Part 17

At the inspection of the body next day, the vessels of the dura mater, and those on the surface of the brain, were gorged with fluid blood. The lateral sinuses also afforded a flow of dark-coloured blood. There was a considerable quantity of serous fluid in the cavity of the arachnoid and in the spinal sheath. The substance of the brain was very soft. (The weather was warm.) The lungs were of a dark purple colour posteriorly, and much loaded with fluid blood and serum, but were everywhere crepitant and healthy. The external surface of the heart was covered almost entirely with fat; in some parts to a considerable thickness. There were two fibrinous spots on its surface. No fluid in the pericardium. The venæ cavæ were full of fluid blood. On removing the heart, a white fibrous coagulum, about as big as a walnut, was found in the commencement of the pulmonary artery. The heart was uncontracted, and the cavities contained a very small quantity of dark fluid blood. The walls of the right ventricle, and of the left auricle, were thinner than natural. Some portions of the substance of the heart were paler than natural:—“In these paler portions of the muscular substance, the fibres had, for the most part, lost their striated aspect, and had become converted into a fine granular material contained in the sarcolemma. Here and there a minute oil-globule could be observed in the muscular fibrillæ, but nowhere did this amount to fatty degeneration.”

In this case all the precautions appear to have been taken which are possible in making a patient insensible with undiluted chloroform, administered on a handkerchief; and the case, therefore, strongly confirms the proposition that chloroform cannot be administered in this way with perfect safety.

The patient was apparently in the most satisfactory condition at the conclusion of the inhalation, and yet, a few seconds afterwards, the heart suddenly ceased to beat, from the effect, as we must conclude, of that portion of vapour which was in the lungs at the moment when the inhalation was discontinued.

Case 24 occurred in October, 1851, at Chipping Norton, Somerset, to a patient of Mr. Farwell, named Elizabeth Hollis, and aged 37. No one observed the manner in which the breathing and circulation ceased, and, as the patient was in a state of extreme debility, it is not quite certain that the chloroform was the sole cause of death. It was administered to prevent the pain of removing the fæces, which became impacted in the rectum on account of extensive cancerous disease of the uterus and vagina. The surgeon reports that “the time occupied in the inhalation was about eight or nine minutes; quantity inhaled 10½ drachms, half a drachm at a time, allowing her frequently to breathe the atmospheric air. She spoke to me during this period. When I found that her arm fell after being raised, I proceeded to and accomplished the operation. At this time she was not inhaling. I then, as I always do, wetted the face with a sponge, with the view of washing off any remaining chloroform from the nose and lips, when, to my surprise, I found that she had ceased to breathe, and all attempts to restore her were in vain.... When I commenced the operation, the pupil was contracted, and the conjunctiva slightly red. After death, the pupil was very dilated, and the countenance extremely pallid.” There was no inspection of the body. This patient had inhaled chloroform on two previous occasions for a similar operation.

Case 25 occurred in St. Bartholomew’s Hospital, on March 17, 1852. Thomas Hayward, aged 23, was suffering from aneurism by anastomosis, occupying the right ear and its neighbourhood. He had inhaled chloroform on the 14th of the previous month, whilst Mr. Lloyd placed ligatures on the temporal artery and some other arteries supplying the tumour; and it was with a view to tie an additional artery, situated between the mastoid process and the ramus of the jaw, that chloroform was again administered.

“The chloroform was some of the same, and the apparatus employed for its administration precisely similar [alluding to the former occasion.] It was administered by one of Mr. Lloyd’s dressers, who well understood, and had great experience in its use. A gentleman of great experience, who had been for years at the hospital, and two years house-surgeon, was watching its effects, and marking the state of the pulse. Other gentlemen were assisting, and also on the look out.

“In from five to ten minutes the usual effect was produced, the patient having previously struggled much. The operation was then commenced; but no sooner had Mr. Lloyd cut the skin, than it was stated that the pulse had suddenly ceased. The chloroform was at once removed; but in a few seconds, the patient had ceased to breathe, and no pulsation could be felt at any of the arteries or the heart.

“Artificial respiration, as well as percussion and compression of the different parts of the body, were immediately employed with energy; and, after continuing the means for a short time, the circulation was observed to be returning, and the act of respiration was several times performed. The state of inanimation, however, speedily returned; but, by the employment of the same means as before, with the use also of galvanism, the circulation and respiration were again restored. Quickly, however, the patient fell into the same state as at first, but was again restored by the same means.

“In a few minutes the state of inanimation again returned, when the external jugular vein, which on the right side was very turgid, was opened, and tracheotomy was performed, and the lungs inflated. The patient was also placed in a warm bath, at the temperature of 104°, artificial respiration being kept up all the time. All, however, was of no avail.”

At the examination of the body, the following are amongst the appearances noted. “The venæ innominatæ and vena cava superior were full of blood, and probably would have been distended, but that two or three ounces of blood had flowed into the coffin from the opening made into the external jugular vein. The right auricle and ventricle were distended with blood, and would probably have been more so but for the escape of blood mentioned above. The left auricle and ventricle contained very little blood; the left ventricle was perfectly contracted in the rigor mortis. The heart was of full size. It appeared in every part natural in its texture, and as if it had possessed full power. Its valves also were all healthy; neither could any disease be found in any of the chief bloodvessels within the chest. All the blood, however, was fluid, and it remained without coagulation after its escape from the heart and vessels. It had also a brownish purple hue, much like that which is commonly observed in the spleen: none of it, when thinly spread out, presented the ordinary dark, black, or crimson hue of venous blood. Both lungs were attached by old adhesions about their apices and posterior surfaces, but these were of small extent. Their texture was healthy, but they appeared more than usually collapsed and dry. Their bloodvessels were not over filled.”

In this case, every precaution seems to have been taken, except that one which is most essential of all, of regulating the proportion of vapour in the inspired air. It had always been made a great point in St. Bartholomew’s Hospital to attend to the pulse very carefully, and on this occasion it was closely examined, but only, as in some other cases, with the result of being able to note the moment when it suddenly ceased.

With regard to the return of the circulation, which is mentioned in the report as having occurred on three occasions, together with the breathing, during the efforts at resuscitation, I understood from inquiries I made of a gentleman present, that this was judged of from the red colour returning to the face and lips, but that the pulse and sounds of the heart were never distinctly perceived after they first ceased. The respiration may cause the colour to return to the face without a true circulation, as I have seen whilst inflating the lungs of still-born children; for if a portion of red blood be mechanically displaced from the lungs by the motion of the chest, it will be propelled by the contractility of the arteries, which continues for some time after death.

Case 26 is related by Dr. Majer, of Ulm. It occurred on June 27th, 1852. The patient, Madame W., was 32 years of age, and of good constitution. She was in very good spirits, and was only waiting the operation of having a tooth extracted, before going to dinner. It was stated that only twenty or twenty-five drops of chloroform were put on a sponge, which was surrounded by a handkerchief. After four or five inspirations, the operator inquired if his patient did not feel a singing in the ears. She replied with a trembling and thick voice. At the same time she stretched out her limbs, the face became bluish, the eyes haggard, the head and the arms fell—she was dead. The patient’s husband said, that the time between the inhalation and death was so short that one could scarcely have said Yes or No.

An examination of the body was made twenty-five hours after death. Putrefaction had commenced, and the body was not rigid. The vessels of the membranes of the brain were gorged with blood containing many bubbles of air. The heart was soft and flaccid; the coronary vessels were engorged with blood and air; the cavities of the heart contained air, but little blood. The lungs were congested at the inferior parts.

Case 27 took place at Melbourne, Australia. The name of the patient was Mr. John Atkinson, but his age is not stated. Dr. Thomas, who was about to operate for fistula in ano, said: “Before administering the chloroform, I asked the deceased particularly if he had ever suffered from any serious illness, to which he replied in the negative. I also inquired whether he had been subject to cough or palpitation, and he answered that, some time ago, he had suffered slightly from cough. The pulse was good, and Mr. Barker proceeded in the usual manner to administer the chloroform, which shortly produced convulsive twitchings of the muscles. I then went to the door to request the nurse to send up some person to assist in holding the patient in a proper position for the operation, and I returned to the bed, and poured a little more chloroform on the handkerchief; when it was applied to the face, I heard him splutter at the mouth; the chloroform was instantly discontinued, but the patient suddenly expired. We tried all the means usually resorted to in other cases of suspended animation, but without effect. I had frequently used the same chloroform in other cases. It was not more than a minute after the first application of chloroform that death occurred. About a drachm had been poured on the handkerchief.”

At the examination after death, “there was considerable serous effusion into the pericardium, and the heart itself was larger and more flabby than usual. It was hypertrophied, and there was dilatation of the cavities; the lungs were healthy, and there was a slight appearance of disease about the liver, such as is observed in persons addicted to intemperance.”

Case 28. On August 10th, 1852, a Mr. Martin, a cattle dealer died near Melrose, in Scotland, after inhaling chloroform for the application of potassa fusa to some ulcers of the leg. Dr. W. M. Brown, who relates the case, says:—“Before proceeding to apply the caustic I gave him chloroform. He was not easily affected by it, and struggled a good deal. After beginning to apply the caustic I found he was not sufficiently insensible to pain, and gave him a little more chloroform, which had the desired effect. I then proceeded with the application of the caustic, and was just finishing, when I observed a sort of catch in his breathing. I immediately stopped, and, on looking at him, I saw the mouth and eyes open, the breathing irregular, the face pale, the eyes slightly turned upwards, and the pupils dilated.” Dr. Brown tried artificial respiration and other means to resuscitate the patient, but without effect. He says, “in a few minutes the man died.” The pulse is not mentioned, nor the age of the patient.

Case 29 took place in the Manchester Royal Infirmary, on December 24th, 1852, during the removal of a malignant tumour of the thigh, by Mr. Jordan. The patient was Henry Hollingsworth, a factory operative. His age is not stated. “The man was very much excited, struggled and talked fast. The chloroform was administered slowly, and every precaution was taken to prevent any danger, and the medical men remarked two or three times how very long it was in taking effect. He at last became insensible, in about seven minutes at least. Mr. Jordan commenced the operation by an incision into the skin covering the tumour. I was assisting the surgeon when Mr. Heath directed my attention to the patient’s face. This was about five minutes after the operation had commenced. I then observed congestion about the face, but there was no stertorous breathing. His pupils appeared almost to have ceased to act. His breathing was becoming exceedingly slow, and he seemed to be sinking fast. I directed the attention of the operator and the other medical men to these symptoms. The operation was then suspended, and means were resorted to for restoring animation, but the pupils had ceased to act, and had become fixed almost immediately. He gave one strong gasp, and then to all appearance was dead. In administering the chloroform, successive doses were given until it took effect. Every dose consisted of a drachm, taken, at intervals, in an inhaler.”

The following remark is made respecting the autopsy. “The post-mortem examination shewed that asphyxia, caused by chloroform, produced the death. There was a congestion both of the brain and lungs.” The appearances met with after death from chloroform do not indicate the way in which death has taken place. In animals that are killed by it, the right cavities of the heart are always found filled with blood, whether they die suddenly by its direct action on the heart, or more slowly by its effects on the brain, and the breathing ceases before the circulation. The lungs are seldom much congested in animals, whichever be the mode of dying, and the appearances in the head are not unusual. The state of the pulse is not mentioned in the above account of the case; but congestion about the face was first observed, and then it was noticed that the breathing was getting slow. It is sufficiently probable that the breathing ceased on account of the action of the heart being first arrested; but even if the respiration was embarrassed by the action of the chloroform on the brain, it is pretty certain that that agent also acted directly on the heart; for it cannot be supposed that the means used for restoring animation would have failed, if the heart had been acting properly when the breathing ceased.

Case 30 took place on March 19th, 1853, in University College Hospital, London. The subject of it was an unmarried woman, named Caroline Baker, aged twenty-eight. The chloroform was administered with the intention of applying nitric acid to a sloughing ulceration of the labia and vagina. “The chloroform, supposed in the first instance to be about a drachm, was poured on lint about five inches square, and folded four or five times over. After a short time the patient became restless, talked loudly, and threw about her arms. Soon afterwards a partial relaxation of the limbs took place, and she became insensible and pulseless.”

Further symptoms are not given, but it is stated that she sank and died. The breathing is not mentioned, but Mr. Erichsen, who, although not present at the accident to his patient, would be made aware of all that occurred, stated at the inquest, that death was produced by a paralysis of the heart from the influence of the chloroform. Dr. Quain examined the structure of the heart with the microscope, and he “found that organ, particularly on the right side, in a state of fatty degeneration.”

Case 31 was communicated to the Society of Surgery of Paris by M. De Vallet, Surgeon-in-chief to the Hôtel-Dieu, d’Orléans. “A soldier of the line, aged twenty-five, apparently in good health, and of strong frame, consulted M. Vallet for a small tumour situated behind the right labial commissure. Before operating, he proceeded to direct the inhalation of chloroform. The patient, fasting, being placed in the horizontal posture, the chloroform (about one gramme) was poured upon a hollow sponge, and applied to the nose, the mouth being left free. At the expiration of a minute, no effect having been produced, four grammes were poured on the sponge, and at the expiration of four minutes, the patient, without having experienced any irritation of the larynx, without having manifested any resistance, without redness of the countenance, and after only a slight period of agitation, fell into a state of insensibility fit for the operation. Scarcely had the incision been made, necessary to expose the cyst, when the patient became pale, respiration was suspended, and he sank into a state of complete collapse. All the usual remedies were tried, and without avail. M. Vallet opened the trachea, and performed artificial respiration with an elastic tube; then an electric current was sent by needles through the region of the heart. The patient died without any sign of reaction.

“Examination of the body.—The vessels of the brain were empty; the lungs were congested with blood, which in some situations was extravasated; the heart was excessively flaccid; there were some soft clots in the right cavities; the left were empty. The stomach was full of gas; the liver, spleen, and kidneys were gorged with black blood.”

Case 32 occurred in the Royal Infirmary of Edinburgh to a man aged forty-three, on whom Dr. Dunsmure was about to operate for stricture of the urethra by perineal section. The chloroform was administered by Dr. Struthers. About an ounce of chloroform was used, and the patient had been put under the influence of this agent on two former occasions, when a similar quantity was employed without ill effect. The following is Dr. Dunsmure’s account of the case:—

“While the patient was inhaling the drug, he struggled considerably, and became a good deal congested in the face and head. He seemed to take a slight convulsion, like an epileptic fit, and such as I have seen on several occasions in people who have led an intemperate life. During the convulsion, the handkerchief containing the chloroform was removed to some distance from the face. In a short time the inhalation took effect, and he began to snore, and although still violent, the chloroform was removed from the face entirely, and the handkerchief placed under the pillow. As soon as the patient became more quiet, he was pulled down on the table, and placed in the proper position for the operation. I then shaved the perineum, and was just going to make my first incision, when one of the assistants said that his pulse was becoming weak. The posterior tibial, Mr. Spence then remarked, was good, but in a second or two after, both gentlemen exclaimed that the pulse was gone. I rushed from my seat to the patient’s head, and found that his breathing had ceased. Those present who had an opportunity of observing the respiration, which I had not, owing to the stool on which I sat being low, positively assert that the breathing did not cease before the pulse. The face was much congested, the jaws were firmly closed, and the pupils were dilated. I immediately forced open the lower jaw by means of the handle of a staff, and with catch forceps pulled out the tongue. Artificial respiration was had recourse to, and in a few minutes he made a long inspiration. This was soon followed by a second, by a third at a longer interval, by a fourth at a still longer period, and then by a fifth, when all attempts at natural breathing ceased. No pulsation could be felt in the radial arteries. The chest was noticed to be much contracted, to have apparently lost its elasticity, and not to expand when the ribs were forcibly compressed during the artificial respiration. I had previously sent for a galvanic apparatus, which was in the flat below, and it arrived almost immediately after the patient had made the fifth inspiration. When the tongue was pulled out, and before the first breath was taken, I was on the point of opening the trachea, but this proceeding was then abandoned; it was now, however, had recourse to, in order to carry on artificial respiration more certainly: the external jugular was also opened, and about a couple of ounces of blood flowed. By the time the tracheotomy tube was inserted, the galvanic apparatus was in working condition, and it was applied on each side of the diaphragm. It acted remarkably well; at each application of the sponges, the muscle descended as if the patient was in life; air passed through the tube in the trachea, and for some time I was in great hopes that the man was to be saved; but the muscle gradually lost its contractility, and although the galvanism was kept up for an hour, it was evident that all our efforts were in vain—that life was extinct. The post-mortem examination was made the following day at one o’clock, rather more than twenty-four hours after the patient’s death, and I give the report of it as drawn up by Dr. Gairdner, the pathologist to the Infirmary:—

“John Mitchell, aged forty-three, died 28th September. A very robust man; height five feet eight inches; diameter (lateral) of base of thorax, ten and a half inches.

“External appearances.—Considerable lividity of face and neck, and more than usual congestion of depending parts. Considerable amount of fat, but more in omentum and around viscera of abdomen than in external parietes.

“Chest.—Right pleura presents a few slight adhesions near the middle; left pleura free. No fluid in either pleural cavity. Pericardium contained about half an ounce of serum, and presented a few opaque patches on its surface. Both sides of heart contained blood, the right side rather more than the left. Blood more than usually fluid. External fat of heart considerable, about three lines on some parts of right ventricle. Muscular tissue of heart generally flabby, and rather pale, but not distinctly disorganized to the naked eye. Valves perfectly healthy. Aorta presented very faint traces of atheroma. A few traces of atrophy of right lung towards its apex and anterior edge, but very limited. In all other respects lungs free from disease, but somewhat congested.