7735 VOL. XVII BROOKLYN-NEW YORK, JANUARY, 1903 ORIGINAL ARTICLES. CONTRI REMARKS UPON SOME OF THE RECENT BUTIONS TO OBSTETRIC THERAPEUTICS. BY CHARLES JEWETT, M.D., FEB Professor of Gynecology and Obstetrics, Long Island College H pital. Read by invitation before the American Therapeutic Association, May, 1902, in New York. No. I these were moribund when they came under TON Stroganoff's observation. The distinctive feature of his treatment is the control of the nervous system by means of morphin and chloral. 18104th grain morphin hydrochlorate is administere hypodermically on the occurrence of a convulston and the drug is repeated in smaller doses p.r.n. Two hours later, 30 to 45 grains of chloral hydrate in aqueous solution are thrown into the bowel. The latter is repeated in smaller quantities at intervals of four to eight hours, as required. A very moderate degree of narcosis is maintained by the use of these two drugs for 24 or 48 hours. All violent measures for provoking the action of skin, bowels and kidneys are withheld. Chloroform is used very little, blood-letting not at all. Peripheral irritation is as far as possible avoided, and cardiac depression is combated. Yet operative delivery is sometimes practised. Most departments of therapeutics deal solely with disease. Childbirth most frequently is a physiological process. It would seem to afford, therefore, a more limited field for therapeutic discovery than other departments of practical medicine. Yet the obstetric art is far from being non-progressive. Each year its resources are enriched by new and valuable acquisitions. In the limited time allotted I can refer to a few only of the recent proposals in obstetric therapeutics, and those but briefly. One theme always prolific of discussion is: Eclampsia. The recent literature of obstetrics abounds in contributions to the study of eclampsia, but the precise nature of this affection still remains unsettled. That, as a rule, it is primarily an autointoxication of other than renal origin there can be little doubt. Whether the fault lies most in the fetal or the maternal metabolism is yet to be determined. The doctrine of infection, the theory of hepatic insufficiency and more recently the relation of the thyroid secretion to the crippled elimination, and even the possible influence of the placenta upon the products of metabolism are among the claimants for consideration. Regardless of the nature and origin of the toxic condition the objects of treatment are essentially three: I. To limit the action of the poison. 2. F. S. Newell, of Boston (Boston Med. and Surg. Journ., Feb. 20, 1902), has reported satisfactory results from this plan of treatment, though falling short of the claims of Stroganoff. Morphin, which in this country is generally looked upon with distrust, is a favorable measure with many English practitioners. Among its champions, too, are such wellknown German authorities as Olshausen, Fehling, Veit, Dienst and many others. It would seem that the drug is deserving of more attention in the treatment of eclampsia than is now given it by American obstetricians. Carefully recorded observations of clinical experience with this agent in small doses of one-fourth to one-sixth grain, would be profitable contributions to the therapy of eclampsia. There is a possible danger for the child in the too free use of morphin before delivery, and it is positively contraindicated in the comatose form of the eclamptic state. My personal experience with morphin in eclampsia is limited to its very moderate use in conjunction with veratrum and for the purpose of controlling the unpleasant effects of the latter drug. I have observed none but good results from it when given in that manner. Most relied on as anti-eclamptics are chloroform, chloral, trinitrin and veratrum viride. Chloroform is universally conceded to be a dan gerous agent. Well nigh indispensable for quick effects in emergencies, and especially during operative delivery, all authority unites in condemning its prolonged use. Veratrum viride and trinitrin are about equally in favor. In the writer's experience veratrum is more efficient than trinitrin. The practitioner who begins the treat ment early with a subcutaneous dose of 15 to 20 minims of Squibb's fluid extract, or of Norwood's tincture, and holds the circulation well under its influence by smaller repeated doses, as required, cannot fail to recognize its value. Its use need not be wholly restricted to high vascular tension. Of eliminative organs, the most important is the kidney. The most prompt and effective diuretic measure is the introduction of large quantities of water directly or indirectly into the circulation. Jardine, of Glasgow (Brit. Med. Journ., May 26, 1900), adds a diuretic salt to the infusion. His solution consists of sodic chlorid and sodic acetate, one drachm of each to the pint of sterilized water, or of sodic chlorid and potassic carbonate in similar strength. Two or three pints are used and repeated as required. Either the intravenous or the subcutaneous route may be chosen, or the solution may be injected into the bowel. Not only the volume of urine, but also the total daily quantity of urinary solids is increased. The post mammary injection is at once so simple, speedy and safe and so easily available that for the writer it has almost wholly replaced the intravenous method. If not promptly effective it soon becomes so under cardiac stimulation. With the usually recognized limitations saline infusions are of the greatest value in the treatment of eclampsia. Jorgens reports good results in eclampsia treated by injections of potassic iodid into the breasts. Saline catharsis is universally practised. C. M. Green (Am. Gyn. and Obstet. Journ., Jan.-Feb., 1901), in addition to usual diaphoretic measures, immerses the patient in water as hot as can be borne till profuse perspiration is established, the heart, meantime, being supported by stimulants, if required. This can scarcely be adopted as a safe routine measure in view of the extreme peripheral irritation involved. Killebrew, Olshausen, Fehling, Wyder, Goedecke and others advocate the abstraction of 12 to 25 ounces of blood immediately followed by injection into the veins of normal salt solution in two or three times the volume of blood taken. It is more than probable that the good results of this treatment are due more to the effect of the saline solution than to the blood letting. Blood letting is doubtless best reserved for cases of deep cyanosis with extreme vascular tension. Its action is to be explained by its effect in diminishing the blood pressure, rather than the removal of toxins, as Schatz has observed. It can scarcely appeal to the rational practitioner as a routine measure for lessening the intoxication. Inhalations of oxygen for relieving cyanosis are useful. In a paper read before the Edinburg Obstetric Society (Brit. Med. Journ., June 22, 1901), Dr. H. Oliphant Nicholson assumes that toxæmia exists in every pregnancy as the result of fetal metabolism. The toxins differ in kind and amount in different instances and in exceptional cases are produced in great abundance. So long as the kidneys are active no evil effects are observed. Toxic symptoms are immediately apparent when the urine is much diminished. Special importance is attached to the relation of impaired function of the thyroid to the mechanism which arrests the renal secretion. The thyroid gland, he believes, exerts an important influence in modifying and destroying proteids. Lange is cited to the effect that out of 25 pregnancies in which the usual hypertrophy of the thyroid gland was not present, 20 had albuminuria. In those in whom the usual physiological enlargement of the thyroid was observed during pregnancy the administration of large doses of thyroidin was followed by marked reduction in the size of the gland, and a decided diuretic effect was noted. In thyroid inadequacy the excretion of urea is diminished and the hepatic functions also are impaired. Accordingly, Nicholson advises the use of thyroid extract in the treatment of the pre-eclamptic state and even during the convulsions. He recommends five-grain doses twice daily for the prophylactic treatment and the injection of 10 minims of liquor thyroidei every one or two hours as a remedial measure. The fresh juice of sheep's thyroid in doses of 10 minims, he regards as still more active than the extract. He suggests that the well-known favorable action of potassic iodid in the treatment of eclampsia may be due to its effect upon the thyroid secretion. Finally, Dr. N. concludes that by the combined use of morphin and thyroidin it is possible to relax the arterial spasm, to arrest for the time general metabolism, and by supplying artificial iodothyrin to combat symptoms due to its de ficiency in the blood and tissues as well as to supply iodin for elaboration of iodothyrin by the thyroid gland itself. Unfortunately for Dr. N.'s conclusions, they must be regarded as based on insufficient grounds. On the advisability of prompt evacuation of the uterus after the onset of convulsions at or near term, there is practically no difference of opinion. The diminished mortality from eclampsia in the German clinics, which is estimated at 10 to 15 per cent., is credited by Söhlein to the uterine dilator. It is variously estimated that convulsions cease in from 50 to 80 per cent. of cases after delivery. All recognize the advantage of a reasonably speedy termination of the labor under a short chloroform narcosis. It must not be assumed that the good results of immediate delivery lend encouragement to Cæsarean section. The statistics of the latter operation in eclampsia are not encouraging. Döderlein estimates the maternal mortality at 42 per cent. after Cæsarean section in eclampsia. Hillman (Monats. f. Geburts. und Gyn., Aug., 1899) reports 22 maternal and 23 fetal deaths in 40 cases—a mortality of 55 and 57.5 per cent. respectively. The fact cannot be too strongly emphasized in all discussions of this subject that the best treatment of eclampsia is prevention. Under a proper supervision of pregnancy the occurrence of puerperal convulsions must be rare. Cæsarean Section in Placenta Prævia.-Cæsarean section for placenta prævia, first suggested by Lawson Tait, has been strongly upheld by Ford, Dudley, Boyd, Zinke and Donoghue. These writers see in the Cæsarean operation a ready escape from the usual dangers of central or nearly central implantation, and they think it especially suited to cases in which the vicious insertion is complicated with primiparity, rigid cervix or a transverse presentation. It is urged in defense of this proposal that the maternal mortality in placenta prævia under the usual obstetric methods of treatment cannot be estimated at less than 10 to 25 per cent., and that the fetal death-rate is 75 to 85 per cent. As Lyle has well said, that treatment in vicious implantation of the placenta which is best for the mother is worst for the child. The converse is equally true. The advantage for the children in Cæsarean section, if any, must be purchased at a considerable cost of maternal lives. Yet the gain for the child must be small since in most cases the fetus is immature. In 8 Thirty authors cited by Zinke give an average maternal mortality of 25 per cent., and a fetal death-rate of 65 per cent. in placenta prævia treated by ordinary obstetric methods. cases referred to by Zinke there were 3 maternal and 2 fetal deaths after Cæsarean section for placenta prævia, a maternal mortality of 37 per cent., and a fetal of 25 per cent. Even granting Zinke's claim, that 2 of the cases should not be counted against the operation, 17 per cent. of the mothers were lost. Contrast these figures with the following results of treatment without abdominal section. In 264 cases in Shauta's clinic only 6.06 per cent. of the mothers were lost, and many of these were admitted in bad condition. Fifty-four per cent. of the children died. In 50 cases of central or total placenta prævia there was a maternal mortality of 18 per cent., and a fetal of 70 per cent. Strassmann is authority for the statement that in the Charité in Berlin, the maternal death-rate was 1.45 per cent. in placenta prævia treated by version by external manipulation, and 8.6 per cent. in cases treated by bi-polar version with slow extraction. Lyle (Brit. Med. Journ., Jan. 19, 1901) publishes 76 cases treated in the Rotunda Hospital. Four mothers were lost, but only one from hemorrhage. Two of the fatal cases were septic on admission and one died of pulmonary œdema on the 10th day. Lomer, in 10 cases, treated by bipolar version without immediate extraction, lost less than 5 per cent. of the mothers. Fornier (L'Obstetrique, Nov. 10, 1900) reports seven cases of placenta prævia treated by artificial dilatation of the cervix and podalic version in which all the mothers and four of the children were saved. Fry, in 14 cases, saved 14 mothers and 4 of the children. De Lee, in 25 cases, saved all the mothers. The comparison is by no means flattering to the new proposal, and especially if the proper value is to be placed on the lives of the mothers. It is not reasonably to be expected that in the best of hands and under the most favorable surroundings the percentage of mothers lost under Cæsarean section upon women exhausted by hemorrhage would fall below 10 or even 20 per cent. And it is extremely seldom that the diagnosis of vicious insertion of the placenta is made. before a hemorrhage of greater or less amount has occurred. Often the woman is nearly ex |