The partial recovery of the patient is a remarkable feature in this case, and it is difficult to explain why he did not recover completely. The number of the pulsations during this partial recovery is mentioned, but not their quality, and I cannot help supposing that the pulse must have been extremely weak, as well as slow, at this period. The ten minutes during which the pulse and breathing returned is mentioned with the qualifying term of “perhaps”, which leads to the supposition that it was not noted by the watch or clock, and under such circumstances of anxiety and suspense, the time might be very much over-rated. The slight fatty degeneration of the heart might probably interfere with the complete recovery of the patient, after this organ had once been paralysed by the chloroform.
Case 41 took place on July 13th, 1854, in the Middlesex Hospital. The patient was a stout, muscular, and florid man, 65 years of age, on whom Mr. De Morgan was about to perform amputation at the upper part of the thigh, on account of a large malignant tumour growing from the inner side of the femur.
“Chloroform was administered by Mr. Sibley, the registrar to the hospital. Snow’s inhaler was employed. The quantity at first placed in the inhaler was rather less than two drachms, and another drachm was added eight minutes afterwards. The patient inhaled the chloroform without difficulty, and went through the usual stages; at the end of about ten minutes violent spasm was induced; this continued about three minutes, and then somewhat abated. The pulse, which had risen to about 120, descended to 70, having a full, steady, and deliberate beat. The pupils, which had been much dilated, became less so. The respiration continued free and deep, but not stertorous. The colour of the face remained good.
“At this moment, which was between thirteen and fourteen minutes from the commencement of the inhalation of the chloroform, the pulse gave a few rapid and irregular beats, and then ceased. Respiration, which, as has been stated, had been going on freely, ceased simultaneously. The face became suddenly pallid and deathlike. The inhaler was removed instantaneously, and cold water dashed on the face. Mr. Sibley immediately commenced to carry on artificial respiration, by applying his mouth to that of the patient, and inflating the lungs. The period that elapsed between the sudden cessation of the pulse and the inflation of the lungs was only a few seconds. After a few inflations, there appeared to be a slight effort at inspiration, but this was the only sign of life discovered after the syncopal attack. Galvanism was in operation within two minutes after the cessation of the pulse.”
“An examination of the body was made by Dr. Corfe forty-eight hours after death. In the head nothing particular was discovered; the brain was firm, and rather more vascular than natural; the blood in the sinus was partly coagulated; the heart was rather larger than natural, and was extremely loaded with fat, especially on the right side, where fat formed three-fourths of the thickness of the wall of the ventricle; the muscular tissue was extremely pale and soft, and exhibited both to the naked eye, and the eye assisted by the microscope, an extreme degree of fatty degeneration; the blood in the cavities of the heart was firmly coagulated; on both sides it was almost purely fibrinous; the clot on the right side was larger than on the left; a fibrinous clot extended down the aorta.”[[113]]
I do not know how the bibulous paper was arranged in the inhaler in this instance, nor whether the inhaler was used with a view to regulating the amount of vapour in the inspired air. The proportion of vapour must have been small during the first ten minutes, as the patient became so slowly insensible; and judging from the result, we must conclude that the proportion was large just before the accident. The firm coagulation of the blood and separation of the fibrin were probably owing to the galvanism which was so promptly applied. I found the fibrin separated from the colouring matter of the blood in the cavities of the heart of a cat, in which shocks of electro-magnetism had been sent through the chest just after it had been killed with chloroform.
Case 42. A man died whilst inhaling chloroform in University College Hospital on October 11th, 1854. The patient was a shoemaker named George Sands, aged 39, and of rather bloated aspect. He inhaled chloroform whilst Mr. Erichsen was endeavouring to introduce a catheter, and had the intention of puncturing the bladder if not successful. The patient was made insensible, and the chloroform was left off, but was reapplied on account of the patient making some expression of pain. “Probably about two minutes of the second inhalation had elapsed, when the man became profoundly insensible, and began to snore with a peculiar and very profound stertor. His face at this time was suffused and flushed, and the inspirations were drawn at rather prolonged intervals. Mr. Erichsen’s attention was at once excited by these symptoms, and, desisting from the use of the catheter, he immediately commenced dashing the patient’s face and chest with water. The chloroform had, of course, been removed. In the course of about a minute, the noise with the breathing gradually lessened, and it became apparent that the respiration was ceasing altogether. Mr. Erichsen now put his finger into the patient’s pharynx, and dragged forwards the root of the tongue; at the same time attempting artificial inflation of the lungs, by applying his own mouth to that of the man. The latter plan did not appear to succeed well, and was almost immediately substituted by the more usual mode of artificial respiration, by compression of the chest, which was kept up most vigorously. The man’s pulse had been felt by the administrator [Mr. Carnell] to be still beating some little time after the commencement of the alarming symptoms and the cessation of respiration. Artificial respiration had been employed for about four minutes, when the man, whose countenance had meanwhile retained its colour and an expression of yet remaining life, began to breathe again. A very short intermission of artificial assistance having been made, he drew spontaneously three or four inspirations; but, as each successive one was more feeble, the artificial aid was at once recommenced. About five minutes from the commencement, the galvanic apparatus was got in readiness and applied. It produced, however, no benefit; and from this time the patient lost colour in the face, and was evidently dead.... The form of inhaler which had been employed was the one in ordinary use at this hospital, viz. a folded piece of lint. The administrator’s hands and the patient’s face had been covered during the inhalation by a towel.”[[114]]
At the examination of the body seventy hours after death, extensive fatty degeneration of the heart was met with. The cavities of the heart were empty, owing, no doubt, to the artificial respiration.[[115]]
The above case differs to a certain extent from those previously quoted, inasmuch as the first symptoms of danger were those of profound coma, and of threatened death by apnœa, as a consequence of the action of the chloroform on the medulla oblongata and nerves of respiration. In addition to this cause of danger, however, the chloroform present in the lungs at the moment when the inhalation was discontinued must have acted directly on the heart, or the prompt assistance of so able an authority on asphyxia as Mr. Erichsen, the moment the breathing was suspended, would surely have restored the patient. The mode of death, although not exactly the same as that in Experiment 24 (page 110), differs from that in the previous experiment, where the heart’s action was good and distinct after the breathing ceased; it resembles the mode of dying in many animals that I have killed with chloroform; being, in fact, a combination of death by apnœa and cardiac syncope, which generally occurs when the quantity of vapour in the respired air is intermediate between that in Experiments 23 and 24, or somewhere between 5 and 10 per cent.
A great peculiarity in the way in which chloroform was administered in the case we are considering was that the head and face of the patient were covered by a towel, under which the lint wetted with chloroform was held. The countenance and state of respiration could not be observed in this mode of giving the chloroform; the person administering it had to depend almost entirely on the pulse; and, except for this cause, there is every reason to conclude that the chloroform would have been withdrawn in this instance in time to save the patient. It was not apparently till a peculiar and very loud stertor attracted the attention of the operating surgeon himself, that the inhalation was discontinued, and the face was already suffused.