of chloroform has been administered, or when its effects have been
allowed to subside too soon. The patient may call out or complain in
articulate words, such as “Oh, you are hurting me,” and yet may assert
afterwards that he had no pain, and knew nothing whatever of the
operation. His own language at the time must, however, be held to decide
that there was some pain, which made so slight an impression on the
disordered mind as not to remain in the memory. Pain which is not
remembered is of very little consequence, and probably is but slight in
degree. It should not be judged of by the expressions of the patient
when he is but partially conscious, and using no self-control.
Chloroform may, lastly, be administered so badly, that the patient
simply falls asleep under the soothing influence of a very gentle dose,
as he might sleep from an ordinary dose of opium, without being
insensible, and, when the operation is commenced he wakes to full
consciousness, and both feels pain and remembers it.
Patients, when insensible, sometimes moan or groan from the effects of
the chloroform, and quite independently of the operation. The groaning
or moaning comes on sometimes and even leaves off again, before the
operation is commenced. When symptoms like those of pain are present
during an operation, one may generally know whether they are the
consequences of it, by observing whether or not they are connected with
each cut of the knife. But even when a flinch or a groan follows each
manipulation of the surgeon, it does not necessarily follow, provided
the patient does not speak, that he is suffering pain. Some amount of
consciousness is essential to the presence of pain, but many of the
lower animals execute movements like those caused by pain, after the
head is cut off, and when, of course, there can be no consciousness.
Although the mind, under ordinary circumstances, is conscious of the
attitude, gestures, and cries, which accompany pain, neither the
intellect nor the will have any share in their production. On the
contrary, they usually take place in spite of the efforts of the will to
prevent them, and one may understand that, when consciousness and
volition are suspended, the actions usually indicative of pain may, for
want of control, be excited by slighter causes, and to a greater degree,
than in the waking state.
It is certain that chloroform may prevent pain in two ways, either by
rendering the mind unconscious of external impressions, or by removing
the sensibility to these impressions, that is, by a true anæsthetic
action, but usually, and always when breathed in a full dose, it acts in
both ways at once.
The patient sometimes supposes that he remembers all the particulars of
the operation, although he did not feel the pain, but on questioning him
it is usually found that it is a dream which he remembers, and not the
actual facts. It is extremely rare for a patient to assert that he has
felt pain from the operation, when he has not felt it, but I have known
this to happen once or twice, and a circumstance which was related to me
by Mr. Robinson proves the possibility of it. He administered
chloroform, or ether, to a lady, with the intention of extracting some
teeth, but could not succeed in getting the mouth open, and the lady
woke before anything had been done, and asserted that she had felt the
operation. She inhaled again, and awoke, and repeated the same statement
once or twice before the teeth were actually extracted.
I have heard it stated that patients have felt the pain of the
operation, but have been unable to make any sign of feeling it. Such an
occurrence may possibly take place when the chloroform is inhaled too
slowly, or not in sufficient quantity; but I have not witnessed it, and
it evidently cannot happen with a sufficient dose.
CIRCUMSTANCES WHICH INFLUENCE OR MODIFY THE EFFECTS OF CHLOROFORM.
I arrived at the conclusion, after much careful observation, that
chloroform might be given with safety and advantage in every case in
which the patient requires, and is in a condition to undergo, a surgical
operation; and having acted on this conclusion for several years, I have
found no reason to change it. It is desirable, however, to pay attention
to every circumstance connected with the health and constitution of the
patient before exhibiting chloroform, as many of these circumstances
influence its effects.
_Age._ The age of the patient has considerable influence in modifying
the effects of chloroform. It acts very favourably on children: they
sometimes oppose the inhalation of it as long as they are conscious, but
it does not occasion the rigidity and struggling after loss of
consciousness, which are sometimes met with in the adult. Anæsthesia is
generally induced with a less amount of narcotism of the nervous centres
in children than in grown up persons. The effects of chloroform are more
quickly produced and also subside more quickly in children than in
adults, owing no doubt to the quicker breathing and circulation. It
often happens, however, that when the insensibility has been kept up for
some time, say twenty minutes or half an hour, in a child, it is
followed by a natural sleep of a few hours duration, provided there is
no painful wound, or other cause, to prevent the sleep. I have given
chloroform in a few cases as early as the ages of eight and ten days,
and in a considerable number before the age of two months; and I have at
this time, June 30th, 1857, memoranda of the cases of 186 infants under
a year old to whom I have administered this agent. There have been no
ill effects from it either in these cases, or in those of children more
advanced in life; and it is worthy of remark that none of the accidents
from chloroform which have been recorded, have occurred to young
children.
There is nothing peculiar in the effects of chloroform on people
advanced in years, except that its influence subsides rather slowly, on
account of the slower breathing and circulation. I have given chloroform
to many patients over seventy-five years of age, and to one as old as
ninety years.
_Strength or Debility._ The comparative strength or debility of the
patient has considerable influence on the way in which chloroform acts.
Usually the more feeble the patient is, whether from illness, or any
other cause, the more quietly does he become insensible; whilst if he is
strong and robust, there is very likely to be mental excitement in the
second degree, and rigidity of the muscles, and probably struggling in
the third degree of narcotism. Patients in a state of debility resemble
children, not only in coming quietly and easily under the influence of
chloroform, but also in the circumstance, that the common sensibility is
suspended with less narcotism of the nervous centres than is generally
required in robust persons. Children and persons in a state of debility
have usually an acute sensibility which causes them to suffer pain from
very slight injuries, but this sensibility is more easily suspended by
chloroform than the less acute sensibility of robust persons. It is in
strong men, accustomed to hard work or athletic sports, that the
rigidity and struggling previously alluded to in describing the effects
of chloroform, most frequently occur after the loss of consciousness.
Some of the patients in whom the struggling and rigidity have been
greatest were gentlemen belonging to boating clubs; but I think the
patient, in whom these symptoms were most violent, was a celebrated
harlequin of one of the London theatres, on whom Mr. Fergusson operated
a few years ago.
The persons in whom the rigidity and struggling are well marked are
often lean and wiry, and these symptoms rarely occur in fat people. The
rigidity and struggling are less marked when the chloroform is given
slowly than when quickly given.
_Hysteria._ Patients who are subject to hysteria sometimes have symptoms
of the complaint, such as sobbing, crying, or laughing, as soon as
consciousness is suspended, or even impaired, by the chloroform; but
these symptoms can always be subdued by proceeding with the inhalation.
In a very few instances the hysterical state returns, and becomes
troublesome as the effect of the vapour subsides. In two or three cases
that I have met with, it continued for three or four hours, but it
usually subsides in a much shorter time. The inhalation should not be
suspended on account of the hysteria, but should be continued till it is
subdued before an operation is performed.
I have rarely seen a decided fit of hysteria from the effects of
chloroform, but in the case of a young married lady, to whom I gave this
agent to prevent the pain of an operation on the rectum, a somewhat
violent paroxysm of hysteria came on directly after the inhalation was
commenced. The surgeon would not permit me to continue the chloroform,
and expressed his intention of operating without it. After waiting for
about half an hour, however, for the hysteria to subside, and finding
that it continued the same as at first, the inhalation was resumed. The
patient was soon rendered insensible, and lay perfectly still whilst the
operation was performed. There was a little hysteria as the effects of
the chloroform subsided, but not so severe as before.
I have several times seen hysterical symptoms in the male, either during
the administration of chloroform, or whilst the patient was recovering
from its effects. But in all these cases, the patients informed me
afterwards that they were subject to hysterics when under the influence
of mental emotion.
In some persons who are subject to hysteria, the breathing becomes
excessively deep and rapid whilst inhaling chloroform. This usually
occurs just as the patient is becoming unconscious, but in a few cases
even earlier, and the patient is aware of the impulse to breathe in this
manner. After this kind of hysterical breathing has lasted a minute, the
patient generally rests nearly a minute without breathing at all, after
which the respiration generally becomes nearly natural. I give the
chloroform very sparingly during this violent breathing, or else
withdraw it altogether for a minute or two.
I do not consider that the hysterical diathesis forms any objection to
the use of chloroform in operations, as the patients would be generally
quite as liable to suffer an attack of hysteria from the pain, if
chloroform were not used.
_Epilepsy._ Chloroform occasionally brings on a fit of epilepsy in
persons who are subject to this disease. It was stated in one of the
foreign medical journals, in 1848, that this agent was so certain to
cause a fit in epileptic persons, that it might be used to detect
impostors pretending to be subject to this disease; but if this
assertion has been acted on, it must have led to great injustice, for I
have many times administered chloroform to the extent of causing
complete insensibility in epileptic patients who required to undergo
operations, without its inducing the least approach to a fit.
In the few cases in which epileptic convulsions are occasioned by
chloroform, they do not appear till the third degree of narcotism is
induced, in this respect differing from hysteria, which comes on in the
second degree, or even earlier, as was stated above. The course to
pursue, when epileptic convulsions appear, is to continue the chloroform
steadily and gently, till they subside. I have never seen the chloroform
fail to subdue the convulsions in a very few minutes, and I have never
seen them recur after the operation, as the effects of the vapour
subsided. In medical and obstetric practice, and for slight operations,
it is not requisite to carry the effects of chloroform so far as that
stage in which an epileptic fit would occur, so that under these
circumstances the fact of a patient being subject to epilepsy hardly
requires to be taken into account.
_Pregnancy._ I have repeatedly given chloroform at all periods of
pregnancy, both for tooth-drawing and more important operations, and I
have not met with any ill effects from it in any of the cases.
_The Menstrual Period._ It is customary to avoid the menstrual period in
fixing the time for a surgical operation, when it can be so arranged.
There are, however, often reasons for not waiting over this period, and
under such circumstances, I do not know any objection to the inhalation
of chloroform. I have administered it frequently during the menstrual
period, and have seen no ill effects from it. I have observed that there
is a little more tendency to slight hysterical symptoms, during its
inhalation at this period, than when the same patients inhale it at
other times, which is what we might expect.
_Diseases of the Lungs._ Affections of the lungs sometimes cause a
little difficulty and delay in the administration of chloroform, as the
vapour is liable to excite coughing when the mucous membrane of the
air-passages is irritable. The inconvenience is, however, confined to
the time of inhalation, for the cough is generally relieved afterwards.
I have given chloroform for surgical operations in many cases where
phthisis was present, and in several patients who had suffered from
hæmoptysis, and have not seen any ill effects from its use in these
cases. Chloroform has indeed often been inhaled with advantage to
relieve the cough in consumption. The cases of chronic bronchitis in
which chloroform is administered for surgical operations are still more
numerous. The effects I have observed have been coughing at the time of
inhalation, and very often a relief of the cough afterwards. Some of the
patients had emphysema of the lungs. It is scarcely necessary to allude,
in this place, to acute diseases of the lungs, as surgical operations
are not performed during their continuance, but from the fact of
chloroform being inhaled occasionally in the treatment of these
affections, it is evident that they would cause no obstacle to its
employment.
_Disease of the Heart._ There is a very general impression that the use
of chloroform is unsafe when disease of the heart exists, more
particularly, fatty degeneration of that organ. This belief has been
encouraged by the circumstance that this affection has been present in a
few of both the real and alleged deaths from chloroform; and also by the
fact that, in the accidents that have been really due to chloroform, the
heart has been the organ on which it has exerted its fatal influence.
When we come to investigate these cases, however, we shall find reason
to conclude that the heart has probably been diseased in quite as great
a proportion of the patients who have taken chloroform without ill
effects, as in those who have succumbed under its influence. As regards
my own practice, indeed, the only case in which death could in any
degree be attributed to the chloroform, was one in which there was
extreme fatty degeneration of the heart; but, on the other hand, I have
given chloroform in numerous cases without ill effects where the
symptoms of this, as well as other affections of the heart, were present
in a very marked degree. Indeed, I have never declined to give
chloroform to a patient requiring a surgical operation, whatever might
be his condition, as I early arrived at the conclusion that this agent,
when carefully administered, causes less disturbance of the heart and
circulation than does severe pain. Whenever I have had an opportunity of
seeing an operation performed without chloroform, I have carefully
observed the pulse, and although none of these operations have been of a
very severe nature, I have found the circulation to be much more
disturbed than it would have been by chloroform carefully administered.
The pulse in most of these cases has been excessively frequent during
the operation, and in some instances it has intermitted to an unusual
extent.
In one instance, I had an opportunity of witnessing a similar operation
on the same patient, first without chloroform, and afterwards under the
influence of this agent. On January the 6th, 1855, Mr. Fergusson
performed lithotrity, in King’s College Hospital, on a man, aged
fifty-one. He generally directs chloroform to be administered in
lithotrity, but in this instance he omitted to do so, as he thought that
the bladder was not very irritable, and that the patient would not
suffer much. I began to feel the pulse just when the patient saw the
lithotrite about to be introduced. It was 120 in the minute. As soon as
the instrument was introduced, the pulse increased to 144, and
immediately afterwards it became uneven, irregular, and intermitting. I
could not count more than three or four beats at a time; and,
occasionally, when the pain seemed greatest, and the man was straining
and holding his breath, the pulse was altogether absent for four or five
seconds. In order to ascertain whether the absence of pulse at the wrist
might not depend on the pressure of the muscles of the arms, caused by
grasping the table, I applied my ear to the chest, and found that there
was no sound whatever to be heard during the intervals when the pulse
was imperceptible. It was evident that the patient held his breath till
the right cavities of the heart became so distended as to stop the
action of that organ till the respiration returned. The man did not
complain or cry out during the operation. A week afterwards the
lithotrity was repeated, but on this occasion I administered chloroform.
The pulse was about 120 in the minute when the patient began to inhale
the chloroform, but it became slower as he was made unconscious, and it
was regular and natural during the operation. It was only towards the
end of the operation, when the effect of the chloroform was allowed to
diminish, and when the man began to strain a little, though not yet
conscious, that the pulse intermitted slightly, passing over a single
beat occasionally. There were none of the long intermissions of the
pulse observed on the former occasion.
It is very evident that if the above mentioned patient had been the
subject of any affection of the heart which weakened or embarrassed its
action, he would have run a much greater risk from the pain of the first
operation, than from the inhalation of chloroform in the second one.
In a few of the patients having the arcus senilis of the cornea, a weak,
intermitting, or irregular pulse, and other signs of fatty degeneration
of the heart, there have been a feeling of faintness and a tendency to
syncope, as the effects of the chloroform were subsiding, especially
when the operation had been performed in the sitting posture; but these
symptoms have soon subsided, in all the cases I have met with, on
placing the patient horizontally, with or without the help of a little
ammonia to the nostrils.
_Cerebral Disease._ Affections of the head offer no obstacle to the
administration of chloroform. I have given it to several patients who
had suffered previously from an attack of apoplexy. Some of them still
retained the paralysis resulting from their attack, but the chloroform
has not been attended or followed by ill effects in any of these cases.
The following case, in which alarming head symptoms had existed a few
hours before the inhalation of chloroform, cannot fail to be
interesting.
The 31st of October, 1854, was appointed by Mr. Fergusson to perform
lithotrity on a gentleman, seventy-eight years of age, who had a
phosphatic calculus in his bladder. He was a patient of Mr. Propert, and
Mr. Fergusson had removed a similar calculus by lithotrity, and I had
given him chloroform at each of the operations, and it was arranged that
he should have chloroform on the present occasion. Mr. Propert informed
Mr. Fergusson and me, on our arrival, that his patient had had an attack
the night before resembling apoplexy; he had been insensible, the
breathing had been stertorous, the pupils dilated, and the face very red
and congested. Mr. Propert had caused him to be cupped to fourteen
ounces, and had given him twenty grains of calomel in the course of the
night, and in the morning he was as well as usual, and remained so at
the time of our visit. We considered the case with Mr. Propert, and as
there were reasons for not postponing the operation, it was determined
that he should inhale the chloroform rather than be subjected to the
pain. The vapour acted very favourably; he recovered his consciousness a
few minutes after the operation, and expressed himself as feeling quite
well.
Mr. Fergusson crushed another calculus in this patient in March 1855,
when I again administered chloroform, and in 1856 I understood that he
was free from the complaint.
_Insanity._ Chloroform acts on insane patients just as it does on
others, that is to say, they are made insensible by it, and, when its
effects completely subside, it leaves them in the same state of mind as
before. Insane people are, however, often so suspicious that they cannot
be persuaded to inhale chloroform, and it can only be given to them by
force. When once under its influence, however, I have seen teeth
extracted, and other operations performed, which it would have been
impossible to accomplish in the same individuals without resorting to
inhalation. The use of chloroform in the treatment of mania will be
alluded to in another part of this work.
_Hard Drinkers._ It was at one time alleged that hard drinkers of
spirituous liquors were not susceptible of the influence of ether or
chloroform, and for a long time there remained an impression that these
persons were difficult to render insensible. I have always found that
hard drinkers were rendered unconscious, and even comatose, by the same
amount of ether or chloroform as other persons; but they sometimes have
a morbid excess of sensibility in the nerves of common sensation, and do
not lie still under the surgeon’s knife except when the nervous centres
are deeply narcotised, and the breathing almost stertorous. On this
account, they sometimes inhale much more chloroform during a protracted
operation than other persons.
AMOUNT OF VAPOUR OF CHLOROFORM ABSORBED TO CAUSE THE VARIOUS DEGREES OF
NARCOTISM.
Before proceeding to describe the mode of administering chloroform, it
is desirable to treat of the quantity of it which produces its different
effects. Without alluding to the facts and experiments which prove that
all narcotics produce their effects by being absorbed into the
circulating fluid, and so reaching the nervous system on which they act,
it is only necessary to mention the following circumstances to show that
this is the case as regards chloroform. In some experiments in which I
assisted Dr. Sibson, we found that the vapour of chloroform produced its
effects after both the pneumogastric nerves had been divided, exactly
the same as before. Chloroform can be detected by means of chemical
tests exhaling in the breath of those who have just previously inhaled
it. It can also be detected in the urine after inhalation, and very
readily in all the tissues of animals that have been killed by it, for
several days after death.
The quantity of chloroform in the blood in the different degrees of
narcotism might be estimated approximatively from the amount used in
inhalation, but I devised some experiments in 1848 for ascertaining the
quantity with accuracy.[52] The experiments were based on the following
circumstances.
When air containing vapour is brought in contact with a liquid, as water
or serum of blood, absorption of the vapour takes place, and continues
till an equilibrium is established; when the quantity of vapour in both
the liquid and air, bears the same relative proportion to the quantity
which would be required to saturate them at the temperature and pressure
to which they are exposed.
This is only what would be expected to occur; but I verified it by
numerous experiments in graduated jars over mercury. The intervention of
a thin animal membrane may alter the rapidity of absorption, but cannot
cause more vapour to be transmitted than the liquid with which it is
imbued can dissolve. The temperature of the air in the cells of the
lungs and that of the blood circulating over their parietes is the same;
and, therefore, when the vapour is too dilute to cause death, and is
breathed till no increased effect is produced, the following formula
will express the quantity of any substance absorbed:—As the proportion
of vapour in the air breathed is to the proportion that the air, or the
space occupied by it, would contain if saturated at the temperature of
the blood, so is the proportion of vapour absorbed into the blood to the
proportion the blood would dissolve.