John Snow

“ Knowing that weakness of human nature which leads a man, in the presence of all evidence, never to admit intoxication as possible in his own proper person, Dr. Snow felt that, in any case where an intoxicated person had been robbed, such person might allege that he had been made insensible by narcotic vapour. The two cases specially noticed in his letter admitted readily of such interpretation, and were clearly not cases in which chloroform had been administered. ”

“ Fear is an affection of the mind, and can no longer exist when the patient is unconscious; but the action of that amount of chloroform which is consistent even with disordered consciousness is stimulating, and increases the force and frequency of the pulse, in the same way as alcohol. I believe that no one would assert that a person would die the sooner of fright for having taken a few glasses of wine, or a small amount of distilled spirits, whatever might be the state of his health. ”

“ When symptoms like those of pain are present during an operation, one may generally know whether they are the consequences of it, by observing whether or not they are connected with each cut of the knife. But even when a flinch or a groan follows each manipulation of the surgeon, it does not necessarily follow, provided the patient does not speak, that he is suffering pain. Some amount of consciousness is essential to the presence of pain, but many of the lower animals execute movements like those caused by pain, after the head is cut off, and when, of course, there can be no consciousness. ”

“ He says:—“But they who object to delirium tremens appear to see no harm in delirium ferox: whereas it is just as incorrect to say delirium is fierce, as to say that it trembles: it is the patient who is furious, even as it is the patient who trembles.” Now, in speaking of a patient, we may speak either of his mind or his body: we may say that a person is learned, or that he is fat. ”

“ I infer that they have been more talked about than read, for few people seem to be aware of the enlarged and positive physiological arguments which they contain. Chloroform and ether are not alone discussed, but all narcotics. Narcotics are not alone considered, but various of the great functions of life. The records of a vast number and variety of experiments are here related, and an amount of information, original in kind, collected, which will always remain as a memorable record in the history of medical literature. ”

“ It is not improbable that, amongst the multitudes of new bodies which chemistry makes known every year, some agent may be found superior to those hitherto used; and besides the great practical advantages which are directly derived from the discovery of inhalation for the prevention of pain, the method of breathing medicinal substances in the gaseous state offers great facilities for the investigation of their effects, and cannot fail to hasten the time when the mode of action of medicines will be a branch of exact knowledge. ”

“ Mr. Erichsen’s attention was at once excited by these symptoms, and, desisting from the use of the catheter, he immediately commenced dashing the patient’s face and chest with water. The chloroform had, of course, been removed. In the course of about a minute, the noise with the breathing gradually lessened, and it became apparent that the respiration was ceasing altogether. Mr. Erichsen now put his finger into the patient’s pharynx, and dragged forwards the root of the tongue; at the same time attempting artificial inflation of the lungs, by applying his own mouth to that of the man. ”

“ 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. Patients in a state of debility resemble children, not only in coming quietly and easily under the influence of chloroform, but also in the circumstance, that the common sensibility is suspended with less narcotism of the nervous centres than is generally required in robust persons. ”

“ I always request the patients who are operated on at the dentist’s, to drive home, as it is not advisable to walk, or use any exertion for an hour or two after the action of chloroform. Indeed, the patient is usually disinclined for any exertion for twenty minutes or half an hour after the influence of this agent, and sometimes for much longer; although I have seen a patient mount the box of a sort of dog-cart, and drive himself away, within five minutes after having several teeth extracted whilst he was in a state of complete insensibility from chloroform. ”

“ I use the term degree in preference to stage, as, in administering chloroform, the slighter degrees of narcotism occur in the later stages of the process, during the recovery of the patient, as well as in the beginning. The division into degrees is made according to symptoms, which, I believe, depend entirely on the state of the nervous centres, and not according to the amount of anæsthesia, which there is good reason to conclude, depends, in a great measure, on the local action of the chloroform on the nerves. The different degrees of narcotism glide insensibly into each other. ”

“ The persons who believe in the existence of a force or power, which they call Mesmerism, or animal magnetism, made many and persevering efforts in recent times to cause insensibility to the surgeon’s knife. In some cases they were imposed on by dishonest and designing patients, who afterwards confessed they had suffered the pain to which they had pretended to be insensible, but in other cases I have no doubt of the operations having really been performed without pain. ”

“ It is probable that there must have been some little circulation going on through the brain whilst the respiration lasted, and in fact, the slight fluttering pulse and feeble sounds of the heart, once or twice perceived, indicate that the circulation was not absolutely arrested. Under these circumstances, we may inquire why the action of the heart does not recover. If the circulation were going on in the coronary arteries, it might be expected that the blood from the lungs, which has been aerated by respiration, and freed from the narcotic vapour, would restore the action of the heart. ”

“ It is desirable to allay the patient’s fears, if possible, before he begins to inhale, as he will then be able to breathe in a more regular and tranquil manner. In a few cases, however, the apprehensions of the patient cannot be removed, and they subside only as he becomes unconscious from the inhalation. It has been said that chloroform ought not to be administered if the patient is very much afraid, on the supposition that fear makes the chloroform dangerous. This is, however, a mistake; the danger, if any, lies in the fear itself. ”

“ I have many times observed how quickly, and, indeed, almost instantaneously, small animals recover from the stupor occasioned by certain permanent gases which are sparingly soluble in watery fluids, as olefiant gas, carbonic oxide and carbonic acid gases, nitrous oxide and the gaseous oxide of methyle. Now amylene is so volatile as to approach to a permanent gas; at a temperature a little above that of the human body it would be a gas, and the vapour is very sparingly soluble in watery fluids, and consequently in the blood. Sulphuric ether is, indeed, as volatile as amylene. ”

“ 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. ”

“ The truth is, however, that if there be too much vapour of chloroform in the air the patient breathes, it may cause sudden death, even without previous insensibility, and whilst the blood in the lungs is of a florid colour. Chloroform may indeed be inhaled freely from a handkerchief without danger, when it is diluted with one or two parts by measure of spirits of wine, but the chloroform evaporates in largest quantity at first, and less afterwards, until a portion of the spirit is left behind by itself. ”

“ There arose hereupon much discussion amongst the learned, much sneering and jeering even; for the pump-handle removal was a fact too great for the abstruse science men who wanted to discover the cause of a great natural phenomenon in some overwhelming scientific problem. But it matters little. Men with great thoughts in their heads, think of little things which little men cover with their wide-spread feet. ”

“ The patient may allow his limbs to lie relaxed when he is scarcely unconscious, and not at all insensible, merely because he is not exerting his will upon them; if the arm is lifted, it may fall listlessly down again, at a time when the knife of the surgeon would rouse the patient to active resistance. Indeed, the limbs, which have been lying relaxed, may become tense as the effect of the chloroform increases, and may remain so during a short operation, in which there is no sign of pain. ”

“ Many writers have stated that accidents from chloroform might always be prevented by a close attention to the symptoms, or to some particular symptom, as the pulse or the breathing. Several authors have attached the utmost importance to feeling the pulse, and have considered this measure of itself sufficient to avert danger; whilst others have asserted that attention to the pulse is of no use at all. Mr. Bickersteth, for instance, writes as follows, in the article from which I previously quoted. “But the pulse should not be taken as any guide during the administration of chloroform. ”

“ In about ten minutes, as the child cried a little, three drops more of chloroform were used for inhalation, and in about eight minutes more the operation was concluded. “On raising the child it laid its head on one side, convulsive twitches of the face were observed, with distortion of the eyeballs and dilatation of the pupils. For one moment the arms were stretched out stiff, then again they were relaxed, and fell as supple as the rest of the body. Death quickly followed—only one pulsation of the heart and a single râle with the expiration being perceived.” ”

“ Insensibility is not caused so much by giving a dose as by performing a process. Nature supplies but one mixture of diluted oxygen, from which each creature draws as much as it requires, and so, in causing narcotism by inhalation, if a proper mixture of air and vapour is supplied, each patient will gradually inhale the requisite quantity of the latter to cause insensibility, according to his size and strength. ”

“ Sometimes the patient is so violent and suspicious that he cannot be made to take opium; but it is much easier to make a person breathe a medicine, than swallow one. It is only necessary to hold a patient, and to apply the chloroform near his face, and he is obliged to breathe it, and as the effect of it subsides, he recovers the power of swallowing before his delirium returns; for whilst he is still unconscious, he will swallow whatever is poured into his throat. ”

“ His grand search was for a narcotic vapour which, having the physical properties and practicability of chloroform, should, in its physiological effects, resemble ether in not producing, by any accident of administration, paralysis of the heart. The fact that in almost every fatal case from chloroform the result had occurred from the action of the narcotic on the central organ of the circulation, was never absent from his thoughts. An agent having this effect, however intrinsically valuable, was not to be put in the hands of every person for administration. ”

“ There is no doubt a combination of causes operating to destroy the heart’s contractile power: the mental influence, the congestion in the systemic, and that in the pulmonary capillaries, will all have a material influence.” And further on he says: “We are obliged, then, from the experience of these cases, to conclude, that in man the death is usually instantaneous, and due, as every instantaneous death is, to paralysis of the heart. In animals the death is usually due to paralysis of the muscles of respiration. ”

“ In little children, the bandages are not usually employed; but in these cases, the person administering the chloroform should hold the head or shoulders of the little patient, just as the surgeon makes his first incision; for the two assistants who are holding the legs, and think they are doing a great deal of good, are really making a fulcrum to enable the child to push itself away from the surgeon, if it makes the least flinch, which it is almost sure to do, if the narcotism is not much deeper than there is any occasion for. ”

“ Placing a taper, during one of our experiments, in a bottle through which chloroform vapour was diffused, and watching the declining flame, he once said, “There, now, is all that occurs in narcotism; but to submit the candle to the action of the narcotic without extinguishing it altogether, you must neither expose it to much vapour at once, nor subject it to the vapour too long; and this is all you can provide against in subjecting a man to the same influence. ”

“ The moment the heart ceases to supply blood to the brain there are loss of consciousness and stoppage of respiration; but on the patient being placed in the horizontal position the blood flows readily into the right cavities of the heart from the great veins of the abdomen and lower extremities; the heart immediately recommences its contractions; the brain is again supplied with blood, and respiration and consciousness return. ”

“ The first degree of narcotism recurs when consciousness returns as the effect of the chloroform is subsiding. At this time, there is generally a greater amount of anæsthesia than at the commencement of inhalation, just before consciousness is removed. I have many times known the introduction of sutures, and such like measures, performed at the concluding part of an operation, after the patient had recovered his consciousness, without his feeling what was being done. As a general rule also, the smarting of the wound does not commence till some time after consciousness has returned. ”

“ But if the air which the patient breathes be too highly charged with vapour, it is easy to understand how the sensibility of the nerves of the heart may be paralysed, notwithstanding their power to bear somewhat more of this agent than the brain and nerves of respiration. I calculated (p. 74) the quantity of chloroform which would suffice to arrest respiration in the adult of average size to be thirty-six minims, provided it were equally diffused through the circulation; but supposing a patient breathes, at any time, air containing ten per cent. ”

“ When we consider how common is fatty degeneration of the heart, especially amongst old persons and those for a long time confined to bed, it is very probable that this affection has been proportionally as frequent, amongst the patients who have inhaled chloroform without ill effects, as in the fatal cases of its inhalation.
There are nine of the fatal cases in which the age of the patient is not stated. ”

“ I understand that several orthopædic surgeons had, at one time, an objection to chloroform in tenotomy, from an impression that it would relax the muscles, and thus render the operation less easy of performance. But it is altogether unnecessary to carry the effects of chloroform so far as to relax the muscles. The pain of this operation can always be prevented without relaxing the muscles, which are indeed often more tense than if the patient were awake. ”