the operation would have been without it. In Guy’s Hospital and St.
Thomas’s the medical officers had a strong objection to narcotism by
inhalation for the first two or three years after the practice was
introduced, and chloroform was used much less generally in these
institutions than in any other of the hospitals of London; yet it was
precisely in these two hospitals that two deaths from chloroform
occurred, before any such accident had happened in any other hospital in
this metropolis. This circumstance is worthy of the consideration of
those who propose to limit the accidents from chloroform by restricting
its use to a few great operations.
In this case the lungs were reported to be extremely congested. Heart
flabby, not particularly distended; about two ounces of fluid blood on
the right side; not more than half an ounce on the left. Head.—Much
congestion of the dura mater; the grey matter of the brain was dark and
congested; fluid was found in the subarachnoid space; and a considerable
quantity of it in both ventricles. Kidneys congested.[88]
_Case 20_ occurred on September 20th, 1850, at the Cavan Infirmary,
Ireland. The case occurred in the practice of Dr. Roe, and I am indebted
to Dr. Robert Adams, of Dublin, for a manuscript account of it. The name
of the patient was James Jones, and his age twenty-four years.
Chloroform was exhibited with the intention of performing amputation
below the knee, on account of scrofulous disease of the ankle, with
ulceration of the cartilages. The patient was reduced to a state of
great debility by the disease, and was suffering from hectic fever, but
had no cough. The following is Dr. Roe’s account of the accident:—
“When placed on the operating table the heart’s action was very quick
and weak, but he did not appear more faint or pale than usual. I then
saw Mr. Nalty, the apothecary, measure one drachm of the chloroform in
the small minim glass measure, and pour it upon a little folded lint,
which was placed in an oval hollow sponge, held in the hand with a small
towel. Recollecting I had used this chloroform in another case, and
finding some delay in producing the anæsthetic effects, I directed Mr.
Nalty to add thirty drops more to that already put on the lint. I then
applied the sponge to the patient’s nose, directing him to keep his
mouth shut, and gave the towel into the care of Dr. Halpin, who was on
the opposite side of the table, while I went to prepare myself for the
operation. Mr. Bird had scarcely screwed up the tourniquette, which had
been previously placed on the thigh, while I was examining the state of
the circulation in the tibial arteries, and which could not have
occupied one minute,—certainly the patient could not have taken fifteen
inspirations,—when Dr. Halpin told me the anæsthetic effects were
produced. This struck me as being unusually quick and sudden, and on
removing the towel from the face, we saw a slight convulsive action of
the left eyelid (the eyelids were partially open), and a small quantity
of frothy saliva at the mouth. I felt rather uneasy, but not much
alarmed, as Dr. Halpin said he had often seen such symptoms from the
effects of chloroform, although I had not met with them. On a more
minute examination of the heart, the eyes, muscles of the limbs, &c. we
found him dead.”
Energetic means were used with a view to restore the patient, but
without effect. No inspection of the body took place.
_Case 21._ The next case of recorded death from chloroform occurred in
the Stepney Workhouse. The patient, named John Holden, age not stated,
was about to undergo an operation on the penis. It was stated at the
inquest that half a drachm of chloroform was administered without
effect, and then half a drachm more was applied, when the patient
suddenly expired. This death occurred in April 1851.
_Case 22_ is important, as having given rise to a prosecution. The
medical man, an officier de santé, named Kobelt, was accused of
homicide, by imprudence, want of precautions, &c. The chloroform was
administered on a handkerchief, and the accident occurred as suddenly as
any of the others. The husband of the patient stated that the whole
process did not last a minute. “I observed attentively,” he said,
“during this time, and the character that her countenance took all at
once made me apprehensive. I spoke of it to the operator, who
tranquillized me, and continued to extract the teeth. After the third
tooth, however, he partook of my apprehension, suspended the operation,
and proceeded to adopt measures indicated by the circumstances.”
Professor Sédillot, who had to pronounce an opinion on the case, after
hearing all the evidence, said, “I do not think that M. Kobelt is guilty
of imprudence or of rashness, because that officier de santé has
followed a practice very habitually employed, and even recommended, by
eminent practitioners, whose example and authority were sufficient to
inspire him with security, and shade him from reproach.” The accused
practitioner was acquitted. The above remark of Sédillot applied to the
plan of causing insensibility very rapidly, as first recommended by Dr.
Simpson; and he added some observations, to the effect that, when used
in a different manner, chloroform is free from danger.
The above case occurred at Strasbourg, on June 10th, 1851. The name of
the patient was Madame Simon, and her age thirty-six. After death the
lungs were found to be somewhat congested, and emphysematous. Heart
flaccid, of middle size; right cavities filled with liquid dark-coloured
blood, mixed with some fibrinous clots. The left cavities contained
similar blood in much smaller quantity.[89]
_Case 23_ occurred on July 8th, 1851, at the Seaman’s Hospital,
Greenwich. The patient was a light-coloured mulatto, aged forty-five,
native of New York. He died during the operation of removing the left
testicle, which was disorganized by suppuration. “The chest had been
carefully examined a few days previously, both by percussion and
auscultation. No physical signs of disease were detected. His pulse was
regular and feeble, about seventy. He was rather nervous, and fearful of
the operation. No arcus senilis. After taking a glass of wine he
commenced the inhalation, twenty minims of chloroform having been poured
on a linen cloth. At the expiration of a few minutes, this had been
dissipated, producing only very trifling excitement; a second dose, of
the same quantity, was then administered in the same way; the man began
to sing and shout, his expressions relating to the firing of guns. The
second quantity having been exhausted, and the effects of the chloroform
becoming more apparent, but sensibility being still perfect, and even
intelligence almost unaffected, a third quantity, of ten minims, was
poured out, and, afterwards, twenty minims more. Having passed through
the usual convulsive stage, and insensibility being established, the
further administration of chloroform was desisted from at the end of
about seven minutes, though this time is merely guessed at; it might
have been more, but was certainly not less. At this time the respiration
was unembarrassed, and the pulse regular, and about seventy, with as
much volume as before the inhalation. The lips were florid; in fact, the
chloroform appeared to have acted in the most benign way. Mr. Busk
commenced the operation by an incision through the scrotum, which
divided a small arterial branch, and some enlarged veins, from which the
blood flowed pretty freely. The flow, however, almost instantaneously
ceased, and Dr. Rooke, who kept his finger on the man’s pulse, found
that cease at the same moment. Respiration appeared to cease almost
instantaneously with the heart’s action. Regular respiration at least
did; for, while we were looking at the man’s face, he fetched one or two
sigh-like inspirations. The ribs and abdomen were compressed, so as to
induce inspiration and expiration; the lungs were inflated by blowing
through the nostrils, the larynx being compressed against the spine,
and, for three or four minutes, upon our efforts being suspended, the
man occasionally took an inspiration; on one occasion three or four in
succession, so as to make us flatter ourselves that he would come
round.... It is worthy of remark that, for a long time after spontaneous
respiration had ceased, the lips retained a florid colour. The muscles
were all relaxed, and the veins on the side of the neck turgid.”[90]
At the inspection of the body next day, the vessels of the dura mater,
and those on the surface of the brain, were gorged with fluid blood. The
lateral sinuses also afforded a flow of dark-coloured blood. There was a
considerable quantity of serous fluid in the cavity of the arachnoid and
in the spinal sheath. The substance of the brain was very soft. (The
weather was warm.) The lungs were of a dark purple colour posteriorly,
and much loaded with fluid blood and serum, but were everywhere
crepitant and healthy. The external surface of the heart was covered
almost entirely with fat; in some parts to a considerable thickness.
There were two fibrinous spots on its surface. No fluid in the
pericardium. The venæ cavæ were full of fluid blood. On removing the
heart, a white fibrous coagulum, about as big as a walnut, was found in
the commencement of the pulmonary artery. The heart was uncontracted,
and the cavities contained a very small quantity of dark fluid blood.
The walls of the right ventricle, and of the left auricle, were thinner
than natural. Some portions of the substance of the heart were paler
than natural:—“In these paler portions of the muscular substance, the
fibres had, for the most part, lost their striated aspect, and had
become converted into a fine granular material contained in the
sarcolemma. Here and there a minute oil-globule could be observed in the
muscular fibrillæ, but nowhere did this amount to fatty degeneration.”
In this case all the precautions appear to have been taken which are
possible in making a patient insensible with undiluted chloroform,
administered on a handkerchief; and the case, therefore, strongly
confirms the proposition that chloroform cannot be administered in this
way with perfect safety.
The patient was apparently in the most satisfactory condition at the
conclusion of the inhalation, and yet, a few seconds afterwards, the
heart suddenly ceased to beat, from the effect, as we must conclude, of
that portion of vapour which was in the lungs at the moment when the
inhalation was discontinued.
_Case 24_ occurred in October, 1851, at Chipping Norton, Somerset, to a
patient of Mr. Farwell, named Elizabeth Hollis, and aged 37. No one
observed the manner in which the breathing and circulation ceased, and,
as the patient was in a state of extreme debility, it is not quite
certain that the chloroform was the sole cause of death. It was
administered to prevent the pain of removing the fæces, which became
impacted in the rectum on account of extensive cancerous disease of the
uterus and vagina. The surgeon reports that “the time occupied in the
inhalation was about eight or nine minutes; quantity inhaled 10½
drachms, half a drachm at a time, allowing her frequently to breathe the
atmospheric air. She spoke to me during this period. When I found that
her arm fell after being raised, I proceeded to and accomplished the
operation. At this time she was not inhaling. I then, as I always do,
wetted the face with a sponge, with the view of washing off any
remaining chloroform from the nose and lips, when, to my surprise, I
found that she had ceased to breathe, and all attempts to restore her
were in vain.... When I commenced the operation, the pupil was
contracted, and the conjunctiva slightly red. After death, the pupil was
very dilated, and the countenance extremely pallid.”[91] There was no
inspection of the body. This patient had inhaled chloroform on two
previous occasions for a similar operation.
_Case 25_ occurred in St. Bartholomew’s Hospital, on March 17, 1852.
Thomas Hayward, aged 23, was suffering from aneurism by anastomosis,
occupying the right ear and its neighbourhood. He had inhaled chloroform
on the 14th of the previous month, whilst Mr. Lloyd placed ligatures on
the temporal artery and some other arteries supplying the tumour; and it
was with a view to tie an additional artery, situated between the
mastoid process and the ramus of the jaw, that chloroform was again
administered.
“The chloroform was some of the same, and the apparatus employed for its
administration precisely similar [alluding to the former occasion.] It
was administered by one of Mr. Lloyd’s dressers, who well understood,
and had great experience in its use. A gentleman of great experience,
who had been for years at the hospital, and two years house-surgeon, was
watching its effects, and marking the state of the pulse. Other
gentlemen were assisting, and also on the look out.
“In from five to ten minutes the usual effect was produced, the patient
having previously struggled much. The operation was then commenced; but
no sooner had Mr. Lloyd cut the skin, than it was stated that the pulse
had suddenly ceased. The chloroform was at once removed; but in a few
seconds, the patient had ceased to breathe, and no pulsation could be
felt at any of the arteries or the heart.
“Artificial respiration, as well as percussion and compression of the
different parts of the body, were immediately employed with energy; and,
after continuing the means for a short time, the circulation was
observed to be returning, and the act of respiration was several times
performed. The state of inanimation, however, speedily returned; but, by
the employment of the same means as before, with the use also of
galvanism, the circulation and respiration were again restored. Quickly,
however, the patient fell into the same state as at first, but was again
restored by the same means.
“In a few minutes the state of inanimation again returned, when the
external jugular vein, which on the right side was very turgid, was
opened, and tracheotomy was performed, and the lungs inflated. The
patient was also placed in a warm bath, at the temperature of 104°,
artificial respiration being kept up all the time. All, however, was of
no avail.”[92]
At the examination of the body, the following are amongst the
appearances noted. “The venæ innominatæ and vena cava superior were full
of blood, and probably would have been distended, but that two or three
ounces of blood had flowed into the coffin from the opening made into
the external jugular vein. The right auricle and ventricle were
distended with blood, and would probably have been more so but for the
escape of blood mentioned above. The left auricle and ventricle
contained very little blood; the left ventricle was perfectly contracted
in the rigor mortis. The heart was of full size. It appeared in every
part natural in its texture, and as if it had possessed full power. Its
valves also were all healthy; neither could any disease be found in any
of the chief bloodvessels within the chest. All the blood, however, was
fluid, and it remained without coagulation after its escape from the
heart and vessels. It had also a brownish purple hue, much like that
which is commonly observed in the spleen: none of it, when thinly spread
out, presented the ordinary dark, black, or crimson hue of venous blood.
Both lungs were attached by old adhesions about their apices and
posterior surfaces, but these were of small extent. Their texture was
healthy, but they appeared more than usually collapsed and dry. Their
bloodvessels were not over filled.”[93]
In this case, every precaution seems to have been taken, except that one
which is most essential of all, of regulating the proportion of vapour
in the inspired air. It had always been made a great point in St.
Bartholomew’s Hospital to attend to the pulse very carefully,[94] and on
this occasion it was closely examined, but only, as in some other cases,
with the result of being able to note the moment when it suddenly
ceased.
With regard to the return of the circulation, which is mentioned in the
report as having occurred on three occasions, together with the
breathing, during the efforts at resuscitation, I understood from
inquiries I made of a gentleman present, that this was judged of from
the red colour returning to the face and lips, but that the pulse and
sounds of the heart were never distinctly perceived after they first
ceased. The respiration may cause the colour to return to the face
without a true circulation, as I have seen whilst inflating the lungs of
still-born children; for if a portion of red blood be mechanically
displaced from the lungs by the motion of the chest, it will be
propelled by the contractility of the arteries, which continues for some
time after death.
_Case 26_ is related by Dr. Majer, of Ulm.[95] It occurred on June 27th,
1852. The patient, Madame W., was 32 years of age, and of good
constitution. She was in very good spirits, and was only waiting the
operation of having a tooth extracted, before going to dinner. It was
stated that only twenty or twenty-five drops of chloroform were put on a
sponge, which was surrounded by a handkerchief. After four or five
inspirations, the operator inquired if his patient did not feel a
singing in the ears. She replied with a trembling and thick voice. At
the same time she stretched out her limbs, the face became bluish, the
eyes haggard, the head and the arms fell—she was dead. The patient’s
husband said, that the time between the inhalation and death was so
short that one could scarcely have said Yes or No.
An examination of the body was made twenty-five hours after death.
Putrefaction had commenced, and the body was not rigid. The vessels of
the membranes of the brain were gorged with blood containing many
bubbles of air. The heart was soft and flaccid; the coronary vessels
were engorged with blood and air; the cavities of the heart contained
air, but little blood. The lungs were congested at the inferior parts.
_Case 27_ took place at Melbourne, Australia. The name of the patient
was Mr. John Atkinson, but his age is not stated. Dr. Thomas, who was
about to operate for fistula _in ano_, said: “Before administering the
chloroform, I asked the deceased particularly if he had ever suffered
from any serious illness, to which he replied in the negative. I also
inquired whether he had been subject to cough or palpitation, and he
answered that, some time ago, he had suffered slightly from cough. The
pulse was good, and Mr. Barker proceeded in the usual manner to
administer the chloroform, which shortly produced convulsive twitchings
of the muscles. I then went to the door to request the nurse to send up
some person to assist in holding the patient in a proper position for
the operation, and I returned to the bed, and poured a little more
chloroform on the handkerchief; when it was applied to the face, I heard
him splutter at the mouth; the chloroform was instantly discontinued,
but the patient suddenly expired. We tried all the means usually
resorted to in other cases of suspended animation, but without effect. I
had frequently used the same chloroform in other cases. It was not more
than a minute after the first application of chloroform that death
occurred. About a drachm had been poured on the handkerchief.”
At the examination after death, “there was considerable serous effusion
into the pericardium, and the heart itself was larger and more flabby
than usual. It was hypertrophied, and there was dilatation of the
cavities; the lungs were healthy, and there was a slight appearance of
disease about the liver, such as is observed in persons addicted to
intemperance.”[96]
_Case 28._ On August 10th, 1852, a Mr. Martin, a cattle dealer died near
Melrose, in Scotland, after inhaling chloroform for the application of
potassa fusa to some ulcers of the leg. Dr. W. M. Brown, who relates the
case, says:—“Before proceeding to apply the caustic I gave him
chloroform. He was not easily affected by it, and struggled a good deal.
After beginning to apply the caustic I found he was not sufficiently
insensible to pain, and gave him a little more chloroform, which had the
desired effect. I then proceeded with the application of the caustic,
and was just finishing, when I observed a sort of catch in his
breathing. I immediately stopped, and, on looking at him, I saw the
mouth and eyes open, the breathing irregular, the face pale, the eyes
slightly turned upwards, and the pupils dilated.” Dr. Brown tried
artificial respiration and other means to resuscitate the patient, but
without effect. He says, “in a few minutes the man died.” The pulse is
not mentioned, nor the age of the patient.[97]
_Case 29_ took place in the Manchester Royal Infirmary, on December
24th, 1852, during the removal of a malignant tumour of the thigh, by
Mr. Jordan. The patient was Henry Hollingsworth, a factory operative.
His age is not stated. “The man was very much excited, struggled and
talked fast. The chloroform was administered slowly, and every
precaution was taken to prevent any danger, and the medical men remarked
two or three times how very long it was in taking effect. He at last
became insensible, in about seven minutes at least. Mr. Jordan commenced
the operation by an incision into the skin covering the tumour. I was
assisting the surgeon when Mr. Heath directed my attention to the
patient’s face. This was about five minutes after the operation had
commenced. I then observed congestion about the face, but there was no
stertorous breathing. His pupils appeared almost to have ceased to act.
His breathing was becoming exceedingly slow, and he seemed to be sinking
fast. I directed the attention of the operator and the other medical men
to these symptoms. The operation was then suspended, and means were
resorted to for restoring animation, but the pupils had ceased to act,
and had become fixed almost immediately. He gave one strong gasp, and
then to all appearance was dead. In administering the chloroform,
successive doses were given until it took effect. Every dose consisted
of a drachm, taken, at intervals, in an inhaler.”[98]
The following remark is made respecting the autopsy. “The post-mortem
examination shewed that asphyxia, caused by chloroform, produced the
death. There was a congestion both of the brain and lungs.” The
appearances met with after death from chloroform do not indicate the way
in which death has taken place. In animals that are killed by it, the
right cavities of the heart are always found filled with blood, whether
they die suddenly by its direct action on the heart, or more slowly by
its effects on the brain, and the breathing ceases before the
circulation. The lungs are seldom much congested in animals, whichever
be the mode of dying, and the appearances in the head are not unusual.
The state of the pulse is not mentioned in the above account of the
case; but congestion about the face was first observed, and then it was
noticed that the breathing was getting slow. It is sufficiently probable
that the breathing ceased on account of the action of the heart being
first arrested; but even if the respiration was embarrassed by the
action of the chloroform on the brain, it is pretty certain that that
agent also acted directly on the heart; for it cannot be supposed that
the means used for restoring animation would have failed, if the heart
had been acting properly when the breathing ceased.
_Case 30_ took place on March 19th, 1853, in University College
Hospital, London. The subject of it was an unmarried woman, named
Caroline Baker, aged twenty-eight. The chloroform was administered with
the intention of applying nitric acid to a sloughing ulceration of the
labia and vagina. “The chloroform, supposed in the first instance to be
about a drachm, was poured on lint about five inches square, and folded
four or five times over. After a short time the patient became restless,
talked loudly, and threw about her arms. Soon afterwards a partial
relaxation of the limbs took place, and she became insensible and
pulseless.”[99]