inhale with the expiratory valve of the face-piece turned on one side,
and it should be gradually advanced to the required extent, over the
opening it is intended to cover, as the sensibility of the lungs becomes
diminished. Not only patients with phthisis or bronchitis, but many
sensitive and irritable persons with sound lungs, have a great
intolerance of the vapour of chloroform at first, on account of its
pungency; and it is necessary to occupy two or three minutes in
gradually commencing the inhalation, before the patient makes any
appreciable progress towards insensibility. In administering chloroform
to children also, it is desirable to begin very gently; by this means,
and with a little persuasion, one generally succeeds in getting them to
inhale voluntarily; although, occasionally, it is necessary to use a
little force to accomplish one’s purpose.
In certain cases of the medicinal application of chloroform, and also in
obstetric cases, where the pains are not severe, it is unnecessary to
render the patient unconscious, but for surgical operations this is
nearly always requisite. No force should ever be employed so long as the
patient is conscious, unless it be to children or lunatics; but some
patients become excited as soon as they are unconscious, and attempt to
leave the couch, or push away the chloroform; under such circumstances,
if they cannot be calmed by what is said to them, they should be held,
and the vapour should be steadily and gently continued, for a minute or
two, till a state of quietude is produced. By far the greater number of
patients remain quiet as they become unconscious, but there is no
difficulty in ascertaining whether a patient is unconscious or not. If
the eyelids remain open, the countenance shows whether the patient is
conscious or not; and, if they are closed, it is only necessary to touch
them gently, to ascertain this circumstance. If he is still conscious,
he will look at his medical man, and probably speak, or, at all events,
show intelligence in his countenance.
_Signs of Insensibility._ The absence of consciousness, and a state of
quietude, are both requisite before the commencement of a surgical
operation, and they go a good way towards the preparation of a patient
for it, but these symptoms may be present and the patient not be ready
for an operation. The surgeon wishes to know whether he will lie still
under the knife, or whether he will make a resistance and outcry which
he would probably not make in his waking state. Some surgeons have
recommended that the patient should be pricked with the point of a knife
or some other instrument. This is not a good or satisfactory plan,
however, for a person will often show no sign of feeling a slight prick,
when a severe incision would rouse him to resistance. A more elegant and
successful plan is to raise the eyelid gently, by placing one finger
just below the eyebrow, and then to touch its ciliary border very
lightly with another finger. This should not be done roughly nor too
frequently, for fear of exhausting the sensibility when it is slight.
Just after unconsciousness is induced, the eyelids are often closed very
strongly when their margins are touched, especially in females, and
there seems to be a positive hyperæsthesia; this, however, is only
apparent, and arises from the control of the will being removed, whilst
sensibility remains. By continuing the chloroform, the sensibility of
the edges of the eyelids diminishes until, at last, they may be touched
without causing winking. Under these circumstances, the most severe
operation may, in almost every case, be commenced without sign of pain.
I have employed this test of the sensibility or insensibility of the
patient ever since chloroform has been in use, and also in the
employment of ether in 1847, and I am satisfied that it affords more
reliable information on this point than any other single symptom. It
even indicates the amount of sensibility where a little remains; when,
for instance, touching the margin of the eyelids causes very slight and
languid winking, the patient will commonly flinch a little if the knife
is used, but only in a manner that can be easily restrained, and will
not interfere with the majority of operations. The cases, in which the
indication afforded by the eyelids is not always to be depended on, are
those of hysterical patients, in whom there is sometimes no winking on
touching the eyelids, even when unconsciousness is scarcely induced. In
such cases, one must judge by the other symptoms, and also by the length
of time the patient has inhaled, the strength of the vapour, and depth
and activity of the breathing. Indeed, these conditions should be
observed and taken into account in every case; and all the symptoms
exhibited by the patient should be watched, such as the expression of
the face, the state of the breathing, and the condition of the limbs
with regard to their tension or relaxation. The last is indeed sometimes
relied on as the chief or sole sign whether the operation may be
commenced, but it is of itself very insufficient, and even fallacious.
The patient may allow his limbs to lie relaxed when he is scarcely
unconscious, and not at all insensible, merely because he is not
exerting his will upon them; if the arm is lifted, it may fall
listlessly down again, at a time when the knife of the surgeon would
rouse the patient to active resistance. Indeed, the limbs, which have
been lying relaxed, may become tense as the effect of the chloroform
increases, and may remain so during a short operation, in which there is
no sign of pain.
Although the pulse of itself gives no indication as to how far a patient
is under the influence of chloroform, it is proper to pay attention to
it, not only during the first administration of the chloroform, but also
throughout the operation, especially if it be attended with much
bleeding. The pulse sometimes becomes intermittent or irregular during
the administration of chloroform, more especially in elderly persons.
This more commonly happens in the first exhibition of it, than when it
is repeated during the course of an operation. I have not seen any harm
from either of these conditions, but it is well to intermit the
chloroform for ten or fifteen seconds, and let the patient have a few
inspirations without it, if the pulse is not in a satisfactory
condition. If the precaution be taken to ensure that the air the patient
breathes shall never contain more than five per cent. of vapour, the
pulse can never be seriously affected by the direct action of the
chloroform, and the state of the breathing affords the best warning
against continuing the inhalation too long at a time.
The breathing is fortunately also a sign that cannot be overlooked. It
is by the breath that the chloroform enters, and it is extremely
improbable that any one would go on giving the vapour after the
breathing became stertorous and laboured.
The patient sometimes holds his breath after he is unconscious, and
before he is insensible; this occurs under two conditions: first, after
deep and rapid breathing, during which the patient seems to absorb more
oxygen than is immediately required, under the circumstances; and in
this condition, I have known him hold his breath for a whole minute,
whilst the pulse was unaffected. The other condition in which the
breathing is suspended, is when there is rigidity in the third degree of
narcotism, and the respiratory muscles seem to partake of the general
rigidity; the holding of the breath in these cases seldom continues so
long as under the former circumstances. I do not consider that there is
any danger from either of these kinds of suspension of breathing. I
believe it always returns as soon as there is a want of oxygen in the
system. Of course the inhaler need not be applied to the face when the
patient is not breathing, and he may as well have an inspiration or two
without chloroform when the breathing is renewed. It is seldom requisite
to carry the effects of chloroform so far that the breathing becomes
stertorous, and whenever stertor is observed, the inhalation should be
suspended; under these circumstances, the patient is always insensible.
In some cases, in which a little more chloroform has been inhaled than
is necessary, the patient breathes for half a minute or so by the
diaphragm only, and breathes in fact hardly at all. The abdomen rises
and falls freely, but, from the muscles of the chest not fixing the
ribs, hardly any air enters the lungs, and the face becomes rather
livid; meanwhile the pulse goes on very well, and at last the patient
draws a deep, sonorous inspiration, the face resumes its proper colour,
and all is right again. I have not heard of any accident from chloroform
commencing in this manner. This state of breathing, when it does occur,
usually takes place a few seconds after the inhalation has been left
off, and arises from the accumulation of the effects of the chloroform,
owing to the absorption into the system of the vapour which was
contained in the lungs at the time when the inhalation was
discontinued.[55] This accumulation or increase of the effects of
chloroform lasts for about twenty seconds; it is not dangerous unless
the vapour is inhaled of too great strength, but it should be borne in
mind in all cases. It may be prevented altogether, by reducing the
strength of the vapour, just as the patient is getting insensible, or by
giving it with intermissions of a few seconds, at this time.
The rigidity and struggling previously mentioned (pages 39 and 50) as
occurring occasionally in the third degree of narcotism, more
particularly in robust persons, often form a very prominent feature in
the effects of chloroform; and have sometimes caused the medical man to
discontinue the exhibition of chloroform, under the belief that it did
not agree with the constitution of the patient, and that its further
exhibition would be unsafe. The proper course to pursue is to continue
the inhalation gently, till the struggling and rigidity are subdued. The
patient is often insensible before these symptoms are subdued, but it is
necessary to have him quiet, in order to enable the surgeon to operate
with convenience and safety. I have always succeeded in subduing the
involuntary struggling and rigidity, but have occasionally occupied five
or six minutes in doing so. It is desirable to proceed slowly and
cautiously, because, when these symptoms occur, the patient has already
absorbed nearly the usual quantity of chloroform, and he often holds his
breath, and then takes a sudden and deep inspiration, when he might
inhale an overdose of vapour, unless it were presented to him in a well
diluted state.
When the rigidity and struggling are subdued, the breathing, in some
cases, becomes stertorous, and relaxation of the muscles takes place,
the limbs appearing quite flaccid; but by proceeding gently, these
effects may generally be avoided, and the patient becomes quiet, whilst
the breathing is natural, and the muscles are in a moderate state of
tension. If the operator should be afraid to proceed with the exhibition
of chloroform, on account of the violence of the muscular spasm and
rigidity, it will be satisfactory to him to know that, if the inhalation
is resumed in a few minutes, these symptoms will be less violent than at
first.
Struggling and rigidity are less likely to occur, when chloroform is
administered slowly, than under opposite circumstances; but it is
impossible to prevent these phenomena altogether in certain patients.
After they are once subdued, they but very rarely recur during the
operation; the patient, in most cases, seems to take on, when he is
subdued by the chloroform, the same relation to it that women, children,
and persons in a state of debility have from the first. M. Chassaignac
has called this condition one of tolerance of the chloroform. It is a
condition in which the patient bears both the chloroform and the
operation very comfortably; but tolerance of a medicine is generally
meant to imply that the patient can take it in larger quantity than
before. But this is the reverse of what occurs when the patient is in a
tranquil state from chloroform; he has already absorbed a considerable
quantity, which has most likely penetrated deeply into the tissues, and
he certainly does not require, and could not bear, so much as in the
earlier stage of inhalation, where he is restless and breathing more
quickly, and thus exhaling and getting rid of the chloroform at a
greater rate.
It might be a question whether the absence of muscular excitement, in a
number of cases, does not arise from the circumstance that anæsthesia,
or absence of common sensibility, is obtained, and the operation
performed, at a stage of narcotism anterior to that in which the
muscular rigidity and spasm occur. This is true in a few cases, but I am
satisfied by careful observation that, in the greater number of
instances in which muscular excitement is absent, it would not occur at
all, though the inhalation should be pushed to the most extreme degree.
Many animals also are killed by chloroform without the least excitement
of the muscular system occurring at any part of the process.
The pupils of the eyes are dilated in the deep state of insensibility
which I have called the fourth degree of narcotism, but it is desirable
to avoid carrying the effects of chloroform to this extent. They are
occasionally dilated, however, under the slighter effects of chloroform,
and even as the patient is recovering from its effects. In the third
degree of narcotism, when the eyes are turned upwards, the pupils are
usually, if not always, contracted; there seems to be a consentaneous
action in the iris and the muscles which turn up the eye. The pupils
seem also to be less sensitive to light, when the patient is insensible
from chloroform, than at other times. This is all the information I am
able to give about the pupils. Some writers have entered into a good
deal of detail about the pupils, but their statements are very
conflicting. The pupils are acted on by other causes, both external and
internal, as well as the chloroform. The amount of light has great
effect on them; and I have seen them remain dilated for some time after
the chloroform was discontinued, and then suddenly contract, as the
patient began to use his eyes. Even if definite laws could be
ascertained with regard to the action of chloroform on the pupils, in
different doses, and under different conditions, there would be some
difficulty in applying them during the administration of the vapour, as
the patient cannot be made to direct his eyes to or from the light.
There is also some difficulty in making correct observations on the
pupils. Very often, when I am exhibiting chloroform, one of the
bystanders lifts the patient’s eyelid and makes a remark on the state of
the pupil, and, on my looking in the face of the speaker, I often have
occasion to tell him that his own pupils are quite as much dilated, or
contracted, as the case may be.
With regard to the position of the eyes, they are usually turned upwards
in the third degree of narcotism, as I have already said, but in a
considerable number of instances they retain their usual position all
through the inhalation. In a few cases, they are turned downwards, the
pupils being almost hid under the lower eyelids, and causing a curious
expression. I have noticed this most frequently in children of ten to
fourteen years of age. I have scarcely ever seen temporary strabismus
under the influence of chloroform.
The length of time which it is most desirable to occupy in the
administration of chloroform, before the commencement of an operation,
is about two minutes in infants, three minutes in children, and four or
five minutes in adults. Circumstances occasionally occur, however, to
lengthen these periods. The time during which the adult patient usually
remains conscious whilst inhaling, is about two and a half minutes, but
this period is sometimes prolonged from the nervousness of the patient,
or his intolerance of the pungency of the vapour. Again, when
unconsciousness is induced, there is, in many cases, an increased flow
of saliva; and although this usually causes no impediment, the patient
sometimes keeps making efforts of deglutition which very much retard the
inhalation; and, at other times, he holds his breath, with his mouth
full of saliva, as if he had some obscure idea of disposing of it in a
suitable manner.[56] The delay which often arises from the struggling
and rigidity has been already mentioned; but notwithstanding all these
circumstances, it hardly ever takes more than seven or eight minutes to
make a patient sufficiently insensible.
I have indeed met with a few cases in which a longer time has been
occupied, but there has always been a physical reason for it. I have
never had occasion to attribute the delay to any idiosyncracy, or great
peculiarity in the patient, but only to the circumstance that the vapour
did not enter the lungs in sufficient quantity within a given time. I
have had under my care several patients who, it was supposed, were not
susceptible of the effects of chloroform, or were, at least, very
difficult to bring under its influence, as previous attempts had failed.
It so happens, however, that I have had no difficulty whatever with any
of these cases.
Two or three female patients who were about to undergo some trifling
operation, preferred to leave off before they were unconscious, on
account of unpleasant sensations in the head or chest, and to have the
operation performed without the full effects of the chloroform; but
there is no doubt the agent would have acted well enough if it had been
continued.
The following case will show that chloroform may be inhaled with
advantage in cases which at first seem very unfavourable. I received a
note in 1849 from a medical man in the country, in which he says:—“I
have now a young lady under my charge, from whom I am about to remove a
tumour attached to the ear. She is anxious to take chloroform, and by
the desire of herself and mother, I yesterday administered it by way of
trial, but only to what would be termed the second, and perhaps you
would say, the first degree. She lost some sensation, but was quite
conscious, and spoke. She felt giddy; there was tumultuous beating of
the heart, and a much accelerated pulse, with a dilated pupil; a perfect
coldness over the whole skin, with an equally cold perspiration; and,
during recovery from this slight effect, severe tremors of the whole
body, so much so as to shake the couch on which she was lying. From this
state she did not recover for nearly an hour. She complained of great
giddiness and oppression at her chest. She is a healthy-looking, florid
girl, but not strong, and has had, from time to time, severe spasm
affecting her chest, so much so as to take away her breath. I have thus
endeavoured to give you an outline of the constitution of my patient,
how she had suffered, and what were the effects of the small dose of
chloroform given by an inhaler. I never witnessed such extreme cold,
tremor, or such tumultuous action of the heart; and am therefore anxious
for the opinion of one who has administered chloroform under a greater
variety of circumstances than myself, and to learn whether the symptoms
I have described are sufficient to deter one from giving a sufficient
dose to cause entire suspension of consciousness. My own impression is
that they are sufficient to deter, but the patient and her friends being
both anxious it should be inhaled if possible, I shall only be too glad
to hear that you have witnessed like symptoms, and that you do not
consider them sufficient indications of danger to deter me from its
careful administration in the case.”
I advised that the chloroform should be administered again, and
continued steadily till the patient should become insensible; expressing
my belief that the unpleasant symptoms would subside as unconsciousness
was induced. I received a reply to the effect that the operation had
been performed very successfully under the influence of chloroform,
although the vapour had an exciting effect for some time.
_Repetition of Chloroform during an Operation._ The first application of
chloroform often suffices for an operation, if it be of short duration,
without repeating the inhalation. In a few cases the patient remains
insensible to the knife for three minutes after the inhalation is left
off, but this is an exception; and one cannot, at all events, make sure
of this prolonged effect of chloroform, without producing a deeper state
of narcotism than is desirable. More usually, if the operation lasts
more than a minute or two, it is necessary to repeat the inhalation; it
is, indeed, generally desirable to let the patient have a few
inspirations of air charged with chloroform vapour every half minute or
so, whilst the operation continues, in order to keep up the
insensibility. When the surgeon is cutting in the neighbourhood of
important parts, it is desirable to prevent any sign of sensibility, and
to keep repeating the chloroform so as to keep up the coma, without,
however, causing embarrassment of the breathing, or wide dilatation of
the pupil. In the greater number of operations, however, it is better to
wait till there is some sign of sensibility, such as a slight cry or
tendency to flinch, before the inhalation is resumed; and then a few
inspirations of well diluted vapour make the patient quiet again.
RECOVERY FROM THE EFFECTS OF CHLOROFORM.
As soon as a patient has ceased to inhale, the chloroform begins to
exhale in the form of vapour from the blood as it passes through the
lungs. It cannot be detected by the sense of smell, after the lungs have
been emptied, by two or three expirations, of the vapour they contained
at the moment when the inhalation was discontinued; but I have detected
it by chemical means, after consciousness had returned. The chloroform
exhales in greatest quantity at first, and the patient usually recovers
his sensibility and consciousness in the time which it ought to take for
the chief part of the chloroform to be exhaled, according to mechanical
principles; as will be explained in treating of the _modus operandi_ of
this agent. The last traces of the chloroform of course exhale more
slowly, and a very minute and insignificant quantity may remain for a
considerable period in the system, not only of the patient, but of
anyone who was standing by whilst he inhaled.
It is probable that a small portion of chloroform passes out by other
channels than that of the expired air: the latter, however, offers such
a ready and expeditious outlet, that the quantity excreted in any other
way is, most likely, very minute. I have on four occasions examined
urine passed after the inhalation of chloroform, by boiling it in a
flask, and passing the vapour, first through a red-hot tube, and
afterwards through a tube moistened inside with solution of nitrate of
silver, and I only on one occasion obtained a very slight precipitate of
chloride of silver.
The patient usually becomes conscious within five minutes after the
inhalation has been discontinued. After a short inhalation, for a very
brief operation, consciousness sometimes returns immediately, and after
a prolonged inhalation the recovery of consciousness is sometimes
retarded till ten minutes have elapsed. Old people are often longer than
others in awaking from the effects of chloroform, owing, no doubt, to
their slower breathing and circulation. Children, on the other hand,
usually recover very quickly from its direct effects; but they often
lapse into a natural sleep which lasts a considerable time—even for
hours if they are not disturbed, and if the operation has left no
painful wound or other cause of uneasiness.