NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
214
LETTER FROM THE GLASGOW CHLOROFORM COMMITTEE.
TO THE EDITORS OF " THE LANCET."
SIRS,—The Hyderabad Report, which appeared in " The Lancet " of January 18th , natu
-
rally attracted our attention and called for remark, especially as it seemed to traverse certain of
our conclusions. On carefully rending the report, it appeared to us that, so far as the facts are
concerned, it generally confirmed our own observations as to the action of chloroform both on
respiration and on the heart. Some of the inferences, however, are opposed to ours ; but they
are also opposed, as we believe, to the facts stated in the report itself. We therefore propose
to criticise the report, and we would have done so immediately after its publication but for a
request communicated to us that we should wait for the publication of the tracings on which
the report is largely based. We
at once agreed to postpone our remarks,*
and only make this
communication lest our silence should be misinterpreted.
C K .
LETTER FROM MR. FREDERIC HEWITT.
TO THE EDITORS OF "THE LANCET."
SIRS.—Although wishing that space would permit me to express my keen appreciation
of the work done by the Commission. I feel that, as there is so much to be said on this important
subject, I m us t at once proceed to the consideration of the questions at issue.
In the first place I would ask what is the true value of the physiological fact that, when
chloroform is administered in toxic doses to the lower animals, respiration ceases before cardiac
a c t i o n ? Ha v e we a n y c l i n i c a l e v i d e n c e t o p r o v e t h a t , u n d e r s i m i l a r c i r c u m s t a n c e s ,t
h i s s e q u e n c e
of events is not met with in human beings ? In most, if not in all, of the rapidly fatal eases
which have occurred under chloroform, it has, for obvious reasons, been a matter of extreme
difficulty to say at what particular moment the heart ceased to beat. Failure of the pulse has
often been taken to mean stoppage of the heart, but without sufficient grounds. If it were
possible to make a series of observations upon human beings with that accuracy which is
attainable when conducting experiments upon lower animals, should not be surprised to learn
that, when chloroform causes de ath solely by reason of its toxic properties, the same sequence
of events as that observed by the Hyderabad Commission invariably occurs. But our know
-
ledge concerning the action of the heart under anæsthetics is almost entirely dependent upon
observations on the pulse ; and it would seem that confusion has frequently arisen in conse-
[* In spite of this statement the Glasgow Committee published their remarks one week before "the publication of the
tracings on which the report is largely based."]
216
involving much danger to life; but we cannot look upon it in this light when we meet with it
upon the operating table.
In conclusion, I would say a few words concerning the indications afforded by the pulse
during chloroform administration. There is much evidence to show that, in whatever way
death occurs during chloroform narcosis, the pulse, if carefully watched, usually gives warning
of the approach of danger before respiration has become seriously affected. In those cases in
which cardiac depression is only indirectly due to the chloroform—such, for example, as the
case I have related—the initial symptoms are obviously cardiac in origin, and are hence to be
detected by alteration in the force and frequency of the pulse. In those cases, too, in which
the symptoms are indisputably due to an overdose of chloroform—such, for example, as the cases
reported by the Commission—the pulse will, in obedience to the fall of vascular tension (which,
as the Commission admits, precedes stoppage of respiration), give indications of the most
important character. If the Commission could prove that, when chloroform is administered in
toxic doses, respiration invariably ceases whilst the radial pulse is practically unaltered in q
u a -
lity, we should begin to look upon chloroform as a respiratory poison only; but these are not
the facts, so far as I understand. I cannot avoid the conviction that the Hyderabad Commis
-
sion have incurred a grave responsibility in eulogising chloroform as an anæsthetic for general
purposes, and in recommending administrators to disregard the indications afforded by the pulse.
As I have before ventured to point out in these columns, we should consider the inexperienced
rather than the experienced in recommending an anæsthetic. I have lately read the records of
every fatal case reported by "The Lancet" and "British Medical Journal" as having occurred
under anæsthetics in the British Isles from 1880 to 1889 inclusive, and I find that out of a
total of 130 chloroform deaths no less than fifty-four took place in connection with minor sur
-
gical operations, most of which were doubtless conducted with somewhat less caution than
would have been employed in more critical cases. Are we to advise the use of chloroform
(which Dr. Lauder Brunton admits to be a most powerful drug) to recently qualified men, who
have perhaps never employed it before? I confess I cannot regard it as advisable to permit
those with but little experience to administer chloroform to patients coming into the surgeries
of hospitals with a dislocated shoulder or a lacerated finger, yet this course is one which the
Commission appear to countenance. Even though we accept the facts so ably put before us by
the Hyderabad Commission, we are, I would submit, in no way justified in agreeing with the
practical conclusions at which the Commission have arrived.
I am, Sirs. yours obediently.
FREDERIC HEWITT,
Instructor in and Lecturer on Anæsthetics
at the London Hospital, &c.
George-Street Hanover-Square, W., Feb. 24th, 1890.
[It is to be observed that when the pulse failed Mr. Hewitt employed artificial respiration to restore it.]
222
LETTER FROM D R. A. MITRA.
TO THE EDITORS OF " THE LANCET."
SIRS,—The point raised by Surgeon-Major Deane in his letter published in The Lancet
of January 25th is no doubt very important to the medical practitioner both in the United
Kingdom and in other parts of Her Majesty's dominions. After the promulgation of the
Hyderabad Chloroform Commission Report, the administrator of chloroform in a case which
may unfortunately be fatal will be in a very awkward position before the coroner's court. We
hear very often of "death from chloroform" in large hospitals in the United Kingdom. Con
-
sidering that greatest care is always taken to entrust the duty to trained and experienced men,
it is impossible to believe that no other factor but want of sufficient care plays part in such
casualties. While fully appreciating the great and good work done by the Commission, I
believe I am justified in saying that there is hardly one new recommendation contained in the
practical conclusions given in the end of the Report which is not already known to the
profession, and which careful surgeons do not observe in their every-day work in the operation
room.
Dr. Deane says :—" For the last fourteen years I have administered chloroform precisely
as the Commission recommends." I can fully bear testimony to this statement, as I had on
several occasions administered chloroform when Dr. Deane was operating. I have adminis
-
tered chloroform in a very large number of cases. I have always held the theory that chloro
-
form stops the respiration before it interferes with the circulation. During the administration
of chloroform I never feel the pulse, but keep a careful eye on the respiration and condition of
lips, &c. ; but, during the last four years, I had on two occasions to abandon the contemplated
operation, and on three others to postpone it, for the danger that stared me in the face after
the administration of only a few whiffs of chloroform. By the time this letter will reach you,
English surgeons will no doubt have given their opinions on the question. The Hyderabad
Commission deserve the highest credit, and it is not too much to say that it is one of
the greatest scientific events of the nineteenth century ; but, at the same time, it must be
observed that the last paragraph of its report has hardly the chance of being universally
admitted, and is calculated to be positively dangerous medico-legally, as Dr. Deane has
pointed out.
A. MITRA,
L.R.C
.P.. L.R.C S.
Kashmir, March 5th, 1890.
223
REMARKS on the REPORT of the SECOND HYDERABAD CHLOROFOR
M
COMMISSION, by JOHN G. MCKENDRICK, M.D., (Professor of Physiology
in the University of Glasgow); JOSEPH COATS, M.D., (Pathologist to
the
Western Infirmary, Glasgow); and DAVID NEWMAN, M.D.,
(Surgeon to the Western Infirmary, Out-door Depart-
ment, Glasgow); Members of the British Medical
Association Committee on Anæsthetics.
(REPRINTED FROM THE BRITISH MEDICAL JOURNAL OF JUNE 14TH, 1890.)
The work of the Commission—The Dangers of Chloroform—Its Action on the Heart
—
Liability to Sudden fall of blood-pressure— Gradual Fall constantly observed
Chloroform or Asphyxia ?—The Relative Importance of Heart and Respiratory
Failure—Points of Agreement.
We desire, in the first instance, to congratulate the members of the Hyderabad Chloro
-
form Commission on the completion of an investigation of great importance to humanity. It
reflects much credit not only on the members of the Commission who carried out the experi
-
ments, but also on the Government of His Highness the Nizam, his Prime Minister Sir Asman
Jah, and especially on Surgeon-Major E. Lawrie, whose zeal and energy originated and
s u c c e s s f u l l y c a r r i e d o u t t h e C o m m i s s i o n . T h e c o m p l e t i o n o f a s c i e n t i f i c i n v e s t i g a t i o n o f s u c h
magnitude, and with the aid of all the refinements of a modern physiological laboratory in
the capital of the largest native Indian State, is an event of historical importance, and may
be regarded as an earnest of the time when East and West will co-operate for advance
-
ment of science
.
2.The report of the Hyderabad Chloroform Commission appeared in the Lancet of
January 18th, 1890 ( vol. i., 1890, p. 149). The Reports of the British Medical Association's
Committee was printed in the Journal, vol, i., 1879, pp. 1, 103, and 921 ; and in vol. ii., 1880,
p. 957.
3.We have to thank Dr, Lawrie for kindly submitting to our inspection the kymo
-
graphic tracings of blood-pressure taken by the Hyderabad Commission, These convey an
idea of the enormous amount of work done by the Commission,—work involving great expendi
-ture of time and energy, and demanding high technical skill. We delayed the present
remarks till we should have the opportunity of examining these tracings, and we have made
the examination with a view to adjusting our points of difference and bringing out our points
of agreement.
4.The main point of difference between the Commission and the British Medical
Association Committee has reference to the action of chloroform on the heart. This will be
t aken up af t er war ds ; meanwhi l e, we may not e t hat i n our r epor t we f ul l y r ecogni s ed t he danger
from failure of the respiration,—a fact which the Hyderabad Commission has omitted to allude
to in referring to our report. Thus, in our report we say : " Chloroform may cause death in
231
It may here be noted that our observations are in complete accord with those recorded by Drs. Wood and Hare, of the University of Pennsylvania, published in the Medical News of
February 22nd, 1890, and reprinted in the Provincial Medical Journal, April 1st, 1890. The
results of numerous experimental observations are embodied in the following paragraph:
—
"The experiments which we have given show that chloroform acts as a powerful de-
pressant poison upon both respiration and circulation, that sometimes the influence is most
felt at the heart, and death results from cardiac arrest; that in other cases the drug paralyses
primarily the respiratory centres, whilst in other instances it seems to act, with equal force
upon both medulla and heart. So far as practical medicine is concerned, it makes little
difference whether the heart stops before or just after respiration, so that those cases in which
cardiac and respiratory arrest are almost simultaneous are, for the purposes of the clinician,
the same as those in which heart arrest precedes respiratory paralysis. Finally, the general
results of our new experiments also coincide with our previous experience in the laboratory,
and with what we believe to be the general belief of physiologists—that cardiac arrest is spe-
cially prone to occur when chloroform is administered rapidly and in a concentrated form."
8. It will probably serve a useful purpose, seeing that the points on which we dis-
agree with the Hyderabad Commission have been set forth in some detail above, if we now
state in a summary form the more important matters on which we are agreed.
(I) We are agreed that death from chloroform occurs by failure of respiration, and that
this is probably the most frequent mode of death.
(II) We are agreed that chloroform causes a gradual fall in the blood-pressure as
registered by kymographic tracings from the carotid artery. This is the normal effect of
chloroform.
(III) We are agreed that when chloroform is pushed this gradual fall may be so great
as to become in itself "dangerous". This is admitted in paragraph (8) of the Hyderabad
Report, where they state that after an animal has been involuntarily holding its breath "the
gasping respiration which succeeds then causes very rapid inhalation of chloroform, with
immediate insensibility and a rapid fall of blood-pressure, which becomes danger ous" .
( T h e
italics are ours.)
(IV) In addition to this, which we may call the normal effect of chloroform on the
heart and blood-pressure, both of us observed peculiarly sudden and unexpected falls of pres-
-sure, with slowing of the heart. We are agreed that this phenomenon occurs, and the
Hyderabad tracings show that it is frequent. We differ as to the casue of its occurrence, the
Hyderabad Commission ascribing it to asphyxia, while we contend that neither in the time of
its occurrence after holding the breath nor in its general characters does it correspond with
the fall of pressure due to asphyxia. Whatever be the explanation, the occurrence is in itself
sufficiently serious, and should not be minimised as forming one of the sources of danger in
the administration of chloroform.
247
necessarily the result of the anæsthetic— see Simpson on Anæsthesia) here in England, probably
the first question of the coroner would be "How much chloroform was administered?" and how
supremely ignorant and careless one would be considered if the answer given was "I have no
idea.", yet it would be a proper reply to a foolish question. This is a point deserving attention.
As regards disease of the heart, Simpson says: "Valvular diseases are those which are most
generally considered and insisted on as contra-indicating the use of chloroform. But this is
really not the case, for that agent may be employed without the least danger in any valvular
disease except, perhaps, disease of the mitral valve . . . There is, perhaps, no necessity for
this dread after all." (Simpson's "Anæsthesia," p. 182.) No one can cherish a more grateful
remembrance of the teaching and personal kindness of Professor Syme than I do, but it was
Simpson who taught us, first, that chloroform should be pure; secondly, t h a t
i n
a d m i n i s t e r i n g
it there should be a free dilution of the vapour with atmospheric air; thirdly, not to use an
inhaler; fourthly, to watch the respiration and beware of stertor; and, fifthly, not to think
about the quantity but the effects of the chloroform.
I am. Sirs, yours truly,
Brighton, June 24th., 1890.
R. WHITTINGTON LOW E,
LETTER FROM SURGEON H. CHESTER NAN
To THE EDITORS OF "THE LANCET"
SIRS,— I can emphatically endorse all you say in your admirable annotation of May 3rd
that "the ever-recurring paragraphs detailing death while u nder chloroform too o ften escape
due notice". During an experience as house surgeon extending over nine years in this and
other hospitals it has fallen to my duty to administer anæsthetics constantly. As I take the
deepest interest in the subject, I hope, I may be excused for writing to you on it. It is
surprising to me how any one can advocate chloroform in preference to ether. The number of
deaths from chloroform recorded in The Lancet
and British Medical Journal during the last
three years is as follows: Sixteen in 1887, twelve in 1888, and thirteens in 1889. In the
same period the same journals only record three deaths from ether, and but one from nitrous
oxide. Again, in a report published in Paris, mentioned in youri s s u e
o f A p r i l 1 2 t h , a c c i d e n t s
due to chloroform are 1 in 1,236, whereas those from ether are but 1 in 12,581 cases. These
facts surely speak for themselves.
In THE LANCET of Oct. 19th, 1889, under the heading "Death under Chloroform",
you describe two deaths,—one in a child four years old. When resident medical officer at
Pendlebury I administered ether to children from six years upwards, and can testify to its
safety for them, and in the hospital here I have administered it to old men up to eighty in
long cases of litholapaxy, and to men of eighty-two in strangulated hernia. I am told by
the staff here that at no period of its history has a death been recorded from an anæsthetic.
Ether is always used, unless contra-indicated. The chief reason why chloroform is given is
250
experimenting with ether and chloroform are the following:—(1) That by administering the
two anæsthetics in the manner explained, when death ensues, it is always caused by arrest
firstly of the respiration, and afterwards of the heart, (2) That in all the animals experi-
mented upon (rabbits, cats, and dogs) chloroform acts most powerfully on the respiration,
stopping it most surely if, after the animal is completely
anæsthetised the anæsthetic is
continued for some time. (3) That ether stops the respiration in frogs, rabbits, and cats, but
its effects are more fugacious, so much so that the respiration is easily restored by employing
the direct artificial respiration. (4) That ether does not stop the respiration of dogs, even
after a continuous and prolonged administration of three hours. (5) That for these reasons
ether is much safer than chloroform. This applies to animals : and if the same laws are
applicable to man, I agree entirely with the Hyderabad Commission on the practical point
that it is not the pulse that is the guide in anæsthetising, but the respiration. In regard to
artificial respiration, that which I call direct artificial respiration consists simply ill applying
the mouth of the operator to the tube which communicates with the trachea and expiring and
inspiring, just as in normal respiration. This tube, as I noted before, has a lateral tube
communicating with the external air, thus establishing a lateral current by which all the air
contained in the lungs is pumped out by the operator's inspiration. and new pure air is pumped
into the lungs with his expiration. By this means I succeeded in resuscitating all my dogs
and rabbits, even thought three minutes had elapsed after stoppage of the respiration : while
with any other method of artificial respiration until now employed ( indirect ), not only could I
not succeed in such cases, but in the great majority of cases the indirect artificial respiration
was unsuccessful, even directly alter the stoppage of respiration. To me this kind of direct
artificial respiration was the most striking feature of my experiments, and I proposed to
adopt it in the case of man. This is very easily done by a metallic canula, conveniently
curved at one end, like a common catheter, and provided with a lateral tube in order to
establish the lateral current. The curved end, which is cut like the end of a Ferguson's
speculum, is easily introduced into the trachea through the mouth and by the operator applying
h i s
m o n t h , —o r , i f o b j e c t i o n a b l e , p u m p i n g a p p a r a t u s , —t o t h e o t h e r e n d , n a t u r a l r e s p i r a t i o n i s
imitated. I am quite satisfied that no other form of artificial respiration equals this inefficacy.
As to the manner of its physiological action. I think that not only by this method is all the
anæsthetic in the lung directly pumped out, but that the pure air pumped into it has a vivify-
ing action oil the nerve endings in the lungs, which are paralysed before paralysis of the
centres of respiration sets in.
I remai n. Si rs, most fai t hful l y yours,
Prof. of Materia Medica to Perugia University.
July 2nd, 1890.
251
LETTER FROM JOHN HOPE POTTER, ESQ.
To THE EDITORS OF "THE LANCET."
SIRS,—Surgeon-Major Lawrie, in his interesting article published in The Lancet of
June 21st, evidently contends that the sudden fall in blood-pressure during the administration
of chloroform is invariably due to a condition of asphyxia, though he admits a gradual fall
in blood-pressure, unattended with danger, during the administration of this anæsthetic.
I would call the attention of your readers to the fact that the condition which often ensues
on the administration of chloroform is a condition of which the most apparent visible sign is
pallor; asphyxia is not, however, accompanied with pallor, but with distension of systemic
veins consequent on contraction of small arieries, and increase of arterial tension (blood-
pressure raised), which condition again is consequent on stimulation of the vaso-motor centre
due to circulation of blood deficient in oxygen. Now, this sequence of events in asphyxia
produces a visible condition of lividity quite different from the pallor which is the danger
signal in chloroform administration. In fact, to recapitulate, we have in asphyxia increased
blood-pressure with lividity; ill fatal chloroform narcosis we have the opposite condition, viz.,
diminished blood-pressure with pallor. It appears to me the contention of Surgeon-Major
Lawrie—that the danger is due to asphyxia, and not to the direct action of the chloroform
vapour—is quite erroneous.
I am, Sirs, yours truly,
JOHN HOPE POTTER,
Cullompton, Devon, June 30th, 1890.
LETTER FROM SURGEON-MAJOR EDWARD LAWRIE.
To THE EDITORS OF "THE LANCET."
SIRS,— In The Lancet of July 19th, 1890. Mr. John Hope Potter states that the
Hyderabad Chloroform Commission contend that "the sudden fall in blood-pressure during
the administration of chloroform is invariably due to a condition of asphyxia." This is a mistake.
In the paper published by me, as President of the Hyderabad Chloroform Commission, in The
Lancet of June 21st, 1890, it is contended that the sudden falls of blood-pressure, with pallor,
which are observed during the improper
administration of chloroform, are invariably due to
reflex or direct stimulation of the vagus, and that while this action of the vagus is in itself a
safeguard, it always shows that the anæsthetic has been administered with insufficient air. The
Hyderabad Commission has proved that asphyxia is only dangerous in chloroform adminis--
tration because it makes people gasps. Mr. Potter further asserts that asphyxia raises the blood-
pressure, and that this is consequent on stimulation of them vaso-motor centre. The tracings of
the experiments of the Hyderabad Commission demonstrate that, contrary to the hitherto
accepted belief, asphyxia lowers the blood-pressure. This is in strict accordance with what
common sense would lead us to expect. It is evident that to raise the blood-pressure is to benefit
the organism, and it cannot be said that asphyxia is ever beneficial. Mr. Potter is in error in