effects of chloroform, but to leave him to collect his ideas, and not
speak to him till he is quite conscious, or makes some remark or inquiry
himself. If not prevented by the medical attendant, the friends of the
patient often address him the moment he opens his eyes; and the words
they generally use are of a very equivocal meaning to one who cannot
understand their application. They usually say “It’s all over”, which
very often has the effect of raising an indefinite feeling of alarm in
the patient; for, until he has had time to recover his memory, the
operation he was to undergo is generally the farthest thing from his
mind. When left to himself the patient usually recovers from the
insensibility in a very tranquil manner. If he has not been moved whilst
insensible, and awakes in the position in which he fell asleep, he
supposes, very commonly, that he has not been asleep at all; and in a
great number of instances will contend this point very stoutly, even
after a protracted operation, and assert that the chloroform has not
taken effect. It is as well to let him remain in this conceit for a
while, or even till he finds out the mistake himself; for, if reminded
of the pain they have been spared, just on waking after an operation,
persons are liable to be excited by emotions of pleasure and gratitude;
but a few minutes later, when the effects of the chloroform have more
completely subsided, they are better able to control their emotions. A
few persons wake with a full recollection of the preceding
circumstances, and inquire if the operation is done; whilst others, on
first awaking, are still entirely occupied with the subject of their
dreams.
The greater number of patients who inhale chloroform have to remain in
bed on account of the operation which has been performed, but after
minor operations, the patient is sometimes able to walk away within five
minutes; although more frequently there is a little languor or feeling
of fatigue for half an hour or so; and it is desirable in all cases for
the patient to sit or lie quietly for this space of time, if not longer,
before he makes any mental or bodily exertion, even if he feels quite
well.
OCCASIONAL SEQUELÆ OF THE INHALATION OF CHLOROFORM.
_Sickness._ The chief drawback to the benefits conferred by chloroform
is the sickness which in many cases follows its use. It is most frequent
when the inhalation takes place soon after a meal, and some of the
precautions which are requisite in order to avoid this symptom, or
render it as rare as possible, have already been described (p. 74); but
it occurs in certain cases, notwithstanding the best measures which may
be used for its prevention. Moving the patient as the effects of the
chloroform are subsiding is very apt to excite vomiting when it might
not otherwise occur; it is therefore desirable, when convenient, to
allow the patient to lie for half an hour or so, without moving his head
from the pillow. By this means, even when a feeling of nausea is
present, it often subsides without the occurrence of vomiting. It is
advisable also not to give the patient anything to eat or drink till
about an hour after the inhalation, and, as a general rule, not even
then, unless there is some inclination for it; for if anything is taken
into the stomach before the effects of the chloroform have entirely
subsided, it is apt to excite vomiting. Even medicine, such as an
opiate, is better delayed for an hour or upwards, unless there is an
urgent necessity for giving it sooner. Severe faintness from loss of
blood during an operation of course forms an exception to this rule; in
such a case brandy and water should be given, and repeated if it should
be vomited.
These rules respecting food are, moreover, meant to apply only to the
use of chloroform in surgical operations, and not to its employment
during labour. Under the latter circumstances, one allows the patient
all the nourishment that is desirable, intermitting the inhalation now
and then for the purpose. And chloroform, given in the moderate way in
which it is employed in labour, hardly ever causes sickness, but often
alleviates it when present from physiological causes.
The sickness induced by chloroform usually subsides of itself in the
course of an hour, or even less; I, therefore, think it advisable not to
do anything for it during this space of time. When it has continued
beyond this period, I have found a little cold brandy and water to
remove it in most cases; and when the tendency to vomit still remained
after a few hours, I have seen it removed by a dose of opium.
Effervescing draughts have not appeared to be of service in the sickness
from chloroform, and sal volatile and draughts of warm water seem
injurious. It is desirable for the patient to make no effort, but only
to vomit if obliged to do so.
Several cases have come within my knowledge, in which the sickness has
continued for two or three days after every thing that was taken into
the stomach. These cases have not been under my care, but under that of
the surgeon. I have been informed, however, that all the usual remedies
for sickness were applied for the time mentioned above without success.
The cases in which the sickness lasts so long form but a very small
portion of the whole number in which chloroform is administered, and
they chiefly occur in persons who are subject to attacks of vomiting
from slight causes, or, as they say, to bilious attacks.
The most usual time for the vomiting to commence is when the inhalation
has been discontinued, and the effects of the chloroform are passing of.
In many cases, it occurs before the patient has become quite conscious,
and he does not know that it has occurred unless he is told. In a few
cases, especially where there is a good deal of food in the stomach, the
vomiting comes on before the operation is finished, or even before it is
commenced. When vomiting comes on during an operation, it is apt to
interfere with the inhalation, and it is sometimes difficult to prevent
the patient from waking; but this can be accomplished by wiping the
patient’s mouth, and reapplying the chloroform, the moment the act of
vomiting ceases. In many cases, however, the sickness does not come on
till the patient is quite awake, and perhaps, even then, not until he
moves. I believe that the sickness which is due to chloroform always
commences within an hour or two, or at the farthest, just after the
first food which is taken. I have known vomiting attributed to the
chloroform which did not occur till the following day, but I ascertained
that a dose of opium had been taken at night, and it was to this that
the sickness was probably owing. In those cases where the chloroform
does cause sickness in the first instance, it is not always the cause of
all the vomiting which the patient may suffer. If the patient becomes
infected or is inoculated with the poison of erysipelas or hospital
gangrene at the time of the operation, he will probably be attacked with
vomiting a day or two afterwards; and if sickness has already been
caused by the chloroform, that which is due to disease may appear to be
a continuation of it.
Soon after the introduction of chloroform, I administered it to a
gentleman, aged about 55, whilst a fatty tumour was removed from the
nape of the neck. It did not turn out as fatty tumours usually do, but
required to be dissected out. The patient had taken a meal before the
operation, and vomited freely afterwards. On his visit the next morning,
the surgeon thought his patient going on well. Vomiting returned,
however, and the patient became affected with partial stupor and
delirium, which his friends attributed to the chloroform. He became
covered with an eruption of erysipelas over a great part of the body,
had a very rapid pulse with great depression, and died on the fifth day.
An examination after death showed that there had been diffuse cellular
inflammation around the seat of the operation. A surgeon who assisted at
the operation on the above patient, and also at the post-mortem
examination, removed an encysted tumour from the scalp of an old lady
the day following the latter event. This operation was performed without
chloroform, but the patient was attacked with erysipelas and diffuse
cellular information, and died in three or four days.
_Faintness and Depression._ Although chloroform acts as a stimulant to
the circulation, increasing the force and frequency of the pulse whilst
it is being inhaled, it is occasionally followed by a feeling of
faintness, especially if the patient remains in the sitting posture. At
one period in the history of medical opinion, it would have been said
that the depression was a consequence of the previous excitement. The
facts, however, would not agree with such a doctrine. The subjects who
are most stimulated by chloroform are the strong and robust, and they do
not suffer from depression afterwards; whilst the feeble and
debilitated, who are most liable to subsequent depression, are but
little stimulated by it at the time of inhaling. Some amount of
faintness and depression usually accompanies the sickness caused by
chloroform, and is in fact a consequence of it, being, like the
sickness, most frequent after a full meal. This depression is usually
relieved by vomiting. I have met with a few cases in which there has
been more decided faintness, and once or twice absolute syncope after
chloroform, which was not attributable to loss of blood. In these cases,
however, the patients were in the sitting posture, and they recovered
from the syncope immediately, on being placed horizontally. The patients
most subject to faintness after chloroform are those who are subject to
this affection at other times, being often persons in a state of anæmia,
or having the symptoms of fatty degeneration of the heart. Faintness is,
however, very much more rare after operations with chloroform than
without it. The only cases in which I have seen it follow the use of
chloroform in the horizontal position, and where there was no
considerable loss of blood, have been two or three of operations on the
rectum, performed before breakfast, and after a brisk purgative had been
taken the previous night. It might be advisable, where persons in a
state of debility have taken a purgative, to make an exception to the
usual rule of prohibiting the breakfast, and to risk the inconvenience
of vomiting rather than the more formidable symptoms of faintness from
inanition.
The faintness which now and then follows an operation under chloroform
should be treated on ordinary principles, as the horizontal posture, the
application of the vapour of ammonia to the nostrils, and the exhibition
of brandy or wine, if the other measures do not suffice. I never give
ammonia internally where a patient is sick or faint, but the spirit of
sal volatile, when at hand, serves very well to pour on the corner of a
towel and apply to the nostrils.
_Hysteria._ I have already stated (p. 51) that chloroform occasionally
excites hysteria in those who are subject to that complaint; and that,
in a few cases, the hysteria, which has been subdued by the chloroform,
reappears as the effects of the vapour subside. It is nearly always in
the female sex that one meets with these phenomena, although I have two
or three times seen hysterical symptoms in the male for half an hour or
so after the inhalation. The hysteria commonly takes the form of
laughing or crying, but the patient sometimes remains quiet, and simply
in an unconscious state. The hysterical symptoms usually pass off
spontaneously, in half an hour or less, without any remedies; if they
last longer, the ordinary remedies for hysteria may be applied. I am not
aware that the hysteria has lasted longer than three or four hours in
any of the cases in which I have administered chloroform, but it may
have done so without my being informed of the circumstance. I was
informed of the case of a young woman in King’s College Hospital, who
remained unconscious, or at least apparently so, for three days after
chloroform had been administered for an operation, the nature of which I
have forgotten. She recovered without ill effects. When the patient does
not wake spontaneously, and cannot be roused to the waking state, within
twenty minutes or half an hour after the inhalation of chloroform has
been left off, we may rest assured that the patient is affected with
hysteria—at least this has been the case in every instance with which I
have become acquainted. The physical properties of this agent do not
permit it to remain long in the system, if the circulation and
respiration are going on properly, and this circumstance ought to
prevent unnecessary alarm, in the absence of other symptoms except the
state of unconsciousness. I have, however, known great alarm to exist
where the properties of chloroform were not well understood. Soon after
its introduction, a medical man administered it to a young woman in
domestic service, for the extraction of a tooth. He became alarmed, in
the first instance, from the impression that he had given an overdose.
In a few minutes, however, the patient burst out in a loud fit of
laughter, but again became unconscious, and various measures were used
to restore her, including even artificial respiration, in the idea that
she was still under the influence of chloroform. I was sent for
thirty-six hours after the inhalation, and found the patient apparently
in a profound state of insensibility, and breathing very feebly. Guided
by the considerations mentioned above, I concluded that she was only
labouring under hysteria, and that the anxiety of those about her tended
very much to keep up the complaint. The anxious attendance on her was
discontinued, she took some medicine containing valerian, and became
quite conscious in few hours. I was told, however, that she did not seem
quite well for some time.
I am not aware of any permanent ill effects having been produced by
chloroform, although, amongst the multitudes of persons who have inhaled
it, some have not failed to blame it for symptoms that have occurred
afterwards.
A clergyman from the country called on me, in 1852, and the following
are some notes I made when he left my room. He is 63 years of age. He
said that he had inhaled chloroform about a year ago to have four teeth
extracted. He felt very well for about a week afterwards, but on his
pupils returning, and his beginning to apply himself to teaching, he
became affected with flushings of the face and a rushing noise in his
head, which lasted occasionally for a day or two, and have troubled him
ever since. An eminent physician, whom he named, prescribed quinine,
under the use of which he became worse. An eminent surgeon prescribed
infusion of hops, etc., and he has tried other medicines without good
effect. He had been recommended to travel, and had been to Switzerland;
but the complaint troubled him when at leisure, as well as when applying
himself mentally. He could not sleep at night, when affected with the
attacks. He is rather deaf, and has been so for three or four years; he
was also occasionally troubled with a rushing sound behind the ears
before he inhaled the chloroform. He is rather short and rather stout,
and has a florid complexion. The pulse was rather feeble. The second
sound of the heart was rather louder than the first. In other respects
its sounds were natural, but its impulse was not strong. In every
respect, except the symptoms above named, the health of the patient was
good, and he felt quite well between the attacks.
It was my opinion that the complaint of this gentleman was coming on
long before he inhaled the chloroform, and that it depended on a much
less transient cause. I have not heard from him since.
CAUSE AND PREVENTION OF DEATH FROM CHLOROFORM.
All narcotics are capable of causing death, and the discovery of
preventing pain by inhalation consists essentially in carrying the
effects of a narcotic much further than had previously been the custom;
there was, therefore, every reason to apprehend that accidents might
occur in the new practice, unless the effects of the medicines employed
could be very effectually controlled. There are certain circumstances
connected with the physiological properties of chloroform, as
ascertained in the experiments previously related, which indicate how
accidents may very easily happen with this agent, if not carefully and
systematically managed. It was calculated (p. 74) that 18 minims of
chloroform is the average quantity in the system of an adult, when
sufficiently insensible for a surgical operation, and that this amount
might be absorbed by the use of 36 minims, allowing one-half of the
quantity breathed to be exhaled again, without being absorbed; but 36
minims of chloroform make only 37·5 cubic inches of vapour, which, at
the temperature of 60° Fah., may exist in combination with 257 cubic
inches of air, making it expand to not quite 300 cubic inches; the whole
of which might be breathed in twelve ordinary inspirations of 25 cubic
inches each. If the inhalation of vapour of this strength were continued
till insensibility was induced, the lungs would still contain a great
quantity of unabsorbed vapour. The amount of air usually present in the
lungs is about 250 cubic inches, and if saturated with chloroform at the
temperature of 60° it would contain the vapour of 30 minims. About half
of this might be absorbed, the remaining half passing off in the expired
air; but the addition of 15 minims to the 18 minims already absorbed
would almost double the quantity of chloroform in the system, and bring
the patient necessarily to the brink of death. It is true that, in the
ordinary methods of inhalation, the air seldom becomes quite saturated
with vapour, and usually is not more than half saturated, or accidents
might be of much more frequent occurrence; but the above considerations
are sufficient to show that the amount of vapour contained in the air
breathed by the patient should not be left to mere accident, such as the
varying temperature of the handkerchief from which the chloroform is
breathed, or the greater or less extent of wetted surface over which the
air passes. It should be recollected also that the patient sometimes
draws a deep and sudden inspiration by which he may inspire 100 cubic
inches of air, which would contain, if strongly charged with vapour, ten
or twelve minims of chloroform—a large quantity to be suddenly added to
that already in the circulation, when the patient is insensible, or
nearly so.
It is, however, only by a knowledge of the different modes in which
chloroform is capable of causing death, that the exact nature of the
accidents from this agent can be understood, together with the means of
preventing them, and the reason why they are usually irremediable when
they happen. If animals are kept for a very long time under the deep
influence of chloroform, they become ultimately exhausted, the
circulation and respiration are gradually weakened, and cease nearly
together. Such a mode of death from this agent is never likely to occur
to the human subject, and therefore need not engage our further
attention. The following experiments illustrate the different modes of
dying, when death is caused more suddenly by this agent.[57]
_Experiment 23._ A young but full grown cat was placed in a glass jar,
of the capacity of 1,600 cubic inches, and a fluid drachm of chloroform
was introduced, by a portion at a time, through a tube in the cover of
the jar. As twenty-five minims of chloroform produce twenty-six cubic
inches of vapour, the atmosphere which the cat had to breathe contained
nearly four per cent. of vapour, and the jar was moved about, to ensure
the uniform mixture of the vapour with the air. In five minutes, the cat
became insensible, and lay breathing naturally. In about ten minutes
more, the breathing became very feeble, and it ceased altogether in
about another minute, or sixteen minutes after the cat commenced to
breathe the chloroform. It was immediately taken out and laid on a
table, and the stethoscope was applied to the chest. The heart could be
heard beating distinctly at first, but the pulsations became slower and
feebler, and in about a minute they could be no longer heard. Just at
this time, however, the cat took a gasping inspiration, and immediately
the heart was heard to beat in a most rapid manner. The gasps were
repeated, and the action of the heart became less rapid, but stronger.
In a little time, both the breathing and the action of the heart became
natural, the cat remaining, however, insensible for some minutes.
_Experiment 24._ A cat, about the same size as the last, was put into
the same jar, and the same quantity of chloroform was introduced. It was
removed at the end of four minutes, when it was so far insensible as to
offer no resistance. Being laid on the table, it was made to breathe air
charged with ten per cent. of vapour of chloroform from a bladder.
Twenty-five minims of chloroform were put into the bladder, which held
250 cubic inches, and it was filled up with the bellows. A portion of
another bladder which was attached to the stop-cock, was made to
surround the head of the cat, which consequently breathed to and from
the bladder. In half a minute it was quite insensible: in about half a
minute more the breathing became difficult, and the sounds of the heart
less distinct. The breathing became gradually slower, and ceased
altogether between three and four minutes after the respiration from the
bladder commenced. The sounds of the heart were rather frequent, and
scarcely audible, just before the breathing ceased, and they could not
be heard afterwards. The chest was opened three-quarters of an hour
after death. The lungs were of a pale red colour, everywhere permeated
with air; and a small quantity of fluid blood flowed from them on making
an incision. The right cavities of the heart were quite full of blood,
and the left cavities contained a small quantity.
_Experiment 25._ A cat was made insensible in the same manner as the two
previous ones. As it made strong efforts to get out of the jar, and
consequently breathed more deeply, the chloroform took effect sooner;
and it was removed and laid on the table, in a passive state, at the end
of two minutes and a half. The respiration and sounds of the heart were
quite natural. The nose of the animal was placed in the mouth of a metal
vessel, lined with bibulous paper, and used as a chloroform inhaler. The
inhaler contained chloroform, and was surrounded with water of the
temperature of 110° Fahr. The stethoscope was kept applied to the chest
whilst the chloroform was exhibited. After four or five inspirations
from the inhaler, the heart suddenly ceased to beat, the breathing still
going on. The inhaler was removed as soon as I was satisfied that the
action of the heart had ceased, and there were two or three rather
convulsive respirations afterwards, and then the breathing stopped; but,
between one and two minutes later, there were two or three feeble
inspirations, accompanied with motion of the nostrils, but no returning
action of the heart could be heard. The chest was opened ten minutes
after death. The lungs were quite pale throughout. There was a little
clear serum in the pericardium. The heart appeared quite motionless when
first observed; but, after exposure to the air for a short time, there
were some slight contractions of a few fibres of the right ventricle.
The right auricle and ventricle were filled with blood.
The air which this cat breathed must have contained much more than ten
per cent. of vapour.
In experiment 23 the breathing was arrested by the influence of the
chloroform on the nervous centres, but the action of the heart
continued, until it was stopped, or very nearly so, for want of
respiration, as in asphyxia from privation of air. In experiments 24 and
25 the action of the heart was arrested by the direct effect of the
chloroform; in one instance at the same moment as the respiration, and
in the other instance, even before it.