On chloroform and other anæsthetics: their action and administration

by John Snow

SYMPTOMS IN THE FATAL CASES OF INHALATION OF CHLOROFORM.

Out of the fifty cases of death from chloroform, related above, there are five in which the symptoms at the time of death are not detailed, viz., Cases 6, 7, 21, 24, and 50; in the two first cases it is merely related that the patient suddenly expired, and, in the two last cases, no one was watching the patient at the time when death took place. In considering the remaining cases they may be conveniently divided into groups, according to the period of the inhalation at which the accident occurred. In six of the cases the fatal symptoms came on suddenly, at the beginning of the inhalation, before the patient had been rendered unconscious; in each of these cases there was the most unequivocal evidence of the sudden arrest of the action of the heart. In cases No. 4 and No. 11 there was sudden pallor of the face at the moment when the circulation ceased. In Nos. 14 and 26 the face became livid at the time of the fatal attack, and, in Nos. 45 and 46, the colour of the face is not mentioned. In all these cases there were also symptoms as if of a sudden shock to the system, such as stretching out of the limbs, foaming at the mouth, rolling of the eyes, or a sudden convulsive start. In Case 4, the patient at Boulogne had just complained of a choking feeling, one sign that the vapour she was breathing was not well diluted. In Case 11 the fatal symptoms occurred immediately on a full inspiration; and in the other cases also the strength of the vapour was left to accident, and the result leads to the conclusion that it was very great at the moment before the fatal symptoms occurred.

In thirteen cases the inhalation was discontinued on account of the sudden appearance of dangerous symptoms, after consciousness had been apparently suspended. These cases are numbered 9, 15, 17, 20, 27, 30, 33, 35, 37, 40, 41, 44, and 47. In the greater number of these cases the over-action of the chloroform appeared to be exerted simply on the heart, the only dangerous symptoms being referrible to the paralysis of that organ; whilst in some of these cases symptoms of over-narcotism of the brain were conjoined with those connected with the heart. In the case of J. Verrier, No. 9, and in the case at Stockholm, No. 15, the sudden and entire cessation of the pulse was the symptom which first called attention to the danger of the patients, whilst the breathing was still going on. In Case 30 the woman became suddenly insensible and pulseless, after a short period of excitement. In Cases 35 and 40, although the pulse did not absolutely and entirely cease at once, its sudden failure was the first alarming symptom. In Case 20, at the Cavan Infirmary, the breathing and action of the heart ceased at the same moment. In Case 41, at the Middlesex Hospital, at a time when the pulse was full and steady, seventy in the minute, it gave a few rapid and irregular beats, and then ceased, and the breathing, which was free and deep, but not stertorous, ceased at the same time. In Case 15, which occurred at Jamaica, the patient, after a period of excitement, made one stertorous inspiration, when the breathing ceased. There were afterwards a few distant inspirations. The pulse is not mentioned; but it is pretty certain that it must have ceased about the time of the stertorous inspiration, or the additional inspirations which took place after the chloroform was withdrawn, would probably have restored the patient; to say nothing of the measures that were resorted to with a view to his resuscitation. Of Case 27, which happened at Melbourne, it is merely related that the patient spluttered at the mouth, and suddenly expired, just after a fresh portion of chloroform had been applied on the handkerchief. The symptom of spluttering at the mouth is recorded as occurring in other cases, just at the moment when the pulse had suddenly ceased.

In Case 44, at the Royal Ophthalmic Hospital, the narcotism of the brain and nervous system proceeded as far as the third degree, which was attended with strong muscular spasms, as not infrequently happens; and an overdose of chloroform appears at this moment to have acted on the heart, for the pulse could not afterwards be felt. In Cases 33, 37, and 47, the narcotism of the brain proceeded as far as the fourth degree, producing stertorous breathing, when the chloroform caused paralysis of the heart, by its direct action on that organ.

There are six cases in which the fatal symptoms came on just after the patient had been rendered insensible, and the inhalation had been discontinued; the operation being about to be commenced. They are numbered 32, 34, 39, 43, 48, and 49. All these cases bear a very close resemblance to each other. In all of them the patient had been made insensible (satisfactorily so as it was thought), when in a few seconds the pulse suddenly stopped, or failed and fluttered just prior to stopping; in Case 32 Dr. Dunsmure thought the time was longer between the discontinuance of inhalation and the cessation of the pulse. The breathing continued a little time after the pulse ceased or failed in all these cases, and there was an absence of the spluttering at the mouth, stretching of the limbs, and other spasmodic actions, which occurred in all the six cases where the heart was paralysed at the beginning of the inhalation, before unconsciousness had been induced, and in some of those when the paralysis of the heart took place at a later period of the inhalation, when the patient had been apparently rendered unconscious, but was not yet insensible. In each of the six cases now under consideration, the fatal event was evidently occasioned by the vapour of chloroform, which remained in the lungs at the moment when the inhalation was discontinued. A portion of this vapour becoming absorbed, and added to that already in the blood, had the effect of paralysing the heart, when it circulated through the coronary arteries.

There remain twenty-two cases in which the fatal symptoms came on during the course of the operation. In twenty of these cases the symptoms are described with more or less detail. I made some remarks respecting cases No. 1 and No. 2, in the place where they are related. In case No. 3, as in these cases, the patient appeared not quite insensible, and showed signs of pain during the operation, when “in a moment his pulse, which was full and natural, sank.” In case No. 5 the patient was probably dead when the incisions on the finger were commenced; the extreme suddenness of the death, and the absence of bleeding, show that death occurred in the way of syncope. The convulsive movements which just preceded death are worthy of note in connection with the other cases, in which death occurred immediately after the commencement of inhalation. Some remarks were appended to case No. 8. In case No. 10 paralysis of the heart is indicated by the absence of bleeding from the arteries, and the absence of pulse, whilst the breathing still continued for a short time. I made some remarks respecting case No. 12 when it was related. The patient seemed to die by embarrassed respiration, but whether that was caused by the action of the chloroform on the brain is doubtful. In case No. 13 the patient died in a moment. In No. 16 the face turned pale, and the pulse and breathing ceased soon after the chloroform was discontinued, showing the effect of the vapour which was present in the lungs at the moment when the inhalation was left off.

In Case 18 the livid countenance and sudden stopping of the pulse prove cardiac syncope. In Case 19 the blood which was gushing out suddenly stopped, and the patient expired. The congested state of the lungs and the blood in the right cavities of the heart prove that the syncope of which he expired was not the ordinary anæmic syncope from hæmorrhage; it was therefore cardiac syncope from the chloroform.

In Case 22 the change of countenance and sudden character of the death are evidences of cardiac syncope. In Case 23 there was sudden cessation of the bleeding and of the pulse; in Case 25 the pulse suddenly ceased. In Case 28 the patient died suddenly, but the pulse was apparently not examined at the time. Some remarks have already been made on Case 29, which happened in the Manchester Infirmary. In Cases 31, 36, and 38 the suddenness of the death showed that it took place by syncope. In the last of these cases the pulse was being examined at the time it ceased. In Case 36 there was no examination of the dead body; but in 31 and 38 the presence of blood in the right cavities of the heart indicates that the kind of syncope was cardiac syncope. Respecting Case 42, some remarks have already been made. The death commenced by deep coma, which embarrassed, and then suspended, the respiration, and cardiac syncope quickly followed. The chloroform was administered by a method which precluded the medical attendant from observing properly the most important symptoms.

The accompanying table of the fatal cases of the inhalation of chloroform contains such short particulars respecting them as seemed capable of being tabulated, and it may assist the reader in retaining a more connected recollection of the facts previously related more in detail.