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and t he general st at e of t he pat i ent . Thi s knowl edge i s t o be obt ai ned from t he respi rat i on,
the pulse, the pupil of the eye, the sensibility of the cornea, and the complexion, all of which
may be under observation at the same time without discontinuing the chloroform, when it is
administered in the manner described by me in a paper read before the West London Medico--
Chirurgical Society, and which is fully reported in The Lancet of March 14th. The condi--
tion of the muscular system, as to relaxation , is also sometimes useful. An anæsthetist who
relies on all these sources for information will sometimes be able to continue an administration
of chloroform when, if he relied upon the respiration solely, he would feel bound to discontinue
it. I have on several occasions had the greatest. difficulty in satisfying myself that respiration
was in progress at all, especially in connection with some operations upon the skull for depressed
fracture or other condition in which the functions of the brain were greatly impaired, and
have found the pulse most valuable as a guide in such cases, justifying me in supplying suffi--
cient chloroform to prevent reflex movements of the patient occurring. As long as respiration
is unimpaired and there is no cyanosis it may not be necessary to go further for information, but
early in the progress of administration the breathing may be accompanied by stertorous noises
—not true stertor,—the pupils be dilated or the corneal reflex abolished, and yet the anæsthesia
may not be sufficient for operation, and in such circumstances the pulse will be found quick
perhaps, and not the slow pulse of complete chloroform anæsthesia. When an operation has
been some time in progress the respiration may still be good while the patient may have the
appearance of extreme exhaustion, and the pulse will then enable the anæsthetist to judge
whether it is necessary to hurry or close the operation, or whether stimulants are imperatively
called for. Shallow respiration is not uncommon and, when the respiration only is relied upon,
dangerously misleading, often when not appreciated giving rise to sudden and alarming symp--
toms. In practice each of the guides mentioned is of great service, and without them opera--
tors would often be disturbed, and sometimes unnecessarily prevented from completing their
operations. The following case throws great light upon the effect of chloroform upon the
heart and respiration.
In January, 1891, J. B.—, aged fifty-one years, came into the theatre for radical
cure of hernia, and it was my intention to give him chloroform; but on seeing him as his appear--
ance presented venous congestion, I gave him ether. After about a quarter of an hour of the
operation there was so much saliva and mucus excited by the ether that it was impossible to
keep the patient properly under, and I therefore changed to chloroform, which I administered
with extra care, for the reason already stated, i.e ., in addition to simply satisfying myself that
the respiration was good, I proceeded with the sprinkled lint lying on the separated figures of
my right, hand in front of the mouth, which enables one to feel the force of expiration; with
my left middle linger on the left temporal pulse and my left thumb holding up the left upper
lid of the patient, and testing the corneal reflex when necessary, watching the respiratory
movements of the abdomen (which was exposed), the complexion of the face, and the pupil of
the eye. After about half an hour I suddenly missed the temporal pulse, and found it was also
absent from the wrist, notwithstanding that the respiration continued. After a few moments
the pulse returned, and the pharyngeal reflex being present I gave two teaspoonsful of brandy
in small quantities, which were swallowed. Then continuing the chloroform, guardedly as