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The Treatment of Hyperemesis Gravidarum
Medical Clinics of North America , March, 1939. Baltimore Number
CLINIC OF DR. LOUIS
H.
DOUGLASS
FROM THE DEPARTMENT OF OBSTETRICS, THE UNIVERSITY OF MARYLAND, SCHOOL OF MEDICINE
THE TREATMENT OF HYPEREMESIS GRAVIDARUM ANY discussion of the treatment of hyperemesis gravidarum must almost of necessity be prefaced by a resume of the etiology of the condition. The older concept of three distinct types of vomiting, reflex, neurotic and toxic, was abandoned some time ago, and the tendency today is more and more to think of all cases as being of a common origin, and to separate them into two main classes, mild and severe, depending upon the signs and symptoms. The main or underlying factor remains undiscovered, and while it is spoken of usually as a toxin, the burden of proof is that there is no toxic substance circulating in the blood stream and causing the vomiting. Of considerable attractiveness is the theory that the condition is caused by some endocrine disturbance, either an excess, a diminution or the failure of the patient to accommodate herself in the usual manner to the changes in hormone excretions which are a normal accompaniment of pregnancy. Finch, in a recent contribution, thinks that these patients are sensitized to the luteinizing hormone of pregnancy, and feels that he can predict before the onset of pregnancy which patients will have nausea by testing their sensitivity. He also claims good results in treatment by a desensitizing regime. Other observers feel th.at there is present an excess of hormone, and attempt to treat the condition by the giving of another and antagonistic hormone, while a third group work upon the theory that the hormone is deficient in amount and use replacement therapy. Since all of these men claim equally good results and since
LOUIS H. DOUGLASS
their methods of treatment are so diametrically opposed to each other, the unbiased observer is forced to the conclusion that the final word remains yet to be said and. that the results claimed are, in most instances at least, due to psychotherapy. Whatever the causative factor, it would appear to be rather definitely established that in the majority of the cases it is present only in sufficient quantity to cause a very moderate amount of vomiting, the usual morning sickness, and that in some individuals this is greatly exaggerated by a neurotic or psychic element. In a few, but a very few instances, the condition does not appear to have a neurotic background and these patients are desperately ill from the very beginning and are quite apt to die in spite of any type of treatment used. These have been spoken of as the cases of true "toxic" vomiting, but in the absence of any proof that there is a toxemia present, it seems much more sane to merely call them acutely severe cases. Probably the most important contribution of recent years to the subject is that of Titus and his coworkers, who seem to have proved rather definitely that in these cases there· is present a definite hypoglycemia, and a lowering of the glycogen reserve of the liver, which is followed by a fatty necrosis of the organ. They further claim that as this process continues, the vomiting is made worse and a vicious cycle is set up, which, unless broken, will lead to the death of the patient. The liver changes found at autopsy would tend to corroborate these findings and claims, for they are the same as those found in experimental starvation of laboratory animals. From the above it would appear that there is very little to be learned definitely about the treatment of hyperemesis from the study of the etiology, and this is true, the treatment being mainly empiric, except in those instances where it is treated upon one of the endocrine theories mentioned above. Since it would seem that there is almost always present the element of neurosis, most observers have found that suggestive therapy of one form or another is of such usefulness that they have adopted the practice of depending largely upon it. Experience has taught us that these patients do much better
TREATMENT OF HYPEREMESIS GRAVIDARUM
419
. in a hospital than in the home, and in most instances transfer is the first step in the treatment. Interestingly enough, there are a not inconsiderable number in whom this seems to be all that is necessary, the improvement beginning very definitely with hospitalization, and continuing. Once in the hospital, strict isolation from family and friends should be ordered and in~ sisted upon, an order which the patient does not relish at all but one which appears definitely to hasten her recovery. In addition to this, there are many forms of psychic appeal which are used and which will be spoken of in some detail later, it being the purpose at this time to take up the treatment in as orderly a manner as possible, and to enumerate the various steps taken as they occur. Therefore it is usually the rule at this time to make some attempt to combat the hypoglycemia, and to restore as rapidly as possible the glycogen reserve of the liver. It is also of importance to overcome the acidosis and to combat the dehydration, both of which are frequently present. "All of these are accomplished most' satisfactorily by the administration of glucose .intravenously and normal saline subcuooneously. Since we wish to administer large amounts of sugar, it should be given in a concentrated solution, Titus recommending and experience teaching us that a 25 per cent solution is quite satisfactory. It should be given in amounts of about 250 cc. and repeated several times a day as seems to be indicated by the condition of the patient, a maximum of 225 Gm. being considered not too much to give in a twentyfour hour period. It is to be remembered that the patient has a definite hypoglycemia and an abundance of insulin in the blood stream already, so that it is not only unnecessary, but possibly definitely harmful to make any attempt to "cover" the glucose with the administration of further insulin. The normal saline is given in amounts and over a period of time necessary to produce the desired results . . In most instances it is deemed wise to give the patient nothing by mouth for a period of twenty-four to seventy-two hours, or until all vomiting has ceased. Again one of the principal reasons for this appears to be its psychic appeal,and
4 20
LOUIS H. DOUGLASS
the patient is often told that it is important to "rest her stomach." They become quite uncomfortable from the dryness of the lips and tongue, and when fluids are allowed by mouth, with the understanding that if vomiting occurs, the "rest period" will have to be repeated, the usual rule is that they are retained. The large majority of these patients are markedly constipated, and it is of decided benefit to overcome this and since nothing can be given by mouth, the result is obtained by enemata, given as a rule twice daily. Any of the usual agents may be used, ordinary soap suds giving as good results as anything. Attention has recently been directed to the fact that many of these patients suffer from an avitaminosis, this being especially true when the vomiting has been present for a long period of time, and the administration of vitamins Band C is highly recommended. There can certainly be no objection to this form of treatment, and theoretically it should prove of considerable value. One hesitates to enter upon a discussion of drugs in the treatment of hyperemesis, because so many have been recommended, used for a time, and then discarded. At the present time sedatives are about the only drugs used and these only in moderation and not by all clinics. Irving has a very attractive form of treatment which in his hands has apparently been very successful. A feeding tube is introduced into the stomach through the nose and the patient is fed continuously and is kept sedated by the administration of one of the barbiturates given through the same tube. This treatment is continued until all evidence of nausea has passed. In other clinics sedation is given per rectum. Unless we consider the administration of the hormones to be drug therapy, this at the present time constitutes about all the medication that is used. The psychologic aspect of these cases is quite interesting and many and various forms of psychotherapy, some of them rather bizarre, have been advocated. There is, for instance, the somewhat classical case which was cured by the use of a
TREATMENT OF HYPEREMESIS GRAVIDARUM
421
medical battery, one pole of which was placed over the cervix and the other over the sacrum; after recovery of the patient the battery was tested and found to be out of order. Many cases have responded to therapy in the form of cervical applications, the agents used being silver nitrate, mercurochrome and at times even plain water from a colored bottle. Hypodermics of sterile water given to the thin dehydrated patient have often proved of benefit and especially if she were told that it was a rare, expensive drug which was obtained only after a great deal of difficulty. There have been several cases which were completely and rapidly cured by a simulated interruption of pregnancy, the patient being taken to the operating room and after elaborate preparations, being lightly anesthetized with nitrous oxide and the perineum sharply pinched with a clamp. The vagina was then filled with mercurochrome to imitate blood and the patient allowed to awaken. She was told that she was no longer pregnant and immediately stopped vomiting. This particular treatment must never be entered into lightly for the physician might find himself severely criticized when the patient found that she had not been interrupted, and possibly he might be sued. While it is unwise in these cases to take the husband or other members of the family into one's confidfnce, for they seem unable to keep the secret for any length 6f time, it should be definitely recorded in the history that the entire procedure was undertaken merely as psychotherapy. A psychiatric consultation with a well-trained man is often of a great deal of benefit; not only do the patients frequently reveal to him the underlying reason for their vomiting but, having unburdened themselves, they seem to improve. In the patient who does not appear to respond to other methods of treatment this is of particular value and should always be advocated . .The occasional case is met with in which either the proper psychic approach cannot be found or in which the response is so poor that it is felt that the interruption of pregnancy is definitely indicated. However, before this is undertaken, there
422
LOUIS H. DOUGLASS
are several things which should be remembered: a true "toxic vomiting" is very rare, secondly many of these patients appear to be desperately ill and very suddenly begin to show improvement and rapidly return to normal and thirdly a termination of pregnancy means the deliberate destruction of life. On the other hand cases are seen in which it would appear that interruption had been delayed too long, for although it is done and the patient ceases to vomit she does not improve and in a few days death ensues. We are therefore placed in the awkward predicament of having to make a decision, knowing that our judgment is not infallible and that we are quite apt to err. If we must make mistakes they should be on the side of conservatism and it is better occasionally to sacrifice a baby unnecessarily rather than to lose the life of a mother which could have been saved. Unfortunately there is no particular thing upon which we can lay our finger and say that if this is present or is absent the pregnancy must be terminated and each case should be individualized and studied carefully. There are a few criteria which have been advocated from time to time and while none of them is infallible all of them are of some help. The pulse and temperature are to be taken into consideration, for a patient whose pulse is consistently high and who has a fever which is more or less constant, is unquestionably ill. A few years ago Stander advocated careful and repeated eyeground examinations in these cases and stated that occasionally hemorrhages in the eyegrounds were seen. He felt that these were indications of a very severe type of vomiting and that, when present, while not a definite indication for interruption, should make one think seriously of it. Since his original article appeared other workers have found that his findi~gs in the main are true, but the burden of proof would be that these hemorrhages should not be taken as a definite indication for interruption, for there have been several cases reported which have recovered although the eyegrounds showed these changes. The laboratory is of very little help to us in making our decision, for all of the findings can be explained on the basis of dehydration and a concentration of the blood, and the
TREATMENT OF HYPEREMESIS GRAVIDARUM
423
changes one would expect with starvation. We may be able to judge of the severity of the vomiting but nothing more than that. The response to a properly timed and executed therapeutic abortion is always good and in most instances so extremely rapid that it seems difficult to explain it upon any other than a psychological. basis. The patient who has been desperately ill and vomiting almost incessantly whether anything was taken by mouth or not, suddenly ceases and in the course of a very few hours is able to take and retain almost any type of fluid or nourishment. Indeed, it is not essential to empty the uterus in these cases, the mere destruction of fetal life by crushing the fetus, tearing the umbilical cord or in some other way producing intra-uterine death, is all that is necessary to effect a complete cure. It seems difficult or almost impossible to correlate this picture with that of a severe toxemia and it is felt that in most cases the condition must have been almost entirely neurotic. It is therefore suggested and recommended that when termination of pregnancy appears to be indicated, before it is actually done the simulated therapeutic abortion spoken of previously be attempted. Only a few hours will be lost in this way and more than likely many unnecessary destructions of fetal life will be avoided. Before the actual abortion is done there must be consultation with one or more competent men and there should be very definite notes on the patient's history stating that it is the unanimous opinion that the procedure is necessary. It is too mild a statement to say that these patients do not take a general anesthetic well and it must be phrased that "these patients do not take an anesthetic," for once having been deeply anesthetized, in many instances they sink into a coma from which they cannot be aroused and death occurs in a very short period. Therefore, should the operation of therapeutic abortion be deemed necessary, it must be carried out either without anesthesia or under some form of nerve block. Local infiltration of the perineum and cervix together with a pudendal block is quite satisfactory and lately we have had
LOUIS H. DOUGLASS
most gratifying results in 1 case in which the operation was done under caudal anesthesia. Since it has been tried only once for this particular operation, very little can be said about it except that it appears to hold great promise. If no anesthesia is used all that is necessary is to enter the cervix with a long curved hysterectomy forceps and destroy fetal life. The patient can then be returned to her bed; she will, in almost all instances, cease to vomit and will at a later date empty the uterus herself; if at this time some operative procedure is necessary it can be carried out with very little risk to the mother. At this point a plea is made to the doctor who has been treating one of these patients in the home and who decides to refer her to a hospital. It is a somewhat common practice under these circumstances for the physician to tell the patient that he has done everything for her that can be done except to interrupt her pregnancy and that it is for this reason that he is referring her. The patient enters the hospital with the idea firmly fixed in her mind that nothing short of therapeutic abortion will be of any value whatsoever and the physician to whom the patient is referred starts out with this very definite handicap. It is therefore urged upon the referring doctor that when he does send the patient to the hospital under these circumstances, he merely state to her that he is having her admitted for further treatment and that he make no reference to the possibility of interrupting pregnancy other than to say that it will be left to the judgment of someone else. Conclusion.-There is little or nothing known about the etiology of hyper'emesis gravidarum which will help in the treatment of the condition and while there is accumulating evidence to point to some endocrine dysfunction as the cause, nothing definitely has been proved up to the present time nor is the treatment on an endocrine basis of sufficient consistency to be of any great value. Best results apparently are obtained when the patient is treated psychotherapeutically, there being many avenues of approach all of which are of value in some cases and none apparently in others. The occasional case is
TREATMENT OF HYPEREMESIS GRAVIDARUM
425
met with in which interruption of pregnancy seems indicated; this should always be done in an open hospital and after competent consultation. The patient must never be given a general anesthetic for this procedure. BmLIOGRAPHY Bokelman, 0.: Arch. f. Gynak., 162: 251, 1936. DeLee, Jos. E.: Princ. and Prac. of Obstet., 7th edition, 1938. Dicker, S.: Schweiz. Med. Wochnschr., 67: 74, 1937. Finch, J. M.: J.A.M.A., 111: 1368, 1938. Fischer, E.: Med. Klin., 32: 1298, 1936. Fitzgerald, J. E., and Webster, A.: Am. J. Obstet. and Gynec.,36: 460, 1938. Freeman, W., et al.: Am. J. Obstet. and Gynec., 33: 618, 1937. Novey, M. A., and Goodhand, C. L.: Am. J. Obstet. and Gynec., 36: 468, 1938. Schoeneck, F. J.: Am. J. Obstet. and Gynec., 32: 104, 1936. Stander, H. J.: Williams Obstet., 1936. Sussman, W.: Am. J. Obstet. and Gynec., 33: 761, 1937. Titus and Dobbs: Am. J. Obstet. and Gynec., 16: 90, 1928. Titus, Hoffman and Givens: J.A.M.A., 74: 777, 1920. Trillat, P., and Bernay, P.: Bull. Soc. d'Obstet. et de Gynec., 26: 213, 1937.
CLINIC OF DR. LOUIS
H.
DOUGLASS
FROM THE DEPARTMENT OF OBSTETRICS, THE UNIVERSITY OF MARYLAND, SCHOOL OF MEDICINE
THE TREATMENT OF HYPEREMESIS GRAVIDARUM ANY discussion of the treatment of hyperemesis gravidarum must almost of necessity be prefaced by a resume of the etiology of the condition. The older concept of three distinct types of vomiting, reflex, neurotic and toxic, was abandoned some time ago, and the tendency today is more and more to think of all cases as being of a common origin, and to separate them into two main classes, mild and severe, depending upon the signs and symptoms. The main or underlying factor remains undiscovered, and while it is spoken of usually as a toxin, the burden of proof is that there is no toxic substance circulating in the blood stream and causing the vomiting. Of considerable attractiveness is the theory that the condition is caused by some endocrine disturbance, either an excess, a diminution or the failure of the patient to accommodate herself in the usual manner to the changes in hormone excretions which are a normal accompaniment of pregnancy. Finch, in a recent contribution, thinks that these patients are sensitized to the luteinizing hormone of pregnancy, and feels that he can predict before the onset of pregnancy which patients will have nausea by testing their sensitivity. He also claims good results in treatment by a desensitizing regime. Other observers feel th.at there is present an excess of hormone, and attempt to treat the condition by the giving of another and antagonistic hormone, while a third group work upon the theory that the hormone is deficient in amount and use replacement therapy. Since all of these men claim equally good results and since
LOUIS H. DOUGLASS
their methods of treatment are so diametrically opposed to each other, the unbiased observer is forced to the conclusion that the final word remains yet to be said and. that the results claimed are, in most instances at least, due to psychotherapy. Whatever the causative factor, it would appear to be rather definitely established that in the majority of the cases it is present only in sufficient quantity to cause a very moderate amount of vomiting, the usual morning sickness, and that in some individuals this is greatly exaggerated by a neurotic or psychic element. In a few, but a very few instances, the condition does not appear to have a neurotic background and these patients are desperately ill from the very beginning and are quite apt to die in spite of any type of treatment used. These have been spoken of as the cases of true "toxic" vomiting, but in the absence of any proof that there is a toxemia present, it seems much more sane to merely call them acutely severe cases. Probably the most important contribution of recent years to the subject is that of Titus and his coworkers, who seem to have proved rather definitely that in these cases there· is present a definite hypoglycemia, and a lowering of the glycogen reserve of the liver, which is followed by a fatty necrosis of the organ. They further claim that as this process continues, the vomiting is made worse and a vicious cycle is set up, which, unless broken, will lead to the death of the patient. The liver changes found at autopsy would tend to corroborate these findings and claims, for they are the same as those found in experimental starvation of laboratory animals. From the above it would appear that there is very little to be learned definitely about the treatment of hyperemesis from the study of the etiology, and this is true, the treatment being mainly empiric, except in those instances where it is treated upon one of the endocrine theories mentioned above. Since it would seem that there is almost always present the element of neurosis, most observers have found that suggestive therapy of one form or another is of such usefulness that they have adopted the practice of depending largely upon it. Experience has taught us that these patients do much better
TREATMENT OF HYPEREMESIS GRAVIDARUM
419
. in a hospital than in the home, and in most instances transfer is the first step in the treatment. Interestingly enough, there are a not inconsiderable number in whom this seems to be all that is necessary, the improvement beginning very definitely with hospitalization, and continuing. Once in the hospital, strict isolation from family and friends should be ordered and in~ sisted upon, an order which the patient does not relish at all but one which appears definitely to hasten her recovery. In addition to this, there are many forms of psychic appeal which are used and which will be spoken of in some detail later, it being the purpose at this time to take up the treatment in as orderly a manner as possible, and to enumerate the various steps taken as they occur. Therefore it is usually the rule at this time to make some attempt to combat the hypoglycemia, and to restore as rapidly as possible the glycogen reserve of the liver. It is also of importance to overcome the acidosis and to combat the dehydration, both of which are frequently present. "All of these are accomplished most' satisfactorily by the administration of glucose .intravenously and normal saline subcuooneously. Since we wish to administer large amounts of sugar, it should be given in a concentrated solution, Titus recommending and experience teaching us that a 25 per cent solution is quite satisfactory. It should be given in amounts of about 250 cc. and repeated several times a day as seems to be indicated by the condition of the patient, a maximum of 225 Gm. being considered not too much to give in a twentyfour hour period. It is to be remembered that the patient has a definite hypoglycemia and an abundance of insulin in the blood stream already, so that it is not only unnecessary, but possibly definitely harmful to make any attempt to "cover" the glucose with the administration of further insulin. The normal saline is given in amounts and over a period of time necessary to produce the desired results . . In most instances it is deemed wise to give the patient nothing by mouth for a period of twenty-four to seventy-two hours, or until all vomiting has ceased. Again one of the principal reasons for this appears to be its psychic appeal,and
4 20
LOUIS H. DOUGLASS
the patient is often told that it is important to "rest her stomach." They become quite uncomfortable from the dryness of the lips and tongue, and when fluids are allowed by mouth, with the understanding that if vomiting occurs, the "rest period" will have to be repeated, the usual rule is that they are retained. The large majority of these patients are markedly constipated, and it is of decided benefit to overcome this and since nothing can be given by mouth, the result is obtained by enemata, given as a rule twice daily. Any of the usual agents may be used, ordinary soap suds giving as good results as anything. Attention has recently been directed to the fact that many of these patients suffer from an avitaminosis, this being especially true when the vomiting has been present for a long period of time, and the administration of vitamins Band C is highly recommended. There can certainly be no objection to this form of treatment, and theoretically it should prove of considerable value. One hesitates to enter upon a discussion of drugs in the treatment of hyperemesis, because so many have been recommended, used for a time, and then discarded. At the present time sedatives are about the only drugs used and these only in moderation and not by all clinics. Irving has a very attractive form of treatment which in his hands has apparently been very successful. A feeding tube is introduced into the stomach through the nose and the patient is fed continuously and is kept sedated by the administration of one of the barbiturates given through the same tube. This treatment is continued until all evidence of nausea has passed. In other clinics sedation is given per rectum. Unless we consider the administration of the hormones to be drug therapy, this at the present time constitutes about all the medication that is used. The psychologic aspect of these cases is quite interesting and many and various forms of psychotherapy, some of them rather bizarre, have been advocated. There is, for instance, the somewhat classical case which was cured by the use of a
TREATMENT OF HYPEREMESIS GRAVIDARUM
421
medical battery, one pole of which was placed over the cervix and the other over the sacrum; after recovery of the patient the battery was tested and found to be out of order. Many cases have responded to therapy in the form of cervical applications, the agents used being silver nitrate, mercurochrome and at times even plain water from a colored bottle. Hypodermics of sterile water given to the thin dehydrated patient have often proved of benefit and especially if she were told that it was a rare, expensive drug which was obtained only after a great deal of difficulty. There have been several cases which were completely and rapidly cured by a simulated interruption of pregnancy, the patient being taken to the operating room and after elaborate preparations, being lightly anesthetized with nitrous oxide and the perineum sharply pinched with a clamp. The vagina was then filled with mercurochrome to imitate blood and the patient allowed to awaken. She was told that she was no longer pregnant and immediately stopped vomiting. This particular treatment must never be entered into lightly for the physician might find himself severely criticized when the patient found that she had not been interrupted, and possibly he might be sued. While it is unwise in these cases to take the husband or other members of the family into one's confidfnce, for they seem unable to keep the secret for any length 6f time, it should be definitely recorded in the history that the entire procedure was undertaken merely as psychotherapy. A psychiatric consultation with a well-trained man is often of a great deal of benefit; not only do the patients frequently reveal to him the underlying reason for their vomiting but, having unburdened themselves, they seem to improve. In the patient who does not appear to respond to other methods of treatment this is of particular value and should always be advocated . .The occasional case is met with in which either the proper psychic approach cannot be found or in which the response is so poor that it is felt that the interruption of pregnancy is definitely indicated. However, before this is undertaken, there
422
LOUIS H. DOUGLASS
are several things which should be remembered: a true "toxic vomiting" is very rare, secondly many of these patients appear to be desperately ill and very suddenly begin to show improvement and rapidly return to normal and thirdly a termination of pregnancy means the deliberate destruction of life. On the other hand cases are seen in which it would appear that interruption had been delayed too long, for although it is done and the patient ceases to vomit she does not improve and in a few days death ensues. We are therefore placed in the awkward predicament of having to make a decision, knowing that our judgment is not infallible and that we are quite apt to err. If we must make mistakes they should be on the side of conservatism and it is better occasionally to sacrifice a baby unnecessarily rather than to lose the life of a mother which could have been saved. Unfortunately there is no particular thing upon which we can lay our finger and say that if this is present or is absent the pregnancy must be terminated and each case should be individualized and studied carefully. There are a few criteria which have been advocated from time to time and while none of them is infallible all of them are of some help. The pulse and temperature are to be taken into consideration, for a patient whose pulse is consistently high and who has a fever which is more or less constant, is unquestionably ill. A few years ago Stander advocated careful and repeated eyeground examinations in these cases and stated that occasionally hemorrhages in the eyegrounds were seen. He felt that these were indications of a very severe type of vomiting and that, when present, while not a definite indication for interruption, should make one think seriously of it. Since his original article appeared other workers have found that his findi~gs in the main are true, but the burden of proof would be that these hemorrhages should not be taken as a definite indication for interruption, for there have been several cases reported which have recovered although the eyegrounds showed these changes. The laboratory is of very little help to us in making our decision, for all of the findings can be explained on the basis of dehydration and a concentration of the blood, and the
TREATMENT OF HYPEREMESIS GRAVIDARUM
423
changes one would expect with starvation. We may be able to judge of the severity of the vomiting but nothing more than that. The response to a properly timed and executed therapeutic abortion is always good and in most instances so extremely rapid that it seems difficult to explain it upon any other than a psychological. basis. The patient who has been desperately ill and vomiting almost incessantly whether anything was taken by mouth or not, suddenly ceases and in the course of a very few hours is able to take and retain almost any type of fluid or nourishment. Indeed, it is not essential to empty the uterus in these cases, the mere destruction of fetal life by crushing the fetus, tearing the umbilical cord or in some other way producing intra-uterine death, is all that is necessary to effect a complete cure. It seems difficult or almost impossible to correlate this picture with that of a severe toxemia and it is felt that in most cases the condition must have been almost entirely neurotic. It is therefore suggested and recommended that when termination of pregnancy appears to be indicated, before it is actually done the simulated therapeutic abortion spoken of previously be attempted. Only a few hours will be lost in this way and more than likely many unnecessary destructions of fetal life will be avoided. Before the actual abortion is done there must be consultation with one or more competent men and there should be very definite notes on the patient's history stating that it is the unanimous opinion that the procedure is necessary. It is too mild a statement to say that these patients do not take a general anesthetic well and it must be phrased that "these patients do not take an anesthetic," for once having been deeply anesthetized, in many instances they sink into a coma from which they cannot be aroused and death occurs in a very short period. Therefore, should the operation of therapeutic abortion be deemed necessary, it must be carried out either without anesthesia or under some form of nerve block. Local infiltration of the perineum and cervix together with a pudendal block is quite satisfactory and lately we have had
LOUIS H. DOUGLASS
most gratifying results in 1 case in which the operation was done under caudal anesthesia. Since it has been tried only once for this particular operation, very little can be said about it except that it appears to hold great promise. If no anesthesia is used all that is necessary is to enter the cervix with a long curved hysterectomy forceps and destroy fetal life. The patient can then be returned to her bed; she will, in almost all instances, cease to vomit and will at a later date empty the uterus herself; if at this time some operative procedure is necessary it can be carried out with very little risk to the mother. At this point a plea is made to the doctor who has been treating one of these patients in the home and who decides to refer her to a hospital. It is a somewhat common practice under these circumstances for the physician to tell the patient that he has done everything for her that can be done except to interrupt her pregnancy and that it is for this reason that he is referring her. The patient enters the hospital with the idea firmly fixed in her mind that nothing short of therapeutic abortion will be of any value whatsoever and the physician to whom the patient is referred starts out with this very definite handicap. It is therefore urged upon the referring doctor that when he does send the patient to the hospital under these circumstances, he merely state to her that he is having her admitted for further treatment and that he make no reference to the possibility of interrupting pregnancy other than to say that it will be left to the judgment of someone else. Conclusion.-There is little or nothing known about the etiology of hyper'emesis gravidarum which will help in the treatment of the condition and while there is accumulating evidence to point to some endocrine dysfunction as the cause, nothing definitely has been proved up to the present time nor is the treatment on an endocrine basis of sufficient consistency to be of any great value. Best results apparently are obtained when the patient is treated psychotherapeutically, there being many avenues of approach all of which are of value in some cases and none apparently in others. The occasional case is
TREATMENT OF HYPEREMESIS GRAVIDARUM
425
met with in which interruption of pregnancy seems indicated; this should always be done in an open hospital and after competent consultation. The patient must never be given a general anesthetic for this procedure. BmLIOGRAPHY Bokelman, 0.: Arch. f. Gynak., 162: 251, 1936. DeLee, Jos. E.: Princ. and Prac. of Obstet., 7th edition, 1938. Dicker, S.: Schweiz. Med. Wochnschr., 67: 74, 1937. Finch, J. M.: J.A.M.A., 111: 1368, 1938. Fischer, E.: Med. Klin., 32: 1298, 1936. Fitzgerald, J. E., and Webster, A.: Am. J. Obstet. and Gynec.,36: 460, 1938. Freeman, W., et al.: Am. J. Obstet. and Gynec., 33: 618, 1937. Novey, M. A., and Goodhand, C. L.: Am. J. Obstet. and Gynec., 36: 468, 1938. Schoeneck, F. J.: Am. J. Obstet. and Gynec., 32: 104, 1936. Stander, H. J.: Williams Obstet., 1936. Sussman, W.: Am. J. Obstet. and Gynec., 33: 761, 1937. Titus and Dobbs: Am. J. Obstet. and Gynec., 16: 90, 1928. Titus, Hoffman and Givens: J.A.M.A., 74: 777, 1920. Trillat, P., and Bernay, P.: Bull. Soc. d'Obstet. et de Gynec., 26: 213, 1937.