THE NARCOTIC EFFECT OF MORPHIA ON THE NEW-BORN CHILD, WHEN ADMINISTERED TO THE MOTHER IN LABOR. BY WALTER R. GILLETTE. M.D., Visiting Physician to Charity Hospital Lying-In Department; Visiting Physician Hew York Lying-in Asylum; Visiting Physician St. Francis Hospital; Late Adj. Prof, of Obstetrics, Medical Department, University City of New York. Reprinted from The American Journal of Obstetrics and Diseases of Women and Children, Vol. X., No. IV, October, 1877. NEW YORK: WILLIAM WOOD & CO., 27 GREAT JONES STREET. 1877. THE NARCOTIC EFFECT OF MORPHIA ON THE NEW-BORN CHILD, WHEN ADMINISTERED TO THE MOTHER IN LABOR. EY \ / WALTER R. GILLETTE, M.D., Visiting Physician to Charity Hospital Lying-in Department; Visiting Physician New York Lying-in Asylum; Visiting Physician St. Francis Hospital; Late Adj. Prof, of Obstetrics, Medical Department, University City of New York. Reprinted from The American Journal of Obstetrics and Diseases of Women and Children, Vol. X., No. IV., October, 1877. NEW YOEK: WILLIAM WOOD & CO., 27 GREAT JONES STREET. 1877. THE NARCOTIC EFFECT OF MORPHIA ON THE NEW-BORN CHILD, WHEN ADMINISTERED TO THE MOTHER IN LABOR. BY WALTER R. GILLETTE, M.D., Visiting Physician to Charity Hospital Lying-in Department; Visiting Physician New York Lying- in Asylum; Visiting Physician St. Francis Hospital; Late Adj. Prof, of Obstetrics, Medical Department, University City of New York. During the recent discussion before the New York Obstet- rical Society, concerning “ The Influence on the Fetus of Medi- cines, particularly Narcotics, administered to the Mother during Pregnancy,” it was my opportunity to present the histories of six cases where, under my observation, morphine had been administered during the second stage of labor, for the direct purpose of determining, so far as such a limited number of ob- servations could, whether it was possible to narcotize the fetus in utero, in a way to be recognized after its birth. These ex- periments were made with a distinct bias in my mind that such an effect could be produced, and this bias arose from observa- tions which had been thrust upon me in the varied accidents and incidents of obstetric practice. The experiments which I reported in these six cases were selected in that the subjects of them were healthy women, who, in the history of former la- bors, or in their condition indicated as near as might be that they were safe and comfortable child-bearers, and presented at the time of observation labors normal in every respect. I thought this attempt at elimination of all possible causes of asphyxia in the new-born necessary to a clear result. In every case the child was born in a state of narcotism—that is, there was a complete absence of or delay in the respiration, and the infants were only sustained and resuscitated by contin- 4 Gillette : Effect of Morphia on New-Born uing every possible method of artificial respiration. The circu- lation was irregular, the surface was cvanosed, the pupils con- tracted, the body limp and flaccid, the jaws dropped, the eye-lids half closed, and the child presented every physical ap- pearance so common to the typical case of opium-poisoning in the adult. The condition in no case resembled any one of the forms of suspended animation in the new-born that I had ever encountered or read of, and it was then deliberately impressed upon me still more strongly than it ever had been accidentally that morphia was a dangerous remedy to use during labor, and when administered to the degree of producing its physiological phenomena in the mother, will invariably produce a relative condition of narcotism in the new-born infant. This statement was opposed by Drs. Barker and Peaslee, who considered mor- phia in labor as innocuous to the child as ether or chloroform. If I may judge by the sentiments expressed by other members of the Society, I think the general opinion was that it was a dangerous drug to administer to its full physiological effect un- der such circumstances. Drs. Thomas, Skene, Green and others, took a very positive stand in the matter, and unhesita- tingly expressed their fear of it. We have now to hear the other side of the question, and Dr. Lusk, in the April No. of this Journal, relates a series of eleven cases, in which morphia was given by Dr. Beckwith, of the Nursery and Child’s Hospital, to women in labor, with an effect upon the new-born so totally opposite to that witnessed in my cases as to call for a re-examination of the subject, and renewed experimentation. First, to expdain the fact that Dr. Beckwith utterly failed to repeat the results which were so marked in my cases. The Doctor administered morphia to eleven women in labor and discovered no narcotic effect in a sin- gle instance among the new-born. Therefore, Dr. Lusk’s inference was apparently proper, that, “ so far as deductions can be drawn from a limited number of observations, there is no reason to apprehend any direct effect to the child from morphia administered to the mother during labor.” But let us examine Dr. Lusk’s observations a little more closely, and see if we do not discover why Dr. Beckwith’s experiments failed to repeat the results I reported. 1 think Dr. Lusk explains the reason of failure clearly. lie says : “ It cannot be objected Child\ when given to the Mother in Labor. 5 that the quantities of morphia given by Dr. Beckwith were in- sufficient, for in seven cases twelve minims of Magendie’s solu- tion were used hypodermically, in one case twenty-four minims, in another twenty-five minims, and in one three-fourths of a grain of morphia was given by the mouth and twenty- four minims of Magendie’s solution were injected under the skin. In this last case, while the mother’s pupils were mani- festly contracted, those of the infant were unaffected. In these comparatively large doses, it is interesting to note that though eight of the eleven ivomen slept, and for the most part soundly, from the morphia given, none of them showed signs of labored breathing or cyanosis. The respiration, the pulse, and the size of the pupils appeared to be only moderately affected.'1'’ This, it seems to me, is a distinct avowal that the quan- tities of morphia given by Dr. Beckwith were manifestly insuffi- cient, inasmuch as they failed to produce the phenomena of opium narcosis in the mothers. The simple phenomenon of “ sleep,” which Dr. Lusk regarded as “ the degree of narcotism of the mother,” is not of itself a sufficient evidence of narcotism; it is rather the character of the sleep which renders the individ- ual partially anesthetic to pain, and the accompanying slowing and irregularity of the respiration, with the congested, dull facies, the contracted pupil, the itching of the nose or other regions, all these and other appearances so clinically familiar make up the picture of the phenomena of opium narcosis. Dr. Beckwith’s experiments, although carried out with great care and exactitude, stopped short of producing that effect with the drug which was related in my cases. Sleep is not an unusual manifestation between pains in ordinary labor when it has been severe or protracted, and taken alone is not evidence of narcosis. Why the Doctor failed to produce a sufficient effect with the quantities of morphia used, is not a matter of con- jecture wholly either, for in Cases 1, 2, 3, 5, and 7, the drug was not administered soon enough to ensure any effect in pa- tients who might have been more tolerant of it from the pains they were suffering. Thus, in Case 1 it was oidy ad- ministered forty-five minutes before labor; Case 2, twenty- five minutes ; Cases 3 and 4, eighteen minutes ; Case 5, eighteen minutes; Case 7, thirty minutes. In all these cases it will he observed also, that the pupils were not contracted below the 6 Gillette : Effect of Morphia on New-Born normal, as compared with the table of measurements of the pupil in the table of normal labors, and “ in none of them (the eleven cases) were there signs of labored breathing or cyanosis,” while “ the respirations, the pulse, and the size of the pupils appeared to be only moderately affected.” Surely, then, there was no decided degree of opium narcosis produced in the mothers. I have records of several cases where precisely the same results as shown, that is, where morphine had been administered to what seemed to be a safe amount, without producing any de- cided symptoms of narcosis in the mother or the child, but where the drug was given to the effect of producing a marked degree of narcosis in the mother, it invariably produced a rela- tive degree of narcosis in the new-born. This will appear upon referring to the cases in the Transactions of the N. Y. Obstet- rical Society, April, 1877. Since that time other observations have been made by Dr. F. Townsend, Dr. F. Parsons, of the House Staff of Charity Hospital, under my supervision and di- rection in the wards of the Lying-in-Department of Charity Hospital, and myself with the results related below, and these it will be seen correspond with the former observations made by Dr. Estabrook, of the House Staff, and myself. I now present fifteen additional cases where morphia was administered to the mother during the first and second stages of labor, at times sufficiently early to subject the fetus to its influence, and in labors complicated in no way, sensibly material to the danger of the child during its birth. In carrying out these ob- servations, no attention was paid to the qua7itity of the drug given, the only desideratum being that a decided degree of narcosis should occur in some of its forms—short of utterly prostrating the woman. In conducting these observations, Dr. Townsend and Dr. Parsons maintained the greatest care and exactitude. I witnessed several of these cases in their different stages of narcosis, and we were particularly careful to push the drug to the extent reported in the former cases. Case I.—Second pregnancy, L. O. A. First stage ten hours’ du- ration; second stage, ten hours and thirty-five minutes. At 11.50 A.M., 12 minims of Magendie’s solution were administered hypodermi- cally, and again 12 minims at 5 p.m., with the effect of slowing pulse from 108 to 87, and respirations from 24 to 22 ; though they rose again. The face was markedly flushed and dull, the pupils con- tracted, and the patient drowsy. Child, when given to the Mother in Labor. 7 The child was born in a condition of suspended animation. Pupils contracted. Surface cyanosed ; made a gasping effort at respiration, which could be restored by vigorous shaking and artificial respira- tion, but which immediately ceased when efforts were stopped. It was twenty minutes before respirations were regularly established, and it had to be watched two hours, as the breathing would occasionally die away. It did not cry until at least twenty minutes, and then it was more a moan than a cry, and the face indicated profound stupor, the jaw being dropped, the eye-lids half closed. This was remarked by myself and others, as almost a clinical picture of the countenance in opium narcosis in the adult. The pulse was 60, and varied be- tween that and 120 for an hour. Case II.—First pregnancy, L. O. A. First stage, nine hours; second stage, two hours and three-quarters. . Gave 12 minims of Magendie at 7.50 p.m., with effect upon the mother similar to Case I., except she did not feel sleepy. The child was born at 10.15 p.m. ; weight lbs., in a condition of suspended animation. It was fifteen minutes before it could be made to breathe independently of artificial aid, and presented almost exactly the phenomena exhibited in Case I. Case III.—Third pregnancy, L. O. A. First stage, one hour; second stage, six hours. Gave 12 minims of Magendie at 4.50 a.m., with effect of reducing pulse from 80 to 60, and the respirations from 36 to 20, in an hour. At 10.30 gave 10 minims more. Mother was sleepy, with contracted pupil, and dusky facies. Child born at 11.13 a.m. ; weight, lbs., in a condition of sus- pended animation. Ten minutes after birth the respirations were only eight per minute, irregular and gasping. The pulse was 90. The pupils were contracted, and the appearances were similar to those noted in the former cases. Case IV.—Fifth pregnancy, L. O. A. First stage, twenty hours; second stage, twenty minutes. Gave 12 minims of Magendie, 5.50 p.m., reducing respirations from 42 to 36. The patient was sleepy, with countenance flushed, and pupils contracted. Child born at 8.50 P.M. ; weight 6£ lbs. It was drowsy, breath- ing forty-two times per minute, five minutes after birth, and remained drowsy and lethargic for some time. The pupils were not contracted. Case V.—First pregnancy, L. O. A. First stage, thirty hours; second stage, twenty minutes. Gave 10 minims of Magendie, hypodermically, at 10 A.M., July 13, slowing the respiration from 20 to 16 in an hour, producing drowsi- ness, itching of nose. Three hours later, patient sleeping ; respira- tions remained at 16. At 10.15 p.m. gave 10 minims more hypoder- mically. Respiration 20 ; face dusky, and pupils contracted. Child'was born at 10.45; weight Easily expelled; very cyanotic; slightly asphyxiated, and did not breathe deeply until several minutes. Case VI.—Second pregnancy, L. O. A. First stage, ten hours ; second stage, one hour fifteen minutes. 8 Gillette: Effect of Morphia on New-Born Gave hypodermically 12 minims of Magendie’s solution at 4.30 r.M., with effect of producing continuous itching of nose ; drowsiness ; con- tracted pupils, and congested facies. At 6 p.m. gave 12 minims more, with effect of continuing former symptoms. Respirations twenty. Child was born at 7.50 p.m. Asphyxiated ten minutes before breathing was established, notwithstanding every effort to resusci- tate. Surface was very blue, except white points in the trunk, which had undergone pressure during quick expulsive pains, and which slowly became of color of rest of the surface. After breathing was established, child would only cry out when slapped severely up- on the nates. The pupils were contracted. Case VII.—First pregnancy, L. O. A. First stage, twelve hours ; second stage, five hours. Gave 12 minims of Magendie hypodermically, at 2.30 a.m., reducing the respirations in three hours from 28 to 18. At 6.30 gave ten minims more, reducing respirations from 22 to 18. At 8 a.m., gave ten minims more. Patient was now sleepy, complaining of itching of her nose. Pupils were normal as regards size, but inactive; facies darkened. Child was born at 10 a.m. in a state of suspended animation. Some minutes before it began to breathe. Case VIII.—First pregnancy, L. O. A. First stage, ten hours; second stage, ten hours fifteen minutes. Gave 12 minims Magendie hypodermically at 9 a.m.; also 12 minims more at 12 a.m., and again 12 minims at 2 p.m. These doses did not seem to affect the pulse or respiration. The facies darkened and pupils contracted; but, nevertheless, the child was born at 5.15 in a condition of suspended animation, similar to the others, and was soon brought to. Case IX.—First pregnancy, R. O. A. First stage, six hours ; second stage, four hours. Gave hypodermically 15 minims Magendie at 8 a.m., with the effect of drying her throat, and producing marked cutaneous irrita- tion. Pulse and respiration not materially affected; but at 12 a.m. appeared semi-narcotized. At 12.30 gave her 10 minims more. From this time on she was dozing and drowsy, with the usual facial appearance of congestion. The child was born at 5.50, weighing lbs. Its surface was very blue, its pupils were distinctly contracted, but it breathed and cried immediately. Case X.—Third pregnancy, L. O. A. First stage, four hours and a half; second stage, twenty-five minutes. Gave 12 minims Magendie hypodermically at 4 a.m. ; no apparent effect, except pupils somewhat contracted and feels sleepy. Child was born at 5.55 a.m. Weight 8£ lbs. Breathed immedi- ately, but was very cyanotic, and pupils contracted. Case XI.—First pregnancy, L. O. A. First stage, twenty-four hours ; second stage, one hour and three-quarters. Gave 10 minims hypodermically at 10.30 a.m., with effect of re- ducing respiration from 28 to 24 during four hours, and making Child, when given to the Mother in Labor. 9 patient drowsy. Respirations went down to 18 and 16 by 5.30 p.m., when they rose at 7.36 p.m. to 26. Ten minims more were injected at 8 p.m., reducing the respiration to 20, producing itching of the nose and usual facial phenomena of narcosis; pupils contracted. Child was born at 9.45 p.m., weighing 8 lbs. Cord was once around the neck. Asphyxia well marked. Yerv cyanotic. During first eight minutes after birth, gasped four times. It was twelve minutes before breathing was established voluntarily. During this time, in response to severe slapping upon the nates, it would open its eyes and slowly close them, but gave no other reflex sign of irrita- tion. During the first five minutes after birth four or five seconds would elapse between each beat of the heart. Even when breath- ing was well established, the infant appeared very drowsy and be- numbed, not responding to moderate irritation by pinching or slapping, and if it was severely pinched it would move the part or attempt to draw it away without a moan or a cry. This certainly was not a case of suspended animation from cerebral congestion or anemia through pressure on the cord. The phenomena were certainly indicative of a more profound impression upon the nerve-centres. The child was bluish, not red and turgid, and respiration only responded to continued efforts. Case XII.—First pregnancy, L. O. A. First stage, twenty-two hours ; second stage, three and one-half hours. Gave 12 minims at 10.45 a.m. Contracting the pupils and so anesthe- tizing the patient that pains are not complained of. Facies dusky. Child born at 2 P.M., weight 9 lbs. Cord was once about infant’s neck, but easily slipped over the shoulder. Child was asphyxiated, breathed once in a minute and a half. Next minute, under artificial respiration, it breathed sixteen times ; the next minute nothing was done, and it breathed once. From this time it was induced to breathe freely. Blood dribbled from the cord instead of being projected. It did not cry for five minutes, and only responded to slapping by slowly opening its eyes, closing them again, and wrinkling its face as if in pain. Pupils were small. Case XII.—First pregnancy, R. O. A. First stage, six hours; second stage, one and one-half hour. Gave 16 minims Magendie at 11.30 a.m., reducing respirations from 30 to 26. Pupils contracted; face congested. Child was born at 1.30 p.m. Asphyxiated, and did not breathe safely for three minutes. Case XIY.—First pregnancy, L. O. A.; first stage, 16 hours; second stage, hours. Gave 12 minims Magendie at 8 p.m., July 25th, reducing the res- pirations from 26 to 22 ; flushing the face, irritating the nose. Res- pirations down to 20 in two hours, pupils contracted; sleeping between pains. At 5.20 a.m., July 26th, gave 12 minims more, with 10 Gillette : Effect of Morphia on New-Born the effect of sleep between pains, and complaining but little of them. Pupils still contracted. As the head was lingering on the perineum 3 iss. of ergot was administered at intervals of forty-five minutes, but with no effect on uterine contraction. Child was born naturally one hour and a quarter after the first dose of ergot. Very cyanotic. Respirations catching and slow. Pupils contracted. Insensible except to rough handling. Case XY.—First pregnancy; R. O. P. rotated to R. O. A.; first stage 20 hours; second stage 2 hours. Gave 15 minims of Magendie at 8.15 p.m. ; effect, reducing respira- tions from 28 to 18; pupils contracted; rubbing nose; partial anes- thesia ; hardly notices labor-pains, with the head on perineum. Child born at 12.25 a.m. Cord once about the neck ; surface very blue; animation suspended. For first five minutes no respirations perceptible ; heart could be felt beating very infrequently. At the end of five minutes (by the watch) gasped once; eighth minute breathed 36 times; ninth minute cried out and stopped breathing. At the eighteenth minute it was breathing but 26 times per minute. The pupils were not contracted. It is possible that the slow delivery of the shoulders, in this ease, was an element of cause in its suspended animation ; but still the peculiar method of its reviving and dying away, the slowness and irregularity of the respiration, to me gives it an appearance of suffering under some other depressing influence, and presumably narcosis. I will here summarize the cases in a table (see pp. 12 and 13), adding some details as to quantity of morphine used, and the pulse, respiration, and temperature of the child ; but no infer- ences can be drawn from them on account of their small number. These cases are almost a repetition of the others I reported, and seem to me to indicate something more than mere obstetric accident in their occurrence. The phenomena in the new-born were so marked, and followed so persistently the administra- tion of the drug to the mother in quantities which insured a positive degree of narcosis, that I can only adhere to my former opinion that the administration of morphine to the degree of producing its physiological phenomena in the mother will in- variably produce a relative degree of narcosis in the new-born. That we are enabled to determine what is the relative extent of manifestations to be expected from a given amount of the drug, is at present impossible, from the few observations which have been made. The effect of the drug is modified, as we all know, by individual idiosyncrasy, dependent upon many Child’ when given to the Mother in Labor. 11 varied, inherited, and acquired conditions. These we are una- ble to determine in any given case where we may choose to use the drug. The object of my first observations was not to show that morphia was an improper agent to use under any circum- stances in labor, but simply to test the proposition held and taught by many—that, so far as the life of the new-born child is concerned, it is a perfectly safe remedy used to its fullest physiological extent—in other words, that it is as free from danger to the neonatus as is the administration of ether or chloroform. So far, my former observations have not been negatived. Dr. Beckwith failed in producing narcosis in the chil- dren born under his experimentation, simply because, as Dr. Lusk states,“None of them (the mothers) showed signs of labored breathing or cyanosis. The respirations, the pulse, the size of the pupils appeared to be only moderately affected.” In other words, he did not push the drug to a sufficient extent to pro- duce even its safe phenomena. I am not surprised at this re- sult, for we had the same experience in cases where we failed to narcotize our patients visibly ; but I am quite satisfied that I can so deeply narcotize the woman in labor as to dangerously jeopardize, and even destroy the life of the child. I have done this. I thoroughly agree with Dr. Lusk, “ that the propriety of its (morphine) use is to be determined by obstetric consid- erations ; ” but I cannot, from the standpoint of the observa- tions made by Fehling, Kormann, Hennig, Ahlfeld, Thomas, Estabrook, Townsend, Parsons, and myself, feel, with Dr. Lusk, that “ there is no reason to apprehend any direct effect to the child from morphia hypodermically administered to the mother during labor; ” on the contrary, so far as we can judge by the evidence submitted, I am more convinced than ever that it is a dangerous remedy when administered without a regard to its effect upon the mother, and in the belief that it is positively powerless to do harm. In the doses usually administered, and in the conditions of labor tolerating unusual quantities of anesthetics—quantities which, under ordinary circumstances, when an individual is not suffering great pain, and is not in a condition of resistance to its effects, would, in many instances, destroy life—it is, to a certain degree, a safe remedy, and generally a mere placebo; hut that it can, by injudicious or reckless administration, de- stroy fetal life during labor, 1 have no doubts at 'present. 12 Gillette : Effect of Morphia on New-Born ce O No. of Preg- nancies and Position of Child. Length of 1st Stage. Length of 2d Stage. Time under Influence of Narcotic. Effects on Mother. Condition of Child at Birth. Minimum of Magen- die's Solu- tion ad- ministered Pulse. Child’s Temp. Itesp. i 2 L. 0. A. 10 hrs. %% hrs. 6 hours. Pulse reduced, 108 to 87; res- piration, 24 to 22; pupils con- tracted ; face suffused and dull; patient drowsy. Suspended animation ; pupils contracted ; surface cyanosed; twenty minutes requir- ed to re-establish respirations; drowsy, with dropped jaw and eyelids half closed ; watched two hours. 24 15 m. after birth, 60; 1 hour after, 108. 15 m. after, 96