itself and for a moment effaced the tablet on which the impressions of mankind are written.

I keep then in the present course to general anæsthesia, and for the sake of avoiding any confusion I keep to the part of the research above mentioned— viz., research to find whether we can make every anæsthetic safe, and thus be able to retain chloroform as the narcotic on which we may at all times, and for all times, confidently rely. I would myself far rather succeed in this research, if it were possible, than discover a substance which should displace chloroform, inasmuch as the discovery of means of safety of the kind named would unfold the richest treasures of medical science and art. If we, by our knowledge, can take a living animal, put it into such deep repose, inertia, that it shall represent in its negative condition blank death, so that persons generally would bury the animal as something dead; and if from this state we could proceed leisurely to set the animal in motion again, as we set a silent and motionless. clock in motion when we give it renewed force from our hand, then we should accomplish far more than if we had discovered a thousand new individual remedies. We should reach then great principles in relation to living action. This restoration of motion in inert organic matter that has lived will be the ultimate and grand result of physiological learning. It is wonderful what is done already towards the result; and it is obvious that every advance we make in studying the extreme action. of chloroform, and in discovering modes of recovery from such extreme action, serves the double purpose of making the administration of one particular medicine safer, and of opening the way further towards the discovery of suspending and restarting, at will, animal organic motion. We will therefore proceed with the

study of death from chloroform solely, and, that we may do so more surely, we will proceed leisurely, taking up first the all-important point what is the actual amount of danger that has to be met.

RATE OF DEATH FROM CHLOROFORM.

In the commencement of our inquiries it is well to consider what is the actual proportion or rate of death from the administration of chloroform. To arrive at correct results on this subject is a difficult task, for many deaths have not been recorded, and there is a natural diffidence on the part of individuals and of the managements of public hospitals to speak of fatal cases. When a practitioner has administered chloroform a very large number of times without having met with a fatal case, he is often led to underestimate the danger, and to ascribe his success to some particular mode of administration. I am satisfied this is not reliable experience. I can myself say that I was never present when a human being died from the administration of any anesthetic, and I have been engaged in the study and practice of general anesthesia ever since the introduction of the practice. But the favourable evidence I should give on my experience would be worse than worthless, for at least three times in my life some accident has prevented me from being present at cases which have ended fatally, and which would have ended in the same way had I been the administrator. Only recently I was conversing with a surgical friend on this subject, who was not himself an administrator of chloroform, and who told me that he had been present at not less than six fatal administrations. Now his experience had not been so large as mine, yet had it been six times as large, it would have been six times.

more unfavourable. I have by me reports, very brief in each case, but most important, of over four thousand administrations of chloroform by the late Dr. Snow, all drawn up by his own hand; the whole record is free of a fatal case; there are some very close escapes of death, but no obvious direct death from the narcotic. This, again, is a remarkable experience, but if I were to compare it with the experience of two other equally careful administrators who have followed faithfully the method and practice of Snow, theirs would differ full half as much as that of mine, and of my surgical friend of whom I have spoken.

Here before us is a still more valuable series of facts. When I was engaged in writing the "Medical History of England" for the Medical Times and Gazette in the years 1864 and 1865 I visited in turn eight hospitalsviz., Norwich, Lynn, Stafford, Wolverhampton, Newcastle-under-Lyne, Brighton, Birmingham General Hospital, and Birmingham Queen's Hospital. From the books of these institutions I collected, personally, the number of administrations of chloroform in each institution from the first, in 1848, and before I arrived at a death I recorded no less than 17,000 administrations. Now, one death in 17,000 cases reduces the mortality to a nominal value, and if this experience were supported by all experiences we need trouble ourselves little for any better agent than chloroform. But mark the result of the five years' subsequent experience in the very same institutions. Since 1864 there have been in these hospitals 7,500 administrations, with six deaths, or one death in every 1,250 cases. After I had visited the hospitals above named in 1864 I visited in the same and the following year six other hospitals-viz., at Lincoln, Bath, Oxford, Cambridge,

Reading, and Nottingham. In these I collected the facts of 7,900 administrations from the year 1848, with a result of three deaths, or one in 2,683 cases. In these same hospitals in the subsequent five years there have been 2,762 administrations, with a result of one death.

If, finally, in relation to these large hospital statistics we put all the facts together, we find that in the twenty-one years from 1848 to 1869 inclusive, in the thirteen hospitals named, there were 35,162 administrations of chloroform, with a proportion of eleven deaths. I believe this to be the largest reliable series of cases of administration as yet collected, and I know it to be just. Doubtful cases of death from the vapour there were none, and in every case a qualified and competent practitioner was the administrator.

When from individual and general hospital experiences we pass to the experiences of particular hospitals, we often find the widest differences of results from chloroform administration. Some hospitals, like some individuals, are fortunate, some unfortunate. There are before me the statistics of two hospitals so alike we might call them twins; they have the same average of patients, the same average number of administrations a year, the same precise length of experience. In one of these there have been 1,575 administrations without a death; but in the other the mortality has been at the rate of one death in 525 cases. I could multiply these illustrations were the labour necessary. It is not necessary. My preliminary purpose is fulfilled if I have proved that, in face of the fact of frequent runs of so-called "good luck" to particular men, to groups of hospitals, or to particular hospitals, there is, under the most favourable aspect of chloroform, a given mortality

which up to this moment seems to be a necessary mortality, just as there is a mortality from accidents. and acute diseases like fevers. The mortality is, moreover, considerably greater than is made known, for cases occur which are not recorded. To compute favourably from the facts given above the rate of mortality stood as one in 3,500 administrations of chloroform; but I think it, generally, is greater, and that one death in 2,000 to 2,500 administrations would be nearer the truth; yet even at the lowest rate we employ no other narcotic that approaches chloroform for danger.*

THE CAUSE OR CAUSES OF MORTALITY FROM
CHLOROFORM.

With the acknowledgment of a certain high mortality from the administration of chloroform staring us in the face, we are obliged to ask what is the cause, or what are the causes, of the penalty. Recovery is the rule; why is there ever an exception to it? We must inquire here, step by step, excluding as far as possible all suspected causes that prove, on inquiry, of no effect, whilst omitting no cause, however trifling it may appear, that seems to lie under suspicion. What then may be a cause, or causes, under suspicion?

(a) The cause may lie in the physical or mental condition of the patient subjected to the chloroform.

(b) The cause may lie in the immediate surroundings

Within the past three years-1889-92-there has been a difference of computation on the mortality from chloroform, the general impression being that the above estimate of one death in two thousand to two thousand five hundred cases-an estimate once considered as too high— is really too low. After reading the arguments that have been ably adduced, I am not inclined to move from my old position. Subject to newer and better correction, it is, I believe, so near to the truth as to be, approximately, and for practical purposes, a normal figure.