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.