of the patient, and especially in those that are atmospherical.

(c) The cause may lie in mode and skill of administration.

(d) The cause may lie in impurity of the chloroform employed.

I propose to follow up our researches under these separate heads. If the answers should be doubtful or negative, it will then be necessary to inquire whether the danger lies in some inherent fault in chloroform itself as an anesthetic, and whether that fault is irremediable. This will lead to the study of means of prevention of danger, and of restoration from danger.

CONDITIONS OF THE PATIENT, PHYSICAL AND MENTAL, AS

CAUSES OF DANGER.

Can unusual danger be predicated from the condition of the patient? Here is a point I am constantly consulted upon. But last week I had two cases before me for advice on this one subject. Well, while I dispute altogether the dogma that whenever an operation is justifiable chloroform is justifiable, because there are numbers of useful operations for which it is unjustifiable, I am not prepared to bring any dogmatical rule against chloroform founded on the condition of the patient. Sometimes persons die under chloroform who have no appreciable disease whatever before death-no disease, that is to say, which the most perfect diagnostician could put his finger on and say there is cause of anxiety from the presence of disease. In the only case where I thought life had been extinguished by chloroform (happily I was wrong) the patient was as perfect a specimen of a healthy body I ever remember to have seen. It was the case of a young lady who had from

her birth been in health; she was free from the least affectation. She came under the influence of the narcotic with the utmost ease; the operation-the extraction of a tooth-was quickly and skilfully performed, and a full minute after the chloroform had been withdrawn the breathing was tranquil, the pulse steady, the countenance natural. Never was a moment when there was less cause for anxiety under the same circumstances, when suddenly there were lighted up all the phenomena of death-the respiration became imperceptible, the heart inaudible, the limbs flaccid. Fortunately, the heart, feeble as it was, continued, and, after three hours of anxious waiting, the recovery was completed. An hour or two previously I administered chloroform to an aged lady for a much longer time, and witnessed no symptom whatever of danger. The same specimen of chloroform (I mean, of course, a specimen out of the same bottle) was used, the same mode of administration was followed, the same hand administered; and yet how different the results. They were results which I, at all events, had not the sagacity or knowledge to predict at the time they occurred, in 1860, and which now would be as far from me as ever.

There is a fact that I have learned, moreover, in experiment, bearing on this same subject, and which deserves notice. I have occasionally had two animals of the same age, breed, and condition in this glass chamber breathing at the same time and for the same time the same atmosphere of chloroform and common air. They have become narcotised by the vapour, and when I have proceeded to remove them I have found one dead and the other alive and apparently free of

* Continued observation up to this year-1892-confirms me in the same opinion.

danger. This is a result which, I think, could not possibly be foreseen. *

We turn from natural to diseased conditions of body, and the difficulties continue. I believe I know of one condition of body which may be diagnosed as specially dangerous for chloroform, and there my knowledge is brought to an end. This unfavourable condition is present when careful diagnosis shows the existence of a weakened and dilated right side of the heart, with enlarged hæmorrhoidal veins, varicose veins of the lower extremities, and large, full, yet not tense, veins in the other parts of the body. In the body thus circumstanced we may be certain that the right side of the heart, which is the most important organ to be sustained in action under chloroform, is much enfeebled, and may readily succumb if subjected to congestion.

Beyond this point of diagnosis, I repeat, I know nothing definite. When I was engaged in the practice of the administration of chloroform I was careful to make diagnosis of disease before administration of the

*I have observed this event occur, especially in the early working of it, on a large scale, in the lethal chamber. The same kind of animals -dogs-scarcely ever die in the same lethal atmosphere at the same minute, although the conditions are the same. All fall asleep nearly at the same moment, but once asleep one may live thirty and even forty minutes after all the rest are dead. In one instance an animal continued breathing an hour in the midst of a number of others that had been dead an hour and were far advanced in rigor mortis. This animal would have rallied back to consciousness had it not been subjected to a new charge of the narcotic vapour. The only practical mode of meeting this singular immunity of particular animals is to submit all to an overwhelming dose of the vapour from the first, and even that does not make the period of death absolutely the same all round. Under the surest system five minutes have to be allowed for the final event, and even then some animals continue to breathe two, three, or four minutes after the majority have entirely ceased to live.

narcotic; and, on referring to the facts, I find I administered it in the presence of the most extreme forms of organic disease in phthisis pulmonalis in various stages; in cancer in various stages of the malady; in chronic bronchitis, asthma, and hydrothorax; in cases of mitral disease, hypertrophy, and dilated aorta; in epilepsy; in idiocy with epileptic disease; in various forms of dropsical effusion; in paralysis and acute mania; in some acute diseases, such as croup and pertussis; and, in disease of the kidney with albuminous urine. In not one of those administrations did it appear that the danger of administration was in any sense increased. But my own experiences are small when compared with those which Dr. Snow has written in his book of recorded cases, and he came to the same general conclusion, expressed above,—a conclusion affirmed, I believe, by all who have become practically conversant with the subject.

Some observations have been made relative to the influence exerted by chloroform on persons of the different sexes and on persons of different stages of life. The evidence in respect to sex is affirmative of no special fact indicating that either sex is subject to peculiar danger, but in the matter of age it has been affirmed that the young are exposed to less danger than the old. It is true that in the lower animals it is easier to resuscitate from apparent death a young than a middle-aged or aged animal; and it has been assumed, on the statistics of fatal cases in the human subject, that fewer deaths have been recorded in the young than in those more advanced in life. But, for my own part, I am unable to come to any satisfactory conclusion; for I find that some young inferior animals. are as easily killed as older animals, and the statistics

relating to the human subject are faulty in the main point, inasmuch as no comparison has been made of mortalities in a given number of administrations. When we consider how many more adults and middleaged and aged persons, massed together, are made to take chloroform than young children, we cannot reason on the subject; in short, a sufficient number of deaths from chloroform has not yet been accurately tabulated to allow of any safe inference being drawn on the point. We may, therefore, leave this question of age and its influence an open question, and wait for further information. Lastly, the effects of mental influence and habit have been considered in relation to the action of chloroform on the body. Snow made a very sound observation on this matter which I have often seen proved true; it is that persons of strong muscle and athletic power are brought under the influence of chloroform with much more difficulty than are persons of weak, sensitive natures, and of refined and highly cultivated minds. It does not, at the same time, follow that the danger in one of these classes of cases is greater than in the other, for those who come readily under the influence of chloroform are subjected to a smaller dose than the stronger class, and this compensates for what might otherwise be a greater danger.

On the whole, the only diagnostic I could give as warning the practitioner of exceptional danger from chloroform is the diagnosis of dilated and weakened right heart, with the other attendant symptoms already explained. If I have one further misgiving in respect to dangerous cases, it relates to cases of kidney disease with albumen in the urine, and disposition to uræmic sleep. Here, however, the misgiving is based on theoretical reasoning alone, is greatly negatived