The primary purpose of the SOAP Endowment Fund (formerly OAPEF) is to create funding for educational endeavors in obstetric anesthesia.
A Treatise On Etherization In Childbirth
Illustrated By Five Hundred And Eighty-One Cases
By Walter Channing, M.D.
Professor of Midwifery and Medical Jurisprudence In The University At Cambridge
Boston: William D. Ticknor And Company
Corner Of Washington And School Streets
ETHERIZATION IN CHILDBIRTH
PLAN AND OBJECTS OF THE WORK
In May, 1847, I published a pamphlet, containing a few cases of labor in which I had employed sulphuric ether with entire success. In July of the same year, a second edition of the same pamphlet, somewhat enlarged, appeared. Cases have gradually accumulated in my practice, in which etherization has been employed. They have been of the different classes of labor, and in sufficient variety and number too, to authorize a cautious generalization. It occurred to me, that these cases might be published, and possibly be of some service as guides, or authority, towards the farther employment of etherization. They were recorded as soon after the labor was over as circumstances allowed. I often wrote the case out immediately upon my return home from it, and the hour is sometimes mentioned. After some thought, it was determined to print the cases just as they were first put down. A different course might have improved their strictly literary character; but it could hardly have happened otherwise than that the freshness if not the truth, of the impression made by the case, would have been affected by any new labor upon them.
In the meantime, etherization was in use here, and in different parts of the country, in midwifery practice. We were hearing of results through journals and newspapers. They existed alone. The thought occurred to me, that, with very little personal trouble, I might collect from various sources, facts in regard to etherization which would, in a much surer manner, make my work useful, than would anything of my own which it might contain. A circular letter was prepared, and addressed to many physicians in Boston and vicinity, containing questions which embraced some of the most important points regarding the use of ether and chloroform.
My great, I had almost said my sole, object in this circular, - in short, in my whole efforts, - was to ascertain here at home, in the birthplace of etherization, what had been the precise results of many experiments, made by many physicians, of the employment of the remedy of pain. My object was to learn if this use of it had been safe, - safe both to mother and to child; and thus, as far as such results might reach, to contribute something towards settling the most important point concerning its further use, namely, that of its safety.
This matter of safety is especially dwelt upon, because much that is related to it, if not all else, has very little in it requiring present discussion or argument. I consider other questions as, in an important sense, settled, and therefore not demanding special attention. Thus we now that pain may be abolished by etherization. We know that voluntary or animal power is very much, if not wholly, suspended during this state. We know that organic power remains. Nay, more, we know that it is often increased, that of the womb for instance; and in the exceptional cases, in which uterine contraction is diminished, or in which it entirely ceases, we know that this is temporary, and that no danger to either mother or child has hence ensued. We know, finally, that during and in consequence of etherization, circumstances highly favorable to safe as well as to easy labor arise. Among these may be enumerated the increase of secretions in the organs immediately concerned in labor, and a more perfect relaxation or dilatability than existed before its use. Dubois first made this last observation, and my latest experience of etherization confirms his early and important statement.
It was, then, to the question of safety, in our experience of etherization here, that my attention was directed in the questions in the circular. But do not for a moment, reader, consider this as a very simple or a single question. It has regard, indeed, to a single fact, - the well-being of mother and child. But to show that, in its uses here, etherization has been safe in midwifery practice, is to declare a most important fact. Safety in this matter involves whatever exists or is done in etherization, as a condition towards this great end. These conditions are few, and cannot be too often repeated. They are, 1st, Purity in the article used. 2d, Such an instrument as will allow the freest escape of the expired, or exhaled air, and the due admixture of atmospheric air with the inhaled. A hollow sponge for ether answers every purpose; for its structure is such as to ensure these conditions. 3d, When etherization is produced, inhalation is to cease. This state is declared by the relaxed condition of the limbs, the inability to raise the eyelids at command, and cessation of complaint. The books are full of other conditions, and in these the diversity of individual observations and views is sufficiently declared. Suffice it to say concerning the mode of exhibiting ether-vapors, that, of the two methods recommended in midwifery, the one by Professor Simpson, which directs so much to be used, and after such a manner, as shall in the shortest time produce the fullest effect, - and the other recommended by observers here in the same practice, which seeks its object by a less quantity, and that moderately administered, - I think, of these the latter is decidedly to be preferred. I am very glad to find, that my old friend and classmate, Professor Mussey, of Cincinnati, takes the same view of the matter, and even extends its application to surgery.
With regard to contra-indications to etherization which are founded in other conditions, whether of co-existing functional or structural disease, - whether of heart, head, or lungs, - I have no experience or observation to offer. I have met with none. I believe I am borne out by fact, when I say, that, in the examinations which have been made of those who have died after etherization, it has not happened, in more than a single case, that any disease existed in any of the organs referred to, whereby to explain the death. The exception occurred lately in New York, and will be referred to more particularly hereafter. And farther it will hereafter be shown, by cases of know and grave structural disease, in which etherization has been employed as a remedy amongst us, that great relief has been afforded by it, and no suspicion, much less proof, furnished, that any untoward results have been produced or death accelerated by it. A case of confirmed phthisis is this moment under my care, in which chloroform has been very excessively and imprudently employed, and from which no other apparent troubles than nausea and vomiting have followed. These ceased when inhalation was omitted. Of contra-indications to etherization arising in diseases and lesions above alluded to, I have no experience to offer.
The object of the circular was to learn what had been the whole result of etherization, so far as it has been employed in midwifery amongst ourselves; and this in order especially to ascertain whether those who had used it had done well or ill, had lived or had died, - the question of safety.
The circular was addressed to many physicians. From some I learned that they had never employed etherization in midwifery; from others, that their experience furnished nothing new. From one came the religious objection. One friend thus writes, and his short letter is a "whole history:"-
I have used the ether in labor a considerable number of times, and with obvious benefit; but my observations have not been made with sufficient precision to be made the basis of statistical results.
"Yours, most truly,
I give this letter with great pleasure. It contains, as far as the writers’ experience goes, a very important answer to the great question of the circular, namely, of the entire safety of etherization. It says that its author has employed ether "a considerable number of times, and with obvious benefit." The character, the intellectual habits, the deep interest in all questions of science, and the caution of the writer in stating results, give to this short testimony of my friend, in favor of ether, great value.
From some, to whom I took the liberty to address the circular, I have received no answer. Thinking that in some of these instances my communication had miscarried, I sent another; and this, because I had learned that the physicians so addressed had valuable information to impart. I regret that I sent my circular in these cases. I acknowledge I had no other right to do so than that which some interest in good science bestows. If I exceeded such privilege in the instances referred to, I here make my best apology, and promise to offend in like manner no more.
From a great many came answers, in more or less detail, to the questions proposed; and, more than this, letters often accompanied them, giving at some length important cases and deliberate opinions. At first it was my purpose to publish, along with my own cases, tabular views of what I had been so very kindly and liberally favored with, together with the accompanying letters, and here rest the case. It was an after-thought to devote some pages to a few of the topics which my subject so directly involves. That subject forms one of the most important epochs in medical history. Was it not due to it to say something of its history, of what it is in itself, of what it had done, and what appears to be its destiny?
It will be perceived that from some of my friends the communication of facts is small, sometimes not exceeding a single case. But that single case, is it without its interest? I answer o. It has its place in what has been done with ether, and deserves a distinct record in its literature. In its entire success, it teaches that it does not stand alone because of a want of confidence in the safety and whole benefit of etherization, and so gives positive support to these facts in our history. From some I learn that they have used, and mean to use, ether or chloroform, only when desired by the patient. No one can question the propriety of this course; but in thus dividing the responsibleness, or laying its weight principally on the patient, I do not know of any one physician who has pursued this course because of his want of confidence in the perfect safety of etherization. Had he felt a doubt, had he had the smallest scruple concerning this its entire safety, would he have done that, or thought for a moment of doing it, which a sick and a most suffering woman asked for, nay demanded, but which to his mind involved the smallest danger? The whole question resolves into safety alone. It has nothing to do with men’s notions of the value or the pleasure of pain. We dismiss this latter from the matter at once as wholly irrelevant. We know of painless labor, of labor wholly without pain; and in too many instances, not now to refer to them, in which the patient was unconscious of delivery, or knew nothing more of it in regard to suffering than of an ordinary defecation, which for the most part is pleasurable rather than painful, and who did not pay the penalty of death for the involuntary violation or temporary suspension of a natural law. Let the reader, then, look at the true point at issue; and, above all, let him not be misled in his judgments by ignorance, by prejudice, or more especially by a priori reasoning.
Since receiving answers t the circular, I have, upon every opportunity, talked to my brethren of what has happened concerning etherization in their practice since they commenced it. I am told by all, that not an untoward occurrence has attended or followed its later use. From one, I learned that, since the newspaper accounts of alarming and even fatal cases in surgical operations, patients and their friends have sometimes held back from etherization in midwifery, and that he waits for it to be asked for. The influence is natural upon patient and physician. And it is both natural and wise to act accordingly. It, however, make nothing against the use of the remedy of pain in childbirth, in which it is known never to have done harm, if an untoward result come of its use in some two or more cases of surgical practice, and in some diseases which are almost invariably fatal, as tetanus and hydrophobia.
The reader may look in this volume for the enunciation of principles concerning etherization which have come out of its facts, and which establish its place in practical medicine. I have examined the journals and papers in which these facts are scattered with a profusion which the importance of the subject certainly authorizes, and with a variety in reasoning or opinion which attaches to few other subjects, but which its novelty and extreme interest fully explain. We are told that everything has two sides, and the one chosen depends on the point of sight. Etherization would seem to have as many sides as there are observers, and doctrines concerning it seem only limited by the number of observers. There is Dubois, with his faith and his fears so well nigh balanced, that one feels that he has been so taken with all sides of the matter, that he hardly seems to have looked thoroughly at any. And there is Simpson of Edinburgh, with his hosts of cases, the living witnesses of the safety of etherization, full of faith and of zeal. Mr. Travers says a man may die as well five days after etherization as twenty-four hours; and that he has known a limb, five days after death, smell of ether, the stump having become gangrenous. And this case has by some been elevated into a principle, that ether makes stumps gangrenous, and kills people in five days or twenty-four hours. How as it with Mr. Wells, of the English navy, who gives one hundred and six operations, in which he used ether-vapor? "No serious effects followed in any case." Not a case of gangrene occurred in a single stump of hundreds of amputations collected by Simpson, and not one after a single surgical operation in our own Hospital. Tetanus has been cured by ether, or recover has followed its use. But it has not cured all. M. Roux has failed; and a writer says concerning this case, that "any such trials (namely, in cases of hydrophobia and tetanus) will assuredly end in disappointment; these diseases being diseases of motion, not of sensation." The physiology may be true, but the fact is diverse. Patients do grow still, when etherized, both in hydrophobia and in tetanus. Spasms are controlled, nay, entirely overcome, but it. Positive rest ensues. We infer the abolition of sensibility. We know that mobility is abolished in etherization. Midwifery is full of teaching on this point. Muscles of voluntary motion become powerless. The limbs to which they are attached falls as dead, when raised and left to themselves; and even when consciousness returns, this want of power sometimes remains. Ask a person in this condition of first waking after ether or chloroform, to raise the head to drink, or if he says he will do this, after handing him the vessel, witness his absolute, sure failure, and the question of the physiological action of ether, in this regard, is settled,
Mr. B. Cooper thinks much of the benefits of pain, which he calls a "premonitory condition; no doubt fitting parts, the subject of lesions, to reparatory action." He farther speaks of vessels losing the power of retraction, and so hemorrhage from small vessels follows: How wholly unlike this is the experience of other surgeons! How different are the results in midwifery! I mean established results, not such as come of mere conjecture, and which are offered as such.
M. Flourens shows the progress of etherization in regard to the nervous centres from the hemispheres to the medulla oblongata, with the inferential caution, that we must not let it reach the last. This knowledge is derived from countless experiments upon all sorts of animals, - men among the rest. The latter, I believe, have all survived, and so did not complete in themselves the experiment. But the poor lower orders have suffered terribly. Vivisections have been done without number and without mercy. It would seem, that ether had come to destroy life, not to save it. I have read the reports over and over, and doubt not for a moment that many animals have suffered, and many more have been killed, in the toil. But the end is not yet. Who is ready to determine, or have determined for him, a wholly practical question,. by results of experiments on animals, which, in their whole history and proof, have no possible relation to the case of a suffering human being? It were easy to extend this narrative of effort and of result, of individual and multiplied fact, and of resulting individual opinion, concerning etherization abroad. But I refrain. A moment for home. How has it been with the etherization question here? The question has various answers. Men have tried etherization; and they who have done this most, whether in surgery or midwifery, have most advocated it. Men have not tried it al all; and it would seem, from the tone of their avowal, that they do not mean to try it. These show it little favor. There are whole communities in which nothing has been done with etherization in midwifery, and very little in surgery. Here, in Boston, it has been tried in both. There has been no rush about it, however. The cautiousness in our sectional phenological development, if M. Flourens will allow the allusion, has prevented a rush. Etherization in midwifery has been employed here now for a year; and, with some industry, my collections of cases do not much exceed five hundred. I have no doubt that many more exist; but, of the certain, I know of those only of which I give reports. The number is not large. But just add them to the hundreds and thousands which are furnished abroad, and they perform a distinguished part in a most important history. They, with all the rest, show that there has not been a case in which, during etherization in labor, any untoward circumstance has occurred. I cannot point to a single established case of disaster, during this state, for an exception even to the rule.
I had written thus far when I lighted upon two letters which much interested me, and from which I will make some extracts. The first is from Professor Simpson, of Edinburgh, to Professor Meigs, of Philadelphia. The extracts will occupy some space; but this matters little, if they will at all aid our inquires.
Professor Simpson’s letter is dated Edinburgh, January 23, 1848. He says: -
"The statements which I have already made, may show you to what an extent the chloroform is used in this country; and our chemists tell me that the demand for it steadily increases with them.
"In surgery, its use is quite general for operations, painful diagnosis, &c. My friend, Dr. Andrew Wood, has just been telling me of a beautiful application of it. A boy fell from a heights, and severely injured his thigh It was so painful that he shrieked when Dr. Wood tried to handle the limb; and would not allow of a proper examination. Dr. Wood immediately chloroformed him - at once ascertained that the femur was fractured - kept him anaesthetic till he sent for his splints - and did not allow his patient to awake till his limb was all properly set, bandaged, and adjusted.
"In medicine, its effects are being extensively tried as an anodyne, an anaesthetic, a diffusible stimulant, &c. Its anti-spasmodic powers in colic, asthma, &c. are everywhere recognized.
"In midwifery, most or all of my brethren in Edinburgh employ it constantly. The ladies themselves insist in not being doomed to suffer, when suffering is so totally unnecessary. In London, Dublin &c. it every day gains converts to its obstetric employment; and I have no doubt that those who most bitterly oppose it now will be yet, in ten or twenty years hence, amazed at their own professional cruelty. They allow their medical prejudices to smother and over-rule the common dictates of their profession, and of humanity.
"No accidents have as yet happened under its use, though several hundred thousand must have already been under the influence of chloroform. Its use here has been a common amusement in drawing-room parties, for the last two or three months.
"I never now apply it with any thing but a silk handkerchief. In surgical cases and operations, the quantity given is not in general measured. We all judge more by the effects than the quantity. Generally, I believe, we pour two or three drachms on the handkerchief at once, and more in a minute, if no sufficient effect increases, and none of use care for them any more than for hysteric symptoms; nor do they leave any bad effect. But the mere appearance of them is enough to terrify a beginner.
"I shall be glad to hear how the cause of anaesthesia gets on among you; and I remain, with great respect, very faithfully yours,
Professor Meigs, in reply, says: -
"I presume you will, ere this date, have received copies of Professor Warren’s pamphlet on "Etherization," which may inform you very fully as to the use of the anaesthetic agent in the Massachusetts General Hospital and in Boston. That eminent gentleman is more reserved as to the obstetric employment of the agent; much more so, I understand, than either Dr. Channing, Dr. Homans, and other practitioners, who make use of it very commonly. In New York, as I learn, the surgical application of chloroform is common, while its obstetrical use has not as yet acquired a general vogue......
"As to its employment in midwifery here (in Philadelphia), notwithstanding a few cases have been mentioned and reported, I think it has not yet begun to find favor with accoucheurs. I have not exhibited it in any case; nor do I, at present, know of any intention in that way, entertained by the leading practitioners of obstetrical medicine and surgery, in this city. I have not yielded to several solicitations as to its exhibition addressed to me by my patients in labor......
"I freely admit - for I know it - that many thousands of persons are daily subjected to its power. Yet I feel that no law of succession of its action on the several distinct parts of the brain has been or can be hereafter ascertained, seeing that the succession is contingent. Many grave objections would perhaps vanish, could the law of the succession of influences on the parts of the brain be clearly made out, and its provisions ensured. There are, indubitably, certain cases in which the intellectual hemispheres are totally hebetized and deprived of power by it, while the co-ordinating lobes remain perfectly unaffected. In others the motor cords of the cerebro-spinal nerves are deprived of power, whilst the sensitive cords enjoy a full activity, and vice versa....
"M. Flourens’s experiments, and others, especially those by the younger Mr. Wakley, of the "Lancet" prove very conclusively that the aspiration of ether or chloroform, continued but a little longer than the period required for hebetizing the hemispheres, the cerebellum, the tubercula quadrigemina, and the cord, overthrows the medulla oblongata, and produces thereby sudden death. I fully believe, with M. Flourens, that the medulla oblongata is the noeud vital; and that, though later brought under the power of chloroformization, it is always reducible under it. Hence I fear, that, in all cases of chloroformal anaesthesia, there remains but one irrevocable step more to the grave.
"I readily hear, before you voice can reach me across the Atlantic, the triumphant reply, that an hundred thousand have taken it without accident! I am a witness that it is attended with alarming accidents, however rarely. But should I exhibit the remedy for pain to a thousand patients in labor, merely to prevent the physiological pain, and for no other motive, and if I should in consequence destroy only one of them, I should feel disposed to clothe me in sackcloth, and cast ashes on my head for the remainder of my days. What sufficient motive have I to risk the life or the death of one in a thousand, in a questionable attempt to abrogate one of the general conditions of man?"
As Professor Meigs’s letter is on chloroform, it did not appear to me perfectly clear that his remarks concerning it were meant to be extended to sulphuric and chloric ether. To learn how this was, I at once sent to Professor Meigs a copy of my circular in a letter, in which I took the liberty to ask him such questions as particularly interested me, concerning his trials and his views on the whole subject. It will be seen, in my first extract from Professor Meigs’s reply to Professor Simpson, that reference is made to a work by Professor Warren, of Boston, on "Etherization," which speaks of his reserve as to its employment in midwifery, and of the freer use made of it by Dr. Homans and Dr. Channing, of Boston. In my very first effort to obtain facts from my professional brethren respecting etherization in childbirth, and I believe before Professor Warren’s book was published, I addressed a copy of my circular to him; feeling particularly anxious to obtain a precise statement both of facts and opinions concerning the employment of etherization, in this application of it, derived directly from his own observations of its effects in midwifery. I was the more desirous to obtain this information from this source, as Professor Warren was among the first to use etherization in important operations in surgery, of which midwifery is a department, and because of the weight of his opinions with the community in which he lives, and abroad. I have not received his reply; but my impression is, that his remarks were intended as a lesson of caution, and not as the results of actual experience.
From Professor Meigs, almost by return of mail, I received the following reply to my letter. It is written in a spirit of so much kindness, so much courtesy, - is expressive of an interest so deep in the important and the true, - of so hearty a love of science, that I cannot withhold this public expression of my thanks to its honored author. As a mere matter of taste, it may be questioned if somewhat of that which is especially personal to myself might not have been left out of the print. But I prefer to publish the letter just as it is, and to take the chances with my reader concerning other and purely inferential matters.
"Dear Sir, - I feel much honored by your letter of the 21st instant, covering certain interrogatories relative to the use of anaesthetic agents in midwifery; and I beg you to accept my sincere thanks for the attention.
"I believe I have read all the articles, within my reach, that have appeared upon the anaesthetic practice; and I misconceive of my own motives, if the hesitation which hitherto has prevented me from employing either chloroform or ether arises from any other than a conscientious scruple as to the administration of remedial agents, that I do not deem it indispensably necessary to employ. I have as yet met with no such case, and have therefore remained an interested observer of what my brethren have deemed it expedient, and certain of them indispensable, to do in the matter. I am therefore incapable of answering your interrogatories; being without any clinical experience in the case.
"Seeing that so many thousands of persons have taken, and do daily take, advantage of the insensibility produced by etherization, to avoid the pain of surgical operations, one might well charge me with being cautious overmuch in so long refraining from adopting the remedy in my own practice; but it seemed to me, that the motives set forth for my recusancy, in a published letter to Professor Simpson, ought to be of weight sufficient to determine my action in the premises. The results thus far attained, although they are doubtless beneficient in most cases, are nevertheless mixed up with elements of distrust, as to the permanency of present opinions and indications of practice, so considerable, that I am most anxious to have a candid exposition of the motive for or against it; comprising an amount of intelligence, drawn from different sources, sufficient to lead the body of the profession to clear views of duty upon the point.
"I hold myself in readiness to yield to conviction upon sufficient evidence of the necessity and propriety of etherization in midwifery; but I beg leave to say, that this is a case in which I should hardly yield my opinions to the force of statistical returns, because I have no doubt of some physiological and therefore needful and useful connection of the pain and the powers of parturition, the inconveniences of which are really less considerable than has by some been supposed. If I am not here in error, I submit that no statistics ought to have a real power to convince. There are a few of my brethren here who have exhibited chloroform or ether in their obstetric cases. The instances are not numerous. Dr. Hodge and Dr. Huston, who enjoy a large share of the public confidence as obstetricians, tell me they have not yet resorted to the anaesthesia, nor do they at present feel inclined to do so. Perhaps, sir, when the volume you are preparing for the press shall have appeared, and we shall have become masters of the results obtained and collected by you, we may all give our adhesion to the recommendation. I shall take great pleasure in studying your work with care, as soon as I can get it from the booksellers.
"I have to-day received Ed. Wm. Murphy’s pamphlet, which he was so good to send me by the "Acadia." Dr. Murphy given us accounts of seven cases, five of which were under his own observation. I cannot say, that nay influence has been produced upon my mind, to change my purpose, by reading Dr. Murphy’s cases and observations. In the seventh case particularly, I do not perceive any good fruits of the administration. The success was extraordinary, but can by no means be attributed to the chloroform.
"It is obviously, my dear sir, so much more agreeable to say yes than to say no to any honorable invitation, and it is so clear that you have many distinguished names to sustain the practice now common in Boston, that I could almost feel ashamed not to be on your side also; but if, after reading your forthcoming work, I shall find all my objections swept away by the power of truth, I shall hasten to confess my conversion, and my obligation to you. It is certain, that those who establish great practical truths, that are efficient in meliorating man’s condition, are deserving of all honor and commendation.
"The motives that govern me thus far are connected with, or rather dependent upon, my views of the nature and offices of different parts of the brain. If you will do me the favor to look over Mons. Flourens’s pamphlet, a copy of which I beg you to accept, you will perhaps see the course of my reasoning against etherization in obstetricy.
"We both seek the truth. I hope that you may find and establish it. In the meantime, I rest, with the greatest respect and esteem, your most obliged, and very faithful servant,
"Ch. D. Meigs."
It will be perceived, that the objection of Professor Meigs is wholly and purely physiological. Etherization being given, this objection demands for its removal the law of succession of its action on the several portions of the brain, from the hemispheres to the medulla oblongata, should it happen to reach so far; while it is at the same time obvious, that no such law as this can be ascertained. It is hence an impossible objection, and the true question is whether an impossible objection, and the true question is whether it should for a moment influence practice. We know not what is the succession of events from the slightest impression made by ether or chloroform on the hemispheres, or upon any intervening point between them and the medulla oblongata. We know not, and cannot know, where safety ends, and danger begins, by any known action of the agent, or by any law of its action. Examinations after death from etherization show every variety of results, from the slightest, or none at all, to the greatest. The heart is found in every condition of emptiness and fullness, and the blood is quite as remarkable for the varieties of lesion it presents. So is it with the lungs; and, in short, so is it everywhere. Then we have the results of Vivisections, after etherization induced in animals expressly to produce death, that its lesions may be made manifest. Now, Vivisections are accompanied by direct effects, which at once prevent all true reasoning from them to the medicinal uses of etherization. The transcendental physiology of Flourens, of Preisser and Melays, and the equally visionary teachings of Snow, have really no pertinence to such an issue. They explain nothing, and should not for a moment be allowed to touch the questions involved in etherization.
I have directed as much, if not more, attention to the state of the respiration and of the circulation, than to any other facts in the history of etherization. These functions have always seemed to me to demand the most attention. They depend on the integrity of the medulla oblongata for their regularity, and for their very continuance. Thus I have counted the pulse and the breathings before etherization. Then, while it was getting established, and during its most perfect state, I have known them to remain wholly undisturbed in the midst and pressure of the total abolition of consciousness and sensibility. The patient has been in a state of entire and perfect repose. It has been the completed work of a second. There has been no time for succession in action, or it has been too small to be measured, or the series of events noted. I have known labor to advance in this state of things and to terminate, and not a limb or a muscle to move, or the face to betray the slightest token of suffering. In another part of this volume, I have related a case in which volition and muscular power partially remained, or was regained during deep etherization. The woman was evidently wearied with her position on the left side, and in the most methodical manner possible turned herself over to the right, and composed her limbs after such a manner as to secure to herself a most comfortable sleep; and sleep she did through the whole of the remainder of the labor. These cases have been perfectly safe.
I have said, that the law of succession of the action of etherization cannot be learned; and I will state some facts which show how impossible that attempt to learn this would, and must continue to be. This condition occurs in many, many instances in so short a time after inhalation as to make observation of any succession in events impossible. I have known it to take place completely after two full inspirations, so that not the least notice was taken of any thing said or done. I spoke of the state of the breathing of the pulse, and the subject will come up under other heads again. Let me here say, in addition to what was remarked of their general natural state, that sometimes we find the reverse. The are sometimes more rapid, sometimes slower, than natural. Sometimes the breathing is perfectly noiseless; at others it is heavy, stertorous snoring. Professor Simpson speaks of this as occurring more frequently in his practice, than has been met with in the cases which have fallen under my own observation.
Not only has the physiological objection to the use of chloroform and ether prevented Professor Meigs employing them in midwifery practice, - and will continue to do so, since it is pretty clear that this objection cannot be obviated, - but it will be perceived, that this same objection has with the professor also destroyed the authority of statistics; a science which, in matters of fact, has been of the greatest practical regard and benefit. It makes no sort of odds, that a thousand or a million cases, duly reported and authenticated, have been most successfully and happily treated by etherization. The possibility, not the probability, - for this is denied in the very statement of the number who have safely used it, - the possibility of one case proving fatal afterwards (not in consequence of etherization, for this cannot be determined) would seem to be regarded as a valid objection by my highly respected correspondent to his ever employing it. At least, notwithstanding the thousands of cases in which etherization has been most successfully used by other, Professor Meigs, in amount, says he has not met with one in which he has thought this agency necessary, or in which it would have been usefully employed. The position of this distinguished professor, and the collateral support which that position, and especially his opinions in midwifery, get from the adhesion of Professors Hodge and Huston to the same, makes it a duty, in the discussion of our subject, to consider all the grounds of his not having employed the remedy of pain in labor. I do not understand, that his associates in doctrine and in practice, in this regard, have, anymore than himself, employed ether or chloroform in childbirth. If they have not, is not the whole reasoning against their use strictly a priori in its whole nature? It is not only indifferent to, but wholly irrespective of facts, which are alike the sources and the basis of all inductive science. Its supporters do not ask, "What has occurred? - what has etherization done in childbirth? - how safe has it been to mother and child?" They ask what it ought, what it should do, upon certain physiological principles; and which show that, as far as we can see, it ought to be, or that it is very likely to be, fatal whenever used. The friends of etherization look to the simple fact, - to what actually has happened in childbirth, after using ether or chloroform. They can learn what this truly is, both from their own observation and from that of others. They know that these remedies of pain have been widely used, and with a success which attaches to no other known remedy in practical medicine. They look to the facts. They collect these; and, when the time for philosophizing has come, they will with great pleasure use physiology, and all other collateral aid, in their important generalizations. While thus waiting, however, they do not reject the teachings of physiology. But in the very imperfect condition of this noble science, and more especially that department of it which concerns the nervous system, they are willing to take the guidance of simple fact, of daily observation, in the conviction that, if wisely followed, it will never lead them astray. It is simply and wholly in view of the great importance of our subject, that another opinion of Professor Meigs will now be referred to. It is a passage in his letter to Professor Simpson, and contains what seems to Professor Meigs a conclusive objection to the use of etherization in childbirth. We have already made the quotation, but repeat it for special remark:-
"I readily hear, before your voice can reach me across the Atlantic, the triumphant reply, that an hundred thousand have taken it without accident! I am a witness that it is attended with alarming accidents, however rarely. But should I exhibit the remedy for pain to a thousand patients in labor, merely to prevent the physiological pain, and for no other motive, and if I should in consequence destroy only one of them, I should feel disposed to clothe me in sackcloth, and cast ashes on my head for the remainder of my days. What sufficient motive have I to risk the life or the death of one in a thousand, in a questionable attempt to abrogate one of the general conditions of man?"
The "alarming accidents" are not stated to have happened in midwifery practice, and probably were not observed in childbirth in which etherization was employed. This opinion is partly derived from the statement of Professor Meigs, that he has never used this agency in labor, and partly from what is stated immediately after concerning the employment of chloroform for the pain of disease, and of surgical operations to which no objection is made. It will be perceived, that the objection to etherization is still a physiological one; for the pain of labor is obviously, from the whole language and reasoning of Professor Meigs, a functional pain. Now, here we join issue, and state what will e met with elsewhere in this volume, that the functional department of labor is the contraction of the womb, the dilatation of its mouth, vagina, and external organs, which are no more necessarily painful that are those which carry forward, and expel the contents of the rectum or bladder. There is no pain in the pure functional actions of the uterus. Pain is the consequence of resistance to the contractions of the womb, which the moving body, the fetus, encounters in its progress to birth. Pain in labor is the result, first, of the imperfect harmony of functional dilatability of the mouth of the womb, with the contractions of the organ; secondly, of a like state of the vagina; and, thirdly and specially, of a like condition of the perineum and external organs. It is in the se contingencies, not natural elements of labor, that the whole pain of labor has its cause. The pressure of the unyielding head on the sacrum also takes its share in the production of the resistance which makes up the whole pain of labor. I do not refer to morbid conditions of the passages, such a s excessive sensibility and others, with which all practitioners of midwifery are so well acquainted. I merely refer to functional conditions or disturbances, which are ordinarily met with, and which give rise to the agony of childbirth. Now, this state is one which demands relief. It does not necessarily belong to labor, since painless, or nearly painless, cases of labor are too common to allow of such a statement for a moment. It is to relieve the unnecessary suffering which results from those conditions referred to, that etherization is employed. And it gives the demanded relief, by increasing dilatabiity, diminishing or suspending sensibility, preventing exhaustion, increasing the secretions, taking away the disturbing action of the will; and thus produces results which strike the observer of the first case in which he witnesses it, as if a miracle had been performed in his presence.
A husband sat at the bedside of his wife, and witnessed her sufferings during labor for some hours. Soon after my arrival, and no contra-indications to etherization being present, she inhaled sulphuric ether-vapor. She very soon experienced its most happy effects, and expressed the positive pleasure which had replaced so much agony. The effect upon her husband was such, of this sudden and entire change in her whole state, that he became faint, left the room and did not return to it till after the child was born.
Let it, then, be distinctly borne in mind, that etherization is not used to suspend uterine contractions (which it most rarely does), but to prevent pain; and, in this way, to make labor safe and happy to both mother and child, and to secure a successful convalescence. The cases that follow will abundantly show how true and how general is this alleged effect of etherization, - the rapid recovery which follows its use. Perhaps no effect has been so frequently alluded to by patients as this. The may be unconscious of what happened during etherization, and are insensible to pain; but the after condition is matter of distinct consciousness, and is always referred to with entire satisfaction.
Professor Meigs speaks of the depth of the sorrow he should endure, should he destroy one in a thousand cases, by using etherization in labor. Whence would come that sorrow? Not on account of wrong-doing, certainly. For what better argument could he or anybody else have for employing the remedy of pain in the thousandth case, than the preceding nine hundred and ninety-nine perfectly successful ones? Would it not at once occur to such experience as this, that the untoward result was in no sense the product of professional delinquency in the employment of a remedy, but that it was a results not to be looked for or anticipated, - which stands as the solitary exception to the universal rule, for such would such an exception make it, - which has hence no relation to practice, - and the very existence and whole history of which beings and ends with the fact itself? Add to this the fact, that in not a single instance of the thousands of recorded cases of childbirth, has there been a single untoward result met with during etherization; and what farther argument do we want to support the position, that this agency in painful labor is not only most reasonably demanded by the sufferer, but that it is the solemn duty of the profession to afford to such suffering its certain relief?
Do not for a single moment let the question be regarded as an impertinence; for it has a most important bearing on the subject. It is this. What becomes of the other physiological objection already noticed; namely, that etherization may quite unexpectedly reach the medulla oblongata, and so suddenly destroy life? I ask, what becomes of this objection, in view of the open recommendation of this agent in medical and surgical contingencies by the opponents of its use in childbirth? Certainly the risk is as great in these, as in the childbirth employment of the same agent. Nay, experience has shown it to be much greater; for fatal results have come of it, as I shall show by and by, in surgical operations, while etherization has never touched the medulla oblongata in any childbearing woman.
I do not mean to support my position regarding etherization in childbirth, by referring to the uncertainties of therapeutics in practical medicine. It may not, however, be out of place to observe, that, often in the gravest diseases, the correctness of the treatment is a matter of inferences from its results, rather than of a priori reasoning, or mere experiment in other like cases. And yet who would or should question the propriety, the wisdom of that course which has its determination in such reasoning or in such experiment? Sydenham, in his noble writings on epidemics, especially new ones; and Gooch, in his admirable paper on puerperal fever, have settled the laws of practice in most important diseases, and, in their wise cautions in the use of powerful means, have proved that their confidence in their remedies and in themselves has not been misplaced but has made the ages long to come their grateful debtors.
I have not confined myself to etherization in childbirth. I have devoted some pages to its employment in surgery and general medicine. I have done this for illustration, and especially for its bearings on labor, both in regard to its agency, and in explanation, and as argument for its safety in this practice. This part of the inquiry seems to me exceedingly pertinent to the whole object in my undertaking, and is surely one of the deepest interest. It forms a most important portion of the teachings of the remedy of pain, and shows how wide is the domain of human suffering which it covers and controls.
Another subject, - the untoward results of etherization. Cases have been collected from home and abroad, in which these results have been alarming, and even fatal. Where original sources of information concerning these cases could be reached, they have been referred to, and the answers to inquiries are recorded. Thus I have published from authentic sources important facts concerning the Cincinnati case; others from Dr. Bartlett, of New Bedford, of a case in which chloroform was inhaled for amusement; from dr. Fling, of Roxburg; from Professor Parker, of New York; and an important correction of a newspaper report of a case of crushed thigh, in which amputation was done during insensibility from chloroform. The correction is by Dr. S.D. Townsend, one of the surgeons of the Massachusetts General Hospital.
The numbers which the cases bear belong to an arrangement for a special object. They have been retained, as answering the purpose quite as well as would initials of names, and without the objection which might have attached to their use.
The word etherization has been used as a generic term, and to express that condition which follows the use of ethers of whatever kind. I have, for the most part, designated the particular agent employed for its induction; and, where this has not been done, no necessity existed for doing it.
The first seven cases in the series were published in a pamphlet referred to in the beginning of this section. They are reprinted without alteration, because of the personal interest with which they are regarded, and because of their immediate relation to, and direct agency in, what I have since done concerning etherization.
It has not been easy, in the composition of this work, to avoid occasional repetition of thought, doctrine, or fact. Reports of cases, and statement of opinion, have been constantly reaching me while writing; and I was not willing to withhold either, though at times it has not been always easy to give them the best place. But the repetitions referred to have not been without design. They sometimes present important truths in different aspects. Sometimes, in their wider application, they involve new and useful practical suggestions. Sometimes they are used for illustration.
As to arrangement, very little attempt has been made to render this exact. Subjects follow each other in sufficient order, however, to indicate somewhat their mutual dependence, while each section is complete in regard to the subject discussed.
In offering this work to my profession, I have only to say that it was undertaken, and is finished, in the hope of adding something to useful medical literature. It has occupied more time than I supposed would have been necessary for its completion. It has been written in the uncertain leisure of a professional life, which makes a daily and like demand on physical and intellectual power. It treats of a noble subject, - the remedy of pain. After ages of suffering, and of frequently and long intermitted pursuit of such a remedy, one has been discovered. It remains with the profession to say whether it shall take its place among the permanent and most important agents in the treatment of disease, and in abolishing pain; or whether it shall pass away with the unimportant and undeserving, until another and a truer age shall revive and give it a wider sphere of usefulness and a surer perpetuity.
I have stated my views fully and freely. They are believed to have a legitimate basis in numerous and well-established facts. These facts have been reported, not to sustain a vague opinion, or to give importance and currency to a poor and an unsafe hypothesis. It is no part of the purpose of the following treatise to teach, or to leave it to be inferred, that untoward result in any case of midwifery in which etherization has been induced, which, by any violence or ingenuity of explication, can be ascribed to this state as its cause. I have met with no record of such.
Sincerely do I hope, that what of earnestness may be discovered in the pages which follow, or in those which have preceded, will be ascribed to interest alone in the truth; and that I shall be saved from anything approaching the charge of a partizanship, of which neither my subject nor my self-respect need, or It rust would allow, the indulgence.
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