Dr. Aschendorf has attributed the death of a child a year old to chloroform.[[129]] The child had a nævus on the face and neck, which extended from the zygoma to the os hyoides, and from the external auditory meatus to the maxillary fossa. No one had been willing to undertake its removal. Dr. Aschendorf operated on the nævus at three different times, by means of seton threads. These operations were performed under the influence of chloroform. The tumour was reduced one-third part in size by these means, and eleven weeks afterwards Dr. Aschendorf determined to extirpate it. The chloroform was administered as on the former occasions, by placing six drops on some tow in a cup. In about ten minutes, as the child cried a little, three drops more of chloroform were used for inhalation, and in about eight minutes more the operation was concluded. “On raising the child it laid its head on one side, convulsive twitches of the face were observed, with distortion of the eyeballs and dilatation of the pupils. For one moment the arms were stretched out stiff, then again they were relaxed, and fell as supple as the rest of the body. Death quickly followed—only one pulsation of the heart and a single râle with the expiration being perceived.”
There can be no doubt of this being a case of death from hæmorrhage, after the direct effects of the chloroform had subsided. Dr. Aschendorf says the quantity of blood lost was about two tablespoonfuls; but it would be necessarily removed by sponges during the operation, and there would be no means of estimating the quantity. The child was probably in a state of syncope during the latter part of the operation, as it would not remain insensible to the knife for eight minutes from a single application of chloroform.
On September 15th, 1852, a patient died to whom I was administering chloroform whilst Mr. Cæsar Hawkins was performing lithotrity. He was a gentleman from the country, aged seventy-three; he was tall and stout, he had a weak intermitting pulse, and a well marked arcus senilis in each cornea. He had inhaled chloroform five or six times, between May 1850 and May 1851, for the same operation, when under the treatment of another surgeon, and it always acted favourably. In the first week of December 1851, Mr. Hawkins performed the operation of lithotrity twice, when the chloroform was administered by Mr. Geo. D. Pollock. On the second of these occasions he became faint during the operation whilst under the influence of the chloroform, but recovered from the faintness before its conclusion. He again fell into a very alarming state of syncope a few minutes after the conclusion of the operation, but rallied, and vomited the breakfast which he had taken a little time before. I first administered the chloroform to this patient on December 15th, 1851, eleven days after the above occurrence. Mr. Hawkins and I were inclined to think that the alarming syncope on the previous occasion might have been connected with the sickness which occurred. It was my firm belief that the patient had fatty disease of the heart; but I did not see any great objection to the chloroform on that account, as I had frequently given it in similar cases, and always with a favourable result. On this occasion (December 15th) he inhaled the chloroform before breakfast. Its effects were quite satisfactory, and it was not accompanied or followed by any unpleasant symptoms whatever. The operation was repeated four days afterwards, when I again exhibited the chloroform with like favourable results. After this the patient went back to the country relieved from his stone. He came back, however, in the autumn of 1852, with a return of his complaint, and I was again requested by Mr. Hawkins to assist him by giving the chloroform on September 15th.
The patient became insensible, without any excitement or struggling, in the course of three or four minutes, and the operation was commenced. A little more chloroform was administered two or three times during the operation, in order to keep up the insensibility. After a few minutes had elapsed, I observed that the face and lips of the patient became pale. At this time he had not inhaled any chloroform for about two minutes. Immediately afterwards, however, his face became red, and he made straining efforts with the muscles of respiration, as if he were beginning to feel the operation. To prevent his becoming altogether sensible, therefore, I commenced to give him a little more chloroform, with the valve of the inhaler about one-third open, as on the former occasions. He had only taken two or three inspirations, however, when the breathing ceased. He appeared to be merely holding his breath, as sometimes happens during the exhibition of chloroform, and I expected that he would begin to breathe again in about a quarter of a minute. In the meantime, I endeavoured to feel the pulse in the temporal artery, but did not perceive any. Instead of the breathing recommencing at the time I expected, the countenance became suddenly pale, and a little afterwards rather livid. I applied my ear over the region of the heart, but could not hear any sound. After a few seconds, however, the patient took a rather deep inspiration, and immediately after this I was pretty sure that I heard the heart beating very feebly and rather frequently, but only for a few seconds, after which no sound could be heard. There were one or two more very feeble inspirations at intervals of about a quarter of a minute, after which there were no further signs of life. As soon as the patient had entirely ceased to breathe, artificial respiration was performed, but no sign of returning animation appeared.
At the examination of the body fifty-two hours after death, the heart was found to be larger than natural, and there was a good deal of fat on its surface. Its right cavities contained air or gas, probably resulting from the partial decomposition of the blood. The right ventricle was dilated, and its walls were very thin. At one place, near the apex, they were extremely thin. The left ventricle was also dilated, but its walls were of the proper thickness. They were, however, like those of the other ventricle, very soft and friable. There was a calcareous incrustation on one of the aortic valves. There was scarcely any blood in the heart, but its lining membrane was stained in places, showing that blood had been present after death.
Mr. Pollock and the late Mr. W. F. Barlow examined the structure of the heart under the microscope, and the latter gentleman furnished me with the following account of the examination:—
“Many of the fibres have been converted into fat completely; in others, fatty degeneration was beginning. The degeneration, which was in various stages, appeared very general. The fasciculi were broken up, here and there, into masses of small irregular fragments, as they may be found frequently in hearts of this kind. Some large fat globules lay between and upon the fibres. A few fibres showed their transverse striæ plainly, and made the changes in the others look the clearer. On the whole, it may be said that the structure of the organ was greatly damaged, and that its action, consequently, was liable to cease suddenly from slight causes.”
I am of opinion that this patient did not die from the direct effects of the chloroform. The air he was breathing just before he died did not contain more than three or four per cent. of vapour of chloroform at the utmost, and he had previously breathed quite as much, both during the same operation and on previous occasions. The patient seemed to be holding his breath at the moment when his heart ceased to beat; and it is whilst holding the breath, and making a straining effort, that patients labouring under disease of the heart not unfrequently expire. Mr. Pollock, who was present when the patient died, expressed to me his belief that he died of his heart disease, and not of the chloroform.
After reflecting on this case, I see no reason to regret the course which was pursued. It was the opinion of Mr. Hawkins that the patient could not have borne the operations without the chloroform; consequently, if we had decided not to permit its use any more, in consequence of the alarming syncope which occurred after the operation under its influence on December 4th, 1851, he would probably have died in great suffering from the calculus, instead of having seven or eight months freedom from the complaint. And, on the other hand, if it had been decided to operate without chloroform, it by no means follows that the patient would have been in less danger, judging from what I have observed of the effect of pain on the circulation, as compared with the effect of the chloroform carefully administered, in numerous other cases of disease of the heart.
On May 11th, 1854, a patient died suddenly in St. George’s Hospital as she was beginning to inhale chloroform. She was a pale and delicate looking woman, aged thirty-seven, from whose left breast Mr. Cæsar Hawkins was about to remove a mammary glandular tumour. “On entering the operating theatre she appeared nervous. Having been placed on the table on her back, in a half reclining position, the administration of chloroform was commenced. Dr. Snow’s inhaler was used. The quantity of chloroform placed in the receiver was a little more than a drachm; and the valve for the admission of air was left wide open. Apparently, from excitement, she did not inhale well, but drew her breath by deep catches, and irregularly. Mr. Potter, noticing this, spoke to her, begging her to compose herself, and try to breathe more quietly. The valve was then slightly turned on, in order that she might inhale but a very small quantity of chloroform. The same spasmodic efforts at inspiration still continued; very shortly afterwards, at most not more than a minute and a half from the commencement of the inhalation, Mr. Potter noticed her breathing to suddenly cease, and that she had become deathly pale. The inhaler was at once removed. On placing the finger on the wrist, no pulse could be found. Endeavours to arouse her by dashing the face and chest with water were immediately adopted; but, proving ineffectual, artificial respiration was commenced within a minute of the first symptoms. During the interval, two sighing attempts at inspiration had been observed; but there had been no pulse whatever; the mouth lay a little open, and the countenance was still extremely pale.”[[130]] Other attempts at resuscitation were made without effect.