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 |
The nine persons whose ages are not given were all adults; one is spoken of as a young man, and another as a young woman, and the rest are mentioned in such a manner that it is certain they were not old people. It follows, therefore, that so far as is known, there has been a complete immunity from death by chloroform at both extremes of life. I have already given my reasons for rejecting Dr. Aschendorf’s case of an infant, and also the case of a gentleman, aged seventy-three, who died whilst inhaling chloroform. The youngest patient who died from chloroform was seven or eight years of age, and the oldest sixty-five, being the only death above sixty. The above table of the ages shows that the number of deaths, in proportion to the number living, increased rapidly after the age of twenty-five, and decreased rapidly after the age of forty-five. The small number of deaths between fifteen and twenty-five may be partly due to the circumstance that surgical operations are but seldom required at this period of life; but the decrease after the age of forty-five cannot be explained in this way; for persons become more liable to require surgical operations as they advance in years. Operations are often performed in infancy and old age, periods at which deaths from chloroform have not been recorded. The greatest proportion of deaths having occurred from thirty-five to forty-five, when the system is often more robust than at any other period, it cannot be supposed that an inability to bear the usual dose of chloroform, when carefully administered, is the ordinary cause of death from this agent.