and Dr. Glover, who reported as follows:—“The body was that of a
well-grown female of about fifteen years of age.... On opening the
chest, the lungs were not collapsed. One or two very slight adhesions
were encountered on separating them from the walls of the chest. The
external appearance of both lungs, over the whole surface, but
especially in the inferior portions, was that of organs in a very high
state of congestion. They were mottled with patches of a deep purple,
blueish, or scarlet hue. They were everywhere crepitant. Along the outer
and interior border of both lungs, particularly of the upper lobe of the
left lung, were several emphysematous bubbles of small size.... The
pulmonary tissue was filled with bloody froth, which was also found in
the interior of the bronchi, mixed with mucus. There was no appearance
of hepatization. On examining the larynx and trachea, the epiglottis was
found reddened at the summit, of a vermilion hue. The mucous membrane of
the larynx was redder than natural—mottled with vascular patches. The
sinuses of the larynx contained a good deal of dark mucus. The œsophagus
was healthy. The stomach was distended with food. Some of the veins were
more distinct than usual. The heart contained dark fluid blood in both
its cavities: very little in the left. Its structure, and that of the
great vessels near it, quite healthy. The brain, externally and
internally, was more congested than usual; and the ventricles contained
rather more than the usual quantity of serum.”[66]
Sir John Fife and Dr. Glover expressed the opinion that chloroform
caused death by producing congestion of the lungs. After the further
experience which has been gained respecting chloroform, this opinion of
the mode in which it caused death, in the above case, would probably not
now be offered. Indeed, in similar cases which have since occurred, the
same opinion has not been advanced; and as the lungs were crepitant
throughout, in the above case, it is probable that the congestion was
not greater than is commonly met with in cases of sudden death without
hæmorrhage. Dr. Simpson published his opinion, immediately after this
case occurred, that it was not caused by the chloroform, but by the
brandy which was given when the alarming symptoms came on; but Dr.
Meggison replied that only a teaspoonful of brandy was given; that it
was swallowed, though with difficulty; that there were no symptoms of
choking from it; and that the girl was without pulse when it was
given.[67]
From the lips becoming suddenly blanched in the above case, there is
every reason to conclude that the heart was suddenly paralysed. The
patient breathed for a little time after this, and was able to swallow,
though with difficulty. The process of inhalation occupied only a little
more than half a minute in Dr. Meggison’s estimation; yet he appeared to
think that the fluid drachm of chloroform which he had put on the
handkerchief had evaporated; for he was about to apply more when the
alarming symptoms appeared. But supposing only one-third of the drachm
was actually inhaled into the lungs in the half minute, the vapour would
necessarily be in a highly concentrated state—probably twenty cubic
inches of vapour in 200 cubic inches of air, which would be adequate to
occasion the result which happened. In the short space of about half a
minute, the blood could not be uniformly impregnated with the vapour;
only a portion of it could pass through the lungs in the time; yet, as
the patient was rendered insensible, this portion must necessarily have
been highly charged with vapour.
It was often the practice to render the patient insensible in as short a
time as half a minute, when chloroform was first introduced, but I
believe never without danger; and I had expressed the opinion before any
accident happened, that, for reasons such as I have stated above, a
patient should on no account be rendered insensible in less than two
minutes.[68]
_Case 2._ The next recorded case in which the inhalation of chloroform
was fatal, occurred at Cincinnati, on the 23rd of February, 1848. The
subject of it, Mrs. Martha G. Simmons, was thirty-five years of age, and
enjoyed good general health; she was the mother of six children, and her
last confinement occurred eight weeks before her death. The patient
exhibited no alarm on account of inhaling the chloroform, which was
administered by two dentists, who were not members of the medical
profession. It was breathed from an inhaler which Dr. Morton of Boston
contrived for sulphuric ether. This inhaler consisted of a glass globe
four inches and a half in diameter, and contained a sponge about
one-third filling the globe, and saturated with chloroform.
Two female friends of the patient reported the following as the events
which occurred. “The respiratory movements appeared to be free; chest
heaving. While inhaling, the face became pale. At the expiration of
about one minute, the instruments were applied, and four roots of teeth
extracted. The patient groaned and manifested what they regarded as
evidences of pain, while the teeth were being extracted, although she
did not speak or exhibit any other sign of consciousness. As the last
root came out, which was about two minutes from the beginning of the
inhalation, the patient’s head turned to one side, the arms became
slightly rigid, and the body drawn somewhat backwards, with a tendency
to slide out of the operating chair. At this instant, Mrs. Pearson
states that she placed her finger upon the patients pulse; observed that
it was feeble, and immediately ceased to beat; respiration also ceased
about the same time. The face, which was previously pale, now became
livid, as did also the finger nails; and the lower jaw dropped, and the
tongue projected a little at one corner of the mouth, and the arms were
perfectly relaxed. The females regarded her as being then quite
dead.”[69]
The dentists gave nearly the same account, saying that the breathing was
at first slow, and that the patient inhaled twelve or fifteen times,
occupying from a minute to seventy-five seconds. They committed the
great error of not placing the patient at once in the horizontal
position, when the alarming symptoms came on, but kept her sitting in
the chair, from five to ten minutes, whilst they sent out for
restoratives. They thought the patient was living during this time, but
her female friends thought not. The patient was placed on a sofa, and
sometime afterwards artificial respiration and galvanism were applied
without effect.
An examination of the body was made twenty-six hours after death by Drs.
Mussey, Lawson, Baker and Mulford. The following are the chief
particulars of the appearances met with. A larger quantity of blood than
usual flowed from the sinuses of the dura mater. General aspect, colour,
and consistence of the brain, normal. Lungs considerably but not
intensely congested; crepitated freely at all points; no extravasation.
Lining membrane of bronchia slightly congested, apparently the result of
recent catarrh; deeply stained by the blood. Pleura at all points highly
injected; six drachms of bloody serum in the right, and two ounces in
the left chest. Pericardium contained six drachms of bloody serum. Heart
flaccid, and all its cavities entirely empty; inner surface of both
ventricles and auricles deeply stained. Abdomen—one ounce and a half of
bloody serum in the right hypochondrium. Stomach and intestines
distended with gas. Partially digested aliment, amounting to about three
gills in the stomach. Blood fluid as water in every part of the body;
not a coagulum was seen in any vessel. Lining membrane of all the
bloodvessels deeply stained. The colour in every part of the system was
that of dark venous blood.
It was estimated, in the inquiry which took place respecting this case,
that one-fourth part by measure of what the patient inhaled might be
vapour of chloroform; but this is evidently an over-calculation, for
there could not be this quantity unless the interior of the glass globe
were maintained at the temperature of 80° Fah. and the air were quite
saturated with vapour in passing through it; however, less than half the
amount of vapour here assumed would have the effect of causing sudden
death, in the way it happened. The period of the inhalation, a minute or
seventy-five seconds, during which the patient took twelve or fifteen
inspirations, did not admit of the blood in the body being regularly and
uniformly charged with the chloroform; and the increase of its effects,
owing, no doubt, to the absorption and circulation of the vapour
contained in the lungs at the moment when the inhalation was
discontinued, was well marked. The patient became pale during the
inhalation, but the alarming symptoms suddenly came on during the
extraction of the fourth stump, probably within half a minute after the
inhalation ceased. The patient seemed, in fact, to die with the slight
struggle that took place at this moment. In the case of Hannah Greener,
related above, the spasm at the moment of dying was even more marked.
This is a symptom I have often seen during the death of animals killed
suddenly with vapour of chloroform in a concentrated state, before they
were made thoroughly insensible. Although the heart was empty, the
stained condition of its cavities showed that they had contained blood
at the time of death and afterwards. Owing to its fluid state, it
probably escaped from the heart during the moving of the body;
especially during the examination of the head, which was made first.
_Case 3._ The next recorded case of death from chloroform is reported by
Dr. John C. Warren, of Boston, U.S., in the _London Medical
Gazette_.[70] His report, apparently extracted from some other report,
is as follows.
“Name—Patrick Coyle. [Age—not stated.] Date—March 1848. Disease—fistula.
Previous use of chloroform—once. Time of inhalation—about one minute.
Quantity consumed—about thirty drops. [Query minims.] Posture—upon the
side. Lapse of time till death—about one minute. Symptoms—showed signs
of pain, by putting his hand to the part; in a moment his pulse, which
was full and natural, sank: death. Morbid appearances—brain, with
membranes, natural and healthy. Heart enlarged, pale, and soft; two or
three ounces of serum in pericardium; bloodvessels with dark fluid
blood. Lungs, studded with tubercles; abscess in each; lower parts
congested; pleura extensively adherent; stomach—mucous membrane
softened, its veins turgid.”
Nothing is said about the apparatus used in this case, but from the
summing-up of Dr. Warren’s paper, it must have been either a towel or a
handkerchief. The quantity of chloroform employed appears to have been
much less than in the two previous cases. In speaking of drops, the
writer probably means minims, or what is the same, a quantity equal to
as many drops of water. Thirty drops of chloroform from a small phial
are only equal to between six and seven minims, and if they were dropped
on a handkerchief, so that they might be counted, they would evaporate
entirely during the process. Supposing the quantity used to have been
what is probably meant—half a fluid drachm—it would be quite adequate,
according to calculations previously made in these pages, to cause the
accident which happened. The period of inhalation was again very
short—one minute; and the evidence of paralysis of the heart is
distinct:—“In a moment his pulse, which was full and natural, sank:
death.”
_Case 4_ was that of Madlle. Stock, aged thirty, and occurred at
Boulogne, in May 1848. The operation was that of opening a sinus in the
thigh, between two and three inches in length, at the bottom of which a
small splinter of wood was found. M. Gorré, the surgeon who attended the
patient, says: “I placed over the nostrils of the patient a handkerchief
moistened with fifteen to twenty drops of chloroform at most.” It is
necessary to remark, however, that a judicial examination of the bottle
from which it had been taken, proved that from five to eight grammes had
been used, a quantity equal to from 77 to 123 grains, and there are
three drops of chloroform to a grain. M. Gorré proceeds to say:
“Scarcely had she taken several inspirations, when she put her hand on
the handkerchief to withdraw it, and cried with a plaintive voice, ‘I
choke.’ Immediately the face became pale; the countenance changed; the
breathing embarrassed; and she foamed at the mouth. At the same instant
(and certainly less than a minute after the beginning of the
inhalation), the handkerchief moistened with chloroform was withdrawn.”
M. Gorré performed the operation, but he expressed the opinion
afterwards that death had already taken place when he made the incision.
Amongst the means used, with a view to resuscitate the patient, was
inflation of the lungs, which was performed with such force as to
produce permanent dilatation of the air-cells. The lungs, besides being
distended from this cause, were found after death to be visibly engorged
in their lower lobes. When cut into, a large quantity of black blood
escaped. The cavities of the heart were empty, but the internal
membrane, especially of the right cavities, was red. The tissue of the
heart was pale, and was easily torn. Air was found in the pulmonary
veins, and in most of the systemic veins throughout the body. The blood
was very dark-coloured and fluid.[71]
M. Gorré reported the above case to the Academy of Medicine of Paris,
and a commission was appointed to inquire and report on it, who came to
the following conclusions.
“1. In the medico-legal fact submitted to our notice, we found no
indication of the poisonous action of chloroform; and consequently we
reply to the minister, that the patient of M. Gorré did not die from the
effect of inhalation of that agent.
“2. There have occurred a great number of analogous cases of sudden and
unforeseen death, during operations, without any administration of
chloroform, in which the most minute examinations have failed in
detecting any assignable cause of death.
“3. In the case in question, the most probable cause, under all
circumstances, seems to have been the mixture of a considerable quantity
of gas with the blood.”[72]
The report on this case gave rise to frequent discussions in the
Academy, extending over several months, and the Academy ultimately
confirmed the above conclusions, but not without considerable opposition
from M. Blandin, M. Jules Guérin, and other members.
M. Malgaigne, the reporter to the commission, and others, who strongly
supported the first of the above propositions, founded their argument
chiefly on the assertion that chloroform always produces intoxication
and insensibility before death; but this is incorrect, as I have
explained above; and I took occasion to make the following remarks on
this point about the time when the discussion in the Academy of Medicine
took place. I said: “I have several times made animals—small birds, mice
and rabbits—breathe air saturated with vapour of chloroform at the
temperature of the atmosphere, and the consequence has always been that,
after attempting for a few seconds to escape from the capacious jar in
which they were enclosed, they suddenly exhibited signs of distress, and
died without any interval of intoxication or insensibility, in periods
varying from less than half a minute to a minute after their first
exposure to the vapour.”[73]
The power of chloroform to cause sudden death without previous
insensibility is now, I believe, generally admitted. The French call
this kind of fatal action _sideration_.
With regard to the second conclusion of the commission, if it had been
really true that the surgeon put only fifteen to twenty _drops_ at the
most of chloroform on the handkerchief, one would have been inclined to
admit it; but with the quantity actually employed, and the strong
sensation of choking it occasioned just before death, one must, in
connection with other cases, and with what is known of the action of
chloroform, attribute the fatal event to this agent, rather than to the
surgical operation, which was not of a serious nature.
With regard to the third of the above conclusions, it is not a little
remarkable that most even of those speakers who opposed the conclusions
of the commission, agreed that death was caused by a sudden development
of air in the veins; and differed from them only in this, that they
considered the chloroform as the cause of the evolution of air or gas,
and that it proved fatal in this way. That the air was not caused by
putrefaction, and that it did not enter by the wound in the thigh, may
be readily admitted, but there remains the artificial respiration, which
was performed with such force as to produce permanent dilatation of the
air-cells. It was argued in the Academy that, as the air was in the
systemic, as well as in the pulmonary veins, it could not have been
introduced by the artificial respiration, since the left ventricle had
previously ceased to act; but the action of the left ventricle is not
necessary for the passage of the contents of the arteries through the
capillaries into the veins, since this commonly goes on after death, the
arteries being usually found entirely empty of the blood they must have
contained at the moment of death. With regard to the passage of the air
out of the heart into the arteries, supposing that the pulmonary veins
were ruptured during the inflation of the lungs, there is an observation
of Dr. Sibson’s which will explain both this circumstance and the fact
of the heart itself being found empty of blood. He found that the heart
was often emptied of blood by distending the lungs with air after death
in preparing the body for his diagrams of the position of the
viscera.[74]
With the conclusions above quoted, some additional ones were adopted
from the second part of the report of the commissioners; in these it was
admitted that chloroform is capable of causing death, if administered
too long, or in too large doses. One of these additional conclusions,
however, is as erroneous as the previous ones. It is, “there is risk of
asphyxia when the anæsthetic vapour is not sufficiently diluted with
air.” When the vapour is not sufficiently diluted with air, the risk is
one of sudden death, by paralysis of the heart. Chloroform does not
yield enough vapour, at the natural temperature and pressure of the
atmosphere, to exclude the air to the extent which would cause asphyxia.
When chloroform vapour largely diluted with air is long continued, it
may cause, not real asphyxia, but a mode of death resembling it, owing
to the medulla oblongata and nerves of respiration becoming over
narcotised.
_Case 5_ is that of a young woman at Hyderabad, who inhaled chloroform
to undergo amputation of the middle finger. A drachm was sprinkled on a
handkerchief and inhaled. The operator described what occurred as
follows: “She coughed a little, and then gave a few convulsive
movements. When these subsided, I performed the necessary incisions,
which of course did not occupy more than a few seconds. Scarcely a drop
of blood escaped.” The absence of bleeding seemed to be the circumstance
which called the attention of the operator to the state of his patient;
and after describing the means which were used without avail to bring
about recovery, he continues, “I am inclined to think that death was
almost instantaneous; for, after the convulsive movements above
described, she never moved or exhibited the smallest sign of life.”[75]
In this case, it is probable that the breathing and the action of the
heart were both arrested at the same time, by the action of the
chloroform.
_Case 6._ Charles Desnoyers, aged twenty-two, a patient in the
Hôtel-Dieu at Lyons, affected with scrofulous disease of the left wrist,
having to undergo transcurrent cauterisation of the joint, inhaled
chloroform from an apparatus for five minutes, and died at the beginning
of the operation.[76] Further particulars are not given.
_Case 7._ A young gentleman, who had returned from Australia to visit
his relatives in the neighbourhood of Govan, inhaled chloroform for an
intended operation on the great toe, in December 1848. It is stated that
the patient, after inhaling it, almost instantly expired. This account
appeared in the _Glasgow Herald_, and was copied into the medical
journals.[77] I believe that no further account of the case was ever
published.
_Case 8_ occurred on January 19th, 1849. It is related by Dr. John C.
Warren.[78] John Griffith, an Irishman, aged thirty-one, a seaman in the
American navy, was admitted into the New York Hospital early in December
1848, on his return from Mexico. He was suffering with diarrhœa,
chancres, and hæmorrhoids. The following is the account of this
accident.
“Gurdon Buck, jun., attending surgeon to the New York Hospital, being
sworn, says, that ‘on or about the 26th of December, I advised that
chloroform should be administered to the deceased, for the purpose of
examining the condition of the rectum, the parts being in such a state
of excessive irritation as scarcely to admit of a separation of the
nates. The patient recovered from the effects of the chloroform, and
remained in all respects in the same condition, except the local
ailments spoken of; and he having never complained of either his head or
his chest, and not having suffered from the first administration of
chloroform, I directed it to be administered to him for the purpose of
performing an operation upon the rectum, and the operation of
circumcision to remove a phymosis caused by the chancres: the patient
soon became excited by the chloroform, as is usually the case, but not
beyond a degree that I have often observed. Shortly after, he became
more tranquil: the deceased was placed upon his side, and the operation
performed, which consisted in the removal of two external tumours, and
the tying of one internal tumour.
“‘At this moment my attention was arrested by my assistant’s calling for
a wet cloth: on examining the patient, I found his face and neck of a
livid leaden hue or colour, the eyes turned upward, the pulse
imperceptible at the wrist, and the whole body relaxed; after two or
three gasps, he ceased to breathe. Every means was promptly used to
restore the deceased, but without effect. The chloroform was obtained
from Kent’s, 91, John Street, and not exceeding three drachms was
administered on a napkin. A portion of chloroform from the same phial
had been administered the day before to a patient without any
unfavourable effects. About ten minutes elapsed from the commencement of
its administration before death took place. On making a post-mortem
examination, twenty-four hours after death, I found the face less livid
than before death; on examining the head, the brain and its membranes
presented no other appearances than are seen in persons dying when in
full health; the lungs were a good deal congested, and discharged, when
cut, a large quantity of bloody serum; the heart was large, its
ventricles and auricles were empty, its condition flabby, the substance
of the left ventricle rather softer than natural; about half an ounce of
watery fluid was found in the pericardium; the viscera of the abdomen
were healthy.’”
This case differs from those previously related in respect to the time
at which the fatal occurrence took place. It was not till ten minutes
from the commencement of inhalation, and when an operation which
probably occupied two or three minutes had been performed, that the
patient suddenly expired. The evidence of paralysis of the heart is,
however, distinct enough in the absence of pulse at the wrist, and the
livid hue of the countenance. In several of the previous cases, there
was sudden pallor at the moment when the heart ceased to inject blood
into the capillaries, but in a patient well supplied with blood, the
sudden arrest of the action of the heart would cause turgescence of the
veins and venous capillaries, which would be evident in the face in a
few seconds. The syncope occasioned by paralysis of the heart differs
from that kind of syncope which is caused by loss of blood, inasmuch as
the right cavities of the heart are full in the former instance, and
empty in the latter.
The circumstance of the patient having inhaled chloroform to
insensibility three weeks previously, without accident or ill effects,
is worthy of notice, as showing that the fatal event did not depend on
any peculiarity of constitution.
Although the heart was found to be empty, its flabby condition and the
watery fluid in the pericardium indicate that it must have contained
blood at the time of death.