Valvular lesions only increase the dan ger if they are obstructive. In that case, even, compensative hypertrophy may also compensate for the extra resistance in duced.
In aortic insufficiency, as emphasized by Giffen, it is necessary to study heart rhythm and arterial pressure. So long as the rapidity of the heart's action does not disturb the rhythm—viz.: first sound, second sound, pause—within reasonable physiological limits, or, in other words, the arterial pressure (composed of the time [rapidity] and intensity- [muscular impulse]) does not overcome rhythm, the amesthetic can be given without in creased danger.
Physicians and surgeons are agreed that accidents in chloroform anfesthesia are not more frequent in patients with aortic or heart disease than in patients with other illness. Nor does cardiac or aortic disease contra-indicate chloroform as an ana.sthetic, if the disease is not acute and infectious. if the patient is not too feeble. or if dyspncea. asystole, or symptoms of pericardial symphysis have not appeared. In some cases of atheroma and cardiac disease the heart condition even improved after chloroformization. The main contra-indication to chloro form in patients with heart disease is the pre,5ence of dyspncea. This , how ever, but temporary. Accidents may be due to impure chloroform, its method of adlninistration, or to errors of the amesthetist. Rarely there may be an idiosyncrasy to chloroform, more fre quent in nervous patients. Death may occur under chloroform, yet may not be due to the chloroform. The question whether ether or chloroform is to be preferred as the amesthetie has not yet been definitely settled. Ether is to be preferred in nervous patients, with kid ney disease, low- arterial tension, pro fonnd anreinia, and depression. It is contra-indicated in pulmonary disease, dyspncea, etc. Ethyl bromide has been given first by Dichelot with success, fol lowing with chloroform after anresthesia has begun. Laborde advises atropine, morphine, and sparteine, hypodermically, before chloroformization. Pure chloro form, well given, to a patient prepared for it, almost never kills. Henri Hu chard (Jour. des Praticiens, _May 31; Phila. :Med. Jour., Sept. 13, 1902).
Disorders of the respiratory tract are as liable to compromise the issue as any ffrave cardiac disease. Great caution should be observed in the administration of chloroform in all asphyxial condi tions,—i.e., when the respiratory area is
to any degree restricted through the pres ence of growths, pycemic accumulations, emphysema, etc. In scrofulous children the presence of enlarged bronchial glands is to be surmised, and the ames thetic should be administered with un usual care. In affections complicated by liquid effusions, however, the danger may be thwarted when it presents itself.
Case showing what timely evacuation of contents of pleura will do in such eases. As soon as evidences of asphyxia showed themselves the skin \l'a S divided with one cut of bistoury and the pleura. was instantly opened and pus evacuated, the almost moribund patient quickly re Dulling to life. Guermonprez (Jour. des Sciences MN. de Lille, May 4, '95).
Fatal accidents during. administration of chloroform are especially liable to oc cur in persons with the lymphatic con dition, enlarg,ed thymus, etc. F. Strass mann (Berliner Klinik, Feb., '98).
Langlois and Richet have shown by experiments on animals that in surgical ananthesia extreme care should be taken that the movements of expiration be not interfered with. This might be extended to expiration, likewise, and the necessity of protecting the via vitiv against the ingress of mucus, saliva, blood, etc., thus emphasized.
Following remarks founded on 6657 ad ministrations of anresthetics at London -Hospital. Other things being equal, the stronger the patient, the more trouble with the amesthetic. Deaths from chloro form are more common in the iniddle period of life, and more men than women die from this agent. Chloroform is more dangerous during the early stages of ad ministration; respiration should be care fully watched, and every breath should be both heard and felt. Watching the chest or abdomen is a fallacious guide. Obstructed breathing is best relieved by unlocking the teeth and pushing the jaw forward. There were 13 ca5cs in the 6657 administrations in which the threatening symptoms occurred. When dang,erous symptoms arise during or after the use of an am-esthetic. one or more of four factors may bc responsible: first, the araestlietic itself; second, the condition of the patient; third, the posture of the patient; and, fourth, the surgical opera tion. W. Hewitt (Lancet, Feb. 19, '98).