In this method the woman is put in a dark, quiet room; 400 to 600 c.c. of blood are withdrawn by venesection, and 0.002 gm. morphine is injected; two hours later 3 gm. chloral is given in an enema. If the fetus presents in a position for prompt delivery it is removed with forceps, or by expression to spare the mother; but expression is a dangerous process always. Zinke[127] of Cincinnati has a method which reduces the maternal mortality, but it has an enormous infantile mortality. He depresses the maternal pulse by veratrum viride, and this depression is probably the cause of the infantile mortality through asphyxia. Veit introduced the use of morphine in eclampsia, and Winckel the use of chloral. It has been found that narcotics check the action of toxins on the nuclei of cells, and in eclampsia the action of narcotics may be of this nature. Baker of Alabama in 1859 first gave veratrum viride in eclampsia. The drug lowers arterial tension by depressing the vasomotor centres and the heart itself. In eclampsia it diverts blood from the brain and depresses the motor neurons of the spinal cord. Aconite has the same effect in acute cerebral congestion without depressing the vasomotor centres or irritating the stomach as veratrum viride does. [127] _New York State Journal of Medicine_, xiii, 8. Cesarean delivery is used frequently of late in eclampsia. The mortality of the children is lowered somewhat by a cesarean section, but the mortality of the mothers is much worse than in the expectant method described by Lichtenstein. Eclamptic women usually have badly affected kidneys, and the anesthetic used in the section may be a cause of the raised mortality. Peterson reviewed 500 cases of cesarean section for eclampsia[128] done by 259 operators in various countries. Up to 1908 the maternal mortality was 47.97 per cent. in 198 cases; from 1908 to 1913 it was 25.79 per cent. in 283 cases. Convulsions ceased in only 54.92 per cent. of the women after cesarean delivery, and in those cases in which the convulsions continued the mortality was 31.53 per cent. In 146 cases where the convulsions ceased the mortality was still 19.8 per cent. for the mothers. The fetal mortality was 10.69 per cent., counting all children who died within three days after delivery by section. The maternal mortality after cesarean section increases with the age of the patient. The cesarean delivery, then, has a maternal mortality of late of 25.79, with a tendency to increase as unskilled men attempt it; the expectant method has a maternal mortality of only 5.3 per cent. The cesarean delivery has a fetal mortality of 10.69 per cent.; the expectant, 14.65 per cent. The expectant method is preferable. [128] _Amer. Jour. Obstetrics and Diseases of Women and Children_, lxix, 6. CHAPTER XIV HEART DISEASES IN PREGNANCY