ON THE INHALATION OF CHLOROFORM, ETC. (continued 4)

Case 41 took place on July 13th, 1854, in the Middlesex Hospital. The patient was a stout, muscular, and florid man, 65 years of age, on whom Mr. De Morgan was about to perform amputation at the upper part of the thigh, on account of a large malignant tumour growing from the inner side of the femur.

“Chloroform was administered by Mr. Sibley, the registrar to the hospital. Snow’s inhaler was employed. The quantity at first placed in the inhaler was rather less than two drachms, and another drachm was added eight minutes afterwards. The patient inhaled the chloroform without difficulty, and went through the usual stages; at the end of about ten minutes violent spasm was induced; this continued about three minutes, and then somewhat abated. The pulse, which had risen to about 120, descended to 70, having a full, steady, and deliberate beat. The pupils, which had been much dilated, became less so. The respiration continued free and deep, but not stertorous. The colour of the face remained good.

“At this moment, which was between thirteen and fourteen minutes from the commencement of the inhalation of the chloroform, the pulse gave a few rapid and irregular beats, and then ceased. Respiration, which, as has been stated, had been going on freely, ceased simultaneously. The face became suddenly pallid and deathlike. The inhaler 181was removed instantaneously, and cold water dashed on the face. Mr. Sibley immediately commenced to carry on artificial respiration, by applying his mouth to that of the patient, and inflating the lungs. The period that elapsed between the sudden cessation of the pulse and the inflation of the lungs was only a few seconds. After a few inflations, there appeared to be a slight effort at inspiration, but this was the only sign of life discovered after the syncopal attack. Galvanism was in operation within two minutes after the cessation of the pulse.”

“An examination of the body was made by Dr. Corfe forty-eight hours after death. In the head nothing particular was discovered; the brain was firm, and rather more vascular than natural; the blood in the sinus was partly coagulated; the heart was rather larger than natural, and was extremely loaded with fat, especially on the right side, where fat formed three-fourths of the thickness of the wall of the ventricle; the muscular tissue was extremely pale and soft, and exhibited both to the naked eye, and the eye assisted by the microscope, an extreme degree of fatty degeneration; the blood in the cavities of the heart was firmly coagulated; on both sides it was almost purely fibrinous; the clot on the right side was larger than on the left; a fibrinous clot extended down the aorta.”^[113]

I do not know how the bibulous paper was arranged in the inhaler in this instance, nor whether the inhaler was used with a view to regulating the amount of vapour in the inspired air. The proportion of vapour must have been small during the first ten minutes, as the patient became so slowly insensible; and judging from the result, we must conclude that the proportion was large just before the accident. The firm coagulation of the blood and separation of the fibrin were probably owing to the galvanism which 182was so promptly applied. I found the fibrin separated from the colouring matter of the blood in the cavities of the heart of a cat, in which shocks of electro-magnetism had been sent through the chest just after it had been killed with chloroform.

Case 42. A man died whilst inhaling chloroform in University College Hospital on October 11th, 1854. The patient was a shoemaker named George Sands, aged 39, and of rather bloated aspect. He inhaled chloroform whilst Mr. Erichsen was endeavouring to introduce a catheter, and had the intention of puncturing the bladder if not successful. The patient was made insensible, and the chloroform was left off, but was reapplied on account of the patient making some expression of pain. “Probably about two minutes of the second inhalation had elapsed, when the man became profoundly insensible, and began to snore with a peculiar and very profound stertor. His face at this time was suffused and flushed, and the inspirations were drawn at rather prolonged intervals. Mr. Erichsen’s attention was at once excited by these symptoms, and, desisting from the use of the catheter, he immediately commenced dashing the patient’s face and chest with water. The chloroform had, of course, been removed. In the course of about a minute, the noise with the breathing gradually lessened, and it became apparent that the respiration was ceasing altogether. Mr. Erichsen now put his finger into the patient’s pharynx, and dragged forwards the root of the tongue; at the same time attempting artificial inflation of the lungs, by applying his own mouth to that of the man. The latter plan did not appear to succeed well, and was almost immediately substituted by the more usual mode of artificial respiration, by compression of the chest, which was kept up most vigorously. The man’s pulse had been felt by the administrator 183[Mr. Carnell] to be still beating some little time after the commencement of the alarming symptoms and the cessation of respiration. Artificial respiration had been employed for about four minutes, when the man, whose countenance had meanwhile retained its colour and an expression of yet remaining life, began to breathe again. A very short intermission of artificial assistance having been made, he drew spontaneously three or four inspirations; but, as each successive one was more feeble, the artificial aid was at once recommenced. About five minutes from the commencement, the galvanic apparatus was got in readiness and applied. It produced, however, no benefit; and from this time the patient lost colour in the face, and was evidently dead.... The form of inhaler which had been employed was the one in ordinary use at this hospital, viz. a folded piece of lint. The administrator’s hands and the patient’s face had been covered during the inhalation by a towel.”^[114]

At the examination of the body seventy hours after death, extensive fatty degeneration of the heart was met with. The cavities of the heart were empty, owing, no doubt, to the artificial respiration.^[115]

The above case differs to a certain extent from those previously quoted, inasmuch as the first symptoms of danger were those of profound coma, and of threatened death by apnœa, as a consequence of the action of the chloroform on the medulla oblongata and nerves of respiration. In addition to this cause of danger, however, the chloroform present in the lungs at the moment when the inhalation was discontinued must have acted directly on the heart, or the prompt assistance of so able an authority on asphyxia as Mr. Erichsen, the moment the breathing was suspended, would surely have restored the patient. 184The mode of death, although not exactly the same as that in Experiment 24 (page 110), differs from that in the previous experiment, where the heart’s action was good and distinct after the breathing ceased; it resembles the mode of dying in many animals that I have killed with chloroform; being, in fact, a combination of death by apnœa and cardiac syncope, which generally occurs when the quantity of vapour in the respired air is intermediate between that in Experiments 23 and 24, or somewhere between 5 and 10 per cent.

A great peculiarity in the way in which chloroform was administered in the case we are considering was that the head and face of the patient were covered by a towel, under which the lint wetted with chloroform was held. The countenance and state of respiration could not be observed in this mode of giving the chloroform; the person administering it had to depend almost entirely on the pulse; and, except for this cause, there is every reason to conclude that the chloroform would have been withdrawn in this instance in time to save the patient. It was not apparently till a peculiar and very loud stertor attracted the attention of the operating surgeon himself, that the inhalation was discontinued, and the face was already suffused.

This plan of administering chloroform with the head and shoulders of the patient covered with a towel, was introduced by Mr. Clover, who was for several years a resident officer of the institution; and it is but right to state that it led to no accident in his hands; in those of his successors it was, however, less successful; three accidents having occurred in a little more than a year and a half. I much regret to find that Mr. Erichsen recommends this method of giving chloroform in the edition of his work on surgery recently published.

185Case 43 occurred in Guy’s Hospital, on December 5th, 1854. The patient was a woman whose leg Mr. Birkett was about to amputate on account of malignant ulceration. She gave her age as fifty-six, but appeared ten years older. “In each eye was a fairly marked arcus senilis, but the woman was not known to have suffered any symptoms referable to thoracic disease.... The administration of the anæsthetic was conducted by Mr. Bryant, the inhaler used consisting of a fold of lint, rather larger than an out-spread hand, and protected on its back by a piece of oiled silk to prevent wasteful evaporation.... In the first instance, about a drachm of the fluid was poured upon the lint. The patient inhaled it kindly; and, after about two minutes, another drachm was added. A stage of excitement now followed, during which the limbs required to be held. Insensibility was just fully established, and Mr. Birkett was on the point of commencing the operation, when Mr. Callaway, who was compressing the femoral artery, exclaimed that the pulse had suddenly ceased entirely. The wrist was examined, and the same found to be the case. Almost immediately afterwards, a long-drawn inspiration, attended with a deep sighing noise, was observed. For two or three breaths the cheeks puffed out during expiration; the respiration next fluttered, and then ceased. Mr. Birkett at once put his finger into the patient’s mouth, and drew forward the tongue, artificial respiration being meanwhile commenced by assistants by means of compression of the chest. A few slight inspirations were attempted by the patient subsequent to the commencement of the artificial assistance; but they did not continue, and no sign of vitality was ever afterwards shown.... It must be noted, that the woman had been very pale both before and throughout the exhibition, and that no change in her appearance was perceived when the alarming symptoms occurred, excepting that the superficial veins of 186the neck and temple became distended with blood. The cessation of the pulse was most sudden. Mr. Callaway stated that it was not preceded by the least premonitory fluttering, the stroke having been good one beat, and entirely wanting the next. This order of symptoms was of course suggestive of death beginning at the heart (cardiac syncope), the cessation of the functions of the nervous system having been markedly subsequent to that of the circulation....

“Autopsy, twenty-four hours after death (conducted by Dr. Wilks). The corpse was much emaciated, and the rigor mortis imperfect. The lungs were much congested with fluid blood, which ran out after incision of their substance. The heart was of normal size, but soft and flabby; its left side was nearly empty, the right being distended with fluid blood. The left ventricle was of good thickness; its muscle of a deep colour, not encroached on by fat, or in the least mottled, the only observable departure from a healthy state being its flabbiness. The right ventricular wall was very thin, the subserous fat having in some parts almost taken the place of the muscular tissue. The layer of the latter, however, although much thinned, had still a good colour, and did not appear to the naked eye as degenerated, an observation which may apply also to the carneæ columnæ. The liver was in an early stage of cirrhosis, and the kidneys were both of them mottled, and contained numerous small cysts in the external part. The brain was rather paler than usual, its convolutions appeared shrunken and atrophied, and there was a quantity of serous fluid in the arachnoid sac and in the ventricles. There was general atheromatous disease of the arterial system, both in the head and other parts of the body. The blood was universally fluid, and of a dark colour.”^[116]

187As far as could be estimated, the time occupied by inhalation was about three minutes in this case.

Case 44 occurred at the Royal Ophthalmic Hospital, on April 10th, 1855, in a man on whom Mr. Bowman was about to perform excision of the left eyeball. The patient, named John Cannon, was forty years old, and was moderately stout, florid, and healthy-looking. He had generally led a temperate life. The disorganisation of the eye was the result of injury.

“The inhaler used was the one devised and recommended by Dr. Snow.... The administration was entrusted to Dr. Playne, of King’s College Hospital. In the commencement of the inhalation, the valve of the mouth-piece was so turned as to admit an abundant supply of air, a point to which Mr. Bowman directed personal attention. During the first four minutes (more or less) nothing unusual occurred. Dr. Playne, who had his finger on the pulse, had noticed that it had rather increased in fulness, and was of good volume. Rather suddenly, however, just as the anæsthetic appeared to be producing its effect, symptoms of excitement occurred. The eyes became fixed and staring, the arms outstretched and rigid, and the face contorted. It was now impracticable to feel the pulse, on account of the tossing about of the arms; but, as is usual in such conditions, the respiration was noticed to be all but, if not quite, suspended by the spasmodic fixture of the chest. The inhaler was at once removed, and the face and chest of the patient dashed with cold water. Almost immediately after, as the respirations had become extremely feeble and sighing, Mr. Bowman commenced practising artificial breathing, by the application of his own mouth to that of the patient. By this means, the chest was made to fill very completely, and the process was kept up almost without intermission for from five to 188eight minutes. During the first three or four minutes after the alarm began, the patient continued at times to make slight sighing efforts at voluntary inspiration, and the case was not thought, by those looking on, to be by any means hopeless. At length, however, these finally ceased, and from that time it was apparent that the man was dead.... At the first opportunity which occurred for examining it after the spasmodic struggling had commenced, the pulse was found to be extinct, and it remained so ever after, although there were, as stated, feeble efforts at inspiration. The patient’s countenance changed somewhat during the treatment, but was mostly suffused and congested.”

At the examination of the body forty-eight hours after death, “the sinuses, and the veins of the brain generally, were much congested, and there was some œdema of the brain substance. The heart, excepting some slight deposits on the curtains of the mitral valve, was healthy. Its muscular substance was easily lacerable. The right ventricle contained a considerable quantity of fluid blood, the left was nearly empty. There were some pleuritic adhesions, and the lungs generally were congested, being also in some parts full of air. The blood in every organ examined was fluid, and without trace of coagulation.”^[117]

It does not seem that the inhaler used in this case was employed with the object for which it was contrived—that of regulating the amount of vapour in the inspired air; and I do not know whether the bibulous paper was arranged properly in the interior.

Case 45. On September 8th, 1855, a lady, aged twenty-nine, the wife of a physician, died suddenly whilst inhaling chloroform for the relief of facial neuralgia. I was sent for 189when the accident happened, and arrived twenty minutes afterwards. I found the deceased lady without any sign of life. The face and lips were very pallid. The husband was performing artificial respiration by mouth to mouth inflation of the lungs, and alternate pressure on the chest, and I assisted him in this for a long time, though with no hope that any thing could be of service. Dr. Barker, of Grosvenor Street, arrived soon after me, and assisted in the same measures. An inhaler was employed in this case consisting of a face-piece, like the one above delineated in this work, and a bent metal tube lined with bibulous paper. Two quantities of ten minims each had been inhaled, with some relief to the pain, and without causing unconsciousness when the inhaler and the chloroform were put away in a closet; but the patient begged to have more chloroform, in order to be completely relieved of the pain, as she had been on a previous day. Ten minims more chloroform, as I was informed, were put into the inhaler, and the patient, being seated on a sofa, began to inhale very eagerly, but had no sooner commenced than she gave a sudden start, as if taken in some kind of fit. Her husband laid her on the floor, but she evinced no further signs of life.

There was no inspection of the body.

The only explanation which the case admits of is that, in her eagerness to get relief, the patient took one or more inspirations of air very highly charged with vapour. The symptoms were those of death by cardiac syncope.

Case 46 occurred in the practice of Dr. Roberts, a surgeon dentist of Edinburgh. The patient was a lady, thirty-six years of age, to whom Dr. Roberts had administered chloroform on four previous occasions within a twelve-month. Dr. Roberts says the chloroform was administered in the usual way, by which he means on a handkerchief. 190He says: “Mrs. H. had only taken about nine or ten inspirations, obtaining but a partial influence of a quantity short of ʒiss poured out from the bottle, and inhaling it for a space of time certainly less than a minute, when she said, ‘You must not operate until I am quite insensible;’ and again, ‘I am not over yet;’ and immediately, even while speaking, she gave a convulsive start, and with a stertorous inspiration, and with the eyes and mouth open, sunk to the floor.” Dr. Simpson was sent for, and arrived within five minutes. Artificial respiration was resorted to, and after it had been applied for a time, there were a few spontaneous inspirations, and the pulse, it is said, could be perceived at the wrist; but these symptoms of reviving animation disappeared.

At the examination of the body, the right cavities of the heart were found gorged with blood. The walls of the right ventricle were thinner than natural, and affected to a certain extent with fatty degeneration.^[118]

A paragraph was inserted in some of the Edinburgh newspapers, and forwarded by Dr. Roberts to the Lancet,^[119] in which it was implied that death in this case was not caused by the chloroform. It is, however, like the preceding case, a well marked instance of the sudden and fatal action of this agent.

Case 47. A sailor, aged thirty, died whilst inhaling chloroform in St. Thomas’ Hospital, in October 1856, preparatory to having some necrosed bone removed from one of his fingers. “He did not appear to be in robust health; still there was no obvious reason against his having the chloroform, which was accordingly administered as follows. One drachm was poured on a sponge folded between two thicknesses of lint, and this held at a little distance from 191his mouth, while he was sitting in a chair. He appeared to be going off very comfortably, when the chloroform was left off for from half a minute to a minute, and then resumed. He now began to raise his hands and tremble, and kept spitting in the lint, and appeared as if about to vomit. Suddenly he was violently convulsed through his whole frame, as if in an epileptic fit. The chloroform was at once discontinued, and he was laid in a semi-horizontal posture. The convulsion only lasted for a few seconds, and when it had ceased he began to breathe with effort and puffing of the lips, and almost immediately to gasp irregularly. His pulse was almost imperceptible and intermittent. Artificial respiration was at once performed by alternate compression and relaxation of the walls of the chest, the tongue being held out of the mouth by the forceps. Ammonia was applied to the nostrils, and cold water dashed in the face, and in about a minute he rallied so as to breathe without assistance, but in a few seconds he relapsed, and could not be recovered.

“At the post-mortem examination there was found to be fatty degeneration of the heart, liver, and spleen, and the membranes of the brain were thickened. The lining of the ventricles presented a peculiar pitted appearance, apparently from inflammatory deposit. The brain itself was pale.”^[120]

“It was ascertained after the man’s death that he had been of intemperate habits, and had had an attack of delirium tremens three weeks previously. In the report of this case in the Association Medical Journal, the following is the account of the appearances met with after death. In the autopsy in the present case, which we observed with particular care, the brain was in a state of œdema and bloodlessness, very like the brain in a patient who died from chloroform in the Ophthalmic Hospital. The liver was 192fatty; but the heart seemed the very model or type of the healthiest kind of heart. All the other organs were also healthy.”^[121]

Case 48 is related by Mr. Paget as follows. “I am anxious to place before the profession, at the earliest opportunity, a narrative of a case in which chloroform proved fatal in my private practice.

“The patient was a boy, nine years old, of delicate constitution, and of nervous, timid disposition; but with no indication of any organic disease, except that for which the operation was to be performed: namely, a tumour of the scapula; for which it was proposed to remove the greater part of that bone.

“At half-past eight A.M., on February 28th, after the patient had passed a night of sound sleep, the chloroform was first administered in a room adjoining that in which the operation was to be performed. He was alarmed at the thought of being put to sleep, and of what would then be done, and was very averse from taking chloroform, but he was persuaded to inhale it; and, though not without resistance, yet with less than is commonly made by patients of the same age, he was brought under its full influence in about three minutes. He sat in bed during the first few inspirations, and after these, was recumbent. It was observed that two or three deep inhalations were quickly followed by complete insensibility; and the next few inspirations were stertorous. He was at once carried, in the horizontal posture, into the room, and laid on the table, arranged for the operation.

“Three or four minutes passed while we were arranging his position and his dress, and while I was pointing out to those who were to assist me the proposed plan of operation. 193During this time the influence of the chloroform so far passed off, that he became sensible, displaced his coverings and pillows, said something expressive of discomfort, and vomited a small quantity of frothy fluid. (He had taken no food since the previous night, when he had had a good supper.) A very small quantity more of chloroform was slowly inhaled, and he became again nearly quiet, and was again placed on his side. I was on the point of commencing the operation, but as he again, by movements, indicated some degree of sensibility, and changed his posture, about forty drops more of chloroform were poured on cotton wool, inclosed in a fold of lint,—an inhaler, with the chloroform on sponge, having been previously used. The lint was held, about half an inch from the face, by Mr. Thomas Smith, my usual assistant in operations. The patient inhaled lightly for a few times, then made one long inspiration, and appeared to pass at once into deep sleep. Except that he thus appeared to come suddenly under the full influence of chloroform, no external change was visible; but, a few seconds later, his pulse, which had been carefully watched, and had been to this time normal, suddenly began to beat very quickly; then it ceased for two or three seconds; then beat rapidly several times, with a kind of flickering movement; and then ceased to be perceptible.

“Just before this change of the pulse was observed, the chloroform had been withdrawn. The one deep inspiration was followed by a few stertorous breathings, but after these he breathed naturally, his complexion and features showed no change, he seemed only calmly asleep, and in this state he continued breathing naturally, and with no change in his appearance, but pulseless, for at least a minute. Then his breathing became less frequent, and seemed as if it might soon cease; his face grew pale, and his lips very slightly livid.

“With the help of cold water sprinkled on his chest and 194face, and cold air blown on his face and throat, he was raised from this state of defective breathing in about two minutes, and again breathed deeply and freely, though slowly, (probably about twelve times in the minute.) He thus breathed for two or three minutes, and during this time the lips, and the pale or slightly livid parts of the face, became pink again, and though no pulse could be felt at the wrists, the heart was heard acting. During this time, also, some wine and brandy were poured into the mouth, and passed down the œsophagus, but without any evident movements of swallowing. His breathing again became gradually infrequent and feeble. Cold air and sprinkling with water, frictions and percussions of the chest, scarcely increased the breathing, and in less than two minutes it ceased. Artificial respiration, by the method of Dr. Marshall Hall, was immediately employed, and many times during the first five minutes of its employment the artificial inspiration obtained, when turning the body over to its side, was followed by a distinct, and sometimes even a full muscular inspiration. But at the end of about five minutes, these signs of life ceased, fæces escaped, and no more indications of life appeared, though the artificial breathing, the friction of the limbs, and other means for resuscitation, were continued for twenty or more minutes.

“I refrain, at present, from all comments on this case. Only, I wish to call particular attention to the fact that good breathing was maintained, and, after a suspension, was renewed, long after the heart had ceased to act with sufficient force to produce a pulse at the wrist. And I would add, that this narration is sanctioned and considered to be exact, by the four gentlemen who were to have assisted in the operation, and to whom I am greatly indebted for their counsel and assistance in the greater difficulty that we had to cope with.”^[122]

195Case 49. This case occurred in the Liverpool Infirmary on April 5, 1857, and is related by Mr. Allan, the resident officer who administered the chloroform. The subject of the case was a labourer, aged 35, on whom Mr. Bickersteth was about to perform amputation of the thigh on account of gangrene following the ligature of the femoral artery. He had inhaled the chloroform six days previously without ill effects, when the femoral artery was tied for popliteal aneurism. On the day of the accident, he was first rendered insensible in the ward by chloroform poured on a piece of lint which was held a short distance from the nose and mouth. Having partially recovered during his removal into the operating theatre, the chloroform was reapplied, and Mr. Allan relates what occurred as follows: “About half a drachm of chloroform was now poured on some lint, which was held to the nostrils, and he then became fully under the influence; respirations good; pulse frequent, feeble. The operation was about to be commenced, and I was pouring about twenty minims more chloroform on the lint, (having pronounced the patient to be in a fit state,) so as to be ready to give him some more as occasion required, but had not applied it, when, turning round, I noticed something peculiar in his general appearance, and, on lifting up the eyelid, found the pupil dilated, and the lid did not close over on the removal of the finger; the eyes were slightly turned up. I at once felt for the temporal artery, but there was no pulsation, and none detected at the left wrist; the respirations had almost ceased. The head was lowered, cold water was dashed on the face, and the abdomen struck with the palm of the hand; the finger thrust into the mouth (there was no action of the heart felt); the legs were elevated, and a wet towel was dabbed over the epigastrium. After one or two blows, the respirations became better, and seemed good, and in about two minutes a pulse was 196felt at the wrist. This continued between two and three minutes, the respiration being good. His pulse then began to fail, and in about a minute more the respirations were less. The tongue was seized with a pair of forceps, and drawn forwards, and artificial respiration tried, and ammonia held to the nostrils; but he was becoming livid in the face, so the Ready Method was at once adopted, and this produced apparently a few natural respirations. But the pulse had gone, and in about two minutes more there was no breathing save artificial. About the time that the pulse stopped, there was a convulsive movement of the muscles of the leg, and a slight clamminess of the skin succeeded. The Ready Method was continued for half an hour, and galvanism tried, but without avail. From the time he was placed on the table to his death, or the cessation of natural respiration, about ten minutes elapsed.”

The writer adds: “He apparently sank from syncope, or cessation of the heart’s action, for his respiration had been good just before he changed, and it continued for a second or two, though faint, when the pulse had stopped; and after the respiration had been restored, and was very good, the pulse was very feeble, and ceased two minutes before the respiration.”

At the autopsy on the following day, the brain was found to be healthy, tolerably firm, and pale; the lungs were healthy; the right cavities of the heart contained some fluid blood, which afterwards coagulated on exposure, and a small clot. The left cavities also contained some blood. The muscular tissue of the heart had an unhealthy look, and very readily tore, but no oil globules were discovered with the aid of the microscope.^[123]

Case 50 occurred in King’s College Hospital, August 7th, 1971857. The following is the account of the case furnished by Mr. C. Heath, the House-surgeon:—

“The patient [Ann Stoner] was a female, aged seventeen, under Mr. Partridge’s care, with syphilitic warts and mucous tubercles. She was admitted July 8th, and had had chloroform administered twice, in order that the sores might be touched with nitric acid, and, on both occasions, not the slightest ill effect was produced. On Friday evening last, chloroform was again administered for the same purpose; only a drachm was put into the inhaler (Snow’s), and as soon as she became unconscious the inhaler was removed, and the acid applied. I and my assistant (who administered the chloroform), then went to see another patient in the same ward, and then washed our hands, during which time the patient was moving her legs about much as they do when recovering, and in addition she made water over the bed. I gave directions to the nurse to apply a poultice as usual, and left the ward, having been up to the bed first without noticing anything unusual about the patient. In a few minutes the nurse came down for some medicine for another patient, and mentioned that this one was looking very pale: I sent up Mr. Liddon to see her at once; he found her pale and senseless, dashed some water over her, and called me, and I went up immediately. I found her pulseless and cold, and immediately commenced artificial respiration (Marshall Hall), and sent for the galvanic battery; this was brought and applied without effect, and the artificial respiration was continued for twenty-five minutes without the slightest effect being produced.”^[124]

I was present at the examination of the body on the following day. The mouth was sore and swollen from the effects of the inunction of mercury. There were a few drachms of clear serum in the pericardium. The heart was 198large for the size of the patient. There was a patch of organised lymph on the pericardium, covering the left ventricle. The right cavities of the heart were full of dark fluid blood, and the left cavities contained a little. The mitral valve was much thickened, but the other valves were healthy. The lungs were healthy, and not much congested. The brain was healthy. The patient had suffered from acute rheumatism before entering the hospital.

It will be observed that the pulse is not mentioned in the above case, until its absence is alluded to, when the patient was already cold, and the breathing is not alluded to throughout the account; indeed, it is not known when the patient died. She was alive after the application of the nitric acid, as she was observed to move her legs, but further than this there is no clear evidence.

It is perhaps an open question whether this patient died at once from the direct effects of the chloroform, or whether she died after partially recovering and going on favourably for a time. The account would, at first view, seem to favour the latter opinion, but it is not corroborated by any other case. Patients have been partially recovered from the effects of an overdose, without being entirely restored, and others have sunk after great operations, attended with hæmorrhage, when the effects of the chloroform had more or less subsided, but there is no instance of a patient going on favourably, and partially recovering from the influence of the vapour, and then dying suddenly without any other known cause. Patients have occasionally become faint whilst recovering from chloroform, more especially if they remain in the sitting posture, but in those cases the right side of the heart is probably insufficiently supplied with blood; whilst, in the case under consideration, the patient was lying, and the right cavities of the heart were found full after death, the serum in the pericardium showing that 199they had probably been distended when death took place. If Mr. Heath had made any observation which enabled him to say that the patient was really alive, when he went up to the foot of the bed, before leaving the ward, it would decide the question, and show that death did not take place at once from the direct effects of the chloroform, but he only makes the negative remark that he did not notice anything unusual about the patient.

I had an opportunity of examining the particular inhaler employed, and found that it was so arranged that the vapour might be breathed from it in much greater proportion than would be safe, if precautions were not taken to leave the expiratory valve a considerable way open, especially when the high temperature of the weather at the time is taken into account.

The foregoing cases comprise all the instances I have seen recorded in which death appears to have been occasioned by the administration of chloroform, and not by other causes in operation about the same time. A few additional cases have indeed been referred to by different authors where death was probably caused by chloroform, but as I do not find that the details have been published, I cannot make them available in an inquiry respecting the cause and prevention of these accidents.

In June 1852, Dr. Simpson alluded in the following terms to an accident from chloroform which had occurred near Glasgow:—“In this instance, chloroform was given by the practitioner for tooth extraction; but, I am sorry to add, none of the parties present were at the time in a condition to give any satisfactory evidence.”^[125]

A person, named Breton, a dealer in porcelain, died in Paris, in the early part of 1853, immediately after a few 200inspirations of chloroform, which was administered with the intention of removing a tumour of the cheek. An action was brought against Dr. Triquet and M. Masson for causing death by imprudence in this case; and at the trial which ensued, various interesting opinions were given, and the accused practitioners were ultimately exonerated.^[126] I have not, however, met with any record of the symptoms which occurred in the case.

In relating the case of death from chloroform, which occurred in his practice, to the Medical and Chirurgical Society of Edinburgh, Dr. Roberts referred to another death from chloroform in tooth-drawing which took place in the neighbourhood from which his own patient came, just previously to October 1855; but I have not met with any account of the case so alluded to. Dr. Mackenzie of Kelso also alluded in the same Society, in the following year, to a death from chloroform which had occurred at Coldstream, and I do not know whether this was the case to which Dr. Roberts had alluded, or a fresh one.

One of the surgeons to the hospital at St. Louis, who was lately visiting the medical institutions of London, informed me that there had been three deaths from chloroform at his hospital out of between six and seven hundred operations in which it had been administered. I did not learn the particulars of those fatal cases.

There have been several cases in which persons have been found dead after inhaling chloroform when no one else was present, either for toothache or some other affection, but I have not included such cases in the above list, as they throw no light on the way in which death is occasioned. The simple way to avoid such accidents as those just alluded to, is for persons to abstain from inhaling chloroform, when no one is by to watch its effects.

201

ALLEGED FATAL CASES OF INHALATION OF CHLOROFORM.

Several deaths have been attributed to chloroform which were due to other causes, or where the cause of death is a subject of great doubt. A gentleman, named Walter Badger, twenty-two years of age, the son of one of the coroners for the county of York, died instantly at Mr. Robinson’s, the dentist’s, in Gower Street, on June 30th, 1848, whilst commencing to inhale chloroform with the intention of having some teeth extracted. The inhaler employed consisted of a face-piece to enclose the mouth and nostrils, and containing a sponge on which the chloroform (ʒiss) was placed. This, according to the evidence of Mr. Robinson and his female servant, who was present in the room, was held not nearer than an inch and a half from the face for less than a minute, and the patient made the remark that the chloroform was not strong enough; Mr. Robinson requested him, as he had done before, to have the operation performed without chloroform, but he again declined; and Mr. Robinson then took away the face-piece and asked his servant to reach the bottle, intending to put more chloroform on the sponge, to replace that which he believed had been lost by evaporation. Just after removing the face-piece, and before any fresh chloroform was poured out, the head and hand of the patient dropped, and he did not show any further sign of life.

I found, on making trial of the kind of inhaler which Mr. Robinson employed, that it is impossible to inhale enough of the vapour to produce any appreciable effect, unless it is applied so as to touch the face. At the distance of an inch no effect is produced, even in five or ten minutes; and therefore I expressed my opinion, soon after this accident, that it was not caused by the chloroform, which properly speaking the patient did not inhale.

202A consideration of the symptoms in this case confirms the view that the death was not caused by chloroform. In six of the fatal cases related above, death took place instantaneously, without insensibility or any of the usual effects of chloroform having been produced; but the mode of dying was not the same as in Mr. Robinson’s patient. In Case 4, that of Madlle. Stock, the patient said “I choke”, and tried to push away the handkerchief; then there was embarrassed breathing and foaming at the mouth. In Case 11, that of Madame Labrune, the fatal attack followed immediately on a full inspiration of chloroform, and there was an immediate alteration of the features, and a convulsive rolling of the eyes, amongst other symptoms. In Case 14, the young lady stretched herself out, and frothed at the mouth, at the moment of the fatal attack, and the face became livid. In Case 26, that of Madame W., who died at Ulm, the voice, when answering the question about singing in her ears, was trembling and thick; she stretched out her limbs, and the face became bluish. In Case 45, that of the wife of a medical man, and in 46, that of Dr. Roberts’s patient in Edinburgh, there was a convulsive start at the moment of the sudden death. It thus appears that when the heart is suddenly paralysed by an overdose of chloroform, before the patient is rendered insensible, there are usually some symptoms as if of a violent shock or injury. After complete insensibility is induced, the heart may be suddenly paralysed by chloroform, as is shown by numerous cases, without this spasmodic action; and it would perhaps be premature to deny that a patient might die thus quietly without being first made insensible; and the nature of the death in this particular case must be chiefly decided by the physical fact that the patient could not have inhaled enough chloroform to produce an appreciable effect of any kind, much less to cause sudden death.

203At the inspection of the body, the liver was found so much enlarged that it weighed eight pounds, and it encroached very much on the chest. The walls of the left ventricle of the heart were found thinner than natural, and the muscular tissue was interspersed with fatty degeneration. There was blood in the right auricle and in both ventricles. In the ventricles it was partly coagulated. The brain presented nothing abnormal.^[127]

It is probable that the immediate cause of death in this instance was fear. The patient had been told in the country that it would be unsafe for him to take chloroform, and yet he could not summon resolution to undergo the operation without it. Mr. Robinson unfortunately allowed his patient to remain seated in the operating chair; and it was only when Dr. Waters had been sent for and arrived from a neighbouring street that he was laid on the floor.

I was present on one occasion with Mr. Peter Marshall at the examination of the body of a woman who died suddenly of fright in consequence of a fire in the next house to that in which she lived, and it is worthy of remark that we found exactly the same diseased conditions as those which were found in Mr. Robinson’s patient; viz., great enlargement of the liver, displacing the viscera of the chest, and fatty degeneration of the heart.

A young man, aged twenty-four, died suddenly of syncope, on June 25th, 1848, at the Hospital Beaujon, at Paris, whilst M. Robert was performing amputation at the hip joint, the thigh bone having been broken into splinters by a bullet during the conflict in the streets of Paris. The patient was in a state of great depression, both physical and moral, before the operation; and it is most likely that he sank under the combined effects of the injury and the operation.

204Another patient had the neck of the humerus broken by a ball in the same conflict; he was much reduced by hæmorrhage and gangrene of the wound; M. Malgaigne performed disarticulation at the shoulder joint; a fresh inhalation took place to enable him to search for the ball, and the patient sank and died during the last incisions. This patient also most probably died from the effects of the operation added to those of the previous injury and loss of blood.

A woman died in Paris, 1848, after removal of the breast. The operation was finished, and the chloroform had been left off some time, and the patient had become conscious, when on raising her into a sitting posture, in order to apply a bandage, she suddenly expired. Although the chloroform was blamed in this instance, death evidently took place by the ordinary kind of syncope, which arises from the heart not being supplied with blood, and which may be called anæmic syncope, in contradistinction to cardiac syncope, which begins at the heart itself, when properly supplied, or even when distended with blood.

A child, aged twelve years, died in the hospital at Madrid in 1849, during amputation of the leg after violent tetanic rigidity.^[128] Death was attributed to the chloroform which had been inhaled, but no further particulars are given, and it is not stated whether or not there was any unusual hæmorrhage, or other cause, which would explain the fatal event.

Dr. Aschendorf has attributed the death of a child a year old to chloroform.^[129] The child had a nævus on the face and neck, which extended from the zygoma to the os hyoides, and from the external auditory meatus to the 205maxillary fossa. No one had been willing to undertake its removal. Dr. Aschendorf operated on the nævus at three different times, by means of seton threads. These operations were performed under the influence of chloroform. The tumour was reduced one-third part in size by these means, and eleven weeks afterwards Dr. Aschendorf determined to extirpate it. The chloroform was administered as on the former occasions, by placing six drops on some tow in a cup. In about ten minutes, as the child cried a little, three drops more of chloroform were used for inhalation, and in about eight minutes more the operation was concluded. “On raising the child it laid its head on one side, convulsive twitches of the face were observed, with distortion of the eyeballs and dilatation of the pupils. For one moment the arms were stretched out stiff, then again they were relaxed, and fell as supple as the rest of the body. Death quickly followed—only one pulsation of the heart and a single râle with the expiration being perceived.”

There can be no doubt of this being a case of death from hæmorrhage, after the direct effects of the chloroform had subsided. Dr. Aschendorf says the quantity of blood lost was about two tablespoonfuls; but it would be necessarily removed by sponges during the operation, and there would be no means of estimating the quantity. The child was probably in a state of syncope during the latter part of the operation, as it would not remain insensible to the knife for eight minutes from a single application of chloroform.

On September 15th, 1852, a patient died to whom I was administering chloroform whilst Mr. Cæsar Hawkins was performing lithotrity. He was a gentleman from the country, aged seventy-three; he was tall and stout, he had a weak intermitting pulse, and a well marked arcus senilis in each cornea. He had inhaled chloroform five or six 206times, between May 1850 and May 1851, for the same operation, when under the treatment of another surgeon, and it always acted favourably. In the first week of December 1851, Mr. Hawkins performed the operation of lithotrity twice, when the chloroform was administered by Mr. Geo. D. Pollock. On the second of these occasions he became faint during the operation whilst under the influence of the chloroform, but recovered from the faintness before its conclusion. He again fell into a very alarming state of syncope a few minutes after the conclusion of the operation, but rallied, and vomited the breakfast which he had taken a little time before. I first administered the chloroform to this patient on December 15th, 1851, eleven days after the above occurrence. Mr. Hawkins and I were inclined to think that the alarming syncope on the previous occasion might have been connected with the sickness which occurred. It was my firm belief that the patient had fatty disease of the heart; but I did not see any great objection to the chloroform on that account, as I had frequently given it in similar cases, and always with a favourable result. On this occasion (December 15th) he inhaled the chloroform before breakfast. Its effects were quite satisfactory, and it was not accompanied or followed by any unpleasant symptoms whatever. The operation was repeated four days afterwards, when I again exhibited the chloroform with like favourable results. After this the patient went back to the country relieved from his stone. He came back, however, in the autumn of 1852, with a return of his complaint, and I was again requested by Mr. Hawkins to assist him by giving the chloroform on September 15th.

The patient became insensible, without any excitement or struggling, in the course of three or four minutes, and the operation was commenced. A little more chloroform was 207administered two or three times during the operation, in order to keep up the insensibility. After a few minutes had elapsed, I observed that the face and lips of the patient became pale. At this time he had not inhaled any chloroform for about two minutes. Immediately afterwards, however, his face became red, and he made straining efforts with the muscles of respiration, as if he were beginning to feel the operation. To prevent his becoming altogether sensible, therefore, I commenced to give him a little more chloroform, with the valve of the inhaler about one-third open, as on the former occasions. He had only taken two or three inspirations, however, when the breathing ceased. He appeared to be merely holding his breath, as sometimes happens during the exhibition of chloroform, and I expected that he would begin to breathe again in about a quarter of a minute. In the meantime, I endeavoured to feel the pulse in the temporal artery, but did not perceive any. Instead of the breathing recommencing at the time I expected, the countenance became suddenly pale, and a little afterwards rather livid. I applied my ear over the region of the heart, but could not hear any sound. After a few seconds, however, the patient took a rather deep inspiration, and immediately after this I was pretty sure that I heard the heart beating very feebly and rather frequently, but only for a few seconds, after which no sound could be heard. There were one or two more very feeble inspirations at intervals of about a quarter of a minute, after which there were no further signs of life. As soon as the patient had entirely ceased to breathe, artificial respiration was performed, but no sign of returning animation appeared.

At the examination of the body fifty-two hours after death, the heart was found to be larger than natural, and there was a good deal of fat on its surface. Its right cavities contained air or gas, probably resulting from the 208partial decomposition of the blood. The right ventricle was dilated, and its walls were very thin. At one place, near the apex, they were extremely thin. The left ventricle was also dilated, but its walls were of the proper thickness. They were, however, like those of the other ventricle, very soft and friable. There was a calcareous incrustation on one of the aortic valves. There was scarcely any blood in the heart, but its lining membrane was stained in places, showing that blood had been present after death.

Mr. Pollock and the late Mr. W. F. Barlow examined the structure of the heart under the microscope, and the latter gentleman furnished me with the following account of the examination:—

“Many of the fibres have been converted into fat completely; in others, fatty degeneration was beginning. The degeneration, which was in various stages, appeared very general. The fasciculi were broken up, here and there, into masses of small irregular fragments, as they may be found frequently in hearts of this kind. Some large fat globules lay between and upon the fibres. A few fibres showed their transverse striæ plainly, and made the changes in the others look the clearer. On the whole, it may be said that the structure of the organ was greatly damaged, and that its action, consequently, was liable to cease suddenly from slight causes.”

I am of opinion that this patient did not die from the direct effects of the chloroform. The air he was breathing just before he died did not contain more than three or four per cent. of vapour of chloroform at the utmost, and he had previously breathed quite as much, both during the same operation and on previous occasions. The patient seemed to be holding his breath at the moment when his heart ceased to beat; and it is whilst holding the breath, and making a straining effort, that patients labouring 209under disease of the heart not unfrequently expire. Mr. Pollock, who was present when the patient died, expressed to me his belief that he died of his heart disease, and not of the chloroform.

After reflecting on this case, I see no reason to regret the course which was pursued. It was the opinion of Mr. Hawkins that the patient could not have borne the operations without the chloroform; consequently, if we had decided not to permit its use any more, in consequence of the alarming syncope which occurred after the operation under its influence on December 4th, 1851, he would probably have died in great suffering from the calculus, instead of having seven or eight months freedom from the complaint. And, on the other hand, if it had been decided to operate without chloroform, it by no means follows that the patient would have been in less danger, judging from what I have observed of the effect of pain on the circulation, as compared with the effect of the chloroform carefully administered, in numerous other cases of disease of the heart.

On May 11th, 1854, a patient died suddenly in St. George’s Hospital as she was beginning to inhale chloroform. She was a pale and delicate looking woman, aged thirty-seven, from whose left breast Mr. Cæsar Hawkins was about to remove a mammary glandular tumour. “On entering the operating theatre she appeared nervous. Having been placed on the table on her back, in a half reclining position, the administration of chloroform was commenced. Dr. Snow’s inhaler was used. The quantity of chloroform placed in the receiver was a little more than a drachm; and the valve for the admission of air was left wide open. Apparently, from excitement, she did not inhale well, but drew her breath by deep catches, and irregularly. Mr. Potter, noticing this, spoke to her, begging her 210to compose herself, and try to breathe more quietly. The valve was then slightly turned on, in order that she might inhale but a very small quantity of chloroform. The same spasmodic efforts at inspiration still continued; very shortly afterwards, at most not more than a minute and a half from the commencement of the inhalation, Mr. Potter noticed her breathing to suddenly cease, and that she had become deathly pale. The inhaler was at once removed. On placing the finger on the wrist, no pulse could be found. Endeavours to arouse her by dashing the face and chest with water were immediately adopted; but, proving ineffectual, artificial respiration was commenced within a minute of the first symptoms. During the interval, two sighing attempts at inspiration had been observed; but there had been no pulse whatever; the mouth lay a little open, and the countenance was still extremely pale.”^[130] Other attempts at resuscitation were made without effect.

“At the post-mortem examination, on the following day, no very noticeable lesions of the viscera were discovered. There was congestion of the whole venous system, and the blood, in every organ, was of a deep purple colour, and quite fluid. The brain substance itself was perhaps a little more vascular than usual, and the veins of its meninges were loaded with blood. The heart was small and fat, the right ventricle being especially loaded with adipose material, and its muscular layer much thinned. Under the microscope there was found to be slight, yet decided, fatty degeneration of the muscular structure. Both chambers, but more particularly the right, were distended with blood in which no coagula could be found. The posterior lobes of the lungs were somewhat congested, but not more than the position in which the corpse had lain might account for. There was no disease of the abdominal viscera.”^[131]

211I made a chemical examination of some blood obtained from the heart and large vessels, and also of portions of the lungs and liver, but I failed to detect any trace of chloroform, although the process I employed is one by which I have very easily detected it in the bodies of small animals killed by it, and also in portions of limbs and tumours removed whilst the patients were under its influence to the usual extent.

It was impossible that this patient could have breathed air strongly charged with vapour. Every one in the operating theatre was a witness that the expiratory valve of the face-piece was not, at any time, more than one-third closed, being two-thirds open. In this way no great effect of any kind can be produced, as very little of the air which the patient breathes passes through the inhaler. Mr. Potter informed me, moreover, that the patient breathed very little even of air, her breathing was so much embarrassed by her frightened condition. He was trying to calm her apprehensions at the moment when she died.

The mental emotion under which the patient was labouring was, no doubt, the cause of the sudden death in this instance, as in that above referred to, which occurred at Mr. Robinson’s. The mode of dying, in the present instance, was evidently by cardiac syncope; the same mode of death, in fact, as that which is occasioned by vapour of chloroform, when not sufficiently diluted; and it is only the absolute knowledge, that any small quantity of vapour which this patient inhaled was very largely diluted with air, that enables one to decide, with confidence, that the chloroform was not the cause of death. It may be observed, however, that there was an absence of the convulsive start or spasm which occurred in all those deaths from chloroform, which took place at the beginning of the inhalation, without loss of consciousness having been first induced.

212The right cavities of the heart were found full of blood in this case, and it is probable that they became so much distended, as the patient was in a state of alarm, and scarcely breathing, that, in the thin and diseased state of the walls of the right ventricle, the action of the heart was arrested. Sudden death not unfrequently takes place during mental emotion, and, in many of the cases, the mode of dying is probably that just mentioned.

SYMPTOMS IN THE FATAL CASES OF INHALATION OF CHLOROFORM.

Out of the fifty cases of death from chloroform, related above, there are five in which the symptoms at the time of death are not detailed, viz., Cases 6, 7, 21, 24, and 50; in the two first cases it is merely related that the patient suddenly expired, and, in the two last cases, no one was watching the patient at the time when death took place. In considering the remaining cases they may be conveniently divided into groups, according to the period of the inhalation at which the accident occurred. In six of the cases the fatal symptoms came on suddenly, at the beginning of the inhalation, before the patient had been rendered unconscious; in each of these cases there was the most unequivocal evidence of the sudden arrest of the action of the heart. In cases No. 4 and No. 11 there was sudden pallor of the face at the moment when the circulation ceased. In Nos. 14 and 26 the face became livid at the time of the fatal attack, and, in Nos. 45 and 46, the colour of the face is not mentioned. In all these cases there were also symptoms as if of a sudden shock to the system, such as stretching out of the limbs, foaming at the mouth, rolling of the eyes, or a sudden convulsive start. In Case 4, the patient at Boulogne had just complained of a choking feeling, one sign that the vapour she was breathing was not 213well diluted. In Case 11 the fatal symptoms occurred immediately on a full inspiration; and in the other cases also the strength of the vapour was left to accident, and the result leads to the conclusion that it was very great at the moment before the fatal symptoms occurred.

In thirteen cases the inhalation was discontinued on account of the sudden appearance of dangerous symptoms, after consciousness had been apparently suspended. These cases are numbered 9, 15, 17, 20, 27, 30, 33, 35, 37, 40, 41, 44, and 47. In the greater number of these cases the over-action of the chloroform appeared to be exerted simply on the heart, the only dangerous symptoms being referrible to the paralysis of that organ; whilst in some of these cases symptoms of over-narcotism of the brain were conjoined with those connected with the heart. In the case of J. Verrier, No. 9, and in the case at Stockholm, No. 15, the sudden and entire cessation of the pulse was the symptom which first called attention to the danger of the patients, whilst the breathing was still going on. In Case 30 the woman became suddenly insensible and pulseless, after a short period of excitement. In Cases 35 and 40, although the pulse did not absolutely and entirely cease at once, its sudden failure was the first alarming symptom. In Case 20, at the Cavan Infirmary, the breathing and action of the heart ceased at the same moment. In Case 41, at the Middlesex Hospital, at a time when the pulse was full and steady, seventy in the minute, it gave a few rapid and irregular beats, and then ceased, and the breathing, which was free and deep, but not stertorous, ceased at the same time. In Case 15, which occurred at Jamaica, the patient, after a period of excitement, made one stertorous inspiration, when the breathing ceased. There were afterwards a few distant inspirations. The pulse is not mentioned; but it is pretty certain that it must have ceased about the time of 214the stertorous inspiration, or the additional inspirations which took place after the chloroform was withdrawn, would probably have restored the patient; to say nothing of the measures that were resorted to with a view to his resuscitation. Of Case 27, which happened at Melbourne, it is merely related that the patient spluttered at the mouth, and suddenly expired, just after a fresh portion of chloroform had been applied on the handkerchief. The symptom of spluttering at the mouth is recorded as occurring in other cases, just at the moment when the pulse had suddenly ceased.

In Case 44, at the Royal Ophthalmic Hospital, the narcotism of the brain and nervous system proceeded as far as the third degree, which was attended with strong muscular spasms, as not infrequently happens; and an overdose of chloroform appears at this moment to have acted on the heart, for the pulse could not afterwards be felt. In Cases 33, 37, and 47, the narcotism of the brain proceeded as far as the fourth degree, producing stertorous breathing, when the chloroform caused paralysis of the heart, by its direct action on that organ.

There are six cases in which the fatal symptoms came on just after the patient had been rendered insensible, and the inhalation had been discontinued; the operation being about to be commenced. They are numbered 32, 34, 39, 43, 48, and 49. All these cases bear a very close resemblance to each other. In all of them the patient had been made insensible (satisfactorily so as it was thought), when in a few seconds the pulse suddenly stopped, or failed and fluttered just prior to stopping; in Case 32 Dr. Dunsmure thought the time was longer between the discontinuance of inhalation and the cessation of the pulse. The breathing continued a little time after the pulse ceased or failed in all these cases, and there was an absence of the spluttering at 215the mouth, stretching of the limbs, and other spasmodic actions, which occurred in all the six cases where the heart was paralysed at the beginning of the inhalation, before unconsciousness had been induced, and in some of those when the paralysis of the heart took place at a later period of the inhalation, when the patient had been apparently rendered unconscious, but was not yet insensible. In each of the six cases now under consideration, the fatal event was evidently occasioned by the vapour of chloroform, which remained in the lungs at the moment when the inhalation was discontinued. A portion of this vapour becoming absorbed, and added to that already in the blood, had the effect of paralysing the heart, when it circulated through the coronary arteries.

There remain twenty-two cases in which the fatal symptoms came on during the course of the operation. In twenty of these cases the symptoms are described with more or less detail. I made some remarks respecting cases No. 1 and No. 2, in the place where they are related. In case No. 3, as in these cases, the patient appeared not quite insensible, and showed signs of pain during the operation, when “in a moment his pulse, which was full and natural, sank.” In case No. 5 the patient was probably dead when the incisions on the finger were commenced; the extreme suddenness of the death, and the absence of bleeding, show that death occurred in the way of syncope. The convulsive movements which just preceded death are worthy of note in connection with the other cases, in which death occurred immediately after the commencement of inhalation. Some remarks were appended to case No. 8. In case No. 10 paralysis of the heart is indicated by the absence of bleeding from the arteries, and the absence of pulse, whilst the breathing still continued for a short time. I made some remarks respecting case No. 12 when it was related. The 216patient seemed to die by embarrassed respiration, but whether that was caused by the action of the chloroform on the brain is doubtful. In case No. 13 the patient died in a moment. In No. 16 the face turned pale, and the pulse and breathing ceased soon after the chloroform was discontinued, showing the effect of the vapour which was present in the lungs at the moment when the inhalation was left off.

In Case 18 the livid countenance and sudden stopping of the pulse prove cardiac syncope. In Case 19 the blood which was gushing out suddenly stopped, and the patient expired. The congested state of the lungs and the blood in the right cavities of the heart prove that the syncope of which he expired was not the ordinary anæmic syncope from hæmorrhage; it was therefore cardiac syncope from the chloroform.

In Case 22 the change of countenance and sudden character of the death are evidences of cardiac syncope. In Case 23 there was sudden cessation of the bleeding and of the pulse; in Case 25 the pulse suddenly ceased. In Case 28 the patient died suddenly, but the pulse was apparently not examined at the time. Some remarks have already been made on Case 29, which happened in the Manchester Infirmary. In Cases 31, 36, and 38 the suddenness of the death showed that it took place by syncope. In the last of these cases the pulse was being examined at the time it ceased. In Case 36 there was no examination of the dead body; but in 31 and 38 the presence of blood in the right cavities of the heart indicates that the kind of syncope was cardiac syncope. Respecting Case 42, some remarks have already been made. The death commenced by deep coma, which embarrassed, and then suspended, the respiration, and cardiac syncope quickly followed. The chloroform was administered by a method which precluded the medical attendant from observing properly the most important symptoms.

217The accompanying table of the fatal cases of the inhalation of chloroform contains such short particulars respecting them as seemed capable of being tabulated, and it may assist the reader in retaining a more connected recollection of the facts previously related more in detail.

MODE OF DEATH IN THE ACCIDENTS FROM CHLOROFORM.

In all the cases in which the symptoms which occurred at the time of death are reported, there is every reason to conclude, as shown above, that death took place by cardiac syncope, or arrest of the action of the heart. In forty of these cases the symptoms of danger appeared to arise entirely from cardiac syncope, and were not complicated by the over-action of the chloroform on the brain. It was only in four cases that the breathing appeared to be embarrassed and arrested by the effect of the chloroform on the brain and medulla oblongata, at the time when the action of the heart was arrested by it; and only in one of these cases (No. 42) that the breathing was distinctly arrested by the effect of the chloroform, a few seconds before that agent also arrested the action of the heart.

It was previously shown that chloroform vapour has the effect of suddenly arresting the action of the heart when it is mixed with the respired air to the extent of eight or ten per cent., or upwards; and we must therefore conclude that, in the fatal cases of its inhalation, the air the patients were breathing just before the accidents occurred contained this amount of vapour. There was no means adopted, so far as is reported, to regulate the proportion of vapour in the inspired air, in any case in which an accident happened; and there was the liability in every case that ten per cent. or more of vapour might be present in the air the patient breathed; and in no case did death occur in the manner that it occurs when the vapour of chloroform does not exceed five per cent. of the inspired air.

218

TABLE OF FATAL CASES OF INHALATION OF CHLOROFORM.

No. Patient. Age in yrs. Operation for which the chloroform was inhaled. Position whilst inhaling. Means by which the chloroform was exhibited. Time from the commencement of inhalation to the beginning of dangerous symptoms. Apparent mode of death. Previous inhalations.

1 Girl 15 Removal of toe-nail. Sitting Towel Half a minute Cardiac syncope Ether once.

2 Married lady 35 Extraction of teeth. Sitting Inhaler About two minutes Cardiac syncope None.

3 Patrick Coyle Operation for fistula in ano Lying on the side Handkerchief About one minute Cardiac syncope One.

4 Single lady 30 Opening of sinus in thigh Lying Handkerchief Probably half a minute Cardiac syncope None.

5 Young woman Amputation of the middle finger Handkerchief A very short time Cardiac syncope None stated.

6 Young man 22 Transcurrent cauterisation of wrist Inhaler Five minutes Symptoms not described None stated.

7 Young man Intended removal of toe-nail. Probably handkerchief Not stated Death very sudden None stated.

8 Seaman 31 Removal of hæmorrhoids Lying on the side Napkin About ten minutes Cardiac syncope One.

9 Miner 17 Intended amputation of middle finger Lying Handkerchief About five minutes Cardiac syncope None.

10 Labourer 36 Amputation of toe Handkerchief Died at the close of the operation Cardiac syncope A previous attempt.

21911 Married lady 33 Intended extraction of tooth Sitting Handkerchief A very short time Cardiac syncope One.

12 Porter 48 Removal of toe-nail Lying Inhaler A little more than two minutes Probably asphyxia None.

13 Married woman Removal of eyeball Probably lying A sponge Died during the operation Cardiac syncope None stated.

14 Young lady 20 Intended extraction of tooth Sitting A sponge enclosed in a napkin Just after beginning to inhale Cardiac syncope Previous attempts.

15 A man A sponge Died before the operation Probably cardiac syncope None.

16 Artilleryman 24 Amputation of middle finger Handkerchief Cardiac syncope None.

17 Bookkeeper 30 Intended operation on testicle Lying Napkin Within five minutes Cardiac syncope None.

18 Boy 8 Sounding the bladder Lying Piece of lint A few minutes Cardiac syncope None.

19 Policeman 34 Removal of portion of hand Napkin Died during operation Cardiac syncope None.

20 Man 24 Intended amputation of leg Lying Folded lint in a hollow sponge A few minutes Cardiac syncope None.

21 Man Intended operation on the penis Lying “Suddenly expired” None stated.

22 Married lady 36 Extraction of teeth Sitting Handkerchief Less than a minute Cardiac syncope None.

23 Mulatto seaman 45 Removal of testicle. Lying Napkin About seven minutes Cardiac syncope None.

24 Married woman 37 Removal of impacted fæces Lying Handkerchief Eight or nine minutes Symptoms not observed Two.

25 Man 23 Ligature of vessels near vascular tumour Lying Inhaler Five to ten minutes Cardiac syncope One.

22026 Married lady 32 Intended extraction of tooth Sitting Sponge surrounded by handkerchief Four or five inspirations Cardiac syncope None stated.

27 Man Intended operation for fistula in ano Lying Handkerchief Not more than a minute Cardiac syncope None.

28 Cattle dealer Applic. of potassa fusa to ulcers of leg Handkerchief Died during operation Probably cardiac syncope None.

29 Factory operative Removal of malignant tumour of thigh. Lying Inhaler About twelve minutes Probably cardiac syncope None.

30 Single woman 28 Intended application of nitric acid to ulcers of pudenda Lying Folded lint Cardiac syncope None.

31 Soldier 25 Removal of small tumour from cheek Lying Hollow sponge Five minutes Cardiac syncope None.

32 Tobacconist 43 Intended perineal section Lying Handkerchief A few minutes Cardiac syncope Two.

33 Woman 40 Intended operation for strangulated hernia Lying Folded lint About five minutes Simultaneous deep coma and cardiac syncope None.

34 Single woman 22 Intended application of actual cautery to sore of vagina Lying Inhaler About five minutes Cardiac syncope One.

35 Young man 19 Intended forcible extension of knee Lying Inhaler Fifty seconds Cardiac syncope None.

36 Girl 13 Removal of tumour from back Apparently sitting Cardiac syncope None stated.

37 Married woman 59 Intended reductionof old dislocation of humerus Lying Hollow sponge About five minutes Deep coma and cardiac syncope None.

22138 Woman 40 Removal of uterine polypus Lying Folded lint A few minutes Cardiac syncope None stated.

39 Married woman 45 Intended removal of breast Lying Sponge, handkerchief, and inhaler Three-quarters of an hour. Cardiac syncope None.

40 Tailor 18 Intended operation for phymosis Lying Inhaler About seven minutes Cardiac syncope None.

41 Labouring man 65 Intended amputation of thigh Lying Inhaler Between 13 and 14 minutes Cardiac syncope None.

42 Shoemaker 39 Catheterism Lying Folded lint A few minutes Deep coma, apnœa, and cardiac syncope None.

43 Woman 56 Intended amputation of leg Lying Folded lint & piece of oiled silk About three minutes Cardiac syncope None.

44 Man 40 Intended excision of eyeball Lying Inhaler About five minutes Cardiac syncope None.

45 Married lady 29 Inhaled to relieve neuralgia Sitting Inhaler A few seconds Cardiac syncope Two or three.

46 Married lady 36 Intended extraction of teeth Sitting Handkerchief A few seconds Cardiac syncope Four.

47 Sailor 30 Intended removal of necrosed bone from finger Sitting Sponge and folded lint Three or four minutes Deep coma and cardiac syncope None.

48 Boy 9 Intended removal of tumour of scapula Lying Cotton wool & folded lint A few minutes Cardiac syncope None.

49 Labourer 35 Intended amputation of thigh Lying Folded lint A few minutes Cardiac syncope One.

50 Young woman 17 Application of nitric acid to syphilitic sores Lying Inhaler Symptoms not observed Two.

222There is in a great number of the cases an evident connection between the accident and the probable strength of the mixture of vapour and air. In six cases the accident occurred just after the commencement of the inhalation; in two of the cases, Nos. 27 and 37, the fatal symptoms occurred just after fresh chloroform had been applied on the handkerchief and sponge; and in several cases, in which the circulation was suddenly arrested just after the patient had been rendered insensible, the insensibility had been induced so quickly as to prove that the vapour must have been inhaled in a very insufficient state of dilution.

THE TWO KINDS OF SYNCOPE.

Dr. Patrick Black has made an objection to the fact of the patients having died of paralysis, or over-narcotism of the heart, in the accidents from chloroform.^[132] He says that paralysis of the heart would be death by syncope, but that the symptoms before death, and the conditions of the organs met with afterwards, are not in accordance with such a view of the case. In order to show that both the symptoms and the after death appearances, in the fatal cases of inhalation of chloroform, are consistent with paralysis of the heart, it is necessary to point out the difference between ordinary syncope and cardiac syncope. One of the best examples of ordinary, or what may be called anæmic syncope, is that which occurs in a common blood-letting, whilst the patient is in the sitting posture. When the bloodvessels, especially the veins, which at all times contain the greater part of the blood in the body, do not accommodate themselves fast enough to the diminished quantity of blood, the right cavities of the heart are supplied with less and less of the circulating fluid; and in a 223little time are not supplied at all, when the heart ceases to beat, in accordance with the observation of Haller, that it does not pulsate when it is not supplied with blood. The moment the heart ceases to supply blood to the brain there are loss of consciousness and stoppage of respiration; but on the patient being placed in the horizontal position the blood flows readily into the right cavities of the heart from the great veins of the abdomen and lower extremities; the heart immediately recommences its contractions; the brain is again supplied with blood, and respiration and consciousness return.^[133]

The blood may remain in the ordinary quantity; but if the bloodvessels do not keep up their usual support, and exert a sufficient pressure on their contents, the same kind of syncope will occur as that from blood-letting. The late Sir George Lefevre related the case of a lady who fainted whenever she left her bed, and assumed the upright posture; no cause could be found for this until it was ascertained that she suffered from varicose veins of the legs: bandages to these extremities prevented the fainting. It is obvious that in this case the mechanism of the syncope was the same as that in blood-letting; the distension of the varicose veins under the weight of the superincumbent blood had the same effect in preventing the supply to the right cavities of the heart, as if the blood had been entirely removed. The faintness which often occurs on first rising, when a person has long kept the recumbent posture from 224any local cause, is probably of the same kind; the veins not having had to support the weight of the usual column of blood for some days or weeks, lose their tone we may presume, and yield when they are all at once subjected to the weight of a column of blood extending from the lower extremities to the heart, so that this organ ceases to be properly supplied with the circulating fluid.

In cardiac syncope, on the other hand, the cavities of the heart, or at all events the right cavities of this organ, are always full, whether the syncope depend on paralysis of the heart by a narcotic, or inherent weakness of its structure, or on its being overpowered by the quantity of blood with which it is distended. After death from this kind of syncope, if the blood have not been displaced by artificial respiration or other causes, the right cavities of the heart and the adjoining great veins will be found filled with blood, and the lungs will in many cases be more or less congested. The appearances in short will be very much the same as in asphyxia by privation of air, which ends in a kind of cardiac syncope, the stoppage of the heart being partly due to over-distension of its right cavities, and partly to loss of power in its structure, from the want of a supply of oxygenated blood through the coronary arteries. In death by anæmic syncope, on the contrary, all the cavities of the heart are found empty, or nearly so, and the same is frequently the case with the adjoining great veins, whilst the lungs are usually pale.

The syncope occasioned by some kinds of mental emotion is of the ordinary or anæmic kind, and consequently the condition of the brain must act first on the bloodvessels, and not directly on the heart. Certain persons are liable to faint on witnessing a surgical operation. Now if the mental emotion of these persons acted directly on the heart, whilst the rest of the vascular system was unaffected, the distribution 225of the blood would be nearly the same as in asphyxia, where the circulation is first impeded in the lungs, and is ultimately arrested by loss of power in the heart. If the action of the heart were weakened, or stopped, in the first instance, by the kind of emotion under consideration, the arteries would be emptied by their contractility and elasticity, and the blood would accumulate in the right cavities of the heart and the great veins leading to them. In a medical student fresh from the country, who is by no means deficient in blood, the jugulars would become distended and the face livid, and the recumbent posture would probably do but little towards removing the symptoms. The phenomena which are witnessed, however, indicate a very different condition of the vascular system. The person about to faint from the cause indicated, frequently becomes pale before he feels anything wrong; and when requested to retire and sit down, often says that there is nothing the matter with him. In a short time he faints, and falls, if no one catches hold of him; but the moment he is in the recumbent posture he recovers. In such a case as this, the effect of the mental emotion must be first exerted on the veins, or the veins and capillaries, through the nerves which supply these vessels; they allow themselves to become distended, and the heart ceases to act for want of its supply of blood, as in syncope from blood-letting, and anæmic syncope from any cause.

Several authors have attributed the empty state of the heart met with after death, in certain cases of fatal syncope, to want of power in the left ventricle to supply the right cavities of the heart; but this is to argue as if the blood passed out of the body after leaving the right ventricle, and the left ventricle had to supply a newly formed fluid. The effects of want of power in the left ventricle are the same as those of an obstruction at the origin of the aorta; the lungs become congested, and the right cavities of the heart more 226or less distended, from the blood not being able to pass readily through the lungs. Patients who die of heart disease die with the cavities of that organ full. Some patients, indeed, with fatty disease of the heart, die suddenly of anæmic syncope, and the heart is found empty; but in these cases it is evident that death is not occasioned by the disease of the heart, but by some condition of the bloodvessels which accompanies it.

Chevalier was, I believe, the first to draw marked attention to cases of sudden death arising from an empty state of the heart, in a paper in the first volume of the Transactions of the Royal Medical and Chirurgical Society; and he rightly attributed the emptiness of the heart to a loss of power in the bloodvessels. His words are as follow:—

“The disease I have now described may, perhaps, be termed asphyxia idiopathica. The essential circumstances of it evidently denote a sudden loss of power in the vessels, and chiefly in the minuter ones, to propel the blood they have received from the heart. In consequence of which, this organ, after having contracted so as to empty itself, and then dilated again, continues relaxed for want of the return of its accustomed stimulus, and dies in that dilated state.”

The word asphyxia has become so closely connected by physiologists with death by privation of air, where the symptoms and appearances are the reverse of those in Chevalier’s case, that it is necessary to discard his name of the disease which he describes, although it is etymologically correct. His cases come under the definition of what is now universally called syncope, and what I have called anæmic to distinguish it from cardiac syncope.

Chevalier speaks of a want of power in the vessels to propel the blood, and as it is not now believed that the vessels take any active share in the propulsion of the blood, this may be the reason why the views of this author have received less attention than they deserve; but it is very obvious 227that a want of tone in the vessels, or any great diminution of that power which enables them to support and compress the blood, is an adequate cause why the blood should be unable to reach the right side of the heart. In the case of varicose veins, previously mentioned, it was physically apparent that the cause of the syncope lay in the vessels. Disease of the arteries is well known to be usually associated with degeneration of the heart; the veins are also large and distensible in old people, who furnish the greater number of those who are liable to anæmic syncope; but the pathology of the veins, as regards both their functions and structure, is not yet sufficiently known.

Persons with disease of the heart, who die suddenly in a fit of anger, probably die always with the heart distended; that is, of cardiac syncope. Dr. Joseph Ridge, however, in his able and interesting remarks on the disease and death of John Hunter,^[134] states his belief that that celebrated man, who had been long subject to attacks of angina pectoris, died at last of syncope, with an empty heart. He died, as is well known, during a fit of anger, and the coronary arteries were found ossified. It is not said that the heart was empty, but that it was small, and that there were no coagula in any of its cavities. It is probable that there was not much blood in its cavities, at the time of the post mortem examination, but the body of Hunter was conveyed in a sedan-chair, from St. George’s Hospital to Leicester Square, a little more than an hour after his death, so that the fluid blood would gravitate downwards. It is related that the stomach and intestines were unusually loaded with blood, and that those parts which were in a depending position, as in the bottom of the pelvis and upon the loins, were congested in a greater degree than the others; and that “this evidently arose from the fluid state of the blood.”

228In syncope from muscular exertion, the cavities of the heart are distended, and its walls have occasionally been ruptured, both from violent exercise and fits of anger.

Fear probably occasions each kind of syncope in different cases. In some cases, the right cavities of the heart become distended owing to impeded respiration, and possibly to a diminution of power in the heart itself. More frequently, the syncope appears to be of the ordinary or anæmic kind, the effect of the mental condition acting first on the more distant parts of the circulation. The pallor caused by fright is proverbial.

Pain is also capable of causing both kinds of syncope. I have alluded to cases (page 55) in which the patients strained and held their breath till the pulse became intermittent, and the action of the heart was temporarily suspended by the arrested breathing; on the other hand, patients often become pale, if they are undergoing any slight operation when seated, and syncope of the anæmic kind occurs, without any previous disturbance of the respiration, but passes off as soon as they are placed in the horizontal posture. I have seen an apparently strong man faint in this manner, during the removal of a tumour from the back not larger than a nut, and where only a few drops of blood were lost. Chloroform was not employed.

SUPPOSED CAUSES OF DEATH FROM CHLOROFORM.

Many writers have supposed that the deaths from chloroform have arisen from some peculiarity in the patient; and when any notable change of structure has been met with after death in any of the vital organs, this has been thought to afford a sufficient explanation of the event; whilst in the cases in which the organs were in a healthy state, surprise has been expressed at the occurrence. In looking over the account of the cases in which the inhalation of chloroform 229has been fatal, there is reason to conclude, however, that the subjects of them were, as regards health and strength, quite equal to the average of the multitude who have inhaled this agent without ill effects. In fifteen out of the fifty cases above related, there was no examination of the body after death. In one of these fifteen cases, the patient was in a state of debility, and had hectic fever, apparently from the disease of the ankle-joint, for he had no cough; in another of these cases, the patient was reduced to a state of great debility from cancerous disease of the uterus. In fourteen out of the thirty-five cases, in which an examination of the dead body took place, all the chief organs were found to be healthy, if we except the local congestions of blood connected with the mode of dying, and a flabby state of the heart in a few of the cases, which probably depended on its being full of blood at the time of death, or its not being in a state of post-mortem rigidity, at the time it was examined.

In one case, No. 25, the only morbid appearances were adhesions of the pleura of small extent; and in No. 47, the only disease was fatty liver. In Case 17, there were signs of chronic disease of the membranes of the brain; and in two cases, Nos. 16 and 22, there was emphysema of the lungs. In the remaining sixteen cases, there was some alteration of the heart, accompanied in a few instances by disease of other organs. In Cases 23 and 32, there was fat on the surface of the heart, but the structure was not degenerated. In Case 43, the right ventricle was thinned, but not fatty. In Case 44, there were slight deposits on the mitral valve, the heart being otherwise healthy. In Case 50, there were deposits of lymph on the mitral valve and also on the surface of the heart, which was somewhat enlarged. In Case 8, the heart is merely stated to be large; and in Case 27, hypertrophied. In Case 3, the heart was enlarged, pale, and soft, and the lungs were tuberculous. In Case 15, 230there was said to be some amount of disease of the aortic valves, and some amount of fatty degeneration of the heart. In Case 37, incipient fatty degeneration was present; and in Case 40, that of a youth of eighteen, the heart was slightly enlarged, with some amount of fatty degeneration. In Case 46, the right ventricle was thinned and slightly fatty. There remain three Cases, Nos. 30, 33, and 42, in which the fatty degeneration was more decided; and one case, No. 41, in which it is spoken of as being present in an extreme degree. This was in a man, aged sixty-five, the oldest person included amongst those who died from chloroform.

When we consider how common is fatty degeneration of the heart, especially amongst old persons and those for a long time confined to bed, it is very probable that this affection has been proportionally as frequent, amongst the patients who have inhaled chloroform without ill effects, as in the fatal cases of its inhalation.

There are nine of the fatal cases in which the age of the patient is not stated. In the other forty-one cases, the ages, when grouped in decennial periods, are shown in the following table, the last column of which shows the proportion which the deaths bear at each period to the number living at that period, out of a thousand persons of all ages in England and Wales.

Under 5 years 0 0

5 and under 15 3 ¹⁄₇₆

15 „ 25 11 ¹⁄₁₈

25 „ 35 10 ¹⁄₁₅

35 „ 45 11 ⅒

45 „ 55 3 ¹⁄₂₇

55 „ 65 2 ¹⁄₂₆

65 and upwards 1 ¹⁄₄₄

231The nine persons whose ages are not given were all adults; one is spoken of as a young man, and another as a young woman, and the rest are mentioned in such a manner that it is certain they were not old people. It follows, therefore, that so far as is known, there has been a complete immunity from death by chloroform at both extremes of life. I have already given my reasons for rejecting Dr. Aschendorf’s case of an infant, and also the case of a gentleman, aged seventy-three, who died whilst inhaling chloroform. The youngest patient who died from chloroform was seven or eight years of age, and the oldest sixty-five, being the only death above sixty. The above table of the ages shows that the number of deaths, in proportion to the number living, increased rapidly after the age of twenty-five, and decreased rapidly after the age of forty-five. The small number of deaths between fifteen and twenty-five may be partly due to the circumstance that surgical operations are but seldom required at this period of life; but the decrease after the age of forty-five cannot be explained in this way; for persons become more liable to require surgical operations as they advance in years. Operations are often performed in infancy and old age, periods at which deaths from chloroform have not been recorded. The greatest proportion of deaths having occurred from thirty-five to forty-five, when the system is often more robust than at any other period, it cannot be supposed that an inability to bear the usual dose of chloroform, when carefully administered, is the ordinary cause of death from this agent.