138 REPORT — 1860. 



observed to take place through the respiratory muscles first, the heart suffering as 

 a mere consequence. There have been probably 100 deaths from chloroform, and 

 twice as many patients saved from impending; death by the proper use of restora- 

 tives, the chief of which is artificial respiration, which "wakes up " the respiratory 

 muscles. These restoratives have been directed so as to excite the reflex and respi- 

 ratory system of nerves. Some patients have probably been lost by means used on 

 the theory of fatty or obstructed heart. Intoxication, delirium tremens, and hysteria 

 all- contraindicate the use of chloroform ; and it was also found during the Crimean 

 war, and more recently at three several seats of Avar in Italy, that nervous fright- 

 ened prisoners were particularly bad subjects for it. Any condition of violent 

 emotion (" exaltation of sensibility ") would appear to approach that state which 

 causes spasm of the glottis, trachelismus, &c, while depressing emotion (fright ?) 

 may lead to syncope. Dr. Snow does not seem to have noticed the effect of delirium 

 tremens ; but in 85 fatal cases, collected by the author in the hospitals, 9 appear 

 due to it, or to intoxication ; the mischief is probably owing to the cerebral hemi- 

 spheres, medulla, and reflex system in the spinal cord being weakened by alcohol. 

 In 4 well-authenticated cases the heart was still beating after respiration had 

 ceased ; this is also very often seen in experiments on animals ; and probably obser- 

 vation only is wanting to establish the more frequent occurrence of this pheno- 

 menon in man. In the author's opinion the heart is one of the very last organs 

 which is depressed by chloroform, and this fact it is which renders its use compa- 

 ratively safe. He fears rather the implication of the " respiratory tract." The chief 

 conclusions at which Dr. Kidd arrives are as follows : — 



1. Ether is little if at all superior to chloroform. In " ether mixtures " the 

 ether is first inhaled pure. Ether causes the pidse to intermit, and is to be avoided 

 where we fear excessive haemorrhage or muscular relaxation ; but in dislocations 

 and in midwifery it has some points in its favour, hut not in a mixture with chloro- 

 form. Ether, too, in a sick room may take fire, but chloroform does not. 



2. There is less reason to fear the effect of anaesthetics in women and children 

 and in severe operations, than on robust men ; especially if given to the use of intoxi- 

 cating liquors, or when the operation is connected with tendinous parts, in which 

 cases syncope often follows wnen no chloroform is used. 



3. Hospital experience tends to prove that chloroform is less dangerous in pro- 

 portion as the operation for which it is used is more severe. "When once the pal- 

 pebral conjunctiva is insensible, there is a period of safety during which the respira- 

 tory action is diminished like that of hybemating mammals ; the heart remains unaf- 

 fected, but the pulse becomes larger. The many instances in which this has been 

 seen, seem to overpower isolated cases of death from diseased heart and chloroform, 

 and should encourage hopeful views on the use of anaesthetics. 



4. Idiosyncrasy has probably little or nothing to do with deaths from anaesthetics, 

 if we omit habits of intoxication, hysteria, and tendency to "fits." Thus re- 

 peated trials of chloroform (" trials cTcssai") on a patient are a mistake, and nowise 

 affect the chance of his safety on any given occasion. 



5. There are two, or perhaps three modes in which anaesthetics may cause death, 

 and which require watching, (a) Ether may do so at some uncertain interval 

 of time dining the first twenty-four hours after an operation. (/3) Chloroform in- 

 stantly, by an action on the laryngeal-recurrent and double respiratory centre in the 

 pneiunogastric nerves. In half these cases, probably, as in apnea or asphyxia, the 

 heart is still beating ; and (y) in other cases by syncope (as a coincidence*?). 



6. In several cases, e y. those of delirium tremens, the death probably occurs 

 because ordinary restoratives fail to act in consequence of the imperfect reflex ner- 

 vous system ; but in cases of impending death, we are to have recourse to artificial 

 respiration by pressure (rather than the Marshall Hall plan), since this also acts 

 upon the engorging cavities of the heart ; tracheotomy if we have reason to fear 

 spasm of the glottis or asphyxia ; sudden dashing (not too long continued) of cold 

 water; fanning of fresh air on the face, &c. ; but as the spasm may subside, we are 

 not to do too much at first. Acupuncture, quickly done, of the muscles of the neck 

 is recommended in order to irritate the spinal accessory and phrenic nerve, but not 

 the eighth pair ; and " Faradisation " here also is most valuable. 



7. Our experience of oxygen gas, common galvanism, &c. as restoratives is not 

 encouraging at present. Injection of port wine into the rectum is better, or the 



