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“2. Always inculcate perfect quietness around the patient, particularly when commencing to give the chloroform.

"3. Only give it during the pains, and withdraw it during the intervals.

Exceptions.-Give a whiff of the chloroform also during the intervals when the pains are very severe, and the patient awakes complaining of them. Give small doses, or only repeat them every second or third pain, when the chloroform affects the action of the heart and uterus. These cases are very rare.

"4. When given during the first stage the anæsthesia need not be deep, unless the suffering be great, or the symptoms of anæsthesia disagreeable.

“5. As the second stage progresses, make the anæsthesia so complete as to destroy all sensibility.

“6. Do not allow the urinary bladder to become over-distended. “7. Do not restrain the patient in one position. “8. Be sure to remove the chloroform as soon as the child is born. “Do not awake the patient artificially” (p. 206).

He seems to have given the preference to the simple handkerchief over all instruments then invented for the exhibition of chloroform ; nor did he believe that any circumstance need interfere with the full effects of the anæsthetic, with the single exception, and that a doubtful one, of mitral disease of the heart. “ This is the only affection where I have the least hesitation in administering chloroform. There is perhaps no necessity for this dread after all ” (p. 182).

Many pages are occupied by cases illustrating the results of anæsthetic treatment—one of those at p. 187 being of considerable interest, as showing the safety which may attend the prolonged exhibition of chloroform, even in the youngest infants. A child being seized with convulsions within ten days of its birth, was about a fortnight subsequently “ placed under the inhalation of chloroform, and kept more or less perfectly under its action .for upwards of twenty-four continuous hours, with the exception of being allowed to awaken eight or ten times during that period for the purpose of suction and nourishment.”

Many more pages are filled with the favourable opinions and comments of practitioners in various parts of the country, which perhaps might have been omitted without detracting materially from the interest or value of the volume.

Part VI treats of Local Anesthesia, giving the results of experiments on the lower animals and on his own person. The devotion and fearless self-sacrifice of the operator are conspicuous on more than one occasion, and well exemplify the spirit in which all such inquiry should be made ; but as the results were negative for the most part, the interest they possess is historical rather than practical, and we may pass at once to the consideration of the second division of the volume.

II. Hospitalism.

If we consider the enormous interests vested in our large palatial hospitals, metropolitan and provincial, their prestige, their dignity, their traditions, and the pride with which they are contemplated both by the public and the profession, it will appear almost impossible that they should be abandoned or materially altered in external feature; yet if there be no fallacy in the figures collected by Sir James Simpson, no error in the conclusions he derives from them, we must look forward to changes in the future more sweeping and startling than any we have yet seen in our hospital system.

The papers on this subject will be remembered as occurring, some in the Edinburgh Monthly Journal, others in the Lancet, where the views they contain were warmly contested by Mr. Timothy Holmes and others. The champions on either side were worthy of the cause, but no impartial reader of all that was said and written can believe that the question has been set at rest, or indeed that it has been more than opened. In a review of this kind it would be impossible even to glance at the whole subject; we shall merely direct attention to the salient points in Sir James Simpson's argument, and hint here and there at a weak, or possibly erroneous, conclusion.

As early as 1848 Sir James Simpson wrote as follows in the pages of the Edinburgh Monthly Journal (November, 1848, p. 328)

“ There are few or no circumstances which would contribute more to save surgical and obstetric patients from phlebitic and other analogous disorders than a total change in the present system of hospital practice. I have often stated and taught that if our present medical, surgical, and obstetric hospitals were changed from being crowded palaces--with a layer of sickness in each flat-into villages or cottages with one, or at most two patients in each room, a great saving of human life would be effected; and if the village were constructed of iron (as is now sometimes done for other purposes) instead of brick or stone, it could be taken down and rebuilt every few years-a matter apparently of much moment in hospital hygiene (p. 290).

And again, as president of the public health section at Belfast, and speaking before the National Association for the Promotion of Social Science, he argues that our hospitals should be changed “from wards into rooms, from stately mansions into simple cottages, from stone and marble palaces into wooden or brick or iron villages.”

The statistics by which these conclusions are upheld are

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derived from a careful analysis of the results which follow the four amputations through the bones of the thigh, leg, arm, and forearm, in large metropolitan or country hospitals, and in the rural homes of the poor respectively. Careful details were collected of 2098 such amputations in country practice, and of 2089 in the larger hospitals of the country, with the following summary of results :

Country practice. large and metropolitan hospitals. Total deaths

10.8 per cent. 41:0 per cent. Thigh

46.5 Leg

13.2 Arm

37.0 Forearm

05

16.4 And a more detailed examination of the individual cases seemed rather to increase than diminish the appalling disparity which these figures exhibit.

1. That the country cases were not less severe, at least those treated after injury, seems proved by the number of successful double amputations after complex injuries, 7 having survived out of 23 operated upon (or 46 operations), whereas “out of a list of the last 11 double primary amputations performed in Edinburgh Infirmary, 10 of the patients died.”

2. The success of amputations in the country on patients over seventy, as compared with the same in hospital practice, would appear to indicate causes which, as we shall presently see, Sir James Simpson persistently ignores. Immunity from hospitalism alone can scarcely account for the fact-if it is a fact, that “limb amputations are not more fatal to the old in rural practice than are the same operations performed upon people of all ages in our large and metropolitan hospitals” (p. 354).

3. Again, the surroundings of a crowded and often dirty cottage, with the obnoxious box-bed so common in Scotland, cannot be favourable conditions under which earn the success which country surgeons claim.

4. Is there no difference in the physique and powers of resisting death? Sir James Simpson appears to think not :

“The amputations in this class of injuries (traumatic) being necessitated by accident, the patients immediately beforehand must be held to be all similar in their state of strength and vital force, They were all alike in the condition of ordinary or normal health a few hours, or a very short time at least, before the operation was resorted to” (p. 373).

Much must depend on the answer to this question, and we cannot at present agree with Mr. Holmes in accepting deaths from shock, after amputation, as the best test of stamina or of debility of constitution.

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The large proportion of deaths in country practice due to this cause, 36-4, per cent., and the small number in the Parisian hospitals, as compared with London hospitals, may possibly point to a different interpretation.

5. Sir James Simpson's position against large hospitals is further fortified by statistics which seem to show that the death-rate after amputation varies directly with the size of the building e. g. In the large Parisian Hospitals

62 in 100 die.
In British Hospitals (300—600 beds)

(300—201
(200—101
(100— 26

(25 beds or less) In isolated rooms in country But many circumstances would lead us to doubt whether the numbers from which the statistics are derived were adequate to the deduction of a true result. When the mortality, for instance, after amputation of the arm varies from 111 per cent. in St. Bartholomew's Hospital (p. 333) to 53:6 per cent. in Edinburgh, whilst it is 12:5 per cent. in Norwegian country practice; when amputation of the leg is followed by a mortality of 27-2 only at St. George's Hospital, while that of the arm (a much less dangerous operation) is 53:3 (p. 336); when at Guy's' amputation of the forearm costs 34.7 lives in 100 submitted to it, that of the leg only 35:3 (p. 335)-much caution will evidently be required in using figures so variable in the solution of important statistical problems.

6. And a similar remark would apply to the figures on which Sir James Simpson grounds his belief that

“The experienced country surgeon, operating upon his patients generally in cottages and villages is, as compared with the experienced city surgeon operating upon his patients in rich and magnificent hospitals, five times more successful(p. 347).

That the mortality after limb amputation is greater in metropolitan hospitals than in country practice cannot be denied, but as an isolated fact it is useless unless we know the actual causes of death. Many and complex causes, social, physiological, and pathological, are at work to bring about the result as we see it. Pyæmia is not unknown in country practice, and isolated cases have occurred in hospital wards without any spreading of the disease. Still there can be no doubt that

When two sick men are laid down in the same room, there is always a chance—slight, in many cases, it may be-of one of them deleteriously affecting in this way, by his exhalations, the bodily state of the other. When a sick or wounded patient is placed in a room or chamber by himself, all such mischances from others are averted; and hence the advantages of perfect isolation of the sick. The danger however, on the other hand, no doubt multiplies as the number of patients aggregated together is increased” (p. 386). And the question still demands an answer, whether by ample space, perfect ventilation, and greater care, the risks here alluded to may not be reduced to a minimum. Many points must be reconsidered and settled before we can finally condemn the noble buildings in which we all feel a pride, and accepting his conclusions, follow the advice of Sir James Simpson :

“ Build up the doors and any other entrances from the wards into the stair-landings, corridors, &c., and make all the wards and all the flats be entered from without, either by new external staircases, if the hospital were not above two stories in height, or by covered balconies or galleries placed upon the outer wall of the ward, and to which balconies or galleries entrance was given by the existing stair

If every ward were thus prevented from sending its deteriorated air into the interior of the house, with the mischance of polluting the general atmosphere of the hospital, and if itself it had only communication with the external atmosphere, then each ward would become a separate cottage hospital, as it were, with a selfventilation entirely its own.'

III. Passing over the essay on hermaphroditism, we must say a few words, in conclusion, on (IV) the paper, reprinted from the Medical Times and Gazette,' on "Stamping-out Smallpox and other Contagious Diseases.” As the poleaxe was the chief measure employed in stamping out rinderpest, so isolation is the chief measure proposed by Sir James Simpson for the stamping out of smallpox. Such a restriction of the liberty of the subject as is implied would be no new feature in legislation. Homicidal lunatics are prevented from destroying the lives of their fellow men, yet smallpox patients yearly destroy hundreds to their one. No harsh measures would be required; none, in fact, which are not now enforced in every well-regulated household when infectious disease assails

any

of its members. The regulations drawn up by Sir James Simpson are at once simple, straightforward, and practical :

“1. The earliest possible notification of the disease after it has once broken out upon any individual or individuals.

“2. The seclusion, at home or in hospital, of those affected, during the wbole progress of the disease, as well as during the convalescence from it, or until all power of infecting others is past.

"3. The surrounding of the sick with nurses and attendants who are themselves non-conductors or incapable of being affected, inasmuch as they are known to be protected against the disease by having already passed through cow-pox or smallpox.

4. The due purification, during and after the disease, by water,

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