MODE OF DEATH IN THE ACCIDENTS FROM CHLOROFORM.

In all the cases in which the symptoms which occurred at the time of death are reported, there is every reason to conclude, as shown above, that death took place by cardiac syncope, or arrest of the action of the heart. In forty of these cases the symptoms of danger appeared to arise entirely from cardiac syncope, and were not complicated by the over-action of the chloroform on the brain. It was only in four cases that the breathing appeared to be embarrassed and arrested by the effect of the chloroform on the brain and medulla oblongata, at the time when the action of the heart was arrested by it; and only in one of these cases (No. 42) that the breathing was distinctly arrested by the effect of the chloroform, a few seconds before that agent also arrested the action of the heart.

It was previously shown that chloroform vapour has the effect of suddenly arresting the action of the heart when it is mixed with the respired air to the extent of eight or ten per cent., or upwards; and we must therefore conclude that, in the fatal cases of its inhalation, the air the patients were breathing just before the accidents occurred contained this amount of vapour. There was no means adopted, so far as is reported, to regulate the proportion of vapour in the inspired air, in any case in which an accident happened; and there was the liability in every case that ten per cent. or more of vapour might be present in the air the patient breathed; and in no case did death occur in the manner that it occurs when the vapour of chloroform does not exceed five per cent. of the inspired air.

There is in a great number of the cases an evident connection between the accident and the probable strength of the mixture of vapour and air. In six cases the accident occurred just after the commencement of the inhalation; in two of the cases, Nos. 27 and 37, the fatal symptoms occurred just after fresh chloroform had been applied on the handkerchief and sponge; and in several cases, in which the circulation was suddenly arrested just after the patient had been rendered insensible, the insensibility had been induced so quickly as to prove that the vapour must have been inhaled in a very insufficient state of dilution.

THE TWO KINDS OF SYNCOPE.

Dr. Patrick Black has made an objection to the fact of the patients having died of paralysis, or over-narcotism of the heart, in the accidents from chloroform.^[132] He says that paralysis of the heart would be death by syncope, but that the symptoms before death, and the conditions of the organs met with afterwards, are not in accordance with such a view of the case. In order to show that both the symptoms and the after death appearances, in the fatal cases of inhalation of chloroform, are consistent with paralysis of the heart, it is necessary to point out the difference between ordinary syncope and cardiac syncope. One of the best examples of ordinary, or what may be called anæmic syncope, is that which occurs in a common blood-letting, whilst the patient is in the sitting posture. When the bloodvessels, especially the veins, which at all times contain the greater part of the blood in the body, do not accommodate themselves fast enough to the diminished quantity of blood, the right cavities of the heart are supplied with less and less of the circulating fluid; and in a little time are not supplied at all, when the heart ceases to beat, in accordance with the observation of Haller, that it does not pulsate when it is not supplied with blood. The moment the heart ceases to supply blood to the brain there are loss of consciousness and stoppage of respiration; but on the patient being placed in the horizontal position the blood flows readily into the right cavities of the heart from the great veins of the abdomen and lower extremities; the heart immediately recommences its contractions; the brain is again supplied with blood, and respiration and consciousness return.^[133]

The blood may remain in the ordinary quantity; but if the bloodvessels do not keep up their usual support, and exert a sufficient pressure on their contents, the same kind of syncope will occur as that from blood-letting. The late Sir George Lefevre related the case of a lady who fainted whenever she left her bed, and assumed the upright posture; no cause could be found for this until it was ascertained that she suffered from varicose veins of the legs: bandages to these extremities prevented the fainting. It is obvious that in this case the mechanism of the syncope was the same as that in blood-letting; the distension of the varicose veins under the weight of the superincumbent blood had the same effect in preventing the supply to the right cavities of the heart, as if the blood had been entirely removed. The faintness which often occurs on first rising, when a person has long kept the recumbent posture from any local cause, is probably of the same kind; the veins not having had to support the weight of the usual column of blood for some days or weeks, lose their tone we may presume, and yield when they are all at once subjected to the weight of a column of blood extending from the lower extremities to the heart, so that this organ ceases to be properly supplied with the circulating fluid.

In cardiac syncope, on the other hand, the cavities of the heart, or at all events the right cavities of this organ, are always full, whether the syncope depend on paralysis of the heart by a narcotic, or inherent weakness of its structure, or on its being overpowered by the quantity of blood with which it is distended. After death from this kind of syncope, if the blood have not been displaced by artificial respiration or other causes, the right cavities of the heart and the adjoining great veins will be found filled with blood, and the lungs will in many cases be more or less congested. The appearances in short will be very much the same as in asphyxia by privation of air, which ends in a kind of cardiac syncope, the stoppage of the heart being partly due to over-distension of its right cavities, and partly to loss of power in its structure, from the want of a supply of oxygenated blood through the coronary arteries. In death by anæmic syncope, on the contrary, all the cavities of the heart are found empty, or nearly so, and the same is frequently the case with the adjoining great veins, whilst the lungs are usually pale.

The syncope occasioned by some kinds of mental emotion is of the ordinary or anæmic kind, and consequently the condition of the brain must act first on the bloodvessels, and not directly on the heart. Certain persons are liable to faint on witnessing a surgical operation. Now if the mental emotion of these persons acted directly on the heart, whilst the rest of the vascular system was unaffected, the distribution of the blood would be nearly the same as in asphyxia, where the circulation is first impeded in the lungs, and is ultimately arrested by loss of power in the heart. If the action of the heart were weakened, or stopped, in the first instance, by the kind of emotion under consideration, the arteries would be emptied by their contractility and elasticity, and the blood would accumulate in the right cavities of the heart and the great veins leading to them. In a medical student fresh from the country, who is by no means deficient in blood, the jugulars would become distended and the face livid, and the recumbent posture would probably do but little towards removing the symptoms. The phenomena which are witnessed, however, indicate a very different condition of the vascular system. The person about to faint from the cause indicated, frequently becomes pale before he feels anything wrong; and when requested to retire and sit down, often says that there is nothing the matter with him. In a short time he faints, and falls, if no one catches hold of him; but the moment he is in the recumbent posture he recovers. In such a case as this, the effect of the mental emotion must be first exerted on the veins, or the veins and capillaries, through the nerves which supply these vessels; they allow themselves to become distended, and the heart ceases to act for want of its supply of blood, as in syncope from blood-letting, and anæmic syncope from any cause.

Several authors have attributed the empty state of the heart met with after death, in certain cases of fatal syncope, to want of power in the left ventricle to supply the right cavities of the heart; but this is to argue as if the blood passed out of the body after leaving the right ventricle, and the left ventricle had to supply a newly formed fluid. The effects of want of power in the left ventricle are the same as those of an obstruction at the origin of the aorta; the lungs become congested, and the right cavities of the heart more or less distended, from the blood not being able to pass readily through the lungs. Patients who die of heart disease die with the cavities of that organ full. Some patients, indeed, with fatty disease of the heart, die suddenly of anæmic syncope, and the heart is found empty; but in these cases it is evident that death is not occasioned by the disease of the heart, but by some condition of the bloodvessels which accompanies it.

Chevalier was, I believe, the first to draw marked attention to cases of sudden death arising from an empty state of the heart, in a paper in the first volume of the Transactions of the Royal Medical and Chirurgical Society; and he rightly attributed the emptiness of the heart to a loss of power in the bloodvessels. His words are as follow:—

“The disease I have now described may, perhaps, be termed asphyxia idiopathica. The essential circumstances of it evidently denote a sudden loss of power in the vessels, and chiefly in the minuter ones, to propel the blood they have received from the heart. In consequence of which, this organ, after having contracted so as to empty itself, and then dilated again, continues relaxed for want of the return of its accustomed stimulus, and dies in that dilated state.”

The word asphyxia has become so closely connected by physiologists with death by privation of air, where the symptoms and appearances are the reverse of those in Chevalier’s case, that it is necessary to discard his name of the disease which he describes, although it is etymologically correct. His cases come under the definition of what is now universally called syncope, and what I have called anæmic to distinguish it from cardiac syncope.

Chevalier speaks of a want of power in the vessels to propel the blood, and as it is not now believed that the vessels take any active share in the propulsion of the blood, this may be the reason why the views of this author have received less attention than they deserve; but it is very obvious that a want of tone in the vessels, or any great diminution of that power which enables them to support and compress the blood, is an adequate cause why the blood should be unable to reach the right side of the heart. In the case of varicose veins, previously mentioned, it was physically apparent that the cause of the syncope lay in the vessels. Disease of the arteries is well known to be usually associated with degeneration of the heart; the veins are also large and distensible in old people, who furnish the greater number of those who are liable to anæmic syncope; but the pathology of the veins, as regards both their functions and structure, is not yet sufficiently known.

Persons with disease of the heart, who die suddenly in a fit of anger, probably die always with the heart distended; that is, of cardiac syncope. Dr. Joseph Ridge, however, in his able and interesting remarks on the disease and death of John Hunter,^[134] states his belief that that celebrated man, who had been long subject to attacks of angina pectoris, died at last of syncope, with an empty heart. He died, as is well known, during a fit of anger, and the coronary arteries were found ossified. It is not said that the heart was empty, but that it was small, and that there were no coagula in any of its cavities. It is probable that there was not much blood in its cavities, at the time of the post mortem examination, but the body of Hunter was conveyed in a sedan-chair, from St. George’s Hospital to Leicester Square, a little more than an hour after his death, so that the fluid blood would gravitate downwards. It is related that the stomach and intestines were unusually loaded with blood, and that those parts which were in a depending position, as in the bottom of the pelvis and upon the loins, were congested in a greater degree than the others; and that “this evidently arose from the fluid state of the blood.”

In syncope from muscular exertion, the cavities of the heart are distended, and its walls have occasionally been ruptured, both from violent exercise and fits of anger.

Fear probably occasions each kind of syncope in different cases. In some cases, the right cavities of the heart become distended owing to impeded respiration, and possibly to a diminution of power in the heart itself. More frequently, the syncope appears to be of the ordinary or anæmic kind, the effect of the mental condition acting first on the more distant parts of the circulation. The pallor caused by fright is proverbial.

Pain is also capable of causing both kinds of syncope. I have alluded to cases (page 55) in which the patients strained and held their breath till the pulse became intermittent, and the action of the heart was temporarily suspended by the arrested breathing; on the other hand, patients often become pale, if they are undergoing any slight operation when seated, and syncope of the anæmic kind occurs, without any previous disturbance of the respiration, but passes off as soon as they are placed in the horizontal posture. I have seen an apparently strong man faint in this manner, during the removal of a tumour from the back not larger than a nut, and where only a few drops of blood were lost. Chloroform was not employed.

SUPPOSED CAUSES OF DEATH FROM CHLOROFORM.

Many writers have supposed that the deaths from chloroform have arisen from some peculiarity in the patient; and when any notable change of structure has been met with after death in any of the vital organs, this has been thought to afford a sufficient explanation of the event; whilst in the cases in which the organs were in a healthy state, surprise has been expressed at the occurrence. In looking over the account of the cases in which the inhalation of chloroform has been fatal, there is reason to conclude, however, that the subjects of them were, as regards health and strength, quite equal to the average of the multitude who have inhaled this agent without ill effects. In fifteen out of the fifty cases above related, there was no examination of the body after death. In one of these fifteen cases, the patient was in a state of debility, and had hectic fever, apparently from the disease of the ankle-joint, for he had no cough; in another of these cases, the patient was reduced to a state of great debility from cancerous disease of the uterus. In fourteen out of the thirty-five cases, in which an examination of the dead body took place, all the chief organs were found to be healthy, if we except the local congestions of blood connected with the mode of dying, and a flabby state of the heart in a few of the cases, which probably depended on its being full of blood at the time of death, or its not being in a state of post-mortem rigidity, at the time it was examined.

In one case, No. 25, the only morbid appearances were adhesions of the pleura of small extent; and in No. 47, the only disease was fatty liver. In Case 17, there were signs of chronic disease of the membranes of the brain; and in two cases, Nos. 16 and 22, there was emphysema of the lungs. In the remaining sixteen cases, there was some alteration of the heart, accompanied in a few instances by disease of other organs. In Cases 23 and 32, there was fat on the surface of the heart, but the structure was not degenerated. In Case 43, the right ventricle was thinned, but not fatty. In Case 44, there were slight deposits on the mitral valve, the heart being otherwise healthy. In Case 50, there were deposits of lymph on the mitral valve and also on the surface of the heart, which was somewhat enlarged. In Case 8, the heart is merely stated to be large; and in Case 27, hypertrophied. In Case 3, the heart was enlarged, pale, and soft, and the lungs were tuberculous. In Case 15, there was said to be some amount of disease of the aortic valves, and some amount of fatty degeneration of the heart. In Case 37, incipient fatty degeneration was present; and in Case 40, that of a youth of eighteen, the heart was slightly enlarged, with some amount of fatty degeneration. In Case 46, the right ventricle was thinned and slightly fatty. There remain three Cases, Nos. 30, 33, and 42, in which the fatty degeneration was more decided; and one case, No. 41, in which it is spoken of as being present in an extreme degree. This was in a man, aged sixty-five, the oldest person included amongst those who died from chloroform.

When we consider how common is fatty degeneration of the heart, especially amongst old persons and those for a long time confined to bed, it is very probable that this affection has been proportionally as frequent, amongst the patients who have inhaled chloroform without ill effects, as in the fatal cases of its inhalation.

There are nine of the fatal cases in which the age of the patient is not stated. In the other forty-one cases, the ages, when grouped in decennial periods, are shown in the following table, the last column of which shows the proportion which the deaths bear at each period to the number living at that period, out of a thousand persons of all ages in England and Wales.

The nine persons whose ages are not given were all adults; one is spoken of as a young man, and another as a young woman, and the rest are mentioned in such a manner that it is certain they were not old people. It follows, therefore, that so far as is known, there has been a complete immunity from death by chloroform at both extremes of life. I have already given my reasons for rejecting Dr. Aschendorf’s case of an infant, and also the case of a gentleman, aged seventy-three, who died whilst inhaling chloroform. The youngest patient who died from chloroform was seven or eight years of age, and the oldest sixty-five, being the only death above sixty. The above table of the ages shows that the number of deaths, in proportion to the number living, increased rapidly after the age of twenty-five, and decreased rapidly after the age of forty-five. The small number of deaths between fifteen and twenty-five may be partly due to the circumstance that surgical operations are but seldom required at this period of life; but the decrease after the age of forty-five cannot be explained in this way; for persons become more liable to require surgical operations as they advance in years. Operations are often performed in infancy and old age, periods at which deaths from chloroform have not been recorded. The greatest proportion of deaths having occurred from thirty-five to forty-five, when the system is often more robust than at any other period, it cannot be supposed that an inability to bear the usual dose of chloroform, when carefully administered, is the ordinary cause of death from this agent.

Idiosyncrasy. The accidents from chloroform have frequently been attributed to idiosyncrasy in the patient. This, it may be observed, is not to give an explanation of them, but merely to state that they depend on something we do not understand; that something, however, being in the person to whom the accident happens. This view receives apparent support from the supposition that the chloroform has been inhaled in exactly the same manner in the fatal cases as in other instances; but this apparent support fails when it is pointed out that the supposed same manner is only an equally uncertain manner. The different effects that have been produced on the same patient at different times, and the great number of instances in which medical men have failed to make the patient insensible, show that most of the usual modes of exhibiting chloroform are extremely uncertain.

What most completely meets the question of idiosyncrasy, however, is the circumstance that in no fewer than eleven out of the fifty recorded cases of death from chloroform, the patient had previously inhaled this medicine without ill effects. In two other cases also, previous attempts had been made to make the patient insensible without success, on the day on which the accident occurred. In the above table of the fatal cases, those are indicated in which previous inhalations had taken place. In twenty-nine cases, I have concluded that the patient had not previously inhaled, for the medical man, having given an account of the state of his patient, and his reasons for administering the chloroform, would certainly have mentioned such a material fact as a previous inhalation if it had occurred. There are ten cases of which only a meagre account is given, and where a previous administration of chloroform may possibly have taken place without being mentioned; but if only eleven, out of the fifty patients, who died from chloroform, had inhaled it previously without ill effects, it is very clear that the fact of having inhaled it with a favourable result, gives no immunity from the possibility of accident. It would be impossible to say what proportion of the patients who have inhaled chloroform have inhaled it more than once, but it is not probable that they amount to more than 22 per cent., if so many.

Alleged Impurity of the Chloroform. At one time accidents from chloroform were loosely attributed to impurity in the medicine, but this was only a guess, and is opposed to the facts. No case of accident has been traced to this cause, and in nearly all the cases of which the details are given, it is distinctly recorded, either that the chloroform was examined and found to be of good quality, or else that chloroform out of the same bottle had been used in other cases without ill effects. I have not thought it necessary to state this in quoting the individual cases.

Apparatus employed. Accidents were at one time, and in one quarter, attributed to the use of inhalers; and it is curious that this allegation was made at a time when no death from chloroform had yet occurred in any cases in which an inhaler was used, except one in America, and one in France, the accounts of which had not reached this country. It is possible that death might be occasioned by want of air from the use of a faulty inhaler, and a case will be mentioned in which this apparently occurred in the administration of sulphuric ether, but there is no recorded case of accident from chloroform in which death was occasioned in this way. In the cases of death previously recorded, a handkerchief, a piece of folded lint, hollow sponge, or some such simple contrivance, was used in thirty-four instances; in twelve cases, an inhaler of some kind or other was used; and in four cases, it is uncertain what were the means employed.

Alleged Exclusion of Air. The assertion has often been made that death might be caused by the vapour of chloroform excluding the air, and so causing asphyxia; but it has already been pointed out in this work that the physical properties of chloroform do not allow it to yield a quantity of vapour which would have that effect, and in much smaller quantity than this the vapour kills by a quicker way than asphyxia, I believe that the only elastic fluids which can cause death simply by excluding the atmospheric air are nitrogen and hydrogen.

Alleged Closure of the Glottis. At the trial which took place in Paris respecting the death of a porcelain dealer previously mentioned, M. Devergie gave evidence, and after saying that chloroform might cause death as a poison, if given in undue proportion, he added: “Also it closes the glottis, and offers an obstacle to respiration. Employed by M. Demarquay on himself, in very small doses, closure of the glottis was occasioned. It was possible that Le Sieur Breton had experienced that accident, and in that case the most able surgeon could not prevent death.”

I have not met with M. Demarquay’s account of his experiment, but I am happy to know that he did not die of the closure of the glottis. It may fairly be denied that a person could commit suicide in this manner if he wished, for he would either have to give up the attempt, or receive the vapour into his lungs, and experience its specific effects. When animals are placed in mixtures of vapour and air, they always breathe them, whatever the strength; and if the vapour amounts to eight or ten per cent., they die much more quickly than they would of mere closure of the glottis. Vapour of chloroform, when not largely diluted with air, is apt to cause cough and closure of the glottis, as soon as a little of it reaches the lungs; but this, so far from being a source of danger, is, as a general rule, a safeguard, by its preventing the patient from readily breathing air which is highly charged with vapour.

In commenting on the fatal case No. 12, which occurred in St. Thomas’s Hospital, I have suggested that the accident might have happened from liquid chloroform being dropped into the throat; but liquid chloroform is very different from the vapour; it causes a lasting irritation if applied to a mucous membrane; when used for toothache, it often blisters the gums. The irritation caused by the vapour, on the contrary, is only momentary, and its local action ceases directly it ceases to be inhaled; for what is left in the air-passages is immediately absorbed or expelled with the expired air. The glottis is not a vital organ of itself. Its closure only causes death by preventing the access of air to the lungs. The glottis does not remain permanently closed, I believe, from the contact of any elastic fluid, however irritating;^[135] but it does from the contact of a liquid, and persons who die by drowning, die with the glottis closed, for they do not fill their lungs with water. Therefore, if the vapour of chloroform did cause persistent closure of the glottis, and if a person were to hold it by force to the patient, the death it would occasion would be precisely like that in drowning. Death by asphyxia is a comparatively slow one. I find that when the access of air to the lungs is entirely cut off, death does not take place in less than three minutes and a half in guinea pigs, and four minutes in cats. In dogs, the process of asphyxia is still slower. Mr. Erichsen states, that on taking the average of nearly twenty experiments, the contractions of the ventricles continued for nine minutes and a quarter after the trachea had been closed, and that the pulsations of the femoral artery also were perceptible for an average period of seven minutes and a half. The process of drowning in the human subject is well known to occupy some minutes; and even if the pungency of the vapour of chloroform should entirely prevent the patient from breathing, and the medical man could overlook the fact that breathing was not going on, it cannot be supposed that he would use the force, and have the perseverance to cause his patient to die slowly by asphyxia. If any patient, therefore, has died from closure of the glottis, it must have been one in whom there was a great tendency to sudden death from any slight interruption to respiration. I do not know the particulars of the case respecting which M. Devergie was giving his evidence, but in those fatal cases previously related, in which the symptoms are sufficiently described, it is not probable that death took place in any instance from closure of the glottis. In the sudden death at St. George’s Hospital (page 209), it is possible that the slight pungency of the vapour might assist the fear under which the patient was labouring in impeding the breathing, and thus add to the distension of the right cavities of the heart, under which the patient apparently died.

In 1855, two years after M. Devergie had given the above opinion, Dr. Black, of St. Bartholomew’s Hospital, who has had great experience in the administration of chloroform, advanced a similar theory in the pamphlet previously alluded to. He did not, however, confine the effects of the supposed closure of the glottis to possibly causing a death here and there, as M. Devergie had done, but he attributed all the accidents which had happened to this cause, and not to the effects of chloroform in the system. He says that “the chloroform has not been even inhaled: its pungency was felt at the glottis, and its inspiration was immediately arrested. The patient would have removed the apparatus, but in this he was restrained. The struggle forthwith commenced, but up to the moment of his death, not a single inspiration took place.” These remarks were not applied to a single case, but generally to the accidents from chloroform. Dr. Black says: “Any concentration of the vapour of chloroform which can be breathed is safe; any condition of dilution which forces the patient to cough or hold his breath is dangerous, and if persevered in for even half a minute, may be fatal.... We have only to attend to the breathing; we may disregard all considerations affecting the relative proportion of the chloroform in the air which is breathed;... if the patient breathes easily he is in safety, whatever be the amount of chloroform which is passing into the lungs.”

In Experiment 28, previously related, where the respiration was kept up by a tube in the trachea, there could be no error in respect to the vapour of chloroform entering the lungs, when a bladder of air charged with ten per cent. of that vapour was substituted for the bladder of simple air; and the immediate paralysis of the heart was evident. An examination of the fatal cases, of which the particulars have been recorded, shows that death did not occur in the manner Dr. Black suggests. In the majority of the cases, the patients were rendered quite insensible by the chloroform, and the operation had either been commenced, or was on the point of commencing; when the fatal symptoms set in. In several other cases, the patients were partially under the influence of the vapour before the symptoms of danger commenced; and in the six cases where death occurred at the beginning of the inhalation, without loss of consciousness having been induced, the patients were not restrained in any way, and it was observed that they did breathe the chloroform; three of them were speaking up to the moment when the pulse stopped, and one took a full inspiration the moment before the fatal symptoms set in. It is only in eighteen of the fatal cases that there is any reason to suppose that the patient required to be held, and then only from mental excitement or muscular spasm, arising from the physiological effects of the absorbed chloroform. It is hardly possible that the struggles of a conscious patient from inability to breathe, would be mistaken for excitement or spasm caused by chloroform.

In a case, No. 34, which occurred at St. Bartholomew’s Hospital whilst Dr. Black was present, and long before his pamphlet was written, the patient inhaled for five minutes, and sank off into a state of complete insensibility without alarming symptoms. The inhalation was discontinued, the patient moved into a proper position, and the operation just about to be commenced, when Dr. Black found the pulse to become extremely feeble and fluttering. Surely this patient breathed the chloroform, and died without any spasm of the glottis. In Case 48, so minutely related by Mr. Paget, the boy made one long inspiration, and became suddenly insensible. In a few seconds, the pulse suddenly failed, and then ceased to be perceptible, but the breathing continued for at least a minute afterwards. There was certainly no closure of the glottis in this instance.

Alleged Exhaustion from Struggling. In cases where the patients have struggled violently whilst getting under the influence of chloroform, the accidents have been attributed to a supposed exhaustion caused by the struggling.^[136] This opinion is, however, contrary to experience; for the patients who struggle violently are precisely those who bear chloroform the best, provided they do not breathe it in an insufficient state of dilution. They are generally cheerful and exhilarated by it, and are less liable to be depressed by its prolonged use, than those who come quietly under its influence. Although the patients who struggle bear the chloroform well, when it is carefully and judiciously administered, it is not improbable that the struggling has been now and then an indirect cause of accident. The muscular spasm and rigidity do not occur till about three-quarters as much chloroform has been absorbed as can be present in the system with safety; and, as the patients often hold their breath whilst struggling, and take deep inspirations suddenly and at long intervals, the greatest care is required that the vapour be administered in a very diluted state. In Cases 9, 44, and 47, the fatal symptoms came on whilst the patients were struggling; and in some other cases, the sudden failure of pulse occurred just after the struggling had ceased, rendering it probable that the patient inhaled too much of the vapour whilst struggling, or just as the spasmodic condition of the muscles was subsiding.

The circumstances just mentioned, are probably the cause why so many of the fatal cases occurred at that period of life when the body is most robust. Very nearly two-thirds (twenty-seven out of forty-one), of those cases in which the ages are recorded, occurred in persons of twenty years and under forty-five years of age, although the proportion of persons living at this period of life, in England and Wales, is only a little more than one-third of the entire population. The majority of the accidents from chloroform occurred also in the stronger sex, in which muscular rigidity and spasm are most frequent:—twenty-nine of the fatal cases happened to males, and only twenty-one to females. According to my experience, the females who inhale chloroform for surgical operations are nearly twice as numerous as the males; and although this may not be the proportion in every one’s practice, it is probable that females inhale this agent quite as frequently as the other sex, in every part of the world.

Sitting Posture. In some of the early cases of death from chloroform, the patients were inhaling it in the sitting posture, and it was surmised that this circumstance was the cause of death.^[137] An examination of the account of the fatal cases, however, does not bear out this supposition. In thirty-one instances the patients were lying, in nine instances sitting, and there are ten cases in which the position is not mentioned, and where from the nature of the operation it may have been either one or the other. In fully one-fourth of the cases of which I have kept notes of the administration of chloroform, the patients were seated in an easy chair; and as in forty fatal cases in which the position is known, only nine, or less than one-fourth, were seated, it does not appear that the position of the patient has had any share either in causing or preventing accidents.

Supposed Effect of the Surgeon’s Knife on the Pulse. Mr. Bickersteth alluded to a peculiar circumstance,^[138] which he thought would account for several of the deaths attributed to chloroform. He relates three instances in which the pulse suddenly ceased on the first incision by the surgeon, and commenced again in a few seconds, the breathing going on naturally all the time. All the three cases were amputation of the thigh, and occurred in the latter part of 1851. Mr. Bickersteth did not observe the circumstance again during the two following years, and I have never observed it, although I have very often examined the pulse at the moment when the operation began, especially after reading Mr. Bickersteth’s remarks. He supposes that the action of the heart was arrested by the shock of the incision, notwithstanding the patient was insensible. I should attribute the temporary stoppage of the pulse in these instances to the direct influence of the chloroform on the heart. The moment when the operation is commenced, is usually a few seconds after the inhalation has been discontinued, and when the effect of the chloroform is at its height. A portion of that which was left in the lungs having been absorbed, in addition to that which was previously in the system. And if the vapour inhaled just at last was not sufficiently diluted, it might paralyse the heart, but not so completely as to prevent the natural respiration from restoring its action, in those cases where respiration continues. I found in experiments on animals that, when the action of the heart has been suspended by the effect of chloroform, it can very often be restored by artificial respiration instantly applied; and it is extremely probable that an accident of this kind not unfrequently occurs during the administration of chloroform, and is remedied by the breathing, without being noticed. The pulse recovered itself, in the cases mentioned by Mr. Bickersteth, just as it does in animals after the heart has been nearly overpowered by chloroform. In the first case, the pulse remained imperceptible for a period of four or five seconds, the countenance at the same time becoming deadly pale. As it returned, it was at first very feeble, but in a few seconds, it regained its usual strength. In the second case, Dr. Simpson administered the chloroform, and after the operation remarked that the pulse had stopped suddenly just as the knife was piercing the thigh, and had recovered itself with a flutter almost immediately.

Mr. Bickersteth’s reason for attributing the stoppage of the pulse to the effect of the knife, rather than the chloroform, was that he had arrived at the conclusion from some experiments which he performed on animals, that the action of the heart cannot be arrested by chloroform, until the breathing has been first suspended. One of Mr. Bickersteth’s experiments (No. 5, on a half-grown cat) exactly resembles the experiment (No. 28 in this work) on a rabbit, which I had published upwards of a year before Mr. Bickersteth’s paper appeared, with the exception that in my experiment the artificial respiration was performed with air containing ten per cent. of vapour, and in Mr. Bickersteth’s the vapour was an unknown quantity. In both experiments, the heart of the animal was exposed. In that which I performed, three or four inflations of the lungs almost paralyzed the heart; and nine or ten inflations, which did not occupy half a minute, had the effect of paralyzing that organ irrecoverably. In Mr. Bickersteth’s experiment, the effect of the artificial respiration was as follows:—“After continuing it for seven minutes, the diaphragm, hitherto unaffected, began to move very irregularly and imperfectly; then its movements became slow and hardly perceptible; and, at the expiration of eleven minutes, they had ceased altogether. During all this time the heart’s action remained strong and regular, but now it got weaker and more rapid, and, in four minutes from the time the diaphragm had ceased acting, had become so feeble (still quite regular) that I feared every moment it would stop.” Mr. Bickersteth says he performed artificial respiration with air saturated with chloroform; but saturated or not, the vapour certainly did not exceed six per cent., and most likely was only between four and five, if the artificial resembled the natural respiration in quantity and frequency. The vapour which can be breathed for seven minutes without causing serious symptoms, and for eleven minutes without arresting the breathing, is of course incapable of stopping the action of the heart by its direct effect. It is scarcely so strong as that which one administers every day to patients with impunity. The vapour which is so diluted as to require to be added by small increments during one hundred and fifty inspirations, before the brain is even narcotized, cannot act directly on the heart, an organ which can bear a much larger amount of chloroform. Mr. Bickersteth fell into the error into which the Committee of the Society of Emulation of Paris afterwards fell, and argued from the rule to the exception. What he witnessed was the mode of death which would occur, if vapour of chloroform of the strength which can be safely inhaled, were deliberately continued till the death of the patient. But an accident from chloroform is an exception, and the mode of dying is as much an exception as the death itself, if the inquiry is extended to what this agent is capable of doing, instead of confining it to what one endeavours to effect with it in the human subject alone.

So many of the deaths during the inhalation of chloroform have occurred before the operation had commenced, or after it had proceeded some way, that Mr. Bickersteth’s explanation would not apply to a great number, even if it were correct; and when it is remembered that the operation is always commenced when the effect of the chloroform is expected to be at its height, the number of cases of cardiac syncope which have happened at the beginning of the operation is not greater than might be expected as the result of the effect of chloroform.

Sudden Death from other Causes. It has been more than once suggested that the deaths which have occurred, during the inhalation of chloroform, are of the same nature as the sudden deaths which have often occurred about the time of surgical operations, apparently without any adequate cause; and that in fact the accident and the chloroform may be a mere coincidence, and not connected as cause and effect. It has been already shown that the Commission of the Academy of Medicine of Paris made this suggestion in treating of the case of Madlle. Stock, and Dr. Simpson has more than once made a similar remark. On one occasion,^[139] he remarked, in speaking of chloroform:—“The first surgical cases in which it was used were operated upon in the Royal Infirmary here, on the 15th of November, 1847. Two days previously, an operation took place in the Infirmary, at which I could not be present, to test the power of chloroform; and so far fortunately so; for the man was operated upon for hernia, without any anæsthetic, and suddenly died after the first incision was made through the skin, and with the operation uncompleted.” I should say, so far unfortunately so, for whatever the cause of the man’s death, that cause could hardly have been present if the patient had been made insensible by chloroform; and so his life would in all probability have been saved. If he died either from fear or from pain, the chloroform would have prevented his death, by removing and preventing these causes; and if his death arose from simple exhaustion, it must be remembered that chloroform is a stimulant, during the first part of its administration, and, as a general rule, so long as it is actually in the system. Even Mr. Bickersteth, who thinks that the knife of the surgeon may have a direct influence on the heart when the patient is quite insensible, expresses his conviction that such an occurrence is far less likely to happen under the influence of chloroform than in the waking state.

I have omitted from the list of deaths by chloroform two cases which are usually attributed to that agent, namely, the case of Mr. Robinson’s patient, and the one at St. George’s Hospital, and have attributed them to fear; and I also rejected the case of the infant on which Dr. Aschendorf operated, for the reasons I stated; and it is quite possible that amongst the fifty cases I have retained, there may be one or two in which the death was not caused by chloroform, especially as the details of some of the cases are very meagre; but when all the circumstances of the cases are examined, and especially when the mode of death is compared to that which chloroform can be made to produce in animals, it cannot be supposed that the fatal event was a more coincidence in the whole fifty cases, or in any great number of them.

There are numerous instances recorded of sudden death during surgical operations, or just before intended ones, without any evident cause, except fear or pain, before the use of narcotic vapours was known; and some even since, in cases in which it was not thought worth while to use them. After the passage quoted above, Dr. Simpson continues:—“I know of another case in Edinburgh, where death instantaneously followed the use of an abscess-lancet without chloroform,—the practitioner, in fact, deeming the case too slight to require any anæsthetic.” Such events have, no doubt, often happened without being recorded; and it is extremely likely that the deaths of this kind which chloroform has prevented are quite as numerous as those it has occasioned by its own effects, but the medical profession will very properly not be satisfied with a result of this kind, if more can be done; and the endeavour of the practitioner of course is, whilst saving life as well as preventing pain by the use of this agent, to avoid as far as possible having any accident from its use.

Falling back of the Tongue. It has been alleged that the falling back of the tongue into the throat, under the deep influence of chloroform, might be the cause of death by suffocation; but this appears to be an error; for the muscles of the larynx and neighbouring parts preserve their action as long as the diaphragm, and contract consentaneously with it. When the breathing has ceased, the tongue is indeed liable to fall backwards, if the person in a state of suspended animation is lying on the back, and this circumstance requires to be attended to in performing artificial respiration.

STATE OF THE CHIEF ORGANS AFTER DEATH FROM CHLOROFORM.

A few years ago, I examined the viscera of the chest, and kept notes of the appearances, in thirty-seven animals killed by chloroform. They consisted of two dogs, twenty-two cats, one kitten, three rabbits, three guineapigs, two mice, two larks, and two chaffinches. Many of the animals were opened immediately after death, and the rest within a day or two. The lungs were not much congested in any instance. In seven of the animals, they were slightly congested; but in the remaining thirty, they were not congested. They were generally of a red colour, but in a few of the cats they were quite pale. I ascertained the specific gravity of the lungs of two of the cats, in which they presented the amount of vascularity I have most usually met with. The specific gravity was 0·605 in one instance, and 0·798 in the other. As many of the animals died in a way resembling asphyxia, the respiration ceasing before the circulation, it might at first be supposed that we should meet with the same congestion of the lungs; but by the time that the respiration is altogether suspended by the action of chloroform, that agent has begun already to influence the heart, which does not inject the blood into the lungs with the same force as when the respiration is mechanically prevented, whilst it is in full vigour. Besides, in the gaspings which so often take place when the heart is ceasing to act, the animal inhaling chloroform draws air freely into the lungs, whilst the asphyxiated animal is prevented from doing so.

As regards the condition of the heart, it was found in the two chaffinches that the auricles were filled with blood, whilst the ventricles were empty. The condition of the heart in the larks is not mentioned, but in all the thirty-three quadrupeds, the right auricle and ventricle were filled with blood. In ten of them, these cavities were much distended; and in some of these instances, the coronary vessels on the surface of the heart were distended also. The left cavities of the heart never contained more than a small quantity of blood, not exceeding a quarter of what they would hold.

The head was examined in only ten of the animals. The substance of the brain was found to be of the natural vascularity, and the sinuses were not very much distended, except in two instances.

With respect to the state of the blood, it may be mentioned, that in every instance in which the chest was opened within an hour after death, the blood which flowed from the cut vessels coagulated immediately and firmly. In eighteen of the animals in which the blood was examined in the heart or large vessels, a day or two after death, it was found to be well coagulated in ten, loosely coagulated in seven instances, and quite fluid in one instance. I have not met with air in the bloodvessels, either in the above thirty-seven examinations, or in any of the numerous other animals that I have opened, after they have been killed by chloroform. The appearances I have met with in animals killed by this agent have usually been such as I have described in the above thirty-seven instances; but I long since ceased, as a general rule, to make careful notes of the appearances, as I did not meet with anything new.

In the fatal cases of inhalation of chloroform previously quoted, the lungs are related to have been congested more frequently, and to a greater extent, than I have met with in animals. But there is no standard of what should be called congestion; and probably many of the medical men who made the examinations were speaking by comparison with cases where persons die after illness, in a state of inanition. In the human subject, the right cavities of the heart, although generally full of blood, were found empty in several cases; but as I previously stated, it is almost certain that they were emptied after death, either by the artificial respiration which was employed, or in some other way.

The blood remained fluid in eighteen out of twenty-five cases of fatal accident from chloroform, in which an examination of the body was made and the condition of the blood recorded; whereas it was only quite fluid in one instance out of eighteen of the animals which were killed by chloroform, and not opened till a day or two afterwards. The fact of the blood coagulating more generally, in the animals on which I have experimented, than in the human subjects who died from chloroform, is probably due to their smaller size. I was formerly of opinion that the fact of the body of a small animal cooling more quickly than the human one was the probable explanation of this, but Dr. Richardson appears to have proved that the blood is kept in a liquid state by the presence of ammonia; and ammonia, we might expect, would escape more readily from the body of a small animal than from the human body. However this may be, it is pretty certain that the blood generally remains fluid in the human body after death from chloroform, only because it usually remains fluid in every kind of sudden death. When a patient dies slowly of illness, the body cools gradually before death takes place, and ammonia keeps exhaling in the breath, if Dr. Richardson is correct, whilst the formation of this alkali must be almost suspended. In many cases, we know that coagulation of the blood commences before the respiration and circulation have ceased. The blood which flows during surgical operations coagulates as quickly and firmly when the patient is under the influence of chloroform as at other times; and, as was mentioned above, the blood which flows from animals, just after they are killed by this agent, coagulates as well as usual; it follows, therefore, that if the coagulation of the blood were prevented by the chloroform, and not by the mere fact of sudden death, it would be by the presence of this agent in the blood after death, and not by any action which it exerted during the life of the patient.