Part 12

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. 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. 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.

It is desirable not to talk to the patient as he is recovering from the 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.