Part 15

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.

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.”

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. 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. 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. 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.”

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.”

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.” 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.