Pilu, Gianluigi

Almae Matris Studiorum Campus

lezione 2b: assistenza prenatale (goals of promaternity care)

APRIL- IPAM--o1PA PLEAFOR APRO-MATERNITY HOSPITAL.By J. W. BALLANTYNE, M.D.,Leoburer on Antenatal Patlhology, University Edinburghi (1900).IN youth or early manhood one plans- enterprisesfully embarks upon projects which in old age arevisionary or Utopian; no one blames Youth for soand projecting, not even Age. La jeunesse vit d'esp&-ance,vieillesse de souvenir. Youth lives on hope and old agemembrance, and a reversal of the roles wouldeven grotesque. So in the infancy of the twentiethit is permissible to suggest schemes which in thethe nineteenth might have been characterisedstigmatised as chimerical. The young century is fulland it is not ashamed: lajeunesse vit d'esp&rance.cancer, the prevention of the preventable (butvented) diseases, the laying of the spectre of morbid heredity,the suppression of the weeds to give the flowers a ";these are some of the hopes in the beating heart oftieth century, and the faint echoes of "Ifantastic,""imagi-nary," "impossible," from the nineteenth do notbeat less high. As the years roll on it may be necessaryconfess to partial failure; it will assuredly be necessaryvise the plans of procedure-it will probably be found,instance, to be better to try to turn the weedsrather than to suppress them ; but who shall dare,membrance of what has been accomplished' in the pasttury, to set limits to the progress to be achievedpresent?In the sphere of medicine one of the most noteworthypraiseworthy advances of the nineteenth centuryand coming of age of scientific gynaecology; it isrealise that in i8oi ovariotomy was unknown and specialpitals for the treatment of gynaecological diseasesof, and yet these are solid facts. The advances insubject of obstetrics were also numerous, if not so startling;there were improvements in the construction ofand in the mode of their use, there was the discoveryreal nature of puerperal fever and of means for preventingand there was the growth of correct views as toment and internal arrangements of the maternityconsequent upon the recogniition of the value of antisepsisasepsis. But there was one department of obstetricsthe same degree of progress could hardly be reported-that,nimely, of the pathology of pregnancy. At thepast century obstetricians were still in doubt asnature of eclampsia gravidarum, of hyperemesisof the malignant jaundice of pregnancy, of hydramnios,of hydatid mole, and of most of the idiopathicof the fcetus, and of many of the causes of foetalat the best they were but slowly seeking after themuch hampered by the absence of reliable informationcerning thephysiology of pregnancy, and more especiallyphysiologicalcelemistry of pregnancy. The conditionurine of the pregnant woman, its toxicity, the changesblood, the modifications in her nervous system,her thyroid gland, the cause of the physilogicalpregnancy,theorigin of the liquoramnii, the nature of theplacental interchanges, the physiology of the fwetus,relation of the life of the mother and the foetus-thesemany other matters were imperfectly knownguessed at in the nineteenth century. Wasexplicable that eclampsia or hyperemesis continuedtheir many victims-mothers andfeetuses-andobstetricians were in almost complete ignorancestate of matters in the gravid uterus, and foundmake their diagnosis of the health or diseasethe uterine contents after their expulsion?fcetal heart was listened to, and a few conclusionstherefrom, and there was a certain degree of accuracyin the palpation of foetal parts; but antenatalfar from exact, and it was indeed little attempted.The question may now be fairly asked iftieth century are going to be contented witk(or ignorance) of the nineteenth in these matters of the phy-siology and pathology of pregnancy, with the maintenance ofthe status quo ante? I suppose obstetricians everywhere willagree that no such easy contentment is possible or to bethought of with the maternal mortality from eclampsia whatit is, and with the number of abortions and antenatal deathsand malformations what it is. This being so, the next ques-tion is whether with the methods and material at our dis-posal we are making all the progress that is possible, andwhether any further means can be suggested for the perfec-tion of antenatal diagnosis and its certain concomitant, theimprovement of antenatal therapeutics? I think it must beadmitted that we are not making all possible haste towardsthe solution of the many problems of prenatal diagnosis andtreatment, and I think that there is a means of investigationwhich has not yet been tried, at least not yet attempted on alarge scale and in a systematised fashion. Herein lies theplea for the pro-maternity hospital.The pro-maternity hospital need not be a separate esta-blishment; it mar quite well be an annexe of the Maternity;in time it may come to be of equal size with the Maternity,but it must be distinct from the Maternity; it will be for thereception of women who are pregnant but who are not yet inlabour. In the first place, doubtless it will be for thereception of patients who have in past pregnanciessuffered from one or other of the many complications ofgestation, or in whose present condition some anomaly ofthe pregnant state has been diagnosed; but in time it maybe taken advantage of by more or less normal ambulants,working women for example who ought to rest during thelast weeks of pregnancy, but who are unable frbm financialreasons to do so, and by the patients who clamour for admit-tance to our maternities, but who are told to come backagain when the "pains have begun." It is worth while for usto realise that practioally no provision is made in existinghospitals for pregnant women. In general hospitals cases ofmorbid pregnancy (for example, hyperemesis gravidarum)are sometimes received and treated, but mostly under pro-test, lest there occur a birth in the wards. In maternitiespregnant women are not welcome much before the full termof gestation, for obvious or easily-ascertained reasons. Suchpatients would be received into the pro-maternity; it wouldbe their special hospital. When labour pains came on theywould be transferred to the adjoining Maternity, and it wouldtherefore be advisable that the two buildings communicatedby a covered way, for example, a system of linked hospitals.The ideaof a pro-maternity hospital has been forced intomy mind by seVeral circumstances during the last few years,but more particularly by communications which I havereceived from medical men in various parts of this countryand the United States. In these communications the par-ticulars of cases of antenatal disease and deformity werestated and an opinion asked for with regard to possible plansof treatment. In some I was able to give advice, in others Ihad to confess that I had little or nothing to propose, but inall I could not help wishing that I knew of a hospital wherethe case could be placed and scientifioally investigated.The first case which powerfully impressed me was one ofrecurrent abortion-so-called "habitual" miscarriage -inwhich there was no evident and sufficient cause forthe tendency which the uterus had, on the slightestprovocation, or on really no provocation at all, toexpel its contents. Had the patient been incircum-stances that would have permitted it, I should haverecommended her to go into a nursing home for thedangerous period in pregnancy, and not only have treatmentwith potassium chlorate, but have also her various excretionsand functions thoroughly investigated, so as, if possible, toascertain the cause of the special"uterine irritability."Anotherpatient who might have benefited by such a hos-pital asI imagine the pro-maternity might be was thesubject of hyperemesis gravidarum which terminated fatallyafter the contents of the uterus had been ex-pelled.I cannot help thinking that the investigation of such casesin the pro-maternity might lead to the adoption of a morescientific method of management than the artificial inductionof abortion which, of course, entails therapeutic foeticide. Infact, one of theprinciples of the pro-maternity would be thedonservation of foetal life, although, of course, not at theex-r2101]Apint 6 goI I Ij PLEA FOR A PRO-MATERNITYI HOSPITAL. TM BILITISH 8igIMIMICA.L JOURNAI814 MEDICAL JOUILJ tYTERINE FIBROIDS. [APRIL 6, 1901.pense of maternal safety; the result aimed at would be thecontinuance of the pregnancy witlh safety to the mother: thatwould be the ideal. Then there have been several cases ofalbuminuria in pregnancy, all of which would, I am certain,have been fit and proper patients for the pro-maternity; severalof them developed eclampsia, and in one of them albumenappeared in the urine for the first time the night before theconvulsions manifested themselves. In a pro-maternity wemight be able to study with scientific exactness not only thepre-eclamptic but also the pre-albuminuric modifications ofthe urine, and we might also discover the relationship wlhichexists between the absence of normal thyroid hypertroply andthe presence of albumen in the urine. In one of the cases ofeclampsia that I have met with during the last twelve monthsthe urine kept for nine months without showilng any signs ofputrefaction and without givilng any positive results on theordinary culture media; this case would have been a suitableone for such scientific investigation as could have been givento it in a pro-maternity.The cases to which I have referred were instances of thepathology of pregnancy in which the maternal factor was ofprimary importanoe, and in which the treatment aimed at thesafety of the mother ; but there were others in which it wasanitenatal therapeutics that came under consideration.There was the case of an alcoholic mother wlho hadgiven birth to an infant with congenital heart disease (persis-tence of the patency of the foramen ovale), and wlo was againpregnant; the obvious treatment was total abstinence fromalcohol, a treatment which might have been carried out withsome chance of success in a special hospital. There was thehmemophilic mother who had given birth to two h.emophilicmale infants, and had suffered from dangerous post-partunmh.emorrhage on each occasion, and who was given calciumchloride during the three last months of the third pregniancy,in the hope of preventing the post-parturn bleeding, andperchance of benefiting the fcetus. There was the case ofthe woman who had given birth to a series of very largechildren, deadborn on account of their great size; in thepro-maternity the effect of variations in the maternal diet (assuggested by Prochownick and others) upon the bulk of thefoetus might be carefully tried. The same remark applies tocases of small pelvis in which a small infant miglht passsafely while a larger one would have to be sacrificed or beextracted prematurely, or born by the Cresarean section atterm. There was the case of the patient who had inprevious pregnancies given birth to imbecile or mentallydefeotive children, and to whom phosphorus was given, withthe apparent result that the next infant was normal in theserespects. Finally, there was the case of the woman, truly amonstripara, who hiad brought three monstrous feetuses intothe world, and had had several abortions; she was willing todo almost anything that might be recommended, in the hopeof having a more satisfactory reproductive record; she wouldundoubtedly have entered the pro-maternity, even if butlittle hope of betterment were held out to her.The number of cases which might be benefited by the sys-tematic and scientific investigation of the bodily functions inpregnancy might easily be increased, but I have contentedmyself with a reference to the actual instances whieh havebeen brought under my notice recently; some of them-forexample, the monstriparous patient-I have published;others-for example, the hbemophilic mother-will be pub-lishied shortly by the medical men in whose practice theyoccurred.I have emphasised the scientific value of such a hospital astlle pro-maternity might be, but the more distinctly economicaspects are not to be lost sight of, especially if it be foundto be true that working women who are able to rest for thelast month or two of pregnancy give birth to larger and morehealthy infants. I have not gone into the question of theinanagement of this as yet imaginary hospital, nor into thematter of the medical staff; but from the scientific stand-point there would have to be every appliance for the perfec-tion of antenatal diagnosis (skiagraphy, cephalometry), andone member of time staff would require to be a skilled physio-logical chemist. That there will be difficulties in tlle waymay be expected; that the idea will be regarded as visionaryor elhimerieal is certain, and will not surprise me, as it hasbeen only by slow degrees that I have come to regard it asanything else. In the meantime this communication maybe looked upon as a " ballon dessai," the whole matter of thepro-maternity being still in nubibus.ON A UTERUS WHICH CONTAINED ONEHUNDRED AND TWENTYFIBROIDS.By J. BLAND-SUTTON, F.R.C.S.,Surgeon, Clhelsea Hospital for Womiian.IT is not uncommon to find twenty fibroids in a uterus, andill thlis JOURNAL (I899, vol. i, p. 839) I figured a uterus wllichcontained one hundred and two.In May, i9oo, my colleague, Dr. Inglis Parsons, asked meto perform hysterectomy on a woman 34 years of age, who hadbeen under his care for profuse bleeding due to fibroids. Thepatient was profoundly anaemic, in spite of the most carefuland assiduous treatment indicated by the plhrase " rest anddrugs." It was evident to all who saw her that " surgical "treatment was a necessity. I removed the body of the uterusby the abdominal route, and left both ovaries and Fallopiantubes. She made an excellent and quick reoovery.The uterus had a peouliar oval shape, and measured 1o cm.in the vertical and 15 em. in the transverse axis. On openingit I was surprised to find four sessile fibroids projecting intothe cavity of the uterus, which had become so moulded toeach other as to form facets on their contact surfaoes suChas are found in multiple gall stones. These fibroids wereabout the size of pigeon's eggs. Tlle cut surfaces of theuterine wall was very thickly dotted with small roundedFig. I.-Tlic iiiintite struc(ture of a seedlinlg fibrlod. Tlle circulal- cellsare spindles cut at riglit angles. This figui-e represents a complletesectioii tlirougli the equator of au eiiibryonic tibi-oid tlle size of aiiiustard sced.fibroids. The specimen was tlhen carefully hardened inmetbylated spirit, and complete sections were madeby meansof a sliarp, thin, broad knife. The uterus was found to con-tain a multitude of fibroids, varying in size from a corianderseed to a cherry stone. From a careful computation of tlhetumours in the various sections, this uterus, which scarcelyexceeded the dimensions of a fist, contained one hundred a

http://campus.unibo.it/273928/1/02b_ballantyne%20promaternity%20care.pdf

lezione 2b: assistenza prenatale (goals of promaternity care)

Abstract

Similar works

Full text

Available Versions

Almae Matris Studiorum Campus

Almae Matris Studiorum Campus