CHLOROFORM IN PARTURITION.
When the practice of inhalation in midwifery was first introduced by Dr. Simpson, he very naturally adopted the plan which is usually followed in surgical operations, making the patient unconscious at once, and keeping her so to the end of the labour. It was soon found, however, by other practitioners, that this is not necessary; and, indeed, it would not be safe in protracted cases. Drs. Murphy and Rigby were, I believe, amongst the first to state, that relief from pain may often be afforded in obstetric cases, without removing the consciousness of the patient; and I soon observed the same circumstance.[[150]] Some persons, indeed, have alleged that the pain of labour can always be prevented, without making the patient unconscious of surrounding objects; whilst others have asserted that no relief can be afforded unless unconsciousness be induced. But both these opinions are directly opposed to experience. There are comparatively few cases in which the suffering can be prevented throughout the labour without interfering with consciousness, although there are very many cases in which it can be in this way prevented in the early part of the labour. This difference depends, in some measure, on the constitution of the patient, but chiefly on the severity of the pain to be prevented. It is in accordance with what is observed in medical and surgical cases, that the pain should be removed, in some instances, without abolishing consciousness, and that in other instances it should not; for, in certain cases of neuralgia, the pain is so severe, that no material relief can be obtained by chloroform as long as consciousness is retained; and in surgical operations, although it now and then happens that the minor and concluding parts of an operation, such as tying vessels and introducing sutures, can be performed without pain, whilst the patient is consciously looking on, a free incision in the skin can hardly ever be made, under similar circumstances, without pain.
With regard to the cases of labour in which chloroform may be employed, it will be readily conceded that, in cases where the pain is not greater than the patient is willing to bear cheerfully, there is no occasion to use chloroform; but when the patient is anxious to be spared the pain, I can see no valid objection to the use of this agent, even in the most favourable cases. The benefits arising from chloroform in severe cases of labour are experienced in a lesser degree in favourable cases; and the patient may be fairly allowed to have a voice in this, as in other matters of detail which do not involve the chief results of the case. The determination of the kind of labours in which chloroform should be used, or withheld, is really a matter of not much importance, because, as we pass from cases that are severe and protracted to those which are short and easy, the quantity of chloroform that is used, and the amount of diminution of the common sensibility, and of interference with the mental functions, become so trifling, that very little remains about which to hold a discussion. Indeed, from what I have observed of the continued use of this agent in medical cases, and its use by healthy persons for experiment, I believe that the quantity which is inhaled in a short and easy labour might be continued daily for an indefinite period, without appreciable effect on the health.
The above remarks apply also, in some measure, to the question as to the period of the labour when the exhibition of chloroform should commence; for, in proportion as the pains are feeble, it must be more sparingly administered. The most usual time when the accoucheur and I have determined that the inhalation should be commenced, has been when the os uteri was nearly dilated to its full extent, and the pains were taking on an expulsive character. In many of the cases which I have attended, it has, however, been commenced much earlier; for the suffering caused by the dilating pains in the first stage of labour is often very great, and the chloroform is consequently of the utmost service when employed at this time.
As regards the manner of giving chloroform, I shall first allude to cases not requiring manual or instrumental assistance. In such cases, when it has been determined to resort to inhalation, the moment to begin is at the commencement of a pain; and the chloroform should be intermitted when the uterine contraction subsides, or sooner, if the patient is relieved of her suffering. It is desirable to give the chloroform very gently at first, increasing the quantity a little with each pain, if the patient is not relieved. The practitioner easily finds, with a little attention, the quantity of vapour which it is desirable to give at any stage of the labour, and in each particular case; his object being to relieve the patient without diminishing the strength of the uterine contractions and the auxiliary action of the respiratory muscles, or with diminishing it as little as possible. At first, it is generally necessary to repeat the chloroform at the beginning of each “pain”; but, after a little time, it commonly happens that sufficient effect has been produced to get the patient over one or two uterine contractions without suffering, before it is resumed.
The external evidences of the uterine contractions continue as before, when the patient is rendered unconscious by chloroform; and the muscles of respiration are called freely into play, to assist the action of the uterus in the second stage of labour. The aspect of the patient under these circumstances, is generally that of one who is suppressing the expression of her sufferings; and any relative or friend who comes in, without knowing that chloroform has been given, begins to praise the unconscious patient for her fortitude. On some occasions, indeed, there are groans and cries, as of suffering; but the mind being unconscious of pain, it can hardly be said to exist.
It may be remarked, that complete anæsthesia is never induced in midwifery, unless in some cases of operative delivery. The diminution of common sensibility to a certain extent, together with the diminution or removal of consciousness, suffice to prevent the suffering of the patient during labour; and she never requires to be rendered so insensible as in a surgical operation, when the knife may be used without causing a flinch or a cry. The nerves of common sensation must be allowed to retain their functions to a certain extent during labour; otherwise the assistance of the respiratory muscles, which consists of reflex action, or “motion arising from sensation, without the aid of volition”, would not take place, even if the contractions of the uterus should still continue.
The effects of chloroform on the brain should not be carried during labour beyond what I denominate the second degree of narcotism, or that condition in which the mental functions are diminished, but not altogether suspended, except when the effect of the vapour is associated with natural sleep. The patient under the influence of chloroform to this extent, has no longer a correct consciousness of where she is, and what is occurring around her, but is capable of being aroused to give incoherent answers, if injudiciously questioned. In this state, the patient will sometimes assist the labour by bearing down voluntarily, if requested to do so, and be otherwise obedient to what is said; and by withholding the chloroform for a few minutes, she at any time becomes quite conscious. As a general rule, it is desirable not to hold any conversation whilst the patient is taking chloroform, in order that her mind may not be excited. The plan mentioned above, of giving the chloroform very gently at first, also has a tendency to prevent its causing mental excitement, the patient coming gradually under its effects. In surgical operations, excitement of the mind can nearly always be avoided by carrying the patient pretty rapidly into a state of insensibility, in which the mental functions are necessarily suspended. But in the practice of midwifery, it is not allowable to cause a state of coma or insensibility, except in certain cases of operative delivery, hereafter to be mentioned.
I nearly always employ, in obstetric cases, the inhaler that I use in surgical operations. There is not the same necessity for an accurate means of regulating the proportion of vapour in the air which the patient is breathing during labour, where but a trifling amount of narcotism requires to be induced, as in surgical operations, where a deeper effect is necessary; still I find the inhaler much more convenient of application than a handkerchief, and it contains a supply of chloroform which lasts for some time, thereby saving the trouble of constantly pouring out more. When I do administer chloroform on a handkerchief during parturition, I follow the plan of putting only ten or fifteen minims of chloroform on the handkerchief at one time.
The quantity of chloroform administered during any one pain, never exceeds a very few minims; but the quantity used in the course of a protracted labour is often considerable. I have several times used from four to six ounces; and in one case, at which I was present the greater part of the time, seventeen fluid ounces of chloroform were used with the inhaler, which would produce as much effect as three or four pounds used on a handkerchief. The inhalation was continued with intermissions over a period of thirty-one hours. The patient was unconscious during the greater part of the last five or six hours, but previously to this, her constant complaint was that she had not enough chloroform. She was the wife of a physician, was thirty-seven years of age, and in her first confinement. The membranes ruptured early. The labour was natural, but there was excessive sensibility. The first twenty-six hours of intermitted inhalation were during the first stage of labour.
Chloroform can be best applied when there is an additional medical man, who has not to attend to the ordinary duties of the accoucheur; but it can be given very well by the accoucheur himself, so as to save the greater part of the suffering of labour; although he perhaps cannot always administer it in the perfect way in which he could, if he had no other duties to divide his attention.
It is probable that the use of chloroform has no particular influence over the duration of labour, in the whole number of cases in which it is employed; but individual labours are occasionally either retarded or quickened by it, according to circumstances. In some cases, the chloroform, even when very moderately employed, diminishes both the strength and the duration of the uterine contractions, and prolongs the interval between them, thereby making the labour somewhat longer—a matter of no consequence, however, as the patient is not suffering in any way. In other cases, the inhalation causes the uterine action to become stronger and more regular, by removing the excess of sensibility by which it has been interfered with. This occurs more particularly in the first stage of labour. In some cases, also, the chloroform seems to act as a direct stimulant to the uterine contractions, increasing their force and frequency—a circumstance at which we need not be surprised, when we remember that both opium and brandy, in moderate quantity, often act in the same manner. Chloroform has also the effect of promoting the dilatation of the os uteri in many cases, even when no rigidity exists; and when there is rigidity of the os uteri, the inhalation is of the utmost service, and shortens labour very much. This is the case, also, when there is rigidity of the perineum.
When the forceps have to be applied, it is desirable to make the patient insensible, as if for a surgical operation just before they are applied; and to leave off the chloroform as soon as they are introduced, in order to allow of the uterine action to return, and assist in the delivery. I have always found the action of the uterus return immediately after the forceps were introduced; and where the child was not delivered at once, I have continued the chloroform in sufficient quantity to keep the patient unconscious, whilst allowing the uterine contractions to continue.
I have administered chloroform on nine occasions in which the forceps were applied; in four of the cases, I was sent for in consequence of the operation being required; and in the other five cases, I was in attendance from an early part of the labour, and had administered chloroform more or less for some hours before the forceps were applied. They were applied in three instances by Dr. Murphy, twice by Dr. Ramsbotham, and in the other cases by Drs. Farre, Frere, and Thudichum, and Mr. Peter Marshall.
I have administered chloroform in two cases of craniotomy, both of which were performed by Dr. Murphy, on account of deformity of the pelvis. The amount of chloroform scarcely requires to be increased during this operation beyond what would be given according to the strength of the pains which may be present at the time.
In the operation of turning the child, the mother requires to be made quite insensible, in order that the uterine contraction may be entirely suspended till the legs of the child are brought down, when the inhalation should be discontinued to allow the contraction of the uterus to return. I have notes of six cases of turning the child, in which I have administered chloroform. The first case, which occurred in 1848, was one of natural presentation, in which turning was performed by Dr. Murphy, on account of narrowness of the pelvis, and the impossibility of applying the forceps; the introduction of the hand was difficult on account of want of space, but the uterus offered no resistance. Dr. Murphy has related the case. Three of the other instances of turning were performed by Mr. French, in cases which had been attended by midwives, and the membranes had been ruptured for several hours. The shoulder and part of the chest were in each case pressed down into the pelvis, and the pains were very strong; yet under a full chirurgical dose of chloroform, the child was turned as easily as if the membranes had not been ruptured. In the first of these three cases, the child was dead before the operation commenced. In the other two, it was born alive. In the last case, the membranes had been ruptured for ten hours before the operation was performed. After the child was delivered, there was found to be a second child presenting naturally, but I did not stay to give any more chloroform. The fifth case of turning was performed in a case of elbow presentation by Mr. Peter Marshall. The membranes had been previously ruptured. I administered chloroform, also for Mr. Marshall, in a case where the hand was presenting below the head; he raised it above the head, and as it did not come down again when the pains returned, the labour was allowed to pursue its natural course, and terminated favourably in two or three hours, the child being alive. The chloroform was not continued after the operation was performed. The remaining case of turning was performed by Mr. Tegart, of Jermyn Street. I was in attendance with him from an early stage in the labour, and the operation was performed before the membranes were ruptured.
I administered chloroform, in 1849, in a case in which Dr. Murphy had to make an artificial os uteri. The patient was, of course, made quite insensible as for any other surgical operation; and the vapour was continued afterwards in a modified degree till the labour was completed.
On December 26th, 1850, I was requested by Mr. Cooper, of Moor Street, Soho, to assist him in a case of retention of the placenta. The patient had given birth to a child two hours before, and Mr. Cooper had introduced his hand, but had been unable to bring away the placenta, on account of firm contraction of the uterus in a sort of hour-glass form. On the chloroform being administered, the hand was easily introduced, and the placenta detached, and extracted. There was very little hæmorrhage.
In some of the many cases at which I have met Dr. Cape, premature labour was induced about the eighth month of utero-gestation, by rupturing the membranes, on account of deformity of the pelvis.
In a case attended by Mr. Cantis, the patient was suffering from osteo-sarcoma of the bones about the shoulder. Dr. Ferguson was present during the latter part of the labour. The lady lived a few weeks after her confinement.
A patient, attended in her confinement by Mr. Colambell of Lambeth, in 1853, to whom I gave chloroform, had been long under the care of Dr. Williams with cavities in the lungs. I heard very lately that she was still living.
A patient of Mr. Robert Dunn, to whom I gave chloroform in her confinement, was at the time in a state of insanity.
In one of the patients whom I have attended with Dr. Arthur Farre, there was separation of the recti muscles of the abdomen; which there is no doubt must have taken place gradually during pregnancy. The patient was but twenty years of age, and in her first labour. Quite early in the labour, before the pains were at all strong, Dr. Farre and I observed that the abdomen was of a peculiar form, the uterus projecting very much forwards, whilst there was a slackness in the flanks. The abdominal muscles did not assist the pains at all; and it was probably from this cause that the labour progressed slowly and was terminated at last with the forceps. The recti muscles recovered their position by careful bandaging.
The chloroform has always been left off as soon as the child was born, but a little has been administered again on several occasions during the expulsion of the placenta. The placenta has generally been expelled very soon in the labours in which I have given chloroform; usually in about five minutes. There has hardly ever been uterine hæmorrhage of any amount, except in patients who had suffered from it in previous labours. In a case attended by Mr. Nathaniel Ward, however, there was a slight hæmorrhage before the birth of the child, and about an hour afterwards there was a considerable hæmorrhage which made the patient feel rather faint for some hours. She afterwards went on favourably, however. She was a young woman who had had several children.
A patient, to whom I was recommended by Sir John Forbes, inhaled chloroform in three confinements. She recovered favourably from the two first; but on the third occasion, after going on favourably till the fifth day, she was attacked with puerperal fever, and died on the seventh day from her confinement.
I am not aware that more than one death has been recorded as having occurred from chloroform during labour; and this took place in England, in 1855, when no medical man was present.[[151]] The patient had inhaled chloroform in America in a previous labour; but her medical man, on the last occasion, who was her particular friend, forbad that agent, and said that if she was determined to have it, he would not attend her. She procured chloroform unknown to him, and a number of scents to put on her handkerchief and hide the odour of it from him. He went to bed in the house, and was not called up till his patient had been dead about an hour. The monthly nurse, who had procured the chloroform for the patient, said that she snored very loudly for an hour after she fell asleep. About five drachms of chloroform were used from the bottle, and the handkerchief from which it was inhaled remained close to the patient’s face till she died. The death seemed to have taken place very slowly, and the monthly nurse was extremely stupid to allow the patient to die. It may also be remarked that the accident would not have taken place except for the medical man’s extreme objection to the use of chloroform.
The chloroform has been occasionally blamed by the friends of patients, or medical men opposed to its use, in cases where patients have died from puerperal convulsions or other causes, so long after the vapour had been left off that it could not be the cause of death. The following case shows how easy it would be to make a mistake with respect to the effects of chloroform. Soon after its introduction, I was requested to administer it to the wife of a medical man who had a great desire for it in her confinement. Mr. Propert was to attend the lady. I was sent for late one evening, but as there were no pains at the time when I arrived, I was requested to go to bed in the house. After a time, I was called by a servant, who told me that the baby was born, and that Mr. Propert was sent for. I found that the birth had been so sudden that the husband, who was in the room, could not get to the bed side before the child was born. Mr. Propert arrived, and I went home, leaving the patient very well. Mr. Propert informed me, that after I left the patient went into such a state of syncope as to make him think she was going to die, and continued so for some time. She ultimately recovered. There was no hæmorrhage or any other cause to account for the faintness, and I understood Mr. Propert to say, that if the patient had inhaled chloroform, he should have blamed it for the condition into which she lapsed.