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"The recent death from chloroform at Bristol"

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British Medical Journal
(20 March 1858): 223-25

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By John Snow, M.D.

The account of the accident from chloroform in the British Medical Journal of March 13th, shows that death took place by paralysis of the heart. As Dr. Wm. Budd said, the patient "died from the primary action of the chloroform on the cardiac ganglia, whereby the action of that single muscle, on which all the functions of life depend, was instantly stopped." But this has been the mode of death in every accident from chloroform, the particulars of which are related. In six of the recorded cases the paralysis of the heart took place, as in the recent case at Bristol, without insensibility having been previously induced. In the remaining cases, however, the patients were rendered more or less insensible before the fatal accident occurred; and in four cases there was an evident over action of chloroform on the brain, in addition to its fatal action on the heart. One of these four was the previous fatal case which occurred in the Bristol Infirmary, on January 21st, 1854. The patient was a woman, aged 59, with an old dislocation of the humerus. She inhaled one drachm of chloroform from a hollow sponge. "Nothing unusual occurring in the patient's condition during inhalation, a second drachm, in about five minutes from the first, was poured upon the sponge, and the inhalation was continued. Almost immediately after the addition of the second drachm, the chloroform was withdrawn, as the patient's breathing became stertorous; and immediately afterwards her pulse, which had hitherto continued pretty firm, was suddenly imperceptible, the respiration ceasing at the same time." (Association Medical Journal, 1854, p.109.) The chloroform in this instance acted directly on the heart, as well as on the brain, otherwise the pulse would have continued for some time after the natural and ordinary breathing had ceased. The pulse has continued after the breathing in one or two accidents from which the patients have been restored by artificial respiration; and it is most probable that it has done so in the three or four cases in which persons lost their lives by imprudently inhaling chloroform when no one was present. [223/224]

The mode in which death takes place when the vapour of chloroform is continued of the strength in which it can safely be administered to a patient, is for the breathing to become embarrassed before it ceases, and for the pulse to go on beating for one, two or three minutes afterwards. An animal can easily be restored by artificial respiration during the interval whilst the heart is still beating; and there are besides often one or more deep gasping inspirations just at the moment when the heart is ceasing to beat, which often have the effect of restoring the creature to life if the chloroform have been withdrawn. The proper strength at which the vapour of chloroform should be inhaled, is four or five per cent of vapour to 95 or 96 per cent of air. With vapour of this strength, I feel very confident that no accident from chloroform would happen in the hands of a careful attentive medical man.

With air containing twice the above quantity of vapour of chloroform, animals can be killed by sudden paralysis of the heart, and they die exactly like the patients who have suffered fatal accidents from this agent. When small animals are placed in air containing ten per cent of vapour, they die suddenly in a state of agitation, if they have previously been made insensible by vapour of a weaker strength. There is every reason to conclude that all the patients who have died from chloroform in the presence of a medical man, have breathed the vapour just before the accident of much more than the proper strength; probably of not less than eight or ten per cent. I believe that there has been no death really due to chloroform in any case where the medical man was making any attempt to regulate the percentage of vapour in the inspired air. When a drachm of chloroform is poured in a hollow sponge, it is quite possible that a patient may breathe air containing eight or ten per cent of vapour. One hundred cubic inches of air at 60┬║ Fahr. will take up fourteen cubic inches of vapour of chloroform when fully saturated, and the resulting compound will contain twelve per cent of vapour. It is quite true, that the air which passes over a sponge or handkerchief does not usually get fully saturated, and that the patient often breathes a good deal of air which has not come in contact with the wetted part of the handkerchief or sponge; the air passages, moreover, often refuse air which contains a large amount of vapour, and for these reasons patients may commonly breathe chloroform from a handkerchief or sponge without accident. There is, however, always some risk of accident when it is endeavoured to make a patient completely insensible in this way, as the amount of vapour in the inspired air cannot be regulated with any approach to accuracy. The persons who administer chloroform in this manner do not get uniform results; they are not aware that the effects of chloroform are as exactly in proportion to the quantity which enters the lungs of the patient, as the wound is in proportion to the depth to which the surgeon's knife enters the flesh. Patients are supposed to be more or less susceptible of the effects of chloroform irrespective of their evident physical condition, and when a fatal accident occurs, it is usually attributed to some peculiarity in the patient.

Out of fifty recorded cases of death from chloroform, however, eleven of the patients are related to have previously inhaled it, and been made insensible by it, without ill effects. It is not probable that more than twenty-two per cent of the persons who have hitherto inhaled chloroform, have inhaled it more than once; and, therefore, those with whom it has been proved to agree, seem quite as liable to accident as others, a circumstance entirely confirming the view, that accidents do not depend on any peculiarity of the patient who suffers them.

In the fatal case which occurred in Bristol in 1854, the coronary arteries were diseased, and a considerable proportion of the fibres of the heart were found in a state of incipient fatty degeneration. This amount of disease of the heart is, I believe, not at all uncommon in patients who inhale chloroform for surgical operations; and in the recent case in the Bristol Infirmary, the affection of the heart was so slight, that Dr. Budd says there was nothing in the slightest degree to account for the accident. The only patient I have lost whilst inhaling chloroform (Medical Times and Gazette, 1852, vol. ii. p.361), had, indeed advanced fatty degeneration of the heart, of which we were aware during his life. But it is my opinion that he died of his heart-disease, and not of the chloroform. His pulse ceased whilst he was straining to hold his breath, as if he were beginning to be affected by the pain of the operation. This case has not prevented me from administering chloroform to every other patient with symptoms of disease of the heart who has come before me, and has required to undergo a surgical operation. Whilst I admit that fatty degeneration of the heart is by no means a desirable accompaniment to the inhalation of chloroform, I consider that it offers a strong reason why the patient should not be subjected to a painful operation without the use of this or some other narcotic vapour. I have frequently observed that the pulse intermits, and the sounds of the heart are entirely suspended, for as much as five seconds at a time, when a patient is straining under the pain of a trifling operation, such as the ligature of the varicose veins, and I consider that such a state of the circulation would be much more dangerous to a weak or fatty heart than the effects of chloroform when carefully administered.

Some alteration in the condition of the heart can very often be found when looked for after death, and has been met with in many of the persons who have died from the effects of chloroform; but there are only four cases out of the whole fifty in which fatty degeneration of the heart is reported to have been decidedly present, and only in one of these in an extreme degree; and I think it not improbable that this complaint has been as frequently present in the patients who have inhaled chloroform without accident. According to my experience, extreme debility, and early infancy, and extreme old age, offer no objection to the use of chloroform. The patients who are least suited for it, in my opinion, are robust and athletic men; they are the most difficult to bring under its influence, and require the most care to avoid accident. They are, however, the persons who least require to be rendered insensible for slight operations. Out of fifty-one accidents which have happened from chloroform, thirty have occurred in the male sex, although females inhale the agent nearly twice as often as males, according to my experience. Infancy and old age have been singularly free from accidents from chloroform; and in proportion to the numbers living in each decennial period, the greatest number of accidents have happened between the ages of 35 and 45, when the frame is usually the strongest and most robust.

I am in the habit of using an inhaler which has been described in this Journal; but I do not consider that its use will prevent accidents, unless it is employed for the purpose of regulating the amount of vapour in the air. If the bibulous paper is arranged the same in July as in January, and the valves are employed in the same manner, it would be very likely that it might lead to accident. Persons who are unwilling to give the subject of chloroform any great scientific consideration, may yet cause insensibility with it by means of a handkerchief or hollow sponge, without risk of accident, if they first dilute it with an equal measure of rectified spirit. I have frequently used it in this way in operations of the face, and I have not found it cause headache, as Dr. Herapath states. Indeed, the spirit remains behind in the sponge, very few drops of it are inhaled; and in a protracted operation it is desirable to be provided with a dry sponge from time to time, on account of the spirit which remains. The effect of the spirit is to lessen the amount of vapour which the chloroform yields to the air. One hundred cubic inches of air, when saturated with vapour from a mixture of equal parts, by measure, of chloroform and rectified spirit of wine, only take up eight cubic inches of vapour, instead of fourteen. The air takes up enough vapour to cause insensibility, but not enough to cause sudden accident. I think it is Dr. Wilkinson, one of the Physicians to the Royal Infirmary at Manchester, who administers the chloroform in that institution, and he informed me that he had long administered it mixed with an equal measure of spirit with very satisfactory results. If headache had followed its use, I feel sure that he would have noticed the circumstance. Mr. Prichard, in commenting on his case, seems inclined to use the chloroform in future diluted with spirit.

I cannot agree with Mr. Prichard and others, who propose to diminish the number of accidents from chloroform by restraining its use to a few great operations, as I consider that accidents are more likely to be avoided by a constant familiarity with the agent. The medical officers of Guy's and St. Thomas's Hospitals had a strong objection to narcotism by inhalation for the first two or thee years after the practice was introduced, and chloroform was used much less frequently in these institutions than in the rest of the hospitals of London; yet it was in those two hospitals that two deaths from chloroform occurred, before any such accident had happened in any other hospital in this metropolis. The greatest benefit to be derived from causing insensibility during operations is, by extending the benefits of surgery. A surgeon could always advise an [224/225] operation, but he could only perform it in those cases in which he obtained the consent of his patient. With the use of an an├Žsthetic, which he can confidently recommend on all occasions, however, he is able to perform almost every operation he recommends, and at the time, also, when it is most advisable.

It would, moreover, be very inconsistent to confine the employment of chloroform to great operations, as the only reason for giving it in any case is to avoid the strong odour, and other inconveniences, of sulphuric ether. It should be recollected, that the prevention of the pain of operations did not commence with chloroform. It was as thoroughly and completely established with sulphuric ether as ever it can be. The insensibility was induced in almost every operation in St. George's and University College Hospitals during the greater part of 1847 without a single failure, and in the time which is most desirable in employing chloroform, viz. in about four minutes. Sulphuric ether is apparently altogether incapable of causing sudden accidents like those which have occurred from chloroform. It is still very extensively used in America and some parts of the continent of Europe, and I believe that no accident has ever occurred from its use, unless it be one in France, which is, however, doubtful. It is a matter both for surprise and regret that those surgeons in England who do not feel that they can use chloroform with safety, do not again resort to the use of sulphuric ether. It should be used alone, not mixed with chloroform, which, being less volatile, would be left to the last, and inhaled when its great strength would be most objectionable. Indeed, one accident has been recorded as occurring in America from a mixture of ether and chloroform.

18, Sackville Street, 13th March, 1858.

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