“Three or four minutes passed while we were arranging his position and his dress, and while I was pointing out to those who were to assist me the proposed plan of operation. During this time the influence of the chloroform so far passed off, that he became sensible, displaced his coverings and pillows, said something expressive of discomfort, and vomited a small quantity of frothy fluid. (He had taken no food since the previous night, when he had had a good supper.) A very small quantity more of chloroform was slowly inhaled, and he became again nearly quiet, and was again placed on his side. I was on the point of commencing the operation, but as he again, by movements, indicated some degree of sensibility, and changed his posture, about forty drops more of chloroform were poured on cotton wool, inclosed in a fold of lint,—an inhaler, with the chloroform on sponge, having been previously used. The lint was held, about half an inch from the face, by Mr. Thomas Smith, my usual assistant in operations. The patient inhaled lightly for a few times, then made one long inspiration, and appeared to pass at once into deep sleep. Except that he thus appeared to come suddenly under the full influence of chloroform, no external change was visible; but, a few seconds later, his pulse, which had been carefully watched, and had been to this time normal, suddenly began to beat very quickly; then it ceased for two or three seconds; then beat rapidly several times, with a kind of flickering movement; and then ceased to be perceptible.
“Just before this change of the pulse was observed, the chloroform had been withdrawn. The one deep inspiration was followed by a few stertorous breathings, but after these he breathed naturally, his complexion and features showed no change, he seemed only calmly asleep, and in this state he continued breathing naturally, and with no change in his appearance, but pulseless, for at least a minute. Then his breathing became less frequent, and seemed as if it might soon cease; his face grew pale, and his lips very slightly livid.
“With the help of cold water sprinkled on his chest and face, and cold air blown on his face and throat, he was raised from this state of defective breathing in about two minutes, and again breathed deeply and freely, though slowly, (probably about twelve times in the minute.) He thus breathed for two or three minutes, and during this time the lips, and the pale or slightly livid parts of the face, became pink again, and though no pulse could be felt at the wrists, the heart was heard acting. During this time, also, some wine and brandy were poured into the mouth, and passed down the œsophagus, but without any evident movements of swallowing. His breathing again became gradually infrequent and feeble. Cold air and sprinkling with water, frictions and percussions of the chest, scarcely increased the breathing, and in less than two minutes it ceased. Artificial respiration, by the method of Dr. Marshall Hall, was immediately employed, and many times during the first five minutes of its employment the artificial inspiration obtained, when turning the body over to its side, was followed by a distinct, and sometimes even a full muscular inspiration. But at the end of about five minutes, these signs of life ceased, fæces escaped, and no more indications of life appeared, though the artificial breathing, the friction of the limbs, and other means for resuscitation, were continued for twenty or more minutes.
“I refrain, at present, from all comments on this case. Only, I wish to call particular attention to the fact that good breathing was maintained, and, after a suspension, was renewed, long after the heart had ceased to act with sufficient force to produce a pulse at the wrist. And I would add, that this narration is sanctioned and considered to be exact, by the four gentlemen who were to have assisted in the operation, and to whom I am greatly indebted for their counsel and assistance in the greater difficulty that we had to cope with.”[[122]]
Case 49. This case occurred in the Liverpool Infirmary on April 5, 1857, and is related by Mr. Allan, the resident officer who administered the chloroform. The subject of the case was a labourer, aged 35, on whom Mr. Bickersteth was about to perform amputation of the thigh on account of gangrene following the ligature of the femoral artery. He had inhaled the chloroform six days previously without ill effects, when the femoral artery was tied for popliteal aneurism. On the day of the accident, he was first rendered insensible in the ward by chloroform poured on a piece of lint which was held a short distance from the nose and mouth. Having partially recovered during his removal into the operating theatre, the chloroform was reapplied, and Mr. Allan relates what occurred as follows: “About half a drachm of chloroform was now poured on some lint, which was held to the nostrils, and he then became fully under the influence; respirations good; pulse frequent, feeble. The operation was about to be commenced, and I was pouring about twenty minims more chloroform on the lint, (having pronounced the patient to be in a fit state,) so as to be ready to give him some more as occasion required, but had not applied it, when, turning round, I noticed something peculiar in his general appearance, and, on lifting up the eyelid, found the pupil dilated, and the lid did not close over on the removal of the finger; the eyes were slightly turned up. I at once felt for the temporal artery, but there was no pulsation, and none detected at the left wrist; the respirations had almost ceased. The head was lowered, cold water was dashed on the face, and the abdomen struck with the palm of the hand; the finger thrust into the mouth (there was no action of the heart felt); the legs were elevated, and a wet towel was dabbed over the epigastrium. After one or two blows, the respirations became better, and seemed good, and in about two minutes a pulse was felt at the wrist. This continued between two and three minutes, the respiration being good. His pulse then began to fail, and in about a minute more the respirations were less. The tongue was seized with a pair of forceps, and drawn forwards, and artificial respiration tried, and ammonia held to the nostrils; but he was becoming livid in the face, so the Ready Method was at once adopted, and this produced apparently a few natural respirations. But the pulse had gone, and in about two minutes more there was no breathing save artificial. About the time that the pulse stopped, there was a convulsive movement of the muscles of the leg, and a slight clamminess of the skin succeeded. The Ready Method was continued for half an hour, and galvanism tried, but without avail. From the time he was placed on the table to his death, or the cessation of natural respiration, about ten minutes elapsed.”
The writer adds: “He apparently sank from syncope, or cessation of the heart’s action, for his respiration had been good just before he changed, and it continued for a second or two, though faint, when the pulse had stopped; and after the respiration had been restored, and was very good, the pulse was very feeble, and ceased two minutes before the respiration.”
At the autopsy on the following day, the brain was found to be healthy, tolerably firm, and pale; the lungs were healthy; the right cavities of the heart contained some fluid blood, which afterwards coagulated on exposure, and a small clot. The left cavities also contained some blood. The muscular tissue of the heart had an unhealthy look, and very readily tore, but no oil globules were discovered with the aid of the microscope.[[123]]
Case 50 occurred in King’s College Hospital, August 7th, 1857. The following is the account of the case furnished by Mr. C. Heath, the House-surgeon:—
“The patient [Ann Stoner] was a female, aged seventeen, under Mr. Partridge’s care, with syphilitic warts and mucous tubercles. She was admitted July 8th, and had had chloroform administered twice, in order that the sores might be touched with nitric acid, and, on both occasions, not the slightest ill effect was produced. On Friday evening last, chloroform was again administered for the same purpose; only a drachm was put into the inhaler (Snow’s), and as soon as she became unconscious the inhaler was removed, and the acid applied. I and my assistant (who administered the chloroform), then went to see another patient in the same ward, and then washed our hands, during which time the patient was moving her legs about much as they do when recovering, and in addition she made water over the bed. I gave directions to the nurse to apply a poultice as usual, and left the ward, having been up to the bed first without noticing anything unusual about the patient. In a few minutes the nurse came down for some medicine for another patient, and mentioned that this one was looking very pale: I sent up Mr. Liddon to see her at once; he found her pale and senseless, dashed some water over her, and called me, and I went up immediately. I found her pulseless and cold, and immediately commenced artificial respiration (Marshall Hall), and sent for the galvanic battery; this was brought and applied without effect, and the artificial respiration was continued for twenty-five minutes without the slightest effect being produced.”[[124]]
I was present at the examination of the body on the following day. The mouth was sore and swollen from the effects of the inunction of mercury. There were a few drachms of clear serum in the pericardium. The heart was large for the size of the patient. There was a patch of organised lymph on the pericardium, covering the left ventricle. The right cavities of the heart were full of dark fluid blood, and the left cavities contained a little. The mitral valve was much thickened, but the other valves were healthy. The lungs were healthy, and not much congested. The brain was healthy. The patient had suffered from acute rheumatism before entering the hospital.