NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
252
supposing that asphyxia stimulates the vase-motor centre. It is more probable that it paralyses
that centre and stimulates the respiratory centre. Chloroform, on the other hand, paralyses
both centres. Fortunately, it effects the respiratory centre most deeply first, so that when
danger of overdosing arises warnings are given by the respiration, whereby that danger can
invariably be averted.
The most important result of the labours of the Hyderabad Chloroform Commission has
undoubtedly been to establish the proof that chloroform has never, under any circumstances
whatever, a direct action upon the human heart; and not the least important of the results of
the Commission's work consists in the exposure of some of the sham physiology which has
passed current as genuine for the last te
n ten years. Not to speak of the condition of animals with
the blood-pressure "minus," it is a well nigh irreparable misfortune that a whole generation of
our profession should have been taught such physiological untruths as that the normal action
of the vagus nerve is to imperil and occasionally to destroy life; and it is degrading to reflect
that one of the main uses to which this false knowledge has been applied in England since 1879
has been to throw dust in the eyes of the public, when coroners' inquests are held on the
victims of chloroform administered in accordance with the erroneous principle advocated by
the Glasgow Committee.
President, Hyderabad Chloroform Commission,
Hyderabad, Aug. 1890.
L E T T E R F R O M D R . A R T H U R H . W .
HUNT, M.R.C.S., &C.
TO THE EDITORS OF "THE LANCET"
SIRS,—I send you a few particulars of a recent death at the Wolverhampton and
Staffordshire General Hospital from the administration of ether, in which the patient died
of syncope, and not from failure of the respiratory function.
A young man aged twenty was admitted under Mr. Vincent Jackson on June
19th last. He was a miller by trade, and sought relief from a swelling at the upper and outer side
of his left leg. He was a stout, flabby man, and rather anæmic. The swelling turned out
to be a chronic abscess. Previously to this he had always been healthy. The abscess was
opened soon after admission, under chloroform, and another, which appeared a few weeks later
was opened under nitrous oxide. In addition to these, two other abscesses were opened
without an anæsthetic.
Last week it was found necessary to again place him under an anæsthetic, in order to
scrape away some unhealthy granulations, and slit open a couple of sinuses. The house
physician and assistant house surgeon were present. The house physician pro lem.
(Mr. Bryett, M.B., Lond.) gave ether with a Clover's inhaler, and the ether was from the same
bottle as that which had been successfully used for other patients. It was obtained from
253
Robbins, Oxford-Street, London. Deceased was not deeply under ether when I commenced and
finished the operation, which only lasted two or three minutes. At no time was the ether on
beyond the mark 3 on the inhaler. On telling the house physician I had finished the inhaler
was put aside, and I commenced to dress the wound. After breathing normally several
times deceased moaned, and then turned pale and ceased breathing. At the same time his
pupils dilated. The tongue was at once drawn out with forceps, and artificial respiration
begun. The chest was slapped with a wet towel, and hypodermic injections of ether and brandy
administered. In addition a battery which was at hand was applied. Artificial respiration
was kept up for forty minutes, but w a s
o f n o a v a i l . T h e p o s t - m o r t e m e x a m i n a t i o n w a s made
by Mr.V i n c e n t J a c k s o n , a t t h e r e q u e s t o f t h e c o r o n e r . T h e r e w a s a c o n s i d e r a b l e l a y e r o f f a t
over the chest, and the muscles were paler than natural. Both lungs were healthy, but there
were some old adhesions in the right pleural cavity. The heart was unduly covered with fat
especially at its apex. The right side was dilated and full of blood, the left empty and contract-
ed. The walls of the right ventricle were thin. The valves were healthy. The heart muscle
was very pale and soft. A small piece examined under the microscope showed marked fatty
changes. The jury returned a verdict accordingly.
This case is interesting, firstb e c a u s e
i t i s o p p o s e d t o t h e v i e w t h a t d e a t h f r o m e t h e r
takes place from asphyxia; and, secondly, from its sudden fatal termination, without any
previous warning.
f a i t h f u l l y ,
ARTHUR H. W. HUNT, M.R.C.S., & c.,
Wolverhampton, Sept. 2nd, 1890
House Surgeon to the Hospital.
OBSERVATIONS on the ADMINISTRATION and DANGERS of AN
ÆS-THETICS. by JAMES DUNLOP M.D., Surgeon to the Royal Infirmary,
Professor of Surgery at Anderson's College, and Medical Examiner in
C r i m i n a l c a s e s , G l a s g o w .
In view of the recent development of this subject, circulars asking for information upon
it have been issued by The Lancett o
s c i e n t i f i c m e d i c a l m e n t h r o u g h o u t t h e w o r l d . T h i s cir-
cular has simulated Dr. Dunlop to record the result of his observations on the subject made in
wards 15, 23 and 24 of the Glasgow Royal Infirmary during the last ten years, and to state
his opinions thereupon.
Allowing of unrecorded cases in these Wards, the following opinions are based on observa-
tions of 3,500 cases within the specified period. To produce a næesthesia in this number of
patients,
chloroform has been principally used. In the administration, the drop method was
adopted. Ether was sometimes employed;i t s u s e b y
C l o v e r ' s a p p a r a t u s w a s b e g a n o n M a r c h
8th, 1882. Its use was greatly dependent on the skill and ability of the assistant, some
assistants administering the drug with greater skill than others. In a general way ether
was administered in the proportion of one case of ether to thirty cases of chloroform. Ether
258
that at all times and under all circumstances chloroform cannot be administered without some
risk to the patient's life. That risk, however, may be greatly diminished
—reduced to a
minimum—by an accurate knowledge of the patient's condition of body and mind and the
skilful administration of the anæsthetic, which includes due attention to the pulse, as well as
watching the respiration.
G l a s g o w.
LETTER FROM SURGEON H, HERBERT.
To THE EDITORS OF "THE LANCET."
SIRS, —On September 10th, while performing a lateral lithotomy on an Arab boy,
about sixteen years old, it was suddenly found that the patient laid stopped breathing.
had been got under perfectly quietly, and he had evidently simply got too much of the anæs--
thetic. It was still being administered when the stoppage of respiration occurred. Artificial
respiration, with head thrown back over the edge of the table and with the ammonia
bottle at the nose, was kept up for, I think, nearly two minutes. The time was not taken,
however and it may have been more or less. Then very feeble respiration began and gra-
dually strengthened. At the beginning neither the pulse at the wrist nor heart impulse could
be felt, but throughout there was a feeble flickering seen in the lines of the carotid vessels in
the neck. Thus there is no doubt that respiration was mainly affected. and artificial breathing
was sufficient to bring the patient round.
I am, Sirs, yours truly,
Aden, Sept. 17th,
H. HERBERT, Surgeon, I.M.S.
ANNOTATION FROM THE LANCET.
We are constantly compelled to record deaths occurring under chloroform, and are
generally impressed by the fact that the reports furnished are not sufficiently complete. A
very natural feeling prompts reticence as regards the lay press. but when the immense im-
portance of the matters at issue are considered, there can be no room. for hesitancy about
furnishing the fullest reports to the professional journals, We some months ago in connection
with the inquiry conducted by the Hyderabad Commission, issued a circular to the profession
individually, and a further circular of inquiry was sent to all the hospitals and dispensaries
requesting an account of personal experience of deaths under amæsthetics. and yet but com-
- p a r a t i v e l y f e w o u t o f t h e g r e a t n u m b e r q u e s t i o n e d h a v e f o u n d l e i s u r e t o a n s w e r o u r a p p e a l .
It is admitted upon all hands that mere experimentation upon the lower animals is, without
clinical experience of the behaviour of human beings under anæsthetics, inconclusive: and this
is further shown by the fact that different observers arrive at different conclusions. We would,
then, earnestly beg of our readers to furnish us with their own experience, and see that those
responsible for the record of cases in the hospitals to which they belong duly fill in and return
266
When we come to study the effects of chloroform upon the lower animals, we find that
it varies very distinctly in its action on the different species. The cat seems to withstand the
fatal influences of chloroform with a power worthy of its reputed "nine lives". Many years ago,
Professor Schiff called attention to the fact that the use of chloroform as an anæsthetic in the
dog is usually attended with the loss of many animals. Professor Martin, of the John Hop-
kin's University, writes me that the margin between complete chloroform anæsthesia in the
dog, and chloroform death, is a very narrow one, This certainly is our experience in the
University of Pennsylvania; we have never been able to use chloroform as an anæsthetic
without losing a very large proportion of our dogs.
Clinical and experimental results, namely, the results of experiments made in the phy-
siological laboratory upon the lower animal, and the results of experiments made in the am-
phitheatre upon the higher animal (man) are again concordant. Chloroform is much more
inimical than ether to animal life. The cause of this singular fatality is not, however, chiefly the
cardiac action of chloroform. Chloroform is more apt to cause cardiac arrest than is ether, but
it is also much more prone than is ether to cause deaths by failure of the respiration. Almost
invariably, when ether is withdrawn before the dog is absolutely in the grasp of death, recovery
occurs; but over and over again I have noticed that although the chloroform was taken away
whilst the respirations were still being maintained with regularity, the arterial pressure much
above zero, and the pulse very apparent, yet the symptoms of cardiac and respiratory failure
continued to increase until the fatal issue was reached.
It seems to me that certain general facts or principles in regard to anæsthesia must be
considered as established:—
(1) That the use of any anæsthetic is attended with an appreciable risk, and that no
care will prevent an occasional loss of life.
(2) That chloroform acts much more promptly and much more powerfully than
ether, both upon the respiratory centres and the heart.
(3) That the action of chloroform is much more persistent and permanent than that
of other.
( 4 )
T h a t c h l o r o f o r m i s c a p a b l e o f c a u s i n g d e a t h e i t h e rb
y
p r i m a r i l y a r r e s t i n g t h e
respiration, or by primarily stopping the heart. but that commonly both
respiration and cardiac functions are abolished at or about the same time.
(5) That ether usually acts very much more powerfully upon the respiration than
upon the circulation, but that occasionally and especially when the heart is
feeble ether is capable of acting as a cardiac paralysant, and may produce
death by cardiac arrest at a time when the respirations are fully maintained.
(6) Chloroform kills, as near as can be made out, proportionately three to five
times as frequently as does ether, partly, no doubt, because it is more
powerful in depressing the heart, but largely because it lets go its hold much
less rapidly than does ether when inhalation ceases. Is it not possible that
273
living, but have made a series of experiments upon dead bodies, which have demonstrated that
usually a face mask is all that is necessary for the performance of artificial respiration. Before
using the mask, the tongue should be well drawn forward, and, if necessary, fixed in this
position by an ordinary piece of silk suture run through it, which can be held in the hand of
the operator. If in any individual case the mask fails, an intubation tube may be introduced
i n t o t h e l a r y n x . I d o n o t b e l i e v e i t wi l l e v e r b e f o u n d n e c e s s a r y t o p e r f o r m a t r a c h e o t o my .
Dr. Fell's apparatus consists of a pair of foot-bellows by which air is forced into a
receiving chamber, which is connected with an apparatus for warming the air, and a valve
which can be opened and shut by a movement of the finger. This valve in turn leads to the
tracheal tube. When the valve is opened the air rushes through the chamber into the lungs
and expands them; the finger is lifted, the valve shuts, the lungs contract; and so the respira
-tion goes on. I have no doubt that this apparatus is efficient in practice, but it is open to the
serious objection of being unnecessarily complex and costly.
A much simpler, cheaper, and probably equally efficient apparatus may consist
simply of a pair of bellows of proper size, a few feet of India rubber tubing, a face mask, and
two sizes of intubation tubes. There should also be set in the tubing a double tube, with
opening similar to that commonly found in the tracheal canula of the physiological labora
-tory, so that it is in the power of the operator to allow for the escape of any excess of air
thrown by the bellows. This whole apparatus can be prepared at a very trifling expense, and
it seems hardly necessary to point out its probable value in various narcotic poisonings, and
other accidents, in which death is produced by a paralysis of the respiratory centres of
temporary nature. The proper use of it,—at least with the face mask,—could be taught to
persons without special medical skill, so that it not only ought to form a part of the surgeon's
outfit, but might be of great service in life-saving stations, about gas works, &c.
In conclusion, I may be allowed to state that if the results and deductions arrived at in
this address are, as I believe, correct, the rules for the proper treatment of accidents during
anæsthesia can be summed up in a very few words:
Avoid the use of all drugs, except strychnine, digitalis and ammonia.
Give the tincture of digitalis hypodermically.
Draw out the tongue, and raise up the angle of the jaw, and see that the respiration is
not mechanically impeded.
Invert the patient briefly and temporarily.
Use forced artificial respiration promptly, and in protracted cases employ external
warmth and stimulation of the surface by the dry electric brush, &c., and, above all, remember
that some at least, and probably many, of the deaths which have been set down as due to
chloroform and ether have been produced by the alcohol which has been given for the relief
of the patient.
35
280
the principle taught by Surgeon-Major Lawrie, namely, to concentrate the whole of their
attention on the breathing of the patient, and not to pay the slightest regard to the heart or
pulse. I understood that it had been clearly and satisfactorily proved by Dr. Lauder Brunton
and the Hyderabad Commission that chloroform did not prove fatal by sudden stoppage of the
heart; yet very little attention seems to have been paid to the addresses of Dr. Lauder Brun-
ton or Professor Wood at the Berlin Medical Congress last August, when the views expressed
by these gentlemen were distinctly opposed to each other. The profession in general are there-
fore left as far as ever from a sound and definite basis for the administration of chloroform.
I am, Sirs, yours truly,
Secunderabad, Deccan.
Surgeon-Major, Medical Staff.
ARTICLE BY DR. DUDLEY W. BUXTON,
[Reprinted from "The Lancet" of December 13th, 1890.]
ONE of the dangers of controversy is the almost inevitable crystallisation of the thought
of those who advocate, or press, the negative of any question. There is certainly some fear in
the present juncture, lest the common-sense side of the chloroform question should be left out
in the cold, while we hotly discuss the modus operandi of its death-dealing properties. On the
pr e s e nt oc c a s i on I hope t o dr a w a t t e nt i on a s c onc i s e l y a s pos s i bl e t o t he va r i ous pr a c t i c a l i s s ue s
involved in my title. Chloroform, I take it, cannot, even if we would, be laid aside; it possesses
properties so valuable and so useful that it will, perhaps for ever, remain a favourite anæsthetic
with many operating surgeons and obstetricians. The main considerations, then, for practical
men are: How far is it a dangerous agent, in what does its danger consist, and can this danger
be abrogated or minimised so as appreciably to render the peril beyond ordinary computation
either by methods of administration or other means; and, lastly, how does it compare, as far as
absolute safety goes, when placed side by side with other anæsthetics?
It may be said that the present time is hardly ripe for opening such an inquiry, since
the subject is still to be further elucidated by the clinical report promised us by the Editors of
THE LANCET. But we should remember that from its very nature such a report must be devoid
of personal colour, being statistical, so that the experiences of practical anæsthetists can neither
forestall nor be devoid of value whatever may be the finding of THE LANCET Chloroform In-
quiry. Death under chloroform is, unhappily, a frequent occurrence. We hear of a few
deaths, probably not all, and if we accept 1 in 3,000 as a working estimate of their frequency
we are probably within the mark, although Surgeon-Major Lawrie says he has given chloro-
290
LETTER FROM SURGEON-MAJOR EDWARD LAWRIE,
TO THE EDITORS OF "THE LANCET"
SIRS,—Dr. Dudley Buxton cannot be allowed to depart from his original statement.
He described his method of giving chloroform in the following precise terms (the italics are
mine): "My plan is to use Lister's open method or Krohne and Sesemann's useful modification
of Junker's inhaler. I also make it a rule to test the vigour of respiration by placing my hand
on the mouth, and to keep a finger upon an artery." It is this plan which I ridiculed. Dr.
Buxton now dexterously tries to make it appear that my criticism was directed against Junker's
inhaler, and that he gives chloroform on Syme's principles, though Syme never took the pulse
as a guide. Dr. Dudley Buxton's plan is impracticable, and its absurdity is only surpassed by
the absurdity of the method of another specialist, Mr. Rickard W. Lloyd, Mr. Lloyd proceeds
to give chloroform* "with the sprinkled lint lying on the separated fingers of my right hand
in front of the mouth, which enables me to feel the force of expiration, with my left middle
finger on the left temporal pulse, and my left thumb holding up the left upper lid of the patient
and testing the corneal reflex when necessary." Mr. Lloyd thus endeavours to obtain inform
-ation as to the state of the patient from three if not four distinct tactile impressions at the same
winch is just as dangerous as it would be for one of my students to administer chloroform
to three or four patients all at once. Dr. Dudley Buxton further states that I must have had
many cases of heart failure under chloroform which I have overlooked, because "Surgeon
-Major Lawrie has never felt the pulse during chloroformisation." The whole of this statement
is a gratuitous invention. All my operations are performed in public; I have never had a case
of heart failure, and I frequently take the opportunity, of demonstrating that the action of the
heart and the pulse are invariably regular when chloroform is properly administered. I do not
allow the pulse to be taken as a guide as to the effect of chloroform, because I know it is no
less useless than dangerous.
Finally, Dr. Dudley Buxton asserts that the Hyderabad Commission has not proved
that there is no such thing as chloroform syncope, because "its conclusions are based upon
purely negative evidence." If Dr. Buxton were as familiar with the A B C of logic as he
would have us believe he is with the A B C of the chloroformist's duties, he would know that
proof' of the absence of anything must always be negative proof. The rest of Dr. Dudley
Buxton's letter consists of a bald statement of creed, unsupported by any explanatory reasons,
and does not call for further notice.
I am, Sirs, your obedient servant,
EDWARD LAWRIE, Surgeon-Major.
May 11th, 1891
* V i d e
T H E L A N C E T , A p r i l 4 t h , 1 8 9 1 .
291
LETTER FROM DR. DUDLEY W. BUXTON,
TO THE EDITORS OF "THE LANCET".
SIRS,—Together with other earnest seekers after truth, I much regret the tone and
lack of courtesy in Dr. Lawrie's reply to my letter upon this subject. Dr. Lawrie will hardly
strengthen his position by accusing me of "gratuitous invention," or by the sneer conveyed in
his sentence: "If Dr. Buxton were as familiar with the A B C of logic as he would have us
believe he is with the A B C of the chloroformist's duties, he would know that proof of the
absence of anything must always be negative proof." The italics are mine. Unfortunately for
Dr. Lawrie's argument, he quotes my words, which are "its (i . e .
, t h e H y d e r a b a d C o m m i s s i o n ' s )
conclusions are based upon purely negative evidence." I cannot suppose Dr. Lawrie can con-
fuse the terms "evidence" and "proof " or the phrases "negative evidence" with "negative
proof." If he does, I may perhaps be excused if I declined to accept his views upon the rules
governing the constitution of the logical syllogism. Dr. Lawrie again indulges in calling what
he regards as my "met hods" by hard names; but t hi s I can forgi ve, for he evi dent l y does not
understand in what they consist. Unless purely personal matters are excluded in discussing
questions, the foundations of which are purely scientific, I must decline to participate in them.
It cannot tend to increase our knowledge of the physiological action of chloroform for us to
hear that Dr. Lawrie of Hyderabad regards Dr. Dudley Buxton's [ of London!!] method as
"impracticable," and its "absurdity only surpassed by the absurdity of another specialist."
Such an unguarded manner of expression can subserve no useful purpose.
I am, Sirs, yours obediently,
DUDLEY W.BUXTON,
Anæsthetist in University College Hospital
.
MORTIMER-STREET, W., May 18 th , 1891.
[Dr. Dudley Buxton accuses Surgeon-Major Lawrie of lack of courtesy,
and if the accusation were well founded, Surgeon-Major Lawrie would apologise
to the whole profession. But the view we take of the matter is this. If
specialists publish their plans of chloroform administration, while adversely
criticising the Hyderabad Commission, they can have no possible ground of
complaint if they are criticised, however severely, in their turn. It argues no
discourtesy that we consider and know it to be impracticable to give chloro
-form safely or properly in the manner described by Dr. Dudley Buxton as
"my plan".
Dr. Buxton made a statement regarding Dr. Lawrie's practice which is
inconsistent with fact. We have yet to learn that any lack of courtesy is
involved in the opportunity Dr. Lawrie afforded Dr. Dudley Buxton of
honorably withdrawing this speculative misstatement when he pointed out
that it was a gratuitous invention.]