Pantopon-scopolamine seminarcosis in labor

PANTOPON-SCOPOLAMINE BY PHILIPS

SEMINARCOSIS

IN LABOR”

J. CARTER, M.D., NEW ORLEANS,LA.

reproaches of medical science in this country is that 0 NEthe ofdeaththe rate of women in childbirth should each year reach the appalling number of nearly 20,000, and that uncounted numbers are rendered more or less permanent invalids besides. No other specialty has made more advances during the last few years, but these figures show the crying need of still better obstetrics. Part of the solution of the problem is coming by way of maternity hospitals and clinics whereby the indigent mother is given every advantage of antepartum, intrapartum and postpartum care. Prenatal care is particularly important for it instills into the mother the consciousness that her unborn child will come into the world vigorous, healthy, and fit for life, while she herself will be restored to her normal state, without subsequent deformity or disease. Relief from pain during labor is one of the greatest assets to the well-being of the average mother, and unless this possibility is impressed upon her at the first consultation, I believe that her prenatal care is incomplete. Every parturient mother has a right to demand alleviation from pain, but the demand can bc gratified only when it can be done with safety to mother and child both at the time of delivery and in after years. I would commend and not condemn any form of painless childbirth,-twilight sleep, synergistic analgesia, ethylene-oxygen, chloroform, ether, regional or any other of the various methods, provided that it will instill within the mother cheerful prenatal influences by removing from her the fear of her ordeal, that it will carry her through her labor in comfort and security, and that it is absolutely safe and harmless both to her and her child. We are all working for the same goal, the relief of suffering humanity, and our spirit should be one of unbiased, unprejudiced investigation, not h&y condemnation. Scopolamine-morphine or better, scopolamine-pantopon seminarcosis, properly employed, has given uniformly satisfactory results wherever it has had a fair and careful trial, but for some reason it has never been generally used or approved in New Orleans. Cross tells us from the collected statistics of 75,000 cases in the United States, that it is not only harmless for both mother and child if the rules and technic are strictly followed but that it is of the greatest benefit to them both. Krebs and Wilson, of St. Louis, studying the second thou*Read at a meeting of the New OrleansGynccologicnland Obstetrical Society, April 16, 1925. 693

sand cases delivered by this met.hod in Barnes Hospital, pod, ~JUI certain very defiuite advantages. Scopolamine-morphine-hyoscinc has been used freely in their service since 1915, with such good results that it is now practically routine with them. When we see obstetricians like Polak, Mosher, Van Hoosen, Beck, Jacobson, Wakefield Livingston, Knipe, Rongy, Broadhead, Schwarz, Krebs and man>’ others using and approving the method, we realize that it certainly must have some merit. Again the author of one of our most widely used obstetrical textbooks condemns the method but uses it as a routine, though in an abbreviated form in all his cases; his inconsistency suggests that he sees in the treatment advantages he is willing to utilize if not to admit,. Wakefield, in commenting on several thousand personally conducted cases, says, “To procure ideal results one must he temperamentally fitted for the work and in a position to drop ot,her work and tie one’s self up with one case for hours at a time. A well-trained staff of assistants, entirely in sympathy with this special method, is csseuGal. The treatment must always be given in a hospital, away from all noise and confusion It calls for an unusual amount of skill and good judgment. ” He emphasizes the fact, too, that the personal element must always enter largely into the situation, though I would stress the point that t,here is no personal hypnosis employed ; the amnesia is purely a drug-produced condition, and the ability of the individual man to make fine differentiations in the states of consciousness will have much to do with individual success. This type of seminarcosis is indicated whenever a normal ratio exists between passage and passenger in broken heart compensation, in tuberculosis, in women of hypersensitiveness, particularly those who look back upon previous agonizing labors with dread, in premature rupture of the membranes, when the first stage is protracted and painful, and in women who have had repair work done, especially where there has been an operation for deep scarring of the cervix. It is generally agreed that nerve exhaustion is one, of the most potent causes of uterine inertia, aad because this method relieves much of the nervous anxiety and racking pain of the first stage it permits a thorough test of labor, with prompt dilatation and no untoward effects. I have reviewed some 200 articles on this subject and find them practically unanimous in their agreement on this point, that scopolaminemorphine is a perfect first stage anesthetic, in that it restrains rather than overworks the system by eliminating pain and physical and nervous exhaustion. Many have condemned this method because of the effect morphine is supposed to have on the child, yet they will willingly employ other methods which call for the use of the same drug. Morphine daes affect the child if used in large closes immediat,ely before delivery, but it

(‘ARTER

:

l’ANTOPON-SCOI’OLB1INE

SI
IN

LABOR

695

has no effect if given under the proper technic in scopolamine-morphine anesthesia. My objection to it is on the mother’s account, not the child’s, as I found in several instances that it produced severe headaches, nausea, and vomiting. For this reason I have suhstituted for it pantopon, which combines the special advantage of opium and morphine without the disadvantages incidental to each. It contains the total alkaloids of opium in the water soluble form of their hydrochlorides but is free from their inert and injurious extractive matter. Experiments by Macht of Johns Hopkins have shown that one grain of pantopon is equivalent to 2.5 grains of opium or 45 minims of laudanum and that it has a more effieient and less depressing effect than morphine. Scopolamine, the other drug used in this treatment, is a powerful somnifacient and cerebral sedative. Small doses abolish cerebral excitement, large doses stimulate it. In therapeutic doses it causes more or less drowsiness from ten minutes to half an hour after its administration, depending upon individual susceptibility. B maximum dose will produce intense thirst, dryness of the n1out.h and fauces, flushes and high blood pressure. The equilibrium will be disturbed as evidenced by incoherent utterances. A toxic dose will dilate the pupils widely, slow the pulse markedly, lower the blood pressure, cause Cheyne-Stokes’ respiration, and produce active delirium accompanied by visual disturbances, auditory hallucinat,ions, and clonic convulsions with opisthotonos. The dosage which this method calls for, however, has been proved to be perfectly safe. Krebs and Wilson, in animal experimentation, have proved that scopolamine in doses much larger than were ever recommended for twilight sleep has no material effect on pressure or respiration, while Opitz, of Freiburg, has proved that the bad results on the babies in a series of 4,279 births which he studied, were due entirely to unwise doses of morphine. For these reasons it is obvious that thorough familiarity with the method and strict adherence to the technic are essential to secure good results, and I cannot emphasize too strongly. that this is a special method and not a general one. It should be employed only by those men who are willing to give their time to it and are in thorough sympathy with it. It should always be given in a hospital with a special nurse in attendance. I do not believe that it is necessary to remove the needed obstetrical apparatus from the patient’s sight, but it is important, that she be handled from beginning to end of her labor in the same room. Neither do I believe in blindfolding the patient, stuffing her ears with cotton, etc.; she knows beforehand from my explanations what the treatment is to be and is ready to cooperate with me without any unnecessary ritual of treatment. She is prepared as for the ordinary delivery. The treatment is begun with the primipara when she

i< at least two fingers tlilatr,l :IJIC~ the l~ains arc srrmlg and regular: and with the multipara as soon as the first strong, regular pains have begun. The patient is then shaved, scrubbed, sterilized and dra.pcd with sterile drapings, so that she is not disturbed again unless opcrative interference is necessary. I iicv(‘r permit my patients to bt: forcibly restrained, and as a rule t.he only difficulty I have with them is keeping them on their backs during the actual delivery. Except for necessary examinations all11 auseultations of the fetal heart sounds the patient is not disturbed. I now use pantopon, gr. $$, with scopolamine, gr. 1/&o, for the initial dose. A second dose of scopolamine alone is given from fortyfive to sixty minutes later, the same amount, gr. :/loo, which is the standard dosage for the average case. Succeeding doses are from, w 3400, to, v. I;!& the time and amount depending upon individual susceptibility and the progress of the labor. A fast labor naturally requires a. shorter interval between the doses, a slow labor requires a longer one, but experience alone ran teach Olle the proper time limits, plus a very careful observation of the patient. I usually follow Dr. Wakefield’s suggestion; he says, “Close observations have taught me that when my patient begins to take on a keen look as though (like a child awakening from sleep) she were endeavoring to place herself and find consciousness, and when, furthermore, she begins successfully to correlatct happenings, she should ha,ve another dose of scopolamine.” In 21 cases delivered in New Orleans under my personal supervision the results have been most. encouraging. Eighteen were perfectly successful and the three failures were anticipated for the reason that labor was far advanced when the drugs were administered and in each instance delivery occurred within an hour after the first dose. There was one fetal. deat,h; autopsy showed cxtensivc hemorrhages int.o t,he brain ; the la.bor had lastc~l less than three hours. There were no blue babies; one child, who cried immediately aft,er delivery, became oligopneic, but returned to normal within a few minutes. One of these babies, I feel absolutely was saved by this treatment, one of the cardinal points of which is frequent auscultation of the fetal heart sounds. In t,his instance the heart sounds rose rapidly from 140 to 190 beats, just as the head reached the perineum. I suspected a short cord and applied forceps immediately; the cord was around the neck and had to be cut before delivery could be completed. The first 15 of these cases received morphine with the initial dose of scopolamine, the last six received pantopon. Moreover, each of these six knew beforehand that she was to be treated by this method of seminarcosis, and I cannot but feel that the fact that each of them went to her labor with full consciousness that, she was to be reIievcd of pain had a good deal to do with the very successful results.

In conclusion, and in reply to those critics who argue that this method should not be employed because of its ba.d effect on t,he children, I wish to quote some relative statistics. In 1919, the infant mortality in the United St.&es was 8.6 per cent; in 1921, in New York, it was 7.1 per cent; the Johns Hopkins records show a 7 per cent mortality; Slemons of Californij gives 5 per cent for 1922; the Chicago figures are 8.9 per cent; Opitz, of Freiburg, gives 3.75 per cent ; Polak, in 1000 cases without prenatal care, gives 7.6 per cent. All of these were cases delivered without any form of relief from pain. On the other hand, in cases treated by the morphine-scopolamine method of seminarcosis, Polak’s infant mortality is 2.5 per cent, Van Hoosen’s 2.3 per cent, Masher’s 2.8 per cent,, Opitz’s 2.1 per cent, Wakefield’s 1.7 per cent, and Gauss’ 1.7 pclr ccllt. These figurcls speak for themselves. Jacobson considers that an explanation of the good results is that the infant does not make efforts to breathe too soon before birth and, therefore, does not aspirate fluids into its lungs. Snother author says that the good results are due to the int.rauterine narcotic action of the drug on the fetal respiratory centers, so that the danger of premature respirations and aspiration of fluid into the bronchial tubes is lessened. Livingston considers that the infant mortality in cases treated by this method surely proves that the method of itself cannot be killing babies and states that in his opinion it is not only relieving the mother of most of her suffering during labor and a good deal of the subsequent morbidity, but, is actually saving the lives of babies as well. Reports

of the six pantopon-scopolamine

casts are appended.

CASE l.-Para iii, age thirty-one years. First pregnancy, induced abortion for pernicious vomiting. Condition recurred in second pregnancy so that abortion was considered but not necessary. Third pregnancy normal after third month, up to which time vomiting was severe. The labor lasted two hours and fifteen minutes, treatment being begun when she was three fingers dilated. Routine dosage, pantopon, gr. $4, scopolamine, gr. yloo, scopolamine, gr. 1/2oo; one additional dose, scopolamine, gr. 1/4oo. Normal delivery, no tear; child cried immediately after being delivered. This case was treated in a boarding house on a noisy carline, and the results were excellent. She knew nothing of the labor after the first injection, although amnesia was not complete until the second dose was given; condition normal within three hours after delivery. CASE 2.-Para i, age twenty-three three fingers dilated. Routine dosage, gr. ILoo. Labor three hours and fifteen soft parts. Child born crying.

years. Treatment began when cervix was plus three additional doses of scopolamine, minutes. Forceps applied because of rigid

CASE 3.-Para i, age twenty. Treatment was begun when cervix was two fingers dilated. Routine dosage, plus an additional dose of scopolamine, gr. 1/2oo. Birth was almost precipitate and would have been except for careful observation. This patient was extremely nervous, in fact almost wild, until treatment was begun.

Within

minutes aftcxr i.11~~iujwtiou, :tmnosia began and continued until dcliccry. C‘hiltl l>trlm in good condition hut became oligopnric for t,wo or three minutes. three

fifteen

hours

after

CASE k.--~lll’a V, :,fC ttvent)‘-foul’. Trca~ illcut began m-hen c:crvis X:IS t,hrr!t; fingers dilated. Routine dosage?, plus an additional dose of scopolamine, gr. +&. Immctlintc forceps delivery following rise of fetal heart sounds from 140 to 190. Short cord about ncek severed bcforo &lively. The child’s fact was purple lxforc& thtl coral was cut but rcgnined iti normal color almost at onw.

CJ.ZSE5.--Para

ii, age twenty-tlircc. Treatment began when cervix was l’on~ R.outinc dosage IJIUS an aJdition:c.l dosc of sc:opolamino, gr. I&,. I)c~liv~~ry two hours later. h’orr~!l~s applic~l for rigid soft Llartb an11 l)roniincnt isehial spines which wcrc hiuclcring delivery. Child in gooii conlliticm. TO tsar. fil @W

tlil:ltod.

C,kSE Ci.-Para iii, age twvcntr-four years. This was the second baby dcli~crt~(i by this method of Case 5. Treatment was begun when ccryis was four fingers \lil:rtcd. Boutinc dosage plus an :tdditional dose of scopola’minc, gr. */ioo. Delivery two hours afterwards, following 31 C.C. of pituitrin. This cast also is worthy of note as it was handled under adverse circumstances because of the crowded Cc!ndition of the hospital. In both of her deliveries she returned to normal consciousncss within three or four hours nt’t.csr labor.

A NEW EXPLANATION ECLAMPSIA

FOR THE OCCURRENCE

OF

IN PREGNANCY

BY HERMAN ELWYN, M.D., NEW YORK, N. Y. (Assistant

Visitixg

Physidan,

i%u%erne?kr Hospital

1

INCE Lever* first called attention to the connection between pregof alhumiu in the twine, nancy, eclampsia, and 1 bra pesenct~ many explanations have been 0fYerrd for the occurrence of eclampsia. Some of the earlier investigators assumed that the phenomena of eclampsia are either due to a compression of the renal vessels or of the ureters, by the gravid uterus ; others that they are due to an alteration in the blood. Such an alteration in the blood has, however, not been found in cclampsia, and Fahr” rightly points out that evidence of congestion in the kidneys or of hydronephrosis, such as one would expect to find in compression of either t.hc renal vessels or of the ureters, is not found. The modern tendency is to nscribc the symptoms of eclampsia to tht: prcscnce of unknown toxic metabolic products absorbed inio the Hood stwam from t.he placenta or the fetus. Eclampsin. is grnwnlly classified among the toxemias of pregnancy. While looking for the origin of the renal symptoms in eelamp& it occurred to me that the whole symptom complex might well be the rcsldt of an excrssivc irritability of two ncnrnmllsd~r mechanisms

S