Coroners Inquest September 1917

Croydon Advertiser 15 September 1917



While having teeth taken out at home, the death occurred on Tuesday of Mrs L B Osborne, aged 32, wife of a farrier, of 46 Howley-road, Croydon. The Borough Coroner (Dr. T. Jackson) held an inquest on Wednesday at Mayday-road.

There was no suggestion of negligence or incapacity against the medical man, Dr. W. A. Montgomery, of St. John's Grove, Croydon, who was conducting the operation without skilled assistance.

The verdict was that death was due to chloroform duly and properly administered for the necessary purpose, accelerated by the state of the deceased's health through pyorrhea arising from tooth decay.

Sidney T Osborne, the husband, said his wife had been in bad health for some time, suffering from toothache and nervous pains, owing to the state of her teeth. Dr. Montgomery said they must be attended to, and it was arranged that they should be extracted after a visit to her parents at Caterham. The operation was on Tuesday morning, when Mrs. Burchell, a neighbour, was present in the bedroom with the doctor. Witness was called in and told that his wife had taken the chloroform badly. He looked at her and she appeared to be dead. The doctor did all he could to try and revive her.

The Coroner said they were all sorry for the husband, but it was a thing that might happen to anyone.

Mrs. K. Burchell, of 48, Howley-road, said Mrs. Osborne asked her to be present when the teeth were extracted. The appointment was for ten in the morning.

The Coroner - a very good time - the best of all, practically.

The deceased (witness continued) was in bed. Dr. Montgomery did not tell witness he was going to give chloroform.

The Coroner - Did he examine her heart?

Witness - I did not notice.

Dr. Montgomery - She was out of the room when I did it.

Witness saw the chloroform administered on something placed over the deceased's face. She seemed a long time going off and did not struggle. Witness believed eight teeth or stumps were removed. Deceased suddenly turned blue and the doctor sent for Mr. Osborne. The blueness deepened and Dr. Montgomery did all he possibly could to revive the patient. The doctor had not hurried in giving the chloroform. He did everything very carefully indeed.


Dr. W. A. Montgomery, explaining the circumstances fully and frankly, said Mrs. Osborne had been a patient four or five years. Lately she had had a nervous breakdown, and suffered from pyorrhea and neuralgia. Pyorrhea was the formation of pus at the root of decayed teeth, and its discharging into the mouth.

The Coroner remarked upon how marvelously pyorrhea varied in its effects with various people. Some had it horribly and did not seem any the worse. With others it poisoned the whole system, and brought on all sorts of troubles.

Witness was not anxious to take out the teeth, but deceased wanted it done and in the end, he yielded. He advised her to first go away and get a bit stronger. When she returned she did not seem in very good fettle.

The Coroner - Having so many teeth to come out, I expect she wanted an anesthetic?

Witness - Yes, she was most careful to impress on me that she did not want to feel anything of it, and hoped I would give her enough. She took the chloroform very quietly and went under rather quickly. In all, she had barely four drams - not a large amount. Before the extraction began her pulse was decidedly good.

The Coroner - No signs of real heart disease?

Witness - None at all. He (witness) had had 20 years experience of teeth extractions, having been in a country practice where he often had to do everything single-handed.

The Coroner - And you have often given chloroform without a second doctor being present?

Witness - I may say hundreds of times. He (witness) saw no cause for apprehension during the operation. He had no difficulty and in three or four minutes completed this work, during which time the chloroform had been discontinued. The anesthetic was given on two folds of linen, over a frame, which enabled plenty of air to get in.

"Deceased turned blue," the doctor added, "and gave two deep sighs, from which moment she was pulseless."

The Coroner - They say that when chloroform kills it is mostly through the lungs - through failure of respiration - rather than of the heart.

Witness thought this was often so. He started artificial respiration at once and kept it up for an hour and a half. If the heart was going to do anything it had plenty of opportunity. He gave a hypodermic injection of strychnine and ether. But from the start there was no sign of life. Death he attributed to *syncop, probably due to the chloroform.

The Coroner - In a system poisoned, no doubt by the pyorrhea, would have hastened it?

Witness - Certainly.

The Coroner said the administration of the chloroform was in accordance with medical practice. In town a second practitioner was mostly present, if one could be got, which was not always the case, even in peace time. Sometimes the patient's means would not run to it. Risk of a fatality was always present. To his mind there was absolutely nothing approaching culpability in this case. Everything that could be was done for the poor woman.

The Coroner then suggested a verdict in the terms above given, and the jury without comment, immediately agreed.

The Coroner was sorry for all concerned including the doctor for, he added, these cases in any circumstances were very distressing.

Transcribed from the original at Croydon Library by Dr B E Osborne January 2009

* Syncope = transient loss of consciousness due to inadequate cerebral blood flow. Fainting.

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COMMENT - The above Inquest findings raise a number of queries. Firstly the evidence is inconsistent regarding how quickly the chloroform took effect. Also the normal accompanying second doctor was dispensed with possibly because of the question of limited finance available from the family. Thirdly, was the dosage really as low as is suggested? The Coroner appears to be leading Dr Montgomery in his replies and perhaps was sympathetic to the situation the good doctor found himself in. Lydia had insisted that the extractions must be painless. Perhaps the good doctor, with the best of intentions, unwittingly overdosed the patient on chloroform, particularly as she was not in a strong physical state. If so this would endorse a family legend that the "dentist" had overdone the dosage. Dr Montgomery was apparently so distressed by the scenario that he later committed suicide. This is unconfirmed at the moment as is the speculation above.


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