A number of remedies have been highly recommended for this at various times. Nearly every alterative drug has had its period of popularity. In the older time nitrate of silver was said to be efficacious. Small doses of ipecac were highly recommended at one time. Small doses of cocain were suggested, and the painting of the back of the throat with cocain. Small doses of morphin had a vogue; codein had its turn after its introduction, and heroin also had a time of popularity. Oxalate of cerium was highly recommended. Any obstetrician of experience will remember many other remedies that have been supposed to be efficacious. Various gynecological procedures have been suggested: the touching of the cervix uteri with a mild caustic, with iodin or with nitrate of silver, slight dilatation of the cervix, sometimes the application of a tampon with just enough glycerin to produce a reaction, but not enough to terminate the pregnancy. Occasionally local applications over the stomach region, a mustard leaf, or certain plasters, or finally even a piece of sized paper bound on over this region have been known to be followed by the cessation of the vomiting. When as many different remedies are recommended and seem for a time to be successful and then later prove to be inefficacious, it is reasonably clear that it is not the remedies but the effect produced by these on the mind that is the important therapeutic factor.
Many obstetricians of wide experience now teach that most of these cases of vomiting in pregnancy are merely neurotic and are to be treated entirely [{456}] as if they were hysterical. The patient's mind is to be distracted from her condition; she is to be assured that even severe vomiting is quite common in pregnancy, that it is annoying, but never serious in its consequences, that it always ends without unfortunate incident for mother or child, and that there need be no solicitude. Above all, no hint of the possibility of the necessity for the termination of the pregnancy, if vomiting continues, should be given. Some physicians are entirely too solicitous in the matter and have by their anxiety made the neurotic condition of their patients worse. Some men see what they call a "pernicious vomiting" in every hundred labors. A well-known obstetrician in New York has had 3,000 births without seeing a single case. He is known for his placidity and lack of over-anxiety. In the great obstetrical clinics in Europe vomiting to the extent that will put mother or child in danger is extremely rare. The greatest obstetrician of the later nineteenth century reports 100,000 obstetrical cases with only one artificial labor.
In foreign obstetrical clinics these cases in recent years have been treated expectantly, without any active interference, especially with pregnancy, and the results have been much more satisfactory than any other method of treatment. There are a number of cases on record now in which pregnant women have lost from twenty to forty pounds as the result of vomiting for weeks, yet after a time the attack has passed and they have carried the child to full term. Where vomiting has occurred and relief has once been afforded by the termination of pregnancy, it is very unlikely that succeeding pregnancies will pass without corresponding conditions in which no remedy will prove effective, except the dreaded obstetrical intervention for the termination of the pregnancy. It is extremely important then that these cases should be treated conservatively and that from the very beginning there should be nothing to arouse the patient's solicitude with regard to herself or above all to give her any hint of the possibility of obstetrical intervention being necessary in her case. For some women the knowledge that a consultation has been held to discuss such a possibility will of itself prove a persistent unfavorable suggestion, that will surely prolong the vomiting.
This may seem a rather strong opinion from one who is not in practical touch with obstetrics. It has been the growing opinion, however, among the great German obstetricians for the last generation. Ahlfeld, in the Archiv für Gynaekologie (Band 18 Heft 2 page 310) said that he had seen [in a very large obstetrical practice] three cases of so-called pernicious vomiting (unstillbaren Erbrechen) in all of which the patients wanted an abortion because they had previously learned the success of this method of treatment, but all of them recovered without incident and carried their children to term. Kronig, ten years ago, in his monograph on "The Significance of Functional Nervous Diseases for Diagnosis and Treatment in Gynaecology" [Footnote 36] said: "The excessive vomiting of pregnant patients has for a long time seemed to be a genital reflex neurosis. We thought that the growing uterus irritates certain nerve tracts which are connected with the mucous membrane of the stomach. We owe it to Kaltenbach that this opinion was overturned and hyperemesis gravidarum set down as the result of a functional neurosis, hysterical in character. A large number of gynaecologists have accepted this opinion in recent [{457}] years (men of all nations) among others Calderini, Charpentier, Schaeffer, Klein, and Graefe."
[Footnote 36: Ueber die Bedeutung der Funktionellen Nervenkrankhelten für die Diagnostik und Therapie in der Gynakologie von Dr. B. Kronig. Leipzig, 1902.]
Winkel and the leading obstetricians of Germany, especially the directors of obstetrical clinics in the large cities, must be quoted as of the same opinion, since Winkel has collected the statistics of 100,000 pregnancies in the large German clinics in which 6,555 obstetrical operations were performed and in only one case was artificial abortion produced. German opinion is rather strong in the assertion that a number of cases of abortion in the practice of an obstetrician indicates over-hastiness in coming to conclusions as to danger, or leaves him open to the suspicion of yielding too readily to the wishes of mothers who would prefer not to carry their children to term. The suggestion of the possible necessity for abortion has done much to make the hysterical vomiting of these patients continue until this remedy is employed. Insistence from the very beginning that vomiting, though it may injure both mother and child, never necessitates abortion—one out of 100,000 cases is practically never—would be the best possible contrasuggestion.
Kronig thinks that the vomiting of pregnancy is an especially favorable subject for suggestive treatment. He inclines to the opinion that the remedies that have been reported to do good and so many of which have subsequently proved unavailing have really owed whatever success they have had to the suggestion that went with them. Bumm, in his text-book of obstetrics (Grundriss zum Studium der Geburtshülfe von Dr. Ernst Bumm, Wiesbaden, 1902), accepts Kaltenbach's and Ahfeld's conclusions and thinks that the consideration of hyperemesis as an hysterical neurosis is well supported by the success and failure of our therapeutics. All sorts of remedies, any number of drugs, all manner of gynecological procedures short of abortion, though also including abortion, have been reported as doing good. All of them even including abortion have failed in a certain number of cases. Evidently suggestion plays a large role. Hypnosis often proves an excellent remedy.
Excessive Salivary Secretion.—Bumm considers that the excess of secretion of saliva which is so often noticed in pregnancy is of the same nature and should be treated rather by suggestion than by any particular remedy, though remedies should be tried because of certain helpful physical effects, and then the psychic element that goes with them. The less importance given to the symptom, the less attention it attracts, the more its passing trivial character is emphasized, the sooner it will subside. Solicitude causes it to persist and even increase.
LABOR
Suggestion in Labor.—When the subjects are normal, expectancy has much to do with the severity of labor pains. In recent years so much fuss has been made and so much said and written about woman's burden and travail in the pains of childbirth, that preliminary dread and anxious attention have wrought young women up to such a poignancy of expectation as to make these pains worse than they really are. In the old days child-bearing was as much a matter of course as the husband going out to his daily work, and the taking of the dangers and fatigues of it was a simple matter of duty. Labor was then [{458}] comparatively easy and, while never pleasant, was also never an over-uncomfortable process. The effect of unfortunate suggestion has been to make it seem ever so much worse than it really is. Multiparae furnish the best proof of this. A healthy woman who has already had more than one child does not dread labor pains very much, or only to a slight degree, because the previous maternities have lessened the physical pain to be experienced, though a healthy woman's tissues are so thoroughly resilient that nature is able to bring about a return to normal conditions so complete that it is not always easy to decide whether a woman has given birth to a child or not. Of course, there are many cases in which tears reveal the former labor, but there are others in which it is not so, and the renewal of the birth process must, therefore, be nearly if not quite as painful as before, especially if it is recalled that succeeding children are usually larger. In spite of this in multiparae, labor has lost most of its terrors because real knowledge of its comparative ease has replaced the previous unfavorable suggestion, and instead there has come a proper appreciation of what will have to be borne, and of the positive pleasure of the relief when it has been borne successfully.