ANAESTHESIA IN PARTURITION. BY A. H. HALBERSTADT, A.M., M.D., POTTSVILLE, PA. EXTRACTED FROM THE TRANSACTIONS OF THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA. PHILADELPHIA: COLLINS, PRINTER, 705 JAYNE STREET. 1878. ANESTHESIA IN PARTURITION. BY A. H. IIALBERSTADT, A.M., M.D., POTTSVILLE, PA. EXTRACTED FROM THE TRANSACTIONS OF THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA. PH IL ADELPHI A: COLLINS, PRINTER, 705 JAYNE STREET. 1878. ANAESTHESIA IN PARTURITION. For a number of years the teachings of this Society have been ominously silent in all allusions to the use of Anaesthesia in Partu- rition, and so markedly was it at the meeting in 1874, that the mere mention of such use in puerperal eclampsia, in the Address in Obstet- rics, elicited from the oldest and ablest members of the profession, who attended that meeting, a discussion on the relative importance of venesection, opium, and purgation that utterly ignored by silence the value of anaesthesia, or even the fact that it had the merit of respectable authority. Whilst it is true that the merits of these agents were not dis- cussed, nor in fact mentioned, beyond a bare introduction, yet, any one present and unfamiliar, from want of practical experience, with the subject, might have supposed from the known grave character of the disease under consideration, that this significant silence surely indicated a scarce toleration of such therapeutic means by the profession in any of the difficulties attending obstetric pro- cedures. The declarations of men, some of whom had large experience to justify their assertions, must have had great weight in forming the opinions of those who, from a perhaps commendable caution, had never solely depended upon anesthesia in so grave and imperative a demand; and as this class of practitioners received their last pub- lic teaching from the Address in Obstetrics a year ago, in which its distinguished author cries aloud “ for cerebral drainage,” and yet proclaims “ that chloroform can only serve in the end to oppress those organs which are already below the normal standard, and hence we believe it to be injurious,” we consider no apology necessary for the selection of this subject to be presented directly to the representatives of the profession of the State. That there should be an aversion to deviate from the old customs is not to be wondered at, especially as in the practice of obstetrics, 4 ANAESTHESIA IN PARTURITION. where habits for generations have been fixed and under the popular notion that a different management might be attended with risk and no advantage to the patient, except escape from pain. Yet, with this view, I ago began the practice in all cases of parturition, when permitted, and considered it entirely justifiable to take some risk in order to save my patient the pain, but it was not long, however, until I discovered that the mere escape from pain was by no means the entire result of the administration, and, seeking subjects among ladies of highest culture and social posi- tion in my locality, careful observation in the first few cases showed beyond doubt its special therapeutic adaptability. Obtaining the consent of the patient, but a small quantity was inhaled at the be- ginning of the second stage of labor—sufficient to produce semi- narcosis, and in almost all cases the effect, within a short time, was first to allay all emotional irritants or excitants, then to moderate central or peripheral nervous irritability, to excite secretion, to dilate the os uteri, to relax the perineum, to give force and direction to uterine contraction, and to establish in all the organs engaged in parturition their true physiological functional activit}’, all of which is so essential for the quick, safe, and happy completion of even the natural labor. In all labors a firm perineum, a dry vagina, a rigid os, and false pains always yielded to the influence of the anaesthetic, but it some- times happened that the force of the contractions was lessened, then ergot was administered, and, if the propulsive effort was not suffi- cient, the above conditions being established, the anaesthetic was pushed to narcosis and the forceps or other means used with much greater safety for the delivery of the child. With this exception no other possible or obstructive evil conse- quences attended, for the physiological therapeutic action was not that of any other condition of life in the same subject. The small quantity necessary to produce semi-narcosis or full narcosis, the absence of nausea, exhaustion, or shock on the return of consciousness, the impossibility of any nervous perturbations, the freedom from hemorrhage, in comparison with cases in which anaesthetics were not administered, the invariably rapid “ getting up,” with a small percentage of stillborn children, and the ques- tionable statement of but two cases of death to the mother, attrib- utable to the anaesthetic in the thousands and thousands of women to whom this aid has been granted, makes it an important consid- eration to all who have charge of child-bearing women as to what their line of duty should be, in good faith, toward conducting their labors to a safe and happy termination. ANAESTHESIA IN PARTURITION. 5 To one of some practical experience it must be difficult to under- stand why in unnatural labors there should be the slightest hesita- tion in the selection of this remedy in order to prepare the patient for the mechanical means necessary to unload the uterus, when, by anaesthesia produced by a confident hand, all the physiological irreg- ularities existing can be subdued, and the woman placed in a posi- tion of non-resistance to any act of the operator by her voluntary muscles, so as to enable him to perform most of the obstetrical manipulations with comparative ease, as version, necessitated by an arm presentation, hours after the waters have been drained off, where the irresistible and intractable conduct of the woman, together with the uterine contractions, are so violent and continuous as to paralyze the hand in the effort to seize a foot and turn the child. And above all, in true puerperal eclampsia, where pathology has failed to establish any fixed lesions beyond renal congestion in its various grades, and nervo-motor consequences, where a modification of that reflex influence, existing between the pelvic organs engaged in parturition and the brain and spinal marrow, is positively and promptly demanded, and where, by venesection, exsanguined systems, rarely and but slowly recover, and are usually attended with loss of the child, as well as the time necessarily lost in effecting the desired impression by opium, how can there be a question as to the selection of the remedy, or any hesitation of instantly adopting an- aesthesia as pre-eminently the indication, by virtue of its sedative action in relieving that extreme nervous irritability of the nerve centres that threatens life, during the period necessary for emptying the uterus of the offending mechanical cause in the body of the child and its appendages? Will any advocate of venesection or opium question the relative tardiness or inefficiency of these agencies with anaesthesia as to time, a matter so essential for the safety of both mother and child, or can any question of additional risk from the anaesthetic be rea- sonably entertained ? We speak from experience, and can declare that where venesec- tion, opium, purgation, enemata, counter-irritation, and baths were depended upon, physicians in this locality not only generally lost the mother, but universally the child. Now we rarely hear of such results ; and, in my own individual practice, have neither lost mother nor child during the last thirteen years, i. e., in cases at full term, where the child was living at the onset of the eclamptic seizure ; because I have always acted in obedience to convictions that have led me to regard anaesthesia in the parturient state as not identical in its toxicological effects with the same agent in the same individual 6 ANiESTIIESIA IN PARTURITION. under other circumstances in a dental chair. And a subject pre- senting conditions that would induce the surgeon to discard his anaesthetic and toss it from the room, should compel the accoucheur to crowd it upon his eclamptic patient, in the full belief that in this vapor, during the paroxysms, rests her safety more than in that of pure atmospheric air. Several years ago I saw, at full term, a primipara with general anasarca, fearfully apprehensive because of her condition, and the fact that her mother died giving her birth, almost blind, urine albuminous and scanty, exhausted from loss of rest, and exhibiting the prodromes of convulsions. Without any evidence of labor I directed an active purge and large doses of bromide of potassium, believing that when labor set in I would have a typical case for the test of the virtues of anaesthesia in this particular character of convulsive trouble. Before either of the remedies could be admin- istered convulsions occurred with great violence, and I commenced at once the inhalation of the English mixture of ether, chloroform, and alcohol at each exacerbation until she was lulled to quiet. Turning a deaf ear to all appeals of the friends for venesection, the anaesthetic was steadily continued for two hours, when it was evi- dent her labor had set in, and the chief aim was to deliver as soon as possible. Whilst bringing down the child with the forceps the general appearance of the woman became so alarming as to unmistakably portend to the by standers certain and immediate death, and so unwilling were my medical assistants to continue the anaesthetic that I was compelled to leave my portion of the work to take the charged towel from their hands and crowd it over the entire face of my patient, who had apparently almost ceased to breathe ; when, to my anxious hope against what seemed an inexorable fate, I soon saw the blueness fade from the finger nails, the extremities assume a more natural color, the pulse increase in force, and the respiration return to its former stertor. This gave confidence, and the assist- ants, assured of no responsibility in the event of a fatal termi- nation, complied with my instructions, and for another tedious hour we so guarded her from death as to complete her labor in safety of a healthy living child. Without relating any further cases in detail, showing the effects of the anaesthetic, as well as others exhibiting almost marvellous escapes, in which such alarming symptoms followed the labor as to have made it impossible to believe otherwise than that the nervous distress in vertigo, formication, numbness of the limbs, profuse sweats, etc., had been the direct effect of such administration, and ANiESTIIESIA IN PARTURITION. 7 in which no anaesthetic had been used, I would submit the follow- ing general conclusions drawn from at least one thousand cases under my own observation and management:— 1st. That the parturient state is the only condition of the system during life in which anaesthetics, judiciously administered, are entirely devoid of danger. 2d. That the physiological action of chloroform, ether, and alco- hol in a woman during labor is not identical with that in an ordinary subject in a dental chair, or upon the surgeon’s table, and from the history of such administration, free from a single well-authenticated case of death, with statistics showing its superiority over venesec- tion, opium, etc., in the desperate emergencies attending irregular labors, as eclampsia, it is fair to infer that this agent is an especial therapeutic indication for parturient women, and should be so regarded in all labors where by its use the pains of the second and third stages could be obviated, and this, too, to the ultimate benefit of the mother and safety of the child. 3d. That in puerperal eclampsia it is especially indicated, because of its direct, rapid, and general action, controlling nervous physio- logical irregularities, exciting secretion, relaxing the os and peri- neum and, in short, so preparing the parts as to aid the accoucheur in his manipulations for the essential emptying of the uterus—to accomplish which, venesection, opiates, purgation, counter-irrita- tion, etc., either singly or combined, bear to anmsthetics the relation of mere fractions to a grand whole. 4th. Its application is universal; no diseased condition of the heart or lungs, at all likely to exist where pregnancy can occur, should forbid its use—for where has a post-mortem examination revealed a dilated and weak right heart from fatty degeneration in the body of a pregnant woman at full term ? 5th. That in view of its known therapeutic action and safety in the small quantity required to produce narcosis, no use of the for- ceps, version, nor obstetric operation of any moment should be performed without it; not only to save the patient from shock and its consequences, but because of the great saving of time and labor and, in most instances, the assistance it affords the operator. 6th. Owing to the fact that uterine contractions are often lessened by the administration, it is always important to precede it by an oxytocic, in all labors and at any stage, where the pains are slight, so as to increase their force, and also to guard against post-partum hemorrhage—a very infrequent occurrence where such precaution is taken. 7th. Accidents to the unemptied bladder, ruptures of perineum 8 ANAESTHESIA IN PARTURITION. and sphincter ani may be prevented, as well as death of the child in prolapsus of the cord by the facilities afforded for rapid delivery, especially in primipara. 8th. That in no instance have I seen narcosis of the child attri- butable to the anesthetic. 9th. Without any special reason, excepting the common dis- agreeable feature of ether, and the supposed risk of chloroform, I have generally used the mixture proposed by the Medico-Chirur- gical Society of London, consisting of ether 3 pts., chloroform 2 pts., and alcohol 1 pt., being careful as to the quality of the pre- paration, and having them recently mixed. With this combination I have never been disappointed, or regretted its use; and, in truth, nearly all the troublesome cases I have had after the labor were those in which, for some reason, the anaesthetic was not used. How few physicians would refuse an anaesthetic to a man or woman who required the lancing of a whitlow, the extraction of a tooth, the amputation of a breast or limb, or any of the ordinary minor or major operations in surgery, where danger to some extent always attends, and in which exists but a small amount of pain, from the shortness of duration, in comparison with that of an average labor, where statistics declare no danger under any ad- ministration can be apprehended from the anaesthetic alone! Where is the man, who as physician or surgeon in his legitimate province, could stand coldly by and see with indifference the writh- ing of a human being in broken or continued pain, without offering to him an anodyne or anaesthetic ; and yet, why the stolid and heartless indifference that same man exhibits when he becomes an accoucheur and has in his sole charge a helpless woman in the ago- nizing throes of labor, earnestly beseeching him to relieve her of her anguish or give to her immediate relief in death ? Fortunately, in unnatural labors many physicians regard anaes- thetics as directly indicated, and rarely attempt version or cranio- tomy without them, but unless some desperate emergency exists, a morbid apprehension of some mythical possibility seems to seize the mind and govern their actions, and a humanity, for which as physicians and surgeons they ma}r be proverbial, deserts them in the very hour when above all others the tenderest sympathies and promptest care should demand the consummation of a possible pain- less and happy conduct by that boon, which to parturient women, in the travail of labor, falls but little short of what may well be termed an especial therapeutic divination.