Lichtenstein[123] reported, from Zweifel's clinic in Leipsic, the results of 400 cases of eclampsia, and he found that the eclamptic convulsions cease in only one-third of the cases after any form of delivery. He says the mortality of induced labor is no better than that after forced delivery, and that the mortality of both methods does not materially differ from the mortality of a long series of cases where there was no such intervention. The difference in the mortality between eclampsia without delivery or with delivery seems to depend on the relative loss of blood. In 40 per cent. of eclamptic cases operated upon, the loss of blood was 500 c.c. above the loss in cases of spontaneous delivery. The loss of blood tends to produce collapse when the blood comes from the uterus, although it may be beneficial if removed by venesection before delivery. Five hundred c.c. of blood is one-eighth to one-ninth of the entire blood supply of the body in a woman of average size. If 500 c.c. of blood is withdrawn before the shock of forced delivery and replaced by an equal quantity of normal salt solution, the toxin is thus reduced by one-fourth or one-third and then diluted by the normal salt solution, so that it has less poisonous effect.
Lichtenstein[124] describes the expectant treatment by phlebotomy and narcotics to replace operative interference, and this method has revolutionized the mortality of the treatment of eclampsia. In ninety-four cases of eclampsia his mortality was only 5.3 per cent., and none of the deaths could be ascribed to the treatment. The infant mortality was 37.3 per cent., as against his 38.8 per cent. in active operative interference during preceding years. Werner, in the Second Gynecological Clinic in the University of Vienna,[125] by this new method in thirty-eight cases of eclampsia had a maternal mortality of 5.2, as Lichtenstein had, but his infant mortality was only 14.65 per cent., an enormous advance for the better. Formerly the mortality in the Viennese clinic was 15.8 for the women and 44.3 for the children, in a series of 120 cases of eclampsia. A mortality of 50 per cent. in the children is common in the old method. In Lichtenstein's cases there were mental disturbances in 2.1 per cent. of the women, as against 6.75 per cent. in the old method. Eclamptics may go insane and kill the child after delivery. Lichtenstein treated 74 consecutive cases without a single death. In 54 per cent. of his cases the convulsions ceased after one venesection, and 42 per cent. of the women with ante-partum attacks recovered before labor came on. Engelmann[126] reported a case where a woman who had had 188 convulsions recovered after the third venesection.
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.
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.
[CHAPTER XIV]
Heart Diseases in Pregnancy
Over 20,000 women die in childbirth each year in the United States, and about 100,000 infants, and more or less permanent injury from parturition is almost general in mothers. The mortality in the trenches during the present great war is 2 per cent.; the mortality of infants during the first year is 14 per cent. Very much of this mortality and invalidism is attributable to lack of skill in the licensed unfit. We commonly deem parturition merely a physiological process, and for that reason the state permits ignorant midwives and quacks to take upon themselves with impunity the responsibility and the risks of delivery.