Instant Download Public Administration in Germany 1st Edition Sabine Kuhlmann PDF All Chapter
Instant Download Public Administration in Germany 1st Edition Sabine Kuhlmann PDF All Chapter
Instant Download Public Administration in Germany 1st Edition Sabine Kuhlmann PDF All Chapter
com
https://ebookmeta.com/product/public-
administration-in-germany-1st-edition-sabine-
kuhlmann/
OR CLICK BUTTON
DOWLOAD EBOOK
https://ebookmeta.com/product/public-administration-and-
governance-in-china-1st-edition-leizhen-zang/
https://ebookmeta.com/product/public-administration-and-public-
affairs-13th-edition-nicholas-henry/
https://ebookmeta.com/product/public-value-and-public-
administration-public-management-and-change-john-m-bryson/
https://ebookmeta.com/product/research-methods-in-public-
administration-and-public-management-an-introduction-2nd-edition-
sandra-van-thiel/
Public School Debt Administration William B. Castetter
https://ebookmeta.com/product/public-school-debt-administration-
william-b-castetter/
https://ebookmeta.com/product/public-administration-the-
basics-1st-edition-salvatore-schiavo-campo/
https://ebookmeta.com/product/public-administration-
understanding-management-politics-and-law-in-the-public-
sector-9th-edition-david-h-rosenbloom/
https://ebookmeta.com/product/introducing-public-
administration-10th-edition-jay-m-shafritz/
https://ebookmeta.com/product/public-administration-in-the-
middle-east-and-north-africa-1st-edition-shahjahan-bhuiyan/
Public Administration
in Germany
Copyright © 2021. Springer International Publishing AG. All rights reserved.
Edited by
Sabine Kuhlmann · Isabella Proeller
Dieter Schimanke · Jan Ziekow
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Governance and Public Management
Series Editor
Paul Joyce
INLOGOV
University of Birmingham
Birmingham, UK
Copyright © 2021. Springer International Publishing AG. All rights reserved.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
IIAS Series: Governance and Public Management
International Institute of Administrative Sciences (IIAS) – Setting the
Governance Agenda Worldwide
Website: http://www.iias-iisa.org
Edited by Paul Joyce
To cover the diversity of its members, the IIAS has set up four
sub-entities:
– The EGPA (European Group for Public Administration)
–The IASIA (International Association of Schools and Institutes of
Administration)
– The LAGPA (Latin American Group for Public Administration)
– The AGPA (Asian Group for Public Administration)
Governance and Public Management Series
This IIAS series of books on Governance and Public Management has a
focus and breadth that reflects the concerns of the International Institute
of Administrative Sciences. The Institute, which was set up in 1930,
involves academics and governments from all around the world. The
Institute’s work involves supporting both practitioners and academics,
which it does by encouraging the production of relevant knowledge on
public governance and public management and by facilitating its dissemi-
nation and utilization.
It is the intention of the series to include books that are forward-look-
Copyright © 2021. Springer International Publishing AG. All rights reserved.
ing, have an emphasis on theory and practice, are based on sound under-
standing of empirical reality, and offer ideas and prescriptions for better
public governance and public management. This means the books will
include not only facts about causes and effects, but also include ideas for
actions and strategies that have positive consequences for the future of
public governance and management. The books will offer a point of view
about responses to the big challenges facing public governance and man-
agement over the next decade, such as sustainable development, the cli-
mate crisis, technological change and artificial intelligence (A.I.), poverty,
social exclusion, international cooperation, and open government.
All books in the series are subject to Palgrave’s rigorous peer review pro-
cess: https://www.palgrave.com/gb/demystifying-peer-review/792492
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Sabine Kuhlmann • Isabella Proeller
Dieter Schimanke • Jan Ziekow
Editors
Public Administration
in Germany
Copyright © 2021. Springer International Publishing AG. All rights reserved.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Editors
Sabine Kuhlmann Isabella Proeller
University of Potsdam University of Potsdam
Potsdam, Germany Potsdam, Germany
© The Editor(s) (if applicable) and The Author(s) 2021. This book is an open access
publication.
Open Access This book is licensed under the terms of the Creative Commons Attribution
4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits
use, sharing, adaptation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, provide a link to the
Copyright © 2021. Springer International Publishing AG. All rights reserved.
This Palgrave Macmillan imprint is published by the registered company Springer Nature
Switzerland AG.
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Foreword
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
vi FOREWORD
Hans-Georg
State Secretary, Engelke
Federal Ministry of the Interior,
Copyright © 2021. Springer International Publishing AG. All rights reserved.
Note
1. See König, K., von Oertzen, H.J., Wagener, F. (eds.) (1983). Public
Administration in the Federal Republic of Germany. Deventer: Kluwer.
König, K., Siedentopf, H. (eds.) (2001). Public Administration in Germany.
Baden-Baden: Nomos.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Acknowledgements
GIZ) for their generous support in the publishing of this book. GIZ is a
state-owned service provider in the field of international cooperation for
sustainable development in all continents. It is specialized, inter alia, in
public sector reforms, administrative transformation and civil society par-
ticipation. This publication is also intended to support the activities of
GIZ and serve as a possible reference model for institution building and
policy advice in different country contexts.
Furthermore, we owe special thanks to the German Federal Government,
specifically the Federal Ministry of the Interior, Building and Community
(Bundesministerium des Innern, für Bau und Heimat—BMI). Besides co-
sponsoring the publication project (Open Access version), some of the
contributing authors are also affiliated to the ministry.
The twenty-two chapters of the book, though each taking a specific
perspective topic-wise, are based on a common understanding of the main
characteristics, attributes and approaches as well as the most relevant
vii
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
viii ACKNOWLEDGEMENTS
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Praise for Public Administration in Germany
“Everything you always wanted to know about public administration in the coun-
try which fathered modern bureaucracy! This book is the indispensable reading for
those students, scholars and practitioners who seek to understand the fascinating
administrative engine under the hood of the political, social and economic success
of contemporary Germany.”
—Jean-Michel Eymeri-Douzans, Professor, University Science Po Toulouse,
France. President of the European Group of Public Administration (EGPA)
“This book is an awesome attempt, covering such significant issues as the historical
underpinnings, inter-governmental relationships and other pragmatic policy prob-
Copyright © 2021. Springer International Publishing AG. All rights reserved.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Contents
1 German
Public Administration: Background and Key Issues 1
Sabine Kuhlmann, Isabella Proeller, Dieter Schimanke, and
Jan Ziekow
2 Constitutional
State and Public Administration 17
Karl-Peter Sommermann
Copyright © 2021. Springer International Publishing AG. All rights reserved.
3 Administrative Federalism 35
Nathalie Behnke and Sabine Kropp
4 Europeanisation
and German Public Administration 53
Hans Hofmann
5 Federal Administration 61
Julia Fleischer
6 The
Federal Administration of Interior Affairs 81
Hans-Heinrich von Knobloch
xi
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
xii Contents
7 The
Peculiarities of the Social Security Systems
(Indirect State Administration) 91
Dieter Schimanke
8 The
Administration of the Länder105
Ludger Schrapper
9 Local
Self-Government and Administration123
Kay Ruge and Klaus Ritgen
10 Politics
and Administration in Germany145
Werner Jann and Sylvia Veit
11 Administrative
Procedures and Processes163
Jan Ziekow
12 Control
and Accountability: Administrative Courts and
Courts of Audit185
Veith Mehde
13 Civil
Service and Public Employment205
Copyright © 2021. Springer International Publishing AG. All rights reserved.
14 Public Finance225
Gisela Färber
15 Transformation
of Public Administration in East
Germany Following Unification253
Hellmut Wollmann
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Contents xiii
16 Administrative
Reforms in the Multilevel System:
Reshuffling Tasks and Territories271
Sabine Kuhlmann and Jörg Bogumil
17 Institutional
Differentiation of Public Service Provision
in Germany: Corporatisation, Privatisation and
Re-Municipalisation291
Benjamin Friedländer, Manfred Röber, and Christina Schaefer
18 Participatory
Administration and Co-production311
Stephan Grohs
19 Digital
Transformation of the German State 331
Ines Mergel
20 The
Federal Ministerial Bureaucracy, the Legislative
Process and Better Regulation357
Sabine Kuhlmann and Sylvia Veit
21 Human
Resource Management in German Public
Copyright © 2021. Springer International Publishing AG. All rights reserved.
Administration375
John Siegel and Isabella Proeller
22 Public
Management Reforms in Germany: New
Steering Model and Financial Management Reforms393
Isabella Proeller and John Siegel
Glossary411
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Notes on Contributors
xv
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
xvi Notes on Contributors
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Notes on Contributors xvii
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
xviii Notes on Contributors
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Notes on Contributors xix
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
List of Figures
xxi
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
List of Tables
xxiii
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
xxiv List of Tables
Table 14.6 Per capita expenditure of state and local governments and
aggregated state-local governments 2018 245
Table 14.7 Changes in the local shares of the compulsory tax sharing
revenue of the Länder 2000–2019 (percentage of state tax
revenue)246
Table 16.1 Structural and functional reforms in the German Länder
(sub-ministerial level) 273
Table 16.2 Territorial structures of counties in Germany 279
Table 16.3 Territorial structures of municipalities in Germany 280
Table 16.4 Territorial reforms in the West German Länder282
Table 16.5 Territorial reforms in the East German Länder285
Table 17.1 Public funds, institutions and enterprises by legal form and
authority305
Table 18.1 Types of provider (in %) from 1998 to 2016–17 322
Table 19.1 Overview of laws governing the digital transformation
of the German state 337
Table 22.1 Implementation of NSM elements 397
Table 22.2 Implementation of accrual accounting in German Länder
and local governments 404
Copyright © 2021. Springer International Publishing AG. All rights reserved.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
CHAPTER 1
S. Kuhlmann • I. Proeller
University of Potsdam, Potsdam, Germany
e-mail: skuhlman@uni-potsdam.de; proeller@uni-potsdam.de
D. Schimanke (*)
Ministry of Labour, Women, Health, Social Affairs of the German Land Saxony-
Anhalt, Magdeburg, Germany
e-mail: Dieterschimanke@aol.com
J. Ziekow
German Research Institute for Public Administration, Speyer, Germany
e-mail: ziekow@foev-speyer.de
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
2 S. KUHLMANN ET AL.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
1 GERMAN PUBLIC ADMINISTRATION: BACKGROUND AND KEY ISSUES 3
and local levels of government and of the current reform processes of the
public sector. They focus, inter alia, on the following areas:
The four topics are addressed in this book. Part I outlines the basic
features, institutions and legal framework of German public administra-
tion at different levels of government and within its multilevel setting. In
Part II, the relationship between politics and administration, administra-
tive procedures, controlling and accountability mechanisms as well as key
resources of administrative action (staff, finances) is analysed. The subse-
quent chapters focus on the various fields of administrative reform and
modernisation, starting in Part III with reforms intended to reshape the
macro-institutional setting of public administration. This includes a his-
torical review of the administrative transformation after unification as well
as more recent approaches to reform, such as the redrawing of territorial
boundaries and jurisdictions, functional and structural reforms, the re-
definition of the relationship between the public and the private sector
through privatisation, and the opening up of public administration vis-à-
Copyright © 2021. Springer International Publishing AG. All rights reserved.
vis citizens and society. Finally, in Part IV, the focus is on changes in the
distribution of responsibilities and resources within administrative organ-
isations, the re-engineering of administrative processes, digital innovations
and e-administration, the internal reorganisation of decision-making rules
designed to enhance management capacities, efficiency in service delivery
and the quality of policymaking.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
4 S. KUHLMANN ET AL.
providing, alongside the principle of legality, the rules, principles and insti-
tutions that ensure the prevention of arbitrary state action and the protec-
tion of individual rights. A dynamic interpretation of the Basic Law (the
German Constitution) of 1949 by the Federal Constitutional Court has
constantly specified and extended the normative scope of fundamental
rights, which are directly binding upon the legislative, executive and judi-
cial powers. The constitutional principle of the welfare state has not only
enhanced the dynamic evolution of the law, but also led to the creation of
largely equivalent levels of infrastructure and services in the different ter-
ritories of the federal state. The continually readjusted cooperation
between the federal level and the Länder level and among the Länder
themselves has strengthened the interoperability and coherence of their
administrations, and competitive elements have fostered innovation.
The German federal architecture is shaped by a peculiar mix of strong
decentralisation and a high degree of autonomy at lower levels of govern-
ment, combined with an administrative culture of uniformity, solidarity
and coordination. Nathalie Behnke and Sabine Kropp recapitulate the
notion of this system as ‘administrative federalism’ to emphasise the prom-
inent role of executives and administrations in policymaking and policy
implementation. The dominant principle of administrative federalism is
the territorial principle as opposed to the functional principle, that is gov-
ernments and administrations at each level are responsible for all the tasks
at this level with the exemption of special regulations for sectoral organisa-
tions. The federal level relies on the states (Länder) for executing its tasks.
Copyright © 2021. Springer International Publishing AG. All rights reserved.
For their part, the Länder executives have rights of co-decision in federal
legislation via the Bundesrat (Federal Council). While formal jurisdictions
are strongly decentralised, a dense web of interlocking powers as well as
processes and institutions of coordination induce territorial governments
to closely cooperate with each other when implementing (compulsory)
joint tasks and coordinating autonomous responsibilities voluntarily. To
date, German-style administrative federalism has been successful in curb-
ing conflict caused by dissent among political parties and in implementing
policies efficiently. However, trends like the upward shift of tasks from the
Länder to the federal level and increasing party system fragmentation chal-
lenge its continued success and consequently require adaptation.
The three-tier system of German public administration is increasingly
being brought in line with the overarching level of the European Union
(EU) and in a special form of vertical arrangement. As Hans Hofmann
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
1 GERMAN PUBLIC ADMINISTRATION: BACKGROUND AND KEY ISSUES 5
calls it, the EU is a union of states sui generis (unique). The Member States
remain independent states and, in principle, retain their sovereignty.
However, the EU’s influence on national public administrations is con-
stantly growing due to the increasing number of regulations (laws, bylaws,
guidelines) and other EU programmes that require implementation in the
Member States. The expanding influence of the EU is not limited to those
areas where the Member States have transferred the authority to make
laws to the EU, but is also spreading to those areas where the Member
States have retained such authority. At the same time, however, there is no
systematic codification of the law on administrative procedures at European
level and no system of legal remedy for Union citizens equivalent to those
at national level.
Germany’s federal administration is significantly small in size (around
ten per cent of all public employees). This special feature of the country’s
administrative system—as described by Julia Fleischer—is based on the
division of responsibilities. The central (federal) level develops and adopts
most of the public programmes and laws, and the state level (together
with the local level) implements them. The administration at the federal
level comprises the ministries, some subordinated agencies for special
issues (e.g. the application of drugs, information security and the registra-
tion of refugees) and selected operational tasks in single administrative
sectors (e.g. foreign affairs, the armed forces, the federal police and the
supreme courts). The capacities to prepare and monitor laws are well
developed. Moreover, the approaches to innovation and the instruments
Copyright © 2021. Springer International Publishing AG. All rights reserved.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
6 S. KUHLMANN ET AL.
The institutions of the social security system are the main providers of
services of the welfare state and cover a large share of the public budgets
(about 45 per cent of expenditures). On the one hand, the system enjoys
a certain degree of autonomy and is therefore called ‘indirect state admin-
istration’, as explained by Dieter Schimanke. On the other hand, the steer-
ing by federal legislation is quite extensive. However, in implementing this
legislation, the institutions are only subject to limited state supervision,
which is restricted to legal supervision (Rechtsaufsicht). Moreover, the
social security institutions can appeal to the ‘social courts’ against the
orders of the supervising state administration.
In Germany’s federal system, the administrations of the 16 federal
states (Länder) have central responsibility for the enforcement of both
federal and state law. Ludger Schrapper observes that notwithstanding the
heterogeneity in terms of their size, administrative tradition and culture,
there is relative uniformity in their administrative structures (with the
exception of the three city-states). Everywhere, the municipalities, which
are part of the state executive under state law, play a significant and, above
all, independent role as bodies of public administration. Still, there are
some differences which are due to whether the administrations of the
Länder have a two-tier or a three-tier structure. Within these varying
structures, administration seems to be relatively homogeneous, not least
because of the very similar staffing structures, career patterns and admin-
istrative cultures. Structural reforms of very different scope have been a
long-term phenomenon since the 1990s.
Copyright © 2021. Springer International Publishing AG. All rights reserved.
The local level, also called the communal level (municipalities, cities
and counties), plays a strong administrative and political role in the
German system. Kay Ruge and Klaus Ritgen demonstrate the weight of
the communal level in the figures for personnel and budgets. The right
to local self-government is guaranteed in the Basic Law and has a long
history. Moreover, the communal administration—and especially the
county level—serves a second function. It is, in principle, the opera-
tional level responsible for implementing the programmes and laws of
the federal and state levels. The local authorities mainly differentiate
themselves from the federal and regional authorities by the mandates of
their elected representative bodies (city council, county council and
municipal council). The head of a local administration (mayor or county
commissioner) is usually directly elected by the citizens. Finally, the
principle of German local self-government and administration is a good
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
1 GERMAN PUBLIC ADMINISTRATION: BACKGROUND AND KEY ISSUES 7
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
8 S. KUHLMANN ET AL.
not the role of the administrative courts and courts of audit to hold
administration accountable. Rather, their role is to provide other actors—
the parliaments, the public, the media, etc.—the opportunity to hold the
respective administration accountable. As part of their role in exercising
administrative jurisdiction, Mehde describes the structure of administrative
courts in Germany, the types of their decisions and the depth and extent
of their control. He also describes the organisation and scope of review of
the courts of audit as well as the effects of their control.
The professionalisation of public service staff is one of the most impor-
tant aspects of efficient administration. The employment structure and
training of these employees is generally characteristic of a national admin-
istrative system. Accordingly, Christoph Reichard and Eckhard Schröter
open their chapter on civil service and public employment with the ques-
tion, ‘What kind of an animal is the German civil service?’ Their contribu-
tion sheds light on the size and structure of public employment in Germany
prior to presenting the two different types of employment status in the
public service, ‘civil servants’ on the one hand and ‘public employees’ on
the other. Following an overview of the legal framework and policies relat-
ing to the civil service, subsequent sections deal with recruitment and
qualifications, compensation schemes and benefits as well as major
reform trends.
‘Money makes the world go round’—this also applies to public admin-
istration. Revenues and expenditures are central to public administration
processes. In the chapter on public finance, Gisela Färber deals with the
Copyright © 2021. Springer International Publishing AG. All rights reserved.
principles of budgeting and the budget cycle as well as the generation and
distribution of tax revenues in Germany. In the latter context, she
addresses, inter alia, the constitutional regulations on the distribution of
financial resources and the structure of public expenditure and revenue—
providing a general structural analysis as well as a breakdown of tax reve-
nues from a federal perspective. Färber goes on to discuss the considerable
importance in the German federal financial system of the vertical and hori-
zontal fiscal equalisation between the various administrative units. The
chapter closes with an account of public indebtedness and budget deficits
in Germany at different government levels.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
1 GERMAN PUBLIC ADMINISTRATION: BACKGROUND AND KEY ISSUES 9
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
10 S. KUHLMANN ET AL.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
1 GERMAN PUBLIC ADMINISTRATION: BACKGROUND AND KEY ISSUES 11
In the final chapter, Isabella Proeller and John Siegel analyse two very
prominent public management reform trajectories in German public
administration over the past three decades since unification. In the 1990s,
the New Steering Model emerged as a German variant of the New Public
Management (NPM). Since the mid-2000s, local governments in Germany
have been subjected to a mandatory reform of their budgeting and
accounting system known as the New Municipal Financial Management
reforms. These reforms have led to substantial changes, but have really
only scratched the surface in terms of changing control mechanisms and
the organisational culture.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
12 S. KUHLMANN ET AL.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
1 GERMAN PUBLIC ADMINISTRATION: BACKGROUND AND KEY ISSUES 13
References
Kuhlmann, S., & Wollmann, H. (2019). Introduction to Comparative Public
Administration. Administrative Systems and Reforms in Europe (2nd ed.).
Cheltenham/Northampton: Edward Elgar.
Raadschelders, J. C. N. (2011). Commentary—Between ‘Thick Description’ and
Large-N Studies. The Fragmentation of Comparative Research. Public
Administration Review, 71(6), 831–833.
von Stein, L. (1870 [2010]). Handbuch der Verwaltungslehre und des
Verwaltungsrechts, Stuttgart: Cotta (reprint U. Schliesky (Ed.)).
Tübingen: Mohr.
Copyright © 2021. Springer International Publishing AG. All rights reserved.
Open Access This chapter is licensed under the terms of the Creative Commons
Attribution 4.0 International License (http://creativecommons.org/licenses/
by/4.0/), which permits use, sharing, adaptation, distribution and reproduction
in any medium or format, as long as you give appropriate credit to the original
author(s) and the source, provide a link to the Creative Commons licence and
indicate if changes were made.
The images or other third party material in this chapter are included in the
chapter’s Creative Commons licence, unless indicated otherwise in a credit line to
the material. If material is not included in the chapter’s Creative Commons licence
and your intended use is not permitted by statutory regulation or exceeds the
permitted use, you will need to obtain permission directly from the copy-
right holder.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
PART I
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
CHAPTER 2
Karl-Peter Sommermann
1 Introduction
Among the characteristics of German public administration that are most
likely to catch the eye of a foreign observer include the following two
phenomena: first, the high density of statutory law (law adopted by the
parliament) regulating the organisation, the procedure and the substantive
criteria for the activities of public administration; and second, the almost
ubiquitous presence of arguments inferred from constitutional law in the
legislative process, court rulings and even administrative decisions. The
practice to constantly emphasise the interconnection of constitutional and
Copyright © 2021. Springer International Publishing AG. All rights reserved.
ordinary law can also be seen in legal education, where professors of public
law teach administrative law against the background of constitutional law.
Unlike in the Romance-speaking countries, most German law faculties do
not clearly separate the chairs of constitutional law from those of adminis-
trative law, but combine them under the denomination of ‘public law’,
notwithstanding the fact that the holders of the chairs will often specialise
more or less in one of the fields.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
18 K.-P. SOMMERMANN
contexts and the attachment of the rule of law to the concept of parlia-
mentary sovereignty, they are inspired by similar insights and by the objec-
tive to protect individual freedom through reliable laws and prevention of
arbitrary state action. The most prominent German author of the first half
of the nineteenth century who pushed forward the idea of the Rechtsstaat
was the liberal Robert von Mohl (1799–1875). His approach even resem-
bles the modern concept of a ‘social’ Rechtsstaat, when he emphasises the
obligation of the state to promote the free development of citizens by
organising ‘the living together of the people in such a manner that each
member of it will be supported and fostered, to the highest degree possi-
ble, in its free and comprehensive exercise and use of its strengths’ (von
Mohl 1844: 8). In the further discussion, scholars put more emphasis on
the formal requirements of the Rechtsstaat, gradually supplementing the
core principles of legality and separation of powers (including judicial
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
2 CONSTITUTIONAL STATE AND PUBLIC ADMINISTRATION 19
tive law is constitutional law put into concrete terms’ (Werner 1959: 527).
This is particularly true for the general principles derived from Article 20
(3) (see Sect. 3.1) and for the normative effect of the fundamental rights
(see Sect. 3.3).
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
20 K.-P. SOMMERMANN
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
2 CONSTITUTIONAL STATE AND PUBLIC ADMINISTRATION 21
Notwithstanding the fact that the Basic Law provides only few concrete
rules for public administration, numerous organisational, procedural and
substantive requirements have been derived from its general principles, its
federal architecture and the duty to protect fundamental rights.
Public Administration in Germany, edited by Sabine Kuhlmann, et al., Springer International Publishing AG, 2021. ProQuest
Another random document with
no related content on Scribd:
CHLOROFORM IN PARTURITION.
When the practice of inhalation in midwifery was first introduced by Dr. Simpson, he very naturally
adopted the plan which is usually followed in surgical operations, making the patient unconscious at
once, and keeping her so to the end of the labour. It was soon found, however, by other practitioners,
that this is not necessary; and, indeed, it would not be safe in protracted cases. Drs. Murphy and Rigby
were, I believe, amongst the first to state, that relief from pain may often be afforded in obstetric cases,
without removing the consciousness of the patient; and I soon observed the same circumstance.[150]
Some persons, indeed, have alleged that the pain of labour can always be prevented, without making the
patient unconscious of surrounding objects; whilst others have asserted that no relief can be afforded
unless unconsciousness be induced. But both these opinions are directly opposed to experience. There
are comparatively few cases in which the suffering can be prevented throughout the labour without
interfering with consciousness, although there are very many cases in which it can be in this way
prevented in the early part of the labour. This difference depends, in some measure, on the constitution
of the patient, but chiefly on the severity of the pain to be prevented. It is in accordance with what is
observed in medical and surgical cases, that the pain should be removed, in some instances, without
abolishing consciousness, and that in other instances it should not; for, in certain cases of neuralgia, the
pain is so severe, that no material relief can be obtained by chloroform as long as consciousness is
retained; and in surgical operations, although it now and then happens that the minor and concluding
parts of an operation, such as tying vessels and introducing sutures, can be performed without pain,
whilst the patient is consciously looking on, a free incision in the skin can hardly ever be made, under
similar circumstances, without pain.
With regard to the cases of labour in which chloroform may be employed, it will be readily conceded
that, in cases where the pain is not greater than the patient is willing to bear cheerfully, there is no
occasion to use chloroform; but when the patient is anxious to be spared the pain, I can see no valid
objection to the use of this agent, even in the most favourable cases. The benefits arising from
chloroform in severe cases of labour are experienced in a lesser degree in favourable cases; and the
patient may be fairly allowed to have a voice in this, as in other matters of detail which do not involve the
chief results of the case. The determination of the kind of labours in which chloroform should be used, or
withheld, is really a matter of not much importance, because, as we pass from cases that are severe and
protracted to those which are short and easy, the quantity of chloroform that is used, and the amount of
diminution of the common sensibility, and of interference with the mental functions, become so trifling,
that very little remains about which to hold a discussion. Indeed, from what I have observed of the
continued use of this agent in medical cases, and its use by healthy persons for experiment, I believe that
the quantity which is inhaled in a short and easy labour might be continued daily for an indefinite
period, without appreciable effect on the health.
The above remarks apply also, in some measure, to the question as to the period of the labour when
the exhibition of chloroform should commence; for, in proportion as the pains are feeble, it must be
more sparingly administered. The most usual time when the accoucheur and I have determined that the
inhalation should be commenced, has been when the os uteri was nearly dilated to its full extent, and the
pains were taking on an expulsive character. In many of the cases which I have attended, it has, however,
been commenced much earlier; for the suffering caused by the dilating pains in the first stage of labour
is often very great, and the chloroform is consequently of the utmost service when employed at this time.
As regards the manner of giving chloroform, I shall first allude to cases not requiring manual or
instrumental assistance. In such cases, when it has been determined to resort to inhalation, the moment
to begin is at the commencement of a pain; and the chloroform should be intermitted when the uterine
contraction subsides, or sooner, if the patient is relieved of her suffering. It is desirable to give the
chloroform very gently at first, increasing the quantity a little with each pain, if the patient is not
relieved. The practitioner easily finds, with a little attention, the quantity of vapour which it is desirable
to give at any stage of the labour, and in each particular case; his object being to relieve the patient
without diminishing the strength of the uterine contractions and the auxiliary action of the respiratory
muscles, or with diminishing it as little as possible. At first, it is generally necessary to repeat the
chloroform at the beginning of each “pain”; but, after a little time, it commonly happens that sufficient
effect has been produced to get the patient over one or two uterine contractions without suffering, before
it is resumed.
The external evidences of the uterine contractions continue as before, when the patient is rendered
unconscious by chloroform; and the muscles of respiration are called freely into play, to assist the action
of the uterus in the second stage of labour. The aspect of the patient under these circumstances, is
generally that of one who is suppressing the expression of her sufferings; and any relative or friend who
comes in, without knowing that chloroform has been given, begins to praise the unconscious patient for
her fortitude. On some occasions, indeed, there are groans and cries, as of suffering; but the mind being
unconscious of pain, it can hardly be said to exist.
It may be remarked, that complete anæsthesia is never induced in midwifery, unless in some cases of
operative delivery. The diminution of common sensibility to a certain extent, together with the
diminution or removal of consciousness, suffice to prevent the suffering of the patient during labour;
and she never requires to be rendered so insensible as in a surgical operation, when the knife may be
used without causing a flinch or a cry. The nerves of common sensation must be allowed to retain their
functions to a certain extent during labour; otherwise the assistance of the respiratory muscles, which
consists of reflex action, or “motion arising from sensation, without the aid of volition”, would not take
place, even if the contractions of the uterus should still continue.
The effects of chloroform on the brain should not be carried during labour beyond what I denominate
the second degree of narcotism, or that condition in which the mental functions are diminished, but not
altogether suspended, except when the effect of the vapour is associated with natural sleep. The patient
under the influence of chloroform to this extent, has no longer a correct consciousness of where she is,
and what is occurring around her, but is capable of being aroused to give incoherent answers, if
injudiciously questioned. In this state, the patient will sometimes assist the labour by bearing down
voluntarily, if requested to do so, and be otherwise obedient to what is said; and by withholding the
chloroform for a few minutes, she at any time becomes quite conscious. As a general rule, it is desirable
not to hold any conversation whilst the patient is taking chloroform, in order that her mind may not be
excited. The plan mentioned above, of giving the chloroform very gently at first, also has a tendency to
prevent its causing mental excitement, the patient coming gradually under its effects. In surgical
operations, excitement of the mind can nearly always be avoided by carrying the patient pretty rapidly
into a state of insensibility, in which the mental functions are necessarily suspended. But in the practice
of midwifery, it is not allowable to cause a state of coma or insensibility, except in certain cases of
operative delivery, hereafter to be mentioned.
I nearly always employ, in obstetric cases, the inhaler that I use in surgical operations. There is not the
same necessity for an accurate means of regulating the proportion of vapour in the air which the patient
is breathing during labour, where but a trifling amount of narcotism requires to be induced, as in
surgical operations, where a deeper effect is necessary; still I find the inhaler much more convenient of
application than a handkerchief, and it contains a supply of chloroform which lasts for some time,
thereby saving the trouble of constantly pouring out more. When I do administer chloroform on a
handkerchief during parturition, I follow the plan of putting only ten or fifteen minims of chloroform on
the handkerchief at one time.
The quantity of chloroform administered during any one pain, never exceeds a very few minims; but
the quantity used in the course of a protracted labour is often considerable. I have several times used
from four to six ounces; and in one case, at which I was present the greater part of the time, seventeen
fluid ounces of chloroform were used with the inhaler, which would produce as much effect as three or
four pounds used on a handkerchief. The inhalation was continued with intermissions over a period of
thirty-one hours. The patient was unconscious during the greater part of the last five or six hours, but
previously to this, her constant complaint was that she had not enough chloroform. She was the wife of a
physician, was thirty-seven years of age, and in her first confinement. The membranes ruptured early.
The labour was natural, but there was excessive sensibility. The first twenty-six hours of intermitted
inhalation were during the first stage of labour.
Chloroform can be best applied when there is an additional medical man, who has not to attend to the
ordinary duties of the accoucheur; but it can be given very well by the accoucheur himself, so as to save
the greater part of the suffering of labour; although he perhaps cannot always administer it in the perfect
way in which he could, if he had no other duties to divide his attention.
It is probable that the use of chloroform has no particular influence over the duration of labour, in the
whole number of cases in which it is employed; but individual labours are occasionally either retarded or
quickened by it, according to circumstances. In some cases, the chloroform, even when very moderately
employed, diminishes both the strength and the duration of the uterine contractions, and prolongs the
interval between them, thereby making the labour somewhat longer—a matter of no consequence,
however, as the patient is not suffering in any way. In other cases, the inhalation causes the uterine
action to become stronger and more regular, by removing the excess of sensibility by which it has been
interfered with. This occurs more particularly in the first stage of labour. In some cases, also, the
chloroform seems to act as a direct stimulant to the uterine contractions, increasing their force and
frequency—a circumstance at which we need not be surprised, when we remember that both opium and
brandy, in moderate quantity, often act in the same manner. Chloroform has also the effect of promoting
the dilatation of the os uteri in many cases, even when no rigidity exists; and when there is rigidity of the
os uteri, the inhalation is of the utmost service, and shortens labour very much. This is the case, also,
when there is rigidity of the perineum.
When the forceps have to be applied, it is desirable to make the patient insensible, as if for a surgical
operation just before they are applied; and to leave off the chloroform as soon as they are introduced, in
order to allow of the uterine action to return, and assist in the delivery. I have always found the action of
the uterus return immediately after the forceps were introduced; and where the child was not delivered
at once, I have continued the chloroform in sufficient quantity to keep the patient unconscious, whilst
allowing the uterine contractions to continue.
I have administered chloroform on nine occasions in which the forceps were applied; in four of the
cases, I was sent for in consequence of the operation being required; and in the other five cases, I was in
attendance from an early part of the labour, and had administered chloroform more or less for some
hours before the forceps were applied. They were applied in three instances by Dr. Murphy, twice by Dr.
Ramsbotham, and in the other cases by Drs. Farre, Frere, and Thudichum, and Mr. Peter Marshall.
I have administered chloroform in two cases of craniotomy, both of which were performed by Dr.
Murphy, on account of deformity of the pelvis. The amount of chloroform scarcely requires to be
increased during this operation beyond what would be given according to the strength of the pains which
may be present at the time.
In the operation of turning the child, the mother requires to be made quite insensible, in order that
the uterine contraction may be entirely suspended till the legs of the child are brought down, when the
inhalation should be discontinued to allow the contraction of the uterus to return. I have notes of six
cases of turning the child, in which I have administered chloroform. The first case, which occurred in
1848, was one of natural presentation, in which turning was performed by Dr. Murphy, on account of
narrowness of the pelvis, and the impossibility of applying the forceps; the introduction of the hand was
difficult on account of want of space, but the uterus offered no resistance. Dr. Murphy has related the
case. Three of the other instances of turning were performed by Mr. French, in cases which had been
attended by midwives, and the membranes had been ruptured for several hours. The shoulder and part
of the chest were in each case pressed down into the pelvis, and the pains were very strong; yet under a
full chirurgical dose of chloroform, the child was turned as easily as if the membranes had not been
ruptured. In the first of these three cases, the child was dead before the operation commenced. In the
other two, it was born alive. In the last case, the membranes had been ruptured for ten hours before the
operation was performed. After the child was delivered, there was found to be a second child presenting
naturally, but I did not stay to give any more chloroform. The fifth case of turning was performed in a
case of elbow presentation by Mr. Peter Marshall. The membranes had been previously ruptured. I
administered chloroform, also for Mr. Marshall, in a case where the hand was presenting below the
head; he raised it above the head, and as it did not come down again when the pains returned, the labour
was allowed to pursue its natural course, and terminated favourably in two or three hours, the child
being alive. The chloroform was not continued after the operation was performed. The remaining case of
turning was performed by Mr. Tegart, of Jermyn Street. I was in attendance with him from an early
stage in the labour, and the operation was performed before the membranes were ruptured.
I administered chloroform, in 1849, in a case in which Dr. Murphy had to make an artificial os uteri.
The patient was, of course, made quite insensible as for any other surgical operation; and the vapour was
continued afterwards in a modified degree till the labour was completed.
On December 26th, 1850, I was requested by Mr. Cooper, of Moor Street, Soho, to assist him in a case
of retention of the placenta. The patient had given birth to a child two hours before, and Mr. Cooper had
introduced his hand, but had been unable to bring away the placenta, on account of firm contraction of
the uterus in a sort of hour-glass form. On the chloroform being administered, the hand was easily
introduced, and the placenta detached, and extracted. There was very little hæmorrhage.
In some of the many cases at which I have met Dr. Cape, premature labour was induced about the
eighth month of utero-gestation, by rupturing the membranes, on account of deformity of the pelvis.
In a case attended by Mr. Cantis, the patient was suffering from osteo-sarcoma of the bones about the
shoulder. Dr. Ferguson was present during the latter part of the labour. The lady lived a few weeks after
her confinement.
A patient, attended in her confinement by Mr. Colambell of Lambeth, in 1853, to whom I gave
chloroform, had been long under the care of Dr. Williams with cavities in the lungs. I heard very lately
that she was still living.
A patient of Mr. Robert Dunn, to whom I gave chloroform in her confinement, was at the time in a
state of insanity.
In one of the patients whom I have attended with Dr. Arthur Farre, there was separation of the recti
muscles of the abdomen; which there is no doubt must have taken place gradually during pregnancy.
The patient was but twenty years of age, and in her first labour. Quite early in the labour, before the
pains were at all strong, Dr. Farre and I observed that the abdomen was of a peculiar form, the uterus
projecting very much forwards, whilst there was a slackness in the flanks. The abdominal muscles did
not assist the pains at all; and it was probably from this cause that the labour progressed slowly and was
terminated at last with the forceps. The recti muscles recovered their position by careful bandaging.
The chloroform has always been left off as soon as the child was born, but a little has been
administered again on several occasions during the expulsion of the placenta. The placenta has generally
been expelled very soon in the labours in which I have given chloroform; usually in about five minutes.
There has hardly ever been uterine hæmorrhage of any amount, except in patients who had suffered
from it in previous labours. In a case attended by Mr. Nathaniel Ward, however, there was a slight
hæmorrhage before the birth of the child, and about an hour afterwards there was a considerable
hæmorrhage which made the patient feel rather faint for some hours. She afterwards went on
favourably, however. She was a young woman who had had several children.
A patient, to whom I was recommended by Sir John Forbes, inhaled chloroform in three
confinements. She recovered favourably from the two first; but on the third occasion, after going on
favourably till the fifth day, she was attacked with puerperal fever, and died on the seventh day from her
confinement.
I am not aware that more than one death has been recorded as having occurred from chloroform
during labour; and this took place in England, in 1855, when no medical man was present.[151] The
patient had inhaled chloroform in America in a previous labour; but her medical man, on the last
occasion, who was her particular friend, forbad that agent, and said that if she was determined to have it,
he would not attend her. She procured chloroform unknown to him, and a number of scents to put on
her handkerchief and hide the odour of it from him. He went to bed in the house, and was not called up
till his patient had been dead about an hour. The monthly nurse, who had procured the chloroform for
the patient, said that she snored very loudly for an hour after she fell asleep. About five drachms of
chloroform were used from the bottle, and the handkerchief from which it was inhaled remained close to
the patient’s face till she died. The death seemed to have taken place very slowly, and the monthly nurse
was extremely stupid to allow the patient to die. It may also be remarked that the accident would not
have taken place except for the medical man’s extreme objection to the use of chloroform.
The chloroform has been occasionally blamed by the friends of
patients, or medical men opposed to its use, in cases where patients
have died from puerperal convulsions or other causes, so long after
the vapour had been left off that it could not be the cause of death.
The following case shows how easy it would be to make a mistake
with respect to the effects of chloroform. Soon after its introduction,
I was requested to administer it to the wife of a medical man who
had a great desire for it in her confinement. Mr. Propert was to
attend the lady. I was sent for late one evening, but as there were no
pains at the time when I arrived, I was requested to go to bed in the
house. After a time, I was called by a servant, who told me that the
baby was born, and that Mr. Propert was sent for. I found that the
birth had been so sudden that the husband, who was in the room,
could not get to the bed side before the child was born. Mr. Propert
arrived, and I went home, leaving the patient very well. Mr. Propert
informed me, that after I left the patient went into such a state of
syncope as to make him think she was going to die, and continued so
for some time. She ultimately recovered. There was no hæmorrhage
or any other cause to account for the faintness, and I understood Mr.
Propert to say, that if the patient had inhaled chloroform, he should
have blamed it for the condition into which she lapsed.
THE INHALATION OF CHLOROFORM IN
MEDICAL CASES.
Neuralgia. When the pain of neuralgia is not extremely severe, it
may be removed by the inhalation of chloroform without causing
unconsciousness; but when it is very severe, it is necessary to make
the patient unconscious before the pain is suspended. In some cases
of neuralgia of the face, the pain is so severe that the signs of it
remain after the patient is rendered unconscious, and only disappear
when he is quite insensible; and then, as the insensibility passes off,
the hand is raised to the face, and the contortions of the features
return before the patient awakes to be aware of his suffering. When
the mental branch of the fifth nerve is affected, the paroxysms of
pain are accompanied by a motion and smacking of the lips. In a
hospital patient I have seen this when he was awake, but in a
gentleman only when his consciousness was removed by the
chloroform, and before complete insensibility was induced; when
awake, he restrained the impulse to this kind of motion of the lips.
In administering chloroform it is desirable to continue it steadily
and gradually till the pain is relieved; and if the patient is rendered
unconscious before the pain is removed, to continue it till all signs of
suffering disappear. After the first inhalation of the vapour, the pain
will generally return in a few minutes, but when again subdued, it
will not return so quickly; and after it has been suspended a few
times by the repetition of the chloroform during the space of an hour
or so, the pain is usually removed either permanently or for two or
three hours. In some cases I have had to repeat the chloroform
occasionally throughout the day, and, on one or two occasions, for
two or three days in succession. The chloroform can, in general, only
be considered a temporary remedy, and therefore such other
medicines should be applied as may be thought advisable.
When I have prescribed chloroform in a liniment, to be applied to
the face, the patient has often found out that he obtained more relief
by smelling at the liniment than by applying it. Chloroform generally
gives great relief, however, when applied locally in neuralgia, either
alone or mixed with camphorated spirit; it is advisable to apply it on
a piece of lint or blotting paper, which should be covered over with
tinfoil, or some other impermeable substance, to prevent the
evaporation. It causes about as much heat and uneasiness as a
mustard poultice, before it relieves the pain.
Spasmodic Asthma. On November 12th, 1850, I administered
chloroform in the Hospital for Consumption, at Brompton, to a
married woman, aged thirty-five, a patient of Dr. Cursham. She was
in a fit of spasmodic asthma, but was the subject also of chronic
bronchitis. Twenty minims of chloroform were inhaled from an
inhaler. It gave immediate relief, producing a momentary state of
unconsciousness, or a state bordering on it. In a few minutes the
difficulty of breathing gradually returned, but not to the same extent,
and the inhalation was repeated with a like effect. The difficulty of
breathing returned less quickly and severely; and after a third
inhalation of twenty minims she was completely relieved, and could
lie down. The patient had a good night, and was better next day. On
the 14th, she had another fit of spasmodic asthma, which was
relieved completely by the chloroform in the same manner as the
previous one. This patient inhaled extract of stramonium every
evening, by a method which will be described further on.
Other cases of spasmodic asthma have been relieved as readily and
completely; but in one or two cases, in which the difficulty of
breathing seemed to depend on disease of the heart, the relief was
not so great; the patient went to sleep, but the breathing remained
embarrassed.
Spasmodic Croup. I have administered chloroform in seven cases
of this complaint. It was recommended in every instance by Dr.
Ferguson, and all the cases ended in recovery. The children were
from eight months to two years of age; the majority being about a
year. I always gave enough chloroform to cause a state of
unconsciousness, for which a few minims suffices in a young child,
and when the effect passed off, or nearly so, I repeated the dose. I
generally gave five or six doses in the course of about half an hour,
after which the child would often sleep for two or three hours. In the
milder cases it was repeated once a day; but in the more severe cases
it was continued, in the above manner, twice a day. I administered it
to a patient of Dr. Van Oven, respecting whom Dr. Ferguson had
been consulted, for fifteen days, twice every day, excepting the last
three days. This child was very ill when the treatment was first
commenced, having a severe fit of spasmodic breathing every five
minutes. When the chloroform is given during the spasm, it is
desirable to give it very cautiously.
Mr. W. J. H. Cox read a paper on the treatment of laryngismus
stridulus, with chloroform, at the London Medical Society, in 1850.
He had entrusted the administration of it to the mother or nurse, and
directed it to be given whenever the spasmodic breathing should
come on. I am inclined to think that this would be the best way of
giving it, if one could be quite sure of the intelligence of the party to
whom it was entrusted.
Hooping-Cough. I have only administered chloroform in two cases
of this complaint. It was recommended in both cases by Dr.
Ferguson. One of the children was extremely ill of bronchitis, and it
died. The other child recovered, but the chloroform was not
continued. I am not aware that chloroform has had any fair trial in
hooping-cough. It should be given whenever a fit of coughing comes
on.
Infantile Convulsions. I have administered chloroform in two
cases of this disease, with the effect of relieving the convulsions, but
the children died. They were both extremely ill before the chloroform
was administered. One was the patient of Mr. Walter Bryant, and Dr.
Seth Thompson was consulted about it. A case has been related by
Dr. Simpson of Edinburgh, in which the chloroform was continued
for a day or two, and in which the infant recovered.
Delirium cum Tremore.[152] Some cases have been related in the
medical journals, in which this complaint was treated successfully by
chloroform alone; but I prefer to use this agent only as an adjunct to
the treatment by opium. Sometimes the patient is so violent and
suspicious that he cannot be made to take opium; but it is much
easier to make a person breathe a medicine, than swallow one. It is
only necessary to hold a patient, and to apply the chloroform near his
face, and he is obliged to breathe it, and as the effect of it subsides,
he recovers the power of swallowing before his delirium returns; for
whilst he is still unconscious, he will swallow whatever is poured into
his throat. Opium can be administered, and the chloroform can be
repeated occasionally so as to keep him asleep for an hour or two till
the opium takes effect and prolongs the sleep. It is a great advantage
of chloroform that the delirium may be subdued in a few minutes by
it, and can be kept away till opium takes effect.
In certain cases of delirium cum tremore, such a quantity of opium
is taken without procuring sleep, that the medical attendant has,
what I believe to be, a well-grounded fear of giving more. A patient
whom I saw with Mr. Peter Marshall, in April 1850, had taken ten
fluid drachms of laudanum and two grains of acetate of morphia,
within twenty-four hours of my seeing him, without any sleep being
procured. He was put to sleep immediately by chloroform, which was
repeated on the following day. The patient got quite well in a few
days.
In December 1851, I saw a patient who had had no sleep for four
days, except three intervals of a quarter of an hour each, although a
great deal of opium had been given. He was very violent; and for the
last twelve hours had spat out all the medicine that was given to him;
his pulse was small and very rapid. He was made insensible in a few
minutes, and the chloroform was repeated, at intervals, for half an
hour, so as to keep him unconscious. Fifty minims of tincture of
opium were given in one of the intervals. I waited an hour and a
quarter after the chloroform was discontinued; the patient was still
sleeping, and his pulse was less frequent. I learnt that when he awoke
he was quite free from delirium, and he was well in a few days.
Delirium in Fever. In November 1857, I administered chloroform
to a youth of seventeen, who had been ill of typhoid fever for sixteen
days. He had been in a state of constant delirium for upwards of
forty-eight hours without having the least sleep, although he had had
tincture of opium in divided doses to the extent of forty-five minims,
and had taken a tablespoonful of wine every four hours. The
chloroform was continued gently for half an hour; he slept for an
hour afterwards, and at intervals during the night. He was a little
better in the morning; and the delirium was not again so violent as it
had been. He died on the nineteenth day of the fever, from a
recurrence of diarrhœa.
Dr. Fairbrother, of Bristol, gave small doses of chloroform by
inhalation, with the best effects, in a case of typhus fever, in the
Bristol Infirmary. The patient was delirious and worn out for want of
sleep, her life being in fact despaired of. She inhaled the chloroform
occasionally for several days, sleep being always procured when it
was applied, and she recovered without any other medicine.[153]
Hydrocephalus. I administered chloroform on two occasions, for
half an hour at a time, to a child, seven years old, when delirious and
screaming violently, in this complaint. The child was much relieved
by the inhalation, but it died on the fourteenth day of the disease.
Tetanus. I have notes of three cases of tetanus in which I have
administered chloroform. The first was a patient of the late Mr.
Keate, in St. George’s Hospital, in February 1849. It was a girl,
fourteen years old, who had received some severe burns in the face
and various parts of the body, a fortnight previously. Four days
before inhaling the chloroform, she was attacked with symptoms
resembling those of chorea, but for the last two days the complaint
was recognised to be tetanus. There was rigidity of the spine and
jaws, and of one arm, which was flexed. Spasms came on every
minute or two, affecting, more particularly, the head and the arm. I
commenced to give chloroform very gently at four in the afternoon.
It prevented the spasm before consciousness was quite removed.
Whenever the spasm offered to return, the inhalation was repeated
with the effect of stopping it. The chloroform was continued till half-
past five, with the effect of keeping the spasm away; and the patient
took some drink during this time, better than she had done
previously. I saw the child again at eight o’clock in the evening, and
found that the spasms had returned soon after I left, and had
continued as before. The chloroform was given again at intervals for
an hour and a half, with the effect of keeping away the spasms, and
inducing sleep; but I found that the child was getting weaker, and
would die even if the spasm was entirely prevented. She died at a
quarter past eight the following morning. There was no inspection of
the body.
The next case was a patient of Mr. Propert, a boy, ten years of age,
who had suffered from sloughing of the skin of the inferior
extremities. The tetanus came on during the healing process, whilst
the greater part of both extremities was in a state of ulceration, and
covered with healthy granulations. The patient was in a very irritable
and feeble state, and his pulse was 150 in the minute. He was made
insensible, and the chloroform was repeated twice in the space of
half an hour. No relaxation of the muscles of the jaws was produced,
although the effect of the chloroform was carried as far as seemed
safe in such a subject. He died twelve hours afterwards.
I administered chloroform lately to a patient of Mr. Salmon in St.
Mark’s Hospital. He underwent an operation by ligature for
prolapsus ani and hæmorrhoids on March 1st; on March 5th tetanus
commenced, and on March 7th chloroform was administered whilst
Mr. Salmon removed some sloughs from the anus; and it was
repeated occasionally afterwards. The patient was a man, fifty-two
years of age; he was the subject of kidney disease, and the tetanus
was extremely severe. He had had four doses, each containing a fluid
drachm of laudanum, between the time when the tetanus
commenced and his inhaling the chloroform. His pupils were
contracted, and he was made insensible by an extremely small
quantity of chloroform. He was, in fact, very much under the
influence of opium, although the spasm of the tetanus prevented his
sleeping.
Chloroform affords great relief to the patient affected with tetanus,
and it probably increases the prospect of recovery in cases which are
not too severe and acute.
Epilepsy. Dr. Todd at one time had chloroform administered by
inhalation, in King’s College Hospital, to the extent of causing
insensibility, at stated intervals, in cases of epilepsy, and he thought
with advantage. I have frequently administered chloroform for
surgical operations to patients who were subject to epilepsy, and
have very rarely found it produce any approach to a fit.
In July 1850, I administered chloroform to a boy, seven years old,
in an epileptic fit, which had lasted about an hour when the
inhalation was commenced. He had had fits previously, the last of
which had occurred a year before, but none of them had lasted so
long as the existing one. He had eaten nine new potatoes for his
dinner, at one o’clock, and the fit came on about eight. I found the
abdomen swollen and very tympanitic. There was constant
convulsive motion of the right arm, and of the neck; the latter
drawing the head to the right side. The mouth was also drawn to the
right at each convulsive motion. The chloroform was given by putting
a few minims at a time on a handkerchief, and holding it to the
mouth and nostrils. It caused immediate cessation of the convulsions
every time it was applied. The convulsions, however, returned again
in a minute or two. In the intervals that he was partially under the
influence of the vapour, he breathed easily without stertor. The
convulsions became gradually less severe, and ceased entirely ten or
fifteen minutes after the commencement of the inhalation.
Puerperal Convulsions. I have not been called to any case of this
complaint since chloroform has been in use; but some cases have
been related in the medical journals in which the inhalation of
chloroform has been employed with a favourable result. One case is
related by Mr. Henry Rudge, of Leominster.[154] When the chloroform
was administered, the patient was in violent convulsions which came
on in frequently succeeding fits. The os uteri was dilated, and the
head presenting. The pains were entirely arrested. The chloroform
was administered by twenty minims, at intervals, on a folded
handkerchief. The convulsions, after a few inhalations, entirely
ceased, and Mr. Rudge extracted the child without difficulty. There
was another child with the head presenting: it was delivered with the
forceps. The placenta was delivered with the hand on account of
smart hæmorrhage. There was only one attack of convulsions after
delivery, and the patient recovered favourably. It was her first
labour, and her age was twenty-three years.
A case of puerperal convulsions was related by Mr. Andrew Bolton
to the Newcastle and Gateshead Pathological Society.[155] His patient,
aged twenty-two, was at the full period of her first pregnancy. The os
uteri was high, slightly dilated, and extremely rigid. She was treated
at first by blood-letting, and full doses of morphia. Mr. Bolton says:
“As her condition appeared hopeless should the paroxysms continue,
chloroform was administered on a piece of linen, in half-drachm
doses, and its full effects kept up for three hours. At two P.M., there
was a slight return of convulsion; skin warm and perspiring; the os
uteri was found steadily dilating; and from her uneasy movements, it
was apparent that uterine action had begun.
“Half-past three. The membranes were ruptured; and brisk uterine
action ensuing, a dead child was expelled, immediately followed by
the placenta. She regained her senses during the expulsive efforts,
but appeared entirely ignorant of her previous condition. Recovery
followed without any bad symptom.
“In conclusion, I would remark, that the convulsions were in no
measure mitigated by the depletion, which was carried to the utmost;
nor was there any yielding of the os uteri until the chloroform was
inhaled.”
The urine was not examined in either of the above cases, and it is
not stated that œdema was present.
Hysterical Paralysis and Contractions. In December 1851, I
administered chloroform in Charing Cross Hospital to a young
woman about twenty-five, a patient of Dr. Chowne. She kept her left
knee in a semiflexed position, and would not allow it to be moved.
She had been in bed in the hospital for two months. She inhaled the
chloroform reluctantly, and, after becoming unconscious, she
breathed and sobbed in a hysterical manner. When insensible, the
limb went down flat on the bed, the knee being quite movable. A
straight splint was applied, and the limb was secured to it with
bandages. I was informed that in a few days she contrived to get her
leg bent again. She was the domestic servant of a nobleman. It was
evident that there was nothing the matter with her limb, and that it
was only influenced by her volition, which was perverted by the
hysteria under which she was labouring.
In November, in the same year, I administered chloroform in the
same hospital to another patient of Dr. Chowne, whose case was
more obscure and complicated. The patient was a woman, aged
thirty-three, who represented that for several months she had been
unable to open her mouth, or to speak, and that she had, for the
same length of time, been paralyzed in the left arm and leg. The
affection, it was said, came on suddenly, in a kind of fit, which was
followed by unconsciousness for three or four weeks. It was also said,
that she had one or two fits the previous year, after which she was
unconscious for a long time. The patient was quite conscious before
inhaling the chloroform, and replied to questions by nodding or
shaking the head, or by writing on a slate. She was unmarried, and
had not menstruated for some months past. The chloroform was
administered with a view to ascertain whether or not she was
feigning. On first becoming unconscious, the patient breathed in a
sobbing and hysterical manner. The chloroform was given very
gradually; and as she became more affected, there were some
struggling and rigidity, when the right arm and leg were moved
about a good deal. The left arm and leg were also distinctly moved,
but not above a tenth part as much as the extremities of the opposite
side. When the patient was quite insensible, the limbs being relaxed,
the pupils turned upwards, and the conjunctiva insensible, attention
was turned to the jaws, which were still firmly closed, but they were
opened by using a moderate degree of force with the fingers. The
effect of the chloroform having been allowed in a great measure to
subside, it was again administered, when the movements of the
limbs recurred, and there was the same difference between the
motion of the right side and that of the left, as before. When I left the
patient, more than half an hour after the chloroform was
discontinued, she had not opened her eyes or answered questions;
and she did not do either for six days. I saw her five days after the
chloroform. The pulse was very rapid on my first going to the
bedside, but its frequency subsided in a few minutes. On my raising
the eyelid, she turned her eye about, as if endeavouring to hide the
pupil under the lid. On the following day she answered questions by
nodding and writing on a slate, and was, in other respects, the same
as before inhaling the chloroform.
The great difference in the amount of motion in the limbs of this
patient, under the influence of chloroform, showed that the paralysis
of the left side was not a mere pretence. It is, indeed, possible that
the absence of motion in the limbs of the left side, for several
months, would cause them to move less than the opposite ones
during the action of chloroform; but it is not to be supposed that the
patient would keep these limbs in one posture during the night, and
when no one was present, without ever moving them, unless she
herself believed that they were paralyzed. I looked on the woman as a
sick person, and not a mere impostor; for although she appeared to
exaggerate her symptoms, and to have a good deal of pretence and
affectation, this circumstance arose, no doubt, from her complaint.
In April 1853, I administered chloroform four times to a patient of
Dr. Arthur Farre, a girl of fifteen years of age, who was affected with
a contraction of the flexor muscles of the left thigh and leg, of the
muscles which bend the body to the left side, and those which bend
and turn the head to the same side, in consequence of which the leg
was drawn up, and the body and head were curved greatly to the left
side. The contraction of the muscles had lasted for several weeks, but
she had been ill for a much longer period, her illness having
commenced with a fever. She took an extremely small quantity of
nourishment, and was very thin. Her bowels were moved with
difficulty. The pulse was very feeble and small, and there was a
tendency to coldness of the surface. An eminent surgeon in the
provinces had expressed his opinion that the distortion of the limbs
and trunk was a feigned disorder; but the action of the chloroform
proved that he was altogether in error. The muscles became
completely relaxed when the patient was quite insensible, and the
limbs and trunk and head could be readily moved into any position;
but as the effects of the chloroform subsided, the deformity returned
on each occasion before the patient recovered her consciousness.
Neither the chloroform nor any other measures were of any service,
and Dr. Farre informed me that the patient died a few weeks after I
saw her.
Mania. I have been informed of several cases in which chloroform
has been administered in acute mania, with the effect of calming the
patient and procuring sleep. I have administered it in two cases with
the same temporary advantage. In one of the cases, the patient was
persuaded to inhale it; in the other, he had to be held by three
keepers till he was unconscious. An eminent and well-known
scientific man, who became insane some years ago, refused to take
food. It was found that after being made unconscious by chloroform,
he would take a meal just as he recovered from its effects, and the
chloroform was given before every meal for a long time.
Spasmodic Pain. In August 1851, I administered chloroform to a
woman who was labouring under a severe paroxysm of spasmodic
pain in the abdomen. The pain was completely removed, without
altogether causing unconsciousness. An opiate was given to prevent
the pain from returning.
I have not had the opportunity of administering chloroform during
the passage of calculi down the ureters, or of gall-stones; but there
can be no doubt that it would be of the greatest service in such cases.
If Dr. Griffin had been provided with chloroform when he attended
the late Mr. Augustus Stafford with an attack of gall-stones,[156] he
would have been able to relieve his patient in five minutes, instead of
taking two or three hours to produce relief by opium. There would
have been no occasion for the venesection, which was carried to
thirty ounces. And at the end of the attack, on Dr. Griffin leaving his
patient for the night, if chloroform had been employed, he would
have left him without any appreciable amount of the narcotic in his
system. As it was, however, he left him with a quantity of opium
unabsorbed from the alimentary canal. The bandage got displaced
from the arm; there was an additional hæmorrhage, the opium
became absorbed more quickly, and a dangerous state of narcotism
was induced.
Frequent and long continued Use of Chloroform. Many patients
have inhaled this agent hundreds of times, and it continued to
produce insensibility as readily as at first. The dose does not require
to be increased on account of its long use. I was informed of the case
of a lady who was affected with a painful cancer, and was attended by
the late Mr. Keate and Mr. Henry Charles Johnson. She inhaled
chloroform at frequent intervals, by day and night, for a very long
time, consuming three or four ounces in the twenty-four hours.
In November 1851, a surgeon in the north of England wrote to me
respecting one of his patients, a lady, who had inhaled a great deal of
chloroform, on account of neuralgia of the uterus. He said that,
during that year, and principally within the last six months, she had
inhaled at least two hundred ounces; that she often inhaled as much
as three ounces in a day; and that it seemed to have produced very
little effect on her general health, except that she seemed to be more
susceptible of pain. He said that he had reluctantly yielded to the
entreaties of his patient to administer it so often, and he wished for
my opinion respecting the propriety of continuing its use, and what
effect it would be likely to produce.
I advised that the chloroform should be continued as long as the
severity of the pain rendered it necessary; and expressed my opinion,
that it would produce as little ultimate effect as any other narcotic
which might be used to relieve the pain. I saw the surgeon in
September of the following year. He informed me that the
chloroform was continued for some time after he had written to me;
but that his patient had recovered from her complaint, and had left
off the chloroform, and was in good health.
Mr. Garner, of Stoke-upon-Trent, has related the case of a lady,
affected with neuralgia, who inhaled sixty-two ounces of chloroform
from her handkerchief, in twelve days.[157]
SULPHURIC ETHER, OR ETHER.