The Bossi Method in the Treatment of Puerperal Eclampsia-Report of Two Cases.

BY W. H. VOGT, M. D.

ST. LOUIS.

N presenting this paper I do not propose to bring up anything new, but but simply to call attention more closely to the method above mentioned, which has been practiced in Europe for several years, but for some reason or other has not been extensively used in this country, and to my knowledge only twice in this city, namely, on the two cases herein reported. Although many hypotheses have been advanced concerning the etiology of eclampsia, yet we are still in the dark as to the true causative factor. We have, however, by experience learned to recognize a few facts regarding the general course of this disease, and one of these is that in the great majority of the cases the convulsions cease either immediately or soon after delivery. According to Duhrsen and Ohlshausen in 93.73 per cent and 85 per cent respectively. It is, I believe, for this reason that most obstetrical authorities are of the one opinion that in cases of eclampsia, during pregnancy, as well as in labor, whenever an early delivery for some reason is not to be expected, the woman should be confined as early as possible, and by that method which seems at the time the proper one and the one offering the best chances for the recovery of the mother and the delivery of a living child, with the least danger of inflicting injury.

Concerning the method which should be used, opinions vary greatly. Some prefer to treat the case medicinally and expectantly, while others urge the rapid emptying of the uterus, and I believe the latter class are in the majority. To lay down any one rule to follow in treating these cases would be ridiculous, for each and every case deserves special consideration, and no two cases can be treated exactly alike.

Halbertsma, in referring to the treatment of this condition in the Centralblatt fur Gynakologie asks the question, "Should we, at the end of pregnancy, or at the onset of labor, wait or hasten delivery I agree with him when he says that the obstetrician should act when the prognosis for the woman seems very poor owing to the severity of the attacks, or in cases of absolute anuria, or if we have no way of knowing whether the pains will soon begin or not, or if we have reasons to believe that the pains when once set in will be of long duration, as in primipara, in the case of a narrow pelvis, or in twin pregnancies. To wait so long until the pulse becomes frequent and weak he holds absolutely wrong, although he admits that even under such circumstances favorable results are sometimes obtained. There is on the other hand no doubt that a number of cases of eclampsia get well, irrespective of what we do or what method of treament we adopt.

The prophylaxis, as well as the medicinal and expectant treatment deserve a high rank in the management of these cases, but owing to the great amount of space the consideration of these methods would consume, I

will refrain from saying anything regarding them, but pass over to the consideration of the methods used for bringing about a rapid delivery.

In those cases in which we have complete dilatation of the os, we have no trouble in deciding which way to act, namely, either by forceps or. version. Fortunately, however, the attacks usually begin early in labor or even before labor has begun when the os is not at all or only slightly dilated, and in such cases our selection naturally becomes more difficult.

We have then two general courses to select from: 1st. Abdominal (Caesarian section or porro Caesarian) or 2d. Vaginal, with its various methods, namely, (a) manual dilatation; (b) dilatation with the various rubber bags (Barnes', the Metreurynter, etc.); (c) Duhren's incisions; (d) vaginal Caesarian section; (e) dilatation with the Bossi dilator.

In reviewing these various modes of procedures and looking through the literature, I find only very few who advocate Caesarian section, and in view of the large death rate following this operation in cases of puerperal eclampsia, I believe the method is indicated in only very rare cases. Ohlshausen, out of 250 cases found only three in which he thought this method indicated. Hillmann collected 40 cases upon which Caesarian section performed, of the 40 mothers, 21 perished and 19 recovered; of the 41 children, 18 perished and 23 recovered. The result therefore obtained from this method, 52.5 per cent of the mothers and 43.9 per cent of the children perishing, is not very encouraging and seems to me does not warrant such a grave operation.

Manual dilatation requires a long time, sometimes several hours, is very tiresome to both operator and patient, it necessitates a hand being in the genital canal for a long time, thereby increasing the danger of infection. In the meantime our patient goes on having her convulsions. Dilatation with the rubber bags is also a very slow process. Any of us who have tried them know that it sometimes requires six hours or longer to bring about complete dilatation and is then not always successful, our patient being subjected, during the entire time required for dilatation, to the dangers connected with the frequent eclamptic attacks.

Duhrsen's Incisions afford probably the quickest means of delivery, but in my opinion, by no means the safest, and especially dangerous is this method for the practitioner who is compelled to deliver his patient as a rule on a low bed, with few or no conveniences at hand in the event of hemorrhage. To apply clamps before making the incisions, as Duhrsen directs to prevent hemorrhage, requires several assistants, which one usually has not at hand, and hence is not practical in private practice.

To vaginal Caesarian section the same objections can be made as with Duhren's incisions, even more so. It requires the skill of one accustomed to operating in this region to be able to perform this work properly.

Dilatation with the Bossi instrument, it is true, has some objectionable features, but I believe less than have the above-mentioned methods, and more in its favor.

(1). It is, first of all, an instrument which dilates completely in a comparatively short time.

(2.) It does this in the hands of a careful man, in properly selected cases, without great danger of bringing on a tear.

(3.) It can be used by any physician who has the ordinary amount of training and skill in obstetrical work and does not require the presence of a number of assistants, only one being necessary to administer the anesthetic.

To draw conclusions from the cases which have thus far been treated by this method would not be decisive, for the number is still too small. But, personally, I believe if his method be used carefully, in properly selected cases of puerperal eclampsia, we will be able to save the life of more of these unfortunate women than by any other means which we have been in the habit of practicing or now possess.

During my service at the Maternity Hospital, Dresden, under Prof. Leopold, had the good opportunity of seeing a large number of cases of enclampsia treated by this method, and with the exception of one death occurring from the persistence of the convulsion post partum and the occurrence of one case of puerperal mania, the outcome of all cases was favorable and all the women recovered. The exact number of children recovering I cannot state, for, unfortunately, I did not keep a record of the same, but I remember well that a large number were brought to the world alive and only very few died later on.

Complete dilatation of the os was brought about in from 15 to 30 minutes and in no case was there a cervical tear. A very important fact to be mentioned is that at the time when the Bossi instrument was being used in the above-mentioned hospital, it was in the hands of men inexperienced in its use, and the results were in all cases good, demonstrating the fact that it does not require a large experience to be able to make use of it. The only real objection that can be brought against this method is the danger of producing tears and this objection has recently been raised by Duhrsen. To my mind, the danger is not as great as with the Duhrsen's incisions. Duhrsen claims we have no way of controlling a tear should one occur. This, however, is not so, for it seems to me that we have perfect control, providing we place the index and second fingers at the cervix, as advised by Bossi himself. In this way we are able to detect a tear at its very earliest beginning, or even recognize an impending tear before it has occurred, and are, at that very moment, able to unscrew the instrument immediately and relieve the pressure. What way have we of preventing the incisions of Duhrsen from tearing further during the progress of labor, when the head. of the child or shoulders are passing through? None. Besides that, these incisions require sewing, and not all of us are prepared to do this.

I am fortunate enough to be able to report the following two cases: CASE I. On May 10th, about 9 p. m., I was called by Dr. Henske to see a case of puerperal eclampsia. The patient, Mrs. D., aet. 23 years. I para. Last menstruation September 9th, 1902, expected to be confined during the first part of June, 1903. Upon examination I found the patient to be of medium height, heart and lungs normal. Temperature 991, pulse 100, strong and regular. There was a general anasarca of considerable de

gree, so much so, that the woman who originally weighed about 100 pounds. seemed to weigh 180 pounds or over.

The external examination revealed a pregnancy at about full term, with head of the fetus fixed in the pelvic inlet back to the left and anteriorly; in other words, a left occipito anterior position. The fetal heart sounds were heard near the median line in the left lower abdominal quadrant, strong and regular 140.

Owing to the great amount of edema, the external pelvic measurements were not taken, since they would not have been at all accurate, but at an examination made at a later date, when all edema had disappeared, proved to be the following: Di. sp. 22 cm.; di. cr. 25.5 cm. ; di: tr. 31 cm. ; ext. conj. 7 cm.; Diag. conj. cm. ; con. vera. 9 cm. ; in other words, a somewhat generally contracted pelvis.

Internal Examination.-Cervix soft, no dilatation. Pubic arch narrow, sacrum fairly well hollowed out. Urine contained a large amount of

albumin and casts.

The following history was received. Patient had been perfectly well until about the fifth month of pregnancy when edema of the lower extremities began. This was at first slight, gradually increasing, however, until about a week before the date when I saw her. At this time the edema was so great that she had difficulty in walking, owing to the large amount of swelling of the labia. On May 8th, two days previous to my first visit, a physician was called to see her, he prescribed some medicine, which patient claimed caused nausea and vomiting. During the last few days she had been suffering with severe headache and vertigo. In the afternoon of May the same physician called again and made multiple incisions in the labia to relieve the edema of these parts. At 5 o'clock p. m. convulsion set in when a neighboring mid-wife was hurriedly called, who administered chloroform. The attack then passed off and at 7 p. m. another convulsion occurred and the mid-wife then sent for Dr. Henske, who, in turn, called me to see the case about 9 o'clock p. m. The patient was perfectly conscious when I saw her, the child was alive, and there seemed to be a possibility of avoiding the occurrence of future attacks. For this reason it was decided to await results. The patient was put to rest, room kept perfectly quiet, and enema and cathartic were administered and chloral and bromides prescribed. Her bowels moved well after the enema and catharatic, and after the second dose of medicine she fell asleep. She was left in charge of the mid-wife, with the instructions to inform us as soon as another convulsion appeared. Patient was perfectly quiet until about 1.00 o'clock a. m., May 11th, when another attack set in and these convulsions then reappeared at longer or shorter intervals until 6 o'clock a. m. For some reason or other I was not notified until 6:00 a. m. after the patient had had ten attacks in all. She was at this time unconscious and the pain had just begun. It was then decided to deliver the woman since her pulse was now becoming weak, her temperature 101, pulse 120 and her life was in danger. The fetal heart tones were at this time irregular, rapid, 165 to 170 and weaker. The method selected to deliver was the Bossi method.

After thoroughly cleansing the genitals, the patient was anesthetized and the Bossi dilator introduced at 7:15 a. m. During the process of dilatation. the membranes were accidently ruptured. Dilatation was completed at 7:45 a. m., duration thirty minutes, and the forceps applied to the head, the fetal heart had by this time become extremely weak, and it was evident that unless the child could be extracted in a very short time, it would die. The forcep attempts were unsuccessful and the fetus died during this time. Had I been aware of the pelvic measurements, might possibly have done a version, and saved the child's life, yet this is questionable, and as said before a pelvic measurement taken at this time would have been very unreliable, owing to the large amount of edema. After it was determined that the fetus was dead no further attempt with the forceps was made, but craniotomy performed in its stead. The dilatation, which, as above stated, was completed in thirty minutes, was done without a tear, no further convulsions occurred. The woman made a good recovery, the edema and albumen rapidly disappeared, so that on the ninth day after delivery, the urine showed no trace of albumen.

CASE II. This case I am able to report through the courtesy of Dr. Henski, who treated the case.

Miss Nora E., aet 38. I para; occupation servant. Inmate of St. Ann's Lying-in Hospital since January 20th, 1903. When seen first she presented signs of albuminuria, edema of feet and legs, of face and hands, frequent headaches and vertigo. The urine loaded with albumen. She was at once placed under treatment for this trouble. On February 6th, when she was about eight months pregnant, suddenly eclampsia set in. Upon examination it was found that the cervix had not yet entirely disappeared, no signs of labor. The patient was at once put under the influence of chloroform, the genitalis made aseptic and the Bossi dilator introduced. It required 26 minutes to produce complete dilatation of the os. Labor was completed with the forceps, time required, all in all, 35 minutes, from the time of introduction of the dilator to complete expulsion of the fetus. The child was born alive and is still living, the convulsions ceased about an hour after confinement, and the patient recovered completely. The albumen disappeared from the urine on the seventh day of the puerperium. Three weeks after confinement the patient had an attack of mania, for which she was sent to the St. Vincent Institute, where she recovered within six weeks. She is now in perfect health.

In the first case reported, I believe dilatation could have been done more rapidly, but since the parts were quite rigid and my experience with the use of this instrument was somewhat limited, I hesitated in forcing dilatation too rapidly and used more than ordinary care in trying to prevent a tear. I am convinced, however, that this great precaution was useless. Both women were subjected to a careful examination immediately after labor and also before they were discharged and no tear could be found. I say no tear, by that I mean no greater tear than takes places in cases where the labor was normal.