Source: Snow, John. London Med. Gazette, vol. 42,  Dec. 15, 1848, pp. 1021-25 (part 8).

On narcotism by the inhalation of vapours

By John Snow, M.D.

Vice-President of the Westminster Medical Society.

[Part 8]

Conditions of the patient which influence the action of chloroform--age--strength or debility--hysteria--epilepsy--renal convulsions--pregnancy--disease of the lungs--of the heart--tendency to congestion of the brain--diet previously to inhaling--- Administration of chloroform in amputations.

Before entering further on the subject of the administration of chloroform, it will be expedient to inquire what are the circumstances, if any, which forbid its use. And experience requires me to make the remark of this substance, which I made last year of ether,--that I know of no state of the patient, with respect either to age, constitution, or disease, which positively contraindicates the use of it, where it is required to prevent the pain of a severe operation, or, I may add, of one the patient greatly dreads. In making this statement, I must not be considered to be recommending the indiscriminate use of chloroform. On the contrary, I consider that everything connected with the patient should be taken into the account, and duly weighed, and the decision arrived at accordingly. And when I state that I have administered chloroform in almost every possible condition in which a patient could require an operation, it must not be considered that I have acted without discrimination, but rather, that going on gradually, and acting on previous experience, supposed objections have one by one vanished, and it has appeared that care in the mode of giving the vapour was the main guarantee, both of safety and success. This view of the subject is entertained by others as well as myself; for, it must be recollected, that I have never given chloroform or ether in an operation, without the concurrence of other medical men.

Chloroform acts more pleasantly, however, on some patients than on others; and we may therefore proceed to consider the circumstances which influence its mode of action. The period of life in which chloroform acts most pleasantly is childhood. In children, under thirteen years of age it scarcely ever causes either mental excitement, or any of the struggling which is not unusual in adults just before insensibility ensues, and immunity from pain is obtained with less narcotism of the nervous centres than in older subjects, as I stated before. It is never necessary to carry the narcotism further than the beginning of the third degree in children, at which time I believe their eyes are always turned up; and very often it is not requisite to carry the effects of the vapour beyond the second degree. Indeed, I have seen a child look about it, with a smile on its face, in the middle of the operation of lithotomy.

In a paper which I read at the be-[1021/1022] ginning of the year, I recommended ether for children, in preference to chloroform, on account of the action of the latter being extremely rapid in young patients; but with the apparatus I described in the last paper, the vapour of chloroform can be so diluted with air as to become as mild and gradual in its action as one pleases, and since I have had small face-pieces suited for infants, I have generally given chloroform, and have administered it to a great number of children, from three weeks old upwards. But when the practitioner is only provided with a handkerchief or sponge, I still consider that the use of chloroform is not perfectly safe, and that ether ought to be employed.

As age advances, the action of chloroform, though equally safe and effectual, is less uniformly pleasant in appearance. In old age, indeed, there is frequently either groaning or a slight degree of stertor, not only during an operation, but even before it begins; so that the effect of the vapour, although quite as satisfactory to the patient, is less agreeable to friends who may be looking on, than in young subjects. I have often exhibited chloroform in extreme old age, and always with the best effects: indeed, I consider that age is not a source of danger when care is taken. Old people are generally rather longer than others in recovering their consciousness, probably because, owing to their circulation and respiration being less active, the vapour requires a longer time to escape by the lungs. They sometimes do not perfectly recover their former state till twenty minutes or half an hour has elapsed from the conclusion of the operation.

The general condition of the patient as regards robustness, or the contrary, has a considerable influence on the way in which chloroform acts. Usually the more feeble the patient is, whether from illness, or any other cause, the more quietly does he become insensible; whilst if he is strong and robust, there is very likely to be mental excitement in the second degree, and rigidity of the muscles, and probably struggling in the third degree of narcotism. This action of the muscles generally occurs when they are well nourished, whilst in the cases in which they are flaccid, and probably pale, it is usually absent.

The special condition termed diatheses, seem to have no regular influence over the action of chloroform, except the hysterical one, and this is apt to occasion a little trouble; for as soon as a patient who is subject to hysteria loses her consciousness, from the effect of the vapour, a paroxysm of the complaint is sometimes occasioned. This, however, can always be subdued by proceeding with the inhalation. But the hysterical state, in a few instances, returns, and becomes troublesome, as the effects of the vapour subsides. In two cases that I have met with, it continued for three or four hours. I saw one case, indeed, in which the hysteria lasted much longer, but it was kept up by the alarm of the practitioner in attendance, who was not well acquainted with the action of chloroform,--had given, I believe, an overdose in the first instance, and afterwards mistook the hysteria for the continued effect of the vapour. I was called upwards of thirty hours after the inhalation, when the anxious attendance on the young woman being discontinued, and some of the usual remedies for hysteria applied, she began to amend, but remained in indifferent health for some time. I believe that one or two cases of continued convulsions after chloroform and ether, related in the medical journals, were cases of hysteria. In trying to estimate how far the provocation of hysteria is a drawback from the benefits of chloroform, it must be remembered that the pain of an operation, and still more, perhaps, the anticipation of it, would cause an attack of hysteria in many patients; and I think the proper view to take of the subject is, that whilst a tendency to this complaint ought strictly to forbid the inhalation for amusement, which was at one time somewhat the fashion, it should not interfere with its use in a painful operation, or in any necessary operation, to which the patient cannot otherwise be induced to submit.

Persons subject to epilepsy are liable to have a fit brought on by inhaling ether or chloroform. This occurred in a young lady who had a tumor of the lower jaw, removed by the late Mr. Liston, and took ether, but I was able to subdue the convulsions before the operation began, by continuing the vapour, and with chloroform, this, of course, could be more quickly accomplished. It was stated, in one of the [1027/1028] foreign medical journals, that chloroform is so certain to cause a fit in epileptic persons, that it may be used to detect impostors pretending to be subject to this disease; but Dr. Todd, who has used chloroform with some advantage in the treatment of epilepsy, in King's College Hospital, has informed me that it does not always produce an attack, even when carried to the extent of causing complete insensibility.

I may here mention a case, though not connected with a surgical operation, in which chloroform caused a recurrence of renal convulsions, from which the patient had been suffering:--A working man, aged about 35, had been in ill health for some weeks before I was called to him on Feb. 19, on account of his being found insensible on the floor. He had in some measure recovered when I arrived, but was in a state of partial stupor, which on the following day was increased, and accompanied with violent convulsions. There was edema of the face and extremities, and his urine was albuminous, scanty, and of diminished specific gravity. He was bled from the arm, and took digitalis of potash, and on the 22nd, had quite recovered from the convulsions and stupor, and the urine was improved. On the 23rd, however, he became affected with delirium cum tremore, and in the evening I administered chloroform to him, having seen it apparently of service in two or three cases of this disorder. It no sooner began to take effect, however, than violent convulsions came on, of exactly the same kind as those with which he had been affected three days before, and accompanied with the same frightful distortions of the features. Although I did not deem it unsafe to continue the chloroform, I thought it more advisable to discontinue it, and to try the effect of opium. The chloroform having been left off, the convulsions almost immediately subsided, and in three or four minutes the patient was in his former state of delirium. He took twenty-five minims of tincture of opium, and the same dose three hours afterwards. He had a good night's rest, the next day was free from the delirium, and he gradually recovered his health. At the time the patient took the chloroform, there is no doubt that his blood still contained a certain amount of urea and other impurities, and the vapour seemed to act as an additional quantity of these impurities would have done, whilst opium had a different and beneficial effect.

Having noticed the general conditions of the patient, it remains to be inquired how far local disease interferes with the action of chloroform; but previously, the state of pregnancy may be noticed. I recollect two instances in which the patients were pregnant. One was that of a lady, about six months advanced, for whom Mr. Rogers removed some teeth. The chloroform had been recommended by her usual physician before I saw her. The other was a patient in St. George's Hospital, less advanced in pregnancy, on whom Mr. H.C. Johnson operated for the removal of a small fatty tumor. The result was quite favourable in both cases. The narcotism was carried only just to the third degree, and I think that care should be taken not to induce very profound insensibility in pregnancy.

Any affection of the lungs that would not prevent a surgical operation, would be no impediment to the administration of chloroform. I have exhibited it in a few cases in which there was evidence of crude tubercles, and in one case in which cavities existed, and the only result was, that the cough was generally relieved for a day or two afterwards. This has generally been the case also in chronic bronchitis, which has existed in a considerable number of patients. There is sometime a troublesome fit of coughing at the commencement of the inhalation, when any pulmonary affection exists, but this soon subsides. I have not seen the least injury to the respiratory organs result from the use of chloroform in any instance.

I have already alluded to affections of the heart, and have little to remark now, except that chloroform, carefully administered, is less likely to be prejudicial than severe pain. The patients, however, should be attended to afterwards, and if the chloroform is followed by sickness and coldness, as happens in a few cases, warmth should be applied externally, cordials given, and, if necessary, effervescing draughts, or an opiate. Patients with heart disease, it is well known, are unfavourable subjects for operation under any circumstances; and if they become infected with an animal poison during or sub-[1023/1024] sequent to the operation, have but little chance of recovery. A man, who had dilatation and thinning of the heart, took ether last year, in St. George's Hospital, whilst amputation of the leg was performed. He was attacked with sloughing phagedena, then prevalent, and died on the seventh day, in one of the cold fits attending the disease, there being apparently not strength enough in the heart to establish a reaction from the rigor. And in the case of a gentleman who inhaled chloroform this last summer for the removal of a tumor, and became affected with erysipelas and diffuse cellular inflammation, the symptoms took on a peculiarly low type, and he died on the fifth day. After death there were found dilation of the heart and thinning of its walls.

As narcotics are usually injurious when there is a tendency to congestion of the brain, it was apprehended by many practitioners that ether and chloroform would be unsafe for such patients; probably the transitory nature of the narcotism induced by inhalation, during an operation, is what renders it harmless. At all events, I have met with no ill results, although some of the patients had suffered from attacks of apoplexy, followed for a time by hemiplegia. This was the case in a man aged 66, on whom Mr. Keate operated, in St. George's Hospital, on the 3rd of August last, for the removal of a tumor situated on the thigh.

It is desirable to give some direction respecting the diet of patients about to inhale chloroform, for if it is inhaled immediately after a meal, there is increased liability to vomiting; and, on the other hand, it is not advisable to inhale after a long fast, for when sickness has occurred in this condition, it has been, in some instances, of considerable duration, and accompanied with more than usual depression. The best preparation appears to be a very moderate breakfast or luncheon two or three hours before the inhalation. The operations in the hospitals are usually performed soon after the patient's dinner hour. The most suitable arrangement in these establishments seems to be, that the subjects of operation should have no dinner, but should have a slender lunch during the forenoon; such as a little bread and butter, bread and milk, or gruel.

Chloroform in amputations.

When moving the patient from his bed to the operating table would cause great pain, as in some cases of ulceration of the cartilages of the knee-joint, the chloroform may be administered with advantage, so as to induce insensibility prior to his being moved. In University and King's College Hospitals, I have exhibited chloroform in several cases of this kind, in the wards, previous to the removal of the patient to the operating theatre, and have afterwards given some more of the vapour just before the operation. In St. George's Hospital this has not been required, as patients so situated have been carried to the theatre on their beds. I have sometimes given just enough chloroform or ether to children to produce unconsciousness, merely to prevent the fright they would experience from seeing any of the preparations for an operation.

The position of the patient usually chosen by the surgeon in the larger amputations--that on the back, with the head and shoulders raised--is very convenient for the chloroform. If the sitting posture is preferred for amputations of the upper extremity, it is desirable to have the patient's back well supported, and the legs raised and supported, either on the couch, or another chair; otherwise he will be liable to slide of his seat when insensible. The tourniquet may be put on either before the inhalation, or after insensibility is induced, but, if before, the screw should not be tightened till afterwards. The tourniquet is occasionally applied during the inhalation in the hospital, in order to save time, and then I inform the patient of the nature of what is being done, that he may not be in dread of the premature use of the knife. It is a good plan to let the patient inhale in a comfortable posture, and then to draw him to the edge of the table, when this required, just before the operation is commenced.

If two fluid drachms of chloroform be put into the inhaler that has been described, they will usually more than suffice to last to the end of the operation. The face-piece should be at first applied with the expiratory valve turned aside, and this valve should be gradually moved over the aperture, more [1024/1025] or less quickly, according to the patient's power of inhaling the vapour, without coughing or complaining of its pungency. So long as he is conscious, his feelings should be attended to, and if nervous, he should be encouraged to persevere with the inhalation; but, when no longer conscious, his apparent dislike of the vapour must not prevent its continuance. The majority of patients become quietly insensible without offering any resistance; but, now and then, the patient, on entering the second degree of narcotism, feeling something unusual, and the purpose of it having escaped from his mind, tries to get rid of the apparatus, and it is necessary to hold his hands. Whilst any voluntary motion continues, either in the eyelids or any other part, all that is required is to go on giving the vapour steadily and gradually. It is seldom necessary to close the expiratory opening completely; it is usually sufficient if the valve cover three-fourths of it, and, if the patient breathe deeply it should not be more than half covered. When voluntary motion is no longer apparent, in order to become informed respecting the state of the patient, the eyelid should be gently raised, touching its free border. If he look up, it is evident that the narcotism has not exceeded the second degree. If no voluntary motion be excited, the third degree is probably attained, and if the eye be found turned up, this is pretty certain. But, notwithstanding this, if involuntary winking be occasioned by touching the edge of the eyelid, it is necessary to continue the vapour a little longer before the operation is commenced. In doing so, however, if the narcotism have already reached the third degree, and there be no particular rigidity or struggling, the valve may be opened a little further, so as to give the vapour in a more diluted form, or the inhalation may be intermitted for two or three inspirations at a time. In this way, insensibility of the nerves is obtained, without increasing the narcotism of the nervous centres. As soon as the sensibility of the conjunctiva is abolished, or so far blunted that the free edge of the eyelid, or the eye itself, can be touched without causing decided winking, the operation may be commenced with confidence that there will be no pain, and no involuntary flinching that will interfere with the operation. When there is struggling, or great rigidity, in the third degree of narcotism, it is requisite to continue the vapour a little longer till it subside. If there be any approach to stertorous breathing, the inhalation should at once be suspended, as was stated in a former paper. Stertor, however, never begins till the patient is perfectly insensible. The time occupied in the inhalation is usually from two to three minutes. The operation having been commenced, the medical man having charge of the chloroform should watch the patient's countenance, and if there be any sign of returning sensibility, give a little more vapour during the short time occupied in removing the limb. After the amputation is completed, the vapour need not be repeated until there is decided evidence of sensation. When the arteries to be tied are not numerous, it is requisite to give a little chloroform at intervals, and if cold water have to be applied to stop the oozing of blood, or the flaps have to be united by sutures, it is advisable to keep the patient partially insensible till this is done.

(To be continued)

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