Part 22

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 │ Operation for │ Position │Means by which │ │ in │ which the │ whilst │the chloroform │ │yrs.│chloroform was │inhaling. │was exhibited. │ │ │ inhaled. │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ ───┼────────────┼────┼───────────────┼──────────┼─────────────── 1│Girl │ 15 │Removal of │Sitting │Towel │ │ │ toe-nail. │ │ 2│Married lady│ 35 │Extraction of │Sitting │Inhaler │ │ │ teeth. │ │ 3│Patrick │ │Operation for │Lying on │Handkerchief │ Coyle │ │ fistula in │ the side│ │ │ │ ano │ │ 4│Single lady │ 30 │Opening of │Lying │Handkerchief │ │ │ sinus in │ │ │ │ │ thigh │ │ 5│Young woman │ │Amputation of │ │Handkerchief │ │ │ the middle │ │ │ │ │ finger │ │ 6│Young man │ 22 │Transcurrent │ │Inhaler │ │ │ cauterisation│ │ │ │ │ of wrist │ │ 7│Young man │ │Intended │ │Probably │ │ │ removal of │ │ handkerchief │ │ │ toe-nail. │ │ 8│Seaman │ 31 │Removal of │Lying on │Napkin │ │ │ hæmorrhoids │ the side│ 9│Miner │ 17 │Intended │Lying │Handkerchief │ │ │ amputation of│ │ │ │ │ middle finger│ │ 10│Labourer │ 36 │Amputation of │ │Handkerchief │ │ │ toe │ │ │ │ │ │ │ 11│Married lady│ 33 │Intended │Sitting │Handkerchief │ │ │ extraction of│ │ │ │ │ tooth │ │ 12│Porter │ 48 │Removal of │Lying │Inhaler │ │ │ toe-nail │ │ │ │ │ │ │ 13│Married │ │Removal of │Probably │A sponge │ woman │ │ eyeball │ lying │ │ │ │ │ │ 14│Young lady │ 20 │Intended │Sitting │A sponge │ │ │ extraction of│ │ enclosed in a │ │ │ tooth │ │ napkin 15│A man │ │ │ │A sponge │ │ │ │ │ │ │ │ │ │ 16│Artilleryman│ 24 │Amputation of │ │Handkerchief │ │ │ middle finger│ │ 17│Bookkeeper │ 30 │Intended │Lying │Napkin │ │ │ operation on │ │ │ │ │ testicle │ │ 18│Boy │ 8 │Sounding the │Lying │Piece of lint │ │ │ bladder │ │ 19│Policeman │ 34 │Removal of │ │Napkin │ │ │ portion of │ │ │ │ │ hand │ │ 20│Man │ 24 │Intended │Lying │Folded lint in │ │ │ amputation of│ │ a hollow │ │ │ leg │ │ sponge 21│Man │ │Intended │Lying │ │ │ │ operation on │ │ │ │ │ the penis │ │ 22│Married lady│ 36 │Extraction of │Sitting │Handkerchief │ │ │ teeth │ │ 23│Mulatto │ 45 │Removal of │Lying │Napkin │ seaman │ │ testicle. │ │ 24│Married │ 37 │Removal of │Lying │Handkerchief │ woman │ │ impacted │ │ │ │ │ fæces │ │ 25│Man │ 23 │Ligature of │Lying │Inhaler │ │ │ vessels near │ │ │ │ │ vascular │ │ │ │ │ tumour │ │ 26│Married lady│ 32 │Intended │Sitting │Sponge │ │ │ extraction of│ │ surrounded by │ │ │ tooth │ │ handkerchief 27│Man │ │Intended │Lying │Handkerchief │ │ │ operation for│ │ │ │ │ fistula in │ │ │ │ │ ano │ │ 28│Cattle │ │Applic. of │ │Handkerchief │ dealer │ │ potassa fusa │ │ │ │ │ to ulcers of │ │ │ │ │ leg │ │ 29│Factory │ │Removal of │Lying │Inhaler │ operative │ │ malignant │ │ │ │ │ tumour of │ │ │ │ │ thigh. │ │ 30│Single woman│ 28 │Intended │Lying │Folded lint │ │ │ application │ │ │ │ │ of nitric │ │ │ │ │ acid to │ │ │ │ │ ulcers of │ │ │ │ │ pudenda │ │ 31│Soldier │ 25 │Removal of │Lying │Hollow sponge │ │ │ small tumour │ │ │ │ │ from cheek │ │ 32│Tobacconist │ 43 │Intended │Lying │Handkerchief │ │ │ perineal │ │ │ │ │ section │ │ 33│Woman │ 40 │Intended │Lying │Folded lint │ │ │ operation for│ │ │ │ │ strangulated │ │ │ │ │ hernia │ │ │ │ │ │ │ 34│Single woman│ 22 │Intended │Lying │Inhaler │ │ │ application │ │ │ │ │ of actual │ │ │ │ │ cautery to │ │ │ │ │ sore of │ │ │ │ │ vagina │ │ 35│Young man │ 19 │Intended │Lying │Inhaler │ │ │ forcible │ │ │ │ │ extension of │ │ │ │ │ knee │ │ 36│Girl │ 13 │Removal of │Apparently│ │ │ │ tumour from │ sitting │ │ │ │ back │ │ 37│Married │ 59 │Intended │Lying │Hollow sponge │ woman │ │ reductionof │ │ │ │ │ old │ │ │ │ │ dislocation │ │ │ │ │ of humerus │ │ 38│Woman │ 40 │Removal of │Lying │Folded lint │ │ │ uterine │ │ │ │ │ polypus │ │ 39│Married │ 45 │Intended │Lying │Sponge, │ woman │ │ removal of │ │ handkerchief, │ │ │ breast │ │ and inhaler 40│Tailor │ 18 │Intended │Lying │Inhaler │ │ │ operation for│ │ │ │ │ phymosis │ │ 41│Labouring │ 65 │Intended │Lying │Inhaler │ man │ │ amputation of│ │ │ │ │ thigh │ │ 42│Shoemaker │ 39 │Catheterism │Lying │Folded lint │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ 43│Woman │ 56 │Intended │Lying │Folded lint & │ │ │ amputation of│ │ piece of │ │ │ leg │ │ oiled silk 44│Man │ 40 │Intended │Lying │Inhaler │ │ │ excision of │ │ │ │ │ eyeball │ │ 45│Married lady│ 29 │Inhaled to │Sitting │Inhaler │ │ │ relieve │ │ │ │ │ neuralgia │ │ 46│Married lady│ 36 │Intended │Sitting │Handkerchief │ │ │ extraction of│ │ │ │ │ teeth │ │ 47│Sailor │ 30 │Intended │Sitting │Sponge and │ │ │ removal of │ │ folded lint │ │ │ necrosed bone│ │ │ │ │ from finger │ │ 48│Boy │ 9 │Intended │Lying │Cotton wool & │ │ │ removal of │ │ folded lint │ │ │ tumour of │ │ │ │ │ scapula │ │ 49│Labourer │ 35 │Intended │Lying │Folded lint │ │ │ amputation of│ │ │ │ │ thigh │ │ 50│Young woman │ 17 │Application of │Lying │Inhaler │ │ │ nitric acid │ │ │ │ │ to syphilitic│ │ │ │ │ sores │ │ ───┴────────────┴────┴───────────────┴──────────┴───────────────

───┬────────────┬────┬──────────────┬────────────┬──────────── No.│ Patient. │Age │Time from the │ Apparent │ Previous │ │ in │ commencement │ mode of │inhalations. │ │yrs.│of inhalation │ death. │ │ │ │ to the │ │ │ │ │ beginning of │ │ │ │ │ dangerous │ │ │ │ │ symptoms. │ │ ───┼────────────┼────┼──────────────┼────────────┼──────────── 1│Girl │ 15 │Half a minute │Cardiac │Ether once. │ │ │ │ syncope │ 2│Married lady│ 35 │About two │Cardiac │None. │ │ │ minutes │ syncope │ 3│Patrick │ │About one │Cardiac │One. │ Coyle │ │ minute │ syncope │ │ │ │ │ │ 4│Single lady │ 30 │Probably half │Cardiac │None. │ │ │ a minute │ syncope │ │ │ │ │ │ 5│Young woman │ │A very short │Cardiac │None stated. │ │ │ time │ syncope │ │ │ │ │ │ 6│Young man │ 22 │Five minutes │Symptoms not│None stated. │ │ │ │ described │ │ │ │ │ │ 7│Young man │ │Not stated │Death very │None stated. │ │ │ │ sudden │ │ │ │ │ │ 8│Seaman │ 31 │About ten │Cardiac │One. │ │ │ minutes │ syncope │ 9│Miner │ 17 │About five │Cardiac │None. │ │ │ minutes │ syncope │ │ │ │ │ │ 10│Labourer │ 36 │Died at the │Cardiac │A previous │ │ │ close of the│ syncope │ attempt. │ │ │ operation │ │ 11│Married lady│ 33 │A very short │Cardiac │One. │ │ │ time │ syncope │ │ │ │ │ │ 12│Porter │ 48 │A little more │Probably │None. │ │ │ than two │ asphyxia │ │ │ │ minutes │ │ 13│Married │ │Died during │Cardiac │None stated. │ woman │ │ the │ syncope │ │ │ │ operation │ │ 14│Young lady │ 20 │Just after │Cardiac │Previous │ │ │ beginning to│ syncope │ attempts. │ │ │ inhale │ │ 15│A man │ │Died before │Probably │None. │ │ │ the │ cardiac │ │ │ │ operation │ syncope │ 16│Artilleryman│ 24 │ │Cardiac │None. │ │ │ │ syncope │ 17│Bookkeeper │ 30 │Within five │Cardiac │None. │ │ │ minutes │ syncope │ │ │ │ │ │ 18│Boy │ 8 │A few minutes │Cardiac │None. │ │ │ │ syncope │ 19│Policeman │ 34 │Died during │Cardiac │None. │ │ │ operation │ syncope │ │ │ │ │ │ 20│Man │ 24 │A few minutes │Cardiac │None. │ │ │ │ syncope │ │ │ │ │ │ 21│Man │ │ │“Suddenly │None stated. │ │ │ │ expired” │ │ │ │ │ │ 22│Married lady│ 36 │Less than a │Cardiac │None. │ │ │ minute │ syncope │ 23│Mulatto │ 45 │About seven │Cardiac │None. │ seaman │ │ minutes │ syncope │ 24│Married │ 37 │Eight or nine │Symptoms not│Two. │ woman │ │ minutes │ observed │ │ │ │ │ │ 25│Man │ 23 │Five to ten │Cardiac │One. │ │ │ minutes │ syncope │ │ │ │ │ │ │ │ │ │ │ 26│Married lady│ 32 │Four or five │Cardiac │None stated. │ │ │ inspirations│ syncope │ │ │ │ │ │ 27│Man │ │Not more than │Cardiac │None. │ │ │ a minute │ syncope │ │ │ │ │ │ │ │ │ │ │ 28│Cattle │ │Died during │Probably │None. │ dealer │ │ operation │ cardiac │ │ │ │ │ syncope │ │ │ │ │ │ 29│Factory │ │About twelve │Probably │None. │ operative │ │ minutes │ cardiac │ │ │ │ │ syncope │ │ │ │ │ │ 30│Single woman│ 28 │ │Cardiac │None. │ │ │ │ syncope │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ 31│Soldier │ 25 │Five minutes │Cardiac │None. │ │ │ │ syncope │ │ │ │ │ │ 32│Tobacconist │ 43 │A few minutes │Cardiac │Two. │ │ │ │ syncope │ │ │ │ │ │ 33│Woman │ 40 │About five │Simultaneous│None. │ │ │ minutes │ deep coma │ │ │ │ │ and │ │ │ │ │ cardiac │ │ │ │ │ syncope │ 34│Single woman│ 22 │About five │Cardiac │One. │ │ │ minutes │ syncope │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ │ 35│Young man │ 19 │Fifty seconds │Cardiac │None. │ │ │ │ syncope │ │ │ │ │ │ │ │ │ │ │ 36│Girl │ 13 │ │Cardiac │None stated. │ │ │ │ syncope │ │ │ │ │ │ 37│Married │ 59 │About five │Deep coma │None. │ woman │ │ minutes │ and │ │ │ │ │ cardiac │ │ │ │ │ syncope │ │ │ │ │ │ 38│Woman │ 40 │A few minutes │Cardiac │None stated. │ │ │ │ syncope │ │ │ │ │ │ 39│Married │ 45 │Three-quarters│Cardiac │None. │ woman │ │ of an hour. │ syncope │ │ │ │ │ │ 40│Tailor │ 18 │About seven │Cardiac │None. │ │ │ minutes │ syncope │ │ │ │ │ │ 41│Labouring │ 65 │Between 13 and│Cardiac │None. │ man │ │ 14 minutes │ syncope │ │ │ │ │ │ 42│Shoemaker │ 39 │A few minutes │Deep coma, │None. │ │ │ │ apnœa, and│ │ │ │ │ cardiac │ │ │ │ │ syncope │ 43│Woman │ 56 │About three │Cardiac │None. │ │ │ minutes │ syncope │ │ │ │ │ │ 44│Man │ 40 │About five │Cardiac │None. │ │ │ minutes │ syncope │ │ │ │ │ │ 45│Married lady│ 29 │A few seconds │Cardiac │Two or │ │ │ │ syncope │ three. │ │ │ │ │ 46│Married lady│ 36 │A few seconds │Cardiac │Four. │ │ │ │ syncope │ │ │ │ │ │ 47│Sailor │ 30 │Three or four │Deep coma │None. │ │ │ minutes │ and │ │ │ │ │ cardiac │ │ │ │ │ syncope │ 48│Boy │ 9 │A few minutes │Cardiac │None. │ │ │ │ syncope │ │ │ │ │ │ │ │ │ │ │ 49│Labourer │ 35 │A few minutes │Cardiac │One. │ │ │ │ syncope │ │ │ │ │ │ 50│Young woman │ 17 │ │Symptoms not│Two. │ │ │ │ observed │ │ │ │ │ │ │ │ │ │ │ ───┴────────────┴────┴──────────────┴────────────┴────────────

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.

THE TWO KINDS OF SYNCOPE.

Dr. Patrick Black has made an objection to the fact of the patients having died of paralysis, or over-narcotism of the heart, in the accidents from chloroform. He says that paralysis of the heart would be death by syncope, but that the symptoms before death, and the conditions of the organs met with afterwards, are not in accordance with such a view of the case. In order to show that both the symptoms and the after death appearances, in the fatal cases of inhalation of chloroform, are consistent with paralysis of the heart, it is necessary to point out the difference between ordinary syncope and cardiac syncope. One of the best examples of ordinary, or what may be called anæmic syncope, is that which occurs in a common blood-letting, whilst the patient is in the sitting posture. When the bloodvessels, especially the veins, which at all times contain the greater part of the blood in the body, do not accommodate themselves fast enough to the diminished quantity of blood, the right cavities of the heart are supplied with less and less of the circulating fluid; and in a little time are not supplied at all, when the heart ceases to beat, in accordance with the observation of Haller, that it does not pulsate when it is not supplied with blood. The moment the heart ceases to supply blood to the brain there are loss of consciousness and stoppage of respiration; but on the patient being placed in the horizontal position the blood flows readily into the right cavities of the heart from the great veins of the abdomen and lower extremities; the heart immediately recommences its contractions; the brain is again supplied with blood, and respiration and consciousness return.

The blood may remain in the ordinary quantity; but if the bloodvessels do not keep up their usual support, and exert a sufficient pressure on their contents, the same kind of syncope will occur as that from blood-letting. The late Sir George Lefevre related the case of a lady who fainted whenever she left her bed, and assumed the upright posture; no cause could be found for this until it was ascertained that she suffered from varicose veins of the legs: bandages to these extremities prevented the fainting. It is obvious that in this case the mechanism of the syncope was the same as that in blood-letting; the distension of the varicose veins under the weight of the superincumbent blood had the same effect in preventing the supply to the right cavities of the heart, as if the blood had been entirely removed. The faintness which often occurs on first rising, when a person has long kept the recumbent posture from any local cause, is probably of the same kind; the veins not having had to support the weight of the usual column of blood for some days or weeks, lose their tone we may presume, and yield when they are all at once subjected to the weight of a column of blood extending from the lower extremities to the heart, so that this organ ceases to be properly supplied with the circulating fluid.

In cardiac syncope, on the other hand, the cavities of the heart, or at all events the right cavities of this organ, are always full, whether the syncope depend on paralysis of the heart by a narcotic, or inherent weakness of its structure, or on its being overpowered by the quantity of blood with which it is distended. After death from this kind of syncope, if the blood have not been displaced by artificial respiration or other causes, the right cavities of the heart and the adjoining great veins will be found filled with blood, and the lungs will in many cases be more or less congested. The appearances in short will be very much the same as in asphyxia by privation of air, which ends in a kind of cardiac syncope, the stoppage of the heart being partly due to over-distension of its right cavities, and partly to loss of power in its structure, from the want of a supply of oxygenated blood through the coronary arteries. In death by anæmic syncope, on the contrary, all the cavities of the heart are found empty, or nearly so, and the same is frequently the case with the adjoining great veins, whilst the lungs are usually pale.

The syncope occasioned by some kinds of mental emotion is of the ordinary or anæmic kind, and consequently the condition of the brain must act first on the bloodvessels, and not directly on the heart. Certain persons are liable to faint on witnessing a surgical operation. Now if the mental emotion of these persons acted directly on the heart, whilst the rest of the vascular system was unaffected, the distribution of the blood would be nearly the same as in asphyxia, where the circulation is first impeded in the lungs, and is ultimately arrested by loss of power in the heart. If the action of the heart were weakened, or stopped, in the first instance, by the kind of emotion under consideration, the arteries would be emptied by their contractility and elasticity, and the blood would accumulate in the right cavities of the heart and the great veins leading to them. In a medical student fresh from the country, who is by no means deficient in blood, the jugulars would become distended and the face livid, and the recumbent posture would probably do but little towards removing the symptoms. The phenomena which are witnessed, however, indicate a very different condition of the vascular system. The person about to faint from the cause indicated, frequently becomes pale before he feels anything wrong; and when requested to retire and sit down, often says that there is nothing the matter with him. In a short time he faints, and falls, if no one catches hold of him; but the moment he is in the recumbent posture he recovers. In such a case as this, the effect of the mental emotion must be first exerted on the veins, or the veins and capillaries, through the nerves which supply these vessels; they allow themselves to become distended, and the heart ceases to act for want of its supply of blood, as in syncope from blood-letting, and anæmic syncope from any cause.

Several authors have attributed the empty state of the heart met with after death, in certain cases of fatal syncope, to want of power in the left ventricle to supply the right cavities of the heart; but this is to argue as if the blood passed out of the body after leaving the right ventricle, and the left ventricle had to supply a newly formed fluid. The effects of want of power in the left ventricle are the same as those of an obstruction at the origin of the aorta; the lungs become congested, and the right cavities of the heart more or less distended, from the blood not being able to pass readily through the lungs. Patients who die of heart disease die with the cavities of that organ full. Some patients, indeed, with fatty disease of the heart, die suddenly of anæmic syncope, and the heart is found empty; but in these cases it is evident that death is not occasioned by the disease of the heart, but by some condition of the bloodvessels which accompanies it.

Chevalier was, I believe, the first to draw marked attention to cases of sudden death arising from an empty state of the heart, in a paper in the first volume of the Transactions of the Royal Medical and Chirurgical Society; and he rightly attributed the emptiness of the heart to a loss of power in the bloodvessels. His words are as follow:—

“The disease I have now described may, perhaps, be termed asphyxia idiopathica. The essential circumstances of it evidently denote a sudden loss of power in the vessels, and chiefly in the minuter ones, to propel the blood they have received from the heart. In consequence of which, this organ, after having contracted so as to empty itself, and then dilated again, continues relaxed for want of the return of its accustomed stimulus, and dies in that dilated state.”

The word asphyxia has become so closely connected by physiologists with death by privation of air, where the symptoms and appearances are the reverse of those in Chevalier’s case, that it is necessary to discard his name of the disease which he describes, although it is etymologically correct. His cases come under the definition of what is now universally called syncope, and what I have called anæmic to distinguish it from cardiac syncope.

Chevalier speaks of a want of power in the vessels to propel the blood, and as it is not now believed that the vessels take any active share in the propulsion of the blood, this may be the reason why the views of this author have received less attention than they deserve; but it is very obvious that a want of tone in the vessels, or any great diminution of that power which enables them to support and compress the blood, is an adequate cause why the blood should be unable to reach the right side of the heart. In the case of varicose veins, previously mentioned, it was physically apparent that the cause of the syncope lay in the vessels. Disease of the arteries is well known to be usually associated with degeneration of the heart; the veins are also large and distensible in old people, who furnish the greater number of those who are liable to anæmic syncope; but the pathology of the veins, as regards both their functions and structure, is not yet sufficiently known.

Persons with disease of the heart, who die suddenly in a fit of anger, probably die always with the heart distended; that is, of cardiac syncope. Dr. Joseph Ridge, however, in his able and interesting remarks on the disease and death of John Hunter, states his belief that that celebrated man, who had been long subject to attacks of angina pectoris, died at last of syncope, with an empty heart. He died, as is well known, during a fit of anger, and the coronary arteries were found ossified. It is not said that the heart was empty, but that it was small, and that there were no coagula in any of its cavities. It is probable that there was not much blood in its cavities, at the time of the post mortem examination, but the body of Hunter was conveyed in a sedan-chair, from St. George’s Hospital to Leicester Square, a little more than an hour after his death, so that the fluid blood would gravitate downwards. It is related that the stomach and intestines were unusually loaded with blood, and that those parts which were in a depending position, as in the bottom of the pelvis and upon the loins, were congested in a greater degree than the others; and that “this evidently arose from the fluid state of the blood.”

In syncope from muscular exertion, the cavities of the heart are distended, and its walls have occasionally been ruptured, both from violent exercise and fits of anger.

Fear probably occasions each kind of syncope in different cases. In some cases, the right cavities of the heart become distended owing to impeded respiration, and possibly to a diminution of power in the heart itself. More frequently, the syncope appears to be of the ordinary or anæmic kind, the effect of the mental condition acting first on the more distant parts of the circulation. The pallor caused by fright is proverbial.

Pain is also capable of causing both kinds of syncope. I have alluded to cases (page 55) in which the patients strained and held their breath till the pulse became intermittent, and the action of the heart was temporarily suspended by the arrested breathing; on the other hand, patients often become pale, if they are undergoing any slight operation when seated, and syncope of the anæmic kind occurs, without any previous disturbance of the respiration, but passes off as soon as they are placed in the horizontal posture. I have seen an apparently strong man faint in this manner, during the removal of a tumour from the back not larger than a nut, and where only a few drops of blood were lost. Chloroform was not employed.

SUPPOSED CAUSES OF DEATH FROM CHLOROFORM.

Many writers have supposed that the deaths from chloroform have arisen from some peculiarity in the patient; and when any notable change of structure has been met with after death in any of the vital organs, this has been thought to afford a sufficient explanation of the event; whilst in the cases in which the organs were in a healthy state, surprise has been expressed at the occurrence. In looking over the account of the cases in which the inhalation of chloroform has been fatal, there is reason to conclude, however, that the subjects of them were, as regards health and strength, quite equal to the average of the multitude who have inhaled this agent without ill effects. In fifteen out of the fifty cases above related, there was no examination of the body after death. In one of these fifteen cases, the patient was in a state of debility, and had hectic fever, apparently from the disease of the ankle-joint, for he had no cough; in another of these cases, the patient was reduced to a state of great debility from cancerous disease of the uterus. In fourteen out of the thirty-five cases, in which an examination of the dead body took place, all the chief organs were found to be healthy, if we except the local congestions of blood connected with the mode of dying, and a flabby state of the heart in a few of the cases, which probably depended on its being full of blood at the time of death, or its not being in a state of post-mortem rigidity, at the time it was examined.

In one case, No. 25, the only morbid appearances were adhesions of the pleura of small extent; and in No. 47, the only disease was fatty liver. In Case 17, there were signs of chronic disease of the membranes of the brain; and in two cases, Nos. 16 and 22, there was emphysema of the lungs. In the remaining sixteen cases, there was some alteration of the heart, accompanied in a few instances by disease of other organs. In Cases 23 and 32, there was fat on the surface of the heart, but the structure was not degenerated. In Case 43, the right ventricle was thinned, but not fatty. In Case 44, there were slight deposits on the mitral valve, the heart being otherwise healthy. In Case 50, there were deposits of lymph on the mitral valve and also on the surface of the heart, which was somewhat enlarged. In Case 8, the heart is merely stated to be large; and in Case 27, hypertrophied. In Case 3, the heart was enlarged, pale, and soft, and the lungs were tuberculous. In Case 15, there was said to be some amount of disease of the aortic valves, and some amount of fatty degeneration of the heart. In Case 37, incipient fatty degeneration was present; and in Case 40, that of a youth of eighteen, the heart was slightly enlarged, with some amount of fatty degeneration. In Case 46, the right ventricle was thinned and slightly fatty. There remain three Cases, Nos. 30, 33, and 42, in which the fatty degeneration was more decided; and one case, No. 41, in which it is spoken of as being present in an extreme degree. This was in a man, aged sixty-five, the oldest person included amongst those who died from chloroform.

When we consider how common is fatty degeneration of the heart, especially amongst old persons and those for a long time confined to bed, it is very probable that this affection has been proportionally as frequent, amongst the patients who have inhaled chloroform without ill effects, as in the fatal cases of its inhalation.

There are nine of the fatal cases in which the age of the patient is not stated. In the other forty-one cases, the ages, when grouped in decennial periods, are shown in the following table, the last column of which shows the proportion which the deaths bear at each period to the number living at that period, out of a thousand persons of all ages in England and Wales.

Under 5 years 0 0 5 and under 15 3 ¹⁄₇₆ 15 „ 25 11 ¹⁄₁₈ 25 „ 35 10 ¹⁄₁₅ 35 „ 45 11 ⅒ 45 „ 55 3 ¹⁄₂₇ 55 „ 65 2 ¹⁄₂₆ 65 and upwards 1 ¹⁄₄₄