NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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before, after twenty minutes the pulse ceased again, and I asked the nurse to give an enema of
half an ounce of brandy with water, called the attention of those around to the absence of pulse
and the continuance of respiration, which they observed before
t h e r e s p i r a t i o n c e a s e d , w h e n a l i t t l e a r t i f i c i a l r e s p i r a t i o n s o f a r r e s t o r e d t h e p a t i e n t t h a t t h e o p e r a t i o n w a s c o n t i n u e d a n d
completed in another twenty minutes. During this latter time a very little chloroform only
was given when the patient had so far recovered as to call out loudly. The patient afterwards
told me he felt nothing of the operation. This patient's heart was, so far as could be ascertained,
practically sound. Here then was an operation taking place under chloroform, during which
the pulse of the patient undoubtedly failed before the respiration on two occasions, the pulse
recovering on the first without cessation of respiration, and the respiration failing on the second
occasion some seconds after the pulse, and while it was still not to be felt.
I have endeavoured to show in this letter the importance of the pulse as a guide to the
anæsthetist, under some circumstances, during chloroform administration; and it is not my
intention to express an opinion as to which of the two,—the respiration or the circulation,—
invariably ceases first in death from chloroform, believing, as I do, that it is sometimes one
and sometimes the other.
I am. Sirs, yours faithfully,
RICKARD W. LLOYD,
Russell-road, Kensington., March 15th, 1891,
REPORTS TO THE SCIENTIFIC GRANTS COMMITTEE
OF THE BRITISH MEDICAL ASSOCIATIONS.
REPORT ON AN EXPERIMENTAL INVETIGATION OF THE ACTION
OF CHLOROFORM AND ETHER.
Read in Abstract in the Section of Medicine at the Meeting of the British Medical
Association at Brimingham, July 1890.
BY JOHN A. MACWILLIAM, M.D., Regius Professor of the Institutes of Medicine
in the University of Aberdeen.
[Reprinted from "British Medical Journal" of Oct. 18th, 25th, & Nov. 1st., 1890.]
THE following research was systematically commenced in 1888, and has been carried on
at intervals since then. The experiments have been conducted upon animals of various kinds,
chiefly upon cats and rabbits. The most important experiments were performed on cats, and
all the results detailed in this paper are to be taken as being applicable to that animal.
322
not more marked or notable than alterations in the respiration occurring at earlier phases of
chloroform administration and attended by no serious consequences, though the giving of the
anæsthetic was not suspended, or any remedial measures adopted.
The sudden and precipitous fall of blood-pressure above referred to as giving warning
of an overdose was, I have no doubt, attended by a marked change in the pulse—such a change
as could have been appreciated had the pulse been felt during its occurrence.
The period intervening between the indication of danger given by the blood-pressure
and that afforded by the respiration in these cases is a short one, but there can be no doubt
that in such cases the gaining of even a very short time may be of extreme importance. The
difference of a very brief period as regards the moment when the further administration of
chloroform is stopped, and remedial measures adopted, may turn the scale in favour of recovery
or death.
PART V.
General Conclusions.
1 . D u r i n g c h l o r o f o r m a n æ s t h e s i a t h e b l o o d - p r e s s u r e i s l o w e r e d a n d t h e h e a r t ' s a c t i o n
is weakened.
2 . D i l a t a t i o n o f t h e h e a r t o c c u r s t o a n a p p r e c i a b l e e x t e n t , e v e n w h e n c h l o r o f o r m i s
administered gently, mixed with abundance of air (under 4 per cent. of chloroform vapour in
the air).
3. Dilatation may occur even before the conjunctival reflex is abolished.
4 . T h e d i l a t a t i o n a f f e c t s a l l p a r t s o f t h e h e a r t m o r e o r l e s s — t h e l e f t s i d e a s w e l l a s t h e
right. It is not due to changes in the pulmonary circuit.
5 . T h e d i l a t a t i o n i s n o t d u e t o t h e a c c o m p a n y i n g f a l l o f p r e s s u r e , t o t h e d i m i n i s h e d
resistance to the ventricular systole, or to the diminished blood-supply through the coronary
arteries. Dilatation does not result from a similar fall of pressure brought about by means
other than chloroform, for example, arterial relaxation caused by section of vaso motor nerves.
Dilatation under chloroform often occurs very quickly, before there is any fall of pressure.
Moreover, when the dilatation has followed a fall of pressure it is not removed by artificially
raising the pressure, for example, by compression of the abdominal aorta.
6. There is no distinct change in the rate of the heart's action when dilatation occurs.
A sudden and complete cessation of the cardiac rhythm is never caused by the inhalation of
chloroform. Cardiac failure occurs by a more or less sudden enfeeblement and dilatation of
the organ; not by a sudden complete cessation of rhythm.
7. The tone of the heart muscle is depressed, the cardiac walls become relaxed, and
the functional efficiency of the organ is impaired.
8. When the heart becomes greatly dilated it fails to be an effective force in keeping
up the circulation, while its rhythmic movement still continues—though so feebly as to be
inefficient.
9. Cardiac failure sometimes occurs in this way a considerable time before the respira
- t i o n s t o p s , t h o u g h g e n e r a l l y t h e r e s p i r a t i o n s t o p s b e f o r e t h e h e a r t h a s b e c o m e i n c a p a c i t a t e d .
10. The failure of artificial respiration to bring about recovery (in some cases of
chloroform collapse), when begun immediately after the spontaneous respiration has ceased,
is in all probability due mainly to the enfeebled and distended state of the heart, which has
become unable to maintain the circulation. Hence the supply of fresh air (by artificial
respiration), free from chloroform, cannot be taken advantage of.
11. The depressing influence of chloroform on the heart—leading to dilatation of its
cavities—is not exerted through the vagus nerves, but is a direct effect of the drug upon the
cardiac mechanism. Section of both vagi does not obviate the weakening and dilating
influence of chloroform upon the heart.
12. The weakening and dilating effects of chloroform are sometimes manifested in toler
- a b l y e q u a l d e g r e e o n b o t h a u r i c l e s a n d v e n t r i c l e s ; b u t s o m e t i m e s m o r e r e a d i l y u p o n t h e a u r i c l e s ,
and at other times upon the ventricles.
13. A peculiar periodic depression of the ventricular action sometimes occurs during
recovery from the primary effects of chloroform.
14. The contrast between the relation to the heart's action of chloroform and ether in
anæsthetic doses is very marked. With chloroform, cardiac dilatation frequently occurs—and
often, indeed, a very marked dilatation—before the conjunctival reflex is abolished. With
ether, the induction of anæsthesia with complete abolition of the conjunctival reflex has not,
been attended by any noteworthy dilatation; indeed effects of a stimulating character have
sometimes been observed, and the peculiar periodic ventricular depression sometimes following
chloroform has been seen to be removed.
1 5 . U n d e r t h e i n f l u e n c e o f c h l o r o f o r m a t e m p o r a r y s l o w i n g o f t h e h e a r t ' s a c t i o n
sometimes occurs—from asphyxial conditions or from sensory stimulation during imperfect
anæsthesia. This slowing is quite different in its nature and causation from the enfeebling and
dilating effect already mentioned. The slowing is not due to direct influence of chloroform on
the heart, but is indirectly brought about through the vagus nerves. It does not appear to be
dangerous in the healthy animal.
16. The occurrence of fibrillar contraction (delirium cordis) does not appear to be a
primary mode of cardiac failure from the inhalation of chloroform in the healthy animal,
though it may sometimes supervene when the heart has become distended and incapacitated by
chloroform.
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17. The fall of blood-pressure under chloroform is in its earlier stages due mainly to
the depressing effect of the anæsthetic on the vaso motor centre, preceded often by a slight
stimulation; the later stages are associated with failure of the heart as well as of the vaso mo-
- t o r c e n t r e .
16. The relative occurrence of cardiac dilatation and vaso motor depression varies.
Sometimes the heart begins to dilate early—before there is any fall of pressure; at other times
a large fall of pressure may occur before cardiac dilatation becomes marked.
19. The lowering of the blood-pressure is in a certain sense protective; it retards the
access of more chloroform to the vital organs. But, on the other hand, the fall of pressure may
become excessive and produce dangerous effects.
20. In certain circumstances, when chloroform is very suddenly taken in, a dangerous
dose may be absorbed, and the heart may become seriously affected before the vaso motor
centre has had time to be much depressed.
21. When a fall of carotid pressure has been brought about by the
g r a d u a l
i n h a l a t i o n o f C h l o r o f o r m i n t h e o r d i n a r y w a y , f i r m p r e s s u r e a p p l i e d t o t h e a b d o m e n c a u s e s a m a r k e d r i s e
of pressure—very much more than can be obtained by inversion of the animal. And
e v e n w h e n t h e f a l l o f p r e s s u r e i s d u e t o t h es
u d d e n
i n h a l a t i o n o f a n e x c e s s o f c h l o r o f o r m , p r e s s u r e
on the abdomen commonly, but not in all cases, leads to a decided rise in the carotid pressure.
The existence of cardiac failure may prevent the possibility a such a change.
22. Changes in the respiration exert a most important influence upon the effects of
chloroform administration. An amount of chloroform which can be given with safety during
easy breathing may speedily become dangerous during deep, rapid respiration.
23. Free dilution of chloroform with air—the restriction of the percentage of
chloroform vapour to 4 or 4½ per cent.—gives no security against an overdose. A
p e r c e n t a g e t h a t g i v e s s a f e a n æ s t h e s i a d u r i n g o r d i n a r y b r e a t h i n g m a y l e a d t o f a t a l c o l l a p s e i f g i v e n d u r i n g
exaggerated respiration.
24. Changes in respiration may be excited by sensory stimulation (operative interfer
- e n c e , t o o s t r o n g c h l o r o f o r m v a p o u r ,e
t c
. , ) d u r i n g i m p e r f e c t a n æ s t h e s i a .
R a p i d , g a s p i n g r e s p i r a t i o n o c c u r r i n g i n s u c h c i r c u m s t a n c e s i s u s u a l l y a c c o m p a n i e d b y a r i s e i n t h e b l o o d
pressure, and, as there may be already a considerable amount of chloroform in the circulation,
there occurs a combination of circumstances specially favourable for the speedy and sudden
development of dangerous collapse.
Note.—I
hope soon to publish tracings illustrative of some of the experimental facts
described in this report.
325
ARTICLE, REPRINTED FROM THE MEDICAL CHRONICLE
OF APRIL 1890.
BY ALEXANDER WILSON,
M.R.C.S.,
Administrator of Anæsthetics, Royal Infirmary, Manchester.
THE opinion that, in a certain number of cases, death from chloroform is due to cardiac
paralysis, was first enunciated by Dr. Sibson ( London Medical Gazette, Vol. XLII., p. 109),
and it is important to note that this conclusion was originally arrived at, not from physio--
logical experiment, but from a consideration of the first fatal cases in man.
There appears to have always been some contradiction between the results obtained by
experiment on animals and those obtained by clinical experience On human subjects. Thus, as
early as Mr. Thomas Wakley proved, by a series of experiments on animals, that in deaths
from chloroform the heart continued to beat after cessation of the respiration, these results being
contirmed by a Commission held in Paris in 1855. ( E Union Medicale , No. 13, 1855).
Notwithstanding these experiments, the reported fatal cases from chloroform inhalation
appeared to indicate that in man, at least, the failure of the heart preceded the cessation of
respiration. The grounds for this belief are that the fatal result is usually sudden, the patient
in the midst of violent struggles, after a deep inspiration, becoming at once practically lifeless,
the pulse stopping before the respirations, and occasionally becoming, distinctly and gradually
feebler before cessation of the respirations. But, no doubt, the main reasons for the belief
were the suddenness of the result, the cessation of the pulse, and the non-success of artificial
respiration to restore the patient.
D r . S n o w w a s t h e f i r s t t o r e c o n c i l e t h e d i f f e r e n c e b e t w e e n t h e r e s u l t s o f e x p e r i m e n t a n d
of clinical practice, by showing that death might happen in one of several ways, according to
the amount of chloroform
(a ) Chloroform inhaled gradually, until death resulted, killed by gradual paralysis of
the respiration, the heart continuing to beat after cessation of the respiration.
(b) But when a l ar ge dose of t he dr ug was suddenl y t aken i nt o t he syst em, t he hear t
ceased beagting before the respiration stopped.
(c) It was also thought that this sudden paralysis might set in before insensibility was
produced. The cardiac paralysis was considered to be the chief factor in the fatal result,
because efficient artificial respiration did not resuscitate these cases.
There was an impression that the cessation of the respiration might be entirely remedied
by artificial respiration, but that the affection of the heart was necessarily fatal.
Clover, writing about 1875, says of chloroform; " . . . besides its liability to cause
apnœa, which is remediable, it may produce total arrest of the heart's action, which is not so."
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vapour to which it is subjected." Chloroform thus given by inhalation may have a more
potent action than when injected into a vein, and the results of the two methods cannot well be
compared.
In Section 12 the effect described as that of asphyxia on the blood-pressure, in causing
a r a p i d f a l l o f b l o o d - p r e s s u r e a n d s l o w i n g o f t h e h e a r t b e a t , i s c o n t r a r y t o t h e r e c e i v e d i d e a s o n
the subject. ("Human Physiology." Landois and Stirling. 1888 edition, p. 198.) During
asphyxia, "the blood-pressure measured in a systemic artery, e.g., the carotid, rises very
rapidly, and to a great extent during the first and second stages; the pulse beats are at first
quicker, but soon become slower and more vigorous. The rise in pressure is due to stimulation
of the general vaso motor centre by the venous blood, and the slow beating of the heart to the
action of the venous blood, on the cardio inhibitory centre in the medulla."
The attempts to produce shock during the inhalation of chloroform (§ 33) uniformly
failed. In experimenting on animals there are several sources of error. In the first instance,
it is doubtful if animals suffer as much from shock as man, there is an absence of mental terror
and the depressing effect of the anticipation of the operation, &c.
It is well known that the extraction of a single tooth in a state of semi-anæsthesia may
produce it considerable amount of shock and a painful mental impression that lasts for weeks,—
an amount of shock far greater than would have been felt had no anæsthetic been exhibited.
The lowering of the blood-pressure in the case of a fatty heart (§ 39) cannot be altogether
an advantage in chloroform administration. It must, by the efforts the heart makes to keep up
the pressure, increase the work of the heart, and at the same time diminish the blood supply to
the heart itself.
It is important to note that in all these experiments there are double and treble reactions,
which, though they have a beneficial effect in diminishing the amount of chloroform absorbed,
are in themselves elements of danger.
Thus, semi-asphyxia and inhibition of the heart are elements of safety by preventing
the "intake" and distribution of (chloroform, but the ultimate result of this is to cause rapid
breathing and quick pulse, which, by the extra "intake" of chloroform and the quick distri--
bution of that already inhaled, is an element of danger.
This change from a slow to a rapid pulse may be attended with very nearly fatal results,
as is shown in Section 34, where an animal was nearly killed by a short inhalation, from the
inhibition of the vagus having been stopped, and a more rapid pulse consequently resulting.
This fall in pressure is in itself, in feebly nourished subjects, a source of danger, causing syn--
cope from cerebral anæmia.
There is a peculiar animus against the feeling of the pulse displayed by Surgeon-Major
Lawrie in the first Report, and not entirely absent in the second. He goes so far as to state,
"that since the year 1855, in Great Britain, there is no death from chloroform recorded in which
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chloroform in some 600 administrations. Death from chloroform is due apparently to paralysis
of the vaso motor and respiratory centres—probably one or both of these may be affected.
When death occurs it is the result of an overdose of the drug.
It cannot be too strongly insisted that the work of the Commission gives us no greater
confidence in chloroform than we had before. That it does not cause cardiac paralysis is no
safeguard, since it produces as sudden and equally fatal vaso motor paralysis, and respiratory
paralysis in addition. Its physical and chemical properties remaining the same, the danger of
permitting the patient to inhale an overdose will remain as great as ever.
In the Practical Conclusions no directions are given for its administration beyond those
which have been in use for years, and in the presence of so many fatalities have occurred,
either from vaso motor, cardiac or respiratory paralysis.
In the face of these it is hardly to be expected that the deaths from chloroform will
much diminish.
[The Hyderabad Commission has proved that the sole duty of the
Chloroformist is to produce normal anæsthesia, and we agree with Mr. Alex
a n - d e r W i l s o n t h a t t h i s d u t y i n c l u d e s k e e p i n g " h i m s e l f i n t o u c h w i t h t h e
w h o l e c o n d i t i o n o f t h e p a t i e n t a l l t h r o u g h t h e o p e r a t i o n " . B u t k e e p i n g i n t o u c h
with the patient's condition is a very different thing from taking the pulse as
a gui de t o t he ef f ect of chl or of or m, f or t he s i mpl e r eas on t hat t he pul s e af f or ds
no indications whatever of normal anæsthesia. The pulse is dangero
usly affect-ed by abnormal chloroform administration; and abnormal inhalation alone
can originate the deadly symptoms of peril for which Mr. Wilson watches it.]
A R T I C L E B Y S U R G E O N - M A J O R E . L A W R I E .
[ R e p r i n t e d
f r o m t h e " M e d i c a l C h r o n i c l e " o f J a n u a r y 1 8 9 1 . ]
I N T H E M E D I C A L C H R O N I C L E o f F e b r u a r y , 1 8 9 0 , there is an ably written review of the
H y d e r a b a d C o m m i s s i o n ' s r e p o r t o n " C h l o r o f o r m , " s i g n e d " A l e x a n d e r W i l s o n . " T h e r e v i e w
ends thus:—"Increased knowledge has added nothing new to the directions for its" [chloro--
form's] "administration." I hope that on reconsideration Mr. Wilson will see fit to modify
this statement, which is inconsistent with fact.
The Hyderabad Commission was appointed to confirm or disprove Syme's and Simpson's
principles that we should be guided as to the effect of chloroform entirely by the respiration.
The Commission has not only proved that these principles are sound, but has also proved
that the art of administering chloroform with safety consists in keeping the breathing
absolutely regular throughout the inhalation. This proof is new, and has never been established
338
anæsthetist is to be tolerated hereafter at all, it must be because he is a man of pleasant presence
and cheerful countenance, who knows how to comfort and re-assure the patient until chloroform
oblivion is secured.
ARTICLE REPRINTED FROM THE MEDICAL CHRONICLE
OF FEBRUARY 1891.
By JOHN A. MACWILLLIAM, M.D.,
Professor of the Institutes of Medicine in the University of Aberdeen.
In the Medical Chronicle of January, 1891, Surgeon-Major Lawrie, in an article on the
Hyderabad Chloroform Commission, makes some comments on certain results obtained by me in
a recent investigation on the action of chloroform and ether, published in the British Medical
Journal, October 11th, 18th, and 25th, 1890. In my paper I described the frequent occurrence
of dilatation of the whole heart under the influence of anæsthetic doses of chloroform. Such
dilatation was not due to changes in the pulmonary circuit or to a fall of arterial pressure.
Dr. Lawrie urges that the cardiac dilatation was due to obstruction of the circulation in
the lungs, or to this along with a fall in the blood-pressure. He says: "The irregularities in
the tracings of the Glasgow Committee and Professor Macwilliam's more recent bogey of dilata--
tion of the heart, are due to obstruction of the circulation in the lungs through interference with
or irregularity of the respiration." And later: "Obstructed circulation in the lungs and a
rapidly-falling blood-pressure are more than enough to account for the dilatation of the whole
heart, which occurred in his experiments, and which he wrongly attributed to the direct action
of chloroform."
Now this hypothesis of Surgeon-Major Lawrie's can be briefly and conclusively disposed
of. There is an abundance of decisive evidence available. First, as regards the alleged influ--
ence of obstruction of the circulation in the lungs in causing dilatation of the heart. In my paper
in the British Medical Journal I stated the fact that such an explanation was incompetent to
explain the cardiac condition, since the whole organ was dilated in my experiments. Dilatation
of the right side of the heart might conceivably (if there were no evidence to the contrary)
be accounted for by the presence of pulmonary obstruction. But dilatation of the left side
(e.g ., the left auricle) could clearly not be accounted for in the same way, since pulmonary
obstruction necessarily diminishes in large measure the flow of blood into the left auricle and
this part becomes small and collapsed. This seemed so obvious to me that I did not discuss the
matter at any great length.
I shall now state briefly some facts in regard to Surgeon-Major Lawrie's hypothesis of
obstructed circulation in the lungs:—
(1) There is no proof whatever of the occurrence of pulmonary obstruction from the
administration in mammals of ansæthetic doses of chloroform sufficiently diluted with air, as