The breathing is not mentioned, but Mr. Erichsen, who, although not
present at the accident to his patient, would be made aware of all that
occurred, stated at the inquest, that death was produced by a paralysis
of the heart from the influence of the chloroform. Dr. Quain examined
the structure of the heart with the microscope, and he “found that
organ, particularly on the right side, in a state of fatty
degeneration.”
_Case 31_ was communicated to the Society of Surgery of Paris by M. De
Vallet, Surgeon-in-chief to the Hôtel-Dieu, d’Orléans. “A soldier of the
line, aged twenty-five, apparently in good health, and of strong frame,
consulted M. Vallet for a small tumour situated behind the right labial
commissure. Before operating, he proceeded to direct the inhalation of
chloroform. The patient, fasting, being placed in the horizontal
posture, the chloroform (about one gramme) was poured upon a hollow
sponge, and applied to the nose, the mouth being left free. At the
expiration of a minute, no effect having been produced, four grammes
were poured on the sponge, and at the expiration of four minutes, the
patient, without having experienced any irritation of the larynx,
without having manifested any resistance, without redness of the
countenance, and after only a slight period of agitation, fell into a
state of insensibility fit for the operation. Scarcely had the incision
been made, necessary to expose the cyst, when the patient became pale,
respiration was suspended, and he sank into a state of complete
collapse. All the usual remedies were tried, and without avail. M.
Vallet opened the trachea, and performed artificial respiration with an
elastic tube; then an electric current was sent by needles through the
region of the heart. The patient died without any sign of reaction.
“Examination of the body.—The vessels of the brain were empty; the lungs
were congested with blood, which in some situations was extravasated;
the heart was excessively flaccid; there were some soft clots in the
right cavities; the left were empty. The stomach was full of gas; the
liver, spleen, and kidneys were gorged with black blood.”[100]
_Case 32_ occurred in the Royal Infirmary of Edinburgh to a man aged
forty-three, on whom Dr. Dunsmure was about to operate for stricture of
the urethra by perineal section. The chloroform was administered by Dr.
Struthers. About an ounce of chloroform was used, and the patient had
been put under the influence of this agent on two former occasions, when
a similar quantity was employed without ill effect. The following is Dr.
Dunsmure’s account of the case:—
“While the patient was inhaling the drug, he struggled considerably, and
became a good deal congested in the face and head. He seemed to take a
slight convulsion, like an epileptic fit, and such as I have seen on
several occasions in people who have led an intemperate life. During the
convulsion, the handkerchief containing the chloroform was removed to
some distance from the face. In a short time the inhalation took effect,
and he began to snore, and although still violent, the chloroform was
removed from the face entirely, and the handkerchief placed under the
pillow. As soon as the patient became more quiet, he was pulled down on
the table, and placed in the proper position for the operation. I then
shaved the perineum, and was just going to make my first incision, when
one of the assistants said that his pulse was becoming weak. The
posterior tibial, Mr. Spence then remarked, was good, but in a second or
two after, both gentlemen exclaimed that the pulse was gone. I rushed
from my seat to the patient’s head, and found that his breathing had
ceased. Those present who had an opportunity of observing the
respiration, which I had not, owing to the stool on which I sat being
low, positively assert that the breathing did not cease before the
pulse. The face was much congested, the jaws were firmly closed, and the
pupils were dilated. I immediately forced open the lower jaw by means of
the handle of a staff, and with catch forceps pulled out the tongue.
Artificial respiration was had recourse to, and in a few minutes he made
a long inspiration. This was soon followed by a second, by a third at a
longer interval, by a fourth at a still longer period, and then by a
fifth, when all attempts at natural breathing ceased. No pulsation could
be felt in the radial arteries. The chest was noticed to be much
contracted, to have apparently lost its elasticity, and not to expand
when the ribs were forcibly compressed during the artificial
respiration. I had previously sent for a galvanic apparatus, which was
in the flat below, and it arrived almost immediately after the patient
had made the fifth inspiration. When the tongue was pulled out, and
before the first breath was taken, I was on the point of opening the
trachea, but this proceeding was then abandoned; it was now, however,
had recourse to, in order to carry on artificial respiration more
certainly: the external jugular was also opened, and about a couple of
ounces of blood flowed. By the time the tracheotomy tube was inserted,
the galvanic apparatus was in working condition, and it was applied on
each side of the diaphragm. It acted remarkably well; at each
application of the sponges, the muscle descended as if the patient was
in life; air passed through the tube in the trachea, and for some time I
was in great hopes that the man was to be saved; but the muscle
gradually lost its contractility, and although the galvanism was kept up
for an hour, it was evident that all our efforts were in vain—that life
was extinct. The post-mortem examination was made the following day at
one o’clock, rather more than twenty-four hours after the patient’s
death, and I give the report of it as drawn up by Dr. Gairdner, the
pathologist to the Infirmary:—
“John Mitchell, aged forty-three, died 28th September. A very robust
man; height five feet eight inches; diameter (lateral) of base of
thorax, ten and a half inches.
“External appearances.—Considerable lividity of face and neck, and more
than usual congestion of depending parts. Considerable amount of fat,
but more in omentum and around viscera of abdomen than in external
parietes.
“Chest.—Right pleura presents a few slight adhesions near the middle;
left pleura free. No fluid in either pleural cavity. Pericardium
contained about half an ounce of serum, and presented a few opaque
patches on its surface. Both sides of heart contained blood, the right
side rather more than the left. Blood more than usually fluid. External
fat of heart considerable, about three lines on some parts of right
ventricle. Muscular tissue of heart generally flabby, and rather pale,
but not distinctly disorganized to the naked eye. Valves perfectly
healthy. Aorta presented very faint traces of atheroma. A few traces of
atrophy of right lung towards its apex and anterior edge, but very
limited. In all other respects lungs free from disease, but somewhat
congested.
“Spleen soft, but not diffluent.
“Liver congested, but otherwise normal.
“Kidneys congested, but otherwise healthy.
“Brain.—The subarachnoid fluid presents considerable milky opacity, and
is of moderate quantity. Moderate congestion of the meninges generally.
About half an ounce of fluid in the ventricles. Substance of brain
healthy. Arteries at base perfectly free from atheroma. Air
passages.—Glottis perfectly patent. Mucous membrane of larynx and
trachea slightly congested.
“Microscopic examination shewed the fibres of the heart to be nearly
normal, though scarcely so distinctly striated as in some cases. The
minute vessels of the brain and pia mater presented at some points a few
clustering granules, but to no great extent.”[101]
Dr. Dunsmure expressed the opinion that four or five minutes elapsed
from the time the chloroform was left off before the pulse failed. But
it is pretty certain that he has much over-estimated the time. Indeed,
if the shaving of the perineum were likely to occupy even half of this
time, the operator would have done it, or had it done, before the
chloroform was administered. Dr. Dunsmure makes the following remark in
his comments on the case: “In several instances where I have seen
chloroform very nearly prove fatal, the respiration became gradually
restored after an inspiration had once been made; in this case, however,
no such fortunate occurrence took place.” In the other cases to which
allusion is here made, the heart has not been paralysed, or at least not
completely, but they show that the method of administering chloroform in
Edinburgh had been far from satisfactory in its results, although no
patient had before that time been actually lost.[102]
_Case 33_ occurred in University College Hospital, London, and the
following account of it was given by Dr. Hillier:
“E. R., aged 40, a woman of moderate height, rather thin. The general
health has been pretty good; she had not been liable to palpitation or
dyspnœa. Had been in the habit of drinking pretty freely. Admitted on
October 5th, at 11 p.m. She was suffering from the symptoms of
strangulated hernia, which had existed two days and a half. Efforts were
made to reduce the hernia, both without and with a warm bath, in which
she was for upwards of half an hour without getting very faint. These
efforts being unsuccessful, an operation was at once determined on. Her
pulse was at this time regular, and of tolerable strength.
“Chloroform was administered in the usual way, on a piece of lint, which
was held three or four inches from the patient’s face, and then brought
to within an inch and a half of her nose and mouth, leaving space around
for the admission of air.
“For three or four minutes nothing unusual presented itself; the pulse
and respiration proceeded normally. There was put on the lint, at first,
one fluid drachm of chloroform; and, at the end of three or four
minutes, forty minims more were added. This was the whole quantity of
chloroform employed. Within a minute after the second quantity of
chloroform was added, the patient struggled violently both with her arms
and legs. During these struggles I was holding her right hand, and was
unable to feel the pulse in consequence of her constant motions. The
struggling lasted about a minute, and on its ceasing, the patient
commenced to breathe with loud, rough stertor. I at once removed the
lint from before the face, and felt for the pulse, which I could not
find. Immediately cold water was dashed on her face. She breathed with
this stertor for two or three short inspirations, and then two or three
long ones, and then the breathing ceased. Immediately artificial
respiration was resorted to, and within a minute galvanism was applied
to the back of her neck and the diaphragm. Under the influence of these
agencies, the patient gasped about three times at intervals; after this,
no further signs of life were exhibited.
“At the time when the stertor commenced and the pulse failed, the pupils
were dilated, and the face of the patient was only slightly altered. The
tongue was not retracted, for one of the bystanders at once put his
fingers into her mouth to ascertain this.”
At the autopsy made by Dr. Garrod thirteen hours after death, the rigor
mortis was well marked; the blood was very fluid in all parts of the
body. There was about an ounce of colourless fluid in the pericardium.
The heart was quite collapsed and empty, but, as Dr. Garrod observes,
this may have been due to the fluidity of the blood. The weight of the
heart was seven ounces and three-quarters; valves healthy. Walls of the
right ventricle flabby and pale; mean thickness one eighth of an inch.
At some parts the muscular substance was in a very thin layer, being
much encroached on by fat. In several places there was scarcely any
muscular fibre visible. This was chiefly the case near the apex.
Examined by the microscope, much fatty degeneration of the muscular
fibres of the right ventricle generally was discovered. The walls of the
left ventricle were flabby, dry in appearance, pale, and very friable.
Both lungs were crepitant throughout, not much engorged. Brain not
congested. The intestines above the strangulation were much distended
with flatus, and inflamed.[103]
_Case 34_ occurred on October 20th, 1853, a few days after the last. The
patient was a young woman named Ann Smith, aged 22 years, under the care
of Mr. Paget in St. Bartholomew’s Hospital, who was about to apply the
actual cautery to a sore of cancroid nature in the vagina. She was a
stout, florid young woman, formerly of dissolute habits, but apparently
in perfect health, with the exception of the local ailment. She had been
put under the full and prolonged influence of chloroform a fortnight
previously for the application of the cautery, without the occurrence of
any untoward symptoms whatever. The chloroform was administered by Dr.
Black, one of the assistant physicians.
“The usual form of inhaler was employed,—a padded metal cup, fitting
over the nose and mouth, and supplied with valves. A drachm, by measure,
was first poured on the sponge, but as the administration did not
immediately commence, a considerable part of this was no doubt wasted;
after a short inhalation, a second drachm was supplied, and subsequently
the further quantity of half a drachm. The patient had gone through the
usual stages of excitement, etc., and the last dose was scarcely used,
as she sank off, almost immediately after its application, into a state
of complete insensibility, unattended by any alarming symptoms. About
five minutes had been occupied by the inhalation, and probably not more
than a drachm and a half of the fluid really inhaled. The apparatus was
now removed from the face, and the patient having been drawn into the
proper position, Mr. Paget was about to commence the operation, when Dr.
Black, who throughout had kept his finger on the pulse, noticed it to
have become extremely weak and fluttering. Almost immediately
afterwards, the patient’s countenance was observed to be dusky, turgid,
and congested, and the respiratory movements began to be performed at
long intervals, and by slight catching efforts. No time was lost; cold
water was at once dashed on the thighs, face, and breast; and, the
failure of the respiration becoming shortly complete, Mr. Paget
immediately began artificial insufflation of the lungs, by alternately
blowing into the nostrils, and compressing the chest. Just before
commencing this process, Mr. Paget had ascertained, by drawing the
tongue forwards and examining the glottis with the finger, that the
epiglottis was not pressed down.”
Other means were employed, but no further signs of life appeared. It is
further recorded that, “immediately after the first alarming symptoms,
the pupils were of the medium size, neither contracted nor dilated. All
efforts at respiration ceased about two minutes after the first
indications of failure; the pulse, however, as a very feeble flutter,
was felt occasionally for at least two minutes later.”[104]
At the autopsy, performed by Mr. Paget, twenty-two hours after death,
“the thorax was first examined, and nothing whatever abnormal could be
detected in any of the viscera; the lungs were healthy and crepitant in
every part; their posterior lobes were not more congested than is seen
in almost every examination; the heart, collapsed, but not contracted,
and containing a small quantity of fluid blood in each cavity, was of
normal size and proportions, in every respect, and its muscular
structure, examined by the microscope, showed no degeneration.... The
brain, its sinuses, ventricles, etc., were all carefully examined, and
neither in texture nor quantity of blood was anything abnormal
detected.”[105]
Although the failure of the pulse was the first symptom of danger in
this case, it continued to be felt as a very feeble flutter for about
four minutes, so that the heart was not so completely paralysed as in
most of the fatal cases. It must, however, have been so far paralysed as
to be past recovery.
_Case 35._ Professor Dumreicher related a case of death from chloroform
at the meeting of the Vienna Society of Physicians, held on November 16,
1853. The patient was a young man, aged nineteen, in somewhat feeble
health, who inhaled chloroform in the recumbent position, in order to
have his anchylosed knee-joint forcibly extended. It was inhaled from a
vessel resembling a snuff-box, which was held to the nostrils. “The
inhalation was continued for fifty seconds, and the patient had spoken a
few seconds previously, when Professor D. observed that the pulse had
become frequent and undulating. He immediately suspended the
administration of the anæsthetic. Trismus occurred; the respirations
became irregular; the face turned livid, and he foamed at the mouth.”
The measures which were employed included the abstraction of eight
ounces of blood from the jugular vein, but they were of no avail. He
only once made a feeble attempt at inspiration.[106]
_Case 36_ occurred in the practice of Dr. Wüstefeldt of Neustedt. “A
young girl, thirteen years of age, had on the dorsal region a voluminous
lipoma, which extended from the last dorsal vertebra to the crest of the
ilium.... One drachm of chloroform was employed. As soon as
insensibility was manifested, the operation was commenced, but scarcely
had the surgeon divided the skin, when the girl, yielding to the laws of
gravity, fell suddenly forwards on her chest. Dr. Wüstefeldt, struck by
the phenomenon, which he had witnessed before under similar
circumstances, immediately desisted from operating, and strove to
restore the patient to life; but every effort was useless, and, in the
course of a few minutes, it became evident that she was dead.”[107]
Further particulars are not given; but as the patient died suddenly,
when the surgeon had scarcely divided the skin, it must be admitted that
he was, in all probability, correct in attributing the event to the
chloroform. The patient usually yields to the laws of gravity when only
partially under the influence of chloroform, and it seems surprising
that the operation should have been undertaken without placing the
patient in the horizontal posture. The proper position of the patient,
when a large tumour of the back is to be removed, is to be lying almost
flat on the abdomen, the head being a little turned on one side, so that
it rests with one ear on the pillow.
_Case 37._ Jane Morgan, aged fifty-nine, died whilst inhaling chloroform
in the Bristol Infirmary, on January 21st, 1854. She was moderately
stout, pale, but not otherwise of unhealthy appearance. “The
stethoscopic indications were favourable, the beat of the heart was
natural, and the air passed freely throughout both lungs; but the chest
movements on the right side were not quite so free as on the left.”
Chloroform was ordered by Mr. Harrison, the senior surgeon of the
Infirmary, with the intention of attempting to reduce a dislocation of
the humerus of eight weeks standing. “Having taken no food since her
breakfast, she commenced the inhalation of one drachm of chloroform, at
2 P.M., in bed in her ward, under the superintendence of Mr. Hore, the
house-surgeon. Nothing unusual occurring in the patient’s general
condition during inhalation, a second drachm, in about five minutes from
the first, was poured upon the sponge, and the inhalation was continued.
Almost immediately after the addition of the second drachm, the
chloroform was withdrawn, as the patient’s breathing became stertorous;
and immediately afterwards her pulse, which had hitherto continued
pretty firm, was suddenly imperceptible, the respiration ceasing at the
same time. The pupils were not dilated.” Various measures were promptly
resorted to with the hope of restoring the patient; but there were no
further signs of life, unless “some convulsive efforts of the
respiratory muscles,” under the application of galvanism, be so
regarded.
At the examination of the body on the following day, the right pleura
was found to be adherent. The lungs were healthy in structure, but
gorged with dark fluid blood. There was about an ounce of fluid in the
pericardium. There was a small quantity of fluid blood in each of the
cavities of the heart. For the length of an inch from their
commencement, both coronary arteries were much dilated, and studded with
atheromatous and bony deposits. The muscular structure of the heart was
examined under the microscope by Dr. William Budd, and a considerable
proportion of the fibres were found in a state of incipient fatty
degeneration. It was learned, after her death, that she had been subject
to occasional attacks of fainting.[108]
_Case 38._ A death from chloroform occurred in the Hôpital St. Antoine,
at Paris, in the spring of 1854. The subject of this was a woman aged
forty, on whom M. Richard was operating for the removal of a uterine
polypus. The surgeon placed the patient in the horizontal posture, and
administered the chloroform on a compress of lint. She became insensible
in two minutes, having first been excited so that it was necessary to
hold her. M. Richard moved the patient to the edge of the bed, gave the
compress containing the chloroform into the hands of an assistant, and
commenced the operation, which was likely to be of short duration. He
had almost completed it, when he was apprised by an assistant, who had
been set to feel the pulse, that it had ceased to beat. He sought for it
himself, but found that it did not beat. The face was extremely pale; a
slow respiration still continued, but soon ceased; and the measures
which were used with the hope of restoring the patient were of no
avail.[109]
At the examination of the body all the organs were found in a healthy
state. The right cavities of the heart and the great veins contained a
considerable quantity of blood, and the left cavities of the heart a
small quantity. The blood was everywhere fluid.[110]
_Case 39._ A patient, named Mrs. Harrup, died at Sheffield from the
effects of chloroform administered with the intention of removing a
cancerous tumour of the left breast. The age of the patient was
forty-five, and she was stated to be in good health, excepting the local
affection.
“The chloroform was administered with more than the usual precautions.
After the inhalation had gone on without any effect for twenty minutes,
it was thought that possibly different chloroform might succeed, and one
ounce was accordingly procured from the public dispensary. After the
inhalation had been conducted with the fresh chloroform about twenty
minutes, the usual effects of the vapour began to manifest themselves.
The pulse, which was 136 before any chloroform had been given, and had
been very gradually decreasing in frequency while it improved in
strength, was now about 104. At this moment muttering—half articulate
delirium—came on, but ceased in a few moments, and was immediately
followed by conclusive signs of the satisfactory action of the
chloroform. Dr. Law now desired Mr. Wright to begin the operation; but
before he could do so, Dr. Law, seeing an alarming change in the
countenance of the deceased, cried, ‘Stop, Mr. Lewis, how is the pulse?’
I replied, ‘It is gone.’” After stating the means which were used with a
view to resuscitate the patient, it is added that the heart had ceased
to beat, and that, after a few short and laboured inspirations, life
became extinct.
At the examination of the body, the cartilages of the ribs were found to
be ossified. The heart and lungs were perfectly healthy, but the lungs
were in a congested condition. There was an extravasation of blood in
the spinal muscles, and a little blood in the spinal canal, in what part
or between what structures is not stated.[111]