the eminent surgeon; and (3) whether the methods commonly adopted are divisible under two headings, viz. that dictated by the so-called teaching of Syme and the Hyderabad Commissions, and another based upon the belief that chloroform kills by acting upon a weakened heart or mechanism of the blood circulation. Let us now consider which, if any, of these conclusions be correct. Some fifty years ago the action of chloroform as an anesthetic was investigated by the late Sir James Young Simpson. It need hardly be said that to his perseverance, ability, and acumen the adoption of chloroform as an anæsthetic was due. There is no question about Simpson's views upon the subject. They are put forth at great length in his works under the heading of Anesthesia;' he taught that chloroform when given diluted with too little air produced death by paralysis of respiration, that is, by suffocation; and he laid down as a canon, that any method of giving it which did not allow of due dilution was faulty. He, however, preferred to employ a cloth upon which was poured an unmeasured quantity of chloroform. This is commonly known as the open method.' Simpson went a step further, as the following quotation from his works shows: 1 'According to all the experimental and clinical observations which have been made, chloroform appears capable of destroying life in two ways, namely (1) by asphyxiation (i.e. suffocation), and (2) by syncope (i.e. direct heart failure). Death by asphyxiation can generally, if not always, be averted by at once arresting the inhalation of the drug whenever the breathing becomes noisy and stertorous death by syncope or sudden stoppage of the action of the heart is doubtless far less under control, and has apparently formed the principal cause of the fatal issues in almost all the cases in which patients have perished when under the use of chloroform.' He then points out that anesthetics in many instances save persons from syncope by abrogating the consequences of shock and fear, many deaths having occurred immediately before and during the performance of grave operations in pre-anesthesia days, due to dread of pain. But it may be said, and the article under consideration would lead us to believe, that Syme was the apostle of the 'safe method,' and it was his teaching and his statistics which have kept alive the sacred flame of truth in the matter of chloroform since the introduction of that anesthetic. As a matter of fact, however, Mr. Syme did not write upon chloroform; he gave directions in his lectures. and he adopted what has been termed by a recent scientific observer 'the slap-dash method' of giving chloroform. Mr. Syme's only published pronouncement on the subject is of great interest, and shows that he advanced neither original views nor performed any experiment, and, as far as I can find out, kept no record of his cases from the point of view of chloroform. In the Lancet for the 20th ''Anæsthesia,' p. 149, Collected Works, Edinburgh, 1871. of January, 1855, is published a clinical lecture by Mr. Syme, delivered before the University of Edinburgh, the subject of which is chloroform. In this lecture he says, 'You observe that in this matter I am very far from taking any credit to myself; all that I have done has been to follow the example of Dr. Simpson' (afterwards Sir James). The gist of the lecture is expressed in the following words : The points that we consider of the greatest importance in the administration of chloroform are, first, the free admixture of air with the vapour of the chloroform, to ensure which a soft porous material, such as a folded towel or handkerchief, is employed.... Secondly... we do not stint the quantity of chloroform. Then-and this is a most important point—we are guided as to the effect, not by the circulation, but entirely by the respiration. . . . We always give the chloroform in the horizontal position. When respiration becomes difficult or ceases, we open the mouth and seize the tongue with artery forceps. "2 It would thus appear that Mr. Syme adopted Sir James Simpson's views and his method, and, further, that difficulties, even dangers followed when that method was employed. That Mr. Syme never had a fatal case himself has been stated; whether this is true I am not in a position to say, since records of such occurrences are not kept in Scotland, as in England; in England a coroner's inquest investigates every death under an anesthetic, in Scotland no such formality is considered requisite. That deaths under anaesthetics occur in Scotland is too well known and authenticated to need further notice. However, if Syme had no deaths from chloroform his master and teacher, Sir James Simpson, did, and upon an occasion when he himself was administering the anaesthetic to the patient. A full account of the occurrence was published by Simpson, and the cause of the fatality was, according to his statement, 'syncope from action of the chloroform on the heart." So far, then, we have to admit that the method of watching the respiration only, as adopted in the open method, was not, in the hands of so great a master as Simpson, devoid of danger. Even before the occurrence of this death Dr. John Snow, one of, if not perhaps the greatest of, those who have investigated the action of chloroform, whose collected papers, published posthumously in 1858, are monumental of the man's patience, scientific method, and accurate observation, had drawn attention to the shortcomings of the reputed 'safe method' of giving chloroform. Here it may be remarked that ex cathedra statements that a thing is proved or not proved, is safe or is not safe, whether advanced by those with technical knowledge or those whose knowledge is borrowed, cannot be accepted as conclusive or valid to rank as proofs. Snow's observations were based entirely upon the study both of experimental and clinical observations, which led him to believe that Simpson's statements were correct in so far as chloroform killed either by 2 See p. 148, ibid. suffocation or by syncope. He at the same time pointed out the grave dangers attending the open method of giving chloroform, and was the first to indicate that the safety of chloroform lay in the rational method of employing it; this rational method was to employ it in given and known doses. Snow devised an inhaler, as many others have done since his time, with a view of enabling the administrator to graduate the dose of the anesthetic according to the necessities of the patient and of the operation to be performed. Snow, as Simpson, as Syme, as those who are responsible for the Hyderabad Commissions, enforced the necessity of watching the respiration; and here it may be said that the value of the Hyderabad Commissions' work, which is undoubtedly great, lies in the emphatic manner they have asserted the necessity of noticing one of the physiological actions of chloroform, namely, its action upon the breathing. It is extremely difficult for those cognisant of the uses of chloroform to believe that any one should attempt to regulate the doses of chloroform by watching the circulation; if such persons exist, the sooner they and their method are relegated to the limbo of desuetude the better for all concerned. Personally I believe such persons are as rare as the dodo or the great auk. In justice, however, to the medical profession, and certainly to that section of it whose particular study lies in the administration of anæsthetics, it must be pointed out that no such baleful doctrine is at present believed in, nor such a deplorable practice pursued. As Snow said, '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.' And he adds: The breathing is also fortunately a sign that cannot be overlooked; it is by the breath that the chloroform enters, and it is extremely improbable that any one should go on giving the vapour after the breathing becomes stertorous or laboured.' Now although Snow's teaching was precise and his method demonstrably free from danger, as no fatalities occurred under his administration, the older method of Syme, recently rehabilitated by the Hyderabad Commissions, was pursued, and is probably at the present day far more commonly adopted, except by experts, than the more rational plan of graduating the dose to the patient and his requirements. It is distinctly a straining of truth to aver that those who have followed Syme's instructions, or, as I prefer to call it, Simpson's method, have enjoyed an immunity from danger whilst giving chloroform. Indeed, the fact that deaths occurred from time to time, one of the earliest taking place in Hyderabad,' led to various commissions being established with the view of further elucidating the action Anæsthesia, p. 89, London, 1858. of chloroform upon the human body. These commissions have in most instances come to the conclusion of Simpson and Snow, that death arises either from asphyxiation (suffocation) or syncope (heart failure). When the first Hyderabad Commission was established, its findings were in favour of the view that death from chloroform always meant death from asphyxia. The second Hyderabad Commission was carried out with a view of extending the work of the first commission and of checking the experiments by the collaboration of an eminent physician and experimentalist. Their conclusions again went to show that chloroform death was due to asphyxia, but, as must be pointed out, the only evidence they could advance against the commonly accepted view that death may also arise from heart failure was of a negative kind. At once and frankly it should be said that the work of this second Hyderabad Commission was admirable, and it is a regrettable circumstance that much of the polemic that has arisen out of its report has shown too little of scientific method and too much of the spirit which induces the bolstering up of argument by personal attacks upon opponents. However, so far from the results of the Hyderabad Commissions being unanimously received by the distinguished physiologists whose researches were carried out through the munificence of the Nyzam of Hyderabad, these observers differed in many important points from the findings of the commissions, and unless we are prepared to ignore the carefully conducted experiments of other commissions, and of the light and leading of the profession, we cannot admit that the Hyderabad Commissions have proved the results they set themselves to demonstrate. It may be again pointed out that the dangers to respiration, which the Hyderabad Commissions so ably demonstrated, have always been recognised and carefully taught for over forty years. Nevertheless so important is the subject that anything which enforces attention to it, and establishes physiological demonstration of it, must do good. It is when attempts are made to go behind this, and to assert, as was asserted in a certain daily paper, that the commissions had shown that to take chloroform was as safe as to take a tumbler of whisky and water,' that it becomes the duty of those with technical knowledge to call a halt, and to point out that dangers do exist over and above that of an asphyxia, caused by carelessness in administering chloroform. No death from this anæsthetic due to asphyxia ought to happen, nor will it occur in competent hands in the case of an average patient; but it is a severe and an unjust charge, unsupported by the weight of scientific evidence, to say that all deaths under chloroform are deaths from asphyxia, and are therefore unnecessary, avoidable, and consequently criminal deaths. The most recent researches upon the subject have gone rather in the other direction, and have apparently shown that the fatalities under chloroform which have been attributed to asphyxia are, in some cases at all events, due in the first instance to the action of chloroform upon the heart and blood-vessels, causing insufficient blood to enter the brain to enable that organ to keep up the control of the movements of respiration. The writer of the paper in the March issue of this Review refers with approval to some trifling statistics collected by a quasi professional journal, but ignores the elaborate statistics which have been brought together by Snow, the Royal Medical Chirurgical Society, and lastly by the Lancet, amounting to some thousands of cases. The preceding remarks may read somewhat as a jeremiad to those who have to take chloroform, and who may have, perhaps, rejoiced to find a reputed 'safe method;' for their comfort it may be pointed out that at the present day the actual percentage of deaths under chloroform is small, and very many of such deaths arise unhappily through the inexperience of youthful administrators, whose sense of responsibility is not always commensurate with their courage. It is now commonly recognised, except by the votaries of the slap-dash' school, that we possess methods which enable us to employ chloroform with the same degree of precision as we do when administering opium, strychnine, or other powerful drugs. Most hospitals possess officers of experience whose duty it is to look after the welfare of patients under anæsthetics, as well as to instruct the medical neophytes before they undertake the administration of anesthetics. Further, there are other anæsthetics, which, in many instances, can with advantage be given in lieu of chloroform, so that even if faith in a safe method' is given up, we may believe that a competent anæsthetist can be found who will be able to follow a system which, if it does not claim for itself the rank of a panacea of all evils, will prove sufficient for all practical purposes. 6 While one deplores the unpleasant personal experiences which Mrs. King narrates, and which might possibly be explained on grounds other than those to which she refers, one cannot but point out that the public are in very many instances the authors of their own miseries. They take little or small pains to ascertain the competence of those into whose hands they commit themselves, and assume that to give chloroform in the best possible way is a routine practice in the hands of every medical man. It requires at least as careful a training and as much practice to become an experienced anææsthetist as to master other departments in science. Under existing circumstances, although, from force of necessity, many medical men possess some knowledge and skill as administrators of chloroform, yet some have not acquired the requisite manipulative skill. It is a matter of great regret that under the present regulations no special certificate of training or of having been taught the administration of anaesthetics is required of our students before they qualify as medical men. Those who have held hospital appointments have acquired a certain experience, but the ruck of students, unless fired by ambition, |