Case 22 is important, as having given rise to a prosecution. The medical man, an officier de santé, named Kobelt, was accused of homicide, by imprudence, want of precautions, &c. The chloroform was administered on a handkerchief, and the accident occurred as suddenly as any of the others. The husband of the patient stated that the whole process did not last a minute. “I observed attentively,” he said, “during this time, and the character that her countenance took all at once made me apprehensive. I spoke of it to the operator, who tranquillized me, and continued to extract the teeth. After the third tooth, however, he partook of my apprehension, suspended the operation, and proceeded to adopt measures indicated by the circumstances.” Professor Sédillot, who had to pronounce an opinion on the case, after hearing all the evidence, said, “I do not think that M. Kobelt is guilty of imprudence or of rashness, because that officier de santé has followed a practice very habitually employed, and even recommended, by eminent practitioners, whose example and authority were sufficient to inspire him with security, and shade him from reproach.” The accused practitioner was acquitted. The above remark of Sédillot applied to the plan of causing insensibility very rapidly, as first recommended by Dr. Simpson; and he added some observations, to the effect that, when used in a different manner, chloroform is free from danger.
The above case occurred at Strasbourg, on June 10th, 1851. The name of the patient was Madame Simon, and her age thirty-six. After death the lungs were found to be somewhat congested, and emphysematous. Heart flaccid, of middle size; right cavities filled with liquid dark-coloured blood, mixed with some fibrinous clots. The left cavities contained similar blood in much smaller quantity.[[89]]
Case 23 occurred on July 8th, 1851, at the Seaman’s Hospital, Greenwich. The patient was a light-coloured mulatto, aged forty-five, native of New York. He died during the operation of removing the left testicle, which was disorganized by suppuration. “The chest had been carefully examined a few days previously, both by percussion and auscultation. No physical signs of disease were detected. His pulse was regular and feeble, about seventy. He was rather nervous, and fearful of the operation. No arcus senilis. After taking a glass of wine he commenced the inhalation, twenty minims of chloroform having been poured on a linen cloth. At the expiration of a few minutes, this had been dissipated, producing only very trifling excitement; a second dose, of the same quantity, was then administered in the same way; the man began to sing and shout, his expressions relating to the firing of guns. The second quantity having been exhausted, and the effects of the chloroform becoming more apparent, but sensibility being still perfect, and even intelligence almost unaffected, a third quantity, of ten minims, was poured out, and, afterwards, twenty minims more. Having passed through the usual convulsive stage, and insensibility being established, the further administration of chloroform was desisted from at the end of about seven minutes, though this time is merely guessed at; it might have been more, but was certainly not less. At this time the respiration was unembarrassed, and the pulse regular, and about seventy, with as much volume as before the inhalation. The lips were florid; in fact, the chloroform appeared to have acted in the most benign way. Mr. Busk commenced the operation by an incision through the scrotum, which divided a small arterial branch, and some enlarged veins, from which the blood flowed pretty freely. The flow, however, almost instantaneously ceased, and Dr. Rooke, who kept his finger on the man’s pulse, found that cease at the same moment. Respiration appeared to cease almost instantaneously with the heart’s action. Regular respiration at least did; for, while we were looking at the man’s face, he fetched one or two sigh-like inspirations. The ribs and abdomen were compressed, so as to induce inspiration and expiration; the lungs were inflated by blowing through the nostrils, the larynx being compressed against the spine, and, for three or four minutes, upon our efforts being suspended, the man occasionally took an inspiration; on one occasion three or four in succession, so as to make us flatter ourselves that he would come round.... It is worthy of remark that, for a long time after spontaneous respiration had ceased, the lips retained a florid colour. The muscles were all relaxed, and the veins on the side of the neck turgid.”[[90]]
At the inspection of the body next day, the vessels of the dura mater, and those on the surface of the brain, were gorged with fluid blood. The lateral sinuses also afforded a flow of dark-coloured blood. There was a considerable quantity of serous fluid in the cavity of the arachnoid and in the spinal sheath. The substance of the brain was very soft. (The weather was warm.) The lungs were of a dark purple colour posteriorly, and much loaded with fluid blood and serum, but were everywhere crepitant and healthy. The external surface of the heart was covered almost entirely with fat; in some parts to a considerable thickness. There were two fibrinous spots on its surface. No fluid in the pericardium. The venæ cavæ were full of fluid blood. On removing the heart, a white fibrous coagulum, about as big as a walnut, was found in the commencement of the pulmonary artery. The heart was uncontracted, and the cavities contained a very small quantity of dark fluid blood. The walls of the right ventricle, and of the left auricle, were thinner than natural. Some portions of the substance of the heart were paler than natural:—“In these paler portions of the muscular substance, the fibres had, for the most part, lost their striated aspect, and had become converted into a fine granular material contained in the sarcolemma. Here and there a minute oil-globule could be observed in the muscular fibrillæ, but nowhere did this amount to fatty degeneration.”
In this case all the precautions appear to have been taken which are possible in making a patient insensible with undiluted chloroform, administered on a handkerchief; and the case, therefore, strongly confirms the proposition that chloroform cannot be administered in this way with perfect safety.
The patient was apparently in the most satisfactory condition at the conclusion of the inhalation, and yet, a few seconds afterwards, the heart suddenly ceased to beat, from the effect, as we must conclude, of that portion of vapour which was in the lungs at the moment when the inhalation was discontinued.
Case 24 occurred in October, 1851, at Chipping Norton, Somerset, to a patient of Mr. Farwell, named Elizabeth Hollis, and aged 37. No one observed the manner in which the breathing and circulation ceased, and, as the patient was in a state of extreme debility, it is not quite certain that the chloroform was the sole cause of death. It was administered to prevent the pain of removing the fæces, which became impacted in the rectum on account of extensive cancerous disease of the uterus and vagina. The surgeon reports that “the time occupied in the inhalation was about eight or nine minutes; quantity inhaled 10½ drachms, half a drachm at a time, allowing her frequently to breathe the atmospheric air. She spoke to me during this period. When I found that her arm fell after being raised, I proceeded to and accomplished the operation. At this time she was not inhaling. I then, as I always do, wetted the face with a sponge, with the view of washing off any remaining chloroform from the nose and lips, when, to my surprise, I found that she had ceased to breathe, and all attempts to restore her were in vain.... When I commenced the operation, the pupil was contracted, and the conjunctiva slightly red. After death, the pupil was very dilated, and the countenance extremely pallid.”[[91]] There was no inspection of the body. This patient had inhaled chloroform on two previous occasions for a similar operation.
Case 25 occurred in St. Bartholomew’s Hospital, on March 17, 1852. Thomas Hayward, aged 23, was suffering from aneurism by anastomosis, occupying the right ear and its neighbourhood. He had inhaled chloroform on the 14th of the previous month, whilst Mr. Lloyd placed ligatures on the temporal artery and some other arteries supplying the tumour; and it was with a view to tie an additional artery, situated between the mastoid process and the ramus of the jaw, that chloroform was again administered.
“The chloroform was some of the same, and the apparatus employed for its administration precisely similar [alluding to the former occasion.] It was administered by one of Mr. Lloyd’s dressers, who well understood, and had great experience in its use. A gentleman of great experience, who had been for years at the hospital, and two years house-surgeon, was watching its effects, and marking the state of the pulse. Other gentlemen were assisting, and also on the look out.
“In from five to ten minutes the usual effect was produced, the patient having previously struggled much. The operation was then commenced; but no sooner had Mr. Lloyd cut the skin, than it was stated that the pulse had suddenly ceased. The chloroform was at once removed; but in a few seconds, the patient had ceased to breathe, and no pulsation could be felt at any of the arteries or the heart.