pleura of small extent; and in No. 47, the only disease was fatty liver.
In Case 17, there were signs of chronic disease of the membranes of the
brain; and in two cases, Nos. 16 and 22, there was emphysema of the
lungs. In the remaining sixteen cases, there was some alteration of the
heart, accompanied in a few instances by disease of other organs. In
Cases 23 and 32, there was fat on the surface of the heart, but the
structure was not degenerated. In Case 43, the right ventricle was
thinned, but not fatty. In Case 44, there were slight deposits on the
mitral valve, the heart being otherwise healthy. In Case 50, there were
deposits of lymph on the mitral valve and also on the surface of the
heart, which was somewhat enlarged. In Case 8, the heart is merely
stated to be large; and in Case 27, hypertrophied. In Case 3, the heart
was enlarged, pale, and soft, and the lungs were tuberculous. In Case
15, there was said to be some amount of disease of the aortic valves,
and some amount of fatty degeneration of the heart. In Case 37,
incipient fatty degeneration was present; and in Case 40, that of a
youth of eighteen, the heart was slightly enlarged, with some amount of
fatty degeneration. In Case 46, the right ventricle was thinned and
slightly fatty. There remain three Cases, Nos. 30, 33, and 42, in which
the fatty degeneration was more decided; and one case, No. 41, in which
it is spoken of as being present in an extreme degree. This was in a
man, aged sixty-five, the oldest person included amongst those who died
from chloroform.
When we consider how common is fatty degeneration of the heart,
especially amongst old persons and those for a long time confined to
bed, it is very probable that this affection has been proportionally as
frequent, amongst the patients who have inhaled chloroform without ill
effects, as in the fatal cases of its inhalation.
There are nine of the fatal cases in which the age of the patient is not
stated. In the other forty-one cases, the ages, when grouped in
decennial periods, are shown in the following table, the last column of
which shows the proportion which the deaths bear at each period to the
number living at that period, out of a thousand persons of all ages in
England and Wales.
Under 5 years 0 0
5 and under 15 3 ¹⁄₇₆
15 „ 25 11 ¹⁄₁₈
25 „ 35 10 ¹⁄₁₅
35 „ 45 11 ⅒
45 „ 55 3 ¹⁄₂₇
55 „ 65 2 ¹⁄₂₆
65 and upwards 1 ¹⁄₄₄
The nine persons whose ages are not given were all adults; one is spoken
of as a young man, and another as a young woman, and the rest are
mentioned in such a manner that it is certain they were not old people.
It follows, therefore, that so far as is known, there has been a
complete immunity from death by chloroform at both extremes of life. I
have already given my reasons for rejecting Dr. Aschendorf’s case of an
infant, and also the case of a gentleman, aged seventy-three, who died
whilst inhaling chloroform. The youngest patient who died from
chloroform was seven or eight years of age, and the oldest sixty-five,
being the only death above sixty. The above table of the ages shows that
the number of deaths, in proportion to the number living, increased
rapidly after the age of twenty-five, and decreased rapidly after the
age of forty-five. The small number of deaths between fifteen and
twenty-five may be partly due to the circumstance that surgical
operations are but seldom required at this period of life; but the
decrease after the age of forty-five cannot be explained in this way;
for persons become more liable to require surgical operations as they
advance in years. Operations are often performed in infancy and old age,
periods at which deaths from chloroform have not been recorded. The
greatest proportion of deaths having occurred from thirty-five to
forty-five, when the system is often more robust than at any other
period, it cannot be supposed that an inability to bear the usual dose
of chloroform, when carefully administered, is the ordinary cause of
death from this agent.
_Idiosyncrasy._ The accidents from chloroform have frequently been
attributed to idiosyncrasy in the patient. This, it may be observed, is
not to give an explanation of them, but merely to state that they depend
on something we do not understand; that something, however, being in the
person to whom the accident happens. This view receives apparent support
from the supposition that the chloroform has been inhaled in exactly the
same manner in the fatal cases as in other instances; but this apparent
support fails when it is pointed out that the supposed same manner is
only an equally uncertain manner. The different effects that have been
produced on the same patient at different times, and the great number of
instances in which medical men have failed to make the patient
insensible, show that most of the usual modes of exhibiting chloroform
are extremely uncertain.
What most completely meets the question of idiosyncrasy, however, is the
circumstance that in no fewer than eleven out of the fifty recorded
cases of death from chloroform, the patient had previously inhaled this
medicine without ill effects. In two other cases also, previous attempts
had been made to make the patient insensible without success, on the day
on which the accident occurred. In the above table of the fatal cases,
those are indicated in which previous inhalations had taken place. In
twenty-nine cases, I have concluded that the patient had not previously
inhaled, for the medical man, having given an account of the state of
his patient, and his reasons for administering the chloroform, would
certainly have mentioned such a material fact as a previous inhalation
if it had occurred. There are ten cases of which only a meagre account
is given, and where a previous administration of chloroform may possibly
have taken place without being mentioned; but if only eleven, out of the
fifty patients, who died from chloroform, had inhaled it previously
without ill effects, it is very clear that the fact of having inhaled it
with a favourable result, gives no immunity from the possibility of
accident. It would be impossible to say what proportion of the patients
who have inhaled chloroform have inhaled it more than once, but it is
not probable that they amount to more than 22 per cent., if so many.
_Alleged Impurity of the Chloroform._ At one time accidents from
chloroform were loosely attributed to impurity in the medicine, but this
was only a guess, and is opposed to the facts. No case of accident has
been traced to this cause, and in nearly all the cases of which the
details are given, it is distinctly recorded, either that the chloroform
was examined and found to be of good quality, or else that chloroform
out of the same bottle had been used in other cases without ill effects.
I have not thought it necessary to state this in quoting the individual
cases.
_Apparatus employed._ Accidents were at one time, and in one quarter,
attributed to the use of inhalers; and it is curious that this
allegation was made at a time when no death from chloroform had yet
occurred in any cases in which an inhaler was used, except one in
America, and one in France, the accounts of which had not reached this
country. It is possible that death might be occasioned by want of air
from the use of a faulty inhaler, and a case will be mentioned in which
this apparently occurred in the administration of sulphuric ether, but
there is no recorded case of accident from chloroform in which death was
occasioned in this way. In the cases of death previously recorded, a
handkerchief, a piece of folded lint, hollow sponge, or some such simple
contrivance, was used in thirty-four instances; in twelve cases, an
inhaler of some kind or other was used; and in four cases, it is
uncertain what were the means employed.
_Alleged Exclusion of Air._ The assertion has often been made that death
might be caused by the vapour of chloroform excluding the air, and so
causing asphyxia; but it has already been pointed out in this work that
the physical properties of chloroform do not allow it to yield a
quantity of vapour which would have that effect, and in much smaller
quantity than this the vapour kills by a quicker way than asphyxia, I
believe that the only elastic fluids which can cause death simply by
excluding the atmospheric air are nitrogen and hydrogen.
_Alleged Closure of the Glottis._ At the trial which took place in Paris
respecting the death of a porcelain dealer previously mentioned, M.
Devergie gave evidence, and after saying that chloroform might cause
death as a poison, if given in undue proportion, he added: “Also it
closes the glottis, and offers an obstacle to respiration. Employed by
M. Demarquay on himself, in very small doses, closure of the glottis was
occasioned. It was possible that Le Sieur Breton had experienced that
accident, and in that case the most able surgeon could not prevent
death.”
I have not met with M. Demarquay’s account of his experiment, but I am
happy to know that he did not die of the closure of the glottis. It may
fairly be denied that a person could commit suicide in this manner if he
wished, for he would either have to give up the attempt, or receive the
vapour into his lungs, and experience its specific effects. When animals
are placed in mixtures of vapour and air, they always breathe them,
whatever the strength; and if the vapour amounts to eight or ten per
cent., they die much more quickly than they would of mere closure of the
glottis. Vapour of chloroform, when not largely diluted with air, is apt
to cause cough and closure of the glottis, as soon as a little of it
reaches the lungs; but this, so far from being a source of danger, is,
as a general rule, a safeguard, by its preventing the patient from
readily breathing air which is highly charged with vapour.
In commenting on the fatal case No. 12, which occurred in St. Thomas’s
Hospital, I have suggested that the accident might have happened from
liquid chloroform being dropped into the throat; but liquid chloroform
is very different from the vapour; it causes a lasting irritation if
applied to a mucous membrane; when used for toothache, it often blisters
the gums. The irritation caused by the vapour, on the contrary, is only
momentary, and its local action ceases directly it ceases to be inhaled;
for what is left in the air-passages is immediately absorbed or expelled
with the expired air. The glottis is not a vital organ of itself. Its
closure only causes death by preventing the access of air to the lungs.
The glottis does not remain permanently closed, I believe, from the
contact of any elastic fluid, however irritating;[135] but it does from
the contact of a liquid, and persons who die by drowning, die with the
glottis closed, for they do not fill their lungs with water. Therefore,
if the vapour of chloroform did cause persistent closure of the glottis,
and if a person were to hold it by force to the patient, the death it
would occasion would be precisely like that in drowning. Death by
asphyxia is a comparatively slow one. I find that when the access of air
to the lungs is entirely cut off, death does not take place in less than
three minutes and a half in guinea pigs, and four minutes in cats. In
dogs, the process of asphyxia is still slower. Mr. Erichsen states, that
on taking the average of nearly twenty experiments, the contractions of
the ventricles continued for nine minutes and a quarter after the
trachea had been closed, and that the pulsations of the femoral artery
also were perceptible for an average period of seven minutes and a half.
The process of drowning in the human subject is well known to occupy
some minutes; and even if the pungency of the vapour of chloroform
should entirely prevent the patient from breathing, and the medical man
could overlook the fact that breathing was not going on, it cannot be
supposed that he would use the force, and have the perseverance to cause
his patient to die slowly by asphyxia. If any patient, therefore, has
died from closure of the glottis, it must have been one in whom there
was a great tendency to sudden death from any slight interruption to
respiration. I do not know the particulars of the case respecting which
M. Devergie was giving his evidence, but in those fatal cases previously
related, in which the symptoms are sufficiently described, it is not
probable that death took place in any instance from closure of the
glottis. In the sudden death at St. George’s Hospital (page 209), it is
possible that the slight pungency of the vapour might assist the fear
under which the patient was labouring in impeding the breathing, and
thus add to the distension of the right cavities of the heart, under
which the patient apparently died.
In 1855, two years after M. Devergie had given the above opinion, Dr.
Black, of St. Bartholomew’s Hospital, who has had great experience in
the administration of chloroform, advanced a similar theory in the
pamphlet previously alluded to. He did not, however, confine the effects
of the supposed closure of the glottis to possibly causing a death here
and there, as M. Devergie had done, but he attributed all the accidents
which had happened to this cause, and not to the effects of chloroform
in the system. He says that “the chloroform has not been even inhaled:
its pungency was felt at the glottis, and its inspiration was
immediately arrested. The patient would have removed the apparatus, but
in this he was restrained. The struggle forthwith commenced, but up to
the moment of his death, not a single inspiration took place.” These
remarks were not applied to a single case, but generally to the
accidents from chloroform. Dr. Black says: “Any concentration of the
vapour of chloroform which can be breathed is safe; any condition of
dilution which forces the patient to cough or hold his breath is
dangerous, and if persevered in for even half a minute, may be fatal....
We have only to attend to the breathing; we may disregard all
considerations affecting the relative proportion of the chloroform in
the air which is breathed;... if the patient breathes easily he is in
safety, whatever be the amount of chloroform which is passing into the
lungs.”
In Experiment 28, previously related, where the respiration was kept up
by a tube in the trachea, there could be no error in respect to the
vapour of chloroform entering the lungs, when a bladder of air charged
with ten per cent. of that vapour was substituted for the bladder of
simple air; and the immediate paralysis of the heart was evident. An
examination of the fatal cases, of which the particulars have been
recorded, shows that death did not occur in the manner Dr. Black
suggests. In the majority of the cases, the patients were rendered quite
insensible by the chloroform, and the operation had either been
commenced, or was on the point of commencing; when the fatal symptoms
set in. In several other cases, the patients were partially under the
influence of the vapour before the symptoms of danger commenced; and in
the six cases where death occurred at the beginning of the inhalation,
without loss of consciousness having been induced, the patients were not
restrained in any way, and it was observed that they did breathe the
chloroform; three of them were speaking up to the moment when the pulse
stopped, and one took a full inspiration the moment before the fatal
symptoms set in. It is only in eighteen of the fatal cases that there is
any reason to suppose that the patient required to be held, and then
only from mental excitement or muscular spasm, arising from the
physiological effects of the absorbed chloroform. It is hardly possible
that the struggles of a conscious patient from inability to breathe,
would be mistaken for excitement or spasm caused by chloroform.
In a case, No. 34, which occurred at St. Bartholomew’s Hospital whilst
Dr. Black was present, and long before his pamphlet was written, the
patient inhaled for five minutes, and sank off into a state of complete
insensibility without alarming symptoms. The inhalation was
discontinued, the patient moved into a proper position, and the
operation just about to be commenced, when Dr. Black found the pulse to
become extremely feeble and fluttering. Surely this patient breathed the
chloroform, and died without any spasm of the glottis. In Case 48, so
minutely related by Mr. Paget, the boy made one long inspiration, and
became suddenly insensible. In a few seconds, the pulse suddenly failed,
and then ceased to be perceptible, but the breathing continued for at
least a minute afterwards. There was certainly no closure of the glottis
in this instance.
_Alleged Exhaustion from Struggling._ In cases where the patients have
struggled violently whilst getting under the influence of chloroform,
the accidents have been attributed to a supposed exhaustion caused by
the struggling.[136] This opinion is, however, contrary to experience;
for the patients who struggle violently are precisely those who bear
chloroform the best, provided they do not breathe it in an insufficient
state of dilution. They are generally cheerful and exhilarated by it,
and are less liable to be depressed by its prolonged use, than those who
come quietly under its influence. Although the patients who struggle
bear the chloroform well, when it is carefully and judiciously
administered, it is not improbable that the struggling has been now and
then an indirect cause of accident. The muscular spasm and rigidity do
not occur till about three-quarters as much chloroform has been absorbed
as can be present in the system with safety; and, as the patients often
hold their breath whilst struggling, and take deep inspirations suddenly
and at long intervals, the greatest care is required that the vapour be
administered in a very diluted state. In Cases 9, 44, and 47, the fatal
symptoms came on whilst the patients were struggling; and in some other
cases, the sudden failure of pulse occurred just after the struggling
had ceased, rendering it probable that the patient inhaled too much of
the vapour whilst struggling, or just as the spasmodic condition of the
muscles was subsiding.
The circumstances just mentioned, are probably the cause why so many of
the fatal cases occurred at that period of life when the body is most
robust. Very nearly two-thirds (twenty-seven out of forty-one), of those
cases in which the ages are recorded, occurred in persons of twenty
years and under forty-five years of age, although the proportion of
persons living at this period of life, in England and Wales, is only a
little more than one-third of the entire population. The majority of the
accidents from chloroform occurred also in the stronger sex, in which
muscular rigidity and spasm are most frequent:—twenty-nine of the fatal
cases happened to males, and only twenty-one to females. According to my
experience, the females who inhale chloroform for surgical operations
are nearly twice as numerous as the males; and although this may not be
the proportion in every one’s practice, it is probable that females
inhale this agent quite as frequently as the other sex, in every part of
the world.
_Sitting Posture._ In some of the early cases of death from chloroform,
the patients were inhaling it in the sitting posture, and it was
surmised that this circumstance was the cause of death.[137] An
examination of the account of the fatal cases, however, does not bear
out this supposition. In thirty-one instances the patients were lying,
in nine instances sitting, and there are ten cases in which the position
is not mentioned, and where from the nature of the operation it may have
been either one or the other. In fully one-fourth of the cases of which
I have kept notes of the administration of chloroform, the patients were
seated in an easy chair; and as in forty fatal cases in which the
position is known, only nine, or less than one-fourth, were seated, it
does not appear that the position of the patient has had any share
either in causing or preventing accidents.
_Supposed Effect of the Surgeon’s Knife on the Pulse._ Mr. Bickersteth
alluded to a peculiar circumstance,[138] which he thought would account
for several of the deaths attributed to chloroform. He relates three
instances in which the pulse suddenly ceased on the first incision by
the surgeon, and commenced again in a few seconds, the breathing going
on naturally all the time. All the three cases were amputation of the
thigh, and occurred in the latter part of 1851. Mr. Bickersteth did not
observe the circumstance again during the two following years, and I
have never observed it, although I have very often examined the pulse at
the moment when the operation began, especially after reading Mr.
Bickersteth’s remarks. He supposes that the action of the heart was
arrested by the shock of the incision, notwithstanding the patient was
insensible. I should attribute the temporary stoppage of the pulse in
these instances to the direct influence of the chloroform on the heart.
The moment when the operation is commenced, is usually a few seconds
after the inhalation has been discontinued, and when the effect of the
chloroform is at its height. A portion of that which was left in the
lungs having been absorbed, in addition to that which was previously in
the system. And if the vapour inhaled just at last was not sufficiently
diluted, it might paralyse the heart, but not so completely as to
prevent the natural respiration from restoring its action, in those
cases where respiration continues. I found in experiments on animals
that, when the action of the heart has been suspended by the effect of
chloroform, it can very often be restored by artificial respiration
instantly applied; and it is extremely probable that an accident of this
kind not unfrequently occurs during the administration of chloroform,
and is remedied by the breathing, without being noticed. The pulse
recovered itself, in the cases mentioned by Mr. Bickersteth, just as it
does in animals after the heart has been nearly overpowered by
chloroform. In the first case, the pulse remained imperceptible for a
period of four or five seconds, the countenance at the same time
becoming deadly pale. As it returned, it was at first very feeble, but
in a few seconds, it regained its usual strength. In the second case,
Dr. Simpson administered the chloroform, and after the operation
remarked that the pulse had stopped suddenly just as the knife was
piercing the thigh, and had recovered itself with a flutter almost
immediately.