Chapter X: Preface (10)

“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.

It was previously shown that chloroform vapour has the effect of suddenly arresting the action of the heart when it is mixed with the respired air to the extent of eight or ten per cent., or upwards; and we must therefore conclude that, in the fatal cases of its inhalation, the air the patients were breathing just before the accidents occurred contained this amount of vapour. There was no means adopted, so far as is reported, to regulate the proportion of vapour in the inspired air, in any case in which an accident happened; and there was the liability in every case that ten per cent. or more of vapour might be present in the air the patient breathed; and in no case did death occur in the manner that it occurs when the vapour of chloroform does not exceed five per cent. of the inspired air.

TABLE OF FATAL CASES OF INHALATION OF CHLOROFORM.

───┬────────────┬────┬───────────────┬──────────┬───────────────
No.│ Patient. │Age │ Operation for │ Position │Means by which
│ │ in │ which the │ whilst │the chloroform
│ │yrs.│chloroform was │inhaling. │was exhibited.
│ │ │ inhaled. │ │
│ │ │ │ │
│ │ │ │ │
│ │ │ │ │
───┼────────────┼────┼───────────────┼──────────┼───────────────
1│Girl │ 15 │Removal of │Sitting │Towel
│ │ │ toe-nail. │ │
2│Married lady│ 35 │Extraction of │Sitting │Inhaler
│ │ │ teeth. │ │
3│Patrick │ │Operation for │Lying on │Handkerchief
│ Coyle │ │ fistula in │ the side│
│ │ │ ano │ │
4│Single lady │ 30 │Opening of │Lying │Handkerchief
│ │ │ sinus in │ │
│ │ │ thigh │ │
5│Young woman │ │Amputation of │ │Handkerchief
│ │ │ the middle │ │
│ │ │ finger │ │
6│Young man │ 22 │Transcurrent │ │Inhaler
│ │ │ cauterisation│ │
│ │ │ of wrist │ │
7│Young man │ │Intended │ │Probably
│ │ │ removal of │ │ handkerchief
│ │ │ toe-nail. │ │
8│Seaman │ 31 │Removal of │Lying on │Napkin
│ │ │ hæmorrhoids │ the side│
9│Miner │ 17 │Intended │Lying │Handkerchief
│ │ │ amputation of│ │
│ │ │ middle finger│ │
10│Labourer │ 36 │Amputation of │ │Handkerchief
│ │ │ toe │ │
│ │ │ │ │
11│Married lady│ 33 │Intended │Sitting │Handkerchief
│ │ │ extraction of│ │
│ │ │ tooth │ │
12│Porter │ 48 │Removal of │Lying │Inhaler
│ │ │ toe-nail │ │
│ │ │ │ │
13│Married │ │Removal of │Probably │A sponge
│ woman │ │ eyeball │ lying │
│ │ │ │ │
14│Young lady │ 20 │Intended │Sitting │A sponge
│ │ │ extraction of│ │ enclosed in a
│ │ │ tooth │ │ napkin
15│A man │ │ │ │A sponge
│ │ │ │ │
│ │ │ │ │
16│Artilleryman│ 24 │Amputation of │ │Handkerchief
│ │ │ middle finger│ │
17│Bookkeeper │ 30 │Intended │Lying │Napkin
│ │ │ operation on │ │
│ │ │ testicle │ │
18│Boy │ 8 │Sounding the │Lying │Piece of lint
│ │ │ bladder │ │
19│Policeman │ 34 │Removal of │ │Napkin
│ │ │ portion of │ │
│ │ │ hand │ │
20│Man │ 24 │Intended │Lying │Folded lint in
│ │ │ amputation of│ │ a hollow
│ │ │ leg │ │ sponge
21│Man │ │Intended │Lying │
│ │ │ operation on │ │
│ │ │ the penis │ │
22│Married lady│ 36 │Extraction of │Sitting │Handkerchief
│ │ │ teeth │ │
23│Mulatto │ 45 │Removal of │Lying │Napkin
│ seaman │ │ testicle. │ │
24│Married │ 37 │Removal of │Lying │Handkerchief
│ woman │ │ impacted │ │
│ │ │ fæces │ │
25│Man │ 23 │Ligature of │Lying │Inhaler
│ │ │ vessels near │ │
│ │ │ vascular │ │
│ │ │ tumour │ │
26│Married lady│ 32 │Intended │Sitting │Sponge
│ │ │ extraction of│ │ surrounded by
│ │ │ tooth │ │ handkerchief
27│Man │ │Intended │Lying │Handkerchief
│ │ │ operation for│ │
│ │ │ fistula _in │ │
│ │ │ ano_ │ │
28│Cattle │ │Applic. of │ │Handkerchief
│ dealer │ │ potassa fusa │ │
│ │ │ to ulcers of │ │
│ │ │ leg │ │
29│Factory │ │Removal of │Lying │Inhaler
│ operative │ │ malignant │ │
│ │ │ tumour of │ │
│ │ │ thigh. │ │
30│Single woman│ 28 │Intended │Lying │Folded lint
│ │ │ application │ │
│ │ │ of nitric │ │
│ │ │ acid to │ │
│ │ │ ulcers of │ │
│ │ │ pudenda │ │
31│Soldier │ 25 │Removal of │Lying │Hollow sponge
│ │ │ small tumour │ │
│ │ │ from cheek │ │
32│Tobacconist │ 43 │Intended │Lying │Handkerchief
│ │ │ perineal │ │
│ │ │ section │ │
33│Woman │ 40 │Intended │Lying │Folded lint
│ │ │ operation for│ │
│ │ │ strangulated │ │
│ │ │ hernia │ │
│ │ │ │ │
34│Single woman│ 22 │Intended │Lying │Inhaler
│ │ │ application │ │
│ │ │ of actual │ │
│ │ │ cautery to │ │
│ │ │ sore of │ │
│ │ │ vagina │ │
35│Young man │ 19 │Intended │Lying │Inhaler
│ │ │ forcible │ │
│ │ │ extension of │ │
│ │ │ knee │ │
36│Girl │ 13 │Removal of │Apparently│
│ │ │ tumour from │ sitting │
│ │ │ back │ │
37│Married │ 59 │Intended │Lying │Hollow sponge
│ woman │ │ reductionof │ │
│ │ │ old │ │
│ │ │ dislocation │ │
│ │ │ of humerus │ │
38│Woman │ 40 │Removal of │Lying │Folded lint
│ │ │ uterine │ │
│ │ │ polypus │ │
39│Married │ 45 │Intended │Lying │Sponge,
│ woman │ │ removal of │ │ handkerchief,
│ │ │ breast │ │ and inhaler
40│Tailor │ 18 │Intended │Lying │Inhaler
│ │ │ operation for│ │
│ │ │ phymosis │ │
41│Labouring │ 65 │Intended │Lying │Inhaler
│ man │ │ amputation of│ │
│ │ │ thigh │ │
42│Shoemaker │ 39 │Catheterism │Lying │Folded lint
│ │ │ │ │
│ │ │ │ │
│ │ │ │ │
43│Woman │ 56 │Intended │Lying │Folded lint &
│ │ │ amputation of│ │ piece of
│ │ │ leg │ │ oiled silk
44│Man │ 40 │Intended │Lying │Inhaler
│ │ │ excision of │ │
│ │ │ eyeball │ │
45│Married lady│ 29 │Inhaled to │Sitting │Inhaler
│ │ │ relieve │ │
│ │ │ neuralgia │ │
46│Married lady│ 36 │Intended │Sitting │Handkerchief
│ │ │ extraction of│ │
│ │ │ teeth │ │
47│Sailor │ 30 │Intended │Sitting │Sponge and
│ │ │ removal of │ │ folded lint
│ │ │ necrosed bone│ │
│ │ │ from finger │ │
48│Boy │ 9 │Intended │Lying │Cotton wool &
│ │ │ removal of │ │ folded lint
│ │ │ tumour of │ │
│ │ │ scapula │ │
49│Labourer │ 35 │Intended │Lying │Folded lint
│ │ │ amputation of│ │
│ │ │ thigh │ │
50│Young woman │ 17 │Application of │Lying │Inhaler
│ │ │ nitric acid │ │
│ │ │ to syphilitic│ │
│ │ │ sores │ │
───┴────────────┴────┴───────────────┴──────────┴───────────────

───┬────────────┬────┬──────────────┬────────────┬────────────
No.│ Patient. │Age │Time from the │ Apparent │ Previous
│ │ in │ commencement │ mode of │inhalations.
│ │yrs.│of inhalation │ death. │
│ │ │ to the │ │
│ │ │ beginning of │ │
│ │ │ dangerous │ │
│ │ │ symptoms. │ │
───┼────────────┼────┼──────────────┼────────────┼────────────
1│Girl │ 15 │Half a minute │Cardiac │Ether once.
│ │ │ │ syncope │
2│Married lady│ 35 │About two │Cardiac │None.
│ │ │ minutes │ syncope │
3│Patrick │ │About one │Cardiac │One.
│ Coyle │ │ minute │ syncope │
│ │ │ │ │
4│Single lady │ 30 │Probably half │Cardiac │None.
│ │ │ a minute │ syncope │
│ │ │ │ │
5│Young woman │ │A very short │Cardiac │None stated.
│ │ │ time │ syncope │
│ │ │ │ │
6│Young man │ 22 │Five minutes │Symptoms not│None stated.
│ │ │ │ described │
│ │ │ │ │
7│Young man │ │Not stated │Death very │None stated.
│ │ │ │ sudden │
│ │ │ │ │
8│Seaman │ 31 │About ten │Cardiac │One.
│ │ │ minutes │ syncope │
9│Miner │ 17 │About five │Cardiac │None.
│ │ │ minutes │ syncope │
│ │ │ │ │
10│Labourer │ 36 │Died at the │Cardiac │A previous
│ │ │ close of the│ syncope │ attempt.
│ │ │ operation │ │
11│Married lady│ 33 │A very short │Cardiac │One.
│ │ │ time │ syncope │
│ │ │ │ │
12│Porter │ 48 │A little more │Probably │None.
│ │ │ than two │ asphyxia │
│ │ │ minutes │ │
13│Married │ │Died during │Cardiac │None stated.
│ woman │ │ the │ syncope │
│ │ │ operation │ │
14│Young lady │ 20 │Just after │Cardiac │Previous
│ │ │ beginning to│ syncope │ attempts.
│ │ │ inhale │ │
15│A man │ │Died before │Probably │None.
│ │ │ the │ cardiac │
│ │ │ operation │ syncope │
16│Artilleryman│ 24 │ │Cardiac │None.
│ │ │ │ syncope │
17│Bookkeeper │ 30 │Within five │Cardiac │None.
│ │ │ minutes │ syncope │
│ │ │ │ │
18│Boy │ 8 │A few minutes │Cardiac │None.
│ │ │ │ syncope │
19│Policeman │ 34 │Died during │Cardiac │None.
│ │ │ operation │ syncope │
│ │ │ │ │
20│Man │ 24 │A few minutes │Cardiac │None.
│ │ │ │ syncope │
│ │ │ │ │
21│Man │ │ │“Suddenly │None stated.
│ │ │ │ expired” │
│ │ │ │ │
22│Married lady│ 36 │Less than a │Cardiac │None.
│ │ │ minute │ syncope │
23│Mulatto │ 45 │About seven │Cardiac │None.
│ seaman │ │ minutes │ syncope │
24│Married │ 37 │Eight or nine │Symptoms not│Two.
│ woman │ │ minutes │ observed │
│ │ │ │ │
25│Man │ 23 │Five to ten │Cardiac │One.
│ │ │ minutes │ syncope │
│ │ │ │ │
│ │ │ │ │
26│Married lady│ 32 │Four or five │Cardiac │None stated.
│ │ │ inspirations│ syncope │
│ │ │ │ │
27│Man │ │Not more than │Cardiac │None.
│ │ │ a minute │ syncope │
│ │ │ │ │
│ │ │ │ │
28│Cattle │ │Died during │Probably │None.
│ dealer │ │ operation │ cardiac │
│ │ │ │ syncope │
│ │ │ │ │
29│Factory │ │About twelve │Probably │None.
│ operative │ │ minutes │ cardiac │
│ │ │ │ syncope │
│ │ │ │ │
30│Single woman│ 28 │ │Cardiac │None.
│ │ │ │ syncope │
│ │ │ │ │
│ │ │ │ │
│ │ │ │ │
│ │ │ │ │
31│Soldier │ 25 │Five minutes │Cardiac │None.
│ │ │ │ syncope │
│ │ │ │ │
32│Tobacconist │ 43 │A few minutes │Cardiac │Two.
│ │ │ │ syncope │
│ │ │ │ │
33│Woman │ 40 │About five │Simultaneous│None.
│ │ │ minutes │ deep coma │
│ │ │ │ and │
│ │ │ │ cardiac │
│ │ │ │ syncope │
34│Single woman│ 22 │About five │Cardiac │One.
│ │ │ minutes │ syncope │
│ │ │ │ │
│ │ │ │ │
│ │ │ │ │
│ │ │ │ │
35│Young man │ 19 │Fifty seconds │Cardiac │None.
│ │ │ │ syncope │
│ │ │ │ │
│ │ │ │ │
36│Girl │ 13 │ │Cardiac │None stated.
│ │ │ │ syncope │
│ │ │ │ │
37│Married │ 59 │About five │Deep coma │None.
│ woman │ │ minutes │ and │
│ │ │ │ cardiac │
│ │ │ │ syncope │
│ │ │ │ │
38│Woman │ 40 │A few minutes │Cardiac │None stated.
│ │ │ │ syncope │
│ │ │ │ │
39│Married │ 45 │Three-quarters│Cardiac │None.
│ woman │ │ of an hour. │ syncope │
│ │ │ │ │
40│Tailor │ 18 │About seven │Cardiac │None.
│ │ │ minutes │ syncope │
│ │ │ │ │
41│Labouring │ 65 │Between 13 and│Cardiac │None.
│ man │ │ 14 minutes │ syncope │
│ │ │ │ │
42│Shoemaker │ 39 │A few minutes │Deep coma, │None.
│ │ │ │ apnœa, and│
│ │ │ │ cardiac │
│ │ │ │ syncope │
43│Woman │ 56 │About three │Cardiac │None.
│ │ │ minutes │ syncope │
│ │ │ │ │
44│Man │ 40 │About five │Cardiac │None.
│ │ │ minutes │ syncope │
│ │ │ │ │
45│Married lady│ 29 │A few seconds │Cardiac │Two or
│ │ │ │ syncope │ three.
│ │ │ │ │
46│Married lady│ 36 │A few seconds │Cardiac │Four.
│ │ │ │ syncope │
│ │ │ │ │
47│Sailor │ 30 │Three or four │Deep coma │None.
│ │ │ minutes │ and │
│ │ │ │ cardiac │
│ │ │ │ syncope │
48│Boy │ 9 │A few minutes │Cardiac │None.
│ │ │ │ syncope │
│ │ │ │ │
│ │ │ │ │
49│Labourer │ 35 │A few minutes │Cardiac │One.
│ │ │ │ syncope │
│ │ │ │ │
50│Young woman │ 17 │ │Symptoms not│Two.
│ │ │ │ observed │
│ │ │ │ │
│ │ │ │ │
───┴────────────┴────┴──────────────┴────────────┴────────────

There is in a great number of the cases an evident connection between the accident and the probable strength of the mixture of vapour and air. In six cases the accident occurred just after the commencement of the inhalation; in two of the cases, Nos. 27 and 37, the fatal symptoms occurred just after fresh chloroform had been applied on the handkerchief and sponge; and in several cases, in which the circulation was suddenly arrested just after the patient had been rendered insensible, the insensibility had been induced so quickly as to prove that the vapour must have been inhaled in a very insufficient state of dilution.

THE TWO KINDS OF SYNCOPE.

Dr. Patrick Black has made an objection to the fact of the patients having died of paralysis, or over-narcotism of the heart, in the accidents from chloroform.[132] He says that paralysis of the heart would be death by syncope, but that the symptoms before death, and the conditions of the organs met with afterwards, are not in accordance with such a view of the case. In order to show that both the symptoms and the after death appearances, in the fatal cases of inhalation of chloroform, are consistent with paralysis of the heart, it is necessary to point out the difference between ordinary syncope and cardiac syncope. One of the best examples of ordinary, or what may be called anæmic syncope, is that which occurs in a common blood-letting, whilst the patient is in the sitting posture. When the bloodvessels, especially the veins, which at all times contain the greater part of the blood in the body, do not accommodate themselves fast enough to the diminished quantity of blood, the right cavities of the heart are supplied with less and less of the circulating fluid; and in a little time are not supplied at all, when the heart ceases to beat, in accordance with the observation of Haller, that it does not pulsate when it is not supplied with blood. The moment the heart ceases to supply blood to the brain there are loss of consciousness and stoppage of respiration; but on the patient being placed in the horizontal position the blood flows readily into the right cavities of the heart from the great veins of the abdomen and lower extremities; the heart immediately recommences its contractions; the brain is again supplied with blood, and respiration and consciousness return.[133]

The blood may remain in the ordinary quantity; but if the bloodvessels do not keep up their usual support, and exert a sufficient pressure on their contents, the same kind of syncope will occur as that from blood-letting. The late Sir George Lefevre related the case of a lady who fainted whenever she left her bed, and assumed the upright posture; no cause could be found for this until it was ascertained that she suffered from varicose veins of the legs: bandages to these extremities prevented the fainting. It is obvious that in this case the mechanism of the syncope was the same as that in blood-letting; the distension of the varicose veins under the weight of the superincumbent blood had the same effect in preventing the supply to the right cavities of the heart, as if the blood had been entirely removed. The faintness which often occurs on first rising, when a person has long kept the recumbent posture from any local cause, is probably of the same kind; the veins not having had to support the weight of the usual column of blood for some days or weeks, lose their tone we may presume, and yield when they are all at once subjected to the weight of a column of blood extending from the lower extremities to the heart, so that this organ ceases to be properly supplied with the circulating fluid.

In cardiac syncope, on the other hand, the cavities of the heart, or at all events the right cavities of this organ, are always full, whether the syncope depend on paralysis of the heart by a narcotic, or inherent weakness of its structure, or on its being overpowered by the quantity of blood with which it is distended. After death from this kind of syncope, if the blood have not been displaced by artificial respiration or other causes, the right cavities of the heart and the adjoining great veins will be found filled with blood, and the lungs will in many cases be more or less congested. The appearances in short will be very much the same as in asphyxia by privation of air, which ends in a kind of cardiac syncope, the stoppage of the heart being partly due to over-distension of its right cavities, and partly to loss of power in its structure, from the want of a supply of oxygenated blood through the coronary arteries. In death by anæmic syncope, on the contrary, all the cavities of the heart are found empty, or nearly so, and the same is frequently the case with the adjoining great veins, whilst the lungs are usually pale.

The syncope occasioned by some kinds of mental emotion is of the ordinary or anæmic kind, and consequently the condition of the brain must act first on the bloodvessels, and not directly on the heart. Certain persons are liable to faint on witnessing a surgical operation. Now if the mental emotion of these persons acted directly on the heart, whilst the rest of the vascular system was unaffected, the distribution of the blood would be nearly the same as in asphyxia, where the circulation is first impeded in the lungs, and is ultimately arrested by loss of power in the heart. If the action of the heart were weakened, or stopped, in the first instance, by the kind of emotion under consideration, the arteries would be emptied by their contractility and elasticity, and the blood would accumulate in the right cavities of the heart and the great veins leading to them. In a medical student fresh from the country, who is by no means deficient in blood, the jugulars would become distended and the face livid, and the recumbent posture would probably do but little towards removing the symptoms. The phenomena which are witnessed, however, indicate a very different condition of the vascular system. The person about to faint from the cause indicated, frequently becomes pale before he feels anything wrong; and when requested to retire and sit down, often says that there is nothing the matter with him. In a short time he faints, and falls, if no one catches hold of him; but the moment he is in the recumbent posture he recovers. In such a case as this, the effect of the mental emotion must be first exerted on the veins, or the veins and capillaries, through the nerves which supply these vessels; they allow themselves to become distended, and the heart ceases to act for want of its supply of blood, as in syncope from blood-letting, and anæmic syncope from any cause.

Several authors have attributed the empty state of the heart met with after death, in certain cases of fatal syncope, to want of power in the left ventricle to supply the right cavities of the heart; but this is to argue as if the blood passed out of the body after leaving the right ventricle, and the left ventricle had to supply a newly formed fluid. The effects of want of power in the left ventricle are the same as those of an obstruction at the origin of the aorta; the lungs become congested, and the right cavities of the heart more or less distended, from the blood not being able to pass readily through the lungs. Patients who die of heart disease die with the cavities of that organ full. Some patients, indeed, with fatty disease of the heart, die suddenly of anæmic syncope, and the heart is found empty; but in these cases it is evident that death is not occasioned by the disease of the heart, but by some condition of the bloodvessels which accompanies it.

Chevalier was, I believe, the first to draw marked attention to cases of sudden death arising from an empty state of the heart, in a paper in the first volume of the Transactions of the Royal Medical and Chirurgical Society; and he rightly attributed the emptiness of the heart to a loss of power in the bloodvessels. His words are as follow:—

“The disease I have now described may, perhaps, be termed _asphyxia idiopathica_. The essential circumstances of it evidently denote a sudden loss of power in the vessels, and chiefly in the minuter ones, to propel the blood they have received from the heart. In consequence of which, this organ, after having contracted so as to empty itself, and then dilated again, continues relaxed for want of the return of its accustomed stimulus, and dies in that dilated state.”

The word asphyxia has become so closely connected by physiologists with death by privation of air, where the symptoms and appearances are the reverse of those in Chevalier’s case, that it is necessary to discard his name of the disease which he describes, although it is etymologically correct. His cases come under the definition of what is now universally called syncope, and what I have called anæmic to distinguish it from cardiac syncope.

Chevalier speaks of a want of power in the vessels to propel the blood, and as it is not now believed that the vessels take any active share in the propulsion of the blood, this may be the reason why the views of this author have received less attention than they deserve; but it is very obvious that a want of tone in the vessels, or any great diminution of that power which enables them to support and compress the blood, is an adequate cause why the blood should be unable to reach the right side of the heart. In the case of varicose veins, previously mentioned, it was physically apparent that the cause of the syncope lay in the vessels. Disease of the arteries is well known to be usually associated with degeneration of the heart; the veins are also large and distensible in old people, who furnish the greater number of those who are liable to anæmic syncope; but the pathology of the veins, as regards both their functions and structure, is not yet sufficiently known.

Persons with disease of the heart, who die suddenly in a fit of anger, probably die always with the heart distended; that is, of cardiac syncope. Dr. Joseph Ridge, however, in his able and interesting remarks on the disease and death of John Hunter,[134] states his belief that that celebrated man, who had been long subject to attacks of angina pectoris, died at last of syncope, with an empty heart. He died, as is well known, during a fit of anger, and the coronary arteries were found ossified. It is not said that the heart was empty, but that it was small, and that there were no coagula in any of its cavities. It is probable that there was not much blood in its cavities, at the time of the post mortem examination, but the body of Hunter was conveyed in a sedan-chair, from St. George’s Hospital to Leicester Square, a little more than an hour after his death, so that the fluid blood would gravitate downwards. It is related that the stomach and intestines were unusually loaded with blood, and that those parts which were in a depending position, as in the bottom of the pelvis and upon the loins, were congested in a greater degree than the others; and that “this evidently arose from the fluid state of the blood.”

In syncope from muscular exertion, the cavities of the heart are distended, and its walls have occasionally been ruptured, both from violent exercise and fits of anger.

Fear probably occasions each kind of syncope in different cases. In some cases, the right cavities of the heart become distended owing to impeded respiration, and possibly to a diminution of power in the heart itself. More frequently, the syncope appears to be of the ordinary or anæmic kind, the effect of the mental condition acting first on the more distant parts of the circulation. The pallor caused by fright is proverbial.

Pain is also capable of causing both kinds of syncope. I have alluded to cases (page 55) in which the patients strained and held their breath till the pulse became intermittent, and the action of the heart was temporarily suspended by the arrested breathing; on the other hand, patients often become pale, if they are undergoing any slight operation when seated, and syncope of the anæmic kind occurs, without any previous disturbance of the respiration, but passes off as soon as they are placed in the horizontal posture. I have seen an apparently strong man faint in this manner, during the removal of a tumour from the back not larger than a nut, and where only a few drops of blood were lost. Chloroform was not employed.

SUPPOSED CAUSES OF DEATH FROM CHLOROFORM.

Many writers have supposed that the deaths from chloroform have arisen from some peculiarity in the patient; and when any notable change of structure has been met with after death in any of the vital organs, this has been thought to afford a sufficient explanation of the event; whilst in the cases in which the organs were in a healthy state, surprise has been expressed at the occurrence. In looking over the account of the cases in which the inhalation of chloroform has been fatal, there is reason to conclude, however, that the subjects of them were, as regards health and strength, quite equal to the average of the multitude who have inhaled this agent without ill effects. In fifteen out of the fifty cases above related, there was no examination of the body after death. In one of these fifteen cases, the patient was in a state of debility, and had hectic fever, apparently from the disease of the ankle-joint, for he had no cough; in another of these cases, the patient was reduced to a state of great debility from cancerous disease of the uterus. In fourteen out of the thirty-five cases, in which an examination of the dead body took place, all the chief organs were found to be healthy, if we except the local congestions of blood connected with the mode of dying, and a flabby state of the heart in a few of the cases, which probably depended on its being full of blood at the time of death, or its not being in a state of post-mortem rigidity, at the time it was examined.

In one case, No. 25, the only morbid appearances were adhesions of the 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.