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On making a general survey of the experiments as reported we cannot help being
struck by one very important fact, viz., the uniformity with which the various phenomena
presented themselves in each series, even in those purposely complicated for special objects.
In other words, the percentage of typical cases is very large, and contrasts markedly with what
is observed in the human subject, where typical form is comparatively uncommon, but is
nevertheless, when it occurs, recognised as the normal and made the point of departure for the
consideration of all others. It is chiefly on this account that I feel I must disagree with the state
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ment of the Commission that, if the rules laid down be followed, "chloroform may be given in
any case requiring an operation with perfect ease and absolute safety." The public, who are our
judges, if anything goes amiss, will—nay, already have supplied the words "by any one, experi
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enced or inexperienced," and this idea, if allowed to gain acceptance, will, I am afraid, be
fraught with disaster. Even assuming for the moment that primary cardiac failure never
occurs in the human subject, cases are continually presenting themselves where the respiratory
signs need the closest watchfulness. Clinical experience shows us that shallow breathing
occurs at the two ends of the scale. On the one hand, when the subject is deeply under the
influence of chloroform; on the other, when he is entering or emerging from its influence. In
our typical eases the interval between the two is well marked, and the two conditions are easily
distinguishable; but in others, not at all infrequent, the interval is so small and so slightly
marked that it may be bridged over by a minute dose of chloroform, or even by a mere altera
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tion of position in the patient. It is here that even the experienced administrator might be
led into a fatal error if he trusted entirely to the ill-defined signs furnis
h e d b y t h e r e s p i r a t o r y
function, and it is only by a careful attention to the important indications yielded by the pulse,
the pupil, the conjunctival reflex, the colour, and temperature of the skin, that he is able to
conduct his patient safely through a truly perilous journey. I cannot conclude this letter with
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out heartily endorsing every word in Dr. Hewitt's valuable letter on the same subject. I have
myself notes of at least two cases in which, during complete and satisfactory chloroform narcosis
and without hæmorrhage of any importance, there was a rapid fall in the volume and tension of
the pulse, attended with blanching of the lips and coldness of the surface, without any prelimi
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nary alteration in the depth or frequency of respiration. Whatever the exact cause may be,
there can be no doubt that during the administration of chloroform we must always be pre
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pared for such an occurrence, whereas with ether we may practically disregard its possibility.
The duty of the anæsthetist during the performance of a surgical operation on the human
subject must be regarded as a highly complicated one, and I am of opinion that the most relia
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ble administrator is the one who, automatically, as it were, is at all times in full possession of
the general condition of his patient, keenly alive to all the indications presented to him, how
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ever trivial, and at once prepared to regulate his procedure accordingly.
I am, Sirs, yours obediently,
CHARLES E. SHEPPARD.
Second Chloroformist to the Middlesex Hospital;
Anæsthetist to Guy's Hospital (Dental School).
Welbeck-Street, Cavendish Square, W., March 4th, 1890.