Part 18

“Spleen soft, but not diffluent.

“Liver congested, but otherwise normal.

“Kidneys congested, but otherwise healthy.

“Brain.—The subarachnoid fluid presents considerable milky opacity, and is of moderate quantity. Moderate congestion of the meninges generally. About half an ounce of fluid in the ventricles. Substance of brain healthy. Arteries at base perfectly free from atheroma. Air passages.—Glottis perfectly patent. Mucous membrane of larynx and trachea slightly congested.

“Microscopic examination shewed the fibres of the heart to be nearly normal, though scarcely so distinctly striated as in some cases. The minute vessels of the brain and pia mater presented at some points a few clustering granules, but to no great extent.”

Dr. Dunsmure expressed the opinion that four or five minutes elapsed from the time the chloroform was left off before the pulse failed. But it is pretty certain that he has much over-estimated the time. Indeed, if the shaving of the perineum were likely to occupy even half of this time, the operator would have done it, or had it done, before the chloroform was administered. Dr. Dunsmure makes the following remark in his comments on the case: “In several instances where I have seen chloroform very nearly prove fatal, the respiration became gradually restored after an inspiration had once been made; in this case, however, no such fortunate occurrence took place.” In the other cases to which allusion is here made, the heart has not been paralysed, or at least not completely, but they show that the method of administering chloroform in Edinburgh had been far from satisfactory in its results, although no patient had before that time been actually lost.

Case 33 occurred in University College Hospital, London, and the following account of it was given by Dr. Hillier:

“E. R., aged 40, a woman of moderate height, rather thin. The general health has been pretty good; she had not been liable to palpitation or dyspnœa. Had been in the habit of drinking pretty freely. Admitted on October 5th, at 11 p.m. She was suffering from the symptoms of strangulated hernia, which had existed two days and a half. Efforts were made to reduce the hernia, both without and with a warm bath, in which she was for upwards of half an hour without getting very faint. These efforts being unsuccessful, an operation was at once determined on. Her pulse was at this time regular, and of tolerable strength.

“Chloroform was administered in the usual way, on a piece of lint, which was held three or four inches from the patient’s face, and then brought to within an inch and a half of her nose and mouth, leaving space around for the admission of air.

“For three or four minutes nothing unusual presented itself; the pulse and respiration proceeded normally. There was put on the lint, at first, one fluid drachm of chloroform; and, at the end of three or four minutes, forty minims more were added. This was the whole quantity of chloroform employed. Within a minute after the second quantity of chloroform was added, the patient struggled violently both with her arms and legs. During these struggles I was holding her right hand, and was unable to feel the pulse in consequence of her constant motions. The struggling lasted about a minute, and on its ceasing, the patient commenced to breathe with loud, rough stertor. I at once removed the lint from before the face, and felt for the pulse, which I could not find. Immediately cold water was dashed on her face. She breathed with this stertor for two or three short inspirations, and then two or three long ones, and then the breathing ceased. Immediately artificial respiration was resorted to, and within a minute galvanism was applied to the back of her neck and the diaphragm. Under the influence of these agencies, the patient gasped about three times at intervals; after this, no further signs of life were exhibited.

“At the time when the stertor commenced and the pulse failed, the pupils were dilated, and the face of the patient was only slightly altered. The tongue was not retracted, for one of the bystanders at once put his fingers into her mouth to ascertain this.”

At the autopsy made by Dr. Garrod thirteen hours after death, the rigor mortis was well marked; the blood was very fluid in all parts of the body. There was about an ounce of colourless fluid in the pericardium. The heart was quite collapsed and empty, but, as Dr. Garrod observes, this may have been due to the fluidity of the blood. The weight of the heart was seven ounces and three-quarters; valves healthy. Walls of the right ventricle flabby and pale; mean thickness one eighth of an inch. At some parts the muscular substance was in a very thin layer, being much encroached on by fat. In several places there was scarcely any muscular fibre visible. This was chiefly the case near the apex. Examined by the microscope, much fatty degeneration of the muscular fibres of the right ventricle generally was discovered. The walls of the left ventricle were flabby, dry in appearance, pale, and very friable. Both lungs were crepitant throughout, not much engorged. Brain not congested. The intestines above the strangulation were much distended with flatus, and inflamed.

Case 34 occurred on October 20th, 1853, a few days after the last. The patient was a young woman named Ann Smith, aged 22 years, under the care of Mr. Paget in St. Bartholomew’s Hospital, who was about to apply the actual cautery to a sore of cancroid nature in the vagina. She was a stout, florid young woman, formerly of dissolute habits, but apparently in perfect health, with the exception of the local ailment. She had been put under the full and prolonged influence of chloroform a fortnight previously for the application of the cautery, without the occurrence of any untoward symptoms whatever. The chloroform was administered by Dr. Black, one of the assistant physicians.

“The usual form of inhaler was employed,—a padded metal cup, fitting over the nose and mouth, and supplied with valves. A drachm, by measure, was first poured on the sponge, but as the administration did not immediately commence, a considerable part of this was no doubt wasted; after a short inhalation, a second drachm was supplied, and subsequently the further quantity of half a drachm. The patient had gone through the usual stages of excitement, etc., and the last dose was scarcely used, as she sank off, almost immediately after its application, into a state of complete insensibility, unattended by any alarming symptoms. About five minutes had been occupied by the inhalation, and probably not more than a drachm and a half of the fluid really inhaled. The apparatus was now removed from the face, and the patient having been drawn into the proper position, Mr. Paget was about to commence the operation, when Dr. Black, who throughout had kept his finger on the pulse, noticed it to have become extremely weak and fluttering. Almost immediately afterwards, the patient’s countenance was observed to be dusky, turgid, and congested, and the respiratory movements began to be performed at long intervals, and by slight catching efforts. No time was lost; cold water was at once dashed on the thighs, face, and breast; and, the failure of the respiration becoming shortly complete, Mr. Paget immediately began artificial insufflation of the lungs, by alternately blowing into the nostrils, and compressing the chest. Just before commencing this process, Mr. Paget had ascertained, by drawing the tongue forwards and examining the glottis with the finger, that the epiglottis was not pressed down.”

Other means were employed, but no further signs of life appeared. It is further recorded that, “immediately after the first alarming symptoms, the pupils were of the medium size, neither contracted nor dilated. All efforts at respiration ceased about two minutes after the first indications of failure; the pulse, however, as a very feeble flutter, was felt occasionally for at least two minutes later.”

At the autopsy, performed by Mr. Paget, twenty-two hours after death, “the thorax was first examined, and nothing whatever abnormal could be detected in any of the viscera; the lungs were healthy and crepitant in every part; their posterior lobes were not more congested than is seen in almost every examination; the heart, collapsed, but not contracted, and containing a small quantity of fluid blood in each cavity, was of normal size and proportions, in every respect, and its muscular structure, examined by the microscope, showed no degeneration.... The brain, its sinuses, ventricles, etc., were all carefully examined, and neither in texture nor quantity of blood was anything abnormal detected.”

Although the failure of the pulse was the first symptom of danger in this case, it continued to be felt as a very feeble flutter for about four minutes, so that the heart was not so completely paralysed as in most of the fatal cases. It must, however, have been so far paralysed as to be past recovery.

Case 35. Professor Dumreicher related a case of death from chloroform at the meeting of the Vienna Society of Physicians, held on November 16, 1853. The patient was a young man, aged nineteen, in somewhat feeble health, who inhaled chloroform in the recumbent position, in order to have his anchylosed knee-joint forcibly extended. It was inhaled from a vessel resembling a snuff-box, which was held to the nostrils. “The inhalation was continued for fifty seconds, and the patient had spoken a few seconds previously, when Professor D. observed that the pulse had become frequent and undulating. He immediately suspended the administration of the anæsthetic. Trismus occurred; the respirations became irregular; the face turned livid, and he foamed at the mouth.” The measures which were employed included the abstraction of eight ounces of blood from the jugular vein, but they were of no avail. He only once made a feeble attempt at inspiration.

Case 36 occurred in the practice of Dr. Wüstefeldt of Neustedt. “A young girl, thirteen years of age, had on the dorsal region a voluminous lipoma, which extended from the last dorsal vertebra to the crest of the ilium.... One drachm of chloroform was employed. As soon as insensibility was manifested, the operation was commenced, but scarcely had the surgeon divided the skin, when the girl, yielding to the laws of gravity, fell suddenly forwards on her chest. Dr. Wüstefeldt, struck by the phenomenon, which he had witnessed before under similar circumstances, immediately desisted from operating, and strove to restore the patient to life; but every effort was useless, and, in the course of a few minutes, it became evident that she was dead.”

Further particulars are not given; but as the patient died suddenly, when the surgeon had scarcely divided the skin, it must be admitted that he was, in all probability, correct in attributing the event to the chloroform. The patient usually yields to the laws of gravity when only partially under the influence of chloroform, and it seems surprising that the operation should have been undertaken without placing the patient in the horizontal posture. The proper position of the patient, when a large tumour of the back is to be removed, is to be lying almost flat on the abdomen, the head being a little turned on one side, so that it rests with one ear on the pillow.

Case 37. Jane Morgan, aged fifty-nine, died whilst inhaling chloroform in the Bristol Infirmary, on January 21st, 1854. She was moderately stout, pale, but not otherwise of unhealthy appearance. “The stethoscopic indications were favourable, the beat of the heart was natural, and the air passed freely throughout both lungs; but the chest movements on the right side were not quite so free as on the left.” Chloroform was ordered by Mr. Harrison, the senior surgeon of the Infirmary, with the intention of attempting to reduce a dislocation of the humerus of eight weeks standing. “Having taken no food since her breakfast, she commenced the inhalation of one drachm of chloroform, at 2 P.M., in bed in her ward, under the superintendence of Mr. Hore, the house-surgeon. Nothing unusual occurring in the patient’s general condition during inhalation, a second drachm, in about five minutes from the first, was poured upon the sponge, and the inhalation was continued. Almost immediately after the addition of the second drachm, the chloroform was withdrawn, as the patient’s breathing became stertorous; and immediately afterwards her pulse, which had hitherto continued pretty firm, was suddenly imperceptible, the respiration ceasing at the same time. The pupils were not dilated.” Various measures were promptly resorted to with the hope of restoring the patient; but there were no further signs of life, unless “some convulsive efforts of the respiratory muscles,” under the application of galvanism, be so regarded.

At the examination of the body on the following day, the right pleura was found to be adherent. The lungs were healthy in structure, but gorged with dark fluid blood. There was about an ounce of fluid in the pericardium. There was a small quantity of fluid blood in each of the cavities of the heart. For the length of an inch from their commencement, both coronary arteries were much dilated, and studded with atheromatous and bony deposits. The muscular structure of the heart was examined under the microscope by Dr. William Budd, and a considerable proportion of the fibres were found in a state of incipient fatty degeneration. It was learned, after her death, that she had been subject to occasional attacks of fainting.

Case 38. A death from chloroform occurred in the Hôpital St. Antoine, at Paris, in the spring of 1854. The subject of this was a woman aged forty, on whom M. Richard was operating for the removal of a uterine polypus. The surgeon placed the patient in the horizontal posture, and administered the chloroform on a compress of lint. She became insensible in two minutes, having first been excited so that it was necessary to hold her. M. Richard moved the patient to the edge of the bed, gave the compress containing the chloroform into the hands of an assistant, and commenced the operation, which was likely to be of short duration. He had almost completed it, when he was apprised by an assistant, who had been set to feel the pulse, that it had ceased to beat. He sought for it himself, but found that it did not beat. The face was extremely pale; a slow respiration still continued, but soon ceased; and the measures which were used with the hope of restoring the patient were of no avail.

At the examination of the body all the organs were found in a healthy state. The right cavities of the heart and the great veins contained a considerable quantity of blood, and the left cavities of the heart a small quantity. The blood was everywhere fluid.

Case 39. A patient, named Mrs. Harrup, died at Sheffield from the effects of chloroform administered with the intention of removing a cancerous tumour of the left breast. The age of the patient was forty-five, and she was stated to be in good health, excepting the local affection.

“The chloroform was administered with more than the usual precautions. After the inhalation had gone on without any effect for twenty minutes, it was thought that possibly different chloroform might succeed, and one ounce was accordingly procured from the public dispensary. After the inhalation had been conducted with the fresh chloroform about twenty minutes, the usual effects of the vapour began to manifest themselves. The pulse, which was 136 before any chloroform had been given, and had been very gradually decreasing in frequency while it improved in strength, was now about 104. At this moment muttering—half articulate delirium—came on, but ceased in a few moments, and was immediately followed by conclusive signs of the satisfactory action of the chloroform. Dr. Law now desired Mr. Wright to begin the operation; but before he could do so, Dr. Law, seeing an alarming change in the countenance of the deceased, cried, ‘Stop, Mr. Lewis, how is the pulse?’ I replied, ‘It is gone.’” After stating the means which were used with a view to resuscitate the patient, it is added that the heart had ceased to beat, and that, after a few short and laboured inspirations, life became extinct.

At the examination of the body, the cartilages of the ribs were found to be ossified. The heart and lungs were perfectly healthy, but the lungs were in a congested condition. There was an extravasation of blood in the spinal muscles, and a little blood in the spinal canal, in what part or between what structures is not stated.

Case 40 occurred in the Lock Hospital, London, in May 1854. Walter Hollis, a tailor, aged eighteen, had been under treatment for sores within the prepuce, and these having healed, he was about to undergo the operation for congenital phymosis. He had been of dissolute habits, and exhibited a pale cachectic appearance.