chloroform was first laid down by Sir James Simpson, and that Mr. Syme only followed in his footsteps. It is always well to be accurate in any matter, but otherwise this is a point which has no interest for the public, and the net result therefore of the whole paper, to one who had hoped to find information as to the reasons advanced by certain anesthetists for using their painful method, is a feeling of total disappointment.

Dr. Buxton's paper is no doubt weighty with medical knowledge and scientific facts, and had my contention lain in the path of such a projectile it would have suffered severely; but Dr. Buxton's fire was concentrated on a side issue, and left my main point untouched. If I were to complain that the high road was a terror to pedestrians by reason of the recklessness of cyclists, and that several deaths had been caused by them, it would hardly be a 'reply' to my complaint to point out that steam-rollers too were sometimes dangerous. And when I protest in the name of humanity against the cruel method of stifling used by certain anesthetists, it is surely beside the mark to say that it is possible for death to be caused in other ways than by suffocation. If this knowledge be indeed a consolation to anyone, it may be derived from Dr. Buxton's paper; but for most people it is enough to know that suffocation is by far the most common form of danger, and, fortunately, is a preventable one. Dr. Buxton says, indeed, that no death due to asphyxia should occur in competent hands, and the dicta of Sir James Simpson and Mr. Syme quoted by him are most emphatic as to the necessity of allowing free admixture of air. How then is the practice of allowing no air-of smothering--to be justified? By inference, Dr. Buxton condemns it utterly, but it is to be wished he had done so explicitly.

From Dr. Buxton's point of view the gravamen of my first paper consisted in the statement that a definite 'safe method' of giving chloroform existed, known to all medical men but not practised by them; and he then proceeds to prove that no method is absolutely safe, as even Simpson himself had a patient die from syncope on one occasion while he was giving him chloroform.

6

But everything seems to point to the fact that this was a very exceptional case; and, be it observed, nowhere does Dr. Buxton assert that the stifling method is safer, while he admits that many deaths arise unhappily through the inexperience of administrators. By his reference, indeed, to the eighty-eight deaths under chloroform last year reported by the Hospital as some trifling statistics,' and his regret that I had ignored the more elaborate statistics brought together by the Lancet, amounting to some thousands of cases, we may infer that the annual tale of victims to chloroform-or to the mode of administering it—is larger than it had been assumed to be, although this is not explicitly stated. This cannot be called reassuring, any more than can Dr. Buxton's assertion that the public are to a great extent

the authors of their own miseries by not taking more pains to ascertain the competence of those anæsthetists into whose hands they commit themselves.

It frequently happens that a person living in the country goes up to London expressly for an operation, and on reaching the surgeon's or dentist's house is met by the anaesthetist. How would Dr. Buxton propose that such a person should proceed to ascertain the competence of the anesthetist? and in what spirit would the anesthetist be likely to receive any implied doubts as to his competence?

Again, while maintaining that the public are to blame for assuming that every medical man has been taught to give chloroform in the best possible way, he expresses no opinion as to what is the best possible way, and merely begs the question by evading the difficulty.

The controversy in the medical papers is conducted, naturally, from the operators' point of view, and is confined almost exclusively to discussing either the precise cause of death or the best means of obviating the risk of death, and there is no want of plain speaking on the part of the writers. Writing in the British Medical Journal on the 23rd of April, Dr. Waller, lecturer on physiology, plainly expresses his conviction that death is nearly always due to unskilful administration,' and quotes Lord Lister as saying that death from chloroform is almost invariably due to faulty administration '—adding that this means the administration of an overdose.

Now the Hyderabad Commissioners assert that interference with the breathing is practically the same thing as overdosing. But this point of interference with the breathing, and the suffering it entails on the patient, is not one that I have seen mentioned in any of the papers on the subject; and it is this point that chiefly affects the public. For every patient that dies there are hundreds that only suffer. The patient's experience, whether painful or otherwise, necessarily ends where unconsciousness begins, and is not affected by his subsequent recovery or death. His recovery does not mitigate any suffering he experienced while consciousness lasted, neither does death during unconsciousness increase it.

From my own point of view, therefore-that of the patientthe gravamen of my first paper did not consist in the statement that there was any definite 'safe method' of giving chloroform, which is a question for medical men to dispute upon, but in the statement-the result of my own experience-that chloroform is frequently administered in such a way as to cause extreme and unnecessary suffering. The extracts from the Hospital and from the 'Report of the Hyderabad Commission' were quoted by no means with any view to enlighten medical men, who presumably are thoroughly acquainted with all such things, but to show the public, who are profoundly ignorant on the subject, first, how large a number of fatal cases occur annually in England; and secondly, how,

judged by the rules laid down by competent authorities, the practice of smothering patients in the way I had been smothered must tend to increase the chances of their dying from suffocation.

But the cause of death is by no means the primary point of my contention; that is a subject for medical men to settle, and one on which they do not appear likely to agree. In medicine, as in religion, remain a hopeless dream,

uniformity of opinion seems doomed to and the fight over the exact causes of death under chloroform-other than suffocation-goes on with perennial vigour.

The vital question, from the point of view of the public, is not whether there are not cases in which death takes place from occult and unexplained causes, but whether it does not frequently take place from suffocation, as would seem only too natural to those who know what it is to have been forcibly and hastily smothered. It is, in fact, with the way in which chloroform is administered that the public are concerned, and on which alone they are entitled to have decided views. Doctors may disagree as they please on problems of physiology without fear of any layman expressing an opinion on the merits of the dispute; but the public have a manifest right to insist that anaesthetists shall not be allowed to inflict needless suffering on their patients. This is the focus of the matter, and only in so far as the differences between medical men affect this point have the public any interest in them. I shall show that there are eminent medical men who hold that the administration of chloroform by stifling does inflict unnecessary suffering and is unjustifiable.

Among the many letters I have received on the subject since the appearance of my first article is one from a lady, whose description of her suffering is so graphic that I may be allowed to quote it:

The agony I suffered from suffocation quite changed my life; it gave me a fear of death, a dread of darkness, and a dread of being left alone. For months afterwards, when falling asleep, an awful terror would come upon me, and make me try to keep awake. I tried to push away the pad that was over my nose and mouth; but my hands were held, and the struggle seemed to me to last for ages. The nervous shock was so great that I am suffering from it to this day.

Another victim, a man, says:

I was only able to breathe the stifling fumes of the chloroform in fits and starts, and I seemed to experience the agony of death, which I can only recall with horror. I have many times since wished I had died, as it left me a legacy of extreme nervousness, which I am unable to shake off.

It is difficult to believe that treatment which involves suffering such as this can be dictated by consideration for the patient's interest. A person who has never been chloroformed in this manner cannot possibly know the degree of agony it entails, and it is therefore essential that any one who defends the system shall have been himself stifled into unconsciousness once at the very least. It is a necessary rite of initiation into the mysteries, and he who has not undergone it,

scientist though he may be, speaks from a different platform to that on which stand the initiated. Dr. Buxton fails to tell us if he has himself gone through the rite of initiation by smothering.

It must throughout be borne in mind that my charge is brought only against anaesthetists of a certain school, whether numerous or not I have no means of knowing. I and other members of my family have taken chloroform many times from doctors of a different school without experiencing the very slightest feeling of suffocation; and those whose happy fortune it has been never to have had any other experience are slow to believe in the existence of any other method. It is my personal experience of the existence of two methods that alone impels me to speak; it is because I know both how pleasant the taking of chloroform can be and how terrible it may be. When given as it can be, and should be, the patient falls asleep gradually and gently, and has no knowledge whatever of the loss of consciousness, no terror, and no motive for struggling or resisting.

Dr. Buxton is of opinion that students should be required to have a special certificate of having been taught how to give chloroform before they qualify as medical men. But when there are two opposite methods of teaching, who is to know how they have been taught? It would be but cold comfort to a person about to take chloroform to know that the doctor had a certificate of competence in the art of smothering. I have no reason for doubting that the anesthetist who last smothered me had been thoroughly taught; he would hardly have done it with such merciless assurance unless he had been.

Among the sympathetic letters I have received is one from a German physician at Brussels, in which he says: 'I have much pleasure in assuring you that my own experience during a lifelong practice entirely corroborates your conclusions, and that I am pleased you published them.' Spontaneous assurances of sympathy and approval such as this have been a great encouragement, and I sincerely thank my unknown correspondents for the support they have given me.

It seems to be very generally admitted that a practical reform in the method of administering chloroform is urgently needed in the interests of the public, as also that the power to effect such a reform lies mainly in their own hands. Dr. Buxton readily admits that it is a matter chiefly affecting the public, all of whom are potential patients. The first step is to awaken the interest of the public, and by the help of the press to spread so widely a knowledge of the two different methods used in giving chloroform as to prevent any one from inadvertently-through ignorance-falling into the hands of an anæsthetist belonging to that school which forcibly stifles the patient into unconsciousness. The adherents of that school are probably sufficiently open to reason to think it advisable to change

their method when they find a widespread reluctance on the part of the public to take chloroform from any one who will not give a guarantee that the inhaler or cloth shall at no time be held close over the nose and mouth. Such an attitude on the part of the public, from whom the victims are drawn, would have more practical influence on what, for the sake of brevity, we may call the School of Stiflers, than any articles, however eloquent, in the medical papers, written by any medical men, however distinguished, belonging to the rival school.

As there are these two directly opposite methods of giving chloroform, the one causing no distress to the patient, the other inflicting the most acute misery, it is obvious that the entire burden of proof rests on those medical men who practise the latter, of showing such good and sufficient reason for persisting in their cruel method as may at once be admitted by all reasonable people to be unanswerable. Cæteris paribus, they have no right to torture a patient. The right to do so could only be conceded to them on their demonstrating to the satisfaction of at least the whole medical world that their system was attended with such advantages in other ways as would outweigh the temporary agony of their patient. I repeat that the onus of proving this rests with them. But it would appear that they do not attempt to prove anything of the kind. They do not put forward any arguments against the safety of the humaner method, nor any claims for the superior safety or advantages of the stifling method. What, then, is the public to conclude? How is it to account for the prevalence of so barbarous a method of dealing with patients?

This is the problem to which an answer is required. It has not been denied that the stifling method is frequently practised, but no reason for its use has been put forward. There is one question that suggests itself to the mind when pondering on the matter, and one of the greatest importance. Does the anesthetist save time by the use of the stifling method?—that is to say, Is the patient put under the influence of the chloroform more quickly in this way than by the 'open' method? If a saving of time enters into the question it opens up a field so wide and so serious that I prefer not to enter upon it.

An anesthetist knows that the risk of killing a patient by the use of the stifling method is not great, not nearly so great as the agony of the process would lead one to suppose, and in the rare event of a patient dying of shock or suffocation he knows that no blame will be laid at his door. It is the patient's heart that was always in fault. The coroner's jury will be guided by the evidence given by himself and the other professional men or nurses present, whose statements are fettered by professional etiquette, and it will exonerate him from all blame in the matter.

It would be different if coroners were roused to a greater sense of their duty to the dead, and were instructed by the proper authorities