In selecting the above as a subject of Thesis, I have particularly at heart, and am sympathetically mindful of the many disadvantages under which country practitioners have to labour over the exhibition of chloroform in midwifery cases.
Bearing in mind the great distances which frequebtly separate the residence of one rural practitioner from that of his proximate neighbour, the probable impossibility of summoning timely aid to an obstetrical operation is so apparent as to scarcely require to be dwelt upon. In towns, however, the circumstances :are .entirely different, and if a medical neighbour be on his rounds, or elsewhere, .when an urgent .call arrives, the messenger may only have to go down the next street to find another practitioner. But they country doctor may have to send a great distance and over á ¡ wild country, only to find perhaps that his friend is as many miles.a.way as himself at a case of a similar nature. All this time the patient may be suffering untold agony, and the exigencies of the case are,as:often as not, of such a kind that relief ought to have been given, or the child delivered, at the time when the messenger started upon his fruitless errand. The patient may now. have been :lying in a dangerous state, six or eight hours having perhaps elapsed before the messenger's :return from his futile attempt to secure assistance. Accordingly,'after all this precious time has been wasted, but two alternatives remain open to the physician in charge of the case, either (a) to deliver with forceps without chloroform (which often the i. patient will not - allow) the woman :already- debilitated, it may be to the danger- point, by an intense suffering that it would obviously be imprudent to aggravate, or (b) to wait probably a score of hours for the arrival of the medical neighbour alluded to as busily engaged in a similar- case elsewhere,with the result that the patient remains, as it were, between life and death for a considerabie part of-the subsequent convalescence. This sequel of a prolonged.: and difficult labour I have experienced more than once; but
2. particularly in a case of the kind which was, by force of unforseen and uncontrollable circumstances, such as described, and which was kept waiting for a day and a half. Now, if the chloroform had been given at the proper time, what a difference it would have made to; all .:patties .concerned,both during the. labour..and after it!
I am, of course, well aware of the rule.- time- honoured in its observance, and enunciated by anaesthetists of an experience that at once ,constitutes them :authorities .upon the subject - that chloroform.: is to be administered by a practitioner other than the one who delivers the patient with the ,instruments; the object being, obviously, to allow of the operator's undivided attention 'being devoted to his responsible and, in most cases, by no means easy manipulations. To adhere .strictly to this :rule, excellent as it may be, is, as :I think must be :apparent from: -the foregoing remarks, frequently impossible in country practice, at least in one so scattered as mine. It .therefor.e. behoves the rural practitioner to neglect no opportunity to accustom himself.. to the administration of anaesthetics in general and of chloroform in particular., so as to gain that confidence and :dexterity bred of ;experience, so that, in a complicated labour case he may be able to work entirely on his own initiative and without .assistance.
The indications for giving chloroform, at the proper .time are: ; (i) The patient is :so: much better-able when she is fairly strong to: withstand the :evil :effects.of the drug. (2) The patient makes a better recovery than would otherwise be the case. .(3) There is a. reduction in. the :amount of her sufferings which .under other .circumstances, :especially when no progress is being made, :would .have to be.. patiently;endured by the :woman. ...(4). In certain instances even a short delay may mean the death. of the :child or, may be, that of the mother as ::well. The following case..will serve to make this point clear: Late one .night, :I was .called to a confinement about :ten miles from my residence. On .arriving,..I found the patient, a stout, plethoric, multipara, had endured severe labour pains for over fifteen hours.: and was by this time in a very exhausted.. condition.On making the usual vaginal ..examination, I became. aware of the case being one of twins, and the presentation hand and forearm of one child protruding into the vagina and firmly interlocked with the head of the other child on the .brim of the pelvis. The
pains were of uncommon :severity, and the os uteri appeared to be in a:state of tonic contraction. Notwithstanding that the patient had ,a fatty and dilated :heart both usually ;;regarded as important contraindications to the use of the drug ,I forthwith decided in the patients interest, and without any assistance beyond that of an aged neighbour, to give chloroform. This done, I found it possible to push the head of the. presenting .child back into the uterus, and subsequently, and without using undue force, to return the arm and hand of the other child. I now found no :difficulty in successively turning both children hand delivering them by the breech. Both mother and children did very well afterwards.
This was obviously a :ease :in which every-moment was precious. There was absolutely no time : to send for extra medical aid, even .were such available; and, owing to the contracted state of the uterus, nothing could .be done until' the patient: was put under the influence of an anaesthetic.
