- Email: [email protected]
" THE AFTER-EFFECTS OF CHLOROFORM."
"THE AFTER-EFFECTS OF CHLOROFORM."
370
entered the navy in 1837, obtained his promotion to StaffSurgeon in January, 1846, Fleet-Surgeon, 1861, and retired as honorary Deputy-Inspector-General of hospitals and fleets in October, 1868. Some cases of cholera have occurred in the Emigration Depot at Cassimode, Madras ; but Surgeon-Major C. M. Thompson considers that they have all been imported and are
sporadic cases.
On Feb. 6th 170 invalids were admitted to the Royal Victoria Hospital. Netley; they were brought home from India in H. M.S. Serapis.
Correspondence. "
Audi alteram parbem.11
" THE AFTER-EFFECTS OF CHLOROFORM." To thi Editors
of
THE LANCET.
SIRS,-The paper published by Dr. Guthrie in the last two numbers of THE LANCET on the "Aftei-effects of Chloroform in Children " is of very great interest and importance and is so learned and carefully thought out that I have the greatest hesitation in saying anything about it. At the same time, as several of the cases were under my care, I should like to state, for what they are worth, my recollections of the cases and the conclusions that I came to at the time, without entering into a criticism of Dr. Guthrie’s paper; and I may say at once that I cannot even now agree with his conclusions that the fatal results were due to after - effects of chloroform. Speaking only of my own cases, the one narrated as Case 3 has always been, to my mind, a clear instance of carbolic poisoning. I had arranged to perform the operation on this patient on a Tuesday, but was prevented from getting to the hospital, and it was accordingly deferred till the next day. In the meantime, on the Tuesday, carbolised cloths had been applied to the skin for two hours, and as a result the child suffered from marked symptoms of carbolic poisoningThis was not mentioned to viz, vomiting, carboluria, &c. me at the time of the operation ; indeed, I did not know of it till after the patient died, otherwise I should certainly have avoided any further use of carbolic acid. I looked on Case 4 as one of fat embolism, but it may also be referred to carbolic acid. Here there was no question of shock, the actual operation only lasting for a few minutes ; the hour of which Dr. Guthrie speaks was in large part taken up by him in getting the patient completely under the anaesthetic and in part in the disinfection of the skin and the careful arrangement of the splints subsequently to operation. The child’s condition next morning did not give rise to any anxiety, and though she was somewhat dull, and had still a little sickness, she was so well in the afternoon that the house surgeon, who was a most capable and careful man, went out for the evening, never suspecting that there was any danger. I was summoned about 8 P. M. because the patient had suddenly passed into a very collapsed state, being somewhat cyanosed and unconscious. I cannot here exclude carbolic poisoning, but the conclusion I came to at the time, when the case was fresh in my mind, was that the fatal result was more likely to be due to fat embolism ; the late onset of the symptoms is quite in accord with such a history. As to Case 7, it is excessively difficult to understand why the patient died ; and apparently there was no reason to account for his death. When the house surgeon saw him at 1 A.M. he noticed nothing wrong, but, to his amazement, he was summoned half-an-hour later and found the patient dead. At the time I could only think that the state of the patient’s kidneys and the use of the carbolic acid were to blame for the result. In Case 9 I see no reason for supposing that the death was due to sublimate poisoning ; there were no symptoms of it, no pressure was used in irrigating the sac, and it was apparently thoroughly emptied afterwards. Here, again, death was quite sudden, the patient having recovered apparently completely from the operation. In this case I did not use carbolic acid and fell back on fat embolism as the most probable explanation ; and certainly, when it is remembered that quite a number of cases of tuberculous meningitis have followed more or less immediately on scraping out glands, joints, &c. there is no reason why one should not have fat emboli as well as emboli of tuberculous material.
I may say that, unfortunately, in none of these cases were either the lungs or the brain examined microscopically, and thus the question of fat embolism remains, as do Dr. Guthrie’s views, purely theoretical. The cries, on which Dr. Guthrie lays so much stress, were not to my recollection in any way unusual or unlike those often met with in young children after operations or when feeling ill, and the gentleman who was house surgeon at the time when several of the cases occurred fully agrees with me in this, To sum up, the first case was, I feel sure, one of carbolic poisoning ; the second and third were probably the same, but in the second I cannot exclude fat embolism ; the fourth was, I think, probably fat embolism. It is a remarkable fact that the first three cases all occurred at a time when we were using carbolic acid very freely, and they led me thencefoith to be extremely careful in its use in children; in fact, except for short purification of the skin, I do not employ it in children. And since I made that change Ihave had no more of these mysterious deaths-a point, to my mind, of the strongest significance in favour of that view as against Dr. Guthrie’s. I may also add that, though these were the only fatal cases, we had in one or two others at that time somewhat similar symptoms which disappeared on changing the carbolic for mercurial dressings. I do not, of course, deny the existence of serious and fatal effects after anaesthetics ; indeed, I believe they are not un. common, especially after ether. In fact I think that, if the after-effects of ether are taken into sufficient consideration there will not be much to choose between it and chloroform in point of view of danger. I would even go so far as to say that if the use of chloroform were entirely prohibited, as was at one time strongly hinted at in some of the journals, andif were used in all instead of only in suitable cases, as at present, its death-roll (including its after-effects) would be as great as, and probably greater than, that of chloroform.
ether
I am, S. s.yours faithfully
j
Harley-street, W.,
Feb. 5th, 1894.
W. WATSON CHEYNE.
’THE CORONER’S COURT. i
I
I
To the _Editors of THE LANCET. SIRS,—I would like, with your permission, to state a case of hardship which, in times such as the present, is felt to be no ordinary inj ustice. On the morning of the 31st ult,, at 7 30, I was called to see a man who was found lying in a pool of blood upon the kitchen floor of his house, I proceeded at once to examine him and found that the man had cut his throat with a table-knife, com. pletely severing his larynx, injuring the oesophagus, and playing havoc with the tissues on each side of his neck; he was unconscious and pulseless. I sent for the police and for hours did what I could for him. About three o’clock in the afternoon he had rallied sufficiently to be sent to the union infirmary, which I considered the wisest course, as the man was most destitute ; he died on Feb. 3rd, having lived for eighty-four hours. My grievance is, firstly, the refusal of the police to grant me a medical aid certificate, though I am the divisional surgeon’s deputy, on the ground that they did not call me, I maintaining that the case from the first was a police case and that, its being an urgent one, I had no right to wait for an order from them ; in fact, had I delayed many minutes, life would have been extinct on my arrival. My second grievance is that at the inquest held at the infirmary the coroner did not summon me as a witness. Surely, birs, I am not complaining unnecessarily when I say that, both by the police and by the coroner, I have not been dealt with justly’ I air my grievance through your columns, as complaints made to the authorities only receive the usual stereotyped replies, and as affording an instance of how the hard-worked practitioner does not receive much consideration even from those who ought to know better.-I am, Sirs, yours faithfully, HENRY LOVE. Mitcham, Fb. 6th, 1894.
"EXPERIMENTAL
DEGENERATION OF THE
PYRAMIDAL TRACT."
To the Editors of THE LANCET.
SIRS,—As the last sentence of Professor Sherrington’5 note on Degeneration of the Spinal Cord and elsewhere consequent on lesions of the cortex cerebri in monkeys may possibly be misconstrued, it appears only just to Dr. Mellus. who is conducting the work referred to by Professor Sherrington, and who is unfortunately abroad, that the following
370
entered the navy in 1837, obtained his promotion to StaffSurgeon in January, 1846, Fleet-Surgeon, 1861, and retired as honorary Deputy-Inspector-General of hospitals and fleets in October, 1868. Some cases of cholera have occurred in the Emigration Depot at Cassimode, Madras ; but Surgeon-Major C. M. Thompson considers that they have all been imported and are
sporadic cases.
On Feb. 6th 170 invalids were admitted to the Royal Victoria Hospital. Netley; they were brought home from India in H. M.S. Serapis.
Correspondence. "
Audi alteram parbem.11
" THE AFTER-EFFECTS OF CHLOROFORM." To thi Editors
of
THE LANCET.
SIRS,-The paper published by Dr. Guthrie in the last two numbers of THE LANCET on the "Aftei-effects of Chloroform in Children " is of very great interest and importance and is so learned and carefully thought out that I have the greatest hesitation in saying anything about it. At the same time, as several of the cases were under my care, I should like to state, for what they are worth, my recollections of the cases and the conclusions that I came to at the time, without entering into a criticism of Dr. Guthrie’s paper; and I may say at once that I cannot even now agree with his conclusions that the fatal results were due to after - effects of chloroform. Speaking only of my own cases, the one narrated as Case 3 has always been, to my mind, a clear instance of carbolic poisoning. I had arranged to perform the operation on this patient on a Tuesday, but was prevented from getting to the hospital, and it was accordingly deferred till the next day. In the meantime, on the Tuesday, carbolised cloths had been applied to the skin for two hours, and as a result the child suffered from marked symptoms of carbolic poisoningThis was not mentioned to viz, vomiting, carboluria, &c. me at the time of the operation ; indeed, I did not know of it till after the patient died, otherwise I should certainly have avoided any further use of carbolic acid. I looked on Case 4 as one of fat embolism, but it may also be referred to carbolic acid. Here there was no question of shock, the actual operation only lasting for a few minutes ; the hour of which Dr. Guthrie speaks was in large part taken up by him in getting the patient completely under the anaesthetic and in part in the disinfection of the skin and the careful arrangement of the splints subsequently to operation. The child’s condition next morning did not give rise to any anxiety, and though she was somewhat dull, and had still a little sickness, she was so well in the afternoon that the house surgeon, who was a most capable and careful man, went out for the evening, never suspecting that there was any danger. I was summoned about 8 P. M. because the patient had suddenly passed into a very collapsed state, being somewhat cyanosed and unconscious. I cannot here exclude carbolic poisoning, but the conclusion I came to at the time, when the case was fresh in my mind, was that the fatal result was more likely to be due to fat embolism ; the late onset of the symptoms is quite in accord with such a history. As to Case 7, it is excessively difficult to understand why the patient died ; and apparently there was no reason to account for his death. When the house surgeon saw him at 1 A.M. he noticed nothing wrong, but, to his amazement, he was summoned half-an-hour later and found the patient dead. At the time I could only think that the state of the patient’s kidneys and the use of the carbolic acid were to blame for the result. In Case 9 I see no reason for supposing that the death was due to sublimate poisoning ; there were no symptoms of it, no pressure was used in irrigating the sac, and it was apparently thoroughly emptied afterwards. Here, again, death was quite sudden, the patient having recovered apparently completely from the operation. In this case I did not use carbolic acid and fell back on fat embolism as the most probable explanation ; and certainly, when it is remembered that quite a number of cases of tuberculous meningitis have followed more or less immediately on scraping out glands, joints, &c. there is no reason why one should not have fat emboli as well as emboli of tuberculous material.
I may say that, unfortunately, in none of these cases were either the lungs or the brain examined microscopically, and thus the question of fat embolism remains, as do Dr. Guthrie’s views, purely theoretical. The cries, on which Dr. Guthrie lays so much stress, were not to my recollection in any way unusual or unlike those often met with in young children after operations or when feeling ill, and the gentleman who was house surgeon at the time when several of the cases occurred fully agrees with me in this, To sum up, the first case was, I feel sure, one of carbolic poisoning ; the second and third were probably the same, but in the second I cannot exclude fat embolism ; the fourth was, I think, probably fat embolism. It is a remarkable fact that the first three cases all occurred at a time when we were using carbolic acid very freely, and they led me thencefoith to be extremely careful in its use in children; in fact, except for short purification of the skin, I do not employ it in children. And since I made that change Ihave had no more of these mysterious deaths-a point, to my mind, of the strongest significance in favour of that view as against Dr. Guthrie’s. I may also add that, though these were the only fatal cases, we had in one or two others at that time somewhat similar symptoms which disappeared on changing the carbolic for mercurial dressings. I do not, of course, deny the existence of serious and fatal effects after anaesthetics ; indeed, I believe they are not un. common, especially after ether. In fact I think that, if the after-effects of ether are taken into sufficient consideration there will not be much to choose between it and chloroform in point of view of danger. I would even go so far as to say that if the use of chloroform were entirely prohibited, as was at one time strongly hinted at in some of the journals, andif were used in all instead of only in suitable cases, as at present, its death-roll (including its after-effects) would be as great as, and probably greater than, that of chloroform.
ether
I am, S. s.yours faithfully
j
Harley-street, W.,
Feb. 5th, 1894.
W. WATSON CHEYNE.
’THE CORONER’S COURT. i
I
I
To the _Editors of THE LANCET. SIRS,—I would like, with your permission, to state a case of hardship which, in times such as the present, is felt to be no ordinary inj ustice. On the morning of the 31st ult,, at 7 30, I was called to see a man who was found lying in a pool of blood upon the kitchen floor of his house, I proceeded at once to examine him and found that the man had cut his throat with a table-knife, com. pletely severing his larynx, injuring the oesophagus, and playing havoc with the tissues on each side of his neck; he was unconscious and pulseless. I sent for the police and for hours did what I could for him. About three o’clock in the afternoon he had rallied sufficiently to be sent to the union infirmary, which I considered the wisest course, as the man was most destitute ; he died on Feb. 3rd, having lived for eighty-four hours. My grievance is, firstly, the refusal of the police to grant me a medical aid certificate, though I am the divisional surgeon’s deputy, on the ground that they did not call me, I maintaining that the case from the first was a police case and that, its being an urgent one, I had no right to wait for an order from them ; in fact, had I delayed many minutes, life would have been extinct on my arrival. My second grievance is that at the inquest held at the infirmary the coroner did not summon me as a witness. Surely, birs, I am not complaining unnecessarily when I say that, both by the police and by the coroner, I have not been dealt with justly’ I air my grievance through your columns, as complaints made to the authorities only receive the usual stereotyped replies, and as affording an instance of how the hard-worked practitioner does not receive much consideration even from those who ought to know better.-I am, Sirs, yours faithfully, HENRY LOVE. Mitcham, Fb. 6th, 1894.
"EXPERIMENTAL
DEGENERATION OF THE
PYRAMIDAL TRACT."
To the Editors of THE LANCET.
SIRS,—As the last sentence of Professor Sherrington’5 note on Degeneration of the Spinal Cord and elsewhere consequent on lesions of the cortex cerebri in monkeys may possibly be misconstrued, it appears only just to Dr. Mellus. who is conducting the work referred to by Professor Sherrington, and who is unfortunately abroad, that the following