Source:  Snow, John. Medical Times and Gazette 8 (1854): 606. [ltr. to ed., 29 May 1854]

On the recent death at St. George's Hospital, while the patient was beginning to inhale chloroform

To the Editor of the Medical Times and Gazette

Sir,--I shall be obliged if you will allow me to make a few remarks respecting the recent death at St. George's Hospital, while chloroform was being inhaled. Mr. Cæsar Hawkins was kind enough to inform me of the circumstance, and I was present at the autopsy on the following day, when I obtained about six ounces of blood and a portion of lungs and liver for chemical examination. The blood was put into a flask, to which a hard glass tube calculated to bear a red heat was attached, and beyond this a tube moistened inside with solution of nitrate of silver. The flask was heated in the water-bath, a portion of the tube through which the air and vapour had to pass being kept red-hot. No precipitate of chloride of silver was formed, although the process was continued some hours. It was interrupted once, in order to break up the coagulum. The portion of lung, and subsequently the portion of liver, were cut in pieces, and treated in the same manner, with a similar negative result.

When an animal has been killed with chloroform, that compound can be very easily detected by the above process in all parts of the body, even for seven or eight days after death.* (*See Medical Gazette, Vol. XLVI., p.324.) I have also detected it readily in a portion of the muscles of a leg removed under the influence of chloroform to the usual extent; in fact, I have obtained a distinct precipitate of chloride of silver from the hundredth part of a grain of chloroform when mixed with six ounces of blood. It is evident, therefore, that the patient at St. George's Hospital must have inhaled only an extremely small quantity of chloroform; indeed, this is the opinion of the Medical men who were present at the time of her death. The inhaler was only applied for a minute and a half, and the valve which admits the air unmixed with vapour was only one-third closed; moreover, Mr. Potter informs me that the patient, who was much agitated, seemed to breathe very little, and he was talking to her, with a view to calm her apprehension, the moment before she died. I have never met with a patient who became insensible until the valve in question was much more than one-third closed, however free the breathing might be. A few days ago, I inhaled chloroform from a similar instrument with the valve one-third closed, and although there were two drachms and a-half of chloroform in the inhaler, and I breathed in the ordinary manner, I was able to observe the time by a watch for eight or nine minutes, and then merely fell asleep.

The case in question appears to have been one of sudden death; the immediate cause of its occurring at the moment when it did occur being probably mental emotion. In this respect it resembles the case of Mr. Badger, which occurred at Mr. Robinson's in 1848. The average number of sudden deaths in England and Wales from 1838 to 1842 was 3600 per annum, or one in 138 of the total deaths. In a certain number of such cases there is rupture of an aneurism or some other evident cause of death; but, in the majority of instances, there is nothing to indicate the immediate cause of dissolution. Mental emotion of some kind is frequently the immediate cause of sudden death. Several cases of this kind have come within my own knowledge, and within the last few days it is related in the newspapers, that "upon the occasion of the recent announcement of a free discharge to the convicts of the Newgate Prison, Dublin, under sentence of penal servitude, so overjoyed were four of them at the sudden intelligence that they dropped dead."

It is not surprising, therefore, that among the great numbers of patients to whom chloroform has been administered during the last six or seven years, two of them should have died suddenly while just beginning to inhale. Patients are known to have died just after being placed on the operating-table, before chloroform was introduced; and it appears that the same accident is still liable to occur, for it unfortunately happens, in many cases, that the intended inhalation of chloroform does not prevent fear. It cannot be supposed, however, that the inhalation of this agent increases the patient's fear, for should he not be more afraid of the pain than of the chloroform, he of course would decline to inhale it; nor can it be supposed that the chloroform increases the effects of fear, for it is matter of daily observation that, as soon as the patient gets so far under its influence as to be unconscious, the pulse, which had been very rapid from apprehension, greatly subsides to nearly its natural frequency.

As regards the post-mortem inspection in the case under consideration, there is nothing which throws any particular light on the cause of death. There was some amount of fatty degeneration of the heart, but not sufficient to account for death. The right cavities of the heart were not empty, as in the kind of syncope produced by loss of blood or anæmia; and it is impossible to ascertain whether or not they were greatly distended at the time of death, for the artificial respiration, and carrying the body down a number of stairs, while the blood was in a liquid state, might displace part of it. It is sufficiently probable that these cavities became over-distended while the patient was in fear and scarcely breathing, and that the action of the heart was thus arrested. The lungs contained a moderate quantity of blood, and neither indicated death by pure syncope nor by pure asphyxia. The brain was somewhat congested, which is quite consistent with death from mental emotion, though no great indication of it. The fluid state of the blood does not indicate anything, for in the human subject the blood generally remains fluid in cases of sudden death from whatever cause. In small animals, such as dogs, cats, and guinea-pigs, the blood generally coagulates, though loosely, in the heart and blood-vessels, after they have been killed by chloroform; and, if the vessels are opened immediately after death, the blood that escapes coagulates firmly. The truth is, that narcotics do not cause death by producing any physical or chemical change in the blood.

The only circumstances to guide us to the cause of death in the above case, are the symptoms just before dissolution, and the fact that the patient did not inhale enough chloroform to produce any effect whatever. In commenting on a case of death not caused by chloroform, it would be somewhat out of place to enter on the consideration of the cause of accidents by this agent, and the way in which they may be avoided; indeed, I have already treated of these subjects in former communications.

I am, etc.

John Snow, M.D.

18, Sackville-street, May 29.

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