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This is a special edition of an established title widely used by colleges and
GLOBAL universities throughout the world. Pearson published this exclusive edition
for the benefit of students outside the United States and Canada. If you
GLOBAL
EDITION purchased this book within the United States or Canada, you should be aware EDITION
EDITION
GLOB AL
that it has been imported without the approval of the Publisher or Author.
Designed for individuals of all skill levels, Whetten and Cameron’s Developing Management
Developing Management Skills

Skills focuses on what effective managers do consistently. The text is based on a
Developing
pioneering, five-step “active” learning model that helps aspiring managers translate
academic theories and principles into personal practice. With this essential guide to hands-
on management, Whetten and Cameron keep the emphasis firmly on employability and
learning through self-analysis and practice.
The tenth edition retains its focus on the personal, interpersonal, and group skills that
are critical for successful management and leadership. Chapters feature contemporary
examples of management challenges and effective practices; new skill assessments and
Management
cases; updated research; and tangible, relevant goals for students to work toward.
KEY HIGHLIGHTS
Skills
• This edition features new sections on topical workplace issues including sexual
harassment in Chapter 5, diagnosing and correcting unacceptable performance in
Chapter 6, and negotiations in Chapter 7.
• The Skill Analysis sections feature new, relevant case studies that help identify the TENTH EDITION
defining competencies of effective managers. For instance, in Chapter 2, a new case
study focuses on stress and its management among millennials.
• Revised Skill Practice exercises, a set of end-of-chapter assignments and activities
that help practice management skills in a classroom setting, include cases and scenarios
EDITION
TENTH
that reflect current issues.
Available separately for purchase is MyLab Management for Developing Management Skills,
the teaching and learning platform that empowers instructors to personalize learning
for every student. This includes video exercises and Personal Inventory Assessments,
a collection of exercises designed to promote self-reflection and engagement. When David A. Whetten
Cameron
Whetten
combined with Pearson’s trusted educational content, this optional suite helps deliver the
desired learning outcomes. Kim S. Cameron
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collection of online exercises designed to promote
self-reflection and engagement in students,
enhancing their ability to connect with
management concepts.
“I most liked the Personal Inventory Assessments because they gave me a deeper
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DEVELOPING
MANAGEMENT
SKILLS
TENTH EDITION
GLOBAL EDITION
David A. Whetten
BRIGHAM YOUNG UNIVERSITY
Kim S. Cameron
UNIVERSITY OF MICHIGAN

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© Pearson Education Limited, 2024
The rights of David A. Whetten and Kim S. Cameron to be identified as the authors of this work have been asserted by
them in accordance with the Copyright, Designs and Patents Act 1988.
Authorized adaptation from the United States edition, entitled Developing Management Skills, 10th Edition, ISBN 978-0-
13-517546-0 by David A. Whetten and Kim S. Cameron, published by Pearson Education © 2020.
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ISBN 10: 1-292-45774-0

ISBN 13: 978-1-292-45774-1
eBook ISBN: 978-1-292-72603-8
British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library
1 21
Typeset in Weidemann ITC Pro and 10 pt by Integra Software Service

Printed and bound by B2R Technologies Pvt. Ltd.
B R I E F TA B L E O F C O N T E N T S
Preface 19
Introduction 27
PART I PERSONAL SKILLS 61

1 Developing Self-Awareness 63
2 Managing Stress and Well-Being 109
3 Solving Problems Analytically and Creatively 155
PART II INTERPERSONAL SKILLS 209

4 Building Relationships by Communicating Supportively 211
5 Gaining Power and Influence 249
6 Motivating Performance 285
7 Negotiating and Resolving Conflict 331
PART III GROUP SKILLS 393

8 Empowering and Engaging Others 395
9 Building Effective Teams and Teamwork 429
10 Leading Positive Change 469
Appendix I Glossary 511

Appendix II References 521
Index 545


CONTENTS
Preface 19
INTRODUCTION 27
THE CRITICAL ROLE OF MANAGEMENT SKILLS 29

The Importance of Competent Managers 30
The Skills of Effective Managers 31
What Are Management Skills? 33
Improving Management Skills 34
An Approach to Skill Development 34
Leadership and Management 35
Contents of the Book 37
Organization of the Book 39
Diversity and Individual Differences 40
Summary 40
SUPPLEMENTARY MATERIAL 41
Diagnostic Survey and Exercises 41
Personal Assessment of Management Skills (PAMS) 41
What Does It Take to Be an Effective Manager? 45
SSS Software In-Basket Exercise 47
SCORING KEY AND COMPARISON DATA 58

Personal Assessment of Management Skills 58
Scoring Key 58
Comparison Data 59
What Does It Take to Be an Effective Manager? 59
SSS Software In-Basket Exercise 59
PART I PERSONAL SKILLS 61
1 DEVELOPING SELF-AWARENESS 63
SKILL ASSESSMENT 64
Diagnostic Surveys for Developing Self-Awareness 64
Developing Self-Awareness 64
The Defining Issues Test 64

Cognitive Style Indicator 67
Tolerance of Ambiguity Scale 68
Core Self-Evaluation Scale (CSES) 69
SKILL LEARNING 70
Key Dimensions of Self-Awareness 70
The Enigma of Self-Awareness 70
The Sensitive Line 71
Understanding and Appreciating Individual Differences 72
Important Areas of Self-Awareness 72
Emotional Intelligence 74
Values and Character Strengths 76
Ethical Decision-Making 81
Cognitive Style 83
Attitudes Toward Change 85
Core Self-Evaluation 87
SUMMARY 88
SKILL ANALYSIS 91
Cases Involving Self-Awareness 91
The Case of Heinz 91
Computerized Exam 92
Decision Dilemmas 93
SKILL PRACTICE 95
Exercises for Improving Self-Awareness Through Self-Disclosure 95
Shipping the Part 95
Through the Looking Glass 95
Diagnosing Managerial Characteristics 97
An Exercise for Identifying Aspects of Personal Culture: A Learning Plan and A
utobiography 99
SKILL APPLICATION 101

Activities for Developing Self-Awareness 101
Suggested Assignments 101
Application Plan and Evaluation 102
SCORING KEYS AND COMPARISON DATA 103

The Defining Issues Test 103
Escaped Prisoner 103
The Doctor’s Dilemma 104
The Newspaper 104
Cognitive Style Indicator 105
Scoring Key 105
Comparison Data 105
Tolerance of Ambiguity Scale 105
Scoring Key 105
Comparison Data 106
Core Self-Evaluation Scale 106
Scoring Key 106
Comparison Data 107
Discussion Regarding the Case of Heinz 107
Discussion Regarding the Shipping the Part Case 108
8 Contents

2 MANAGING STRESS AND WELL-BEING 109
SKILL ASSESSMENT 110

Diagnostic Surveys for Managing Stress and Well-Being 110
Managing Stress and Well-Being 110
Social Readjustment Rating Scale 110
Sources of Personal Stress 113
Flourishing Scale 114
SKILL LEARNING 114

Managing Stress and Fostering Well-Being 114
Major Elements of Stress 115
Coping with Stress 116
Managing Stressors 118
Eliminating Stressors 119
Eliminating Time Stressors Through Time Management 119
Eliminating Encounter Stressors Through Community, Contribution, and Emotional Intelligence 124
Eliminating Situational Stressors Through Work Redesign 127
Eliminating Anticipatory Stressors Through Prioritizing, Goal Setting, and Small Wins 128
Developing Resiliency and Well-Being 130
Life Balance 130
Temporary Stress-Reduction Techniques 135
SUMMARY 136
SKILL ANALYSIS 138

Cases Involving Stress Management 138
The Case of the Missing Time 138
Stress and the Millennial Generation 141
SKILL PRACTICE 143

Exercises for Long-Term and Short-Term Stress Management and Well-Being 143
The Small-Wins Strategy 143
Life-Balance Analysis 145
Deep Relaxation 146
Monitoring and Managing Time 148
Generalized Reciprocity 149

Activities for Managing Stress 150

Comparison Data 152
Sources of Personal Stress 152
Flourishing Scale 153
Comparison Data 153
Contents 9

3 SOLVING PROBLEMS ANALYTICALLY AND CREATIVELY 155

Diagnostic Surveys for Creative Problem-Solving 156
Problem-Solving, Creativity, and Innovation 156
Solving Problems Analytically and Creatively 156
How Creative Are You? © 156
Innovative Attitude Scale 158
Creative Style Assessment 159
SKILL LEARNING 161

Problem-Solving, Creativity, and Innovation 161
Steps in Analytical Problem-Solving 161
Defining the Problem 161
Generating Alternatives 162
Evaluating Alternatives 163
Implementing the Solution 163
Limitations of the Analytical Problem-Solving Model 164
Impediments to Creative Problem-Solving 164
Multiple Approaches to Creativity 165
Conceptual Blocks 168
Percy Spencer’s Magnetron 169
Spence Silver’s Glue 170
The Four Types of Conceptual Blocks 170
Review of Conceptual Blocks 178
Conceptual Blockbusting 178
Stages in Creative Thought 178
Methods for Improving Problem Definition 179
Ways to Generate More Alternatives 183
International Caveats 186
Hints for Applying Problem-Solving Techniques 187
Fostering Creativity in Others 187
Management Principles 187
SUMMARY 191
SKILL ANALYSIS 193

Cases Involving Problem-Solving 193
Chip and Bin 193
Creativity at Apple 196
SKILL PRACTICE 198

Exercises for Applying Conceptual Blockbusting 198
Individual Assignment—Analytical Problem-Solving (10 minutes) 198
Team Assignment—Creative Problem-Solving (20 minutes) 199
Moving Up in the Rankings 200
Elijah Gold and His Restaurant 201
Creative Problem-Solving Practice 204

Activities for Solving Problems Creatively 205
10 Contents

How Creative Are You?© 206
Scoring Key 206
Comparison Data 208
Innovative Attitude Scale 208
Comparison Data 208
Creative Style Assessment 208
Scoring Key 208
Comparison Data 208
PART II INTERPERSONAL SKILLS 209
4 BUILDING RELATIONSHIPS BY COMMUNICATING

SUPPORTIVELY 211

Diagnostic Surveys for Supportive Communication 212
SKILL LEARNING 212

Building Positive Interpersonal Relationships 212
High-Quality Connections 213
The Key 214
The Importance of Effective Communication 214
Communication Problems 215
What Is Supportive Communication? 215
Coaching and Counseling 217
Defensiveness and Disconfirmation 218
Principles of Supportive Communication 219
Supportive Communication Is Based on Congruence, Not Incongruence 219
Supportive Communication Is Descriptive, Not Evaluative 220
Supportive Communication Is Problem-Oriented, Not Person-Oriented 222
Supportive Communication Is Validates Rather Than Invalidates Individuals 223
Supportive Communication Is Specific (Useful), Not Global (Nonuseful) 225
Supportive Communication Is Conjunctive, Not Disjunctive 226
Supportive Communication Is Owned, Not Disowned 226
Supportive Communication Requires Supportive Listening, Not One-Way
Message Delivery 227
The Personal Management Interview 232
SUMMARY 235
SKILL ANALYSIS 237

Cases Involving Building Positive Relationships 237
Find Somebody Else 237
Rejected Plans 238
SKILL PRACTICE 240

Exercises for Diagnosing Communication Problems and Fostering Understanding 240
United Chemical Company 240
Byron vs. Thomas 242
Active Listening Exercise 244
Contents 11

Activities for Communicating Supportively 246
5 GAINING POWER AND INFLUENCE 249
SKILL LEARNING 250

Building a Strong Power Base and Using Influence Wisely 250
Gaining Power: Polarized Perspectives 251
Opportunities for Gaining Power 254
Sources of Personal Power 254
Sources of Positional Power 259
Transforming Power into Influence 263
Influence Strategies: The Three Rs 263
The Pros and Cons of Each Strategy 265
Exercising Upward Influence Utilizing The Reason Strategy 267
Acting Assertively: Neutralizing Influence Attempts 269
The Special Case of Sexual Harassment 271
SUMMARY 271
SKILL ANALYSIS 275

Case Involving Power and Influence 275
Dynica Software Solutions 275
SKILL PRACTICE 276

Exercise for Gaining Power 276
Repairing Power Failures in Management Circuits 276
Exercise for Using Influence Effectively 277
Kalina Ivanov’s Proposal 278
Exercises for Neutralizing Unwanted Influence Attempts 278
Cindy’s Fast Foods 279
9:00 to 7:30 280

Activities for Gaining Power and Influence 281
6 MOTIVATING PERFORMANCE 285
SKILL LEARNING 286

Increasing Motivation and Performance 286
Understanding the Prerequisites for Successful Task Performance 287
12 Contents

Fostering High Performance 288
Strengthen the Motivation S Performance Link 289
Expectations and Goals 289
Ability 291
Strengthen the Performance S Outcomes Link 293
Extrinsic Reinforcement 294
Intrinsic Reinforcement 299
Strengthen the Outcomes S Satisfaction Link 303
Human Needs 303
Reward Salience 304
Reward Equity 306
Diagnosing and Correcting the Causes of Unacceptable Performance 307
Diagnostic Framework 307
Benefits of the E-A-M Approach 308
SUMMARY 309
SKILL ANALYSIS 312

Case Involving Motivation Problems 312
Electro Logic 312
SKILL PRACTICE 319

Exercises for Diagnosing Work Performance Problems 319
Joe Chaney 319
Motivating Performance Assessment 320
Exercise for Assessing Job Characteristics 321
Job Diagnostic Survey 321

Activities for Motivating Performance 324

Motivating Performance Assessment 327
Scoring Key 327
Job Diagnostic Survey 328
Scoring Key 328
7 NEGOTIATING AND RESOLVING CONFLICT 331
SKILL LEARNING 332

The Pervasiveness of Organizational Conflict 332
Negotiating Effectively 333
Types of Negotiation 333
The Basics of Negotiation 334
Keys to Effective Integrative Negotiation 335
Resolving Conflicts Successfully 337
Understanding Different Types of Conflict 337
Selecting an Appropriate Conflict Management Approach 341
Selection Criteria 343
Personal Preferences 343
Situational Factors 344
Contents 13

Using Collaboration to Resolve People-Focused Confrontations 345
Initiator 346
Responder 349
Mediator 351
All Roles 354
SUMMARY 354
SKILL ANALYSIS 358

Case Involving Interpersonal Conflict 358
Educational Pension Investments 358
SKILL PRACTICE 362

Exercise for Negotiating 362
A Home by the Sea 362
Negotiation Planning Document 364
Exercises for Diagnosing Types of Conflict 365
SSS Software Management Problems 365
Exercises for Selecting an Appropriate Conflict Management Strategy 374
The Red Cow Grill 374
Avocado Computers 375
Phelps Inc. 375
Exercises for Resolving People-Focused Conflict 376
Sabrina Moffatt 376
Can Larry Fit In? 380
Meeting at Hartford Manufacturing Company 381

Activities for Resolving Conflict 387
PART III GROUP SKILLS 393
8 EMPOWERING AND ENGAGING OTHERS 395
SKILL LEARNING 396

Empowering and Engaging Others 396
The Meaning of Empowerment 397
Dimensions of Empowerment 398
Self-Efficacy 398
Self-Determination 399
Personal Consequence 399
Meaning 400
Trust 400
Review of Empowerment Dimensions 401
14 Contents

How to Develop Empowerment 402
A Clear Goal 402
Fostering Personal Mastery Experiences 403
Modeling 403
Providing Support 403
Emotional Arousal 404
Providing Information 404
Providing Resources 405
Connecting to Outcomes 405
Creating Confidence 406
Review of Empowerment Principles 407
Inhibitors to Empowerment 409
Attitudes about Subordinates 409
Personal Insecurities 409
Need for Control 409
Overcoming Inhibitors 410
Fostering Engagement 410
Deciding When to Engage Others 411
Deciding Whom to Engage 412
Deciding How to Engage Others 413
Review of Engagement Principles 415
SUMMARY 416
SKILL ANALYSIS 418

Cases Involving Empowerment and Engagement 418
Minding the Store 418
Changing the Portfolio 419
SKILL PRACTICE 420

Exercises for Empowerment 420
Executive Development Associates 420
Empowering Ourselves 424
Deciding to Engage Others 425

Activities for Empowerment and Engagement 426
9 BUILDING EFFECTIVE TEAMS AND TEAMWORK 429

Diagnostic Surveys for Building Effective Teams 430
Team Development Behaviors 430
Building Effective Teams and Teamwork 430
Diagnosing the Need for Team Building 430
SKILL LEARNING 431

The Advantages of Teams 431
An Example of an Effective Team 435
Contents 15

Team Development 435
The Forming Stage 436
The Norming Stage 437
The Storming Stage 439
The Performing Stage 441
Leading Teams 444
Developing Credibility 444
Establish SMART Goals and Everest Goals 446
Team Membership 449
Advantageous Roles 449
Unproductive Roles 452
Providing Feedback 453
SUMMARY 454
SKILL ANALYSIS 455

Cases Involving Building Effective Teams 455
Losing to a Weaker Foe 455
The Cash Register Incident 457
SKILL PRACTICE 459

Exercises in Building Effective Teams 459
Leadership Roles in Teams 459
Team Diagnosis and Team Development Exercise 459
Winning the War for Talent 461
Team Performance Exercise 463

Activities for Building Effective Teams 465

Diagnosing the Need for Team Building 466
Comparison Data 466
Leadership Roles in Teams (Examples of Correct Answers) 467
10 LEADING POSITIVE CHANGE 469

Diagnostic Surveys for Leading Positive Change 470
Leading Positive Change 470
Reflected Best-Self Feedback 470
SKILL LEARNING 472

Ubiquitous and Escalating Change 473
The Need for Frameworks 473
A Framework for Leading Positive Change 475
Establishing a Climate of Positivity 478
Creating Readiness for Change 482
Articulating a Vision of Abundance 485
16 Contents

Generating Commitment to the Vision 488
Fostering Sustainability 490
SUMMARY 494
SKILL ANALYSIS 496

Cases Involving Leading Positive Change 496
Corporate Vision Statements 496
Jim Mallozzi: Implementing Positive Change in Prudential Real Estate and Relocation 501
SKILL PRACTICE 504

Exercises in Leading Positive Change 504
Reflected Best-Self Portrait 504
Positive Organizational Diagnosis Exercise 505
A Positive Change Agenda 506

Activities for Leading Positive Change 507

Reflected Best-Self Feedback™ Exercise 509
APPENDIX I GLOSSARY 511
APPENDIX II REFERENCES 521
INDEX 545
Contents 17


P R E FA C E
Why Focus on Management Skill Development?
Given that a “skill development” course requires more time and effort than a course using
the traditional lecture/discussion format, we are sometimes asked this question by stu-
dents, especially those who have relatively little work experience.
Reason #1: It focuses attention on what effective managers

actually do.
In an influential article, Henry Mintzberg (1975) argued that management education had
almost nothing to say about what managers actually do from day to day. He further faulted
management textbooks for introducing students to the leading theories about manage-
ment while ignoring what is known about effective management practice. Sympathetic
to Mintzberg’s critique, we set out to identify the defining competencies of effective
managers.
Although no two management positions are exactly the same, the research summa-
rized in the Introduction highlights ten personal, interpersonal, and group skills that form
the core of effective management practice. Each chapter addresses one of these skills:
Personal Skills
1. Developing Self-Awareness
2. Managing Stress and Well-Being
3. Solving Problems Analytically and Creatively
Interpersonal Skills
4. Building Relationships by Communicating Supportively
5. Gaining Power and Influence
6. Motivating Performance
7. Negotiating and Resolving Conflict
Group Skills
8. Empowering and Engaging Others
9. Building Effective Teams and Teamwork
10. Leading Positive Change
Consistent with our focus on promoting effective management practice, the

material in these chapters provides guidance for a variety of contemporary manage-
ment challenges, including: “How can I help others accept new goals, new ideas, new
19

Another random document with
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TABLE OF FATAL CASES OF INHALATION OF CHLOROFORM.
No. Patient. Age Operation Position Means by Time from the Apparent Pr
in for which the whilst which the commencement mode of inha
yrs. chloroform inhaling. chloroform of inhalation to death.
was inhaled. was the beginning
exhibited. of dangerous
symptoms.
1 Girl 15 Removal of toe- Sitting Towel Half a minute Cardiac Ethe
nail. syncope
2 Married 35 Extraction of Sitting Inhaler About two Cardiac None
lady teeth. minutes syncope
3 Patrick Operation for Lying on the Handkerchief About one minute Cardiac One.
Coyle fistula in ano side syncope
4 Single lady 30 Opening of Lying Handkerchief Probably half a Cardiac None
sinus in minute syncope
thigh
5 Young Amputation of Handkerchief A very short time Cardiac None
woman the middle syncope
finger
6 Young man 22 Transcurrent Inhaler Five minutes Symptoms not None
cauterisation described
of wrist
7 Young man Intended Probably Not stated Death very None
removal of handkerchief sudden
toe-nail.
8 Seaman 31 Removal of Lying on the Napkin About ten minutes Cardiac One.
hæmorrhoids side syncope
9 Miner 17 Intended Lying Handkerchief About five Cardiac None
amputation minutes syncope
of middle
finger
10 Labourer 36 Amputation of Handkerchief Died at the close Cardiac A
toe of the operation syncope att
11 Married 33 Intended Sitting Handkerchief A very short time Cardiac One.
lady extraction of syncope
tooth
12 Porter 48 Removal of toe- Lying Inhaler A little more than Probably None
nail two minutes asphyxia
13 Married Removal of Probably A sponge Died during the Cardiac None
woman eyeball lying operation syncope
14 Young lady 20 Intended Sitting A sponge Just after Cardiac Prev
extraction of enclosed in a beginning to syncope att
tooth napkin inhale
15 A man A sponge Died before the Probably None
operation cardiac
syncope
16 Artilleryman 24 Amputation of Handkerchief Cardiac None
middle finger syncope
17 Bookkeeper 30 Intended Lying Napkin Within five Cardiac None
operation on minutes syncope
testicle
18 Boy 8 Sounding the Lying Piece of lint A few minutes Cardiac None
bladder syncope
19 Policeman 34 Removal of Napkin Died during Cardiac None
portion of operation syncope
hand
20 Man 24 Intended Lying Folded lint in a A few minutes Cardiac None
amputation hollow syncope
of leg sponge
21 Man Intended Lying “Suddenly None
operation on expired”
the penis
22 Married 36 Extraction of Sitting Handkerchief Less than a Cardiac None
lady teeth minute syncope
23 Mulatto 45 Removal of Lying Napkin About seven Cardiac None
seaman testicle. minutes syncope
24 Married 37 Removal of Lying Handkerchief Eight or nine Symptoms not Two.
woman impacted minutes observed
fæces
25 Man 23 Ligature of Lying Inhaler Five to ten Cardiac One.
vessels near minutes syncope
vascular
tumour
26 Married 32 Intended Sitting Sponge Four or five Cardiac None
lady extraction of surrounded inspirations syncope
tooth by
handkerchief
27 Man Intended Lying Handkerchief Not more than a Cardiac None
operation for minute syncope
fistula in ano
28 Cattle dealer Applic. of Handkerchief Died during Probably None
potassa fusa operation cardiac
to ulcers of syncope
leg
29 Factory Removal of Lying Inhaler About twelve Probably None
operative malignant minutes cardiac
tumour of syncope
thigh.
30 Single 28 Intended Lying Folded lint Cardiac None
woman application syncope
of nitric acid
to ulcers of
pudenda
31 Soldier 25 Removal of Lying Hollow sponge Five minutes Cardiac None
small tumour syncope
from cheek
32 Tobacconist 43 Intended Lying Handkerchief A few minutes Cardiac Two.
perineal syncope
section
33 Woman 40 Intended Lying Folded lint About five Simultaneous None
operation for minutes deep coma
strangulated and cardiac
hernia syncope
34 Single 22 Intended Lying Inhaler About five Cardiac One.
woman application minutes syncope
of actual
cautery to
sore of
vagina
35 Young man 19 Intended Lying Inhaler Fifty seconds Cardiac None
forcible syncope
extension of
knee
36 Girl 13 Removal of Apparently Cardiac None
tumour from sitting syncope
back
37 Married 59 Intended Lying Hollow sponge About five Deep coma and None
woman reductionof minutes cardiac
old syncope
dislocation of
humerus
38 Woman 40 Removal of Lying Folded lint A few minutes Cardiac None
uterine syncope
polypus
39 Married 45 Intended Lying Sponge, Three-quarters of Cardiac None
woman removal of handkerchief, an hour. syncope
breast and inhaler
40 Tailor 18 Intended Lying Inhaler About seven Cardiac None
operation for minutes syncope
phymosis
41 Labouring 65 Intended Lying Inhaler Between 13 and 14 Cardiac None
man amputation minutes syncope
of thigh
42 Shoemaker 39 Catheterism Lying Folded lint A few minutes Deep coma, None
apnœa, and
cardiac
syncope
43 Woman 56 Intended Lying Folded lint & About three Cardiac None
amputation piece of oiled minutes syncope
of leg silk
44 Man 40 Intended Lying Inhaler About five Cardiac None
excision of minutes syncope
eyeball
45 Married 29 Inhaled to Sitting Inhaler A few seconds Cardiac Two
lady relieve syncope
neuralgia
46 Married 36 Intended Sitting Handkerchief A few seconds Cardiac Four
lady extraction of syncope
teeth
47 Sailor 30 Intended Sitting Sponge and Three or four Deep coma and None
removal of folded lint minutes cardiac
necrosed syncope
bone from
finger
48 Boy 9 Intended Lying Cotton wool & A few minutes Cardiac None
removal of folded lint syncope
tumour of
scapula
49 Labourer 35 Intended Lying Folded lint A few minutes Cardiac One.
amputation syncope
of thigh
50 Young 17 Application of Lying Inhaler Symptoms not Two.
woman nitric acid to observed
syphilitic
sores
There is in a great number of the cases an evident connection between the accident and the probable
strength of the mixture of vapour and air. In six cases the accident occurred just after the
commencement of the inhalation; in two of the cases, Nos. 27 and 37, the fatal symptoms occurred just
after fresh chloroform had been applied on the handkerchief and sponge; and in several cases, in which
the circulation was suddenly arrested just after the patient had been rendered insensible, the
insensibility had been induced so quickly as to prove that the vapour must have been inhaled in a very
insufficient state of dilution.
THE TWO KINDS OF SYNCOPE.
Dr. Patrick Black has made an objection to the fact of the patients having died of paralysis, or over-
narcotism of the heart, in the accidents from chloroform.[132] He says that paralysis of the heart would be
death by syncope, but that the symptoms before death, and the conditions of the organs met with
afterwards, are not in accordance with such a view of the case. In order to show that both the symptoms
and the after death appearances, in the fatal cases of inhalation of chloroform, are consistent with
paralysis of the heart, it is necessary to point out the difference between ordinary syncope and cardiac
syncope. One of the best examples of ordinary, or what may be called anæmic syncope, is that which
occurs in a common blood-letting, whilst the patient is in the sitting posture. When the bloodvessels,
especially the veins, which at all times contain the greater part of the blood in the body, do not
accommodate themselves fast enough to the diminished quantity of blood, the right cavities of the heart
are supplied with less and less of the circulating fluid; and in a little time are not supplied at all, when
the heart ceases to beat, in accordance with the observation of Haller, that it does not pulsate when it is
not supplied with blood. 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.[133]
The blood may remain in the ordinary quantity; but if the bloodvessels do not keep up their usual
support, and exert a sufficient pressure on their contents, the same kind of syncope will occur as that
from blood-letting. The late Sir George Lefevre related the case of a lady who fainted whenever she left
her bed, and assumed the upright posture; no cause could be found for this until it was ascertained that
she suffered from varicose veins of the legs: bandages to these extremities prevented the fainting. It is
obvious that in this case the mechanism of the syncope was the same as that in blood-letting; the
distension of the varicose veins under the weight of the superincumbent blood had the same effect in
preventing the supply to the right cavities of the heart, as if the blood had been entirely removed. The
faintness which often occurs on first rising, when a person has long kept the recumbent posture from
any local cause, is probably of the same kind; the veins not having had to support the weight of the usual
column of blood for some days or weeks, lose their tone we may presume, and yield when they are all at
once subjected to the weight of a column of blood extending from the lower extremities to the heart, so
that this organ ceases to be properly supplied with the circulating fluid.
In cardiac syncope, on the other hand, the cavities of the heart, or at all events the right cavities of this
organ, are always full, whether the syncope depend on paralysis of the heart by a narcotic, or inherent
weakness of its structure, or on its being overpowered by the quantity of blood with which it is
distended. After death from this kind of syncope, if the blood have not been displaced by artificial
respiration or other causes, the right cavities of the heart and the adjoining great veins will be found
filled with blood, and the lungs will in many cases be more or less congested. The appearances in short
will be very much the same as in asphyxia by privation of air, which ends in a kind of cardiac syncope,
the stoppage of the heart being partly due to over-distension of its right cavities, and partly to loss of
power in its structure, from the want of a supply of oxygenated blood through the coronary arteries. In
death by anæmic syncope, on the contrary, all the cavities of the heart are found empty, or nearly so, and
the same is frequently the case with the adjoining great veins, whilst the lungs are usually pale.
The syncope occasioned by some kinds of mental emotion is of the ordinary or anæmic kind, and
consequently the condition of the brain must act first on the bloodvessels, and not directly on the heart.
Certain persons are liable to faint on witnessing a surgical operation. Now if the mental emotion of these
persons acted directly on the heart, whilst the rest of the vascular system was unaffected, the
distribution of the blood would be nearly the same as in asphyxia, where the circulation is first impeded
in the lungs, and is ultimately arrested by loss of power in the heart. If the action of the heart were
weakened, or stopped, in the first instance, by the kind of emotion under consideration, the arteries
would be emptied by their contractility and elasticity, and the blood would accumulate in the right
cavities of the heart and the great veins leading to them. In a medical student fresh from the country,
who is by no means deficient in blood, the jugulars would become distended and the face livid, and the
recumbent posture would probably do but little towards removing the symptoms. The phenomena which
are witnessed, however, indicate a very different condition of the vascular system. The person about to
faint from the cause indicated, frequently becomes pale before he feels anything wrong; and when
requested to retire and sit down, often says that there is nothing the matter with him. In a short time he
faints, and falls, if no one catches hold of him; but the moment he is in the recumbent posture he
recovers. In such a case as this, the effect of the mental emotion must be first exerted on the veins, or the
veins and capillaries, through the nerves which supply these vessels; they allow themselves to become
distended, and the heart ceases to act for want of its supply of blood, as in syncope from blood-letting,
and anæmic syncope from any cause.
Several authors have attributed the empty state of the heart met with after death, in certain cases of
fatal syncope, to want of power in the left ventricle to supply the right cavities of the heart; but this is to
argue as if the blood passed out of the body after leaving the right ventricle, and the left ventricle had to
supply a newly formed fluid. The effects of want of power in the left ventricle are the same as those of an
obstruction at the origin of the aorta; the lungs become congested, and the right cavities of the heart
more or less distended, from the blood not being able to pass readily through the lungs. Patients who die
of heart disease die with the cavities of that organ full. Some patients, indeed, with fatty disease of the
heart, die suddenly of anæmic syncope, and the heart is found empty; but in these cases it is evident that
death is not occasioned by the disease of the heart, but by some condition of the bloodvessels which
accompanies it.
Chevalier was, I believe, the first to draw marked attention to cases of sudden death arising from an
empty state of the heart, in a paper in the first volume of the Transactions of the Royal Medical and
Chirurgical Society; and he rightly attributed the emptiness of the heart to a loss of power in the
bloodvessels. His words are as follow:—
“The disease I have now described may, perhaps, be termed asphyxia idiopathica. The essential
circumstances of it evidently denote a sudden loss of power in the vessels, and chiefly in the minuter
ones, to propel the blood they have received from the heart. In consequence of which, this organ, after
having contracted so as to empty itself, and then dilated again, continues relaxed for want of the return
of its accustomed stimulus, and dies in that dilated state.”
The word asphyxia has become so closely connected by physiologists with death by privation of air,
where the symptoms and appearances are the reverse of those in Chevalier’s case, that it is necessary to
discard his name of the disease which he describes, although it is etymologically correct. His cases come
under the definition of what is now universally called syncope, and what I have called anæmic to
distinguish it from cardiac syncope.
Chevalier speaks of a want of power in the vessels to propel the blood, and as it is not now believed
that the vessels take any active share in the propulsion of the blood, this may be the reason why the
views of this author have received less attention than they deserve; but it is very obvious that a want of
tone in the vessels, or any great diminution of that power which enables them to support and compress
the blood, is an adequate cause why the blood should be unable to reach the right side of the heart. In
the case of varicose veins, previously mentioned, it was physically apparent that the cause of the syncope
lay in the vessels. Disease of the arteries is well known to be usually associated with degeneration of the
heart; the veins are also large and distensible in old people, who furnish the greater number of those
who are liable to anæmic syncope; but the pathology of the veins, as regards both their functions and
structure, is not yet sufficiently known.
Persons with disease of the heart, who die suddenly in a fit of anger, probably die always with the
heart distended; that is, of cardiac syncope. Dr. Joseph Ridge, however, in his able and interesting
remarks on the disease and death of John Hunter,[134] states his belief that that celebrated man, who had
been long subject to attacks of angina pectoris, died at last of syncope, with an empty heart. He died, as
is well known, during a fit of anger, and the coronary arteries were found ossified. It is not said that the
heart was empty, but that it was small, and that there were no coagula in any of its cavities. It is probable
that there was not much blood in its cavities, at the time of the post mortem examination, but the body
of Hunter was conveyed in a sedan-chair, from St. George’s Hospital to Leicester Square, a little more
than an hour after his death, so that the fluid blood would gravitate downwards. It is related that the
stomach and intestines were unusually loaded with blood, and that those parts which were in a
depending position, as in the bottom of the pelvis and upon the loins, were congested in a greater degree
than the others; and that “this evidently arose from the fluid state of the blood.”
In syncope from muscular exertion, the cavities of the heart are distended, and its walls have
occasionally been ruptured, both from violent exercise and fits of anger.
Fear probably occasions each kind of syncope in different cases. In some cases, the right cavities of the
heart become distended owing to impeded respiration, and possibly to a diminution of power in the
heart itself. More frequently, the syncope appears to be of the ordinary or anæmic kind, the effect of the
mental condition acting first on the more distant parts of the circulation. The pallor caused by fright is
proverbial.
Pain is also capable of causing both kinds of syncope. I have alluded to cases (page 55) in which the
patients strained and held their breath till the pulse became intermittent, and the action of the heart was
temporarily suspended by the arrested breathing; on the other hand, patients often become pale, if they
are undergoing any slight operation when seated, and syncope of the anæmic kind occurs, without any
previous disturbance of the respiration, but passes off as soon as they are placed in the horizontal
posture. I have seen an apparently strong man faint in this manner, during the removal of a tumour
from the back not larger than a nut, and where only a few drops of blood were lost. Chloroform was not
employed.
SUPPOSED CAUSES OF DEATH FROM CHLOROFORM.
Many writers have supposed that the deaths from chloroform have arisen from some peculiarity in the
patient; and when any notable change of structure has been met with after death in any of the vital
organs, this has been thought to afford a sufficient explanation of the event; whilst in the cases in which
the organs were in a healthy state, surprise has been expressed at the occurrence. In looking over the
account of the cases in which the inhalation of chloroform has been fatal, there is reason to conclude,
however, that the subjects of them were, as regards health and strength, quite equal to the average of the
multitude who have inhaled this agent without ill effects. In fifteen out of the fifty cases above related,
there was no examination of the body after death. In one of these fifteen cases, the patient was in a state
of debility, and had hectic fever, apparently from the disease of the ankle-joint, for he had no cough; in
another of these cases, the patient was reduced to a state of great debility from cancerous disease of the
uterus. In fourteen out of the thirty-five cases, in which an examination of the dead body took place, all
the chief organs were found to be healthy, if we except the local congestions of blood connected with the
mode of dying, and a flabby state of the heart in a few of the cases, which probably depended on its being
full of blood at the time of death, or its not being in a state of post-mortem rigidity, at the time it was
examined.
In one case, No. 25, the only morbid appearances were adhesions of the pleura of small extent; and in
No. 47, the only disease was fatty liver. In Case 17, there were signs of chronic disease of the membranes
of the brain; and in two cases, Nos. 16 and 22, there was emphysema of the lungs. In the remaining
sixteen cases, there was some alteration of the heart, accompanied in a few instances by disease of other
organs. In Cases 23 and 32, there was fat on the surface of the heart, but the structure was not
degenerated. In Case 43, the right ventricle was thinned, but not fatty. In Case 44, there were slight
deposits on the mitral valve, the heart being otherwise healthy. In Case 50, there were deposits of lymph
on the mitral valve and also on the surface of the heart, which was somewhat enlarged. In Case 8, the
heart is merely stated to be large; and in Case 27, hypertrophied. In Case 3, the heart was enlarged, pale,
and soft, and the lungs were tuberculous. In Case 15, there was said to be some amount of disease of the
aortic valves, and some amount of fatty degeneration of the heart. In Case 37, incipient fatty
degeneration was present; and in Case 40, that of a youth of eighteen, the heart was slightly enlarged,
with some amount of fatty degeneration. In Case 46, the right ventricle was thinned and slightly fatty.
There remain three Cases, Nos. 30, 33, and 42, in which the fatty degeneration was more decided; and
one case, No. 41, in which it is spoken of as being present in an extreme degree. This was in a man, aged
sixty-five, the oldest person included amongst those who died from chloroform.
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. In the other forty-one
cases, the ages, when grouped in decennial periods, are shown in the following table, the last column of
which shows the proportion which the deaths bear at each period to the number living at that period, out
of a thousand persons of all ages in England and Wales.
Under 5 years 0 0
5 and under 15 3 ¹⁄₇₆
15 „ 25 11 ¹⁄₁₈
25 „ 35 10 ¹⁄₁₅
35 „ 45 11 ⅒
45 „ 55 3 ¹⁄₂₇
55 „ 65 2 ¹⁄₂₆
65 and upwards 1 ¹⁄₄₄
The nine persons whose ages are not given were all adults; one is spoken of as a young man, and
another as a young woman, and the rest are mentioned in such a manner that it is certain they were not
old people. It follows, therefore, that so far as is known, there has been a complete immunity from death
by chloroform at both extremes of life. I have already given my reasons for rejecting Dr. Aschendorf’s
case of an infant, and also the case of a gentleman, aged seventy-three, who died whilst inhaling
chloroform. The youngest patient who died from chloroform was seven or eight years of age, and the
oldest sixty-five, being the only death above sixty. The above table of the ages shows that the number of
deaths, in proportion to the number living, increased rapidly after the age of twenty-five, and decreased
rapidly after the age of forty-five. The small number of deaths between fifteen and twenty-five may be
partly due to the circumstance that surgical operations are but seldom required at this period of life; but
the decrease after the age of forty-five cannot be explained in this way; for persons become more liable
to require surgical operations as they advance in years. Operations are often performed in infancy and
old age, periods at which deaths from chloroform have not been recorded. The greatest proportion of
deaths having occurred from thirty-five to forty-five, when the system is often more robust than at any
other period, it cannot be supposed that an inability to bear the usual dose of chloroform, when carefully
administered, is the ordinary cause of death from this agent.
Idiosyncrasy. The accidents from chloroform have frequently been attributed to idiosyncrasy in the
patient. This, it may be observed, is not to give an explanation of them, but merely to state that they
depend on something we do not understand; that something, however, being in the person to whom the
accident happens. This view receives apparent support from the supposition that the chloroform has
been inhaled in exactly the same manner in the fatal cases as in other instances; but this apparent
support fails when it is pointed out that the supposed same manner is only an equally uncertain manner.
The different effects that have been produced on the same patient at different times, and the great
number of instances in which medical men have failed to make the patient insensible, show that most of
the usual modes of exhibiting chloroform are extremely uncertain.
What most completely meets the question of idiosyncrasy, however, is the circumstance that in no
fewer than eleven out of the fifty recorded cases of death from chloroform, the patient had previously
inhaled this medicine without ill effects. In two other cases also, previous attempts had been made to
make the patient insensible without success, on the day on which the accident occurred. In the above
table of the fatal cases, those are indicated in which previous inhalations had taken place. In twenty-nine
cases, I have concluded that the patient had not previously inhaled, for the medical man, having given an
account of the state of his patient, and his reasons for administering the chloroform, would certainly
have mentioned such a material fact as a previous inhalation if it had occurred. There are ten cases of
which only a meagre account is given, and where a previous administration of chloroform may possibly
have taken place without being mentioned; but if only eleven, out of the fifty patients, who died from
chloroform, had inhaled it previously without ill effects, it is very clear that the fact of having inhaled it
with a favourable result, gives no immunity from the possibility of accident. It would be impossible to
say what proportion of the patients who have inhaled chloroform have inhaled it more than once, but it
is not probable that they amount to more than 22 per cent., if so many.
Alleged Impurity of the Chloroform. At one time accidents from chloroform were loosely attributed to
impurity in the medicine, but this was only a guess, and is opposed to the facts. No case of accident has
been traced to this cause, and in nearly all the cases of which the details are given, it is distinctly
recorded, either that the chloroform was examined and found to be of good quality, or else that
chloroform out of the same bottle had been used in other cases without ill effects. I have not thought it
necessary to state this in quoting the individual cases.
Apparatus employed. Accidents were at one time, and in one quarter, attributed to the use of inhalers;
and it is curious that this allegation was made at a time when no death from chloroform had yet
occurred in any cases in which an inhaler was used, except one in America, and one in France, the
accounts of which had not reached this country. It is possible that death might be occasioned by want of
air from the use of a faulty inhaler, and a case will be mentioned in which this apparently occurred in the
administration of sulphuric ether, but there is no recorded case of accident from chloroform in which
death was occasioned in this way. In the cases of death previously recorded, a handkerchief, a piece of
folded lint, hollow sponge, or some such simple contrivance, was used in thirty-four instances; in twelve
cases, an inhaler of some kind or other was used; and in four cases, it is uncertain what were the means
employed.
Alleged Exclusion of Air. The assertion has often been made that death might be caused by the vapour
of chloroform excluding the air, and so causing asphyxia; but it has already been pointed out in this
work that the physical properties of chloroform do not allow it to yield a quantity of vapour which would
have that effect, and in much smaller quantity than this the vapour kills by a quicker way than asphyxia,
I believe that the only elastic fluids which can cause death simply by excluding the atmospheric air are
nitrogen and hydrogen.
Alleged Closure of the Glottis. At the trial which took place in Paris respecting the death of a porcelain
dealer previously mentioned, M. Devergie gave evidence, and after saying that chloroform might cause
death as a poison, if given in undue proportion, he added: “Also it closes the glottis, and offers an
obstacle to respiration. Employed by M. Demarquay on himself, in very small doses, closure of the
glottis was occasioned. It was possible that Le Sieur Breton had experienced that accident, and in that
case the most able surgeon could not prevent death.”
I have not met with M. Demarquay’s account of his experiment, but I am happy to know that he did
not die of the closure of the glottis. It may fairly be denied that a person could commit suicide in this
manner if he wished, for he would either have to give up the attempt, or receive the vapour into his
lungs, and experience its specific effects. When animals are placed in mixtures of vapour and air, they
always breathe them, whatever the strength; and if the vapour amounts to eight or ten per cent., they die
much more quickly than they would of mere closure of the glottis. Vapour of chloroform, when not
largely diluted with air, is apt to cause cough and closure of the glottis, as soon as a little of it reaches the
lungs; but this, so far from being a source of danger, is, as a general rule, a safeguard, by its preventing
the patient from readily breathing air which is highly charged with vapour.
In commenting on the fatal case No. 12, which occurred in St. Thomas’s Hospital, I have suggested
that the accident might have happened from liquid chloroform being dropped into the throat; but liquid
chloroform is very different from the vapour; it causes a lasting irritation if applied to a mucous
membrane; when used for toothache, it often blisters the gums. The irritation caused by the vapour, on
the contrary, is only momentary, and its local action ceases directly it ceases to be inhaled; for what is
left in the air-passages is immediately absorbed or expelled with the expired air. The glottis is not a vital
organ of itself. Its closure only causes death by preventing the access of air to the lungs. The glottis does
not remain permanently closed, I believe, from the contact of any elastic fluid, however irritating;[135] but
it does from the contact of a liquid, and persons who die by drowning, die with the glottis closed, for they
do not fill their lungs with water. Therefore, if the vapour of chloroform did cause persistent closure of
the glottis, and if a person were to hold it by force to the patient, the death it would occasion would be
precisely like that in drowning. Death by asphyxia is a comparatively slow one. I find that when the
access of air to the lungs is entirely cut off, death does not take place in less than three minutes and a
half in guinea pigs, and four minutes in cats. In dogs, the process of asphyxia is still slower. Mr. Erichsen
states, that on taking the average of nearly twenty experiments, the contractions of the ventricles
continued for nine minutes and a quarter after the trachea had been closed, and that the pulsations of
the femoral artery also were perceptible for an average period of seven minutes and a half. The process
of drowning in the human subject is well known to occupy some minutes; and even if the pungency of
the vapour of chloroform should entirely prevent the patient from breathing, and the medical man could
overlook the fact that breathing was not going on, it cannot be supposed that he would use the force, and
have the perseverance to cause his patient to die slowly by asphyxia. If any patient, therefore, has died
from closure of the glottis, it must have been one in whom there was a great tendency to sudden death
from any slight interruption to respiration. I do not know the particulars of the case respecting which M.
Devergie was giving his evidence, but in those fatal cases previously related, in which the symptoms are
sufficiently described, it is not probable that death took place in any instance from closure of the glottis.
In the sudden death at St. George’s Hospital (page 209), it is possible that the slight pungency of the
vapour might assist the fear under which the patient was labouring in impeding the breathing, and thus
add to the distension of the right cavities of the heart, under which the patient apparently died.
In 1855, two years after M. Devergie had given the above opinion, Dr. Black, of St. Bartholomew’s
Hospital, who has had great experience in the administration of chloroform, advanced a similar theory
in the pamphlet previously alluded to. He did not, however, confine the effects of the supposed closure
of the glottis to possibly causing a death here and there, as M. Devergie had done, but he attributed all
the accidents which had happened to this cause, and not to the effects of chloroform in the system. He
says that “the chloroform has not been even inhaled: its pungency was felt at the glottis, and its
inspiration was immediately arrested. The patient would have removed the apparatus, but in this he was
restrained. The struggle forthwith commenced, but up to the moment of his death, not a single
inspiration took place.” These remarks were not applied to a single case, but generally to the accidents
from chloroform. Dr. Black says: “Any concentration of the vapour of chloroform which can be breathed
is safe; any condition of dilution which forces the patient to cough or hold his breath is dangerous, and if
persevered in for even half a minute, may be fatal.... We have only to attend to the breathing; we may
disregard all considerations affecting the relative proportion of the chloroform in the air which is
breathed;... if the patient breathes easily he is in safety, whatever be the amount of chloroform which is
passing into the lungs.”
In Experiment 28, previously related, where the respiration was kept up by a tube in the trachea, there
could be no error in respect to the vapour of chloroform entering the lungs, when a bladder of air
charged with ten per cent. of that vapour was substituted for the bladder of simple air; and the
immediate paralysis of the heart was evident. An examination of the fatal cases, of which the particulars
have been recorded, shows that death did not occur in the manner Dr. Black suggests. In the majority of
the cases, the patients were rendered quite insensible by the chloroform, and the operation had either
been commenced, or was on the point of commencing; when the fatal symptoms set in. In several other
cases, the patients were partially under the influence of the vapour before the symptoms of danger
commenced; and in the six cases where death occurred at the beginning of the inhalation, without loss of
consciousness having been induced, the patients were not restrained in any way, and it was observed
that they did breathe the chloroform; three of them were speaking up to the moment when the pulse
stopped, and one took a full inspiration the moment before the fatal symptoms set in. It is only in
eighteen of the fatal cases that there is any reason to suppose that the patient required to be held, and
then only from mental excitement or muscular spasm, arising from the physiological effects of the
absorbed chloroform. It is hardly possible that the struggles of a conscious patient from inability to
breathe, would be mistaken for excitement or spasm caused by chloroform.
In a case, No. 34, which occurred at St. Bartholomew’s Hospital whilst Dr. Black was present, and long
before his pamphlet was written, the patient inhaled for five minutes, and sank off into a state of
complete insensibility without alarming symptoms. The inhalation was discontinued, the patient moved
into a proper position, and the operation just about to be commenced, when Dr. Black found the pulse to
become extremely feeble and fluttering. Surely this patient breathed the chloroform, and died without
any spasm of the glottis. In Case 48, so minutely related by Mr. Paget, the boy made one long
inspiration, and became suddenly insensible. In a few seconds, the pulse suddenly failed, and then
ceased to be perceptible, but the breathing continued for at least a minute afterwards. There was
certainly no closure of the glottis in this instance.
Alleged Exhaustion from Struggling. In cases where the patients have struggled violently whilst
getting under the influence of chloroform, the accidents have been attributed to a supposed exhaustion
caused by the struggling.[136] This opinion is, however, contrary to experience; for the patients who
struggle violently are precisely those who bear chloroform the best, provided they do not breathe it in an
insufficient state of dilution. They are generally cheerful and exhilarated by it, and are less liable to be
depressed by its prolonged use, than those who come quietly under its influence. Although the patients
who struggle bear the chloroform well, when it is carefully and judiciously administered, it is not
improbable that the struggling has been now and then an indirect cause of accident. The muscular
spasm and rigidity do not occur till about three-quarters as much chloroform has been absorbed as can
be present in the system with safety; and, as the patients often hold their breath whilst struggling, and
take deep inspirations suddenly and at long intervals, the greatest care is required that the vapour be
administered in a very diluted state. In Cases 9, 44, and 47, the fatal symptoms came on whilst the
patients were struggling; and in some other cases, the sudden failure of pulse occurred just after the
struggling had ceased, rendering it probable that the patient inhaled too much of the vapour whilst
struggling, or just as the spasmodic condition of the muscles was subsiding.
The circumstances just mentioned, are probably the cause why so many of the fatal cases occurred at
that period of life when the body is most robust. Very nearly two-thirds (twenty-seven out of forty-one),
of those cases in which the ages are recorded, occurred in persons of twenty years and under forty-five
years of age, although the proportion of persons living at this period of life, in England and Wales, is
only a little more than one-third of the entire population. The majority of the accidents from chloroform
occurred also in the stronger sex, in which muscular rigidity and spasm are most frequent:—twenty-nine
of the fatal cases happened to males, and only twenty-one to females. According to my experience, the
females who inhale chloroform for surgical operations are nearly twice as numerous as the males; and
although this may not be the proportion in every one’s practice, it is probable that females inhale this
agent quite as frequently as the other sex, in every part of the world.
Sitting Posture. In some of the early cases of death from chloroform, the patients were inhaling it in
the sitting posture, and it was surmised that this circumstance was the cause of death.[137] An
examination of the account of the fatal cases, however, does not bear out this supposition. In thirty-one
instances the patients were lying, in nine instances sitting, and there are ten cases in which the position
is not mentioned, and where from the nature of the operation it may have been either one or the other.
In fully one-fourth of the cases of which I have kept notes of the administration of chloroform, the
patients were seated in an easy chair; and as in forty fatal cases in which the position is known, only
nine, or less than one-fourth, were seated, it does not appear that the position of the patient has had any
share either in causing or preventing accidents.
Supposed Effect of the Surgeon’s Knife on the Pulse. Mr. Bickersteth alluded to a peculiar
circumstance,[138] which he thought would account for several of the deaths attributed to chloroform. He
relates three instances in which the pulse suddenly ceased on the first incision by the surgeon, and
commenced again in a few seconds, the breathing going on naturally all the time. All the three cases
were amputation of the thigh, and occurred in the latter part of 1851. Mr. Bickersteth did not observe the
circumstance again during the two following years, and I have never observed it, although I have very
often examined the pulse at the moment when the operation began, especially after reading Mr.
Bickersteth’s remarks. He supposes that the action of the heart was arrested by the shock of the incision,
notwithstanding the patient was insensible. I should attribute the temporary stoppage of the pulse in
these instances to the direct influence of the chloroform on the heart. The moment when the operation is
commenced, is usually a few seconds after the inhalation has been discontinued, and when the effect of
the chloroform is at its height. A portion of that which was left in the lungs having been absorbed, in
addition to that which was previously in the system. And if the vapour inhaled just at last was not
sufficiently diluted, it might paralyse the heart, but not so completely as to prevent the natural
respiration from restoring its action, in those cases where respiration continues. I found in experiments
on animals that, when the action of the heart has been suspended by the effect of chloroform, it can very
often be restored by artificial respiration instantly applied; and it is extremely probable that an accident
of this kind not unfrequently occurs during the administration of chloroform, and is remedied by the
breathing, without being noticed. The pulse recovered itself, in the cases mentioned by Mr. Bickersteth,
just as it does in animals after the heart has been nearly overpowered by chloroform. In the first case,
the pulse remained imperceptible for a period of four or five seconds, the countenance at the same time
becoming deadly pale. As it returned, it was at first very feeble, but in a few seconds, it regained its usual
strength. In the second case, Dr. Simpson administered the chloroform, and after the operation
remarked that the pulse had stopped suddenly just as the knife was piercing the thigh, and had
recovered itself with a flutter almost immediately.
Mr. Bickersteth’s reason for attributing the stoppage of the pulse to the effect of the knife, rather than
the chloroform, was that he had arrived at the conclusion from some experiments which he performed
on animals, that the action of the heart cannot be arrested by chloroform, until the breathing has been
first suspended. One of Mr. Bickersteth’s experiments (No. 5, on a half-grown cat) exactly resembles the
experiment (No. 28 in this work) on a rabbit, which I had published upwards of a year before Mr.
Bickersteth’s paper appeared, with the exception that in my experiment the artificial respiration was
performed with air containing ten per cent. of vapour, and in Mr. Bickersteth’s the vapour was an
unknown quantity. In both experiments, the heart of the animal was exposed. In that which I performed,
three or four inflations of the lungs almost paralyzed the heart; and nine or ten inflations, which did not
occupy half a minute, had the effect of paralyzing that organ irrecoverably. In Mr. Bickersteth’s
experiment, the effect of the artificial respiration was as follows:—“After continuing it for seven minutes,
the diaphragm, hitherto unaffected, began to move very irregularly and imperfectly; then its movements
became slow and hardly perceptible; and, at the expiration of eleven minutes, they had ceased
altogether. During all this time the heart’s action remained strong and regular, but now it got weaker
and more rapid, and, in four minutes from the time the diaphragm had ceased acting, had become so
feeble (still quite regular) that I feared every moment it would stop.” Mr. Bickersteth says he performed
artificial respiration with air saturated with chloroform; but saturated or not, the vapour certainly did
not exceed six per cent., and most likely was only between four and five, if the artificial resembled the
natural respiration in quantity and frequency. The vapour which can be breathed for seven minutes
without causing serious symptoms, and for eleven minutes without arresting the breathing, is of course
incapable of stopping the action of the heart by its direct effect. It is scarcely so strong as that which one
administers every day to patients with impunity. The vapour which is so diluted as to require to be
added by small increments during one hundred and fifty inspirations, before the brain is even
narcotized, cannot act directly on the heart, an organ which can bear a much larger amount of
chloroform. Mr. Bickersteth fell into the error into which the Committee of the Society of Emulation of
Paris afterwards fell, and argued from the rule to the exception. What he witnessed was the mode of
death which would occur, if vapour of chloroform of the strength which can be safely inhaled, were
deliberately continued till the death of the patient. But an accident from chloroform is an exception, and
the mode of dying is as much an exception as the death itself, if the inquiry is extended to what this
agent is capable of doing, instead of confining it to what one endeavours to effect with it in the human
subject alone.
So many of the deaths during the inhalation of chloroform have occurred before the operation had
commenced, or after it had proceeded some way, that Mr. Bickersteth’s explanation would not apply to a
great number, even if it were correct; and when it is remembered that the operation is always
commenced when the effect of the chloroform is expected to be at its height, the number of cases of
cardiac syncope which have happened at the beginning of the operation is not greater than might be
expected as the result of the effect of chloroform.
Sudden Death from other Causes. It has been more than once suggested that the deaths which have
occurred, during the inhalation of chloroform, are of the same nature as the sudden deaths which have
often occurred about the time of surgical operations, apparently without any adequate cause; and that in
fact the accident and the chloroform may be a mere coincidence, and not connected as cause and effect.
It has been already shown that the Commission of the Academy of Medicine of Paris made this
suggestion in treating of the case of Madlle. Stock, and Dr. Simpson has more than once made a similar
remark. On one occasion,[139] he remarked, in speaking of chloroform:—“The first surgical cases in which
it was used were operated upon in the Royal Infirmary here, on the 15th of November, 1847. Two days
previously, an operation took place in the Infirmary, at which I could not be present, to test the power of
chloroform; and so far fortunately so; for the man was operated upon for hernia, without any
anæsthetic, and suddenly died after the first incision was made through the skin, and with the operation
uncompleted.” I should say, so far unfortunately so, for whatever the cause of the man’s death, that
cause could hardly have been present if the patient had been made insensible by chloroform; and so his
life would in all probability have been saved. If he died either from fear or from pain, the chloroform
would have prevented his death, by removing and preventing these causes; and if his death arose from
simple exhaustion, it must be remembered that chloroform is a stimulant, during the first part of its
administration, and, as a general rule, so long as it is actually in the system. Even Mr. Bickersteth, who
thinks that the knife of the surgeon may have a direct influence on the heart when the patient is quite
insensible, expresses his conviction that such an occurrence is far less likely to happen under the
influence of chloroform than in the waking state.
I have omitted from the list of deaths by chloroform two cases which are usually attributed to that
agent, namely, the case of Mr. Robinson’s patient, and the one at St. George’s Hospital, and have
attributed them to fear; and I also rejected the case of the infant on which Dr. Aschendorf operated, for
the reasons I stated; and it is quite possible that amongst the fifty cases I have retained, there may be
one or two in which the death was not caused by chloroform, especially as the details of some of the
cases are very meagre; but when all the circumstances of the cases are examined, and especially when
the mode of death is compared to that which chloroform can be made to produce in animals, it cannot be
supposed that the fatal event was a more coincidence in the whole fifty cases, or in any great number of
them.
There are numerous instances recorded of sudden death during surgical operations, or just before
intended ones, without any evident cause, except fear or pain, before the use of narcotic vapours was
known; and some even since, in cases in which it was not thought worth while to use them. After the
passage quoted above, Dr. Simpson continues:—“I know of another case in Edinburgh, where death
instantaneously followed the use of an abscess-lancet without chloroform,—the practitioner, in fact,
deeming the case too slight to require any anæsthetic.” Such events have, no doubt, often happened
without being recorded; and it is extremely likely that the deaths of this kind which chloroform has
prevented are quite as numerous as those it has occasioned by its own effects, but the medical profession
will very properly not be satisfied with a result of this kind, if more can be done; and the endeavour of
the practitioner of course is, whilst saving life as well as preventing pain by the use of this agent, to avoid
as far as possible having any accident from its use.
Falling back of the Tongue. It has been alleged that the falling back of the tongue into the throat,
under the deep influence of chloroform, might be the cause of death by suffocation; but this appears to
be an error; for the muscles of the larynx and neighbouring parts preserve their action as long as the
diaphragm, and contract consentaneously with it. When the breathing has ceased, the tongue is indeed
liable to fall backwards, if the person in a state of suspended animation is lying on the back, and this
circumstance requires to be attended to in performing artificial respiration.
STATE OF THE CHIEF ORGANS AFTER DEATH FROM
CHLOROFORM.
A few years ago, I examined the viscera of the chest, and kept notes of the appearances, in thirty-seven
animals killed by chloroform. They consisted of two dogs, twenty-two cats, one kitten, three rabbits,
three guineapigs, two mice, two larks, and two chaffinches. Many of the animals were opened
immediately after death, and the rest within a day or two. The lungs were not much congested in any
instance. In seven of the animals, they were slightly congested; but in the remaining thirty, they were not
congested. They were generally of a red colour, but in a few of the cats they were quite pale. I ascertained
the specific gravity of the lungs of two of the cats, in which they presented the amount of vascularity I
have most usually met with. The specific gravity was 0·605 in one instance, and 0·798 in the other. As
many of the animals died in a way resembling asphyxia, the respiration ceasing before the circulation, it
might at first be supposed that we should meet with the same congestion of the lungs; but by the time
that the respiration is altogether suspended by the action of chloroform, that agent has begun already to
influence the heart, which does not inject the blood into the lungs with the same force as when the
respiration is mechanically prevented, whilst it is in full vigour. Besides, in the gaspings which so often
take place when the heart is ceasing to act, the animal inhaling chloroform draws air freely into the
lungs, whilst the asphyxiated animal is prevented from doing so.
As regards the condition of the heart, it was found in the two chaffinches that the auricles were filled
with blood, whilst the ventricles were empty. The condition of the heart in the larks is not mentioned,
but in all the thirty-three quadrupeds, the right auricle and ventricle were filled with blood. In ten of
them, these cavities were much distended; and in some of these instances, the coronary vessels on the
surface of the heart were distended also. The left cavities of the heart never contained more than a small
quantity of blood, not exceeding a quarter of what they would hold.
The head was examined in only ten of the animals. The substance of the brain was found to be of the
natural vascularity, and the sinuses were not very much distended, except in two instances.
With respect to the state of the blood, it may be mentioned, that in every instance in which the chest
was opened within an hour after death, the blood which flowed from the cut vessels coagulated
immediately and firmly. In eighteen of the animals in which the blood was examined in the heart or
large vessels, a day or two after death, it was found to be well coagulated in ten, loosely coagulated in
seven instances, and quite fluid in one instance. I have not met with air in the bloodvessels, either in the
above thirty-seven examinations, or in any of the numerous other animals that I have opened, after they
have been killed by chloroform. The appearances I have met with in animals killed by this agent have
usually been such as I have described in the above thirty-seven instances; but I long since ceased, as a
general rule, to make careful notes of the appearances, as I did not meet with anything new.
In the fatal cases of inhalation of chloroform previously quoted, the lungs are related to have been
congested more frequently, and to a greater extent, than I have met with in animals. But there is no
standard of what should be called congestion; and probably many of the medical men who made the
examinations were speaking by comparison with cases where persons die after illness, in a state of
inanition. In the human subject, the right cavities of the heart, although generally full of blood, were
found empty in several cases; but as I previously stated, it is almost certain that they were emptied after
death, either by the artificial respiration which was employed, or in some other way.
The blood remained fluid in eighteen out of twenty-five cases of fatal accident from chloroform, in
which an examination of the body was made and the condition of the blood recorded; whereas it was
only quite fluid in one instance out of eighteen of the animals which were killed by chloroform, and not
opened till a day or two afterwards. The fact of the blood coagulating more generally, in the animals on
which I have experimented, than in the human subjects who died from chloroform, is probably due to
their smaller size. I was formerly of opinion that the fact of the body of a small animal cooling more
quickly than the human one was the probable explanation of this, but Dr. Richardson appears to have
proved that the blood is kept in a liquid state by the presence of ammonia; and ammonia, we might
expect, would escape more readily from the body of a small animal than from the human body. However
this may be, it is pretty certain that the blood generally remains fluid in the human body after death
from chloroform, only because it usually remains fluid in every kind of sudden death. When a patient
dies slowly of illness, the body cools gradually before death takes place, and ammonia keeps exhaling in
the breath, if Dr. Richardson is correct, whilst the formation of this alkali must be almost suspended. In
many cases, we know that coagulation of the blood commences before the respiration and circulation
have ceased. The blood which flows during surgical operations coagulates as quickly and firmly when the
patient is under the influence of chloroform as at other times; and, as was mentioned above, the blood
which flows from animals, just after they are killed by this agent, coagulates as well as usual; it follows,
therefore, that if the coagulation of the blood were prevented by the chloroform, and not by the mere fact
of sudden death, it would be by the presence of this agent in the blood after death, and not by any action
which it exerted during the life of the patient.
FURTHER REMARKS ON THE PREVENTION OF ACCIDENTS FROM
CHLOROFORM.
In consequence of the prevailing opinion that accidents from chloroform depended chiefly on the
condition of the patient, the main endeavours to prevent a fatal result have taken the direction of a
careful selection of the persons who were to inhale this agent. It may be doubted, however, whether this
line of practice has had so much effect in limiting the number of accidents, as in curtailing the benefits to
be derived from the discovery of preventing pain by inhalation. In nearly all the recorded cases of
accident from chloroform, it is stated that the patients had been carefully examined, and such proofs of
disease as were met with after death were chiefly those which had not been detected; and, as already has
been stated, were probably not greater on an average than in the cases in which no accident happened.
I have not myself declined to give chloroform in any case in which a patient required to undergo a
painful operation, whatever evidence of organic disease I have met with on careful examination; and
although I have memoranda of upwards of four thousand cases in which I have administered this agent,
I have not, as I believe, lost a patient from its use; the only person who died whilst under its influence
having, in my opinion, succumbed from other causes, as I have already explained.
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. It should be wholly
disregarded except under certain circumstances, when syncope is to be feared from loss of blood during
the performance of a capital operation. The pulse is only affected secondarily in consequence of the
failure of the respiration.”
If the person administering chloroform was always quite sure that the vapour did not constitute more
than five per cent. of the inspired air, it is quite true that the pulse might be wholly disregarded. I can
never produce more certain and uniform results with chloroform than when I am giving it to small
animals enclosed in glass jars, where of course the pulse cannot be felt. In surgical practice, however,
where the amount of vapour in the inspired air is often very uncertain, watching the pulse may be of
great service, irrespective of loss of blood; and although it will not always prevent accident, I am
persuaded that it has saved many lives. In some of the accidents that have happened, the pulse has
ceased suddenly, whilst it was being very carefully watched; but more usually it would show some signs
of failure before entirely ceasing.
In giving chloroform freely to animals from a napkin or sponge, whilst the ear or the hand was applied
over the heart, I have usually found that its pulsations became embarrassed and enfeebled before they
ceased; and by withdrawing the chloroform when the heart’s action first became affected, the life of the
animal could often be saved.
The importance of attending to the respiration of the patient has been previously noticed, and it is so
obvious a symptom that it can hardly be disregarded, if anyone is watching the patient; it speaks,
moreover, almost to one’s instincts, as well as to one’s medical knowledge. It is probable that no patient
has been lost by disregard of the respiration, unless it be one or two whom no one was watching, or in
which the head and shoulders were covered with a towel.
It has already been shown in this work, from experiments on animals, and from the physiological
effects and physical properties of chloroform, that accidents from this agent would arise by its suddenly
paralyzing the heart, if it were not sufficiently diluted with air; and a careful review of all the recorded
cases of fatal accident shows that nearly every one of them has happened in this way, and not from any
neglect in watching the symptoms induced, or mistaking their import.
The first rule, therefore, in giving chloroform, is to take care that the vapour is so far diluted that it
cannot cause sudden death, without timely warning of the approaching danger; and the next rule is to
watch the symptoms as they arise. A description of those symptoms, and what they indicate, has already
been given.
I have previously stated that the most exact way of giving chloroform to a patient is to put so much of
it into a bag or balloon as will make four per cent. of vapour when it is filled up with the bellows; but I
have not often resorted to this plan, on account of its being somewhat troublesome. I have previously
described (p. 81) the inhaler which I employ. By arranging the bibulous paper suitably, and by
ascertaining, with the inhaler in the scales, how much chloroform a given quantity of air carries off at
different temperatures, I am able to produce very uniform results in the administration of chloroform.
But, as I previously stated, those who do not wish to have the trouble of studying a suitable inhaler, may
give chloroform on a handkerchief without danger, and with results sufficiently certain, by diluting this
agent with an equal measure of spirits of wine. As the spirit (nearly all of it) remains behind, it is
desirable, in a protracted operation, to change the handkerchief or sponge, now and then, for a dry one.
TREATMENT OF SUSPENDED ANIMATION FROM CHLOROFORM.
It is probable that artificial respiration, very promptly applied, will restore all those patients who are
capable of being restored from an overdose of chloroform. All the patients who are related to have been
restored after this agent has occasioned a complete state of suspended animation, have been
resuscitated by this means. It is only by artificial respiration that I have been able to recover animals
from an overdose of chloroform, when I felt satisfied that they would not recover spontaneously. And
under these circumstances I have not been able to restore them, even by this means, except when a tube
had been introduced into the trachea, by an incision in the neck, before giving them what would have
been the fatal dose.
M. Ricord succeeded in restoring two patients who were in a state of suspended animation by mouth
to mouth inflation of the lungs. The first was a woman, aged twenty-six, who had been made rapidly
insensible by a few inspirations of chloroform from a sponge. He had scarcely commenced the operation
of removing some vegetations, when his assistant informed him that the pulse had ceased. The breathing
also ceased about the same time.
In the second case, he completed the operation of circumcision, and the patient, a young man, not
coming to himself, M. Ricord found that the breathing had ceased, and the pulse was becoming more
and more extinct, and very soon ceased entirely, till restored by the artificial respiration.
After these cases, hopes were expressed that M. Ricord had discovered the means by which all patients
might be restored from the over-action of chloroform; but these hopes have not been verified by events.
In the first of the cases, the heart had probably not been so entirely paralyzed by the action of the vapour
as sometimes happens, and in the second case, that organ was apparently not paralyzed by the
chloroform at all. It was only after the breathing had ceased, that M. Ricord found the pulse was failing.
This was a case, therefore, in which artificial respiration might reasonably be expected to restore the
patient.
The following cases of resuscitation, from the over effects of chloroform, are related by Mr.
Bickersteth in the paper previously quoted. They occurred in Edinburgh:
“Case 1. A boy was cut for stone by my friend Mr. Hakes, on the 29th of March, 1849. Chloroform was
administered on a piece of sponge, and the full anæsthetic effect produced, before proceeding to tie him
up in the ordinary position: the inhalation was continued, without any regard to his condition, until the
operation had been completed—altogether about five minutes from the time he first became insensible.
It was noticed that during the operation scarce a drop of blood escaped. When it was over, the child was
found, to all appearance, dead; the muscles were flaccid; the surface of the body pale; the respiration had
ceased; the pulse could not be felt; the heart sounds were not audible (but the room was by no means
quiet); the eyes were half open; the jaw dropped; the pupils dilated; and the corneæ without their
natural brilliancy. Several means were tried to resuscitate him, but without effect. At length artificial
respiration was commenced; the air escaped with a cooing sound, as if from a dead body. After
continuing it for a while, the breathing commenced, at first very slowly and feebly. Soon it improved. In
two hours the child had quite recovered.”
“Case 2. In December 1851, a child, a few months old, was put under the influence of chloroform for
the purpose of having a nævus removed from the right cheek. As soon as insensibility was produced, the
operation was commenced—the handkerchief containing the chloroform remaining over the face, as
some difficulty had been experienced in keeping up the anæsthetic effect. Suddenly the breathing
ceased; the muscles became flaccid; the countenance pale and collapsed, and the lips of a purple colour.
Artificial respiration was employed, and in less than a minute the breathing returned, and the child was
restored.”
“Case 3. On the 6th of March, 1852, I had occasion to remove the finger of a robust, healthy-looking
young man, in the Royal Infirmary. He was already under the influence of chloroform when I entered
the room, and as there had been some difficulty in producing complete anæsthesia, and the last of the
chloroform in the bottle was already on the handkerchief, it was thought advisable by my friend in
charge of its administration to keep up the inhalation, in order to produce a coma sufficiently profound
to last until the completion of the operation. It was therefore left over his face, and I commenced and
removed the finger, slowly disarticulating it from the metacarpal bone. I distinctly recollect hearing the
man breathing quickly and shortly; and I also remember, that when just about to look for the vessels, my
attention was attracted to his condition, by not any longer hearing the respiration. The handkerchief was
still on his face. I took it off, and found, to my consternation, that the breathing had ceased; the face was
livid; the eyes suffused; the pupils dilated; the mouth half open. He was to all appearance dead; still the
pulse could be distinguished as a small, hardly perceptible thread, beating slowly. Immediately artificial
respiration was commenced. For a minute or two, his condition did not alter in any respect—then the
lividity of the countenance increased, the pulse was no longer perceptible, and the sounds of the heart
could not be satisfactorily heard. During the whole of this time, artificial respiration had been diligently
employed, but still the air appeared to enter the chest very imperfectly. I despaired. I felt certain that the
man was dead, and that no human aid could restore him; and if it had not been that those standing near
me urged me to persevere, I believe I should then have deserted the case as hopeless. Just at this time it
occurred to me to put my finger in the mouth and draw forward the tongue, in order to secure there
being no impediment to the air entering the lungs. Retaining it in this position, we again began the
artificial respiration, and found that then the chest was fully expanded by each inflation. After keeping it
up for a minute or two, the gentleman, who had all along kept his hand on the pulse, exclaimed, to our
delight, that he could again feel it—‘It was just like a slight flutter that reached the uppermost of his four
fingers,’ all of them being placed over the course of the artery. It gradually became more distinct and
firmer, and at the same time, the lividity of the face decidedly lessened. In another minute, the man
made a slight inspiratory effort. I ceased directly the artificial respiration, and merely assisted the
expiration by pressure upon the ribs. Another and another inspiration followed, and in a short time he
breathed freely without assistance. The countenance became natural, and he appeared as if in a sound
sleep. In half an hour, he spoke when roused; then he vomited, and complained of giddiness. In an hour
afterwards, he had recovered sufficiently to walk home.
“Moments of intense anxiety appear much longer than they really are; but even allowing this, I am
quite sure that, at the very least, five minutes elapsed from the time when the man ceased breathing
before the first inspiratory effort took place, and that for not less than one minute the pulse was
imperceptible, and the heart’s action almost, if not altogether, inaudible.”
“Case 4. A few weeks after the occurrence just described, I was assisting Mr. Syme in removing the
breast of a lady. A gentleman, my superior in the hospital, was conducting the inhalation of chloroform.
Anæsthesia was complete, and the breathing good, when the operation commenced. The chloroform was
allowed to remain over the face during the whole time of its performance. Before it was over, I noticed
the respiration become very quick and incomplete, and suggested, in consequence, the propriety of
removing the handkerchief. My remark was neglected for eight or ten seconds, and then, just as it was
taken away, the breathing ceased suddenly. The face became deadly pale; the eyes vacant; the lips livid.
Instant dissolution appeared inevitable (the pulse was not felt). Artificial respiration was immediately
commenced, but the air not entering the lungs freely, the tongue was pulled forwards, and retained so by
the artery forceps. The chest then expanded freely with each inflation, the air escaping with a cooing
sound. In rather less than a minute, the respiratory movements recommenced, but at first so slowly and
imperfectly that it was necessary to assist expiration. When recovery was a little more established, the
operation was completed. Before the putting in of the sutures, sensation had partially returned, and in a
short time the lady had perfectly recovered.”
Mr. Bickersteth very properly adds: “There can be no doubt, that in the foregoing cases, a grievous
error was committed by continuing the inhalation after anæsthesia was produced, and that it was in
consequence of this, the accidents, so nearly fatal, occurred.”
As these accidents seem to have occurred from continuing the inhalation too long, they differ entirely
from nearly all those which were actually fatal, and which, as we have seen, arose from the too great
concentration of the vapour, and not from any want of care in watching the patient, so as to be able to
leave off at the right moment, if it were possible. I have previously stated, that after breathing vapour of
the proper strength for inhalation, animals may always be readily restored by artificial respiration after
the breathing has ceased, provided the heart is still beating. In the cases related by Mr. Bickersteth, the
heart had ceased to beat before the patients were restored; but in the third case, there is distinct
evidence that the heart continued to beat for four minutes after the breathing had ceased. It was,
therefore, certainly not paralyzed by the direct action of the chloroform. The patient was nearly in the
condition of a drowned person, where we know that there is a good prospect of recovery by artificial
respiration during the first few minutes after the breathing has ceased, even if the action of the heart be
imperceptible. In the other three cases, also, it is probable that the breathing ceased before the action of
the heart; and, at all events, this organ was not paralyzed so thoroughly as in the cases in which artificial
respiration was promptly applied without effect.
Several other cases have been related in the medical journals in which patients have been restored by
artificial respiration, after animation had been suspended, more or less completely, by chloroform; but
the above remarks would, I believe, be applicable to all these cases.
Where patients have recovered under the use of other measures, without artificial respiration, it is
probable that animation was not completely suspended, and that the recovery was spontaneous.
M. Delarue related a case of accident from chloroform to the Academy of Medicine, on August 20th,
1850, which was apparently of this nature. After administering the vapour, and when he was about to
divide some sinuses in the thigh, he found that his patient (a woman) was in a state of collapse, and the
breathing and pulse, “pour ainsi dire”, insensible. The face was injected, and there was a bloody froth at
the mouth. The uvula was titillated, and there was immediate movement of the eyelids, which was soon
followed by copious vomiting, and the patient recovered.[140]
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. They recovered just as if nothing had been done. It is difficult to suppose a case in which the
breathing should be arrested by the effects of chloroform whilst the skin remained sensible, yet it is only
in such a case that the dashing of cold water on the patient could be of use. There is, however, no harm
in the application of this and such like means, provided they do not usurp the time which ought to be
occupied in artificial respiration; for this measure should be resorted to the moment the natural
breathing has entirely ceased.
I have only seen two cases in which the patients seemed in imminent danger from the direct effects of
chloroform. One of these occurred in 1853. It was the case of a child, aged six years, but small and
ricketty, which had the greater part of the eyeball removed on account of melanotic disease. The usual
inhaler was employed, and when the child seemed sufficiently insensible, it was withdrawn. The
operation was commenced by introducing a large curved needle, armed with a thick ligature, through
the globe of the eye, in order to draw it forward. As the needle was introduced, the child cried out a very
little, and thinking the parents, who were in the adjoining room, would be alarmed, I poured some
undiluted chloroform hastily on a rather large sponge, and placed it over the nostrils and mouth. The
sponge became pressed by the surgeon’s hand closer on the nose than I intended, but it was removed
after the child had taken a few inspirations. The operation was quickly concluded without any further
sign of sensation than that mentioned above. At the end of the operation, the breathing was natural, but
the face was pale, and the lips blue, and the limbs were also relaxed. I tried to feel the pulse at the wrist,
but did not discover any. The chloroform had at this time been left off half a minute at least. The pallor
and blueness continued, and in a little time the breathing became slow and embarrassed, and appeared
about to cease altogether, the pulse being still absent. The windows were opened, and cold water dashed
freely on the face. The child made gasping inspirations now and then, but they did not follow
immediately, or seem connected with each application of the water. The gasps became more frequent,
till the breathing was thoroughly reestablished, when the colour returned to the lips, and the pulse was
again felt at the wrist. In a minute afterwards, the child was red in the face, and crying violently from
pain, which was relieved by a little more chloroform. It appeared to be a minute or a minute and a half
from the time when the sponge with chloroform was removed, till the breathing became of a gasping
character. There is no doubt that in this case the heart was paralyzed, or nearly so, by the chloroform,
and that its action was restored by the spontaneous gasping inspirations of the child. The accident could
have been prevented by having the chloroform, which was put on the sponge, diluted with spirit.
The other case occurred in the latter part of 1852. I have no notes of it, as it took place at the beginning
of an illness, which prevented me from writing for some time; but I recollect the chief particulars of it
sufficiently well. The patient was a lady rather more than sixty years of age, rather tall and thin. She
required to have a polypus removed from the nose. Mr. Fergusson, who was about to operate, was nearly
an hour after the appointed time, and during this interval she was pacing up and down the room,
apparently in a great fright. She was placed in an easy chair for the operation, and the pulse was small
and feeble when she began to inhale. Nothing particular occurred during the inhalation, but just at the
time when the patient was becoming insensible, the breathing ceased, and the pulse could not be felt.
She appeared to have fainted, and was immediately placed on a bed which was in the room. I applied my
ear to the chest, but could hear no sound whatever. Mr. Fergusson applied his mouth to that of the
patient, and with a very strong expiration, inflated her lungs, so as to expand the chest very freely. I
immediately heard the heart’s action recommence with very rapid and feeble strokes, as I had so often
heard it recommence in animals. The patient soon began to make distant gasping inspirations, and the
natural breathing and pulse were soon reestablished. Mr. Fergusson made only one or two inflations of
the lungs after the first one, which of itself was the means of restoring the patient. It was about twenty
minutes, however, before she became conscious; and during the greater part of this time there were
spasmodic twitchings of the features and limbs on one side. In about an hour, she was pretty well; and
on the following day the operation was performed without chloroform.
The most ready and effectual mode of performing artificial respiration is undoubtedly the postural
method, introduced by Dr. Marshall Hall a little time before his death. It consists in placing the patient
on the face and making pressure on the back; removing the pressure, and turning the patient on his side
and a little beyond; then turning him back on the face and making pressure on the back again; these
measures being repeated in about the time of natural respiration.
Whether the artificial breathing is successful or not must depend chiefly on the extent to which the
heart has been paralyzed by the chloroform, as was previously observed. The fact of the breathing
continuing after the action of the heart has ceased, in some of the fatal cases, shows that the heart may
be so paralyzed as not to be readily restored by the breathing. It is probable that in all cases in which
artificial respiration can restore the patient, its action would be very prompt; still it is desirable to
persevere with this measure for a good while.
As already stated, there is every reason to conclude that the right cavities of the heart are distended
with blood, in all cases of suspended animation by chloroform, and therefore it would be desirable to
open one of the jugular veins if the artificial respiration does not immediately restore the patient. In
opening animals, just after death from this agent, I have observed the contractions of the heart to return,
to a certain extent, when the distension of its right cavities was diminished by the division of the vessels
about the root of the neck. Opening the jugular veins has been resorted to in a few of the cases of
accident from chloroform, but hitherto without success.
I have not succeeded in restoring an animal from an overdose of chloroform, by means of electricity,
in any case where I felt satisfied that it would not recover spontaneously; and I have not heard of any
patient being restored by its means. For keeping up respiration, mechanical means, such as the postural
method, are better; as they cause air to enter the lungs without exhausting the remaining sensibility. If
electricity be used, it should be directed towards restoring the action of the heart. It is probable that the
electric current would not reach the heart without the help of the acupuncture needle; but it would be
justifiable to use this in a desperate case, when other measures had failed. The needles should be coated
with wax, or some other non-conductor of electricity, except near the points.
In the fatal cases Nos. 40 and 48, previously related, the action of the heart partially returned during
the efforts that were made for the restoration of the patient, but did not become thoroughly
reestablished. It is probable that the circulation through the coronary vessels of the heart was not
restored in those cases, or else the blood which must have been freed from chloroform, in its passage
through the lungs, would most likely have enabled the heart to recover completely. Dr. Cockle has
expressed the opinion, which is very probable, that the blood enters the coronary arteries in a retrograde
manner, during the diastole of the ventricles, when the aorta and other great arteries are contracting on
their contents; if so, with a very feeble circulation, the elasticity of the aorta, perhaps, cannot sufficiently
act to cause a backward current; and perhaps, also, the over-narcotism of the heart is itself an obstacle to
the coronary circulation, on account of the congestion of the capillaries which always attends on
narcotism.
The knowledge how seldom anything effectual can be done for a person who has inhaled a dose of
chloroform from which he would not spontaneously recover, ought to impress the rule very strongly on
every one, to use the greatest care in its administration.

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PART I PERSONAL SKILLS 61

PART II INTERPERSONAL SKILLS 209

PART III GROUP SKILLS 393

Appendix I Glossary 511

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THE CRITICAL ROLE OF MANAGEMENT SKILLS 29

SCORING KEY AND COMPARISON DATA 58

PART I PERSONAL SKILLS 61

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SKILL APPLICATION 101

SCORING KEYS AND COMPARISON DATA 103

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SKILL ASSESSMENT 110

SKILL LEARNING 114

SKILL ANALYSIS 138

SKILL PRACTICE 143

SKILL APPLICATION 150

SCORING KEYS AND COMPARISON DATA 152

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SKILL ASSESSMENT 156

SKILL LEARNING 161

SKILL ANALYSIS 193

SKILL PRACTICE 198

SKILL APPLICATION 205

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PART II INTERPERSONAL SKILLS 209

4 BUILDING RELATIONSHIPS BY COMMUNICATING

SKILL ASSESSMENT 212

SKILL LEARNING 212

SKILL ANALYSIS 237