USE OF CHLOROFORM IN MIDWIFERY.
AN ENQUIRY INTO THE UTILITY AND PROPRIETY OF PREVENTING THE PAIN AND SUFFERING WHICH USUALLY ATTENDS CHILDBIRTH, WITH AN ACCOUNT OF THE MEANS TO BE EMPLOYED FOR THAT PURPOSE.
Inthe preface to this work I remarked that a great part, and, perhaps, nearly the whole, of the suffering and danger to which parturient females are exposed, arises, undoubtedly, from their bad physical education and mode of life; and that, in a more rational state of existence, it was probable that both would be so slight as to excite no apprehension. This improved state of things is much to be desired, and should, of course, be striven for by all friends of humanity. But, in the mean time, it is proper to consider whether there are any means by which those now living can be relieved in their hours of distress. The agony which many females endure at this time is so great that there are few circumstances under which relief is more needed, or would be more acceptable; and I, for one, cannot subscribe to the doctrine that such relief would be improper, unless it prove to be injurious. There are some persons, I know, who say that this suffering has beenordainedfor woman, and that itought to beendured. This notion, I think, needs no refutation, it being just as unreasonable as to say that the sick should be allowed to suffer and die without assistance, becausetheircondition has been ordained. There are others, and men of science, too, who think that the pains of childbirth are necessary to its safe accomplishment, and that they are also valuable in amoralpoint of view. This opinion will be examined by and by, and the facts on which it is founded, carefully analyzed; but it is first necessary to state the means ofprevention usually employed, and to note their mode of action, and effects.
Some years ago, a celebrated physiologist, who supposed that the chief cause of pain and difficulty in labor was the size and hardness of the child'sbones, advanced the theory that if these bones were less developed, and softer, the pain and difficulty would be materially lessened, if not entirely removed. He proposed, therefore, since the hardness of the bones is caused by the deposition oflimein them, which is derived, of course, from the blood of the mother, that she should avoid taking anything to eat or drink, during pregnancy, that contained lime. This, he supposed, would keep the bones of the child soft till after birth, and so allow them to give way and crush together during delivery, and thus prevent the suffering and difficulty usually experienced. It was also thought that the bones of the mother would be partially softened at the same time, and give way a little, so as to facilitate the process still more.
I am not aware, however, that this theory has ever succeeded in practice, either in the human species or in the lower animals, though frequently tried. Nature will work on her own plan, and will develop the bones of the fœtus, while in the womb, to a certain extent, providing she has the means to do so; and if these are withheld, she is very likely to suspend its development altogether, rather than send it forth imperfect. I have known cases where everything was withheld, for the whole period, that contained a particle of lime, and yet the child's bones were as hard at birth as in any other case; the material being, probably, taken from the bones of the mother, which might be thus weakened, and made liable to displacement, without any good result whatever. It is also a question whether such a course, supposing it to succeed, might not be dangerous in another way, by causing an imperfection in the child which its future growth could not overcome. I have known some cases where this practice appeared to have caused abortion from imperfect development, and several others in which there was too much reason to fear that thechild was injured, though safely born. As this is, therefore, at best, a very uncertain and ineffective process, and is also, probably, dangerous to the mother or child, or both, it does not appear to me worthy of further attention, and I merely allude to it in order to make the present sketch of such means complete.
The other means are such as do not interfere, in any way, with the natural processes, but merely prevent sensation or feeling at the time of delivery.Mesmerismhas been recommended, and, in some few instances, tried, for this purpose, but its success has either been so small, or its action so uncertain, that no dependance can be placed upon it, notwithstanding many persons assert its power. Opium and other powerful drugs have also been given, but so much of them is required, at that time, to produce a sufficient effect, that their use becomes dangerous. Other substances, in the form ofvapour, orgas, have also been used, the effects of which only last for a short time, and are not, generally speaking, at all dangerous. Among them may be mentioned nitrous oxide, orlaughing gas, carbonic acid, sulphuric ether, and chloric ether, all of which were first employed in severe surgical operations.
The success of these agents, especiallyetherandchloroform, inpreventing pain, is undoubted; nor do they appear to have any other effect, nor to prevent any necessary effort or process of nature, except in a few cases which will be mentioned further on. Many hundred operations of the most severe kind, such as cutting off limbs, removing tumors, stones, and so forth, have been performed while the patients were under the influence of these agents, and without causing themthe slightest pain; in fact, many remain, during the whole process, in a pleasant dream, and cannot be persuaded, when they wake, that the dreaded operation is over. The same thing has also been observed in hundreds of cases of midwifery, both in natural labor and when instruments have been used. In numerous instances the female has beenput to sleep, and safely delivered, without knowing or feeling anything whatever, during the whole time;the first intimation that she had become a mother, being the cheering cry of her newborn babe. In some instances, the state of insensibility has been continued for a long time, and during its continuance, the most hazardous operations have been safely performed.
So far as can be safely judged, from the limited time during which such means have been used, it appears that there is no danger whatever, from their employment, except when improperly administered, and in certain peculiar conditions of the system; which causes of danger will, of course, be removed by competent experience and knowledge. It is highly encouraging however, to note, though ether and chloroform have both been used so extensively and indiscriminately, both by those who understood their nature and those who did not, that the cases in which they are proved to have done injury, arenot more than two or three; and in all those that I have heard of, some obvious impropriety had been committed in their use. It should be borne in mind, however, that even if the danger from them was considerable, we might still be justified in their use. It is well known that, in numerous cases, thefearof suffering, beforehand, and its severity while being endured, produce the most serious, and even fatal results. Many a patient has passed safely through the ordinary effects of a painful operation, and yet sunk from the mere effects offearand physical suffering. Instances have even been known in which a fear of this kind has causeddeath, and frequently it has given a shock from which the patient never fully recovered. There is also, frequently, great danger from the violent efforts and struggles of a person in pain, and many necessary operations are even prevented altogether by them; this is often observed in difficult labors. When insensibility is produced, however, all these causes of difficulty and danger are removed; the patient'sfearsare quieted, suffering is entirely prevented, and there is no struggling to prevent the necessary assistance. Supposing, therefore, that the ill effects of these agents were more certain and greater in amount than has yet appeared, it would still be a question whetherthe evil they really prevent is not greater than that which they possiblymaycause.
In regard to the two agents now chiefly used,ether and chloroform, there is no difference in their mode of action, but the chloroform appears to be more speedy, certain, and efficacious, and is, therefore, the most valuable, but proportionably more dangerous when improperly administered. There are numerous instruments orinhalers, for administering these vapors, most of which are both costly and complicated, and all of which may be easily dispensed with. A very good plan is to take a large sponge and dip it in hot water, then squeeze out the water and pour on the ether or chloroform, and hold it over the mouth and nose. In two or three minutes consciousness and feeling will both be gone, and the patient will sink into a calm sleep which will last sometimes ten or fifteen minutes, and may be kept up as long as desired, by putting the sponge to the mouth for a few minutes whenever there are signs of waking. When it is left off the patient gradually comes round as if waking from ordinary sleep, and frequently speaks of having been in a dream, sometimes of a very pleasant character, but never knows what has taken place. No ill effects follow, but sometimes there is a little drowsiness or stiffness of the limbs, which soon passes off. A pocket handkerchief soaked in the fluid, and held over the mouth and nose will answer equally well; but whatever is used,it must not be pressed close, because a portion of air ought to enter with the vapor to prevent suffocation; and it should also be removed immediately the effect is produced. When it is borne in mind how much these requisites have been neglected, and howimpurethe ether or chloroform has often been, it is wonderful that more accidents have not occurred; and the fact that so few have happened under such a state of things, and with our little experience, goes far to prove that there is little or no danger at all in competent hands, with pure materials. The accounts circulated in the papers of "death from ether," and "fatal effects of chloroform," have mostly been gross exaggerations, and frequentlyfalse altogether. In most of the cases where death hasfollowedfrom the use of these agents, it has been proved to arise from other causes, and would have happened if they had not been used. In one or two cases, however, of surgical operations, the ether itself appears to have caused death by producing suffocation, or congestion of the lungs; but, even in these, it has been shown that it was used in an improper manner. Thus a young woman in Newcastle in England, inhaled ether to have a diseased toe-nail cut off, and died. It appears, however, that there was an evident disposition in her to congestion or rushes of blood, and therefore she was not a fit subject, and besides, the ether was poured on athick table cloth, which, of course, prevented the entrance ofairalong with the vapor, and thus suffocated. I believe there isnot a single caseon record of injury resulting when due precautions have been used, and I have not heard of one at all in midwifery practice.
Etherhaving been the first article used, I shall first give an account of its effects, and then proceed to chloroform, explaining the mode of administration, and other incidental matters, as I proceed. The best article on ether which I have met with, is a review in the British and Foreign Medical Review for April, 1847, of some pamphlets on the subject, from which I shall make an extract.
In the state of perfect etherization we believe all sensation is abolished; in a less perfect state an obscure perception of external objects remains, while the sense of pain is extinct. The psychical state is various. Generally speaking, the sense of external impressions becomes at first confused, then dull, then false, with optical spectra or auditory illusions, general mental confusion, and then a state of dreaming or utter oblivion. In the majority of cases the mind is busy in dreaming, the dreams being generally of an active kind, often agreeable, sometimes the reverse, occasionally most singular; and, frequently, a great deal is transacted in the few short moments of this singular trance. Many of the patients who have undergone the most dreadful operations, such as amputation of one or both thighs or arms, extraction of the stone, excisionof bones, extirpation of the mamma, have readily detailed to us, and most with wondering thankfulness, the dreams with which, and with which alone, they were occupied during the operations. The character of the dreams seemed to be influenced, as in ordinary cases, by various causes, immediate or remote, present or past, relating to events or flowing from temperament.A good many seemed to fancy themselves on the railway amid its whirl and noise and smoke; some young men were hunting, others riding on coaches; the boys were happy at their sports in the open fields, or the filthy lane; the worn Londoner was in his old haunts carousing with his fellows; and our merry friend, Paddy, of the London Hospital, was again at his fair, wielding his shelala in defence of his friends. Others, of milder mood, and especially some of the women patients from the country, felt themselves suddenly transported from the great city and the crowded hospital-ward to their old quiet home in the distant village, happy once more with their mothers and brothers and sisters. As with the dying gladiator of the poet, the thoughts of these poor people—"Were with the heart, and that was far away."Some seemed transported to a less definite but still happy region, which they vaguely indicated by saying they were in heaven; while others had still odder and warmer visions, which need not be particularized.For the purpose of obtaining information on all the points of this most interesting subject, we personally questioned all the patients in the London hospitals, who, at the period of our visits, still remained in the wards after the ether-operations. They were in all fifty-four, and the great majority had been the subjects of capital operations. They were unanimous in their expressions of delight and gratitude at having been relieved from their diseases without suffering. In listening to their reports, it was not always easy to remain unmoved under the influence of the conceptions thereby communicated, of the astonishing contrast between the actual physical condition of the mangled body in its apparent tortures on the operating table of a crowded theatre, and the really happy mental state of the patient at the time.
In the state of perfect etherization we believe all sensation is abolished; in a less perfect state an obscure perception of external objects remains, while the sense of pain is extinct. The psychical state is various. Generally speaking, the sense of external impressions becomes at first confused, then dull, then false, with optical spectra or auditory illusions, general mental confusion, and then a state of dreaming or utter oblivion. In the majority of cases the mind is busy in dreaming, the dreams being generally of an active kind, often agreeable, sometimes the reverse, occasionally most singular; and, frequently, a great deal is transacted in the few short moments of this singular trance. Many of the patients who have undergone the most dreadful operations, such as amputation of one or both thighs or arms, extraction of the stone, excisionof bones, extirpation of the mamma, have readily detailed to us, and most with wondering thankfulness, the dreams with which, and with which alone, they were occupied during the operations. The character of the dreams seemed to be influenced, as in ordinary cases, by various causes, immediate or remote, present or past, relating to events or flowing from temperament.
A good many seemed to fancy themselves on the railway amid its whirl and noise and smoke; some young men were hunting, others riding on coaches; the boys were happy at their sports in the open fields, or the filthy lane; the worn Londoner was in his old haunts carousing with his fellows; and our merry friend, Paddy, of the London Hospital, was again at his fair, wielding his shelala in defence of his friends. Others, of milder mood, and especially some of the women patients from the country, felt themselves suddenly transported from the great city and the crowded hospital-ward to their old quiet home in the distant village, happy once more with their mothers and brothers and sisters. As with the dying gladiator of the poet, the thoughts of these poor people—
"Were with the heart, and that was far away."
Some seemed transported to a less definite but still happy region, which they vaguely indicated by saying they were in heaven; while others had still odder and warmer visions, which need not be particularized.
For the purpose of obtaining information on all the points of this most interesting subject, we personally questioned all the patients in the London hospitals, who, at the period of our visits, still remained in the wards after the ether-operations. They were in all fifty-four, and the great majority had been the subjects of capital operations. They were unanimous in their expressions of delight and gratitude at having been relieved from their diseases without suffering. In listening to their reports, it was not always easy to remain unmoved under the influence of the conceptions thereby communicated, of the astonishing contrast between the actual physical condition of the mangled body in its apparent tortures on the operating table of a crowded theatre, and the really happy mental state of the patient at the time.
This perfect freedom from pain is proved by every case wherein the vapor has been efficiently administered,although there are frequently the same cries uttered, and the same motions practised as when pain is experienced which proves that nothing is prevented but the merefeeling, which it can be of no use whatever for any one to suffer from.
Chloroformhas been more recently introduced than ether, but has nevertheless been used quite as much, or probably more, and, in general, with still more success. It was first described, I believe, by Professor Simpson of Edinburgh, at a sitting of the medical society of that city, in November, 1847, and several cases were narrated, two of which I quote.
I have employed it in obstetric practice with entire success. The lady to whom it was first exhibited during parturition, had been previously delivered in the country by perforation of the head of the infant, after a labor of three days' duration. In this, her second confinement, pains supervened a fortnight before the full time. Three hours and a half after they commenced, ere the dilatation of the os uteri was completed, I placed her under the influence of the chloroform, by moistening with half a teaspoonful of the liquid, a pocket-handkerchief, rolled up in a funnel shape, and with the broad or open end of the funnel placed over her mouth and nostrils. In consequence of the operation of the fluid it was once more renewed in about ten or twelve minutes. The child was expelled in twenty-five minutes after the inhalation was begun. The mother subsequently remained longer soporose than commonly happens after ether. The crying of the child did not, as usual, rouse her; and some minutes elapsed after the placenta was expelled, and after the child was removed by the nurse into another room, before the patient awoke. She then turned round and observed to me that she had "enjoyed a very comfortable sleep, and, indeed, required it as she was so tired, but would now be more able for the work before her." I evaded entering into conversation with her, believing, as I have already stated, that the most complete possible quietude forms one of the principal secrets for the successful employment of either ether or chloroform. In a little time, she again remarked, that she was afraid her "sleep had stopped the pains." Shortly afterwards her infant was brought in by the nurse from the adjoining room, and it was a matter of no smalldifficulty to convince the astonished mother that the labor was entirely over, and that the child presented to her was really her "own living baby."Perhaps I may be excused for adding, that since publishing on the subject of ether inhalation in midwifery, seven or eight months ago, and then for the first time directing the attention of the profession to its great use and importance in natural and morbid parturition, I have employed it, with few and rare exceptions, in every case of labor that I have attended, and with the most delightful results. And I have no doubt whatever, that some years hence the practice will be general. Obstetricians may oppose it, but I believe our patients themselves will force the use of it upon the profession. I have never had the pleasure of watching over a series of better and more rapid recoveries, nor once witnessed any disagreeable result follow to either mother or child, whilst I have often seen an immense amount of maternal pain and agony saved by its employment. And I most conscientiously believe that the proud mission of the physician is distinctly twofold—namely, to alleviate human suffering, as well as preserve human life.
I have employed it in obstetric practice with entire success. The lady to whom it was first exhibited during parturition, had been previously delivered in the country by perforation of the head of the infant, after a labor of three days' duration. In this, her second confinement, pains supervened a fortnight before the full time. Three hours and a half after they commenced, ere the dilatation of the os uteri was completed, I placed her under the influence of the chloroform, by moistening with half a teaspoonful of the liquid, a pocket-handkerchief, rolled up in a funnel shape, and with the broad or open end of the funnel placed over her mouth and nostrils. In consequence of the operation of the fluid it was once more renewed in about ten or twelve minutes. The child was expelled in twenty-five minutes after the inhalation was begun. The mother subsequently remained longer soporose than commonly happens after ether. The crying of the child did not, as usual, rouse her; and some minutes elapsed after the placenta was expelled, and after the child was removed by the nurse into another room, before the patient awoke. She then turned round and observed to me that she had "enjoyed a very comfortable sleep, and, indeed, required it as she was so tired, but would now be more able for the work before her." I evaded entering into conversation with her, believing, as I have already stated, that the most complete possible quietude forms one of the principal secrets for the successful employment of either ether or chloroform. In a little time, she again remarked, that she was afraid her "sleep had stopped the pains." Shortly afterwards her infant was brought in by the nurse from the adjoining room, and it was a matter of no smalldifficulty to convince the astonished mother that the labor was entirely over, and that the child presented to her was really her "own living baby."
Perhaps I may be excused for adding, that since publishing on the subject of ether inhalation in midwifery, seven or eight months ago, and then for the first time directing the attention of the profession to its great use and importance in natural and morbid parturition, I have employed it, with few and rare exceptions, in every case of labor that I have attended, and with the most delightful results. And I have no doubt whatever, that some years hence the practice will be general. Obstetricians may oppose it, but I believe our patients themselves will force the use of it upon the profession. I have never had the pleasure of watching over a series of better and more rapid recoveries, nor once witnessed any disagreeable result follow to either mother or child, whilst I have often seen an immense amount of maternal pain and agony saved by its employment. And I most conscientiously believe that the proud mission of the physician is distinctly twofold—namely, to alleviate human suffering, as well as preserve human life.
In another part of the same publication Professor Simpson has another list of cases, all equally favorable. In some of these the labors were protractedmany hours, and in others, operations with instruments were performed, of the most terrible character, such as would, under ordinary circumstances, have been attended with the most horrible suffering. As this article gives an instance of nearly every kind of delivery under the influence of chloroform, and contains also some admirable reflections upon its employment, I quote it in order to make the present account complete.
Case 2.—Seen with Mr. Carmichael; a second labor; she began the chloroform inhalation before the dilatation of the os uteri was entirely completed; the child was expelled in fifty minutes afterwards. I kept her under the chloroform for a quarter of an hour, till the placenta was removed, the binder applied, and the body and bed-clothes were arranged and adjusted. On awaking she declared that she had been sleeping refreshingly; she was quite unaware that the child was born, till she suddenly heard it crying at its first toilet in thenext room. An hour afterwards she declared she felt perfectly unfatigued, and not as if she had borne a child at all. In her first or preceding confinement she had been in severe labor for twenty hours, followed by flooding. No hæmorrhage on the present occasion.Case 3.—Patient unmarried; a first labor; twins; the first child presented by the pelvis, the second with the hand and head. The chloroform was exhibited when the os uteri was nearly fully dilated; the passages speedily became greatly relaxed, (as has happened in other cases placed under its full influence,) and in a few pains the first child was born, assisted by traction. I broke the membranes of the second, pushed up the hand, and secured the more complete presentation of the head; three pains expelled the child. The mother was then bound up, her clothes were changed, and she was lifted into another bed; during all this time she slept soundly on, and for a full hour afterwards, the chloroform acting in this as in other cases of its prolonged employment, as a soporific. The patient recollected nothing from the time of the first inhalations, and was greatly distressed when not one but two living children were brought in by the nurse to her. Dr. Christison, who was anxious to observe the effect of the chloroform upon the uterus, went along with me to this patient.Case 4.—Primipara; of full habit; when the first examination was made, the passages were rigid, and the os uteri difficult to reach. Between six and seven hours after labor began, the patient, who was complaining much, was apathized with the chloroform. In about two hours afterwards, the os uteri was fully dilated, and in four hours and a half after the inhalation was begun, a large child was expelled. The placenta was removed, and the patient bound up and dressed before she was allowed to awake. This patient required an unusual quantity of chloroform, and Dr. Williamson, who remained beside her, states to me, in his notes of the case, "the handkerchief was moistened often, in order to keep up the soporific effect. On one occasion I allowed her to emerge from this state for a short time, but on the accession of the first pain, she called out so loudly for the chloroform that it was necessary to pacify her by giving her some immediately. In all, four ounces of chloroform were used." Like the others, she was quite unconscious of what had gone on during her soporised state, and awoke altogether unaware that her child was born.Case 6.—Second labor. The patient—a person of a small form and delicate constitution—bore her first child prematurely at the seventh month. After being six hours in labor, the os uteri was fully expanded, and the head well down in the pelvic cavity. For two hours subsequently it remained fixed in nearly the same position, and scarcely, if at all, advanced, although the pains were very distressing, and the patient becoming faint and exhausted. She entertained some mistaken religious feelings against ether or chloroform, which had made her object to the earlier use of the latter; but I now placed her under its influence. She lay, as usual, like a person soundly asleep under it, and I was now able, without any suffering on her part, to increase the intensity and force of each recurring pain, by exciting the uterus and abdominal muscles through pressure on the lower part of the vagina and perinæum. The child was expelled in about fifteen minutes after the inhalation was commenced. In a few minutes she awoke to ask if it was really possible that her child had been born, and was overjoyed to be told that it was so. I have the conviction, that in this case the forceps would in all probability have been ultimately required, provided I had not been able to have interfered in the way mentioned. I might, it is true, have followed the same proceeding, though the patient was not in an anæsthetic state; but I could not have done so without inflicting great agony upon her.Case 7.—A third labor; the patient had been twice before confined of dead premature children; once of twins, under the care of Mr. Stone, of London; the second time of a single child under my charge. The liquor amnii began to escape about one o'clock,A.M., but without pains for some time. I saw her between three and four o'clock, with the pains commencing and the os uteri beginning to dilate. In two hours afterwards, the third stage was well advanced, and the pains becoming very severe, she had the chloroform exhibited to her, and slept soundly under its influence. In twenty minutes the child was born and cried very loudly without rousing the mother. In about twelve or fifteen minutes more she awoke as the application of the binder was going on, and immediately demanded if her child was really born alive, as she thought she had some recollection of hearing the nurse say so. She was rejoiced beyond measure on her son being brought in and presented to her.Case 9.—In the Maternity Hospital; first child. Laborbegan at 10P.M., (Nov. 21st.) I was desired to see her at sixA.M., (22nd.) The os uteri was well dilated, but it was evident that the pelvic canal was contracted throughout, and the head was passing with unusual difficulty through the brim. The patient was complaining much of her sufferings. It was evident that it would be a very tedious, and probably, at last, an instrumental case, and one therefore calculated to test the length of time during which chloroform might be used. She began to inhale it at a quarter past six,A.M., and was kept under its influence till a quarter past seven,P.M.,—the date of her delivery—thirteen hoursin all. From the time it was begun till the time delivery was completed, her cries and complaints ceased, and she slept on soundly throughout the day. The bladder required to be emptied several times with the catheter. The head passed the os uteri at tenA.M., and during the day, gradually descended through the pelvis. At sevenP.M., I at last deemed it proper to deliver her by the forceps; the head, which was now elongated and œdematous, having by that time rested for some hours against the contracted pelvic outlet, with little or no evidence of advancement; the bones of the fœtal cranium overlapping each other, and the fœtal heart becoming less strong and distinct in its pulsations. A warm bath, irritation of the chest, &c., were necessary to excite full and perfect respiration in the infant. Whilst we were all busied with the infant, the mother lost some blood, but the placenta was immediately removed, and the uterus contracted perfectly. On afterwards measuring the quantity of blood lost, it was calculated to amount to fifteen or eighteen ounces. The mother's clothes were changed, she was bound up, and removed to a dry bed before she awoke. She had at first no idea that the child was born, and was in no respect conscious of being delivered. In fact, she had been "sleeping," according to her own account, from the time she had begun the inhalation, and thought she remembered or dreamed that she heard Dr. Williamson, the house-surgeon, speak near her once or twice. Dr. Beilby, Dr. Ziegler, &c., saw the case with me. Three days afterwards I found the mother and child perfectly well. She continued to recover so rapidly, that she insisted on leaving the hospital on the tenth day after delivery.
Case 2.—Seen with Mr. Carmichael; a second labor; she began the chloroform inhalation before the dilatation of the os uteri was entirely completed; the child was expelled in fifty minutes afterwards. I kept her under the chloroform for a quarter of an hour, till the placenta was removed, the binder applied, and the body and bed-clothes were arranged and adjusted. On awaking she declared that she had been sleeping refreshingly; she was quite unaware that the child was born, till she suddenly heard it crying at its first toilet in thenext room. An hour afterwards she declared she felt perfectly unfatigued, and not as if she had borne a child at all. In her first or preceding confinement she had been in severe labor for twenty hours, followed by flooding. No hæmorrhage on the present occasion.
Case 3.—Patient unmarried; a first labor; twins; the first child presented by the pelvis, the second with the hand and head. The chloroform was exhibited when the os uteri was nearly fully dilated; the passages speedily became greatly relaxed, (as has happened in other cases placed under its full influence,) and in a few pains the first child was born, assisted by traction. I broke the membranes of the second, pushed up the hand, and secured the more complete presentation of the head; three pains expelled the child. The mother was then bound up, her clothes were changed, and she was lifted into another bed; during all this time she slept soundly on, and for a full hour afterwards, the chloroform acting in this as in other cases of its prolonged employment, as a soporific. The patient recollected nothing from the time of the first inhalations, and was greatly distressed when not one but two living children were brought in by the nurse to her. Dr. Christison, who was anxious to observe the effect of the chloroform upon the uterus, went along with me to this patient.
Case 4.—Primipara; of full habit; when the first examination was made, the passages were rigid, and the os uteri difficult to reach. Between six and seven hours after labor began, the patient, who was complaining much, was apathized with the chloroform. In about two hours afterwards, the os uteri was fully dilated, and in four hours and a half after the inhalation was begun, a large child was expelled. The placenta was removed, and the patient bound up and dressed before she was allowed to awake. This patient required an unusual quantity of chloroform, and Dr. Williamson, who remained beside her, states to me, in his notes of the case, "the handkerchief was moistened often, in order to keep up the soporific effect. On one occasion I allowed her to emerge from this state for a short time, but on the accession of the first pain, she called out so loudly for the chloroform that it was necessary to pacify her by giving her some immediately. In all, four ounces of chloroform were used." Like the others, she was quite unconscious of what had gone on during her soporised state, and awoke altogether unaware that her child was born.
Case 6.—Second labor. The patient—a person of a small form and delicate constitution—bore her first child prematurely at the seventh month. After being six hours in labor, the os uteri was fully expanded, and the head well down in the pelvic cavity. For two hours subsequently it remained fixed in nearly the same position, and scarcely, if at all, advanced, although the pains were very distressing, and the patient becoming faint and exhausted. She entertained some mistaken religious feelings against ether or chloroform, which had made her object to the earlier use of the latter; but I now placed her under its influence. She lay, as usual, like a person soundly asleep under it, and I was now able, without any suffering on her part, to increase the intensity and force of each recurring pain, by exciting the uterus and abdominal muscles through pressure on the lower part of the vagina and perinæum. The child was expelled in about fifteen minutes after the inhalation was commenced. In a few minutes she awoke to ask if it was really possible that her child had been born, and was overjoyed to be told that it was so. I have the conviction, that in this case the forceps would in all probability have been ultimately required, provided I had not been able to have interfered in the way mentioned. I might, it is true, have followed the same proceeding, though the patient was not in an anæsthetic state; but I could not have done so without inflicting great agony upon her.
Case 7.—A third labor; the patient had been twice before confined of dead premature children; once of twins, under the care of Mr. Stone, of London; the second time of a single child under my charge. The liquor amnii began to escape about one o'clock,A.M., but without pains for some time. I saw her between three and four o'clock, with the pains commencing and the os uteri beginning to dilate. In two hours afterwards, the third stage was well advanced, and the pains becoming very severe, she had the chloroform exhibited to her, and slept soundly under its influence. In twenty minutes the child was born and cried very loudly without rousing the mother. In about twelve or fifteen minutes more she awoke as the application of the binder was going on, and immediately demanded if her child was really born alive, as she thought she had some recollection of hearing the nurse say so. She was rejoiced beyond measure on her son being brought in and presented to her.
Case 9.—In the Maternity Hospital; first child. Laborbegan at 10P.M., (Nov. 21st.) I was desired to see her at sixA.M., (22nd.) The os uteri was well dilated, but it was evident that the pelvic canal was contracted throughout, and the head was passing with unusual difficulty through the brim. The patient was complaining much of her sufferings. It was evident that it would be a very tedious, and probably, at last, an instrumental case, and one therefore calculated to test the length of time during which chloroform might be used. She began to inhale it at a quarter past six,A.M., and was kept under its influence till a quarter past seven,P.M.,—the date of her delivery—thirteen hoursin all. From the time it was begun till the time delivery was completed, her cries and complaints ceased, and she slept on soundly throughout the day. The bladder required to be emptied several times with the catheter. The head passed the os uteri at tenA.M., and during the day, gradually descended through the pelvis. At sevenP.M., I at last deemed it proper to deliver her by the forceps; the head, which was now elongated and œdematous, having by that time rested for some hours against the contracted pelvic outlet, with little or no evidence of advancement; the bones of the fœtal cranium overlapping each other, and the fœtal heart becoming less strong and distinct in its pulsations. A warm bath, irritation of the chest, &c., were necessary to excite full and perfect respiration in the infant. Whilst we were all busied with the infant, the mother lost some blood, but the placenta was immediately removed, and the uterus contracted perfectly. On afterwards measuring the quantity of blood lost, it was calculated to amount to fifteen or eighteen ounces. The mother's clothes were changed, she was bound up, and removed to a dry bed before she awoke. She had at first no idea that the child was born, and was in no respect conscious of being delivered. In fact, she had been "sleeping," according to her own account, from the time she had begun the inhalation, and thought she remembered or dreamed that she heard Dr. Williamson, the house-surgeon, speak near her once or twice. Dr. Beilby, Dr. Ziegler, &c., saw the case with me. Three days afterwards I found the mother and child perfectly well. She continued to recover so rapidly, that she insisted on leaving the hospital on the tenth day after delivery.
A sufficient number of such accounts as these couldbe collected to fill a large volume; but these are quite sufficient for our purpose.
In regard to the objections to using chloroform or ether, in midwifery, it will be thought by most persons, and with good reason, too, that the safety and success which has attended their use, is itself a sufficient answer to all objections.
It was at first thought, by some physicians, that the expulsive force of the womb was lessened when the pain was prevented; but this is not the case; on the contrary, it has been, in many cases, much increased. It was also thought by others that there was more danger from flooding, and convulsions, than in ordinary cases; but this is also equally at variance with truth, for it appears, beyond doubt, after a careful examination of all the cases recorded, that there is muchlessdanger, particularly from convulsions, than when the patient is allowed to be tortured and terrified by feeling pain. Dr. Simpson remarks in another part of the article above quoted:—
The question which I have been repeatedly asked is this—Will we ever be "justified" in using the vapor of ether to assuage the pains of natural labor? Now, if experience betimes goes fully to prove to us the safety with which ether may, under proper precautions and management, be employed in the course of parturition, then, looking to the facts of the case, and considering the actual amount of pain usually endured, I believe that the question will require to be quite changed in its character. For, instead of determining, in relation to it, whether we shall be "justified" in using this agent under the circumstances named, it will become, on the other hand, necessary to determine whether, on any grounds, moral or medical, a professional man could deem himself "justified" in withholding andnotusing any such safe means, (as we at present presuppose this to be,) provided he had the power, by it, of assuaging the pains and anguish of the last stage of natural labor, and thus counteracting what Velpeau describes as "those piercing cries, that agitation so lively, those excessive efforts, those inexpressible agonies, and those pains apparentlyintolerable," which accompany the termination of natural parturition in the human mother.Since the latter end of January I have employed etherization with few and rare exceptions, in every case of labor which has been under my care. And the results, as I already stated inThe Lancet, have been, indeed, most happy and gratifying. I never had the pleasure of watching over a series of more perfect or more rapid recoveries; nor have I once witnessed any disagreeable result to either mother or child. I do not remember a single patient to have taken it who has not afterwards declared her sincere gratitude for its employment, and her indubitable determination to have recourse again to similar means under similar circumstances. Most have subsequently set out, like zealous missionaries, to persuade other friends to avail themselves of the same measure in the hour of suffering. And a number of my most esteemed professional brethren in Edinburgh have adopted it with success and results equal to my own. At the same time, I most sincerely believe that we are, all of us, called upon to employ it, by every principle of true humanity, as well as by every principle of true religion. Medical men may oppose, for a time, the superinduction of anæsthesia in parturition, but they will oppose it in vain; for certainly our patients themselves and their friends will force the use of it upon the profession. The whole question is, I believe, even now, one merely of time. It is not—Shall the practice come to be generally adopted? but—When shall it be generally adopted? And, for my part, I more than doubt if any man (rejecting willingly its benefits) is really justified, on any grounds, moral or medical, in deliberately desiring and asking his patients to shriek and writhe in their agonies for a few months, or a few years longer, in order that, by doing so, they may defer, forsooth, to his professional apathy, or pander to his professional caprices and prejudices.
The question which I have been repeatedly asked is this—Will we ever be "justified" in using the vapor of ether to assuage the pains of natural labor? Now, if experience betimes goes fully to prove to us the safety with which ether may, under proper precautions and management, be employed in the course of parturition, then, looking to the facts of the case, and considering the actual amount of pain usually endured, I believe that the question will require to be quite changed in its character. For, instead of determining, in relation to it, whether we shall be "justified" in using this agent under the circumstances named, it will become, on the other hand, necessary to determine whether, on any grounds, moral or medical, a professional man could deem himself "justified" in withholding andnotusing any such safe means, (as we at present presuppose this to be,) provided he had the power, by it, of assuaging the pains and anguish of the last stage of natural labor, and thus counteracting what Velpeau describes as "those piercing cries, that agitation so lively, those excessive efforts, those inexpressible agonies, and those pains apparentlyintolerable," which accompany the termination of natural parturition in the human mother.
Since the latter end of January I have employed etherization with few and rare exceptions, in every case of labor which has been under my care. And the results, as I already stated inThe Lancet, have been, indeed, most happy and gratifying. I never had the pleasure of watching over a series of more perfect or more rapid recoveries; nor have I once witnessed any disagreeable result to either mother or child. I do not remember a single patient to have taken it who has not afterwards declared her sincere gratitude for its employment, and her indubitable determination to have recourse again to similar means under similar circumstances. Most have subsequently set out, like zealous missionaries, to persuade other friends to avail themselves of the same measure in the hour of suffering. And a number of my most esteemed professional brethren in Edinburgh have adopted it with success and results equal to my own. At the same time, I most sincerely believe that we are, all of us, called upon to employ it, by every principle of true humanity, as well as by every principle of true religion. Medical men may oppose, for a time, the superinduction of anæsthesia in parturition, but they will oppose it in vain; for certainly our patients themselves and their friends will force the use of it upon the profession. The whole question is, I believe, even now, one merely of time. It is not—Shall the practice come to be generally adopted? but—When shall it be generally adopted? And, for my part, I more than doubt if any man (rejecting willingly its benefits) is really justified, on any grounds, moral or medical, in deliberately desiring and asking his patients to shriek and writhe in their agonies for a few months, or a few years longer, in order that, by doing so, they may defer, forsooth, to his professional apathy, or pander to his professional caprices and prejudices.
Another objection has also been advanced against the employment of ether or chloroform, the force of which must be estimated by every one for themselves. It is well known that many, if not most of the lower animals during labor, or immediately afterward,experience certain feelings and desires stronger than at any other time; and it is supposed that such would be the case, asa general rule, with human beings, if it were not for thepainwhich overpowers everything else. This supposition has, in fact, been partly verified in a few cases; several females having confessed, after recovering from a painless labor under the influence of ether, that their dreams during the sleep were ofa peculiar warm character!How far this may begenerallythe case, of course, we have no means of ascertaining, nor do I consider it to be practically of any consequence to know, because it can in no way interfere with the safe progress and termination of the labor, which alone is what we are properly concerned in. I have merely thought it proper to state the fact as being a singular one, and to make my readers acquainted with it. Physicians are well aware that the peculiar feelings referred to are frequently produced by various causes which act on the nervous system, such asmesmerism, and even bystrong devotional excitement. I have known females with strong moral impressions who always carefully avoidedboththe above causes, from having discovered their liability to produce such effects; in fact, this has been one objection raised to allowing mesmerists to operate upon young persons, and several cases of moral failing having been attributed to this cause. It is not at all improbable, therefore, that such results may occasionally occur during labor, though we are not at all justified in assuming that they will in any particular case. How far this may be considered an objection to the employment of such means, must be however, as I before remarked, decided by all personsfor themselves, andfor themselves only!It is not amedicalquestion at all.