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.