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A CASE OF SUDDEN DEATH AFTER AN ANÆSTHETIC
384
"lying"cases. (b) Numbers of acute ai large number of men admitted from the same convoy, The same district, were gassed. (requiring special cots), acute medical,gand who came fromofthe none of the symptoms of gas poisoncomplained heat patient tuberculars, venereals, exhaustion, enterics, dysenteries, neither were any at any time noticed. An X ray (c) The number of Colonial, Allied, oring, eye cases, &c. examination was made, and showed a metal fragment in the prisoners sick. (d) Patients for debarkation at interveningsole of the foot just behind the base of the fifth metatarsal. ports. Wards are allotted in accordance with these data. It was decided to remove this and to provide freer drainage. 2. Distribution.—At the "distributing" station (usually Accordingly, on the following day, May 1st, chloroform was near the embarkation gangway) a N.C.O. inspects eachadministered, the wound and track were excised, and the (a) Number of
surgical,
fractures
ticket as he walka or is carried aboard, and callsmetal was found and removed. The missile had grazed the and diagnosis. A second N.C.O. checks the ’outer side of the os calcis and the cuboid and had opened "the calcaneo-cuboid joint. The operation was trivial and name on the nominal roll. and the O.C. troops " sizes up a few minutes. There was no struggling, and the patient and tears off an appropriate ticket from the only occupied abnormal was noticed either during induction or nothing embarkation board, giving it to the patient, who will retainduring the stage of anaesthesia. Very little anasthetic was it for the voyage, because it shows the position of his ward,required, and the pulse and colour were both normal throughThe entire procedure takes aboutout. The anaesthesia was so light that while a gauze drain cot, and life-boat. being inserted the patient moved his leg with con1; seconds per man, and therefore does not appreciably was siderable vigour. When the patient was about to be delay an embarkation. Cabins will be allotted to sickremoved from the operation room to the ward it was noticed officers in the same manner. that he had quite suddenly become rather cyanosed and that 3. Cabins;Summarising.—When embarkation is com- he was straining as though about to vomit. The jaw was pleted the "stateis copied on to the orderly-room black- held forwards and the anaesthetist remained with him for board. The numbers on the top tickets remaining on the some minutes until his colour was quite good and respiraembarkation board show the numbers of the cots vacant in tion normal. By this time he was practically round from the each ward and also the boat.accommodation remaining. This anaesthetic and even sat up on the stretcher and spat out a little mucus. The pulse was unaffected during this attack latter may be allotted to "I lying " cases. did not cause any anxiety. There was no 4. Allotmaent of orderlies to boats.—Tickets for the R.A.M.C. and his condition vomiting and no excessive secretion of mucus. in be in these wards the various wards kept employed may Instructions were now given to take the patient back to by the sister or N.C.O. in charge. They are handed to the his ward and the anaesthetist returned to the theatre to orderlies at the beginning of each voyage. Space is allowed anaesthetise another patient. After a very short interval, for them when allocating patients to boats. This plan however, certainly not more than three minutes, and before the patient had been taken back to the ward, it was ensures that orderlies accompany their own patients in the reported that the man had suddenly collapsed. He was seen boats. at once and was apparently dead. The face was an ashy C.—Avantages. grey colour, the lips were slightly cyanosed, respiration had 1. Segregation of patients in groups according to their ceased, the pupils were dilated, and the pulse and cardiac ’impulse were imperceptible. There had been no vomiting, diseases, latrine requirements, and general welfare. 2. Certain cases may be placed under the care of a medical and no obstruction could be felt on digital examination of the Artificial respiration was started at once and officer who specialises in a particular branch of his profession was pharynx. for an hour, but without any effect, though the kept up -e.g., eye cases, venereals, X ray. air could be both heard and felt to enter and leave the chest 3. The number of patients actually embarked is auto- without any difficulty. In addition strychnine and pituitrin matically registered and the hospital state" ascertained were injected, hot cloths were applied to the precordial at any moment. area, and tongue traction was employed, but without any 4. When debarking sick transferred to an intervening port, response. On the following day a post-mortem examination was a ward is completely evacuated and can be thoroughly made G. Richardson, R.A.M.C. The whole heart cleansed and disinfected before a corresponding number of was by Captain very dilated, especially the right auricle and ventricle; is embarked. patients the valves were, however, competent. There was no evidence 5. When two or more pack-stores exist one of these can of any vomiting having occurred and no obstruction of any be devoted to the wards to be evacuated at intervening ports. sort in the air passages. Tracheitis was present and was 6. The position of any Medical Officer, Sister, or Orderly especially marked just above the bifurcation. The lungs in the hospital can be ascertained at a glance. were slightly congested and oedematous, particularly at the 7. Each man is provided with a life-boat ticket before bases. The stomach was nearly empty and the other viscera The whole appearance was characteristic of were normal. sailing, the first 24 hours being usually in a danger zone." gas poisoning, and the amount of cardiac dilatation suggested 8. R.A.M.C. staff accompany their own patients in the that the gas in question was phosgene. Death was due to boats. primary cardiac failure. These advantages are magnified when dealing with Remarks. numerous small drafts of sick. In such a case as the above probably the only physical sign that would have been noticed from a thorough examination of the heart would have been some displacement of the A CASE OF cardiac impulse. Nothing abnormal was noticed on auscultaSUDDEN DEATH AFTER AN ANÆSTHETIC tion. In any case the operation would have been carried out, as the local condition was one of considerable IN A LATENT CASE OF SHELL GAS POISONING. In the absence of any vomiting or of any urgency. obstruction in the air passages the cause of death at BY PHILIP TURNER, M.S. LOND., F.R.C.S. ENG., the time was attributed to primary cardiac failure, but MAJOR, R.A.M.C. the reason of this was obscure until the post-mortem examination. When seen within two or three minutes of being THIS case is recorded for two reasons. In the first place, apparently all right and coming round from the anaesthetic sudden death after an anaesthetic which has been taken normally the patient was obviously dead, and though without any unusual symptoms having been noticed, and attempts at resuscitation were kept up for an hour there where the patient is so nearly round that he is able to sit up was at no time any response or any suggestion of recovery. and spit out mucus, is very unusual; and, secondly, because He had already been observed to sit up once, and the the possibility of such an occurrence in a man who has been probability is that he did this again or made some similar exposed to the action of poison gases should be borne in slight muscular effort, with the result that the dilated and weakened heart had thrown upon it a strain which it was mind, even though no symptoms have been observed. Private H., aged 22, was admitted to a general hospital in unable to bear. Indeed, one lesson to be learnt from this France on April 30th, 1918, suffering from a wound of the case is that all movements after an anassthetic in patients right foot which had been received on the previous day. where there is any suspicion of gas poisoning should be There was an entry wound only, situated just in front of checked., and that they should be kept strictly in the and below the right external malleolus. There was a good horizontal position. deal of swelling and tenderness, and the wound was His condition be infected. to obviously general appeared A DEVONSHIRE CENTENARIAN.—Miss Jane Welsford, satisfactory, though he was rather anaemic and there was due to the wound. doubtless There was no of Newton Abbot, celebrated the 104th anniversary of her slight pyrexia, mention of gas poisoning on the field medical card, though birthday on August 21st.
patient’s out the
name
’
"lying"cases. (b) Numbers of acute ai large number of men admitted from the same convoy, The same district, were gassed. (requiring special cots), acute medical,gand who came fromofthe none of the symptoms of gas poisoncomplained heat patient tuberculars, venereals, exhaustion, enterics, dysenteries, neither were any at any time noticed. An X ray (c) The number of Colonial, Allied, oring, eye cases, &c. examination was made, and showed a metal fragment in the prisoners sick. (d) Patients for debarkation at interveningsole of the foot just behind the base of the fifth metatarsal. ports. Wards are allotted in accordance with these data. It was decided to remove this and to provide freer drainage. 2. Distribution.—At the "distributing" station (usually Accordingly, on the following day, May 1st, chloroform was near the embarkation gangway) a N.C.O. inspects eachadministered, the wound and track were excised, and the (a) Number of
surgical,
fractures
ticket as he walka or is carried aboard, and callsmetal was found and removed. The missile had grazed the and diagnosis. A second N.C.O. checks the ’outer side of the os calcis and the cuboid and had opened "the calcaneo-cuboid joint. The operation was trivial and name on the nominal roll. and the O.C. troops " sizes up a few minutes. There was no struggling, and the patient and tears off an appropriate ticket from the only occupied abnormal was noticed either during induction or nothing embarkation board, giving it to the patient, who will retainduring the stage of anaesthesia. Very little anasthetic was it for the voyage, because it shows the position of his ward,required, and the pulse and colour were both normal throughThe entire procedure takes aboutout. The anaesthesia was so light that while a gauze drain cot, and life-boat. being inserted the patient moved his leg with con1; seconds per man, and therefore does not appreciably was siderable vigour. When the patient was about to be delay an embarkation. Cabins will be allotted to sickremoved from the operation room to the ward it was noticed officers in the same manner. that he had quite suddenly become rather cyanosed and that 3. Cabins;Summarising.—When embarkation is com- he was straining as though about to vomit. The jaw was pleted the "stateis copied on to the orderly-room black- held forwards and the anaesthetist remained with him for board. The numbers on the top tickets remaining on the some minutes until his colour was quite good and respiraembarkation board show the numbers of the cots vacant in tion normal. By this time he was practically round from the each ward and also the boat.accommodation remaining. This anaesthetic and even sat up on the stretcher and spat out a little mucus. The pulse was unaffected during this attack latter may be allotted to "I lying " cases. did not cause any anxiety. There was no 4. Allotmaent of orderlies to boats.—Tickets for the R.A.M.C. and his condition vomiting and no excessive secretion of mucus. in be in these wards the various wards kept employed may Instructions were now given to take the patient back to by the sister or N.C.O. in charge. They are handed to the his ward and the anaesthetist returned to the theatre to orderlies at the beginning of each voyage. Space is allowed anaesthetise another patient. After a very short interval, for them when allocating patients to boats. This plan however, certainly not more than three minutes, and before the patient had been taken back to the ward, it was ensures that orderlies accompany their own patients in the reported that the man had suddenly collapsed. He was seen boats. at once and was apparently dead. The face was an ashy C.—Avantages. grey colour, the lips were slightly cyanosed, respiration had 1. Segregation of patients in groups according to their ceased, the pupils were dilated, and the pulse and cardiac ’impulse were imperceptible. There had been no vomiting, diseases, latrine requirements, and general welfare. 2. Certain cases may be placed under the care of a medical and no obstruction could be felt on digital examination of the Artificial respiration was started at once and officer who specialises in a particular branch of his profession was pharynx. for an hour, but without any effect, though the kept up -e.g., eye cases, venereals, X ray. air could be both heard and felt to enter and leave the chest 3. The number of patients actually embarked is auto- without any difficulty. In addition strychnine and pituitrin matically registered and the hospital state" ascertained were injected, hot cloths were applied to the precordial at any moment. area, and tongue traction was employed, but without any 4. When debarking sick transferred to an intervening port, response. On the following day a post-mortem examination was a ward is completely evacuated and can be thoroughly made G. Richardson, R.A.M.C. The whole heart cleansed and disinfected before a corresponding number of was by Captain very dilated, especially the right auricle and ventricle; is embarked. patients the valves were, however, competent. There was no evidence 5. When two or more pack-stores exist one of these can of any vomiting having occurred and no obstruction of any be devoted to the wards to be evacuated at intervening ports. sort in the air passages. Tracheitis was present and was 6. The position of any Medical Officer, Sister, or Orderly especially marked just above the bifurcation. The lungs in the hospital can be ascertained at a glance. were slightly congested and oedematous, particularly at the 7. Each man is provided with a life-boat ticket before bases. The stomach was nearly empty and the other viscera The whole appearance was characteristic of were normal. sailing, the first 24 hours being usually in a danger zone." gas poisoning, and the amount of cardiac dilatation suggested 8. R.A.M.C. staff accompany their own patients in the that the gas in question was phosgene. Death was due to boats. primary cardiac failure. These advantages are magnified when dealing with Remarks. numerous small drafts of sick. In such a case as the above probably the only physical sign that would have been noticed from a thorough examination of the heart would have been some displacement of the A CASE OF cardiac impulse. Nothing abnormal was noticed on auscultaSUDDEN DEATH AFTER AN ANÆSTHETIC tion. In any case the operation would have been carried out, as the local condition was one of considerable IN A LATENT CASE OF SHELL GAS POISONING. In the absence of any vomiting or of any urgency. obstruction in the air passages the cause of death at BY PHILIP TURNER, M.S. LOND., F.R.C.S. ENG., the time was attributed to primary cardiac failure, but MAJOR, R.A.M.C. the reason of this was obscure until the post-mortem examination. When seen within two or three minutes of being THIS case is recorded for two reasons. In the first place, apparently all right and coming round from the anaesthetic sudden death after an anaesthetic which has been taken normally the patient was obviously dead, and though without any unusual symptoms having been noticed, and attempts at resuscitation were kept up for an hour there where the patient is so nearly round that he is able to sit up was at no time any response or any suggestion of recovery. and spit out mucus, is very unusual; and, secondly, because He had already been observed to sit up once, and the the possibility of such an occurrence in a man who has been probability is that he did this again or made some similar exposed to the action of poison gases should be borne in slight muscular effort, with the result that the dilated and weakened heart had thrown upon it a strain which it was mind, even though no symptoms have been observed. Private H., aged 22, was admitted to a general hospital in unable to bear. Indeed, one lesson to be learnt from this France on April 30th, 1918, suffering from a wound of the case is that all movements after an anassthetic in patients right foot which had been received on the previous day. where there is any suspicion of gas poisoning should be There was an entry wound only, situated just in front of checked., and that they should be kept strictly in the and below the right external malleolus. There was a good horizontal position. deal of swelling and tenderness, and the wound was His condition be infected. to obviously general appeared A DEVONSHIRE CENTENARIAN.—Miss Jane Welsford, satisfactory, though he was rather anaemic and there was due to the wound. doubtless There was no of Newton Abbot, celebrated the 104th anniversary of her slight pyrexia, mention of gas poisoning on the field medical card, though birthday on August 21st.
patient’s out the
name
’