these cases, but also the especial liability
of permanent injury of some of the special
senses, that necessitates prompt action.
Many cases have their eye sight injured;
some even have progressive atrophy of
the optic nerve.. Some loose the sense
of smell; some have paralysis of certain
muscles as a sequel.
Hence, all around, it is the most serious
condition occurring in . the puerperal
state. The many other papers on that
subject cover the cause, generaJ manage-
ment and medical treatment of these
cases, so I will only take up the surgical
side of the question.
Mild attacks of eclampsia are readily
controlled by medication and other treat-
ment which is used to remove the cause,
or to terminate labor at leisure. The
kind I want to refer to is, that severe
variety characterized by a series of con-
vulsions recurring every fifteen to thirty
minutes or an hour, accompanied by the
most profound coma and not relieved by
medication. The patient continues in this
state for 12, 24 or 48 hours and finally
dies undelivered. Sometimes even labor
sets in and by manual effort, dilatation
with rubber bags, your hand, or steel di-
*Read before the Section on Obstetrics and
Gynecology at the annual meeting of the Mich-
igan State Medical Society at Grand Rapids,
May 26, 1904, and approved for publication by
the Committee on Publication of the Council.
lator, labor can be sometimes finished in
a short time. In puerperal eclampsia it
has been found that the convulsions cease
as soon as the labor is completed. There
are exceptional cases where the convul-
sions still recur afterwards although
mild, and there are still other cases,
though very rare, where attacks do not
come on until after labor is finished.
Hence the great object should be to finish
labor as quickly as possible. An hour,
half-an-hour, minutes even may be of im-
portance in saving the patient's life or
some vital part of the body.
This can be most easily accomplished
by classical Caesarean section that has been
recommended and employed, but as this
Caesarean section is more or less diflScult.
Duhrsen has recommended what he calls
"Vaginal Caesarean Section" — opening
the cervix sufficiently to be able to apply
forceps or deliver by version. This is an
operation not difficult and not dangerous,
and can be carried out by any general
practitioner and delivery accomplished in
five or ten minutes.
The operation is performed as follows :
An incision is made at the junction of the
cervix and the bladder, transversely
across about an inch or l^^ inches in
length down to the uterine muscles. With
the handle of a knife the bladder can be
easily separated and lifted up for an inch
or two inches. The peritoneum is not
opened. The cervix is grasped on one
side with vulsellum forceps, or what is
better, with one on each side. The cer\'ix
is now cut from without inward as near
the median line as possible, up to the in-
ternal OS, or a little farther* If you stick
October, 1904. ECI.AMPSIA and VAG. CiESAREAN SEC— CARSTENS. 449
to the median line there will be very little
hemorrhage, but if you get on one side or
the other there seems to be a good deal
more. The uterus being opened you can
easily turn or apply the forceps and de-
liver in a few minutes. If the incision
is not long enough you can increase it.
The placenta can then be removed by in-
serting the hand. I have used hypoder-
mic of ergot, as a rule, before I start the
operation or use the chloroform, so as to
get good contractions as soon as the
foetus is removed. When the uterus is
emptied it can be easily pulled out of the
vulva. Catgut sutures (or for that mat-
ter any other kind) are used to sew up
the opening and stop the hemorrhage.
The little oozing that has taken place with
the first cut through the mucous mem-
brane at the junction of the bladder and
uterus has stopped by this time, and a
few sutures introduced to close up the
mucous membrane. The whole operation
should not last more than 15 minutes.
The little hemorrhage, that you can
readily control, will do no harm as you
"have not opened the peritoneal cavity and
your patient has been promptly delivered
and the convulsions cease.
•In conclusion I simply want to make
these points:
1. Severe continuous puerperal con-
vulsions are often fatal or leave serious
sequelae, hence require the most heroic
treatment.
2. Vaginal Caesarean section enables
the accoucher to deliver promptly.
3. Prompt delivery affords the best,
in fact, only chance for success.
DISCUSSION ON THE PAPERS OF DRS.
COLLINS AND CARSTENS.
J. J. Mulheron, Detroit: I would not
mystify this subject any more by attempting to
review the pathology of the affection. It is a
notorious fact that puerperal eclampsia is one
of the least understood, or the most misunder-
stood, of diseases. Dr. Collins has gone over
the field and given us the various theories which
have, from time to time, been advanced, and you
cannot have failed to notice from his reyiew how
mixed we are on this subject. ♦
I want to take exception to one remark that
he made, particularly with regard to the obser-
vations made by Ludwig and Savor. I think
the doctor has misunderstood the conclusions of
these gentlemen. He says they attributed the
source of the materies morbi to the foetus. It
was my fortune to be present during a consid-
erable portion of the time with Ludwig and
Savor when they were making these observa-
tions, and that was not the conclusion that they
then reached. They regarded that as one of
the possible sources of the poison, but they were
inclined rather to believe the origin was through
some disturbance of metabolism, in which the
liver was chiefly at fault. I remember the en-
thusiasm with which they entered upon the sub-
ject, and the amount of material they had at
their disposal. At the lying-in hospital at Vienna
they average fifty cases of labor a day, and the
aggregate of eclampsia occurring there is very
large.
Another point is. Dr. Collins* declaration that
puerperal eclampsia is a preventable disease. I
take exception to this statement. I think cases
will occur occasionally where every precaution
will fail in preventing an onset of the attack. I
want to report one case as an illustration. A
number of gentlemen will remember the very in-
teresting paper which Dr. Bonafield, of Cincin-
nati, read before the Wayne County Medical
Society, in which he advanced the idea that
veratrum viride is almost a specific in puerperal
eclampsia. I had at that time a patient under
my care, who had been sent to Detroit from
Chatham, Ontario, where she had developed
symptoms of the disease. The physicians she
consulted at Chatham advised that she be im-
mediately taken to the hospital and prematurely
delivered. The symptoms, in their judgment,
were so threatening as to demand immediate
interference. She did not like the idea and
coming to Dtroit I was engaged to take care
of her. I found the secretion of urine down to
six ounces in twenty-four hours. I put her â– >n
Ba^ham's mixture, fed her buttermilk or skimmed
milk, and was fortunate at the end of a week
in increasing the secretion to twenty-four ounces
and later it went up as high as twenty-eight
ounces. The woman went along, and every, symp-
torn of favorable ^u.^con[.gy(ev^^[§he went
450 ECLAMPSIA and VAG. CESAREAN SEC— CARSTENS. Jour. M. S. M. S.
a little over the time she was exoected for con-
finement. I was sent for when labor set in and
got there about eight o'clock in the evening. At
four o'clock in the morning I delivered her of
a boy (the child weighing fully eight pounds)
without the slightest untoward complication. You
can understand I was very apprehensive of a
convulsion, and applied the forceps just as soon
as dilatation was complete, no difficulty being
experienced in delivering her. Everything was
very promising, and all supposed we had averted
a catastrophe. I called around the same day at
ten o'clock and found everything doing very
nicely. Everybody was pleased, as the case was
a peculiar one, and a great deal depended upon
the birth of the child. At nine o'clock p. m. I
was sent for. I did not happen to be in. Dr.
Lake, of our city, who lives in the neighbor-
hood, was called and when I got home about
eleven o'clock I went down and found Dr. Lake
in attendance on a case of violent puerperal
eclampsia. He had given a dose of croton oil,
had erected a tent over the bed and was apply-
ing hot dry air. H's had given three twenty-dro)
doses of veratrum viride. I entered the room
just as the woman was having a convulsion.
There had been no cessation as the result of the
treatment. It was the ninth case of puerperal
convulsions which it had been my fortune to
treat. In the eight previous cases I was for-
tunate in having a recovery in each case. I had
never seen a fatal case of puerperal eclampsia,
which was certainly a singular run of good luck.
My treatmsnt had always been venesection. I
immediately opened the vein m the woman's arm
and withdrew twenty ounces of blood. The con-
vulsions ceased immediately. I left again about
four o'clock in the morning, and left the woman
sleeping nicely. Called around the next mom"
ing about nine o'clock and found her bright and
cheerful, mind perfectly clear, very happy and
everything promising well. At nin€ o'clock that
same night I was again summoned and found
the woman in a violent convulsion and in a coma-
tose condition from which she did not recover.
Now here was a case in which every known
precaution had been taken, and the eclampsia was
nof averted; a case in which labor was normal,
practically, and in which the emptying of the
uterus did not avail towards the averting of the
catastrophe. So that while Dr. Collins' remarks
may, in a general way, be correct, I mention
this striking case, which has just happened in
my experience, to illustrate the possibility of
exceptions to what may be a very general rule.
Mortimer Willson, Port Huron: I wish to
express my appreciation of these two papers.
and very briefly to relate a case which came
under my observation, to which I was called in
1902 by Dr. W. P. Derek, of Marysville. He
knew nothing of the history of the case; he had
not seen her since conception until they sent
for him one evening and said the woman had
become blind. He went to see the patient, and
while he was making a slight examination she
had violent convulsions. She had not had one
before she became suddenly blind. He sent for
me. I was there in about an hour. I took a
lamp and went to the bedside and held it before
her eyes, and said, "Can you see anything?"
She said "No." I §aid, "Can't you see a lamp?"
She said, "No." While making a slight exam-
ination, she again passed into a violent convulsion.
Dr. Derek gave her chloroform — it was about the
seventh month or a little beyond probably — he
gave her chloroform, and in about 45 minutes,
by rapid dilation, I delivered the woman. The
child had been living that afternoon, but on
account of the convulsions or the violence of
the poison the child was dead when born. In
sixty hours she had regained normal vision, had
no recurrence of eclampsia, has had no trouble
with the vision since. I have had to deliver quite
a number prematurely, both those who had not
had -eclampsia and those who had. Of course, in
my own practice, if I find the nitrogenous waste
or elimination falling below a certain standard
which is considered the critical point, I do not
wait for eclampsia, but simply deliver them. I
have never had a case that demanded the pelvic
or vaginal cesarean section. I think under
chloroform, in any case I have ever .seen myself,
rapid dilatation with the finger can be accom-
plished and within an hour delivery effected.
There may be cases in which this cannot be
done, but all that I have ever Seen can be
managed in that way.
H. W. Longyear, Detroit: I shall not at-
tempt to discuss the etiology and pathology
of the disease which the doctor has so well
given us in his paper.
There is one point of treatment that seems
to me it might be well to farther emphasize,
although the doctor emphasized it pretty well
also, and that is the treatment to prevent
convulsions. As he has very well said, that
is what we have to do, principally, in these
cases, and I think th«t is what he meant when
he said it was a preventable disease. That
can only be done by frequent examinations
of the urine, and patients must have it im-
pressed on their mind; they must bring, it
for examination during the laat 4hree mpnths
Digitized by VjOOQIC
OcTORER, 1904. ECLAMPSIA and VAG. CESAREAN SEC— CARSTENS. 451
of pregnancy, and if a trace of albumen is
foimd that urine must be examined daily —
not for the amount of albumen at all, but for
the amount of urea. If you find that the spe-
cific gravity is running down in the daily
amount, get the quantity and percentage of
urea. If you find it getting down to the dan-
ger line, and you cannot by those methods of
medication, diet, etc., which are often suffi-
cient — if you cannot bring that urea up —
you should not wait. If it gets down to the
danger point, say for one, or two, or possibly
three days, the woman should be delivered
without delay. I deliver always, in such
cases, and do not wait, because if you do in
nine cases out of ten you will soon be handi-
capped, and will have to deliver her in con-
vulsions, when the danger to her life as well
as the child's is so well known. I think that
is the point the paper should bring out more
than anything else.. For treatment to prevent
convulsions in 'that stage of gestation, we
should watch the urine carefully, and it can
be done accurately by daily examination,
when you find that albumen is present. I be-
lieve that in the convulsions veratrum veridc
is valuable as a remedy. Watched carefully
you can bring the pulse to 45. If you find the
pulse is getting tao weak, it is easy to bring
it up by a little alcoholic stimulant. It will
respond almost immediately to a dose of
brandy. Watching it that way and keeping
the pulse down you can frequently stop con-
vulsions by that treatment alone. Then the
application of heat I think is valuable — build-
ing a tent over the patient and getting up
perspiration. Where you get these extreme
cases that Dr. Carstens spoke of, with a
rigid OS, when you cannot dilate, as Dr. Will-
son said, if you can do it with your hands
that is all right. If you cannot, you have to
use something more powerful. When you get
to this point, when you have to come to the
consideration of that, I think the Bossi dila-
tor is all right in a good many cases, and
that can be used by most any one. But the
assertion of Dr. Carstens that the general
practitioner can do a vaginal cesarean section
is too broad. The doctor is so expert and so
accustomed to his work that he thinks any-
body ought to do it because it is so simple
for him; but the general practitioner cannot
do it. Once in a while you might find one
that knows something about surgery that can
do it, but the average practitioner would
make a bungling job of it. • I think you all
know that. I don't think that statement
should go out unqualified. The Bossi dilator
he can use. I agree that it makes a tear of
the cervix and considerable bruising, but we
find that to be the case frequently in normal
labor. But the Bossi dilator can be used by
the general practitioner, and I believe it would
be safer for him to use that than for him to
make the vaginal cesarean section, which I
believe is a proper operation in the hands of
a skilful operator.
H. W. Yates, Detroit: I was glad to hear
Dr. Longyear bring out the point in regard
to the specific gravity of the urine. We
may often have a normal amount of urine
eliminated an<i a very small or deficient
amount of solids. In consequence of this I
believe our test should be one for the spe-
cific gravity as being much more important
than one as to absolute quantity. More than
that, we should frequently have microscopic
examinations "made to ascertain whether or
not there are old kidney lesions. As up to
this treatment, this thought occurs to me:
Take a woman whom we know has a chronic
interstitial nephritis and suppose she become
pregnant. What should be our attitude
towards her pregnant state? Now I believe
it is conceded that pregnancy does endanger
a woman who is suffering from a chronic in-
terstitial kidney trouble. If that is so — if this
trouble is increased by it — she never returns to
the condition in which she was before preg-
nancy occurred. Moreover, the interstitial de-
posits will gradully become worse as pregnan-
cy continues. Therefore, as a prophylactic to
eclampsia, as a preventative of eclampsia, as
Dr. Collins has put it, I believe that we are
on right grounds when given such a case and
knowing the circumstances connected with
it, to empty that uterus at once. I believe it
is wrong, knowing that the interstitial trouble
goes on and on and leaves the patient in a
worse condition than she was at first, to leave
that uterus unemptied. I know there are many
who will take exception to that on the
grounds of infanticide. If pregnancy is al-
lowed to go on and eclampsia develops
death of the foetus takes place in the mijori y
of those casedl with great danger toi the
mother.
James E. Davis, Detroit: I would like to
ask Dr. Collins in closing the discussion if
he would develop the point brought out by
Digitized by VjOOQIC
452 ECLAMPSIA and VAG. CJESAREAN SEC-CARSTENS. Jour. M- S. M. S.
Dr. Yates, and tell us what class of symp-
toms we might find in cases that would be
prone to eclampsia, so that we could be able
to advise such patients against beomng
pregnant. As I understood Dr. Collins' paper
he stated that every case might be cured if
the pathological conditions had not proceeded
too far. It seem§ to me that this point as
brought out is exceedingly important, for if
the uterus is emptied early enough and proper
treatment instituted, then we can expect good
results, but if we wait until the pathological
conditions have continued so far that irre-
parable damage has been done, then we will
not obtain good results.
Another good point brought out by Dr.
MulheroTi, is the value of venesection. But
the employment of veratrum veride is yet
better, for it substitutes the blood-letting, and
the patient is bled into her own veins, which
thereby conserves that amount of blood and
accomplishes the same purpose.
Albert Patterson, Grand Rapids: It is not
my purpose to attempt to enlarge upon the
papers, but to emphasize some particular
points. It has been my unfortunate experi-
ence to meet several cases of eclampsia. One
case I recall where the patient lost her eye-
sight. Under the advice of the physician I
induced labor at six months, and she was de-
livered without untoward symptoms — no sign
of eclampsia. A little over a year she was preg-
nant again and went to full time and had
eclampsia and died within a short time after
having a few spasms. During the last two
years I have had two cases in which I had
opportunity to watch them from time to time.
I saw them early, I limited their diet, advised
a reasonable amount of exercise, baths, and
carefully watched the urine from week to
week. I carried them eight months and then
induced labor and delivered them. Both
women and babies are healthy. The babies
were small, but I could deliver them rapidly
because they were small. Both women had
convulsions. One had three — one before I
delivered her, two afterwards. After the
third convulsion I bled her, probably taking
16 to 18 ounces, and she had no more con-
vulsions. The other case I chloroformed im-
diately, dilated with my hand, and delivered
under chloroform. She had only one convul-
sion. The condition of the urine should be
carefully watched in every case of pregnancy.
A. N. ColHns, Petroit: In regard to Dr.
Mulheron's case, I think it is exceedingly^ in-
teresting. Ludwig and Savor state that the
increased elimination brought about by the
foetus, had undoubtedly much to do with
more matter to be eliminated than the struc-
tures could eliminate. That there was a con-
dition depending upon the foetus was the
assertion I made. You may have pressure of
every kind, so far as mechanical conditions
are concerned, and you never get puerperal
eclampsia unless there be a foe*«s present.
Can we avoid the conclusion that the thing
is dependent upon the life history of the
foetus?
In Dr. Mulheron's unfortunate case, if I
did not know him so well, and know what an
excellent practitioner he is, I might draw my
own conclusions, if this case came to him as
a suspicious case. He increased the quantity
of urine, but had he carefully made, from
day to day, a curve of the urea that eman-
ated, I am afraid he would have found that
curve was at a low point about the time she
was delivered. That case when she came
to him first, without all of these pathological
changes which our postmortems have shown
us do occur — and which it was the purpose
of my paper to get us to stop before they do
come, and to show the hopelessness when
they are present — those changes ought not
to have gone on. That case was a preventable
case, as I asserted, had labor been brought
on timely and early enough. That very case
cited as one that was not preventable, was a
preventable case. Any case in which labor
can be brought on early enough is a preventa-
ble case. It is our business to know when it
should be brought on.
Dr. Davis asked what are the symptoms
to warrant us in bringing on labor. In the
amount of urea eliminated I believe we have
the best symptom. When you first detect
this deficient elimination, when you first be-
gin to get restlessness, sleeplessness, head-
ache, Hashes of light, and anemia, and as a
rule pallor, you begin your treatment, and
for a short time it is sufficient if you increase
the quantity of elimination and the specific
gravity of your urine. After a little the
treatment ceases to avail; it goes the other
way. After it has been modified by treat-
ment everything is well for a time, and then
again it goes the other way. You will find
that to get the second effect from the treat-
Digitized by
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OcTOBBR, 1594. PNEUMONIA IN CHILDREN - CURTISS.
453
ment is very difficult. It is then when we
fail to get that second rea<:tion, that we
should bring a1>out labor. The liver and kid-
neys arc in a condition where they are be-
yond our control in a great many cases. We
should not permit our cases to get beyond
our control. I still assert that it is a prevent-
able disease. This case cited was a prevent-
able case had it been followed along in that
way. Now it is a fact that very many of
those cases that have spasms, and convul-
sions, die of ruptured blood vessels or apo-
plexy. What can you do with a ruptured
blood vessel in the brain? The coma
comes on, they will develop high fever,
and will die. I assert again, those cases
are preventable if they get under our
observation at the proper time and if we
do what we ought to do. A case ought not
to get to that point where it is beyond our
control, as it is a preventable condition. Our
warning should be, as I say, when our treat-
ment fails to do what it should have done;
it is then that a case gets beyond our reach.
Many cases will get well, but we do not
know which will get well or which will die. If
we watch the urine and if we have facilities to
get to them, it is a preventable disease, and
it is the business of the physician to stop
them.
J. H. Carstens, Detroit: I want to say I
strongly endorse, on the general subject, what
Dr. Collins says. I thmk patients do not
come to see the doctor soon enough. They
wait until the last minute, when we are vir-
tually helpless. We want to wait until the
child is viable, if possible, but if not viable
and the case progresses, there is only one
thing to do, and that is, induce labor, and
that we must do. It may take 12 or 24 hours,
but that woman will not be safe until she is
delivered and all the serious consequences
prevented.
In reference to what I stated about the
vaginal Cesarean section, my jocore fri nd
from Grand Rapids may laugh all he likes,
it has no effect on me. I am trying to teach
the general practitioner something, not tell
you what I can do. I know they can do it.
There may be some little timidity, and their
hand may tremble a little, but it takes pluck