Part 14

Experiment 30. Another guineapig of the same age was treated in the same manner, except that I removed the tube from the nose for a short time between every two or three inspirations, in order to see if I could not make it insensible in this way without a fatal result. In half a minute or so the animal no longer required to be held, but lay on the table without making any resistance, the conjunctiva being still sensible, and some motion of the limbs, apparently voluntary, remaining. It only inhaled once after Dr. Sibson ceased to hold it, and whilst in the state just described, and then only for two or three inspirations. After this it appeared quite insensible, and no more chloroform was given. It breathed at first naturally, except more slowly and gently than before the inhalation; but the breathing became slower, and ceased altogether about a quarter of a minute after the inhalation had been left off. The body was opened immediately. When the pericardium was opened, the auricles were observed to contract slightly, and the contractions increased after their exposure to the air.

The amount of vapour in the air breathed by these two guineapigs is not known, but there is no doubt that it was upwards of eight per cent.

FATAL CASES OF INHALATION OF CHLOROFORM.

If it were possible for a medical man to mistake or disregard the symptoms of approaching danger, and to go on exhibiting vapour of chloroform, diluted to a proper strength, till the death of the patient, this event would take place slowly and gradually, as in Experiment 23, related above, and every other experiment in which the air did not contain more than five per cent. of vapour. The action of the heart would survive the respiration; there would be a great tendency to spontaneous recovery, and the patient would be easily restored by artificial respiration, if it were performed whilst the heart was still acting; as I have always found it to be successful in animals under these circumstances.

In examining the recorded cases of fatal inhalation of chloroform, we shall find, however, that they have none of them taken place in this gradual manner; but that in all cases the fatal symptoms, if not the actual death, have come on very suddenly. Dr. Sibson was, I believe, the first to point out that, in the fatal cases of inhalation of chloroform, death was caused by its paralysing the heart; but he was not at that time aware of the physical conditions under which this agent may act directly on the heart. In commenting on the first four deaths from chloroform, he says: “In all the four cases it is manifest that the immediate cause of the instantaneous death lay in the heart. The heart, influenced by the poison, ceased to contract, not from the cessation of respiration, for the heart in asphyxia will beat from one to three minutes after respiration has ceased, but from immediate death of the heart. There is no doubt a combination of causes operating to destroy the heart’s contractile power: the mental influence, the congestion in the systemic, and that in the pulmonary capillaries, will all have a material influence.” And further on he says: “We are obliged, then, from the experience of these cases, to conclude, that in man the death is usually instantaneous, and due, as every instantaneous death is, to paralysis of the heart. In animals the death is usually due to paralysis of the muscles of respiration. It is chiefly owing to the superior control of the mind over the body in man, that in him the poison acts on the heart more than in dogs.”

I had been long aware that chloroform was capable of paralysing the heart in animals; and, indeed, that sulphuric ether would do so when it could reach the heart in sufficient quantity; and soon after Dr. Sibson’s remarks I was able to ascertain and point out the strength of the vapour which will produce this effect, and how one may avoid the risk of it, by having the vapour sufficiently diluted. The greater number of experimenters who have killed animals with chloroform have found that the action of the heart continued after the breathing ceased; but they did not either control or ascertain the proportion which the vapours of chloroform bore to the inspired air. In Mr. Thomas Wakley’s experiments the action of the heart continued after the breathing had ceased; and this was the case in a great number of experiments performed by a Commission which reported to the Society of Emulation of Paris, in 1855.

This Commission came to the conclusion that, in all instances in which animals are killed by chloroform, the action of the heart survives the respiration; but they might have administered chloroform to an equal number of human patients without any one of them being cut off by sudden paralysis of the heart. If animals were usually to die suddenly of paralysis of the heart, when the chloroform is given in a manner similar to what may be called its ordinary administration to patients, we should be at a loss to know how this agent could be used at all. It is only reasonable to suppose that, in experiments so conducted, that mode of death should usually be met with which would occur to the human subject, if the chloroform were continued, in the disregard of dangerous symptoms, till death should ensue. I have, indeed, been informed of several instances in which animals died in a sudden, and what was thought an unaccountable manner, whilst chloroform was given to prevent the pain and struggles which would be occasioned by physiological experiments. In these cases there is no doubt the heart was paralysed; but the experimenters were often too intent on other matters to observe the circumstance. By a proper arrangement of circumstances, however, one may produce at will the event in animals which occurs, in fact, so very rarely to a patient, although it may at any time happen if great caution, guided also by right principle, is not used.

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.”

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.”

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.

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.

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.”

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. 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.

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.”

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.”