diff options
Diffstat (limited to 'old/68315-0.txt')
| -rw-r--r-- | old/68315-0.txt | 20347 |
1 files changed, 0 insertions, 20347 deletions
diff --git a/old/68315-0.txt b/old/68315-0.txt deleted file mode 100644 index b669458..0000000 --- a/old/68315-0.txt +++ /dev/null @@ -1,20347 +0,0 @@ -The Project Gutenberg eBook of On chloroform and other anæsthetics:, -by John Snow - -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you -will have to check the laws of the country where you are located before -using this eBook. - -Title: On chloroform and other anæsthetics: - their action and administration - -Author: John Snow - -Editor: Benjamin W. Richardson - -Release Date: June 14, 2022 [eBook #68315] - -Language: English - -Produced by: Richard Tonsing and the Online Distributed Proofreading - Team at https://www.pgdp.net (This file was produced from - images generously made available by The Internet Archive) - -*** START OF THE PROJECT GUTENBERG EBOOK ON CHLOROFORM AND OTHER -ANÆSTHETICS: *** - - - - - - ON - CHLOROFORM - AND - OTHER ANÆSTHETICS: - THEIR - ACTION AND ADMINISTRATION. - - - BY - - JOHN SNOW, M.D. - LICENTIATE OF THE ROYAL COLLEGE OF PHYSICIANS. - - EDITED, - - WITH A MEMOIR OF THE AUTHOR, - - BY - BENJAMIN W. RICHARDSON, M.D., - LICENTIATE OF THE ROYAL COLLEGE OF PHYSICIANS. - - - LONDON: - JOHN CHURCHILL, NEW BURLINGTON STREET. - MDCCCLVIII. - - - - - PREFACE. - - -The book here presented to the reader is the legacy to science of Dr. -JOHN SNOW. The completion of the work was his last act and deed. In -editing the book, therefore, all that remained to be done consisted in -the construction of the index, and in this a plan suggested by the -author himself has been followed. - -In contributing the memoir, I have performed a painful and unexpected -duty: the fulfilment of a promise given at a moment when two friends who -often enjoyed close companionship met at one of their happiest meetings. -The promise was given with the idea of fulfilment far distant, or -improbable altogether, and, as connected with a more extended -biographical survey, reserved for the work of years long in the future; -it is called for now hastily and in deep sorrow. - -Writing with the fact of my late friend’s death not as yet fully -realized; with the sensation still on me at intervals (like one who has -lost a part of his own body, and yet at times conceives the lost -present), that he cannot possibly be so far away; I may, perchance be -pardoned for any deficiencies in style or matter. I have done my best, -and leave it so. - - B. W. RICHARDSON. - - _12, Hinde Street, Manchester Square. - August 6th, 1858._ - - - - - CONTENTS. - - - HISTORICAL INTRODUCTION 1 to 24 - GENERAL REMARKS ON INHALATION 25–26 - - CHLOROFORM 27–344 - History and composition of 27–8 - Mode of preparation 28–9 - Chemical and physical properties 29–30 - Adulterations 30–32 - Vapour of 32–34 - PHYSIOLOGICAL EFFECTS OF CHLOROFORM 34–48 - Degrees of narcotism 35–43 - Effect of chloroform on the pulse 43–4 - Action of chloroform on the nervous system 44–8 - CIRCUMSTANCES WHICH INFLUENCE OR MODIFY THE EFFECTS OF - CHLOROFORM 48–58 - Age 49–50 - Strength or debility 50 - Hysteria 50–2 - Epilepsy 52–3 - Pregnancy 53 - The menstrual period 53 - Diseases of lungs 53–4 - —— —— heart 54–6 - Cerebral disease 56–7 - Insanity 57 - Hard drinking 57–8 - AMOUNT OF VAPOUR OF CHLOROFORM ABSORBED TO CAUSE THE VARIOUS - DEGREES OF NARCOTISM 58–74 - Experiments 60–73 - PREPARATIONS FOR INHALING CHLOROFORM 74–78 - MODE OF ADMINISTERING CHLOROFORM 78–97 - Signs of insensibility 87–97 - Repetition of chloroform during an operation 97 - RECOVERY FROM THE EFFECTS OF CHLOROFORM 97–100 - OCCASIONAL SEQUELÆ OF THE INHALATION OF CHLOROFORM 100–107 - Sickness 100–3 - Faintness and depression 103–4 - Hysteria 104–7 - CAUSE AND PREVENTION OF DEATH FROM CHLOROFORM 107–120 - FATAL CASES OF INHALATION OF CHLOROFORM 120–200 - ALLEGED FATAL CASES OF INHALATION OF CHLOROFORM 201–212 - SYMPTOMS IN FATAL CASES OF INHALATION OF CHLOROFORM 212–217 - MODE OF DEATH IN THE ACCIDENTS FROM CHLOROFORM 217–222 - THE TWO KINDS OF SYNCOPE 222–228 - SUPPOSED CAUSES OF DEATH FROM CHLOROFORM 228–245 - Idiosyncrasy 231–2 - Alleged impunity of chloroform 233 - Apparatus employed 233 - Alleged exclusion of air 233–4 - Alleged closure of glottis 234–8 - Alleged exhaustion from struggling 238–9 - Sitting posture 239–40 - Effect of surgeon’s knife 240–3 - Sudden death from other causes 243–5 - Falling back of the tongue 245 - STATE OF THE CHIEF ORGANS AFTER DEATH FROM CHLOROFORM 245–8 - FURTHER REMARKS ON THE PREVENTION OF ACCIDENTS FROM CHLOROFORM 248–251 - TREATMENT OF SUSPENDED ANIMATION FROM CHLOROFORM 251–262 - EFFECT OF CHLOROFORM ON THE RESULTS OF OPERATIONS 263–270 - ADMINISTRATION OF CHLOROFORM IN THE DIFFERENT KINDS OF - OPERATIONS 271–318 - Lithotomy 271–4 - Lithotrity 274–5 - Perinæal section 275–6 - Stricture 276 - Amputation of thigh 276–7 - —— —— leg 277 - —— —— arm 277–8 - —— —— ankle 278 - Other amputations 278 - Operations for necrosis 278–9 - Excision of head of femur 279 - Excision of elbow 279–80 - —— —— knee 280 - —— —— wrist 280 - Removal of tumours of upper jaw 280–5 - —— —— —— of lower jaw 285 - Tumours of female breast 285–7 - Other tumours 287–9 - Nævi 289 - Ligature of arteries 289–91 - Tumours of bone 291 - Hare-lip 291–3 - Cancer of the lip 294 - Division of nerves 294–6 - Operations on the eye 295–8 - —— —— —— ear 298 - —— —— —— nose 298–9 - —— —— —— mouth 299–300 - Plastic operations 300–1 - Raising depressed skull 301–2 - Operations for ununited fracture 302 - Reduction of dislocations 302–3 - Forcible movement of joints 303 - Tenotomy 303–4 - Operations for hernia 304–5 - —— —— —— hæmorrhoids and prolapsus 305–7 - Fissure of anus 307–8 - Fistula in ano 308 - Operations on ovarian tumours 308–10 - Operations for cancer of vagina 310 - —— —— —— rupture of perinæum 310 - Removal of testicle 310–1 - Operations for phymosis 311 - Removal of bursa 311 - Evulsion of nails 311 - Laryngotomy 312 - Extraction of teeth 313–18 - Secondary hæmorrhage after operations 318 - CHLOROFORM IN PARTURITION 318–329 - THE INHALATION OF CHLOROFORM IN MEDICAL CASES 329–344 - Neuralgia 329–31 - Spasmodic asthma 331 - Spasmodic croup 331–2 - Hooping-cough 332 - Infantile convulsions 332–3 - Delirium cum tremore 333–4 - Delirium in fever 334–5 - Hydrocephalus 335 - Tetanus 335–6 - Epilepsy 336–7 - Puerperal Convulsions 337–9 - Hysterical paralysis and contractions 339–41 - Mania 342 - Spasmodic pain 342–3 - Frequent and long continued use of chloroform 343–4 - - SULPHURIC ETHER, OR ETHER 345–371 - History and composition 345 - Chemical and physical properties 345–9 - Physiological effects 349–55 - Administration of ether 356–61 - Great safety of 362–9 - The combination of chloroform and ether 369–71 - - AMYLENE 372–410 - Preparation and properties 372–7 - Physiological effects 378–86 - Use in surgical operations 386–94 - Use in parturition 394–7 - Its effects 397–419 - - THE MONOCHLORURRETTED CHLORIDE OF ETHYLE 420–23 - - - ILLUSTRATIONS. - Chloroform inhaler 82 - Ether inhaler 349 - - - - - THE - LIFE OF JOHN SNOW, M.D. - - -There is not much credit in the mere acts of living and dying; in being -driven by unavoidable fate through the common journey, with shoulders -uncovered and the whip over them; in doing nothing save the drudgery of -existence; in enjoying, in an approach to the recognition of enjoyment, -the brief dreams of childhood; in struggling into manhood; in battling -through the after-strife obedient to the castigator behind; and in dying -at last, as though life had never been; dead to-day, wept for tomorrow, -and forgotten by the morrow’s succeeding sun. There is not much credit -in this surely, for credit must be earned by something done beyond that -which all must perforce do. But, in the face of all the struggles -incidental to the existence, so to have managed as to have stolen out of -time hours which other men knew not in their calendar—so to have defied -the inexorable taskmaster as to perform more than is included in his -demands; so to have willed and acted as to live on when death has done -his worst; to assist all coming wayfarers in their conflict wherever -they may meet it; to prove that there is something more in life than -labour lost, and nothing more in death than an idea—_Hoc opus hic labor -est_—in this there is achieved the grand attainment; the perpetual life. - -He whom I, with poor biographer’s pencil, put forward now in brief -sketch, is one amongst the few who have thus realized the ideality of -death. It were but little matter, therefore, though no biography should -appear at all; it is of but little count that such biography, as the -recollections of friends and intimates shall call forth, be scanty in -its details; it is of but little count that the life of him who is to be -shadowed forth is destitute of incident fitted for the taste of -wonder-loving, passion-courting, romance-devouring, readers. Biographies -for these are common. Good men are scarce. - -JOHN SNOW, the subject of the present memoir, was born at York, on the -fifteenth day of June, 1813. He was the eldest son of his parents. His -father was a farmer. His mother, who is living, resides still at York. -As a child, he showed his love of industry; and increasing years added -only to the intensity with which he applied himself to any work that was -before him. He occasionally assisted his father in agricultural -pursuits, and often in later life spoke with great _naïveté_ of the -recollections of those early winter mornings when his boy’s fingers were -too intimately to be pleasantly acquainted with the effects of benumbing -cold. He was first sent to a private school at York, where he learned -all that he could learn there. He was fond of the study of mathematics, -and in arithmetic became very proficient. At the age of fourteen, he -went to Newcastle-on-Tyne, as an apprentice to Mr. William Hardcastle, -surgeon, of that place. He had also the opportunities of studying at the -Newcastle Infirmary. During the third year of his apprenticeship, viz., -when he was seventeen years old, he formed an idea that the vegetarian -body-feeding faith was the true and the old; and with that consistency -which throughout life attended him, tried the system rigidly for more -than eight years. He was a noted swimmer at this time, and could make -head against the tide longer than any of his omnivorous friends. I have -heard him tell that so long as he continued to qualify his vegetables -with milk and butter, the vegetarian plan supported him fairly. But on -one unfortunate morning, when taking his milk breakfast, some quizzical -friend, learned in botany, cross-examined him as to the vegetable on -which he was then feeding. The joke went home; and the use of milk, as -food for a pure vegetarian, became too absurd for consistency. The milk, -therefore, must be put aside, and the butter and the eggs. The -experiment did not answer; the health of our pure vegetarian gave way -under the ordeal, and although in after life he maintained that an -approach to the vegetarian practice was commendable, in that it kept the -body in better tone for the exercise of the mind, he admitted that in -his own case his health paid the forfeit of his extreme adherence to an -hypothesis. Amongst his earlier scientific readings was a book in -defence of the vegetable regimen by John Frank Newton. This book is -annotated by himself, 1833. It is an useful book, full of curious -arguments, facts and suggestions, many of which, as his own after -writings indicate, he had carefully studied and applied. - -At or about the same time that he adopted his vegetarian views, he also -took the extremity of view and of action, in reference to the temperance -cause. He not only joined the ranks of the total abstinence reformers, -but became a powerful advocate of their principles for many succeeding -years. In the latter part of his life, he occasionally and by necessity -took a little wine, but his views on the subject remained to the end -unchanged; he had strong faith in the temperance cause, and a belief -that it must ultimately become an universal system. - -In 1831–32, cholera visited Newcastle and its neighbourhood, and proved -terribly fatal. In the emergency, Mr. Snow was sent by Mr. Hardcastle to -the Killingworth Colliery, to attend the sufferers from the disease -there. In this labour he was indefatigable, and his exertions were -crowned with great success. He made also on this occasion many -observations relating to this disease, which proved to him of immense -account in after years. - -He left Newcastle in 1833, and engaged himself as assistant to Mr. -Watson of Burnop Field, near Newcastle. Here he resided for twelve -months, fulfilling the assistant duties; regarding which it can only be -said, and that from analogy, that they were neither without their -anxiety nor their reward. Leaving Burnop Field in 1834–5, he revisited -his native place, York; made a short stay, and thence, to a certain -half-inaccessible village called Pately Bridge, in Yorkshire, to -assistant it with Mr. Warburton, surgeon there. Some few years ago a -friend of mine went to the same village, by the recommendation of Dr. -Snow, as assistant to the present Mr. Warburton of that place, a son of -Dr. Snow’s “old master”. The circumstance of this recommendation often -led Dr. Snow to refer to his life at Pately Bridge in our conversations. -He invariably, on such occasions, spoke of Mr. Warburton, his “old -master”, in terms of sincere respect, and depicted his own life there -with great liveliness. He was a vegetarian then, and his habits puzzled -the housewives, shocked the cooks, and astonished the children. His -culinary peculiarities were, however, attended to with great kindliness. -Eighteen months at Pately Bridge, with many rough rides, a fair share of -night work, a good gleaning of experience, and this sojourn was over. -Now back again went our student to York, to stay this time a few months, -and—not to be idle—to take an active share in the formation of -temperance societies. In leisure days during this period it was his -grand amusement to make long walking explorations into the country. In -these peregrinations he collected all kinds of information, geological, -social, sanitary, and architectural. - -At last York must be again left; the London student life was in view. In -the summer of the year at which we have arrived, 1836, he set off from -York to Liverpool, and, trudging it afoot from Liverpool through the -whole of North and South Wales, turned London-ward, calling at Bath by -the way, on a visit to his uncle, Mr. Empson, to whom, to the end of his -life, he was devotedly attached. October 1836—eventful October—brought -him to the “great city”, and placed him on the benches of the Hunterian -School of Medicine in Windmill-street: a school long since closed, and -now almost a myth; like the mill which gave the name to the locality. - -I am indebted to the courtesy of Mr. Joshua Parsons of Beckington, near -Bath, for an insight into the life and manners of my beloved friend -during his student career. Mr. Parsons had the happiness to be the -special fellow-student of Snow. Their friendship, cemented early in -life, never declined, but had added to it, “on my part,” says Mr. -Parsons, “respect and admiration for the solid talents and industry of -my old colleague.” Speaking of their common labours, Mr. Parsons writes -as follows: - -“Our acquaintance commenced in 1836, at the Hunterian School of Medicine -in Windmill-street, where we were both dissecting at that time. It -happened that we usually overstayed our fellows, and often worked far on -into the evening. The acquaintance thus grew into intimacy, which ended -by our lodging and reading together. We were constant companions from -that time till I left town, in October 1837. During that period Dr. Snow -was, as a student, characterized by the same mental qualities which have -marked him ever since. Not particularly quick of apprehension, or ready -in invention, he yet always kept in the foreground by his indomitable -perseverance and determination in following up whatever line of -investigation was open to him. The object of this steady pursuit with -him was always _truth_: the naked truth, for its own sake, was what he -sought and loved. No consideration of honour or profit seemed to have -power to bias his opinions on any subject. At the period of our -co-residence he was a strict vegetarian, and many and great were the -controversies held between us on the subject. These led to trials of our -comparative strength and endurance, in one of which, on Easter Monday -1837, we walked to St. Alban’s, and back to town through Harrow,—a -distance, I believe, of rather more than fifty miles. On reaching the -Edgeware Road, my companion was fairly beaten, and obliged to reach home -in an omnibus. But though this, you will say, shows a fair amount of -strength, yet it was my impression that my friend’s constitutional -powers were impaired by his mode of living, for I observed that he -suffered from an amount of physical excitability not to be looked for in -a man of his bodily powers and placid mental organization. I remember, -on two or three occasions, so slight an injury as a cut of the finger -with a dinner knife, or a graze of the skin, producing such an amount of -fever, attended by so rapid a pulse, and so intense a flush upon the -cheeks, that I once asked the opinion of an experienced medical friend -about him, and was by that opinion alone restrained from summoning his -uncle to his bedside. He also was subject to great drowsiness, so that -he was obliged often to close his books, and retire to bed long before -his inclination would have led him to do so.” - -In October 1837, Mr. Snow took out his hospital practice at the -Westminster Hospital. On May 2nd, 1838, he passed his examination, and -was entered duly as a member of the Royal College of Surgeons of -England. He lived at this time at 11, Bateman’s Buildings, Soho-square. - -In July 1838, Mr. Thurnham having resigned his post of apothecary to the -Westminster Hospital, Mr. Snow, with much promise of support from the -medical staff, competed for the vacant post. He presented excellent -testimonials from Mr. Hardcastle, Mr. James Allen of York, Dr. Conquest, -Mr. W. B. Lynn, Surgeon to the Westminster Hospital, Mr. Anthony White, -Sir Anthony Carlisle, Mr. Warburton, and Dr. Hunter Lane. His canvass -was very satisfactory; but he was compelled to resign his claims from a -cause which he did not expect. By the laws of the hospital, the office -of apothecary could only be held by a member of the Apothecaries’ -Company. In those days the worshipful Company were sometimes lenient in -admitting students to examination. The leniency, however, clearly -extended to those only who had friends at court. To render himself -eligible, Mr. Snow addressed a very simple, earnest, and gentlemanly -request to the Court of Examiners of the Apothecaries’ Company, begging -to be allowed to go up to his examination at the second court in July -instead of the first in October, at which he was legally admissible. The -request, under the circumstances, was not very great; but for some -reason it met with refusal. After the refusal he addressed a second note -to the Court, equal in tone with the first. In this note he urged the -simple character of the request; he reminded the sapient body that they -had allowed a similar extension of privilege to that asked by himself to -others, and even for less important reasons. He explained that he had -attended the practice of the Newcastle Infirmary; and promised that if -he could be admitted, he would fulfil the required term of hospital -curriculum rigidly. Lastly, he stated the expenses into which the -canvass had led him, and once more prayed for leniency of the examiners, -from “confidence in their kindness”. The confidence was misplaced. The -Blackfriars Shylocks demanded the pound of flesh; and our disappointed -student, on the very eve of success, was compelled to relate his -discomfiture in the following address: - - “_To the Governors of Westminster Hospital._ - - “MY LORDS, LADIES, AND GENTLEMEN, - - “I became a candidate for the vacant office of Apothecary to - the Hospital a little before my term of study was completed, expecting - that the Court of Examiners of the Apothecaries’ Company would admit - me for examination in time for the election, knowing that they had - granted a similar boon to my fellow-students on less important - occasions. I have asked the favour of that Court with all due respect - and ceremony, showing them that my course of study had already been - twice as long as they require; and they have refused to examine me - till my last item of study was completed according to their own - peculiar curriculum, without stating any reason for their refusal. I - must therefore necessarily resign, which I beg most respectfully to - do, and to offer my sincere thanks to all those who have taken trouble - in my behalf,” - -On the first Court of October 1838, held on October 4th of that year, -Mr. Snow met the Blackfriars Shylocks by legal right. They had not -forgotten him, and gave him good proof of their remembrances. He passed, -however, safe and sound; and, having the double qualification, laid -himself out for the duties of a general practitioner in medicine in the -great city. - -At this time there existed in London a society (now sunken into the -“Medical Society of London”) called the “Westminster Medical Society.” -It was a society which had long given encouragement to those junior -members of the medical profession who might wish for a hearing at its -meetings and debates. Mr. Snow was not the man to lose an opportunity -such as this. I have often heard him say, both privately and publicly, -that, upon this early connexion with the “Westminster Medical,” his -continuance in London depended, and all his succeeding scientific -success. When he first attended the meetings of the “Westminster -Medical,” he was very timid; and although he always spoke to the point, -found it difficult to obtain a favourable notice. At first, as he told -me, nobody ever replied to what he said. After a long time some grave -counsellor condescended to refer to him as the “last speaker”. “In -reference to an observation made by the last speaker, Mr. President, I -could bring forward many practical objections; but I prefer to observe -on the admirable, and, I have no hesitation in saying profound, remarks -which Dr. Goldstick” (a very great gun, of course) “has done us the -favour to lay before the society.” A little later and somebody ventured -to name the “last speaker” even by his name. Then some one, bolder -still, concurred with Mr. Snow; and ultimately Mr. Snow became -recognized more and more, until, as we shall see in the sequel, the -presidential honours were his own. - -Frith-street, Soho-square, No. 54, was the house at which Mr. Snow, to -use his own words, first “nailed up his colours”. He removed from -Bateman’s Buildings in the beginning of September 1838, and became, in -Frith-street, the tenant of Mrs. Williamson, widow of Captain -Williamson, known as the author of several works on India. He bought no -practice, nor exhibited any pretence. Like mighty Columbus, his caravel -was very insignificant when compared with the voyage on which he -embarked, and through which he sailed so successfully. He did not find -the voyage very smooth either at first. How could he? A man cast at -large in the modern Babylon, with few introductions, no plethora of -purse, and great purposes in hand, need never ignore the necessities -from the idea of rising to the crest of the wave by three cheers and a -long pull. Snow was too foreseeing to be ignorant of this, and he -prepared accordingly. A more thoroughly girded man for the world’s -encounter could hardly be conceived than he at this time. He took no -wine nor strong drink; he lived simply of the simple, on anchorite’s -fare, with more than anchorite resolution, with the temptations of the -world always before him; he clothed plainly, and made the best of -everything; he kept no company, and found every amusement in his science -books, his experiments, in his business, and in simple exercise. - -To fill up time till the money patients should come, he became one of -the visitors of the out-patients of Charing Cross Hospital; and to many -a poor representative of the great half-starved, extended a skill which -would have been a blessing to a duke. The Librarian of the College of -Surgeons’ Library knew him as a quiet man, who read closely, and was not -too proud to ask for a translation when an original bothered him. All -who knew him said he was a quiet man, very reserved and peculiar—a -clever man at bottom perchance, but not easy to be understood and very -peculiar. - -The connection with the “Westminster Medical” led to Mr. Snow’s first -attempts at authorship. On October the 16th, 1841, he read at the -Society a paper on “Asphyxia and on the Resuscitation of new-born -Children.” The paper in full will be found in the _London Medical -Gazette_ for November the 5th of the same year. The paper is remarkable -for the soundness of its reasonings, and the advanced knowledge which it -displays. The object of the paper was to introduce to the Society a -double air-pump, for supporting artificial respiration, invented by a -Mr. Read, of Regent Circus. The instrument was so devised that by one -action of the piston, the air in the lungs could be drawn into one of -the cylinders, and by the reverse action, the said air could be driven -away, and the lungs supplied with a stream of pure air from the second -cylinder. There was also advanced, in the concluding part of the -communication, a sentence or two on the cause of the first inspiration, -which is well worthy of note. The cause of the first inspiration, he -explained, is probably the same as the second or the last, viz., a -sensation or impression arising from a want of oxygen in the system. So -long as the placenta performs its functions, the fœtus is perfectly at -ease, and feels no need of respiration; but whenever this communication -between the child and its mother is interrupted, at least in the later -months of pregnancy, the child makes convulsive efforts at respiration -similar to those made by a drowning animal. - -On December the 18th, 1841, Mr. Snow was again before the “Westminster -Medical” with a very ingenious instrument which he had invented for -performing the operation of paracentesis of the thorax. The description -of the instrument will be found in the _Medical Gazette_ of January -28th, 1842. - -In the _Medical Gazette_ for November 11th, 1842, Mr. Snow published a -note on a new mode for securing the removal of the placenta in cases of -retention with hæmorrhage; and in the same journal for March 3rd, 1843, -he communicated an essay on the circulation in the capillary vessels. -The essay was selected and rearranged from papers read before the -“Westminster Medical” on January 21 and February the 4th. We have in -this essay an admirable sketch of the capillary circulation. He -advanced, on this occasion, the idea that the force of the heart is not -alone sufficient to carry on the circulation, but that there is a force -generated in the capillary system which assists the motion. He explained -also the great importance of the cutaneous exhalation, and reasoned that -in febrile states, accompanied with hot skin, the transpiration from the -skin is in reality greater than is normal, and that the good effect of -poultices and similar applications to inflamed skin is due to their -influence in checking the transpiration from the affected part. - -But what of practice during all this work at the purer science of -medicine? The story to be told is an old one. Practice did not come, at -least not from the wealthy. He had plenty of practice in so far as -seeing patients was concerned certainly, for he was encumbered with four -sick clubs; and his club practice, together with the out-patient work at -the Charing Cross Hospital, kept the bell ringing all day, and not -unfrequently enlivened the night with the clamorous music. But the -patients with the fees in their hands kept at a respectful distance. -Why? The answer gives another old story—because the practitioner at 54, -Frith Street, Soho, was an earnest man, with not the least element of -quackery in all his composition, with a retiring manner and a solid -scepticism in relation to that routine malpractice which the people -love. I have heard many reasons alleged for the want of success which -attended Mr. Snow’s first labours as a claimant on the public -confidence. These reasons have all had one reading, in that they refer -to every cause but the true one. The true cause was, that a young man -having no personal introduction to the bedsides of dowagers of the -pillmania dynasty, sought to establish his fame on the basis of a sound -and rational medicine—because impressed with the knowledge of the -external origin of disease, he went in for the removal of external -causes, and studied nature in preference to the Pharmacopœia. - -Pushing on in the higher branches of his profession, and aiming always -at the best, the degree of the University of London became a temptation, -and _Mr._ became _Dr._ Snow on the 23rd of November, 1843, by passing -the M.B. examination. He was enrolled in the second division on this -occasion. On the 20th of December in the following year, he passed the -M.D. examination, and came out in the first division of candidates. - -The harass of London life by this time commenced to tell on Dr. Snow. He -had suffered a few years previously from threatened symptoms of phthisis -pulmonalis, but took plenty of fresh air, and recovered. He again became -slowly unhinged for work, and in the summer of 1845, was attacked with -acute and alarming symptoms of renal disorder. His friend and neighbour, -Mr. Peter Marshall, then of Greek Street, now of Bedford Square, gave -him his able assistance, and the advice of Dr. Prout, and, I believe, of -Dr. Bright, was obtained. He was induced by their general opinion to -change his mode of living, and even to take wine in small quantities. In -the autumn of 1845, he paid a visit to his friend and old colleague, Mr. -Joshua Parsons, at Beckington, with whom he stayed a fortnight, enjoying -himself very much. The friends resumed their old controversies, and the -Doctor admitted that he had been obliged to relinquish his vegetable -diet in favour of a mixed regimen. He improved greatly, says Mr. -Parsons, during his stay; but it was obvious that London life and hard -study had hold of him. From Beckington he went to the Isle of Wight, but -soon returned to London and to his work. A little after this, he was -elected Lecturer on Forensic Medicine at the Aldersgate School of -Medicine, and held the appointment till the establishment dissolved in -1849. I have often heard from him, in his quiet droll way, many -laughable stories in relation to his duties in the forensic chair. When -he left off teaching, he found that, in addition to the labour implied -and the cost of experiments, he had to pay, with the rest of his -colleagues, a ransom for his release. - - -There is no night without its morning. The eventful medical year of 1846 -proved the turn of tide season with our struggling Esculapian. In this -year, the news came over from America that operations could be performed -without pain under the influence of sulphuric ether. - -The fact was just such an one as would at once attract the earnest -attention of Dr. Snow. It was a physiological, as well as a practical -fact. It was rational in its meaning, and marvellously humane in its -application. The question once before him, was in a scientific sense his -own. His previous experimental studies on respiration and asphyxia had -prepared him for this new inquiry. He lost no time, therefore, in -investigating the new fact; he took it up for its own sake, however, not -from any thought, at the time, of a harvest of gold. - -The first inhalations of ether in this country were not so successful as -to astonish all the surgeons, or to recommend etherization as a common -practice. The distrust arose from the manner in which the agent was -administered. Dr. Snow at once detected this circumstance; and, as he -explains in the pages of the work now in the hands of the reader, -remedied the mistake by making an improved inhaler. He next carried out -many experiments on animals and on himself, and brought the -administration to great perfection. One day, on coming out of one of the -hospitals (I am giving the narrative as he gave it to me), he met Mr. —— -(a druggist whom he knew) bustling along with a large ether apparatus -under his arm. “Good morning!” said Dr. Snow. “Good morning to you, -doctor!” said the friend; “but, don’t detain me, I am giving ether here -and there and everywhere, and am getting quite into an ether practice. -Good morning, doctor!” “Good morning to you!” Rather peculiar! said the -doctor to himself; rather peculiar, certainly! for the man has not the -remotest chemical or physiological idea on the subject. An “ether -practice! If he can get an ether practice, perchance some scraps of the -same thing might fall to a scientific unfortunate.” Consequently, with -his improved inhaler, Dr. Snow lost no time in asking to be allowed to -give ether at St. George’s Hospital. He got permission to give it there -to the out-patients, in cases of tooth-drawing. Dr. Fuller, of -Manchester-square, standing by, was surprised to see with what happy -effects ether was administered when administered properly. A day or two -afterwards, an operation having to be performed, and the surgeon (I -believe, Mr. Cutler) not approving of the ether in the way in which it -had previously acted, Dr. Fuller remarked on the superiority of Dr. -Snow’s mode of administering it; and the result was, that he was asked -to give it on operating days. He did so with great success. He -administered it at University College with the same success. Liston, -then the leading operator, struck with the new man who came before him -in such an able and unaffected way, took him by the hand; and from that -time the ether practice in London came almost exclusively to him. -Science for once put assumption in its right place. - -The new field once open, it were impossible but that he should cultivate -it diligently. The Westminster Medical Society was often favoured with -his communications and experiments on etherization; and in the September -of 1847, he embodied, in his first work, the whole of his experience up -to that time. The work was remarkable for the care with which it was -written, the science which it displayed, and the complete mastery of the -subject which it everywhere conveyed. - -What had been a mere accidental discovery, I had almost said a lucky -adventure, was turned by the touch of the master into a veritable -science. The book was readily appreciated by the profession, and was -just beginning to sell, when the discovery of the application of -chloroform threw ether into the shade and the book with it. - -Dr. Snow, though a man of great firmness when once his mind was made up, -was always ready for new inquiry. Chloroform, therefore, was no sooner -brought before the profession by Dr. Simpson, than he began to institute -a series of independent researches, and having satisfied himself -personally as to the effects and greater practicability of chloroform, -he at once commenced its use, and forgot sooner almost than others all -predilections for ether. In 1848, he commenced a series of experimental -papers on narcotic vapours in the _Medical Gazette_, and continued them -until 1851, when the _Medical Gazette_ virtually ceased to exist. The -papers on narcotics, in accordance with his other and earlier -productions, were stamped with the evidences of profound and careful -research, and still more careful deduction. I infer that they have been -more talked about than read, for few people seem to be aware of the -enlarged and positive physiological arguments which they contain. -Chloroform and ether are not alone discussed, but all narcotics. -Narcotics are not alone considered, but various of the great functions -of life. The records of a vast number and variety of experiments are -here related, and an amount of information, original in kind, collected, -which will always remain as a memorable record in the history of medical -literature. But the great points in these papers are those in which the -author enters on the physiological action of narcotics. Here appear the -generalizations and insights into the relations of allied phenomena -which mark the man of true power. His greatest deduction on these -matters, and the proofs on which it is based, are to be found in his -observations, where he explains that the action of the volatile -narcotics is that of arresting or limiting those combinations between -the oxygen of the arterial blood and the tissues of the body, which are -essential to sensation, volition, and all the animal functions. He -demonstrated that these substances modify and, in large quantities, -arrest the animal functions in the same way, and by the same power as -that by which they modify and arrest combustion, the slow oxidation of -phosphorus and other kinds of oxidation unconnected with the living body -when they (the narcotics) are mixed with the atmospheric air. - -In his modest way, he often spoke to me, with honest pride, on this -observation. He himself thought it the best observation he had ever -made, and believed that it would not be lost as an historical truth. -Placing a taper, during one of our experiments, in a bottle through -which chloroform vapour was diffused, and watching the declining flame, -he once said, “There, now, is all that occurs in narcotism; but to -submit the candle to the action of the narcotic without extinguishing it -altogether, you must neither expose it to much vapour at once, nor -subject it to the vapour too long; and this is all you can provide -against in subjecting a man to the same influence. I could illustrate -all the meaning of this great practical discovery of narcotism on a -farthing candle, but I fear the experiment would be thought rather too -commonplace.” - -The year of the world’s fair in London, 1851, may be considered a -fortunate one for Dr. Snow. His affairs had taken a new turn, and the -tide was fairly in his favour. He had a positive holiday, physical and -mental. The harass of the professional struggle was over, the world was -opening its eyes to his intrinsic merits; old friends flocked around -him, brought to the grand show in town, and all was well. He did but -little this year, except to write a characteristic letter to Lord -Campbell, who was pushing on a bill in the House of Lords, called the -“Prevention of Offences Bill,” in which a clause was introduced to -prevent, by severe punishment, any attempt that might be made by any -person to administer chloroform or other stupifying drug for unlawful -purposes. Dr. Snow, believing that Lord Campbell was actuated in -introducing this clause by the fact of certain trials having recently -occurred for the offence of using chloroform unlawfully, and being -himself convinced that, in two of the cases (the one the case of a -robbery in Thrale-street; the other, of a robbery attempted on London -Bridge), the evidence against the prisoners, of attempting to produce -insensibility by chloroform, was without any reason or possibility, he -opposed the afore named clause in the bill on the ground that if it -became law numerous frivolous and false charges would be constantly -brought up against innocent people, or against guilty persons, but -persons not guilty of the special charge laid against them, that, -namely, of administering a volatile narcotic by inhalation. Knowing that -weakness of human nature which leads a man, in the presence of all -evidence, never to admit intoxication as possible in his own proper -person, Dr. Snow felt that, in any case where an intoxicated person had -been robbed, such person might allege that he had been made insensible -by narcotic vapour. The two cases specially noticed in his letter -admitted readily of such interpretation, and were clearly not cases in -which chloroform had been administered. Lord Campbell, on the receipt of -Dr. Snow’s letter, referred to it in very complimentary terms in the -Lords’, but intimated that the reasoning of the letter did not alter his -determination. The editor of the _Medical Gazette_, Dr. Alfred Taylor, -opened fire on Dr. Snow; and for two or three weeks a sharp contest -occurred between the two doctors; but the matter soon rested, each -author retaining his own opinions, and both agreeing to differ. - -Dr. Snow’s amiable but firm nature led him often to this ultimatum. -Freedom of expression was a right he always claimed; but for this reason -he extended the same privilege to others. He was never stirred into -provocation by any difference of opinion. It was enough for him to form -carefully his own opinions, and then to hold to what he had said, so -long as he felt, from his internal convictions, that he was right. - -In the year 1848, Dr. Snow, in the midst of his other occupations, -turned his thoughts to the questions of the cause and propagation of -cholera. He argued in his own mind that the poison of cholera must be a -poison acting on the alimentary canal by being brought into direct -contact with the alimentary mucous surface, and not by the inhalation of -any effluvium. In all known diseases, so he reasoned, in which the blood -is poisoned in the first instance, there are developed certain general -symptoms, such as rigors, headache, and quickened pulse; and these -symptoms all precede any local demonstration of disease. But in cholera -this rule is broken; the symptoms are primarily seated in the alimentary -canal, and all the after symptoms of a general kind are the results of -the flux from the canal. His inference from this was, that the poison of -cholera is taken direct into the canal by the mouth. This view led him -to consider the mediums through which the poison is conveyed, and the -nature of the poison itself. Several circumstances lent their aid in -referring him to water as the chief, though not the only, medium, and to -the excreted matters from the patient already stricken with cholera, as -the poison. He first broached these ideas to Drs. Garrod and Parkes, -early in 1848; but feeling that his data were not sufficiently clear, he -waited for several months, and having in 1849 obtained more reliable -data, he published his views _in extenso_ in a pamphlet entitled “The -Mode of Communication of Cholera”. During subsequent years, but -specially during the great epidemic outbreak of the disease in London in -1854, intent to follow out his grand idea, he went systematically to his -work. He laboured personally with untiring zeal. No one but those who -knew him intimately can conceive how he laboured, at what cost, and at -what risk. Wherever cholera was visitant, there was he in the midst. For -the time, he laid aside as much as possible the emoluments of practice; -and when even, by early rising and late taking rest, he found that all -that might be learned was not, from the physical labour implied, within -the grasp of one man, he paid for qualified labour. The result of his -endeavours, in so far as scientific satisfaction is a realization, was -truly realized, in the discovery of the statistical fact, that of 286 -fatal attacks of cholera, in 1854, occurring in the south districts of -the metropolis, where one water company, the Southwark and Vauxhall, -supplied water charged with the London fæcal impurities, and another -company, the Lambeth, supplied a pure water, the proportion of fatal -cases to each 10,000 houses supplied by these waters, was to the -Southwark and Vauxhall Company’s water 71, to the Lambeth 5. - -There was, however, another fact during this epidemic, which more than -the rest drew attention to Dr. Snow’s labours and deductions. In the -latter part of August 1854, a terrific outbreak of cholera commenced in -and about the neighbourhood of Broad-street, Golden-square. Within two -hundred and fifty yards of the spot where Cambridge-street joins -Broad-street, there were upwards of five hundred fatal attacks of -cholera in ten days. To investigate this fearful epidemic was at once -the selfimposed task of Dr. Snow. On the evening of Thursday, the 7th of -September, the vestrymen of St. James’s were sitting in solemn -consultation on the causes of the visitation. They might well be solemn, -for such a panic possibly never existed in London since the days of the -great plague. People fled from their homes as from instant death, -leaving behind them, in their haste, all the mere matter which before -they valued most. While, then, the vestrymen were in solemn -deliberation, they were called to consider a new suggestion. A stranger -had asked, in modest speech, for a brief hearing. Dr. Snow, the stranger -in question, was admitted, and in few words explained his view of the -“head and front of the offending”. He had fixed his attention on the -Broad-street pump as the source and centre of the calamity. He advised -the removal of the pump-handle as the grand prescription. The vestry was -incredulous, but had the good sense to carry out the advice. The -pump-handle was removed, and the plague was stayed. There arose hereupon -much discussion amongst the learned, much sneering and jeering even; for -the pump-handle removal was a fact too great for the abstruse science -men who wanted to discover the cause of a great natural phenomenon in -some overwhelming scientific problem. But it matters little. Men with -great thoughts in their heads, think of little things which little men -cover with their wide-spread feet. It matters little, for the plague was -stayed; and whoever will now read dispassionately the report of a -committee, afterwards published by the vestry, and the demonstrative -evidence of the Rev. Mr. Whitehead, will find that the labours and -suggestion of Dr. Snow, in reference to the Broad-street epidemic of -cholera, must become each day better and better appreciated, as time, -which never yet told a lie, tells the tale and points the moral of the -event which is here so imperfectly described. Some who, at first, were -amongst those who held up the labours of our friend to ridicule, or -passed them over in contemptuous silence, have, indeed, since modified -their opinions, and have either tacitly accepted his facts, or have done -far worse by attempting to put them forward as though they were the work -of no single man, or of some one unknown, or as though their connection -with a theory destroyed the originality of the facts themselves. It was -my privilege, during the life of Dr. Snow, to stand on his side. It is -now my duty, in his death, as a biographer who feels that his work will -not be lost, to claim for him not only the entire originality of the -theory of the communication of cholera by the direct introduction of the -excreted cholera poison into the alimentary system; but, independently -of that theory, the entire originality of the discovery of a connection -between impure water supply and choleraic disease. The whole of his -inquiries in regard to cholera were published in 1855, in the second -edition of his work on the “Mode of Communication of Cholera”—a work in -the preparation and publication of which he spent more than £200 in hard -cash, and realized in return scarcely so many shillings. - -In 1856, he made a visit to Paris in company with his uncle, Mr. Empson, -who having personally known the present Emperor many years, had on this -occasion special imperial favours shown to him, in which the nephew -participated. During the visit, Dr. Snow lodged a copy of his work on -Cholera at the “Institute”, in competition for the prize of £1,200 -offered for the discovery of a means for preventing or curing the -disease. The decision of the judges has since been published, but no -note seems to have been made of Dr. Snow’s researches. - -The Medical Society of London, reformed under that name in 1849–50, by -amalgamation with the Westminster Medical, was at this time the -principal scene of Dr. Snow’s scientific exertions. In 1852, the Society -elected him as Orator for the ensuing year; and at the eightieth -anniversary of the Society, held on March the 8th, at the Thatched House -Tavern, he delivered an admirable oration on “Continuous Molecular -Changes, more particularly in their Relation to Epidemic Diseases.” He -made no claim to the orator’s gown; but the address was too forcible and -first class not to call forth the enthusiasm of the audience. It was -admirably received; and few of us who were present on that interesting -occasion will forget the simple and genuine earnestness of our beloved -associate, as in the twinkling twilight he carried us along with the -smooth current of his thoughts. He spent nearly twelve months in the -preparation of this oration. It was intended to convey, in the most -pleasing manner at his command, a broad view of his observations on the -communication of certain spreading diseases. He advanced, on this -occasion, the idea that intermittent fever, and perhaps yellow fever, -are, like cholera, carried by their poisons direct into the alimentary -system. - -Two years after this event, having, meantime, passed the office of -vice-president, the Society elected him to the highest honour it can -confer,—to the presidential chair. He took his place as President, in -his unassuming manner, on March 10th, 1855, delivering a short but -pleasing address. Throughout the year he carried out the duties of his -office with great success. One of his presidential acts was peculiarly -graceful. One evening, while presiding, Dr. Clutterbuck (then the -father, or oldest member of the Society) came into the meeting. The -venerable and distinguished old man, then long past his eightieth year, -had lately been a stranger to the assembly, and was known but to few of -the members. The President, as Dr. Clutterbuck entered the room, himself -rose, and in a way that was irresistible in its simple courtesy resigned -his chair to the veteran Esculapian. “It is near fifty years,” said Dr. -Clutterbuck with emotion, as he took the proffered seat, “since I last -occupied this honourable position.” At the next anniversary meeting, -held on March the 8th, 1856, Dr. Clutterbuck came to his last meeting, -and to see (so the fates willed it) his friend the President play also -his last part in presidential duties. At the anniversary dinner on that -same day, the President reviewed, in feeling terms, his own career in -the professional strife, and expressed that his success in life had -originated in his acquaintance with the Society over which he then -governed by the general will. - -In addition to the fellowship of the Medical Society, Dr. Snow belonged -to the Royal Medical and Chirurgical, Pathological, and Epidemiological -societies. He was also a member of the British Medical Association. The -Medical Society, from its old associations, was, however, that in which -he took the most active part. Next to this, the Epidemiological Society -claimed his regard. When Mr. Tucker first contemplated the formation of -the Epidemiological Society, Dr. Snow was one of the first with whom he -held consultation, and from whom he received that able support which -enabled him to found that excellent institution. From the first of the -Society, Dr. Snow was an active member. He was on many of its -committees; he was a member of council, and a frequent contributor to -its _Transactions_. He used often to meet with opponents to his peculiar -opinions at the meetings of this Society, but he always retained -friendships. - -The position which he took as an epidemiologist was original, and in -opposition to the views of many eminent men who had in the matters -relating to public health considerable influence, scientific and -political. He could not consequently, and did not, expect to go on his -way unopposed. But he did sometimes expect a more deliberate and -considerate attention to his hard wrought labours than he received or -deserved. He used constantly, though no great professor of Shakespearian -lore, to deplore the long admitted fact, that nothing so inevitably -tends to transform an earnest inquiring and enthusiastic man, into a -supercilious, superficial, and cold-hearted egotist, as translation from -the stool of self-reliance and independence, into the gilded chair of -office and brief authority. - -It must be admitted that Dr. Snow’s views on the spread of epidemics -were extreme in character; but from the slight which they too hastily -received, they were not, I believe, properly understood. It has often -been said that he encouraged by his arguments the perpetuation of -certain offensive arts and occupations which are injurious to the public -health; and in 1855, several journalists commented on him severely for -this supposed error. But the fact is, he never presumed that any man -could breathe with impunity other gaseous mixture than oxygen and -nitrogen in atmospheric proportion. He knew too well the effect of -inhaling chemical substances to allow of such supposition to enter his -mind. But he contended, in regard to pure epidemic disorders, -distinguished by specific symptoms, that these have a specific poison, -which is propagated by certain fixed laws, which attains its progression -and increase in and through animal bodies; which is communicated from -one animal body to another, and which is the same in its essence from -first to last. This was his position, and he adhered to it. No mere -emanation arising from evolution of foul smelling gas can, per se, -according to his views, originate a specific disease, such as small-pox -or scarlet-fever; as well expect that the evolution of such gas should -plant a plain with oaks or a garden with crocuses. True, small-pox may -occur over a cesspool as an oak may spring up from a manure heap; but -the small-pox would never appear over the cesspool in the absence of its -specific poison; nor the oak rise from the manure heap in the absence of -the acorn which seeded it. - -In 1855, Dr. Snow gave evidence before the select committee on the -“Public Health and Nuisances Removal Bill,” in which evidence he strove -to convey the impressions which are condensed above. Feeling that he had -not been correctly understood, he afterwards wrote a letter to Sir -Benjamin Hall, in which he set forth the whole of his argument very -distinctly and sensibly. He indicated in this letter that he was no -defender of nuisances, but that whereas a bad smell cannot simply -because it is a bad smell give rise to specific disease, so an offensive -business conducted in a place where it ought not be should be proceeded -against by ordinary law as a nuisance, without using in regard to it the -word pestiferous, or otherwise dragging in and distorting the science of -medicine. As time rolls on, it will probably be elicited that the -groundwork of Dr. Snow’s theory is sound. That if he committed error, it -was in adhering too closely to the abstract fact, and in not allowing -sufficient importance to the favouring influence of impure conditions in -the propagation and distribution of the specific poisons of the specific -diseases. - -At all events, the view he had maintained originally, he maintained to -the end, and throughout conscientiously; and the aspersions that the -object of his argument was to support his special theory regarding the -communication of cholera, are utterly unfounded. In the present year, -1858, he read at the Epidemiological Society, and published in the -_Medical Times and Gazette_, a repetition of his previous opinions, -strengthening them by a statistical record, showing that the mortality -of persons working at so-called offensive occupations is at certain ages -lower, and at certain ages slightly higher, than in the general -population. When the paper was read at the Epidemiological Society, Mr. -Edwin Chadwick made a long series of objections to the paper, and -complained that the argument was illogical. It was so, doubtless, on Mr. -Chadwick’s premises; but on the premises advanced by Dr. Snow, as to the -specific propagation of specific diseases by specific poisons, -physiological problems on which, from his experimental researches and -knowledge, he was far the best authority, his arguments were perfectly -logical, and perfectly consistent. - -In relation to public health, Dr. Snow contributed many other -observations. In the first number of the _Sanitary Review_, he -communicated a valuable paper, previously read at the Epidemiological -Society, on the “Comparative Mortality of Town and Rural Districts”; -and, previous to his decease, he was busily occupied in investigating -the question of adulteration of bread with alum. He made several -analyses of different specimens of bread, but his papers merely leave a -brief record of the fact, without any comments or results. - -We return for a few moments to some further points connected with his -researches on inhalation. In addition to his experiments with volatile -narcotics, he carried out for a long time a series of inquiries with -other medicinal substances, and administered many remedies by inhalation -at the Brompton Hospital, during a period of twenty months. In 1851, he -recorded the result of this experience at the Medical Society of London, -and explained the modes of administering various agents. Some, as -morphia and stramonium, were inhaled with the aid of heat; others, as -hydrocyanic acid and conia, were inhaled at the ordinary temperature. -The particulars of these experiments will be found in a short paper in -the _London Journal of Medicine_ for January 1851. - -He continued steadily to investigate the effects of various volatile -agents for the production of insensibility, and arrived by frequent -experiment to such a degree of positive knowledge regarding agents of -this class, that the composition and boiling point of any new chemical -body having been supplied, he could predict whether or not its vapour -would produce narcotism by inhalation. Other than the volatile narcotics -referred to in his present essay, he performed a variety of experiments -with carbonic acid, carbonic oxide, cyanogen, hydrocyanic acid, Dutch -liquid, ammonia, nitrogen, amylovinic ether, puff-ball smoke, allyle, -cyanide of ethyle, chloride of amyle, a carbo-hydrogen from Rangoon tar, -a carbo-hydrogen coming over with amylene, and various combinations of -these. His grand search was for a narcotic vapour which, having the -physical properties and practicability of chloroform, should, in its -physiological effects, resemble ether in not producing, by any accident -of administration, paralysis of the heart. The fact that in almost every -fatal case from chloroform the result had occurred from the action of -the narcotic on the central organ of the circulation, was never absent -from his thoughts. An agent having this effect, however intrinsically -valuable, was not to be put in the hands of every person for -administration. “There would be a great uproar,” he remarked on one -occasion, “if a student were to undertake on the operating table to tie -the femoral artery, and were to open the femoral vein. Yet at some of -our hospitals, the administration of chloroform has been entrusted to -the porter, who would only grin in ignorance, if informed that each time -his services were required, he performed the grand act of suspending for -a time the oxidation of the whole body, and of inducing a temporary -death; and who would tell you, if you asked him the composition of -chloroform, that it was smelling stuff.” He spoke this from no selfish -feeling, but with that kind of regret which an educated engineer would -feel, on referring to the fact of a railway porter who, knowing nothing -of steam, how to put it on, when to take it off, or why it propelled, -had mounted an engine and driven a host of confiding passengers to their -destruction. This is the way in which he expressed himself, and it would -be difficult to show that he was not correct. - -Intent on the discovery of some new anæsthetic, which might be more -safely entrusted to general use, Dr. Snow began, in 1856, to experiment -with amylene. As usual, he went to work cautiously and with precision. -First he ascertained the boiling point of the specimen supplied to him; -then the point of saturation of air with the vapour at different -temperatures; then the effects of inhalation of the vapour by inferior -animals, and the quantity required to be inspired, with the air -breathed, to produce insensibility. These were the usual steps in all -his inquiries of this kind. When he had obtained any substance which -would produce insensibility favourably on animals, he pushed it, in one -or two experiments, to its extreme in animals of different kinds; and -having produced death by the inhalation, both by giving rapidly a large -dose, and by giving a small dose for a long period, he observed the mode -of death, whether it occurred by cessation of the heart, or by cessation -of the respiration primarily. If the agent seemed to promise favourably -from these inquiries, he commenced to try it on man; and the first man -was invariably his own self. His friends, knowing his unflinching -courage in the ardour of his inquiries, often expostulated with him in -regard to the risks he ran. It was of no avail. He felt the personal -trial a duty, and he did it. I do not believe, as some have supposed, -that these personal experiments had any effect in producing his early -death; but it is certain that he underwent many risks in the performance -of his investigations, and that he held his own life of least -consideration when the lives or well-being of others were under -consideration. - -There is yet another trait in his character which I cannot but notice, -and which I would respectfully commend to all physiological inquirers. -While he held it as a necessity to use inferior animals for the purpose -of experiment, he never touched living thing with the physiologist’s -finger without having before him some definite object; and never -performed experiment on any animal without providing with scrupulous -care against the infliction of all unnecessary suffering. The interests -of humanity were, according to his rule, best advanced by the practice -of a humanity that was universal. - -He paid considerable attention to the subject of local anæsthesia, and -tried numerous methods for attaining to a knowledge of a perfect local -anæsthetic. He performed experiments with freezing mixtures, with -chloroform; and for the production of rapid and efficient benumbing by -cold, he tried, in 1854, the effects of applying solid carbonic acid to -the skin. At one of the meetings of the Medical Society, he reported at -length the results he had arrived at; but he was never satisfied with -them, and soon relinquished the inquiry, in order to concentrate his -energies on the discovery of what he felt sure must be discovered -ultimately,—an anæsthetic which might be inhaled with absolute safety, -and which would destroy common sensation without destroying -consciousness. - -To some extent he succeeded in this latter direction, in his discovery -of the physiological effects of amylene; and for some time he was -sanguine as to the great safety of the new agent. But the deaths which -he has so faithfully recorded as occurring in his own hands from -amylene, removed his expectations, and he discontinued its use as soon -as he learned the risks which might follow its administration. - -By his earnest labours Dr. Snow soon acquired a professional reputation, -in relation to his knowledge of the action of anæsthetics, which spread -far and wide; and the people, through the profession, looked up to him -from all ranks, as the guide to whom to entrust themselves in “Lethe’s -walk”. On April the 7th, 1853, he administered chloroform to Her Majesty -at the birth of the Prince Leopold. A note in his diary records the -event. The inhalation lasted fifty-three minutes. The chloroform was -given on a handkerchief, in fifteen minim doses; and the Queen expressed -herself as greatly relieved by the administration. He had previously -been consulted on the occasion of the birth of Prince Arthur, in 1850, -but had not been called in to render his services. Previous to the birth -of Prince Leopold, he had been honoured with an interview with His Royal -Highness the Prince Albert, and returned much overjoyed with the -Prince’s kindness and great intelligence on the scientific points which -had formed the subject of their conversation. On April 14th, 1857, -another note in the diary records the fact of the second administration -of chloroform to Her Majesty, at the birth of the Princess Beatrice. The -chloroform again exerted its beneficent influence; and Her Majesty once -more expressed herself as much satisfied with the result. - -Inquisitive folk often overburthened Snow, after these events, with a -multitude of questions of an unmeaning kind. He answered them all with -goodnatured reserve. “Her Majesty is a model patient,” was his usual -reply: a reply which, he once told me, seemed to answer every purpose, -and was very true. One lady of an inquiring mind, to whom he was -administering chloroform, got very loquacious during the period of -excitement, and declared she would inhale no more of the vapour unless -she were told what the Queen said, word for word, when she was taking -it. Her Majesty, replied the dry doctor, asked no questions until she -had breathed very much longer than you have; and if you will only go on -in loyal imitation, I will tell you everything. The patient could not -but follow the example held out to her. In a few seconds she forget all -about Queen, Lords, and Commons; and when the time came for a renewal of -hostilities, found that her clever witness had gone home to his dinner, -leaving her with the thirst for knowledge still on her tongue. - - -From the literary and general history of Dr. Snow, let us turn for a few -pages to his history personal. I will take the mean of the last eight -years of his life,—the period in which I knew him,—as the period from -which to draw particulars. He was of middle size, and, some years since, -slender; but of late he had become of slightly fuller build. His long -life in comparative student loneliness had made him reserved in manner -to strangers; but with private friends he was always open, and of sweet -companionship. With his increased popularity he became less reserved to -strangers; and within the last few years he so far threw off restraint -as to visit the opera occasionally. But he moderated every enjoyment, -and let nothing personal stand in the way of his scientific pursuits. He -was the impersonation of order. He had his time and place for -everything; he kept a diary, in which he recorded the particulars of -every case in which he administered chloroform or other anæsthetic, with -comments on the results of the administration, and hints as to dangers -avoided or chanced. He kept a record of all his experiments, and short -notes of observations made by his friends. He rose early, and retired -early to rest,—at eleven o’clock. He seemed, whenever he was waited on, -as though he had nothing in hand, and were always open to an engagement. - -Anything and everything of scientific interest arrested his attention, -and his kindliness of heart was at all times in the foreground. When I -was living at Mortlake, he would run down, on request, after his day’s -duties were over, to a _post-mortem_, to see a poor patient, or to take -part in an experiment, returning as cheerily as though he had been to -receive the heaviest fee. I name this as but one example of his kindly -nature; there are many who could corroborate the example in like -personal manner. - -He laid no claim to eloquence, nor had he that gift. A peculiar -huskiness of voice, indeed, rendered first hearings from him painful; -but this was soon felt less on acquaintance, and the ear once accustomed -to the peculiarity, the mind was quickly interested in the matter of his -discourse, for he always spoke earnestly, clearly, and to the point. In -the societies he spoke very often, and gave expression to views, on -which he had spent great thought, with a generous freedom which, in so -far as the fame of his originality was concerned, had been better held -in reserve. It had been better, that is to say, for him to have -carefully elaborated some of his views in the closet, and published them -fully, than to have sent them forth in the hurry of debate. Had he -lived, he would possibly have collected many stray labours thus put -forward, and have given to them the matured consideration which they -deserved. One of his views, on which he would have bestowed great -attention, refers to the origin of various morbid growths, as cancer. He -believed that these morbid formations are all of local origin; that they -arise in the parts of the body where they are found, from some -perversion of nutrition; and that the constitutional effects are -secondary to and dependent on the local disorder. He had made many -observations on this important subject, notices of which are to be found -scattered, here and there, in the proceedings of the Medical Society of -London, but no connected record was ever completed. - -His private conversation was both instructive and amusing; he was full -of humorous anecdotes, which he told in a quiet, and irresistibly droll -style; and when he laughed, his goodnatured face laughed in every -feature.[1] His anecdotes were never given in set form, but were -elicited by some circumstance or other which might happen to suggest -them. Once, when a friend of ours related at dinner some of the -economical measures of an odd old doctor who was known to some of the -company, he gave us an anecdote, showing how a man may work too hard for -his money. “When I was a very young man,” he said, “I went for a brief -period to assist a gentleman who had a large parochial practice. I found -his surgery in a very disorderly state, and thinking on my first day -with him that I would enhance myself in his opinion by my industry, I -set to work, as soon as his back was turned, to cleanse the Augean -stable. I took off my coat, cleared out every drawer, relieved the -counter of its unnecessary covering, relabelled the bottles, and got -everything as clean as a new pin. When the doctor returned, he was quite -taken by storm with the change, and commenced to prescribe in his day -book. There was a patient who required a blister, and the worthy doctor, -to make dispensing short, put his hand into a drawer to produce one. To -his horror, the drawer was cleansed. Goodness! cried he, why where are -all the blisters? The blisters, I replied, the blisters in that drawer? -I burnt them all; they were old ones. Nay, my good fellow, was the -answer, that is, the most extravagant act I ever heard of; such -proceedings would ruin a parish doctor. Why, I make all my parochial -people return their blisters when they have done with them. One good -blister is enough for at least half a dozen patients. You must never do -such a thing again, indeed you must not. I did not, for he and I soon -found a good many miles of ground between us, though we never had any -more serious misunderstanding.” - -His replies, when under the fire of cross-question, were ready and -commonsense. Once, he observed that in his opinion sulphuric ether was a -safer narcotic than chloroform. Why, then, said a listener, do you not -use ether? I use chloroform, he resumed, for the same reason that you -use phosphorus matches instead of the tinder box. An occasional risk -never stands in the way of ready applicability. On another occasion, -after one of the meetings of the “Medical Society,” when the subject of -a specific cholera cell had been under debate, some one asked him, as a -poser and rather ironically, where he thought the first cholera cell -came from? “Exactly,” he replied, with a droll face. “But to begin, do -you tell me where the first tiger or the first upas tree came from; nay, -tell me where you came from yourself, and I will then tell you the -origin of the first cholera cell, and give you the full history of the -first case; but I want a model before I venture on the description of -ultimate facts.” - -As an author, his style was plain, clear, and smoothly elegant. His -argument was always carefully studied and as carefully rendered. He sent -manuscript to the printer which required scarcely a letter of -correction. Both in writing and speaking, he made the expression of -truth his first business. Neither provocation nor temptation could ever -lead him aside from that principle. His readings were select. He chiefly -read scientific works, old and new. He had great relish for some of the -old medical writers—the masters in physic. He had read Bacon, but agreed -with Harvey’s criticism that Bacon wrote science like a lord chancellor. -He had a notion that there had been a history long previous to any we -know of from existing records, in which the sciences generally had risen -to a greater perfection than they are at this present. His conversance -with Sprengel’s _History of Medicine_ had possibly led him to this -opinion. He was fond of general history also, but studied it little. He -never read novels, because the hours devoted to them were, he felt, -hours thrown away. At the same time, he enjoyed as much as any man -ridiculous life-pictures naturally cast. When he came to see me, and -leisure was with us, I used often to read to him some of the more -amusing passages from Dickens and Thackeray, or from one of the older -writers, as Swift. It was a new world to him, and provoked great fun. He -would ask to have passages read over again, that he might better realize -the conception. He enjoyed vastly any anecdotes about the old men in -physic, the Cullens and Meads and Arbuthnotts and Harveys. Any such -anecdotes he took into his memory and never forgot them. - -On such occasions I would, in ridiculous mood, sing him absurd songs to -any tune, two or three tunes, or to no tune at all, and without any -pretence at voice. At first he would listen with his hands flat together -and with a perfect melancholy on his face, as if he could hear it no -longer. Bit by bit he would relax, and at last get into a continued -laughter. Then I would stop, and he would begin to open out his list of -anecdotes, professional and general, upon which the laughter came over -to me with compound interest, for of men enriched with stores of droll -stories, few could equal him. Nor was he inventive in these narrations; -he had simply observed character shrewdly, and described it in its -humorous phases. If he had written as he related, he would have ranked -as one of the humorists of the age of no second order. - -He thought severely of the reviewer’s art, and would never of late -review any book critically. If a book were good, it carried the review -of its own merits. If it were bad, it were better left untouched. He, at -all events, with so much original work before him, could not stop to -criticize his compeers or their transactions. Let the dead bury their -dead; he must march with the living while life gave power. - -Notwithstanding, he was fond of controversy and courted it. I expressed -to him once some surprise that he with such an even temper should write -so often in controversial style; and that surely it were better to -follow Harvey’s and old Sam Johnson’s plan, to do the best oneself, and -leave the controversy altogether to others less personally influenced. -He agreed that this was by far the best system, but did not think it -practicable generally, and feared that silence might often be -misinterpreted. - -Men who have something in them take different courses in the way of -accepting the world’s recognition of their labours. The beginning, in -most cases, is after a given pattern; the end is modified and turned -about variously, according to the stamp of the man. All start with an -exaggerated appreciation of their own doings, and with exaggerated -feelings respecting the critics who first notice them. The critic is -Jove the all wise, or Pluto the all black. There was never middleman -critic yet. Some men stop at the first, either too elated with the -pleasure of the first reception to venture more, or too cast down from -the pain of a sharp reception to tempt fortune further. Cowards these -both, in one word. Others enter into violent controversies; in the heat -of the same, drop one or two contradictions, and, wishing every month -that Cadmus had been still born, go on always at controversy, boring -everybody, and especially those who would believe if not bored. Others, -again, soon find their own level, and not only their own, but the level -of their critics. Surfeited with commendation, or hardened by attacks, -these care little for either, and make no retorts save such as are by -ambuscade and go right home. A fourth class, of immovable temper and -self-reliant, fall into what seems, superficially, indifference, but -which means, deeply, the soul of earnestness. These do always the best -thing at the time, and, when it is done to their own satisfaction, put -it forward, with no anxiety whatever as to what may be said of it, with -no intention of entering into any defence of it, and with no intention -of doing anything less than themselves correct all such errors in it as -after knowledge may indicate, or commit it to the flames, if destruction -be its best fate. Fatalists in letters, men of this class, if it be -pleasure to call them so; but great fatalists too—honest reviewers of -their own works, who fear their own criticisms, and none other; who -offer immense labours, and die to them as they offer. Dr. Snow, as we -have seen, was the representative rather of the controversial class of -workers. But he had his own way of doing the controversy business, which -saved friendships, and exhibited a firm principle and an exact -knowledge. It is not to be denied, however, that, had he put his labours -before the world, and trusted in them and on the world’s justice, never -replying a syllable, he would have avoided an extremity of argument -which was often not merely unnecessary in relation to his propositions, -but injurious to them, as reasonings overstrained. - -He admired art, and felt real pleasure in advancing it. He enjoyed -innocent recreations, and was ever at home in the family circle. He had -his regrets that he had never married, the fates had been against him -permanently on that score. He loved the prattle of children. When he -went to court during last season, and had arrayed himself in his court -suit, nothing connected with the event amused him so much as the saying -of the child of a friend, who, on seeing him start, with his sword and -flattened hat, held up her hands, and exclaimed: “Oh! isn’t Dr. Snow -_pretty_, mamma.” The idea of being considered pretty roused in him -quite a new and droll sensation, which he could not help telling about -as a rare incident in a courtier’s career. The anecdote is simple, but -it gives a good idea of the simple and genial nature of the man. - -It has been shown that the tendency of Dr. Snow’s mind for philosophical -pursuits led him away in some measure from the practical drudgery of -professional life. From this fact, it has been too hastily inferred that -he was therefore, in the common parlance, “not a practitioner.” Those -who knew him as a practitioner, who had had the advantage of his -assistance in cases of doubt or difficulty, have a very different -opinion. These speak of him, with one accord, as having been, without -any ostentation, one of the soundest and most acute of our modern -physicians. He had great tact in diagnosis; an observant eye, a ready -ear, a sound judgment, a memory admirably stored with the recollection -of cases bearing on the one in point, and a faculty of grouping together -symptoms and foreshadowing results, which very few men possess. Mr. -Peter Marshall, of Bedford Square, who often called in Dr. Snow in -consultation, has remarked to me in nearly the same terms as I have -expressed, his independent appreciation of Dr. Snow’s practical -knowledge. For my part, I never had the good fortune to put many fees -into his pocket; but as I had often the pleasure of meeting him on pure -scientific grounds in cases of interest, I can bear truthful testimony -to his eminent qualities as a practitioner, and to the fact that his -philosophical labours only served to render him more intelligent and -profound in matters relating to diseases and their treatment. He did not -become the idol of the people in common practice, far from it: but the -failure arose not from deficiency of knowledge, but from a more perfect -knowledge with assumption whipped out of it. It is no discredit to his -memory that he was not the idol of the people in common practice, though -it cost him much suffering to feel himself kept down, by that wisdom -which is the oil to the water of popular ignorance concerning life and -its laws. For, to be the idol of the people in physic, is too often to -be the Juggernaut of physic,—an idol of wood or of stone in showy gold -and tinsel. This idol has neither sense nor force; if it had, it were -not an idol; it would walk off, or tell the worshippers no longer to -shake hands constantly with themselves in its presence. - -But, when the opportunity offered for obtaining remunerative practice by -the exercise of his scientific skill, Snow showed himself, both in act -and industry, competent for success. He soon overcame all difficulties, -and managed by his frugality to lay in store for a rainy day for -himself, and to help such friends as needed. Many rumours as to the -extent of his gains abound which it is right to correct. His income of -late years was near £1,000 a year, but it never exceeded that sum. For -this, he exhibited chloroform or one or other anæsthetic about four -hundred and fifty times annually, taking an average of the ten years -preceding his death. In a large number of these cases, however, his -services were gratuitously supplied. - -In his private relations, Dr. Snow was a man of the strictest integrity -and purest honour. The experiences of life, instead of entwining about -him the vices of the world, had weaned him from the world. Without any -pretence, maintaining no connection with sect or party, living by the -rules of the eternal laws which, according to the best of his abilities, -he could read from the universe, he carried out a practical religion, -independently of any hypothesis or abstruse profession, which few -professors could approach. A child of nature, he knew no way of -recognizing the Divine influences so purely as in silent and -inexpressible admiration of those grand external phenomena which -pharisees see not, but which each moment convey to men of his character, -the direct impression of a Power all present and revealing itself for -ever. - -We approach the end. In the midst of his success, when medicine most -needed him and his hand was most powerful, he stood one day in his -mental strength, and the next day fell. Death found him at his work, and -the stern enemy came on him suddenly, though not without -forewarnings.[2] - -His health had long been indifferent; he had suffered from hæmatemesis -several times in the last few years, for which Dr. Budd had attended -him, and he had his own forebodings that his life was not of the -longest. In the month of December 1857 he was suddenly seized one -evening with vertigo and sickness, which compelled him to keep the -recumbent position for more than twenty-four hours. At the end of this -time he felt better, and went about his usual avocations. He had no -convulsions at this time, nor did he lose his consciousness. After this -attack, he complained on many different occasions, both to his -housekeeper and to several of his medical friends, of numbness in his -extremities. Some of these to whom he mentioned this circumstance, do -not recollect whether this symptom was greater on one side of the body -than on the other; while others distinctly state that it was referred to -the left side only. His housekeeper was certain that he never complained -of this numbness before the attack in December; and even afterwards, it -would appear to have been only an occasional symptom. For six weeks -before his final seizure he had made no mention of it. About three weeks -before his last attack, he had complained, for some days, of a severe -pain in the back of his head, which he himself considered neuralgic, and -for which he treated himself. This pain quite left him, and for about a -fortnight he had been enjoying excellent health. - -On the evening of Tuesday, June the 8th, 1858, he attended a meeting of -the Royal Medical and Chirurgical Society. On the following evening -there was a meeting of a private society for the study of chest -diseases, held at Dr. Quain’s. The subject discussed was the cause of -the first sound of the heart. On this, the last occasion of the kind at -which he was present, he was in unusual spirits, and looked exceedingly -well. He entered into the debate with great earnestness, agreed to form -one of a committee to inquire into the cause of the first sound by -experiment, and left his friends with enthusiastic expression as to the -success of the proposed undertaking. We exchanged our last farewells -that night. - -He went to bed at half-past eleven o’clock on June 9th, and on the -following morning he came down stairs at 8 A.M. When he came down, he -complained to his housekeeper of slight giddiness, and she thought he -did not walk very steadily. He reclined on the sofa, and said that he -should be well again in a few minutes, but that he did not think he -could eat any breakfast. Soon after, however, he got up, said he felt -very hungry, and ate a very hearty breakfast. When this was done, he -proceeded to write a portion of the manuscript of the work on -anæsthetics now published. He had written to the last printed sentence, -when his housekeeper, who had scarcely left him, heard a great noise, as -if some one had fallen. She ran up again and found her master on the -floor, making vain endeavours to regain his chair. He does not appear to -have had any convulsions, and his consciousness was unimpaired, for he -remarked when his housekeeper came into the room, that though he did not -quite understand the nature of his complaint, he was very sure he never -had had any such symptoms before. His housekeeper observed that he had -quite lost all power over his left arm and leg, and that his mouth -appeared drawn to the right side. She had him lifted on the sofa; and -here he remained for twenty-four hours before any medical assistance was -sent for. This was his own wish, as he said he should soon be better, -and that he did not wish to trouble any one. During this period he -complained much of pain over the lower end of the sternum, which he -endeavoured to relieve by frequent inhalations of sulphuric ether, but -he neither ate nor slept the whole time. At 6 A.M. on the morning of -Friday, June 11th, retching came on, and he vomited a considerable -quantity of blood. Upon this his housekeeper sent for Dr. Budd, who, -along with Dr. Murchison, continued to attend him to the last. His -symptoms, when seen by these gentlemen, were briefly as -follows:—Complete paralysis of motion over the whole of the left side of -the body, but without loss of sensibility; the left angle of the mouth -falling down, and the apex of the tongue deviating to the left; memory -and consciousness were unimpaired; there was pain and great tenderness -in the epigastrium, with urgent hiccup and hæmatemesis; there were -slight indications of albuminuria, but there were no dropsical symptoms. - -The hæmatemesis ceased after about twenty-four hours, but the vomiting -and hiccup continued. By Monday, the 14th, these symptoms also had -subsided, but others of a more alarming nature began to show themselves. -The pulse and respiration became accelerated, the countenance and -extremities became livid, and there was occasional wandering delirium. -These symptoms gradually increased in severity; but he retained his -consciousness until 11 A.M. of Wednesday, June 16th, when the breathing -became stertorous, and deglutition impossible. Throughout his illness, -he had been sanguine of recovery, and expressed his belief frequently -that he should soon be at his professional work again. On this, the last -morning of his life, the fact of the danger in which he was placed was -explained. He met the intelligence with calmness, but felt a wish to see -Dr. Todd. Soon he sank into a somnolent state approaching to -dissolution, and at 3 P.M. death took him.[3] - -On the Monday following, Dr. Snow was buried at the Brompton Cemetery. -It was the wish of many of his medical friends to follow him to his last -home. But his relations, recalling his own unostentatious feelings, laid -him in the grave in simple ceremony; and there, ingenuous friend, in the -sleep that knows no waking, he sleeps on and takes his rest; the rest he -has earned. The old changes of the world live after him, women mourning -for their children; youths exulting on the marriage day; the inanimate -returning to the elements; the animate returning to the infinite. But in -the gaping time shall it chance rarely, for another science-man to come -and go, who, taking him all in all, may call him “brother”! - - - - - HISTORICAL INTRODUCTION. - - -The most important discovery that has been made in the practice of -medicine since the introduction of vaccination, is, undoubtedly, the -power of making persons perfectly insensible to the most painful -surgical operations, by the inhalation of the vapours of ether, -chloroform, and other agents of the same kind. - -In giving a brief outline of this discovery, it is necessary to inquire -into the attempts of every kind which had previously been made to -prevent severe pain; and also to notice the history of medicinal -inhalations, whether undertaken with the view of preventing pain, or of -relieving or curing disease. - -The practice of taking opium and other vegetable narcotics, to relieve -pain or procure sleep, was common in the most remote periods to which -history extends; but the earliest notices which remain of any attempts -to prevent the pain of surgical operations were written at the period of -the Roman Empire. They were alluded to by Dr. Simpson at the -Medico-Chirurgical Society of Edinburgh in November, 1847.[4] -Dioscorides,[5] speaking of mandragora, says, “Some persons boil the -root in wine down to a third part, and preserve the decoction, of which -they administer a cyathus (rather more than an ounce and a half) in want -of sleep and severe pains of any part, and also before operations with -the knife or the actual cautery, that they may not be felt.” (Ante -sectiones ustionesve, ut ne sentiantur.) Further on he says: “A wine is -prepared from the bark of the root without boiling, and three pounds of -it are put into a _cadus_ (about eighteen gallons) of sweet wine, and -three cyathi of this are given to those who require to be cut or -cauterized: when being thrown into a deep sleep they do not feel any -pain.” - -The same author also adds,[6] in speaking of a kind of mandragora called -morion, “They relate that a drachm of it being taken as a draught, or -eaten in a cake or other food, causes infatuation, and takes away the -use of the reason. The person sleeps without sense, in the attitude in -which he ate it, for three or four hours afterwards. Medical men also -use it when they have to resort to cutting or burning.” - -In treating of mandragora, Pliny[7] remarks that the juice of the leaves -is more powerful than the preparations made from the root. He says, -“Some persons even die from a considerable draught. It has the power of -causing sleep in those who take it. The dose is half a cyathus (six -drachms). It is taken against serpents, and before cuttings and -puncturings, lest they be felt. For these purposes it is sufficient for -some persons to have sought sleep from the smell (of the medicine).” - -Apuleius,[8] under the head mandragora, says, “If any one eat it he will -immediately die, unless he be treated with butter and honey, and vomit -quickly. Further, if any one is to have a limb mutilated, burnt, or -sawn, he may drink half an ounce with wine, and whilst he sleeps the -member may be cut off without any pain or sense.” - -After reading the above passages from such well-known authors, it may be -asked how it was that the practice of preventing the pain of surgical -operations was entirely unknown just prior to 1846. - -The reason, no doubt, was that the statement these passages contain was -looked upon as a vulgar error of the period, which had imposed on the -credulity of the authors. Dr. Woodville,[9] speaking of the use of -mandragora by the ancients, says, “They employed it principally in -continued watchings, and in those more painful and obstinate affections -which were found to resist less powerful medicines.” He gives, in a foot -note, a reference to the place in Dioscorides from which the passages -above quoted are taken, and had he believed in the performance of -operations without pain, we may conclude he would not have passed over -so important a fact in silence. - -With the knowledge we at present possess, however, a different view must -be taken of the subject; and it must at least be allowed that the -statements of the ancients had some foundation in truth. This is -rendered more certain by the circumstance that atropa mandragora belongs -to the same genus as belladonna, which has a greater power in annulling -the common sensibility than any plant in present use, unless it be -aconite. The loss of reason, described by Dioscorides as caused by -mandragora, is a striking symptom of poisoning by the class of plants -(the solanaceæ) to which it belongs. It appears from some remarks of -Aretæus[10] and Cælius Aurelianus[11] that people were in the habit of -taking mandragora as an inebriating agent in the time of the ancients, -as an allied plant, the datura, is used at present by the natives of -India. This practice would lead to a correct knowledge of the quantity -which might be taken with impunity. - -The mandrake is scarcely used in medicine at present, but its narcotic -properties are well established. Hoffberg[12] administered the root in -doses of three grains in some cases of gout, with the effect of -relieving the pain. - -Cases of poisoning by belladonna end, with very few exceptions, in -recovery, however large the dose, and however alarming the symptoms may -be; and, taking all the above circumstances into account, it is -probable, that after ascertaining the right quantity to be administered -for the purpose, this medicine or mandragora might be used, with -considerable success, and no great danger, to prevent the pain of -operations, if chemistry had not supplied us with agents much more -convenient. - -Not many ages after the Greek and Roman authors above quoted were -describing the effects of mandrake in preventing the pain of operations, -another plant, the Indian hemp, was employed for the same purpose in a -more remote part of the world. M. Stanislas Julien, in an article on -Chinese Medicine,[13] gives a notice of a work entitled “Koukin-i-tong, -or a General Collection of Ancient and Modern Medicine,” in fifty -volumes, 4to., and makes an extract from it respecting Hoa-tho, a -practitioner, who flourished under the dynasty of Wei, between 220 and -230 of our era. Respecting Hoa-tho, it is stated that—“When he found -that it was necessary to employ acupuncture, he applied it in two or -three places; he did the same with the moxa, if it was indicated by the -nature of the affection which he had to treat. But if the malady was -situated in parts on which the needle, the moxa, or liquid medicines -could not act—for example, in the bones, in the medulla of the bones, in -the stomach, or the intestines, he gave to the patient a preparation of -hemp (Ma-yo), and, at the end of some instants, he became as insensible -as if he had been drunk, or deprived of life. Then, according to the -case, he made openings and incisions, performed amputations, and removed -the cause of mischief; he then brought together the tissues with points -of suture, and applied liniments. After a certain number of days (at the -end of a month, according to the annals of the later Hân) the patient -found himself reestablished, without having experienced the slightest -pain during the operation.” - -We are not informed of the way in which the hemp was administered. If -insensibility was caused so quickly, as is stated, it must have been by -inhaling the fumes of the hemp when exposed to heat, and not by taking -it into the stomach. This view of the matter is rendered more probable -by the circumstance that the ancient Scythians were in the habit of -inhaling the fumes of hemp,[14] several centuries before the time of -Hoa-tho, and also by the practice of the Hindoos at present, who inhale -the fumes of hemp from a pipe. The remark that the patient became -reestablished at the end of a certain number of days, must refer to his -recovery from the wound caused by the operation, and we are not informed -how long the state of insensibility continued. - -The next notice of any attempt to prevent the pain of operations, that I -am aware of, occurs in the work on Surgery of Theodoric, an author who -lived in Italy in the latter half of the thirteenth century. He writes -as follows:[15] “The making of a flavour for performing surgical -operations according to Dominus Hugo. It is thus made:—take of opium, of -the juice of the unripe mulberry, of hyoscyamus, of the juice of -hemlock, of the juice of the leaves of mandragora, of the juice of the -woody ivy, of the juice of the forest mulberry, of the seeds of lettuce, -of the seeds of the dock, which has large round apples, and of the water -hemlock [cicuta]—each an ounce; mix all these in a brazen vessel, and -then place in it a new sponge; let the whole boil, as long as the sun -lasts on the dog days, until the sponge consumes it all, and it is -boiled away in it (the sponge). As oft as there shall be need of it, -place this sponge in hot water for an hour, and let it be applied to the -nostrils of him who is to be operated on, until he has fallen asleep; -and so let the surgery be performed. This being finished, in order to -awaken him, apply another sponge, dipped in vinegar, frequently to the -nose, or throw the juice of the root of fenugrek into the nostrils; -shortly he awakes.” - -I altogether disbelieve that a sponge, prepared as above, would, after -being placed in hot water, give off any odour or vapour which would -cause insensibility. The active ingredients, as they exist in the -various plants, are not sufficiently volatile to be given off at a heat -below that of boiling water. Hemlock, indeed, contains a volatile -principle, which can be liberated by an alkali; but, even if it were set -free by any chance during the preparation of the sponge, it would all be -dissipated by the long boiling. - -If sleep were really caused in this way, it must have been by some of -the moisture from the sponge reaching the mouth or throat, and being -swallowed; and it may be remarked that the author speaks of the -preparation of a taste or flavour (confectio saporis), rather than an -odour, although the sponge is certainly directed to be applied to the -nostrils. It must be remarked, also, that if the patient were made so -insensible, as not to feel the surgeon’s knife, he would be little -affected by vinegar, or the juice of fenugrek, in his nostrils. - -Immediately after the prescription quoted above, and in the same -paragraph with it, Theodoric gives another recipe from Master Hugo, -directing antimony, quicksilver, soap, quick lime, and a little arsenic, -to be sublimed together. A portion of the resulting compound, the size -of a nut, is directed to be placed over a hernia, or whatever else is to -be operated on. Then follows a rather lengthy direction for subliming -arsenic, also from Dominus Hugo. The arsenic so sublimed is described as -rendering surgical operations extremely pleasant. The words are—“hæc -acus fiat mitis et suavis: sicut sudor beatæ virginis quum peperit -Christum.” - -I have applied arsenic to the skin for twenty-four hours, with no other -effect than irritation, and an eruption of pimples, the sensibility of -the part being increased; and in my opinion, arsenic would not cause -insensibility, unless it were applied so long that the inflammation -caused by it should end in gangrene. I consider that the statement of -Theodoric, respecting arsenic, strengthens the doubts I have expressed -concerning his spongia somnifera. There is another reason for disputing -the efficiency of the above mentioned recipes. Theodoric directs the -patients about to undergo operations to be tied, or held by strong men. -In the operation for hernia, for instance, he directs the patient to be -tied to the bench, or table, with three bands, one round the ankles, -another round the thighs, and a third across the chest, holding the arms -and hands. This circumstance is the more significant, since Theodoric -had lived some time with Hugo, and seen his practice, as he states in -the dedication to his work. - -It is reasonable also to conclude that if any successful plan of -preventing the pain of surgical operations had been introduced after the -revival of literature, it would not have fallen into disuse and been -forgotten. - -In an interesting paper by Dr. Silvester,[16] an anecdote is quoted, -with an intention to show that anæsthetics were commonly had recourse to -in severe operations as late as the end of the seventeenth century. The -quotation is from a German work by A. G. Meissner, called _Skizzen_, or -Sketches, and published at Carlsruhe in 1782. It is as follows:— - -“Augustus, King of Poland and Elector of Saxony, suffered from a wound -in his foot, which threatened to mortify. The court medical men were -opposed to the operation of amputation; but during sleep, induced by a -certain potion surreptitiously administered, his favourite surgeon, -Weiss, a pupil of Petit, of Paris, cut off the decaying parts. The royal -patient was disturbed by the proceeding, and inquired what was being -done, but on receiving a soothing answer he again fell asleep, and did -not discover till the following morning, after his usual examination, -that the operation of amputation had really been performed.” - -It is most probable that the potion surreptitiously administered in this -case, was an ordinary sleeping draught, and that only the “decaying -parts” were cut off, as in fact is stated. The decaying parts of course -would be without feeling. - -The mind of surgeons seems now and then to have turned spontaneously -towards preventing or alleviating the pain of operations, and certain -attempts and suggestions were made with this object during the later -part of the last century, in apparent ignorance of what had been done by -the ancients in this direction. - -Ambroise Tranquille Sassard, principal surgeon of the Hospital la -Charité at Paris, recommended the employment of a narcotic previous to -serious and painful operations, the dose to be proportioned to the age -and strength of the patient.[17] He does not state whether the plan was -actually tried. - -Mr. James Moore, surgeon,[18] recommended compression of the large -nerves, and tried it on a patient in St. George’s Hospital, whose leg -Mr. John Hunter amputated below the knee. The crural and sciatic nerves -were compressed for nearly an hour by an instrument contrived for the -purpose, and Mr. Moore considered that the greater part of the pain was -prevented. The patient complained more of the sawing of the bone than of -the cutting part of the operation. I am not aware whether this plan was -tried in other instances, but it is certain that it did not come into -general use. - -M. le docteur Liégard (de Caen) has stated,[19] that the peasants in his -part of France are in the habit of tying a band very tightly round the -arm or leg before operations on the extremities. He had himself removed -a toe-nail in two cases, without pain, after a handkerchief had been -tied very tightly round the lower part of the leg. By this measure both -the nerves and blood vessels are, of course, more or less compressed. - -The persons who believe in the existence of a force or power, which they -call Mesmerism, or animal magnetism, made many and persevering efforts -in recent times to cause insensibility to the surgeon’s knife. In some -cases they were imposed on by dishonest and designing patients, who -afterwards confessed they had suffered the pain to which they had -pretended to be insensible, but in other cases I have no doubt of the -operations having really been performed without pain. Absence of -consciousness and sensation is a common symptom in many cases of -hysteria and catalepsy, and in certain susceptible persons, hysteria and -catalepsy, or conditions nearly resembling them, can be induced by -acting on the imagination, or by exhausting the attention by means of -the fixed stare and monotonous “passes” of the so-called Mesmerisers. - -Dr. Esdaile was more successful in putting Hindoos to sleep, and -operating on them in the hypnotized[20] state, than any one has been -with Europeans: yet it was only in a portion of the cases in which it -was tried that the alleged agent took effect. In many instances, efforts -continued for two or three months had no effect on the patient; and in -many of the operations, which were reported as successful, “there was -much convulsive movement of the limbs, corrugation of the brows, and -even loud cries and sobs,” although the patients afterwards denied all -knowledge of what had passed.[21] - -The discovery of the means of preventing pain, which will occupy the -greater number of the following pages, did not arise out of any of the -attempts either in ancient or modern times above enumerated. It sprung -directly from the practice of inhaling chemical and medicinal -substances. - -The custom of inhaling the fumes of narcotic plants existed at the very -commencement of the historic period, as appears by the following -passages from Herodotus. Speaking of the people who inhabited some small -islands on the river Araxes, which flows into the Caspian Sea, he -says,[22] “They add that they have discovered other trees that produce -fruit of a peculiar kind, which the inhabitants, when they meet together -in companies, and have lit a fire, throw on the fire as they sit round -in a circle; and that by inhaling the fumes of the burning fruit that -has been thrown on, they become intoxicated by the odour, just as the -Greeks do by wine; and that the more fruit is thrown on, the more -intoxicated they become, until they rise up to dance and betake -themselves to singing.” - -Again, when treating of the funeral ceremonies of the Scythians, he -says,[23] “When they have set up three pieces of wood, leaning against -each other, they extend round them woollen cloths; and having joined -them together as closely as possible, they throw red-hot stones into a -vessel placed in the middle of the pieces of wood and the cloths. They -have a sort of hemp growing in this country very like flax, except in -thickness and height; in this respect the hemp is far superior: it grows -both spontaneously and from cultivation; and from it the Thracians make -garments very like linen, nor would any one who is not well skilled in -such matters distinguish whether they are made of flax or hemp, but a -person who has never seen this hemp would think the garment was made of -flax. When, therefore, the Scythians have taken some seed of this hemp, -they creep under the cloths, and then put the seed on the red-hot -stones; but this, being put on, smokes, and produces such a steam, that -no Grecian vapour-bath would surpass it. The Scythians, transported with -the vapour, shout aloud; and this serves them instead of washing, for -they never bathe the body in water.” - -Mental illusions of all kinds have frequently been looked on as divine -revelations, not only by savages, but even by nations having a -considerable amount of civilization. The priestess at Delphos became -intoxicated with the fumes of narcotic plants before delivering her -oracular responses, and it is a curious circumstance that when America -was discovered by Columbus, it was the custom of the Indians to throw -tobacco on the fire during their religious ceremonies, when the piaches, -or priests, who officiated, were thrown into a state of ecstatic -inebriation by the smoke they inhaled. - -I have already stated my belief that the Indian hemp administered, -previous to surgical operations, in China, by Hoa-tho, in the beginning -of the third century of our era, was exhibited by inhalation. - -The fumes of various narcotic plants are inhaled by eastern nations at -present, for smoking in the east is an entirely different process from -smoking in the west of Europe, where the fumes of tobacco are merely -drawn into the mouth and then puffed out again. In Asia and some of the -eastern parts of Europe, the fumes of opium, tobacco, datura, Indian -hemp, or whatever else is smoked, are always inhaled into the lungs. - -John Baptista Porta of Naples makes the following statement in his work -on Natural Magic,[24] published in 1597:— - -“At last shall be related a wonderful method by which any sleeping -person may inhale a soporific medicine. From what we have said, any one -will easily know that he is liable to suffer severely after sleep caused -by medicine, and to have his suspicions aroused. - -“But the quintessence is extracted from a number of the above named -medicines by somniferous menstrua. This is put into leaden vessels -perfectly closed, lest the least aura should escape, for the medicine -would vanish away. When it is used, the cover being removed, it is -applied to the nostrils of the sleeping person, he draws in the most -subtile power of the vapour by smellings, and so blocks up the fortress -of the senses that he is plunged into the most profound sleep, and -cannot be roused without the greatest effort. After the sleep, no -heaviness of the head remains, nor any suspicion of trick or fraud. -These things are plain to the skilful physician, but unintelligible to -the wicked.” - -The author does not make known what the “somniferis menstruis” were, -with which the “quinta essentia” were extracted. As sulphuric ether had -been described more than fifty years before he published his work, it is -not improbable that this was the evanescent substance which required to -be so carefully closed up, and that the profound sleep was simply caused -by this, as the narcotic principles dissolved in it would remain in the -bottle in the form of extracts. The benefit of inhalation has been -frequently attributed to medicines which were supposed to be inhaled, -when it was really due to the menstruum in which the medicines were -dissolved. This often happens at present when the menstruum is merely -water. Baptista Porta does not say that operations were performed under -the influence of the inhalation, or, in fact, that it was applied to any -useful purpose whatever. - -The Persian Pharmacopœia[25] contains some recipes for fumigation, -called bouc-houri, that were inhaled, for the medicines are directed to -be made up into balls or cubes which are to be placed on the live coals, -and the head is to be held over them. Some of the prescriptions contain -myrrh, camphor, mace, and storax, and are for the cure of coryza and -catarrh; one containing musk, camphor, guaiacum, etc., is said to -comfort the brain and intellect, and to be useful in palpitation of the -heart, faintness, and debility of the senses. This Pharmacopœia also -contains[26] a “remedium odorativum somniferum”, which consists of opium -and camphor, besides the seeds of roses and the root of mandragora. The -ingredients are to be powdered and put in a box, for the purpose of -being smelt at. There is also[27] a stupifying remedy prepared with five -drachms of opium and ten drachms of black poppy, which are directed to -be boiled to dryness in water with a pound of wheat, and then powdered. -It is added that whoever shall take a drachm and a half of this wheat -will be alienated from his senses. With regard to the last but one of -the above prescriptions—that to be put in a box for smelling, it may be -observed that, as heat was not applied, the only ingredient which would -produce any effect is the camphor. - -The discoveries of Cavendish, Priestley, Lavoisier, and others -respecting the nature of atmospheric air and the more important gases, -gave an impetus to medicinal inhalations, at the latter part of the last -century. Dr. Beddoes, in particular, distinguished himself by the -administration of oxygen, hydrogen, carbonic acid, and other gases, in -consumption and various diseases. Dr. Richard Pearson exhibited the -vapour of ether in consumption with some advantage in the year 1795.[28] -Three years afterwards, a medical pneumatic institution was established -at Bristol, by the exertions of Dr. Beddoes and others. The celebrated -Humphrey Davy was the superintendent. This establishment was not very -successful in the immediate objects for which it was instituted, but -Davy made at this place his masterly researches concerning nitrous oxide -gas. In the course of his experiments, he found that severe pain arising -from inflammation of his gums was relieved by breathing this gas, and he -published the following opinion:— - -“As nitrous oxide in its extensive operation seems capable of destroying -physical pain, it may probably be used with advantage during surgical -operations in which no great effusion of blood takes place.”[29] - -This suggestion of Sir Humphrey Davy was not acted on either by himself -or any other person for nearly half a century, when the late Mr. Horace -Wells, Surgeon Dentist of Hartford, Connecticut, having witnessed the -exhibition of nitrous oxide gas by a public lecturer, named G. Q. -Colston, was induced, in consequence of what he saw of its effects, to -request Mr. Colston to accompany him to his office and exhibit the gas -to him, whilst another dentist, named Dr. Riggs, extracted a tooth for -him which was troublesome. The tooth was extracted without pain, and Mr. -Wells, after the effect of the gas had subsided, exclaimed, “A new era -in tooth pulling.” This took place on December 11th, 1844.[30] Mr. Wells -administered the nitrous oxide in thirteen or fourteen cases of -tooth-drawing in Hartford with a success more or less complete, and -before the end of the year he repaired to Boston to introduce his -discovery to the professors at the Massachusetts General Hospital. He -called on Drs. Warren and Hayward, who invited him to exhibit the gas to -one of the patients, who was expecting to have a limb amputated. He -remained two or three days in Boston, but the patient decided not to -have the operation performed at that time. The nitrous oxide was -consequently tried on an individual who required to have a tooth -extracted. This patient felt some pain, and the application was -considered to be a failure. It is worthy of remark that Drs. Charles T. -Jackson, and W. T. G. Morton, were present on this occasion. Mr. Wells -returned to Hartford in disappointment. He expressed his opinion to his -friends that the nitrous oxide gas was uncertain in its action, and not -to be relied on; and he altogether abandoned the use of it until some -time after Dr. Morton’s discovery of the effects of sulphuric ether in -preventing pain. - -As long ago as 1818 an article, which is believed to have been written -by Mr. Faraday, appeared in the _Quarterly Journal of Science and -Arts_,[31] describing the great resemblance between the effects of the -vapour of ether and nitrous oxide gas. This circumstance has since been -published in all the standard works on chemistry; and it was the annual -custom of the late Professor Turner, of University College, London, to -pour a little ether into a bladder of air, and allow some of the -students to inhale the vapour. The same practice prevailed, more or -less, in other colleges, both in Europe and America, when the lecture on -ether was delivered. The resemblance between the action of nitrous oxide -and that of vapour of ether was therefore extensively known. - -Dr. Morton, surgeon dentist of Boston, in America, administered -sulphuric ether, by inhalation, to a man in his office, on the 30th of -September, 1846, and extracted a tooth without causing any pain. He -applied the ether in several cases of a similar kind during the next few -days. Having obtained the permission of Dr. J. C. Warren, he -administered it to a patient in the Massachusetts General Hospital, on -whom that surgeon performed an operation on the neck. On the following -day, Dr. Morton exhibited ether to a woman in the same hospital, whilst -Dr. Hayward removed a large fatty tumour from the arm, and after this -date it was frequently administered. - -Dr. Morton was well acquainted with Mr. Horace Wells, before alluded to, -and had been in partnership with him. Before administering the ether to -his patient in September 30th, Dr. Morton had a conversation with Dr. -Charles J. Jackson, Professor of Chemistry, respecting the safety and -propriety of the application, and the names of these gentlemen were -associated in a patent which they took out for the discovery. Dr. -Jackson asserts that Dr. Morton knew nothing of the effects of the -vapour of ether till he gave him the information; whilst the latter says -it was his intention to use the ether before he went into Dr. Jackson’s -laboratory. It seems impossible to arrive at the exact truth on this -point, but it is admitted on all hands, that Morton was the first who -administered ether to prevent the pain of an operation. Dr. Jackson[32] -has indeed claimed the whole merit of the discovery, on the ground of -the alleged information he gave to Dr. Morton; but, if every word Dr. -Jackson says be admitted, it only appears that he suggested the use of -ether to Dr. Morton, just as Sir Humphrey Davy had suggested the use of -nitrous oxide to all the world in the year 1800. Dr. Jackson had inhaled -ether as hundreds of others had done, and being aware of Davy’s -suggestion of nitrous oxide for preventing the pain of operations, he -concluded that ether might also have that effect. - -It will be shown further on that Mr. Waldie, of Liverpool, had a greater -share in the introduction of chloroform than Dr. Jackson had in the -introduction of ether—even supposing that Dr. Morton was previously -quite ignorant of that medicine; for when he informed Dr. Simpson of the -existence and nature of chloroform, he was able to give him, not merely -an opinion, but an almost certain knowledge of its effects; yet Dr. -Simpson is justly considered to be the person who discovered and -introduced the use of undiluted chloroform as a substitute for ether. - -The practice of the ancients in giving mandragora and Indian hemp has no -connection with the recent discovery for preventing the pain of -operations, which may be briefly related as follows:—Sir Humphrey Davy -made the suggestion that nitrous oxide gas might be employed for this -purpose, and, at the end of forty-four years, Mr. Horace Wells carried -this suggestion into practice, but failed to bring the nitrous oxide -into general use, and gave the matter up. Two years later, Dr. Morton, -who was well acquainted with the efforts of Mr. Wells, applied the -vapour of ether, which was already known to resemble nitrous oxide in -its action. He succeeded completely in preventing the pain of -operations, and in bringing his discovery into general use throughout -the civilized world. In a short time the inhalation of ether was found -to be so safe and certain in its action, and to prevent the pain of -operations so entirely, that the most ardent imagination could scarcely -conceive that anything further could be desired in this direction. - -Dr. Morton withheld at first the name of the agent he was employing, but -its strong and peculiar odour revealed it so plainly that concealment -was impossible. Dr. Bigelow, of Boston, having tried sulphuric ether, -and found it to produce all the effects of the so-called letheon, he -made the subject known, not only to his own countrymen, but also by -letter to Dr. Boot of London. The first operation under the influence of -ether on this side of the Atlantic, was the extraction of a tooth, at -the house of Dr. Boot, on Dec. 19th, 1846. Mr. Robinson, of Gower -Street, administered the ether and performed the operation. The patient -was a lady, named Miss Lonsdale. The ether was quite successful in -preventing the pain in this case, as well as in two operations performed -at University College two days afterwards, by the late Mr. Liston. These -operations were amputation of the thigh, and evulsion on both sides of -the great toe-nail. The ether was given by Mr. Squire, of Oxford Street, -with an apparatus which he contrived for the occasion. - -Considerable opposition was made to the inhalation of ether in America, -soon after its introduction, and it seemed likely to fall into disuse, -when the news of its successful employment in the operations of Mr. -Liston, and others in London, caused the practice of etherization to -revive. Mr. Robinson, dentist, gave much time and attention to the -exhibition of ether in London on its first introduction, and was on the -whole very successful. This was not generally the case, however, with -other operators during the first six weeks of the new practice. Owing to -imperfections in the inhalers employed and in the method of using them, -the ether often either failed altogether or only made the patient partly -insensible; and Mr. Liston, and some other surgeons, were inclined to -discountenance the use of it, in consequence of the struggles and cries -of patients to whom it had been administered. - -It soon became apparent, however, that the vapour of ether was capable -of inducing a state of perfect quietude, with entire absence of pain, -during all kinds of surgical operations. From the 28th of January the -ether produced the desired effect in every operation that was performed -in St. George’s Hospital, until the time when chloroform was introduced -as a substitute for this agent.[33] - -Ether was employed in Paris a few days after its first application in -London, and in a short time it was in use nearly all over the world. - -On the 19th of January 1847, just a month after the first application of -ether for the prevention of pain on this side of the Atlantic, Dr. -Simpson of Edinburgh administered the vapour in a case of labour, and -ascertained that it was capable of removing the sufferings of the -patient without interfering with the process of parturition. -Etherization was soon afterwards employed in the reduction of -strangulated hernia and dislocations of the femur and humerus, some of -them of long standing. It was also used with advantage in neuralgia, -tetanus, and the convulsions of infants, and it became more and more -general in surgical operations. - -No great improvement in the practice of medicine was probably ever -established so readily as the inhalation of ether for the prevention of -pain. Yet it met with stout opposition in certain quarters, and when a -serious operation in which ether had been used terminated unfavourably, -there were those who attributed the patient’s death to the new practice, -although numerous other patients had sunk in exactly the same manner -long before ether was used. In one of these cases a coroner’s inquest -was held, and the jury returned a verdict that the death of the deceased -was caused by the inhalation of ether, although the patient had not even -been made insensible by it, had felt all the pain of the operation, -which was retarded by her struggles, and did not die till the third day. -Notwithstanding a certain amount of opposition and mistrust, the -inhalation of ether was becoming more general in the course of the year -1847, and there is every reason to conclude that it would very soon have -obtained the complete confidence of the medical profession and the -public, had it not been for circumstances which must next be considered. - -A medicine called chloric ether has been in use since 1831. It consists -of a solution of chloroform in spirits of wine. It is somewhat variable -in strength, but usually contains about twelve per cent. of its volume -of chloroform. Dr. Henry Jacob Bigelow of Boston tried this by -inhalation, as well as other substances, when Dr. Morton first used -sulphuric ether, but he did not succeed with it in causing insensibility -to pain. Mr. Jacob Bell of London tried the chloric ether in the -beginning of 1847, and succeeded in causing insensibility with it in -some cases.[34] After this time the chloric ether was exhibited -occasionally in St. Bartholomew’s and the Middlesex hospitals, and in -the private practice of Mr. Lawrence, but it did not come into general -use, owing to its expense, and its frequently failing to cause -insensibility. - -The relation of chloroform to chloric ether is exactly the same as that -of opium to laudanum, and no one acquainted with this circumstance could -doubt for a moment that chloroform inhaled alone would produce the -effects which it did when inhaled from its solution in spirit; the only -uncertainty about the matter that could possibly exist would be whether -it might not be too strong for use in its undiluted state. - -The true nature of the so-called chloric ether was, however, known to -very few persons. It did not enter into the pharmacopœias, and it was -mentioned in very few of the works on materia medica. I examined a -specimen of it, and found that its properties when inhaled were due to a -volatile body containing chlorine, which evaporated first, leaving a -great quantity of spirits of wine behind. I concluded that the volatile -body was hydrochloric ether, and as this article is so volatile that it -exists in the form of gas except in comparatively cold weather, and -consequently could not be conveniently used for inhalation, I did not -consider the matter any further. M. Flourens had indeed experimented on -animals with undiluted chloroform, but was so struck with its great and -dangerous power, that he was far from recommending its use in surgical -practice. - -It was left for Dr. Simpson of Edinburgh, who had already the merit of -having discovered the use of inhalation in midwifery, to be the first to -administer chloroform in an undiluted state, and to recommend it -successfully for general use. Mr. Waldie, of the Apothecaries’ Hall of -Liverpool, first mentioned chloroform to Dr. Simpson, as the latter -states in a foot-note to his first pamphlet on the subject. Mr. Waldie -has given the following account of the circumstance in a pamphlet on -chloroform.[35] - -“When in Scotland, in October last, Dr. Simpson introduced the subject -to me, inquiring if I knew anything likely to answer. Chloric ether was -mentioned during the conversation; and, being well acquainted with its -composition, and with the volatility, agreeable flavour, and medicinal -properties of the chloroform, I recommended him to try _it_, promising -to prepare some after my return to Liverpool, and to send it to him. -Other engagements and various impediments prevented me from doing this -so soon as I should have wished; and in the meantime Dr. Simpson, having -procured some in Edinburgh, obtained the results which he communicated -to the Medico-Chirurgical Society of Edinburgh on the 10th of November, -and which he published in a pamphlet entitled—‘Notice of a New -Anæsthetic Agent as a Substitute for Sulphuric Ether in Surgery and -Midwifery.’” - -Dr. Simpson’s first experiments with chloroform were made in the early -part of November 1847, and his pamphlet on the subject, which was -published on the 15th of that month, had a wide circulation, and created -great interest. Chloroform was immediately used everywhere to a greater -extent than ether had been. An impression became very prevalent that -chloroform was safer than ether. This impression arose rather from the -general tenour of Dr. Simpson’s essay than from any direct statement, -for he had not treated on this point. - -The great strength of chloroform as compared with ether, and the extreme -care required in its use, were indeed soon pointed out;[36] these -precautions, however, attracted but little attention till the first -death from chloroform occurred near Newcastle on the 28th January, 1848. -Ether was exhibited by inhalation during eleven months in Europe, and -about sixteen months in America, before chloroform was introduced. -During all this time no death was occasioned by its use, if we except -one at Auxerre in France, which appeared to be occasioned by want of -air, owing to an imperfect inhaler, and not to the effect of ether. -Chloroform had only been employed between two and three months when the -above mentioned death occurred, and this was soon followed by others in -nearly all parts of the world. These accidents have prevented many -persons from inhaling chloroform, and they have prevented a still -greater number from enjoying that freedom from anxiety and apprehension -before an operation, which ought to be one of the greatest advantages of -any plan for preventing pain. As chloroform possesses advantages over -ether, in being more convenient and less disagreeable, it continues to -be used, to the exclusion of the latter agent, in most parts of the -world. In the Massachusetts General Hospital, however, where sulphuric -ether was first employed, it was resumed three or four years ago, and -the use of chloroform was prohibited by the governors, on account of two -accidents from it. Ether is also employed out of the hospital, both in -surgical and obstetric practice, in Boston and the neighbourhood; and I -have been informed that this is also the case in Philadelphia, whilst in -the state of New York both chloroform and ether are employed. I learned -last year that ether was the agent employed for causing insensibility at -Naples and at Lyons. - -Several volatile substances have been tried in a few cases with the -effect of causing insensibility, since the introduction of chloroform, -but none of them came into use except amylene, which was first employed -by me in King’s College Hospital in November 1856, after I had made -several experiments on animals with it, and inhaled small quantities of -it myself. I have administered it in a great number of operations -already, and find it to possess certain advantages over chloroform in -the greater number of cases. Although it has not yet been generally -employed in this country, it has been used extensively in Paris, -Strasbourg, Lyons, and other places on the continent, with very -favourable results. - -It is not improbable that, amongst the multitudes of new bodies which -chemistry makes known every year, some agent may be found superior to -those hitherto used; and besides the great practical advantages which -are directly derived from the discovery of inhalation for the prevention -of pain, the method of breathing medicinal substances in the gaseous -state offers great facilities for the investigation of their effects, -and cannot fail to hasten the time when the mode of action of medicines -will be a branch of exact knowledge. - - - - - ON THE - INHALATION OF CHLOROFORM, ETC. - - - GENERAL REMARKS ON INHALATION. - -Inhalation is simply the act of breathing, or at least so much of it as -consists of inspiring, or drawing the air into the lungs. The term is -usually applied when any medicinal substance is added to the air which -the patient breathes, and the process is altogether different from that -called “smoking,” as practised by the nations of western Europe and of -America, where the fumes of tobacco are merely drawn into the mouth and -puffed out again. The eastern nations, however, always inhale when they -smoke, as was stated before (page 12). This process of inhaling smoke, -as I first witnessed it in a gentleman connected with one of the eastern -embassies to this metropolis, is very instructive, as showing that the -lungs become emptied of their contents by three rather full expirations -and inspirations. When this gentleman took the cigar from his mouth to -speak, the smoke could be seen issuing thickly with each word till there -was a momentary pause as he took a fresh inspiration, then the smoke -could be seen issuing with each word as before, only not so thick, and -after another inspiration, the smoke could be still perceived in the -expired air, but in a very diluted state; but after a third inspiration, -it could no longer be seen till he had resumed the cigar. - -The following are the chief reasons for resorting to inhalation. - -1. Certain agents, as nitrous oxide and oxygen, being permanently in the -gaseous form, cannot be administered in any other way. - -2. By taking advantage of the immense surface of the air-cells of the -lungs for absorption, a more sudden and profound effect may be produced -by medicine than it would be safe, or, in some cases, even possible to -produce in any other way. It is to this circumstance, and to the -rapidity with which certain volatile medicines exhale in the breath, and -leave the patient free from their effects, that the power of preventing -the pain of surgical operations is due. - -3. Many medicines which have a disagreeable taste—as turpentine, -creasote, and camphor—are not unpleasant when inhaled in the form of -vapour; and the process of digestion is less interfered with than by -taking them into the stomach. - -4. Medicines, such as benzoic acid, and some of the gum-resins, which -are believed to exert a local action on the mucous membrane of the -air-passages, may be expected to have a greater effect when inhaled, -than when they are taken into the stomach in the same doses, and reach -the lungs only through the circulation. - -5. Some agents, as chlorine and ammonia, have a local action when -inhaled, which they could not exert if exhibited in any other way. - -In every kind of inhalation, the breathing should be allowed to go on -freely, and in the natural way. - -Medicines may be inhaled either at the ordinary temperature, or with the -aid of artificial heat; and in the latter case they may be breathed with -the addition of vapour of water, or with only so much of it as is -naturally present in the atmosphere. The medicines in use for the -prevention of severe pain, are always inhaled at the ordinary -temperature. - - - CHLOROFORM. - -_History and Composition._ Chloroform was first made in 1831 by two -chemists who operated independently of each other. The liquid, which is -formed by the union of equal volumes of chlorine and olefiant gas, and -which is usually called Dutch liquid, was named chloric ether by Dr. -Thos. Thomson (_System of Chemistry_, 6th ed., 1820). In consequence of -a statement in Silliman’s _Elements of Chemistry_, that the alcoholic -solution of this chloric ether was useful in medicine as a diffusible -stimulant, Mr. Guthrie, an American chemist, attempted an easy method of -obtaining it.[37] He distilled together chloride of lime and alcohol, -and he considered that the product he had obtained was an alcoholic -solution of the chloric ether of Dr. Thomson,[38] and it is still used -in medicine under that name. About the same time, M. Soubeiran distilled -together the above ingredients in France, and analysed the chloroform -which he obtained. His analysis, which was incorrect, led him to name -the liquid bichloric ether.[39] In 1832, Liebig examined the liquid -which has been since named chloroform, but as he failed to detect the -hydrogen which it contains, he called the liquid chloride of carbon,[40] -a name which its alcoholic solution occasionally bore afterwards when -used as a medicine. In 1831, Dumas examined this liquid. He proved that -Soubeiran and Liebig had not obtained it pure, or had been incorrect in -their analysis.[41] He showed that it consists of two atoms carbon, one -atom hydrogen, and three atoms chlorine. - -Dumas gave the name of chloroform to the liquid, on account of the -relation it bears in composition to formic acid, which consists of two -atoms carbon, one hydrogen, and three oxygen.[42] Liebig, who, in common -with other chemists, admits the accuracy of Dumas’ analysis, has -proposed the name of perchloride of formyle.[43] He supposes that the -carbon and hydrogen which enter, in the same definite proportion, into -numerous compounds, form a base which he calls formyle; and although -this base has never been obtained in a separate form, its existence is -well supported by analogy, and the term formyle is useful in assisting -the memory to retain the composition of a number of substances. For all -practical purposes, however, the medicine we are considering is likely -to go by the name of chloroform. In the last edition of the London -Pharmacopœia, the article has received a name intermediate between the -other two. It is called chloroformyl, a name which departs from the -brevity of the word chloroform, without having the merit of expressing -the chemical constitution of the substance. I believe that no one uses -the word chloroformyl; not even the Fellows of the College of Physicians -in their individual capacity. - -_Mode of Preparation._ Chloroform can be obtained in various ways, but -the most convenient process, and the one which yields it in greatest -purity, is that alluded to above, by which it was first procured. The -following are the directions in the London Pharmacopœia for making it. - -“Take of chlorinated lime, lb. iv; rectified spirit, Oss; water, Ox; -chloride of calcium, broken in pieces, ʒj. Put the lime first mixed with -the water into a retort, and add the spirit to them, so that the mixture -may fill only the third part of the retort. Then heat them in a -sand-bath, and as soon as ebullition begins, withdraw the heat as -quickly as possible, lest the retort should be broken by the sudden -increase of heat. Let the liquid distil into the receiver so long that -there may be nothing which subsides, the heat being reapplied if -necessary. To the distilled liquid add a quarter of the water, and shake -them all well together. Carefully separate the heavier portion which -subsides, and add the chloride to it, and frequently shake them for an -hour. Lastly, let the liquid distil again from a glass retort into a -glass receiver.”[44] - -Some manufacturers of chloroform prefer to rectify it from dry carbonate -of potassa, since they consider that it is liable to get an acid -reaction from decomposition of the chloride of calcium, when it is -distilled from that substance. The truth is, however, that there is very -little occasion to use either of these substances; for the small -quantity of water which chloroform can hold in solution is of no -consequence. - -_Chemical and Physical Properties._ Chloroform is a clear colourless -liquid, having a hot and intensely sweet taste. It is not inflammable, -but when paper moistened with it is introduced into the flame of a -candle, it is destroyed with the evolution of smoke and chlorine gas. It -is just half as heavy again as distilled water. Its specific gravity was -formerly stated to be 1·483, but the liquid used for inhalation of late -years has been heavier than this. I find that pure chloroform, when -saturated with water, has a specific gravity of 1·500 at 60° Fah.; and -after agitating it with sulphuric acid, to deprive it of the water, the -specific gravity is 1·503. The amount of water that chloroform can hold -in solution is only one part in from 200 to 300; and when this is -separated by oil of vitriol, the chloroform is liable to undergo -spontaneous decomposition.[45] - -Chloroform is soluble in alcohol and ether in all proportions, but it is -very sparingly soluble in water. It has been said to require 2000 parts -of water for its solution, but this is an error. As the solubility of -this and similar medicines in watery fluids has a very important -connexion with their physiological action, I took great pains to -ascertain the solubility of chloroform correctly. By admitting small -quantities of water into graduated jars containing chloroform vapour, I -was able to ascertain that chloroform is soluble in about 288 times its -volume of water. Chloroform is itself an active solvent of many bodies; -dissolving camphor, caoutchouc, gutta percha, wax, resin, iodine, and -some other substances very readily. It is a very mobile liquid, and when -dropped from the lip of a small phial, the drops are very small. There -are three drops to a grain of the liquid, and as a minim of it weighs a -grain and a half, there are nine drops in two minims. Consequently -persons should not speak indiscriminately of drops and minims, as they -sometimes do, when talking of chloroform. - -_Adulterations._ The odour of chloroform is by no means disagreeable. -The only liquids that resemble it in smell are Dutch liquid and the -chlorinated products of hydrochloric ether, but as they are much more -difficult to prepare than chloroform, they are not likely to be -substituted for it, or used for its adulteration. The smell of -chloroform is therefore a good criterion of its purity and identity. -When dropped on the hand, it should quickly evaporate, leaving not the -least moisture or smell behind. If a disagreeable odour remains on the -hand after the evaporation of the chloroform, it has probably been made -from impure spirit, or even from wood spirit or acetone, and is unfit -for medicinal use.[46] When chloroform becomes decomposed from any -cause, it acquires a greenish-yellow colour, and gives off chlorine and -hydrochloric acid, so that the alteration is at once apparent. When -chloroform is pure it has no reaction on test-paper, but is quite -neutral. The best way to detect a small quantity of hydrochloric acid in -it, is to moisten a slip of blue litmus paper with distilled water, and -hold it just within the neck of the bottle exposed to the vapour. If -sulphuric acid should be present, it may be discovered by agitating the -chloroform with distilled water, and adding nitrate of baryta. - -The only article that can be mixed with chloroform without altering its -appearance and smell is alcohol. This can be detected by the reduction -it occasions in the specific gravity of the chloroform; or, if it be -present in any considerable quantity, it may be discovered by adding -water to a little of the chloroform in a graduated tube or measure, when -a diminution of its volume takes place, owing to the water abstracting -the alcohol. The chloroform also acquires a milky opacity under these -circumstances. M. Miahle[47] speaks of the milky opacity of the -chloroform on the addition of water as a very delicate test of the -presence of alcohol; but I find that it requires upwards of two per -cent. of alcohol to cause this appearance on the addition of water. - -It has been asserted, and often repeated, that the presence of alcohol -in chloroform causes it to have caustic properties, and makes its vapour -unusually irritating. I have never seen any evidence of this, although I -have had hundreds of opportunities of witnessing the action of -chloroform mixed with spirit. Under certain circumstances, it is -advisable to dilute chloroform with alcohol previous to its -administration, as will be explained hereafter. - -The chloroform I have met with in London has always been sufficiently -pure for inhalation, except in a few cases where a small quantity had -become decomposed, probably from having been left a long time exposed to -strong daylight. In these instances, its altered appearance generally -prevented its being used. I am not aware of serious consequences having -arisen anywhere from the impurity or adulteration of chloroform. A case -occurred in the London Hospital, where cough and a feeling of -suffocation were caused by hydrochloric acid with which the chloroform -was contaminated, but the inhalation was discontinued, and no ill -consequences resulted.[48] - -Chloroform should be kept in well-stoppered bottles, and protected from -the light. It boils at 140 Fah. under the ordinary pressure of the -atmosphere. It is consequently one of the most volatile liquids employed -in medicine, with the exception of sulphuric ether and amylene. - -_The Vapour of Chloroform_ is more than four times as heavy as -atmospheric air. It has a specific gravity of 4·2 at 60° Fah. Under -ordinary circumstances, the vapour of chloroform has of course no -separate existence, but is always mixed with air. It can exist in a pure -state only when the temperature is raised to 140° or upwards; or when -the pressure of the atmosphere is in a great measure removed by the -air-pump. The quantity of vapour of chloroform that the air will hold in -solution at different temperatures, under the ordinary pressure of the -atmosphere, depends on the elastic force of the vapour at these -temperatures. It is governed by a law precisely analogous to that which -determines the amount of watery vapour which air will hold in solution. - -The following table shows the result of experiments I made to determine -the quantity of vapour of chloroform that 100 cubic inches of air will -take up, and retain in solution, at various temperatures. - - Temp. Fah. Cubic inches. - 40° 7 - 45 8 - 50 9 - 55 11 - 60 14 - 65 19 - 70 24 - 75 29 - 80 36 - 85 44 - 90 55 - -In the above table, the air is a constant quantity of 100 cubic inches -which becomes expanded to 107, and so on; but it may be convenient to be -able to view at a glance the quantity of vapour in 100 cubic inches of -the saturated mixture of vapour and air, at different temperatures, and -in the table which follows the figures are so arranged as to show this. - - Temp. Fah. Air. Vapour. - 40° 94 6 - 45 93 7 - 50 92 8 - 55 90 10 - 60 88 12 - 65 85 15 - 70 81 19 - 75 78 22 - 80 74 26 - 85 70 30 - 90 65 35 - -As the effects of chloroform when inhaled depend entirely on the -quantity of vapour present in the air which the patient breathes, the -effect of temperature on its volatility is of great practical -importance. The air, it is true, does not become fully saturated with -vapour during the process of inhalation, but the effects of temperature -are relatively as great. If, for instance, a person inhales chloroform -from a handkerchief or an inhaler, in such a way that the air he -breathes shall be half saturated with the vapour, then supposing the -temperature of the apartment, the handkerchief, etc., to be 50°, the air -he breathes will contain 4 per cent.; but if the temperature be 70°, the -air will contain 9·5 per cent. of the vapour. - -A considerable amount of caloric becomes latent during the evaporation -of chloroform, and the temperature of the vapour and air which the -patient breathes are generally reduced a good deal, but not to the same -extent as during the inhalation of ether. In giving chloroform from a -small sponge which had been squeezed out of water, I have sometimes -observed, after laying it down, that it became covered with a kind of -hoar frost; the minute particles of frozen water having a slight taste -of chloroform. The cold produced by the evaporation of a liquid like -chloroform is often the means of checking the evaporation to a certain -extent, and limiting the amount of vapour which is taken up by the air. - - - PHYSIOLOGICAL EFFECTS OF CHLOROFORM. - -Chloroform belongs to the large class of medicines known as -narcotico-irritants. This and some other agents which have been inhaled -for the prevention of pain are often called anæsthetics; a name to which -there is no objection, so long as it does not lead to the idea that they -have a different action from other narcotics, or more precisely -speaking, narcotico-irritants; there being no such medicines as pure -narcotics. The term anæsthesia has been frequently employed to designate -the insensibility and suspension of consciousness caused by chloroform -and ether; but, in describing the effects of these agents, I shall -confine this term to its original meaning, privation of feeling, and I -shall employ the term narcotism to designate the entire effects of these -agents on the nervous system. This is the sense in which the term -narcotism has always been employed. It has been the custom, however, to -restrict the use of the word very much to cases in which stupor existed, -but I shall apply it to designate the slighter, as well as the more -profound effects of a narcotic, as I am entitled to do by strict -etymology. - -In order to facilitate the description of the effects of chloroform, I -have been in the habit of dividing them into degrees. I use the term -degree in preference to stage, as, in administering chloroform, the -slighter degrees of narcotism occur in the later stages of the process, -during the recovery of the patient, as well as in the beginning. The -division into degrees is made according to symptoms, which, I believe, -depend entirely on the state of the nervous centres, and not according -to the amount of anæsthesia, which there is good reason to conclude, -depends, in a great measure, on the local action of the chloroform on -the nerves. The different degrees of narcotism glide insensibly into -each other. - -In the first degree, I include all the effects of chloroform that exist -while the patient retains a perfect consciousness of where he is, and -what is occurring around him. This degree constitutes all that a person -remembers of the effects of the vapour, except when he happens to dream, -and recollect it afterwards. The sensations caused by inhaling -chloroform are usually agreeable, when it is taken merely for curiosity; -and individuals who have inhaled nitrous oxide at some previous time of -their lives, often describe their feelings as being very much the same -from both agents. Patients who are about to undergo a surgical operation -are, however, not always in a state for receiving agreeable impressions, -and they sometimes complain of palpitation of the heart, and a feeling -of fulness in the head. There is generally a sense of dizziness, with -singing in the ears and tingling in the limbs. Many persons have a -feeling like that of rapid travelling, and as an appearance of darkness -sometimes comes on from the failure of the sight, whilst there is also a -loud noise in the ears, it not unfrequently happens that a person feels -as if he were entering a railway tunnel, just when he is becoming -unconscious. - -Those persons whose mental faculties are most cultivated appear usually -to retain their consciousness longest whilst inhaling chloroform; and, -on the other hand, certain navigators and other labourers, whom one -occasionally meets with in the hospital, having the smallest possible -amount of intelligence, often lose their consciousness, and get into a -riotous drunken condition, almost as soon as they have begun to inhale. -There is a widely different class of persons who also yield up their -consciousness very readily, and get very soon into a dreaming condition -when inhaling chloroform. I allude to hysterical females. - -There is often a considerable diminution of the common sensibility -during the first degree of narcotism by chloroform, more especially when -it is inhaled very slowly, so that the patient is kept some minutes -partially under its influence. In this way neuralgia can often be -relieved, without removing the consciousness, when it is not extremely -severe, and the suffering of labour may often be removed in the same -manner, when the pains are not very sharp. In a few cases, the -extraction of a tooth and other minor operations have been performed -without pain, whilst consciousness has been retained; but as a general -rule, it is better not to operate under these circumstances, for failure -is more likely than success; and this plan does not succeed in any case -without inhaling longer, and consuming more chloroform, than would be -necessary in the usual way. The complete recovery of the patient from -the effects of the vapour, after a protracted inhalation of this kind, -is also more tardy. - -The first degree of narcotism recurs when consciousness returns as the -effect of the chloroform is subsiding. At this time, there is generally -a greater amount of anæsthesia than at the commencement of inhalation, -just before consciousness is removed. I have many times known the -introduction of sutures, and such like measures, performed at the -concluding part of an operation, after the patient had recovered his -consciousness, without his feeling what was being done. As a general -rule also, the smarting of the wound does not commence till some time -after consciousness has returned. - -In the second degree of narcotism, there is no longer correct -consciousness. The mental functions are impaired, but not necessarily -suspended. When a patient inhales chloroform quietly for a medical or -surgical purpose, he usually appears as if asleep in this degree; but if -his eyelid be raised, he will move his eyes in a voluntary manner. There -are occasionally voluntary movements of the limbs; and although the -patient is generally silent, he may nevertheless laugh, talk, or sing. -Persons sometimes remember what occurs whilst they are in this state, -but generally they do not. Any dreams that the patient has, occur whilst -he is in this degree, or just going into, or emerging from it, as I have -satisfied myself by comparing the expressions of patients with what they -have related afterwards. There is sometimes a little trouble with the -patient in this degree of narcotism. He feels the inconvenience of the -vapour he is breathing, and having become unconscious of the object for -which it is inhaled, he endeavours to push away the inhaler. As a person -in this condition can generally hear and partly understand what is said, -a few kind words will often render him tractable. This is generally true -of all those who have been brought up with care and kindness, more -especially patients of the female sex; but the man who has been roughly -treated from the time of his birth, can often be made insensible only by -means of a little restraint. - -There is generally a considerable amount of anæsthesia connected with -this degree of narcotism, and I believe that it is scarcely ever -necessary to proceed beyond it in obstetric practice, not even in -artificial delivery, unless for the purpose of arresting powerful -uterine action, in order to facilitate turning the fœtus. The loss of -sensation is indeed sometimes so complete in this degree, especially in -children, that the surgeon’s knife may be used without pain; I have -indeed seen a child unconsciously handling its toys all the time that -the operation of lithotomy was performed on it. Commonly, however, the -use of the knife, when the narcotism has not proceeded further than this -degree, occasions expressions indicative of pain, which are either not -remembered, or are recollected as having occurred in a dream. The -patient is generally in this degree during the greater part of the time -occupied in protracted operations; for although, in most cases, it is -necessary to induce a further amount of narcotism before the operation -is commenced, it is not usually necessary to maintain it at a point -beyond this. - -In the third degree of narcotism, there are no longer any voluntary -motions. The eyes, for instance, are not directed towards any object; -and although the limbs may move, they are not directed to any purpose. -The pupils are generally inclined upwards in this degree, and are at the -same time usually somewhat contracted. The bloodvessels of the -conjunctiva are generally somewhat enlarged in this degree in all -persons who are well nourished and not deficient in blood. It is in this -degree of narcotism that rigidity and spasms of the muscles occur in -certain cases. These phenomena occur most frequently in cases where the -muscles have been much exercised, and are consequently well nourished. -They are never met with in infancy, and rarely before puberty. They are -much more common in the male than the female sex. The rigidity and spasm -are greatest and most constant in labourers and persons accustomed to -athletic exercises, and they are usually absent in patients who have -been long confined to the room, or are much reduced in strength from any -cause. They are less marked in old age than in the middle period of -life, and they are not by any means so frequent or strong in fat, as in -thin, muscular persons. I have seen the spasms take an epileptiform -character in a few cases; but by gently continuing the chloroform, they -have always been subdued. In a great number of cases, the patient -mutters in an almost inarticulate and a perfectly unintelligible manner, -just as the muscular rigidity and spasm are subdued. Under these -circumstances, I have never heard a single word pronounced so that it -could be understood. If articulate language is uttered just after the -muscular rigidity, it is evidence that the effects of the chloroform are -being allowed to diminish, and that the patient is going back into the -second degree of narcotism. - -In the third degree of narcotism, a person is quite incapable of having -any perception or consciousness of pain, but anæsthesia is not a -necessary part of this amount of narcotism when it is first induced, and -in some cases a patient may flinch, and put on an expression of -countenance which seems indicative of pain. He may also cry out, but not -in an articulate manner. By continuing the chloroform gently for a -minute or so, a state of complete anæsthesia can be induced in nearly -every case, without carrying the narcotism of the nervous centres -further than this degree. The loss of sensibility of the conjunctiva, as -shown by the absence of winking when the edges of the eyelids are gently -touched, is the best criterion that the patient will bear the knife -without flinching or crying. - -The circumstance of the anæsthesia, or loss of common sensibility, not -keeping pace with the degree of narcotism of the brain, as shown by the -presence or absence of consciousness and volition, appears to depend on -the chloroform acting on the peripheral distribution of the nerves, as -well as on the nervous centres.[49] The following considerations support -this view. 1. Chloroform has the effect of diminishing the sensibility -of a part to which it is applied locally, even to the sound cuticle. -When the cuticle is removed, the local anæsthesia of the surface is -complete; and in frogs, which have a thin permeable skin, and a languid -circulation, one limb can be rendered insensible, by the local -application of this agent, before the remainder of the animal is much -affected. 2. Chloroform when inhaled immediately circulates throughout -the body, in all parts of which it can be detected by chemical means. 3. -Chloroform and other narcotics suspend the function of the nerves, when -locally applied to them. 4. When inhaled, the local effect of chloroform -must be greatest when it has had time to exude through the coats of the -vessels, into the extra vascular liquor sanguinis, and come into -immediate contact with the nervous fibrillæ; and it must take some -little time after the chief part of the chloroform has escaped from the -blood during its passage through the lungs, before that which is in the -lymph external to the vessels can pass back again into them, by -endosmosis. The brain, on the other hand, is without lymph and -lymphatics. The blood in this organ is all contained within the vessels, -in which, moreover, it circulates with more velocity than in the -external parts of the body. It can be easily understood, therefore, how -the brain may escape from the effects of the vapour whilst the nerves of -sensation throughout the body still remain partially under its -influence. 5. It is in young subjects, in whom, connected with the more -active process of nutrition, the quantity of lymph external to the -vessels is greatest, that the general insensibility most frequently -remains, whilst the cerebral hemispheres are resuming their functions; -whilst in persons of spare habit, approaching the middle or later -periods of life, there is little anæsthesia except in the unconscious -state. - -The co-operation of the brain with the nerves is, of course, necessary -to sensation; and it is possible by a large dose of chloroform to -produce complete anæsthesia very suddenly, before there is time for the -nerves to be acted on locally to any extent; and if the chloroform is -not continued, the anæsthesia may subside as quickly as it was induced. -The large ganglia of sensation, the optic thalami, seem to require a -greater quantity of chloroform to suspend their function than is -necessary to suspend that of the cerebral hemispheres, but, by occupying -three or four minutes in giving chloroform, one is enabled to add its -local action on the nerves to its influence on the brain, and thus to -induce anæsthesia with less narcotism of the nervous centres than would -otherwise be required. - -It must not be supposed that the difference of the action of chloroform -on the cerebral hemispheres, and on the optic thalami, will of itself -explain the want of uniformity between the loss of consciousness and -loss of feeling. If it were a mere difference of degree, it might be so -explained; but the absence of all regular relation between these -phenomena can only be satisfactorily accounted for when the -circumstances connected with the circulation and the liquor sanguinis, -that I have endeavoured to explain above, are taken into account. - -In the fourth degree of narcotism, the breathing is stertorous, the -pupils are dilated, and the muscles completely relaxed. The patient is -always perfectly insensible. It is very seldom necessary to carry the -effects of chloroform as far as this degree. It is, however, sometimes -requisite to do so, in attempting to reduce dislocations of long -standing in muscular persons, and whilst the surgeon is dissecting in -the neighbourhood of important vessels and nerves, in certain robust -subjects and others who seem to have acquired an excess of sensibility -by hard drinking, and who can hardly be kept quiet under the knife, -except when the breathing is stertorous. - -There are some further effects of chloroform with which one becomes -acquainted in experiments on the lower animals. If the inhalation is -continued after the symptoms just described are produced, the breathing -is rendered difficult, feeble, or irregular, and is sometimes performed -only by the diaphragm, whilst the intercostal muscles are paralysed. If -the dose of chloroform is gradually increased after these effects are -produced, the breathing entirely ceases, but the heart continues to -pulsate very distinctly, till its action becomes arrested by the absence -of respiration, as in asphyxia. This interval, including the -embarrassment and cessation of the breathing, I call the fifth degree of -narcotism. - -Although the respiration may be suspended by an amount of chloroform -that has very little direct effect in the motion of the heart, it is -quite possible to stop the heart’s action by the immediate effect of -this agent. When frogs are exposed to the action of the vapour, they go -on absorbing it by the skin, after the respiratory movements have -ceased; and in this way the pulsations of the heart are arrested, when a -certain amount of chloroform has been absorbed into the blood. And when -animals of warm blood are made to breathe air containing as much as -eight or ten per cent. of the vapour of chloroform, the blood which is -passing through the lungs becomes so charged with it as to stop the -action of the heart, when it reaches that organ through the coronary -arteries. It is in this way that accidents from chloroform have -happened. The power of this agent to arrest the pulsations of the heart -can also be shewn, by blowing a stream of the vapour on its surface, -when the chest is opened immediately after the breathing has ceased, and -whilst it is still beating. - -The ultimate and greatest effect that chloroform is capable of producing -on the animal body is to destroy the irritability of the muscles, and -produce the post-mortem rigidity. Either the whole body or a single limb -can be rendered instantly rigid by injecting the arteries with a little -chloroform shaken up with water. The rigidity remains for weeks in the -dead body, and would probably be permanent if the chloroform were -prevented from evaporating. Whilst it lasts, putrefaction is of course -prevented. - -_Effect of Chloroform on the Pulse._ I have not mentioned the state of -the pulse in the above description of the effects of chloroform, for it -affords no criterion of the amount of narcotism, and it was better -therefore to reserve it for a separate notice. It is nearly always -increased both in force and frequency, more especially at the early part -of the inhalation. After the patient has become quite insensible, the -pulse indeed generally settles down nearly to the natural standard, and -in the middle of the most formidable operations, it is often beating -with natural volume and force, not more than sixty or seventy times a -minute. The pulse rarely becomes weaker or slower than natural under the -influence of chloroform, except from considerable loss of blood, or -where the patient is about to be sick. I have twice found the pulse as -slow as 44 in the minute at the conclusion of an operation attended with -great loss of blood. One of the cases was the removal of a large tumour -of the labium pudendi, in a woman, aged forty-five, on the 28th of -April, 1849, at King’s College Hospital, by Mr. Fergusson. The pulse -was, however, not small or weak, and there was no faintness. In a few -minutes, the patient vomited, and the pulse immediately resumed its -natural frequency.[50] - -There is occasionally a feeble state of pulse with a feeling of -faintness as the effects of the chloroform subside, and in two or three -cases in which the patient was in a sitting posture, positive syncope -occurred, which, however, was promptly removed by the horizontal -position. The persons most liable to a feeling of faintness after -chloroform, are those who are subject to syncope from slight causes. - -_Action of Chloroform on the Nervous System._ Chloroform, when inhaled, -immediately reaches every part of the nervous system through the -circulation, and it acts on every part of that system from the first, as -a careful observation of the symptoms proves. It does not, however, act -equally on all parts of the nervous system, according to the quantity -which is absorbed; some parts of that system have their functions -entirely, or almost, suspended, whilst others are but little under the -influence of the vapour, and it is owing to this fact that the most -severe pain may be prevented without danger. M. Flourens made the -following remarks respecting the action of sulphuric ether, and they -apply equally well to the effects of chloroform, when it is inhaled -gradually: “Under the action of ether, the nervous centres lose their -powers in regular succession—first, the cerebral lobes lose theirs, -viz., the intellect; next, the cerebellum loses its, viz., the power of -regulating locomotion; thirdly, the spinal marrow loses the principle of -sensitiveness and of motion; the medulla oblongata still retains its -functions, and the animal continues to live: with loss of power in the -medulla oblongata, life is lost.”[51] I may add, that after the -breathing has ceased, from the loss of power of the medulla oblongata, -the ganglionic nerves still perform their functions, and the heart and -intestines continue to move for a time, often with vigour. - -Owing to the unequal effects of a given quantity of chloroform on -different parts of the nervous centres, and owing to its acting also on -the nerves, a variety of states may be met with during a surgical -operation, some of which have often been thought curious, or anomalous. -The most usual state of the patient during an operation, when chloroform -is successfully administered, is one of perfect quietude, without any -sign of consciousness or sensation. The patient under chloroform may, -however, moan, or cry, or flinch, or show other symptoms which are -usually thought indicative of pain, but without using any articulate -language, or remembering anything of the operation afterwards. If his -flinching or crying out has neither interfered with the surgeon, nor -distressed the friends who may be present, a case of this kind may be -considered satisfactory. A third condition of the patient under the -influence of chloroform is that in which he talks, or laughs, or sings -during the operation, his words having no reference to what is being -done. If he is sufficiently quiet for the proceedings of the surgeon, -the application of the chloroform must be considered successful, and -this condition proves the absence of pain even more completely than that -in which there is neither sign nor sound, except the breathing and -pulsation of the heart and blood vessels. A fourth condition of the -patient is that in which he is conscious, and can look on whilst the -surgeon is performing some small operation, or the minor part of a large -one, without feeling it, or whilst feeling it in a manner which is not -painful. This condition, when it occurs, is the most satisfactory proof -of the power of chloroform to prevent pain. It happens but rarely, -however, and cannot be induced at will, and it is usually at the -concluding part of an operation, during which the patient has been -unconscious, that this condition is met with. He wakes whilst there is -still a vessel to tie, or a suture to be introduced, and does not feel -it, owing, as was stated before, to some of the chloroform being -detained in the extra vascular liquor sanguinis, whilst the brain has -become almost free from the medicine. When the knife, or the needle, is -felt without being painful, it is because the common sensibility, -without being entirely abolished, is so much reduced, that what would -otherwise cause acute pain only occasions an ordinary sensation. - -A fifth state of the patient is met with when an insufficient quantity -of chloroform has been administered, or when its effects have been -allowed to subside too soon. The patient may call out or complain in -articulate words, such as “Oh, you are hurting me,” and yet may assert -afterwards that he had no pain, and knew nothing whatever of the -operation. His own language at the time must, however, be held to decide -that there was some pain, which made so slight an impression on the -disordered mind as not to remain in the memory. Pain which is not -remembered is of very little consequence, and probably is but slight in -degree. It should not be judged of by the expressions of the patient -when he is but partially conscious, and using no self-control. -Chloroform may, lastly, be administered so badly, that the patient -simply falls asleep under the soothing influence of a very gentle dose, -as he might sleep from an ordinary dose of opium, without being -insensible, and, when the operation is commenced he wakes to full -consciousness, and both feels pain and remembers it. - -Patients, when insensible, sometimes moan or groan from the effects of -the chloroform, and quite independently of the operation. The groaning -or moaning comes on sometimes and even leaves off again, before the -operation is commenced. When symptoms like those of pain are present -during an operation, one may generally know whether they are the -consequences of it, by observing whether or not they are connected with -each cut of the knife. But even when a flinch or a groan follows each -manipulation of the surgeon, it does not necessarily follow, provided -the patient does not speak, that he is suffering pain. Some amount of -consciousness is essential to the presence of pain, but many of the -lower animals execute movements like those caused by pain, after the -head is cut off, and when, of course, there can be no consciousness. -Although the mind, under ordinary circumstances, is conscious of the -attitude, gestures, and cries, which accompany pain, neither the -intellect nor the will have any share in their production. On the -contrary, they usually take place in spite of the efforts of the will to -prevent them, and one may understand that, when consciousness and -volition are suspended, the actions usually indicative of pain may, for -want of control, be excited by slighter causes, and to a greater degree, -than in the waking state. - -It is certain that chloroform may prevent pain in two ways, either by -rendering the mind unconscious of external impressions, or by removing -the sensibility to these impressions, that is, by a true anæsthetic -action, but usually, and always when breathed in a full dose, it acts in -both ways at once. - -The patient sometimes supposes that he remembers all the particulars of -the operation, although he did not feel the pain, but on questioning him -it is usually found that it is a dream which he remembers, and not the -actual facts. It is extremely rare for a patient to assert that he has -felt pain from the operation, when he has not felt it, but I have known -this to happen once or twice, and a circumstance which was related to me -by Mr. Robinson proves the possibility of it. He administered -chloroform, or ether, to a lady, with the intention of extracting some -teeth, but could not succeed in getting the mouth open, and the lady -woke before anything had been done, and asserted that she had felt the -operation. She inhaled again, and awoke, and repeated the same statement -once or twice before the teeth were actually extracted. - -I have heard it stated that patients have felt the pain of the -operation, but have been unable to make any sign of feeling it. Such an -occurrence may possibly take place when the chloroform is inhaled too -slowly, or not in sufficient quantity; but I have not witnessed it, and -it evidently cannot happen with a sufficient dose. - - - CIRCUMSTANCES WHICH INFLUENCE OR MODIFY THE EFFECTS OF CHLOROFORM. - -I arrived at the conclusion, after much careful observation, that -chloroform might be given with safety and advantage in every case in -which the patient requires, and is in a condition to undergo, a surgical -operation; and having acted on this conclusion for several years, I have -found no reason to change it. It is desirable, however, to pay attention -to every circumstance connected with the health and constitution of the -patient before exhibiting chloroform, as many of these circumstances -influence its effects. - -_Age._ The age of the patient has considerable influence in modifying -the effects of chloroform. It acts very favourably on children: they -sometimes oppose the inhalation of it as long as they are conscious, but -it does not occasion the rigidity and struggling after loss of -consciousness, which are sometimes met with in the adult. Anæsthesia is -generally induced with a less amount of narcotism of the nervous centres -in children than in grown up persons. The effects of chloroform are more -quickly produced and also subside more quickly in children than in -adults, owing no doubt to the quicker breathing and circulation. It -often happens, however, that when the insensibility has been kept up for -some time, say twenty minutes or half an hour, in a child, it is -followed by a natural sleep of a few hours duration, provided there is -no painful wound, or other cause, to prevent the sleep. I have given -chloroform in a few cases as early as the ages of eight and ten days, -and in a considerable number before the age of two months; and I have at -this time, June 30th, 1857, memoranda of the cases of 186 infants under -a year old to whom I have administered this agent. There have been no -ill effects from it either in these cases, or in those of children more -advanced in life; and it is worthy of remark that none of the accidents -from chloroform which have been recorded, have occurred to young -children. - -There is nothing peculiar in the effects of chloroform on people -advanced in years, except that its influence subsides rather slowly, on -account of the slower breathing and circulation. I have given chloroform -to many patients over seventy-five years of age, and to one as old as -ninety years. - -_Strength or Debility._ The comparative strength or debility of the -patient has considerable influence on the way in which chloroform acts. -Usually the more feeble the patient is, whether from illness, or any -other cause, the more quietly does he become insensible; whilst if he is -strong and robust, there is very likely to be mental excitement in the -second degree, and rigidity of the muscles, and probably struggling in -the third degree of narcotism. Patients in a state of debility resemble -children, not only in coming quietly and easily under the influence of -chloroform, but also in the circumstance, that the common sensibility is -suspended with less narcotism of the nervous centres than is generally -required in robust persons. Children and persons in a state of debility -have usually an acute sensibility which causes them to suffer pain from -very slight injuries, but this sensibility is more easily suspended by -chloroform than the less acute sensibility of robust persons. It is in -strong men, accustomed to hard work or athletic sports, that the -rigidity and struggling previously alluded to in describing the effects -of chloroform, most frequently occur after the loss of consciousness. -Some of the patients in whom the struggling and rigidity have been -greatest were gentlemen belonging to boating clubs; but I think the -patient, in whom these symptoms were most violent, was a celebrated -harlequin of one of the London theatres, on whom Mr. Fergusson operated -a few years ago. - -The persons in whom the rigidity and struggling are well marked are -often lean and wiry, and these symptoms rarely occur in fat people. The -rigidity and struggling are less marked when the chloroform is given -slowly than when quickly given. - -_Hysteria._ Patients who are subject to hysteria sometimes have symptoms -of the complaint, such as sobbing, crying, or laughing, as soon as -consciousness is suspended, or even impaired, by the chloroform; but -these symptoms can always be subdued by proceeding with the inhalation. -In a very few instances the hysterical state returns, and becomes -troublesome as the effect of the vapour subsides. In two or three cases -that I have met with, it continued for three or four hours, but it -usually subsides in a much shorter time. The inhalation should not be -suspended on account of the hysteria, but should be continued till it is -subdued before an operation is performed. - -I have rarely seen a decided fit of hysteria from the effects of -chloroform, but in the case of a young married lady, to whom I gave this -agent to prevent the pain of an operation on the rectum, a somewhat -violent paroxysm of hysteria came on directly after the inhalation was -commenced. The surgeon would not permit me to continue the chloroform, -and expressed his intention of operating without it. After waiting for -about half an hour, however, for the hysteria to subside, and finding -that it continued the same as at first, the inhalation was resumed. The -patient was soon rendered insensible, and lay perfectly still whilst the -operation was performed. There was a little hysteria as the effects of -the chloroform subsided, but not so severe as before. - -I have several times seen hysterical symptoms in the male, either during -the administration of chloroform, or whilst the patient was recovering -from its effects. But in all these cases, the patients informed me -afterwards that they were subject to hysterics when under the influence -of mental emotion. - -In some persons who are subject to hysteria, the breathing becomes -excessively deep and rapid whilst inhaling chloroform. This usually -occurs just as the patient is becoming unconscious, but in a few cases -even earlier, and the patient is aware of the impulse to breathe in this -manner. After this kind of hysterical breathing has lasted a minute, the -patient generally rests nearly a minute without breathing at all, after -which the respiration generally becomes nearly natural. I give the -chloroform very sparingly during this violent breathing, or else -withdraw it altogether for a minute or two. - -I do not consider that the hysterical diathesis forms any objection to -the use of chloroform in operations, as the patients would be generally -quite as liable to suffer an attack of hysteria from the pain, if -chloroform were not used. - -_Epilepsy._ Chloroform occasionally brings on a fit of epilepsy in -persons who are subject to this disease. It was stated in one of the -foreign medical journals, in 1848, that this agent was so certain to -cause a fit in epileptic persons, that it might be used to detect -impostors pretending to be subject to this disease; but if this -assertion has been acted on, it must have led to great injustice, for I -have many times administered chloroform to the extent of causing -complete insensibility in epileptic patients who required to undergo -operations, without its inducing the least approach to a fit. - -In the few cases in which epileptic convulsions are occasioned by -chloroform, they do not appear till the third degree of narcotism is -induced, in this respect differing from hysteria, which comes on in the -second degree, or even earlier, as was stated above. The course to -pursue, when epileptic convulsions appear, is to continue the chloroform -steadily and gently, till they subside. I have never seen the chloroform -fail to subdue the convulsions in a very few minutes, and I have never -seen them recur after the operation, as the effects of the vapour -subsided. In medical and obstetric practice, and for slight operations, -it is not requisite to carry the effects of chloroform so far as that -stage in which an epileptic fit would occur, so that under these -circumstances the fact of a patient being subject to epilepsy hardly -requires to be taken into account. - -_Pregnancy._ I have repeatedly given chloroform at all periods of -pregnancy, both for tooth-drawing and more important operations, and I -have not met with any ill effects from it in any of the cases. - -_The Menstrual Period._ It is customary to avoid the menstrual period in -fixing the time for a surgical operation, when it can be so arranged. -There are, however, often reasons for not waiting over this period, and -under such circumstances, I do not know any objection to the inhalation -of chloroform. I have administered it frequently during the menstrual -period, and have seen no ill effects from it. I have observed that there -is a little more tendency to slight hysterical symptoms, during its -inhalation at this period, than when the same patients inhale it at -other times, which is what we might expect. - -_Diseases of the Lungs._ Affections of the lungs sometimes cause a -little difficulty and delay in the administration of chloroform, as the -vapour is liable to excite coughing when the mucous membrane of the -air-passages is irritable. The inconvenience is, however, confined to -the time of inhalation, for the cough is generally relieved afterwards. - -I have given chloroform for surgical operations in many cases where -phthisis was present, and in several patients who had suffered from -hæmoptysis, and have not seen any ill effects from its use in these -cases. Chloroform has indeed often been inhaled with advantage to -relieve the cough in consumption. The cases of chronic bronchitis in -which chloroform is administered for surgical operations are still more -numerous. The effects I have observed have been coughing at the time of -inhalation, and very often a relief of the cough afterwards. Some of the -patients had emphysema of the lungs. It is scarcely necessary to allude, -in this place, to acute diseases of the lungs, as surgical operations -are not performed during their continuance, but from the fact of -chloroform being inhaled occasionally in the treatment of these -affections, it is evident that they would cause no obstacle to its -employment. - -_Disease of the Heart._ There is a very general impression that the use -of chloroform is unsafe when disease of the heart exists, more -particularly, fatty degeneration of that organ. This belief has been -encouraged by the circumstance that this affection has been present in a -few of both the real and alleged deaths from chloroform; and also by the -fact that, in the accidents that have been really due to chloroform, the -heart has been the organ on which it has exerted its fatal influence. -When we come to investigate these cases, however, we shall find reason -to conclude that the heart has probably been diseased in quite as great -a proportion of the patients who have taken chloroform without ill -effects, as in those who have succumbed under its influence. As regards -my own practice, indeed, the only case in which death could in any -degree be attributed to the chloroform, was one in which there was -extreme fatty degeneration of the heart; but, on the other hand, I have -given chloroform in numerous cases without ill effects where the -symptoms of this, as well as other affections of the heart, were present -in a very marked degree. Indeed, I have never declined to give -chloroform to a patient requiring a surgical operation, whatever might -be his condition, as I early arrived at the conclusion that this agent, -when carefully administered, causes less disturbance of the heart and -circulation than does severe pain. Whenever I have had an opportunity of -seeing an operation performed without chloroform, I have carefully -observed the pulse, and although none of these operations have been of a -very severe nature, I have found the circulation to be much more -disturbed than it would have been by chloroform carefully administered. -The pulse in most of these cases has been excessively frequent during -the operation, and in some instances it has intermitted to an unusual -extent. - -In one instance, I had an opportunity of witnessing a similar operation -on the same patient, first without chloroform, and afterwards under the -influence of this agent. On January the 6th, 1855, Mr. Fergusson -performed lithotrity, in King’s College Hospital, on a man, aged -fifty-one. He generally directs chloroform to be administered in -lithotrity, but in this instance he omitted to do so, as he thought that -the bladder was not very irritable, and that the patient would not -suffer much. I began to feel the pulse just when the patient saw the -lithotrite about to be introduced. It was 120 in the minute. As soon as -the instrument was introduced, the pulse increased to 144, and -immediately afterwards it became uneven, irregular, and intermitting. I -could not count more than three or four beats at a time; and, -occasionally, when the pain seemed greatest, and the man was straining -and holding his breath, the pulse was altogether absent for four or five -seconds. In order to ascertain whether the absence of pulse at the wrist -might not depend on the pressure of the muscles of the arms, caused by -grasping the table, I applied my ear to the chest, and found that there -was no sound whatever to be heard during the intervals when the pulse -was imperceptible. It was evident that the patient held his breath till -the right cavities of the heart became so distended as to stop the -action of that organ till the respiration returned. The man did not -complain or cry out during the operation. A week afterwards the -lithotrity was repeated, but on this occasion I administered chloroform. -The pulse was about 120 in the minute when the patient began to inhale -the chloroform, but it became slower as he was made unconscious, and it -was regular and natural during the operation. It was only towards the -end of the operation, when the effect of the chloroform was allowed to -diminish, and when the man began to strain a little, though not yet -conscious, that the pulse intermitted slightly, passing over a single -beat occasionally. There were none of the long intermissions of the -pulse observed on the former occasion. - -It is very evident that if the above mentioned patient had been the -subject of any affection of the heart which weakened or embarrassed its -action, he would have run a much greater risk from the pain of the first -operation, than from the inhalation of chloroform in the second one. - -In a few of the patients having the arcus senilis of the cornea, a weak, -intermitting, or irregular pulse, and other signs of fatty degeneration -of the heart, there have been a feeling of faintness and a tendency to -syncope, as the effects of the chloroform were subsiding, especially -when the operation had been performed in the sitting posture; but these -symptoms have soon subsided, in all the cases I have met with, on -placing the patient horizontally, with or without the help of a little -ammonia to the nostrils. - -_Cerebral Disease._ Affections of the head offer no obstacle to the -administration of chloroform. I have given it to several patients who -had suffered previously from an attack of apoplexy. Some of them still -retained the paralysis resulting from their attack, but the chloroform -has not been attended or followed by ill effects in any of these cases. -The following case, in which alarming head symptoms had existed a few -hours before the inhalation of chloroform, cannot fail to be -interesting. - -The 31st of October, 1854, was appointed by Mr. Fergusson to perform -lithotrity on a gentleman, seventy-eight years of age, who had a -phosphatic calculus in his bladder. He was a patient of Mr. Propert, and -Mr. Fergusson had removed a similar calculus by lithotrity, and I had -given him chloroform at each of the operations, and it was arranged that -he should have chloroform on the present occasion. Mr. Propert informed -Mr. Fergusson and me, on our arrival, that his patient had had an attack -the night before resembling apoplexy; he had been insensible, the -breathing had been stertorous, the pupils dilated, and the face very red -and congested. Mr. Propert had caused him to be cupped to fourteen -ounces, and had given him twenty grains of calomel in the course of the -night, and in the morning he was as well as usual, and remained so at -the time of our visit. We considered the case with Mr. Propert, and as -there were reasons for not postponing the operation, it was determined -that he should inhale the chloroform rather than be subjected to the -pain. The vapour acted very favourably; he recovered his consciousness a -few minutes after the operation, and expressed himself as feeling quite -well. - -Mr. Fergusson crushed another calculus in this patient in March 1855, -when I again administered chloroform, and in 1856 I understood that he -was free from the complaint. - -_Insanity._ Chloroform acts on insane patients just as it does on -others, that is to say, they are made insensible by it, and, when its -effects completely subside, it leaves them in the same state of mind as -before. Insane people are, however, often so suspicious that they cannot -be persuaded to inhale chloroform, and it can only be given to them by -force. When once under its influence, however, I have seen teeth -extracted, and other operations performed, which it would have been -impossible to accomplish in the same individuals without resorting to -inhalation. The use of chloroform in the treatment of mania will be -alluded to in another part of this work. - -_Hard Drinkers._ It was at one time alleged that hard drinkers of -spirituous liquors were not susceptible of the influence of ether or -chloroform, and for a long time there remained an impression that these -persons were difficult to render insensible. I have always found that -hard drinkers were rendered unconscious, and even comatose, by the same -amount of ether or chloroform as other persons; but they sometimes have -a morbid excess of sensibility in the nerves of common sensation, and do -not lie still under the surgeon’s knife except when the nervous centres -are deeply narcotised, and the breathing almost stertorous. On this -account, they sometimes inhale much more chloroform during a protracted -operation than other persons. - - -AMOUNT OF VAPOUR OF CHLOROFORM ABSORBED TO CAUSE THE VARIOUS DEGREES OF - NARCOTISM. - -Before proceeding to describe the mode of administering chloroform, it -is desirable to treat of the quantity of it which produces its different -effects. Without alluding to the facts and experiments which prove that -all narcotics produce their effects by being absorbed into the -circulating fluid, and so reaching the nervous system on which they act, -it is only necessary to mention the following circumstances to show that -this is the case as regards chloroform. In some experiments in which I -assisted Dr. Sibson, we found that the vapour of chloroform produced its -effects after both the pneumogastric nerves had been divided, exactly -the same as before. Chloroform can be detected by means of chemical -tests exhaling in the breath of those who have just previously inhaled -it. It can also be detected in the urine after inhalation, and very -readily in all the tissues of animals that have been killed by it, for -several days after death. - -The quantity of chloroform in the blood in the different degrees of -narcotism might be estimated approximatively from the amount used in -inhalation, but I devised some experiments in 1848 for ascertaining the -quantity with accuracy.[52] The experiments were based on the following -circumstances. - -When air containing vapour is brought in contact with a liquid, as water -or serum of blood, absorption of the vapour takes place, and continues -till an equilibrium is established; when the quantity of vapour in both -the liquid and air, bears the same relative proportion to the quantity -which would be required to saturate them at the temperature and pressure -to which they are exposed. - -This is only what would be expected to occur; but I verified it by -numerous experiments in graduated jars over mercury. The intervention of -a thin animal membrane may alter the rapidity of absorption, but cannot -cause more vapour to be transmitted than the liquid with which it is -imbued can dissolve. The temperature of the air in the cells of the -lungs and that of the blood circulating over their parietes is the same; -and, therefore, when the vapour is too dilute to cause death, and is -breathed till no increased effect is produced, the following formula -will express the quantity of any substance absorbed:—As the proportion -of vapour in the air breathed is to the proportion that the air, or the -space occupied by it, would contain if saturated at the temperature of -the blood, so is the proportion of vapour absorbed into the blood to the -proportion the blood would dissolve. - -The manner in which the experiments were performed, was to place a small -animal in a glass jar, so large that it formed a capacious apartment for -it, and held much more air than it could require in the course of the -experiment. The jar was covered with a closely fitting lid, and a -carefully weighed portion of chloroform was allowed to diffuse itself -through the air of the jar. The experiments were continued till the -chloroform produced no further effect. I shall pass over a number of -tentative experiments, and adduce only a few of those which were made -after I had ascertained the quantities requisite to produce the desired -effect. The results obtained in these experiments were entirely due to -the degree of dilution of the vapour; for the quantity of chloroform -employed was, in every instance, more than would have killed the animal -in a much shorter time than the experiment lasted, if it had been -conducted in a smaller jar. It is assumed that the proportions of vapour -and air remain unaltered during the experiment; for the quantity -absorbed must be limited to what the animal can breathe in the time, -which is so small a part of the whole that it may be disregarded. - -_Experiment 1._ A guineapig and a white mouse were placed in a jar -holding 3,000 cubic inches, and fifteen grains of chloroform were -introduced by a tube in the lid of the jar, which was closed immediately -by a screw. The chloroform fell on some blotting paper suspended in the -jar, and in a minute or two was converted into vapour and diffused -through the air in the jar. The animals were allowed to remain half an -hour, and were unaffected by the chloroform, except that they appeared -to be a little less brisk than usual, during the first two or three -minutes after their removal. - -_Experiment 2._ A guineapig was placed in the same jar, and twenty-two -and a half grains of chloroform were introduced in the same manner as -before, being three-quarters of a grain to each hundred cubic inches of -air. In two or three minutes the chloroform was converted into vapour -and diffused through the air in the jar. Six minutes afterwards the -guineapig began to stagger, and soon afterwards was unable to keep on -its legs. It was kept for half an hour in the jar, but did not become -further affected. It was occasionally quiet, but always tried to walk -when disturbed by moving the jar. When taken out, it flinched on being -pricked, and it tried to walk, although unable to support itself on its -legs. It recovered from the effects of the chloroform in three or four -minutes. - -_Experiment 3._ Another guineapig was placed in the same jar, and thirty -grains of chloroform were introduced. In three or four minutes the -chloroform had evaporated and diffused itself through the air in the -jar. In two minutes afterwards the guineapig lay down, but stirred when -the jar was moved. It was allowed to remain in the jar for half an hour, -being asleep except when disturbed. When taken out it awoke and -endeavoured to walk, but was unable to support itself at first. It -flinched on being pricked. Recovered in three or four minutes. - -_Experiment 4._ A cat was placed in the same jar, and the same quantity -of chloroform was introduced. In three minutes it had evaporated, and, -when ten minutes had elapsed, the cat began to stagger. Soon afterwards -it was unable to support itself on its legs; and, when a quarter of an -hour had elapsed, it seemed asleep, but raised its head when the jar was -inclined. It remained apparently sleeping till the end of an hour, when -it was taken out. It was unable to stand, but was sensible to the -slightest pinch. It recovered gradually in the course of twenty minutes. - -_Experiment 5._ Sixteen grains of chloroform were put into a jar holding -1,600 cubic inches, being one grain to each 100 cubic inches of air, as -in the two last experiments. When it was converted into vapour, a white -mouse was introduced, by moving the lid a little to one side for a -moment. After running about for a minute and a half, it began to stagger -and to lose power, but it continued to run with little intermission till -three minutes had expired. After this it lay still, except when the jar -was inclined, when it always endeavoured to maintain its balance and to -walk. It also moved its limbs now and then, when not disturbed. It was -removed at the end of ten minutes, when it tried to walk, but was -unable. It did not flinch when its tail was pinched, but flinched, half -a minute after its removal, on one of its toes being pinched. It -recovered in two or three minutes. - -_Experiment 6._ A guineapig was placed in the jar holding 3,000 cubic -inches, and 37·5 grains of chloroform were introduced in the same manner -as in the former experiments, being a grain and a quarter to each 100 -cubic inches of air. The chloroform took three or four minutes to -evaporate and diffuse itself in the jar; and by the end of this time the -guineapig, which had been excited and running about, began to stagger, -and in two minutes longer it was unable to walk, but endeavoured to keep -its balance when the jar was inclined. At the end of a quarter of an -hour it was lying still, but moved its limbs when it was rolled over by -inclining the jar; but it made no voluntary effort. It was taken out -when thirty-three minutes had elapsed. It moved its limbs as it was -removed, though apparently not in a voluntary manner. Its limbs were not -relaxed. It was quite insensible to pricking. It recovered in about ten -minutes. The temperature in the axilla before it was put into the jar -was 100° Fah., and immediately after its removal 96°. - -_Experiment 7._ A guineapig was placed in the same jar, and forty-five -grains of chloroform were introduced, being a grain and a half to each -100 cubic inches of air. In four minutes after the chloroform had -evaporated, the guineapig was unable to walk. In half a minute more it -seemed asleep, but there was a tremulous motion of the hind legs, which -continued till ten minutes had elapsed. Afterwards it lay still, but -winked now and then spontaneously. When rolled over by moving the jar, -it made no voluntary effort. It was taken out twenty minutes after the -chloroform had evaporated. It winked spontaneously, and also when the -eyes were touched. It did not flinch when the ear was pricked, but -flinched when the paw was pricked. The temperature in the axilla before -the experiment was 100°, and immediately afterwards it was 96°. The -guineapig recovered from the effects of the chloroform in ten minutes. - -_Experiment 8._ A guineapig was put into the same jar, and 52·5 grains -of chloroform were introduced, being a grain and three-quarters to each -100 cubic inches of air. The chloroform evaporated in the course of four -minutes, at the end of which time the guineapig was altered in its -manner, as if partially inebriated. In two minutes more it was becoming -drowsy. A little while afterwards it was lying down. Six minutes after -the evaporation of the chloroform was complete, the guineapig made no -effort when turned over by inclining the jar, but only moved its feet, -as it were automatically. At the end of nine minutes, it was lying -quietly and breathing naturally. When fifteen minutes had elapsed it was -in the same condition, and was removed from the jar. It cried and -flinched on the foot being pricked. The temperature in the axilla was -97°. In five minutes after its removal it was fast recovering, and in -ten minutes was quite recovered. - -_Experiment 9._ A guineapig was placed in the jar used in the last three -experiments, and sixty grains of chloroform were introduced in the same -manner, being two grains to each 100 cubic inches of air. In four -minutes it was all converted into vapour, and the guineapig was -beginning to be affected by it. In two minutes more it was unable to -stand or walk. In five minutes from the time when the evaporation was -complete, the guineapig showed no sign of sensibility when turned over -by inclining the jar; the breathing was natural. At the end of ten -minutes it was lying still, breathing gently forty times in the minute. -At the end of fifteen minutes it was in the same condition. From -seventeen to twenty minutes, it stretched out one of its hind legs -several times, and was doing so when taken out, at the end of twenty -minutes. It showed no sign of sensibility when pricked. The temperature -in the axilla was 96°. It began to recover gradually in a minute or two, -and recovered completely in from ten to fifteen minutes. - -_Experiment 10._ A cat was placed in the same jar, and the same quantity -of chloroform was introduced in the same manner. It became quite -insensible in a few minutes after the chloroform was introduced; and it -was allowed to remain for twenty-five minutes, when it was taken out. It -was perfectly insensible to pricking, and its muscles were quite -relaxed; it was breathing gently, and the pulsations of the heart were -between sixty and seventy in the minute. It was immediately made the -subject of another experiment of drowning whilst insensible, which need -not be related in this place. - -_Experiment 11._ Four grains of chloroform were put into a glass jar -holding 200 cubic inches, and when it had evaporated and was diffused -through the air in the jar, a white mouse was introduced, by momentarily -removing the cover a little to one side. A minute after its introduction -the mouse was lying, but it moved its legs for a quarter of a minute -longer. When four minutes had elapsed, the breathing became slow, and it -was taken out. It was totally insensible for the first three minutes -after its removal, and recovered during the two following minutes. - -_Experiment 12._ Thirty-two grains of chloroform were diffused through -the air of a jar holding 1,600 cubic inches, being two grains to each -100 cubic inches, as in the last three experiments. A white mouse was -introduced by moving the cover a little to one side for a moment. In one -minute it was insensible, and did not make any effort on being rolled -about by inclining the jar, but it moved its paws for half a minute -longer. It remained insensible, breathing 160 times in the minute, till -it was taken out at the end of five minutes. It was quite insensible to -pinching. It began to walk in a minute or two. Its temperature before -the experiment was 98°, and immediately afterwards was 92°. The -temperature of the room was 68°. - -_Experiment 13._ A guineapig was put into a jar holding 3,000 cubic -inches, and 67·5 grains of chloroform were introduced on blotting paper -suspended within the jar, being 2¼ grains to each 100 cubic inches. In -four minutes, the chloroform had all evaporated, and the guineapig was -becoming affected. In two minutes more, it was quite insensible. Eight -minutes after the chloroform had evaporated, it was lying still, -breathing forty times in the minute. During the next three or four -minutes, it moved one or other of its legs occasionally. At the end of -seventeen minutes, it was lying still, and the breathing was twenty-six -in the minute. It was taken out at the end of twenty minutes quite -insensible; in three or four minutes it began to try to walk, and in ten -minutes, was quite recovered. - -_Experiment 14._ Two white mice, one being full grown, and the other -about three-quarters grown, were placed in the jar holding 1,600 cubic -inches, and forty grains of chloroform were introduced on blotting -paper, being two grains and a half to each hundred cubic inches. In two -minutes, the chloroform had evaporated, and the mice were much excited. -In another minute, they were unsteady in walking; and in a minute more, -the old mouse was lying insensible, and breathing deeply and -laboriously. In four minutes more, _i. e._, six minutes after the -chloroform had evaporated, the young mouse was insensible also, but was -moving one of its hind legs. In other four minutes, the young mouse was -breathing by slow gasps, whilst the old one continued to breathe deeply -as before. Three minutes later, i. e., thirteen minutes after the -chloroform had evaporated, the old mouse had begun to gasp, and the -young one was gasping only at intervals. They were removed, and -recovered completely in ten minutes. The young one recovered most -quickly. Their temperature, on being removed, was about 90°. - -_Experiment 15._ A cat was put into the jar holding 3,000 cubic inches, -and 82·5 grains of chloroform were introduced, being two grains and -three-quarters to each hundred cubic inches. In five minutes, it had -evaporated, and the cat began to stagger in its walk. In two minutes -more, it was unable to stand. Five minutes after the chloroform had -evaporated, the cat was breathing deeply, seventy-five times in the -minute. At eight minutes, it was breathing less deeply, one hundred and -seventeen times in the minute. Ten minutes after the chloroform had -evaporated, the cat was quite insensible, and breathing one hundred and -twenty-six times in the minute. It was now taken out. The temperature in -the axilla was 98°. In half an hour after its removal from the jar, it -had recovered its consciousness, but was still drowsy. - -It was now put into the jar again, and the same quantity of chloroform -was introduced in the same manner as before. In five minutes, it had -evaporated, and the cat was again insensible. In other five minutes, it -was breathing rather deeply, forty-eight times in the minute. Twelve -minutes after the chloroform had evaporated, the cat was breathing in -the same manner, but sixty-eight times in the minute. The breathing -afterwards became shallow and feeble, and half an hour after the -chloroform had evaporated, it was eighty-eight in the minute. In five -minutes more, the breathing ceased. The cat was taken out of the jar, -and the stethoscope was applied to the chest. The heart could not be -heard to beat at first, but in a short time, the cat gave a gasp, and -the heart’s action returned, and the breathing became reestablished. - -_Experiment 16._ Forty-eight grains of chloroform were put into a jar -holding 1,600 cubic inches, being three grains to each hundred cubic -inches, and when it was converted into vapour and diffused through the -air in the jar, a white mouse was introduced. It ran about for a minute -and a half, and then it was unable to move any longer. In nine minutes -and a half, the breathing was getting very slow, and the mouse was -immediately removed. Before it could be got out, it appeared to have -entirely ceased to breathe, but it immediately began to gasp at -intervals. In a minute, the breathing improved, and soon became natural. -Three minutes after its removal, the mouse began to walk in a ring, and -in seven minutes, it had quite recovered. - -_Experiment 17._ A guineapig was placed in a jar holding 1,600 cubic -inches, and fifty-four grains of chloroform were introduced on blotting -paper, in the manner previously explained; being three grains and -three-eighths to each hundred cubic inches of air. In four minutes, the -chloroform had evaporated, and become diffused through the air in the -jar, and the guineapig was drowsy. In three minutes more, it was lying -apparently insensible, and breathing feebly, thirty times in the minute. -After this, it kicked occasionally for a few minutes. When six minutes -had elapsed from the time when the chloroform had evaporated, the -breathing was very feeble, and apparently performed only by the -diaphragm. From fifteen to eighteen minutes, I could hardly see whether -the animal was breathing or not, and it was taken out of the glass at -eighteen minutes, when the breathing appeared to have ceased. The -stethoscope was applied to the chest, and the sounds of the heart could -scarcely be heard at first, but the breathing returned in a few seconds, -and the action of the heart improved. The guineapig gradually recovered, -but it was not able to walk for twenty-five minutes. - -_Experiment 18._ Sixty grains of chloroform were introduced into the jar -employed in the last experiment, being three grains and three-quarters -to each hundred cubic inches of air contained in the jar. When it had -evaporated, and was diffused through the air, a white mouse was -introduced, whilst the lid of the jar was moved a little to one side for -a moment. It ran about at first, but suddenly ceased to run, and became -insensible, at the end of three-quarters of a minute. It lay breathing -deeply and rapidly till two minutes had elapsed, when the respiration -became slow, and it ceased at two minutes and three-quarters after the -mouse was introduced. It was removed at this time, and it gasped a few -seconds afterwards; this gasp was soon followed by another; the gaspings -became more frequent, and in a short time, the natural breathing was -resumed. In five minutes, the mouse was able to walk. - -The third, fourth, and fifth of the above experiments show that one -grain of chloroform to each hundred cubic inches of air suffices to -induce the second degree of narcotism, or that state in which -consciousness and voluntary motion are disturbed, but not entirely -abolished. Now one grain of chloroform produces 0·767 of a cubic inch of -vapour at 60°, when its specific gravity is 4·2; and, when the vapour is -inhaled, it expands somewhat, as it is warmed to the temperature of the -lungs; but it expands only to the same extent as the air with which it -is mixed, and therefore the proportions remain unaltered. But air, when -saturated with vapour of chloroform at 100°, contains 43·3 cubic inches -in 100; and - - As 0·767 : 43·3 :: 0·0177 : 1. - -So that if the point of complete saturation be considered as unity, -0·0177 or 1–56th, will express the degree of saturation of the air from -which the vapour is immediately absorbed into the blood; and, -consequently, also the degree of saturation of the blood itself. - -I find that serum of blood at 100°, and at the ordinary pressure of the -atmosphere, will dissolve about its own volume of vapour of chloroform; -and since chloroform of specific gravity 1·483 is 288 times as heavy as -its own vapour, 0·0177 ÷ 288 gives 0·0000614, or one part in 16,285, as -the average proportion of chloroform by measure in the blood, in the -second degree of narcotism. - -It is evident, from the experiments numbered 9 to 12 inclusive, that two -grains of chloroform to each hundred cubic inches of the inspired air -cause a state of very complete insensibility, corresponding with what I -have designated the fourth degree of narcotism; and by the method of -calculation employed above we get 0·0354, or 1–28th, as representing the -degree of saturation of the blood, and 0·0001228 the proportion by -measure in the blood. - -In experiments 6, 7, and 8, in which quantities of chloroform were -employed intermediate between one and two grains to each hundred cubic -inches of air, a moderate amount of insensibility was induced, -corresponding very much with the state of patients during operations -under chloroform. - -The experiments from 13 to 18 show that quantities of chloroform, -exceeding two grains to 100 cubic inches of air, have a tendency to -embarrass and arrest the function of respiration, if the inhalation is -continued. I have not yet been able to determine satisfactorily the -exact proportion of chloroform which requires to be absorbed to arrest -the respiration of animals of warm blood. I believe there is a definite -proportion which has this effect, but there are two reasons why it is -not so easy to ascertain it, as to ascertain the proportion which causes -the minor degrees of narcotism. In the first place, the breathing often -becomes very feeble before it ceases, so that the animal inhales and -absorbs but very little chloroform, and remains on the brink of dying -for some time. In the next place, the temperature of the body falls in a -deep state of narcotism, especially in small animals; and, as the -temperature falls, the amount of chloroform which the blood can dissolve -from any given mixture of air and vapour increases. - -Judging from the experiments numbered 14 to 18, three grains of -chloroform to each hundred cubic inches of air must be very nearly the -quantity which has the power of arresting the breathing when the -temperature of the body is 100°; and as three grains of chloroform -produce 2·3 cubic inches of vapour, and air at 100° is capable of taking -up 43·3 per cent. of its volume, it follows that the blood must contain -between 1–18th and 1–19th as much chloroform as it is capable of -dissolving, at the time when the respiration is arrested. In the 14th -experiment, the breathing of the two mice was on the point of being -stopped by two and a half grains of chloroform in each hundred cubic -inches of air, but during the thirteen minutes which the mice breathed -the vapour, their temperature fell to about 90°. Air, when saturated -with the vapour of chloroform at this temperature, contains 35 per -cent., and two grains and a half of chloroform yield 1·917 cubic inches -of vapour; so by a calculation similar to that made at page 68, the mice -at the time when the breathing was about to cease must have absorbed -1–18th part as much chloroform as their circulating fluids were capable -of dissolving. - -The reader will have observed that, in the experiments related above, -the mice became much more quickly affected than the guineapigs and cats. -The reason of this is their quicker respiration and circulation, and -much more diminutive size. Little birds, such as linnets and sparrows, -are also very quickly affected by chloroform. Frogs are more slowly -affected, owing to their languid respiration, unless the vapour to which -they are exposed is very strong. - -They can, however, owing to their low temperature, be rendered -insensible by proportions of vapour too small to affect animals of warm -blood; and as they have no proper temperature of their own, the amount -of vapour (in proportion to the air in which they are placed) that will -affect them, depends entirely on the temperature of that air. - -The following experiment was several times performed on frogs with the -same result, the temperature of the room being about 55°, as it was in -winter. - -_Experiment 19._ 4·6 grains of chloroform were diffused through the air -of a jar of the capacity of 920 cubic inches, and a frog was introduced. -In a few minutes, it became affected, and at the end of ten minutes, was -quite motionless and flaccid; but the respiration was still going on. -Being now taken out, it was found to be insensible to pricking: it -recovered in a quarter of an hour. - -In a repetition of this experiment, in which the frog continued a few -minutes longer in the vapour, the respiration ceased, and the recovery -was more tardy. On one occasion, the frog was left in the jar for an -hour, but when taken out, and turned on its back, the pulsations of the -heart could be seen. In an hour after its removal, it was found to be -completely recovered. - -The first of the experiments related above (page 60), showed that an -atmosphere containing half a grain of chloroform to each hundred cubic -inches, produced scarcely any appreciable effect on animals of warm -blood; but the following calculation explains why this quantity acts so -energetically on the frog, and proves that this creature is affected by -chloroform according to the same law as animals of warm blood. The -vapour is absorbed into the blood and lymph of the frog at the -temperature of the external air, whose point of relative saturation -therefore remains unaltered, both in the lungs and in contact with the -skin of the animal; and as half a grain of chloroform produces 0·383 -cubic inches of vapour, and air at 55° contains, when saturated, 10 per -cent. of vapour; 0·0383, or 1–26th, expresses the degree of saturation -of the air, and also of the blood of the frog. And this is a very little -more than the quantity (0·0354 or 1–28th) which was calculated above to -be the greatest amount which could be absorbed with safety into the -blood of the mammalia. It must be observed, however, that the pulmonary -respiration of the frog was arrested by this proportion of 1–26th as -much chloroform as the blood would dissolve, whilst we calculated that -it required about as much as 1–18th to arrest the breathing of animals -of warm blood. It must be remembered, however, that the pulmonary -respiration of frogs is a process of swallowing air, which only goes on -when the creature is comparatively active. In the torpid state, the -respiration takes place only by the skin, and the frog never breathes -with the aid of the same muscles and nerves as mammalia and birds. - -By warming a frog, together with the air in which it is placed, it is, -in accordance with the law explained above, rendered comparatively proof -against an amount of chloroform which would otherwise render it -insensible. - -_Experiment 20._ A frog, which had been a few days previously subjected -to the experiment just narrated, was put into the same jar, which was -placed near the fire, till a thermometer inside marked 75° Fah.; 4·6 -grains of chloroform were then introduced, and diffused through the air -in the jar. The jar was kept for twenty minutes, with the thermometer -indicating the same temperature within one degree. For the first -seventeen minutes, the frog was unaffected; and only was dull and -sluggish, but not insensible, when taken out. Air at 75°, when saturated -with vapour of chloroform, contains 22 per cent., and therefore the -0·383 per cent. of vapour, which at 55° was capable of saturating the -fluids of the frog to the extent of 1–26th of what they would dissolve, -was, at 75°, capable of saturating them only to the extent of 1–57th. - -At one of Dr. Wilson’s Lumleian Lectures, at the College of Physicians, -on March 29th, 1848, I had the honour of performing some experiments, -and making some remarks, on chloroform, and I combined together two -experiments on frogs and small birds, in a way which shows how entirely -the effects of a narcotic vapour depend on the quantity of air with -which it is mixed, and on other physical conditions. - -_Experiment 21._ I introduced a chaffinch, in a very small cage, into a -glass jar holding nearly 1,000 cubic inches, and put a frog into the -same jar, covered it with a plate of glass, and dropped five grains of -chloroform on a piece of blotting paper suspended within. In less than -ten minutes, the frog was insensible, but the bird was not affected. - -_Experiment 22._ I then placed another frog and another small bird in a -jar containing but 200 cubic inches, with exactly the same quantity of -chloroform. In about a minute and a half, they were both taken out,—the -bird totally insensible, but the frog not appreciably affected, as from -its less active respiration it had not had time to absorb much of the -vapour. - -The blood in the human adult is estimated by M. Valentin to average -about thirty pounds. M. Valentin’s experiments were so conducted that -this quantity must include the extra vascular liquor sanguinis, as well -as the blood actually contained within the vessels. On this account, his -estimate is all the better fitted for calculating the amount of -chloroform absorbed, since this medicine, when inhaled gradually, passes -by exosmosis through the coats of the bloodvessels into the fluid in -which the tissues are immediately bathed. The above quantity of blood -would contain 26 pounds 5 ounces of serum, which, allowing for its -specific gravity, would measure 410 fluid ounces. This being reduced to -minims, and multiplied by 0·0000614, the proportion of chloroform in the -blood required to produce narcotism to the second degree (see page 68), -gives 12 minims as the whole quantity in the blood. More than this is -used in practice, because a considerable portion is not absorbed, being -thrown out again when it has proceeded no further than the trachea, the -mouth and nostrils, or even the face-piece. But I find that if I put -twelve minims into a bladder containing a little air, and breathe it -over and over again, in the manner of taking nitrous oxide, it suffices -to remove consciousness, producing the second degree of its effects. - -To induce the third degree of narcotism, or the condition in which -surgical operations are usually commenced, would require that about 18 -minims should be absorbed by an adult of average size and health, -according to the above method of calculation; and to induce the deep -state of insensibility, which I have termed the fourth degree of -narcotism, would require 24 minims; whilst to arrest the function of -respiration would require that about 36 minims should be absorbed. - - - PREPARATIONS FOR INHALING CHLOROFORM. - -The only direction which it is usually requisite to give beforehand, to -the patient who is to inhale chloroform, is to avoid taking a meal -previous to the inhalation; for chloroform is very apt to cause -vomiting, if inhaled whilst there is a quantity of food in the stomach. -The sickness is not attended with any danger, but it constitutes an -unpleasantness and inconvenience which it is desirable to avoid. The -best time of all for an operation under chloroform is before breakfast, -but the customs and arrangements of this country do not often admit of -that time being chosen, and it is unadvisable to make the patient fast -beyond his usual hour. It answers very well to perform an operation -about the time when the patient would be ready for another meal, or, if -the time of operation fall two or three hours after the usual time of -eating, to request the patient to make only a slender repast at that -time, so as just to prevent the feeling of hunger. It is impossible to -prevent vomiting in some cases with the best precautions, for the -stomach occasionally will not digest when the patient is expecting a -surgical operation, and the breakfast may be rejected in an unaltered -state hours after it has been taken. In other cases the patient does not -vomit, even when he inhales chloroform shortly after a full meal. - -The most convenient position in which the patient can be placed whilst -taking chloroform is lying on the back, or side, as he is then duly -supported in the state of insensibility, and can be more easily -restrained if he struggle whilst becoming insensible. The semi-recumbent -posture on a sofa does very well, and there is no objection to the -sitting posture, when that is most convenient to the operator. In that -case, however, the patient should be placed in a large easy chair with a -high back, so that the head as well as the trunk may be supported -without any effort, otherwise he would have a tendency to slide or fall -when insensible. It has been said that it is unsafe to give chloroform -in the sitting posture, on the supposition that it would in some cases -so weaken the power of the heart, as to render it unable to send the -blood to the brain. Observation has proved, however, that chloroform -usually increases the force of the circulation; and although the -horizontal position is certainly the best for the patient under an -operation in all circumstances, I consider that the sitting posture is -by no means a source of danger, when chloroform is given, if the -ordinary precaution be used, which would be used without chloroform—that -of placing the patient horizontally if symptoms of faintness come on. I -have preserved notes of nine hundred and forty-nine cases in which I -have given chloroform to patients in the sitting posture, and no ill -effects have arisen in any of these cases. - -The person who is about to inhale chloroform is occasionally in a state -of alarm, either about that agent itself or the operation which calls -for its use. It is desirable to allay the patient’s fears, if possible, -before he begins to inhale, as he will then be able to breathe in a more -regular and tranquil manner. In a few cases, however, the apprehensions -of the patient cannot be removed, and they subside only as he becomes -unconscious from the inhalation. It has been said that chloroform ought -not to be administered if the patient is very much afraid, on the -supposition that fear makes the chloroform dangerous. This is, however, -a mistake; the danger, if any, lies in the fear itself. Two cases will -be related hereafter in which the patients died suddenly from fear, -whilst they were beginning to inhale chloroform, and before they were -affected by it; but the probability is that, if they had lived till the -chloroform took effect, they would have been as safe as other patients -who inhaled it. If chloroform were denied to the patients who are much -afraid, the nervous and feeble, who most require it, would often be -deprived of its benefits. Moreover, the patients would either be -prevented altogether from having the advantage of surgery, or they would -be subjected to the still greater fear of the pain, as well as the pain -itself; for whatever undefined and unreasoning fears a patient may have -when the moment comes for inhaling chloroform, he has only chosen to -inhale it on account of a still greater fear of pain. - -Fear and chloroform are each of them capable of causing death, just as -infancy and old age both predispose to bronchitis, but it seems -impossible that fear should combine with the effects of chloroform to -cause danger, when that agent is administered with the usual -precautions. Fear is an affection of the mind, and can no longer exist -when the patient is unconscious; but the action of that amount of -chloroform which is consistent even with disordered consciousness is -stimulating, and increases the force and frequency of the pulse, in the -same way as alcohol. I believe that no one would assert that a person -would die the sooner of fright for having taken a few glasses of wine, -or a small amount of distilled spirits, whatever might be the state of -his health. When chloroform has been absorbed in sufficient quantity to -cause unconsciousness, fear subsides, and with the fear its effects on -the circulation. It is a subject of almost daily observation with me -that the pulse, which is extremely rapid from some ill defined -apprehension, when certain patients begin to inhale chloroform, settles -down to its natural frequency after they become unconscious. - -The practice I have always followed has been to try to calm the patient, -by the assurance that there was nothing to apprehend from the -chloroform, and that it would be sure to prevent all pain; but where it -has been impossible to remove the fears of the patient in this way, I -have always proceeded to remove them by causing a state of -unconsciousness. It would of course be wrong to choose a moment for -beginning the inhalation, when fear was producing a very marked -depression of the circulation. On feeling the pulse of a gentleman, -about twenty-one years of age, in March 1855, who had just seated -himself in the chair to take chloroform, previous to having some teeth -extracted, by Mr. Thos. A. Rogers, I found it to be small, weak, and -intermitting, and it became more feeble as I was feeling it. I told the -patient that he would feel no pain, and that he had nothing whatever to -apprehend. His pulse immediately improved. He inhaled the chloroform, -had his teeth extracted, woke up, and recovered without any feeling of -depression. Now if the inhalation had been commenced in this case, -without inquiry or explanation, the syncope which seemed approaching -would probably have taken place, and it would have had the appearance of -being caused by the chloroform, although not so in reality. - - - MODE OF ADMINISTERING CHLOROFORM. - -The experiments previously related show that air containing rather less -than two grains of chloroform, in one hundred cubic inches, is capable -of causing a state of insensibility, sufficiently deep for surgical -operations; but in a creature the size of the human being, an -inconvenient length of time would be occupied in causing insensibility -with vapour so much diluted. About four cubic inches of vapour, or -rather more than five grains of chloroform to each hundred cubic inches -of air, is the proportion which I have found most suitable in practice -for causing insensibility to surgical operations. In medical and -obstetric cases, it should be inhaled in a more diluted form. - -Dr. Simpson recommended chloroform to be administered on a -handkerchief—the method in which sulphuric ether was administered by Dr. -Morton, in the first case in which he exhibited that medicine. The -objection to giving chloroform on a handkerchief, especially in surgical -operations, where it is necessary to cause insensibility, is that the -proportions of vapour and of air which the patient breathes cannot be -properly regulated. Indeed, the advocates of this plan proceed on the -supposition that there is no occasion to regulate these proportions, and -that it is only requisite that the patient should have sufficient air -for the purposes of respiration, and sufficient chloroform to induce -insensibility, and all will be right.[53] The truth is, however, that if -there be too much vapour of chloroform in the air the patient breathes, -it may cause sudden death, even without previous insensibility, and -whilst the blood in the lungs is of a florid colour. Chloroform may -indeed be inhaled freely from a handkerchief without danger, when it is -diluted with one or two parts by measure of spirits of wine, but the -chloroform evaporates in largest quantity at first, and less afterwards, -until a portion of the spirit is left behind by itself. The process, -however, of inhaling chloroform from a handkerchief is always uncertain -and irregular, and is apt to confirm the belief in peculiarities of -constitution, idiosyncrasies and predispositions, which have no -existence in the patient.[54] - -The most exact way in which it is practicable to exhibit chloroform to a -patient about to undergo an operation, is to introduce a measured -quantity into a bag or balloon of known size, then to fill it up by -means of the bellows, and allow the patient to inhale from it; the -expired air being prevented from returning into the balloon, by one of -the valves of the face-piece to which it is attached. I tried this plan -in a few cases, in 1849, with so much chloroform in the balloon as -produced four per cent. of vapour in proportion to the air. The effects -were extremely uniform, the patients becoming insensible in three or -four minutes, according to the greater or less freedom of respiration; -and the vapour was easily breathed, owing to its being so equally mixed -with the air. I did not try, however, to introduce this plan into -general use, as the balloon would sometimes have been in the way of the -surgeon, and filling it with the bellows would have occasioned a little -trouble. It seemed necessary to sacrifice a little of absolute -perfection to convenience, and I therefore continued the plan which I -had already followed. - -The great point to be observed in causing insensibility by any narcotic -vapour, is to present to the patient such a mixture of vapour and air as -will produce its effects gradually, and enable the medical man to stop -at the right moment. Insensibility is not caused so much by giving a -dose as by performing a process. Nature supplies but one mixture of -diluted oxygen, from which each creature draws as much as it requires, -and so, in causing narcotism by inhalation, if a proper mixture of air -and vapour is supplied, each patient will gradually inhale the requisite -quantity of the latter to cause insensibility, according to his size and -strength. It is indeed desirable to vary the proportions of vapour and -air, but rather according to the purpose one has in view, whether -medicinal, obstetric, or surgical, than on account of the age or -strength of the patient; for the respiratory process bears such a -relation to the latter circumstances, as to cause each person to draw -his own proper dose from a similar atmosphere in a suitable time. - -The inhaler represented in the adjoining engraving is, with some slight -alterations, the same that I have employed since the latter part of -1847. It is made of metal, and consists of a double cylinder, the outer -space of which contains cold water, and the inner serves for the -evaporation of the chloroform which the patient is to breathe. Into the -inner part of the cylinder there is screwed a frame, having numerous -openings for the admission of air, and four stout wires which descend -nearly to the bottom of the space, and are intended to support two coils -of stout bibulous paper, which are tied round them, and reach to the -bottom of the inhaler. In the lower part of this paper four notches are -cut, to allow the air to pass in the direction indicated by the arrows. -As the quantity of chloroform which is put in should never fill the -apertures or notches, the air which passes through the inhaler meets -with no obstruction whatever. There is a glass tube communicating with -the interior of the inhaler, and passing to the outside, to enable the -operator to see when the chloroform requires to be renewed. The elastic -tube which connects the inhaler to the face-piece is three-quarters of -an inch in internal diameter, to allow of the passage of as much air as -the patient can possibly breathe. On the introduction of the practice of -inhaling sulphuric ether there was no tubing in this country fit to be -breathed through; that in ordinary use was only about one-third, or -three-eighths of an inch in diameter,—not more than a quarter of the -proper calibre. - -[Illustration] - -The face-piece, to include both the mouth and nostrils, of which that -shown in the engraving is one of the modifications, is one of the -greatest mechanical aids to the process of inhalation which has been -contrived in modern times. Dr. Francis Sibson is its inventor. Dr. -Hawkesley did indeed contrive a very similar one about the same time as -Dr. Sibson,—early in 1847,—but he did not make it known. Dr. Ingen Housz -made patients inhale oxygen through the nostrils by means of a bottle of -India rubber with the bottom cut off; and Mr. Waugh, of Regent Street, -had more recently contrived a mouth-piece to be adapted outside the -lips, but the usual practice of inhalation previous to 1847, was for the -patient to draw in the medicated air by means of a tube placed in the -mouth. This led generally to great awkwardness at first, as the patient -usually began to puff as if he were smoking a pipe; and it had the -further inconvenience, in the administration of ether, that the tube -dropped from the mouth, and the patient began to breathe by the -nostrils, just as he was getting unconscious. The sides of the -face-piece delineated in the engraving are made of thin sheet lead, -which is pliable, and enables it to be adapted exactly to the -inequalities of the face, and the patient can breathe either by the -nostrils or mouth, just as his will, or instinct, or other nervous -functions, determine. - -I have introduced two valves into this face-piece, one which rises on -inspiration, to admit the air and vapour from the inhaler, and closes -again on expiration, and the other which rises to allow the expired air -to escape. I contrived the latter valve to turn more or less to one -side, as indicated by the additional line in the engraving, and thus -admit more or less of the external air to dilute still further that -which has passed through the inhaler, and become charged with vapour. By -this means the patient can begin by breathing air containing very little -vapour, and more and more of the air which has passed over the moistened -bibulous paper can be admitted, as the air-passages become blunted to -the pungency of the vapour. - -The object of the water-bath is to supply the caloric which is rendered -latent, and carried off, as the chloroform is converted into vapour, and -thus to render the process of inhalation steady and uniform. Without the -water-bath, the evaporation of the chloroform would soon reduce the -temperature of the inhaler below the freezing point of water, and limit -very much the amount of vapour the patient would inhale; and if the -apparatus were warmed by the hand, the temperature would be too high, -and the amount of vapour too great. A medical author of great reputation -in Paris sent to inquire at what temperature I used the water-bath, and -being informed, at the ordinary temperature, published his opinion that -it had no effect, and might as well be left off. He appeared not to have -considered the relations of heat, either to liquids or vapours. - -In arranging the bibulous paper in the inhaler, it is my object to -contrive that the air passing through, in the ordinary process of -inhalation, and at the ordinary temperature of about 60°, shall take up -about five per cent. of vapour. This quantity can be diminished, as much -as is desired, by turning the expiratory valve of the face-piece a -little to one side; and in winter I usually place a short coil of -bibulous paper against the outer circumference of the inside of the -inhaler, in addition to the central coils which are delineated. - -I commonly put two, or two and a half, fluid drachms of chloroform into -the inhaler at first. About a drachm of this is absorbed by the -filtering paper, and the rest remains at the bottom of the inhaler; and -in a protracted operation, when it is seen, by means of the glass tube, -that the latter part of the chloroform has disappeared, more is added, -by a drachm or so at a time, to prevent the paper ever becoming dry. Mr. -Matthews, 8, Portugal Street, Lincoln’s Inn Fields, makes the inhaler. -There are smaller face-pieces for children. The patient never inhales in -so upright a posture as the artist has represented. - -There are several other kinds of apparatus in use for the inhalation of -chloroform. The most usual consist of Dr. Sibson’s face-piece more or -less altered, and with a small piece of sponge placed inside. The -apparatus which is in most reputation on the continent is that of M. -Charrière; it consists of a glass vase with suitable valves, and a -fabric for exposing a surface wetted with chloroform to the air which -passes through it. - -M. Duroy, of Paris, has contrived an ingenious, but very complicated, -apparatus, which he calls an anæsthesimeter. The object of it is to -regulate the amount of chloroform which is inhaled in a given time, and -this can be varied from four to sixty drops in the minute; but the -experiments which I have related show that the quantity of chloroform -employed is not so important as the proportion of it in the inspired -air; and although each of these circumstances has considerable influence -over the other, in many cases there are conditions in which no regular -relation exists between them. For instance, if the inhaler were supplied -with sixty drops of chloroform per minute, these sixty drops weigh -twenty grains, and produce 15·3 cubic inches of vapour; and if an adult -patient were breathing the average quantity of four hundred cubic inches -per minute, the air he would breathe would contain nearly four per cent. -of vapour, which would answer extremely well; but if the breathing were -slow or feeble, or if he should hold his breath for an interval and -commence again, he might breathe air much more highly charged with -vapour. Indeed it would depend on the amount of surface moistened with -chloroform, the temperature of the air, and other physical conditions, -whether or not the air he inhaled might not be charged with chloroform -to a dangerous degree; whilst, on the other hand, if the breathing were -deep and rapid, as often happens whilst the patient is getting slightly -under the influence of the chloroform;—if, for instance, the patient -were to breathe at the rate of 1,600 cubic inches, instead of 400, the -air he would inhale would contain less than one per cent. of vapour, and -he would not become insensible with the utmost supply of the -anæsthesimeter, till his breathing should be moderated. M. Duroy also -follows the rude and objectionable plan of using a nose clasp, and thus -compelling the patient to breathe by the mouth alone. - -It is advisable to request the patient to breathe gently and quietly, -when he commences to inhale chloroform; in other words, to do nothing -but conduct himself as if he were about to fall asleep naturally; for, -if he breathes deeply, the vapour feels much more pungent than it -otherwise would do, and is apt to excite coughing, or a feeling of -suffocation. - -In using the inhaler described above, the patient should commence to -inhale with the expiratory valve of the face-piece turned on one side, -and it should be gradually advanced to the required extent, over the -opening it is intended to cover, as the sensibility of the lungs becomes -diminished. Not only patients with phthisis or bronchitis, but many -sensitive and irritable persons with sound lungs, have a great -intolerance of the vapour of chloroform at first, on account of its -pungency; and it is necessary to occupy two or three minutes in -gradually commencing the inhalation, before the patient makes any -appreciable progress towards insensibility. In administering chloroform -to children also, it is desirable to begin very gently; by this means, -and with a little persuasion, one generally succeeds in getting them to -inhale voluntarily; although, occasionally, it is necessary to use a -little force to accomplish one’s purpose. - -In certain cases of the medicinal application of chloroform, and also in -obstetric cases, where the pains are not severe, it is unnecessary to -render the patient unconscious, but for surgical operations this is -nearly always requisite. No force should ever be employed so long as the -patient is conscious, unless it be to children or lunatics; but some -patients become excited as soon as they are unconscious, and attempt to -leave the couch, or push away the chloroform; under such circumstances, -if they cannot be calmed by what is said to them, they should be held, -and the vapour should be steadily and gently continued, for a minute or -two, till a state of quietude is produced. By far the greater number of -patients remain quiet as they become unconscious, but there is no -difficulty in ascertaining whether a patient is unconscious or not. If -the eyelids remain open, the countenance shows whether the patient is -conscious or not; and, if they are closed, it is only necessary to touch -them gently, to ascertain this circumstance. If he is still conscious, -he will look at his medical man, and probably speak, or, at all events, -show intelligence in his countenance. - -_Signs of Insensibility._ The absence of consciousness, and a state of -quietude, are both requisite before the commencement of a surgical -operation, and they go a good way towards the preparation of a patient -for it, but these symptoms may be present and the patient not be ready -for an operation. The surgeon wishes to know whether he will lie still -under the knife, or whether he will make a resistance and outcry which -he would probably not make in his waking state. Some surgeons have -recommended that the patient should be pricked with the point of a knife -or some other instrument. This is not a good or satisfactory plan, -however, for a person will often show no sign of feeling a slight prick, -when a severe incision would rouse him to resistance. A more elegant and -successful plan is to raise the eyelid gently, by placing one finger -just below the eyebrow, and then to touch its ciliary border very -lightly with another finger. This should not be done roughly nor too -frequently, for fear of exhausting the sensibility when it is slight. -Just after unconsciousness is induced, the eyelids are often closed very -strongly when their margins are touched, especially in females, and -there seems to be a positive hyperæsthesia; this, however, is only -apparent, and arises from the control of the will being removed, whilst -sensibility remains. By continuing the chloroform, the sensibility of -the edges of the eyelids diminishes until, at last, they may be touched -without causing winking. Under these circumstances, the most severe -operation may, in almost every case, be commenced without sign of pain. -I have employed this test of the sensibility or insensibility of the -patient ever since chloroform has been in use, and also in the -employment of ether in 1847, and I am satisfied that it affords more -reliable information on this point than any other single symptom. It -even indicates the amount of sensibility where a little remains; when, -for instance, touching the margin of the eyelids causes very slight and -languid winking, the patient will commonly flinch a little if the knife -is used, but only in a manner that can be easily restrained, and will -not interfere with the majority of operations. The cases, in which the -indication afforded by the eyelids is not always to be depended on, are -those of hysterical patients, in whom there is sometimes no winking on -touching the eyelids, even when unconsciousness is scarcely induced. In -such cases, one must judge by the other symptoms, and also by the length -of time the patient has inhaled, the strength of the vapour, and depth -and activity of the breathing. Indeed, these conditions should be -observed and taken into account in every case; and all the symptoms -exhibited by the patient should be watched, such as the expression of -the face, the state of the breathing, and the condition of the limbs -with regard to their tension or relaxation. The last is indeed sometimes -relied on as the chief or sole sign whether the operation may be -commenced, but it is of itself very insufficient, and even fallacious. -The patient may allow his limbs to lie relaxed when he is scarcely -unconscious, and not at all insensible, merely because he is not -exerting his will upon them; if the arm is lifted, it may fall -listlessly down again, at a time when the knife of the surgeon would -rouse the patient to active resistance. Indeed, the limbs, which have -been lying relaxed, may become tense as the effect of the chloroform -increases, and may remain so during a short operation, in which there is -no sign of pain. - -Although the pulse of itself gives no indication as to how far a patient -is under the influence of chloroform, it is proper to pay attention to -it, not only during the first administration of the chloroform, but also -throughout the operation, especially if it be attended with much -bleeding. The pulse sometimes becomes intermittent or irregular during -the administration of chloroform, more especially in elderly persons. -This more commonly happens in the first exhibition of it, than when it -is repeated during the course of an operation. I have not seen any harm -from either of these conditions, but it is well to intermit the -chloroform for ten or fifteen seconds, and let the patient have a few -inspirations without it, if the pulse is not in a satisfactory -condition. If the precaution be taken to ensure that the air the patient -breathes shall never contain more than five per cent. of vapour, the -pulse can never be seriously affected by the direct action of the -chloroform, and the state of the breathing affords the best warning -against continuing the inhalation too long at a time. - -The breathing is fortunately also a sign that cannot be overlooked. It -is by the breath that the chloroform enters, and it is extremely -improbable that any one would go on giving the vapour after the -breathing became stertorous and laboured. - -The patient sometimes holds his breath after he is unconscious, and -before he is insensible; this occurs under two conditions: first, after -deep and rapid breathing, during which the patient seems to absorb more -oxygen than is immediately required, under the circumstances; and in -this condition, I have known him hold his breath for a whole minute, -whilst the pulse was unaffected. The other condition in which the -breathing is suspended, is when there is rigidity in the third degree of -narcotism, and the respiratory muscles seem to partake of the general -rigidity; the holding of the breath in these cases seldom continues so -long as under the former circumstances. I do not consider that there is -any danger from either of these kinds of suspension of breathing. I -believe it always returns as soon as there is a want of oxygen in the -system. Of course the inhaler need not be applied to the face when the -patient is not breathing, and he may as well have an inspiration or two -without chloroform when the breathing is renewed. It is seldom requisite -to carry the effects of chloroform so far that the breathing becomes -stertorous, and whenever stertor is observed, the inhalation should be -suspended; under these circumstances, the patient is always insensible. -In some cases, in which a little more chloroform has been inhaled than -is necessary, the patient breathes for half a minute or so by the -diaphragm only, and breathes in fact hardly at all. The abdomen rises -and falls freely, but, from the muscles of the chest not fixing the -ribs, hardly any air enters the lungs, and the face becomes rather -livid; meanwhile the pulse goes on very well, and at last the patient -draws a deep, sonorous inspiration, the face resumes its proper colour, -and all is right again. I have not heard of any accident from chloroform -commencing in this manner. This state of breathing, when it does occur, -usually takes place a few seconds after the inhalation has been left -off, and arises from the accumulation of the effects of the chloroform, -owing to the absorption into the system of the vapour which was -contained in the lungs at the time when the inhalation was -discontinued.[55] This accumulation or increase of the effects of -chloroform lasts for about twenty seconds; it is not dangerous unless -the vapour is inhaled of too great strength, but it should be borne in -mind in all cases. It may be prevented altogether, by reducing the -strength of the vapour, just as the patient is getting insensible, or by -giving it with intermissions of a few seconds, at this time. - -The rigidity and struggling previously mentioned (pages 39 and 50) as -occurring occasionally in the third degree of narcotism, more -particularly in robust persons, often form a very prominent feature in -the effects of chloroform; and have sometimes caused the medical man to -discontinue the exhibition of chloroform, under the belief that it did -not agree with the constitution of the patient, and that its further -exhibition would be unsafe. The proper course to pursue is to continue -the inhalation gently, till the struggling and rigidity are subdued. The -patient is often insensible before these symptoms are subdued, but it is -necessary to have him quiet, in order to enable the surgeon to operate -with convenience and safety. I have always succeeded in subduing the -involuntary struggling and rigidity, but have occasionally occupied five -or six minutes in doing so. It is desirable to proceed slowly and -cautiously, because, when these symptoms occur, the patient has already -absorbed nearly the usual quantity of chloroform, and he often holds his -breath, and then takes a sudden and deep inspiration, when he might -inhale an overdose of vapour, unless it were presented to him in a well -diluted state. - -When the rigidity and struggling are subdued, the breathing, in some -cases, becomes stertorous, and relaxation of the muscles takes place, -the limbs appearing quite flaccid; but by proceeding gently, these -effects may generally be avoided, and the patient becomes quiet, whilst -the breathing is natural, and the muscles are in a moderate state of -tension. If the operator should be afraid to proceed with the exhibition -of chloroform, on account of the violence of the muscular spasm and -rigidity, it will be satisfactory to him to know that, if the inhalation -is resumed in a few minutes, these symptoms will be less violent than at -first. - -Struggling and rigidity are less likely to occur, when chloroform is -administered slowly, than under opposite circumstances; but it is -impossible to prevent these phenomena altogether in certain patients. -After they are once subdued, they but very rarely recur during the -operation; the patient, in most cases, seems to take on, when he is -subdued by the chloroform, the same relation to it that women, children, -and persons in a state of debility have from the first. M. Chassaignac -has called this condition one of tolerance of the chloroform. It is a -condition in which the patient bears both the chloroform and the -operation very comfortably; but tolerance of a medicine is generally -meant to imply that the patient can take it in larger quantity than -before. But this is the reverse of what occurs when the patient is in a -tranquil state from chloroform; he has already absorbed a considerable -quantity, which has most likely penetrated deeply into the tissues, and -he certainly does not require, and could not bear, so much as in the -earlier stage of inhalation, where he is restless and breathing more -quickly, and thus exhaling and getting rid of the chloroform at a -greater rate. - -It might be a question whether the absence of muscular excitement, in a -number of cases, does not arise from the circumstance that anæsthesia, -or absence of common sensibility, is obtained, and the operation -performed, at a stage of narcotism anterior to that in which the -muscular rigidity and spasm occur. This is true in a few cases, but I am -satisfied by careful observation that, in the greater number of -instances in which muscular excitement is absent, it would not occur at -all, though the inhalation should be pushed to the most extreme degree. -Many animals also are killed by chloroform without the least excitement -of the muscular system occurring at any part of the process. - -The pupils of the eyes are dilated in the deep state of insensibility -which I have called the fourth degree of narcotism, but it is desirable -to avoid carrying the effects of chloroform to this extent. They are -occasionally dilated, however, under the slighter effects of chloroform, -and even as the patient is recovering from its effects. In the third -degree of narcotism, when the eyes are turned upwards, the pupils are -usually, if not always, contracted; there seems to be a consentaneous -action in the iris and the muscles which turn up the eye. The pupils -seem also to be less sensitive to light, when the patient is insensible -from chloroform, than at other times. This is all the information I am -able to give about the pupils. Some writers have entered into a good -deal of detail about the pupils, but their statements are very -conflicting. The pupils are acted on by other causes, both external and -internal, as well as the chloroform. The amount of light has great -effect on them; and I have seen them remain dilated for some time after -the chloroform was discontinued, and then suddenly contract, as the -patient began to use his eyes. Even if definite laws could be -ascertained with regard to the action of chloroform on the pupils, in -different doses, and under different conditions, there would be some -difficulty in applying them during the administration of the vapour, as -the patient cannot be made to direct his eyes to or from the light. -There is also some difficulty in making correct observations on the -pupils. Very often, when I am exhibiting chloroform, one of the -bystanders lifts the patient’s eyelid and makes a remark on the state of -the pupil, and, on my looking in the face of the speaker, I often have -occasion to tell him that his own pupils are quite as much dilated, or -contracted, as the case may be. - -With regard to the position of the eyes, they are usually turned upwards -in the third degree of narcotism, as I have already said, but in a -considerable number of instances they retain their usual position all -through the inhalation. In a few cases, they are turned downwards, the -pupils being almost hid under the lower eyelids, and causing a curious -expression. I have noticed this most frequently in children of ten to -fourteen years of age. I have scarcely ever seen temporary strabismus -under the influence of chloroform. - -The length of time which it is most desirable to occupy in the -administration of chloroform, before the commencement of an operation, -is about two minutes in infants, three minutes in children, and four or -five minutes in adults. Circumstances occasionally occur, however, to -lengthen these periods. The time during which the adult patient usually -remains conscious whilst inhaling, is about two and a half minutes, but -this period is sometimes prolonged from the nervousness of the patient, -or his intolerance of the pungency of the vapour. Again, when -unconsciousness is induced, there is, in many cases, an increased flow -of saliva; and although this usually causes no impediment, the patient -sometimes keeps making efforts of deglutition which very much retard the -inhalation; and, at other times, he holds his breath, with his mouth -full of saliva, as if he had some obscure idea of disposing of it in a -suitable manner.[56] The delay which often arises from the struggling -and rigidity has been already mentioned; but notwithstanding all these -circumstances, it hardly ever takes more than seven or eight minutes to -make a patient sufficiently insensible. - -I have indeed met with a few cases in which a longer time has been -occupied, but there has always been a physical reason for it. I have -never had occasion to attribute the delay to any idiosyncracy, or great -peculiarity in the patient, but only to the circumstance that the vapour -did not enter the lungs in sufficient quantity within a given time. I -have had under my care several patients who, it was supposed, were not -susceptible of the effects of chloroform, or were, at least, very -difficult to bring under its influence, as previous attempts had failed. -It so happens, however, that I have had no difficulty whatever with any -of these cases. - -Two or three female patients who were about to undergo some trifling -operation, preferred to leave off before they were unconscious, on -account of unpleasant sensations in the head or chest, and to have the -operation performed without the full effects of the chloroform; but -there is no doubt the agent would have acted well enough if it had been -continued. - -The following case will show that chloroform may be inhaled with -advantage in cases which at first seem very unfavourable. I received a -note in 1849 from a medical man in the country, in which he says:—“I -have now a young lady under my charge, from whom I am about to remove a -tumour attached to the ear. She is anxious to take chloroform, and by -the desire of herself and mother, I yesterday administered it by way of -trial, but only to what would be termed the second, and perhaps you -would say, the first degree. She lost some sensation, but was quite -conscious, and spoke. She felt giddy; there was tumultuous beating of -the heart, and a much accelerated pulse, with a dilated pupil; a perfect -coldness over the whole skin, with an equally cold perspiration; and, -during recovery from this slight effect, severe tremors of the whole -body, so much so as to shake the couch on which she was lying. From this -state she did not recover for nearly an hour. She complained of great -giddiness and oppression at her chest. She is a healthy-looking, florid -girl, but not strong, and has had, from time to time, severe spasm -affecting her chest, so much so as to take away her breath. I have thus -endeavoured to give you an outline of the constitution of my patient, -how she had suffered, and what were the effects of the small dose of -chloroform given by an inhaler. I never witnessed such extreme cold, -tremor, or such tumultuous action of the heart; and am therefore anxious -for the opinion of one who has administered chloroform under a greater -variety of circumstances than myself, and to learn whether the symptoms -I have described are sufficient to deter one from giving a sufficient -dose to cause entire suspension of consciousness. My own impression is -that they are sufficient to deter, but the patient and her friends being -both anxious it should be inhaled if possible, I shall only be too glad -to hear that you have witnessed like symptoms, and that you do not -consider them sufficient indications of danger to deter me from its -careful administration in the case.” - -I advised that the chloroform should be administered again, and -continued steadily till the patient should become insensible; expressing -my belief that the unpleasant symptoms would subside as unconsciousness -was induced. I received a reply to the effect that the operation had -been performed very successfully under the influence of chloroform, -although the vapour had an exciting effect for some time. - -_Repetition of Chloroform during an Operation._ The first application of -chloroform often suffices for an operation, if it be of short duration, -without repeating the inhalation. In a few cases the patient remains -insensible to the knife for three minutes after the inhalation is left -off, but this is an exception; and one cannot, at all events, make sure -of this prolonged effect of chloroform, without producing a deeper state -of narcotism than is desirable. More usually, if the operation lasts -more than a minute or two, it is necessary to repeat the inhalation; it -is, indeed, generally desirable to let the patient have a few -inspirations of air charged with chloroform vapour every half minute or -so, whilst the operation continues, in order to keep up the -insensibility. When the surgeon is cutting in the neighbourhood of -important parts, it is desirable to prevent any sign of sensibility, and -to keep repeating the chloroform so as to keep up the coma, without, -however, causing embarrassment of the breathing, or wide dilatation of -the pupil. In the greater number of operations, however, it is better to -wait till there is some sign of sensibility, such as a slight cry or -tendency to flinch, before the inhalation is resumed; and then a few -inspirations of well diluted vapour make the patient quiet again. - - - RECOVERY FROM THE EFFECTS OF CHLOROFORM. - -As soon as a patient has ceased to inhale, the chloroform begins to -exhale in the form of vapour from the blood as it passes through the -lungs. It cannot be detected by the sense of smell, after the lungs have -been emptied, by two or three expirations, of the vapour they contained -at the moment when the inhalation was discontinued; but I have detected -it by chemical means, after consciousness had returned. The chloroform -exhales in greatest quantity at first, and the patient usually recovers -his sensibility and consciousness in the time which it ought to take for -the chief part of the chloroform to be exhaled, according to mechanical -principles; as will be explained in treating of the _modus operandi_ of -this agent. The last traces of the chloroform of course exhale more -slowly, and a very minute and insignificant quantity may remain for a -considerable period in the system, not only of the patient, but of -anyone who was standing by whilst he inhaled. - -It is probable that a small portion of chloroform passes out by other -channels than that of the expired air: the latter, however, offers such -a ready and expeditious outlet, that the quantity excreted in any other -way is, most likely, very minute. I have on four occasions examined -urine passed after the inhalation of chloroform, by boiling it in a -flask, and passing the vapour, first through a red-hot tube, and -afterwards through a tube moistened inside with solution of nitrate of -silver, and I only on one occasion obtained a very slight precipitate of -chloride of silver. - -The patient usually becomes conscious within five minutes after the -inhalation has been discontinued. After a short inhalation, for a very -brief operation, consciousness sometimes returns immediately, and after -a prolonged inhalation the recovery of consciousness is sometimes -retarded till ten minutes have elapsed. Old people are often longer than -others in awaking from the effects of chloroform, owing, no doubt, to -their slower breathing and circulation. Children, on the other hand, -usually recover very quickly from its direct effects; but they often -lapse into a natural sleep which lasts a considerable time—even for -hours if they are not disturbed, and if the operation has left no -painful wound or other cause of uneasiness. - -It is desirable not to talk to the patient as he is recovering from the -effects of chloroform, but to leave him to collect his ideas, and not -speak to him till he is quite conscious, or makes some remark or inquiry -himself. If not prevented by the medical attendant, the friends of the -patient often address him the moment he opens his eyes; and the words -they generally use are of a very equivocal meaning to one who cannot -understand their application. They usually say “It’s all over”, which -very often has the effect of raising an indefinite feeling of alarm in -the patient; for, until he has had time to recover his memory, the -operation he was to undergo is generally the farthest thing from his -mind. When left to himself the patient usually recovers from the -insensibility in a very tranquil manner. If he has not been moved whilst -insensible, and awakes in the position in which he fell asleep, he -supposes, very commonly, that he has not been asleep at all; and in a -great number of instances will contend this point very stoutly, even -after a protracted operation, and assert that the chloroform has not -taken effect. It is as well to let him remain in this conceit for a -while, or even till he finds out the mistake himself; for, if reminded -of the pain they have been spared, just on waking after an operation, -persons are liable to be excited by emotions of pleasure and gratitude; -but a few minutes later, when the effects of the chloroform have more -completely subsided, they are better able to control their emotions. A -few persons wake with a full recollection of the preceding -circumstances, and inquire if the operation is done; whilst others, on -first awaking, are still entirely occupied with the subject of their -dreams. - -The greater number of patients who inhale chloroform have to remain in -bed on account of the operation which has been performed, but after -minor operations, the patient is sometimes able to walk away within five -minutes; although more frequently there is a little languor or feeling -of fatigue for half an hour or so; and it is desirable in all cases for -the patient to sit or lie quietly for this space of time, if not longer, -before he makes any mental or bodily exertion, even if he feels quite -well. - - - OCCASIONAL SEQUELÆ OF THE INHALATION OF CHLOROFORM. - -_Sickness._ The chief drawback to the benefits conferred by chloroform -is the sickness which in many cases follows its use. It is most frequent -when the inhalation takes place soon after a meal, and some of the -precautions which are requisite in order to avoid this symptom, or -render it as rare as possible, have already been described (p. 74); but -it occurs in certain cases, notwithstanding the best measures which may -be used for its prevention. Moving the patient as the effects of the -chloroform are subsiding is very apt to excite vomiting when it might -not otherwise occur; it is therefore desirable, when convenient, to -allow the patient to lie for half an hour or so, without moving his head -from the pillow. By this means, even when a feeling of nausea is -present, it often subsides without the occurrence of vomiting. It is -advisable also not to give the patient anything to eat or drink till -about an hour after the inhalation, and, as a general rule, not even -then, unless there is some inclination for it; for if anything is taken -into the stomach before the effects of the chloroform have entirely -subsided, it is apt to excite vomiting. Even medicine, such as an -opiate, is better delayed for an hour or upwards, unless there is an -urgent necessity for giving it sooner. Severe faintness from loss of -blood during an operation of course forms an exception to this rule; in -such a case brandy and water should be given, and repeated if it should -be vomited. - -These rules respecting food are, moreover, meant to apply only to the -use of chloroform in surgical operations, and not to its employment -during labour. Under the latter circumstances, one allows the patient -all the nourishment that is desirable, intermitting the inhalation now -and then for the purpose. And chloroform, given in the moderate way in -which it is employed in labour, hardly ever causes sickness, but often -alleviates it when present from physiological causes. - -The sickness induced by chloroform usually subsides of itself in the -course of an hour, or even less; I, therefore, think it advisable not to -do anything for it during this space of time. When it has continued -beyond this period, I have found a little cold brandy and water to -remove it in most cases; and when the tendency to vomit still remained -after a few hours, I have seen it removed by a dose of opium. -Effervescing draughts have not appeared to be of service in the sickness -from chloroform, and sal volatile and draughts of warm water seem -injurious. It is desirable for the patient to make no effort, but only -to vomit if obliged to do so. - -Several cases have come within my knowledge, in which the sickness has -continued for two or three days after every thing that was taken into -the stomach. These cases have not been under my care, but under that of -the surgeon. I have been informed, however, that all the usual remedies -for sickness were applied for the time mentioned above without success. -The cases in which the sickness lasts so long form but a very small -portion of the whole number in which chloroform is administered, and -they chiefly occur in persons who are subject to attacks of vomiting -from slight causes, or, as they say, to bilious attacks. - -The most usual time for the vomiting to commence is when the inhalation -has been discontinued, and the effects of the chloroform are passing of. -In many cases, it occurs before the patient has become quite conscious, -and he does not know that it has occurred unless he is told. In a few -cases, especially where there is a good deal of food in the stomach, the -vomiting comes on before the operation is finished, or even before it is -commenced. When vomiting comes on during an operation, it is apt to -interfere with the inhalation, and it is sometimes difficult to prevent -the patient from waking; but this can be accomplished by wiping the -patient’s mouth, and reapplying the chloroform, the moment the act of -vomiting ceases. In many cases, however, the sickness does not come on -till the patient is quite awake, and perhaps, even then, not until he -moves. I believe that the sickness which is due to chloroform always -commences within an hour or two, or at the farthest, just after the -first food which is taken. I have known vomiting attributed to the -chloroform which did not occur till the following day, but I ascertained -that a dose of opium had been taken at night, and it was to this that -the sickness was probably owing. In those cases where the chloroform -does cause sickness in the first instance, it is not always the cause of -all the vomiting which the patient may suffer. If the patient becomes -infected or is inoculated with the poison of erysipelas or hospital -gangrene at the time of the operation, he will probably be attacked with -vomiting a day or two afterwards; and if sickness has already been -caused by the chloroform, that which is due to disease may appear to be -a continuation of it. - -Soon after the introduction of chloroform, I administered it to a -gentleman, aged about 55, whilst a fatty tumour was removed from the -nape of the neck. It did not turn out as fatty tumours usually do, but -required to be dissected out. The patient had taken a meal before the -operation, and vomited freely afterwards. On his visit the next morning, -the surgeon thought his patient going on well. Vomiting returned, -however, and the patient became affected with partial stupor and -delirium, which his friends attributed to the chloroform. He became -covered with an eruption of erysipelas over a great part of the body, -had a very rapid pulse with great depression, and died on the fifth day. -An examination after death showed that there had been diffuse cellular -inflammation around the seat of the operation. A surgeon who assisted at -the operation on the above patient, and also at the post-mortem -examination, removed an encysted tumour from the scalp of an old lady -the day following the latter event. This operation was performed without -chloroform, but the patient was attacked with erysipelas and diffuse -cellular information, and died in three or four days. - -_Faintness and Depression._ Although chloroform acts as a stimulant to -the circulation, increasing the force and frequency of the pulse whilst -it is being inhaled, it is occasionally followed by a feeling of -faintness, especially if the patient remains in the sitting posture. At -one period in the history of medical opinion, it would have been said -that the depression was a consequence of the previous excitement. The -facts, however, would not agree with such a doctrine. The subjects who -are most stimulated by chloroform are the strong and robust, and they do -not suffer from depression afterwards; whilst the feeble and -debilitated, who are most liable to subsequent depression, are but -little stimulated by it at the time of inhaling. Some amount of -faintness and depression usually accompanies the sickness caused by -chloroform, and is in fact a consequence of it, being, like the -sickness, most frequent after a full meal. This depression is usually -relieved by vomiting. I have met with a few cases in which there has -been more decided faintness, and once or twice absolute syncope after -chloroform, which was not attributable to loss of blood. In these cases, -however, the patients were in the sitting posture, and they recovered -from the syncope immediately, on being placed horizontally. The patients -most subject to faintness after chloroform are those who are subject to -this affection at other times, being often persons in a state of anæmia, -or having the symptoms of fatty degeneration of the heart. Faintness is, -however, very much more rare after operations with chloroform than -without it. The only cases in which I have seen it follow the use of -chloroform in the horizontal position, and where there was no -considerable loss of blood, have been two or three of operations on the -rectum, performed before breakfast, and after a brisk purgative had been -taken the previous night. It might be advisable, where persons in a -state of debility have taken a purgative, to make an exception to the -usual rule of prohibiting the breakfast, and to risk the inconvenience -of vomiting rather than the more formidable symptoms of faintness from -inanition. - -The faintness which now and then follows an operation under chloroform -should be treated on ordinary principles, as the horizontal posture, the -application of the vapour of ammonia to the nostrils, and the exhibition -of brandy or wine, if the other measures do not suffice. I never give -ammonia internally where a patient is sick or faint, but the spirit of -sal volatile, when at hand, serves very well to pour on the corner of a -towel and apply to the nostrils. - -_Hysteria._ I have already stated (p. 51) that chloroform occasionally -excites hysteria in those who are subject to that complaint; and that, -in a few cases, the hysteria, which has been subdued by the chloroform, -reappears as the effects of the vapour subside. It is nearly always in -the female sex that one meets with these phenomena, although I have two -or three times seen hysterical symptoms in the male for half an hour or -so after the inhalation. The hysteria commonly takes the form of -laughing or crying, but the patient sometimes remains quiet, and simply -in an unconscious state. The hysterical symptoms usually pass off -spontaneously, in half an hour or less, without any remedies; if they -last longer, the ordinary remedies for hysteria may be applied. I am not -aware that the hysteria has lasted longer than three or four hours in -any of the cases in which I have administered chloroform, but it may -have done so without my being informed of the circumstance. I was -informed of the case of a young woman in King’s College Hospital, who -remained unconscious, or at least apparently so, for three days after -chloroform had been administered for an operation, the nature of which I -have forgotten. She recovered without ill effects. When the patient does -not wake spontaneously, and cannot be roused to the waking state, within -twenty minutes or half an hour after the inhalation of chloroform has -been left off, we may rest assured that the patient is affected with -hysteria—at least this has been the case in every instance with which I -have become acquainted. The physical properties of this agent do not -permit it to remain long in the system, if the circulation and -respiration are going on properly, and this circumstance ought to -prevent unnecessary alarm, in the absence of other symptoms except the -state of unconsciousness. I have, however, known great alarm to exist -where the properties of chloroform were not well understood. Soon after -its introduction, a medical man administered it to a young woman in -domestic service, for the extraction of a tooth. He became alarmed, in -the first instance, from the impression that he had given an overdose. -In a few minutes, however, the patient burst out in a loud fit of -laughter, but again became unconscious, and various measures were used -to restore her, including even artificial respiration, in the idea that -she was still under the influence of chloroform. I was sent for -thirty-six hours after the inhalation, and found the patient apparently -in a profound state of insensibility, and breathing very feebly. Guided -by the considerations mentioned above, I concluded that she was only -labouring under hysteria, and that the anxiety of those about her tended -very much to keep up the complaint. The anxious attendance on her was -discontinued, she took some medicine containing valerian, and became -quite conscious in few hours. I was told, however, that she did not seem -quite well for some time. - -I am not aware of any permanent ill effects having been produced by -chloroform, although, amongst the multitudes of persons who have inhaled -it, some have not failed to blame it for symptoms that have occurred -afterwards. - -A clergyman from the country called on me, in 1852, and the following -are some notes I made when he left my room. He is 63 years of age. He -said that he had inhaled chloroform about a year ago to have four teeth -extracted. He felt very well for about a week afterwards, but on his -pupils returning, and his beginning to apply himself to teaching, he -became affected with flushings of the face and a rushing noise in his -head, which lasted occasionally for a day or two, and have troubled him -ever since. An eminent physician, whom he named, prescribed quinine, -under the use of which he became worse. An eminent surgeon prescribed -infusion of hops, etc., and he has tried other medicines without good -effect. He had been recommended to travel, and had been to Switzerland; -but the complaint troubled him when at leisure, as well as when applying -himself mentally. He could not sleep at night, when affected with the -attacks. He is rather deaf, and has been so for three or four years; he -was also occasionally troubled with a rushing sound behind the ears -before he inhaled the chloroform. He is rather short and rather stout, -and has a florid complexion. The pulse was rather feeble. The second -sound of the heart was rather louder than the first. In other respects -its sounds were natural, but its impulse was not strong. In every -respect, except the symptoms above named, the health of the patient was -good, and he felt quite well between the attacks. - -It was my opinion that the complaint of this gentleman was coming on -long before he inhaled the chloroform, and that it depended on a much -less transient cause. I have not heard from him since. - - - CAUSE AND PREVENTION OF DEATH FROM CHLOROFORM. - -All narcotics are capable of causing death, and the discovery of -preventing pain by inhalation consists essentially in carrying the -effects of a narcotic much further than had previously been the custom; -there was, therefore, every reason to apprehend that accidents might -occur in the new practice, unless the effects of the medicines employed -could be very effectually controlled. There are certain circumstances -connected with the physiological properties of chloroform, as -ascertained in the experiments previously related, which indicate how -accidents may very easily happen with this agent, if not carefully and -systematically managed. It was calculated (p. 74) that 18 minims of -chloroform is the average quantity in the system of an adult, when -sufficiently insensible for a surgical operation, and that this amount -might be absorbed by the use of 36 minims, allowing one-half of the -quantity breathed to be exhaled again, without being absorbed; but 36 -minims of chloroform make only 37·5 cubic inches of vapour, which, at -the temperature of 60° Fah., may exist in combination with 257 cubic -inches of air, making it expand to not quite 300 cubic inches; the whole -of which might be breathed in twelve ordinary inspirations of 25 cubic -inches each. If the inhalation of vapour of this strength were continued -till insensibility was induced, the lungs would still contain a great -quantity of unabsorbed vapour. The amount of air usually present in the -lungs is about 250 cubic inches, and if saturated with chloroform at the -temperature of 60° it would contain the vapour of 30 minims. About half -of this might be absorbed, the remaining half passing off in the expired -air; but the addition of 15 minims to the 18 minims already absorbed -would almost double the quantity of chloroform in the system, and bring -the patient necessarily to the brink of death. It is true that, in the -ordinary methods of inhalation, the air seldom becomes quite saturated -with vapour, and usually is not more than half saturated, or accidents -might be of much more frequent occurrence; but the above considerations -are sufficient to show that the amount of vapour contained in the air -breathed by the patient should not be left to mere accident, such as the -varying temperature of the handkerchief from which the chloroform is -breathed, or the greater or less extent of wetted surface over which the -air passes. It should be recollected also that the patient sometimes -draws a deep and sudden inspiration by which he may inspire 100 cubic -inches of air, which would contain, if strongly charged with vapour, ten -or twelve minims of chloroform—a large quantity to be suddenly added to -that already in the circulation, when the patient is insensible, or -nearly so. - -It is, however, only by a knowledge of the different modes in which -chloroform is capable of causing death, that the exact nature of the -accidents from this agent can be understood, together with the means of -preventing them, and the reason why they are usually irremediable when -they happen. If animals are kept for a very long time under the deep -influence of chloroform, they become ultimately exhausted, the -circulation and respiration are gradually weakened, and cease nearly -together. Such a mode of death from this agent is never likely to occur -to the human subject, and therefore need not engage our further -attention. The following experiments illustrate the different modes of -dying, when death is caused more suddenly by this agent.[57] - -_Experiment 23._ A young but full grown cat was placed in a glass jar, -of the capacity of 1,600 cubic inches, and a fluid drachm of chloroform -was introduced, by a portion at a time, through a tube in the cover of -the jar. As twenty-five minims of chloroform produce twenty-six cubic -inches of vapour, the atmosphere which the cat had to breathe contained -nearly four per cent. of vapour, and the jar was moved about, to ensure -the uniform mixture of the vapour with the air. In five minutes, the cat -became insensible, and lay breathing naturally. In about ten minutes -more, the breathing became very feeble, and it ceased altogether in -about another minute, or sixteen minutes after the cat commenced to -breathe the chloroform. It was immediately taken out and laid on a -table, and the stethoscope was applied to the chest. The heart could be -heard beating distinctly at first, but the pulsations became slower and -feebler, and in about a minute they could be no longer heard. Just at -this time, however, the cat took a gasping inspiration, and immediately -the heart was heard to beat in a most rapid manner. The gasps were -repeated, and the action of the heart became less rapid, but stronger. -In a little time, both the breathing and the action of the heart became -natural, the cat remaining, however, insensible for some minutes. - -_Experiment 24._ A cat, about the same size as the last, was put into -the same jar, and the same quantity of chloroform was introduced. It was -removed at the end of four minutes, when it was so far insensible as to -offer no resistance. Being laid on the table, it was made to breathe air -charged with ten per cent. of vapour of chloroform from a bladder. -Twenty-five minims of chloroform were put into the bladder, which held -250 cubic inches, and it was filled up with the bellows. A portion of -another bladder which was attached to the stop-cock, was made to -surround the head of the cat, which consequently breathed to and from -the bladder. In half a minute it was quite insensible: in about half a -minute more the breathing became difficult, and the sounds of the heart -less distinct. The breathing became gradually slower, and ceased -altogether between three and four minutes after the respiration from the -bladder commenced. The sounds of the heart were rather frequent, and -scarcely audible, just before the breathing ceased, and they could not -be heard afterwards. The chest was opened three-quarters of an hour -after death. The lungs were of a pale red colour, everywhere permeated -with air; and a small quantity of fluid blood flowed from them on making -an incision. The right cavities of the heart were quite full of blood, -and the left cavities contained a small quantity. - -_Experiment 25._ A cat was made insensible in the same manner as the two -previous ones. As it made strong efforts to get out of the jar, and -consequently breathed more deeply, the chloroform took effect sooner; -and it was removed and laid on the table, in a passive state, at the end -of two minutes and a half. The respiration and sounds of the heart were -quite natural. The nose of the animal was placed in the mouth of a metal -vessel, lined with bibulous paper, and used as a chloroform inhaler. The -inhaler contained chloroform, and was surrounded with water of the -temperature of 110° Fahr. The stethoscope was kept applied to the chest -whilst the chloroform was exhibited. After four or five inspirations -from the inhaler, the heart suddenly ceased to beat, the breathing still -going on. The inhaler was removed as soon as I was satisfied that the -action of the heart had ceased, and there were two or three rather -convulsive respirations afterwards, and then the breathing stopped; but, -between one and two minutes later, there were two or three feeble -inspirations, accompanied with motion of the nostrils, but no returning -action of the heart could be heard. The chest was opened ten minutes -after death. The lungs were quite pale throughout. There was a little -clear serum in the pericardium. The heart appeared quite motionless when -first observed; but, after exposure to the air for a short time, there -were some slight contractions of a few fibres of the right ventricle. -The right auricle and ventricle were filled with blood. - -The air which this cat breathed must have contained much more than ten -per cent. of vapour. - -In experiment 23 the breathing was arrested by the influence of the -chloroform on the nervous centres, but the action of the heart -continued, until it was stopped, or very nearly so, for want of -respiration, as in asphyxia from privation of air. In experiments 24 and -25 the action of the heart was arrested by the direct effect of the -chloroform; in one instance at the same moment as the respiration, and -in the other instance, even before it. - -The paralysing effect on the heart of large doses of chloroform was -shown in the first experiments which were made with this substance, -viz., those by Dr. R. M. Glover in 1842.[58] In animals which were -killed by injecting it into the jugular vein, the irritability of the -heart was found to be destroyed, whilst this organ retained its -irritability in those that were killed by the injection of chloroform -into the arteries, stomach, or peritoneum. I have frequently arrested -the action of the heart remaining in animals which were opened -immediately after death, by blowing the vapour of chloroform on it; and -I ascertained by some experiments on frogs, that the motion of the heart -can be arrested by an amount of chloroform somewhat greater than -suffices to suspend the respiration. As absorption of chloroform vapour -is continued by the skin of these animals after the respiratory -movements have ceased, they can be exposed to the vapour till the action -of the heart is suspended by its direct influence. - -_Experiment 26._ Four and a half grains of chloroform were introduced -into a jar containing 600 cubic inches, being three-quarters of a grain -to each 100 cubic inches, and, the vapour having been equally diffused, -two frogs were put in. They tried to climb up the side of the jar, as if -wishing to make their escape, and one or the other occasionally ceased -to breathe for a minute or two, probably from disliking the vapour, but -commenced to breathe again. In about five minutes the efforts to escape -ceased, and they only moved to adjust their equilibrium when the jar was -disturbed. They were now breathing regularly, and continued to do so -till about ten minutes after their introduction, when all voluntary -power ceased, and the breathing began to be performed only at intervals. -They were allowed to remain till half an hour had elapsed, during the -last ten minutes of which time no respiratory movement was observed in -either of them. On taking them out, and laying them on their backs, the -pulsations of the heart were observed on each side of the sternum. These -pulsations were the more distinct, from the lungs being apparently -empty. I continued the experiment on these frogs, placing one of them -back again, in the course of two or three minutes, in the same jar, with -three grains of chloroform, and the other in a jar of 400 cubic inches -capacity, with five grains. They were laid on their backs, and the heart -of the former one, in air containing half a grain of chloroform to each -100 cubic inches, continued to beat distinctly and regularly, 45 times -in the minute, for four hours that it remained in the jar, and it was -not observed to breathe during the whole time, although it was watched -almost constantly. The respiration commenced again within half an hour -after its removal. In about an hour, it recovered its power of voluntary -motion, and it was not injured by the long narcotism. - -The pulsations of the heart of the other frog, in air containing a grain -and a quarter of chloroform to each 100 cubic inches of air, became -slower and more feeble, and in a quarter of an hour could not be -observed. The frog was left in the jar a quarter of an hour longer, and -removed when it had been in half an hour. The under part of the thorax -was immediately opened sufficiently to expose the heart. It was -moderately full of blood, but not contracting at all, and it did not -evince the least irritability on being pricked, either at first or after -exposure to the air for some time. It is evident that the heart of this -last frog became paralysed by the absorption into the blood of more -vapour, in addition to the quantity that was sufficient to arrest the -respiration. The temperature of the room during this experiment was 65° -Fah. - -The effect of chloroform on the heart of the frog is further shewn by -the next experiment. - -_Experiment 27._ A frog was placed in the jar containing 600 cubic -inches, with six grains of chloroform. In twenty minutes the respiration -had ceased, but the heart continued to pulsate strongly. At the end of -three-quarters of an hour, the pulsations were more feeble, and had -diminished from 40 to 30 in the minute. An hour and five minutes from -the commencement of the experiment, no movement of the heart could be -observed. The frog was taken out of the vapour, and a portion of the -sternum and integuments removed, so as partly to expose the heart, when -it was found to be still contracting, with a very feeble undulatory -motion. This motion increased in force, and, in a quarter of an hour -after its removal, the heart was pulsating regularly and strongly, the -ventricle apparently emptying itself perfectly. When the frog had been -out twenty minutes, it was placed again in the same jar, with the same -quantity of chloroform. In about ten minutes, the heart’s action began -to fail again; and in about twenty minutes, the slightest movement could -no longer be perceived in it. The frog was immediately taken out, and -the ventricle of the heart was pricked with a needle. In a few seconds, -a slight quivering was observed,—whether the result of the prick is not -certain,—and the action of the heart became gradually reestablished as -before. It was arrested a third time by exposure to the vapour; and -although, in its third removal, the anterior extremities of the frog had -become rigid, the heart resumed its action partially, and continued to -contract feebly for three or four hours after the rigidity of death had -invaded the body and limbs of the animal. The temperature of the room -was 62° during this experiment.[59] - -In the human being and all other creatures of warm blood, any vapour -which is inhaled and absorbed in the lungs passes at once to the left -side of the heart, and as the coronary arteries are the first branches -given off from the aorta, the heart must, during the process of -inhalation, be always a very little in advance of the rest of the body, -as regards the amount of vapour to which it is subjected. This, however, -is no source of danger, as regards chloroform, if the inhalation takes -place in a gradual and uniform manner; for the heart being able, as -shown by the above experiments on frogs, to bear a greater amount of -this narcotic than the brain, its action continues even after -respiration has ceased, if the vapour is added only by a little at once -to the blood, as it passes through the lungs. But if the air which the -patient breathes be too highly charged with vapour, it is easy to -understand how the sensibility of the nerves of the heart may be -paralysed, notwithstanding their power to bear somewhat more of this -agent than the brain and nerves of respiration. I calculated (p. 74) the -quantity of chloroform which would suffice to arrest respiration in the -adult of average size to be thirty-six minims, provided it were equally -diffused through the circulation; but supposing a patient breathes, at -any time, air containing ten per cent. of vapour of chloroform, a -considerable part of this might enter the lungs at a very few -inspirations, for thirty-six minims of chloroform occupy only 37·5 cubic -inches, and would be contained in 375 cubic inches of air, and might be -breathed in less than a minute; but for the whole of the blood to pass -through the lungs occupies a considerable time—I believe about four -minutes in the adult—and therefore the portion of blood which is passing -through the lungs, at the time when vapour of the above strength is -inhaled, must become much overcharged with chloroform, making every -allowance for the portion of vapour which is expired again, without -being absorbed. - -I have observed the manner in which the breathing and circulation ceased -in a great number of instances, with the stethoscope applied to the -chest of the animal, when the quantity of chloroform contained in the -air it breathed was known, and have notes of the result. The animals -were chiefly cats, which would otherwise have been killed by prussic -acid, or in some other way. In every instance in which the quantity of -vapour in the air breathed by the animals was from three to six per -cent., the respiration ceased whilst the sounds of the heart were still -very distinct, as in Experiment 23, related above; in many instances the -heart continued to beat from two to three minutes after the breathing -had ceased, and, in a great number of instances, there were one or more -gasping inspirations just at the moment when the sounds of the heart -ceased. In many cases these gasping inspirations caused the action of -the heart to return, as in Experiment 23, if the animal had been -withdrawn from the chloroform; but this was not always the case; and if -the chloroform was still breathed during these gasping efforts, all -signs of life immediately ceased in every instance. - -When, on the other hand, the air breathed by the animals contained eight -or ten per cent., or upwards, of vapour of chloroform, the action of the -heart was always seriously affected and rendered extremely feeble, if it -did not actually cease, at the time the breathing was arrested. In -several instances, indeed, the sounds of the heart entirely ceased -before the breathing, as in Experiment 25; and although the chloroform -was withdrawn, in this and many other experiments, the moment the heart -ceased to beat, and fresh air was drawn in by inspiratory efforts, it -very rarely had the effect of restoring the heart’s action, although -this happened so frequently when that organ had gradually ceased to act -on account of suspension of the breathing, by the effect of more diluted -vapour. - -In order to see more precisely the action of the vapour of chloroform on -the heart, when not sufficiently diluted, the chest and pericardium were -opened on four occasions, in cats and a rabbit, and chloroform was -exhibited by artificial respiration. I was assisted by Mr. Peter -Marshall in these experiments, and the following is the account of one -of them.[60] - -_Experiment 28._ A young rabbit, rather more than half-grown, was made -insensible by breathing air charged with four per cent. of vapour of -chloroform in a large jar. The trachea was then opened, and a tube was -introduced and tied. The lungs and heart were then exposed, by making an -incision and removing the lower half of the sternum, with the adjoining -part of the cartilages of the ribs on each side. The front of the -pericardium was also cut away, to expose the heart. Whilst these -operations were performed, artificial respiration was kept up by means -of a bladder of air attached to the tube in the trachea. The heart -contracted vigorously and quickly, and the lungs were of a light red -colour. The rabbit was beginning to show signs of returning sensibility, -when the bladder of air was changed for one containing ten per cent. of -vapour of chloroform. The bladder contained 125 cubic inches, and twelve -minims of chloroform were put in before it was filled with the bellows. -Three or four inflations of the lungs only were made, when I perceived -that the heart was beginning to be affected, and I changed the -chloroform for a bladder containing only air. These three or four -inflations of the lungs with chloroform, had the effect of causing the -right cavities of the heart to become distended with blood, and its -pulsations to become much slower. In two or three minutes, however, the -action of the heart was quite reestablished by the artificial -respiration, the pulsations being vigorous and frequent, and the -ventricles being apparently emptied at each contraction. The bladder -charged with ten per cent. of chloroform was again attached, and -artificial respiration was made with it. The right ventricle began -almost immediately to become distended; and, by the time that eight or -ten inflations of the lungs had been made, the contractions of the heart -were very slow and feeble. Artificial respiration with air was resumed, -but without the effect of restoring the action of the heart. The lungs -were observed at the time when the right ventricle was becoming -distended, and it was noticed that their colour was unchanged. They -afterwards became paler, as the artificial respiration was continued -after the ventricle had ceased to empty itself. No contractions of the -diaphragm were observed after the first inflation of the lungs with -chloroform, and the rabbit did not gasp at any time; whilst the cats -were observed to make a few gasping efforts at the time when the heart’s -action was ceasing. - -The circumstance of the lungs not changing in colour at the moment when -the right ventricle was becoming distended, which was observed in the -cats as well as in the rabbit, shows that the distension arose from the -failure of the contractile power of the heart, and not from impediment -to the pulmonary circulation; for, in the latter case, the lungs would -have become congested, and of a deeper colour. In one of the cats, it -appeared to me that the left, as well as the right ventricle, was -distended with blood; but this distension of the left ventricle did not -continue. - -In the Experiments 24 and 25, related above, the animals were first made -insensible by vapour of moderate strength, in order to keep them quiet -for the application of the stethoscope whilst the stronger vapour was -inhaled, but when animals are made to breathe air containing ten per -cent. or so of vapour of chloroform from the first, death takes place in -the same manner, _i. e._ by the direct action of the chloroform on the -heart. Under these circumstances the creatures die suddenly, after a -brief interval of agitation and excitement, without previous -insensibility. This is what has happened in some of the accidents from -chloroform, to be related further on; whilst in many cases death has -happened after a longer or shorter period of insensibility. - -In many of the fatal cases of inhalation of chloroform the alarming -symptoms commenced whilst the patient was still inhaling, but in a -considerable number there was no sign of danger until after the -inhalation had been left off; and this is a result which may be imitated -on animals. The two following experiments, which were made at Dr. -Sibson’s on December 27th, 1849, illustrate this point. - -_Experiment 29._ The subject of this experiment was a young guineapig, -about half-grown. Ten or twelve drops of chloroform were put into a -short bent metal tube, lined with bibulous paper, which formed part of -an inhaler, and one end of the tube was applied to the animal’s nose, -which closed it. The guineapig consequently breathed backwards and -forwards through the tube, which was, moreover, warm from being held in -the hand. It struggled at first, endeavouring to get away from Dr. -Sibson, who held it; but in twenty or thirty seconds it became quiet; -and observing that the conjunctiva was insensible, I withdrew the -chloroform, and the guineapig was laid on the table. We remarked that -the breathing was very slow; and scarcely had this remark been made, -when it ceased altogether, three or four inspirations only having been -made since the inhalation was left off. Dr. Sibson proceeded immediately -to open the body; but as soon as he had divided the integuments of the -chest the animal began to make some convulsive gasping inspirations, -during which the mouth was widely opened, and we observed that the -diaphragm acted alone, the ribs being pressed inwards by the atmosphere. -The heart was not contracting at all when the pericardium was first -opened; but in a few moments the auricles began to contract -rhythmically. The lungs were of a light red colour. - -_Experiment 30._ Another guineapig of the same age was treated in the -same manner, except that I removed the tube from the nose for a short -time between every two or three inspirations, in order to see if I could -not make it insensible in this way without a fatal result. In half a -minute or so the animal no longer required to be held, but lay on the -table without making any resistance, the conjunctiva being still -sensible, and some motion of the limbs, apparently voluntary, remaining. -It only inhaled once after Dr. Sibson ceased to hold it, and whilst in -the state just described, and then only for two or three inspirations. -After this it appeared quite insensible, and no more chloroform was -given. It breathed at first naturally, except more slowly and gently -than before the inhalation; but the breathing became slower, and ceased -altogether about a quarter of a minute after the inhalation had been -left off. The body was opened immediately. When the pericardium was -opened, the auricles were observed to contract slightly, and the -contractions increased after their exposure to the air. - -The amount of vapour in the air breathed by these two guineapigs is not -known, but there is no doubt that it was upwards of eight per cent. - - - FATAL CASES OF INHALATION OF CHLOROFORM. - -If it were possible for a medical man to mistake or disregard the -symptoms of approaching danger, and to go on exhibiting vapour of -chloroform, diluted to a proper strength, till the death of the patient, -this event would take place slowly and gradually, as in Experiment 23, -related above, and every other experiment in which the air did not -contain more than five per cent. of vapour. The action of the heart -would survive the respiration; there would be a great tendency to -spontaneous recovery, and the patient would be easily restored by -artificial respiration, if it were performed whilst the heart was still -acting; as I have always found it to be successful in animals under -these circumstances. - -In examining the recorded cases of fatal inhalation of chloroform, we -shall find, however, that they have none of them taken place in this -gradual manner; but that in all cases the fatal symptoms, if not the -actual death, have come on very suddenly. Dr. Sibson was, I believe, the -first to point out that, in the fatal cases of inhalation of chloroform, -death was caused by its paralysing the heart; but he was not at that -time aware of the physical conditions under which this agent may act -directly on the heart. In commenting on the first four deaths from -chloroform, he says:[61] “In all the four cases it is manifest that the -immediate cause of the instantaneous death lay in the heart. The heart, -influenced by the poison, ceased to contract, not from the cessation of -respiration, for the heart in asphyxia will beat from one to three -minutes after respiration has ceased, but from immediate death of the -heart. There is no doubt a combination of causes operating to destroy -the heart’s contractile power: the mental influence, the congestion in -the systemic, and that in the pulmonary capillaries, will all have a -material influence.” And further on he says: “We are obliged, then, from -the experience of these cases, to conclude, that in man the death is -usually instantaneous, and due, as every instantaneous death is, to -paralysis of the heart. In animals the death is usually due to paralysis -of the muscles of respiration. It is chiefly owing to the superior -control of the mind over the body in man, that in him the poison acts on -the heart more than in dogs.” - -I had been long aware that chloroform was capable of paralysing the -heart in animals; and, indeed, that sulphuric ether would do so when it -could reach the heart in sufficient quantity;[62] and soon after Dr. -Sibson’s remarks I was able to ascertain and point out the strength of -the vapour which will produce this effect, and how one may avoid the -risk of it, by having the vapour sufficiently diluted.[63] The greater -number of experimenters who have killed animals with chloroform have -found that the action of the heart continued after the breathing ceased; -but they did not either control or ascertain the proportion which the -vapours of chloroform bore to the inspired air. In Mr. Thomas Wakley’s -experiments the action of the heart continued after the breathing had -ceased; and this was the case in a great number of experiments performed -by a Commission which reported to the Society of Emulation of Paris, in -1855.[64] - -This Commission came to the conclusion that, in all instances in which -animals are killed by chloroform, the action of the heart survives the -respiration; but they might have administered chloroform to an equal -number of human patients without any one of them being cut off by sudden -paralysis of the heart. If animals were usually to die suddenly of -paralysis of the heart, when the chloroform is given in a manner similar -to what may be called its ordinary administration to patients, we should -be at a loss to know how this agent could be used at all. It is only -reasonable to suppose that, in experiments so conducted, that mode of -death should usually be met with which would occur to the human subject, -if the chloroform were continued, in the disregard of dangerous -symptoms, till death should ensue. I have, indeed, been informed of -several instances in which animals died in a sudden, and what was -thought an unaccountable manner, whilst chloroform was given to prevent -the pain and struggles which would be occasioned by physiological -experiments. In these cases there is no doubt the heart was paralysed; -but the experimenters were often too intent on other matters to observe -the circumstance. By a proper arrangement of circumstances, however, one -may produce at will the event in animals which occurs, in fact, so very -rarely to a patient, although it may at any time happen if great -caution, guided also by right principle, is not used. - -Air, when saturated only at 60° Fah., contains 12 per cent. of vapour of -chloroform, and at 70° 19 per cent. (p. 33); and 8 or 10 per cent. in -the inspired air is capable, as we have seen, of causing sudden death by -paralysing the heart; but in practice the air is usually far from being -saturated, in passing over a handkerchief or similar material, even at -the temperature at which it is inhaled; and this is generally lowered -considerably by the absorption of caloric by the chloroform, as it -changes its condition from a liquid to a vapour. Moreover, air strongly -charged with vapour of chloroform is not easy to breathe, owing to its -pungency; and the physiological knowledge and close attention of every -medical man who administers this medicine causes him to withdraw it -immediately on the least appearance of danger. - - -_Case 1._ The first death from chloroform was that of Hannah Greener, -which occurred at Winlaton, near Newcastle, on the 28th of January, -1848. The patient was a girl of 15, who required to have the nail of the -great toe removed. A similar operation had been performed on the other -foot, in the previous November, in the Newcastle Infirmary, when ether -was administered with a satisfactory result. The following is the -account of the accident by Dr. Meggison, who administered the -chloroform: “She appeared to dread the operation, and fretted a good -deal: in fact, she commenced sobbing on our entering the house, and -continued so until seated in the operating chair, and commencing the -inhalation, which was done from a handkerchief on which a teaspoonful of -chloroform had been poured. After drawing her breath twice, she pulled -my hand from her mouth. I told her to put her hands on her knees, and -breathe quietly, which she did. In about half a minute, seeing no change -in breathing, or alteration of pulse, I lifted her arm, which I found -rigid. I looked at the pupil and pinched her cheek, and, finding her -insensible, requested Mr. Lloyd to begin the operation. At the -termination of the semilunar incision she gave a kick or twitch, which -caused me to think the chloroform had not sufficient effect. I was -proceeding to apply more to the handkerchief, when her lips, which had -been previously of a good colour, became suddenly blanched, and she -spluttered at the mouth, as if in epilepsy. I threw down the -handkerchief, dashed cold water in her face, and gave her some -internally, followed by brandy, without, however, the least effect, not -the slightest attempt at a rally being made. We laid her on the floor, -opened a vein in her arm, and the jugular vein, but no blood flowed. The -whole process of inhalation, operation, venesection, and death, could -not, I should say, have occupied more than two minutes.”[65] - -An examination of the body was made the day after death by Sir John Fife -and Dr. Glover, who reported as follows:—“The body was that of a -well-grown female of about fifteen years of age.... On opening the -chest, the lungs were not collapsed. One or two very slight adhesions -were encountered on separating them from the walls of the chest. The -external appearance of both lungs, over the whole surface, but -especially in the inferior portions, was that of organs in a very high -state of congestion. They were mottled with patches of a deep purple, -blueish, or scarlet hue. They were everywhere crepitant. Along the outer -and interior border of both lungs, particularly of the upper lobe of the -left lung, were several emphysematous bubbles of small size.... The -pulmonary tissue was filled with bloody froth, which was also found in -the interior of the bronchi, mixed with mucus. There was no appearance -of hepatization. On examining the larynx and trachea, the epiglottis was -found reddened at the summit, of a vermilion hue. The mucous membrane of -the larynx was redder than natural—mottled with vascular patches. The -sinuses of the larynx contained a good deal of dark mucus. The œsophagus -was healthy. The stomach was distended with food. Some of the veins were -more distinct than usual. The heart contained dark fluid blood in both -its cavities: very little in the left. Its structure, and that of the -great vessels near it, quite healthy. The brain, externally and -internally, was more congested than usual; and the ventricles contained -rather more than the usual quantity of serum.”[66] - -Sir John Fife and Dr. Glover expressed the opinion that chloroform -caused death by producing congestion of the lungs. After the further -experience which has been gained respecting chloroform, this opinion of -the mode in which it caused death, in the above case, would probably not -now be offered. Indeed, in similar cases which have since occurred, the -same opinion has not been advanced; and as the lungs were crepitant -throughout, in the above case, it is probable that the congestion was -not greater than is commonly met with in cases of sudden death without -hæmorrhage. Dr. Simpson published his opinion, immediately after this -case occurred, that it was not caused by the chloroform, but by the -brandy which was given when the alarming symptoms came on; but Dr. -Meggison replied that only a teaspoonful of brandy was given; that it -was swallowed, though with difficulty; that there were no symptoms of -choking from it; and that the girl was without pulse when it was -given.[67] - -From the lips becoming suddenly blanched in the above case, there is -every reason to conclude that the heart was suddenly paralysed. The -patient breathed for a little time after this, and was able to swallow, -though with difficulty. The process of inhalation occupied only a little -more than half a minute in Dr. Meggison’s estimation; yet he appeared to -think that the fluid drachm of chloroform which he had put on the -handkerchief had evaporated; for he was about to apply more when the -alarming symptoms appeared. But supposing only one-third of the drachm -was actually inhaled into the lungs in the half minute, the vapour would -necessarily be in a highly concentrated state—probably twenty cubic -inches of vapour in 200 cubic inches of air, which would be adequate to -occasion the result which happened. In the short space of about half a -minute, the blood could not be uniformly impregnated with the vapour; -only a portion of it could pass through the lungs in the time; yet, as -the patient was rendered insensible, this portion must necessarily have -been highly charged with vapour. - -It was often the practice to render the patient insensible in as short a -time as half a minute, when chloroform was first introduced, but I -believe never without danger; and I had expressed the opinion before any -accident happened, that, for reasons such as I have stated above, a -patient should on no account be rendered insensible in less than two -minutes.[68] - - -_Case 2._ The next recorded case in which the inhalation of chloroform -was fatal, occurred at Cincinnati, on the 23rd of February, 1848. The -subject of it, Mrs. Martha G. Simmons, was thirty-five years of age, and -enjoyed good general health; she was the mother of six children, and her -last confinement occurred eight weeks before her death. The patient -exhibited no alarm on account of inhaling the chloroform, which was -administered by two dentists, who were not members of the medical -profession. It was breathed from an inhaler which Dr. Morton of Boston -contrived for sulphuric ether. This inhaler consisted of a glass globe -four inches and a half in diameter, and contained a sponge about -one-third filling the globe, and saturated with chloroform. - -Two female friends of the patient reported the following as the events -which occurred. “The respiratory movements appeared to be free; chest -heaving. While inhaling, the face became pale. At the expiration of -about one minute, the instruments were applied, and four roots of teeth -extracted. The patient groaned and manifested what they regarded as -evidences of pain, while the teeth were being extracted, although she -did not speak or exhibit any other sign of consciousness. As the last -root came out, which was about two minutes from the beginning of the -inhalation, the patient’s head turned to one side, the arms became -slightly rigid, and the body drawn somewhat backwards, with a tendency -to slide out of the operating chair. At this instant, Mrs. Pearson -states that she placed her finger upon the patients pulse; observed that -it was feeble, and immediately ceased to beat; respiration also ceased -about the same time. The face, which was previously pale, now became -livid, as did also the finger nails; and the lower jaw dropped, and the -tongue projected a little at one corner of the mouth, and the arms were -perfectly relaxed. The females regarded her as being then quite -dead.”[69] - -The dentists gave nearly the same account, saying that the breathing was -at first slow, and that the patient inhaled twelve or fifteen times, -occupying from a minute to seventy-five seconds. They committed the -great error of not placing the patient at once in the horizontal -position, when the alarming symptoms came on, but kept her sitting in -the chair, from five to ten minutes, whilst they sent out for -restoratives. They thought the patient was living during this time, but -her female friends thought not. The patient was placed on a sofa, and -sometime afterwards artificial respiration and galvanism were applied -without effect. - -An examination of the body was made twenty-six hours after death by Drs. -Mussey, Lawson, Baker and Mulford. The following are the chief -particulars of the appearances met with. A larger quantity of blood than -usual flowed from the sinuses of the dura mater. General aspect, colour, -and consistence of the brain, normal. Lungs considerably but not -intensely congested; crepitated freely at all points; no extravasation. -Lining membrane of bronchia slightly congested, apparently the result of -recent catarrh; deeply stained by the blood. Pleura at all points highly -injected; six drachms of bloody serum in the right, and two ounces in -the left chest. Pericardium contained six drachms of bloody serum. Heart -flaccid, and all its cavities entirely empty; inner surface of both -ventricles and auricles deeply stained. Abdomen—one ounce and a half of -bloody serum in the right hypochondrium. Stomach and intestines -distended with gas. Partially digested aliment, amounting to about three -gills in the stomach. Blood fluid as water in every part of the body; -not a coagulum was seen in any vessel. Lining membrane of all the -bloodvessels deeply stained. The colour in every part of the system was -that of dark venous blood. - -It was estimated, in the inquiry which took place respecting this case, -that one-fourth part by measure of what the patient inhaled might be -vapour of chloroform; but this is evidently an over-calculation, for -there could not be this quantity unless the interior of the glass globe -were maintained at the temperature of 80° Fah. and the air were quite -saturated with vapour in passing through it; however, less than half the -amount of vapour here assumed would have the effect of causing sudden -death, in the way it happened. The period of the inhalation, a minute or -seventy-five seconds, during which the patient took twelve or fifteen -inspirations, did not admit of the blood in the body being regularly and -uniformly charged with the chloroform; and the increase of its effects, -owing, no doubt, to the absorption and circulation of the vapour -contained in the lungs at the moment when the inhalation was -discontinued, was well marked. The patient became pale during the -inhalation, but the alarming symptoms suddenly came on during the -extraction of the fourth stump, probably within half a minute after the -inhalation ceased. The patient seemed, in fact, to die with the slight -struggle that took place at this moment. In the case of Hannah Greener, -related above, the spasm at the moment of dying was even more marked. -This is a symptom I have often seen during the death of animals killed -suddenly with vapour of chloroform in a concentrated state, before they -were made thoroughly insensible. Although the heart was empty, the -stained condition of its cavities showed that they had contained blood -at the time of death and afterwards. Owing to its fluid state, it -probably escaped from the heart during the moving of the body; -especially during the examination of the head, which was made first. - - -_Case 3._ The next recorded case of death from chloroform is reported by -Dr. John C. Warren, of Boston, U.S., in the _London Medical -Gazette_.[70] His report, apparently extracted from some other report, -is as follows. - -“Name—Patrick Coyle. [Age—not stated.] Date—March 1848. Disease—fistula. -Previous use of chloroform—once. Time of inhalation—about one minute. -Quantity consumed—about thirty drops. [Query minims.] Posture—upon the -side. Lapse of time till death—about one minute. Symptoms—showed signs -of pain, by putting his hand to the part; in a moment his pulse, which -was full and natural, sank: death. Morbid appearances—brain, with -membranes, natural and healthy. Heart enlarged, pale, and soft; two or -three ounces of serum in pericardium; bloodvessels with dark fluid -blood. Lungs, studded with tubercles; abscess in each; lower parts -congested; pleura extensively adherent; stomach—mucous membrane -softened, its veins turgid.” - -Nothing is said about the apparatus used in this case, but from the -summing-up of Dr. Warren’s paper, it must have been either a towel or a -handkerchief. The quantity of chloroform employed appears to have been -much less than in the two previous cases. In speaking of drops, the -writer probably means minims, or what is the same, a quantity equal to -as many drops of water. Thirty drops of chloroform from a small phial -are only equal to between six and seven minims, and if they were dropped -on a handkerchief, so that they might be counted, they would evaporate -entirely during the process. Supposing the quantity used to have been -what is probably meant—half a fluid drachm—it would be quite adequate, -according to calculations previously made in these pages, to cause the -accident which happened. The period of inhalation was again very -short—one minute; and the evidence of paralysis of the heart is -distinct:—“In a moment his pulse, which was full and natural, sank: -death.” - - -_Case 4_ was that of Madlle. Stock, aged thirty, and occurred at -Boulogne, in May 1848. The operation was that of opening a sinus in the -thigh, between two and three inches in length, at the bottom of which a -small splinter of wood was found. M. Gorré, the surgeon who attended the -patient, says: “I placed over the nostrils of the patient a handkerchief -moistened with fifteen to twenty drops of chloroform at most.” It is -necessary to remark, however, that a judicial examination of the bottle -from which it had been taken, proved that from five to eight grammes had -been used, a quantity equal to from 77 to 123 grains, and there are -three drops of chloroform to a grain. M. Gorré proceeds to say: -“Scarcely had she taken several inspirations, when she put her hand on -the handkerchief to withdraw it, and cried with a plaintive voice, ‘I -choke.’ Immediately the face became pale; the countenance changed; the -breathing embarrassed; and she foamed at the mouth. At the same instant -(and certainly less than a minute after the beginning of the -inhalation), the handkerchief moistened with chloroform was withdrawn.” -M. Gorré performed the operation, but he expressed the opinion -afterwards that death had already taken place when he made the incision. -Amongst the means used, with a view to resuscitate the patient, was -inflation of the lungs, which was performed with such force as to -produce permanent dilatation of the air-cells. The lungs, besides being -distended from this cause, were found after death to be visibly engorged -in their lower lobes. When cut into, a large quantity of black blood -escaped. The cavities of the heart were empty, but the internal -membrane, especially of the right cavities, was red. The tissue of the -heart was pale, and was easily torn. Air was found in the pulmonary -veins, and in most of the systemic veins throughout the body. The blood -was very dark-coloured and fluid.[71] - -M. Gorré reported the above case to the Academy of Medicine of Paris, -and a commission was appointed to inquire and report on it, who came to -the following conclusions. - -“1. In the medico-legal fact submitted to our notice, we found no -indication of the poisonous action of chloroform; and consequently we -reply to the minister, that the patient of M. Gorré did not die from the -effect of inhalation of that agent. - -“2. There have occurred a great number of analogous cases of sudden and -unforeseen death, during operations, without any administration of -chloroform, in which the most minute examinations have failed in -detecting any assignable cause of death. - -“3. In the case in question, the most probable cause, under all -circumstances, seems to have been the mixture of a considerable quantity -of gas with the blood.”[72] - -The report on this case gave rise to frequent discussions in the -Academy, extending over several months, and the Academy ultimately -confirmed the above conclusions, but not without considerable opposition -from M. Blandin, M. Jules Guérin, and other members. - -M. Malgaigne, the reporter to the commission, and others, who strongly -supported the first of the above propositions, founded their argument -chiefly on the assertion that chloroform always produces intoxication -and insensibility before death; but this is incorrect, as I have -explained above; and I took occasion to make the following remarks on -this point about the time when the discussion in the Academy of Medicine -took place. I said: “I have several times made animals—small birds, mice -and rabbits—breathe air saturated with vapour of chloroform at the -temperature of the atmosphere, and the consequence has always been that, -after attempting for a few seconds to escape from the capacious jar in -which they were enclosed, they suddenly exhibited signs of distress, and -died without any interval of intoxication or insensibility, in periods -varying from less than half a minute to a minute after their first -exposure to the vapour.”[73] - -The power of chloroform to cause sudden death without previous -insensibility is now, I believe, generally admitted. The French call -this kind of fatal action _sideration_. - -With regard to the second conclusion of the commission, if it had been -really true that the surgeon put only fifteen to twenty _drops_ at the -most of chloroform on the handkerchief, one would have been inclined to -admit it; but with the quantity actually employed, and the strong -sensation of choking it occasioned just before death, one must, in -connection with other cases, and with what is known of the action of -chloroform, attribute the fatal event to this agent, rather than to the -surgical operation, which was not of a serious nature. - -With regard to the third of the above conclusions, it is not a little -remarkable that most even of those speakers who opposed the conclusions -of the commission, agreed that death was caused by a sudden development -of air in the veins; and differed from them only in this, that they -considered the chloroform as the cause of the evolution of air or gas, -and that it proved fatal in this way. That the air was not caused by -putrefaction, and that it did not enter by the wound in the thigh, may -be readily admitted, but there remains the artificial respiration, which -was performed with such force as to produce permanent dilatation of the -air-cells. It was argued in the Academy that, as the air was in the -systemic, as well as in the pulmonary veins, it could not have been -introduced by the artificial respiration, since the left ventricle had -previously ceased to act; but the action of the left ventricle is not -necessary for the passage of the contents of the arteries through the -capillaries into the veins, since this commonly goes on after death, the -arteries being usually found entirely empty of the blood they must have -contained at the moment of death. With regard to the passage of the air -out of the heart into the arteries, supposing that the pulmonary veins -were ruptured during the inflation of the lungs, there is an observation -of Dr. Sibson’s which will explain both this circumstance and the fact -of the heart itself being found empty of blood. He found that the heart -was often emptied of blood by distending the lungs with air after death -in preparing the body for his diagrams of the position of the -viscera.[74] - -With the conclusions above quoted, some additional ones were adopted -from the second part of the report of the commissioners; in these it was -admitted that chloroform is capable of causing death, if administered -too long, or in too large doses. One of these additional conclusions, -however, is as erroneous as the previous ones. It is, “there is risk of -asphyxia when the anæsthetic vapour is not sufficiently diluted with -air.” When the vapour is not sufficiently diluted with air, the risk is -one of sudden death, by paralysis of the heart. Chloroform does not -yield enough vapour, at the natural temperature and pressure of the -atmosphere, to exclude the air to the extent which would cause asphyxia. -When chloroform vapour largely diluted with air is long continued, it -may cause, not real asphyxia, but a mode of death resembling it, owing -to the medulla oblongata and nerves of respiration becoming over -narcotised. - - -_Case 5_ is that of a young woman at Hyderabad, who inhaled chloroform -to undergo amputation of the middle finger. A drachm was sprinkled on a -handkerchief and inhaled. The operator described what occurred as -follows: “She coughed a little, and then gave a few convulsive -movements. When these subsided, I performed the necessary incisions, -which of course did not occupy more than a few seconds. Scarcely a drop -of blood escaped.” The absence of bleeding seemed to be the circumstance -which called the attention of the operator to the state of his patient; -and after describing the means which were used without avail to bring -about recovery, he continues, “I am inclined to think that death was -almost instantaneous; for, after the convulsive movements above -described, she never moved or exhibited the smallest sign of life.”[75] - -In this case, it is probable that the breathing and the action of the -heart were both arrested at the same time, by the action of the -chloroform. - - -_Case 6._ Charles Desnoyers, aged twenty-two, a patient in the -Hôtel-Dieu at Lyons, affected with scrofulous disease of the left wrist, -having to undergo transcurrent cauterisation of the joint, inhaled -chloroform from an apparatus for five minutes, and died at the beginning -of the operation.[76] Further particulars are not given. - - -_Case 7._ A young gentleman, who had returned from Australia to visit -his relatives in the neighbourhood of Govan, inhaled chloroform for an -intended operation on the great toe, in December 1848. It is stated that -the patient, after inhaling it, almost instantly expired. This account -appeared in the _Glasgow Herald_, and was copied into the medical -journals.[77] I believe that no further account of the case was ever -published. - - -_Case 8_ occurred on January 19th, 1849. It is related by Dr. John C. -Warren.[78] John Griffith, an Irishman, aged thirty-one, a seaman in the -American navy, was admitted into the New York Hospital early in December -1848, on his return from Mexico. He was suffering with diarrhœa, -chancres, and hæmorrhoids. The following is the account of this -accident. - -“Gurdon Buck, jun., attending surgeon to the New York Hospital, being -sworn, says, that ‘on or about the 26th of December, I advised that -chloroform should be administered to the deceased, for the purpose of -examining the condition of the rectum, the parts being in such a state -of excessive irritation as scarcely to admit of a separation of the -nates. The patient recovered from the effects of the chloroform, and -remained in all respects in the same condition, except the local -ailments spoken of; and he having never complained of either his head or -his chest, and not having suffered from the first administration of -chloroform, I directed it to be administered to him for the purpose of -performing an operation upon the rectum, and the operation of -circumcision to remove a phymosis caused by the chancres: the patient -soon became excited by the chloroform, as is usually the case, but not -beyond a degree that I have often observed. Shortly after, he became -more tranquil: the deceased was placed upon his side, and the operation -performed, which consisted in the removal of two external tumours, and -the tying of one internal tumour. - -“‘At this moment my attention was arrested by my assistant’s calling for -a wet cloth: on examining the patient, I found his face and neck of a -livid leaden hue or colour, the eyes turned upward, the pulse -imperceptible at the wrist, and the whole body relaxed; after two or -three gasps, he ceased to breathe. Every means was promptly used to -restore the deceased, but without effect. The chloroform was obtained -from Kent’s, 91, John Street, and not exceeding three drachms was -administered on a napkin. A portion of chloroform from the same phial -had been administered the day before to a patient without any -unfavourable effects. About ten minutes elapsed from the commencement of -its administration before death took place. On making a post-mortem -examination, twenty-four hours after death, I found the face less livid -than before death; on examining the head, the brain and its membranes -presented no other appearances than are seen in persons dying when in -full health; the lungs were a good deal congested, and discharged, when -cut, a large quantity of bloody serum; the heart was large, its -ventricles and auricles were empty, its condition flabby, the substance -of the left ventricle rather softer than natural; about half an ounce of -watery fluid was found in the pericardium; the viscera of the abdomen -were healthy.’” - -This case differs from those previously related in respect to the time -at which the fatal occurrence took place. It was not till ten minutes -from the commencement of inhalation, and when an operation which -probably occupied two or three minutes had been performed, that the -patient suddenly expired. The evidence of paralysis of the heart is, -however, distinct enough in the absence of pulse at the wrist, and the -livid hue of the countenance. In several of the previous cases, there -was sudden pallor at the moment when the heart ceased to inject blood -into the capillaries, but in a patient well supplied with blood, the -sudden arrest of the action of the heart would cause turgescence of the -veins and venous capillaries, which would be evident in the face in a -few seconds. The syncope occasioned by paralysis of the heart differs -from that kind of syncope which is caused by loss of blood, inasmuch as -the right cavities of the heart are full in the former instance, and -empty in the latter. - -The circumstance of the patient having inhaled chloroform to -insensibility three weeks previously, without accident or ill effects, -is worthy of notice, as showing that the fatal event did not depend on -any peculiarity of constitution. - -Although the heart was found to be empty, its flabby condition and the -watery fluid in the pericardium indicate that it must have contained -blood at the time of death. - - -_Case 9_ occurred on January 24th, 1849, at the Hôtel-Dieu, Lyons, where -case 6 previously happened. The patient was a youth, aged seventeen, -named J. Verrier, who had been employed as a miner. He was of good -constitution, and was about to undergo amputation of the middle finger -for necrosis of the first phalanx. The following is the account of the -accident. - -“As the patient’s health was good, he was at once, and by his free -consent, placed under the influence of chloroform. As usual, a piece of -fine gauze was employed; it was spread over the face, leaving a free -passage for atmospheric air; the chloroform was dropped from time to -time upon that portion of the gauze which was over the nostrils. It was -administered by two assistants who were accustomed to its use, and who -at the time attended to the pulse. The operator superintended the -assistants. At the end of four or five minutes, the patient still felt -and spoke; and at the end of another minute, he still spoke and was -somewhat restless. Up to this time, from a drachm to a drachm and a half -of chloroform had been employed. The pulse was regular, and of the -normal strength. All at once the patient raised his body, and struggled -so that the limbs escaped from the hold of the assistants, who however -seized them quickly, and replaced the patient in his position. Within a -quarter of a minute, one of the assistants stated that the pulse at the -wrist had ceased to beat. The handkerchief was removed. The countenance -was completely altered. The action of the heart had altogether ceased; -the pulse could not be felt anywhere; and the sounds over the region of -the heart could no longer be heard. Respiration still continued, but it -became irregular, weak, and slow; and at length ceased completely in the -space of about half a minute. - -“The extreme danger of the patient was manifest, and immediate and -energetic means were employed to rouse him. Ammonia was held to the -nostrils, and rubbed in large quantity over the surface of the chest and -abdomen. It was also applied to the most delicate parts of the skin, _e. -g._, the lips and the extremity of the penis, with a view to excite -irritation. Mustard was used; the head was inclined over the bed; and, -finally, an attempt was made to restore respiration by means of -alternate pressure on the abdomen and chest. After two or three minutes, -respiration reappeared, and even acquired a certain fulness, but the -pulse nowhere returned. Frictions were continued. Respiration became -again slower, and at length ceased. Artificial inflation was practised, -at first through the mouth, and afterwards through the larynx, by -passing a tube through the glottis, as it was perceived that air had -passed from the mouth into the stomach. The precordial, epigastric, and -laryngeal regions were energetically cauterised with a hot iron. The -pulse did not return. For the space of half an hour every effort was -made to resuscitate the patient; but in vain. - -“The autopsy could not be made until seventy-two hours after death. The -temperature being low, the body showed no signs of decomposition; there -was still rigidity of the limbs. The features were not altered. The -examination of all the organs was made with care. - -“The stomach contained about one ounce and a half of a thick fluid, of -the colour of the lees of wine, in no respect resembling an alimentary -fluid. The organ was distended with gas, as was also the rest of the -alimentary canal, which was otherwise sound. The liver and spleen were -somewhat congested. - -“The heart, which was normal in volume, was flaccid and empty, contained -neither blood nor air. The ventricular parietes were moistened by a -fine, very red foam, as if from the presence of a little blood, which -had been, as it were, whipped by the fleshy columns of the heart. The -venæ cavæ and the portal veins were distended by black fluid blood in -great quantity. On the Eustachian valve there was a fibrinous clot, -moderately firm, and weighing from sixty to seventy grains. It was the -only clot met with in the cavities of the heart and great vessels. These -cavities, which were carefully opened, did not contain any appreciable -quantity of air. - -“The lungs retracted on opening the chest. They presented both in their -surface and in their substance a very black colour; otherwise their -tissue was healthy. The larynx and trachea presented no lesion. The -brain was normal. The sinuses of the dura mater contained a considerable -quantity of black uncoagulated blood.”[79] - -In this case every precaution appears to have been taken, except that -which is the most essential, of regulating the amount of vapour in the -respired air. Arrangement was made that there should be amply sufficient -air for the purpose of respiration; the patient was carefully watched by -three persons at least, one of whom was constantly attending to the -pulse, but with no other result than to be able to announce the exact -moment when it suddenly stopped. The arrest of the action of the heart -in this case took place at a time when the patient was not yet rendered -insensible by the chloroform, although he had been inhaling it for five -minutes. We must conclude that during these five minutes the vapour he -inhaled was largely diluted with air, and that he then inhaled vapour in -a much less diluted form. It is not improbable that he took a deep -inspiration of strong vapour, just at the moment when he struggled -violently, and within a quarter of a minute of the time when his pulse -suddenly ceased. - -The breathing continued a little time after the heart ceased to beat, -and it is therefore very probable that, if this organ had not been -irrecoverably paralysed, the natural breathing would have restored its -action after a short pause, that would have attracted but a momentary -attention. As the spontaneous breathing of the patient did not restore -the heart’s action, there is no ground for surprise that the measures -adopted did not succeed. - - -_Case 10_ was that of a labourer, named Samuel Bennett. It occurred on -February 20th, 1849, at a dispensary in Westminster. The patient inhaled -chloroform for amputation of one of the toes. Half an ounce of -chloroform was “sprinkled on a handkerchief, and held over the mouth and -nose.... This quantity of the agent failed, however, to produce -anæsthesia, having caused only the ordinary excitement and struggling.” -After a delay of two hours, more chloroform was procured, and half an -ounce was again applied on a handkerchief, “care being taken to allow -the entrance of air at short intervals.” Insensibility was induced, and -the toe was amputated; the chloroform being applied, as I was told, -during part of the time of the operation. At the close of the operation, -no blood escaped when the pressure was removed from the arteries; the -patient was in fact dying, and in a short time expired. “A few -inspiations were noticed after the pulse had ceased at the wrist.”[80] - -The lungs were of a dark venous hue throughout, a large quantity of -blood escaping from them when cut into. Mucous membrane of trachea and -bronchi congested. Heart rather large but flabby; auricles empty; each -ventricle contained about an ounce of semi-fluid blood (the lungs had -been inflated). Head: sinuses and veins contained blood, but not to any -remarkable amount. But few bloody points occurred in cutting into the -cerebral mass. Kidneys congested. - -The failure of the first attempt to cause insensibility in this case, -when so large a quantity of chloroform was used, illustrates very -forcibly the uncertainty and irregularity of the way in which it was -administered. On the first occasion only excitement and struggling were -produced, and on the next the patient died suddenly. - - -_Case 11_ occurred on August 23rd, 1849, at Langres, France. The subject -of it, Madame Labrune, was reported to be a healthy married woman. She -inhaled chloroform with the intention of having a tooth extracted. -“Complete insensibility was not produced at the first trial: more -chloroform was placed on the handkerchief, and she drew a full -inspiration. Her countenance immediately became pallid; her features -were visibly altered; there was dilatation of the pupils, with a -convulsive rolling of the eyes; and no pulse could be felt. Every -attempt was made to restore life, but without success. She died as if -struck by lightning.”[81] The instantaneous arrest of the circulation, -on a full inspiration being taken, immediately after more chloroform had -been placed on the handkerchief, is particularly worthy of notice. The -heart was paralysed, in this instance, as quickly as in experiment No. -25, above related. - -No inspection of the body is reported in this case. - - -_Case 12_ is the first which occurred in any of the hospitals in this -metropolis. The following is the account of it. - -“John Shorter, aged forty-eight, a porter, known to Mr. Solly for some -time as a very active messenger, habits intemperate, but apparently in -perfect health, was admitted into George’s ward, under Mr. Solly, on the -9th October, 1849, suffering from onychia of the left great toe, which -had existed some time. It was determined to remove the nail, the man -having decided before entering the hospital on taking chloroform. - -“On Wednesday, October 10th, at a quarter to two P.M., he began to -inhale the chloroform with one drachm in the inhaler. It had no visible -effect for about two minutes; it then excited him, and the instrument -was removed from the mouth, and about ten drops more were added; he then -almost immediately became insensible; the chloroform was taken away, and -the nail removed. He continued insensible; and, his face becoming dark, -the pulse small, quick, but regular, respiration laborious, his -neckerchief was removed, and the chest exposed to fresh air from a -window near to the bed; cold water was dashed in his face, the chest -rubbed, and ammonia applied to the nose. After struggling for about a -minute, he became still, the skin cold, pulse scarcely perceptible, and -soon ceased to be felt at the wrist; respiration became slow and at -intervals, but continued a few seconds after the cessation of the pulse. -Immediately on the appearance of these symptoms, artificial respiration -was commenced by depressing the ribs with the hands and then allowing -them to rise again until the proper apparatus was brought, when -respiration was kept up by means of the trachea tube and bellows, and -oxygen gas introduced into the lungs by the same means. Galvanism was -also applied through the heart and diaphragm, but all signs of life -ceased about six or seven minutes after the commencement of inhalation. -These means were persisted in until a quarter past three, but to no -purpose. On removing the inhaler, the sponge, which only contains one -drachm, fell upon the floor, and the chloroform splashed about,—thus -showing that a considerable part of the chloroform remained unused; so -that the patient could not have inhaled more than a drachm. Every -endeavour was made to procure a post-mortem examination, but in -vain.”[82] - -The above account is published in the _Medical Gazette_ as communicated -by Mr. Solly, but it is clearly not written by him, and it presents a -very confused narrative of what occurred. If we are to understand the -events in the sequence in which they are related, we must conclude that -the patient became insensible and had the operation performed, that he -then exhibited alarming symptoms for which cold water was dashed in his -face and other measures were employed, and yet that after this he -struggled for about a minute. This would be a state of things -inconsistent, in my opinion, with death from chloroform; but possibly -the proper sequence is not observed in detailing what occurred. There is -some obscurity also about the amount of chloroform used in connection -with what remained on removing the inhaler. If the sponge was adapted to -hold a drachm in the proper manner, the chloroform could not splash -about on its falling, unless there was a good deal more than a drachm in -it. But whatever was the quantity of chloroform remaining in the sponge, -as it was in a condition to splash about, it is difficult to perceive -what prevented the liquid chloroform from dropping into the patient’s -throat, as he lay on his back in bed. Chloroform is as pungent as the -essential oils. I have been informed of a case in which a patient was -nearly suffocated by one drop falling into the throat; and the narrative -of what occurred to Mr. Solly’s patient is not at all inconsistent with -death from spasm of the glottis arising from this cause. If, however, -the patient died from the vapour of chloroform, we must conclude that he -inhaled it at one moment not sufficiently diluted with air. - -The chloroform in this case was administered by a non-medical person—a -sort of surgery-man. After this accident, however, the chloroform in St. -Thomas’s Hospital was always entrusted to some one belonging to the -profession. - - -_Case 13_ occurred at Shrewsbury, to a Mrs. Jones, a patient of Mr. -Clement, surgeon, who had partly performed the operation of excision of -the eyeball, when his patient suddenly died. Mr. Clement has, I believe, -not published any account of the case, but the evidence which he gave at -the inquest was reported in various local newspapers, and copied into -the medical journals. The death was very characteristic of the effects -of chloroform vapour not sufficiently diluted. Mr. Clement is reported -to have said: “He gave her but a small dose to commence with, imbibed -from a sponge, and then commenced the operation. Finding that did not -make her insensible, about a drachm more was poured on the sponge, which -she inhaled again for a few seconds. He then went on with the operation, -and shortly afterwards heard a peculiar sound, which he could not -describe, and she died in a moment; all the attempts to rouse her proved -ineffectual. She spoke in Welsh before she died, but so quickly that he -did not know what she said; he had no doubt that she died from the -effects of the chloroform.”[83] - - -_Case 14_ occurred at Berlin. The subject of it was a young lady twenty -years of age, of good health, well made, and of a good constitution. The -chloroform was inhaled for the extraction of a tooth. It was -administered on a sponge, covered with a napkin. The dentist who -administered it was not a medical man. He made five unsuccessful -attempts to extract the tooth under chloroform. Three of these attempts -were at nine in the morning, and two about noon, just before the -accident. His patient suddenly died almost at the commencement of the -last attempt to administer chloroform, stretching herself out, and -frothing at the mouth at the moment of death; the countenance at the -same time becoming livid. - -An examination of the body took place fifty hours after death, when -putrefaction had set in. - -“The lungs presented nothing morbid; the bronchi contained a little -bloody froth. The blood was of the colour and consistence of cherry -juice. The heart was soft, flabby and collapsed. Its coronary vessels -and cavities were empty, and presented the bluish-red discoloration of -decomposition.”[84] The other organs were healthy. - - -_Case 15_ occurred in the public hospital of Kingston, Jamaica, on -January 29, 1850. The name of the patient was William Bryan, his age is -not stated, nor the nature of the operation he was about to undergo. He -had previously, however, undergone the operation of amputation of the -penis, on account of cancer of that organ, but it was performed without -chloroform. Mr. Maygarth, the surgeon who administered the chloroform, -stated as follows: “I had about a drachm poured on the sponge, and -applied it over his mouth and nostrils, but at first not in close -contact—at no period was the atmospheric air totally excluded. He bore -it badly, and I was frequently obliged to withdraw it, to facilitate his -breathing. The stage of excitement which is usual came on, and he -struggled and kept away the sponge for some seconds; it was again -reapplied, when, after a few more seconds, observing that he made one -stertorous inspiration, I removed it altogether. He ceased to breathe; -but after some seconds had elapsed, made another inspiration, and this -occurred several times, until at length respiration ceased entirely.” -The measures which were employed were of the usual kind, but were of no -avail. - -The brain and its membranes were found to be congested. The lungs were -congested, especially posteriorly. The right side of the heart contained -dark fluid blood, and the inner surface of its left cavities, and of the -aorta, were stained with blood. There was some disease of the aortic -valves, and the heart had undergone some amount of fatty -degeneration.[85] - - -_Case 16._ In February 1850, a death from chloroform occurred on board -ship at the Mauritius. A report of the case was sent to the Board of -Ordnance, and also to the Admiralty. The secretary of Sir William -Burnett first informed me of the case, and a day or two afterwards I had -an opportunity, through the kindness of the late Marquis of Anglesey, of -reading the report which was sent to him as Master of the Ordnance, and -I made a note of the chief particulars as soon as I got home. As the -report was a very able one, it is to be regretted it has not been -published. The accident occurred to an artilleryman, aged 24, who -required to have the last phalanx of the middle finger removed. In other -respects, he was considered to be in good health. Two scruples of -chloroform were first poured on the handkerchief with which it was -administered, and then one scruple more. It was observed that the face -turned pale, and the pulse and breathing ceased, soon after the -chloroform was discontinued. The measures which were employed to restore -him were of no service. The lungs after death were found to be -emphysematous; and, upon inquiry, it was ascertained that he had been -short of breath on exertion. The right cavities of the heart were filled -with fluid blood. The sinuses of the dura mater contained less blood -than usual, and the brain was pale. The medical man reporting the case -considered that the emphysema was the cause of death, by interfering -with expiration, and thus detaining the vapour; and it must be admitted -that, if the vapour were not sufficiently diluted with air, the -emphysema might increase the danger. I have, however, administered -chloroform in several cases in which emphysema existed to an extreme -degree, without any ill effects; consequently, when the vapour is -properly diluted with air, this affection appears to be no source of -danger. - - -_Case 17_ was that of a patient of Professor Carl Santesson, in the -Seraphim Hospital at Stockholm. I was indebted to Mr. Paget for my first -information about this case, and to Dr. W. D. Moore, of Dublin, for some -further particulars respecting it. - -The patient, a man thirty years of age, was affected with hydrocele, and -there was some suspicion of disease of the testicle. It was consequently -intended to operate on the hydrocele by incision, in order that the -testicle, if diseased, might be removed. The chloroform was administered -in the same way that Professor Santesson had seen it exhibited by Dr. -Simpson, except that it was poured on a little cotton, which was placed -at the small end of the cone, into which the folded towel he made use of -was rolled. About a drachm and a half was first poured on the cotton, -and the patient was told to inhale in long and deep inspirations. This -quantity being nearly evaporated in two or three minutes, a drachm more -was added. After a few inspirations rigidity and struggling came on: -these subsided, but in a little time returned more strongly than before, -and the towel was removed from the face until the struggling ceased. The -patient, however, not being sufficiently insensible to undergo the -operation with the necessary quietness, the towel was reapplied, when, -after a few inspirations, the pulse suddenly ceased. The face and the -whole surface of the body turned pale, the eyes rolled upwards and -inwards, and the breathing became very slow, but full and deep, the -intervals between the inspirations becoming longer, until the -respiration ceased altogether. The patient died before the operation was -begun, and within five minutes from the commencement of inhalation. -During the application of various means of resuscitation, including the -dropping of cold water _guttatim_ on the epigastrium, the breathing -returned, and continued for the space of three or four minutes; but the -pulse and sounds of the heart did not return. - -At the examination, thirty-two hours after death, the dura mater was -found to be congested, and there was considerable serous effusion -between the membranes of the brain. There were also some bony deposits -under the dura mater, and some adhesions of the arachnoid, indicating -long standing disease of the membranes. - -The heart was of normal size, and flaccid; the vessels on its surface -strongly distended with blood. The left ventricle was empty; the left -auricle, on the contrary, and the entire of the right side of the heart, -with the great veins, were filled with thin uncoagulated blood. In the -right ventricle only was a little loose coagulum found. The lungs, -posteriorly, were highly congested, exhibiting here and there -infiltrations of blood from the size of a pea to that of a small -hazel-nut. The pulmonary tissue was otherwise sound; giving, however, -when cut into, the odour of chloroform, but more feebly than the brain -did. The mucous membrane of the larynx and bronchial tubes were slightly -reddened from sanguineous congestion. The blood was everywhere of the -same thin juice-like nature.[86] - - -_Case 18._ I am indebted for my information respecting this case to Dr. -James Adams, of Glasgow, who was good enough to send me a copy of the -notes respecting it, from the case book of his colleague, Mr. Lyon, in -whose practice, in the Glasgow Infirmary, the case occurred, in March -1850. The patient was a boy seven or eight years old, from the -Highlands, whose health was considerably impaired by years of suffering -from calculus. Mr. Lyon says, “being laid in bed, I placed a piece of -lint, moistened with chloroform, near to his face, when, in a few -minutes, he ceased crying. I now told my clerk to take charge of the -chloroform, and introduced the sound. I thought I detected a calculus, -but could not hear the click distinctly, in consequence of the patient -moaning. One of the bystanders held his hand between my ears and the -patient’s face, when the click was at once heard. I withdrew the -instrument, and was horror-struck with the livid countenance and vacant -eye of the patient; the cardiac and radial pulses were gone, and, making -one deep gasp, he was to all appearance dead.” Artificial respiration -and other measures were employed without effect. “The external jugulars -being remarkably turgid, and the face still very livid, the right -jugular was opened, when several ounces of dark blood flowed rapidly.” -This measure, and galvanism, which was applied afterwards, were of no -avail. - - -_Case 19._ The subject of this case was Alexander Scott, aged -thirty-four, a police constable, who died in Guy’s Hospital in June -1850, whilst undergoing an operation for the removal of a portion of the -right hand. Mr. Cock, the operator, said that he was certain there was -no disease about the patient. He described the accident as follows:—“The -ordinary machine was used, and, as it had not the effect, witness -directed that a napkin should be folded into the shape of a cone, which -was applied with chloroform. The occupation of removing a portion of the -bone occupied one minute and a half, but before it was completed, the -blood which was gushing out, suddenly stopped, when witness directed Mr. -Lacy to feel the pulse of deceased, and they found that deceased had -expired.”[87] - -The sudden stopping of the hæmorrhage shews that, in this case, as in -the others, the action of the heart was suddenly arrested. The first -attempt to cause insensibility failed in this as in some other cases. - -Mr. Cock tried to dissuade his patient from having chloroform, severe as -the operation would have been without it. In Guy’s Hospital and St. -Thomas’s the medical officers had a strong objection to narcotism by -inhalation for the first two or three years after the practice was -introduced, and chloroform was used much less generally in these -institutions than in any other of the hospitals of London; yet it was -precisely in these two hospitals that two deaths from chloroform -occurred, before any such accident had happened in any other hospital in -this metropolis. This circumstance is worthy of the consideration of -those who propose to limit the accidents from chloroform by restricting -its use to a few great operations. - -In this case the lungs were reported to be extremely congested. Heart -flabby, not particularly distended; about two ounces of fluid blood on -the right side; not more than half an ounce on the left. Head.—Much -congestion of the dura mater; the grey matter of the brain was dark and -congested; fluid was found in the subarachnoid space; and a considerable -quantity of it in both ventricles. Kidneys congested.[88] - - -_Case 20_ occurred on September 20th, 1850, at the Cavan Infirmary, -Ireland. The case occurred in the practice of Dr. Roe, and I am indebted -to Dr. Robert Adams, of Dublin, for a manuscript account of it. The name -of the patient was James Jones, and his age twenty-four years. -Chloroform was exhibited with the intention of performing amputation -below the knee, on account of scrofulous disease of the ankle, with -ulceration of the cartilages. The patient was reduced to a state of -great debility by the disease, and was suffering from hectic fever, but -had no cough. The following is Dr. Roe’s account of the accident:— - -“When placed on the operating table the heart’s action was very quick -and weak, but he did not appear more faint or pale than usual. I then -saw Mr. Nalty, the apothecary, measure one drachm of the chloroform in -the small minim glass measure, and pour it upon a little folded lint, -which was placed in an oval hollow sponge, held in the hand with a small -towel. Recollecting I had used this chloroform in another case, and -finding some delay in producing the anæsthetic effects, I directed Mr. -Nalty to add thirty drops more to that already put on the lint. I then -applied the sponge to the patient’s nose, directing him to keep his -mouth shut, and gave the towel into the care of Dr. Halpin, who was on -the opposite side of the table, while I went to prepare myself for the -operation. Mr. Bird had scarcely screwed up the tourniquette, which had -been previously placed on the thigh, while I was examining the state of -the circulation in the tibial arteries, and which could not have -occupied one minute,—certainly the patient could not have taken fifteen -inspirations,—when Dr. Halpin told me the anæsthetic effects were -produced. This struck me as being unusually quick and sudden, and on -removing the towel from the face, we saw a slight convulsive action of -the left eyelid (the eyelids were partially open), and a small quantity -of frothy saliva at the mouth. I felt rather uneasy, but not much -alarmed, as Dr. Halpin said he had often seen such symptoms from the -effects of chloroform, although I had not met with them. On a more -minute examination of the heart, the eyes, muscles of the limbs, &c. we -found him dead.” - -Energetic means were used with a view to restore the patient, but -without effect. No inspection of the body took place. - - -_Case 21._ The next case of recorded death from chloroform occurred in -the Stepney Workhouse. The patient, named John Holden, age not stated, -was about to undergo an operation on the penis. It was stated at the -inquest that half a drachm of chloroform was administered without -effect, and then half a drachm more was applied, when the patient -suddenly expired. This death occurred in April 1851. - - -_Case 22_ is important, as having given rise to a prosecution. The -medical man, an officier de santé, named Kobelt, was accused of -homicide, by imprudence, want of precautions, &c. The chloroform was -administered on a handkerchief, and the accident occurred as suddenly as -any of the others. The husband of the patient stated that the whole -process did not last a minute. “I observed attentively,” he said, -“during this time, and the character that her countenance took all at -once made me apprehensive. I spoke of it to the operator, who -tranquillized me, and continued to extract the teeth. After the third -tooth, however, he partook of my apprehension, suspended the operation, -and proceeded to adopt measures indicated by the circumstances.” -Professor Sédillot, who had to pronounce an opinion on the case, after -hearing all the evidence, said, “I do not think that M. Kobelt is guilty -of imprudence or of rashness, because that officier de santé has -followed a practice very habitually employed, and even recommended, by -eminent practitioners, whose example and authority were sufficient to -inspire him with security, and shade him from reproach.” The accused -practitioner was acquitted. The above remark of Sédillot applied to the -plan of causing insensibility very rapidly, as first recommended by Dr. -Simpson; and he added some observations, to the effect that, when used -in a different manner, chloroform is free from danger. - -The above case occurred at Strasbourg, on June 10th, 1851. The name of -the patient was Madame Simon, and her age thirty-six. After death the -lungs were found to be somewhat congested, and emphysematous. Heart -flaccid, of middle size; right cavities filled with liquid dark-coloured -blood, mixed with some fibrinous clots. The left cavities contained -similar blood in much smaller quantity.[89] - - -_Case 23_ occurred on July 8th, 1851, at the Seaman’s Hospital, -Greenwich. The patient was a light-coloured mulatto, aged forty-five, -native of New York. He died during the operation of removing the left -testicle, which was disorganized by suppuration. “The chest had been -carefully examined a few days previously, both by percussion and -auscultation. No physical signs of disease were detected. His pulse was -regular and feeble, about seventy. He was rather nervous, and fearful of -the operation. No arcus senilis. After taking a glass of wine he -commenced the inhalation, twenty minims of chloroform having been poured -on a linen cloth. At the expiration of a few minutes, this had been -dissipated, producing only very trifling excitement; a second dose, of -the same quantity, was then administered in the same way; the man began -to sing and shout, his expressions relating to the firing of guns. The -second quantity having been exhausted, and the effects of the chloroform -becoming more apparent, but sensibility being still perfect, and even -intelligence almost unaffected, a third quantity, of ten minims, was -poured out, and, afterwards, twenty minims more. Having passed through -the usual convulsive stage, and insensibility being established, the -further administration of chloroform was desisted from at the end of -about seven minutes, though this time is merely guessed at; it might -have been more, but was certainly not less. At this time the respiration -was unembarrassed, and the pulse regular, and about seventy, with as -much volume as before the inhalation. The lips were florid; in fact, the -chloroform appeared to have acted in the most benign way. Mr. Busk -commenced the operation by an incision through the scrotum, which -divided a small arterial branch, and some enlarged veins, from which the -blood flowed pretty freely. The flow, however, almost instantaneously -ceased, and Dr. Rooke, who kept his finger on the man’s pulse, found -that cease at the same moment. Respiration appeared to cease almost -instantaneously with the heart’s action. Regular respiration at least -did; for, while we were looking at the man’s face, he fetched one or two -sigh-like inspirations. The ribs and abdomen were compressed, so as to -induce inspiration and expiration; the lungs were inflated by blowing -through the nostrils, the larynx being compressed against the spine, -and, for three or four minutes, upon our efforts being suspended, the -man occasionally took an inspiration; on one occasion three or four in -succession, so as to make us flatter ourselves that he would come -round.... It is worthy of remark that, for a long time after spontaneous -respiration had ceased, the lips retained a florid colour. The muscles -were all relaxed, and the veins on the side of the neck turgid.”[90] - -At the inspection of the body next day, the vessels of the dura mater, -and those on the surface of the brain, were gorged with fluid blood. The -lateral sinuses also afforded a flow of dark-coloured blood. There was a -considerable quantity of serous fluid in the cavity of the arachnoid and -in the spinal sheath. The substance of the brain was very soft. (The -weather was warm.) The lungs were of a dark purple colour posteriorly, -and much loaded with fluid blood and serum, but were everywhere -crepitant and healthy. The external surface of the heart was covered -almost entirely with fat; in some parts to a considerable thickness. -There were two fibrinous spots on its surface. No fluid in the -pericardium. The venæ cavæ were full of fluid blood. On removing the -heart, a white fibrous coagulum, about as big as a walnut, was found in -the commencement of the pulmonary artery. The heart was uncontracted, -and the cavities contained a very small quantity of dark fluid blood. -The walls of the right ventricle, and of the left auricle, were thinner -than natural. Some portions of the substance of the heart were paler -than natural:—“In these paler portions of the muscular substance, the -fibres had, for the most part, lost their striated aspect, and had -become converted into a fine granular material contained in the -sarcolemma. Here and there a minute oil-globule could be observed in the -muscular fibrillæ, but nowhere did this amount to fatty degeneration.” - -In this case all the precautions appear to have been taken which are -possible in making a patient insensible with undiluted chloroform, -administered on a handkerchief; and the case, therefore, strongly -confirms the proposition that chloroform cannot be administered in this -way with perfect safety. - -The patient was apparently in the most satisfactory condition at the -conclusion of the inhalation, and yet, a few seconds afterwards, the -heart suddenly ceased to beat, from the effect, as we must conclude, of -that portion of vapour which was in the lungs at the moment when the -inhalation was discontinued. - - -_Case 24_ occurred in October, 1851, at Chipping Norton, Somerset, to a -patient of Mr. Farwell, named Elizabeth Hollis, and aged 37. No one -observed the manner in which the breathing and circulation ceased, and, -as the patient was in a state of extreme debility, it is not quite -certain that the chloroform was the sole cause of death. It was -administered to prevent the pain of removing the fæces, which became -impacted in the rectum on account of extensive cancerous disease of the -uterus and vagina. The surgeon reports that “the time occupied in the -inhalation was about eight or nine minutes; quantity inhaled 10½ -drachms, half a drachm at a time, allowing her frequently to breathe the -atmospheric air. She spoke to me during this period. When I found that -her arm fell after being raised, I proceeded to and accomplished the -operation. At this time she was not inhaling. I then, as I always do, -wetted the face with a sponge, with the view of washing off any -remaining chloroform from the nose and lips, when, to my surprise, I -found that she had ceased to breathe, and all attempts to restore her -were in vain.... When I commenced the operation, the pupil was -contracted, and the conjunctiva slightly red. After death, the pupil was -very dilated, and the countenance extremely pallid.”[91] There was no -inspection of the body. This patient had inhaled chloroform on two -previous occasions for a similar operation. - - -_Case 25_ occurred in St. Bartholomew’s Hospital, on March 17, 1852. -Thomas Hayward, aged 23, was suffering from aneurism by anastomosis, -occupying the right ear and its neighbourhood. He had inhaled chloroform -on the 14th of the previous month, whilst Mr. Lloyd placed ligatures on -the temporal artery and some other arteries supplying the tumour; and it -was with a view to tie an additional artery, situated between the -mastoid process and the ramus of the jaw, that chloroform was again -administered. - -“The chloroform was some of the same, and the apparatus employed for its -administration precisely similar [alluding to the former occasion.] It -was administered by one of Mr. Lloyd’s dressers, who well understood, -and had great experience in its use. A gentleman of great experience, -who had been for years at the hospital, and two years house-surgeon, was -watching its effects, and marking the state of the pulse. Other -gentlemen were assisting, and also on the look out. - -“In from five to ten minutes the usual effect was produced, the patient -having previously struggled much. The operation was then commenced; but -no sooner had Mr. Lloyd cut the skin, than it was stated that the pulse -had suddenly ceased. The chloroform was at once removed; but in a few -seconds, the patient had ceased to breathe, and no pulsation could be -felt at any of the arteries or the heart. - -“Artificial respiration, as well as percussion and compression of the -different parts of the body, were immediately employed with energy; and, -after continuing the means for a short time, the circulation was -observed to be returning, and the act of respiration was several times -performed. The state of inanimation, however, speedily returned; but, by -the employment of the same means as before, with the use also of -galvanism, the circulation and respiration were again restored. Quickly, -however, the patient fell into the same state as at first, but was again -restored by the same means. - -“In a few minutes the state of inanimation again returned, when the -external jugular vein, which on the right side was very turgid, was -opened, and tracheotomy was performed, and the lungs inflated. The -patient was also placed in a warm bath, at the temperature of 104°, -artificial respiration being kept up all the time. All, however, was of -no avail.”[92] - -At the examination of the body, the following are amongst the -appearances noted. “The venæ innominatæ and vena cava superior were full -of blood, and probably would have been distended, but that two or three -ounces of blood had flowed into the coffin from the opening made into -the external jugular vein. The right auricle and ventricle were -distended with blood, and would probably have been more so but for the -escape of blood mentioned above. The left auricle and ventricle -contained very little blood; the left ventricle was perfectly contracted -in the rigor mortis. The heart was of full size. It appeared in every -part natural in its texture, and as if it had possessed full power. Its -valves also were all healthy; neither could any disease be found in any -of the chief bloodvessels within the chest. All the blood, however, was -fluid, and it remained without coagulation after its escape from the -heart and vessels. It had also a brownish purple hue, much like that -which is commonly observed in the spleen: none of it, when thinly spread -out, presented the ordinary dark, black, or crimson hue of venous blood. -Both lungs were attached by old adhesions about their apices and -posterior surfaces, but these were of small extent. Their texture was -healthy, but they appeared more than usually collapsed and dry. Their -bloodvessels were not over filled.”[93] - -In this case, every precaution seems to have been taken, except that one -which is most essential of all, of regulating the proportion of vapour -in the inspired air. It had always been made a great point in St. -Bartholomew’s Hospital to attend to the pulse very carefully,[94] and on -this occasion it was closely examined, but only, as in some other cases, -with the result of being able to note the moment when it suddenly -ceased. - -With regard to the return of the circulation, which is mentioned in the -report as having occurred on three occasions, together with the -breathing, during the efforts at resuscitation, I understood from -inquiries I made of a gentleman present, that this was judged of from -the red colour returning to the face and lips, but that the pulse and -sounds of the heart were never distinctly perceived after they first -ceased. The respiration may cause the colour to return to the face -without a true circulation, as I have seen whilst inflating the lungs of -still-born children; for if a portion of red blood be mechanically -displaced from the lungs by the motion of the chest, it will be -propelled by the contractility of the arteries, which continues for some -time after death. - - -_Case 26_ is related by Dr. Majer, of Ulm.[95] It occurred on June 27th, -1852. The patient, Madame W., was 32 years of age, and of good -constitution. She was in very good spirits, and was only waiting the -operation of having a tooth extracted, before going to dinner. It was -stated that only twenty or twenty-five drops of chloroform were put on a -sponge, which was surrounded by a handkerchief. After four or five -inspirations, the operator inquired if his patient did not feel a -singing in the ears. She replied with a trembling and thick voice. At -the same time she stretched out her limbs, the face became bluish, the -eyes haggard, the head and the arms fell—she was dead. The patient’s -husband said, that the time between the inhalation and death was so -short that one could scarcely have said Yes or No. - -An examination of the body was made twenty-five hours after death. -Putrefaction had commenced, and the body was not rigid. The vessels of -the membranes of the brain were gorged with blood containing many -bubbles of air. The heart was soft and flaccid; the coronary vessels -were engorged with blood and air; the cavities of the heart contained -air, but little blood. The lungs were congested at the inferior parts. - - -_Case 27_ took place at Melbourne, Australia. The name of the patient -was Mr. John Atkinson, but his age is not stated. Dr. Thomas, who was -about to operate for fistula _in ano_, said: “Before administering the -chloroform, I asked the deceased particularly if he had ever suffered -from any serious illness, to which he replied in the negative. I also -inquired whether he had been subject to cough or palpitation, and he -answered that, some time ago, he had suffered slightly from cough. The -pulse was good, and Mr. Barker proceeded in the usual manner to -administer the chloroform, which shortly produced convulsive twitchings -of the muscles. I then went to the door to request the nurse to send up -some person to assist in holding the patient in a proper position for -the operation, and I returned to the bed, and poured a little more -chloroform on the handkerchief; when it was applied to the face, I heard -him splutter at the mouth; the chloroform was instantly discontinued, -but the patient suddenly expired. We tried all the means usually -resorted to in other cases of suspended animation, but without effect. I -had frequently used the same chloroform in other cases. It was not more -than a minute after the first application of chloroform that death -occurred. About a drachm had been poured on the handkerchief.” - -At the examination after death, “there was considerable serous effusion -into the pericardium, and the heart itself was larger and more flabby -than usual. It was hypertrophied, and there was dilatation of the -cavities; the lungs were healthy, and there was a slight appearance of -disease about the liver, such as is observed in persons addicted to -intemperance.”[96] - - -_Case 28._ On August 10th, 1852, a Mr. Martin, a cattle dealer died near -Melrose, in Scotland, after inhaling chloroform for the application of -potassa fusa to some ulcers of the leg. Dr. W. M. Brown, who relates the -case, says:—“Before proceeding to apply the caustic I gave him -chloroform. He was not easily affected by it, and struggled a good deal. -After beginning to apply the caustic I found he was not sufficiently -insensible to pain, and gave him a little more chloroform, which had the -desired effect. I then proceeded with the application of the caustic, -and was just finishing, when I observed a sort of catch in his -breathing. I immediately stopped, and, on looking at him, I saw the -mouth and eyes open, the breathing irregular, the face pale, the eyes -slightly turned upwards, and the pupils dilated.” Dr. Brown tried -artificial respiration and other means to resuscitate the patient, but -without effect. He says, “in a few minutes the man died.” The pulse is -not mentioned, nor the age of the patient.[97] - - -_Case 29_ took place in the Manchester Royal Infirmary, on December -24th, 1852, during the removal of a malignant tumour of the thigh, by -Mr. Jordan. The patient was Henry Hollingsworth, a factory operative. -His age is not stated. “The man was very much excited, struggled and -talked fast. The chloroform was administered slowly, and every -precaution was taken to prevent any danger, and the medical men remarked -two or three times how very long it was in taking effect. He at last -became insensible, in about seven minutes at least. Mr. Jordan commenced -the operation by an incision into the skin covering the tumour. I was -assisting the surgeon when Mr. Heath directed my attention to the -patient’s face. This was about five minutes after the operation had -commenced. I then observed congestion about the face, but there was no -stertorous breathing. His pupils appeared almost to have ceased to act. -His breathing was becoming exceedingly slow, and he seemed to be sinking -fast. I directed the attention of the operator and the other medical men -to these symptoms. The operation was then suspended, and means were -resorted to for restoring animation, but the pupils had ceased to act, -and had become fixed almost immediately. He gave one strong gasp, and -then to all appearance was dead. In administering the chloroform, -successive doses were given until it took effect. Every dose consisted -of a drachm, taken, at intervals, in an inhaler.”[98] - -The following remark is made respecting the autopsy. “The post-mortem -examination shewed that asphyxia, caused by chloroform, produced the -death. There was a congestion both of the brain and lungs.” The -appearances met with after death from chloroform do not indicate the way -in which death has taken place. In animals that are killed by it, the -right cavities of the heart are always found filled with blood, whether -they die suddenly by its direct action on the heart, or more slowly by -its effects on the brain, and the breathing ceases before the -circulation. The lungs are seldom much congested in animals, whichever -be the mode of dying, and the appearances in the head are not unusual. -The state of the pulse is not mentioned in the above account of the -case; but congestion about the face was first observed, and then it was -noticed that the breathing was getting slow. It is sufficiently probable -that the breathing ceased on account of the action of the heart being -first arrested; but even if the respiration was embarrassed by the -action of the chloroform on the brain, it is pretty certain that that -agent also acted directly on the heart; for it cannot be supposed that -the means used for restoring animation would have failed, if the heart -had been acting properly when the breathing ceased. - - -_Case 30_ took place on March 19th, 1853, in University College -Hospital, London. The subject of it was an unmarried woman, named -Caroline Baker, aged twenty-eight. The chloroform was administered with -the intention of applying nitric acid to a sloughing ulceration of the -labia and vagina. “The chloroform, supposed in the first instance to be -about a drachm, was poured on lint about five inches square, and folded -four or five times over. After a short time the patient became restless, -talked loudly, and threw about her arms. Soon afterwards a partial -relaxation of the limbs took place, and she became insensible and -pulseless.”[99] - -Further symptoms are not given, but it is stated that she sank and died. -The breathing is not mentioned, but Mr. Erichsen, who, although not -present at the accident to his patient, would be made aware of all that -occurred, stated at the inquest, that death was produced by a paralysis -of the heart from the influence of the chloroform. Dr. Quain examined -the structure of the heart with the microscope, and he “found that -organ, particularly on the right side, in a state of fatty -degeneration.” - - -_Case 31_ was communicated to the Society of Surgery of Paris by M. De -Vallet, Surgeon-in-chief to the Hôtel-Dieu, d’Orléans. “A soldier of the -line, aged twenty-five, apparently in good health, and of strong frame, -consulted M. Vallet for a small tumour situated behind the right labial -commissure. Before operating, he proceeded to direct the inhalation of -chloroform. The patient, fasting, being placed in the horizontal -posture, the chloroform (about one gramme) was poured upon a hollow -sponge, and applied to the nose, the mouth being left free. At the -expiration of a minute, no effect having been produced, four grammes -were poured on the sponge, and at the expiration of four minutes, the -patient, without having experienced any irritation of the larynx, -without having manifested any resistance, without redness of the -countenance, and after only a slight period of agitation, fell into a -state of insensibility fit for the operation. Scarcely had the incision -been made, necessary to expose the cyst, when the patient became pale, -respiration was suspended, and he sank into a state of complete -collapse. All the usual remedies were tried, and without avail. M. -Vallet opened the trachea, and performed artificial respiration with an -elastic tube; then an electric current was sent by needles through the -region of the heart. The patient died without any sign of reaction. - -“Examination of the body.—The vessels of the brain were empty; the lungs -were congested with blood, which in some situations was extravasated; -the heart was excessively flaccid; there were some soft clots in the -right cavities; the left were empty. The stomach was full of gas; the -liver, spleen, and kidneys were gorged with black blood.”[100] - - -_Case 32_ occurred in the Royal Infirmary of Edinburgh to a man aged -forty-three, on whom Dr. Dunsmure was about to operate for stricture of -the urethra by perineal section. The chloroform was administered by Dr. -Struthers. About an ounce of chloroform was used, and the patient had -been put under the influence of this agent on two former occasions, when -a similar quantity was employed without ill effect. The following is Dr. -Dunsmure’s account of the case:— - -“While the patient was inhaling the drug, he struggled considerably, and -became a good deal congested in the face and head. He seemed to take a -slight convulsion, like an epileptic fit, and such as I have seen on -several occasions in people who have led an intemperate life. During the -convulsion, the handkerchief containing the chloroform was removed to -some distance from the face. In a short time the inhalation took effect, -and he began to snore, and although still violent, the chloroform was -removed from the face entirely, and the handkerchief placed under the -pillow. As soon as the patient became more quiet, he was pulled down on -the table, and placed in the proper position for the operation. I then -shaved the perineum, and was just going to make my first incision, when -one of the assistants said that his pulse was becoming weak. The -posterior tibial, Mr. Spence then remarked, was good, but in a second or -two after, both gentlemen exclaimed that the pulse was gone. I rushed -from my seat to the patient’s head, and found that his breathing had -ceased. Those present who had an opportunity of observing the -respiration, which I had not, owing to the stool on which I sat being -low, positively assert that the breathing did not cease before the -pulse. The face was much congested, the jaws were firmly closed, and the -pupils were dilated. I immediately forced open the lower jaw by means of -the handle of a staff, and with catch forceps pulled out the tongue. -Artificial respiration was had recourse to, and in a few minutes he made -a long inspiration. This was soon followed by a second, by a third at a -longer interval, by a fourth at a still longer period, and then by a -fifth, when all attempts at natural breathing ceased. No pulsation could -be felt in the radial arteries. The chest was noticed to be much -contracted, to have apparently lost its elasticity, and not to expand -when the ribs were forcibly compressed during the artificial -respiration. I had previously sent for a galvanic apparatus, which was -in the flat below, and it arrived almost immediately after the patient -had made the fifth inspiration. When the tongue was pulled out, and -before the first breath was taken, I was on the point of opening the -trachea, but this proceeding was then abandoned; it was now, however, -had recourse to, in order to carry on artificial respiration more -certainly: the external jugular was also opened, and about a couple of -ounces of blood flowed. By the time the tracheotomy tube was inserted, -the galvanic apparatus was in working condition, and it was applied on -each side of the diaphragm. It acted remarkably well; at each -application of the sponges, the muscle descended as if the patient was -in life; air passed through the tube in the trachea, and for some time I -was in great hopes that the man was to be saved; but the muscle -gradually lost its contractility, and although the galvanism was kept up -for an hour, it was evident that all our efforts were in vain—that life -was extinct. The post-mortem examination was made the following day at -one o’clock, rather more than twenty-four hours after the patient’s -death, and I give the report of it as drawn up by Dr. Gairdner, the -pathologist to the Infirmary:— - -“John Mitchell, aged forty-three, died 28th September. A very robust -man; height five feet eight inches; diameter (lateral) of base of -thorax, ten and a half inches. - -“External appearances.—Considerable lividity of face and neck, and more -than usual congestion of depending parts. Considerable amount of fat, -but more in omentum and around viscera of abdomen than in external -parietes. - -“Chest.—Right pleura presents a few slight adhesions near the middle; -left pleura free. No fluid in either pleural cavity. Pericardium -contained about half an ounce of serum, and presented a few opaque -patches on its surface. Both sides of heart contained blood, the right -side rather more than the left. Blood more than usually fluid. External -fat of heart considerable, about three lines on some parts of right -ventricle. Muscular tissue of heart generally flabby, and rather pale, -but not distinctly disorganized to the naked eye. Valves perfectly -healthy. Aorta presented very faint traces of atheroma. A few traces of -atrophy of right lung towards its apex and anterior edge, but very -limited. In all other respects lungs free from disease, but somewhat -congested. - -“Spleen soft, but not diffluent. - -“Liver congested, but otherwise normal. - -“Kidneys congested, but otherwise healthy. - -“Brain.—The subarachnoid fluid presents considerable milky opacity, and -is of moderate quantity. Moderate congestion of the meninges generally. -About half an ounce of fluid in the ventricles. Substance of brain -healthy. Arteries at base perfectly free from atheroma. Air -passages.—Glottis perfectly patent. Mucous membrane of larynx and -trachea slightly congested. - -“Microscopic examination shewed the fibres of the heart to be nearly -normal, though scarcely so distinctly striated as in some cases. The -minute vessels of the brain and pia mater presented at some points a few -clustering granules, but to no great extent.”[101] - -Dr. Dunsmure expressed the opinion that four or five minutes elapsed -from the time the chloroform was left off before the pulse failed. But -it is pretty certain that he has much over-estimated the time. Indeed, -if the shaving of the perineum were likely to occupy even half of this -time, the operator would have done it, or had it done, before the -chloroform was administered. Dr. Dunsmure makes the following remark in -his comments on the case: “In several instances where I have seen -chloroform very nearly prove fatal, the respiration became gradually -restored after an inspiration had once been made; in this case, however, -no such fortunate occurrence took place.” In the other cases to which -allusion is here made, the heart has not been paralysed, or at least not -completely, but they show that the method of administering chloroform in -Edinburgh had been far from satisfactory in its results, although no -patient had before that time been actually lost.[102] - - -_Case 33_ occurred in University College Hospital, London, and the -following account of it was given by Dr. Hillier: - -“E. R., aged 40, a woman of moderate height, rather thin. The general -health has been pretty good; she had not been liable to palpitation or -dyspnœa. Had been in the habit of drinking pretty freely. Admitted on -October 5th, at 11 p.m. She was suffering from the symptoms of -strangulated hernia, which had existed two days and a half. Efforts were -made to reduce the hernia, both without and with a warm bath, in which -she was for upwards of half an hour without getting very faint. These -efforts being unsuccessful, an operation was at once determined on. Her -pulse was at this time regular, and of tolerable strength. - -“Chloroform was administered in the usual way, on a piece of lint, which -was held three or four inches from the patient’s face, and then brought -to within an inch and a half of her nose and mouth, leaving space around -for the admission of air. - -“For three or four minutes nothing unusual presented itself; the pulse -and respiration proceeded normally. There was put on the lint, at first, -one fluid drachm of chloroform; and, at the end of three or four -minutes, forty minims more were added. This was the whole quantity of -chloroform employed. Within a minute after the second quantity of -chloroform was added, the patient struggled violently both with her arms -and legs. During these struggles I was holding her right hand, and was -unable to feel the pulse in consequence of her constant motions. The -struggling lasted about a minute, and on its ceasing, the patient -commenced to breathe with loud, rough stertor. I at once removed the -lint from before the face, and felt for the pulse, which I could not -find. Immediately cold water was dashed on her face. She breathed with -this stertor for two or three short inspirations, and then two or three -long ones, and then the breathing ceased. Immediately artificial -respiration was resorted to, and within a minute galvanism was applied -to the back of her neck and the diaphragm. Under the influence of these -agencies, the patient gasped about three times at intervals; after this, -no further signs of life were exhibited. - -“At the time when the stertor commenced and the pulse failed, the pupils -were dilated, and the face of the patient was only slightly altered. The -tongue was not retracted, for one of the bystanders at once put his -fingers into her mouth to ascertain this.” - -At the autopsy made by Dr. Garrod thirteen hours after death, the rigor -mortis was well marked; the blood was very fluid in all parts of the -body. There was about an ounce of colourless fluid in the pericardium. -The heart was quite collapsed and empty, but, as Dr. Garrod observes, -this may have been due to the fluidity of the blood. The weight of the -heart was seven ounces and three-quarters; valves healthy. Walls of the -right ventricle flabby and pale; mean thickness one eighth of an inch. -At some parts the muscular substance was in a very thin layer, being -much encroached on by fat. In several places there was scarcely any -muscular fibre visible. This was chiefly the case near the apex. -Examined by the microscope, much fatty degeneration of the muscular -fibres of the right ventricle generally was discovered. The walls of the -left ventricle were flabby, dry in appearance, pale, and very friable. -Both lungs were crepitant throughout, not much engorged. Brain not -congested. The intestines above the strangulation were much distended -with flatus, and inflamed.[103] - - -_Case 34_ occurred on October 20th, 1853, a few days after the last. The -patient was a young woman named Ann Smith, aged 22 years, under the care -of Mr. Paget in St. Bartholomew’s Hospital, who was about to apply the -actual cautery to a sore of cancroid nature in the vagina. She was a -stout, florid young woman, formerly of dissolute habits, but apparently -in perfect health, with the exception of the local ailment. She had been -put under the full and prolonged influence of chloroform a fortnight -previously for the application of the cautery, without the occurrence of -any untoward symptoms whatever. The chloroform was administered by Dr. -Black, one of the assistant physicians. - -“The usual form of inhaler was employed,—a padded metal cup, fitting -over the nose and mouth, and supplied with valves. A drachm, by measure, -was first poured on the sponge, but as the administration did not -immediately commence, a considerable part of this was no doubt wasted; -after a short inhalation, a second drachm was supplied, and subsequently -the further quantity of half a drachm. The patient had gone through the -usual stages of excitement, etc., and the last dose was scarcely used, -as she sank off, almost immediately after its application, into a state -of complete insensibility, unattended by any alarming symptoms. About -five minutes had been occupied by the inhalation, and probably not more -than a drachm and a half of the fluid really inhaled. The apparatus was -now removed from the face, and the patient having been drawn into the -proper position, Mr. Paget was about to commence the operation, when Dr. -Black, who throughout had kept his finger on the pulse, noticed it to -have become extremely weak and fluttering. Almost immediately -afterwards, the patient’s countenance was observed to be dusky, turgid, -and congested, and the respiratory movements began to be performed at -long intervals, and by slight catching efforts. No time was lost; cold -water was at once dashed on the thighs, face, and breast; and, the -failure of the respiration becoming shortly complete, Mr. Paget -immediately began artificial insufflation of the lungs, by alternately -blowing into the nostrils, and compressing the chest. Just before -commencing this process, Mr. Paget had ascertained, by drawing the -tongue forwards and examining the glottis with the finger, that the -epiglottis was not pressed down.” - -Other means were employed, but no further signs of life appeared. It is -further recorded that, “immediately after the first alarming symptoms, -the pupils were of the medium size, neither contracted nor dilated. All -efforts at respiration ceased about two minutes after the first -indications of failure; the pulse, however, as a very feeble flutter, -was felt occasionally for at least two minutes later.”[104] - -At the autopsy, performed by Mr. Paget, twenty-two hours after death, -“the thorax was first examined, and nothing whatever abnormal could be -detected in any of the viscera; the lungs were healthy and crepitant in -every part; their posterior lobes were not more congested than is seen -in almost every examination; the heart, collapsed, but not contracted, -and containing a small quantity of fluid blood in each cavity, was of -normal size and proportions, in every respect, and its muscular -structure, examined by the microscope, showed no degeneration.... The -brain, its sinuses, ventricles, etc., were all carefully examined, and -neither in texture nor quantity of blood was anything abnormal -detected.”[105] - -Although the failure of the pulse was the first symptom of danger in -this case, it continued to be felt as a very feeble flutter for about -four minutes, so that the heart was not so completely paralysed as in -most of the fatal cases. It must, however, have been so far paralysed as -to be past recovery. - - -_Case 35._ Professor Dumreicher related a case of death from chloroform -at the meeting of the Vienna Society of Physicians, held on November 16, -1853. The patient was a young man, aged nineteen, in somewhat feeble -health, who inhaled chloroform in the recumbent position, in order to -have his anchylosed knee-joint forcibly extended. It was inhaled from a -vessel resembling a snuff-box, which was held to the nostrils. “The -inhalation was continued for fifty seconds, and the patient had spoken a -few seconds previously, when Professor D. observed that the pulse had -become frequent and undulating. He immediately suspended the -administration of the anæsthetic. Trismus occurred; the respirations -became irregular; the face turned livid, and he foamed at the mouth.” -The measures which were employed included the abstraction of eight -ounces of blood from the jugular vein, but they were of no avail. He -only once made a feeble attempt at inspiration.[106] - - -_Case 36_ occurred in the practice of Dr. Wüstefeldt of Neustedt. “A -young girl, thirteen years of age, had on the dorsal region a voluminous -lipoma, which extended from the last dorsal vertebra to the crest of the -ilium.... One drachm of chloroform was employed. As soon as -insensibility was manifested, the operation was commenced, but scarcely -had the surgeon divided the skin, when the girl, yielding to the laws of -gravity, fell suddenly forwards on her chest. Dr. Wüstefeldt, struck by -the phenomenon, which he had witnessed before under similar -circumstances, immediately desisted from operating, and strove to -restore the patient to life; but every effort was useless, and, in the -course of a few minutes, it became evident that she was dead.”[107] - -Further particulars are not given; but as the patient died suddenly, -when the surgeon had scarcely divided the skin, it must be admitted that -he was, in all probability, correct in attributing the event to the -chloroform. The patient usually yields to the laws of gravity when only -partially under the influence of chloroform, and it seems surprising -that the operation should have been undertaken without placing the -patient in the horizontal posture. The proper position of the patient, -when a large tumour of the back is to be removed, is to be lying almost -flat on the abdomen, the head being a little turned on one side, so that -it rests with one ear on the pillow. - - -_Case 37._ Jane Morgan, aged fifty-nine, died whilst inhaling chloroform -in the Bristol Infirmary, on January 21st, 1854. She was moderately -stout, pale, but not otherwise of unhealthy appearance. “The -stethoscopic indications were favourable, the beat of the heart was -natural, and the air passed freely throughout both lungs; but the chest -movements on the right side were not quite so free as on the left.” -Chloroform was ordered by Mr. Harrison, the senior surgeon of the -Infirmary, with the intention of attempting to reduce a dislocation of -the humerus of eight weeks standing. “Having taken no food since her -breakfast, she commenced the inhalation of one drachm of chloroform, at -2 P.M., in bed in her ward, under the superintendence of Mr. Hore, the -house-surgeon. Nothing unusual occurring in the patient’s general -condition during inhalation, a second drachm, in about five minutes from -the first, was poured upon the sponge, and the inhalation was continued. -Almost immediately after the addition of the second drachm, the -chloroform was withdrawn, as the patient’s breathing became stertorous; -and immediately afterwards her pulse, which had hitherto continued -pretty firm, was suddenly imperceptible, the respiration ceasing at the -same time. The pupils were not dilated.” Various measures were promptly -resorted to with the hope of restoring the patient; but there were no -further signs of life, unless “some convulsive efforts of the -respiratory muscles,” under the application of galvanism, be so -regarded. - -At the examination of the body on the following day, the right pleura -was found to be adherent. The lungs were healthy in structure, but -gorged with dark fluid blood. There was about an ounce of fluid in the -pericardium. There was a small quantity of fluid blood in each of the -cavities of the heart. For the length of an inch from their -commencement, both coronary arteries were much dilated, and studded with -atheromatous and bony deposits. The muscular structure of the heart was -examined under the microscope by Dr. William Budd, and a considerable -proportion of the fibres were found in a state of incipient fatty -degeneration. It was learned, after her death, that she had been subject -to occasional attacks of fainting.[108] - - -_Case 38._ A death from chloroform occurred in the Hôpital St. Antoine, -at Paris, in the spring of 1854. The subject of this was a woman aged -forty, on whom M. Richard was operating for the removal of a uterine -polypus. The surgeon placed the patient in the horizontal posture, and -administered the chloroform on a compress of lint. She became insensible -in two minutes, having first been excited so that it was necessary to -hold her. M. Richard moved the patient to the edge of the bed, gave the -compress containing the chloroform into the hands of an assistant, and -commenced the operation, which was likely to be of short duration. He -had almost completed it, when he was apprised by an assistant, who had -been set to feel the pulse, that it had ceased to beat. He sought for it -himself, but found that it did not beat. The face was extremely pale; a -slow respiration still continued, but soon ceased; and the measures -which were used with the hope of restoring the patient were of no -avail.[109] - -At the examination of the body all the organs were found in a healthy -state. The right cavities of the heart and the great veins contained a -considerable quantity of blood, and the left cavities of the heart a -small quantity. The blood was everywhere fluid.[110] - - -_Case 39._ A patient, named Mrs. Harrup, died at Sheffield from the -effects of chloroform administered with the intention of removing a -cancerous tumour of the left breast. The age of the patient was -forty-five, and she was stated to be in good health, excepting the local -affection. - -“The chloroform was administered with more than the usual precautions. -After the inhalation had gone on without any effect for twenty minutes, -it was thought that possibly different chloroform might succeed, and one -ounce was accordingly procured from the public dispensary. After the -inhalation had been conducted with the fresh chloroform about twenty -minutes, the usual effects of the vapour began to manifest themselves. -The pulse, which was 136 before any chloroform had been given, and had -been very gradually decreasing in frequency while it improved in -strength, was now about 104. At this moment muttering—half articulate -delirium—came on, but ceased in a few moments, and was immediately -followed by conclusive signs of the satisfactory action of the -chloroform. Dr. Law now desired Mr. Wright to begin the operation; but -before he could do so, Dr. Law, seeing an alarming change in the -countenance of the deceased, cried, ‘Stop, Mr. Lewis, how is the pulse?’ -I replied, ‘It is gone.’” After stating the means which were used with a -view to resuscitate the patient, it is added that the heart had ceased -to beat, and that, after a few short and laboured inspirations, life -became extinct. - -At the examination of the body, the cartilages of the ribs were found to -be ossified. The heart and lungs were perfectly healthy, but the lungs -were in a congested condition. There was an extravasation of blood in -the spinal muscles, and a little blood in the spinal canal, in what part -or between what structures is not stated.[111] - - -_Case 40_ occurred in the Lock Hospital, London, in May 1854. Walter -Hollis, a tailor, aged eighteen, had been under treatment for sores -within the prepuce, and these having healed, he was about to undergo the -operation for congenital phymosis. He had been of dissolute habits, and -exhibited a pale cachectic appearance. - -“The inhaler used was a simple mouth-piece by which the nostrils are -left uncovered. About two drachms of the fluid were poured into the -instrument. After about six minutes inhalation, insensibility seemed to -be coming on, and at this moment the pulse was ascertained to be of good -volume. Nothing whatever had occurred to indicate the impending danger, -when, after a few more inhalations, the pulse suddenly failed, became -quite imperceptible, and the countenance assumed a pale and leaden hue. -The inhalation was immediately stopped, and attempts to resuscitate, by -means of striking the chest sharply with a wet towel, applying ammonia -to the nostrils, and by artificial respiration, were at once commenced. -These were employed for three or four minutes before any signs of life -were perceived; but, subsequently, the pulse was again to be felt, and -spontaneous respiration was renewed. Artificial respiration was desisted -from on the occurrence of these signs of returning life, and for upwards -of ten minutes the chest continued to fill regularly, and the pulse beat -at a rate of from 40 to 50 in the minute; the countenance of the patient -also much improved, and even assumed a slight flush. After the -expiration of, perhaps, a little more than ten minutes, however, these -indications of returning vitality again disappeared, the pulse and -respiratory efforts simultaneously ceased, and the countenance became -deathlike. Artificial respiration and the other means were again -adopted, but this time without the slightest success.... Post-mortem -examination on the next day shewed great venous congestion within the -cranium; the lungs were also somewhat congested. The heart was slightly -enlarged, and the ventricular parietes were thinned; in the muscular -fibres the microscope detected decided fatty degeneration. The blood was -universally fluid.”[112] - -The partial recovery of the patient is a remarkable feature in this -case, and it is difficult to explain why he did not recover completely. -The number of the pulsations during this partial recovery is mentioned, -but not their quality, and I cannot help supposing that the pulse must -have been extremely weak, as well as slow, at this period. The ten -minutes during which the pulse and breathing returned is mentioned with -the qualifying term of “perhaps”, which leads to the supposition that it -was not noted by the watch or clock, and under such circumstances of -anxiety and suspense, the time might be very much over-rated. The slight -fatty degeneration of the heart might probably interfere with the -complete recovery of the patient, after this organ had once been -paralysed by the chloroform. - - -_Case 41_ took place on July 13th, 1854, in the Middlesex Hospital. The -patient was a stout, muscular, and florid man, 65 years of age, on whom -Mr. De Morgan was about to perform amputation at the upper part of the -thigh, on account of a large malignant tumour growing from the inner -side of the femur. - -“Chloroform was administered by Mr. Sibley, the registrar to the -hospital. Snow’s inhaler was employed. The quantity at first placed in -the inhaler was rather less than two drachms, and another drachm was -added eight minutes afterwards. The patient inhaled the chloroform -without difficulty, and went through the usual stages; at the end of -about ten minutes violent spasm was induced; this continued about three -minutes, and then somewhat abated. The pulse, which had risen to about -120, descended to 70, having a full, steady, and deliberate beat. The -pupils, which had been much dilated, became less so. The respiration -continued free and deep, but not stertorous. The colour of the face -remained good. - -“At this moment, which was between thirteen and fourteen minutes from -the commencement of the inhalation of the chloroform, the pulse gave a -few rapid and irregular beats, and then ceased. Respiration, which, as -has been stated, had been going on freely, ceased simultaneously. The -face became suddenly pallid and deathlike. The inhaler was removed -instantaneously, and cold water dashed on the face. Mr. Sibley -immediately commenced to carry on artificial respiration, by applying -his mouth to that of the patient, and inflating the lungs. The period -that elapsed between the sudden cessation of the pulse and the inflation -of the lungs was only a few seconds. After a few inflations, there -appeared to be a slight effort at inspiration, but this was the only -sign of life discovered after the syncopal attack. Galvanism was in -operation within two minutes after the cessation of the pulse.” - -“An examination of the body was made by Dr. Corfe forty-eight hours -after death. In the head nothing particular was discovered; the brain -was firm, and rather more vascular than natural; the blood in the sinus -was partly coagulated; the heart was rather larger than natural, and was -extremely loaded with fat, especially on the right side, where fat -formed three-fourths of the thickness of the wall of the ventricle; the -muscular tissue was extremely pale and soft, and exhibited both to the -naked eye, and the eye assisted by the microscope, an extreme degree of -fatty degeneration; the blood in the cavities of the heart was firmly -coagulated; on both sides it was almost purely fibrinous; the clot on -the right side was larger than on the left; a fibrinous clot extended -down the aorta.”[113] - -I do not know how the bibulous paper was arranged in the inhaler in this -instance, nor whether the inhaler was used with a view to regulating the -amount of vapour in the inspired air. The proportion of vapour must have -been small during the first ten minutes, as the patient became so slowly -insensible; and judging from the result, we must conclude that the -proportion was large just before the accident. The firm coagulation of -the blood and separation of the fibrin were probably owing to the -galvanism which was so promptly applied. I found the fibrin separated -from the colouring matter of the blood in the cavities of the heart of a -cat, in which shocks of electro-magnetism had been sent through the -chest just after it had been killed with chloroform. - - -_Case 42._ A man died whilst inhaling chloroform in University College -Hospital on October 11th, 1854. The patient was a shoemaker named George -Sands, aged 39, and of rather bloated aspect. He inhaled chloroform -whilst Mr. Erichsen was endeavouring to introduce a catheter, and had -the intention of puncturing the bladder if not successful. The patient -was made insensible, and the chloroform was left off, but was reapplied -on account of the patient making some expression of pain. “Probably -about two minutes of the second inhalation had elapsed, when the man -became profoundly insensible, and began to snore with a peculiar and -very profound stertor. His face at this time was suffused and flushed, -and the inspirations were drawn at rather prolonged intervals. Mr. -Erichsen’s attention was at once excited by these symptoms, and, -desisting from the use of the catheter, he immediately commenced dashing -the patient’s face and chest with water. The chloroform had, of course, -been removed. In the course of about a minute, the noise with the -breathing gradually lessened, and it became apparent that the -respiration was ceasing altogether. Mr. Erichsen now put his finger into -the patient’s pharynx, and dragged forwards the root of the tongue; at -the same time attempting artificial inflation of the lungs, by applying -his own mouth to that of the man. The latter plan did not appear to -succeed well, and was almost immediately substituted by the more usual -mode of artificial respiration, by compression of the chest, which was -kept up most vigorously. The man’s pulse had been felt by the -administrator [Mr. Carnell] to be still beating some little time after -the commencement of the alarming symptoms and the cessation of -respiration. Artificial respiration had been employed for about four -minutes, when the man, whose countenance had meanwhile retained its -colour and an expression of yet remaining life, began to breathe again. -A very short intermission of artificial assistance having been made, he -drew spontaneously three or four inspirations; but, as each successive -one was more feeble, the artificial aid was at once recommenced. About -five minutes from the commencement, the galvanic apparatus was got in -readiness and applied. It produced, however, no benefit; and from this -time the patient lost colour in the face, and was evidently dead.... The -form of inhaler which had been employed was the one in ordinary use at -this hospital, viz. a folded piece of lint. The administrator’s hands -and the patient’s face had been covered during the inhalation by a -towel.”[114] - -At the examination of the body seventy hours after death, extensive -fatty degeneration of the heart was met with. The cavities of the heart -were empty, owing, no doubt, to the artificial respiration.[115] - -The above case differs to a certain extent from those previously quoted, -inasmuch as the first symptoms of danger were those of profound coma, -and of threatened death by apnœa, as a consequence of the action of the -chloroform on the medulla oblongata and nerves of respiration. In -addition to this cause of danger, however, the chloroform present in the -lungs at the moment when the inhalation was discontinued must have acted -directly on the heart, or the prompt assistance of so able an authority -on asphyxia as Mr. Erichsen, the moment the breathing was suspended, -would surely have restored the patient. The mode of death, although not -exactly the same as that in Experiment 24 (page 110), differs from that -in the previous experiment, where the heart’s action was good and -distinct after the breathing ceased; it resembles the mode of dying in -many animals that I have killed with chloroform; being, in fact, a -combination of death by apnœa and cardiac syncope, which generally -occurs when the quantity of vapour in the respired air is intermediate -between that in Experiments 23 and 24, or somewhere between 5 and 10 per -cent. - -A great peculiarity in the way in which chloroform was administered in -the case we are considering was that the head and face of the patient -were covered by a towel, under which the lint wetted with chloroform was -held. The countenance and state of respiration could not be observed in -this mode of giving the chloroform; the person administering it had to -depend almost entirely on the pulse; and, except for this cause, there -is every reason to conclude that the chloroform would have been -withdrawn in this instance in time to save the patient. It was not -apparently till a peculiar and very loud stertor attracted the attention -of the operating surgeon himself, that the inhalation was discontinued, -and the face was already suffused. - -This plan of administering chloroform with the head and shoulders of the -patient covered with a towel, was introduced by Mr. Clover, who was for -several years a resident officer of the institution; and it is but right -to state that it led to no accident in his hands; in those of his -successors it was, however, less successful; three accidents having -occurred in a little more than a year and a half. I much regret to find -that Mr. Erichsen recommends this method of giving chloroform in the -edition of his work on surgery recently published. - - -_Case 43_ occurred in Guy’s Hospital, on December 5th, 1854. The patient -was a woman whose leg Mr. Birkett was about to amputate on account of -malignant ulceration. She gave her age as fifty-six, but appeared ten -years older. “In each eye was a fairly marked arcus senilis, but the -woman was not known to have suffered any symptoms referable to thoracic -disease.... The administration of the anæsthetic was conducted by Mr. -Bryant, the inhaler used consisting of a fold of lint, rather larger -than an out-spread hand, and protected on its back by a piece of oiled -silk to prevent wasteful evaporation.... In the first instance, about a -drachm of the fluid was poured upon the lint. The patient inhaled it -kindly; and, after about two minutes, another drachm was added. A stage -of excitement now followed, during which the limbs required to be held. -Insensibility was just fully established, and Mr. Birkett was on the -point of commencing the operation, when Mr. Callaway, who was -compressing the femoral artery, exclaimed that the pulse had suddenly -ceased entirely. The wrist was examined, and the same found to be the -case. Almost immediately afterwards, a long-drawn inspiration, attended -with a deep sighing noise, was observed. For two or three breaths the -cheeks puffed out during expiration; the respiration next fluttered, and -then ceased. Mr. Birkett at once put his finger into the patient’s -mouth, and drew forward the tongue, artificial respiration being -meanwhile commenced by assistants by means of compression of the chest. -A few slight inspirations were attempted by the patient subsequent to -the commencement of the artificial assistance; but they did not -continue, and no sign of vitality was ever afterwards shown.... It must -be noted, that the woman had been very pale both before and throughout -the exhibition, and that no change in her appearance was perceived when -the alarming symptoms occurred, excepting that the superficial veins of -the neck and temple became distended with blood. The cessation of the -pulse was most sudden. Mr. Callaway stated that it was not preceded by -the least premonitory fluttering, the stroke having been good one beat, -and entirely wanting the next. This order of symptoms was of course -suggestive of death beginning at the heart (cardiac syncope), the -cessation of the functions of the nervous system having been markedly -subsequent to that of the circulation.... - -“Autopsy, twenty-four hours after death (conducted by Dr. Wilks). The -corpse was much emaciated, and the rigor mortis imperfect. The lungs -were much congested with fluid blood, which ran out after incision of -their substance. The heart was of normal size, but soft and flabby; its -left side was nearly empty, the right being distended with fluid blood. -The left ventricle was of good thickness; its muscle of a deep colour, -not encroached on by fat, or in the least mottled, the only observable -departure from a healthy state being its flabbiness. The right -ventricular wall was very thin, the subserous fat having in some parts -almost taken the place of the muscular tissue. The layer of the latter, -however, although much thinned, had still a good colour, and did not -appear to the naked eye as degenerated, an observation which may apply -also to the carneæ columnæ. The liver was in an early stage of -cirrhosis, and the kidneys were both of them mottled, and contained -numerous small cysts in the external part. The brain was rather paler -than usual, its convolutions appeared shrunken and atrophied, and there -was a quantity of serous fluid in the arachnoid sac and in the -ventricles. There was general atheromatous disease of the arterial -system, both in the head and other parts of the body. The blood was -universally fluid, and of a dark colour.”[116] - -As far as could be estimated, the time occupied by inhalation was about -three minutes in this case. - - -_Case 44_ occurred at the Royal Ophthalmic Hospital, on April 10th, -1855, in a man on whom Mr. Bowman was about to perform excision of the -left eyeball. The patient, named John Cannon, was forty years old, and -was moderately stout, florid, and healthy-looking. He had generally led -a temperate life. The disorganisation of the eye was the result of -injury. - -“The inhaler used was the one devised and recommended by Dr. Snow.... -The administration was entrusted to Dr. Playne, of King’s College -Hospital. In the commencement of the inhalation, the valve of the -mouth-piece was so turned as to admit an abundant supply of air, a point -to which Mr. Bowman directed personal attention. During the first four -minutes (more or less) nothing unusual occurred. Dr. Playne, who had his -finger on the pulse, had noticed that it had rather increased in -fulness, and was of good volume. Rather suddenly, however, just as the -anæsthetic appeared to be producing its effect, symptoms of excitement -occurred. The eyes became fixed and staring, the arms outstretched and -rigid, and the face contorted. It was now impracticable to feel the -pulse, on account of the tossing about of the arms; but, as is usual in -such conditions, the respiration was noticed to be all but, if not -quite, suspended by the spasmodic fixture of the chest. The inhaler was -at once removed, and the face and chest of the patient dashed with cold -water. Almost immediately after, as the respirations had become -extremely feeble and sighing, Mr. Bowman commenced practising artificial -breathing, by the application of his own mouth to that of the patient. -By this means, the chest was made to fill very completely, and the -process was kept up almost without intermission for from five to eight -minutes. During the first three or four minutes after the alarm began, -the patient continued at times to make slight sighing efforts at -voluntary inspiration, and the case was not thought, by those looking -on, to be by any means hopeless. At length, however, these finally -ceased, and from that time it was apparent that the man was dead.... At -the first opportunity which occurred for examining it after the -spasmodic struggling had commenced, the pulse was found to be extinct, -and it remained so ever after, although there were, as stated, feeble -efforts at inspiration. The patient’s countenance changed somewhat -during the treatment, but was mostly suffused and congested.” - -At the examination of the body forty-eight hours after death, “the -sinuses, and the veins of the brain generally, were much congested, and -there was some œdema of the brain substance. The heart, excepting some -slight deposits on the curtains of the mitral valve, was healthy. Its -muscular substance was easily lacerable. The right ventricle contained a -considerable quantity of fluid blood, the left was nearly empty. There -were some pleuritic adhesions, and the lungs generally were congested, -being also in some parts full of air. The blood in every organ examined -was fluid, and without trace of coagulation.”[117] - -It does not seem that the inhaler used in this case was employed with -the object for which it was contrived—that of regulating the amount of -vapour in the inspired air; and I do not know whether the bibulous paper -was arranged properly in the interior. - - -_Case 45._ On September 8th, 1855, a lady, aged twenty-nine, the wife of -a physician, died suddenly whilst inhaling chloroform for the relief of -facial neuralgia. I was sent for when the accident happened, and arrived -twenty minutes afterwards. I found the deceased lady without any sign of -life. The face and lips were very pallid. The husband was performing -artificial respiration by mouth to mouth inflation of the lungs, and -alternate pressure on the chest, and I assisted him in this for a long -time, though with no hope that any thing could be of service. Dr. -Barker, of Grosvenor Street, arrived soon after me, and assisted in the -same measures. An inhaler was employed in this case consisting of a -face-piece, like the one above delineated in this work, and a bent metal -tube lined with bibulous paper. Two quantities of ten minims each had -been inhaled, with some relief to the pain, and without causing -unconsciousness when the inhaler and the chloroform were put away in a -closet; but the patient begged to have more chloroform, in order to be -completely relieved of the pain, as she had been on a previous day. Ten -minims more chloroform, as I was informed, were put into the inhaler, -and the patient, being seated on a sofa, began to inhale very eagerly, -but had no sooner commenced than she gave a sudden start, as if taken in -some kind of fit. Her husband laid her on the floor, but she evinced no -further signs of life. - -There was no inspection of the body. - -The only explanation which the case admits of is that, in her eagerness -to get relief, the patient took one or more inspirations of air very -highly charged with vapour. The symptoms were those of death by cardiac -syncope. - - -_Case 46_ occurred in the practice of Dr. Roberts, a surgeon dentist of -Edinburgh. The patient was a lady, thirty-six years of age, to whom Dr. -Roberts had administered chloroform on four previous occasions within a -twelve-month. Dr. Roberts says the chloroform was administered in the -usual way, by which he means on a handkerchief. He says: “Mrs. H. had -only taken about nine or ten inspirations, obtaining but a partial -influence of a quantity short of ʒiss poured out from the bottle, and -inhaling it for a space of time certainly less than a minute, when she -said, ‘You must not operate until I am quite insensible;’ and again, ‘I -am not over yet;’ and immediately, even while speaking, she gave a -convulsive start, and with a stertorous inspiration, and with the eyes -and mouth open, sunk to the floor.” Dr. Simpson was sent for, and -arrived within five minutes. Artificial respiration was resorted to, and -after it had been applied for a time, there were a few spontaneous -inspirations, and the pulse, it is said, could be perceived at the -wrist; but these symptoms of reviving animation disappeared. - -At the examination of the body, the right cavities of the heart were -found gorged with blood. The walls of the right ventricle were thinner -than natural, and affected to a certain extent with fatty -degeneration.[118] - -A paragraph was inserted in some of the Edinburgh newspapers, and -forwarded by Dr. Roberts to the _Lancet_,[119] in which it was implied -that death in this case was not caused by the chloroform. It is, -however, like the preceding case, a well marked instance of the sudden -and fatal action of this agent. - - -_Case 47._ A sailor, aged thirty, died whilst inhaling chloroform in St. -Thomas’ Hospital, in October 1856, preparatory to having some necrosed -bone removed from one of his fingers. “He did not appear to be in robust -health; still there was no obvious reason against his having the -chloroform, which was accordingly administered as follows. One drachm -was poured on a sponge folded between two thicknesses of lint, and this -held at a little distance from his mouth, while he was sitting in a -chair. He appeared to be going off very comfortably, when the chloroform -was left off for from half a minute to a minute, and then resumed. He -now began to raise his hands and tremble, and kept spitting in the lint, -and appeared as if about to vomit. Suddenly he was violently convulsed -through his whole frame, as if in an epileptic fit. The chloroform was -at once discontinued, and he was laid in a semi-horizontal posture. The -convulsion only lasted for a few seconds, and when it had ceased he -began to breathe with effort and puffing of the lips, and almost -immediately to gasp irregularly. His pulse was almost imperceptible and -intermittent. Artificial respiration was at once performed by alternate -compression and relaxation of the walls of the chest, the tongue being -held out of the mouth by the forceps. Ammonia was applied to the -nostrils, and cold water dashed in the face, and in about a minute he -rallied so as to breathe without assistance, but in a few seconds he -relapsed, and could not be recovered. - -“At the post-mortem examination there was found to be fatty degeneration -of the heart, liver, and spleen, and the membranes of the brain were -thickened. The lining of the ventricles presented a peculiar pitted -appearance, apparently from inflammatory deposit. The brain itself was -pale.”[120] - -“It was ascertained after the man’s death that he had been of -intemperate habits, and had had an attack of delirium tremens three -weeks previously. In the report of this case in the _Association Medical -Journal_, the following is the account of the appearances met with after -death. In the autopsy in the present case, which we observed with -particular care, the brain was in a state of œdema and bloodlessness, -very like the brain in a patient who died from chloroform in the -Ophthalmic Hospital. The liver was fatty; but the heart seemed the very -model or type of the healthiest kind of heart. All the other organs were -also healthy.”[121] - - -_Case 48_ is related by Mr. Paget as follows. “I am anxious to place -before the profession, at the earliest opportunity, a narrative of a -case in which chloroform proved fatal in my private practice. - -“The patient was a boy, nine years old, of delicate constitution, and of -nervous, timid disposition; but with no indication of any organic -disease, except that for which the operation was to be performed: -namely, a tumour of the scapula; for which it was proposed to remove the -greater part of that bone. - -“At half-past eight A.M., on February 28th, after the patient had passed -a night of sound sleep, the chloroform was first administered in a room -adjoining that in which the operation was to be performed. He was -alarmed at the thought of being put to sleep, and of what would then be -done, and was very averse from taking chloroform, but he was persuaded -to inhale it; and, though not without resistance, yet with less than is -commonly made by patients of the same age, he was brought under its full -influence in about three minutes. He sat in bed during the first few -inspirations, and after these, was recumbent. It was observed that two -or three deep inhalations were quickly followed by complete -insensibility; and the next few inspirations were stertorous. He was at -once carried, in the horizontal posture, into the room, and laid on the -table, arranged for the operation. - -“Three or four minutes passed while we were arranging his position and -his dress, and while I was pointing out to those who were to assist me -the proposed plan of operation. During this time the influence of the -chloroform so far passed off, that he became sensible, displaced his -coverings and pillows, said something expressive of discomfort, and -vomited a small quantity of frothy fluid. (He had taken no food since -the previous night, when he had had a good supper.) A very small -quantity more of chloroform was slowly inhaled, and he became again -nearly quiet, and was again placed on his side. I was on the point of -commencing the operation, but as he again, by movements, indicated some -degree of sensibility, and changed his posture, about forty drops more -of chloroform were poured on cotton wool, inclosed in a fold of lint,—an -inhaler, with the chloroform on sponge, having been previously used. The -lint was held, about half an inch from the face, by Mr. Thomas Smith, my -usual assistant in operations. The patient inhaled lightly for a few -times, then made one long inspiration, and appeared to pass at once into -deep sleep. Except that he thus appeared to come suddenly under the full -influence of chloroform, no external change was visible; but, a few -seconds later, his pulse, which had been carefully watched, and had been -to this time normal, suddenly began to beat very quickly; then it ceased -for two or three seconds; then beat rapidly several times, with a kind -of flickering movement; and then ceased to be perceptible. - -“Just before this change of the pulse was observed, the chloroform had -been withdrawn. The one deep inspiration was followed by a few -stertorous breathings, but after these he breathed naturally, his -complexion and features showed no change, he seemed only calmly asleep, -and in this state he continued breathing naturally, and with no change -in his appearance, but pulseless, for at least a minute. Then his -breathing became less frequent, and seemed as if it might soon cease; -his face grew pale, and his lips very slightly livid. - -“With the help of cold water sprinkled on his chest and face, and cold -air blown on his face and throat, he was raised from this state of -defective breathing in about two minutes, and again breathed deeply and -freely, though slowly, (probably about twelve times in the minute.) He -thus breathed for two or three minutes, and during this time the lips, -and the pale or slightly livid parts of the face, became pink again, and -though no pulse could be felt at the wrists, the heart was heard acting. -During this time, also, some wine and brandy were poured into the mouth, -and passed down the œsophagus, but without any evident movements of -swallowing. His breathing again became gradually infrequent and feeble. -Cold air and sprinkling with water, frictions and percussions of the -chest, scarcely increased the breathing, and in less than two minutes it -ceased. Artificial respiration, by the method of Dr. Marshall Hall, was -immediately employed, and many times during the first five minutes of -its employment the artificial inspiration obtained, when turning the -body over to its side, was followed by a distinct, and sometimes even a -full muscular inspiration. But at the end of about five minutes, these -signs of life ceased, fæces escaped, and no more indications of life -appeared, though the artificial breathing, the friction of the limbs, -and other means for resuscitation, were continued for twenty or more -minutes. - -“I refrain, at present, from all comments on this case. Only, I wish to -call particular attention to the fact that good breathing was -maintained, and, after a suspension, was renewed, long after the heart -had ceased to act with sufficient force to produce a pulse at the wrist. -And I would add, that this narration is sanctioned and considered to be -exact, by the four gentlemen who were to have assisted in the operation, -and to whom I am greatly indebted for their counsel and assistance in -the greater difficulty that we had to cope with.”[122] - - -_Case 49._ This case occurred in the Liverpool Infirmary on April 5, -1857, and is related by Mr. Allan, the resident officer who administered -the chloroform. The subject of the case was a labourer, aged 35, on whom -Mr. Bickersteth was about to perform amputation of the thigh on account -of gangrene following the ligature of the femoral artery. He had inhaled -the chloroform six days previously without ill effects, when the femoral -artery was tied for popliteal aneurism. On the day of the accident, he -was first rendered insensible in the ward by chloroform poured on a -piece of lint which was held a short distance from the nose and mouth. -Having partially recovered during his removal into the operating -theatre, the chloroform was reapplied, and Mr. Allan relates what -occurred as follows: “About half a drachm of chloroform was now poured -on some lint, which was held to the nostrils, and he then became _fully_ -under the influence; respirations _good_; pulse frequent, feeble. The -operation was about to be commenced, and I was pouring about twenty -minims more chloroform on the lint, (having pronounced the patient to be -in a fit state,) so as to be ready to give him some more as occasion -required, but had not applied it, when, turning round, I noticed -something peculiar in his general appearance, and, on lifting up the -eyelid, found the pupil dilated, and the lid did not close over on the -removal of the finger; the eyes were slightly turned up. I at once felt -for the temporal artery, but there was no pulsation, and none detected -at the left wrist; the respirations had almost ceased. The head was -lowered, cold water was dashed on the face, and the abdomen struck with -the palm of the hand; the finger thrust into the mouth (there was no -action of the heart felt); the legs were elevated, and a wet towel was -dabbed over the epigastrium. After one or two blows, the respirations -became better, and seemed good, and in about two minutes a pulse was -felt at the wrist. This continued between two and three minutes, the -respiration being good. His pulse then began to fail, and in about a -minute more the respirations were less. The tongue was seized with a -pair of forceps, and drawn forwards, and artificial respiration tried, -and ammonia held to the nostrils; but he was becoming livid in the face, -so the Ready Method was at once adopted, and this produced apparently a -few _natural_ respirations. But the pulse had gone, and in about two -minutes more there was no breathing save artificial. About the time that -the pulse stopped, there was a convulsive movement of the muscles of the -leg, and a slight clamminess of the skin succeeded. The Ready Method was -continued for half an hour, and galvanism tried, but without avail. From -the time he was placed on the table to his death, or the cessation of -natural respiration, about ten minutes elapsed.” - -The writer adds: “He apparently sank from syncope, or cessation of the -heart’s action, for his respiration had been good just before he -changed, and it continued for a second or two, though faint, when the -pulse had stopped; and after the respiration had been restored, and was -very good, the pulse was very feeble, and ceased two minutes before the -respiration.” - -At the autopsy on the following day, the brain was found to be healthy, -tolerably firm, and pale; the lungs were healthy; the right cavities of -the heart contained some fluid blood, which afterwards coagulated on -exposure, and a small clot. The left cavities also contained some blood. -The muscular tissue of the heart had an unhealthy look, and very readily -tore, but no oil globules were discovered with the aid of the -microscope.[123] - - -_Case 50_ occurred in King’s College Hospital, August 7th, 1857. The -following is the account of the case furnished by Mr. C. Heath, the -House-surgeon:— - -“The patient [Ann Stoner] was a female, aged seventeen, under Mr. -Partridge’s care, with syphilitic warts and mucous tubercles. She was -admitted July 8th, and had had chloroform administered twice, in order -that the sores might be touched with nitric acid, and, on both -occasions, not the slightest ill effect was produced. On Friday evening -last, chloroform was again administered for the same purpose; only a -drachm was put into the inhaler (Snow’s), and as soon as she became -unconscious the inhaler was removed, and the acid applied. I and my -assistant (who administered the chloroform), then went to see another -patient in the same ward, and then washed our hands, during which time -the patient was moving her legs about much as they do when recovering, -and in addition she made water over the bed. I gave directions to the -nurse to apply a poultice as usual, and left the ward, having been up to -the bed first without noticing anything unusual about the patient. In a -few minutes the nurse came down for some medicine for another patient, -and mentioned that this one was looking very pale: I sent up Mr. Liddon -to see her at once; he found her pale and senseless, dashed some water -over her, and called me, and I went up immediately. I found her -pulseless and cold, and immediately commenced artificial respiration -(Marshall Hall), and sent for the galvanic battery; this was brought and -applied without effect, and the artificial respiration was continued for -twenty-five minutes without the slightest effect being produced.”[124] - -I was present at the examination of the body on the following day. The -mouth was sore and swollen from the effects of the inunction of mercury. -There were a few drachms of clear serum in the pericardium. The heart -was large for the size of the patient. There was a patch of organised -lymph on the pericardium, covering the left ventricle. The right -cavities of the heart were full of dark fluid blood, and the left -cavities contained a little. The mitral valve was much thickened, but -the other valves were healthy. The lungs were healthy, and not much -congested. The brain was healthy. The patient had suffered from acute -rheumatism before entering the hospital. - -It will be observed that the pulse is not mentioned in the above case, -until its absence is alluded to, when the patient was already cold, and -the breathing is not alluded to throughout the account; indeed, it is -not known when the patient died. She was alive after the application of -the nitric acid, as she was observed to move her legs, but further than -this there is no clear evidence. - -It is perhaps an open question whether this patient died at once from -the direct effects of the chloroform, or whether she died after -partially recovering and going on favourably for a time. The account -would, at first view, seem to favour the latter opinion, but it is not -corroborated by any other case. Patients have been partially recovered -from the effects of an overdose, without being entirely restored, and -others have sunk after great operations, attended with hæmorrhage, when -the effects of the chloroform had more or less subsided, but there is no -instance of a patient going on favourably, and partially recovering from -the influence of the vapour, and then dying suddenly without any other -known cause. Patients have occasionally become faint whilst recovering -from chloroform, more especially if they remain in the sitting posture, -but in those cases the right side of the heart is probably -insufficiently supplied with blood; whilst, in the case under -consideration, the patient was lying, and the right cavities of the -heart were found full after death, the serum in the pericardium showing -that they had probably been distended when death took place. If Mr. -Heath had made any observation which enabled him to say that the patient -was really alive, when he went up to the foot of the bed, before leaving -the ward, it would decide the question, and show that death did not take -place at once from the direct effects of the chloroform, but he only -makes the negative remark that he did not notice anything unusual about -the patient. - -I had an opportunity of examining the particular inhaler employed, and -found that it was so arranged that the vapour might be breathed from it -in much greater proportion than would be safe, if precautions were not -taken to leave the expiratory valve a considerable way open, especially -when the high temperature of the weather at the time is taken into -account. - - -The foregoing cases comprise all the instances I have seen recorded in -which death appears to have been occasioned by the administration of -chloroform, and not by other causes in operation about the same time. A -few additional cases have indeed been referred to by different authors -where death was probably caused by chloroform, but as I do not find that -the details have been published, I cannot make them available in an -inquiry respecting the cause and prevention of these accidents. - -In June 1852, Dr. Simpson alluded in the following terms to an accident -from chloroform which had occurred near Glasgow:—“In this instance, -chloroform was given by the practitioner for tooth extraction; but, I am -sorry to add, none of the parties present were at the time in a -condition to give any satisfactory evidence.”[125] - -A person, named Breton, a dealer in porcelain, died in Paris, in the -early part of 1853, immediately after a few inspirations of chloroform, -which was administered with the intention of removing a tumour of the -cheek. An action was brought against Dr. Triquet and M. Masson for -causing death by imprudence in this case; and at the trial which ensued, -various interesting opinions were given, and the accused practitioners -were ultimately exonerated.[126] I have not, however, met with any -record of the symptoms which occurred in the case. - -In relating the case of death from chloroform, which occurred in his -practice, to the Medical and Chirurgical Society of Edinburgh, Dr. -Roberts referred to another death from chloroform in tooth-drawing which -took place in the neighbourhood from which his own patient came, just -previously to October 1855; but I have not met with any account of the -case so alluded to. Dr. Mackenzie of Kelso also alluded in the same -Society, in the following year, to a death from chloroform which had -occurred at Coldstream, and I do not know whether this was the case to -which Dr. Roberts had alluded, or a fresh one. - -One of the surgeons to the hospital at St. Louis, who was lately -visiting the medical institutions of London, informed me that there had -been three deaths from chloroform at his hospital out of between six and -seven hundred operations in which it had been administered. I did not -learn the particulars of those fatal cases. - -There have been several cases in which persons have been found dead -after inhaling chloroform when no one else was present, either for -toothache or some other affection, but I have not included such cases in -the above list, as they throw no light on the way in which death is -occasioned. The simple way to avoid such accidents as those just alluded -to, is for persons to abstain from inhaling chloroform, when no one is -by to watch its effects. - - - ALLEGED FATAL CASES OF INHALATION OF CHLOROFORM. - -Several deaths have been attributed to chloroform which were due to -other causes, or where the cause of death is a subject of great doubt. A -gentleman, named Walter Badger, twenty-two years of age, the son of one -of the coroners for the county of York, died instantly at Mr. -Robinson’s, the dentist’s, in Gower Street, on June 30th, 1848, whilst -commencing to inhale chloroform with the intention of having some teeth -extracted. The inhaler employed consisted of a face-piece to enclose the -mouth and nostrils, and containing a sponge on which the chloroform -(ʒiss) was placed. This, according to the evidence of Mr. Robinson and -his female servant, who was present in the room, was held not nearer -than an inch and a half from the face for less than a minute, and the -patient made the remark that the chloroform was not strong enough; Mr. -Robinson requested him, as he had done before, to have the operation -performed without chloroform, but he again declined; and Mr. Robinson -then took away the face-piece and asked his servant to reach the bottle, -intending to put more chloroform on the sponge, to replace that which he -believed had been lost by evaporation. Just after removing the -face-piece, and before any fresh chloroform was poured out, the head and -hand of the patient dropped, and he did not show any further sign of -life. - -I found, on making trial of the kind of inhaler which Mr. Robinson -employed, that it is impossible to inhale enough of the vapour to -produce any appreciable effect, unless it is applied so as to touch the -face. At the distance of an inch no effect is produced, even in five or -ten minutes; and therefore I expressed my opinion, soon after this -accident, that it was not caused by the chloroform, which properly -speaking the patient did not inhale. - -A consideration of the symptoms in this case confirms the view that the -death was not caused by chloroform. In six of the fatal cases related -above, death took place instantaneously, without insensibility or any of -the usual effects of chloroform having been produced; but the mode of -dying was not the same as in Mr. Robinson’s patient. In Case 4, that of -Madlle. Stock, the patient said “I choke”, and tried to push away the -handkerchief; then there was embarrassed breathing and foaming at the -mouth. In Case 11, that of Madame Labrune, the fatal attack followed -immediately on a full inspiration of chloroform, and there was an -immediate alteration of the features, and a convulsive rolling of the -eyes, amongst other symptoms. In Case 14, the young lady stretched -herself out, and frothed at the mouth, at the moment of the fatal -attack, and the face became livid. In Case 26, that of Madame W., who -died at Ulm, the voice, when answering the question about singing in her -ears, was trembling and thick; she stretched out her limbs, and the face -became bluish. In Case 45, that of the wife of a medical man, and in 46, -that of Dr. Roberts’s patient in Edinburgh, there was a convulsive start -at the moment of the sudden death. It thus appears that when the heart -is suddenly paralysed by an overdose of chloroform, before the patient -is rendered insensible, there are usually some symptoms as if of a -violent shock or injury. After complete insensibility is induced, the -heart may be suddenly paralysed by chloroform, as is shown by numerous -cases, without this spasmodic action; and it would perhaps be premature -to deny that a patient might die thus quietly without being first made -insensible; and the nature of the death in this particular case must be -chiefly decided by the physical fact that the patient could not have -inhaled enough chloroform to produce an appreciable effect of any kind, -much less to cause sudden death. - -At the inspection of the body, the liver was found so much enlarged that -it weighed eight pounds, and it encroached very much on the chest. The -walls of the left ventricle of the heart were found thinner than -natural, and the muscular tissue was interspersed with fatty -degeneration. There was blood in the right auricle and in both -ventricles. In the ventricles it was partly coagulated. The brain -presented nothing abnormal.[127] - -It is probable that the immediate cause of death in this instance was -fear. The patient had been told in the country that it would be unsafe -for him to take chloroform, and yet he could not summon resolution to -undergo the operation without it. Mr. Robinson unfortunately allowed his -patient to remain seated in the operating chair; and it was only when -Dr. Waters had been sent for and arrived from a neighbouring street that -he was laid on the floor. - -I was present on one occasion with Mr. Peter Marshall at the examination -of the body of a woman who died suddenly of fright in consequence of a -fire in the next house to that in which she lived, and it is worthy of -remark that we found exactly the same diseased conditions as those which -were found in Mr. Robinson’s patient; viz., great enlargement of the -liver, displacing the viscera of the chest, and fatty degeneration of -the heart. - -A young man, aged twenty-four, died suddenly of syncope, on June 25th, -1848, at the Hospital Beaujon, at Paris, whilst M. Robert was performing -amputation at the hip joint, the thigh bone having been broken into -splinters by a bullet during the conflict in the streets of Paris. The -patient was in a state of great depression, both physical and moral, -before the operation; and it is most likely that he sank under the -combined effects of the injury and the operation. - -Another patient had the neck of the humerus broken by a ball in the same -conflict; he was much reduced by hæmorrhage and gangrene of the wound; -M. Malgaigne performed disarticulation at the shoulder joint; a fresh -inhalation took place to enable him to search for the ball, and the -patient sank and died during the last incisions. This patient also most -probably died from the effects of the operation added to those of the -previous injury and loss of blood. - -A woman died in Paris, 1848, after removal of the breast. The operation -was finished, and the chloroform had been left off some time, and the -patient had become conscious, when on raising her into a sitting -posture, in order to apply a bandage, she suddenly expired. Although the -chloroform was blamed in this instance, death evidently took place by -the ordinary kind of syncope, which arises from the heart not being -supplied with blood, and which may be called anæmic syncope, in -contradistinction to cardiac syncope, which begins at the heart itself, -when properly supplied, or even when distended with blood. - -A child, aged twelve years, died in the hospital at Madrid in 1849, -during amputation of the leg after violent tetanic rigidity.[128] Death -was attributed to the chloroform which had been inhaled, but no further -particulars are given, and it is not stated whether or not there was any -unusual hæmorrhage, or other cause, which would explain the fatal event. - -Dr. Aschendorf has attributed the death of a child a year old to -chloroform.[129] The child had a nævus on the face and neck, which -extended from the zygoma to the os hyoides, and from the external -auditory meatus to the maxillary fossa. No one had been willing to -undertake its removal. Dr. Aschendorf operated on the nævus at three -different times, by means of seton threads. These operations were -performed under the influence of chloroform. The tumour was reduced -one-third part in size by these means, and eleven weeks afterwards Dr. -Aschendorf determined to extirpate it. The chloroform was administered -as on the former occasions, by placing six drops on some tow in a cup. -In about ten minutes, as the child cried a little, three drops more of -chloroform were used for inhalation, and in about eight minutes more the -operation was concluded. “On raising the child it laid its head on one -side, convulsive twitches of the face were observed, with distortion of -the eyeballs and dilatation of the pupils. For one moment the arms were -stretched out stiff, then again they were relaxed, and fell as supple as -the rest of the body. Death quickly followed—only one pulsation of the -heart and a single râle with the expiration being perceived.” - -There can be no doubt of this being a case of death from hæmorrhage, -after the direct effects of the chloroform had subsided. Dr. Aschendorf -says the quantity of blood lost was about two tablespoonfuls; but it -would be necessarily removed by sponges during the operation, and there -would be no means of estimating the quantity. The child was probably in -a state of syncope during the latter part of the operation, as it would -not remain insensible to the knife for eight minutes from a single -application of chloroform. - -On September 15th, 1852, a patient died to whom I was administering -chloroform whilst Mr. Cæsar Hawkins was performing lithotrity. He was a -gentleman from the country, aged seventy-three; he was tall and stout, -he had a weak intermitting pulse, and a well marked arcus senilis in -each cornea. He had inhaled chloroform five or six times, between May -1850 and May 1851, for the same operation, when under the treatment of -another surgeon, and it always acted favourably. In the first week of -December 1851, Mr. Hawkins performed the operation of lithotrity twice, -when the chloroform was administered by Mr. Geo. D. Pollock. On the -second of these occasions he became faint during the operation whilst -under the influence of the chloroform, but recovered from the faintness -before its conclusion. He again fell into a very alarming state of -syncope a few minutes after the conclusion of the operation, but -rallied, and vomited the breakfast which he had taken a little time -before. I first administered the chloroform to this patient on December -15th, 1851, eleven days after the above occurrence. Mr. Hawkins and I -were inclined to think that the alarming syncope on the previous -occasion might have been connected with the sickness which occurred. It -was my firm belief that the patient had fatty disease of the heart; but -I did not see any great objection to the chloroform on that account, as -I had frequently given it in similar cases, and always with a favourable -result. On this occasion (December 15th) he inhaled the chloroform -before breakfast. Its effects were quite satisfactory, and it was not -accompanied or followed by any unpleasant symptoms whatever. The -operation was repeated four days afterwards, when I again exhibited the -chloroform with like favourable results. After this the patient went -back to the country relieved from his stone. He came back, however, in -the autumn of 1852, with a return of his complaint, and I was again -requested by Mr. Hawkins to assist him by giving the chloroform on -September 15th. - -The patient became insensible, without any excitement or struggling, in -the course of three or four minutes, and the operation was commenced. A -little more chloroform was administered two or three times during the -operation, in order to keep up the insensibility. After a few minutes -had elapsed, I observed that the face and lips of the patient became -pale. At this time he had not inhaled any chloroform for about two -minutes. Immediately afterwards, however, his face became red, and he -made straining efforts with the muscles of respiration, as if he were -beginning to feel the operation. To prevent his becoming altogether -sensible, therefore, I commenced to give him a little more chloroform, -with the valve of the inhaler about one-third open, as on the former -occasions. He had only taken two or three inspirations, however, when -the breathing ceased. He appeared to be merely holding his breath, as -sometimes happens during the exhibition of chloroform, and I expected -that he would begin to breathe again in about a quarter of a minute. In -the meantime, I endeavoured to feel the pulse in the temporal artery, -but did not perceive any. Instead of the breathing recommencing at the -time I expected, the countenance became suddenly pale, and a little -afterwards rather livid. I applied my ear over the region of the heart, -but could not hear any sound. After a few seconds, however, the patient -took a rather deep inspiration, and immediately after this I was pretty -sure that I heard the heart beating very feebly and rather frequently, -but only for a few seconds, after which no sound could be heard. There -were one or two more very feeble inspirations at intervals of about a -quarter of a minute, after which there were no further signs of life. As -soon as the patient had entirely ceased to breathe, artificial -respiration was performed, but no sign of returning animation appeared. - -At the examination of the body fifty-two hours after death, the heart -was found to be larger than natural, and there was a good deal of fat on -its surface. Its right cavities contained air or gas, probably resulting -from the partial decomposition of the blood. The right ventricle was -dilated, and its walls were very thin. At one place, near the apex, they -were extremely thin. The left ventricle was also dilated, but its walls -were of the proper thickness. They were, however, like those of the -other ventricle, very soft and friable. There was a calcareous -incrustation on one of the aortic valves. There was scarcely any blood -in the heart, but its lining membrane was stained in places, showing -that blood had been present after death. - -Mr. Pollock and the late Mr. W. F. Barlow examined the structure of the -heart under the microscope, and the latter gentleman furnished me with -the following account of the examination:— - -“Many of the fibres have been converted into fat completely; in others, -fatty degeneration was beginning. The degeneration, which was in various -stages, appeared very general. The fasciculi were broken up, here and -there, into masses of small irregular fragments, as they may be found -frequently in hearts of this kind. Some large fat globules lay between -and upon the fibres. A few fibres showed their transverse striæ plainly, -and made the changes in the others look the clearer. On the whole, it -may be said that the structure of the organ was greatly damaged, and -that its action, consequently, was liable to cease suddenly from slight -causes.” - -I am of opinion that this patient did not die from the direct effects of -the chloroform. The air he was breathing just before he died did not -contain more than three or four per cent. of vapour of chloroform at the -utmost, and he had previously breathed quite as much, both during the -same operation and on previous occasions. The patient seemed to be -holding his breath at the moment when his heart ceased to beat; and it -is whilst holding the breath, and making a straining effort, that -patients labouring under disease of the heart not unfrequently expire. -Mr. Pollock, who was present when the patient died, expressed to me his -belief that he died of his heart disease, and not of the chloroform. - -After reflecting on this case, I see no reason to regret the course -which was pursued. It was the opinion of Mr. Hawkins that the patient -could not have borne the operations without the chloroform; -consequently, if we had decided not to permit its use any more, in -consequence of the alarming syncope which occurred after the operation -under its influence on December 4th, 1851, he would probably have died -in great suffering from the calculus, instead of having seven or eight -months freedom from the complaint. And, on the other hand, if it had -been decided to operate without chloroform, it by no means follows that -the patient would have been in less danger, judging from what I have -observed of the effect of pain on the circulation, as compared with the -effect of the chloroform carefully administered, in numerous other cases -of disease of the heart. - -On May 11th, 1854, a patient died suddenly in St. George’s Hospital as -she was beginning to inhale chloroform. She was a pale and delicate -looking woman, aged thirty-seven, from whose left breast Mr. Cæsar -Hawkins was about to remove a mammary glandular tumour. “On entering the -operating theatre she appeared nervous. Having been placed on the table -on her back, in a half reclining position, the administration of -chloroform was commenced. Dr. Snow’s inhaler was used. The quantity of -chloroform placed in the receiver was a little more than a drachm; and -the valve for the admission of air was left wide open. Apparently, from -excitement, she did not inhale well, but drew her breath by deep -catches, and irregularly. Mr. Potter, noticing this, spoke to her, -begging her to compose herself, and try to breathe more quietly. The -valve was then slightly turned on, in order that she might inhale but a -very small quantity of chloroform. The same spasmodic efforts at -inspiration still continued; very shortly afterwards, at most not more -than a minute and a half from the commencement of the inhalation, Mr. -Potter noticed her breathing to suddenly cease, and that she had become -deathly pale. The inhaler was at once removed. On placing the finger on -the wrist, no pulse could be found. Endeavours to arouse her by dashing -the face and chest with water were immediately adopted; but, proving -ineffectual, artificial respiration was commenced within a minute of the -first symptoms. During the interval, two sighing attempts at inspiration -had been observed; but there had been no pulse whatever; the mouth lay a -little open, and the countenance was still extremely pale.”[130] Other -attempts at resuscitation were made without effect. - -“At the post-mortem examination, on the following day, no very -noticeable lesions of the viscera were discovered. There was congestion -of the whole venous system, and the blood, in every organ, was of a deep -purple colour, and quite fluid. The brain substance itself was perhaps a -little more vascular than usual, and the veins of its meninges were -loaded with blood. The heart was small and fat, the right ventricle -being especially loaded with adipose material, and its muscular layer -much thinned. Under the microscope there was found to be slight, yet -decided, fatty degeneration of the muscular structure. Both chambers, -but more particularly the right, were distended with blood in which no -coagula could be found. The posterior lobes of the lungs were somewhat -congested, but not more than the position in which the corpse had lain -might account for. There was no disease of the abdominal viscera.”[131] - -I made a chemical examination of some blood obtained from the heart and -large vessels, and also of portions of the lungs and liver, but I failed -to detect any trace of chloroform, although the process I employed is -one by which I have very easily detected it in the bodies of small -animals killed by it, and also in portions of limbs and tumours removed -whilst the patients were under its influence to the usual extent. - -It was impossible that this patient could have breathed air strongly -charged with vapour. Every one in the operating theatre was a witness -that the expiratory valve of the face-piece was not, at any time, more -than one-third closed, being two-thirds open. In this way no great -effect of any kind can be produced, as very little of the air which the -patient breathes passes through the inhaler. Mr. Potter informed me, -moreover, that the patient breathed very little even of air, her -breathing was so much embarrassed by her frightened condition. He was -trying to calm her apprehensions at the moment when she died. - -The mental emotion under which the patient was labouring was, no doubt, -the cause of the sudden death in this instance, as in that above -referred to, which occurred at Mr. Robinson’s. The mode of dying, in the -present instance, was evidently by cardiac syncope; the same mode of -death, in fact, as that which is occasioned by vapour of chloroform, -when not sufficiently diluted; and it is only the absolute knowledge, -that any small quantity of vapour which this patient inhaled was very -largely diluted with air, that enables one to decide, with confidence, -that the chloroform was not the cause of death. It may be observed, -however, that there was an absence of the convulsive start or spasm -which occurred in all those deaths from chloroform, which took place at -the beginning of the inhalation, without loss of consciousness having -been first induced. - -The right cavities of the heart were found full of blood in this case, -and it is probable that they became so much distended, as the patient -was in a state of alarm, and scarcely breathing, that, in the thin and -diseased state of the walls of the right ventricle, the action of the -heart was arrested. Sudden death not unfrequently takes place during -mental emotion, and, in many of the cases, the mode of dying is probably -that just mentioned. - - - SYMPTOMS IN THE FATAL CASES OF INHALATION OF CHLOROFORM. - -Out of the fifty cases of death from chloroform, related above, there -are five in which the symptoms at the time of death are not detailed, -viz., Cases 6, 7, 21, 24, and 50; in the two first cases it is merely -related that the patient suddenly expired, and, in the two last cases, -no one was watching the patient at the time when death took place. In -considering the remaining cases they may be conveniently divided into -groups, according to the period of the inhalation at which the accident -occurred. In six of the cases the fatal symptoms came on suddenly, at -the beginning of the inhalation, before the patient had been rendered -unconscious; in each of these cases there was the most unequivocal -evidence of the sudden arrest of the action of the heart. In cases No. 4 -and No. 11 there was sudden pallor of the face at the moment when the -circulation ceased. In Nos. 14 and 26 the face became livid at the time -of the fatal attack, and, in Nos. 45 and 46, the colour of the face is -not mentioned. In all these cases there were also symptoms as if of a -sudden shock to the system, such as stretching out of the limbs, foaming -at the mouth, rolling of the eyes, or a sudden convulsive start. In Case -4, the patient at Boulogne had just complained of a choking feeling, one -sign that the vapour she was breathing was not well diluted. In Case 11 -the fatal symptoms occurred immediately on a full inspiration; and in -the other cases also the strength of the vapour was left to accident, -and the result leads to the conclusion that it was very great at the -moment before the fatal symptoms occurred. - -In thirteen cases the inhalation was discontinued on account of the -sudden appearance of dangerous symptoms, after consciousness had been -apparently suspended. These cases are numbered 9, 15, 17, 20, 27, 30, -33, 35, 37, 40, 41, 44, and 47. In the greater number of these cases the -over-action of the chloroform appeared to be exerted simply on the -heart, the only dangerous symptoms being referrible to the paralysis of -that organ; whilst in some of these cases symptoms of over-narcotism of -the brain were conjoined with those connected with the heart. In the -case of J. Verrier, No. 9, and in the case at Stockholm, No. 15, the -sudden and entire cessation of the pulse was the symptom which first -called attention to the danger of the patients, whilst the breathing was -still going on. In Case 30 the woman became suddenly insensible and -pulseless, after a short period of excitement. In Cases 35 and 40, -although the pulse did not absolutely and entirely cease at once, its -sudden failure was the first alarming symptom. In Case 20, at the Cavan -Infirmary, the breathing and action of the heart ceased at the same -moment. In Case 41, at the Middlesex Hospital, at a time when the pulse -was full and steady, seventy in the minute, it gave a few rapid and -irregular beats, and then ceased, and the breathing, which was free and -deep, but not stertorous, ceased at the same time. In Case 15, which -occurred at Jamaica, the patient, after a period of excitement, made one -stertorous inspiration, when the breathing ceased. There were afterwards -a few distant inspirations. The pulse is not mentioned; but it is pretty -certain that it must have ceased about the time of the stertorous -inspiration, or the additional inspirations which took place after the -chloroform was withdrawn, would probably have restored the patient; to -say nothing of the measures that were resorted to with a view to his -resuscitation. Of Case 27, which happened at Melbourne, it is merely -related that the patient spluttered at the mouth, and suddenly expired, -just after a fresh portion of chloroform had been applied on the -handkerchief. The symptom of spluttering at the mouth is recorded as -occurring in other cases, just at the moment when the pulse had suddenly -ceased. - -In Case 44, at the Royal Ophthalmic Hospital, the narcotism of the brain -and nervous system proceeded as far as the third degree, which was -attended with strong muscular spasms, as not infrequently happens; and -an overdose of chloroform appears at this moment to have acted on the -heart, for the pulse could not afterwards be felt. In Cases 33, 37, and -47, the narcotism of the brain proceeded as far as the fourth degree, -producing stertorous breathing, when the chloroform caused paralysis of -the heart, by its direct action on that organ. - -There are six cases in which the fatal symptoms came on just after the -patient had been rendered insensible, and the inhalation had been -discontinued; the operation being about to be commenced. They are -numbered 32, 34, 39, 43, 48, and 49. All these cases bear a very close -resemblance to each other. In all of them the patient had been made -insensible (satisfactorily so as it was thought), when in a few seconds -the pulse suddenly stopped, or failed and fluttered just prior to -stopping; in Case 32 Dr. Dunsmure thought the time was longer between -the discontinuance of inhalation and the cessation of the pulse. The -breathing continued a little time after the pulse ceased or failed in -all these cases, and there was an absence of the spluttering at the -mouth, stretching of the limbs, and other spasmodic actions, which -occurred in all the six cases where the heart was paralysed at the -beginning of the inhalation, before unconsciousness had been induced, -and in some of those when the paralysis of the heart took place at a -later period of the inhalation, when the patient had been apparently -rendered unconscious, but was not yet insensible. In each of the six -cases now under consideration, the fatal event was evidently occasioned -by the vapour of chloroform, which remained in the lungs at the moment -when the inhalation was discontinued. A portion of this vapour becoming -absorbed, and added to that already in the blood, had the effect of -paralysing the heart, when it circulated through the coronary arteries. - -There remain twenty-two cases in which the fatal symptoms came on during -the course of the operation. In twenty of these cases the symptoms are -described with more or less detail. I made some remarks respecting cases -No. 1 and No. 2, in the place where they are related. In case No. 3, as -in these cases, the patient appeared not quite insensible, and showed -signs of pain during the operation, when “in a moment his pulse, which -was full and natural, sank.” In case No. 5 the patient was probably dead -when the incisions on the finger were commenced; the extreme suddenness -of the death, and the absence of bleeding, show that death occurred in -the way of syncope. The convulsive movements which just preceded death -are worthy of note in connection with the other cases, in which death -occurred immediately after the commencement of inhalation. Some remarks -were appended to case No. 8. In case No. 10 paralysis of the heart is -indicated by the absence of bleeding from the arteries, and the absence -of pulse, whilst the breathing still continued for a short time. I made -some remarks respecting case No. 12 when it was related. The patient -seemed to die by embarrassed respiration, but whether that was caused by -the action of the chloroform on the brain is doubtful. In case No. 13 -the patient died in a moment. In No. 16 the face turned pale, and the -pulse and breathing ceased soon after the chloroform was discontinued, -showing the effect of the vapour which was present in the lungs at the -moment when the inhalation was left off. - -In Case 18 the livid countenance and sudden stopping of the pulse prove -cardiac syncope. In Case 19 the blood which was gushing out suddenly -stopped, and the patient expired. The congested state of the lungs and -the blood in the right cavities of the heart prove that the syncope of -which he expired was not the ordinary anæmic syncope from hæmorrhage; it -was therefore cardiac syncope from the chloroform. - -In Case 22 the change of countenance and sudden character of the death -are evidences of cardiac syncope. In Case 23 there was sudden cessation -of the bleeding and of the pulse; in Case 25 the pulse suddenly ceased. -In Case 28 the patient died suddenly, but the pulse was apparently not -examined at the time. Some remarks have already been made on Case 29, -which happened in the Manchester Infirmary. In Cases 31, 36, and 38 the -suddenness of the death showed that it took place by syncope. In the -last of these cases the pulse was being examined at the time it ceased. -In Case 36 there was no examination of the dead body; but in 31 and 38 -the presence of blood in the right cavities of the heart indicates that -the kind of syncope was cardiac syncope. Respecting Case 42, some -remarks have already been made. The death commenced by deep coma, which -embarrassed, and then suspended, the respiration, and cardiac syncope -quickly followed. The chloroform was administered by a method which -precluded the medical attendant from observing properly the most -important symptoms. - -The accompanying table of the fatal cases of the inhalation of -chloroform contains such short particulars respecting them as seemed -capable of being tabulated, and it may assist the reader in retaining a -more connected recollection of the facts previously related more in -detail. - - - MODE OF DEATH IN THE ACCIDENTS FROM CHLOROFORM. - -In all the cases in which the symptoms which occurred at the time of -death are reported, there is every reason to conclude, as shown above, -that death took place by cardiac syncope, or arrest of the action of the -heart. In forty of these cases the symptoms of danger appeared to arise -entirely from cardiac syncope, and were not complicated by the -over-action of the chloroform on the brain. It was only in four cases -that the breathing appeared to be embarrassed and arrested by the effect -of the chloroform on the brain and medulla oblongata, at the time when -the action of the heart was arrested by it; and only in one of these -cases (No. 42) that the breathing was distinctly arrested by the effect -of the chloroform, a few seconds before that agent also arrested the -action of the heart. - -It was previously shown that chloroform vapour has the effect of -suddenly arresting the action of the heart when it is mixed with the -respired air to the extent of eight or ten per cent., or upwards; and we -must therefore conclude that, in the fatal cases of its inhalation, the -air the patients were breathing just before the accidents occurred -contained this amount of vapour. There was no means adopted, so far as -is reported, to regulate the proportion of vapour in the inspired air, -in any case in which an accident happened; and there was the liability -in every case that ten per cent. or more of vapour might be present in -the air the patient breathed; and in no case did death occur in the -manner that it occurs when the vapour of chloroform does not exceed five -per cent. of the inspired air. - - TABLE OF FATAL CASES OF INHALATION OF CHLOROFORM. - - ───┬────────────┬────┬───────────────┬──────────┬─────────────── - No.│ Patient. │Age │ Operation for │ Position │Means by which - │ │ in │ which the │ whilst │the chloroform - │ │yrs.│chloroform was │inhaling. │was exhibited. - │ │ │ inhaled. │ │ - │ │ │ │ │ - │ │ │ │ │ - │ │ │ │ │ - ───┼────────────┼────┼───────────────┼──────────┼─────────────── - 1│Girl │ 15 │Removal of │Sitting │Towel - │ │ │ toe-nail. │ │ - 2│Married lady│ 35 │Extraction of │Sitting │Inhaler - │ │ │ teeth. │ │ - 3│Patrick │ │Operation for │Lying on │Handkerchief - │ Coyle │ │ fistula in │ the side│ - │ │ │ ano │ │ - 4│Single lady │ 30 │Opening of │Lying │Handkerchief - │ │ │ sinus in │ │ - │ │ │ thigh │ │ - 5│Young woman │ │Amputation of │ │Handkerchief - │ │ │ the middle │ │ - │ │ │ finger │ │ - 6│Young man │ 22 │Transcurrent │ │Inhaler - │ │ │ cauterisation│ │ - │ │ │ of wrist │ │ - 7│Young man │ │Intended │ │Probably - │ │ │ removal of │ │ handkerchief - │ │ │ toe-nail. │ │ - 8│Seaman │ 31 │Removal of │Lying on │Napkin - │ │ │ hæmorrhoids │ the side│ - 9│Miner │ 17 │Intended │Lying │Handkerchief - │ │ │ amputation of│ │ - │ │ │ middle finger│ │ - 10│Labourer │ 36 │Amputation of │ │Handkerchief - │ │ │ toe │ │ - │ │ │ │ │ - 11│Married lady│ 33 │Intended │Sitting │Handkerchief - │ │ │ extraction of│ │ - │ │ │ tooth │ │ - 12│Porter │ 48 │Removal of │Lying │Inhaler - │ │ │ toe-nail │ │ - │ │ │ │ │ - 13│Married │ │Removal of │Probably │A sponge - │ woman │ │ eyeball │ lying │ - │ │ │ │ │ - 14│Young lady │ 20 │Intended │Sitting │A sponge - │ │ │ extraction of│ │ enclosed in a - │ │ │ tooth │ │ napkin - 15│A man │ │ │ │A sponge - │ │ │ │ │ - │ │ │ │ │ - 16│Artilleryman│ 24 │Amputation of │ │Handkerchief - │ │ │ middle finger│ │ - 17│Bookkeeper │ 30 │Intended │Lying │Napkin - │ │ │ operation on │ │ - │ │ │ testicle │ │ - 18│Boy │ 8 │Sounding the │Lying │Piece of lint - │ │ │ bladder │ │ - 19│Policeman │ 34 │Removal of │ │Napkin - │ │ │ portion of │ │ - │ │ │ hand │ │ - 20│Man │ 24 │Intended │Lying │Folded lint in - │ │ │ amputation of│ │ a hollow - │ │ │ leg │ │ sponge - 21│Man │ │Intended │Lying │ - │ │ │ operation on │ │ - │ │ │ the penis │ │ - 22│Married lady│ 36 │Extraction of │Sitting │Handkerchief - │ │ │ teeth │ │ - 23│Mulatto │ 45 │Removal of │Lying │Napkin - │ seaman │ │ testicle. │ │ - 24│Married │ 37 │Removal of │Lying │Handkerchief - │ woman │ │ impacted │ │ - │ │ │ fæces │ │ - 25│Man │ 23 │Ligature of │Lying │Inhaler - │ │ │ vessels near │ │ - │ │ │ vascular │ │ - │ │ │ tumour │ │ - 26│Married lady│ 32 │Intended │Sitting │Sponge - │ │ │ extraction of│ │ surrounded by - │ │ │ tooth │ │ handkerchief - 27│Man │ │Intended │Lying │Handkerchief - │ │ │ operation for│ │ - │ │ │ fistula _in │ │ - │ │ │ ano_ │ │ - 28│Cattle │ │Applic. of │ │Handkerchief - │ dealer │ │ potassa fusa │ │ - │ │ │ to ulcers of │ │ - │ │ │ leg │ │ - 29│Factory │ │Removal of │Lying │Inhaler - │ operative │ │ malignant │ │ - │ │ │ tumour of │ │ - │ │ │ thigh. │ │ - 30│Single woman│ 28 │Intended │Lying │Folded lint - │ │ │ application │ │ - │ │ │ of nitric │ │ - │ │ │ acid to │ │ - │ │ │ ulcers of │ │ - │ │ │ pudenda │ │ - 31│Soldier │ 25 │Removal of │Lying │Hollow sponge - │ │ │ small tumour │ │ - │ │ │ from cheek │ │ - 32│Tobacconist │ 43 │Intended │Lying │Handkerchief - │ │ │ perineal │ │ - │ │ │ section │ │ - 33│Woman │ 40 │Intended │Lying │Folded lint - │ │ │ operation for│ │ - │ │ │ strangulated │ │ - │ │ │ hernia │ │ - │ │ │ │ │ - 34│Single woman│ 22 │Intended │Lying │Inhaler - │ │ │ application │ │ - │ │ │ of actual │ │ - │ │ │ cautery to │ │ - │ │ │ sore of │ │ - │ │ │ vagina │ │ - 35│Young man │ 19 │Intended │Lying │Inhaler - │ │ │ forcible │ │ - │ │ │ extension of │ │ - │ │ │ knee │ │ - 36│Girl │ 13 │Removal of │Apparently│ - │ │ │ tumour from │ sitting │ - │ │ │ back │ │ - 37│Married │ 59 │Intended │Lying │Hollow sponge - │ woman │ │ reductionof │ │ - │ │ │ old │ │ - │ │ │ dislocation │ │ - │ │ │ of humerus │ │ - 38│Woman │ 40 │Removal of │Lying │Folded lint - │ │ │ uterine │ │ - │ │ │ polypus │ │ - 39│Married │ 45 │Intended │Lying │Sponge, - │ woman │ │ removal of │ │ handkerchief, - │ │ │ breast │ │ and inhaler - 40│Tailor │ 18 │Intended │Lying │Inhaler - │ │ │ operation for│ │ - │ │ │ phymosis │ │ - 41│Labouring │ 65 │Intended │Lying │Inhaler - │ man │ │ amputation of│ │ - │ │ │ thigh │ │ - 42│Shoemaker │ 39 │Catheterism │Lying │Folded lint - │ │ │ │ │ - │ │ │ │ │ - │ │ │ │ │ - 43│Woman │ 56 │Intended │Lying │Folded lint & - │ │ │ amputation of│ │ piece of - │ │ │ leg │ │ oiled silk - 44│Man │ 40 │Intended │Lying │Inhaler - │ │ │ excision of │ │ - │ │ │ eyeball │ │ - 45│Married lady│ 29 │Inhaled to │Sitting │Inhaler - │ │ │ relieve │ │ - │ │ │ neuralgia │ │ - 46│Married lady│ 36 │Intended │Sitting │Handkerchief - │ │ │ extraction of│ │ - │ │ │ teeth │ │ - 47│Sailor │ 30 │Intended │Sitting │Sponge and - │ │ │ removal of │ │ folded lint - │ │ │ necrosed bone│ │ - │ │ │ from finger │ │ - 48│Boy │ 9 │Intended │Lying │Cotton wool & - │ │ │ removal of │ │ folded lint - │ │ │ tumour of │ │ - │ │ │ scapula │ │ - 49│Labourer │ 35 │Intended │Lying │Folded lint - │ │ │ amputation of│ │ - │ │ │ thigh │ │ - 50│Young woman │ 17 │Application of │Lying │Inhaler - │ │ │ nitric acid │ │ - │ │ │ to syphilitic│ │ - │ │ │ sores │ │ - ───┴────────────┴────┴───────────────┴──────────┴─────────────── - - ───┬────────────┬────┬──────────────┬────────────┬──────────── - No.│ Patient. │Age │Time from the │ Apparent │ Previous - │ │ in │ commencement │ mode of │inhalations. - │ │yrs.│of inhalation │ death. │ - │ │ │ to the │ │ - │ │ │ beginning of │ │ - │ │ │ dangerous │ │ - │ │ │ symptoms. │ │ - ───┼────────────┼────┼──────────────┼────────────┼──────────── - 1│Girl │ 15 │Half a minute │Cardiac │Ether once. - │ │ │ │ syncope │ - 2│Married lady│ 35 │About two │Cardiac │None. - │ │ │ minutes │ syncope │ - 3│Patrick │ │About one │Cardiac │One. - │ Coyle │ │ minute │ syncope │ - │ │ │ │ │ - 4│Single lady │ 30 │Probably half │Cardiac │None. - │ │ │ a minute │ syncope │ - │ │ │ │ │ - 5│Young woman │ │A very short │Cardiac │None stated. - │ │ │ time │ syncope │ - │ │ │ │ │ - 6│Young man │ 22 │Five minutes │Symptoms not│None stated. - │ │ │ │ described │ - │ │ │ │ │ - 7│Young man │ │Not stated │Death very │None stated. - │ │ │ │ sudden │ - │ │ │ │ │ - 8│Seaman │ 31 │About ten │Cardiac │One. - │ │ │ minutes │ syncope │ - 9│Miner │ 17 │About five │Cardiac │None. - │ │ │ minutes │ syncope │ - │ │ │ │ │ - 10│Labourer │ 36 │Died at the │Cardiac │A previous - │ │ │ close of the│ syncope │ attempt. - │ │ │ operation │ │ - 11│Married lady│ 33 │A very short │Cardiac │One. - │ │ │ time │ syncope │ - │ │ │ │ │ - 12│Porter │ 48 │A little more │Probably │None. - │ │ │ than two │ asphyxia │ - │ │ │ minutes │ │ - 13│Married │ │Died during │Cardiac │None stated. - │ woman │ │ the │ syncope │ - │ │ │ operation │ │ - 14│Young lady │ 20 │Just after │Cardiac │Previous - │ │ │ beginning to│ syncope │ attempts. - │ │ │ inhale │ │ - 15│A man │ │Died before │Probably │None. - │ │ │ the │ cardiac │ - │ │ │ operation │ syncope │ - 16│Artilleryman│ 24 │ │Cardiac │None. - │ │ │ │ syncope │ - 17│Bookkeeper │ 30 │Within five │Cardiac │None. - │ │ │ minutes │ syncope │ - │ │ │ │ │ - 18│Boy │ 8 │A few minutes │Cardiac │None. - │ │ │ │ syncope │ - 19│Policeman │ 34 │Died during │Cardiac │None. - │ │ │ operation │ syncope │ - │ │ │ │ │ - 20│Man │ 24 │A few minutes │Cardiac │None. - │ │ │ │ syncope │ - │ │ │ │ │ - 21│Man │ │ │“Suddenly │None stated. - │ │ │ │ expired” │ - │ │ │ │ │ - 22│Married lady│ 36 │Less than a │Cardiac │None. - │ │ │ minute │ syncope │ - 23│Mulatto │ 45 │About seven │Cardiac │None. - │ seaman │ │ minutes │ syncope │ - 24│Married │ 37 │Eight or nine │Symptoms not│Two. - │ woman │ │ minutes │ observed │ - │ │ │ │ │ - 25│Man │ 23 │Five to ten │Cardiac │One. - │ │ │ minutes │ syncope │ - │ │ │ │ │ - │ │ │ │ │ - 26│Married lady│ 32 │Four or five │Cardiac │None stated. - │ │ │ inspirations│ syncope │ - │ │ │ │ │ - 27│Man │ │Not more than │Cardiac │None. - │ │ │ a minute │ syncope │ - │ │ │ │ │ - │ │ │ │ │ - 28│Cattle │ │Died during │Probably │None. - │ dealer │ │ operation │ cardiac │ - │ │ │ │ syncope │ - │ │ │ │ │ - 29│Factory │ │About twelve │Probably │None. - │ operative │ │ minutes │ cardiac │ - │ │ │ │ syncope │ - │ │ │ │ │ - 30│Single woman│ 28 │ │Cardiac │None. - │ │ │ │ syncope │ - │ │ │ │ │ - │ │ │ │ │ - │ │ │ │ │ - │ │ │ │ │ - 31│Soldier │ 25 │Five minutes │Cardiac │None. - │ │ │ │ syncope │ - │ │ │ │ │ - 32│Tobacconist │ 43 │A few minutes │Cardiac │Two. - │ │ │ │ syncope │ - │ │ │ │ │ - 33│Woman │ 40 │About five │Simultaneous│None. - │ │ │ minutes │ deep coma │ - │ │ │ │ and │ - │ │ │ │ cardiac │ - │ │ │ │ syncope │ - 34│Single woman│ 22 │About five │Cardiac │One. - │ │ │ minutes │ syncope │ - │ │ │ │ │ - │ │ │ │ │ - │ │ │ │ │ - │ │ │ │ │ - 35│Young man │ 19 │Fifty seconds │Cardiac │None. - │ │ │ │ syncope │ - │ │ │ │ │ - │ │ │ │ │ - 36│Girl │ 13 │ │Cardiac │None stated. - │ │ │ │ syncope │ - │ │ │ │ │ - 37│Married │ 59 │About five │Deep coma │None. - │ woman │ │ minutes │ and │ - │ │ │ │ cardiac │ - │ │ │ │ syncope │ - │ │ │ │ │ - 38│Woman │ 40 │A few minutes │Cardiac │None stated. - │ │ │ │ syncope │ - │ │ │ │ │ - 39│Married │ 45 │Three-quarters│Cardiac │None. - │ woman │ │ of an hour. │ syncope │ - │ │ │ │ │ - 40│Tailor │ 18 │About seven │Cardiac │None. - │ │ │ minutes │ syncope │ - │ │ │ │ │ - 41│Labouring │ 65 │Between 13 and│Cardiac │None. - │ man │ │ 14 minutes │ syncope │ - │ │ │ │ │ - 42│Shoemaker │ 39 │A few minutes │Deep coma, │None. - │ │ │ │ apnœa, and│ - │ │ │ │ cardiac │ - │ │ │ │ syncope │ - 43│Woman │ 56 │About three │Cardiac │None. - │ │ │ minutes │ syncope │ - │ │ │ │ │ - 44│Man │ 40 │About five │Cardiac │None. - │ │ │ minutes │ syncope │ - │ │ │ │ │ - 45│Married lady│ 29 │A few seconds │Cardiac │Two or - │ │ │ │ syncope │ three. - │ │ │ │ │ - 46│Married lady│ 36 │A few seconds │Cardiac │Four. - │ │ │ │ syncope │ - │ │ │ │ │ - 47│Sailor │ 30 │Three or four │Deep coma │None. - │ │ │ minutes │ and │ - │ │ │ │ cardiac │ - │ │ │ │ syncope │ - 48│Boy │ 9 │A few minutes │Cardiac │None. - │ │ │ │ syncope │ - │ │ │ │ │ - │ │ │ │ │ - 49│Labourer │ 35 │A few minutes │Cardiac │One. - │ │ │ │ syncope │ - │ │ │ │ │ - 50│Young woman │ 17 │ │Symptoms not│Two. - │ │ │ │ observed │ - │ │ │ │ │ - │ │ │ │ │ - ───┴────────────┴────┴──────────────┴────────────┴──────────── - -There is in a great number of the cases an evident connection between -the accident and the probable strength of the mixture of vapour and air. -In six cases the accident occurred just after the commencement of the -inhalation; in two of the cases, Nos. 27 and 37, the fatal symptoms -occurred just after fresh chloroform had been applied on the -handkerchief and sponge; and in several cases, in which the circulation -was suddenly arrested just after the patient had been rendered -insensible, the insensibility had been induced so quickly as to prove -that the vapour must have been inhaled in a very insufficient state of -dilution. - - - THE TWO KINDS OF SYNCOPE. - -Dr. Patrick Black has made an objection to the fact of the patients -having died of paralysis, or over-narcotism of the heart, in the -accidents from chloroform.[132] He says that paralysis of the heart -would be death by syncope, but that the symptoms before death, and the -conditions of the organs met with afterwards, are not in accordance with -such a view of the case. In order to show that both the symptoms and the -after death appearances, in the fatal cases of inhalation of chloroform, -are consistent with paralysis of the heart, it is necessary to point out -the difference between ordinary syncope and cardiac syncope. One of the -best examples of ordinary, or what may be called anæmic syncope, is that -which occurs in a common blood-letting, whilst the patient is in the -sitting posture. When the bloodvessels, especially the veins, which at -all times contain the greater part of the blood in the body, do not -accommodate themselves fast enough to the diminished quantity of blood, -the right cavities of the heart are supplied with less and less of the -circulating fluid; and in a little time are not supplied at all, when -the heart ceases to beat, in accordance with the observation of Haller, -that it does not pulsate when it is not supplied with blood. The moment -the heart ceases to supply blood to the brain there are loss of -consciousness and stoppage of respiration; but on the patient being -placed in the horizontal position the blood flows readily into the right -cavities of the heart from the great veins of the abdomen and lower -extremities; the heart immediately recommences its contractions; the -brain is again supplied with blood, and respiration and consciousness -return.[133] - -The blood may remain in the ordinary quantity; but if the bloodvessels -do not keep up their usual support, and exert a sufficient pressure on -their contents, the same kind of syncope will occur as that from -blood-letting. The late Sir George Lefevre related the case of a lady -who fainted whenever she left her bed, and assumed the upright posture; -no cause could be found for this until it was ascertained that she -suffered from varicose veins of the legs: bandages to these extremities -prevented the fainting. It is obvious that in this case the mechanism of -the syncope was the same as that in blood-letting; the distension of the -varicose veins under the weight of the superincumbent blood had the same -effect in preventing the supply to the right cavities of the heart, as -if the blood had been entirely removed. The faintness which often occurs -on first rising, when a person has long kept the recumbent posture from -any local cause, is probably of the same kind; the veins not having had -to support the weight of the usual column of blood for some days or -weeks, lose their tone we may presume, and yield when they are all at -once subjected to the weight of a column of blood extending from the -lower extremities to the heart, so that this organ ceases to be properly -supplied with the circulating fluid. - -In cardiac syncope, on the other hand, the cavities of the heart, or at -all events the right cavities of this organ, are always full, whether -the syncope depend on paralysis of the heart by a narcotic, or inherent -weakness of its structure, or on its being overpowered by the quantity -of blood with which it is distended. After death from this kind of -syncope, if the blood have not been displaced by artificial respiration -or other causes, the right cavities of the heart and the adjoining great -veins will be found filled with blood, and the lungs will in many cases -be more or less congested. The appearances in short will be very much -the same as in asphyxia by privation of air, which ends in a kind of -cardiac syncope, the stoppage of the heart being partly due to -over-distension of its right cavities, and partly to loss of power in -its structure, from the want of a supply of oxygenated blood through the -coronary arteries. In death by anæmic syncope, on the contrary, all the -cavities of the heart are found empty, or nearly so, and the same is -frequently the case with the adjoining great veins, whilst the lungs are -usually pale. - -The syncope occasioned by some kinds of mental emotion is of the -ordinary or anæmic kind, and consequently the condition of the brain -must act first on the bloodvessels, and not directly on the heart. -Certain persons are liable to faint on witnessing a surgical operation. -Now if the mental emotion of these persons acted directly on the heart, -whilst the rest of the vascular system was unaffected, the distribution -of the blood would be nearly the same as in asphyxia, where the -circulation is first impeded in the lungs, and is ultimately arrested by -loss of power in the heart. If the action of the heart were weakened, or -stopped, in the first instance, by the kind of emotion under -consideration, the arteries would be emptied by their contractility and -elasticity, and the blood would accumulate in the right cavities of the -heart and the great veins leading to them. In a medical student fresh -from the country, who is by no means deficient in blood, the jugulars -would become distended and the face livid, and the recumbent posture -would probably do but little towards removing the symptoms. The -phenomena which are witnessed, however, indicate a very different -condition of the vascular system. The person about to faint from the -cause indicated, frequently becomes pale before he feels anything wrong; -and when requested to retire and sit down, often says that there is -nothing the matter with him. In a short time he faints, and falls, if no -one catches hold of him; but the moment he is in the recumbent posture -he recovers. In such a case as this, the effect of the mental emotion -must be first exerted on the veins, or the veins and capillaries, -through the nerves which supply these vessels; they allow themselves to -become distended, and the heart ceases to act for want of its supply of -blood, as in syncope from blood-letting, and anæmic syncope from any -cause. - -Several authors have attributed the empty state of the heart met with -after death, in certain cases of fatal syncope, to want of power in the -left ventricle to supply the right cavities of the heart; but this is to -argue as if the blood passed out of the body after leaving the right -ventricle, and the left ventricle had to supply a newly formed fluid. -The effects of want of power in the left ventricle are the same as those -of an obstruction at the origin of the aorta; the lungs become -congested, and the right cavities of the heart more or less distended, -from the blood not being able to pass readily through the lungs. -Patients who die of heart disease die with the cavities of that organ -full. Some patients, indeed, with fatty disease of the heart, die -suddenly of anæmic syncope, and the heart is found empty; but in these -cases it is evident that death is not occasioned by the disease of the -heart, but by some condition of the bloodvessels which accompanies it. - -Chevalier was, I believe, the first to draw marked attention to cases of -sudden death arising from an empty state of the heart, in a paper in the -first volume of the Transactions of the Royal Medical and Chirurgical -Society; and he rightly attributed the emptiness of the heart to a loss -of power in the bloodvessels. His words are as follow:— - -“The disease I have now described may, perhaps, be termed _asphyxia -idiopathica_. The essential circumstances of it evidently denote a -sudden loss of power in the vessels, and chiefly in the minuter ones, to -propel the blood they have received from the heart. In consequence of -which, this organ, after having contracted so as to empty itself, and -then dilated again, continues relaxed for want of the return of its -accustomed stimulus, and dies in that dilated state.” - -The word asphyxia has become so closely connected by physiologists with -death by privation of air, where the symptoms and appearances are the -reverse of those in Chevalier’s case, that it is necessary to discard -his name of the disease which he describes, although it is -etymologically correct. His cases come under the definition of what is -now universally called syncope, and what I have called anæmic to -distinguish it from cardiac syncope. - -Chevalier speaks of a want of power in the vessels to propel the blood, -and as it is not now believed that the vessels take any active share in -the propulsion of the blood, this may be the reason why the views of -this author have received less attention than they deserve; but it is -very obvious that a want of tone in the vessels, or any great diminution -of that power which enables them to support and compress the blood, is -an adequate cause why the blood should be unable to reach the right side -of the heart. In the case of varicose veins, previously mentioned, it -was physically apparent that the cause of the syncope lay in the -vessels. Disease of the arteries is well known to be usually associated -with degeneration of the heart; the veins are also large and distensible -in old people, who furnish the greater number of those who are liable to -anæmic syncope; but the pathology of the veins, as regards both their -functions and structure, is not yet sufficiently known. - -Persons with disease of the heart, who die suddenly in a fit of anger, -probably die always with the heart distended; that is, of cardiac -syncope. Dr. Joseph Ridge, however, in his able and interesting remarks -on the disease and death of John Hunter,[134] states his belief that -that celebrated man, who had been long subject to attacks of angina -pectoris, died at last of syncope, with an empty heart. He died, as is -well known, during a fit of anger, and the coronary arteries were found -ossified. It is not said that the heart was empty, but that it was -small, and that there were no coagula in any of its cavities. It is -probable that there was not much blood in its cavities, at the time of -the post mortem examination, but the body of Hunter was conveyed in a -sedan-chair, from St. George’s Hospital to Leicester Square, a little -more than an hour after his death, so that the fluid blood would -gravitate downwards. It is related that the stomach and intestines were -unusually loaded with blood, and that those parts which were in a -depending position, as in the bottom of the pelvis and upon the loins, -were congested in a greater degree than the others; and that “this -evidently arose from the fluid state of the blood.” - -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. - -_Idiosyncrasy._ The accidents from chloroform have frequently been -attributed to idiosyncrasy in the patient. This, it may be observed, is -not to give an explanation of them, but merely to state that they depend -on something we do not understand; that something, however, being in the -person to whom the accident happens. This view receives apparent support -from the supposition that the chloroform has been inhaled in exactly the -same manner in the fatal cases as in other instances; but this apparent -support fails when it is pointed out that the supposed same manner is -only an equally uncertain manner. The different effects that have been -produced on the same patient at different times, and the great number of -instances in which medical men have failed to make the patient -insensible, show that most of the usual modes of exhibiting chloroform -are extremely uncertain. - -What most completely meets the question of idiosyncrasy, however, is the -circumstance that in no fewer than eleven out of the fifty recorded -cases of death from chloroform, the patient had previously inhaled this -medicine without ill effects. In two other cases also, previous attempts -had been made to make the patient insensible without success, on the day -on which the accident occurred. In the above table of the fatal cases, -those are indicated in which previous inhalations had taken place. In -twenty-nine cases, I have concluded that the patient had not previously -inhaled, for the medical man, having given an account of the state of -his patient, and his reasons for administering the chloroform, would -certainly have mentioned such a material fact as a previous inhalation -if it had occurred. There are ten cases of which only a meagre account -is given, and where a previous administration of chloroform may possibly -have taken place without being mentioned; but if only eleven, out of the -fifty patients, who died from chloroform, had inhaled it previously -without ill effects, it is very clear that the fact of having inhaled it -with a favourable result, gives no immunity from the possibility of -accident. It would be impossible to say what proportion of the patients -who have inhaled chloroform have inhaled it more than once, but it is -not probable that they amount to more than 22 per cent., if so many. - -_Alleged Impurity of the Chloroform._ At one time accidents from -chloroform were loosely attributed to impurity in the medicine, but this -was only a guess, and is opposed to the facts. No case of accident has -been traced to this cause, and in nearly all the cases of which the -details are given, it is distinctly recorded, either that the chloroform -was examined and found to be of good quality, or else that chloroform -out of the same bottle had been used in other cases without ill effects. -I have not thought it necessary to state this in quoting the individual -cases. - -_Apparatus employed._ Accidents were at one time, and in one quarter, -attributed to the use of inhalers; and it is curious that this -allegation was made at a time when no death from chloroform had yet -occurred in any cases in which an inhaler was used, except one in -America, and one in France, the accounts of which had not reached this -country. It is possible that death might be occasioned by want of air -from the use of a faulty inhaler, and a case will be mentioned in which -this apparently occurred in the administration of sulphuric ether, but -there is no recorded case of accident from chloroform in which death was -occasioned in this way. In the cases of death previously recorded, a -handkerchief, a piece of folded lint, hollow sponge, or some such simple -contrivance, was used in thirty-four instances; in twelve cases, an -inhaler of some kind or other was used; and in four cases, it is -uncertain what were the means employed. - -_Alleged Exclusion of Air._ The assertion has often been made that death -might be caused by the vapour of chloroform excluding the air, and so -causing asphyxia; but it has already been pointed out in this work that -the physical properties of chloroform do not allow it to yield a -quantity of vapour which would have that effect, and in much smaller -quantity than this the vapour kills by a quicker way than asphyxia, I -believe that the only elastic fluids which can cause death simply by -excluding the atmospheric air are nitrogen and hydrogen. - -_Alleged Closure of the Glottis._ At the trial which took place in Paris -respecting the death of a porcelain dealer previously mentioned, M. -Devergie gave evidence, and after saying that chloroform might cause -death as a poison, if given in undue proportion, he added: “Also it -closes the glottis, and offers an obstacle to respiration. Employed by -M. Demarquay on himself, in very small doses, closure of the glottis was -occasioned. It was possible that Le Sieur Breton had experienced that -accident, and in that case the most able surgeon could not prevent -death.” - -I have not met with M. Demarquay’s account of his experiment, but I am -happy to know that he did not die of the closure of the glottis. It may -fairly be denied that a person could commit suicide in this manner if he -wished, for he would either have to give up the attempt, or receive the -vapour into his lungs, and experience its specific effects. When animals -are placed in mixtures of vapour and air, they always breathe them, -whatever the strength; and if the vapour amounts to eight or ten per -cent., they die much more quickly than they would of mere closure of the -glottis. Vapour of chloroform, when not largely diluted with air, is apt -to cause cough and closure of the glottis, as soon as a little of it -reaches the lungs; but this, so far from being a source of danger, is, -as a general rule, a safeguard, by its preventing the patient from -readily breathing air which is highly charged with vapour. - -In commenting on the fatal case No. 12, which occurred in St. Thomas’s -Hospital, I have suggested that the accident might have happened from -liquid chloroform being dropped into the throat; but liquid chloroform -is very different from the vapour; it causes a lasting irritation if -applied to a mucous membrane; when used for toothache, it often blisters -the gums. The irritation caused by the vapour, on the contrary, is only -momentary, and its local action ceases directly it ceases to be inhaled; -for what is left in the air-passages is immediately absorbed or expelled -with the expired air. The glottis is not a vital organ of itself. Its -closure only causes death by preventing the access of air to the lungs. -The glottis does not remain permanently closed, I believe, from the -contact of any elastic fluid, however irritating;[135] but it does from -the contact of a liquid, and persons who die by drowning, die with the -glottis closed, for they do not fill their lungs with water. Therefore, -if the vapour of chloroform did cause persistent closure of the glottis, -and if a person were to hold it by force to the patient, the death it -would occasion would be precisely like that in drowning. Death by -asphyxia is a comparatively slow one. I find that when the access of air -to the lungs is entirely cut off, death does not take place in less than -three minutes and a half in guinea pigs, and four minutes in cats. In -dogs, the process of asphyxia is still slower. Mr. Erichsen states, that -on taking the average of nearly twenty experiments, the contractions of -the ventricles continued for nine minutes and a quarter after the -trachea had been closed, and that the pulsations of the femoral artery -also were perceptible for an average period of seven minutes and a half. -The process of drowning in the human subject is well known to occupy -some minutes; and even if the pungency of the vapour of chloroform -should entirely prevent the patient from breathing, and the medical man -could overlook the fact that breathing was not going on, it cannot be -supposed that he would use the force, and have the perseverance to cause -his patient to die slowly by asphyxia. If any patient, therefore, has -died from closure of the glottis, it must have been one in whom there -was a great tendency to sudden death from any slight interruption to -respiration. I do not know the particulars of the case respecting which -M. Devergie was giving his evidence, but in those fatal cases previously -related, in which the symptoms are sufficiently described, it is not -probable that death took place in any instance from closure of the -glottis. In the sudden death at St. George’s Hospital (page 209), it is -possible that the slight pungency of the vapour might assist the fear -under which the patient was labouring in impeding the breathing, and -thus add to the distension of the right cavities of the heart, under -which the patient apparently died. - -In 1855, two years after M. Devergie had given the above opinion, Dr. -Black, of St. Bartholomew’s Hospital, who has had great experience in -the administration of chloroform, advanced a similar theory in the -pamphlet previously alluded to. He did not, however, confine the effects -of the supposed closure of the glottis to possibly causing a death here -and there, as M. Devergie had done, but he attributed all the accidents -which had happened to this cause, and not to the effects of chloroform -in the system. He says that “the chloroform has not been even inhaled: -its pungency was felt at the glottis, and its inspiration was -immediately arrested. The patient would have removed the apparatus, but -in this he was restrained. The struggle forthwith commenced, but up to -the moment of his death, not a single inspiration took place.” These -remarks were not applied to a single case, but generally to the -accidents from chloroform. Dr. Black says: “Any concentration of the -vapour of chloroform which can be breathed is safe; any condition of -dilution which forces the patient to cough or hold his breath is -dangerous, and if persevered in for even half a minute, may be fatal.... -We have only to attend to the breathing; we may disregard all -considerations affecting the relative proportion of the chloroform in -the air which is breathed;... if the patient breathes easily he is in -safety, whatever be the amount of chloroform which is passing into the -lungs.” - -In Experiment 28, previously related, where the respiration was kept up -by a tube in the trachea, there could be no error in respect to the -vapour of chloroform entering the lungs, when a bladder of air charged -with ten per cent. of that vapour was substituted for the bladder of -simple air; and the immediate paralysis of the heart was evident. An -examination of the fatal cases, of which the particulars have been -recorded, shows that death did not occur in the manner Dr. Black -suggests. In the majority of the cases, the patients were rendered quite -insensible by the chloroform, and the operation had either been -commenced, or was on the point of commencing; when the fatal symptoms -set in. In several other cases, the patients were partially under the -influence of the vapour before the symptoms of danger commenced; and in -the six cases where death occurred at the beginning of the inhalation, -without loss of consciousness having been induced, the patients were not -restrained in any way, and it was observed that they did breathe the -chloroform; three of them were speaking up to the moment when the pulse -stopped, and one took a full inspiration the moment before the fatal -symptoms set in. It is only in eighteen of the fatal cases that there is -any reason to suppose that the patient required to be held, and then -only from mental excitement or muscular spasm, arising from the -physiological effects of the absorbed chloroform. It is hardly possible -that the struggles of a conscious patient from inability to breathe, -would be mistaken for excitement or spasm caused by chloroform. - -In a case, No. 34, which occurred at St. Bartholomew’s Hospital whilst -Dr. Black was present, and long before his pamphlet was written, the -patient inhaled for five minutes, and sank off into a state of complete -insensibility without alarming symptoms. The inhalation was -discontinued, the patient moved into a proper position, and the -operation just about to be commenced, when Dr. Black found the pulse to -become extremely feeble and fluttering. Surely this patient breathed the -chloroform, and died without any spasm of the glottis. In Case 48, so -minutely related by Mr. Paget, the boy made one long inspiration, and -became suddenly insensible. In a few seconds, the pulse suddenly failed, -and then ceased to be perceptible, but the breathing continued for at -least a minute afterwards. There was certainly no closure of the glottis -in this instance. - -_Alleged Exhaustion from Struggling._ In cases where the patients have -struggled violently whilst getting under the influence of chloroform, -the accidents have been attributed to a supposed exhaustion caused by -the struggling.[136] This opinion is, however, contrary to experience; -for the patients who struggle violently are precisely those who bear -chloroform the best, provided they do not breathe it in an insufficient -state of dilution. They are generally cheerful and exhilarated by it, -and are less liable to be depressed by its prolonged use, than those who -come quietly under its influence. Although the patients who struggle -bear the chloroform well, when it is carefully and judiciously -administered, it is not improbable that the struggling has been now and -then an indirect cause of accident. The muscular spasm and rigidity do -not occur till about three-quarters as much chloroform has been absorbed -as can be present in the system with safety; and, as the patients often -hold their breath whilst struggling, and take deep inspirations suddenly -and at long intervals, the greatest care is required that the vapour be -administered in a very diluted state. In Cases 9, 44, and 47, the fatal -symptoms came on whilst the patients were struggling; and in some other -cases, the sudden failure of pulse occurred just after the struggling -had ceased, rendering it probable that the patient inhaled too much of -the vapour whilst struggling, or just as the spasmodic condition of the -muscles was subsiding. - -The circumstances just mentioned, are probably the cause why so many of -the fatal cases occurred at that period of life when the body is most -robust. Very nearly two-thirds (twenty-seven out of forty-one), of those -cases in which the ages are recorded, occurred in persons of twenty -years and under forty-five years of age, although the proportion of -persons living at this period of life, in England and Wales, is only a -little more than one-third of the entire population. The majority of the -accidents from chloroform occurred also in the stronger sex, in which -muscular rigidity and spasm are most frequent:—twenty-nine of the fatal -cases happened to males, and only twenty-one to females. According to my -experience, the females who inhale chloroform for surgical operations -are nearly twice as numerous as the males; and although this may not be -the proportion in every one’s practice, it is probable that females -inhale this agent quite as frequently as the other sex, in every part of -the world. - -_Sitting Posture._ In some of the early cases of death from chloroform, -the patients were inhaling it in the sitting posture, and it was -surmised that this circumstance was the cause of death.[137] An -examination of the account of the fatal cases, however, does not bear -out this supposition. In thirty-one instances the patients were lying, -in nine instances sitting, and there are ten cases in which the position -is not mentioned, and where from the nature of the operation it may have -been either one or the other. In fully one-fourth of the cases of which -I have kept notes of the administration of chloroform, the patients were -seated in an easy chair; and as in forty fatal cases in which the -position is known, only nine, or less than one-fourth, were seated, it -does not appear that the position of the patient has had any share -either in causing or preventing accidents. - -_Supposed Effect of the Surgeon’s Knife on the Pulse._ Mr. Bickersteth -alluded to a peculiar circumstance,[138] which he thought would account -for several of the deaths attributed to chloroform. He relates three -instances in which the pulse suddenly ceased on the first incision by -the surgeon, and commenced again in a few seconds, the breathing going -on naturally all the time. All the three cases were amputation of the -thigh, and occurred in the latter part of 1851. Mr. Bickersteth did not -observe the circumstance again during the two following years, and I -have never observed it, although I have very often examined the pulse at -the moment when the operation began, especially after reading Mr. -Bickersteth’s remarks. He supposes that the action of the heart was -arrested by the shock of the incision, notwithstanding the patient was -insensible. I should attribute the temporary stoppage of the pulse in -these instances to the direct influence of the chloroform on the heart. -The moment when the operation is commenced, is usually a few seconds -after the inhalation has been discontinued, and when the effect of the -chloroform is at its height. A portion of that which was left in the -lungs having been absorbed, in addition to that which was previously in -the system. And if the vapour inhaled just at last was not sufficiently -diluted, it might paralyse the heart, but not so completely as to -prevent the natural respiration from restoring its action, in those -cases where respiration continues. I found in experiments on animals -that, when the action of the heart has been suspended by the effect of -chloroform, it can very often be restored by artificial respiration -instantly applied; and it is extremely probable that an accident of this -kind not unfrequently occurs during the administration of chloroform, -and is remedied by the breathing, without being noticed. The pulse -recovered itself, in the cases mentioned by Mr. Bickersteth, just as it -does in animals after the heart has been nearly overpowered by -chloroform. In the first case, the pulse remained imperceptible for a -period of four or five seconds, the countenance at the same time -becoming deadly pale. As it returned, it was at first very feeble, but -in a few seconds, it regained its usual strength. In the second case, -Dr. Simpson administered the chloroform, and after the operation -remarked that the pulse had stopped suddenly just as the knife was -piercing the thigh, and had recovered itself with a flutter almost -immediately. - -Mr. Bickersteth’s reason for attributing the stoppage of the pulse to -the effect of the knife, rather than the chloroform, was that he had -arrived at the conclusion from some experiments which he performed on -animals, that the action of the heart cannot be arrested by chloroform, -until the breathing has been first suspended. One of Mr. Bickersteth’s -experiments (No. 5, on a half-grown cat) exactly resembles the -experiment (No. 28 in this work) on a rabbit, which I had published -upwards of a year before Mr. Bickersteth’s paper appeared, with the -exception that in my experiment the artificial respiration was performed -with air containing ten per cent. of vapour, and in Mr. Bickersteth’s -the vapour was an unknown quantity. In both experiments, the heart of -the animal was exposed. In that which I performed, three or four -inflations of the lungs almost paralyzed the heart; and nine or ten -inflations, which did not occupy half a minute, had the effect of -paralyzing that organ irrecoverably. In Mr. Bickersteth’s experiment, -the effect of the artificial respiration was as follows:—“After -continuing it for seven minutes, the diaphragm, hitherto unaffected, -began to move very irregularly and imperfectly; then its movements -became slow and hardly perceptible; and, at the expiration of eleven -minutes, they had ceased altogether. During all this time the heart’s -action remained strong and regular, but now it got weaker and more -rapid, and, in four minutes from the time the diaphragm had ceased -acting, had become so feeble (still quite regular) that I feared every -moment it would stop.” Mr. Bickersteth says he performed artificial -respiration with air saturated with chloroform; but saturated or not, -the vapour certainly did not exceed six per cent., and most likely was -only between four and five, if the artificial resembled the natural -respiration in quantity and frequency. The vapour which can be breathed -for seven minutes without causing serious symptoms, and for eleven -minutes without arresting the breathing, is of course incapable of -stopping the action of the heart by its direct effect. It is scarcely so -strong as that which one administers every day to patients with -impunity. The vapour which is so diluted as to require to be added by -small increments during one hundred and fifty inspirations, before the -brain is even narcotized, cannot act directly on the heart, an organ -which can bear a much larger amount of chloroform. Mr. Bickersteth fell -into the error into which the Committee of the Society of Emulation of -Paris afterwards fell, and argued from the rule to the exception. What -he witnessed was the mode of death which would occur, if vapour of -chloroform of the strength which can be safely inhaled, were -deliberately continued till the death of the patient. But an accident -from chloroform is an exception, and the mode of dying is as much an -exception as the death itself, if the inquiry is extended to what this -agent is capable of doing, instead of confining it to what one -endeavours to effect with it in the human subject alone. - -So many of the deaths during the inhalation of chloroform have occurred -before the operation had commenced, or after it had proceeded some way, -that Mr. Bickersteth’s explanation would not apply to a great number, -even if it were correct; and when it is remembered that the operation is -always commenced when the effect of the chloroform is expected to be at -its height, the number of cases of cardiac syncope which have happened -at the beginning of the operation is not greater than might be expected -as the result of the effect of chloroform. - -_Sudden Death from other Causes._ It has been more than once suggested -that the deaths which have occurred, during the inhalation of -chloroform, are of the same nature as the sudden deaths which have often -occurred about the time of surgical operations, apparently without any -adequate cause; and that in fact the accident and the chloroform may be -a mere coincidence, and not connected as cause and effect. It has been -already shown that the Commission of the Academy of Medicine of Paris -made this suggestion in treating of the case of Madlle. Stock, and Dr. -Simpson has more than once made a similar remark. On one occasion,[139] -he remarked, in speaking of chloroform:—“The first surgical cases in -which it was used were operated upon in the Royal Infirmary here, on the -15th of November, 1847. Two days previously, an operation took place in -the Infirmary, at which I could not be present, to test the power of -chloroform; and so far fortunately so; for the man was operated upon for -hernia, without any anæsthetic, and suddenly died after the first -incision was made through the skin, and with the operation uncompleted.” -I should say, so far unfortunately so, for whatever the cause of the -man’s death, that cause could hardly have been present if the patient -had been made insensible by chloroform; and so his life would in all -probability have been saved. If he died either from fear or from pain, -the chloroform would have prevented his death, by removing and -preventing these causes; and if his death arose from simple exhaustion, -it must be remembered that chloroform is a stimulant, during the first -part of its administration, and, as a general rule, so long as it is -actually in the system. Even Mr. Bickersteth, who thinks that the knife -of the surgeon may have a direct influence on the heart when the patient -is quite insensible, expresses his conviction that such an occurrence is -far less likely to happen under the influence of chloroform than in the -waking state. - -I have omitted from the list of deaths by chloroform two cases which are -usually attributed to that agent, namely, the case of Mr. Robinson’s -patient, and the one at St. George’s Hospital, and have attributed them -to fear; and I also rejected the case of the infant on which Dr. -Aschendorf operated, for the reasons I stated; and it is quite possible -that amongst the fifty cases I have retained, there may be one or two in -which the death was not caused by chloroform, especially as the details -of some of the cases are very meagre; but when all the circumstances of -the cases are examined, and especially when the mode of death is -compared to that which chloroform can be made to produce in animals, it -cannot be supposed that the fatal event was a more coincidence in the -whole fifty cases, or in any great number of them. - -There are numerous instances recorded of sudden death during surgical -operations, or just before intended ones, without any evident cause, -except fear or pain, before the use of narcotic vapours was known; and -some even since, in cases in which it was not thought worth while to use -them. After the passage quoted above, Dr. Simpson continues:—“I know of -another case in Edinburgh, where death instantaneously followed the use -of an abscess-lancet without chloroform,—the practitioner, in fact, -deeming the case too slight to require any anæsthetic.” Such events -have, no doubt, often happened without being recorded; and it is -extremely likely that the deaths of this kind which chloroform has -prevented are quite as numerous as those it has occasioned by its own -effects, but the medical profession will very properly not be satisfied -with a result of this kind, if more can be done; and the endeavour of -the practitioner of course is, whilst saving life as well as preventing -pain by the use of this agent, to avoid as far as possible having any -accident from its use. - -_Falling back of the Tongue._ It has been alleged that the falling back -of the tongue into the throat, under the deep influence of chloroform, -might be the cause of death by suffocation; but this appears to be an -error; for the muscles of the larynx and neighbouring parts preserve -their action as long as the diaphragm, and contract consentaneously with -it. When the breathing has ceased, the tongue is indeed liable to fall -backwards, if the person in a state of suspended animation is lying on -the back, and this circumstance requires to be attended to in performing -artificial respiration. - - - STATE OF THE CHIEF ORGANS AFTER DEATH FROM CHLOROFORM. - -A few years ago, I examined the viscera of the chest, and kept notes of -the appearances, in thirty-seven animals killed by chloroform. They -consisted of two dogs, twenty-two cats, one kitten, three rabbits, three -guineapigs, two mice, two larks, and two chaffinches. Many of the -animals were opened immediately after death, and the rest within a day -or two. The lungs were not much congested in any instance. In seven of -the animals, they were slightly congested; but in the remaining thirty, -they were not congested. They were generally of a red colour, but in a -few of the cats they were quite pale. I ascertained the specific gravity -of the lungs of two of the cats, in which they presented the amount of -vascularity I have most usually met with. The specific gravity was 0·605 -in one instance, and 0·798 in the other. As many of the animals died in -a way resembling asphyxia, the respiration ceasing before the -circulation, it might at first be supposed that we should meet with the -same congestion of the lungs; but by the time that the respiration is -altogether suspended by the action of chloroform, that agent has begun -already to influence the heart, which does not inject the blood into the -lungs with the same force as when the respiration is mechanically -prevented, whilst it is in full vigour. Besides, in the gaspings which -so often take place when the heart is ceasing to act, the animal -inhaling chloroform draws air freely into the lungs, whilst the -asphyxiated animal is prevented from doing so. - -As regards the condition of the heart, it was found in the two -chaffinches that the auricles were filled with blood, whilst the -ventricles were empty. The condition of the heart in the larks is not -mentioned, but in all the thirty-three quadrupeds, the right auricle and -ventricle were filled with blood. In ten of them, these cavities were -much distended; and in some of these instances, the coronary vessels on -the surface of the heart were distended also. The left cavities of the -heart never contained more than a small quantity of blood, not exceeding -a quarter of what they would hold. - -The head was examined in only ten of the animals. The substance of the -brain was found to be of the natural vascularity, and the sinuses were -not very much distended, except in two instances. - -With respect to the state of the blood, it may be mentioned, that in -every instance in which the chest was opened within an hour after death, -the blood which flowed from the cut vessels coagulated immediately and -firmly. In eighteen of the animals in which the blood was examined in -the heart or large vessels, a day or two after death, it was found to be -well coagulated in ten, loosely coagulated in seven instances, and quite -fluid in one instance. I have not met with air in the bloodvessels, -either in the above thirty-seven examinations, or in any of the numerous -other animals that I have opened, after they have been killed by -chloroform. The appearances I have met with in animals killed by this -agent have usually been such as I have described in the above -thirty-seven instances; but I long since ceased, as a general rule, to -make careful notes of the appearances, as I did not meet with anything -new. - -In the fatal cases of inhalation of chloroform previously quoted, the -lungs are related to have been congested more frequently, and to a -greater extent, than I have met with in animals. But there is no -standard of what should be called congestion; and probably many of the -medical men who made the examinations were speaking by comparison with -cases where persons die after illness, in a state of inanition. In the -human subject, the right cavities of the heart, although generally full -of blood, were found empty in several cases; but as I previously stated, -it is almost certain that they were emptied after death, either by the -artificial respiration which was employed, or in some other way. - -The blood remained fluid in eighteen out of twenty-five cases of fatal -accident from chloroform, in which an examination of the body was made -and the condition of the blood recorded; whereas it was only quite fluid -in one instance out of eighteen of the animals which were killed by -chloroform, and not opened till a day or two afterwards. The fact of the -blood coagulating more generally, in the animals on which I have -experimented, than in the human subjects who died from chloroform, is -probably due to their smaller size. I was formerly of opinion that the -fact of the body of a small animal cooling more quickly than the human -one was the probable explanation of this, but Dr. Richardson appears to -have proved that the blood is kept in a liquid state by the presence of -ammonia; and ammonia, we might expect, would escape more readily from -the body of a small animal than from the human body. However this may -be, it is pretty certain that the blood generally remains fluid in the -human body after death from chloroform, only because it usually remains -fluid in every kind of sudden death. When a patient dies slowly of -illness, the body cools gradually before death takes place, and ammonia -keeps exhaling in the breath, if Dr. Richardson is correct, whilst the -formation of this alkali must be almost suspended. In many cases, we -know that coagulation of the blood commences before the respiration and -circulation have ceased. The blood which flows during surgical -operations coagulates as quickly and firmly when the patient is under -the influence of chloroform as at other times; and, as was mentioned -above, the blood which flows from animals, just after they are killed by -this agent, coagulates as well as usual; it follows, therefore, that if -the coagulation of the blood were prevented by the chloroform, and not -by the mere fact of sudden death, it would be by the presence of this -agent in the blood after death, and not by any action which it exerted -during the life of the patient. - - - FURTHER REMARKS ON THE PREVENTION OF ACCIDENTS FROM CHLOROFORM. - -In consequence of the prevailing opinion that accidents from chloroform -depended chiefly on the condition of the patient, the main endeavours to -prevent a fatal result have taken the direction of a careful selection -of the persons who were to inhale this agent. It may be doubted, -however, whether this line of practice has had so much effect in -limiting the number of accidents, as in curtailing the benefits to be -derived from the discovery of preventing pain by inhalation. In nearly -all the recorded cases of accident from chloroform, it is stated that -the patients had been carefully examined, and such proofs of disease as -were met with after death were chiefly those which had not been -detected; and, as already has been stated, were probably not greater on -an average than in the cases in which no accident happened. - -I have not myself declined to give chloroform in any case in which a -patient required to undergo a painful operation, whatever evidence of -organic disease I have met with on careful examination; and although I -have memoranda of upwards of four thousand cases in which I have -administered this agent, I have not, as I believe, lost a patient from -its use; the only person who died whilst under its influence having, in -my opinion, succumbed from other causes, as I have already explained. - -Many writers have stated that accidents from chloroform might always be -prevented by a close attention to the symptoms, or to some particular -symptom, as the pulse or the breathing. Several authors have attached -the utmost importance to feeling the pulse, and have considered this -measure of itself sufficient to avert danger; whilst others have -asserted that attention to the pulse is of no use at all. Mr. -Bickersteth, for instance, writes as follows, in the article from which -I previously quoted. “But the pulse should not be taken as any guide -during the administration of chloroform. It should be wholly disregarded -except under certain circumstances, when syncope is to be feared from -loss of blood during the performance of a capital operation. The pulse -is only affected secondarily in consequence of the failure of the -respiration.” - -If the person administering chloroform was always quite sure that the -vapour did not constitute more than five per cent. of the inspired air, -it is quite true that the pulse might be wholly disregarded. I can never -produce more certain and uniform results with chloroform than when I am -giving it to small animals enclosed in glass jars, where of course the -pulse cannot be felt. In surgical practice, however, where the amount of -vapour in the inspired air is often very uncertain, watching the pulse -may be of great service, irrespective of loss of blood; and although it -will not always prevent accident, I am persuaded that it has saved many -lives. In some of the accidents that have happened, the pulse has ceased -suddenly, whilst it was being very carefully watched; but more usually -it would show some signs of failure before entirely ceasing. - -In giving chloroform freely to animals from a napkin or sponge, whilst -the ear or the hand was applied over the heart, I have usually found -that its pulsations became embarrassed and enfeebled before they ceased; -and by withdrawing the chloroform when the heart’s action first became -affected, the life of the animal could often be saved. - -The importance of attending to the respiration of the patient has been -previously noticed, and it is so obvious a symptom that it can hardly be -disregarded, if anyone is watching the patient; it speaks, moreover, -almost to one’s instincts, as well as to one’s medical knowledge. It is -probable that no patient has been lost by disregard of the respiration, -unless it be one or two whom no one was watching, or in which the head -and shoulders were covered with a towel. - -It has already been shown in this work, from experiments on animals, and -from the physiological effects and physical properties of chloroform, -that accidents from this agent would arise by its suddenly paralyzing -the heart, if it were not sufficiently diluted with air; and a careful -review of all the recorded cases of fatal accident shows that nearly -every one of them has happened in this way, and not from any neglect in -watching the symptoms induced, or mistaking their import. - -The first rule, therefore, in giving chloroform, is to take care that -the vapour is so far diluted that it cannot cause sudden death, without -timely warning of the approaching danger; and the next rule is to watch -the symptoms as they arise. A description of those symptoms, and what -they indicate, has already been given. - -I have previously stated that the most exact way of giving chloroform to -a patient is to put so much of it into a bag or balloon as will make -four per cent. of vapour when it is filled up with the bellows; but I -have not often resorted to this plan, on account of its being somewhat -troublesome. I have previously described (p. 81) the inhaler which I -employ. By arranging the bibulous paper suitably, and by ascertaining, -with the inhaler in the scales, how much chloroform a given quantity of -air carries off at different temperatures, I am able to produce very -uniform results in the administration of chloroform. But, as I -previously stated, those who do not wish to have the trouble of studying -a suitable inhaler, may give chloroform on a handkerchief without -danger, and with results sufficiently certain, by diluting this agent -with an equal measure of spirits of wine. As the spirit (nearly all of -it) remains behind, it is desirable, in a protracted operation, to -change the handkerchief or sponge, now and then, for a dry one. - - - TREATMENT OF SUSPENDED ANIMATION FROM CHLOROFORM. - -It is probable that artificial respiration, very promptly applied, will -restore all those patients who are capable of being restored from an -overdose of chloroform. All the patients who are related to have been -restored after this agent has occasioned a complete state of suspended -animation, have been resuscitated by this means. It is only by -artificial respiration that I have been able to recover animals from an -overdose of chloroform, when I felt satisfied that they would not -recover spontaneously. And under these circumstances I have not been -able to restore them, even by this means, except when a tube had been -introduced into the trachea, by an incision in the neck, before giving -them what would have been the fatal dose. - -M. Ricord succeeded in restoring two patients who were in a state of -suspended animation by mouth to mouth inflation of the lungs. The first -was a woman, aged twenty-six, who had been made rapidly insensible by a -few inspirations of chloroform from a sponge. He had scarcely commenced -the operation of removing some vegetations, when his assistant informed -him that the pulse had ceased. The breathing also ceased about the same -time. - -In the second case, he completed the operation of circumcision, and the -patient, a young man, not coming to himself, M. Ricord found that the -breathing had ceased, and the pulse was becoming more and more extinct, -and very soon ceased entirely, till restored by the artificial -respiration. - -After these cases, hopes were expressed that M. Ricord had discovered -the means by which all patients might be restored from the over-action -of chloroform; but these hopes have not been verified by events. In the -first of the cases, the heart had probably not been so entirely -paralyzed by the action of the vapour as sometimes happens, and in the -second case, that organ was apparently not paralyzed by the chloroform -at all. It was only after the breathing had ceased, that M. Ricord found -the pulse was failing. This was a case, therefore, in which artificial -respiration might reasonably be expected to restore the patient. - -The following cases of resuscitation, from the over effects of -chloroform, are related by Mr. Bickersteth in the paper previously -quoted. They occurred in Edinburgh: - -“_Case 1._ A boy was cut for stone by my friend Mr. Hakes, on the 29th -of March, 1849. Chloroform was administered on a piece of sponge, and -the full anæsthetic effect produced, before proceeding to tie him up in -the ordinary position: the inhalation was continued, without any regard -to his condition, until the operation had been completed—altogether -about five minutes from the time he first became insensible. It was -noticed that during the operation scarce a drop of blood escaped. When -it was over, the child was found, to all appearance, dead; the muscles -were flaccid; the surface of the body pale; the respiration had ceased; -the pulse could not be felt; the heart sounds were not audible (but the -room was by no means quiet); the eyes were half open; the jaw dropped; -the pupils dilated; and the corneæ without their natural brilliancy. -Several means were tried to resuscitate him, but without effect. At -length artificial respiration was commenced; the air escaped with a -cooing sound, as if from a dead body. After continuing it for a while, -the breathing commenced, at first very slowly and feebly. Soon it -improved. In two hours the child had quite recovered.” - -“_Case 2._ In December 1851, a child, a few months old, was put under -the influence of chloroform for the purpose of having a nævus removed -from the right cheek. As soon as insensibility was produced, the -operation was commenced—the handkerchief containing the chloroform -remaining over the face, as some difficulty had been experienced in -keeping up the anæsthetic effect. Suddenly the breathing ceased; the -muscles became flaccid; the countenance pale and collapsed, and the lips -of a purple colour. Artificial respiration was employed, and in less -than a minute the breathing returned, and the child was restored.” - -“_Case 3._ On the 6th of March, 1852, I had occasion to remove the -finger of a robust, healthy-looking young man, in the Royal Infirmary. -He was already under the influence of chloroform when I entered the -room, and as there had been some difficulty in producing complete -anæsthesia, and the last of the chloroform in the bottle was already on -the handkerchief, it was thought advisable by my friend in charge of its -administration to keep up the inhalation, in order to produce a coma -sufficiently profound to last until the completion of the operation. It -was therefore left over his face, and I commenced and removed the -finger, slowly disarticulating it from the metacarpal bone. I distinctly -recollect hearing the man breathing quickly and shortly; and I also -remember, that when just about to look for the vessels, my attention was -attracted to his condition, by not any longer hearing the respiration. -The handkerchief was still on his face. I took it off, and found, to my -consternation, that the breathing had ceased; the face was livid; the -eyes suffused; the pupils dilated; the mouth half open. He was to all -appearance dead; still the pulse could be distinguished as a small, -hardly perceptible thread, beating slowly. Immediately artificial -respiration was commenced. For a minute or two, his condition did not -alter in any respect—then the lividity of the countenance increased, the -pulse was no longer perceptible, and the sounds of the heart could not -be satisfactorily heard. During the whole of this time, artificial -respiration had been diligently employed, but still the air appeared to -enter the chest very imperfectly. I despaired. I felt certain that the -man was dead, and that no human aid could restore him; and if it had not -been that those standing near me urged me to persevere, I believe I -should then have deserted the case as hopeless. Just at this time it -occurred to me to put my finger in the mouth and draw forward the -tongue, in order to secure there being no impediment to the air entering -the lungs. Retaining it in this position, we again began the artificial -respiration, and found that then the chest was fully expanded by each -inflation. After keeping it up for a minute or two, the gentleman, who -had all along kept his hand on the pulse, exclaimed, to our delight, -that he could again feel it—‘It was just like a slight flutter that -reached the uppermost of his four fingers,’ all of them being placed -over the course of the artery. It gradually became more distinct and -firmer, and at the same time, the lividity of the face decidedly -lessened. In another minute, the man made a slight inspiratory effort. I -ceased directly the artificial respiration, and merely assisted the -expiration by pressure upon the ribs. Another and another inspiration -followed, and in a short time he breathed freely without assistance. The -countenance became natural, and he appeared as if in a sound sleep. In -half an hour, he spoke when roused; then he vomited, and complained of -giddiness. In an hour afterwards, he had recovered sufficiently to walk -home. - -“Moments of intense anxiety appear much longer than they really are; but -even allowing this, I am quite sure that, at the very least, five -minutes elapsed from the time when the man ceased breathing before the -first inspiratory effort took place, and that for not less than one -minute the pulse was imperceptible, and the heart’s action almost, if -not altogether, inaudible.” - -“_Case 4._ A few weeks after the occurrence just described, I was -assisting Mr. Syme in removing the breast of a lady. A gentleman, my -superior in the hospital, was conducting the inhalation of chloroform. -Anæsthesia was complete, and the breathing good, when the operation -commenced. The chloroform was allowed to remain over the face during the -whole time of its performance. Before it was over, I noticed the -respiration become very quick and incomplete, and suggested, in -consequence, the propriety of removing the handkerchief. My remark was -neglected for eight or ten seconds, and then, just as it was taken away, -the breathing ceased suddenly. The face became deadly pale; the eyes -vacant; the lips livid. Instant dissolution appeared inevitable (the -pulse was not felt). Artificial respiration was immediately commenced, -but the air not entering the lungs freely, the tongue was pulled -forwards, and retained so by the artery forceps. The chest then expanded -freely with each inflation, the air escaping with a cooing sound. In -rather less than a minute, the respiratory movements recommenced, but at -first so slowly and imperfectly that it was necessary to assist -expiration. When recovery was a little more established, the operation -was completed. Before the putting in of the sutures, sensation had -partially returned, and in a short time the lady had perfectly -recovered.” - -Mr. Bickersteth very properly adds: “There can be no doubt, that in the -foregoing cases, a grievous error was committed by continuing the -inhalation after anæsthesia was produced, and that it was in consequence -of this, the accidents, so nearly fatal, occurred.” - -As these accidents seem to have occurred from continuing the inhalation -too long, they differ entirely from nearly all those which were actually -fatal, and which, as we have seen, arose from the too great -concentration of the vapour, and not from any want of care in watching -the patient, so as to be able to leave off at the right moment, if it -were possible. I have previously stated, that after breathing vapour of -the proper strength for inhalation, animals may always be readily -restored by artificial respiration after the breathing has ceased, -provided the heart is still beating. In the cases related by Mr. -Bickersteth, the heart had ceased to beat before the patients were -restored; but in the third case, there is distinct evidence that the -heart continued to beat for four minutes after the breathing had ceased. -It was, therefore, certainly not paralyzed by the direct action of the -chloroform. The patient was nearly in the condition of a drowned person, -where we know that there is a good prospect of recovery by artificial -respiration during the first few minutes after the breathing has ceased, -even if the action of the heart be imperceptible. In the other three -cases, also, it is probable that the breathing ceased before the action -of the heart; and, at all events, this organ was not paralyzed so -thoroughly as in the cases in which artificial respiration was promptly -applied without effect. - -Several other cases have been related in the medical journals in which -patients have been restored by artificial respiration, after animation -had been suspended, more or less completely, by chloroform; but the -above remarks would, I believe, be applicable to all these cases. - -Where patients have recovered under the use of other measures, without -artificial respiration, it is probable that animation was not completely -suspended, and that the recovery was spontaneous. - -M. Delarue related a case of accident from chloroform to the Academy of -Medicine, on August 20th, 1850, which was apparently of this nature. -After administering the vapour, and when he was about to divide some -sinuses in the thigh, he found that his patient (a woman) was in a state -of collapse, and the breathing and pulse, “_pour ainsi dire_”, -insensible. The face was injected, and there was a bloody froth at the -mouth. The uvula was titillated, and there was immediate movement of the -eyelids, which was soon followed by copious vomiting, and the patient -recovered.[140] - -Such measures as dashing cold water on the patient, and applying ammonia -to the nostrils, can hardly be expected to have any effect on a patient -who is suffering from an overdose of chloroform; for they would have no -effect whatever on one who has inhaled it in the usual manner, and is -merely ready for a surgical operation, but in no danger. I have applied -the strongest ammonia to the nostrils of animals that were narcotized by -chloroform to the third or fourth degree, and it did not affect the -breathing in the least. They recovered just as if nothing had been done. -It is difficult to suppose a case in which the breathing should be -arrested by the effects of chloroform whilst the skin remained sensible, -yet it is only in such a case that the dashing of cold water on the -patient could be of use. There is, however, no harm in the application -of this and such like means, provided they do not usurp the time which -ought to be occupied in artificial respiration; for this measure should -be resorted to the moment the natural breathing has entirely ceased. - -I have only seen two cases in which the patients seemed in imminent -danger from the direct effects of chloroform. One of these occurred in -1853. It was the case of a child, aged six years, but small and -ricketty, which had the greater part of the eyeball removed on account -of melanotic disease. The usual inhaler was employed, and when the child -seemed sufficiently insensible, it was withdrawn. The operation was -commenced by introducing a large curved needle, armed with a thick -ligature, through the globe of the eye, in order to draw it forward. As -the needle was introduced, the child cried out a very little, and -thinking the parents, who were in the adjoining room, would be alarmed, -I poured some undiluted chloroform hastily on a rather large sponge, and -placed it over the nostrils and mouth. The sponge became pressed by the -surgeon’s hand closer on the nose than I intended, but it was removed -after the child had taken a few inspirations. The operation was quickly -concluded without any further sign of sensation than that mentioned -above. At the end of the operation, the breathing was natural, but the -face was pale, and the lips blue, and the limbs were also relaxed. I -tried to feel the pulse at the wrist, but did not discover any. The -chloroform had at this time been left off half a minute at least. The -pallor and blueness continued, and in a little time the breathing became -slow and embarrassed, and appeared about to cease altogether, the pulse -being still absent. The windows were opened, and cold water dashed -freely on the face. The child made gasping inspirations now and then, -but they did not follow immediately, or seem connected with each -application of the water. The gasps became more frequent, till the -breathing was thoroughly reestablished, when the colour returned to the -lips, and the pulse was again felt at the wrist. In a minute afterwards, -the child was red in the face, and crying violently from pain, which was -relieved by a little more chloroform. It appeared to be a minute or a -minute and a half from the time when the sponge with chloroform was -removed, till the breathing became of a gasping character. There is no -doubt that in this case the heart was paralyzed, or nearly so, by the -chloroform, and that its action was restored by the spontaneous gasping -inspirations of the child. The accident could have been prevented by -having the chloroform, which was put on the sponge, diluted with spirit. - -The other case occurred in the latter part of 1852. I have no notes of -it, as it took place at the beginning of an illness, which prevented me -from writing for some time; but I recollect the chief particulars of it -sufficiently well. The patient was a lady rather more than sixty years -of age, rather tall and thin. She required to have a polypus removed -from the nose. Mr. Fergusson, who was about to operate, was nearly an -hour after the appointed time, and during this interval she was pacing -up and down the room, apparently in a great fright. She was placed in an -easy chair for the operation, and the pulse was small and feeble when -she began to inhale. Nothing particular occurred during the inhalation, -but just at the time when the patient was becoming insensible, the -breathing ceased, and the pulse could not be felt. She appeared to have -fainted, and was immediately placed on a bed which was in the room. I -applied my ear to the chest, but could hear no sound whatever. Mr. -Fergusson applied his mouth to that of the patient, and with a very -strong expiration, inflated her lungs, so as to expand the chest very -freely. I immediately heard the heart’s action recommence with very -rapid and feeble strokes, as I had so often heard it recommence in -animals. The patient soon began to make distant gasping inspirations, -and the natural breathing and pulse were soon reestablished. Mr. -Fergusson made only one or two inflations of the lungs after the first -one, which of itself was the means of restoring the patient. It was -about twenty minutes, however, before she became conscious; and during -the greater part of this time there were spasmodic twitchings of the -features and limbs on one side. In about an hour, she was pretty well; -and on the following day the operation was performed without chloroform. - -The most ready and effectual mode of performing artificial respiration -is undoubtedly the postural method, introduced by Dr. Marshall Hall a -little time before his death. It consists in placing the patient on the -face and making pressure on the back; removing the pressure, and turning -the patient on his side and a little beyond; then turning him back on -the face and making pressure on the back again; these measures being -repeated in about the time of natural respiration. - -Whether the artificial breathing is successful or not must depend -chiefly on the extent to which the heart has been paralyzed by the -chloroform, as was previously observed. The fact of the breathing -continuing after the action of the heart has ceased, in some of the -fatal cases, shows that the heart may be so paralyzed as not to be -readily restored by the breathing. It is probable that in all cases in -which artificial respiration can restore the patient, its action would -be very prompt; still it is desirable to persevere with this measure for -a good while. - -As already stated, there is every reason to conclude that the right -cavities of the heart are distended with blood, in all cases of -suspended animation by chloroform, and therefore it would be desirable -to open one of the jugular veins if the artificial respiration does not -immediately restore the patient. In opening animals, just after death -from this agent, I have observed the contractions of the heart to -return, to a certain extent, when the distension of its right cavities -was diminished by the division of the vessels about the root of the -neck. Opening the jugular veins has been resorted to in a few of the -cases of accident from chloroform, but hitherto without success. - -I have not succeeded in restoring an animal from an overdose of -chloroform, by means of electricity, in any case where I felt satisfied -that it would not recover spontaneously; and I have not heard of any -patient being restored by its means. For keeping up respiration, -mechanical means, such as the postural method, are better; as they cause -air to enter the lungs without exhausting the remaining sensibility. If -electricity be used, it should be directed towards restoring the action -of the heart. It is probable that the electric current would not reach -the heart without the help of the acupuncture needle; but it would be -justifiable to use this in a desperate case, when other measures had -failed. The needles should be coated with wax, or some other -non-conductor of electricity, except near the points. - -In the fatal cases Nos. 40 and 48, previously related, the action of the -heart partially returned during the efforts that were made for the -restoration of the patient, but did not become thoroughly reestablished. -It is probable that the circulation through the coronary vessels of the -heart was not restored in those cases, or else the blood which must have -been freed from chloroform, in its passage through the lungs, would most -likely have enabled the heart to recover completely. Dr. Cockle has -expressed the opinion, which is very probable, that the blood enters the -coronary arteries in a retrograde manner, during the diastole of the -ventricles, when the aorta and other great arteries are contracting on -their contents; if so, with a very feeble circulation, the elasticity of -the aorta, perhaps, cannot sufficiently act to cause a backward current; -and perhaps, also, the over-narcotism of the heart is itself an obstacle -to the coronary circulation, on account of the congestion of the -capillaries which always attends on narcotism. - -The knowledge how seldom anything effectual can be done for a person who -has inhaled a dose of chloroform from which he would not spontaneously -recover, ought to impress the rule very strongly on every one, to use -the greatest care in its administration. - - - EFFECT OF CHLOROFORM ON THE RESULT OF OPERATIONS. - -Besides the great benefit conferred by chloroform in the prevention of -pain, it probably confers still greater advantages by the extension -which it gives to the practice of surgery. Many operations take place in -children which could not be performed in the waking state; excisions of -joints and tedious operations for the removal of necrosed bone are often -performed on persons who would be altogether unable to go through them -except in a state of anæsthesia; and the moving of stiff joints by force -is an operation now frequently performed, although it would probably not -have been thought of if narcotism by inhalation had not been discovered. -The surgeon also obtains the ready assent of his patient to a number of -other operations, where it would either not be obtained at all, or not -at the most favourable time, if the patient had to suffer the pain of -them. - -The effect of chloroform cannot fail to be favourable, to a certain -extent, in large operations. The patient is in a more tranquil and -cheerful condition after the operation, than he would be in if he had -suffered the pain of it. His pulse is usually of the natural frequency; -and after an amputation, there is generally an entire absence of the -starting of the stump, which was formerly so distressing. After all the -minor operations in which chloroform is used, and which according to my -experience comprise at least one-half of the cases, there is never a -death; and the only inconvenience is a troublesome sickness of stomach -in a very few instances. Moreover, when patients die after the more -formidable operations, they succumb to causes which are well known, and -were in operation before the practice of anæsthesia. I only know of a -very few instances where there has been a reasonable doubt on the mind -of the surgeon, whether the chloroform may not have had some share in -preventing the recovery of the patient, after a severe operation. These -were cases in which the sickness, which occasionally follows chloroform, -continued for three or four days, indeed till the death of the patient. -This is a point which it would be difficult to decide, for the latter -part of the sickness might depend on the sinking state of the patient, -and might have come on if chloroform had not been used. Moreover, as -sickness is seldom very prolonged after chloroform in minor operations, -except in persons who are not in a good state of health, it is most -probable, that the patients who died after a great operation with -continued sickness, would not have done well if no chloroform had been -used. - -Some attempts have been made to determine, by statistical inquiry, -whether the result of operations has been more favourable since the -introduction of anæsthesia. These attempts have been confined to the -larger amputations, as they are the only operations which sufficiently -resemble each other to admit of the application of statistical inquiry; -and even in the case of these operations, the inquiries which had been -made previously to the introduction of etherization differed widely in -their results. - -Dr. Simpson took great trouble, in the early part of 1848, to collect -the account of the amputations of the thigh, leg, and arm, which had -been performed under the influence of ether or chloroform in forty-nine -of the hospitals in Great Britain; and for comparison, he collected from -thirty British hospitals the results of the same amputations, for the -two or three years preceding 1847. He found that the mortality in the -period preceding the use of ether was 29 per cent. in these amputations, -and the return of patients whose limbs had been amputated under the use -of ether and chloroform gave a mortality of 23 per cent.; and he -concluded that 6 per cent. of the lives of those who had undergone these -amputations had been saved by the use of these agents. In his -application for an account of cases, however, Dr. Simpson merely asked -for the number of cases, and the number of deaths. Nothing was said as -to the time when the amputations had been performed; and there is reason -to believe that a number of cases still under treatment may have been -included; some of which may have ended fatally after the returns were -made. The cutting part of a large amputation is of very short duration. -The loss of blood is not great; and patients hardly ever died during the -performance of an amputation, but some time afterwards, of diseases -which ether and chloroform have not been found capable of preventing. It -was therefore not to be expected that these agents should save the lives -of so many as 6 per cent. of those who underwent the larger amputations. - -In the early part of 1849, I published an account of fifty-five -amputations of the thigh, leg, and arm, in which I had administered -ether or chloroform, and the mortality was 27 per cent.[141] - -Dr. James Arnott has lately been investigating this subject in a very -persevering manner. During the last three or four years, all the cases -of amputation performed in the London hospitals have been reported in -the _Medical Times and Gazette_, together with their results; and Dr. -James Arnott has stated that the average per centage of deaths, after -the three kinds of amputation above mentioned, is 34·4 per cent. There -is obviously no means of ascertaining what was the mortality after -amputations in the hospitals of London before the use of ether and -chloroform, but Dr. James Arnott brings forward four papers, which state -the mortality for a short period, in four hospitals, a little time -before the introduction of etherization. The number of cases in these -papers is 174, and the number of deaths 41. Dr. James Arnott states the -per centage of deaths to be 21·9,[142] although it appears to me that it -would be 23·5; and it may be remarked that the four papers from which -these numbers are taken might probably not have been published if the -numbers they contain had not been favourable. Dr. James Arnott, in a -second table, gives the number of amputations and deaths from the -several hospitals in London which are named. The cases are said to have -occurred “during eighteen months from June 1855 to June 1856, -inclusive;” here being obviously a mistake. The number of cases is 204, -and the number of deaths 61; which would give a mortality of 29·9 per -cent.; almost exactly the same as that which Dr. Simpson had obtained -from thirty provincial hospitals before the use of ether. The numbers in -Dr. Simpson’s table are 618 cases, and 183 deaths, or 29·6 per cent. Dr. -James Arnott does not, however, mention the per centage of deaths in his -second table, but gives another table, for a different period, in which -the names of the hospital are not given. The numbers he gives in this -table are 430 cases and 148 deaths, giving a mortality of 34·4 per cent. -Dr. James Arnott therefore concludes that chloroform causes the death of -upwards of 12 per cent. of those who inhale it for the purpose of -undergoing amputation. It is evident that he can have had no experience -of the effects of chloroform, or he would have perceived at once the -error of his conclusions, for this agent is given for a much longer time -than in amputations, in numerous operations of which the entire -mortality is less than 12 per cent. In the removal of tumours of the -female breast, for instance, more chloroform is generally administered -than in an amputation, and the loss of blood is also much greater, yet -the entire mortality after this operation is considerably less than that -which Dr. J. Arnott supposes that chloroform adds to the ordinary -mortality after amputations. - -Dr. J. Arnott stated that the pyæmia, of which many of the patients died -after amputation, had probably been rendered more prevalent and fatal by -the use of chloroform; but Mr. Thomas Holmes, in one of his able replies -to the remarks of Dr. Arnott, points out that pyæmia had been prevalent -also in cases of compound fracture, and others in which the patients had -no chloroform. He stated that this complaint had been more prevalent in -St. George’s Hospital during the three years in which Dr. J. Arnott’s -statistics of amputations had been collected, than in the previous five -years, in which chloroform had been used.[143] - -A very valuable paper on the result of operations performed in the -Newcastle Infirmary, before and since the use of ether and chloroform, -was published last year by Dr. Fenwick.[144] He says, respecting his -tables, “in the first series are included the operations registered in -the operation books of the Newcastle Infirmary from 1823 to 1843; but, -as the record is imperfect, the actual period embraced is seventeen and -a half years. In the second, are the operations registered since the -first employment of ether; and as the use of anæsthetic agents has been -general in all the more important operations since that time, these -figures may be used to show any disadvantages likely to arise from the -employment of chloroform.” Dr. Fenwick continues:—“Before the use of -chloroform, there were registered 225 amputations of the thigh, leg, and -arm, of which 54, or 24 per cent., died. Since the use of anæsthetic -agents, 149 cases of similar operations have been recorded, of which 36 -died, showing also a mortality of 24 per cent. - -“Before, however, we can draw any conclusion from such facts, we must -carefully exclude all those circumstances which are already known to -produce an effect upon the mortality of amputations. It is, for -instance, well known that amputations performed on account of accidents -are, on the whole, nearly twice as fatal as those required for long -standing disease. Now, if we divide the foregoing numbers into these two -classes, we shall find that before the introduction of chloroform there -were 144 pathological amputations, with a mortality of 19 per cent.; -while since its employment there have been only 61, of which 13 per -cent. have died; and while of 81 traumatic amputations which took place -in the former period 32 per cent. died, only 31 per cent. perished in -the latter period. The equal mortality obtained from a general average -of all amputations is thus seen to have arisen from the smaller -comparative number of operations performed for diseases.” - -After giving a table which shows the result of each kind of amputation -in the two periods, he adds, “It is plain from the above table that -since the employment of chloroform there has been a diminution of -mortality; thus in amputations of the thigh for disease there has been 5 -per cent. less death, while after accidents 17 per cent. have been -restored to health, who formerly would have perished. In the -pathological amputations of the leg there is a difference of 8 per cent. -in favour of chloroform; and while one out of three died after the -removal of the forearm for accidents in the former series of cases, no -death had occurred out of eight in the latter. The only exceptions are -to be found in the traumatic amputations of the leg, and in the -pathological amputations of the arm. In the former there is an excess of -deaths since the introduction of chloroform amounting to 5 per cent.; -and in the latter, the cases, being only two in number, do not warrant -us in drawing any deduction from them.” - -Dr. Fenwick found that the mortality from lithotomy had been greater -since the introduction of chloroform than before, but that the increase -was confined to the cases occurring in adults; and he justly attributes -this to the fact of the more favourable cases having been operated on by -lithotrity. He says, “However paradoxical it may appear, I believe that -as surgery improves the general average of mortality, both after -amputations and lithotomy, will increase; in the former, from the -operation being confined more and more to those suffering from -accidents, and in the latter, from those with a healthy condition of the -kidneys and bladder being selected for the action of the lithotrite, and -the worst cases only submitting to the knife.” - -Dr. Fenwick gives a table showing the causes of death in the fatal cases -of lithotomy before the use of chloroform and afterwards, by which it is -seen that, in the latter set of cases, a larger proportion of the -patients had been afflicted with organic disease, in addition to the -stone. He says:—“This table shows that the relative proportion of deaths -arising from the operation in healthy persons has diminished since the -use of chloroform, 58 per cent. having died in the former, and only 47 -per cent. in the latter.” - -Dr. Fenwick inquires into the result of a considerable number of -operations in the Newcastle Infirmary, before and after the use of -chloroform, in addition to those mentioned above; and gives the -following summary towards the end of his paper.[145] “We find that there -has been a decrease in mortality since the introduction of chloroform in -the following operations:— - - Per cent. - Pathological amputations of the thigh 5 - Traumatic amputations of the thigh 17 - Pathological amputations of the leg 8 - Amputation at the shoulder joint 7 - Traumatic amputation of the arm 5 - Pathological amputation of the forearm 33 - Traumatic amputation of the forearm 16 - Ligature of the brachial artery 20 - Ligature of the arteries of the forearm 25 - Amputation of the penis 11 - Amputation of the testis 14 - Excision of the elbow 30 - Tumours of the axilla, etc. 8 - Tumours of the bones, etc. 4 - -“There has been an increase of mortality in:— - - Per cent. - Traumatic amputation of the leg 5 - Pathological amputation of the arm 41 - Lithotomy 10 - Herniotomy 12 - Amputation of the breast 1 - Tumours of the head, etc. 5.” - -Dr. Fenwick very properly remarks that other circumstances may have had -an influence over the mortality of the various operations, as well as -the fact of chloroform being used or not used: but his inquiry is very -important, as it shows the result of operations in the same institution -since the employment of ether and chloroform, and for a long period -immediately preceding the use of those agents. - - - THE ADMINISTRATION OF CHLOROFORM IN THE DIFFERENT KINDS OF OPERATIONS. - -General directions for the exhibition of chloroform have already been -given, but it is desirable to say a few words regarding its employment -in some of the individual operations of surgery. - -_Lithotomy._ In this operation, it is advisable to have the patient -placed on the operating table with his head supported by one or two -pillows, and to administer the chloroform before the sound is -introduced. This having been done, it is generally requisite to -administer a little more vapour cautiously and gently, whilst the -bandages are applied to the hands and feet, and the patient is drawn -down towards the foot of the table. The bandaging should on no account -be neglected in the adult patient. It would be an abuse of chloroform to -carry its effects so far in every case that the slightest contraction of -the muscles could not be excited by the use of the knife, merely to save -the trouble of applying a bandage. In little children, the bandages are -not usually employed; but in these cases, the person administering the -chloroform should hold the head or shoulders of the little patient, just -as the surgeon makes his first incision; for the two assistants who are -holding the legs, and think they are doing a great deal of good, are -really making a fulcrum to enable the child to push itself away from the -surgeon, if it makes the least flinch, which it is almost sure to do, if -the narcotism is not much deeper than there is any occasion for. In this -operation the patient should be fully insensible when the surgeon makes -his first incisions; and the chloroform must be repeated or not during -the operation as occasion may require. - -I have memoranda of fifty-seven cases in which I have administered -chloroform in the adult, and thirty-four in children, down to the -present time, the end of March 1858. It was my expectation that I should -be able to give the result of these, and all the other important -operations; but I have in a few cases either not ascertained whether the -patient recovered or not, or have neglected to make a note of the -circumstances at the time; and although the deficiencies might perhaps -be made up by private correspondence, and by searching the books of -three hospitals, I regret that I have not time at present for such an -undertaking. - -A large proportion of the above cases of lithotomy were performed by Mr. -Fergusson, either in his private practice, or in King’s College -Hospital, and the remaining operations were performed by a number of -surgeons. On April 19th, 1855, Mr. Fergusson removed eight calculi, as -large as pigeon eggs, from the bladder of a gentleman, aged sixty-nine, -who had a favourable recovery. - -On June 7th, in the same year, he removed fourteen calculi from the -bladder of an elderly gentleman, who also recovered. In January 1857, he -removed forty-two calculi from the bladder of a gentleman, aged -sixty-six; twelve of them were nearly as large as chesnuts, and the rest -about as big as hazel-nuts. This patient died, I think, within a -fortnight. He had disease of the kidneys. A considerable number of the -elderly men on whom lithotomy has been performed have had well marked -symptoms of fatty degeneration of the heart; but the chloroform has -acted favourably on all of them. In January 1853, Mr. Fergusson -performed lithotomy in the country on a gentleman, aged sixty-four, -removing a rather large calculus. The patient weighed eighteen stone; he -had a pulse which was liable to intermit, some of his relations had died -suddenly, and his usual medical attendant was very much alarmed about -the chloroform; but its action was very satisfactory. The patient -recovered his consciousness without sickness, or any unpleasant symptom; -and he had a favourable recovery. On August 11th, 1855, I administered -chloroform in King’s College Hospital to a man, aged seventy-five, -whilst Mr. Fergusson performed lithotomy. The patient had suffered from -apoplexy a year before; he was still paralyzed on one side, he had the -arcus senilis well marked in both eyes, and the temporal arteries were -very thick and rigid. He went through the operation well; the pulse -being good all the time. He died on the fifth day, and the following -appears in the _Medical Times and Gazette_ respecting the appearances -found after death. “At the autopsy, the cellular tissue of the pelvis -was found infiltrated with pus. The kidneys were contracted, and -occupied by many cysts; the ureters were inflamed and contained pus. The -bladder was extensively sacculated, and its mucous membrane so much -congested as to appear on the point of sloughing. There was no -peritonitis. The heart was large and fatty, and its aortic valves -diseased to a small extent. The brain was congested, and its -bloodvessels extensively ossified.” On December 22nd, 1855, I -administered chloroform in King’s College Hospital to a very fat man, -aged sixty-one, with a soft weak pulse, and arcus senilis of the cornea. -Mr. Fergusson performed lithotomy. He went well through the operation, -and recovered promptly from the effects of the chloroform. He died on -the seventh day, with purulent effusion into the left knee, and around -the left shoulder. The heart was large and flabby, and the substance of -the left ventricle was very friable. The right ventricle was dilated and -thinned, and its walls were soft and friable, and encroached on -externally by fat; at one place there seemed scarcely any muscular -substance left. - -I have memoranda of four cases of lithotomy in the female, in which the -urethra was divided as well as dilated to extract the stone; and I -recollect two other cases of the same kind of which I have no notes. - -_Lithotrity._ I have memoranda of 155 operations of lithotrity in which -I have administered chloroform. The number of cases of stone in which -these operations took place was sixty, but some of the patients had -operations performed, either without chloroform, or when it was -administered by some one else. The earliest cases of lithotrity in which -I administered chloroform were in St. George’s Hospital, and a great -number of the patients to whom I have given it were the private patients -of Mr. Fergusson, who is entirely satisfied of its utility in this -operation. Speaking of this operation in his _Practical Surgery_ (third -ed., p. 800), he says: “I am of opinion that there is not any department -of practical surgery in which anæsthesia has been of more service than -in this.” I have administered chloroform in a few operations of -lithotrity by Sir Benjamin Brodie; but I believe that he does not -approve of it in this operation, as a general rule. The following are -amongst the other surgeons whom I have frequently assisted by giving -chloroform in this operation: Mr. Cæsar Hawkins, Mr. Cutler, Mr. -Coulson, Mr. Charles Hawkins, and Mr. Henry Lee. Mr. Fergusson, in one -of his operations, extracted some portions of gutta percha bougie round -which a phosphatic calculus had formed. He was not informed of the -presence of the bougie in the bladder, until it was extracted. On -another occasion, a patient was brought from the country soon after a -bougie of this description had broken off, and he extracted with the -lithotrite the piece remaining in the bladder. It was between two and -three inches in length. - -It is generally desirable to make the patient quite insensible during -the operation of lithotrity; and the patient sometimes groans during its -performance, when he is in a condition that, so far as one can judge, he -would show no sign of sensation under the use of the knife; but he, of -course, has no recollection of the operation afterwards. The bladder is -sometimes apt to expel the water which is injected, if the patient is -not well under the influence of the chloroform; but when the vapour has -been continued for a few minutes, and the narcotism is complete, the -bladder will, I believe, always hold water as well as if the operation -were performed in the waking state, and generally much better. There are -some surgeons who occasionally raise the breech of the patient for a -short time during this operation, so that the head becomes considerably -lower than the body. Stout old men generally snore more loudly when in -this position under the influence of chloroform; but I have not met with -any ill effects, nor expected any, from the head being lowered for a -short time. From ten to twenty minutes has been the most usual duration -of the operations under chloroform at which I have been present. - -I have administered chloroform six times in female children whilst Mr. -Fergusson performed lithotrity. The patients were three in number. I -think the calculus all came away after the first operation, and the -second was only an examination of the bladder. I administered chloroform -also, on one occasion, to a lady whilst Mr. Spencer Wells repeated the -operation of lithotrity. - -_Section of the Urethra in the Perinæum._ I have notes of 56 cases of -this operation. A great proportion of them were performed by Mr. -Fergusson, either in King’s College Hospital, or in private practice. -Amongst the other surgeons whom I have assisted in this operation were -the late Messrs. Guthrie, Bransby Cooper, and Avery. In a great number -of the cases, it was impossible to get a catheter into the bladder until -after the incision was made in the perinæum, and many of the operations -were very tedious; several of them lasting above an hour. It is very -desirable to apply the bandages in this operation, as in that of -lithotomy, especially if the assistants are not numerous. - -_Other Operations for Stricture, etc._ I have notes of four operations -in which the stricture was divided internally by a urethratome; and of -two operations in which the orifice of the urethra was enlarged; and of -nine plastic operations to restore deficiencies of the walls of the -urethra, congenital or otherwise. I have memoranda of 66 cases in which -I have administered chloroform for sounding the bladder or the -introduction of a catheter. In catheterism under chloroform the patient, -of course, lies on his back, which is indeed the position in which he -ought to be during this operation, when chloroform is not administered. - -_Amputation of the Thigh._ This operation is often performed for disease -of the knee, when the joint is in such a state of tenderness that the -least motion causes great pain. In such cases, I have administered the -chloroform to the patient in bed, before his removal to the operating -table, and given a little more chloroform just before the operation was -commenced. In King’s College Hospital, I have several times given the -chloroform in the ward in such cases, before the patient was removed to -the operating theatre; but in St. George’s Hospital, the passages and -doors being wide, the patient has been carried on his bed into the -theatre, where the chloroform was administered just before his being -lifted on the table. In those cases in which the tourniquet is applied, -in preference to pressure with the fingers, it should be adjusted as the -patient is getting under the influence of the chloroform, and tightened -just before the operation begins. It is desirable to keep the patient -quite insensible till the limb is removed, and the femoral artery is -tied; after which a little chloroform may be given whenever the patient -shows by a slight flinch, or contraction of his features, that sensation -is returning. A few patients have recovered their consciousness during -the tying of the smaller arteries, and have entered into a conversation -without feeling the pain, but this condition is quite the exception. I -have notes of 49 cases of amputation of the thigh in which I have -administered chloroform. Some of the patients, who were almost grown up -to the adult age, did not know that the limb was removed till three or -four days had elapsed. - -_Amputation of the Leg._ I have notes of 31 cases in which I have -administered chloroform during this amputation. The remarks made above -with regard to amputation of the thigh are applicable to this operation. - -_Amputation of the Arm._ I have only administered chloroform five times -in this operation, and only in one case during the last seven years. -This case was that of a boy, aged sixteen; Mr. Hancock was the operator, -and the patient recovered. I have no note of the disease for which the -operation was performed, but in two or three of the remaining cases, the -arm was amputated on account of malignant disease of the forearm. In one -of the operations, the patient was seated in an easy chair, but in the -others, the patients were lying on a sofa, or operating table, with the -head and shoulders a little raised. - -Amputation of the arm has apparently been much less frequently performed -of late years, owing to the increasing practice of performing excision -of the elbow; and it appears to me that all the great amputations are -much less frequently performed now than they were a few years ago. -During a little more than nine months of 1847, I administered sulphuric -ether in 32 amputations of the thigh, leg, and arm; and in the last ten -years and four months, I have only administered chloroform in 85 of the -same operations; in the last three years, indeed, in only 16 cases; so -that the practice of amputation is still diminishing. This is due to the -practice of anæsthesia, which enables the surgeon to explore and to -remove diseased joints and portions of diseased bone by operations that -would be too long and too painful to be endured in the waking state. -This circumstance confirms the remark of Dr. Fenwick, previously quoted, -that the mortality after amputations may be expected to become greater, -as they will cease to be performed, except after accidents, or in very -desperate cases. - -_Amputation of the Ankle._ I have notes of 15 cases of amputation at the -ankle. They were chiefly performed by Mr. Fergusson, and generally in -the manner recommended by Mr. Syme, or nearly so; but latterly Mr. -Fergusson and Mr. Partridge have, in three or four cases, adopted the -modification of this operation introduced by Prof. Pirogoff, by which a -portion of the os calcis is left. - -_Other Amputations._ I have notes of nine cases of amputation of the -forearm; four of these operations were performed in 1850, and only three -since that year. I have memoranda of twelve cases in which I have given -chloroform whilst Chopart’s or other partial operations of the foot were -performed. Also of three cases in which Mr. Fergusson performed -amputation at the knee, and three cases in which he performed amputation -at the wrist in King’s College Hospital. I have notes also of 65 cases -in which I have administered it during the amputation of one or more -fingers or toes. - -_Operations for Necrosis._ Anæsthesia is of the utmost service in these -operations, which are often tedious, and would be of the most painful -nature. The operations are of the most successful kind of any in -surgery; they usually relieve the patient from a very painful affection, -and leave no mutilation. I have administered chloroform in many cases of -necrosis in which an operation could not have been undertaken without -its assistance; and in a still larger number, in which the operation -could not otherwise have been satisfactorily completed. I have memoranda -of 197 cases of necrosis in which I have given chloroform. In 70 of -these, the tibia was the bone affected; in 15 cases, the femur; in 24 -cases, the humerus; in 14 cases, the radius, or ulna, or both of these -bones; in 29 cases, the bones either of the carpus or tarsus, or -metacarpus or metatarsus. I have notes of six cases of necrosis of the -sternum; in five of these the operation was performed by Mr. Fergusson, -and in one case by Mr. Solly. Great care was required in some of the -cases to avoid going through into the chest with the bone nippers. There -have been nine operations for necrosis of the os calcis. In one of -these, Mr. Wm. Adams lately removed, along with the necrosed bone, a -small bullet which had been in the bone for six years. - -The other cases of necrosis comprise the upper and lower jaw, the -parietal bone, the edge of the orbit, the scapula and clavicle, the -sacrum, the ileum, and the phalanges of the fingers and toes. - -_Excision of the Head of the Femur._ I have notes of five cases of this -operation. They all occurred in children from eight to thirteen years of -age. Three of the operations were performed by Mr. Fergusson, one by Mr. -Bowman, and one by Mr. French; I also recollect assisting Mr. Henry -Smith in a similar operation in a child in 1848, at a time when I did -not keep any account of the operations in which I administered -chloroform. In one of Mr. Fergusson’s operations, he removed some -diseased portions of the acetabulum. - -_Excision of the Elbow._ There is every reason to conclude that this -excellent operation has been performed more frequently in consequence of -the inhalation of narcotic vapours than it otherwise would have been. I -have memoranda of 19 cases of this operation in which I have exhibited -chloroform; 18 of them were performed by Mr. Fergusson, and the -remaining one was performed by Mr. Coulson, whilst Mr. Fergusson was -present. - -_Excision of the Knee._ I have notes of 17 cases in which I have given -chloroform during the performance of this operation. Thirteen of the -operations were performed by Mr. Fergusson, two by Mr. Bowman, one by -Mr. Partridge, and one by Mr. Henry Smith. - -This operation had been rarely performed till within the last seven -years, and there is every reason to believe that it never would have -been frequently performed, if the practice of producing anæsthesia had -not been introduced. I shall speak of this operation again in treating -of amylene. - -_Excision of Wrist._ There have been two cases of this operation -performed by Mr. Fergusson in King’s College Hospital. - -_The Removal of Tumours of the Upper Jaw._ Mr. Syme, Mr. Lizars, and -some other surgeons, expressed an opinion at one time that chloroform -could not be safely used in this operation, as the blood would be liable -to flow into the lungs. This is not the case, however, as the glottis -retains its sensibility apparently unimpaired, if the influence of the -chloroform is not too deep or long continued. It is only necessary to -hold the head forward now and then, when the throat is very full of -blood, in order to allow the patient the same opportunity of breathing -that he would require if he were awake. A good deal of blood passes into -the stomach in great operations about the mouth under the influence of -chloroform; and if a few drops pass into the windpipe, they are coughed -up again, as they would be in the waking state; there is, however, less -appearance of suffocation in operations where the blood flows back into -the throat, when the patient is insensible, than when he is awake. The -glottis appears to retain some sensibility as long as a creature is -capable of breathing, for I have placed the head of more than one cat -under water after making them thoroughly insensible with chloroform, and -the action of the respiratory muscles lasted more than two minutes, but -no water entered the lungs. - -I have always made the patient insensible in the usual way, with the -inhaler, before the operation of removing tumours of the jaw, and have -kept up the insensibility during the operation by means of a mixture of -chloroform and spirit on a hollow sponge; or in cases in which I have -not been provided with this mixture, I have put not more than fifteen or -twenty minims of chloroform on the sponge at one time. Owing to the -hands of the surgeon and his assistants being very much in the way, I -have not always been able to keep the patient quite insensible -throughout the operation. He has sometimes struggled or cried out, but -there has been hardly any case in which the patient afterwards -remembered any considerable part of the operation. - -I have notes of twelve cases of removal of the upper jaw in which I have -administered chloroform, in addition to four cases to which I alluded in -the _Medical Gazette_, in the early part of 1849. In some of the cases, -the malar bone was removed, as well as the superior maxillary. Eleven of -these operations were performed by Mr. Fergusson, and the others were -performed by Mr. Partridge, Mr. Henry Charles Johnson, Mr. Hewett, Mr. -Henry Smith, and Mr. Haynes Walton. - -Mr. Fergusson introduced a great improvement in this operation about -seven years ago; instead of the incisions through the cheek or lip, or -both of these parts, he merely slits open the lip exactly in the mesial -line, as far as the columna of the nose, and then carries the knife -along one side of the base of the columna into the nostril, next the -tumour. He says: “By opening the nostril in this way as much relaxation -was gained as if the knife had been carried from the root of the ala an -inch up the side of the nose, and as much facility was given for the -future steps of the operation, as if an incision three inches in length -had been made through the lip and side of the nose, while a grand object -was gained in leaving the slightest possible conspicuous appearance -afterwards.”[146] This plan has the further great advantage of avoiding -the very copious hæmorrhage which arises from a deep incision in the -side of the face. - -In one of the operations which was performed before this improvement was -introduced, the patient died of hæmorrhage. The case is related by Mr. -Prescott Hewett in the _Medico-Chirurgical Transactions_ for 1851. This -operation was performed in St. George’s Hospital, in May 1848, with the -consent of the surgical staff of the hospital. The patient was a man, -aged twenty-five; the tumour was of nearly six years duration. For some -time previous to the operation, he had suffered occasionally from -hæmorrhage from the affected nostril, to an extent which had reduced him -considerably. The vapour was given to him rather slowly, with the -apparatus I commonly employ, and he became gradually insensible, without -previous excitement or struggling. In about three minutes, the -inhalation was discontinued, the narcotism having reached the third -degree. The patient was passive, but the muscles were not relaxed. The -breathing was not stertorous. Some teeth were now extracted without -causing any sign of pain. A little more chloroform was then given to -him, and when the inhalation was discontinued a second time, he was in -the same state as before the teeth were drawn. The operation was -immediately commenced. The superior maxillary and malar bones of the -left side were removed. During the first part of the operation, whilst -the flaps were made, the patient was perfectly quiet and silent; but -afterwards he began to groan and move his limbs, and he was not again -rendered altogether insensible; for although a few minims of chloroform -were from time to time sprinkled over a sponge, which was, now and then, -held near his face, yet, owing to the hands of the operator and his -assistants being in the way, and the cavity of the mouth and nostril -being laid widely open, he got very little of the vapour, and the only -effect of it was partially to quiet him on one or two occasions. After -the first two or three minutes of the operation, the effect of the -chloroform never exceeded the second degree. The patient executed -voluntary movements of his arms and legs; sometimes it was necessary to -hold his hands, and at one time he appeared conscious, for he folded his -arms as if making an effort not to raise his hands to the seat of pain. -He coughed now and then, and seemed somewhat embarrassed with the blood -in his throat. He was seated in a chair, but as there was no window in -the operating theatre except the skylight, his head was obliged to be -inclined rather backwards. He was leaned forwards once or twice, to -allow him to get rid of the blood, and it appeared that he vomited some -on one of these occasions. Towards the conclusion of the operation, and -at a time when he was very little under the influence of chloroform, he -fainted. He was laid down, and brandy was given to him. No more -chloroform was administered after this time. He partially rallied from -the syncope, but again became faint. The actual cautery was applied, but -oozing of blood continued until the moment of death,—about half an hour -after his removal into another room. During this interval, he was much -exhausted; his pulse was small, and difficult to feel. He was tossing -himself about in a restless manner, but there was no difficulty of -breathing. He seemed quite conscious, doing as he was told, but, of -course, could not speak, from the nature of the operation. I left a few -minutes before the patient’s death. When he ceased to breathe, -laryngotomy was performed, and artificial respiration exercised by the -opening, with no beneficial result. In my opinion, this measure was not -indicated, but of course it could do no harm. - -One of the surgeons who was present when the patient died informed me -that blood entered his windpipe from the wound, when he became moribund. - -It was found during the operation that the tumour did not involve the -superior maxillary or malar bones, but was situated behind them. In his -address to the class immediately after the operation, Mr. Hewett -estimated the loss of blood at sixteen ounces. It appeared to me to be -much greater; besides that a great deal of blood would certainly be -swallowed. - -After death, portions of the tumour were found still remaining attached -to the posterior and upper part of the cavity, and projecting into the -foramen lacerum of the orbit and right nostril, as well as in other -directions. The trachea and bronchi contained some frothy blood. -Numerous small dark spots of congestion were met with in the lung, -resulting from some of the small bronchi being filled with blood. - -The late Mr. Liston lost a patient from hæmorrhage during the removal of -a tumour of the upper jaw, before the prevention of pain by inhalation -was discovered; and it is evident that the chloroform did not contribute -either directly or indirectly to the death of Mr. Hewett’s patient. His -symptoms were simply those of exhaustion from loss of blood; he -recovered from the effects of the chloroform some time before he died; -and the small quantity of blood which spotted the lungs, and was -observed to enter as he was dying, would not have led to any immediate -urgent symptoms if it had entered during the operation. - -_Tumours of the Lower Jaw._ I have notes of twelve cases in which I have -given chloroform during this operation. Eight of the operations were -performed by Mr. Fergusson, and the others by Mr. Stanley, Mr. Tatum, -Mr. Hancock, and Dr. Pettigrew. In some of the cases the jaw was divided -on each side above its angles, and in most of the others it was -disarticulated on one side, and divided near the symphysis. Three of the -patients died within three days, from the hæmorrhage which occurred at -the time of the operation, but the others all recovered. - -The remarks which were made respecting the application of chloroform in -the removal of tumours of the upper jaw are applicable here. After the -operation has been commenced, one should endeavour to keep up the -insensibility by means of a mixture of chloroform and spirit on a hollow -sponge. In tumours, both of the upper and lower jaw, the operating table -is preferable to an easy chair for the patient under chloroform. The -head and shoulders must be raised by the movable flap of the table, or -by some other contrivance if the operation be performed in a private -house. I have, however, seen the operation performed on a sofa, and with -the patient in bed. The blood does not flow into the throat so much in -the removal of tumours of the lower jaw, as in those of the upper one. - -_Tumours of the Female Breast._ I have memoranda of 222 cases in which I -have given chloroform during the removal of tumours of the breast, or -tumours which returned after the breast had been removed. I do not -include with these a considerable number of small tumours, situated -upon, and near the gland, but not involving it. By far the greater -number of the tumours of the breast were looked upon as malignant, but I -am not able to state the numbers which were believed to be malignant, -and which were thought not to be so. I may state that there is no -surgeon whom I am in the habit of assisting who does not occasionally -remove malignant, as well as non-malignant, tumours of the breast. By -far the greatest proportion of the above mentioned operations on tumours -of the breast were performed in private practice. In a number of cases -diseased glands were removed from the axilla, in addition to the mammary -gland. It is desirable in the removal of large tumours of the breast -that the surgeon should be well seconded, by assistants who are in the -constant habit of assisting him, in order that the bleeding may be -restrained and arrested as quickly as possible. I have not seen any case -in which the patient did not go through the operation, and live, as far -as I can remember, for two or three days. But a few of the patients have -been very faint from bleeding during the operation, and faintness from -hæmorrhage seldom takes place during the influence of chloroform unless -the loss of blood is very great. The greater portion of the patients who -have been faint during the operation have done well afterwards, but a -few of them have not. In cases where there is a great loss of blood, and -a very large wound remains, the patients are apt to sink and die in from -three to five days. Most patients may recover from a considerable -hæmorrhage, and most patients may be able to bear up during the healing -of a large wound, but the combination of a great hæmorrhage and a great -wound is apt to be fatal; especially to patients who are already reduced -by illness. The largest tumour of the breast I have seen removed, was -one on which Mr. Fergusson operated, in King’s College Hospital, on Feb. -26th, 1853; it weighed eighteen pounds and a half. On the 4th of June, -following, the same patient had a small tumour removed from the same -situation. It probably resulted from a portion of the large one which -had been left behind. - -There are a few surgeons who prefer to have the patient seated in an -easy chair whilst removing a tumour of the breast; but it is more -convenient, under the influence of chloroform, that the patient should -lie on a table, or sofa, or in bed. I usually keep the patient -unconscious till the wound is stitched up, and the plaster and bandage -applied. - -I have administered chloroform in four cases of tumour of the male -breast. These tumours were all of them malignant, I believe. - -_Other Tumours._ I have had to administer chloroform during the removal -of several large and deep-seated tumours of the face, situated just in -front of the ear, over the parotid gland, with which some of them were -thought to be connected. These operations were generally extremely -difficult and tedious, owing to the necessity of avoiding the division -of the branches of the facial nerve which passed over the tumour. When -the branches of the facial nerve are touched with the forceps, or back -of the scalpel, during these operations, the muscles of the face to -which the branches are distributed contract very freely, at a time when -the patient is perfectly insensible. Mr. Stanley, Mr. Fergusson, and Mr. -Tatum, are amongst the surgeons whom I have assisted in the removal of -tumours of this kind. - -I have memoranda of 41 tumours situated behind the angle of the jaw, in -the removal of which I have exhibited chloroform. These tumours, which -mostly consisted of diseased lymphatic glands, were often very -deep-seated, passing near to the carotid artery, and it was necessary on -that account to keep the patient quite insensible, to prevent his -flinching during the operation. The greater number of these tumours were -removed by Mr. Fergusson. - -Seventy-one of the tumours of the removal of which I have notes, are -stated to have been of the encysted kind. Sixteen of them were situated -on the eyelids, sixteen on the scalp, three or four in the orbit, -several in front, or at the side of the neck, and the rest in different -parts of the body. - -I have memoranda of 66 fatty tumours which were removed from different -parts of the body. Some of them were of great size; one weighed fifteen -pounds. One which Mr. Fergusson removed in 1855 from the arm of a lady, -the patient of Messrs. Maurice and Harris of Reading, was situated -beneath the biceps muscle, and weighed two pounds six ounces and a half. -The diagnosis of it was very difficult. The fatty tumours were easily -removed, except in a few instances, in which the fat was infiltrated in -the surrounding tissues. - -I have notes of the removal of 87 other tumours of various kinds, as -fibrous, scirrhous, epithelial, melanotic, fungoid, etc. - -On February 11th, 1854, Mr. Fergusson removed a large fibrous tumour, -situated over the right scapula of a stout gentleman about forty. It -weighed about three pounds. The tumour was very adherent to all the -surrounding tissues, and the removal of it occupied five or ten minutes, -and was attended with considerable hæmorrhage. At the time when the -tumour was completely detached, the patient became pale, and the pulse -could no longer be felt in either wrist or in the temporal arteries. He -did not faint, however, for the breathing continued to be well and -regularly performed. He partially recovered his feeling once or twice, -whilst the vessels were being tied, and more chloroform was given to -him. At the end of the operation he was quite conscious, and did not -complain of being faint, although no pulse could be felt. The pulse had -not returned when I left him half an hour after the operation, and I was -informed that it did not return for about three hours. Four hours after -the operation, when I called to see him, he had a frequent and very -distinct pulse. He had some hot brandy and water just after the -operation, and about ten minutes afterwards he insisted on going to the -water-closet in the next room, and could not be persuaded to lie still. -The moment he was raised on his feet, however, he fainted, but was -immediately laid down again, when he as quickly recovered his -consciousness, and was content to lie still. This was the only faintness -he had. It is my opinion that the effect of the chloroform kept up the -breathing and prevented syncope, whilst the smaller arteries of the -exterior of the body contracted so as to confine the remaining blood -very much to the vital organs. The patient seemed in some danger for two -or three days, but was walking out quite well in less than a fortnight. - -In April 1856, Mr. Paget removed a fibro-cellular tumour, weighing -probably ten or twelve pounds, from a lady a few weeks out of her -confinement. The tumour was situated over the sacrum and nates. Sir -Benjamin Brodie was present at the operation. The patient recovered -favourably. - -_Nævi._ I have memoranda of 116 operations on vascular tumours, the -greater part of them in infants. The operations have generally been -performed by subcutaneous ligature, and have been extremely successful. -The greater number of them have been performed by Mr. Fergusson and Mr. -Bowman, in private practice and in King’s College Hospital. Some of the -nævi on the faces of infants, which were operated on by Mr. Fergusson, -were very large, and required a succession of operations. - -_Ligature of Arteries._ I have administered chloroform in three cases of -ligature of the carotid artery, by Mr. Bowman, Mr. Lane, and Mr. Haynes -Walton. Mr. Walton’s patient was an infant six months old. The right -common carotid artery was tied, on account of a tumour which pushed -forward the eye to a great extent. On the child being brought under the -influence of chloroform, the prominence of the eye diminished very much, -as I was informed that it had done when chloroform was given for some -reason on a previous occasion. On the ligature being placed under the -artery, the chloroform was discontinued, and its effects allowed to -subside before the ligature was tied. As the effects of the chloroform -went off, the eye became as prominent as before; and the tightening of -the ligature had no effect on this prominence whilst I remained, -although it instantly stopped the pulsation of the temporal artery. I -was informed that this child was cured by the operation. - -I have also administered chloroform in three cases of ligature of the -external iliac artery, for aneurism of the femoral. Two of the -operations were performed by Mr. Fergusson, and the other by Mr. Henry -Smith. One of Mr. Fergusson’s patients was a very stout gentleman; the -external iliac artery was diseased at the usual situation of the -ligature, and it had to be tied near to the common iliac. This patient -died. Mr. Henry Smith’s patient recovered, as I believe did the other of -Mr. Fergusson’s. It is necessary that the patient should be kept very -insensible during the operation of tying the carotid or external iliac -artery, to prevent the possibility of his flinching. - -I have exhibited chloroform six times for the ligature of the -superficial femoral artery, on account of aneurism in the popliteal -space. Two of these operations were performed by Mr. Bowman on the same -man with an interval of three weeks. He had an aneurism in the popliteal -space of both limbs. There was a case of false aneurism of the radial -artery, on which Mr. Fergusson operated by tying the artery above and -below, and turning out the clot; and also a case in which Mr. Hancock -tied the vessels for a false aneurism, situated between the metacarpal -bones of the thumb and forefinger. There were two cases also in which -the radial artery was tied for a recent wound; one by Mr. Henry Charles -Johnson, the other by Mr. Henry Lee. - -_Tumours of Bone._ I have administered chloroform in a number of cases -of the removal of enchondroma, and other tumours of bone. In June 1849 I -assisted the late Mr. Aston Key whilst he removed a bony tumour from a -youth about sixteen, situated at the inner and anterior part of the -femur, just above the knee; and I have seen two or three other tumours -of the same kind, exactly in the same situation. I have no notes of the -other cases; but one was a patient of Mr. Quain, and another, I think, -of Mr. Fergusson. After an incision is made, the tumour can be clipped -clean off at once with a pair of strong, curved bone nippers. Unless the -bone nippers are curved, the operation is troublesome and difficult. - -_Hare-Lip._ I have notes of 147 operations for hare-lip, for which I -have given chloroform. A few of these operations were performed by Mr. -Arnott, Mr. Cæsar Hawkins, Mr. Bowman, Mr. Henry Charles Johnson, and -others, but nearly nine-tenths of the whole number were performed by Mr. -Fergusson, either in his private practice or in King’s College Hospital. -A great number of Mr. Fergusson’s operations were in children from three -to six weeks old; and some were younger than this, one being only eight -days. There used to be an objection against operating for hare-lip on -very young infants, as it was said that they often died of convulsions, -which I believe to be true. The convulsions were supposed to be caused -by the shock of the operation on the nervous system, which I believe to -be entirely untrue. I believe they were caused by hæmorrhage; and I -would not recommend the surgeon to perform his first operations for -hare-lip on very young and feeble infants. The great success of this -operation of late years, in the first weeks of life, depends on the -dexterity of the surgeon who performs the operation so quickly that -scarcely any blood is lost. When Mr. Fergusson performs this operation, -the infant is held by a nurse, who is seated opposite to him, whilst its -head is placed in his own lap between his thighs. An assistant -compresses the labial artery on the right side, by grasping the lip -between his finger and thumb, just at the angle of the mouth; a -sharp-pointed scalpel is pushed through the lip on the right side, just -below the nose, and carried downwards so as to cut away the edge of the -fissure; then the same performance is done on the left side of the -fissure, while Mr. Fergusson compresses the labial artery on that side -with the finger and thumb of his left hand. In about twenty seconds from -the beginning of the operation, the hare-lip pins are introduced, and -the cut edges of the lip being pressed together, the bleeding is at once -entirely stopped. I have no doubt that many lives are saved by early -operation, especially amongst the poor, as a child with a bad hare-lip -cannot take the breast till it is operated on, and there is a very great -mortality amongst infants brought up by hand. - -The blood which escapes when the infant is laid on its back flows back -into the throat, and it usually passes on each side of the epiglottis, -and runs into the stomach without any act of deglutition. In a few cases -of strong children, in whom the bleeding is rather free, the breathing -gets embarrassed, and Mr. Fergusson turns the face of the child -downwards for a moment to let the blood run out of its mouth. When the -quantity of blood flowing into the throat is greater than can run down -into the stomach, in the way I have mentioned above, the glottis closes -and the breathing stops, which gives the indication for turning the face -downwards. I have seen a few operations in the hospital for hare-lip, -without chloroform, whilst the children were on their backs. In these -cases they cried violently from the pain, set the blood in the mouth -into violent commotion, and then drawing a deep inspiration, drew a -little of the blood into the larynx, which caused a violent cough; so -that there was usually much more appearance of choking than in the cases -where chloroform was given. Moreover, in these latter cases, it is -usually towards the end of the operation that the children sometimes -become embarrassed with the blood; not because the quantity of blood is -greater, but because the sensibility is returning. I have seen one case -which shows that the effects of chloroform, when deep or long continued, -will diminish the sensibility of the glottis. After an infant was made -insensible some years ago for an operation for hare-lip, it was found -that an instrument for dividing the projecting intermaxillary bone was -wanting, and I kept the child insensible for several minutes, by -administering chloroform occasionally, until the instrument was found; -the bleeding was rather free, and some of it entered the windpipe and -caused a tracheal râle. The child coughed it up on awaking, and no ill -consequences followed; but the occurrence confirms the opinion -previously expressed, that the insensibility should not be both deep and -long continued at a time when copious hæmorrhage is flowing into the -throat. The effects of chloroform pass off very quickly in infants, and -it is not often that they last till the operation of hare-lip is -finished, short as that operation is. In private practice, indeed, when -the parents of the infant are close by, I usually have an opportunity to -apply a little chloroform, mixed with spirit, on a sponge, in the course -of the operation, when it is required to prevent crying; but in the -hospital, the children sometimes cry a little before the operation is -concluded. - -_Cancer of the Lip._ I have memoranda of nineteen cases of cancer of the -lower lip, and three or four of the upper lip, in which I have -administered chloroform. As there is never an easy chair in the -operating theatre of an hospital, and it is difficult to keep the -patient in a common chair when he is under the influence of chloroform, -it is better to place the hospital patient on the operating table, with -his head and shoulders raised during this operation; but in private -practice the patient may either be placed on a sofa, or in a large easy -chair with a high back. The effect of the chloroform often lasts to the -end of the operation, if it be completed within two or three minutes; -but I always go provided with a hollow sponge, and a mixture of -chloroform and spirit to apply during the operation, if required. - -_Division of the Sensory Nerves of the Face._ I have notes of nineteen -cases in which I have administered chloroform during this operation. -They were chiefly performed by Mr. Fergusson, but a few of them by Mr. -Bowman. The operation is of so painful a nature, that I believe it was -seldom performed before the practice of inhaling narcotic vapours was -introduced. It is done subcutaneously, by means of a small sharp-pointed -bistoury, by which the affected nerves are chopped up by twenty or -thirty incisions, at and near the points where they issue from their -respective foramina. In operating on the mental branch of the fifth -nerve, the bistoury is sometimes introduced from the face, and sometimes -from the interior of the mouth. The pain continues for two or three -days, till the inflammation caused by the operation subsides, when there -is usually a complete absence of pain for three or six months, at the -end of which time the operation has often to be repeated. I am not aware -whether the relief has been permanent in any case, but it has often been -very complete for a time. One patient, on whom Mr. Fergusson operated in -King’s College Hospital, looked like an old man at the time of the -operation, but this was the effect of his severe suffering; for a week -or two afterwards he looked his real age, which I think was less than -forty. This operation is not performed for the milder cases of -neuralgia, or for cases that can be cured by quinine or iron; but only -for the more terrible forms of the complaint, which fortunately are -somewhat rare. Rare as they are, however, they occur sometimes in near -relatives. - -_Division of other Nerves of Sensation._ I have notes of nine cases in -which nerves in other parts of the body were divided, and a portion cut -out, for neuralgia. On four occasions the nerve was situated in a stump -following amputation; and on two occasions a tumour of the nerve was -removed. The operations were performed by Mr. Fergusson, Mr. Solly, and -Mr. Paget. - -_Operations on the Eye._ The operations for cataract are frequently -performed without chloroform, when the patient has sufficient resolution -to keep his eye steady. I have, however, administered chloroform -fifty-three times during the extraction of cataract; thirty of the cases -occurred in the private practice of Mr. Bowman. On November 25th, 1851, -I administered chloroform whilst Mr. White Cooper extracted a piece of -flint from the interior of the eye; and on February 7th, 1852, whilst -Mr. Bowman extracted the capsule of the lens. On February 17th of the -same year, I assisted Mr. White Cooper with chloroform whilst he -extracted a cataract from the eye of an elderly lady; and I assisted him -in eleven other cases during that and the following year. I assisted Mr. -George Pollock in two operations of the extraction of cataract in June -1852; and Mr. Lawrence in three operations in 1853. Eighteen of Mr. -Bowman’s operations were performed in the summer and autumn of 1854, and -were of the usual kind; but in six out of the twelve cases in which I -have since assisted him, the cataract was first drilled and then -removed, in a softened state, through a small opening in the cornea, by -means of a small scoop. I have assisted Mr. Alexander in two cases, and -Mr. Critchett also in two. Several of the patients were over eighty -years of age. - -The operation for the extraction of cataract is said not to be a painful -one, but the patient requires to be as insensible during its performance -as if he were about to undergo lithotomy, or a great amputation; without -this, the eye and eyelids will not be steady. The insensibility must be -kept up completely until the cataract is extracted. - -It is necessary that the stomach should be empty when the patient -inhales chloroform for this operation, in order that vomiting may, if -possible, be avoided. There was a little vomiting in a very few of the -cases in which I administered chloroform, but it was not attended with -straining, and I believe it did no harm in any case. Mr. Bowman informed -me of a case of his in which chloroform was administered in the -Ophthalmic Hospital for the extraction of cataract, and the woman -vomited violently afterwards, and the eye was destroyed. She, however, -was a person of bad constitution, and the vomiting might have occurred -without the chloroform. The patients were lying on a sofa in all the -operations, except, I think, one by Mr. Alexander. - -I have notes of nine cases of the drilling of cataract in which I have -administered chloroform, and there were some other cases in 1848, of -which I have no memoranda. Some of the early operations were performed -by Mr. George Pollock, and the more recent ones by Mr. Bowman. Many of -the patients were infants or children. There have been two cases of the -removal of coagulated lymph from the interior of the eye, by Mr. Bowman -and Mr. White Cooper; and six cases of the formation of artificial -pupil, by the same surgeons, and Mr. Dixon; and in two cases lately, Mr. -Bowman has removed a portion of the iris. - -I have given chloroform in 25 cases of excision of the eyeball; 20 of -the operations have occurred within the last two years, in addition to -some in which I administered amylene. The whole of the operations were -performed by Mr. Bowman, except one by Mr. Fergusson, and one by Mr. -Hancock. The operation is of late years a much less formidable one than -formerly, owing to the plan of commencing to dissect off the conjunctiva -just around the cornea. After the eyeball is removed, the edges of the -conjunctiva are drawn together by a fine suture, so that scarcely any -wound is left, and the patient can generally begin to wear an artificial -eye in four or five days. In cases of malignant disease extending beyond -the globe, of course, the more formidable and extensive operation would -still require to be performed. - -I have administered chloroform for the removal of sparks of iron and -other foreign bodies from the cornea, chiefly in cases in which the -surgeon had previously tried without success. Under the influence of -chloroform, the foreign matters were always removed very readily. There -have also been operations for the removal of growths from the eye and -granular growths from the conjunctiva, and also for staphyloma and -pterygion. - -I have memoranda of 54 operations for strabismus in which I have -administered chloroform. The greater number of them were performed by -Mr. Bowman, but several by Mr. Fergusson, and a few by other surgeons. -One operation was performed by the late Mr. Dalrymple. Mr. Bowman -generally operates on both eyes at the same time. A great number of the -patients who have taken chloroform for this operation were children. -They have nearly all been lying down during the operation. - -There have been nine operations for ectropion and entropion, chiefly by -Mr. Bowman. I have administered chloroform on four occasions whilst Mr. -Bowman has performed a plastic operation for the formation of a new -eyelid. On three occasions, the eyelid had been destroyed by a burn, and -the material for the new one was taken from the integuments of the -forehead. The operations were necessarily tedious. - -_Removal of Foreign Bodies and Polypi from the Ear._ In May 1849, Mr. -Henry Charles Johnson extracted a pea from the ear of a child, six years -of age. The pea had been a month in the ear, and Mr. Johnson had -endeavoured to examine the ear without chloroform, but could not do so. -In May 1857, I administered chloroform to a child aged three years, a -patient of Mr. Tuach, whilst Mr. Hewett extracted a glass bead with -sharp edges from the ear. He got it out with a director. I have notes of -four cases in which a polypus was removed from the ear by Mr. Partridge, -Mr. Fergusson, Mr. Henry Lee, and Mr. Henry Smith; and I recollect -giving chloroform more than once at Mr. Toynbee’s whilst he performed a -similar operation, although I have no memoranda of the circumstances. - -_The Removal of Polypi and Foreign Bodies from the Nose._ I have -memoranda of fourteen cases in which I have administered chloroform for -the removal of polypi from the nose. The operations were nearly all -performed by Mr. Fergusson. The patient was nearly always seated in an -easy chair, and the chloroform, in several cases, was repeated to keep -up the insensibility till the operation should be completed. In one of -the cases, the polypus caused a protrusion of the nasal bones; the -nostril was slit up, and there was very great hæmorrhage as the polypus -was brought away. The pulse became small for a time, but there was no -syncope. The patient did well. In June 1852, I gave chloroform to a -girl, five years old, and Mr. Fergusson scooped out some polypus growth -from the right nostril, and also an oval softened body, rather bigger -than a horse-bean, which was a young orange that the child had pushed up -her nose in India. The case had given rise to a good deal of difference -of opinion amongst medical men in India and Malta, who generally -discredited the child’s account of the orange. In August 1856, Mr. -Stanley removed a bean from the nose of a child. - -_Certain Operations in the Mouth._ I have notes of six operations for -cancer of the tongue, performed by the late Mr. Keate, Mr. Quain, Mr. -Hancock, and Mr. Paget. Mr. Paget’s was a case of epithelial cancer, in -a lady, about twenty-five. The operation was one of excision of the -tumour, and I lately heard that the patient remained free from the -complaint. The other operations were by ligature. Mr. Quain’s was a -hospital patient, and I do not know the ultimate result of the case. The -other patients had a return of the disease, and died after great -suffering. - -I have notes of ten operations for epulis, chiefly by Mr. Fergusson. The -patient was generally on a sofa or the operating table, with the head -and shoulders raised. As the operations were soon completed, the -chloroform seldom required to be repeated. There have been some cases of -cancerous disease of the gums and alveolar process in which I have -administered chloroform. One of these was a patient of Mr. Bell, the -dentist, on whom Mr. Hilton operated. I assisted the late Mr. Avery by -giving chloroform in two operations for cleft palate. A large cork with -a string to it[147] was kept between the molar teeth on one side during -the operation; and the inhalation was repeated from time to time. The -surgeon, however, much prefers to have the patient awake during this -operation, when he can get his assent. - -I have administered chloroform four times for the removal of the -tonsils. Three times in children, and once in the adult. In the case of -a child on which Mr. Curling lately operated, he removed one of the -enlarged tonsils very easily and very well, but just as he was beginning -to remove the other, the child began to vomit its breakfast, and the -throat was afterwards so filled with mucus and blood, that we thought it -better to defer the remainder of the operation till another day. - -_Plastic Operations._ I have memoranda of 50 plastic operations in which -I have administered chloroform, in addition to those on the eyelids, -previously mentioned. Eight of the operations were for the formation of -a new nose. Five of them were by Mr. Fergusson, two by Mr. Critchett -when Mr. Fergusson was present, and one by Mr. Samuel A. Lane. I made -the patients insensible with the inhaler before the operation was -commenced, and afterwards kept up the insensibility by means of -chloroform, diluted with spirit, on a hollow sponge. No fewer than 24 of -the plastic operations were for the remedy or mitigation of deformity -caused by burns. In fourteen of these cases, the operation was performed -on the neck, but often extended to the breast and lower part of the -face. The other ten operations were for burns on the face and arms and -other parts of the body. Nearly all these operations were performed by -Mr. Fergusson. One of his patients was a gentleman from New York, who -had a most severe burn in the face when a child. The operations, without -the action of a narcotic, would be of the most painful nature; and the -greater number of those at which I have been present would not have been -performed, except for the discovery of narcotism by inhalation. The -remaining eighteen plastic operations were for a variety of purposes, -such as replacing the loss of a lip, the closing of artificial anus, and -of openings in the cheek, and a variety of other defects, either -congenital, or arising from injury or disease. They were nearly all -performed by Mr. Fergusson. - -_Raising depressed Portions of Skull._ In Dec. 1848, I administered -chloroform to a gentleman in Norfolk, aged sixty-two, on whom the late -Mr. Aston Key operated. The patient had been thrown from his horse four -years previously, and probably kicked whilst on the ground. He believed -that he did not lose his consciousness. There was a considerable -depression of a portion of the right parietal bone, near its upper and -posterior angle; but there were no symptoms of cerebral pressure or -irritation for two years after the accident; but at that time he fell -from his seat in some kind of fit, after which he had partial paralysis -of the left arm, impaired vision, and a melancholy or apathetic state of -mind. He was also subject to attacks of real or apparent suspension of -breathing, and to occasional attacks of vomiting. - -His ordinary medical attendant, Dr. Bell of Aylsham, objected to the -chloroform, on account of feeble and irregular action of the heart, in -addition to the above symptoms. The patient, however, became gradually -insensible, without any unfavourable symptoms. After making incisions in -the scalp, Mr. Key sawed out a good sized piece of the parietal bone -with Hey’s saw. The insensibility was kept up gently during the -operation, which lasted above half an hour. There was pus under the -bone, and the dura mater was diseased, and gave way during the -operation. Mr. Key immediately expressed a bad opinion of the case. The -patient recovered his consciousness in about a quarter of an hour, and -in a little time was in the perfect enjoyment of all his faculties, -being very cheerful, and in a totally different state from the one of -apathy and almost unconsciousness, in which he appeared when we first -saw him. He was attacked with inflammation of the brain on the third -day, and died on the fifth. - -In May 1855, I administered chloroform in St. George’s Hospital to a -young man who had been kicked by a horse. The frontal bone above the -right eye was driven in to a good depth, and a little of the brain had -escaped. Mr. Cæsar Hawkins cut a piece from the frontal bone, just above -the depressed portion, with the bone forceps, to enable him to introduce -the elevator. The depressed portion being quite loose, was removed, -together with the roof of the orbit. The youth was partially comatose -before chloroform was given, but made a resistance to the operation. A -week after the operation, when I saw him, he was conscious, but -feverish, and he died a week or two later. - -Mr. Bowman, on one occasion, made an incision over the frontal sinus in -a gentleman; and made an aperture in the outer table of the frontal -bone, which gave exit to a quantity of pus which had been formed in the -sinus. - -In the summer of 1847 the late Mr. Liston performed a similar operation -on a lady, the patient of Dr. Locock, who was present. I exhibited -sulphuric ether on that occasion. - -_Operations for ununited Fracture._ I have notes of seven operations by -Mr. Fergusson and Mr. Bowman, for ununited fracture of the femur, -humerus, radius, and ulna. The usual course has been to scrape and -puncture the ends of the bones by subcutaneous incision, and where this -has not succeeded, to cut down on the bones and saw off the ends; or to -bore holes near the ends, and introduce ivory pegs. - -_The Reduction of Dislocations._ I have notes of twenty-seven cases in -which I have administered chloroform during the reduction, or attempted -reduction, of dislocations. Only three of these were recent -dislocations. One had existed a few days; and the other twenty-three for -some weeks or months. Twelve of the operations were performed by Mr. -Fergusson, and the others by Mr. Cæsar Hawkins, Mr. Cutler, Mr. Bransby -Cooper, Mr. Partridge, Mr. Tatum, Mr. H. C. Johnson, Mr. Charles -Hawkins, Mr. Hewett, Mr. Henry Lee, and Mr. Price. Most of the -dislocations at the shoulder were quite successfully reduced; one of -them by the late Mr. Bransby Cooper, as long as ten weeks after the -accident. Dislocations of the hip were successfully reduced in three -weeks and five weeks after the accident. At longer periods, dislocations -of the femur were often benefited by the operation, but not completely -reduced. The dislocations at the elbow were not successfully reduced -except when recent, although the position and motion of the forearm were -improved in several cases by the operation. Pulleys were applied, often -for a length of time, in the old dislocations; and many even of the -successful operations could not have been performed except the patient -had been in a state of anæsthesia. A full dose of chloroform is required -in the attempts to reduce old standing dislocations, in order to -suspend, as nearly as may be, the resistance of the muscles. - -_Forcible Movement of Stiff Joints._ I have given chloroform in -twenty-two operations of this kind, within the last three years, for the -restoration of motion in the knee, elbow, and hip, after the joints had -become fixed in one position, generally by adhesions resulting from -disease. The first operation of the kind in which I assisted was one -performed by Mr. Brodhurst, whom I have since assisted more frequently -in these kinds of operations than any other surgeon; but other -operations have been performed by Mr. Fergusson, Mr. Cæsar Hawkins, Mr. -Partridge, Mr. Bowman, Mr. Hewett, and Mr. Edwin Canton. These -operations would evidently not have been performed except for the -discovery of producing a state of anæsthesia by inhalation. - -_Tenotomy._ I have memoranda of 78 cases of tenotomy in which I have -administered chloroform. In some of the cases which have occurred during -the last two or three years, forcible movement of a stiff joint has been -resorted to, in addition to the tenotomy. I applied chloroform in St. -George’s Hospital in tenotomy, when the agent was first introduced; and -have also given it in King’s College Hospital for ten years. During -these ten years I have also administered chloroform to a number of the -private patients of Mr. Fergusson, whilst he has performed tenotomy, and -to those of other surgeons occasionally. During the last three years, I -have given it in several operations by Mr. William Adams. I understand -that several orthopædic surgeons had, at one time, an objection to -chloroform in tenotomy, from an impression that it would relax the -muscles, and thus render the operation less easy of performance. But it -is altogether unnecessary to carry the effects of chloroform so far as -to relax the muscles. The pain of this operation can always be prevented -without relaxing the muscles, which are indeed often more tense than if -the patient were awake. - -_Operations for Strangulated Hernia._ I have notes of only nineteen -cases of operations for strangulated hernia in which I have administered -chloroform since the end of 1849. This operation is, I believe, often -performed without the use of this agent. Fifteen of the cases in which I -have exhibited chloroform were inguinal or femoral hernia, and four -cases were umbilical hernia. In these latter cases, the patients all -died. - -In one of the cases, there was a complication, in addition to the -hernia. The patient was an old gentleman, and the surgeon had directed -him to apply ice and salt, and had either given no directions respecting -the time it was to be applied, or the directions were misunderstood. The -patient was a scientific man, and applied the ice and salt most -effectually for about four hours. When we arrived, a portion of the -integuments around the umbilicus, larger than the palm of the hand, was -as hard as a board, and of a dull white colour. The surgeon said that he -could not turn back the flaps of the integument, if he made them whilst -it was in that hardened state. The part thawed whilst the patient was -inhaling chloroform, and when the incisions were made some fluid blood -of a light crimson colour flowed. Iced water was applied to the part -immediately after the operation, for a short time. The integuments which -had been frozen sloughed two days after the operation. The patient had -peritonitis, and died on the fifth day. - -On March 6th, 1848, a man was placed on the operating table in St. -George’s Hospital, with a strangulated femoral hernia. I administered -chloroform to him at the request of Mr. H. C. Johnson; and when he -became completely insensible and the muscular system relaxed, Mr. -Johnson readily reduced the hernia by means of the taxis, although it -was previously quite incapable of reduction. If the taxis had not been -successful, the operation, for which the instruments were arranged -ready, would at once have been performed whilst the patient was -insensible. I do not think that chloroform has been sufficiently -employed of late years during the application of the taxis to -strangulated hernia. - -In every case in which sickness was present, it was relieved by the -chloroform. And vomiting returned in scarcely any instance, after the -chloroform, so long as I remained in the room. - -_Operations for Hæmorrhoids and Prolapsus Ani._ I have memoranda of 171 -operations for these affections in which I have administered chloroform. -A great number of these operations have been performed by Mr. Fergusson -and Mr. Salmon; but I have also assisted Mr. Cæsar Hawkins, Mr. Bowman, -Mr. Quain, Mr. Erichsen, and a number of other surgeons, whilst -performing this operation. The patient always lies on one or the other -side during this operation, with the knees drawn up towards the stomach. -The chloroform should be inhaled till the patient is quite insensible, -that is, till the edge of the eyelid can be touched without causing -winking, otherwise he is apt to stretch out his legs, as soon as the -operation is commenced. Ligatures always, or nearly always, introduced -with a needle, have been applied to the mucous membrane in every case -both of hæmorrhoids and prolapsus ani, except in two or three in which -Mr. Henry Lee applied nitric acid and the actual cautery. In a great -number of the cases, however, folds of redundant and diseased skin were -cut away from around the anus, with a pair of large curved scissors, -after the ligatures had been applied to the mucous membrane. It is the -rule in these cases never to cut the mucous membrane, and never to tie -the skin. It is desirable to get the patient to protrude the hæmorrhoids -by bearing down at the night stool before he inhales the chloroform, and -they always remain protruded during the operation; indeed, there is -generally a good deal of bearing down during the operation under -chloroform, and if the bowels have not been entirely emptied, they are -apt to act as the operation is being performed. It is customary, and -very desirable, to give a full dose of opium almost as soon as the -patient wakes from the chloroform, to diminish the pain caused by the -ligatures. I have, in a few cases, continued to administer the -chloroform at intervals for an hour or two after the operation, till the -opium began to take effect; and I consider that it would be useful, in -some cases, to give the opiate two or three hours before the operation. -I administered chloroform to two ladies, one a patient of Mr. Bowman, -and the other of Mr. Wm. Adams, whilst hæmorrhoids were removed by the -écraseur. The operations lasted rather more than half an hour; but the -chloroform, after the commencement of the operation, required only to be -kept up to a moderate extent. There was no hæmorrhage in either case; -and it seemed to me that the great pain which is caused by the presence -of the ligatures would be prevented by this means of operating. - -Hæmorrhoids and prolapsus ani are peculiarly prevalent in the upper -class of society. That small portion of English people who dine in the -evening seem to furnish more cases of hæmorrhoids for operation than all -the rest of the population. And I am inclined to attribute the -circumstance to the habit of taking the greater part of the food towards -the close of the day, after a long fast; by which means congestion of -the liver, and obstruction to the return of blood from the bowels is -induced. Many of the patients with hæmorrhoids are ladies who are far -from luxurious in their habits, indeed many of them are abstemious; and -many of the male patients are the reverse of sedentary, as they spend a -great part of their time in hunting, and other field sports. Again, the -complaint cannot in my opinion be attributed to highly seasoned food, as -I think the working classes use more pepper than fashionable people. I -am inclined to believe that the habit of taking the chief meal of the -day at twelve or one o’clock, is the principal reason why bad cases of -hæmorrhoids are comparatively so rare in the working and middle classes, -many of whom live luxuriously, and are more sedentary in their habits -than the higher class of society. - -Several of the patients operated on for hæmorrhoids were extremely -blanched, from the continued loss of blood arising from the disease; but -these patients underwent both the action of the chloroform and the -operation very well. The operation, it must be remembered, is not -attended with loss of blood. - -_Fissure of the Anus._ I have notes of forty-four cases in which I have -exhibited chloroform in operations for the cure of this disease. Two of -them were performed by the late Mr. Copeland. The sphincter ani was -divided in the greater number of the operations. In addition to these -cases, there were some in which fissure existed, along with hæmorrhoids, -or fistula _in ano_. The patient was always placed on his side, in the -same position as in the operation for hæmorrhoids. - -_Operations for Fistula in Ano._ The position of the patient in this -operation should be the same as in those for hæmorrhoids and fissure of -the anus, unless the patient is placed on the back, in the lithotomy -position, as I have seen in a few cases. - -I have memoranda of 218 cases in which I have given chloroform in -operations for fistula _in ano_. In many of the cases the sinuses were -very numerous and extensive. It is necessary that the patient should be -quite insensible during this operation, to prevent the possibility of -his moving suddenly whilst the bistoury is being used. - -_Operations on Ovarian Tumours._ I have notes of three cases in which I -gave chloroform during the removal of an ovarian cyst. The first of -these was in March 1850. Twenty-four pints of liquid were first -evacuated from the tumour. It consisted of four cysts united together, -two of which contained serous fluid of slightly different colour; the -third contained serum tinged with blood, and the fourth and smallest -cyst, a purulent fluid. An incision was made, twelve or fourteen inches -in length, extending from the pubes to midway between the umbilicus and -sternum. Some slender adhesions were removed at one spot. The tumour was -attached by a membranous pedicle, with the left iliac fossa, and the -fundus of the uterus. Needles were passed through the pedicle, and it -was tied in three or four portions, when the tumour was removed. After -the tumour was removed, the patient seemed to breathe entirely by the -ribs, the diaphragm remaining relaxed, and not contracting, whilst the -wound in the abdomen was being closed. Scarcely any blood was lost -during the operation. The patient died of peritonitis early on the -fourth day. - -The next case occurred on August 27th, 1850, and is reported in the -_Medico-Chirurgical Transactions_ for 1851. Mr. Duffin was the operator, -and the patient made a favourable recovery. - -The third operation was performed on the 31st of January, 1854. The -patient was a spinster, twenty-eight years of age, and the tumour had -not been tapped. It contained about two gallons of clear fluid, and was -removed through an opening in the median line above the umbilicus, about -seven inches in length. There was no depression when the patient awoke -after the operation. She died within three days. - -I administered chloroform in two cases where it was intended to remove -an ovarian cyst. In one case the cyst was so adherent to the peritoneum -that it could not be removed; in the other case, there was no cyst, but -some serum in the peritoneal cavity, and a tumour growing from the -fundus of the uterus. This tumour was allowed to remain. Several medical -men, in addition to the operator, had diagnosed an ovarian tumour in -this case. These two patients recovered. - -I exhibited chloroform in four operations in which an ovarian cyst was -opened, and the cut edges of it sewed to the wound in the abdominal -parietes. These four patients, I believe, all died. I am quite certain -as regards three of them. - -On March 10th, 1852, I administered chloroform in St. Mary’s Hospital to -a woman, apparently about thirty-five, who had suffered from an ovarian -cyst about eighteen years. Mr. Isaac Baker Brown made an incision, about -six inches in length, into the peritoneal cavity, drew out a portion of -the cyst, tapped it, and removed several pints of clear serum. He then -cut away a piece of the anterior wall of the cyst, about as large as the -hand, and allowed the rest of the cyst to remain loose in the abdomen. -The wound in the parietes of the abdomen was stitched up. If I remember -rightly, the patient died, but I have no note of the result. - -_Operations for Cancer of the Vagina._ I have notes of eighteen cases in -which I have given chloroform for operations of this kind by the knife, -which would have been extremely painful without the use of an -anæsthetic. - -I exhibited this agent, in 1848, to a lady, whilst the late Mr. Aston -Key applied the actual cautery to malignant excrescence of the os uteri; -and I have administered it in several cases in which potassa and other -caustics have been applied to the os uteri. In operations on the vagina -or perineum, the woman should inhale chloroform whilst lying on her -back; and when insensible, should be drawn to the edge of the bed, or -the foot of the operating table, and have the knees held back and -separated. - -_Operations for Rupture of the Perineum._ I have notes of fourteen -operations for this accident. Six of them were performed by Mr. I. B. -Brown, five by Mr. Fergusson, and the others by Mr. Paget, Dr. Protheroe -Smith, and Mr. Henry Lee. Mr. Fergusson has, in five cases, performed an -operation for prolapsus uteri, by paring the edges of the outlet of the -vagina, and stitching them together so as to diminish the orifice. - -I have given chloroform in several operations for vesicovaginal fistula, -some of which were performed by Mr. Spencer Wells; and also for the -removal of warts and other growths from the labia pudendi, either by the -knife or caustics. - -_Removal of the Testicle; Amputation of the Penis, etc._ I have -memoranda of twenty-seven cases in which I have administered chloroform -during the removal of a testicle, generally for malignant disease; and -six cases in which I have administered it for amputation of the penis, -always for malignant disease. There were six operations, also, in which -a part of the penis was removed for malignant disease; and eleven cases -in which warts were removed from the glans penis, generally with the -knife. In two cases in August 1854, Mr. Acton destroyed a number of -venereal warts on the glans penis and prepuce by a caustic composed of -potassa and lime. In all the operations on the testicle and penis, under -chloroform, the patients have been lying on the back. - -_Operations for Phymosis._ I have memoranda of 76 operations for -phymosis, in which I have exhibited chloroform. The operations were -generally in the adult, although the complaint was, in most cases, -congenital. I have known two cases in which cancer of the penis was -produced by the patient’s suffering a congenital phymosis to remain to -about the age of fifty. The cancer commenced in the glans from the -irritation of the retained urine. One of the patients died of the -disease. - -_Removal of enlarged Bursa._ I have notes of six cases in which the -bursa of the patella was dissected out by the surgeons of King’s College -Hospital for housemaid’s knee. The patients were charwomen and domestic -servants. In two cases a bursa was removed from the forefinger. - -_Evulsion of the Nails._ I have notes of twenty-five cases in which I -have given chloroform for cutting down the nail of the great toe, and -tearing away the whole, or the two edges of it; and also of three cases -in which one or more finger nails were removed by a similar process. -This operation is one of the most painful of the minor operations of -surgery. It is better that the patient should be lying when it is done -under chloroform. - -_Laryngotomy._ I administered chloroform to one or two infants in which -Mr. Henry Smith performed laryngotomy for croup. I also administered it, -on four occasions, to a patient of Mr. Partridge, a boy four years old, -who was believed to have a button in some part of the air-passages. The -larynx had been opened a few days previously to the first occasion in -which I gave chloroform, and I administered it on a sponge, held near to -the tube in the larynx. It was necessary to give the vapour gently at -first, just as if it was entering in the usual way. When it was given at -all strong, whilst the patient was still conscious, he showed exactly -the distress that a patient experiences when he says that the vapour -produces a choking feeling; which confirms my opinion that the feeling -referred to the throat, from the action of pungent vapours and gases, is -caused by their presence in the lungs. The chloroform was given to keep -the child quiet whilst Mr. Partridge searched for the supposed button in -the larynx and bronchi. When the child recovered from the chloroform, -before the operation was concluded, the explorations in its air-passages -embarrassed the breathing much more, and caused more apparent -threatening of suffocation, than they did when he was under the -influence of the vapour. This little boy remained for months in King’s -College Hospital; and at last the embarrassment in his breathing -subsided, the tube was removed from the larynx, and the wound allowed to -heal; and he left quite well, although the button, which was supposed to -have gone down his windpipe at the moment when his symptoms first -suddenly came on, was never found. - -I have administered chloroform in a great variety of surgical -operations, in addition to those mentioned above, but as they required -only the usual management in the application of the vapour, I need not -allude to them, but shall, however, make a few remarks regarding dental -operations. - -_Extraction of Teeth._ It is the custom in the medical journals and -medical societies, to object occasionally to the use of chloroform in -tooth-drawing, as if the operation were not sufficiently severe to -require it. I will say nothing of the wives and daughters of medical men -in connexion with this subject, but will only allude to the case of an -elderly lady, who had for thirty years been the private friend, as well -as the patient, of one of the Council of the College of Surgeons. After -she had had ten necrosed teeth extracted, and had awakened from the -effects of the chloroform, her friend and surgeon, who had been looking -on, discoursed eloquently on her case, explaining how the state of her -mouth was ruining her health; how impossible it would have been for her -to go through the operation without chloroform, and what a great -advantage it was. - -Dr. Watson says in his Lectures:[148] “I am not at all sure that the -increased longevity of modern generations is not, in some degree, -attributable to the capability of chewing their food which the skill of -the dentist prolongs to persons far advanced in life.” I have seen at -least fifty cases in which the dentist has been able to exert his skill -in enabling his patient to masticate only by the aid of chloroform; -cases of feeble, aged, or debilitated persons, whose mouths contained -between twenty and thirty stumps of teeth or necrosed teeth; and who -were able to get rid of them all at two or three operations a few days -apart; but without the opportunity of being made insensible, would -undoubtedly have continued with the mouth in a tender and painful state. - -It was in consequence of the relief afforded by nitrous oxide gas, in -pain caused by a tooth, that Sir Humphrey Davy suggested its application -in surgical operations; it was for the extraction of a tooth that Mr. -Horace Wells first carried out the suggestion of Davy; and it was in the -extraction of teeth that Dr. Morton first employed sulphuric ether as a -substitute for nitrous oxide gas. These circumstances seem to point to a -demand for anæsthetics in operations on the teeth; and when the great -frequency of these operations is considered, it is probable that more -pain may be prevented during their performance than in any other class -of operations. - -I have notes of 867 cases in which I have administered chloroform during -the extraction of teeth, chiefly by dentists living in this -neighbourhood: amongst whom are Mr. Saunders, Mr. Cartwright, Mr. Samuel -Cartwright, Mr. Arnold Rogers, Mr. Thomas A. Rogers, Mr. Tomes, Mr. -Bigg, Mr. Crampten, Mr. F. W. Rogers, Mr. Alfred Canton, Mr. Woodhouse, -Mr. Lintott, Mr. Rahn, Mr. Vasey, Mr. Sercombe, Mr. Fletcher, and -several others; and there is one dentist in the City, Mr. West of Broad -Street, whom I have frequently assisted. The number of teeth, or stumps -of teeth, extracted in these 867 operations, has been about 3021. In -some cases in which several teeth have been removed, I have not been -sure of the exact number, but have put down about the number. - -The number of teeth extracted at an operation has varied from one to -nineteen. The latter number was extracted by Mr. Canton on one occasion, -and on two or three occasions, Mr. Arnold Rogers and Mr. Samuel -Cartwright extracted seventeen at one sitting; but these gentlemen and -others, as well as myself, have thought it better, as a general rule, to -make more than one operation, when the number of teeth to be drawn -exceeded ten, in order that the mouth might not contain too many wounds -at one time, and that the loss of blood might not be very great. A great -number of the operations have been for the extraction of the four first -permanent molars, in children about thirteen, as these teeth are very -apt to decay at an early period. - -I have on 181 occasions, of which I have memoranda, given chloroform for -the extraction of a single tooth. I exhibited it lately to a lady, aged -eighty-six, whilst Mr. Bigg extracted an abortive wisdom tooth, which -had recently come through the gum, and was giving pain. She awoke in -about two minutes after the operation, and was quite cheerful and well. - -The patients have been seated in an easy chair in all the operations on -the teeth, except in a very few cases where a female patient was too ill -to sit up. In many cases, and always if there was any feeling of -faintness, the patient has been placed on a sofa, after the operation, -for twenty minutes or half an hour. I am not aware of any inconvenience -from the chloroform, in any of the cases of tooth-drawing, excepting -sickness and vomiting, which in a very few of the cases have been -troublesome for some time. - -It is necessary in tooth-drawing to make the patient unconscious, and to -continue the chloroform a little while after unconsciousness is induced, -till the sensibility of the edge of the eyelid is very much diminished, -or almost altogether suspended, otherwise the patient will probably make -a resistance that will interfere with the operation, or scream out and -alarm his or her friends. I nearly always take about four minutes in the -inhalation. It is not desirable to take longer than five or six minutes, -as the patient would be slower than is desirable in recovering -completely from the effects of the vapour. - -The patient is usually in the third degree of narcotism when the -operation is performed, and, in this degree, as was previously stated, -there is not unfrequently a contracted and rigid state of the muscles. -This state often affects the muscles of the jaws, and interferes with -the opening of the mouth, if it be closed. I generally tell the patient -to keep his mouth open whilst inhaling, and by that means it often -remains open when he is insensible. Not unfrequently, however, he closes -it on becoming insensible. One can generally open it by pressing on the -chin; but as the chin does not afford a very favourable hold, there are -a very few cases in which the mouth cannot be opened easily in this way, -at least not unless the effects of the chloroform are carried further -than is desirable for these operations. I therefore carry with me a -little instrument of two blades, made to open by means of a screw. The -ends of the blades are covered with leather, and, if introduced between -the teeth, at the corner of the mouth on the side opposite to that on -which the dentist is about to operate, the mouth can easily be -opened.[149] The power of the instrument is only such that I can -scarcely open it with one hand, when I hold the blades with the other. -It would not enable one to open the mouth of an adult if he were closing -it by voluntary power; but the spasm caused by chloroform is very much -less powerful than the action of the muscles when influenced by the -will. I never use the instrument for opening the mouth when the patient -is closing it voluntarily under the influence of a disordered -consciousness, but always wait till consciousness and volition are -entirely suspended. When the mouth is once opened, it can generally be -kept open with the fingers, and the instrument may be withdrawn. - -The bleeding during tooth-drawing is never so free as to interfere with -the breathing; but when more than two or three teeth are extracted, and -especially if they be in the back part of the mouth, some of the blood -which escapes nearly always flows into the stomach; it flows down the -fauces and œsophagus usually without any act of deglutition; but the -evidence of its having gone into the stomach is obtained in those cases -where the patient vomits. In consequence of the blood flowing into the -stomach, vomiting cannot so generally be prevented by the precaution of -not taking a meal before the operation in tooth-drawing as in other -operations; but the sickness usually subsides as soon as the patient has -emptied his stomach. - -The chloroform has occasionally to be repeated in tooth-drawing before -the operation is completed, especially in cases where several teeth -require to be extracted. When this is the case, I always reapply it as -soon as the patient begins to show signs of feeling the operation, -without waiting till he recovers his consciousness. In many cases, -however, a number of teeth are extracted without any repetition of the -chloroform; and in the instances in which as many as fifteen, seventeen, -or nineteen teeth were extracted at one operation, it was chiefly -because the first application of the vapour enabled the dentist to take -out such a number, otherwise, in most of these cases, a number of the -teeth would have been left for a succeeding operation. It has -occasionally happened, however, that the chloroform has required to be -repeated, once or twice even, for the extraction of a single stump. When -the chloroform is repeated once or twice, it is generally a longer time -before the patient is able to leave the dentist’s house. I always -request the patients who are operated on at the dentist’s, to drive -home, as it is not advisable to walk, or use any exertion for an hour or -two after the action of chloroform. Indeed, the patient is usually -disinclined for any exertion for twenty minutes or half an hour after -the influence of this agent, and sometimes for much longer; although I -have seen a patient mount the box of a sort of dog-cart, and drive -himself away, within five minutes after having several teeth extracted -whilst he was in a state of complete insensibility from chloroform. - -I have administered chloroform in a great number of cases for the -destruction of the nerves of the teeth. The patient requires to be made -as insensible in this operation as in tooth-drawing. - -_Secondary Hæmorrhage_ after Operations. The hæmorrhage which -occasionally comes on several days after an operation, from sloughing, -ulceration, or the non-formation of a coagulum in an artery, is probably -as liable to occur now as formerly; but I believe that hæmorrhage, a few -hours after an operation, is much less frequent since the practice of -narcotism by inhalation. Before this practice, it was extremely common -for the patient to faint during an operation, when the bleeding of the -smaller arteries stopped, and they escaped the ligature, to break out in -hæmorrhage occasionally afterwards; but under the influence of narcotic -vapours it is unusual for the patient to faint, and consequently every -vessel which is capable of bleeding is tied during the operation. - - - CHLOROFORM IN PARTURITION. - -When the practice of inhalation in midwifery was first introduced by Dr. -Simpson, he very naturally adopted the plan which is usually followed in -surgical operations, making the patient unconscious at once, and keeping -her so to the end of the labour. It was soon found, however, by other -practitioners, that this is not necessary; and, indeed, it would not be -safe in protracted cases. Drs. Murphy and Rigby were, I believe, amongst -the first to state, that relief from pain may often be afforded in -obstetric cases, without removing the consciousness of the patient; and -I soon observed the same circumstance.[150] Some persons, indeed, have -alleged that the pain of labour can always be prevented, without making -the patient unconscious of surrounding objects; whilst others have -asserted that no relief can be afforded unless unconsciousness be -induced. But both these opinions are directly opposed to experience. -There are comparatively few cases in which the suffering can be -prevented throughout the labour without interfering with consciousness, -although there are very many cases in which it can be in this way -prevented in the early part of the labour. This difference depends, in -some measure, on the constitution of the patient, but chiefly on the -severity of the pain to be prevented. It is in accordance with what is -observed in medical and surgical cases, that the pain should be removed, -in some instances, without abolishing consciousness, and that in other -instances it should not; for, in certain cases of neuralgia, the pain is -so severe, that no material relief can be obtained by chloroform as long -as consciousness is retained; and in surgical operations, although it -now and then happens that the minor and concluding parts of an -operation, such as tying vessels and introducing sutures, can be -performed without pain, whilst the patient is consciously looking on, a -free incision in the skin can hardly ever be made, under similar -circumstances, without pain. - -With regard to the cases of labour in which chloroform may be employed, -it will be readily conceded that, in cases where the pain is not greater -than the patient is willing to bear cheerfully, there is no occasion to -use chloroform; but when the patient is anxious to be spared the pain, I -can see no valid objection to the use of this agent, even in the most -favourable cases. The benefits arising from chloroform in severe cases -of labour are experienced in a lesser degree in favourable cases; and -the patient may be fairly allowed to have a voice in this, as in other -matters of detail which do not involve the chief results of the case. -The determination of the kind of labours in which chloroform should be -used, or withheld, is really a matter of not much importance, because, -as we pass from cases that are severe and protracted to those which are -short and easy, the quantity of chloroform that is used, and the amount -of diminution of the common sensibility, and of interference with the -mental functions, become so trifling, that very little remains about -which to hold a discussion. Indeed, from what I have observed of the -continued use of this agent in medical cases, and its use by healthy -persons for experiment, I believe that the quantity which is inhaled in -a short and easy labour might be continued daily for an indefinite -period, without appreciable effect on the health. - -The above remarks apply also, in some measure, to the question as to the -period of the labour when the exhibition of chloroform should commence; -for, in proportion as the pains are feeble, it must be more sparingly -administered. The most usual time when the accoucheur and I have -determined that the inhalation should be commenced, has been when the os -uteri was nearly dilated to its full extent, and the pains were taking -on an expulsive character. In many of the cases which I have attended, -it has, however, been commenced much earlier; for the suffering caused -by the dilating pains in the first stage of labour is often very great, -and the chloroform is consequently of the utmost service when employed -at this time. - -As regards the manner of giving chloroform, I shall first allude to -cases not requiring manual or instrumental assistance. In such cases, -when it has been determined to resort to inhalation, the moment to begin -is at the commencement of a pain; and the chloroform should be -intermitted when the uterine contraction subsides, or sooner, if the -patient is relieved of her suffering. It is desirable to give the -chloroform very gently at first, increasing the quantity a little with -each pain, if the patient is not relieved. The practitioner easily -finds, with a little attention, the quantity of vapour which it is -desirable to give at any stage of the labour, and in each particular -case; his object being to relieve the patient without diminishing the -strength of the uterine contractions and the auxiliary action of the -respiratory muscles, or with diminishing it as little as possible. At -first, it is generally necessary to repeat the chloroform at the -beginning of each “pain”; but, after a little time, it commonly happens -that sufficient effect has been produced to get the patient over one or -two uterine contractions without suffering, before it is resumed. - -The external evidences of the uterine contractions continue as before, -when the patient is rendered unconscious by chloroform; and the muscles -of respiration are called freely into play, to assist the action of the -uterus in the second stage of labour. The aspect of the patient under -these circumstances, is generally that of one who is suppressing the -expression of her sufferings; and any relative or friend who comes in, -without knowing that chloroform has been given, begins to praise the -unconscious patient for her fortitude. On some occasions, indeed, there -are groans and cries, as of suffering; but the mind being unconscious of -pain, it can hardly be said to exist. - -It may be remarked, that complete anæsthesia is never induced in -midwifery, unless in some cases of operative delivery. The diminution of -common sensibility to a certain extent, together with the diminution or -removal of consciousness, suffice to prevent the suffering of the -patient during labour; and she never requires to be rendered so -insensible as in a surgical operation, when the knife may be used -without causing a flinch or a cry. The nerves of common sensation must -be allowed to retain their functions to a certain extent during labour; -otherwise the assistance of the respiratory muscles, which consists of -reflex action, or “motion arising from sensation, without the aid of -volition”, would not take place, even if the contractions of the uterus -should still continue. - -The effects of chloroform on the brain should not be carried during -labour beyond what I denominate the second degree of narcotism, or that -condition in which the mental functions are diminished, but not -altogether suspended, except when the effect of the vapour is associated -with natural sleep. The patient under the influence of chloroform to -this extent, has no longer a correct consciousness of where she is, and -what is occurring around her, but is capable of being aroused to give -incoherent answers, if injudiciously questioned. In this state, the -patient will sometimes assist the labour by bearing down voluntarily, if -requested to do so, and be otherwise obedient to what is said; and by -withholding the chloroform for a few minutes, she at any time becomes -quite conscious. As a general rule, it is desirable not to hold any -conversation whilst the patient is taking chloroform, in order that her -mind may not be excited. The plan mentioned above, of giving the -chloroform very gently at first, also has a tendency to prevent its -causing mental excitement, the patient coming gradually under its -effects. In surgical operations, excitement of the mind can nearly -always be avoided by carrying the patient pretty rapidly into a state of -insensibility, in which the mental functions are necessarily suspended. -But in the practice of midwifery, it is not allowable to cause a state -of coma or insensibility, except in certain cases of operative delivery, -hereafter to be mentioned. - -I nearly always employ, in obstetric cases, the inhaler that I use in -surgical operations. There is not the same necessity for an accurate -means of regulating the proportion of vapour in the air which the -patient is breathing during labour, where but a trifling amount of -narcotism requires to be induced, as in surgical operations, where a -deeper effect is necessary; still I find the inhaler much more -convenient of application than a handkerchief, and it contains a supply -of chloroform which lasts for some time, thereby saving the trouble of -constantly pouring out more. When I do administer chloroform on a -handkerchief during parturition, I follow the plan of putting only ten -or fifteen minims of chloroform on the handkerchief at one time. - -The quantity of chloroform administered during any one pain, never -exceeds a very few minims; but the quantity used in the course of a -protracted labour is often considerable. I have several times used from -four to six ounces; and in one case, at which I was present the greater -part of the time, seventeen fluid ounces of chloroform were used with -the inhaler, which would produce as much effect as three or four pounds -used on a handkerchief. The inhalation was continued with intermissions -over a period of thirty-one hours. The patient was unconscious during -the greater part of the last five or six hours, but previously to this, -her constant complaint was that she had not enough chloroform. She was -the wife of a physician, was thirty-seven years of age, and in her first -confinement. The membranes ruptured early. The labour was natural, but -there was excessive sensibility. The first twenty-six hours of -intermitted inhalation were during the first stage of labour. - -Chloroform can be best applied when there is an additional medical man, -who has not to attend to the ordinary duties of the accoucheur; but it -can be given very well by the accoucheur himself, so as to save the -greater part of the suffering of labour; although he perhaps cannot -always administer it in the perfect way in which he could, if he had no -other duties to divide his attention. - -It is probable that the use of chloroform has no particular influence -over the duration of labour, in the whole number of cases in which it is -employed; but individual labours are occasionally either retarded or -quickened by it, according to circumstances. In some cases, the -chloroform, even when very moderately employed, diminishes both the -strength and the duration of the uterine contractions, and prolongs the -interval between them, thereby making the labour somewhat longer—a -matter of no consequence, however, as the patient is not suffering in -any way. In other cases, the inhalation causes the uterine action to -become stronger and more regular, by removing the excess of sensibility -by which it has been interfered with. This occurs more particularly in -the first stage of labour. In some cases, also, the chloroform seems to -act as a direct stimulant to the uterine contractions, increasing their -force and frequency—a circumstance at which we need not be surprised, -when we remember that both opium and brandy, in moderate quantity, often -act in the same manner. Chloroform has also the effect of promoting the -dilatation of the os uteri in many cases, even when no rigidity exists; -and when there is rigidity of the os uteri, the inhalation is of the -utmost service, and shortens labour very much. This is the case, also, -when there is rigidity of the perineum. - -When the forceps have to be applied, it is desirable to make the patient -insensible, as if for a surgical operation just before they are applied; -and to leave off the chloroform as soon as they are introduced, in order -to allow of the uterine action to return, and assist in the delivery. I -have always found the action of the uterus return immediately after the -forceps were introduced; and where the child was not delivered at once, -I have continued the chloroform in sufficient quantity to keep the -patient unconscious, whilst allowing the uterine contractions to -continue. - -I have administered chloroform on nine occasions in which the forceps -were applied; in four of the cases, I was sent for in consequence of the -operation being required; and in the other five cases, I was in -attendance from an early part of the labour, and had administered -chloroform more or less for some hours before the forceps were applied. -They were applied in three instances by Dr. Murphy, twice by Dr. -Ramsbotham, and in the other cases by Drs. Farre, Frere, and Thudichum, -and Mr. Peter Marshall. - -I have administered chloroform in two cases of craniotomy, both of which -were performed by Dr. Murphy, on account of deformity of the pelvis. The -amount of chloroform scarcely requires to be increased during this -operation beyond what would be given according to the strength of the -pains which may be present at the time. - -In the operation of turning the child, the mother requires to be made -quite insensible, in order that the uterine contraction may be entirely -suspended till the legs of the child are brought down, when the -inhalation should be discontinued to allow the contraction of the uterus -to return. I have notes of six cases of turning the child, in which I -have administered chloroform. The first case, which occurred in 1848, -was one of natural presentation, in which turning was performed by Dr. -Murphy, on account of narrowness of the pelvis, and the impossibility of -applying the forceps; the introduction of the hand was difficult on -account of want of space, but the uterus offered no resistance. Dr. -Murphy has related the case. Three of the other instances of turning -were performed by Mr. French, in cases which had been attended by -midwives, and the membranes had been ruptured for several hours. The -shoulder and part of the chest were in each case pressed down into the -pelvis, and the pains were very strong; yet under a full chirurgical -dose of chloroform, the child was turned as easily as if the membranes -had not been ruptured. In the first of these three cases, the child was -dead before the operation commenced. In the other two, it was born -alive. In the last case, the membranes had been ruptured for ten hours -before the operation was performed. After the child was delivered, there -was found to be a second child presenting naturally, but I did not stay -to give any more chloroform. The fifth case of turning was performed in -a case of elbow presentation by Mr. Peter Marshall. The membranes had -been previously ruptured. I administered chloroform, also for Mr. -Marshall, in a case where the hand was presenting below the head; he -raised it above the head, and as it did not come down again when the -pains returned, the labour was allowed to pursue its natural course, and -terminated favourably in two or three hours, the child being alive. The -chloroform was not continued after the operation was performed. The -remaining case of turning was performed by Mr. Tegart, of Jermyn Street. -I was in attendance with him from an early stage in the labour, and the -operation was performed before the membranes were ruptured. - -I administered chloroform, in 1849, in a case in which Dr. Murphy had to -make an artificial os uteri. The patient was, of course, made quite -insensible as for any other surgical operation; and the vapour was -continued afterwards in a modified degree till the labour was completed. - -On December 26th, 1850, I was requested by Mr. Cooper, of Moor Street, -Soho, to assist him in a case of retention of the placenta. The patient -had given birth to a child two hours before, and Mr. Cooper had -introduced his hand, but had been unable to bring away the placenta, on -account of firm contraction of the uterus in a sort of hour-glass form. -On the chloroform being administered, the hand was easily introduced, -and the placenta detached, and extracted. There was very little -hæmorrhage. - -In some of the many cases at which I have met Dr. Cape, premature labour -was induced about the eighth month of utero-gestation, by rupturing the -membranes, on account of deformity of the pelvis. - -In a case attended by Mr. Cantis, the patient was suffering from -osteo-sarcoma of the bones about the shoulder. Dr. Ferguson was present -during the latter part of the labour. The lady lived a few weeks after -her confinement. - -A patient, attended in her confinement by Mr. Colambell of Lambeth, in -1853, to whom I gave chloroform, had been long under the care of Dr. -Williams with cavities in the lungs. I heard very lately that she was -still living. - -A patient of Mr. Robert Dunn, to whom I gave chloroform in her -confinement, was at the time in a state of insanity. - -In one of the patients whom I have attended with Dr. Arthur Farre, there -was separation of the recti muscles of the abdomen; which there is no -doubt must have taken place gradually during pregnancy. The patient was -but twenty years of age, and in her first labour. Quite early in the -labour, before the pains were at all strong, Dr. Farre and I observed -that the abdomen was of a peculiar form, the uterus projecting very much -forwards, whilst there was a slackness in the flanks. The abdominal -muscles did not assist the pains at all; and it was probably from this -cause that the labour progressed slowly and was terminated at last with -the forceps. The recti muscles recovered their position by careful -bandaging. - -The chloroform has always been left off as soon as the child was born, -but a little has been administered again on several occasions during the -expulsion of the placenta. The placenta has generally been expelled very -soon in the labours in which I have given chloroform; usually in about -five minutes. There has hardly ever been uterine hæmorrhage of any -amount, except in patients who had suffered from it in previous labours. -In a case attended by Mr. Nathaniel Ward, however, there was a slight -hæmorrhage before the birth of the child, and about an hour afterwards -there was a considerable hæmorrhage which made the patient feel rather -faint for some hours. She afterwards went on favourably, however. She -was a young woman who had had several children. - -A patient, to whom I was recommended by Sir John Forbes, inhaled -chloroform in three confinements. She recovered favourably from the two -first; but on the third occasion, after going on favourably till the -fifth day, she was attacked with puerperal fever, and died on the -seventh day from her confinement. - -I am not aware that more than one death has been recorded as having -occurred from chloroform during labour; and this took place in England, -in 1855, when no medical man was present.[151] The patient had inhaled -chloroform in America in a previous labour; but her medical man, on the -last occasion, who was her particular friend, forbad that agent, and -said that if she was determined to have it, he would not attend her. She -procured chloroform unknown to him, and a number of scents to put on her -handkerchief and hide the odour of it from him. He went to bed in the -house, and was not called up till his patient had been dead about an -hour. The monthly nurse, who had procured the chloroform for the -patient, said that she snored very loudly for an hour after she fell -asleep. About five drachms of chloroform were used from the bottle, and -the handkerchief from which it was inhaled remained close to the -patient’s face till she died. The death seemed to have taken place very -slowly, and the monthly nurse was extremely stupid to allow the patient -to die. It may also be remarked that the accident would not have taken -place except for the medical man’s extreme objection to the use of -chloroform. - -The chloroform has been occasionally blamed by the friends of patients, -or medical men opposed to its use, in cases where patients have died -from puerperal convulsions or other causes, so long after the vapour had -been left off that it could not be the cause of death. The following -case shows how easy it would be to make a mistake with respect to the -effects of chloroform. Soon after its introduction, I was requested to -administer it to the wife of a medical man who had a great desire for it -in her confinement. Mr. Propert was to attend the lady. I was sent for -late one evening, but as there were no pains at the time when I arrived, -I was requested to go to bed in the house. After a time, I was called by -a servant, who told me that the baby was born, and that Mr. Propert was -sent for. I found that the birth had been so sudden that the husband, -who was in the room, could not get to the bed side before the child was -born. Mr. Propert arrived, and I went home, leaving the patient very -well. Mr. Propert informed me, that after I left the patient went into -such a state of syncope as to make him think she was going to die, and -continued so for some time. She ultimately recovered. There was no -hæmorrhage or any other cause to account for the faintness, and I -understood Mr. Propert to say, that if the patient had inhaled -chloroform, he should have blamed it for the condition into which she -lapsed. - - - THE INHALATION OF CHLOROFORM IN MEDICAL CASES. - -_Neuralgia._ When the pain of neuralgia is not extremely severe, it may -be removed by the inhalation of chloroform without causing -unconsciousness; but when it is very severe, it is necessary to make the -patient unconscious before the pain is suspended. In some cases of -neuralgia of the face, the pain is so severe that the signs of it remain -after the patient is rendered unconscious, and only disappear when he is -quite insensible; and then, as the insensibility passes off, the hand is -raised to the face, and the contortions of the features return before -the patient awakes to be aware of his suffering. When the mental branch -of the fifth nerve is affected, the paroxysms of pain are accompanied by -a motion and smacking of the lips. In a hospital patient I have seen -this when he was awake, but in a gentleman only when his consciousness -was removed by the chloroform, and before complete insensibility was -induced; when awake, he restrained the impulse to this kind of motion of -the lips. - -In administering chloroform it is desirable to continue it steadily and -gradually till the pain is relieved; and if the patient is rendered -unconscious before the pain is removed, to continue it till all signs of -suffering disappear. After the first inhalation of the vapour, the pain -will generally return in a few minutes, but when again subdued, it will -not return so quickly; and after it has been suspended a few times by -the repetition of the chloroform during the space of an hour or so, the -pain is usually removed either permanently or for two or three hours. In -some cases I have had to repeat the chloroform occasionally throughout -the day, and, on one or two occasions, for two or three days in -succession. The chloroform can, in general, only be considered a -temporary remedy, and therefore such other medicines should be applied -as may be thought advisable. - -When I have prescribed chloroform in a liniment, to be applied to the -face, the patient has often found out that he obtained more relief by -smelling at the liniment than by applying it. Chloroform generally gives -great relief, however, when applied locally in neuralgia, either alone -or mixed with camphorated spirit; it is advisable to apply it on a piece -of lint or blotting paper, which should be covered over with tinfoil, or -some other impermeable substance, to prevent the evaporation. It causes -about as much heat and uneasiness as a mustard poultice, before it -relieves the pain. - -_Spasmodic Asthma._ On November 12th, 1850, I administered chloroform in -the Hospital for Consumption, at Brompton, to a married woman, aged -thirty-five, a patient of Dr. Cursham. She was in a fit of spasmodic -asthma, but was the subject also of chronic bronchitis. Twenty minims of -chloroform were inhaled from an inhaler. It gave immediate relief, -producing a momentary state of unconsciousness, or a state bordering on -it. In a few minutes the difficulty of breathing gradually returned, but -not to the same extent, and the inhalation was repeated with a like -effect. The difficulty of breathing returned less quickly and severely; -and after a third inhalation of twenty minims she was completely -relieved, and could lie down. The patient had a good night, and was -better next day. On the 14th, she had another fit of spasmodic asthma, -which was relieved completely by the chloroform in the same manner as -the previous one. This patient inhaled extract of stramonium every -evening, by a method which will be described further on. - -Other cases of spasmodic asthma have been relieved as readily and -completely; but in one or two cases, in which the difficulty of -breathing seemed to depend on disease of the heart, the relief was not -so great; the patient went to sleep, but the breathing remained -embarrassed. - -_Spasmodic Croup._ I have administered chloroform in seven cases of this -complaint. It was recommended in every instance by Dr. Ferguson, and all -the cases ended in recovery. The children were from eight months to two -years of age; the majority being about a year. I always gave enough -chloroform to cause a state of unconsciousness, for which a few minims -suffices in a young child, and when the effect passed off, or nearly so, -I repeated the dose. I generally gave five or six doses in the course of -about half an hour, after which the child would often sleep for two or -three hours. In the milder cases it was repeated once a day; but in the -more severe cases it was continued, in the above manner, twice a day. I -administered it to a patient of Dr. Van Oven, respecting whom Dr. -Ferguson had been consulted, for fifteen days, twice every day, -excepting the last three days. This child was very ill when the -treatment was first commenced, having a severe fit of spasmodic -breathing every five minutes. When the chloroform is given during the -spasm, it is desirable to give it very cautiously. - -Mr. W. J. H. Cox read a paper on the treatment of laryngismus stridulus, -with chloroform, at the London Medical Society, in 1850. He had -entrusted the administration of it to the mother or nurse, and directed -it to be given whenever the spasmodic breathing should come on. I am -inclined to think that this would be the best way of giving it, if one -could be quite sure of the intelligence of the party to whom it was -entrusted. - -_Hooping-Cough._ I have only administered chloroform in two cases of -this complaint. It was recommended in both cases by Dr. Ferguson. One of -the children was extremely ill of bronchitis, and it died. The other -child recovered, but the chloroform was not continued. I am not aware -that chloroform has had any fair trial in hooping-cough. It should be -given whenever a fit of coughing comes on. - -_Infantile Convulsions._ I have administered chloroform in two cases of -this disease, with the effect of relieving the convulsions, but the -children died. They were both extremely ill before the chloroform was -administered. One was the patient of Mr. Walter Bryant, and Dr. Seth -Thompson was consulted about it. A case has been related by Dr. Simpson -of Edinburgh, in which the chloroform was continued for a day or two, -and in which the infant recovered. - -_Delirium cum Tremore._[152] Some cases have been related in the medical -journals, in which this complaint was treated successfully by chloroform -alone; but I prefer to use this agent only as an adjunct to the -treatment by opium. Sometimes the patient is so violent and suspicious -that he cannot be made to take opium; but it is much easier to make a -person breathe a medicine, than swallow one. It is only necessary to -hold a patient, and to apply the chloroform near his face, and he is -obliged to breathe it, and as the effect of it subsides, he recovers the -power of swallowing before his delirium returns; for whilst he is still -unconscious, he will swallow whatever is poured into his throat. Opium -can be administered, and the chloroform can be repeated occasionally so -as to keep him asleep for an hour or two till the opium takes effect and -prolongs the sleep. It is a great advantage of chloroform that the -delirium may be subdued in a few minutes by it, and can be kept away -till opium takes effect. - -In certain cases of delirium cum tremore, such a quantity of opium is -taken without procuring sleep, that the medical attendant has, what I -believe to be, a well-grounded fear of giving more. A patient whom I saw -with Mr. Peter Marshall, in April 1850, had taken ten fluid drachms of -laudanum and two grains of acetate of morphia, within twenty-four hours -of my seeing him, without any sleep being procured. He was put to sleep -immediately by chloroform, which was repeated on the following day. The -patient got quite well in a few days. - -In December 1851, I saw a patient who had had no sleep for four days, -except three intervals of a quarter of an hour each, although a great -deal of opium had been given. He was very violent; and for the last -twelve hours had spat out all the medicine that was given to him; his -pulse was small and very rapid. He was made insensible in a few minutes, -and the chloroform was repeated, at intervals, for half an hour, so as -to keep him unconscious. Fifty minims of tincture of opium were given in -one of the intervals. I waited an hour and a quarter after the -chloroform was discontinued; the patient was still sleeping, and his -pulse was less frequent. I learnt that when he awoke he was quite free -from delirium, and he was well in a few days. - -_Delirium in Fever._ In November 1857, I administered chloroform to a -youth of seventeen, who had been ill of typhoid fever for sixteen days. -He had been in a state of constant delirium for upwards of forty-eight -hours without having the least sleep, although he had had tincture of -opium in divided doses to the extent of forty-five minims, and had taken -a tablespoonful of wine every four hours. The chloroform was continued -gently for half an hour; he slept for an hour afterwards, and at -intervals during the night. He was a little better in the morning; and -the delirium was not again so violent as it had been. He died on the -nineteenth day of the fever, from a recurrence of diarrhœa. - -Dr. Fairbrother, of Bristol, gave small doses of chloroform by -inhalation, with the best effects, in a case of typhus fever, in the -Bristol Infirmary. The patient was delirious and worn out for want of -sleep, her life being in fact despaired of. She inhaled the chloroform -occasionally for several days, sleep being always procured when it was -applied, and she recovered without any other medicine.[153] - -_Hydrocephalus._ I administered chloroform on two occasions, for half an -hour at a time, to a child, seven years old, when delirious and -screaming violently, in this complaint. The child was much relieved by -the inhalation, but it died on the fourteenth day of the disease. - -_Tetanus._ I have notes of three cases of tetanus in which I have -administered chloroform. The first was a patient of the late Mr. Keate, -in St. George’s Hospital, in February 1849. It was a girl, fourteen -years old, who had received some severe burns in the face and various -parts of the body, a fortnight previously. Four days before inhaling the -chloroform, she was attacked with symptoms resembling those of chorea, -but for the last two days the complaint was recognised to be tetanus. -There was rigidity of the spine and jaws, and of one arm, which was -flexed. Spasms came on every minute or two, affecting, more -particularly, the head and the arm. I commenced to give chloroform very -gently at four in the afternoon. It prevented the spasm before -consciousness was quite removed. Whenever the spasm offered to return, -the inhalation was repeated with the effect of stopping it. The -chloroform was continued till half-past five, with the effect of keeping -the spasm away; and the patient took some drink during this time, better -than she had done previously. I saw the child again at eight o’clock in -the evening, and found that the spasms had returned soon after I left, -and had continued as before. The chloroform was given again at intervals -for an hour and a half, with the effect of keeping away the spasms, and -inducing sleep; but I found that the child was getting weaker, and would -die even if the spasm was entirely prevented. She died at a quarter past -eight the following morning. There was no inspection of the body. - -The next case was a patient of Mr. Propert, a boy, ten years of age, who -had suffered from sloughing of the skin of the inferior extremities. The -tetanus came on during the healing process, whilst the greater part of -both extremities was in a state of ulceration, and covered with healthy -granulations. The patient was in a very irritable and feeble state, and -his pulse was 150 in the minute. He was made insensible, and the -chloroform was repeated twice in the space of half an hour. No -relaxation of the muscles of the jaws was produced, although the effect -of the chloroform was carried as far as seemed safe in such a subject. -He died twelve hours afterwards. - -I administered chloroform lately to a patient of Mr. Salmon in St. -Mark’s Hospital. He underwent an operation by ligature for prolapsus ani -and hæmorrhoids on March 1st; on March 5th tetanus commenced, and on -March 7th chloroform was administered whilst Mr. Salmon removed some -sloughs from the anus; and it was repeated occasionally afterwards. The -patient was a man, fifty-two years of age; he was the subject of kidney -disease, and the tetanus was extremely severe. He had had four doses, -each containing a fluid drachm of laudanum, between the time when the -tetanus commenced and his inhaling the chloroform. His pupils were -contracted, and he was made insensible by an extremely small quantity of -chloroform. He was, in fact, very much under the influence of opium, -although the spasm of the tetanus prevented his sleeping. - -Chloroform affords great relief to the patient affected with tetanus, -and it probably increases the prospect of recovery in cases which are -not too severe and acute. - -_Epilepsy._ Dr. Todd at one time had chloroform administered by -inhalation, in King’s College Hospital, to the extent of causing -insensibility, at stated intervals, in cases of epilepsy, and he thought -with advantage. I have frequently administered chloroform for surgical -operations to patients who were subject to epilepsy, and have very -rarely found it produce any approach to a fit. - -In July 1850, I administered chloroform to a boy, seven years old, in an -epileptic fit, which had lasted about an hour when the inhalation was -commenced. He had had fits previously, the last of which had occurred a -year before, but none of them had lasted so long as the existing one. He -had eaten nine new potatoes for his dinner, at one o’clock, and the fit -came on about eight. I found the abdomen swollen and very tympanitic. -There was constant convulsive motion of the right arm, and of the neck; -the latter drawing the head to the right side. The mouth was also drawn -to the right at each convulsive motion. The chloroform was given by -putting a few minims at a time on a handkerchief, and holding it to the -mouth and nostrils. It caused immediate cessation of the convulsions -every time it was applied. The convulsions, however, returned again in a -minute or two. In the intervals that he was partially under the -influence of the vapour, he breathed easily without stertor. The -convulsions became gradually less severe, and ceased entirely ten or -fifteen minutes after the commencement of the inhalation. - -_Puerperal Convulsions_. I have not been called to any case of this -complaint since chloroform has been in use; but some cases have been -related in the medical journals in which the inhalation of chloroform -has been employed with a favourable result. One case is related by Mr. -Henry Rudge, of Leominster.[154] When the chloroform was administered, -the patient was in violent convulsions which came on in frequently -succeeding fits. The os uteri was dilated, and the head presenting. The -pains were entirely arrested. The chloroform was administered by twenty -minims, at intervals, on a folded handkerchief. The convulsions, after a -few inhalations, entirely ceased, and Mr. Rudge extracted the child -without difficulty. There was another child with the head presenting: it -was delivered with the forceps. The placenta was delivered with the hand -on account of smart hæmorrhage. There was only one attack of convulsions -after delivery, and the patient recovered favourably. It was her first -labour, and her age was twenty-three years. - -A case of puerperal convulsions was related by Mr. Andrew Bolton to the -Newcastle and Gateshead Pathological Society.[155] His patient, aged -twenty-two, was at the full period of her first pregnancy. The os uteri -was high, slightly dilated, and extremely rigid. She was treated at -first by blood-letting, and full doses of morphia. Mr. Bolton says: “As -her condition appeared hopeless should the paroxysms continue, -chloroform was administered on a piece of linen, in half-drachm doses, -and its full effects kept up for three hours. At two P.M., there was a -slight return of convulsion; skin warm and perspiring; the os uteri was -found steadily dilating; and from her uneasy movements, it was apparent -that uterine action had begun. - -“Half-past three. The membranes were ruptured; and brisk uterine action -ensuing, a dead child was expelled, immediately followed by the -placenta. She regained her senses during the expulsive efforts, but -appeared entirely ignorant of her previous condition. Recovery followed -without any bad symptom. - -“In conclusion, I would remark, that the convulsions were in no measure -mitigated by the depletion, which was carried to the utmost; nor was -there any yielding of the os uteri until the chloroform was inhaled.” - -The urine was not examined in either of the above cases, and it is not -stated that œdema was present. - -_Hysterical Paralysis and Contractions._ In December 1851, I -administered chloroform in Charing Cross Hospital to a young woman about -twenty-five, a patient of Dr. Chowne. She kept her left knee in a -semiflexed position, and would not allow it to be moved. She had been in -bed in the hospital for two months. She inhaled the chloroform -reluctantly, and, after becoming unconscious, she breathed and sobbed in -a hysterical manner. When insensible, the limb went down flat on the -bed, the knee being quite movable. A straight splint was applied, and -the limb was secured to it with bandages. I was informed that in a few -days she contrived to get her leg bent again. She was the domestic -servant of a nobleman. It was evident that there was nothing the matter -with her limb, and that it was only influenced by her volition, which -was perverted by the hysteria under which she was labouring. - -In November, in the same year, I administered chloroform in the same -hospital to another patient of Dr. Chowne, whose case was more obscure -and complicated. The patient was a woman, aged thirty-three, who -represented that for several months she had been unable to open her -mouth, or to speak, and that she had, for the same length of time, been -paralyzed in the left arm and leg. The affection, it was said, came on -suddenly, in a kind of fit, which was followed by unconsciousness for -three or four weeks. It was also said, that she had one or two fits the -previous year, after which she was unconscious for a long time. The -patient was quite conscious before inhaling the chloroform, and replied -to questions by nodding or shaking the head, or by writing on a slate. -She was unmarried, and had not menstruated for some months past. The -chloroform was administered with a view to ascertain whether or not she -was feigning. On first becoming unconscious, the patient breathed in a -sobbing and hysterical manner. The chloroform was given very gradually; -and as she became more affected, there were some struggling and -rigidity, when the right arm and leg were moved about a good deal. The -left arm and leg were also distinctly moved, but not above a tenth part -as much as the extremities of the opposite side. When the patient was -quite insensible, the limbs being relaxed, the pupils turned upwards, -and the conjunctiva insensible, attention was turned to the jaws, which -were still firmly closed, but they were opened by using a moderate -degree of force with the fingers. The effect of the chloroform having -been allowed in a great measure to subside, it was again administered, -when the movements of the limbs recurred, and there was the same -difference between the motion of the right side and that of the left, as -before. When I left the patient, more than half an hour after the -chloroform was discontinued, she had not opened her eyes or answered -questions; and she did not do either for six days. I saw her five days -after the chloroform. The pulse was very rapid on my first going to the -bedside, but its frequency subsided in a few minutes. On my raising the -eyelid, she turned her eye about, as if endeavouring to hide the pupil -under the lid. On the following day she answered questions by nodding -and writing on a slate, and was, in other respects, the same as before -inhaling the chloroform. - -The great difference in the amount of motion in the limbs of this -patient, under the influence of chloroform, showed that the paralysis of -the left side was not a mere pretence. It is, indeed, possible that the -absence of motion in the limbs of the left side, for several months, -would cause them to move less than the opposite ones during the action -of chloroform; but it is not to be supposed that the patient would keep -these limbs in one posture during the night, and when no one was -present, without ever moving them, unless she herself believed that they -were paralyzed. I looked on the woman as a sick person, and not a mere -impostor; for although she appeared to exaggerate her symptoms, and to -have a good deal of pretence and affectation, this circumstance arose, -no doubt, from her complaint. - -In April 1853, I administered chloroform four times to a patient of Dr. -Arthur Farre, a girl of fifteen years of age, who was affected with a -contraction of the flexor muscles of the left thigh and leg, of the -muscles which bend the body to the left side, and those which bend and -turn the head to the same side, in consequence of which the leg was -drawn up, and the body and head were curved greatly to the left side. -The contraction of the muscles had lasted for several weeks, but she had -been ill for a much longer period, her illness having commenced with a -fever. She took an extremely small quantity of nourishment, and was very -thin. Her bowels were moved with difficulty. The pulse was very feeble -and small, and there was a tendency to coldness of the surface. An -eminent surgeon in the provinces had expressed his opinion that the -distortion of the limbs and trunk was a feigned disorder; but the action -of the chloroform proved that he was altogether in error. The muscles -became completely relaxed when the patient was quite insensible, and the -limbs and trunk and head could be readily moved into any position; but -as the effects of the chloroform subsided, the deformity returned on -each occasion before the patient recovered her consciousness. Neither -the chloroform nor any other measures were of any service, and Dr. Farre -informed me that the patient died a few weeks after I saw her. - -_Mania._ I have been informed of several cases in which chloroform has -been administered in acute mania, with the effect of calming the patient -and procuring sleep. I have administered it in two cases with the same -temporary advantage. In one of the cases, the patient was persuaded to -inhale it; in the other, he had to be held by three keepers till he was -unconscious. An eminent and well-known scientific man, who became insane -some years ago, refused to take food. It was found that after being made -unconscious by chloroform, he would take a meal just as he recovered -from its effects, and the chloroform was given before every meal for a -long time. - -_Spasmodic Pain._ In August 1851, I administered chloroform to a woman -who was labouring under a severe paroxysm of spasmodic pain in the -abdomen. The pain was completely removed, without altogether causing -unconsciousness. An opiate was given to prevent the pain from returning. - -I have not had the opportunity of administering chloroform during the -passage of calculi down the ureters, or of gall-stones; but there can be -no doubt that it would be of the greatest service in such cases. If Dr. -Griffin had been provided with chloroform when he attended the late Mr. -Augustus Stafford with an attack of gall-stones,[156] he would have been -able to relieve his patient in five minutes, instead of taking two or -three hours to produce relief by opium. There would have been no -occasion for the venesection, which was carried to thirty ounces. And at -the end of the attack, on Dr. Griffin leaving his patient for the night, -if chloroform had been employed, he would have left him without any -appreciable amount of the narcotic in his system. As it was, however, he -left him with a quantity of opium unabsorbed from the alimentary canal. -The bandage got displaced from the arm; there was an additional -hæmorrhage, the opium became absorbed more quickly, and a dangerous -state of narcotism was induced. - -_Frequent and long continued Use of Chloroform._ Many patients have -inhaled this agent hundreds of times, and it continued to produce -insensibility as readily as at first. The dose does not require to be -increased on account of its long use. I was informed of the case of a -lady who was affected with a painful cancer, and was attended by the -late Mr. Keate and Mr. Henry Charles Johnson. She inhaled chloroform at -frequent intervals, by day and night, for a very long time, consuming -three or four ounces in the twenty-four hours. - -In November 1851, a surgeon in the north of England wrote to me -respecting one of his patients, a lady, who had inhaled a great deal of -chloroform, on account of neuralgia of the uterus. He said that, during -that year, and principally within the last six months, she had inhaled -at least two hundred ounces; that she often inhaled as much as three -ounces in a day; and that it seemed to have produced very little effect -on her general health, except that she seemed to be more susceptible of -pain. He said that he had reluctantly yielded to the entreaties of his -patient to administer it so often, and he wished for my opinion -respecting the propriety of continuing its use, and what effect it would -be likely to produce. - -I advised that the chloroform should be continued as long as the -severity of the pain rendered it necessary; and expressed my opinion, -that it would produce as little ultimate effect as any other narcotic -which might be used to relieve the pain. I saw the surgeon in September -of the following year. He informed me that the chloroform was continued -for some time after he had written to me; but that his patient had -recovered from her complaint, and had left off the chloroform, and was -in good health. - -Mr. Garner, of Stoke-upon-Trent, has related the case of a lady, -affected with neuralgia, who inhaled sixty-two ounces of chloroform from -her handkerchief, in twelve days.[157] - - - - - SULPHURIC ETHER, OR ETHER. - - -_History and Composition._ “This liquid is first described by Valerius -Cordus, in 1540, under the name of _oleum vitrioli dulce_. The term -_ether_ was applied to it a hundred and ninety years afterwards by -Frobenius, who, in a paper in the _Philosophical Transactions_, -described its singular properties; at the end of this paper is a note by -Godfrey Hankwitz, Mr. Boyle’s operator, mentioning the experiments that -had been made upon it by Boyle and by Newton.”[158] - -The present chemical name of ether, or sulphuric ether, is oxide of -ethyle. It consists of four atoms carbon, five atoms hydrogen, and one -atom oxygen. Its atomic number is consequently 37. - -The usual way of making ether, is to distil common alcohol (the hydrated -oxide of ethyle) with sulphuric acid. - -_Chemical and physical Properties._ Ether is a clear, colourless liquid, -of the specific gravity of 0·715 at 68°. It boils at 96° Fahr.; and the -specific gravity of its vapour is 2·565. It is soluble, in all -proportions, in alcohol, and it is soluble in nine parts, by measure, of -water. Water is also soluble in nine parts, by measure, of ether, so -that after ether has been agitated with water, it retains one-tenth of -its volume of that fluid. Ether is very inflammable, and, as it yields -its vapour very freely, great care is required in pouring it out by -artificial light. Its vapour is also very explosive when mixed, in -certain proportions, with atmospheric air. - -The ordinary ether of the shops contains a portion of alcohol which has -distilled over with it; the alcohol should be removed by agitating the -ether with twice its volume of water, before it is used for inhalation. -The ether which has been treated in this way is called washed ether. The -water which it takes up during the washing can be removed by distilling -it from lime, or dry carbonate of potassa; but this is unnecessary, as -the water does not interfere with the action of the ether when inhaled; -and part of the water evaporates and is inhaled with the ether, when the -atmospheric air is not already saturated with moisture. - -Ether has a peculiar and very strong odour; in this respect it differs -extremely from chloroform. The odour of a single drop of ether can be -distinctly perceived all over a large operating theatre, whilst a pint -of chloroform may be spilt without its odour being much noticed. The -strong odour of ether is, indeed, one of the greatest objections to its -use, since another agent has been discovered which is free from this -objection. As was previously stated, the odour of chloroform cannot be -perceived in the breath, after the lungs are emptied by one or two -expirations of the vapour just taken in; whilst the smell of ether can -be perceived in the breath for twenty-four, and sometimes for -forty-eight, hours after the patient has inhaled it. The surgeon, and -others who have been about the patient, also smell of the ether to a -less degree. When a rabbit has been killed by the inhalation of ether, a -starving cat will not eat its flesh even after it has been boiled; -whereas the odour of chloroform cannot be perceived in the bodies of -animals that have been killed by it. - -If ether is exposed to atmospheric air by being kept a long time in a -bottle but partly filled, it is apt to be decomposed into acetic acid -and water. - -The following Table shows the result of experiments which I made to -ascertain the quantity of vapour of ether that 100 cubic inches of air -will take up, when saturated with it, at various temperatures, the -barometric pressure being 30 inches of mercury. The ether I employed in -the experiments was washed, but not dried. It was, therefore, saturated -with water, of which it contained one-tenth of its volume. It had a -specific gravity of 0·735 at 60° Fahr., and it boiled at 98°. - - Temp. Fah. Cubic inches of vapour. Minims of ether. - 50° 52 64 - 51 54 66 - 52 56 69 - 53 59 72 - 54 62 76 - 55 65 80 - 56 68 84 - 57 72 88 - 58 76 93 - 59 80 98 - 60 84 102 - 61 88 107 - 62 92 112 - 63 97 117 - 64 102 122 - 65 107 128 - 66 112 134 - 67 117 140 - 68 123 147 - 69 130 156 - 70 138 165 - -In the above Table the air is a constant quantity of 100 cubic inches, -which becomes expanded to 152, and so on; but the following Table shows -the quantity of vapour in 100 cubic inches of the saturated mixture of -vapour and air at different temperatures:— - - Temp. Fah. Air. Vapour. - 40° 73 27 - 42 72 28 - 44 70 30 - 46 69 31 - 48 67 33 - 50 66 34 - 52 64 36 - 54 62 38 - 56 60 40 - 58 57 43 - 60 54 46 - 62 52 48 - 64 49 51 - 66 47 53 - 68 45 55 - 70 42 58 - 72 40 60 - 74 37 63 - 76 34 66 - 78 32 68 - 80 29 71 - -The absorption of caloric during the evaporation of ether is much -greater than during that of chloroform, owing both to the greater -quantity of vapour it yields on account of its lower boiling point, and -to the lower specific gravity of the vapour. The evaporation of ether -from the bulb of a thermometer usually lowers the temperature nearly to -zero of Fahrenheit. When the inhalation of ether was first commenced, -the inhalers employed consisted generally of glass vases containing -sponge, to afford a surface for the evaporation of the ether. Both glass -and sponge being very indifferent conductors of caloric, the interior of -the inhalers became much reduced in temperature, the evaporation of -ether was very much checked, and the patient breathed air much colder -than the freezing point of water, and containing very little of the -vapour of ether. On this account, and through other defects in the -inhalers, the patient was often very long in becoming insensible, and, -in not a few cases, he did not become affected beyond a degree of -excitement and inebriety. - -To ensure the ether taking effect in a short time in every case, I made -use of the conducting power of the metals, and the great capacity of -water for caloric. The inhaler which I employed was made of plated -copper, and was placed in two or three pints of water, of the ordinary -temperature. The form of the inhaler was that of one which had been -contrived by Mr. Julius Jeffries for the inhalation of aqueous -vapour.[159] No sponge or bibulous paper, or other material, was used; -and the air, before being inhaled, was made to pass over a considerable -surface of ether by means of a spiral volute, soldered to the top of the -inhaler, and reaching nearly to the bottom. The accompanying engraving -shows the interior of the inhaler, on a scale of half the dimensions, -the bottom being removed. - -[Illustration] - -_The Physiological Effects of Ether_ are essentially the same as those -of chloroform. The various degrees of narcotism which I described in the -earlier part of this work, when treating of chloroform, were first -described by me when treating of ether in 1847, before chloroform was in -use.[160] All the remarks which I made with respect to the manner in -which age, strength or debility, and other circumstances, influence the -action of chloroform, apply also in an equal degree to ether. - -I performed some experiments in 1848,[161] for ascertaining the -proportions of vapour of ether present in the blood in the different -degrees of narcotism. They were conducted on the same principles as -those previously related, which were performed for the purpose of -determining the same point in regard to chloroform. - -_Experiment 31._ Two grains of ether were put into a jar holding 200 -cubic inches, and the vapour diffused equally, when a tame mouse was -introduced, and allowed to remain a quarter of an hour, but it was not -appreciably affected. - -_Experiment 32._ Another mouse was placed in the same jar, with three -grains of ether, being a grain and a half to each 100 cubic inches. In a -minute and a half, it was unable to stand, but continued to move its -limbs occasionally. It remained eight minutes without becoming further -affected. When taken out, it was sensible to pinching, but fell over on -its side in attempting to walk. In a minute and a half, the effect of -the ether appeared to have gone off entirely. - -_Experiment 33._ A white mouse in the same jar, with four grains of -ether, was unable to stand at the end of a minute, and at the end of -another minute ceased to move, but continued to breathe naturally, and -was taken out at the end of five minutes. It moved on being pinched, -began to attempt to walk at the end of a minute, and in two minutes more -seemed quite recovered. - -_Experiment 34._ Five grains of ether, being two and a half grains to -each 100 cubic inches, were diffused throughout the same jar, and a -mouse put in. It became rather more quickly insensible than the one in -the last experiment. It was allowed to remain eight minutes. It moved -its foot a very little when pinched, and recovered in the course of four -minutes. - -_Experiment 35._ A white mouse was placed in the same jar with six -grains of ether. In a minute and a half, it was lying insensible. At the -end of three minutes, the breathing became laborious, and accompanied by -a kind of stertor. It continued in this state till taken out, at the end -of seven minutes, when it was found to be totally insensible to -pinching. The breathing improved at the end of a minute; it began to -move at the end of three minutes; and five minutes after its removal, it -had recovered. - -_Experiment 36._ The same mouse was put into this jar on the following -day, with seven grains of ether, being 3·5 grains to the 100 cubic -inches. Stertorous breathing came on sooner than before; it seemed at -the point of death when four minutes had elapsed; and being then taken -out, was longer in recovering than after the last experiment. - -_Experiment 37._ Two or three days afterwards, the same mouse was placed -in the jar, with eight grains of ether, being four grains for each 100 -cubic inches. It became insensible in half a minute. In two minutes and -a half, the breathing became difficult; and at a little more than three -minutes, it appeared that the breathing was about to cease, and the -mouse was taken out. In a minute or two, the breathing improved; and in -the course of five minutes from its removal, it had recovered. - -The temperature of the mice employed in the above experiments was about -100°. That of the birds in the following experiments was higher, as is -stated; and they differ widely from the mice in the strength of vapour -required to produce a given effect, although I found but little -difference between the mice and birds, in this respect, in the former -experiments on chloroform. And one of the linnets was employed in both -sets of experiments. Having seen MM. Dumeril and Demarquay’s statement -of the diminution of animal temperature from inhalation of ether and -chloroform, before the following experiments were performed, the -thermometer was applied at the beginning and conclusion of some of them. -I have selected every fourth experiment from a larger series on birds. - -_Experiment 38._ 18·4 grains of ether were diffused through a jar -holding 920 cubic inches, being two grains to each 100 cubic inches, and -a green linnet was introduced. After two or three minutes it staggered -somewhat, and in a few minutes more appeared so drowsy, that it had a -difficulty in holding up its head. It was taken out at the end of a -quarter of an hour, quite sensible, and in a minute or two, was able to -get on its perch. The temperature under the wing was 110° before the -experiment began, and the same at the conclusion. - -_Experiment 39._ Another linnet was placed in the same jar, with four -grains of ether to each 100 cubic inches of air. In two minutes it was -unable to stand, and in a minute more, voluntary motion had ceased. It -lay breathing quietly till taken out, at the end of a quarter of an -hour. It moved its foot slightly when it was pinched. In three minutes -it began to recover voluntary motion, and was soon well. The temperature -was 110° under the wing, when put into the jar, and 105° when taken out. - -_Experiment 40._ A green linnet was put into the same jar with 55·2 -grains of ether, being six grains to 100 cubic inches. It was insensible -in a minute and a half, and lay motionless, breathing naturally, till -taken out at the end of a quarter of an hour. It moved its toes very -slightly when they were pinched with the forceps, and it began to -recover voluntary motion in two or three minutes. Temperature 110° -before the experiment, and 102° at the end. - -_Experiment 41._ A linnet was placed in the same jar, containing eight -grains of ether to each 100 cubic inches. Voluntary motion ceased at the -end of a minute. The breathing was natural for some time, but afterwards -became feeble, and at the end of four minutes appeared to have ceased; -and the bird was taken out, when it was found to be breathing very -gently. It was totally insensible to pinching. The breathing improved, -and it recovered in four minutes. - -_Experiment 42._ 9·2 grains of ether, being one grain to each 100 cubic -inches of air, were diffused through the jar, holding 920 cubic inches -of air, and a frog was introduced. At the end of a quarter of an hour, -it had ceased to move spontaneously, but could be made to move its -limbs, by inclining the jar so as to turn it over. At the end of half an -hour, voluntary motion could no longer be excited, and the breathing was -slow. It was removed, at the end of three-quarters of an hour, quite -insensible, and the respiratory movements being performed only at long -intervals, but the heart beating naturally; and it recovered in the -course of half an hour. The temperature of the room was 55° at the time -of this experiment. - -We find from the 32nd experiment, that a grain and a half of ether for -each 100 cubic inches of air, is sufficient to induce the second degree -of narcotism in the mouse; and a grain and a half of ether make 1·9 -cubic inch of vapour, of specific gravity 2·586. Now the ether I -employed boiled at 96°. At this temperature, consequently, its vapour -would exclude the air entirely; and ether vapour, in contact with the -liquid giving it off, could only be raised to 100° by such a pressure as -would cause the boiling point of the ether to rise to that temperature. -That pressure would be equal to 32·4 inches of mercury, or 2·4 inches -above the usual barometrical pressure; and the vapour would be condensed -somewhat, so that the space of 100 cubic inches would contain what would -be equivalent to 108 cubic inches at the usual pressure. This is the -quantity, then, with which we have to compare 1·9 cubic inch, in order -to ascertain the degree of saturation of the space in the air-cells of -the lungs, and also of the blood; and by calculation, as when treating -of chloroform, - - 1·9 is to 108 as 0·0175 is to 1. - -So that we find 0·0175, or 1–57th to be the amount of saturation of the -blood by ether necessary to produce the second degree of narcotism; and -as by Experiment 35, three grains in 100 cubic inches produced the -fourth degree of narcotism, we get 0·035, or 1–28th, as the amount of -saturation of the blood in this degree. Now this is within the smallest -fraction of what was found to be the extent of saturation of the blood -by chloroform, requisite to produce narcotism to the same degrees. But -the respective amount of the two medicines in the blood differs widely; -for whilst chloroform required about 288 parts of serum to dissolve it, -I find that 100 parts of serum dissolve five parts of ether at 100°; -consequently 0·05 × 0·0175 gives 0·000875, or one part in 1142, as the -proportion in the blood in the second degree of narcotism; and 0·05 × -0·035 gives 0·00175, or one part in 572, as the proportion in the fourth -degree. - -In Experiment 42 the frog was rendered completely insensible by vapour -of a strength which was not sufficient to produce any appreciable effect -on the mouse in Experiment 31. This is in accordance with what was met -with in the experiments with chloroform. Air, when saturated with ether -at 55°, contains 32 grains in each 100 cubic inches; so that the blood -of the frog might contain 1–32nd part as much as it would dissolve, -which, although not quite so great a proportion as was considered the -average for the fourth degree of narcotism in the mice, yet was more -than sufficient to render insensible the mouse in Experiment 34. - -There is a remarkable difference between the birds and the mice, in -respect to the proportions of ether and air required to render them -insensible, a difference that was not observed with respect to -chloroform. In some experiments with ether on guineapigs, which are not -adduced, they were found to agree with mice in the effects of various -quantities. - -The birds were found to require nearly twice as much; five grains to 100 -cubic inches, the quantity used in an experiment between the -thirty-ninth and fortieth, which is not related, may be taken as the -average for the fourth degree of narcotism in these birds, with a -temperature of 110°. By the kind of calculation made before, we should -get a higher amount of saturation of the blood than for the same degree -in mice. But as serum at 110° dissolves much less ether than at 100°, -the quantity of this medicine in the blood of birds is not greater than -in that of other animals; and, considered in relation to what the blood -would dissolve at 100°, the degree of saturation is the same. - -By Experiments 36, 37, and 41, we find that with ether, as with -chloroform, a quantity of vapour in the air, somewhat greater than -suffices to induce complete narcotism, has the effect of arresting the -respiratory movements. - -In treating of chloroform (page 74), the average quantity of serum in -the adult human subject was estimated at 410 fluidounces. In order to -find the quantity of ether in the system, we may multiply 410 by -0·000875 for the second degree of narcotism, and by 0·00175 for the -fourth degree, when we shall obtain 0·358 and 0·71 of an ounce, _i. e._ -f. ʒii. ♏︎l in the first instance, and f. ʒv. ♏︎xl in the second. In the -third degree of narcotism, in which surgical operations are usually -performed, the quantity is intermediate, or a little over four drachms. - -_On the Administration of Ether._ About a fluid ounce of ether is -usually inhaled by an adult patient in becoming insensible; fully -one-half of this is, however, thrown back from the lungs, windpipe, -nostrils, and face-piece, without being absorbed. I usually put two -fluid ounces of ether into the inhaler above described, at the beginning -of the inhalation, and this quantity often lasts to the end of the -operation, if it is not a protracted one. The inhaler is connected, by -means of a wide elastic tube, with a face-piece similar to that -described and delineated in treating of chloroform. It is necessary that -the inhalation should commence, as in the case of chloroform, with the -expiratory valve of the face-piece turned on one side, for the admission -of air which is not charged with ether, and that the vapour should be -admitted to the air-passages by degrees, to avoid the irritation that -would arise from suddenly inspiring any considerable quantity of the -vapour. The vapour of ether is very much less pungent than an equal -quantity of the vapour of chloroform; but as the patient requires to -breathe about six times as much of it in the inspired air, it feels -quite as pungent as that of chloroform, and, perhaps, a little more so. -Whilst the patient never requires to take in more than four or five per -cent. of vapour of chloroform in the inspired air, he requires to inhale -about thirty per cent. of vapour of ether, in order to be rendered -insensible in a convenient time. The air-passages, however, soon get -accustomed to the presence of the vapour of ether, and in a minute and a -half or two minutes after the patient begins to inhale, he can usually -bear the valve to be closed so far as to charge the air with as much -vapour as is necessary speedily to cause insensibility. The inhaler -yields quite sufficient vapour when the water-bath is at 50° Fahr.; and -at the seasons of the year when the temperature of the water is higher, -the expiratory valve of the face-piece can be left more or less open to -admit a portion of air which has not passed through the inhaler. - -I prefer the flavour of ether vapour to that of chloroform; and the -sensations I experience from the inhalation of ether are more -pleasurable than those from chloroform. Many persons agree with me on -both those points; but some prefer chloroform. The quantity of ether -expended in causing insensibility is eight or ten times as great as that -of chloroform, but the quantity used in a protracted operation is not so -disproportionate; for, owing to the great solubility of ether and the -large quantity of it which is absorbed, it is much longer in exhaling by -the breath, and when the patient is once fairly insensible, it does not -require to be repeated so frequently as chloroform. - -In administering ether, I usually rendered adult patients insensible in -four or five minutes, and children in two or three minutes. A somewhat -longer time was occasionally occupied in cases in which the air-passages -were irritable, or where there was much rigidity and struggling. I never -failed to make the patient insensible in any one instance in which I -administered ether. I have notes of 152 cases in which I administered -ether, before chloroform was introduced, and twelve cases in which I -have exhibited it since. - -Nearly all the great operations of surgery were included several times -amongst the cases in which I administered ether. Amputation of the thigh -was performed in nineteen cases; fifteen of the patients recovered, and -four died. Amputation of the leg was performed eleven times; eight of -the patients recovered, and three died. The arm was amputated three -times; one of the patients died, and two recovered. There were thus -thirty-three of the larger amputations with eight deaths, being a -mortality of twenty-four per cent. There were two amputations of the -forearm, and both patients recovered. There were nine operations of -lithotomy; seven of the patients recovered, and two died. Five of the -patients were children, who all recovered; the two deaths occurring -amongst the four adult patients. Eighteen female patients had the breast -removed for tumour, and they all recovered except one. - -On July 1st, 1847, Mr. Cutler amputated the leg of a man, aged -forty-four, in St. George’s Hospital, who had suffered from disease of -the tibia and ankle, which had existed thirty years, and was caused by -an accident. This patient died on the seventh day, of sloughing -phagedena, which was present in the hospital. It was then found that he -had disease of the heart. Its structure was soft and easily lacerable; -much fat was mixed up with the muscular structure. The aortic valves -were much thickened, and almost cartilaginous in structure. Two of them -were so much contracted that they were together about the size of a -healthy one. The left ventricle was dilated, and the right ventricle -still more so; its walls being extremely thin. The ether had acted quite -favourably on this man. - -I administered ether repeatedly in infants and old people. Some of the -infants were operated on by Mr. George Pollock, in 1847, for congenital -cataract by drilling; and two of them were operated on, in 1857, for -hare-lip, by Mr. Fergusson and Mr. Bowman. A gentleman, one of whose -toes the late Mr. Liston amputated in 1847, was said to be subject to -apoplectic attacks. The ether acted very favourably. Amongst the -operations which Mr. Liston performed on patients to whom I administered -ether, was the tying of the external iliac artery in a man, aged forty, -for an aneurism of the groin, situated partly above Poupart’s ligament. -The patient lay perfectly still in this, as in all the other important -operations in which I administered ether. He recovered. - -On June 18th, 1847, I exhibited, in University College Hospital, ether -to a man, aged forty-two, with stricture of the urethra, caused by an -accident. He passed his urine only in drops, and the attempts to pass a -catheter had all failed. It was Mr. Liston’s intention to divide the -urethra in the perinæum, but when the patient was placed fully under the -influence of ether to the fourth degree of narcotism, a catheter (No. 1) -passed into the bladder, and the operation was not required. Larger -catheters were introduced in a few days, and on July 27th, the patient -was discharged, being able to pass his urine in a good stream. - -Ether was administered in many cases of midwifery by Dr. Simpson, who -had first applied it in obstetric cases, and by a number of other -practitioners. I only exhibited it in one case, and then only for a -short time. Mr. Lansdown of Bristol used it in thirty cases.[162] In one -case, it was continued for eleven hours and a half, and fourteen fluid -ounces of ether were used. He said that he invariably found the perinæum -relaxed before the head came to bear on it, thereby not requiring the -pressure of the head to force it open, in cases where ether was used. He -says: “I find the uterus sending out the placenta immediately after the -expulsion of the child, and there has been scarcely any hæmorrhage -following.” Mr. Lansdown said that he had found the action of the uterus -to be induced by ether, when in a sluggish state, but he had not found -this effect from chloroform, in the cases in which he had used it. - -Ether was used with great advantage in most of the kinds of medical -cases in which chloroform was afterwards applied. In the summer of 1847, -an infant, nine months old, was brought to me in a convulsive fit, which -had lasted twenty minutes. I poured twenty minims of ether on a sponge, -and applied it to its mouth and nostrils; in two or three minutes, the -quantity was repeated. The spasm subsided, and the child fell asleep. It -had no return of the fit. It was labouring under hooping-cough at the -time, which had existed a week. - -The inhalation of ether was employed in the treatment of asthma, -hooping-cough, and tetanus, before it was employed in surgical -operations. It has been already stated (page 14) that Dr. Richard -Pearson administered the vapour of ether in consumption in 1795. Dr. -Robert Willis sent an article to the _Medical Gazette_ on February 2nd, -1847,[163] in which the following passages occur. - -“Ether, given by the mouth, has long been familiarly employed in the -treatment of asthma. I have for many years been aware of the fact that -it is vastly more efficacious administered directly in vapour by the -breath. My plan of using it is extremely simple. I have had recourse to -no kind of apparatus for this purpose, but have been content to pour -two, three, or four drachms of the fluid upon a clean handkerchief, and -to direct this to be held closely to the mouth and nostrils: a single -short and difficult inspiration is hardly made before the effect is -experienced; and I have occasionally seen the paroxysm ended in six or -eight minutes, the respiration having in that brief interval become -almost natural. - -“It is not otherwise with hooping-cough: the paroxysms of coughing are -positively cut short by having the ether and the handkerchief in -readiness, and using them when the fit is perceived to be coming on.” - -I have been informed of a case of tetanus which was treated successfully -by inhalation of ether more than twenty years before this medicine was -used to prevent the pain of operations, but I am not able at present to -give a reference to the case. Mr. C. A. Hawkesworth, surgeon, of -Burton-on-Trent, wrote me an account of a case of tetanus, which had -recovered under the inhalation of ether in 1847. The patient was a -healthy-looking butcher’s boy, about twelve years old, who had received -a slight scalp wound, which was followed by general tetanus. Mr. -Hawkesworth administered the vapour of ether to him during the greater -part of one day. The spasm relaxed most completely whilst the influence -of the ether continued, but returned in great degree when the inhalation -was intermitted. He took no other medicine except calomel and jalap, -with a view to purgation; the calomel, however, acted on his mouth. He -recovered speedily and completely. Some other cases of recovery from -tetanus under the inhalation of ether have been recorded in the medical -journals. - -In February, 1847, Dr. Sibson related several cases of facial neuralgia -that had been greatly benefited by the inhalation of ether;[164] and it -has been used in many cases since. - -The inhalation of ether causes an increased flow of saliva in many -cases; quite as frequently, in fact, as chloroform. Vomiting also -follows the use of ether quite as often as that of chloroform. The -insensibility from ether lasts longer than that from chloroform without -repeating the inhalation when the narcotism is carried to the same -degree. When the narcotism from ether is carried to the fourth degree -there is generally a complete absence of pain for three minutes, and a -state of unconsciousness for five minutes longer, a period during which -any pain there might be would not be remembered afterwards. On account -of this longer duration of the effects of ether, it is better adapted -than chloroform for certain operations on the face, as removal of -tumours of the jaws, the operation for hare-lip, and making a new nose. -The relaxation of the muscular system from the effects of ether seems -greater in general than from chloroform, and ether therefore seems to be -the better agent to employ in the reduction of old dislocations, and -strangulated hernia. - -_Great safety of Ether._ I believe that ether is altogether incapable of -causing the sudden death by paralysis of the heart, which has caused the -accidents which have happened during the administration of chloroform. I -have not been able to kill an animal in that manner with ether, even -when I have made it boil, and administered the vapour almost pure. The -heart has continued to beat after the natural breathing has ceased, even -when the vapour has been exhibited without air; and in all cases in -which animals have been made to breathe air saturated with ether vapour, -at the ordinary temperatures of this country, they have always recovered -if they were withdrawn from the vapour before the breathing ceased. Even -in cases where the natural breathing had ceased, if the animal made a -gasping inspiration after its removal from the ether it recovered. - -I hold it, therefore, to be almost impossible that a death from this -agent can occur in the hands of a medical man who is applying it with -ordinary intelligence and attention. - -I am only aware of two deaths which have been recorded as occurring -during the administration of ether, and it is not probable that the -death in either case was due to the ether. The first of these cases -occurred in France, at the Hotel Dieu d’Auxerre, on July 10th, -1847.[165] The patient was a man fifty-five years of age, who had a -cancerous tumour of the left breast of seven months duration. He was -robust, and had no general lesion resulting from the cancerous disease. -The ether was exhibited with the apparatus of Charrière. The patient had -hardly inhaled two or three minutes when he became strongly excited. The -trunk and limbs were agitated with violent starts and shocks. The -breathing became frequent, and the face injected. He endeavoured to push -away the inhaler, and babbled as if drunk. This state lasted for five -minutes, and the prick of a pin showed that sensibility still remained. -The apparatus was still applied, but in opening to the ether vapour an -issue as large as the instrument permitted; for the tap which gave -passage to it had hitherto been but half turned, and that progressively. -At the end of ten minutes from the beginning of inhalation, the -relaxation and immobility of the limbs was complete, the insensibility -was not doubtful, the respiration was deep, gentle, but free from râle. -The muscles of the face had ceased to be agitated, and it was of a -violet red colour, as was also the skin in front of the chest; the -pupils were turned upwards, dilated and immovable. - -The apparatus was taken away, and the operation was commenced; but the -incision had only given issue to a small quantity of black blood, when -it was perceived that the features were altered and become entirely -violet, and that the respiration was extremely feeble. The pulse, -touched on this moment for the first time, was soft, full, and very -slow. All at once it ceased to beat. - -Twenty-four hours after death, all parts of the body yielded a strong -odour of ether. The blood was deep black, fluid, and rather viscous. The -blood which gorged the back part of the lungs had a consistence and -colour somewhat like treacle. The mucous membrane of the bronchi, -trachea, and larynx was very much congested. The spleen was so softened -in its interior as to resemble the lees of wine. - -This patient appears to have died rather from the want of admission of -sufficient air to the lungs than from the effects of ether. The -apparatus was applied without intermission, long after the face became -injected, and was kept applied till it became of a violet colour. The -pulse was not felt till the patient was dying. Artificial respiration -was not attempted, although it would most likely have restored the -patient. - -The other death which happened whilst the patient was under the -influence of ether took place at the Hotel Dieu de Lyons, on September -11th, 1852.[166] The patient was a woman, aged fifty-five, but looking -much older. She was affected with a tumour of the superior maxillary -bone, and was weak and in a bad state of general health. M. Barrier was -reluctant to remove the tumour, but yielded to the entreaties of the -patient. The ether was administered from a sponge placed in a bladder, -and the patient was quickly put to sleep. M. Barrier had made the -incisions in the face, and had just divided the ascending process of the -jaw, when the breathing stopped. There was no pulse at the wrist, and it -was doubtful whether there was any at the precordial region. The patient -was placed horizontally, and artificial respiration and other measures -were applied, but without success. - -This patient evidently died of hæmorrhage; the mode of death which M. -Barrier must have been dreading, as we perceive from his reluctance to -perform the operation. According to the result of my experiments on -animals, ether is not capable of causing the kind of death which this -patient died. - -There were three or four cases in which ether was blamed by the -operating surgeons for causing the death of patients, who recovered from -its effects, and, died some days, or at least hours, afterwards. The -nature and circumstances of the operation were sufficient to account for -the fatal result in each of these cases, whilst the extended use of -ether has confirmed the opinion that it cannot be the cause of deaths -which occur days, or even hours, after its use. - -On Friday, the 12th of February, 1847, Mr. Roger Nunn performed -lithotomy, in the Colchester Hospital, on a man who, as it was found -after his death, had disease of the kidneys. The ether seemed to act -favourably. Mr. Nunn says: “There was neither difficulty nor loss of -time in cutting into the bladder; but having done so, some little delay -occurred in grasping the stone, which was small, very flat, and lying in -the posterior part of the bladder; the delay was also increased by the -extremely relaxed state of the bladder itself, which seemed to fall in -folds on the forceps, and to cover the stone.”[167] This delay in -grasping the stone is attributed by Mr. Nunn to a collapsed state of the -bladder caused by the ether, but it can only have arisen from the fact -of the urine having escaped from the bladder, before the stone was -seized. The small vessels divided in making the first incision showed -much inclination to bleed, and Mr. Nunn secured them immediately after -the patient was put to bed. - -Speaking of his patient and the ether, Mr. Nunn says: “He recovered from -its effects after a short time, and continued in a quiet passive state, -but without decided reaction for twenty-four hours. At this period he -had a chill, which lasted for nearly twenty minutes.” Stimulants were -given, but without much effect. The patient seemed incoherent from eight -o’clock P.M. of Saturday till nine A.M. of the following day. From this -time he gradually sank, and died at five o’clock P.M. of that day, -Sunday, being sensible to the last. - -On March 9th, 1847, Mr. Wm. Robbs, of Grantham, removed an -osteo-sarcomatous tumour from the back part of the left thigh of Ann -Parkinson, a married woman, aged twenty-one, the mother of one -child.[168] Mr. Robbs tried to make his patient insensible with ether, -but did not succeed. He says, indeed, that in about ten minutes its -usual effects were produced; but these could not have been its full and -proper effects; for he says, “she appeared quite sensible to the pain -during the whole of the operation.” It is reported that she appeared to -feel the first cut. Mr. Robbs says that during the early part of the -operation, the patient “cried out much, complained, and writhed in great -agony of pain.” The operation was begun by an incision commencing midway -between the tuberosity of the ischium and the trochanter major, and -extending about six inches down the thigh. The fascia was next divided, -and the muscles were next separated with the handle of the scalpel, so -as to expose the upper surface of the tumour. After this had been done, -the inhaler was replaced to the mouth of the patient whilst the -operation proceeded, but the ether appeared to take no effect. The -tumour was “very adherent to the long head of the biceps flexor cruris, -which nearly covered it anteriorly, while posteriorly it rested on the -sheath of the great sciatic nerve. It took its origin from the common -tendon of the flexor muscles, close to the tuber ischii, and was -inserted into the short head of the same muscle just below its origin.” -Mr. Robbs says: “The dissection was protracted longer than I expected, -from the violent contractions of the muscles, and the struggles of the -patient.” He estimated the time occupied in the operation at twenty-five -or thirty minutes; and the sister-in-law of the patient, who gave her -evidence at the inquest, expressed her opinion that the operation lasted -an hour all but five minutes. At the end of the operation, the patient -appeared very faint, and the pulse was very rapid and feeble. The -patient remained much depressed, with a pulse of 140 in the minute, -small, and without much power, having her intellect perfect; she died -forty hours after the operation. - -A coroner’s inquest was held, but neither the coroner nor any of the -jury appeared to have any knowledge or suspicion that a surgical -operation on the thigh could possibly be the cause of death. A surgeon -who gave evidence stated, that “the shock from the operation was not -simply the cause of death, as the seat of the disease was not essential -to life.” The verdict was, that the death of deceased was caused by the -inhalation of ether; and that no blame was attached to the surgeon, as -ether had been used and recommended by eminent medical men. - -I cannot tell whether Mr. Robbs would have undertaken the operation if -ether had not been about to be used, but if he had undertaken it without -ether, one may presume that he would have done what every surgeon does -who undertakes a great operation, that he would have informed the -patient and her friends that it would be attended with some amount of -danger. In his communication to the _Medical Gazette_, Mr. Robbs -complains of the friends of his patient having thought it necessary to -obtain a coroner’s inquest; but he has himself to blame for that. After -he had attributed the death entirely to a new agent, which had been -given with a view to prevent the pain, and had entirely failed even in -that, it was very natural that they should seek for a legal -investigation of the affair. - -Mr. Robbs makes no admission that the pain his patient suffered could be -due to any defect in the administration of the ether. He states, that he -“was quite unprepared for that perfect state of prostration of the brain -and nervous system which it appears in this case to have induced”. The -fact of the patient crying much, and complaining, and writhing in great -agony of pain, and the contraction of the muscles, and the struggles -which protracted the operation, do not look like a prostration of the -brain and nervous system. At the end of the operation she was, to be -sure, prostrated by its long duration, and the great loss of blood which -must have occurred; but her brain and nervous system were not so much -affected as the vascular and muscular system. She spoke of the operation -as having been very severe, and she retained her mental faculties -perfectly to her death. Ever since 1818 many of the students at lectures -on chemistry had inhaled the vapour of ether to quite as great an extent -as Mr. Robbs’ patient. - -As a proof how far the feelings will suspend both reason and common -sense, it may be mentioned that some of the medical men, who were -strongly opposing the use of ether in 1847, did not hesitate to allude -to the inquest in this case, as showing that ether had caused the death -of a patient. - -Mr. Eastment, of Wincanton, Somersetshire, related a case[169] in which -he attributed the death of the patient to ether. It was apparently the -first time he had seen ether employed on the human subject; and with a -larger experience of its effects, he would no doubt alter his opinion -respecting the cause of death in the case he related. - -A boy, aged eleven years, became entangled in the machinery of a mill, -about eight A.M., on February 23rd, 1847, in consequence of which he -sustained a very severe compound fracture of the left thigh, with great -laceration of the soft parts, and a simple fracture of the right thigh. -The surgeons in attendance waited till four P.M. for the boy to recover -from the shock of the injury, and then performed amputation of the left -thigh. Ether was given, but so badly, that the patient’s sufferings were -so severe on the circular incision being made, that it appeared to be a -complete failure. The inhalation was repeated, however, and the pain of -the latter part of the operation was prevented. The patient died three -hours after the operation, being in a state of great exhaustion, with -occasional mental excitement, during the three hours. - -This patient’s chance of life would probably have been improved if the -ether had been more effectually given, so as to prevent all the pain of -the operation; but I believe that his chance of recovery would have been -most improved by administering the ether soon after the accident in the -morning, which would most likely have removed the collapse, and enabled -the surgeon to perform amputation at once, and thus have prevented the -eight hours suffering and depressing effects of the great laceration of -the thigh. - -M. Bouisson[170] has mentioned a case in which death was attributed to -ether by a surgeon named Roël, of Madrid. Dolorès Lopes, aged fifty, of -very feeble constitution, and addicted to drunkenness, had long suffered -from a cancerous tumour of the breast. It was removed after the patient -had inhaled ether for half an hour, and it weighed three pounds and a -quarter. The patient died seven hours after the operation. But the -operation itself was sufficient to account for the death of such a -patient; and she could not die from ether at the end of seven hours -after inhaling it. - -On account of its great safety, ether is extremely well adapted for -medical cases, in which it is necessary that a narcotic vapour should be -administered by the patient’s nurse. - -_The Combination of Chloroform and Ether._ Some practitioners have -recommended the inhalation of the vapour from a mixture of chloroform -and ether; but the result is a combination of the undesirable qualities -of both agents, without any compensating advantage. Ether is about six -times as volatile as chloroform—that is to say, if equal measures of -each be placed in two evaporating dishes kept side by side, at the same -temperature, the ether evaporates in about one-sixth the time of the -chloroform; and when the two liquids are mixed, although they then -evaporate together, the ether is converted into vapour much more -rapidly; and, in whatever proportions they are combined, before the -whole is evaporated the last portion of the liquid is nearly all -chloroform: the consequence is that at the commencement of the -inhalation the vapour inspired is chiefly ether, and towards the end -nearly all chloroform: the patient experiencing the stronger pungency of -ether when it is most objectionable, and inhaling the more powerful -vapour at the conclusion, when there is the most need to proceed -cautiously. - -A death which occurred during a surgical operation in America, has been -attributed to the mixture of chloroform and ether which was -employed;[171] but there is no doubt that the patient died of -hæmorrhage. Dr. R Crockett, of Wytheville, Virginia, removed a fatty -tumour from the back of a boy, aged five years. Four parts of washed -ether by measure were mixed with one part by measure of chloroform, and -a drachm of this mixture was poured on a funnel-shaped sponge which was -applied near the mouth and nostrils. The tumour was very large, and -required two incisions of nine inches in length for its removal. Six -arteries required to be tied; and just as the last one was secured, the -child began to vomit. He was found to be pulseless, and he died three or -four minutes from the commencement of vomiting. Dr. Kincannon, who was -present, and watching the patient, said that up to the time he began to -vomit, there was nothing in the circulation or respiration to produce -the least apprehension. - -The operator said that the patient probably lost four ounces of blood, -certainly not six. It must be observed that as the blood during an -operation is carried away by the sponges, it is impossible to estimate -the amount. It could be ascertained only by an analysis of the water in -which the sponges are washed. But even admitting that in the present -case the loss of blood did not exceed six ounces, it is probable that -this amount, flowing suddenly from a child of five years of age, might -cause death. Vomiting does not take place when a patient is deeply under -the influence of ether or chloroform, and the fact of no signs of over -narcotism having appeared, confirms the view that death was occasioned -by the loss of blood. - - - - - AMYLENE. - - -This substance was discovered and described in 1844 by M. Balard, -Professor of Chemistry to the Faculty of Sciences of Paris.[172] M. -Auguste Cahours had given this name five years previously to a product -which is isomeric with amylene, and is produced at the same time, but is -now termed paramylene. - -Amylene is made by distilling amylic alcohol with chloride of zinc. The -amylic alcohol is obtained from crude fusel oil, otherwise called oil of -grain, or oil of potatoe spirit. The fusel oil must be submitted to a -careful distillation, with a thermometer in the retort. It begins to -boil at a comparatively low temperature, but that portion only is to be -retained which comes over from 266° to 284° Fah. Caustic potash is -added, to decompose the œnanthic ether which the distilled liquid -contains, and it is then redistilled, and that portion which boils -steadily at 270° Fah. is collected as pure amylic alcohol. Amylene can -be obtained from amylic alcohol in the same manner that olefiant gas, or -ethylene, can be made from common alcohol, namely, by heating it with -dishydrating agents, as sulphuric, phosphoric, fluoboric and fluosilic -acids, and chloride of zinc; but most conveniently with the last -substance, which is the one that M. Balard employed. The product which -is obtained when amylic alcohol and chloride of zinc are distilled -together, contains at least three distinct hydrocarbons, amylene, -paramylene, and metamylene; and the amylene which is the most volatile -is separated from the others by successive distillations. - -Amylene is a colourless and very mobile liquid, of extremely low -specific gravity; being one of the lightest liquids known. The amylene -made for me by Mr. Bullock[173] had a specific gravity of 0·659 at 56°. -It is very volatile, boiling at 102° Fah. according to M. Balard, and at -95° according to Frankland, and the specific gravity of its vapour is -2·45. It is composed of ten atoms carbon and ten atoms hydrogen, and -bears the same relation to amylic alcohol that olefiant gas, or -ethylene, bears to common alcohol. - -It is inflammable, burning with a brilliant white flame; and in pouring -it out by candle light, the same care is required as in dealing with -sulphuric ether. A slight explosion may be obtained by applying a light -to a mixture of a small amount of its vapour with a large quantity of -air. - -It is soluble in alcohol and ether in all proportions, but is very -sparingly soluble in water, being in fact a hundred times less soluble -than many substances which are ordinarily spoken of as insoluble. From a -number of careful experiments which I made, I found that water dissolves -2·35 per cent. of its volume of the vapour of amylene. It follows -therefore, from the specific gravity of amylene and of its vapour stated -above, that amylene requires 9319 parts of water for its solution. The -water which has dissolved this small quantity of amylene tastes as -distinctly of it as amylene itself. - -Amylene has more odour than chloroform, but much less than sulphuric -ether, and the odour does not remain long in the patient’s breath. The -smell of amylene somewhat resembles that of wood spirit. The first -specimens which Mr. Bullock made were slightly offensive, but the odour -improved and diminished in strength, as he obtained the substance in a -state more nearly approaching to purity. Many persons, who thought the -odour disagreeable at first, began to like it after they had been -exposed to it three or four times. It is almost without taste, and it -produces no irritation, or effect of any kind on the sound skin, even -when confined, and prevented from evaporating. The vapour is almost -entirely without pungency, furnishing in this respect a remarkable -contrast to both ether and chloroform. Its presence can be perceived on -first beginning to inhale it, but after two or three inspirations, one -cannot tell whether the air one is breathing contains any of the vapour -or not. It does not cause any cough unless there is great irritability -of the air-passages, or the vapour is breathed of great strength in the -very first inspirations. - -Amylene produces about as much cold during its evaporation as sulphuric -ether does. If a sponge or piece of blotting paper wetted with amylene -is exposed to the air, a portion of the moisture of the air becomes -condensed on its surface, by the cold caused during the evaporation of -the amylene; and by the further effect of the cold the condensed -moisture is frozen, and the sponge or paper is covered with hoar frost. - -The boiling point of pure amylene would probably be that which I have -quoted above from Frankland, viz., 35° cent. or 95° Fah.; but the -amylene which has been obtained for inhalation contains other -hydrocarbons of an analogous composition, and its boiling point is not -steady: 95° Fah. was indeed about the average boiling point of the -greater part of the amylene furnished to me by Mr. Bullock, for it -usually commenced to boil at 86°, and as it evaporated, the boiling -point gradually rose to 109°, or higher. - -No method is at present known of separating amylene from the products -which come over with it, except a number of distillations; and although -these may be carried so far as to obtain a small quantity almost pure, -the price of it would be too great to admit of its employment for -inhalation. For this purpose, one must be content with a product -approaching to purity. Dr. Debout, in an article on amylene,[174] says -that the boiling point commences at 28° (82° Fah.), and rises gradually -to 40° or 45° (104° or 113°) in the best products which have been -obtained by Mr. Bullock of London, M. Hepp of Strasbourg, and the house -of Ménier at Paris. - -M. Duroy published an elaborate paper on amylene, on April 9th, -1857.[175] In this paper, he gives the result of an examination of four -specimens of amylene: the first, which he calls A, was amylene made by -Mr. Bullock; the second (B) was the amylene of M. Ménier; the third (C) -was some that he had prepared according to the process of M. Hepp; the -fourth (D) was amylene which he had obtained by a process which he -described. In this process, he employed dry chloride of zinc and amylic -alcohol. M. Balard recommended a solution of chloride of zinc of a -certain strength to be used. I may state, however, that Mr. Bullock had -from the first used dry chloride of zinc. - -The following table shows the temperature at which the different -specimens began to boil, and the temperature to which they rose before -being boiled entirely away. - - A 30° cent. = 86° Fah. to 46° cent. = 115° Fah. - B 29 „ = 84 „ to 75 „ = 167 „ - C 30 „ = 86 „ to 62 „ = 143 „ - D 31 „ = 88 „ to 57 „ = 134 „ - -Mr. Bullock’s amylene went through the smallest range of temperature -whilst boiling away. - -M. Duroy found that potassium was oxidized to a certain extent in all -these specimens of amylene, and a small quantity of hydrogen gas was -produced, showing that they did not consist entirely of hydrocarbons, -but that there distilled over with them a small quantity, either of -amylic alcohol, or amylic ether. - -The following table shows the cubic centimetres of hydrogen gas which -were disengaged from three grammes of each of the different kinds of -amylene. - - A 64 - B 91 - C 75 - D 69 - -Examined in this way, Mr. Bullock’s amylene showed the smallest quantity -of impurity; and, next to that, the amylene made by M. Duroy. - -M. Duroy found that amylene can be purified from the substances -containing oxygen by distilling it again with dry chloride of zinc. He -was able to obtain pure amylene, boiling steadily at 35° cent., but to -get at this result he made so many distillations that he had only forty -grammes of amylene from five litres of amylic alcohol. - -He states that the following are the characters of absolute amylene. - -To boil steadily at 35° cent. - -To be without action on potassium, and to preserve that metal like -naphtha. - -Not to be coloured, even by prolonged contact with caustic potassa. - -Not to give rise to valerianic acid under the action of hydrated -potassa. - -The following table shows the amount of vapour of amylene in air which -is saturated with it at various temperatures. The specimen of amylene -with which I made the experiments began to boil at 95° Fah. - - Temp. Fah. Vapour. Air. - 24° 20·3 79·7 - 26 20·9 79·1 - 28 21·6 78·4 - 30 22·3 77·7 - 32 23·2 76·8 - 34 24·3 75·7 - 36 25·5 74·5 - 38 26·8 73·2 - 40 28·2 71·8 - 42 29·6 70·4 - 44 31·1 68·9 - 46 32·7 67·3 - 48 34·3 65·7 - 50 36·0 64·0 - 51 36·9 63·1 - 53 38·6 61·4 - 55 40·0 60·0 - 57 42·5 57·5 - 58 43·7 56·3 - 59 45·0 55·0 - 60 46·5 53·5 - 61 47·7 52·3 - 63 50·4 49·6 - 65 53·1 46·9 - 67 55·9 44·1 - 69 58·8 41·2 - 71 61·9 38·1 - 73 65·1 34·9 - 75 68·6 31·4 - -I was not aware of the existence of amylene till 1856, or I should have -tried it sooner; for I made inquiry in 1848 for a substance named eupion -by Reichenbach, its discoverer, but was unable to obtain it. Eupion is a -carbo-hydrogen, described as having all the physical characters which -belong to amylene, though obtained in a different way; and I believe it -is the same substance, or the hydride of amyle. Reichenbach obtained it -from coal tar, but other chemists have not been able to make it. - -Judging from experiments which I had made on analogous substances, there -could be no doubt of amylene causing insensibility when inhaled; but I -could not tell, without actual trial, whether it might not be unpleasant -in its action. - -I believe that amylene had but rarely been made, and only in very small -quantity, until I requested Mr. Bullock to make it for me. For some time -afterwards, soon after my first paper had appeared on the subject, M. -Berthé, of Paris, made some amylene and submitted it to M. Balard, its -discoverer, who acknowledged its purity, and was astonished at the great -quantity M. Berthé had obtained. This quantity, however, appears to have -only been forty grammes, or about ten fluid drachms. - -As soon as Mr. Bullock succeeded in making some amylene for me, I -proceeded to perform some experiments with it on small animals. I found -that it was necessary that an animal should breathe air containing about -10 per cent. of the vapour in order to lose its consciousness, and that -20 per cent. caused a deep state of insensibility, whilst 25 per cent. -could be breathed with perfect safety. - -The following are a few of the experiments. - -_Experiment 43._ A guinea pig was placed in a glass jar holding four -hundred and twenty-eight cubic inches. Fifteen grains of amylene were -dropped through a small tube in the air-tight cover of the jar, fell -upon blotting paper suspended within, and quickly evaporated and became -mixed with the air. In three or four minutes the guinea pig staggered -and became altered in its manner. It did not become further affected, -although it was allowed to remain for ten minutes. When taken out its -sensibility did not seem impaired. Each grain of amylene produces 1·315 -cubic inch of vapour, and consequently the air in this experiment -contained 4·6 per cent. of vapour. - -_Experiment 44._ The same guinea pig was placed in the same jar three -days afterwards, and twenty-five grains of amylene were introduced in -the same manner. At the end of two or three minutes the guinea pig -seemed estranged in its manner, and turned its head from side to side. -In a little time it seemed getting drowsy, but at the end of twelve -minutes it was still on its legs and moving voluntarily. Eleven grains -more of amylene were now introduced. In a little time it sank down -unable to stand, and on being turned over by inclining the jar it made -efforts to right itself, which became more and more feeble. It was taken -out at the end of fifteen minutes, _i. e._, three minutes after the -introduction of the additional amylene. It gave a slight squeak, and -moved its feet and eyelids on being lifted. On being pricked it gave -decided evidence of sensation. It recovered in a few minutes. There were -7·7 cubic inches of vapour in each one hundred cubic inches of air in -the first part of the experiment, and eleven cubic inches in the latter -part. - -_Experiment 45._ Six fluid drachms of amylene in a little bottle were -put into a glass jar of the capacity of one thousand six hundred cubic -inches, and the mouth of the jar was tied over with a large piece of -oiled silk. The bottle was emptied by inclining the jar, and the amylene -was made to run about the sides of the jar till it had all evaporated. A -guinea pig was then folded in the superabundant oiled silk beyond the -string which tied it, the string was then opened, and the animal -introduced into the jar without allowing any communication with the -external air. The guinea pig began to be affected within half a minute, -and in a minute it was lying insensible, but moved its limbs when it was -rolled about in the jar. In two minutes it was flaccid, and could be -rolled about without causing any resistance or muscular action. It lay -relaxed and motionless till taken out at the end of four minutes, -although by an occasional motion of the eyelids it seemed not altogether -insensible. It was quickly taken out, but the moment it was removed it -began to kick, and being pricked it flinched. It was not able to stand -for two minutes, but after this it quickly recovered. Six fluid drachms -of amylene weigh 240 grains, and produce 315 cubic inches of vapour; -consequently there was nearly 20 per cent. of vapour in the air in this -experiment. - -_Experiment 46._ A guinea pig, a fortnight old, was placed in the jar -holding 428 cubic inches, and eighty-two grains of amylene were -introduced on blotting paper. It was six minutes in evaporating. The -guinea pig became gradually affected, and, a minute or two before the -amylene had all evaporated, it was lying unable to walk. It was allowed -to remain till ten minutes had elapsed, that is, four minutes after the -amylene was all converted into vapour; but it did not, apparently, -become quite insensible. The limbs were never quite relaxed, and when -turned over in the jar there was a little motion of the limbs and head. -There was also a little quivering motion of the limbs occasionally when -not disturbed, and at one time it opened and shut its mouth. On its -removal, pricking the soft parts of its toes caused sometimes a slight -groan. It recovered slowly and gradually. In ten minutes it was quite -conscious, but not as brisk as before the experiment. There was 25 per -cent. of vapour in the air the guinea pig breathed in this experiment. - -Guinea pigs have a great tendency to flinch when pricked whilst they are -under the influence of amylene. I did not find this to be the case with -other animals. - -_Experiment 47._ A lean, starved cat was placed in a glass jar holding -1,600 cubic inches, and 120 grains of amylene were introduced upon -blotting paper. The cat became inebriated whilst the amylene was -evaporating; and by the time it had all evaporated—which was four and a -half minutes—the cat had sunk down in a state of insensibility. The eyes -were turned downwards, so as to expose the white; but its limbs were not -relaxed. In a minute or two afterwards it made no effort when rolled -about in the jar. It was taken out at the end of nine minutes from the -commencement of introducing the amylene. It was breathing noisily; its -limbs were not relaxed; it was totally insensible to pricking of the -ears and paws. It began to recover in about a minute: in two or three -minutes it flinched on being pricked; it staggered for two or three -minutes longer, and in ten minutes it was pretty well recovered. The -amylene would produce 158 cubic inches of vapour, or very nearly ten per -cent. in this experiment. - -_Experiment 48._ A linnet was placed in a jar holding 428 cubic inches, -and forty grains of amylene were introduced on blotting paper. In two -minutes it had evaporated. Until it had nearly evaporated, the bird was -hardly affected, only evincing a desire to escape. As soon as the -amylene had evaporated, the linnet lay unable to move, but evincing -consciousness and sensibility by the motion of its eyelids and eyes, and -by moving its legs when it was turned over by inclining the jar. It -remained in this state for three minutes, when eight grains more of -amylene were introduced into the jar. The bird almost immediately closed -its eyes; and it opened its bill a little, from which a little liquid -flowed. The motion of its legs also ceased, and its breathing was -slower. It was taken out half a minute after the last portion of amylene -was introduced. It seemed quite insensible when removed, but began to -recover in a few seconds. When its foot was pricked, twenty or thirty -seconds after its removal, it flinched. In two or three minutes it was -quite recovered. There were 12·3 per cent. of vapour in the air in the -first part of this experiment; and 14·7 per cent. in the latter part. - -_Experiment 49._ Another linnet was placed in the same jar, and -forty-eight grains of amylene were introduced in the same manner. It -took nearly three minutes to evaporate, hoar frost being produced on the -blotting paper. The bird began to stagger when the amylene was about -half evaporated; and by the time it was all evaporated, the bird was -lying apparently insensible, with its eyes closed, and breathing -quickly. It was allowed to remain two and a half minutes, during which -it did not alter. It was often rolled about by moving the jar; and -during the last minute and a half it made no effort, except once or -twice a slight motion of the wings. It was taken out two and a half -minutes after the amylene had all evaporated. It was quite passive, and -insensible to pricking of the toes, for half a minute or so after its -removal, when it began to recover, went through a stage of staggering, -and was well in three or four minutes. The amount of vapour in the air, -in this experiment, amounted to 14·7 per cent. - -_Experiment 50._ Fifty grains of amylene were diffused in a glass jar -holding 330 cubic inches, and a linnet was introduced by momentarily -moving the lid a little to one side. It was quickly affected, and in -about a quarter of a minute was lying quite insensible. It remained so, -breathing quickly and naturally, and made no effort whatever when rolled -about in the jar. It was allowed to remain three minutes, and there was -a slight fluttering motion of the wings just before its removal. It was -quite passive when removed, and insensible to pricking of the soft part -of the foot. It began to recover its sensibility in three-quarters of a -minute. In two minutes it was able to stand, and in six minutes it got -on the perch. There was twenty per cent. of vapour in the air in this -experiment. - -As amylene boils nearly at the temperature of the blood, that fluid -would be able to absorb about one-fifth as much as it would be able to -dissolve, when an atmosphere is breathed containing twenty per cent. of -the vapour, which produces a complete state of insensibility, or the -fourth degree of narcotism. When ten per cent. is breathed, which has -been shown to cause the second degree of narcotism, about one-tenth as -much vapour as the blood would dissolve must be absorbed. In treating of -chloroform and ether, it was previously shewn that the fourth degree of -narcotism was caused by one twenty-eighth part as much of these agents -as the blood would absorb; and the second degree by one fifty-sixth -part. And these were the proportions absorbed of several other agents -which are made from ordinary alcohol, and will afterwards be mentioned. - -Although the proportion of amylene absorbed is large in relation to the -whole quantity which the blood would dissolve, it is a very small amount -on account of the extremely slight solubility of the agent. If we -estimate the average amount of serum of the blood in the human adult at -410 fluid ounces, as before, then, as amylene requires 9,319 parts of -watery fluids for its solution (as nearly as I could ascertain), the -quantity of this agent in the system must be rather less than three -grains in the fourth degree of narcotism; rather less than a grain and a -half in the second degree; and a very little over two grains in the -third degree of narcotism, the condition in which surgical operations -are usually performed. Amylene is therefore, when absorbed, about as -powerful in its medicinal properties as the alkaloids. - -The following fact also proves that but a very small quantity of amylene -is absorbed. In breathing this agent backwards and forwards from a small -bladder containing 200 cubic inches of air, fourteen minims was the -largest quantity I could put into the bladder without being rendered -unconscious; but in employing a large bladder holding 670 cubic inches, -I could put in forty-five minims, and breathe it backwards and forwards -for some time without being rendered unconscious. With fifty minims of -amylene I immediately forgot where I was; but awoke in a minute or two, -seated in the same position, and with the bladder in my hand. Fifty -minims of amylene would produce between six and seven per cent. of -vapour in the bladder; and after the air in the lungs became mixed with -that in the bladder, there would be rather more than five per cent. of -vapour in it. - -Viewed in the light of the small quantity which requires to be absorbed -into the system to cause insensibility, amylene is a very powerful -agent; but when considered in relation to the quantity which is consumed -during inhalation in the ordinary way, it is very far from being -powerful. This arises from the great tension and the small solubility of -the vapour, in consequence of which it is, with the exception of a small -fraction, expelled from the lungs again without being absorbed. In this -respect it resembles, to a great extent, the nitrogen gas of the -atmosphere, with which the lungs are always four-fifths filled, while -the blood contains but a few cubic inches. It takes from three to four -fluid drachms of amylene to cause insensibility in the adult. - -I found, by my experiments on animals, that amylene is, like chloroform -and some other agents, capable of causing sudden death by over-narcotism -of the heart, and paralysis of that organ; but that it is more difficult -to cause this kind of sudden death with amylene than with chloroform. - -_Experiment 51._ One hundred and twenty grains of amylene were made to -evaporate in a jar holding 330 cubic inches, and a full grown guinea pig -was suddenly introduced, the cover being partly removed for a moment. It -was allowed to remain for about a minute, when the breathing became of a -gasping character. Being taken out, and the stethoscope applied -immediately to the chest, the heart could not be heard to beat; and its -action did not return, although the gasping continued for about a -minute. There was nearly 48 per cent. of vapour in the air in this -experiment, except that a small quantity might escape as the guinea pig -was introduced. I had tried guinea pigs with smaller proportions of -vapour in the air, but had not succeeded in arresting the action of the -heart. - -The lungs were rather congested, and the right cavities of the heart -were filled, and somewhat distended with coagulated blood. - -_Experiment 52._ A kitten, six weeks old, was placed in a jar holding -330 cubic inches, after ninety-five grains of amylene had been made to -evaporate and diffuse itself. The kitten remained three-quarters of a -minute in the jar, and was suddenly taken out. It was scarcely -insensible on its removal, but soon became so. The stethoscope was -applied, and the heart was found to be beating rapidly. The kitten -quickly recovered. - -One hundred and six grains of amylene were made to evaporate in the same -jar, and the kitten was quickly introduced, as before, by moving the -cover for a moment. It was allowed to remain for half a minute, and -removed with the same symptoms and result as before. - -The same quantity of amylene was employed, and the kitten was introduced -again, and allowed to remain for fifty seconds. On its first removal the -heart was not beating, but the kitten was gasping; and just afterwards -the heart was heard to be beating rapidly. The kitten quickly recovered. - -One hundred and twenty grains of amylene were allowed to evaporate in -the jar, and the kitten was introduced again. It was allowed to remain a -minute, and was taken out as the breathing appeared to be on the point -of ceasing. The heart was beating when the stethoscope was employed, and -the kitten quickly recovered. It seemed impossible to kill it with -amylene, except by allowing it to remain and inhale the vapour, by those -gasping inspirations which took place when the action of the heart was -arrested, and which restored the action of this organ, when the kitten -was withdrawn from the vapour. In the different parts of this experiment -there were 37, 42, and 47 per cent. of amylene in the air. - -When mice are placed in air containing 30 per cent. and upwards of -vapour of amylene, they usually recover, as in the following experiment, -if the breathing has not entirely ceased on their removal; whilst if -they are placed for a quarter of a minute in air containing 8 or 10 per -cent. of vapour of chloroform, they generally die, although they may be -breathing well, and hardly insensible, when they are removed. - -_Experiment 53._ Eighty grains of amylene were introduced into a jar -holding 330 cubic inches, and when it had evaporated, a white mouse was -introduced. In about five seconds it was quite insensible, and in about -a quarter of a minute the breathing appeared to have ceased. The mouse -was quickly withdrawn, and immediately began to gasp. After a few gasps -the quick breathing returned. In half a minute after its removal the -mouse was recovering, and it was soon quite well. There was 32 per cent. -of vapour of amylene in the air in this experiment. - -I administered amylene with the inhaler which I had used for several -years in exhibiting chloroform, and which I have described in treating -of that agent. In administering chloroform it is desirable that the -patient should breathe 4 or 5 per cent. of the vapour in the air he -inspires; and the air, when saturated with vapour of chloroform at 60°, -contains 12 per cent., or nearly three times as much as the patient ever -requires. In administering amylene for surgical operations, it is -desirable that the patient should take in 15 per cent. of the vapour -with the air he breathes; and air, when saturated with this vapour at -60°, contains 465. per cent., or fully three times as much as the -patient ever requires. It therefore seemed reasonable that the inhaler -which had answered so well with the former agent, might be employed in -the same manner, and used successfully with the latter agent. Vapour of -chloroform, when inhaled of twice the proper strength, _i. e._, of 8 or -10 per cent., is capable of causing sudden death by over-narcotism of -the heart; but amylene is required to be of nearly 40 per cent., or more -than twice the proper strength, before it could produce this result: and -it seemed, therefore, reasonable to expect that the inhaler which had -been employed for so many years with chloroform, might be employed in -exhibiting amylene with an equally satisfactory result. And if the -amylene furnished for inhalation had been a constant and uniform -product, boiling steadily at the same temperature, like chloroform, -there is no doubt that these expectations would have been fulfilled. - -I first administered amylene, in King’s College Hospital, on the 10th of -November 1856, to two boys, about fourteen years old, previous to Mr. -Samuel Cartwright extracting some teeth. I had but a few drachms, and -being very sparing of its use, it did not entirely remove consciousness -in either case, and the pain was not altogether prevented: the effects, -however, as far as they extended, were so favourable as to encourage a -further trial, which was made in the same institution, on December 4. - -On this occasion I exhibited the amylene to four patients—two men, a -young woman, and a girl of ten years old: it occasioned complete -unconsciousness and absence of pain in each case. The first man was -about thirty-five years of age. Half a fluid ounce of amylene was put -into the inhaler, and he inhaled for three minutes. At first the valve -of the face-piece was about one-third open, but it was gradually moved -till it was almost closed. The man breathed readily, without coughing, -and in a very little time seemed to be unconscious. The pulse became -quick and slightly irregular; the skin became flushed; and in about two -minutes there was a rather free sweating of the forehead; the eyes did -not turn upwards; the conjunctivæ did not become insensible; there was -no relaxation of the limbs, and, on the contrary, no struggling. The -patient sat well, supporting himself, without any tendency to slide out -of the chair; the mouth was partly open, and there was a tendency to -laugh, just as the amylene was discontinued. The tooth was extracted by -Mr. S. Cartwright, without making him flinch or cry in the least. In -less than a minute he awoke. He looked a little strange at first, but -immediately remembered all the circumstances of his situation, but knew -nothing of the operation; and, three minutes after the extraction of the -tooth, and six minutes after entering the room, he went away feeling, as -he said, quite well. The amylene put into the inhaler was nearly used. - -A young man, about twenty years old, next inhaled the same quantity, in -exactly the same manner, for just three minutes; there was no -irregularity of pulse, and no sweating; otherwise the symptoms were -exactly the same. The tooth was extracted without his knowledge, and -without causing a cry or flinch. He awoke, and was able to go in three -minutes. - -A young woman in bad health, an out-patient of one of the physicians of -the hospital, next inhaled. She breathed the amylene for four minutes, -and about three drachms were used. The effect was carried to the -commencement of the third degree of narcotism; and the eyes were -inclined to turn up, but did not do so persistently. The edges of the -eyelids also remained sensible. There was a little trouble and delay in -getting the mouth open, as the muscles of the jaws were rather rigid; -and when the tooth was extracted, she flinched, and cried out a little. -She did not remember the operation. She said she had had a very -unpleasant dream, and she was dizzy and uncomfortable for about ten -minutes, after which she was better. - -A little girl ten years old inhaled for four minutes, and between two -and three drachms were used. The eyes were turned up for a short time. -She did not flinch or cry as the first tooth came out, but did both as -two others were afterwards extracted. She did not, however, know -anything afterwards of the operation. She recovered her consciousness in -a minute or two, and quite recovered from the effects of the vapour in a -few more minutes. There was no sickness, and no increased flow of -saliva, in any of the cases. - -On December 11th, I administered the amylene again in five more cases of -tooth-drawing, with very similar results to those obtained in the -previous cases; and on December 13th, I exhibited it in some more -important cases. - -Mr. Fergusson performed an operation for fungus of the testicle; Mr. -Bowman removed some diseased glands from the groin; and there were two -cases of tenotomy, in one of which forcible extension of the knee was -made. - -From November 1856 to July 1857, I exhibited amylene in 238 cases. There -were seven cases of lithotomy; six of the patients were children, and -the seventh a young man of seventeen. They all recovered. Five of the -operations were performed by Mr. Fergusson, in King’s College Hospital; -and two were performed in St. George’s Hospital, by Mr. H. C. Johnson -and Mr. George Pollock. - -There were five cases of resection of the knee; three of the patients -got well, and two died. These operations were performed in King’s -College Hospital, one of them by Mr. Partridge, and the other four by -Mr. Fergusson. Of the seventeen cases of resection of the knee, -mentioned at page 280, in which chloroform was administered, I know the -result only in thirteen of the cases. Of these, eight recovered, one of -them after undergoing subsequent amputation at the thigh; and five died. - -Some statistics of this operation have been gathered by collecting the -cases which happen to be reported in the medical journals, but such -statistics are likely to be extremely erroneous. The cases that are -reported are probably far more favourable than those that are not -reported. A surgeon undertakes an operation of this kind with no other -view than the benefit of his patient, and without thinking of the -medical journals; and, if his first or second case is unsuccessful, he -is probably not inclined to repeat the operation. If the cases should be -successful, however, he is inclined to repeat the operation when -opportunity occurs, and may ultimately give the result of his experience -to the profession. - -Mr. Bowman removed the head of the femur in two little boys to whom I -administered amylene; they both recovered, as did a girl who inhaled -amylene whilst Mr. Fergusson performed resection of the elbow. I -administered amylene in four cases of amputation of the thigh: one of -these operations was performed by Mr. Henry Lee, on January 7th, 1857, -on a girl aged twelve or thirteen, who underwent resection of the knee -on the 1st of November previously. That operation was performed by Mr. -Bowman, and the girl inhaled chloroform. At the time of the amputation, -she was suffering from pyæmia, was extremely weak, and had a pulse of -150 in the minute. The vapour was exhibited to the patient in bed, -before her removal to the operating table. There was an examination of -the knee before the operation; and the anæsthesia was kept up till the -dressings were applied, which was twenty-five minutes from its -commencement, and nearly three fluid ounces of amylene were used. She -went through the operation extremely well. There was no sign of pain, -and the pulse remained the same throughout the operation, and there was -no depression. The patient recovered. - -There was one operation of amputation below the knee by Mr. Fergusson, -in which I administered amylene. The patient was a woman of twenty. The -operation was performed on account of paralysis of the muscles of the -leg and foot. She recovered. There was an amputation of the forearm; two -amputations of the great toe, with its metatarsal bone; and two or three -of toes and fingers: four cases of operation for stricture of the -urethra by perinæal section—three of them by Mr. Fergusson, and one by -Mr. Curling. There were three operations of lithotrity, two for -hæmorrhoids and prolapsus ani, and four for fistula _in ano_. There were -nine operations for the removal of tumours of the female breast; there -were seventeen operations for necrosis of the tibia, femur, lower jaw, -and other bones. - -I administered amylene in several operations on the eye. There were two -operations for cataract by extraction, and one by drilling, performed by -Mr. Bowman; eight cases of excision of the eye by that surgeon, as well -as some operations for artificial pupil, for the removal of foreign -bodies from the eye, for staphyloma, and one for the separation of the -eyelids from the globe. There were also twelve operations for -strabismus, eleven of them by Mr. Bowman, and one by Mr. Fergusson. - -I exhibited amylene in forty-eight operations of tenotomy. Several of -them were performed by Mr. Fergusson, but the greater number were -performed by Mr. W. Adams and the late Mr. Lonsdale, in the Orthopædic -Hospital. The narcotism was scarcely carried beyond the second degree in -any of these cases. The eyes were open, and the features generally had -an expression as if the mind was active on some subject or other. The -muscles were nearly always in a state of tension, at least they were not -relaxed in any case. Many of the patients were children, and a number of -them only inhaled between one and two minutes. There were five -operations for the forcible extension of stiff joints, and two for -dislocation of the humerus: the latter were treated in the St. James’s -Parochial Infirmary. The first case was a dislocation downwards in a -woman aged sixty-eight. She inhaled for three minutes, when, extension -being made, the bone slipped into its place with the utmost ease, -although Mr. French had found a good deal of resistance in an attempt he -made just before sending to me—not any serious resistance or pain, but -so much of both as led him to think it would be a good opportunity for -trying the amylene. In two minutes after the reduction of the -dislocation, and five minutes after beginning to inhale, the patient was -quite awake again, and said that she had felt nothing. The other case -was a dislocation forwards in a man aged seventy-two. No attempt to -reduce it was made till the amylene was administered. The case was under -the care of Mr. Buzzard. After inhaling two or three minutes, the old -man got into a state of muscular rigidity, and did not get beyond this -state, although I continued the inhalation nearly ten minutes, until -about two ounces of amylene were used. He was quite insensible, but the -rigidity prevented the reduction of the dislocation. So I discontinued -it, and sent for some chloroform, which I administered a few minutes -afterwards. It produced muscular rigidity rather stronger than that -which the amylene had caused; but, by continuing the inhalation steadily -for about two minutes, the limbs became relaxed, and the humerus slipped -easily into its place. This is the only case in which the amylene has -not effected the purpose for which I have exhibited it; and I have no -doubt that I could have produced relaxation of the voluntary muscles by -increasing the strength of the vapour the patient was breathing; for I -have always been able to produce relaxation of the muscular system of -animals with it; but there were one or two circumstances which at the -moment stood in the way of this. The patient’s face was so hollow from -his loss of teeth that the face-piece fitted badly; and, as it was early -in a frosty morning, the water-bath of the inhaler was colder than -usual. These defects could have been remedied if necessary, but I -thought it as well to use chloroform; and I am inclined to think that -chloroform and ether are better agents to employ in those instances -where relaxation of the voluntary muscular system is required. - -Sixteen tumours of different kinds were removed from different parts of -the body, in addition to the tumours of the breast previously mentioned, -in cases in which I administered amylene; and there was also a number of -miscellaneous operations which I have not mentioned. - -One of the patients of the late Mr. Lonsdale at the Orthopædic Hospital -was a girl of seventeen, who had the scapula drawn up in an -extraordinary manner by the action of the muscles. When she became -unconscious from the amylene the shoulder came into its right position, -with hardly any pressure, although her muscular system was not in the -least relaxed from the action of the vapour; and the deformity remained -absent for three days. The amylene was repeated three or four times with -the same temporary benefit, and chloroform was given on one occasion -when I was not present with a similar result. I have not heard of the -subsequent progress of the case. I cannot suppose that the direct effect -of amylene would remain three days on the nervous system, and I conclude -that the result was brought about by some change in the emotions of the -patient. - -I gave amylene in twenty-four cases of tooth-drawing, including those -which were previously mentioned. One of the cases was that of a lady -under the care of Dr. Oldham. She was suffering from a large ovarian -tumour, and was unable to rise from the sofa. Mr. Bell extracted four -teeth whilst she was under the influence of the amylene. She became -insensible without the least excitement, was perfectly quiet during the -operation, and recovered in a minute or two, feeling quite cheerful and -well. - -I have administered amylene in seven cases of labour. The first patient -was under the care of Mr. Buzzard in St. James’s Infirmary, on January -20th, 1857. It was the patient’s second labour, and was a lingering one, -having lasted thirty-five hours. I administered the amylene only during -the last twenty minutes preceding the birth of the child, the head being -advanced so as to rest on the perinæum. The vapour was given, well -diluted, at the beginning of each pain. The patient breathed very -deeply, and got relief very quickly from each pain; the mind was quite -clear between the pains, and I could not tell whether or not the -consciousness was removed for half a minute or so during each pain. Half -a fluid ounce of amylene was used. The next case occurred in an -out-patient of King’s College Hospital, under the care of Mr. Meadows, -Dr. Farre’s assistant. It was the patient’s third confinement. I arrived -three hours after the commencement of labour, and two hours before the -birth of the child. The os uteri was almost dilated on my arrival, and -the pains were very strong, recurring every three minutes or so. They -continued to increase in strength to the last. The patient was probably -unconscious for a brief period during the uterine contractions, while -the amylene was administered, but between the pains she was quite -conscious. Under the use of chloroform, in a labour with brisk and -frequently recurring pains, as in this case, the patient usually sleeps -on from one pain to another. The amount of amylene inhaled in this case -was three fluid ounces. The quantity used in each of these cases must -have been about half a fluid drachm in each pain, and this is the -quantity I had previously recommended Dr. Tyler Smith to employ, when he -did me the honour to ask me some questions about amylene before he -employed it in a case of labour. The results arrived at by Dr. Tyler -Smith, in a case in which he employed amylene, were similar to my own, -viz. relief of suffering during the uterine contraction, consciousness -between the pains, and no interference with the progress of the labour. - -On April 28, 1857, I administered amylene in Brownlow Street, Drury -Lane, to a woman in her sixth labour, attended by Mr. Ponsonby R. Adair, -one of Dr. Farre’s assistants. She had been in labour since three P.M. -the previous day. The os uteri was fully dilated, and the amylene was -commenced at 5·25 A.M., and continued till 5·50, when the child was -born. The placenta was expelled in a few minutes with very little -bleeding. The amylene was exhibited with the inhaler at the beginning of -each pain, which it soon relieved, although the patient did not become -unconscious. The pains came on every two minutes or so, and kept -increasing in force till the birth. About six drachms of amylene were -used. - -On May 1st., I administered amylene to another woman in her sixth -labour, also attended by Mr. Adair. The vapour was commenced at 9·30 -P.M., the patient having been in labour a few hours. The os uteri was -not fully dilated. The pains came on regularly every three minutes, but -were not very strong; they, however, gradually increased, and the child -was born at half-past eleven. The cord was round the neck, and the child -was nearly asphyxiated in the birth, but it was restored readily by Dr. -Marshall Hall’s method. The placenta was expelled a few minutes after -the child with very little hæmorrhage. The patient inhaled with every -pain, which was very quickly relieved. The last quarter of an hour, she -seemed to be altogether unconscious. About three fluid ounces of amylene -were used. - -On May 14th, I exhibited amylene for about an hour to a woman in her -third labour, attended by Mr. Adair. The os uteri was nearly dilated -when I arrived, and the patient had been in labour about ten hours. The -pains occurred every three or four minutes, but were not strong. Amylene -was inhaled with each pain for about an hour, when the pains almost -ceased, just as the os uteri was fully dilated. I waited for half an -hour without giving amylene, and then left to attend to another -engagement. Mr. Adair informed me that the pains returned soon after I -left, and that the child was born in about half an hour. The patient was -hardly rendered unconscious by the amylene. Between two and three fluid -ounces were used. - -I exhibited amylene for an hour and ten minutes, on May 25th, to a woman -aged 20, in her first labour. She was attended by Mr. Adair. She had -been in labour since three P.M. the previous day, and the os uteri was -not fully dilated. The amylene was commenced at 9·30 A.M., and inhaled -with each pain, which it relieved in a very manifest way. The pains -recurred every two minutes and a half. I left off giving the amylene at -10·40 to attend to other business. Mr. Adair informed me that the labour -was concluded at one P.M. - -On July 1st, I exhibited amylene to a woman in labour with her third or -fourth child. Labour commenced at midnight of June 27th, and continued -during the following day till the os uteri was dilated to the size of a -crown piece, when the pains subsided on the evening of that day, and did -not return to be effectual till the evening of July 1st. The amylene was -commenced at 10·25, the os uteri being almost dilated, and the pains -recurring every three or four minutes. The uterine contractions -increased in force and frequency, and the child was born at 11·45. There -was a gush of blood two or three minutes after the birth of the child, -and Mr. Adair introduced his hand and removed the placenta, which was -only partially detached. The hæmorrage immediately ceased. The patient -was feeble and emaciated, and had suffered repeated beatings by her -drunken husband. She recovered favourably, as did the other patients. - -The action of the amylene was very favourable in these obstetric cases. -The pains were relieved very promptly by it, generally by the time the -patient had taken two or three inspirations, and the effect of the -vapour passed off in most cases between each pain. - -The great ease with which amylene can be breathed, owing to its entire -want of pungency, is a decided advantage which it possesses over both -ether and chloroform. Insensibility can always be induced with amylene -in as short a time as is desirable, namely, in from three to four -minutes in the adult, and about two minutes in young children. It is not -desirable to cause insensibility in a shorter time than this with any -agent. If narcotism is induced too quickly, the symptoms are not uniform -or in regular order, owing, no doubt, to the circumstance that the -narcotic vapour is not equally distributed through the blood, which must -convey it to the nervous centres. Insensibility can, indeed, be -generally induced with chloroform in the time above mentioned, but there -are many cases in which there is considerable delay at the commencement -of inhalation, owing to the pungency of the vapour, especially in -nervous and in sensitive patients, and in persons with irritability of -the air-passages from chronic bronchitis, phthisis, or any other cause. - -In the use of amylene, absence of pain has been obtained with less -profound coma than usually accompanies the employment of chloroform and -ether. There are some cases, indeed, in which the minor parts of an -operation, under these latter agents, may be performed without pain -while the patient is in a semi-conscious state, or even altogether -conscious, but they form an exception; while in the use of amylene, the -patient has very often been half-conscious during the operation. In -operations under chloroform, the patients usually indicate the necessity -of repeating the inhalation by a tendency to flinch or cry, without -showing any signs of consciousness; but in the use of amylene, they have -more frequently begun to look about and to speak before showing any sign -of pain. There are some patients who will not lie still under the -surgeon’s knife while chloroform is being used, unless its effects are -carried so far that the breathing is on the borders of being stertorous, -but I have not met with any such case in using amylene. - -The greater number of the operations under amylene were performed while -the patient was in the second degree of narcotism, being apparently -awake, although not really conscious of surrounding objects. This usual -absence of coma in the employment of amylene cannot be looked on -otherwise than as an advantage. It must conduce to the safety of the -agent when the proportion of vapour in the air is properly regulated. -The reason why no accident is known to have happened from chloroform, in -the practice of midwifery, when superintended by a medical man, is no -doubt due to the circumstance that it is only requisite to induce a -slight effect, in comparison with the effect required in surgical -operations. - -The best indication that the patient will quietly bear an operation -under chloroform, is the more or less complete absence of sensibility of -the ciliary edge of the eyelid; but during the inhalation of amylene the -patient is often entirely regardless of the surgeon’s knife, whilst the -edges of the eyelids retain their full sensibility, and the slightest -touch causes strong winking. In operations on the eye, however, and in -all other cases where great steadiness on the part of the patient is -required, I have thought it best to continue the amylene till the -sensibility of the margin of the eyelids was almost abolished; and to -effect this it has usually been requisite to carry the influence of the -vapour as far as the beginning of the third degree of narcotism, or that -condition in which there is no longer voluntary motion of the eyes, or -any other part, and in which the eyelids are usually closed, and the -pupils inclined upwards. But even in these cases the patient has usually -reverted to the second degree of narcotism before the end of the -operation, and has shown signs of ideas by the voluntary motion of the -eyes and eyelids, or in some cases by speaking. In several cases, -however, the sensibility of the eyelid has been removed in the second -degree of narcotism; and important operations have been commenced before -the patient was “off”, to use an expression familiar on these occasions. -One instance of this kind was the operation of lithotomy by Mr. -Fergusson, on the 14th of March, 1857, in a young man, aged 17, in -King’s College Hospital. The sound was first introduced, and the stone -being detected, the assistants were requested to tie the patient up; and -finding his limbs somewhat rigid, they requested me to give him some -more vapour. If I had been using chloroform I should have done so -without any request, in order to cause relaxation; but I allowed the -effect of the amylene to partially subside, and in less than a minute -the bandages could be easily applied. I then proceeded to give a little -more amylene, but soon found that the margin of the eyelids was -insensible; so the operation was performed whilst he was calmly looking -about, as if awake; but he showed no sign of pain, and knew nothing of -the operation. I never saw a capital operation performed on the adult, -under the influence of chloroform or ether, whilst the patient was in -this condition; but I once administered chloroform in St. George’s -Hospital to a child of three or four years old, which was cut for stone -whilst lying calmly with its eyes open, and holding a toy in its hand, -all the time of the operation, without letting it fall. - -The pulse is almost always increased in frequency and force during the -inhalation of amylene,—especially during the early part of the -inhalation, and to a greater extent than happens with chloroform. The -respiration is very often accelerated during the inhalation,—about as -often, I think, as with ether, and more frequently than with chloroform. -In many of the early cases in which I administered amylene, the pupil -was dilated for a short time; but I consider that this arose from giving -the vapour rather stronger than is desirable. I afterwards gave it more -gently, and very seldom observed the pupils to be dilated. They -remained, as nearly as I could tell, of the natural size, and also -sensible to light, in the cases where I made an observation on that -point. - -The colour of the countenance is generally heightened more or less -during the whole period of the inhalation, and in a few cases there was -sweating,—a symptom met with now and then under the influence of -chloroform and ether. Amylene does not cause the great increase in the -flow of saliva which is so often met with during the inhalation of -chloroform, and especially of ether. - -There is a tendency to laugh during the inhalation of amylene much more -frequently than during the use of chloroform. It occurs just after the -patient has lost his consciousness, but is soon subdued by the -increasing effect of the vapour. I only met with strong mental -excitement in a very few patients, chiefly females. It subsided in half -a minute in one case, on leaving off the vapour, and did not recur when -the inhalation was resumed. In the other cases it was subdued by -continuing the inhalation. - -The expression of the countenance generally remains calm and cheerful -during the action of amylene; but in a few instances there is a -singular, and even unpleasant, aspect of the face for a short time, -arising apparently from a brief spasmodic action of the muscles. - -I met with less rigidity and struggling during the administration of -amylene than in the use of chloroform; but this probably arose from the -circumstance that the effects of amylene were very frequently not -carried to that degree in which rigidity and struggling are liable to -appear. It is in the third degree of narcotism from narcotic vapours -that rigidity is met with in those cases in which it occurs, but the -greater number of the operations under amylene were performed in the -second degree of narcotism. The rigidity from amylene, when it occurs, -is of a somewhat different kind, and takes place in patients in whom we -should not expect it from chloroform. In the spasm and rigidity from the -latter agent, the head is more commonly bent forwards or turned to one -side, although it is occasionally thrown back; but under amylene, the -latter is the usual position it assumes when rigidity occurs, -constituting a brief opisthotonos. The rigidity under the influence of -chloroform is usually accompanied with struggling, while in that caused -by amylene the patient is generally quieter. The persons in whom -rigidity and struggling are most violent from the effects of chloroform -are lean, muscular men, who work at hard labour, or follow athletic -sports, such as hunting, and especially boating; while those who lead a -sedentary life, or are reduced by illness, seldom exhibit these -phenomena. Women and children seldom exhibit any rigidity under -chloroform, and fat persons least of all. Old people do sometimes, -especially if thin. Under the use of amylene, on the other hand, I have -most frequently met with some amount of rigidity in children and young -persons, while many robust men, in whom it would be almost certain to -occur under chloroform, have not shown any signs of it. The cause of -this probably is, that the operation has generally been performed -without carrying the narcotism beyond the second degree, while rigidity -does not take place till the third degree is attained. In every case -where rigidity and struggling have occurred in the employment of -chloroform, however violent these symptoms might be, I have continued -the vapour gently and steadily till they were subdued, either by -removing the tendency to these symptoms, or by carrying the narcotism to -the fourth degree, which is accompanied by relaxation of the voluntary -muscular system, and usually with some tendency to stertor. In the use -of amylene, on the contrary, I have not attempted to subdue the spasm by -continuing the inhalation, but have, with the exception of a case of -dislocation previously mentioned, withdrawn the vapour when the rigidity -appeared, and the operation has either been performed at once, or else, -if it was of a nature that the spasm would interfere with, I have waited -a short time, and exhibited a little more vapour very gently, so as to -get a state of anæsthesia without the recurrence of the spasm. - -Mr. Jones, of Jersey, favoured me with the following account of a case -in which amylene acted much more favourably on his patient than -chloroform. - -John D., æt. 41, stout and of very ruddy complexion, so injured his leg -that it was deemed advisable to saw off the fractured ends of the tibia. -Chloroform was at first given (March 16, 1857), but the effect it -produced, though administered with the utmost caution, was evidently of -so dangerous a nature, that it is more than probable that death would -have resulted had it been persevered in longer than five or six minutes -(the period it was employed). The patient became quite apoplectic, and -had two or three very severe convulsions. Amylene was at once -substituted, and with the happiest result. The patient appeared -conscious, but was not so, and the operation, which was a tedious one, -was commenced and finished without his experiencing the least pain, -indeed without his having the slightest knowledge that operative -measures had been resorted to. - -Amylene differs widely from chloroform, and still more from sulphuric -ether, in the promptitude with which patients generally recover from its -effects. This is a character of amylene which might have been predicted -from its physical properties. I have many times observed how quickly, -and, indeed, almost instantaneously, small animals recover from the -stupor occasioned by certain permanent gases which are sparingly soluble -in watery fluids, as olefiant gas, carbonic oxide and carbonic acid -gases, nitrous oxide and the gaseous oxide of methyle. Now amylene is so -volatile as to approach to a permanent gas; at a temperature a little -above that of the human body it would be a gas, and the vapour is very -sparingly soluble in watery fluids, and consequently in the blood. -Sulphuric ether is, indeed, as volatile as amylene. I cannot remember -any other two bodies whose volatility is so nearly alike; but sulphuric -ether is very soluble in watery fluids, in comparison with amylene. -Water dissolves a tenth of its volume of liquid ether, or 23 volumes of -the vapour. Consequently a large quantity of ether is absorbed during -inhalation, and the blood has to pass many times through the lungs -before it is freed from it. The quantity of amylene which is absorbed -is, on the contrary, extremely small, as I have explained above, and -this, together with its volatility, is no doubt the reason why the -patient recovers so promptly from its influence. In about a minute after -the operation is concluded, and the inhalation left off, the patient -usually awakes from the influence of amylene, and completely recovers -his consciousness. The same quick recovery may take place after -chloroform, but more frequently it is a few minutes before the patient -is quite conscious. I have seen two or three instances in which a child -has slept for twenty minutes or half an hour after amylene, but it must -be remembered that children sometimes sleep for hours after chloroform -in cases where the operation has not produced a painful wound. The quick -recovery of the patient is a decided advantage in all minor operations. -In great operations, where the patient is obliged to keep his bed -afterwards, it is of less consequence whether he wakes promptly or not, -although, even under these circumstances, his friends are generally -anxious to see him recover his consciousness. The smarting of the wound -after an operation is often prevented longer when chloroform has been -employed than after the use of amylene, and this may be considered as a -slight advantage which chloroform possesses in certain cases. In some -instances, however, in which chloroform has been used, the patient -begins to show symptoms of suffering pain in the wound before he has -entirely recovered his consciousness, while after amylene I have not -seen symptoms of pain in the wound till consciousness had completely -returned. In any cases where the pain after an operation, either from a -wound or ligatures or caustic, is very great, the inhalation of the -agent which has been employed may be gently repeated at times until the -pain has a tendency to subside, or till an opiate shall take effect. - -The patient generally seems surprised or confused on first recovering -from the effects of the amylene, but in a few seconds he becomes, in -most cases, completely conscious of his position, and feels that his -mind has been wandering. He often says he does not know where he has -been in his dreams, or that he has been a long way. Sometimes he does -not remember exactly what he has dreamed about; at other times he does. -All this is common enough after chloroform, except that the process of -recovery is generally much slower; but there is one condition of mind -which is very common after chloroform, which I have rarely met after -amylene, I allude to that condition in which the patient asserts that -the vapour has not taken effect, and that he has not been asleep at all. - -Amylene appears to support the pulse under loss of blood at least as -well as chloroform. I have not found the pulse to fail, although there -was rather free hæmorrhage in some of the operations. - -There has been a little headache in a few of the cases as the effects of -this agent were subsiding, but it passed off in a few minutes. - -In administering amylene, the vapour must be given of such a strength as -will cause insensibility in about three minutes, or it will not succeed -at all unless the strength of the vapour be altered. In giving -chloroform, the vapour may be of less than half the desirable strength, -and by continuing more than twice the usual time, the patient may be -rendered insensible; and in using sulphuric ether, the vapour may be -breathed of one-seventh the proper strength, and by continuing it -constantly for seven times the usual period, _i. e._, for half an hour, -the patient might be rendered insensible; but in using amylene, time -will not make up for deficiency in the strength of the vapour. If the -vapour be not strong enough to cause insensibility in about three -minutes, it might be breathed for an indefinite period without causing -insensibility; and the patient is solely affected by what he has inhaled -within two or three minutes. - -On account of the very rapid subsidence of the effects of amylene, it -requires to be very frequently repeated during the performance of an -operation. The patient generally requires to inhale a little of it every -half minute or so to keep up its effect. On this account, it is not well -adapted for certain operations on the face. I did, however, administer -it with complete success in several operations on the face in King’s -College Hospital. Amongst these, there were four operations by Mr. -Fergusson for making a new nose in which I administered amylene, and -succeeded in preventing the pain by holding a hollow sponge, wetted with -that agent frequently, near the mouth and nose. - -In cases of tooth-drawing, in which a number of teeth or stumps have to -be taken out, the effects of the amylene are apt to pass off before the -operation is completed, and the inhalation has to be repeated once or -twice, but in cases when only one or two teeth require to be extracted, -amylene has a great advantage in the promptitude with which the patient -recovers from its effects. There is occasionally some difficulty in -opening the mouth with amylene, as with chloroform. - -The patient has nearly always a very cheerful expression of countenance -when he recovers from the amylene, and the state of his mind, as -indicated by his conversation, corresponds to his look. Dr. Debout has -noticed the same circumstances. Speaking of the patients operated on -under amylene in Paris, he says, “A leur réveil et le premier moment de -stupeur passé, leur physionomie est épanouie.” The same state of -countenance and mind is met with after chloroform only now and then, and -is by no means the rule. - -Hysterical symptoms occurred in a few women after operations under -amylene. They were met with about as frequently, I think, as after -chloroform. These symptoms generally subsided in a few minutes; but in -one or two young women in the hospital, they lasted nearly an hour. - -The greatest advantage that amylene possesses over ether and chloroform, -is the great infrequency with which it excites sickness. I only saw -vomiting occur in two of the 238 cases in which I administered amylene, -although it occurred before I left the patients’ room in twenty-two -cases out of 100 in which I administered chloroform and kept an account -of this symptom, at the time I was using amylene. In the greater number -of the cases in which chloroform was exhibited, the patients had been -requested not to take a meal; whilst in the cases in which amylene was -administered, no directions regarding diet had as a general rule been -given. - -I made subsequent inquiries respecting most of the patients who inhaled -amylene, and I was only able to hear of sickness in eight or ten cases, -and it was not distressing or troublesome in any of these. It generally -occurred three or four hours after the amylene, and subsequently to the -patient taking his first meal after the inhalation. In one of the two -cases in which vomiting occurred after amylene before I left the room, -there was retching for four hours; but I did not hear of so much -sickness after any other case in which I administered this agent; and -there was no faintness or depression either in this case or any other in -which amylene was employed, although faintness and depression often -accompany the sickness which is occasioned by chloroform. Some of the -patients who inhaled amylene without being sick, had previously suffered -from sickness after inhaling chloroform. I administered amylene, on -January 30th, 1857, to a lady, about twenty-five, whilst Mr. Bowman -operated for strabismus, and there was no vomiting or sickness, either -at the time of the operation or afterwards; but the same patient had -undergone a similar operation a week previously, when chloroform was -administered, and on that occasion vomiting commenced before the -operation was finished, and recurred every quarter of an hour, with -violent retching, for twelve hours. - -I had the misfortune to lose two patients from the inhalation of -amylene. The following are the particulars of these cases. - -Mr. Fergusson requested me to assist him on the 7th of April, 1857, in -the case of a gentleman on whom he was about to operate for fistula _in -ano_. The patient was thirty-three years of age, and was in good health, -with the exception of the local complaint, although he had lived -somewhat freely. Mr. Fergusson examined the patient’s chest the day -before the operation, and found the sounds of the heart to be normal. I -felt his pulse just before he began to inhale. It was natural, but -somewhat accelerated, as usually happens just before an operation. He -was lying on his side in bed. About six fluid drachms of amylene were -put into the inhaler (I never intentionally used all I put in, but added -more before the paper became dry), and he breathed steadily and gently. -The valve was gradually advanced over the opening in the face-piece till -it about three-quarters covered it, and the patient appeared to become -quietly unconscious in about two minutes. He breathed quickly for a few -inspirations just as he appeared to become unconscious. Just after this, -Mr. Fergusson came and felt the patient’s pulse, and he says it was very -good. I felt it also. I looked at my watch at this time, and it was two -minutes and a half or two and three-quarters from the beginning of the -inhalation. Mr. Fergusson commenced to use the probe, and, finding the -patient did not flinch, he began to use the bistoury. Mr. P. C. Price -assisted at the operation. I held the patient’s thigh with one hand, as -I often do in such an operation, lest he should flinch. He did not -flinch, however, but kept his limbs tense, without moving them. Just at -this moment, I observed that the valve of the face-piece, which I had -left three-quarters covering the opening, had moved so as to cover it -entirely, but I cannot say whether or not the patient had taken an -inspiration a little stronger than I intended, and thought nothing of -the matter, as I have frequently had to close the valve completely in -giving amylene. It could not, however, have been many seconds in that -position, for I paid no attention to the operation, except so much as -was requisite to guide me in what I was doing. The inhalation was -discontinued at the moment I have mentioned, and on looking round -directly after, I found that the operation, which had apparently been -but one incision, was finished. I now began to feel for the pulse, more -out of constant habit, and from a scientific curiosity, than from any -supposed necessity of doing so. Although it had been good only half a -minute before, I could not find it in the left wrist, and only a slight -flutter in the right one. His breathing was, however, good, indeed quite -natural, and he did not seem even to be very insensible, for there was -some motion both of his features and limbs, as if he were about to -awake. I watched the patient with great anxiety, thinking that surely -his good and natural breathing would restore the pulse, and feeling that -at all events this superseded any other measures at the moment. In two -or three minutes, however, he seemed to be getting more insensible; he -did not wink on the edge of the eyelids being touched, and the breathing -was getting slower and deeper. I called Mr. Fergusson’s attention to the -patient, and both he, who was preparing to go away, and Mr. Price, who -had all the time been standing by the patient, were surprised to find -that anything could be wrong, as they had seen the patient going on -apparently so well, not only during the inhalation, but after it was -discontinued. They dashed cold water in his face, which did not seem to -have any effect. His countenance was now livid, and his breathing of a -gasping character. It soon began to leave off, with the exception of -deep, distant, gasping inspirations, and we therefore began to perform -artificial respiration, by Dr. Marshall Hall’s method, placing him in -the prone position, and bringing him partly round, while Mr. Price kept -the mouth open. The air could be distinctly heard passing through the -larynx during this motion. We also tried pressing on the chest with the -head on one side and the mouth open, which answered very well as -regarded the ingress and egress of air. Inflation from mouth to mouth -was tried, but did not seem to answer so well. Although deep gasping -inspirations were made by the patient till fully ten minutes had elapsed -from the failure of the pulse, the measures used had no effect; I -believe that I heard a feeble motion of the heart even after this -period; and, as Mr. Fergusson perceived a slight pulsation at the same -time in the right wrist, I was probably not mistaken. There were no -further signs of life after this, although the artificial respiration -was continued for a long time. I am quite sure as to the length of time -respiration continued after the failure of the heart’s action. The pulse -ceased to be distinctly perceptible at ten minutes before five, and the -patient was still breathing at five o’clock. He had not taken food for -some hours, but drank a pint bottle of ale a little while before the -operation. A good portion of amylene remained in the inhaler after it -had been uncovered for an hour and a half. - -There was an examination of the body forty-eight hours after death. The -body was rigid. There was a good amount of fat beneath the integuments. -The cartilages of the ribs were ossified. The lungs were large, and did -not collapse; they completely filled the cavity of the chest, and seemed -by their texture to be emphysematous, although there were no large cells -on the surface. There was a little congestion at the posterior surface -of the left one, otherwise they were not very vascular. There was a -little clear fluid in the pericardium. There was a good deal of fat on -the surface of the heart, which was somewhat larger than natural. It was -removed by cutting the great vessels before it was opened, and in -removing it three or four ounces of dark-coloured fluid blood escaped. -The right ventricle was somewhat dilated, otherwise the heart was -healthy; the walls of the left ventricle seemed very thick, but it was -contracted, so as almost to obliterate the cavity. The liver was -vascular, dark-coloured, and friable. The stomach was healthy, and -contained only a little mucus. The other organs were not examined. There -was no odour of amylene in the body. - -I believe the patient had emphysema of the lungs. There was no such -force used in the artificial respiration as could permanently dilate the -air-cells, and the dilatation of the right ventricle indicates some -chronic obstruction to the pulmonary circulation. - -The other death from amylene occurred in St. George’s Hospital on July -30th, 1857, in a case in which Mr. Cæsar Hawkins removed a small -epithelial tumour from the back. The patient, a short, muscular man, was -a tailor, twenty-four years of age, who had been in the Hospital several -months, and had had three similar tumours removed, by as many -operations, under chloroform; the last of these operations having been -performed three weeks previously. He inhaled the amylene without any -difficulty; in about two minutes he appeared to be unconscious, and, in -another minute, the sensibility of the margin of the eyelids was -somewhat diminished, and I told Mr. Hawkins that he might perform the -operation. For this purpose the patient, who had been lying on his side -on the table, was turned a little more on his face, or at least it was -attempted to turn him, when he burst out into a kind of hysterical -excitement, laughed loudly, and was with difficulty held on the table. -Nothing was done during this excitement, which lasted about a minute. -After it had subsided, I administered a little more amylene, although -the patient had not recovered his consciousness; and then Mr. Hawkins -performed the operation, which I believe did not last more than two -minutes altogether. During the operation, the patient was turned on his -face. He rested, I think, chiefly on his knees and elbows. He was -muttering in an incoherent manner, and making slight attempts to move, -but was easily restrained. I gave him an inspiration or two of amylene -now and then during the operation, with the intention of preventing his -waking prematurely; for this purpose, I turned the head a little to one -side, and raised the face a little from the table.[176] I had concluded -that the patient would not require any more amylene, and was expecting -that he would show signs of returning consciousness or sensibility -almost as soon as Mr. Hawkins had tied the suture which he was -introducing; but, instead of this, the limbs became relaxed, and the -breathing, though free enough, took on a noisy, snoring character. - -This is a state which is common enough in the use of chloroform, and -excites no alarm whatever, but I felt that it ought not to occur in the -use of amylene, especially after it was left off. I therefore sought -again for the pulse at the wrist, and could perceive it only with -difficulty, if at all. I spoke to Mr. Hawkins, and we immediately turned -the patient on his back. His face had already become livid, and his -breathing was of a gasping character. Mouth to mouth insufflation of the -lungs was performed, and between the insufflations there were -spontaneous acts of inspiration, during which the air seemed to enter -the lungs freely. In a minute or two, the lips became of a proper -colour, and the countenance had altogether such a natural aspect that -the patient seemed to be recovering. The pulse at the wrist, however, -could not be felt. No one listened to the chest at this time, for fear -of interrupting the process of artificial respiration. After two or -three minutes, Dr. Marshall Hall’s method of artificial breathing was -substituted for the insufflation, and it was continued very perfectly by -the house surgeons and others for an hour and a half, with the exception -of two short intermissions, which will be mentioned. During -three-quarters of an hour of this time, there were spontaneous -inspirations, during which air entered the lungs, in addition to that -which entered during the turning process. Twenty minutes after the -accident, the process of artificial respiration was suspended for about -a quarter of a minute, to enable me to listen to the chest. I thought I -could hear the heart beating regularly, but very feebly, and certainly -there was a good vesicular murmur, and the air seemed to enter the lungs -by the patient’s own breathing, almost as freely as in health. At the -end of three-quarters of an hour, with the permission of Mr. Hawkins, I -introduced two hare-lip pins which had been connected with the -electro-magnetic battery, with the intention of performing -galvano-puncture of the heart. The needles were introduced to the depth -of about an inch and a half between the cartilages of the ribs, just to -the left of the sternum, and on a level with the nipple. They were -afterwards found to have penetrated the walls of the left ventricle, -near the septum, but without reaching the cavity. There was a quivering -contraction of the pectoral muscle when the needles were first applied, -but no effect on the heart. The needles ought probably to have been -coated with some non-conducting substance almost as far as their points. -There were no further efforts of inspiration after this time, but this -was probably only a coincidence. The electro-magnetic battery had been -applied in the early part of the treatment by means of the wet sponges -applied to each side of the chest, but it produced no effect. - -An examination of the body was made by Mr. Holmes, the Curator of the -Hospital Museum, on the following day. A good deal of dark-coloured -fluid blood flowed from the right cavities of the heart, and the left -cavities contained but little blood. The heart was pale and somewhat -friable; but a microscopic examination by Mr. Holmes did not show any -fatty degeneration. The lungs were moderately vascular, and contained -some small epithelial tumours of the same character as those removed -from the back. There was a large cyst in one kidney; but, with these -exceptions, the organs were healthy. The vessels of the brain were not -distended, and that organ was altogether less vascular than is usual -after sudden death. No smell of amylene was perceived in the body. - -The continuance of the respiration so long after the heart was paralyzed -in these two cases, and especially in the second one, is a remarkably -curious event. The respiration continued after the heart had ceased to -act in several cases of death from chloroform, but not for so long a -time as in these deaths from amylene. It is probable that there must -have been some little circulation going on through the brain whilst the -respiration lasted, and in fact, the slight fluttering pulse and feeble -sounds of the heart, once or twice perceived, indicate that the -circulation was not absolutely arrested. Under these circumstances, we -may inquire why the action of the heart does not recover. If the -circulation were going on in the coronary arteries, it might be expected -that the blood from the lungs, which has been aerated by respiration, -and freed from the narcotic vapour, would restore the action of the -heart. But it is probable, for the reasons stated at page 262, when -treating of accidents by chloroform, that the circulation through the -coronary arteries is arrested. - -The accident clearly commenced at the heart in both these cases, and I -believe that the brain was never more than partially under the influence -of the amylene in either of them. In the _Medical Times and Gazette_ of -July 25th, 1857, M. Devergie is related to have expressed an opinion in -the Academy of Medicine of Paris, that the first of the above deaths -from amylene was caused, in great part, under the influence of true -asphyxia, using that term in its modern acceptation. Now that is -altogether an error, arising, probably, from M. Devergie not having seen -any original account of the case. There was no cause of asphyxia, either -internal or external; the patient breathed well until after his heart -had ceased to beat, unless in the most feeble and doubtful manner. The -valve which was closed only altered the direction, but not the amount of -air. In fact, the patient was throughout supplied with as much air as -could enter through a tube twice the size of his windpipe. - -I had scarcely any hope of the patient in St. George’s Hospital from the -very commencement of the accident; for I felt that if he could be -recovered by artificial respiration, his own breathing would have -remedied the accident, even before it was discovered. From what has been -published respecting the pulse sometimes stopping and commencing again, -during the inhalation of chloroform, it is probable that many accidents, -in which the heart has been nearly paralysed, have happened, and -rectified themselves, without attracting much notice. - -I have no doubt that in each of these accidents the patient must have -taken into his lungs at one moment air containing upwards of thirty per -cent. of vapour of amylene. And there is no doubt that the cause of this -was the unsteady boiling point of the agent. If the amylene with which I -was supplied had boiled steadily at the same temperature, there is no -doubt that the means which I was employing, and which had enabled me for -ten years, whilst exhibiting chloroform, to give four per cent. of the -vapour, probably without ever allowing the quantity to exceed six per -cent., would have enabled me to give fifteen per cent. of vapour of -amylene without permitting the quantity to exceed twenty per cent. - -The alteration in the boiling point of a specimen of amylene from 86° to -115° Fah. would cause it to give off more than twice as much vapour in -the beginning of its evaporation as towards the end; and, moreover, the -different specimens of it did not always possess the same amount of -volatility. - -The temperature of the external air as it influenced that of the -water-bath of the inhaler would have some influence over the evaporation -of the amylene, but I altered the amount of evaporating surface of paper -according to the season of the year for amylene, as I was in the habit -of doing for chloroform. The highest temperature of April 7, the day on -which the first accident happened, was at Greenwich, according to the -Report of the Astronomer Royal, 62°; and on July 30, the day on which -the second accident happened, was 78·7°. After the first accident, I had -reduced the surface of bibulous paper in the inhaler to one-half of what -it had previously been. - -The first of the above accidents happened in the 144th case in which I -administered amylene, and the second in the 238th case. In the ninety -cases and upwards in which I administered amylene between these two -accidents, I never had occasion to feel a moment’s uneasiness about it. - -In the future cases in which I employ amylene, it is my intention to -administer it from a bag or balloon, putting in so much of the liquid as -will make fifteen per cent. of vapour when the bag is filled up with -air. In this manner, the variability in the boiling point of the amylene -can have no influence whatever on the amount of vapour which the patient -breathes; and if the vapour be breathed over again, within certain -limits, in the manner of nitrous oxide gas, there will be a great saving -in the amount of amylene consumed. - -In my first paper on amylene, which was read on January 10th, 1857, I -said: “While I cannot venture to predict for it the absolute safety -which seems to attend sulphuric ether under all circumstances, I trust -that it will be perfectly safe with careful management”[177] And I added -further on, “It is my opinion that the cold produced during its -evaporation would, in all the ordinary methods of inhalation, prevent -the air from taking up a quantity of the vapour which would be -dangerous.” - -Although amylene was largely used in Paris, Strasbourg, Montpelier, and -Lyons, soon after I published my first account of it, and although I -have lately heard that it is still employed in Paris and Berlin, nearly -eighteen months after its first use in these places, I am happy that I -have not heard of any accident from its use except the two which -happened in my own hands. - -M. Giraldis, of Paris, who was present at the operating theatre of St. -George’s Hospital when the accident happened at that institution, had -already employed amylene in 100 cases in children, and I believe that he -continues to use it. Given on a handkerchief or sponge, I believe that -amylene is safer than chloroform, owing to the greater cold produced -during its evaporation, and the limit thereby put to the amount of -vapour which is given off; but I have seldom given it in this manner, as -I do not think it would be certain and regular in its action, and any -doubt on these points would, with me, have quite overbalanced its other -advantages. In applying amylene on a sponge, M. Rigaud of Strasbourg -used 100 grammes (between four and five fluid ounces) in making an adult -patient insensible, although half a fluid ounce suffices with the -inhaler I employed. - -Mr. Clarke, of Bristol, in a paper which he published on amylene,[178] -says: “It seemed impossible to get too much into the system, and with -this I have been greatly impressed; it is this fact that appears to me -to promise an immunity from danger.... It requires to be given almost -unintermittingly, and requires the same amount of attention to keep up -its effects as chloroform does to keep the patient safe. The direction -of the attention, however, is one less calculated to give anxiety.” - -Dr. Debout stated, as the result of some experiments on animals, in -which he was assisted by M. Duroy, that if it sufficed to double the -quantity of chloroform in order to transform the anæsthetic dose of that -agent into a poisonous dose, it was necessary to quadruple that of -ether, and to quintuple that of amylene, in order to arrive at the same -result; and that, therefore, the innocuousness of the new agent was -still greater than that of sulphuric ether.[179] - -In a paper which Professor Tourdes, of Strasbourg, read before the -Academy of Medicine of Paris, he came also to the conclusion, from a -series of experiments and observations, that “amylene was evidently much -less dangerous than chloroform, perhaps even than ether.”[180] - -According to my experiments, amylene ought to be placed between -chloroform and ether in respect to its comparative safety by the -ordinary methods of administration; and by breathing it from a bag, in -the manner previously mentioned, it would be absolutely safe, so long as -the right quantity were put into the bag. - -Papers on amylene were read to the Academy of Medicine of Paris by Dr. -Debout and M. Tourdes, and were reported on favourably. M. Giraldis -afterwards presented a paper in which he stated the very favourable -result of seventy-nine cases in which he had employed it. The Academy on -this occasion recommended the disuse of amylene on account of the -accidents which had happened in my hands, apparently overlooking the -circumstance that M. Giraldis himself had been much more successful in -the use of amylene than in that of chloroform. M. Jobert de Lamballe, -the reporter of the Commission, stated that amylene deprived the blood -of its red colour and that chloroform does not. But there is no -difference between these agents in this respect; the blood retains its -proper colour under the use of either of them, unless the effects are -carried so far as to interfere with the breathing. - - - - - THE MONOCHLORURRETTED - CHLORIDE OF ETHYLE. - - -This substance was discovered some few years ago by M. M. G. Regnault. -It is made by exposing to the sun’s rays a mixture of the vapour of -chloride of ethyle (muriatic ether) and chlorine gas. One equivalent of -the hydrogen of the chloride of ethyle is replaced by an equivalent of -chlorine. Its composition is four atoms carbon, four atoms hydrogen, and -two atoms chlorine. It has the same composition as Dutch Liquid, which -is made by the combination of olefiant gas and chlorine gas; the -specific gravity of its vapour, 3·42, is also the same as that of Dutch -liquid, which it resembles also in taste and smell. The boiling point is -however different, and it differs from Dutch liquid in not being -decomposed by an alcoholic solution of potassa. - -I tried several times to make the monochlorurretted chloride of ethyle -in 1849 and 1850, but did not succeed in procuring more than a drachm or -two at once, owing to the constant over-action of the chlorine and the -production of other chlorurretted products. In 1851, however, these -products which result from the decomposition of muriatic ether by -chlorine gas were recommended in Paris as local applications in -rheumatism and other painful affections, and Mr. Mason was kind enough -to obtain for me from that capital a pint bottle of a liquid consisting -chiefly of the monochlorurretted chloride of ethyle. It was mixed with a -certain portion of the bichlorurretted and terchlorurretted products, -but I was able to separate by distillation as much of the -monochlorurretted product as enabled me to administer it to twenty-two -patients. Mr. Mason was, however, not able to obtain any more liquid -containing any of the monochlorurretted chloride. What he afterwards was -able to obtain had a very high boiling point, and consisted chiefly of -chloride of carbon; carbon four atoms, chlorine five atoms. - -The monochlorurretted chloride of ethyle resembles chloroform very much -in taste and smell, and in its physiological properties. Its boiling -point is 149°, whilst that of chloroform is 140°; the specific gravity -of its vapour is also lower; for these reasons, it is considerably less -volatile than chloroform, and it is therefore pretty certain that it -would not be liable to cause the sudden deaths which have occasionally -been produced by the administration of chloroform, even if it were given -freely and with no great care. The difficulty of procuring it in a state -of purity is, however, a barrier to its introduction into practice. - -I first administered this preparation in King’s College Hospital, on -June 20th, 1851, to a young woman, whilst Mr. Wm. Hewett, the house -surgeon, repeated the operation of paring off venereal warts and -applying nitric acid. The patient breathed it very readily without -appearing to suffer from the pungency. She was a little longer in -becoming unconscious than on former occasions from the chloroform, but -soon after becoming unconscious, the sensibility of the conjunctiva -diminished, and the operation was commenced. There was some flinching, -so that she required to be held, but there were no cries or other signs -of sensation. Consciousness returned almost immediately, and she seemed -more exhilarated than after chloroform. She had had her dinner just -before the operation, and at one time, soon after recovering her -consciousness, she said that she felt rather sick, but this feeling -passed off without vomiting, and she did not remember it afterwards. She -did not begin to cry out from the smarting till twenty minutes after the -operation, when she had been quite conscious, collected, and rational -for a quarter of an hour, although on the two former occasions, after -chloroform had been inhaled, she began to cry immediately after the -operation, and almost before consciousness had returned. Next day she -was very well. - -On the following day I administered the same preparation to three -patients on whom Mr. Fergusson operated in King’s College Hospital. The -first was a boy seven years old, who had the forefinger removed, -together with part of the metacarpal bone, on account of a large -enchondroma. The second was an infant three months old, which was -operated on for hare-lip; and the third was a woman about thirty-five, -who had some venereal warts removed from the pudenda. There was no -sickness in either of the cases, although the little boy and the woman -had taken their dinners just before the operation. - -On June 25th, I administered the preparation with the chloroform -inhaler, as in all the other cases, to a muscular young man, about 25, -whilst Mr. Henry Lee removed some piles, and applied nitric acid to the -raw surface. The patient was six feet three inches in height, and -weighed fourteen stone. He became insensible rather slowly, with low -muttering and a good deal of rigidity. The operation lasted about ten -minutes, during which the inhalation was repeated two or three times. -There was no pain. He recovered his consciousness in two or three -minutes after the conclusion of the operation; he said that he felt -drunk, and he appeared so for a few minutes. He was very cheerful, and -had no sickness, although he had had his dinner just before coming to -the hospital to have the operation performed. Half a fluid ounce of the -monochlorurretted compound was inhaled, being about the same quantity as -would have been consumed of chloroform. - -The other operations in which I administered this preparation, consisted -of the removal of a tumour situated below the angle of the jaw in a -young woman, by Mr. Fergusson; an operation on the tibia and fibula of a -little boy, for ununited fracture, by Mr. Bowman; trephining the tibia -of a young man, and giving exit to a collection of pus, by Mr. Henry -Lee; an operation for necrosis of the tibia, by the late Mr. Avery; two -operations for hare-lip; two operations for fistula _in ano_; one for -nævus on the forehead; one for tenotomy; and one for removal of a fatty -tumour, by Mr. Fergusson.[181] - - -THE END. - - - - - INDEX. - - - A. - - Absorption of vapours by fluids, 59 - - —— —— —— by the lungs, formula of, 59 - - Academy of Medicine of Paris, reports by, 132–4 - - Accidents from chloroform, treatment and prevention of, 248–62 - - Age, influence of, on effects of chloroform, 49, 50 - - Age in fatal cases from chloroform, 230–1; - from amylene, 401–2 - - Air, saturation of, with chloroform vapour, 68, 123; - with amylene, 376 - - —— amount of, in lungs, 108 - - —— respired during chloroform, 108 - - Allen, Mr., on a fatal case from chloroform, 195–6 - - Alleged fatal cases from chloroform, 201–12 - - Ammonia, use of, after chloroform, 104 - - —— use of, during accidents from chloroform, 258 - - Amputations under chloroform of thigh, 276–7; - of leg, 277; - of arm, 277–8; - of the ankle, 278; - of other parts, _ib._ - - Amylene, first application of, by author, 23 - - —— applications of, in Paris, Strasbourg, and Lyons, 24 - - —— discovery of, 372; - preparation of, _ib._ - - —— chemical and physical characters of, 373–7 - - —— volatility of different specimens of, 416 - - —— experiments with, 378–86 - - —— administration of, for operations, 386, 400 - - —— administration of, in parturition, 394–7 - - —— mode of administration of, 386–7, 405–6, 416 - - —— symptoms produced by, 399, 400 - - —— spasms and rigidity from, 401–2 - - —— does not produce vomiting, 406–7 - - —— effects of, on different persons, 401–2 - - —— effects of, on author, 384 - - —— amount of, required to produce insensibility, 384 - - —— effects of, on the heart, 384 - - —— time of inhalation of, to produce insensibility, 397 - - —— effects of, on consciousness, 398–403 - - —— promptitude of action of, 403 - - —— effects of, on respiration and circulation, 400 - - —— —— —— on the salivary glands, 400 - - —— chloroform, and sulphuric ether, effects of, compared, 403–5 - - —— after-effects of, 406–7 - - —— fatal cases from inhalation of, 408–16 - - —— amount of vapour of, inhaled in fatal cases, 415 - - Amylene, author’s prediction regarding safety of, 417 - - —— mode of administration of, by M. Rigaud, 417–18 - - —— Mr. Clarke’s remarks on, 418; - - —— Dr. Debout’s remarks on, _ib._ - - —— Professor Tourdes’ remarks on, _ib._ - - —— author’s computation of safety of, _ib._ - - —— M. Giraldis on use of, 419 - - —— M. Jobert de Lamballe on use of, _ib._ - - Anæsthesia, modes of production of, 40–1 - - Anæsthetics, definition of, 34–5 - - Ancients, views of the, 3 - - Animals, various, experiments on, with narcotic vapours, 60 to 73 - - Anus, operations on, under chloroform, 307, 308–9 - - Animation suspended by chloroform, treatment of, 251–62 - - Apuleius on effects of mandragora, 2 - - Apoplexy, administration of chloroform after, 57 - - Aretæus’ description of mandragora, 3 - - Arnott, Dr. James, statistics of operations before and after - introduction of etherisation, 265–7 - - —— on pyæmia following chloroform, 267 - - Arteries, coronary, circulation of the, 262 - - Artificial respiration, value of, 121, 251–7, 260 - - —— —— applied in cases of death from chloroform, 139, 144, 151, 156, - 159, 163, 166, 167–8, 173, 179, 181, 183, 185, 187–8, 190–1, 194, - 196–7, 207, 210 - - Artificial respiration applied in case of death from amylene, 410–413 - - Arteries, ligature of, under chloroform, 289–291 - - Aschendorf, Dr., on alleged fatal case from chloroform, 204–5 - - Asphyxia idiopathica, 226 - - Asphyxia, death from, 235 - - Asthma, treatment of, with chloroform, 331 - - Athletics least susceptible of chloroform, 50 - - Augustus of Poland, operation on, without pain, 8 - - Aurelianus Cælius on mandragora, 3 - - - B. - - Balard, Professor, discovery of amylene, 372 - - Balloon for inhalation of chloroform, 80 - - Barlow, Mr. W. F., report on case of alleged death from chloroform, 208 - - Barrière, M., case of alleged death from ether, 364 - - Bath warm, use of, in fatal case from chloroform, 159 - - Beddoes, Dr., administration of gases in disease, 14 - - —— —— his pneumatic institution at Bristol, _ib._ - - Bell, Mr. Jacob, on chloric ether, 20 - - Belladonna, effects of, 4 - - Berthé, M., discovery of amylene, 378 - - Bickersteth, Mr., on supposed effect of surgeon’s knife on pulse, 240–3 - - —— —— on the pulse during inhalation of chloroform, 249–50 - - —— —— cases of resuscitation from over effects of chloroform, 253–6 - - Bigelow, Dr., use of sulphuric ether as an anæsthetic, 18 - - —— —— administration of chloric ether by, 20 - - Birds quickly affected by chloroform, 70 - - Black, Dr. Patrick, on asphyxia and syncope, 222 - - —— —— on closure of the glottis by chloroform, 236 - - —— —— on modes of inhaling chloroform, 236–7 - - Blood, serum of, absorption of chloroform by, 69 - - —— absorption of amylene by, 382–4 - - —— quantity of, in body, 73; - amount of serum, 74 - - —— chemical examination of, in alleged case of death from chloroform, - 211 - - —— condition of, after death from chloroform, 247 - - —— saturation of, with ether, 354–5 - - Blood-letting in accidents from chloroform, 261 - - —— from external jugular, tried in case of death from chloroform, 151, - 159, 168, 174 - - Body, temperature of, falls under chloroform, 70 - - Bolton, Mr. Andrew, case of puerperal convulsions treated with - chloroform, 338 - - Bone, removal of tumours of, under chloroform, 291 - - Boot, Dr., first operation in England without pain, 18 - - Bouisson, M., on a case of supposed death from ether, 369 - - Bowman, Professor, removal of pus from frontal sinus after inhalation - by chloroform, 302 - - Breathing modified by chloroform vapour, 69, 70 - - —— conditions of, under chloroform, 89, 90, 91, 92 - - Breast, tumours of, removal under chloroform, 285–7 - - Breton, supposed death of, from chloroform, 199–200 - - Brodie, Sir Benjamin, on use of chloroform in lithotrity, 274 - - Buck, Mr. Gurdon, report of death from chloroform by, 136–8 - - Bullock, Mr. Lloyd, manufacture of amylene by, 374–8 - - Bursa, the, operations on, under chloroform, 311 - - - C. - - Cahours, M. Auguste, invention of name of amylene, 372 - - Cancer of the lip, operation for, under chloroform, 294 - - Cases dangerous from chloroform, 258–60 - - —— of death from chloroform during labour, from neglect, 328 - - Cases, fatal, from inhalation of chloroform, 120–200 - - Case 1, of Hannah Greener, Winlaton, Newcastle, 123–7; - 2, of Martha G. Simmons, Cincinnati, 127–30; - 3, of Patrick Coyle, 130–1; - 4, of Mdlle. Stock, Boulogne, 131–5; - 5, of a woman at Hyderabad, 135; - 6, of Charles Desnoyers, Hôtel-Dieu, Lyons, 135–6; - 7, of a young gentleman at Govan, 136; - 8, of John Griffith, New York, Hospital, 136–8; - 9, of J. Verrier, Hôtel-Dieu, Lyons, 138–141; - 10, of Samuel Bennett, Westminster, 141–2; - 11, of Mdlle. Labrune, at Langres, 142–3; - 12, of John Shorter, St. Thomas’s Hospital, 143–5; - 13, of Mrs. Jones, at Shrewsbury, 145–6; - 14, at Berlin, 146; - 15, of William Bryan, Kingston, Jamaica, 147; - 16, of an artilleryman, Mauritius, 147–8; - 17, at Seraphim Hospital, Stockholm, 148–50; - 18, of a boy of seven, Glasgow Infirmary, 150–1; - 19, of Alexander Scott, Guy’s Hospital, 151–2; - 20, of James Jones, Cavan Infirmary, 152–3; - 21, of John Holden, Stepney Workhouse, 153–5; - 22, of Mdme. Simon, Strasbourg, 154–5; - 23, at Seaman’s Hospital, Greenwich, 155–7; - 24, of Elizabeth Hollis, Chipping Norton, 157–8; - 25, of Thomas Hayward, of Bartholomew’s Hospital, 158–61; - 26, of Mdme. W., at Ulm, 161; - 27, of Mr. John Atkinson, Melbourne, 162; - 28, of Mr. Martin, at Melrose, 162–3; - 29, of Henry Hollingsworth, Manchester Royal Infirmary, 163–4; - 30, of Caroline Baker, of University College Hospital, 165; - 31, of a French soldier, Hôtel - Dieu., d’Orléans, 165–6; - 32, of John Mitchell, at Royal Infirmary, Edinburgh, 166–70; - 33, of E. R., at University College Hospital, 170–2; - 34, of Ann Smith, at St. Bartholomew’s, 172–4; - 35, of a young man in Vienna, 174; - 36, of a young girl at Neustedt, 174–5; - 37, of Jane Morgan, Bristol Infirmary, 175–6; - 38, of a woman, Hôpital St. Antoine, 176–7; - 39, of Mrs. Harrup, Sheffield, 177–8; - 40, of Walter Hollis, Lock Hospital, 178–80; - 41, of a man, at Middlesex Hospital, 180–2; - 42, of George Sands, University College Hospital, 182–4; - 43, of a woman, in Guy’s Hospital, 185–7; - 44, of John Cannon, Royal Ophthalmic Hospital, 187–8; - 45, of a lady, London, 188–9; - 46, of Mrs. H., Edinburgh, 189–90; - 47, of a sailor, St. Thomas’s Hospital, 190–2; - 48, of a boy, recorded by Mr. Paget, 192–4; - 49, of a man, Liverpool Infirmary, 195–6; - 50, of Ann Stoner, King’s College Hospital, 196–9; - cases, supposed, of death from chloroform, 199, 200; - case, fatal, during labour from neglect, 328 - - Cases, alleged fatal, from inhalation of chloroform, 201–12; - of Mr. Walter Badger, 201; - case reported by M. Malgaigne, 204; - of a woman, in Paris, _ib._; - of a child, in the hospital, Madrid, _ib._; - of a child, by Dr. Aschendorf, 204–5; - case by the author, 205–9; - case at St. George’s Hospital, 209–12 - - Cases, alleged fatal, from ether, 362–8 - - —— medical, inhalation of chloroform in, 329–44. - _See Medical Cases_ - - —— surgical, use of chloroform in different kinds of, 271–318. - _See Operations_ - - —— fatal, from inhalation of amylene, 408–16 - - Cats, experiments on, with chloroform, 61, 66, 109, 110, 111 - - Cat, experiment on, with amylene, 380–1 - - Cataract, operations for, under chloroform, 296 - - Cause and prevention of death from chloroform, 107–120 - - Causes, supposed, of death from chloroform, 228–45. - _See Death_ - - Cerebral diseases and chloroform, 56 - - —— —— treated by chloroform, 56–7 - - Chaffinch, experiments on, with chloroform, 73 - - Charrière, M., inhaler for chloroform by, 85 - - Chassaignac, M., on tolerance of chloroform, 92 - - Chevalier, M., on asphyxia idiopathica, 226 - - Chinese, use of Indian hemp by, 5 - - Chloroform, first experiments with, by Glover, 112; - first experiments with, by Flourens, 21 - - —— recommended by Dr. Simpson, 21 - - —— rapid introduction of, 22 - - —— first death from, 22 - - —— disused in Boston, Massachusetts, Philadelphia, Naples, and Lyons, - 23 - - —— history and composition of, 27 - - —— analysed by M. Soubeiran, and named bichloric ether, 27 - - —— examined by Liebig, and named liquid chloride of carbon, 27 - - —— examined by Dumas, and named chloroform, 27 - - —— called chloroformyl in London Pharmacopœia, 28 - - —— mode of preparation of, 28–9 - - —— chemical and physical properties of, 29–30 - - —— adulterations of, 30–2 - - —— effects of, mixed with alcohol, 31 - - Chloroform, how to be preserved, 32 - - —— properties of vapour of, 32 - - —— quantity of vapour of, taken up by air at various temperatures, 33, - 68 - - —— effects of inhalation of vapour of, at different temperatures, 34 - - —— physiological effects of, 34 - - —— a narcotico-irritant, 34 - - —— degrees of narcotism from, 35–43 - - —— symptoms during first degree, 35–37; - second degree, 37–38; - third degree, 38–42; - fourth and fifth degrees, 42–43 - - —— effects on the heart of a sudden overdose of, 43 - - —— produces post-mortem rigidity, 43 - - —— effects of, on pulse, 43, 44, 77, 89 - - —— action of, on the nervous system, 44–45 - - —— effects of, during an operation, 45 - - —— varying effects of, on patients, 45–8 - - —— circumstances which influence or modify its effects, 48 - - —— influence of age in modifying effects of, 49–50 - - —— effects of, as regards strength or debility, 50 - - —— effects when given slowly, 50 - - —— effects of, in hysteria, 50–2 - - —— effects of, in epilepsy, 52 - - —— effects of, during menstrual period, 53 - - —— effects of, during pregnancy, 53 - - —— effects of, in cases of disease of the lungs, 53–4 - - —— effects of, in case of phthisis described, 53–54 - - —— effects of, in cases of heart disease, 54–56 - - —— effects of, in cerebral disease, 56–57 - - —— effects of, on the insane, 57 - - —— effects of, on hard drinkers, 57–58 - - —— amount of vapour of, absorbed to cause the various degrees of - narcotism, 58–74 - - —— is absorbed into the circulation during inhalation, 58 - - —— is exhaled in the secretions, 58 - - —— experiments on inhalation of, 59–74. - _See Experiments_ - - —— absorption of, by blood serum, 69 - - —— proportion of, required to arrest respiration, 69, 70, 74, 115, 116 - - —— action of, on frogs, 71–73 - - —— action of, on chaffinch, 73 - - —— action of, on animals of warm and cold blood, 70–73 - - —— preparations for administering the, 74 - - —— should not be administered after a meal, 74 - - —— vomiting in relation to administration of, 74–75 - - —— position of patient during inhalation of, 75 - - —— fears regarding the, 76–77 - - —— and fear, relative effects of, 77 - - —— removes fear as it destroys consciousness, 77 - - —— prevents syncope from fear, 77–78 - - —— mode of administering the, 78 - - —— amount of, required to produce insensibility, 78, 107 - - —— Dr. Simpson’s administration of the, 78 - - —— objections to administration of, on handkerchief, 78–79 - - —— may cause death without producing insensibility, 79, 133 - - Chloroform, effects of, not modified by idiosyncracies, 79 - - —— inhaled from a balloon, 80 - - —— inhaler for, the author’s, described, 81–84 - - —— diagram of, 82 - - —— amount of, used for inhalation, 84 - - —— how to be administered with inhaler, 86 - - —— use of, in obstetric cases, 87 - - —— use of, in surgical operations, 87 - - —— signs of insensibility from, 87 - - —— effects of, eyelid test, 88 - - —— effect of, on breathing, 89–93 - - —— effect of, on pupil, 93–94, 158 - - —— on position of the eyes, 94 - - —— accumulation of, in lungs, 91 - - —— rigidity and struggling under, to be subdued by continued - inhalation, 91, 92, 93 - - —— on tolerance of, M. Chassaignac, 92 - - —— how long to be inhaled by patients of different ages, 94 - - —— always takes effect, 95–96 - - —— repetition of, during operations, 97 - - —— recovery from, 97–100 - - —— sequelæ of inhalation of, 100–107 - - —— cause and prevention of death from, 107–120 - - —— effect of prolonged inhalation of, 109 - - —— experiments illustrating mode of dying from, 109–120 - - —— paralyzing effects on the heart from large doses of, 112 - - —— fatal cases of inhalation from, 120–200 - - —— alleged cases of death from inhalation of, 201–212 - - —— danger of rapid inhalation of, 126, 127 - - —— the mode of administration of, in fatal cases from, 124, 127, 130, - 131, 135, 137, 138, 142, 143, 144–5, 146, 147, 148, 149, 150, 151, - 153, 154, 155, 158–9, 161, 162, 164, 165–6, 167, 170, 172, 174, 176, - 177, 178, 180, 183–4, 185, 187, 189, 190–1, 193, 195, 197 - - —— mode of inhalation of, in alleged cases of death from, 201, 205, - 207, 209–10 - - —— symptoms in the fatal cases of inhalation of, 212–17 - - —— mode of death in accidents from, 217 - - —— table of fatal cases of inhalation of, 218–22 - - —— supposed causes of death from, 228–45, - _see Death_ - - —— state of the chief organs after death from, 245–8 - - —— further remarks on the prevention of accidents from, 248–51 - - —— rules in administration of, 250–1 - - —— treatment of suspended animation from, 251–62 - - —— the effect of, on the results of operations, 263–70 - - —— benefits conferred by, in operations, 263–4 - - —— administration of, in the different kinds of operations, 271–318, - _see Operations_ - - —— in parturition, 318–29 - - —— introduced by Dr. Simpson into obstetric practice, 318 - - —— need not produce unconsciousness during labour, 318 - - —— cases of labour in which it may be employed, 319–20 - - —— period for its administration in labour, 320 - - —— mode of administration in labour, 320–21 - - —— does not influence the duration of labour, 323 - - Chloroform, its use in operations during labour, 324–6 - - —— its use in peculiar cases of labour, 327–8 - - —— death from, by neglect during labour, 328 - - —— in relation to puerperal convulsions, 329 - - —— inhalation of, in medical cases, 329–44 - - —— frequent and long continued use of, 343–4 - - —— and ether, analogous action of, 349 - - —— and ether, combination of, 369–79 - - —— sulphuric ether, and amylene, effects of, compared, 403–5 - - Chowne, Dr., cases of hysteria treated with chloroform, 339–41 - - Circumstances which influence or modify the effects of chloroform, 48 - - Clarke, Mr., on amylene, 418 - - Clement, Mr., on case of death from chloroform, 145–6 - - Clover, Mr., his mode of administering chloroform, 184 - - Cockle, Dr., on the circulation in the coronary arteries, 262 - - Cocks, Mr. W. G. H., on treatment of laryngismus stridulus with - chloroform, 332 - - Colston, Mr. G. Q., administration of nitrous oxyde by, 14–15 - - Combination of chloroform and ether, 369–71 - - —— case of supposed death from inhalation of, 370 - - Consciousness, recovery of, after chloroform, 98 - - Consumption, treatment of, by ether, 14, 360 - - Convulsions, epileptiform, in fatal case from chloroform, 191 - - —— infantile, use of chloroform in, 332–3 - - —— puerperal, use of chloroform in, 337–9 - - —— treatment of, with ether, 359 - - Corfe, Dr., report of a post-mortem after death from chloroform, 181–2 - - Countenance, expression of, under amylene, 401 - - Crockett, Dr., on a case of supposed death from combination of - chloroform and ether, 370 - - Croup, spasmodic, use of chloroform in, 331–2 - - - D. - - Davy, Sir Humphrey, experiments of, with nitrous oxyde, 14 - - —— suggested use of nitrous oxyde by, to remove pain of operations, 14 - - Death from chloroform without insensibility, 79–133 - - —— cause and prevention of, from chloroform, 107–20 - - —— under chloroform from paralysis of heart, 131, 138, 141, 143, 151, - 156, 165, 178–9, 181, 186, 189, 196 - - —— two modes of, from chloroform, 135 - - —— from chloroform, cases of, 120–200, - _see Operations, fatal_ - - —— symptoms of, from chloroform, 124, 127–28, 130, 131, 135, 137, - 139–41, 142, 143, 144, 146, 147, 148, 149, 151, 153, 154, 155–6, - 157–8, 159, 161, 162, 163–4, 165, 166, 167–8, 170–1, 172–3, 174–5, - 175–6, 176–7, 177–8, 178–9, 180–1, 182–3, 185–6, 187–8, 189, 190, - 191, 192–4, 195–6, 197 - - —— from chloroform, cases of alleged, 201, 203, 204, 205, 209 - - —— mode of, in accidents from chloroform, 217 - - —— supposed causes of, from chloroform, 228–45; - age, 230–31; - idiosyncracy, 231–2; - impurity of chloroform, 233; - apparatus employed, 233; - exclusion of air, 233–4; - closure of the glottis, 234–8; - exhaustion from struggling, 238–9; - sitting posture, 239–40; - effect of surgeon’s knife, 240–3; - sudden death from other causes, 243–5; - falling back of the tongue, 245 - - Death, sudden, from other causes during inhalation of chloroform, 244–5 - - —— during operations without anæsthetics, 245 - - Debout, Dr., on amylene, 375, 406, 418 - - Delarue, M., on titillation of the uvula during accidents from - chloroform, 257–8 - - Delirium cum tremore, treatment of, by chloroform, 333–4 - - —— in fever, 334–5 - - Delphos, Priestess of, intoxicated by narcotic fumes, 11 - - Demarquay, M., on closure of the glottis by chloroform, 234 - - Diagram of chloroform inhaler, 82 - - —— of ether inhaler, 349 - - Dinners, late, a cause of hæmorrhoids, 307 - - Dioscorides, on decoction of mandragora, 1 - - —— on symptoms from mandragora, 3 - - Discovery of anæsthetics, importance of, 1–2 - - Dislocations, reduction of, under chloroform, 302–3 - - Devergie, M., on closure of the glottis by chloroform, 234 - - —— on death from amylene, 415 - - Dominus Hugo, his recipe for a narcotic, 5–6 - - —— his prescription for a local application, 6 - - Dumas, M., on analysis of chloroform and name, 27 - - Duroy, M., anæthesimeter of, 85 - - —— on amylene, 375–6 - - Dutch liquid, nature of, 27 - - - E. - - Ear, operations on, under chloroform, 298 - - Eastment, Mr., case by, of alleged death from ether, 368–9 - - Effect of chloroform on the results of operations, 263–70 - - Elbow, excision of, under chloroform, 279–80 - - Electricity, use of, in a fatal case from chloroform, 166 - - —— value of, during accidents from chloroform, 261–2 - - —— use of, in case of death of from amylene, 413 - - Emphysema, in a fatal case from chloroform, 148 - - Epilepsy, influence of chloroform on, 52 - - —— use of chloroform in, 336–7 - - Esdaile, Dr., on hypnotism in the Hindoos, 10 - - Ether, _sulphuric_, or ether, 15 to 27, 345 to 371 - - —— effects of, vapour, described by Faraday, 15 - - —— effects experimentally shewn by Professor Turner, 16 - - —— vapour as an anæsthetic, discovery of, 15, 16, 17 - - —— application of, summary, 17, 18 - - —— treatment of diseases by, 19 - - —— supposed death from, 20 - - —— use of, in Massachusetts Hospital, Boston, Philadelphia, New York, - Naples, and Lyons, 23 - - —— action of, on nervous centres, 45 - - —— administered for operation for removal of pus from frontal sinus, - 302 - - —— history and composition of, 345 - - —— chemical and physical properties, 345–9 - - —— physiological effects of, 349–55 - - Ether, _sulphuric_, administration of, 356–8 - - —— —— in medical cases, 358–61 - - —— great safety of, 22–3, 362 - - —— alleged deaths from, 362–9 - - —— chloroform and amylene, effects of, compared, 403–5 - - —— saturation of the blood with, 354; - flavour of, 357; - - —— quantity of, inhaled to produce insensibility, 356–7 - - —— operations under, 357–9 - - —— and chloroform, combination of, 369–71 - - —— —— analogous action of, 349–50 - - —— _chloric_, composition of, 20 - - —— chloric, introduction of, as an anæsthetic, _ib._ - - —— its relation to chloroform, _ib._ - - —— author’s experiments with, 21; - named by Dr. Thompson, 27 - - —— alcoholic solution of, made by Guthrie, 27 - - —— known as a diffusible stimulant, 27 - - Eupion, properties of, 377 - - Excitement, muscular, under chloroform, 93 - - Exhaustion from struggling, a supposed cause of death from chloroform, - 238–9 - - Experiments with chloroform, mode of conducting the, 59, 60 - - —— on animals with chloroform, 60–74 - - —— illustrating modes of dying from chloroform, 109 - - —— with ether, 350–5; - with amylene, 378–386 - - Eye, operations on, under chloroform, 295–8 - - Eyelids, sensibility of, under chloroform, a test, 88 - - - F. - - Face, division of nerves of, under chloroform, 294–5 - - Faintness from chloroform, 103–4 - - Faraday, Professor, description of effects of ether vapour, 16 - - Farr, Dr. Arthur, on hysteria treated with chloroform, 341 - - Fatal cases from inhalation of chloroform, 120–200 - - —— alleged, from chloroform, 201–12 - - —— alleged, from inhalation of ether, 362–8 - - Fear, effects of, 77; - subsides with unconsciousness, 77 - - —— possible cause of death, cases of, 203, 209–12 - - Femur, excision of head of, under chloroform, 279 - - Fenwick, Dr., statistics of operations since the introduction of - anæsthetics, 267–70, 278 - - Fergusson, Mr., on utility of chloroform in lithotrity, 274 - - —— improvement of operation by, for removal of jaw, 281–2 - - —— operation by, for hare-lip, 292 - - —— observations of, in case of death from amylene, 408–11 - - Fibrine separated after application of galvanism, 181–2 - - Fife, Sir John, on the _post-mortem_ appearances in a case of death - from chloroform, 125 - - Flourens, M., experiments by chloroform, 21 - - —— on the action of sulphuric ether, 45 - - Frogs, experiments on, with chloroform, 71, 72, 112 - - —— mode of action of chloroform upon, 71–2 - - —— modified by different temperatures, 72 - - Further remarks on the prevention of accidents from chloroform, 248–51 - - - G. - - Galvanism applied in cases of death from chloroform, 144, 151, 167–8, - 181, 183, 197 - - Garner, Mr., on treatment of neuralgia with chloroform, 344 - - Garrod, Dr., report of _post-mortem_ after a death from chloroform, - 171–2 - - Giraldis, M., on use of amylene, 419 - - _Glasgow Herald_, report by, of case of death from chloroform, 136 - - Glottis, closure of, during inhalation of chloroform, 234–38 - - Glover, Dr., first experiments with chloroform, 112 - - —— report of _post-mortem_, appearances after death from chloroform, - 124, 125 - - Gorré, M., on death from chloroform, 131–2 - - Guineapigs, experiments on, with chloroform, 60–67 - - —— experiments on, with amylene, 378–385 - - Guthrie, Mr., method of obtaining chloric ether, 27 - - - H. - - Hall, Dr. Marshall, reference to the author, 109 - - —— description of his “ready method”, 260–1 - - —— his “ready method” of artificial respiration tried in fatal cases - from chloroform, 194, 196, 197 - - —— “ready method” applied in cases of death from amylene, 410–13 - - Haller on influence of the blood in the heart, 223 - - Hæmorrhage, a cause of death during inhalation of chloroform, 205, - 282–4, 370–1 - - —— death from, during removal of tumour from jaw, 284–5 - - —— secondary, after operations, prevented by chloroform, 318 - - Hæmorrhoids, operations for, under chloroform, 305–7 - - —— why prevalent in the upper classes, 307 - - Hard drinkers, effects of chloroform on, 57–8 - - Hare-lip, operations for, under chloroform, 291–3 - - Harlequin, a, note concerning, 50 - - Harrison, Mr., observations by, in fatal case from chloroform, 175–6 - - Hawkesley, Dr., invention of mouth-piece for an inhaler by, 83 - - Hawkesworth, Mr. C. A., on tetanus treated with ether, 360–1 - - Hayward, Dr., operation by, on a patient narcotized by ether, 16 - - Head symptoms supposed as result of chloroform, 106–7 - - —— condition of, after death by chloroform, 246 - - Heart, diseases of, in relation to chloroform, 54 - - —— symptoms during recovery from chloroform, 56 - - —— fatal cases from chloroform inhalation during diseases of, 162, 165, - 206 - - Heart, special influence of chloroform on, in different animals, - 112–13, 114, 117, 122 - - —— human, special influence of chloroform upon, 115, 164 - - —— sudden death from paralysis of, from chloroform, 131, 138, 141, 143, - 151, 156, 165, 178–9, 181, 186, 189, 196 - - —— condition of, during syncope, 223–5, 228 - - —— condition of, after death, from chloroform, 246 - - —— circulation in coronary vessels of, 262 - - —— paralysis of, in case of death from amylene, 409, 413 - - Hernia, strangulated, operations for, under chloroform, 304–5 - - Herodotus on inhalation of narcotic vapours, 10, 11 - - Hewitt, Mr. Prescott, report of fatal operation for removal of tumour - from jaw, 282–4 - - Hillier, Dr., report of a fatal case from chloroform, 170–2 - - History of anæsthetics, 1, 24 - - Hoa-tho, his use of Indian hemp for deadening pain, 4, 12 - - Hoffberg, use of mandrake as a narcotic, 4 - - Holmes, Mr. Thomas, on pyæmia and chloroform, 267 - - Hooping-cough, treatment of, by chloroform, 332; - by ether, 360 - - Housz, Dr., oxygen inhaler of, 83 - - Hunter, Mr. John, death of, 227 - - Hydrocephalus, treatment of, by chloroform, 335 - - Hysteria, influence of chloroform in, 51–2 - - —— cases of, in which chloroform was administered, 51–2 - - —— after chloroform, 104–7; - after amylene, 406 - - Hysterical paralysis and contractions treated by chloroform, 339–40 - - - I. - - Idiosyncrasy, supposed case of, 96 - - —— supposed cause of death from chloroform, 231–2 - - Indian hemp as a narcotic, 4 - - —— fumes of, inhaled by Hindoos, 5 - - Inhalation, definition of, 25; - reasons for, 26 - - —— agents administered by, 26; - how to be performed, _ib._ - - Inhalers for chloroform, description of, 81–86; - diagram of, 82 - - —— of M. Charrière and Duroy, 85 - - —— of the author, use of, 86 - - —— for ether, diagram of, 349 - - Insanity, use of chloroform during, 57 - - Insensibility by chloroform, a _process_, 80 - - —— signs of, under chloroform, 87, 88 - - —— eyelid test of, 88 - - - J. - - Jackson, Dr. Charles J., assertion of priority of application of ether - as an anæsthetic, 16, 17 - - Jaw, upper, removal of tumours of, under chloroform, 280–5 - - —— lower, removal of tumours of, under chloroform, 285 - - Jeffreys, Mr. Julius, inhaler of, 349 - - Joints, stiff, forcible movement of, under chloroform, 303 - - Jones, Mr., of Jersey, report of operation by, under amylene, 402–3 - - Jorden, Mr., operation by, in fatal case from chloroform, 163 - - Jugular, external, opened in deaths from chloroform, 151, 159, 168, 174 - - —— value of opening the, during accidents from chloroform, 261 - - Julien Stanislaus on Chinese medicine, 4 - - - K. - - Kittens, experiments on, with amylene, 385–6 - - Knee, excision of, under chloroform, 280 - - Kobelt, M., prosecution of, for fatal case from chloroform, 154 - - - L. - - Labour, cases of, in which chloroform may be used, 319–20 - - —— consciousness need not be destroyed during, 318 - - —— period of, for exhibition of chloroform, 320 - - —— mode of administering chloroform during, 320–4 - - —— use of chloroform during operations in, 324–6 - - Labour, use of amylene during, 394–7; - use of ether during, 359 - - Lamballe, M. Jobert de, on use of amylene, 419 - - Lansdown, Mr. W., on ether in midwifery, 359 - - Laryngismus stridulus, treatment of, by chloroform, 332 - - Laryngotomy, operation of, under chloroform, 312 - - Lawrence, Mr., on chloric ether, 20 - - Lefevre, Sir George, case of syncope, related by, 223 - - Leg, amputation of, under chloroform, 277 - - Letheon, Morton’s term for ether, 18 - - Liebig, Dr. Justus, on analysis of chloroform or liquid chloride of - carbon, 27 - - —— proposed name of perchloride of formyle, 28 - - Liégard, on deadening pain by compression, 9 - - Ligature of arteries under chloroform, 289–91 - - Limbs, state of, under chloroform, 89 - - Linnets, experiments on, with ether, 352–3; - with amylene, 381–2 - - Lip, cancer of, operation for, under chloroform, 294 - - Liston, Mr., first operations on patients etherized, 18 - - —— case of fatal operation from hæmorrhage, 284 - - Lithotomy, administration of chloroform for, 271–4 - - Lithotrity, administration of chloroform for, 274–5 - - Lonsdale, Miss, first patient who inhaled ether in England, 18 - - Lopez, Dolorès, supposed death of, from ether, 369 - - Lungs, diseases of, administration of chloroform during, 53 - - —— condition of, after death from chloroform, 245–6 - - - M. - - Mackenzie, Dr., of Kelso, on a case of death from chloroform, 200 - - Majer, Dr., on a fatal case from chloroform, 161 - - Malgaigne, M., opinion of, on the case of Mdlle. Stock, 133 - - —— case by, of death from chloroform with exhaustion, 204 - - Mandragora, narcotic effects of, 1, 2; - antidote for, 2 - - Mandrake, once used as a narcotic, 4 - - Mania, treatment of, with chloroform, 342 - - Marshall, Mr. Peter, the author’s experiments with, 117–20 - - —— on case of death from fright, 203 - - Masson and Triquet, action brought against, for causing death by - imprudent use of chloroform, 200 - - Maygarth, Mr., on a case of death from chloroform, 147 - - Meals, rules regarding the, before inhalation of chloroform, 75 - - Medical cases, inhalation of chloroform in, 329–44; - in neuralgia, 329–31; - in spasmodic asthma, 331; - in spasmodic croup, 331–2; - in laryngismus stridulus, 332; - in hooping-cough, _ib._; - in infantile convulsions, 332–3; - in delirium cum tremore, 333–4; - in delirium in fever, 334–5; - hydrocephalus, 335; - in tetanus, 335–6; - in epilepsy, 336–7; - in puerperal convulsions, 337–8; - in hysterical paralysis and contractions, 339–41; - in mania, 342; - in spasmodic pain, 342–3; - in frequent and long continued use of chloroform, 343–4 - - Medical cases, inhalation of ether in, 359–61; - in convulsions, 359–60; - in asthma, 360; - in hooping-cough, 360; - in consumption, 360; - in tetanus, 360–1; - in neuralgia, 361 - - Meggison, Dr., on a case of death from chloroform, 124 - - Meissner, A. G., sketches by, 8 - - Menstruation, use of chloroform during, 53 - - Mesmerism, presumed effects of, 9 - - Mice, white, experiments on, with chloroform, 60, 61, 64, 65, 67, 68 - - —— quickly affected by chloroform, 70 - - —— experiments on, with ether, 350–1; - with amylene, 386–7 - - Miller, Prof., on modes of administering chloroform in Edinburgh, 79 - - Modes of death in accidents from chloroform, 217 - - Monochlorurretted chloride of ethyle, 420–3 - - —— discovery and preparation of, 420 - - —— chemical and physical characters of, 420–1 - - —— supplied to author by Mr. Mason, _ib._ - - —— administration of, by author, as an anæsthetic, 421–2; - effects of, 421–3 - - —— quantity inhaled to produce insensibility, 421–3 - - Moore, Mr. James, on compression of nerves to deaden pain, 9 - - Morbid appearances in cases of death from chloroform, 229–30 - - Morton, Dr., first application of sulphuric ether by, for removal of - pain; his dispute with Dr. Jackson; his claims for priority, 16–18, - 78 - - Morion, a kind of mandragora used before operations, 2 - - Mouth, operations in, under chloroform, 299–300 - - - N. - - Nævi, operations on, under chloroform, 289 - - Nails, evulsion of, under chloroform, 311 - - Narcotics, nature of, 35 - - Narcotism, degrees of, from chloroform, 35–43 - - —— amount of vapour of chloroform absorbed to cause the various degrees - of, 58–74 - - Necrosis, operations for, under chloroform, 278–9 - - Nerves of sensation, division of, under chloroform, 294–5 - - Nervous system, action of chloroform upon, 44–8 - - Neuralgia, inhalation of chloroform for relief of, 189, 329–30 - - —— treatment of, by ether, 361 - - Nose, operations on, under chloroform, 298–9 - - Nunn, Mr. Roger, on case of alleged death from ether, 365 - - - O. - - Operations, surgical, author’s experience of chloroform during, - 271–318; - lithotomy 271–4; - lithotrity, 274–5; - stricture, 275–6; - amputation of thigh, 276–7; - amputation of leg, 277; - amputation of arm, 277–8; - amputation of ankle, 278; - amputations, other, _ib._; - for necrosis, 278–9; - excision of head of femur, 279; - excision of elbow, 279–30; - excision of knee, 280; - excision of wrist, _ib._; - for tumours of jaw, 280–7; - for other tumours, 287–9; - for nævi, 289; - ligature of arteries, 289–91; - tumour of bone, 291; - hare-lip, 291–3; - cancer of lip, 294; - division of nerves, 294–5; - on the eye, 295–8; - on the ear, 298; - on the nose, 298–9; - in the mouth, 299; - plastic operations, 300–1; - raising depressed skull, 301–2; - for ununited fracture, 302; - for dislocations, 303; - extension of stiff joints, _ib._; - tenotomy, _ib._; - strangulated hernia, 304–5; - hæmorrhoids and prolapsus, 305–7; - fissure of anus, 307–8; - fistula _in ano_, 308; - ovarian tumours, 308–9; - cancer of vagina, 310; - rupture of perineum, _ib._; - removal of testicle, 310–1; - phymosis, 311; - enlarged bursa, _ib._; - evulsion of nails, _ib._; - laryngotomy, 312; - extraction of teeth, 313–18 - - Operations, surgical, repetition of chloroform during, 97 - - _Operations fatal_ under chloroform, 120–200 - - —— of removing toe-nail, 123–7 - - —— of tooth extraction, 127–30 - - —— for fistula, 130, 132 - - —— of opening a sinus, 131–35 - - —— of removing middle finger, 135 - - —— of transcurrent cauterization of wrist, 135–6 - - —— intended, on great toe, 136 - - —— on rectum, 136–8 - - —— amputation of middle finger, 138–41 - - —— amputation of a toe, 141–2 - - —— for tooth extraction, 142–3 - - —— for onychia of great toe, 143–5 - - —— excision of eyeball, 145–6 - - —— of extraction of tooth, 146–147 - - —— intended, case not described, 147 - - —— for removal of portion of middle finger, 147–8 - - —— intended for hydrocele, 148–50 - - —— detection of vesical calculus, 150–1 - - —— for removal of portion of right hand, 151–2 - - —— amputation below the knee, 152–3 - - —— intended, on penis, 153–4 - - —— for removal of testicle, _ib._ - - —— of tooth extraction, 155–7 - - —— for removal of fæces from rectum, 157–8 - - —— on an aneurism, 158–60 - - —— intended extraction of tooth, 161 - - —— intended, for fistula _in ano_, 162–3 - - —— application of caustic to an ulcer, 163 - - —— removal of a tumour, 163–4 - - —— application of nitric acid to an ulcer, 165 - - —— removal of a tumour, _ib._; - of perineal section, 166–70 - - —— intended, for hernia, 170–72 - - —— application of actual cautery, 172–4 - - —— for extension of an anchylosed joint, 174 - - —— to remove a lipoma, 174–5 - - —— for reduction of a dislocation, 175–6 - - —— removal of uterine polypus, ditto, 176–7 - - —— removal of tumour, 177–8 - - —— for phymosis, ditto, 178–80 - - —— amputation of the thigh, 180–2 - - —— intended catheterization, 182–4 - - —— intended amputation of leg, 185–7 - - —— intended excision of eyeball, 187–8 - - —— for facial neuralgia, 188–9 - - —— dental, 189–90 - - —— removal of necrosed bone, 190–2 - - —— removal of tumour, 192–4 - - —— amputation of the thigh, 195–6 - - —— application of nitric acid, 196–9 - - —— various, details imperfect, 199–200 - - Operations alleged fatal from chloroform, 201–212 - - —— of intended tooth extraction, 201–3; - on shoulder joint, 204; - for removal of breast, _ib._; - amputation of leg, _ib._ - - —— for removal of tumour, 204–5 - - Operation of lithotrity, 205–9 - - —— for removal of tumour, 209–12 - - Operations, the effect of chloroform on results of, 263–70 - - —— statistics regarding, before and after chloroform, 264–9 - - —— administration of chloroform in the different kinds of, 271–318 - - —— performed under ether, 357–9 - - —— in which ether is preferable to chloroform, 361 - - —— attended with alleged death from ether, 362–9 - - —— _under the influence of amylene_, 387–400 - - —— of extraction of teeth, 387–9, 394 - - —— for removal of tumours, 389–393 - - —— for tenotomy, 389, 391–2 - - —— for lithotomy, 389 - - —— for resection of knee, 389–90 - - —— for resection of head of femur, 390 - - —— for amputation, 390–1 - - —— on the eye, 391 - - —— for lithotrity, 391 - - —— for forcible extension of joints, 392 - - —— for reduction of dislocation, 392–3 - - —— for fistula, death from amylene during, 408–11 - - —— for removal of tumour, death from amylene during, 411–15 - - —— under the monochlorurretted chloride of ethyle, 421–3 - - Oxygen gas, artificial respiration of, in case of death from - chloroform, 144 - - - P. - - Paget, Professor, on a fatal case from chloroform, 172, 192 - - Pain, effects of, on operations, 55 - - Parkinson, Ann, death of, alleged from inhalation of ether, 365–8 - - Partridge, Professor, performance of laryngotomy by, under chloroform, - 312 - - Parturition, use of chloroform in, 318–29 - - —— use of amylene in, 394–7 - - Patients, varying sensations of, under chloroform, 45–8 - - —— susceptible to chloroform, 50 - - —— fears of, regarding chloroform, 76 - - Patients, treatment of, during recovery from chloroform, 99–100 - - Pearson, Dr. Richard, use of ether by, in consumption, 14, 360 - - Pearson, Mrs., description of a case of death from chloroform, 127–8 - - Perinæum, operations on, under chloroform, 310 - - Persian Pharmacopœia, recipe for a remedium odorativum somniferum, 13 - - Phthisis pulmonalis, inhalation of chloroform during existence of, 53 - - Phymosis, operation for, under chloroform, 311 - - Pliny on use of mandragora in operations, 2 - - Porta, John Baptista, on effects of the somniferous menstrua, 12 - - Post-mortem rigidity produced by chloroform, 43 - - —— appearances after death by chloroform, 110, 111, 124, 125, 128–9, - 130, 132, 137, 140–41, 142, 146, 147, 148, 149–50, 152, 154–5, - 156–7, 159–60, 161, 162, 164, 166, 168–9, 171–2, 173, 176, 177, 178, - 179, 181, 183, 186, 188–90, 191–2, 197–8 - - —— in cases of alleged death from chloroform, 203, 207–9, 210–12 - - —— appearances after alleged death from ether, 363 - - Post-mortem appearances after death from amylene, 410–11, 414 - - Posture, sitting, supposed cause of death during inhalation of - chloroform, 239–40 - - Pregnancy, administration of chloroform during time of, 53 - - Preparations for inhaling chloroform, 75 - - Prevention of accidents from chloroform, further remarks on, 248–51 - - Prolapsus ani, operations for, under chloroform, 305–7 - - Propert, Mr., case of, where lithotrity was performed under chloroform - after apoplexy, 56–7 - - Pupils, state of, under chloroform, 93–4, 158 - - Pulse, effect of chloroform on, 43–4, 77, 89 - - —— before and after inhalation of chloroform, 77–8 - - - R. - - Rabbits, experiments on, with chloroform, 117 - - Recovery from effects of chloroform, 97, 98, 99, 100 - - Regnault, M. M. G., discovery of the monochlorurretted chloride of - ethyle, 420 - - Reichenbach, discovery of eupion, 377 - - Respiration modified by chloroform vapour, 69–70 - - —— quantity of chloroform sufficient to arrest the, 74, 115 - - —— artificial, its use, 121 - - —— artificial, applied in cases of death from chloroform, 139, 144, - 150, 159, 163, 166, 167–8, 173, 179, 181, 183, 185, 187–8, 190, 191, - 194, 196, 197, 207, 210 - - —— artificial, value of, in accidents from chloroform, 251–7 - - —— artificial, applied in case of death from amylene, 410, 413 - - Richardson, Dr. B. W., on syncope, 223 - - —— on the cause of the fluidity of the blood, 248 - - Ricord, M., on artificial respiration in accidents from chloroform, 252 - - Ridge, Dr. Joseph, on the death of John Hunter, 227 - - Rigaud, M., mode of administration of amylene, 417–18 - - Riggs, Dr., extraction of tooth for Horace Wells without pain, 15 - - Robert, M., on a case of death from syncope, 203 - - Roberts, Dr., reference to a death from chloroform, 200 - - Robinson, Mr., first administered ether in England, 18 - - —— case narrated by, 48 - - —— on case of alleged death from chloroform, 201 - - Robbs, Dr. William, on a case of alleged death from ether, 365–8 - - Rudge, Mr. Henry, on treatment of puerperal convulsions with - chloroform, 337–8 - - - S. - - Saliva, increased flow of, from chloroform, 95 - - Sassard, Ambroise Tranquille, on narcotics before operations, 8 - - Scythians inhaled narcotic vapours, 11 - - Sequelæ of the inhalation of chloroform, 100–7; - sickness, 100–3; - faintness and depression, 103–4; - hysteria, 104–6; - head symptoms, 106–7 - - Serum of blood, absorption of chloroform by, 69 - - —— amount of, in blood, 74 - - Sibson, Dr., experiments with, on dividing pneumogastric nerves, 58 - - —— his mouth-piece for inhaler, 83 - - —— treatment of neuralgia by inhalation of ether, 361 - - —— experiments with chloroform, 119, 120 - - Sibson, Dr., on cause of death from chloroform, 121, 122 - - —— on blood in the heart after death, 134 - - Sideration, 133 - - Signs of insensibility under chloroform, 87 - - Silliman on chloric ether as a stimulant, 27 - - Simpson, Dr., on history of anæsthesia, 1 - - —— his introduction of chloroform, 17 - - —— on use of ether during parturition, 19, 359 - - —— first administers and recommends chloroform, 21–2 - - —— on the death of Hannah Greener, 126 - - —— on a supposed death from chloroform, 199 - - —— on sudden death during an operation without an anæsthetic, 245 - - —— statistics of operations after chloroform, 264–5 - - Sitting posture supposed cause of death during inhalation of - chloroform, 239–40 - - Skull, raising depressed, under chloroform, 301–2 - - Society of Emulation of Paris, on death by chloroform, 122 - - Solly, Mr., on a case of death from chloroform, 143–5 - - Soubeiran, M., on analysis of chloroform, or chloric ether, 27 - - Spasm as preceding death from chloroform, 129 - - Spasmodic pain, treatment of, with chloroform, 342 - - Squire, Mr., invention of an ether inhaler by, 18 - - Stafford, Mr. Augustus, treatment of case of, 342–3 - - Stertor under chloroform how to be met, 90 - - St. Louis Hospital, surgeon of, on number of deaths from chloroform, - 200 - - Strabismus, operation for, under chloroform, 297 - - Strength and debility in relation to effects of chloroform, 50 - - Stricture, operations for, with chloroform, 276 - - Struggling and rigidity under chloroform how to be met, 91, 92, 93 - - —— and rigidity under amylene, 401–2 - - —— exhaustion from, a supposed cause of death from chloroform, 238–9 - - Supposed causes of death from chloroform, 228–45 - - Surgeon’s knife, supposed effects of, during inhalation of chloroform, - 240–3 - - Sylvester, Dr., on anæsthetics, 7 - - Symptoms in cases of death from chloroform, 124, 127–8, 130, 131, 135, - 137, 139, 142, 143, 144, 146, 147, 148, 149, 151, 153, 154, 155–6, - 157–8, 159, 161, 162, 163, 163–4, 165, 166, 167–8, 170–1, 172–3, - 174, 174–5, 175–6, 176–7, 177–8, 178–9, 180–1, 182–3, 185–6, 187–8, - 189, 190, 191, 192–4, 195–6, 197 - - —— in alleged cases of death from chloroform, 201–205, 206–7, 209–10 - - Symptoms in fatal cases of inhalation, summary of, 212–17 - - —— to be attended to during administration of chloroform, 249–50 - - —— in cases of death from amylene, 409–10, 412–13 - - Syncope sometimes prevented by chloroform, 77–8 - - —— after chloroform, 104 - - —— possible deaths from, independently of chloroform, 204–9, 211–12 - - —— anæmic, distinguished from cardiac, 204; - description of, 222–4 - - —— the two kinds of, 222–8 - - —— condition of heart during, 223–6 - - —— does not commence at the brain, 223 - - —— during disease of the heart, 227 - - —— from mental emotion, 224–5; - from anger, 227 - - —— from muscular exertion, 228; - from pain, _ib._ - - - T. - - Table of fatal cases of inhalation of chloroform, 218–22 - - —— shewing ages of fatal cases from chloroform, 230 - - —— Dr. Fenwick’s, on result of operations after chloroform, 270 - - —— shewing quantity of chloroform vapour in air at various - temperatures, 33 - - —— relating to ether, 347–8 - - —— shewing evaporation of amylene, 377 - - Teeth, extraction of, under chloroform, 313–18 - - —— number of, extracted under, 314 - - —— extraction, mode of administering chloroform for, 315 - - Tenotomy, performance of, under chloroform, 303–4 - - Tetanus, use of chloroform in, 335–6 - - —— treatment of, by inhalation of ether, 360–1 - - Testicle, removal of, under chloroform, 310–11 - - The administration of chloroform in the different kinds of operations, - 271–318 - - The inhalation of chloroform in medical cases, 329–44 - - Theodoric on prevention of pain in operations, 5 - - —— his directions for securing patients during operation, 7 - - Thigh, amputation of, under chloroform, 276–7 - - Thompson, Dr. Thomas, chloric ether, 27 - - Tobacco smoke inhaled in Asia and Eastern parts of Europe, 12 - - Tongue, falling back of, supposed cause of death during inhalation of - chloroform, 245 - - Tourdes, Professor, on amylene, 418 - - Treatment of suspended animation from chloroform, 251–62 - - Triquet and Masson, action brought against, for causing death by - chloroform, 200 - - Trismus, occurrence of, in fatal case from chloroform, 174 - - Tumours, ovarian operations of, under chloroform, 308–10 - - —— of upper jaw, removal of, under chloroform, 280–5 - - —— of lower jaw under chloroform, 285 - - —— of the female breast, removal of, under chloroform, 285–7 - - —— other, removal of, under chloroform, 287–9 - - —— of bone, removal of, under chloroform, 291 - - Turner, Professor, experiments on inhalation of ether vapour, 16 - - - U. - - Uvula, titillation of, practised in an accident from chloroform, 257 - - - V. - - Vagina, cancer of, operations on, under chloroform, 310 - - Valentin, M., on amount of blood in the body, 73 - - Vapour of chloroform, amount of, absorbed to cause the various degrees - of narcotism, 58–74 - - —— absorption of, by fluids, laws which govern the, 59 - - —— absorption of, in the lungs, formula for expressing quantity of, 59 - - Venesection tried in fatal cases from chloroform, 151, 159, 168, 174 - - —— value of, in accidents from chloroform, 261 - - Vomiting caused by chloroform, 74, 100–3 - - —— prevention of a treatment, 75, 101 - - —— after inhalation of ether, 361 - - —— rarity of, from amylene, 406–7 - - - W. - - Wakley, Mr. Thomas, experiments by, 122 - - Waldie, Mr., on chloroform, 17, 21–2 - - Warren, Dr. J. C., operation by, on a patient narcotized by ether, 16 - - —— report of death of Patrick Coyle from chloroform, 130 - - —— report of death of John Griffith from chloroform, 136–8 - - Water, application of, during accidents from chloroform, 258 - - —— bath of chloroform inhaler, uses of, 84 - - Watson, Dr., on dentistry and longevity, 313 - - Waugh, Mr., on a mouth-piece inhaler, 83 - - Wells, Mr. Horace, on effects of nitrous oxyde, 14, 15 - - Wilks, Dr., report of post-mortem after death from chloroform, 186 - - Willis, Dr. Robert, on treatment of hooping-cough by inhalation of - ether, 360 - - Wilson, Dr., Lumleian lectures of, 73 - - Wine of mandragora given before operations, 2 - - Woodville, Dr., on use of mandragora, 3 - - Wrist, excision of, under chloroform, 280 - - - T. RICHARDS, 37, GREAT QUEEN STREET, LINCOLN’S INN. - ------ - -Footnote 1: - - Messrs. Maule and Polyblank have an excellent photographic portrait of - Dr. Snow in their “Scientific Portrait Gallery” series. Mr. Empson has - also a bust, which has been greatly admired for its correctness and - for its superiority as an artistic work. - -Footnote 2: - - Dr. Murchison, who with Dr. Budd rendered Dr. Snow all that able - assistance which the best of medicine can offer, has kindly given me - several particulars in regard to the fatal illness, which I embody in - the text, with many thanks. - -Footnote 3: - - Dr. Murchison has also given me an outline of the _post-mortem_ - appearances, which is subjoined. “The _post-mortem_ examination - revealed slight white softening, only detectable by the microscope, in - the right corpus striatum and optic thalamus, and fatty degeneration - of the minute cerebral vessels. The heart was slightly fatty, but - there was no valvular disease, nor atheromatous disease of aorta. The - lungs were congested, and showed marked evidence of old disease at the - apices. Both the kidneys were much contracted and granular, with - numerous cysts, the right organ being almost entirely converted into - cysts; with the uriniferous tubes either denuded, or containing - granular disintegrating epithelium. There was distinct cicatrix of an - old ulcer in duodenum, and the stomach was much congested, with - numerous hæmorrhagic spots.” - -Footnote 4: - - See Monthly Journal of Med. Sc., vol. viii, p. 452. - -Footnote 5: - - Liber iv, cap. 76.? - -Footnote 6: - - Loc. cit. - -Footnote 7: - - Natural. Hist., lib. xxv, cap. 13. - -Footnote 8: - - De Herbarum Virtutibus, cap. 131. - -Footnote 9: - - Medical Botany, p. 236. - -Footnote 10: - - De Causis Morb. Diut., lib. i, cap. 6. - -Footnote 11: - - De Morbis Acutis, lib. i, cap. 4. - -Footnote 12: - - Vet. Acad. Handl., 1763, vol. xxiv, p. 229. - -Footnote 13: - - Comptes Rendus de l’Acad. de Sc., t. xxviii, 1849, p. 195. - -Footnote 14: - - See Herodotus, book iv, 73–5. - -Footnote 15: - - Lib. iv, cap. 8. - -Footnote 16: - - Med. Gaz., vol. xli, p. 515. - -Footnote 17: - - Observations sur la Physique, tome xvi (1780), p. 256. - -Footnote 18: - - Method of preventing or diminishing Pain in several Operations of - Surgery. Lond. 1784. - -Footnote 19: - - Gazette des Hôpitaux, 1st April, 1854. - -Footnote 20: - - Hypnotism is the term employed by Mr. Braid of Manchester for the - peculiar sleep produced by the Mesmerists. - -Footnote 21: - - Record of Cases treated in the Mesmeric Hospital. Calcutta, 1848. - -Footnote 22: - - Cary’s Herodotus, book i, 202. - -Footnote 23: - - Book iv, 73–5. - -Footnote 24: - - Liber viii, cap. 1. - -Footnote 25: - - Translated into Latin by Father Angelus, Paris, 1681, p. 21. - -Footnote 26: - - P. 287. - -Footnote 27: - - P. 88. - -Footnote 28: - - See Medicinal Use of Different Kinds of Airs, by Dr. Pearson. - Birmingham, 1795. - -Footnote 29: - - Researches concerning Nitrous Oxide, p. 556. - -Footnote 30: - - See 32nd Congress, 2nd Session [Senate] Rep. Com. No. 421, p. 17. - -Footnote 31: - - Vol. iv, p. 158. - -Footnote 32: - - A Defence of Dr. Charles T. Jackson’s Claims to the Discovery of - Etherization. Boston, 1848. - -Footnote 33: - - The Inhalation of the Vapour of Ether in Surgical Operations. By John - Snow, M.D. 1847. - -Footnote 34: - - Pharmaceutical Journal, Feb. 1847, p. 357; and Med. Gaz., 1847, vol. - xl, p. 939. - -Footnote 35: - - Quoted in Med. Gaz., 1847, vol. xl, p. 1153. - -Footnote 36: - - Lancet, Nov. 27, 1847, p. 575; and Med. Gaz., 1847, vol. xl, p. 1031. - -Footnote 37: - - Dr. Pereira in Pharmaceutical Journal, March 1846, vol. v, No. 9. - -Footnote 38: - - Silliman’s American Journal of Science and Art, vol. xxi, p. 64, Jan. - 1832. - -Footnote 39: - - Ann. de Chim. et de Physique, t. xlviii, p. 131. - -Footnote 40: - - Ibid., t. xlix, p. 146. - -Footnote 41: - - Ibid., t. lvi, p. 134. - -Footnote 42: - - Formic acid is so named because it was originally obtained from the - red ant (_Formica rufa_). It is now made from starch. - -Footnote 43: - - Turner’s Chemistry, 8th ed., p. 1009. - -Footnote 44: - - Nearly all the chloroform used in Great Britain and her colonies is - made in Edinburgh, where the spirit duty is lower than in England. The - London druggists have almost ceased to make it, as they find it - cheaper to get it from the trade in Edinburgh. - -Footnote 45: - - The Edinburgh druggists suffered a great loss in 1850 from purifying - their chloroform in this way on the recommendation of Dr. Gregory, who - was not aware of the consequences, although they had been stated by - Dumas (_Ann. de Chim. et de Physique_, t. lvi, p. 117). - -Footnote 46: - - I have seen some specimens of chloroform that left a white, - limy-looking stain on the hand, which I believe was a minute quantity - of crystalline chloride of carbon. These specimens were - unobjectionable for all practical purposes, and had the merit of - keeping remarkably well. - -Footnote 47: - - See Med. Gaz., vol. xl, p. 1092. - -Footnote 48: - - Dr. Letheby in Med. Gaz., vol. xlvi, p. 1037. - -Footnote 49: - - Lancet, Feb. 12, 1848. - -Footnote 50: - - Since the above was written, I have met with an instance in which the - pulse was only 40 in the minute, as the effects of the chloroform were - subsiding. There was neither sickness nor loss of blood. The case was - that of a gentleman in good general health, who inhaled chloroform - whilst Mr. Brodhurst endeavoured to make forcible flexion of the femur - on the pelvis. He woke without any unpleasant symptoms, and the pulse - resumed its natural frequency. - -Footnote 51: - - Gazette des Hôpitaux, 20 Mars, 1847. - -Footnote 52: - - Medical Gazette, vol. xli-ii. - -Footnote 53: - - According to Professor Miller, chloroform was given, at one time, in - the Royal Infirmary of Edinburgh, in a somewhat slovenly, and not very - cleanly manner; he describes the means of applying it as, “anything - that will admit of chloroform in vapour being brought fully in contact - with the mouth and nostrils; a handkerchief, a towel, a piece of lint, - a _worsted glove_, a _nightcap_, a sponge.” He says, “In the winter - season, the _glove_ of a clerk, _dresser_, or onlooker, has been not - unfrequently pressed into the service.... The object is to produce - insensibility as completely and as _soon_ as we can; and there is no - saying, _à priori_, whether this is to be accomplished by _fifty_ - drops or _five hundred_. We begin with generally two or three drachms - _spilt_ on the handkerchief or lint; and we refresh that, or not, from - time to time, as circumstances require.” _Surgical Experience of - Chloroform_, Edin., 1848, pp. 16 and 17. The italics are not in the - original. - -Footnote 54: - - Curious arguments are sometimes used in support of the idea of - peculiarities and idiosyncrasies. A medical man informed me, one day, - that he had seen a patient inhale an ounce of chloroform without any - effect. I expressed my opinion that if she had taken the vapour of one - drachm into her lungs within four minutes, or the vapour of a little - more than half a drachm within two minutes, she would have been - insensible; and that the chloroform had mostly evaporated into the - room, without entering the patient’s lungs. Then, he said, it would - have made all of us insensible. Now to charge the air of a moderate - sized room of twenty feet square and ten feet high, uniformly with - only a grain and a half of chloroform to each hundred cubic inches, so - that, if all the crevices were closed, a person inside might, in - course of time, absorb about eighteen minims of the medicine, and be - rendered insensible, would require nearly fifteen pounds of - chloroform. - -Footnote 55: - - The increase of effects of chloroform after the inhalation is - discontinued, was pointed out by Prof. Sédillot of Strasbourg and - myself almost simultaneously. I explained the circumstance in a paper - read to the Westminster Medical Society, on January 8th, 1848, and M. - Sédillot announced it to the Academy of Sciences of Paris, on January - 10th. My remarks were published in the _Medical Gazette_ of January - 14th, and those of M. Sédillot in the _Gazette Médicale_ of January - 15th. - -Footnote 56: - - I have reason to conclude that the increased secretion of saliva is - caused, not so much by the action of the chloroform on the mucous - membrane of the mouth, and the extremities of the gland ducts, as by - its action on the capillary circulation of the glands themselves; for - on inhaling the vapour carefully by the nostrils, so that none enters - the mouth, I still find that there is an increased secretion of - saliva. - -Footnote 57: - - London Journal of Medicine, April 1852. - - In one of the latest communications of Dr. Marshall Hall to the - _Lancet_, he did me the honour to quote the account of the three - following experiments, together with some accompanying remarks from - the _London Journal of Medicine_, and to make the following - observation respecting the pages from which he quoted. - - “I have no hesitation in affirming that the first three pages of this - paper are amongst the most able and valuable in physiology, and I beg - to be allowed to reproduce them in the pages of the _Lancet_.” - (_Lancet_, April 18th, 1857, p. 397.) - -Footnote 58: - - Edin. Med. and Surg. Journal, vol. lviii. - -Footnote 59: - - Lond. Med. Gaz., vol. xlii, p. 414. - -Footnote 60: - - London Journal of Medicine, April, 1852. - -Footnote 61: - - London Medical Gazette, vol. xlii, 1848, p. 109. - -Footnote 62: - - On the Inhalation of the Vapour of Ether, p. 82. - -Footnote 63: - - Medical Gazette, vol. xlii, p. 415. - -Footnote 64: - - See l’Union Médicale, 1855, No. 13. - -Footnote 65: - - London Medical Gazette, vol. xli, p. 255. - -Footnote 66: - - Opus cit., p. 253. - -Footnote 67: - - Opus cit., p. 341. - -Footnote 68: - - London Medical Gazette, vol. xli, p. 75. - -Footnote 69: - - London Medical Gazette, vol. xlii, p. 80, from Western Lancet, and - Phil. Med. Exam. April 1848. - -Footnote 70: - - Vol. xliii, p. 682. - -Footnote 71: - - Gazette Médicale, 8 Juillet, 1848; and London Medical Gazette, vol. - xlii, p. 211. - -Footnote 72: - - Proceedings of Academy on Feb. 6th, 1849. See London Journal of Med., - 1849, p. 307. - -Footnote 73: - - London Journal of Medicine, 1849, p. 324. - -Footnote 74: - - Lond. Med. Gaz., vol. xliii, p. 694. - -Footnote 75: - - London Med. Gaz., vol. xlii, p. 84. - -Footnote 76: - - Bouisson, Traité de la Méthode Anesthésique, p. 398. - -Footnote 77: - - London Med. Gaz., vol. xliii, p. 41. - -Footnote 78: - - Ibid., p. 712. - -Footnote 79: - - Ibid., p. 747, from l’Union Médicale. - -Footnote 80: - - Lancet, 1849, vol. i, p. 205. - -Footnote 81: - - L’Union Médicale, Sept. 8th, 1849; and Med. Gaz., vol. xliv, p. 478. - -Footnote 82: - - Lond. Med. Gaz., vol. xliv, p. 757. - -Footnote 83: - - Journal of Prov. Med. and Surg. Assoc., 1849, p. 698. - -Footnote 84: - - Casper’s Wochenschrift, Jan. 12, 1850; and Lond. Med. Gaz., vol. xlv, - p. 483. - -Footnote 85: - - Edin. Monthly Journal, April 1850, p. 377. - -Footnote 86: - - Hygiea, October 1850, p. 602. - -Footnote 87: - - Lond. Med. Gaz., vol. xlvi, p. 39. - -Footnote 88: - - Lancet, 1850, vol. ii, p. 21. - -Footnote 89: - - L’Union Médicale, January 29, 1852. - -Footnote 90: - - Medical Times, 1851, vol. ii, p. 98. - -Footnote 91: - - Medical Times, 1851, vol. ii, p. 620. - -Footnote 92: - - Medical Times and Gazette, vol. i, p. 293. - -Footnote 93: - - Medical Times and Gazette, p. 318. - -Footnote 94: - - See a clinical lecture by Mr. Stanley, Med. Times, Nov. 22, 1851. - -Footnote 95: - - Gaz. Médicale, 1852, p. 630, from Medicinisches Correspondenz Blatt. - -Footnote 96: - - Medical Times and Gazette, 1852, vol. ii, p. 531. - -Footnote 97: - - Monthly Journal of Med., vol. xv, 1852, p. 377. - -Footnote 98: - - Lancet, 1853, vol. i, p. 21. - -Footnote 99: - - Lancet, 1853, vol. i, p. 307. - -Footnote 100: - - Med. Times and Gaz., 1853, vol. ii, p. 47. - -Footnote 101: - - Monthly Journal, Nov. 1853, p. 427. - -Footnote 102: - - Since writing the above, I have noted by the watch the time which a - surgeon occupied in shaving the perinæum before the operation of - lithotomy; it was twelve seconds. - -Footnote 103: - - Medical Times and Gazette, 1853, vol. ii, p. 422. - -Footnote 104: - - Medical Times and Gaz., 1853, vol. ii, p. 449. - -Footnote 105: - - Ibid., p. 450. - -Footnote 106: - - Edin. Monthly Jour., vol. xix, 1854, p. 372. - -Footnote 107: - - Med. Times and Gaz., 1854, vol. i, p. 19, from Med. Zeitung von den - Vercine für Heilkunde in Preussen, No. 44, Berlin, Nov. 2, 1853. - -Footnote 108: - - Association Med. Jour., 1854, p. 109. - -Footnote 109: - - L’Union Médicale, 1854, p. 171. - -Footnote 110: - - Ibid., p. 187. - -Footnote 111: - - Association Medical Journal, 1854, p. 315. - -Footnote 112: - - Medical Times, 1854, vol. i, p. 572. - -Footnote 113: - - Medical Times and Gazette, 1854, vol. ii, p. 86. - -Footnote 114: - - Med. Times and Gaz., 1854, vol. ii, p. 390. - -Footnote 115: - - Ibid., p. 442. - -Footnote 116: - - Med. Times and Gaz., 1854, vol. ii, p. 501. - -Footnote 117: - - Medical Times and Gazette, 1855, vol. i, p. 363. - -Footnote 118: - - Edin. Med. Jour., 1855, p. 524. - -Footnote 119: - - 1855, vol. ii, p. 479. - -Footnote 120: - - Medical Times and Gazette, 1856, vol. ii, p. 442. - -Footnote 121: - - Association Med. Jour., 1856, p. 903. - -Footnote 122: - - Medical Times and Gaz., 1856, vol. i, p. 236. - -Footnote 123: - - Lancet, 1857, vol. i, p. 429. - -Footnote 124: - - Med. Times and Gaz., 1857, vol. ii, p. 171. - -Footnote 125: - - Med. Times and Gaz., 1852, vol. i, p. 627. - -Footnote 126: - - Gaz. Médicale, 1853, p. 304. - -Footnote 127: - - Lancet, 1848, vol. ii, p. 47. - -Footnote 128: - - Bouisson, Méthode Anesthésique, p. 398. - -Footnote 129: - - Casper’s Wochenschrift, September 6, 1850; and London Med. Gaz. vol. - xlvii, p. 261. - -Footnote 130: - - Medical Times and Gazette, 1854, vol. i, p. 516. - -Footnote 131: - - Ibid., p. 517. - -Footnote 132: - - Chloroform: How shall we ensure Safety in its Administration? - Pamphlet. London: 1855. - -Footnote 133: - - See some interesting papers on the value of recumbent position in - syncope, by Dr. Richardson, in the _Association Medical Journal_ for - 1854. I entirely agree with Dr. Richardson that no kind of syncope - commences at the brain, and that, during recovery, the heart always - resumes its functions before consciousness is restored. The - restoration of the heart’s action in ordinary syncope by the re-supply - of blood to its cavities, without any alteration in the condition of - the brain, was well proved by Dr. Richardson by means of some - interesting experiments on animals which I had the opportunity of - witnessing. - -Footnote 134: - - Oration before the Hunterian Society. Pamphlet, 1855. - -Footnote 135: - - Hydrochloric acid gas and ammonia are no exceptions to this rule, for - they cease to exist as gases so soon as they come in contact with the - moist lining membrane of the air-passages. Carbonic acid gas will be - treated of in another part of this work. - -Footnote 136: - - See Med. Times and Gaz., 1853, vol. ii, p. 562. - -Footnote 137: - - See above, p. 75. - -Footnote 138: - - Edin. Monthly Jour., 1853, vol. xvii, p. 220. - -Footnote 139: - - Med. Times and Gaz., 1852, vol. i, p. 627. - -Footnote 140: - - L’Union Médicale, 1850, p. 411. - -Footnote 141: - - Lond. Med. Gaz., vol. xliii, p. 230. - -Footnote 142: - - Medical Times and Gaz., 1856, vol. ii, p. 413. - -Footnote 143: - - Med. Times and Gaz., 1856, vol. ii, p. 478. - -Footnote 144: - - Ib., 1857, vol. i, p. 559. - -Footnote 145: - - Page 648. - -Footnote 146: - - Practical Surgery, 3rd ed., p. 682. - -Footnote 147: - - I never allow of a cork or any such substance being put into a - patient’s mouth when insensible unless it is well tied to a string, - lest it should be swallowed. - -Footnote 148: - - Fourth edit., vol. ii, p. 467. - -Footnote 149: - - It was made by Mr. Matthews, Portugal Street. It was not contrived by - me. - -Footnote 150: - - London Journal of Medicine, vol. i, pp. 54, 976. - -Footnote 151: - - See Medical Times and Gaz., 1855, vol. i, p. 361. - -Footnote 152: - - Dr. Watson defends the original name of this complaint, delirium - tremens. He says:—“But they who object to _delirium tremens_ appear to - see no harm in delirium ferox: whereas it is just as incorrect to say - _delirium_ is fierce, as to say that it trembles: it is the patient - who is furious, even as it is the patient who trembles.” Now, in - speaking of a patient, we may speak either of his mind or his body: we - may say that a person is learned, or that he is fat. A patient may be - fierce on account of the kind of delirium with which his mind is - affected, and the term ferox applies both to him and the complaint; - but the act of trembling affects only his body. - -Footnote 153: - - Med. Gaz., vol. xli, 1848, p. 102. - -Footnote 154: - - Association Med. Jour., 1853, p. 706. - -Footnote 155: - - See Med. Times and Gaz., 1853, vol. ii, p. 412. - -Footnote 156: - - Med. Times and Gaz., 1857, vol. ii, p. 553, and 600. - -Footnote 157: - - Med. Times and Gaz., 1856, vol. ii, p. 528. - -Footnote 158: - - Brande’s Chemistry, 5th ed., p. 1274. - -Footnote 159: - - Lond. Med. Gaz., Feb. 1842. - -Footnote 160: - - On the Inhalation of the Vapour of Ether in Surgical Operations. - London, 1847. - -Footnote 161: - - Papers on Narcotism by Inhalation. Lond. Med. Gaz., vol. xli-ii. - -Footnote 162: - - Lancet, Jan. 1, 1848. - -Footnote 163: - - Vol. xxxix, p. 271. - -Footnote 164: - - Medical Gazette, vol. xxxix, p. 358. - -Footnote 165: - - Gaz. Médicale, Mars 4, 1848, p. 170. - -Footnote 166: - - Gaz. des Hôpitaux, Juin 18, 1853. - -Footnote 167: - - Medical Gazette, vol. xxxix, p. 414. - -Footnote 168: - - Ibid., vol. xxxix, p. 585. - -Footnote 169: - - Medical Gazette, vol. xxxix, p. 631. - -Footnote 170: - - Méthode Anesthésique, p. 394. - -Footnote 171: - - American Journal of Med. Science, July 1857, p. 284. - -Footnote 172: - - Annales de Chimie et de Physique, 3ème série, tom. xii, p. 320. - -Footnote 173: - - 15, Hanover Street, Hanover Square. - -Footnote 174: - - Bulletin Général de Thérapeutique, t. lii, p. 312. - -Footnote 175: - - L’Union Médicale, p. 175. - -Footnote 176: - - Less than an ounce of amylene was poured out, and it was not all used. - -Footnote 177: - - Medical Times and Gazette, 1857, vol. i, p. 84. - -Footnote 178: - - British Medical Journal, March 28th, 1857. - -Footnote 179: - - Bulletin Général de Thérapeutique, t. lii, p. 223. - -Footnote 180: - - Gazette Hebdomadaire, 1857, p. 164. - -Footnote 181: - - In the act of writing this last sentence, Dr. Snow was seized with his - fatal illness. The sentence required, however, but the addition of a - word or two, to render it complete.—[EDITOR.] - ------------------------------------------------------------------------- - - _London, New Burlington Street, - September, 1858._ - - - - - MR. CHURCHILL’S - - Publications, - - IN - - MEDICINE, SURGERY, - - AND - - SCIENCE. - - -[Illustration] - -“It would be unjust to conclude this notice without saying a few words -in favour of Mr. Churchill, from whom the profession is receiving, it -may be truly said, the most beautiful series of Illustrated Medical -Works which has ever been published.”—_Lancet._ - -“All the publications of Mr. Churchill are prepared with so much taste -and neatness, that it is superfluous to speak of them in terms of -commendation.”—_Edinburgh Medical and Surgical Journal._ - -“No one is more distinguished for the elegance and recherché style of -his publications than Mr. Churchill.”—_Provincial Medical Journal._ - -“Mr. Churchill’s publications are very handsomely got up: the engravings -are remarkably well executed.”—_Dublin Medical Press._ - -“The typography, illustrations, and getting up are, in all Mr. -Churchill’s publications, most beautiful.”—_Monthly Journal of Medical -Science._ - -“Mr. Churchill’s illustrated works are among the best that emanate from -the Medical Press.”—_Medical Times._ - -“We have before called the attention of both students and practitioners -to the great advantage which Mr. Churchill has conferred on the -profession, in the issue, at such a moderate cost, of works so highly -creditable in point of artistic execution and scientific merit.”—_Dublin -Quarterly Journal._ - -MR. CHURCHILL is the Publisher of the following Periodicals, offering to -Authors a wide extent of Literary Announcement, and a Medium of -Advertisement, addressed to all Classes of the Profession. -COMMUNICATIONS, BOOKS for REVIEW, addressed to the respective Editors, -are received and duly forwarded by Mr. Churchill. - - - THE BRITISH AND FOREIGN MEDICO-CHIRURGICAL REVIEW; - - OR, - - QUARTERLY JOURNAL OF PRACTICAL MEDICINE. - - Price Six Shillings. Nos. I. to XLIII. - - - THE QUARTERLY JOURNAL OF MICROSCOPICAL SCIENCE. - - Edited by EDWIN LANKESTER, M.D., F.R.S., F.L.S., and GEORGE BUSK, - F.R.C.S.E., F.R.S., F.L.S. Price 4_s._ Nos. I. to XXIV. - - - THE MEDICAL TIMES AND GAZETTE. - - Published Weekly, price Sevenpence, or Stamped, Eightpence. - - Annual Subscription, £1. 10_s._, or Stamped, £1. 14_s._ 8_d._, and - regularly forwarded to all parts of the Kingdom. - -The MEDICAL TIMES AND GAZETTE is favoured with an amount of Literary and -Scientific support which enables it to reflect fully the progress of -Medical Science, and insure for it a character, an influence, and a -circulation possessed at the present time by no Medical Periodical. - - - THE HALF-YEARLY ABSTRACT OF THE MEDICAL SCIENCES. - -Being a Digest of the Contents of the principal British and Continental -Medical Works; together with a Critical Report of the Progress of -Medicine and the Collateral Sciences. Edited by W. H. RANKING, M.D., -Cantab., and C. B. RADCLIFFE, M.D., Lond. Post 8vo. cloth, 6_s._ 6_d._ -Vols. I. to XXVII. - - - THE JOURNAL OF PSYCHOLOGICAL MEDICINE AND MENTAL PATHOLOGY. - - Being a Quarterly Review of Medical Jurisprudence and Insanity. Edited - by FORBES WINSLOW, M.D. Price 3_s._ 6_d._ Nos. I. to XI. _New Series._ - - - THE PHARMACEUTICAL JOURNAL. - - EDITED BY JACOB BELL, F.L.S., M.R.I. - - Published Monthly, price One Shilling. - - ⁂ Vols. I. to XVII., bound in cloth, price 12_s._ 6_d._ each. - - - THE DUBLIN MEDICAL PRESS. - - Published Weekly, Stamped, price Sixpence, free to any part of the - Empire. - - - THE LONDON AND PROVINCIAL MEDICAL DIRECTORY. - - Published Annually. 12mo. cloth, 8_s._ 6_d._ - - - - - A CLASSIFIED INDEX - - TO - - MR. CHURCHILL’S CATALOGUE. - - - ANATOMY. - PAGE - Anatomical Remembrancer 1003 - Beale on Liver 1005 - Hassall’s Micros. Anatomy 1014 - Holden’s Human Osteology 1015 - Jones’ and Sieveking’s Pathological Anatomy 1017 - Maclise’s Surgical Anatomy 1019 - Paget’s Catalogue 1021 - Sibson’s Medical Anatomy 1025 - Toynbee’s Catalogue 1028 - Wheeler’s Handbook 1030 - Wilson’s Anatomy 1031 - - - CHEMISTRY. - - Abel & Bloxam’s Handbook 1004 - Bowman’s Practical Chemistry 1007 - Do. Medical do. 1007 - Chalmers’ Electro-Chemistry 1008 - Fownes’ Manual of Chemistry 1012 - Do. Actonian Prize 1012 - Do. Qualitative Analysis 1012 - Do. Chemical Tables 1012 - Fresenius’ Chemical Analysis 1012 - Galloway’s First Step 1012 - Do. Analysis 1012 - Do. Diagrams 1012 - Griffiths’ Four Seasons 1013 - Horsley’s Chem. Philosophy 1016 - Jones.—Mulder on Wine 1017 - Odling’s Practical Chemistry 1021 - Plattner on Blowpipe 1022 - Speer’s Pathol. Chemistry 1026 - - - CHOLERA. - - Acland on Cholera at Oxford 1003 - Baly and Gull—Reports 1004 - Snow on Cholera 1026 - - - CLIMATE. - - Francis on Change of Climate 1012 - Hall on Torquay 1014 - Haviland on Climate 1014 - Lee on Climate 1018 - Martin on the Undercliff 1019 - Martin (J. R.) on Tropical 1020 - - - DEFORMITIES, &c. - - Bigg on Deformities 1006 - Bishop on Deformities 1006 - Do. Articulate Sounds 1006 - Brodhurst on Spine 1007 - Do. on Clubfoot 1007 - Hare on Spine 1014 - Hugman on Hip-Joint 1016 - Inman on Spine 1016 - Tamplin on Spine 1027 - - - DENTISTRY. - - Blundell’s Painless Extraction 1007 - Clark’s Odontalgist 1009 - Gray on the Teeth 1013 - Odontological Soc. Transactions 1021 - - - DISEASES of the URINARY and GENERATIVE ORGANS, and - SYPHILIS. - - Acton on Reproductive Organs 1003 - Coote on Syphilis 1009 - Coulson on Bladder 1010 - Do. on Lithotomy 1010 - Egan on Syphilis 1011 - Judd on Syphilis 1017 - Milton on Gonorrhœa 1020 - Parker on Syphilis 1022 - Todd on Urinary Organs 1028 - Wilson on Syphilis 1031 - - - DISEASES OF WOMEN AND CHILDREN. - - Bennet on Uterus 1005 - Do. on Uterine Pathology 1005 - Bird on Children 1006 - Brown on Women 1007 - Do. on Scarlatina 1007 - Eyre’s Practical Remarks 1011 - Hood on Crowing 1016 - Lee’s Ovarian & Uterine Diseases 1018 - Lee on Diseases of Uterus 1018 - Do. on Speculum 1018 - Roberton on Women 1024 - Rowe on Females 1024 - Smith on Leucorrhœa 1025 - Tilt on Diseases of Women 1027 - Do. on Change of Life 1027 - Underwood on Children 1028 - West on Women 1029 - Whitehead on Abortion 1030 - - - HYGIENE. - - Armstrong on Naval Hygiene 1003 - Beale’s Laws of Health 1004 - Do. Health and Diseases 1004 - Blundell’s Medicina Mechanica 1006 - Carter on Training 1008 - Cornaro on Long Life 1009 - Hartwig on Sea Bathing 1014 - Do. Physical Education 1014 - Hufeland’s Art 1016 - Lee’s Watering Places of England 1018 - Do. do. Germany, France, and Switzerland 1018 - Lee’s Rhenish Watering Places 1018 - Pickford on Hygiene 1022 - Robertson on Diet 1024 - Roth on Movements 1024 - Rumsey’s State Medicine 1024 - Van Oven’s Decline of Life 1029 - Wilson on Healthy Skin 1031 - Do. on Mineral Waters 1031 - - - MATERIA MEDICA and PHARMACY. - - Bateman’s Magnacopia 1004 - Beasley’s Formulary 1005 - Do. Receipt-Book 1005 - Do. Book of Prescriptions 1005 - Lane’s Materia Medica 1017 - Pereira’s Selecta e Præscriptis 1022 - Pharmacopœia Londinensis 1022 - Prescriber’s Pharmacopœia 1023 - Royle’s Materia-Medica 1024 - Spurgin’s Materia Medica 1026 - Squire’s Pharmacopœia 1026 - Steggall’s Materia Medica 1026 - Do. First Lines for Chemists 1026 - Stowe’s Toxicological Chart 1027 - Taylor on Poisons 1027 - Wittstein’s Pharmacy 1031 - - - MEDICINE. - - Adams on Rheumatic Gout 1004 - Addison on Supra-Renal Capsules 1004 - Addison on Cells 1003 - Alexander on Rheumatism 1003 - Arnott on a Local Anæsthenic 1003 - Barclay on Diagnosis 1005 - Barlow’s Practice of Medicine 1004 - Beale on Urine 1005 - Billing’s First Principles 1005 - Bird’s Urinary Deposits 1006 - Bird on Charcoal 1006 - Brinton on Ulcer 1007 - Budd on the Liver 1007 - Do. on Stomach 1007 - Camplin on Diabetes 1008 - Chambers on Digestion 1008 - Davey’s Ganglionic 1010 - Eyre on Stomach 1011 - Fuller on Rheumatism 1012 - Gairdner on Gout 1012 - Garrett on E. and N. E. Winds 1012 - Granville on Sudden Death 1013 - Gully’s Simple Treatment 1013 - Habershon on Stomach 1013 - Hall on Apnœa 1014 - Hall’s Observations 1014 - Harrison on Lead in Water 1014 - Headland on Medicines 1015 - Hooper’s Medical Dictionary 1016 - Hooper’s Physician’s Vademecum 1013 - Jones’ Animal Chemistry 1017 - Lugol on Scrofula 1019 - Peacock on Influenza 1022 - Do. on Heart 1022 - Pym on Yellow Fever 1023 - Roberts on Palsy 1024 - Robertson on Gout 1024 - Savory’s Compendium 1024 - Semple on Cough 1025 - Shaw’s Remembrancer 1025 - Steggall’s Medical Manual 1026 - Do. Gregory’s Conspectus 1026 - Do. Celsus 1026 - Thomas’ Practice of Physic 1027 - Wegg’s Observations 1029 - Wells on Gout 1030 - What to Observe 1019 - Whitehead on Transmission 1030 - Williams’ Principles 1030 - Wright on Headaches 1030 - - - MICROSCOPE. - - Beale on Microscope in Medicine 1005 - Do. How to Work 1005 - Carpenter on Microscope 1008 - Schacht on do. 1025 - - - MISCELLANEOUS. - - Acton on Prostitution 1003 - Atkinson’s Bibliography 1004 - Bascome on Epidemics 1005 - Bryce on Sebastopol 1008 - Cooley’s Cyclopædia 1009 - Forbes’ Nature and Art in Disease 1011 - Gully on Water Cure 1013 - Guy’s Hospital Reports 1013 - Haycock’s Veterinary 1015 - Lane’s Hydropathy 1018 - Marcet on Food 1019 - Massy on Recruits 1020 - Oxford Editions 1021 - Part’s Case Book 1022 - Pettigrew on Superstitions 1022 - - - NERVOUS DISEASES AND INDIGESTION. - - Anderson on Nervous Affections 1004 - Arnott on Indigestion 1003 - Carter on Hysteria 1008 - Child on Indigestion 1008 - Downing on Neuralgia 1011 - Hunt on Heartburn 1016 - Lobb on Nervous Affections 1019 - Radcliffe on Epilepsy 1023 - Reynolds on the Brain 1023 - Rowe on Nervous Diseases 1024 - Sieveking on Epilepsy 1025 - Todd on Nervous System 1028 - Turnbull on Stomach 1028 - - - OBSTETRICS. - - Barnes on Placenta Prævia 1004 - Lee’s Clinical Midwifery 1018 - Pretty’s Aids during Labour 1023 - Ramsbotham’s Obstetrics 1023 - Do. Midwifery 1023 - Smellie’s Obstetric Plates 1025 - Smith’s Manual of Obstetrics 1025 - Do. Periodoscope 1025 - Swayne’s Aphorisms 1026 - Waller’s Midwifery 1029 - - - OPHTHALMOLOGY. - - Cooper on Near Sight 1009 - Dalrymple on Eye 1010 - Dixon on the Eye 1011 - Hogg on Ophthalmoscope 1015 - Holthouse on Strabismus 1015 - Do. on Impaired Vision 1015 - Jacob on Eye-ball 1016 - Jones’ Ophthalmic Medicine 1017 - Do. Defects of Sight 1017 - Do. Eye and Ear 1017 - Walton on Ophthalmic 1029 - - - PHYSIOLOGY. - - Carpenter’s Human 1008 - Do. Comparative 1008 - Do. Manual 1008 - Cottle’s Human 1010 - Hilton on the Cranium 1015 - Richardson on Coagulation 1023 - - - PSYCHOLOGY. - - Bucknill and Tuke’s Psychological Medicine 1007 - Burgess on Madness 1007 - Burnett on Insanity 1009 - Conolly on Asylums 1009 - Davey on Nature of Insanity 1010 - Dunn’s Physiological Psychology 1011 - Hood on Criminal Lunatics 1016 - Jacobi on Hospitals, by Tuke 1028 - Knaggs on Criminal Lunatics 1017 - Millingen on Treatment of Insane 1020 - Monro on Insanity 1020 - Do. Private Asylums 1020 - Noble on Psychology 1020 - Do. on Mind 1020 - Williams (J.) on Insanity 1030 - Williams (J. H.) Unsoundness of Mind 1030 - Winslow’s Lettsomian 1031 - Do. Law of Lunacy 1031 - - - PULMONARY and CHEST DISEASES, &c. - - Addison on Healthy and Diseased Structure 1003 - Billing on Lungs and Heart 1005 - Blakiston on the Chest 1006 - Bright on the Chest 1007 - Cotton on Consumption 1010 - Do. on Stethoscope 1010 - Davies on Lungs and Heart 1011 - Fenwick on Consumption 1011 - Laennec on Auscultation 1017 - Madden on Consumption 1019 - Markham on Heart 1020 - Richardson on Consumption 1023 - Skoda on Auscultation 1019 - Thompson on Consumption 1027 - Wardrop on the Heart 1029 - Weber on Auscultation 1029 - - - SCIENCE. - - Bird’s Natural Philosophy 1006 - Burnett’s Philosophy of Spirits 1008 - Garner’s Eutherapeia 1013 - Hardwich’s Photography 1014 - Hinds’ Harmonies 1015 - Holland on Appendages 1015 - Jago on Ocular Spectres 1016 - Jones on Vision 1017 - Do. on Body, Sense, and Mind 1017 - Mayne’s Lexicon 1019 - Price’s Photographic Manipulation 1023 - Nourse’s Students’ Tables 1021 - Reymond’s Animal Electricity 1023 - Taylor’s Medical Jurisprudence 1027 - Vestiges of Creation 1028 - Sequel to ditto 1028 - Unger’s Botanical Letters 1028 - - - SURGERY. - - Arnott on Urethra 1003 - Ashton on Rectum 1004 - Bellingham on Aneurism 1006 - Bigg on Artificial Limbs 1006 - Bishop on Bones 1006 - Chapman on Ulcers 1009 - Do. Varicose Veins 1009 - Cooper (Sir A.) on Testis 1010 - Cooper’s (B.) Surgery 1009 - Do. (S.) Surg. Dictionary 1009 - Curling on Rectum 1010 - Do. on Testis 1010 - Druitt’s Surgery 1011 - Fergusson’s Surgery 1011 - Gay on Femoral Rupture 1013 - Do. on Ulcers 1013 - Harrison on Stricture 1014 - Higginbottom on Nitrate of Silver 1015 - Hodgson on Prostate 1015 - Hunt on Skin 1016 - Laurence on Cancer 1018 - Lawrence on Ruptures 1018 - Lee on Hæmorrhoids 1018 - Liston’s Surgery 1018 - Macleod’s Surgery of the Crimea 1019 - Maclise on Fractures 1019 - Nottingham on the Ear 1020 - Nunneley on Erysipelas 1021 - Pirrie on Surgery 1022 - Skey’s Operative Surgery 1025 - Smith on Stricture 1025 - Steggall’s Surgical Manual 1026 - Thompson on Stricture 1027 - Wade on Stricture 1029 - Watson on the Larynx 1029 - Wilson on the Skin 1031 - Do. Portraits of Skin Diseases 1031 - Yearsley on Deafness 1031 - Do. on Throat 1031 - - - DR. ACLAND. - - MEMOIR ON THE CHOLERA AT OXFORD IN THE YEAR 1854; with Considerations - suggested by the Epidemic. 4to. cloth, with Maps, 12_s._ - - - MR. ACTON, M.R.C.S. - - I. - - THE FUNCTIONS AND DISORDERS OF THE REPRODUCTIVE ORGANS IN YOUTH, IN - ADULT AGE, AND IN ADVANCED LIFE. Considered in their Physiological, - Social, and Psychological Relations. Second Edition. 8vo. cloth, - 7_s._ - - II. - - PROSTITUTION: Considered in its Moral, Social, and Sanitary Bearings, - with a View to its Amelioration and Regulation. 8vo. cloth, 10_s._ - 6_d._ - - - DR. WILLIAM ADDISON, F.R.S. - - I. - - CELL THERAPEUTICS. 8vo. doth, 4_s._ - - II. - - ON HEALTHY AND DISEASED STRUCTURE, AND THE TRUE PRINCIPLES OF - TREATMENT FOR THE CURE OF DISEASE, ESPECIALLY CONSUMPTION AND - SCROFULA, founded on MICROSCOPICAL ANALYSIS. 8vo. cloth, 12_s._ - - - DR. ALEXANDER, F.R.C.S. BY EXAM. - - RHEUMATISM: its Nature, Causes, and Cure. - - GOUT: its Nature, Causes, Cure, and Prevention. - - Post 8vo. cloth, 7_s._ 6_d._ - - THE ANATOMICAL REMEMBRANCER; OR, COMPLETE POCKET ANATOMIST. Fifth - Edition, carefully Revised. 32mo. cloth, 3_s._ 6_d._ - - - DR. ALEXANDER ARMSTRONG, R.N. - - OBSERVATIONS ON NAVAL HYGIENE AND SCURVY. More particularly as the - latter appeared during a Polar Voyage. 8vo. cloth, 5_s._ - - - DR. JAMES ARNOTT. - - I. - - ON THE REMEDIAL AGENCY OF A LOCAL ANÆSTHETIC OR BENUMBING TEMPERATURE, - in various painful and inflammatory Diseases. 8vo. cloth, 4_s._ - 6_d._ - - II. - - ON INDIGESTION; its Pathology and its Treatment, by the Local - Application of Uniform and Continuous Heat and Moisture. With an - Account of an improved Mode of applying Heat and Moisture in - Irritative and Inflammatory Diseases. With a Plate. 8vo. 5_s._ - - III. - - PRACTICAL ILLUSTRATIONS OF THE TREATMENT OF OBSTRUCTIONS IN THE - URETHRA, AND OTHER CANALS, BY THE DILATATION OF FLUID PRESSURE. 8vo. - boards, 3_s._ - - - MR. F. A. ABEL, F.C.S., & MR. C. L. BLOXAM. - - HANDBOOK OF CHEMISTRY: THEORETICAL, PRACTICAL, AND TECHNICAL. Second - Edition. 8vo. cloth, 15_s._ - - - DR. ADAMS, A.M. - - A TREATISE ON RHEUMATIC GOUT; OR, CHRONIC RHEUMATIC ARTHRITIS. 8vo. - cloth, with a Quarto Atlas of Plates, 21_s._ - - - DR. ADDISON. - - ON THE CONSTITUTIONAL AND LOCAL EFFECTS OF DISEASE OF THE SUPRA-RENAL - CAPSULES. 4to. cloth. Coloured Plates, 21_s._ - - - MR. ANDERSON, F.R.C.S. - - THE CAUSES, SYMPTOMS, & TREATMENT OF ECCENTRIC NERVOUS AFFECTIONS. - 8vo. cloth, 5_s._ - - - MR. T. J. ASHTON. - - ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE RECTUM AND ANUS. - Second Edition. 8vo. cloth, 8_s._ - - - MR. ATKINSON. - - MEDICAL BIBLIOGRAPHY. Vol. I. Royal 8vo. 16_s._ - - - DR. WILLIAM BALY, F.R.S., & DR. WILLIAM W. GULL. - - REPORTS ON EPIDEMIC CHOLERA; its Cause and Mode of Diffusion, Morbid - Anatomy, Pathology and Treatment. Drawn up at the desire of the - Cholera Committee of the Royal College of Physicians. With Maps, - 8vo. cloth, 16_s._ - - - DR. BARLOW. - - A MANUAL OF THE PRACTICE OF MEDICINE. Fcap. 8vo. cloth, 12_s._ 6_d._ - - - DR. BARNES. - - THE PHYSIOLOGY AND TREATMENT OF PLACENTA PRÆVIA; being the Lettsomian - Lectures on Midwifery for 1857. Post 8vo. cloth, 6_s._ - - - MR. BATEMAN. - - MAGNACOPIA: A Practical Library of Profitable Knowledge, communicating - the general Minutiæ of Chemical and Pharmaceutic Routine, together - with the generality of Secret Forms of Preparations; including - Concentrated Solutions of Camphor and Copaiba in Water, Mineral - Succedaneum, Marmoratum, Silicia, Terro-Metallicum, Pharmaceutic - Condensions, Prismatic Crystallization, Crystallized Aromatic Salt - of Vinegar, Spa Waters; newly-invented Writing Fluids; Etching on - Steel or Iron; with an extensive Variety of _et cætera_. Third - Edition. 18mo. 6_s._ - - - MR. LIONEL J. BEALE, M.R.C.S. - - I. - - THE LAWS OF HEALTH IN THEIR RELATIONS TO MIND AND BODY. A Series of - Letters from an Old Practitioner to a Patient. Post 8vo. cloth, - 7_s._ 6_d._ - - II. - - HEALTH AND DISEASE, IN CONNECTION WITH THE GENERAL PRINCIPLES OF - HYGIENE. Fcap. 8vo., 2_s._ 6_d._ - - - DR. BEALE, F.R.S. - - I. - - HOW TO WORK WITH THE MICROSCOPE. Crown 8vo. cloth, 5_s._ - - II. - - THE MICROSCOPE, IN ITS APPLICATION TO PRACTICAL MEDICINE. With 2 - Plates, and upwards of 200 Engravings on Wood. Second Edition. 8vo. - cloth, 12_s._ 6_d._ - - III. - - ON THE ANATOMY OF THE LIVER. Illustrated with 66 Photographs of the - Author’s Drawings. 8vo. cloth, 6_s._ 6_d._ - - IV. - - ILLUSTRATIONS OF THE SALTS OF URINE, URINARY DEPOSITS, and CALCULI. 37 - Plates, containing upwards of 170 Figures copied from Nature, with - descriptive Letterpress. 8vo. cloth, 9_s._ 6_d._ - - - DR. BARCLAY. - - A MANUAL OF MEDICAL DIAGNOSIS. Fcap. 8vo. cloth, 8_s._ 6_d._ - - - DR. BASCOME. - - A HISTORY OF EPIDEMIC PESTILENCES, FROM THE EARLIEST AGES. 8vo. cloth, - 8_s._ - - - MR. BEASLEY. - - I. - - THE BOOK OF PRESCRIPTIONS; containing 2900 Prescriptions. Collected - from the Practice of the most eminent Physicians and Surgeons, - English and Foreign. 24mo. cloth, 6_s._ - - II. - - THE DRUGGIST’S GENERAL RECEIPT-BOOK: comprising a copious Veterinary - Formulary and Table of Veterinary Materia Medica; Patent and - Proprietary Medicines, Druggists’ Nostrums, &c.; Perfumery, Skin - Cosmetics, Hair Cosmetics, and Teeth Cosmetics; Beverages, Dietetic - Articles, and Condiments; Trade Chemicals, Miscellaneous - Preparations and Compounds used in the Arts, &c.; with useful - Memoranda and Tables. Fourth Edition. 24mo. cloth, 6_s._ - - III. - - - DR. HENRY BENNET. - - I. - - A PRACTICAL TREATISE ON INFLAMMATION AND OTHER DISEASES OF THE UTERUS. - Third Edition, revised, with Additions. 8vo, cloth, 12_s._ 6_d._ - - II. - - A REVIEW OF THE PRESENT STATE OF UTERINE PATHOLOGY. 8vo. cloth, 4_s._ - - - DR. BILLING, F.R.S. - - I. - - ON DISEASES OF THE LUNGS AND HEART. 8vo. cloth, 6_s._ - - II. - - FIRST PRINCIPLES OF MEDICINE, Fifth Edition, Revised and Improved. - 8vo. 10_s._ 6_d._ - - - DR. O’B. BELLINGHAM. - - ON ANEURISM, AND ITS TREATMENT BY COMPRESSION. 12mo. cloth, 4_s._ - - - MR. HENRY HEATHER BIGG. - - I. - - THE MECHANICAL APPLIANCES NECESSARY FOR THE TREATMENT OF DEFORMITIES. - Post 8vo. cloth, 4_s._ - - II. - - ARTIFICIAL LIMBS; THEIR CONSTRUCTION AND APPLICATION. With Engravings - on Wood. 8vo. cloth, 3_s._ - - - MR. P. HINCKES BIRD, F.R.C.S. - - PRACTICAL TREATISE ON THE DISEASES OF CHILDREN AND INFANTS AT THE - BREAST. Translated from the French of M. Bouchut, with Notes and - Additions. 8vo. cloth. 20_s._ - - - DR. GOLDING BIRD, F.R.S. - - I. - - URINARY DEPOSITS; THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL - INDICATIONS. With Engravings on Wood. Fifth Edition. Post 8vo, - cloth, 10_s._ 6_d._ - - II. - - ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental Introduction to - the Study of the Physical Sciences. Illustrated with numerous - Engravings on Wood. Fourth Edition. By GOLDING BIRD, M.D., F.R.S., - and CHARLES BROOKE, M.B. Cantab., F.R.S. Fcap. 8vo. cloth, 12_s._ - 6_d._ - - - MR. JAMES BIRD. - - VEGETABLE CHARCOAL: its MEDICINAL and ECONOMIC PROPERTIES; with - Practical Remarks on its Use in Chronic Affections of the Stomach - and Bowels. Second Edition, 8vo. cloth, 3_s._ 6_d._ - - - MR. BISHOP, F.R.S. - - I. - - ON DEFORMITIES OF THE HUMAN BODY, their Pathology and Treatment. With - Engravings on Wood. 8vo. cloth, 10_s._ - - II. - - ON ARTICULATE SOUNDS, AND ON THE CAUSES AND CURE OF IMPEDIMENTS OF - SPEECH. 8vo. cloth, 4_s._ - - III. - - LETTSOMIAN LECTURES ON THE PHYSICAL CONSTITUTION, DISEASES AND - FRACTURES OF BONES. Post 8vo., 2_s._ 6_d._ - - - DR. BLAKISTON, F.R.S. - - PRACTICAL OBSERVATIONS ON CERTAIN DISEASES OF THE CHEST; and on the - Principles of Auscultation. 8vo. cloth, 12_s._ - - - DR. JOHN W. F. BLUNDELL. - - MEDICINA MECHANICA; or, the Theory and Practice of Active and Passive - Exercises and Manipulations in the Cure of Chronic Disease. Post - 8vo. cloth, 6_s._ - - - MR. WALTER BLUNDELL. - - PAINLESS TOOTH-EXTRACTION WITHOUT CHLOROFORM; with Observations on - Local Anæsthesia by Congelation in General Surgery. Second Edition, - 2_s._ 6_d._ cloth. Illustrated on Wood and Stone. - - - MR. JOHN E. BOWMAN. - - I. - - PRACTICAL CHEMISTRY, including Analysis. With numerous Illustrations - on Wood. Third Edition. Foolscap 8vo. cloth, 6_s._ 6_d._ - - II. - - MEDICAL CHEMISTRY; with illustrations on Wood. Third Edition. Fcap. - 8vo. cloth, 6_s._ 6_d._ - - - DR. BRINTON. - - THE SYMPTOMS, PATHOLOGY, AND TREATMENT OF ULCER OF THE STOMACH. Post - 8vo. cloth, 5_s._ - - - DR. JAMES BRIGHT. - - ON DISEASES OF THE CHEST AND AIR PASSAGES; with a Review of the - several Climates recommended in these Affections. Second Edition. - Post 8vo. cloth, 7_s._ 6_d._ - - - MR. ISAAC BAKER BROWN, F.R.C.S. - - I. - - ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREATMENT. With - Plates, 8vo. cloth, 10_s._ 6_d._ - - II. - - ON SCARLATINA: its Nature and Treatment. Second Edition. Fcap. 8vo. - cloth, 3_s._ - - - MR. BERNARD E. BRODHURST. - - I. - - ON LATERAL CURVATURE OF THE SPINE: its Pathology and Treatment. Post - 8vo. cloth, with Plates, 3_s._ - - II. - - ON THE NATURE AND TREATMENT OF CLUBFOOT AND ANALOGOUS DISTORTIONS - involving the TIBIO-TARSAL ARTICULATION. With Engravings on Wood. - 8vo. cloth, 4_s._ 6_d._ - - - DR. JOHN CHARLES BUCKNILL, & DR. DANIEL H. TUKE. - - A MANUAL OF PSYCHOLOGICAL MEDICINE: containing the History, Nosology, - Description, Statistics, Diagnosis, Pathology, and Treatment of - Insanity. 8vo. cloth, 15_s._ - - - DR. BUDD, F.R.S. - - I. - - ON DISEASES OF THE LIVER. - - Illustrated with Coloured Plates and Engravings on Wood. Third - Edition. 8vo. cloth, 16_s._ - - II. - - ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF THE STOMACH. 8vo. - cloth, 9_s._ - - - DR. BURGESS. - - THE MEDICAL AND LEGAL RELATIONS OF MADNESS; showing a Cellular Theory - of Mind, and of Nerve Force, and also of Vegetative Vital Force. - 8vo. cloth, 7_s._ - - - DR. BURNETT. - - I. - - THE PHILOSOPHY OF SPIRITS IN RELATION TO MATTER. 8vo. cloth, 9_s._ - - II. - - INSANITY TESTED BY SCIENCE. 8vo. cloth, 5_s._ - - - DR. BRYCE. - - ENGLAND AND FRANCE BEFORE SEBASTOPOL, looked at from a Medical Point - of View. 8vo. cloth, 6_s._ - - - DR. JOHN M. CAMPLIN, F.L.S. - - ON DIABETES, AND ITS SUCCESSFUL TREATMENT. Fcap. 8vo. cloth, 3_s._ - - - MR. ROBERT B. CARTER, M.R.C.S. - - I. - - ON THE INFLUENCE OF EDUCATION AND TRAINING IN PREVENTING DISEASES OF - THE NERVOUS SYSTEM. Fcap. 8vo., 6_s._ - - II. - - THE PATHOLOGY AND TREATMENT OF HYSTERIA. Post 8vo. cloth, 4_s._ 6_d._ - - - DR. CARPENTER, F.R.S. - - I. - - PRINCIPLES OF HUMAN PHYSIOLOGY. With numerous Illustrations on Steel - and Wood. Fifth Edition. 8vo. cloth, 26_s._ - - II. - - PRINCIPLES OF COMPARATIVE PHYSIOLOGY. Illustrated with 300 Engravings - on Wood. Fourth Edition. 8vo. cloth, 24_s._ - - III. - - A MANUAL OF PHYSIOLOGY. With numerous Illustrations on Steel and Wood. - Third Edition. Fcap. 8vo. cloth, 12_s._ 6_d._ - - - IV. - - THE MICROSCOPE AND ITS REVELATIONS. With numerous Engravings on Wood. - Second Edition. Fcap. 8vo. cloth, 12_s._ 6_d._ - - - MR. CHARLES CHALMERS. - - ELECTRO-CHEMISTRY, with Positive Results; and Notes for Inquiry on the - Sciences of Geology and Astronomy: with a Tract of Miscellanies. - 8vo. cloth, 3_s._ 6_d._ - - - DR. CHAMBERS. - - DIGESTION AND ITS DERANGEMENTS. Post 8vo. cloth, 10_s._ 6_d._ - - - DR. G. C. CHILD. - - ON INDIGESTION, AND CERTAIN BILIOUS DISORDERS OFTEN CONJOINED WITH IT. - Second Edition. 8vo. cloth, 6_s._ - - - MR. H. T. CHAPMAN, F.R.C.S. - - I. - - THE TREATMENT OF OBSTINATE ULCERS AND CUTANEOUS ERUPTIONS OF THE LEG - WITHOUT CONFINEMENT. Second Edition. Post 8vo. cloth, 3_s._ 6_d._ - - II. - - VARICOSE VEINS: their Nature, Consequences, and Treatment, Palliative - and Curative. Post 8vo. cloth, 3_s._ 6_d._ - - - MR. J. PATERSON CLARK, M.A. - - THE ODONTALGIST; OR, HOW TO PRESERVE THE TEETH, CURE TOOTHACHE, AND - REGULATE DENTITION FROM INFANCY TO AGE. With plates. Post 8vo. - cloth, 5_s._ - - - DR. CONOLLY. - - THE CONSTRUCTION AND GOVERNMENT OF LUNATIC ASYLUMS AND HOSPITALS FOR - THE INSANE. With Plans. Post 8vo. cloth, 6_s._ - - - LEWIS CORNARO. - - SURE METHODS OF ATTAINING A LONG AND HEALTHFUL LIFE. Thirty-eighth - Edition. 18mo., 1_s._ - - - MR. COOLEY. - - COMPREHENSIVE SUPPLEMENT TO THE PHARMACOPŒIAS. - - THE CYCLOPÆDIA OE PRACTICAL RECEIPTS, AND COLLATERAL INFORMATION IN - THE ARTS, PROFESSIONS, MANUFACTURES, AND TRADES, INCLUDING MEDICINE, - PHARMACY, AND DOMESTIC ECONOMY; designed as a Compendious Book of - Reference for the Manufacturer, Tradesman, Amateur, and Heads of - Families. Third and greatly enlarged Edition, 8vo. cloth, 26_s._ - - - MR. BRANSBY B. COOPER, F.R.S. - - LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. 8vo. cloth, 21_s._ - - - MR. W. WHITE COOPER. - - ON NEAR SIGHT, AGED SIGHT, IMPAIRED VISION, AND THE MEANS OF ASSISTING - SIGHT. With 31 Illustrations on Wood. Second Edition. Fcap. 8vo. - cloth, 7_s._ 6_d._ - - - MR. COOPER. - - A DICTIONARY OF PRACTICAL SURGERY; comprehending all the most - interesting Improvements, from the Earliest Times down to the - Present Period. Seventh Edition. One very thick volume, 8vo., 1_l._ - 10_s._ - - - MR. HOLMES COOTE, F.R.C.S. - - A REPORT ON SOME IMPORTANT POINTS IN THE TREATMENT OF SYPHILIS. 8vo. - cloth, 5_s._ - - - SIR ASTLEY COOPER, BART., F.R.S. - - ON THE STRUCTURE AND DISEASES OF THE TESTIS. Illustrated with 24 - highly finished Coloured Plates. Second Edition. Royal 4to. _Reduced - from_ £3. 3_s._ _to_ £1. 10_s._ - - - DR. COTTLE. - - A MANUAL OF HUMAN PHYSIOLOGY FOR STUDENTS; being a Condensation of the - Subject, a Conservation of the Matter, and a Record of Facts and - Principles up to the present Day. Fcap. 8vo., 5_s._ - - - DR. COTTON. - - I. - - ON CONSUMPTION: Its Nature, Symptoms, and Treatment. To which Essay - was awarded the Fothergillian Gold Medal of the Medical Society of - London. Second Edition. 8vo. cloth, 8_s._ - - II. - - PHTHISIS AND THE STETHOSCOPE: a concise Practical Guide to the - Physical Diagnosis of Consumption. Foolscap 8vo. cloth, 3_s._ 6_d._ - - - MR. COULSON. - - I. - - ON DISEASES OF THE BLADDER AND PROSTATE GLAND. The Fifth Edition, - revised and enlarged. 8vo. cloth, 10_s._ 6_d._ - - II. - - ON LITHOTRITY AND LITHOTOMY; with Engravings on Wood. 8 vo. cloth, - 8_s._ - - III. - - ON DISEASES OF THE JOINTS. 8vo. _In the Press._ - - - MR. CURLING, F.R.S. - - I. - - OBSERVATIONS ON DISEASES OF THE RECTUM. Second Edition. 8 vo. cloth, - 5_s._ - - II. - - A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMATIC CORD, AND - SCROTUM. Second Edition, with Additions. 8vo. cloth, 14_s._ - - - MR. JOHN DALRYMPLE, F.R.S., F.R.C.S. - - PATHOLOGY OF THE HUMAN EYE. Complete in Nine Fasciculi: imperial 4to., - 20_s._ each; half-bound morocco, gilt tops, 9_l._ 15_s._ - - - DR. DAVEY. - - I. - - THE GANGLIONIC NERVOUS SYSTEM: its Structure, Functions, and Diseases. - 8vo. cloth, 9_s._ - - II. - - ON THE NATURE AND PROXIMATE CAUSE OF INSANITY. Post 8vo. cloth, 3_s._ - - - DR. HERBERT DAVIES. - - ON THE PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNGS AND HEART. Second - Edition. Post 8vo. cloth, 8_s._ - - - MR. DIXON. - - A GUIDE TO THE PRACTICAL STUDY OF DISEASES OF THE EYE. Post 8vo. - cloth, 8_s._ 6_d._ - - - DR. TOOGOOD DOWNING. - - NEURALGIA: its various Forms, Pathology, and Treatment. THE JACKSONIAN - PRIZE ESSAY FOR 1850. 8vo. cloth, 0_s._ 6_d._ - - - DR. DRUITT, F.R.C.S. - - THE SURGEON’S VADE-MECUM; with numerous Engravings on Wood. Seventh - Edition. Foolscap 8vo. cloth 2_s._ 6_d._ - - - MR. DUNN, F.R.C.S. - - AN ESSAY ON PHYSIOLOGICAL PSYCHOLOGY. 8vo. cloth, 4_s._ - - - DR. JOHN C. EGAN. - - SYPHILITIC DISEASES: THEIR PATHOLOGY, DIAGNOSIS, AND TREATMENT: - including Experimental Researches on Inoculation, as a Differential - Agent in Testing the Character of these Affections. 8vo. cloth, - 9_s._ - - - SIR JAMES EYRE, M.D. - - I. - - THE STOMACH AND ITS DIFFICULTIES. Fourth Edition. Fcap. 8vo. cloth, - 2_s._ 6_d._ - - II. - - PRACTICAL REMARKS ON SOME EXHAUSTING DISEASES. Second Edition. Post - 8vo. cloth, 4_s._ 6_d._ - - - DR. FENWICK. - - ON SCROFULA AND CONSUMPTION. Clergyman’s Sore Throat, Catarrh, Croup, - Bronchitis, Asthma. Fcap. 8vo., 2_s._ 6_d._ - - - MR. FERGUSSON, F.R.S. - - A SYSTEM OF PRACTICAL SURGERY; with numerous Illustrations on Wood. - Fourth Edition. Fcap. 8vo. cloth, 2_s._ 6_d._ - - - =SIR JOHN FORBES, M.D., D.C.L.= (OXON.), =F.R.S.= - - NATURE AND ART IN THE CURE OF DISEASE. Second Edition. Post 8vo. - cloth, 6_s._ - - - DR. D. J. T. FRANCIS. - - CHANGE OF CLIMATE; considered as a Remedy in Dyspeptic, Pulmonary, and - other Chronic Affections; with an Account of the most Eligible - Places of Residence for Invalids in Spain, Portugal, Algeria, &c., - at different Seasons of the Year; and an Appendix on the Mineral - Springs of the Pyrenees, Vichy, and Aix les Bains. Post 8vo. cloth, - 8_s._ 6_d._ - - - C. REMIGIUS FRESENIUS. - - ELEMENTARY INSTRUCTION IN CHEMICAL ANALYSIS, AS PRACTISED IN THE - LABORATORY OF GIESSEN. Edited by LLOYD BULLOCK, late Student at - Giessen. - - QUALITATIVE; Fourth Edition. 8vo. cloth, 9_s._ - - QUANTITATIVE. Second Edition. 8vo. cloth, 15_s._ - - - MR. FOWNES, PH.D., F.R.S. - - I. - - A MANUAL OF CHEMISTRY; with numerous Illustrations on Wood. Sixth - Edition. Fcap. 8vo. cloth, 12_s._ 6_d._ - - Edited by H. BENCE JONES, M.D., F.R.S., and A. W. HOFMANN, PH.D., - F.R.S. - - II. - - CHEMISTRY, AS EXEMPLIFYING THE WISDOM AND BENEFICENCE OF GOD. Second - Edition. Fcap. 8vo. cloth, 4_s._ 6_d._ - - III. - - INTRODUCTION TO QUALITATIVE ANALYSIS. Post 8vo. cloth, 2_s._ - - - IV. - - CHEMICAL TABLES. Folio, price 2_s._ 6_d._ - - - DR. FULLER. - - ON RHEUMATISM, RHEUMATIC GOUT, AND SCIATICA: their Pathology, - Symptoms, and Treatment. Second Edition. 8vo. cloth, 12_s._ 6_d._ - - - DR. GAIRDNER. - - ON GOUT; its History, its Causes, and its Cure. Third Edition. Post - 8vo. cloth, 8_s._ 6_d._ - - - MR. GALLOWAY. - - I. - - THE FIRST STEP IN CHEMISTRY. Second Edition. Fcap. 8vo. cloth, 5_s._ - - II. - - A MANUAL OF QUALITATIVE ANALYSIS. Second Edition. Post 8vo. cloth, - 4_s._ 6_d._ - - III. - - CHEMICAL DIAGRAMS. On Four large Sheets, for School and Lecture Rooms. - 5_s._ 6_d._ the Set. - - - DR. GARRETT. - - ON EAST AND NORTH-EAST WINDS; the Nature, Treatment, and Prevention of - their Suffocating Effects. Fcap. 8vo. cloth, 4_s._ 6_d._ - - - MR. ROBERT GARNER, F.L.S. - - EUTHERAPEIA; or, AN EXAMINATION OF THE PRINCIPLES OF MEDICAL SCIENCE, - including Researches on the Nervous System. Illustrated with 9 - Engravings on Copper, and Engravings on Wood. 8vo. cloth, 8_s._ - - - MR. GAY, F.R.C.S.E. - - I. - - FEMORAL RUPTURE: ITS ANATOMY, PATHOLOGY, AND SURGERY. With a New Mode - of Operating. 4to., Plates, 10_s._ 6_d._ - - II. - - A MEMOIR ON INDOLENT ULCERS. Post 8vo. cloth, 3_s._ 6_d._ - - - DR. GRANVILLE, F.R.S. - - ON SUDDEN DEATH. Post 8vo., 2_s._ 6_d._ - - - MR. GRAY, M.R.C.S. - - PRESERVATION OF THE TEETH indispensable to Comfort and Appearance, - Health, and Longevity. 18mo. cloth, 3_s._ - - - MR. GRIFFITHS. - - CHEMISTRY OF THE FOUR SEASONS—Spring, Summer, Autumn, Winter. - Illustrated with Engravings on Wood. Second Edition. Foolscap 8vo. - cloth, 7_s._ 6_d._ - - - DR. GULLY. - - I. - - THE WATER CURE IN CHRONIC DISEASE: an Exposition of the Causes, - Progress, and Terminations of various Chronic Diseases of the - Viscera, Nervous System, and Limbs, and of their Treatment by Water - and other Hygienic Means. Fifth Edition. Foolscap 8vo. sewed, 2_s._ - 6_d._ - - II. - - THE SIMPLE TREATMENT OF DISEASE; deduced from the Methods of - Expectancy and Revulsion. 18mo. cloth, 4_s._ - - - DR. GUY. - - HOOPER’S PHYSICIAN’S VADE-MECUM; OR, MANUAL OF THE PRINCIPLES AND - PRACTICE OF PHYSIC. New Edition, considerably enlarged, and - rewritten. Foolscap 8vo. cloth, 12_s._ 6_d._ - - GUY’S HOSPITAL REPORTS. Third Series. Vols. I. to III., 8vo., 7_s._ - 6_d._ each. - - - DR. HABERSHON. - - OBSERVATIONS ON DISEASES OF THE ALIMENTARY CANAL, ŒSOPHAGUS, STOMACH, - CÆCUM, and INTESTINES. 8vo. cloth, 10_s._ 6_d._ - - - DR. MARSHALL HALL, F.R.S. - - I. - - PRONE AND POSTURAL RESPIRATION IN DROWNING AND OTHER FORMS OF APNŒA OR - SUSPENDED RESPIRATION. Post 8vo. cloth. 5_s._ - - II. - - PRACTICAL OBSERVATIONS AND SUGGESTIONS IN MEDICINE. Post 8vo. cloth, - 8_s._ 6_d._ - - DITTO. =Second Series.= Post 8vo. cloth, 8_s._ 6_d._ - - - DR. C. RADCLYFFE HALL. - - TORQUAY IN ITS MEDICAL ASPECT AS A RESORT FOR PULMONARY INVALIDS. Post - 8vo. cloth, 5_s._ - - - MR. HARDWICH. - - A MANUAL OF PHOTOGRAPHIC CHEMISTRY. Fourth Edition. Foolscap 8vo. - cloth, 6_s._ 6_d._ - - - MR. HARE, M.R.C.S. - - PRACTICAL OBSERVATIONS ON THE PREVENTION, CAUSES, AND TREATMENT OF - CURVATURES OF THE SPINE; with Engravings. Third Edition. 8vo. cloth, - 6_s._ - - - MR. HARRISON, F.R.C.S. - - THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETHRA. 8vo. cloth, - 5_s._ - - - MR. JAMES B. HARRISON, F.R.C.S. - - ON THE CONTAMINATION OF WATER BY THE POISON OF LEAD, and its Effects - on the Human Body. Foolscap 8vo. cloth, 3_s._ 6_d._ - - - DR. HARTWIG. - - I. - - ON SEA BATHING AND SEA AIR. Fcap. 8vo., 2_s._ 6_d._ - - II. - - ON THE PHYSICAL EDUCATION OF CHILDREN. Fcap. 8vo., 2_s._ 6_d._ - - - DR. A. H. HASSALL. - - THE MICROSCOPIC ANATOMY OF THE HUMAN BODY, IN HEALTH AND DISEASE. - Illustrated with Several Hundred Drawings in Colour. Two vols. 8vo. - cloth, £1. 10_s._ - - - MR. ALFRED HAVILAND, M.R.C.S. - - CLIMATE, WEATHER, AND DISEASE; being a Sketch of the Opinions of the - most celebrated Ancient and Modern Writers with regard to the - Influence of Climate and Weather in producing Disease. With Four - coloured Engravings. 8vo. cloth, 7_s._ - - - MR. WILLIAM HAYCOCK, M.R.C.V.S. - - A TREATISE ON THE PRINCIPLES AND PRACTICE OF VETERINARY MEDICINE AND - SURGERY. 8vo. boards, 6_s._ 6_d._ - - - DR. HEADLAND. - - ON THE ACTION OF MEDICINES IN THE SYSTEM. Being the Prize Essay to - which the Medical Society of London awarded the Fothergillian Gold - Medal for 1852. Second Edition. 8vo. cloth, 10_s._ - - - MR. HIGGINBOTTOM, F.R.S., F.R.C.S. - - I. - - AN ESSAY ON THE USE OF THE NITRATE OF SILVER IN THE CURE OF - INFLAMMATION, WOUNDS, AND ULCERS. Second Edition. Price 5_s._ - - II. - - ADDITIONAL OBSERVATIONS ON THE NITRATE OF SILVER; with full Directions - for its Use as a Therapeutic Agent. 8vo., 2_s._ 6_d._ - - - MR. JOHN HILTON, F.R.S. - - ON THE DEVELOPMENT AND DESIGN OF CERTAIN PORTIONS OF THE CRANIUM. - Illustrated with Plates in Lithography. 8vo. cloth, 6_s._ - - - DR. HINDS. - - THE HARMONIES OF PHYSICAL SCIENCE IN RELATION TO THE HIGHER - SENTIMENTS; with Observations on Medical Studies, and on the Moral - and Scientific Relations of Medical Life. Post 8vo., cloth, 5_s._ - - - DR. DECIMUS HODGSON. - - THE PROSTATE GLAND, AND ITS ENLARGEMENT IN OLD AGE. With 12 Plates. - Royal 8vo., cloth, 6_s._ - - - MR. JABEZ HOGG. - - THE OPHTHALMOSCOPE: an Essay on its value in the Exploration of - Internal Eye Diseases. Cloth, 3_s._ 6_d._ - - - MR. LUTHER HOLDEN, F.R.C.S. - - HUMAN OSTEOLOGY: with Plates, showing the Attachments of the Muscles. - Second Edition. 8vo. cloth, 16_s._ - - - DR. G. CALVERT HOLLAND. - - THE CONSTITUTION OF THE ANIMAL CREATION, expressed in Structural - Appendages, as Hair, Horns, Tusks, and Fat. 8vo. cloth, 10_s._ 6_d._ - - - MR. C. HOLTHOUSE. - - I. - - ON SQUINTING, PARALYTIC AFFECTIONS OF THE EYE, and CERTAIN FORMS OF - IMPAIRED VISION. Fcap. 8vo. cloth, 4_s._ 6_d._ - - II. - - LECTURES ON STRABISMUS, delivered at the Westminster Hospital. 8vo. - cloth, 4_s._ - - - DR. W. CHARLES HOOD. - - SUGGESTIONS FOR THE FUTURE PROVISION OF CRIMINAL LUNATICS. 8vo. cloth, - 5_s._ 6_d._ - - - MR. P. HOOD. - - THE SUCCESSFUL TREATMENT OE SCARLET FEVER; also, OBSERVATIONS ON THE - PATHOLOGY AND TREATMENT OF CROWING INSPIRATIONS OF INFANTS. Post - 8vo. cloth, 5_s._ - - - DR. HOOPER. - - THE MEDICAL DICTIONARY; containing an Explanation of the Terms used in - Medicine and the Collateral Sciences. Eighth Edition. Edited by - KLEIN GRANT, M.D. 8vo. cloth, 30_s._ - - - MR. JOHN HORSLEY. - - A CATECHISM OF CHEMICAL PHILOSOPHY; being a Familiar Exposition of the - Principles of Chemistry and Physics. With Engravings on Wood. - Designed for the Use of Schools and Private Teachers. Post 8vo. - cloth, 6_s._ 6_d._ - - - DR. HUFELAND. - - THE ART OF PROLONGING LIFE. A New Edition. Edited by ERASMUS WILSON, - F.R.S. Foolscap 8vo., 2_s._ 6_d._ - - - MR. W. CURTIS HUGMAN, F.R.C.S. - - ON HIP-JOINT DISEASE; with reference especially to Treatment by - Mechanical Means for the Relief of Contraction and Deformity of the - Affected Limb. 8vo. cloth, 3_s._ 6_d._ - - - DR. HENRY HUNT. - - ON HEARTBURN AND INDIGESTION. 8vo. cloth, 5_s._ - - - MR. T. HUNT. - - DISEASES OF THE SKIN: a Guide for their Treatment and Prevention. - Second Edition. Fcap. 8vo., 2_s._ 6_d._ - - - DR. INMAN. - - THE PHENOMENA OF SPINAL IRRITATION AND OTHER FUNCTIONAL DISEASES OF - THE NERVOUS SYSTEM EXPLAINED, and a Rational Plan of Treatment - deduced. With Plates. 8vo. cloth, 6_s._ - - - DR. ARTHUR JACOB, F.R.C.S. - - A TREATISE ON THE INFLAMMATIONS OF THE EYE-BALL. Foolscap 8vo. cloth, - 5_s._ - - - DR. JAMES JAGO, A.B., CANTAB.; M.B., OXON. - - OCULAR SPECTRES AND STRUCTURES AS MUTUAL EXPONENTS. Illustrated with - Engravings on Wood. 8vo. cloth, 5_s._ - - - DR. HANDFIELD JONES, F.R.S. & DR. EDWARD H. SIEVEKING. - - A MANUAL OF PATHOLOGICAL ANATOMY. Illustrated with numerous Engravings - on Wood. Foolscap 8vo. cloth, 12_s._ 6_d._ - - - MR. WHARTON JONES, F.R.S. - - I. - - A MANUAL OF THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND - SURGERY; illustrated with Engravings, plain and coloured. Second - Edition. Foolscap 8vo. cloth, 12_s._ 6_d._ - - II. - - THE WISDOM AND BENEFICENCE OF THE ALMIGHTY, AS DISPLAYED IN THE SENSE - OF VISION; being the Actonian Prize Essay for 1851. With - Illustrations on Steel and Wood. Foolscap 8vo. cloth, 4_s._ 6_d._ - - III. - - DEFECTS OF SIGHT: their Nature, Causes, Prevention, and General - Management. Fcap. 8vo. 2_s._ 6_d._ - - - IV. - - A CATECHISM OF THE MEDICINE AND SURGERY OF THE EYE AND EAR. For the - Clinical Use of Hospital Students. Fcap. 8vo. 2_s._ 6_d._ - - - V. - - A CATECHISM OF THE PHYSIOLOGY AND PHILOSOPHY OF BODY, SENSE, AND MIND. - For Use in Schools and Colleges. Fcap. 8vo., 2_s._ 6_d._ - - - DR. BENCE JONES, F.R.S. - - I. - - MULDER ON WINE. Foolscap 8vo. cloth, 6_s._ - - II. - - ON ANIMAL CHEMISTRY, in its relation to STOMACH and RENAL DISEASES. - 8vo. cloth, 6_s._ - - - MR. JUDD. - - A PRACTICAL TREATISE ON URETHRITIS AND SYPHILIS: including - Observations on the Power of the Menstruous Fluid, and of the - Discharge from Leucorrhœa and Sores to produce Urethritis: with a - variety of Examples, Experiments, Remedies, and Cures. 8vo. cloth, - £1. 5_s._ - - - MR. KNAGGS. - - UNSOUNDNESS OF MIND CONSIDERED IN RELATION TO THE QUESTION OF - RESPONSIBILITY IN CRIMINAL CASES. 8vo. cloth, 4_s._ 6_d._ - - - DR. LAENNEC. - - A MANUAL OF AUSCULTATION AND PERCUSSION. Translated and Edited by J. - B. Sharpe, M.R.C.S. 3_s._ - - - DR. HUNTER LANE, F.L.S. - - A COMPENDIUM OF MATERIA MEDICA AND PHARMACY; adapted to the London - Pharmacopœia, 1851, embodying all the new French, American, and - Indian Medicines, and also comprising a Summary of Practical - Toxicology. Second Edition. 24mo. cloth, 5_s._ 6_d._ - - - DR. LANE, M.A. - - HYDROPATHY; OR, THE NATURAL SYSTEM OF MEDICAL TREATMENT. An - Explanatory Essay. Post 8vo. cloth, 3_s._ 6_d._ - - - MR. LAURENCE, M.B., F.R.C.S. - - THE DIAGNOSIS OF SURGICAL CANCER. The Liston Prize Essay for 1854. - Second Edition. Plates, 8vo. cloth, 7_s._ 6_d._ - - - MR. LAWRENCE, F.R.S. - - A TREATISE ON RUPTURES. The Fifth Edition, considerably enlarged. 8vo. - cloth, 6_s._ - - - DR. EDWIN LEE. - - I. - - THE EFFECT OF CLIMATE ON TUBERCULOUS DISEASE, with Notices of the - chief Foreign Places of Winter Resort. Small 8vo. cloth, 6_s._ - - II. - - THE WATERING PLACES OF ENGLAND, CONSIDERED with Reference to their - Medical Topography. Third Edition. Foolscap 8vo. cloth, 5_s._ 6_d._ - - III. - - THE BATHS OF GERMANY, FRANCE, & SWITZERLAND. Third Edition. Post 8vo. - cloth, 8_s._ 6_d._ - - - IV. - - THE BATHS OF RHENISH GERMANY. Post 8vo. cloth, 4_s._ - - - MR. HENRY LEE, F.R.C.S. - - PATHOLOGICAL AND SURGICAL OBSERVATIONS; including an Essay on the - Surgical Treatment of Hemorrhoidal Tumors. 8vo. cloth, 7_s._ 6_d._ - - - DR. ROBERT LEE, F.R.S. - - I. - - A TREATISE ON THE SPECULUM; with Three Hundred Cases. 8vo. cloth, - 4_s._ 6_d._ - - II. - - CLINICAL REPORTS OF OVARIAN AND UTERINE DISEASES, with Commentaries. - Foolscap 8vo. cloth, 6_s._ 6_d._ - - III. - - CLINICAL MIDWIFERY: comprising the Histories of 545 Cases of - Difficult, Preternatural, and Complicated Labour, with Commentaries. - Second Edition. Foolscap 8vo. cloth, 5_s._ - - - IV. - - PRACTICAL OBSERVATIONS ON DISEASES OF THE UTERUS. With coloured - Plates. Two Parts. Imperial 4to., 7_s._ 6_d._ each Part. - - - MR. LISTON, F.R.S. - - PRACTICAL SURGERY. Fourth Edition. 8vo. cloth, 2_s._ - - - MR. H. W. LOBB, L.S.A., M.R.C.S.E. - - ON SOME OF THE MORE OBSCURE FORMS OF NERVOUS AFFECTIONS, THEIR - PATHOLOGY AND TREATMENT. With an Introduction on the Physiology of - Digestion and Assimilation, and the Generation and Distribution of - Nerve Force. Based upon Original Microscopical Observations. With - Engravings. 8vo. cloth, 0_s._ 6_d._ - - - LONDON MEDICAL SOCIETY OF OBSERVATION. - - WHAT TO OBSERVE AT THE BED-SIDE, AND AFTER DEATH. Published by - Authority. Second Edition. Foolscap 8vo. cloth, 4_s._ 6_d._ - - - M. LUGOL. - - ON SCROFULOUS DISEASES. Translated from the French, with Additions by - W. H. RANKING, M.D., Physician to the Suffolk General Hospital. 8vo. - cloth, 0_s._ 6_d._ - - - DR. GEORGE H. B. MACLEOD, F.R.C.S. (EDIN.) - - NOTES ON THE SURGERY OF THE CRIMEAN WAR; with REMARKS on GUN-SHOT - WOUNDS. 8vo. cloth, 0_s._ 6_d._ - - - MR. JOSEPH MACLISE, F.R.C.S. - - I. - - SURGICAL ANATOMY. A Series of Dissections, illustrating the Principal - Regions of the Human Body. - - The Second Edition, complete in XIII. Fasciculi. Imperial folio, 5_s._ - each; bound in cloth, £3. 2_s._; or bound in morocco, £4. 4_s._ - - II. - - ON DISLOCATIONS AND FRACTURES. This Work will be Uniform with the - Author’s “Surgical Anatomy;” each Fasciculus will contain Four - beautifully executed Lithographic Drawings, and be completed in Nine - Numbers. Fasciculus I., imperial folio, 5_s._ - - - DR. MAYNE. - - AN EXPOSITORY LEXICON OF THE TERMS, ANCIENT AND MODERN, IN MEDICAL AND - GENERAL SCIENCE, including a complete MEDICAL AND MEDICO-LEGAL - VOCABULARY, and presenting the correct Pronunciation, Derivation, - Definition, and Explanation of the Names, Analogues, Synonymes, and - Phrases (in English, Latin, Greek, French, and German,) employed in - Science and connected with Medicine. Parts I. to VII., price 5_s._ - each. - - - DR. WM. H. MADDEN. - - THOUGHTS ON PULMONARY CONSUMPTION; with an Appendix on the Climate of - Torquay. Post 8vo. cloth, 5_s._ - - - DR. MARCET. - - ON THE COMPOSITION OF FOOD, AND HOW IT IS ADULTERATED; with Practical - Directions for its Analysis. 8vo. cloth, 6_s._ 6_d._ - - - DR. MARTIN. - - THE UNDERCLIFF, ISLE OF WIGHT: its Climate, History, and Natural - Productions. Post 8vo. cloth, 0_s._ 6_d._ - - - DR. MARKHAM. - - I. - - DISEASES OF THE HEART: THEIR PATHOLOGY, DIAGNOSIS, AND TREATMENT. - Post. 8vo. cloth, 6_s._ - - II. - - SKODA ON AUSCULTATION AND PERCUSSION. Post 8vo. cloth, 6_s._ - - - MR. J. RANALD MARTIN, F.R.S. - - THE INFLUENCE OF TROPICAL CLIMATES ON EUROPEAN CONSTITUTIONS. - Originally by the late JAMES JOHNSON, M.D., and now entirely - rewritten; including Practical Observations on the Diseases of - European Invalids on their Return from Tropical Climates. Seventh - Edition. 8vo. cloth, 6_s._ - - - DR. MASSY. - - ON THE EXAMINATION OF RECRUITS; intended for the Use of Young Medical - Officers on Entering the Army. 8vo. cloth, 5_s._ - - - DR. MILLINGEN. - - ON THE TREATMENT AND MANAGEMENT OF THE INSANE; with Considerations on - Public and Private Lunatic Asylums. 18mo. cloth, 4_s._ 6_d._ - - - MR. JOHN L. MILTON, M.R.C.S. - - PRACTICAL OBSERVATIONS ON A NEW WAY OF TREATING GONORRHŒA. With some - Remarks on the Cure of Inveterate Cases. 8vo. cloth, 5_s._ - - - DR. MONRO. - - I. - - REMARKS ON INSANITY: its Nature and Treatment. 8vo. cloth, 6_s._ - - II. - - REFORM IN PRIVATE LUNATIC ASYLUMS. 8vo. cloth, 4_s._ - - - DR. NOBLE. - - I. - - ELEMENTS OF PSYCHOLOGICAL MEDICINE: AN INTRODUCTION TO THE PRACTICAL - STUDY OF INSANITY. Second Edition. 8vo. cloth, 0_s._ - - II. - - THE HUMAN MIND IN ITS RELATIONS WITH THE BRAIN AND NERVOUS SYSTEM. - Post 8vo. cloth, 4_s._ 6_d._ - - - MR. J. NOTTINGHAM, F.R.C.S. - - DISEASES OF THE EAR. Illustrated by Clinical Observations. 8vo. cloth, - 2_s._ - - - MR. NOURSE, M.R.C.S. - - TABLES FOR STUDENTS. Price One Shilling. - - 1. Divisions and Classes of the Animal Kingdom. - - 2. Classes and Orders of the Vertebrate Sub-kingdom. - - 3. Classes of the Vegetable Kingdom, according to the Natural and - Artificial Systems. - - 4. Table of the Elements, with their Chemical Equivalents and - Symbols. - - - MR. NUNNELEY. - - A TREATISE ON THE NATURE, CAUSES, AND TREATMENT OF ERYSIPELAS. 8vo. - cloth, 10_s._ 6_d._ - - - =Oxford Editions.=—Edited by DR. GREENHILL. - - I. ADDRESS TO A MEDICAL STUDENT. Second Edition, 18mo. cloth, - 2_s._ 6_d._ - - II. PRAYERS FOR THE USE OF THE MEDICAL PROFESSION. Second - Edition, cloth, 1_s._ 6_d._ - - III. LIFE OF SIR JAMES STONHOUSE, BART., M.D. Cloth, 4_s._ 6_d._ - - IV. ANECDOTA SYDENHAMIANA. Second Edition, 18mo. 2_s._ - - V. LIFE OF THOMAS HARRISON BURDER, M.D. 18mo. cloth, 4_s._ - - VI. BURDER’S LETTERS FROM A SENIOR TO A JUNIOR PHYSICIAN, ON - PROMOTING THE RELIGIOUS WELFARE OF HIS PATIENTS. 18mo. sewed, - 6_d._ - - VII. LIFE OF GEORGE CHEYNE, M.D. 18mo. sewed, 2_s._ 6_d._ - - VIII. HUFELAND ON THE RELATIONS OF THE PHYSICIAN TO THE sick, to - the public, and to his colleagues. 18mo. sewed, 9_d._ - - IX. GISBORNE ON THE DUTIES OF PHYSICIANS. 18mo. sewed, 1_s._ - - X. LIFE OF CHARLES BRANDON TRYE. 18mo. sewed, 1_s._ - - XI. PERCIVAL’S MEDICAL ETHICS. Third Edition, 18mo. cloth, 3_s._ - - XII. CODE OF ETHICS OF THE AMERICAN MEDICAL ASSOCIATION. 8_d._ - - XIII. WARE ON THE DUTIES AND QUALIFICATIONS OF PHYSICIANS. 8_d._ - - XIV. MAURICE ON THE RESPONSIBILITIES OF MEDICAL STUDENTS. 9_d._ - - XV. FRASER’S QUERIES IN MEDICAL ETHICS. 9_d._ - - - DR. ODLING. - - A COURSE OF PRACTICAL CHEMISTRY, FOR THE USE OF MEDICAL STUDENTS. - Arranged with express reference to the Three Months’ Summer Course. - Post 8vo. cloth, 4_s._ 6_d._ - - - .ni - - TRANSACTIONS OF THE ODONTOLOGICAL SOCIETY OF LONDON. With Plates. Vol. - I., 8vo. cloth, 8_s._ 6_d._ - - - MR. PAGET. - - A DESCRIPTIVE CATALOGUE OF THE ANATOMICAL MUSEUM OF ST. BARTHOLOMEW’S - HOSPITAL. VOL. I. Morbid Anatomy. 8vo. cloth, 5_s._ - - DITTO. Vol. II. Natural and Congenitally Malformed Structures, and - Lists of the Models, Casts, Drawings, and Diagrams. 5_s._ - - - MR. LANGSTON PARKER. - - THE MODERN TREATMENT OF SYPHILITIC DISEASES, both Primary and - Secondary; comprising the Treatment of Constitutional and Confirmed - Syphilis, by a safe and successful Method. Third Edition, 8vo. - cloth, 10_s._ - - - MR. JAMES PART, F.R.C.S. - - THE MEDICAL AND SURGICAL POCKET CASE BOOK, for the Registration of - important Cases in Private Practice, and to assist the Student of - Hospital Practice. Second Edition. 3_s._ 6_d._ - - - DR. THOMAS B. PEACOCK, M.D. - - I. - - ON MALFORMATIONS, ETC. OF THE HUMAN HEART, with Original Cases. With - Eight Plates, 8vo. cloth, 8_s._ - - II. - - ON THE INFLUENZA, OR EPIDEMIC CATARRHAL FEVER OF 1847–8. 8vo. cloth, - 5_s._ 6_d._ - - - DR. PEREIRA, F.R.S. - - SELECTA E PRÆSCRIPTIS. Twelfth Edition. 24mo. cloth, 5_s._ - - - MR. PETTIGREW, F.R.S. - - ON SUPERSTITIONS connected with the History and Practice of Medicine - and Surgery. 8vo. cloth, 7_s._ - - - DR. PICKFORD. - - HYGIENE; or, Health as Depending upon the Conditions of the - Atmosphere, Food and Drinks, Motion and Rest, Sleep and Wakefulness, - Secretions, Excretions, and Retentions, Mental Emotions, Clothing, - Bathing, &c. 8vo. cloth, 9_s._ - - - MR. PIRRIE, F.R.S.E. - - THE PRINCIPLES AND PRACTICE OF SURGERY. With numerous Engravings on - Wood. 8vo. cloth, 1_s._ - - PHARMACOPŒIA COLLEGII REGALIS MEDICORUM LONDINENSIS. 8vo. cloth, - 9_s._; or 24mo. 5_s._ - - IMPRIMATUR. - Hic liber, cui titulus, PHARMACOPŒIA COLLEGII REGALIS MEDICORUM - LONDINENSIS. Datum ex Ædibus Collegii in comitiis censoriis, - Novembris Mensis 14^{to} 1850. - - JOHANNES AYRTON PARIS. _Præses._ - - - PROFESSORS PLATTNER & MUSPRATT. - - THE USE OF THE BLOWPIPE IN THE EXAMINATION OF MINERALS, ORES, AND - OTHER METALLIC COMBINATIONS. Illustrated by numerous Engravings on - Wood. Third Edition. 8vo. cloth, 10_s._ 6_d._ - - - THE PRESCRIBER’S PHARMACOPŒIA; containing all the Medicines in the - London Pharmacopœia, arranged in Classes according to their Action, - with their Composition and Doses. By a Practising Physician. Fourth - Edition. 32mo. cloth, 2_s._ 6_d._; roan tuck (for the pocket), 3_s._ - 6_d._ - - - DR. JOHN ROWLISON PRETTY. - - AIDS DURING LABOUR, including the Administration of Chloroform, the - Management of Placenta and Post-partum Hæmorrhage. Fcap. 8vo. cloth, - 4_s._ 6_d._ - - - MR. LAKE PRICE. - - PHOTOGRAPHIC MANIPULATION: Treating of the Practice of the Art, and - its various appliances to Nature. With Fifty Engravings on Wood. - Post 8 vo. cloth, 6_s._ 6_d._ - - - SIR WM. PYM, K.C.H. - - OBSERVATIONS UPON YELLOW FEVER, with a Review of “A Report upon the - Diseases of the African Coast, by Sir WM. BURNETT and Dr. BRYSON,” - proving its highly Contagious Powers. Post 8vo. 6_s._ - - - DR. RADCLIFFE. - - EPILEPSY, AND OTHER CONVULSIVE AFFECTIONS; their Pathology and - Treatment. Second Edition. Post 8vo. cloth, 7_s._ 6_d._ - - - DR. F. H. RAMSBOTHAM. - - THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY. - Illustrated with One Hundred and Twenty Plates on Steel and Wood; - forming one thick handsome volume. Fourth Edition. 8vo. cloth, - 22_s._ - - - DR. RAMSBOTHAM. - - PRACTICAL OBSERVATIONS ON MIDWIFERY, with a Selection of Cases. Second - Edition. 8vo. cloth, 12_s._ - - - DR. DU BOIS REYMOND. - - ANIMAL ELECTRICITY; Edited by H. BENCE JONES, M.D., F.R.S. With Fifty - Engravings on Wood. Foolscap 8vo. cloth, 6_s._ - - - DR. REYNOLDS. - - THE DIAGNOSIS OF DISEASES OF THE BRAIN, SPINAL CORD, AND THEIR - APPENDAGES. 8vo. cloth, 8_s._ - - - DR. B. W. RICHARDSON. - - I. - - ON THE CAUSE OF THE COAGULATION OF THE BLOOD. Being the ASTLEY COOPER - PRIZE ESSAY for 1856. With a Practical Appendix. 8vo. cloth, 16_s._ - - II. - - THE HYGIENIC TREATMENT OF PULMONARY CONSUMPTION. 8vo. cloth, 5_s._ - 6_d._ - - - DR. W. H. ROBERTSON. - - I. - - THE NATURE AND TREATMENT OF GOUT. 8vo. cloth, 10_s._ 6_d._ - - II. - - A TREATISE ON DIET AND REGIMEN. Fourth Edition. 2 vols. post 8vo. - cloth, 12_s._ - - - MR. ROBERTON. - - ON THE PHYSIOLOGY AND DISEASES OF WOMEN, AND ON PRACTICAL MIDWIFERY. - 8vo. cloth, 12_s._ - - - MR. WILLIAM ROBERTS. - - AN ESSAY ON WASTING PALSY; being a Systematic Treatise on the Disease - hitherto described as ATROPHIE MUSCULAIRE PROGRESSIVE. With Four - Plates. 8vo. cloth, 7_s._ 6_d._ - - - DR. ROTH. - - ON MOVEMENTS. An Exposition of their Principles and Practice, for the - Correction of the Tendencies to Disease in Infancy, Childhood, and - Youth, and for the Cure of many Morbid Affections in Adults. - Illustrated with numerous Engravings on Wood. 8vo. cloth, 10_s._ - - - DR. ROWE, F.S.A. - - I. - - ON SOME OF THE MORE IMPORTANT DISEASES OF WOMEN and CHILDREN. Second - Edition. Fcap. 8vo. cloth, 4_s._ 6_d._ - - II. - - NERVOUS DISEASES, LIVER AND STOMACH COMPLAINTS, LOW SPIRITS, - INDIGESTION, GOUT, ASTHMA, AND DISORDERS PRODUCED BY TROPICAL - CLIMATES. With Cases. Fifteenth Edition. Fcap. 8vo. 2_s._ 6_d._ - - - DR. ROYLE, F.R.S. - - A MANUAL OF MATERIA MEDICA AND THERAPEUTICS. With numerous Engravings - on Wood. Third Edition. Fcap. 8vo. cloth, 12_s._ 6_d._ - - - MR. RUMSEY, F.R.C.S. - - ESSAYS ON STATE MEDICINE. 8vo. cloth, 10_s._ 6_d._ - - - MR. SAVORY. - - A COMPENDIUM OF DOMESTIC MEDICINE, AND COMPANION TO THE MEDICINE - CHEST; comprising Plain Directions for the Employment of Medicines, - with their Properties and Doses, and Brief Descriptions of the - Symptoms and Treatment of Diseases, and of the Disorders incidental - to Infants and Children, with a Selection of the most efficacious - Prescriptions. Intended as a Source of Easy Reference for Clergymen, - and for Families residing at a Distance from Professional - Assistance. Fifth Edition. 12mo. cloth, 5_s._ - - - DR. SCHACHT. - - THE MICROSCOPE, AND ITS APPLICATION TO VEGETABLE ANATOMY AND - PHYSIOLOGY. Edited by FREDERICK CURREY, M.A. Fcap. 8vo. cloth, 6_s._ - - - DR. SEMPLE. - - ON COUGH: its Causes, Varieties, and Treatment. With some practical - Remarks on the Use of the Stethoscope as an aid to Diagnosis. Post - 8vo. cloth, 4_s._ 6_d._ - - - MR. SHAW, M.R.C.S. - - THE MEDICAL REMEMBRANCER; OR, BOOK OF EMERGENCIES: in which are - concisely pointed out the Immediate Remedies to be adopted in the - First Moments of Danger from Poisoning, Drowning, Apoplexy, Burns, - and other Accidents; with the Tests for the Principal Poisons, and - other useful Information. Fourth Edition. Edited, with Additions, by - JONATHAN HUTCHINSON, M.R.C.S. 32mo. cloth, 2_s._ 6_d._ - - - DR. SIBSON, F.R.S. - - MEDICAL ANATOMY. With coloured Plates. Imperial folio. Fasciculi I. to - V. 5_s._ each. - - - DR. E. H. SIEVEKING. - - ON EPILEPSY AND EPILEPTIFORM SEIZURES: their Causes, Pathology, and - Treatment. Post 8vo. cloth, 7_s._ 6_d._ - - - MR. SKEY, F.R.S. - - OPERATIVE SURGERY: with Illustrations engraved on Wood. 8vo. cloth, - 12_s._ 6_d._ - - - DR. SMELLIE. - - OBSTETRIC PLATES: being a Selection from the more Important and - Practical Illustrations contained in the Original Work. With - Anatomical and Practical Directions. 8vo. cloth, 5_s._ - - - MR. HENRY SMITH, F.R.C.S. - - ON STRICTURE OF THE URETHRA. 8vo. cloth, 7_s._ 6_d._ - - - DR. W. TYLER SMITH. - - I. - - A MANUAL OF OBSTETRICS, THEORETICAL AND PRACTICAL. Illustrated with - 186 Engravings. Fcap. 8vo. cloth, 12_s._ 6_d._ - - II. - - THE PATHOLOGY AND TREATMENT OF LEUCORRHŒA. With Engravings on Wood. - 8vo. cloth, 7_s._ - - III. - - THE PERIODOSCOPE, a new Instrument for determining the Date of Labour, - and other Obstetric Calculations, with an Explanation of its Uses, - and an Essay on the Periodic Phenomena attending Pregnancy and - Parturition. 8vo. cloth, 4_s._ - - - DR. SNOW. - - ON THE MODE OF COMMUNICATION OF CHOLERA. Second Edition, much - Enlarged, and Illustrated with Maps. 8vo. cloth, 7_s._ - - - DR. STANHOPE TEMPLEMAN SPEER. - - PATHOLOGICAL CHEMISTRY, IN ITS APPLICATION TO THE PRACTICE OF - MEDICINE. Translated from the French of MM. BECQUEREL and RODIER. - 8vo. cloth, 12_s._ - - - DR. SPURGIN. - - LECTURES ON MATERIA MEDICA, AND ITS RELATIONS TO THE ANIMAL ECONOMY. - Delivered before the Royal College of Physicians. 8vo. cloth, 5_s._ - 6_d._ - - - MR. SQUIRE, F.L.S. - - THE PHARMACOPŒIA, (LONDON, EDINBURGH, AND DUBLIN,) arranged in a - convenient TABULAR FORM, both to suit the Prescriber for comparison, - and the Dispenser for compounding the formulæ; with Notes, Tests, - and Tables. 8vo. cloth, 12_s._ - - - DR. SWAYNE. - - OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COMMENCING MIDWIFERY - PRACTICE. With Engravings on Wood. Fcap. 8 vo. cloth, 3_s._ 6_d._ - - - DR. STEGGALL. - - STUDENTS’ BOOKS FOR EXAMINATION. - - I. - - A MEDICAL MANUAL FOR APOTHECARIES’ HALL AND OTHER MEDICAL BOARDS. - Eleventh Edition. 12mo. cloth, 10_s._ - - II. - - A MANUAL FOR THE COLLEGE OF SURGEONS; intended for the Use of - Candidates for Examination and Practitioners. Second Edition. 12mo. - cloth, 10_s._ - - III. - - GREGORY’S CONSPECTUS MEDICINÆ THEORETICÆ. The First Part, containing - the Original Text, with an Ordo Verborum, and Literal Translation. - 12mo. cloth, 10_s._ - - - IV. - - THE FIRST FOUR BOOKS OF CELSUS; containing the Text, Ordo Verborum, - and Translation. Second Edition. 12mo. cloth, 8_s._ - - - V. - - A TEXT-BOOK OF MATERIA-MEDICA AND THERAPEUTICS. 12mo. cloth, 7_s._ - - - VI. - - FIRST LINES FOR CHEMISTS AND DRUGGISTS PREPARING FOR EXAMINATION AT - THE PHARMACEUTICAL SOCIETY. Second Edition. 18mo. cloth, 3_s._ 6_d._ - - - MR. STOWE, M.R.C.S. - - A TOXICOLOGICAL CHART, exhibiting at one view the Symptoms, Treatment, - and Mode of Detecting the various Poisons, Mineral, Vegetable, and - Animal. To which are added, concise Directions for the Treatment of - Suspended Animation. Eleventh Edition. On Sheet, 2_s._; mounted on - Roller, 5_s._ - - - MR. TAMPLIN, F.R.C.S.E. - - LATERAL CURVATURE OF THE SPINE: its Causes, Nature, and Treatment. - 8vo. cloth, 4_s._ - - - DR. ALFRED S. TAYLOR, F.R.S. - - I. - - A MANUAL OF MEDICAL JURISPRUDENCE. Sixth Edition. Fcap. 8vo. cloth, - 12_s._ 6_d._ - - II. - - ON POISONS, in relation to MEDICAL JURISPRUDENCE AND MEDICINE. Fcap. - 8vo. cloth, 12_s._ 6_d._ - - - DR. THEOPHILUS THOMPSON, F.R.S. - - I. - - CLINICAL LECTURES ON PULMONARY CONSUMPTION. With Plates. 8vo. cloth, - 7_s._ 6_d._ - - II. - - LETTSOMIAN LECTURES ON PULMONARY CONSUMPTION; with Remarks on - Microscopical Indications, and on Cocoa-nut Oil. Post 8vo., 2_s._ - 6_d._ - - - DR. THOMAS. - - THE MODERN PRACTICE OF PHYSIC; exhibiting the Symptoms, Causes, Morbid - Appearances, and Treatment of the Diseases of all Climates. Eleventh - Edition. Revised by ALGERNON FRAMPTON, M.D. 2 vols. 8vo. cloth, - 28_s._ - - - HENRY THOMPSON, M.B. LOND., F.R.C.S. - - STRICTURE OF THE URETHRA; its Pathology and Treatment. The last - Jacksonian Treatise of the Royal College of Surgeons. With Plates. - 8vo. cloth, 10_s._ - - - DR. TILT. - - I. - - ON DISEASES OF WOMEN AND OVARIAN INFLAMMATION IN RELATION TO MORBID - MENSTRUATION, STERILITY, PELVIC TUMOURS, AND AFFECTIONS OF THE WOMB. - Second Edition. 8vo. cloth, 9_s._ - - II. - - THE CHANGE OF LIFE IN HEALTH AND DISEASE: a Practical Treatise on the - Nervous and other Affections incidental to Women at the Decline of - Life. Second Edition. 8vo. cloth, 6_s._ - - - DR. ROBERT B. TODD, F.R.S. - - I. - - CLINICAL LECTURES ON PARALYSIS, DISEASES OF THE BRAIN, and other - AFFECTIONS of the NERVOUS SYSTEM. Second Edition. Foolscap 8vo. - cloth, 6_s._ - - II. - - CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY ORGANS, AND ON - DROPSIES. Fcap. 8vo. cloth, 6_s._ - - - MR. JOSEPH TOYNBEE, F.R.S. - - A DESCRIPTIVE CATALOGUE OF PREPARATIONS ILLUSTRATIVE OF THE DISEASES - OF THE EAR, IN HIS MUSEUM. 8vo. cloth, 5_s._ - - - MR. SAMUEL TUKE. - - - .ni - - DR. JACOBI ON THE CONSTRUCTION AND MANAGEMENT OF HOSPITALS FOR THE - INSANE. Translated from the German. With Introductory Observations - by the Editor. With Plates. 8vo. cloth, 9_s._ - - - DR. TURNBULL. - - A PRACTICAL TREATISE ON DISORDERS OF THE STOMACH with FERMENTATION; - and on the Causes and Treatment of Indigestion, &c. 8vo. cloth, - 6_s._ - - - DR. UNDERWOOD. - - TREATISE ON THE DISEASES OF CHILDREN. Tenth Edition, with Additions - and Corrections by HENRY DAVIES, M.D. 8vo. cloth, 15_s._ - - VESTIGES OF THE NATURAL HISTORY OF CREATION. Tenth Edition. - Illustrated with 100 Engravings on Wood. 8vo. cloth, 12_s._ 6_d._ - - - BY THE SAME AUTHOR. - - EXPLANATIONS: A SEQUEL TO “VESTIGES.” - - Second Edition. Post 8vo. cloth, 5_s._ - - - DR. UNGER. - - BOTANICAL LETTERS. Translated by Dr. B. PAUL. Numerous Woodcuts. Post - 8vo., 5_s._ - - - DR. VAN OVEN. - - ON THE DECLINE OF LIFE IN HEALTH AND DISEASE; being an Attempt to - Investigate the Causes of LONGEVITY, and the Best Means of Attaining - a Healthful Old Age. 8vo. cloth, 10_s._ 6_d._ - - - MR. WADE, F.R.C.S. - - STRICTURE OF THE URETHRA; its Complications and Effects. With - Practical Observations on its Causes, Symptoms, and Treatment; and - on a Safe and Efficient Mode of Treating its more Intractable Forms. - 8vo. cloth, 5_s._ - - - DR. WALLER. - - ELEMENTS OF PRACTICAL MIDWIFERY; or, Companion to the Lying-in Room. - Fourth Edition, with Plates. Fcap. cloth, 4_s._ 6_d._ - - - MR. HAYNES WALTON, F.R.C.S. - - OPERATIVE OPHTHALMIC SURGERY. With Engravings on Wood. 8vo. cloth, - 18_s._ - - - DR. WARDROP. - - ON DISEASES OF THE HEART. 8vo. cloth, 12_s._ - - - DR. EBEN. WATSON, A.M. - - ON THE TOPICAL MEDICATION OF THE LARYNX IN CERTAIN DISEASES OF THE - RESPIRATORY AND VOCAL ORGANS. 8vo. cloth, 5_s._ - - - DR. WEBER. - - A CLINICAL HAND-BOOK OF AUSCULTATION AND PERCUSSION. Translated by - JOHN COCKLE, M.D. 5_s._ - - - DR. WEGG. - - OBSERVATIONS RELATING TO THE SCIENCE AND ART OF MEDICINE. 8vo. cloth, - 8_s._ - - - DR. WEST. - - LECTURES ON THE DISEASES OF WOMEN. 8vo. cloth, 10_s._ 6_d._ - - - MR. T. SPENCER WELLS, F.R.C.S. - - PRACTICAL OBSERVATIONS ON GOUT AND ITS COMPLICATIONS, and on the - Treatment of Joints Stiffened by Gouty Deposits. Foolscap 8vo. - cloth, 5_s._ - - - MR. WHEELER. - - HAND-BOOK OF ANATOMY FOR STUDENTS OF THE FINE ARTS. New Edition, with - Engravings on Wood. Fcap. 8vo., 2_s._ 6_d._ - - - DR. WHITEHEAD, F.R.C.S. - - I. - - ON THE TRANSMISSION FROM PARENT TO OFFSPRING OF SOME FORMS OF DISEASE, - AND OF MORBID TAINTS AND TENDENCIES. Second Edition. 8vo. cloth, - 10_s._ 6_d._ - - II. - - THE CAUSES AND TREATMENT OF ABORTION AND STERILITY: being the result - of an extended Practical Inquiry into the Physiological and Morbid - Conditions of the Uterus, with reference especially to Leucorrhœal - Affections, and the Diseases of Menstruation. 8vo. cloth, 12_s._ - - - DR. WILLIAMS, F.R.S. - - PRINCIPLES OF MEDICINE: An Elementary View of the Causes, Nature, - Treatment, Diagnosis, and Prognosis, of Disease. With brief Remarks - on Hygienics, or the Preservation of Health. The Third Edition. 8vo. - cloth, 15_s._ - - - DR. JOSEPH WILLIAMS. - - INSANITY: its Causes, Prevention, and Cure; including Apoplexy, - Epilepsy, and Congestion of the Brain. Second Edition. Post 8vo. - cloth, 10_s._ 6_d._ - - - DR. J. HUME WILLIAMS. - - UNSOUNDNESS OF MIND, IN ITS MEDICAL AND LEGAL CONSIDERATIONS. 8vo. - cloth, 7_s._ 6_d._ - - - DR. HENRY Q. WRIGHT. - - HEADACHES; their Causes and their Cure. Second Edition. Fcap. 8vo. - 2_s._ 6_d._ - - - MR. ERASMUS WILSON, F.R.S. - - I. - - THE ANATOMIST’S VADE-MECUM: A SYSTEM OF HUMAN ANATOMY. With numerous - Illustrations on Wood. Seventh Edition. Foolscap 8vo. cloth, 12_s._ - 6_d._ - - II. - - DISEASES OF THE SKIN: A Practical and Theoretical Treatise on the - DIAGNOSIS, PATHOLOGY, and TREATMENT OF CUTANEOUS DISEASES. Fourth - Edition. 8vo. cloth, 16_s._ - - THE SAME WORK; illustrated with finely executed Engravings on Steel, - accurately coloured. 8vo. cloth, 34_s._ - - III. - - HEALTHY SKIN: A Treatise on the Management of the Skin and Hair in - relation to Health. Fifth Edition. Foolscap 8vo. 2_s._ 6_d._ - - - IV. - - PORTRAITS OF DISEASES OF THE SKIN. Folio. Fasciculi I. to XII., - completing the Work. 20_s._ each. - - - V. - - ON SYPHILIS, CONSTITUTIONAL AND HEREDITARY; AND ON SYPHILITIC - ERUPTIONS. With Four Coloured Plates. 8vo. cloth, 16_s._ - - - VI. - - A THREE WEEKS’ SCAMPER THROUGH THE SPAS OF GERMANY AND BELGIUM, with - an Appendix on the Nature and Uses of Mineral Waters. Post 8vo. - cloth, 6_s._ 6_d._ - - - DR. FORBES WINSLOW, D.C.L. OXON. - - I. - - LETTSOMIAN LECTURES ON INSANITY. 8vo. cloth, 5_s._ - - II. - - A SYNOPSIS OF THE LAW OF LUNACY; as far as it relates to the - Organization and Management of Private Asylums for the Care and - Treatment of the Insane. In the form of a Chart, varnished, mounted - on canvas and rollers, price 6_s._ - - - DR. G. C. WITTSTEIN. - - PRACTICAL PHARMACEUTICAL CHEMISTRY: An Explanation of Chemical and - Pharmaceutical Processes, with the Methods of Testing the Purity of - the Preparations, deduced from Original Experiments. Translated from - the Second German Edition, by STEPHEN DARBY. 18mo. cloth, 6_s._ - - - MR. YEARSLEY. - - I. - - DEAFNESS PRACTICALLY ILLUSTRATED; being an Exposition of Original - Views as to the Causes and Treatment of Diseases of the Ear. Fifth - Edition. Foolscap 8vo., 2_s._ 6_d._ - - II. - - ON THE ENLARGED TONSIL AND ELONGATED UVULA, and other Morbid - Conditions of the Throat. Sixth Edition. 8vo. cloth, 5_s._ - - - - - CHURCHILL’S SERIES OF MANUALS. - - -“We here give Mr. Churchill public thanks for the positive benefit -conferred on the Medical Profession, by the series of beautiful and -cheap Manuals which bear his imprint.”—_British and Foreign Medical -Review._ - - - AGGREGATE SALE 91,000 COPIES. - - - DR. BARLOW. - - A MANUAL OF THE PRACTICE OF MEDICINE. - - Fcap. 8vo. cloth, 12_s._ 6_d._ - - - DR. GOLDING BIRD, F.R.S., and CHARLES BROOKE, M.B. Cantab, F.R.S. - - ELEMENTS OF NATURAL PHILOSOPHY; - - Being an Experimental Introduction to the Study of the Physical - Sciences. With numerous Illustrations on Wood. Fourth Edition. Fcap. - 8vo. cloth, 12_s._ 6_d._ - - - DR. CARPENTER, F.R.S. - - A MANUAL OF PHYSIOLOGY. - - With numerous Illustrations on Steel and Wood. Third Edition. Fcap. 8vo. - cloth, 12_s._ 6_d._ - - BY THE SAME AUTHOR. - - THE MICROSCOPE AND ITS REVELATIONS. - - With numerous Engravings on Wood. Second Edition. Fcap. 8vo. cloth, - 12_s._ 6_d._ - - - MR. FERGUSSON, F.R.S.E. - - A SYSTEM OF PRACTICAL SURGERY. - - With numerous Illustrations on Wood. Fourth Edition. Fcap. 8vo. cloth, - 12_s._ 6_d._ - - - MR. FOWNES, PH.D., F.R.S. - - A MANUAL OF CHEMISTRY. - - With numerous Illustrations on Wood. Sixth Edition. Fcap. 8vo. cloth, - 12_s._ 6_d._ - - - MR. WHARTON JONES, F.R.S. - - A MANUAL OF OPHTHALMIC MEDICINE & SURGERY. - - With Coloured Engravings on Steel, and Illustrations on Wood. - - Second Edition. Fcap. 8vo. cloth, 12_s._ 6_d._ - - - DR. HANDFIELD JONES, F.R.S., & Dr. EDWARD H. SIEVEKING. - - A MANUAL OF PATHOLOGICAL ANATOMY. - - Illustrated with numerous Engravings on Wood. Fcap. 8vo., cloth, 12_s._ - 6_d._ - - - DR. ROYLE, F.R.S., and DR. HEADLAND, F.L.S. - - A MANUAL OF MATERIA-MEDICA. - - With numerous Illustrations on Wood. Third Edition. Fcap. 8vo. cloth, - 12_s._ 6_d._ - - - Dr. W. TYLER SMITH. - - A MANUAL OF OBSTETRICS. - - Illustrated with 186 Engravings. Fcap. 8vo. cloth, 12_s._ 6_d._ - - - DR. ALFRED TAYLOR, F.R.S. - - A MANUAL OF MEDICAL JURISPRUDENCE. - - Sixth Edition. Fcap. 8vo. cloth, 12_s._ 6_d._ - - BY THE SAME AUTHOR. - - ON POISONS. - - Fcap. 8vo. cloth, 12_s._ 6_d._ - - - MR. ERASMUS WILSON, F.R.S. - - THE ANATOMIST’S VADE-MECUM; - - A SYSTEM OF HUMAN ANATOMY. With numerous Illustrations on Wood. Seventh - Edition. Fcap. 8vo. cloth, 12_s._ 6_d._ - - - Printed by W. BLANCHARD & SONS, 62, Millbank Street, Westminster. - ------------------------------------------------------------------------- - - - - - TRANSCRIBER’S NOTES - - - 1. Silently corrected obvious typographical errors and variations in - spelling. - 2. Retained archaic, non-standard, and uncertain spellings as printed. - 3. Re-indexed footnotes using numbers and collected together at the end - of the last chapter. - 4. Enclosed italics font in _underscores_. - 5. Enclosed bold font in =equals=. - 6. Denoted superscripts by a caret before a single superscript - character or a series of superscripted characters enclosed in - curly braces, e.g. M^r. or M^{ister}. - -*** END OF THE PROJECT GUTENBERG EBOOK ON CHLOROFORM AND OTHER -ANÆSTHETICS: *** - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the -United States without permission and without paying copyright -royalties. Special rules, set forth in the General Terms of Use part -of this license, apply to copying and distributing Project -Gutenberg-tm electronic works to protect the PROJECT GUTENBERG-tm -concept and trademark. Project Gutenberg is a registered trademark, -and may not be used if you charge for an eBook, except by following -the terms of the trademark license, including paying royalties for use -of the Project Gutenberg trademark. If you do not charge anything for -copies of this eBook, complying with the trademark license is very -easy. You may use this eBook for nearly any purpose such as creation -of derivative works, reports, performances and research. Project -Gutenberg eBooks may be modified and printed and given away--you may -do practically ANYTHING in the United States with eBooks not protected -by U.S. copyright law. Redistribution is subject to the trademark -license, especially commercial redistribution. - -START: FULL LICENSE - -THE FULL PROJECT GUTENBERG LICENSE -PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK - -To protect the Project Gutenberg-tm mission of promoting the free -distribution of electronic works, by using or distributing this work -(or any other work associated in any way with the phrase "Project -Gutenberg"), you agree to comply with all the terms of the Full -Project Gutenberg-tm License available with this file or online at -www.gutenberg.org/license. - -Section 1. General Terms of Use and Redistributing Project -Gutenberg-tm electronic works - -1.A. By reading or using any part of this Project Gutenberg-tm -electronic work, you indicate that you have read, understand, agree to -and accept all the terms of this license and intellectual property -(trademark/copyright) agreement. If you do not agree to abide by all -the terms of this agreement, you must cease using and return or -destroy all copies of Project Gutenberg-tm electronic works in your -possession. If you paid a fee for obtaining a copy of or access to a -Project Gutenberg-tm electronic work and you do not agree to be bound -by the terms of this agreement, you may obtain a refund from the -person or entity to whom you paid the fee as set forth in paragraph -1.E.8. - -1.B. "Project Gutenberg" is a registered trademark. It may only be -used on or associated in any way with an electronic work by people who -agree to be bound by the terms of this agreement. There are a few -things that you can do with most Project Gutenberg-tm electronic works -even without complying with the full terms of this agreement. See -paragraph 1.C below. There are a lot of things you can do with Project -Gutenberg-tm electronic works if you follow the terms of this -agreement and help preserve free future access to Project Gutenberg-tm -electronic works. See paragraph 1.E below. - -1.C. The Project Gutenberg Literary Archive Foundation ("the -Foundation" or PGLAF), owns a compilation copyright in the collection -of Project Gutenberg-tm electronic works. Nearly all the individual -works in the collection are in the public domain in the United -States. If an individual work is unprotected by copyright law in the -United States and you are located in the United States, we do not -claim a right to prevent you from copying, distributing, performing, -displaying or creating derivative works based on the work as long as -all references to Project Gutenberg are removed. Of course, we hope -that you will support the Project Gutenberg-tm mission of promoting -free access to electronic works by freely sharing Project Gutenberg-tm -works in compliance with the terms of this agreement for keeping the -Project Gutenberg-tm name associated with the work. You can easily -comply with the terms of this agreement by keeping this work in the -same format with its attached full Project Gutenberg-tm License when -you share it without charge with others. - -1.D. The copyright laws of the place where you are located also govern -what you can do with this work. Copyright laws in most countries are -in a constant state of change. If you are outside the United States, -check the laws of your country in addition to the terms of this -agreement before downloading, copying, displaying, performing, -distributing or creating derivative works based on this work or any -other Project Gutenberg-tm work. The Foundation makes no -representations concerning the copyright status of any work in any -country other than the United States. - -1.E. Unless you have removed all references to Project Gutenberg: - -1.E.1. The following sentence, with active links to, or other -immediate access to, the full Project Gutenberg-tm License must appear -prominently whenever any copy of a Project Gutenberg-tm work (any work -on which the phrase "Project Gutenberg" appears, or with which the -phrase "Project Gutenberg" is associated) is accessed, displayed, -performed, viewed, copied or distributed: - - This eBook is for the use of anyone anywhere in the United States and - most other parts of the world at no cost and with almost no - restrictions whatsoever. You may copy it, give it away or re-use it - under the terms of the Project Gutenberg License included with this - eBook or online at www.gutenberg.org. If you are not located in the - United States, you will have to check the laws of the country where - you are located before using this eBook. - -1.E.2. If an individual Project Gutenberg-tm electronic work is -derived from texts not protected by U.S. copyright law (does not -contain a notice indicating that it is posted with permission of the -copyright holder), the work can be copied and distributed to anyone in -the United States without paying any fees or charges. If you are -redistributing or providing access to a work with the phrase "Project -Gutenberg" associated with or appearing on the work, you must comply -either with the requirements of paragraphs 1.E.1 through 1.E.7 or -obtain permission for the use of the work and the Project Gutenberg-tm -trademark as set forth in paragraphs 1.E.8 or 1.E.9. - -1.E.3. If an individual Project Gutenberg-tm electronic work is posted -with the permission of the copyright holder, your use and distribution -must comply with both paragraphs 1.E.1 through 1.E.7 and any -additional terms imposed by the copyright holder. Additional terms -will be linked to the Project Gutenberg-tm License for all works -posted with the permission of the copyright holder found at the -beginning of this work. - -1.E.4. Do not unlink or detach or remove the full Project Gutenberg-tm -License terms from this work, or any files containing a part of this -work or any other work associated with Project Gutenberg-tm. - -1.E.5. Do not copy, display, perform, distribute or redistribute this -electronic work, or any part of this electronic work, without -prominently displaying the sentence set forth in paragraph 1.E.1 with -active links or immediate access to the full terms of the Project -Gutenberg-tm License. - -1.E.6. You may convert to and distribute this work in any binary, -compressed, marked up, nonproprietary or proprietary form, including -any word processing or hypertext form. However, if you provide access -to or distribute copies of a Project Gutenberg-tm work in a format -other than "Plain Vanilla ASCII" or other format used in the official -version posted on the official Project Gutenberg-tm website -(www.gutenberg.org), you must, at no additional cost, fee or expense -to the user, provide a copy, a means of exporting a copy, or a means -of obtaining a copy upon request, of the work in its original "Plain -Vanilla ASCII" or other form. Any alternate format must include the -full Project Gutenberg-tm License as specified in paragraph 1.E.1. - -1.E.7. Do not charge a fee for access to, viewing, displaying, -performing, copying or distributing any Project Gutenberg-tm works -unless you comply with paragraph 1.E.8 or 1.E.9. - -1.E.8. You may charge a reasonable fee for copies of or providing -access to or distributing Project Gutenberg-tm electronic works -provided that: - -* You pay a royalty fee of 20% of the gross profits you derive from - the use of Project Gutenberg-tm works calculated using the method - you already use to calculate your applicable taxes. The fee is owed - to the owner of the Project Gutenberg-tm trademark, but he has - agreed to donate royalties under this paragraph to the Project - Gutenberg Literary Archive Foundation. Royalty payments must be paid - within 60 days following each date on which you prepare (or are - legally required to prepare) your periodic tax returns. Royalty - payments should be clearly marked as such and sent to the Project - Gutenberg Literary Archive Foundation at the address specified in - Section 4, "Information about donations to the Project Gutenberg - Literary Archive Foundation." - -* You provide a full refund of any money paid by a user who notifies - you in writing (or by e-mail) within 30 days of receipt that s/he - does not agree to the terms of the full Project Gutenberg-tm - License. You must require such a user to return or destroy all - copies of the works possessed in a physical medium and discontinue - all use of and all access to other copies of Project Gutenberg-tm - works. - -* You provide, in accordance with paragraph 1.F.3, a full refund of - any money paid for a work or a replacement copy, if a defect in the - electronic work is discovered and reported to you within 90 days of - receipt of the work. - -* You comply with all other terms of this agreement for free - distribution of Project Gutenberg-tm works. - -1.E.9. If you wish to charge a fee or distribute a Project -Gutenberg-tm electronic work or group of works on different terms than -are set forth in this agreement, you must obtain permission in writing -from the Project Gutenberg Literary Archive Foundation, the manager of -the Project Gutenberg-tm trademark. Contact the Foundation as set -forth in Section 3 below. - -1.F. - -1.F.1. Project Gutenberg volunteers and employees expend considerable -effort to identify, do copyright research on, transcribe and proofread -works not protected by U.S. copyright law in creating the Project -Gutenberg-tm collection. Despite these efforts, Project Gutenberg-tm -electronic works, and the medium on which they may be stored, may -contain "Defects," such as, but not limited to, incomplete, inaccurate -or corrupt data, transcription errors, a copyright or other -intellectual property infringement, a defective or damaged disk or -other medium, a computer virus, or computer codes that damage or -cannot be read by your equipment. - -1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right -of Replacement or Refund" described in paragraph 1.F.3, the Project -Gutenberg Literary Archive Foundation, the owner of the Project -Gutenberg-tm trademark, and any other party distributing a Project -Gutenberg-tm electronic work under this agreement, disclaim all -liability to you for damages, costs and expenses, including legal -fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT -LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE -PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE -TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE -LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR -INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH -DAMAGE. - -1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a -defect in this electronic work within 90 days of receiving it, you can -receive a refund of the money (if any) you paid for it by sending a -written explanation to the person you received the work from. If you -received the work on a physical medium, you must return the medium -with your written explanation. The person or entity that provided you -with the defective work may elect to provide a replacement copy in -lieu of a refund. If you received the work electronically, the person -or entity providing it to you may choose to give you a second -opportunity to receive the work electronically in lieu of a refund. If -the second copy is also defective, you may demand a refund in writing -without further opportunities to fix the problem. - -1.F.4. Except for the limited right of replacement or refund set forth -in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO -OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT -LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE. - -1.F.5. Some states do not allow disclaimers of certain implied -warranties or the exclusion or limitation of certain types of -damages. If any disclaimer or limitation set forth in this agreement -violates the law of the state applicable to this agreement, the -agreement shall be interpreted to make the maximum disclaimer or -limitation permitted by the applicable state law. The invalidity or -unenforceability of any provision of this agreement shall not void the -remaining provisions. - -1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the -trademark owner, any agent or employee of the Foundation, anyone -providing copies of Project Gutenberg-tm electronic works in -accordance with this agreement, and any volunteers associated with the -production, promotion and distribution of Project Gutenberg-tm -electronic works, harmless from all liability, costs and expenses, -including legal fees, that arise directly or indirectly from any of -the following which you do or cause to occur: (a) distribution of this -or any Project Gutenberg-tm work, (b) alteration, modification, or -additions or deletions to any Project Gutenberg-tm work, and (c) any -Defect you cause. - -Section 2. Information about the Mission of Project Gutenberg-tm - -Project Gutenberg-tm is synonymous with the free distribution of -electronic works in formats readable by the widest variety of -computers including obsolete, old, middle-aged and new computers. It -exists because of the efforts of hundreds of volunteers and donations -from people in all walks of life. - -Volunteers and financial support to provide volunteers with the -assistance they need are critical to reaching Project Gutenberg-tm's -goals and ensuring that the Project Gutenberg-tm collection will -remain freely available for generations to come. In 2001, the Project -Gutenberg Literary Archive Foundation was created to provide a secure -and permanent future for Project Gutenberg-tm and future -generations. To learn more about the Project Gutenberg Literary -Archive Foundation and how your efforts and donations can help, see -Sections 3 and 4 and the Foundation information page at -www.gutenberg.org - -Section 3. Information about the Project Gutenberg Literary -Archive Foundation - -The Project Gutenberg Literary Archive Foundation is a non-profit -501(c)(3) educational corporation organized under the laws of the -state of Mississippi and granted tax exempt status by the Internal -Revenue Service. The Foundation's EIN or federal tax identification -number is 64-6221541. Contributions to the Project Gutenberg Literary -Archive Foundation are tax deductible to the full extent permitted by -U.S. federal laws and your state's laws. - -The Foundation's business office is located at 809 North 1500 West, -Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up -to date contact information can be found at the Foundation's website -and official page at www.gutenberg.org/contact - -Section 4. Information about Donations to the Project Gutenberg -Literary Archive Foundation - -Project Gutenberg-tm depends upon and cannot survive without -widespread public support and donations to carry out its mission of -increasing the number of public domain and licensed works that can be -freely distributed in machine-readable form accessible by the widest -array of equipment including outdated equipment. Many small donations -($1 to $5,000) are particularly important to maintaining tax exempt -status with the IRS. - -The Foundation is committed to complying with the laws regulating -charities and charitable donations in all 50 states of the United -States. Compliance requirements are not uniform and it takes a -considerable effort, much paperwork and many fees to meet and keep up -with these requirements. We do not solicit donations in locations -where we have not received written confirmation of compliance. To SEND -DONATIONS or determine the status of compliance for any particular -state visit www.gutenberg.org/donate - -While we cannot and do not solicit contributions from states where we -have not met the solicitation requirements, we know of no prohibition -against accepting unsolicited donations from donors in such states who -approach us with offers to donate. - -International donations are gratefully accepted, but we cannot make -any statements concerning tax treatment of donations received from -outside the United States. U.S. laws alone swamp our small staff. - -Please check the Project Gutenberg web pages for current donation -methods and addresses. Donations are accepted in a number of other -ways including checks, online payments and credit card donations. To -donate, please visit: www.gutenberg.org/donate - -Section 5. General Information About Project Gutenberg-tm electronic works - -Professor Michael S. Hart was the originator of the Project -Gutenberg-tm concept of a library of electronic works that could be -freely shared with anyone. For forty years, he produced and -distributed Project Gutenberg-tm eBooks with only a loose network of -volunteer support. - -Project Gutenberg-tm eBooks are often created from several printed -editions, all of which are confirmed as not protected by copyright in -the U.S. unless a copyright notice is included. Thus, we do not -necessarily keep eBooks in compliance with any particular paper -edition. - -Most people start at our website which has the main PG search -facility: www.gutenberg.org - -This website includes information about Project Gutenberg-tm, -including how to make donations to the Project Gutenberg Literary -Archive Foundation, how to help produce our new eBooks, and how to -subscribe to our email newsletter to hear about new eBooks. |