As these accidents seem to have occurred from continuing the inhalation too long, they differ entirely from nearly all those which were actually fatal, and which, as we have seen, arose from the too great concentration of the vapour, and not from any want of care in watching the patient, so as to be able to leave off at the right moment, if it were possible. I have previously stated, that after breathing vapour of the proper strength for inhalation, animals may always be readily restored by artificial respiration after the breathing has ceased, provided the heart is still beating. In the cases related by Mr. Bickersteth, the heart had ceased to beat before the patients were restored; but in the third case, there is distinct evidence that the heart continued to beat for four minutes after the breathing had ceased. It was, therefore, certainly not paralyzed by the direct action of the chloroform. The patient was nearly in the condition of a drowned person, where we know that there is a good prospect of recovery by artificial respiration during the first few minutes after the breathing has ceased, even if the action of the heart be imperceptible. In the other three cases, also, it is probable that the breathing ceased before the action of the heart; and, at all events, this organ was not paralyzed so thoroughly as in the cases in which artificial respiration was promptly applied without effect.
Several other cases have been related in the medical journals in which patients have been restored by artificial respiration, after animation had been suspended, more or less completely, by chloroform; but the above remarks would, I believe, be applicable to all these cases.
Where patients have recovered under the use of other measures, without artificial respiration, it is probable that animation was not completely suspended, and that the recovery was spontaneous.
M. Delarue related a case of accident from chloroform to the Academy of Medicine, on August 20th, 1850, which was apparently of this nature. After administering the vapour, and when he was about to divide some sinuses in the thigh, he found that his patient (a woman) was in a state of collapse, and the breathing and pulse, “pour ainsi dire”, insensible. The face was injected, and there was a bloody froth at the mouth. The uvula was titillated, and there was immediate movement of the eyelids, which was soon followed by copious vomiting, and the patient recovered.[[140]]
Such measures as dashing cold water on the patient, and applying ammonia to the nostrils, can hardly be expected to have any effect on a patient who is suffering from an overdose of chloroform; for they would have no effect whatever on one who has inhaled it in the usual manner, and is merely ready for a surgical operation, but in no danger. I have applied the strongest ammonia to the nostrils of animals that were narcotized by chloroform to the third or fourth degree, and it did not affect the breathing in the least. They recovered just as if nothing had been done. It is difficult to suppose a case in which the breathing should be arrested by the effects of chloroform whilst the skin remained sensible, yet it is only in such a case that the dashing of cold water on the patient could be of use. There is, however, no harm in the application of this and such like means, provided they do not usurp the time which ought to be occupied in artificial respiration; for this measure should be resorted to the moment the natural breathing has entirely ceased.
I have only seen two cases in which the patients seemed in imminent danger from the direct effects of chloroform. One of these occurred in 1853. It was the case of a child, aged six years, but small and ricketty, which had the greater part of the eyeball removed on account of melanotic disease. The usual inhaler was employed, and when the child seemed sufficiently insensible, it was withdrawn. The operation was commenced by introducing a large curved needle, armed with a thick ligature, through the globe of the eye, in order to draw it forward. As the needle was introduced, the child cried out a very little, and thinking the parents, who were in the adjoining room, would be alarmed, I poured some undiluted chloroform hastily on a rather large sponge, and placed it over the nostrils and mouth. The sponge became pressed by the surgeon’s hand closer on the nose than I intended, but it was removed after the child had taken a few inspirations. The operation was quickly concluded without any further sign of sensation than that mentioned above. At the end of the operation, the breathing was natural, but the face was pale, and the lips blue, and the limbs were also relaxed. I tried to feel the pulse at the wrist, but did not discover any. The chloroform had at this time been left off half a minute at least. The pallor and blueness continued, and in a little time the breathing became slow and embarrassed, and appeared about to cease altogether, the pulse being still absent. The windows were opened, and cold water dashed freely on the face. The child made gasping inspirations now and then, but they did not follow immediately, or seem connected with each application of the water. The gasps became more frequent, till the breathing was thoroughly reestablished, when the colour returned to the lips, and the pulse was again felt at the wrist. In a minute afterwards, the child was red in the face, and crying violently from pain, which was relieved by a little more chloroform. It appeared to be a minute or a minute and a half from the time when the sponge with chloroform was removed, till the breathing became of a gasping character. There is no doubt that in this case the heart was paralyzed, or nearly so, by the chloroform, and that its action was restored by the spontaneous gasping inspirations of the child. The accident could have been prevented by having the chloroform, which was put on the sponge, diluted with spirit.
The other case occurred in the latter part of 1852. I have no notes of it, as it took place at the beginning of an illness, which prevented me from writing for some time; but I recollect the chief particulars of it sufficiently well. The patient was a lady rather more than sixty years of age, rather tall and thin. She required to have a polypus removed from the nose. Mr. Fergusson, who was about to operate, was nearly an hour after the appointed time, and during this interval she was pacing up and down the room, apparently in a great fright. She was placed in an easy chair for the operation, and the pulse was small and feeble when she began to inhale. Nothing particular occurred during the inhalation, but just at the time when the patient was becoming insensible, the breathing ceased, and the pulse could not be felt. She appeared to have fainted, and was immediately placed on a bed which was in the room. I applied my ear to the chest, but could hear no sound whatever. Mr. Fergusson applied his mouth to that of the patient, and with a very strong expiration, inflated her lungs, so as to expand the chest very freely. I immediately heard the heart’s action recommence with very rapid and feeble strokes, as I had so often heard it recommence in animals. The patient soon began to make distant gasping inspirations, and the natural breathing and pulse were soon reestablished. Mr. Fergusson made only one or two inflations of the lungs after the first one, which of itself was the means of restoring the patient. It was about twenty minutes, however, before she became conscious; and during the greater part of this time there were spasmodic twitchings of the features and limbs on one side. In about an hour, she was pretty well; and on the following day the operation was performed without chloroform.
The most ready and effectual mode of performing artificial respiration is undoubtedly the postural method, introduced by Dr. Marshall Hall a little time before his death. It consists in placing the patient on the face and making pressure on the back; removing the pressure, and turning the patient on his side and a little beyond; then turning him back on the face and making pressure on the back again; these measures being repeated in about the time of natural respiration.
Whether the artificial breathing is successful or not must depend chiefly on the extent to which the heart has been paralyzed by the chloroform, as was previously observed. The fact of the breathing continuing after the action of the heart has ceased, in some of the fatal cases, shows that the heart may be so paralyzed as not to be readily restored by the breathing. It is probable that in all cases in which artificial respiration can restore the patient, its action would be very prompt; still it is desirable to persevere with this measure for a good while.
As already stated, there is every reason to conclude that the right cavities of the heart are distended with blood, in all cases of suspended animation by chloroform, and therefore it would be desirable to open one of the jugular veins if the artificial respiration does not immediately restore the patient. In opening animals, just after death from this agent, I have observed the contractions of the heart to return, to a certain extent, when the distension of its right cavities was diminished by the division of the vessels about the root of the neck. Opening the jugular veins has been resorted to in a few of the cases of accident from chloroform, but hitherto without success.