PAINLESS CHILDBIRTH.

559 liat the use of nitrous oxide and oxygen for conmoments is impracticable in the vast majority of ases. Certainly it can be employed in institutions, mrsing homes and hospitals, and in private houses f special arrangements can be made, but there must )e a narrow bed and there must be cumbersome Lpparatus. Given these and a skilled anaesthetist )repared to devote unlimited time to the case, then a LONDON:SATURDAY, MARCH 17, 1928. iormal confinement can be conducted so as to savetll pain and so as to leave the patient less disturbed )y the process than is possible in any other circumPAINLESS CHILDBIRTH. Nitrous oxide is, of course, a non-toxic stances. THE due provision of anaesthesia, during labour is anaesthetic; the metabolism of mother and child is not so simple as it appears at first sight, or to those entirely unaffected, and the uterine contractions of The who have not considered the problem as it affects abour are neither delayed nor diminished. the motherhood of the nation as a whole. On one ame advantages cannot, all of them, be claimed for aspect only of the subject was complete unanimity bhe anaesthetic most commonly employed for confinedisplayed during the discussion recently held at the ments in Great Britain-namely, chloroform. Not1 of Medicine. That Royal Society unanimity was withstanding its defects, however, most of the expressed regarding the desirability of using anoes- speakers at the discussion to which we have referred thetics for confinement cases. It was pointed out, were prepared to defend and advocate its employwith undoubted truth, that it would be a national ment. This may at first sight seem strange when we advantage for women to be rid of the traditional remember the almost general condemnation of chlorofear of the pains of childbirth, and for them to know form as a routine anaesthetic for operations nowadays. that the process might be made at least as painless Nevertheless the apparent contradiction is fully Too many justified. The proper use of chloroform in midwifery as any ordinary surgical operation. women are deterred from motherhood, or their safety is very different from its use for surgical operations. is threatened, by that fear of pain which, as Dr. The conditions are different and the object aimed at EARDLEY HOLLAND pointed out, is instilled into is different. To begin with, there is in the woman their minds from childhood upwards by words in the in labour an entire absence of that psychic danger Book of Common Prayer, if not from other sources which arises from fear of taking the anaesthetic. The also. A new tradition of painless labour should be woman in labour, so far from being afraid of an propagated. And it must be founded on fact. It is anaesthetic, is crying out for one. This rules out in not enough to show -that a confinement can always her case that formidable and not entirely explicable be freed from any grave amount of pain. It must risk which is involved in the induction of anaesthesia actually be made free. Of objections to the use of by chloroform in a patient who is fearful of it. Again, anaesthetics during labour those based on religious the drug is used during labour, when it is used expertly, grounds are now happily regarded as dead and buried. in such a way that a condition of little more than Later opposition has depended on the belief that the analgesia is produced during the attacks of pain. anaesthetics delayed labour, or were injurious to the It is entirely withheld in the intervals, and surgical mother or the child, or to both. The truth is that, anaesthesia is produced, if at all, only when the head properly employed, anaesthetics need never delay is passing over the perineum. The accumulated and can actually expedite the child-bearing process. evidence of years supports the contention that in For there is a stage of that process when the patient i skilled hands chloroform can be more safely used When may do all she can to retard the oncoming head owing in confinements than in general surgery. to the agony of pain which its advance is causing. abnormal labours or obstetric operations are conAnalgesia or anaesthesia at this time will, as was cerned most anaesthetists, we believe, prefer ether, pointed out at the discussion, lead actually to a and assist the case on ordinary surgical lines. The diminution of the time spent on giving birth to the use of twilight sleep as the chief means of avoiding child. Though it is true that all anaesthetics have pain does not appear to have many supporters, but experimentally been shown to have the power to a modified use of sedative drugs-chloral, omnopon, delay the contractions of the uterus, there is much morphia, and scopolamine-early in labour is evidently difference between their use in order to demonstrate favoured by those best qualified to speak, and is this fact in the laboratory and their skilful clinical practised in conjunction with anaesthetics. What is employment. When properly used anaesthetics can known as "synergistic anæsthesia" has not been abolish pain at a normal confinement without delay- widely employed in this country. It often involves ing progress. This proper use implies a method by several intramuscular injections as well as a rectal which a state of analgesia, rather than anaesthesia, injection. On a priori grounds the rectum would not is kept up intermittently throughout the greater usually be selected as a convenient introductory route part of the time. Between the " pains " the patient in the pregnant woman, and it does in fact appear slumbers, at the " pains" she inhales anaesthetic that sometimes there is difficulty in getting the enough to keep her free from pain, and this state is catheter past the fcetal head. Moreover, the patient pushed to true surgical anaesthesia only at the critical not infrequently expels the rectal injection. (This part of the expulsive stage, or at the accoucheur’s was indeed alluded to by one sarcastic speaker as the sole recommendation of the method.) These request. There is more than one way of obtaining this disadvantages would have to be ignored, of course, desired state of analgesia and anaesthesia. It seems if the method were shown to have the great superiority to be admitted widely that the ideal is reached by claimed by its American originators, but from their the skilled employment of nitrous oxide and oxygen, own country there has lately come a well-supported but most ideals are difficult of attainment, and this review2 of " synergistic anaesthesia" which is by It is here stated that is no exception. In fact, it may be said with truth no means encouraging.

THE

LANCET.

B.

I

1

See THE LANCET, March 10th, p. 498.

2

Jour. Amer. Med. Assoc., Dec. 17th, 26th, 31st, 1927.

560 "

GWATHMEY and his associates have attempted to principle as far as possible, but reinforces it with comdevelop a method of anaesthesia without an adequate pulsion. In future if a patient breaks off his visits, experimental basis ; hence they have fallen into his doctor will first ask him to resume treatment. errors which could have been avoided, and GWATHMEY On refusal the doctor will report the case either to has based theories on erroneous views which havee the observation station or to the health authorities, been accepted and repeated by other writers." which in their turn will summon him to resume the Strong arguments are adduced against the actual course. These two summonses will contain no occurrence of the synergism described as resulting threat ; it is only when the patient refuses to comply from the cooperation of morphia and magnesium with the summons of the health authorities that sulphate and ether in the technique recommended by coercive measures will be taken, involving compulsory GWATHMEY, while it is admitted that " the action of treatment and (if necessary) detention in hospital. morphine on the respiratory centre is synergistic with The change in the law is that the health authorities that of ether and magnesium sulphate and that can enforce compulsion which was not-and still is the competence of the observation numerous deaths have resulted from their combined not-within stations. Treatment involving serious risk may not use." Whatever be the method of anaesthesia decided on be prescribed without the patient’s consent. He may choose his own doctor, and the doctor may choose as most generally desirable in obstetrics, the great practical. problem in this country still remains un- his own method of treatment ; treatment of this solved. That problem is how to bring this desired class of disease is confined to doctors qualified to anaesthesia within reach of the great majority of practise in Germany. The new law abandons comchild-bearing women. At the present time a large pulsion in respect of the police regulation of prostimajority of the children born in England are born tution, but it allows the competent health authority under the aegis not of a medical man but of a certified to require a person suspected of spreading infection midwife. The midwife has no authority to use, and to present a medical certificate or to submit to medical no training in the use of, anaesthetic drugs in the examination in an approved hospital. Doctors, as second stage of labour, although under the rules of Dr. ROESCHMANN observes, have always tried to the Central Midwives Board she is at liberty to obtain voluntary evidence of the source of a new administer sedatives such as morphia, chloral and infection and to persuade the person responsible to bromide in the first stage and has received appro- submit to treatment. In the event of refusal there Should this priate instruction. arrangement was, however, no other legal remedy than the cuiiibe extended

so

that these

are trained in anaesthetic adminisis not resorted to,

women

specified safe, simple If that expedient tration ?’?

some

in what way is the medical profession to answer the demand which it is making-that every childbearing mother should be relieved of her pain at labour ? The problem is a thorny one. There are members of the profession who believe that the use of anaesthetics is already not sufficiently safeguarded, and who would like to see a special instituted to mark out the man who has special skill and knowledge in this department of practice. The mere idea of a midwife using anaesthetics at all would obviously be anathema to those who think thus. We can make no pretence to offering a solution of the problem of supplying adequate anaesthesia for obstetrics in the country at large ; but the recognition that a problem exists is the first step towards its solution, and we hope that the questions involved will receive serious attention. They merit it.

diploma

LEGAL COMPULSION IN VENEREAL DISEASE TREATMENT. A

RECENT

account 01 venereal disease

legislation

in Germany touches significantly upon the problem which the Edinburgh Corporation Bill has brought into prominence. Writing on the new German law in the World’s Health for March, Dr. ROESCHMANN, of Berlin, naturally dwells upon the familiar fact that many patients, either from ignorance or callousness, neglect their treatment before they are completely cured, and thus become liable to dangerous relapses which make them a constant peril to others. On this account, he says, the national insurance institutes in Germany organised in 1916 antivenereal observation stations which exercised a sort of supervision by summoning patients to report until completely cured. The system was voluntary; if the patient ignored the summons, he could not be compelled. The new German law preserves the voluntary

brous invocation of Articles 223-4 and 230-1 of the Penal Code which provided penalties for the infliction of bodily injury with or without malice aforethought. This latter step was rarely taken because the persons concerned shunned publicity and because the medical profession was bound by its rule of secrecy. Henceforth, says Dr. ROESCHMANN, doctors are free to report sources of infection to the health authorities in Germany, since the employees of the health service are themselves bound to professional secrets. Further, he adds, the notification of a case to the health authorities involves no inconvenience to the patient ; it is only when the patient refuses to submit to treatment that coercion begins. These extracts deal with but one aspect of the new law passed in 1927 by the Reichstag and depending in part upon detailed regulations with which the several States of the German Republic have subsesupplemented the Reich law. The extracts have been selected for their bearing upon the Edinburgh Bill controversy. In that controversy all parties have really but a single purpose-to stamp out venereal disease at the earliest possible, moment Their only difference is as to method. The Bill, say its opponents, relies upon compulsion when the ful possibilities of the voluntary system have not yet been exhausted. The general medical practitioner, they say, is not always competent to use modern technique for the detection and treatment of syphilis and gonorrhcea ; the Bill will lead to the giving of medical certificates of freedom from infection which will not always be trustworthy. There is a threat, say the opponents of the Bill, to the professional tradition of secrecy, a danger of abuse of the denuneiation of suspected persons. Compulsory notification, they continue, might be largely ignored by private practitioners, so that the only persons penalised would be those attending venereal disease ceutres. The effect of the Bill, they contend, would be to deter the infected person from reporting for treatment or to induce him to give a false name and address to even such persons do already. a greater extent than These arguments are undeniably weighty ; it is for

keep

quently