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.