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Colonial Cases

Japan

Japan Weekly Mail, 16 July 1870, 328-330

Inquest

CORONER'S INQUEST.

At 1 1/2 PM. on Tuesday, an inquest was held on the body of Captain Gilfillan, who died yesterday while under the influence of Chloroform, administered to him during a surgical operation, consisting in the reduction of a dislocated shoulder to its proper place.

F. Lowder, Esq., H. B. M.'s Consul, acted as coroner, Messrs. Chas. Melhuish. Jos. Russell and A. H. Prince, were jurors.

The body of the deceased was inspected at the International Hotel and the inquest continued at H. B. M.'s Consulate.

Mr. Whymark, sworn:-I am a partner of Mr. Curtis. Last evening about 5 o'clock, I was informed by Mr. Curtis that Captain Gilfillan had hurt his arm. I went up to his room to see if I could render any assistance. I found Dr Dalliston on trying to reduce the arm into its socket in the shoulder. I assisted to hold him; he seemed to suffer great pain. After two trials, the doctor was obliged to let him rest. Dr. Dalliston then suggested chloroform, which was sent for. He inhaled the whole of a small bottle without any effect. A second bottle was sent for. Before it arrived, Captain Gilfillan was perfectly conscious, he remarked that he did not think the dose strong enough. When the second bottle was brought, he expressed the desire that it should be given to him slowly. On the second application of it, he struggled as if in a spasm. Dr. Dalliston at once applied his ear to Captain Gilflillan's breast and said: "I think he is gone." Dr. Dalliston tried to restore animation. He applied a galvanic battery, and tried by artificial means to bring about respiration. and afterwards two Galvanic batteries were used but without effect. I do not think ten minutes elapsed between the application of first and second bottle. The contents of the bottles were poured upon a handkerchief, a little at a time, and inhaled. (Produced two small bottles). These are the bottles. The first was wholly emptied, the second only partially. Of the second bottle only two doses was given. After artificial respiration had been tried deceased gasped once or twice. Whether that was a reaction from the artificial means I cannot say. At the moment of his death no other doctor was present. Dr. Siddall arrived about a quarter of an hour after. At the commencement of the administration of chloroform deceased struggled violently; he spoke incoherently. Before the second bottle arrived he had, however, apparently thoroughly recovered. He made no objection to take chloroform the second time, only he expressed the wish that it should be given to him slowly. Deceased has been at the hotel twelve or fourteen days. I am not aware that he had seen any doctor during that time. I think he was a healthy man. There were people with the body till past seven because many had an idea that he was not dead. I saw no signs of life after the doctor left. I last saw the body about 11 o'clock last night. During dinner a gentleman came and said the body was warm yet. Both Dr. Dalliston and Dr. Siddall were sent for. Dr.Siddall came, and went to see the body, but had no hesitation in saying that the body had been dead some time.

Dr. Siddall, sworn: Last night about half-past five I was in my house, when Dr. Dalliston came and asked me if I had a galvanic battery. He said a person had died from chloroform. He asked me if I would go down and see the man. I sent him to Mr. Whitfield for the battery, and in the meantime went to see the body. It was apparently quite dead, and I was told it was twenty minutes since the time it was first thought to be dead. I was told that Dr. Dalton had tried artificial respiration, but without effect. Dr. Dalliston and Mr. Whitfield came, bringing with them a galvanic battery, which was applied for about seven minutes, but without other effect than producing violent muscular contraction. The case was hopeless and nothing further was done. As far as I could judge, deceased was dead when I arrived, and at no time after had I reason to believe he was not. I have often administered chloroform. The rule in administration of it is to give plenty of air, and not very large doses at once. It is always advisable that two medical men should be present when chloroform is administered. I have heard that the deceased had got his shoulder dislocated; dislocation of the shoulder would not cause death. It is impossible to give a general rule how much chloroform should be administered. The quantity varies in every case. Supposing deceased to be is healthy man, I should not have the slightest hesitation in giving him chloroform. These bottles are ounce bottles. I can say, I never used more than two ounces myself. I should never administer chloroform by myself when I can get assistance, and therefore I should not, where I could avoid it, undertake task to set a dislocated shoulder and a administer chloroform, all by myself without any assistance. If I could not get assistance, I think I should risk to administer chloroform in setting a shoulder. The effect of an overdose of chloroform is to cause death, either by paralysation of the hearts action or suffocation. If the patient has a fatty heart, chloroform should not be administered to him. I see how much has been used from the second chloroform bottle. After the patient had inhaled one ounce, I should not put so much on the handkerchief for inhalation in one dose. I do not know if deceased was suffering from any disease. I think it would take me twenty minutes to bring about insensibility through the administration of one ounce of chloroform. Giving it more quickly would be dangerous to the health or even life of the patient. Having administered a whole ounce without effect, or the patient having recovered from the partial effect, I should not hesitate in administering more. From inspection of the body of the deceased last evening I could not tell what was the cause of death. My attendance could have been procured yesterday afternoon. I was at home until 6 p.m. I was not sent for to assist during the administration of chloroform.

Dr. Dalliston was asked by the Court if he, for his own satisfaction wished a post-mortem examination, but he replied in the negative.

Thomas H. King, sworn:- I live at the Hotel. I have heard the deposition of the first witness. I entered the room at the same time he did and remained there with him. I corroborate his evidence with one exception. The suggestion to administer chloroform did not come from Dr. Dallison, but from a gentleman present, who asked deceased if he had ever taken chloroform or seen it taken. Deceased replied that he had several times seen Dr. Dilliston administer it, and appeared desirous that it should be used. That gentleman was Mr. Howles. I think the administration of the first bottle took about twenty-five minutes. Two doses were administered from the second bottle, with an interval of from five to seven minutes. The second dose was poured upon the back of the handkerchief, which was not taken from the face of the patient. He spoke, however, but incoherently. Ten or twelve, perhaps fifteen minutes elapsed from the time the first bottle was finished before the second was used. Deceased was then perfectly sensible. He made no objection, he only wanted it to be given slowly, the handkerchief was not held too close to his face. He had asked the same thing during the administration of the first bottle. About one minute after the second dose from the second bottle a spasm ensued, and then a total relaxation and collapse. It was about 23 minutes past 5 when he died. I do not know from whence the chloroform came. I think the operation commenced at about a quarter to five. When Dr. Dalliston first left I thought the man was dead. I remained with the body two or three hours, but after the collapse mentioned above I saw not the slightest sign of life. During dinner I left the table with several others and went to see the body, on account of is report that the man was yet alive. I found the body quite stiff. Dr. Dalliston stopped with the body half or three quarters of an hour after the arrival of Dr. Siddall  they went away together. During the administration I think there were present seven persons. The administration of the chloroform was done by Dr. Dalliston himself. Mr. Howles poured the chloroform on the lhandkerchief, and Dr. Dilliston applied it to the patient. Dr. Dalliston pronounced the patient had died. The room was not close, a large window immediately over the patient was open.

Mr. Howles, sworn:-Yesterday afternoon I went into the Hotel, and heard Captain Gilfillan had fallen off his horse and hurt his shoulder. I went upstairs to see if he was seriously ill. I saw Dr. Dalliston and 4 or 5 gentlemen trying to set his arm. Captain Gilfillan said he could not bear the pain. I believe he asked for chloroform, but I heard Dr. Dalliston say he had better take chloroform. Dr. Dalliston then wrote for chloroform. I asked the Captain if he had ever taken chloroform? He replied, no. I asked him if he was troubled with heart disease? He answered, no. I then asked him if he was willing to take chloroform? He said, yes, he could not  bear the pain. When the chloroform came Dr. Dilliston made all preparations for pulling the arm in joint. I was at the side of the Captain holding the bottle. During the taking of chloroform the Captain breathed very lightly. I told him if he would only take one deep draught, he would immediately go to sleep. When the whole of the bottle had been consumed, a second bottle was sent for. The first dose was delivered inside the handkerchief, the second outside the handkerchief. While the handkerchief was under the note I heard somebody say that the Captain was dead. Dr. Dalliston then also pronounced him dead and asked all of us to rub him. This we did. Dr. Dalliston then brought in a galvanic battery, it was applied, but there was no life. I think the death happened at half-past six. I think it was a quarter to live when I entered the Hotel. I think half an hour or three quarters elapsed before the chloroform was brought. The second bottle came five or six minutes after the first bottle was finished. The administration of the first bottle did not take more than, at the outside, ten minutes. I sometimes poured out the chloroform, sometimes the doctor did. Of the two doses from the second bottle I believe the doctor poured the first, and I the second. I did so at the doctor's direction. It was only a few minutes after death that Dr. Dilliston went for the galvanic battery. The administration of the two doses from the second bottle may have taken three or four minutes. I have myself taken chloroform on two occasions. The first bottle was administered in about six doses.

Mr. Skinner, sworn: On Sunday morning I accompanied the deceased to Tana on horseback. His pony was unruly and troublesome. While at Tana, he complained of being sick, and refused food. Coming back, he was left in company with Mr. Curnow. Waiting for him at a tea house I retraced my steps, and met him coming in a kango with his arm strapped up, and he said he thought his arm dislocated. We arrived at Yokohama on Monday afternoon. It was past five in the afternoon when I went to look for Dr. Dalliston. I looked in vain for him in several places, it was about half past five when he was found and came to the Hotel. I went upstairs with the doctor and assisted with several others in trying to set the arm. Dr. Dalliston suggested chloroform. Mr. Curnow went for it. After the first dose of the second bottle was administered, deceased appeared to me to be in a fair way to go to sleep, and as I was very tired I left. Some time after Mr. Curnow came and told me the Captain was dead. I went again to the Hotel; I should say the efforts to set the arm took at least ten minutes. After that it did not take another ten minutes before the chloroform came. The administration of the bottle took about a quarter of an hour. After the administration of the first bottle five minutes may have elapsed before the second bottle came. I could not tell, when I left the Hotel. I was personally acquainted with the deceased, I have known him for more than two years. It does appear to me that due care was not taken in the administration of the chloroform. The operation went altogether too fast. I have not seen chloroform given before. The deceased took it with great difficulty and asked repeatedly that it should be given to him slowly. Deceased had had no liquor either that or the previous day. He told me that the horse had stumbled with him. When deceased asked that the chloroform should be given him more slowly Dr. Dilliston said, we will give you plenty of air, and raised the handkerchief higher for the air to pass. He struggled very violently, it took two of us to hold his legs. I do not think he drinking hard lately, nor have I known him to suffer from a weak heart. He did not complain of any other illness than the dislocation of the shoulder.

Mr. Whymark: I can inform the Jury of the exact time that the Captain died. It was a quarter past six. Captain King was altogether mistaken about the time.

Mr. Sandford, sworn:- About half-past six last evening I was standing near theYokohama Hotel, and being told of the death of Captain Gilfillan, went over to see. He looked quite natural, but was motionless. The galvanic battery was brought in and applied. There was a contraction of the muscles, but that ceased. After dinner I went over again and felt the body. I found the arm and leg warm, and pulsation. I went and told Mr. Curtis. Doctors were sent for, then the pulsation had gone, and the expression of the face had entirely changed. I feel as morally certain that the limit was alive when I saw him the second time, as I feel now that he is dead. Mr. Hall and Mr. Roper had observed similar symptoms.

Court adjourned until 10 a.m. tomorrow.

-

Wednesday, the 13th July, 1870.

Mr. Sandford (continued) On first application of the galvanic battery it appeared to me that there was some slight muscular contraction at the hand. But afterwards it was found that the battery had no effect, not even upon a bystander. Another battery was procured, but of slight power. Finally the Captain was positively pronounced dead, and the doctors left. I left for dinner, and after dinner, about a quarter past eight I went over again. I met Mr. Hall who told me he had just been to see the body and it did not seem to him quite dead, I asked who was with the body. He said, no one. I proposed we should remain with the body. I was surprised at this change that had come over the face since I left. The lips appeared less blue. I felt the heart beat. I rushed for Mr. Curtis and asked him to come upstairs as I thought the man was alive. When I arrived with Mr. Curtis, I again put my hand over the heart, and again distinctly felt it beat. Some one went for Dr. Dalliston. I myself went for Dr. Done. When I came back, after about six minutes, I found several people employing friction. When I tried the heart it was still. About five minutes after, Dr. Siddall came, applied the stethoscope to the body and pronounced the man positively dead. During the examination Dr. Dalliston arrived, examined the body carefully, and coincided with Dr. Siddall. I noticed then a peculiar change come over the features.

Mr. Roper, sworn :-I was in the Yokohama Hotel when the Captain of the Stag came and said, Captain Gilfillan had just died. He proposed that we should go over. Dr. Dalliston was there, using galvanic battery, Dr. Siddall was also there. When the body had been pronounced dead, I left. After dinner I went over again with Mr. Hall. In the room there was only a Malay besides the body of the captain. I kept my hand for one or two minutes on the captain's heart, and I distinctly felt it beat. I ran as fast I could to Dr. Siddall. I told him that I did not think the captain dead. He said, the man is perfectly dead, it is of no use that I go there, but I will come. He went with me, placed his stethoscope on the body and pronounced it dead. I was intimately acquainted with deceased, I think he drank pretty freely. I never saw him intoxicated. I know he was in the Yokohama hospital for some time. I was told that he was suffering from delirium tremens. I think he was under the treatment of Dr. Dalliston.

Mr. Curnow, sworn:- On Sunday morning at 6 o'clock I started with deceased to go to Tana. On the way up he complained of being unwell. I rode on ahead, and left him with a betto. I arrived at Tanabefore 1 p.m. Half an hour after the betto came on Captain Gilfillan's pony, saying that the Captain was unwell, staying at a farmhouse, and requesting a chair to be sent for him. A chair was sent. A couple of hours elapsed before he arrived at Tana. He took neither food nor drink until evening, when he took tea and chocolate. At 9 p.m. he was taken with vomiting, and afterwards went to sleep. In the morning he said he did not feel any better but he would not take a kango. After riding about seven miles I stopped at a farm-house. waiting for him to come up. He came, leading his pony, and said he had dislocated his arm. I sent to the next village for a chair. He said he thought. he should faint. He appeared to be suffering very much. At about 5 p.m. I heard that he had arrived at the hotel. I went over to tender my assistance in setting his arm. I went for the chloroform. I consider that he was insensible when the first bottle was finished. Before the second bottle arrived he came to his senses again, and remarked that he would require something stronger than chloroform to go to sleep. Then he expired, Dr. Dalliston said, "I believe he is gone," and added, "this is the first time this has happened to me." He threw cold water on his breast, and blew into his mouth, requesting us to keep the body in motion while he went for a galvanic battery. When Dr. Siddall came, he asked how long the Captain had been dead. I answered, "ten minutes," but some one in the room said twenty minutes. It was twenty minutes to six by Schwartz's time-piece when I brought the chloroform from the Dispensary. To reach the hotel from there would take about five minutes. It was administered immediately. The first dose from the second bottle took immediate effect. I knew deceased well.  I heard that he had been suffering from delirium tremens. He had no liquor on Monday except a glass of brandy immediately after he hurt his arm. I did not see the doctor feel the pulse while deceased was under the influence of chloroform.

Mr. Escombe, sworn:- I have known deceased for about two years. I know he was in the hospital, I think in February last. I think he was there about a month. I believe Dr. Dalliston attended him. He was suffering from drink. I have no knowledge of what life he has led since he left the hospital.

Dr. Wellings, sworn:- I am a member of the college of physicians of Edinburgh. I have been in medical practice since 1846. I have administered chloroform. Careful measuring of the doses, free admission of the air, attending to the state of the pulse, are among the general rules for the administration. It is always advisable to have another medical man present when you administer chloroform. Generally chloroform is poured into a glass measure, and that is sprinkled upon a handkerchief. About a drachm is considered a dose. I have frequently administered chloroform without using any measure. It would take about twenty-five minutes to administer an ounce of chloroform. If one ounce had not taken effect, I should not hesitate to apply another. I have seen up to four ounces given. A luxation of one of the joints is a prima facie case for administration of large doses of chloroform. If I knew the patient had been suffering from delirium tremens, it would not prevent me from employing chloroform. It is always advisable to examine the heart before administering chloroform. Drink does affect the brain, not necessarily the heart. Three or four hours is the longest time I have seen people under influence of chloroform. By cessation of the action of the heart I should know when my patient had died under chloroform. If I had no medical assistant in administering chloroform, I should use tho measure spoken of above. The strength of doses depends much upon the individual. It is rather the exception that patients die from chloroform, it does occasionally happen. The hearts' action is the only symptom, by which one can know that it is not advisable to give a patient any more chloroform; as long as the patient. is struggling, I think it quite safe to go on with the chloroform. It is necessary constantly to examine the state of the heart of the patient. It is possible but not convenient at the same time to pay due attention to the action of the patient's heart, and to set his dislocated shoulder. If other medical men were to be had, I should not attempt to do so by myself alone. Before administering chloroform, I should examine the heart with a stethoscope. The fact of the patient's sudden death under chloroform proves that too much has been given.

To Dr. Dalliston:- There are cases on record of deaths from chloroform where several medical men have been present. I do not think the question of life or death is a question of plurality of medical men. The number of medical men does not lessen the risk of death. The number of medical men is a question of convenience to the operating doctor. The quantity of chloroform requisite varies very much. In giving chloroform you are guided not by the quantity but by the approach to the insensibility. Speaking from my own knowledge, the best way of applying chloroform is with a handkerchief. Standing close to the head of a man you can hold the handkerchief over his mouth and reach his heart with your hand. I have seen it stated that there have been more fatal accidents in giving chloroform in case of a dislocated shoulder than in any other cases. In warm weather like this, holding the handkerchief some distance from the patients mouth would cause a great loss of chloroform which would not be inhaled by the patient at all.

To the Court:- The sudden stoppage of the heart's action would warn a medical man that there was danger, and in every case it would not be too late to apply restorative. I cannot think that deceased would have had a better chance of being alive if there had been more than one medical man present. As a rule, the previous application of a stethoscope would inform you if the patient. was a fit subject for treatment with chloroform.

To Dr. Dalliston:- I can ascertain the sound of the heart by applying my ear to the chest.

Mr. Whymark:- I could not say if Dr. Dalliston examined the patient's heart before administering the chloroform.

Dr. Dalliston:- I merely observe that I did not examine the heart at all on that occasion. It was not with that end I put the question to Dr. Welling.

Mr. Whymark:- During the administration of chloroform. I saw Dr. Dalliston put his hand on the patient's breast several times. The handkerchief was always held some distance from the patient's mouth and nostrils.

Dr. Done, sworn:- I am a medical doctor. I have had seven years' practice. I should think it would take about ten minutes to administer an ounce of chloroform. In the administration of chloro-form there is always a chance of the patient dying. There are many cases in which chloroform is administered easily and with safety, but those are precisely the cases which it is impossible to determine beforehand. Every medical man administering chloroform runs the risk of seeing the patient dying under his hands. I think the presence of two medical men lessens the risk by enabling the patient to be more narrowly watched; one attending to the respiration, another to the heart. In the case of emergency, I should not deem it indispensable to have another medical man. I do not consider it possible that a man could revive five minutes after the heart had ceased to beat. I do not think the quantity of chloroform is of so much consequence as the lesser or greater admixture of atmospheric air. Chloroform is usually administered continuously until the desired effect is obtained A constitution worn down by excess in drink would probably be more by affected by chloroform than another. If I knew that a man had been suffering lately from delirium tremens, I should be cautious about administering chloroform. There are conditions where it becomes almost indispensable to administer chloroform. To set a powerful man's dislocated shoulder may be such a case. It is a routine process to use a stethoscope before giving chloroform. I consider it a proper precaution, not absolutely necessary. If I knew the individual well before, it would not be necessary to examine him. The patient may die under chloroform even if he is not suffering from a weak heart. In that case I should attribute his death to being poisoned by chloroform, insufficiently mixed with atmospheric air. I could have attended at the hotel on Monday last, between 5 and 6 p.m. if sent for. My residence is the second door from the hotel.

Dr. Siddall to Dr, Dalliston:- I have never used more than two ounces of chloroform on any one patient myself. I am aware that people have died from chloroform, notwithstanding several medical men were present. I cannot venture any opinion as to the cause of Captain Gilfillan's death. I have heard he died from the effects of chloroform. If it was the heart's action that was stopped or the brain that was paralyzed, I have no means to judge.

To the Court:- I do not measure chloroform as I administer it. If the patient had been of late suffering from delirium tremens, and afterwards been freely drinking, I should give it slowly and watch the heart continuously. I should not administer it by myself alone, if I could have medical assistance.

The Coroner addressed Dr. Dalliston and told him that he was at liberty to make his statement, but he warned that that it could be used against him.

Dr. Dalliston, said that certainly he had expected to be called for his statement, which he thought was the principal one. After what had fallen from the Coroner he wanted to know if what was in his favour in his statement would be taken in consideration.

The Coroner: - I think not.

Dr. Dalliston then declined to make any statement. The room was cleared, and after a lapse of three quarters of an hour the jury gave the following:-

VERDICT.

We find that the deceased Capt. Gilfillan died at the International Hotel, No, 18, Yokohama, on Monday last, the 11th instant, between the hours of six and half-past p.m. from the effects of chloroform administered by Dr. J. J. R. Dalliston without proper degree of care. [BK]

 

The North-China Herald, 8 September 1870

IN H.B.M.'s COURT FOR JAPAN.

KANAGAWA, August 22nd, 1870.

Before Sir E. HORNBY - Chief Judge.

Re JOHN GILFILLAN, DECEASED.

   Upon reading the evidence taken before Mr. Consul Lowder sitting as Coroner on an enquiry into the cause of the death or John Gilfillan, who died on the 11th day of July, 1870, and upon finding that there was no committal of J. J. R. Dalliston for trial on the verdict of the Coroner's Jury, and being also of opinion that there is no evidence that the said John Gilfillan came to his death, or that his death was caused by the mode in which J. J. R. Dalliston administered chloroform to him, I hereby order the bail bond given by himself and his sureties to be forthwith discharged.

 

North China Herald, 5 February 1874

YOKOHAMA.

   An inquiry was held at the British Consulate on the 8th inst. into the death of William Wishart, who was found dead in one of the cells of the Foreign Police Station.  The jury found that death resulted from natural causes, but felt it their "duty to call attention to the inadequate supply of blankets provided at the station, and request H. B. M.'s Consul to bring this matter to the notice of the proper authorities; as also the desirability of keeping the cells at a fair temperature of warmth during cold weather, and of seeing that there is proper ventilation in summer."

 

North China Herald, 23 May 1874

YOKOHAMA.

   The Herald records an attempt at murder, and a suicide which happened on the 9th instant, at the British Camp.  About half-past eight o'clock several shots were heard, and on search being made, a woman and a private of the Royal Marines were found lying between two of the huts, both wounded.  The particulars of the circumstance appear to be as follows: - A private named Ingram had been for some time attached to a young woman named Jennie Anderson (or Mills).  Some time ago they had a quarrel, jealousy being said to be the cause, but this had been healed, and on Saturday, Ingram being confined to camp for breaking his leave, wrote to Mrs. Anderson to request her to come and visit him.  This she did, and the evening was passed in a friendly manner, and about half-past eight she rose to go home, Ingram going out with her to wish her good-bye.  Shortly afterwards the shots were heard, and on search being made the two persons were found as above stated.  Ingram appears to have pulled out a revolver and fired at Mrs. Anderson from behind, the ball slightly cutting the side of her face and her ear, and he then shot himself through the head.  An enquiry was held and a verdict delivered that Ingram came to his death by a wound self-inflicted, whilst in a state of temporary insanity.

Published by Centre for Comparative Law, History and Governance at Macquarie Law School