20 Dr. Watt?Puerperal Eclampsia.

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PUERPERAL ECLAMPSIA.

By WALTER L. WATT, M.D., Winnipeg.

Eclampsia is the term applied to recurrent convulsive attacks occurring in pregnant or puerperal women, which are the manifestations of an intoxication arising as an indirect result of the pregnancy.

Morbid Anatomy.

Post-mortem examinations reveal a series of more or less

constant morbid conditions, none of which, however, can be

regarded as primary in nature. The liver is yellower than normal owing to commencing

fatty degeneration. Small haemorrhages are met with both beneath the capsule and in the liver substance, and also areas of necrosis round the portal spaces from which emboli may be carried into other organs. Kidneys.?The commonest condition is the pregnancy

kidney. Here there is a fatty degeneration of the epithelium, which permits the passage of albumen and interferes with the excretion of urine. Distributed round some of the convoluted tubes there are found minute areas of necrosis resembling those in the liver. The spleen is enlarged, congested, and soft. Small areas

of necrosis, as above mentioned, are found, and also minute haemorrhages beneath the capsule and in the splenic substance. The brain is sometimes hyperaemic, sometimes anaemic,,

somewhat cedematous, with flattening of the convolutions. Minute haemorrhages in various parts are frequently found. The lungs are cedematous, especially at their base. Sub-

pleural ecchymoses are seen, and emboli are often found, which probably come from the liver.

Etiology.

The etiology of eclampsia is still shrouded in mystery. Only a few scattered facts, like the first rays of the morning sun, serve to accentuate the enveloping darkness of the manifold theories and hypotheses which still cloud the minds of the medical and scientific world. Without going into all their details, the purpose of this paper, I think, will be fulfilled by stating the generally accepted present status of this much- debated question. Eclampsia is considered to be due to the

Dr. Watt?Puerperal Eclampsia. 21

retention of the normal urinary toxins in the blood, owing to a failure of function on the part of the kidneys?i.e., a urinsemia. We know that, coincident with the onset of

premonitory symptoms of eclampsia, the urine is found to contain a diminished quantity of these substances, and that the total amount of urine passed is considerably diminished. Coincident with the recovery of the patient, the quantity of toxic substances in the urine is considerably increased, and also the total amount of urine passed. As a corollary to this, Fehling has proved that the urine in eclampsia is less toxic than in the normal puerperal condition, while the blood serum has markedly poisonous properties, thus showing that the poisonous substances which are normally eliminated

through the kidneys are retained in the circulation, and so produce the characteristic symptoms of eclampsia. A modifica- tion of this theory is that of Bouchard, who includes also a failure in function on the part of the liver. This view has

recently been considerably strengthened by the experiments of Russian investigators with carbamic acid, which is nearly the same as uric acid, and only one step below urea in the oxidation process. They have found that when this substance is given to rabbits by the mouth and stomach, it exhibits no poisonous properties, but, when the blood is diverted from the liver and carried directly into the vena cava, it is extremely poisonous. In other words, the liver evidently renders the carbamic acid innocuous.

In a certain percentage of cases (about five) no evidences of kidney or liver trouble are present, and these are believed to be due to heightened irritability of the nerve centres, or to excessively strong stimuli from the uterus. Pregnancy un- doubtedly heightens the excitability and irritability of the nervous system, and also increases the tendency to reflex action. This predisposition must be most manifest in nervous women and in primiparse, especially if the pregnancy is illegitimate. It is

precisely in these cases that eclampsia most frequently occurs. Accepting this etiology, we now have the foundation upon

which to build a workable hypothesis of the causation of the convulsions and the various morbid conditions. The con-

vulsions are probably the result of an acute cerebral anaemia, brought about by violent contractions of the arterioles, due to direct irritation of the brain centres by the toxic substances in the blood. Later, as a result of the intense muscular action

during the convulsions, the circulation is interfered with, and the blood, seeking the easiest outlet, is forced into non-

muscular regions, as the brain, liver, lungs, kidneys, &c., to

22 Dr. Watt?Puerperal Eclampsia.

such a degree that the congestion of these parts may become excessive, thus leading to cerebral haemorrhage, ciedema of the

lungs, and complete loss of the renal function.

Treatment.

"

Eclampsia occurs almost exclusively in women whose

urine has not been examined during pregnancy." In every case where a physician is engaged for some weeks before the

expected date of confinement, he should at intervals make a

thorough examination of the urine. A hurried heat-test for

albumen is not sufficient, as sometimes there may be no

albumen present, but there may be a decided decrease in the amount of urea excreted, which is a danger signal of much greater importance. A decrease to below H per cent needs

watching; to below 1 per cent, immediate action. When intoxi- cation exists, as manifested by slight digestive disturbances, headache, &c., free catharsis and restriction of diet will usually suffice. As Tarnier says,

" A woman who is put on milk diet for a week will almost to a certainty escape eclampsia." The amount of urine should be carefully noted in order to immediately detect any marked diminution. If this occurs,

give hydragogue cathartics at once, followed, if the decrease is considerable, by a wet pack or hot baths. A good purgative in these cases is 5 to 10 grs. of calomel with 40 grs. to 1 dr. of

compound jalap powder, followed in six hours by an enema, if necessary. If, in spite of all precautions, an eclamptic fit occurs, our aim must be to control the convulsion and prevent any recurrence. Unfortunately, for the attainment of this end, many different methods have been recommended, but the three requiring most consideration are these?

1. Chloral and chloroform.?This consists in administering at the onset 30 grs. of chloral hydrate by the rectum, and repeating every two hours till the fits cease. The inhalation of chloroform is commenced as soon as any signs of the onset of a convulsion occur, and continued until they cease.

2. Morphia sulphate.?This consists in the administration of large doses of morphia hypodermically, as recommended by G. Weit. The initial dose is half a grain, to be followed by a quarter grain every two hours until the fits cease. Not more than 3 grains should be given in the twenty-four hours.

3. Veratrum viride.?This is essentially an American treat- ment. The convulsion is controlled by chloroform, and, after it is over, 15 minims of the tincture are administered hypo- dermically. If the fits continue, the drug is repeated in 5 minim doses until the convulsions are under control. It is

Dr. Watt?Puerperal Eclampsia. 23

sometimes combined with chloral hydrate, as much as 1 oz, of this drug being injected as an initial dose into the rectum. As to the relative value of these three methods, it is

extremely difficult to reach a definite conclusion. There is, however, no doubt that both chloral and veratrum viride are more depressant to the heart than morphia, and consequently favour that most dreaded complication, heart failure. The lowest mortality ever recorded is that of Weit, who

in sixty cases had only two deaths?a remarkable result. As a comparison of the chloral and morphia methods, the following statistics from the Rotunda Hospital, Dublin, are of consider- able importance, since the treatment was carried out with the same class of women, and under similar conditions, whether favourable or otherwise. In twenty-six cases treated by chloral and chloroform, there were eight deaths, a percentage of nearly 31 ; in seventeen cases treated with morphia there were three deaths. In one of these, there was considerable doubt whether the case was eclampsia or not, but, taking the mortality as three, this gives a percentage of nearly 18, thus favouring strongly the latter method. In private practice better results can undoubtedly be obtained, since, in some cases at least, women are only sent into hospital when in extremis. The average mortality with veratrum viride in the United States is between 20 and 25 per cent. ]t is un-

fortunate that there is no institution where the three .different methods have been used, so that an accurate estimate could be arrived at of their comparative value. There can be little

doubt, however, that morphia wTould win the victory. Our second line of attack, which is common to all the above

methods, consists in endeavouring to eliminate the poisonous substances circulating in the blood. For this purpose, wre first cause free purgation. If the patient is conscious, calomel and jalap as above mentioned may be given, or repeated doses of concentrated Epsom salts. If, however, the patient is comatose, two minims of croton oil, made into a small bolus with butter, should be placed as far back on the tongue as possible, or elaterium (quarter grain) similarly prepared may be used. A few hours afterwards, use a large soap suds enema if

necessary. Every effort should also be made to encourage free sweating. The patient must be kept in blankets, and repeated hot baths should be given if she is conscious. If not, a hot wet pack, or, if possible, a steam or vapour bath, which is more efficacious, should be given, lasting twenty to thirty minutes. Endeavour, also, to increase the amount of urine

by hot stupes over the kidneys, and abundance of fluid by the mouth if the patient is conscious. An excellent and

24 Dr. Watt?Puerperal Eclampsia.

reliable means of promoting diaphoresis, and, at the same time diluting the toxic blood, is saline infusion. As much as

a pint may be injected under one or both breasts, or, if the

necessary apparatus is not present, several quarts may be

passed high into the rectum. In either case, the only force used should be that of gravity. Pilocarpin need only be mentioned to be condemned. The mortality in the Edinburgh Maternity Hospital while it was in use there was 66*6 per cent. It strongly predisposes to pulmonary oedema, which explains the high mortality. Our third aim in treatment is to prevent complications.

Great care must be taken to prevent the patient from injuring herself during the convulsions. The onset of a fit is usually heralded by eye symptoms, such as nystagmus and irregular contraction or dilatation of the pupils, and sometimes by vaso- motor disturbances, as sudden flushings of parts of the face or neck. These should be closely watched for, and, if chloroform is being used, it should at once be administered. An ice-bag to the head tends to prevent congestion of the brain. All

feeding by the mouth must be stopped, on account of the danger of setting up deglutition pneumonia; if food is

necessary, nutrient enemata may be given. The head should be kept low, and turned to the side to prevent the saliva from reaching the lungs. If the heart becomes weak and rapid, strychnia should be given hypodermically. We now come to some disputed points in treatment. First, the advisability of induction of premature labour, or

of immediate delivery. The supporters of these methods claim that, with the emptying of the uterus, the fits will cease.

Clinically, this is opposed to facts, since uterine contractions directly excite the convulsive attacks, and the effects of

pregnancy on the maternal organism by no means disappear immediately after delivery. It would seem better not to induce labour unless all other means of checking the con- vulsions have failed. In such cases, probably the most

satisfactory course, where there is only slight dilatation of the os, would be to use the method of Krause?i.e., to pass slowly one or two large rubber catheters, well sterilised, deeply into the uterus. This is easily done, and above all causes the least possible irritation to the maternal organism. A point worthy of notice is the rapid dilatation which often occurs during a vapour bath, due, probably, to the almost complete relaxa- tion ; cases are even on record of delivery during the course of such a bath. If, however, labour comes on spontaneously, the best plan would be to shorten its duration as much as

Dr. Watt?Puerperal Eclampsia. 25

possible. Apply the forceps and deliver the child as soon as the necessary conditions are present, but always under deep anaesthesia. Never adopt such violent measures as accouche- ment force with or without podalic version, or wide crucial incisions of the cervix, as advocated by Dlihrssen. The

dangers are enormous as compared with the problematic good that may result.

Another unsettled point is the advisability or otherwise of venesection. In most cases, I think this would be contra- indicated on account of the resulting increased tendency to heart failure, which is already very great. Its only justifica- tion would be with a strong plethoric woman, with over- distention of the right heart. Even here, free diaphoresis, with saline subcutaneous injections, would be of less danger and of equal value, and would serve the same ends. The

blood of eclamptic women contains highly poisonous sub-

stances, and it is natural to suppose that all the fluids in the

body are equally contaminated with these substances, though, perhaps, not in so concentrated a form. Venesection is

performed, and a considerable quantity of blood is drawn off*. Immediately, the depleted blood-vessels begin to exact con-

tributions of fluid wherever obtainable, but from contaminated sources. In a comparatively short time, the amount of fluid circulating in the vascular system is as great as before, with this difference, however, that it is a fluid still toxic in

character, perhaps almost as poisonous as before, but containing a greatly diminished quantity of its vital elements?the red blood corpuscles?and hence very weak in its nourishing and supporting qualities. The favourable effects of the venesection, as often happens, pass off in a few hours, and the convulsions return. We now have to deal with a patient in whose blood- vessels is circulating a fluid still toxic, consisting largely of serum, and whose vital force has been artificially greatly diminished. Can such a woman stand the same chance of

recovery as one whose whole system has been flushed by free purgation, diaphoresis, and saline infusions, and whose blood still contains in undiminished proportion the essentials for the best sustenance of her body ? The prognosis for the life of the infant in eclampsia is

always grave; at least 50 per cent of the children die. The danger to the mother varies with the period. During pregnancy it is less dangerous than during labour, and it is

least of all dangerous during the puerperium. If the con-

vulsions are checked before labour comes on, the prognosis is improved. If labour comes on before they are checked, the

26 Dr. Watt?Puerperal Eclampsia.

shorter its duration the more hopeful is the outlook. Of

course, the more convulsions there are the more gloomy is the prognosis, but there is always hope, as recovery has been reported after one hundred seizures; as a rule, ten constitute a serious case. A clinical point may be mentioned here: women whose urine is loaded with albumen, and who

present a condition of general anasarca, are less liable to have convulsions, and, when they do occur, more readily respond to treatment than those in whom there is perhaps only a trace of albumen in the urine, but wTith tube-casts present, and marked diminution in the amount of urea excreted. The following short notes of three cases, with rather

unusual aspects, may be of interest. The first two occurred in the Rotunda Hospital, Dublin :?

Case I.?M. S., aet. 24, primipara, seven months pregnant. Prior to admission, she had seven eclamptic seizures, and was given half a grain of morphia hypodermically. On her way she had another fit. Immediately on arrival, she was given 2 minims of croton oil. In the next six hours she had seven

fits, half a grain of morphia being given. During the next three hours two more convulsions occurred, quarter of a grain of morphia being given; also two enemata, both of which were retained. One hour later she had another seizure; a steam pack was used, which caused free perspiration. Some hours later labour supervened, and she was delivered with the

forceps of a dead child as soon as dilatation was complete. Next morning, after being unconscious for thirty hours, she became semi-conscious, and passed 16 oz. of urine. She wTas

given calomel and compound senna mixture. A short time afterwards the bowels moved freely, and she passed 16 oz. of urine. Two days later, puerperal mania developed ; she was

very restless and excited, with hallucinations, refusing food. This lasted three days, and disappeared. The patient became convalescent, and was discharged on the thirteenth day. In

all, this woman had eighteen fits.

Case II.?M. R., set. 30, primipara, seven and a half months pregnant. Patient had some pains during the night, and, thinking that labour was coming on, walked with her husband some miles to the hospital. Some hours after, she had a peculiar fit, in which she tried to strike anyone who came near her; it lasted one minute. The bladder was catheterised, and 4 oz. of blood-stained, highly albuminous urine with- drawn. Forty minutes later she had another seizure, half

Dr. Watt?Puerperal Eclampsia. 27

a grain of morphia was administered, and she was put in a Vapour bath for thirty minutes. She did not again become conscious, fits occurring every forty-five minutes. Three

minims of croton oil had no effect. Quarter of a grain of morphia was given in four hours, and again in two hours; also, two more vapour baths. The temperature rose to 106*6?, the pulse to 134, and she died shortly after. In all, there were thirteen fits, the longest lasting five minutes. Vaginal examination showed the os to be dilated to the size of one

finger. The post-mortem revealed that the uterus was studded with

small myomata, and that the liver was extremely large and fatty. The other organs presented the usual changes.

Case III.?E. J., set. 29, primipara, full term. The patient was confined on 13th August, 1901, at 7 a.m.; normal labour, a healthy child being born. At 2*30 P.M. she had an eclamptic seizure, another at 5, another at 6. Fifteen grains of chloral were given by the rectum. A fourth fit occurred at 10 p.m. One-sixth of a grain of pilocarpin was administered hypo- dermically. Three more convulsions occurred during the

night and early morning, a quarter of a grain of morphia being given. At 7 a.m. she was taken to the Maternity Hospital, and a quarter of a grain of morphia again given. I saw her for the first time at 9 A.M., in consultation. She was then comatose, and becoming very restless, and therefore a quarter of a grain of morphia was again given. She was

then given a vapour bath, lasting thirty minutes, which

produced free diaphoresis. A large amount of saline infusion was injected high into the rectum, and 2 minims of croton oil were given. She remained quiet during the rest of the day, although unconscious. At 9 p.m. she was found almost dead, the throat being plugged up with mucus, and the lungs markedly oedematous, probably the result of the earlier treatment. The mucus was immediately sucked out with

a catheter, hot fomentations applied to the chest, and strych- nine administered hypodermically. She improved rapidly, passed a fair night, and woke up next morning conscious for the first time in thirty-six hours. She continued to

improve, but there was slight pyrexia from the onset, with some cough. On the sixth day, she left for home. A

puerperal ulcer developed in the site of the perineal laceration, but this yielded to treatment. I saw her twice again in consultation, as the fever and cough continued. She did not

look at all seriously ill, but the lungs presented signs of

28 Current Topics.

pneumonic phthisis, although no bacilli could be found. A

month after leaving the hospital, her husband was wakened by hearing a spasm of coughing, and, a few seconds later, blood welled out of the mouth, and she fell back dead. It was afterwards learned that she had been coughing for some time before her confinement, although this was denied by the patient herself. The husband's first wife died of tuberculosis two years before.

While there are many diseases in which the physician may well feel sceptical as to the value of medicines, there is no doubt that, in the large majority of cases of eclampsia, we can go forward fearlessly, with the knowledge that, in the fight with grim death, our chances of success are good. The effects of proper treatment are immediate, showing themselves within a few hours in the disappearance of convulsions, the return of consciousness, and the re-establishment of the normal urinary secretion; and thus we are encouraged to continue the

struggle with the grave problems which ever present them- selves to prove our professional attainments and knowledge.