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Clinical Researches ON CHLOROFORM.
APRIL 18, 1857. is of the
Clinical
Researches
highest importance in a physiological point of view, is It is evidently due, in our opinion, to
worthy of attention.
the simultaneous tonic contraction- of the four recti and the two oblique muscles, which maintain the eye in a state of perfect immobility. Is it not, however, an interesting fact to the physiologist, that while chloroform places the muscles of the entire body in a state of resolution, its action should be directly the reverse on the muscles of the eye, which enter, under its BY M. CHASSAIGNAC, influence, into a species of spasmodic contraction, entirely at SURGEON TO THE HOPITAL LARIBOISIERE, PROFESSEUR AGREGE AT THE variance with the general state of the patient ? FACULTE DE MEDECINE DE PARIS. 3. The immediate consequence of the above-mentioned fact is the tendency of the humours. contained in the different Translated by BENJAMIN BALL, ESQ., Interne des Hôpitaux de chambers of the eye to escape as soon as the membranes which surround them are divided. Paris; and JOHN CRAVEN, ESQ., M.R.C.S.E. & L.A.C. 4. The action of chloroform on the eye may be divided into two distinct periods, the results of which ought not to be conCHAPTER VI. founded-1st, during the state of excitement; 2ndly, during the state of collapse. REMARKS ON OCULAR ANÆSTHESIA. Irritation is the first effect produced by chloroform on the As soon as the discovery of chloroform enabled us to modify conjunctiva; we therefore see most patients close their eyes a.t will sensibility and motion, those two great manifestations during the first period of inhalation. The next result is, a of life, it became natural to inquire whether any benefit might modification of the contractile powers of the iris; and this exof its action deserves special attenbe derived from its application to the surgical treatment of ceedingly complicated part tion. During the first period of anaesthesia, and consequently ocular diseases. The general results of anaesthesia could not in in the stage of excitement, chloroform produces a considerable this instance provide us with an answer; and the only possible dilatation of the pupil; but, strange to say, at the moment method of solving the question in a practical sense was to ob. when insensibility is complete, the pupil, formerly dilated, contracts a few instants after the eyelids are opened. This serve with peculiar care, in a great number of cases, the action action seems to’ belong to the singular class of of chloroform on the eye. The numerous opportunities which physiological described under the name of reflex actions; for in phenomena a vast surgical service affords have enabled us to examine the that stage the brain receives no luminous impressions from influence of this agent-1st, on the eyelids; 2ndly, on the con- without. We therefore. see that surgeons who expect to find. junctiva ; 3rdly, on the motions of tHe eye; 4thly, on the the pupil expanded under the influence of chloroform ,might be considerably surprised by the phenomena, we have just decontractions of the iris. Before resuming, in a few general propositions, the results of scribed. This fact has led us to state in another paper that chloroform is a bad dilatator of the pupil. our experience, we feel authorized to say that chloroform is 5. The eyelids present another singular phenomenon, equally certainly destined to render great service in the treatment of deserving our attention, and which we.have described under ocular diseases, provided its mode of action be thoroughly under- the name of " immobilite cadavérique des paupires. In a stood. Both surgeon and patient might otherwise be sadly de- certain number of cases, when anaesthesia, has been carried to,a considerable extent, the eyelids remain motionless, and if ceived, the results which theory leads us to anticipate from our do not close again. This remarkable fact appears of of the effects chloroform general being, opened present knowledge almost alarming to those who witness it for the first time. So in this particular instance, often contradicted by experience. great is the absence of muscular tonicity that it seems imposA German ophthalmologist, Dr. Jungken, has already described sible the vital powers should not be deeply endangered after the effects of chloroform in a vast number of operations on the spontaneous action has so completely disappeared. 6. Another fact, which should always be present to the eye; but so different are his conclusions from our own, that we is the sudden re-appearance of the pupillary almost doubt whether his opinions are rather the result of operator’s mind, to laws hitherto unknown. The pupil contraction, according is often seen to contract after considerable expansion, without theory than of practice. 1. When the process cf inhalation has been carried suffi- any known cause. This takes place in the operation for ciently far to obtain muscular resolution, the constant effect of cataract, after the lens has been removed. chloroform is to render the eyeball completely motionless. This 7. The age of our patients does not seem to exercise any symptom is by far the most constant of all, since the dilatation definite influence upon the general results of the experiment; of the pupil undergoes numerous variations, and is sometimes it seems, however, that constitutional debility facilitates the succeeded by contraction, in the most advanced stage of anæs- action of chloroform upon the eye, the patient’s vital resistance thesia. considerably diminished. The study of these peculiar phenomena is far from being so 2. Another phenomenon, which appears equally to deserve ’, notice, especially as regards the operation for cataract, is, if we easy as one might be led to imagine. There exist innumerable may borrow the expression of Barthez, the " power of fixity" difficulties and causes of error which have compelled us to exwhich the eye acquires under anaesthetic influence; whatever clude from our statistics every case in which a doubt was posits position may happen to be when the state of anæsthesia sible. The reader will therefore easily understand the motives begins, that position is invariably retained throughout the which lead us to select no more than 35 cases, out of a large whole duration of the experiment. the period of insen- number, for the purpose of establishing the ordinary effects of sibility, the eye is usually turned upwards, and lies concealed chloroform on the eye. under the upper eyelid; it then becomes quite impossible to Out of these 35 cases, 8 patients were from sixteen to twenty move it by the mere pressure of the firgers, without the assistyears of age; 10 from twenty to thirty; 11 from thirty to ance of an instrument-a fact of the highest importance, since forty ; and 6 above that age. it might in certain cases become an obstacle to the operation On all patients in the state of collapse the absolute immofor cataract. bility of the eyelids was found to exist; but in the stage of The two preceding propositions may at first sight appear excitation it only made its appearance five times out of thirtyidentical, "immobility" and "fixity" being synonymous; but five. This symptom may therefore be considered as one of the if language establishes no great difference between the words, best signs of complete insensibility. The state of the visual functions has not been examined in clinical facts do so, and in the following manner. If we compare the state of the eye on the dead body with that under the preceding cases, on account of the difficulty encountered which it is placed through anaesthetic influence, we find that in judging the sensations of the patient. How can we know the eyeball on the dead body lies no doubt motionless, but the whether he does not see the instrument about to be plunged fingers easily move it in any given direction; we can incline it into his eye, or whether, although seeing it, he is unable to downwards, upwards, right or left, without difficulty. In the move and consequently to avoid it? state of anaesthesia, not only is the eyeball motionless, but it In four cases of cataract, the pupil was completely dilated lies fixed in a determinate position, which the pressure of the during the operation; in two cases, out of four, the pupil confinger is totally insufficient to alter. As a whole, the eyeball tracted immediately after extraction of the lens. A similar may of course be displaced, but it ceases entirely to revolve fact has been observed by M. Follin, on the patient whose " either on its vertical or on its transverse axis. This fact. which case is related in the "Memoires de la Societé de Chirurgie." ON
CHLOROFORM.
being
During
No. 1755.
Clinical
Researches
highest importance in a physiological point of view, is It is evidently due, in our opinion, to
worthy of attention.
the simultaneous tonic contraction- of the four recti and the two oblique muscles, which maintain the eye in a state of perfect immobility. Is it not, however, an interesting fact to the physiologist, that while chloroform places the muscles of the entire body in a state of resolution, its action should be directly the reverse on the muscles of the eye, which enter, under its BY M. CHASSAIGNAC, influence, into a species of spasmodic contraction, entirely at SURGEON TO THE HOPITAL LARIBOISIERE, PROFESSEUR AGREGE AT THE variance with the general state of the patient ? FACULTE DE MEDECINE DE PARIS. 3. The immediate consequence of the above-mentioned fact is the tendency of the humours. contained in the different Translated by BENJAMIN BALL, ESQ., Interne des Hôpitaux de chambers of the eye to escape as soon as the membranes which surround them are divided. Paris; and JOHN CRAVEN, ESQ., M.R.C.S.E. & L.A.C. 4. The action of chloroform on the eye may be divided into two distinct periods, the results of which ought not to be conCHAPTER VI. founded-1st, during the state of excitement; 2ndly, during the state of collapse. REMARKS ON OCULAR ANÆSTHESIA. Irritation is the first effect produced by chloroform on the As soon as the discovery of chloroform enabled us to modify conjunctiva; we therefore see most patients close their eyes a.t will sensibility and motion, those two great manifestations during the first period of inhalation. The next result is, a of life, it became natural to inquire whether any benefit might modification of the contractile powers of the iris; and this exof its action deserves special attenbe derived from its application to the surgical treatment of ceedingly complicated part tion. During the first period of anaesthesia, and consequently ocular diseases. The general results of anaesthesia could not in in the stage of excitement, chloroform produces a considerable this instance provide us with an answer; and the only possible dilatation of the pupil; but, strange to say, at the moment method of solving the question in a practical sense was to ob. when insensibility is complete, the pupil, formerly dilated, contracts a few instants after the eyelids are opened. This serve with peculiar care, in a great number of cases, the action action seems to’ belong to the singular class of of chloroform on the eye. The numerous opportunities which physiological described under the name of reflex actions; for in phenomena a vast surgical service affords have enabled us to examine the that stage the brain receives no luminous impressions from influence of this agent-1st, on the eyelids; 2ndly, on the con- without. We therefore. see that surgeons who expect to find. junctiva ; 3rdly, on the motions of tHe eye; 4thly, on the the pupil expanded under the influence of chloroform ,might be considerably surprised by the phenomena, we have just decontractions of the iris. Before resuming, in a few general propositions, the results of scribed. This fact has led us to state in another paper that chloroform is a bad dilatator of the pupil. our experience, we feel authorized to say that chloroform is 5. The eyelids present another singular phenomenon, equally certainly destined to render great service in the treatment of deserving our attention, and which we.have described under ocular diseases, provided its mode of action be thoroughly under- the name of " immobilite cadavérique des paupires. In a stood. Both surgeon and patient might otherwise be sadly de- certain number of cases, when anaesthesia, has been carried to,a considerable extent, the eyelids remain motionless, and if ceived, the results which theory leads us to anticipate from our do not close again. This remarkable fact appears of of the effects chloroform general being, opened present knowledge almost alarming to those who witness it for the first time. So in this particular instance, often contradicted by experience. great is the absence of muscular tonicity that it seems imposA German ophthalmologist, Dr. Jungken, has already described sible the vital powers should not be deeply endangered after the effects of chloroform in a vast number of operations on the spontaneous action has so completely disappeared. 6. Another fact, which should always be present to the eye; but so different are his conclusions from our own, that we is the sudden re-appearance of the pupillary almost doubt whether his opinions are rather the result of operator’s mind, to laws hitherto unknown. The pupil contraction, according is often seen to contract after considerable expansion, without theory than of practice. 1. When the process cf inhalation has been carried suffi- any known cause. This takes place in the operation for ciently far to obtain muscular resolution, the constant effect of cataract, after the lens has been removed. chloroform is to render the eyeball completely motionless. This 7. The age of our patients does not seem to exercise any symptom is by far the most constant of all, since the dilatation definite influence upon the general results of the experiment; of the pupil undergoes numerous variations, and is sometimes it seems, however, that constitutional debility facilitates the succeeded by contraction, in the most advanced stage of anæs- action of chloroform upon the eye, the patient’s vital resistance thesia. considerably diminished. The study of these peculiar phenomena is far from being so 2. Another phenomenon, which appears equally to deserve ’, notice, especially as regards the operation for cataract, is, if we easy as one might be led to imagine. There exist innumerable may borrow the expression of Barthez, the " power of fixity" difficulties and causes of error which have compelled us to exwhich the eye acquires under anaesthetic influence; whatever clude from our statistics every case in which a doubt was posits position may happen to be when the state of anæsthesia sible. The reader will therefore easily understand the motives begins, that position is invariably retained throughout the which lead us to select no more than 35 cases, out of a large whole duration of the experiment. the period of insen- number, for the purpose of establishing the ordinary effects of sibility, the eye is usually turned upwards, and lies concealed chloroform on the eye. under the upper eyelid; it then becomes quite impossible to Out of these 35 cases, 8 patients were from sixteen to twenty move it by the mere pressure of the firgers, without the assistyears of age; 10 from twenty to thirty; 11 from thirty to ance of an instrument-a fact of the highest importance, since forty ; and 6 above that age. it might in certain cases become an obstacle to the operation On all patients in the state of collapse the absolute immofor cataract. bility of the eyelids was found to exist; but in the stage of The two preceding propositions may at first sight appear excitation it only made its appearance five times out of thirtyidentical, "immobility" and "fixity" being synonymous; but five. This symptom may therefore be considered as one of the if language establishes no great difference between the words, best signs of complete insensibility. The state of the visual functions has not been examined in clinical facts do so, and in the following manner. If we compare the state of the eye on the dead body with that under the preceding cases, on account of the difficulty encountered which it is placed through anaesthetic influence, we find that in judging the sensations of the patient. How can we know the eyeball on the dead body lies no doubt motionless, but the whether he does not see the instrument about to be plunged fingers easily move it in any given direction; we can incline it into his eye, or whether, although seeing it, he is unable to downwards, upwards, right or left, without difficulty. In the move and consequently to avoid it? state of anaesthesia, not only is the eyeball motionless, but it In four cases of cataract, the pupil was completely dilated lies fixed in a determinate position, which the pressure of the during the operation; in two cases, out of four, the pupil confinger is totally insufficient to alter. As a whole, the eyeball tracted immediately after extraction of the lens. A similar may of course be displaced, but it ceases entirely to revolve fact has been observed by M. Follin, on the patient whose " either on its vertical or on its transverse axis. This fact. which case is related in the "Memoires de la Societé de Chirurgie." ON
CHLOROFORM.
being
During
No. 1755.