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._




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                           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


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                          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}.