Toxicology Unit, Department of Clinical Biochemistry, Kings College Hospital NHS Foundation Trust, Bessemer Road, Denmark Hill, London SE5 9RS, UK
Centre for Forensic and Legal Medicine, University of Dundee, Dundee DD1 4HN, UK
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 26 September 2009
Received in revised form 9 December 2009
Accepted 18 December 2009
Available online 13 January 2010
Chloroform is still encountered occasionally in clinical and forensic toxicology, hence knowledge of the
special problems presented in the detection and measurement of this compound in biological specimens
may be required. The aim of this paper is to review the available documentation on this topic in the
context of a chloroform-related death.
Early one morning in February 1999 a 34-year-old female was found dead fully clothed on a path near
to a neighbours garden. Amfetamine intoxication combined with hypothermia was accepted as the
cause of the death in the absence of any other identiable cause. Further investigation 17 months later
revealed a blood chloroform concentration of 31 mg/L and the cause of death was revised to chloroform
poisoning. A murder trial ensued, the indictment specifying forced inhalation as the route of exposure.
The liver chloroform concentration measured 38 months after collection was reported as 1064 mg/kg
and opinions were offered at trial that the autopsy ndings, which included a gastritis, but no evidence of
injury to the inside of the mouth and oesophagus, excluded the possibility of ingestion of a toxic dose of
chloroform. It was asserted that the explanation for the high liver concentration was that the liver had
concentrated chloroform from blood after death against a concentration gradient. At appeal against
conviction 7 years later the conviction was quashed. It was found that the liver concentration should
have been reported at trial as 1 mg/kg. Moreover, chloroform found in the stomach contents (162 mg/kg)
86 months after collection was irrefutable evidence that some, if not all, of the chloroform had been
ingested.
Screening for volatile poisons should always be considered if a cause of death is not immediately
obvious, especially in young people and in known substance abusers. If the presence of an unstable or
volatile analyte is suspected then sample collection, transport, and storage must be performed with the
analysis in mind. Quantitative analysis of all available specimens should proceed forthwith once the
presence of an unstable analyte is established if the cause of death is in doubt or if prosecution may
follow. In the case of chloroform especial precautions are needed: (i) headspace analysis should be
performed at 35 8C to preclude the possibility of artefactual formation from trichloroacetic acid, (ii)
precautions to prevent cross-contamination of biological samples in the laboratory must be taken, and
(iii) interpretation of analytical results must take account of the widespread presence of chloroform in
the environment on the one hand, and that the toxicity of chloroform varies greatly depending on the
circumstances and intensity of exposure on the other.
2010 Elsevier Ireland Ltd. All rights reserved.
Keywords:
Chloroform poisoning
Chloroform analysis
Chloroform stability
Chloroform-biological specimens
Poisoning-volatile substances
1. Introduction
Although long superseded as an analgesic and anaesthetic agent
in clinical practice, chloroform is still encountered occasionally in
clinical and forensic toxicology. Hence knowledge of the analytical
and clinical toxicology of this compound remains important. An
* Corresponding author. Tel.: +44 20 3299 5824; fax: +44 20 3299 5825.
E-mail address: robert.anagan@nhs.net (R.J. Flanagan).
0379-0738/$ see front matter 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.forsciint.2009.12.061
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R.J. Flanagan, D.J. Pounder / Forensic Science International 197 (2010) 8996
water and/or alcohol since chloroform (to which 12%, v/v, ethanol
is usually added nowadays as a preservative) is an irritant poison
and as such whitens mucous membranes and reddens skin
(rubefacient action).
The original chloroform preparations or variants were soon
used with therapeutic intent, notably by Formby in 1836 who
found it benecial in the treatment of hysteria [13]. The rst
documented death under chloroform anaesthesia occurred on 28
January 1848 [4]. There were at least 50 such deaths by 1859 [1],
prompting the Lancet commission that invited doctors in Britain
and its colonies to report anaesthesia-related deaths [5]. Similar
concerns were prevalent in the US [6]. The possibility of fatal
complications occurring days after inhalational exposure must be
remembered [7]. Delayed hepatotoxicity due to chloroform
anaesthesia or analgesia during childbirth was reported widely,
for example [811], and was more likely when exposure was
prolonged.
Deliberate inhalation of chloroform in order to achieve
intoxication pre-dated its use in anaesthesia [12]. The American
dentist Horace Wells became dependent on chloroform and
committed suicide by cutting an artery in his groin whilst inhaling
chloroform having been imprisoned after throwing sulfuric acid
over a pair of prostitutes (1848). On 8 February 1848, Arthur
Walker, a young assistant in a drug warehouse in Aberdeen, was
seen to be leaning forward on a counter with his head stooped. He
appeared to be inhaling chloroform vapour from some folds in his
apron. His father was summoned, but when he arrived some
20 min later his son was dead [13]. This was a forerunner of many
thousand accidental sudden snifng deaths worldwide, although
nowadays chloroform itself is rarely encountered in such volatile
substance abuse (VSA)-related deaths [14]. Contributing factors in
sudden VSA-related deaths are thought to be cardiac sensitisation
to circulating catecholamines, vagal inhibition, and respiratory
depression or hypoxia, any of which may promote a fatal
arrhythmia [15,16]. The sudden exposure of the heart and/or
brain to relatively high concentrations of the agent inhaled, which
may be exacerbated by catecholamine release (ght or ight
reaction) if inhalation is forced or if an abuser is surprised, for
example by the unexpected appearance of a parent or of police, are
thought to be factors in some such deaths.
Deliberate inhalation, ingestion, on indeed injection of chloroform in order to commit suicide is well-documented [1,1721], as
is its use/attempted use in the perpetration of serious crime such as
rape, other assault, and murder [7,22] (Table 1). Use of chloroform
in order to commit rape and other felonies was made a criminal
offence in England, Wales and Ireland in 1851 (Prevention of
Offences Act, 13 and 15 Vict. ch. 19, s. 3). Deliberate inhalation to
enhance sexual (self-)gratication has also been described,
sometimes with fatal consequences [28,32,33,36]. Accidental
ingestion of chloroform has occurred, again sometimes with fatal
consequences [1,37].
When ingested the fatal dose of chloroform is much higher and
death occurs much later (generally 56 h post-ingestion) than
reported after inhalation [7]. This is because systemic absorption is
slower than after inhalation and the ingested chloroform has rst
to pass through the hepatic portal system before reaching the heart
and thence the brain. Thus, blood chloroform concentrations are
inevitably lower for a given dose and increase more slowly than
after inhalation. In such cases death is likely to be due either to
indirect causes such as inhalation of vomit, or to the respiratory
depressant effects of the drug.
Non-fatal ingestion or chronic inhalation of chloroform is
usually accompanied by features of hepatic damage that develop
25 days post-exposure and are otherwise similar to those
observed after prolonged anaesthesia [3741]. Signs of hepatic
damage have been reported after occupational exposure to
R.J. Flanagan, D.J. Pounder / Forensic Science International 197 (2010) 8996
91
Table 1
Post-mortem chloroform concentrations in blood, brain, liver, and stomach contents after acute poisoning in man.
Age (year),
sex
Blood
(mg/L)
Liver
(mg/kg)z
Stomach
contents (mg/kg)
Brain
(mg/kg)z
30, M
24, F
60
43
44
49
18, F
17
25
55
?
?
48
10
37
39
7
45, M
36
71
143
16, F
36
72
94
52, M
52, M
17, M
40
30
51z
86
16
201
<1
<1
7130
156
2650
113
29, M
123
540
133
131
85124#
120
180
3
280
64
116
298
24
800
7
23
<1
21
54
258
3
46
770
33
88
16
124
33, M
274
178
63
113
28, M
47
188
74
38, M
3, M
6, F
8, F
16, F
16, F
13, F
33
102
5
73
86
115
834
40
71
23
23,
31,
54,
52,
72,
78,
52,
F
F
F
M
F
M
M
39, F
z
#
Comment
Reference
McGee et
al. [26]
Table 2
Evidence of recent injuries recorded at the post-mortem examination.
No.
Injury
1
2
3
4
5
6
7
Faint blue bruise, 1.5 1 cm, on the front of the right arm, located 15 cm below the top of the shoulder.
Slightly raised blue bruise, 0.5 1.2 cm, located on the left upper eyelid in the outer half.
Speckled pink intradermal (supercial) bruise, 1.5 0.3 cm, located on the front of the left shoulder, 15 cm to the left of the anterior midline.
Very faint orange-based abrasion, 0.2 0.2 cm, located on the point of the chin, 1 cm to the left of the anterior midline.
Faint blue bruise, 0.3 0.5 cm, located on the lateral (outer) aspect of the left thigh, 30 cm below the level of the anterior superior iliac spine.
Very faint bluish bruise, 0.3 0.5 cm, located on the lateral aspect of the left thigh, 34 cm below the level of the anterior superior iliac spine.
Triangular shaped blue bruise, 3 3 cm, located on the lateral aspect of the dorsum of the right foot immediately below the lateral malleolus.
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Table 3
Summary of chloroform analytical data.
Sample
Container
Storage
Opened/thawed
before analysis?
Months before
analysis
[Chloroform]
Blood
Plastic screw-capped
Sterilin vial
10 days, 28 8C,
subsequently 15 to 20 8C
until rst analysis,
thereafter variable
No
17
31 mg/L
Yes
36
Vitreous
humour
Liver
Plastic
Yes
17
Not measured
Yes
38
Stomach contents
Plastic
screw-capped vial
10 days, 28 8C,
subsequently 15 to 20 8C
10 days, 28 8C,
subsequently 15 to 20 8C
until sent for pesticide
analysis, thereafter variable
10 days, 28 8C,
subsequently 15 to 20 8C
No
86
162 mg/kg
Plastic
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4. General discussion
It is at rst sight surprising that the fact that the death was
possibly chloroform-related was only realised 17 months after the
discovery of the body since a sensitive test to detect exposure to
trichloro-compounds has been available since 1914 (Fujiwara
test). Indeed the availability of simple methodology to detect
exposure to chloroform and to chloral hydrate led to a marked
decline in the use of these compounds for criminal purposes.
Nowadays of course HS-GC provides simple methodology for
detection, identication, and measurement of chloroform and
many other volatile poisons, some more common than others
[14,54]. That such methods are not used in difcult cases as a
matter of course is a consequence of the restructuring of toxicology
laboratories to deal with common problems (alcohol and other
drugs of abuse on the one hand, and drugs commonly used in selfpoisoning on the other) in order to contain costs on the assumption
that the circumstances will always dene the analysis required.
Toseland [59] drew attention to the folly of this approach. Lawler
[60], ironically writing from Manchester, the home of serial
homicidal poisoner Harold Shipman, emphasized the need to keep
an open mind and to pursue toxicological investigation when
confronted with an unascertained cause of death.
Once the presence of the chloroform in the blood sample from the
deceased was conrmed, neglect of the need to promptly analyse all
the remaining samples (HS-GC, 35 8C) in order to provide as much
evidence as possible as to the magnitude and possible route(s) of
exposure led to much debate and difculty. Of course, it now seems
that the value of the liver sample had been compromised before it
was analysed for chloroform prior to the trial. Be this as it may, the
presentation of the erroneous liver measurement at trial (i) diverted
attention from other possible causes of death, and (ii) generated the
entirely erroneous hypothesis that the liver had somehow managed
to concentrate chloroform out of blood after death against a
concentration gradient. This error was compounded by a one-sided
representation of the pathological features to be expected after
ingestion of chloroform.
5. Conclusions
In the case described, the fact that the likely cause of death,
chloroform intoxication, escaped detection initially and then that
the indictment specied forced inhalation as the route of exposure
caused many difculties. The opinions offered at trial that the
autopsy ndings excluded the possibility of ingestion of a toxic dose
of chloroform were incorrect. The chloroform found in the stomach
contents 86 months after collection was irrefutable evidence that
some, if not all, of the chloroform had been ingested. Screening for
volatile poisons should always be considered if a cause of death is not
immediately obvious, especially in young people and in known
substance abusers. If the presence of an unstable or volatile analyte
is suspected then sample collection, transport, and storage must be
performed with the analysis in mind. Quantitative analysis of all
available specimens should proceed forthwith once the presence of
an unstable analyte is established if the cause of death is in doubt or if
prosecution may follow.
Acknowledgement
We thank Mr JD Keegan QC for helpful criticism of the
manuscript.
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