Read by title before I.H.A., Bureau of Obstetrics, July 27, 1939.
A. V. GONZALEZ, M.D.
On dealing with disorders of gastric motility, PHYSIOLOGY explains that vomiting is a reflex action having its start on the endings of certain nerves, such as the pneumogastric, trigeminal, glossopharyngeal, etc.
It may be provoked by exciting the base of the tongue, the soft palate, mucous lining of the stomach, gastric disturbances of a chemical nature of the intestine, of the uterus, of the breast, etc., or it may well be from the brain (psychic influences).
It may also be produced by some substances of the type of ipecacuanha, whose principal reactive is emetine which acts directly on the nervous centers and probably also on the sensitive nerve endings of the mucous membrane of the stomach.
The antiperistaltic contractions of the stomach play only a secondary role in the mechanism of vomiting; the expulsion of matter is the result of the energetic compression of the stomach due to contraction of the abdominal muscles. Magendie demonstrated this with his well known experiment in which he provoked vomiting with an intravenous injection of an emetic in an animal whose stomach had been removed and a bladder used in its place.
These few remarks about the physiopathology of vomiting in general may serve us as an orienting concept when passing upon what has been said about the etiology of vomiting in pregnancy.
Many are the theories that try to explain the etiology of vomiting in pregnancy; but none of them as yet give us a satisfactory explanation upon all the cases of vomiting under the condition we deal with in this paper; even in this pathological problem which has a common denominator it is not possible when dealing with its etiology to overlook the morbid individuality so well expressed in the maxim, “There are diseased, but no diseases and parodying causes, no single cause.”.
From these causes we shall mention only those which are more frequent or at least better known.
C.J. Andrews deals with the etiological problem making a typical classification under three main headings: neurotic, toxaemic and reflex.
In his opinion there is no justification for making another subdivision as the condition is the same all, the only difference being that some features are more prominent in some cases than in others. “A great many clinical facts have given us light upon this matter and have served us as a basis for treatment which otherwise would be entirely empirical,” says the author.
The deficiency o of glycogen in the liver seems to be an accepted fact and according to Titus and Dodds, hypo-glycemia is also demonstrable. Hadden and Guffy find a low sodium chloride content and suggest that this phenomenon is analogous to the vomiting associated with intestinal obstruction.
Franz Arzt, after an extensive study of the gastric contents, concludes that the free hydrochloric acid and total acid of the stomach are lower in pregnancy than in the non- pregnant and that this deficiency is more marked early, at the time nausea and vomiting are most common. This lessening of the free acid in the stomach is probably due to the neutralization caused by the alkaline regurgitations of the duodenal content tot he stomach.
In the opinion of other authors hyperemesis gravidarum is caused by metabolic disorders with perhaps an underlying toxemia of unknown character as the primary disturbing factor. Carbohydrate deficiency is usually evident in its toxic absorption into the blood stream and is response for disturbing the carbohydrate metabolism.
According to E.B. Craigir, vomiting occurring in the early stages of pregnancy may be reflex or neurotic in origin and in the pernicious cases a toxic factor is usually associated with them. Generally speaking, the output of urine diminishes and usually shows the presence of ketone bodies, while both liver and kidneys show pathological changes.
Finally, according to other authors, vomiting is caused by endocrine disorders not being infrequent the finding of exophthalmic goitre coexisting with these cases as also an insufficiency of corpus luteum.
Hyperemesis gravidarum is described as the toxemia of early pregnancy. Cases may be divided into four types:
(1) those in which the vomiting is due to some cause other than the pregnancy, e.g., appendicitis, ulcer, gallstones; (2) those in which irritation of the genitals, such as retroflexed uterus, cervicitis, etc., appears to be mainly responsible: (3) those of nervous origin, such as brain tumor, meningitis, psychosis; (4) those of toxic origin. The latter constitute the largest group.
Though the main symptom is vomiting, the prostration, delirium, neuritis, psychoses and renal changes show that the poisons affect many vital organs. It is not easy to tell when the mild nausea and vomiting of which so many gravidae complain passes over into the pernicious or uncontrollable. The following symptoms may be noted: constancy of nausea and great frequency of vomiting, incessant retching, exhaustion, loss of weight and sleep, salivation, haematemesis, fever and rapid pulse. The last three symptoms indicate that the disease is far advanced, especially if albumin, casts, blood, bile and acetone bodies are found in the urine.
The above remarks constitute part of the opinion of Joseph B. DeLee upon the subject.
According to R.J. Crossen, for purposes of classification, patients are divided into one of two groups-mild or severe.
In the so-called mild group are included those presenting the following characteristics:.
1. The nausea and vomiting is of an intermittent type, some water or nourishment being retained. The weight is stationary or there is only a slight loss.
2. There is acetone or diacetic acid in the urine.
3. The blood and urine findings are normal except for the ketonuria just mentioned.
The severe cases are characterized by the following findings:.
1. The vomiting is so frequent in the severe cases that the patient retains very little nourishment. In severe cases the vomiting continues between meals, causing a loss of gastric juice which becomes serious because of the loss of hydrochloric acid.
2. Concentration of the urine with its attendant effects. Acetone may be marked in the early stage, reaching a maximum and then decreasing, so that the acetone and diacetic acid may be absent even in a severe case.
3. Changes in the constitution of the blood as already outlined.
5. Normal or elevated temperature and pulse, probably due to dehydration.
6. Increased bile pigments in the blood and sometimes clinical jaundice. These changes are probably due to an increased production and a decreased secretion of bile pigments. The icteric index is helpful in following the progress of these cases. The Rosenthal test shows marked retention of the dye at times but this rapidly becomes normal when fluid and carbohydrates are supplied.
The homoeopathic clinician will have to consider these cases in the same manner as any others. First, to get a complete picture of the case according to its symptoms; second, the classification of the same according to their importance; third, to look for the proper Hahnemannian treatment which covers the totality of the symptoms.
This, which is quite simple when the picture is clear and concise and one has a complete knowledge of materia medica, is not true in a good many cases in which the symptomatology is scarce, confused; and if we add to that the fact that Kent mentions sixty medicaments under the heading of Nausea in pregnancy and sixty-eight under Vomiting, it is easy to understand that the search for the similimum requires time and patience in order to be precise.
Following are some cases in which I have observed with clearness and speed the action of some medicaments somewhat alarming.
CASE I. J.G.S., 28 years old.
Medium constitution. Past pathological history: None, except a hard but painless tumor about the size of a hens egg in the right mammary gland and which had almost disappeared under the action of Conium mac. CM.
In the history of the case we find two pregnancies in which vomiting was present during the gravity of the case. Vomiting started when the catamenial flux stopped, appearing only in the morning upon getting up. The condition became worse on taking cold drinks and lessened with hot ones. These symptoms were not very intense up to the fifth month when I was called in. I found the woman in an accentuated state of exhaustion, anxious, very restless and with an intense feeling of coming death. Vomiting was frequent during the day as well as night, the patient being able to hold small quantities of warm water. I prescribed Ars. alb. 200.
The following day I was informed that she had slept all night, but upon waking up, vomiting had returned, her condition being the same as when I first saw her. I then sent her another dose of Ars. alb. 200 to be dissolved in a half glass of boiled water with strict directions as follows: one teaspoonful after vomiting. Only five teaspoonfuls were necessary. Vomiting did not occur again and childbirth was normal.
CASE II. M.G.V., 32 years old; tall, dark complexion Past pathological history: None.
Obstetric history: One pregnancy with incoercible vomiting from the beginning, treated by an allopath who reached the conclusion that an abortion would have to be practiced to save the life of a mother; but due to the religious beliefs of the woman she refused to accept such treatment. She consulted another physician who sent her to bed and fed her ice-cold champagne; other food was given her per rectum. She gave birth under the most deplorable conditions of exhaustion so the physician suggested means of preventing pregnancy but these were refused by the woman.
A second pregnancy produced again incoercible vomiting. The attending physician applied without success several ampoules of pregnant mare serum; a second failure was met with ampoules of Fukuend, another physician was called and he advised ampoules of corpus luteum. In despair the patient called in a homoeopath who prescribed a teaspoonful of Ipecac 200 every half hour; this also failed. The second prescription was Symphoricarpus 10M. one dose only; complete success. No more vomiting and the woman gave birth under normal conditions to a robust girl.
CASE III. J.C.P., 38 years old. Dark complexion, medium constitution.
Past pathological history: She has suffered with hepatic colics, which have disappeared for the last three years. Has had malaria several times and since the second childbirth an excoriating vaginal discharge, probably blennorrhagic.
Past obstetrical history: Two abortions of one and one-half months each, followed by two normal parturitions, then another abortion of three months, then a miscarriage which occurred at the seventh month followed by the case under discussion. Vomiting was present in each pregnancy in an alarming degree up to the time of parturition.
Vomiting starts with pregnancy, a hard pain is present in the epigastrium, a sensation of heaviness and nausea, intense acrid and mucous salivation, heartburn, a burning feeling in the stomach, constipation, a great quantity of yellow, burning vaginal discharge, a sensation of heaviness in the vagina as if something were coming out of it, and burning and foul smelling urine heavy with a yellowish sediment.
On October 10, 1938 I prescribed Sepia 200. Vomiting stopped on the third day and all discharges disappeared slowly except the vaginal discharge which increased greatly, there appearing at the same time an itchy eruption of small vesicles around the vulva. On November 20, 1938, corresponding to the second month of pregnancy, I prescribed Sepia 1M. When the patient visited me at the beginning of her eighth month she informed me that all the time that had passed she had been feeling well and only the smallest amount of vaginal discharge had persisted, though lately she had had some vomiting and a feeling of nausea. I prescribed Sepia 10M., with which all the symptoms disappeared, and childbirth was normal.
CASE IV. M.T.G., 26 years old. Dark complexion; strong constitution.
Past pathological history: Luetic and malarial positives.
Past obstetrical history: Four pregnancies. The first one was an abortion on the third month. The following three were treated by an allopathic physician. Vomiting was present in each pregnancy.
During the last pregnancy about the middle of the third month a haemorrhage of consideration appeared, leading one to believe of a sure abortion. Vomiting was present frequently and nausea was persistent, clear tongue and not very intense salivation. I prescribed Ipecac 200, after which all the symptoms disappeared.
Later on the patient had malaria with the following symptoms: chills were present between 10 and 11 in the morning, heavy perspiration around the neck, piercing headaches, typical mapped tongue; vomiting and nausea returned with persistency. i prescribed Natrum mur. 10M. The nausea and vomiting stopped. As the date of this pregnancy was not known they called me to ascertain the probable date of parturition. Upon investigation, I found that the foetus lay in a transverse position. Believing that parturition would take that same week I prescribed Puls. 200 to correct the position and only forty-eight hours later labor pin began, parturition being entirely normal.