From the lips becoming suddenly blanched in the above case, there is every reason to conclude that the heart was suddenly paralysed. The patient breathed for a little time after this, and was able to swallow, though with difficulty. The process of inhalation occupied only a little more than half a minute in Dr. Meggison’s estimation; yet he appeared to think that the fluid drachm of chloroform which he had put on the handkerchief had evaporated; for he was about to apply more when the alarming symptoms appeared. But supposing only one-third of the drachm was actually inhaled into the lungs in the half minute, the vapour would necessarily be in a highly concentrated state—probably twenty cubic inches of vapour in 200 cubic inches of air, which would be adequate to occasion the result which happened. In the short space of about half a minute, the blood could not be uniformly impregnated with the vapour; only a portion of it could pass through the lungs in the time; yet, as the patient was rendered insensible, this portion must necessarily have been highly charged with vapour.
It was often the practice to render the patient insensible in as short a time as half a minute, when chloroform was first introduced, but I believe never without danger; and I had expressed the opinion before any accident happened, that, for reasons such as I have stated above, a patient should on no account be rendered insensible in less than two minutes.[[68]]
Case 2. The next recorded case in which the inhalation of chloroform was fatal, occurred at Cincinnati, on the 23rd of February, 1848. The subject of it, Mrs. Martha G. Simmons, was thirty-five years of age, and enjoyed good general health; she was the mother of six children, and her last confinement occurred eight weeks before her death. The patient exhibited no alarm on account of inhaling the chloroform, which was administered by two dentists, who were not members of the medical profession. It was breathed from an inhaler which Dr. Morton of Boston contrived for sulphuric ether. This inhaler consisted of a glass globe four inches and a half in diameter, and contained a sponge about one-third filling the globe, and saturated with chloroform.
Two female friends of the patient reported the following as the events which occurred. “The respiratory movements appeared to be free; chest heaving. While inhaling, the face became pale. At the expiration of about one minute, the instruments were applied, and four roots of teeth extracted. The patient groaned and manifested what they regarded as evidences of pain, while the teeth were being extracted, although she did not speak or exhibit any other sign of consciousness. As the last root came out, which was about two minutes from the beginning of the inhalation, the patient’s head turned to one side, the arms became slightly rigid, and the body drawn somewhat backwards, with a tendency to slide out of the operating chair. At this instant, Mrs. Pearson states that she placed her finger upon the patients pulse; observed that it was feeble, and immediately ceased to beat; respiration also ceased about the same time. The face, which was previously pale, now became livid, as did also the finger nails; and the lower jaw dropped, and the tongue projected a little at one corner of the mouth, and the arms were perfectly relaxed. The females regarded her as being then quite dead.”[[69]]
The dentists gave nearly the same account, saying that the breathing was at first slow, and that the patient inhaled twelve or fifteen times, occupying from a minute to seventy-five seconds. They committed the great error of not placing the patient at once in the horizontal position, when the alarming symptoms came on, but kept her sitting in the chair, from five to ten minutes, whilst they sent out for restoratives. They thought the patient was living during this time, but her female friends thought not. The patient was placed on a sofa, and sometime afterwards artificial respiration and galvanism were applied without effect.
An examination of the body was made twenty-six hours after death by Drs. Mussey, Lawson, Baker and Mulford. The following are the chief particulars of the appearances met with. A larger quantity of blood than usual flowed from the sinuses of the dura mater. General aspect, colour, and consistence of the brain, normal. Lungs considerably but not intensely congested; crepitated freely at all points; no extravasation. Lining membrane of bronchia slightly congested, apparently the result of recent catarrh; deeply stained by the blood. Pleura at all points highly injected; six drachms of bloody serum in the right, and two ounces in the left chest. Pericardium contained six drachms of bloody serum. Heart flaccid, and all its cavities entirely empty; inner surface of both ventricles and auricles deeply stained. Abdomen—one ounce and a half of bloody serum in the right hypochondrium. Stomach and intestines distended with gas. Partially digested aliment, amounting to about three gills in the stomach. Blood fluid as water in every part of the body; not a coagulum was seen in any vessel. Lining membrane of all the bloodvessels deeply stained. The colour in every part of the system was that of dark venous blood.
It was estimated, in the inquiry which took place respecting this case, that one-fourth part by measure of what the patient inhaled might be vapour of chloroform; but this is evidently an over-calculation, for there could not be this quantity unless the interior of the glass globe were maintained at the temperature of 80° Fah. and the air were quite saturated with vapour in passing through it; however, less than half the amount of vapour here assumed would have the effect of causing sudden death, in the way it happened. The period of the inhalation, a minute or seventy-five seconds, during which the patient took twelve or fifteen inspirations, did not admit of the blood in the body being regularly and uniformly charged with the chloroform; and the increase of its effects, owing, no doubt, to the absorption and circulation of the vapour contained in the lungs at the moment when the inhalation was discontinued, was well marked. The patient became pale during the inhalation, but the alarming symptoms suddenly came on during the extraction of the fourth stump, probably within half a minute after the inhalation ceased. The patient seemed, in fact, to die with the slight struggle that took place at this moment. In the case of Hannah Greener, related above, the spasm at the moment of dying was even more marked. This is a symptom I have often seen during the death of animals killed suddenly with vapour of chloroform in a concentrated state, before they were made thoroughly insensible. Although the heart was empty, the stained condition of its cavities showed that they had contained blood at the time of death and afterwards. Owing to its fluid state, it probably escaped from the heart during the moving of the body; especially during the examination of the head, which was made first.
Case 3. The next recorded case of death from chloroform is reported by Dr. John C. Warren, of Boston, U.S., in the London Medical Gazette.[[70]] His report, apparently extracted from some other report, is as follows.
“Name—Patrick Coyle. [Age—not stated.] Date—March 1848. Disease—fistula. Previous use of chloroform—once. Time of inhalation—about one minute. Quantity consumed—about thirty drops. [Query minims.] Posture—upon the side. Lapse of time till death—about one minute. Symptoms—showed signs of pain, by putting his hand to the part; in a moment his pulse, which was full and natural, sank: death. Morbid appearances—brain, with membranes, natural and healthy. Heart enlarged, pale, and soft; two or three ounces of serum in pericardium; bloodvessels with dark fluid blood. Lungs, studded with tubercles; abscess in each; lower parts congested; pleura extensively adherent; stomach—mucous membrane softened, its veins turgid.”
Nothing is said about the apparatus used in this case, but from the summing-up of Dr. Warren’s paper, it must have been either a towel or a handkerchief. The quantity of chloroform employed appears to have been much less than in the two previous cases. In speaking of drops, the writer probably means minims, or what is the same, a quantity equal to as many drops of water. Thirty drops of chloroform from a small phial are only equal to between six and seven minims, and if they were dropped on a handkerchief, so that they might be counted, they would evaporate entirely during the process. Supposing the quantity used to have been what is probably meant—half a fluid drachm—it would be quite adequate, according to calculations previously made in these pages, to cause the accident which happened. The period of inhalation was again very short—one minute; and the evidence of paralysis of the heart is distinct:—“In a moment his pulse, which was full and natural, sank: death.”