Chapter 9

On December 17, 1897, a fatality occurred during the administration of ether. The patient, a woman aged forty-four years, who suffered from "internal cancer," was admitted for operation into the new hospital for women, Euston Road. It was considered that an operation would afford a chance of the prolongation of her life. At the time of admission the patient was in a very exhausted condition. Mrs. Keith, the anæsthetist to the hospital, administered nitrous oxide gas, followed by ether, which combination of anæsthetics the patient took well. After the expiration of thirty minutes and while the operation was in progress the patient became so collapsed that the surgeon was requested by the anæsthetist to desist from further surgical procedure and she at once complied. Resuscitative measures were at once applied, but the patient died after about ten minutes from circulatory failure arising from surgical shock and collapse. We have not received any particulars as to the means adopted to restore the woman or whether hemorrhage was severe. In all such cases posture, warmth and guarding the patient from the effects of hemorrhage are undoubtedly the most important points for attention both before and during the operation. The fact is established that both chloroform and ether cause a fall of body temperature, and so increase shock unless the trunk and limbs are kept wrapped in flannel or cotton-wool. The fall of temperature under severe abdominal and vaginal operations again is considerable. A profound anæsthesia allows of a considerable drop in arterial tension, which has been shown to be least when the limbs and pelvis are placed at a higher level than the head. Again, saline transfusion of Ringer's fluid certainly lessens the collapse in such cases when the bleeding, always severe, has been excessive. We do not doubt that such a severe operation undertaken when the patient was in a dangerous state of exhaustion was as far as possible safeguarded by every precaution, and we regret we have not been favored with the particulars of the methods employed. A death following the administration of ether is reported from the Corbett Hospital, Stourbridge.[1] The patient, aged thirty-nine years, was admitted on September 21, 1897, suffering from fracture of the right femur. A prolonged application of splints led to a stiffness with adhesions about the knee joint which were to be dealt with under an anæsthetic on December 8. Ether was given from a Clover's inhaler; one ounce was used. The induction was slightly longer than usual but was marked by no unusual phenomena. No sickness occurred during or after anæsthesia and no respiratory spasm was seen. There was a short struggling stage followed by true anæsthesia when the operation, a very brief one, was rapidly performed. The patient was then taken back to the ward and the corneal reflex was noticed as being present. Voluntary movements were also said to have been seen. Later he opened his eyes "and seemed to recognize an onlooker." After this no special supervision was exercised. A hospital porter engaged in the ward noticed the man was breathing in gasps; this was twenty minutes after the patient had been taken from the operating theater and half an hour subsequent to the first administration of the ether. The surgeons were fetched from the operating theater and found by that time that the man was dead. "He was lying with his head thrown back, so that no possible difficulty of breathing could have arisen due to his position. The eyes were open and the lips slightly parted; nor was there any sign of any struggle for breath having taken place." The ether was analyzed and found to fulfill the British Pharmacopoeia tests for purity. The necropsy revealed that the right heart was distended with venous fluid blood. The lungs also were loaded with blood, as were all the viscera. We cannot but feel that the fact shown at the post mortem examination seemed to indicate that the man died from asphyxia and not from heart failure. No doubt patients appear to resume consciousness after an anæsthetic and even mutter semi-intelligible words and recognize familiar faces. They then sink into deep sleep just like the stupefaction of the drunken, and in this condition the tongue falls back and the slightest cause--a little thick mucus or the dropping of the jaw--will completely prevent ventilation of the lungs taking place. Two very similar cases occurred in the practice of a French surgeon, who promptly opened the trachea and forced air into the lungs, with the result that both patients survived. In his cases chloroform had been given. A death under chloroform occurred at the infirmary, Kidderminster. The patient, a boy, aged eight years and nine months, suffered from a congenital hernia upon which it became necessary to operate for its radical cure. The house surgeon, Mr. Oliphant, M.B., C.M. Edin., administered chloroform from lint. In about eight minutes the breathing ceased, the operation not having then been commenced. Upon artificial respiration being adopted the child appeared to rally, but sank almost immediately and died within two minutes. The necropsy showed no organic disease. At the inquest the coroner asked Dr. Oliphant whether an inhaler was not a better means of giving chloroform, and whether that substance was not the most dangerous of the anæsthetics in common use, and received the answer that inhalers were not satisfactory for giving chloroform and that it was a matter of opinion as to which was the most dangerous anæsthetic. We so often hear that the Scotch schools never meet with casualties under anæsthetics because they always use chloroform, and prefer to dispense with any apparatus, that we can readily accept the replies given to the coroner as representing the views current among the majority of even the thoughtful alumni of those great centers of medical training. A glance over the long list of casualties under chloroform will unfortunately show that whatever charm Syme exercised during his life has not survived to his followers, and overdosage with chloroform proves as fatal in the hands of those who hail from beyond the Tweed as well as "down south." A death from chloroform contained in the A.C.E. mixture occurred at the General Hospital, Birmingham, on December 15. The patient, a girl, aged five years and ten months, suffered from hypertrophied tonsils and post-nasal adenoid growths. She was given the A.C.E. mixture by Mr. McCardie, one of the anæsthetists to the institution, and tonsillotomy was performed. As consciousness was returning some chloroform was given to enable Mr. Haslam, the operator, to remove the growths. She died at once from respiratory failure, in spite of restorative measures. A necropsy showed absence of organic disease. The anæsthetist regarded the death as one from cardiac failure due to reflex inhibition by irritation of the vagus. We are not told the posture of the child or the method employed.--The Lancet.

[Footnote 1: We are indebted to Mr. Hammond Smith, honorary surgeon to the hospital, and Mr. Edgar Collis for the notes of the case.--Ed. Lancet]

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The resistance of nickel steel to the attack of water increases with the nickel contents. The least expanding alloys, containing about 36 per cent. of nickel, are sufficiently unassailable, and can be exposed for months to air saturated with moisture without being tainted by rust. With a view of testing the expansion of nickel steel, experiments have been carried out by allowing measuring rods to remain in warm water for some hours, according to The Iron and Coal Trades Review. They were not wiped off when taken out, but were exposed for a longer period to hot steam, but the lines traced on the polished surfaces were not altered. The rough surfaces, when exposed to steam, were covered after several days with a continuous, but little adhesive, coat of rust.

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