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A NEW THEORY 
 
 OF 
 
 CHLOROFORM SYNCOPE, 
 
 SHOWING HOW THE ANESTHETIC OUGHT TO BE 
 ADMINISTERED. 
 
 BY 
 
 ROBERT KIRK, M.D. Edinr., F.F.P. & S., Glasgow. 
 
 PHYSICIAN TO THE DISPENSARY FOR DISEASES OF WOMEN, 
 GLASGOW WESTERN INFIRMARY. 
 
 GLASGOW : 
 JOHN THOMLINSON, STANLEY WORKS, PARTICK. 
 
 EDINBURGH & GLASGOW: JOHN MENZIES & CO. 
 
 1890. 
 
CONTENTS. 
 
 Preface, - - - - 5 
 
 Introduction, - - 9 
 
 The New Theory, - - 13 
 
 Facts, 17 
 
 Deductions, 21 
 
 Theories of Death from Chloroform, and Fatal 
 
 Cases, 26 
 
 Pseudo-An/Esthesia under Chloroform, - - - 33 
 
 Danger of Overdose, 35 
 
 Fall of Blood-Pressure under Chloroform, - - 38 
 
 The Chloroform Atmosphere, and how to keep 
 
 IT up, 39 
 
 Administration of the An/esthetic, - - - - 41 
 
 Appendix, 49 
 
PREFACE. 
 
 Nothing but a strong conviction of being in the right 
 could justify the author of the following pages for express- 
 ing views which must give a violent wrench to pre-conceived 
 opinions, and which will almost certainly be met with 
 opposition from all parties. These views, however, it may 
 be stated, are not a thing of yesterday, having been present 
 to the mind of the writer, in a more or less definite form, for 
 fifteen years before they finally crystallised in their present 
 shape. During that period new facts have been added to 
 our knowledge, which, together with the complete failure 
 of all attempts to look for an explanation of chloroform 
 syncope in other directions, have only tended to confirm 
 his belief in the soundness of his opinions. Various 
 reasons might be assigned why the theory here advanced 
 has not been published earlier, and some of these, but not 
 all, may here be stated. In the first place experiment, 
 although it gave some countenance to the author's view, 
 did not fully prove it, as will be seen in the sequel. Next 
 just as he had concluded his investigation of the question, 
 there appeared the first report of the Glasgow Chloroform 
 
A NEW THEORY 
 
 OF 
 
 CHLOROFORM SYNCOPE. 
 
 Introduction. — The most interesting question in 
 anaesthesia centres in the causation of those lamen- 
 table, and ap'parently anomalous and inexplicable fatalities 
 which have occurred with chloroform in the human sub- 
 ject. Two theories, diametrically opposed to each other, 
 have been advanced as to the cause of these accidents ; 
 one being that they were due to an overdose of the poison 
 having been used, and the other that they have in some 
 way or other happened when no overdose, but rather an 
 underdose, had been administered. The rules laid down 
 for the administration of the anaesthetic have varied ac- 
 cordingly. The first representatives of the one school 
 were Sir James Simpson and his colleague. Prof Syme. 
 " We give the patient good chloroform, and plenty of it, 
 and we never have accidents here," was the oft-repeated 
 utterance of the latter, while the language of Simpson was 
 
lO INTRODUCTION. 
 
 Still more forcible. " Put the patient as quickly as pos- 
 sible under a strong and overwhelming dose of the 
 poison " was one of his injunctions, which, slightly varied, 
 will be found to recur frequently in his works. Both 
 insisted not only that the patient should be deeply 
 anaesthetised, but that deep narcosis should be kept up 
 throughout the entire operation to be performed, and they 
 attributed fatal accidents to the interminable struggling 
 which supervened when the chloroform was too slowly 
 administered, or to the shock of the operation, which, in 
 their view, might have been prevented if the narcotism 
 had been complete. In their views and practice, how- 
 ever, they have been followed by no other school, and let 
 us now contrast the above with some of the statements of 
 the exponents of a different doctrine. The following from 
 Dechambre's dictionary* reads like a direct reply to 
 Simpson's instructions : — " Quelques chirurgiens ont 
 conseille de donner d'emblee et dans le plus court delai 
 possible, une grande quantite de chloroform e afin de 
 traverser rapidement on de supprimer la periode d'exci- 
 tationj on sidere le malade, comme on dit. C'est une 
 methode des plus dangereuses, non seulement parce 
 qu'elle expose a depasser le but, a produire brusquement 
 un etat de coUapsus inquietant, mais surtout parce qu'elle 
 provoke ces perturbations contingentes du cote du coeur, 
 
 *Art. Anesth^sie Chirurgicale. 
 
INTRODUCTION. 1 1 
 
 qu'il importe surtout d'eviter. Nous ne saurions trop re- 
 commander de proceder aux inhalations par gradations 
 insensibles, en commenQant de telle sorte que I'impression 
 locale des vapeurs soit a peine ressentie." 
 
 This latter method of administration has been approved 
 of, in general terms, by Claude Bernard, the London Chlo- 
 roform Committee of 1864, by Dr. Snow, and numerous 
 others. It has not only the advantage over the other of 
 being apparently more reasonable, but has also been sup- 
 ported by the evidence derived from numerous careful 
 and laborious experiments on animals. To the present 
 day, however, the controversy remains in the same posi- 
 tion as when it was first started. When Sir George 
 Macleod, in a clinical lecture,* expressed the opinion that 
 he feared more deaths were due to too little than to too 
 much chloroform being given, and that drops might kill 
 when drachms v/ould save; and when this was im- 
 mediately condemned by the late Mr. Clover as an 
 erroneous and dangerous doctrine, we had a com- 
 paratively recent illustration of the same irreconcilable 
 difference of opinion amongst authorities on this subject. 
 
 These contradictions appear extraordinary, but I think 
 it may be satisfactorily shown that Simpson and Syme did 
 not employ an atmosphere of a too concentrated kind, 
 one which could be proved by experiments on animals to 
 
 * Brit. Med. Journ., Jany. ist, 1876, p. 7. 
 
12 INTRODUCTION. 
 
 be dangerously strong. The most important outcome of 
 the different teaching of the two schools was probably 
 this, that the followers of the one went boldly on with the 
 administration without intermission until true surgical 
 anaesthesia was complete, while those of the other inter- 
 rupted the inhalation frequently for various symptoms, 
 indicative of real or imaginary danger, and stopped short 
 at a stage of anaesthesia thought just sufficient to enable 
 the necessary operation to be performed. It is generally 
 admitted that the former is entitled to claim the greatest 
 amount of success. Of ten thousand cases in the practice 
 of Simpson and Syme, only one proved fatal, and hardly 
 any will doubt their conscientiousness and veracity in this 
 statement of results. The solitary fatal case occurred in 
 the hands of the former, and was immediately published. 
 Almost unbounded confidence in the safety of the agent 
 is still entertained by surgeons in Scotland, and we often 
 have expressions of a similar trust in the medical journals 
 from various practitioners, some of whom confess to using 
 it in a free and apparently reckless manner. The latest of 
 these has come from Surgeon-Major Lawrie, and is as 
 emphatically and strongly expressed as any that have 
 gone before. It would appear that there must be some- 
 thing in connection with the subject which has never yet 
 been satisfactorily explained, and it remains to be seen 
 whether any light is to be derived from the new theory 
 which I here venture to propound. 
 
THE NEW THEORY. 1 3 
 
 The New Theory. — The theory of chloroform syn- 
 cope here advanced is one which I have long enter- 
 tained, and of the truth of which I have become more 
 strongly convinced as time has passed, and further facts 
 have accumulated, but it differs so radically from current 
 views that I might still hesitate to publish it, for no 
 doubt it will be received with incredulity. In my view 
 of it, the solution of the problem has proved impossible 
 because it has been sought for where it was not to be 
 found, namely, in the sole action of the chloroform in 
 the blood. Were this the only effect, the agent might be 
 regarded as a single force acting in one direction, and the 
 effects should have been uniform and easily understood. 
 Experience has proved, however, that the phenomena are 
 too complicated to be explained in this way, and that 
 there is still something awanting. The new theory takes 
 its starting-point from the hypothesis that there must be 
 an effect produced by the vapour on the pulmonary 
 mucous membrane, and that we have this also to reckon 
 with. The idea of such an action of an anaesthetic 
 vapour is not novel. Lallemand, Perrin, et Duroi, in 
 their work Du Role de VAlcool et des Anesthesiques dans 
 rOrgams7Jte, p. 253, expressly assume that such vapours 
 have a direct paralysing influence on the extremities of 
 the vagi, that they diminish the oxygenation of the blood, 
 and suspend the besoin de respirer^ — a true observation, 
 as it appears to me, but one of which they did not see 
 
14 THE NEW THEORY. 
 
 the full importance in the case of chloroform. Dr. Snow 
 does not notice this subject, and neither the London 
 Chloroform Committee of 1864, nor Claude Bernard, 
 admit any action of the kind, except an irritating and 
 asphyxiating effect from concentrated atmospheres. The 
 latter must have been wrong, however, if it should be 
 found that the supposed anomalies of chloroform can be 
 explained by the hypothesis that the vapour produces an 
 action and reaction of sufficient intensity here. 
 
 It is at once evident that if, besides the action of the 
 chloroform dissolved in the blood, there is a further effect 
 due to the vapour in the pulmonary cells, one half of 
 the field of inquiry has hitherto lain hidden from view, 
 and no wonder the action of the anaesthetic has re- 
 mained a mystery. If there be this action on the 
 pulmonary mucous membrane the agent must be re- 
 garded as two forces, acting at two several points, one 
 without and the other within the circulation^ and the 
 resulting phenomena are to be ascribed to the action and 
 reaction of these two forces, and to the varying degrees 
 of intensity with which they operate at different stages of 
 the inhalation. In considering these forces it must be 
 evident that the first, the external one, will soon reach its 
 maximum of intensity, and at a period when that of the 
 second is so slight that for the sake of simplicity it may 
 be left out of account. We have next to consider the 
 probable reaction of such a force, that is, the effect likely 
 
THE NEW THEORY. 
 
 15 
 
 to ensue when it is withdrawn and ceases to act. Clearly, 
 this is determined with mathematical exactitude by a 
 definite principle — the effect will be in precise proportion 
 to the intensity with which the force was acting, and to the 
 suddenness with which it is withdrawn. Now the action 
 of the force must be the ordinary anaesthetic effect of 
 the agent, causing retardation and stagnation of the cor- 
 puscles in the vessels, and a diminution of all the pro- 
 cesses going on there, attended, through reflex action, 
 with corresponding results on the systemic circulation. 
 If we suppose that these processes are diminished by a 
 fourth, then the effect may be compared to that of a 
 tourniquet compressing one of the iliac arteries ; if by 
 a half, to a similar compression of the abdominal aorta. 
 It must be evident that if such be the intensity of the 
 force, its sudden withdrawal will be attended with the 
 same liability to syncope as would be the sudden re- 
 moval of the tourniquet in the two supposed cases. Now, 
 when the patient is allowed to breathe fresh air the 
 force ceases to act with remarkable suddenness, for after 
 a few inspirations it is gone. The result is a violent 
 reaction — a violent rebound or whirl of the circulation 
 terminating, in its most pronounced form, in syncope. 
 This, and nothing else than this, I believe to be the cause 
 of primary chloroform syncope. Let us now suppose 
 the case in which the inhalation of the anaes- 
 thetic is continued and absorption goes on ; the 
 
l6 THE NEW THEORY. 
 
 internal force, acting in the same direction as the 
 external one, i.e.^ producing the same anaesthetic effects, 
 gradually increases in intensity until finally the two come 
 into equilibrium. There is now no reaction on removing 
 the vapour, this being counteracted by the chloroform in 
 the blood, and as this is eliminated in a slow and gradual 
 manner, recovery also takes place slowly, and the normal 
 state is quietly and safely regained. Short of this point 
 of equilibrium there will be numerous points at which, if 
 the inhalation is interrupted, oscillations of the circula- 
 tion of varying degrees of intensity will occur, and by 
 these are to be explained all the various degrees of syn- 
 cope, from complete stoppage of the heart's action to a 
 momentary pause indicated by mere transitory pallor of the 
 countenance. All are produced, not by the absorption of 
 chloroform, but by the elimination of the vapour from the 
 lungs at an early stage, and a reversal of the process that 
 ought to have gone on. Beyond the point of equilibrium — 
 in deeper anaesthesia, the disturbing influence of the ex- 
 ternal force is neutrahsed ; the chloroform is now a 
 single force acting in one direction and, with ordinary 
 per-centages, tending to death in the most slow and 
 gradual manner possible. Indeed, in this latter respect, 
 I am convinced that it is by far the safest of all anaes- 
 thetics, and that this is capable of proof and demon- 
 stration. 
 
FACTS. 17 
 
 Facts. — Is there any evidence in favour of this 
 theory ? Yes. In two observations, published eight 
 years ago in Holmes' System of Surgery (3rd Ed., vol. 
 iii., p. 618), I showed that in a cat recovering from mere 
 stupefaction with chloroform, produced by breathing 2 J 
 per cent, of the vapour in a large glass jar with a close- 
 fitting lid for little more than a minute, the pulse rose to 
 200, and that this was abruptly followed by a complete 
 pause in the heart's action lasting 60 seconds, during 
 which there was no audible action of the organ when the 
 stethoscope was applied to the chest. It is needless to 
 say that there was no respiration during this pause, which 
 was a veritable syncope. The capacity of the jar was 
 5000 cubic inches, so that the cat could move freely 
 about in it, and the amount of the anaesthetic absorbed 
 by the animal was so inconsiderable as not to affect the 
 atmosphere to any appreciable extent. The cat was taken 
 out when it was only so far under the influence of the 
 agent as to lay its head fiat on the bottom of the jar, and 
 it was ascertained that for the first few seconds the heart 
 was beating slowly and regularly before the sudden rise 
 took place. The period of acceleration lasted about a 
 minute before the pause occurred. On repeating the ex- 
 periment the same rise in the pulse rate was observed, but 
 the failure in the heart's action sometimes amounted only 
 to some degree of retardation. Now, neither of these phe- 
 nomena was ever observed when deep anaesthesia had 
 
1 8 FACTS. 
 
 been in the first instance induced. I believe the solu- 
 tion of the problem lies hidden in these simple facts as in 
 a nutshell. I regard the retardation in the action of the 
 heart, observed by the Glasgow Chloroform Committee 
 in a dog *, as entirely analogous with what I have de- 
 scribed in the cat. It is now fifteen years since I was led 
 to conjecture, when ruminating on reported fatalities from 
 chloroform, that some such effect was to be found, and 
 although experiment on the rabbit gave purely negative 
 results I was not satisfied until I made a trial on the cat, 
 and with better success. It seemed reasonable to suppose 
 that if the views of Simpson and Syme were correct there 
 must be some unknown source of danger in allowing 
 elimination of the vapour, and partial recovery to take 
 place at certain stages of the inhalation, and, if so, that 
 this ought to be capable of demonstration on animals. 
 Neither the London Chloroform Committee of 1864, 
 nor the recent Hyderabad Commission, obtained this 
 result, although the latter "tried hard." Dr. Lauder 
 Brunton tells us that they even stopped short at an 
 early stage in search of it, but I can only suppose 
 that they were still too deep, or they must have 
 found it. If, instead of performing various operations 
 on animals which were merely stupefied with chloroform, 
 they had made observations with the stethoscope or 
 
 * Brit. Med. Journ., June 21, 1879, p. 921. 
 
FACTS. 19 
 
 the kymograph, they would surely have done so. That 
 these animals did not die does not disprove this, for 
 neither does the cat appear to die under any circum- 
 stances from this form of syncope — a fact which very 
 much disappointed me when I first observed it. Never- 
 theless, I still think it reasonable to regard this as the 
 analogue of what has so often proved fatal in the human 
 subject, for it is the only ray of light which can be shed 
 on the question. Recent research in some directions 
 gives additional warrant to the belief that such may be 
 the case. Here I would chiefly refer to that form 
 of syncope characterised by fibrillar contraction, and 
 spoken of by pathologists as delirium cordis. Professor 
 M'William, of Aberdeen, has ascertained that this form of 
 syncope is readily induced by galvanic and faradic shocks 
 applied to the cardiac muscle, and that it is much more 
 dangerous in the higher mammals than in the lower, 
 and may cause speedy death in a dog* . This may be of 
 great significance in regard to chloroform syncope also. 
 If the primary chloroform syncope cannot be induced in 
 a rabbit at all, in which the influence of the vagus on the 
 heart is comparatively slight, we are not in a position to 
 deny that this form of syncope may be frequently fatal in 
 the human subject, although the cat seems always to 
 recover from it. And if the fatalities in the human 
 
 * British Med. Journ., Feby. 16th, 1889, p. 348. 
 
20 FACTS. 
 
 subject have almost invariably been caused by this form 
 of syncope they are to be added to the facts which go to 
 support the above theory. I must differ from the 
 Glasgow Committee in their statement that their dog 
 was previously in deep anaesthesia ; at all events, if my 
 view be correct, in sufficiently deep anaesthesia the 
 retardation of the heart would not have occurred, while, 
 had the anaesthesia been more superficial, it would have 
 been more pronounced. If all parties differ here, how- 
 ever, let this matter be re-investigated, for I take it to be 
 the very crux of the problem to be solved. What is the 
 action and reaction of certain anaesthetic vapours on the 
 pulmonary mucous membrane ? To determine this it is 
 probable that tetrachloride of carbon, or even some sub- 
 stance quite insoluble in the blood, would answer better 
 than chloroform. 
 
 Although the Hyderabad Commission could not 
 obtain the same tracing as the Glasgow Committee had 
 done as the direct effect of chloroform, they found they 
 could reproduce what they regarded as identical with it by 
 asphyxiating the animal. Hence they came to the con- 
 clusion that accidental asphyxia must have been the cause 
 of its being obtained by the latter Committee also. But 
 if what I have observed in the cat be the counterpart of 
 what the Glasgow Committee found in the dog — and the 
 cat presented a similar series of events in an even exag- 
 gerated degree — the explanation is erroneous, and I have 
 
DEDUCTIONS. 21 
 
 no doubt will be refuted by the latter on other grounds 
 also. Possibly enough, the tracing produced by asphyxia, 
 and that resulting from the perturbation of the circulation 
 above described, may be the same, for during the pause 
 in the heart's action it is probable that the arteries and 
 capillaries are almost empty, and that the blood has ac- 
 cumulated in the venous system. But there was no 
 possible cause of asphyxia in the cat, and however similar 
 the results, the primary and sole cause was the chloro- 
 form. 
 
 Deductions. — It may be interesting and important 
 to notice some of the consequences of the above princi- 
 ples. It will be readily granted that an agent which 
 produces deep anaesthesia is to be regarded as a force of 
 very considerable intensity. It may be laid down as an 
 axiom that no force acting with great intensity on the 
 animal system can be suddenly removed with safety. 
 Hence, if we could conceive of the internal force, the 
 chloroform in the blood, being removed as suddenly as 
 the external one, the same consequence would follow, 
 namely, syncope. We can readily imagine an agent 
 capable of being so suddenly removed — a substance of 
 slight solubility, but so powerful that a small quantity of 
 it might suffice to produce deep ansesthesia. These 
 were just the very characteristics of amylene, and furnish 
 one reason why, in the hands of the late Dr. Snow, it 
 
2 2 DEDUCTIONS. 
 
 proved a treacherous and dangerous agent, the result 
 being the very reverse of what its introducer expected. 
 It further follows from the same principle that if the 
 external force, instead of being removed suddenly and 
 completely, were slowly withdrawn by allowing the per- 
 centage of vapour gradually to diminish, the tendency to 
 syncope would be altogether obviated. Another obvious 
 consequence is, that if the external force be not suffici- 
 ently intense, dangerous syncope will not follow. It 
 would appear that an atmosphere of 2 or 2 J per cent, 
 of chloroform vapour is required to produce an intense 
 reaction on its removal, and, therefore, a " few whiffs "" 
 of chloroform may be given without much danger if the 
 atmosphere does not exceed i or ij per cent. 
 
 The most important consequence of the theory, how- 
 ever, is one which deserves to be specially noticed, from 
 its bearing on possible objections which may be urged. 
 It is clear from the foregoing that the point of maximum 
 danger, the point at which the worst form of syncope will 
 occur if the external force is suddenly withdrawn, i.e.^ if 
 the inhalation is at once stopped, is but one of many, 
 and that an administrator quite ignorant of it has a great 
 many chances of escaping it. If it were not so cases of 
 syncope would be much more com.mon than they are, 
 and it might evidently be objected that they ought to 
 be more common if such an initial danger as that above 
 indicated exists. But let us suppose that the time 
 
DEDUCTIONS. 23 
 
 required to induce deep anaesthesia is five minutes (300 
 seconds), and let us imagine this to be represented by a 
 line divisible into 300 parts or segments, one of which, 
 near the beginning, represents the point of maximum 
 danger. It is clear that the ignorant administrator would 
 only incur the risk of striking the fatal point once in 300 
 times. Again, his chance of escape would be further 
 increased by the consideration that although he stopped 
 short at the fatal point, he might not withdraw the vapour 
 at once and completely, but gradually allovv^ the strength 
 of it to diminish, thus breaking the force of the reaction. 
 Finally, observation in the cat shows that the reaction 
 ensuing on withdrawing the external force lasts a minute, 
 (in its worst form) before terminating in syncope, and 
 during this minute the administrator has a chance of re- 
 applying the force, and again reversing the process 
 In this way, then, the chance of falling into the fatal 
 syncope might be reduced to i in 2000, or any given 
 number of times. Another important consideration 
 comes in here. While, by the hypothesis, the point of 
 maximum danger is but one of many, points of lesser 
 danger will be more numerous, and therefore more fre- 
 quently encountered by the administrator, supposed to be 
 ignorant of them. And hence, I believe, the reason why 
 we so often read of pallor of the countenance being ob- 
 served in the early stages of chloroform inhalation. This 
 is nothing more nor less than a certain degree of syncope, 
 
24 DEDUCTIONS. 
 
 due to withdrawing the external force before the internal 
 had come into eqiiiUbrium with it. 
 
 When we look at the matter a little more in detail, the 
 manner in which the different degrees of the primary 
 syncope are produced will become clearer. The worst 
 form of syncope in the cat comes on after breathing 2 J 
 per cent, of the vapour for little more than a minute. 
 The reaction which ensues consists of two parts; (i), 
 a period of acceleration of the circulation, lasting one 
 minute, and (2) a pause in the heart's action lasting the 
 same length of time. Now, if the theory be true, it 
 follows that if the inhalation be continued somewhat 
 longer, this reaction will be modified by the increased 
 intensity of the internal force, and by the more 
 gradual manner in which the latter ceases to act. This 
 modification, evidently, will show itself by a lengthening 
 of the entire duration of the reaction, by a diminution 
 of its violence, and by a change in the relative time 
 occupied by the periods of acceleration and retardation 
 respectively, the latter gradually becoming shorter, until, 
 when the two forces have come into equilibrium it dis- 
 appears altogether. That is to say, by making the nar- 
 cosis a little deeper the pause in the heart's action might 
 be made to manifest itself at the end of two or three 
 minutes, when it would be of shorter duration, and con- 
 sist only of retardation or momentary failure. 
 
 If the above theory of the nature of chloroform syn- 
 
DEDUCTIONS. 
 
 25 
 
 cope be correct, it follows that we. could illustrate it at 
 will on almost every human being (except, perhaps, in 
 parturient females, and a few others), as we can do on a 
 cat. All that is necessary is to make any one breathe 
 2J per cent, of the vapour for a minute or so, and 
 suddenly stop short, when the syncope will be almost 
 certain to show itself at the end of the next minute. 
 This is exactly what happened in the first fatal case 
 of chloroform syncope, in the girl at Winlaton, near 
 Newcastle, who breathed the vapour for about a minute, 
 and died at the end of the next minute. There can be 
 no doubt that precisely the same thing would occur again 
 in the same circumstances, as, indeed, has occurred in 
 many other fatal cases. According to the theory all such 
 cases would have been quite safe had the patients gone 
 straight on breathing the same per-centage of vapour for 
 five, ten, or even fifteen minutes, and this is the only 
 thing which could have saved them. It follows that 
 chloroform syncope can easily be avoided in every case, 
 and I do not hesitate to record my settled conviction that 
 there is not a man, woman, or child in the world who 
 could not be chloroformed without the slightest risk of 
 incurring the primary syncope. Let us now briefly review 
 the various opinions which have been advanced as to the 
 cause of death from the anaesthetic, that they may be 
 seen side by side with the view suggested by the above 
 theory. 
 
26 THEORIES OF DEATH FROM CHLOROFORM. 
 
 Theories of Death fFom Chlorofopm.— Dr. Snow 
 
 consistently maintained the opinion that death was al- 
 most invariably due to the administration of an unduly 
 concentrated atmosphere. The suddenness of the 
 occurrence, and the fact that the catastrophe generally 
 happened in the early stages of the inhalation, favoured 
 this view. Experience has amply shown, however, that 
 it is untenable. It is emphatically negatived by numer- 
 ous facts j by the fact that a towel at 70° F. does not 
 give off an overdose ; that the anaesthetic can be safely 
 administered to children ; that it is safe in the hottest 
 climates, in which it is still held in high favour ; but, 
 above all, by the fact that fatalities have been most 
 common in the hands of the most cautious adminis- 
 trators. The opinion that the deaths which have 
 occurred in the human subject have been caused by 
 undue prolongation of the inhalation has nothing at all 
 to be said in its favour, so that it need hardly be dis- 
 cussed. Even Dr. Snow, with all his caution, admitted 
 that this was scarcely possible. Both of the above 
 opinions, therefore, must be dismissed ; the hecatombs 
 of animals which have been sacrificed to prove the effects 
 of concentrated atmospheres and of prolonged inhalation 
 have availed nothing : the results have been as wide of 
 the mark as one pole is from another. It is a most 
 important fact that a cat can go on breathing a per-cent- 
 age of the vapour which has produced deep anaesthesia 
 
THEORIES OF DEATH FROM CHLOROFORM. 27 
 
 in a given time, several times longer than the x^eriod 
 necessary to produce the narcosis. If there is any 
 comparison between a cat and the human subject chloro- 
 form is in this respect the safest of all anaesthetics, and 
 from five to ten times safer than ether. I make this 
 startling statement not rashly, but advisedly, all authori- 
 ties to the contrary notwithstanding. If, then, the fatali- 
 ties in the human subject have not been due to either 
 of the above causes, we are driven to ascribe them to 
 individual idiosyncrasies, or to some fault of the admini- 
 strator of a vague kind, which cannot be precisely 
 specified. If idiosyncrasy is to be held accountable for 
 these catastrophes in some cases, the problem before us 
 is to explain the nature of this idiosyncrasy, and to define 
 it so that we can diagnose it before and not after the 
 event — a truly difficult and impossible task. Under the 
 new theory there will still be room allowed for the play 
 of idiosyncrasy, but the role at present attributed to it 
 merely shows the profundity of our ignorance, for 
 individual peculiarities cannot possibly explain w^hy people, 
 both in India and in Scotland, can breathe with safety 
 an amount of chloroform vapour which, in the opinion 
 of London experts, ought to kill them ten times over. 
 Simpson, although he soon arrived, as if by a marvellous 
 intuition, at the proper method of administering chloro- 
 form, in which he was followed by Syme, could never 
 satisfactorily explain the deaths which so frequently 
 
28 THEORIES OF DEATH FROM CHLOROFORM. 
 
 attended an opposite method, and so failed to convince 
 Others. The suggestion that they were due to the shock 
 of the operation failed to meet the case, as they so 
 frequently occurred before any operation was commenced. 
 The solitary fatal case which happened in the hands 
 of Simpson himself was clearly one of the primary 
 syncope ; the patient moved during the first incision, 
 vomited, and this was almost immediately succeeded by 
 the fatal syncope. Other teachers of the Edinburgh 
 school have been betrayed into a lamentable incon- 
 sistency, which has rendered their teaching nugatory, and 
 which clearly shows that some leading principle has 
 hitherto been awanting. For instance. Sir Joseph Lister 
 laments that the anaesthetic is often given in such a 
 way as to be almost useless, and recommends that it 
 should be poured freely on the towel, unmeasured and 
 unstinted. Of what avail this injunction when he else- 
 where arrives at the conclusion that deaths must gener- 
 ally have been due to the unguarded or careless admin- 
 istration of an overdose of the powerful anesthetic? 
 Similarly with Dr. Lauder Brunton. He returns from 
 Hyderabad and warns us that danger is from an overdose 
 or from asphyxia. Of what use is it after this to quote 
 with approval, as he does, (and as he has often done 
 before) the saying of Syme that one reason of his success 
 was that he gave *' plenty of it " ? The bewildered 
 reader is impaled on the horns of a dilemma by these 
 
THEORIES OF DEATH FROM CHLOROFORM. 29 
 
 contradictions. The position is an utterly inconsistent 
 one. The advice of the Hyderabad Commission, to give 
 the anaesthetic with excessive caution, is the very same as 
 was recommended by Dr. Snow and the London Com- 
 mittee, and which Simpson summoned all his energy and 
 vehemence to oppose. If safety is secured by giving 
 plenty of it, there must be some danger in giving too little, 
 and on this point the Hyderabad Commission has 
 elicited nothing. 
 
 The theory which I have here advanced appears to 
 furnish the only key to the solution of the enigma. 
 The reaction which follows the sudden removal of the 
 external force — the chloroform tourniquet acting on the 
 pulmonary mucous membrane, explains everything. It 
 is not the chloroform inside, but the vapour outside 
 of the circulation which has done the fatal work on the 
 human subject, and which has taken its departure a full 
 minute before the fatal effect has become manifest. 
 There is scarcely any chloroform at all in the blood when 
 the dreaded catastrophe occurs ; the little that had been 
 absorbed having been nearly all eliminated during the re- 
 action preceding the syncope. Hence the danger of a "few 
 whiffs" of chloroform; hence the pallor of the countenance 
 often seen before the second supply on the cloth reaches 
 the patient, sufficient time having elapsed for him to have 
 lost all that he had got. We can at once see how 
 patients have been killed without even being anaesthe- 
 
30 . THEORIES OF DEATH FROM CHLOROFORM. 
 
 tised ; how the catastrophe has generally been encount- 
 ered in the early stages of the administration, and in the 
 hands of those who allow elimination to take place ; and 
 how it has been frequent in the case of trifling operations 
 when it has been thought that a small dose of chloro- 
 form was sufficient for the purpose. We can understand 
 how the strongest in the prime of life have often been 
 the victims, when the weaker have escaped, although the 
 former would have lived twice as long as the latter had 
 both been compelled to breathe an atmosphere of the 
 same strength until death ensued. Indeed, I believe 
 that the theory explains all the phenomena, and that all 
 objections to it may be met. It may be interesting and 
 instructive to particularise a few more cases of syncope in 
 the human subject, in addition to the one above alluded 
 to. A few which have been cited, or for the first time 
 reported, since the result of the Hyderabad Commission 
 was published, will answer the purpose. 
 
 Three very typical cases of the kind are cited by Mr. 
 Braine in the Lancet for Feby. 8th of the present year, p. 
 316, the first being that of the girl at Newcastle already 
 
 noticed. Let us take the other two. i. Patrick C , 
 
 age not stated. March, 1848. Disease, fistula. Had 
 taken chloroform once previously. Time of inhalation, 
 about one minute. Quantity consumed, half a drachm. 
 Lapse of time till death, about one minute. Patient on 
 his side ; chloroform was administered on a handkerchief 
 
THEORIES OF DEATH FROM CHLOROFORM. 3 I 
 
 or towel. Immediately the operation was commenced the 
 patient became pulseless, his pulse previously being full 
 and natural. 
 
 Whatever might be due to the shock of the operation 
 in the above case, it is clear that according to the theory 
 the administration was as certain to lead to syncope as if 
 it had been a physiological experiment intended to illus- 
 trate the subject. 
 
 2. J. V. , aged seventeen, Hotel Dieu, Lyons, 
 
 January, 1849. Amputation of finger. Chloroform was 
 dropped upon gauze spread over the face, leaving a free 
 passage for air. At the end of five minutes patient still 
 felt and spoke, at the end of six minutes he became rest- 
 less and still spoke. One drachm and a half of chloro- 
 form had now been given; pulse regular and good. He 
 
 now struggled violently, and within a quarter of a minute 
 the pulse at the wrist became imperceptible. The gauze 
 
 was removed, no pulse anywhere to be felt, and no cardiac 
 
 sounds audible. Respiration continued, and ceased in 
 
 half a minute. Means of resuscitation were employed, 
 
 and respiration reappeared in two minutes' time, and then 
 
 again gradually ceased. The pulse did not return. 
 
 I agree with Mr Braine that cases have gone on 
 
 occurring in much the same way ever since ; indeed, it 
 
 may truly be said of cases of chloroform syncope, ex uno 
 
 disce omnes. But I dissent from his conclusion that they 
 
 will continue so to do as long as chloroform is adminis- 
 
32 THEORIES OF DEATH FROM CHLOROFORM. 
 
 tered. On the contrary, I say they were quite preven- 
 table. In the latter case, if an ounce and a half of the 
 liquid had been administered in six minutes, by pouring 
 two drachms on a towel, and renewing it every minute, 
 the patient would have been anaesthetised with absolute 
 safety. And similarly with the former case. But Mr 
 Braine's citation of these cases is very pertinent and 
 opportune. We have a right to call upon those who 
 presume to be teachers in anaesthesia to give us their 
 explanation of these cases. Accidents can never be pre- 
 vented in the future until we know how they were caused 
 in the past, nor until every chloroformist is convinced 
 as to the true explanation. Were these deaths due to an 
 overdose, or to asphyxia, or could they have been prevented 
 by watching the respiration? No; and I assert that if my 
 theory do not furnish the true explanation there is no 
 other possible theory which can justify us in maintaining 
 that chloroform is a safe agent in all cases, and the 
 doctrine of Simpson and Syme must have been erroneous. 
 Numerous other fatal cases, of quite recent occurrence, 
 appear to admit of a similar explanation, although the 
 necessary facts are not always given in the reports. Two 
 fatal cases in children have recently been published by 
 two American surgeons, and these are adduced as proving 
 that chloroform is not safe in childhood, as has hitherto 
 been believed. In one of these, a boy of five, anaethesia 
 had been established not longer than one minute and a 
 
PSEUDO-ANESTHESIA UNDER CHLOROFORM. T,T, 
 
 half, and not more than a drachm of chloroform had 
 been poured on the towel. We are told that anaesthesia 
 was easily produced, but are not informed how long the 
 inhalation lasted. The boy had been chloroformed on 
 three previous occasions, when more chloroform had been 
 used than in the fatal administration. Now, a single 
 drachm of chloroform cannot produce deep narcosis in a 
 boy of five, although it is quite capable of producing a re- 
 action, terminating in syncope, in the way I have pointed 
 out. In the other case, a girl of two, the anaesthesia is 
 said not to have been profound, and the child cried out 
 occasionally during the operation. The whole affair, in 
 short, seems to have been a mere mockery of chloroform 
 anaesthesia, as might truly be said of nearly every fatal 
 case of administration, and it cannot be too strongly in- 
 sisted on that it is not safe to give the anaesthetic in this 
 •fashion, even to children. It is hardly worth while to 
 notice, in detail, any more of these cases, and I pass on to 
 speak of another consequence of the above theory, which 
 I would refer to under the designation of false anaesthesia. 
 
 Pseudo-Anaesthesia under Chloroform. — It 
 
 follows from the views above expressed that the inhala- 
 tion of chloroform may give rise to two apparently 
 identical, but widely different conditions, which may be 
 aptly called true and false anaesthesia. True anaesthesia 
 results from the continued absorption of the agent, and 
 
34 PSEUDO-ANESTHESIA UNDER CHLOROFORM. 
 
 its accumulation to a sufficient amount in the blood, and 
 is characterised by certain well-known symptoms. What 
 I would call false anaesthesia is the consequence of 
 stopping the inhalation at an early stage, and allowing 
 elimination of the vapour to take place, when the patient 
 may pass into a more profound state of insensibility than 
 if he had gone on absorbing chloroform. In the worst 
 form of this we have the aspect of death itself, and in 
 slighter forms all the symptoms of deep anaesthesia may 
 be present, — muscular relaxation, loss of conjunctional 
 reflex, and stertor, all due to comparatively empty arteries 
 and capillaries, and not to the presence of chloroform. 
 These symptoms, therefore, no more prove that the 
 anaesthesia is of the true sort than a temperature of 
 104° F. proves a case to be one of scarlet fever or of 
 pneumonia. In one important particular the two con- 
 ditions are differentiated as widely in symptomatology as 
 they are in etiology. If false anaesthesia does not pass 
 into death, recovery is rapid, and there is soon return 
 of rigidity and lid-reflex, or even of perfect conscious- 
 ness. In this way are explained the sudden transitions 
 from deep insensibility to consciousness, mentioned in 
 Dechambre's Dictionary, and elsewhere. In true anaes- 
 thesia this sudden return of the sephenomena is impossi- 
 ble, and the distinction is of the utmost importance. 
 How often do we read that the patient was fully anaes- 
 thetised when it is clear from the description that the 
 
DANGER OF OVERDOSE. 35 
 
 administrator knows nothing of true anaesthesia, nor of 
 the fact that his patient could safely have breathed five 
 or ten times more of the vapour, nay, that this was 
 necessary to ensure safety. How often do we read that 
 the patient took the anaesthetic badly, when it ought to 
 have been said that he got it badly. Syncope occurring 
 even after prolonged narcosis may still be of the primary 
 sort, for a patient may be subjected to a number of these 
 dangerous oscillations of the circulation — tossed as in a 
 whirlpool, during a single administration. If a guiding 
 principle has all along been awanting, we may be allowed 
 to doubt the testimony of even the most experienced; those 
 who have had the unhappy experience of being thirty 
 or forty years in the wrong have everything to unlearn. 
 Administrators are to be excused when eminent physi- 
 ologists and pathologists, invested with a commission to 
 inquire into the subject which gave them a sort of 
 oracular authority, have shown their ignorance of the 
 distinction between mere stupor and deep anaesthesia. 
 It must be evident how bad after-effects, sickness, vomit- 
 ing, faintness, and even recurrence of alarming syncope, are 
 liable to be entailed by the faulty method of adminis- 
 tration above indicated. Before treating of the adminis- 
 tration of chloroform, I would make a few remarks on the 
 alleged danger of giving an overdose. 
 
 Danger of Overdose. — According to the Glasgow 
 
36 DANGER OF OVERDOSE. 
 
 Committee, chloroform has a disastrous effect on the 
 heart and respiratory centres, and a dog or rabbit will soon 
 die under its influence, while either will live a long time 
 if ether be used. The impression conveyed is that there 
 is much more danger of giving an overdose of the former 
 than of the latter. The fallacy underlying the reasoning 
 of the Committee is so transparent as hardly to require 
 refutation, and it seems to me they have presumed far on 
 the supposed ignorance or want of reasoning power of the 
 profession. It is true that chloroform is a more powerful 
 agent than ether, a fact which was well known before the 
 Committee commenced their investigations. But if the 
 anaesthetic power of the former is great in proportion to 
 its toxic influence, or power to kill, and if the dose neces- 
 sary to produce a desired anaesthetic effect can be easily 
 regulated, their contention falls to the ground. And the 
 simple fact is that the ratio of the anaesthetic to the toxic 
 power is greater in the case of chloroform than in that of 
 ether, so that on the side of an overdose it is the safer 
 agent of the two. Evidently the comparison, to be fair, 
 should be made with percentages of the vapour of each 
 having the same anaesthetic effect, per-centages which 
 might be regarded as anaesthetic equivalents. If this were 
 done two facts could be proved. It could be shown that 
 chloroform produces deeper anaesthesia before death ensues 
 than ether can do, which simply means that the vital phe- 
 nomena can be reduced to a smaller flame short of actual 
 
DANGER OF OVERDOSE. 37 
 
 extinction of life by the former than by the latter. Chloro- 
 form, in short, is a fine adjustment for this purpose, and 
 ether a coarse one. Second, it could be demonstrated that 
 when anaesthetic equivalents are used the time which elapses 
 between a given depth of anaesthesia and death is much 
 longer with chloroform than with ether. In this respect 
 the former is more than five times safer than the latter. 
 Indeed, so long is this interval that the question whether 
 the heart or respiration fails first I regard as of no practical 
 importance whatever. Never had anything less foundation 
 in fact than the prevalent idea that a patient in deep chloro- 
 form narcosis is tottering on the verge of a precipice, where 
 the slightest touch, or the slightest additional whiff, will 
 push him over. I incline to the opinion that he is rather 
 safer than the average individual, exposed to the ordinary 
 casualties of life. If it be said that there is still the 
 danger of an unduly concentrated atmosphere of chloro- 
 form to consider, the answer is that this danger is purely 
 visionary. As will be shown a little further on it is im- 
 possible to get an overdose from a towel at 70° F. 
 however freely the liquid may be poured on it. The 
 cautious Dr. Snow restri(^ted the limit of safety to 5 per 
 cent., and this is much beyond what can be got from a 
 towel at the temperature mentioned. Let any one attempt 
 to apply his nose to the mouth of a jar charged with 5 per 
 cent, of chloroform vapour and he will be readily con- 
 vinced that an atmosphere of this strength has never been 
 
38 FALL OF BLOOD-PRESSURE UNDER CHLOROFORM. 
 
 administered to the human subject. I hold the con- 
 clusions of the Glasgow Committee on this important 
 point, therefore, to be entirely erroneous, and in the highest 
 degree pernicious in their tendency, which naturally is to 
 deter any administrator from deep chloroform narcosis — 
 the only safe state of anaesthesia under this agent. 
 
 Fall of Blood-Ppessure under Chloroform.— 
 
 Before the London Committee of 1864 commenced their 
 series of carefully conducted experiments, clinical experi- 
 ence had amply shown that chloroform was a dangerous 
 agent. Finding, therefore, that when administered to 
 animals it promptly lowered the pressure in the vessels, 
 they naturally inferred that this afforded one indication 
 of its dangerous character, and this view has been almost 
 universally accepted. There are grounds for calling even 
 this in question, however, and I gather from various state- 
 ments of Dr. Lauder Brunton that he does not unhesi- 
 tatingly accept it, but seems rather inclined to an opposite 
 opinion. I hail this with satisfaction, as I have long be- 
 lieved the view of that Committee to be unfounded. 
 Indeed, if the statement made in the preceding paragraph be 
 a fact, that life is more slowly extinguished under chloro- 
 form than under an anaesthetic equivalent of ether, it must 
 be so. This fact, indeed, is partly due to the greater 
 lowering of the pressure under chloroform, and partly to 
 the slighter solubility of this agent as compared with ether, 
 
THE CHLOROFORM ATMOSPHERE AND HOW TO KEEP IT UP. 39 
 
 circumstances which combine to permit of its passage into 
 the blood in only a very gradual manner, especially beyond 
 the stage of surgical anaesthesia. But whatever the reason 
 of this great prolongation of life under chloroform, the 
 practical value of the fact is the same. I believe that the 
 above are not the only arguments which could be adduced 
 in favour of the opinion that the greater power of chloro- 
 form to lower the blood-pressure is at once an indication 
 of its superiority to ether, and of its greater safety on the 
 side of an overdose. 
 
 The ChloFofopm Atmosphere and how to keep 
 
 it up. — In order to reduce these principles to practice, 
 we must know how to keep up a sufficient atmosphere of 
 chloroform. The amount of vapour given off from a towel 
 depends on the temperature and dryness of the air. Sir 
 Joseph Lister performed an experiment to show that 
 there is no danger of getting an overdose of vapour 
 from a towel, even at 70° F.* He found, by weighing 
 a towel on which ij drachms of chloroform had been 
 poured, and circumstanced as nearly as possible as in 
 actual inhalation, and estimating the loss of weight dur- 
 ing one minute's evaporation, that the atmosphere given 
 off did not exceed 4^ per cent, supposing the patient to 
 inspire the average amount of air necessary for a healthy 
 
 * Holmes' System of Surgery, 3rd Ed., Vol. iii., Arudc—Ana'si/tesia 
 
40 THE CHLOROFORM ATMOSPHERE AND HOW TO KEEP IT UP. 
 
 adult. In repeating this experiment, which I have done 
 carefully several times, I was struck with the fact that I 
 never got a stronger chloroform atmosphere than 3^^ per 
 cent, and the result was the same if half-an-ounce of the 
 liquid was poured on the cloth. In the course of the 
 experiment another point worth noticing was ascertained. 
 After two minutes evaporation, although the towel smelt 
 strongly of chloroform, very little more vapour was given 
 off — so Httle that a patient breathing the atmosphere must 
 have been eliminating, instead of absorbing, the anaes- 
 thetic. This is of the utmost importance in connection 
 with the objectionable practice of many who do not 
 renew the dose of liquid until the smell of the anaes- 
 thetic has left the cloth, and who go on frequently smell- 
 ing the latter instead of making the patient do so, a 
 practice truly ludicrous were it not dangerous. To 
 keep up a proper atmosphere of the vapour, therefore, 
 requires an expenditure of two drachms of the liquid every 
 minute (or at a little longer interval), and it is well also 
 to have a temperature of 65° F. 
 
 I witnessed some ridiculous scenes of chloroform 
 administration on my first coming to this city. I cannot 
 forget the terror I have seen depicted on the countenance 
 of some old and experienced practitioners when one 
 insisted on renewing the dose on the towel. And I well 
 remember one case in which pallor of the countenance 
 and disagreeable after-effects, lasting for several months, 
 
ADMINISTRATION OF CHLOROFORM. 41 
 
 according to the patient's account, resulted from the prac- 
 tice of the administrator smelHng the towel before renewing 
 the dosei It seems that he had always seen this done in the 
 Royal Infirmary, and I could hardly prevail on him to de- 
 sist, or to allow the dose to be renewed, and the result was 
 very unsatisfactory (and, as I am now thoroughly con- 
 vinced, dangerous), anaesthesia, at the end of fifteen or 
 twenty minutes. He was afterwards persuaded, however, to 
 adopt a different method, and expressed great surprise at the 
 difference in the result. Such scenes are still common, 
 and I believe that one half of the profession have hardly 
 any conception of the manner in which chloroform is 
 administered by the other. 
 
 Administpation of Chloroform.— It would appear 
 from the foregoing that chloroform is an even more for- 
 midable weapon than had previously been supposed ; 
 that it is, in fact, a two-edged sword with which the 
 unskilful should not meddle, and in particular a very 
 dangerous agent for self-inhalation. The initial danger 
 at the outset has to be added to the further risk of giving 
 an overdose in the deeper stages of narcosis, so that the 
 chloroformist must steer between Scylla and Charybdis, 
 and his motto must be : in medio iutissi?nus ibis. Hitherto 
 he has only been warned against being wrecked on the 
 old rock Scylla, which has been well enough known and 
 recognised since the first day the anaesthetic came into 
 
42 ADMINISTRATION OF CHLOROFORM. 
 
 use. The Hyderabad Commission has but added an- 
 other to these admonitions to avoid Scylla, the result 
 being of course to drive the mariner with all the more 
 certainty into the whirlpool on the other side of the 
 channel. It is fortunate that the conclusions of the 
 Commission, as is clear from various letters which have 
 appeared in the medical journals, are not generally 
 regarded as satisfactory. The results of clinical ex- 
 perience, and the opposite doctrines of different schools 
 as to the proper method of administration, are not 
 explained by the work of the Commission. Already 
 they have been confronted with these clinical results — ■ 
 with cases which have proved fatal in two minutes or so, 
 in which no overdose had been administered, and in 
 which there is not the shadow of a reason for saying that the 
 primary syncope could have been avoided by watching 
 the respiration. The Commission has made matters 
 worse than before, for they have declared that death 
 from chloroform is certainly preventable without having 
 in the least shown how this consummation is to be 
 attained. The result will not be to induce those who 
 are already too much afraid of chloroform to give it 
 freely, like Syme or Surgeon-Major Lawrie himself, but 
 the very reverse, and with a probable increase in the 
 mortality. It was not by watching the respiration, but 
 by giving " plenty of it," that Syme achieved his results. 
 By administering a continuous atmosphere he was clear 
 
ADMINISTRATION OF CHLOROFORM. 43 
 
 of Charybdis in a few minutes, when nobody was watch- 
 ing anything, and it was only in deep anaesthesia that he 
 sometimes found it necessary to watch the respiration. 
 The admonition to watch the latter applies correctly to 
 Scylla only, and not to Charybdis ; those who run the 
 risk of falling into the latter have much need to fear a 
 sudden stoppage of the pulse. 
 
 The Glasgow Committee stumbled on Charybdis, for 
 they had not previously suspected its existence. They 
 were far from appreciating its importance, however, 
 and, in fact, failed even to recognise it, for they were 
 careful to state that the dog did not receive an over- 
 dose, and evidently had no suspicion of the fact that 
 the retardation of the heart observed by them was due 
 to the animal having got an underdose. They leave us 
 to infer that this danger may be encountered anywhere 
 in chloroform narcosis, and that we are never to know 
 when and where. If this were so, then indeed the 
 case would be finally closed against chloroform. But 
 it is not so ; Charybdis occupies a definite position ; 
 its latitude and longitude may be exactly defined, and 
 the mariner provided with a chart which will enable him 
 to steer clear of it with ease and safety. My observations 
 on the cat, and the experience of the boldest admini- 
 strators, who have met with the greatest success, prove 
 conclusively that this is the case. There is plenty of 
 room in mid-channel, and the dangers on either side 
 
44 ADMINISTRATION OF CHLOROFORM. 
 
 have but to be known to be easily avoided. Hitherto, 
 the experience of the chloroformist might be truly ex- 
 pressed (with a transposition of two words) by the line : 
 
 Incidit in Scyllam qui vult vitare Charybdim. 
 But he need neither strike against the one nor go down 
 in the other. 
 
 The above principles point to a single plain rule for 
 the administration of chloroform. This is to keep up a 
 continuous atmosphere of the vapour until deep anaes- 
 thesia is induced, and not to stop short of this point for 
 any reason whatever, and no matter what the operation. 
 The chloroform tourniquet having been once applied to 
 the pulmonary circulation is to be kept there until the 
 internal force comes into equilibrium with it. I here 
 record my strong conviction that whenever this is done 
 in all cases chloroform syncope will become a thing of 
 the past. It may be objected : Are we not to stop for 
 a few seconds when the patient says he is being choked, 
 or when he holds his breath, or coughs, or struggles 
 violently ? The answer to each and all of these ques- 
 tions is an emphatic NO. By bringing the towel 
 gradually near during the first few seconds the feeling 
 of choking may be nearly prevented, but if the patient 
 still complains of it the administrator should say, never 
 mind, all the better ; and go on. When the patient 
 holds his breath for a considerable time, as he often does 
 irum the diminution of the besoin de respirer^ there is no 
 
ADMINISTRATION OF CHLOROFORM. 45 
 
 harm in waiting till respiration spontaneously returns, but 
 as this causes loss of time it is better to tell him to go on 
 breathing so long as he can hear and respond. With 
 respect to struggling and excitement it will be found that 
 they are reduced to a minimum by the continuous 
 method of administration here recommended. Danger- 
 ous struggling may be caused by the interrupted method 
 of inhalation. What of alarming pallor of the counten- 
 ance ? This, the slightest form of the primary syncope, 
 will never be seen ; on the contrary, it will be found, as I 
 have constantly observed, that there is a distinct heighten- 
 ing of the complexion in children and people with trans- 
 parent skins. So with regard to vomiting, which only 
 occurs during elimination, and not while absorption is 
 going on. It ought to be known, too, that salivation is 
 an indication that the atmosphere being breathed is 
 weak, for it will not occur with one of 3 or 4 per cent. 
 I take this salivation to be another proof of the local 
 action of the vapour, and there can be no doubt that it 
 exerts a powerful influence on the whole respiratory tract. 
 It seems to me that some details of Surgeon-Major 
 Lawrie's clinical experience would be valuable, perhaps 
 more so than all the results of the Hyderabad Commission. 
 He says that he has never had a case of syncope. Has 
 he ever seen any dangerous symptom within the first five 
 minutes, or before the stage of deep anaesthesia was 
 reached ? How long does he generally take to induce satis- 
 
46 ADMINISTRATION OF CHLOROFORM. 
 
 factory narcosis, and what is the amount of Hquid used in 
 doing so ? How much is employed in a given time in the 
 course of long operations ? What is the dose poured on the 
 towel, and how often is it renewed, as a rule ? What is 
 the temperature of the air in the hottest weather, and does 
 he then find it necessary to be very careful to guard 
 against an overdose ? Answers to these questions by one 
 who has had 10,000 successful administrations would be 
 valuable for comparison with those reports of fatal cases 
 with which we are all too familiar. 
 
 So far from there being any danger of getting an un- 
 duly concentrated atmosphere of chloroform vapour in our 
 climate, the difficulty is all the other way, to get it strong 
 enough. Since performing the experiments with the 
 towel already mentioned I constantly take care, when 
 giving chloroform, to have the apartment heated to 65° or 
 70° R, and to have two towels thoroughly warmed and 
 dried at the fire. Two drachms of the liquid is poured 
 on the cloth, which is then held close to the nose and 
 mouth, and this dose is repeated in little more than a 
 minute, and always in less than two minutes. Each 
 successive dose is poured on a different part of the towel, 
 not cooled by previous evaporation, which is then reversed 
 so suddenly that the patient never gets a breath of air unim- 
 pregnated with the proper per-centage of the anaesthetic. 
 By this procedure there is no danger of dropping any 
 of the liquid on the lips or nostrils, which would certainly 
 
ADMINISTRATION OF CHLOROFORM. 47 
 
 be objectionable, and probably dangerous. I often open 
 up the towel so as to have only one or two layers over 
 the patient's face, the object being to hasten evaporation 
 as far as possible, and for this purpose also the second 
 warm towel is brought into requisition if necessary. 
 Throughout the entire process my sole care is to see 
 that the atmosphere is kept up ; I watch the bottle and 
 the towel and pay nothing but an incidental attention to 
 the pulse or respiration, satisfied that nothing can go 
 wrong with these short of the deepest surgical anaes- 
 thesia. Let the atmosphere be watched, and those 
 deputed to watch the countenance, pulse, or respiration, 
 will find their occupation gone. It is truly ludicrous to 
 picture half-a-dozen skilled attendants round an operating 
 table, watching for an event which should never happen. 
 The above method may be wasteful, for it requires 
 several ounces of chloroform to induce anaesthesia, but 
 it is not hasty or reckless, as might be thought, for true 
 anaesthesia is not produced by it in less than five 
 minutes, even in a child of ten, and the atmosphere is 
 probably never more than 3 per cent. Drops of chloro- 
 form may produce false anaesthesia and even death, but 
 according to my experience, it is impossible that true and 
 satisfactory narcosis can be induced by these small quan- 
 tities. If the above views are correct they show that the 
 teaching of Syme and Simpson rested on a truly scientific 
 foundation, and that the practice of many must be 
 
48 ADMINISTRATION OF CHLOROFORM. 
 
 radically altered. The interrupted method of admin- 
 istration must be for ever abandoned ; the administrator 
 must recognise that there is no danger in the early stages 
 but in going backward, and it will soon be found that 
 there is no more marvellous instrument of precision, 
 certainty, and safety in the whole range of the materia 
 medica than chloroform. 
 
APPENDIX. 
 
 Since these sheets were put into the hands of the 
 printer there has appeared in the British Medical Journal, 
 of June i4thj an article by the Glasgow Committee, 
 entitled " Remarks on the Report of the Second Hydera- 
 bad Chloroform Commission," and this was followed next 
 week by a rejoinder in the Lancet from Surgeon-Major 
 Lawrie, along with some further details of the work of the 
 Commission. — {^Lancet, June 21, p. 1369). Before com- 
 menting on these I would, on further consideration, draw 
 attention to some statements made by the Commission in 
 their first report, published in the Lancet, of January 1 8th, 
 1890, p. 149, with respect to blood-pressure. These seem 
 to me of special importance in connection with one of 
 their experiments, to be immediately noticed. If, in the 
 preceding pages, I have overlooked this experiment, it is 
 largely to be accounted for by the fact that it is only re- 
 ferred to in a very general way, and what I regard as 
 necessary details of fact are altogether awanting. I still 
 labour under the same disadvantage, but shall try to make 
 the most of it in the circumstances. The Commission 
 found that the administration of chloroform caused a 
 continuous fall of blood-pressure, and that after the inhal- 
 ation was discontinued there was still an after-fall for some 
 time, the rate of which depended altogether on the rapidity 
 
50 Appendix, 
 
 of the fall while the chloroform was being inhaled. They 
 have expressed the belief that this after-fall is probably 
 due to absorption of a portion of the residue of chloroform 
 in the air-passages after the stoppage of the inhalation. 
 The occurrence of this after-fall corresponds with what was 
 long ago pointed out by Dr Snow and M. Sedillot, viz., that 
 the effects of chloroform increased after the inhalation was 
 left off, owing to the absorption into the system of the 
 vapour which was contained in the lungs at the time when 
 the inhalation was discontinued.* Dr. Snow, however, 
 makes the further important remark that this accumulation 
 or increase of the effects of chloroform lasts for about 
 twenty seconds only. In the beginning of his work he 
 points out, from observation of the habits of eastern 
 nations, who inhale when they smoke, that the lungs 
 become emptied of their contents by three rather full 
 expirations and inspirations, t He describes the process 
 as witnessed by himself, "When this gentleman (a 
 smoker) took the cigar from his mouth to speak, the smoke 
 could be seen issuing thickly with each word till there was 
 a momentary pause as he took a fresh inspiration, then 
 the smoke could be seen issuing with each word as before, 
 only not so thick, and after another inspiration, the smoke 
 could be still perceived in the expired air, but in a very 
 diluted state; but after a third inspiration, it could no longer 
 
 * Snow on Anaesthetics, p. 91. t loc. cit., pp. 12 and 25. 
 
Appendix. 5 1 
 
 be seen till he had resumed the cigar." I may here remark 
 that it was partly on this observation of Dr. Snow that I 
 based my statement with respect to the rapidity with 
 which the vapour ceases to act in the lungs when the in- 
 halation is stopped. I readily grant that an after-fall of 
 blood-pressure may be explained, at all events partly, by 
 this absorption from the residue of vapour in the lungs, 
 but I would say that such a fall must be continuous and 
 limited to the time mentioned by Dr. Snow, viz., twenty 
 seconds, or not much more. Passing over the fall caused 
 by the animal holding its breath, or by stopping its mouth 
 and nose and producing temporary asphyxia, the Com- 
 mission refer to another severe and prolonged after-fall 
 which may occur in an animal in which the chloroform is 
 pushed without sufficient dilution with air, causing 
 struggling and alternate holding of the breath, until re- 
 spiration ceases. This also has no bearing on the question 
 to which I wish to refer. But the Commission mention 
 still another fall of pressure under apparently different 
 circumstances, and it is this to which I desire specially to 
 direct attention. 
 
 Speaking of artificial respiration they say, * "the 
 success of artificial respiration in restoring the blood- 
 pressure is in some cases very remarkable ; vide especially 
 experiment 40, in which the heart had apparently ceased 
 
 * Lancet, January i8th, 1890, p. 156. 
 
52 Appendix. 
 
 beating, and the dog was believed by every one present to 
 be dead, and yet recovered with artificial respiration. The 
 success in this instance is due to the fact that chloroform 
 had only been administered for a few seconds, and that 
 the depression w^as the result, not of continuous chloro- 
 form administration until respiration ceased, but of a long 
 and severe after-fall." 
 
 In the succeeding paragraph they go on to comment, 
 in what appears to me an extraordinary manner, on this 
 experiment. " It corresponds to those cases which are so 
 often reported, in which dangerous failure of the heart is 
 said to have occurred some minutes after the administration 
 of chloroform had been discontinued, and which are some- 
 times restored, and sometimes not, by artificial respiration. 
 There is nothing at all sudden about the failure of the 
 heart in these cases, but the attention of the chloroformist, 
 which had been wandering, is suddenly called to the fact 
 that the patient is apparently dead." 
 
 Of the 600 experiments performed by the Commission 
 one may be more valuable than all the rest, and I cer- 
 tainly take more interest in this one than in the remaining 
 599. I should like to know every detail of this interesting 
 observation. It has always seemed to me that one of the 
 most important statements made by the London Com- 
 mittee was that the heart might sometimes cease before 
 the respiration, even when very dilute vapour was being 
 inhaled, and that they should have given every particular 
 
Appetidix. 5 3 
 
 about the case in which this' was observed, but as far as I 
 could find they did not do so. And so I think the 
 Commission should have told us everything about the 
 above case, and should have repeated the experiment 
 under the same conditions. The most important facts 
 communicated are that the respiration had not ceased 
 when the inhalation was discontinued, and that there was 
 a long and severe after-fall. But we want to know much 
 more. Passing over the per-centage of vapour breathed 
 by the animal, which the Commission have not taken the 
 trouble to estimate in any case, an omission which very 
 much detracts from the value of their experiments, I 
 would ask, How many seconds was the inhalation con- 
 tinued? Was the animal supposed to be in deep anaes- 
 thesia when the administration was stopped ? Was the 
 after-fall of pressure continuous from the first ? How 
 long did it last ? 
 
 As far as the description goes it seems to warrant me 
 in connecting the case with that of the cat already 
 mentioned. The dog had inhaled the vapour only for a 
 short time, and a state of apparent death had ensued 
 sometime after it had been allowed to breathe fresh air. 
 If so, the Commission have altogether failed to explain it, 
 and it is hardly possible to conceive of anything more 
 illogical than their reasoning on the subject. It would 
 appear that the agent that may produce this alarming 
 effect, even after its use has been discontinued for some 
 
54 Appendix. 
 
 time, is still quite a safe one. It is as clear as day that if 
 there is not some principle of administration which 
 renders us quite free from this subsequent danger, chloro- 
 form is for ever condemned. According to the Committee 
 it (the above experiment) corresponds to those cases in 
 the human subject in which dangerous failure of the heart 
 is said to have occurred some minutes after the admini- 
 stration of chloroform had been discontinued, and 
 concerning which they go on to make the further sapient 
 remark that there is nothing at all sudden about the 
 failure of the heart in these cases, but the attention of 
 the chloroformist, which had been wandering, is suddenly 
 called to the fact that the patient is apparently dead. If 
 this case of the Commission really corresponds, as it 
 appears to do, to cases of syncope in the human subject, 
 it illustrates everything for which I contend. The heart 
 failure in both is produced by stopping the administration 
 too soon. The case stands in direct contradiction to a 
 previous statement of the Commission to the effect that if 
 the administration of the chloroform is stopped at an early 
 stage, the pressure very soon begins to rise again, and 
 gradually becomes normal. A prolonged after-fall could 
 not have been caused by absorption of some of the residue 
 of vapour in the lungs, neither in the case of an animal 
 which was still breathing when the inhalation was stopped 
 could such a lengthened fall have been a continuous one. 
 The fall of pressure observed by the Glasgow Committee 
 
Appendix. 5 5 
 
 was not a continuous one, lasting from the time when the 
 chloroform was left off, for when the connection with the 
 kymograph was first made (two minutes after the stoppage 
 of the inhalation) the pressure was nearly normal. Would 
 the Hyderabad dog have died without artificial respiration? 
 If so, it would have still further corresponded with cases 
 in the human subject, for it would have been a death 
 from the primary syncope, but it would have differed from 
 the cat, which recovers from the same apparent death 
 with the same certainty without artificial respiration as 
 with it. The Commission tell us nothing about any 
 previous failure of the respiration in the above case, nor 
 how the stoppage of the heart could have been prevented 
 by watching it. Neither the heart nor the respiration, as 
 far as I have observed, can be influenced by watching 
 them, and if they cannot be left to look after themselves 
 some minutes after the chloroform has been withdrawn 
 the agent is an excessively dangerous one, and its use 
 should be abandoned. As well tell a captain that safety 
 is to be secured by watching the prow of the vessel. 
 This, it is evident, can only apprise him of the earliest 
 occurrence of disaster which may be irretrievable. The 
 advice is inadequate ; he must know the external danger — 
 the situation of the sunken rock or the treacherous whirl- 
 pool. And the danger to the chloroformist lies in the 
 chloroform atmosphere. Failure of the heart after the 
 chloroform is withdrawn can only be certainly prevented 
 
56 Appendix. 
 
 by making the anaesthesia sufficiently deep in the first 
 instance. 
 
 The Glasgow Committee, in the article above referred 
 to, point out that the tracings obtained by them in dogs 
 under chloroform are not identical with those caused by 
 asphyxia. As I have already remarked, whether this be 
 so or not, it can be distinctly proved that they are directly 
 due to the chloroform. If direct stimulation of the vagus 
 may produce the same tracing as asphyxia, so may some 
 other influence bring about a state of the circulation which 
 will give the same result. But the most important state- 
 ment made by the Committee is that they agree with the 
 Commission in explaining the retardation of the heart, 
 observed by them two minutes after the chloroform had 
 been withdrawn, by the supposition that it was probably 
 due to absorption of a portion of the residue of chloroform 
 in the air-passages after the stoppage of the inhalation. 
 This proves how far the Committee are from seeing what 
 I apprehend to be the true explanation of the case. And 
 the hypothesis can be easily disproved. Dr. Snow was right 
 in limiting any effect of this kind to about twenty seconds. 
 The fall observed by the Committee was not continuous, 
 and if it were caused as they suggest it would be quite 
 impossible to give chloroform with safety. But one fact 
 negatives their argument completely. It is that when the 
 anaesthesia is made sufficiently deep in a cat the pause in 
 the heart, which I have above described, does not occur 
 
Appendix. 57 
 
 during recovery, and neither would the sudden fall of 
 pressure observed by the Committee take place in the 
 same circumstances. Both are due to the reaction ensuing 
 in the lungs after the vapour is withdrawn, and this explains 
 the difficulty, and finally settles the matter. 
 
 In the last report of the Hyderabad Commission* they 
 have not yet given us the details of experiment 40, In 
 the experiments of which details are furnished there is 
 nothing whatever bearing on the point. In this report 
 Surgeon-Major Lawrie says that the fall of blood-pressure 
 produced by chloroform is in no sense a danger . . unless 
 it is excessive^ — that is to say unless an overdose of chloro- 
 form is inhaled. Then we are to suppose that the dog in 
 experiment 40 had really inhaled an overdose. How is 
 this supposition to be reconciled with the fact that it had 
 only breathed the vapour for a few seconds ? It lies with 
 the Commission to harmonise these apparent contradictions. 
 
 While willing to admit that asphyxia may produce all 
 the results attributed to it by the Commission in chloro- 
 form narcosis, I nevertheless express my conviction that it 
 has had nothing to do with the fatalities which have 
 occurred in the human subject, and that it is no source of 
 danger in the ordinary administration of the anaesthetic. 
 The conclusions of the London Committee on this point 
 were, in my opinion, much more accurate. Surgeon-Major 
 
 * Lancet^ June 21, 1890, p. 1369. 
 
5 8 Appendix. 
 
 Lawrie's description of the ignorant and timid administrator 
 asphyxiating the patient is drawn entirely from his own 
 imagination. He does the very reverse : he gives the 
 patient air when he ought to have continued the chloro- 
 form, and syncope is often the consequence. One would 
 suppose that Surgeon-Major Lawrie was quite ignorant of 
 the clinical records of chloroform syncope. The fatal 
 catastrophe has often occurred in the hands of the most 
 experienced and cautious, the excess of caution, in my 
 view, affording the real explanation of its occurrence. 
 
 It might be supposed that after administering chloro^ 
 form "in every conceivable way," as the Commission claim 
 to have done, all the facts in connection with the subject 
 must have been elicited. But this is far from being the 
 case, and the Commission do not even seem to be cog- 
 nisant of many facts which have been accumulated by their 
 predecessors. Not a single member of the Commission, 
 or of the Glasgow Committee, could answer a number of 
 simple questions which could be put to them on anaesthesia. 
 The most interesting and instructive fact in connection 
 with the Commission is that it has been a stupendous 
 failure. 
 
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