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From the above date the cases reported in the countries of England, Scotland and France were numerous. It was on February 10, 1847, that Simpson laid this subject at some length before the Obstetrical Society of his own city, and presented the lessons derived from his experience, and to show you how clear and concise were his first utterances upon this most important discovery, I here produce his conclusions:

First: That the inhalation of ether procured for the patient a more or less perfect immunity from conscious pain and suffering attendant upon labor.

Second: That it did not diminish the strength or regularity of the contraction of the uterus.

Third: That on the other hand, it apparently (more especially when combined with ergot) sometimes increased them in severity and number.

Fourth: That the contractions of the uterus after delivery seemed perfect and healthy when it was administered.

Fifth: That its employment might not save only the mother from more pain in the last stage of labor, but its use might probably save her also in some degree from the occurrences and consequences of the nervous shock attendant upon delivery and thereby reduce the danger and fatality of childbed.

Sixth: The exhibition of anesthesia did not seem to be injurious to the child.

The gist of these conclusions of this distinguished writer lies in the second proposition, that the contraction of the uterus was not diminished by the exhibition of the anesthetic and also that no deleterious influence was exerted by the anesthetic.

Ether was the anesthetic first employed, in 1847, and after a few months chloroform was employed by the same surgeon in obstetrics. Almost immediately, for various reasons, chloroform became largely the anesthetic employed, notwithstanding the dangerous symptoms that were occasionally shown by its use.

The third period in the history of this subject comprises the active contest to the application of an anesthetic in normal labor. Those of you who have been interested in this subject know what a long and bitter controversy was awakened in the profession at home and abroad, and the storm of hostility that was aroused by the persistent efforts of the ultraenthusiasts over the introduction of chloroform in normal labor. Upon the one side was the firm conviction of right and a noble impulse to benefit humanity; upon the other a caution, a wholesome fear of interference with a natural process, and a dread of powerful medical agents unless life was in danger. Let it be remembered though that during all this controversy there was a singular unanimity in regard to the use of anesthetics in all cases of obstetrics requiring surgical interference, no discordant note was heard.

Those who opposed the exhibition of chloroform in normal labor advanced the theory that the mother, not having suffered in giving birth to her child, the maternal instincts would be lessened or abolished; that the practice was immoral; that etherization was similar to intoxication and there was drunkenness; that the pains of childbirth were physiologic in character and soon recovered from; that there had been an increase in the mortality in the cases of labor where anesthesia was given; finally, and more potent an influence probably than all the others, it was charged that anesthesia was a sacrilegious attempt to set aside the decrees of Providence; and that it was an impious interference with the awful majesty of divine justice which had sentenced woman to suffer the pangs of childbirth.

No one will doubt that the administration of anesthesia in normal labor was a wonderful innovation and did great violence to long-cherished opinions. Though those brilliant medical minds who had been first to administer anesthetics in labor were not dismayed at their arraignment by their more conservative brethren, but of all the obstetricians of that day who believed in the use of anesthetics, none wrote more effectively of the good effects of its use than did Sir James

Y. Simpson, who had thus far fought the battle almost single-handed. He was ingenious in argument, apt in illustration and beyond question a lover of controversy. He showed from medical history the opposition to other medical advances, such as the discovery of the blood, of vaccination, and of the fatal effects of pain per se when long continued; he was ably sustained by strong men in our own land. The name of Channing was a tower of strength to the advocates of anesthesia in normal labor, and his classic work, which was published in 1848, placed its author in the same class with Simpson. No one circumstance had such a worldwide effect upon this famous discussion of the use of anesthesia in normal labor as the acceptance of it in 1853 by the Queen of England, who permitted her attending physicians to use chloroform in her seventh confinement. The eminent success attendant upon this proved a great incentive throughout England, and indeed all Europe was ready to receive the great boon.

The administration of anesthesia in obstetrics may be divided into two classes--that of the exhibition of it in difficult labor, involving turning and forceps delivery—and in the use of it in normal labor. No one here will for a moment question its efficiency or its usefulness in the first class, but in the second class-that of anesthesia in normal labor without any complications-I think many seriously question its usefulness in the first stage of labor. Some very excellent practicians, however, make use of it in cases where a rigid os is encountered; but my practice is to wait, or give a full dose of hydrate of chloral, which usually answers all purposes.

In the second stage, where the pains are strong and the patient possibly weak from the protracted labor, it is my custom to give chloroform intermittently until the head is born, believing that many lacerations of the perineum are prevented by the exhibition of an anesthetic in this stage. This is not the time to discuss with you the choice of anesthetics, for we will all concede that chloroform is pre

eminently the anesthetic to use unless there are contraindications for not using it. The danger of anesthesia in labor is very greatly diminished by the intelligent administration of the same. The giving of it during pain only renders the danger almost nil, and gives to the patient exhilaration as well as relief from immediate pain. To hold a patient in a state of analgesia is a difficult and delicate task, requiring the closest watch and constant attention.

The late Prof W. T. Lusk is very happy in his remarks bearing upon this. He says, speaking of the more general use of anesthesia in labor : "That the hesitancy is in a measure due to the fact that few practitioners give themselves the trouble to master the necessary modus operandi, to study the limitations of their usefulness, or to learn the conditions of their safe administration." The same author also says: "It should be steadfastly borne in mind that the giving of anesthetics in labor is an art to be acquired, a very simple one perhaps, but the practice of which admits of neither ignorance nor carelessness." These words are full of meaning to all of us and should be earnestly considered in this discussion.

In closing this paper, the central thought I wish to leave with you is embodied in the words just quoted, together with the following: the indications for administering the anesthetic, when to give it and the degree to which it can be given with safety to the patient in normal labor, with a thought always for the safety of the mother and the child.

When to Use the Forceps

By FRANK S. CLARK, A. M., M. D., Cleveland

The time-limit of ten minutes makes it impossible to enter very fully into the discussion of the subject assigned me. My presentation of it will be more from a practical than theoretic standpoint. As we are more frequently confronted with the need of choosing between forceps and version than

the major operations, this will receive more attention than the wording of the subject may seem to justify.

It is a wise obstetric aphorism which says, "Wait till you see what Nature can effect—not what she can endure,” but unfortunately this is too often forgotten. The gynecologist will tell how often he must operate because of the injudicious or unskillful use of forceps, for it is an instrument that, while it can save many lives and stop untold suffering, is in the hands of many most destructive.

To answer the question, asked by the title of this paper, in the negative, the forceps should never be used till the membranes are broken, a self-evident truth not necessary to state if such attempts had not been made in the past. The os must be dilated or easily dilatable and the head engaged. To these two conditions there are occasionally justifiable exceptions which will be referred to later. If the child is dead, forceps should not be used unless the head is low down and can be easily delivered. Perforation alone is justifiable in difficult cases under such circumstances. Forceps are never justifiable to save the time of a physician.

To answer the question in the affirmative, forceps should be used whenever the life of either mother or child or both is endangered. On the part of the mother this may be sudden or gradual, resulting from hemorrhage, eclampsia, a debilitated condition from acute or chronic disease, or simply from a too-prolonged labor. On the part of the child a weakening pulse and prolapsed cord require interference.

Before taking up the more generally recognized causes for using forceps, I wish to refer to the indications for forceps seen in the character of the fetal heart, which is so frequently disregarded. I doubt not that the life of many a stillborn child could be saved by an earlier application of forceps, if during the progress of labor close attention had been given to this indication of danger. Seldom have I found, when asked to see a case in consultation, that the fetal heart has been systematically examined or

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