THE CONSERVATIVE TREATMENT OF ECLAMPSIA.

A Preliminary Report.

BY

ROSS MCPHERSON, M. D.
Attending Surgeon.

IN June 1909, before the Obsterical Section of the American Medical Association at a meeting held in Atlantic City, the writer presented a paper entitled "A Study of Eclampsia with the results in two hundred and fifty cases". These cases were the entire number which had occurred in the service of the New York Lying-In Hospital up to that time, and represented all types of convulsive toxemias treated by a considerable number of operators, but in the same general way, namely by means of operative interference in nearly every case as soon as the diagnosis was made.

Indeed, to quote the final paragraph of the article mentioned, and, parenthetically it may be observed, a paragraph whose sentiments met with practically the unanimous approval of the section, "until we have a more tangible knowledge of the actual cause of these toxemic convulsions -the only feasible treatment for the condition of eclampsia is immediate evacuation of the uterine contents followed by proper eliminative care in the puerperium."

Truly a radical statement, but honestly and sincerely made and expressing what at that time seemed to the writer to be the most logical form of treatment of the condition under discussion.

As stated in another paragraph of the same article the mortality both maternal and fetal was appalling, namely from 30.8-23% in the former and 44% in the latter. These mortality figures were subject to some analysis and explanation, but in the end result the fact remained that about one fourth of the mothers died and nearly one half of the children were still born or died very shortly after birth. While these figures compared very favorably with those published by other operators and from other clinics, it readily can be seen that a complication which carries such a mortality in its train is a serious problem and any treatment which holds out hope of better results, at least merits serious consideration.

Medical men, however, to put it mildly, are apt to be conservative and although Tweedy & Wrench's text-book (Rotunda Practical Midwifery) was published in 1908 and although Leighton and numerous others have published articles from time to time on another method of handling the convulsive toxemias it was not until 1915 that the writer definitely decided to apply the so-called "Rotunda" treatment to all cases coming under his observation.

An arrangement was made whereby all cases of convulsive toxemia occurring in the wards of the First Division of the New York Lying-In Hospital were assigned to the author for care, and the results were carefully noted. Since this time there have occurred thirty-five cases of convulsive toxemia, in all of whom the treatment later to be described was administered: Of these thirty-three mothers were discharged from the hospital well, fifteen children were born alive and were discharged well, fourteen children were still-born and six children died within a few hours after birth. This leaves a maternal mortality in the series of 8.6% and a still birth mortality of 40%. Compare this with the figures quoted in the article already referred to, or in the published articles of most operators and it will seem as if the result speaks for itself, for so far as the mothers were concerned, the mortality has been reduced by over two-thirds, and the still birth mortality has not been increased.

All of these cases were true convulsive toxemias having had one or more convulsions before admission, and all were treated in approximately the same way.

Coming now to the specific treatment as it has been conducted in the cases comprising this series, it is as follows:

Immediately on entrance to the hospital, the patient's blood pressure is taken, a catheterized specimen of urine obtained and she is put into an isolation room which is darkened and as much quiet as possible obtained. She is then given by hypodermatic injection 1⁄2 grain morphine sulphate, her stomach is washed out, 2 ounces of castor oil is poured down the tube, at the end of the lavage, and she is given a colonic irrigation of 5 gallons of 5% glucose solution.

If the blood pressure is over 175 systolic, phlebotomy is done and a sufficient quantity of blood is extracted to bring the pressure down to 150. In the opinion of the writer it is unwise to bleed the patient if the pressure is lower than 175 systolic, as if it becomes for any reason necessary to operate a little later and a good deal of blood is lost during the operation, the pressure will be reduced so low that the patient may die from shock. The same objection applies to the ante-partum administration of large doses of veratrum viride.

The patient is now kept quiet and 14 grain morphine administered every hour until the respirations drop to eight per minute. At this time convulsions have usually ceased, the patient will have fallen into labor, and, as has happened in practically all of our cases, will deliver herself in a short time.

Of the cases included, twenty-three were spontaneous deliveries nine were delivered by low forceps, two by version and breech extraction, one breech presentation and delivery.

It is interesting to note that all the patients in whom a fetal heart was heard on admission were delivered of living children, and that in none of these were there any signs whatever of the morphine which had been

administered to the mother, which is interesting in view of the enormous amount of unfavorable comment caused by the opponents of scopolaminmorphine amnesia, where as a rule only 1-6 of one grain of morphine is used during the whole treatment.

In conclusion, let it be understood that it is fully recognized by the writer that the number of cases reported is very small but taken in conjunction with the similar reports published by other authors, it would seem as if in the outlined treatment of the convulsive toxemias we had a method which was far in advance of our previous ones and which should merit careful and thoughtful attention of all those men under whose observation this class of case may fall.

IS THE OPERATION OF CESAREAN SECTION INDICATED IN THE DELIVERY OF BREECH PRESENTATION.*

BY

ROSS MCPHERSON, M.D.
Attending Surgeon

A WELL-KNOWN teacher of obstetrics once remarked in the writer's hearing, that if he were asked how to determine the capability of an obstetrician, he would like to be present and watch the operator's method of conducting a breech presentation and delivery; and that he would be willing to let his opinion of the physician's skill as an accoucheur rest on the manner in which the case was treated. This may sound rather like a radical statement, but after thoughtful reflection upon the complication under consideration, it does not seem that such a judgment would be entirely unwarranted.

An abnormality which occurs in 3 to 4 per cent of all labors, with a fetal mortality estimated by various authors as from 10 to 30 per cent., certainly merits more than superficial thought, and if with our present recognized modes of delivery such an extreme fetal mortality really does result, it would seem that we should look somewhat further afield, and attempt to discover and carefully consider some other method which will yield more living children, always provided that the maternal risk is not increased thereby.

With the idea of trying to discover what the actual figures would be in a large number of cases, the writer has attempted to analyze 3412 cases of breech presentation and delivery which have occurred in 97,000 confinements, all in the service of the New York Lying-In Hospital from its inception to September, 1915. An earnest effort has been made to include in the fetal mortality only those cases in which the cause of the stillbirth could be directly attributed to the breech delivery. Such *Appears also in American Journal of Obstetrics, November, 1916.

causes as prematurity, placenta previa, toxemia of pregnancy, deformed pelvis, abdominal and pelvic tumors while noted, have been eliminated, as it is impossible, if these complications are included, to determine what proportion of the still-births was caused by the existence of the abnormal presentation with the subsequent abnormal labor, and what proportion was due to the complication. Such an elimination in the same way, and for the same reason is necessary in order to determine the maternal mortality in breech presentation and delivery, and it is most essential to have an absolutely clear view of the maternal death rate, in order to compare it with that of any other operative procedure which we may wish to substitute for the recognized methods of delivery in this complication. The actual etiology of breech presentation is not entirely clear, it being stated that gravity, flaccid uterine and abdominal walls, impediments to the engagement of the head, etc., etc., all play a large part. Williams' believes that in primiparae, particularly, the existence of a breech presentation always means some disproportion between the fetus and pelvis or the fetus and the uterine cavity. He states, however, that "there will still remain, in spite of the most careful examination, a large number of cases in which no definite disproportion between the fetus and pelvis can be demonstrated before delivery."

There would, therefore, seem to be considerable doubt as to the cause of breech presentation, and the fact of universal disproportion in primiparae does not seem to the writer to have been proved.

The frequency of occurrence of the abnormality under discussion in Pinard's series taken from 100,000 labors was 3.3 per cent, in our series the complication occurred in 97,000 cases, 3412 times or 3.5 per cent or in 2.3 per cent of cases reaching term. Pinard states that 59 per cent of all cases occurred in multiparae. In our series 72.3 per cent occurred in multiparae.

In contradistinction to these figures are those of De Normandie2, based on a much smaller series it is true, who found that breech presentation occurred in primiparae in 57.2 per cent of his cases at the Boston Lying-In Hospital.

So far as prognosis for the mother is concerned, the maternal mortality does not, and should not, differ greatly from that of vertex presentation in uncomplicated cases. The maternal mortality in our series, including cases complicated by convulsive toxemia (eclampsia), of which there were thirty seven, placenta previa, of which there were sixty-three, chronic nephritis, chronic endocarditis, pneumonia, etc., all of which have a mortality of their own, was 0.96 per cent. Excluding these complications, the mortality was found to be 0.47 per cent, which is not excessive, when it is considered that many of these cases had been handled by outside physicians and midwives.

Coming to the prognosis for the child, however, here we find a much higher mortality than in vertex presentation. The fetal mortality is

generally estimated by various authors at from 10 to 30 per cent. In our series of the 3412 cases of breech presentation, 336 children at term were stillborn, a mortality of 9.4 per cent, 422 were premature, and would in all probability not have survived in any event. We are, therefore, concerned with the treatment of a complication, as a result of which 9.5 per cent of the children are stillborn.

Regarding the parity of the mothers, 944 were primiparae; 2468 were multiparae.

Regarding the fetus, there were 198 still births in the 944 primiparae and 560 still births in the 2468 multiparae, a percentage of 21.6 per cent, and 22.7 per cent, respectively. In other words, the difference in mortality in the children between primiparae and multiparae was so small as not to be considered.

Broadly speaking then, the operative choice of a means of delivery lies between the usual method by the vaginal route or by means of an abdominal hysterotomy, which latterly seems to be the panacea for all obstetrical ills and malpositions.

Williams, of Boston3, in an article entitled "Cesarean Section for Primiparous Breech Presentation," frankly expresses himself in his concluding paragraph as being committed to the abdominal hysterotomy for a breech presentation in the majority of cases, and quotes the history of two cases in which he performed the operation with favorable outcome for both mother and child.

It is unfortunate for the subject in hand that these two patients showed exactly what they did, for in the first one, while it is true that the fetus presented by the breech, the patient in addition had a submucous fibroid; this prevented the descent of the presenting part which would have been just as great a bar to a fetus presenting by the vertex. According to the measurements given, the pelvis was large, the baby of moderate size (71⁄2 pounds), and the abdominal hysterotomy in the last analysis was done, not for breech presentation, but for fibroid. The second case above referred to showed a 91⁄2-pound baby, and a pelvis with a true conjugate of 10 cm. with the external measurements very slightly contracted, and Williams takes the ground that owing to the fact that the breech was not engaged an abdominal Cesarean section was indicated which he successfully performed. This argument presupposes that a 912-pound breech cannot be delivered through a pelvis which is practically normal, a statement which the writer is strongly inclined to doubt.

Let it be understood that we are far from believing that there will not occasionally be a patient, either multipara or primipara, in whom there will be a disproportion between the size of the child and the mother, in breech as well as in vertex presentations, and in whom an abdominal Cesarean section is indicated in order to save the life of the child; nevertheless, there is a definite maternal mortality to Cesarean section, even in the best and most conservative hands, of from 2 to 4 per cent which