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.
CAUSE AND PREVENTION OF DEATH FROM CHLOROFORM.
All narcotics are capable of causing death, and the discovery of preventing pain by inhalation consists essentially in carrying the effects of a narcotic much further than had previously been the custom; there was, therefore, every reason to apprehend that accidents might occur in the new practice, unless the effects of the medicines employed could be very effectually controlled. There are certain circumstances connected with the physiological properties of chloroform, as ascertained in the experiments previously related, which indicate how accidents may very easily happen with this agent, if not carefully and systematically managed. It was calculated (p. 74) that 18 minims of chloroform is the average quantity in the system of an adult, when sufficiently insensible for a surgical operation, and that this amount might be absorbed by the use of 36 minims, allowing one-half of the quantity breathed to be exhaled again, without being absorbed; but 36 minims of chloroform make only 37·5 cubic inches of vapour, which, at the temperature of 60° Fah., may exist in combination with 257 cubic inches of air, making it expand to not quite 300 cubic inches; the whole of which might be breathed in twelve ordinary inspirations of 25 cubic inches each. If the inhalation of vapour of this strength were continued till insensibility was induced, the lungs would still contain a great quantity of unabsorbed vapour. The amount of air usually present in the lungs is about 250 cubic inches, and if saturated with chloroform at the temperature of 60° it would contain the vapour of 30 minims. About half of this might be absorbed, the remaining half passing off in the expired air; but the addition of 15 minims to the 18 minims already absorbed would almost double the quantity of chloroform in the system, and bring the patient necessarily to the brink of death. It is true that, in the ordinary methods of inhalation, the air seldom becomes quite saturated with vapour, and usually is not more than half saturated, or accidents might be of much more frequent occurrence; but the above considerations are sufficient to show that the amount of vapour contained in the air breathed by the patient should not be left to mere accident, such as the varying temperature of the handkerchief from which the chloroform is breathed, or the greater or less extent of wetted surface over which the air passes. It should be recollected also that the patient sometimes draws a deep and sudden inspiration by which he may inspire 100 cubic inches of air, which would contain, if strongly charged with vapour, ten or twelve minims of chloroform—a large quantity to be suddenly added to that already in the circulation, when the patient is insensible, or nearly so.
It is, however, only by a knowledge of the different modes in which chloroform is capable of causing death, that the exact nature of the accidents from this agent can be understood, together with the means of preventing them, and the reason why they are usually irremediable when they happen. If animals are kept for a very long time under the deep influence of chloroform, they become ultimately exhausted, the circulation and respiration are gradually weakened, and cease nearly together. Such a mode of death from this agent is never likely to occur to the human subject, and therefore need not engage our further attention. The following experiments illustrate the different modes of dying, when death is caused more suddenly by this agent.[[57]]