from The Lancet Jan 1848, p.10-11
On the use of ether and chloroform in surgery and midwifery
by J. G. Lansdown, MRCSE, surgeon to the Bristol General Hospital.
The recent discovery, by Professor Simpson, of the anaesthetic effects produced by the inhalation of chloroform, will no doubt prove a great boon, not only to the public generally, but especially to those medical men who may think fit to apply its use practically. For my own part, I consider myself much in debt to get it to the professor, not merely for the discovery he has made, but also for his great kindness in so early forwarding to me an account of it.
I did not fail to take the first opportunity afforded me of testing its qualities, and I have found that the experience of my own practice fully bears out its properties, as described by Professor Simpson, and the advantage of the chloroform over ether, which he has stated to be case in his pamphlet, the greater part of which appeared in THE LANCET for Nov. 20th.
I have used it several times to relieve pain in natural labour, in operations, and in tooth-drawing; also for the reduction of strangulated hernia, and in a case of delirium tremens. Each time I have used it I have found the effects produced more suddenly than they can be with the ether and that the state of sleep can be continued for a much longer period without a renewal of the inhalation, should such be desired, as in performing operations about the mouth, when a renewal of the vapour may be impracticable. It is also by many considered exceedingly pleasant in taste. This, added to the peculiar state of quietude or happiness which many experience during the period they are under its influence, renders it inhalation of thing to be desired rather then dreaded, or, at the best, to be taken as the alternative against the suffering of pain. One lady, to whom I was administering it in natural labour, having been in come a complete state of rest for about two hours, aroused only by its return of the uterine contraction, when they her she would make signs for a renewal of the inhalation, remarked, at a time when her friends, thinking she was fast asleep, were indulging in a little talk, - “ I enjoy it more when you are quiet, ” - thereby implying that she was not suffering from the pains of her labour, but that she was actually enjoying the happy state of the repose into which she was thrown by the chloroform. She inhaled 2 drachms and 40 minims in three hours 10 minutes. The rapidity with which it takes effect of renders it peculiarly applicable to obstetrics practice. In such cases the patient is insensible with the chloroform in 10 seconds, while with ether the usual average is 25 seconds. Thus it being more speedy in its actions, a less quantity is required to be taken previously to the pain coming on with its full force, after it has given the patient the warning of its approach, thereby allowing her to be insensible to pain before the time arrives for her to cry out; whereas, when inhaling the ether, should the action of the uterus assume its full force before insensibility is produce, the patient will sometimes cry out instead of continuing the continuing to inhale. In the case of strangulated hernia, an old lady of seventy-two was completely insensible in half a minute, when the tumour, which before had been exceedingly tense, became perfectly soft, and the slightest pressure returned it immediately. The patient in delirium had taken six grains of opium, divided into three doses, in the course of 12 hours. Two of these doses I had myself given, therefore I knew they had been duly administered. Seven hours after the last dose had been taken, no sleep had been procured, and I covered his nose and mouth with a cloth, upon which I had thrown 45 drops; in half a minute he was asleep. Quiet having been once obtained, the opium took effect, and he slept for four hours, awaking perfectly quiet and rational; and now, four days since he took it, he is quite well, and has required no medicine.
The use of ether having been superseded, it would appear now to be almost useless to mention those cases which have occurred in our practice; but as the chloroform is a very similar agent, it may not be amiss to mention some in which I have used it, and the extent to which I have at times carried it amongst my obstetric patients. My practice being of a mixed character, and not paying more attention to the midwifery then to the surgical department, I cannot be expected to have used it so frequently in that class of practice as others who have paid exclusive attention to that branch of the profession. Upon one occasion of a labour, I went on imperceptibly hour after hour not thinking how time was passing, until my patient had been inhaling the ether for eleven hours and a half and intervals of about five minutes apart and had consumed fourteen fluid ounces of ether. Not a bad symptom followed: there was neither headache nor anything else unpleasant; but she was the next day very well, having herself been spared the knowledge, and her system the shock, of what would otherwise have been a very painful and tedious labour of twenty-eight hours’ duration. Having mentioned this one, the others I have given the ether three or four hours and upwards, which I have done in several instances, must sink into the shade. I have never had occasion to regret using the ether in my midwifery practice, which I they have had much more rapid recoveries than is usual upon ordinary occasions. I find the uterus sending out the placenta immediately after the expulsion of the child, and there have been scarcely been any haemorrhage following. Since I commenced my practice in 1828, I have seldom gone to a labour without my tincture of ergot in my pocket; not with the intention of using it during labour, - a mode of practice which, when employed indiscriminately, by way of hurrying the labour, cannot, I think, be too much condemned, - but for the purpose of suppressing haemorrhage after the expansion of the placenta, should such occur. I have now quite forsaken my little bottle for the ether, which in its turn must make way for the chloroform. But the state of the perinæum is a thing which has forcibly struck me while using the ether; that has invariably relaxed before the head has come to bear upon it, thereby not requiring the pressure of the head to force it open and to lacerate it, as was frequently the case where left to itself in the old mode off practice. This advantageous quality I have not observed by using the chloroform, the parts under its use continuing unaffected by it; neither have I found the action of the uterus, when in the sluggish state, induced by the chloroform as it is by the ether.
In the case of strangulated hernia, in which I have used the ether, the result was similar to that I have before mentioned while speaking of the chloroform. The ether was much longer in producing its effect, the man being unwilling to inhale; therefore in such cases the chloroform is to be preferred, for the reason, that should be inhalation be opposed, the effect is so much more rapidly produced, that the patient becomes narcotic before he is aware it. I have also freely given the ether in the case of tetanus, accompanied by trismus, which has lasted three weeks; the only thing by which the mouth could be opened was with the inhalation of ether. The poor fellow has struggled through it thus far, and the trismus has now nearly left him. I hope to report this case at length in THE LANCET, when I shall have time to do so. Dr Protheroe Smith, in the perusal of whose letters I have felt much interested, in his paper on chloroform, inserted in THE LANCET of Nov. 27th, has so worded his last paragraph but one, that it may by many be understood that he was the first who recorded in the pages of THE LANCET his experience of the use of ether in obstetric cases in England. If I am so to read it, I must beg to correct him. I am quite aware that his was the first case in which it was used in England, but mine following immediately after, was recorded in THE LANCET of April 24th, one week previous to Dr P. Smith's announcement; and if there is any honour of being the first to have used it in natural labour in England, I may claim that and its publication also, as my first case of natural labour took place on April 7th - Dr Smith's April 27th.
While writing the foregoing, I was called at half past 6 p.m., December 2nd, to Mrs H., a fine robust woman, aged 28, in labour with her first child. I found the os uteri fully dilated, the head presenting in proper position, and every probability of a speedy delivery. At five minutes past seven I commenced using the chloroform; the labour proceeded slowly, but naturally. At eleven the head was at the outlet, and I expected that child would soon have been born; but the head continued in the same position, not pressing against the outlet, but remaining steadily there. By half past four the following morning, having exhausted my entire stock of chloroform, I went home for some ether, which she commenced to inhale at twenty minutes past five and continued to do so until twenty-five minutes past twelve p.m. when, everything being favourable, with plenty of room for the application of the forceps, I introduced them, and in five minutes from the commencement of the inhalation for that purpose, the child was brought away alive and well. In a few minutes she was awake, and was astonished to hear the child cry, not being aware that she had been delivered by means of instruments. The ether was used seven hours and ten minutes, making a total of sixteen hours and a half during which she was having the chloroform or ether. In this case I particularly remarked that the chloroform acted merely as an anaesthetic agent; it neither increased the force nor the frequency of the action. I will not say positively that it arrested the action, but I sometimes almost fancied it did so. After eleven o'clock when the head came to the outlet, the vagina continued in the same condition as before, and towards the close of its use the vagina and surrounding parts were hot and dry, as they would have been in protracted labour without the chloroform. No sooner, however, did she commence to inhale the ether, then the action of the uterus was more frequent and lasting, the vagina gradually gave way and the parts assumed a more favourable condition, moisture taking the place of dryness and heat, which before was so marked; and when introducing the blades of the forceps, they passed in without any opposition from the sides of the vagina. During the inhalation she was not once sick, neither was she uncomfortable in any way. Today, December 4th, she is as well as she would have been under the most favourable description of labour.
I may remark, that out of 111 cases in which I have used the ether, only four have been sick, and two of those were persons to whom I exhibited it in natural labour.
St James's Square, Bristol, December, 1847