"Death from chloroform in a case of fatty degeneration of the heart"

Medical Times and Gazette
(9 October 1852): 361-362

By John Snow, M.D.

I was requested by Mr. Cæsar Hawkins to give chloroform to a patient, on December 15th, 1851, while he repeated the operation of lithotrity, which he had performed on two occasions within the previous fortnight, when the chloroform had been administered by Mr. Geo. D. Pollock. The patient had also inhaled chloroform five or six times, between May, 1850, and May, 1851, for the same operation, when under the treatment of another surgeon. He was a gentleman from the country, seventy-three years of age. I was informed that the last time he inhaled chloroform, on December 4th, he fell into an 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 have since been informed by Mr. Pollock, that the patient became faint also during the operation, but recovered from the faintness before the conclusion.

The patient was tall and stout, had an intermitting pulse, and well-marked arcus senilis of the corneæ. It was my belief that he had 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. 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; and this time he inhaled the chloroform before breakfast. Its effects were quite satisfactory, and were not accompanied or followed by any unpleasant symptoms whatever. The operation was repeated four days afterwards, when I again exhibited the chloroform with a like favourable result.

After this the patient returned to the country relieved from his stone. He came back, however, this autumn 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 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 a little more chloroform, keeping the valve of the inhaler partly open, to dilute the vapour very largely with air. He had only take two or three inspirations, however, when his 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. 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 am pretty sure that I heard the heart beating very feebly and rather frequently, but for only a few seconds, after which no sound could be heard. There were one or two more inspirations, very feeble, and at intervals of about a quarter of a minute, after which there were no signs of life.

While I was listening to the chest, Mr. Hawkins was sprinkling cold water on the face, and rubbing a little brandy on the inside of the lips. As soon as the patient had entirely ceased to breathe, we performed artificial respiration as well as we could; first, by pressure on the chest and abdomen; and next, by blowing into the nostrils, first with the mouth, and afterwards with the bellows; but no sign of returning animation appeared.

Examination of the Body Fifty-two Hours after Death.--The chest and abdomen were covered with a very thick layer of soft fat. The heart was 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. The left ventricle was dilated, and its walls were very 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 in one of the aortic valves. There was scarcely any blood in the heart, but its lining membrane was stained in places, showing that there had been blood present after death. The kidneys were highly congested, and one of them presented a slightly granular appearance. The bladder contained a phosphatic calculus, a great part of which was crushed into powder and small fragments. The mucous membrane of the bladder was somewhat inflamed, and the orifices of the ureters, together with the third lobe of the prostate, (which was somewhat enlarged,) were encrusted with phosphates. The remaining viscera appeared healthy.

Mr. Pollock and Mr. W. F. Barlow have kindly examined the structure of the heart under the microscope, and the latter gentleman has furnished me with the following result 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 [361/362] 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. Portions of the rectus abdominis muscle were examined, and found perfectly healthy. The striæ were clearly marked."

It is my intention to enter on the inquiry whether, in cases of presumed fatty degeneration of the heart, it is more desirable to give chloroform or ether,--to operate without anæsthesia, or to leave the patient without surgical assistance; but, as I do not wish the publication of the case to be delayed, I must leave these questions till another opportunity.

18, Sackville-street.