A Lecture on the Utility and Safety of theW. Tyler Smith
Inhalation of Ether in Obstetric Practice
The only authorities who have published their opinions and experience on the subject I am about to consider, are Baron Dubois and Professor Simpson; but in the accounts of these obstetricians, though valuable facts are recorded, little attempt is made to reconcile the experience and the phenomena of etherization, with physiological and pathological actions, the true basis upon which its ultimate adoption or rejection must rest. The task of fixing the relations and true position of a new agency, of such extraordinary powers, is one of great difficulty, but it seems to me that the time is arrived when at least the attempt to do this should be made.
Our opinions respecting the value of etherization in practical midwifery must chiefly depend on our knowledge of the manner in which this state of insensibility can modify the physiological actions of parturition, and also on our observation of the results in those obstetric cases in which it has been or may be employed.
If the production of the etherized state merely removed pain without inducing any other complication, the question, as it relates to midwifery, might be readily decided. The relief of the pangs of travail would indeed be an invaluable boon. But the problem to be solved is by no means so simple or so uncomplicated. The inhalation of ether takes away from the parturient woman several other elements natural to her condition besides mere physical pain, while it adds thereto other states of the system, which are not observed in strictly natural labours.
The true mode of proceeding is to examine carefully what there is subtracted from, what there is added to, the processes of labour, and then to come to a decision as to whether the advantages or the disadvantages of the use of ether in midwifery are likely to preponderate. Etherization is chiefly a new condition of the nervous system, and we must examine the modes in which the different divisions of the nervous system are affected.
And, first, as regards the cerebral division of the nervous system.
Sensation is for a time impaired or abolished. There can be no doubt that, as one one of its effects, the pains of labour may be alleviated or abolished by this new application.We must therefore inquire into the uses of sensation, volition, and emotion, to parturition, all of them being intimately associated together in natural labour.
Volition may also be suspended; all the voluntary movements are in abeyance when the patient is fully under the influence of ether. In the partially etherized states, violent actions of the voluntary muscles takes place, but they are irregular, like the movements of ordinary intoxication.
Emotion is, in the fully etherized state, withdrawn, or the ordinary emotions are replaced by the disordered emotions of dreaming or delirium.
In the expulsory stage of labour, after the dilatation of the os uteri, the efforts of volition are of some assistance to delivery. The efforts of expiration, and especially of the abdominal muscles, are increased, and the patient aids in fixing the thorax and the pelvis, by grasping firmly with the hands, and planting the feet against some convenient place. Sensation and emotion are, in a physiological sense, even of more importance than volition to parturition. In the last pains of labour, when the motor power is prodigious, and the patient is threatened with laceration, the sensation and emotion of pain comes in as a preservative. All the ordinary actions of labour at this period are reflex in their nature, and are, whatever their violence, uncontrollable by the will. But whenever the pain becomes too intense to be borne, -- and pain is here a measure of danger, -- the patient, chiefly under the influence of emotion, cries out, and her cry, by opening the glottis, takes away all expiratory pressure, and leaves the uterus acting alone. So, in the last stage of labour, upon the mingled agony and exertion of which obstetricians have exhausted their descriptive powers, pain and its attendant emotion play a benign and salutary part. It is now that laceration of the perinæum is most impending, and at this point not only is the glottis opened, but the sphincter ani and the sphincter vesicæ are suddenly dilated, so as to relieve the perinæ um to a very great degree. lt cannot but be considered as a singular provision of Nature, that at the moment when the outlet of the vagina is threatened with the greatest danger, these two sphincters should suddenly relax before and behind it. We may even deduce from this fact a reason for the anatomical position of the vagina betwixt the rectum and the bladder. Thus, then, volition, and especially the sensation of pain, and its attendant emotion, are of considerable importance in natural parturition.
Some interesting points relating to sensation have been suggested by the facts observed in etherization. It has been again and again noticed that patients may preserve ordinary consciousness, and the use of the special senses, with a total insensibility to pain. They have in some cases talked rationally, and have seen and heard perfectly, while they were unconscious of the performance of the most painful operations. Separate seats have been proposed for ordinary consciousness and the perception of pain. Both the seat of pain, and the exact nerves which are the communicators of pain, are as yet unascertained. It is evident that the nerves of special sense are not the conductors of pain the optic, olfactory, and auditory, are insensible to pain, and a whitlow affecting the cushion of the finger, upon which the tactile nerves are accumulated, is not more painful than a burn on the back of the hand, or than an inflamed peritonæum. Thus, the nerves of special sense, as such, are not ordinarily conductors of pain. Besides the fact that the intellect may remain clear while sensation is abolished, there are other reasons for believing that the cerebrum is not the seat of the sensation of pain. Longet, for instance, removed the whole of the brain of a living animal, leaving only the medulla oblongata; and on being pinched or punctured, it cried out, and gave the most lively manifestations of pain. These facts would lead to the inference that there must be a special seat of pain, and special nerves for its propagation, from the periphery to this centre of painful sensations. Lastly, it becomes a question whether ether affects the seat of pain, or the nerves which conduct to it. Mr. Adams, of the London Hospital, made the ingenious suggestion that the blood was altered in etherization, and that the altered blood paralyzed the extremities of the nerves. Others have maintained that this altered condition of the blood depends on the imperfect inhalation of the ether, and partial asphyxia. We know that a writer of eminence on the nervous system is of opinion, that the central seat of pain, with that of pleasurable sensations, and emotion, and respiration, is in that noed vital, or nodus vitalis, the medulla oblongata, whilst its actual seat is in some part of the ganglionic system. Probably, under the full influence of ether, the whole of the nervous system concerned in the production and perception of pain is simultaneously affected.
But whatever its nature and seat, sensation is removed by the influence of ether, the parturient woman may pass at once from her agony, into a state of oblivion to pain. Pain is taken away!
Labour itself, like a surgical operation, produces what has been termed shock. In certain cases, the vital powers fail, the contractions of the uterus and the actions of the heart sink together, and the patient may even die from the pure influence of shock. This may take place in labours, difficult it may be, but still from which the majority of women recover in the usual way, so that we have no certain means of estimating beforehand the probable power of the shock of parturition in any given case. Professor Simpson, in his recent paper, asks, "On what division of the nervous system does the nervous shock operate -- the cerebral, spinal, or ganglionic? If on the former, it should be kept in abeyance by due etherization." Now, I conceive this important point need hardly be put as an interrogation, or if so, that it should meet with something like a definite answer. Shock is composed of several elements, and is certainly not confined to the brain, those which are really referrible to the cerebrum, and to the medulla oblongata, which partakes both of the nature of brain and spinal marrow, -- for here the cerebral and spinal systems seem fused, -- are, pain and emotion, and the effects of these depend on the perfect presence of consciousness and the perception of physical suffering.
We must doubtless look on pain -- I mean, physical suffering -- as distinct from uterine contraction, which in midwifery almost takes the term to itself, not only as a great evil, but as a source of other evils. No human suffering, perhaps, exceeds in intensity the piercing agonies of child-bearing, and no benevolent mind but would consider it an inestimable blessing to be able to relieve women with safety from so great a trial. I do not underrate the importance of pain or of its alleviation. There are women who after one labour remain their life long depressed and in dread of the repetition of their sufferings. But in the present subject it is with the immediate effects of pain that we have most to do. Acute physical pain, in the majority of cases, inflicts a shock upon the system, the shock being in proportion to the depressing effects of the pain endured. Pain, then, when it depresses the system, is one element of shock, whether in parturition or in surgical operations. But it must be said that it is not always depressing; on the contrary, it sometimes acts as a stimulant, and as such is probably salutary rather than prejudicial. Even this great evil is not unmixed with good.
Emotion constitutes another element of shock, as when fear or despair, or some kindred emotion, depresses the vital powers; and this element begins to act, it must be borne in mind, before the commencement of the operation. Thus, to put an extreme case, the step of the criminal falters, and his heart fails, on the way to execution. But as emotion begins to operate before pain or danger is actually present, it may exert a bad effect on a patient about to be operated on, or delivered, in the etherized state, if there should be any great fear or dread for the result. However, in the majority of cases, pain and emotion, as elements of shock, would disappear when insensibility commenced. Many parturient women are destroyed, dlrectly or indirectly, by emotion alone, and so are many surgical patients, these latter, however, in a different mode from the former; there is no escape from labour, but that extreme emotion, which in midwifery is so dangerous, prevents surgical patients from undergoing the proper operations at all, and in this manner such patients die. We shall see hereafter whether in midwifery there are not counterbalancing evils more than sufficient to weigh against the partial deliverance from emotion and physical pain accomplished by etherization.
I now pass on to speak of the spinal marrow, by which I mean the true spinal marrow, the seat of the reflex function in its most extended signification; and of the ganglionic system.
There is, speaking generally, in the application of ether, a point at which the cerebral faculties are suspended without any affection whatever of the spinal marrow. But after this has been passed, the respiration becomes stertorous, and spasmodic twitchings, or even general convulsions, may ensue the spinal marrow is now fully involved as well as the brain. Still later, according to the experiments of Baron Flourens and M. Serres, this organ becomes inexcitable; no reflex movements follow upon the application of an excitant to the surface; and even the spinal marrow itself may be pricked and lacerated without inducing any convulsive action. If etherization be still further continued, the animal dies. In the cases in which ether has been employed in midwifery, it has not affected the uterine contractions -- that is, it has not been pushed so far as to materially depress the spinal functions. I have little doubt that accurate observation will show that it may either not influence them at all, or that it may increase or diminish them according to the condition of the patient, and the extent to which it may be employed, though the effects of its successful use would be almost invariably the suspension of voluntary motion, sensation, and emotion, the uterine reflex actions remaining natural, or being but slightly affected. I cannot enter here into the physiology of Baron Dubois, but it is evident that this distinguished accoucheur is quite unaware of the reflex physiology of parturition, and engages in the discussion of points about which there is no doubt.
I have already spoken of the influence of shock upon the brain; still more important is the influence of severe injuries upon the spinal marrow and the ganglionic nerves. An experiment and a fact will prove this. If the whole of the contents of the cranium are removed from a frog, so as not to affect the circulation, and the thigh or the pelvis be now crushed by the sudden blow of a hammer, the heart's action is arrested, and for a time no reflex actions can be excited by external irritation. This experiment shows the part borne by the spinal marrow in the phenomena of shock. You must bear in mind that this physical shock is quite independent of the brain and of sensation. If a man is shot with a bullet through the body, he may drop instantly, though he has not felt himself wounded. He falls, not from the effects of pain, and before the effects of loss of blood are felt, but probably from the simple effects of shock upon the spinal marrow and the ganglionic system.
This fact, that shock in its major part may be still present, though a state of perfect insensibility has been induced, has escaped the attention of all writers on the subject of ether. Cases have been detailed, and the inhalation of ether eulogized, not only as the assuager of pain in surgery, but at the alleviator of the shock of operations. It is most important that it should be understood, that in its true nature shock affects the spinal marrow and the ganglionic system even more imminently than it does the brain.
The stimulant effect of ether upon the brain and spinal marrow at one stage of its operation is of great importance in considering its applicability to midwifery. It has been used by Dr. Ranking in tetanus with the effect of increasing the spasm it has also been found prejudicial in hysterical and epileptic convulsions; and it has produced convulsions in persons who have inhaled it merely for experiment or for surgical purposes. Baron Dubois vividly describes the symptoms produced in one of his obstetric patients, in which all the most intense premonitory signs of convulsion were induced; the congestion was so great, that he almost expected the eyeballs to syringe forth blood. Now, knowing the tendency to convulsion which belongs to the puerperal and pregnant states, it would at once seem improper to resort, without very grave reason, to the use of an agent so capable of adding to the utero-spinal excitement of labour, a new and a direct stimulant of the organ concerned in convulsions.
In some operations there has been a considerable amount of reflex action; in others, the twitchings of the stump after amputation has been considerably diminished. In one of Baron Dubois' cases, the limbs remained motionless, in another, a movement of the thigh occurred on the introduction of one of the blades of the forceps. These and similar facts show that the spinal marrow may be either excited or depressed by this agent. I cannot now enter fully into this subject; but in some cases the loss of sensation and consciousness, and the persistence of reflex action, have been very remarkable. The cerebral and spinal divisions of the nervous system have been as completely separated as they could be by actual experiment. The inhalation of ether has, with almost the certainty of a chemical reagent, decomposed the old cerebro-spinal system into two, and the cessation of its influence has as suddenly reunited them -- thus offering an additional proof, if such were necessary, of the independent function of the true spinal marrow. Baron Flourens has also obtained further proofs of his doctrine of the separation of the contents of the cranium into excitor and inexcitor parts, by the phenomena observed in etherization.
One extraordinary circumstance relating to this subject must not be forgotten -- namely, the occasional incitement of the sexual passion in patients under the influence of ether. In one of the cases observed by Baron Dubois, the woman drew an attendant towards her to kiss, as she was lapsing into insensibility, and this woman afterwards confessed to dreaming of coitus with her husband while she lay etherized. In ungravid women, rendered insensible for the performance of surgical operations, erotic gesticulations have occasionally been observed, and in one case, in which enlarged nymphæ were removed, the woman went unconsciously through the movements attendant on the sexual orgasm, in the presence of numerous bystanders. Sexual excitement has also been observed in the male subject. Viewed apart from the moral considerations involved, there is not, in the whole of the wonders related of this extraordinary agent, anything more wonderful than this exchange of the smarting of the knife and the throes of parturition, not for mere oblivion, but for sensations of an opposite kind, pain, in fact being metamorphosed into its antithesis. Still, I may venture to say, that to the women of this country the bare possibility of having feelings of such a kind excited and manifested in outward uncontrollable actions, would be more shocking even to anticipate, than the endurance of the last extremity of physical pain. I am only surprised that the distinguished French obstetrician should not have made some observation of this kind. In many of the lower animals, we know that an erotic condition of the ovaria is present during parturition, and that sexual congress and conception may take place immediately upon delivery. It was, however, reserved for the phenomena of etherization to show that, as regards sexual emotion, the human female may possibly exchange the pangs of travail for the sensations of coitus, and so approach to the level of the brute creation. I have no doubt -- indeed, I have accumulated evidence to prove, as a general law -- that at the time of parturition in all ovipara and vivipara, the human female included, the ovaria are in a state fitted for fecundation. May it not be, that in woman the physical pain neutralizes the sexual emotion, which would otherwise, probably, be present, but which would tend very much to alter our estimation of the modesty and retiredness proper to the sex, and which are never more prominent or more admirable than on these occasions? If this be so, women would scarcely part with pain, hard as their sufferings may be to bear; chastity of feeling, and, above all, emotional self-control, at a time when women are receiving such assistance as the accoucheur can render, are of far more importance than insensibility to pain. They would scarcely submit to the possibility of a sexual act in which their unborn offspring should take the part of excitor; and as the erotic condition has been chiefly observed in patients undergoing operations on the sexual organs, we must assign as the exciting cause, either the manipulation of the attendant or the passage of the child. Lucina, fabled as she was to have been born without pain, was a name often given to the severe Juno, and to the chaste and cold Diana, but never to the Paphian queen.
We are now, I think, in a position to argue the questions as they relate to midwifery -- What benefits can be conferred, what injuries hazarded, by the use of ether? Pain and emotion may be obliterated; all, or nearly all, of shock which belongs to pain and mental emotion may be averted; but, at the same time, volition, and the salutary influence exerted by pain and emotion on the motor actions of labour, are withdrawn. In successful cases -- that is, when the brain only was affected -- parturition, as a reflex function, would not be interfered with. There remains to the woman, in its full intensity, all that portion of shock which depends on the spinal marrow and the ganglionic system. There is added, in some cases, the increased tendency to puerperal convulsions, and the collapse described in the cases of Messrs. Nunn and Robbs as the effects of the ether itself, and which has also occurred in many unrecorded cases. The dangers incurred by the use of ether in midwifery would be that of convulsion, and of the meeting of the physical shock of parturition with the shock or collapse produced by the ether itself. Whenever this complication occurred, there would be considerable danger. The moral considerations which relate to our decision I have already alluded to. Briefly, I may repeat, there is, on the one hand, the absence of pain and of painful emotion, with their attendant evils; on the other, there is the physical shock unaverted, the tendency to convulsion, and the possibility of dangerous collapse -- a possibility which, in some surgical cases, has passed into fatal certainty.
I know it is ungracious to take the part of an alarmist on such a question but many fatal cases have now occurred after operations in which etherization has been practised. The patient who underwent the Cæ sarian operation died; another patient, on whom extirpation of the eyeball was performed, sank; a clergyman, whose leg was amputated, never rallied after the operation; two of the women delivered while under the influence of ether, by the Baron Dubois, subsequently died; and fatal collapse occurred in the case of a woman from whose thigh a tumour was removed. Probably other fatal cases have occurred, of which we have no information. It would be difficult to say in how many of these instances the ether contributed to the fatal results: in some, death would no doubt have taken place under any circumstances; but in others, it may be considered wellnigh certain that its use was the chief, if not the sole, cause of death.
The morbid phenomena fairly attributable to ether, observed in cases which have recovered, have been -- nausea, sickness, stertorous breathing, pulmonary and cerebral congestion, convulsions, and protracted failure of the heart's action. Now, the bare possibility of producing symptoms such as these by a remedial agent, however valuable, renders it imperative that we should be able to distinguish the cases in which the more serious of them are likely to occur, otherwise the agent itself must inevitably fall into disrepute. As is well known, digitalis may produce failure of the heart; opium, congestion of the brain; and hydrocyanic acid, convulsions: and consequently, caution is always observed in the administration of these. Still valuable remedies; but after etherization, we may have effects which resemble either undue narcotization, an over-dose of hydrocyanic acid, or the cumulative results of digitalis; so that it behoves us to be triply careful respecting its indications and its exhibition. In two fatal cases, a fluid state of the blood has been found after death.
As yet, very little has been done towards indicating the proper cases for resorting to ether, and those in which it should be avoided. There has been a general rush towards the operating room, such as the world has never before witnessed. Great numbers of cases were successful on its first introduction, and this gave an éclat to the subject, and induced a confident state of mind in patients, which has doubtless been an element in the successful results; but now that fatal cases have occurred, all that was mere prestige must [f]all to the [g]round; and unless the proper cases for etherization can be distinguished with something approaching to certainty, patients upon whom it may be used will go under the knife influenced by previous dread rather than confidence; and so an item of evil, not properly belonging to etherization itself, will come into play. Such is the constitution of the human mind, that a few fatal cases, even by the side of a great number of successful ones, will be sufficient to transmute hope into fear, confidence into timidity and mistrust. Probably the fatal cases which have become known have already produced this effect, and it is believed that many of our most eminent surgeons are declining the use of ether as much as possible. For the sake of etherization itself, then, something like a pause is required, otherwise it is to be feared that the old empire of pain will return, and if so, it will seem for the future doubly difficult of endurance, because of the hopeful promise that, in surgical operations at least, it was conquered for ever.
It may be said, that in the dangerous and fatal cases the ether was, unduly or improperly inhaled, -- and from an examination, it does appear that the ether was inhaled for a longer time than usual by some of the patients who died, -- but in none does it appear to have been inhaled longer than was necessary to produce insensibility, and in Mr. Robbs' case, if we may believe that reflex movements were not mistaken for movements of volition, complete insensibility was not present at any time during the operation. It would appear as though the ether occasionally followed an erratic course, not, as is usual, affecting the brain at all, but still going on to poison the spinal marrow and the ganglionic system, and to alter the condition of the circulating fluid. Indeed, so various have been the symptoms observed by different operators, that ether seems almost as volatile in its effects, as in its physical constitution.
In all I have said I am merely setting forth my individual opinion. I have given you the data upon which it is founded, and which, I believe, will stand the test of examination. I should observe, in conclusion, that Professor Simpson is far more sanguine than myself in his views of the application of ether to midwifery. His last paper upon the subject ends in the following terms: --
"I have stated that the question which I have been repeatedly asked is this: -- Will we ever be 'justified' in using the vapour of ether to assuage the pains of natural labour? Now, if experience betimes goes fully to prove to us the safety with which ether may, under proper precautions and management, be employed in the course of parturition, then, looking to the facts of the case, and considering the actual amount of pain usually endured, (as shown in the above descriptions of Merriman, Naegele, and others,) I believe that the question will require to be quite changed in its character. For instead of determining in relation to it whether we shall be 'justified' in using this agent under the circumstances named, it will become, on the other hand, necessary to determine, whether on any grounds, moral or medical, a professional man could deem himself 'justified' in withholding, and not using any such safe means, (as we at present pre-suppose this to be), provided he had the power by it of assuaging the agonies of the last stage of natural labour, and thus counteracting what Velpeau 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 in the human mother.
Baron Dubois concluded his address to the Academy of Medicine, as reported in THE LANCET, in less glowing terms:--"My profound conviction is, (he said,) that inhalation of ether in midwifery should be restrained to a very limited number of cases, the nature of which ulterior experience will better allow us to determine."More recent experience has certainly not been in favour of enlarging the limits of its applicability either in practical midwifery. In our own department there is good reason to believe, that after a short time, unless some certain mode of binding or disciplining this Prometheus shall be discovered, it will be rarely, if ever, used in difficult parturition or obstetric operations, and certainly never in natural labour. It will be a disappointment to have to turn from this promised good, but it is better to do so than to follow an ignis fatuus, if so it prove, to the neglect of real and scientific advancement. Let us hope that this glimpse of deliverance from this heavy infliction on humanity, may act as a stimulus to Science to continue her search after some certain and available relief from physical pain -- possibly a visionary search, -- but still one for which human nature will never cease to yearn.
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