Chapter XI: Preface (11)

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.

Mr. Bickersteth’s reason for attributing the stoppage of the pulse to 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.”

“_Case 3._ On the 6th of March, 1852, I had occasion to remove the finger of a robust, healthy-looking young man, in the Royal Infirmary. He was already under the influence of chloroform when I entered the room, and as there had been some difficulty in producing complete anæsthesia, and the last of the chloroform in the bottle was already on the handkerchief, it was thought advisable by my friend in charge of its administration to keep up the inhalation, in order to produce a coma sufficiently profound to last until the completion of the operation. It was therefore left over his face, and I commenced and removed the finger, slowly disarticulating it from the metacarpal bone. I distinctly recollect hearing the man breathing quickly and shortly; and I also remember, that when just about to look for the vessels, my attention was attracted to his condition, by not any longer hearing the respiration. The handkerchief was still on his face. I took it off, and found, to my consternation, that the breathing had ceased; the face was livid; the eyes suffused; the pupils dilated; the mouth half open. He was to all appearance dead; still the pulse could be distinguished as a small, hardly perceptible thread, beating slowly. Immediately artificial respiration was commenced. For a minute or two, his condition did not alter in any respect—then the lividity of the countenance increased, the pulse was no longer perceptible, and the sounds of the heart could not be satisfactorily heard. During the whole of this time, artificial respiration had been diligently employed, but still the air appeared to enter the chest very imperfectly. I despaired. I felt certain that the man was dead, and that no human aid could restore him; and if it had not been that those standing near me urged me to persevere, I believe I should then have deserted the case as hopeless. Just at this time it occurred to me to put my finger in the mouth and draw forward the tongue, in order to secure there being no impediment to the air entering the lungs. Retaining it in this position, we again began the artificial respiration, and found that then the chest was fully expanded by each inflation. After keeping it up for a minute or two, the gentleman, who had all along kept his hand on the pulse, exclaimed, to our delight, that he could again feel it—‘It was just like a slight flutter that reached the uppermost of his four fingers,’ all of them being placed over the course of the artery. It gradually became more distinct and firmer, and at the same time, the lividity of the face decidedly lessened. In another minute, the man made a slight inspiratory effort. I ceased directly the artificial respiration, and merely assisted the expiration by pressure upon the ribs. Another and another inspiration followed, and in a short time he breathed freely without assistance. The countenance became natural, and he appeared as if in a sound sleep. In half an hour, he spoke when roused; then he vomited, and complained of giddiness. In an hour afterwards, he had recovered sufficiently to walk home.

“Moments of intense anxiety appear much longer than they really are; but even allowing this, I am quite sure that, at the very least, five minutes elapsed from the time when the man ceased breathing before the first inspiratory effort took place, and that for not less than one minute the pulse was imperceptible, and the heart’s action almost, if not altogether, inaudible.”

“_Case 4._ A few weeks after the occurrence just described, I was assisting Mr. Syme in removing the breast of a lady. A gentleman, my superior in the hospital, was conducting the inhalation of chloroform. Anæsthesia was complete, and the breathing good, when the operation commenced. The chloroform was allowed to remain over the face during the whole time of its performance. Before it was over, I noticed the respiration become very quick and incomplete, and suggested, in consequence, the propriety of removing the handkerchief. My remark was neglected for eight or ten seconds, and then, just as it was taken away, the breathing ceased suddenly. The face became deadly pale; the eyes vacant; the lips livid. Instant dissolution appeared inevitable (the pulse was not felt). Artificial respiration was immediately commenced, but the air not entering the lungs freely, the tongue was pulled forwards, and retained so by the artery forceps. The chest then expanded freely with each inflation, the air escaping with a cooing sound. In rather less than a minute, the respiratory movements recommenced, but at first so slowly and imperfectly that it was necessary to assist expiration. When recovery was a little more established, the operation was completed. Before the putting in of the sutures, sensation had partially returned, and in a short time the lady had perfectly recovered.”

Mr. Bickersteth very properly adds: “There can be no doubt, that in the foregoing cases, a grievous error was committed by continuing the inhalation after anæsthesia was produced, and that it was in consequence of this, the accidents, so nearly fatal, occurred.”

As these accidents seem to have occurred from continuing the inhalation too long, they differ entirely from nearly all those which were actually fatal, and which, as we have seen, arose from the too great concentration of the vapour, and not from any want of care in watching the patient, so as to be able to leave off at the right moment, if it were possible. I have previously stated, that after breathing vapour of the proper strength for inhalation, animals may always be readily restored by artificial respiration after the breathing has ceased, provided the heart is still beating. In the cases related by Mr. Bickersteth, the heart had ceased to beat before the patients were restored; but in the third case, there is distinct evidence that the heart continued to beat for four minutes after the breathing had ceased. It was, therefore, certainly not paralyzed by the direct action of the chloroform. The patient was nearly in the condition of a drowned person, where we know that there is a good prospect of recovery by artificial respiration during the first few minutes after the breathing has ceased, even if the action of the heart be imperceptible. In the other three cases, also, it is probable that the breathing ceased before the action of the heart; and, at all events, this organ was not paralyzed so thoroughly as in the cases in which artificial respiration was promptly applied without effect.

Several other cases have been related in the medical journals in which patients have been restored by artificial respiration, after animation had been suspended, more or less completely, by chloroform; but the above remarks would, I believe, be applicable to all these cases.

Where patients have recovered under the use of other measures, without artificial respiration, it is probable that animation was not completely suspended, and that the recovery was spontaneous.

M. Delarue related a case of accident from chloroform to the Academy of Medicine, on August 20th, 1850, which was apparently of this nature. After administering the vapour, and when he was about to divide some sinuses in the thigh, he found that his patient (a woman) was in a state of collapse, and the breathing and pulse, “_pour ainsi dire_”, insensible. The face was injected, and there was a bloody froth at the mouth. The uvula was titillated, and there was immediate movement of the eyelids, which was soon followed by copious vomiting, and the patient recovered.[140]

Such measures as dashing cold water on the patient, and applying ammonia to the nostrils, can hardly be expected to have any effect on a patient who is suffering from an overdose of chloroform; for they would have no effect whatever on one who has inhaled it in the usual manner, and is merely ready for a surgical operation, but in no danger. I have applied the strongest ammonia to the nostrils of animals that were narcotized by chloroform to the third or fourth degree, and it did not affect the breathing in the least. They recovered just as if nothing had been done. It is difficult to suppose a case in which the breathing should be arrested by the effects of chloroform whilst the skin remained sensible, yet it is only in such a case that the dashing of cold water on the patient could be of use. There is, however, no harm in the application of this and such like means, provided they do not usurp the time which ought to be occupied in artificial respiration; for this measure should be resorted to the moment the natural breathing has entirely ceased.

I have only seen two cases in which the patients seemed in imminent danger from the direct effects of chloroform. One of these occurred in 1853. It was the case of a child, aged six years, but small and ricketty, which had the greater part of the eyeball removed on account of melanotic disease. The usual inhaler was employed, and when the child seemed sufficiently insensible, it was withdrawn. The operation was commenced by introducing a large curved needle, armed with a thick ligature, through the globe of the eye, in order to draw it forward. As the needle was introduced, the child cried out a very little, and thinking the parents, who were in the adjoining room, would be alarmed, I poured some undiluted chloroform hastily on a rather large sponge, and placed it over the nostrils and mouth. The sponge became pressed by the surgeon’s hand closer on the nose than I intended, but it was removed after the child had taken a few inspirations. The operation was quickly concluded without any further sign of sensation than that mentioned above. At the end of the operation, the breathing was natural, but the face was pale, and the lips blue, and the limbs were also relaxed. I tried to feel the pulse at the wrist, but did not discover any. The chloroform had at this time been left off half a minute at least. The pallor and blueness continued, and in a little time the breathing became slow and embarrassed, and appeared about to cease altogether, the pulse being still absent. The windows were opened, and cold water dashed freely on the face. The child made gasping inspirations now and then, but they did not follow immediately, or seem connected with each application of the water. The gasps became more frequent, till the breathing was thoroughly reestablished, when the colour returned to the lips, and the pulse was again felt at the wrist. In a minute afterwards, the child was red in the face, and crying violently from pain, which was relieved by a little more chloroform. It appeared to be a minute or a minute and a half from the time when the sponge with chloroform was removed, till the breathing became of a gasping character. There is no doubt that in this case the heart was paralyzed, or nearly so, by the chloroform, and that its action was restored by the spontaneous gasping inspirations of the child. The accident could have been prevented by having the chloroform, which was put on the sponge, diluted with spirit.

The other case occurred in the latter part of 1852. I have no notes of it, as it took place at the beginning of an illness, which prevented me from writing for some time; but I recollect the chief particulars of it sufficiently well. The patient was a lady rather more than sixty years of age, rather tall and thin. She required to have a polypus removed from the nose. Mr. Fergusson, who was about to operate, was nearly an hour after the appointed time, and during this interval she was pacing up and down the room, apparently in a great fright. She was placed in an easy chair for the operation, and the pulse was small and feeble when she began to inhale. Nothing particular occurred during the inhalation, but just at the time when the patient was becoming insensible, the breathing ceased, and the pulse could not be felt. She appeared to have fainted, and was immediately placed on a bed which was in the room. I applied my ear to the chest, but could hear no sound whatever. Mr. Fergusson applied his mouth to that of the patient, and with a very strong expiration, inflated her lungs, so as to expand the chest very freely. I immediately heard the heart’s action recommence with very rapid and feeble strokes, as I had so often heard it recommence in animals. The patient soon began to make distant gasping inspirations, and the natural breathing and pulse were soon reestablished. Mr. Fergusson made only one or two inflations of the lungs after the first one, which of itself was the means of restoring the patient. It was about twenty minutes, however, before she became conscious; and during the greater part of this time there were spasmodic twitchings of the features and limbs on one side. In about an hour, she was pretty well; and on the following day the operation was performed without chloroform.

The most ready and effectual mode of performing artificial respiration is undoubtedly the postural method, introduced by Dr. Marshall Hall a little time before his death. It consists in placing the patient on the face and making pressure on the back; removing the pressure, and turning the patient on his side and a little beyond; then turning him back on the face and making pressure on the back again; these measures being repeated in about the time of natural respiration.

Whether the artificial breathing is successful or not must depend chiefly on the extent to which the heart has been paralyzed by the chloroform, as was previously observed. The fact of the breathing continuing after the action of the heart has ceased, in some of the fatal cases, shows that the heart may be so paralyzed as not to be readily restored by the breathing. It is probable that in all cases in which artificial respiration can restore the patient, its action would be very prompt; still it is desirable to persevere with this measure for a good while.

As already stated, there is every reason to conclude that the right cavities of the heart are distended with blood, in all cases of suspended animation by chloroform, and therefore it would be desirable to open one of the jugular veins if the artificial respiration does not immediately restore the patient. In opening animals, just after death from this agent, I have observed the contractions of the heart to return, to a certain extent, when the distension of its right cavities was diminished by the division of the vessels about the root of the neck. Opening the jugular veins has been resorted to in a few of the cases of accident from chloroform, but hitherto without success.

I have not succeeded in restoring an animal from an overdose of chloroform, by means of electricity, in any case where I felt satisfied that it would not recover spontaneously; and I have not heard of any patient being restored by its means. For keeping up respiration, mechanical means, such as the postural method, are better; as they cause air to enter the lungs without exhausting the remaining sensibility. If electricity be used, it should be directed towards restoring the action of the heart. It is probable that the electric current would not reach the heart without the help of the acupuncture needle; but it would be justifiable to use this in a desperate case, when other measures had failed. The needles should be coated with wax, or some other non-conductor of electricity, except near the points.