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THE PROPOSED RECONSTITUTION OF THE LONDON UNIVERSITY.
317 kerchief or towel. Immediately the operation was commenced the patient became pulseless, his pulse previously being full and natural. Here the period of inhalation was very short, one minute, and the evidence of paralysis of the heart distinct. CASE 3.-J. V-, aged seventeen. Hotel Dieu, Lyons, January, 1849. Amputation of finger. Chloroform was dropped upon gauze spread over the face, leaving a free passage for air. At the end of five minutes patient still and spoke, at the end of six minutes he became restless and still spoke. One drachm and a half of chloroform had i now been given; pulse regular and good. He now struggled violently, and within a quarter of a minute the pulse at the wrist became imperceptible. The gauze was removed, no pulse anywhere to be felt, and no cardiac sounds audible. Respiration continued, and ceased in half a minute. Means of resuscitation were employed, and respiration reappeared in two minutes’ time, and then again gradually ceased. The pulse did not return. And now we come to the practical conclusions which are generally the first read, and are usually the most interesting parts of the whole paper, no matter on what subject it is written. It is difficult to see how the Committee arrived at its first practical conclusion as to the position of the patient on the back being the best. This position is not so comfortable to the patient as when lying on his side; any of the anaesthetic fluid accidentally spilt falls on his face instead of on the pillow, and, in fat people especially, the diaphragm does not descend so well owing to the weight of the fat on the abdomen pressing on it. Again, in this position the patient usually swallows all the saliva which is secreted, often in large quantity, and this produces aftervomiting ; whereas when the patient is on his side the saliva will run out of the corner of his mouth, and consequently cannot irritate the mucous membrane of the stomach. Also, when the patient is lying on his side, the tongue is not liable to fall back and thus impede respiration ; in natural sleep and in cases of apoplexy how constantly do we notice that a patient on his back snores heavily and breathes uneasily, but when turned on his side all noise ceases and he breathes quietly. The next conclusion I agree with, provided the patient is placed on his side for the reasons above stated. The principles of the next five paragraphs have been taught in the London schools for years. I can answer for Charing-cross Hospital, where the pupils are systematically instructed in the theoretical and practical details of anaesthetics. In paragraph 33 of the report the Committee state that they performed a large number of operations which are reputed to be particularly dangerous from shock, such as extraction of teeth, evulsion of nails, section of muscles of the eye, &c. These operations were performed in all stages of anaesthesia, and even when the animal was merely stupefied with chloroform); in no case was there anything suggestive of syncope or failure of the heart’s action. And yet in Conclusion VIII. we find " as a rule no operation should be commenced until the patient is fully under the influence of the anaesthetic, so as to avoid all chance of death from surgical shock or fright." Now, how are we to reconcile these two statements ? Is it not apparent that animals do not suffer from surgical shock and cardiac failure, and are in this respect different from human beings. I venture to state that there is no anaesthetist, even of moderate experience, who has not noticed cases of shock from insufficient anaesthesia, due to the surgeon commencing the operation before asking the administrator whether the patient is
felt
’
ready.
Conclusion IX. states : "The administrator should be
guided as to the effect entirely by the respiration. His only object, while producing anaesthesia, is to see that the respiration is not interfered with." From the large experience I have had of administering anaesthetics in England during the last thirty years, I feel absolutely certain that if
this deduction is acted upon, the number of fatal cases, even now too numerous, will rapidly increase. I maintain that the administrator should watch equally the face, the pulse, and the respiration, sudden pallor of the face being of far more importance than partial interference with the breathing. The precautions mentioned in the remaining paragraphs are usually carried out in the London hospitals. Time alone will show whether the sanguine future the Commission believe to be in store for chloroform will come to pass if their rules for its administration are carried out. I remain, Sirs, yours faithfully, Feb
3rd,
1890.
WOODHOUSE BEAINE.
To the Editors of THE LANCET. SIRS,-Just as modern industrial life is the outcome of the introduction of steam, so modern surgery is based upon the use of anesthetics. Whatever relates to fatalitiesduring anaesthesia is therefore of the greatest importance to every practical surgeon. With nearly half a century’s experience at our back, it is surprising-in these days of advancing science and greater accuracy in many respectsto find that even now we have no really reliable information as to the relative frequency of such occurrences. Rough estimates there are in abundance, the value of which may bejudged from the fact that they vary, for chloroform, from, 1 in 36,500 to 1 in 2666 administrations. My object in writing this letter is to point out that a perfectly reliable source of information is now available, so. that in future there can be no excuse for ambiguity. Fo? many years past there has been kept at St. Bartholomew’s Hospital a most admirable record of the administration of anæesthetics and of the fatalities which have occurred. These have been published from year to year with the annual statistical reports of the hospital. Believing thesubject well worth a little trouble, I have tabulated these records for the ten years 1878-1887. During this time chloroform was administered 12,368 times, with 10 deaths (1 in 1236). During the same period ether was administered 14,581 times, with 3 deaths (1 in 4560. In 9072 of these cases ether was preceded by gas ; 1 fatal case belongs to this category. In the other 5509 cases ether alone wasgiven, and 2 deaths occurred.1 These facts are very eloquent ; they require no lengthy comment. I havelong been aware of the safety of ether, and have therefore preferred it to chloroform in most cases, notwithstanding its disadvantages in some other respects. I believe this is the goal towards which professional opinion is steadily moving; and I think this movement likely to be most beneficial. Experience at other hospitals leads me to, believe that the results obtained at St. Bartholomew’s may be accepted as reliable averages. There can be no doubt, in these cases at least, that most of the fatalities occurred in spite of the greatest skill and care being used in the administration of the anaesthetic agents. Such being the case, it is impossible to arrive at any other conclusion than that such occurrences are unavoidable in a certain proportion of
greater
cases.
I cannot conclude this letter without emphatic protest against the dictum of the Hyderabad Commission, that such deaths must be ascribed entirely to carelessness on the part of the administrators. Such a statement is opposed to allclinical experience, and it is simply preposterous. I am, Sirs, yours truly, W. ROGER WILLIAMS. Welbeck-street, W., Jan. 30th, 1890.
THE PROPOSED RECONSTITUTION OF THE LONDON UNIVERSITY. To the Editors of THE LANCET. SIRS,—AT the last meeting of Convocation of the London University there seemed to be a practically unanimous feeling against the proposals of the Senate, as far as they had leaked out or could be guessed at, and a resolution was passed to the effect that the proposals of the Senate should, be forwarded to members of Convocation at an early date. This is a step in the right direction, though a very short and tardy one. As one of those who believe that the graduates have a right to be treated with the fullest confidence in matters so vitally affecting their well-being, I amof opinion that at the very first a draft of the scheme should have been circulated amongst all graduatesof the University,, whether members of Convocation or not. The reorganisation or disorganisation of the University, whichever it be,, is a matter calling for the most serious consideration of all who hold, or hope to hold, a degree from the University. And looked on in that light, it seems insufficient that, when. the scheme is officially before us, its rejection, adoption, or amendment should rest with a meeting of Convocation numbering, perhaps, 150 members at most. Of the graduates who are members of Convocation, the great majority, scattered as they are through the country, would naturally be debarred by professional pursuits from attending its meetings, and it is most important that their opinion, as well as.
right to state that in each of these cases the patient was in exceedingly feeble and collapsed state before exhibition of the anæsthetic owing to prolonged intestinal obstruction. 1
an
It is
318 that of younger graduates, should be obtained on questions of such moment to all. A meeting of all interested might be convened specially to discuss the whole question as soon as we are kindly permitted to know the proposals ; or, if necessary, graduates might be canvassed by a series of printed questions, so that they may not plead ignorance as an excuse for the disastrous reformation to which they will have tacitly assented. Rumours of wholesale creation of Doctors, converting Bachelors into Masters, of the lowering of examination standards, and of the general cheapening of degrees, are in the air, and although we have no right to meet trouble half way we have a right and a duty to be on the alert to guard our privileges, and to protest against the undignified competition with the Royal Colleges of a University we once respected. It is generally admitted that the London University has up to the present filled its unique position satisfactorily, and that its prosperity is undiminisbed-nay, increasing yearly. On the other hand, it is freely acknowledged that a new institution could be more easily formed than the old one remodelled ; therefore, by ill-timed silence or inaction in the immediate future London graduates will inflict a deadly blow on themselves, and be denied the consolation of having conferred any sortof benefit on others by their self-betrayal. I am, Sirs, yours faithfully, Feb. 3rd, 1890. M.D., B.S. LOND.
of between 2000 and £3000 is raised
annually by the Hospital Sunday and Saturday Funds ; the subscription list is but little over £2000 yearly ; while the expenditure has long exceeded 12,000, and in the new buildings will probably be much more. The new infirmary will be opened perhaps in the summer ; it will contain all the most recent improvements, and will be well worthy of a visit by all members of the profession visiting Liverpool. The Abattoirs.
Nearly fifty years ago the City Council granted the lease of a piece of ground in what was then the east end of Liverpool, but has now become centralised and surrounded with buildings. These leases are for seventy-five years, and some years ago the Abattoir Company asked for a renewal of the lease, which was opposed by the medical profession on sanitary grounds and refused. More recently this same company has asked not only for a renewal of the lease, but for additional land to erect more buildings. The members of the medical profession have strongly opposed this. A meeting was held at the Medical Institution, and a resolution unanimously adopted condemning strongly any further retention of the abattoirs within the centre of the city, and a deputation, comprising the leading physicians and
The surgeons, waited upon the Finance Committee. Abattoir Company have not been idle, and have also presented reports giving their grounds for wishing to retain the site. They have urged that slaughterhouses are not prejudicial to health, but the fact remains that wherever there are slaughterhouses there must also be places for gut cleansing, hides, and other accessories. A special report has been made by the medical officer of health, in consequence of which, combined with the general protest of the medical profession and the common sense of its members, the Finance Committee, by a majority of twelve to three, resolved to recommend the Council not to grant renewal of the lease. As the latter has still twenty years to run, no hardship could accrue to the leaseholders, who would have plenty of time to look out for and find more suitable quarters outside the city. The City Council have referred the matter back to the Finance Committee for further consideration. Prolonged Gestatzon. Dr. Armstrong read a paper at the Medical Institution on the case of a lady in whom he induced premature labour under circumstances different from those which generally indicate the necessity for this operation. This lady had four children, and in two the period of i previously borne gestation was stated to have been protracted considerably beyond the usual term. Thus, in the second confinement, the period from the appearance of the last menstruation to the birth of the child was 303 days. The patient’s husband was absent for three months after conception had taken place, and delivery occurred nine calendar months and three weeks from the time of his leaving home. It was remarkable that the child was very sparely developed, in consequence of which the labour was easy and rapid. The fourth confinement was calculated to take place about Dec. 10th, 1887, dating from March 6th, whereas it did not occur until January 15th, 1888, or 319 days. The labour, a most difficult one, was completed with instruments ; the child was stillborn, and the convalescence very protracted. When the patient was pregnant for the fifth time she consulted Dr. Armstrong, having a great dread of it in consequence of what she had previously suffered. He recommended the induction of premature labour within a fortnight of the normal term, his reason being that gestation having been prolonged on two occasions another difficult labour might have to be undergone, which would be intensified should the child be a male. She accordingly came to Liverpool three weeks before the expected time, and after a week’s rest premature labour was induced on Nov. 6th, 1889, probably the 267th day of gestation. The shoulder presented, requiring version, which was easily done, no difficulty being experienced with the after-coming head ; the child, a female, was living and healthy, and the mother made an excellent recovery, returning to her distant homeby the end of the month.
,
%/’ Any meeting as suggested must be an informal one, as a special meeting of Convocation can only be convened by the Senate, or at the request in writing of twenty or more members of Convocation. The provisional scheme recently put forward by the Senate is now being discussed by the Senate and the representatives of University and King’s Colleges in conference (vide p. 314), and until some final scheme is agreed on by these bodies, or their conferences have led to no result, nothing can be put forward by the Senate or the sanction of Convocation.-ED. L. MIDLAND COUNTIES VETERINARY MEDICAL ASSOCIATION AND ITS REPORT ON ROARING IN HORSES.
SIRS,—I accept the explanation offered in your issue of 18th, that your criticisms did not apply to the actual report of this Association, but to a letter which appears to have been forwarded with a copy of the report by some
Jan
Your memory is with the signature of the letter. I have no cognisance of it whatever, and, so far from being able to furnish you with a copy, I should be extremely pleased if you could favour me with one. I am, Sirs, yours faithfully,
irresponsible individual unknown to me.
at fault when you credit
me
-
JOHN MALCOLM,
-
-
--
-
F.R.C.V.S.,
Hon. Sec. Midland Veterinary Association.
Birmingham, Jan. 18th, 1890. ** This letter was unfortunately crowded out of our last issue. We regret that we are still unable to place our hands upon the letter that accompanied the report, which, as we have already intimated, we at the time regarded as having been sent to us by the secretary of the Association.-ED. L.
LIVERPOOL. (FROM OUR OWN CORRESPONDENT.) The Royal Infirmary. THE annual meeting of the Royal Infirmary was held on the 31st ult. The chairman announced that the new buildings were rapidly approaching completion, and that, though no money had been spent in outward adornment, internally nothing would be wanting. He lamented that out of the large sum raised by the public, upwards of 9100,000, there would be no balance left to fund for the benefit of the infirBut he conmary and to increase the annual income. fidently trusted that the citizens of Liverpool would show their appreciation of their new infirmary by supporting it heartily. It will be opened, it is believed, free of debt, but the permanent annual incomeis only f2000 a year ; a sum
the
Death under Chloroform. An inquest was held by the city coroner on the 30th ult. on the body of a dock labourer aged thirty-eight, who died at the Northern Hospital during the administration of chloroform for the purpose of reducing a dislocated shoulder.
felt
’
ready.
Conclusion IX. states : "The administrator should be
guided as to the effect entirely by the respiration. His only object, while producing anaesthesia, is to see that the respiration is not interfered with." From the large experience I have had of administering anaesthetics in England during the last thirty years, I feel absolutely certain that if
this deduction is acted upon, the number of fatal cases, even now too numerous, will rapidly increase. I maintain that the administrator should watch equally the face, the pulse, and the respiration, sudden pallor of the face being of far more importance than partial interference with the breathing. The precautions mentioned in the remaining paragraphs are usually carried out in the London hospitals. Time alone will show whether the sanguine future the Commission believe to be in store for chloroform will come to pass if their rules for its administration are carried out. I remain, Sirs, yours faithfully, Feb
3rd,
1890.
WOODHOUSE BEAINE.
To the Editors of THE LANCET. SIRS,-Just as modern industrial life is the outcome of the introduction of steam, so modern surgery is based upon the use of anesthetics. Whatever relates to fatalitiesduring anaesthesia is therefore of the greatest importance to every practical surgeon. With nearly half a century’s experience at our back, it is surprising-in these days of advancing science and greater accuracy in many respectsto find that even now we have no really reliable information as to the relative frequency of such occurrences. Rough estimates there are in abundance, the value of which may bejudged from the fact that they vary, for chloroform, from, 1 in 36,500 to 1 in 2666 administrations. My object in writing this letter is to point out that a perfectly reliable source of information is now available, so. that in future there can be no excuse for ambiguity. Fo? many years past there has been kept at St. Bartholomew’s Hospital a most admirable record of the administration of anæesthetics and of the fatalities which have occurred. These have been published from year to year with the annual statistical reports of the hospital. Believing thesubject well worth a little trouble, I have tabulated these records for the ten years 1878-1887. During this time chloroform was administered 12,368 times, with 10 deaths (1 in 1236). During the same period ether was administered 14,581 times, with 3 deaths (1 in 4560. In 9072 of these cases ether was preceded by gas ; 1 fatal case belongs to this category. In the other 5509 cases ether alone wasgiven, and 2 deaths occurred.1 These facts are very eloquent ; they require no lengthy comment. I havelong been aware of the safety of ether, and have therefore preferred it to chloroform in most cases, notwithstanding its disadvantages in some other respects. I believe this is the goal towards which professional opinion is steadily moving; and I think this movement likely to be most beneficial. Experience at other hospitals leads me to, believe that the results obtained at St. Bartholomew’s may be accepted as reliable averages. There can be no doubt, in these cases at least, that most of the fatalities occurred in spite of the greatest skill and care being used in the administration of the anaesthetic agents. Such being the case, it is impossible to arrive at any other conclusion than that such occurrences are unavoidable in a certain proportion of
greater
cases.
I cannot conclude this letter without emphatic protest against the dictum of the Hyderabad Commission, that such deaths must be ascribed entirely to carelessness on the part of the administrators. Such a statement is opposed to allclinical experience, and it is simply preposterous. I am, Sirs, yours truly, W. ROGER WILLIAMS. Welbeck-street, W., Jan. 30th, 1890.
THE PROPOSED RECONSTITUTION OF THE LONDON UNIVERSITY. To the Editors of THE LANCET. SIRS,—AT the last meeting of Convocation of the London University there seemed to be a practically unanimous feeling against the proposals of the Senate, as far as they had leaked out or could be guessed at, and a resolution was passed to the effect that the proposals of the Senate should, be forwarded to members of Convocation at an early date. This is a step in the right direction, though a very short and tardy one. As one of those who believe that the graduates have a right to be treated with the fullest confidence in matters so vitally affecting their well-being, I amof opinion that at the very first a draft of the scheme should have been circulated amongst all graduatesof the University,, whether members of Convocation or not. The reorganisation or disorganisation of the University, whichever it be,, is a matter calling for the most serious consideration of all who hold, or hope to hold, a degree from the University. And looked on in that light, it seems insufficient that, when. the scheme is officially before us, its rejection, adoption, or amendment should rest with a meeting of Convocation numbering, perhaps, 150 members at most. Of the graduates who are members of Convocation, the great majority, scattered as they are through the country, would naturally be debarred by professional pursuits from attending its meetings, and it is most important that their opinion, as well as.
right to state that in each of these cases the patient was in exceedingly feeble and collapsed state before exhibition of the anæsthetic owing to prolonged intestinal obstruction. 1
an
It is
318 that of younger graduates, should be obtained on questions of such moment to all. A meeting of all interested might be convened specially to discuss the whole question as soon as we are kindly permitted to know the proposals ; or, if necessary, graduates might be canvassed by a series of printed questions, so that they may not plead ignorance as an excuse for the disastrous reformation to which they will have tacitly assented. Rumours of wholesale creation of Doctors, converting Bachelors into Masters, of the lowering of examination standards, and of the general cheapening of degrees, are in the air, and although we have no right to meet trouble half way we have a right and a duty to be on the alert to guard our privileges, and to protest against the undignified competition with the Royal Colleges of a University we once respected. It is generally admitted that the London University has up to the present filled its unique position satisfactorily, and that its prosperity is undiminisbed-nay, increasing yearly. On the other hand, it is freely acknowledged that a new institution could be more easily formed than the old one remodelled ; therefore, by ill-timed silence or inaction in the immediate future London graduates will inflict a deadly blow on themselves, and be denied the consolation of having conferred any sortof benefit on others by their self-betrayal. I am, Sirs, yours faithfully, Feb. 3rd, 1890. M.D., B.S. LOND.
of between 2000 and £3000 is raised
annually by the Hospital Sunday and Saturday Funds ; the subscription list is but little over £2000 yearly ; while the expenditure has long exceeded 12,000, and in the new buildings will probably be much more. The new infirmary will be opened perhaps in the summer ; it will contain all the most recent improvements, and will be well worthy of a visit by all members of the profession visiting Liverpool. The Abattoirs.
Nearly fifty years ago the City Council granted the lease of a piece of ground in what was then the east end of Liverpool, but has now become centralised and surrounded with buildings. These leases are for seventy-five years, and some years ago the Abattoir Company asked for a renewal of the lease, which was opposed by the medical profession on sanitary grounds and refused. More recently this same company has asked not only for a renewal of the lease, but for additional land to erect more buildings. The members of the medical profession have strongly opposed this. A meeting was held at the Medical Institution, and a resolution unanimously adopted condemning strongly any further retention of the abattoirs within the centre of the city, and a deputation, comprising the leading physicians and
The surgeons, waited upon the Finance Committee. Abattoir Company have not been idle, and have also presented reports giving their grounds for wishing to retain the site. They have urged that slaughterhouses are not prejudicial to health, but the fact remains that wherever there are slaughterhouses there must also be places for gut cleansing, hides, and other accessories. A special report has been made by the medical officer of health, in consequence of which, combined with the general protest of the medical profession and the common sense of its members, the Finance Committee, by a majority of twelve to three, resolved to recommend the Council not to grant renewal of the lease. As the latter has still twenty years to run, no hardship could accrue to the leaseholders, who would have plenty of time to look out for and find more suitable quarters outside the city. The City Council have referred the matter back to the Finance Committee for further consideration. Prolonged Gestatzon. Dr. Armstrong read a paper at the Medical Institution on the case of a lady in whom he induced premature labour under circumstances different from those which generally indicate the necessity for this operation. This lady had four children, and in two the period of i previously borne gestation was stated to have been protracted considerably beyond the usual term. Thus, in the second confinement, the period from the appearance of the last menstruation to the birth of the child was 303 days. The patient’s husband was absent for three months after conception had taken place, and delivery occurred nine calendar months and three weeks from the time of his leaving home. It was remarkable that the child was very sparely developed, in consequence of which the labour was easy and rapid. The fourth confinement was calculated to take place about Dec. 10th, 1887, dating from March 6th, whereas it did not occur until January 15th, 1888, or 319 days. The labour, a most difficult one, was completed with instruments ; the child was stillborn, and the convalescence very protracted. When the patient was pregnant for the fifth time she consulted Dr. Armstrong, having a great dread of it in consequence of what she had previously suffered. He recommended the induction of premature labour within a fortnight of the normal term, his reason being that gestation having been prolonged on two occasions another difficult labour might have to be undergone, which would be intensified should the child be a male. She accordingly came to Liverpool three weeks before the expected time, and after a week’s rest premature labour was induced on Nov. 6th, 1889, probably the 267th day of gestation. The shoulder presented, requiring version, which was easily done, no difficulty being experienced with the after-coming head ; the child, a female, was living and healthy, and the mother made an excellent recovery, returning to her distant homeby the end of the month.
,
%/’ Any meeting as suggested must be an informal one, as a special meeting of Convocation can only be convened by the Senate, or at the request in writing of twenty or more members of Convocation. The provisional scheme recently put forward by the Senate is now being discussed by the Senate and the representatives of University and King’s Colleges in conference (vide p. 314), and until some final scheme is agreed on by these bodies, or their conferences have led to no result, nothing can be put forward by the Senate or the sanction of Convocation.-ED. L. MIDLAND COUNTIES VETERINARY MEDICAL ASSOCIATION AND ITS REPORT ON ROARING IN HORSES.
SIRS,—I accept the explanation offered in your issue of 18th, that your criticisms did not apply to the actual report of this Association, but to a letter which appears to have been forwarded with a copy of the report by some
Jan
Your memory is with the signature of the letter. I have no cognisance of it whatever, and, so far from being able to furnish you with a copy, I should be extremely pleased if you could favour me with one. I am, Sirs, yours faithfully,
irresponsible individual unknown to me.
at fault when you credit
me
-
JOHN MALCOLM,
-
-
--
-
F.R.C.V.S.,
Hon. Sec. Midland Veterinary Association.
Birmingham, Jan. 18th, 1890. ** This letter was unfortunately crowded out of our last issue. We regret that we are still unable to place our hands upon the letter that accompanied the report, which, as we have already intimated, we at the time regarded as having been sent to us by the secretary of the Association.-ED. L.
LIVERPOOL. (FROM OUR OWN CORRESPONDENT.) The Royal Infirmary. THE annual meeting of the Royal Infirmary was held on the 31st ult. The chairman announced that the new buildings were rapidly approaching completion, and that, though no money had been spent in outward adornment, internally nothing would be wanting. He lamented that out of the large sum raised by the public, upwards of 9100,000, there would be no balance left to fund for the benefit of the infirBut he conmary and to increase the annual income. fidently trusted that the citizens of Liverpool would show their appreciation of their new infirmary by supporting it heartily. It will be opened, it is believed, free of debt, but the permanent annual incomeis only f2000 a year ; a sum
the
Death under Chloroform. An inquest was held by the city coroner on the 30th ult. on the body of a dock labourer aged thirty-eight, who died at the Northern Hospital during the administration of chloroform for the purpose of reducing a dislocated shoulder.