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may pass their curriculum and become highly qualified medical practitioners without any special training in the use of anæsthetics. On the other band, no medical man can be qualified till be produces evidence of having attended a class of instruction in vaccination ; the operation per se of vaccination cannot be considered as one of material gravity, whereas since any person who anæsthetises another undoubtedly holds the cords of that individual's life in his hands, his lack of knowledge or skill may produce results of a most serious character. It is, of course, necessary that the public should be satisfactorily guarded by certificates in the matter of efficient vaccination, but it is also important that special certificates should be required from those who practise giving anæsthetics, since their practice is in certain cases intrinsically dangerous to life.
In conclusion it may be said that all and more, far more than is given in the article ' Deaths under Chloroform,' is familiar to all medical men who are abreast of the knowledge of their profession; and if they do not follow blindly the teaching of the Hyderabad Commissions, it is because they do not accept them in their entirety. All recognise the danger of paralysing the brain centres with chloroform, and so causing asphyxia, and always have recognised it, but the weight of both modern and less recent experiment and clinical observation compels us to recognise also the second and far more terrible danger, that of the onset of syncope from the direct action of chloroform upon the heart muscle.
DUDLEY W. BUXTON, M.D.
The article in the last issue of this Review by Mrs. King must have been read with interest by all those (and they are not a few) whose fate it has been, at one time or another, to be obliged to submit to the influence of chloroform or ether. The benefit of anæsthesia during surgical operations both to the patient and to the operator is incalculable; without it many operations which are now of everyday occurrence, and which do much to relieve suffering and to prolong life, would be impossible. But, as Mrs. King points out, there are different ways of administering anæsthetics, and what may, in some hands, lead to a painless state of insensibility, may in others be attended by great irritation and may even produce fatal results. Moreover the effect of long-continued exposure to an anæsthetic is often violent retching and sickness; and, apart from the inconvenience which such a disturbance of the normal physical conditions entails, there is often serious danger to the patient, owing to the displacement of the freshly united surfaces of the wound. This is especially the case in abdominal operations.
The writer of this article, though not himself a medical man, has frequently in the course of his experience been led to give some attention to the subject of the administration of anæsthetics, not indeed as an anæsthetist, but as the corpus vile in whom anaesthesia was induced for experimental purposes. And, as a chemist, he has frequently had to examine samples of chloroform and ether, with a view to their suitability for their purpose. It appears to him that a few notes which he has made at different times may not be without interest to the readers of this Review, and may possibly prove of service to the public, It may
be stated at the outset that the chloroform and ether which are administered to patients are frequently impure. It is true that the total amount of impurity is very small and is difficult to detect by chemical tests ; indeed, if detectable it is doubtful whether a patient could be induced to respire the anesthetic. These impurities are not present when the anæsthetic comes from the manufacturer ; they are produced by the slow decomposition of the substance on exposure to air, water, and light. Knowing the instability of their
chloroform, the manufacturers are in the habit of adding a small amount of alcohol to it before putting it on the market; and the presence of alcohol is said materially to lessen the decomposition of the drug. The chemistry of the change which has taken place in old chloroform is very simple, and even those who have had no special training in that science may follow its explanation to some extent.
Chloroform is a compound of carbon, hydrogen, and chlorine. The atmospheric air contains oxygen. It is probable that chloroform, perfectly dry, could be kept in a sealed tube for an indefinite time without alteration. But the oxygen of the air, which, of course, enters the bottle after some chloroform has been removed, causes hydrochloric acid gas to be formed, and itself takes the place of this compound, producing a substance well known to chemists named carbonyl chloride. Now, hydrochloric acid, though in this form not a poison, is very irritating to the respiratory organs; and carbonyl chloride, though also not present in amount sufficient to act as a poison, decomposes on contact with the moisture of the mouth and lungs into hydrochloric and carbonic acid gases; and the first of these is wholly irrespirable in quantity, and if present in even very small amount it provokes violent coughing. It is for this reason that operations in a small room illuminated by gaslight prove so disagreeable to the operator and assistants, for the chloroform vapour, coming into contact with the gas flame, undergoes a change of the nature mentioned. This change, with pure chloroform, may take place to such an extent in the course of a couple of months as to produce a liquid which fumes in the air, and which certainly would never be used for the purpose of anæsthesia.
A similar, though a less easily explained, change takes place with ether. Exposure to the prolonged action of air results in the formation of a sharp-smelling compound, which is probably one known as peroxide of ethyl; at least, after such exposure, ether gives the reactions characteristic of a peroxide. The presence of this substance occasions difficulty in respiring ether vapour; it provokes coughing and has a somewhat disagreeable taste.
If anæsthetists would put in practice a somewhat modified form of the golden rule, and would try themselves what they give to others, the administration of impure anæsthetics would seldom occur. There is no danger in inhaling a couple of breaths of either chloroform or ether; the experiment is not even attended with momentary dizziness; and the difference can at once be detected between a vapour which passes sweetly and softly' into the lungs and one which occasions some difficulty in respiration, and has a 'rough' feeling. This experiment is carried out by the patient, however; and his experience of anæsthetics is not usually sufficient to enable him to judge of the nature of the compound which he is made to breathe, nor, as a rule, is he in a fit condition to exercise his judgment. He is generally in a nervous, excited state; he knows that he is going to have an unpleasant time, and he takes for granted that the operation of chloroforming is the first stage. Moreover, in order to diminish the risk of sickness, he has been kept from food for a considerable time, and this has reduced his powers of successful protest.
Now, it is quite unnecessary to administer impure drugs. If it involved a great amount of trouble on the part of the anæsthetist to procure pure compounds one might understand their occasional administration in an impure state. But, as a matter of fact, both the manufacturers and the anæsthetists do their best to provide and to use pure articles. It is the subsequent slow action of the air which renders them impure. The operation of purification is so exceedingly simple that any one may put it in practice without any difficulty, and by the employment of the commonest materials. A little slaked lime in the chloroform bottle and a little metallic mercury in the ether bottle are all that is required. The lime removes the hydrochloric acid and destroys the carbonyl chloride, and the mercury becomes oxidised by the peroxide present in the ether. As usual, the advice must be given that the mixture shall be 'shaken before it is taken,' or rather administered; the cloudiness in the bottle will soon subside to the bottom. With ether, if impure, a dirty black precipitate is formed; if pure, the mercury remains untarnished. After such treatment breathing the vapour of either substance becomes, if not exactly a pleasure (for that is a matter of taste), at least not unpleasant. And I have been told by a medical friend who has put these suggestions in frequent practice that sickness is much rarer if the anæsthetics have been purified in this manner. Even with the same individual there was on one occasion violent sickness with the unpurified anæsthetic after a first operation ; while after a second, during which the purified chloroform was used, the sickness was slight and lasted for only a short time, although the anesthesia had been kept up for a much longer time than during the first operation.
In this paper, the nature of the anæsthetic, and not the manner of its administration, has been dealt with ; and the author will deem himself amply rewarded if by its means some useful hints may reach the medical profession, and some relief may attend those unfortunate persons who have to place themselves in the surgeon's hands.
A STUDY IN TRADE UNIONISM
It is generally assumed, although Mr. Sidney Webb does not admit it, that the modern trade unions are the lineal successors of the mediæval trade gilds, which Bacon called 'fraternities in evil.' However this may be we can find in the methods and results of the new unionism some things which recall the operations of the old gildism. The unions, like the gilds, are close corporations of labour, and, like the gilds, have by their exactions and limitations driven away industries from localities. Thus, just as the crafts left the mediaval towns and settled anew in remote districts away from the arm of the gilds, so shipbuilding, under the pressure of local trade unionism, left the Thames for the Tyne and Clyde ; lace-making left Nottingham for Ayrshire; and glass-making left England and Scotland for Germany and Belgium. The old trade gilds ruined the mediaval cities : is the new trade union going to ruin the industry of the whole country ? The subject demands the most serious inquiry.
The strike of the engineers, with all its pitiful detail, its financial loss, and its attendant suffering, has, after all, given us something to be thankful for. It has served to open the eyes of even the Morleyan * plain man' to some of the practices of those organisations of labour which for five-and-twenty years economists have been trying to teach us to fall down and worship, and which politicians have been elevating into the dignity of a fifth estate. During the progress of the strike there has been revealed, bit by bit and with relentless precision, a most damaging and thought-provoking series of facts. The old monopolists, whose operations in restraint of trade' were so denounced by the old school of economists, are succeeded by the trade unionists whose operations in restraint of labour have been brought to the light of day. Their methods, it is true, have long been more or less familiar to those actually engaged in industrial pursuits; but it is safe to say that not one of the engineer employers realised how much the engineering industry was being injured by trade unionism until last year they began to compare notes. It was the discovery they made of the extent to which they were being victimised that drew the employers closer into line. There is not in industrial history a more striking incident than this drawing together