This plan of administering chloroform with the head and shoulders of the patient covered with a towel, was introduced by Mr. Clover, who was for several years a resident officer of the institution; and it is but right to state that it led to no accident in his hands; in those of his successors it was, however, less successful; three accidents having occurred in a little more than a year and a half. I much regret to find that Mr. Erichsen recommends this method of giving chloroform in the edition of his work on surgery recently published.

Case 43 occurred in Guy’s Hospital, on December 5th, 1854. The patient was a woman whose leg Mr. Birkett was about to amputate on account of malignant ulceration. She gave her age as fifty-six, but appeared ten years older. “In each eye was a fairly marked arcus senilis, but the woman was not known to have suffered any symptoms referable to thoracic disease.... The administration of the anæsthetic was conducted by Mr. Bryant, the inhaler used consisting of a fold of lint, rather larger than an out-spread hand, and protected on its back by a piece of oiled silk to prevent wasteful evaporation.... In the first instance, about a drachm of the fluid was poured upon the lint. The patient inhaled it kindly; and, after about two minutes, another drachm was added. A stage of excitement now followed, during which the limbs required to be held. Insensibility was just fully established, and Mr. Birkett was on the point of commencing the operation, when Mr. Callaway, who was compressing the femoral artery, exclaimed that the pulse had suddenly ceased entirely. The wrist was examined, and the same found to be the case. Almost immediately afterwards, a long-drawn inspiration, attended with a deep sighing noise, was observed. For two or three breaths the cheeks puffed out during expiration; the respiration next fluttered, and then ceased. Mr. Birkett at once put his finger into the patient’s mouth, and drew forward the tongue, artificial respiration being meanwhile commenced by assistants by means of compression of the chest. A few slight inspirations were attempted by the patient subsequent to the commencement of the artificial assistance; but they did not continue, and no sign of vitality was ever afterwards shown.... It must be noted, that the woman had been very pale both before and throughout the exhibition, and that no change in her appearance was perceived when the alarming symptoms occurred, excepting that the superficial veins of the neck and temple became distended with blood. The cessation of the pulse was most sudden. Mr. Callaway stated that it was not preceded by the least premonitory fluttering, the stroke having been good one beat, and entirely wanting the next. This order of symptoms was of course suggestive of death beginning at the heart (cardiac syncope), the cessation of the functions of the nervous system having been markedly subsequent to that of the circulation....

“Autopsy, twenty-four hours after death (conducted by Dr. Wilks). The corpse was much emaciated, and the rigor mortis imperfect. The lungs were much congested with fluid blood, which ran out after incision of their substance. The heart was of normal size, but soft and flabby; its left side was nearly empty, the right being distended with fluid blood. The left ventricle was of good thickness; its muscle of a deep colour, not encroached on by fat, or in the least mottled, the only observable departure from a healthy state being its flabbiness. The right ventricular wall was very thin, the subserous fat having in some parts almost taken the place of the muscular tissue. The layer of the latter, however, although much thinned, had still a good colour, and did not appear to the naked eye as degenerated, an observation which may apply also to the carneæ columnæ. The liver was in an early stage of cirrhosis, and the kidneys were both of them mottled, and contained numerous small cysts in the external part. The brain was rather paler than usual, its convolutions appeared shrunken and atrophied, and there was a quantity of serous fluid in the arachnoid sac and in the ventricles. There was general atheromatous disease of the arterial system, both in the head and other parts of the body. The blood was universally fluid, and of a dark colour.”[[116]]

As far as could be estimated, the time occupied by inhalation was about three minutes in this case.

Case 44 occurred at the Royal Ophthalmic Hospital, on April 10th, 1855, in a man on whom Mr. Bowman was about to perform excision of the left eyeball. The patient, named John Cannon, was forty years old, and was moderately stout, florid, and healthy-looking. He had generally led a temperate life. The disorganisation of the eye was the result of injury.

“The inhaler used was the one devised and recommended by Dr. Snow.... The administration was entrusted to Dr. Playne, of King’s College Hospital. In the commencement of the inhalation, the valve of the mouth-piece was so turned as to admit an abundant supply of air, a point to which Mr. Bowman directed personal attention. During the first four minutes (more or less) nothing unusual occurred. Dr. Playne, who had his finger on the pulse, had noticed that it had rather increased in fulness, and was of good volume. Rather suddenly, however, just as the anæsthetic appeared to be producing its effect, symptoms of excitement occurred. The eyes became fixed and staring, the arms outstretched and rigid, and the face contorted. It was now impracticable to feel the pulse, on account of the tossing about of the arms; but, as is usual in such conditions, the respiration was noticed to be all but, if not quite, suspended by the spasmodic fixture of the chest. The inhaler was at once removed, and the face and chest of the patient dashed with cold water. Almost immediately after, as the respirations had become extremely feeble and sighing, Mr. Bowman commenced practising artificial breathing, by the application of his own mouth to that of the patient. By this means, the chest was made to fill very completely, and the process was kept up almost without intermission for from five to eight minutes. During the first three or four minutes after the alarm began, the patient continued at times to make slight sighing efforts at voluntary inspiration, and the case was not thought, by those looking on, to be by any means hopeless. At length, however, these finally ceased, and from that time it was apparent that the man was dead.... At the first opportunity which occurred for examining it after the spasmodic struggling had commenced, the pulse was found to be extinct, and it remained so ever after, although there were, as stated, feeble efforts at inspiration. The patient’s countenance changed somewhat during the treatment, but was mostly suffused and congested.”

At the examination of the body forty-eight hours after death, “the sinuses, and the veins of the brain generally, were much congested, and there was some œdema of the brain substance. The heart, excepting some slight deposits on the curtains of the mitral valve, was healthy. Its muscular substance was easily lacerable. The right ventricle contained a considerable quantity of fluid blood, the left was nearly empty. There were some pleuritic adhesions, and the lungs generally were congested, being also in some parts full of air. The blood in every organ examined was fluid, and without trace of coagulation.”[[117]]

It does not seem that the inhaler used in this case was employed with the object for which it was contrived—that of regulating the amount of vapour in the inspired air; and I do not know whether the bibulous paper was arranged properly in the interior.

Case 45. On September 8th, 1855, a lady, aged twenty-nine, the wife of a physician, died suddenly whilst inhaling chloroform for the relief of facial neuralgia. I was sent for when the accident happened, and arrived twenty minutes afterwards. I found the deceased lady without any sign of life. The face and lips were very pallid. The husband was performing artificial respiration by mouth to mouth inflation of the lungs, and alternate pressure on the chest, and I assisted him in this for a long time, though with no hope that any thing could be of service. Dr. Barker, of Grosvenor Street, arrived soon after me, and assisted in the same measures. An inhaler was employed in this case consisting of a face-piece, like the one above delineated in this work, and a bent metal tube lined with bibulous paper. Two quantities of ten minims each had been inhaled, with some relief to the pain, and without causing unconsciousness when the inhaler and the chloroform were put away in a closet; but the patient begged to have more chloroform, in order to be completely relieved of the pain, as she had been on a previous day. Ten minims more chloroform, as I was informed, were put into the inhaler, and the patient, being seated on a sofa, began to inhale very eagerly, but had no sooner commenced than she gave a sudden start, as if taken in some kind of fit. Her husband laid her on the floor, but she evinced no further signs of life.

There was no inspection of the body.