Chapter VII: Preface (7)

Air, when saturated only at 60° Fah., contains 12 per cent. of vapour of chloroform, and at 70° 19 per cent. (p. 33); and 8 or 10 per cent. in the inspired air is capable, as we have seen, of causing sudden death by paralysing the heart; but in practice the air is usually far from being saturated, in passing over a handkerchief or similar material, even at the temperature at which it is inhaled; and this is generally lowered considerably by the absorption of caloric by the chloroform, as it changes its condition from a liquid to a vapour. Moreover, air strongly charged with vapour of chloroform is not easy to breathe, owing to its pungency; and the physiological knowledge and close attention of every medical man who administers this medicine causes him to withdraw it immediately on the least appearance of danger.

_Case 1._ The first death from chloroform was that of Hannah Greener, which occurred at Winlaton, near Newcastle, on the 28th of January, 1848. The patient was a girl of 15, who required to have the nail of the great toe removed. A similar operation had been performed on the other foot, in the previous November, in the Newcastle Infirmary, when ether was administered with a satisfactory result. The following is the account of the accident by Dr. Meggison, who administered the chloroform: “She appeared to dread the operation, and fretted a good deal: in fact, she commenced sobbing on our entering the house, and continued so until seated in the operating chair, and commencing the inhalation, which was done from a handkerchief on which a teaspoonful of chloroform had been poured. After drawing her breath twice, she pulled my hand from her mouth. I told her to put her hands on her knees, and breathe quietly, which she did. In about half a minute, seeing no change in breathing, or alteration of pulse, I lifted her arm, which I found rigid. I looked at the pupil and pinched her cheek, and, finding her insensible, requested Mr. Lloyd to begin the operation. At the termination of the semilunar incision she gave a kick or twitch, which caused me to think the chloroform had not sufficient effect. I was proceeding to apply more to the handkerchief, when her lips, which had been previously of a good colour, became suddenly blanched, and she spluttered at the mouth, as if in epilepsy. I threw down the handkerchief, dashed cold water in her face, and gave her some internally, followed by brandy, without, however, the least effect, not the slightest attempt at a rally being made. We laid her on the floor, opened a vein in her arm, and the jugular vein, but no blood flowed. The whole process of inhalation, operation, venesection, and death, could not, I should say, have occupied more than two minutes.”[65]

An examination of the body was made the day after death by Sir John Fife and Dr. Glover, who reported as follows:—“The body was that of a well-grown female of about fifteen years of age.... On opening the chest, the lungs were not collapsed. One or two very slight adhesions were encountered on separating them from the walls of the chest. The external appearance of both lungs, over the whole surface, but especially in the inferior portions, was that of organs in a very high state of congestion. They were mottled with patches of a deep purple, blueish, or scarlet hue. They were everywhere crepitant. Along the outer and interior border of both lungs, particularly of the upper lobe of the left lung, were several emphysematous bubbles of small size.... The pulmonary tissue was filled with bloody froth, which was also found in the interior of the bronchi, mixed with mucus. There was no appearance of hepatization. On examining the larynx and trachea, the epiglottis was found reddened at the summit, of a vermilion hue. The mucous membrane of the larynx was redder than natural—mottled with vascular patches. The sinuses of the larynx contained a good deal of dark mucus. The œsophagus was healthy. The stomach was distended with food. Some of the veins were more distinct than usual. The heart contained dark fluid blood in both its cavities: very little in the left. Its structure, and that of the great vessels near it, quite healthy. The brain, externally and internally, was more congested than usual; and the ventricles contained rather more than the usual quantity of serum.”[66]

Sir John Fife and Dr. Glover expressed the opinion that chloroform caused death by producing congestion of the lungs. After the further experience which has been gained respecting chloroform, this opinion of the mode in which it caused death, in the above case, would probably not now be offered. Indeed, in similar cases which have since occurred, the same opinion has not been advanced; and as the lungs were crepitant throughout, in the above case, it is probable that the congestion was not greater than is commonly met with in cases of sudden death without hæmorrhage. Dr. Simpson published his opinion, immediately after this case occurred, that it was not caused by the chloroform, but by the brandy which was given when the alarming symptoms came on; but Dr. Meggison replied that only a teaspoonful of brandy was given; that it was swallowed, though with difficulty; that there were no symptoms of choking from it; and that the girl was without pulse when it was given.[67]

From the lips becoming suddenly blanched in the above case, there is every reason to conclude that the heart was suddenly paralysed. The patient breathed for a little time after this, and was able to swallow, though with difficulty. The process of inhalation occupied only a little more than half a minute in Dr. Meggison’s estimation; yet he appeared to think that the fluid drachm of chloroform which he had put on the handkerchief had evaporated; for he was about to apply more when the alarming symptoms appeared. But supposing only one-third of the drachm was actually inhaled into the lungs in the half minute, the vapour would necessarily be in a highly concentrated state—probably twenty cubic inches of vapour in 200 cubic inches of air, which would be adequate to occasion the result which happened. In the short space of about half a minute, the blood could not be uniformly impregnated with the vapour; only a portion of it could pass through the lungs in the time; yet, as the patient was rendered insensible, this portion must necessarily have been highly charged with vapour.

It was often the practice to render the patient insensible in as short a time as half a minute, when chloroform was first introduced, but I believe never without danger; and I had expressed the opinion before any accident happened, that, for reasons such as I have stated above, a patient should on no account be rendered insensible in less than two minutes.[68]

_Case 2._ The next recorded case in which the inhalation of chloroform was fatal, occurred at Cincinnati, on the 23rd of February, 1848. The subject of it, Mrs. Martha G. Simmons, was thirty-five years of age, and enjoyed good general health; she was the mother of six children, and her last confinement occurred eight weeks before her death. The patient exhibited no alarm on account of inhaling the chloroform, which was administered by two dentists, who were not members of the medical profession. It was breathed from an inhaler which Dr. Morton of Boston contrived for sulphuric ether. This inhaler consisted of a glass globe four inches and a half in diameter, and contained a sponge about one-third filling the globe, and saturated with chloroform.

Two female friends of the patient reported the following as the events which occurred. “The respiratory movements appeared to be free; chest heaving. While inhaling, the face became pale. At the expiration of about one minute, the instruments were applied, and four roots of teeth extracted. The patient groaned and manifested what they regarded as evidences of pain, while the teeth were being extracted, although she did not speak or exhibit any other sign of consciousness. As the last root came out, which was about two minutes from the beginning of the inhalation, the patient’s head turned to one side, the arms became slightly rigid, and the body drawn somewhat backwards, with a tendency to slide out of the operating chair. At this instant, Mrs. Pearson states that she placed her finger upon the patients pulse; observed that it was feeble, and immediately ceased to beat; respiration also ceased about the same time. The face, which was previously pale, now became livid, as did also the finger nails; and the lower jaw dropped, and the tongue projected a little at one corner of the mouth, and the arms were perfectly relaxed. The females regarded her as being then quite dead.”[69]

The dentists gave nearly the same account, saying that the breathing was at first slow, and that the patient inhaled twelve or fifteen times, occupying from a minute to seventy-five seconds. They committed the great error of not placing the patient at once in the horizontal position, when the alarming symptoms came on, but kept her sitting in the chair, from five to ten minutes, whilst they sent out for restoratives. They thought the patient was living during this time, but her female friends thought not. The patient was placed on a sofa, and sometime afterwards artificial respiration and galvanism were applied without effect.

An examination of the body was made twenty-six hours after death by Drs. Mussey, Lawson, Baker and Mulford. The following are the chief particulars of the appearances met with. A larger quantity of blood than usual flowed from the sinuses of the dura mater. General aspect, colour, and consistence of the brain, normal. Lungs considerably but not intensely congested; crepitated freely at all points; no extravasation. Lining membrane of bronchia slightly congested, apparently the result of recent catarrh; deeply stained by the blood. Pleura at all points highly injected; six drachms of bloody serum in the right, and two ounces in the left chest. Pericardium contained six drachms of bloody serum. Heart flaccid, and all its cavities entirely empty; inner surface of both ventricles and auricles deeply stained. Abdomen—one ounce and a half of bloody serum in the right hypochondrium. Stomach and intestines distended with gas. Partially digested aliment, amounting to about three gills in the stomach. Blood fluid as water in every part of the body; not a coagulum was seen in any vessel. Lining membrane of all the bloodvessels deeply stained. The colour in every part of the system was that of dark venous blood.

It was estimated, in the inquiry which took place respecting this case, that one-fourth part by measure of what the patient inhaled might be vapour of chloroform; but this is evidently an over-calculation, for there could not be this quantity unless the interior of the glass globe were maintained at the temperature of 80° Fah. and the air were quite saturated with vapour in passing through it; however, less than half the amount of vapour here assumed would have the effect of causing sudden death, in the way it happened. The period of the inhalation, a minute or seventy-five seconds, during which the patient took twelve or fifteen inspirations, did not admit of the blood in the body being regularly and uniformly charged with the chloroform; and the increase of its effects, owing, no doubt, to the absorption and circulation of the vapour contained in the lungs at the moment when the inhalation was discontinued, was well marked. The patient became pale during the inhalation, but the alarming symptoms suddenly came on during the extraction of the fourth stump, probably within half a minute after the inhalation ceased. The patient seemed, in fact, to die with the slight struggle that took place at this moment. In the case of Hannah Greener, related above, the spasm at the moment of dying was even more marked. This is a symptom I have often seen during the death of animals killed suddenly with vapour of chloroform in a concentrated state, before they were made thoroughly insensible. Although the heart was empty, the stained condition of its cavities showed that they had contained blood at the time of death and afterwards. Owing to its fluid state, it probably escaped from the heart during the moving of the body; especially during the examination of the head, which was made first.

_Case 3._ The next recorded case of death from chloroform is reported by Dr. John C. Warren, of Boston, U.S., in the _London Medical Gazette_.[70] His report, apparently extracted from some other report, is as follows.

“Name—Patrick Coyle. [Age—not stated.] Date—March 1848. Disease—fistula. Previous use of chloroform—once. Time of inhalation—about one minute. Quantity consumed—about thirty drops. [Query minims.] Posture—upon the side. Lapse of time till death—about one minute. Symptoms—showed signs of pain, by putting his hand to the part; in a moment his pulse, which was full and natural, sank: death. Morbid appearances—brain, with membranes, natural and healthy. Heart enlarged, pale, and soft; two or three ounces of serum in pericardium; bloodvessels with dark fluid blood. Lungs, studded with tubercles; abscess in each; lower parts congested; pleura extensively adherent; stomach—mucous membrane softened, its veins turgid.”

Nothing is said about the apparatus used in this case, but from the summing-up of Dr. Warren’s paper, it must have been either a towel or a handkerchief. The quantity of chloroform employed appears to have been much less than in the two previous cases. In speaking of drops, the writer probably means minims, or what is the same, a quantity equal to as many drops of water. Thirty drops of chloroform from a small phial are only equal to between six and seven minims, and if they were dropped on a handkerchief, so that they might be counted, they would evaporate entirely during the process. Supposing the quantity used to have been what is probably meant—half a fluid drachm—it would be quite adequate, according to calculations previously made in these pages, to cause the accident which happened. The period of inhalation was again very short—one minute; and the evidence of paralysis of the heart is distinct:—“In a moment his pulse, which was full and natural, sank: death.”

_Case 4_ was that of Madlle. Stock, aged thirty, and occurred at Boulogne, in May 1848. The operation was that of opening a sinus in the thigh, between two and three inches in length, at the bottom of which a small splinter of wood was found. M. Gorré, the surgeon who attended the patient, says: “I placed over the nostrils of the patient a handkerchief moistened with fifteen to twenty drops of chloroform at most.” It is necessary to remark, however, that a judicial examination of the bottle from which it had been taken, proved that from five to eight grammes had been used, a quantity equal to from 77 to 123 grains, and there are three drops of chloroform to a grain. M. Gorré proceeds to say: “Scarcely had she taken several inspirations, when she put her hand on the handkerchief to withdraw it, and cried with a plaintive voice, ‘I choke.’ Immediately the face became pale; the countenance changed; the breathing embarrassed; and she foamed at the mouth. At the same instant (and certainly less than a minute after the beginning of the inhalation), the handkerchief moistened with chloroform was withdrawn.” M. Gorré performed the operation, but he expressed the opinion afterwards that death had already taken place when he made the incision. Amongst the means used, with a view to resuscitate the patient, was inflation of the lungs, which was performed with such force as to produce permanent dilatation of the air-cells. The lungs, besides being distended from this cause, were found after death to be visibly engorged in their lower lobes. When cut into, a large quantity of black blood escaped. The cavities of the heart were empty, but the internal membrane, especially of the right cavities, was red. The tissue of the heart was pale, and was easily torn. Air was found in the pulmonary veins, and in most of the systemic veins throughout the body. The blood was very dark-coloured and fluid.[71]

M. Gorré reported the above case to the Academy of Medicine of Paris, and a commission was appointed to inquire and report on it, who came to the following conclusions.

“1. In the medico-legal fact submitted to our notice, we found no indication of the poisonous action of chloroform; and consequently we reply to the minister, that the patient of M. Gorré did not die from the effect of inhalation of that agent.

“2. There have occurred a great number of analogous cases of sudden and unforeseen death, during operations, without any administration of chloroform, in which the most minute examinations have failed in detecting any assignable cause of death.

“3. In the case in question, the most probable cause, under all circumstances, seems to have been the mixture of a considerable quantity of gas with the blood.”[72]

The report on this case gave rise to frequent discussions in the Academy, extending over several months, and the Academy ultimately confirmed the above conclusions, but not without considerable opposition from M. Blandin, M. Jules Guérin, and other members.

M. Malgaigne, the reporter to the commission, and others, who strongly supported the first of the above propositions, founded their argument chiefly on the assertion that chloroform always produces intoxication and insensibility before death; but this is incorrect, as I have explained above; and I took occasion to make the following remarks on this point about the time when the discussion in the Academy of Medicine took place. I said: “I have several times made animals—small birds, mice and rabbits—breathe air saturated with vapour of chloroform at the temperature of the atmosphere, and the consequence has always been that, after attempting for a few seconds to escape from the capacious jar in which they were enclosed, they suddenly exhibited signs of distress, and died without any interval of intoxication or insensibility, in periods varying from less than half a minute to a minute after their first exposure to the vapour.”[73]

The power of chloroform to cause sudden death without previous insensibility is now, I believe, generally admitted. The French call this kind of fatal action _sideration_.

With regard to the second conclusion of the commission, if it had been really true that the surgeon put only fifteen to twenty _drops_ at the most of chloroform on the handkerchief, one would have been inclined to admit it; but with the quantity actually employed, and the strong sensation of choking it occasioned just before death, one must, in connection with other cases, and with what is known of the action of chloroform, attribute the fatal event to this agent, rather than to the surgical operation, which was not of a serious nature.

With regard to the third of the above conclusions, it is not a little remarkable that most even of those speakers who opposed the conclusions of the commission, agreed that death was caused by a sudden development of air in the veins; and differed from them only in this, that they considered the chloroform as the cause of the evolution of air or gas, and that it proved fatal in this way. That the air was not caused by putrefaction, and that it did not enter by the wound in the thigh, may be readily admitted, but there remains the artificial respiration, which was performed with such force as to produce permanent dilatation of the air-cells. It was argued in the Academy that, as the air was in the systemic, as well as in the pulmonary veins, it could not have been introduced by the artificial respiration, since the left ventricle had previously ceased to act; but the action of the left ventricle is not necessary for the passage of the contents of the arteries through the capillaries into the veins, since this commonly goes on after death, the arteries being usually found entirely empty of the blood they must have contained at the moment of death. With regard to the passage of the air out of the heart into the arteries, supposing that the pulmonary veins were ruptured during the inflation of the lungs, there is an observation of Dr. Sibson’s which will explain both this circumstance and the fact of the heart itself being found empty of blood. He found that the heart was often emptied of blood by distending the lungs with air after death in preparing the body for his diagrams of the position of the viscera.[74]

With the conclusions above quoted, some additional ones were adopted from the second part of the report of the commissioners; in these it was admitted that chloroform is capable of causing death, if administered too long, or in too large doses. One of these additional conclusions, however, is as erroneous as the previous ones. It is, “there is risk of asphyxia when the anæsthetic vapour is not sufficiently diluted with air.” When the vapour is not sufficiently diluted with air, the risk is one of sudden death, by paralysis of the heart. Chloroform does not yield enough vapour, at the natural temperature and pressure of the atmosphere, to exclude the air to the extent which would cause asphyxia. When chloroform vapour largely diluted with air is long continued, it may cause, not real asphyxia, but a mode of death resembling it, owing to the medulla oblongata and nerves of respiration becoming over narcotised.

_Case 5_ is that of a young woman at Hyderabad, who inhaled chloroform to undergo amputation of the middle finger. A drachm was sprinkled on a handkerchief and inhaled. The operator described what occurred as follows: “She coughed a little, and then gave a few convulsive movements. When these subsided, I performed the necessary incisions, which of course did not occupy more than a few seconds. Scarcely a drop of blood escaped.” The absence of bleeding seemed to be the circumstance which called the attention of the operator to the state of his patient; and after describing the means which were used without avail to bring about recovery, he continues, “I am inclined to think that death was almost instantaneous; for, after the convulsive movements above described, she never moved or exhibited the smallest sign of life.”[75]

In this case, it is probable that the breathing and the action of the heart were both arrested at the same time, by the action of the chloroform.

_Case 6._ Charles Desnoyers, aged twenty-two, a patient in the Hôtel-Dieu at Lyons, affected with scrofulous disease of the left wrist, having to undergo transcurrent cauterisation of the joint, inhaled chloroform from an apparatus for five minutes, and died at the beginning of the operation.[76] Further particulars are not given.

_Case 7._ A young gentleman, who had returned from Australia to visit his relatives in the neighbourhood of Govan, inhaled chloroform for an intended operation on the great toe, in December 1848. It is stated that the patient, after inhaling it, almost instantly expired. This account appeared in the _Glasgow Herald_, and was copied into the medical journals.[77] I believe that no further account of the case was ever published.

_Case 8_ occurred on January 19th, 1849. It is related by Dr. John C. Warren.[78] John Griffith, an Irishman, aged thirty-one, a seaman in the American navy, was admitted into the New York Hospital early in December 1848, on his return from Mexico. He was suffering with diarrhœa, chancres, and hæmorrhoids. The following is the account of this accident.

“Gurdon Buck, jun., attending surgeon to the New York Hospital, being sworn, says, that ‘on or about the 26th of December, I advised that chloroform should be administered to the deceased, for the purpose of examining the condition of the rectum, the parts being in such a state of excessive irritation as scarcely to admit of a separation of the nates. The patient recovered from the effects of the chloroform, and remained in all respects in the same condition, except the local ailments spoken of; and he having never complained of either his head or his chest, and not having suffered from the first administration of chloroform, I directed it to be administered to him for the purpose of performing an operation upon the rectum, and the operation of circumcision to remove a phymosis caused by the chancres: the patient soon became excited by the chloroform, as is usually the case, but not beyond a degree that I have often observed. Shortly after, he became more tranquil: the deceased was placed upon his side, and the operation performed, which consisted in the removal of two external tumours, and the tying of one internal tumour.

“‘At this moment my attention was arrested by my assistant’s calling for a wet cloth: on examining the patient, I found his face and neck of a livid leaden hue or colour, the eyes turned upward, the pulse imperceptible at the wrist, and the whole body relaxed; after two or three gasps, he ceased to breathe. Every means was promptly used to restore the deceased, but without effect. The chloroform was obtained from Kent’s, 91, John Street, and not exceeding three drachms was administered on a napkin. A portion of chloroform from the same phial had been administered the day before to a patient without any unfavourable effects. About ten minutes elapsed from the commencement of its administration before death took place. On making a post-mortem examination, twenty-four hours after death, I found the face less livid than before death; on examining the head, the brain and its membranes presented no other appearances than are seen in persons dying when in full health; the lungs were a good deal congested, and discharged, when cut, a large quantity of bloody serum; the heart was large, its ventricles and auricles were empty, its condition flabby, the substance of the left ventricle rather softer than natural; about half an ounce of watery fluid was found in the pericardium; the viscera of the abdomen were healthy.’”

This case differs from those previously related in respect to the time at which the fatal occurrence took place. It was not till ten minutes from the commencement of inhalation, and when an operation which probably occupied two or three minutes had been performed, that the patient suddenly expired. The evidence of paralysis of the heart is, however, distinct enough in the absence of pulse at the wrist, and the livid hue of the countenance. In several of the previous cases, there was sudden pallor at the moment when the heart ceased to inject blood into the capillaries, but in a patient well supplied with blood, the sudden arrest of the action of the heart would cause turgescence of the veins and venous capillaries, which would be evident in the face in a few seconds. The syncope occasioned by paralysis of the heart differs from that kind of syncope which is caused by loss of blood, inasmuch as the right cavities of the heart are full in the former instance, and empty in the latter.

The circumstance of the patient having inhaled chloroform to insensibility three weeks previously, without accident or ill effects, is worthy of notice, as showing that the fatal event did not depend on any peculiarity of constitution.

Although the heart was found to be empty, its flabby condition and the watery fluid in the pericardium indicate that it must have contained blood at the time of death.

_Case 9_ occurred on January 24th, 1849, at the Hôtel-Dieu, Lyons, where case 6 previously happened. The patient was a youth, aged seventeen, named J. Verrier, who had been employed as a miner. He was of good constitution, and was about to undergo amputation of the middle finger for necrosis of the first phalanx. The following is the account of the accident.

“As the patient’s health was good, he was at once, and by his free consent, placed under the influence of chloroform. As usual, a piece of fine gauze was employed; it was spread over the face, leaving a free passage for atmospheric air; the chloroform was dropped from time to time upon that portion of the gauze which was over the nostrils. It was administered by two assistants who were accustomed to its use, and who at the time attended to the pulse. The operator superintended the assistants. At the end of four or five minutes, the patient still felt and spoke; and at the end of another minute, he still spoke and was somewhat restless. Up to this time, from a drachm to a drachm and a half of chloroform had been employed. The pulse was regular, and of the normal strength. All at once the patient raised his body, and struggled so that the limbs escaped from the hold of the assistants, who however seized them quickly, and replaced the patient in his position. Within a quarter of a minute, one of the assistants stated that the pulse at the wrist had ceased to beat. The handkerchief was removed. The countenance was completely altered. The action of the heart had altogether ceased; the pulse could not be felt anywhere; and the sounds over the region of the heart could no longer be heard. Respiration still continued, but it became irregular, weak, and slow; and at length ceased completely in the space of about half a minute.

“The extreme danger of the patient was manifest, and immediate and energetic means were employed to rouse him. Ammonia was held to the nostrils, and rubbed in large quantity over the surface of the chest and abdomen. It was also applied to the most delicate parts of the skin, _e. g._, the lips and the extremity of the penis, with a view to excite irritation. Mustard was used; the head was inclined over the bed; and, finally, an attempt was made to restore respiration by means of alternate pressure on the abdomen and chest. After two or three minutes, respiration reappeared, and even acquired a certain fulness, but the pulse nowhere returned. Frictions were continued. Respiration became again slower, and at length ceased. Artificial inflation was practised, at first through the mouth, and afterwards through the larynx, by passing a tube through the glottis, as it was perceived that air had passed from the mouth into the stomach. The precordial, epigastric, and laryngeal regions were energetically cauterised with a hot iron. The pulse did not return. For the space of half an hour every effort was made to resuscitate the patient; but in vain.

“The autopsy could not be made until seventy-two hours after death. The temperature being low, the body showed no signs of decomposition; there was still rigidity of the limbs. The features were not altered. The examination of all the organs was made with care.

“The stomach contained about one ounce and a half of a thick fluid, of the colour of the lees of wine, in no respect resembling an alimentary fluid. The organ was distended with gas, as was also the rest of the alimentary canal, which was otherwise sound. The liver and spleen were somewhat congested.

“The heart, which was normal in volume, was flaccid and empty, contained neither blood nor air. The ventricular parietes were moistened by a fine, very red foam, as if from the presence of a little blood, which had been, as it were, whipped by the fleshy columns of the heart. The venæ cavæ and the portal veins were distended by black fluid blood in great quantity. On the Eustachian valve there was a fibrinous clot, moderately firm, and weighing from sixty to seventy grains. It was the only clot met with in the cavities of the heart and great vessels. These cavities, which were carefully opened, did not contain any appreciable quantity of air.

“The lungs retracted on opening the chest. They presented both in their surface and in their substance a very black colour; otherwise their tissue was healthy. The larynx and trachea presented no lesion. The brain was normal. The sinuses of the dura mater contained a considerable quantity of black uncoagulated blood.”[79]

In this case every precaution appears to have been taken, except that which is the most essential, of regulating the amount of vapour in the respired air. Arrangement was made that there should be amply sufficient air for the purpose of respiration; the patient was carefully watched by three persons at least, one of whom was constantly attending to the pulse, but with no other result than to be able to announce the exact moment when it suddenly stopped. The arrest of the action of the heart in this case took place at a time when the patient was not yet rendered insensible by the chloroform, although he had been inhaling it for five minutes. We must conclude that during these five minutes the vapour he inhaled was largely diluted with air, and that he then inhaled vapour in a much less diluted form. It is not improbable that he took a deep inspiration of strong vapour, just at the moment when he struggled violently, and within a quarter of a minute of the time when his pulse suddenly ceased.

The breathing continued a little time after the heart ceased to beat, and it is therefore very probable that, if this organ had not been irrecoverably paralysed, the natural breathing would have restored its action after a short pause, that would have attracted but a momentary attention. As the spontaneous breathing of the patient did not restore the heart’s action, there is no ground for surprise that the measures adopted did not succeed.

_Case 10_ was that of a labourer, named Samuel Bennett. It occurred on February 20th, 1849, at a dispensary in Westminster. The patient inhaled chloroform for amputation of one of the toes. Half an ounce of chloroform was “sprinkled on a handkerchief, and held over the mouth and nose.... This quantity of the agent failed, however, to produce anæsthesia, having caused only the ordinary excitement and struggling.” After a delay of two hours, more chloroform was procured, and half an ounce was again applied on a handkerchief, “care being taken to allow the entrance of air at short intervals.” Insensibility was induced, and the toe was amputated; the chloroform being applied, as I was told, during part of the time of the operation. At the close of the operation, no blood escaped when the pressure was removed from the arteries; the patient was in fact dying, and in a short time expired. “A few inspiations were noticed after the pulse had ceased at the wrist.”[80]

The lungs were of a dark venous hue throughout, a large quantity of blood escaping from them when cut into. Mucous membrane of trachea and bronchi congested. Heart rather large but flabby; auricles empty; each ventricle contained about an ounce of semi-fluid blood (the lungs had been inflated). Head: sinuses and veins contained blood, but not to any remarkable amount. But few bloody points occurred in cutting into the cerebral mass. Kidneys congested.

The failure of the first attempt to cause insensibility in this case, when so large a quantity of chloroform was used, illustrates very forcibly the uncertainty and irregularity of the way in which it was administered. On the first occasion only excitement and struggling were produced, and on the next the patient died suddenly.

_Case 11_ occurred on August 23rd, 1849, at Langres, France. The subject of it, Madame Labrune, was reported to be a healthy married woman. She inhaled chloroform with the intention of having a tooth extracted. “Complete insensibility was not produced at the first trial: more chloroform was placed on the handkerchief, and she drew a full inspiration. Her countenance immediately became pallid; her features were visibly altered; there was dilatation of the pupils, with a convulsive rolling of the eyes; and no pulse could be felt. Every attempt was made to restore life, but without success. She died as if struck by lightning.”[81] The instantaneous arrest of the circulation, on a full inspiration being taken, immediately after more chloroform had been placed on the handkerchief, is particularly worthy of notice. The heart was paralysed, in this instance, as quickly as in experiment No. 25, above related.

No inspection of the body is reported in this case.

_Case 12_ is the first which occurred in any of the hospitals in this metropolis. The following is the account of it.

“John Shorter, aged forty-eight, a porter, known to Mr. Solly for some time as a very active messenger, habits intemperate, but apparently in perfect health, was admitted into George’s ward, under Mr. Solly, on the 9th October, 1849, suffering from onychia of the left great toe, which had existed some time. It was determined to remove the nail, the man having decided before entering the hospital on taking chloroform.

“On Wednesday, October 10th, at a quarter to two P.M., he began to inhale the chloroform with one drachm in the inhaler. It had no visible effect for about two minutes; it then excited him, and the instrument was removed from the mouth, and about ten drops more were added; he then almost immediately became insensible; the chloroform was taken away, and the nail removed. He continued insensible; and, his face becoming dark, the pulse small, quick, but regular, respiration laborious, his neckerchief was removed, and the chest exposed to fresh air from a window near to the bed; cold water was dashed in his face, the chest rubbed, and ammonia applied to the nose. After struggling for about a minute, he became still, the skin cold, pulse scarcely perceptible, and soon ceased to be felt at the wrist; respiration became slow and at intervals, but continued a few seconds after the cessation of the pulse. Immediately on the appearance of these symptoms, artificial respiration was commenced by depressing the ribs with the hands and then allowing them to rise again until the proper apparatus was brought, when respiration was kept up by means of the trachea tube and bellows, and oxygen gas introduced into the lungs by the same means. Galvanism was also applied through the heart and diaphragm, but all signs of life ceased about six or seven minutes after the commencement of inhalation. These means were persisted in until a quarter past three, but to no purpose. On removing the inhaler, the sponge, which only contains one drachm, fell upon the floor, and the chloroform splashed about,—thus showing that a considerable part of the chloroform remained unused; so that the patient could not have inhaled more than a drachm. Every endeavour was made to procure a post-mortem examination, but in vain.”[82]

The above account is published in the _Medical Gazette_ as communicated by Mr. Solly, but it is clearly not written by him, and it presents a very confused narrative of what occurred. If we are to understand the events in the sequence in which they are related, we must conclude that the patient became insensible and had the operation performed, that he then exhibited alarming symptoms for which cold water was dashed in his face and other measures were employed, and yet that after this he struggled for about a minute. This would be a state of things inconsistent, in my opinion, with death from chloroform; but possibly the proper sequence is not observed in detailing what occurred. There is some obscurity also about the amount of chloroform used in connection with what remained on removing the inhaler. If the sponge was adapted to hold a drachm in the proper manner, the chloroform could not splash about on its falling, unless there was a good deal more than a drachm in it. But whatever was the quantity of chloroform remaining in the sponge, as it was in a condition to splash about, it is difficult to perceive what prevented the liquid chloroform from dropping into the patient’s throat, as he lay on his back in bed. Chloroform is as pungent as the essential oils. I have been informed of a case in which a patient was nearly suffocated by one drop falling into the throat; and the narrative of what occurred to Mr. Solly’s patient is not at all inconsistent with death from spasm of the glottis arising from this cause. If, however, the patient died from the vapour of chloroform, we must conclude that he inhaled it at one moment not sufficiently diluted with air.

The chloroform in this case was administered by a non-medical person—a sort of surgery-man. After this accident, however, the chloroform in St. Thomas’s Hospital was always entrusted to some one belonging to the profession.

_Case 13_ occurred at Shrewsbury, to a Mrs. Jones, a patient of Mr. Clement, surgeon, who had partly performed the operation of excision of the eyeball, when his patient suddenly died. Mr. Clement has, I believe, not published any account of the case, but the evidence which he gave at the inquest was reported in various local newspapers, and copied into the medical journals. The death was very characteristic of the effects of chloroform vapour not sufficiently diluted. Mr. Clement is reported to have said: “He gave her but a small dose to commence with, imbibed from a sponge, and then commenced the operation. Finding that did not make her insensible, about a drachm more was poured on the sponge, which she inhaled again for a few seconds. He then went on with the operation, and shortly afterwards heard a peculiar sound, which he could not describe, and she died in a moment; all the attempts to rouse her proved ineffectual. She spoke in Welsh before she died, but so quickly that he did not know what she said; he had no doubt that she died from the effects of the chloroform.”[83]

_Case 14_ occurred at Berlin. The subject of it was a young lady twenty years of age, of good health, well made, and of a good constitution. The chloroform was inhaled for the extraction of a tooth. It was administered on a sponge, covered with a napkin. The dentist who administered it was not a medical man. He made five unsuccessful attempts to extract the tooth under chloroform. Three of these attempts were at nine in the morning, and two about noon, just before the accident. His patient suddenly died almost at the commencement of the last attempt to administer chloroform, stretching herself out, and frothing at the mouth at the moment of death; the countenance at the same time becoming livid.

An examination of the body took place fifty hours after death, when putrefaction had set in.

“The lungs presented nothing morbid; the bronchi contained a little bloody froth. The blood was of the colour and consistence of cherry juice. The heart was soft, flabby and collapsed. Its coronary vessels and cavities were empty, and presented the bluish-red discoloration of decomposition.”[84] The other organs were healthy.

_Case 15_ occurred in the public hospital of Kingston, Jamaica, on January 29, 1850. The name of the patient was William Bryan, his age is not stated, nor the nature of the operation he was about to undergo. He had previously, however, undergone the operation of amputation of the penis, on account of cancer of that organ, but it was performed without chloroform. Mr. Maygarth, the surgeon who administered the chloroform, stated as follows: “I had about a drachm poured on the sponge, and applied it over his mouth and nostrils, but at first not in close contact—at no period was the atmospheric air totally excluded. He bore it badly, and I was frequently obliged to withdraw it, to facilitate his breathing. The stage of excitement which is usual came on, and he struggled and kept away the sponge for some seconds; it was again reapplied, when, after a few more seconds, observing that he made one stertorous inspiration, I removed it altogether. He ceased to breathe; but after some seconds had elapsed, made another inspiration, and this occurred several times, until at length respiration ceased entirely.” The measures which were employed were of the usual kind, but were of no avail.

The brain and its membranes were found to be congested. The lungs were congested, especially posteriorly. The right side of the heart contained dark fluid blood, and the inner surface of its left cavities, and of the aorta, were stained with blood. There was some disease of the aortic valves, and the heart had undergone some amount of fatty degeneration.[85]

_Case 16._ In February 1850, a death from chloroform occurred on board ship at the Mauritius. A report of the case was sent to the Board of Ordnance, and also to the Admiralty. The secretary of Sir William Burnett first informed me of the case, and a day or two afterwards I had an opportunity, through the kindness of the late Marquis of Anglesey, of reading the report which was sent to him as Master of the Ordnance, and I made a note of the chief particulars as soon as I got home. As the report was a very able one, it is to be regretted it has not been published. The accident occurred to an artilleryman, aged 24, who required to have the last phalanx of the middle finger removed. In other respects, he was considered to be in good health. Two scruples of chloroform were first poured on the handkerchief with which it was administered, and then one scruple more. It was observed that the face turned pale, and the pulse and breathing ceased, soon after the chloroform was discontinued. The measures which were employed to restore him were of no service. The lungs after death were found to be emphysematous; and, upon inquiry, it was ascertained that he had been short of breath on exertion. The right cavities of the heart were filled with fluid blood. The sinuses of the dura mater contained less blood than usual, and the brain was pale. The medical man reporting the case considered that the emphysema was the cause of death, by interfering with expiration, and thus detaining the vapour; and it must be admitted that, if the vapour were not sufficiently diluted with air, the emphysema might increase the danger. I have, however, administered chloroform in several cases in which emphysema existed to an extreme degree, without any ill effects; consequently, when the vapour is properly diluted with air, this affection appears to be no source of danger.

_Case 17_ was that of a patient of Professor Carl Santesson, in the Seraphim Hospital at Stockholm. I was indebted to Mr. Paget for my first information about this case, and to Dr. W. D. Moore, of Dublin, for some further particulars respecting it.

The patient, a man thirty years of age, was affected with hydrocele, and there was some suspicion of disease of the testicle. It was consequently intended to operate on the hydrocele by incision, in order that the testicle, if diseased, might be removed. The chloroform was administered in the same way that Professor Santesson had seen it exhibited by Dr. Simpson, except that it was poured on a little cotton, which was placed at the small end of the cone, into which the folded towel he made use of was rolled. About a drachm and a half was first poured on the cotton, and the patient was told to inhale in long and deep inspirations. This quantity being nearly evaporated in two or three minutes, a drachm more was added. After a few inspirations rigidity and struggling came on: these subsided, but in a little time returned more strongly than before, and the towel was removed from the face until the struggling ceased. The patient, however, not being sufficiently insensible to undergo the operation with the necessary quietness, the towel was reapplied, when, after a few inspirations, the pulse suddenly ceased. The face and the whole surface of the body turned pale, the eyes rolled upwards and inwards, and the breathing became very slow, but full and deep, the intervals between the inspirations becoming longer, until the respiration ceased altogether. The patient died before the operation was begun, and within five minutes from the commencement of inhalation. During the application of various means of resuscitation, including the dropping of cold water _guttatim_ on the epigastrium, the breathing returned, and continued for the space of three or four minutes; but the pulse and sounds of the heart did not return.

At the examination, thirty-two hours after death, the dura mater was found to be congested, and there was considerable serous effusion between the membranes of the brain. There were also some bony deposits under the dura mater, and some adhesions of the arachnoid, indicating long standing disease of the membranes.

The heart was of normal size, and flaccid; the vessels on its surface strongly distended with blood. The left ventricle was empty; the left auricle, on the contrary, and the entire of the right side of the heart, with the great veins, were filled with thin uncoagulated blood. In the right ventricle only was a little loose coagulum found. The lungs, posteriorly, were highly congested, exhibiting here and there infiltrations of blood from the size of a pea to that of a small hazel-nut. The pulmonary tissue was otherwise sound; giving, however, when cut into, the odour of chloroform, but more feebly than the brain did. The mucous membrane of the larynx and bronchial tubes were slightly reddened from sanguineous congestion. The blood was everywhere of the same thin juice-like nature.[86]

_Case 18._ I am indebted for my information respecting this case to Dr. James Adams, of Glasgow, who was good enough to send me a copy of the notes respecting it, from the case book of his colleague, Mr. Lyon, in whose practice, in the Glasgow Infirmary, the case occurred, in March 1850. The patient was a boy seven or eight years old, from the Highlands, whose health was considerably impaired by years of suffering from calculus. Mr. Lyon says, “being laid in bed, I placed a piece of lint, moistened with chloroform, near to his face, when, in a few minutes, he ceased crying. I now told my clerk to take charge of the chloroform, and introduced the sound. I thought I detected a calculus, but could not hear the click distinctly, in consequence of the patient moaning. One of the bystanders held his hand between my ears and the patient’s face, when the click was at once heard. I withdrew the instrument, and was horror-struck with the livid countenance and vacant eye of the patient; the cardiac and radial pulses were gone, and, making one deep gasp, he was to all appearance dead.” Artificial respiration and other measures were employed without effect. “The external jugulars being remarkably turgid, and the face still very livid, the right jugular was opened, when several ounces of dark blood flowed rapidly.” This measure, and galvanism, which was applied afterwards, were of no avail.

_Case 19._ The subject of this case was Alexander Scott, aged thirty-four, a police constable, who died in Guy’s Hospital in June 1850, whilst undergoing an operation for the removal of a portion of the right hand. Mr. Cock, the operator, said that he was certain there was no disease about the patient. He described the accident as follows:—“The ordinary machine was used, and, as it had not the effect, witness directed that a napkin should be folded into the shape of a cone, which was applied with chloroform. The occupation of removing a portion of the bone occupied one minute and a half, but before it was completed, the blood which was gushing out, suddenly stopped, when witness directed Mr. Lacy to feel the pulse of deceased, and they found that deceased had expired.”[87]

The sudden stopping of the hæmorrhage shews that, in this case, as in the others, the action of the heart was suddenly arrested. The first attempt to cause insensibility failed in this as in some other cases.

Mr. Cock tried to dissuade his patient from having chloroform, severe as the operation would have been without it. In Guy’s Hospital and St. Thomas’s the medical officers had a strong objection to narcotism by inhalation for the first two or three years after the practice was introduced, and chloroform was used much less generally in these institutions than in any other of the hospitals of London; yet it was precisely in these two hospitals that two deaths from chloroform occurred, before any such accident had happened in any other hospital in this metropolis. This circumstance is worthy of the consideration of those who propose to limit the accidents from chloroform by restricting its use to a few great operations.

In this case the lungs were reported to be extremely congested. Heart flabby, not particularly distended; about two ounces of fluid blood on the right side; not more than half an ounce on the left. Head.—Much congestion of the dura mater; the grey matter of the brain was dark and congested; fluid was found in the subarachnoid space; and a considerable quantity of it in both ventricles. Kidneys congested.[88]