Case Notes on Hyoscine, Morphine and Cactin—H-M-C Comp.

Ad: HMC anesthetic. C. W. HUNT, M. D., BREVARD, N. C.

Fractured leg, very painful, hypodermic injection of one tablet, repeated the dose in one hour, the effect was perfect. I gave all necessary treatment, left the patient sleeping soundly.

In obstetrical cases, either in true labor or in "false alarms," I always give a tablet immediately. I find it the best treatment for threatened abortion and premature labor or false alarms. In true labor if lingering and slow, it gives both physician and patient rest. It has relieved all the first pains of labor, the cutting and nagging pains, those mostly complained of by the patient.

If labor is active and the first dose is given at once, it prepares the way, and makes time for a second dose. The second dose should not be given sooner than one hour after the first and then, a half tablet only may be given as the dose. When a sufficient length of time has not elapsed for a second dose of tablets, and if labor is nearly finished and pain severe or even uncomfortable, I give a few drops of chloroform. (I would beg to state here that I believe in relieving all of the pain of labor and all of the afterpains.) I administer a whole tablet by placing it under the tongue and allow it to be absorbed. If not so quick as a hypodermic injection, the effect is more lasting and is better suited.

For an obstetrical case when a dose is given at the commencement of labor; if a quicker effect was desired, when labor is well advanced, one by hypodermic injection would be best. I find that one tablet first and then followed by chloroform in from two to four or six drops, for each contraction as needed, gives perfect results.

The respiration and pulse may be first noticeably affected by one tablet. I have not noticed any effect upon the baby.

I have used the H-M-C tablet for various conditions for one year and I think they are all that is claimed for them by The Alkaloidal Company. All we need is more practice in their use and we should never forget their power and become careless in their use.

Mrs. D. Severe "false labor" pains, one month before the time of confinement. H-M-C tablets gave satisfaction.

June 19th. Mrs. S., primipara, first stage, gave her a tablet, at 2:30 a.m. The patient was easy and slept till 6 a.m. (Am glad to say that the doctor also slept a bit.) Six a. m. os well dilated; a few drops of chloroform were given at each pain; (only a fraction of as much as used on the many other occasions when no tablet was given;) painless delivery at 7 a. m.

Mrs. D. Fourth labor. June 23rd, 4:30 a.m. first stage dilatation of cervix scarcely commenced, rigid os, subsequent dilation very slow, for which manipulation and Abbott's treatment for rigid os given with perfect results. First tablet given. The patient was heavily influenced at the end of the first hour. This continued for three hours and the control of pain continued for the next three hours, making six hours, in the third three hours of the twelve hour period, the effect was good but a little lighter, the last three hours of the twelve hour period at 4:30 p. m. though patient was sleepy, sleeping some during some of the contractions without aid of chloroform, yet some of the contractions required from two to six drops of chloroform, when we take this into account the loss by evaporation, the loss of chloroform by an account of patient's failure to inhale promptly, we realize how little chloroform that the patient actually received.

Fewer drops were required during the first, second and third three hour sections of the twelve hour period, more required during last quarter of the twelve hours, say about six drops, contraction also growing stronger as labor advanced. At 8 p. m. the second tablet was given. The bag of waters ruptured at 11:45 p.m.; baby born 12:45 a.m.; not affected by tablets; full of life and crying.

The 8 p. m. tablet gave profound sleep in forty-five to sixty minutes. Relief was nearly completed till eleven o'clock and a few drops of chloroform only given every fourth or fifth contraction, 11:30 to 12:45 influence of tablets exhausted. In looking over this case, I now believe that if the second tablets had been given by hypodermic injection, it would have given quicker relief, lasting long enough to cover the remaining labor.

Mrs. H., 12th confinement. June 25th. (In this case no chloroform was given.) The head under pubic arch. Tablet given under tongue 10:30. 10:55 delivered. Pain much lessened and after pains, for which the patient is famous, were prevented till 7 p. m. Had I not been pressed for time, this tablet should have been given hypodermic-ally, for a quicker effect if not so lasting. While the patient felt some pain, she was well satisfied with the effect of the tablet. I had in former labors given her chloroform and she knew how labor pains could and should be relieved.

June 26th. Mrs. L., a little over 16 years of age. First labor. Well advanced, head starting under pubic arch. I immediately gave tablet 3:35 p. m. The continuous pains between regular contraction relieved and pain of height of contraction was greatly soothed. By 4:20 head descending and contraction much more severe, patient quite soothed and states that the pains were easier then before I came, while all of the pain was not relieved—the effect was wonderful and pleasing. At 4:45 commenced giving a little chloroform, and account of rigid perineum a very small amount used, effect greatly enhanced by preceding tablet, painless delivery at 5:50, baby all O. K. Placenta removed, and then the mother was awakened.

Mrs. L. July 5th. Slow pains, dry labor, head high up, cervix slightly dilated, pains regular, though short, patient nervous, very sensitive to pains. No chloroform used. 4 a. m. gave one tablet under the tongue. This soon relieved seemingly three-quarters of the pain. The patient cried out a little during the height of pain. She slept nicely during pains. For one hour a soothed state increased. The patient did not notice the pain from the commencing and ending of a contraction, only moaned during acme of pain. At five and six a. m. I gave half a tablet, this intensified the hypnotic condition, the patient only moaned slightly, though she was awake and conscious during much of the pain, the head becoming more engaged and pains more severe. The baby was born at 10:00 a. m. At nine the head descended under the pubic arch and pressed the vaginal floor. Pains more severe and effect of medicine seemed to be decreasing which allowed the patient to suffer more. though her greatest pain was light and well borne, sleeping soundly between all pains and during a greater part of, each pain, and went to sleep after the baby was born. I considered this quite a victory for the tablets, as I make it a practice if possible to relieve all of the pain of labor, allowing the patient to be barely unconscious. I have formulated the following rule for my painless obstetrical cases to get a perfect relief from all pain, I consider that too much of the H-M-C tablet would be required, i. e.—that the system would be too profoundly affected between pains, by a sufficient amount of H-M-C given to relieve all pain and cause sleep at the acme of each pain, I therefore have formulated the following rule:

I give one tablet at once, and if necessary a half tablet every hour, then if pain is not sufficiently relieved, to supplement the effect of H.M-C by a fractional amount of chloroform, this can be given or not, as the case requires at every pain, or only occasionally, whereas if an additional amount of H-M-C is given, we get a continuously increased effect at the time of, and between the pains, whereas the supplemental chloroform's action is only temporary and can be withdrawn or withheld at pleasure. Besides one might not be certain whether labor pains will be regular. The contraction may cease without any reason, in such cases too much of the H-M-C or chloroform would be dangerous.

In surgical work, the surgeon should take the increased time demanded by anesthesia, with H-M-C and give his patient the benefit of this cheaper, safer and improved method, In surgery the pain is not so uncertain, irregular and intermittent as in obstetrical cases, the full dose can be given and measured, to a much more regular and uniform pain. The surgeon could allow a professional nurse to administer the first hypodermic, but he should take time and examine the patient and administer the second personally, and then take time to get the effect of the medicine before operating.

Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.