w A. TREATISE ETHERIZATION IN CHILDBIRTH. illustrated by FIVE HUNDRED AND EIGHTY-ONE CASES. BY WALTER CHANNLNG, MJ). PROFESSOR OF MIDWIFERY AND MEDICAL JURISPRUDENCE IN THE UNIVERSITY AT CAMBRIDGE. " Give me the facts, said my Lord Judge: your reasonings are the mere guess- work of the imagination." — Old Play. BOSTON: WILLIAM D. TICKNOR AND COMPANY, CORNER OF WASHINGTON AND SCHOOL STREETS. M.ncnc.XLViil. WOA Entered, according to Act of Congress, in the year 1848, by Walter Chanxing, In the Clerk's Office of the District Court of the District of Massachusetts. BOSTON: PRINTED BY JOHN WILSON, No. 21, School Street. TO JAMES JACKSON, M.D. PROFESSOR EMERITUS OF THEORY AND PRACTICE OF PHYSIC IN THE UNIVERSITY AT CAMBRIDGE, HONORARY MEMBER OF THE ROYAL MEDICO-CHIRURGICAL SOCIETY OF LONDON, ETC. ETC. Dear Sir, Please to accept the accompanying volume. It is written, not as I would, but as I have been able. The remedy of pain was discovered in this city, and has already taken its place among the most important agencies for the benefit of man. It is due to it, that what it has accomplished should have its earliest embodiment in our own literature. In relation to Surgery, this has already been done in the publications of John C. Warren, M.D. Professor Emeritus of Anatomy and Operative Surgery, and George Hayward, M.D. Pro- fessor of Surgery, in the University at Cambridge; and of J. Mason Warren, M.D. Occupying a somewhat public position as a teacher of Midwifery, — a department of medicine which has derived special and vast benefit from the discovery referred to, — it seemed not out of place for me to collect, and present to the profession, the results of its application, amongst ourselves and elsewhere, to that branch of the medical art. This I have attempted to do in the following pages. In my labor, I have not forgotten — nor do I forget, now that my work is done — that I received from you my earliest and most important lessons in the study of medicine. I was then a young man; and, now that I am an old one, it is to me a most pleasant office to ask your acceptance of this, the latest product of my professional life, and, with it, assurances of a grateful memory and a sincere respect. Very truly your obliged friend, WALTER CHANNING. Boston, September, 1848. The Appendix is referred to in the body of the Work. But I would again solicit for it the reader's attention, as it contains both original and selected matter, which has an important bearing on the subject of the volume. CONTENTS. Plan and Objects of the Work Page 1 Safety of etherization ... 2 Conditions.....3 Contra-indications ... 4 Opinions.....7 Prof. Simpson's let. to Prof. Meigs 10 Prof. Meigs's reply . . .11 Prof. Meigs's letter to the author 13 Of pain in labor, what ? . . 20 Comparative safety of etherization in surgery and midwifery . 22 Untoward results of etherization in surgery 24 Discovery and Use of Etherization in Medicine and Surgery 26 Prof. J. C. Warren's operation with sulphuric ether in Massachusetts General Hospital . . .26 Prof. G. Hayward's ... 26 Dr. N. C. Keep's use of sulphuric ether in natural labor . .26 The author's, in instrumental . 26 The author's use of sulphuric ether in disease.....27 Prof. Hayward on discovery and introduction of sulphuric ether . 27 Chloroform, discovery and use . 28 Chloric ether . . . .30 Compound ether . . . .30 Physiological Agencies of Etherization 32 Dr. Perkins's experiments on capil- lary circulation of the frog ^ . 32 Sensations produced by etherization 34 State of brain . • • .35 Consciousness . • • .36 Sensibility . . • .38 Muscular (voluntary) action . . 39 Involuntary muscular action. . 41 This not diminished by etherization 42 Alleged diminution . . .44 Dr. Charles E. Ware's letter on certain effects of ether . . 44 Explanation attempted . • 45 Prof. Simpson's opinion . .47 Prof. Dubois's opinion . . 48 Prof. Velpeau's opinion . • 50 M. Stoltz's opinion of etherization in turning . . • .50 Rigby on period of pregnancy for turning . • • ■ .51 Dr. J. D. Fisher on occasional state of os uteri in turning . .51 State of womb and ease of turning in etherization . . . .52 Respiration and circulation . .53 Pulse......54 Functions of abdominal viscera . 55 Dr. H. C. Perkins's experiments with chloroform . . .57 Dr. Gardner on untoward effects of etherization . • • .58 Reply to same . • • .59 VI CONTENTS. Etherization, — its Production, Conditions, Signs, and Results 60 Mr. Lawrence employs chloric ether for sulphuric . Mr. Coote shows why, and results Dr. Dalton, jr. to Dr. S. D. Town- send, on chloric ether Opinions of Prof. Simpson, Park- er and Mott of New York, and Dr. Bartlett of New Bedford, on chloroform Prof. Brande, Dr. Pluviez of Lille and Mr. Huttman, on same Conditions of safety in etherization Instruments for etherization Perfect etherization not necessary in natural labor Pregnancy in its relations to ethe rization .... Labor in its relations to etheriza- tion .... Disease in its relations to etheri zation .... Is etherization to be used in all cases of labor ? Author's course in regard to using etherization Effects of etherization 61 62 63 64 65 69 70 74 75 76 85 89 94 95 Insanity .... Convulsions Effects in labor and extraction of teeth in same person Delirium tremens — tetanus - cases .... Uterine contraction not pain Uterine contraction, not pain, mo ther's safety Uterine contraction not diminish ed by etherization . Etherization in hydrophobia, asth ma, rheumatism, neuralgia Unfavorable occurrences after etherization Prof. Willard Parker's letter Dr. S. D. Townsend's letter Case at Newcastle-upon-Tyne Roxbury and Cincinnati cases Case at Birkenhead " Why state these cases of ill sue cess?" Answer Comparative claims of sulphuric ether, chloric ether, and chloro- form .... Conical inhaler (cut) . The Treatment of Abnormal Effects of Etherization Predisposition as influencing ethe- rization .....127 Symptoms Treatment Objections to Etherization in Childbirth I. Labor not so painful as to re- quire it . . . 135 Of pain in its relations to the safety of operations . .137 Prof. Simpson on results of thigh amputations, with and without etherization . 137 Mr. Astley Cooper's case . 138 II. Etherization not certain, and may be unsafe . . .139 IH. The religious objection Letter on same Prof. Noyes's first letter Prof. Simpson's opinion Prof. Noyes's second letter Prof. B. Rush's opinions rV. Moral objection . Extract from English paper Dr. Lyman Bartlett's letter V. Etherization may injure the child Cases I. II. Instrumental labor III. IV. Natural labor . V. Instrumental labor VI. Complicated labor VII.—IX. Natural labor . X. Instrumental labor XL Natural labor . XII. Instrumental labor XIII. XIV. Natural labor . 159 169 173 177 181 182 184 186 188 XV. Protracted labor XVI. XVII. Natural labor . XVIII. Natural labor. He morrhage before XIX. Preternatural labor XX. Labor with convuls XXI. Instrumental labor XXII. Natural labor . XXILL Instrumental labor CONTENTS. vii Cases (continued) XXIV.—XXXV. Natural labor . XXXVI. Preternatural labor . XXXVII. Internal hemorrhage XXXVIII. Natural labor . XXXIX. Natural labor . XL. XLI. Instrumental labor . XLIL—XLVII. Natural labor . XLVILL Instrumental labor . XLIX. Natural labor . L. Presentation of hand and cord LI. Natural labor . LII. Preternatural. Hand LIII. Preternat. labor. Up- per extremity LIV. Premature labor LV. Convulsions LVI. Natural labor LVII. Convulsions LVIH. Natural labor LIX. LX. Natural labor LXI. Convulsions 203 223 224 225 226 227 231 238 243 245 246 247 249 250 251 253 254 255 257 261 LXII. LXIII. LXIV. LXV. LXVI. LXVII. LXVIII. LXIX. LXX. LXXI. LXXII. LXXIII. LXXIV. LXXV. LXXVI. LXXVII. LXXVIII. Natural labor . Instrumental labor Placental presentation 266 Natural labor Natural labor Natural labor Internal hemorrhage after delivery Convulsions Instrumental labor Convulsions Convulsions Placental presentation 291 Natural labor Preternat. labor. Up- per extremity Instrum. labor. For ceps Placental presentation Complic. labor. Ac- cidental uterine he- morrhage Page 203 263 265 270 271 272 277 278 282 285 287 293 295 296 297 319 Tables of Cases 299 Circular .'-.... 299 Number of cases . . .299 Number of natural labors in Table First.....299 Still-births in natural labor . 302 Number of cases in Tables Second and Third . . . .306 Analytical Table of these . .307 Advant. of etherization in these . 308 Letter from Dr. Homans . .312 Analysis of Table Fourth . .313 Comparat. results of cases treated with and without etherization . 315 Metcalf's Statistics of Midwifery, extract from . . . .317 Porter's Statistics of Obstetrical Cases.....318 Letter from Dr. Metcalf . .318 Table First: Natural labor during etherization .... 322 Table Second: Instrumental, pre- ternatural, &c. Consultations . 328 Table Third: Instrumental, &c. labors. Communicated . . 329 Table Fourth: Instrumental, &c. without etherization . . 330 Correspondence Letter from Dr. A. Gould Dr. C. M. Windship Dr. A. R. Thompson Prof. John Ware Dr. John W. Bemis Dr. Henry G. Clark Prof. J. Bigelow Dr. John Homans Dr. A. L. Peirson Dr. M. S. Perry Dr. J. H. Lane Dr. Lyman Bartlett Dr. Simeon Tucker Dr. F. H. Gray Dr. John Jeffries Dr.------- 332 . 332 Letter from Dr. W. Strong 346 333 , Dr. A. K. Gardner . 346 334 , Dr. Chas. Gordon 348 . 336 , Dr. N. B. Shurtleff . 349 . 336 , Dr. S. S. Whitney . 349 . 337 , Dr. Charles Chase 350 . 337 , Dr. D. V. Folts 350 . 338 , Dr. W. T. Parker . 352 . 339 , Dr. A. Phelps . 353 . 341 , Dr. Wm. P. Dexter . 354 . 341 , Dr. E. D. Miller 355 . 342 , Dr. C. H. Allen 355 . 343 , Dr. J. D. Fisher 357 . 344 , Dr. C. G. Putnam . 358 . 344 , Dr. Anson Hooker . 360 . 345 Rei narks on the Correspondence. 362 Vlll CONTENTS. Appendix Puerperal fever after use of chlo- roform .....367 Puerperal fever in which chloro- form was not used, or in which etherization did not occur . 374 Puerperal fever in cases attended by physicians who had either recently had erysipelas, or were in attendance on this disease . 376 Bills of mortality of Boston . 379 Case of etherization in vomiting of early pregnancy, threatening life......380 Case of etherization in vomiting, spasms, &c. in middle of preg- nancy, threatening life . . 382 Case of cholera, with spasms, trea- ted successfully with etheriza- tion . . . . . 385 Case of typhoid fever (?), with spasms, in which etherization was successfully employed . 387 Case of puerperal convulsions, (LXXTX.) treated successfully with chloroform . . . 390 Case of puerperal convulsions re- ferred to . • Case of puerperal convulsions, by Dr. Samuel Cabot, treated suc- cessfully with sulphuric ether . Case of puerperal convulsions, by Dr. J. P. White, treated suc- cessfully with chloroform Extract from Dr. M. S. Perry's letter ..... Letter on moral, physiological, and chemical agencies of ethe- rization ..... Case of increased and uninterrupt- ed uterine contractions after chloroform .... First case of labor in which ethe- rization was used in America, by N. C. Keep, M.D. Case of instrumental labor, by Dr. J. W. Bemis .... Cases of arm presentation, by Dr. C. G. Putnam Profes. Lindsly, of Washington, D.C. on etherization in labor . 367 392 393 394 395 395 396 397 397 398 399 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 num- ber 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 im- proved 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. i 2 ETHERIZATION IN CHILDBIRTH. 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 any thing of my own which it might contain. A circular letter was prepared, and addressed to many phy- sicians 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 cir- cular, — 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 set- tling 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 know 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 PLAN AND OBJECTS OF THE WORK. 3 of etherization, circumstances highly favorable to safe as well as to easy labor arise. Among these may be enume- rated the increase of secretions in the organs immediately concerned in labor, and a more perfect relaxation or dilata- bility 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 pro- duced, 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 effects, — 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. 4 ETHERIZATION IN CHILDBIRTH. I am very glad to find, that my old friend and class-mate. 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 known 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 con- firmed phthisis is this moment under my care, in which chloroform has been very excessively and imprudently em- ployed, and from which no other apparent troubles than nausea and vomiting have followed. These ceased when inhalation was omitted. Of contra-indications to etheriza- tion 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 em- ployed 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 PLAN AND OBJECTS OF THE WORK. 5 nothing new. From one came the religious objection. One friend thus writes, and his short letter is a " whole history:" — " Dear Doctor, " 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 statisti- cal results. " Yours, most truly, " February 10." "Enoch Hale. I give this letter with great pleasure. It contains, as far as the writer's 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 acknow- ledge I had no other right to do so than that which some interest in good science bestows. If I exceeded such privi- lege 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 6 ETHERIZATION IN CHILDBIRTH. 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 has done, and what appears to be its destiny 1 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 1 I answer no. 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 involun- tary violation or temporary suspension of a natural law. PLAN AND OBJECTS OF THE WORK. 7 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 to the circular, I have, upon every opportunity, talked to my brethren of what has hap- pened 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 alarm- ing 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, makes 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 medi- cine. I have examined the journals and papers in which these facts are scattered with a profusion which the impor- tance 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 every thing 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 doc- trines 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 Edin- s ETHERIZATION IN CHILDBIRTH. burgh, with his hosts of cases, the living witnesses ol the safety of etherization, full of faith and of zeal. Mr. Travels says a man may die as well five clays after etherization as twenty-four hours; and that he has known a limb, five days after death, smell of ether, the stump having become gan- grenous. 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 was 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 recovery has followed its use. But it has not cured all. M. Roux has failed; and a writer says concern- ing this case, that " any such trials (namely, in cases of hydrophobia and tetanus) will assuredly end in disappoint- ment; these diseases being diseases of motion, not of sen- sation." 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, by it. Positive rest ensues. We infer the abolition of sensibility. We know that mobility is abol- ished in etherization. Midwifery is full of teaching on this point. Muscles of voluntary motion become power- less. The limbs to which they are attached fall as dead, when raised and left to themselves; and, even when con- sciousness 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 PLAN AND OBJECTS OF THE WORK. 9 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 un- like this is the experience of other surgeons! How differ- ent 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. Vivi- sections 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 experi- ments on animals, which, in their whole history and proof, have no possible relation to the case of a suffering human being X 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 at 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 etheri- zation in midwifery, and very little in surgery. Here, in 2 10 ETHERIZATION IN CHILDBIRTH. Boston, it has been tried in both. There has been no rush about it, however. The cautiousness in our sectional phrenological 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 hun- dreds 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 excep- tion even to the rule. I ha*d 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 inquiries. 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 Avith them. " In surgery, its use is quite general for operations, painful diag- nosis, &c. My friend, Dr. Andrew Wood, has just been telling me of a beautiful application of it. A boy fell from a height, 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 amcsthetic till he sent for his splints__and did not allow his patient to awake till his limb was all properly set, bandaged, and adjusted. PLAN AND OBJECTS OF THE WORK. 11 " 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 hun- dred 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 mea- sured. 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 is produced, and we stop when sonorous respiration begins. Not unfrequently, spasms, rigidity, &c. come on; but they disappear as the effect increases, and none of us 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, " J. Y. Simpson." 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 Hos- pital 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 applica- tion 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], notwith- standing 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. 12 ETHERIZATION IN CHILDBIRTH. entertained by the leading practitioners of obstetrical medicine and sur- gery, 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 pro- visions 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 nazud 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 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 ? " 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. PLAN AND OBJECTS OF THE WORK. 13 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 mid- wifery, 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 etheriza- tion in important operations in surgery, of which mid- wifery 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 can- not 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 infer- ential matters. " Philadelphia, April 26, 1848. " Dear Sir, — I feel much honored by your letter of the 21st instant, covering certain interrogatories relative to the use of anaesthetic agents 14 ETHERIZATION IN CHILDBIRTH. in midwifery : and I beg you to accept my sincere thanks for the atten- tion. " 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 employ- ing 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 interroga- tories ; 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 beneficent 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 evi- dence 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. PLAN AND OBJECTS OF THE WORK. 15 " I have to-day received Ed. Wm. Murphy's pamphlet, which he was so good as to send me by the ' Acadia.' Dr. Murphy gives us accounts of seven cases, five of which were under his own observation. I cannot say, that any 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 prac- tical truths, that are efficient in meliorating man's condition, are deserv- ing 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." " Professor Channing." 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 obvi- ous, that no such law as this can be ascertained. It is hence 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 impres- sion 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, 16 ETHERIZATION IN CHILDBIRTH. or by any law of its action. Examinations after death from etherization show every variety of results, from the slight- est, or none at all, to the greatest. The heart is found in every condition of emptiness and fulness, 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 etheriza- tion 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 ethe- rization. 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 etheriza- tion. 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 ter- minate, 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 PLAN AND OBJECTS OF THE WORK. 17 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 com- posed 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 the 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. They are sometimes more rapid, some- times slower, than natural. Sometimes the breathing is perfectly noiseless; at others it is a heavy, stertorous snor- ing. 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 obvi- ated, __but it will be perceived, that this same objection has with the professor also destroyed the authority of sta- tistics ; 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 proba- 3 is ETHERIZATION IN CHILDBIRTH. bility,— 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 etheri- zation, for this cannot be determined) would seem to be regarded as a valid objection by my highly respected cor- respondent to his ever employing it. At least, notwith- standing the thousands of cases in which etherization has been most successfully used by others, 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, any more 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 1 It is not only indif- ferent 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 V 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 ethe- rization 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; PLAN AND OBJECTS OF THE WORK. 19 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 wait- ing, 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 hap- pened 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 20 ETHERIZATION IN CHILDBIRTH. the whole language and reasoning of Professor Meigs, a functional pain. Now, here we join issue, and state what will be met with elsewhere in this volume, that the func- tional department of labor is the contraction of the womb, the dilatation of its mouth, vagina, and external organs, which are no more necessarily painful than 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 foetus, encounters in its progress to birth. Pain in labor is the result, first, of the imperfect harmony of functional dilata- bility 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 these 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 as 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 em- ployed. And it gives the demanded relief, by increasing dilatability, diminishing or suspending sensibility, prevent- ing 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 wit- nesses it, as if a miracle had been performed in his presence. PLAN AND OBJECTS OF THE WORK. 21 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 posi- tive 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 se- cure 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. They may be unconscious of what hap- pened 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 expe- rience 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 result 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 22 ETHERIZATION IN CHILDBIRTH. very existence and whole history of which begins and ends with the fact itself I 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 phys- iological objection already noticed; namely, that etheriza- tion 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 sur- gical operations, while etherization has never touched the medulla oblongata in any childbearing woman. I do not mean to support my position regarding etheri- zation 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 dis- eases, the correctness of the treatment is a matter of infer- ence 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 1 Sydenham, in his noble writings on epidem- ics, 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 PLAN AND OBJECTS OF THE WORK. 23 use of powerful means, have proved that their confidence in their remedies and in themselves has not been mis- placed, 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 under- taking, 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 suffer- ing 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 authen- tic 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. Flint, of Roxbury; 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 insen- sibility from chloroform. The correction is by Dr. S. D. Townsend, one of the surgeons of the Massachusetts Gene- ral Hospital. The numbers which the cases bear belong to an arrange- ment 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, 24 ETHERIZATION IN CHILDBIRTH. 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 statements of opinion, have been con- stantly 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 re- ferred 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 illus- tration. 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 depend- ence, 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 occu- pied 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 poAver. It treats of a noble subject, — the remedy of pain. After ages of suffer- ing, and of frequently and long intermitted pursuit of such a remedy, one has been discovered. It remains with the PLAN AND OBJECTS OF THE WORK. 2o 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 tiuer 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 results have not followed, or will not again follow, etherization. But I can and do say, that I have not met with an 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 any thing approach- ing the charge of a partizanship, of which neither my subject nor my self-respect need, or I trust would allow, the indulgence. ^ Q 178, Tremont-street, Boston, June, 1848. 4 26 ETHERIZATION IN CHILDBIRTH. DISCOVERY AND USE OF ETHERIZATION IN MEDICINE AND SURGERY. In October, 1846, surgical operations were successfully performed in this city during etherization, or while patients were under the influence of sulphuric ether, and induced by inhaling its vapor. These operations were first per- formed in private practice, and immediately afterwards upon patients in the Massachusetts General Hospital. The first of these operations in the Hospital was per- formed by Dr. John C. Warren, one of the surgeons of that institution, and professor of anatomy and operative surgery in Harvard University. This was on the 13th of October, 1846. The second operation was performed the following day, October 14, by Dr. George Hayward, also a surgeon of the Hospital, and professor of the principles of surgery and of clinical surgery in the same University. The anaesthetic power of sulphuric ether, when inhaled, was first used in childbirth in this city, in a case of natural labor, on the 7th April, 1847, by Dr. N. C. Keep, and was successful.* Etherization in operative midwifery was first employed in America, in Boston, in a case which occurred here on the 5th of May, 1847; it being the second in which it had been at all used in this country in childbirth. This case had existed forty-two hours, and with extreme violence and great suffering, when inhalation was begun. Etherization was perfect, and the operations for accomplishing delivery were performed during complete insensibility. This case stands first in the following series. Recovery was perfect. * For report of Dr. Keep's case, see Appendix, A. DISCOVERY AND USE OF ETHERIZATION. 27 The first case in which etherization was induced in this country for disease occurred July, 1846; and inhalation was employed the 4th of that month. This trial was perfectly successful, and the report of it is in the Ap- pendix, B. Such was the time and place of the introduction of ether by inhalation into the practice of medicine and surgery. What was the manner of its discovery 1 and how was it introduced into practice 1 The power of sulphuric ether to abolish pain during surgical operations was ascertained by actual experiment. It was a strictly philosophical induction, and thus takes its place with all other questionless and most important dis- coveries. It was tried in this city in a special way, namely, by inhalation, — in a special case, and for a special purpose. Inhalation was followed by insensibility. The operation was performed during this state. There was no conscious- ness of present suffering. There was no memory of pain afterwards. The operation was wholly successful. The following on the discovery and introduction of sul- phuric ether is quoted from a pamphlet by Dr. George Hayward, entitled, "Some Account of the First Use of Sulphuric Ether by Inhalation in Surgical Practice: " — " It is understood, that Dr. C. T. Jackson, well known by his great attainments in geology and chemistry, first suggested the use of the ether; but to Dr. Morton, I think, must be awarded the credit of being the first who demonstrated, by actual experiment on the human sub- ject, the existence of this wonderful property.....The ether was administered at the Hospital by Dr. Morton, on the 16th of October, to a man upon whom Dr. Warren was to operate for a tumor on the face. The effect in this case was not complete. The.suffering, however, was very much less than it would have been under ordinary circumstances; and the result was on the whole so satisfactory, that a second trial was made on the following day. "The patient to whom the ether was administered on the 17th of October was a female, with a fatty tumor on the arm, between the shoul- der and the elbow. At the request of Dr. Warren, I did the operation. 28 ETHERIZATION IN CHILDBIRTH. The patient was insensible during the whole time, and was entirely unconscious. The operation lasted about seven minutes, but could not be regarded as a very severe one." We have thus made, of unsettled opinion, an established fact. We have done this by an experiment too widely and too wisely made, to admit of a moment's question. And this ^ure experience is our own. It is our own in its thought, its true conception. It is our own in its present and surely enduring life. With the feelings of a parent of a noble child, let us hold fast and cherish our own offspring. Its service, its blessing, we freely give to the world. It is at home then, in this city, here, we find the true birthplace of a discovery which has received the gratitude of the world. By the agency of ether, we now actually control most important intellectual and physical functions or phenomena; we hold in check, so to speak, a vital func- tion, — separate effect from cause, — restore harmony to the disturbed or disordered functions of an organ, the womb, to which disturbance I have ascribed the pain of labor, and so abolish its suffering; and all this without danger to life, and by the substitution of perfect ease, and often positive pleasure, for a pain, a suffering, an agony, which heretofore the universal experience had taught was as natural and as necessary as it was incidental to the cir- cumstances under which it occurred. Not many months after the discovery of the anaesthetic power of sulphuric ether, other agents, other ethers, were brought forward, possessing a like power with it, but under certain modifications, which, as it was supposed, would supply some of its deficiencies, or avoid some of its incon- veniences. I will briefly allude here to such as have come to my knowledge. Future reference to them, in their practical relations, may be made. 1. Chloroform, the perchloride of formyle, was first used in the practice of midwifery, and, I beiieve, first em- ployed at all for abolishing pain by Professor Simpson, of DISCOVERY AND USE OF ETHERIZATION. 29 Edinburgh, who deserves so much for his introduction of ether into the same department of medicine. The discovery of this substance is ascribed by Professor Simpson to Du- mas, to Liebig, and to Soubeiran, well-known and distin- guished chemists in Europe. By Soubeiran it was discov- ered in 1831, by Liebig in 1832, and by Dumas in 1835. In America it was discovered in 1832 by Samuel Guthrie, Esq. of Sackett's Harbor, New York; from whose letter to the editors of the " Commercial Advertiser " on the subject, I make the following extract: — " In making experiments, some eighteen years ago, with chlorine and alcohol, I obtained a new product, having the properties of the chlorine ether of the Dutch chemists, with which I supposed it to be identical. As I first obtained it, it was in solution in alcohol. In consequence of its pleasant flavor, and the delightful sensation it produced when taken into the stomach, it was greatly sought for in my neighborhood as an exhilarating drink. After seeing its effects in producing a higher degree of jollification and mirth than I had ever seen from intoxicating drinks, and finding that I was introducing a dangerous auxiliary to the cause of intemperance, I refused peremptorily ever to sell another drop to be used as an exciting beverage. " From seeing its surprising powers in restoring a daughter, nearly dead from the effects of burning charcoal in a close room, and other known qualities, I thought it might prove of much value in Asiatic chol- era ; and, while that disease was traversing this continent, I sent it into Canada, New York, New Haven, &c. in the hope that it might be tested in that frightful disease. " When first obtained, it was in solution in alcohol; and my first object was to separate it from all foreign matter, and to present it in a state of absolute purity. This I effected on the 6th of January, 1832, by concentrating it to a specific gravity of 9.486. An account of the discovery and improvements in constructing it, up to that time, was published in the ' American Journal of Science and Art,' by Professor Silliman. " It was important to find a more simple mode of concentration than any I had used; and, finding it was very sparingly soluble in water, I concluded that low proof-spirits might be used instead of alcohol in gen- erating it, and that the product might be washed freely with water, and thus freed from alcohol. The trial was made, and resulted in complete success. kk To o-ive an idea how easily and rapidly chloroform may be made, 30 ETHERIZATION IN CHILDBIRTH. and of great purity and strength, I will detail one operation made in 1832, from which course I have never since had occasion to deviate: — Into a 500-gallon copper still I poured 100 gallons of common whiskey, and then plunged in 240 lbs. of chloride of lime. The still became instantly hot; and, before I had luted on the head, I had a full stream of chloroform from the still worm. It continued to run freely for some time without fuel. When the product ceased to come over sweet, I removed the receiver, and ran off the remainder of the spirit for future use. The product was .re-distilled from a profusion of water, or was well washed in some five or six waters, Avhen it had reached a specific gravity of 1.473. From 2,000 lbs. of ordinary chloride of lime, I obtained nearly 100 lbs. of chloroform." 2. Chloric Ether, which is a solution of chloroform in spirit and water, was used to produce insensibility in sur- gical operations by Mr. Surgeon Lawrence in London, before chloroform was used by Professor Simpson in child- birth. 3. Compound Ether. — This is a solution of chloroform in sulphuric ether; and, from a newspaper report of its effects, it would seem to promise to replace its predecessors. Its introduction was not unlike that which brought chloric ether before the profession; namely, that some of the incon- veniences and alleged grave results of ether, when used alone, might be prevented by their combination. There would almost seem to be something fanciful in the attempt to check the excesses of chloroform, by the moderation of sulphuric ether, by their intimate combination. A neutral, it seems, is the product of their union; and, if this want the whole force of ether, when used alone, and nothing be gained in power by the combination, it would appear to have properties of its own, which promise to it much popu- larity with profession and public. The following is the only report I have met with of the new ether: — " Chloroform : Successful Experiments. — Two amputations were performed yesterday at Bellevue Hospital: the one, that of an arm by Dr. Cox, one of the assistant physicians ; and the other, that of a part DISCOVERY AND USE OF ETHERIZATION. 31 of the foot, by Dr. Childs, one of the visiting surgeons. In both cases, the patients were first rendered insensible to pain by the use of chloro- form, diluted with four times its bulk of sulphuric ether, with which a sponge was moistened and held to the nostrils by the resident physician, Dr. Reese, who has had extensive experience in the use of both chloro- form and ether, although we learn that this was the first time these agents had been used in combination. The complete success of the first trial of the mixture, in both cases, would seem to confirm the inference which suggested it, that the ether alone is too slow and uncertain, while the chloroform by itself is too rapid and hazardous in its effects; and hence the union of these two agencies has been considered as likely to be more gradual and safe. The result of these instances, if confirmed by sub- sequent trials, will go far to remove the terrors which have been excited by the few disastrous cases which have been reported from chloroform. Both these patients were kept in a state of complete insensibility during the operations, and both are doing well, having recovered from all the effects of chloroform in ten minutes afterward. The medical Board of the Hospital were present, as also many other physicians and surgeons, all of whom expressed themselves much gratified with the complete suc- cess of the inhalation of chloroform and ether, — a mixture which none of them had seen tried before, and one which promises to remove all the objections which have been urged against both. It is worthy of remark, that both these patients were over fifty years of age." :*2 ETHERIZATION IN CHILDBIRTH. PHYSIOLOGICAL AGENCIES OF ETHERIZATION. Feb. 16,1848. — I witnessed an experiment to-day, which showed some effects of etherization not before met with. They were made upon the web of a frog's foot by my friend Dr. Perkins, of Newburyport. The frog was etherized by being put into a glass globe, into an opening of which a bit of sponge wet with sulphuric ether was placed, and kept there by the cork. The first effects were much leap- ing, then crawling, then slow projection of the limbs, then drawing the limbs together, and lastly entire rest. This frog, a young one, had been kept in water in the globe for about three months, for experiments. It had received no other food than water during this whole time, and had very often in that time been etherized. It seemed in perfect health. The water was poured off before etherization, as its presence lengthened this process. There was an abun- dant cuticular secretion afterwards. When perfectly etherized, the frog was removed from the vessel, its head and body put in a bag, and its web brought into the field of a strong compound microscope. Looked at immediately, not the least motion was perceived. The capillaries were perfectly visible; but their contents pre- sented nothing by which to distinguish them. Soon, how- ever, you saw, at the edge of the portion nearest the body, a very slight movement in a vessel. It gradually increased, until you saw a fluid, the components of which were per- fectly visible, slowly passing along the course of the vessel. Two of the components were sufficiently distinguished from each other, — the blood globules and the lymph globules. The first, the blood globules, were depressed discs or circles, with a very narrow black border or edge. They moved PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 33 along by the side of each other, in the centre of the capil- laries, without the least confusion, or even touching one another. It was most striking to observe the order, so to speak, of their motion. The lymph globules were circular, of less diameter than the blood globules, having the same dark border, and so moving as to present their circular shape as in perspective. They moved as on their surface, along the ivalls of the capillaries, but without the least confusion among themselves, or between them and the blood globules. When the motion was slowest, it was interrupted, and at regular intervals, as if the movement were continued by a contraction of the vessel, as a pulse. But I could not discover in the vessel itself the least change of place. The vessel was quiescent, — perfectly still; and, when the circulation became brisk, which it soon did, you saw that the motion of the blood was wavelike or uninter- rupted. The experiment was truly beautiful. The connec- tions between the trunks and branches, the meeting of many currents, and their undisturbed progress in their proper places, — these things, in their novelty and perfectness, could not be seen without the liveliest satisfaction. Now, what are inferences from these experiments 1 They show the state of the capillary circulation during etheriza- tion. This is placed beyond question. The microscope presented the organization of the web greatly magnified. Every vessel was most distinct. For a time the rest was perfect, as of an inorganic structure, — of something which had never had motion or life. Then you saw a movement, and of a mass of such size, and of constituents of such form and magnitudes, as allowed you to see them in the fullest manner. This was the first sign of recovery from etherization. Not the least organic or physiological damage or lesion followed this state of things. This frog had been submitted for three months to a variety of experiments, and was still in perfect health. The circulation was as complete in every 5 3J ETHERIZATION IN CHILDBIRTH. vessel, in every part of the web, as it was when the trial was first made. Dr. Perkins informed me, that he had met with a report of an experiment upon a translucent water-plant, the chara, with ether, in which the appearances corresponded with those observed in the web of the frog's foot. The plant was placed in a vessel, filled with ether-vapor, and then examined with the microscope. At first there was no motion perceived in its vessels. Soon after, a motion was seen in the capillary sap-vessels, which was ascribed to the movement of that fluid in these vessels. In a letter on the first experiments above noticed on the frog, Dr. Perkins observes: — " Under a slight dose of ether, the circulation in the capillaries is uninterrupted: under a larger dose, the circulation stagnates in them; that is, they are filled with blood, but not in motion. As the effects pass off, the motion of the globules is gradually renewed, and the circu- lation restored. " Under the chloroform, that state of things occurs which you have described. The capillaries are empty. As its effects pass off, the blood and lymph globules appear coursing through the vessels, slowly and scatteringly at first; then in larger numbers, and a fuller current. This same effect would undoubtedly be the consequence of a large dose of ether." What application have these facts to the observed results of etherization in man \ It has been observed, after inspir- ing both ether and chloroform, that there is a sensation very exactly resembling that of a limb in the state of being asleep, as it is called, — a sense of tingling or prickling throughout the whole body, especially in the extremities. May not this be explained by the state of the capillary cir- culation, or non-circulation, or the condition accompanying its renewal? A very observing person, who was fully affected by chloroform, told me that the tingling, she thought, was observed before any other effect. All others who have spoken of it have referred it to the moment of PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 35 returning consciousness and sensibility. One individual, who was very slightly affected, felt the sensation referred to upon one side only, the left. It embraced the upper and lower extremity, and half of the trunk. In looking back upon the experiment upon the web of the frog's foot, I could not but be profoundly impressed with the power, the agencies, of the capillary system. The artificer of the body, in every instant of time repairing its waste out of the same material, the blood, and in itself the same organ everywhere, — making various and essentially diverse organs the source of as diverse secretions, — pro- ducing animal heat, the very atmosphere, so to speak, in which all functions live and have their being, — the capil- lary system, so wonderful, so important, — is it not, asked I, the maker, the producer, of that very power, sensibility, which establishes the mysterious relations which subsist alike in the organs and in the functions of both animal and organic life, and which may be the foundation-principle or cause of that life itself] Second, Of the state of the head in etherization. — A very common and immediate result of inhaling ether or chloroform is noise in the head. At times, this is very slight; at others, it is very considerable. I have never heard it spoken of as annoying. It is compared to many things, and especially to things in motion, as the noise of a rail-car, — of that which is heard in a machine shop, — a cotton mill, &c. &c. I have almost invariably heard it ascribed to any noise which has particularly attracted the notice of the person. One of the most common occupa- tions in these persons, during etherization, is travelling on the railroad very rapidly and pleasantly. May not the imperfect associations of cerebral phenomena with some previous occupation or situation explain the frequency with which a particular position or occupation, during etheriza- tion, is referred to 1 Dizziness, or rather confusion, is another of the cerebral ;jg TTHERIZATION IN CHILDBIRTH. phenomena. Excitement, pleasurable or otherwise, occa- sionally occurs. At times, under the influence of one or the other, we observe strong opposition to or desire for inhalation. Whatever, however, may be the condition directly following, it does not last long, or very rarely does it so. Unconsciousness, apparent or real, and insensibility, put an end to these sensations, so far as they be disturbing; and a very pleasurable one succeeds. This last may be often resolved into the negative condition of absence of pain. But, in this case, this even becomes positively agreeable. Whatever, however, may have been the cerebral condition or functions during etherization, I can say with entire con- fidence, that I have never known it to continue beyond the state itself; namely, a few minutes after removal of its cause. I have never observed any loss of strength follow- ing its use. On the contrary, the absence of pain during labor has been attended and followed by a remarkable preservation of strength. The uterus has acted with more true power, and patients have returned sooner to ordinary duty, the family, than after any preceding labor. In this observation, I am sustained by that of almost every one who has employed inhalation in midwifery practice. I beg this to be especially understood and recollected; for it can- not but have a very decided and favorable effect upon the continued use of inhalation. Of Consciousness during inhalation. — This presents a variety of phenomena. At times it is perfect. Every thing said is heard and remembered. The patient betrays no consciousness and no sensibility. The last is wanting: the first continues; and, more, what happened during etheriza- tion is remembered when it is entirely passed away. At other times, consciousness is disturbed. Persons are mis- taken : still they are talked to with apparent perfect cohe- rence, though an entire ignorance exists of the persons themselves. An instance may be named. I was called to attend a case, before I had seen the patient. I was a per- PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 37 feet stranger. She had been in labor many hours before I saw her, and was in severe pain when I reached the address. She very soon inhaled ether, and at once was etherized. She was without pain; but her mind was quite active. It was a pleasant condition altogether. She looked intently at me at one time, and said with emphasis, " Why, grandfather, how very, very old you do look! How long and how grey is your hair! Why, grandfather," &c. &c. The excitement continued for a minute or two after the labor was over, expressing itself in gentle singing. At my morning visit, two or three hours after, I asked this patient if she remembered what happened during ethe- rization. She said no. I asked if she remembered calling me grandfather; repeating what, in immediate connection, she said as above. She was surprised at the question; adding that, considering she had never before seen me, it would have been very improper for her to have asked such questions. There was a naturalness in all this so perfect, a truth, too, in this very quality, that at once proved to you how unconscious my patient had been. She had lived in true relations with the persons and things around her. She had recognized them, in a perfect misapprehension of others. She had spoken and acted in what, to her mental state, was in entire harmony with it; and still was there not the least memory of what she had said, or of what had happened. — Other cases present a very different state of things. There is consciousness; but nothing betrays it. A perfect repose exists. Not a word is said; not a volun- tary act done. And yet, when the person comes out of this state, is there the most perfect memory of what has been said and done. So diverse are results in what seems the same experi- ment, or which presents the like phenomena. It is in these, as well as in the abolition of sensibility, that we find in etherization a matter for the deepest thought and the widest interest. Physiology has a new agent for the prose- 3S I.THERIZATION IN CHILDBIRTH. cution of its inquiries; medicine, a new agent for the relief of suffering and the saving of life. Suppose we learn, in the progress of our researches, that the suspension of mor- bid processes, in the arrest of what is tending to the gravest results, may be the product of agents introduced by inhala- tion into the system. Do we not, in these facts alone, have that accomplished which will permit restorative processes, which are always at hand in the living being, however- diseased, to exert their power, and to replace the diseased by the healthy, — to effect recovery % And may not the means of art, medicines so called, exert powers which under other circumstances they fail to do \ Of Sensibility. — This is the power by which impres- sions made upon the living body are perceived. Sensation is the product of the exertion of this power. It is painful or pleasurable. The same agent may produce either of these. The effect is wholly in harmony with the cause. The predisposition to be affected beyond proportion to the agency used is an exception to the rule. Pain is produced by external violence, by diseased actions within, and by mechanical resistance to the performance of a single natural function. As the consequence of external violence and of disease, pain gives immediate notice of danger by suffering, and makes immediate demand for relief. Labor is the function referred to. Uneasiness in women, and in all other animals, in labor, gives notice of the function. So far, it is useful. Beyond this, it will not be difficult to show that it is useless, and may be even injurious. This will be done hereafter. Etherization suspends sensibility. Labor goes on, but is not perceived. It is without pain. During uterine con- tractions in etherization, it is very common to hear expres- sions indicating effort. Respiration becomes embarrassed by uterine contraction, and you perceive this often in the apparently voluntary effort which attends it. It is precisely what occurs during sleep, when, from an unfavorable posi- PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 39 tion of the body, or other cause, functions become embar- rassed. The brain is at once informed of this, and as soon applies the remedy. During this effort, the breath is held; then is forced, alternately, until change of place is effected. Now, there is no pain in all this; nor is the effort nor the change of place remembered how much the necessity for both may be perceived by the sleeper. Etherization does just what sleep does. It is sleep, profound sleep; and, though effort is made, and because an impediment to easy performance of function exists, still is there no pain. Of Muscular Action during etherization. — We have reached a most interesting part in our investigations. What is the condition of the muscular system under this power 1 Volition seems to be suspended, and the organs of volun- tary motion are at rest. I say seems, because there are facts which to some make the unqualified statement ques- tionable. I think that there may be, and that there is, a degree of etherization which is not incompatible with vol- untary muscular action; and still that there may be no sensibility, or, to be still more precise, no sensibility which is accompanied by pain, or pain which is remembered. I find an argument for this in what was observed of sleep. There occurs in that state an occasion for motion, by muscles of voluntary power. Change of place here is effected at once without the consciousness of the sleeper, and is without pain. No one at all conversant with ethe- rization has not had abundant opportunity to observe, that there are limits which may be placed by him to the power. Nay, what is still more remarkable is this: the patient may, and does, determine or place this limit herself, just when and where she pleases; and, in fact, frequently does this when the sponge or the inhaler is in her own hand. She lets it fall, when that point is reached. When she does not so by volition, the limit is exceeded, and the instrument falls by its own weight, and by muscular relaxation, from between the fingers. It is this which constitutes one of 40 ETHERIZATION TN CHILDBIRTH. the most important, I may add beautiful, facts in our sub- ject; and it furnishes us with this practical rule, whicli should never be forgotten ; namely, — Entire etherization is unnecessary in midwifery, except in instrumental and other difficult cases. There is no danger in the completeness of this state. There is in its perfect induction no cause of alarm. But it is not necessary, as it is thought to be in severe surgical operations, during which the patient is kept perfectly ethe- rized. In instrumental delivery, in turning, &c. where the suffering is great, and it is important to produce entire relaxation, and to have perfect control of the voluntary powers, then complete etherization should be reached. I have not often witnessed this state. I have seen a person apparently in the fullest state of etherization, preparatory to a very severe surgical operation. But, at the first stroke of the knife, which passed extensively through sensitive tex- tures and at once, the patient forcibly drew up the limbs, tried to move the body, as if to get out of the reach of that which produced suffering; and, in cases of severe ope- rative midwifery, I have at times observed the same thing. There has been no memory of uneasiness or pain, if the feeble struggles referred to were felt. Here again, as in profound sleep, where effort is for some cause made, there was probably no pain at all. These brief notices of the relations of etherization to physiology, in its agency with voluntary functions, — its powers in regard to consciousness and sensibility, — give to it the deepest interest in the highest philosophy. The etherized person is not drunk, — is not intoxicated. There is the helplessness of sleep; but there are going on most important functions, and without the least disturbance, nay, with increased power. The person wakes from this state at once. The mind declares itself in its clearness, fullness, naturalness. There is not a moment of that apop- lectic sleep which follows intoxication, — none of that PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 41 surfeited aspect, as if the person, in having been relieved of pain, had for the time become allied to the brute, and did not lose the relation when consciousness has returned. Espe- cially is this true after chloroform. Etherization by this is at once followed by entire return of the faculties. Chlo- roform very soon disappears from the breath, and is found in none of the excretions, showing how evanescent is its agency, however important and grateful has been its power. He who witnesses the agencies now under consideration has before him facts which must command his attention; and I am not at all surprised to find how much the moral and intellectual aspects of etherization have arrested attention, and how much more vividly remembered are they and recorded than its more perfectly physical pheno- mena. I would, in passing, however, remark that, not- withstanding the interest in the psychological bearings of the subject, it is of extreme importance, that what pertains directly to physical functions, so to speak, should be care- fully and habitually studied. Among these functions are the circulation; respiration; temperature; state of com- plexion ; perspiration; state of limbs and body, as to motion or rest; secretions; dilatability of organs con- cerned in labor; state of uterine contraction, whether regular, or intermitted longer than before, or suspended, and how long. In short, nothing should be omitted which belongs to the physiological condition under notice, whether it be for personal knowledge and after-use, or for the advan- tage of the profession. Above all things, we owe it to our subject, to the public, and to ourselves, to state just what happens, whether favorable or otherwise, and alike during etherization and what follows. I have spoken of the action of voluntary muscles during etherization. How is it with involuntary action during the same state 1 The actions of the womb in labor are automatic. They are involuntary. The will may bring to its aid neighboring 6 42 ETHERIZATION IN CHILDBIRTH. organs or powers.. The will may seem to retard the pro- gress of labor; but it never produces contractions. A case is recorded in this volume, in which the agency of volition was strikingly seen. I had applied the forceps before ethe- rization. A pain came on, and I was surprised to find the instrument forcibly drawn into the vagina, and almost out of my reach. The woman here was trying to diminish suffering. After ether was used, and its full effects pro- duced, not the least effort of this kind was made. In another case, the patient was living some miles from town. When I reached the address, I found the case far advanced, and that my visit had been very anxiously looked for. I was told, that, by strong voluntary effort, the labor had been unquestionably retarded, lest it should have been over before my arrival. She inhaled ether at once, and in a very short time was delivered without pain. Etherization has no necessary effect to diminish the organic action of the womb, any more than it has to stop the circulation or digestion. There have been cases in which uterine contraction is said to have ceased during the action of ether. It has occurred after etherization has ended, and again been checked by its reproduction. Are not these exceptional cases 1 and have they not proceeded from circumstances in individuals which are in no sense general % I have not, in my own practice, met with a single instance in which diminution or a suspension of contraction has occurred, which has differed from those in which these same things have happened without ether. In some of the following cases, ergot has been given. But it has been used when hemorrhage has followed a previous labor or labors, and to prevent its recurrence, just as we would use ergot, had etherization been unknown. I have given it in some, because the labor has been protracted, or the contractions, though accompanied by much pain, have been ineffectual, and because the pains following its use have been as easily controlled by ether as are normal efforts. Nay, I have PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 43 found the persistent contractions, so common and often so distressing from ergotism, perfectly controlled by the ether- power ; and in no instance has still-birth been met with after etherization in these cases, which is so frequent an event after the use of ergot. These considerations are very important, and give to our subject the highest interest. Its physiological relations are novel and truly striking. We see in it the suspension of physiological laws, and still the economy suffers no harm. We hold pain, as it were, in our hands. It comes and it goes at our pleasure. One of the gravest inflictions of disease has lost its power, and remedial agents may now exert their influences without disturbance, and in quantities, and after periods, much more productive of beneficial results. We cannot yet see what are the limits of the powers so recently introduced into medicine. Let us try them wisely, and with the utmost scrutiny. Let us not fear them, until their power and ten- dency to do harm declare themselves with an emphasis which can neither be mistaken nor resisted. Thus far it may be said of etherization, that it has produced no such effects in midwifery practice as for a moment suggest the thought that it should be laid aside, or make its entire safety a question. I have not met with a case, either of personal observation or of record, in which any thing untoward has occurred in midwifery during etherization, which has not been explained without referring it to any malign influence of this condition. Labor has been met with having its gravest complications after the use of ether, just as these have occurred before its power was known. And, again, these very complications have been wanting after etherization, while they have occurred in a most alarm- ing form after labor without it. Hemorrhage has been among these complications. It is the most frequent of all others. I have not met it with more frequently of late than formerly; and, of all the cases which have been com- municated to me, or which I have met with in books, I have 44 ETHERIZATION IN CHILDBIRTH. not found one which without question should be ascribed to etherization. I have within the week met with a case of hemorrhage, and a grave one too, in which, during the labor, I offered ether because of the severity of the suffer- ing, but which the patient refused to inspire. It was a perfectly natural and short labor, in a woman of the fullest health. How false might have been the teachings of this case, had ether been employed, and hemorrhage followed, and etherization put down as its cause! In the Correspondence, the subject of the diminution or suspension of uterine contraction by ether will be found noticed. I think the weight of evidence is against the doctrine or opinion, that ether checks labor. On the con- trary, we find it often recorded that dilatation has proceeded much more rapidly during etherization; that lubrication by secretion has become more abundant; that contractions have increased, and labor been more rapidly terminated. From one of my correspondents, and for whose opinions I have sincere respect, the doctrine that labor is retarded by etherization is so strongly put, that I have placed his com- munication here by itself for distinct notice. It is from Dr. Charles E. Ware, and is in answer to my circular formerly referred to. " From my own limited experience, I should say, that the invariable effect of the ether was to diminish the force of the pains, and retard the labor, whenever the inhalation was carried sufficiently far to diminish materially the suffering. This consequence has been so unvarying, that it has been difficult for me to believe, that the experience of others should differ so widely from my own as has been represented to me by many. When the ether has been carried to entire insensibility, as it has been repeatedly, the consequence has been, that, for a considerable inter- val, I should say fifteen or twenty minutes at least, there has been an entire cessation of pains, when the intervals before had not been more than two or three minutes; and, when pains did occur, they would never bring the head down as low as it had been before. In the cases where I have used it, I have always experimented frequently at different stages of the labor, so as to leave no doubt as to the fact. Indeed, it has been so obvious to those around, that they have generally been urged to desist PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 45 from the use of it. This experience has deterred me from proposing the use of ether to patients, although I have never objected to it when it has been first suggested by them. Twice, in cases of first child, the use of the ether has been a source of great comfort to the mother, by giving her long intervals of entire repose ; after which, she would wake up refreshed to go on with the labor, although the disappointment has been great to discover that it was not all over." Dr. Ware adds in pencil: — " Dear Sir, — I send you these remarks in their present state. Indeed, I don't know that I should have any thing essential to add, had I time; although I did intend, a fortnight or more since, when I commenced, to go into the subject a little more fully. I was interrupted, threw the paper into my drawer, and forgot it. — Yours truly, " Chas. E. Wake." It will be perceived, that the intervals of contraction in Dr. Ware's cases were not very long, — from fifteen to twenty-five minutes. They were, however, much longer than were those which occurred before etherization, they being only two or three, and so were unusually short. In two of the cases, these intervals were very grateful to the patient, from the entire rest which accompanied and constituted them. The contractions, too, which followed were, I infer, as strong as those which had preceded them, — a necessary condition of delivery in these instances, and which, as was stated, very commonly happens. In explanation of such results of etherization as are recorded by Dr. Ware, I would ask if the lengthened inter- vals and diminished uterine action of which he speaks are not the replacement of the irregular and violent, and so non-natural, uterine effort by normal or true action ? Dur- ing perfect etherization, — and it is to this that the facts recorded refer, — the will exerts no power; and its agency in stimulating to excessive and irregular action, either by shortening interval or increasing force, is taken away. That the will has such power is familiar to every one con- versant with the phenomena and history of labor. I have already showed how it can retard labor; and this, too, 46 ETHERIZATION IN CHILDBIRTH. every physician has observed. Where animal and organic functions have become at all so associated, that one comes to be at all dependent upon the other, — the latter, for instance, upon the former,—is not the explanation perfectly easy of a temporary increase in interval, and diminution or even suspension of the organic, in the abolition of the animal, the voluntary function 1 I have again and again witnessed this temporary and even lengthened interval of uterine effort, and diminution of its force during etherization. But it has not been a cause of discomfort or regret. It has seemed only the natural state of the function, and which etherization has produced, and so has been welcomed. The recurrence of uterine contraction has not been with diminished force, and it has been attended by speedy and painless delivery. I have said, that during etherization it is not very un- common to observe suspension of uterine effort; but is not the same thing true in natural labor, pursuing its course without any foreign agency? Pains very often slacken, nay, quite fade away; and this state of rest will continue for some time. It excites no uneasiness, unless when induced by protracted and violent labor. In the natural case, we wait patiently, or give secale or some other stimu- lant, which ordinarily produces the desired action. I do not place Dr. Ware's cases among these; for they are too many to be resolved into mere coincidences. But still, as they differ from a wider experience, they are not intended to make an objection to the continued use of etherization. One fact in their history is very important. Hemorrhage was not a result of this intermission of uterine contraction. It did not extend beyond the stage of labor in which the child is delivered. The last stage, the deliv- ery of the afterbirth, was without accident. I have spoken, as was just said, of the power of ether and chloroform over sensibility and voluntary action. We know that the motory and sensory nerves have their origin PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 47 in different columns of the spinal cord; and, though they come together to form bundles, in which they pursue their course together without forming any direct union, no confusion of function comes from this arrangement. But in the organs of organic life, so called, over the functions of which the will has no control, we find chloroform and ether, selecting, as it were, which function it will suspend, and which it will leave untouched. Sensibility is dimin- ished or suspended. Contraction continues unaffected. This is, however, true only in some functions. The heart, a muscle of the organic life, " gives as healthful music" under etherization, as when this state does not exist. You say this is a vital organ, and so is placed beyond the reach of agencies which may powerfully affect non-vital functions. Yes; but digestion goes on, and so do other non-vital actions under etherization; and, should they before have been performed with pain, etherization has been found to remove this, and so give to the function its healthful way. It selects, so to speak, the functions which it would control, and leaves others to pursue their ordinary course. It is this which gives to the discovery of this state, and of its power, its extreme interest. We know not of its limits in physiological and psychological science. We have these for special and most interesting study. The foreign views entertained of this very important » subject have not been yet noticed. Concerning it, Profes- sor Simpson of Edinburgh says, " In every case, the uterine contractions continued as regular in their recurrence and duration after the state of etherization had been induced, as before the inhalation was begun.....Indeed, in some cases, the pains have appeared to me to have become increased, as the consciousness of the patient became dim- inished. This has more particularly occurred with one or two patients, who breathed ether combined with tincture of ergot, or containing a solution of its oil." This was the result of his earliest observations. But now that Professor 4S ETHERIZATION IN CHILDBIRTH. Simpson numbers his cases by hundreds, he bears the same testimony to the happiest effects of etherization. I cannot refrain from making one quotation here from this writer. It is his answer to the question, "Will we ever be 'justi- fied ' in using the vapor of ether to assuage the pains of natural labor ? " The answer comes from his observation of the whole results of etherization, and so has great authority. " For, instead of determining in relation to it (natural labor), 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, and not using any such safe means (as we at present presuppose this to be), provided he had the power by it of assuaging the agonies of the last stage of natural labor, and thus counteracting what Vel- peau describes as ' those piercing cries, that agitation so lively, those excessive efforts, those inexpressible agonies, and those pains apparently intolerable,' which accompany the termination of natural parturition of the human mother." The answer to the question here given, or so clearly im- plied, has not, as far as my knowledge of Professor Simp- son's writings goes, been in the least degree changed or modified by his latest experience. What next are the opinions of Baron Paul Dubois, clini- , cal professor of midwifery in the Faculty of Paris, concern- ing etherization in childbirth % They are, — 1. It has the power of preventing pain during obstetrical operations; such as turning, applications of forceps, &c. 2. It may momentarily suspend the pains of natural labor. 3. It does not suspend uterine contractions, nor impede the synergetic action of the abdominal muscles. 4. It appears to lessen the natural resistance which the perineal muscles oppose to the expulsion of the head. PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 49 5. It has not appeared to exert any bad influence over the life or health of the child. These opinions or inferences are advanced with some caution, but are not the less valuable on that account. They belong to the earliest period of the history of etheri- zation. They have been remarkably confirmed by a wider and later experience. Dubois had early witnessed some deaths by puerperal fever in his hospital, after etherization. These cases doubtlessly impressed his mind, and were cal- culated to influence his opinions, — perhaps more so than they would have affected others more remote from the scene of their occurrence, especially as it is known that puerperal fever was at that very time prevalent in that hospital. But whatever of qualification of opinion these facts may have suggested to Dubois, our extracts give much confirmation to the views advanced of the physiological relations of etherization. One exception only occurs. It is in what is said of the continuance of voluntary power, — the action of the abdominal muscles during etherization. This might have been owing to the imperfect induction of this state in some cases, or the occasional appearance of such voluntary action might have led to some deception in some other cases. I have often witnessed the same thing, and can understand how they may be the sources of error. The person, in these instances, seems to be exerting volun- tary power, because of the forced or embarrassed respiration which accompanies uterine contraction. This action of the womb has associated with it the voluntary action of the abdominal muscles, where inhalation is not practised, and is attended with an obvious effort. During etherization which is not perfect, the same thing occurs in various degrees. When it is perfect, the effort is only apparent, and is owing to embarrassment of respiration, as above stated. I find the following question, touching the subject of our present inquiry, in a popular work: — " Has ether the 50 ETHERIZATION IN CHILDBIRTH. effect, as supposed by Velpeau, of suspending or diminish- ing the power of the uterine contractions, so far as to facilitate certain obstetrical operations, such as the version of the foetus 1" The following fact is given in the work referred to, as an answer to the question: — " M. Stoltz, of Strasburg, was called to a primipara, Oct. 24, of strong constitution, and in the sixth month of pregnancy. She received a fall on the 1st of March; and, after suffering somewhat from pain in the abdomen and sacral region, she was taken in labor on the 5th of the same month. On examination, M. Stoltz found the right foot and right arm at the uterine orifice: from the shape of the uterus, it was concluded that the foetal head was to the left and inferior portion of the uterus, and the pelvic extremity to the right and upper side. The absence of a battement showed the foetus to be dead. M. Stoltz determined to deliver by turning: the patient was placed in the required position, and ether exhibited with the usual results. Seeing that sensibility had almost entirely ceased, M. Stoltz attempted the introduction of his hand into the vagina, when the woman immediately wakened up, and resisted with loud cries; he then desisted for two or three minutes, until insensibility was complete. From that moment he was enabled to introduce his hand into the vagina, and accomplish the necessary operation, without the patient at all resisting him or complaining, although the passage of his hand through the vulva was not effected with more ease than is usual in primipara?. Having seized the foot which presented at the os uteri, M. Stoltz attempted to extract the foetus; but so powerful were the ute- rine contractions, that the thighs could not be disengaged. Having applied a noose upon the right foot, M. Stoltz then introduced his hand again, in order to seize the other foot still in the uterus. He had at first great difficulty to pass his hand through the os uteri; and, even after having succeeded in this, he was unable, in consequence of the violence of the uterine contractions, to penetrate far enough into the uterus to reach the left foot. He found himself compelled to desist from this attempt, and at length with great difficulty succeeded in extracting the body of the foetus from the uterus; but the os uteri still contracted so powerfully round the neck of the foetus, that he could not proceed with the extraction. During the whole of this time, the ethereal inhalation had been continued, and the patient had remained in a state of complete and uninterrupted repose and insensibility. The patient at length showed an inclination to vomit, and without much effort ejected a large quantity of frothy mucus. About a minute thereafter, she woke up, and said she had dreamed that some one had attempted to deliver her, and thereby had PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 51 caused her pain. She gradually recovered, and complained only of a slight uneasiness in her head and throat. The head of the foetus remained all this time encircled by the os uteri. In about an hour, uterine con- tractions were renewed, and a few slight extracting efforts sufficed to complete the birth of the foetus." — Monthly Journal of Med. Sciences, July, 1847 ; from Gaz. Med. de Strasburg, March, 1847. This seems to me an unfortunate case, either for the foundation or for the illustration of a doctrine. Rigby, — the elder Rigby, who, with his distinguished predecessor Levret, was an original discoverer of so much concerning uterine hemorrhage which is of permanent value, — Rigby shows how very difficult, if not impossible, it is to pass the hand into the uterus, for the purpose of turning, before the completion of the sixth month of pregnancy. The neck of the womb, up to this time, has undergone no change in its length, and remains as firm as in the unimpregnated state. The functional condition of the organ distinguishes it from that which characterizes it at the close of preg- nancy. It is more sensitive. It is performing important functions. It is full of life and of power. Its cavity is too little developed, for no demand as yet has been made upon it, to allow of manipulation within it, without producing great suffering and resistance. Was not the resistance in M. Stoltz's case, or the difficulty of the operation, the con- sequence of a state of the organ incident to early pregnan- cy, rather than to excessive or unusual contractions % Does the case show more than this, that uterine contraction is not suspended by ether ? Another circumstance in the case may have a passing word. I refer to the contraction of the os uteri round the neck of the foetus. There can be no question that this happened as stated. A case is given, in very interesting and valuable detail, by Dr. Fisher, in the Correspondence, in which the same kind of contraction occurred, and to a degree quite as remarkable as happened in the case of Stoltz. I refer to it here, because, when Dr. Fisher's case 52 ETHERIZATION IN CHILDBIRTH. was first communicated to the Society for Medical Improve- ment, it was thought that he might have made some mis- take as to the state of the os uteri. I refer to it also as adding confirmation to the general opinion, that uterine contraction is not injuriously interfered with by etheriza- tion, and as further illustrating its physiological agencies. I very cheerfully take the risk of fatiguing my reader, in my desire and attempt to give to this part of our subject the fullest attention. I know of few points which demand a freer discussion, or more distinct enunciation. In speaking to such questions as are involved in the views of MM. Velpeau and Stoltz, it is impossible not to refer to one's own experience. Turning is not so rare an operation as to leave any doubt of what was its difficulty before etherization was used. And, in the gravest condi- tions in which it may be called for, — namely, in those which accompany the presentation of the upper extremity, in any part of it, — who has not learned how fatal it has been to the child,.and how much of agony, and often dan- ger, it has inflicted upon the mother ] Look now at the same operation, done in the same conditions, in the same presentation, during etherization. I can appeal to personal experience, and to that of most credible witnesses, of the difference in operation and in result which has come sim- ply and solely of etherization. Where the foetus is not dead before the operation is begun, it is now born alive; and, in the gravest cases which I have seen, and which have become so by long and most painful and exhausting labor, the mother has been at once relieved from suffering, and has uniformly done well. The ease and the success of the operation have not been at all the result of the suspen- sion of uterine contraction by ether or chloroform. In some cases, indeed, the contractions have already lost much of their power by its waste in ineffectual labor; but in others this has not been the case. The contractions, and of course power to contract, have existed perfectly. In one of my own cases, PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 53 turning was done very early in labor, when the womb was acting vigorously. In this case, the child was born alive, under most adverse circumstances of presentation. The woman did well. M. Velpeau supposes, that the ease of turning in etherization is owing to the suspension of uter- ine contractions. This to me does not seem the explana- tion of the matter. I have rarely known it occur, that the contractions underwent this entire suspension. The ease of turning has been found in the perfect relaxation and non-resistance which attend entire etherization, — in the absence of volition, and in the muscular repose which accompanies this state of the will. I mean here muscular relaxation. Besides this, we have a striking change pro- duced in the state of the passages, both external and inter- nal. The os uteri declares this equally with the rest. The hand, when within the uterus, perceives contractions as under other circumstances, or when etherization does not exist. These are not, however, declared as in those cases. The organic sensibility, the irritability, of the womb is suspended, as is animal sensibility, and violent or spas- modic action is not perceived. At least, I know of no better explanation of the uterine condition during perfect etherization, and the consequent ease of turning. I have referred to my own observation in this explana- tion of the ease and safety of turning during etherization. A reference to the Table of Cases of Instrumental and of other Labors, to their results, and to the Correspondence, will furnish the reader with the evidence of a wide and diversified experience in regard to the effect of etherization on uterine contraction. How is it with Respiration and Circulation during etherization 1 Respiration is, for the most part, hurried somewhat in the first inhalations ; which is rather to be ascribed to the mental excitement which accompanies this moment in etherization, than to any direct effect of the agent used 54 ETHERIZATION IN CIIILDH1RT11. to produce it. Breathing is slower during the state itself, and sometimes becomes exceedingly still, noiseless as well as slow. I have very rarely met with the stertorous breathing of chloroform, noticed by Professor Simpson, and never that condition, of which he speaks, in which etheri- zation from chloroform is closely allied to the snoring of intoxication, or other conditions in which the brain is affected. I say I have rarely met with this state of respi- ration. I can remember but two or three cases of it, and in these it was hardly noticeable. This is thus distinctly stated, because the effects of choloform have been much more frequently induced in their most perfect degree, than have those from sulphuric ether; and because dyspnoea has been oftener observed after its use, than after that of the latter. Pulse. — As with respiration, so with the pulse: At first there may be more rapid movement than before. This, too, is evidently mental, and belongs to that general excitement which is sometimes, and by some observers, thought so generally to characterize the state in which the nervous centres may be just reached, or somewhat disturbed in their functions, and the expression of which is not, and may not be, controlled. When this condition ceases, and quiet is restored, the pulse becomes calm too. It soon returns to its ordinary beat, and then not rarely falls below it, though I have known it to remain exactly the same as in ordinary health. To ascertain these facts, it is always useful to learn the number of the pulse before inhaling. Its comparative force is to be learned in the same way; and, of this, exact knowledge should always be obtained. This detail of pro- fessional duty or office, when etherization is to be practised, and during its induction and continuance, may by some seem trivial or useless; but he who thinks so had better not employ it. If he have not interest enough in such an agency, so curious in its phenomena, and so important in its effects, he had much better let it alone, as he may some- PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 55 times be indulging his ignorance at the expense of his patient's safety. He differs in this not much from him who gives an active medicine without knowing what is the safe dose, or what is the order in which its natural or ex- cessive action manifests itself. One change in the pulse is very striking. It is the diminution in frequency, and increase in force, which some- times attend on etherization. I have known the pulse fall to between thirty and forty beats in the minute after chlo- roform. I have never observed this change to this extent after sulphuric ether. This slowness of pulse in different degrees almost always accompanies the perfect quiet and unconsciousness of full etherization. Whenever this state of pulse occurs, if you have not removed the inhaler, do it now. The whole state of the patient shows that our ob- ject is obtained. The labor goes on; contractions increase in effect; the child is advancing. There is no complaint; there is no pain. Stop inhalation. If the slowness of pulse be noticed in the interval of contractions, which is the time of its greatest intensity, a change in the circulation at once is declared, when uterine contraction returns ; and we shall find that the natural state of the pulse will be restored, and this the more as the consciousness and sensibility return. In the farther use of inhalation, and especially the time of each trial of it, attend to the pulse in all cases, and especi- ally in those in which the circulation is found to be most easily and decidedly influenced by etherization. Of the Functions of the Abdominal Viscera. — The only organ which has been disturbed by etherization is the stomach. Nausea and vomiting have been particularly referred to. My observation in these regards has been singular. I do not remember to have met with more than a single case of vomiting, and this after chloric ether; and not more than once or twice with nausea. Among the "special effects " which are inquired for in my circular, I do not find that a single correspondent has stated that these conditions 56 ETHERIZATION IN CHILDBIRTH. of the stomach were observed, or that either of them existed. There may be exceptions, but they are not striking ones. I have employed ether in cholera morbus, in which nausea and vomiting were most pressing symptoms, and had been so for full eleven hours ; and there wras vomiting but once after inhalation. What was striking in this case was this: ether was singularly disagreeable to this person, affect- ing the stomach very unpleasantly. In a case of vomiting in the early months of pregnancy, and which seriously threatened life, chloroform was very freely used, and, for a time, with much relief of sickness. A correspondent writes, that he has used ether with much benefit in a case of severe spasmodic affection of the stomach, produced by indigestible food. This person was a great sufferer from chronic dyspepsia. The only case in which I have known the stomach gravely disturbed was that of a nurse who was compelled to inhale chloroform, as the atmosphere of the lying-in chamber was filled with the vapor by the mode of inhalation adopted by the patient before my arrival. This nurse vomited freely. The patient was not at all sick. I am aware that my experience in this respect differs from that of others. But I have been quite well pleased to find, that, in the sixty or seventy cases in which I have witnessed etherization, its best advantages have been enjoyed with so large an absence of the disagreeable accompaniments which others have noticed. How strikingly do these phenomena of the circulation in the patient during labor correspond to the discoveries revealed by the microscope, in the experiments which stand at the head of this section ! In the frog, the circulation was actually suspended. The capillary circulation did not exist. And how slowly did it return 1 and by what rapi- dity was it characterized as the animal came out of the influence of ether 1 And all without the slightest lesion of function, or of blood. The blood and the lymph globules retained their perfect vitality, and the rapid recovery of the PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 57 little animal showed how untouched were the nervous centres. It is with great pleasure that I insert here a letter from Dr. Perkins, which contains his observations of the effects of chloroform upon the capillaries of the web of the frog's foot. I was exceedingly desirous that these experiments should be made; for they are our best, if not only, means of ascertaining in what respects the action of chloroform upon the capillary system differs, if it differ at all, from that of sulphuric ether, and of thus learning its com- parative influence upon the human organism. At the time that Dr. Perkins made his experiments with chlo- roform, he had not witnessed its effects upon the human system. Have these experiments any bearing upon some of the results of chloroform etherization in surgical prac- tice \ and may they not furnish an explanation — I had said the explanation — of some of the results of its minor operations \ " Dr. Channing. " Newburyport, Feb. 14, 1848. " Dear Sir, — At your suggestion, I have watched the action of chlo- roform upon the circulation in the web of the frog's foot, and find it similar to that you saw as the effect of etherization. The only percepti- ble difference consists in its more rapid, energetic, and prolonged action upon the animal; a more marked and perfect annihilation, rather than suspension, of the capillary circulation (the smaller vessels appearing entirely empty) ; and in the more sudden and perfect restoration of mus- cular action as its influence passed away. — Yours respectfully, " H. C. Perkins." Before leaving this subject, which is of extreme interest, I make an extract from an article in the number of the " Boston Medical and Surgical Journal" for Feb. 16, 1848, entitled, " Philadelphia Medical Schools — Chloroform and Ether." It does not appear that these opinions are the results of any experiments of the effects of these agents upon the blood, and they certainly get no support from the experiments of Dr. Perkins. 8 5 s ETHERIZATION IN CHILDBIRTH. " Dr. Gardner, professor of chemistry in the Philadelphia Medical College, gave the chloroform to a number of gentlemen of his class. He subsequently informed the class, in a lecture on the ether and chloroform, that its inhalation was followed by the same series of unpleasant symptoms which have been enumerated; and, in his own person, the feelings of prostration were sensibly felt the second day after inhaling it. The doctor asserted, that from the chemical constitution of chloroform, when it comes in contact with the blood globules, the chlorine, which it con- tains, will exert a destructive or decomposing effect upon these bodies; and this, in his opinion, is the solution of the phenomenon of the persis- tent nervous and muscular weakness; as it is now a well-settled fact, that muscular power and nervous energy are in the direct ratio of the proportional number and integrity of the red globules, circulating in the blood. The ether, when absorbed and taken into the circulating blood, Dr. Gardner affirmed, absorbed oxygen from the blood, and became con- verted into carbonic acid and water; and thus acted chemically on the blood, in extracting its oxygen and substituting carbonic acid and water, while the undecomposed portion of the ether was carried throughout the brain and nervous system, and at first frequently produced an exciting effect, but soon followed by stupor if it was continued." In reply to this opinion of Prof. Gardner, the following remarks, communicated by a friend, are submitted:— " Sulphuric ether, taken into the circulation through the lungs, is not decomposed, as is shown by its presence in respiration for hours, or even days, after administration; but it continues to circulate unchanged like alcohol, until apparently the whole is given out again by the lungs with the carbonic acid of respiration. It is possible that the kidneys or other glands may separate a portion of it also from the blood, either changed or unchanged. I repeat, the examination of the secretions, under the use of ether or chloroform, might give interesting results. The persistence of sulphuric ether in the circulation is a fact which should be taken advantage of, where it is desired to produce a continued sedative, or rather specific, effect upon the nervous system. " Chloroform is evidently decomposed in the circulation, not, how- ever, probably by re-acting on the blood, as Dr. Gardner supposes, but by the vital action to which all the fluids circulating in the body are subjected. This can be tested by a very simple experiment: — Add a few drops of chloroform to an ounce of blood, and, after standing, ascertain if the smell of the chloroform has disappeared. Concentrated chloroform may dissolve the blood globules introduced into it, and so might sulphu- ric ether; but this would be no proof as to what takes place in the body, PHYSIOLOGICAL AGENCIES OF ETHERIZATION. 59 where a very minute portion of chloroform is present in the blood, and where the blood globules are protected by the vital influence. Dr. Perkins's experiment on the circulation in the frog's foot is conclusive on this point. As to chlorine, it is not a foreign ingredient, introduced into the system, but one of its general, probably essential, constituents; two of its combinations, chloride of sodium and muriatic acid, performing important functions in the system. Into what products the chloroform is decomposed must be ascertained by examining the various secretions and the blood. Its influence on the various organs, especially of secre- tion, is another branch of the general subject, deserving investigation. It apparently stimulates the perspiratory organs, and probably the kid- neys. May it not have some influence upon the liver or digestive organs ? " 60 ETHERIZATION IN CHILDBIRTH. ETHERIZATION, — ITS PRODUCTION, ITS CONDITIONS, ITS SIGNS, AND ITS RESULTS. This volume treats of etherization in midwifery. This has interests peculiar to itself. It is not, however, without relations with other departments of the profession. In these, etherization has been employed, and in surgery some time before its use in midwifery. For illustration, and to show what is the present position of our subject in its his- tory, — in the uses and results of etherization, — some references will be made in this chapter to such facts as may aid in the elucidation of its employment in midwifery, and indicate its earlier and later general history. Sulphuric ether, chloric ether, and chloroform, are em- ployed to abolish pain. Each has its advocates. With some, the longer tried, and so the better known, is preferred. By others, the newer, but the more convenient, is selected. The claims of pure sulphuric ether to confidence may be considered as having been settled, especially in regard to its use in midwifery, before chloric ether and chloroform were offered to the profession. It had been largely and fairly tried. Never perhaps has the new been more cor- dially received; and how rarely has been character so early established! It has been used in quantities varying from a few drams to a pound or more in the individual case; its use has been continued from a few minutes to many hours, and the result as to safety and success has been most remarkably uniform. A wise care has been observed in its use; and how well has this been rewarded! Untoward effects are recorded as having followed its use in surgical practice; but the thorough investigation of these under the highest and most authoritative sanctions of the law, in some of the earlier cases, showed how much cause there was, in ETHERIZATION-- ITS PRODUCTION,. ETC. 61 what had preceded and accompanied etherization, to explain the result. There has been no attempt made to conceal what has happened; and this has proved not only the wisest, but the most fortunate, course of procedure in regard to the progress of the remedy of pain. It has been grateful to see in this progress, that in midwifery practice, in which sulphuric-ether has been so much employed, not a case has occurred in which a disastrous result has followed its use, which could by any violence of reasoning or of prejudice be ascribed to it. Four cases of puerperal fever occurred in a Paris hospital after etherization. These were explained, and without the least reference of them to ether, by the fact that this very fever existed in the hospital before ether was introduced into it. Everybody knows how fatal is it, and how rapid is the communication of it, in such situation, by its own mysterious agency. Sulphuric ether was thus getting daily into wider use, when a new agent was tried. This was chloric ether. It was tried because in some cases the sulphuric produced dyspnoea and cough. Mr. Lawrence, the distinguished surgeon, made the substitution; and he says it answered perfectly well. It does not seem that it excited much, if any, attention. The cases are rare in which a proper use of sulphuric ether does produce the difficulties referred to. So far from it, it is used here, and has been for some time, in several cases of asthma and phthisis, in which the dis- ease has almost reached its termination, in which distress from dyspnoea is extreme, and in which it seems impossible to sustain life without almost constant etherization. Chlo- ric ether is the solution of the perchloride of formyle or chloroform in spirit and water; and, very soon after the trials with chloric ether by Mr. Lawrence, Professor Simp- son, who, it seems, was experimenting on other vapors with a view to their powers of abolishing pain, employed chloro- form for this purpose, and with satisfactory results. Its success in his hands was so complete, that it seems with 62 ETHERIZATION IN CHILDBIRTH. him to have entirely taken the place of sulphuric ether. By some this has been regretted. It has been felt that the latter was under fair trial; that new facts of great interest were daily coming to light concerning it; that the princi- ples which should govern its use were to be the results of these facts. Finally, it was thought, that after this man- ner, a method truly philosophical, its place in medicine would have been ascertained, and thus its use thoroughly established. The following extract from Mr. Holmes Coote's Report of Surgical Operations done upon patients rendered insen- sible to pain by the inhalation of chloroform, gives some account of the use of chloric ether in St. Bartholomew's Hospital, London: — " Without wishing in any way to detract from the very great merit of Professor Simpson, in introducing this valuable agent, I may observe that for some considerable time Mr. Lawrence has used, in private prac- tice, the chloric ether, which is chloroform in spirit and water. Patients with irritable lungs, who could not tolerate the violent paroxysms of coughing induced by the sulphuric ether, readily inhaled the chloric ether, the taste and smell of which are similar to those of chloroform: the anaesthetic effect was more gently induced, and there were fewer complaints, on recovery, of soreness of the chest, headache, &c. The less irritating effect of the chloric ether was noticed by Mr. Taylor and by myself, in some experiments (reported in this journal) performed upon animals. Their efforts to escape were most violent, when immersed in the vapor of sulphuric ether. " One of the students of the hospital, who in the early part of the year was anxious to have some painful stumps of teeth removed from the jaw, kindly consented to take the ethers upon two different occasions, and to report the result. He described the taste of the chloric ether as much more agreeable than that of the sulphuric; the effect upon the lungs as less irritating and oppressive: but he thought that the state of unconsciousness was not equally complete. Mr. Lawrence has, however, performed many most severe operations upon patients rendered perfectly insensible to pain by the inhalation of the chloric ether; and he is now in the habit of directing its administration." Chloric ether is in general use in the surgical depart- ment of our hospital. It is used very much after the same ETHERIZATION-- ITS PRODUCTION, ETC. 63 manner and quantity as is sulphuric ether. A hollow sponge is a very good and convenient instrument. The article employed for inhalation differs from that which is taken internally for medicinal purposes, in being more con- centrated. Let me ask in what does chloric ether, in pro- ducing etherization, differ from chloroform \ It is a mixture of chloroform with spirit. Does not a separation of these occur in inhalation, and by pulmonary action 1 — so that, after all, chloroform is the sole agent in the production of that state. The process is slower with chloric ether; for the chloroform is slower in reaching its destination, and may be thus more manageable in regard to the time in which its effects are manifested. But it is chloroform alone which produces them. The following note, kindly placed in my hands by one of the surgeons of the hospital, and addressed to him by one of the resident officers, gives some information of its comparative agencies. Chloric ether is used in midwifery, and answers very well. I do not think there is as much satisfaction expressed with it as with the other ethers; and this may be because it is less faithfully used. It is certainly slower in its effects, as far as I have observed its operation; but as this, with many, will be a recommendation, it may gradually get into use. " Dr. Townsend. " Boston, May 25, 1848. " Dear Sir, — So far as I am able to judge, I should think that chlo- ric ether differed from chloroform, principally in being less depressing in its effects; while the insensibility to pain is quite as complete. It is more depressing than sulphuric ether; but this disadvantage is perhaps compensated by its being, at the same time, much less irritating to the glottis ; so that, on the whole, patients take it more readily. It requires about the same quantity and the same length of time to produce insensi- bility, as in the case of sulphuric ether. Nausea and vomiting, &c. occur, as secondary effects, about as frequently with the one as with the other. Both the chloric and sulphuric ethers are always given, at the hospital, on a sponge, without any inhaling apparatus. " Yours respectfully, lt JXO. C. D.VLION, JUN." 64 ETHERIZATION IN CHILDBIRTH. Chloroform was substituted for sulphuric ether, because it was found, that in much smaller quantities it produced abolition of pain; from six to one hundred drops being sufficient for the purpose. Second, it acts sooner, more completely, and more persistently, than sulphuric ether. Third, is more grateful to the patient, and less annoying to others. Fourth, Is less expensive. These are its compara- tive advantages, according to Professor Simpson. Professor W. Parker, of New York, gives similar testimony, and adds that it saves the nervous system from the shock of the operation, removes danger, and promotes recovery. Professor V. Mott, having highly spoken of it, says, — " In several of the patients, there has been slight vomiting, before the full effect was induced; but in no case have I seen any unpleasant consequences attend or follow its administration." Dr. Bartlett, of New Bedford, Mass. hav- ing used both ether and chloroform in a great number of cases, in speaking of them together, says, in his letter, which is published in full in the Appendix, — "I have perceived no material difference between ether and chloro- form, except that the latter usually seems to act more promptly than the former, but more frequently produces nausea. My impression is, that the exhilarating effects of chloroform are less uniformly agreeable to the patient than those of ether." In a preceding paragraph, Dr. Bartlett says, — "I have used chloroform in a great number of instances, and never with any accident when it was given under my direction." I introduce here an extract from the London " Athenae- um," which contains some very important observations concerning ether and chloroform from distinguished men abroad:— " Royal Institution. — Jan. 28. — The Duke of Northumberland, President, in the chair; Professor Brande,' On the Composition of Ether and Chloroform, and their Physiological Effects.' Having given a suc- cinct outline of the chemical history of ether, from the first notice of this ETHERIZATION---ITS PRODUCTION, ETC. 65 substance in the dispensatories of the sixteenth century to the present time, Professor Brande noticed the more recent discovery of the nature and composition of chloroform by Dumas, Liebig, and other continental philosophers. The formation of these bodies was traced from their ulti- mate elements. It was shown how growing vegetables elaborate starch from the carbon, hydrogen, and oxygen, which they derive from the soil, how starch may be made to pass into sugar, — and how, in the pro- cess of fermentation, sugar is converted into alcohol, — how alcohol, as was experimentally demonstrated, is split up, as it were, into ether and water, when brought into contact with oil of vitriol at a particular tem- perature. The derivation of chloroform from the same substance (alcohol) by means of chlorine, with the aid of a basic oxide, was explained. The curious relation of this liquid to the acid derived from ants (from which its name originates), as well as the modern hypotheses in regard to orga- nic metalloids, were briefly stated; and many experiments were made to demonstrate the physical and chemical properties of ether and chloroform. The remaining portion of Professor Brande's discourse was devoted to an inquiry into the physiological effects of the vapors of these substances. These effects were classified as being comprised in five definite and pro- gressive stages: — 1. In the first stage, which is transient, the patient is exhilarated, but conscious of Avhat passes before him, able to direct the motions of his limbs, and sensitive to pain. 2. In the second stage, mental functions, as well as voluntary movements, are performed, but irregularly. The patient knows not where he is ; — is generally, but not always, ready to do what he is directed. This, according to Dr. Snow, who has investigated the whole subject with great accuracy, is the stage of dreams. 3. It is in the third stage that the mental functions and the voluntary movements become dormant, although external impressions may here produce involuntary action. Any pain inflicted in this stage might call forth a groan; but it would not be expressed by articulate words. 4. In the fourth stage, no movement, besides that occasioned by the action of the heart and lungs, takes place. This stage is charac- terized by the snoring of the patient, which indicates him to be in a condition of absolute insensibility. 5. In the fifth stage, which has been witnessed only in the inferior animals, the breathing becomes labored and irregular, involuntary and voluntary muscles are alike powerless, res- piration and circulation successively cease, and death ensues. Having alluded to the psychological question whether (as, for example, in the second stage) it was possible that pain should be felt, but not remem- bered afterwards, Professor Brande concluded by remarking that this new application of chloroform exhibited organic chemistry from a point of view from which philosophers delighted to regard it; — that a proof was here afforded of the utility of every discovery ; while the hope was 9 66 ETHERIZATION IN CHILDBIRTH. encouraged, that human researches in this branch of science might ere long be rewarded by obtaining something which, in its capability of benefiting mankind, might become in regard to chloroform what chloro- form was to ether. "At the French Academy, January 17, a letter was received from Dr. Plouviez, of Lille, with an account of an experiment on a dog with chloroform. A small dog, weighing about eight pounds, was made to inhale a gramme and a half of chloroform. At the expiration of ten to fifteen seconds, the animal was in a state of insensibility. The breath- ing was soon difficult, and in a short time the animal was dead. The time that elapsed between the exhibition of this dose (about the twentieth part of an ounce) and death was a minute and a half. On dissection, there was nothing to indicate the cause of death. Dr. Plouviez, in order to ascertain what course could be taken in the event of such an accident occurring to a human patient, made several experiments with various animals which were ceasing to breathe after the use of chloroform. He introduced air into the lungs in the same way as is done with persons who have been suffocated with the fumes of charcoal, by stimulating the act of respiration, and from time to time slightly compressing the chest. By adopting this means, all the animals speedily resumed their former state. In some cases, he even waited until the breathing had entirely ceased, and the animals were apparently dead. In various periods of time, from thirty seconds to four minutes, he was able to bring them to life. " At the Medico-Botanical Society, on Thursday evening last, a Mr. Huttman stated his reasons for believing, that the extraordinary proper- ties of chloroform — viz. the production of insensibility and the creation of dreams — were known in very remote times, but used most probably for magical purposes only. He first drew attention to the words formica and myrmex, the Latin and Greek names of the ant, the insect which yields the formic acid. These words, together with morphe, the Greek word for form, he stated to have a common origin, and to have reference to the property of creating dreams or immaterial forms. They also gave the name of Morpheus to the God of Dreams, and furnished the root of numerous words having reference to those things which produce sleep and dreams, as well as to the various phenomena connected therewith, and even to death itself, viz. Mors, which the ancients personified as the Bro- ther of Sleep.. Admitting these points, the speaker said they contained ample proof, that, in giving the names formica and myrmex to the ant, the ancients selected that distinguishing property which the insect possessed of inducing dreams or forms (morphai); and this would carry back the knowledge of this property to a very remote antiquity, probably to the time when the Magian College in Chaldea was in its zenith, and when chem- istry and astronomy flourished under the influence of religious zeal." ETHERIZATION --ITS PRODUCTION, ETC. 61 It will be observed, that in the French experiment the animal was placed in an atmosphere of chloroform, without admixture of common air. This is inferred from the state- ment ; for, if atmospheric air had been present, it is proba- ble that the state of apparent death would not have been induced, from which afterwards recovery took place by forcing atmospheric air into the lungs. From what is stated in the fifth stage, induced by chlo- roform, it is also probable, that in this the animal inhaled chloroform only; the experiment being to show the pheno- mena which are followed by death, where nothing is done to prevent its taking place. In the other four stages, I infer that chloroform was not inhaled alone, as in these it was inhaled by patients, and, of course, after a manner which would, as far as possible, not only produce insensi- bility, but also with the greatest safety. It is exceedingly important, that these facts in the evi- dence be distinctly borne in mind; and it is sincerely to be regretted, that original papers, and frequently abstracts of them, which only may meet the professional or the public eye, are often so wanting in details which are of the utmost importance in regard to practice. I copy, from a London print of Feb. 5, the following, which shows a result of an experiment in Mr. Brande's lecture, which is not referred to in the quotation: — " When Mr. Brande's lecture on chloroform was reported on Saturday last, it was not known that the guinea-pig which was placed under its influence has died. The little animal had, some days before, been sub- jected to chloroform vapor, and had not, apparently, suffered from its effects after its recovery from insensibility. The same quantity of chlo- roform was used during the lecture that had before been employed, and in all respects the guinea-pig was similarly treated; but, upon being exposed to the air, it only partially rallied, and then relapsed and died; thus showing how completely in its infancy is the use of this agent, how dangerous are its effects under certain circumstances, the nature of which was yet unknown, and how necessary were the cautions regard- ing its employment given by the learned lecturer. The result is to be 68 ETHERIZATION IN CHILDBIRTH. esteemed most instructive, as indicating the difficulty that exists of knowing to what extent the inhalation may be carried without endan- gering life." Everybody may not come to the same conclusion with regard to the safety of using chloroform in midwifery, in disease, or in surgery, which the London writer has reached. The guinea-pig, it seems, had been subjected to various experiments with chloroform before the fatal one. As in the case of experiments with other animals, it probably was placed in a situation in which common air did not reach it. It was worn out by previous trials, and died by the accu- mulated effects of a slow poison. Or, supposing it breathed no pure air along with the chloroform, death came in the usual way in which death by suffocation is ordinarily induced. Now, shall we reason from such experiments to such as are instituted when etherization is employed for remedial purposes in the human system ? Shall we place the experiment upon the brute animal, so often made to gratify physiological curiosity, and often with little regard to such consequences as life or death, — shall we place such an experiment along side with that or those, existing as they now do in such vast numbers, and say that, because the animal died, it is no longer safe to use the remedy for pain with other animals, — namely, with men and women, — when not a case of death has occurred among the latter whicli was not much more probably owing to causes in which etherization in itself had no direct agency, than to that state ? Shall we so question our experience in regard to etherization and its effects, — an experience so abundant, so various, so unequivocally successful, and resting upon indisputable evidence, — shall we so ques- tion such experience, as to leave the impression that we think it unworthy our confidence; and that, in this the " infancy " of our knowledge of the powers of the agent, we have no such assurance of its effects as will authorize us to use it at all? Safety in etherization can only come ETHERIZATION--ITS PRODUCTION, ETC. 69 of conditions; and the true question in such a discussion is this, What are these conditions ? These are found in the article used; the instrument, or inhaler; the mode of using it; the present state of the patient, and effects. The investigation would have been easier and more satisfactory, had professional attention not been turned from the observation and study of ether, by the introduction of chloroform and of chloric ether; and this before our knowledge of the whole agency of the first was fully established. The inquirer is now forced, whether he will or no, to make a comparison of the two or more ethers employed in the production of etherization; and this before the positive claims of either have been settled. As to the article used, there can be little question that it should be pure. At least, the successful use of chloric ether, which is a solution of chloroform in spirit, as em- ployed by Mr. Lawrence, in a few cases, is insufficient to show that an impure article is ever to be preferred to a pure one. In regard to sulphuric ether especially, there can be no question that the comfort of the patient in using it depends on its freedom from alcohol, and all other impurities; while the most perfect safety in its use can only proceed from the same condition of its purity. This need not be farther insisted on. It is abundantly proved by the whole history of the inhalation of ether. Of chloroform, the same is true. This should be per- fectly pure. Chloric ether is not chloroform; and it should have the same element of purity as a condition of its use, as has sulphuric ether or chloroform. As it seems to me, the alleged fatal results from using chloroform, which have been referred to, and which do not at all belong to the earlier period of its introduction, — these results, I say, should lead to a more careful consideration of this condition or element of purity in the article used. We may not be able to know why death has happened in these cases; but we could have known if the agent was pure. 70 ETHERIZATION IN CHILDBIRTH. Let me speak of the instruments used for inhalation, and of the mode of inducing etherization. These instruments are numerous. At first a hollow sponge or a handkerchief is enough. Both are obtained with ease, and both are safe. For ether, sponge answers per- fectly well by itself. It is used in the various instruments which have been made for inhalation. Chloroform requires for its easiest, or at least most comfortable exhibition, that the substance by means of which it is applied should not touch the lips or nose, as it irritates, and may inflame them. It will not be questioned, that the safest and best instrument is one which allows of the freest escape from it of the expired air. This should be effected by a valvular apparatus placed between the sponge or other material which contains the ether or chloroform, and the mouth and nose, if both are covered by the inhaler, and so does not require that this impure air should pass through the sponge, or again enter the lungs. Another and a very important condition in any instrument is an opening of sufficient diameter to admit pure atmospheric air freely to the sponge. This is specially important. A person is inhaling ether, or especially chloroform. The apparatus admits no atmospheric air, or in insufficient quantities, and retains the expired air and pulmonary exhalation. He comes soon to have little else to breathe than impure air. He makes no complaint. He seems and is perfectly easy, and suddenly dies. You examine him after death, and may discover nothing to explain the disaster. A case of this kind, it is said, has actually occurred in this country lately, and has large place in the public press. Other cases of like termination are reported; and it is highly probable that many of them may be referred to the extreme ignor- ance or more culpable carelessness of those who have exhibited the vapors referred to. A diagram of a verv simple instrument, which has the conditions of safety ap- parently well answered, is at the end of the chapter. ETHERIZATION -- ITS PRODUCTION, ETC. 71 Various instruments were referred to. A very simple one is a ball of cotton wetted slightly with chloroform, and wrapped up in a narrow strip of cotton batting. This covers the mouth alone. This is perfectly safe, if the con- ditions for using such an instrument be observed. It must not be too thick or solid, to prevent the admission of pure air. The respired air must also be allowed the freest exit. With this cotton inhaler, I see no other mode of effect- ing this than through the cotton itself, upon which is dropped the ether or chloroform. A correspondent says, he has always used an old-fashioned steel tobacco-box, gilded on the inside to prevent rusting. A bit of sponge is put into the box, and upon it the ether or chloroform is poured. When taken from the patient, the box is closed; and evaporation, together with waste and the escape of the ether-vapor into the room, is prevented. The writer reports twenty-seven cases in which this apparatus was used, and in which there was no untoward result. It will be perceived, that an instrument so shaped will hardly exclude pure air from the lungs, on the free expiration of the foul. Other instruments are made of glass, and of many shapes. We have them of tin, of silver, and of other materials. From a roll of paper, or a bit of rag, up to silver gilt, we have instruments in every variety in shape, material, and price; and he must be difficult to suit, indeed, who, after all, finds it necessary to tax his own ingenuity to find out something which may throw into the shade all that has preceded it. From the report of the few fatal cases whicli have occurred during etherization, may not most of them be ascribed to the presence of irrespirable air, retained by the instru- ment used ? and in those which have been fatal some hours after, except where obvious organic disease of heart, lungs, or brain, has satisfactorily explained the death, may not this have been the result of the same agent, only occurring more slowly ? The pulmonary, cerebral, or cardiac engorgements, 7'2 ETHERIZATION IN CHILDBIRTH. which have been noticed, do not diminish at all the correct- ness or importance of this explanation, since such engorge- ments are observed where death has been known to have been produced immediately by irrespirable gases. If the opinion here given be correct, how easy will it be to prevent all future trouble from etherization? Let the instrument used be as perfect as it can be made, and let him who uses it know what are safe and what are unsafe symptoms of etherization. I am satisfied that safety mainly depends on the provision for admitting with the vapor so much atmospheric air as will make a respirable mixture. The quantities are easily regulated. The main point is not to exclude pure air. Sponge of an average quality of fineness will not do this. There collects in sponge in which ether or chloroform has been used (and perhaps most after the former), a substance which becomes fixed, more or less, in the sponge, and which may be perceived some time after its use. This residuum may clog the sponge, and render the ether-vapor less pure. It may be washed out with alcohol, and the sponge freed from this last, afterwards, by water. It should always be washed after use. I am thus particular in this matter, because my subject demands even fastidious minuteness of detail concerning every point which relates to the use of what I am sure may do only good; but which, as in the case of every other powerful means of benefit, from ignorance or carelessness, may and will do harm; and, in this way, one of the most important discoveries may fail of accomplishing its mission to the world. In the use of the inhaler, it should be remembered that the effect of ethers upon the lungs varies in different indi- viduals. In some, dyspnoea and cough at once follow, and seem to contra-indicate their farther use. Other trouble- some effects may be manifested. Thus there may be very disagreeable sensations in the head, distress more or less severe, noises, flashes of light, tingling of the limbs and ETHERIZATION --ITS PRODUCTION, ETC. 73 trunk, sometimes confined to one side, at others more general, nausea, vomiting, Sec. &c. To avoid many of these, it is necessary to observe some rules in beginning inhalation. Let it be moderate at first. Approach the instrument slowly to the mouth and nose, if designed to cover both, which I believe to be the best mode of inhalation; and, if choking or other uneasy sensation or effect occur, remove the inhaler somewhat, and at length bring it where it is designed to be placed. If the lungs be previously emptied by a full expiration, the sooner is etherization established. Let the breathing now be full and slow, and observe its effects. Ask the person to raise the eyelids, to speak, or to move a limb. Raise a limb; and, if it fall suddenly and powerless, the desired effect is pro- duced. Now remove the inhaler at once, and afterwards the person may indicate its application, apply it herself (I speak of its use in midwifery practice only), or we may re-apply it as circumstances indicate. It will be found almost without exception, that the continuance of etheriza- tion will be effected with a moderate use of its agents, after it has been once established. This remark is of much practical value in midwifery practice, since many hours may elapse before a labor is terminated from the first inha- lations. In some, and in a majority, the state is induced easily, and continued with a very small amount of ether; while in others there is a strong antagonism in the system to its establishment and preservation. In giving the experiment on the web of the frog's foot, which was made to show the fullest effects of etherization, its physiological agencies in their completest manifestation, its effects on the capillary circulation were distinctly pointed out. It was also showed, that they did not in the least interfere with its health or its life. Now, in the medicinal employment of the ethers, it is never necessary to produce their physiological effects in such extent of them. The diminution, and even the abolition, of sensibility, when 10 74 ETHERIZATION IN CHILDBIRTH. thought necessary, takes place far short of them. We know this by the pulse, the respiration, the temperature, the complexion ; all which functions remain undisturbed in this the medicinal, the pathological use of the remedy of pain. The cases, in which these facts are everywhere stated, and place all this beyond doubt, are particularly referred to for their important practical teachings. A remark in this connection may be repeated here, and which is of great practical value. It is not necessary in midwifery practice to induce so full and perfect a state of etherization, namely, of unconsciousness and of insensibility, as is supposed to be demanded in surgical operations. I speak of the use of ether or chloroform in natural labor. In operative midwifery, it often becomes necessary to pro- duce and sustain fuller etherization. The object in ordi- nary midwifery practice, or in the severer forms of labor pains, in the use of etherization, is to diminish suffering. There is much of this pain which is tolerated readily; and from this the patient does not demand relief from extraordinary agents. So true is this in practice, that cases daily occur in which etherization is induced, and in which the patient determines exactly its extent. In the intervals of uterine contractions, the instrument is removed by the patient, or by her direction given in some way, and which is at once understood. She knows when the pain is com- ing, and demands the inhaler. She graduates, so to speak, the supply exactly by the demand; and in this way is pre- sented to the observation of the practitioner one of the most important and interesting agencies in operation for reliev- ing suffering, sometimes agony, which he ever notices. He has seen nothing like, or approaching to the like of it be- fore. His function is to see the patient the practitioner, while he is only to observe effects. I would appeal to the whole profession, and ask if he who has most employed inhalation in midwifery practice has ever seen any thing in the mode of using it, just now stated, which has at all ETHERIZATION --ITS PRODUCTION, ETC. 75 disturbed him, by making the safety of his patient a ques- tion. In my limited observation, I have met with no such case. If I have observed any thing, or any result of ethe- rization, which for the moment has given me the least anxiety, it has been in those cases in which unconscious- ness and insensibility have been so complete, that it has been necessary for me to direct the repetition of inhalation, when they were evidently returning. This has been judged necessary in some of those cases of great severity, which have demanded extraordinary assistance, and in which the most perfect repose or quiet of the patient has been demanded. Of Pregnancy in its relations to Etherization. — In preg- nancy, new and important agencies are at work. A new function, suddenly induced, and rapidly developing itself both in its local and general agencies, has been established. An extraordinary vitality prevails everywhere. The blood gets new characters, and those, too, of an intenser life. Res- piration is more rapid and fuller. The temperature is increased. Excretions undergo very remarkable changes. A new being is growing, getting nourishment, and every hour developing a higher vitality, in this mysterious condition. Now, do we not see enough in these facts of pregnancy, and which are lightly considered because so common, — do we not see in them something which may account for the entire safety and most happy consequences which accompany and which follow etherization? It matters not how this state is induced, whether by ether or chloro- form, the same is the happy result. I think it is Professor Simpson who says, that it is highly probable that etheriza- tion may come, in process of time, to be confined to the practice of midwifery. Whether the remark be properly credited or not, I cannot but say, that, from the extraor- dinary fact, the safety of inhalation in midwifery, there seems to be one ground at least for the opinion. This may have been, and if so may continue to be in part, a result 76 ETHERIZATION IN CHILDBIRTH. of the condition previous to labor, above described, and of the comparatively imperfect etherization which childbirth requires. Next, Of Labor. — This is a function of a living organ. It is the latest in a series of functions, and intimately related to them all, which began in conception, and has its end in childbirth. This is neither an accidental nor a mechanical function. It has its beginning in a law of nature, as well established as is any other law of living organs. This law is development, — a develop- ment of the uterine contents of pregnancy, — and espe- cially of the uterine adaptation for their growth and accommodation. The body and fundus of the womb first grow for this foetal accommodation and development. Be- tween the sixth and seventh month, the cervix begins to contribute its share to the same objects. At the comple- tion of the ninth, the neck with the os uteri have contrib- uted their whole share; and a point is now reached, in which this process can only proceed by the opening of the os uteri. Now, this opening is wholly functional. It has no dependence at all on mechanical forces, — the contrac- tions of the womb, for instance; and, besides, these are wholly functional. The os uteri opens itself before the least contraction manifests itself. It is upon its dilatation alone that natural labor depends. When it is complete before the womb begins to act to expel its contents, the labor is terminated suddenly, or wholly unexpectedly, and without pain. These are the cases of painless labor already referred to. Of these I have in memory notable instances. In one, upon my arrival at the address, the patient said, — " It is very rare for a physician to be present when I am ill; for I know too little about it to send in time, and the child is born without one." She was sitting in her chair, and I felt her pulse. Said she, " I have one of my pains now." There was not the least intimation of this in any motion of the hand. Not a muscle of the arm moved, and ETHERIZATION -- ITS PRODUCTION, ETC. 77 the pulse beat as if nothing unusual were going on. I said I would visit a patient near by, and return to be ready to attend her. I went, and found her on the bed when I returned. She said the waters had come away, and she had gone to bed in consequence. I proposed to get what might be wanted after the child was born, a ligature, &c. when she said, in the most natural manner possible, that she thought I had better hurry; for she believed her child was born. And this was true. It was already born, and lustily crying. Here was a case of painless labor. Perfect dilatation had taken place in the uterus, and an almost unperceived contraction had expelled its contents. A continuous effort was made, and labor gently completed. The afterbirth came in the same way. In truth, the deliv- ery of the child was precisely the same with the most silent delivery of the secundines. I might give other instances; but this is a fair specimen of the class. It is, then, to a law, an established law of the economy, we are to ascribe the occurrence of natural labor, namely, labor at the full time. This law is development, which brings in its progress, or at its close, a most important change in the relations of the various portions of the gravid womb. This change is the separation of the edges of the mouth of the organ, by which it becomes open. A follower of Mr. John Hunter — and who that deserves a place in our profession is not in every important point his follower ? — a disciple of Mr. Hunter might find in this state of the os uteri the " stimulus of imperfection," such as is a wound; and as this last produces those processes of inflammation by which the lesion may be repaired, so may the open state of the os uteri below produce contraction of the organ above, and so its contents be expelled. Without, however, insisting on this point, it cannot be denied that the most intimate connection subsists between the alleged cause and its effect. Who does not know that artificial dilatation of the os uteri is the surest means of exciting uterine con- 7S ETHERIZATION IN CHILDBIRTH. tractions, at whatever period of pregnancy ? What prac- titioner is ignorant of the immediate effect in increasing pain, of the dilatation of the os uteri, whether this be effected by blood-letting, medicines, or mechanically, in protracted labor, with imperfect functional development? Ever) thing teaches this doctrine of function in the subject-matter of our inquiry. A professional inaccuracy in language sometimes misleads the inquirer, the student. I refer to the use of the word " rigidity," in its application to that state of the os uteri in which functional dilatability has not taken place. In these cases, there is no rigidity at all. True labor has not yet occurred. The womb is acting violently, but irregularly, morbidly, out of place. Its mouth remains just where and as it was before contractions hap- pened ; and so will it remain, unless you quiet these spas- modic morbid contractions, or until dilatation occurs of itself, which sometimes happens, before the woman is ex- hausted : oftener, however, these become cases of most difficult management and dangerous termination. Seriously do I hope, that this word " rigidity " will be dropped by the teacher of midwifery. It is false pathology, involves much suffering, and may lead to very grave results. Now, what has etherization to do with these physiologi- cal views of pregnancy and labor ? It has this to do with them, and showTs how wide is the domain in midwifery to which it extends. It meets the whole case of difficulty and of suffering which belongs to it. It suspends those morbid, irregular, convulsive movements of the womb which consti- tute false labor, as by a charm, and hence is a most avail- able remedy in accidental abortion. Especially does it the same thing in these cases of uterine contraction, which, from any cause, precede the dilatation, or state of functional dilatation of the mouth of the womb, and brings perfect rest. It does more: it suspends voluntary power, which, in its violent exercise, only increases the disturbance and suffering which accompany irregular and morbid uterine ETHERIZATION--ITS PRODUCTION, ETC. 79 muscular action. In the entire rest thus induced and sustained, labor is delayed till the time of its natural occurrence arrive, or till the os uteri has taken on and accomplished its preparatory office. But, suppose true labor be present, disturbance in the order of its events may occur. The bony pelvis may not readily allow passage to the head, or this may not be of standard dimensions, these being exceeded; or its position and presentation may be unfavorable. Here we have a case in which there may be great suffering; and, to get relief, the will calls into action all muscular agencies which can be commanded. Consequently, strength is wasted; progress is impeded; organs become irritable and tender; secretions are diminished or are morbid; swelling occurs, &c. &c.; complications both very troublesome and absolutely alarm- ing. Here, etherization, as in the last case, comes in with most happy influences. Contractions are controlled. They may even be suspended, for such will pretty surely be the case if the labor be wholly spurious ; or, even when this is not the case, but where increased resistance is operating to prevent timely and healthful delivery, the same useful effect may be produced. If, however, violence be con- trolled, and dilatability and increased secretions take place, how much better is the prospect of a good delivery! Now, take into the account the abolition of pain, which is, among the most common, the safest and most welcome of the effects of etherization, — what more can be required of any medicinal agent than is offered to the profession by the remedy of pain ? Thus it is that both pregnancy and labor, alike and equally, present conditions, which, it may be, beyond all other possible states or kinds of human suffering, claim the profoundest attention and gratitude of the profession. In conclusion of this subject here, let me ask — what was in my mind to say when I began this inquiry concerning the comparative relations of etherization to labor — let me 80 ETHERIZATION IN CHILDBIRTH. ask if etherization does not produce cases of painless labor, exactly resembling that above described, as an instance in most important points, and differing only in this, that un- consciousness of true relations with persons and things around, sometimes, not always, exists during this state, while there is an entire unconsciousness of the moment and circumstances attendant on the birth of the child ? I have alluded to the state of entire health, and of the augmented vitality of pregnancy, as a reason for the uni- form salutary uses of etherization, and in so diversified observation of them, in midwifery practice. I have done this because of the striking contrast which this condition exhibits, when compared with that of patients who have been deprived of sensibility while undergoing surgical ope- rations. Such persons are not only suffering from some local affection, which must be removed by violence, in order to save life: they often are suffering from some internal disease, of which the external is only a sign. A notable case in illustration occurred recently in New York. A man at the Crosby-street Hospital was operated on for fistula in ano. Two fistulse were cut, and on different days. The operations were done during etherization. He never came out of this state after the last, but soon died. It was dis- covered that his lungs were greatly diseased. His disease, in short, was phthisis; having, at its close, a frequent com- plication and consequence, namely, fistula. We see in such a case, hi which life is with great difficulty sustained on any terms, how the sudden and continued, although it may be only a transient, derangement in the respiratory func- tion and agencies, and such as etherization produces, may be fatal. But surgical operations have been, and continue to be, fatal occasionally, after etherization, in cases in which no grave organic lesion is discovered after death, or any lesion whatever. The explanation: — It is judged, in such operations, that perfect etherization should be induced before the operation is begun, and continued ETHERIZATION--ITS PRODUCTION, ETC. 81 without the least return of sensibility till the operation is over. Again, a surgical operation is not a function, a natural function, which may be performed with suffering; and which suffering merely accompanies the effort to over- come a mechanical resistance to the easy performance of that function. Such an operation is a violence done to sensitive textures, the most sensitive which enter into the composition of the body. There is no interval during which there is perfect rest from suffering, as in labor; and hence there may be no respite from inhalation. Much of the domain of surgery is disease; and how certain, and often how deep, is the extent of the influence of such disease over the whole system, and how often it is con- stitutional in its origin, is familiar to every professional man. It is not, then, at all to be wondered at, if we have not given the whole explanation,—it is not surprising, that occasionally, though very rarely does it happen, that a surgi- cal operation, done during etherization, should be unto- ward in its result. I say, very rarely. There has been but a single fatal case in the Massachusetts General Hos- pital, after surgical operations, following etherization; and, in that case, there was nothing which could for a moment connect the death with etherization. It was in that hospi- tal that the use of ether in surgery had its earliest trial, and its fullest success. In probably no institution in America or elsewhere, has a greater number of surgical operations been done during etherization. Another suggestion occurs in regard to the fatal cases which have happened, whether at home or abroad. It is, that, in the cases referred to, some constitutional peculi- arity, some individual predisposition, may have existed, which led to the fatal result. It has been suggested, that the condition under which surgical operations are occa- sionally done may influence the result, when etherization has been established; and so they may sometimes ter- minate unfortunately, when compared to midwifery cases. 11 82 ETHERIZATION IN CHILDBIRTH. There can. be no sort of doubt, that the condition whicli is produced by sudden violence — the crushing of a limb by a rail car, by external injuries from powder ex- plosions, &c. — is most unfavorable to the successful per- formance of a grave surgical operation, whether during etherization or not. It is not ether or chloroform which kills here. It is the shock to the nervous system which first perilled life; and the operation, which gave the only chance of recovery, would probably have been followed by death, let the circumstances under which it was done have been what they may. But, besides the condition referred to, there is frequently a state of mind, — an emotional state, so to speak, — which may in some cases explain the phe- nomena under notice. There is fear in this matter, — the greater, on account of the apprehended violence of the operation to which the persons to be operated on hardly supposed themselves liable under any circumstances. The heart beats tumultuously. The respiration is hurried, and otherwise embarrassed. The temperature is lessened. Exactly such a condition may thus exist, which is unfavor- able, in the individual case, to the best effects of etheriza- tion. There is here, then, a shock to the nervous system, produced by mental violence, so to speak, which may have the issue referred to. I remember a case of this kind which impressed me very deeply. It was a woman who, during labor, had breathed ether with excellent effects. She went to a dentist, some months after, to have a tooth drawn. Etherization was readily produced, and the tooth taken out; but immediately a state followed which was exceed- ingly alarming. The pulse sunk. The skin became cold and deadly pale. She could not be roused. A state of complete catalepsy came on; and, for nearly four hours, she was apparently in much danger. She came out of this condition gradually, and with great distress. This was an extreme case of the morbid, nervous influence under consideration. In less degree it is not unfre- ETHERIZATION -- ITS PRODUCTION, ETC. 83 quently noticed; sometimes only by the person who is its subject. But, let the explanation be what it may, it is of the utmost consequence that the truth be stated alike in regard to the fortunate and untoward results of trials with ether and chloroform. This has been the experience, from the very first cases, both in France and in England; and it has been the same here. It is due to the public confidence, which has been so freely extended to these beneficent agents, that any ill success should always be recorded. The object should not be to make a case for or against ether or chloroform. The sole and important object of every trial which may be made with them should be, first, to prevent suffering; and, second, to learn thor- oughly what are the precise results in every case in which these trials have been made, as it regards both safety and life to the parties concerned. The success of etherization in midwifery has, I believe, been perfect. I do not remember a case in which it has been induced either by ether or chloroform, in which there has been the least reason to question its entirely useful agency, both in regard to mother and child. The cases which follow, whether of personal observation, or which have been communicated to me by others, fully sustain this assertion; and from Europe the news daily comes of its successful use. In again alluding to the conditions which may influence the results of etherization in midwifery, I would remark, that cases occur (one of which is hereafter stated, and which is more particularly referred to because it was very striking) in which the first impression or effects of etherization are very unpromising; such, in short, as do not seem to autho- rize its farther employment. It is sometimes so exceedingly disagreeable in all its effects, that the patient will no longer employ it. In other cases, it is very urgently de- manded, and any risk which seemed to be incurred in its first S4 ETHERIZATION IN CHILDBIRTH. use is not allowed by the patient to be of the least weight in the pressure of severe suffering. I have permitted inha- lation in such cases, and with the happiest results. At times it has happened, from removing the inhaler before the desired effect has been produced or established, that etheri- zation has suddenly disappeared; and this is often followed by expressions of much disappointment, and sometimes emphatic complaint. Said a patient to me one day, who was very abruptly roused by the sudden removal of the instrument, while under the happiest influences of inha- lation, — " Why did you take that instrument away ? I had just entered a rail car; the bell was ringing; it was just moving, and I should have had a beautiful ride; and you have ruined it all." This person remembered this fact, which made it still more remarkable; and said, after her child was born, which occurred during perfect insensi- bility, that she did not enter the car again. Etherization is continued much more easily than it is produced. This imposes a caution, in its use in midwifery. In grave surgical operations, in which, as we have seen, every stroke of the knife is the infliction of a new, and, it may be, very severe violence, inhalation is necessarily con- tinued after a manner not demanded in midwifery. This matter is recurred to, as quite worthy notice in watching the effects as they are successively developed during inha- lation; and for the purpose especially of preventing all excessive, and so unnecessary, etherization. The state cer- tainly admits of or presents different degrees of perfectness; and that degree should be the aim of the physician which more or less completely removes sensibility, renders pain tolerable, and ensures the greatest safety. With regard to the ease of inducing and continuing etherization, the evidence is very complete, that it is greatest, and so most striking, in those who have the fullest faith in its power to prevent pain. This is a highly favor- able condition. I have been, perhaps, more frequently ETHERIZATION--ITS PRODUCTION, ETC. 85 struck with this fact in the history of our subject than with any other. Thus, in those cases in which it has been settled beforehand to employ ether or chloroform; among those persons especially who have beforehand tried upon themselves what inhalation will do, and who have also provided themselves with the article to be used, — I have almost always found in these individuals the happiest effects from etherization. The preparation is sometimes made with much forethought. Thus I have found ether and chloroform side by side on the table, "which to choose," — or one only, had either been already tried. It would seem from these facts, that the state of the mind in regard to the matter has some positive relation to the effects of inhalation, and should be regarded in its use. It cer- tainly may be so far considered as to prevent an early or too rapid use of ether or chloroform; and so, by delaying it till the emergency for its employment is clear, its best agency may be secured. In the midst of severe suffering, the demand is pretty sure to come; and where it does not, pain does not so exist as to make demand for the remedy, and its use should certainly not be pressed. I have, how- ever, introduced this subject here, rather with a view to show how far the state of the mind may affect the induc- tion and the results of etherization, than for suggesting a rule of practice. Of Disease in its relations to Etherization. — I have spo- ken of childbirth, and of surgical diseases, and of accidents, as furnishing conditions which may possibly influence the results of etherization. How is it with disease? It has often happened here, as in other questions which can be alone settled by experiment, that the result of such experi- ment has not always confirmed the preconceived opinion. Thus we were early told, that diseases of the head or brain, of the heart, of the lungs, were in themselves contra-indi- cations for etherization. But how has it turned out here ? What has trial showed ? Both ether and chloroform have 86 ETHERIZATION IN CHILDBIRTH. been used in these very diseases as remedies, and I know of no sinister result. Thus in phthisis, and in its latest stages, ether has been tried; and so grateful has been its effects, that it has come to be demanded as the only and the sure means of relief. The quantity has been very large which, in some cases of this disease, has been em- ployed, reaching to nearly or quite a quart in twenty-four hours. Asthma has been also greatly benefited by it; and it has happened in very grave cases of this most distressing disease, that etherization has been demanded, almost con- stantly, by asthmatic patients, as the only condition on which life has been tolerable. In spasmodic cough, the same thing has happened; and so has it in those coughs from irritation, in which the trouble has been in the larynx or trachea, and which has rendered the state of the sufferer most uncomfortable. In affections of the heart, or in those in which this organ has manifested much, and habitual or chronic disturbance, etherization has been safely used. I remember a case of childbirth, in which trouble of the heart had existed for some time, but of which I knew nothing; my attendance in labor being my first acquaintance with the patient. I gave ether under the strongest demand of the patient for its use, and for many hours, and in larger quantities than in any other case, but in which the only sensation was that of relief. The trouble of the heart declared itself, and this not in a severe way, two or three days after delivery. In affections of the brain, or of the head so called, I have met with cases in which etherization has been freely used and without harm, and with its usual grateful effects. It has been a strictly remedial agent in cases of chronic, paroxysmal headach, and in very severe ones too; and in childbirth I have used it where the same thing has existed. In spasmodic affections, and hi those too in which the lesion has appeared to be in the nervous centres, I have used etherization with benefit. Very recently, in a case of ETHERIZATION --ITS PRODUCTION, ETC. 87 chorea of eight years' standing, and which ended fatally, — a termination which I have not met with in any other case of this disease, — ether was inhaled with very great relief. Some months before, I used ether in the same case. It was then inhaled from a sponge. In that mode of admin- istration, it gave great distress. It was at once rejected, and its further use abandoned. But now it was exceedingly grateful. It was applied on a handkerchief; this not being much wetted, and not held so near to the nose as to pre- vent large dilution of the vapor with common air. I have before observed the advantages of this use of ether. The symptoms for which it was now used did not exist when it was before inhaled. These wTere most distressing and tonic contractions of the muscles of the neck and back, and of those of the pharynx and larynx; making both breathing and swallowing exceedingly difficult, the latter at times impossible. The relief was showed in entire rest of the body, which at other times was in constant and most exhausting motion. The hand could be moved by the will, and extended that the pulse might be felt. Local spasms, as of the throat and neck, were also diminished and removed; and a most wretched condition in this aged woman, she being between sixty and seventy, was changed to one comparatively comfortable. I have used it in cholera, which, in its spasmodic symptoms and in its ex- haustion, approached very nearly to the Asiatic form of the disease, as I saw it in 1832. The spasms existing in the extremities and trunk were universal. The vomiting, which had continued about eleven hours when I first saw the woman, was constant, and accompanied by extreme distress. She was etherized. The spasms almost imme- diately ceased, and at most there were but two vomitings afterwards. I am acquainted with a case of cramp, chronic cramp, in a friend between eighty and ninety years of age, who has long suffered from gout; which last disease has pro- ss ETHERIZATION IN CHILDBIRTH. duced its most embarrassing and painful effects in the hands and feet. My friend early tried etherization, and for some time with great benefit. Time and use have diminished its power. He uses always the same quantity, four ounces; and, to be exact, a phial containing this quantity is every day placed on his night-stand. This, with a large, hollow sponge, completes his arrangements for ethe- rization. After he gets into bed, he empties the phial upon the sponge, lies down, and inhales till he is etherized. I have not heard from him, or from his family, that he has experienced the least inconvenience from this practice. Acute disease, in which pain has been a symptom, has been treated in the same way, and with much advantage. And so has disease in which watchfulness has been a symptom: delirium tremens furnishes an example; and we see the same in other diseases with sleeplessness. In the cases alluded to in this paragraph, etherization has relieved pain or procured sleep, without any of the un- friendly results which so often attend opium, in all its forms, when used in like circumstances. The whole effect is tem- porary. When it has passed, nothing remains to mark that it has been. The functions* of important organs are not disturbed. Nervous energy has been preserved, the strength not wasted; and, if cure do not follow, it certainly is not retarded. I am here asked, if, by reference to such facts as these, I mean to recommend etherization as a means of removing the diseases in which it has been found useful; or to be more precise with the question, or to give it as it comes, — " Do you mean to use it in all cases or in all diseases in which trial has showed it to be useful and safe, and in others in which it has not yet been tried ? " It has not been with any such purpose that I have stated results of tried ex- periments ; I have stated them as facts in a most important history, — facts which are not the less interesting because of their recent observation, or because their number is no ETHERIZATION --ITS PRODUCTION, ETC. 89 greater. They stand just as do all facts which have their birth and being in a recent discovery. They are some of them solitary, but even here not absolutely alone, for they are nigh neighbors to kindred facts. Some of them are in sufficient numbers to establish principles, and thus to give to the domain of a noble philosophy a most interesting and valuable addition. It is not, then, to recommend etheriza- tion in all cases of disease, or in such as resemble those referred to, that the reference has been made. It is rather to state what has been done, and leave it to others to deter- mine for themselves whether they will give to their patients the opportunity for obtaining a like good. Is not the use of a remedy in extreme cases, and which has resulted in good wholly, a reason for trying it before the extreme con- tingency arrives? Is not medical reasoning sufficiently established to show, that, where the evil is less, as in the be- ginning of a disease, a remedy may be useful in much smaller quantity than in a later period of it; and when, the disease being graver, it may be of perfectly safe experiment ? To be sure, we may delay etherization in labor to its later or latest periods. But we do so, because labor is not a disease; and, as such, may be growing more difficult of relief, because of its longer continuance. We postpone etheriza- tion here; because, in the first place, pain is often very tolerable in the beginning of the process, and there is no accumulative difficulty to be apprehended, from the time the suffering may have existed, in procuring a remote relief. To recur to and to conclude the discussion of a subject of great practical importance. Is etherization to be induced in all cases of labor? Professor Simpson, who introduced ether into midwifery practice, says* " Since the latter part of January, I have employed etherization, with few and * " Remarks on the Superinduction of Anaesthesia in Natural and Morbid Partu- rition. By J. Y. Simpson, M.D. F.R.S.E. Prof. Med. Univ. Edin. &c. Read, &c. Dec. 1847." 12 90 ETHERIZATION IN CHILDBIRTH. rare exceptions, in every case of labor whicli has been under my care; and the results, as I have already elsewhere stated, have been, indeed, most happy and gratifying." A like answer to this of Professor Simpson can hardly be looked for from anybody else abroad; for he tells us that in London, in Dublin, and elsewhere, etherization in labor has been rarely induced, and that many physicians in very large practice do not employ it at all. He has been charged with an excessive, if not unsafe employment of it, and even with making out his case by suppressing unsuc- cessful results. It is not difficult to explain the frequent and free use of ether and chloroform in labor by Prof. Simpson. He first used them both, and both with entire success, in all his cases; and hence had an argument from experience for continuing this use, which very few, if any other, prac- titioners had. These latter persons, with their imaginary facts and a priori reasonings, denounced etherization as unnatural, unscriptural, and unsafe. And with them there the matter rested. Professor Simpson was daily, if not hourly, observing its salutary and safe uses; and from an experience to which success, enthusiasm, and gratitude, gave the warmest coloring, has he gone to patient after patient, and come before the public with essay upon essay, to prove the truth of his earliest statements; and to extend the blessings of etherization in childbirth, by newer, more numerous, and as successful results. One is not surprised, then, at the answer to our question which comes from him. From his own account of the matter, there would hardly seem to have been cases enough in his own practice, in which he has not employed it, to form exceptions to the rule of using it always. In this city, in which etherization was first tried in labor, in America, there has been, as we have seen, no excessive zeal in its use in midwifery. Some physicians have not tried it at all; others have employed it only when the patients have demanded it; others, in difficult cases only; and some ETHERIZATION -- ITS PRODUCTION, ETC. 91 would seem to have been so little inclined to try it as to dissuade from its use altogether, or so imperfectly to have used it as to have formed no positive opinion concerning its agency. Many, however, have used it in many instances, too, with increasing confidence in its powers, and with the happiest results. I think the evidence which has been obtained here on the subject, and which is presented in this volume, derives much interest and importance from these facts in its history. There has been no such extravagant zeal or unwisely placed confidence, as so often comes from the partisan spirit with which sometimes even scientific investigations are conducted, and which so often direct attention from the thing to the person, and with injury to both.' Are not the number and characters of those from whom the evidence comes, further cause for the public con- fidence ? and, if the question be still an open one, how generally shall etherization be employed in midwifery? and what are the safe and proper limits of its use ? — the time which has been occupied in the observation of the facts, has not certainly been lost time; and the result can only be regarded as happy both for the public and for the remedy. But I am unwilling to leave the question just where these remarks may place it. A great many facts have been collected, and from many sources. These do settle some points. In my continued and increasing use of etherization in childbirth, I have been governed by the consideration of its present effects on the labor itself, — by its immediate results to the mother and to the child, and to the circum- stances which attend the " getting up," or the puerperal condition of patients. From the very first case down to the latest, I have seen nothing in any of them to diminish my confidence, or to lead me to a conclusion that it is not proper in any case of labor, or that it has been injurious or unsafe in any one. The evidence from all others who have been consulted by me is to the same general purport. The 92 ETHERIZATION IN CHILDBIRTH. exceptions which have been reported to me do not disturb the rule. They are not designed to do this. They proceed from differences, not conflicts, of opinion, and are not stated to influence the practice of others. One only says, that he thinks that an equal number of cases of childbirth with- out ether have done better than have those which have been treated by it. But he offers no evidence, that the ether has done harm in any one. I may be asked here why I do not refer to the fact, that some physicians have reported for this volume single or very few cases only, in wiiich ether has been employed; and that from some I have received no reply to my circular. I answer, that, in regard to the first, not a word is said that would lead for a moment to the idea, that farther trials have not been made because the least untoward circum- stance attended or followed the first. I think these single or few cases are of great value in answering our question. If danger in the first trial had been the reason why farther experiments have not been made, this most important fact would have been stated. The reason would surely have been given. But, in the instance of the physician who has reported but one case as the whole amount of his trial with ether, it is stated that the attendant symptoms and the whole result were most happy. In no case reported have they been said to have been more so. The single case stands alone indeed; but it stands so, without prejudice, without qualification, without a reason against it. Again, are we asked, why any practical unwillingness, in any member of a profession whose mission it is to re- lieve suffering, to employ agents so safe and so successful? Why has he who, in the one case, has found such excel- lent results from etherization, stopped short at that one case ? and why does another wait till the demand comes from the sufferer for the remedy of pain ? There is a moral element to which Ave may refer the fact, and in which find its explanation. This is caution, called also prudence; and ETHERIZATION -- ITS PRODUCTION, ETC. 93 which, in its higher or highest expression, has another designation. It is not difficult to see how this element may come to affect us, when the question concerns a new agent, and which is to be used in a natural process, child- birth ; and, farther, which is to alter the whole character or manifestation of that function. Some risk is thought to be incurred, some chance of trouble; and this, though the whole history of obstetric etherization does not furnish a case of disaster or of apparent danger. Probably, men feel quite comfortable, nay, rejoice, that things have gone so Avell in the one or two cases in which they have ven- tured to try the new remedy, and do not care to run any risk of disturbing this agreeable self-complacency by a new experiment. The person has lived through it, and that is enough. Moral temperament may thus come in to affect medical practice, and great suffering be allowed to attend a function which might be perfectly and safely relieved of this most distressing accompaniment, because of a state of mind in the practitioner in which more respect is paid to moral indecision, than to those teachings of the intellect which come of abundant and sure experience. There can be no objection hi the world to such course; for the moral state which leads to it is not a favorable one for employing etherization, or for observing its effects. It is the part of wisdom, as well as of duty, under such circumstances, not to attempt to induce etherization. But it makes no argu- ment against it, that a few men or that many men hold such \iews. The single case, as we have seen, is, so far as it goes, evidence in favor of, certainly not against, the remedy of pain; and so it has value. And, again, such experience can make no possible objection to employing the remedy as freely as it may be thought necessary; since the widest, like the narrowest, experience shows, that its use has been wholly salutary. The no-experience should have no place in settling the question. We have already considered the objection to etherization 94 ETHERIZATION IN CHILDBIRTH. which has its whole origin and continued being in theory, and have endeavored to show, that this should inner be allowed, in a question which can be resolved only by direct experiment or observation, to influence general practice. In such cases, the determination should only proceed from facts. If I am now asked what is my precise course in regard to etherization in midAvifery practice, and in diseases in which pain is a distressing symptom, I answer: — 1. I generally take with me ether or chloroform, or both, and an instrument which I have found to be of easy and safe use. 2. If I am not desired to employ etherization, and the pains are very severe, I offer inhalation as a sure and safe means of abolishing pain; and this in perfectly na- tural labor, and when it is proceeding rapidly and favor- ably. 3. In protracted labor, in which dilatation goes on very slowly, and notwithstanding very severe contractions and great suffering, I recommend and employ inhalation. 4. In any labor, if along with imperfect dilatation, or when this is natural, but the secretions are deficient, and whether morbid irritability or sensibility exist or not, I use inhalation. 5. In protracted cases, if dilatation be slow, and the contractions defective, or the same character of contractions be accompanied with more ready dilatation or dilatability, I use inhalation. 6. In instrumental labor, I use inhalation; applying always the instrument before etherization is begun. 7. In those cases of preternatural labor in which turn- • ing is necessary, I employ etherization. 8. In any case in which increased contractions do not attend etherization, or in which they are diminished, and in cases in which hemorrhage has folloAved a preceding labor, I give an infusion of ergot; rarely, if ever, with ETHERIZATION --ITS PRODUCTION, ETC. 95 the poAvder; just as I would have prescribed secale, had etherization not been discovered. 9. If the patient object to inhalation, I do not press it. For the most part, the objection is made in terms suf- ficiently explicit, before the suggestion to employ etheriza- tion is made, to prevent its being offered. And, again, its forced use will probably fail to produce its desired effects; and so to the untoward, should that follow, will have to be added the consciousness of failure, and the sure memory of it by others. In this enumeration of the circumstances in Avhich I think etherization proper, and in which I feel disposed to suggest it, I have simply stated the facts or conditions in individual cases in which I have employed the remedy of pain. I need hardly stop to state particular results. Suffice it to say, that, in a far greater number of carefully observed cases, I have found anticipations realized, results produced from etherization, than I have met with from the use of any other remedy in medical practice. I have been less frequently disappointed in reaching in detail, so to say, effects actually looked for, than from other agencies. And let me add here, Avhat is equally true, that the whole benefit has been obtained, not only without apparent danger, but with both safety and success. These conclusions are stated in the consciousness of the whole responsibleness which must attend to the communi- cation of them. They are not stated for the first time, and so the responsibleness is still individual. Many and perti- nent facts have been brought out, and many collected, which have before only had their place in men's minds, or in uncertain records. They form a most important part of this volume. From such have our practical conclusions come, and such are ever their surest and safest foundations. Under this head of the conditions for using or not using etherization, I put down its effects. I did so, because, although these are discoveries which trials with it haAre 96 ETHERIZATION IN CHILDBIRTH. made, and so may refer to Avhat has happened, and not to the existing case in Avhich Ave propose to employ etheriza- tion, still the experience practically Avill be felt to have a relation to it, which Ave cannot and should not avoid per- ceiving, and by Avhich, consciously or otherwise, avc shall be more or less governed. There is another reason for con- sidering the effects of etherization, of whatever character, whether good or bad. It is this: — The popular mind is always reached by them, and, whether favourable or unfa- vorable, is more or less influenced by them in its opinion or employment of the neAV remedy. Thus Ave find the unfavorable, all of them, published. They are items of much value. The daily press collects and spreads them everywhere. And who is not glad that • it has done so in the matter under notice ? How deep is the public interest and welfare in the whole result of the experiment with the remedy of pain! How wide is the experiment! How successful the result! The exceptions, we have seen, are hardly in number large enough to prove the rule. I pro- pose, then, by and by, briefly to give some account of these exceptions, to show in what circumstances the cases which make them, differ from all others, with a view to their bear- ings on the continued, the future use of etherization. In speaking of effects in this connection, I refer to what has attended and to what has followed, come after, the use of ether and chloroform, — to present symptoms and to remoter results. To no topic connected with our discussion has professional and public attention been more earnestly turned than to this, and none deserves a stricter or more unprejudiced regard. The unknown syrup which cures all the consumptions, and the unknown lozenge which brings away all the worms, stand uncontradicted, and with daily accumula- tive testimony in their favor. Not a death has place in such people-loving records; not a death happens, Ave are told, to record. Every man is made his own physician; ETHERIZATION — ITS PRODUCTION, ETC. 97 and "physician heal thyself" is the prescription and the practice of every hour. I leave the lozenge and the syrup to enjoy their unqualified and their enlightened reputation. Let the physician, he Avho has given his mind and his heart, his moral and his intellectual nature, to noble works, — to the study of disease, and to the relief of suffering and the prevention of death, — let him be true to his great calling ; let him use known means, and make them and their best uses the free property of a suffering world. If, in the individual case, untoward result come, let him find, in the care and Avisdom Avith Avhich he has used his remedies, and in their otherAvise universal success, an abiding assurance that he has ever done his duty. The popular mind sees in that which follows the use of an agent, the effect of that agent. Post hoc, ergo, propter hoc, is often a safe, though not always the wisest or truest, philosophizing. It holds the agent as responsible for the untoward results, and, with great authority, says, Beware! when its subsequent use comes into question. In medi- cine, this reasoning has ever been common, and ever highly popular. I am not disposed to abate a jot of its salutary poAver. But the question is pertinent, if it have not some- times an influence which does not, and should not, belong to it. Before giving the exceptions, however, our attention is both naturally and necessarily directed to the ordinary agencies of etherization, — to what we daily observe to be its effects. In speaking of its physiological phenomena or effects, I have alluded to some of those Avhich are mani- fested by the brain, and Avhich so refer to that earliest period of it in which consciousness is still present, and Avhich so remarkably continues in cases in AA^hich sensi- bility is abolished. Sometimes, this effect of etherization, or this state in which consciousness remains, and insen- sibility is perfect, may lead to much embarrassment, and CA'en to apprehension, on the part of friend or physician, and Avhich is quite without true cause. The patient is 13 98 ETHERIZATION IN CHILDBIRTH. conscious of novel sensations, and of mental action, per- haps never before experienced. These, as Ave have seen, may be even distressing, — as noises, flashes of light, apprehension, dread, Sec.; and Ave have exclamations cor- responding to these states, " I am dying; " — "I am scared; " — " What shall I do ? " — " What have you been doing ?" &c. &c. Again, Ave have another series of effects referred to the brain, and in which unconsciousness exists, or of AAirich no memory remains. Among these are excite- ment, generally pleasurable, laughing, talking, singing. There is in such effects as these no real cause of alarm. Ordinarily they soon pass off during the continued use of ether or chloroform, being the consequence of their imper- fect action. If they do not go off, but rather increase, under the fair use of the agents, we then omit them entirely, or for a time, as the results of reneAved trials may indicate. Cases like these are by no means very rare. In further speaking of the effects of etherization, I shall take them up in such order as will, as it seems to me, make the statement and discussion most practically useful. I shall speak alike of the alleged effects, the doubtful, the untoward, Avhich have been ascribed to etherization; and of those which daily experience declares to be its results. Proceeding, then, Avith the subject above adverted to, — the effects of etherization upon the brain and its functions, — I Avould speak, in the first place, of a very important effect ascribed to it: I mean, insanity. It has been again and again asserted, that insanity may be produced by ethe- rization. I find no cases Avhich, in the smallest degree, confirm this doctrine or theory ; for it is not advanced as a fact. I do not find such a case in the Avhole records of surgical practice, which, in the Massachusetts General Hospital alone, now embrace several hundred cases of the successful uses of ether, of chloric ether, and of chloroform. Nor does the AAide experience of other parts of this country or of Europe furnish any fact to support the opinion. ETHERIZATION--ITS PRODUCTION, ETC. 99 Etherization in midAvifery gives the same denial, and out of a Avider experience too, to the same doctrine. So far from there being any known truth in it, I can declare here, that the only cases of puerperal mania Avhich haAe come under my direct observation or knowledge since the intro- duction of etherization in midAvifery have occurred in cases in AA'hich this Avas not used. Suppose for a moment that ether had been used in these cases, hoAv wide Avould have been the report! They Avould haA'e spread on " flying words " and with lightning-speed over this Avhole country, and by the first steamer they Avould have found their sure Avay to Europe. How false would have been the expe- rience, and how much injury Avould its falsehood have done! I dwell upon this point here with the more empha- sis, because puerperal mania is not a very rare disease, and because of the exceedingly free use which has been made of etherization in midAvifery without the occurrence of a single case of that affection. In the reports which follow of cases, a single one of insanity is recorded. It Avill be found in the Correspond- ence. This case is of great interest, being one of pregnancy and labor occurring in an insane person. She had been delivered before during insanity, and very great annoyance and embarrassment greAv out of this state. In the last labor, ether Avas used, and Avith the effect to produce per- fect quiet, a suspension of the insanity, and a comfort and ease in the process, before unknown in the same person. This case is full of interest. It shoAvs how useful is etheri- zation ; and, more than this, and infinitely more important, does it not show that the mental excitement to Avhich I shall next refer, as an effect of etherization, depends on circumstances Avholly removed from those Avhich lead to insanity, as it ordinarily shows itself, and from which Ave need have no apprehension as to the effect on the mind ? We occasionally, I may say not unfrequently, meet with 100 ETHERIZATION IN CHILDBIRTH. mental excitement in its different forms and degrees dur- ing etherization. We meet Avith this in general medi- cal and surgical practice; and, in some rare cases, it has continued for a day or tAvo. I knoAV of no such continu- ance of morbid or excessive excitement from etherization in midAvifery. The contrary has been observed. A very remarkable quiet is the rule, — an absence of pain, after- pain, and the coming on of tranquil sleep. It has been after trifling surgical operations, such as pulling a tooth, and after unprofessional uses of ether or chloroform, Avhcn it has been inhaled in large quantities, and without any observation of effects by competent persons, — it has been after and under these circumstances, that a state of con- tinued unconsciousness, and eA^en of spasm, has declared itself. Cases of this kind Avill be referred to. A very recent one has occurred in a neighboring city, in which inhalation from a few drops of chloroform Avas used to prevent the suffering of draAving a tooth. The operation was done Avhile the patient was perfectly insensible. She left the physician's office, and called to see a friend, and Avas soon afterwards seized with violent spasmodic action, Avith men- tal disturbance, which threatened life or insanity. This state of things continued tAvo or three days, when the woman became convalescent. A friend, who is a highly accomplished surgeon, has recently suggested to me, that the occasional dangerous and fatal results of etherization in slight operations — as tooth-drawing, for instance — may be the result of the suddenness with which the operation is done, and the ab- sence of hemorrhage; whereas in midAvifery practice, and in surgical operations properly so called, there is more time taken, more excitability " used up," so to speak, less sud- denness in the lesions produced, and much greater loss of blood. In the girl's case above given, repeated blood- lettings formed a part, and an important part, of the treat- ment for the disease Avhich folloAved etherization. I think ETHERIZATION--ITS PRODUCTION, ETC. 101 the sug^stion of my friend an important and valuable one, and that it may lead to useful methods of treating some of the accidents of etherization. Among the alleged lesions of function of the nervous centres during or after etherization, is convulsive disease. Thus, Ave are told, puerperal convulsions may be produced by them. My attention has been particularly directed to this subject, because the diseases in question form the gra- Arest complication of labor. I have not, hoAvever, met Avith a single instance of this complication from etherization, at home or from abroad. So far from this, I have cases of most grave puerperal convulsions, in which ether has been used as a remedy, and Avith excellent effects. In the first case I met Avith after the introduction of ether, and Avhich Avas the third of the same disease in the same patient, ether Avas not used till after delivery. The disease was so severe, life Avas so strongly threatened, that it was not deemed prudent to try the remedy. It was tried after delivery, and there was no farther convulsion after its use. In a very important case communicated by Dr. Bartlett, of New Bed- ford, convulsions occurred during pregnancy, and ushered in labor. Bleeding was at once and freely employed, and then an opiate, Avith the happiest effects. The convulsions ceased. After some hours of rest, labor came on in earnest. Etherization Avas now induced, and Avas attended by the happiest effects. The child was born alive, and both it and the mother have done perfectly well. A still more striking case is that of Dr. Cabot, of this city, given hereafter. In this the convulsions Avere Aery severe. They had continued some time before the case Avas seen. Blood-letting was at once freely employed, and repeated. The disease continued. Ether was inhaled. Its full effects Avere produced. The fits were suspended for betAvcen three and four hours, and in this time the child Avas born and living. Convulsions recurred. Ether did not iioav check them. Opium and asafcetida were pre- 102 ETHERIZATION IN CHILDBIRTH. scribed, and Avith excellent results. The mother |nd child have done perfectly Avell. I have pretty recently Avitnessed a case which has an indirect bearing only on my subject, but is still so related to it as not to be wholly Avithout interest in this connec- tion. I attended a patient in labor, some months ago, to AA'hom I exhibited ether-vapor with good effect. She Avas exceedingly exhausted, Avhen labor occurred, by much dis- ease, Avhich had attended pregnancy; and it seemed espe- cially important to diminish suffering, as far as it Avas safe, and so to preserve the remaining strength. She got through Avell. Her convalescence Avas sIoav. She had the constant care of her child, and chose to have it; and this kept her fatigued and feeble. Three or four months or more after her confinement, haAing occasion to have some operations on the teeth, Avhich could not be done Avithout great pain, and having experienced the safe and successful uses of etherization, she determined to use it again. This was done. After a few inhalations, — amounting, as the dentist said, to not more than five, — she was soon etherized. She was partially unconscious. The teeth Avere removed, but Avith great difficulty; the jaws requiring great force to separate them. This violence she Avas conscious of. It Avas observed, that she did not " come to " after the opera- tion, but, on the contrary, exhibited appearances which Avere alarming. She could not be roused. The pulse had nearly ceased at the wrists. The face Avas livid. Respira- tion could scarcely be perceived. Physicians Avere sent for, and various means for restoration used. Air was freely admitted; friction to limbs; stimulants to nostrils and mouth. I saAv her after some amendment began to appear. But the above symptoms continued more than an hour. They Avere replaced, soon after my arrival, by convulsive actions. There was complete rigidity, and a true catalep- tic state soon shoAved itself. The limbs might be placed in any position, however forced, and it would be retained. ETHERIZATION --ITS PRODUCTION, ETC. 103 The fingers were bent in various directions, as in a lay- figure ; and they remained so bent. There Avas as yet no return of consciousness. There Avas no groaning, no com- plaint. The pulse at length returned, but very feebly; and the skin became less livid, but remained deadly pale. In about four hours from etherization, she Avas sufficiently recovered to alloAV of her removal to her own house. She sloAvly became convalescent. Within a Aveek or two, I have been called to the same person. I found her recovering from an attack of convul- sions, described, in many respects, to resemble the disease above narrated. There had been less rigidity; but, in its general characters, it Avas like the state AA the complexion also. I left Mrs.----about an hour after delivery, having first learned that there was not the least hemorrhage present, and that every thing promised well, between 11 and 12 o'clock. Aug. 4th. — Remained very quiet through night; but sleep was disturbed by noise in the court. She exhibits the same repose Avhich marked her condition last evening. She spoke of herself as being very well, — of the ease of her labor. Said she had nursed her infant; and the nurse 24 ISli ETHERIZATION IN CHILDBIRTH. said, the child had had a fan meal. Mrs. ---- had passed water, and the lochia was natural. Child Aveighs eight pounds. 5th. — Doing perfectly Avell. Pulse 72. 6th. — As well. Milk in abundance, and with no pre- cursory disturbance. Pulse 72. No digestion. Oil and sue. lim. one dram each in morning. Case XII. — Instrumented Labor. No. 160, age about thirty; third labor. Called to visit Mrs.----, in consultation, about 12, noon, August 6th. Was taken in labor about 4, p.m. of the 5th. Two former labors Avere laborious, instrumental, with children still- born. As the head Avas still high up in the pelvis; but, according to Dr.----, lower than at his morning visit; and as pains were good, as were pulse and strength, I advised delay, and agreed to call again with Dr.----at 6, p.m. Six, p.m. saw Mrs.----. The head is rather lower in pelvis; or rather, the scalp, much SAvollen, is lower, but still above outlet. The base of the cranium is probably not fairly through the brim. The head was firmly impacted in the pelvis. It was agreed to apply the forceps, and to administer ether. The instruments went as easily as usual over sides of the head, and locked without any difficulty. I used Hodge's long forceps, which I much prefer to any other, and which of late I have most used. The ether was now used. At first, Mrs.----strongly resisted its use, notAvithstandmg her previous demand for it. But, after a short time, she consented to try it. She now persisted in its use, so that it was difficult to remove it, though she Avas fairly under its power. She spoke of the perfect relief it gave — of the pleasure it afforded. Upon making an effort Avith the forceps, I saw, by the kind of complaint and CASES. 187 effort she made, that etherization was not perfect, and again applied the sponge. This was necessary tAvice more, when the full effect of ether was produced. The child was delivered Avithout the least consciousness on her part. It Avas born alive, and soon breathed, and cried strongly. There was above the right temple a depression of the bone, produced either by the forceps, or by the projecting pro- montory of the sacrum, of some depth. But there was not the least evidence of compressed brain. The afterbirth did not come away; and, some flowing occurring, I introduced my hand to learn what Avas the condition of the placenta. I found a part of it separated, the womb Avell contracted upon it. Upon passing the hand beyond this, the rest of the placenta was found firmly adherent, and required some time and effort to bring it away. This, however, Avas done; and, after applying a swathe, we left Mrs.----with a good pulse, and as comfortable as are women in general after labor. A friend was present Avho had been Avith Mrs.----in her previous labors. She said she never had so short a time; had neArer been so manageable, and never so com- fortable after labor. The statement Avas made by a Avoman whose manner during the labor showed excellent judg- ment, and whose opinion evidently deserved credit. Aug. 7. — Reports very comfortable. Slept well. Urine natural. No hemorrhage. Pulse more rapid than natural. Tongue coated, as from old coat. Her manner is very bright, shoAving entire freedom from uneasiness. After- pains slight — much less than usual. I noAV asked about effects of ether. She says she recollects asking for ether, then resisting its use, and then holding to it Avith all her might; all of which was true. I asked now if she had any recollection of pain after she had fully used it, and after the sponge was forced aAvay from her face. She said no, most emphatically. She kneAv nothing after that; she felt no- thing after that; her attention first being raised by some lss ETHERIZATION IN CHILDBIRTH. one saying that the child Avas alive. That she heard said, and she heard the child cry. So that, during the Avhole use of the forceps, Avhich was unusually long and severe, she knew nothing, but was still making vehement com- plaints as of great suffering. This makes the interest of the case; and I have never seen the want of harmony between extreme suffering and recollection of it more striking. The child does well. The depression of the bones of the cranium has disappeared. Case XIII. — Natural Labor. No. 154, by reckoning, Avas to be in labor, August 9. I was called to her, Aug. 8, at 12, noon. She was taken sick on 7th. Pains moderate; intervals clear; sitting up, pulse, &c. good. Examination showed fair progress. Head low in pelvis. Os uteri dilated and dilatable. No water between scalp and membranes. Pains continued; but very little progress was made. Half an ounce of the infusion of ergot was given; and, in an hour, an ounce. Pains in- creased, and the labor advanced. When the process Avas obviously near to its close, and the sufferings great, ether was inhaled. At first, this Avas imperfectly done. Then came its full effects, and the relief of pain. With the last pains there was no suffering. The child Avas born alive. The placenta soon followed. The womb contracted per- fectly, and there was not the least hemorrhage. I left her, about an hour after delivery, perfectly quiet, Avith the appearance of approaching sleep. This case is recorded on account of tAvo circumstances of interest which occurred. One of these was a sense of faintness, which attended the first inhalations. Mrs.---- has been always prone to faint on very slight occasions, and this showed itself now. The pulse remained firm, and CASES. 189 there was no pallor; but still such Avas the complaint of being faint, that inhalation Avas suspended. At length, however, this faintness ceased, and inhalation was very perfectly performed. The second fact I would state was the effect on the pulse. Before inhalation, it Avas natural in force and frequency; but it became slower and stronger afterwards. After deliv- ery, it remained strong, at sixty beats in the minute. It has been remarked, that the pulse becomes quicker during etherization; and I have certainly observed this to be the case. In Mrs.----it was entirely the reverse of this. I have observed a diminished frequency in the beat before; but I do not remember to have observed, that this has been so striking as in the above instance. 9th. — Doing well. 10th. — Doing Avell. Pulse 60. Is Avithout complaint. Is Avell enough, strong enough, to rise, and go about house, as she says. Case XIV. — Natural Labor. No. 163, twenty-two ; first child. I first saAv Mrs.----, Sunday, Aug. 15th, wiien she was in labor. The Avaters came away at 9, a.m. at beginning of the process. I saw her about 2, p.m. She is very small, short, thin, pale. Has been ill during the Avhole of pregnancy. Her complaints . refer most to the stomach. Nausea, but no vomiting ; acid stomach; severe heartburn; oppression from all sorts of food; flatulence, — these and associated symptoms have been almost constant. Her pulse Avas small, but not fre- quent. Examination showed presentation natural. Os uteri about size of a cent, but firm, thin, and undilatable. Very little show. Very little pressure during pains. I left her to be called when pains demanded. Saw her again about 6, p.m. Progress good. Pains 190 ETHERIZATION IN CHILDBIRTH. stronger. Os uteri dilatable. Much complaint of pains. Begs for ether. I soon found, that the progress Avas not in proportion to effort and state of os uteri, and gave an ounce of infusion of secale, without the powder. Change folloAved this, both in the force or character and effects of contraction. Inhalation was hoav alloAved, and it produced excellent effects. Pains continued good: complaint of them almost ceased. Quiet marked the process. The intervals Avere passed in entire repose. There was scarcely any con- sciousness at the last; and, though pain in the back Avas remembered, it was barely7 alluded to. It seemed more like the memory of a dream of past trouble, than the con- sciousness of a present grievance. The child, a boy, Aveigh- ing about eight pounds, Avas born with great ease. The afterbirth soon folloAved. The Avomb contracted Avell, and no hemorrhage occurred. Pulse 72; respiration natural; complexion and temperature as at beginning of labor. Soon after she was made comfortable in bed, she began to complain of very severe distress at the stomach. It was like that which had troubled her so much during preg- nancy. Sometimes it extended to the throat, by the oeso- phagus ; sometimes a ball seemed to SAvell into and fill that passage to and from the stomach. I now asked Avhat she had eaten. She said, for her, very bad food. It Avas baked beans at breakfast, and huckleberry pie for dinner. She could hardly have selected more unsuitable food for her state of stomach. She took for this trouble, which Avas accompanied by constant eructations, salceratus. Tincture of peppermint, and other things, she had tried before. As this distress declined, after-pains in the night declared themselves, and were very troublesome. I saw her early in the morning of the 16th. I found the abdomen very full, and not resonant anywhere on percussion. The uterus was well contracted, but unusually high in the abdomen. The bladder, greatly distended, had carried it into its novel situation, and was doubtless an agent in her sufferings. CASES. 191 She had passed water naturally, Sunday, during labor. I used the catheter, and drew aAvay more than a quart of Avater; and a good deal did not enter the vessel. Great relief followed. The abdomen acquired its usual size, and the womb its usual situation. It was well contracted. At noon, or 2, p.m. I saAv Mrs.----again. Her troubles had returned, and the bladder was again full. She was raised on to a vessel in bed, and passed quite as much urine, in a full stream, as had been drawn off a few hours before. Again relief. The distress in stomach entirely gone. Pulse of good strength, 72 in the minute. Relieved of all trouble. Dover's powder directed, should pains recur. 7, p.m. — Nursing her child. Is more comfortable; pains less. In all respects doing well. 17th. — Got Dover's powder with relief. 01. ric. and sue lim. tAvo drams each, in the morning. 18th. — Got physic, Avhich has operated well, and gene- ral condition good. Milk sufficient. 24th. — Gradually improved. Pains continued an un- usual time, and were often very severe. Has long suffered prolapsus uteri; very painful catamenia; Avith much and very distressing bearing-down. These symptoms have troubled her since labor. Great care has been taken, by continued rest in horizontal position, to save her from her old troubles. Case XV. — Protracted Labor. No. 161 Avas to have been confined in September, but Avas taken in labor, Aug. 15th. Says she has had pains occa- sionally for a week; is thirty-four years old; has had five labors, and suffered greatly in them all. As her pains are slight — no show — and as she has \rery troublesome diarrhoea with much straining attending evacuations, I pre- scribed an opiate, and left her. 192 ETHERIZATION IN CHILDBIRTH. 16th, 4, p.m. — SaAv "Mrs.----again. Pains stronger, but still only the precursory efforts of labor; and I left to be called, if she grew worse. Was called betAveen one and tAvo of the morning of the 17 th. Labor was noAV present, as manifested by positive symptoms, and as proved by exa- mination. I now ascertained AAiiat had been her previous condition. She had suffered, during the Avhole of preg- nancy, most severe dyspepsia. Her stomach had been in constant distress. She had observed the most rigid rules of diet, and had given the strictest attention to time, quan- tity, and quality, in using food. She had suffered from numbness of the lower extremities, and occasional loss of power over them. As her friends said, had been frequently paralyzed. Her pulse was rapid, small. Her strength little — emaciation striking. She looked to labor Avith deep anxiety about the result, and her friends sympathized with her in foreboding of ill. Pains increased in strength soon after my arrival, and I found labor had made good progress. The os uteri was dilated well, and dilatable. ShoAV abundant, and water filling the membranes, and pro- truding them during a pain. In the height of her suffering, she asked for ether. It was used. She inhaled it with unusual avidity, and insisted on being well supplied Avith it. Its effects were diminution, or almost a cessation, of complaint; repose in the intervals entire. It was obvious, that the happiest effects of etherization were present. Pains increased. Relaxation of perineum Avas more perfect than I have long noticed it to be. The child was born alive and vigorous; and the placenta, in about half an hour, was expelled. The womb contracted well, and no hemorrhage occurred. Mrs. ---- Avas asked of her sensations during labor. She said she did not entirely lose consciousness of pain; but it was easily borne. She was most struck with her feeling of strength. She had looked for exhaustion, she said, but had more strength than she had knoAvn for Aveeks. CASES. 193 The effects of the diarrhoea had passed by, and she felt as if she had been well during the whole of pregnancy. The pulse Avas less frequent, and of better strength. She spoke with a firmer voice, and asked to be taken from bed, or to be permitted to sit up, that her bed might be made up, and so her comfort increased. I left her at about 4 o'clock, a.m. quite as well as women commonly appear after delivery. 17th. — Quite as well generally. Diarrhoea more trouble- some, but no weakness complained of from it. Pulse rapid; skin warm. Suffers not at all. Tinct. opii, p. r. n. 18th. — As yesterday, except diarrhoea is less. Pulse and skin as before. Says, in former labors, not only has labor been very distressing, but after-pains have been excessive, and for many days. Last labor, they lasted five days. Has not suffered from these pains at all since ether; and but for the diarrhoea, she Avould be Avell. 24th. — Diarrhoea has continued, but is gradually de- creasing. Pulse is slower. Has milk. Very little pain in abdomen. Soreness, which is relieved by flaxseed meal poultice. 31st. — Mrs. ---- has gradually improved. At times has had dysenteric discharges. Has been much benefited by a mixture of one part diluted nitric acid, and tAvo of tinct. opium, in tAventy-drop doses, three or more times a day. Discharges, after this medicine, have become less fre- quent and of better character. Sept. 2d. — Still better than on 31st. Milk has disap- peared entirely. Case XVI. — Natural Labor. No. 159, confined August 30th. Boy, weight seven pounds ; third child. Was taken in labor in evening. I was called about 10, p.m. Pains present, but slight. Found 25 194 ETHERIZATION IN CHILDBIRTH. her sitting up. She soon Avent to bed. Pains rapidly increased. She asked for ether. This Avas administered. It was used at her request, as pains came on, and ahvays Avith marked relief of suffering. The last pains were not at all complained of, so unconscious was she of these. A sAvathe Avas applied. Afterbirth came readily aAvay. Some after-pains. The womb expelled a firm coagulum as large as a fist, and with much relief. I left her perfectly quiet, and with scarce any pain, towards 1, a.m. 31st. — Pulse 72. Perfectly comfortable. No after- pains. Some sleep in night. Says she felt weak under etherization. Could make little exertion, voluntary power being sensibly diminished. No milk. Sept. 1. — Doing well. 2d. — Milk coming. Some excitement. Slight after-pain. Two coagula, firm, from womb in night. Case XVII. — Natural Labor. No. 143, fourth child. Taken in labor, Aug. 31, at noon. Called to her between 2 and 3, p.m. SaAV her between 4 and 5, same afternoon. Left her sitting up, with light pains. Examined. Head presenting. Called again between 9 and 10, or about 10. Found labor advancing. Exam- ined, and found head descending, and os uteri dilated and very dilatable. At a quarter before 12, administered ether; and its effects soon declared themselves, in gradual dimi- nution, and soon entire abolition, of suffering. She was entirely ignorant about events; did not knoAv Avhether she Avas delivered or not, and was entirely happy. This Avas very striking, when the pains are ordinarily most distress- ing, viz. when perineal tumor is fully formed, and the head is forcibly separating labia. The contractions were very strong at this time, but no apparent voluntary effort pres- ent. She was still, and making no other sound than that CASES. 195 Avhich accompanied forcible inhalation of the ether. The child Avas born in this state of things. It cried lustily, and the cord Avas divided. A swathe was noAV passed round the abdomen and perineum. The Avomb contracted, and first threAv off a small firm coagulum ; and the afterbirth soon folloAved. The child, a girl, weighed fully ten pounds, the Aveight of her former children. I now asked of her state during labor. She expressed herself wholly delighted. She had been in a railroad car all the time, and had had a beau- tiful ride. She said, again and again, that she could hardly believe she was delivered. She had always suffered so severe- ly in former labors, and noAV the most she could recollect of suffering was a little uneasiness; but where situated, or what, she could not possibly tell. She hoped every Avoman Avould be allowed the use of ether. She made me promise always to use it. She was surprised, that its effects had not been known years and yrears before. In this case, as in others, the natural lubrication was abundant, making all other unnecessary. The os uteri, which had not disappeared Avhen ether was first administered, was gone in a pain or . tAvo aftenvards. Her temperament declared itself strik- ingly. She is remarkably calm always, not at all nervous ; and such was her condition now. Her pulse, at the time ether was used, — for it was counted accurately just before inhalation, — Avas 116 in a minute. It soon fell to 96, and Avas 84 exactly Avhen the afterbirth came away. I left her, between 1 and 2, entirely free from after-pains, with her child on her arm, about to take the breast. She suf- fered after her last labor, five days and nights, from most severe and uncontrollable after-pains. I close this record at ten minutes past 2, a.m. in the fullest memory of the case, and after witnessing the happiest effects of ether. Sept. 2d. — Night good; pulse 72; one dejection, natu- ral ; scarce any after-pains. Has nursed her child. Urine free. Every thing in condition of patient good. 5th. — Perfectly well. Says she feels as much better 196 ETHERIZATION IN CHILDBIRTH. than after any other confinement, as her late labor was easier than any preceding one. " I have none of those wrenching pains which have ahvays troubled me before. I feel well." Her bowels have been regular daily, Avithout medicine. Has not taken any medicine since confinement. No trouble about nursing. Case XVIII. Natural Labor. Hemorrhage before Labor. No. 158, age tAventy-four; third labor. Sept. 1st, took a long walk at noon, about a mile. Got home to dinner. At the table, Avas taken with uterine hemorrhage. Lost much blood in a short time, and Avas carried to her cham- ber ; being too weak and faint to Avalk up stairs. I saw her soon after. She was still faint; required to be fanned; was pale; pulse feeble. I prescribed stimulants moderate- ly; examined and found os uteri closed; head of child distinctly to be felt through uterus. The hemorrhage had ceased. Positive rest in the horizontal position Avas en- joined. Her chamber Avas to be kept quiet, and her chil- dren were put into another room. Sept. 6th. —Nothing has happened since the 1st. Mrs. ---- has had no return of hemorrhage. Was taken in labor this morning. Has had pains before, like the precur- sory ones of true labor. Now there is much pressure about the pelvis, and a constant discharge of a colorless liquid. The pains continued through the day, becoming more severe in the evening; and at length, becoming intolerable, Mrs. ----asked to inhale ether. She did so, and soon came under its kindest influence. It was necessary to repeat inhalation not more than four or five times in the hour and half before delivery. The child, a boy weighing eight pounds, Avas born alive, without her being at all conscious of the event. She asked Avhen it would be born, some CASES. 197 minutes after its birth. Before return of entire conscious- ness, a slight hysteric state occurred. There Avas smiling, and moderate laughing. Questions were readily answered, and entire freedom from pain manifested. The afterbirth soon followed, without difficulty. The pulse was more rapid before etherization than after- Avards. It fell to 72, its natural beat, and remained at this. There Avas an obvious effect produced on the os uteri, soon after inhalation. It became softer and more dilatable. The pains were more efficient, and the os soon disappeared. There had been abundant lubrication during the case, and I Avas not aware of any increase in it. The aqueous dis- charge continued, but no blood. The hemorrhage which occurred on the 1st led to some uneasiness; but I had met with the same occurrence in other cases, and, no sub- sequent trouble happening in them, I did not look for any in this. Before the placenta came away, there Avas a firm coagulum throAvn off, but no jloiving ; nor did any happen afterwards. 7th. — Pulse 72. After-pains but slight. After last labor, and during a whole day, these pains were very seA'ere, ]yrrs.----saying, more so than those of the labor. Lest present pains should increase, I directed inhalation, and to repeat it as it might be necessary. This she did, and was soon relieved of all suffering. Had a good night. Urine natural; lochia natural. 8th. — Pulse 72. One after-pain only, this morning. In all respects doing and feeling well. Milk abundant. 9th. — Pulse 72. One dejection, without medicine. 10th. — As well. One dejection, without medicine. Pulse as before. Case XIX. — Preternatural Labor. N0 i 68. — Second labor. Breech presentation. I was called to see this patient just after labor was over, on IDS ETHERIZATION IN CHILDBIRTH. account of sinking after hemorrhage. The Aoav Avas sud- den; much blood, coagulated and liquid, Avas lost; and sinking and fainting at once induced. This patient had inhaled ether-vapor, but not after such manner as to pro- duce its full effects. The labor Avas long and exhausting. I record it because of the hemorrhage Avhich folloAved the use of ether, not because for a moment haA e I believed ether produced it, but because of the importance of every untoAvard fact Avhich may have the least apparent connec- tion Avith the employment of ether, hoAvever imperfectly used. This case occurred in August. Mother and child did well. Case XX. — Labor with Convulsions. Sept. 13th. — No. 170 AAras taken with pain in abdomen, resembling labor, but more like colic. Had severe cholera morbus in night. Next morning, got castor oil; and, in forenoon, an injection, and was thoroughly purged. At 12, noon, was taken with convulsions. This is her third pregnancy, period seven months. In her first, she had convulsions at the seventh month, and was delivered by natural effort. In the second, at about eight months, had convulsions, and was delivered by the womb. Her physi- cian, finding she had suffered before fits with severe head- ach, and Avas deeply red in the face, bled her largely. Her fits, however, continued very strong, not at all diminished by bleeding and previous purging. I saw her about 6, p.m. She Avas in a very excited state, talking constantly, and tossing herself about vehemently. Her face and lips deadly pale ; skin cold; pulse rapid, 150 in a minute. Every thing showed a state of extreme ex- haustion, still with remaining poAver to make great muscular exertions. No pains ; slight dilatation of os uteri; os uteri soft, dilatable; show abundant. I have never knoAvn the CASES. 199 ordinary attendants of labor more abundantly present, and still no contractions, or so slight as hardly to deserve the name. An attempt had been made to break the membranes, before I saAv the patient, and to induce labor. She soon had a fit, a violent convulsion, followed by deep stertor and stupor. She came out of this in about seven minutes, and began again to talk, and to throw herself about. This state continued. At length, I ruptured the membranes; but no relief came. The Avomb did not act. The intervals of convulsions lessened. The pulse sunk. She lost poAver to speak or to move, and lay wholly uncon- scious on her bed. It seemed impossible that she should long survive this state of things, and it was decided that an attempt should be made to deliver. The os uteri admitted readily two fingers, and Avas dilatable. I was further en- couraged to make an attempt to save life, because of the smallness of the uterine tumor, and the belief hence that the foetus was very small. The head was perforated, and the brain remoAred; and, after a long trial, effort being occasionally suspended, the foetus was removed. It was very small for the time of pregnancy. The placenta fol- loAved. The Avomb contracted, and no hemorrhage ensued. She had tAvo convulsions during the operation. I left her quiet at 2, a.m. of the 14th. 14th. — Fits occurred after I left. This had happened to her before, and is not an uncommon occurrence in such cases. In the morning, she was very much exhausted. Pulse very rapid. Great restlessness. Apparently threat- ened convulsions. Ether was now, for the first time, em- ployed. She soon became calm. Had two slight fits after- wards ; but, in the course of two or three hours, fell asleep, and had a long and quiet repose. No more fits; but, as they were again threatened, inhalation was employed, and Avith the best effects. I saAv her about 7, p.m. I found her sleeping very quietly. Pulse 112, soft, and of good strength. Skin 200 ETHERIZATION IN CHILDBIRTH. warm, soft. Expression and complexion natural, good. No urine. Catheter recommended in the morning, or ear- lier, if need be. 15th. — Report favorable of state in morning. Urine, during operation of an enema, very copious. 16th. — Report same. Has consciousness ; knows Avho is about her. Continued comfortable throughout yester- day ; night good. To-day, urine natural. No milk. Ab- domen entirely free from soreness or pain. Is surprised to find herself in bed. Knows of nothing which has hap- pened. Feels perfectly well, and wishes to get up, and be about as usual. Is cheerful. 17th. — Doing well this morning. Every thing promises Avell. Is very cheerful. Is Avithout any complaint. Abdo- men without tenderness; external organs Avithout SAvelling. No difficulty of urine; no scalding; no appearance of any lesion of structure or function. 18th. — In all respects as well as yesterday. Recovery perfect. Case XXI. — Instrumental Labor. No. 172, first child. Began to have pains, Friday, Sept. 17th. She had intervals of hours between pains, till Sun- day, the 19th; then went to bed. Pains very severe in night. So, on Monday, most suffering at night. Tuesday, 21st. — Cramps in lower extremities very severe. Uterine effort comparatively slight. I was called to see her between 12 and 1, noon. Found head Ioav in pelvis. Mem- branes had ruptured some time before. No uterine effort. Cranium strongly compressed, and impacted in pelvis. Sagittal suture strongly marked by overlapping of bones. Bladder somewhat distended. Catheter used. Had taken oil lately. Bowels well emptied. Pulse good. By auscul- tation, placentary murmur well marked at times. Foetal heart not heard. It was decided to employ forceps. Some CASES. 201 difficulty of application, from os uteri not having entirely disappeared. Ether was now inhaled. At first, ether pro- duced much excitement. Its use was resisted. Unusual restlessness occurred. But shortly its full power Avas mani- fested, and extraction begun. The os uteri descended with head. Soon, however, entire relaxation took place, and os disappeared. Perineal tumor began to form. Dilatation went on well, and the head was born without the least laceration; the woman being entirely unconscious of pain. The child, a girl, was still-born; but the heart was beating, and respiration was soon established. Mrs.----asked for ether, while placenta was coming aAvay, and was greatly pleased with its effects. She begged for it afterwards again, and Avas gratified. She said she had been in a dream, and Avas perfectly happy. I left her free from complaint soon after. 23d. — Has done perfectly Avell since delivery, and con- tinues to do so. Case XXII. — Natural Labor. Sept. 23d. — No. 167. Labor came on to-day in the morning. I Avas called betAveen 8 and 9, a.m. Process completed at half-past 9, a.m. A boy, weighing nine pounds. Ether Avas asked for at the close, and produced its Avonted relief. This was the fourth labor. Severe after-pains in two last. 24th. — No after-pains; night good; and dejection with- out medicine. Has had mammary abscess in both breasts. As yet, breasts .give no trouble. Pulse 72. 26th. —■ Doing very well. No after-pains. 30th. — Has continued well till to-day. To-day I was desired to see her on account of some tenderness in one breast, which much troubled her on account of her former suffering. Prescribed flaxseed meal poultice, and, •26 202 ETHERIZATION IN CHILDBIRTH. in the evening, a mixture of nitre, tart, antimonii, and tr. opii. 31st. — Breast relieved. Has had perfect recovery. Case XXIII. — Instrumental Labor. No. 175, second labor; first premature. I Avas called to see Mrs.----, in consultation, about 2, a.m. Sept. 26th. I learned she had been in labor seventy-two hours, not con- stantly, but for the most part, in pain. I found the scalp just within external organs. Presentation good. Head firmly fixed; the parietal protuberances resting closely against the rami, and apparently allowing no room for any thing to pass betAveen them. Here it had been for many hours, and this notwithstanding very strong pains. These had, however, begun to subside. The bladder was emptied by the catheter, and Hodge's forceps applied. This required great care. As soon as the first branch had gained its po- sition, and a passage been made into the womb, a gush of lig. am. strongly colored by meconium, folloAved. This continued to Aoav. The head descended kindly, and was delivered. The child did not breathe. The cord Avas firmly round the neck tAvice. The uterus soon contracted, and the shoulders descended. The child Avas born through the loops of the cord. Pulsation continued, and the heart beat, though feebly. The cord was tied and divided, and various means Avere used to animate the child, but in vain. Ether Avas used in this case, and insensibility produced. The patient made no resistance to instruments, and in- creased relaxation soon followed etherization. The pulse, respiration, and temperature, continued natural, and no hemorrhage folloAved. There was no smell of ether in the placenta. Recovery perfect. CASES. 203 Case XXIV. — Natural Labor. No. 153. Labor occurred in this case, 9, p.m. Sept. 29th. I was called, 2, a.m. of the 30th. Much pain in back, cutting, grinding; in no sense expulsatory. Examined. Excessive tenderness of external organs, and vagina. Os uteri reached with difficulty; very slightly open, admitting a finger. Uterine tumor very Ioav in pelvis. Head felt through uterus, presenting. I Avent to bed, and Avas called betAveen 3 and 4. Very little alteration in character of pains, except they Avere more severe. Things Avent on thus not long, pains becoming decidedly forcing. Still, os uteri and external organs remained much as before. I should haA^e said there was no shoAv. This was a first labor, and Avithout question at the fullest time. Person very small. Abdominal tumor very large. At 7, ether. The changes Avhich soon folloAved were softening of organs, dilatability of os uteri, abundant shoAv, and diminished sensitiveness of external organs. Expulsatory efforts iioav increased. Ethe- rization Avas produced, but at no time so decidedly as in many cases. At length, pains slackened; the head Avas a ery Ioav ; every thing favorable; and a third part of an infusion of pulv. secale, one dram to teacup boiling water, AA'as given. Pains soon increased. Head descended, and the child was deliArered. The perineum Avas Aery slow in yielding, and some laceration was produced. She was delivered betAveen 12 and 1, noon. Child, a girl, weighed ten pounds. No hemorrhage, — no pain followed. Ute- rus contracted firmly and permanently. Oct. 1st. — Doing Avell. No urine since delivery. Night good. 2d. —. Report good. Urine abundant. No dejection. Pulse good, as it has been from beginning of labor. Alto- gether comfortable. 3d. — Milk abundant. In all respects doing well. No 204 ETHERIZATION IN CHILDBIRTH. dejection. One dram ol. ric. and as much lemon juice in the morning, if no dejection before. 4th. — BoavcIs moved. No disease. Case XXV. — Natural Labor. No. 165 Avas taken in labor early on Friday morning, Oct. 1. 1 Avas called Sunday morning, Oct. 3d. Says pain Avas slight on Friday, and did not prevent sleep in night. Saturday, pains more decided; and no sleep, Saturday night. This is the fourth labor. Patient very fleshy, strong ; has been unusually Avell during pregnancy. Last labor Aery painful, and of forty-eight hours' continuance. Upon exa- mination, os uteri high in pelvis, not at all dilated. Gene- ral softness of organs, and some shoAV. I left, to be called when pains were more decided. Called at 2, p.m. Noav very severe pains. More shoAV. Os uteri dilatable. Waters have come away. Head pre- sents well. Pains so severe, that I gave ether at half-past 2. Its best effects soon followed. Strong pains, more dilata- tion, and more shoAV. For nearly three hours, the best effects of inhalation were manifested. " Hoav beautiful! " " Do ahvays use ether." " Beautiful," &c. &c. in same strain. At end of three hours, less favorable effects of ether appeared. Nu?nbness Avas complained of, to Avhich she is subject; confusion of head ; says she is dying, &c. Sec. The ether Avas at once laid aside. It Avas obvious that its favor- able effects Avere not present. In meantime, labor-pains Avere Aery strong.- I have hardly met Avith them more so. The vagina Avas forced down before the head in folds. The soft parts about symphysis pubis became much SAvollen. The pelvis Avas nearly filled by the congestion of the vagina. Os uteri nearly disappeared, and then remained, at the anterior part of pelvis, strongly compressed betAveen head and symphysis and rami pubis. The ether was again in- CASES. 205 haled freely, but Avas still followed by disagreeable results, as before. I noAV waited between two and three hours. The pains were efficient. The head came doAvn, cleared the os uteri, and pressed aAvay the soft parts which had so long been before it. So much suffering was now declared, that I again gave the ether. Now its best effects appeared. The pain in the back, which before had been most distress- ing, and for which firm pressure and friction were emphat- ically demanded, passed entirely aAvay. The pleasurable feelings from the ether were as strongly expressed as upon its first inhalation. It was demanded; and the patient chose to hold the sponge herself, that she might get the Avhole benefit of it. If it Avas removed, as was noAV and then done, she continued to inspire rapidly and deeply, as if it were still over her mouth and nose, just as happens so often when the gas bag, containing nitrous oxide gas, is pulled away. The pains were as strong as ever. No com- plaint Avas made of the back, and pressure was omitted there. The head Avas born under full etherization, and the trunk and limbs soon followed. The child, a girl, cried soon after birth, and was separated from the placenta. A SAvathe was applied. Contractions soon came on; the sponge Avas at once seized by the patient, and inhalation begun. The placenta soon followed. No hemorrhage. The patient was soon made comfortable by removal of things about her, and was easily placed in bed. Pulse, temper- ature, color, perfectly natural. I now asked as to her sensations in the last hour of her labor, this being the time about during which ether was last used. She said her sufferings were as nothing. She knew Avhat had happened. She knew when labor Avas over; but so slight had been the uneasiness during the time, and especially when the head and body passed, that she hardly remembered it. She was glad she had not been more unconscious, as it would have been disagreeable to her to have been Avholly ignorant of the birth of her child. 206 ETHERIZATION IN CHILDBIRTH. I haA'c met Avith no case in Avhich such entire satisfaction has been expressed Avith the use of ether. She had felt certain that her child was dead ; but it Avas alive and doing Avell. She had had fearful forebodings of Avhat might hap- pen to herself; she Avas Avell, and perfectly comfortable. It was truly grateful to be the Avitness of such a termina- tion of a case Avhich had, for so many hours, been so unpromising; and nenv confidence in etherization Avas its result. Record made, Oct. 3d, half-past 10, p.m. 4th. — After-pains ; got forty drops of laudanum. Slept afterAvards. Noav some re-action ; skin Avarm ; pulse rapid. No pain, and thinks symptoms proportionate to suffering of labor. Recovery perfect. Case XXVI. — Natural Labor. No. 149, third child. Labor began Oct. 3d, after mid- night. I Avas called betAveen 7 and 8, Oct. 4th. I found natural presentation ; pains moderate, but expulsatory; pulse, &c. good. Rapid increase of pains soon took place; and, at a quarter past 10, ether Avas asked for. Etheriza- tion occurred very soon, and was sustained Avith great case, that is, Avith occasional applications only of the sponge, and for a Aery short time. Labor was happily ended in about tAvo hours from first inhalation. The child, a girl, weighed about eleven pounds, and has, with the mother, done very Avell. In this case, for a time, pains were very severe. They, however, did not advance the child, but were accom- panied by a forcing effort, much of it voluntary, Avhich projected forward rectum and neighboring parts Avith very little progress of the head. Infus. secale was gi\en with very manifest advantage. The head began to descend soon after its use, and suffering Avas prevented by ether. I have rarely met with a case in Avhich a larger child lias been born Avith less suffering, and in which everv thing at the CASES. 207 close of the process promised better. I saAv this patient again in course of day, and found every thing comfortable. 5th. — Pulse, &c. Avell; good night. No after-pains, or one or two only, and so slight as hardly to desene notice. ('hild very lively, and doing well. Recovery perfect. Case XXVII. — Natural Labor. No. 131. Labor began Saturday, Oct. 2d. I Avas called Sunday evening, 11 o'clock, and found pains present. These had increased from Saturday, so that it Avas thought necessary to send for me. This is the third labor. Tavo first Avere of breech presentations, and, in both, child irre- coverably still-born. Great desire for children, and much anxiety in regard to present labor (age betAveen thirty and forty, patient exceedingly fleshy). Examination shoAved head at brim of pelvis, not at all in the brim. Os uteri perfectly dilated, as were vagina and external organs. Lu- brication abundant. I left in the morning, as the pains did not produce the least effect on child or head. Monday, Oct. 4th, things exactly the same. Pains strong, constantly promising progress; but none was made. An opiate (tAvo gr. op. tAvo gr. sapon.) Avas given at bedtime. Tuesday morning, Oct. 5th, some sleep; but pains continue; no descent of head. Urine free; pulse rapid, 120. Skin warm. Pelvic viscera in good state, — moist, cool, not swollen. No headach; stomach hardly at all disturbed. No dejection since 2d. 01. ricin. and sue. lirnon. of each half an ounce. Was called between 4 and 5, p.m. I noAV found very severe contractions present. They had begun about 3, p.m. ; and the head Avas descending, and every thino- promised well. Ether was not asked for; and, when proposed, it Avas not accepted. I was not sorry for this. Former labors had been so untoward, their terminations so unhappy, that I aatxs not disposed to interpose an agent of 20N ETHERIZATION IN CHILDBIRTH. so much known power as is ether, in the midst of occur- rences so entirel} promising. Things Avent on Avell for an hour or tAvo, Avhen cramps in the loAver extremities occurred of a most severe and singularly distressing character. I had gone below, but Avas soon called up to do something to mitigate the suffering. Ether Avas used. It produced its effects on consciousness less strikingly than is frequently observed ; but on the pain its effects Avere very notice- able. The cramps first yielded, and in a short time Avere hardly alluded to. So Avith pain in the back, this Avas relieved. Contractions became very strong. Ether was continued. I have rarely knoAvn pains stronger after the use of ergot. The head came doAvn rapidly, and soon entered the arch. It passed this with great ease. The child was born Avithout any complaint from the mother. It Avas a boy, of large size, Aveighing ten pounds and a half. At first it breathed feebly. Its eyes were opened, and very bright; much mucus was in the nose and mouth, and Avas wiped aAvay; and in a minute or two he cried, and the cord Avas tied and cut. A swathe was at once applied to the mother, firmly and largely. Two firm and large coagula preceded the birth of the placenta. This last soon followed, and the patient Avas made comfortable. The swathe Avas tightened; and I left mother and child, an hour after, doing Avell. I speak particularly of the use of a sAvathe in this case, immediately after delivery of child, and again after delivery of placenta. I think this use of it very important in all cases, and does most to prevent such relaxation of the womb as may give rise to hemorrhage. 6th. — Comfortable. No after-pains; has not had them after former labors. Pulse rapid; skin warm and moist; Avhole manner sIioavs fair re-action. 7th. — Pulse sloAver. In all respects doing well. CASES. 209 Case XXVIII. — Natural Labor. Oct. 4th. — No. 177, aged thirty-seven; sixth pregnancy. I Avas called early in evening of the 5th. Night before, pain preventing sleep; slighter through early part of the day. In afternoon, contractions strong; and I was called suddenly, in the belief that labor Avould soon be completed. Upon examination, I could not reach the os uteri, so high was it, and so strongly turned towards promontory of sacrum. Through the Avomb I felt a firm tumor, which I belieAred to be the head. The pains Avere very strong, but made no pressure on head, or presenting part. I left with directions that an opiate pill should be given, if sleep did not occur, and labor did not advance. ' I Avas called betAveen 1 and 2 of the 6th, and found head advancing. Os uteri soft, dilated somewhat, and dilatable. Presentation natural, and every thing promising well. Pain became more and more distressing, and cramps were soon added to them. I suggested ether; but it was objected to. The smallest stimulus ahvays greatly disturbs the head; and opium, in all forms, produces wildness and delirium. My pill had not been taken. At length, however, suffer- ing became so severe, that she desired ether. It was tried. It first caused choking, and Avas very imperfectly inhaled afterwards. It produced no pleasant effects, but excited and distressed the patient. After a fair trial, it Avas aban- doned as promising no benefit. There was no reason AAiiatever to continue further a doubtful experiment. La- bor continued, and a girl Avas born about 4, a.m. The placenta soon folloAved, and the mother and child left com- fortable in an hour after. 7th and 8th. — Doing Avell. On the 8th, got one dram ol. ric. and sue. limon. and had many discharges. 9th. — In morning, comfortable. Much disturbed yes- terday Avith protracted and violent crying and screaming of 27 210 ETHERIZATION in childbirth. infant. 9th, p.:m. — Less Avell. About an hour ago, felt faint, Aveak, exhausted. Has constantly attended her child; sitting up in bed on elboAv to nurse it, and fatiguing her- self excessively by other care of it. Nurse does not satisfy her. Pulse as good as in morning. Milk coming. State doubtless OAving to fatigue. Recovery perfect. Case XXIX. — Natural Labor. No. 178, age twenty-seven; first labor. Says she Avas married nine months to-morroAV, Oct. 9th. Has not had catamenia since. Was taken in labor this morning, the 8th, at about 5, a.m. Was at dinner Avith the family. Lig. amnii came away at 1, p.m. I saAv her between 2 and 3. She was sitting up, but lay down that an exami- nation might be made. She was much disturbed morally, on account of this process. She had not expected to be taken ill so soon; nothing was ready. She wept vehe- mently, and showed an unusual nervous impressibility. Os uteri barely admitted the finger. It was very high up, and Avas reached Avith difficulty. There being no occasion for my staying, I left, to be called when uterine effort oc- curred of a more decided character. I was called again between 3 and 4. Contractions were now urgent. On examination, no other change had occured in the os uteri, except its being more dilatable. The ether Avas asked for; and, at about a quarter past 4, it was exhibited. It very soon produced its effects. First, loquacity; laughing; ex- pressions of relief; strange feelings; &c. &c. Contractions soon became stronger than they had been. Ether Avas more emphatically demanded. Os uteri dilated rapidly; shoAv became abundant; head descended. At length, full etherization shoAved itself, viz. a heavy, sleepy, perfectly quiet state. Not the least voluntary effort during uterine contractions. She could be roused to bear doAvn. Some CASES. 211 Avarm tea was offered her, which she expressed a desire for; but she had no poAver to raise or to move her head. She could make the effort, but said listlessly she had no poAver to do it. Her face became exceedingly pale and cold; pulse distinct, not rapid nor slow; respiration natural; temperature, except of skin of face, good. Now, in the midst of all this perfect repose, the contractions went on. The head descended into the bony outlet. She still asked for ether, rather by signs than words, but with that faint- ness in enunciation that showed it did not proceed from acute suffering, and so was strikingly contrasted Avith the manner in which ether was demanded in the earlier part of the labor. No more ether Avas used. The head came upon the perineum. It formed its tumor, and began to separate the external labia. It receded A*ery suddenly Avhen contraction ceased. At length it was pressed by most vig- orous contraction nearly through, and then would retreat by a bound so sudden as to rouse the patient. After two or three such efforts, the head was born. I passed my finger to the neck, and found the cord drawn twice tightly round it. This, Avhich may have delayed the head at the close of the labor, much embarrassed the delivery of the trunk. The child, however, was soon entirely born, alive, before 6, p.m. an hour and a half after etherization was begun, and about four from the beginning of true labor. The child, a girl, cried stoutly, and Avas soon separated from the placenta. This last soon followed under and by firm contractions of the womb, without pain and without hemorrhage. It Avas not stated above, that Mrs. ----, about two months before delivery, had fallen down stairs, had recov- ered herself, and fallen again, producing a bruise on the anterior and loAver part of the abdomen; and which spot Avas the seat of the only pain complained of during labor. This gave much interest to the case. A. complication of labor might have occurred of the most serious character, — 212 etherization in childbirth. rupture of the Avomb; Avhich lesion has of late been by some Avritcrs ascribed to previous disease, or injury of the organ, during pregnancy. Record made, Oct. 8th, at half-past 8, p.m. Oct. 9th, a.m. — Very comfortable. Night somewhat disturbed by after-pains, which probably were OAving to distended bladder; for they disappeared entirely after vol- untary and free discharge of urine. Pulse 84. Skin Avarm, of natural color. Respiration perfectly easy, and all things doing Avell. Child's Aveight, seven pounds and a half. Pa- tient says to question, that before marriage she has ahvays suffered seA ere pain at the catamenial period, accompanied Avith very large discharge. Recovery rapid and perfect. Case XXX. — Natural Labor. Oct. 17th. — No. 176, first labor; age tAventy-tAvo. Ex- ceedingly diminutive person; arms so small that you might suppose she Avould break them in her efforts during labor. No show. Dilatation not Avanting, though slight. No ex- pulsatory efforts, though much suffering. I Avas called at 1, a.m. 17th, Sunday morning. BetAveen 2 and 3, took ether-vapor. Contractions were distressing and expulsa- tory. Soon after inhalation, shoAV abundant. Water came aAvay by puncture of membranes, Avhich Avere very thick and firm, and os uteri well dilated. Much relief after ether. Pain in back, before very urgent, no longer complained of. Outcry entirely omitted in contractions. Urgent demands for ether, if at all Avithheld. Great relief acknowledged. Effects on muscular action very pronounced. Labor over between 4 and 5, a.m. Every thing favorable. No hemor- rhage. Uterus Avell contracted. After-pains soon set in. Increased, accompanied by strong desire to pass urine. Failure. I used catheter, and at once relieved after-pains. CASES. 213 and removed all suffering. More than a quart taken aAvay. Has suffered dysuria during close of pregnancy. — Are not after-pains more frequently the consequence of state of bladder than is commonly supposed 1 Case XXXI. — Natural Labor. No. 171. Engaged for Sept. 27th. Labor begun night of Oct. 28th. I Avas called about 9, a.m. 29th. Examina- tion shoAved the head coming doAvn, but still at or just below the brim. Os uteri dilated; a large bag of Avater filling pelvis. Contractions were very strong; suffering great. Nausea; choking; vomiting. Great distress at stomach. She breathed ether between 10 and 11. Stom- ach soon and entirely relieved. Less influence of ether on suffering, though this became gradually less and less. The last contractions were very strong, as the effort became stronger as the ether Avas more freely used. But suffering less. Pulse, temperature, color of skin, complexion, respi- ration, remained perfectly natural. Child born about 12, noon; a girl, crying lustily at once, and weighing eight pounds. I saAv her two hours after, and found her perfectly comfortable. No hemorrhage. After-pains very slight, as she still, Avhen she pleased, used ether. Recovered Avell. Case XXXII. — Natural Labor. No. 180, thirty-six years old; mother of two children. Labors, tAventy-four hours long, very severe, attended Avith much distress in head, dizziness, confusion, pain, a lifting sensation as if top of head were in motion, and rising up. Labor occurred 1, a.m. Oct. 30th, by waters coming aAvay before contractions had taken place. These soon folloAved, and became sca ere. I Avas called betAveen 6 and 7, a.m. 214 etherization in childbirth. Efforts strong; much suffering. Head of patient in state above described, requiring pressure constantly; as this Avas said to afford some relief. Pulse rapid, not full. Exami- nation discovered head far up in pelvis, scarcely to be reached. Os uteri dilated and dilatable. Vagina and external organs dilatable; very little shoAv. Demand for ether Avas not gratified till betAveen 8 and 9. Effect pro- duced very soon, after about eight inspirations. Great comfort reported from its use. It was given in less than usual quantity, and at considerable intervals; the times between contractions being passed in perfect quiet. The uneasiness of head entirely disappeared under its use, and pains accompanied by much less suffering than before ethe- rization Avas produced. Contractions became more and more pronounced; the head descended; the scalp became corrugated; shoAv abundant; and relaxation of organs as great as could be desired. I learned that, in former labors, more than usual hemorrhage had followed the delivery of the placenta; and, to prevent this, one dram of ergot Avas infused in six ounces hot Avater, and one ounce of the clear tea given. As the labor approached its close, and the pres- sure and pain increased, the ether was inspired more freely, and its whole effect produced. The child Avas born at about 10, a.m. and with no apparent suffering to mother, or cer- tainly with none Avhich was expressed by complaint. The child cried strongly at once upon being born, and Avas separated from the placenta. The placenta soon folloAved, and no hemorrhage occurred. The child was a boy, weigh- . ing ten pounds. I saAv her two hours after labor. Has had some after- pains, Avith strong demand for emptying the bladder, which she did freely. I noAV learned she had before suffered from strangury. The trouble occurred Avith the pains. A large coagulum came away during one of these. Ether Avas again inspired. Valerian, the liquid extract, given; and, at my evening call, 1 learned there had been very little CASES. 215 suffering since my previous Aisit, and that noAV her head was well. One circumstance particularly interested me. This was the fact as stated, that there was no feeling of Aveakness, of exhaustion, which had so strikingly followed previous labors. She said she felt able to get up, and to go about as if nothing had happened. This has been again and again stated by others Avho have inspired ether in labor. This case occupied about nine hours, dating from rupture of membranes; contractions coming on after that event. The preceding labors had been twenty-four hours each. The suffering was as nothing compared with that Avhich accompanied the preceding cases. The condition afterwards was strikingly different, 31st. — Comfortable ; one dejection without medicine. Some uneasiness occasionally in head. Nov. 1st. — Perfectly well. One dejection, natural. Feels strong as in ordinary health; head well. 4th. — Quite as well. Milk abundant; no precursory trouble. BoAvels as regular as in ordinary health. Says again her health is as good, her strength the same, as it ever is. In about a fortnight after labor, this patient made a jour- ney, with her infant, of about forty miles; being in perfect health and strength. After former labors, convalescence very slow; after one, keeping her in bed five weeks. Case XXXIII. — Natural Labor. No. 184, aged thirty-nine; third labor. Has suffered much in former labors. Pains distressing to an extraordi- nary degree, and of long continuance. Her present labor begun, Nov. 2d, at 10, p.m. Her physician was called early in the morning of the 3d. He found but slight progress had been made, and left to be called when wanted. Was called about 12, noon. Suffering now, — and is also 21(5 etherization in childbirth. most severe. He has neAcr seen contractions stronger. They are almost Avithout interval, resembling those pro- duced by ergot. At a quarter to one, he administered ether-vapor. He did it, as he believed, thoroughly, but AAith no effect to diminish pain or consciousness. He believed something more was necessary, and asked my aid. I found this woman in the extremity of suffering, not judg- ing by outcries and Aiolent movements, but by that exces- sive effort, and the suppressed groans and screams, Avhich so well indicate hoAV much is patiently endured. On ex- amination, I found the head well doAvn; bones strongly overlapping each other. The presentation Avas natural; position good. The pains had no such effect as led me to look for speedy labor, though every thing seemed to favor it. A small portion of the os uteri Avas pressed doAvn between the head and symphysis pubis, but, being returned, did not prolapse again. Here Avas a fair case of the power of ether. I begged Dr.----to Avet his sponge thoroughly, and to apply it carefully over the mouth and nose. This Avas done and repeated; and, in a very feAV minutes, it Avas clear she Avas under its full influence. She was quiet in the intervals of effort. These intervals Avere more- strongly marked. She Avas first incoherent in Avhat she said, talking of " foAvls," &c. &c. and at length not talking at all. Voluntary effort Avas obviously diminished, if not entirely Avanting. Dr. ----Avas desired to press firmly upon the uterine tumor. The head descended, and Avas at length born. The child Avas alive. The body soon followed; the placenta came aAvay by uterine effort; no hemorrhage. The woman, upon recovering consciousness, said that the first thing she heard or knew after the ether Avas used, after I came in, Avas the crying of her child. She Avas perfectly insensible during the last hour or more that passed before her child Avas born. It Avas a boy, and Aveighed ten pounds and a half. Recovery perfect. CASES. 217 Case XXXIV. — Natural Labor. No. 173. This case was to me of much interest. Mrs. ---- is aged twenty-four; has been married twenty-two months. First menstruated at eighteen; then Avas without a period for eighteen months. Swelled much in abdomen. Suffered ordinary symptoms of amenorrhea. Took strong emenagogues, and menstruated. After a time, function again ceased for seven months, with ordinary troubles; then re-appeared, while using stimulants of various kinds. Since marriage, has been irregular; has had SAvelling, re- sembling pregnancy, as before, but distinguished from the enlargement of pregnancy, by absence of all other signs, and by the rapidity and irregularity of its increase, and the great amount of it. Ten months anterior to the 5th Nov., catamenia, having been more or less regular before that time, again ceased; being absent, during marriage, four months without pregnancy. This was not attended by any other sign of pregnancy than the increased size of the ab- domen, which took place much after the manner which has been noticed above. Her health was now good. Had abundant flesh and perfectly healthy complexion. Mrs.----called on me for advice occasionally in the last ten months. I examined her carefully, felt no foetal motion, nor did she; and the sounds of the foetal heart, and of the placenta, were not perceived. The os uteri and neck had undergone no change, the examination being made be- fore the sixth month. I saw Mrs.----again after this time. I noAV examined her again. She called, because of a new symptom, a bloody discharge from the nipples, which had occurred at the catamenial period, at what she considered the sixth month from the last suppression of the function, and had occurred at the seventh. I felt now distinctly the foetal motion. She felt it also for the first time. She had before felt a waving sensation in the abdomen, Avhich she had 218 etherization in childbirth. ascribed to Avind. I examined the breasts, and found Avell- marked areolae, and the glands within them strongly deAreloped. I told her then, that, dating from the middle period betAveen the last, and Avhat should have been a catamenial Aoav, I thought she would be taken in labor the last of October. I saAv some of the bloody fluid discharged in a small vessel, Avhich had been applied to the nipple to receiA'e it. This appeared again at the eighth month, Avhen the catamenia should have appeared, and Avas replaced soon after by a discharge of a fluid resembling milk. Airs.----continued in her usual state; many of her friends, disbelieving entirely that pregnancy existed, until Nov. 5th. She Avas taken early in the morning Avith pain in the abdomen, Avhich she regarded as colic. Regular uterine effort soon declared itself, and I Avas called to see her at noon. I found her in labor, but that so little pro- gress had been made that it Avas not necessary for me to remain. I was called again between 5 and 6, p.m. I now found the os uteri partially dilated, and the head descending favorably. One thing especially attracted attention. This was the extreme sensitiveness of the external and internal organs. Examination, made Avith the greatest care, gave exquisite pain. The suffering was described as infinitely greater than that which accompanied uterine effort, though this Avas very severe. There Avas abundant shoAV, and suf- ficient dilatability; but, from the os externum to the os uteri, every line of substance Avas in a state of tenderness, never before met with by me. Again, Mrs.-----had, in addition to uterine pain, contractions, a deep-seated pain, referred to the left side, reaching to the groin, and more distressing than was uterine contraction. This existed during the interval, and was quite as severe then as during regular effort. She described this trouble not clearly. She said it Avas an indescribable misery. At about 8, the patient's distress having much increased, I proposed she should inhale ether-vapor. To this she CASES. 219 objected. She had no fear of it, but was desirous to have her first child naturally, that she might know what child- birth was. There was a sentiment wrapped up in this which I was not willing to disturb. At length, the various suffering of this woman imperiously demanded abatement, if this could be safely obtained. She inhaled ether. Its full effect, and soon after beginning its use, Avas produced; and this very suddenly, she passing at once into a state of perfect insensibility. She was quiet, — involuntary effort ceased, — she was unable to raise the eyelids, or to ansAver any question, or to shoAV at all that she heard or kneAv of any thing said or done around her. Pulse natural. Breath- ing easy. Temperature and complexion as usual. She passed as suddenly out of this state as she did into it. First, breathing became strong, hurried, then short and labored. She moved the head suddenly, and at length began to speak. At first, I could not understand what Avas said. I then learned that she was in distress; her head was confused; that the effects of ether had been only distressing; that she had heard what had been said, but could gixe no answer; that she had tried, and her suffering Avas greater, because she could not communicate with those around her. She felt, she said, so sadly, such a deep melancholy was over her spirit, that she could only weep. Examination shoAved greater descent of head, more dilatation, bag of water, &c. Labor was evidently advancing. Tenderness of organs, pain in side, and suffering during pains, as great as ever. Some relief was produced by the catheter, and a mustard plaster to side. Ether was again tried, with very little un- pleasant effect, except an uneasiness of head, for which it Avas again laid aside. To relieve the side, change of position Avas resorted to; and, at length, Mrs.-----got off the bed, and had some pains on the floor. She Avas soon tired of this position, and desired to be again placed on the bed. Examination shoAved satisfactory progress. Pains noAV became vehement, 220 etherization in childbirth. and relief Avas demanded by the patient Avith its least equi- vocal expression. She demanded ether. She cared not for its preAious effects, or for her previous disinclination to its use. She Avas in agony, and must be relieved. I gave it to her. She inhaled it freely. She noAV experienced from it only its kindest effects. She could not be easy a moment without it. It Avas constantly inhaled. Labor advanced. The side Avas reported free from pain. The tenderness of the organs Avas no longer felt. The child was born Avithout her consciousness, and its cries Avere heard Avith strongly expressed satisfaction. In the midst of these latest effects of ether, she was asked, Avhen consciousness recurred, if she suffered as she did at first. She said she kneAv nothing about that. She believed her head was well enough. She did not care. She only wanted to be relieved, and cared not how. Mrs.----- continued to inhale ether during the delivery of the afterbirth, and for great soreness and distress in the vagina and external organs, which folloAved the birth of her child. Relief of this trouble followed this use of it. Pain, resembling after-pains, soon followed delivery. This disappeared entirely by emptying the bladder by voluntary effort, and by the passage of some coagula along with the urine. I left her betAveen 11 and 12 at night. Child, a girl; Aveight about eight pounds. Nov. 6th. — Night tolerably good. Sleep troubled by outAvard disturbance, noise in street, and fire alarm. Has passed Avater. Pulse 72. Sleepy, quiet, without any pain. Report altogether comfortable. No dejection. 7th. — Quite as comfortable, except the pain in left side, as during labor, and soreness in abdomen, as at that time. The first has the character of after-pain in its periodical attacks, and the last is referred to flatus. Pulse 72; urine natural. 8th. — Much as yesterday. Prescribed ol. ricin. and sue. limon. one dram each. Mix. Take now, and repeat if need CASES. 221 be; afterwards, if uneasiness, pulv. Dov. five grains; and repeat p. r. n. 9th- — One dose of oil operated once, and well. Pain much relieved; not complained of. Slept well. Milk abun- dant. Pulse 72. Appetite good. Recovery perfect. Case XXXV. — Natural Labor. No. 155. Labor, Nov. 11th. Age thirty-nine; has had three children. First is eighteen; last, thirteen years old. Has been in much doubt concerning time of pregnancy. Engaged a nurse to attend her niore than twTo months ago. Labor began in the forenoon. Contractions slight. Some shoAv, night before. I Avas called between 2 and 3, p.m. of 11th. Head high up. SIioav abundant. Much relaxation of organs. Mouth, or rather neck, of Avomb loose, flabby, hanging doAvn, and as if period of pregnancy was not accomplished. Finger did not detect opening of os; and this because of the great looseness of neck, it passing from finger wherever pressure upon it Avas made. Her previous labors have been very soon over; a few pains suddenly finishing them, or when not at all looked for. On this account, I remained with the patient. Contractions gradually' increased till about 6, p.m. Avhen they Avere so urgent that ether was strongly desired. Ether was now inhaled. It did not as soon produce its effects as in other cases, requiring two or three minutes. But when these effects occurred, they Avere of the most favorable kind. The pains, first, Avere diminished in suffering; the intervals Avere without suffering; and, at length, a state more nearly resembling sleep than any thing else occurred. This Avas shoAved after this wise. She Avould be without complaint; pains strong, advancing the child; but not a word Avould be said. If the inhalation was too long interrupted, she Avould come out of the state of unconsciousness, and ask ')•)•) etherization in childbirth. Avith emphasis why we woke her up. This occurred a few- times in the tAvo hours in AA'hich she used ether. She said, " This is the greatest invention in the world." — "I va ill Avork every day I live, to make money to buy ether with for the poor." — " Who invented it 1" &c. &c. This Avoid invent Avas invariably used Avhen she spoke of the discovery of the power of ether to abolish pain. She Avas delivered about 8, p.m. and Avas first conscious of this on hearing the cry of the child. She said there was a baby there, but had no notion that it was hers. The placenta soon folloAved, preceded by a large mass of coagula, firm, and of different sizes. The Avomb contracted strongly. A SAvathe Avas applied Avith a compress of soft cloth betAveen the skin and itself, as she complained of soreness of the abdomen on pressure. Pulse, temperature, &c. Avell. Child, a boy, Aveighing nine pounds. I left her about 7 in a quiet sleep, Avaking easily Avhen I Avas leaving her chamber, and then at once falling off to sleep again. 12th. — Comfortable. Pulse 72. Some after-pain in night, but slept. Renal excretion free, three times since delivery. Strength unimpaired. Appetite good. 13th. — Quite as well. Pulse 68. No dejection. Nurses her child. Respiration, &c. well. Noav speaks more of her labor. Says she was wholly unconscious of the birth of her child. First sensation Avas pain, while I Avas pinning the swathe. Knew when the afterbirth came away. Was altogether comfortable during the whole, or recollects no- thing of its events. Is most struck now, hoAvever, with the continuance and consciousness of strength. Says she could do Avhat she ordinarily does, and Avith pleasure. As far as poAver of action is concerned, knows no difference from ordinary health. The expression of countenance, voice, and manner, perfectly natural. Recovery perfect. CASES. 223 Case XXXVI. — Preternatural Labor. No. 192, aged thirty-five; third labor. First labor, arm presented; child dead. Second, natural presentation, child dead. In both, process between two and three days, and accompanied with great suffering. Was taken in present labor, Dec. 2d. I Avas called to see her in the country, Dec. 4th. Shoulder presentation. Cord largely prolapsed, and pulsation had ceased many hours before my arrival. It was livid. Pains have entirely ceased. Pulse rapid; skin hot; face flushed. Bowels and bladder have been attended to. Hand had been brought doAvn, and reduced. I advised ether, and then turning. Etherization was readily induced. I passed the hand into the vagina with very little trouble, before ether Avas inspired. Some pain Avas complained of. Previous manipulations to turn had produced good dilatability. In state of perfect etherization, I reached a foot, and brought it doAvn. Some difficulty occurring in the turning, I passed the hook into the ham, and it advanced as rapidly as usual. The child soon followed, and then the placenta; the Avhole being completed in less than an hour after my arri- val. The child had obviously been dead some time. In this case, ether was singularly useful. There was not ■ the least voluntary resistance. The womb had been empty of Avater many hours. Pains had ceased, and the con- tractility of texture and muscular action had brought the Avomb into close contact Avith the child. This I learned in the operation. There was most perfect quiet of the body, and not a complaint uttered. The patient says she AAras conscious of what Avas doing, but betrayed none; and sensibility Avas entirely suspended. It Avas perhaps the most satisfactory case I have met Avith. Remarks. — A case of attempted turning, during etheri- 224 ETHERIZATION IN CHILDBIRTH. zation, is reported in a French journal, and is said to have have been unsuccessful, or presented nothing AA'hich distin- guished it from the operation Avhen done under common circumstances. A case of arm presentation is inserted in Appendix, from Dr. Putnam's paper in " Boston Medical Journal." Case XXXVII. — Internal Hemorrhage. No. 194. In this patient, Avhom I saAv in consultation, ether was used, during labor, to diminish pain, and had the desired effect. Her labor wras perfectly easy. Mrs.---- continued comfortable for an hour after delivery. She then began to fail. Her pulse flagged; skin became pale and cold, and great faintness was complained of. No external hemorrhage. Stimulants Avere given, and the hand passed into the womb. It was full of coagula: these Avere broken down and removed, and a great flow of liquid blood fol- lowed. Attempts were made by friction of the Avomb inside, and pressure outside, to produce contraction ; and, failing, a bit of ice was carried into the organ, Avhich now at once contracted, and for the moment seemed to have accom- plished its Avhole work. But, soon after, the womb relaxed again; and the re-action Avhich had begun Avas at once checked, and the alarming symptoms recurred. I was noAV asked to see the patient, and learned above particulars. I found her, as described, extremely sunken; pulse not at all perceptible in left wrist, and very feeble in the right. The face pale and cold. A constant and urgent demand for air, by fanning, and from abroad through an open window. The womb was alternately contracting and re- laxing, notwithstanding constant pressure. Applications of ice to abdomen ; internal use of ergot; stimulants, &c. I learned that delivery had taken place more than two hours before my arrival; that there had been no hemor- rhage for some time ; and that the state of the patient, as CASES. 225 described, was rather the result of what had happened, than of Avhat Avas going on. I found the Avomb, at one moment, firmly contracted; then becoming soft, and disappearing from pressure. The Avails of the abdomen Avere pendulous, loose, and fat; and pressure by the hand was not easily or usefully made. It was suggested to place graduated thin compresses over the womb, and keep them in their place; and the Avhole abdo- men under firm pressure by a wide, strong swathe. A strong sinapism Avas applied over the epigastrium. Warm gruel Avas adAised in place of other and cold drinks before used; and aqua ammoniae and tinct. cinnam. for other diffusible stimulants. Pulv. ergot, one dram, in tea-cup Avarm gruel, was given. These means were soon folloAved by some improvement. Copious vomiting occurred, preceded by much distress, but succeeded by re-action. The pulse earliest manifested change for the better. The skin grew Avarm. The lips got color. Mrs.----took the vessel into her own hand to drink from, &c. &c. I left her about 11, p.m. promising well, four hours after my arrival; recommending that she should not be removed till morning. Dec. 11th, a.m. — Has gradually improved. Pulse, skin, &c. fair. It Avas agreed to move her, and change her dress. This was done by lifting and moving her on a sheet in the horizontal posture. She bore the process well. Child, a girl, full size. Dec. 12th and 13th. — Doing well. Case XXXVIII. — Natural Labor. No. 190. I Avas engaged to attend on the 15th Dec. I Avas called between 12 and 1, a.m. of that day. Labor began half-past 11, p.m. of the 14th. I am particular about these facts, as this is one of the few cases in Avhich I have 29 226 ETHERIZATION IN CHILDBIRTH. been engaged for a particular day, so far as my memory serves, and in Avhich delivery has been accomplished at the time predicted. This is a fifth labor. Patient is about thirty, small, delicate, and suffers exceedingly during parturition. I found the child advancing with the pains.* The waters discharged, and os uteri very well dilated. I proposed ether, merely to relieve pain. She readily inspired it. It slightly diminished the suffering of the first and second pain I Avitnessed. But, from these till delivery, she had no more pain. The first thing she heard, after etherization, Avas the cry of her child. She was delivered about half-past 1, the Avhole process being over in about tAvo hours. Why, in such a case, use ether ? Why let a woman suffer"? In this case the pain was most intense. Mrs.-----has great poAver of patient endurance; but the sufferings in her labors have ahvays seemed insupportable. I was most grateful for an agent which, Avithout the least injury, or approach to it, so entirely checked this agony. Case XXXIX. — Natural Labor. No. 198. Dec. 20th. — Called eight miles from the city this morning, between 8 and 9, a.m. This is the third labor, and began last night at about 12. I found the la- bor Avell advanced. The os uteri dilated; the head enter- ing the outlet, and a full bag of Avater before it during pain. She had looked for my arrival Avith much interest; feared I Avould not reach ; had resisted pains as far as Avas in her poAver, and Avas still doing it. She desired the ether to be administered. This was done. She came almost imme- * The word pains used here, and elsewhere in this work, means contractions; uterine contractions; and never suffering. This explanation should have been ^ivon before. It will, however, answer its purpose as well now. CASES. 227 diately under its influence ; was perfectly still, and, during a very strong pain, made no complaint. The Avater came aAvay. Upon recurrence of another contraction, she inhaled again; and this a third time, when the child Avas born — a son — alive and vigorous, and of more than average size. Mrs.-----was unconscious. She said that the first thing she heard, after inhaling, Avas the cry of her child. Her recovery has been perfectly good. Case XL. — Instrumental Labor. No. 200. Dec. 26th, 3, p.m. — I received a note desiring me to meet a professional friend in consultation, closing thus: " Suppose you bring your forceps and ether." Upon reaching the address, I learned that the patient Avas twenty- six years of age; that the case Avas one of first labor, of about fifteen hours' duration; that the head had advanced to the outlet, and there it had rested for some hours. The pains had been extremely severe for most of the time; but they made no change in the position of the head. About three hours before my arrival, one dram and a half of poAvdered ergot, in infusion, had been given. It had pro- duced the characteristic action of ergot in its severest form; but the head remained unmoved. The same strong, violent contractions still manifested themselves. I examined, and ascertained that the statement of the attending physician Avas entirely correct. It was agreed to use ether. It Avas at once resorted to. It was used freely. The sponge Avas saturated Avith it. Very soon its effects declared them- selves in the fullest manner. The patient Avas Avholly unconscious ; she greAV very pale, but not livid ; remained perfectly at rest. The pulse Avas natural, and the breathing easy. Contractions continued, but produced no complaint, and no effect on head of child. It Avas now agreed that the forceps should be used. The instrument Avas applied 228 ETHERIZATION IN CHILDBIRTH. Avith perfect ease. The head soon began to descend, and delivery aatis accomplished sIoavIv, but in an aAcrage time. The face and scalp Avere black. The cord Avas found tightly draAvn about the neck, feebly pulsating. Much tinuf. regarding the effects of delay, under the circumstances, as making that long which under other circumstances might have occasioned but little uneasiness, — much time passed before the labor Avas completed. The child struggled slightly once in its progress through the external organs ; but, by the time it Avas delivered, the heart had ceased to beat, and efforts at animation failed. The perineum did not suffer any lesion; and the head wras free from marks of unusual pressure, or injury, from the instrument. Un- consciousness remained some minutes after delivery. The pulse Avas good. The breathing easy. The color Avas natural. A quiet sleep had taken the place of the con- dition of unrest and pain Avhich had preceded the action of the ether. At length, she, roused someAvhat, opened her eyes. She Avas asked if she Avas in pain, and her answer Avas — no. She Avas asked if she kneAv that her child Avas born ; she ansAvered Avith marked distinctness, no. The Avomb contracted Avell, and there Avas no hemorrhage. A bandage Avas applied, and the patient made comfortable, with as little disturbance as possible. I said to the physician, that the forceps had been intro- duced during insensibility. Said he, " I am glad this aatis done; for you Avould hardly have been able to apply them, had she been sensible to pain." And said further, that such Avas the acute suffering of the patient, during exami- nations conducted Avith the greatest care, that it Avas hardly possible to make them. Pallor was alluded to aboA^e, as very striking in this case. This is not the only case in which this has been noticed. In one, it existed to a degree Avhich Avas alarming to the bystanders. The face avus as Avhite as the sheet upon which the cheek rested. The lips were livid. The temperature CASES. 229 Avas sensibly diminished. The quiet of the patient Avas profound. You might have supposed her dead. The case occurred in the day, as did the above; and phenomena like these, change in complexion, &c. Avere strikingly apparent. But the pulse continued good in that case, as it did in this. Respiration Avas steady and natural. The womb acted Avith its best energy, and the child Avas delivered as if by its OAvn volitions, so wanting was all evidence of any agency of the mother in that event. WThen the patient Avas sufficiently recovered to take drink, and to shoAV that she Avished to drink, it Avas impossible for her to raise the head enough to bring the mouth Avithin reach of the vessel; and Avhen raised, and left to itself, it fell; and so suddenly, too, that for a moment you might question if it Avould ever move again. The means used were free ventilation ; Avarmth to the trunk and extremities; entire rest; gentle friction; volatile alkali to the nose; and Aveak brandy and water, when deglutition Avas possible. What Avas said Avas in no sense of a depressing tendency, but Avas hopeful and cheering. This Avas attended to, because I kneAv of cases in Avhich insensibility and apparent unconsciousness con- tinued nearly an hour after etherization, but in which patients afterward declared they had heard and understood every thing that was said; were conscious of the brisk friction Avhich had been practised; and, especially, of the remarks which were made of diagnosis and prognosis. The means used in the case alluded to (No. 178) might not have been necessary. The patient would probably have done perfectly well without them. But, in such circumstances, the physician must do something. He cannot remain a spectator merely, where there are many Avitnesses, and wiiere interest in Avhat is going on is too deep to alloAV of his inaction. Let him be collected and calm and he Avill probably do little he will afterAvards look upon with regret. The patient did perfectly Avell, and Avas a striking in- 2o0 ETHERIZATION IN CHILDBIRTH. stance of that rapid recovery Avhich is so generally observed to folloAv judicious etherization.* Case XLI. — Instrumental Labor. No. 201. I Avas called to this number about 3, a.m. Dec. 31st. The messenger said the patient had been some time in labor. I learned from the attending physician that Mrs.---- Avas thirty-two years old; that she had been more than tAventy-four hours in labor; and that this Avas her first child; that, Avhen he first examined, the os uteri Avas dilated equal to a fiVe-cent piece, Avas very firm, and looked strongly to the hollow of the sacrum. Dilata- tion proceeded sloAvly; but such Avas the strength and the severity of the contractions, that he began to use ether at 2, p.m. Mrs.---- had been more or less under its influence ever since. About a dram ansAvered at first to diminish or stop pain; but so great had been the demand for it, and so long continued its use, that he had used nearly a quart, Avhen I first saAv the patient. He had bled her, and AAras aftenvards able to slip the os uteri over the head. Still the head did not advance. The pains lost none of their power, though the suffering was much dimin- ished, and often entirely wanting. Dr.---- had, during etherization, succeeded in passing his hand beyond the head to the neck, and found that closely surrounded by the firm os uteri. I asked Avhat had been the state of the pulse, and learned that, before venesection, it was 90 in the minute. I counted it accurately, and it was noAV 160. I Avatched the pains and their effects for some time. No progress Avas made by the strongest; and, at length, it Avas agreed to try the forceps. They were applied with ease; * Since writing above, I have met with a case in which wiping the face and forehead with cold water was quite sufficient to produce consciousness, and entire recovery from etherization. CASES. 231 and the patient then brought under the full power of ether. The delivery was accomplished very sloAvly. Slight lace- ration of the perineum occurred. The child, a male, was born alive. The womb contracted well; separated and expelled the placenta. Usual floAving afterwards. The labor was completed at 5, a.m. twenty-seven hours from the beginning. I left the patient very comfortable at 7. Remarks. — Ether had been used in this case from 2, p.m. of Dec. 30th to 5, a.m. Dec. 31st, about fifteen hours. It produced not the slightest unpleasant effect. It was regu- larly asked for, and its uniform good effects Avere con- stantly acknowledged. This is the longest time, during Avhich ether was employed, I have met with; and it certainly did no harm. I am satisfied that it was only useful. Dr.----asked if the delay of delivery Avas not probably the result of the close contraction of the os uteri round the child's neck. I have certainly seen cases of delay of delivery which would seem had an explanation in the con- dition of the os uteri referred to. Did not etherization produce such change in the before-unyielding mouth of the Avomb, as allowed of early and safe delivery % See Appen- dix, for Dr. Fisher's report of this case. Case XLII. — Natural Labor. No. 202, aged twenty-two; second labor. Evening, 25th March, membranes broke, and much water came away. Pains folloAved, and I was called betAveen 11 and 12. Os uteri well dilated; head low, pains very strong, and suf- fering much; cannot prevent groans and outcries. When head Avas so far advanced, that it Avas obvious a few pains Avould terminate the case, inhalation (sulphuric ether) Avas advised. Very fair etherization soon followed. The pa- tient was perfectly still, the limbs relaxed, and no apparent 232 ETHERIZATION IN CHILDBIRTH. consciousness. In a minute or two, consciousness returned, and with it the most distinct perception of the state of etherization. " I am dying," Avas said more than once. Pulse, respiration, temperature, good. I said hush, and not a Avord more was said. Pain recurred after usual interval, and with increased force; and, after a second uterine effort, the child Avas born. In a former labor, the first, and before ether Avas used to abolish pain, there came on, in an hour more or less, after the child Avas born, and after I had left, faintings, Avhich were very alarming to bystanders. I Avas sent for, as also a neighbor physician. I found her pale, sunken, faint. Pulse Aery feeble; abdomen large, Avomb large. No exter- nal hemorrhage. Fland passed into the uterus ; discharged a large mass of coagula. Contraction at once took place, and was permanent. Re-action was soon established. I remained after the present, the second labor, an hour or more, Avhen fainting declared itself. Pulse remained, however, at the Avrist, and the womb was felt to be Avell contracted. Some external hemorrhage. A second swathe was applied without removing the first, and draAvn very tight. This afforded immediate relief, and there was no more trouble. 26th. — Very comfortable and bright. Slight after-pains, when child draws the breast. Pulse, &c. well. Case XLIII. — Natural Labor. Jan. 10th. — No. 203 was taken in labor this day, betAveen 7 and 8, a.m. I saw her first at half-past 2, p.m. She is nineteen, and this her first labor; in excellent health. The pains were, as expressed, of great severity; the back suf- fered most; and she Avould not, for a moment, allow the hand to be removed from it. Her outcry became stronger as her pains increased. Os uteri dilated to size of a dollar; CASES. 233 bag of water pushing strongly through it during pain; os firm, but dilatable. I suggested chloroform. She refused it. She was too much engrossed by her suffering to listen to any thing. I poured half a tea-spoonful on the sponge in the inhaler, and applied the instrument over the nose and mouth. She inhaled imperfectly; and, for a few minutes, no effect was observed. At length, she inhaled pretty freely, and became calm. She ceased to complain, and the hand Avas not required at her back. There Avas no effect whatever observed from the chloroform but quiet. At times there was sleep, but no continuous sleeping. With regard to the progress of the labor, the facts were of great interest. The pains rapidly increased. The show, Avhich was at first very small indeed, became abundant, and of the true character. The os uteri rapidly dilated. The waters came away, and the child was born alive, twenty- five minutes past 3, about an hour and tAventy minutes from the first use of chloroform. It was a boy, and weighed nine pounds and three quarters. The cord was three times round the neck ; and it was necessary to cut it, before the shoulders passed, such was the struggling and danger of the child. Mrs.---- was asked what were her recollections of the effects of chloroform, especially at the close of the labor. She said, she knew what Avas going on most of the time, — at times was fast asleep; and, at the last, though she knew when the child was born, her feeling Avas like Avhat occurred in the beginning of labor, a slight pain only in her back. There Avas no suffering. 11th. —Perfectly well. Case XLIV. — Natural Labor. No. 209 Avas taken in labor, Jan. 21st. She is about thirty, and this her first pregnancy. General health very good. Pulse natural. 30 234 ETHERIZATION IN CHILDBIRTH. Slight pains through the day; more strong towrards even- ing. I Avas called about 1, a.m. of the 22d. She Avas making great complaint. Pain in back severe; patient requiring an attendant constantly to " shove it," as she expresses it. Is very uneasy during intervals of pain, being no time free from suffering. Os uteri dilated to size of dol- lar, — dilatable, — bag of Avater protruding largely from it- Pains very strong, making a Arery decided impression upon the head, Avhich Avas the presenting part. I advised chlo- roform. The patient at first refused to use it; at length unwillingly consented to try it. Inhaled imperfectly Avith frequent interruptions. Complaints soon became less emphatic. Intervals of pain passed Avithout complaint, in apparently sound sleep. She, hoAvever, still demanded pressure to the back. The contractions became manifestly stronger. The lig. am. Avas discharged, and in large quantity. The head soon passed through the os uteri, and the scalp became strongly corrugated, the bones over- lapping each other broadly. Inhalation Avas at length practised better than at any earlier period, and the full effects of chloroform were manifested. A sound sleep, accompanied with loud and deep snoring, occupied the intervals of pains; and the pains Avere not at all noticed by the patient. I note this, more especially because of the rapidly increased force of the contractions, while under the fullest effects of chloroform. The woman's disinclination to the use of the remedy noAV showed itself soon after these effects disappeared, and after a manner too disagreeable to lead to any considerable further use of it, and, in a short time after, to its entire discontinuance. I Avas satisfied Avith this, for I had witnessed the effects of chloroform in this case in their best manifestation. Not the least excite- ment preceded, accompanied, or followed them. A state of entire tranquillity, as in profound and grateful sleep, accompanied them, and gave to me increased confidence in the agent, and in the means of using it. CASES. 235 Case XLV. — Natural Labor. No.----has had two children; is in excellent health. Was taken in labor at 6, a.m. Jan. 28th. I saAv her in about an hour after. She had resolved to inhale ether or chloroform; and I found both of these in her chamber. The os uteri was largely dilated; show abundant; and pains strong and expulsatory. She begged me at once to exhibit either chloroform or ether, as I preferred. The sponge in my conical inhaler was made thoroughly wet with chlo- roform ; and inhalation, deep and regular, Avas begun. Almost at once an effect Avas noticed, AA'hich shoAved the influence of the chloroform. A strong effort Avas manifested on the part of the Avomb; but no complaint was uttered. In the interval there was sleep. This Avas accompanied by the same placidness of countenance; the expression of that pleasurable repose which I have before noticed, after using this agent. As soon as contraction began, a demand Avas made for the chloroform, and the same results Avere noticed. In the mean time, the womb acted Avith increasing energy in eA^ery succeeding contraction. The perineal tumor soon formed, and the child Avas delivered without the least apparent suffering, in about an hour from beginning the inhalation. The afterbirth soon follo\Ared. The uterus contracted perfectly, and not the least hemorrhage occurred. The child Avas a male, weighing eight pounds, and cried lustily at birth. When the patient, if this term can be applied to such a case, had recovered, so as to state what had been her feelings during inhalation and her present consciousness, she said that insensibility occurred with the very first inhalation; and that she had not suffered a moment since. She had at times, consciousness of Avhat Avas going on about her; heard Avhat Avas said, &c.; but that this was not accompanied by any return of sensibility. This her statement is in perfect 236 ETHERIZATION IN CHILDBIRTH. correspondence Avith her apparent state. The countenance remained tranquil during uterine contractions of great force, and the body almost at rest. She expressed her gratitude for the relief she had experienced. Her first labor had been forty-eight hours in length, and Avas attended Avith great suffering. Her second Avas short, but very painful. With this, her third, she had experienced nothing but pleasure. She was asked of her present sensations. She described these as very singular, but not at all unpleasant. There Avas a universal tingling, such as is felt when a limb is " asleep," as it is called. This attracted her attention a good deal, but gave her not the least uneasiness, and soon passed of. Her pulse was decidedly slower than before inhalation. Jan. 29th. — In all respects doing AArell. Jan. 30th. — Sitting up. Appearance of perfect health. Manner natural, and as if nothing had happened. Had eaten her ordinary breakfast. Sleep good. Bowels moved yesterday, without medicine. Milk abundant. The after-pains in this case have been so slight as hardly to attract attention. The inhaler Avas left, that chloroform might be used if desired ; but it was not thought necessary. Case XLVI. — Natural Labor. No. 187 Avas taken in labor this morning, Feb. 11th, about 3 o'clock. Third mature labor. Flas flooded severely in former labors, and has much suffered from pains. I saw her between'8 and 9, a.m. Water came aAvay early this morning in great quantity, and has continued to floAV so largely that a vessel is constantly used in bed to receive it. Child has advanced well into the pelvis. Os uteri still partly covers head, but is perfectly dilatable. Pain soon groAving veryr seAere, chloroform was inhaled. It produced its full effects in less than a minute; the inspirations being four or five, and not remarkably deep. She Avas spoken to CASES. 237 with clear full voice, but gave no answer; was told to raise eyelids, but did not at all move them. Strong pains. In interval, became conscious. Said she had felt no pain since inhalation. As soon as pain began, demand was made for the inhaler, and so for about six times before the labor ended. She did not knoAv by pain when the child wras born. The Avomb contracted well. Placenta was readily throAvn off. Moderate discharge of blood followed. Labor Avas completed in about an hour after my arrival. She said that, at first, there was noise and confusion in head, but not such as at all interfered Avith consciousness. She knew Avhat Avas said and done, but had had no pain. There was tingling, principally confined to hands, and slight cramp in right leg. This occurred after moving the limb. She had good color, good pulse, no flowing; still felt that voluntary poAver was very slight. She did not move her limbs Avhen requested to do this, not feeling she had power to do so. Her eyes Avere very sensible to light, and the room was darkened. I was desirous to learn what was the state of the breath as to odor. The odor of ether-vapor remains so long, even for days in some cases, I Avas anxious to knoAV how it Avas Avith chloroform. The breath was perfectly free from any sinell whatever; that state which accompanies perfect health of the teeth, gums, throat, and lungs. I think the least trace of chloroform Avould have been detected, if one had existed. The examination was made as soon after perfect consciousness was restored as was convenient, Avhich Avas in a few minutes after the afterbirth came away. I left her after 10, a.m. Avithout hemorrhage, or any existing trouble. This case more nearly resembled, in the heavy sleep and snoring during intervals of pains, the cases reported by Professor Simpson, than any I have met with. 12th. — Very comfortable. Pulse and respiration na- tural. Has still a feeling in head, resembling Avhat folloAA^ed 23 h ETHERIZATION IN CHILDBIRTH. inhalation and delivery. Not disagreeable, but singular. Still says muscular power diminished; or she feels as if she should try to walk, she might fail. Chloroform has produced the same effect in experiments Avith it on persons in perfect health, men and Avomen. Has milk ; no dejec- tion ; urine natural. 13th. — To-day, reports very AArell. All feeling con- nected with inhalation gone. Has excellent appetite. Feels that she could get up and Avalk about as usual. Has not been so Avell after previous labors. Pulse, Sec. Avell. No dejection. In morning take early ol. ric. and sue. limon. each one dram. Recovery perfect. Case XLVII. — Natural Labor. Feb. 13th. — No. 215, aged thirty; third pregnancy; taken in labor about noon. Contractions strong towards evening. I Avas called between 5 and 6, p.m. I found head at brim. Os uteri perfectly dilated. Bag of water formed. Organs soft, dilatable ; pulse good; health perfect. Contraction, soon after arrival, very strong, causing outcry. Pain in back very severe. Chloroform inhaled well, and soon came fairly, but mo- derately, under its influence. Outcry ceased. Back scarcely complained of. Bag broke, head descended rapidly, and Avithout pain; and child, a girl, Avas born alive, and Avith scarce any consciousness of the event. Four inhalations in intervals of so many contractions; child born after fifth. Not the smallest untoAvard circumstance occurred; and she Avas left perfectly comfortable, and rapidly recovered. Case XLVIII. — Instrumental Labor. Feb. 14th. — No. 216, aged thirty-one; first labor. I first saAv this patient between thirty and forty hours from the be- CASES. 239 ginning of the labor. For more than twenty-four hours, severe and urgent contractions. Bag broke about 10, p.m. of the 13th. Progress very sIoav and very painful. Vomiting in day. No sleep. No urine during the day. Yesterday, frequent and sufficient micturition. I found the skin hot and dry. The organs very much in the same state. No shoAv; but, on the contrary, that ichorous discharge Avhich ahvays gives the sensation of hard water. Contractions noAV slight; a short effort, quickly over, and accompanied by a jerking grunt; a sound Avhich always says, that, how- ever distressing the condition or pain which produces it, it does no sort of good. No tumor in ordinary situation of bladder; but, in the right iliac fossa, quite to the right of the linea alba, a sAvelling, distinct from the uterine, was felt, and which eAidently contained a fluid. A long, flat, and nearly straight, female catheter Avas introduced, but did not bring aAvay a drop of urine. A very small curved catheter, exactly shaped like the male instrument, but shorter, was now used, and its point directed towards the right iliac fossa. The urine iioav floAved freely, and the fullness there disappeared. The Avoman Avas noAV carefully examined. The os uteri had not disappeared. The head Avas at the very outlet, with the scalp much swollen, so as to prevent the sutures from being felt. The anterior part of the pelvis Avas entirely filled by the cranium. The back part less filled, as Avhen the face is to the symphysis pubis; and the os uteri being still low in front, and that part so full that you might have supposed that the face was there. The pains grew slighter, Avith longer intervals. What was to be done? The attending physician suggested ergot, and I saw no reason against trying it. It Avas used, and some increase of effect followed. This, however, produced but little, if any, effect upon the head; and this increase of contraction soon passed aAvay. Upon consultation, neither the beat of the fcetal heart, nor the placentary bruit, Avas heard. I belieAred 240 ETHERIZATION IN CHILDBIRTH. I felt a faint moArement of the foetus. The Avomb Avas firmly and constantly contracted. Its hardness Avas very striking. Under these circumstances, I recommended the forceps. The patient was asking, in a Aery faint voice, but Avith all she could command, " When shall I be relieved ?" " Shall I get well V I used the common English forceps, made after Smellie's. I chose this, because space was so exceedingly small in the sides of the pelvis, and toAvards which the parietal protuberances looked. The branches were introduced Avithout difficulty, and were locked easily, near the perineum. The usual examinations were made to ascertain that the instrument Avas Avell applied; and, every thing being satisfactory, the chloroform Avas inhaled. The sponge in the conical inhaler was Avetted, by inverting upon it quickly the mouth of a small-necked phial three times, and a sufficient quantity Avas receiAed by the sponge to moisten it thoroughly. The instrument Avas applied over the mouth and nose, and inhalation freely performed. In less than a minute, etherization was fully established. Not the smallest consciousness could be discovered. The breath- ing was low, gentle, inaudible. The pulse was fuller than before the experiment, and natural in beat. The stillness Avas so entire that I asked if breathing was performed. Complexion perfectly good. The arm, being raised, fell poAverless on the bed. No nausea, though vomiting Avas present just before inhalation. Extraction Avas now made. It was made steadily, but firmly, and the instrument kept its place. Effort and interval Avent on, and the head very kindly descended. The perineal tumor formed; the head came upon it. The Avomb acted well; and, in about half an hour from begin- ning the operation, it was completed, without the slightest accident. The inhaler was used once only after the first, because the patient made a slight movement of a hand. It was used for a moment only, and then the same quiet occurred as after its first use. During the Avhole delhrery, CASES. 241 and the force required Avas as great as I have ordinarily noticed it to be, and which heretofore has been so exqui- sitely painful, — during the Avhole of the operation, not the least noise was heard, not a groan nor a grunt, nor the least observable motion of the head or of a limb. I have seen many persons during etherization. I have seen natural and instrumental labor, Avhen its influence seemed perfect; but my observation has given to me no such case as this. It seemed to be the silence, the repose of death, Avhich Ave Avere witnessing, and not simply the suspension of voluntary functions, Avhich to the common observer declare the fact of living. The child, a girl, Avas born aliAc. Its motions Avere at first feeble, but soon became sufficiently pronounced. Its cries Avere clear and loud. The Avomb contracted perfectly, separating and expelling the placenta readily, and without any hemorrhage. The patient, if such a term can be used in such a case, soon began to revive. Consciousness gradually, and Avithout the least distress, returned. She heard her child cry, and immediately expressed her joy, and an extreme solicitude that it should be taken good care of. She Avas asked how she had been during labor. She declared she kneAv nothing about it. She had not felt a pain since inhalation. Her head had been perfectly Avell. Not the least noise in, or ringing in the ears, flashings of light, &c. Nothing to disturb her had for a moment been felt. " I heard a Avord said sometimes," she said, and this Avas all. She had been in profound sleep, and still had not been Avithout the enjoyment AAithAvhich such sleep, after such fatigue, seems to haA'e accompanying it. There are doubters in the profession, of the propriety or expediency of ether- ization ; and there are clergymen who say it is a violation of the " curse of God " — if such language be not blasphemy — to mitigate or remove human suffering. From my heart do I Avish that such had been in that poor Avomans only room, and witnessed Avhat occurred in it, — its perfect peace and 31 242 ETHERIZATION IN CHILDBIRTH. pleasure, Avhere before Avas agony; and the joy Avhich so largely and richly replaced that former Avretcliedness and fear! 15th. — Night very comfortable. Pulse 80. Urine natural. Says she feels perfectly well. Has had no trouble whatever since delivery. RecoArery perfect. Case XLIX. — Natural Labor. Feb. 17th. — No. 218, aged twenty-two; first child. Taken in night of 16th. AAvake all night. Pains severe at 3, a.m. 17th. I was called betAveen 7 and 8, a.m. I found her in a chair, pale, and apparently much exhausted. She spoke very feebly, saying she had been in hard labor since 3 o'clock, and aAvake all night. Her bed Avas pre- pared, and she went to it. Os uteri dilated to size of dol- lar; very thin, and this thinness extending an inch or more towards the body of the uterus. Edge sharp, but someAvhat dilatable. During a pain Avhich came on, it yielded a little, but was felt drawn tight round the cranium. There Avas no bag of water formed. When contraction had subsided, and during its greatest pressure, she lay with her eyes closed, face very pale, without making any effort, and as if asleep. Pulse small, frequent. I asked if she suffered. She said, in a faint Avhisper, that she did excessively. Between 9 and 10, the labor had advanced; and, her suffering being great, and her appear- ance exhausted, she inhaled chloroform. She soon said that it made her faint, and she could not use it longer. I noAV learned that she fainted often in ordinary health. The pulse showed no sign of diseased heart. She now suffered less during pains, which were rather increased than less- ened after inhalation. She still looked as if in profound sleep. Suffering returned; and in about an hour she inhaled again, and, at about the same inteiwals, five times CASES. 243 more. After one of them, before the last, she Avas entirely insensible and partially unconscious. Pains continued, and the head reached the perineum. This yielded very sloAvly, and at length became greatly distended; a portion of the scalp, with a very little of the cranium, only protrud- ing. The distress from this cause soon became extreme. She now inhaled freely, and in less than a minute Avas un- der the full influence of the chloroform. She very slowly turned from her left to right side, adjusted her limbs, and fell into a profound sleep, whispering for a moment or two, as the sleeper often does. I have never seen a moAement like this during etherization. You see sometimes the arms move someAvhat freely up and doAvn, or from side to side, and now and then other involuntary movements. But, in this case, the whole action resembled that Avhich occurs noAV and then in sleep, and simply because of uneasiness of the posi- tion. The will determines these motions, and the muscles obey. This is in no sense spasmodic, involuntary, con- vulsive ; nor did it seem at all so in my patient. The perineum yielded most readily under a strong uterine con- traction, and without the least effort of a muscle Avhich Avas not its own. The natural lubrication Avas abundant. The head passed with perfect ease, not suddenly, but after a manner which prevented injury. The trunk soon folloAved, and the placenta was delivered, and the sAvathe put on be- fore any appearance of consciousness. A moderate flow preceded the placenta, but none folloAved. The child, a male, was alive, cried lustily, and weighed ten pounds and six ounces. This was just before 2, p.m. about six hours from my reaching the address. On account of the appearance of exhaustion, I directed nourishment, as gruel, and stimulants Avhen they seemed indicated. An infusion of tAvo drams of secale powder was made by pouring the poAvder into hot coffee, of the clear tea of Avhich she noAV and then drank. This Avas given, not because pains were at any time wanting, — they " running 214 ETHERIZATION IN CHILDBIRTH. together,"' before, as the nurse said, — but because of the slow- progress of the head, and the appearance of the w oman. It Avas also very desirable to provide, if possible, for good con- traction after delivery. At no time Avas the ordinary action of secale present. The pains remained much as they were, gradually increasing as labor dreAv nearer to a close. There was no continuous effort. The intervals of pains were as strongly marked as in any case in Avhich the infusion has not been taken. During the almost entire unconsciousness after one inhalation, and its entire absence during the latest contractions, the pains Avere as strong, nay, stronger than at any other time. I did not leave this patient from the time of entering the chamber, till she Avas made comfortable after delivery in bed. I wished to ob- serve the effects of etherization, especially in regard to its effects on uterine action. I can noAV say, that I never saAv it more salutary. I called about 6, p.m. and found the patient quiet and very comfortable. She had nursed her child, having had milk for some Aveeks. She had slept most of the time, being only iioav and then disturbed by slight after- pains. 18th. — Reports a good night, and is now perfectly com- fortable. Renal excretion free. Pulse 80, of good strength. Was taken out of bed last evening, Avhile her bed Avas made, and Avithout being at all faint or fatigued, and has been up this morning. I regretted this had been done. But, as an experiment upon the condition of the Avoman in regard to strength, it Avas not Avithout interest. 19th. — Report good. No dejection. 01. ric. two drams, sue. lim. tAvo drams. Mix. Morning. 20th. — Night good. Some headach in day. Milk abundant. No dejection. Enema. Recover) sIoav, but perfect. CASES. 245 Case L. — Presentation of Hand and Cord. No. 217, age thirty. Has had — as I learned at this my first visit, Feb. 20th — four children. The first Avas born alive ; the three folloAving were dead-born. Was taken in labor this day, 20th. After dinner, at 6 o'clock, pains Avere urgent. I Avas desired to visit her at a little past 10. She Avas sitting up, but soon lay down. Examined. Ex- ternal organs soft, dilatable, with abundant shoAV. At the brim of the pelvis, the vagina being perfectly relaxed and empty, a loose bagging texture was felt, Avhich was the os uteri and a portion of the neck, with the flaccid membranes within. Os uteri perfectly dilatable. No presenting part Avas at first reached. At length, Avhat Avas thought the head Avas felt, though so imperfectly made out that it Avas questionable if it Avere the head. A pain came on, and the bag of Avater became very tense, and protruded strongly and largely into the vagina. Examined again when the pain ceased. A hand Avas felt in the bag; the head, if such it were, having passed beyond reach. Under all the circumstances, the previous long and pain- ful labors, and the many disappointments of my patient, — for the child, Avhich Avas born alive, did not live long, — I determined to proceed at once to deliver by turning. The Avater came away during a pain; and iioav, in addition to a hand, I found the cord Avas presenting. Its pulsation Avas sIoav, say about 60 in a minute, but firm and unintermit- ting. Etherization Avas iioav produced by chloroform. At first it Avas accompanied by some intellectual excitement, Avhich shoAved itself by talking of her former labors and other matters, and by some movements of the body. There Avas no violence or extravagance in either, and they soon passed away. The left hand Avas carried into the Avomb, and Avith great ease. The head was lying in the right iliac fossa, or near to it. A foot was easily felt, seized, and 246 ETHERIZATION IN CHILDBIRTH. sIoavIa brought doAvn. The breech soon folioAved ; then the trunk and upper extremities. The last Avere aided in their descent. The head Avas sIoav in its progress ; but the Avomb, acting vigorously during the Avhole operation of turning, together with careful traction, soon accomplished the delivery. There Avas no pain from the establishment of etherization. The child, a girl, breathed feebly at first; but cold water to the chest, and friction, Avere soon folloAved by free respiration. I first saw this patient a feAV minutes past 10 ; and at 11 the labor Avas accomplished, and about thirty minutes from beginning the use of chloroform. The placenta Avas ex- pelled in the usual time, and Avithout hemorrhage. I left the patient Aery comfortable a little after 11. 21st. — Perfectly comfortable. Slept well. Slight after- pains. Says she has never felt so strong after any previous labor. Pulse Avell; lochia natural. Recovery perfect. Case LI. — Natural Labor. No. 222, age tvventy7-t\vo ; third labor. Taken with slight pains, afternoon of Feb. 24th. I saAv her at a quarter to 11, p.m. Os uteri someAvhat dilated, and dilatable. Pains slight; soon increased in strength. Bag formed, very large; head sloAvly descended. I told her I had chloroform with me; and, if she found her sufferings to be so severe as to lead her to desire their diminution, she might breathe it. At 12 she asked for it, and at once inhaled it. A small tea-spoonful Avas poured upon the sponge, and she inhaled freely. In about a minute, its effect was manifested. She could not raise her eyelids, but seemed aware of my direc- tion that she should do so. Contractions very soon showed great increase in strength, and the head reached the bony outlet. Another spoonful of chloroform Avas poured on the sponge. Contractions became not only very strong, but CASES. 247 soon Avere almost continuous. The head advanced rapidly. The perineal tumor formed, and the delivery was completed. The child, a girl, cried lustily. This took place at twenty- five minutes past 12, just so many minutes from beginning inhalation. There was imperfect consciousness of delivery; but insensibility was so nearly complete, that suffering was not in the least experienced. The afterbirth soon followed. The womb contracted well. There was no hemorrhage. The pulse was full and strong, and entire satisfaction expressed Avith the chloroform. In this case, the quantity of water Avas much larger than usual, so that it floAved over the bed upon the floor. This has been the case in both of the preceding cases. I left her at a few minutes before one. 25th. — Night good. Slight after-pains ; more floAving after I left than in former labors; but no faintness nor exhaustion. Now good pulse; temperature natural; no pain; general feelings good. Child Avell. It weighs eight pounds. 26th. — Doing perfectly well. I examined the breath immediately after the labor Avas over. There was not the least odor of chloroform observed. Case LII. — Preternatural Labor. Presentation of Hand. No. 224, age thirty; seventh labor. In preceding six, only one child born alive. Taken in labor, Feb. 28th. Waters coming aAvay. Attended by a midwife till this morning, March 3d, at 12 o'clock, midnight. Dr.----Avas then called. Had attended her in former labors. These had been long, severe, very painful, and had resulted as above stated. He found the hand presenting. The Avomb strongly contracted upon the body of the foetus, and the waters entirely drained away. He attempted to turn ; got a foot down to the neighborhood of the symphysis pubis, 24 s ETHERIZATION IN CHILDBIRTH. Avhere it stopped, and from AAiiich situation no effort of his could move it. I AA-as called in consultation between 3 and 4, a.m. Found hand in vagina, within external organs; — latter swollen, hot, dry, tender. I advised etherization. Not because of severity of pains Avas this recommended, for contractions had nearly ceased, but because of the suffering Avhich the most careful examination produced, and Avhich could not but be immediately increased by the difficulties incident to turning. I did advise it. The ether Avas to be sent for, and I had time to make observations. The Avoman breathed heavily, — sometimes Avith slight groaning, as if from lurking pain. The skin Avas bathed in heavy SAveat; but the pulse had force, Avas stead}", and not above a hundred in the minute. There Avas time to prepare and to administer some nourishment. It Avas taken Avith relish, and w7as Avell borne. There had been no vomiting. The renal and alvine functions Avere not much disturbed. There Avas no hemorrhage. The ether Avas brought. It Avas Avillingly and freely inhaled; for the patient kneAv one Avho in childbirth had recently used it, and Avith benefit. She Avas soon under its poAver. I noAV proceeded to turn. The hand Avas first felt, and next the foot. It was firm in its place. I could not move it Avith the finger and thumb, with Avhich I Avith dif- ficulty reached it. It was now embraced by an appropriate instrument, and was brought doAvn Ioav enough to be reached and surrounded by a fillet. Extraction Avas iioav made, with difficulty indeed; but progress Avas evident. At length, the feet, and then a part of the trunk, appeared. Great difficulty now occurred. It Avas removed by bringing doAvn one arm ; and then, by an instrument, the other came along, and with it the head quite easily. The Avomb con- tracted well; but it Avas judged best to remove the after- birth, while the effects of ether lasted; and so the labor Avas accomplished Avithout any complaint during most of the CASES. 249 process. The time required Avas less than an hour. A swathe Avas applied, and the woman Avas made as com- fortable as circumstances allowed. She soon came out of the state of etherization. The pulse was as firm as before it Avas induced. She took some nourishment with pleasure, and Avas left in a perfectly quiet state, disposed to sleep, having for days and nights been Avithout rest. Recovery perfect. Case LIII. — Preternatural Labor. Upper Extremity. No. 225, age thirty; third labor. Says present labor began, Monday, Feb. 29th. I saAv her first this evening about 7, March 4th. Hand, forearm, humerus, and part of the shoulder, fill the pelvis; neither protruding. During first tAvo or three days, has been attended by a woman, and has been seen by three physicians since. Two met me this evening. I learned from the first, that he was called to see her last evening, the 3d; that the pelvis was filled by the membranes containing the waters; and that, after the contraction ceased, and the bag became flaccid, the finger detected no part of the foetus below the brim of the pelvis; and, at that strait, the portion felt seemed to resemble a hip, more than any thing else. The other medical attendant felt the hand in the pelvis, when he examined to-day. I found the brim of the pelvis perfectly filled by the shoulder and a portion of the chest. Had not the pains almost subsided, spontaneous evolution might have been expected, and Avith safety waited for. As it Avas, exhaus- tion Avas present, and labor Avithout aid impracticable. What Avas the aid to be I The fcetal motions had not been felt for tAvo days. There Avas no pulse in the arm of the foetus, and it Avas enormously swollen. Ether Avas inhaled; and, under its imperfect influence, an attempt Avas made to turn. This Avas impracticable. The brim of the pelvis was 32 250 ETHERIZATION IN CHILDBIRTH. croAvded full, and Avould not admit any thing through it. It Avas agreed, that the arm should be removed at the shoulder, and the chest opened, and its contents removed. This Avas done, and the thorax noAV allowed of sufficient compression to permit the hand to enter the uterine cavity. A foot was reached and brought down during complete etherization, and very easily was the delivery completed. The arm which was removed was perfectly black, and full twice the size of the other. The Avomb contracted, and separated and expelled the placenta. No hemorrhage. I left her, soon after, in a tranquil sleep, with easy respira- tion, good temperature, and firm, and not morbidly fre- quent pulse. March 12th. — I have not made a daily record; for it has not been necessary on account of any trouble from chloroform. She had seA ere cough immediately following delivery, and, I learned, had suffered from this some days before labor began. It Avas masked during labor, as far as I witnessed this: at least, it did not attract my attention in the graver troubles present. She had rusty and copious expectoration for a few days. This pulmonary trouble did not produce any other, and gradually decreased. The milk came, and was abundant, and continues now. Lochia has been perfectly natural. Is this day without complaint, and says she Avas never better at this time after delivery. Case LIV. — Premature Labor. March 14th. — No. 228. Without knoAvn cause, water came away in eA'ening of 13th. Has aborted before, and was in great danger from flooding. Has had two natural labors. Is of feeble health, and of very nervous, irritable temperament. I was called betAveen 11 and 12, p.m. of 13th. Has pains, with large discharge of colored fluid. Presentation not CASES. 251 Avithin reach. Abdomen very pendulous, and uterine tumor largely thrust forward. Pains gradually increased, and became very severe. When presentation was determined, it Avas found to be head, somewhat squeezed into the os uteri. The latter very firm, with hard, unyielding edge. At first, ether was not desired. It was offered because it has been safely used during some operations on the teeth. At length, it was willingly inhaled. It was used because of the severity of pain, the sense of exhaustion, and the undilatable state of os uteri. Its effects were what they Avere when used as referred to by the dentist. The lower limbs felt as asleep. They were moved rapidly, but not excessively. There was confusion in the head, and gen- erally not pleasant consciousness. But pain was diminished. When this latter was greatest, a desire was expressed to sit up, in the belief that this would facilitate delivery. This was done, and the Avomb speedily expelled its contents. No hemorrhage; no after-pains. Was seen between 5 and 6, p.m. entirely comfortable, with a pulse of 72, and good strength. 14th. — Doing well. Recovery perfect.* Case LV. — Convulsions. No. 229, age twenty-eight; fifth labor. Seized with con- vulsions about 8, p.m. March 13th, there having been severe headach through day. (Edematous. I saw her at about 10. Venesection had been used, and with excellent effect. Ice constantly to head. Fits have not appeared since. I left with her medical attendant, to go again if deemed neces- sary. It Avas agreed that venesection should be repeated, if necessary; afterwards ether, if convulsions. My engage- ment with No. 228 prevented my keeping my appointment, * In some cases, this statement does not occur. It is, however, always to be understood, unless some other manner of termination is given. 252 ETHERIZATION IN CHILDBIRTH. till early in the morning of 14th. I noAV learned that the venesection had been repeated freely, and then sulphuric ether Avas inhaled. The effect Avas perfectly salutary. The conAulsions ceased. The labor advanced rapidly ; sensibil- ity and consciousness being entirely absent, and still volun- tary effort apparently as strong as in any labor Avithout etherization. The child Avas alive. It was born in about three hours after inhalation, and Avithout the least convul- sive complication. In half an hour after delivery, fits returned. I Avent in just after the first was over. Ether had been tried again, and Avithout effect; and it Avas judged best to lay it aside. An enema of asafoetida and tinct. opii Avas now directed. It Avas folloAved by perfect quiet, last- ing about three hours; the time being passed in quiet, noiseless sleep. This state Avas folloAved, betAveen 11 and 12, Avith return of convulsions, which continued Avhen I left about 1, p.m. The pulse was good; and, in inteiwals, there Avas natural expression of countenance, and good color and respiration. It aatis agreed to continue the anti- spasmodics. A full dose of hyd. submur. had been given in the forenoon; and it was further agreed, that an infu- sion of senna, Avith sulphate of magnesia, should be pre- pared, and given as circumstances might alloAV. 15th, 10, a.m. — No convulsion from about 1 yesterday, Avhen I left, till 5, p.m. Then a fit, and four more before 8. Copious dejections then took place, Avith great apparent relief. The pulse Avas more natural; respiration easy; skin, of good appearance and temperature. I learned there had been threatenings of convulsions, in their interval, in the preceding afternoon; but the antispasmodic remedy at once produced, or Avas followed by, quiet. Is noAV in per- fectly tranquil sleep. Has had body and bed clothes changed, and in every respect made comfortable. Has ansAvered by monosyllables. Pulse 72, soft, good. Skin moist. Takes gruel readilyr. 16th. — Consciousness returned perfectly, soon after CASES. 253 morning visit of yesterday. To-day perfectly comfortable. Child well. 19th. — Well. Case LVI. — Natural Labor. No. 212. During a very severe attack of vomiting, accompanied Avith intense headach, the membranes broke, and the liquor amnii Avas discharged. The stomach became quiet under the use of the hydrocyanic acid, and the head- ach disappeared. This happened about a week ago. Labor began this morning, April 4th, at 4, p.m. The contractions Avere strong at 6, and I Avas called about 7. Head low; anterior fontanelle to right acetabulum; os uteri dilated; and promise of a speedy delivery. Very little progress, hoAv- ever, Avas made, though the contractions continued strong, and accompanied by much pain. The pulse Avas natural in number, and very firm. Respiration good, and no com- plaint but of the uterine action. After waiting towards two hours, and every thing being favorable, I gave an infusion of secale. Contractions Avere soon stronger, but AAith regular intervals; the continuous tonic contractions which accompany the specific action of secale being quite wanting. When the pains had reached a point of such severity as to make the demand for relief very strong, and this coming from the patient, chloroform Avas used, about two drams in the Avhole, and etherization produced. The passage of the head was felt; but it Avas without pain. The strongest expressions Avere made of gratitude for this good deliverance. The child, a male, was born, vigorously livino-, in tAventy minutes from beginning to inhale chloro- form. Placenta followed, and no hemorrhage. In the first labor, — this being the second, — much excitement folloAved immediately upon delivery. A similar state of things folloAved this. I left the patient Aery comfortable. Recovery perfect. 254 ETHERIZATION IN CHILDBIRTH. Case LVII. — Convulsions. No. 234, age thirty-three; three children at full time, one at seven months, accompanied by profuse hemorrhage; and three abortions. Is noAV seven months pregnant. Has had poor health during Avhole time. Asthma has much annoyed her, and, Avithin three or four Aveeks, has suffered from severe attack of influenza. Has gradually become universally and greatly anasarcous. On 9th, severe headach, but Avas doAvn to dinner. Took very little food. Headach increased, p.m. ; and, at about 1, a.m. of 10th, was seized Avith convulsion. Got active ene- mata soon, and inhaled sulphuric ether. Great excitement folloAved, becoming almost uncontrollable. Chloroform Avas substituted for ether, and the change in things Avas almost immediate. Great quiet took place; and, though fits con- tinued, their intervals were long, and she was partially conscious during them. Headach continued. Attempts had been made to bleed, but failed. Leeches were applied to temple. Chloroform continued. I first saAv patient betAveen 4 and 5, a.m. The convulsions recurred at long intervals, retaining their character of violence. Some con- sciousness still in intervals. Os uteri closed, very high up. Organs generally very dilatable. Mucus secretion suffi- cient. Another attempt was made to bleed, and success- fully. About twenty ounces of blood were drawn from a large orifice, and in a very short time, when it Avas judged best to stop the flow. When the leeches came off, the bites continued to discharge blood quite freely. Chloroform Avas in use at the time; and, after an inhalation, the bleeding entirely ceased, and did not at all recur. Convulsions con- tinued as before, and it was noAV agreed to employ anti- spasmodic and narcotic remedies; the tinct. opii, and an emulsion of asafoetida, one dram to an enema, and from thirty to forty drops of the former. These obAiously, for a CASES. 255 time, checked the convulsions; and at length, after various experiences of their use, the fits ceased about 10, p.m. and did not recur. She had a perfectly quiet night; and this morning, Apr. 11, she was found comfortable and conscious. She took yesterday fifteen grains of hyd. submur. with ten of fine sugar and gum-arabic, by floating them on water, and putting them into the mouth before they were dis- solved. No dejection. Renal excretion natural. Comp. inf. sennae, directed till catharsis. 12th. — Senna has operated sufficiently. Night com- fortable, and so is this morning. Pulse good. Tono-ue very sore. I was called to see her at 10, a.m. in the absence of her physician, but did not get the message till nearly 12, noon. The child (the head presenting) was born just before I arrived. The placenta soon followed. The child was still-born, and, from appearances, had been some time dead. Extensive cuticular abrasion had taken place, and the whole seemed as if it had undergone long maceration. Recovery perfect. Case LVIII. — Natural Labor. No. 197, age twenty-four; first labor. Short; strong. Black hair and eyes; florid brunette. Before pregnancy, always well. Latter months, occasional severe vomiting, which may continue many hours. For some days before labor, great tenderness and soreness over abdomen; diffused. Can scarcely bear weight of clothes. Labor, April 18th. For two or three days before, precursory symptoms more or less pronounced. At 2, a.m. of 18th, contractions strong, colored show, &c. I Avas called at 4, a.m. Pains good; not frequent. Os uteri of size of quarter of a dollar, thin at edges, generally soft, but still, at extreme edge,firm or sharp ; a state easily recognized, but not easily described. Con- tractions increase in force,; inteiwals fair, but no progress. 256 ETHERIZATION IN CHILDBIRTH. Os uteri as before. Water bag protrudes through os. At half-past 12, I exhibited chloroform. It Avas inhaled avcII, and produced not the least unpleasant result. Etherization occurred after very feAV inhalations, sometimes not more than two. It, for the most part, continued a very short time, only making frequent inhalation necessary. The quantity of chloroform at a time on the sponge, in the conical inhaler, was from half a dram to a dram and a half. Great relief always experienced and expressed. At times, unconsciousness and insensibility Avere complete; and it was during these that uterine action was strongest and most efficacious. Pulse, at beginning of etherization, was about 80, soft, strong. It was examined about every half- hour. It fell once to 68; but, for the most part, Avas at from 72 to 74. Breathing was throughout good. Warmth and perspiration natural. At times pale, at others flushed. Demands for chloroform unusually urgent, and some irrita- bility when not promptly allowed. Renal function natural. No confusion of head. Some numbness, and more tingling of extremities; phenomena exceedingly common during etherization. During complete action of chloroform, any proper amount of pressure of abdomen perfectly tolerated. At all other times, sensibility here very acute, and strong complaint of any pressure. Some effects deserve special notice: — 1. Increased dilatability Avithin half an hour after etheri- zation. 2. Manifest increase of pain or contraction. 3. Intervals remained about the same, and were passed in most perfect, quiet sleep. 4. Pain in back, which before demanded constant pres- sure during contraction, was hardly referred to. At half-past 6, p.m. and having used about three ounces of chloroform, the child, a male, Avas easily born, and in full life; and in six hours from beginning of etherization. Cord more than once round neck and body. CASES. 257 In this case the os uteri came doAvn Avith and before the head, after an unusual manner, considering its dilatability. It was carried up, and Avithout difficulty, but would descend again as soon as contraction began. The position probably favored this, the face being to the left acetabulum. The os began to SAvell. Congestion in it had taken place. It Avas getting firm. I now did Avhat I often find useful in such a case. I gave the infusion of secale, after the manner already stated. This was soon folloAved by such con- tractions as, by shortening the womb, dreAV the mouth fairly above the head, and prevented further descent. The peculiar character of pains Avhich attend ergotism Avas not for a moment present, the intervals being as perfect as before its use; a condition of things before observed, after using secale during etherization, and which may explain the rareness of still-birth in these cases. Case LIX. — Natural Labor. No. 219, aged twenty; second labor; first, eighteen months ago. For very severe headach, to which she is very subject, chloroform Avas inhaled, some three months since. About a Aveek ago, another attack Avas treated in the same way by the patient. Labor occurred in the evening of May 8th. I Avas called about 3, a.m. of the 9th. The odor of chloroform filled the chamber, and after a manner I had not noticed before. I asked how this hap- pened. A friend of the patient said that Mrs.----had been using it for some time, and was now fully under its influence. I found at once that this Avas the case. She used it thus: — A tea-spoonful was poured into a tumbler; and this she held to her face, until, overcome by the vapor, it fell from her hand, or, being quite free from pain, enough consciousness remained to alloAV her to put the tumbler upon the bed. The atmosphere Avas so charged Avith the 33 258 ETHERIZATION IN CHILDBIRTH. vapor, that her attendant was frequently obliged to leave the room, and Avas severely vomited. The patient had not the least nausea. I substituted the conical inhaler for the tumbler, with much advantage. The vapor Avas very soon removed by opening a window, and no further trouble occurred. The pulse, respiration, temperature, were perfectly natural. A quiet sleep prevailed, marked by the repose of countenance, and appearance of most perfect ease, Avhich are so characteristic of etherization. The head was quite low in the pelvis ; os uteri well dilated, and dilating rapidly during each contraction. Intervals Avere short, and uterine effort progressively increasing; and this without the least complaint, or apparent voluntary effort. The membranes became full and tense, and remaining unbroken, notwithstanding the entire disappearance of os uteri, and descent of the head, they were broken, and the waters discharged. Delivery soon after took place; and the child, of large size, a female, Avas born, with scarce any evidence of uneasiness. The womb contracted well. The placenta was soon cast off from the uterus, and with a slight effort removed from the vagina. No hemorrhage followed. This patient had suffered very severely from after-pains in her first labor. For some hours they annoyed her excessively; and the nursing of her infant, for some time, reneAved them. She noAV meant to try Avhat chloroform Avould do to prevent or lessen this trouble. I left with her the inhaler and chloroform. She was visited in the course of the forenoon, and expressed her obligations to the remedy of pain, as the after-pains had been made quite tolerable. 10th. — Very comfortable. Pulse, &c. well. Abdomen soft, Avithout pain. Womb well contracted, and occupying the usual place at this time from labor. She was still inhaling chloroform, as after-pains made it necessary. I well remember a case, communicated by a friend who has very kindly aided me in my collections for this volume, in CASES. 259 which sulphuric ether was used during the labor. His patient Avas a sufferer from after-pains, in a very extra- ordinary extent. She was living some miles from town; and, when my friend left her, he left her a large bottle, con- taining about a quart of ether, to be used as circumstances might require. She used it freely, and with the happiest effects, and Avithout the least untoward occurrence. 11th.—Day and night good. Milk in abundance. Slight after-pains. Pulse well. No fullness or tenderness of abdomen. No dejection. Nausea. Is easily moved by cathartics. Cannot take ol. ricin. Salts a favorite medicine. Directed one dram magnes. sulphat. and half a dram mag. calcinat. May 12th. — Has not taken medicine, as she had natural dejection yesterday, p.m. Nausea gone. Pulse 72. Ab- domen Avell. Had last evening headach, Avhich threaten- ing to be severe, she inhaled chloroform, not very satis- factorily, she added, as she had not the inhaler. Pain, however, Avas relieved. Has always been subject to nausea; very great care as to diet alloAving her any comfort; and often this fails.. Has taken salts, &c. as prescribed day before yesterday. Reports herself much better than after former confinement; was then obliged to keep her bed for three Aveeks and four days. 13th. — Doing well. Salts have operated freely. Milk abundant. No uneasiness in abdomen. Pulse 72. 14th. — Doing Avell. Pulse, &c. as before. v) Case LX. — Natural Labor. No. 221; first child. Taken with pain, Thursday, May 11th. At 5, p.m. labor, more declared, prevented sleep. At 9, a.m. of 12th, pains very severe. I was called betAveen 12 and 1, noon. Patient Avalking about in much distress, begging for chloroform. I had none with me. It Avas '2v') ETHERIZATION IN CHILDBIRTH. soon procured; and the patient and the bed being prepared for labor, she laid herself doAvn, and, at ten minutes past 1, began to inhale chloroform. Her pulse was about 70, small. Skin cool, yet quite red; hands and arms especially so. In every respect feeling Avell. Etherization was produced almost immediately, from a small tea-spoonful poured upon a handkerchief. At first the pulse Avas but slightly altered. In a succeeding induction of etherization, it fell to 48. It was firm, strong, but very sIoav. The first effects were noises in the head, Avith somnolency. As soon as the state of the pulse Avas ascertained, less and less chloroform Avas used, and a feAV drops only were often sufficient. The patient managed inhalation very much by herself. It Avas directly abandoned as soon as its effects were produced. It seemed to me, by attending to the pulse, it Avas as easy, quite as easy, to regulate the use and the effects of chloroform, as it is to manage the exhibition of any other active medicine. I felt here, in this case, hoAV important is the fact in the history of a medicinal agent, that it has power ; that it can do some- thing ; yes, do a great deal. As soon as you deal Avith such agents, you feel the strongest obligation of duty to observe, almost every moment, their effects. This case Avas full of the Avisest and best teachings, and I listened to all its Avords. I regret I did not at the moment make a record of CAerv change the pulse undenvent. I examined it constantly; my Avatch Avas by me on the bed; the hour Avas noon, and the sun was in the chamber. I had every facility, and I improAed it all. I felt perfectly assured of the Avhole safety of the case. I should as soon haAe felt disturbed by the operation of an emetic dose of ipecacuanha, as by Avhat was passing before my eyes. The labor Avas terminated at ten minutes past 2. A acta large male child Avas born, in full health and life. The mother kneAv of this fact only by its cry, and then Avas obliged, by the circumstances of her delivery, to ask Avhat child that Avas. — Avas it hers 1 CASES. 261 The afterbirth soon followed. Perfect uterine con- tractions took place. Some pain attended this, or rather forcing effort, for which she begged for a little more chlo- roform; and her Avish Avas gratified. No hemorrhage occurred, and I left her perfectly well, about an hour after her child Avas born. May 13th, 9, a.m. — Very comfortable. Pulse 72, soft, natural. Slept well. Is strong, and looks in usual health. Some milk. Abdomen soft, not at all tender. 14th. — Doing Avell. Pulse 72. Had pain in abdomen, loAver part (uterus), last evening (after-pain), Avhich dis- turbed sleep first part of night; then slept well. No dejec- tion. If none in course of day, take to-morroAv morning one dram magnes. sulphat. and fifteen grains magnes. calc. Recovery perfect. ' ^ Case LXI. — Convulsions. No. 253 Avas seized with most severe pain or cramp in the stomach, about 4, p.m. May 7th; and this without the least error in diet, or the presence of any known disease, or change from ordinary health. In the evening, convulsions. These were very severe. They had been preceded by that state of stomach to which Denman and others ascribe such important agency in the production of this most formidable disease. For a time, some consciousness occurred between the fits. This Avas not of long continuance. Bloodletting, and leeching to head, Avere practised. But the skin Avas pale and cold, and the pulse feeble; and much blood Avas not taken, — and this with very little, if any, relief. Chloroform was inhaled, but did not diminish the violence, or increase the intervals betAveen the fits. These, for the most part, Avere about half an hour; once, an hour and half. Urine, draAvn by the catheter, shoAved some striking deviations from the healthy condition of this secretion. It 262 ETHERIZATION IN CHILDBIRTH. Avas of a blackish brown color, not at all resembling urine; and in smell it Avas still more unlike it, it being entirely destitute of urinous odor. I first saAv this patient betAA-een 12 and 1, noon, of the 8th. She was perfectly unconscious. Her breathing Avas heavy and noisy. Her pulse Aery rapid, small, Aviry ; much heat, especially about the face. The face Avas SAvollen, leaden pale, and haggard. Anasarca existed everywhere. Her loAver extremities Avere especially SAvollen. Ramsbo- tham and others have showed how common is the disease, convulsions, in this condition of the cellular tissue. Exa- mination showed that labor had begun. Os uteri dilated someAvhat, and dilatable. The membranes separated from the scalp byr liquor amnii, and ready to protrude through os uteri. Lubrication sufficient, and organs generally in a healthful state. A fit soon came on. It was violent. The head Avas turned strongly to right shoulder, and convulsive motion Avas much more striking in this extremity than in the left. Especially was this the case in the beginning of the parox- ysm. Aftenvards the left arm shook nearly as violently as the right. During the height of the fit, the pulse at the Avrist Avas Avanting. As chloroform had not controlled the fits, sulphuric ether was inhaled. For a short time, the intervals were length- ened ; but, after this, the fits became as frequent, and more so than before. Labor had advanced, so that the membranes fairly protruded beyond the os uteri. The state of the patient was obviously groAving worse. The disease had noAV existed many hours: it was obviously increasing. It Avas agreed to puncture the membranes. This was done, and much water passed off. Some temporary diminution of the fits followed; but they soon became as pronounced as ever. As the child was now within reach of instruments, and as a ery careful auscultation discovered no evidence of the continuance of fcetal life, it Avas agreed to deli\er. This CASES. 263 Avas done; and, during the operation and for some time after, fits did not occur. The pulse improved, — gained strength, and Avas slower. The breathing was good, and lividity entirely disappeared. I left her in this comfortable state towards evening. Convulsions recurred soon after, but ceased again; and, Thursday evening, she was comfortable. This state, how- ever, did not last. Sinking gradually came on, and death took place forty-eight hours from the birth of the child. Case LXII. — Natural Labor. No. 251 has had one child. Was taken in labor, Mon- day, June 12th, noon. I was called at 1, a.m. 13th. I learned that, since 10, p.m. of 12th, she had been in almost constant and most severe pain. The contractions were almost continuous, as is the case from secale. She made great complaint, and vehemently demanded ether. She had said that she Avould never use it; but such was her misery, she would do any thing to have it lessened or removed. I had with me chloroform and chloric ether, and resolved to try the latter. A hollow sponge was well Avetted Avith it, and she began inhalation. The effect was to diminish suf- fering, — to render it tolerable, but not to destroy either consciousness or sensibility7. The contractions Avere not in the least lessened. The head was found to be very low; membranes entire, and nearly protruding beyond external organs. The water was soon discharged, and the head came upon the perineum. Labor proceeded very rapidly. An abundant secretion took the place of unusual dryness, Avhich existed before inhalation; and the process was soon completed by the birth of a living female child, which Avas found to Aveigh ten pounds. The afterbirth soon folloAved; and, after it, a large mass of liquid and firmly coagulated blood was expelled. No 264 ETHERIZATION IN CHILDBIRTH. hemorrhage, or other untoward accident, occurred. In this case, etherization Avas incomplete; but great relief was produced, just AAThat is wanted in such, or in any, cases of suffering. Chloric ether Avas first used by me in this case; at least, was Avholly depended on. It irritated the throat at first, producing cough, as does sulphuric ether. It also vomited the patient; and this is the first instance in Avhich I observed vomiting in etherization. It seemed less powerful than either sulphuric ether or chloroform; that is, a very free use of it certainly produced less effect than such use of them is generally accompanied by. The pulse, the breathing, and the temperature and complexion, remained unaffected during its use. I left the patient perfectly well, tAvo or three hours after delivery. Recovery Avas very rapid. No after-pains. The patient asked if this Avas not rare. I said they were very common; but exceptions often occurred. My attention has been particularly called to this subject of the effect of etheriza- tion on after-pains. I have met with at least tAvo cases in which very severe after-pains occurred after very perfect action of ether. My general experience, however, shows a very different result. A friend yesterday said, that he had very recently used etherization as a remedy for after-pains, and asked me if I had so employed it. I said, yes, and Avith excellent effect, and remembered a case which was communicated to me, in which these pains Avere exceedingly severe, but Avhich Avere entirely held in check by ether. My friend said that he had not used ether or chloroform for this purpose until lately. He had been deterred by some theoretical fear, that the womb might possibly be relaxed by the use of ether, and so hemorrhage be pro- duced. But, he added, he had lately used it in cases of most severe after-pains, and Avith perfect relief, and Avithout hemorrhage or any other untoward result. CASES. 265 Case LXIII. — Instrumental Labor. No. 256, age thirty-eight; first labor. Was taken, June 19th. Membranes broke at the very beginning of labor, and contractions began with great strength very soon after. These were attended with great pain. They continued with very slow dilatation, and slight progress in the case, till the 21st, Avhen they decidedly slackened betAveen 3 and 4, p.m. I should have said there had been very little, if any, sleep since the beginning of labor; dozings merely in the inter- vals of contractions. I was desired to see her, and reached the address betAveen 6 and 7, p.m. of 21st, about forty-eight hours after the beginning of labor. This was the state of things. Pulse betAveen 120 and 130, with the characters of exhaustion. Skin hot; face deeply flushed with that fixed and dark red Avhich the complexion assumes after long-continued exertion, attended with much forced retention of breath. Head very hot, demanding constant and frequently renewed applications of cold water. She said she was utterly Avorn out, exhaust- ed, and asked for relief. Head of foetus low. Left ear under symphysis, the free portion looking toward right acetabulum; the face being to left side of pelvis, nearly crossing it. The head, though low, had not cleared the arch. I examined, during a number of contractions, to ascertain what was their effect upon the head. It was more or less forced doAvn by them; but you felt that they produced no true progress. No absolute descent, as marked by positive change of place in the head, could be detected. There Avas distinct pressure felt by the patient while con- traction lasted, and so had there been during the whole day; but there was no feeling of progress. This is very noticeable in protracted and painful labor, and perhaps as surely indicating its true character as any other sign. It aatis agreed in consultation, that the forceps should be 34 266 ETHERIZATION IN CHILDBIRTH. used. There was no promise of delivery, and it was clear that exhaustion Avas increasing. I first applied the instru- ment over the ears. But the pressure of the perineum became so great, that it Avas not deemed safe to continue extraction in this direction; and the rule, I think, of Lob- stein Avas adopted, of applying the branches in the direction of the sides of the pelvis. This was done, but with more difficulty than usual; as the former effort Avith the instru- ment had someAvhat and permanently advanced the head. It was asked if she would inhale ether-vapor. She was most happy to do so, if it Avould diminish her intense suf- fering. As soon as the forceps were adjusted, a holloAv sponge Avas wetted Avith chloric ether, and inhalation was begun. It Avas continued with the greatest eagerness and success. Its effects were wholly agreeable. These were a pleasant excitement, a moderate laugh, the absence of all complaint; but frequent declarations that Ave were hurting her, that she could not be cheated, &c.; — but, through the whole, a manner which showed hoAV slight was sensibility, if any at all existed. The child Avas very soon born, was alive, and soon cried fairly. The womb silently, and with- out pain, contracted, separated, and expelled the afterbirth in a feAV minutes. No hemorrhage followed or attended the process. A swathe was applied, and the patient made comfortable in bed. The expressions in this case were such as are made after the happiest use of etherization. There was nothing exag- gerated in them, but showed Iioav much relief had been afforded, and how earnest and true was the gratitude which this relief had inspired. \y Case LXIV. — Placental Presentation. No. 259, age 36; fourth labor. July 4th, the day on Avhich labor has been predicted. In ninth month, four CASES. 267 hemorrhages. The three first before the 4th July. Mo- derate ; mostly coagula, solid, some large; and colored liquid.* Was directed to keep bed after the first flow, and has done so. This attack occurred in night; was more urgent than others, and accompanied by pains or uterine contractions. I Avas called to see her Avith her medical attendant, betAveen 3 and 4, a.m. Pulse from 125 to 134. Speaks of exhaustion. Contractions have nearly ceased. FIoav moderate, and of liquid and coagulated blood. Mic- turition frequent. Sounds of foetal heart very distinct about midAvay of abdominal tumor, but to left of median line. In this part, tumor is very firm, roundish, as if the foetus were closely embraced by the womb; and the Avaters dis- charged. Placentary murmur I do not hear. At loAver part of abdomen, toAvards right side, Avomb is firm, but does not reach to hypochonclrium, as does the left. Examination discovered nothing, except coagula and liquid blood. Os uteri not to be reached by ordinary means. Passing along symphysis pubis, the uterine tumor Avas felt; but Avhat Avas Avithin the womb at that point Avas not ascertained. As hemorrhage had occurred so many times, and was obviously producing untoward effects; and as it was not at all knoAvn, except by induction, what was the precise state of things, it Avas agreed that the patient should be put under the influence of chloroform, the hand * Sometimes these occasional discharges of coagulated blood, and continued flow of colored watery Liquid, give rise to uneasiness; as it is supposed active hem- orrhage is present. This is especially alarming to the patient. A constant, how- ever small, stream of warm fluid keeps up the idea, that hemorrhage is going on; and " I am flowing ! " is a frequent exclamation. The explanation is simple. Slight hemorrhage exists. The blood is delayed and coagulates, and the serum which is separated from the clot escapes. If the patient move, the flow is greater; and, not unfrequently, coagula, dark and solid, are also expelled. This state of things demands much attention. But it is obvious that it may come, for the most part, of what has happened, and show itself even when hemorrhage has actually ceased. Let the state of the womb be carefully attended to, especially in regard to contrac- tion. Let the pulse, and whole state of the patient, have close regard; and let the vaginal discharges be carefully examined. In this way, real danger will be timely discovered, or the patient's mind put at ease. 268 ETHERIZATION IN CHILDBIRTH. introduced, and the real state of the case ascertained. Chloroform was used. It had been employed in the night to procure rest, and had produced no unpleasant effects. Inhalation Avas begun, and etherization soon followed. When it Avas nearly established, the hand Avas passed, and Avith great ease. Contractions had ceased for some time, or Avere exceedingly slight. The placenta Avas felt directly over the os uteri, the membranes presenting at no point. It Avas very firm, and Avas in close contact with Avhat Avas beyond it. Os uteri readily admitted a portion of the hand ; and, Avhen further easy progress Avas stopped, the hand Avas kept at rest, until, by the knoAvn action of etherization, relaxation should be produced. This soon occurred, and the hand passed readily into the uterine cavity, and towards the right iliac fossa, Avhere Avas sufficient room for its accommodation. The membranes Avere first reached in that place, — were broken, and a knee at once felt. The cord was near the knee, and Avas carefully examined. Pulsation had entirely ceased. I recollected how distinct was the pulsation of the foetal heart a short time before, and was struck with the state of the cord. But very soon pulsation was felt, at first feeble and very sIoav, but soon of its ordi- nary frequency and force. It reminded me of a case in Avhich the cord came down by the side of the head, and in Avhich, during a contraction, pulsation ceased, but which returned as soon as uterine relaxation took place. At first it Avas feeble and very sIoav, but became shortly frequent and strong. During this time, the uterus Avas perfectly quiet. Its contractions had nearly or quite ceased before etherization. The utmost freedom was experienced in moving about the hand to reach the ham, and in bringing down the foot. Every thing Avas conducted Avith entire deliberation. Not a complaint Avas made by the patient, though, before inha- lation, almost any examination produced severe suffering. Some obstacle to the descent of the foot occurred. Effort CASES. 269 at once Avas suspended, in order that the greatest relaxation might occur. In this way, turning proceeded, and was completed in about twenty-five minutes from the beginning of the operation. The usual delay occurred before the head Avas born, and the cord ceased to pulsate. The heart of the child, however, continued to beat; and, after use of ordinary means, respiration was established. Some uterine effort Avas manifested at the close of the labor, and aided the delivery of the head. It continued aftenvards, producing good uterine contraction, and separation of the placenta, which shortly came away with slight assistance, and with- out any hemorrhage. Among the first words spoken by the patient Avere questions which shoAved how perfectly unconscious had been the patient: — "Is the child born 1 Was it delivered Avith instruments 1 Is it alive 1 Has the afterbirth come away 1" She declared she Avas conscious of every thing that had been done. The memory Avas entirely wanting of the most important facts. The child was born about 8, a.m. Said the patient, as we were about to leaAe, " I give my testimony for chloroform." 7, p.m. — Very comfortable. No after-pains ; no hemor- rhage. Renal excretion free. Pulse 120. Skin warm. Sleep. Breathing natural. It should have been said, that the pulse and respiration continued unaffected by etheriza- tion. At this Aisit, patient spoke of her three former labors. The first Avas an instrumental case; the child dead-born; her getting-up very sIoav, and with much suffering. The second Avas severe; the third less so, but convalescence Aery sIoav, and suffering from after-pains extreme. She spoke of her present comparative comfort as a state she had not before known. Especially did she speak of the entire absence of suffering from after-pains. The child had made fair progress since the morning; 'had a free alvine discharge; had swallowed pretty Avell; and, for the first time, and during the visit, cried. There Avas a 270 ETHERIZATION IN CHILDBIRTH. remarkable deficiency of development of the cranial bones, shoAved by unusually large fontanelles, and Avidely gaping sutures, as of grave malformation. But the size of the child and appearance Avere otherwise natural. 5th. — Mother perfectly Avell. No after-pains, lias suffered much from these before. Child improved, but still does not come up to fair re-action. Cranium as before. Mrs.----has done perfectly Avell. Child died a fcwv days after birth. Case LXV — Natural Labor. No. 239, age thirty-six. July 5th; seventh labor. Taken sick this evening. I was called about 11, p.m. Contractions strong, painful, frequent. Os uteri partially dilated, pre- senting a firm, sharp edge. Membranes protruding. Dress Avas arranged, and patient Avent to bed. Pain rapidly increasing, and occasioning strong expression of suffering. A hollow sponge Avas Avell soaked with sulphuric ether, and inhalation Avas begun. At first there Avas a slight sensation of choking. This soon went off, and the most grateful effects of etherization replaced it. The membranes soon gave Avay, and much Avater was discharged. The os uteri yielded to the contractions in the kindest manner. There Avas no complaint; no motion of body or limbs; and no mental excitement manifested. The sponge Avas used at every pain, ether being added as required; and, after six or eight contractions, the child, a boy, was born, crying at the very top of his voice. He Aveighed eleven pounds and half. In the last uterine effort, the sponge being misplaced, there seemed to be some suffering; but, after labor Avas over, none was remembered. Nor was she conscious Avhen the child Avas born. Being asked of her state during etheri- zation, she said that she had been listening to reading the Avhole of the time, and supposed one of us had been enter- CASES. 271 taining those present in this manner. She Avas made com- fortable ; a swathe applied; and I left her about 12, midnight. The pulse was carefully attended to, being examined before inhalation, and it preserved its firmness and frequency throughout; the respiration also being per- fectly natural. July 6th, 12 and quarter, a.m. — Doing Avell. 7th. — Doing perfectly well. Case LXVI. — Natural Labor. No. 247, age thirty-one; second labor. First child twenty months old. Flealth good. Pulse from 80 to 84. Respiration natural; complexion clear, good ; temperature natural. Labor begun, Aug. 13th. I Avas called 3, a.m. 14th. Contractions regular, strong; intervals not long; os uteri dilated; membranes in close contact Avith the scalp. Liq. am. collected, and was discharged about 4, by a strong pain. Progress slow. It did not seem that any advance Avas made; the head remaining in about the same place an hour or more after my arrival, as I first found it. Though contractions were very strong, no pressure was felt during examination, Avhen they were greatest. The uterine tumor at such times Avas very hard, shoAving good con- traction. It seemed to me very clear that the labor was delayed by voluntary effort to diminish suffering. At length, ether was asked for, and the sulphuric was used. Its effects were good. Pulse, complexion, temperature, continued perfectly natural. Complaint ceased. Con- tractions as frequent as before etherization, and much stronger. Labor began soon to advance. Ether was demanded; and, sponge held by patient, it Avas dropped Avhen no longer needed. Labor proceeded rapidly. Every contraction advanced the child, until it Avas born, about 6, a.m. very suddenly, but Avith no mishap. It cried loudly, a 272 ETHERIZATION IN CHILDBIRTH. boy, Aveight eight pounds and a half. The afterbirth was soon throAvn off. No hemorrhage. I saAv this patient about an hour and half after labor was completed, and found her doing Avell. Pulse as at beginning of process, and countenance only expressing ease and comfort. I asked concerning etherization. She said that she did not lose consciousness, but Avas so much relieved of suffering, that it ceased to disturb her. She Avas most aAvare of the difference of her feeling, as contraction approached. It had been looked to with alarm and uneasiness before inhalation; but, after that, there Avas no such feeling pro- duced by its coming. There was the most perfect con- sciousness that the child was advancing by uterine effort; and this had not been perceived before. Here was a case of imperfect etherization, but not at all the less interesting on that account. Has it not a higher interest in this, that so much diminution of suffering, and such progress, Avere given to the case, by such slight, but effi- cient and safe means ? This is one of the many like cases which have been noted of the practicability of graduating etherization to the demand. In this case, suffering was so far diminished as to lose its character of pain, at least to such a degree as to be perfectly tolerable; and the con- sciousness was sufficient to permit of a comparison of present state Avith the severe distress of a former labor. These, to my mind, are among the most interesting facts presented by our subject; and hoAV fruitful are they in suggestions, which will certainly gi\e to etherization Avider and most important agencies in medicine! Case LXVII. — Natural Labor. No. 261, age 43 ; seventh labor. Labors, Avith a single exception, all more or less difficult, protracted, and painful. The first had occupied three days and tAvo nights before I CASES. 273 called in consultation. The head Avas low. It had been so for many, many hours, and without any change in place, notAvithstandmg severe uterine contractions frequently re- peated. It was agreed that forceps should be used. The instrument was applied; and, after a trial with it unparal- lelled to my knowledge for its length, the child was born. It was a boy, and still-born. It was, however, made to breathe, and lived some hours. Severe hemorrhage and general collapse followed. I have rarely known the effects of protracted labor more declared. The uterus seemed incapable of contraction. After efforts continued for hours, re-action took place, and good recovery. In two other labors, great difficulty and suffering occurred. DeliArery at length took place, but was fatal to both chil- dren, by cause of entire suspension of uterine effort, and of physical inability to complete the labor after the birth of the head, before death had occurred. These children were boys, and, like the first, very large and of great weight; being each over eleven pounds, and one very near twelve. Since these three births, two male children have been born, and are living. I was present with the family medical attendant in this as well as in the three first cases, and can bear witness to their difficulties. The placenta was mor- bidly adherent, or retained in most of them, rendering very painful measures necessary for their removal. The fifth labor was of a female, of fair size, but born with so much ease, and with so little attendant uneasiness, that the deliv- ery was accomplished before either of three physicians, who were called, arrived. The sixth Avas of a boy, and much of the old difficulty was experienced. The seventh labor begun, July 15th, 1848, the day when it Avas predicted, at 7, a.m. For months before, much anx- iety had been felt about the result. The abdominal tumor Avas excessively large, — larger than ever before, and annoy- ing by its great bulk. The nights were restless, sleep dis- turbed, and the days uncomfortable, from both mental and 35 274 ETHERIZATION IN CHILDBIRTH. physical troubles. She Avas blooded, but Avith little benefit. The approach of labor was dreaded. In all previous ones, there had been great moral firmness; and great and long- continued suffering Avas, I may say, nobly borne. Why the present misgiving, Avas not explained. The only, and Avholly vague, reason Avas, that nothing of the kind had existed before; that things Avere not as they had been, and trouble must come. The labor began Avithout pain. There Avas evidently uterine contraction; but it Avas hardly, if at all, perceived. The evidence of labor Avas in dilatation of the os uteri, and in its perfect dilatability, — in abundant shoAV, and dilata- bility of all the organs, external as Avell as internal, — in presentation of the head, — and in alternate protrusion, and disappearance of the membranes. This state of things continued twenty-four hours. The night was restless, and the day uncomfortable, but not from pain. Contractions Avere perceiATd, but were not painful. At about 8, a.m. of the 16th, Avhile the medical attendant Avas making an ex- amination, the membranes were pressed Avith so much force and suddenness upon his finger, that they Avere broken, and a very large quantity of fluid folioAved. As this looked more unequivocally like labor than any thing else, I was desired to see the case in consultation, having been before- hand engaged to do so. I found great mental uneasiness present. It was all wrong. Delivery would never take place. There was ex- treme exhaustion or utter weariness, from disappointment and from sleeplessness. Occasionally, a pain Avas felt; but it Avas nothing, — and instruments must be used, or the child would neA-er be delivered. It would not be easy to exaggerate the utter discomfort Avhich Avas present, or the complaints Avhich expressed it. Examination shoAved what is above given from the description of the attendant. The head wras at the brim of the pelvis, on entering it. It was perfectly Avell placed; moveable; every thing in excellent CASES. 275 preparation for easy delivery. Upon moving the head, a great gush of liq.* am. took place; and this was repeated again and again; and, being received into a IioIIoav of the bed, which was covered by India-rubber cloth, and so could not soak aAvay, a perfect bath was produced. This flow of liquor amnii explained someAvhat the great distension in the latter months of pregnancy. The abdominal tumor now became smaller and firmer, and stronger uterine con- tractions occurred. I should have said that, the patient being about the room most of the time since the membranes gave way, the liquor amnii had freely floAved two or three hours before my arrival. It was agreed to Avait the effects of increased uterine effort. Not the least change Avas noticeable in the presen- tation. Every thing seemed favorable to rapid delivery. Still it did not occur. It was noAV agreed to give infusion of secale. One dram was infused in six ounces of boiling Avater, and one ounce of the clear tea given; and this dose Avas to be repeated as circumstances might require. There Avas no objection made to its use, if ether or chloroform might be inhaled, should pain occur along with increased contractions. It was promised that this should be done. The pulse remained quick. The skin was hot and dry. The mucus secretions were replaced by a watery one, which had no lubricating property. The mental depression Avas extreme. More vigorous uterine action soon followed the first dose of the infusion, and a repetition of it added to its poAver and efficiency. The head descended favorably, and at length reached the outlet. Chloroform was demanded and inhaled. The quantity used Avas small, say about twenty drops at a time on a folded handkerchief. It soon produced mental quiet. Complaint and apprehension were diminished, and soon ceased. The intervals of contrac- tion were passed in perfect rest, like quiet sleep. The con- * In two or more instances, this word has been incorrectly spelled Kg. 276 ETHERIZATION IN CHILDBIRTH. tractions themselves Avere at times less strong; at others, more so. The infusion of secale Avas occasionally given. About 10, a.m. the head Avas born, Avithout the conscious- ness of the patient. The uterine action ceased at once. Friction to the abdomen, and other means, were used to excite the womb to effort. The head grew deeply livicl; the nose and mouth Avere clogged AAith thick frothy mucus. It seemed impossible to save the child. At length, the finger reached an armpit, which looked toAvards the sacrum, and this the more readily from the extreme dilatability of the organs; and the child Avas made to descend. Con- tractions came on, and the shoulders soon folloAved, and then the trunk and extremities. The child, a girl, cried strongly at once. Its weight Avas aftenvards found to be nearly eleA-en pounds. There Avas a remarkable similarity in the birth of this child, — the delay, &c. Avhich so strongly characterized the birth of the three sons. Hemorrhage at once showed itself as before. Ergot tea had been given to secure uterine contraction after the head was born, and to prevent hemorrhage in the third stage of the labor. The loss was sudden and large. Firm pressure Avas made upon the uterine tumor, AA'hich Avas soon felt to be hard, but large. As it had been necessary, in the preceding labors, to remove the placenta manually, I passed the hand as I had done before. Pain was complained of, and chloro- form was inhaled. The placenta Avas found partly detached, but mostly firmly adherent. The Avomb was contracted irregularly upon it, closely adapting itself to the inequali- ties presented by the placenta. At length, hoAvever, it Avas separated, and taken aw7ay. There Avas no more loss. A swathe Avas applied, and the patient placed comfortably and easily in bed, expressing the warmest gratitude for her painless deliverance. This was about 12, noon. BetAveen 3 and 4, p.m. I left her very comfortable and happy. RecoArery perfect. CASES. 277 Case LXVIII. Natural Labor. Internal Hemorrhage after Delivery. No. 248, age nineteen; first child. Liquor amnii was discharged this morning, June 17th, at 5, a.m. waking the patient up. She is in excellent health. Has been very Avell during pregnancy, exercising freely, and living well. Contractions soon occurred, and became severe and painful. I was called about 8, a.m. Presentation natural. Head midway in pelvis. Os uteri Avell dilated, and dilatable. Secretion sufficient; and contractions evidently, but slowly, advancing the labor. As the dilatation of external organs Avas slight, and the perineum very firm, and much suffering present, sulphuric ether was inhaled, and with great com- fort. The contractions rapidly increased. The intervals greAv shorter. The head advanced. The child was born between 9 and 10, a.m. with perfect ease, and without com- plaint. The placenta soon followed by the action of the womb, and no hemorrhage attended its delivery, or imme- diately followed it. A SAvathe, to which afterwards Avas added a compress, was applied Avith much care over the uterine tumor, and every thing promised well. I was entirely alone with this patient, having literally no one to render the, least assistance. Upon coming to the bedside, a short time after, I found her looking pale; and, upon inquiry, she said she felt faint. Her pulse remained dis- tinct. A female neighbor, a stranger, noAv arrived. I found very little external flow; but, upon removing the SAvathe, the womb Avas found large, though not soft, as if relaxed. I desired the attendant to place her hand firmly upon the uterine tumor, to which I directed it, and pro- ceeded to examine the state of the womb. I found the pehis and Avomb filled with firm coagula, the womb being Aery large. I at once emptied it of the coagula. It con- tracted most promptly and firmly. It Avas at once reduced 27 N ETHERIZATION IN CHILDBIRTH. to its smallest size after delivery. The compress, and then a SAvathe, Avere re-applied; and re-action,firm and decided, \ cry- soon declared itself. No more hemorrhage occurred, except in moAing her in the afternoon, Avhich, howeA'cr, Avas Avith- out trouble; and at 6, p.m. she remained very comfortable. The child, a female, Aveighed ten pounds and six ounces. The pulse in this case Avas very frequently counted. Its number, at my first count, Avas 84. It scarcely a aricd from this during the labor. It did reach 90, but this Avas at the close of the process; and did not long remain so, coming- do Avn again to 84. The breathing Avas natural, and the complexion was not at all changed from its ordinary very- healthful color. But there Avas internal hemorrhage in this case, and sul- phuric ether Avas inhaled. Etherization Avas never pro- found. It produced its usual pleasant and most grateful effects, and the last contraction had no suffering. As in the preceding case, in whicli chloroform Avas used, there was a steady increase of pain during etherization, and marked rapidity in the progress of the case. The blood, in the last case, Avas most firmly coagulated; and contrac- tion, after emptying the Avomb, Ave have seen, Avas as per- fect as it could be. Nothing, for a moment, existed of the untoward, Avhich one at all acquainted Avith the subject could refer to ether. I have rarely met Avith a case of hemorrhage in Avhich a check Avas more readily given to the floAV, or in Avhich re-action Avas so kindly and readily established. Case LXIX. — Convulsions. No. 262, age eighteen; first labor. Was taken Avith distinct uterine contractions, July 21st, at about 11, p.m. Had slept badly, and had irregular and painful uterine action for three or four preceding days. The labor had advanced very favorably, though with mud: complaint, till CASES. 279 9, a.m. of 22d; Avhen, Avithout any observed precursors, except very slight headach, convulsions occurred. At first, or in the intervals betAveen the four first fits, con- sciousness returned. The jaAv Avas dislocated during one of these attacks ; and the patient called the attention of the physician to this occurrence, from her inability to move the jaw, or to shut the mouth. Reduction Avas at once accom- plished. Partial dislocation occurred tAvice afterwards. During the continuance of the disease from the fourth con- vulsion, consciousness did not return. The labor made steady progress, and delivery took place at noon; the . child, a boy, of strikingly large size, being born alive. The placenta folloAved naturally. This was also of very great size. The labor was completed during the sixth convulsion. Extreme restlessness accompanied and folloAved the con- traction, which terminated the labor. Many persons Avere constantly occupied with efforts to keep the patient on the bed, and from injuring herself. It lasted an hour. This violent action ceased, as the next fit manifested itself; and, from this time, there Avas alternately a fit, and an attack of excessive restlessness, similar to the first above described. The treatment consisted in blood-letting, a solution of tar- tarized antimony, iced water to the head, and leeches to the temples. The convulsions continued, and increased in vio- lence and in frequency; and, at about 6, p.m. I was desired to see the patient in consultation Avith her medical attendant. There were some circumstances which attracted my atten- tion. The pulse Avas rapid, between 130 and 140, and not deficient in strength. The skin was very hot, and perfectly dry. The face was generally pale, the lips being quite red. The eyelids Avere naturally closed, and a state of rest or of quiet sleep which I have rarely obseiwed in the genuine puerperal convulsions. Unconsciousness Avas entire. The abdomen was full, and there was much flatus. But a portion of its bulk was produced by the womb, Avhich 280 ETHERIZATION IN CHILDBIRTH. Avas very large, extending above the umbilicus, and very hard. Renal excretion had occurred in the day. A fit soon came on. Its first intimation Avas Avide opening of the eyes. I have never seen the conjunctivae so largely exposed as in this case. The whole circumference of the orbit seemed visible. At first, the lids Avere still; then in rapid motion. Next, the head wras drawn strongly down to right shoulder, and soon was throAvn into rapid and violent jerking motions. The arms Avere also strongly bent, and forcibly compressed the trunk. The fit passed off gradu- ally, and was followed by none of the heavy stertor whicli so generally succeeds. The face had an expression of ex- treme distress. At first, it was moderately suffused, but soon became livid white. This began about the forehead and eyes, and passed rapidly over the whole face, affecting the lips less than any other feature. The skin looked as if stretched, and presented the glistening which marks that state. Deglutition became more and more difficult, till at length the attempt to swalloAV produced symptoms of very embarrassing suffocation. Ten grains hyd. submur. and as much finely powdered sugar, were laid upon the tongue, and at length apparently swallowed. I attentively noticed the distress Avhich was manifested, and soon it was per- ceived that it resembled what occurs with after-pains; and, upon placing the hand upon the uterine tumor during rest- lessness, it Avas felt to be much firmer, harder than at other times, and occupied less space; in other Avords, that it was then more fully contracted than at other times. With these facts before me, I suggested etherization, and with sulphuric ether. The sponge was wetted and applied as accurately as much restlessness and a cork betAveen the teeth would allow. The ether was renewed three times in the course of about an hour. There was unconsciousness before inhaling. This Avas not to be produced by etheri- zation. The principal change observed was the greater quiet, and the increased length of the intcnal betAveen the CASES. 281 fits after inhalation. She had a fit in about an hour after etherization. The pulse was noAV more frequent, smaller, and the convulsion very severe. A dram of asafoetida in an emulsion, Avith thirty drops of laudanum, Avas now given as an enema, and retained. Quiet Avas very decidedly greater after the enema. A state as of gentle sleep, Avith Aery easy breathing, came on. The complexion and expres- sion Avere more natural. You felt that important changes Avere in progress. The last convulsion Avas at five minutes before 7, p.m. Occasionally there Avas restlessness, and a bearing effort; and, as these were evidently increasing about 10, another injection of asafoetida and laudanum Avas given. Examination shoAved fullness in hypogastrium; and the catheter Avas introduced, and much dark-colored urine draAvn off. 23d. — The night Avas passed on the Avhole tranquilly. There Avas no convulsion. She regained the power to sAvalloAV, and took drinks readily. I found her much improved at my morning visit, between 5 and 6, a.m. Pulse from 96 to 100, of good strength. When called by name, she distinctly ansAvered, " What % " as if conscious of the question and the reply. Flatus had been freely dis- charged in the night, but no dejection. A soap and oil enema was directed, to be followed by ol. ricin. if required. Most perfect quiet Avas enjoined, and prudence in Avhat might be said when consciousness should return. Catheter; a pint of urine, similar in appearance to that drawn before, Avas remoArcd. 24th, 8, a.m. — Report of day and night favorable. Enema did not operate, and the oil Avas given. Five dejec- tions since. Now, pulse 108, soft, sufficiently full. Lies on left side, in easy position. Countenance and manner natural. Takes food Avith relish. Protruded tongue, when desired to do so. Tongue clean. Answered a question, though not disposed to do more. Seems as if uncertain of 36 282 ETHERIZATION IN CHILDBIRTH. her position, and so prefers silence to the chance of mistake. Catheter. 25th. — Doing perfectly well. Has nursed her child. Has passed Avater. Mind becomes more active. Appear- ance natural. Recovery perfect. Case LXX. — Instrumental Labor. July 28th, p.m. — No. 265. On reaching the address, I learned the following: — First child. Labor began afternoon of 27th. A midAvifc was called in the evening; and, from the pains and progress, believed delivery Avould soon happen. The night passed, and a physician was called in at 8, a.m. Such Avas the state of things, that he felt certain that labor was soon to be accomplished. Hours passed Avithout this event. Con- tractions were strong; the sufferings, very severe. Ergot was given. The efforts were greater, and some progress was made. The sufferings Avere augmented. At length, the head reached a certain point, and there stopped. There was no diminution of contraction or of pain. Examination discovered the scalp to be just Avithin the labia. The cranium was farther from this point; the space between being occupied by a large tumor, filled Avith a liquid believed to be blood. Uterine system exceedingly irritable. Contractions and pain, declared by loud screaming, Avere produced by the most carefully conducted examination. It was not that there was soreness, intolerance of pres- sure ; but that morbid sympathy, from labor Avith long and intense suffering, which induced uterine action from any contact Avith its appendages. I have rarely, if ever, met Avith this state of things more strikingly declared. Vomiting, or rather eructation; forced spitting of a dark substance, in small quantities. Complexion deep red; face swollen; pulse rapid. Expression of suffering vehement, CASES. 283 and strong desire for relief manifested. Uninterrupted labor had noAV been present tAventy-four hours; the head in its present place, six or eight. It Avas agreed that the forceps should be used, though consented to Avith reluctance by the family physician. He felt certain that nothing but diminishing the cranium would allow of delivery. Motion had long ceased, and the cra- nium was very compressible. The application Avas easy, as pressure on the cranium easily made room for the forceps. Suffering Avas very little greater than attended ordinary examination. The priest had been sent for, and arrived soon after; but, as there Avas no evidence of immediate danger to life, he remained below. Sulphuric ether was inhaled. Its first effect Avas disturb- ing. It produced some restlessness, — some expressions of uncertainty as to the place, what Avas doing, &c.; but soon quiet replaced this state, and moderate etherization occurred. Contractions now ceased. There Avas perfect rest; and, Avhen a few minutes had passed in this state, I remarked that it Avas a condition of repose into which the system fell, AArhen excessive and irregular, but ineffectual, action had been for a long time sustained; in Avhich, in short, ergot had been used; and its effects had not ceased. Extraction Avas now attempted. This roused the pa- tient, and loud cries Avere made. These Avere uncontrolled by the Avill, and hence Avere more vehement than before. After a short but fair trial, and without any progress being made, the forceps Avere removed. Craniotomy was noAV determined on, and done. A large quantity of blood escaped from between the scalp and cranium. The opera- tion was easily performed, and extracting effort made. Progress Avas now evident. Inhalation was again employed, but Avith no mitigation of complaint. Delivery Avas very soon accomplished. The afterbirth Avas naturally separated and expelled. No hemorrhage. Inquiry was noAV made of sensibility and consciousness. It was declared that every 284 ETHERIZATION IN CHILDBIRTH. thing Avas known which had occurred, and severe x)am had been felt. Soon after delivery, pain in the head was complained of; but, except this, general case and comfort were reported. 29th, 10, a.m. — Very comfortable. No headach. Slept better; part of night, Avell. Renal excretion natural. Pulse 74, soft. Skin Avarm, moist. No pain or tenderness of abdomen. She Avas asked Avhat she recollected during etherization. She answered Avith distinctness, that she kneAv nothing of the first operation, namely, of the use of the forceps; that she was then Avholly insensible. But she kneAv Avhen the child's head was born, and suffered severely. But her suf- fering was less than before inhalation. By the first use of ether, etherization Avas established; in the second, it Avas not. Points in this case are of practical interest. Among these I Avould notice the great confusion and the restless- ness Avhich inhalation first produced, and the perfect quiet which soon followed the removal of the sponge. Etheriza- tion wTas then perfect. When extracting effort was made, great outcry and complaint at once folloAved, and continued till the effort ceased. But it was not remembered. During extraction after craniotomy, ether Avas again inhaled; but its effects were slight. Great outcry again was made, and the suffering which it expressed Avas remembered. These facts strongly illustrate the two very opposite states of per- fect and imperfect etherization, both in regard to conscious- ness and insensibility. It is not uncommon to have much confusion, restlessness, and great outcry, accompany its per- fect establishment, — the state in AAiiich both consciousness and sensibility are abolished, — and this Avithout the least remembrance of Avhat has happened. A case of this kind is among those recorded in this volume, in Avhich there Avas an almost uncontrollable tossing about, Avhile the forceps were used. The child Avas born alive, and the Avoman did CASES. 2i. R. Thompson. Note from Dr. A. R. Thompson. Walter Channing, M.D. Charlestown, June 5, 1848. Dear Sir, — Since my first communication to you, I have used chloro- form in fifteen different cases in obstetric practice, with great benefit to my patients. With great respect, your obedient servant, Abm. R. Thompson. 336 ETHERIZATION IN CHILDBIRTH. From Professor John Ware, M.D. To Dr. Channing. Boston, Feb. 1848. 1. Tavo. Both natural. One premature, and only for artificial ex- traction of placenta. 2. About four ounces in each, but not economically. Wasted. 3. About half an hour, at intervals, in each. 4. Almost immediately. 5. Very moderate in case of retained placenta. Not entire in the other. 6. Moderately in both. 7. None worthy of mention. 8. None. 9. Perfect and unusually favorable recovery in both. 10. One dead, at seven months, and decomposed. The other well, at the full time, and nothing special. 11. Favorable as to both. Preference to chloroform, from its general effects. Yours, &c. John Wake. From Jon. W. Bemis, M.D. To Dr. Channing. CharlestoAvn, Feb. 1848. 1. I do not recollect more than four cases; two of them were natural, and tAvo instrumental, labor. 2. In one instance, six or eight ounces; in the others, less. 3. In one case, for three hours, at intervals. 4. In about five minutes. 5. In one case, wholly unconscious at times; in the others, not so. 6. Wholly insensible in two cases. 7. I should think it induced relaxation of the whole system. I thought it had the effect, in one case, to make the pains less frequent, than when not under the influence of it. I think the effects were not unpleasant, as the individuals asked for its repetition. 8. No dangerous effects manifested. 9. No bad results to the mother in either case. 10. In tAvo cases of difficult labor, I supposed the children not living, when employed. In two cases of natural labor, the children lived, and are well now. 11. I should not think it best to use it in common cases. I published a case of some importance in Medical Journal, in July the 21st; in which case, I felt as if the life of the patient was saved by its use at the time. At any rate, its use afforded me great satisfaction. Yours, very truly, Jox. W. Bemis. CORRESPONDENCE. 337 From Henry G. Clark, M.D. To Dr. Channing. Boston, Feb. 1848. 1. Perhaps six or eight. 2. Generally from two to ten ounces of ether. 3. Sometimes three or four hours, at intervals, as the effects passed aAvay. 4. A few minutes only. 5, 6, and 7. There Avas often insensibility to pain, while the woman would answer, and seem quite conscious of the nisus, or propulsion; sometimes the state was that of perfect sleep, without or Avith dreams. 8. I have not seen any alarming symptoms, when the article was pure, and properly, and not suddenly or violently, administered. 9. In one case, severe flooding followed. I don't know hoAV much it might have been, owing to the chloroform, which was given in this case; but it seemed to me that it had something to do with it. 10. The children have done well. 11. I think they should be used as other remedial agents, according to circumstances ; and that they ought by no means to be used in every case of labor, any more than a cathartic or enema should be given for every costive defecation, or a catheter for every case of strangury. I hope the answers will serve your purpose; although, as you see, my experience has been limited by my notions of the proper cases for its use. As to the choice of articles, ether or chloroform, they have both peculiarities Avhich may make it advisable to retain both. I have used chiefly the ether. Very respectfully and truly yours, Henet G. Clark. From Professor J. Bigelow, M.D. To Dr. Channing. Boston, Feb. 1848. 1. Ether in eight cases; chloroform in two. Not given, except in cases Avhere it was requested by patient. 2. Chloroform, one ounce in a tube ; ether, one ounce to 16 on a sponge. 3. From half an hour to twenty-four hours, at intervals. 4. From one to five minutes. 5 and 6. Both occurred in six cases, with perfect quiet during the passage of the head, and no subsequent recollection of the fact. 7. Nervous excitement, with laughing in five cases; expressions of delight in about as many ; hysterical screaming in two, for a short time ; anxiety to repeat inhalation in all. 8. None. In one case of protracted labor, the lips and nails re- peatedly became purple, but resumed their natural appearance on with- drawal of the ether, and after a feAv inspirations of pure air. 43 3?kS ETHERIZATION IN CHILDBIRTH. 9. Never unfavorable; always seemingly beneficial, by the saving of alarm, pain, and exhaustion; also by the apparent relaxation of the passage. 10. One child did not breathe, till cold water Avas thrown upon it. The rest, immediately. 11. An experiment not yet settled in all its bearings, but promising much for the relief of human suffering. From John Homans, M.D. To Dr. W. Channing. Boston, Feb. 1848. Dear Sir, — 1. I have administered sulphuric ether in thirty-one cases of labor, and chloroform in two ; making in all, thirty-three. 2. The ether, in quantities varying from three to sixteen ounces; in general, I have found four to six ounces sufficient. Chloroform, in one case, tAvo drams; in another, six. In the latter, there may have been some wasted. 3. From fifteen minutes to eight hours. I have usually deferred their use until dilatation of the os uteri has someAvhat advanced, and expulsive pains Avere about commencing, or had already commenced. 4. Generally from one to two minutes. In eight cases, in which I observed the time by a watch, in one minute and a half. 5. So far as not to realize the birth of the child in three instances. In most cases, so as to be ignorant or unmindful of the lapse of time; sometimes mistaking a feAV minutes for an hour, and the reverse. 6. So far as to blunt acuteness of the pains, more or less, in thirty-tAvo cases. In one only, no effect was produced: in that, however, I had doubts as to the purity of the material. In six or eight cases, the pains Avere so much alleviated, that the patients said they had suffered very little; in the others, the suffering seemed much diminished. 7. As to physical effects. Pulse accelerated at first, and afterwards lessened in frequency. Pupils of the eyes became dilated, and eyes partly closed; Avhen open, fixed. Drowsiness comes on, and at length sleep; sometimes slight convulsive motions. In most cases, I have ob- served increased moisture of the vagina, and more ready dilatation. As to moral effects, these are various : in some, pleasant sensations and de- lightful dreams ; laughter in others, painful sensations, and indescribable distress, frightful dreams, sobbing and Aveeping. As to intellectual effects : new and strange ideas ; imagination active ; thoughts fly rapidly through the brain; in some, incoherent expressions; forgetfulness of their condition. In one case, mental distress was very great; indescri- bable misery, so as to cause the patient to strike those near her, and to thrust them from her Avith violence. In some, objects Avhich are near CORRESPONDENCE. 339 appear distant, as if gradually receding. When the effect of inhalation commences, the voices of persons present become more and more distant. 8. I have seen no danger; although I did so far apprehend it, as to desist from its further use in one case, Avhere great distress was mani- fested, and convulsive motions of the muscles supervened. 9. Generally a contraction of the uterus, and speedy delivery of the placenta; and a more tranquil state of mind, and more comfortable state of body, than in cases in Avhich etherization was not used. Sometimes, however, on first recovering from its effects, distress is manifested; but no bad effects afterwards. 10. In all cases, the children have been born alive, and well in all respects, and have continued to thrive. 11. I consider etherization valuable, inasmuch as the strength of the patient is less exhausted, by reason of the voluntary efforts being less, and inasmuch as the muscular and soft parts are relaxed by it; and thereby the last stage of labor expedited. The soreness and lameness of the muscles, consequent on efforts, is much diminished; and the patient is so sensible of the mitigation of suffering, as to ask for and demand it, after a few minutes' use of it. The same remarks will apply to the chloroform, which seems to affect mentally the patient more agreeably, and is less repugnant to the sense of smell and taste, than sulphuric ether. [For whole number of cases by Dr. Homans, 56, see Table First.] From A. L. Peirson, M.D. Salem, Feb. 1, 1848. Aug. 1, 1847. — A lady, betAveen thirty and forty years of age, fell in labor with her first child. Her travail was perfectly normal, but lasted rather more than twenty-four hours. Hers was the first case of midwifery in which ether has been used in this city. She had pre- viously determined upon using it, from the advice of her Boston friends, who had furnished her with your report of the first cases in which you had employed it. When her pains first came on, her friends and neigh- bors, who came to assist her, dissuaded her from the experiment; and she passed a whole night with severe preparatory pains, requiring me to be in the house, and frequently at her bedside, till, in the morning, she Avas Avearied and disconsolate. She now begged for the ether, or any thing to alleviate her sufferings. At the first inhalations from the sponge, she broke out into exclamations, — " O beautiful! O glorious ! Now I can bear any thing. I feel as if I had had a good night's rest. Send for a full supply of ether" (for we had but little). She assured me she 340 ETHERIZATION IN CHILDBIRTH. could manage for herself; that she would not call for it, except she was in pain. She kept the sponge in her hand, and held it to be filled when necessary ; and when the pain arrived, as often as once in ten minutes, she pressed the sponge over her mouth, and expressed, from time to time, the entire satisfaction it gave her. She Avas never made unconscious; but, being of an imaginative turn of mind, entertained us with a spirited conversation, mainly upon the merits of ether, the timidity of her friends, and the cautions of her medical attendant. In this way, she continued the respiration from 7 in the morning till 7 at night; using up, in the time, a pint of ether ; when she Avas delivered of a full-grown male child, Avithout the slightest untoAvard circumstance. She averred that she had suffered no pain, to be compared in severity Avith those of the previous night; and that she should not have dreaded her first pains, if she could have mitigated them with ether. Her convalescence was watched with jealous eyes ; for it Avas agreed, that any unpleasant symptom Avhich might occur should be laid to the ether. The recovery, hoAvever, was without the slightest accident; and mother and child continued in perfect health, till she resumed her duties in the family. Oct. 23, 1847. —A young woman, not more than twenty, had a healthy child, Avith a smart first travail of three hours. She had an hour's pain before I saw her, Avithout the use of ether. She had used inhalation of ether to mitigate the pain of tooth-drawing, and begged for it in travail. She was rejoiced to avail of it, and, when under its influence, was elo- quent in its praises. " O blessed invention of the nineteenth century ! " was her constant exclamation. The travail was finished with scarcely the slightest consciousness of suffering. She continued inhaling from the sponge impregnated Avith ether, at every pain, for the last two hours. Her recovery was perfect during the Aveek of my attendance, though she had mammory abscess afterAvards. On the 20th December, I Avas called in consultation in a case of pro- tracted parturition. The Avoman (Irish) had been in labor of her first child three days, and had used the ether freely, with very satisfactory mitigation of pain, and apparently without diminishing effort. She had taken ergot, and the head was impacted in the superior strait. I deliv- ered her Avith Leveret's long forceps, with considerable difficulty. She inhaled ether freely during the application and employment of the forceps, with very great relief to herself, and assistance to her medical attendants. Her convalescence Avas without the slightest accident. Her child was full-groAvn and still-born, which I attribute rather to the ergot than the forceps; and, when I contrast this case with that of another IrishAvoman whom I saAv in consultation in the summer, who obstinately resisted the inhalation, and Avhere it was necessary to open the head, I cannot but feel convinced that the patient and the operator derive the greatest assist- CORRESPONDENCE. 341 ance, in instrumental cases, from the use of an agent which can produce total or partial insensibility. I have used ether once only in puerperal convulsions. The general convulsions had spent themselves; the rhonchous breathing only remained, Avith occasional stiffening of the extremities. On respiring ether for a few minutes, the breathing became easy, noiseless; and the patient appeared to enjoy a ten minutes' sleep, perfectly relaxed. On return of the hard breathing and muscular rigidity, the inhalation was ahvays suc- cessful in removing them. She remained unconscious from the first attack of convulsions, and died within twenty hours from the birth of twins. I have never used chloroform in cases of parturition, but, on other occasions, have found it more speedy in its effects, and less exciting than ether. — Sincerely, your friend, Dr. Channing. A. L. Peirson. From Marshall S. Perry, M.D. Boston, Feb. 15, 1848. When I am asked, as I am frequently, what I think of the use of ether in labor, my ansAver is, it is going through a series of experi- ments which will result, I have no doubt, in some definite rules, by Avhich it can be administered with safety and benefit. — Yours, &c. M. S. Perky. \_Note. — Since above Avas received, Dr. Perry has communicated to me verbally some cases of natural labor, in Avhich he has used chloroform very successfully, and a second of arm presentation, in Avhich his success Avas as perfect as in the first. — W. C] From J. H. Lane, M.D. 1. Ether used in ten cases; chloroform in four cases, all natural; and labor not severe. 2. From one to six ounces ether; from tAvo drams to one ounce chloroform. 3. From five minutes to several hours. 4. Usually very soon. 5 and 6. I have generally used it, only to take off the acuteness of suffering, and not to produce entire unconsciousness and continued insensibility. 7. Nothing requiring very special remark. In some cases, labor- pains seemed to be strengthened under its use; in other cases, the pains Beemed to be somewhat diminished in force, but not entirely suspended. 312 ETHERIZATION IN CHILDBIRTH. About four weeks ago, I attended a lady in confinement, who has been insane for some years. She Avas confined about three years ago, and Avas then exceedingly noisy and boisterous for some hours; but, at length, Avas confined, and did well. In the last confinement, she Avas groAving quite troublesome as before, Avhen I resorted to the use of the chloro- form, which tranquillized her speedily. Her labor-pains also subsided; and I gave her ergot, which soon restored them ; and she was soon de- livered of a very large and healthy child. 8. None. 9. Nothing remarkable. If headach existed before etherization, it Avas usually relieved. 10. No bad result. 11. The effects of ether, as noticed by all, were somewhat unpleasant, and on that account objectionable........Chloroform I am much better pleased Avith, on account of its agreeable odor, its speedy operation, the rapid return of consciousness, and the state of freedom and comfort in which the patient is left after its use. It seems to possess all the anaesthetic power of ether, without its unpleasantness. — Yours, J. H. Lane. From Lyman Bartlett, M.D. Dear Sir, — In ansAver to your questions, — 1. I have used ether in tAvo cases, one natural and one instrumental case. Have not used chloroform in any case of obstetrics. 2. Used about half a pound in first case, and about six ounces the second case. 3. Used for tAvo hours in first case; for tAventy or thirty minutes in second case. 4. Effects in two or three minutes. 5. Unconscious of suffering, but would answer questions by yes and no. 6. Most of the time, complete insensibility to suffering ; the rest of the time, nearly complete. 7. The first case Avas one of a second pregnancy. Had had tAvo attacks of convulsions during pregnancy, and a third attack at the onset of labor. Was bled freely. Took an opiate, and lay quiet for twelve hours. Labor then commenced in earnest, and continued for eighteen hours, the pains all the time very severe. Os uteri dilated about tAvo inches, but edges thick and rigid. Edges immediately became thin and yielding, under the use of the ether. Pains, perhaps, slightly diminished in force for about twenty minutes, but then returned Avith undiminished force for tAvo hours, Avhen the delivery was completed. There Avas in no CORRESPONDENCE. 343 way any unpleasant effects from the etherization; but, during the Avhole period of it, she expressed herself as transported to the regions of perfect bliss, hearing seraphic music, &c. The second case Avas one of first pregnancy, a little dumpy Irish woman, aged 43. Presentation of the face to the left acetabulum. Duration of labor, eighteen hours. No progress for the last eight hours. No foetal pulsation for six hours. Forceps then applied (pains having nearly died away, and patient greatly exhausted). After the forceps Avere applied, she Avas etherized, and delivered in about twenty minutes. Was completely unconscious during etherization. Had no unpleasant effects, but "had a pleasant dream." 8. No apparent danger. 9. The first case occurred on the 27th of Oct. 1847; the other on the 10th of Nov. 1847. Recovery, in both instances, remarkably speedy, and without the slightest unpleasant symptoms, up to the present date, March 8, 1848. 10. The first child seemed partially asphyxied at birth, but was soon restored by warm bath, &c. It was of large size, and has been perfectly healthy and well ever since. The second case was still-born. 11. I think highly of the use of ether in certain cases of childbirth, but should not be inclined to use it in ordinary cases. I have not used chloroform in childbirth; but, at the urgent request of friends, I made several attempts to use it in a case of abortion, at the third month; but it produced a deathly expression of countenance, and seemed invariably to arrest nearly all uterine action. NeAv Bedford, March, 1848. Lyman Bartlett. From Simeon Tucker, M.D. Stoughton, Feb. 22, 1848. . . . I have used ether in six cases of labor. In one of these, the woman was not under its influence, until the last pain, which did not appear to be at all mitigated by its use. In one other case, the woman was not conscious of any pain, when the head of the child was born. The other four expressed themselves as being very much relieved, though not entirely unconscious of pain. Except the case in which there was no relief, I have generally commenced the use of it about half an hour before the child was born. It did not appear in any instance to diminish — I sometimes thought it increased — uterine action. In no case was it at- tended with any unfavourable consequences. Respectfully yours, Simeon Tucker. 344 ETHERIZATION IN CHILDBIRTH. From F. H. Gray, M.D. .............With regard to query No. 6, in no case did that insensibility manifest itself, Avhich we see in a patient that has fainted. Though, in all cases, they replied to questions and distinguished persons, yet they Avholly mistook the scenes in which they Avere placed, and the labor that was going on. This delusion applies only to the tAvo cases in which unconsciousness is said to have occurred. Yours, F. H. Gray. From John Jeffries, M.D. 1. Ether in eight cases. Chloroform, tAvo cases. All natural. 2. As the ether Avas generally used from an inhaler, the quantity used could not be measured. It was probably from tAvo to six ounces, accord- ing to the time in using. The quantity of chloroform was, in one case, half an ounce; in the other, it Avas an ounce. 3. From fifteen minutes to tAvo hours. 4. The effect of the ether was from four to six minutes. In one, not before ten to tAvelve. In one, where the inhalation was imperfect, it produced very little influence. Chloroform immediate. 5. Unconsciousness, at each repetition of the inhalation, in six cases. 6. Insensibility to suffering, in all but one case. 7. In three cases, it was thought to diminish the action of the uterus, as Avell as to produce insensibility. No other effects but as in ansAvers 6 and 7. 8. No apparent danger was manifested by the result. In one case, an attack of intermittent fever might have been mistaken for the effect of chloroform. 9. In those cases in which it was not the first labor, the patient had a better getting-up from confinement than in previous labors. No inju- rious results are knoAvn in any case. 10. No injury to the child in any case. 11. I think the ether more safe than the chloroform, but not so con- venient for use. One or the other of them may be used with safety and great advantage in relieving pain, in all cases of severe or protracted suffering. I do not know of any objection to their use, even in short and mild cases. — Yours truly, John Jeffries. CORRESPONDENCE. 345 June 12, 1848. My dear Sir, — I am sorry I am unable to give a better account of the ether cases. If you can make any use of them, I shall be glad. . . 1847. Date. April 17 A.W. Agent. Ether. May 16. W.N. Ether. May 20. G. B. Ether. July Nov. 23. 27. J. L. O.P. Ether. Ether. Remarks. Given early in labor. Pains appeared less frequent while under the influence of ether. It was omit- ted tAvice for a short time; and during each of these intervals, the pains were more frequent. Successful. Mother and child did well. Occasioned great dizziness and headach.. Perse- vered, and was under the influence 30 minutes; then conscious, and refused further inhalation. Has had intermitting pulse from that time. Child well. Quite successful. Taken near termination of labor, which was quick. Child and mother did weU. Successful. Recovery from confinement rapid. Not completely etherized. Difficult to induce her to inhale. Not quiet; tossing about bed. Did not like the ether; but no ill effects followed to mother or child. In aU these cases, the child's breath, for several hours after birth, smelled strongly of ether. Successful. Recovery rapid. Insensible one hour thirty minutes. Successful. Recovery very slow. Now suffering under pulmonary affection. Child remarkably healthy and strong. Successful. Two hours twenty minutes insensible. Recovery good. Child well. Insensible only during the first and middle stages of labor.- Breech presented. Delay was feared in dehvery of head. Successful. Child and mother well. Successful. Child and mother doing well. My own impression is, that, while the patient is fully under the ether, throes are not as frequent as in the natural state. It is also my impres- sion, that they are not, as a general rule, so propulsive as in the natural state. With these views, I did not feel willing to give the agent during the termination of the breech case. In the case of intermitting pulse since administering ether, the patient is firmly convinced, that it was the effect of the ether. Of this you are a better judge than I am. I think I have observed, that the children born under the influence of ether did not cry as quick or as strong as in natural labor, or Avhen under the influence of chloroform. Very respectfully yours,--------------. 44 848. Jan. 8. Chloroform. „ Feb. 15. Chloroform. „ March 9. Chloroform. „ May 18. Chloroform. „ May 23. Chloroform. „ June 6. Chloroform. 346 ETHERIZATION IN CHILDBIRTH. From Woodbridge Strong, M.D. To Dr. Channing. Boston, Feb. 1848. 1. I have not used either in natural labor, and the ether in only one case of instrumental labor. 2. Quantity about half a pound. 3. About three hours in all. 4. The effects Avere almost immediate. 5. She seemed unconscious, and usually fell into a sleepy state, from Avhich she soon aroused, — perhaps in ten or fifteen minutes, Avhen she called for it again, and again Avent into the same state, and this until delivery. 6. The insensibility Avas nearly, if not quite, entire. 7. No special effects to notice. 8. SaAv nothing to notice as dangerous. 9. No results to be laid to this. The mother came out of the sleepy state immediately after the delivery, Avhich Avas by instruments. She said she neither felt the application of the instruments, the forceps, nor knew Avhen she Avas delivered. She Avas delivered in the morning, and afterAvards slept more than usual during the day. 10. The child was alive when delivered, but almost dead, — so much so, that I hardly expected that it Avould survive ; and yet this might have been OAving to the previous pressure which it had been subjected to; but, since this, the child has done Avell, and is thriving. 11. I have been opposed to its use, and have only yielded to impor- tunity, Avhen I gave it; and this not because I had seen any bad effect, but because I prefer to pursue old methods, Avhich have been found safe and sufficient, in preference to enter upon the use of an untried remedy. One case can settle no practice, or the operation of any medicine; and yet I should infer from this case, that, in proportion as the narcotism was complete, the labor Avas retarded. Whether the child Avould have been born naturally Avithout the ether, I do not know. But, as it was, using the ether, I became discouraged. The mother also became so ; and, at her request, the child Avas delivered instrumentally. — Respectfully, W. Strong. From A. K. Gardner, M.D. Dr. W. Channing. NeAv York, 151, Wooster-street, May 3, 1848. . . . . Feb. 2. — Was called at 7, a.m. to Mrs. D. (Greenwich- street), in labor Avith her fifth, full-timed child. Two hours previously, the membranes ruptured ; since then, the pains Avere strong and frequent. The position was the first of Baudelocque. At 9, a.m. the os was per- CORRESPONDENCE. 347 fectly dilated, the pains increasing in frequency and force; and I then administered the chloroform (almost for the first time that it had been used in New York, during labor). She inhaled it, placed upon a sponge. The effect was immediate ; for she soon became unconscious of Avhat was passing around. Talked incessantly of matters Avhich had occurred some days anterior. The pains Avere evidently rendered less frequent; but of their effects, and the suffering, she was entirely ignorant, AArhile under the full effects of the chloroform; and but partially as the medicine evapo- rated. She was kept under its influence till 11 (two hours), Avhen a male child was born, crying lustily, of which she was entirely ignorant. She took, in all, one ounce ; and neither she nor child experienced the slightest unpleasant symptom. She declares that she will never again be confined without using the chloroform. Feb. 4. — A. B. an exceedingly robust and powerful Avoman. . . . Had never been ill in her life. Pains commenced at 4, p.m. At 10, p.m. when I first saAv her, she Avas much excited, tossing herself about, and refusing to submit to any restraint. . . . At 11, first administered the chloroform. This added to her excitement.....Having but a small quantity of the chloroform, I was unable to administer it as freely as was desirable; it, nevertheless, had the effect of markedly soothing her, and quieting the pains, when tolerably under its influence. . . Shortly after 11, the membranes ruptured; and the pains, while inhaling the chloroform, in great measure ceased, though she was never completely under its influence. Friction to the abdomen Avas useless. Pulv. sec. cornut. one scrup. was administered, ten grains, each half hour, but with no avail; and not till the chloroform Avas reduced in quan- tity were the pains reneAved..........Thus it went on till 3, a.m. of the 5th, when the child, which had remained for some time locked in the lower strait, and restrained by the rigid perineum, entered the world. A larger quantity of chloroform than had yet been given was administered at this period, and the patient Avas completely un- conscious of its birth. The head of the child was very seriously affected by the pressure, far more than usual; the bones riding over one another to a very great degree. The child, a female, Aveighing eight pounds, Avas still-born ; the cord slightly pulsating, but no beating of the foetal heart. Mother did very Avell. Administered, in all, one ounce of chloroform. April 12, 10, a.m. — Was called to Mrs. Eliza J. at the Bloomingdale Hospital. Had felt some pain during the previous night. Os is now fully dilated, and membranes ruptured for several hours. Occiput in lower strait, first position of Baudelocque. First child. At half-past 10, administered chloroform; and she Avas kept under its influence till half-past 12, p.m. not completely, for in that state the pains Avere entirely arrested, but partially. At this time she Avas delivered of a female child. 348 ETHERIZATION IN CHILDBIRTH. Both infant and mother did well, haAdng not the least noticeable result arising from the use of the chloroform. — Yours, Augustus K. Gardner. From Charles Gordon, M.D. [Dr. Charles Gordon, of Boston, communicates five cases; of which tAvo are printed, the first and the last.] Case No. 1. — Mrs. C.; second labor. I was called four hours after the pains began. Os uteri partially dilated; vertex presented. After about an hour, the liquor amnii Avas discharged, and, almost immediately, powerful expulsive pains ensued. At this period, ether Avas administered ; tAvo ounces Avere poured upon a sponge. In from five to ten minutes, she became unconscious. The pains continued rapidly and forcibly for about tAventy minutes, Avhen the child was born. Very soon, the mother recovered sufficiently to realize her condition, and expressed, in very enthusiastic terms, her love for an article that had so completely annihilated her suffering; and, at the same time, complained of my not administering it at an earlier stage. The mother and child did well. Case No. 5. — Mrs. H.; fifth labor. I Avas called six hours after the pains began. Os uteri partially dilated and dilatable ; vertex presented ; pains regular and severe. I administered sixty drops of chloroform with an inhaler. Unconsciousness almost immediately followed; and this state Avas kept up almost completely for an hour and a half, by repeated inhalations given in small quantities, about twenty drops at a time being sufficient for the purpose. During this period, the child Avas born, Avith- out the consciousness of the mother; and she expressed herself in the strongest terms of the delightful effects of the chloroform, and also of the trifling amount of suffering she had experienced in the present instance, in comparison Avith that of her previous labors. The placenta was retained from thirty to forty minutes after the birth of the child; but - this is not an uncommon occurrence. The amount of chloroform used was about half an ounce. The mother and child did well. [The following extract from Dr. Gordon's letter contains his ansAver to the 11th question in the circular: —] The important question to be settled now seems to be the safety and propriety of the use of the anaesthetic agents in natural labor. Of course, no one doubts the propriety of their use in such cases as require the interference of art, either by the aid of instruments, or in any Avay that will cause a great degree of suffering. It will be observed, that, in the foregoing cases, these agents were employed in natural labor; and also at a period when the circumstances CORRESPONDENCE. 349 of each case justified the expectation of speedy delivery; when the os uteri was well dilated; the pains regular and severe; every thing announcing the beginning of the expulsive stage. At this period, these agents, cautiously administered, afforded the patients great relief; and in neither case occurred a single circumstance to the mother or child, to render their use unsafe or improper. I should not hesitate to employ them at the advanced periods of natural labor, provided no conditions of the constitution or health at the time contra-indicated. The use of these agents at the commencement of labor, before dilata- tion has taken place, may be injudicious, inasmuch as the time frequently required for this act is very long, especially in first labors. Like every other means in the hands of the physician, their use must depend on his judgment; and it would seem as if all accidents in the employment of ether or chloroform in labor may be prevented by the same amount of discrimination as is required for the use of other means for the relief of human suffering, which are powerful, and may be dangerous. From N. B. Shurtleff, M.D. . . . I have made it a practice to inform my obstetrical patients, that the means of relief were within their reach; and I have left the motion to come from them, and have them administer the relief. I prefer chloroform for its pleasantness, easiness of application, quickness of effect, and duration. Many of my patients have preferred to trust to their powers of endu- rance, and have not used ether or chloroform, although in the room, and at their disposal. — Respectfully yours, Nathl. B. Shurtleff. From Samuel S. Whitney, M.D. of Dedham. [The following is an extract from Dr. Whitney's opinion of etheriza- tion in labor, and in medical and surgical practice: —] . . . . As it regards the use of either of the two agents in ques- tion, you will have anticipated my opinion from what has already been said. With the experience of more than two hundred cases before me, without one solitary instance of evil resulting from their use, it Avould be singular indeed if the impressions received respecting their administration and effects should not have been of the most favorable character. I do not wish to be understood by this, however, as believing the exhibition of ether or chloroform to be unattended by any risk or danger. . . . 350 ETHERIZATION IN CHILDBIRTH. From Charles Chase, M.D. . . . My opinion is favorable to the use of both ether and chlo- roform in difficult cases of obstetrics, so far as I have Avitnessed their effects ; although I have used them Avith great caution, and have ahvays discouraged Avomen from using them, except in severe or protracted cases. The case of instrumental labor spoken of, under No. 1, was a second child; the first child being nine years of age, and weighing at birth five pounds. After a continued labor of tAventy-five hours, and very severe for nine hours, and without any progress for the last six hours, I applied the forceps, and speedily delivered her of a living male child, Aveighing nine pounds and a half. The mother, under the influence of chloroform, manifested no sign of pain during delivery, fell into a quiet sleep imme- diately after, and aAvoke to perfect consciousness in about thirty minutes. She never suspected that forceps Avere used, until informed of it ten days after confinement. Both mother and child did well, never exhibiting the slightest unpleasant symptoms. — With great respect, yours, &c. Chelsea, June 24, 1848. Charles Chase, From Daniel V. Folts, M.D. .....You Avill see, that usually an ounce of chloroform has been sufficient for the induction and continuance of anaesthesia one hour. The pulse has seldom been much influenced either way, — usually les- sened from eight to tAvelve in a minute. My experience Avith sulphuric ether has been confined pretty much to surgical cases. The results were highly satisfactory; but, for reasons often enumerated, I have been led to substitute chloroform in its stead. — Your friend, &c. East Boston, May 10, 1848. Dane. V. Folts, Case 1. — Mrs. M'G.; aged about twenty. Had been in labor for six or eight hours, when I was called to see her. The pains were fre- quent, but of short duration, and the os uteri but slightly dilated. She was left, to attend to other calls a few hours; and, when I returned, found the labor progressing, but at the same time very sloAvly. After the first stage had passed, the pains, Avhich, until now, had been referred to the back almost exclusively, became very severe, — to the patient's mind intolerable. As the labor was progressing but sloAvly at this stage, and the external parts unyielding, I suggested chloroform. It Avas ~ inhaled from the sponge. At first, the sensation to the patient Avas very unpleasant, and anaesthesia was imperfectly induced. Yet four to five CORRESPONDENCE. 351 minutes ansAvered the purpose; and the patient was as in a natural, quiet slumber. There Avas manifestation of suffering when the pains came on, but the patient totally unconscious. With the exception of a feAV wake- ful moments, which Avere spent in begging for more chloroform, she was kept in this state for three hours and a half, when the labor terminated in the birth of a fine, healthy child. Slept Avell the first night; after- wards suffered severely from after-pains. Mother and child both did Avell. Amount of chloroform inhaled, about fourteen drams. Case 7. — Mrs. L. had suffered a good deal from pain in her breasts, and a copious secretion of milk, before half the period of utero-gestation Avas accomplished: otherAvise, nothing remarkable in the case. It was her first confinement. Was called at 6, a.m. and learned that the pains had been Arery frequent through the night, and now came on every five minutes; still, Avere quite transient and ineffective. The os uteri scarcely dilated, but dilatable. Left to attend other engagements, and returned in about three hours. The labor had made some progress, though pains much as before ; none in the back. At the end of two or three hours more, found the pains better, and uterine contractions more efficient. The cervix uteri was noAV rapidly disappearing. Every thing going on well. Called for again, in great haste, a little past 12 o'clock, m. Pains Avere noAV severe, and second stage of labor had somewhat pro- gressed. The patient Avas in great agony, and begged for something to be given her to ease the pains. But the chloroform-phobia had become deeply rooted in the minds of husband and friends. I reasoned: she entreated ; and, finally, consent Avas obtained. Anaesthesia Avas rapidly induced, say in one minute. The patient noAV, for the first time in many hours, lay quiet; and, Avhen the pains came on, there was an involuntary bearing doAvn of abdominal muscles. The perineum, which Avas very thick and unyielding, now became relaxed; the disproportion between the head of child and maternal passage Avas rapidly disappearing. The head, which for hours had been stationary, noAV began to descend, and the termination of labor Avas evidently hastening on. But the patient became loquacious, and the husband became alarmed. She talked about patent rights and all manner of rights, and he about the dangers of chloroform; said she must have no more. But she begged still. The pains became more severe, and she begged harder. Again he yielded; and again she became quiet, while the pains became more effective. The child was born ; the afterbirth removed; and still she slept. The friends noAV became again alarmed. But pulse and respiration perfectly natural: I assured them there Avas no danger. Consciousness now returned, and she Avas asked if she had any pain. " No." — " Shall we keep you in this state, so that you may sleep to-night ? " — " No, no ! I Avant smart 352 ETHERIZATION IN CHILDBIRTH. pains so as to get through; but you will give me the chloroform, won't you?" The cries of the child now attracted her attention, and the charm was over. Both mother and child have done unusually well. Duration of anaesthesia about four hours, including the short interrup- tion referred to. Chloroform inhaled, nearly two ounces. From Wm. Thornton Parker, M.D. Walter Channing, M.D. South Boston, Jan. 25, 1848. Dear Sir, — I received your communication, in regard to ether and chloroform, yesterday, and regret that my experience can furnish but two cases of etherization in labor. The chloroform I have not seen used at all. In my first case, perfect quietness, and rest of limbs and uterus, succeeded, for tAventy minutes, to a state of unusual uneasiness and jactitation; and, on waking at the end of that time, the patient objected to a repetition of its use, preferring to complete the labor in the natural way. The second case occurred, Nov. 3, 1847, — a case of tedious labor, the termination of which you may remember to have seen, — Mrs. F. She was under the influence of the ether three and a half hours. The quan- tity inhaled was from ten to twelve ounces. The results to the mother were every way happy. In regard to the infant, it is perhaps remarkable, that it did not close its eyes for the eighteen hours succeeding its delivery, which occurred at half-past 4 o'clock, p.m. In this case, the ether seemed to increase " the pain." And having since seen in the sixth volume of the American reprint of the " London Lancet" (Nos. 4 and 5, pp. 312 and 378), three cases reported, where a similar effect seems to have resulted from its administration, I am anxious to know, if your large experience favors a supposition that ether or chloroform ever causes such effects ? I am, with the deepest respect, your most obedient servant, Wm. Thornton Parker. [In answer to Dr. Parker's question in the last paragraph of his letter, I say yes. I have met with cases, and I would say in many of those in which I have induced etherization, in which, uterine contractions have been increased, and in which labor has been completed after a much shorter time than its previous progress indicated. The same has been observed by others, whose communications are in this Correspondence, and to which I, with great pleasure, refer Dr. Parker.] CORRESPONDENCE. 353 A Third Case of Labor, from Dr. Parker. Mrs. K. aged thirty-two. Short, sanguine, robust. Her fifth pregnancy. My first attendance upon her. Her labors, sometimes having been pre- ceded by six days of premonitory pain, have ahvays commenced with rupture of the membranes, and continued Avith awful suffering from ten to fourteen hours. Three of the children were of a weight a little above the average ; one, a little beloAv. Feb. 28, 1848. — Called to her at half-past 10, p.m. She has suffered uneasy pains for twelve hours. At 9 o'clock, p.m. the pains increased; and, at 10 o'clock, the liquor amnii escaped. Found the pains were abating; the os uteri undilated. Left her free from pain at 3 o'clock, a.m. Feb. 29. Feb. 29, 9 o'clock, a.m.—Has slept Avell. Is up and dressed, and more comfortable than she has been for several days. Recalled at 11 o'clock, p.m. Has severe pain. No other symptom of labor. Left her again free from pain, at 2 o'clock, a.m. March 1. March 1, 9 o'clock, a.m. — Slept Avell the latter part of the night. Is up and dressed and comfortable. Recalled at half-past 12 o'clock, m. — Severe and regular pains com- menced at 12 o'clock, m. Is in excessive pain and terror, and has con- sented to the exhibition of chloroform. The os uteri dilating. The presentation natural. At ten minutes past 1 o'clock, commenced the inhalation. The pulse, Avhich had been 80, Avas in ten minutes reduced to 50, where it remained till the inhalation was discontinued. The uterine effort ceased to be intermittent, and became continuous. The os uteri rapidly dilated, and the labor as rapidly advanced. The patient regulated herself the supply of chloroform, and, seeming to be in full possession of her faculties throughout the whole, constantly expressed her delight at the almost perfect relief from suffering she experienced. In this manner the labor progressed till 2 o'clock, p.m. when a boy, Aveighing eight pounds and a half, was safely born. The placenta came aAvay in ten minutes. There was no hemorrhage or after-pains. Every thing in relation to her " getting-up" was fortunate and prompt. From A. Phelps, M.D. Walter Channing, M.D. Boston, Feb. 10, 1848. 1. I have used the sulphuric ether in twenty-seven cases Avith good success, and Avithout instruments, or accident to mother or child. 2. The quantity of ether used in my first case was about four ounces. . . 45 354 ETHERIZATION IN CHILDBIRTH. 3. "Hoav long used?" AnsAver : Only till the pain nearly subsides, but not wholly ; Avhich, in most cases, is less than two minutes. In no case do I alloAV the inhalation more than two minutes at a time, and generally much less; but I direct it to be repeated at every pain, until the child is born, and the placenta taken, which has occupied from tAventy-tAvo minutes up (in two cases only) to ten hours. 4. " How long before effects ?" AnsAver : Ahvays Avithin two minutes. 5 and 6. In no obstetric patient have I perceived " unconsciousness" or " insensibility."............ 7. " The special effects," in every case, have been more or less to diminish the suffering of the patient; to prevent the usual exhaustion of strength; to expedite the labor more than one half; and to increase courage, confidence, and hope, in the mind of the patient. 8. I have seen no case of "apparent danger" whatever. 9. The " results to mother, both immediately and after delivery and later," have been highly satisfactory. Her after-pains have been much less, and in some cases none. Her strength generally has been as much at the end of the first week, as formerly, Avithout ether, at the end of the fourth Aveek; and nothing unfavorable since has appeared in a single case. 10. Every child has been born alive, and I think Avith more apparent strength and health than usual............ 11. My "opinion of the use of ether in childbirth" will be inferred from my previous answers.............. From William P. Dexter, M.D. Brookline, March 2, 1848. Dear Sir, — I have been permitted to employ etherization, in mid- Avifery in but two instances. . In one of these, I was present at so late a stage, and the pains Avere so severe and continuous, that the patient was not able to inhale the ether in sufficient quantity to produce any effect. In the second case, in Avhich I had the advice and assistance of Dr. Hale, of Boston, I used the chloroform to the amount (2.) of betAveen six and seven ounces, inhaled by means of the conical tube introduced, I believe, by yourself. It Avas used (3.) at intervals, from about 11, a.m. to about 3, p.m. and almost constantly from that time till the termination of the labor at near midnight. The effect was perceptible in a very few min- utes : (4.) the patient was buried in profound slumber, from Avhich, how- ever, she was always partially aroused by the return of pain. A state of incomplete unconsciousness Avas produced, attended with delirium. I do not think that she was at any time insensible to her pain, though its severity Avas so far mitigated as to- lead her to beg that the chloroform CORRESPONDENCE. 355 might be again given. (7.) In her delirium, she seemed busily occupied Avith her ordinary duties ; giving directions about the house, &c. I saAv no appearance of danger to the mother. She seemed, on the contrary, refreshed by each inspiration and the consequent sleep, and aAVoke with renewed strength on the accession of the next pain. Her subsequent recovery has been rapid, and unattended by any symptoms attributable to the chloroform. She was delivered eventually by the crotchet. During the extraction, the chloroform Avas administered with the greatest free- dom ; notAvithstanding Avhich, it Avas found impossible to keep her as quiet as Ave could Avish, and she Avas by no means insensible to her sufferings. From a single case I have no right to form an opinion upon the value of etherization in labor. Any further particulars I shall be most happy to communicate, and am, Avith respect, your obedient servant, Dr. Channing. Wm. P. Dexter. [Some weeks after, Dr. Dexter called to inform me, that phlegmasia dolens had attacked one leg in the above case; and the same thing hap- pened in one of the forceps cases which came under my notice.] From Erasmus D. Miller. Dr. Channing. Dorchester, May 30, 1848. Dear Sir, — In answer to the note I had the honor to receive from you a few days since in relation to the use of chloroform in obstetric practice, I would say that my experience is limited. I have made use of it in only twelve or fourteen cases, but in these with the happiest results ; not one unpleasant symptom having followed its use. In its administration, I seek merely to make the patient comfortable; and, so far, I have had no difficulty in so doing, Avithout affecting in one instance the patient's consciousness. After the patient has been once brought under its influence, I knoAv of no better criterion, in its admini- stration, than to trust to the Avishes of the woman. As far as I can judge from so limited a use of chloroform, those women recover more rapidly and permanently Avho use it than those who do not. Respectfully yours, Erasmus D. Miller. From C. H. Allen, M.D. Walter Channing, M.D. Cambridgeport, July 29, 1848. Dear Sir, — In reply to your inquiries, hoAV extensively, and Avith Avhat results, I had used ether or chloroform, I cheerfully state Avhat occurs to me as Avorthy of recording. 355 ETHERIZATION IN CHILDBIRTH. During the last eight or ten months, I have administered chloroform in a variety of diseases and conditions, as colic, asthma, and convulsions, to children of three years, as well as to adults. I have given it under painful surgical operation, Avith wonderful and entire freedom from the usual attendant pain. In eight obstetric cases, I have Avitnessed its most admirable effect; placing the patient beyond the bounds of anguish, and yet allowing her to return to her natural state, Avithout any subsequent unhappy results, — indeed so far so, that, in every case, patients recov- ered more rapidly than usual. Of these eight cases, I will refer particu- larly only to two, as the others Avere similar. No. 1, first labor. Full habit; firm muscles. Was called at 10, a.m. Was told by women present, that the patient had had excruciating pains since 12 of the previous night. She hoped to get along without a phy- sician ; but her case seemed so severe and desperate, that she had sent for me ; hoped I should save her life. I found her entirely exhausted, having been in a variety of positions, — on the bed, on the floor, on her feet, on her knees ; and still the labor hung on. Examination found the os uteri partially dilated; the waters had passed away; the vaginal pas- • sage rigid. I immediately comfortably arranged the bed; placed her in the usual position; applied chloroform to her mouth, by means of a concave piece of sponge, covered with cloth on all sides except the loAver, through Avhich atmospheric air freely passed; kept my finger upon the os uteri, to observe Avhat, and hoAV rapidly, changes might occur. In ten minutes, sheVas so much etherized, that apparently severe pains did not disturb her. She remained perfectly quiet for thirty minutes longer, Avhen the infant was born; and, shortly after, the placenta expelled. I observed, that, in a few moments after etherization commenced, the os uteri began to dilate, and this passage to be relaxed. In fifteen minutes longer, the mother Avas sensible of her condition, — Avas surprised to learn, that her infant was born, and Avas sucking its fist. No mother ever recovered more rapidly. Did not feel one half so much exhausted on the infant's birth, as on my entering the chamber. She told her female friends, that with chloroform it was nothing to have babies; that she meant to have another. I administered about one ounce of chloro- form. No. 2, second labor ; age thirty-seven. First birth, tAvo years previous, AA'hich Avas so excruciatingly severe, and prolonged so many hours (seven- teen), that she dreaded the present one exceedingly, and desired me to place her entirely under the influence of chloroform. I Avas called at 4, a.m. ; found she had been in labor three hours. Os uteri but slightly dilated ; the passages firm and unrelaxed. I requested a female attend- ant to administer the chloroform; Avhilst, Avith my finger on the os, I observed Avhat changes occurred. Dilatation of all the parts concerned CORRESPONDENCE. 357 took place in a few moments, and the labor was completed in one hour, to her great joy, without her having been conscious of any suffering. Her after-pains and hemorrhage were less, and her recovery was more rapid, than after her first labor. The infant was born alive ; and both it and the mother have done well. In all the cases in which I have used chloroform, unusually rapid recovery Avas observed. No unfortunate result has occurred. Very truly, your obedient servant, Charles H. Allen. From J. D. Fisher, M.D. [From Dr. J. D. Fisher's very full and elaborate reply to the circular, I make the following extracts: —] 4. The effects of the inhalation of both the ether and chloroform mani- fested themselves after periods varying in duration in different individuals, and even in the same individual. As has already been suggested, this seemed to me to depend, in some measure, on the temperament of the individual; but it also evidently depended very much upon the facility and force Avith which the inhalation was practised and accomplished. Those Avomen who inhaled freely and forcibly enough at each inspiration, to completely expand and fill the lungs Avith the medicated air, came under its influence sooner than those whose lungs were but moderately distended by each inspiratory effort. The first two or three applications of these vapors required, in some cases, more time for the manifestation of their effects than they did subsequently; and, in two instances, the ether, after having been employed for some hours, seemed to lose in a great degree its influence in annulling sensibility to the labor-pains. I have not observed the same circumstance to attend the employment of the chloroform, in the few cases in which I have made use of it. I have also observed, in regard to the ether, that, in some instances, the first inhalations of it were folloAved by a prompt and complete cessation, for a time, of the uterine contractions. Whether this was owing to the influ- ence of the ether, or of terror excited in the mind of the patient by inhaling the vapor, I have not been able to determine. I am disposed to believe, hoAvever, that it Avas not OAving to the ether; since, on the re-establishment of the contractions of the womb, the breathing of it Avas not attended by a similar occurrence. In the seven cases in which I em- ployed the chloroform, no such circumstance occurred, which is, I think, an additional proof that the subsidence of contractile action of the uterus ought to be attributed to the impression of fear made on the mind of the patient, rather than to the action of the ether on her organism. 358 ETHERIZATION IN CHILDBIRTH. 7. In no case have I employed chloroform for the purpose of abolishing the poAver of intelligence; and I have administered ether only in tAvo instances, Avith the vieAV of producing perfect unconsciousness. The first Avas in a lady, in whom it Avas necessary to separate the placenta from the walls of the uterus by the hand ; the operation Avas performed, and the placenta extracted, while the patient Avas perfectly unconscious. In the second instance, the head of the child being retained in a fixed posi- tion for some hours, I administered the ether, and Avas enabled to pass my hand above the head of the child, and to feel the os uteri hard and ri°id, and firmly contracted to the size of a dollar round the child's neck. Not having made a similar observation before, nor seen this occurrence recorded by any author as the cause of protracted delivery, and wishing to be certain in regard to it, I again placed the patient under the influ- ence of the ether, and Avas able completely to verify my previous diag- nosis. As bleeding and other remedies failed to advance the delivery, the curved long forceps Avere applied during the state of perfect uncon- sciousness in the patient, from the use of the ether; and the child was thus extracted, living and healthy, with no knowledge, on the part of the mother, of the manipulations. In the latter case, it will be seen that the unconsciousness was produced at three different times: in the two for- mer of these, it was maintained about four minutes each; and in the last, about eight minutes. Soon after discontinuing the inhalation, the Avoman recovered her natural faculties, and the result Avas favorable and most gratifying. 8. In no instance was there any danger manifest, either in the simple or complicated labors that have occurred in my practice ; and the admi- nistration of ether or chloroform, in the careful manner of my OAvn cases, cannot, I think, be attended Avith danger. 9. All the Avomen did well. In fact, their recovery seemed to be, if there Avas any difference, more rapid and free from anxiety, than under the ordinary circumstances. In two or three, the subsequent floAving appeared to have been increased; but this point is of so doubtful a nature, that I am not willing to lay stress upon it. J. D. Fisher. From C. G. Putnam, M.D. 1. Twenty-four. 2. Chloroform, fifteen drops to half an ounce. Sulphuric ether, one to tAvelve ounces. 3. From less than one minute to tAventy-four hours, at intervals. 1. From half a minute to five minutes. CORRESPONDENCE. 359 5, 6, 7. Sometimes insensibility; sometimes entire unconsciousness. 8. None. 9. Favorable. 10. Favorable in tAventy-six. One still-birth, arm presentation, Avith prolapse of cord. A continued use of etherization has confirmed my opinion of its in- estimable value. I cannot better answer your inquiries than by a short extract from my communication to the " Boston Journal" of February, 1848: — " The paramount question in regard to etherization is its safety. We are not justified in introducing so disturbing an element into a natural and for the most part healthy process, unless it is unquestionably safe to mother and child. "Within my OAvn observation, there has not occurred any serious accident, immediate or remote, that could be attributed to the use of ether. " I do not invariably use it; for its effects, though never dangerous, are sometimes disagreeable, and may overbalance the suffering from the pains which the patient has anticipated, and is prepared to endure. " There are conditions, however, in which the positive, unequivocal advantages of ether far outweigh any temporary evils, — in which it is not merely yielded to the patient's comfort, but demanded by her neces- sities. The muscular action may be inordinate, wasting the strength without advancing the labor, inflicting injurious pressure upon the soft parts, and thereby compromising the safety of mother and child. These, besides various mental disturbances, are materially controlled and relieved by the use of ether. Above all, in obstetric operations, the patient is saved much suffering. Apart from the prostration and other immediate and remote evils consequent upon the use of antimony, opium, and vene- section, — which, to be effective, must be full, — they often fail to pro- duce the desired relaxation and repose. If the cases related should not prove to be exceptions, we have in ether a most valuable auxiliary. " Fears have been expressed that ether would endanger the well-being of the child and the convalescence of the mother; that it would cause imperfect contraction of the uterus, whereby the process of labor would be delayed, and the risk of subsequent hemorrhage incurred. " I have several times examined the foetal heart during labor, and have detected nothing unusual; and, though the breath has sometimes smelt strongly of ether, no ill consequences have folloAved. The same is true of the convalescence of the mother. Indeed, if any measure had been adopted expressly for the purpose of promoting convalescence, the result Avould have been considered successful. 360 ETHERIZATION IN CHILDBIRTH. " In three cases there Avas hemorrhage after delivery. The first Avas after a lingering labor, Avhich Avas terminated by the forceps. The second after a tedious breech presentation, — the patient being at the time in feeble health. The subject of the third case had hemorrhage after the birth of her tAvo first children; and I had taken the precaution, on three subsequent deliveries, to give ergot just before the child was born. It caused her, hoAvever, considerable pain, and the last time I omitted it. She did well; and, trusting to that, I omitted it on this occa- sion. The result was not so fortunate. I think it will not be doubted that the causes of the hemorrhage Avere to be found in the nature of the cases, and were independent of ether. With these exceptions, the con- traction of the uterus Avas, in every case, immediate and thorough." Yours, Avith respect, Boston, Sept. 11, 1848. C. G. Putnam. From Anson Hooker, M.D. Dr. Channing. Dear Sir, — I will give you very brief answers to your inquiries, as to my experience in the use of sulphuric ether and chloroform in my obstetric practice. I have used ether and chloroform in tAventy cases, — all natural labors except tAvo. In the first of these tAvo, I gave sulphuric ether, after the patient had been in severe labor for three hours. Her previous labors, three in number, had been easy and expeditious. The pains were very severe and distressing. The membranes I found ruptured, and the labor progressing slowly. Her pains were so agonizing, I gave her ether ; but, soon after she became fully under the influence of it, the pains began to subside. I continued the ether, and gave ergot, Avhich soon brought back the pains. They both acted kindly together ; but the child did not advance, the head being firmly locked in the pelvis, the face inclined toAvards the pubes. I completed the labor with the forceps. I was par- ticularly pleased Avith the manner in which the ether and ergot acted together. The ergot acted as promptly as in cases in which the patient is not under the influence of ether. The ether was used nearly three hours, and the Avoman Avas insensible to pain nearly the Avhole of the time. Both mother and child did Avell. The second case Avas an arm and shoulder presentation. In this case, I had your very valuable assistance. You will recollect the patient had been under the care of a midwife; that the patient had been in labor more than tAventy-four hours ; that the hand and arm had been present- ing (the hand protruding from the external organs) for more than eighteen hours previous to my seeing her ; that I had succeeded in reaching a CORRESPONDENCE. 361 foot, and bringing it partly down, but could not, by any force I could bring to bear upon the child, unaided, complete the labor. You will remember the swollen state of the arm, the contracted pelvis, the small space there was between the sacrum and pubes, and the long-continued and very strong efforts we were obliged to make to complete the turn- ing, and accomplish the delivery. During this time, which occupied nearly three hours, the patient continued to inhale sulphuric ether almost con- stantly, but not with perfect insensibility. This case, although looking very unpromising when you left, did well. The patient was about her room in a fortnight. Her breath retained the smell of ether for four days. The largest quantity of ether I have used in any case was sixteen ounces in seven hours. No stupor or headach, or lung affection, suc- ceeded. Both mother and child did Avell. The largest quantity of chlo- roform, four ounces in four hours, Avith the happiest results. The length of time required to produce their effects varies in different cases, and the same may be said of the amount and degree of unconsciousness and insensibility. I do not find that parturition changes or modifies the effects of either of these agents. They act in this as in other cases, in which a like amount of suffering is to be endured. In a majority of cases, there has been less exhaustion than it would seem there would have been, if unconsciousness or insensibility to pain had not been induced. In no case has any thing occurred to excite in me any alarm; nor has any thing happened to the child that could pos- sibly be attributed to either ether or chloroform. As to the case of these agents in obstetric practice, it seems to me there can be but one opinion. In the twenty cases in which I have used one or the other of them, I have not only not seen any ill effects ; but, on the contrary, an immense amount of pain and suffering prevented. I there- fore deem it to be as much the duty of the physician to administer some of the ethers or chloroform, in severe and protracted labors, as to give opium in severe spasmodic affections, or stimulants in extreme exhaus- tion. Yours very respectfully, Anson Hooker. East Cambridge, April, 1848. P.S. — Since writing the above, I have given it in two cases, in addition to those I have related, and with the same good effects. 46 362 ETHERIZATION IN CHILDBIRTH. REMARKS ON THE CORRESPONDENCE. The preceding Tables contain analyses of the Correspondence, and give in detail the answers to the questions in the circular. From the Letters have been selected such portions as may supply such deficiencies as the nature of tabular views renders almost unavoidable. Keeping in view that it is the object of this volume to present facts, and such mainly as bear upon the question of the safety and utility of etherization, such portions of the Correspondence as are of a practical nature have been given. While this acknoAvledgment is made, it is not its object to involve the inference, that the strictly speculative views offered by the writers are not of interest. Had not the volume already exceeded the limits originally assigned to it, and were there not a department before referred to (the Appendix) still to be given, the Avhole of the Correspondence would most cheerfully haAre been inserted. Much that is cautionary is communicated. This has been embodied in the volume, and has contributed very much to its interest. It is gratifying to remark, that the latest experience of those Avho have most frequently employed etherization, as far as it has reached me, confirms the specific ansAvers given by the writers to each of the questions con- tained in the circular, which are so wholly favorable to etherization. I refer with great pleasure to the correspondence of Dr. Thompson in this connection. His first Letter was dated Jan. 28 ; the second, June 5; and alike furnish important evidence in favor of both ether and chloroform. Dr. Perry also, in a subsequent verbal communication, confirms the state- ments in his first, in regard to the safety of etherization. To be sure, Dr. Perry does not think so much of its benefit, from a comparison of its cases with those in which etherization was not used, as, perhaps Avithout exception, does every other correspondent; but still he says not a word against its future employment. In fact, he has continued to use it. I have placed in the Appendix that portion of Dr. Perry's Letter which refers to this subject, along with another matter, for reason stated. Dr. Clark speaks of a case of flooding after chloroform, in which he says he does not knoAv hoAV much the loss was OAving to chloroform, but is inclined to think it had something to do Avith it. Flooding has been met with after etherization by other correspondents ; but it has so closely resem- bled the same occurrence in ordinary practice, both in itself and in the agency of means employed to check it, that, although it has come after, it has not been for a moment ascribed to inhalation. The religious objection to etherization has place in this volume, prin- cipally because of its having been urged by a correspondent. I have, Avithin a day or tAvo, been much gratified to learn from him, that a case CORRESPON DEN CE. 363 has occurred in his practice in Avhich he felt called upon to employ it, and Avas exceedingly pleased with its effects. He used chloroform. While I am writing, I have heard of the feeling about etherization in Florence. Two ladies from this city, looking for confinement, inquired of their physicians if they would use ether in their cases. They were promptly answered, no ; that nothing would induce them to exhibit such an agent, in such a way, for such a purpose; that it was highly danger- ous, as they had heard, or was altogether useless. Knowing that there Avas a physician in Rome from their native city, they sent for him. He came, and exhibited the remedy of pain. In one, etherization Avas imper- fect, but highly grateful, on account of the great diminution of suffering in this, compared with former labors. In the other case, the patient came under the full power of ether after one or two inhalations, and knew nothing of the labor till she heard the cry of her child. These probably are the first cases in which etherization has been employed in midAvifery in Italy; and it is not without interest that I make the record, that the patients were natives of Boston, and that it was used by a physician, a native of the city in which the remedy of pain was discovered. Dr. Gardner and others notice diminution and suspension of pain during 'etherization. Was contraction diminished or stopped in this state, in the cases referred to ? In instances of the most perfect etheriza- tion, when there was not the least apparent effort, — when breathing was hardly to be heard, so gentle was it, labor has gone on, and the child has been born. The progress of labor, in these cases, was only known by examination. The child is born as if by its own effort. Dr. Homans has stated to me verbally a like interesting fact, and it has been noticed again and again by other careful observers. I have, how- ever, endeavoured to explain the occurrence in question in an early part of the volume, and recur to it now to ask for it the careful observation which, as it seems to me, it emphatically deserves. In the Letter on page 345, intermitting pulse is stated as having occurred in one case; and the question is put, if this Avere not an effort of etherization, the patient feel- ing sure that it was. I know of no such effect in seventy-eight cases Avhich are reported in this volume, as having been under my immediate observation and care, and in which the pulse was particularly attended to ; nor is such effect of etherization mentioned by any other correspond- ent. Professor Simpson mentions no such result, and his observation of etherization has been very wide ; nor do I recollect having seen in any report of hospital or private practice, at home or abroad, an allusion to any permanent disturbance of the circulation folloAving that state. It is well known that the pulse is at times faster or sloAver than usual during etherization ; but, in my own cases in Avhich this happened, it has inva- riably returned in a short time to its healthy beat. Dr. Putnam relates 364 ETHERIZATION IN CHILDBIRTH. a case of hemorrhage, in AArhich ether had been used. This patient had hemorrhage in a previous labor; but, ergot having been given in three succeeding ones, no loss took place. Ergot Avas omitted in another, and no hemorrhage occurred. In the last case, ether Avas used, and ergot again omitted, and hemorrhage folloAved. Dr. Putnam, very justly as I think, in no degree attributes this complication to etherization. I Avas particularly struck with the remarks of Dr. Hooker on the use of ergot in cases in which contractions slackened during etherization. He found excellent effects to folloAV its use. " They both acted kindly together," says the doctor; and Professor Simpson says the same thing of them; and my OAvn observation coincides perfectly with theirs. This matter has been distinctly referred to before, and a mode of using ergot indicated. I allude to it again, as Avorthy to be borne in mind. One may be always ready for a demand for ergot, by having it with him. There should, however, be no hurry in its use; and especially would I advise that the physician be certain that progress has stopped, before he exhibits it, since, as has been seen, the labor may be steadily advancing Avithout any of the symptoms which usually denote it. Errors of the press are corrected in the errata. Two or three more important ones are corrected here : — In the Second Table, Case No. 223 is inserted by oversight. No. 270 is in the Analysis. The last case in Table Third is in the Analysis, but is not counted among the cases in the Table. In the Analysis, page 307, for 1 still-birth in unavoidable hem- orrhage, read 2. Of the six still-births from convulsions,/^ only are counted, as one was an abortion. APPENDIX. APPENDIX. I have placed the folloAAring cases by themselves, because they did not occur during etherization, and because, as it seems to me, they have no other connection Avith that state than that of mere sequence. They have been alluded to before, when considering the comparative merits of ether and of chloroform. I recur to that notice of them, because of the fact then stated, namely, that, in the same year, cases of grave and fatal puer- peral diseases, puerperal fever among them, Avere occurring, and in numbers too considerable to be regarded as accidental, but as arising from circumstances which now and then are so productive of such puerperal maladies. Puerperal Fever after Chloroform. Case I. — Mrs. ----, age tAventy-eight; first labor. Taken with slight pains in abdomen, on the evening of the 4th of May, 1848. These increased, and I Avas called betAveen 12 and 1, a.m. of the 5th. I found much suffering complained of, referred to the loAver part of the back, accompanying the pains, and making change of position from horizontal to erect, and from standing to AAralking, necessary to any degree of com- fort. Comfort, at least, was looked for from the change. She had lon°" determined to use chloroform-inhalation in her labor. The presentation Avas natural. Membranes entire. • No Avater betAveen them and cranium. Head low. Os uteri somewhat dilated, — imperfectly dilatable. Very little or no natural lubrication of passages. General health good. Flesh very firm, and much increased during pregnancy. No anasarca. At 3, a.m. or soon after, distress being very great, and changes slowly taking place under strong uterine contractions, chloroform Avas used. About a dram was poured upon the sponge in the conical inhaler, and inhalation begun. In a very few seconds, effects Avere manifested. These were first of pleasure, then of quiet, then sound sleep. Respiration, pulse, color, temperature, Avere first examined, and found natural. The 368 ETHERIZATION IN CHILDBIRTH. pulse Avas accelerated, as is not uncommon in active labor; being about 80, but perfectly soft and firm. I examined the pulse during etheriza- tion, and found it as it was before. Though so easily induced, and so perfect, etherization continued a very short time. It had sensibly passed away before the succeeding pain occurred. Inhalation Avas at once used again, as pain came on. But the patient Avas very restless, as she had been from the beginning of labor ; exceedingly impatient of suffering, and not to be persuaded to keep quiet long enough for chloroform to act. This course Avas pursued for about three hours. In the mean time, os uteri became dilated, and disappeared. The membranes were ruptured. Lubrication increased. The head descended. The contractions increased in force, and the intervals lessened. Etherization became more and more decided, sound snoring sleep accompanying it; the quantity of chloroform used, at the same time, being steadily diminished. But its effects Avere still so short in their endurance, that the patient com- plained, saying, " Chloroform constantly promises me something, Avhich I never fully realize." She repeated this after labor was over, and in almost precisely the same terms. In regard to the pulse in the trial Avith chloroform, thus far reported, once only, during full etherization, it fell below 70, being about 68. I noAV substituted sulphuric ether for chloroform. There was a strik- ing difference betAveen the tAvo in regard to the time required for etheri- zation. With the sulphuric ether many minutes were required; and the intervals betAveen contractions had groAvn so short, and the pains so severe, that very imperfect effects only were produced. The patient soon demanded chloroform ; for that did give positive and entire relief while its effects lasted, and always diminished suffering. The labor noAV rapidly advanced. The pain was less and less urgent, or complained of. But, in the midst of these comfortable events, it was noticed that the mouth was filled with blood. It was wiped out, again and again. The pulse Avas perfectly good ; respiration, complexion, tem- perature, all good. There was no cough, and nothing indicating pulmonary lesion. Still, as this state of the mouth was unusual, I desisted from further use of chloroform, much to the annoyance of my patient. The time to delivery, however, was very short, — about three contractions, — and the child Avas born Avith scarcely any complaint; she hardly knoAving when birth occurred. Consciousness soon returned. It Avas very imper- fect during etherization. I asked at once about her mouth, and Avhether her tongue or her cheek had been bitten, and if either noAV felt sore. She at once recollected about the blood in her mouth; that she had been denied the use of chloroform, and that something had been said in regard to bleeding ; and added that her gums had been very tender during preg- nancy, and had often and readily bled, — and this Avas the cause of blood APPENDIX. 369 being found in her mouth. Thus was a symptom, Avhich, taken in con- nection with pulmonary congestion, and other lesions alleged to be produced by chloroform, showed strongly, at once explained ; and all uneasiness, if any existed, was dissipated. I left about an hour after delivery, every thing being well. May 6th, 10, a.m. — Soon after I left, very severe after-pains occurred, accompanied with much distress, and entirely prevented sleep. The intervals betAveen the pains were very short. I regretted not being called Avhen this trouble occurred. She had no nurse ; and the friend with her thought it unnecessary to trouble me, as I had passed the whole night Avith her, and was not well. I learned, for the first time, that abortion of three months had once occurred previous to present pregnancy, but had been concealed ; that much anxiety and great fatigue h.acf recently been encountered during a very severe illness of the patient's mother, which had ended fatally. She regarded her labor premature, — about a month earlier than looked for, and probably from fatigue. She added, that she took cold at the mother's funeral, and had suffered much from cough since. It seems to have been an attack of the preA'ailing influenza, from which she has not yet recovered. I am particular in stating these facts in this case, as they can hardly fail to have some influence on the puer- peral state; especially the abortion, upon the occurrence of after-pains. The pains were less at my visit than at an earlier hour. Abdomen soft. Some tenderness, on pressure; some fullness. Pulse from 90 to 96, strong, full. Skin warm, moist, flushed, as from external causes of heat. Room very warm, and winter bed-clothing still in use. Has had an agent to see her on some indispensable business, her husband being absent in a distant state. No milk; no chill. Is very cheerful, and without any complaint. Urgent cough, which greatly increases trouble in abdomen. I prescribed a mixture of nit. potas., ant. tart, and tinct. opii. Was called between 1 and 2, p.m. and found her suffering greatly. The morning pains had returned with extreme severity. They were almost constant; and, in their intervals, much soreness of abdomen remained. Pulse not above morning beat; less strong and full. Flush gone. Skin of natural temperature. Tongue moist, clean. Urine free, twice since morning visit. Has a feeling that a discharge from bowels would give relief. On pressure of abdomen, much pain and tenderness. Lochia natural. No chill. Suppresses cough, as it increases suffering, as does also full inspiration. I prescribed Dover's poAvder, the continuance of hop fomentation to abdomen, and an enema of soap and water wjth castor oil and spirit. terebinth. 6, p.m. — More comfortable. Skin noAV moist; perspiration free, not -17 370 ETHERIZATION IN CHILDBIRTH. hot. Pains less. Pulse as before. No dejection. Has taken twenty grains Dover's poAvder. No nausea. No sleep. Pressure of abdomen produces pain. After-pain, Avith much flinching from soreness, especially in right iliac region. It is in this spot that inflammatory disease for the most part earliest shoAvs itself. To be sure, I am told that the pain and tenderness move about: still the degree of sensitiveness in the place referred to much engaged my attention. I asked if she had ever been bled. She said, yes, many times; and, indeed, the veins showed it. She added that venesection was always attended with marked relief. She coughed, and I observed her effort to suppress it, as it much aggravated suffering in the abdomen. NotAvithstandmg the partial improvement since morning, I determined to bleed her, because of the threatening symptoms whfch remained. She said, after last bleeding, she had fainted. About fourteen ounces were abstracted. Its effect was very agreeable during the operation. Much general and local relief was expressed. Breathing was deeper, and pain in abdomen diminished. Occasional after-pains occurred, but were slight. She became faint after venesec- tion, but not by any means to complete syncope, and soon rallied. As she had had no dejection, I wrote for two pills of hyd. submur. alone; one to be taken at once, the other six hours after if no dejection; and a small dose of ol. ricin. and sue. limon. in morning, if required. Dover's poAvder, p. r. n. May 7th, 9, a.m. — Less pain and soreness in night, but no sleep. No dejection. Has taken both pills. Faintness at times in night. Has taken oil, and rejected it. Pulse more frequent and more feeble. Coun- tenance sunken. Complains of great fatigue, and longs for sleep. Abdomen full, tympanitic; and, on pressure, betrays great tenderness in right iliac region. Still feels that a dejection would relieve her. Hyd. submur. three grains in a pill, to be repeated in four hours if no dejec- tion, and then an enema if need be. Respiration very little hurried, nor has it been at any time. Lies with limbs straight, as under ordinary circumstances. I examined the blood drawn last evening. It presented no other lesion than inflammatory blood commonly shoAvs. The clot Avas small; deeply cupped ; very firm ; of ordinary color, under free exposure to air. The serum was large, of its usual color; having dissolved none of the blood globules. I examined the blood with much care, because of the possible bearings of its condition on the case itself. It manifested not the smallest signs of decomposition, but rather that appearance of excessive life, so to speak, which characterizes the blood of pregnancy, and some stages of inflammation. 3, p.m. — About an hour, a dejection large, foecal, and Avithout pain ; then four more, the last a short time before my visit, smaller than the others, but which I found Avas natural. Much relief. Pulse more fre- APPENDIX. 371 quent. Tenderness in abdomen continues ; and, though fullness is less, pressure, although very light, produces much distress. Vesication of right iliac region; and elixir opii, with stimulants, if diarrhoea or sinking. 9, p.m. — Altogether more ill. Pulse and respiration more frequent. No vesication; no diarrhoea; no sleep. Vomiting. Pale, moist, sunken. Opiate. Stimulants as at noon. 8th. — Vomiting in night, but more sleep than since the beginning of labor. I found her reporting herself more comfortable. Less pain, on pressure in abdomen. Skin is not moist, but soft and of good tempera- ture. Pulse very rapid. Respirations not labored, but more frequent than before. Countenance very natural; expression singularly pleasing, having lost much of the anxiety and distortion \Arhich have remarkably accompanied the periods of greater suffering. Vomiting is constant. The stomach rejects, as if without effort, Avhatever is taken into it. In a case of alarming vomiting, — in a puerperal case, of about the same period of pregnancy as this, and in which the suffering was greater, the pain and soreness of the abdomen being aggravated by the pressure of a large tumor, of some years' existence, — in that case, benefit had been derived from ice taken internally, and applied externally to the region of the stomach. That patient recovered. Ice was used in this case. It was very grateful, but did not restrain vomiting. Two dejections occurred in course of day. Sinking increased. The surface grew cold; the pulse quickened, and became Aveaker; and she died, without apparent suffering, early on the morning of the 9 th. I Avas called to this patient to administer chloroform. I had made no engagement to attend her, and had no previous knoAvledge of the case. Chloroform Avas procured after I had learned the object of my summons. It was inhaled in small quantities, as is my custom. It produced its effects in an unusually short time. They Avere evanescent. Consciousness was never abolished during uterine action ; and the present complaint of pain, and the after-memory of it, Avere very distinct. Restlessness prevented the induction or continuance of etherization during pain. Hence nothing was gained by inhalation, except some diminution of the pains, and rest in the intervals. These effects were obviously produced by chloroform. Why not continue inhalation after etherization Avas produced, in the intervals of contractions, and so abolish pain during contractions ? This Avas done once. The pulse fell rapidly to 64, and the attempt was abandoned. I left the patient comfortable. There Avas no floAving, or any approach to hemorrhage. NotAvithstandmg her plethoric appearance, her greatly increased flesh during pregnancy, and an excellent state of the circulation, there was very little blood lost on the separation, and after the expul- sion of the placenta. Very severe after-pains soon came on, and con- 372 ETHERIZATION IN CHILDBIRTH. tinued without any mitigation during the day and Avhole night. She had thus had no rest or sleep for forty-eight hours. I found her Avith rapid pulse, much general excitement, having frequent and strong pains, and constant tenderness or soreness of abdomen in their intervals. Pressure, I found, however slight, produced such increase of suffering as not to be for an instant tolerated. Fomentations and opiates were prescribed, and an enema. ToAvards evening, the after-pains were less ; but soreness was so distinct, that I bled her. She had been often bled ; her sister had said since, a great many times. She had fainted after last bleeding. I took a moderate quantity of blood, from tAvelve to fourteen ounces, with marked relief, and with no approach to faintness. She became faint after- Avards. Her night Avas sleepless, from restlessness and abdominal trouble. The blood was found next day such as accompanies inflammation. I gave this patient very little medicine. The enema did not operate. On Saturday, she got tAvo pills, five grains each of submur. hyd. at an interval of six hours between them. Oil, which was taken Sunday morning, because the pills had not operated, Avas at once rejected. One pill of three grains was given Sunday morning. In that forenoon, the boAvels were freely, but not excessively, moved. No diarrhoea occurred. The abdominal symptoms, with increased pulse and continued tenderness, remained uncontrolled. Her best time was Sunday night, when she slept a little, and there was improvement in the state of the skin, and in her general appearance. But vomiting occurred. It increased rapidly in violence. The pulse became more and more rapid and weak, and she died on Tuesday morning. Here Avas a case of fever occurring in a person who had been exhaust- ed, as stated in the report, by constant attendance on her mother through a fatal disease; by severe cough, produced by exposure AArhile attending the funeral; and by premature labor, ascribed to the same events. She had spoken of the misgivings Avith which she looked forward to her confinement, and that her funeral would soon felloAv that of her parent. Not an untoward circumstance accompanied the labor, Avith the single exception of the restlessness Avith Avhich it Avas ushered in, and which so strikingly marked its history. Chloroform was inhaled very sparingly, and produced unusually slight impression on the pains. Not an unto- ward circumstance attended its use. The very slight hemorrhage of the mouth, Avhich did not exceed two drams, Avas • satisfactorily accounted for by the patient herself. I found, at my first visit, tAventy-four hours after labor, a grave disease present, under which she rapidly sunk, and died. Case 2. — Mrs. ----, age seventeen ; first child. Was taken in labor, Monday, May 1st, 1848, in forenoon, and Avas delivered in about tAvelve APPENDIX. 373 hours after. Asked for and inhaled chloroform for the two hours imme- diately preceding delivery, and Avith unusually happy effect. Her child, a large one, was born Avhile she Avas fully etherized. For thirty-six hours, she continued perfectly well. Was then feverish, with slight pain in abdomen, for which got Dover's powder, and afterwards sol. of nitre and ant. tart. On Wednesday, not having had any dejection since delivery, her physician ordered an ounce of ol. ricin. and about tAvo drams of spirit. terebinth. Three dejections folloAved that day, Avhich were described as not excessive, or accompanied with any trouble. Thursday night, came on profuse, excessive diarrhoea. Was found feverish in morning, Friday, Avith slight pain in abdomen and some SAvelling. Diarrhoea continues, accompanied by vomiting. Prostration extreme, and suddenly folloAving the diarrhoea. The pulse Avas from 160 to 170; breathing, very rapid. Physician Avas called early, and gave astringents Avith opiates and stimu- lants. These controlled the diarrhoea, and towards night the pulse was less frequent, and the fever Avas diminished. This amendment did not last; for, in night, diarrhoea occurred as profuse as before, and Avas alloAved to continue by the friends, lest harm should come of its being checked. These facts were stated by the physician in attendance, by whom I Avas called early Saturday morning to see this patient, in consultation. I found her exceedingly sunken. She Avas pale; the skin cold, and as if sodden Avith perspiration. Pulse from 160 to 170; respirations from 40 to 44; not at all noisy, or as if accompanied by distress. Lies on her back, Avith knees strongly drawn up. Abdomen tympanitic; tender on pressure, especially in right iliac region. Tenderness and pain diminished by raising the loAver limbs, and keeping them bent on trunk. The pulse, though so very rapid, was quite distinct, and not with- out strength. Nausea, vomiting, and purging, urgent till within an hour, since Avhen medicine has controlled them. It was agreed that a blister • should be applied, occupying the seat of pain above indicated, and stimu- lants and opiates be continued as they might be indicated and borne. Such nourishment as might be best borne by the stomach was also allowed. I learned that a case of puerperal fever had occurred recently in the neighborhood of this patient, in a case in which chloroform Avas not used. I was informed this day, May 10th, by the attendant physician, that this patient continued to sink, and died Sunday at 1, a.m. There Avas con- stantly increasing soreness and pain in the abdomen, in the tAvo last days of disease. This patient had been well from Monday till Wednesday, Avhen she took an active cathartic. It operated moderately three times. Diarrhoea occurred Thursday night, and Avas very severe. It was checked by opiates. It recurred on Friday night with vomiting, and no means were used by the friends, from fear of doing harm. On Saturday morn- ^1 /{ o /4 ETHERIZATION IN CHILDBIRTH. ing, the symptoms of fatal sinking, above described, Avere present. The symptoms of peritoneal inflammation Avere distinctly marked, and became more strikingly developed, until Sunday morning, when she died. The complication of puerperal peritonitis, Avith vomiting and diarrhoea, is not rare, and makes one of the most unmanageable and fatal forms of the disease. Every one, at all conversant Avith this disease, knows that it has folloAved active cathartic medicine, especially Avhen any thing like an epidemic constitution exists; and that, at such times, the fever, so excited, is very frequently attended Avith vomiting and diarrhoea. Case 3. — I was desired to see, in consultation, an obscure and threat- ening disease of the puerperal state. Chill had occurred on third day after labor, and had been folloAved by heat; SAvelling and tenderness of abdomen, more especially at one point, in the right iliac region; quick pulse, &c. Convalescence Avas very slow, and Avas interrupted by a return of the symptoms; and I had been desired to see her tAvo Aveeks or more after their re-appearance. I was desired to see another woman more recently confined, and in the neighborhood of the other, Avho had suffered someAvhat in the same way, and in whom severe lameness in the right loAver extremity had occurred. In this case, the abdominal pain and soreness Avere in the right iliac region, and especially in the coecal region; and reminded me of cases of abscess, Avhich I had seen here in the puerperal state, and in the same spot. The precursory hardness and fullness which have accom- panied that disease Avere not present. I asked the physician if he had used etherization in labor. He said that he had not in these cases; but he had employed ether in several, and Avith the happiest effects. He had tried chloroform but once, and then not because he wished to do so, but because his patient pre- ferred it; because, in short, he had been sent for to exhibit it. He tried * it; but its effects Avere so unlike those he had noticed after the use of ether, that he soon refused to employ it further. These effects were excitement; restlessness ; no apparent unconsciousness ; and very little, if any, diminution of pain. Etherization, in short, was not produced. Her labor noAV went on naturally, and she was easily delivered. After four days of perfectly satisfactory convalescence, puerperal fever occurred, and Avas fatal. I have made special record of these three cases of puerperal fever, and placed them here because they occurred after etherization. They appeared as does this disease in its ordinary invasion, and proceeded to the fatal result as it ordinarily does. The third case is recorded for its connection Avith two other cases, one of Avhich Avas a case of puerperal fever, Avith protracted convalescence. In the other, the earlier symptoms APPENDIX. 375 resembled the same disease in an irregular form, and terminated, as does the phlebitis which sometimes complicates it, in chronic and severe lame- ness of the right loAver extremity, corresponding to the abdominal region in Avhich pain and tenderness were first noticed. These cases have done Avell. The fatal ones had, in the time of invasion, in the symptoms, and in the time of termination, the characters of the most malignant form of epidemic puerperal fever. This fact in their history led me to inquire into the collateral or contemporaneous medical history of the periods preceding and subsequent to their occurrence; and some important facts have been established by the inquiry. I was desired in April to visit a patient in consultation, and gathered the folloAving facts in the case : — It was a case of puerperal fever. The physician had recently suffered a severe attack of erysipelas. He had been ill nineteen days, and confined to his house. After having been abroad three days, he attended a case of labor. This was on a Friday. Puerperal fever attacked the Avoman a day or two after delivery, and she died on the Tuesday following. On the same day he attended this case, he Avas called to another. This woman was seized with the same fever, and recovered. On Friday of the same week, he attended another, — the patient I was called to see. She had twins. One was still-born, and the other died two or three days after. Sunday morning following, puerperal fever declared itself, and soon assumed its worst characters. I saw her on Thursday; she was vomiting constantly. Her pulse was 160; breathing very rapid, attended with a cough-like catch or grunt, Avhich showed it to be most distressing. The abdomen Avas distended or swollen to its extremest limits, and tympanitic. Diarrhoea had been a symptom ; but this had subsided a feAV hours before my visit. The skin was damp and cold. The evidence of hopeless sinking was too strong to leave any doubt as to her state, and she rapidly sank and died. Etheri- zation Avas not employed in these cases. In May, I was again consulted in regard to puerperal fever. I learned that the physician had, April 29, been called to attend a case of ery- sipelas, in which he felt great interest, and saw often each day. It was phlegmonous, attacking, in succession, most of the face, but extending slightly only on the scalp or neck. There was no vesication, and no desquamation. No member of the family has been affected. May 2d, the same physician attended a case of premature childbirth. The child Avas putrid. The woman did well. On the 3d of May, he attended another case. This was at the full time. The child of extraordinary size ; labor-pains violent; and, at length, an operation was done to sa\re the mother. She did well. May 6th, he attended Mrs. ----, aged thirty. Feeble during preg- nancy. Labor easy, but folloAved by free flowing. Comfortable for 376 ETHERIZATION IN CHILDBIRTH. twenty-four hours, Avhen she Avas seized Avith puerperal fever, which resisted treatment, and Avas fatal on the fourth day. " The usual vomit- ing set in," said Dr. -----, " Avhich continued Avithout abatement till near death," Avhich took place on the 10th instant. May 9th, he attended Mrs. -----, aged tAventy-five. Her labor Avas easy, and Avas accomplished in about three hours. She Avas seized Avith fever thirty-six hours after, accompanied with symptoms very exactly resembling those of the preceding case. She died on the fifth day. May 11th. — Mrs. ----, aged thirty-one. Labor characterized by long and severe pain. Next day, comfortable. Fever attacked her thirty-six hours after delivery, having taken food very heartily, as Avas reported. The seizure Avas much like that of the above first-reported case. There Avas some hope, for first three days, that this case might do Avell; but the attending physician Avas then dismissed. NeAv measures adopted. Death occurred on the fifth day. Etherization Avas not used in these labors. I Avas consulted concerning these cases, but did not see one of them. The following fact has an important connection with these cases, and I shall give it as stated to me by attending physician: — " The first Avoman Avho died left an infant daughter. She attempted to nurse it once, but did not succeed. It then passed over to other hands. At the end of ten or fifteen days, I Avas called to it; found it cold, Avith pulse scarcely observable, laboring under diarrhoea. The nurse shoAved its body. There was a band of phlegmonous erysipelatous inflammation gird- ing the middle, from three to five inches in width, including, of course, breech, pudenda, &c. No vesicles; no exudation. Beyond this limit, it passed not. The child soon died." I have called this an interesting case. I do not recollect its parallel in the many histories which have appeared of puerperal fever. My friend's description shows hoAV closely allied Avas it, how identical with the erysipelas of infants. Was it communicated from the mother ? We meet with cases of infantile erysipelas, which very closely resemble the above, and Avhich happen Avithout the knoAvn existence of the disease elseAvhere. This form of it attacks the same region as in the above, the lower part of the trunk, nates, and genital organs. It is often fatal. I have seen but one examination after death. The appearances very nearly resemble those noticed in puerperal fever. The abdomen Avas filled Avith pus and serum, and masses of coagulable lymph, glueing together the intestines. The pelvis Avas filled with pus. A case Avas communicated to me, in Avhich precisely similar appearances Avere met Avith. It Avas these cases especially which impressed me Avith the idea of the identity of erysipelas and puerperal fever. May 10th. — I Avas called to see in consultation Mrs.-----, Avho had APPENDIX. 377 been delivered of her fifth child, Friday, May 5th. She was thirty-eight. Her labor had been easy; and, save only that she had not slept, or for a feAV minutes only, once or twice, she had appeared to have done Avell. On Monday, had chill, and got a moderate dose of castor oil, having had no dejection since delivery, and three motions folloAved. On Tuesday, slight diarrhoea, with much flatus, and some uneasiness in the abdomen. No milk. Tuesday evening or afternoon, three papers Avere left, each containing three grains of Dover's poAvder. She took one, and, towards evening, a second. Without any premonitory symptoms, delirium came on very soon after. About tAvelve years before, after one of her labors, something of the same kind occurred, and lasted about twenty-four hours, I was desired to see this patient, Wednesday noon, the 10th. I found her asleep, and was told she had slept a feAV minutes a short time before my arrival. Her sleep Avas heavy ; countenance placid ; breathing sIoav. Pulse about 90, not Avanting in strength. An unusually disagreeable odor about the patient. I examined the abdomen. It Avas tumid; and, from the extreme thinness of the Avails, the size and course of the intes- tines could be readily seen, making the surface singularly irregular, or broken up into rounded elevations and depressions. The uterine tumor was large, unusually large for this time, from delivery; being about mid- way between the brim and umbilicus. It was tender. This was most striking in the right iliac region, into Avhich the womb extended. Pres- sure here produced the only evidence of consciousness betrayed during the examination. She opened her eyes, indeed, once or twice, but Avith- out apparent consciousness. She shrunk visibly from even slight pres- sure in the spot indicated. The breasts Avere perfectly empty. It was agreed that a small blister should be applied to the seat of pain, and an enema given, should one be judged necessary. It had been found impossible, except by violence, to get medicine into the stomach; and, in her present state, it was not judged proper to make any effort to accomplish such object by such means. 11th, 9, a.m. — Has slept some. Enema was given with good effect. One dejection. Abdomen less tumid, and less tender in blistered part. No soreness observed. Uterus still large. Some milk in breasts, it was thought, at 4, a.m. Child seemed to draw and to SAvallow. Now breasts perfectly empty. Pulse 96, of sufficient strength. Very slight delirium remains. Appears doing very well. 13th. — I did not see this patient yesterday, her physician considering her to be doing well. He proposed an enema in the course of the day, which she resisted. Her former acquiescence in this matter was OAving to her delirium. 01. ricin. about half an ounce, and about tAvo drams of spirit, terebinth. Avere substituted, say at 10, p.m. It soon operated, and 18 378 ETHERIZATION IN CHILDBIRTH. continued to do so to the extent of eight dejections, preventing sleep, Thursday and Friday night; and, on the latter night, experienced very severe shivering, Avithout coldness of skin. I was called again this morning, 13th. I found Mrs.----less Avell; feeble ; sleepy. Pulse 120. Skin hot, alternately moist and dry, as stated by nurse. Is taking chalk mixture, a tea-spoonful, as indicated by diarrhoea ; and an hour has passed since the last dejection. I directed a continuance of the treatment. 14th, 7, a.m. — Very much the same, through day and night. Pulse less rapid, 108. Abdomen less tender; as tumid as before. No milk. Tongue coated. Seems like one much exhausted. Diarrhoea continues; and, though patient says she is conscious of dejections, she gives no notice of their occurrence, and they take place in bed. Additional astrin- gents Avere directed, and stimulants if they became necessary. She gradually got better, but, about the 20th, complained of pain in right loAver limb. It Avas found to be swollen; painful, especially in calf, Avhere the sAvelling Avas greatest, and in the right groin and course of the iliac vein. The SAvelling increased rapidly, and the leg became entirely useless and immovable, feeling more like a log than a limb. It was tense, and as Avhite as is usual in phlegmasia alba dolens, as Albers desig- nates it. It did not prove to be a very severe attack; but the decline of the disease Avas accompanied by a swelling in the left limb, which now, the 9th June, presents the disease at its height. The constitutional symptoms are by no means severe, and the local suffering is far less than is commonly met with Avhere the disease is so pronounced. NotAvithstandmg the disappearance of milk in this case, and the per- fect quiet in Avhich the breasts have remained, an abscess has twice formed in one of them, and discharged freely. Mrs. ----, aged thirty-eight. Has children. Labor, Saturday, May 13th, half-past 3, a.m. easy, natural. Sunday night, chill. Attending physician Avas called, Monday morning, at 7. Found pains in abdo- men, and gave Dover's poAvder. More tenderness, on pressure of abdomen, left side. Venesection. Relief. Vesicated. The symptoms Avhich fol- loAved Avere restlessness ; very rapid pulse ; tympany. Tuesday, reported better. Pulse exceedingly rapid, — dyspnoea. Cathartic, Avhich ope- rated Avell. Wednesday, symptoms much the same ; gradually, however, increasing in intensity. Thursday, p.m. I Avas desired to see this patient Avith her physician. I found her exceedingly ill. Abdomen greatly distended, tender ; respi- ration rapid, laborious; pulse small, too rapid to be counted ; constant vomiting; skin cold and Avet. Stimulants had been ordered, and they were continued. She rapidly sunk, and died in the night. APPENDIX. 379 While visiting Case 2, before given, I Avas informed that a case of puerperal fever had occurred in the neighborhood. The Bills of mortality of Boston, for the last three months, show an unusually large number of deaths in " childbed." Puerperal fever falls under this head, and is the cause of by far the greater number of these deaths. In March, four cases of " childbed " are reported ; in April, six ; in May, ten. I may add, that, in this first week of June, we have two. Thus, in about three months, the mortality from childbed is twenty-tAVO. The number is probably greater; for all deaths in " childbed" are not reported as such. Thus, of the tAventy-two just enumerated, one at least is returned as " inflammation of the bowels," Avhich I saAv in consulta- tion, and Avhich Avas a case of unequivocal puerperal fever. The defects Avhich we all know to characterize the Reports of deaths in our Bills of mortality are easily accounted for. There is no law here Avhich requires of the physician to leave a certificate of the disease which has been mortal, subscribed by him, and Avhich must be had before per- mission for burial is granted. This is the course in other cities, and is the only Avay in Avhich any thing approaching accuracy can be secured to a most important public interest. In Boston, and probably through the State, the sexton reports the cause of death from such materials as he may gather from the family. Of course, our Bills are frequently as incorrect as such documents can Avell be. They are probably more correct in regard to deaths reported as " childbed; " for, in these, the connection of death with its immediate antecedent is too direct and obvious to lead to much error. Speaking of this subject, one cannot but be surprised at the indiffer- ence concerning it which the community here — the State and municipal governments — manifest. Attempts are almost annually made to get a better system established. The authorized registration of marriages, births, and deaths, and the most accurate reports of diseases, belong to very important departments of political economy, and of the public health. The system in England is a perfect one, and works admirably well. It shows how deep is the interest in that country in human life. The government may not be able to remove much which is injurious to public health, and Avhich so terribly Avastes life there. But it can and does make itself acquainted Avith the Avhole fact, and in this way has its atten- tion directed in the strongest manner to the consideration of the means of prevention and of relief. It is to be hoped, that we shall here take hold of this subject Avisely and manfully, learn what are the defects of the present system, Avhich Avill be easily done, and proceed to provide the remedy. In the Table of instrumental and other labors in Avhich etherization was not employed, are some cases to which I was called, Avhich occurred 380 ETHERIZATION IN CIllLDIHKTH. in the immediate vicinity of Boston, but which have no place in its Bills. Now, compare the returns of " childbed," for the three months speci- fied, Avith those of the last year, the Avhole of it. For that time, the return is thirty-six only, shoAving a very great increase of mortality for the present year, at least for the time named; that being twenty-two. But further, erysipelas has existed in Boston and neighborhood, at the same time, after a manner quite unusual. Noav, it is an established fact, that this disease and puerperal fever very frequently exist together, giv- ing a strongly malignant character to the fever, and shoAving an identity betAveen them which the profession has long recognized. While I state these facts, because of their bearing on any question of the agency of etherization in the premises, it is my duty to state, that in a very few only of the cases of puerperal fever Avhich have so recently occurred has it been ascertained that etherization during the preceding labor had been employed. I believe that all the cases in Avhich it had been used are reported in the preceding Tables. My inquiries, I think, Avould certainly have led to different results, had other cases been found. It will not be out of place to advert for a moment to another portion of the history of the late medical year, dating from May last, when ethe- rization in childbirth was first used in this country. In the four Tables Avill be found seventeen of convulsions. Etherization, indeed, has nothing to do with these cases, in their production at least, since it Avas employed as a remedy. Five cases have occurred within a month. I should think this unusual. Does it not lead to the idea, that a more than common predisposition has existed recently for grave occurrences in pregnancy and childbirth, and, taken Avith other facts, mark the year as somewhat peculiar in its medical history ? Of the seventeen cases, ten Avere treated with etherization, and six recovered. In the remaining seven, etheriza- tion was not used at all. Of these, six died. This subject has, hoAvever, been already dAvelt on. It is referred to here, only on account of its connection with the medical year under notice. Case of Etherization in Nausea of Early Pregnancy threatening Life. Mrs.-----. I saw this patient in consultation. Previous health good. Second pregnancy. Vomiting during whole of first, producing such exhaustion as threatened life. She was delivered, at the full time, of a living child. As soon as labor was over, vomiting ceased, appetite returned, and health Avas re-established. Says three relatives had died of vomiting during pregnancy. Is very anxious. Supposes pregnancy to be about twelve weeks advanced. Vomiting almost constant, and has been so bstween iuven and eight weeks. Is sitting up ; not showing much APPENDIX. 381 exhaustion, though emaciation is very strongly marked. Pulse more frequent than natural, though not Avanting in strength. Distress or pain in lower part of abdomen. Renal excretion natural. Tongue slightly coated. Directed to keep very still, and to take small quantities of food. Says meat is better borne, and more easily taken, than other things : is advised to eat it. Is sn sure that she shall soon be worn out by vomit- ing, that she wishes that labor may be induced at once. After very careful consultation, it is decided to defer it, and observe progress of case. Second visit. — Nothing better ; vomiting constant. Literally bears nothing on stomach. Is distressed by merely washing mouth or lips. Third. — Nothing better ; vomiting constant. Great oppression, amounting to severe and distressing pain about precordia. Enemata, of decoctions of beef, Avith tinct. opii; also gruel in the same Avay. Inhaled chloroform; at first Avith relief of vomiting, but at length Avithout any benefit. It was tried again, and for a short time stomach was again quiet. It Avas, however, soon obvious, that only temporary benefit re- sulted from etherization. The time of relief greAV shorter ; and, at length, chloroform became as disgusting as any other means employed for relief. I introduce this case here to show, that, though the early benefit at first obtained from inhalation soon failed to attend it, there Avere no such symptoms induced by it as to give rise to a moment's un- easiness. The specific effects of chloroform were produced without the least injury. It was noAV resolved to remove the contents of the Avomb, as the only means of saving life. The exhaustion was extreme, and emaciation seemed to increase every hour. She could not leavre her bed for a mo- ment. Much difficulty was experienced in reaching the membranes. From the extreme relaxation of the whole body, and the pressure of constant vomiting and straining upon the womb, this organ had become anteverted; its fundus pressing firmly against the symphysis pubis, and the os uteri tilted up towards the promontory of the sacrum. This occa- sioned much difficulty and embarrassment. The organ Avas readily reduced, but fell back again into its old place, as soon as support Avas removed. At length, however, the physician in attendance succeeded in carrying up the fundus, and of supporting it there by his hand. The membranes Avere noAV readily reached, and the waters discharged. Some relief followed this event; and, in eighteen hours after, the uterine con- tents Avere expelled. Almost immediately, improvement showed itself. Appetite returned, and was at once indulged. In less than twenty-four hours, I found her eating freely, and Avithout the least harm; nay, with positive benefit, 3,s2 ETHERIZATION IN CHILDBIRTH. as Avell as Avith extreme pleasure. Next day, she Avas up, — out of bed; and, in tAvo or three more, she was rapidly convalescent, and has since continued perfectly Avell. Case of Etherization in Vomiting, Spasms, Sfc. in Middle of Pregnancy, threatening Life. Mrs. ----, in sixth month of pregnancy, arrived here after a voyage of thirty-one days, Sunday, 20th May. Vomiting during the Avhole voyage. Sickness of early months had ceased before embarking. Was then fleshy and well. Reached here emaciated ; constant vomiting ; diar- rhoea ; exceedingly prostrated. This state of things continued, till 30th, unchanged; and neAV symptoms, in the meantime, had showed them- selves. Among these Avere hiccupping and spasms of the limbs, Avith permanent and very strong contractions of the forearms on the arms, of the wrists on the forearms, and of the fingers across the thumbs and into the palms of the hand. This last symptom, this strong spasm, Avas exceedingly painful and long-continued. I saw her first this day, and, along Avith these symptoms, observed very dry tongue and offensive breath; unequal distribution of heat, the hands and arms being very hot and dry. Trembling of the loAver extremities, Avith slight cramps in them. Nausea, vomiting, and complaints of universal distress. Exami- tion discovered os uteri to be dilated someAvhat, soft, thin, dilatable; haad presenting ; and membranes loosely covering it. Delirium at times for some days. As the stomach tolerated nothing, it Avas agreed in con- sultation to try chloroform. It Avas inhaled Avith readiness, first on cotton Avadding; but, as this produced soreness of the nose, the conical inhaler AAras substituted. Pulse at beginning of process, from 110 to 120, at 7 o'clock and 10 minutes. Very slight etherization Avas induced. Con- sciousness remained perfect. Some disturbance of head Avas spoken of, and a feeling of lightness, — "a droll or funny feeling." The pulse was not at all diminished in frequency, and, at some counts, Avas found more rapid than at the beginning. Some uterine pain. Os uteri more dilated. Membranes protruding. It Avas agreed to puncture them. It Avas done. She was left someAvhat relieved about 8, Avith directions to continue inhalation, as spasms might demand. About 9, p.m. — A great change had occurred since last report. The spasms, and muscular contractions and tremblings, had entirely disap- peared. She Avas reported more comfortable, and had been so for some time. Vomiting, hoAvever, occurred, though less frequently than before, and Avith less attendant distress. The condition of the limbs attracted much attention, and showed Iioav important, and at the same time how novel, Avas this operation of chloroform. The contractions have APPENDIX. 383 entirely ceased ; the fingers were open, or gently flexed ; and the hands used after the ordinary way. There Avas no loss of muscular poAver, or of its use by the Avill. A state of great suffering had been replaced by one of perfect ease ; and a morbid condition of the muscles, by a healthy one. The brain and nerves were enabled, by the agency of chloroform, to perform their functions; and, though it had done so much in preA'ent- ing morbid, violent, and*«most painful contractions of the muscles of both upper extremities, its agency did not for a moment exceed the limit Avithin Avhich voluntary motion is performed. I Avas much impressed Avith these results of etherization. There AAras no Avant of consciousness. The relations of the patient with persons and things Avere as perfectly recognized and acted upon as they ever were. She continued to ask for chloroform when she thought it needed, and used it just so far as the circumstances demanded. More pain had been felt in abdomen since visit, and now womb Avas felt to be well contracted during abdominal uneasiness. Os uteri more dilated. Free lubrication by natural secretion. Head lower; labor advancing. May 31st, betAveen 7 and 8, a.m. — Since last visit, no vomiting. Some quiet sleep. More food has been taken and borne than for some time before. She Avas sleepy. It Avas learned that, an hour or tAvo before, as more pain had been felt than before in the abdomen, (uterine contrac- tions ?) an opiate had been given by an attendant, as at other times, during her illness. Chloroform had been used in the night, but in the smallest quantities; for the demand for it Avas very slight, and its effects never reached beyond A\-hat had before folloAved its use. After the opiate, the uterine effort gradually subsided, and soon ceased. I examined, and found the head just within the external organs, and ready to be expelled by slight effort. It was soft, the bones yielding to the slightest pressure ; and its size too small, and dilatation too perfect, to have required much effort for its delivery. I noAV examined the patient. Her pulse was smaller, more rapid; the countenance shoAving more exhaustion than I had before seen. The lips Avere of perfectly good color, but elsewhere the face Avas pale and sunken. She said her sight Avas failing. This had happened some days before. Spasms Avere again declaring themselves, and contractions Avere complained of in all her limbs. Nausea again occurred, and the cough-like hiccup. Very slight and short uterine effort. The attending physician noAV came in, and it was agreed to accomplish the delivery, which Avas done with perfect ease, and apparently very little if any pain. Chloroform Avas not inhaled, for it Avas not required. Firm pressure Avas noAV made by the physician over the uterine tumor, in order to secure if possible uterine contraction, and to prevent hemorrhage, as far 384 ETHERIZATION IN CHILDBIRTH. as might be done. The placenta Avas separated, and expelled in a per- fectly natural manner, and Avith so little blood, that the membranes Avere not stained AA'ith it, and no hemorrhage folloAved. But it Avas evident, that sinking, Avhich had so strongly manifested itself before delivery, had not been checked by the slight re-action Avhich had accompanied the removal of the child. The pulse rapidly sunk; the skin became cold ; consciousness was entirely gone; spasms recurred, and she died. Just before death, a discharge of liquid and coagulated blood from the vagina took place. I have placed this case in close proximity Avith the last, because of their points of resemblance ; but it is apparent in Avhat they differ. The first seemed the most threatening. The danger was in the very rapid increase of bad symptoms. In a feAV days, the extreme of prostration had been reached; and it Avas clear that life, under existing circum- stances, could not be sustained much longer. In No. 249, causes had been operating to destroy life forty-one days before delivery was accom- plished ; and a singular complication of diseases, hardly mere symptoms, marked and increased the hopelessness of the case. I had expressed to the attending physician my views Avith regard to the Avhole prospect, and especially of the uncertainty of the issue. What were the complications and the circumstances Avhich had given such fearful characters to this case ? — 1. A sea-voyage, Avhich, with all the kindness and effort to diminish suffering which could be afforded, Avas one of almost unmitigated distress. The inability, in such extreme Aveakness, to resist the motion of the ship had led to bruises which showed hoAV severe had been the injury received. 2. Constant vomiting. The husband again and again referred to the strictness of the truth of this statement. ' For thirty-one days on ship- board, it seemed to him that nothing had been borne on the stomach; and, for ten days since reaching the shore, no change in this respect had occurred. She was in excellent flesh and health Avhen she embarked, and now she was greatly emaciated. 3. Diarrhoea at sea, and on shore, Avhich nothing had checked. 4. Delirium. 5. Spasms, amounting to fits or convulsions; and rigid, tetanic con- tractions, of a most painful kind, of the limbs, especially the upper. So severe were they, that it was necessary to keep solid bodies in the hands to prevent the nails cutting deep into the flesh. 6. Hiccup, resembling spasmodic cough, — so violent was the action of the diaphragm and abdominal muscles; and often accompanied with vomiting of bile, or of other contents of the stomach, or by severe eruc- tations. APPENDIX. 385 7. Obstinate watchfulness, — keeping the patient always conscious of her sufferings. 8. Pulse rapid, — small. From this enumeration, it will be seen how many and how important were the organs and functions implicated in this deeply interesting case of this stranger, who had arrived here only to die. It was expected, when the voyage was over, that, as so generally happens, nausea and vomiting would cease. But nine days passed with- out any change in these respects ; and, in the mean time, new and worse symptoms showed themselves. It Avas believed, that the utmost limit of patience had been reached, and that means should be employed Avhich alone promised relief. But why use etherization ? It had been used in cases resembling this in their symptoms, and in their apparent causes. It had been safely used in these, and with great relief to the severest suffering. Almost the first word I heard from the patient was " Chloroform." The demand was made in the strongest terms for relief. She suffered everyAvhere, and in the severest way. I felt not the least question of the perfect safety in the use of the remedy ; and my colleague, Avho had employed it as often as I have done, felt not the least doubt of the propriety of using it, or any distrust as to its beneficial results. Would it not have been the strongest failure in duty, if, under the circumstances, suffering, and hourly increas- ing sinking, had been allowed to have proceeded, Avithout any attempt at relief? The only mode by Avhich remedies could be applied in the case was inhalation. It Avas tried, and the beneficial result stated. Labor had begun. It was accelerated by discharging the liquor amnii, when the state of the os uteri showed it could be advantageously done. The child advanced, and in the morning Avas ready to be born, with very little effort. But this effort Avas wanting. What could be done by the womb, had been done; and, in the mean time, things had grown worse. The child Avas removed with entire ease. The rest of the labor Avas completed, and with no untoward symptom. Sinking went on rapidly, and death soon occurred. A Case of Cholera, with Cramps and Spasms, treated by Etherization. Miss----, aged tAventy-six, was seized, on Sunday, July 4, 1847, with very severe pain about the root of an incisor tooth, which had been cut off seven years before, and to which a tooth had been attached by a pivot. The pain became so intolerable in the afternoon, that she had the tooth removed. This gave no relief. The pain continued through the night and the next day, Monday, July 5th. Through that whole day, the pain continued so that she used up an ounce of laudanum; applying it 49 386 ETHERIZATION IN CHILDBIRTH. constantly, by means of cotton, to the tooth, and to the neighboring parts. At about 11, p.m. the pain suddenly ceased ; and she was very soon after seized Avith vomiting, of a most distressing character. The attacks occurred at intervals of from ten to fifteen minutes, and at length had complicated with them severe cramps of the extremities, more espe- cially the hands, which Avere also numb, and with strong cramps of the abdominal muscles. The suffering Avas so intense, that as many as five persons Avere required to be Avith, and aid her. I was called in consulta- tion by the family physician about 9, a.m. July 6th. There had been a someAvhat longer interval from the preceding attack of vomiting, when I arrived at the address ; but the cramps Avere very severe, and, being so extensive, presented a case of great suffering. She vomited while I was present. The effort Avas violent, but followed only by a little mucus, or a little bitter, and occasionally acid fluid, I prescribed the hydrocyanic acid, and left her, to return after making some medical visits. I did so, and took with me ether, and a sponge for its inhalation. I found she had vomited the acid about fifteen minutes before I arrived, and Avas still suffering from cramp. This was about 10 o'clock, eleven hours from the beginning of the disease, during Avhich time she had suffered most severely, and had not slept at all. I suggested the use of ether. The physician in attendance acceded to the proposal, and it was inhaled. The folloAving was the condition of the patient: — Stomach quiet. Cramps and numbness present. Pulse 84. Respiration natural. Complexion and temperature natural. Tongue clean. Head clear. Pressure over region of stomach, and over abdomen generally, gives no pain. The sponge was well saturated. At first, the breathing Avas embarrassed by the vapor, and slight choking Avas noticed. This, hoAvever, soon passed off, and she inspired the vapor freely. In about a minute, she became perfectly still. Her breathing was hardly perceptible. Her countenance had the expression of perfect repose. The color was as before inhalation. Her pulse was 96. Breathing slow, but sufficiently deep. Temperature as at first. I asked her to open her eyes. An ineffectual attempt Avas made, the lids scarcely parting. I asked what were her feelings. She made no ansAver. The sponge was re- moved, and she remained in this state some minutes. She now roused up. Said, " How sick I am! That ether makes me sick." She soon vomited. The effort Avas very strong, as strong as any previous one, producing much distress, but accompanied by no cramps; only a slight numbness of the hands. She hardly complained of it. At length the vomiting ceased. The numbness, and all disagreeable sensations, passed away. She had a threatening of retching once afterwards, but which was only expulsion of flatus. To quiet the stomach, ice in a toAvel was now applied freely to the epigastrium and left hypochondrium, and with APPENDIX. 387 marked comfort. Ice was also urgently demanded to be held in the mouth. It was exceedingly grateful. I left her betAveen 11 and 12, so much relieved that I believed the disease had subsided, and improvement was constantly advancing. The pulse was again 84 ; and, though some paleness was present, and some faintness complained of, I felt that she was doing well. I saw her again about 1, p.m. and found good progress had been made. Nausea, cramps, and numbness, had entirely left her. She enjoyed the ice greatly, and asked for nourishment. I left her, and was to learn if any return of vomiting or any other trouble occurred. She expressed her gratitude for the relief she had derived from the use of ether. July 7th, 10, a.m. — Patient remained comfortable through the day. Restless at night, suffering much from the great heat of the Aveather, and from a rash which has appeared extensively on the skin. It should have been said before, that a rash was abundant on Sunday the 4th, and dis- appeared Avith the pain in the face, on Monday evening, just before the attack of vomiting and cramps. Was never troubled with this skin- disease till since a very severe and dangerous attack of the erysipelas, some months ago. Rash now on face, neck, and back. Skin hot. Pulse full, not very frequent. Tongue coated. Thirsty. In short, is very much as she before has been during attacks of rash. There has been no trouble of the stomach, no cramps, no numbness, since the speedy relief Avhich followed inhalation of ether yesterday. Expresses more fully than before hoAV much she feels indebted to inhalation. Ether, in this case, was used on account of the violence of spasm, — cramps, Avhich constituted its chief suffering. Cramp did not happen once after its use. Case of Typhoid Fever, accompanied by Spasms, in which Etherization was employed. Edward Sutton Smith, the son of Dr. J. V. C. Smith, editor of the " Boston Medical and Surgical Journal," and aged seventeen, — in per- fect health, — was, after bathing, attacked Avith the precursory symptoms of fever, on Wednesday, Aug. 2d, 1848. These symptoms Avere chills, headach, pain in the back, diminished appetite and strength. He Avas at school in the country, and came home on Saturday; eat some food ; threAV himself on the bed, complaining of cold, notAvithstanding the great heat of the day, and, though dressed in thick clothes, asking for blankets to make him Avarm. On Wednesday following, he was seized with spasms ; rigidity being one of the marked symptoms. On Friday, these Avere greatly aggravated; and on Saturday, Aug. 12th, — not the smallest relief having been afforded by what had been done, and death seeming inevitable, — Dr. Smith called on me to exhibit ether or chloroform, in 388 ETHERIZATION IN CHILDBIRTH. order to diminish the agony Avhich Avas regarded as a sure precursor of death. I found the patient in a state of universal spasm. The limbs were perfectly rigid; the Avrists strongly bent, so that the fingers looked to the forearm ; the forearm strongly bent on the humerus, the thighs on the pelvis, and the legs on the thighs, — presenting an instance of universal and tonic contraction. The eyes were suffused, and constantly open. The body and limbs Avere hot, but bathed in full and dense SAveat, as from strong exercise. At times there Avas general convulsion, but Avith no relaxation of contraction in the intervals. Pulse 144. Respiration rapid ; at times, catchings. Tympany. Muttering constantly in German and other languages, Avhich he has recently been studying. I had taken with me sulphuric ether; and, Avith the concurrence of Dr. John Ware, who came in immediately after me, I filled a sponge Avith ether, and applied it over his nose and mouth. He inhaled the vapor readily, and its quieting effects soon began to appear. Dr. Ware now suggested chloroform; and this Avas sent for, and used in place of ether. The patient came gradually and most kindly under its influence. The spas- modic tAvitchings, at times, were entirely absent; and, when returning, were easily checked by renewed inhalation. He Avas now left, directions being given to reneAv inhalation when indicated by return of spasm. My first visit was made late Saturday afternoon, the spasms having then been constantly present since the preceding Wednesday. I saw the patient again in the evening. I found him calm. Rigidity less, so that his legs had been extended. Pulse 120. Skin dry, and not hot. Respirations easier. Less prone to talk, and takes drinks with apparently much satisfaction. Chloroform to be continued. Ice constantly to the head. 13th, Sunday, 8, a.m. — Night reported to have been comfortable. Some sleep. Chloroform frequently inhaled. Pulse 84, softer. Skin comfortable. Less rigidity ; and convulsive motions diminished, and for the most part entirely wanting. No dejection yesterday or to-day. 01. ric. one dram; and, in four hours, an enema, if no operation before. ArroAV root or barley water for diet. 12, noon. —As in morning, except pulse, which is somewhat acceler- ated. 7, p.m. — One sufficient dejection after enema. Very little flatus. Tympany remains as before; abdomen being quite tense, firm, and reso- nant. Very little occasion for chloroform through the day; it being used only Avhen spasms have recurred. Rigidity hardly perceptible; the fingers being flexible, and the hand easily bending on the wrist. Takes nour- ishment Avith relish. Protruded his tongue to-day, when desired to do so ; Avhite coat upon it. Recognized persons, — showing improvement in state of mind. Pulse between 80 and 90. APPENDIX. 389 14th, Monday, 9, a.m. — Comfortable, though less calm than yester- day. Very little rigidity. Occasional tAvitchings, particularly of face. 1, p.m. — More heat. Pulse towards 100. More restlessness. Mind more disturbed. At times greatly distressed, and then relieved by free passage of urine, 8, p.m. — Cooler; pulse slower; less restless. Distress, as yester- day, before urine. One asked him, in loud voice, what was the matter. " I want to make Avater," said he. He was asked if he would get on his knees, and try. He said he would, but without effect. Preparation was making to pass catheter, when the bladder Avas emptied naturally and freely. Now disposed to sleep. Sleeps soundly, and Avithout the least restlessness. 15th, Tuesday, 9, a.m. — Great change for better. Pulse 72. Skin cool. No restlessness. Has had a good night. Craves milk. Said to me he Avas starved. I asked what he Avould eat. Said he with emphasis, " Dipped toast." This is a favorite article of food. Mind much clearer than at any time in the disease. No chloroform yesterday or last night. One can hardly believe that this is the same person he saw in such dan- ger and agony on Saturday. 5, p.m. — Febrile paroxysm as yesterday at noon, but less severe. Trouble of passing Avater still exists, though after a time it is passed freely. He had craved milk and Avater, but refused it Avhen offered. His tongue is hard, rough, coated. Cold water continues to be most relished. Has taken at will orange sherbet; water ice, flavored with orange. Got an enema in morning, Avhich not operating, has had another this afternoon. Pulse between 70 and 80. Skin natural. Occasional slight contractions of fingers and arms, but not preventing extension. Has had this, now and then, since the use of chloroform and ether, but not in a degree to make etherization necessary. 16th, Wednesday, 10, a.m. — Report of night less favorable ; restless ; more excitement. But this morning more comfortable than before. Pulse 72. Tongue cleaner, softer. Asks for roast beef. Does not like liquid, farinaceous diet. Urinary function less troublesome. May eat grapes. Relishes sherbet better than any thing else. Marked improvement in cerebral functions. Mind much more clear. 8, p.m. — Quite as Avell. Is raised up to take his drinks, and likes the motion, or change of place. Has turned himself fairly in bed, and arranged his position with much reference to comfort. Pulse rather more rapid, probably from recent exertion. As the object of this record is to shoAv the effects of etherization in convulsions of apparently fatal character, and occurring early in a most severe disease, a further report of the case seems unnecessary. This patient had been seen by several physicians, before ether Avas used; and 390 ETHERIZATION IN CHILDBIRTH. I believe there Avas no difference of opinion among them as to the fatal issue of the case. The change in its whole circumstances, during etheri- tion, Avas not to be questioned. Perfect quiet replaced violent convulsive disturbance, and relaxation of the Avhole system of voluntary motion gradually followed. A new character Avas given to the disease. That on which spasms depended, and Avhich had given to them their whole character and threatening issue, had been removed. Functions necessary to life — the circulation, respiration, innervation, all of which had been so seriously disturbed — came again into a comparatively natural state, and gave promise of ultimate recovery. Was not this cure ? Was not the Avhole object of a remedial agent, as far as a specific object Avas looked to, attained ? Was not life preserved, and by an unquestionable action of the means employed ? I Avrite six weeks from the attack. This young man is not well. He is still emaciated, and suffers much from lameness and contraction of the right leg. Whether this be OAving to cerebral lesion, or to long lying upon it, and keeping it bent, I knoAv not. His appetite is excellent. His mind is clear, and he takes his old and strong interest in books. He is still confined to his bed or chair; and a convalescence, already so pro- tracted, may demand much more time for its completion. Since above record, electricity has been used, and Avith great benefit, both in regard to the lameness and pain in right loAver extremity, and Avith much general improvement. Case LXXIX.* — Puerperal Convulsions. No. 279, age tAventy-one ; pregnancy, sixth month. I was desired to see this case, attended by homoeopathic physicians, Sept. 14. On reaching the address, I learned that this patient had, for some time, occasionally suffered from various affections of the head, such as dizziness, sense of fullness, pain, occurring suddenly from emotions, exertion, &c. There was often flushing of face, patches of rash on the neck and cheek, coming and going suddenly. On the 11th inst. pain in the head had been unusually severe, referred to top of head. 12th, more severe; and, towards even- ing her medical attendant Avas called, and prescribed cold water to head. Much anasarca, Avith cedematous fullness of face and neck, had occurred. She Avas in the middle of sixth month. I Avas further informed that at 8, p.m. 13th, there Avas a convulsion. Consciousness occurred after the spasm ceased. After about an hour's interval, another spasm ; and tAvo more followed, consciousness still continuing. Opium Avas given in * This case occurred while the Appendix was going through the press, and is not in the Tables nor Analysis. APPENDIX. 391 homceopathic doses, and four hours' interval followed. Spasms then recurred. Opium failed now to check them, and veratrine and belladonna were given, after the Hahnemann plan. After 7, a.m. 14th, and Avhen a number of convulsions had occurred, consciousness Avas abolished. Ho- moeopathy was then abandoned. About twenty ounces of blood were next taken from the arm, and with some relief. I was called at noon to see this patient in consultation. I found her with a pulse of 120, not strong or full. Comatose; incapable of being roused. Skin hot, turgid, mottled; mouth open; tongue swollen, and protruded between the teeth! Examination discovered os uteri and neck in ordinary state, at the sup- posed period of pregnancy. Uterine contractions had occurred. A pain soon came on, and, almost contemporaneously with it, a con- vulsion. This last began Avith rapid motion, and separation of the eyelids. The muscles of the face tAvitched violently ; the head was drawn strongly to one side ; the whole frame became rigid; the lower extremities pro- jected straight from the trunk; and, lastly, universal and violent shaking took place. The face at first grew pale, then deeply livid; and imme- diately the livor shoAved itself, and quite as obviously in the hands as in the face. The spasm Avas short, but little exceeding a minute; but, I think, as violent in its whole characters as I have ever witnessed. Heavy, almost suffocating stertor now came on ; and, after some time, respiration became easier. It was noAV agreed on to use chloroform at the beginning and through the next pain, and to observe what followed. The spasm Avas over about ten minutes past 1, p.m. Contractions soon occurred, and chloroform was at once inhaled. No spasm attended or folloAved. Pains continued to occur, but no fits. At 4, another but lighter attack. It was sooner over, and the stertor less. The chloroform was now inhaled during a number of pains ; then intermitted for one or more. The intermission was because of some supposed indication, such as diminished force and frequency of the pulse; its marked slowness; coldness of the extremities; suspension or diminution of contraction; — symptoms which occurred slowly or suddenly, and indicated effects of disease or of remedies, and made it a duty to wait for further developments. In the meantime, something was done to obviate symptoms. Sinapisms Avere applied to the lower extremities ; a vesicating plaster to back of neck; cold to the head. The spasms seemed now to be within control; so that, from 4 to 11, p.m. there was no fit. Contractions increased. Os uteri dilated. Enemata had been fre- quently given, but Avith no effect. Hyd. submur. ten grains were given. Chloroform was steadily continued. Once, pain was apparently less severe ; and a dram of pulv. secal. in half pint Avater, as an enema, was given. This operated as a laxative, and brought away flatus. Two or 392 ETHERIZATION IN CHILDBIRTH. three hours after, a free alvine dejection, supposed to be from the hyd. submur. Good progress Avas made in the case. The liquor amnii was discharged; dilatation Avent on rapidly; secretion was abundant; and, betAAreen 9 and 10, a.m. 15th, the child was born. The placenta and membranes soon folloAved; and, in hour after, I left her Avith good pulse and skin, and good promise of recovery. 16th. — Report favorable. Last evening, apparently recognized her husband. Slept Avell last night, and Avas, by nurse's account, very com- fortable at 6, this morning. I passed tAventy-four hours Avith this patient, and had opportunity to observe symptoms, and the effects of etherization. Inhalation was used to prevent convulsions. It Avas used for some time at the very beginning of uterine effort, and was continued till it ceased. As intervals greAv longer, chloroform was less regularly used; but this was regulated entirely by the character of the pain, its severity, length, &c. The report shoAvs how perfectly the object of etherization was attained. Con- vulsions were prevented, so that, with the exception of one fit, the disease did not declare itself after inhalation Avas begun. I think, for interest, — for the important instruction it gives concerning etherization, — it stands among the most important cases I have observed, of the use of the remedy of pain. I stated these facts to a medical friend, the day after their occurrence. Said he, " A case of like interest has just come under my notice. In it very severe convulsions occurred, about thirteen hours after delivery. She had inhaled chloroform during labor. It was inhaled during the convulsions; and they were entirely controlled by etherization. They amounted to four in all. Great prostration followed the suspension of the spasms. Fair re-action occurred after about tAvelve hours. Gradual amend- ment, manifested by return of consciousness ; improved pulse ; good state of skin. After third day, some diarrhoea. Later, dyspnoea and cough, with somnolency. Gradual sinking, and death, a fortnight from the termi- nation of labor.'' On examination after death, the only lesion observed was pneumonia in a portion of the middle, and lower part of upper right lobes. The urine coagulated by heat; confirming the observation of Professor Simpson, Avho says that he has ahvays found coagulable urine in puerpe- ral convulsions. The kidneys in the above case Avere normal. The heart was examined with care, but presented no morbid appearance. The brain, with the exception of a small quantity of water in the ventri- cles, and beneath the membranes, was perfectly healthy. A sketch of the following case has been already given; but it is with i great pleasure I present to the reader the fuller history of the same, \ by the attending physician : — APPENDIX. 393 Case of Puerperal Convulsions. By Samuel Cabot, M.D. " Mrs. H. strong and healthy, twenty-seven years of age. Married at seventeen; mother of four children. Ahvays has had very short and easy labors of about ten minutes' duration. Supposed herself to be at about the full period of gestation. Fell upon back with considerable violence, about a week before, and had had some nausea, with uneasiness in head, from that time. " At 8, p.m. March 13th, was found upon the bed in a violent convulsion, blood floAving in considerable quantity from mouth; convulsions recurring every fifteen minutes. At 9, I saAv her. The muscles of head, chest, and arms, principally affected, diaphragm also; left side rather more than right. Left pupil dilated. Head of child very high, and mouth of womb not felt. Took sixteen ounces of blood from arm. Applied ice to head, and sinapisms to feet. Pulse strong and full before venesection; small and feeble after. In about thirty minutes after venesec- tion, recovered senses for a short time, so as to answer questions coherently. Had another convulsion at an hour and a half after venesection. Bled her again at a quarter past 11, eighteen ounces. After venesection, quite pale; pulse small and weak; pupils fixed, and rather contracted, but equally. In an hour, had another fit; and one each successive hour, for three hours; then becoming oftener, until once in twenty minutes. " At half-past 3, a.m. 14th March, I applied, at the apparent commencement of a convulsion, a sponge, saturated with sulphuric ether over her mouth and nose. The spasmodic action soon ceased; and, in about three minutes, she was in a deep sleep. Upon examination, head of child someAvhat advanced; could only reach anterior part of neck of womb; rather soft, and much shortened. Ether was used at every threatening of convulsion. Almost immediately after patient was obviously etherized, regular labor-pains commenced, and continued at short intervals, until, at 6, a.m. the child was born. I think, any one, ignorant of the circumstances of the case, who had come in while the head of the child was passing the external organs, would have thought, from the expression of the mother's face, that it was an ordinary case of labor. The child cried almost immediately after the passage of the head. Boy, large; cord very large; placenta normal. The child, some hours after, did not smell of ether. One scruple of ergot was administered, as womb did not contract well. After birth of child, patient slept quietly about an hour ; then had another convulsion, there having been an interval of nearly four hours since last spasm. Ether was again used; but pulse became so feeble and small before any effect could be produced, that it was discontinued; and an enema of tinct. opii, one dram, and pulv. asafoetid. one dram, in half a cup of starch, was administered; and hyd. submur. fifteen grains, given by the mouth. After this, patient slept quietly for three hours; then had a convulsion every half hour, until 2, p.m. ; when, after considerable difficulty, got doAvn tinct. opii, thirty drops ; pulv. asafcet. ten grains. Had one more convulsion soon after taking it, and then slept quietly for two hours; and thenr beginning to move as if about to have a convulsion, I gave her tr. op. and asafoetida, as before; and, after a few struggles not amounting to convulsion, became again quiet, and remained so untd about half-past 5, when, after having taken some senna and salts, convulsions again came on; the first continuing about half an hour, and hardly ceasing before another commenced, which lasted about the same time; then there was a short interval, and then another not severe convulsion; after which, she had no return of them. At 9, took a teacup of infusion of senna; then slept quietly till 10, when medicine operated; after which, slept until half-past 9, March 15th, when took a little food, and answered rationally. Very feeble. Tongue very sore, having been wounded in several places. Lochia abundant. On the 50 394 ETHERIZATION IN CHILDBIRTH. morning of 16th, found that she had been delirious in the night, and had slept but very little. Lochia scanty. Relishes food. "17th. — Mibi has begun to come, and, in afternoon, wa> very abundant, — more than child could take. — Recovery perfect." The beneficial effects of chloroform in convulsions are well displayed in the following case, which is extracted from the Sept. number, 1848, of the "Buffalo Medical Journal;" a periodical which is very ably con- ducted by Austin Flint, M.D.: — •• Case of Puerperal Convulsions, treated with Chloroform. " By James P. White, M.D. "July 18th, 1848.— Was requested by Dr. Devening to see Mrs. Brady, then in labor, and suffering from a violent attack of puerperal convulsions. I found an Irishwoman, of full habit, in her third pregnancy; the two previous labors having been favorable. Dr. Devening had been Avith her but a short time; the convulsive paroxysms succeeding each other Avith great rapidity; the face flushed, and pulse fuU. He had bled her twenty or twenty-four ounces Avith partial relief. As the pulse continued full, and the muscular efforts during the fits were violent, I deemed it prudent to repeat the bleeding, which was done to about the previous amount. On examination per vaginam, the breech was found occupying the superior strait, the soft parts dilatable, and the pelvis roomy. As the convulsions continued AA-ith but slight diminution, and the parts were favorable, though the pains were slight, it was deemed prudent to proceed AAithout delay to deliver the child. To secure the tonic contraction of the uterus, and guard against hemorrhage, two drams of the wine of ergot were given. It occurred to me, that chloroform might assist in controlling the woman, and lessening the agitation, while making the attempt to bring down the child. Dr. Devening accordingly applied some of Chdton's preparation to the nostrils, whilst I introduced my fingers into the A'agina, and hooked them into the groin of the foetus. " The muscular agitation, which before could not be controUed, now subsided, and dehvery was effected without difficulty; the uterine contraction continuing to be moderate. After applying such restoratives as were requisite to recover the child from a state of partial asphyxia, I applied a ligature to the cord, and laid it upon the bed. By placing the hand upon the abdomen, it was found to be stOl distended. Upon the re-introduction of the finger into the vagina, it came in con- tact Avith the arm of a second child, which I proceeded to turn and deliver; the patient inhaling the chloroform, and remaining quiet, with tolerably firm contrac- tion of the uterus upon the hand during the operation. The double placenta and membranes were very soon pushed down into the vagina by the tonic contraction of the uterus, and were removed by Dr. Devening. Very little hemorrhage fol- loAved; and, the proper bandage being applied, the patient was carefuUy laid back upon the bed. During the entire period succeeding the application of the anes- thetic agent, the woman was unconscious and calm; but at no time did we carry it so far as to produce stertorous breathing. "21st.— The patient comfortable, and consciousness entirely restored. She has no recollection of any thing which occurred during her labor after being seized Avith convulsions. The children are of good size, and doing weU. " 25th. — From Dr. Devening I learn that the woman has so far recovered as to rei>un~.e her usual domestic duties." APPENDIX. 395 I have transferred the following portion of Dr. Perry's Letter from the Correspondence to the Appendix, because it relates mainly to occur- rences in the puerperal state, and not to those of childbirth, or to im- mediate and ob\'ious effects of etherization : — ....." In two of the cases, it produced some hysterical symptoms, but not sufficient to induce me to suspend the use of it. I have seen no unpleasant moral or intellectual effects produced by it. One case was followed, on the fifth day, by fatal peritonitis; and one, a fortnight after, by phlebitis, which gave Avay to local depletion. Two cases were followed by profuse SAveating, which passed off in a few hours. These were the only unpleasant physical effects which I have seen follow the use of ether; and hoAV far these were influenced by it, I am unable to judge. In the case of hand presentation, I put the woman under the influence of it, and turned the chdd without any difficulty; and both mother and child did well. I have seen no immediate danger resulting from its use, in the cautious way in which I have used it. The children of aU that have taken ether have done weU, Avith one exception. This child, which was apparently healthy when born, was taken in convulsions a fortnight after, and died. No disease was found in the brain, or any other part of the body, upon examination after death. " These are all the important facts, in relation to the cases in which I have tried it; and, if I were to compare these with the cases which I have had, and in which I have not tried it, during the same period, I should draw an unfavorable opinion of its use in obstetric practice. You will be able, from the large number of cases which you will collect, to come to some more correct results. " I have not used chloroform in any case of labor, and therefore can say nothing of its comparative merits." I insert the following Letter Avith great pleasure. Its author is a physician and chemist, — a worker in his laboratory. The views offered by him are curious, and not without practical application. They recog- nize mental action in relation to a most interesting and obscure function, and propose, out of the remedy of pain, to find an agency Avhich shall diminish the amount of pain itself, by producing a perfectly healthy organization: — "Boston, Feb. 8, 1848. " Dear Sir, — As you are writing on etherization, I wish to suggest tAvo or three things which have occurred to me as deserving consideration. " Win there not be an nnportant effect produced upon the constitution and development of the future child, by relieving the mother of the anxiety and terror which now beset pregnancy ? Will there not be an improvement in the progeny from this cause, acting during the Avhole of pregnancy ? Do not the fears of the mother now occasion a portion of the distressing symptoms of pregnancy, which Aveaken and permanently injure the child ? I haAre not seen this subject discussed; but I should not wonder if the experience of a few years should rank it among the greatest benefits derived from etherization. " A second subject, which is of interest, is the chemical action of sulphuric ether and chloroform in the system. I have no doubt that chloroform is decom- posed in the circulation, from the fact that it does not continue to be expired by the lungs, and also that its effects cease so soon and so entirely. This would also 396 ETHERIZATION IN CHILDBIRTH. be anticipated from the circumstance, that there is a provision in the mucous coat of the stomach for the secretion of chlorine, in the form of muriatic acid, out of the salt (chloride of sodium) in the blood. The corresponding soda of the salt is secreted out by the hver. Now, very probably, the chlorine of the perchloride of formyl is secreted out by the digestive organs ; and the base formyl, probably un- dergoing some further decomposition, may be secreted out by the hver, as part of the organic matter of the bile, or possibly by the kidneys. The examination of the urine and bile Avill be matters of interest and importance. It is, of course, very desirable to know the whole extent of its action in the organization. " I have observed, on breathing chloroform myself, a peculiar swelling and soreness of the palate and throat to result invariably, and continue for a day. Is this a general fact ? If so, it should be noted. It may have a specific action on the throat, which might be turned to account. " I will mention one other circumstance belonging to the history of chloroform, though not connected Avith etherization. Dr. Jackson introduced the impure chlo- roform of Guthrie (more concentrated than common ' chloric ether' ), several years a^o, for the cure of toothach, by applying it on cotton in the cavity of a tooth. I have made one experiment Avith the pure chloroform, and find that its action is instantaneous in relieAdng the pain. I believe the effect, in many cases, would be permanent. This has almost as important applications as the use of the same substance in preparing for the extraction of teeth. Of course, the gum and cheek must be protected from contact with so acrid a principle. " I have throAvn out these matters for your consideration. " Sincerely yours," A Case in which Contractions were greatly increased after Chloroform. COMMUNICATED. It is not rare to find an increase in uterine effort, from the inhalation of ether and chloroform. At times, this occurs early in the labor, or soon after etherization; at others, it is noticed later in this process. In a very few cases, I have knoAvn after- pains to be unusually severe after etherization, and this even in first labors. The explanation of this last-mentioned occurrence is not easy, since, in the cases in Avhich it happens, the womb is weU contracted, and there is no hemorrhage; and, in the great majority of cases, after-pains are less severe than in the cases in which chloroform or ether has not been employed. In the case Avhich has led to these remarks, and which has recently occurred (September), chloroform Avas inhaled Avith great benefit; the pains Avhich, before its use, were very severe, being mitigated in their violence by inhalation; and the pro- gress of the labor being very satisfactory. The head had reached the inferior strait, and seemed in a fair way soon to pass through it, when progress Avas impeded. Uterine action now became more strong than it had been at any earlier time in the case, and Avas uninterrupted, resembling exactly the tonic, — continued contraction which is so generally produced by ergot. The attention of the physician in attendance Avas strongly attracted by what had so unexpectedly happened. Etherization was perfect; the contraction continued without the least abatement; the child advanced; and still the labor was not com- pleted. It was supposed that five minutes had elapsed, when it was determined to ascertain how much longer this condition of the womb would last, by recurrin" to the watch. This was done, and it was found that the contraction continued five minutes more without any relaxation, Avhen the head was born. It was now dis- APPENDIX. 397 covered that the face had been to the symphysis pubis, and the delay in the dehvery was at once accounted for. Both mother and child did well. Upon inquiry, it was learned that complete insensibility existed during the whole of the long pain by which the labor was brought to a close; and, though so much effort Avas apparent, it was nevertheless accompanied by no suffering. It was apprehended, that the child would be still-born, from the long-continued and uninterrupted pressure; but it was born alive. The labor Avas terminated much sooner than it would have been, had not the increase of pain referred to taken place. This, with the entire relaxation of the passages, and the abundant lubrication, will account not only for the safety of the child, but also for the short time which the last stage of the labor required for its completion. The folloAving case has an historical interest Avhich specially commends it to the notice of the profession. It is the first case in which sul- phuric ether Avas exhibited by inhalation in eabok in this country. Besides its historical interest, it has in itself much Avhich is practically useful. Thus ether was inhaled " between each pain. Consciousness was unimpaired, and labor not retarded. No unpleasant symptoms oc- curred, and the result Avas highly satisfactory." {From the Boston Medical and Surgical Journal, April 14, 1847.) "To the Editor of the Boston Medical and Surgical Journal. " Dear Sir, — On the 7th instant, I administered the vapor of ether in a case of natural labor. The patient was in good health, and in labor of her third child. Five and a half hours having elapsed from the commencement of labor, her pains, which had been light, but regular, becoming severe, the vapor of ether was inhaled by the nose, and exhaled by the mouth. The patient had no difficulty in taking the vapor in this manner from the reservoir, without any valvular apparatus. " In the course of twenty minutes, four pains had occurred without suffering; the vapor of ether being administered between each pain. Consciousness was unimpaired, and labor not retarded. Inhalation was then suspended, that a com- parison might be made betAveen the effective force of the throes Avith and Avithout the vapor of ether. No material difference was detected; but the distress of the patient was great. Inhalation was resumed; but the progress of the labor Avas so rapid, that time could not be found for sufficient inhalation to bring the system perfectly under its influence : stiU the sufferings of the last moments were greatly mitigated. From the commencement of the inhalation to the close of the labor, thirty minutes. Number of inhalations, five. No unpleasant symptoms occurred, and the result Avas highly satisfactory. " ^ ours, &c. " Boston, April 10, 1847." " N- C- Keep- {From the Boston Medical and Surgical Journal, July 21, 1847.) " To the Editor of the Boston Medical and Surgical Journal. " Sir, — Having been caUed to one of those difficult and embarrassing cases of labor Avhich are occasionally met with, and finding so much relief to my patient, and satisfaction to myself, from the inhalation of ether, I wiU give you a history of the case. " June 10th. — Was called to Mrs. II. in labor with her first chdd. From some feelings of dehcacy, she engaged a midAvife from Boston to be with her at the time 398 ETHERIZATION IN CHILDBIRTH. of confinement. After having been there some twelve or fourteen hours, as she says, during which time the pains were regular, and, as she thought, sufficiently severe to accomplish delivery, she found somethmg Avrong, and told the husband that she could not be delivered, as there was something very unusual in the pre- sentation, and she Avished a physician sent for. About 6, p.m. I found her in great distress ; had been in severe labor since morning. On examination, I found both arms doAvn, the right one as far as the scapula ; the cord had been down from the commencement of labor, and had ceased to pulsate, as the midAvife said, from the time of its first coming doAvn. The waters were discharged with the first pains. I could just make out that there was a foot to be felt over the right shoulder, Avhich led me to suppose it possible there might be more than one child; though the arms were so large that I could hardly believe it to be the case. " Her pulse was very frequent, and her pains severe and continuous. I tried to make some change in the position, but could not. I concluded to let her inhale the ether; thinking that, if I could not then succeed in effecting a change of position, I should remove the arms. I gave the ether, and in five minutes she became insensible. The pains Avere very severe; but no change in the position could be effected. I told the woman, after some delay, that I should endeavor to remoAre the child in portions, as I did not feel it safe to delay longer. She begged for me to do it, but wanted the ether. After again being fully under its influence, I removed one arm at the shoulder-blade, and the other, after several trials, at the shoulder-joint. I could then get hold of the foot which Avas over the shoulder, but could not find the other, or feel that there was a head ; nor could I, until the contents of the abdomen of the child had escaped through an opening which I made, succeed in bringing down the feet. The child was then delivered without great delay. The position was very unusual; the head being bent back upon the sacrum of the child, the arms forced down, and the child so doubled up as to cause one foot to be felt over the shoulder. " She said she suffered nothing, comparatively, during the three hours which Avere required to accomplish delivery, being under the influence of the ether much of the time. She recovered, without any unfavorable symptoms. — Yours, " CharlestoAvn, June 30, 1847." " J' Wl BemiS> I make the following extract from Dr. Putnam's paper on " Etheriza- tion in Labor," Avhich appeared in the " Boston Medical and Surgical Journal" for Jan. 26, 1848 : — " Arm presentation. ' Waters' discharged and arm protruded four days. Pains constant. A professional friend, who asked me to assist him, stated that he had just been caUed to the case, and found her in the condition above described. He had made an attempt to ' turn,' but had relinquished it. When I saw her, the pains Avere strong. The protruded arm livid, but the foetal pulsations were distinct. " After inhaling for two or three minutes, she became furiously excited, and was restrained Avith considerable difficulty. Repose being essential to the success of the operation, we persisted in the application of the sponge, weU fiUed with ether for about six minutes, when she relapsed into a state of utter unconscious- ness. I Avas then able to pass my hand through the os uteri, and reached the feet Avith very little effort, and without being in the least degree cramped. There Avas no liquor amnii in the cavity, and the uterus Avas closely applied to the unequal surfaces of the foetus. A foot Avas brought down to the os uteri, and a tape looped APPENDIX. 399 round the ancle. By draAving upon this Avith the right hand, and at the same time rotating the femur Avith the left, the arm began to recede ; and the evolution, once begun, was readily completed. The child was delivered living; the placenta throAvn off, and removed at once. During the whole time of the dehvery, — a little more than half an hour, — she Avas motionless and unconscious, and yet the child was scarcely washed when she insisted on sitting up in bed to give directions about its dress." Dr. Putnam has since communicated to me tAvo other cases of arm presentation, in one of Avhich sulphuric ether Avas employed ; in the other, chloroform. To the first of these he was called by a professional friend, soon after the rupture of the membranes. The turning Avas commenced as soon as the patient was etherized, and she was delivered during insen- sibility, Avhich lasted about fifteen minutes. The uterus contracted at once, and both mother and child did Avell. The second case was compli- cated by prolapse of the cord. The mother did Avell; but the child could not be resuscitated. While engaged in preparing almost the last page of this volume, the folloAving extract from the "Boston Medical Journal" for Sept. for the first time fell under my notice. It is from Professor Lindsly, of Wash- ington, D.C., and, in its few words, shoAvs how judiciously he has em- ployed etherization, and hoAV wisely he has observed and stated results. I beg leave to acknoAvledge the pleasure afforded me by finding so many striking coincidences, both in opinion and practice, betAveen Pro- fessor Lindsly and myself, in relation to the most important questions touching the employment of etherization in childbirth. Professor Lind- sly's position gives to his opinions much weight, Avhile the directness and simplicity with which they are expressed will save them from all captious criticism. I am most happy to close this volume with such substantial endorsement of the safety and benefit of etherization in labor:— " Having observed, in several papers, notices of the report Avhich I presented at the late meeting of the American Medical Association in behalf of the Committee on Obstetrics, that are erroneous in various respects, I beg leave, through your valuable Journal, to offer a few remarks on etherization, in AA'hich some of these errors Avill be corrected. " It has always been very remote from my intention to take an ultra or partizan stand in favor of etherization in midAvifery. I beheve, in the very great majority of cases, no interference Avith the natural progress of labor is necessary or justifiable; but I also beheve that there are cases where it is proper for the practitioner to resort to a remedy which is confessedly efficient in relieving pain, and which I have no doubt is, with due caution, entirely safe. And I regret to see physicians of high standing in the community not only condemn Avithout trial, but take the lead in denouncing, means, of which they are experimentally ignorant; thus reversing the sound advice of Hunter to Jenner, — * Do not think, but try;' for these gen- tlemen say by their actions, ' We Avill think (and condemn), but we Avill not try.' 400 ETHERIZATION IN CHILDBIRTH. " Those who object to the trial of chloroform in midAvifery as unsafe, seem to forget that it is possible to make a trial of it Avithout producing the full anaesthetic effect. I contend, and I know it by personal observation, that an effect very far short of complete anaesthesia Avill give very great rehef, by allaying pain, and espe- cially by soothing that nervous excitability Avhich is so distressing to many parturient women. The inhalation of ten or tAventy drops of chloroform wiU often accomplish this; and I do not beheve a patient can be found Avho could not inhale this quantity Avith perfect safety, especiaUy if the handkerchief or sponge be occasionally removed (for a moment) from the mouth or nostrils, so that atmospheric air alone may be inspired. There can be no doubt, that chloroform, like all other narcotics, can be given in doses that are unquestionably safe, and that these smaller doses may be of great benefit, Avithout giving entire rehef, just as opium or any other anodyne may soothe pain, Avithout wholly removing it. Complete insensibility cannot be produced by opium, Avithout giving it in dangerous quantities; and yet no one pretends for a moment that this is any reason AA'hy it should not be employed in quantities that are safe, for the purpose of affording partial rehef. If we should admit, therefore, for the sake of argument, that chloroform cannot be safely given so as to produce complete anaesthesia, there still remains the same reason for pre- scribing it, as leads us to the use of other narcotics, viz. that it can be given with perfect safety, so as to reheve pain, Avithout causing insensibility. Its safety (given in this Avay) and efficiency being admitted, it unquestionably possesses three most important advantages over opium : — It produces its effects almost instantaneously ; it does not retard, but rather hastens, the progress of the labor ; and it causes no ulterior bad results. "The important practical doctrine which I Avish to inculcate is this; that suffi- cient evidence has now been adduced in favor of etherization in midAvifery practice — it having been employed in probably tAvo thousand cases, Avithout a single fatal result — to render it the duty of the profession to give it further trial, to experiment Avith it cautiously and judiciously, in order to see if we cannot finally a^ive at general laws and principles, Avhich Avill enable us to administer it without danger or apprehension." ERRATA. Paiic 43, line 34, for met it with, read met with it. „ 83, „ 6, for experience, read practice. „ 95, ,, 26, for attend, read attach. „ 95, ,, 35, after /, insert have. Page 216, line 18, for case of, read case for. » 2~2, „ 18, in a few copies, for given, read were given. „ 330, ,, 26, dele consultation after VII. „ 363, „ 32, for effort, read effect. V" I cheerfully state here, that the Printer, Mr. John Wilson, is not responsible for the thus noticed and corrected. — \\". C. NATIONAL LIBRARY OF MEDICINE NLM DlDbfl7DS A IS! ,«-■-- • vvjf