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.[[152]] 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.[[153]]
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.[[154]] 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.[[155]] 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.
“In conclusion, I would remark, that the convulsions were in no measure mitigated by the depletion, which was carried to the utmost; nor was there any yielding of the os uteri until the chloroform was inhaled.”
The urine was not examined in either of the above cases, and it is not stated that œdema was present.
Hysterical Paralysis and Contractions. In December 1851, I administered chloroform in Charing Cross Hospital to a young woman about twenty-five, a patient of Dr. Chowne. She kept her left knee in a semiflexed position, and would not allow it to be moved. She had been in bed in the hospital for two months. She inhaled the chloroform reluctantly, and, after becoming unconscious, she breathed and sobbed in a hysterical manner. When insensible, the limb went down flat on the bed, the knee being quite movable. A straight splint was applied, and the limb was secured to it with bandages. I was informed that in a few days she contrived to get her leg bent again. She was the domestic servant of a nobleman. It was evident that there was nothing the matter with her limb, and that it was only influenced by her volition, which was perverted by the hysteria under which she was labouring.
In November, in the same year, I administered chloroform in the same hospital to another patient of Dr. Chowne, whose case was more obscure and complicated. The patient was a woman, aged thirty-three, who represented that for several months she had been unable to open her mouth, or to speak, and that she had, for the same length of time, been paralyzed in the left arm and leg. The affection, it was said, came on suddenly, in a kind of fit, which was followed by unconsciousness for three or four weeks. It was also said, that she had one or two fits the previous year, after which she was unconscious for a long time. The patient was quite conscious before inhaling the chloroform, and replied to questions by nodding or shaking the head, or by writing on a slate. She was unmarried, and had not menstruated for some months past. The chloroform was administered with a view to ascertain whether or not she was feigning. On first becoming unconscious, the patient breathed in a sobbing and hysterical manner. The chloroform was given very gradually; and as she became more affected, there were some struggling and rigidity, when the right arm and leg were moved about a good deal. The left arm and leg were also distinctly moved, but not above a tenth part as much as the extremities of the opposite side. When the patient was quite insensible, the limbs being relaxed, the pupils turned upwards, and the conjunctiva insensible, attention was turned to the jaws, which were still firmly closed, but they were opened by using a moderate degree of force with the fingers. The effect of the chloroform having been allowed in a great measure to subside, it was again administered, when the movements of the limbs recurred, and there was the same difference between the motion of the right side and that of the left, as before. When I left the patient, more than half an hour after the chloroform was discontinued, she had not opened her eyes or answered questions; and she did not do either for six days. I saw her five days after the chloroform. The pulse was very rapid on my first going to the bedside, but its frequency subsided in a few minutes. On my raising the eyelid, she turned her eye about, as if endeavouring to hide the pupil under the lid. On the following day she answered questions by nodding and writing on a slate, and was, in other respects, the same as before inhaling the chloroform.
The great difference in the amount of motion in the limbs of this patient, under the influence of chloroform, showed that the paralysis of the left side was not a mere pretence. It is, indeed, possible that the absence of motion in the limbs of the left side, for several months, would cause them to move less than the opposite ones during the action of chloroform; but it is not to be supposed that the patient would keep these limbs in one posture during the night, and when no one was present, without ever moving them, unless she herself believed that they were paralyzed. I looked on the woman as a sick person, and not a mere impostor; for although she appeared to exaggerate her symptoms, and to have a good deal of pretence and affectation, this circumstance arose, no doubt, from her complaint.
In April 1853, I administered chloroform four times to a patient of Dr. Arthur Farre, a girl of fifteen years of age, who was affected with a contraction of the flexor muscles of the left thigh and leg, of the muscles which bend the body to the left side, and those which bend and turn the head to the same side, in consequence of which the leg was drawn up, and the body and head were curved greatly to the left side. The contraction of the muscles had lasted for several weeks, but she had been ill for a much longer period, her illness having commenced with a fever. She took an extremely small quantity of nourishment, and was very thin. Her bowels were moved with difficulty. The pulse was very feeble and small, and there was a tendency to coldness of the surface. An eminent surgeon in the provinces had expressed his opinion that the distortion of the limbs and trunk was a feigned disorder; but the action of the chloroform proved that he was altogether in error. The muscles became completely relaxed when the patient was quite insensible, and the limbs and trunk and head could be readily moved into any position; but as the effects of the chloroform subsided, the deformity returned on each occasion before the patient recovered her consciousness. Neither the chloroform nor any other measures were of any service, and Dr. Farre informed me that the patient died a few weeks after I saw her.
Mania. I have been informed of several cases in which chloroform has been administered in acute mania, with the effect of calming the patient and procuring sleep. I have administered it in two cases with the same temporary advantage. In one of the cases, the patient was persuaded to inhale it; in the other, he had to be held by three keepers till he was unconscious. An eminent and well-known scientific man, who became insane some years ago, refused to take food. It was found that after being made unconscious by chloroform, he would take a meal just as he recovered from its effects, and the chloroform was given before every meal for a long time.
Spasmodic Pain. In August 1851, I administered chloroform to a woman who was labouring under a severe paroxysm of spasmodic pain in the abdomen. The pain was completely removed, without altogether causing unconsciousness. An opiate was given to prevent the pain from returning.
I have not had the opportunity of administering chloroform during the passage of calculi down the ureters, or of gall-stones; but there can be no doubt that it would be of the greatest service in such cases. If Dr. Griffin had been provided with chloroform when he attended the late Mr. Augustus Stafford with an attack of gall-stones,[[156]] he would have been able to relieve his patient in five minutes, instead of taking two or three hours to produce relief by opium. There would have been no occasion for the venesection, which was carried to thirty ounces. And at the end of the attack, on Dr. Griffin leaving his patient for the night, if chloroform had been employed, he would have left him without any appreciable amount of the narcotic in his system. As it was, however, he left him with a quantity of opium unabsorbed from the alimentary canal. The bandage got displaced from the arm; there was an additional hæmorrhage, the opium became absorbed more quickly, and a dangerous state of narcotism was induced.
Frequent and long continued Use of Chloroform. Many patients have inhaled this agent hundreds of times, and it continued to produce insensibility as readily as at first. The dose does not require to be increased on account of its long use. I was informed of the case of a lady who was affected with a painful cancer, and was attended by the late Mr. Keate and Mr. Henry Charles Johnson. She inhaled chloroform at frequent intervals, by day and night, for a very long time, consuming three or four ounces in the twenty-four hours.
In November 1851, a surgeon in the north of England wrote to me respecting one of his patients, a lady, who had inhaled a great deal of chloroform, on account of neuralgia of the uterus. He said that, during that year, and principally within the last six months, she had inhaled at least two hundred ounces; that she often inhaled as much as three ounces in a day; and that it seemed to have produced very little effect on her general health, except that she seemed to be more susceptible of pain. He said that he had reluctantly yielded to the entreaties of his patient to administer it so often, and he wished for my opinion respecting the propriety of continuing its use, and what effect it would be likely to produce.
I advised that the chloroform should be continued as long as the severity of the pain rendered it necessary; and expressed my opinion, that it would produce as little ultimate effect as any other narcotic which might be used to relieve the pain. I saw the surgeon in September of the following year. He informed me that the chloroform was continued for some time after he had written to me; but that his patient had recovered from her complaint, and had left off the chloroform, and was in good health.
Mr. Garner, of Stoke-upon-Trent, has related the case of a lady, affected with neuralgia, who inhaled sixty-two ounces of chloroform from her handkerchief, in twelve days.[[157]]