the body, has been fully insisted upon as indicative of some particular line of treatment to be pursued.

The mode of applying the cold water douche merely consists in placing the patient in any convenient position, so that, while water is being poured over him, frictions may be applied to the limbs. After the gasping has ceased, this process is to be continued until the depressing effect of cold, shivering, and chattering sets in, when the pulse will begin to fall. The patient is then to be placed in bed, having been well rubbed. In a short time, when warmth begins to return, relapse will take place. The water is to be repeated in the same manner as above, and persevered in so often as collapse returns. After each repetition, its effect will be found to be more palpable and more prolonged; until at length, through the agency of the imbibed oxygen, the system is restored to its wonted power.

Many have mentioned, in a general way, the good effect of cold water in cholera; but none, I think, have understood the reason of this good effect, and, therefore, it has not been carried to its full extent.

It may be well to add, for the satisfaction of those who cling to the idea that cholera is a disease of vomiting, purging, and cramps, that under the water treatment, as described, these symptoms will soon cease to be objects of attention. They will, in general, subside on the first application, and seldom reappear after the third or fourth.

As to internal remedies, water to drink freely will be found the most agreeable to the patient's taste, less productive of nausea and depression, and not so prone to give rise to the often fatal consecutive fever.

As to the premonitory diarrhoea, on which much stress is laid, I would remark that in the worst cases of cholera it neither precedes nor accompanies the disease; that often, where it subsides, cholera sets in; that where it continues, cholera does not necessarily follow; that it is not part and parcel of the disease; that to view it as such, and to treat it accordingly, can only be in accordance with that style of medical reasoning which has ever puzzled the profoundest lawyers.-Association Med. Journal, Aug. 26, 1853, p. 754.

ADDENDA.

168.-ON THE MODE OF DEATH FROM THE INHALATION OF CHLOROFORM.

By E. R. BICKERSTETH, Esq., Liverpool.

[There can be no question that unless proper precautions are used during its administration, chloroform is a powerful and poisonous drug. Mr. Bickersteth has performed many experiments illustrating its effects, and he says:]

From these experiments the following conclusions may be derived :

:

1st, That, in death from the inhalation of chloroform, the respiratory movements cease before the cardiac.

2nd, That the heart continues its action, uninfluenced by the chloroform, for a period longer or shorter after the cessation of respiration, and that its then failing may be considered as a natural consequence of the respiration having ceased, and as independent of the influence of chloroform.

3rd, That if after the respiration has ceased, and while the heart is still in action, chloroform continues to be absorbed into the system, its movements may become impaired or cease-the chloroform in such case acting directly upon the heart.

4th, That if artificial respiration be resorted to before the cardiac contractions are seriously affected, and be properly maintained for a sufficient period, the respiratory function may be re-established.

It remains now to show that these principles are applicable to the human subject; and to do this, I shall narrate some cases that have occurred under my own observation, in which artificial respiration was the means of restoring the natural respiratory efforts when life appeared to have been all but gone.

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 anesthetic 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 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 cornea 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 commenced-the handkerchief containing the chloroform remaining over the face, as some difficulty had been experienced in keeping up the anesthetic 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 anesthesia, 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. The words of the gentleman who put his ear to the chest, and who was well practised in auscultation, were, "I cannot be certain." 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 the man was dead, and that no human aid could restore him; and if it had not been that those standing near me had 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 with 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 assisted merely 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 sufficintly 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. Anesthesia 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 with 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.

I would here direct attention to the expediency of drawing forward the tongue, in all cases when it is found necessary to resort to artificial respiration. When the patient is lying on the back, so soon as the breathing ceases and the jaw drops, the tongue is particularly liable to fall backwards and close the orifice of the glottis. Artificial respiration, under such circumstances, is worse than useless. It is better at once to pull the tongue well out of the mouth, and passing a hook through the tip, confide it to the care of an assistant. I am convinced that in some of the cases in which artificial respiration has failed, it has been from the neglect or too tar adoption of this very simple means. Time of the utmost value has been los

absurd attempt to restore animation, by applying stimulants to the nostrils, or pouring cordials into the mouth, without even a thought that the first can have little or no effect after the respiration has ceased, or that the second would as likely pass into the trachea and bronchi, as into the stomach.

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. After anesthesia has been induced, the object for which chloroform is given is already accomplished, and there can be no use whatever for its further administration. It is very easy and safe to maintain complete anesthesia for hours together, by occasionally giving a few inhalations of the vapour when there are signs of approaching return of sensation; but to continue the inhalation without interruption after anesthesia is fairly established, is most certainly very dangerous, and will, sooner or later, varying according to age and constitution, prove fatal. Anesthesia, or paralysis of the nerves of sensation, is but one of a series of changes produced upon the system by chloroform. Paralysis of the respiratory system is the next and follows quickly afterward, and if yet more be taken up, the nerves also of the organic system cease to perform their functions, and the heart in consequence is paralysed. It is thus only in death that the influence of chloroform ceases. Let it be especially remarked, how precisely analogous the symptoms in the foregoing cases were to those observed in animals under similar circumstances. The respiration ceased for a considerable period before the pulse, and artificial respiration being employed, the pulse returned before the respiration was re-established.

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 capital operations. The pulse is only affected secondarily in consequence of the failure of the respiration. It therefore follows that our attention should be mainly directed to the latter, while the former may be altogether neglected, or at any rate considered as only of secondary importance. By carefully watching the pulse, the attention must in a measure be taken away from the respiration, and exactly to such a degree, it is productive of evil; for, in order to guard against mishaps, and at the same time conduct the inhalation with confidence, the breathing must be observed with the greatest care and attention. But when it is thus asserted, that death always commences in the organs of respiration, and that the heart only ceases to act in consequence of the lungs having previously failed in the performance of their functions, I would wish to be understood. In the first place, I should be sorry to deny the existence of individuals with such peculiar nervous idiosyncrasy, that the converse of this (the ordinary rule) might obtain. With such an example however I have never met, nor have I ever encountered a single occurrence that would lead me to suppose the heart peculiarly or rather primarily susceptible. In the second place, it must be remembered that if, after respiration has ceased, chloroform in any considerable quantity be absorbed into the system, it will act directly upon the heart and speedily stop its contractions. And thus, if with the last inspiration a sufficient quantity of the pure vapour is inhaled, the movements of the heart will cease almost immediately, and so it might appear that the respiration and cardiac contractions have stopped simultaneously, although in fact a brief interval has existed, an interval, in short, long enough to permit of the absorption of the chloroform taken into the lungs with the last inspiration.-Monthly Journal of Med. Science, Sept. 1853, p.

211.

169.-Case of Suspended Animation under Chloroform; Artificial Respiration; Recovery. By EDWARD WILLIAM Lowe, Esq., late House Surgeon to St. Bartholomew's Hospital.-[In this case the patient was a young man, aged 22. The operation about to be performed was partial excision of the left elbow-joint. He seemed in all respects a proper subject for the administration of chloroform. Mr. Lowe continues:]

Dr. Scott, who has so frequently administered the chloroform, did so on the present occasion. The man was rather restive, but nevertheless took it moderately well, and, having been rendered insensible, I had proceeded with the operation almost

to its completion, when the patient became suddenly deadly pale and cold, his pulse intermitting alarmingly, and his breathing becoming convulsive. His face was quickly bathed with cold water, and fresh air admitted freely to him; he, however, grew still worse, his respirations became more feeble, and his pulse could no longer be felt at the wrist. He was instantly laid on the floor, and the feeble action of the chest gently aided by the hands; in spite of this, in about a minute or so from his first seizure, he gave two or three short respirations, and, with a convulsive struggle, ceased to breathe, and his jaw dropped. As he did so, quick as thought, we bent over him, and Dr. Scott, closing the mouth, inflated the lungs by the nose, first covered with a cambric handkerchief, while I, with a hand on each side of the chest, gently emptied them; thus we continued for full four minutes without producing any sensible result; at last a gentleman who held the wrist exclaimed, "There is a beat!" and after the lapse of a few seconds, "There is another!" Then a third. Now it began to beat violently, and the chest to heave deeply, but with a short period between each action. Presently the pulse beat more slowly, quietly, and regularly, but more feebly, and the chest acted spontaneously. After the lapse of a few more minutes, the man opened his eyes and smiled; being asked, he said he could swallow, so, ceasing all aids to his respiration, he was given a little brandy; but not a drop was given until he declared he could swallow. He was now sensible, his respiration restored, and his pulse acting naturally, though feebly; yet he still remained of a deathly coldness, and it required no little trouble to make him warm; his own expression well explained his condition, "He was as cold as if he were dead;" and, indeed, he was so. Brandy inside, blankets and hot water bottles outside, did, after a time, manage to restore him to something like a natural state of heat, and shortly afterwards he was able to sit up, and, in a little while, to be sent in a carriage home. He has, since this, continued to go on quite well, never having felt any uncomfortableness, excepting a slight occasional tightness at the chest (which is often experienced after chloroform), and even now he is quite ignorant of his narrow escape. I am fully persuaded that this case is a convincing testimony in favour of a steady perseverance in artificial respiration, as a remedy for the fatal effects of chloroform. To M. Ricord we owe its first recommendation and adoption. There can, I believe, be no doubt of its superiority over every other plan; but to make it effective it must be done well, and steadily persevered in. The present case tells well in favour of perseverance. Four minutes is a long time, under such circumstances, to continue steadily one plan without obtaining any benefit, and yet it triumphed in the end, and, to complete our victory, we had to continue the artificial respiration for full eight minutes without cessation. Our reward was success; and I cannot but believe the same reward awaits every one, who, under similar circumstances, will steadily pursue the same treatment.-Med. Times and Gazelle, Aug. 13, 1853, p. 174.

170-ON THE ARSENICAL TREATMENT OF CASES OF

SNAKE-BITE.

By BENJAMIN TRAVERS, Jun., Esq., F.R.S.

This subject has always been one of especial interest to me, in consequence of the great probability that we possess in arsenic a remedy which, if administered boldly and in time, will rescue the sufferer from an imminent and painful death. I believe no one has ever questioned the accuracy of the facts recorded of the comparatively certain operation of the Tanjore pill, and Mr. Ireland's cases, of which he enumerates five treated with unvarying success, are powerfully corroborative of Dr. Russell's statements. Mr. Ireland, on his arrival in the island of St. Lucie, having previously heard the facts concerning the efficacy of arsenic stated in Mr. Chevalier's lectures, proceeded at once to test the truth of the proposition, by administering one grain doses of the mineral (in the form of arsenite of potash, as it exists in Fowler's solution), every half hour until the patient began to revive. He treated five cases with perfect success in this manner. The men severally took six, seven, and eight doses of the following form, before the irritating operation of the arsenic began to show itself by vomiting and purging. What is very remarkable, is the immediate and complete recovery of these patients, without the arsenic having produced any