NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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chloroform lowers the blood-pressure and paralyses the heart, which ether never
does, but drew the important conclusion from experiments on one dog only
that this action is sometimes exerted in an unexpected and capricious manner.
11. The state of opinion regarding chloroform in America may be inferred
from the statements made regarding it in the last edition. of H. C. Wood's
Therapeutics," one of the best American works on the subject. He says "As an
anæsthetic chloroform possesses the advantages of quickness and pleasantness
of operation, smallness of dose, and cheapness. These advantages are, however,
so out-balanced by the dangers which attend its use that its employment under
ordinary circumstances is unjustifiable, It kills without warning so suddenly
that no forethought or skill can guard against the fatal result. It kills alike
the robust and the weak, the well and the diseased; even the previous safe
passage through one or more inhalations is no guarantee against its lethal action.
Statistics seem to indicate a mortality of about one in three thousand inhalations,
and hundreds of utterly unnecessary deaths have been produced by the extra-
ordinary persistence in its use of a portion of the profession. It ought never to
be employed except under special circumstances, as when. a speedy action is
desired in puerperal eclampsia or when. the more bulky anæsthetics cannot be
transported as in the field in war time.”
12. These passages from the work of one of the greatest authorities on
the subject in America show that in. that continent chloroform is regarded with
somewhat of the same disfavour with which it is looked upon in England, and
probably upon the same grounds. Although the experiments of the Hyderabad
Commission are much more numerous than those made in any previous investi-
gation, yet their number is infinitesimal in comparison with the number of times
anæsthetics have been given. all over the -world, and each administration may
be regarded as an experiment on the action of the particular anæsthetic employed.
When it is considered
that, after SO many administrations, or experiments as these
may be termed, On the human subject, opinions are so divided in regard to the
action of chloroform as at present, we cannot think that the conclusions at. which
the Hyderabad Commission have arrived will necessarily carry- conviction. to
those who hold opinions opposed to them. The objection may be made that the
Hyderabad experiments have been made on the lower animals, and, however
correct the Commission's conclusions may be in regard to them, they do not hold
for man. To this objection it is a sufficient answer that the fear of chloroform
paralysing the heart is based on the results of laboratory experiments, rather
than on clinical experience. Deaths have occurred during the administration of
2
10
ether as well as of chloroform, and it is not the deaths during operations, but the
observations on blood-pressure and on the action of chloroform on the exposed
or excised heart which have led to the unfounded dread in the profession that it
may paralyse this organ when given as an anæsthetic.
13. But there is still another difficulty ;—however fair and impartial the
Hyderabad Commission may try to be, and even though those who differ from
them may credit them with care, honesty, and impartiality, its conclusions will
always be open to the objection that the Commission may be mistaken, and any
mistake on its part would be all the more fatal and disastrous, because its con-
clusions would be very difficult to disprove since they are founded on such a
mass of experimental evidence as has never been collected before, and is hardly
likely to be collected again at least for many years. To avoid such a possibility
the Commission have tried, as far as possible, to give the experimental data from
which their conclusions are derived, so that at any future time and in any part
of the world these data will be as available to others as to themselves, and may be
used by them either for the purpose of criticising the Commission's conclusions
or drawing conclusions of their own. The utility of such a course has been im-
pressed upon the Commission during the progress of this investigation by the
example of the Glasgow Committee which they have followed. The Glasgow
Committee drew from one experiment alone the sweeping conclusion that
chloroform has sometimes an unexpected and capricious effect on the heart's
action, and that “ the occurrence of the sudden and unlooked-for effects seems to
be a source of' serious danger.”‫٭٭‬ This conclusion is obviously of the utmost im-
portance in regard to chloroform and, if correct, would justify the condemnation
of its use by the American author already- quoted. If the Glasgow Committee
had only given their conclusions, it would have been very difficult indeed to
disprove them; but fortunately they have published a copy of the manometer trac-
ing on which these conclusions are founded, and an inspection of this leads in-
evitably to the belief that the sudden and unlooked-for effects on the heart's action
which the Committee attributed to chloroform are not really due to it at all, but
are due to irritation of the vagi quite apart from the action of the anæsthetic, and
are the results of accidental asphyxia. The Commission have followed the ex-
cellent example of the Glasgow Committee and reproduced by photography the
tracings on which their opinion is based, so that all those who look at them and
compare them with the tracings of the Glasgow Committee, which they have also
reproduced, may judge for themselves and form their own opinions on the subject
* vide page 115, Experiment No. 148, Observation Q,
11
14. Dr. Lauder Brunton and Surgeon-Major Bomford arrived in Hyderabad
on the 21st of October 1889, and the second Commission was constituted at once
as follows:—
Surgeon-Major E. Lawrie, M.B., Edinburgh, President.
Dr. T. Lauder Brunton, F.R.S.,
Surgeon-Major Gerald Bomford, M.D., London,
Dr. Rustomji, H. H. the Nizam's Medical Service,
Members
Secretary.—Dr. Bomford.
15. Associated with the second Commission were the President and Mem-
bers of the first Commission, viz .:—
Surgeon P. Hehir, M.D., President.
Mr. J . A. Kelly, L.R.C.P. &amp; S. (Ed.), L.F.P. &amp; S. (Glas.)
Mr. A. Chamarette,L.M.S.
Members.
The Commission is very much indebted to all the gentlemen mentioned, as
well as to Mr. William Mayberry, who gave chloroform; but is especially so to
Dr. Arthur Chamarette, to whose energy and fertility of resource the success of
the experiments is mainly due. The Commission also desires to thank Mr. Tripp,
the Deputy Principal of the Medical School, and Mr. Carroll, His Highness
the Nizam's Medical Storekeeper, for much valuable assistance ungrudgingly
afforded.
16. The Commission commenced work on the 23rd October and met daily,
except on Sundays and holidays, from 7 A.M . till 5 P.M., until the 18th of Decem-
ber, when the experiments were concluded.
17. The Commission was divided into two Committees: one, which
will be referred to throughout the report as the Committee, was composed
of Drs. Lauder Brunton, Bomford, Hehir and Chamarette; the other,
which will be referred to as the Sub-Committee, was composed of Dr. Rustomji,
Mr. Kelly, and Dr. Gay (who volunteered to help), assisted by students.
18. The Committee first of all performed twenty-seven experiments, num-
bered from 1 to 28, omitting 25, which was a manometer experiment, to test the
12
work of the first Commission. From No. 29 the Committee were employed
principally with blood-pressure experiments. The ordinary experiments, per-
formed without recording apparatus, were then made over to the Sub-Committee,
which continued to work in the same room under the supervision of the
Commission.
19. The experiments of the Sub-Committee are numbered continuously
with those of the Committee, so as to form a consecutive series and facilitate
reference.
Part II.--GENERAL EXPERIMENTS WITHOUT
RECORDING APPARATUS.
20. The experiments of the Sub-Committee, together with the first 28
performed. by the Commit tee, Form a total number of 430, and are divided into
seven. sections. These experiments are recorded in a tabular form at Appen-
dix B. 268 dogs and 31 monkeys were killed outright, and 86 dogs and 39
monkeys were subjected to artificial respiration at varying intervals after the
natural. respiration had been arrested with chloroform. The animals which were
killed had chloroform. administered to them in every possible way and under
every conceivable condition. A large number of dogs were killed just as they
were caught in the bazaars; others at various intervals after having heavy meals
of meat or farinaceous food or fat; others f
asting; others after the administra-
tion of Liebig's extract of meat, coffee. rectified spirits of wine or ammonia.
Most of these animals were healthy, but some of them had cardiac disease and in
many the heart and other organs were rendered fatty by the previous adminis-
tration of phosphorus. In a large number of cases morphine, strychnine and
atropine, singly and in combination, were given by subcutaneous injection at in-
tervals before the inhalation was begun. Chloroform was given with and
without inhalers in the vertical and recumbent positions; in glass and
wooden boxes; in large and small doses; by being pumped into the trachea
with bellows; and in fact in every way that could suggest itself to the Commission,
21. The results in one respect are uniform. In every case where chloro-
form was pushed the respiration stopped before the heart. The following
table shows the interval of time between the cessation of respiration and of the
heart's action in dogs and monkeys in uncomplicated cases, and in cases com-
13
plicated by asphyxia and by the administration of certain drugs subcutaneously
before the chloroform inhalation was commenced
Interval of time between stoppage of respiration and stoppage of heart.
The heart stopped beating under 1, 2, 3, 4, 5, 6, 7, 8, 9,10,11, 12, minutes after the stoppage
of the respiration.
In Dogs.
T o t a l .
In uncomplicated cases ...
...
...
... 1 10 45 53 32 16 8 3 2 2 1 ... 171
I n c a s e s c o m p l i c a t e d —
(a) by very slow and prolonged administration ... 2 2
(b) by asphyxia
...
...
...
4 4
In Monkeys.
In uncomplicated cases ...
...
...
...
„, ... 2 8 4 2 2 4 2 ... 1 ... ... 26
In Dogs.
Injected with cocaine into peritoneum
half an hour before chloroform
...
Gr. ¼
1 1
2
"
½
...
2
2
"
1
1 1
2
" 1 ½
2 1
3
„ 2
1 1 1
3
Do,
strychnine
..
..
"
1/20
2 1
3
" 1/ 10
3 .
3
"
3/20
1 1 1
3
"
1/ 5
2 1
3
" Morphine
...
... ... " ¼ ... 1 ... 2 1 1
5
"
"
" ½
2 2 1
5
"
Atropine
. . .
. . .
"
1/23 ...
2 1
3
"
"
. . .
" 1/10
1 2
3
" "
. . .
. . .
... " 1/ 5
1 2
3
"
"
. . .
. . .
" 1/3 1
1 ... 1
3
„
Morphine Gr. ½ strychnine
„ 1/50
1 4
1 1
7
"
"
"
" "
3/100 1
3 2 2
8
"
"
" ½ atropine "
1/100
1
1
"
"
"
" "
1/50
1
1
"
" "
"
" 3/100
1
1
"
""
"
"
1/25
1
1
"
"
"
"
" 1/20
1
1
'
"
" " "
"
3/50
1
1
"
""
"
"
7/100
1
1
"
"
"
" "
8/100
1
1
"
"
"
" "
9/100
1
1
1/ 10
1
1
„
Morphine Atropine Strychnine.
"
gr. ½
gr. 1/100
gr. 1/ 100
1
1
" "
1 / 5 0
1 / 5 0
1
1
"
"
3/100
3 / 1 0 0
1
1
" "
1/ 25
1 / 2 5
1
1
"
" 1/20
1 / 2 0
1
"
"
3/ 50 3/50
1
"
"
4 / 1 0 0
7/ 100
1
1
"
"
8/100
8 / 1 0 0
1
1
"
"
9/100
9/ 100
1
1
"
"
1/ 10
1 / 1 0
2
1
3
14
22. The movement of the heart was in the first 66 cases of the Sub-Com-
mittee tested by auscultation, but afterwards by a needle inserted through the
chest-wall into the organ and the thoracic cavity was laid open when doubt existed.
23. In the majority of the uncomplicated cases, which include those fed in
different ways before inhalation, the heart ceased to act in from two to six
minutes after stoppage of the respiration. In one uncomplicated case the heart's
action ceased within one minute after the breathing stopped. The heart ceased
within one minute after the respiration stopped in two cases where the inhala-
tion was very slow and prolonged, in four cases complicated by asphyxia, and in
one where the subcutaneous injection of morphine gr. ½ and strychnine gr
. 3 / 1 0 0
w a s a d m i n i s t e r e d b e f o r e h a n d . T h e m a x i m u m t i m e t h e h e a r t c o n t i n u e d t o
beat after the respiration ceased, in the experiments of the Sub-Committee, was
eleven minutes in a dog and twelve in a monkey.
24. The effects of chloroform do not appear to be interfered with or much
influenced by any of the variations in the method of preparation of the animal
for or of the administration of, the anæsthetic. There are four general excep-
tions to this statement. In very slow and prolonged administration, and in
cases complicated with partial asphyxia, as well as in one case where one-third
of a grain of atropine was administered before the inhalation, the heart stopped
very soon after the respiration ceased; and in all cases where the inhalation was
accompanied by struggling the animals became insensible with unusual rapidity.
In these cases also the interval between the cessation of respiration and the
time of possible restoration by artificial respiration was shortened. ( V i d e
tables in Appendix B.)
25. As regards the restorative effects of artificial respiration the Sub-Com-
mittee found it was nearly always successful if commenced within thirty seconds
after the respiration ceased, very seldom successful if commenced between thirty
and sixty seconds after, and always -unsuccessful if -not begun till after sixty
seconds. In forty-four cases, in which artificial respiration proved successful, it.
was commenced on an average 28·2 seconds after natural respiration ceased.
In thirty-eight unsuccessful cases the average was 31·5 seconds.
26. The Sub-Committee formed the opinion that artificial respiration was
less successful in restoring the respiration after it had been stopped by chloro-
form in cases where a subcutaneous injection of morphia was administered before
the inhalation was commenced. There were eighteen cases in which this was tried.
In the first six artificial respiration was commenced eight seconds after cessation
15
of natural respiration. Of these five died. In three cases artificial respiration
was begun fifteen seconds after the natural respiration ceased, and of these two
recovered and one died. In three cases in which artificial respiration was com-
menced twenty seconds after the respiration stopped, two out of the three died
and, lastly, in six cases where artificial respiration was not commenced till thirty
seconds afterwards five died and one was revived. The average of those cases
that were revived was 17.6 seconds and of those that died in this series, 26.4
seconds. This opinion was tested by blood-pressure experiments Nos. 162 and
178, the results of which did not support. their conclusion.
Part III—EXPERIMENTS WITH RECORDING
APPARATUS.
27. The experiments carried out by the Committee with self-recording
apparatus consist of Nos. 25 and 29 to No. 185 inclusive. In a certain number
of cases the animal died accidentally before it was ready to be attached to the
manometer, and in others for various reasons the experiment was not completed;
but for the sake of convenience they have all been left in the order in which they
occurred, and are described seriatim in the explanatory notes. A full. descrip-
tion of the kymographs, with the aid of which the blood-pressure experiments
were carried on, is given in page; and all these experiments ar
e
illustrated by photographs of the kymographic records. A few of these plates
illustrate experiments in which the movements of the heart only were recorded
by a simple apparatus, which is also described Appendix A. In every case
in which a tracing was obtained it has been without exception preserved, and is
reproduced in this report by photography. In this way the whole of the work
of the Committee recorded by the manometer has been rendered available for
study at any time by any one who is interested in the subject. The photographs
are on a reduced scale, but with the aid of a 2 or 3-inch lens and perusal of the
explanatory notes, on the page opposite to them, the reader will have no difficulty
in deciphering and understanding the remarks recorded on the tracings. The
explanatory notes which were written partly at the time of, and partly im-
mediately after, each experiment, were made from the remarks which were
recorded on the manometer during the course of the experiments. It is impossible
to arrange the manometer experiments so as to group together those which appear
to illustrate particular points, because almost every experiment includes a variety
of procedures which suggested themselves at the time as likely to elucidate
something in the action of the different anæsthetics employed. An index is printed
at the end of the plates, in which the anæsthetics or drugs given to the different
animals, the operations performed upon them, the actions of interest taken in them,
16
and the changes of every kind which occurred in their condition, are referred
to the number of the experiments in which they took place.
28. The majority of the experiments were made upon dogs or monkeys,
and a few upon horses, goats, cats and rabbits.
29. The experiments of the Committee were designed to show the effect
upon the blood-pressure, heart, and respiration of the inhalation of chloroform,
ether, and the A. C. E. mixture, administered in various ways and under vary-
ing conditions. The objects of the Commission were five in number
: —
To test the suitability and safety of chloroform as an anæsthetic.
The experiments with ether and the A.C.E. mixture were instituted
principally for the sake of comparison with chloroform on certain
points, and it is not pretended that they afford a complete exposi-
tion of the action of those agents on the system.
II. The effect of pushing the above-named amæsthetics, (a) to a dangerous
degree, and more especially until the respiration ceases, (b) until
death results.
III. The modifications in the effect of these anæsthetics which result from
(a) asphyxia in varying degrees and produced by various means ( b
) f r o m t h e u s e o f d r u g s s u c h a s m o r p h i n e , a t r o p i n e , p h y s o s t i g m i n e
and others.
IV. The reality or otherwise of the alleged liability during ordinary
chloroform administration to the occurrence of primary or secondary
syncope or stoppage of the heart, brought about either by shock or
through fatty or weak heart, or by hæmorrhage, or by changes in
the position of the body. To investigate these points, in the first
place, a large number of operations which are reported to be
especially dangerous in reference to shock were performed in
every stage of anæsthesia, and numerous experiments were also
made to show the effect of direct irritation of the vagus. Secondly,
a number of animals were dosed with phosphorus before they were
experimented on. This caused weakening of the heart by fatty
degeneration of its fibres, but at the same time other complicated
changes in the whole of the organs of the body not met with
in the condition known as fatty heart in human beings. On the
other hand, there are conditions often met with in the fatty
heart, such as changes of the coronary vessels, which were not
produced by the phosphorus.
17
1 7
V. The effect of the anæsthetics above mentioned upon different animals,
more especially upon monkeys, as the nearest approach to human
beings.
30. The conclusions to which the Commission has been brought by the
study of these experiments are the following :—
(1) Chloroform, when given continuously by any means which ensures
its free dilution with air causes a gradual fall in the mean blood-pressure,* pro-
vided the animal's respiration is not impeded in any way, and it continues to
breathe quietly without struggling or involuntary holding of the breath—as
almost always happens when the chloroform is sufficiently diluted. As this fall
continues the animal first becomes insensible, then the respiration gradually
ceases, and, lastly, the heart stops beating. If the chloroform is less diluted the
fall is more rapid, but is always gradual, so long as the other conditions are
maintained ; and however concentrated the chloroform may be, it never causes
sudden death from stoppage of the heart. The greater the degree of dilution the
less rapid is the fall, until a degree of dilution is reached, which no longer appre-
ciably lowers the blood-pressure or produces anæsthesia.
(2) If the inhalation is interrupted at any stage, the fall of pressure still
continues at a rate which depends altogether on the rapidity of the fall while
the chloroform was being inhaled. This after-fall is probably due to absorption
of a portion of the residue of chloroform in the air-passages after the stoppage,
of the inhalation. In this way it often happens, if chloroform is given rather
freely, that though the respiration may be going on when the chloroform is
discontinued, it afterwards stops.
(3) If the administration of the chloroform is stopped at an early stage the
pressure very soon begins to rise again, and gradually becomes normal ; but if
the chloroform is pushed further, there comes a time, not easy to define, when
the blood-pressure and respiration will no longer be restored spontaneously,
although the heart continues to beat after the inhalation is stopped.
(4) If the fall has been very gradual, it may occasionally happen that the
respiration stops completely, and still the blood-pressure rises again, the respira-
tion recommencing spontaneously in the course of the rise. In the same way
when the inhalation has been discontinued, the respiration may stop during the
* Vide especially 168, 169 and 170 and Experiment No. 186 of March 6th, 1890.
3
18
after-fall of the blood-pressure and begin again spontaneously. As a rule, if
the respiration has stopped, or even becomes slow and feeble at the time when
the inhalation is discontinued and artificial respiration is not resorted to, the fall
in blood-pressure will continue until death ensues.
(5) There are two conditions which frequently disturb the gradual fall o
f
the blood-pressure, viz ., struggling and holding the breath, and it is only by
great care that they can be avoided in animals,
(6) Struggling, independently of any change in the respiratory rhythm,
appears generally to raise the blood-pressure.* In one case of a dog much
weakened from phosphorus† the pressure fell every time he struggled.
(7) When struggling is accompanied, as it often is, by acceleration of the
respiration and pulse, especially if the respiration is deep and gasping, it leads
to a more rapid inhalation of chloroform, and consequently to a more rapid
of blood-pressure and a greater after-fall. In order to keep the chloroform cap or
inhaler in its place during the animal's struggles, the administrator is obliged
thold it down more tightly over the nose and mouth, and this materially assists
in hastening the rapidity of the inhalation, and consequently of the fall in
bloodpressure.
(8) The effect of involuntarily holding the breath which. as anybody
can prove by experiment upon himself, must happen when an inhaler saturated
with chloroform is first applied to the face, is much more remarkable, the pres-
sure often falling with great suddenness while the heart's action is markedly
slowed.‡ As soon as the animal draws breath again the pressure rises as
suddenly as it fell ; but the gasping respiration which succeeds then causes very
rapid inhalation of chloroform with immediate insensibility and a rapid fall of
blood-pressure which quickly becomes dangerous.
(9) The combination of struggling with alternate holding the breath and
gasping, which results if chloroform is applied closely to the face without suffi-
cient dilution
w
ith air, causes violent fluctuations, and then a speedy fall of the
blood-pressure, which very soon leads to a dangerous depression with deep
insensibility and early stoppage of the respiration. The after-fall under these
circumstances is rapid and prolonged. It is this combination of events which
causes struggling animals to go under chloroform so quickly.
* Vide Experinment No. 82.
† Do, No. 161. See also Experiment No. 183.
Do,
Nos. 103, 119 Fick 2, 157 Fick 4, and many others. See Index under "Breath-holding".