Part 19

“The inhaler used was a simple mouth-piece by which the nostrils are left uncovered. About two drachms of the fluid were poured into the instrument. After about six minutes inhalation, insensibility seemed to be coming on, and at this moment the pulse was ascertained to be of good volume. Nothing whatever had occurred to indicate the impending danger, when, after a few more inhalations, the pulse suddenly failed, became quite imperceptible, and the countenance assumed a pale and leaden hue. The inhalation was immediately stopped, and attempts to resuscitate, by means of striking the chest sharply with a wet towel, applying ammonia to the nostrils, and by artificial respiration, were at once commenced. These were employed for three or four minutes before any signs of life were perceived; but, subsequently, the pulse was again to be felt, and spontaneous respiration was renewed. Artificial respiration was desisted from on the occurrence of these signs of returning life, and for upwards of ten minutes the chest continued to fill regularly, and the pulse beat at a rate of from 40 to 50 in the minute; the countenance of the patient also much improved, and even assumed a slight flush. After the expiration of, perhaps, a little more than ten minutes, however, these indications of returning vitality again disappeared, the pulse and respiratory efforts simultaneously ceased, and the countenance became deathlike. Artificial respiration and the other means were again adopted, but this time without the slightest success.... Post-mortem examination on the next day shewed great venous congestion within the cranium; the lungs were also somewhat congested. The heart was slightly enlarged, and the ventricular parietes were thinned; in the muscular fibres the microscope detected decided fatty degeneration. The blood was universally fluid.”

The partial recovery of the patient is a remarkable feature in this case, and it is difficult to explain why he did not recover completely. The number of the pulsations during this partial recovery is mentioned, but not their quality, and I cannot help supposing that the pulse must have been extremely weak, as well as slow, at this period. The ten minutes during which the pulse and breathing returned is mentioned with the qualifying term of “perhaps”, which leads to the supposition that it was not noted by the watch or clock, and under such circumstances of anxiety and suspense, the time might be very much over-rated. The slight fatty degeneration of the heart might probably interfere with the complete recovery of the patient, after this organ had once been paralysed by the chloroform.

Case 41 took place on July 13th, 1854, in the Middlesex Hospital. The patient was a stout, muscular, and florid man, 65 years of age, on whom Mr. De Morgan was about to perform amputation at the upper part of the thigh, on account of a large malignant tumour growing from the inner side of the femur.

“Chloroform was administered by Mr. Sibley, the registrar to the hospital. Snow’s inhaler was employed. The quantity at first placed in the inhaler was rather less than two drachms, and another drachm was added eight minutes afterwards. The patient inhaled the chloroform without difficulty, and went through the usual stages; at the end of about ten minutes violent spasm was induced; this continued about three minutes, and then somewhat abated. The pulse, which had risen to about 120, descended to 70, having a full, steady, and deliberate beat. The pupils, which had been much dilated, became less so. The respiration continued free and deep, but not stertorous. The colour of the face remained good.

“At this moment, which was between thirteen and fourteen minutes from the commencement of the inhalation of the chloroform, the pulse gave a few rapid and irregular beats, and then ceased. Respiration, which, as has been stated, had been going on freely, ceased simultaneously. The face became suddenly pallid and deathlike. The inhaler was removed instantaneously, and cold water dashed on the face. Mr. Sibley immediately commenced to carry on artificial respiration, by applying his mouth to that of the patient, and inflating the lungs. The period that elapsed between the sudden cessation of the pulse and the inflation of the lungs was only a few seconds. After a few inflations, there appeared to be a slight effort at inspiration, but this was the only sign of life discovered after the syncopal attack. Galvanism was in operation within two minutes after the cessation of the pulse.”

“An examination of the body was made by Dr. Corfe forty-eight hours after death. In the head nothing particular was discovered; the brain was firm, and rather more vascular than natural; the blood in the sinus was partly coagulated; the heart was rather larger than natural, and was extremely loaded with fat, especially on the right side, where fat formed three-fourths of the thickness of the wall of the ventricle; the muscular tissue was extremely pale and soft, and exhibited both to the naked eye, and the eye assisted by the microscope, an extreme degree of fatty degeneration; the blood in the cavities of the heart was firmly coagulated; on both sides it was almost purely fibrinous; the clot on the right side was larger than on the left; a fibrinous clot extended down the aorta.”

I do not know how the bibulous paper was arranged in the inhaler in this instance, nor whether the inhaler was used with a view to regulating the amount of vapour in the inspired air. The proportion of vapour must have been small during the first ten minutes, as the patient became so slowly insensible; and judging from the result, we must conclude that the proportion was large just before the accident. The firm coagulation of the blood and separation of the fibrin were probably owing to the galvanism which was so promptly applied. I found the fibrin separated from the colouring matter of the blood in the cavities of the heart of a cat, in which shocks of electro-magnetism had been sent through the chest just after it had been killed with chloroform.

Case 42. A man died whilst inhaling chloroform in University College Hospital on October 11th, 1854. The patient was a shoemaker named George Sands, aged 39, and of rather bloated aspect. He inhaled chloroform whilst Mr. Erichsen was endeavouring to introduce a catheter, and had the intention of puncturing the bladder if not successful. The patient was made insensible, and the chloroform was left off, but was reapplied on account of the patient making some expression of pain. “Probably about two minutes of the second inhalation had elapsed, when the man became profoundly insensible, and began to snore with a peculiar and very profound stertor. His face at this time was suffused and flushed, and the inspirations were drawn at rather prolonged intervals. Mr. Erichsen’s attention was at once excited by these symptoms, and, desisting from the use of the catheter, he immediately commenced dashing the patient’s face and chest with water. The chloroform had, of course, been removed. In the course of about a minute, the noise with the breathing gradually lessened, and it became apparent that the respiration was ceasing altogether. Mr. Erichsen now put his finger into the patient’s pharynx, and dragged forwards the root of the tongue; at the same time attempting artificial inflation of the lungs, by applying his own mouth to that of the man. The latter plan did not appear to succeed well, and was almost immediately substituted by the more usual mode of artificial respiration, by compression of the chest, which was kept up most vigorously. The man’s pulse had been felt by the administrator [Mr. Carnell] to be still beating some little time after the commencement of the alarming symptoms and the cessation of respiration. Artificial respiration had been employed for about four minutes, when the man, whose countenance had meanwhile retained its colour and an expression of yet remaining life, began to breathe again. A very short intermission of artificial assistance having been made, he drew spontaneously three or four inspirations; but, as each successive one was more feeble, the artificial aid was at once recommenced. About five minutes from the commencement, the galvanic apparatus was got in readiness and applied. It produced, however, no benefit; and from this time the patient lost colour in the face, and was evidently dead.... The form of inhaler which had been employed was the one in ordinary use at this hospital, viz. a folded piece of lint. The administrator’s hands and the patient’s face had been covered during the inhalation by a towel.”

At the examination of the body seventy hours after death, extensive fatty degeneration of the heart was met with. The cavities of the heart were empty, owing, no doubt, to the artificial respiration.

The above case differs to a certain extent from those previously quoted, inasmuch as the first symptoms of danger were those of profound coma, and of threatened death by apnœa, as a consequence of the action of the chloroform on the medulla oblongata and nerves of respiration. In addition to this cause of danger, however, the chloroform present in the lungs at the moment when the inhalation was discontinued must have acted directly on the heart, or the prompt assistance of so able an authority on asphyxia as Mr. Erichsen, the moment the breathing was suspended, would surely have restored the patient. The mode of death, although not exactly the same as that in Experiment 24 (page 110), differs from that in the previous experiment, where the heart’s action was good and distinct after the breathing ceased; it resembles the mode of dying in many animals that I have killed with chloroform; being, in fact, a combination of death by apnœa and cardiac syncope, which generally occurs when the quantity of vapour in the respired air is intermediate between that in Experiments 23 and 24, or somewhere between 5 and 10 per cent.

A great peculiarity in the way in which chloroform was administered in the case we are considering was that the head and face of the patient were covered by a towel, under which the lint wetted with chloroform was held. The countenance and state of respiration could not be observed in this mode of giving the chloroform; the person administering it had to depend almost entirely on the pulse; and, except for this cause, there is every reason to conclude that the chloroform would have been withdrawn in this instance in time to save the patient. It was not apparently till a peculiar and very loud stertor attracted the attention of the operating surgeon himself, that the inhalation was discontinued, and the face was already suffused.

This plan of administering chloroform with the head and shoulders of the patient covered with a towel, was introduced by Mr. Clover, who was for several years a resident officer of the institution; and it is but right to state that it led to no accident in his hands; in those of his successors it was, however, less successful; three accidents having occurred in a little more than a year and a half. I much regret to find that Mr. Erichsen recommends this method of giving chloroform in the edition of his work on surgery recently published.

Case 43 occurred in Guy’s Hospital, on December 5th, 1854. The patient was a woman whose leg Mr. Birkett was about to amputate on account of malignant ulceration. She gave her age as fifty-six, but appeared ten years older. “In each eye was a fairly marked arcus senilis, but the woman was not known to have suffered any symptoms referable to thoracic disease.... The administration of the anæsthetic was conducted by Mr. Bryant, the inhaler used consisting of a fold of lint, rather larger than an out-spread hand, and protected on its back by a piece of oiled silk to prevent wasteful evaporation.... In the first instance, about a drachm of the fluid was poured upon the lint. The patient inhaled it kindly; and, after about two minutes, another drachm was added. A stage of excitement now followed, during which the limbs required to be held. Insensibility was just fully established, and Mr. Birkett was on the point of commencing the operation, when Mr. Callaway, who was compressing the femoral artery, exclaimed that the pulse had suddenly ceased entirely. The wrist was examined, and the same found to be the case. Almost immediately afterwards, a long-drawn inspiration, attended with a deep sighing noise, was observed. For two or three breaths the cheeks puffed out during expiration; the respiration next fluttered, and then ceased. Mr. Birkett at once put his finger into the patient’s mouth, and drew forward the tongue, artificial respiration being meanwhile commenced by assistants by means of compression of the chest. A few slight inspirations were attempted by the patient subsequent to the commencement of the artificial assistance; but they did not continue, and no sign of vitality was ever afterwards shown.... It must be noted, that the woman had been very pale both before and throughout the exhibition, and that no change in her appearance was perceived when the alarming symptoms occurred, excepting that the superficial veins of the neck and temple became distended with blood. The cessation of the pulse was most sudden. Mr. Callaway stated that it was not preceded by the least premonitory fluttering, the stroke having been good one beat, and entirely wanting the next. This order of symptoms was of course suggestive of death beginning at the heart (cardiac syncope), the cessation of the functions of the nervous system having been markedly subsequent to that of the circulation....

“Autopsy, twenty-four hours after death (conducted by Dr. Wilks). The corpse was much emaciated, and the rigor mortis imperfect. The lungs were much congested with fluid blood, which ran out after incision of their substance. The heart was of normal size, but soft and flabby; its left side was nearly empty, the right being distended with fluid blood. The left ventricle was of good thickness; its muscle of a deep colour, not encroached on by fat, or in the least mottled, the only observable departure from a healthy state being its flabbiness. The right ventricular wall was very thin, the subserous fat having in some parts almost taken the place of the muscular tissue. The layer of the latter, however, although much thinned, had still a good colour, and did not appear to the naked eye as degenerated, an observation which may apply also to the carneæ columnæ. The liver was in an early stage of cirrhosis, and the kidneys were both of them mottled, and contained numerous small cysts in the external part. The brain was rather paler than usual, its convolutions appeared shrunken and atrophied, and there was a quantity of serous fluid in the arachnoid sac and in the ventricles. There was general atheromatous disease of the arterial system, both in the head and other parts of the body. The blood was universally fluid, and of a dark colour.”

As far as could be estimated, the time occupied by inhalation was about three minutes in this case.

Case 44 occurred at the Royal Ophthalmic Hospital, on April 10th, 1855, in a man on whom Mr. Bowman was about to perform excision of the left eyeball. The patient, named John Cannon, was forty years old, and was moderately stout, florid, and healthy-looking. He had generally led a temperate life. The disorganisation of the eye was the result of injury.

“The inhaler used was the one devised and recommended by Dr. Snow.... The administration was entrusted to Dr. Playne, of King’s College Hospital. In the commencement of the inhalation, the valve of the mouth-piece was so turned as to admit an abundant supply of air, a point to which Mr. Bowman directed personal attention. During the first four minutes (more or less) nothing unusual occurred. Dr. Playne, who had his finger on the pulse, had noticed that it had rather increased in fulness, and was of good volume. Rather suddenly, however, just as the anæsthetic appeared to be producing its effect, symptoms of excitement occurred. The eyes became fixed and staring, the arms outstretched and rigid, and the face contorted. It was now impracticable to feel the pulse, on account of the tossing about of the arms; but, as is usual in such conditions, the respiration was noticed to be all but, if not quite, suspended by the spasmodic fixture of the chest. The inhaler was at once removed, and the face and chest of the patient dashed with cold water. Almost immediately after, as the respirations had become extremely feeble and sighing, Mr. Bowman commenced practising artificial breathing, by the application of his own mouth to that of the patient. By this means, the chest was made to fill very completely, and the process was kept up almost without intermission for from five to eight minutes. During the first three or four minutes after the alarm began, the patient continued at times to make slight sighing efforts at voluntary inspiration, and the case was not thought, by those looking on, to be by any means hopeless. At length, however, these finally ceased, and from that time it was apparent that the man was dead.... At the first opportunity which occurred for examining it after the spasmodic struggling had commenced, the pulse was found to be extinct, and it remained so ever after, although there were, as stated, feeble efforts at inspiration. The patient’s countenance changed somewhat during the treatment, but was mostly suffused and congested.”

At the examination of the body forty-eight hours after death, “the sinuses, and the veins of the brain generally, were much congested, and there was some œdema of the brain substance. The heart, excepting some slight deposits on the curtains of the mitral valve, was healthy. Its muscular substance was easily lacerable. The right ventricle contained a considerable quantity of fluid blood, the left was nearly empty. There were some pleuritic adhesions, and the lungs generally were congested, being also in some parts full of air. The blood in every organ examined was fluid, and without trace of coagulation.”

It does not seem that the inhaler used in this case was employed with the object for which it was contrived—that of regulating the amount of vapour in the inspired air; and I do not know whether the bibulous paper was arranged properly in the interior.

Case 45. On September 8th, 1855, a lady, aged twenty-nine, the wife of a physician, died suddenly whilst inhaling chloroform for the relief of facial neuralgia. I was sent for when the accident happened, and arrived twenty minutes afterwards. I found the deceased lady without any sign of life. The face and lips were very pallid. The husband was performing artificial respiration by mouth to mouth inflation of the lungs, and alternate pressure on the chest, and I assisted him in this for a long time, though with no hope that any thing could be of service. Dr. Barker, of Grosvenor Street, arrived soon after me, and assisted in the same measures. An inhaler was employed in this case consisting of a face-piece, like the one above delineated in this work, and a bent metal tube lined with bibulous paper. Two quantities of ten minims each had been inhaled, with some relief to the pain, and without causing unconsciousness when the inhaler and the chloroform were put away in a closet; but the patient begged to have more chloroform, in order to be completely relieved of the pain, as she had been on a previous day. Ten minims more chloroform, as I was informed, were put into the inhaler, and the patient, being seated on a sofa, began to inhale very eagerly, but had no sooner commenced than she gave a sudden start, as if taken in some kind of fit. Her husband laid her on the floor, but she evinced no further signs of life.

There was no inspection of the body.

The only explanation which the case admits of is that, in her eagerness to get relief, the patient took one or more inspirations of air very highly charged with vapour. The symptoms were those of death by cardiac syncope.

Case 46 occurred in the practice of Dr. Roberts, a surgeon dentist of Edinburgh. The patient was a lady, thirty-six years of age, to whom Dr. Roberts had administered chloroform on four previous occasions within a twelve-month. Dr. Roberts says the chloroform was administered in the usual way, by which he means on a handkerchief. He says: “Mrs. H. had only taken about nine or ten inspirations, obtaining but a partial influence of a quantity short of ʒiss poured out from the bottle, and inhaling it for a space of time certainly less than a minute, when she said, ‘You must not operate until I am quite insensible;’ and again, ‘I am not over yet;’ and immediately, even while speaking, she gave a convulsive start, and with a stertorous inspiration, and with the eyes and mouth open, sunk to the floor.” Dr. Simpson was sent for, and arrived within five minutes. Artificial respiration was resorted to, and after it had been applied for a time, there were a few spontaneous inspirations, and the pulse, it is said, could be perceived at the wrist; but these symptoms of reviving animation disappeared.

At the examination of the body, the right cavities of the heart were found gorged with blood. The walls of the right ventricle were thinner than natural, and affected to a certain extent with fatty degeneration.

A paragraph was inserted in some of the Edinburgh newspapers, and forwarded by Dr. Roberts to the Lancet, in which it was implied that death in this case was not caused by the chloroform. It is, however, like the preceding case, a well marked instance of the sudden and fatal action of this agent.

Case 47. A sailor, aged thirty, died whilst inhaling chloroform in St. Thomas’ Hospital, in October 1856, preparatory to having some necrosed bone removed from one of his fingers. “He did not appear to be in robust health; still there was no obvious reason against his having the chloroform, which was accordingly administered as follows. One drachm was poured on a sponge folded between two thicknesses of lint, and this held at a little distance from his mouth, while he was sitting in a chair. He appeared to be going off very comfortably, when the chloroform was left off for from half a minute to a minute, and then resumed. He now began to raise his hands and tremble, and kept spitting in the lint, and appeared as if about to vomit. Suddenly he was violently convulsed through his whole frame, as if in an epileptic fit. The chloroform was at once discontinued, and he was laid in a semi-horizontal posture. The convulsion only lasted for a few seconds, and when it had ceased he began to breathe with effort and puffing of the lips, and almost immediately to gasp irregularly. His pulse was almost imperceptible and intermittent. Artificial respiration was at once performed by alternate compression and relaxation of the walls of the chest, the tongue being held out of the mouth by the forceps. Ammonia was applied to the nostrils, and cold water dashed in the face, and in about a minute he rallied so as to breathe without assistance, but in a few seconds he relapsed, and could not be recovered.

“At the post-mortem examination there was found to be fatty degeneration of the heart, liver, and spleen, and the membranes of the brain were thickened. The lining of the ventricles presented a peculiar pitted appearance, apparently from inflammatory deposit. The brain itself was pale.”

“It was ascertained after the man’s death that he had been of intemperate habits, and had had an attack of delirium tremens three weeks previously. In the report of this case in the Association Medical Journal, the following is the account of the appearances met with after death. In the autopsy in the present case, which we observed with particular care, the brain was in a state of œdema and bloodlessness, very like the brain in a patient who died from chloroform in the Ophthalmic Hospital. The liver was fatty; but the heart seemed the very model or type of the healthiest kind of heart. All the other organs were also healthy.”