With the conclusions above quoted, some additional ones were adopted from the second part of the report of the commissioners; in these it was admitted that chloroform is capable of causing death, if administered too long, or in too large doses. One of these additional conclusions, however, is as erroneous as the previous ones. It is, “there is risk of asphyxia when the anæsthetic vapour is not sufficiently diluted with air.” When the vapour is not sufficiently diluted with air, the risk is one of sudden death, by paralysis of the heart. Chloroform does not yield enough vapour, at the natural temperature and pressure of the atmosphere, to exclude the air to the extent which would cause asphyxia. When chloroform vapour largely diluted with air is long continued, it may cause, not real asphyxia, but a mode of death resembling it, owing to the medulla oblongata and nerves of respiration becoming over narcotised.
Case 5 is that of a young woman at Hyderabad, who inhaled chloroform to undergo amputation of the middle finger. A drachm was sprinkled on a handkerchief and inhaled. The operator described what occurred as follows: “She coughed a little, and then gave a few convulsive movements. When these subsided, I performed the necessary incisions, which of course did not occupy more than a few seconds. Scarcely a drop of blood escaped.” The absence of bleeding seemed to be the circumstance which called the attention of the operator to the state of his patient; and after describing the means which were used without avail to bring about recovery, he continues, “I am inclined to think that death was almost instantaneous; for, after the convulsive movements above described, she never moved or exhibited the smallest sign of life.”[[75]]
In this case, it is probable that the breathing and the action of the heart were both arrested at the same time, by the action of the chloroform.
Case 6. Charles Desnoyers, aged twenty-two, a patient in the Hôtel-Dieu at Lyons, affected with scrofulous disease of the left wrist, having to undergo transcurrent cauterisation of the joint, inhaled chloroform from an apparatus for five minutes, and died at the beginning of the operation.[[76]] Further particulars are not given.
Case 7. A young gentleman, who had returned from Australia to visit his relatives in the neighbourhood of Govan, inhaled chloroform for an intended operation on the great toe, in December 1848. It is stated that the patient, after inhaling it, almost instantly expired. This account appeared in the Glasgow Herald, and was copied into the medical journals.[[77]] I believe that no further account of the case was ever published.
Case 8 occurred on January 19th, 1849. It is related by Dr. John C. Warren.[[78]] John Griffith, an Irishman, aged thirty-one, a seaman in the American navy, was admitted into the New York Hospital early in December 1848, on his return from Mexico. He was suffering with diarrhœa, chancres, and hæmorrhoids. The following is the account of this accident.
“Gurdon Buck, jun., attending surgeon to the New York Hospital, being sworn, says, that ‘on or about the 26th of December, I advised that chloroform should be administered to the deceased, for the purpose of examining the condition of the rectum, the parts being in such a state of excessive irritation as scarcely to admit of a separation of the nates. The patient recovered from the effects of the chloroform, and remained in all respects in the same condition, except the local ailments spoken of; and he having never complained of either his head or his chest, and not having suffered from the first administration of chloroform, I directed it to be administered to him for the purpose of performing an operation upon the rectum, and the operation of circumcision to remove a phymosis caused by the chancres: the patient soon became excited by the chloroform, as is usually the case, but not beyond a degree that I have often observed. Shortly after, he became more tranquil: the deceased was placed upon his side, and the operation performed, which consisted in the removal of two external tumours, and the tying of one internal tumour.
“‘At this moment my attention was arrested by my assistant’s calling for a wet cloth: on examining the patient, I found his face and neck of a livid leaden hue or colour, the eyes turned upward, the pulse imperceptible at the wrist, and the whole body relaxed; after two or three gasps, he ceased to breathe. Every means was promptly used to restore the deceased, but without effect. The chloroform was obtained from Kent’s, 91, John Street, and not exceeding three drachms was administered on a napkin. A portion of chloroform from the same phial had been administered the day before to a patient without any unfavourable effects. About ten minutes elapsed from the commencement of its administration before death took place. On making a post-mortem examination, twenty-four hours after death, I found the face less livid than before death; on examining the head, the brain and its membranes presented no other appearances than are seen in persons dying when in full health; the lungs were a good deal congested, and discharged, when cut, a large quantity of bloody serum; the heart was large, its ventricles and auricles were empty, its condition flabby, the substance of the left ventricle rather softer than natural; about half an ounce of watery fluid was found in the pericardium; the viscera of the abdomen were healthy.’”
This case differs from those previously related in respect to the time at which the fatal occurrence took place. It was not till ten minutes from the commencement of inhalation, and when an operation which probably occupied two or three minutes had been performed, that the patient suddenly expired. The evidence of paralysis of the heart is, however, distinct enough in the absence of pulse at the wrist, and the livid hue of the countenance. In several of the previous cases, there was sudden pallor at the moment when the heart ceased to inject blood into the capillaries, but in a patient well supplied with blood, the sudden arrest of the action of the heart would cause turgescence of the veins and venous capillaries, which would be evident in the face in a few seconds. The syncope occasioned by paralysis of the heart differs from that kind of syncope which is caused by loss of blood, inasmuch as the right cavities of the heart are full in the former instance, and empty in the latter.
The circumstance of the patient having inhaled chloroform to insensibility three weeks previously, without accident or ill effects, is worthy of notice, as showing that the fatal event did not depend on any peculiarity of constitution.