to show that the term puerperal mania is wrong in more ways than one, for we find that a large number of cases are not cases of “mania" at all, but of melancholia; while a considerable number are not, strictly speaking, "puerperal," as they either come on during pregnancy, or long after the immediate risks of the puerperal period are over, being in the latter case associated with anæmia produced by over-lactation. For the sake of brevity the generic term, puerperal insanity," may be employed to cover all cases of mentaĺ disorders connected with gestation, which may be further conveniently subdivided into three classes, each having its special characteristics, viz.: 66 I. The insanity of pregnancy. II. Puerperal insanity, properly so called; that is, insanity coming on within a limited period after delivery. III. The insanity of lactation. This division is a strictly natural one, and includes all the cases likely to come under observation. The relative proportion these classes bear to each other can only be determined by accurate statistical observations on a large scale, but these materials we do not possess. The returns from large asylums are obviously open to objection, for only the worst and most confirmed cases find their way into these institutions, while by far the greater proportion, both before and after labor, are treated in their own homes. Proportion of these forms of insanity. Taking such returns as only approximate, we find from Dr. Batty Tuke' that in the Edinburgh Asylum, out of 155 cases of puerperal insanity, 28 occurred before delivery, 73 during the puerperal period, and 54 during lactation. The relative proportions of each per hundred are as follows: Insanity of pregnancy Insanity of lactation. 18.06 per cent. 34.83 66 Marcé collects together several series of cases from various authorities, amounting to 310 in all, and the results are not very different from those of the Edinburgh Asylum, except in the relatively smaller number of cases occurring before delivery. The percentage is calculated from his figures : Insanity of pregnancy Insanity of lactation. 8.06 per cent. 58.06 66 30.30 64 As each of these classes differs in various important respects from the others, it will be better to consider each separately. The Insanity of Pregnancy is, without doubt, the least common of the three forms. The intense mental depression which in many women accompanies pregnancy, and causes the patient to take a despondent view of her condition, and to look forward to the result of her labor with the most gloomy apprehension, seems to be often 1 Edin. Med. Journ., vol. x. 2 Traité de la Folie des Femmes enceintes. |