Eclampsia Again.

To the Editor of THE WORLD:-I reported a case of eclampsia in THE WORLD for December, and now have another case to submit: This was an emergency case, which came to me in consequence of a friend's inability to leave another patient to attend. Aurore F., primipara, aged 27; seven months pregnant; had been in care of Dr. Couillard for persistent albuminuria. April 18 she was attackt and had two convulsions an hour apart, passing from a comatose condition into the second convulsion. I reached her bedside when the second attack had lasted half an hour. The treatment was 20 minims of Norwood's tincture subcutaneously, followed by alcoholic stimulation-a little-and strychnin for a slight intermitting in the pulse while still somewhat convulsed. After the administration of the veratrum at 4.30 the pulse fell from 120 to 96 at 4.45, 84 at 4.55, 72 at 5.10. Hot applications to the extremities and over the renal region seemed to aid the quieting effect of the veratrum and overcome the nausea. For lack of a more activ cathartic I placed 10 grains of calomel on the tongue. Coma continued. Little calomel was retained. The respiration fell into CheyneStokes rhythm. I gave a high enema of half an ounce of saleratus in half a pint of water. Breathing returned to the normal rhythm. Retching continued, altho consciousness had returned by eight o'clock sufficiently so that she askt for water. She fell into troubled sleep with muttering delirium. The pulse was hard, full and bounding. I bled her a little, so little that I thought it would have no effect, but as the delirium stopt and the pulse became more normal I stopt the bleeding after only a few ounces had flowed. At 10.30 consciousness returned and the patient recognized her aunt. I began to think I could go home. She was sleeping quietly and naturally, when the third and last convulsion came. This time I was able to observe the entire sequence of phenomena. There was first an epileptiform convulsion with frothing at the mouth and tongue biting and involuntary evacuations; second, relaxation, all but the neck, which was retracted and rigid. Then came a period of mania as at first. I was told that the seizure was less violent than the first two. Pulse did not rise above 72. I gave veratrum 10 minims subcutaneously in the first interval of quiet. The maniacal stage was followed by coma and stertorous breathing, during which I gave another high enema of nearly a quart of water containing a tablespoonful of saleratus. There followed a period of retching till the enema produced a discharge from the bowels. Consciousness had not returned. I gave a quarter grain of morphin subcutaneously and she slept from about 1.30 till 4 a. m., when she askt for water; slept again, and at six counted the stroke of the clock aloud. She

passed about an ounce of highly albuminous urin and two hours later I felt safe to go home for a time. Labor had not begun, but nine days later she was delivered of a macerated fetus. At this writing, eight weeks after the eclamptic attack, she is still in bed and under the care of my colleague, to whom she returned. The first urinary sediments contained no casts. After a week they appeared, "a few hyalin and finely granular casts and some cylindroids of albumin," all of small diameter, not easily detected by the low power, and almost all of short lengths as if broken."

There is no obstetric emergency which will more thoroly test the attendant's resources than a case of eclampsia. That is my experience. Reading up afterward to get additional help one is confused. One finds he has several methods to choose from. There is Veit's method, morphin subcutaneously onehalf grain, repeated after every convulsion. Then there are those who rely on veratrum or chloral, and others who say induce labor at once, and against each one of these classes of practicians is a group whose members say "don't" for each and every method of procedure. Here in the last (May) number of Dr. Sajous' Cyclopedia is a report from the Rotunda Hospital describing their success with Veit's morphin method, reducing their mortality from 35.3 percent to 16.9 percent; and almost the same day comes the New York Medical Journal (June 2) containing an article by Dr. Randle, of Germantown. says: "When eclampsia is present the uterus should be emptied as rapidly as possible. . . . Veratrum viride I employ most cautiously. Morphin I do not use." The Rotunda people never induce labor, and use forceps only in exceptional cases. gets your eclampsia, and you takes your choice.

He

You

But there is one feature in which all methods of the present day seem to agree, and that is the securing of elimination by every possible channel. The opponents of morphin object because it "locks up the secretions." The men who do not operate object to the elimination of the fetus because producing labor adds a source of irritation to a too irritable nervous system without aiding in the elimination of the poison which causes the convulsion. But they all agree in saying, set the skin and bowels to work discharging waste matter.

When a physician finds himself by the bedside of an eclamptic patient he ought to make up his mind to stay right there till the patient is out of danger or dead. Then he may choose his method of treatment according to his armamentarium. Veratrum may or may not be at hand. I believe in using it in a 20-minim dose at once. If I were caught without this medicin I would use morphin, one-half grain. Everything will have to be

given subcutaneously. I would push morphin to the limit of safety. The fear of locking up the secretions would not hinder me, for with a syringe and saleratus it is possible to make the bowels act vigorously in spite of morphin. I believe that an alkali is indicated in this condition. I think it aids in neutralizing the poisons in the circulation. Heat should be applied to induce the skin to act. My favorit vehicle for administering heat is a stove cover right off the stove, well wrapt in newspapers or anything else that is handy. The stove cover is always hot if anything in the house is, so you need not wait for some one to set a flatiron on the stove or bring some water from the well and heat it. Moreover, it is flat and fits the small of the back pretty well, right where the books tell you to apply a poultice so as to relieve the renal congestion. If you get careless and the patient lives to have a blister over the loins, you can comfort yourself that even that is sometimes advocated. But I would rather not have to explain again to the patient how much she was benefited by such a blister. (See THE WORLD for December last.) When you can, you should wash out the stomach. I have no doubt that the distressing retching which appeared in the case here reported was a part of Nature's effort to eliminate. I had no stomach tube to assist..

I would administer croton oil in drop doses in glycerin or oil or on sugar if I had it with me and the patient could swallow. Elaterin will purge if given subcutaneously, and so will Epsom salts. I have never used these remedies in this way. Hypodermoclysis is called for in these cases, and you can add the purgativ to the fluid you inject.

A good, clear-headed, brotherly physician in consultation is one of the best remedies for nervousness in the attending physician, and two are better than one when it comes to standing guard for 10 or 12 hours; they can relieve each other.

Prophylaxis is more important than treatment during the attack. The key to this is elimination again. The urin ought to be examined. The specific gravity affords a most important danger signal. I would fear eclampsia even without albuminuria if the specific gravity were low and the quantity of urin not increast in inverse proportion. There have been cases of eclampsia where there was no albuminuria, and cases of normal labor in women with pronounced renal lesions-albuminuria and casts but with a sufficient quantity of urin excreted to carry off the poisons.

Rest in bed till the danger symptoms have passed away is an important remedial agent, and should be faithfully applied along with cathartics and sudorifics. With all care and medicin, some cases will go from bad to worse. The interests of mother and fetus may become incompatible. If the case goes to full

term both may die, and the child is pretty certain to perish. If, then, the outbreak of convulsions can be held off until the child is viable, the induction of labor does not add materially to the child's peril, and may save the mother. In the case I have just reported, Dr. Couillard talkt with me about this procedure on the morning of the day on which the convulsions began. I thought better to wait a little to give the baby a better chance. Before midnight the baby's chance was gone, tho there were but three convulsions.

A case of threatening eclampsia occurred in my practise four years ago, of which I have these notes: "Jan. 16, 1902. Mrs. Florinda C. (Canadian-French), age 21. Primipara. Cta. June 7th she thinks less than usual. Expects confinement Feb. or March. Now suffering from asthma. Relieved by apomorphin gr. hourly yesterday and free catharsis. Urin 1010, pale; albumin; edema. Heart: : exaggerated second sound over aortic and pulmonary valves; first sound faint; no lesion evident on auscultation. Anemic. Fetus presents vertex. Uterin tumor extends half way to ensiform (from navel). Jan. 23d the relief obtained was temporary. In spite of free use of salines and large draughts of water the asthma returned on the 25th. Relief was obtained by further use of apomorphin, followed by chloral and by apocynum. Sweating was induced quite easily, and altho the urin had been nearly suppressed for 10 or 12 hours (20th), the danger of convulsion was warded off except for a slight twitching of the head like a spasmodic torticollis on the night of the 20th. This lasted only a few minutes and appeared only once to my observation. Chloral seemed the agent which controled the spasm. The 21st was a time of relief, but at midnight labor came on, terminating in the delivery of a living 7 months (?) fetus at 6 a.m. (Jan. 22d). The child was taken to church contrary to directions, but otherwise discreetly handled. It died before night. Mother's temperature at evening visit was 102°. This morning pulse 130, temperature 101.5°. Respiration greatly quickened, short cough, pleuritic pain, and increast resonance on right side," etc.

My patient passed thru a severe bronchitis or abortiv pneumonia. I have since attended her in an unquestionable pneumonia and delivered her of two children, the latest last February. There were no complications either time. I thought and still think the jerking of the head above mentioned was an abortiv eclampsia. I just happened to see it and jumped from my seat in alarm. Then they told me it had twitched like that once or twice before and she couldn't help it, and in fact did not know about it. There was just a momentary cessation of consciousness, and then a dazed condition.

I think the child's life was destroyed by being taken to church to christen. She lived

East Douglass, Mass.

PAUL F. ELA, M.D.

Obstetric Charges in Multiple Births. Editor MEDICAL WORLD:-In regard to the case mentioned in July WORLD, page 252, the decision of the court was very just and equitable. Doubtless a good judge. Now let the doctor in future say this: If your lady gives birth to one babe only, $18; twins, $27 ; triplets, $36; quadruplets, $45, and so on ad infinitum. The doctor was simply caught by not being sufficiently explicit in his contract, and the court was right.

Bowling Green, Fla.

W. S. HART, M.D.

Superstitious Remedy for Afterpains. Editor MEDICAL WORLD:-In your July WORLD, page 261, is a report from Dr. H. A. Saults on an obstetric superstition which called to my mind a similar case I had some years ago. Confined my patient with but little or no trouble. As it was her third child, told her I would send something for afterpains. She informed me it would not be necessary, as she removed that trouble with her first child. I wanted to know how she did it. You can imagin my surprise and disgust when she informed me it was a teaspoonful of placental blood on birth of her first child. Told her any one who was so simple ought to suffer. I never had a more stubborn case, before or since.

Confined her several times afterwards, and always told her to try her first remedy, but she decided I had a better and more cleanly W. J. STEVENSON, M.D.

one.

Lauderdale, Miss.

A Monstrosity.

Editor MEDICAL WORLD:-In February WORLD, page 62, Dr. I. N. Woodman gives a case of closed stomach and absent bladder in infant. I believe I can beat him. A great many peculiar things have come my way since my first day's practise; but here is one that breaks the record: February 1st I was called three miles distant in the country to attend Mrs. W. in confinement. I had no engagement in the case until called. When I arrived the husband met me at the door and exclaimed, "The baby has been born fifteen minutes and is dead." In haste I cleansed my hands and proceeded to examin; found fetus, placenta and membranes all in a mass; no hemorrhage; uterus contracted nicely; mother resting easy. Examination revealed umbilical cord two inches in length. First feature noticed was cleft palate; second, fetus had only one leg and foot. This leg seemed to originate at the left coxo-femoral articulation, running posteriorly across to the

66

ing the buttocks. On the under border was an anus, and by the side of it a rudimentary vulva. This first thigh, as I call it, terminated on the right side into a femorofemoral" joint. From this joint originated a natural thigh and leg, with foot, talipes varus. About two-thirds of the anterior abdominal wall was made up of a thick membrane seeming to originate from the skin. Just to the left of the ensiform appendix, protruding thru a round opening, was the heart, standing erect outwards and upwards, about threequarters of its entire bulk external to the chest wall, envelopt in its thin pericardium. Thru an oval opening just below its normal position the liver seemed to have escaped, and occupied a position external to the abdominal wall; the umbilical cord was attacht to its under border, the remainder of the vessels entering the abdominal cavity thru this oval opening. Just below anus to the left of the liver externally was a mass resembling placental tissue in texture, its under surface being attacht to the membranous abdominal wall. On this mass were carved very visible rudimentary intestins, showing the entire colon and intestins; no stomach visible. The chest, head, arms and hands were well developt and natural.

This was a premature labor at about seven months. The timidity and suspicious sentiment of the mother prevented my preserving the fetus. However, it was inspected by several parties present. Now as to the cause of this, it is too deep for me. She is 40; this was her seventh labor; has been in very delicate health for one year; has great resolution; complains very little, notwithstanding her bad health. About six months ago I treated her for what I diagnosed bilious colic. However, I was never satisfied as to the correctness of the diagnosis. She suffered `untold agonies for six or eight hours, having intense soreness in the right abdominal muscles and chest muscles. During her suffering she said those cramping pains seemed to originate in the liver and radiate to the heart and left shoulder, exclaiming, "It seems like my heart, stomach and bowels are being dragged out." Could it have been caused by this mental impression? Or could it be owing to this short cord, those organs being pulled out as growth advanced? Or should I be excused for my ignorance? Whitefield, I. T.

J. CULBERTSON.

[The above was reported promptly after the occurrence (last Feb.), but more urgent matter has crowded it out until now.-Ed.]

Death in Labor.

Editor MEDICAL WORLD:-In the July number I read the article of Dr. J. J. Lowe

(page 282) on "Death in Labor." He says he is but a youth in the practise of medicin and has an immense amount to learn. This reminds me of the young man who went to college to enter the freshman class, and when he was askt what he knew, said, "Not a darn thing." The professor said, "I think you have a good start."

With regard to Dr. Lowe's case, I will give him the course I would pursue in such a case and you may all judge. He says, "the os was partly dilated, but the bag of water could not be felt." I would have given that woman three grains of quinin and one-half a grain of morphin and would have left her, in case her condition were not grave, and would have returned in six, eight or ten hours and made another examination. I would not have made an attempt to dilate with the fingers nor by any other means. I would have left her three or four one-quarter grain morphin pills, in case of returning pain, to be taken at intervals of an hour if necessary.

I would not have ruptured the bag of water until the womb was sufficiently dilated, or at least soft, flabby and yielding. I would have told her at 9 p. m. to sit on a commode or bucket containing warm water, and to change to walking or lying down occasionally. There is no reason to hurry a case when the head is not making hard pressure on the soft parts. I would then have left for home, with instructions to be notified if anything especial should turn up, had I not been too far from home. It is always a good thing for a nervous doctor not to be too near a patient who is continually moaning when he is sure the moaning is due more to nervousness than to anything else.

Any vagina or inferior strait that will not allow the passage of a small or fairly large hand is too small for a child's head to pass thru. If the child was dead, craniotomy would have been proper; if not sure that the child was dead, then cesarian section would have been in place and the older doctors should have stood by you like true soldiers in one of the worst battles instead of deserting you and leaving the woman to her fate.

Lastly, the Doctor asks the cause of that fetus not being expelled. Who could know that from the history given? No one, I venture to say. This is a question that needs explanation, not by the young doctor, but by the older fellows who left the young man in the lurch.

I venture to say that there is no vaginal orifice so small that an ordinary man's hand cannot be workt into it and up to and even into the womb at labor. Going along, it must be a poor judge who cannot measure with his hand, nearly correctly, the sacropubic and the lateral diameters, and when

his hand is in the womb he should be able to know whether it is a possibility to turn or not, or whether there are or ever were fetal adhesions.

If I could not get my hand into the vagina and thru the inferior and superior strait of a woman's pelvis I would perform cesarian section, and before the woman was exhausted. If I were certain that the child was dead, I would resort to craniotomy.

Older men who have had experience have no business to let younger men stick in such a ditch as was Dr. Lowe; and Doctor, if you ever get such a case again, think of the above pointers, and also of David Crockett's motto: "Be sure you are right, then go ahead.”

Other cases are reported in THE WORLD which seem very interesting and worthy of consideration by every practician of obstetrics. Here I will ask and answer some questions pertaining to labor and childbirth.

Should we give ergot during and at the beginning of labor? No. Learn to have patience and wait until the proper time comes; but be sure to try quinin and morphin first before giving ergot, and do not give ergot unless the womb is open and doing nothing.

How about administering ether or chloroform? Don't administer unless absolutely necessary. When is it necessary? When the woman is weak, very nervous, the os well dilated, the head well down in the pelvis and the mother not a primipara. Let the parts have time to get ready before you jump for your forceps and your ether. Both are dangerous things to handle.

When do you give ether? When labor is slow, the head pressing too long on the soft parts of the pelvis, particularly the bladder or rectum. Do not attempt to apply the forceps until your vertex is to the front. You may get one blade in the nape of the neck and the other over the forehead and injure the child permanently. If you cannot lock your forceps easily, push your hand up the vagina and get your head right. This I have done on occasions. When all is ready, then give ether, but do not monkey with it too long, for it endangers the life of the child and also of the mother.

Do you give it frequently? No; very seldom. I always point out the danger, and if the patient insists, I give it at the risk of the mother and child. Why? I believe I have had at least several still-born children due to ether taken by the mother that might have been otherwise had they not taken ether. I say, I believe, without knowing.

When would you use the forceps? Not until there is an urgent need. Forceps, like ether, are only to be used under urgent circumstances; the time when, and the way how, cannot always be pointed out to the practician, neither can he run for his textbook; but he must get there somehow, and

A Disastrous Case of Labor. Editor MEDICAL WORLD:-In regard to Dr. Lowe's case of death during labor, in July WORLD (page 282), I would like to express to him my sincere sympathy. I feel that it would have been proper to perform craniotomy and attempt to save the mother.

With your permission I will relate a case which happened in my own family. I was practising in the country at the time, and it was my wife's first confinement. I had an old and tried physician with me. It was on the morning of September 2, 1905, that slight pains began. Toward night they became severe. On my own examination and also that of my brother physician we found vertex presentation, but could not find any fontanels, and very little dilation of os uteri.

The severe pains kept up till morning of 3d, still no progress. I attempted to dilate os with my fingers but failed. My wife was failing rapidly, so I decided something must be done, and askt my colleague to apply forceps, as I dreaded to do so. He would not, so I was compelled to attempt it.

Head was too high to reach well with forceps, but it was a life and death case and had to be done. I applied forceps and made traction; they slipt and tore the perineum badly. This happened a second time, when I told my brother physician that craniotomy must be performed. It was, when child was extracted. There was very much laceration, and broad ligaments were badly injured. a month my wife was able to go about, but her health has never been good since.

In

Memphis, Tenn. W. P. MOORE, M.D. [It would have added to the value of your report of the case if you had included a statement as to the condition of the child's head. Was there premature ossification (as your remarks on failure to locate the fontanels would indicate)? Or was there any tendency to hydrocephalus? Also, what was your theory as to why the head failed to engage? If there was no disproportion in the size of the head and of the outlet of the pelvis, anesthetization, version, and extraction would have been the indicated procedure; and might have saved the child's life and the mother's health. If you had owned a pair of axis traction forceps, you would not probably have had difficulty in application or extrac

tion. Unless the mother's condition were very grave indeed, we would not proceed to such a radical measure as craniotomy on a twentyfour hours' duration of labor. In a primipara, even forty-eight hours' hard labor is not uncommonly followed by a delivery, even without instrumentation, when there is nothing abnormal in proportionate size of mother and child. In what way were the broad ligaments injured? Aren't you a little mixt in your anatomy?-ED.]

Cancer of Clitoris.

Editor MEDICAL WORLD:-As I am continually walking about with a chip on my shoulder, and as Dr. Roh (page 274, July WORLD) has knocked it off, I want to say my little piece.

Dr. Roh wants reports on cancer of clitoris and cannot find a case reported in American medical literature. Now, if a disease is so rare that there has not been a case reported, it strikes me that it is not a very momentuous subject.

While I do not wish to be dictatorial, I would like to propose the following subjects instead: "How to Treat the Bellyache by "How to Hold Cholera Infantum Proxy," Cases Until the Undertaker is Ready," "Typhoid Fever and the Great Hence. Hoping these suggestions will be received in the spirit in which they are given, I am yours truly, J. F. STONG.

Barada, Neb.

Menstruation During Pregnancy.-Gonorrhea. Editor MEDICAL WORLD:-I am now treating a woman who is having her periods regularly every twenty-eight days, with the accompanying backache, etc.; but I will swear she must be five months "gone." She gives the symptoms of having felt life (quickening) some three weeks ago, and nauseated for six weeks. I am treating her for uremia, which was the cause of her coming to me for aid. She has borne one child (which is now 3 years old), and had her periods two or three times, she said, after she was pregnant; so that did not worry her this time.

What I want to know most is, concerning her being pregnant and menstruating. (She is now wearing wrappers, so you see she must be five months or more.) I find apparently nothing on this subject in the books I have; neither have I seen an account of this condition discust in your valuable journal. Is this a case of double uterus, one side being pregnant, the other menstruating? Is there any need of interfering? She is seemingly in good health excepting this kidney lesion. Patient is about 28 years of age, weighs about 145 lbs., 5 feet 6 inches in height, limbs puffed up some, pain in the gastric region. Visual disturbances, and in fact the nausea and headache that she has,