does the benefit end here. By annulling the parturient pains and shock, and their direct and primary depressing effects upon the constitution, we ward off, I believe, to a more or less marked extent, the chances and dangers of those secondary vascular excitements which are always apt to follow indirectly upon them. We increase the chances of a more speedy and a more healthy convalescence. And both patients and practitioners have, as a general rule, had occasion to observe, that the period of convalescence has been evidently curtailed and shortened by the previous adoption of anæsthesia during delivery.

Such certainly has been my own experience. For, since following the practice of anesthesia, my strong conviction is, that I have seen both more rapid recoveries than formerly, and fewer puerperal complications. One patient, however, had a short attack of peritonitis, requiring leeches, &c. It was her third accouchement and her first living child; and, after her two former deliveries, she had required to be bled, and treated for similar inflammatory attacks. At her first labor she suffered severely from puerperal convulsions. In two others of my patients the convalescence was delayed, in one by an attack of the affection described by Dr. Marshall Hall as "intestinal irritation" in the puerperal female; and in the other by a fit of jaundice, which supervened two or three weeks subsequently to delivery, and after the patient had been for several days in the drawing-room. In December and January last, an epidemic of puerperal fever swept fatally over Edinburgh and other parts of Scotland. During the period of its prevalence, two of my patients were seized with it and died. But the previous employment of anæsthesia in these cases had nothing to do with this distressing result. Some of my professional brethren here and elsewhere, who were not using ether or chloroform, were much more unfortunate than I was. In a district in the neighborhood of Edinburgh, one of the medical attendants informed me that, at that time, above twenty mothers were attacked and died, and in none of those whom the disease seized upon, did ether or chloroform happen to be used; while several who demanded chloroform during their labors, all fortunately escaped. The first of the two cases which I met with was after a second labor. The patient's first labor was extremely tedious and prolonged, and, at last, symptoms supervened which demanded the delivery of the child by the forceps. In her second delivery, the labor was much shorter; the second stage lasted only for about twenty minutes, and during it she was completely anæs. thetized. For fifty hours after delivery she progressed most favorably; and after seeing her at that time with a pulse at eighty, and otherwise well, I was suddenly summoned, in consequence

of

extremely severe pain having come on in the uterine region after some muscular exertion. Rigors, rapidity of the pulse, tympanitis, &c., supervened, and she speedily sank, with all the usual symptoms of puerperal peritonitis. The second case alluded to was in a primipara. The labor was tedious, the pain severe, and the patient was anesthetized for four or five hours before delivery. For some days after delivery she went on prosperously, until she became unhappily and greatly excited by discovering intemperate habits on the part of the monthly nurse who was taking charge of her infant and herself. A fit of convulsions (a disease to which, in earlier life, she had been long subject) immediately supervened, and recurred several times. Fatal febrile symptoms then set in, with tympanitis and excessive diarrhoea.

I may add that, in the period during which these 150 cases occurred, I have had under my professional charge 20 or 30 other cases of labor in which anæsthesia was not employed, from the rapidity and facility of the delivery, from the patient being too late to send for assistance, from an aversion on the part of patients to the use of anaesthetics, more especially when ether first began to be used during last year, or from other causes. One of the children in these cases was still-born, and a second died two or three days after delivery. Two of the mothers suffered from crural phlebitis; a third had a severe attack of puerperal fever, but recovered. Two others died; one of them under an attack of puerperal convulsions and coma, which supervened fourteen days after delivery.' In the other fatal case, the patient, who had suffered much in her previous labors, came to the immediate neighborhood of Edinburgh to be confined, and with the view of using chloroform. But the labor proved unusually rapid, and she was delivered before the call for assistance reached my house. Her recovery went on uninterruptedly for two weeks, when a severe attack of dyspnoea supervened. My friend, Professor Miller, her ordinary medical adviser, saw her in my absence, and suspected some acute affection of the heart. When we visited her together shortly afterwards, the symptoms were then apparently those of acute endocarditis. She was submitted to the usual antiphlogistic treatment, and in four or five days felt again so well as to insist upon being allowed to rise, which was forbidden. In the course of a few hours afterwards, another fit of dyspnoea suddenly supervened, and, before Mr. Miller reached the patient's house, she was dead. We did not procure an autopsy. If unfortunately she had used chloroform during the labor, as was

1 Since November last I have used chloroform in all the cases of labor, where I have been called in time, except two.

2 See details of it in Monthly Journal for 1847, p. 213.

her intention and wish, many of the objectors to its employment would, I fear, have unhesitatingly attributed the fatal issue in this case to its previous employment.'

In addition to the 150 cases of artificial anesthesia that have occurred in my own midwifery practice, and to which the preceding remarks apply, I have witnessed, during the last eighteen months, a considerable number of instances in which anaesthetic agents were employed in consultation and hospital practice; and I have frequently had recourse to their assistance in various obstetric operations which I have been called upon to perform, as in the separation and removal of the placenta, in various cases of turning, in one craniotomy case, and in several patients who required to be deli

1 In order to show the caution that is necessary in reasoning upon cases of death apparently from the exhibition of chloroform during surgical operations, I may add that, since November last, scarcely an operation has been performed in Edinburgh without previous anæsthesia, except where the throat or mouth was the seat of incisions, or the operation itself slight and trivial. Amid all the numerous patients thus operated on in public or private practice, when under the use of chloroform, no kind of misadventure or accident has happened; except one case of temporary fainting, a few minutes after recovery from the state of anæsthesia, be regarded as such. On the other hand, among the few exceptional cases in which, since November last, patients have been operated on in this city without chloroform, two have died on the table. One of the two was being operated on by Professor Miller for a hernia, which had been strangulated for about fifteen hours; when, after the skin merely was divided, the patient complained of great faintness, vomited, and died with the operation unfinished. This occurred on the 8th of November, two or three days after the anaesthetic effects of chloroform were discovered, and nearly proved the first operation in which it was tried. The second case, a patient of Dr. Pattison, had an abscess high up in the neck, requiring simple puncture for its evacuation. He died without hemor rhage, or admission of air, or other apparent cause, a minute or two after the puncture was made. If chloroform had been used in these cases, would it not by some have been blamed for the result?

Twelve or fourteen months ago, Professor Syme was performing primary amputation of the thigh in the hospital, upon a patient upon whom there was no sign of reaction, and who was not etherized for the operation. "Upon the incisions being made, relaxation of the sphincters took place, the contents of the rectum and bladder were voided, and an effort at vomiting seemed the prelude of immediate dissolution. Before tying," says he, "the arte ries, I waited to ascertain whether the condition of the patient depended upon syncope or death. My colleague, Dr. Duncan, by causing alternate pressure and relaxation of the chest, effected artificial respiration for some time without any sign of returning life; but by and by the actions of the system were gradually restored, and maintained through the use of stimulants."-See Monthly Journal of Medical Science, vol. 1847-48, p. 76. Such dangerous symptoms, coming on in an anæsthetized patient, might have been mistaken for the effects of the anesthesia.

Some time ago, before either ether or chloroform were used in surgery, Dr. John Argyll Robertson was called, a few miles out of Edinburgh, to perform the operation for strangulated hernia. After having shaved the groin for this purpose, his patient complained of sickness and faintness, and died before any incisions were made.

Last year, Dr. Girdwood of Falkirk, came to Edinburgh to see the practice of anæsthesia, in order to be able to apply it in a case of amputation. The day for the operation and anæsthesia was fixed; but, some hours previously, sudden apoplexy came on, and the patient died.

vered instrumentally by the long or short forceps.' In all these varieties of operative practice, the previous superinduction of anæsthesia has appeared to me to be of the greatest and most undoubted benefit. For, besides freeing the mother from the additional corporeal suffering and additional mental anxiety attendant upon operative delivery, the state of anesthesia enables the practitioner to apply any operative interference that may be necessary with more ease and facility to himself, and consequently also with more safety and success to his patient. When the state of anesthesia is rendered adequately deep, it renders the patient quiet and unresisting during the required operative procedures; it prevents, on her part, those sudden shrinkings and changes of position which the boldest and firmest woman cannot sometimes abstain from when her mind and body have been worn out, as happens in most operative cases, by a previous long and protracted endurance of exhausting but still ineffectual labor pains;—the introduction of the hand into the maternal passages, or of the hand to guide our instruments, is greatly facilitated both by the passiveness and apathetic state of the mother, and by that relaxation of the passages which deep anesthesia almost always induces; and, lastly, this state of relaxation and dilatability renders the process of the artificial extraction of the infant through these passages alike more easy for the practitioner, less dangerous for the child, and more safe for the structures of the mother. Besides, in midwifery, as in surgery, the utility of anesthesia before operating, is not, I believe, limited to the mere annulment and abrogation of conscious pain on the part of the patient, and the rendering of the operation itself more easy to the practitioner, but it adds to the safety of our instrumental or artificial interference. Fer, in modifying and obliterating the condition of conscious pain, the "nervous shock" otherwise liable to be produced by such pain, particularly wherever it is extreme in degree or duration, or intensely waited for and endured, is saved to the already tried and shattered constitution of the mother; and thus an escape is so far gained from those states of immediate vascular and nervous depression, and of subsequent febrile and inflammatory reactions, that are always apt to follow more directly or indirectly in its train.

In one case of placenta prævia to which I was called, the mother had lost much blood, and her lips were pale, and her pulse very weak. On administering chloroform, the circulation and pulse rallied; I separated the placenta, no bleeding recurred; and several hours afterwards the child was born. The mother made an excellent recovery.

CHAPTER VII.

MODE OF EXHIBITING CHLOROFORM; DOSE, ETC.'

In the course of the preceding observations I have omitted making any remarks on the degree of artificial anesthesia required in obstetric practice, with the exception of stating that when instrumental or operative interference is adopted, the anesthetic state must be made adequately deep-so deep, that the patient must be rendered quite passive and apathetic. In fact, when induced for operative purposes in midwifery, the anaesthetic state should be as complete and profound as when it is induced for operative purposes in surgery. But, in common cases of parturition, the anesthetic agent employed, whether chloroform or ether, does not, in general, require to be given in such large doses as in surgical practice. And in obstetric practice, the rules which I have usually followed in exhibiting the chloroform (the only agent I believe now used in Edinburgh and most other places), are those which I briefly stated when first writing on the subject for the Monthly Journal in November last. the first full dose, a few inhalations, before or with each returning uterine contraction, are generally sufficient. The state of anæsthesia should be made more deep as the head is passing the perineum and vulva." I have elsewhere in the same journal stated these rules at somewhat greater length.3

"After

Occasionally I have at first, and especially in the early stages of labor, given the chloroform in small doses only, so as to obtund or obliterate the sensations of pain, without altogether abrogating the state of consciousness. In many patients, this degree of anesthesia, with the results stated, viz., the loss, in a great measure, of pain without the entire loss of consciousness, can be readily enough induced, and answers excellently well; but, as a general rule, it has appeared to me in some cases objectionable. For not unfrequently small doses, such as produce this condition, are accompanied with excitement and talking; and sometimes patients have complained to me of this renewal of the chloroform in small doses with each pain, being accompanied each time with a renewal of the ringing in the ears, flashes of light, and other disagreeable sensations accompanying, in some persons, the primary effects of the inhalation. Besides, we are never thus sure that we are really saving the patient to the full extent by the means we are using. If, on the 1 From Edinburgh Monthly Journal of Medical Science, October, 1848, p. 220. • Monthly Journal, vol. for 1847-48, p. 417. Ibid. No. for April, p. 762.