No individual practitioner has employed this agent so extensively or so successfully as Prof. Simpson,* and any observations of his on this subject merit especial attention. He furnishes the following directions on the subject: - The two main difficulties, he observes, are to keep the patient in a state unconscious of pain, and yet not so deeply anaesthetized as to have the uterine action interrupted; lor too deep a state of anaesthesia, in general, interferes with the force and frequency of the uterine contractions; while a lesser degree of the anesthetic state leaves the contractions unaffected; and in a still smaller dose it often excites and increases them. The influence of the inhaled agent passes off in a few minutes; and if at any time the anAesthetic effect be too deep, and the uterine actum in consequence impeded, all that is necessary is to abstain from exhibiting the Chloroform for a short time, till the parturient contractions have been allowed to come back to their proper degree of strength and frequency; and then the Chloroform may be given as before, by employing the vapour at every recurring pain, but in smaller doses, and for a shorter time than was previously practised.
The quantity of Chloroform required varies both according to the duration of the labour, and the sensibility of the patient. Usually, when the handkerchief is used, about an ounce an hour is necessary; a small quantity being poured upon it from time to time. A less quantity will succeed in some, and others require more. The first quantity which Dr. Simpson pours on the handkerchief is from three to four drachms; but he adds, " I always judge by the effects, not by measuring the dose, and I pour on an additional quantity in a minute or so if it be required. In holding the handkerchief towards the patient take care that plenty of atmospheric air is admitted, and never put it in contact with the face." He adds further, " I have usually begun the employment of Chloroform when the os uteri was well dilated, or towards the termination of the first and the commencement of the second stage of labour; but when the pains were severe, I have commenced it earlier, and when the os uteri was still comparatively little dilated. There is, I believe, no limit to the date at which we may give it." To these valuable instructions of Dr. Simpson's we may add that the dose should be administered at the commencement of each pain, and the dose increased when the head is passing over the perinAeum. Although the quantity employed must be regulated by the effects produced, it is always advisable to measure the dose, in order that the practitioner may judge of the proportion between the effects and the dose, which may serve, in a degree, as a guide for its administration in other cases. It must be remembered that in using the handkerchief a large quantity of the Chloroform is wasted. If an inhaler be employed, a very much smaller quantity will produce the desired effect.
* Treatise on Anaesthetic Midwifery, p. 16, et seq.
From the observations of Prof. Simpson, it appears that he induces complete insensibility at first, and keeps up just so much of the effect as he deems advisable. Dr. Rigby, Dr. Snow, and others prefer commencing with small doses in natural labour, and increasing them if necessary; but when manual assistance is required, it is better to place the patient under the full influence at once. Dr. Beatty* observes that, in lingering labours with insufficient pains, the use of Chloroform may be beneficially combined with that of the Ergot.
[The following are the rules for the use of Chloroform in Midwifery laid down by the Committee of the Royal Medical and Chirurgical Society,
(a) In Natural Labour. - The careful administration of Chloroform during labour is not attended with special danger, there being. either in this country or abroad, so far as is known to this committee, no well-authenticated instance of sudden death where it has been given by a medical practitioner; but the occasional occurrence of unfavourable symptoms demands the exercise of caution during its employment. Administered in a moderate degree, it does not, as a rule, weaken the expulsive powers, and is decidedly beneficial in promoting dilatation of the maternal passages. It does not predispose to puerperal convulsions or other like complications. The balance of opinion is nearly equal as to whether it predisposes to imperfect contraction of the uterus after delivery. As a rule, it in no way retards the convalescence of the mother, nor has it any tendency to interfere injuriously with the function of lactation; nor has it any injurious influence on the child.
(6) In Abnormal Labour. - The anaesthetic may be employed with advantage in various obstetrical operations - as forceps, turning, craniotomy, and extraction of retained placenta - unless the patient is much enfeebled by haemorrhage; when, if given. it ought to be accompanied by the use of stimulants. It may also be employed advantageously to check the paroxysms in puerperal convulsions.
(c) Ax to the preference of Ether. There are no reasons for giving preference to Ether over Chloroform, the latter being much more desirable in obstetrical practice generally, the only exceptions being those in which Chloroform notably disagrees.
In addition to the rules given for its administration in ordinary cases, it is generally desirable to observe the following rules during its administration in labour, subject to modifications at the discretion of the practitioner: - In natural labour, begin to give it generally at or after the termination of the first stage; but it may be given earlier if the first stage is unduly painful, or if the os uteri resists dilatation. Give it only during the pains, and withdraw it in the intervals. When the foetal head bears on the perineum, give it more freely to promote relaxation and relieve the increased pain. Withdraw the Chloroform immediately after the child is expelled. If the patient is depressed or the pains are sluggish during its administration, an occasional stimulant may be administered. In cases where it seems to interfere with the progress of labour it may be necessary to suspend its use for a time, and re-apply it after an interval, or even to withdraw it altogether. In turning and instrumental deliveries deep anaesthesia must be induced, as in surgical operations, and the administration should then be entrusted to a competent person, whose sole duty should be to attend to it. In midwifery a special inhaler for its administration is not generally necessary or desirable, a handkerchief or towel, so folded as to prevent blistering the face and to allow free admixture of atmospheric air, being sufficient for the purpose.]
* Dublin Quarterly Journal, Aug. 1880.
Med. Times and Gazette, July 16, 1864.
840. As a mean* of Diagnosis in Spurious Pregnancy, the importance of Chloroform was first pointed out by Professor Simpson,* who remarks that, "generally speaking. Chloroform will in any case of doubt solve the difficulty completely, if only given deep enough. When the patient is fairly put to sleep with Chloroform, the tense abdominal muscles become perfectly relaxed, and on pressing on the abdomen you will find that the walls will give way before your hand, and sink backwards till you can feel the spinal column quite distinctly, and you will then find the uterus to be of the normal size." The examination should be made whilst the patient is fully under the influence of the anaesthetic; for when she comes out of her sleep again, in a case of spurious pregnancy, the muscles begin to contract and to become tense as before, so that by the time the patient is fully awake, the abdomen is as large and rounded as before. The value of anaesthesia as an adjuvant in aiding and establishing a correct diagnosis in such cases cannot be overrated.
841. The Objections which have been urged against the use of Chloroform in Midwifery by Dr. Gream and others, are - 1, that anaesthesia from these agents (Chloroform, Ether, &c.) is no more or less than drunkenness; 2. that it gives rise to indecent dreams, expressions, and actions; 3, that it induces convulsions; and 4, that it may cause death. The force of these propositions has, however, been weakened by the almost unanimous evidence of those who have employed these agents the most extensively.