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(J42                                                 MEDICAL JUKtSPRUDENCE

cold and moist. All the muscles are relaxed, and the limbs can be bent in
any direction. Surgical operations are performed during this stage, which
can be maintained for hours. If the inhalation is stopped, the condition may
ordinarily last for twenty to forty minutes, although it may last ±or a much
longer period in some cases. Sometimes, fatal results occur atter the with-
drawal of the inhalation.

3. Stage of Paralysis.— li the inhalation be still continued, the patient
passes into the stage of paralysis. The muscular tone is abolished, and con-
sequently the muscles become quite flaccid. The urine and fseces are passed
involuntarily. The lips become blue. The surface is cyanosed and ^ bathed
in cold perspiration. The pupils are widely dilated. The respirations
become slow and irregular with a long pause. The pulse is weak and irre-
gular. Death occurs from stoppage of the heart's action or from respiratory-
paralysis. It may also oc"cur at any stage, when it may be due to the heart's
paralysis or asphyxia brought about by the passage of vomited matter or
blood into the air-passages, or by the closure of the glottis from the pressure
of the tongue, or possibly by status lymphaticus in the case of children.

Delayed chloroform poisoning occurs about ten hours to six days after
recovery from anaesthesia, especially if the quantity administered was large
and continued for a long time. It is more common in persons suffering from
acetonuria, rickets, hepatic disorders, and wasting diseases, and is especially
frequent in children. The symptoms, which resemble those of phosphorus
poisoning, are restlessness, violent and persistent vomiting, jaundice, tender-
ness over the liver, frequent pulse, delirium, coma and death. Sometimes,
there may be cutaneous haemorrhages. The urine contains acetone and
diacetic acid. The post-mortem examination shows fatty degeneration of the
liver, heart and kidneys.

Reichl30 reports seven cases of late deaths from chloroform which occurred in his
clinic in the course of nine days in May 1925. After a so-called incubation period of
24 to 36 hours the patients became restless with a frequent pulse, somnolence, subicteric
discoloration of the sclerotics and skin, delirium and a rise of temperature often as high
as 104°F. They rapidly grew weaker, and death followed in 2J to 3 days in children and
in 4 or 5 days in adults. At the necropsy acute yellow atrophy of the liver was found
in all the seven cases. The principal post-mortem finding was severe degeneration of
the liver, shown by fatty degeneration of the liver cells with necrosis of the centre of
the acini.

Fatal Dose. — It is difficult to ascertain the exact lethal dose. Large
quantities have been inhaled during surgical operations without any dele-
terious effects. A concentration of two to three per cent of chloroform in
air is the limit of safety for inducing surgical anaesthesia ; whereas the
concentration of five per cent or more is considered dangerous. A concen-
tration of 0.035 per cent by weight of chloroform in the blood produces
anaesthesia, while a concentration of 0.06 per cent by weight in the blood
causes death.31

Fatal Period. — Death may occur within a few minutes of the beginning
of administration or at any time during the course of anaesthesia. Death
from delayed poisoning occurs from ten hours to twenty days, the average
period being four to five days.

Treatment— Stop inhalation, lower the head and pull the tongue forward
either with a pair of forceps or by carrying the lower jaw forward with the
hands. Start artificial respiration and apply the faradic current or use
oxygen inhalation. Administer hypodermic injections of strychnine, caffeine
or ether, and start cardiac massage by the sub-diaphragmatic route. Injec-
tion of adrenaline directly into the heart muscle often induces recovery.

t?-   ™€\.^iu^T1>£ 1926' ?• 899; J51"**' Med' Jour" Au£- 14» 1926> Epitome, p. 23
31.   Clark, Applied Pharmacology, Ed. V, p. 164.