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Chloroform as an obstetrical anesthetic
CHLOROFORM
AS AN OBSTETRICAL A Report
ANESTHETIC*
of 13,3Q!2 Cases
CAMERON DUNCAN, M.D.,t JOSEPH F. HIND&IAN, M.D., HAROLD W. MAYBERGER, M.D., BROOKLYN,N.Y. (From
St. John’s
Episcopal
AND
Hospital)
‘I’ IS the purpose of this paper to state our clinical experiences over a thirtyyear period with chloroform as an obstetrical anesthetic, pointing out our success with it in contrast to the detrimental reports commonly circulated. I
Material The records of 22,724 consecutive deliveries at St. John’s Episcopal Hospital from June, 1924, to Dec. 31, 1954, inclusive, have been reviewed. Of this total number, 17,737 patients received chloroform alone as their obstetrical anesthetic; 565 received chloroform in combination with some other agent, making a total of 18,302 patients who received chloroform during delivery. During the same years, 3,671 patients were delivered with other agents as obstetrical anesthetics, and 751 patients were delivered with no anesthesia. In the 18,302 cases in which chloroform was administered for delivery, there were 7 deaths, none directly attributable to the use of chloroform as an anesthetic agent. Case Reports These 7 deaths are listed briefly : 1. 1940. A 45year-old Negro primipara with multiple fibroids who died on the fifth postpartum day of septicemia. 2. 1940. A 25-year-old white primipara who died 7 hours post partum of hemorrhage. 3. 1941. A 27-year-old white primipara who died on the forty-third postpartum day of pulmonary infarction. 4. 1941. A 33-year-old Negro multipara who died 1 hour and 20 minutes after versicn and extraction of the second twin. A ruptured uterus was found on autopsy. 5. 1942. A 3%year-old white multipara who died on the eighth postpartum day of pulmonary embolism. 6. 1943. A 17-year-old Negro primipara who died in a crisis of sickle-cell anemia 2% Cardiac dilatation, sickle-cell anemia, and tuberculous hours after premature delivery. vaginitis were found at autopsy. 7. 1949. A 19-year-old Negro primipara who died 33 hours post partum of a fulminatAcute necrosis of the ing postpartum toxemia, pituitary necrosis, and afibrinogenemia. pituitary gland, peripheral necrosis of the liver lobules, and glomerular ischemia were described on autopsy.
It is apparent that none of these died of cardiac or respiratory arrest and only one case, No. 7, might be questioned as a possible example of late chloroform poisoning. It does not follow the accepted pattern of late chloroform toxicity, however. *Presented at a meeting of tDr. Duncan died on March
the Brooklyn 4, 1956.
Gynecological
1004
Society,
May
18,
1955.
Volume
72
U,*n,hcrr
CHLOROFORM
AS OBSTETKICAT~
ASiWTIIETI(:
IO05
Advantages There are certain advantages to the patient and to the physician in the use of chloroform for anesthesia, the first of which is the speed with which anesthesia can be accomplished. Preanesthctic medication is less necessary with chloroform and no preliminary induction agent is needed. There is less production of mucus in the occasional case not given scopolamine or atr*opinc* than would be seen with ether. The excitement period is very short and a.tlequate anesthesia can be achieved quickly should the labor be precipitate. An-other advantage is the rapid and easy recovery experienced by the patieni. It, is our experience in clinical observations, supported by the observations of others’ that retching and vomiting are less common among patients ant’sthetized with chloroform than with ether. Its low volatility, noninflammability, nonexplosiveness, relative inexpensiveness, and convenience of handling are also advantages.” Cumbersome and expcnsivc apparatus is not, necessar? for its administration. While chloroform has been shown to pass the placental barrier?“) * thtx amount received by the infant, if the recommended technique of administration is followed, has not appeared to be sufficient to cause respiratory dcl)rclssion.
Disadvantages The oft-quoted disadvantages in the use of chloroform include cardiac arrest, which we have not seen; respiratory depression to apnea, which is a priori evidence of overdosage ; and diminution of the powers of labor with relaxation of the uterus and increased postpartum bleeding, which should not The tendency of chloroform occur if the technique recommended is followed. to decrease the strength of uterine contractions can be used as an advantage in cases of tetany, or extremely violent labor. It need not be a disadvantage if the anesthetic is used only at the end of the second stage. Late toxic maniI’estations of hepatic and renal damage have not been demonstrated in our series. It would be presumptuous of us to attempt laboratory evidence of the effect of chloroform on the liver and kidneys when we could SO much bettel refer to the monograph on chloroform by Wa,t(,rs.’
Techniques The technique of administration of chloroform for anesthesia is probably the most important element in its safe and satisfactory use. The very potency which gives chloroform some of its advantages also gives it a low safety index, but anyone administering chloroform with care and adequate knowledge of the essentials of anesthesia should have no difficulty in maintaining the very light anesthesia which is necessary for obstetrical delivery. We use a wire mesh mask covered with nine or ten layers of gauze carefully trimmed to prevent soaking, which is supported about 2 fingerbreadths above the patient’s chin, thereby allowing free circulation of air. The patient’s face is protected by a film of petroleum jelly ancl a drop of mineral oil is placed in each eye. Chloroform should be dropped onto the mask so slowly that each drop rnay be counted. Chloroform has little tendenqy to stimulate respiration and a gradThe adminual depression of respiration occurs with deepening anesthesia. istrator must take care not to give too strong a concentration of vapor. Physical signs acceptable in estimating depth and control in dosage of other agent,s are often unreliable in the case of chloroform. ’ ’ A condition bordering on analgesia only is often sufficient for the continuation of a procedure, onrc atlc.. qua.te saturation has been establishecl. “; It is our belief that adequate preparation of the patient as to fluid balance a,nd glucose, when necessary for support. combine(l with the generally better
1006
DUNCAN,
HINDMAN,
AND
MAYBERGER
Am. .1. Ok.
% Gynec.
Nuremher.
1956
nutrition prevalent today, adds greatly to the margin of safety, especially with regard to damage to the liver. It should also be mentioned that methionine and cystine6 and sulfanilamide’ provide considerable protrction to the liver, even when administered after the anesthetic. They, therefore, could be used to counteract the effect of an unexpectedly prolonged period of anesthesia, although with proper selection of patients they should not be necessary. Should a deeper and more prolonged anesthetic be needed, it is our practice to change to open-drop ether. For repair of an extensive episiotomy, a local anesthetic can be used to supplement chloroform, which is used very sparingly. Chloroform should not be given to an eclamptic or even to a pre-eclamptic patient no matter how mild the case. A patient who has been in labor for a long time should be properly hydrated and supported with glucose before anesthesia is administered. Pre-existing hepatic, cardiac, or renal disease is a contraindication to the use of chloroform. It should be noted here that the number of maternal deaths in our 4,422 cases in which chloroform was not used was higher (11 deaths), than among the 18,302 that did receive chloroform. However, all our sicker patients and those for whom chloroform was not considered safe were put in that smaller group. Therefore, no comparison can be ma.de of the anesthetic agents themselves.
Summary We have conducted a survey of 22,724 consecutive deliveries, 18,302 of them under chloroform anesthesia either alone or in combination with another agent. Of the maternal deaths in this group, none is directly attributed to the anesthetic agent. We do not propose chloroform as the ideal anesthetic. We feel, however, that its several advantages deserve reappraisal in the light of modern obstetrics and proper administration and should not be lost sight of If chloroform were to be studied as a new because of ancient prejudice. agent by current methods of investigation, along with modern obstetrical techniques, its effectiveness and acceptance might rival that of any of the new agents. A recent favorable report by Lenahan and Babbages is a study of chloroform in a modern setting. Irving W. Potter9 of Buffalo has used chloroform as his anesthetic of choice in approximately 30,000 deliveries, and continues to use it. We repeat that our observations are purely clinical and we are indebted to others for laboratory work which supports our findings.
Conclusion Chloroform, properly used, has been a convenient, agent for obstetrical anesthesia.
pleasant,
and safe
References 1. Gillespie, 2. Lundy, 3. Snyder, 4. 5. 6. 7. 8. 9.
N. : Personal communication,. 1950. 5. S.: Clinical Anesthesia, Philadelphia, 1942, W. B. Saunders Company, p. 333. F. F.: Obstetrical Analgesia and Anesthesia, Philadelphia, 1949, W. B. Saunders Company, p. 326. Whipple, G. H.: J. Exper. Med. 15: 246, 1912. Waters, R. M.: Chloroform. A Study After 100 Years, Madison, Wis., 1951, University of Wisconsin Press. Miller, L. L., Ross, J. F, and Whipple, G. H.: Am. J. M., Se. 200: 739, 1940. Tanturi, E. A., Lonchanch, J. A., and Banfi, R. F.: Surg., Gynec. & Obst. 84: 477, 1947. Lenahan, R. M., and Babbage, E. D.: New York J. Med. 50: 1717, 1950. Potter, I. W.: Personal communication, 1950.
AS AN OBSTETRICAL A Report
ANESTHETIC*
of 13,3Q!2 Cases
CAMERON DUNCAN, M.D.,t JOSEPH F. HIND&IAN, M.D., HAROLD W. MAYBERGER, M.D., BROOKLYN,N.Y. (From
St. John’s
Episcopal
AND
Hospital)
‘I’ IS the purpose of this paper to state our clinical experiences over a thirtyyear period with chloroform as an obstetrical anesthetic, pointing out our success with it in contrast to the detrimental reports commonly circulated. I
Material The records of 22,724 consecutive deliveries at St. John’s Episcopal Hospital from June, 1924, to Dec. 31, 1954, inclusive, have been reviewed. Of this total number, 17,737 patients received chloroform alone as their obstetrical anesthetic; 565 received chloroform in combination with some other agent, making a total of 18,302 patients who received chloroform during delivery. During the same years, 3,671 patients were delivered with other agents as obstetrical anesthetics, and 751 patients were delivered with no anesthesia. In the 18,302 cases in which chloroform was administered for delivery, there were 7 deaths, none directly attributable to the use of chloroform as an anesthetic agent. Case Reports These 7 deaths are listed briefly : 1. 1940. A 45year-old Negro primipara with multiple fibroids who died on the fifth postpartum day of septicemia. 2. 1940. A 25-year-old white primipara who died 7 hours post partum of hemorrhage. 3. 1941. A 27-year-old white primipara who died on the forty-third postpartum day of pulmonary infarction. 4. 1941. A 33-year-old Negro multipara who died 1 hour and 20 minutes after versicn and extraction of the second twin. A ruptured uterus was found on autopsy. 5. 1942. A 3%year-old white multipara who died on the eighth postpartum day of pulmonary embolism. 6. 1943. A 17-year-old Negro primipara who died in a crisis of sickle-cell anemia 2% Cardiac dilatation, sickle-cell anemia, and tuberculous hours after premature delivery. vaginitis were found at autopsy. 7. 1949. A 19-year-old Negro primipara who died 33 hours post partum of a fulminatAcute necrosis of the ing postpartum toxemia, pituitary necrosis, and afibrinogenemia. pituitary gland, peripheral necrosis of the liver lobules, and glomerular ischemia were described on autopsy.
It is apparent that none of these died of cardiac or respiratory arrest and only one case, No. 7, might be questioned as a possible example of late chloroform poisoning. It does not follow the accepted pattern of late chloroform toxicity, however. *Presented at a meeting of tDr. Duncan died on March
the Brooklyn 4, 1956.
Gynecological
1004
Society,
May
18,
1955.
Volume
72
U,*n,hcrr
CHLOROFORM
AS OBSTETKICAT~
ASiWTIIETI(:
IO05
Advantages There are certain advantages to the patient and to the physician in the use of chloroform for anesthesia, the first of which is the speed with which anesthesia can be accomplished. Preanesthctic medication is less necessary with chloroform and no preliminary induction agent is needed. There is less production of mucus in the occasional case not given scopolamine or atr*opinc* than would be seen with ether. The excitement period is very short and a.tlequate anesthesia can be achieved quickly should the labor be precipitate. An-other advantage is the rapid and easy recovery experienced by the patieni. It, is our experience in clinical observations, supported by the observations of others’ that retching and vomiting are less common among patients ant’sthetized with chloroform than with ether. Its low volatility, noninflammability, nonexplosiveness, relative inexpensiveness, and convenience of handling are also advantages.” Cumbersome and expcnsivc apparatus is not, necessar? for its administration. While chloroform has been shown to pass the placental barrier?“) * thtx amount received by the infant, if the recommended technique of administration is followed, has not appeared to be sufficient to cause respiratory dcl)rclssion.
Disadvantages The oft-quoted disadvantages in the use of chloroform include cardiac arrest, which we have not seen; respiratory depression to apnea, which is a priori evidence of overdosage ; and diminution of the powers of labor with relaxation of the uterus and increased postpartum bleeding, which should not The tendency of chloroform occur if the technique recommended is followed. to decrease the strength of uterine contractions can be used as an advantage in cases of tetany, or extremely violent labor. It need not be a disadvantage if the anesthetic is used only at the end of the second stage. Late toxic maniI’estations of hepatic and renal damage have not been demonstrated in our series. It would be presumptuous of us to attempt laboratory evidence of the effect of chloroform on the liver and kidneys when we could SO much bettel refer to the monograph on chloroform by Wa,t(,rs.’
Techniques The technique of administration of chloroform for anesthesia is probably the most important element in its safe and satisfactory use. The very potency which gives chloroform some of its advantages also gives it a low safety index, but anyone administering chloroform with care and adequate knowledge of the essentials of anesthesia should have no difficulty in maintaining the very light anesthesia which is necessary for obstetrical delivery. We use a wire mesh mask covered with nine or ten layers of gauze carefully trimmed to prevent soaking, which is supported about 2 fingerbreadths above the patient’s chin, thereby allowing free circulation of air. The patient’s face is protected by a film of petroleum jelly ancl a drop of mineral oil is placed in each eye. Chloroform should be dropped onto the mask so slowly that each drop rnay be counted. Chloroform has little tendenqy to stimulate respiration and a gradThe adminual depression of respiration occurs with deepening anesthesia. istrator must take care not to give too strong a concentration of vapor. Physical signs acceptable in estimating depth and control in dosage of other agent,s are often unreliable in the case of chloroform. ’ ’ A condition bordering on analgesia only is often sufficient for the continuation of a procedure, onrc atlc.. qua.te saturation has been establishecl. “; It is our belief that adequate preparation of the patient as to fluid balance a,nd glucose, when necessary for support. combine(l with the generally better
1006
DUNCAN,
HINDMAN,
AND
MAYBERGER
Am. .1. Ok.
% Gynec.
Nuremher.
1956
nutrition prevalent today, adds greatly to the margin of safety, especially with regard to damage to the liver. It should also be mentioned that methionine and cystine6 and sulfanilamide’ provide considerable protrction to the liver, even when administered after the anesthetic. They, therefore, could be used to counteract the effect of an unexpectedly prolonged period of anesthesia, although with proper selection of patients they should not be necessary. Should a deeper and more prolonged anesthetic be needed, it is our practice to change to open-drop ether. For repair of an extensive episiotomy, a local anesthetic can be used to supplement chloroform, which is used very sparingly. Chloroform should not be given to an eclamptic or even to a pre-eclamptic patient no matter how mild the case. A patient who has been in labor for a long time should be properly hydrated and supported with glucose before anesthesia is administered. Pre-existing hepatic, cardiac, or renal disease is a contraindication to the use of chloroform. It should be noted here that the number of maternal deaths in our 4,422 cases in which chloroform was not used was higher (11 deaths), than among the 18,302 that did receive chloroform. However, all our sicker patients and those for whom chloroform was not considered safe were put in that smaller group. Therefore, no comparison can be ma.de of the anesthetic agents themselves.
Summary We have conducted a survey of 22,724 consecutive deliveries, 18,302 of them under chloroform anesthesia either alone or in combination with another agent. Of the maternal deaths in this group, none is directly attributed to the anesthetic agent. We do not propose chloroform as the ideal anesthetic. We feel, however, that its several advantages deserve reappraisal in the light of modern obstetrics and proper administration and should not be lost sight of If chloroform were to be studied as a new because of ancient prejudice. agent by current methods of investigation, along with modern obstetrical techniques, its effectiveness and acceptance might rival that of any of the new agents. A recent favorable report by Lenahan and Babbages is a study of chloroform in a modern setting. Irving W. Potter9 of Buffalo has used chloroform as his anesthetic of choice in approximately 30,000 deliveries, and continues to use it. We repeat that our observations are purely clinical and we are indebted to others for laboratory work which supports our findings.
Conclusion Chloroform, properly used, has been a convenient, agent for obstetrical anesthesia.
pleasant,
and safe
References 1. Gillespie, 2. Lundy, 3. Snyder, 4. 5. 6. 7. 8. 9.
N. : Personal communication,. 1950. 5. S.: Clinical Anesthesia, Philadelphia, 1942, W. B. Saunders Company, p. 333. F. F.: Obstetrical Analgesia and Anesthesia, Philadelphia, 1949, W. B. Saunders Company, p. 326. Whipple, G. H.: J. Exper. Med. 15: 246, 1912. Waters, R. M.: Chloroform. A Study After 100 Years, Madison, Wis., 1951, University of Wisconsin Press. Miller, L. L., Ross, J. F, and Whipple, G. H.: Am. J. M., Se. 200: 739, 1940. Tanturi, E. A., Lonchanch, J. A., and Banfi, R. F.: Surg., Gynec. & Obst. 84: 477, 1947. Lenahan, R. M., and Babbage, E. D.: New York J. Med. 50: 1717, 1950. Potter, I. W.: Personal communication, 1950.