Part 31

A patient, to whom I was recommended by Sir John Forbes, inhaled chloroform in three confinements. She recovered favourably from the two first; but on the third occasion, after going on favourably till the fifth day, she was attacked with puerperal fever, and died on the seventh day from her confinement.

I am not aware that more than one death has been recorded as having occurred from chloroform during labour; and this took place in England, in 1855, when no medical man was present. The patient had inhaled chloroform in America in a previous labour; but her medical man, on the last occasion, who was her particular friend, forbad that agent, and said that if she was determined to have it, he would not attend her. She procured chloroform unknown to him, and a number of scents to put on her handkerchief and hide the odour of it from him. He went to bed in the house, and was not called up till his patient had been dead about an hour. The monthly nurse, who had procured the chloroform for the patient, said that she snored very loudly for an hour after she fell asleep. About five drachms of chloroform were used from the bottle, and the handkerchief from which it was inhaled remained close to the patient’s face till she died. The death seemed to have taken place very slowly, and the monthly nurse was extremely stupid to allow the patient to die. It may also be remarked that the accident would not have taken place except for the medical man’s extreme objection to the use of chloroform.

The chloroform has been occasionally blamed by the friends of patients, or medical men opposed to its use, in cases where patients have died from puerperal convulsions or other causes, so long after the vapour had been left off that it could not be the cause of death. The following case shows how easy it would be to make a mistake with respect to the effects of chloroform. Soon after its introduction, I was requested to administer it to the wife of a medical man who had a great desire for it in her confinement. Mr. Propert was to attend the lady. I was sent for late one evening, but as there were no pains at the time when I arrived, I was requested to go to bed in the house. After a time, I was called by a servant, who told me that the baby was born, and that Mr. Propert was sent for. I found that the birth had been so sudden that the husband, who was in the room, could not get to the bed side before the child was born. Mr. Propert arrived, and I went home, leaving the patient very well. Mr. Propert informed me, that after I left the patient went into such a state of syncope as to make him think she was going to die, and continued so for some time. She ultimately recovered. There was no hæmorrhage or any other cause to account for the faintness, and I understood Mr. Propert to say, that if the patient had inhaled chloroform, he should have blamed it for the condition into which she lapsed.

THE INHALATION OF CHLOROFORM IN MEDICAL CASES.

Neuralgia. When the pain of neuralgia is not extremely severe, it may be removed by the inhalation of chloroform without causing unconsciousness; but when it is very severe, it is necessary to make the patient unconscious before the pain is suspended. In some cases of neuralgia of the face, the pain is so severe that the signs of it remain after the patient is rendered unconscious, and only disappear when he is quite insensible; and then, as the insensibility passes off, the hand is raised to the face, and the contortions of the features return before the patient awakes to be aware of his suffering. When the mental branch of the fifth nerve is affected, the paroxysms of pain are accompanied by a motion and smacking of the lips. In a hospital patient I have seen this when he was awake, but in a gentleman only when his consciousness was removed by the chloroform, and before complete insensibility was induced; when awake, he restrained the impulse to this kind of motion of the lips.

In administering chloroform it is desirable to continue it steadily and gradually till the pain is relieved; and if the patient is rendered unconscious before the pain is removed, to continue it till all signs of suffering disappear. After the first inhalation of the vapour, the pain will generally return in a few minutes, but when again subdued, it will not return so quickly; and after it has been suspended a few times by the repetition of the chloroform during the space of an hour or so, the pain is usually removed either permanently or for two or three hours. In some cases I have had to repeat the chloroform occasionally throughout the day, and, on one or two occasions, for two or three days in succession. The chloroform can, in general, only be considered a temporary remedy, and therefore such other medicines should be applied as may be thought advisable.

When I have prescribed chloroform in a liniment, to be applied to the face, the patient has often found out that he obtained more relief by smelling at the liniment than by applying it. Chloroform generally gives great relief, however, when applied locally in neuralgia, either alone or mixed with camphorated spirit; it is advisable to apply it on a piece of lint or blotting paper, which should be covered over with tinfoil, or some other impermeable substance, to prevent the evaporation. It causes about as much heat and uneasiness as a mustard poultice, before it relieves the pain.

Spasmodic Asthma. On November 12th, 1850, I administered chloroform in the Hospital for Consumption, at Brompton, to a married woman, aged thirty-five, a patient of Dr. Cursham. She was in a fit of spasmodic asthma, but was the subject also of chronic bronchitis. Twenty minims of chloroform were inhaled from an inhaler. It gave immediate relief, producing a momentary state of unconsciousness, or a state bordering on it. In a few minutes the difficulty of breathing gradually returned, but not to the same extent, and the inhalation was repeated with a like effect. The difficulty of breathing returned less quickly and severely; and after a third inhalation of twenty minims she was completely relieved, and could lie down. The patient had a good night, and was better next day. On the 14th, she had another fit of spasmodic asthma, which was relieved completely by the chloroform in the same manner as the previous one. This patient inhaled extract of stramonium every evening, by a method which will be described further on.

Other cases of spasmodic asthma have been relieved as readily and completely; but in one or two cases, in which the difficulty of breathing seemed to depend on disease of the heart, the relief was not so great; the patient went to sleep, but the breathing remained embarrassed.

Spasmodic Croup. I have administered chloroform in seven cases of this complaint. It was recommended in every instance by Dr. Ferguson, and all the cases ended in recovery. The children were from eight months to two years of age; the majority being about a year. I always gave enough chloroform to cause a state of unconsciousness, for which a few minims suffices in a young child, and when the effect passed off, or nearly so, I repeated the dose. I generally gave five or six doses in the course of about half an hour, after which the child would often sleep for two or three hours. In the milder cases it was repeated once a day; but in the more severe cases it was continued, in the above manner, twice a day. I administered it to a patient of Dr. Van Oven, respecting whom Dr. Ferguson had been consulted, for fifteen days, twice every day, excepting the last three days. This child was very ill when the treatment was first commenced, having a severe fit of spasmodic breathing every five minutes. When the chloroform is given during the spasm, it is desirable to give it very cautiously.

Mr. W. J. H. Cox read a paper on the treatment of laryngismus stridulus, with chloroform, at the London Medical Society, in 1850. He had entrusted the administration of it to the mother or nurse, and directed it to be given whenever the spasmodic breathing should come on. I am inclined to think that this would be the best way of giving it, if one could be quite sure of the intelligence of the party to whom it was entrusted.

Hooping-Cough. I have only administered chloroform in two cases of this complaint. It was recommended in both cases by Dr. Ferguson. One of the children was extremely ill of bronchitis, and it died. The other child recovered, but the chloroform was not continued. I am not aware that chloroform has had any fair trial in hooping-cough. It should be given whenever a fit of coughing comes on.

Infantile Convulsions. I have administered chloroform in two cases of this disease, with the effect of relieving the convulsions, but the children died. They were both extremely ill before the chloroform was administered. One was the patient of Mr. Walter Bryant, and Dr. Seth Thompson was consulted about it. A case has been related by Dr. Simpson of Edinburgh, in which the chloroform was continued for a day or two, and in which the infant recovered.

Delirium cum Tremore. Some cases have been related in the medical journals, in which this complaint was treated successfully by chloroform alone; but I prefer to use this agent only as an adjunct to the treatment by opium. Sometimes the patient is so violent and suspicious that he cannot be made to take opium; but it is much easier to make a person breathe a medicine, than swallow one. It is only necessary to hold a patient, and to apply the chloroform near his face, and he is obliged to breathe it, and as the effect of it subsides, he recovers the power of swallowing before his delirium returns; for whilst he is still unconscious, he will swallow whatever is poured into his throat. Opium can be administered, and the chloroform can be repeated occasionally so as to keep him asleep for an hour or two till the opium takes effect and prolongs the sleep. It is a great advantage of chloroform that the delirium may be subdued in a few minutes by it, and can be kept away till opium takes effect.

In certain cases of delirium cum tremore, such a quantity of opium is taken without procuring sleep, that the medical attendant has, what I believe to be, a well-grounded fear of giving more. A patient whom I saw with Mr. Peter Marshall, in April 1850, had taken ten fluid drachms of laudanum and two grains of acetate of morphia, within twenty-four hours of my seeing him, without any sleep being procured. He was put to sleep immediately by chloroform, which was repeated on the following day. The patient got quite well in a few days.

In December 1851, I saw a patient who had had no sleep for four days, except three intervals of a quarter of an hour each, although a great deal of opium had been given. He was very violent; and for the last twelve hours had spat out all the medicine that was given to him; his pulse was small and very rapid. He was made insensible in a few minutes, and the chloroform was repeated, at intervals, for half an hour, so as to keep him unconscious. Fifty minims of tincture of opium were given in one of the intervals. I waited an hour and a quarter after the chloroform was discontinued; the patient was still sleeping, and his pulse was less frequent. I learnt that when he awoke he was quite free from delirium, and he was well in a few days.

Delirium in Fever. In November 1857, I administered chloroform to a youth of seventeen, who had been ill of typhoid fever for sixteen days. He had been in a state of constant delirium for upwards of forty-eight hours without having the least sleep, although he had had tincture of opium in divided doses to the extent of forty-five minims, and had taken a tablespoonful of wine every four hours. The chloroform was continued gently for half an hour; he slept for an hour afterwards, and at intervals during the night. He was a little better in the morning; and the delirium was not again so violent as it had been. He died on the nineteenth day of the fever, from a recurrence of diarrhœa.

Dr. Fairbrother, of Bristol, gave small doses of chloroform by inhalation, with the best effects, in a case of typhus fever, in the Bristol Infirmary. The patient was delirious and worn out for want of sleep, her life being in fact despaired of. She inhaled the chloroform occasionally for several days, sleep being always procured when it was applied, and she recovered without any other medicine.

Hydrocephalus. I administered chloroform on two occasions, for half an hour at a time, to a child, seven years old, when delirious and screaming violently, in this complaint. The child was much relieved by the inhalation, but it died on the fourteenth day of the disease.

Tetanus. I have notes of three cases of tetanus in which I have administered chloroform. The first was a patient of the late Mr. Keate, in St. George’s Hospital, in February 1849. It was a girl, fourteen years old, who had received some severe burns in the face and various parts of the body, a fortnight previously. Four days before inhaling the chloroform, she was attacked with symptoms resembling those of chorea, but for the last two days the complaint was recognised to be tetanus. There was rigidity of the spine and jaws, and of one arm, which was flexed. Spasms came on every minute or two, affecting, more particularly, the head and the arm. I commenced to give chloroform very gently at four in the afternoon. It prevented the spasm before consciousness was quite removed. Whenever the spasm offered to return, the inhalation was repeated with the effect of stopping it. The chloroform was continued till half-past five, with the effect of keeping the spasm away; and the patient took some drink during this time, better than she had done previously. I saw the child again at eight o’clock in the evening, and found that the spasms had returned soon after I left, and had continued as before. The chloroform was given again at intervals for an hour and a half, with the effect of keeping away the spasms, and inducing sleep; but I found that the child was getting weaker, and would die even if the spasm was entirely prevented. She died at a quarter past eight the following morning. There was no inspection of the body.

The next case was a patient of Mr. Propert, a boy, ten years of age, who had suffered from sloughing of the skin of the inferior extremities. The tetanus came on during the healing process, whilst the greater part of both extremities was in a state of ulceration, and covered with healthy granulations. The patient was in a very irritable and feeble state, and his pulse was 150 in the minute. He was made insensible, and the chloroform was repeated twice in the space of half an hour. No relaxation of the muscles of the jaws was produced, although the effect of the chloroform was carried as far as seemed safe in such a subject. He died twelve hours afterwards.

I administered chloroform lately to a patient of Mr. Salmon in St. Mark’s Hospital. He underwent an operation by ligature for prolapsus ani and hæmorrhoids on March 1st; on March 5th tetanus commenced, and on March 7th chloroform was administered whilst Mr. Salmon removed some sloughs from the anus; and it was repeated occasionally afterwards. The patient was a man, fifty-two years of age; he was the subject of kidney disease, and the tetanus was extremely severe. He had had four doses, each containing a fluid drachm of laudanum, between the time when the tetanus commenced and his inhaling the chloroform. His pupils were contracted, and he was made insensible by an extremely small quantity of chloroform. He was, in fact, very much under the influence of opium, although the spasm of the tetanus prevented his sleeping.

Chloroform affords great relief to the patient affected with tetanus, and it probably increases the prospect of recovery in cases which are not too severe and acute.

Epilepsy. Dr. Todd at one time had chloroform administered by inhalation, in King’s College Hospital, to the extent of causing insensibility, at stated intervals, in cases of epilepsy, and he thought with advantage. I have frequently administered chloroform for surgical operations to patients who were subject to epilepsy, and have very rarely found it produce any approach to a fit.

In July 1850, I administered chloroform to a boy, seven years old, in an epileptic fit, which had lasted about an hour when the inhalation was commenced. He had had fits previously, the last of which had occurred a year before, but none of them had lasted so long as the existing one. He had eaten nine new potatoes for his dinner, at one o’clock, and the fit came on about eight. I found the abdomen swollen and very tympanitic. There was constant convulsive motion of the right arm, and of the neck; the latter drawing the head to the right side. The mouth was also drawn to the right at each convulsive motion. The chloroform was given by putting a few minims at a time on a handkerchief, and holding it to the mouth and nostrils. It caused immediate cessation of the convulsions every time it was applied. The convulsions, however, returned again in a minute or two. In the intervals that he was partially under the influence of the vapour, he breathed easily without stertor. The convulsions became gradually less severe, and ceased entirely ten or fifteen minutes after the commencement of the inhalation.

Puerperal Convulsions. I have not been called to any case of this complaint since chloroform has been in use; but some cases have been related in the medical journals in which the inhalation of chloroform has been employed with a favourable result. One case is related by Mr. Henry Rudge, of Leominster. When the chloroform was administered, the patient was in violent convulsions which came on in frequently succeeding fits. The os uteri was dilated, and the head presenting. The pains were entirely arrested. The chloroform was administered by twenty minims, at intervals, on a folded handkerchief. The convulsions, after a few inhalations, entirely ceased, and Mr. Rudge extracted the child without difficulty. There was another child with the head presenting: it was delivered with the forceps. The placenta was delivered with the hand on account of smart hæmorrhage. There was only one attack of convulsions after delivery, and the patient recovered favourably. It was her first labour, and her age was twenty-three years.

A case of puerperal convulsions was related by Mr. Andrew Bolton to the Newcastle and Gateshead Pathological Society. His patient, aged twenty-two, was at the full period of her first pregnancy. The os uteri was high, slightly dilated, and extremely rigid. She was treated at first by blood-letting, and full doses of morphia. Mr. Bolton says: “As her condition appeared hopeless should the paroxysms continue, chloroform was administered on a piece of linen, in half-drachm doses, and its full effects kept up for three hours. At two P.M., there was a slight return of convulsion; skin warm and perspiring; the os uteri was found steadily dilating; and from her uneasy movements, it was apparent that uterine action had begun.

“Half-past three. The membranes were ruptured; and brisk uterine action ensuing, a dead child was expelled, immediately followed by the placenta. She regained her senses during the expulsive efforts, but appeared entirely ignorant of her previous condition. Recovery followed without any bad symptom.