Chloroformum

Relief Of Certain Forms Of Pain

The relief which the application

CHLOROFORM. 71-3

of chloroform to the skin affords in certain types of neuralgia he attributes to its stimulating properties rather than to narcotic action. He says in his truly interesting work on Stimulants and Narcotics, page 331, "I have always noticed that when chloroform inhalation, for instance, relieves a severe tic, it does this in one of two ways: either it removes the pain during the very earliest inspirations, and before the slightest degree of true anaesthesia is produced, or it fails alto- gether to produce any impression while a state of consciousness supervenes. The former is the true medicinal action, and it is cer- tainly a form of stimulation, since the amount of chloroform absorbed into the blood in such cases is quite insufficient to produce any paralyzing influence upon the sensory nerves."

Arrest Of Convulsive Muscular Movements

Dr. Anstie, to demonstrate this, poisoned several animals with doses of strychnine sufficiently large to produce the characteristic symptoms of poisoning with that drug. Immediately after the administration of strychnine he gave chloroform by injection under the skin, or by placing the animal in a glass jar charged with a mixture of chloroform vapor and atmospheric air. The animals showed only tremor and partial paralysis, instead of the violent convulsions which follow the exhi- bition of strychnine ; and when they died, they did so from the effects of chloroform ; decided rigor mortis followed almost at once the cessation of the heart's action. In defense of this belief, that the cessation of convulsive action is not due to the narcotic action of chloroform, the writer urges the fact that the patient, who is uncon- scious during the convulsions, very frequently recovers consciousness under the action of the remedy.

3. Restoration of the natural movements of the uterus in par- turition, when they are deficient. Dr. Anstie and other authorities strongly affirm this power of chloroform to increase the force of, and to regulate the contractions of the womb. From this belief, and from the supposition, whether false or true, that under its action the external passages greatly relax, thus facilitating the ex- pulsion of the uterine contents, dates the use of chloroform in obstetrical practice. I cannot let this opportunity pass, without pro- testing against such a procedure as unnecessary and dangerous, even though advocated by some experienced practitioners. If it becomes necessary to bring on more forcible labor-pains or to regulate them, the homoeopathic physician has at his command medicinal agents, which will not only do all he can desire to accomplish, but will do

714 CHLOROFORM.

it with safety to the patient. Even the sensible advocates of the chloroform practice at the bedside of the lying-in woman, admit the danger of inertia of the womb developing itself, if the use of the agent be pushed a trifle too far, into the narcotic stage of the drug.

These remarks do not, as a matter of course, refer to the use of chloroform as an anaesthetic in difficult cases of labor where surgical operations may have become unavoidable, and where perfect quiet on the part of the patient is indispensable.

Larger doses of chloroform produce narcotic effects, upon which the anaesthetic power of the drug depends. Given to animals, either by inhalation or by injection under the skin, it produces an increase of the heart's action, followed by unconsciousness. Recovery takes place very promptly, without any serious symptoms, if the experi- ment is not continued too long, and if the chloroform is given in small quantities. If the experiment is carried to a length Avhich leads to a fatal termination ; comparatively moderate doses produce insensibility, unconsciousness, partial paralysis of the posterior ex- tremities ; at first rapid, then slow and even gasping respiration ; rapid, running action of the heart; death. In a majority of such cases the pupils of the eye were widely dilated, but sensitive to a slight degree ; and the heart continued to beat for some time, and with considerable force, after respiration had ceased. In most in- stances, after the heart had ceased to act, irritants, pricking, etc., would re-excite its action.

When given in very large doses, convulsions or perfect rigidity set in at once, accompanied by gasping respiration, running action of the heart ; death from the direct effects of the chloroform upon the heart, through the medulla oblongata. In all the cases of this class the heart was found inirritable.

A dog, full-grown, weighing about fifteen pounds, and in excellent health, had one-half ounce of chloroform injected into his right pleura. The animal gave one cry and then lay still for a few moments : but in less than forty seconds the eyeballs turned up and became fixed, and all the limbs were seized with violent clonic con- vulsions. Eespiration was gasping ; the heart made, as it were, a short rapid run of feeble contractions, and came to a dead stop in less than seventy seconds from the moment of injection. The thorax was quickly opened, and the last quiver of the auricles was witnessed. No amount of irritation, by pricking or by dropping cold water on the surface of the heart, nor by pricking or roughly rubbing the thoracic ganglia of the sympathetic, nor by stirring up the cardiac plexuses with the handle of a scalpel, was able to re-

CHLOROFORM. 715

induce the smallest visible contractions. The phrenic nerves were totally unheritable. Although the abdomen was quickly opened, no peristaltic movements of the bowels could be seen. (Anstie's experiment.)

A terrier, weighing about fifteen pounds, and quite healthy, was placed in a very large glass jar, charged with seven per cent of chlo- roform vapor. The animal gave one or two convulsive starts, and fell. It was removed to the outer air in less than a minute from its introduction into the jar ; its limbs were stretched out in a state of tonic spasm, the head was bent on the chest, and the whole body rigid. The heart was beating in a mere flutter, and stopped in a few seconds. On opening the chest, it was found relaxed and motionless ; no irritation would re-excite contractions ; not even strong irritation of the sympathetic ganglia. Immediately after death the body became entirely relaxed ; no note is preserved of the time when rigor mortis commenced. (Ibid.)

Fifty adults, who were placed under the influence of chloloform for surgical purposes, and who were under the full narcotic influence of the anaesthetic in an average time of four minutes, presented the following features :

Pulse

Increase during the first minute, possibly due in part to the alarm of the patient. This increase continued during the second minute, dropping, however, to its previous level at the end of the third and remaining there or falling below its normal standard after complete anaesthesia had been produced.

Kespiration. — Was not interfered with, unless in very nervous persons, or hi cases where the administration of chloroform was carried to a dangerous extent.

Nervous System

At first a brightening up of intellectual power, followed at the conclusion of the first minute by loss of clear- ness of memory, consciousness ; partial paralysis of the tongue, showing itself in heavy, inarticulate speech. Excitement of the emotional sphere. Loss of co-ordination. Paralysis of the skin- sensibility during the second minute, with the exception of the matrix of the great toe-nail, the margin of the anus, and the whole of the skin of the organs of generation, all of which retained their sensibility for a remarkably long time. Voluntary motor power was not usually lost until the end of the second minute.

Sympathetic System. — Flushing of the face, occurred late. Contraction of the pupil during the second and third minutes, fol- lowed by dilatation when complete anaesthesia had been reached.

Medulla Oblongata. — Stertorous, laborious breathing. This is

<16 CHLOROFORM.

one of the last effects of chloroform, and at this stage the one in charge of its administration must be on his guard against untoward symptoms.

Reflex Symptoms. — Coughing (did not occur after the conclu- sion of the second minute, except as a sequel of vomiting.) Vomit- ing. Expulsion of feces, which is an unpleasant symptom, especially if it is accompanied by other symptoms of great depression, as syncope.

Dr. Anstie says : "In one fatal accident from chloroform which I witnessed the urine was forcibly ejected almost immediately before death, and I have often observed the same occurrence in animals. When vomiting occurs after a state of syncope, it is to be looked upon as a decidedly favorable symptom, indicating a certain amount of reaction." Spasmodic rigidity of the principle flexor muscles, affecting both sides alike. In ten cases out of fifty there were scarcely perceptible clonic convulsions.

It has been claimed that narcosis could not be produced by the administration of chloroform by the stomach. Dr. Anstie took, in an ounce and a half of thin mucilage, forty-five minims of chloro- form upon an empty stomach. He experienced great warmth at the epigastrium, and an immediate feeling of flushing all over the body. Five minutes later the heart was beating with great violence ; pulse 100; also confusion of mind. Five minutes later, nausea; the pulse had lowered; he became unconscious and remained so for 36 minutes, awakening from this state with heaviness and numbness in the lower extremities, inability to stand, shivering, nausea, headache, twinges of pain ; all of these symptoms continued some length of time.

Chloroform, administered by inhalation or by injection into the yortal vein, produces diabetic symptoms. Whether this effect de- pends upon the lessening of the respiratory movements or upon a paralytic affection of the hepatic sympathetic nerves, has not yet been decided.

Among the conclusions of greatest interest, drawn by Dr. Anstie, after the careful study of the subject, and while administering chlo- roform more than three thousand times in a period of six years and experimenting with it upon animals to a large extent, are the following :

The rapidity with which narcotism develops, depends upon the rapidity with which the arterial circulation becomes charged with the agent. When the impregnation of blood takes place with moderate

CHLOROFORM. 717

rapidity, the sympathetic nervous system is the ultimum morions, and death begins at the lungs. When the circulation becomes very rapidly charged with a large proportion of chloroform, the narcotic effect may fall with such force upon the sympathetic nerves as to extinguish their vitality at once. The greatest possible importance attaches to this distinction ; for one of the consequences of the latter occurrence is the production of instantaneous paralysis of the heart. From the symptoms which Dr. Anstie has observed in all fatal and grave cases of chloroform-narcosis he considers that paralysis of the heart is the great source of danger in its administration for surgical purposes. He considers the use of an apparatus which will supply an atmosphere of uniform and moderate strength, and not above 3 to 5 per cent for inhalation, a great necessity.

Chloroform is given by inhalation in doses of from one to three drachms. Dr. Simpson has used eight fluid ounces in thirteen hours in a case of protracted labor. The mode of administration varies. Sponges, handkerchiefs, cotton batting, wrapped in a funnel-shaped, twisted paper, are of common use. Dr. J. G-. Jones (Cin. Med. Ad- vance, Sept., 1879-,) gives the following directions, using a two-ounce bottle for chloroform, with a perforated cork, such as we find in many perfumery bottles. "The patient should lie perfectly straight on a bed or table, placed in a large, well -ventilated room (about 75° to 80°), and directed to breathe regularly and deeply as soon as the chloro- form is placed to the mouth and nose. All clothing about the neck and waist should be loosened. The tip of the nose, the chin and the prominence of the cheeks should be covered with a thin layer of glycerine, as this prevents the chloroform from affecting the skin ; and then the towel should be placed over the whole face, as the patient will take it better if not disturbed by noticing other proceed- ings in the room. About ten drops of chloroform are allowed to fail upon the towel just below the nose and over the mouth, and after that the bottle is inverted, permitting a drop to fall every three to five seconds, keeping a spot about an inch in diameter constantly wet. * * * Ordinarily, a patient can be fully anaesthetized in this way with less than a drachm, and then kept under the influence for fifteen to thirty minutes with as much more." Various instru- ments are used, so arranged that the patient inhales atmospheric air charged with a certain per cent of chloroform. The apparatus devised by Dr. Snow, and improved at a more recent date, has been found to do excellent service.

718 CICUTA VIR0SA.

When dangerous symptoms are produced, cold affusions may be used; above all, artificial respiration must be established. (Marshal Hall's method.) This may be successful if death by interference with respiration is threatened; all efforts will be unavailing if paralysis of the heart takes place.

It has been taught that persons laboring under organic and other grave diseases of the heart or lungs were not fit subjects for the administration of chloroform; this statement is directly contradicted by Anstie and Snow, both of whom are excellent authorities on the subject. The former says: "It is my firm conviction that, with proper care, chloroform may be safely administered to any patient who is fit to undergo an operation at all, whether there be any exist- ing disease of heart, kings, brain, or not."

Chloroform has been used not only for the purpose of producing anaesthesia, but for the relief of various neuralgic, nervous and other pains. It has been given in convulsions, tetanic or otherwise; in chorea, hydrophobia, delirium tremens, epilepsy, etc.

The production of temporary quiet often gives the worn-out system a chance to recuj^erate and, by its own inherent vigor, to overcome the disease. At least it gives temporary relief when nothing else may be able to do so ; and no honorable physician will fail to use such palliative treatment where curative efforts are apparently useless.

We may add that the latest investigations seem to prove far greater danger to the patient from the effects of partial anaesthesia than appear to exist when completely under the influence of this agent. Of its internal use we need not speak, but especial mention may be made of the fact, that the use of chloroform, by inhalation, becomes indispensable in convulsions arising from poisoning by strychnine.