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mental and moral qualities in after life; and that some women are so constituted, mentally and physically, that impressions on the mother's mind will stamp deformity on their unborn infants, and the mental and physical condition of all mothers, during the period of gestation, exercises a controlling influence over their offspring.
How much to be reprobated is the habit of some mothers, devoted to fashionable life and city amusements, who, regardless of the future of their frail fætus, their hopeful heir in “futuro,” visit the midnight dance and masquerade, the party or crowded theatre, who live in a continued round of excitement and heartless frivolity! For such an infringement of natural law they and their offspring must suffer the penalty.
Medical Intelligence and Deports.
PROCEEDINGS OF CINCINNATI ACADEMY OF MEDICINE.
THE Academy met in the Hall, Monday evening, October 10—the President, Dr. Stevens, in the chair. Professor Mendenhall read the following paper on anæsthetics in labor.
When a new remedy is introduced to the notice of the profession, it is usually very difficult, as we all know, to form a proper estimate of its true value. On one hand its valuable properties are often extolled beyond what is warranted by the truth; while on the other it is depreciated far below its just merits. This has been the case most emphatically in regard to the value of anæsthetic agents in obstetrical practice. They must be subjected to the great ordeal of professional experience, and the reports of honest and acute observers must be placed side by side, and, divested of prejudice, await the impartial verdict of the profession as to the position they are to occupy. This ordeal has resulted in much more accurate views than were formerly entertained, but the time has hardly yet arrived for unanimity of opinion as to the value of anæsthetics in labor. By one portion of the profession they are recommended in all cases of parturition; thus intending to obliterate at a dash the pains and anguish which are inseparable from child-birth. The most prominent of this class is Professor Simpson, who states that “all of us, I most sincerely believe, are called upon to employ it (chloroform) by every principle of true humanity as well as every principle of true religion. Medical men may oppose for a time the superinduction of anesthesia in parturition, but they will oppose it in vain, for certainly our patients themselves will force the use of it upon the profession. The whole question is, even now, one merely of time. It is not, shall the practice come to be generally adopted ? but, when shall it come to be generally adopted ?”
Another portion would exclude them entirely in a summary manner (except under extraordinary circumstances) from obstetric practice. Dr. Ramsbotham and Dr. Lee may be taken as the representatives of this view of the subject. Dr. R. says there are only one or two contingencies in which he could imagine the propriety of placing the patient completely under the influence of an anaesthetic. One of these is where a transverse presentation exists, the membranes ruptured for a long time, and the woman positively refusing to submit to the operation of turning. Another is where the forceps are required, and the woman refuses to sub
mit to the operation. These are contingencies which seldom if ever happen, and the rule, therefore, may be looked upon as excluding anæsthetics.
Others, again, propose to use these agents, as I think all remedies should be used, in cases and conditions to which their properties adapt them in relieving disordered or unfavorable conditions, and thereby lessening pain and saving life.
In this classification I prefer to occupy the latter position, and endeavor to study those deviations from the most favorable conditions occurring during labor in which anæsthetic remedies are found to be valuable. I believe this is the ground occupied by a majority of the profession at the present time.
In this brief paper I do not propose to consider the general subject of anästhesia, or the peculiar mode in which the different articles that are used produce their effects, but will content myself with stating that chloroform and sulph. ether are the only articles that are entitled, at the present time, to be considered in this connection. The principal points for consideration, therefore, are the circumstances under which women in labor may be benefited by the use of anæsthetics. I think we are warranted in excluding all cases in which the safety of the woman or child would not be increased, or the labor expedited, by their use. The alleviation of physiological pain, therefore, in itself
, would not, with this view, justify the use of chloroform or ether. The question may be asked, why not give it so as to produce painless labors in all cases? The reasons are : It is not always safe to either mother or child, and our responsibility is greater than in surgical cases where a patient may have a right to risk, somewhat, his own life to save himself from pain; but he has no right to unnecessarily risk that of another, as would be the case in parturition. Here we have two lives depending upon our management instead of one. It is a well-established fact, as has just been assumed, that anæsthetics are not unattended with risk to both mother and child, for the proof of which several authorities may be referred to; and if so, we are not justified in using them, unless, under the circumstances, the risks are diminished by adopting them.
Dr. Gream (Med. Gaz., Sept. 7, 1848) mentions a case in which the child died a few hours after its birth, the mother having been etherized, where the pericardium was filled with serum. He attributes this morbid condition to the drug. Dubois mentions two cases where, during insensibility of the mother, the fætal heart beat 160 strokes in a minute, but when the mother recovered her senses it fell to the healthy condition.
Dr. Ramsbotham mentions a case where the woman died soon after labor, in which the effect during labor seemed to be pleasant. One and a half hours after labor she had dyspnea, became livid, showing signs of engorgement of the lungs and heart; finally convulsions and death closed the scene.
Dr. R. also mentions four cases, from Gream, of mania, in which no lucid intervals occurred between the inhalation and the complete existence of mania.
Dr. Sutherland relates three cases of mania from chloroform, which he Dr. Lee, in a paper read before the Royal Medico-Chirurgical Society, relates seventeen cases which came directly under his own observation, in which pernicious effects occurred. In two cases, the contractions of the uterus were arrested, and a delivery was effected by craniotomy. In seven cases, insanity and great disturbance of the brain followed. In five cases, the necessity for delivery by the forceps arose from the use of chloroform. In four cases, peritonitis or phlebitis ensued. Epilepsy occurred in one case, and dangerous fits of syncope in another.
He also says that many other cases have been reported to him by his friends, and public rumor swelled the list still further; but he preferred to confine his attention to those with which he was personally acquainted.
It may be a very nice point to adjust these risks and determine which may preponderate-the complication affecting the labor, or the effect of the anesthetic—but we are called upon every day in our prescriptions to make similar distinctions, and in the accuracy of which lies, to a great extent, the difference between practitioners in reference to success.
We believe, however, that there are conditions during labor in which the risks to life are very small, and yet we may be justified in using an anæsthetic in such a way that the duration of labor and the sufferings of the woman may be much abridged, and with very little risk. In some of these cases the hazard may not be great, whether the remedy is used or not, and yet the probabilities preponderate in favor of its use.
It is important in considering this question to bear in mind that the pains attendant upon parturition are physiological : they pertain to a physiological process, and we believe it will be found to be unwise to interfere with this process so long as the natural, unaided powers of the woman are accomplishing their object in the best possible manner. There is, therefore, an important distinction which ought to be borne in mind between physiological pain and pathological pain, or the pain resulting from a surgical operation.
Another point may not be unworthy of attention. We have stated that labor-pains within certain limits were physiological : they are the condition entailed upon woman as the price of maternity; and in this provision of Providence are there not results intended to affect the relation between the mother and her offspring ? What mother does not love her child better and take a deeper interest in its welfare when she reflects upon her parturient sufferings? The relation is a physiological one; and it seems to me the reflections of a mother must be more pleasant when her child is brought forth while she is in such a condition of consciousness as to appreciate the magnitude of the event, instead of being insensible to the child's first cry, which thrills through every nerve of the conscious, joyful mother, and who at this moment feels that she is amply repaid for all her sufferings. This pleasure is reserved for mothers who are not stupefied by an anæsthetic.
Having, however, admitted the propriety of the use of anæsthetic agents in certain conditions, while we condemn their use in the majority of cases of labor, it becomes a very important point to determine the conditions in which they may be used to advantage.
In deducing rules for their use, I have been guided by such authorities
as I consider the most reliable, and by my own experience and reflections on the subject. In the first stage of labor, when there is a rigid and tender condition of the os, and the pains are harassing and irregular, and the progress disproportioned to the efforts of the woman, I think anæsthetics may be very useful. Uterine contractions, which had previously been irregular and painful, often become regular, effective, and much more bearable to the patient. In such cases, chloroform or ether may accelerate instead of diminish uterine action, and thereby hasten the progress of labor.
I would not hesitate to administer an anesthetic in any stage of labor, nothing contra-indicatiug its use, when the pains were not regular and well defined as to periodicity, or not uniform in their character, or where, instead of repose between their recurrence, the patient should be harassed with inefficient pain. Its use in these cases will generally produce sleep between the pains, which will refresh the woman and allow her to proceed with the labor in a more satisfactory manner.
In cases of labor where there is rigidity of the soft parts, and particularly if accompanied with increased sensibility, anæsthetic agents often prove satisfactory in relieving pain and increasing the dilatability. These conditions often interfere with the progress of labor, not only by the obstruction to the passage of the head, but from the increased pain they inflict upon the woman, and which prevents the full development of the uterine contractions.
In cases, also, when sympathetic pain exists, as in the abdominal muscles, back, hips, or inferior extremities, and interfere with the efficiency of the uterine contractions, anæsthetics will usually act beneficially. Excessive anguish in labor, in which the nervous system of the woman becomes severely agitated from any cause, and under which she loses her self-control, may be often relieved and calmness restored by the soothing influence of anæsthetics.
In presentations for the delivery of which greater distension is required, and therefore greater suffering, than in occipito-anterior positions of the head, anæsthetics may be proper, for the purpose of relieving excessive pain and increasing the dilatability of the soft parts. Chloroform and ether are almost indispensable when the operation of turning is required, and the contractions of the uterus or the rigidity of the soft parts present any serious obstacle to the introduction of the hand and the necessary manipulations for accomplishing our object. But in cases where the soft parts are dilated or easily dilatable, and the uterus not firmly contracted so as to present considerable obstacle to delivery, I believe it will be better to abstain from the use of these articles.
In the application of the forceps, I should prefer, unless the soft parts are unusually tender, that the patient retain her usual sensibilities, at least until the instrument is adjusted properly and traction commenced.
After the adjustment of the forceps, if there is rigidity or excessive pain, anæsthetics may be useful during extraction, as in other cases where these conditions exist.
In embryulcia I should prefer the patient to possess her usual sensibilities to pain, unless there was increased sensibility of the parts, rigidity,