Ernest Watson Cushing.

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Salicin (3 gr. every four hours) for the Quinine, and in one week,
with no other change in treatment, her fever had disappeared, the
foul discharge had stopped, the tongue was clear, and the patient
ate and slept well.

Xashiia, X. TT.



My paf)(*r iniglit be more cornn'tly designated "Hygiene and
Medical Super\'ision of Pregnancy," and wliile T regard the sub-
ject as one of very great importance, it is neither my object nor
expectation to enlighten the body of physicians on this subject,
but to elicit discussion for my own edification, and, perhaps, of
others who feel an equal interest, as well as want of information.

Now we know that this most interesting of conditions, "preg-
nancy," is purely physiological, yet the pregnant woman needs
ei^pecial care, and should have medical supervision throughout the

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ng as soon as she is aware that

e husband out of justice to his
[) the future welfare of his off-
physician that the wife is "en-
\ supervision. Under normal
othing for the physician to do

general hygienic regulations.
le, which is so full of such vari-

have his hands full in getting

s in the matter of dress, as our
ir social relations that a great
:ly dress in a manner that is highly deleteri-
3 themselves in an attempt to hide their con-
?ir prospective maternity was a crime or dis-
most exalted position to which it is possible
nd the especial object of their creation,
lant women who do not injure themselves by
through a false modesty, immune themselves
rcise and fresh air, and thus become victims
ing themselves unfit for the ordeal toward

•oundings mentioned, the prospective mother
lit comfortable fitting garments of medium
lostly, or entirely, from the shoulders, with-
be one especially provided for the pregnant
tnportant that there should be as little con-
ion as possible of the chest or abdomen dur-
aent, for no doubt many complications arise
r at time of delivery, because of improper
ve its influence in faulty development of the

it the woman who is "enciente" should have
rcise; that she may have pure air, which will
Ithy muscular tonicity, good appetite and di-
irgely aid her in being light-hearted or cheer-
ental as well as bodilv emnlovraent or diver-

Bgnant women immuned to the four walls of

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304 J. H. PRESTON.

their room, or who only roam about the house, will become moody
or melancholic from brooding over their prospective confinement
This should be avoided, for it often times has an unfavorable in-
fluence on the course or termination
should have a happy, cheerful woman <
a happy, uncomplicated delivery of a
ing baby, a mother's joy and the fat!
expect a safe and comfortable passa

It is a fact admitted by physiologis
tion, that maternal emotions do affect i
well as its mental organization. As
monstrosities and imbeciles that can b<
way, yet none have been able to explai

In the light of these facts, the wis
direct the mind of his patient as well as
sudden, unpleasant news, frights or
avoided, and instead, everything possi
surroundings, with kind assurance of (
and that she has our gentle and protecti

In all of this the physician can be o:
mal pregnancy, should he assume conti
another and more weighty reason why
vision of pregnancy is, that many diseai
and often do, arise during this period
prompt and judicious action, or intellif
of which the physician will be better
early acquainted with her condition.

I stated in the outset that pregnancy
condition." Then if so, why so mncl

I would answer, because, like somi
cesses (for instance, menstruation and d
purely physiological), pregnancy is in
greater complications or accidents, an

Almost any disease to which mankind
the course of gestation, thus engenderin
pregnancy may occur, and often does ii
inherited disease. Pregnancy may be

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arouses some latent disease, or predisposition to the disease, int(i

Besides, there are a number of disturbances that might be
termed physiological phenomena, as they are not fully explained
except by reflex nerve action. Among this class we have the
vomiting of pregnancy, with which we are all familiar, and often-
times disagreeably so; neuralgia of the teeth, which occurs inde-
pendently of caries; reflex or nervous respiratory interference,
as cough and dyspnoea. I have a patient in my care now who has,
in her two preceding pregnancies, suffered from dyspnoea througli-
out the entire period of gestation, this being her third pregnancy.

In all these troubles our advice is needed and it requires our
best skill to combat them, and the best means of doing so is a close
application of the laws of hygiene.

One of the most fatal diseases that can supervene in the preg-
nant state is pneumonia, which is better treated by prevention.
That is, by proper hygienic care, it can almost always be avoided.

Diseases of the urinary system, either actual or sympathetic,
call for our intervention perhaps oftener than any one class of

We are often asked to prescribe for irritability of the bladder
or dysuria in first pregnancies, though rarely see incontinence in
such cases, but do frequently meet with it in later pregnancies.

Retention of urine is not an infrequent, and sometimes a very
grave accident, that is met with in pregnancy. If met with early
in pr^nancv, it may be attributed to reflex contraction of the
neck of the bladder. But it is most frequently met with as a
symptom of retroversion, at about the fourth month, or later, as
a result of cystocele. In either case, it is a condition requiring
prompt action, and if the physician had had the full confiSence
and oversight of his patient, he is all the better qualified to meet
the emergency.

If there is any one function of the entire organization of the
pregnant woman that requires especial care or attention over an-
other, or all others, it is the renal. Four different forms of renal
disease may be met with in pregnant women. Acute and chronic
parenchymatous and interstitial nephritis, as well as a special
form peculiar to pregnancy, and called pregnancy-kidney, or
pregnancy-nephritis. This last not only begins during preg-
nancy, but ends with it. The symptoms are oedema and albumi-

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306 J- H. PRESTON.

nuria. The course is usually favorable, but sudden increase of
the albumin and dropsy, with lessened excretion of urine, brings
eclampsia, the horror of the pregnant and parturient state. Acute
nephritis may also cause eclampsia, but it rarely occurs in the
chronic form.

The differentiation of the three forms is made probable by the
albumin appearing early in the chronic form, while it is not usual-
ly seen in pregnancy-kidney until the beginning of the last half
of pregnancy.

Acute nephritis is characterized by scanty and highly albu-
minous urine containing red blood corpuscles. In these cases the
physician should be wide-awake and alert that he may save his pa-
tient the horror of eclampsia. This can often be done by careful
observation and judicious treatment during pregnancy.

T feel confident that I have, in several instances, averted this
accident by pursuing this course.

For albuminuria that is very grave, the absolute milk diet is
said to bo the best treatment. Foumier says: "T^ot only is milk
diet the best curative treatment of the albuminuria of pregnancy,
but it is the best prophylactic treatment of eclampsia." He says,
further, "that he has never seen a pregnant woman, subjected to
this treatment for a week, become eclamptic."

But it is not my purpose in this paper to give you a dissertation
on eclampsia, or any other disorder or accident of pregnancy. I
only wish to emphasize the importance of an early knowledge of
any coexisting disease or complication, that we may act intelli-
gently for the welfare of our patients, and thus retain their confi-
dence, as well as protect the reputation of our profession.

An additional means to the understanding of the condition dur-
ing pregnancy, is an examination of the abdomen, after foetal via-
bility by external palpation, as there may be something learned
regarding the state of the fcetus as to position or multiple preg-

Tt is rightly proper that every woman in her first pregnancy,
or one who has had special difliculty in a previous parturition, be
examined by external and intewial pelvimetry about the seventh
or eighth month, for if the labor promises to be long, painful or
difficult from obstruction of any kind, the obstetrician ought to
know it in advance that he may elect, at the proper time before
parturition, whether to choose the induction of a premature labor.

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to depend upon the use of forceps or to resort to j)odalic version,
symphysiotomy or a Csesarean section, and thus avoid craniotomy.

We know that in the management of pregnancy no special rule
can be followed, as no two pregnancies are alike, even in the same
woman. So we are to be governed by general principles, our
treatment being largely expectant. Our main reliance is in the
carrying out of hygienic instructions.

Twill say in conclusion that I am aware that my thoughts in this
paper are not as systematically set forth as they might have been,
but they serve to express my idea of the importance of the subject,
which idea was the true motive for this paper. Another was that
we are sometimes asked if there is no means of making child-
bearing easier, and are told that some doctor in the community
has said that he prepares his patients for the time of confinement,
and by so doing makes their labor shorter and less painful. I
have attended some women who said they had used some prepa-
ration advertised as "Woman's Friend," or "Child-bearing Made
Easy," with benefit.

I saw no difference. In fact, I attended one lady in two con-
finements, one without, the other after she had used "Woman's
Friend." The latter was the more tedious and painful, lasting
about thirty-six hours.

Xow, if there be any %alm in Gilead" for the parturient wom-
an, T would be glad to have it.

TTuni1>oldt, Tenn.



As eclampsia may occur before, during or after confinement, it
will be best to consider the treatment from each of these periods.

With no desire to trespass upon the ground assigned another, I
will refer briefly to some recent opinions that have been advanced
anent the causation of the disease. Dr. P. Kollman (in Cent. Bl.
fiir.Gvnacol., 1897) says he does not attribute eclampsia to retro-
grade nitrogenous changes found in the blood, but to a dispropor-
tion of the physiological constituents of the blood — the accumula-

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tion of fibrinous material in globulin or its derivations which may
be found in the venous blood of eclampsia. This autointoxication
has its origin in nephritis or mechanical obstruction which pre-
vents the elimination of the poisonous fibrinous and nitrogenous
elements which originate both in the maternal and fetal cells.

Allbut, in the Lancet, 1897, opposes the hypothesis that prea-
Bure upon the urinif erous tubules or nephritic veins by the gravid
uterus or spasm of the nephritic arteries would cause eclampsia,
but believes the accumulation of poisonous material in the blood
produces the changes in the kidney.

He accounts for the greater number of cases occurring in primi-
para, not from reflex Jipasm from the uterus, but from lack of im-
munity. In multipara he holds that the toxines circulating in the
blood have to a certain extent produced immunity. Volihard
(Mon-Sehr of Geburtsh in Gynacol., 1897) experimented on rab-
bits with the serum and urine of healthy and eclampsia patients.
He got negative results from the serum, but with the urine, in two
cases, intra-venous injections produced coagulation during life.
He says if this property of the urine in labor or eclampsia is veri-
fied by subsequent experiments, Schmorl's theory that eclampsia
is due to autointoxication by an irritating coagulating substance
will be tenable. The exact cause of eclampsia seems no nearer a
solution than it w^s ten years ago. The whole trend of opinion is
towards the acceptance of a poison in the blood as a cause.

Eclampsia being so universally associated with albuminuria
whenever albumen is found in the urine of a pregnant woman,
it should be regarded as a warning that eclampsia may occur dur-
ing gestation, parturition or the puerperium. In approaching the
treatment of a disease attended by such violent symptoms and
such a high mortality, preventive treatment is of the greatest im-

It is a matter of no slight importance that we have in a measure
a successful preventive treatment. When a pregnant woman
has albumen in her urine she should at once be placed upon a milk
diet, which should be continued until the albumen disappears.
Every few days a dose of mineral water or other mild laxative
should be given; bismuth, saline, salol, benzonapthol and occa-
sionally some mercurial salt to keep the alimentary canal disin-
fected. After the urine is free from albumen, tonics snoh as

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quinine, gentian or iron may be given. If albumen reappears,
resort again to milk diet.

In a word, every care should be exercised to keep the different
organs of the body in a state of healthy equilibrium. If, as some-
times happens, milk is not tolerated by the patient, bleeding may
be tried, wet cups applied to the lumbar region, vapor baths. If
all these preventive measures fail, or if they have not been em-
ployed and an attack of eclampsia come on before term, what shall
we do ? The first thing is to prevent a recurrence, if possible, con-
sistent with the continuance of the patient's life.

Chloroform, chloral, morphine, veratrum, and other remedies,
have been recommended. The room should be well ventilated,
the clothing loosened, and the bladder examined to ascertain
whether or not it is distended by urine.

The first duty, however, is to administer some medicine that
will control the convulsions as much as possible consistent with a
continuance of the patient's life.

^Morphine, I think, has no place in the treatment of eclampsia.
Veratrum viridi has its advocates; it is given hypodermically, in
sufficient doses to bring down and maintain the pulse at about 56
or 60 beats per minute. I have no personal experience with it in

Chloroform, when pushed, which must be done to get its ef-
fects, will usually control the paroxysms, but if continued for any
great length of time, it becomes a question not always easy to de-
cide, which is the worse, the disease or the remedy.

Of all remedies, according to the statistics which I have exam-
ined, chloral, given alone, has been followed by the best results.
By rectum is the only practical way to administer chloral.

Dissolve 150 grains of chloral in 10 ounces of pure water; in-
ject 4 ounces into the rectum. Then every fifteen to thirty min-
utes, inject 1 ounce until convulsions cease, or until the whole
amount is given. If the convulsions continue, it is best to wait a
few hours, provided the medicine has all been retained, before
giving more. Another way to give chloral, which varies slightly
from the above, is to give 60 grains by enema. If this is only
partly retained, give a second or a third dose of 60 grains. Wait
five or six hours, and if necessary, give another 60 grain dose.

At the end of twenty-four hours, in either case, it is well to
give another dose of chloral.

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Too frequent examinations should not be made, nor should the
patient be restrained by holding the hands and feet, as these
manoeuvres tend to excite recurrences. The tongue should be
protected by holding a cork or soft piece of wood between the
teeth during the attack.

If the convulsions cease and the chil
quent treatment up to term should be tl
is found before the inception of eclampsi
given. If, however, the child is dead, (
dency to continue, the uterus should be
lay as possible. If the attack occurs at
should be instituted and the same atten
and emptying of the bladder. The ute
its contents as soon as practicable. The
tying of the uterus may call for a tern
chloroform, but this should be disconti
and chloral substituted. If the attacks >
istration by rectum of 150 grains chlorj
high and the pulse strong, additional dos
to 200 grains have been given during t

A case is reported by Charpentier, i:
given in ten hours and the patient made
much chloral should be given, strychnia
act the excessive effects. The subsequei
rected in keeping bowel and kidneys
normal, and to the improvement of the
tion of tonics and iron. A combinatioi
results in my hands as a blood purifier <
about the following:

T}. Potass. Chlor.,

Tr. Ferri. Mur.,
Rvr. Limon.,
M. Sig. Teaspoon ful in water ever

The diet should consist for some day
not overtax the digestive and eliminativi
not be well to adhere so strictly to a mil
ive treatment.

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If eclampsia occur during the puerperium, the same remedies
used at confinement should be employed. Give calomel so as to
get copious actions from the bowel, apply hot stupes to the ab-
domen, and give warm vaginal douches. Tf the lochia is offen-
sive irrigate the endometrium with warm water, and remove clots
or pieces of placenta, if present, with a curette.

M'Gregor, Texas.



By puerperal ei'lampsia we mean eclampsia occurring during
pregnancy or immediately afterward. This may occur at an>*
time during gestation, but is more prone to occur during accouche
ment, or very soon afterward. We would not include in this
class the various cases of eclampsia that might be accidental, or
due to other, and distinct causes, as epilepsy, chorea, hysteria, etc..
basing our diagnosis upon the symptomatology and frequency of
these attacks at other times in individuals subject to these disor
ders, taking into consideration the possibility of puerperal

Prodromal symptoms are more often present when eclampsia
occurs during the course of pregnancy than at the time of partu-
rition or subsequently, and prominently among these are cephal-
algia, usually frontal, defects of vision, as diplopia, indistinct vis-
ion or blindness, dyspnoea, and epigastric pain. I am inclined to
attach considerable importance to severe headache, vertigo, and
partial or complete loss of vision.

Sometimes insomnia will precede an attack of eclampsia. Al-
buminuria is a prodromal symptom of much importance. ^^Tiile
every case of albuminuria does not result in puerperal eclampsia
it is extremely probable that c^ses of eclampsia may and do occur
without the appearance of albuminuria. For the integrity of the
vessels and secreting cells of the kidneys being good, insufficiency
Hoes not occur even though the system is overloaded with urea.

Again, it is well to eliminate all possible chances of error be-
fore attaching grave importance to albuminuria by knowing that

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312 T. W. SHEARER.

it results from insufficiency of the kidneys, and not from ure-
thritis, cystitis, pyelitis, leucorrhcea, etc.

The author is strongly of the opinion that albuminuria would
eventually be symptomatic of all cases of puerperal eclampsia,
should the causal relations exist for a long enough time to injure
the parenchymia of the kidneys. The fact that the parenchyma-
tous structure of the kidneys is strong enough to resist the escape
of albumen or blood cells for a time does not prove that the blood
may not be surcharged with urea, and other products of nitro-
genous metabolism which are capable of producing the phenome-
na attending puerperal eclampsia. But more often the secreting
cells of the kidneys become congested and less capable to perform
the extra work entailed upon them, insufficiency occurs and albu-
minuria results. Albuminuria occurs in about ten per cent of
all pregnancies, and eclampsia occurs once in about three hundred
and fifty pregnancies, which leave quite a discrepancy between the
two in point of number, but how many of these cases are due to
diseases of the heart, liver, lungs, Bright's disease, the sexual or
urinary organs, etc., the statistician (Auvard) does not say. How-
ever, we are inclined to consider albuminuria the most important
symptom of puerperal eclampsia, although we believe that preg
nancy in some manner at times arrests or interferes with the nitro-
genous metabolism of the organism resulting in the accumulation
of intermediate products of oxidation as creatin, creatinin, or
other products that are even more poisonous than urea.

The above symptoms may be premonitory for some weeks or
days; yet in many cases there are only a few hours or minutes, or
no warning at all before the eclampsic attack. Some involuntary
twitching of the facial muscles and rolling of the eyes quickly
followed by a tonic convulsion which may or may not show
opisthotonos or pleurothotonos, depending mainly upon the
severity of the muscles involved. This in a short time gives way
to clonic convulsive movements of the entire body, the convulsive
movements growing less violent until they cease, which is geii-
erally in a few minutes, consciousness usually returns unless the
first seizure is rapidly followed by others, in which case conscioua-
noss may not return and a series of convulsions is followed by a
deep sleep. There is usually a temperature, and if the tongiie i"
lacerated, bloody froth may issue from the mouth. The piior-
pf^ral convulsions resemble epilepsy in many particulars: there

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may be only one, or many may recur in rapid succession. The
breathing becomes more or less stertorous, followed by profound
coma. Death may result from asphyxia due to prolonged con-
traction of the respiratory muscles, or the shock to brain and sym-
pathetic nervous system may be so severe as to paralyze the heart's
action, and heart failure ends the scene, or a general enfeeble-
ment of body and mind results, which may terminate fatally some
weeks afterwards.

The author has had four cases of puerperal eclampsia, two of
which occurred during accouchement, and two shortly after de-

Albuminuriawas present in every case, severe cephalalgia,front-
al in three, occipital in one. Dimness of vision and sudden at-
tacks of vertigo with blindness occurred in two of the above cases.
One suffered with dyspnoea. Two recovered rapidly, one having
three or four other convulsions, all the convulsions occurring with-
in six hours; there was extreme nervousness and little coma. One
died on the second day after delivery in a tonic spasm, the first
and only convulsion after delivery. The fourth and last case had
sixteen or eighteen convulsions, extending over a period of three
weeks, and was comatose most of the time, with intervals of con-
sciousness in which she suffered with cephalalgia and extreme ner-
vousness. The urine was examined often in this case, and the
condition of the kidneys seemed to serve as a barometric indica-
tion of the case; as they improved the patient grew better and re-
covered. All the cases reported were primipara, and all young,
otherwise healthy women.

Wallisville, Texas.

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The Use of Sugar of ^Milk to Hasten Labor or to Facili-
tate THE Expulsion of Retained Miscarriage. — ^In a recent is-
sue of the Revue obstetricale intemationale is to be found a paper
of obstetrical interest by Dr. Klein, intern in the maternity of the
St. Antoine Hospital of Paris.

Of recent years much attention has been given to the value of
foods containing sugar as stimulants of the muscular fibre. Gly-
cogene of the muscle, and especially glycose of the blood, have
been found to be factors in the production of muscular energy,
and a decrease in the fatigue of muscles or an increase in the activ-
ity of their contractions has been obtained by increasing the
amount of sugar in the blood.

Several recent papers have demonstrated the influence of the
ingestion of sugar on muscular work, and generally speaking it

Online LibraryErnest Watson CushingAnnals of medical practice → online text (page 28 of 77)