NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
186
instant when anything worthy of note occurred, the time, minute by minute.
When the revolution of the cylinder or drum was complete it was removed, and
a second drum, which was kept ready smoked, was substituted. The tracing on
the first drum was at once cut off and varnished, and another paper put on and
smoked, so as to be in readiness when required.
The movement of the cylinder in these experiments is much slower than
that usually employed, but it has the double advantage of allowing the whole
record of the experiment to be reproduced and of rendering distinct even
small variations of pressure which are apt to escape observation in the long
tracing taken on a rapidly revolving drum. But the tracing taken on such a
slow drum as we employed has the disadvantage of being so compressed
that the individual pluse-beats are invisible.
To obviate this defect a method of double registration was adopted, which
had been devised by one of us for a previous research. In the connection be-
tween Ludwig's kymograph arid the artery a Y tube was inserted, by means of
which a second kymograph, the cylinder which revolved once in 3m. 9s., or
about ten times as rapidly as the first could also be brought into communication
with the artery. Both provided with stop-cocks, so that they might either
be allowed to work simultaneously, or the communication of either or both
with the artery cut off at will. If a mercurial. manometer had been used in
the second kymograph it would have given the number of pulse-beats. but the
oseillation of the mercury itself would have modified their size and form. One
of Fick's spring manometers was therefore used, and in order to prevent the
oscillations of the mercury in the other manometer affecting Flick's the stop-
- c o c k c o n n e c t i n g t h e f o r m e r w i t h t h e a r t e r y w a s a l m o s t a l w a y s t u r n e d o f f
when the latter was turned on. This plan had the further advantage that the
straight line traced by the float of Ludwig's kymograph attracts the eve so that
a glance al the tracing at once shows when a tracing has been taken by
Flick's manometer, and by attaching corresponding numbers to these blanks in the trac-
ing from Ludwig's kymograph and the tracings Fick's kymograph the
relation of the tracings to each other can be at once ascertained. The clock-work
of Fick's kymograph was usually started at the moment when the stop-cock
connecting it with the artery was opened, A short time is required for the clock-
work to attain its fall speed, and therefore at the beginning of a tracing the, oscilla-
tions may be closer together, and the pulse may appear to be quicker at the begin-
ning than the end of a reading of Fick's kymograph, although the pulse rate
might be really the same throughout. The cylinder was usually, though not
187
always, allowed to revolve a little space after the connection of the manometer
with the artery had been cut off in order that the readings might be more dis-
tinctly separated from one another. The mercurial manometer was connected
with the artery partly by metal and partly by India-rubber tubing. The Fick's
manometer was connected entirely by India-rubber tubing in the experiments
up to November 5th, but after that the connection was made partly by India-
rubber and partly by metal, exactly as in the Ludwig's. The whole of the
connecting tubes, except those between the Y tube and the manometers where
water was used, were filled with a solution of sodium bicarbonate in order to
prevent coagulation occurring in them.
This solution was made by saturating boiling water with sodium bi-
carbonate and then boiling it for some minutes, so as partly to convert it into
carbonate. It was then allowed to cool, and was poured into a large glass
vessel furnished with a tabulature near the bottom, and suspended on the Wall
of the room at a height or 7 ft. from the floor and 44 ½ ft. above the level of the
table From the tubalature of this vessel the solution was conveyed by
Inlia-rubber tubing to a glass T-piece inserted in the connection between the
manometers and the artery. By means of clamps the soda solution could be
passed. at will through the tubes haling to the artery. Before beginning an
experiment the pressure within the manometer was raised by means of the
soda solution to a height approximating to the estimated blood-pressure
in the animal so as to prevent the blood from passing too far up the tubes
and forming clots. This was also done whenever the artery and mano-
meter had to be disconnected on account of clots having formed. In
order further to lessen the tendency to form clots an elongated
glass bulb
was introduced into the tubing, and was connected by a short piece of
India-rubber tube with the glass canula in the artery. The canulas used
for insertion into the artery were blown with
a short neck to hold the
ligature and prevent the canula from slipping out or the artery. They
were of various sizes so as to fit the artery of the animal experimented on.
In all the experiments, with one exception. the animal was first rendered
insensible by being placed in a box with chloroform, as ether give in this way
would have been useless. As soon as it became insensible it was taken down
and the legs fastened with cords to a simple piece of board 4 ft. 6 in, long by
2 ft. 2 in. broad. To one end of this one of Bernard's dog-holders was attached
and in this the animal's head was put so as to hold it still. Chloroform
or
ether was then administered on a nose-cap as required to keep the animal
188
anæ sthetised and one carotid exposed, the left being selected in every case as
it was nearest to the manometer. Occasionally one or both vagi were also
exposed and a loop of thread placed under them, but not tightened round them.
The artery was firmly ligatured on its distal side, and the proximal side
was compressed by spring forceps covered with India-rubber tubing to prevent
their injuring the coats of the artery. The artery was then opened, the canula
inserted, and firmly tied in, The canula was then filled with soda solution by
means of a pipette, and connected with the glass bulb already mentioned, care
being taken that no air bubbles were present. The spring forceps were then
removed from the artery, the stop-cock of the manometer turned so as to open
the connection with the artery, and the tracing commenced. All this time the
animal was kept unconscious by the administration of all an æ sthetic from time
to time as required.
Registration of the Movements of the Heart.
These were sometimes registered by inserting a needle into the heart,
and connecting a thread to the end which projected outside the thorax when
this was unopened, or outside the cardiac walls When the thorax was opened
and the heart exposed. This thread was in the first instance tied to the lever
of a Marev's tambour (A ), and the movement transmitted by it to a second.
one (B), which recorded it. The resistance of the two tambours, however, was
too great, and the tracings obtained were unsatishietory. Better results were
obtained by connecting the needle in the heart with a time-marker by
means of two very light wooden pulleys. The lever of the lime-markers being kept
up by a very fine spring, a very slight pull sufficed to depress it, and thus it
marked even when the cardiac action was weak, and had the further advantage
of opposing very little resistance to the action of the hart.
Registration of the Respiration.
For this purpose the two Marey's tambours A and B were used. A was
usually connected to a needle pushed through the chest walls into the
diaphragm. On one or two occasions en incision was made just under the
margin of the ribs, and a piece or thick copper-wire flattened at one end, was
introduced, so that the flat pieces lay between the diaphragm and liver. The
other end projected outside, and the thread from Marcy's tambour was fastened
to it. In some of the later experiments a fish-hook was used instead of a
needle.
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PART VIII.—THE CONTROVERSY ON ANESTHETICS
AND THE HYDERABAD COMMISSION.
IN this part of the report, it is deemed advisable to reproduce, prefaced
by Syme's lecture, every thing of importance bearing on an æ sthetics and the
Hyderabad Commission, which has been published between the time when the
conclusions or the Commission were put, forward in The Lancet, and the present,
publication of their tracings and experiments. The Commission has always
courted criticism, and has frankly recognized that the chloroform question can
only be settled by full and free discussion ; and the soundness of this conviction
is illustrated by the primary disagreement, between the Ilyderabad Commission
and the Glasgow Committee. The Glasgow Committee inferred from their
research that the chief dangers of chloroform are reduction of blood-pressure
and sudden stoppage of the heart. Their animals, however, did not die, and
the ground for this inference, which was drawn from a variety or falls of the
blood-pressure in their experiments, is the universal belief that a general fall
of blood-pressure is in itself a source of danger. The Ilyderabad Commission
has proved that stoppage of the heart under chloroform may be a safeguard
against poisoning or overdosing ; and this discovery is irreconcilable with
the finding of the Glasgow Committee,. But prolonged consideration and
ventilation of the matter have made it clear that a general fall of the blood-
pressure is not necessarily a sign of weakening of the heart ; and it is there-
fore at once evident that the Glasgow and Hyderabad experiments are in
complete accord. Both demonstrate that sudden aml gradual falls of blood-
pressure may occur under chloroform without danger to the organism ;
a n d
the fact that a general fall of the blood-pressure, whether gradual or sudden,
is not in itself dangerous, Forms in reality the physiolog ical foundation of
the clinical truth that normal chloroform anæ sthesia is free from risk. Nothing
but good can arise from the controversy ; and accordingly the agreement now
established, between the experimental data of the Glasgow Committee and
those of the Hyderabad Commission, has only to be extended to their con-
clusions to be the means of settling the chloroform question and saving
thousands of lives.
190
LECTURE ON CLINICAL SURGERY DELIVERED DURING
THE WINTER SESSION OF 1854-55 BY JAMES
SYME, Esq., PROFESSOR OF CLINICAL
SURGERY IN THE UNIVERSITY
OF EDINBURGH.
From“ The Lancet,” dated 20th January 1885.
CHLOROFORM.
I HAVE now to speak of some cases in which chloroform will be given as
usual, in consequence of the pain otherwise attendant on the operations to be
performed ; but before the patients are brought in I may take this opportunity
of saying a few words regarding the use of chloroform, as you see that fatal
cases, I am sorry to say, still occur, and that the medical journals, conse
-quently, express doubts as to the use of chloroform at all, or say that, if used.
it must be only with the greatest caution. Chloroform is no doubt a very
powerful agent, sufficient to destroy the strongest individual if employed freely
enough. Its fatal effects were shown at an early period in the following way :
a lecturer in London was illustrating its action upon a guineapig, which was
placed under a glass j ar al ong wi t h s ome of t he anæs t het i c : t he pr of es s or , i n
the eagerness of his discourse, left the animal too long under the jar, and it
d ied. He explained to his audience the cause of the accident, but, though the
reasons he gave were satisfactory, yet an impression was made upon the public
which was not soon effaced. In this respect, however, there is nothing peculiar
to chloroform as a medicinal agent ; opium. prussic acid, strychnia, &C.. not
only may, but often do, destroy life, through being used in over-doses. But the
question is, may it be used judiciously so as to do the good without exposing
the patient to the risk of theevil ?I t
i s s a i d i n L o n d o n t h a t i t c a n n o t ; t h a t
the risk is so great that it is only justifiable to use it in case of operations
accompanied with an extreme degree of pain, or where stillness on the part of
the patient is essential to success, and that the greatest caution is required in
its administration ; here we say that, if used with moderate care, it is perfectly
safe. It was in this theatre that chloroform was first administered in public, by
Dr. Simpson, seven years ago ; since then it has been almost daily given here,
yet we have not had a fatal case. It is true one solitary instance of death from
chloroform has occurred in another part of the hospital, but that case has
191
nothing to do with us ; so far as my department is concerned, it might as well
have been at. Guy's Hospital or in Kamschatka. or anywhere else ; indeed, it so
happened that at. the very time when, that unfortunate event was taking place
in another part of the establishment, I was myself performing an operation on
a patient under chloroform in this theatre.
In inquiring into the reason of this dif ference between the experience of
chloroform in London and here. we have not far to search for the explanation ;
it must lie in one of three things, riz., difference in the chloroform, difference in
the patients, or difference in the mode of administration : with regard to the
chloroform, I believe, that most of that which is used in London is made in
Edinburgh, and I know that some of the fatal eases might be shown
to have
occurred with Edinburgh chloroform.
With respect to the patients, it appears that great care is taken in London
to use chloroform only in persons free from chest affections, especially cardiac
derangements : here we never ask any questions as to the state of the heart or
constitution or the patients. In all cases where chloroform is required for an
operation, it is freely given. Now, considering the frequency of cardiac disease.
and particularly of fatly heart,—which, in fact, is I believe rarely absent, at
any rate in elderly persons,—and considering also the immense number of
patients operated on, you cannot doubt that many hundreds with fatty degene
-ration of the heart have had chloroform administered to them here ; we even
give chloroform without scruple, where we know disease of the heart exists.
within the last week, a case in point occurred in my practice. A patient, with
great dread of pain, and also with a horror of chloroform. had long endured
severe pain from his disease, till existence had become a burden, because he
could not Venture to undergo the necessary operation w ithout chloroform, while
his medical adviser considered that to take it would be for him almost certain
death on account of disease known to exist in the heart, for which he
had consulted. and which it may he remarked had been recognized by Dr.
Addison of Guy's Hospital. At length his medical attendant said to him, that
he had suffered so much from his complaint, that even if he died under chlo
-roform this would be better than remaining as he was ; while, if it should so
happen that he should recover. he would b e able to enjoy the rest of his life
free from the disease. the patient. could not resist the force of this argument,
and came to Edinburgh prepared for either alternative. I performed the opera
-tion under chloroform ; and the first thing that he did on waking was to ask
for a cigar.
192
As another example, I may mention the case of an old gentleman, aged
seventy-four, affected with disease of the heart, from whose bladder I removed
a large stone, some years ago. Chloroform was administered as he lay in bed ;
and he was put so fully under its influence, that he was taken from the bed,
was operated on, and put back to bed, before he woke from his sleep. He
recovered perfectly ; but some time afterwards died and Dr. Begbie, on examin--
ing the body, found the disease of the heart, which had been diagnosed during
life. We cannot therefore attribute the absence of deaths here to our being
more discriminating than others in the patients to whom we administer chloro--
form ; the very reverse, in fact, being the case.
I think then, gentlemen, that we are necessarily led to the conclusion
that the difference of results depends on difference in the mode of administra--
tion. We know that in other cases differences in the method of procedure had
led to differences of results, e.g., it was said in London that amputation at the
ankle invariably caused sloughing ; but it turned out that the surgeon who
made this statement performed the operation in a manner that deviated much
from the principles on which it is here performed successfully, and which led
inevitably to sloughing
so of di vi di ng st ri ct ure by ext ernal i nci si on, i t was
said that the extravasation of urine must necessarily take place in a dangerous
manner, and that other serious complications may occur ; but it turned out
that the incision had been made without guide on a silver catheter ; in short,
with such deviations from principles as fully to account for the results.
So far as I can ascertain, from what I have heard and read upon the sub-
- j e c t , t h e r e a r e i m p o r t a n t d i f f e r e n c e s b e t w e e n t h e m o d e o f a d m i n i s t r a t i o n o f
chloroform here and in London. It appears that here it is given according to
principle, there according to rule. There great attention is paid to the number
of drachms or minims employed ; here we are entirely regardless of the amount
used, and are guided only by the symptoms of the patient. The points that we
consider of the greatest importance in the administration of chloroform are, first,
a free admixture of air with the vapour of the chloroform, to ensure which a
soft porous material, such as a folded towel or handkerchief, is employed. pre--
senting a pretty large surface, instead of a small piece of lint or any other
apparatus held to the nose ; secondly, if this is attended to the more rapidly
the chloroform is given, the better, till the effect is produced ; and hence, we
do not stint the quantity of chloroform. Then—and this is a most important
point—we are guided as to the effect, not by the circulation but entirely by
193
t h e r e s p i r a t i o n ; y o u n e v e r s e e a n y b o d y h e r e wi t h h i s f i n g e r o n t h e p u l s e wh i l e
chloroform is given. So soon as the breathing becomes stertorous, we cease
t he admi ni s t r at i on; f r om what I have l ear ned i t i s s omet i mes pus hed f ur t her
e lsewhere,but thisweconsider in the highest degree dangerous. Attention to
the tongue is another point which we find of great consequence. When respira--
tion becomes difficult, or ceases, we open the mouth, seize the tip of the tongue
with artery-forceps, and pull it well forward; and there can be little doubt that
death would have occurred in some cases if it had not been for the use of this
expedient. We also always give the chloroform in the horizontal. position, and
take care that there is no article of clothing constricting the neck. There are
thus considerable differences between our practice and that which prevails more
or less elsewhere.We use no apparatus whatever
,take the
respiration for ourguide, attend to the condition of the tongue. and never continue beyond the
point when the patient is fully under the influence of the anæsthetic.
You observe that in this matter I am very far from taking any credit to
myself ; all that I have done has been to follow the example of Dr. Simpson,
and all that I would say respecting our brethren in London, is, that they have
not been so fortunate as to get into the right way in the first instance, and
I would urge upon them to banish all previous notions, and to keep in view the
essential points to which I have alluded; then, if unfortunately theres h o u l d
still be fatal cases, I shall not presume to speak further upon the subject. As
the matter at present stands, the discussions prevalent in the profession tend to
give the public a dread of chloroform, and to limit the advantages which it
confers; and so long as the d i f f e r e n c e o f o p i n i o n
s e e m e d d u e t o i m p o r t a n t
difference of practice, I felt
c a l l e d
upon to address to you the obser vations I
have made.
205
these it appears that deaths from chloroform in the London hospitals amount to about 1 in
1,236, and from ether to 1.i n - 4 , 8 6 0 a d m i n i s t r a t i o n s . T h e l a t e M r . S y m e ' s c a s e s a n d m y o w n
form a continuous series of daily administrations* of chloroform in Europe and in India, from
1847 to 1890, without any deaths, and if Mr. Roger Williams's reasoning from statistics is
correct, it is logical to infer that the administration neither of chloroform nor of ether, as
conducted in London, is as safe as the administration of chloroform on the principles advocated
by Mr. Syme.
There can be no doubt that there is a flaw somewhere in the London teaching with
reference to anæsthetics, and evidence on this point is supplied by the letter of Mr. Woodhouse
Braine, who maintains that it is far more important to watch for 'pallor of the face than for
partial interference with the breathing in chloroform administration, having previously stated
that pallor of the face is one of the signs that the patient is dead, Mr. Braille -writes as if the
acceptance of the truth about chloroform would be disastrous to anæsthesia specialists. The
reverse of this would be the case, as it is well known that immense numbers of people are
deterred from having operations performed on account of the dread of anæsthesia caused by
the present position of anæsthetics.
It is for anesthetists themselves, however, or for the surgeons who employ them, to
decide which policy is likely to be more conducive to their own interests ; to persevere in an-
nouncing publicly that anæsthetics cannot be given safely in London, or to a fair trial to
syme's principles, which have stood the test of experience, ;and have been proved by the
IIyderabad Commission to rest on a secure physiological foundation. The question of chloro-
form administration is no longer one of doubt or of opinion, and moreover it is one of common
sense. If Hyderabad students can be taught to give chloroform as they do day after day, with
guaranteed safety, a forliori it must be a much more easy task to teach Loudon students to do
the same.
Hyderabad, Deccan, March 12th, 1890.
MEDICAL SOCIETY OF LONDON.
AN ordinary meeting of this Society was held on February 10th, the President,
Dr. Theodore Williams, in the chair.
The President sail that so much hung upon the valuable work of the Commission at
Hyderabad that the council of the Society- had decided to give up an evening to listening to
Dr. Lauder Brunton's account of experiments, and to the discussion following thereon.
[*By daily administrations must be understood several administrations every day.—ED. L.]