case 6 previously happened. The patient was a youth, aged seventeen,
named J. Verrier, who had been employed as a miner. He was of good
constitution, and was about to undergo amputation of the middle finger
for necrosis of the first phalanx. The following is the account of the
accident.
“As the patient’s health was good, he was at once, and by his free
consent, placed under the influence of chloroform. As usual, a piece of
fine gauze was employed; it was spread over the face, leaving a free
passage for atmospheric air; the chloroform was dropped from time to
time upon that portion of the gauze which was over the nostrils. It was
administered by two assistants who were accustomed to its use, and who
at the time attended to the pulse. The operator superintended the
assistants. At the end of four or five minutes, the patient still felt
and spoke; and at the end of another minute, he still spoke and was
somewhat restless. Up to this time, from a drachm to a drachm and a half
of chloroform had been employed. The pulse was regular, and of the
normal strength. All at once the patient raised his body, and struggled
so that the limbs escaped from the hold of the assistants, who however
seized them quickly, and replaced the patient in his position. Within a
quarter of a minute, one of the assistants stated that the pulse at the
wrist had ceased to beat. The handkerchief was removed. The countenance
was completely altered. The action of the heart had altogether ceased;
the pulse could not be felt anywhere; and the sounds over the region of
the heart could no longer be heard. Respiration still continued, but it
became irregular, weak, and slow; and at length ceased completely in the
space of about half a minute.
“The extreme danger of the patient was manifest, and immediate and
energetic means were employed to rouse him. Ammonia was held to the
nostrils, and rubbed in large quantity over the surface of the chest and
abdomen. It was also applied to the most delicate parts of the skin, _e.
g._, the lips and the extremity of the penis, with a view to excite
irritation. Mustard was used; the head was inclined over the bed; and,
finally, an attempt was made to restore respiration by means of
alternate pressure on the abdomen and chest. After two or three minutes,
respiration reappeared, and even acquired a certain fulness, but the
pulse nowhere returned. Frictions were continued. Respiration became
again slower, and at length ceased. Artificial inflation was practised,
at first through the mouth, and afterwards through the larynx, by
passing a tube through the glottis, as it was perceived that air had
passed from the mouth into the stomach. The precordial, epigastric, and
laryngeal regions were energetically cauterised with a hot iron. The
pulse did not return. For the space of half an hour every effort was
made to resuscitate the patient; but in vain.
“The autopsy could not be made until seventy-two hours after death. The
temperature being low, the body showed no signs of decomposition; there
was still rigidity of the limbs. The features were not altered. The
examination of all the organs was made with care.
“The stomach contained about one ounce and a half of a thick fluid, of
the colour of the lees of wine, in no respect resembling an alimentary
fluid. The organ was distended with gas, as was also the rest of the
alimentary canal, which was otherwise sound. The liver and spleen were
somewhat congested.
“The heart, which was normal in volume, was flaccid and empty, contained
neither blood nor air. The ventricular parietes were moistened by a
fine, very red foam, as if from the presence of a little blood, which
had been, as it were, whipped by the fleshy columns of the heart. The
venæ cavæ and the portal veins were distended by black fluid blood in
great quantity. On the Eustachian valve there was a fibrinous clot,
moderately firm, and weighing from sixty to seventy grains. It was the
only clot met with in the cavities of the heart and great vessels. These
cavities, which were carefully opened, did not contain any appreciable
quantity of air.
“The lungs retracted on opening the chest. They presented both in their
surface and in their substance a very black colour; otherwise their
tissue was healthy. The larynx and trachea presented no lesion. The
brain was normal. The sinuses of the dura mater contained a considerable
quantity of black uncoagulated blood.”[79]
In this case every precaution appears to have been taken, except that
which is the most essential, of regulating the amount of vapour in the
respired air. Arrangement was made that there should be amply sufficient
air for the purpose of respiration; the patient was carefully watched by
three persons at least, one of whom was constantly attending to the
pulse, but with no other result than to be able to announce the exact
moment when it suddenly stopped. The arrest of the action of the heart
in this case took place at a time when the patient was not yet rendered
insensible by the chloroform, although he had been inhaling it for five
minutes. We must conclude that during these five minutes the vapour he
inhaled was largely diluted with air, and that he then inhaled vapour in
a much less diluted form. It is not improbable that he took a deep
inspiration of strong vapour, just at the moment when he struggled
violently, and within a quarter of a minute of the time when his pulse
suddenly ceased.
The breathing continued a little time after the heart ceased to beat,
and it is therefore very probable that, if this organ had not been
irrecoverably paralysed, the natural breathing would have restored its
action after a short pause, that would have attracted but a momentary
attention. As the spontaneous breathing of the patient did not restore
the heart’s action, there is no ground for surprise that the measures
adopted did not succeed.
_Case 10_ was that of a labourer, named Samuel Bennett. It occurred on
February 20th, 1849, at a dispensary in Westminster. The patient inhaled
chloroform for amputation of one of the toes. Half an ounce of
chloroform was “sprinkled on a handkerchief, and held over the mouth and
nose.... This quantity of the agent failed, however, to produce
anæsthesia, having caused only the ordinary excitement and struggling.”
After a delay of two hours, more chloroform was procured, and half an
ounce was again applied on a handkerchief, “care being taken to allow
the entrance of air at short intervals.” Insensibility was induced, and
the toe was amputated; the chloroform being applied, as I was told,
during part of the time of the operation. At the close of the operation,
no blood escaped when the pressure was removed from the arteries; the
patient was in fact dying, and in a short time expired. “A few
inspiations were noticed after the pulse had ceased at the wrist.”[80]
The lungs were of a dark venous hue throughout, a large quantity of
blood escaping from them when cut into. Mucous membrane of trachea and
bronchi congested. Heart rather large but flabby; auricles empty; each
ventricle contained about an ounce of semi-fluid blood (the lungs had
been inflated). Head: sinuses and veins contained blood, but not to any
remarkable amount. But few bloody points occurred in cutting into the
cerebral mass. Kidneys congested.
The failure of the first attempt to cause insensibility in this case,
when so large a quantity of chloroform was used, illustrates very
forcibly the uncertainty and irregularity of the way in which it was
administered. On the first occasion only excitement and struggling were
produced, and on the next the patient died suddenly.
_Case 11_ occurred on August 23rd, 1849, at Langres, France. The subject
of it, Madame Labrune, was reported to be a healthy married woman. She
inhaled chloroform with the intention of having a tooth extracted.
“Complete insensibility was not produced at the first trial: more
chloroform was placed on the handkerchief, and she drew a full
inspiration. Her countenance immediately became pallid; her features
were visibly altered; there was dilatation of the pupils, with a
convulsive rolling of the eyes; and no pulse could be felt. Every
attempt was made to restore life, but without success. She died as if
struck by lightning.”[81] The instantaneous arrest of the circulation,
on a full inspiration being taken, immediately after more chloroform had
been placed on the handkerchief, is particularly worthy of notice. The
heart was paralysed, in this instance, as quickly as in experiment No.
25, above related.
No inspection of the body is reported in this case.
_Case 12_ is the first which occurred in any of the hospitals in this
metropolis. The following is the account of it.
“John Shorter, aged forty-eight, a porter, known to Mr. Solly for some
time as a very active messenger, habits intemperate, but apparently in
perfect health, was admitted into George’s ward, under Mr. Solly, on the
9th October, 1849, suffering from onychia of the left great toe, which
had existed some time. It was determined to remove the nail, the man
having decided before entering the hospital on taking chloroform.
“On Wednesday, October 10th, at a quarter to two P.M., he began to
inhale the chloroform with one drachm in the inhaler. It had no visible
effect for about two minutes; it then excited him, and the instrument
was removed from the mouth, and about ten drops more were added; he then
almost immediately became insensible; the chloroform was taken away, and
the nail removed. He continued insensible; and, his face becoming dark,
the pulse small, quick, but regular, respiration laborious, his
neckerchief was removed, and the chest exposed to fresh air from a
window near to the bed; cold water was dashed in his face, the chest
rubbed, and ammonia applied to the nose. After struggling for about a
minute, he became still, the skin cold, pulse scarcely perceptible, and
soon ceased to be felt at the wrist; respiration became slow and at
intervals, but continued a few seconds after the cessation of the pulse.
Immediately on the appearance of these symptoms, artificial respiration
was commenced by depressing the ribs with the hands and then allowing
them to rise again until the proper apparatus was brought, when
respiration was kept up by means of the trachea tube and bellows, and
oxygen gas introduced into the lungs by the same means. Galvanism was
also applied through the heart and diaphragm, but all signs of life
ceased about six or seven minutes after the commencement of inhalation.
These means were persisted in until a quarter past three, but to no
purpose. On removing the inhaler, the sponge, which only contains one
drachm, fell upon the floor, and the chloroform splashed about,—thus
showing that a considerable part of the chloroform remained unused; so
that the patient could not have inhaled more than a drachm. Every
endeavour was made to procure a post-mortem examination, but in
vain.”[82]
The above account is published in the _Medical Gazette_ as communicated
by Mr. Solly, but it is clearly not written by him, and it presents a
very confused narrative of what occurred. If we are to understand the
events in the sequence in which they are related, we must conclude that
the patient became insensible and had the operation performed, that he
then exhibited alarming symptoms for which cold water was dashed in his
face and other measures were employed, and yet that after this he
struggled for about a minute. This would be a state of things
inconsistent, in my opinion, with death from chloroform; but possibly
the proper sequence is not observed in detailing what occurred. There is
some obscurity also about the amount of chloroform used in connection
with what remained on removing the inhaler. If the sponge was adapted to
hold a drachm in the proper manner, the chloroform could not splash
about on its falling, unless there was a good deal more than a drachm in
it. But whatever was the quantity of chloroform remaining in the sponge,
as it was in a condition to splash about, it is difficult to perceive
what prevented the liquid chloroform from dropping into the patient’s
throat, as he lay on his back in bed. Chloroform is as pungent as the
essential oils. I have been informed of a case in which a patient was
nearly suffocated by one drop falling into the throat; and the narrative
of what occurred to Mr. Solly’s patient is not at all inconsistent with
death from spasm of the glottis arising from this cause. If, however,
the patient died from the vapour of chloroform, we must conclude that he
inhaled it at one moment not sufficiently diluted with air.
The chloroform in this case was administered by a non-medical person—a
sort of surgery-man. After this accident, however, the chloroform in St.
Thomas’s Hospital was always entrusted to some one belonging to the
profession.
_Case 13_ occurred at Shrewsbury, to a Mrs. Jones, a patient of Mr.
Clement, surgeon, who had partly performed the operation of excision of
the eyeball, when his patient suddenly died. Mr. Clement has, I believe,
not published any account of the case, but the evidence which he gave at
the inquest was reported in various local newspapers, and copied into
the medical journals. The death was very characteristic of the effects
of chloroform vapour not sufficiently diluted. Mr. Clement is reported
to have said: “He gave her but a small dose to commence with, imbibed
from a sponge, and then commenced the operation. Finding that did not
make her insensible, about a drachm more was poured on the sponge, which
she inhaled again for a few seconds. He then went on with the operation,
and shortly afterwards heard a peculiar sound, which he could not
describe, and she died in a moment; all the attempts to rouse her proved
ineffectual. She spoke in Welsh before she died, but so quickly that he
did not know what she said; he had no doubt that she died from the
effects of the chloroform.”[83]
_Case 14_ occurred at Berlin. The subject of it was a young lady twenty
years of age, of good health, well made, and of a good constitution. The
chloroform was inhaled for the extraction of a tooth. It was
administered on a sponge, covered with a napkin. The dentist who
administered it was not a medical man. He made five unsuccessful
attempts to extract the tooth under chloroform. Three of these attempts
were at nine in the morning, and two about noon, just before the
accident. His patient suddenly died almost at the commencement of the
last attempt to administer chloroform, stretching herself out, and
frothing at the mouth at the moment of death; the countenance at the
same time becoming livid.
An examination of the body took place fifty hours after death, when
putrefaction had set in.
“The lungs presented nothing morbid; the bronchi contained a little
bloody froth. The blood was of the colour and consistence of cherry
juice. The heart was soft, flabby and collapsed. Its coronary vessels
and cavities were empty, and presented the bluish-red discoloration of
decomposition.”[84] The other organs were healthy.
_Case 15_ occurred in the public hospital of Kingston, Jamaica, on
January 29, 1850. The name of the patient was William Bryan, his age is
not stated, nor the nature of the operation he was about to undergo. He
had previously, however, undergone the operation of amputation of the
penis, on account of cancer of that organ, but it was performed without
chloroform. Mr. Maygarth, the surgeon who administered the chloroform,
stated as follows: “I had about a drachm poured on the sponge, and
applied it over his mouth and nostrils, but at first not in close
contact—at no period was the atmospheric air totally excluded. He bore
it badly, and I was frequently obliged to withdraw it, to facilitate his
breathing. The stage of excitement which is usual came on, and he
struggled and kept away the sponge for some seconds; it was again
reapplied, when, after a few more seconds, observing that he made one
stertorous inspiration, I removed it altogether. He ceased to breathe;
but after some seconds had elapsed, made another inspiration, and this
occurred several times, until at length respiration ceased entirely.”
The measures which were employed were of the usual kind, but were of no
avail.
The brain and its membranes were found to be congested. The lungs were
congested, especially posteriorly. The right side of the heart contained
dark fluid blood, and the inner surface of its left cavities, and of the
aorta, were stained with blood. There was some disease of the aortic
valves, and the heart had undergone some amount of fatty
degeneration.[85]
_Case 16._ In February 1850, a death from chloroform occurred on board
ship at the Mauritius. A report of the case was sent to the Board of
Ordnance, and also to the Admiralty. The secretary of Sir William
Burnett first informed me of the case, and a day or two afterwards I had
an opportunity, through the kindness of the late Marquis of Anglesey, of
reading the report which was sent to him as Master of the Ordnance, and
I made a note of the chief particulars as soon as I got home. As the
report was a very able one, it is to be regretted it has not been
published. The accident occurred to an artilleryman, aged 24, who
required to have the last phalanx of the middle finger removed. In other
respects, he was considered to be in good health. Two scruples of
chloroform were first poured on the handkerchief with which it was
administered, and then one scruple more. It was observed that the face
turned pale, and the pulse and breathing ceased, soon after the
chloroform was discontinued. The measures which were employed to restore
him were of no service. The lungs after death were found to be
emphysematous; and, upon inquiry, it was ascertained that he had been
short of breath on exertion. The right cavities of the heart were filled
with fluid blood. The sinuses of the dura mater contained less blood
than usual, and the brain was pale. The medical man reporting the case
considered that the emphysema was the cause of death, by interfering
with expiration, and thus detaining the vapour; and it must be admitted
that, if the vapour were not sufficiently diluted with air, the
emphysema might increase the danger. I have, however, administered
chloroform in several cases in which emphysema existed to an extreme
degree, without any ill effects; consequently, when the vapour is
properly diluted with air, this affection appears to be no source of
danger.
_Case 17_ was that of a patient of Professor Carl Santesson, in the
Seraphim Hospital at Stockholm. I was indebted to Mr. Paget for my first
information about this case, and to Dr. W. D. Moore, of Dublin, for some
further particulars respecting it.
The patient, a man thirty years of age, was affected with hydrocele, and
there was some suspicion of disease of the testicle. It was consequently
intended to operate on the hydrocele by incision, in order that the
testicle, if diseased, might be removed. The chloroform was administered
in the same way that Professor Santesson had seen it exhibited by Dr.
Simpson, except that it was poured on a little cotton, which was placed
at the small end of the cone, into which the folded towel he made use of
was rolled. About a drachm and a half was first poured on the cotton,
and the patient was told to inhale in long and deep inspirations. This
quantity being nearly evaporated in two or three minutes, a drachm more
was added. After a few inspirations rigidity and struggling came on:
these subsided, but in a little time returned more strongly than before,
and the towel was removed from the face until the struggling ceased. The
patient, however, not being sufficiently insensible to undergo the
operation with the necessary quietness, the towel was reapplied, when,
after a few inspirations, the pulse suddenly ceased. The face and the
whole surface of the body turned pale, the eyes rolled upwards and
inwards, and the breathing became very slow, but full and deep, the
intervals between the inspirations becoming longer, until the
respiration ceased altogether. The patient died before the operation was
begun, and within five minutes from the commencement of inhalation.
During the application of various means of resuscitation, including the
dropping of cold water _guttatim_ on the epigastrium, the breathing
returned, and continued for the space of three or four minutes; but the
pulse and sounds of the heart did not return.
At the examination, thirty-two hours after death, the dura mater was
found to be congested, and there was considerable serous effusion
between the membranes of the brain. There were also some bony deposits
under the dura mater, and some adhesions of the arachnoid, indicating
long standing disease of the membranes.
The heart was of normal size, and flaccid; the vessels on its surface
strongly distended with blood. The left ventricle was empty; the left
auricle, on the contrary, and the entire of the right side of the heart,
with the great veins, were filled with thin uncoagulated blood. In the
right ventricle only was a little loose coagulum found. The lungs,
posteriorly, were highly congested, exhibiting here and there
infiltrations of blood from the size of a pea to that of a small
hazel-nut. The pulmonary tissue was otherwise sound; giving, however,
when cut into, the odour of chloroform, but more feebly than the brain
did. The mucous membrane of the larynx and bronchial tubes were slightly
reddened from sanguineous congestion. The blood was everywhere of the
same thin juice-like nature.[86]
_Case 18._ I am indebted for my information respecting this case to Dr.
James Adams, of Glasgow, who was good enough to send me a copy of the
notes respecting it, from the case book of his colleague, Mr. Lyon, in
whose practice, in the Glasgow Infirmary, the case occurred, in March
1850. The patient was a boy seven or eight years old, from the
Highlands, whose health was considerably impaired by years of suffering
from calculus. Mr. Lyon says, “being laid in bed, I placed a piece of
lint, moistened with chloroform, near to his face, when, in a few
minutes, he ceased crying. I now told my clerk to take charge of the
chloroform, and introduced the sound. I thought I detected a calculus,
but could not hear the click distinctly, in consequence of the patient
moaning. One of the bystanders held his hand between my ears and the
patient’s face, when the click was at once heard. I withdrew the
instrument, and was horror-struck with the livid countenance and vacant
eye of the patient; the cardiac and radial pulses were gone, and, making
one deep gasp, he was to all appearance dead.” Artificial respiration
and other measures were employed without effect. “The external jugulars
being remarkably turgid, and the face still very livid, the right
jugular was opened, when several ounces of dark blood flowed rapidly.”
This measure, and galvanism, which was applied afterwards, were of no
avail.
_Case 19._ The subject of this case was Alexander Scott, aged
thirty-four, a police constable, who died in Guy’s Hospital in June
1850, whilst undergoing an operation for the removal of a portion of the
right hand. Mr. Cock, the operator, said that he was certain there was
no disease about the patient. He described the accident as follows:—“The
ordinary machine was used, and, as it had not the effect, witness
directed that a napkin should be folded into the shape of a cone, which
was applied with chloroform. The occupation of removing a portion of the
bone occupied one minute and a half, but before it was completed, the
blood which was gushing out, suddenly stopped, when witness directed Mr.
Lacy to feel the pulse of deceased, and they found that deceased had
expired.”[87]
The sudden stopping of the hæmorrhage shews that, in this case, as in
the others, the action of the heart was suddenly arrested. The first
attempt to cause insensibility failed in this as in some other cases.