NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
340
the action of chloroform; and that the hypothesis of pulmonary obstruction may at once be
dismissed as entirely insufficient and inapplicable, as far as an explanation of the cardiac
dilatation occurring under chloroform is concerned.
Seeing that it is easy to dispose of the question of pulmonary obstruction in regard to
the effects of chloroform upon the heart, I shall now advert briefly to the possibility of cardiac
dilatation being dependent on a rapidly falling blood-pressure, as alleged by Dr. Lawrie. This
is a matter which I carefully considered in my paper, and in regard to which I was able to state
definitely that the cardiac dilatation is not due to a fall of blood-pressure. This is conclusively
proved by the following facts:—"(1) Dilatation of the heart does not by any means always
run parallel to the fall of pressure which ordinarily results from the administration of chloroform.
Sometimes there is a very marked fall of pressure, with little or no dilatation of the heart;
while at other times the heart begins to dilate before the pressure begins to fall. (2) Moreover,
the heart in some instances begins to dilate during the temporary rise of pressure which at times
precedes the fall. (3) Further, there may be distinct dilatation of the heart without any change
of pressure at all. (4) Lastly, it can easily be shown that a simple fall of pressure, equal in
amount to that which ordinarily occurs under chloroform, induced by means which do not
directly affect the heart (e.g., section of a vaso motor nerve, hæmorrhage, etc.), does not cause
dilatation of the organ as chloroform does."
It is clear, then, that the dilatation of the heart brought about by chloroform cannot be
due to obstruction of the circulation in the lungs, or to a fall of systemic blood-pressure; it
must result from a depressing influence exerted by the anæsthetic on the organ (1) directly, or
(2) through the vagus nerves.
Finally, as this depressing influence, leading to dilatation, is readily manifested after
section of both vagi, it is obvious that chloroform must act upon the heart directly.
I cannot help feeling that even a comparatively slight amount of actual observation of
the features and results of a simple lowering of the blood-pressure and of real pulmonary
obstruction would have prevented Surgeon-Major Lawrie from putting forward and adhering
to such a hypothesis as I have here discussed,—a hypothesis at once insufficient, absolutely
untenable, and in conflict with large and somewhat elementary facts in the physiology of
the circulation.
ARTICLE BY SURGEON-MAJOR EDWARD LAWRIE.
[Reprinted from the "Medical Chronicle" of May 1891.]
CONTROVERSIES on medical topics, even where great principles are involved, are apt to
degenerate into mere word-quibbling or wrangling. I shall endeavour in the present article
on chloroform to conduct the discussion between the Hyderabad Commission and Professor
Macwilliam into a channel of agreement which will interest the whole profession, by whose
judgment the question in dispute must ultimately be decided.
345
arise; and this object can be attained by any intelligent medical man who chooses to follow
implicitly the teaching of the Hyderabad Commission. The matter can, however, very easily
be brought to the proof. On the facts established by the Hyderabad Commission, I challenge
the Glasgow Committee, or Professor Wood or Professor Macwilliam, to produce either an
irregular trace or a dangerous dilatation of the heart with chloroform, before stoppage of
the respiration, in any animal whose breathing is normal and regular throughout the
administration.
ARTICLE BY PATRICK HEHIR, M.D., F.R.C.S.E.
Surgeon, Bengal Medical Service; President, First Hyderabad Chloroform Commission
.
[Reprinted from the "Medical Chronicle" of June 1891.]
THE various, discrepant and irreconcilable opinions recently expressed in medical
periodicals regarding the question as to the right method of inducing chloroform anæsthesia
in the human being, indicate that even the highest authorities on the subject entertain almost
opposite views. These opinions have poured in from all quarters during the last twelve months,
that is, since the publication of the Report of the Second Hyderabad Chloroform Commission.
When we consider that it is this very difference of opinion in regard to the proper method of
producing insensibility by inhalation of chloroform vapour (in other words, that it is the varia-
tions in the way of administering it) that lies at the foundation of the great disparity of
mortality statistics from chloroform anæsthesia, we must admit that the question itself is a most
momentous one, and one that might with credit to the profession be removed from its present
equivocal basis.
The history of the origin of the Hyderabad Chloroform Commission is too well known
to require any further explanation here beyond that of stating that the object in view was to
show that the principles upon which the late Professor Syme administered chloroform were
sound and reliable. We cannot be too frequently reminded as to what these principles are:
"Free admixture of air with the vapour of chloroform, which is ensured by using some soft,
porous material, as a towel or lint, presenting a large surface; no stint in the quantity of
chloroform given; watch the respiration."* He considered that there was never any occasion
to feel the pulse or examine the heart either before or during anæsthesia.
The main practical points brought out by the Hyderabad Chloroform Commissions,
were: (1) that primary cardiac syncope during chloroformisation does not occur, and (2) that
the respiration is the only safe guide to the effect of chloroform. In the report of the First
Hyderabad Chloroform Commission we made the following statement:† "In no case did car
- d i a c s y n c o p e o c c u r . T h e C o m m i s s i o n c o n s i d e r s t h a t i t i s i m p o s s i b l e f o r c h l o r o f o r m v a p o u r t o
kill a dog by acting primarily on the heart, and this holds good no matter in what doses or
* Vide Lancet, 1855, Vol.I., p. 55. † Vide Lancet, January 22, 1890.
44
357
inquired into yet, but, from his own clinical experience, he believed the views and conclusions
of the Hyderabad Commission were not far from the truth.
Dr. Arnott said he was glad to find the views of Dr. Lawrie were the same as he had
been taught by Professor Lister twenty-five years ago ; in that Sir Joseph Lister insisted that the
great safeguard in the giving of chloroform was the dilution of the chloroform, and that the
giving of the chloroform in a concentrated form, such as a closed cone, closely applied over
the nose and mouth of the patient, was not a safe method of administration ; but that some
method of dilution must be adopted to the amount which Dr. Lawrie had quoted, and which,
he thought, was about the amount quoted by Professor Lister some twenty-five y ears ago. He
had no doubt that the administration of diluted chloroform was as safe as Dr. Lawrie
had said.
Dr. Hatch next explained his experiences in chloroform administration. During ten
or twelve years he had only known of two deaths, and one of those he had some doubts about
before administering. In these case the chloroform was administered with the closed cone,
which it was not necessary to place close to the nose.
Dr. Blane y said he had been Coroner of Bombay for fifteen years, and every death that
had been reported as haying occurred from chloroform or from any other anæsthetic, had been
inquired into by him, as it was his duty to do, but he said it was to the credit of the medical
profession of Bombay that they stood behind no other city he knew of in the successful
administration of chloroform. Those reports he had received of deaths from chloroform, he did
not consider worth the paper they had been written on. Chloroform, during the time he had
been Coroner, must have been administered in Bombay many thousands of times, but
there were only two deaths during that time which really resulted from chloroform or
anæsthetics.
Some other gentlemen reported their experiences, saying they had had no deaths from
chloroform, and expressing the opinion that there was no danger from chloroform if properly
administered and diluted. At the same time it was necessary, some thought, to watch the
pulse as well as the respiration.
Dr. Lawrie said that before the Commission he used to watch the respiration for signs
whereby danger might be arrested, but that since the session of the Commission he did not
merel y watch the respiration, but insisted on its being kept absolutely regular throughout the
whole administration so as to produce normal inhalation and normal anæsthesia.
Surgeon-General Pinkerton proposed a heart y vote of thanks to Dr. Lawrie for coming
there and delivering that lecture ; and to H.H. the Nizam for affording the means of
research.
The motion was heartily responded to, and the meeting separated.
PART IX.—CLINICAL RESULTS.
[By THE PRESIDENT.]
The system of note-taking in chloroform administration, now in force in
the Afzulgunj Hospital, has been developed very gradually since the comple-
tion of the experiments of the Commission. In the first 272 cases in which
an accurate record of chloroformisation was kept, the notes were taken by
students. The average time to produce anæsthesia in these cases, which
include children and adults, was 3m. 44s. In 82.9 per cent. abolition of the
corneal reflex, in 16.8 per cent. stertorous breathing, and in one case complete
relaxation of the muscles was the first sign of full anæsthesia. There was no
instance of respiratory embarrassment or of accident or delay of any kind due
to over-dosing, and the patient was never allowed to inhale the anæsthetic
while the breathing was in any way irregular.
From Case No. 273 the notes were taken by the surgeon. The system of
administration and note-taking was improved by the adoption of suggestions
made by two of the most distinguished surgeons in Europe during the discussion
on anæsthetics in Glasgow. Sir George Macleod stated that in all his public
operations he administers chloroform himself until full anæsthesia is produc-
ed, Dr. William MacEwen said that during chloroform inhalation every one of
the patient's respirations should be registered on the chloroformist's tympanum.
Effect was given to both these principles. Sir George Macleod's method has
been practically followed by the surgeon himself taking notes of every case
of chloroform administration in the presence of the clinical class, while the
administration has been entrusted to students as before. In this way the
responsibility for the whole case rests with the surgeon as it always ought to
rest, unless we are to go back to the days of barber surgery when the surgeon
simply did as he was told ; at the same time the students, without exception,
have the opportunity of becoming skilful and safe chloroformists. Throughout
the inhalation the chloroformist carries out Dr. MacEwen's rule to the letter and
every one present is kept informed of the rate of the patient's respirations by
an assistant who stands near the chloroformist and taps the table after every
completed breath the patient takes.
359
The administration of chloroform in the Afzulgunj Hospital is now
conducted in the following manner. When all is ready for the operation
the surgeon gives the signal to begin the inhalation. The method of adminis-
tration is described on page 286. While it is proceeding no one is allowed to do
anything in the operating room, not even speak, and everybody's attention
is thus concentrated on the administration until the patient is fully
anæs-thetised. From the moment the inhalation is commenced until anæsthesia is
produced, the surgeon records every event, even of the most trivial kind, with
the exact time of its occurrence. This is in strict conformity with Dr. Bomford's
plan of recording on the tracings everything, as it took place, during the
manometer experiments of the Commission. Each entry is notified to the
class as the surgeon records it, and after the operation is finished, and the
patient has been removed, one of the students is made to describe from
memory what happened during the inhalation. His description is compared
with the record, and finally, the record is read out to the class.
In the cases detailed it will be remarked that the respiratory pauses,
which are sometimes referred to as " apnœa" and sometimes as '' holding
breath," were systematically followed by one breath of pure air. This
requires a word of explanation. During chloroform administration the patient
usually holds his breath from apnœa, or owing to over-concentration of the
vapour, or from increasing narcosis of the respiratory centre. Holding the
breath from apnœa, which occurs in the early stages of the inhalation, is
generally due to rapid breathing, and when the patient begins to breathe again he
does so quietly and without gasping. Holding the breath from over-concentra-
tion of the vapour of chloroform or from sluggishness of the respiratory
centre, though a natural safeguard, leads to asphyxia, and when the patient is
compelled to breathe again he gasps. It is not always possible to determine
the cause of holding the breath; but it is evident that as the patient can
take in no chloroform as long as he is not breathing, it does not waste
time to remove the chloroform cap from his face until he breathes again.
When the patient does breathe again, however, it makes all the difference in
the world whether the chloroform cap is over his face or not. If it is, and he
gasps, an over-dose may be taken in or still further irregularity of the
respiration may be produced ; in either case the result is abnormal inhalation.
But if the first inspiration after holding the breath, or after any abnormality of
the breathing, consists of a breath of pure air, all danger is avoided. Normal
respiration is restored ; and normal respiration alone is compatible with normal
inhalation and normal anæsthesia.
360
Cases of chloroform administration at the Afzulgunj Hospital.
August 22nd, 1891.—No. 273.
Temperature of operating room 73.7°F. Healthy Mahomedan male ætat
29. Disease—hydrocele. Operation—excision of sac. Chloroformed by student
Krishtiah at 8h. 13m. 30s. Anæsthesia complete at 8h. 17m. 45s.; operation
commenced at 8h. 18m. 0s.; finished and patient, removed from table at 8h.
44m. 30s. Retched and brought up a little frothy mucus at 8h. 41m. 55s.
Observations.
H. M. S.
A. 8 13 30.—Chloroform on cap; patient blowing hard.
B. 8 14 20.—Apnœa; cap entirely removed till 8h. 14m. 45s.
; one breath fresh air.
C. 8 14 45.—Chloroform; regular breathing.
D. 8 16 10.—Struggling; regular breathing. Struggling con-
tinued till 8h. 16m. 50s. when one breath of
fresh air was given. and the struggling ceased.
E. 8 17 0.——Snoring; at 8h. 17m. 30s. the snoring was accom-
panied by noisy expiration.
F. 8 17 45.—Breathing stertorous; stop chloroform.
G. 8 17 55.—Cornea insensitive.
H. 8 18 0.—Operation commenced.
I. 8 44 30.—Operation completed.
In this and in all subsequent cases, unless it is expressly stated to the
contrary, the anæsthesia was continued until the completion of the operation and
the application of the dressings, in the usual way, by giving chloroform from
time to time.
August 22nd, 1891.—No. 274.
Temperature of room 76·3°F. Shurfun Bee (female infant), ætat 1 year.
Disease–abscess. Operation—incision. Chloroformed by student. Miss
Williams at 9h. 3m. 0s. Anæsthesia complete at 9h. 4m. 10s. Chloroform
stopped and operation finished at 9h. 7m. 15s.
361
Observations.
H. M. S.
A. 9 3 0.—Chloroform on cap; crying and struggling; breath
-ing regular.
B. 9 4 10.—Cornea insensitive; kept under chloroform till the
dressing was applied, and the child was removed
from the table at 9h. 7m. 15s.
August 22nd, 1891.—No. 275.
Temperature of room 76·3° F. Male Mahomedan child, Mahomed Sahib,
ætat. 1 year. Disease—wound. Explored under chloroform and sutured.
Chloroformed by student Miss Williams at 9h. 12m. 55s. Under at 9h. 13m.
40s. Administration stopped and operation finished at 9h. 18m. 5s.
H. M. S.
A. 9 12 55.—Chloroform on cap; crying and struggling; breath-
ing regular.
B. 9 13 10.—Holding breath; chloroform cap removed.
C. 9 13 20.—Gasped fresh air; chloroform again.
D. 9 13 30.—Regular breathing.
E. 9 13 40.—Cornea insensitive; kept under chloroform till 9h.
18m. 5s.
August 24th, 1891.—No. 276.
Temperature of room 73·1° F. Well-nourished Hindoo male, Krishna
Row, ætat. 44. Disease—leprosy. Operation—nerve splitting and cleaning.
Chloroformed by student Krishtiah at 7h. 40m. 0s. Full anæsthesia at 7h.
45m. 10s. Chloroform stopped at 8h. 8m. 5s.
Observations.
H. M. S.
A. 7 40 0.—Chloroform on cap; blowing gently.
B. 7 42 30.—While more chloroform was being poured into the
cap the patient took three breaths of pure air.
C. 7 43 30.—Noisy expiration.
D. 7 44 15.—Breathing irregular; one breath of pure air.
E. 7 45 0.—Snoring.
F. 7 45 10.—Stertorous breathing; chloroform stopped. Kept
under till the operation was finished at 8h. 8m. 5s.
362
August 24th, 1891.—No. 277.
Temperat ure of room 73. 1° F. Weakl y Mahomedan mal e, Shai k Jamal ,
ætat. 30. Disease—abscess. Operation—incision. Chloroformed by student
Krishtiah at 8h. 13m. 50s. Full anæsthesia at 8h. 18m. 50s. Administration
stopped at 8h. 24m. 30s.
Observations.
H. M.
s.
A. 8 13 15.—Chloroform on cap; blowing very rapidly into the
cap, 68 times a minute.
B. 8 15 0.—Cap close to face.
C. 8 15 10.—Breathing irregular; one breath of fresh air.
D. 8 16 0.—Regular breathing, 24 respirations a minute.
E. 8 17 10.—Snoring.
F. 8 17 30.—Two breaths of fresh air while more chloroform
was added.
G. 8 18 45.—Noisy expiration.
H. 8 18 50.—Cornea insensitive; chloroform stopped. Adminis-
tration afterwards continued till 8h. 24m. 30s.
August 24th, 1891.—No. 278.
Temperature of room 73.1° F. Healthy Hindoo male, Ramiah, ætat. 20.
Disease—needle in the buttock. Operation—excision. Chloroformed by
student Krishtiah at 8h. 31m. 50s. Full anæsthesia at 8h. 36m. 5s. Adminis
-tration stopped at 8h. 40m. 0s.
Observations.
H. M. S.
A. 8 31 15.—Chloroform on cap; blowing rapidly 52 times a
minute.
B. 8 31 50.—Talking.
C. 8 32 5.—Cap close to the face.
D. 8 32 10.—Apnœa; cap removed.
E, 8 32 20.—One breath of fresh air. Cap re-applied. Regular
breathing 24 times a minute.
363
H.
M.
S.
F. 8 33 10.—More chloroform on cap ; took two breaths of
fresh air.
G. 8 34
0.—Moving legs and arms.
H. 8 34 15.—Holding breath and struggling ; cap removed.
I. 8 34 45.-Gasped fresh air ; cap re-applied ; regular breath-
ing.
J. 8 34 50.—Talking.
K. 8 35 10. —Noisy expiration.
L. 8 36
5.—Cornea insensitive ; chloroform stopped. Admin-
istration afterwards continued till 8h. 40m. 0s.
August 24th, 1891.—No. 279.
Temperature of room 731° F. Healthy Hindoo male, Kissensingh, ætat. 40
_Disease-necrosis of the lower jaw. Operation-removal of dead bone. Chloro
formed by student Krishtia.h at 8h. 52111. 0s. Full. anæstliesia at 8h. 59m. 55s.
the administration was slow on account of bleeding into the mouth. (A probe
had been introduced into the sinus before the operation was decided on.)
Observations.
H.
M.
S .
A. 8 52
0.—Chloroform on cap ; blowing regularly.
B. 8 53
5.—Cap brought close to face,
C. 8 54 30.—More chloroform ; two breaths of fresh air.
D. 8 55 40.—Noisy expiration.
E. 8 56 20.—Coughing violent ly ; one breath of fresh air.
F . 8 57 20.—More chloroform on cap ; two breaths of fresh
air.
G . 8 59 55.—Cornea insensitive ; ad 1) tinistration continued till
9h. 4m. 55s.
August 24th. 1891.—No. 280.
Temperature of room 86.50 F. Healthy Hindoo female, Lutchoo, ætat. 40
Disease—Ovarian cysts, Operation—double ovariotoniy. Chloroformed at the
Residency Hospital at lh. 0m. 0s. by student Miss Williams. Full anæs-
-thesia at 1h. 4w. 30s. Continued until the operation was finished at lh. 59m. 0s.
364
Observations.
H.
M.
S.
A.
1
0
0.—Chloroform on cap ; blowing regularly 36 times a
minute.
B.
1
0
40.—Cap close to face.
C.
1
0
55.—Noisy expiration ; 32 respirations a minute.
D.
1
1
25.—Took three breaths of pure air while chloroform
was added to the cap.
E. 1
2
0.—Holding breath ; cap entirely removed.
F.
1
2
15.—Gasped pure air ; chloroform again.
G.
1
2
40.—Holding breath, cap entirely removed.
H.
1
2
55.—Gasped pure air ; chloroform again.
I.
1
3
40.—Talking ; regular breathing.
J.
1
3
50.—Regular breathing 24 times a minute.
K.
1
4
30.—Cornea insensitive ; stop chloroform. Continued
afterwards until the operation was finished at,
1k. 59m. Os.
August 25th, 1891.—No. 281.
Temperature of room 74.2º F. Healthy European boy, F. C. Harding, ætat.
13. Disease—abscess of the neck. Operation—incision. Chloroformed by
student Abclullah Khan at 7h. 55m. 10s. Anæthesia complete at 7h. 59m. 55s. ;
administration stopped at 8h. 10m. 30s.
Observations.
H.
M.
S.
A.
7
55
10.—Chloroform on cap ; blowing gently and crying.
B.
7
56
20.—Cap brought close to the face.
C.
7
56
45.—Calling out.
D.
7
57
45.—Took two breaths of fresh air while more chloro-
form was added to the cap.
E.
7
58
0.—Regular breathing.
F.
7
59
35.—Snoring.
G.
7
59
55.—Cornea insensitive ; anæsthesia afterwards kept up
till 8h. 10m. 30s.
365
August 25th, 1891.-No. 282.
Temperature of room 74 . 2° F. Healthy Mahomedan, lahonied Brix,
fetat. 56. Disease-stricture of the urethra and perineal abscess. Operation-
incision, and dilatation of the stricture with Holt's dilator. Chloroformed at
8h. 12m. 40s. by student Krishtiah. Full anae sthesia 8h. 16m. 45s. Anesthesia
continued till the operation was finished at 8h. 37m. 5s.
Observations.
II.
M.
S.
A. 8 12 45.-Chloroform on cap ; blowing rapidly.
B. 8 13
0.-Coughing.
C. 8 14 10.-Holding breath ; cap removed till 8h. 14m. 22s.
D. 8 14 20.-C asped fresh air ; chloroform again ; regular
breathing.
E. 8 14 40.-Struggling till 811. 15m. 15s. ; regular breathing.
F. 8 15 15.-Irregular breathing.
G. 8 15 20.-One breath of fresh air ; regular breathing.
II. 8 16 30.-Stertorous breathing. ; chloroform stopped.
I. 8 16 45.-Cornea insensitive ; kept under afterwards until the
operation was finished at 811. 37m. 5s.
August 25th, 1891.-No. 283.
Temperature of room 78 . 4° F. Healthy Native Christian, Francis, wtat. 51.
Disease-stricture of the urethra and extravasation of urine. Operation-peri-
neal. section and incisions. Chloroformed by student Krishtiah at 811. 54m. 30s.
Fell ane'stliesia at 811. 59m. 15s. ; administration stopped at 9h. 3m. 40s.
Observations.
II.
M.
s.
A.
8 54 30.-Chloroform on cap ; blowing gently.
B. 8 55 15.-Cap brought close to the face.
C.
8 55 30.-Moaning.
D. 8 55 45.-Slight struggling ; regular breathing.
E. 8 56 10.-Moving hands and arms.
F. 8 56 30.-Breathing irregular ; one breath of fresh air.
366
H. M. S.
G. 8 56 50.—Breathing irregular again ; one breath of fresh air.
H. 8 57 30.—More chloroform poured into cap ; took two breaths
of fresh air.
I. 8 58 30.—Talking.
J. 8 59
0.—Rapid regular breathing.
K. 8 59 50.—Cornea insensitive ; administration afterwards con-
tinued till 9h. 3m. 40s.
August 25th, 1891.—No. 284.
Temperature of room 78.4º F. Weakly ill-nourished child, ætat. 1 year,
Mahomed Saheb. Disease—abscess. Operation—incision. Chloroformed by
student Ismail Khan at 9h. 54m. 0s. Anæsthesia complete at 9h. 55m. 45s.
Administration stopped at 10h. 1m. 30s.
H . M. s.
A. 9 54
0.—Chloroform on cap ; regular breathing.
B . 9 54 30 .—Two breaths of fresh air given without any parti-
c u l a r r e a s o n .
C. 9 55
0.—Regular breathing. 32 a minute.
D. 9 55 45.—Cornea insensitive ; cap removed. Administration
continued till 10h, 1m. 30s.
August 26th, 1891.—No. 285.
Temperature of room 74.7º F. Healthy Hindoo female, Rungoo, ætat. 30.
Disease—whitlow. Operation—incision and removal of necrosed phalanx.
Chloroformed by student Miss Williams at 8h. 20m. 0s. Full anæsthesia at
8h. 24m. 15s. Administration ended at 8h. 26m. 55s. The breathing became
stertorous fifteen seconds after the chloroform was stopped when the cornea
became insensitive.
Observations.
H. M. S.
A. 8 20 0.—Resisting and breathing
irregularly ; struggled
violently and cried till 8h. 20m. 50s.
B. 8 21 10.—Gasping noisy inspirations.
C. 8 21 15.—One breath of pure air.