ON THE INHALATION OF CHLOROFORM, ETC. (continued 3)

Case 2. The next recorded case in which the inhalation of chloroform was fatal, occurred at Cincinnati, on the 23rd of February, 1848. The subject of it, Mrs. Martha G. Simmons, was thirty-five years of age, and enjoyed good general health; she was the mother of six children, and her last confinement occurred eight weeks before her death. The patient exhibited no alarm on account of inhaling the chloroform, which was administered by two dentists, who were not members of the medical profession. It was breathed from an inhaler which Dr. Morton of Boston contrived for sulphuric ether. This inhaler consisted of a glass globe four inches and a half in diameter, and contained a sponge about one-third filling the globe, and saturated with chloroform.

Two female friends of the patient reported the following as the events which occurred. “The respiratory movements appeared to be free; chest heaving. While inhaling, the face became pale. At the expiration of about one minute, the instruments were applied, and four roots of teeth extracted. The patient groaned and manifested what they regarded as evidences of pain, while the teeth were being extracted, although she did not speak or exhibit any other sign of consciousness. As the last root came out, which was about two minutes from the beginning of the inhalation, the patient’s head turned to one side, the arms became slightly rigid, and the body drawn somewhat backwards, with a tendency to slide out of the operating chair. At this instant, Mrs. Pearson states that she placed her finger 128upon the patients pulse; observed that it was feeble, and immediately ceased to beat; respiration also ceased about the same time. The face, which was previously pale, now became livid, as did also the finger nails; and the lower jaw dropped, and the tongue projected a little at one corner of the mouth, and the arms were perfectly relaxed. The females regarded her as being then quite dead.”^[69]

The dentists gave nearly the same account, saying that the breathing was at first slow, and that the patient inhaled twelve or fifteen times, occupying from a minute to seventy-five seconds. They committed the great error of not placing the patient at once in the horizontal position, when the alarming symptoms came on, but kept her sitting in the chair, from five to ten minutes, whilst they sent out for restoratives. They thought the patient was living during this time, but her female friends thought not. The patient was placed on a sofa, and sometime afterwards artificial respiration and galvanism were applied without effect.

An examination of the body was made twenty-six hours after death by Drs. Mussey, Lawson, Baker and Mulford. The following are the chief particulars of the appearances met with. A larger quantity of blood than usual flowed from the sinuses of the dura mater. General aspect, colour, and consistence of the brain, normal. Lungs considerably but not intensely congested; crepitated freely at all points; no extravasation. Lining membrane of bronchia slightly congested, apparently the result of recent catarrh; deeply stained by the blood. Pleura at all points highly injected; six drachms of bloody serum in the right, and two ounces in the left chest. Pericardium contained six drachms of bloody serum. Heart flaccid, and all its cavities entirely empty; inner surface of both ventricles and auricles deeply 129stained. Abdomen—one ounce and a half of bloody serum in the right hypochondrium. Stomach and intestines distended with gas. Partially digested aliment, amounting to about three gills in the stomach. Blood fluid as water in every part of the body; not a coagulum was seen in any vessel. Lining membrane of all the bloodvessels deeply stained. The colour in every part of the system was that of dark venous blood.

It was estimated, in the inquiry which took place respecting this case, that one-fourth part by measure of what the patient inhaled might be vapour of chloroform; but this is evidently an over-calculation, for there could not be this quantity unless the interior of the glass globe were maintained at the temperature of 80° Fah. and the air were quite saturated with vapour in passing through it; however, less than half the amount of vapour here assumed would have the effect of causing sudden death, in the way it happened. The period of the inhalation, a minute or seventy-five seconds, during which the patient took twelve or fifteen inspirations, did not admit of the blood in the body being regularly and uniformly charged with the chloroform; and the increase of its effects, owing, no doubt, to the absorption and circulation of the vapour contained in the lungs at the moment when the inhalation was discontinued, was well marked. The patient became pale during the inhalation, but the alarming symptoms suddenly came on during the extraction of the fourth stump, probably within half a minute after the inhalation ceased. The patient seemed, in fact, to die with the slight struggle that took place at this moment. In the case of Hannah Greener, related above, the spasm at the moment of dying was even more marked. This is a symptom I have often seen during the death of animals killed suddenly with vapour of chloroform in a concentrated state, before they were made thoroughly insensible. 130Although the heart was empty, the stained condition of its cavities showed that they had contained blood at the time of death and afterwards. Owing to its fluid state, it probably escaped from the heart during the moving of the body; especially during the examination of the head, which was made first.

Case 3. The next recorded case of death from chloroform is reported by Dr. John C. Warren, of Boston, U.S., in the London Medical Gazette.^[70] His report, apparently extracted from some other report, is as follows.

“Name—Patrick Coyle. [Age—not stated.] Date—March 1848. Disease—fistula. Previous use of chloroform—once. Time of inhalation—about one minute. Quantity consumed—about thirty drops. [Query minims.] Posture—upon the side. Lapse of time till death—about one minute. Symptoms—showed signs of pain, by putting his hand to the part; in a moment his pulse, which was full and natural, sank: death. Morbid appearances—brain, with membranes, natural and healthy. Heart enlarged, pale, and soft; two or three ounces of serum in pericardium; bloodvessels with dark fluid blood. Lungs, studded with tubercles; abscess in each; lower parts congested; pleura extensively adherent; stomach—mucous membrane softened, its veins turgid.”

Nothing is said about the apparatus used in this case, but from the summing-up of Dr. Warren’s paper, it must have been either a towel or a handkerchief. The quantity of chloroform employed appears to have been much less than in the two previous cases. In speaking of drops, the writer probably means minims, or what is the same, a quantity equal to as many drops of water. Thirty drops of chloroform from a small phial are only equal to between six and 131seven minims, and if they were dropped on a handkerchief, so that they might be counted, they would evaporate entirely during the process. Supposing the quantity used to have been what is probably meant—half a fluid drachm—it would be quite adequate, according to calculations previously made in these pages, to cause the accident which happened. The period of inhalation was again very short—one minute; and the evidence of paralysis of the heart is distinct:—“In a moment his pulse, which was full and natural, sank: death.”

Case 4 was that of Madlle. Stock, aged thirty, and occurred at Boulogne, in May 1848. The operation was that of opening a sinus in the thigh, between two and three inches in length, at the bottom of which a small splinter of wood was found. M. Gorré, the surgeon who attended the patient, says: “I placed over the nostrils of the patient a handkerchief moistened with fifteen to twenty drops of chloroform at most.” It is necessary to remark, however, that a judicial examination of the bottle from which it had been taken, proved that from five to eight grammes had been used, a quantity equal to from 77 to 123 grains, and there are three drops of chloroform to a grain. M. Gorré proceeds to say: “Scarcely had she taken several inspirations, when she put her hand on the handkerchief to withdraw it, and cried with a plaintive voice, ‘I choke.’ Immediately the face became pale; the countenance changed; the breathing embarrassed; and she foamed at the mouth. At the same instant (and certainly less than a minute after the beginning of the inhalation), the handkerchief moistened with chloroform was withdrawn.” M. Gorré performed the operation, but he expressed the opinion afterwards that death had already taken place when he made the incision. Amongst the means used, with a view to resuscitate the 132patient, was inflation of the lungs, which was performed with such force as to produce permanent dilatation of the air-cells. The lungs, besides being distended from this cause, were found after death to be visibly engorged in their lower lobes. When cut into, a large quantity of black blood escaped. The cavities of the heart were empty, but the internal membrane, especially of the right cavities, was red. The tissue of the heart was pale, and was easily torn. Air was found in the pulmonary veins, and in most of the systemic veins throughout the body. The blood was very dark-coloured and fluid.^[71]

M. Gorré reported the above case to the Academy of Medicine of Paris, and a commission was appointed to inquire and report on it, who came to the following conclusions.

“1. In the medico-legal fact submitted to our notice, we found no indication of the poisonous action of chloroform; and consequently we reply to the minister, that the patient of M. Gorré did not die from the effect of inhalation of that agent.

“2. There have occurred a great number of analogous cases of sudden and unforeseen death, during operations, without any administration of chloroform, in which the most minute examinations have failed in detecting any assignable cause of death.

“3. In the case in question, the most probable cause, under all circumstances, seems to have been the mixture of a considerable quantity of gas with the blood.”^[72]

The report on this case gave rise to frequent discussions in the Academy, extending over several months, and the Academy ultimately confirmed the above conclusions, but 133not without considerable opposition from M. Blandin, M. Jules Guérin, and other members.

M. Malgaigne, the reporter to the commission, and others, who strongly supported the first of the above propositions, founded their argument chiefly on the assertion that chloroform always produces intoxication and insensibility before death; but this is incorrect, as I have explained above; and I took occasion to make the following remarks on this point about the time when the discussion in the Academy of Medicine took place. I said: “I have several times made animals—small birds, mice and rabbits—breathe air saturated with vapour of chloroform at the temperature of the atmosphere, and the consequence has always been that, after attempting for a few seconds to escape from the capacious jar in which they were enclosed, they suddenly exhibited signs of distress, and died without any interval of intoxication or insensibility, in periods varying from less than half a minute to a minute after their first exposure to the vapour.”^[73]

The power of chloroform to cause sudden death without previous insensibility is now, I believe, generally admitted. The French call this kind of fatal action sideration.

With regard to the second conclusion of the commission, if it had been really true that the surgeon put only fifteen to twenty drops at the most of chloroform on the handkerchief, one would have been inclined to admit it; but with the quantity actually employed, and the strong sensation of choking it occasioned just before death, one must, in connection with other cases, and with what is known of the action of chloroform, attribute the fatal event to this agent, rather than to the surgical operation, which was not of a serious nature.

With regard to the third of the above conclusions, it is 134not a little remarkable that most even of those speakers who opposed the conclusions of the commission, agreed that death was caused by a sudden development of air in the veins; and differed from them only in this, that they considered the chloroform as the cause of the evolution of air or gas, and that it proved fatal in this way. That the air was not caused by putrefaction, and that it did not enter by the wound in the thigh, may be readily admitted, but there remains the artificial respiration, which was performed with such force as to produce permanent dilatation of the air-cells. It was argued in the Academy that, as the air was in the systemic, as well as in the pulmonary veins, it could not have been introduced by the artificial respiration, since the left ventricle had previously ceased to act; but the action of the left ventricle is not necessary for the passage of the contents of the arteries through the capillaries into the veins, since this commonly goes on after death, the arteries being usually found entirely empty of the blood they must have contained at the moment of death. With regard to the passage of the air out of the heart into the arteries, supposing that the pulmonary veins were ruptured during the inflation of the lungs, there is an observation of Dr. Sibson’s which will explain both this circumstance and the fact of the heart itself being found empty of blood. He found that the heart was often emptied of blood by distending the lungs with air after death in preparing the body for his diagrams of the position of the viscera.^[74]

With the conclusions above quoted, some additional ones were adopted from the second part of the report of the commissioners; in these it was admitted that chloroform is capable of causing death, if administered too long, or in too large doses. One of these additional conclusions, however, is as erroneous as the previous ones. It is, “there is risk of 135asphyxia when the anæsthetic vapour is not sufficiently diluted with air.” When the vapour is not sufficiently diluted with air, the risk is one of sudden death, by paralysis of the heart. Chloroform does not yield enough vapour, at the natural temperature and pressure of the atmosphere, to exclude the air to the extent which would cause asphyxia. When chloroform vapour largely diluted with air is long continued, it may cause, not real asphyxia, but a mode of death resembling it, owing to the medulla oblongata and nerves of respiration becoming over narcotised.

Case 5 is that of a young woman at Hyderabad, who inhaled chloroform to undergo amputation of the middle finger. A drachm was sprinkled on a handkerchief and inhaled. The operator described what occurred as follows: “She coughed a little, and then gave a few convulsive movements. When these subsided, I performed the necessary incisions, which of course did not occupy more than a few seconds. Scarcely a drop of blood escaped.” The absence of bleeding seemed to be the circumstance which called the attention of the operator to the state of his patient; and after describing the means which were used without avail to bring about recovery, he continues, “I am inclined to think that death was almost instantaneous; for, after the convulsive movements above described, she never moved or exhibited the smallest sign of life.”^[75]

In this case, it is probable that the breathing and the action of the heart were both arrested at the same time, by the action of the chloroform.

Case 6. Charles Desnoyers, aged twenty-two, a patient in the Hôtel-Dieu at Lyons, affected with scrofulous disease of the left wrist, having to undergo transcurrent cauterisation 136of the joint, inhaled chloroform from an apparatus for five minutes, and died at the beginning of the operation.^[76] Further particulars are not given.

Case 7. A young gentleman, who had returned from Australia to visit his relatives in the neighbourhood of Govan, inhaled chloroform for an intended operation on the great toe, in December 1848. It is stated that the patient, after inhaling it, almost instantly expired. This account appeared in the Glasgow Herald, and was copied into the medical journals.^[77] I believe that no further account of the case was ever published.

Case 8 occurred on January 19th, 1849. It is related by Dr. John C. Warren.^[78] John Griffith, an Irishman, aged thirty-one, a seaman in the American navy, was admitted into the New York Hospital early in December 1848, on his return from Mexico. He was suffering with diarrhœa, chancres, and hæmorrhoids. The following is the account of this accident.

“Gurdon Buck, jun., attending surgeon to the New York Hospital, being sworn, says, that ‘on or about the 26th of December, I advised that chloroform should be administered to the deceased, for the purpose of examining the condition of the rectum, the parts being in such a state of excessive irritation as scarcely to admit of a separation of the nates. The patient recovered from the effects of the chloroform, and remained in all respects in the same condition, except the local ailments spoken of; and he having never complained of either his head or his chest, and not having suffered from the first administration of chloroform, I directed it to be administered to him for the purpose of performing 137an operation upon the rectum, and the operation of circumcision to remove a phymosis caused by the chancres: the patient soon became excited by the chloroform, as is usually the case, but not beyond a degree that I have often observed. Shortly after, he became more tranquil: the deceased was placed upon his side, and the operation performed, which consisted in the removal of two external tumours, and the tying of one internal tumour.

“‘At this moment my attention was arrested by my assistant’s calling for a wet cloth: on examining the patient, I found his face and neck of a livid leaden hue or colour, the eyes turned upward, the pulse imperceptible at the wrist, and the whole body relaxed; after two or three gasps, he ceased to breathe. Every means was promptly used to restore the deceased, but without effect. The chloroform was obtained from Kent’s, 91, John Street, and not exceeding three drachms was administered on a napkin. A portion of chloroform from the same phial had been administered the day before to a patient without any unfavourable effects. About ten minutes elapsed from the commencement of its administration before death took place. On making a post-mortem examination, twenty-four hours after death, I found the face less livid than before death; on examining the head, the brain and its membranes presented no other appearances than are seen in persons dying when in full health; the lungs were a good deal congested, and discharged, when cut, a large quantity of bloody serum; the heart was large, its ventricles and auricles were empty, its condition flabby, the substance of the left ventricle rather softer than natural; about half an ounce of watery fluid was found in the pericardium; the viscera of the abdomen were healthy.’”

This case differs from those previously related in respect to the time at which the fatal occurrence took place. It was not till ten minutes from the commencement of inhalation, 138and when an operation which probably occupied two or three minutes had been performed, that the patient suddenly expired. The evidence of paralysis of the heart is, however, distinct enough in the absence of pulse at the wrist, and the livid hue of the countenance. In several of the previous cases, there was sudden pallor at the moment when the heart ceased to inject blood into the capillaries, but in a patient well supplied with blood, the sudden arrest of the action of the heart would cause turgescence of the veins and venous capillaries, which would be evident in the face in a few seconds. The syncope occasioned by paralysis of the heart differs from that kind of syncope which is caused by loss of blood, inasmuch as the right cavities of the heart are full in the former instance, and empty in the latter.

The circumstance of the patient having inhaled chloroform to insensibility three weeks previously, without accident or ill effects, is worthy of notice, as showing that the fatal event did not depend on any peculiarity of constitution.

Although the heart was found to be empty, its flabby condition and the watery fluid in the pericardium indicate that it must have contained blood at the time of death.

Case 9 occurred on January 24th, 1849, at the Hôtel-Dieu, Lyons, where case 6 previously happened. The patient was a youth, aged seventeen, named J. Verrier, who had been employed as a miner. He was of good constitution, and was about to undergo amputation of the middle finger for necrosis of the first phalanx. The following is the account of the accident.

“As the patient’s health was good, he was at once, and by his free consent, placed under the influence of chloroform. As usual, a piece of fine gauze was employed; it was spread over the face, leaving a free passage for atmospheric air; the chloroform was dropped from time to time upon that 139portion of the gauze which was over the nostrils. It was administered by two assistants who were accustomed to its use, and who at the time attended to the pulse. The operator superintended the assistants. At the end of four or five minutes, the patient still felt and spoke; and at the end of another minute, he still spoke and was somewhat restless. Up to this time, from a drachm to a drachm and a half of chloroform had been employed. The pulse was regular, and of the normal strength. All at once the patient raised his body, and struggled so that the limbs escaped from the hold of the assistants, who however seized them quickly, and replaced the patient in his position. Within a quarter of a minute, one of the assistants stated that the pulse at the wrist had ceased to beat. The handkerchief was removed. The countenance was completely altered. The action of the heart had altogether ceased; the pulse could not be felt anywhere; and the sounds over the region of the heart could no longer be heard. Respiration still continued, but it became irregular, weak, and slow; and at length ceased completely in the space of about half a minute.

“The extreme danger of the patient was manifest, and immediate and energetic means were employed to rouse him. Ammonia was held to the nostrils, and rubbed in large quantity over the surface of the chest and abdomen. It was also applied to the most delicate parts of the skin, e. g., the lips and the extremity of the penis, with a view to excite irritation. Mustard was used; the head was inclined over the bed; and, finally, an attempt was made to restore respiration by means of alternate pressure on the abdomen and chest. After two or three minutes, respiration reappeared, and even acquired a certain fulness, but the pulse nowhere returned. Frictions were continued. Respiration became again slower, and at length ceased. Artificial inflation was practised, at first through the mouth, and afterwards 140through the larynx, by passing a tube through the glottis, as it was perceived that air had passed from the mouth into the stomach. The precordial, epigastric, and laryngeal regions were energetically cauterised with a hot iron. The pulse did not return. For the space of half an hour every effort was made to resuscitate the patient; but in vain.

“The autopsy could not be made until seventy-two hours after death. The temperature being low, the body showed no signs of decomposition; there was still rigidity of the limbs. The features were not altered. The examination of all the organs was made with care.

“The stomach contained about one ounce and a half of a thick fluid, of the colour of the lees of wine, in no respect resembling an alimentary fluid. The organ was distended with gas, as was also the rest of the alimentary canal, which was otherwise sound. The liver and spleen were somewhat congested.

“The heart, which was normal in volume, was flaccid and empty, contained neither blood nor air. The ventricular parietes were moistened by a fine, very red foam, as if from the presence of a little blood, which had been, as it were, whipped by the fleshy columns of the heart. The venæ cavæ and the portal veins were distended by black fluid blood in great quantity. On the Eustachian valve there was a fibrinous clot, moderately firm, and weighing from sixty to seventy grains. It was the only clot met with in the cavities of the heart and great vessels. These cavities, which were carefully opened, did not contain any appreciable quantity of air.

“The lungs retracted on opening the chest. They presented both in their surface and in their substance a very black colour; otherwise their tissue was healthy. The larynx and trachea presented no lesion. The brain was 141normal. The sinuses of the dura mater contained a considerable quantity of black uncoagulated blood.”^[79]

In this case every precaution appears to have been taken, except that which is the most essential, of regulating the amount of vapour in the respired air. Arrangement was made that there should be amply sufficient air for the purpose of respiration; the patient was carefully watched by three persons at least, one of whom was constantly attending to the pulse, but with no other result than to be able to announce the exact moment when it suddenly stopped. The arrest of the action of the heart in this case took place at a time when the patient was not yet rendered insensible by the chloroform, although he had been inhaling it for five minutes. We must conclude that during these five minutes the vapour he inhaled was largely diluted with air, and that he then inhaled vapour in a much less diluted form. It is not improbable that he took a deep inspiration of strong vapour, just at the moment when he struggled violently, and within a quarter of a minute of the time when his pulse suddenly ceased.

The breathing continued a little time after the heart ceased to beat, and it is therefore very probable that, if this organ had not been irrecoverably paralysed, the natural breathing would have restored its action after a short pause, that would have attracted but a momentary attention. As the spontaneous breathing of the patient did not restore the heart’s action, there is no ground for surprise that the measures adopted did not succeed.

Case 10 was that of a labourer, named Samuel Bennett. It occurred on February 20th, 1849, at a dispensary in Westminster. The patient inhaled chloroform for amputation of one of the toes. Half an ounce of chloroform was 142“sprinkled on a handkerchief, and held over the mouth and nose.... This quantity of the agent failed, however, to produce anæsthesia, having caused only the ordinary excitement and struggling.” After a delay of two hours, more chloroform was procured, and half an ounce was again applied on a handkerchief, “care being taken to allow the entrance of air at short intervals.” Insensibility was induced, and the toe was amputated; the chloroform being applied, as I was told, during part of the time of the operation. At the close of the operation, no blood escaped when the pressure was removed from the arteries; the patient was in fact dying, and in a short time expired. “A few inspiations were noticed after the pulse had ceased at the wrist.”^[80]

The lungs were of a dark venous hue throughout, a large quantity of blood escaping from them when cut into. Mucous membrane of trachea and bronchi congested. Heart rather large but flabby; auricles empty; each ventricle contained about an ounce of semi-fluid blood (the lungs had been inflated). Head: sinuses and veins contained blood, but not to any remarkable amount. But few bloody points occurred in cutting into the cerebral mass. Kidneys congested.

The failure of the first attempt to cause insensibility in this case, when so large a quantity of chloroform was used, illustrates very forcibly the uncertainty and irregularity of the way in which it was administered. On the first occasion only excitement and struggling were produced, and on the next the patient died suddenly.

Case 11 occurred on August 23rd, 1849, at Langres, France. The subject of it, Madame Labrune, was reported to be a healthy married woman. She inhaled chloroform with the intention of having a tooth extracted. “Complete 143insensibility was not produced at the first trial: more chloroform was placed on the handkerchief, and she drew a full inspiration. Her countenance immediately became pallid; her features were visibly altered; there was dilatation of the pupils, with a convulsive rolling of the eyes; and no pulse could be felt. Every attempt was made to restore life, but without success. She died as if struck by lightning.”^[81] The instantaneous arrest of the circulation, on a full inspiration being taken, immediately after more chloroform had been placed on the handkerchief, is particularly worthy of notice. The heart was paralysed, in this instance, as quickly as in experiment No. 25, above related.

No inspection of the body is reported in this case.

Case 12 is the first which occurred in any of the hospitals in this metropolis. The following is the account of it.

“John Shorter, aged forty-eight, a porter, known to Mr. Solly for some time as a very active messenger, habits intemperate, but apparently in perfect health, was admitted into George’s ward, under Mr. Solly, on the 9th October, 1849, suffering from onychia of the left great toe, which had existed some time. It was determined to remove the nail, the man having decided before entering the hospital on taking chloroform.

“On Wednesday, October 10th, at a quarter to two P.M., he began to inhale the chloroform with one drachm in the inhaler. It had no visible effect for about two minutes; it then excited him, and the instrument was removed from the mouth, and about ten drops more were added; he then almost immediately became insensible; the chloroform was taken away, and the nail removed. He continued insensible; and, his face becoming dark, the pulse small, quick, but regular, respiration laborious, his neckerchief was removed, 144and the chest exposed to fresh air from a window near to the bed; cold water was dashed in his face, the chest rubbed, and ammonia applied to the nose. After struggling for about a minute, he became still, the skin cold, pulse scarcely perceptible, and soon ceased to be felt at the wrist; respiration became slow and at intervals, but continued a few seconds after the cessation of the pulse. Immediately on the appearance of these symptoms, artificial respiration was commenced by depressing the ribs with the hands and then allowing them to rise again until the proper apparatus was brought, when respiration was kept up by means of the trachea tube and bellows, and oxygen gas introduced into the lungs by the same means. Galvanism was also applied through the heart and diaphragm, but all signs of life ceased about six or seven minutes after the commencement of inhalation. These means were persisted in until a quarter past three, but to no purpose. On removing the inhaler, the sponge, which only contains one drachm, fell upon the floor, and the chloroform splashed about,—thus showing that a considerable part of the chloroform remained unused; so that the patient could not have inhaled more than a drachm. Every endeavour was made to procure a post-mortem examination, but in vain.”^[82]

The above account is published in the Medical Gazette as communicated by Mr. Solly, but it is clearly not written by him, and it presents a very confused narrative of what occurred. If we are to understand the events in the sequence in which they are related, we must conclude that the patient became insensible and had the operation performed, that he then exhibited alarming symptoms for which cold water was dashed in his face and other measures were employed, and yet that after this he struggled for about a minute. This would be a state of things inconsistent, 145in my opinion, with death from chloroform; but possibly the proper sequence is not observed in detailing what occurred. There is some obscurity also about the amount of chloroform used in connection with what remained on removing the inhaler. If the sponge was adapted to hold a drachm in the proper manner, the chloroform could not splash about on its falling, unless there was a good deal more than a drachm in it. But whatever was the quantity of chloroform remaining in the sponge, as it was in a condition to splash about, it is difficult to perceive what prevented the liquid chloroform from dropping into the patient’s throat, as he lay on his back in bed. Chloroform is as pungent as the essential oils. I have been informed of a case in which a patient was nearly suffocated by one drop falling into the throat; and the narrative of what occurred to Mr. Solly’s patient is not at all inconsistent with death from spasm of the glottis arising from this cause. If, however, the patient died from the vapour of chloroform, we must conclude that he inhaled it at one moment not sufficiently diluted with air.

The chloroform in this case was administered by a non-medical person—a sort of surgery-man. After this accident, however, the chloroform in St. Thomas’s Hospital was always entrusted to some one belonging to the profession.

Case 13 occurred at Shrewsbury, to a Mrs. Jones, a patient of Mr. Clement, surgeon, who had partly performed the operation of excision of the eyeball, when his patient suddenly died. Mr. Clement has, I believe, not published any account of the case, but the evidence which he gave at the inquest was reported in various local newspapers, and copied into the medical journals. The death was very characteristic of the effects of chloroform vapour not sufficiently diluted. Mr. Clement is reported to have said: 146“He gave her but a small dose to commence with, imbibed from a sponge, and then commenced the operation. Finding that did not make her insensible, about a drachm more was poured on the sponge, which she inhaled again for a few seconds. He then went on with the operation, and shortly afterwards heard a peculiar sound, which he could not describe, and she died in a moment; all the attempts to rouse her proved ineffectual. She spoke in Welsh before she died, but so quickly that he did not know what she said; he had no doubt that she died from the effects of the chloroform.”^[83]

Case 14 occurred at Berlin. The subject of it was a young lady twenty years of age, of good health, well made, and of a good constitution. The chloroform was inhaled for the extraction of a tooth. It was administered on a sponge, covered with a napkin. The dentist who administered it was not a medical man. He made five unsuccessful attempts to extract the tooth under chloroform. Three of these attempts were at nine in the morning, and two about noon, just before the accident. His patient suddenly died almost at the commencement of the last attempt to administer chloroform, stretching herself out, and frothing at the mouth at the moment of death; the countenance at the same time becoming livid.

An examination of the body took place fifty hours after death, when putrefaction had set in.

“The lungs presented nothing morbid; the bronchi contained a little bloody froth. The blood was of the colour and consistence of cherry juice. The heart was soft, flabby and collapsed. Its coronary vessels and cavities were empty, and presented the bluish-red discoloration of decomposition.”^[84] The other organs were healthy.

147Case 15 occurred in the public hospital of Kingston, Jamaica, on January 29, 1850. The name of the patient was William Bryan, his age is not stated, nor the nature of the operation he was about to undergo. He had previously, however, undergone the operation of amputation of the penis, on account of cancer of that organ, but it was performed without chloroform. Mr. Maygarth, the surgeon who administered the chloroform, stated as follows: “I had about a drachm poured on the sponge, and applied it over his mouth and nostrils, but at first not in close contact—at no period was the atmospheric air totally excluded. He bore it badly, and I was frequently obliged to withdraw it, to facilitate his breathing. The stage of excitement which is usual came on, and he struggled and kept away the sponge for some seconds; it was again reapplied, when, after a few more seconds, observing that he made one stertorous inspiration, I removed it altogether. He ceased to breathe; but after some seconds had elapsed, made another inspiration, and this occurred several times, until at length respiration ceased entirely.” The measures which were employed were of the usual kind, but were of no avail.

The brain and its membranes were found to be congested. The lungs were congested, especially posteriorly. The right side of the heart contained dark fluid blood, and the inner surface of its left cavities, and of the aorta, were stained with blood. There was some disease of the aortic valves, and the heart had undergone some amount of fatty degeneration.^[85]

Case 16. In February 1850, a death from chloroform occurred on board ship at the Mauritius. A report of the case was sent to the Board of Ordnance, and also to the Admiralty. The secretary of Sir William Burnett first informed 148me of the case, and a day or two afterwards I had an opportunity, through the kindness of the late Marquis of Anglesey, of reading the report which was sent to him as Master of the Ordnance, and I made a note of the chief particulars as soon as I got home. As the report was a very able one, it is to be regretted it has not been published. The accident occurred to an artilleryman, aged 24, who required to have the last phalanx of the middle finger removed. In other respects, he was considered to be in good health. Two scruples of chloroform were first poured on the handkerchief with which it was administered, and then one scruple more. It was observed that the face turned pale, and the pulse and breathing ceased, soon after the chloroform was discontinued. The measures which were employed to restore him were of no service. The lungs after death were found to be emphysematous; and, upon inquiry, it was ascertained that he had been short of breath on exertion. The right cavities of the heart were filled with fluid blood. The sinuses of the dura mater contained less blood than usual, and the brain was pale. The medical man reporting the case considered that the emphysema was the cause of death, by interfering with expiration, and thus detaining the vapour; and it must be admitted that, if the vapour were not sufficiently diluted with air, the emphysema might increase the danger. I have, however, administered chloroform in several cases in which emphysema existed to an extreme degree, without any ill effects; consequently, when the vapour is properly diluted with air, this affection appears to be no source of danger.

Case 17 was that of a patient of Professor Carl Santesson, in the Seraphim Hospital at Stockholm. I was indebted to Mr. Paget for my first information about this case, and to Dr. W. D. Moore, of Dublin, for some further particulars respecting it.

149The patient, a man thirty years of age, was affected with hydrocele, and there was some suspicion of disease of the testicle. It was consequently intended to operate on the hydrocele by incision, in order that the testicle, if diseased, might be removed. The chloroform was administered in the same way that Professor Santesson had seen it exhibited by Dr. Simpson, except that it was poured on a little cotton, which was placed at the small end of the cone, into which the folded towel he made use of was rolled. About a drachm and a half was first poured on the cotton, and the patient was told to inhale in long and deep inspirations. This quantity being nearly evaporated in two or three minutes, a drachm more was added. After a few inspirations rigidity and struggling came on: these subsided, but in a little time returned more strongly than before, and the towel was removed from the face until the struggling ceased. The patient, however, not being sufficiently insensible to undergo the operation with the necessary quietness, the towel was reapplied, when, after a few inspirations, the pulse suddenly ceased. The face and the whole surface of the body turned pale, the eyes rolled upwards and inwards, and the breathing became very slow, but full and deep, the intervals between the inspirations becoming longer, until the respiration ceased altogether. The patient died before the operation was begun, and within five minutes from the commencement of inhalation. During the application of various means of resuscitation, including the dropping of cold water guttatim on the epigastrium, the breathing returned, and continued for the space of three or four minutes; but the pulse and sounds of the heart did not return.

At the examination, thirty-two hours after death, the dura mater was found to be congested, and there was considerable serous effusion between the membranes of 150the brain. There were also some bony deposits under the dura mater, and some adhesions of the arachnoid, indicating long standing disease of the membranes.

The heart was of normal size, and flaccid; the vessels on its surface strongly distended with blood. The left ventricle was empty; the left auricle, on the contrary, and the entire of the right side of the heart, with the great veins, were filled with thin uncoagulated blood. In the right ventricle only was a little loose coagulum found. The lungs, posteriorly, were highly congested, exhibiting here and there infiltrations of blood from the size of a pea to that of a small hazel-nut. The pulmonary tissue was otherwise sound; giving, however, when cut into, the odour of chloroform, but more feebly than the brain did. The mucous membrane of the larynx and bronchial tubes were slightly reddened from sanguineous congestion. The blood was everywhere of the same thin juice-like nature.^[86]

Case 18. I am indebted for my information respecting this case to Dr. James Adams, of Glasgow, who was good enough to send me a copy of the notes respecting it, from the case book of his colleague, Mr. Lyon, in whose practice, in the Glasgow Infirmary, the case occurred, in March 1850. The patient was a boy seven or eight years old, from the Highlands, whose health was considerably impaired by years of suffering from calculus. Mr. Lyon says, “being laid in bed, I placed a piece of lint, moistened with chloroform, near to his face, when, in a few minutes, he ceased crying. I now told my clerk to take charge of the chloroform, and introduced the sound. I thought I detected a calculus, but could not hear the click distinctly, in consequence of the patient moaning. One of the bystanders held his hand between my ears and the patient’s face, when the click was 151at once heard. I withdrew the instrument, and was horror-struck with the livid countenance and vacant eye of the patient; the cardiac and radial pulses were gone, and, making one deep gasp, he was to all appearance dead.” Artificial respiration and other measures were employed without effect. “The external jugulars being remarkably turgid, and the face still very livid, the right jugular was opened, when several ounces of dark blood flowed rapidly.” This measure, and galvanism, which was applied afterwards, were of no avail.

Case 19. The subject of this case was Alexander Scott, aged thirty-four, a police constable, who died in Guy’s Hospital in June 1850, whilst undergoing an operation for the removal of a portion of the right hand. Mr. Cock, the operator, said that he was certain there was no disease about the patient. He described the accident as follows:—“The ordinary machine was used, and, as it had not the effect, witness directed that a napkin should be folded into the shape of a cone, which was applied with chloroform. The occupation of removing a portion of the bone occupied one minute and a half, but before it was completed, the blood which was gushing out, suddenly stopped, when witness directed Mr. Lacy to feel the pulse of deceased, and they found that deceased had expired.”^[87]

The sudden stopping of the hæmorrhage shews that, in this case, as in the others, the action of the heart was suddenly arrested. The first attempt to cause insensibility failed in this as in some other cases.

Mr. Cock tried to dissuade his patient from having chloroform, severe as the operation would have been without it. In Guy’s Hospital and St. Thomas’s the medical officers had a strong objection to narcotism by inhalation 152for the first two or three years after the practice was introduced, and chloroform was used much less generally in these institutions than in any other of the hospitals of London; yet it was precisely in these two hospitals that two deaths from chloroform occurred, before any such accident had happened in any other hospital in this metropolis. This circumstance is worthy of the consideration of those who propose to limit the accidents from chloroform by restricting its use to a few great operations.

In this case the lungs were reported to be extremely congested. Heart flabby, not particularly distended; about two ounces of fluid blood on the right side; not more than half an ounce on the left. Head.—Much congestion of the dura mater; the grey matter of the brain was dark and congested; fluid was found in the subarachnoid space; and a considerable quantity of it in both ventricles. Kidneys congested.^[88]

Case 20 occurred on September 20th, 1850, at the Cavan Infirmary, Ireland. The case occurred in the practice of Dr. Roe, and I am indebted to Dr. Robert Adams, of Dublin, for a manuscript account of it. The name of the patient was James Jones, and his age twenty-four years. Chloroform was exhibited with the intention of performing amputation below the knee, on account of scrofulous disease of the ankle, with ulceration of the cartilages. The patient was reduced to a state of great debility by the disease, and was suffering from hectic fever, but had no cough. The following is Dr. Roe’s account of the accident:—

“When placed on the operating table the heart’s action was very quick and weak, but he did not appear more faint or pale than usual. I then saw Mr. Nalty, the apothecary, measure one drachm of the chloroform in the small minim 153glass measure, and pour it upon a little folded lint, which was placed in an oval hollow sponge, held in the hand with a small towel. Recollecting I had used this chloroform in another case, and finding some delay in producing the anæsthetic effects, I directed Mr. Nalty to add thirty drops more to that already put on the lint. I then applied the sponge to the patient’s nose, directing him to keep his mouth shut, and gave the towel into the care of Dr. Halpin, who was on the opposite side of the table, while I went to prepare myself for the operation. Mr. Bird had scarcely screwed up the tourniquette, which had been previously placed on the thigh, while I was examining the state of the circulation in the tibial arteries, and which could not have occupied one minute,—certainly the patient could not have taken fifteen inspirations,—when Dr. Halpin told me the anæsthetic effects were produced. This struck me as being unusually quick and sudden, and on removing the towel from the face, we saw a slight convulsive action of the left eyelid (the eyelids were partially open), and a small quantity of frothy saliva at the mouth. I felt rather uneasy, but not much alarmed, as Dr. Halpin said he had often seen such symptoms from the effects of chloroform, although I had not met with them. On a more minute examination of the heart, the eyes, muscles of the limbs, &c. we found him dead.”

Energetic means were used with a view to restore the patient, but without effect. No inspection of the body took place.

Case 21. The next case of recorded death from chloroform occurred in the Stepney Workhouse. The patient, named John Holden, age not stated, was about to undergo an operation on the penis. It was stated at the inquest that half a drachm of chloroform was administered without 154effect, and then half a drachm more was applied, when the patient suddenly expired. This death occurred in April 1851.

Case 22 is important, as having given rise to a prosecution. The medical man, an officier de santé, named Kobelt, was accused of homicide, by imprudence, want of precautions, &c. The chloroform was administered on a handkerchief, and the accident occurred as suddenly as any of the others. The husband of the patient stated that the whole process did not last a minute. “I observed attentively,” he said, “during this time, and the character that her countenance took all at once made me apprehensive. I spoke of it to the operator, who tranquillized me, and continued to extract the teeth. After the third tooth, however, he partook of my apprehension, suspended the operation, and proceeded to adopt measures indicated by the circumstances.” Professor Sédillot, who had to pronounce an opinion on the case, after hearing all the evidence, said, “I do not think that M. Kobelt is guilty of imprudence or of rashness, because that officier de santé has followed a practice very habitually employed, and even recommended, by eminent practitioners, whose example and authority were sufficient to inspire him with security, and shade him from reproach.” The accused practitioner was acquitted. The above remark of Sédillot applied to the plan of causing insensibility very rapidly, as first recommended by Dr. Simpson; and he added some observations, to the effect that, when used in a different manner, chloroform is free from danger.

The above case occurred at Strasbourg, on June 10th, 1851. The name of the patient was Madame Simon, and her age thirty-six. After death the lungs were found to be somewhat congested, and emphysematous. Heart flaccid, of 155middle size; right cavities filled with liquid dark-coloured blood, mixed with some fibrinous clots. The left cavities contained similar blood in much smaller quantity.^[89]

Case 23 occurred on July 8th, 1851, at the Seaman’s Hospital, Greenwich. The patient was a light-coloured mulatto, aged forty-five, native of New York. He died during the operation of removing the left testicle, which was disorganized by suppuration. “The chest had been carefully examined a few days previously, both by percussion and auscultation. No physical signs of disease were detected. His pulse was regular and feeble, about seventy. He was rather nervous, and fearful of the operation. No arcus senilis. After taking a glass of wine he commenced the inhalation, twenty minims of chloroform having been poured on a linen cloth. At the expiration of a few minutes, this had been dissipated, producing only very trifling excitement; a second dose, of the same quantity, was then administered in the same way; the man began to sing and shout, his expressions relating to the firing of guns. The second quantity having been exhausted, and the effects of the chloroform becoming more apparent, but sensibility being still perfect, and even intelligence almost unaffected, a third quantity, of ten minims, was poured out, and, afterwards, twenty minims more. Having passed through the usual convulsive stage, and insensibility being established, the further administration of chloroform was desisted from at the end of about seven minutes, though this time is merely guessed at; it might have been more, but was certainly not less. At this time the respiration was unembarrassed, and the pulse regular, and about seventy, with as much volume as before the inhalation. The lips were florid; in fact, the chloroform appeared to have acted 156in the most benign way. Mr. Busk commenced the operation by an incision through the scrotum, which divided a small arterial branch, and some enlarged veins, from which the blood flowed pretty freely. The flow, however, almost instantaneously ceased, and Dr. Rooke, who kept his finger on the man’s pulse, found that cease at the same moment. Respiration appeared to cease almost instantaneously with the heart’s action. Regular respiration at least did; for, while we were looking at the man’s face, he fetched one or two sigh-like inspirations. The ribs and abdomen were compressed, so as to induce inspiration and expiration; the lungs were inflated by blowing through the nostrils, the larynx being compressed against the spine, and, for three or four minutes, upon our efforts being suspended, the man occasionally took an inspiration; on one occasion three or four in succession, so as to make us flatter ourselves that he would come round.... It is worthy of remark that, for a long time after spontaneous respiration had ceased, the lips retained a florid colour. The muscles were all relaxed, and the veins on the side of the neck turgid.”^[90]

At the inspection of the body next day, the vessels of the dura mater, and those on the surface of the brain, were gorged with fluid blood. The lateral sinuses also afforded a flow of dark-coloured blood. There was a considerable quantity of serous fluid in the cavity of the arachnoid and in the spinal sheath. The substance of the brain was very soft. (The weather was warm.) The lungs were of a dark purple colour posteriorly, and much loaded with fluid blood and serum, but were everywhere crepitant and healthy. The external surface of the heart was covered almost entirely with fat; in some parts to a considerable thickness. There were two fibrinous spots on its surface. No fluid in 157the pericardium. The venæ cavæ were full of fluid blood. On removing the heart, a white fibrous coagulum, about as big as a walnut, was found in the commencement of the pulmonary artery. The heart was uncontracted, and the cavities contained a very small quantity of dark fluid blood. The walls of the right ventricle, and of the left auricle, were thinner than natural. Some portions of the substance of the heart were paler than natural:—“In these paler portions of the muscular substance, the fibres had, for the most part, lost their striated aspect, and had become converted into a fine granular material contained in the sarcolemma. Here and there a minute oil-globule could be observed in the muscular fibrillæ, but nowhere did this amount to fatty degeneration.”

In this case all the precautions appear to have been taken which are possible in making a patient insensible with undiluted chloroform, administered on a handkerchief; and the case, therefore, strongly confirms the proposition that chloroform cannot be administered in this way with perfect safety.

The patient was apparently in the most satisfactory condition at the conclusion of the inhalation, and yet, a few seconds afterwards, the heart suddenly ceased to beat, from the effect, as we must conclude, of that portion of vapour which was in the lungs at the moment when the inhalation was discontinued.

Case 24 occurred in October, 1851, at Chipping Norton, Somerset, to a patient of Mr. Farwell, named Elizabeth Hollis, and aged 37. No one observed the manner in which the breathing and circulation ceased, and, as the patient was in a state of extreme debility, it is not quite certain that the chloroform was the sole cause of death. It was administered to prevent the pain of removing the fæces, which 158became impacted in the rectum on account of extensive cancerous disease of the uterus and vagina. The surgeon reports that “the time occupied in the inhalation was about eight or nine minutes; quantity inhaled 10½ drachms, half a drachm at a time, allowing her frequently to breathe the atmospheric air. She spoke to me during this period. When I found that her arm fell after being raised, I proceeded to and accomplished the operation. At this time she was not inhaling. I then, as I always do, wetted the face with a sponge, with the view of washing off any remaining chloroform from the nose and lips, when, to my surprise, I found that she had ceased to breathe, and all attempts to restore her were in vain.... When I commenced the operation, the pupil was contracted, and the conjunctiva slightly red. After death, the pupil was very dilated, and the countenance extremely pallid.”^[91] There was no inspection of the body. This patient had inhaled chloroform on two previous occasions for a similar operation.

Case 25 occurred in St. Bartholomew’s Hospital, on March 17, 1852. Thomas Hayward, aged 23, was suffering from aneurism by anastomosis, occupying the right ear and its neighbourhood. He had inhaled chloroform on the 14th of the previous month, whilst Mr. Lloyd placed ligatures on the temporal artery and some other arteries supplying the tumour; and it was with a view to tie an additional artery, situated between the mastoid process and the ramus of the jaw, that chloroform was again administered.

“The chloroform was some of the same, and the apparatus employed for its administration precisely similar [alluding to the former occasion.] It was administered by one of Mr. Lloyd’s dressers, who well understood, and had great experience in its use. A gentleman of great experience, who 159had been for years at the hospital, and two years house-surgeon, was watching its effects, and marking the state of the pulse. Other gentlemen were assisting, and also on the look out.

“In from five to ten minutes the usual effect was produced, the patient having previously struggled much. The operation was then commenced; but no sooner had Mr. Lloyd cut the skin, than it was stated that the pulse had suddenly ceased. The chloroform was at once removed; but in a few seconds, the patient had ceased to breathe, and no pulsation could be felt at any of the arteries or the heart.

“Artificial respiration, as well as percussion and compression of the different parts of the body, were immediately employed with energy; and, after continuing the means for a short time, the circulation was observed to be returning, and the act of respiration was several times performed. The state of inanimation, however, speedily returned; but, by the employment of the same means as before, with the use also of galvanism, the circulation and respiration were again restored. Quickly, however, the patient fell into the same state as at first, but was again restored by the same means.

“In a few minutes the state of inanimation again returned, when the external jugular vein, which on the right side was very turgid, was opened, and tracheotomy was performed, and the lungs inflated. The patient was also placed in a warm bath, at the temperature of 104°, artificial respiration being kept up all the time. All, however, was of no avail.”^[92]

At the examination of the body, the following are amongst the appearances noted. “The venæ innominatæ and vena cava superior were full of blood, and probably would have been distended, but that two or three ounces of blood had flowed into the coffin from the opening made into 160the external jugular vein. The right auricle and ventricle were distended with blood, and would probably have been more so but for the escape of blood mentioned above. The left auricle and ventricle contained very little blood; the left ventricle was perfectly contracted in the rigor mortis. The heart was of full size. It appeared in every part natural in its texture, and as if it had possessed full power. Its valves also were all healthy; neither could any disease be found in any of the chief bloodvessels within the chest. All the blood, however, was fluid, and it remained without coagulation after its escape from the heart and vessels. It had also a brownish purple hue, much like that which is commonly observed in the spleen: none of it, when thinly spread out, presented the ordinary dark, black, or crimson hue of venous blood. Both lungs were attached by old adhesions about their apices and posterior surfaces, but these were of small extent. Their texture was healthy, but they appeared more than usually collapsed and dry. Their bloodvessels were not over filled.”^[93]

In this case, every precaution seems to have been taken, except that one which is most essential of all, of regulating the proportion of vapour in the inspired air. It had always been made a great point in St. Bartholomew’s Hospital to attend to the pulse very carefully,^[94] and on this occasion it was closely examined, but only, as in some other cases, with the result of being able to note the moment when it suddenly ceased.

With regard to the return of the circulation, which is mentioned in the report as having occurred on three occasions, together with the breathing, during the efforts at resuscitation, I understood from inquiries I made of a gentleman present, that this was judged of from the red 161colour returning to the face and lips, but that the pulse and sounds of the heart were never distinctly perceived after they first ceased. The respiration may cause the colour to return to the face without a true circulation, as I have seen whilst inflating the lungs of still-born children; for if a portion of red blood be mechanically displaced from the lungs by the motion of the chest, it will be propelled by the contractility of the arteries, which continues for some time after death.

Case 26 is related by Dr. Majer, of Ulm.^[95] It occurred on June 27th, 1852. The patient, Madame W., was 32 years of age, and of good constitution. She was in very good spirits, and was only waiting the operation of having a tooth extracted, before going to dinner. It was stated that only twenty or twenty-five drops of chloroform were put on a sponge, which was surrounded by a handkerchief. After four or five inspirations, the operator inquired if his patient did not feel a singing in the ears. She replied with a trembling and thick voice. At the same time she stretched out her limbs, the face became bluish, the eyes haggard, the head and the arms fell—she was dead. The patient’s husband said, that the time between the inhalation and death was so short that one could scarcely have said Yes or No.

An examination of the body was made twenty-five hours after death. Putrefaction had commenced, and the body was not rigid. The vessels of the membranes of the brain were gorged with blood containing many bubbles of air. The heart was soft and flaccid; the coronary vessels were engorged with blood and air; the cavities of the heart contained air, but little blood. The lungs were congested at the inferior parts.

162Case 27 took place at Melbourne, Australia. The name of the patient was Mr. John Atkinson, but his age is not stated. Dr. Thomas, who was about to operate for fistula in ano, said: “Before administering the chloroform, I asked the deceased particularly if he had ever suffered from any serious illness, to which he replied in the negative. I also inquired whether he had been subject to cough or palpitation, and he answered that, some time ago, he had suffered slightly from cough. The pulse was good, and Mr. Barker proceeded in the usual manner to administer the chloroform, which shortly produced convulsive twitchings of the muscles. I then went to the door to request the nurse to send up some person to assist in holding the patient in a proper position for the operation, and I returned to the bed, and poured a little more chloroform on the handkerchief; when it was applied to the face, I heard him splutter at the mouth; the chloroform was instantly discontinued, but the patient suddenly expired. We tried all the means usually resorted to in other cases of suspended animation, but without effect. I had frequently used the same chloroform in other cases. It was not more than a minute after the first application of chloroform that death occurred. About a drachm had been poured on the handkerchief.”

At the examination after death, “there was considerable serous effusion into the pericardium, and the heart itself was larger and more flabby than usual. It was hypertrophied, and there was dilatation of the cavities; the lungs were healthy, and there was a slight appearance of disease about the liver, such as is observed in persons addicted to intemperance.”^[96]

Case 28. On August 10th, 1852, a Mr. Martin, a cattle 163dealer died near Melrose, in Scotland, after inhaling chloroform for the application of potassa fusa to some ulcers of the leg. Dr. W. M. Brown, who relates the case, says:—“Before proceeding to apply the caustic I gave him chloroform. He was not easily affected by it, and struggled a good deal. After beginning to apply the caustic I found he was not sufficiently insensible to pain, and gave him a little more chloroform, which had the desired effect. I then proceeded with the application of the caustic, and was just finishing, when I observed a sort of catch in his breathing. I immediately stopped, and, on looking at him, I saw the mouth and eyes open, the breathing irregular, the face pale, the eyes slightly turned upwards, and the pupils dilated.” Dr. Brown tried artificial respiration and other means to resuscitate the patient, but without effect. He says, “in a few minutes the man died.” The pulse is not mentioned, nor the age of the patient.^[97]

Case 29 took place in the Manchester Royal Infirmary, on December 24th, 1852, during the removal of a malignant tumour of the thigh, by Mr. Jordan. The patient was Henry Hollingsworth, a factory operative. His age is not stated. “The man was very much excited, struggled and talked fast. The chloroform was administered slowly, and every precaution was taken to prevent any danger, and the medical men remarked two or three times how very long it was in taking effect. He at last became insensible, in about seven minutes at least. Mr. Jordan commenced the operation by an incision into the skin covering the tumour. I was assisting the surgeon when Mr. Heath directed my attention to the patient’s face. This was about five minutes after the operation had commenced. I then observed congestion about the face, but there was no stertorous breathing. 164His pupils appeared almost to have ceased to act. His breathing was becoming exceedingly slow, and he seemed to be sinking fast. I directed the attention of the operator and the other medical men to these symptoms. The operation was then suspended, and means were resorted to for restoring animation, but the pupils had ceased to act, and had become fixed almost immediately. He gave one strong gasp, and then to all appearance was dead. In administering the chloroform, successive doses were given until it took effect. Every dose consisted of a drachm, taken, at intervals, in an inhaler.”^[98]

The following remark is made respecting the autopsy. “The post-mortem examination shewed that asphyxia, caused by chloroform, produced the death. There was a congestion both of the brain and lungs.” The appearances met with after death from chloroform do not indicate the way in which death has taken place. In animals that are killed by it, the right cavities of the heart are always found filled with blood, whether they die suddenly by its direct action on the heart, or more slowly by its effects on the brain, and the breathing ceases before the circulation. The lungs are seldom much congested in animals, whichever be the mode of dying, and the appearances in the head are not unusual. The state of the pulse is not mentioned in the above account of the case; but congestion about the face was first observed, and then it was noticed that the breathing was getting slow. It is sufficiently probable that the breathing ceased on account of the action of the heart being first arrested; but even if the respiration was embarrassed by the action of the chloroform on the brain, it is pretty certain that that agent also acted directly on the heart; for it cannot be supposed that the means used for restoring animation would have failed, if the heart had been acting properly when the breathing ceased.

165Case 30 took place on March 19th, 1853, in University College Hospital, London. The subject of it was an unmarried woman, named Caroline Baker, aged twenty-eight. The chloroform was administered with the intention of applying nitric acid to a sloughing ulceration of the labia and vagina. “The chloroform, supposed in the first instance to be about a drachm, was poured on lint about five inches square, and folded four or five times over. After a short time the patient became restless, talked loudly, and threw about her arms. Soon afterwards a partial relaxation of the limbs took place, and she became insensible and pulseless.”^[99]

Further symptoms are not given, but it is stated that she sank and died. The breathing is not mentioned, but Mr. Erichsen, who, although not present at the accident to his patient, would be made aware of all that occurred, stated at the inquest, that death was produced by a paralysis of the heart from the influence of the chloroform. Dr. Quain examined the structure of the heart with the microscope, and he “found that organ, particularly on the right side, in a state of fatty degeneration.”

Case 31 was communicated to the Society of Surgery of Paris by M. De Vallet, Surgeon-in-chief to the Hôtel-Dieu, d’Orléans. “A soldier of the line, aged twenty-five, apparently in good health, and of strong frame, consulted M. Vallet for a small tumour situated behind the right labial commissure. Before operating, he proceeded to direct the inhalation of chloroform. The patient, fasting, being placed in the horizontal posture, the chloroform (about one gramme) was poured upon a hollow sponge, and applied to the nose, the mouth being left free. At the expiration of a minute, no effect having been produced, four grammes 166were poured on the sponge, and at the expiration of four minutes, the patient, without having experienced any irritation of the larynx, without having manifested any resistance, without redness of the countenance, and after only a slight period of agitation, fell into a state of insensibility fit for the operation. Scarcely had the incision been made, necessary to expose the cyst, when the patient became pale, respiration was suspended, and he sank into a state of complete collapse. All the usual remedies were tried, and without avail. M. Vallet opened the trachea, and performed artificial respiration with an elastic tube; then an electric current was sent by needles through the region of the heart. The patient died without any sign of reaction.

“Examination of the body.—The vessels of the brain were empty; the lungs were congested with blood, which in some situations was extravasated; the heart was excessively flaccid; there were some soft clots in the right cavities; the left were empty. The stomach was full of gas; the liver, spleen, and kidneys were gorged with black blood.”^[100]

Case 32 occurred in the Royal Infirmary of Edinburgh to a man aged forty-three, on whom Dr. Dunsmure was about to operate for stricture of the urethra by perineal section. The chloroform was administered by Dr. Struthers. About an ounce of chloroform was used, and the patient had been put under the influence of this agent on two former occasions, when a similar quantity was employed without ill effect. The following is Dr. Dunsmure’s account of the case:—

“While the patient was inhaling the drug, he struggled considerably, and became a good deal congested in the face and head. He seemed to take a slight convulsion, like an epileptic fit, and such as I have seen on several occasions 167in people who have led an intemperate life. During the convulsion, the handkerchief containing the chloroform was removed to some distance from the face. In a short time the inhalation took effect, and he began to snore, and although still violent, the chloroform was removed from the face entirely, and the handkerchief placed under the pillow. As soon as the patient became more quiet, he was pulled down on the table, and placed in the proper position for the operation. I then shaved the perineum, and was just going to make my first incision, when one of the assistants said that his pulse was becoming weak. The posterior tibial, Mr. Spence then remarked, was good, but in a second or two after, both gentlemen exclaimed that the pulse was gone. I rushed from my seat to the patient’s head, and found that his breathing had ceased. Those present who had an opportunity of observing the respiration, which I had not, owing to the stool on which I sat being low, positively assert that the breathing did not cease before the pulse. The face was much congested, the jaws were firmly closed, and the pupils were dilated. I immediately forced open the lower jaw by means of the handle of a staff, and with catch forceps pulled out the tongue. Artificial respiration was had recourse to, and in a few minutes he made a long inspiration. This was soon followed by a second, by a third at a longer interval, by a fourth at a still longer period, and then by a fifth, when all attempts at natural breathing ceased. No pulsation could be felt in the radial arteries. The chest was noticed to be much contracted, to have apparently lost its elasticity, and not to expand when the ribs were forcibly compressed during the artificial respiration. I had previously sent for a galvanic apparatus, which was in the flat below, and it arrived almost immediately after the patient had made the fifth inspiration. When the tongue was pulled out, and before 168the first breath was taken, I was on the point of opening the trachea, but this proceeding was then abandoned; it was now, however, had recourse to, in order to carry on artificial respiration more certainly: the external jugular was also opened, and about a couple of ounces of blood flowed. By the time the tracheotomy tube was inserted, the galvanic apparatus was in working condition, and it was applied on each side of the diaphragm. It acted remarkably well; at each application of the sponges, the muscle descended as if the patient was in life; air passed through the tube in the trachea, and for some time I was in great hopes that the man was to be saved; but the muscle gradually lost its contractility, and although the galvanism was kept up for an hour, it was evident that all our efforts were in vain—that life was extinct. The post-mortem examination was made the following day at one o’clock, rather more than twenty-four hours after the patient’s death, and I give the report of it as drawn up by Dr. Gairdner, the pathologist to the Infirmary:—

“John Mitchell, aged forty-three, died 28th September. A very robust man; height five feet eight inches; diameter (lateral) of base of thorax, ten and a half inches.

“External appearances.—Considerable lividity of face and neck, and more than usual congestion of depending parts. Considerable amount of fat, but more in omentum and around viscera of abdomen than in external parietes.

“Chest.—Right pleura presents a few slight adhesions near the middle; left pleura free. No fluid in either pleural cavity. Pericardium contained about half an ounce of serum, and presented a few opaque patches on its surface. Both sides of heart contained blood, the right side rather more than the left. Blood more than usually fluid. External fat of heart considerable, about three lines on some parts of right ventricle. Muscular tissue of heart 169generally flabby, and rather pale, but not distinctly disorganized to the naked eye. Valves perfectly healthy. Aorta presented very faint traces of atheroma. A few traces of atrophy of right lung towards its apex and anterior edge, but very limited. In all other respects lungs free from disease, but somewhat congested.

“Spleen soft, but not diffluent.

“Liver congested, but otherwise normal.

“Kidneys congested, but otherwise healthy.

“Brain.—The subarachnoid fluid presents considerable milky opacity, and is of moderate quantity. Moderate congestion of the meninges generally. About half an ounce of fluid in the ventricles. Substance of brain healthy. Arteries at base perfectly free from atheroma. Air passages.—Glottis perfectly patent. Mucous membrane of larynx and trachea slightly congested.

“Microscopic examination shewed the fibres of the heart to be nearly normal, though scarcely so distinctly striated as in some cases. The minute vessels of the brain and pia mater presented at some points a few clustering granules, but to no great extent.”^[101]

Dr. Dunsmure expressed the opinion that four or five minutes elapsed from the time the chloroform was left off before the pulse failed. But it is pretty certain that he has much over-estimated the time. Indeed, if the shaving of the perineum were likely to occupy even half of this time, the operator would have done it, or had it done, before the chloroform was administered. Dr. Dunsmure makes the following remark in his comments on the case: “In several instances where I have seen chloroform very nearly prove fatal, the respiration became gradually restored after an inspiration had once been made; in this case, however, no such fortunate occurrence took place.” In the other cases 170to which allusion is here made, the heart has not been paralysed, or at least not completely, but they show that the method of administering chloroform in Edinburgh had been far from satisfactory in its results, although no patient had before that time been actually lost.^[102]

Case 33 occurred in University College Hospital, London, and the following account of it was given by Dr. Hillier:

“E. R., aged 40, a woman of moderate height, rather thin. The general health has been pretty good; she had not been liable to palpitation or dyspnœa. Had been in the habit of drinking pretty freely. Admitted on October 5th, at 11 p.m. She was suffering from the symptoms of strangulated hernia, which had existed two days and a half. Efforts were made to reduce the hernia, both without and with a warm bath, in which she was for upwards of half an hour without getting very faint. These efforts being unsuccessful, an operation was at once determined on. Her pulse was at this time regular, and of tolerable strength.

“Chloroform was administered in the usual way, on a piece of lint, which was held three or four inches from the patient’s face, and then brought to within an inch and a half of her nose and mouth, leaving space around for the admission of air.

“For three or four minutes nothing unusual presented itself; the pulse and respiration proceeded normally. There was put on the lint, at first, one fluid drachm of chloroform; and, at the end of three or four minutes, forty minims more were added. This was the whole quantity of chloroform employed. Within a minute after the second quantity of chloroform was added, the patient struggled violently both with her arms and legs. During these struggles I was 171holding her right hand, and was unable to feel the pulse in consequence of her constant motions. The struggling lasted about a minute, and on its ceasing, the patient commenced to breathe with loud, rough stertor. I at once removed the lint from before the face, and felt for the pulse, which I could not find. Immediately cold water was dashed on her face. She breathed with this stertor for two or three short inspirations, and then two or three long ones, and then the breathing ceased. Immediately artificial respiration was resorted to, and within a minute galvanism was applied to the back of her neck and the diaphragm. Under the influence of these agencies, the patient gasped about three times at intervals; after this, no further signs of life were exhibited.

“At the time when the stertor commenced and the pulse failed, the pupils were dilated, and the face of the patient was only slightly altered. The tongue was not retracted, for one of the bystanders at once put his fingers into her mouth to ascertain this.”

At the autopsy made by Dr. Garrod thirteen hours after death, the rigor mortis was well marked; the blood was very fluid in all parts of the body. There was about an ounce of colourless fluid in the pericardium. The heart was quite collapsed and empty, but, as Dr. Garrod observes, this may have been due to the fluidity of the blood. The weight of the heart was seven ounces and three-quarters; valves healthy. Walls of the right ventricle flabby and pale; mean thickness one eighth of an inch. At some parts the muscular substance was in a very thin layer, being much encroached on by fat. In several places there was scarcely any muscular fibre visible. This was chiefly the case near the apex. Examined by the microscope, much fatty degeneration of the muscular fibres of the right ventricle generally was discovered. The walls of the left ventricle were flabby, dry in appearance, pale, 172and very friable. Both lungs were crepitant throughout, not much engorged. Brain not congested. The intestines above the strangulation were much distended with flatus, and inflamed.^[103]

Case 34 occurred on October 20th, 1853, a few days after the last. The patient was a young woman named Ann Smith, aged 22 years, under the care of Mr. Paget in St. Bartholomew’s Hospital, who was about to apply the actual cautery to a sore of cancroid nature in the vagina. She was a stout, florid young woman, formerly of dissolute habits, but apparently in perfect health, with the exception of the local ailment. She had been put under the full and prolonged influence of chloroform a fortnight previously for the application of the cautery, without the occurrence of any untoward symptoms whatever. The chloroform was administered by Dr. Black, one of the assistant physicians.

“The usual form of inhaler was employed,—a padded metal cup, fitting over the nose and mouth, and supplied with valves. A drachm, by measure, was first poured on the sponge, but as the administration did not immediately commence, a considerable part of this was no doubt wasted; after a short inhalation, a second drachm was supplied, and subsequently the further quantity of half a drachm. The patient had gone through the usual stages of excitement, etc., and the last dose was scarcely used, as she sank off, almost immediately after its application, into a state of complete insensibility, unattended by any alarming symptoms. About five minutes had been occupied by the inhalation, and probably not more than a drachm and a half of the fluid really inhaled. The apparatus was now removed from the face, and the patient having been drawn into the proper position, Mr. Paget was about to commence the 173operation, when Dr. Black, who throughout had kept his finger on the pulse, noticed it to have become extremely weak and fluttering. Almost immediately afterwards, the patient’s countenance was observed to be dusky, turgid, and congested, and the respiratory movements began to be performed at long intervals, and by slight catching efforts. No time was lost; cold water was at once dashed on the thighs, face, and breast; and, the failure of the respiration becoming shortly complete, Mr. Paget immediately began artificial insufflation of the lungs, by alternately blowing into the nostrils, and compressing the chest. Just before commencing this process, Mr. Paget had ascertained, by drawing the tongue forwards and examining the glottis with the finger, that the epiglottis was not pressed down.”

Other means were employed, but no further signs of life appeared. It is further recorded that, “immediately after the first alarming symptoms, the pupils were of the medium size, neither contracted nor dilated. All efforts at respiration ceased about two minutes after the first indications of failure; the pulse, however, as a very feeble flutter, was felt occasionally for at least two minutes later.”^[104]

At the autopsy, performed by Mr. Paget, twenty-two hours after death, “the thorax was first examined, and nothing whatever abnormal could be detected in any of the viscera; the lungs were healthy and crepitant in every part; their posterior lobes were not more congested than is seen in almost every examination; the heart, collapsed, but not contracted, and containing a small quantity of fluid blood in each cavity, was of normal size and proportions, in every respect, and its muscular structure, examined by the microscope, showed no degeneration.... The brain, its sinuses, ventricles, etc., were all carefully examined, and neither in texture nor quantity of blood was anything abnormal detected.”^[105]

174Although the failure of the pulse was the first symptom of danger in this case, it continued to be felt as a very feeble flutter for about four minutes, so that the heart was not so completely paralysed as in most of the fatal cases. It must, however, have been so far paralysed as to be past recovery.

Case 35. Professor Dumreicher related a case of death from chloroform at the meeting of the Vienna Society of Physicians, held on November 16, 1853. The patient was a young man, aged nineteen, in somewhat feeble health, who inhaled chloroform in the recumbent position, in order to have his anchylosed knee-joint forcibly extended. It was inhaled from a vessel resembling a snuff-box, which was held to the nostrils. “The inhalation was continued for fifty seconds, and the patient had spoken a few seconds previously, when Professor D. observed that the pulse had become frequent and undulating. He immediately suspended the administration of the anæsthetic. Trismus occurred; the respirations became irregular; the face turned livid, and he foamed at the mouth.” The measures which were employed included the abstraction of eight ounces of blood from the jugular vein, but they were of no avail. He only once made a feeble attempt at inspiration.^[106]

Case 36 occurred in the practice of Dr. Wüstefeldt of Neustedt. “A young girl, thirteen years of age, had on the dorsal region a voluminous lipoma, which extended from the last dorsal vertebra to the crest of the ilium.... One drachm of chloroform was employed. As soon as insensibility was manifested, the operation was commenced, but scarcely had the surgeon divided the skin, when the girl, yielding to the laws of gravity, fell suddenly forwards 175on her chest. Dr. Wüstefeldt, struck by the phenomenon, which he had witnessed before under similar circumstances, immediately desisted from operating, and strove to restore the patient to life; but every effort was useless, and, in the course of a few minutes, it became evident that she was dead.”^[107]

Further particulars are not given; but as the patient died suddenly, when the surgeon had scarcely divided the skin, it must be admitted that he was, in all probability, correct in attributing the event to the chloroform. The patient usually yields to the laws of gravity when only partially under the influence of chloroform, and it seems surprising that the operation should have been undertaken without placing the patient in the horizontal posture. The proper position of the patient, when a large tumour of the back is to be removed, is to be lying almost flat on the abdomen, the head being a little turned on one side, so that it rests with one ear on the pillow.

Case 37. Jane Morgan, aged fifty-nine, died whilst inhaling chloroform in the Bristol Infirmary, on January 21st, 1854. She was moderately stout, pale, but not otherwise of unhealthy appearance. “The stethoscopic indications were favourable, the beat of the heart was natural, and the air passed freely throughout both lungs; but the chest movements on the right side were not quite so free as on the left.” Chloroform was ordered by Mr. Harrison, the senior surgeon of the Infirmary, with the intention of attempting to reduce a dislocation of the humerus of eight weeks standing. “Having taken no food since her breakfast, she commenced the inhalation of one drachm of chloroform, at 2 P.M., in bed in her ward, under the superintendence 176of Mr. Hore, the house-surgeon. Nothing unusual occurring in the patient’s general condition during inhalation, a second drachm, in about five minutes from the first, was poured upon the sponge, and the inhalation was continued. Almost immediately after the addition of the second drachm, the chloroform was withdrawn, as the patient’s breathing became stertorous; and immediately afterwards her pulse, which had hitherto continued pretty firm, was suddenly imperceptible, the respiration ceasing at the same time. The pupils were not dilated.” Various measures were promptly resorted to with the hope of restoring the patient; but there were no further signs of life, unless “some convulsive efforts of the respiratory muscles,” under the application of galvanism, be so regarded.

At the examination of the body on the following day, the right pleura was found to be adherent. The lungs were healthy in structure, but gorged with dark fluid blood. There was about an ounce of fluid in the pericardium. There was a small quantity of fluid blood in each of the cavities of the heart. For the length of an inch from their commencement, both coronary arteries were much dilated, and studded with atheromatous and bony deposits. The muscular structure of the heart was examined under the microscope by Dr. William Budd, and a considerable proportion of the fibres were found in a state of incipient fatty degeneration. It was learned, after her death, that she had been subject to occasional attacks of fainting.^[108]

Case 38. A death from chloroform occurred in the Hôpital St. Antoine, at Paris, in the spring of 1854. The subject of this was a woman aged forty, on whom M. Richard was operating for the removal of a uterine polypus. The surgeon placed the patient in the horizontal posture, 177and administered the chloroform on a compress of lint. She became insensible in two minutes, having first been excited so that it was necessary to hold her. M. Richard moved the patient to the edge of the bed, gave the compress containing the chloroform into the hands of an assistant, and commenced the operation, which was likely to be of short duration. He had almost completed it, when he was apprised by an assistant, who had been set to feel the pulse, that it had ceased to beat. He sought for it himself, but found that it did not beat. The face was extremely pale; a slow respiration still continued, but soon ceased; and the measures which were used with the hope of restoring the patient were of no avail.^[109]

At the examination of the body all the organs were found in a healthy state. The right cavities of the heart and the great veins contained a considerable quantity of blood, and the left cavities of the heart a small quantity. The blood was everywhere fluid.^[110]

Case 39. A patient, named Mrs. Harrup, died at Sheffield from the effects of chloroform administered with the intention of removing a cancerous tumour of the left breast. The age of the patient was forty-five, and she was stated to be in good health, excepting the local affection.

“The chloroform was administered with more than the usual precautions. After the inhalation had gone on without any effect for twenty minutes, it was thought that possibly different chloroform might succeed, and one ounce was accordingly procured from the public dispensary. After the inhalation had been conducted with the fresh chloroform about twenty minutes, the usual effects of the vapour began to manifest themselves. The pulse, which was 136 before any chloroform had been given, and had 178been very gradually decreasing in frequency while it improved in strength, was now about 104. At this moment muttering—half articulate delirium—came on, but ceased in a few moments, and was immediately followed by conclusive signs of the satisfactory action of the chloroform. Dr. Law now desired Mr. Wright to begin the operation; but before he could do so, Dr. Law, seeing an alarming change in the countenance of the deceased, cried, ‘Stop, Mr. Lewis, how is the pulse?’ I replied, ‘It is gone.’” After stating the means which were used with a view to resuscitate the patient, it is added that the heart had ceased to beat, and that, after a few short and laboured inspirations, life became extinct.

At the examination of the body, the cartilages of the ribs were found to be ossified. The heart and lungs were perfectly healthy, but the lungs were in a congested condition. There was an extravasation of blood in the spinal muscles, and a little blood in the spinal canal, in what part or between what structures is not stated.^[111]

Case 40 occurred in the Lock Hospital, London, in May 1854. Walter Hollis, a tailor, aged eighteen, had been under treatment for sores within the prepuce, and these having healed, he was about to undergo the operation for congenital phymosis. He had been of dissolute habits, and exhibited a pale cachectic appearance.

“The inhaler used was a simple mouth-piece by which the nostrils are left uncovered. About two drachms of the fluid were poured into the instrument. After about six minutes inhalation, insensibility seemed to be coming on, and at this moment the pulse was ascertained to be of good volume. Nothing whatever had occurred to indicate the impending danger, when, after a few more inhalations, 179the pulse suddenly failed, became quite imperceptible, and the countenance assumed a pale and leaden hue. The inhalation was immediately stopped, and attempts to resuscitate, by means of striking the chest sharply with a wet towel, applying ammonia to the nostrils, and by artificial respiration, were at once commenced. These were employed for three or four minutes before any signs of life were perceived; but, subsequently, the pulse was again to be felt, and spontaneous respiration was renewed. Artificial respiration was desisted from on the occurrence of these signs of returning life, and for upwards of ten minutes the chest continued to fill regularly, and the pulse beat at a rate of from 40 to 50 in the minute; the countenance of the patient also much improved, and even assumed a slight flush. After the expiration of, perhaps, a little more than ten minutes, however, these indications of returning vitality again disappeared, the pulse and respiratory efforts simultaneously ceased, and the countenance became deathlike. Artificial respiration and the other means were again adopted, but this time without the slightest success.... Post-mortem examination on the next day shewed great venous congestion within the cranium; the lungs were also somewhat congested. The heart was slightly enlarged, and the ventricular parietes were thinned; in the muscular fibres the microscope detected decided fatty degeneration. The blood was universally fluid.”^[112]

The partial recovery of the patient is a remarkable feature in this case, and it is difficult to explain why he did not recover completely. The number of the pulsations during this partial recovery is mentioned, but not their quality, and I cannot help supposing that the pulse must have been extremely weak, as well as slow, at this period. The ten 180minutes during which the pulse and breathing returned is mentioned with the qualifying term of “perhaps”, which leads to the supposition that it was not noted by the watch or clock, and under such circumstances of anxiety and suspense, the time might be very much over-rated. The slight fatty degeneration of the heart might probably interfere with the complete recovery of the patient, after this organ had once been paralysed by the chloroform.