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.

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:—

“There has been an increase of mortality in:—

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.

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.