finger of a robust, healthy-looking young man, in the Royal Infirmary.
He was already under the influence of chloroform when I entered the
room, and as there had been some difficulty in producing complete
anæsthesia, and the last of the chloroform in the bottle was already on
the handkerchief, it was thought advisable by my friend in charge of its
administration to keep up the inhalation, in order to produce a coma
sufficiently profound to last until the completion of the operation. It
was therefore left over his face, and I commenced and removed the
finger, slowly disarticulating it from the metacarpal bone. I distinctly
recollect hearing the man breathing quickly and shortly; and I also
remember, that when just about to look for the vessels, my attention was
attracted to his condition, by not any longer hearing the respiration.
The handkerchief was still on his face. I took it off, and found, to my
consternation, that the breathing had ceased; the face was livid; the
eyes suffused; the pupils dilated; the mouth half open. He was to all
appearance dead; still the pulse could be distinguished as a small,
hardly perceptible thread, beating slowly. Immediately artificial
respiration was commenced. For a minute or two, his condition did not
alter in any respect—then the lividity of the countenance increased, the
pulse was no longer perceptible, and the sounds of the heart could not
be satisfactorily heard. During the whole of this time, artificial
respiration had been diligently employed, but still the air appeared to
enter the chest very imperfectly. I despaired. I felt certain that the
man was dead, and that no human aid could restore him; and if it had not
been that those standing near me urged me to persevere, I believe I
should then have deserted the case as hopeless. Just at this time it
occurred to me to put my finger in the mouth and draw forward the
tongue, in order to secure there being no impediment to the air entering
the lungs. Retaining it in this position, we again began the artificial
respiration, and found that then the chest was fully expanded by each
inflation. After keeping it up for a minute or two, the gentleman, who
had all along kept his hand on the pulse, exclaimed, to our delight,
that he could again feel it—‘It was just like a slight flutter that
reached the uppermost of his four fingers,’ all of them being placed
over the course of the artery. It gradually became more distinct and
firmer, and at the same time, the lividity of the face decidedly
lessened. In another minute, the man made a slight inspiratory effort. I
ceased directly the artificial respiration, and merely assisted the
expiration by pressure upon the ribs. Another and another inspiration
followed, and in a short time he breathed freely without assistance. The
countenance became natural, and he appeared as if in a sound sleep. In
half an hour, he spoke when roused; then he vomited, and complained of
giddiness. In an hour afterwards, he had recovered sufficiently to walk
home.
“Moments of intense anxiety appear much longer than they really are; but
even allowing this, I am quite sure that, at the very least, five
minutes elapsed from the time when the man ceased breathing before the
first inspiratory effort took place, and that for not less than one
minute the pulse was imperceptible, and the heart’s action almost, if
not altogether, inaudible.”
“_Case 4._ A few weeks after the occurrence just described, I was
assisting Mr. Syme in removing the breast of a lady. A gentleman, my
superior in the hospital, was conducting the inhalation of chloroform.
Anæsthesia was complete, and the breathing good, when the operation
commenced. The chloroform was allowed to remain over the face during the
whole time of its performance. Before it was over, I noticed the
respiration become very quick and incomplete, and suggested, in
consequence, the propriety of removing the handkerchief. My remark was
neglected for eight or ten seconds, and then, just as it was taken away,
the breathing ceased suddenly. The face became deadly pale; the eyes
vacant; the lips livid. Instant dissolution appeared inevitable (the
pulse was not felt). Artificial respiration was immediately commenced,
but the air not entering the lungs freely, the tongue was pulled
forwards, and retained so by the artery forceps. The chest then expanded
freely with each inflation, the air escaping with a cooing sound. In
rather less than a minute, the respiratory movements recommenced, but at
first so slowly and imperfectly that it was necessary to assist
expiration. When recovery was a little more established, the operation
was completed. Before the putting in of the sutures, sensation had
partially returned, and in a short time the lady had perfectly
recovered.”
Mr. Bickersteth very properly adds: “There can be no doubt, that in the
foregoing cases, a grievous error was committed by continuing the
inhalation after anæsthesia was produced, and that it was in consequence
of this, the accidents, so nearly fatal, occurred.”
As these accidents seem to have occurred from continuing the inhalation
too long, they differ entirely from nearly all those which were actually
fatal, and which, as we have seen, arose from the too great
concentration of the vapour, and not from any want of care in watching
the patient, so as to be able to leave off at the right moment, if it
were possible. I have previously stated, that after breathing vapour of
the proper strength for inhalation, animals may always be readily
restored by artificial respiration after the breathing has ceased,
provided the heart is still beating. In the cases related by Mr.
Bickersteth, the heart had ceased to beat before the patients were
restored; but in the third case, there is distinct evidence that the
heart continued to beat for four minutes after the breathing had ceased.
It was, therefore, certainly not paralyzed by the direct action of the
chloroform. The patient was nearly in the condition of a drowned person,
where we know that there is a good prospect of recovery by artificial
respiration during the first few minutes after the breathing has ceased,
even if the action of the heart be imperceptible. In the other three
cases, also, it is probable that the breathing ceased before the action
of the heart; and, at all events, this organ was not paralyzed so
thoroughly as in the cases in which artificial respiration was promptly
applied without effect.
Several other cases have been related in the medical journals in which
patients have been restored by artificial respiration, after animation
had been suspended, more or less completely, by chloroform; but the
above remarks would, I believe, be applicable to all these cases.
Where patients have recovered under the use of other measures, without
artificial respiration, it is probable that animation was not completely
suspended, and that the recovery was spontaneous.
M. Delarue related a case of accident from chloroform to the Academy of
Medicine, on August 20th, 1850, which was apparently of this nature.
After administering the vapour, and when he was about to divide some
sinuses in the thigh, he found that his patient (a woman) was in a state
of collapse, and the breathing and pulse, “_pour ainsi dire_”,
insensible. The face was injected, and there was a bloody froth at the
mouth. The uvula was titillated, and there was immediate movement of the
eyelids, which was soon followed by copious vomiting, and the patient
recovered.[140]
Such measures as dashing cold water on the patient, and applying ammonia
to the nostrils, can hardly be expected to have any effect on a patient
who is suffering from an overdose of chloroform; for they would have no
effect whatever on one who has inhaled it in the usual manner, and is
merely ready for a surgical operation, but in no danger. I have applied
the strongest ammonia to the nostrils of animals that were narcotized by
chloroform to the third or fourth degree, and it did not affect the
breathing in the least. They recovered just as if nothing had been done.
It is difficult to suppose a case in which the breathing should be
arrested by the effects of chloroform whilst the skin remained sensible,
yet it is only in such a case that the dashing of cold water on the
patient could be of use. There is, however, no harm in the application
of this and such like means, provided they do not usurp the time which
ought to be occupied in artificial respiration; for this measure should
be resorted to the moment the natural breathing has entirely ceased.
I have only seen two cases in which the patients seemed in imminent
danger from the direct effects of chloroform. One of these occurred in
1853. It was the case of a child, aged six years, but small and
ricketty, which had the greater part of the eyeball removed on account
of melanotic disease. The usual inhaler was employed, and when the child
seemed sufficiently insensible, it was withdrawn. The operation was
commenced by introducing a large curved needle, armed with a thick
ligature, through the globe of the eye, in order to draw it forward. As
the needle was introduced, the child cried out a very little, and
thinking the parents, who were in the adjoining room, would be alarmed,
I poured some undiluted chloroform hastily on a rather large sponge, and
placed it over the nostrils and mouth. The sponge became pressed by the
surgeon’s hand closer on the nose than I intended, but it was removed
after the child had taken a few inspirations. The operation was quickly
concluded without any further sign of sensation than that mentioned
above. At the end of the operation, the breathing was natural, but the
face was pale, and the lips blue, and the limbs were also relaxed. I
tried to feel the pulse at the wrist, but did not discover any. The
chloroform had at this time been left off half a minute at least. The
pallor and blueness continued, and in a little time the breathing became
slow and embarrassed, and appeared about to cease altogether, the pulse
being still absent. The windows were opened, and cold water dashed
freely on the face. The child made gasping inspirations now and then,
but they did not follow immediately, or seem connected with each
application of the water. The gasps became more frequent, till the
breathing was thoroughly reestablished, when the colour returned to the
lips, and the pulse was again felt at the wrist. In a minute afterwards,
the child was red in the face, and crying violently from pain, which was
relieved by a little more chloroform. It appeared to be a minute or a
minute and a half from the time when the sponge with chloroform was
removed, till the breathing became of a gasping character. There is no
doubt that in this case the heart was paralyzed, or nearly so, by the
chloroform, and that its action was restored by the spontaneous gasping
inspirations of the child. The accident could have been prevented by
having the chloroform, which was put on the sponge, diluted with spirit.
The other case occurred in the latter part of 1852. I have no notes of
it, as it took place at the beginning of an illness, which prevented me
from writing for some time; but I recollect the chief particulars of it
sufficiently well. The patient was a lady rather more than sixty years
of age, rather tall and thin. She required to have a polypus removed
from the nose. Mr. Fergusson, who was about to operate, was nearly an
hour after the appointed time, and during this interval she was pacing
up and down the room, apparently in a great fright. She was placed in an
easy chair for the operation, and the pulse was small and feeble when
she began to inhale. Nothing particular occurred during the inhalation,
but just at the time when the patient was becoming insensible, the
breathing ceased, and the pulse could not be felt. She appeared to have
fainted, and was immediately placed on a bed which was in the room. I
applied my ear to the chest, but could hear no sound whatever. Mr.
Fergusson applied his mouth to that of the patient, and with a very
strong expiration, inflated her lungs, so as to expand the chest very
freely. I immediately heard the heart’s action recommence with very
rapid and feeble strokes, as I had so often heard it recommence in
animals. The patient soon began to make distant gasping inspirations,
and the natural breathing and pulse were soon reestablished. Mr.
Fergusson made only one or two inflations of the lungs after the first
one, which of itself was the means of restoring the patient. It was
about twenty minutes, however, before she became conscious; and during
the greater part of this time there were spasmodic twitchings of the
features and limbs on one side. In about an hour, she was pretty well;
and on the following day the operation was performed without chloroform.
The most ready and effectual mode of performing artificial respiration
is undoubtedly the postural method, introduced by Dr. Marshall Hall a
little time before his death. It consists in placing the patient on the
face and making pressure on the back; removing the pressure, and turning
the patient on his side and a little beyond; then turning him back on
the face and making pressure on the back again; these measures being
repeated in about the time of natural respiration.
Whether the artificial breathing is successful or not must depend
chiefly on the extent to which the heart has been paralyzed by the
chloroform, as was previously observed. The fact of the breathing
continuing after the action of the heart has ceased, in some of the
fatal cases, shows that the heart may be so paralyzed as not to be
readily restored by the breathing. It is probable that in all cases in
which artificial respiration can restore the patient, its action would
be very prompt; still it is desirable to persevere with this measure for
a good while.
As already stated, there is every reason to conclude that the right
cavities of the heart are distended with blood, in all cases of
suspended animation by chloroform, and therefore it would be desirable
to open one of the jugular veins if the artificial respiration does not
immediately restore the patient. In opening animals, just after death
from this agent, I have observed the contractions of the heart to
return, to a certain extent, when the distension of its right cavities
was diminished by the division of the vessels about the root of the
neck. Opening the jugular veins has been resorted to in a few of the
cases of accident from chloroform, but hitherto without success.
I have not succeeded in restoring an animal from an overdose of
chloroform, by means of electricity, in any case where I felt satisfied
that it would not recover spontaneously; and I have not heard of any
patient being restored by its means. For keeping up respiration,
mechanical means, such as the postural method, are better; as they cause
air to enter the lungs without exhausting the remaining sensibility. If
electricity be used, it should be directed towards restoring the action
of the heart. It is probable that the electric current would not reach
the heart without the help of the acupuncture needle; but it would be
justifiable to use this in a desperate case, when other measures had
failed. The needles should be coated with wax, or some other
non-conductor of electricity, except near the points.
In the fatal cases Nos. 40 and 48, previously related, the action of the
heart partially returned during the efforts that were made for the
restoration of the patient, but did not become thoroughly reestablished.
It is probable that the circulation through the coronary vessels of the
heart was not restored in those cases, or else the blood which must have
been freed from chloroform, in its passage through the lungs, would most
likely have enabled the heart to recover completely. Dr. Cockle has
expressed the opinion, which is very probable, that the blood enters the
coronary arteries in a retrograde manner, during the diastole of the
ventricles, when the aorta and other great arteries are contracting on
their contents; if so, with a very feeble circulation, the elasticity of
the aorta, perhaps, cannot sufficiently act to cause a backward current;
and perhaps, also, the over-narcotism of the heart is itself an obstacle
to the coronary circulation, on account of the congestion of the
capillaries which always attends on narcotism.
The knowledge how seldom anything effectual can be done for a person who
has inhaled a dose of chloroform from which he would not spontaneously
recover, ought to impress the rule very strongly on every one, to use
the greatest care in its administration.
EFFECT OF CHLOROFORM ON THE RESULT OF OPERATIONS.
Besides the great benefit conferred by chloroform in the prevention of
pain, it probably confers still greater advantages by the extension
which it gives to the practice of surgery. Many operations take place in
children which could not be performed in the waking state; excisions of
joints and tedious operations for the removal of necrosed bone are often
performed on persons who would be altogether unable to go through them
except in a state of anæsthesia; and the moving of stiff joints by force
is an operation now frequently performed, although it would probably not
have been thought of if narcotism by inhalation had not been discovered.
The surgeon also obtains the ready assent of his patient to a number of
other operations, where it would either not be obtained at all, or not
at the most favourable time, if the patient had to suffer the pain of
them.
The effect of chloroform cannot fail to be favourable, to a certain
extent, in large operations. The patient is in a more tranquil and
cheerful condition after the operation, than he would be in if he had
suffered the pain of it. His pulse is usually of the natural frequency;
and after an amputation, there is generally an entire absence of the
starting of the stump, which was formerly so distressing. After all the
minor operations in which chloroform is used, and which according to my
experience comprise at least one-half of the cases, there is never a
death; and the only inconvenience is a troublesome sickness of stomach
in a very few instances. Moreover, when patients die after the more
formidable operations, they succumb to causes which are well known, and
were in operation before the practice of anæsthesia. I only know of a
very few instances where there has been a reasonable doubt on the mind
of the surgeon, whether the chloroform may not have had some share in
preventing the recovery of the patient, after a severe operation. These
were cases in which the sickness, which occasionally follows chloroform,
continued for three or four days, indeed till the death of the patient.
This is a point which it would be difficult to decide, for the latter
part of the sickness might depend on the sinking state of the patient,
and might have come on if chloroform had not been used. Moreover, as
sickness is seldom very prolonged after chloroform in minor operations,
except in persons who are not in a good state of health, it is most
probable, that the patients who died after a great operation with
continued sickness, would not have done well if no chloroform had been
used.
Some attempts have been made to determine, by statistical inquiry,
whether the result of operations has been more favourable since the
introduction of anæsthesia. These attempts have been confined to the
larger amputations, as they are the only operations which sufficiently
resemble each other to admit of the application of statistical inquiry;
and even in the case of these operations, the inquiries which had been
made previously to the introduction of etherization differed widely in
their results.
Dr. Simpson took great trouble, in the early part of 1848, to collect
the account of the amputations of the thigh, leg, and arm, which had
been performed under the influence of ether or chloroform in forty-nine
of the hospitals in Great Britain; and for comparison, he collected from
thirty British hospitals the results of the same amputations, for the
two or three years preceding 1847. He found that the mortality in the
period preceding the use of ether was 29 per cent. in these amputations,
and the return of patients whose limbs had been amputated under the use
of ether and chloroform gave a mortality of 23 per cent.; and he
concluded that 6 per cent. of the lives of those who had undergone these
amputations had been saved by the use of these agents. In his
application for an account of cases, however, Dr. Simpson merely asked
for the number of cases, and the number of deaths. Nothing was said as
to the time when the amputations had been performed; and there is reason
to believe that a number of cases still under treatment may have been
included; some of which may have ended fatally after the returns were
made. The cutting part of a large amputation is of very short duration.
The loss of blood is not great; and patients hardly ever died during the
performance of an amputation, but some time afterwards, of diseases
which ether and chloroform have not been found capable of preventing. It
was therefore not to be expected that these agents should save the lives
of so many as 6 per cent. of those who underwent the larger amputations.
In the early part of 1849, I published an account of fifty-five
amputations of the thigh, leg, and arm, in which I had administered
ether or chloroform, and the mortality was 27 per cent.[141]
Dr. James Arnott has lately been investigating this subject in a very
persevering manner. During the last three or four years, all the cases
of amputation performed in the London hospitals have been reported in
the _Medical Times and Gazette_, together with their results; and Dr.
James Arnott has stated that the average per centage of deaths, after
the three kinds of amputation above mentioned, is 34·4 per cent. There
is obviously no means of ascertaining what was the mortality after
amputations in the hospitals of London before the use of ether and
chloroform, but Dr. James Arnott brings forward four papers, which state
the mortality for a short period, in four hospitals, a little time
before the introduction of etherization. The number of cases in these
papers is 174, and the number of deaths 41. Dr. James Arnott states the
per centage of deaths to be 21·9,[142] although it appears to me that it
would be 23·5; and it may be remarked that the four papers from which
these numbers are taken might probably not have been published if the
numbers they contain had not been favourable. Dr. James Arnott, in a
second table, gives the number of amputations and deaths from the
several hospitals in London which are named. The cases are said to have
occurred “during eighteen months from June 1855 to June 1856,
inclusive;” here being obviously a mistake. The number of cases is 204,
and the number of deaths 61; which would give a mortality of 29·9 per
cent.; almost exactly the same as that which Dr. Simpson had obtained
from thirty provincial hospitals before the use of ether. The numbers in
Dr. Simpson’s table are 618 cases, and 183 deaths, or 29·6 per cent. Dr.
James Arnott does not, however, mention the per centage of deaths in his
second table, but gives another table, for a different period, in which
the names of the hospital are not given. The numbers he gives in this
table are 430 cases and 148 deaths, giving a mortality of 34·4 per cent.
Dr. James Arnott therefore concludes that chloroform causes the death of
upwards of 12 per cent. of those who inhale it for the purpose of
undergoing amputation. It is evident that he can have had no experience
of the effects of chloroform, or he would have perceived at once the
error of his conclusions, for this agent is given for a much longer time
than in amputations, in numerous operations of which the entire
mortality is less than 12 per cent. In the removal of tumours of the
female breast, for instance, more chloroform is generally administered
than in an amputation, and the loss of blood is also much greater, yet
the entire mortality after this operation is considerably less than that
which Dr. J. Arnott supposes that chloroform adds to the ordinary
mortality after amputations.
Dr. J. Arnott stated that the pyæmia, of which many of the patients died
after amputation, had probably been rendered more prevalent and fatal by
the use of chloroform; but Mr. Thomas Holmes, in one of his able replies
to the remarks of Dr. Arnott, points out that pyæmia had been prevalent
also in cases of compound fracture, and others in which the patients had
no chloroform. He stated that this complaint had been more prevalent in
St. George’s Hospital during the three years in which Dr. J. Arnott’s
statistics of amputations had been collected, than in the previous five
years, in which chloroform had been used.[143]
A very valuable paper on the result of operations performed in the
Newcastle Infirmary, before and since the use of ether and chloroform,
was published last year by Dr. Fenwick.[144] He says, respecting his
tables, “in the first series are included the operations registered in
the operation books of the Newcastle Infirmary from 1823 to 1843; but,
as the record is imperfect, the actual period embraced is seventeen and
a half years. In the second, are the operations registered since the
first employment of ether; and as the use of anæsthetic agents has been
general in all the more important operations since that time, these
figures may be used to show any disadvantages likely to arise from the
employment of chloroform.” Dr. Fenwick continues:—“Before the use of
chloroform, there were registered 225 amputations of the thigh, leg, and
arm, of which 54, or 24 per cent., died. Since the use of anæsthetic
agents, 149 cases of similar operations have been recorded, of which 36
died, showing also a mortality of 24 per cent.
“Before, however, we can draw any conclusion from such facts, we must
carefully exclude all those circumstances which are already known to
produce an effect upon the mortality of amputations. It is, for
instance, well known that amputations performed on account of accidents
are, on the whole, nearly twice as fatal as those required for long
standing disease. Now, if we divide the foregoing numbers into these two
classes, we shall find that before the introduction of chloroform there
were 144 pathological amputations, with a mortality of 19 per cent.;
while since its employment there have been only 61, of which 13 per
cent. have died; and while of 81 traumatic amputations which took place
in the former period 32 per cent. died, only 31 per cent. perished in
the latter period. The equal mortality obtained from a general average
of all amputations is thus seen to have arisen from the smaller
comparative number of operations performed for diseases.”