chloroform.[129] The child had a nævus on the face and neck, which
extended from the zygoma to the os hyoides, and from the external
auditory meatus to the maxillary fossa. No one had been willing to
undertake its removal. Dr. Aschendorf operated on the nævus at three
different times, by means of seton threads. These operations were
performed under the influence of chloroform. The tumour was reduced
one-third part in size by these means, and eleven weeks afterwards Dr.
Aschendorf determined to extirpate it. The chloroform was administered
as on the former occasions, by placing six drops on some tow in a cup.
In about ten minutes, as the child cried a little, three drops more of
chloroform were used for inhalation, and in about eight minutes more the
operation was concluded. “On raising the child it laid its head on one
side, convulsive twitches of the face were observed, with distortion of
the eyeballs and dilatation of the pupils. For one moment the arms were
stretched out stiff, then again they were relaxed, and fell as supple as
the rest of the body. Death quickly followed—only one pulsation of the
heart and a single râle with the expiration being perceived.”
There can be no doubt of this being a case of death from hæmorrhage,
after the direct effects of the chloroform had subsided. Dr. Aschendorf
says the quantity of blood lost was about two tablespoonfuls; but it
would be necessarily removed by sponges during the operation, and there
would be no means of estimating the quantity. The child was probably in
a state of syncope during the latter part of the operation, as it would
not remain insensible to the knife for eight minutes from a single
application of chloroform.
On September 15th, 1852, a patient died to whom I was administering
chloroform whilst Mr. Cæsar Hawkins was performing lithotrity. He was a
gentleman from the country, aged seventy-three; he was tall and stout,
he had a weak intermitting pulse, and a well marked arcus senilis in
each cornea. He had inhaled chloroform five or six times, between May
1850 and May 1851, for the same operation, when under the treatment of
another surgeon, and it always acted favourably. In the first week of
December 1851, Mr. Hawkins performed the operation of lithotrity twice,
when the chloroform was administered by Mr. Geo. D. Pollock. On the
second of these occasions he became faint during the operation whilst
under the influence of the chloroform, but recovered from the faintness
before its conclusion. He again fell into a very alarming state of
syncope a few minutes after the conclusion of the operation, but
rallied, and vomited the breakfast which he had taken a little time
before. I first administered the chloroform to this patient on December
15th, 1851, eleven days after the above occurrence. Mr. Hawkins and I
were inclined to think that the alarming syncope on the previous
occasion might have been connected with the sickness which occurred. It
was my firm belief that the patient had fatty disease of the heart; but
I did not see any great objection to the chloroform on that account, as
I had frequently given it in similar cases, and always with a favourable
result. On this occasion (December 15th) he inhaled the chloroform
before breakfast. Its effects were quite satisfactory, and it was not
accompanied or followed by any unpleasant symptoms whatever. The
operation was repeated four days afterwards, when I again exhibited the
chloroform with like favourable results. After this the patient went
back to the country relieved from his stone. He came back, however, in
the autumn of 1852, with a return of his complaint, and I was again
requested by Mr. Hawkins to assist him by giving the chloroform on
September 15th.
The patient became insensible, without any excitement or struggling, in
the course of three or four minutes, and the operation was commenced. A
little more chloroform was administered two or three times during the
operation, in order to keep up the insensibility. After a few minutes
had elapsed, I observed that the face and lips of the patient became
pale. At this time he had not inhaled any chloroform for about two
minutes. Immediately afterwards, however, his face became red, and he
made straining efforts with the muscles of respiration, as if he were
beginning to feel the operation. To prevent his becoming altogether
sensible, therefore, I commenced to give him a little more chloroform,
with the valve of the inhaler about one-third open, as on the former
occasions. He had only taken two or three inspirations, however, when
the breathing ceased. He appeared to be merely holding his breath, as
sometimes happens during the exhibition of chloroform, and I expected
that he would begin to breathe again in about a quarter of a minute. In
the meantime, I endeavoured to feel the pulse in the temporal artery,
but did not perceive any. Instead of the breathing recommencing at the
time I expected, the countenance became suddenly pale, and a little
afterwards rather livid. I applied my ear over the region of the heart,
but could not hear any sound. After a few seconds, however, the patient
took a rather deep inspiration, and immediately after this I was pretty
sure that I heard the heart beating very feebly and rather frequently,
but only for a few seconds, after which no sound could be heard. There
were one or two more very feeble inspirations at intervals of about a
quarter of a minute, after which there were no further signs of life. As
soon as the patient had entirely ceased to breathe, artificial
respiration was performed, but no sign of returning animation appeared.
At the examination of the body fifty-two hours after death, the heart
was found to be larger than natural, and there was a good deal of fat on
its surface. Its right cavities contained air or gas, probably resulting
from the partial decomposition of the blood. The right ventricle was
dilated, and its walls were very thin. At one place, near the apex, they
were extremely thin. The left ventricle was also dilated, but its walls
were of the proper thickness. They were, however, like those of the
other ventricle, very soft and friable. There was a calcareous
incrustation on one of the aortic valves. There was scarcely any blood
in the heart, but its lining membrane was stained in places, showing
that blood had been present after death.
Mr. Pollock and the late Mr. W. F. Barlow examined the structure of the
heart under the microscope, and the latter gentleman furnished me with
the following account of the examination:—
“Many of the fibres have been converted into fat completely; in others,
fatty degeneration was beginning. The degeneration, which was in various
stages, appeared very general. The fasciculi were broken up, here and
there, into masses of small irregular fragments, as they may be found
frequently in hearts of this kind. Some large fat globules lay between
and upon the fibres. A few fibres showed their transverse striæ plainly,
and made the changes in the others look the clearer. On the whole, it
may be said that the structure of the organ was greatly damaged, and
that its action, consequently, was liable to cease suddenly from slight
causes.”
I am of opinion that this patient did not die from the direct effects of
the chloroform. The air he was breathing just before he died did not
contain more than three or four per cent. of vapour of chloroform at the
utmost, and he had previously breathed quite as much, both during the
same operation and on previous occasions. The patient seemed to be
holding his breath at the moment when his heart ceased to beat; and it
is whilst holding the breath, and making a straining effort, that
patients labouring under disease of the heart not unfrequently expire.
Mr. Pollock, who was present when the patient died, expressed to me his
belief that he died of his heart disease, and not of the chloroform.
After reflecting on this case, I see no reason to regret the course
which was pursued. It was the opinion of Mr. Hawkins that the patient
could not have borne the operations without the chloroform;
consequently, if we had decided not to permit its use any more, in
consequence of the alarming syncope which occurred after the operation
under its influence on December 4th, 1851, he would probably have died
in great suffering from the calculus, instead of having seven or eight
months freedom from the complaint. And, on the other hand, if it had
been decided to operate without chloroform, it by no means follows that
the patient would have been in less danger, judging from what I have
observed of the effect of pain on the circulation, as compared with the
effect of the chloroform carefully administered, in numerous other cases
of disease of the heart.
On May 11th, 1854, a patient died suddenly in St. George’s Hospital as
she was beginning to inhale chloroform. She was a pale and delicate
looking woman, aged thirty-seven, from whose left breast Mr. Cæsar
Hawkins was about to remove a mammary glandular tumour. “On entering the
operating theatre she appeared nervous. Having been placed on the table
on her back, in a half reclining position, the administration of
chloroform was commenced. Dr. Snow’s inhaler was used. The quantity of
chloroform placed in the receiver was a little more than a drachm; and
the valve for the admission of air was left wide open. Apparently, from
excitement, she did not inhale well, but drew her breath by deep
catches, and irregularly. Mr. Potter, noticing this, spoke to her,
begging her to compose herself, and try to breathe more quietly. The
valve was then slightly turned on, in order that she might inhale but a
very small quantity of chloroform. The same spasmodic efforts at
inspiration still continued; very shortly afterwards, at most not more
than a minute and a half from the commencement of the inhalation, Mr.
Potter noticed her breathing to suddenly cease, and that she had become
deathly pale. The inhaler was at once removed. On placing the finger on
the wrist, no pulse could be found. Endeavours to arouse her by dashing
the face and chest with water were immediately adopted; but, proving
ineffectual, artificial respiration was commenced within a minute of the
first symptoms. During the interval, two sighing attempts at inspiration
had been observed; but there had been no pulse whatever; the mouth lay a
little open, and the countenance was still extremely pale.”[130] Other
attempts at resuscitation were made without effect.
“At the post-mortem examination, on the following day, no very
noticeable lesions of the viscera were discovered. There was congestion
of the whole venous system, and the blood, in every organ, was of a deep
purple colour, and quite fluid. The brain substance itself was perhaps a
little more vascular than usual, and the veins of its meninges were
loaded with blood. The heart was small and fat, the right ventricle
being especially loaded with adipose material, and its muscular layer
much thinned. Under the microscope there was found to be slight, yet
decided, fatty degeneration of the muscular structure. Both chambers,
but more particularly the right, were distended with blood in which no
coagula could be found. The posterior lobes of the lungs were somewhat
congested, but not more than the position in which the corpse had lain
might account for. There was no disease of the abdominal viscera.”[131]
I made a chemical examination of some blood obtained from the heart and
large vessels, and also of portions of the lungs and liver, but I failed
to detect any trace of chloroform, although the process I employed is
one by which I have very easily detected it in the bodies of small
animals killed by it, and also in portions of limbs and tumours removed
whilst the patients were under its influence to the usual extent.
It was impossible that this patient could have breathed air strongly
charged with vapour. Every one in the operating theatre was a witness
that the expiratory valve of the face-piece was not, at any time, more
than one-third closed, being two-thirds open. In this way no great
effect of any kind can be produced, as very little of the air which the
patient breathes passes through the inhaler. Mr. Potter informed me,
moreover, that the patient breathed very little even of air, her
breathing was so much embarrassed by her frightened condition. He was
trying to calm her apprehensions at the moment when she died.
The mental emotion under which the patient was labouring was, no doubt,
the cause of the sudden death in this instance, as in that above
referred to, which occurred at Mr. Robinson’s. The mode of dying, in the
present instance, was evidently by cardiac syncope; the same mode of
death, in fact, as that which is occasioned by vapour of chloroform,
when not sufficiently diluted; and it is only the absolute knowledge,
that any small quantity of vapour which this patient inhaled was very
largely diluted with air, that enables one to decide, with confidence,
that the chloroform was not the cause of death. It may be observed,
however, that there was an absence of the convulsive start or spasm
which occurred in all those deaths from chloroform, which took place at
the beginning of the inhalation, without loss of consciousness having
been first induced.
The right cavities of the heart were found full of blood in this case,
and it is probable that they became so much distended, as the patient
was in a state of alarm, and scarcely breathing, that, in the thin and
diseased state of the walls of the right ventricle, the action of the
heart was arrested. Sudden death not unfrequently takes place during
mental emotion, and, in many of the cases, the mode of dying is probably
that just mentioned.
SYMPTOMS IN THE FATAL CASES OF INHALATION OF CHLOROFORM.
Out of the fifty cases of death from chloroform, related above, there
are five in which the symptoms at the time of death are not detailed,
viz., Cases 6, 7, 21, 24, and 50; in the two first cases it is merely
related that the patient suddenly expired, and, in the two last cases,
no one was watching the patient at the time when death took place. In
considering the remaining cases they may be conveniently divided into
groups, according to the period of the inhalation at which the accident
occurred. In six of the cases the fatal symptoms came on suddenly, at
the beginning of the inhalation, before the patient had been rendered
unconscious; in each of these cases there was the most unequivocal
evidence of the sudden arrest of the action of the heart. In cases No. 4
and No. 11 there was sudden pallor of the face at the moment when the
circulation ceased. In Nos. 14 and 26 the face became livid at the time
of the fatal attack, and, in Nos. 45 and 46, the colour of the face is
not mentioned. In all these cases there were also symptoms as if of a
sudden shock to the system, such as stretching out of the limbs, foaming
at the mouth, rolling of the eyes, or a sudden convulsive start. In Case
4, the patient at Boulogne had just complained of a choking feeling, one
sign that the vapour she was breathing was not well diluted. In Case 11
the fatal symptoms occurred immediately on a full inspiration; and in
the other cases also the strength of the vapour was left to accident,
and the result leads to the conclusion that it was very great at the
moment before the fatal symptoms occurred.
In thirteen cases the inhalation was discontinued on account of the
sudden appearance of dangerous symptoms, after consciousness had been
apparently suspended. These cases are numbered 9, 15, 17, 20, 27, 30,
33, 35, 37, 40, 41, 44, and 47. In the greater number of these cases the
over-action of the chloroform appeared to be exerted simply on the
heart, the only dangerous symptoms being referrible to the paralysis of
that organ; whilst in some of these cases symptoms of over-narcotism of
the brain were conjoined with those connected with the heart. In the
case of J. Verrier, No. 9, and in the case at Stockholm, No. 15, the
sudden and entire cessation of the pulse was the symptom which first
called attention to the danger of the patients, whilst the breathing was
still going on. In Case 30 the woman became suddenly insensible and
pulseless, after a short period of excitement. In Cases 35 and 40,
although the pulse did not absolutely and entirely cease at once, its
sudden failure was the first alarming symptom. In Case 20, at the Cavan
Infirmary, the breathing and action of the heart ceased at the same
moment. In Case 41, at the Middlesex Hospital, at a time when the pulse
was full and steady, seventy in the minute, it gave a few rapid and
irregular beats, and then ceased, and the breathing, which was free and
deep, but not stertorous, ceased at the same time. In Case 15, which
occurred at Jamaica, the patient, after a period of excitement, made one
stertorous inspiration, when the breathing ceased. There were afterwards
a few distant inspirations. The pulse is not mentioned; but it is pretty
certain that it must have ceased about the time of the stertorous
inspiration, or the additional inspirations which took place after the
chloroform was withdrawn, would probably have restored the patient; to
say nothing of the measures that were resorted to with a view to his
resuscitation. Of Case 27, which happened at Melbourne, it is merely
related that the patient spluttered at the mouth, and suddenly expired,
just after a fresh portion of chloroform had been applied on the
handkerchief. The symptom of spluttering at the mouth is recorded as
occurring in other cases, just at the moment when the pulse had suddenly
ceased.
In Case 44, at the Royal Ophthalmic Hospital, the narcotism of the brain
and nervous system proceeded as far as the third degree, which was
attended with strong muscular spasms, as not infrequently happens; and
an overdose of chloroform appears at this moment to have acted on the
heart, for the pulse could not afterwards be felt. In Cases 33, 37, and
47, the narcotism of the brain proceeded as far as the fourth degree,
producing stertorous breathing, when the chloroform caused paralysis of
the heart, by its direct action on that organ.
There are six cases in which the fatal symptoms came on just after the
patient had been rendered insensible, and the inhalation had been
discontinued; the operation being about to be commenced. They are
numbered 32, 34, 39, 43, 48, and 49. All these cases bear a very close
resemblance to each other. In all of them the patient had been made
insensible (satisfactorily so as it was thought), when in a few seconds
the pulse suddenly stopped, or failed and fluttered just prior to
stopping; in Case 32 Dr. Dunsmure thought the time was longer between
the discontinuance of inhalation and the cessation of the pulse. The
breathing continued a little time after the pulse ceased or failed in
all these cases, and there was an absence of the spluttering at the
mouth, stretching of the limbs, and other spasmodic actions, which
occurred in all the six cases where the heart was paralysed at the
beginning of the inhalation, before unconsciousness had been induced,
and in some of those when the paralysis of the heart took place at a
later period of the inhalation, when the patient had been apparently
rendered unconscious, but was not yet insensible. In each of the six
cases now under consideration, the fatal event was evidently occasioned
by the vapour of chloroform, which remained in the lungs at the moment
when the inhalation was discontinued. A portion of this vapour becoming
absorbed, and added to that already in the blood, had the effect of
paralysing the heart, when it circulated through the coronary arteries.
There remain twenty-two cases in which the fatal symptoms came on during
the course of the operation. In twenty of these cases the symptoms are
described with more or less detail. I made some remarks respecting cases
No. 1 and No. 2, in the place where they are related. In case No. 3, as
in these cases, the patient appeared not quite insensible, and showed
signs of pain during the operation, when “in a moment his pulse, which
was full and natural, sank.” In case No. 5 the patient was probably dead
when the incisions on the finger were commenced; the extreme suddenness
of the death, and the absence of bleeding, show that death occurred in
the way of syncope. The convulsive movements which just preceded death
are worthy of note in connection with the other cases, in which death
occurred immediately after the commencement of inhalation. Some remarks
were appended to case No. 8. In case No. 10 paralysis of the heart is
indicated by the absence of bleeding from the arteries, and the absence
of pulse, whilst the breathing still continued for a short time. I made
some remarks respecting case No. 12 when it was related. The patient
seemed to die by embarrassed respiration, but whether that was caused by
the action of the chloroform on the brain is doubtful. In case No. 13
the patient died in a moment. In No. 16 the face turned pale, and the
pulse and breathing ceased soon after the chloroform was discontinued,
showing the effect of the vapour which was present in the lungs at the
moment when the inhalation was left off.
In Case 18 the livid countenance and sudden stopping of the pulse prove
cardiac syncope. In Case 19 the blood which was gushing out suddenly
stopped, and the patient expired. The congested state of the lungs and
the blood in the right cavities of the heart prove that the syncope of
which he expired was not the ordinary anæmic syncope from hæmorrhage; it
was therefore cardiac syncope from the chloroform.
In Case 22 the change of countenance and sudden character of the death
are evidences of cardiac syncope. In Case 23 there was sudden cessation
of the bleeding and of the pulse; in Case 25 the pulse suddenly ceased.
In Case 28 the patient died suddenly, but the pulse was apparently not
examined at the time. Some remarks have already been made on Case 29,
which happened in the Manchester Infirmary. In Cases 31, 36, and 38 the
suddenness of the death showed that it took place by syncope. In the
last of these cases the pulse was being examined at the time it ceased.
In Case 36 there was no examination of the dead body; but in 31 and 38
the presence of blood in the right cavities of the heart indicates that
the kind of syncope was cardiac syncope. Respecting Case 42, some
remarks have already been made. The death commenced by deep coma, which
embarrassed, and then suspended, the respiration, and cardiac syncope
quickly followed. The chloroform was administered by a method which
precluded the medical attendant from observing properly the most
important symptoms.
The accompanying table of the fatal cases of the inhalation of
chloroform contains such short particulars respecting them as seemed
capable of being tabulated, and it may assist the reader in retaining a
more connected recollection of the facts previously related more in
detail.
MODE OF DEATH IN THE ACCIDENTS FROM CHLOROFORM.
In all the cases in which the symptoms which occurred at the time of
death are reported, there is every reason to conclude, as shown above,
that death took place by cardiac syncope, or arrest of the action of the
heart. In forty of these cases the symptoms of danger appeared to arise
entirely from cardiac syncope, and were not complicated by the
over-action of the chloroform on the brain. It was only in four cases
that the breathing appeared to be embarrassed and arrested by the effect
of the chloroform on the brain and medulla oblongata, at the time when
the action of the heart was arrested by it; and only in one of these
cases (No. 42) that the breathing was distinctly arrested by the effect
of the chloroform, a few seconds before that agent also arrested the
action of the heart.