There remain twenty-two cases in which the fatal symptoms came on during the course of the operation. In twenty of these cases the symptoms are described with more or less detail. I made some remarks respecting cases No. 1 and No. 2, in the place where they are related. In case No. 3, as in these cases, the patient appeared not quite insensible, and showed signs of pain during the operation, when “in a moment his pulse, which was full and natural, sank.” In case No. 5 the patient was probably dead when the incisions on the finger were commenced; the extreme suddenness of the death, and the absence of bleeding, show that death occurred in the way of syncope. The convulsive movements which just preceded death are worthy of note in connection with the other cases, in which death occurred immediately after the commencement of inhalation. Some remarks were appended to case No. 8. In case No. 10 paralysis of the heart is indicated by the absence of bleeding from the arteries, and the absence of pulse, whilst the breathing still continued for a short time. I made some remarks respecting case No. 12 when it was related. The patient seemed to die by embarrassed respiration, but whether that was caused by the action of the chloroform on the brain is doubtful. In case No. 13 the patient died in a moment. In No. 16 the face turned pale, and the pulse and breathing ceased soon after the chloroform was discontinued, showing the effect of the vapour which was present in the lungs at the moment when the inhalation was left off.
In Case 18 the livid countenance and sudden stopping of the pulse prove cardiac syncope. In Case 19 the blood which was gushing out suddenly stopped, and the patient expired. The congested state of the lungs and the blood in the right cavities of the heart prove that the syncope of which he expired was not the ordinary anæmic syncope from hæmorrhage; it was therefore cardiac syncope from the chloroform.
In Case 22 the change of countenance and sudden character of the death are evidences of cardiac syncope. In Case 23 there was sudden cessation of the bleeding and of the pulse; in Case 25 the pulse suddenly ceased. In Case 28 the patient died suddenly, but the pulse was apparently not examined at the time. Some remarks have already been made on Case 29, which happened in the Manchester Infirmary. In Cases 31, 36, and 38 the suddenness of the death showed that it took place by syncope. In the last of these cases the pulse was being examined at the time it ceased. In Case 36 there was no examination of the dead body; but in 31 and 38 the presence of blood in the right cavities of the heart indicates that the kind of syncope was cardiac syncope. Respecting Case 42, some remarks have already been made. The death commenced by deep coma, which embarrassed, and then suspended, the respiration, and cardiac syncope quickly followed. The chloroform was administered by a method which precluded the medical attendant from observing properly the most important symptoms.
The accompanying table of the fatal cases of the inhalation of chloroform contains such short particulars respecting them as seemed capable of being tabulated, and it may assist the reader in retaining a more connected recollection of the facts previously related more in detail.
MODE OF DEATH IN THE ACCIDENTS FROM CHLOROFORM.
In all the cases in which the symptoms which occurred at the time of death are reported, there is every reason to conclude, as shown above, that death took place by cardiac syncope, or arrest of the action of the heart. In forty of these cases the symptoms of danger appeared to arise entirely from cardiac syncope, and were not complicated by the over-action of the chloroform on the brain. It was only in four cases that the breathing appeared to be embarrassed and arrested by the effect of the chloroform on the brain and medulla oblongata, at the time when the action of the heart was arrested by it; and only in one of these cases (No. 42) that the breathing was distinctly arrested by the effect of the chloroform, a few seconds before that agent also arrested the action of the heart.
It was previously shown that chloroform vapour has the effect of suddenly arresting the action of the heart when it is mixed with the respired air to the extent of eight or ten per cent., or upwards; and we must therefore conclude that, in the fatal cases of its inhalation, the air the patients were breathing just before the accidents occurred contained this amount of vapour. There was no means adopted, so far as is reported, to regulate the proportion of vapour in the inspired air, in any case in which an accident happened; and there was the liability in every case that ten per cent. or more of vapour might be present in the air the patient breathed; and in no case did death occur in the manner that it occurs when the vapour of chloroform does not exceed five per cent. of the inspired air.
| TABLE OF FATAL CASES OF INHALATION OF CHLOROFORM. | ||||||||
|---|---|---|---|---|---|---|---|---|
| No. | Patient. | Age in yrs. | Operation for which the chloroform was inhaled. | Position whilst inhaling. | Means by which the chloroform was exhibited. | Time from the commencement of inhalation to the beginning of dangerous symptoms. | Apparent mode of death. | Previous inhalations. |
| 1 | Girl | 15 | Removal of toe-nail. | Sitting | Towel | Half a minute | Cardiac syncope | Ether once. |
| 2 | Married lady | 35 | Extraction of teeth. | Sitting | Inhaler | About two minutes | Cardiac syncope | None. |
| 3 | Patrick Coyle | Operation for fistula in ano | Lying on the side | Handkerchief | About one minute | Cardiac syncope | One. | |
| 4 | Single lady | 30 | Opening of sinus in thigh | Lying | Handkerchief | Probably half a minute | Cardiac syncope | None. |
| 5 | Young woman | Amputation of the middle finger | Handkerchief | A very short time | Cardiac syncope | None stated. | ||
| 6 | Young man | 22 | Transcurrent cauterisation of wrist | Inhaler | Five minutes | Symptoms not described | None stated. | |
| 7 | Young man | Intended removal of toe-nail. | Probably handkerchief | Not stated | Death very sudden | None stated. | ||
| 8 | Seaman | 31 | Removal of hæmorrhoids | Lying on the side | Napkin | About ten minutes | Cardiac syncope | One. |
| 9 | Miner | 17 | Intended amputation of middle finger | Lying | Handkerchief | About five minutes | Cardiac syncope | None. |
| 10 | Labourer | 36 | Amputation of toe | Handkerchief | Died at the close of the operation | Cardiac syncope | A previous attempt. | |
| 11 | Married lady | 33 | Intended extraction of tooth | Sitting | Handkerchief | A very short time | Cardiac syncope | One. |
| 12 | Porter | 48 | Removal of toe-nail | Lying | Inhaler | A little more than two minutes | Probably asphyxia | None. |
| 13 | Married woman | Removal of eyeball | Probably lying | A sponge | Died during the operation | Cardiac syncope | None stated. | |
| 14 | Young lady | 20 | Intended extraction of tooth | Sitting | A sponge enclosed in a napkin | Just after beginning to inhale | Cardiac syncope | Previous attempts. |
| 15 | A man | A sponge | Died before the operation | Probably cardiac syncope | None. | |||
| 16 | Artilleryman | 24 | Amputation of middle finger | Handkerchief | Cardiac syncope | None. | ||
| 17 | Bookkeeper | 30 | Intended operation on testicle | Lying | Napkin | Within five minutes | Cardiac syncope | None. |
| 18 | Boy | 8 | Sounding the bladder | Lying | Piece of lint | A few minutes | Cardiac syncope | None. |
| 19 | Policeman | 34 | Removal of portion of hand | Napkin | Died during operation | Cardiac syncope | None. | |
| 20 | Man | 24 | Intended amputation of leg | Lying | Folded lint in a hollow sponge | A few minutes | Cardiac syncope | None. |
| 21 | Man | Intended operation on the penis | Lying | “Suddenly expired” | None stated. | |||
| 22 | Married lady | 36 | Extraction of teeth | Sitting | Handkerchief | Less than a minute | Cardiac syncope | None. |
| 23 | Mulatto seaman | 45 | Removal of testicle. | Lying | Napkin | About seven minutes | Cardiac syncope | None. |
| 24 | Married woman | 37 | Removal of impacted fæces | Lying | Handkerchief | Eight or nine minutes | Symptoms not observed | Two. |
| 25 | Man | 23 | Ligature of vessels near vascular tumour | Lying | Inhaler | Five to ten minutes | Cardiac syncope | One. |
| 26 | Married lady | 32 | Intended extraction of tooth | Sitting | Sponge surrounded by handkerchief | Four or five inspirations | Cardiac syncope | None stated. |
| 27 | Man | Intended operation for fistula in ano | Lying | Handkerchief | Not more than a minute | Cardiac syncope | None. | |
| 28 | Cattle dealer | Applic. of potassa fusa to ulcers of leg | Handkerchief | Died during operation | Probably cardiac syncope | None. | ||
| 29 | Factory operative | Removal of malignant tumour of thigh. | Lying | Inhaler | About twelve minutes | Probably cardiac syncope | None. | |
| 30 | Single woman | 28 | Intended application of nitric acid to ulcers of pudenda | Lying | Folded lint | Cardiac syncope | None. | |
| 31 | Soldier | 25 | Removal of small tumour from cheek | Lying | Hollow sponge | Five minutes | Cardiac syncope | None. |
| 32 | Tobacconist | 43 | Intended perineal section | Lying | Handkerchief | A few minutes | Cardiac syncope | Two. |
| 33 | Woman | 40 | Intended operation for strangulated hernia | Lying | Folded lint | About five minutes | Simultaneous deep coma and cardiac syncope | None. |
| 34 | Single woman | 22 | Intended application of actual cautery to sore of vagina | Lying | Inhaler | About five minutes | Cardiac syncope | One. |
| 35 | Young man | 19 | Intended forcible extension of knee | Lying | Inhaler | Fifty seconds | Cardiac syncope | None. |
| 36 | Girl | 13 | Removal of tumour from back | Apparently sitting | Cardiac syncope | None stated. | ||
| 37 | Married woman | 59 | Intended reductionof old dislocation of humerus | Lying | Hollow sponge | About five minutes | Deep coma and cardiac syncope | None. |
| 38 | Woman | 40 | Removal of uterine polypus | Lying | Folded lint | A few minutes | Cardiac syncope | None stated. |
| 39 | Married woman | 45 | Intended removal of breast | Lying | Sponge, handkerchief, and inhaler | Three-quarters of an hour. | Cardiac syncope | None. |
| 40 | Tailor | 18 | Intended operation for phymosis | Lying | Inhaler | About seven minutes | Cardiac syncope | None. |
| 41 | Labouring man | 65 | Intended amputation of thigh | Lying | Inhaler | Between 13 and 14 minutes | Cardiac syncope | None. |
| 42 | Shoemaker | 39 | Catheterism | Lying | Folded lint | A few minutes | Deep coma, apnœa, and cardiac syncope | None. |
| 43 | Woman | 56 | Intended amputation of leg | Lying | Folded lint & piece of oiled silk | About three minutes | Cardiac syncope | None. |
| 44 | Man | 40 | Intended excision of eyeball | Lying | Inhaler | About five minutes | Cardiac syncope | None. |
| 45 | Married lady | 29 | Inhaled to relieve neuralgia | Sitting | Inhaler | A few seconds | Cardiac syncope | Two or three. |
| 46 | Married lady | 36 | Intended extraction of teeth | Sitting | Handkerchief | A few seconds | Cardiac syncope | Four. |
| 47 | Sailor | 30 | Intended removal of necrosed bone from finger | Sitting | Sponge and folded lint | Three or four minutes | Deep coma and cardiac syncope | None. |
| 48 | Boy | 9 | Intended removal of tumour of scapula | Lying | Cotton wool & folded lint | A few minutes | Cardiac syncope | None. |
| 49 | Labourer | 35 | Intended amputation of thigh | Lying | Folded lint | A few minutes | Cardiac syncope | One. |
| 50 | Young woman | 17 | Application of nitric acid to syphilitic sores | Lying | Inhaler | Symptoms not observed | Two. | |
There is in a great number of the cases an evident connection between the accident and the probable strength of the mixture of vapour and air. In six cases the accident occurred just after the commencement of the inhalation; in two of the cases, Nos. 27 and 37, the fatal symptoms occurred just after fresh chloroform had been applied on the handkerchief and sponge; and in several cases, in which the circulation was suddenly arrested just after the patient had been rendered insensible, the insensibility had been induced so quickly as to prove that the vapour must have been inhaled in a very insufficient state of dilution.