Dr. Bodine. therefore. concludes that fright may be an element in the pro duction of death in eases in which chloroform is -used. lle states that seven out of every ten deaths reported from ehloroform amestliesia occur during the preliminary stage, when only a few drops up to a drachm have been given. There is negative evidence also in the fact that in obstetrical praetice chloroform is the am:esthetic of choice; this is due to al most complete absence of a chloroform mortality during labor. As an explana tion of this freedom from danger we have the circumstance that women are not fearful about the anresthetie in their confinement, but ask freely for it. Children, also, are not frightened as adults are, and consequently suffer little from chloroform as an athestlietic. Pr. Bodine refers, in addition, to the inter esting fact that the negro of the South ern States stands chloroform very well; lie has a ehild-like faith in his physician and does not fear any of the measures that he may adopt. Yet the negro may (lie from fright, as a graphic story of a student trick told by the writer proves.
The conclusion is, therefore, reached that we min-A. for the safe administra tion of chloroform, eliminate fri-rht. Dr. Bodine tells his patient to put his bands tightly together, the fingers interlacing, and to ,grip them firmly; he asks him to fix his mind upon that action, to listen to the VOlee of the amesthetist and to do what Ile tells him. and tc.) breathe deeply and quietly and not to mind the sensations which come over him. (_4eneral conversation in the neigh borhood of the patient should not be allowed. The writer, in conclusion, thinks that if deaths from fright could be elimi nated, chloroform would be a much safer amesthetic than ether, and says: "If I had to choose an amTsthetic for myself to-morrow, I should take chloroform, hut I should want it administered by a careful expert am-esthetist." These views, althongh perhaps opti mistic, are well worthy of being kept in mind by the profession on this side of the Atlantic. Editorial (Brit. Med.:Tour., Feb. 21, 1903).
Too prolonged a fast prior to taking chloroform is considered dangerous by .Murray-Aynsley. Christopher Heath, when an operation is likely to be very prolonged. administers an enema of hot beef-tea. half an hour before the admin istration. Silk has recommended the "hospital regimen" for some days before the operation.
Stimulants were advocated even by B. W. Richardson, who. gave alcohol in definite doses, twenty minutes before the inhalation.
Formula:— I; Tinct. chloroformi, 1 drachm. Spir. tenuior, 1 ounce.
This was given in water and sweetened if preferred.
Foxwell also gave alcohol when the heart was not orderly and calm five min utes before beginning the administra tion of the amesthetic, but opium, given two or three hours before, he considered even better.
Too little importance is usually at tached to struggl-ing, which, according to Lawrie, is produced (1) by fright, leading to purposeful resistance; (2) by choking or asphyxia from overconcen tration of the vapor, owing, generally, to the cap being held too close to the face at first or afterward when the chloro form is being- renewed; and (3) by in toxication,—i.e., the so-called "strug
gling stage." Dudley Buxton considers the struggling of intoxication as ex tremely dangerous. The breathing is then irregular and the amount of chloro form in the circulation is considerable, amesthesia being nearly complete: fac tors markedly increasing the chances of cardiac syncope and general toxmnia.
The inhaler should be removed from the face for a few respirations, which does not necessarily cause a break in the narcosis, as chloroform still remains in the air-cells; and, as soon as respiration has resnmed its normal character, the chloroform is reapplied.
Certain regions are especially prone to encourage cardiac syncope when sub mitted to rough handling in surgical pro cedures. Traction -upon the omentum and undue manipulation of the intestines and other viscera are probably the most active factors of this kind. Operations _upon the anus have also shown a tend ency in this direction. Operations that would be attended by great pain without an amnsthetic seem to show the greatest tendency to produce cardiac failure.
The part played by reflex action in the production of syncope has not as yet re ceived much attention. Laborde, some years ago (1890), observed that the heart of the monkey was immediately arrested by the irritative action of chloroform vapor on the nasal distribution of the trigeminus, and observed that the ap plication of a solution of cocaine to the nasal mucous surfaces prevented the untoward resnit. Recently Rosenberg, Guttmann, and others have utilized this prophylactic measure during surgical amesthesia, and have lauded its merits.
The vapors of this drug are able, by their irritating action upon the -nervous elements within the naso-pharyngeal mucous memlwane, to determine a brusque arrest of the heart and respira tion. This paralysis occurs. moreover, very easily if the subject he put under chloroform during a state of very great excitement. In order to prevent as far as possible this cause of death, which is always imminent, as soon as one ap proaches the nose of a siek person with a compress soaked with chloroform it is necessary to decrease the unnecessary excitement of the patient and the sus ceptibility of the terminal expansion of the fifth cranial nerves. '17ne hest means, according to the author, of accomplish ing, this purpose consists in giving a pre ventive injection consisting, of hydrate of morphine. 0.10 gramme; sulphate of atropine, 0.01 gramme; sulphate nf sparteine, 1.00 gramme: distilled water, 10 grammes, to every individual to be chloroformed. Irrigation of the nasal nmeons membrane and of the pharynx and glottis with a concentrated solution of cocaine also of great benefit in sup pressing the susceptibility of these re gions. It is also necessary to have care to keep the tongue forward in the mouth with special forceps during the entire duration of the chloroformization, thus avoiding a sliding of this organ back ward over the orifice of the glottis, thereby provoking asphyxia, and being ready to carry out rhythmical traction on this organ in case unfavorable symp toms arise. Laborde (Medical News, July 5, 1902).