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The Treatment of Puerperal Eclampsia

A. B. Steele
1872 BMJ (Clinical Research Edition)  
August 3 , living, and well ; three who have held office in the dispensary since the year I867 are also well; and the present senior dispenser has been with us for ten years. Many others have been in this department since the opening of the hospital, but only one has been known to have been consumptive. The resident clinical assistants, of whom we are able to obtain reliable information, amount to seventy-eight in number. Three of these are said to be phthisical ; but only one has been known to
more » ... e has been known to have died of phthisis. This gentleman I knew intimately; he was always of consumptive appearance, and one of his sisters had died of phthisis. Our resident medical officer, Mr. Edwards, to whom I am indebted for the statistics I am now giving, has held office for more than twentyone years; and all those who know him can testify both to his continued health and his undiminished energy and usefulness. The present matron has also been in her office for more than twenty-one years, during which long period her health has been excellent. The present secretary has been at his post for fifteen years ; and his only predecessor, who is still alive and well, had held the same office for sixteen years. The assistant-secretary has been at his duties within the hospital for eighteen years; and a clerk-whose office it is to register the out-patients, and who must, on that account, be exposed to an unusually great extent to phthisical contagion, did such existhas been at his work for five years. I am happy to add that all of the above are now in excellent health. The present chaplain has been with us for twenty-two years ; and his two predecessors are still living. Happily all of them are well. Of the staff of physicians and assistant-physicians-nineteen in number-one only has been affected with phthisis; and he was a young man of delicate and decidedly consumptive aspect. The period of office which some of us have had is unusually long. Of the present physicians, two have been upon the staff twenty-four years each b one for seventeen years; one for thirteen years; one for nine years; and one for five years. The late senior physician, who resigned only three years ago, had been attached to the hospital, and in constant work there, from its very foundation. Two of the former physicians who resigned their appointments, and subsequently died of disease quite distinct from phthisis, had held office in the hospital for fifteen and nineteen years respectively. I have elsewhere given my experience of the statistics of pbthisis, in one of our chief metropolitan general hospitals ; and the subsequent observation which I have had only .tends to convince me the more that the evidence in this respect is greatly in favour of the Hospital for Consumption. ThIERE is no complication of labour which causes so much terror to bystanders, or demands greater calmness and self-possession on the part of the practitioner, or requires more prompt, decisive, and discriminating treatment, than an attack of convulsions; and yet there are few of the accidents of childbirth, the appropriate management of which is the subject of such diverse and conflictirig opinions. Until a comparatively recent period, there was almost an universal agreement as to the necessity of free general depletion in all the severe forms of this affection. Latterly, however, the necessity and even the propriety of the use of the lancet in this disease has been called in question. Chloroform, which undoubtedly has considerable control in many instances over the paroxysms, lhas been considered by some to be a specific remedy, -while others have advocated, in all cases of puerperal eclampsia, manual dilatation of the os uteri and speedy delivery; others, againi, have founid perforation of the membranes and the evacuation of the liquor amnii, wlhere that fluidl has been in excess, sufficient to diminish and ultimately to arrest entirely the convulsions. It is probable that these differences of opinion are to a great extent apparent only, and that theoretical disagreement as to principles would frequently finid a soluitioni in a much greater uniiformity in actual practice than might be supposed. To paraphrase ani expression of Dr. Billing, in his Pvri/csw51ps (fJf/ib't', "Because it is right for me to bleed my * Read in the Midwcifery Sectioni at the Anntial Mfeeting of the British MIedical Associationi at Birmingham, Aiugust I872. patient in convulsions, it does not follow that it would be right for you to bleed your patient in the same disease". In fact, this formidable affection is not to be managed according to any fixed or undeviating formula, but requires for its successful treatment a pure system of eclecticism. The rule laid down by a large number of high authorities, that copious blood-letting is the first and great remedy, the extent to which it is to be carried being regulated chiefly by the violence and frequency of the fits, is founded upon a twofold fallacy: first, an entire repudiation of widely differing types and phases which the disease assumes ; and secondly, a misapprehension of its true nature and of the effects of blood-letting upon it. Convulsions have been attributed to an overloaded state of the cerebral vessels, as in apoplex)y, to relieve which copious evacuation is necessary, when in truth, as was shown by Marshall Hall, eclampsia is a disease not of the brain at all, but of the true spinal system; and Trousseau and Niemeyer have also maintainecd that congestion of the brain in convulsions is an effect rather than a cause. The propriety and extent of blood-letting must be estimated not by the violence of the disease, but by the state of the circulation in the intervals of the paroxysms. In an overloaded condition of the vascular system, blood-letting acts as a direct sedative to the spinal cord; ir, the opposite condition, that of anxmia, or when carried too far, it only adds to the mischief, by increasing the already irritable condition of the spinal centres resulting from their anremic condition; the pathology of the remedy, as Dr. Tyler Smith has quaintly said, thus closely trenching upon its therapeutic effect. There is, however, one condition in which blood-letting acts directly through its influence on the cerebral vessels--namely, when serous or sanguineous effusion or overdistention of the brain itself causes counter-pressure on the medulla oblongata, and thus indirectly gives rise to convulsions by spinal irritation. There is yet a further most important effect of blood-letting not generally recognised-namely, its preservative influence in lessening the turgidity of the vessels of the head caused by recurring paroxysms, and which may lead to fatal cerebral congestion or effusion. Thus blood-letting in plethoric states of the circulation is curative in its action on the spinal marrow, preservative in its action upon the brain. There is a common belief that in the uroemic form of convulsions blood-letting is less effective, or altogether inadmissible : this I believe to be a mistake. Where the other indications for depletion are present, the fact that the blood is charged with a poisonous element is an additional reason in favour of lessening the amount of the circulating fluid, and thus at once eliminating an appreciable quantity of the deleterious matter. Dr. Richardson has recorded the beneficial effects of blood-letting in the convulsions which occur in albuminuria, which he explains on the ground just stated. The necessity for bleeding more copiously in this than in most other diseases, depends upon the special condition of the vascular system in the parturienit female. We know that loss of blood produces little or no effect upon the maternal pulse until it is carried beyond the point which exhauists the surplus blood, so to speak, required for the maintenance of the uterine and foetal circulation. Chloroform is unquestionably a valaable remedy in convulsions; but it is neither a specific, nor can it supersede the necessity for bloodletting in plethoric conditions of the system. Nor do I believe that it vill, as has been asserted, invariably lessen the violence or frequency of the paroxysms. These being truly reflex in their character, and the influence of chloroform over reflex action being limited, after free depletion, or in cases where depletion is contraindicated, it is most useful. Early and speedy delivery is undoubtedly the best treatment in certairn coniditions-namely, when, by the eliminative process of reasoning, we arrive at the conclusion that distension of the uterus or the presence of the ovum is the exciting cause of the fits ; but the view that it should be adopted as an universal rule is shown to be a fallacy by the following facts. Convulsions in some cases do not occur until after delivery; more often they persist and even increase in intensity after delivery. This practice has been recommended oni the ground that the urremic condition speedily proves fatal, first to the child and then tco the mother. But many cases are on record where convulsions exist when there is no evidence of urremia at all ; and again, even when convulsions have lasted for many hours, the case has terminated favourably both to mother and child. I believe that the (leath of the fetus, when it occurs, is in most instances to be attributed to asphyxia, froirm interruption of the placental circulation, from the violence anid frequency of the paroxysms, and not to urzemia. Against indiscriminate and hasty interference witlh the natural course of labour in convulsions there are strong grounds, both theoretical and practical. Any additional source of reflex irritation may frequently
doi:10.1136/bmj.2.609.240 fatcat:schxqdtcm5aezaqfoomy2zn2s4