Hollis, a tailor, aged eighteen, had been under treatment for sores
within the prepuce, and these having healed, he was about to undergo the
operation for congenital phymosis. He had been of dissolute habits, and
exhibited a pale cachectic appearance.
“The inhaler used was a simple mouth-piece by which the nostrils are
left uncovered. About two drachms of the fluid were poured into the
instrument. After about six minutes inhalation, insensibility seemed to
be coming on, and at this moment the pulse was ascertained to be of good
volume. Nothing whatever had occurred to indicate the impending danger,
when, after a few more inhalations, the pulse suddenly failed, became
quite imperceptible, and the countenance assumed a pale and leaden hue.
The inhalation was immediately stopped, and attempts to resuscitate, by
means of striking the chest sharply with a wet towel, applying ammonia
to the nostrils, and by artificial respiration, were at once commenced.
These were employed for three or four minutes before any signs of life
were perceived; but, subsequently, the pulse was again to be felt, and
spontaneous respiration was renewed. Artificial respiration was desisted
from on the occurrence of these signs of returning life, and for upwards
of ten minutes the chest continued to fill regularly, and the pulse beat
at a rate of from 40 to 50 in the minute; the countenance of the patient
also much improved, and even assumed a slight flush. After the
expiration of, perhaps, a little more than ten minutes, however, these
indications of returning vitality again disappeared, the pulse and
respiratory efforts simultaneously ceased, and the countenance became
deathlike. Artificial respiration and the other means were again
adopted, but this time without the slightest success.... Post-mortem
examination on the next day shewed great venous congestion within the
cranium; the lungs were also somewhat congested. The heart was slightly
enlarged, and the ventricular parietes were thinned; in the muscular
fibres the microscope detected decided fatty degeneration. The blood was
universally fluid.”[112]
The partial recovery of the patient is a remarkable feature in this
case, and it is difficult to explain why he did not recover completely.
The number of the pulsations during this partial recovery is mentioned,
but not their quality, and I cannot help supposing that the pulse must
have been extremely weak, as well as slow, at this period. The ten
minutes during which the pulse and breathing returned is mentioned with
the qualifying term of “perhaps”, which leads to the supposition that it
was not noted by the watch or clock, and under such circumstances of
anxiety and suspense, the time might be very much over-rated. The slight
fatty degeneration of the heart might probably interfere with the
complete recovery of the patient, after this organ had once been
paralysed by the chloroform.
_Case 41_ took place on July 13th, 1854, in the Middlesex Hospital. The
patient was a stout, muscular, and florid man, 65 years of age, on whom
Mr. De Morgan was about to perform amputation at the upper part of the
thigh, on account of a large malignant tumour growing from the inner
side of the femur.
“Chloroform was administered by Mr. Sibley, the registrar to the
hospital. Snow’s inhaler was employed. The quantity at first placed in
the inhaler was rather less than two drachms, and another drachm was
added eight minutes afterwards. The patient inhaled the chloroform
without difficulty, and went through the usual stages; at the end of
about ten minutes violent spasm was induced; this continued about three
minutes, and then somewhat abated. The pulse, which had risen to about
120, descended to 70, having a full, steady, and deliberate beat. The
pupils, which had been much dilated, became less so. The respiration
continued free and deep, but not stertorous. The colour of the face
remained good.
“At this moment, which was between thirteen and fourteen minutes from
the commencement of the inhalation of the chloroform, the pulse gave a
few rapid and irregular beats, and then ceased. Respiration, which, as
has been stated, had been going on freely, ceased simultaneously. The
face became suddenly pallid and deathlike. The inhaler was removed
instantaneously, and cold water dashed on the face. Mr. Sibley
immediately commenced to carry on artificial respiration, by applying
his mouth to that of the patient, and inflating the lungs. The period
that elapsed between the sudden cessation of the pulse and the inflation
of the lungs was only a few seconds. After a few inflations, there
appeared to be a slight effort at inspiration, but this was the only
sign of life discovered after the syncopal attack. Galvanism was in
operation within two minutes after the cessation of the pulse.”
“An examination of the body was made by Dr. Corfe forty-eight hours
after death. In the head nothing particular was discovered; the brain
was firm, and rather more vascular than natural; the blood in the sinus
was partly coagulated; the heart was rather larger than natural, and was
extremely loaded with fat, especially on the right side, where fat
formed three-fourths of the thickness of the wall of the ventricle; the
muscular tissue was extremely pale and soft, and exhibited both to the
naked eye, and the eye assisted by the microscope, an extreme degree of
fatty degeneration; the blood in the cavities of the heart was firmly
coagulated; on both sides it was almost purely fibrinous; the clot on
the right side was larger than on the left; a fibrinous clot extended
down the aorta.”[113]
I do not know how the bibulous paper was arranged in the inhaler in this
instance, nor whether the inhaler was used with a view to regulating the
amount of vapour in the inspired air. The proportion of vapour must have
been small during the first ten minutes, as the patient became so slowly
insensible; and judging from the result, we must conclude that the
proportion was large just before the accident. The firm coagulation of
the blood and separation of the fibrin were probably owing to the
galvanism which was so promptly applied. I found the fibrin separated
from the colouring matter of the blood in the cavities of the heart of a
cat, in which shocks of electro-magnetism had been sent through the
chest just after it had been killed with chloroform.
_Case 42._ A man died whilst inhaling chloroform in University College
Hospital on October 11th, 1854. The patient was a shoemaker named George
Sands, aged 39, and of rather bloated aspect. He inhaled chloroform
whilst Mr. Erichsen was endeavouring to introduce a catheter, and had
the intention of puncturing the bladder if not successful. The patient
was made insensible, and the chloroform was left off, but was reapplied
on account of the patient making some expression of pain. “Probably
about two minutes of the second inhalation had elapsed, when the man
became profoundly insensible, and began to snore with a peculiar and
very profound stertor. His face at this time was suffused and flushed,
and the inspirations were drawn at rather prolonged intervals. Mr.
Erichsen’s attention was at once excited by these symptoms, and,
desisting from the use of the catheter, he immediately commenced dashing
the patient’s face and chest with water. The chloroform had, of course,
been removed. In the course of about a minute, the noise with the
breathing gradually lessened, and it became apparent that the
respiration was ceasing altogether. Mr. Erichsen now put his finger into
the patient’s pharynx, and dragged forwards the root of the tongue; at
the same time attempting artificial inflation of the lungs, by applying
his own mouth to that of the man. The latter plan did not appear to
succeed well, and was almost immediately substituted by the more usual
mode of artificial respiration, by compression of the chest, which was
kept up most vigorously. The man’s pulse had been felt by the
administrator [Mr. Carnell] to be still beating some little time after
the commencement of the alarming symptoms and the cessation of
respiration. Artificial respiration had been employed for about four
minutes, when the man, whose countenance had meanwhile retained its
colour and an expression of yet remaining life, began to breathe again.
A very short intermission of artificial assistance having been made, he
drew spontaneously three or four inspirations; but, as each successive
one was more feeble, the artificial aid was at once recommenced. About
five minutes from the commencement, the galvanic apparatus was got in
readiness and applied. It produced, however, no benefit; and from this
time the patient lost colour in the face, and was evidently dead.... The
form of inhaler which had been employed was the one in ordinary use at
this hospital, viz. a folded piece of lint. The administrator’s hands
and the patient’s face had been covered during the inhalation by a
towel.”[114]
At the examination of the body seventy hours after death, extensive
fatty degeneration of the heart was met with. The cavities of the heart
were empty, owing, no doubt, to the artificial respiration.[115]
The above case differs to a certain extent from those previously quoted,
inasmuch as the first symptoms of danger were those of profound coma,
and of threatened death by apnœa, as a consequence of the action of the
chloroform on the medulla oblongata and nerves of respiration. In
addition to this cause of danger, however, the chloroform present in the
lungs at the moment when the inhalation was discontinued must have acted
directly on the heart, or the prompt assistance of so able an authority
on asphyxia as Mr. Erichsen, the moment the breathing was suspended,
would surely have restored the patient. The mode of death, although not
exactly the same as that in Experiment 24 (page 110), differs from that
in the previous experiment, where the heart’s action was good and
distinct after the breathing ceased; it resembles the mode of dying in
many animals that I have killed with chloroform; being, in fact, a
combination of death by apnœa and cardiac syncope, which generally
occurs when the quantity of vapour in the respired air is intermediate
between that in Experiments 23 and 24, or somewhere between 5 and 10 per
cent.
A great peculiarity in the way in which chloroform was administered in
the case we are considering was that the head and face of the patient
were covered by a towel, under which the lint wetted with chloroform was
held. The countenance and state of respiration could not be observed in
this mode of giving the chloroform; the person administering it had to
depend almost entirely on the pulse; and, except for this cause, there
is every reason to conclude that the chloroform would have been
withdrawn in this instance in time to save the patient. It was not
apparently till a peculiar and very loud stertor attracted the attention
of the operating surgeon himself, that the inhalation was discontinued,
and the face was already suffused.
This plan of administering chloroform with the head and shoulders of the
patient covered with a towel, was introduced by Mr. Clover, who was for
several years a resident officer of the institution; and it is but right
to state that it led to no accident in his hands; in those of his
successors it was, however, less successful; three accidents having
occurred in a little more than a year and a half. I much regret to find
that Mr. Erichsen recommends this method of giving chloroform in the
edition of his work on surgery recently published.
_Case 43_ occurred in Guy’s Hospital, on December 5th, 1854. The patient
was a woman whose leg Mr. Birkett was about to amputate on account of
malignant ulceration. She gave her age as fifty-six, but appeared ten
years older. “In each eye was a fairly marked arcus senilis, but the
woman was not known to have suffered any symptoms referable to thoracic
disease.... The administration of the anæsthetic was conducted by Mr.
Bryant, the inhaler used consisting of a fold of lint, rather larger
than an out-spread hand, and protected on its back by a piece of oiled
silk to prevent wasteful evaporation.... In the first instance, about a
drachm of the fluid was poured upon the lint. The patient inhaled it
kindly; and, after about two minutes, another drachm was added. A stage
of excitement now followed, during which the limbs required to be held.
Insensibility was just fully established, and Mr. Birkett was on the
point of commencing the operation, when Mr. Callaway, who was
compressing the femoral artery, exclaimed that the pulse had suddenly
ceased entirely. The wrist was examined, and the same found to be the
case. Almost immediately afterwards, a long-drawn inspiration, attended
with a deep sighing noise, was observed. For two or three breaths the
cheeks puffed out during expiration; the respiration next fluttered, and
then ceased. Mr. Birkett at once put his finger into the patient’s
mouth, and drew forward the tongue, artificial respiration being
meanwhile commenced by assistants by means of compression of the chest.
A few slight inspirations were attempted by the patient subsequent to
the commencement of the artificial assistance; but they did not
continue, and no sign of vitality was ever afterwards shown.... It must
be noted, that the woman had been very pale both before and throughout
the exhibition, and that no change in her appearance was perceived when
the alarming symptoms occurred, excepting that the superficial veins of
the neck and temple became distended with blood. The cessation of the
pulse was most sudden. Mr. Callaway stated that it was not preceded by
the least premonitory fluttering, the stroke having been good one beat,
and entirely wanting the next. This order of symptoms was of course
suggestive of death beginning at the heart (cardiac syncope), the
cessation of the functions of the nervous system having been markedly
subsequent to that of the circulation....
“Autopsy, twenty-four hours after death (conducted by Dr. Wilks). The
corpse was much emaciated, and the rigor mortis imperfect. The lungs
were much congested with fluid blood, which ran out after incision of
their substance. The heart was of normal size, but soft and flabby; its
left side was nearly empty, the right being distended with fluid blood.
The left ventricle was of good thickness; its muscle of a deep colour,
not encroached on by fat, or in the least mottled, the only observable
departure from a healthy state being its flabbiness. The right
ventricular wall was very thin, the subserous fat having in some parts
almost taken the place of the muscular tissue. The layer of the latter,
however, although much thinned, had still a good colour, and did not
appear to the naked eye as degenerated, an observation which may apply
also to the carneæ columnæ. The liver was in an early stage of
cirrhosis, and the kidneys were both of them mottled, and contained
numerous small cysts in the external part. The brain was rather paler
than usual, its convolutions appeared shrunken and atrophied, and there
was a quantity of serous fluid in the arachnoid sac and in the
ventricles. There was general atheromatous disease of the arterial
system, both in the head and other parts of the body. The blood was
universally fluid, and of a dark colour.”[116]
As far as could be estimated, the time occupied by inhalation was about
three minutes in this case.
_Case 44_ occurred at the Royal Ophthalmic Hospital, on April 10th,
1855, in a man on whom Mr. Bowman was about to perform excision of the
left eyeball. The patient, named John Cannon, was forty years old, and
was moderately stout, florid, and healthy-looking. He had generally led
a temperate life. The disorganisation of the eye was the result of
injury.
“The inhaler used was the one devised and recommended by Dr. Snow....
The administration was entrusted to Dr. Playne, of King’s College
Hospital. In the commencement of the inhalation, the valve of the
mouth-piece was so turned as to admit an abundant supply of air, a point
to which Mr. Bowman directed personal attention. During the first four
minutes (more or less) nothing unusual occurred. Dr. Playne, who had his
finger on the pulse, had noticed that it had rather increased in
fulness, and was of good volume. Rather suddenly, however, just as the
anæsthetic appeared to be producing its effect, symptoms of excitement
occurred. The eyes became fixed and staring, the arms outstretched and
rigid, and the face contorted. It was now impracticable to feel the
pulse, on account of the tossing about of the arms; but, as is usual in
such conditions, the respiration was noticed to be all but, if not
quite, suspended by the spasmodic fixture of the chest. The inhaler was
at once removed, and the face and chest of the patient dashed with cold
water. Almost immediately after, as the respirations had become
extremely feeble and sighing, Mr. Bowman commenced practising artificial
breathing, by the application of his own mouth to that of the patient.
By this means, the chest was made to fill very completely, and the
process was kept up almost without intermission for from five to eight
minutes. During the first three or four minutes after the alarm began,
the patient continued at times to make slight sighing efforts at
voluntary inspiration, and the case was not thought, by those looking
on, to be by any means hopeless. At length, however, these finally
ceased, and from that time it was apparent that the man was dead.... At
the first opportunity which occurred for examining it after the
spasmodic struggling had commenced, the pulse was found to be extinct,
and it remained so ever after, although there were, as stated, feeble
efforts at inspiration. The patient’s countenance changed somewhat
during the treatment, but was mostly suffused and congested.”
At the examination of the body forty-eight hours after death, “the
sinuses, and the veins of the brain generally, were much congested, and
there was some œdema of the brain substance. The heart, excepting some
slight deposits on the curtains of the mitral valve, was healthy. Its
muscular substance was easily lacerable. The right ventricle contained a
considerable quantity of fluid blood, the left was nearly empty. There
were some pleuritic adhesions, and the lungs generally were congested,
being also in some parts full of air. The blood in every organ examined
was fluid, and without trace of coagulation.”[117]
It does not seem that the inhaler used in this case was employed with
the object for which it was contrived—that of regulating the amount of
vapour in the inspired air; and I do not know whether the bibulous paper
was arranged properly in the interior.
_Case 45._ On September 8th, 1855, a lady, aged twenty-nine, the wife of
a physician, died suddenly whilst inhaling chloroform for the relief of
facial neuralgia. I was sent for when the accident happened, and arrived
twenty minutes afterwards. I found the deceased lady without any sign of
life. The face and lips were very pallid. The husband was performing
artificial respiration by mouth to mouth inflation of the lungs, and
alternate pressure on the chest, and I assisted him in this for a long
time, though with no hope that any thing could be of service. Dr.
Barker, of Grosvenor Street, arrived soon after me, and assisted in the
same measures. An inhaler was employed in this case consisting of a
face-piece, like the one above delineated in this work, and a bent metal
tube lined with bibulous paper. Two quantities of ten minims each had
been inhaled, with some relief to the pain, and without causing
unconsciousness when the inhaler and the chloroform were put away in a
closet; but the patient begged to have more chloroform, in order to be
completely relieved of the pain, as she had been on a previous day. Ten
minims more chloroform, as I was informed, were put into the inhaler,
and the patient, being seated on a sofa, began to inhale very eagerly,
but had no sooner commenced than she gave a sudden start, as if taken in
some kind of fit. Her husband laid her on the floor, but she evinced no
further signs of life.
There was no inspection of the body.
The only explanation which the case admits of is that, in her eagerness
to get relief, the patient took one or more inspirations of air very
highly charged with vapour. The symptoms were those of death by cardiac
syncope.
_Case 46_ occurred in the practice of Dr. Roberts, a surgeon dentist of
Edinburgh. The patient was a lady, thirty-six years of age, to whom Dr.
Roberts had administered chloroform on four previous occasions within a
twelve-month. Dr. Roberts says the chloroform was administered in the
usual way, by which he means on a handkerchief. He says: “Mrs. H. had
only taken about nine or ten inspirations, obtaining but a partial
influence of a quantity short of ʒiss poured out from the bottle, and
inhaling it for a space of time certainly less than a minute, when she
said, ‘You must not operate until I am quite insensible;’ and again, ‘I
am not over yet;’ and immediately, even while speaking, she gave a
convulsive start, and with a stertorous inspiration, and with the eyes
and mouth open, sunk to the floor.” Dr. Simpson was sent for, and
arrived within five minutes. Artificial respiration was resorted to, and
after it had been applied for a time, there were a few spontaneous
inspirations, and the pulse, it is said, could be perceived at the
wrist; but these symptoms of reviving animation disappeared.
At the examination of the body, the right cavities of the heart were
found gorged with blood. The walls of the right ventricle were thinner
than natural, and affected to a certain extent with fatty
degeneration.[118]
A paragraph was inserted in some of the Edinburgh newspapers, and
forwarded by Dr. Roberts to the _Lancet_,[119] in which it was implied
that death in this case was not caused by the chloroform. It is,
however, like the preceding case, a well marked instance of the sudden
and fatal action of this agent.
_Case 47._ A sailor, aged thirty, died whilst inhaling chloroform in St.
Thomas’ Hospital, in October 1856, preparatory to having some necrosed
bone removed from one of his fingers. “He did not appear to be in robust
health; still there was no obvious reason against his having the
chloroform, which was accordingly administered as follows. One drachm
was poured on a sponge folded between two thicknesses of lint, and this
held at a little distance from his mouth, while he was sitting in a
chair. He appeared to be going off very comfortably, when the chloroform
was left off for from half a minute to a minute, and then resumed. He
now began to raise his hands and tremble, and kept spitting in the lint,
and appeared as if about to vomit. Suddenly he was violently convulsed
through his whole frame, as if in an epileptic fit. The chloroform was
at once discontinued, and he was laid in a semi-horizontal posture. The
convulsion only lasted for a few seconds, and when it had ceased he
began to breathe with effort and puffing of the lips, and almost
immediately to gasp irregularly. His pulse was almost imperceptible and
intermittent. Artificial respiration was at once performed by alternate
compression and relaxation of the walls of the chest, the tongue being
held out of the mouth by the forceps. Ammonia was applied to the
nostrils, and cold water dashed in the face, and in about a minute he
rallied so as to breathe without assistance, but in a few seconds he
relapsed, and could not be recovered.
“At the post-mortem examination there was found to be fatty degeneration
of the heart, liver, and spleen, and the membranes of the brain were
thickened. The lining of the ventricles presented a peculiar pitted
appearance, apparently from inflammatory deposit. The brain itself was
pale.”[120]