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and more violent and rapidly the convulsive movements extend more or less down the body. The head is turned from side to side; the tongue is protruded; and a tonic spasm of the muscles of mastication closes the lower jaw upon the tongue, wounding it unless guarded.
Then inspiration ceases almost entirely and there occurs a gasping expiration with a hissing sound, driving out the saliva colored with blood if the tongue has been injured. The eyes are rolled up until only the whites are seen.
The face becomes livid, swollen, and distorted by the muscular contractions into the ghastly sardonic grin, causing the most beautiful female face to become a horrible mask of startling ugliness. The lividity extends in my experience over the whole body. This condition lasts a varying length of time-most authorities say never over one half a minute. When apparently longer they say the mistake is made of counting several paroxysms as one. Then the patient relapses, and either after a longer or shorter interval has succeeding paroxysms of greater and greater intensity, in one of which she may die, or she sinks into coma which may continue until death, or after the first or some subsequent convulsion she lies in a more or less comatose condition, from which she slowly and gradually rises to a semi-consciousness from which she may be aroused to answer in a very confused way. This semi-consciousness continues an indefinite time, six, twelve, twentyfour, even thirty-six hours, and in some rare cases even much longer, but generally within twenty-four hours she is restored to a mystified consciousness in which she has no definite idea of what has occurred. Slowly things are restored to her consciousness, but generally there are vacant periods of time and haziness about other periods. Then comes the anxious after-period of convalescence to see whether there is present a permanent kidney lesion. The symptomatology has been fairly well covered, except that no mention was made of the appearing of numbness in the different parts of the body.
But the prodromic symptoms of eclampsia are the same as those credited to Bright's disease in the non-pregnant.
The pathology is the pathology of Bright's disease.
Etiology. We have an exalted condition of the nervous system due to some centric or eccentric cause associated with a laboring kidney; the great additional debris resulting from gestation produces a toxemia beyond the eliminating ability of the impaired kidneys unassisted by the skin and with diminished assistance from a torpid bowel; thus we
have the initial nervous exaltation heightened by the resultant toxemia to such an extent that an explosion occurs or is produced by the addition of some shock not necessarily of any great magnitude, and we have the convulsion.
I think the arguments about primiparity being a cause of eclampsia are very weak. Certainly there are more eclamptics among primipara, just as the eruptive diseases are more common in childhood. Any irritation
be sufficient to institute a convulsion when the nervous system is in a sufficiently exalted state just as in strychnia poisoning or in tetanus.
Treatment.—(Prophylactic— Treating Eclampsia-After-Care in Convalescence.) The prophylactic treatment has already been covered above.
Treating Eclampsia: (1) Medicine; (2) blood-letting; (3) hastening labor; (4) cesarean section; (5) induction of premature labor.
Medical treatment: Chloroform to surgical anesthesia in the majority of cases will control the convulsion. But alone it is not sufficient, for you can not keep it up indefinitely, and it is not curative. as the convulsion is controlled stop the .chloroform and watch your patient, and at the first twitching of any part of the body push the chloroform again.
Chloral : Thirty-grain doses by the mouth or sixty grains by the rectum, and we have reliable authority for very large amounts in twentyfour hours.
On technical grounds potash is objected to, but the bromide of sodium renders considerable help. Croton oil on the tongue to force elimination, certainly by the bowel possibly by the skin.
Elaterin or jalap and calomel by the mouth if she can swallow.
Jaborandi or its active principle, pilocarpine, have some strong supporters, but the depression it produces makes it a questionable agent in this condition.
Veratrum viride I object to on the same grounds as pilocarpine.
Morphine I have left for the last, as it properly only comes after the others. It has been highly recoin mended, especially by C. C. P. Clark, who recommends it hypodermically from the beginning in one and one-half grain doses, to be repeated as needed, but I do not think it is allowable until you have more or less exhausted the measures suggested above, or until you have obtained some elimination and evacuated the uterus.
Blood-letting, either general or local, is thought highly of by many, but in my opinion it is too costly with the exhaustion natural to uremia and the after-coming labor with its more or less hemorrhage.
Hastening labor: If labor is very rapid, as it often is in eclamptics, there is no call for hastening, but if there is any delay assistance should be given to hurry delivery.
Cesarean section has a very doubtful if any place in my consideration. Only when the mother is dead and the child is alive should its removal by cesarean section be considered.
Induction of labor: This impresses me as the most important question to be decided in the treatment of eclampsia. Gooch said, soine time since, “take care of the convulsion and let labor take care of itself.” This has been the war-cry of those opposing active interfer
It has all the strength that an epigram carries, which is great, however lacking in wisdom it may later be shown. If the fetus is at a viable age, then many concede that it is possibly allowable in grave cases as a last resort.
But this same majority oppose it if the fetus has not reached the viable age. It is opposed by many on the ground that it will excite convulsions and that labor will produce the additional shock to the already struggling vitality that will topple it over. In reply I say every means known to us should be used in kidney failure to prevent eclampsia, but that when a true eclamptic convulsion occurs the time for temporizing has passed. The uterus should be emptied as soon as possible, because, if pregnancy has a causal relation, then it should be stopped before it produces permanent kidney alteration or death from kidney failure.
If blood-letting produces any beneficial effect, even temporarily, then by taking away the fetus, the amniotic fuid and the inore or less hemorrhage natural at such a time you would do more good. With the uterus emptied we would have a much better chance of obtaining vicarious elimination by the bowels.
After the uterus is emptied there is much less objection to the use of morphia. As to the additional shock, if necessary obliterate the reflexes by anesthesia.
Lastly, so far as the child is concerned, the mother's life, with me, far outweighs the life of the fetus in utero, especially so when we know that eclamptics generally abort, the fetus dies in utero, or if it is born alive it has a precarious existence.
Some measure must be used to protect the tongue. A cork or a rubber pad between the teeth is the common practice. I am very favorably impressed with a handkerchief, used as a bit, holding the tongue down and out of the way.
The after-care of the patient is the care of a case with the symptoms of Bright's disease possibly in its pre-organic period, but the same as if she had not been pregnant, excepting that the anemia is more marked than in the early stage of Bright's disease in the non-pregnant.
A CONTRIBUTION TO THE STUDY OF EYE-STRAIN AS A CAUSE
OF NERVOUS DISEASES.*
BY A. G. BLINCOE, A. M., M. D.
Two years ago I prepared a short paper on eye-strain, which was published in the Transactions of this society for the year 1896, in which I gave the results of treatment of sixty-one cases of headache by correcting refractive and muscle errors, about forty per cent being cured, and fifty per cent benefited, making ninety per cent cured or benefited.
In looking over the notes of my cases for the past two years I find I have treated seventy-three cases of headache and various nervous troubles by the same methods, with fully as good results. Of these there were four cases of neurasthenia, two cured and two benefited; two cases of vertigo, both cured; one case of chronic chorea of a year or two's duration, and one case of cramping of the muscles bordering on same, both cured; one case of cerebral hyperemia, with mental derangement and delusion, cured; this case, however, had bromides and ergot in addition to the eye treatinent; two cases of epilepsy, both of which seem to have been benefited-one has gone three or four months at a time without a spell and without medicine, though for years
she averaged two or three a week; the other has had no spell for over • three months, having previously had them every three or four weeks.
Both of these cases have, in addition to their ainetropia which has been corrected, a muscle error, and are still under treatment for the latter. The remainder of the cases treated were headache sufferers. One of these, a young man, had been going on crutches for two years prior to the time I fitted him with a pair of spectacles over a year and a
*Read at the May meeting of the Kentncky State Medical Society, 1898,
half ago. A few months ago he called to see me, saying his headache was entirely cured and that he had laid aside his crutches, having gained in weight, strength, and general health.
An old lady, sixty-eight years of age, came into iny office last August, saying she wanted me to cure her headache with a pair of spectacles, as she knew of several whom I cured in that way. I told het that it was mostly younger persons whom I cured, but made an examination of her eyes and found she had, besides a refractive error, compound hypermetropic astigmatism, sixteen degrees of esophoria, an amount usually thought to require an operation. I, however, loaned her a pair of prisms to wear a week or so. She then reported them comfortable and beneficial, so I ordered her a pair of spherocylindrical lenses ground with prisms of required strength, base out, with a reading glass in the form of bifocals, for constant wear, and I am reliably informed by one of her neighbors, who came to me to get fitted with glasses for the same purpose, that she is entirely cured.
One of the cases of vertigo with occasional "blind headaches" had been paying monthly doctors' bills for years, but has had no trouble since putting on spectacles about four months ago. This case was peculiar in having near-sighted astigmatism in one eye and far-sighted in the other.
A clergyınan, thirty-five years of age, single, has been a neurasthenic since boyhood, and has for years been troubled with profuse sweat ing of the feet, for which he had tried numerous remedies, including strychnia in full doses. Nearly four months ago I fitted him with a pair of glasses, and in a recent letter, in reply to one that I had written him, he says: “I find the glasses comfortable, and would find it uncomfortable without them. Have worn them constantly. My general health has improved considerably, and I can stand twice as much work as I could before I got the glasses. My feet do not perspire as much as before, and I am not troubled as often with my heart as formerly. I believe I am improving all the time and that the improvement is due to the glasses." I hope to hear, in the course of a few months, of still further improvement in this case.
Last summer I was called to an adjoining county in consultation, and before leaving the place a farmer of the neighborhood, twentyeight years old, married, who complained of dyspepsia, headache, vertigo, insomnia, and palpitation of the heart, asked me to prescribe for him. I suggested that he come to my office for examination. The