the effect of the knife, rather than the chloroform, was that he had
arrived at the conclusion from some experiments which he performed on
animals, that the action of the heart cannot be arrested by chloroform,
until the breathing has been first suspended. One of Mr. Bickersteth’s
experiments (No. 5, on a half-grown cat) exactly resembles the
experiment (No. 28 in this work) on a rabbit, which I had published
upwards of a year before Mr. Bickersteth’s paper appeared, with the
exception that in my experiment the artificial respiration was performed
with air containing ten per cent. of vapour, and in Mr. Bickersteth’s
the vapour was an unknown quantity. In both experiments, the heart of
the animal was exposed. In that which I performed, three or four
inflations of the lungs almost paralyzed the heart; and nine or ten
inflations, which did not occupy half a minute, had the effect of
paralyzing that organ irrecoverably. In Mr. Bickersteth’s experiment,
the effect of the artificial respiration was as follows:—“After
continuing it for seven minutes, the diaphragm, hitherto unaffected,
began to move very irregularly and imperfectly; then its movements
became slow and hardly perceptible; and, at the expiration of eleven
minutes, they had ceased altogether. During all this time the heart’s
action remained strong and regular, but now it got weaker and more
rapid, and, in four minutes from the time the diaphragm had ceased
acting, had become so feeble (still quite regular) that I feared every
moment it would stop.” Mr. Bickersteth says he performed artificial
respiration with air saturated with chloroform; but saturated or not,
the vapour certainly did not exceed six per cent., and most likely was
only between four and five, if the artificial resembled the natural
respiration in quantity and frequency. The vapour which can be breathed
for seven minutes without causing serious symptoms, and for eleven
minutes without arresting the breathing, is of course incapable of
stopping the action of the heart by its direct effect. It is scarcely so
strong as that which one administers every day to patients with
impunity. The vapour which is so diluted as to require to be added by
small increments during one hundred and fifty inspirations, before the
brain is even narcotized, cannot act directly on the heart, an organ
which can bear a much larger amount of chloroform. Mr. Bickersteth fell
into the error into which the Committee of the Society of Emulation of
Paris afterwards fell, and argued from the rule to the exception. What
he witnessed was the mode of death which would occur, if vapour of
chloroform of the strength which can be safely inhaled, were
deliberately continued till the death of the patient. But an accident
from chloroform is an exception, and the mode of dying is as much an
exception as the death itself, if the inquiry is extended to what this
agent is capable of doing, instead of confining it to what one
endeavours to effect with it in the human subject alone.
So many of the deaths during the inhalation of chloroform have occurred
before the operation had commenced, or after it had proceeded some way,
that Mr. Bickersteth’s explanation would not apply to a great number,
even if it were correct; and when it is remembered that the operation is
always commenced when the effect of the chloroform is expected to be at
its height, the number of cases of cardiac syncope which have happened
at the beginning of the operation is not greater than might be expected
as the result of the effect of chloroform.
_Sudden Death from other Causes._ It has been more than once suggested
that the deaths which have occurred, during the inhalation of
chloroform, are of the same nature as the sudden deaths which have often
occurred about the time of surgical operations, apparently without any
adequate cause; and that in fact the accident and the chloroform may be
a mere coincidence, and not connected as cause and effect. It has been
already shown that the Commission of the Academy of Medicine of Paris
made this suggestion in treating of the case of Madlle. Stock, and Dr.
Simpson has more than once made a similar remark. On one occasion,[139]
he remarked, in speaking of chloroform:—“The first surgical cases in
which it was used were operated upon in the Royal Infirmary here, on the
15th of November, 1847. Two days previously, an operation took place in
the Infirmary, at which I could not be present, to test the power of
chloroform; and so far fortunately so; for the man was operated upon for
hernia, without any anæsthetic, and suddenly died after the first
incision was made through the skin, and with the operation uncompleted.”
I should say, so far unfortunately so, for whatever the cause of the
man’s death, that cause could hardly have been present if the patient
had been made insensible by chloroform; and so his life would in all
probability have been saved. If he died either from fear or from pain,
the chloroform would have prevented his death, by removing and
preventing these causes; and if his death arose from simple exhaustion,
it must be remembered that chloroform is a stimulant, during the first
part of its administration, and, as a general rule, so long as it is
actually in the system. Even Mr. Bickersteth, who thinks that the knife
of the surgeon may have a direct influence on the heart when the patient
is quite insensible, expresses his conviction that such an occurrence is
far less likely to happen under the influence of chloroform than in the
waking state.
I have omitted from the list of deaths by chloroform two cases which are
usually attributed to that agent, namely, the case of Mr. Robinson’s
patient, and the one at St. George’s Hospital, and have attributed them
to fear; and I also rejected the case of the infant on which Dr.
Aschendorf operated, for the reasons I stated; and it is quite possible
that amongst the fifty cases I have retained, there may be one or two in
which the death was not caused by chloroform, especially as the details
of some of the cases are very meagre; but when all the circumstances of
the cases are examined, and especially when the mode of death is
compared to that which chloroform can be made to produce in animals, it
cannot be supposed that the fatal event was a more coincidence in the
whole fifty cases, or in any great number of them.
There are numerous instances recorded of sudden death during surgical
operations, or just before intended ones, without any evident cause,
except fear or pain, before the use of narcotic vapours was known; and
some even since, in cases in which it was not thought worth while to use
them. After the passage quoted above, Dr. Simpson continues:—“I know of
another case in Edinburgh, where death instantaneously followed the use
of an abscess-lancet without chloroform,—the practitioner, in fact,
deeming the case too slight to require any anæsthetic.” Such events
have, no doubt, often happened without being recorded; and it is
extremely likely that the deaths of this kind which chloroform has
prevented are quite as numerous as those it has occasioned by its own
effects, but the medical profession will very properly not be satisfied
with a result of this kind, if more can be done; and the endeavour of
the practitioner of course is, whilst saving life as well as preventing
pain by the use of this agent, to avoid as far as possible having any
accident from its use.
_Falling back of the Tongue._ It has been alleged that the falling back
of the tongue into the throat, under the deep influence of chloroform,
might be the cause of death by suffocation; but this appears to be an
error; for the muscles of the larynx and neighbouring parts preserve
their action as long as the diaphragm, and contract consentaneously with
it. When the breathing has ceased, the tongue is indeed liable to fall
backwards, if the person in a state of suspended animation is lying on
the back, and this circumstance requires to be attended to in performing
artificial respiration.
STATE OF THE CHIEF ORGANS AFTER DEATH FROM CHLOROFORM.
A few years ago, I examined the viscera of the chest, and kept notes of
the appearances, in thirty-seven animals killed by chloroform. They
consisted of two dogs, twenty-two cats, one kitten, three rabbits, three
guineapigs, two mice, two larks, and two chaffinches. Many of the
animals were opened immediately after death, and the rest within a day
or two. The lungs were not much congested in any instance. In seven of
the animals, they were slightly congested; but in the remaining thirty,
they were not congested. They were generally of a red colour, but in a
few of the cats they were quite pale. I ascertained the specific gravity
of the lungs of two of the cats, in which they presented the amount of
vascularity I have most usually met with. The specific gravity was 0·605
in one instance, and 0·798 in the other. As many of the animals died in
a way resembling asphyxia, the respiration ceasing before the
circulation, it might at first be supposed that we should meet with the
same congestion of the lungs; but by the time that the respiration is
altogether suspended by the action of chloroform, that agent has begun
already to influence the heart, which does not inject the blood into the
lungs with the same force as when the respiration is mechanically
prevented, whilst it is in full vigour. Besides, in the gaspings which
so often take place when the heart is ceasing to act, the animal
inhaling chloroform draws air freely into the lungs, whilst the
asphyxiated animal is prevented from doing so.
As regards the condition of the heart, it was found in the two
chaffinches that the auricles were filled with blood, whilst the
ventricles were empty. The condition of the heart in the larks is not
mentioned, but in all the thirty-three quadrupeds, the right auricle and
ventricle were filled with blood. In ten of them, these cavities were
much distended; and in some of these instances, the coronary vessels on
the surface of the heart were distended also. The left cavities of the
heart never contained more than a small quantity of blood, not exceeding
a quarter of what they would hold.
The head was examined in only ten of the animals. The substance of the
brain was found to be of the natural vascularity, and the sinuses were
not very much distended, except in two instances.
With respect to the state of the blood, it may be mentioned, that in
every instance in which the chest was opened within an hour after death,
the blood which flowed from the cut vessels coagulated immediately and
firmly. In eighteen of the animals in which the blood was examined in
the heart or large vessels, a day or two after death, it was found to be
well coagulated in ten, loosely coagulated in seven instances, and quite
fluid in one instance. I have not met with air in the bloodvessels,
either in the above thirty-seven examinations, or in any of the numerous
other animals that I have opened, after they have been killed by
chloroform. The appearances I have met with in animals killed by this
agent have usually been such as I have described in the above
thirty-seven instances; but I long since ceased, as a general rule, to
make careful notes of the appearances, as I did not meet with anything
new.
In the fatal cases of inhalation of chloroform previously quoted, the
lungs are related to have been congested more frequently, and to a
greater extent, than I have met with in animals. But there is no
standard of what should be called congestion; and probably many of the
medical men who made the examinations were speaking by comparison with
cases where persons die after illness, in a state of inanition. In the
human subject, the right cavities of the heart, although generally full
of blood, were found empty in several cases; but as I previously stated,
it is almost certain that they were emptied after death, either by the
artificial respiration which was employed, or in some other way.
The blood remained fluid in eighteen out of twenty-five cases of fatal
accident from chloroform, in which an examination of the body was made
and the condition of the blood recorded; whereas it was only quite fluid
in one instance out of eighteen of the animals which were killed by
chloroform, and not opened till a day or two afterwards. The fact of the
blood coagulating more generally, in the animals on which I have
experimented, than in the human subjects who died from chloroform, is
probably due to their smaller size. I was formerly of opinion that the
fact of the body of a small animal cooling more quickly than the human
one was the probable explanation of this, but Dr. Richardson appears to
have proved that the blood is kept in a liquid state by the presence of
ammonia; and ammonia, we might expect, would escape more readily from
the body of a small animal than from the human body. However this may
be, it is pretty certain that the blood generally remains fluid in the
human body after death from chloroform, only because it usually remains
fluid in every kind of sudden death. When a patient dies slowly of
illness, the body cools gradually before death takes place, and ammonia
keeps exhaling in the breath, if Dr. Richardson is correct, whilst the
formation of this alkali must be almost suspended. In many cases, we
know that coagulation of the blood commences before the respiration and
circulation have ceased. The blood which flows during surgical
operations coagulates as quickly and firmly when the patient is under
the influence of chloroform as at other times; and, as was mentioned
above, the blood which flows from animals, just after they are killed by
this agent, coagulates as well as usual; it follows, therefore, that if
the coagulation of the blood were prevented by the chloroform, and not
by the mere fact of sudden death, it would be by the presence of this
agent in the blood after death, and not by any action which it exerted
during the life of the patient.
FURTHER REMARKS ON THE PREVENTION OF ACCIDENTS FROM CHLOROFORM.
In consequence of the prevailing opinion that accidents from chloroform
depended chiefly on the condition of the patient, the main endeavours to
prevent a fatal result have taken the direction of a careful selection
of the persons who were to inhale this agent. It may be doubted,
however, whether this line of practice has had so much effect in
limiting the number of accidents, as in curtailing the benefits to be
derived from the discovery of preventing pain by inhalation. In nearly
all the recorded cases of accident from chloroform, it is stated that
the patients had been carefully examined, and such proofs of disease as
were met with after death were chiefly those which had not been
detected; and, as already has been stated, were probably not greater on
an average than in the cases in which no accident happened.
I have not myself declined to give chloroform in any case in which a
patient required to undergo a painful operation, whatever evidence of
organic disease I have met with on careful examination; and although I
have memoranda of upwards of four thousand cases in which I have
administered this agent, I have not, as I believe, lost a patient from
its use; the only person who died whilst under its influence having, in
my opinion, succumbed from other causes, as I have already explained.
Many writers have stated that accidents from chloroform might always be
prevented by a close attention to the symptoms, or to some particular
symptom, as the pulse or the breathing. Several authors have attached
the utmost importance to feeling the pulse, and have considered this
measure of itself sufficient to avert danger; whilst others have
asserted that attention to the pulse is of no use at all. Mr.
Bickersteth, for instance, writes as follows, in the article from which
I previously quoted. “But the pulse should not be taken as any guide
during the administration of chloroform. It should be wholly disregarded
except under certain circumstances, when syncope is to be feared from
loss of blood during the performance of a capital operation. The pulse
is only affected secondarily in consequence of the failure of the
respiration.”
If the person administering chloroform was always quite sure that the
vapour did not constitute more than five per cent. of the inspired air,
it is quite true that the pulse might be wholly disregarded. I can never
produce more certain and uniform results with chloroform than when I am
giving it to small animals enclosed in glass jars, where of course the
pulse cannot be felt. In surgical practice, however, where the amount of
vapour in the inspired air is often very uncertain, watching the pulse
may be of great service, irrespective of loss of blood; and although it
will not always prevent accident, I am persuaded that it has saved many
lives. In some of the accidents that have happened, the pulse has ceased
suddenly, whilst it was being very carefully watched; but more usually
it would show some signs of failure before entirely ceasing.
In giving chloroform freely to animals from a napkin or sponge, whilst
the ear or the hand was applied over the heart, I have usually found
that its pulsations became embarrassed and enfeebled before they ceased;
and by withdrawing the chloroform when the heart’s action first became
affected, the life of the animal could often be saved.
The importance of attending to the respiration of the patient has been
previously noticed, and it is so obvious a symptom that it can hardly be
disregarded, if anyone is watching the patient; it speaks, moreover,
almost to one’s instincts, as well as to one’s medical knowledge. It is
probable that no patient has been lost by disregard of the respiration,
unless it be one or two whom no one was watching, or in which the head
and shoulders were covered with a towel.
It has already been shown in this work, from experiments on animals, and
from the physiological effects and physical properties of chloroform,
that accidents from this agent would arise by its suddenly paralyzing
the heart, if it were not sufficiently diluted with air; and a careful
review of all the recorded cases of fatal accident shows that nearly
every one of them has happened in this way, and not from any neglect in
watching the symptoms induced, or mistaking their import.
The first rule, therefore, in giving chloroform, is to take care that
the vapour is so far diluted that it cannot cause sudden death, without
timely warning of the approaching danger; and the next rule is to watch
the symptoms as they arise. A description of those symptoms, and what
they indicate, has already been given.
I have previously stated that the most exact way of giving chloroform to
a patient is to put so much of it into a bag or balloon as will make
four per cent. of vapour when it is filled up with the bellows; but I
have not often resorted to this plan, on account of its being somewhat
troublesome. I have previously described (p. 81) the inhaler which I
employ. By arranging the bibulous paper suitably, and by ascertaining,
with the inhaler in the scales, how much chloroform a given quantity of
air carries off at different temperatures, I am able to produce very
uniform results in the administration of chloroform. But, as I
previously stated, those who do not wish to have the trouble of studying
a suitable inhaler, may give chloroform on a handkerchief without
danger, and with results sufficiently certain, by diluting this agent
with an equal measure of spirits of wine. As the spirit (nearly all of
it) remains behind, it is desirable, in a protracted operation, to
change the handkerchief or sponge, now and then, for a dry one.
TREATMENT OF SUSPENDED ANIMATION FROM CHLOROFORM.
It is probable that artificial respiration, very promptly applied, will
restore all those patients who are capable of being restored from an
overdose of chloroform. All the patients who are related to have been
restored after this agent has occasioned a complete state of suspended
animation, have been resuscitated by this means. It is only by
artificial respiration that I have been able to recover animals from an
overdose of chloroform, when I felt satisfied that they would not
recover spontaneously. And under these circumstances I have not been
able to restore them, even by this means, except when a tube had been
introduced into the trachea, by an incision in the neck, before giving
them what would have been the fatal dose.
M. Ricord succeeded in restoring two patients who were in a state of
suspended animation by mouth to mouth inflation of the lungs. The first
was a woman, aged twenty-six, who had been made rapidly insensible by a
few inspirations of chloroform from a sponge. He had scarcely commenced
the operation of removing some vegetations, when his assistant informed
him that the pulse had ceased. The breathing also ceased about the same
time.
In the second case, he completed the operation of circumcision, and the
patient, a young man, not coming to himself, M. Ricord found that the
breathing had ceased, and the pulse was becoming more and more extinct,
and very soon ceased entirely, till restored by the artificial
respiration.
After these cases, hopes were expressed that M. Ricord had discovered
the means by which all patients might be restored from the over-action
of chloroform; but these hopes have not been verified by events. In the
first of the cases, the heart had probably not been so entirely
paralyzed by the action of the vapour as sometimes happens, and in the
second case, that organ was apparently not paralyzed by the chloroform
at all. It was only after the breathing had ceased, that M. Ricord found
the pulse was failing. This was a case, therefore, in which artificial
respiration might reasonably be expected to restore the patient.
The following cases of resuscitation, from the over effects of
chloroform, are related by Mr. Bickersteth in the paper previously
quoted. They occurred in Edinburgh:
“_Case 1._ A boy was cut for stone by my friend Mr. Hakes, on the 29th
of March, 1849. Chloroform was administered on a piece of sponge, and
the full anæsthetic effect produced, before proceeding to tie him up in
the ordinary position: the inhalation was continued, without any regard
to his condition, until the operation had been completed—altogether
about five minutes from the time he first became insensible. It was
noticed that during the operation scarce a drop of blood escaped. When
it was over, the child was found, to all appearance, dead; the muscles
were flaccid; the surface of the body pale; the respiration had ceased;
the pulse could not be felt; the heart sounds were not audible (but the
room was by no means quiet); the eyes were half open; the jaw dropped;
the pupils dilated; and the corneæ without their natural brilliancy.
Several means were tried to resuscitate him, but without effect. At
length artificial respiration was commenced; the air escaped with a
cooing sound, as if from a dead body. After continuing it for a while,
the breathing commenced, at first very slowly and feebly. Soon it
improved. In two hours the child had quite recovered.”
“_Case 2._ In December 1851, a child, a few months old, was put under
the influence of chloroform for the purpose of having a nævus removed
from the right cheek. As soon as insensibility was produced, the
operation was commenced—the handkerchief containing the chloroform
remaining over the face, as some difficulty had been experienced in
keeping up the anæsthetic effect. Suddenly the breathing ceased; the
muscles became flaccid; the countenance pale and collapsed, and the lips
of a purple colour. Artificial respiration was employed, and in less
than a minute the breathing returned, and the child was restored.”