intemperate habits, and had had an attack of delirium tremens three
weeks previously. In the report of this case in the _Association Medical
Journal_, the following is the account of the appearances met with after
death. In the autopsy in the present case, which we observed with
particular care, the brain was in a state of œdema and bloodlessness,
very like the brain in a patient who died from chloroform in the
Ophthalmic Hospital. The liver was fatty; but the heart seemed the very
model or type of the healthiest kind of heart. All the other organs were
also healthy.”[121]
_Case 48_ is related by Mr. Paget as follows. “I am anxious to place
before the profession, at the earliest opportunity, a narrative of a
case in which chloroform proved fatal in my private practice.
“The patient was a boy, nine years old, of delicate constitution, and of
nervous, timid disposition; but with no indication of any organic
disease, except that for which the operation was to be performed:
namely, a tumour of the scapula; for which it was proposed to remove the
greater part of that bone.
“At half-past eight A.M., on February 28th, after the patient had passed
a night of sound sleep, the chloroform was first administered in a room
adjoining that in which the operation was to be performed. He was
alarmed at the thought of being put to sleep, and of what would then be
done, and was very averse from taking chloroform, but he was persuaded
to inhale it; and, though not without resistance, yet with less than is
commonly made by patients of the same age, he was brought under its full
influence in about three minutes. He sat in bed during the first few
inspirations, and after these, was recumbent. It was observed that two
or three deep inhalations were quickly followed by complete
insensibility; and the next few inspirations were stertorous. He was at
once carried, in the horizontal posture, into the room, and laid on the
table, arranged for the operation.
“Three or four minutes passed while we were arranging his position and
his dress, and while I was pointing out to those who were to assist me
the proposed plan of operation. During this time the influence of the
chloroform so far passed off, that he became sensible, displaced his
coverings and pillows, said something expressive of discomfort, and
vomited a small quantity of frothy fluid. (He had taken no food since
the previous night, when he had had a good supper.) A very small
quantity more of chloroform was slowly inhaled, and he became again
nearly quiet, and was again placed on his side. I was on the point of
commencing the operation, but as he again, by movements, indicated some
degree of sensibility, and changed his posture, about forty drops more
of chloroform were poured on cotton wool, inclosed in a fold of lint,—an
inhaler, with the chloroform on sponge, having been previously used. The
lint was held, about half an inch from the face, by Mr. Thomas Smith, my
usual assistant in operations. The patient inhaled lightly for a few
times, then made one long inspiration, and appeared to pass at once into
deep sleep. Except that he thus appeared to come suddenly under the full
influence of chloroform, no external change was visible; but, a few
seconds later, his pulse, which had been carefully watched, and had been
to this time normal, suddenly began to beat very quickly; then it ceased
for two or three seconds; then beat rapidly several times, with a kind
of flickering movement; and then ceased to be perceptible.
“Just before this change of the pulse was observed, the chloroform had
been withdrawn. The one deep inspiration was followed by a few
stertorous breathings, but after these he breathed naturally, his
complexion and features showed no change, he seemed only calmly asleep,
and in this state he continued breathing naturally, and with no change
in his appearance, but pulseless, for at least a minute. Then his
breathing became less frequent, and seemed as if it might soon cease;
his face grew pale, and his lips very slightly livid.
“With the help of cold water sprinkled on his chest and face, and cold
air blown on his face and throat, he was raised from this state of
defective breathing in about two minutes, and again breathed deeply and
freely, though slowly, (probably about twelve times in the minute.) He
thus breathed for two or three minutes, and during this time the lips,
and the pale or slightly livid parts of the face, became pink again, and
though no pulse could be felt at the wrists, the heart was heard acting.
During this time, also, some wine and brandy were poured into the mouth,
and passed down the œsophagus, but without any evident movements of
swallowing. His breathing again became gradually infrequent and feeble.
Cold air and sprinkling with water, frictions and percussions of the
chest, scarcely increased the breathing, and in less than two minutes it
ceased. Artificial respiration, by the method of Dr. Marshall Hall, was
immediately employed, and many times during the first five minutes of
its employment the artificial inspiration obtained, when turning the
body over to its side, was followed by a distinct, and sometimes even a
full muscular inspiration. But at the end of about five minutes, these
signs of life ceased, fæces escaped, and no more indications of life
appeared, though the artificial breathing, the friction of the limbs,
and other means for resuscitation, were continued for twenty or more
minutes.
“I refrain, at present, from all comments on this case. Only, I wish to
call particular attention to the fact that good breathing was
maintained, and, after a suspension, was renewed, long after the heart
had ceased to act with sufficient force to produce a pulse at the wrist.
And I would add, that this narration is sanctioned and considered to be
exact, by the four gentlemen who were to have assisted in the operation,
and to whom I am greatly indebted for their counsel and assistance in
the greater difficulty that we had to cope with.”[122]
_Case 49._ This case occurred in the Liverpool Infirmary on April 5,
1857, and is related by Mr. Allan, the resident officer who administered
the chloroform. The subject of the case was a labourer, aged 35, on whom
Mr. Bickersteth was about to perform amputation of the thigh on account
of gangrene following the ligature of the femoral artery. He had inhaled
the chloroform six days previously without ill effects, when the femoral
artery was tied for popliteal aneurism. On the day of the accident, he
was first rendered insensible in the ward by chloroform poured on a
piece of lint which was held a short distance from the nose and mouth.
Having partially recovered during his removal into the operating
theatre, the chloroform was reapplied, and Mr. Allan relates what
occurred as follows: “About half a drachm of chloroform was now poured
on some lint, which was held to the nostrils, and he then became _fully_
under the influence; respirations _good_; pulse frequent, feeble. The
operation was about to be commenced, and I was pouring about twenty
minims more chloroform on the lint, (having pronounced the patient to be
in a fit state,) so as to be ready to give him some more as occasion
required, but had not applied it, when, turning round, I noticed
something peculiar in his general appearance, and, on lifting up the
eyelid, found the pupil dilated, and the lid did not close over on the
removal of the finger; the eyes were slightly turned up. I at once felt
for the temporal artery, but there was no pulsation, and none detected
at the left wrist; the respirations had almost ceased. The head was
lowered, cold water was dashed on the face, and the abdomen struck with
the palm of the hand; the finger thrust into the mouth (there was no
action of the heart felt); the legs were elevated, and a wet towel was
dabbed over the epigastrium. After one or two blows, the respirations
became better, and seemed good, and in about two minutes a pulse was
felt at the wrist. This continued between two and three minutes, the
respiration being good. His pulse then began to fail, and in about a
minute more the respirations were less. The tongue was seized with a
pair of forceps, and drawn forwards, and artificial respiration tried,
and ammonia held to the nostrils; but he was becoming livid in the face,
so the Ready Method was at once adopted, and this produced apparently a
few _natural_ respirations. But the pulse had gone, and in about two
minutes more there was no breathing save artificial. About the time that
the pulse stopped, there was a convulsive movement of the muscles of the
leg, and a slight clamminess of the skin succeeded. The Ready Method was
continued for half an hour, and galvanism tried, but without avail. From
the time he was placed on the table to his death, or the cessation of
natural respiration, about ten minutes elapsed.”
The writer adds: “He apparently sank from syncope, or cessation of the
heart’s action, for his respiration had been good just before he
changed, and it continued for a second or two, though faint, when the
pulse had stopped; and after the respiration had been restored, and was
very good, the pulse was very feeble, and ceased two minutes before the
respiration.”
At the autopsy on the following day, the brain was found to be healthy,
tolerably firm, and pale; the lungs were healthy; the right cavities of
the heart contained some fluid blood, which afterwards coagulated on
exposure, and a small clot. The left cavities also contained some blood.
The muscular tissue of the heart had an unhealthy look, and very readily
tore, but no oil globules were discovered with the aid of the
microscope.[123]
_Case 50_ occurred in King’s College Hospital, August 7th, 1857. The
following is the account of the case furnished by Mr. C. Heath, the
House-surgeon:—
“The patient [Ann Stoner] was a female, aged seventeen, under Mr.
Partridge’s care, with syphilitic warts and mucous tubercles. She was
admitted July 8th, and had had chloroform administered twice, in order
that the sores might be touched with nitric acid, and, on both
occasions, not the slightest ill effect was produced. On Friday evening
last, chloroform was again administered for the same purpose; only a
drachm was put into the inhaler (Snow’s), and as soon as she became
unconscious the inhaler was removed, and the acid applied. I and my
assistant (who administered the chloroform), then went to see another
patient in the same ward, and then washed our hands, during which time
the patient was moving her legs about much as they do when recovering,
and in addition she made water over the bed. I gave directions to the
nurse to apply a poultice as usual, and left the ward, having been up to
the bed first without noticing anything unusual about the patient. In a
few minutes the nurse came down for some medicine for another patient,
and mentioned that this one was looking very pale: I sent up Mr. Liddon
to see her at once; he found her pale and senseless, dashed some water
over her, and called me, and I went up immediately. I found her
pulseless and cold, and immediately commenced artificial respiration
(Marshall Hall), and sent for the galvanic battery; this was brought and
applied without effect, and the artificial respiration was continued for
twenty-five minutes without the slightest effect being produced.”[124]
I was present at the examination of the body on the following day. The
mouth was sore and swollen from the effects of the inunction of mercury.
There were a few drachms of clear serum in the pericardium. The heart
was large for the size of the patient. There was a patch of organised
lymph on the pericardium, covering the left ventricle. The right
cavities of the heart were full of dark fluid blood, and the left
cavities contained a little. The mitral valve was much thickened, but
the other valves were healthy. The lungs were healthy, and not much
congested. The brain was healthy. The patient had suffered from acute
rheumatism before entering the hospital.
It will be observed that the pulse is not mentioned in the above case,
until its absence is alluded to, when the patient was already cold, and
the breathing is not alluded to throughout the account; indeed, it is
not known when the patient died. She was alive after the application of
the nitric acid, as she was observed to move her legs, but further than
this there is no clear evidence.
It is perhaps an open question whether this patient died at once from
the direct effects of the chloroform, or whether she died after
partially recovering and going on favourably for a time. The account
would, at first view, seem to favour the latter opinion, but it is not
corroborated by any other case. Patients have been partially recovered
from the effects of an overdose, without being entirely restored, and
others have sunk after great operations, attended with hæmorrhage, when
the effects of the chloroform had more or less subsided, but there is no
instance of a patient going on favourably, and partially recovering from
the influence of the vapour, and then dying suddenly without any other
known cause. Patients have occasionally become faint whilst recovering
from chloroform, more especially if they remain in the sitting posture,
but in those cases the right side of the heart is probably
insufficiently supplied with blood; whilst, in the case under
consideration, the patient was lying, and the right cavities of the
heart were found full after death, the serum in the pericardium showing
that they had probably been distended when death took place. If Mr.
Heath had made any observation which enabled him to say that the patient
was really alive, when he went up to the foot of the bed, before leaving
the ward, it would decide the question, and show that death did not take
place at once from the direct effects of the chloroform, but he only
makes the negative remark that he did not notice anything unusual about
the patient.
I had an opportunity of examining the particular inhaler employed, and
found that it was so arranged that the vapour might be breathed from it
in much greater proportion than would be safe, if precautions were not
taken to leave the expiratory valve a considerable way open, especially
when the high temperature of the weather at the time is taken into
account.
The foregoing cases comprise all the instances I have seen recorded in
which death appears to have been occasioned by the administration of
chloroform, and not by other causes in operation about the same time. A
few additional cases have indeed been referred to by different authors
where death was probably caused by chloroform, but as I do not find that
the details have been published, I cannot make them available in an
inquiry respecting the cause and prevention of these accidents.
In June 1852, Dr. Simpson alluded in the following terms to an accident
from chloroform which had occurred near Glasgow:—“In this instance,
chloroform was given by the practitioner for tooth extraction; but, I am
sorry to add, none of the parties present were at the time in a
condition to give any satisfactory evidence.”[125]
A person, named Breton, a dealer in porcelain, died in Paris, in the
early part of 1853, immediately after a few inspirations of chloroform,
which was administered with the intention of removing a tumour of the
cheek. An action was brought against Dr. Triquet and M. Masson for
causing death by imprudence in this case; and at the trial which ensued,
various interesting opinions were given, and the accused practitioners
were ultimately exonerated.[126] I have not, however, met with any
record of the symptoms which occurred in the case.
In relating the case of death from chloroform, which occurred in his
practice, to the Medical and Chirurgical Society of Edinburgh, Dr.
Roberts referred to another death from chloroform in tooth-drawing which
took place in the neighbourhood from which his own patient came, just
previously to October 1855; but I have not met with any account of the
case so alluded to. Dr. Mackenzie of Kelso also alluded in the same
Society, in the following year, to a death from chloroform which had
occurred at Coldstream, and I do not know whether this was the case to
which Dr. Roberts had alluded, or a fresh one.
One of the surgeons to the hospital at St. Louis, who was lately
visiting the medical institutions of London, informed me that there had
been three deaths from chloroform at his hospital out of between six and
seven hundred operations in which it had been administered. I did not
learn the particulars of those fatal cases.
There have been several cases in which persons have been found dead
after inhaling chloroform when no one else was present, either for
toothache or some other affection, but I have not included such cases in
the above list, as they throw no light on the way in which death is
occasioned. The simple way to avoid such accidents as those just alluded
to, is for persons to abstain from inhaling chloroform, when no one is
by to watch its effects.
ALLEGED FATAL CASES OF INHALATION OF CHLOROFORM.
Several deaths have been attributed to chloroform which were due to
other causes, or where the cause of death is a subject of great doubt. A
gentleman, named Walter Badger, twenty-two years of age, the son of one
of the coroners for the county of York, died instantly at Mr.
Robinson’s, the dentist’s, in Gower Street, on June 30th, 1848, whilst
commencing to inhale chloroform with the intention of having some teeth
extracted. The inhaler employed consisted of a face-piece to enclose the
mouth and nostrils, and containing a sponge on which the chloroform
(ʒiss) was placed. This, according to the evidence of Mr. Robinson and
his female servant, who was present in the room, was held not nearer
than an inch and a half from the face for less than a minute, and the
patient made the remark that the chloroform was not strong enough; Mr.
Robinson requested him, as he had done before, to have the operation
performed without chloroform, but he again declined; and Mr. Robinson
then took away the face-piece and asked his servant to reach the bottle,
intending to put more chloroform on the sponge, to replace that which he
believed had been lost by evaporation. Just after removing the
face-piece, and before any fresh chloroform was poured out, the head and
hand of the patient dropped, and he did not show any further sign of
life.
I found, on making trial of the kind of inhaler which Mr. Robinson
employed, that it is impossible to inhale enough of the vapour to
produce any appreciable effect, unless it is applied so as to touch the
face. At the distance of an inch no effect is produced, even in five or
ten minutes; and therefore I expressed my opinion, soon after this
accident, that it was not caused by the chloroform, which properly
speaking the patient did not inhale.
A consideration of the symptoms in this case confirms the view that the
death was not caused by chloroform. In six of the fatal cases related
above, death took place instantaneously, without insensibility or any of
the usual effects of chloroform having been produced; but the mode of
dying was not the same as in Mr. Robinson’s patient. In Case 4, that of
Madlle. Stock, the patient said “I choke”, and tried to push away the
handkerchief; then there was embarrassed breathing and foaming at the
mouth. In Case 11, that of Madame Labrune, the fatal attack followed
immediately on a full inspiration of chloroform, and there was an
immediate alteration of the features, and a convulsive rolling of the
eyes, amongst other symptoms. In Case 14, the young lady stretched
herself out, and frothed at the mouth, at the moment of the fatal
attack, and the face became livid. In Case 26, that of Madame W., who
died at Ulm, the voice, when answering the question about singing in her
ears, was trembling and thick; she stretched out her limbs, and the face
became bluish. In Case 45, that of the wife of a medical man, and in 46,
that of Dr. Roberts’s patient in Edinburgh, there was a convulsive start
at the moment of the sudden death. It thus appears that when the heart
is suddenly paralysed by an overdose of chloroform, before the patient
is rendered insensible, there are usually some symptoms as if of a
violent shock or injury. After complete insensibility is induced, the
heart may be suddenly paralysed by chloroform, as is shown by numerous
cases, without this spasmodic action; and it would perhaps be premature
to deny that a patient might die thus quietly without being first made
insensible; and the nature of the death in this particular case must be
chiefly decided by the physical fact that the patient could not have
inhaled enough chloroform to produce an appreciable effect of any kind,
much less to cause sudden death.
At the inspection of the body, the liver was found so much enlarged that
it weighed eight pounds, and it encroached very much on the chest. The
walls of the left ventricle of the heart were found thinner than
natural, and the muscular tissue was interspersed with fatty
degeneration. There was blood in the right auricle and in both
ventricles. In the ventricles it was partly coagulated. The brain
presented nothing abnormal.[127]
It is probable that the immediate cause of death in this instance was
fear. The patient had been told in the country that it would be unsafe
for him to take chloroform, and yet he could not summon resolution to
undergo the operation without it. Mr. Robinson unfortunately allowed his
patient to remain seated in the operating chair; and it was only when
Dr. Waters had been sent for and arrived from a neighbouring street that
he was laid on the floor.
I was present on one occasion with Mr. Peter Marshall at the examination
of the body of a woman who died suddenly of fright in consequence of a
fire in the next house to that in which she lived, and it is worthy of
remark that we found exactly the same diseased conditions as those which
were found in Mr. Robinson’s patient; viz., great enlargement of the
liver, displacing the viscera of the chest, and fatty degeneration of
the heart.
A young man, aged twenty-four, died suddenly of syncope, on June 25th,
1848, at the Hospital Beaujon, at Paris, whilst M. Robert was performing
amputation at the hip joint, the thigh bone having been broken into
splinters by a bullet during the conflict in the streets of Paris. The
patient was in a state of great depression, both physical and moral,
before the operation; and it is most likely that he sank under the
combined effects of the injury and the operation.
Another patient had the neck of the humerus broken by a ball in the same
conflict; he was much reduced by hæmorrhage and gangrene of the wound;
M. Malgaigne performed disarticulation at the shoulder joint; a fresh
inhalation took place to enable him to search for the ball, and the
patient sank and died during the last incisions. This patient also most
probably died from the effects of the operation added to those of the
previous injury and loss of blood.
A woman died in Paris, 1848, after removal of the breast. The operation
was finished, and the chloroform had been left off some time, and the
patient had become conscious, when on raising her into a sitting
posture, in order to apply a bandage, she suddenly expired. Although the
chloroform was blamed in this instance, death evidently took place by
the ordinary kind of syncope, which arises from the heart not being
supplied with blood, and which may be called anæmic syncope, in
contradistinction to cardiac syncope, which begins at the heart itself,
when properly supplied, or even when distended with blood.
A child, aged twelve years, died in the hospital at Madrid in 1849,
during amputation of the leg after violent tetanic rigidity.[128] Death
was attributed to the chloroform which had been inhaled, but no further
particulars are given, and it is not stated whether or not there was any
unusual hæmorrhage, or other cause, which would explain the fatal event.