CASE OF DEATH UNDER CHLOROFORM.

897

help expressing surprise that so influential journal as THE LANCET should, by implication if not directly, charge me with something more than mere dereliction of duty when evidence to the contrary exists in its own columns. Again, you say:"Practitioners are the creation of colleges such as Dr. Atthill represents." The Irish College of Physicians, which I represent, has always required six months’ attendance on a lying-in hospital or maternity, and proof of having attended thirty cases of labour. We have the courage of our convictions, though we lose thereby, for many students go in consequence to Scotland for their qualifications, where they are admitted on easier terms, at least so far as midwifery is concerned. You ask : "Do I really mean to indicate a preference for illiterate women over even badly educated students" I fear and I cannot

a

I must answer in the affirmative. Doubtless the ill-educated student might deliver a woman with the forceps where the illiterate woman would allow the patient to linger on, but his success would be due to pure "luck," the os being fully dilated and the cervix retracted but in the next case the cervix might be stretched over the head, and as in the be torn away by the blade cases I have mentioned, thrust through it. The illiterate woman in general trusts to nature alone, seldom attempts to interfere, and may not send for aid till too late ; the ill-educated student attempts operations that he cannot safely perform and frequently inflicts serious injury on the patient, and very often these operations are attempted too soon. In truth, we are on the horns of a dilemma. The opinions I have formed and which I enunciated before the Committee are doubtless distasteful to many, but I formed them after mature experience and much thought. My desire is to raise the standard of education and to benefit the suffering poor, and if I can aid in this I shall be indifferent to the opinion of I am, Sirs, yours truly, interested persons. LOMBE ATTHILL.

To the Editors

of THE LANCET. SiRs.-I scarcely have the audacity to address you for a moment longer on this subject. Mr. Humphreys having, however, contrary to my expectation, raised one or two points in a letter which he intimates is his last, and having again fallen into a most egregious blunder-if he will pardon the expres-

sion-because he says : " Mr. Sers practically advocates the formation of a partially educated, wholly uncontrolled

chaotic mass of petty details in which it appears to be hopelessly buried alive, and I placed it side by side with considerations of great magnitude; but Mr. Humphreys affected to pooh-pooh what he knows, or ought to know as well as I, to a

be serious

length as

considerations, and

to

he

idea of the rising

repudiate the

even

ventured, to such a experience being

common

of any service amongst generation of practitioners. because he happened to know some obstetrical genius who, according to his showing scarcely ever conducted a case. I am, Sirs, yours faithfully, CLEMENT H. SERS. We at cannot devote more z* present to this disspace L.

I Icussion.-ED.

THE SURGERY OF STONE IN THE BLADDER. To the Editors of THE LANCET.

SIRS, —Brigadier - Surgeon - Lieutenant- Colonel J. Forbes on "The Complete Abandonment of the Cutting Operation for removing Calculi entire from the Bladder," the last of which appears in THE LANCET of Sept. 30th, seem to me to demand notice from those Keith’s papers

surgeons specially interested in the surgery of stone in the bladder. Surgeon-Colonel Keith’s enterprise and daring command admiration and I have read his cases with great interest, not unmixed with wonder at the immense tolerance of the Indian bladder. With reference to his methods, we must not forget that Vixere fortes ante Agamemnona and that the late Dr. Dolbeau of Paris practised and described the operation of perineal lithotrity and brought the operation prominently before the profession. I wish, however, particularly to point out that* although lithotrity may be pushed to its utmost limits, as has been boldly done by Surgeon-Colonel Keith, we shall never be able to abandon If he will read my papers on ’’ The some form of lithotomy. Importance of the Post-Prostatic Pouch in the Surgery of Vesical Calculus," which were published in THE LANCET of April 18th and 25th, 1891, and my paper in vol. xxiii. of the Transactions of the Clinical Society of London on "Two Rare Cases of Encysted Vesical Calculi in the Male successfully removed by Suprapubic Lithotomy," I think he will be convinced that in suggesting that we shall abandon the removal of all calculi entire and unbroken from the bladder by a vesical incision his enthusiasm in favour of lithotrity has carried him a little too far. Surgeons regularly employed in removing calculi from the bladders of elderly men, and even of women and children, are absolutely certain occasionally to meet with stones which, by reason of their position, defy all attempts at extraction except by vesical incision. I am, Sirs, yourstruly, truly, G. BUCKSTON BROWNE.

class,"&c., I must beg your indulgence for an instant longer. Before I do so, however, I have to thank Mr. Humphreys for calling attention to an error which, if it is an error, I have unwittingly fallen into, although it is not to the point of my argument, and that is with regard to my statement that the bulk of midwifery cases are attended by our own profession ; and as I gathered from this and other fixed data that antiseptics are more or less neglected by our profession I unnecessarily reflect on medical men. I therefore with pleasure withdraw it, because it is obvious that this inCASE OF DEATH UNDER CHLOROFORM. ference-i. e., the neglect of antiseptics on our part--would be invalidated to a greater or less extent according to the proTo the Editors (If THE LANCET. portion of cases in the hands of outsiders. Secondly, with SIRS,-A robust, healthy man aged sixty-three, a miner, regard to my advocating "the formation of a partially educated, wholly uncontrolled class," Mr. Humphreys, if he was admitted on Sept. 18th for the removal of a large nasal will only be pleased to observe with a little more accuracy, growth which had recurred after three previous operations, will find that I am advocating nothing of the kind, as my policy for each of which chloroform had been given, the anaesthetic happens to be a let-alone one. It is therefore neither on being well taken and soon recovered from. On the 29th he It is was again placed under chloroform, which was given on a my part a policy of integration or disintegration. llr. Humphreys who is, indeed, advocating both, because he piece of lint. He took the ansesthetic well, with some slight The growth was easily removed. It proposes a scheme which threatens disintegration, on the one initial struggling. hand-i.e., the elimination of the Gamps-or integration, sprang from the middle turbinated bone, completely blocking on the other, by bringing into existence a new class—i. e., the nostril, but did not encroach on the posterior nares. registered midwives ; and surely this latter class may be Throughout the operation the pulse was regular, respiration denominated "a partially educated class." It is, Sirs, easy and full, and the pupils reacted to light. On comwith the view of exposing the feeble grasp which some of pletion of the operation the chloroform was stopped and the the most prominent supporters of the scheme possess, and patient quickly began to resume consciousness. The connot with any idea of cavilling, that I criticise those state- junctive were fully sensitive, and he moved when roused. ments. I am perfectly ready to admit that in an abstract Just as he was about to be taken back to the ward the sense the position of the promoters is a true one-that breathing suddenly became shallow and ceased, and the is to say, a registered midwife is, taking all in all, pre- pupils were dilated. Artificial respiration was at once begun, ferable to a Gamp, and, in the second place, the mortality the head was lowered, and hypodermics of ether and the would be smaller provided an equal exchange could be ensured battery were applied to the chest-walls, which were also between one and the other-a highly improbable desideratum. flicked with a towel wrung out of cold water &c. Natural But it is begging the whole question to shirk discussion respiration began, the patient coughed once or twice and beyond this. In my first letter I attempted to uncoil this attempted to vomit, and though artificial respiration was conquestion by dragging it from its infinitesimal shell and from tinued all danger seemed to be over. Breathing, however

898

again ceased. Tracheotomy was performed

and all endeavours The heart, which till now had continued beating, gradually failed and acupuncture failed to stimulate it. Efforts to revive were continued for over half an hour, till it was evident that they would be of no avail. Post mortem there were found old but not extensive pleuritic adhesions of both .1.ungs posteriorly, each pleural cavity containing a few drachms of clear fluid. The lungs were deeply pigmented, but healthy. The pericardium was covered with much fat and contained The heart was somea drachm or so of clear fluid. what enlarged and the coronary vessels were much engorged. All the valves were healthy and competent. The walls of the ventricles showed very slight signs of fatty degeneration, that of the right one being thin and pale. About three-quarters of an inch above the aortic valves there was a small calcareous - nodule. The stomach contained a little fluid semi-digested food. All the other organs were healthy, and there was no obstruction in the pharynx or trachea. Rather less than one .ounce of chloroform was used from a graduated drop bottle. The chloroform, which was from the same bottle, was .apparently quite pure on test and had been used in other - cases both before and since the one under discussion without any bad effect. The coroner’s jury returned a verdict to the .effect that death was due to syncope following the administration of chloroform properly and carefully given. There is little to add to the above. This was purely a - death from chloroform. The slight amount of fatty degeneration found in the heart post mortem did not preclude it from being regarded as an unusually healthy one for a man of ’that age and could have had little influence on the fatal issue. It is a curious point how many of these " accidents " occur in trivial operations. In this case, at all events, the patient was fully "under." There was ample interval between the different operations to negative any "cumulative" effect of the drug. .Again, it is an example of the truth of the deductions of the Hyderabad Chloroform Commission in that the respiratory failure gave the first indications of danger. There was no ’.alcoholic history in the patient and the post-mortem examination proved an unusually healthy condition, taking into consideration the age and employment of the patient. Given, as in this instance, the experience of the anaesthetist, the purity of the anaesthetic, and the apparent health of the patient, this and similar cases are, under our present knowledge, We are, Sirs, yours truly, unexplainable. SELBY W. PLUMMER, M.D., B.S. ROBT. ROBINSON, M.B, C.M. were

renewed.

’

AMERICAN

MEDICAL

SCHOOLS.

to look to the students’ fees for their support, cannot The University of Pennsylvania make the desired changes. has always been a pioneer in this direction, yet it would be suicidal to require a classical or scientific entrance examination, and it is in this that we lack-viz., the preliminary education. I American M.D., " in THE LANCET Of Sept. 16th, apparently advances quantity in defence of his alma mater. Until three years ago Jefferson College of Philadelphia and Bellevue of New York City ground out between two and three hundred men every spring. Why ? Because the course consisted of two terms of about twenty-four weeks each ; hence it furnished an easy road to the coveted end. At Ann Arbor the fees are much less than at any of our Eastern colleges, but the institution has a very fair rating. Though nominally a four years course, a year spent with a preceptor exempts the candidate from the first year provided he passes an examiIt is quality we want; quantity we nation in osteology. have. I sincerely trust that I may some day see the following plan in operation : firstly, a rigorous preliminary examination in science or arts ; and, secondly, a separate examining board. Then may we expect to see our physicians accorded the same lofty standing which our surgeons have so richly won. I am, Sirs, yours truly, W. E. ROBERTSON, M.D.

pelled

THE EARLY HISTORY OF OVARIOTOMY. To the Editors of THE LANCET.

SiRs,-In your obituary notice in THE LANCET of Sept. 30th

of Mr.

Clay reference is made to him as "the pioneer of ovariotomy, " and it is stated that he performed his first ovariotomy in September, 1842. I do not think that it is generally known that my father (Dr. Protheroe Smith) in 1842, the year in which he founded the Hospital for Women, performed his first ovariotomy, which was one of the first, if not the first, performed in this country. I am, Sirs, yours faithfully, HEYWOOD SMITH.

SCARLET

FEVER AND ROTHELN.

To the Editors of THE LANCET. SiRs,-With reference to an article by Dr. Atkinson in THE LANCET of Sept. 23rd on the diagnosis between scarlet fever and rötheln, ’I confess that the association of the following features would make me think twice before I said definitely that the case might not be scarlet fever. " Dark scarlatinal-looking rash on the neck and chest, a slightly ulcerated throat, the temperature when first seen 100° F., followed by peeling, which continued for one month afterwards." Surely Dr. Atkinson does not mean to say that the glanduls ooncatenatas are never enlarged in scarlet fever ? I am, Sirs, yours truly, EDWARD CULLINAN, M.R.C.S., L. R. C. P. Lond.

To the Editors oj THE LANCET. BIRs,-I regret the fact that my epistle will not reach you until the eleventh hour, for I should like to be permitted to add my mite on behalf of our institutions. First, permit me to state, with all due respect, that, whilst you have made a good representative selection, you have not done justice to them. You disparage the short term of eight or eight months and a half, yet, for climatic reasons, I scarcely see how it could be prolonged, for it would tax the powers of FORMER IDEAS REGARDING CHOLERA. any student to work with the thermometer ranging from To the Editors of THE LANCET. ’90° to 100’F. in the shade, or 104° as we bad it in the summer of 1892. Hence the number of hours spent at SIRS,-Sir Thomas Watson’s belief that a great majority of clinical and didactic lectures each day-viz., from four to the cases of cholera are attributable not to direct contagion -eight, which with "quizzes" often mounts up to ten hours, but to the poison diffused through the atmosphere" was exclusively of the time devoted to study in the sanctum. declared half a century ago ; but the impulse itought to have Without going into detail, you can readily perceive that this given to investigation into the meteorological factors or method brings the number of lecture hours almost, if not features of the epidemic seems to have unaccountably colquite, up to that required in your own schools. You say lapsed. Some of your lay contemporaries have drawn in your Students’ Number: "The Americans are amongst attention to the cholera cloud,"or, as others term it, the shrewdest and most practical of mankind," and truly the "cholera mist," which so frequently harbingers an they must be, for, despite the immature state of medicine on explosion of the disease. That atmospheric phenomenon - this continent, witness the brilliant superstructures which have was observed by Captain Norman in the Black Sea waters been raised upon a foundation far more open to condemnation off Varna during the terrible visitation of 1854; nay, than that now under discussion, whose industry and achieve- twenty-two years before that date, during the first appear- ments have won world-wide fame, and whose books are used ance of the malady in 1832, the coincidence of a cloud - as text-books in English and German schools. Until we are which preceded the descent of the invader on the Dumfriesrepresented in the Federal Government by a Cabinet medical shire coast had not escaped the eye of Thomas Carlyle; officer who, with competent men selected from the various but of all descriptions of the ominous "cholera cloud" none States, constitutes an advising and governing board, we can- is so dramatic as that given in ’The Times of 1867, in the not hope for much improvement in the rank and file. Whilst autumn of which year there occurred at Albano, near cheap schools and schools whose examinations are notoriously Rome, one of the most frightful outbreaks of the disease In the first week of August easy to pass are permitted to foist their "products " on the known in medical annals. unsuspecting public, the better schools, which are also com- that delightful retreat was especially crowded with visitors