Arthur Jefferson
1884 The Lancet  
HOUSE-SURGEON, YORK COUNTY HOSPITAL. UNTIL the following case came under my observation I never thought it necessary to examine the heart before administering ether. In all cases, provided the patient was neither a young child nor an old person, I was in the habit of giving ether without making any further examination than glancing at the chest walls, to see that they were not too rigid, and asking the question, " Have you a cough ?" Both these points being settled in the negative, the
more » ... ative, the anaesthetic was given without further delay. Having given the anæsthetic in several cases of regurgitant valvular affection, and having noticed its great stimulating effect in this form of cardiac derangement-so great that in three cases the murmur has been found to disappear under the ether, reappearing gradually as the effects of the drug wore off,-and also in the almost pulseless heart of collapse; the conclusion was somewhat hastily arrived at that the state of the heart did not matter in ether giving. However, last year a male patient, aged fifty-two, was admitted to the hospital under the care of Mr. Jalland, who decided to perform an operation upon him. Accordingly, the man not being emphysematous and not having a cough, the administration of ether was commenced. The patient took the anaesthetic badly, and there was a good deal of struggling, some minutes elapsing before conjunctival insensibility was arrived at. Just at this stage the patient's breathing began to excite attention; it became somewhat hurried and very shallow. The pulse, however, continued regular and strong; in a very few seconds the face commenced to turn blue, and the respiration became so shallow as to be purely laryngeal, no movement of the abdomen nr chest-wall!1 percentible. The fthfr was a,t rmcf discontinued, and artificial respiration commenced. After t a few minutes the blueness of the face had disappeared, r and the respiration had become fairly normal. As r it was important that the operation should be at r once performed, the patient was allowed to partially come t round, and then, his heart having been stethoscoped and found to be apparently healthy, chloroform was administered. 1 Up to this time, even when he appeared to be on the verge of death from the first anaesthetic, his pulse had remained good, but now, after a couple of minutes of chloroform mhalation, it rapidly failed, becoming irregular. By means of the cold water towel and brandy the patient was brought round and the operation postponed. In the evening of the same day the man's heart was again examined, this time more carefully; there was now found a slight thrill at the apex and a somewhat presystolic murmur in the same situation, which murmur could only be heard over about half a square inch of chest surface. These symptoms evidently indicated mitral stenosis. A week after the patient was again brought into the operating room and kept under the influence of unmixed chloroform for about fortyfive minutes, without at any time showing any alarming symptom. Remarks.-In this case what would appear to have happened is somewhat as follows. The heart, under the influence of the ether, commenced as usual to contract more vigorously, the consequence of this being that while its right side was urging on an increased quantity of blood into the lungs, this same surplus was prevented from escaping thence by reason of the contracted mitral orifice. Hence the lungs became more and more congested ; this congestion, added to the pAculiar respiratory effects of the ether itself, caused the patient to assume, little by little, the appearance of one about to die of asphyxia. No lung complication being suspected at that time, it was inferred that the patient'!' condition was caused by some susceptibility of his respiratory centre ; it was not thought that chloroform could have any direct influence on this, and therefore the heart being seemingly healthy, this anesthetic was given. It can easily be imagined that this drug, acting on a diseased heart struggling with still congested lungs, would cause the irregularity of the pulse which ensued. Finally, it was de. monstrated in the following week that chloroform could be given, in the absence of the congestion of the lungs, with perfect safety. This case would seem to show that the heart should always be examined before ether is given; &nd that the giving of this anaesthetic is, at any rate, a very questionable practice in cases where there is ob. structive valvular disease on the left side. Nnlla antem estalia pro certo noscendi via, nisiquamplurimas et morboram at dissectionum hiBtoriaB, tum aliorum tum proprias collectas habere, et Inter se comparare.-MORGAGNI Do Sed. et Caue. Morb., lib. iv. Prowmium, WEST LONDON HOSPITAL. ACUTE TRAUMATIC (?) TETANUS ; DEATH ON SEVENTH DAY OF ILLNESS ; AUTOPSY ; REMARKS. speech, except m cYa yvu affected, and uuauo were taken and swallowed without difficulty or resulting spasm, The chest muscles were not much affected, and the diaphragm moved freely. The arms were unaffected, both as regards motion and sensation. The extensor muscles of the thigh, the muscles of the back, and, to a less extent, those of the abdomen, were affected with tonic spasms of momentary duration, and but slight severity, occurring once or twice in a minute. Risus sardonicus was observable during each spasm, but the spine was not notice. ably arched. The patient complained of pain in the back and in the affected muscles, especially the thighs, which was worse during the spasms. Turning in bed or movement of the legs was painful, and produced the painful contractions mentioned above. The back was reddened and slightly blistered by the fomentations and turpentine stupes which had been applied before his admission, but there did not appear to be any especially tender spot elicited either by pressure or the hot sponge. There was no priapism, nor loss of sensation or motor power. Urination was normal; bowels confined. The patient was quite sensible, and remained so to the moment of death. The temperature was 1010; pulse 90, quickened with each spasm; heart sounds normal. No history of wound or injury was given on admission, but he had a small healed-up scratch on the hypothenar eminence of one hand, which was said to have been done by a rusty nail about a fortnight previously. He said he had got wet through a week or so before admission, and thought he might have taken cold. Aug. 5th.-The patient's condition was substantially unchanged ; the spasms, if anything, were less severe. At no time was there any noticeable retraction of the head or approach to opisthotonos. The breathing was more shallow and chiefly diaphragmatic, the chest walls moving but slightly. There was little pain, except during the spasms, which continued to be several to the minute and lasting two or three seconds. At 7 P.M. he was suddenly attacked with a very severe convulsive spasm, engaging all the muscles of the body and arching the body to one side, stopping respiration and apparently the heart's action. For a minute or so he lay motionless and apparently moribund. Breathing, however, returned in short gasps, drawn through the clenched
doi:10.1016/s0140-6736(02)13777-9 fatcat:evvyqlddynfjxa24kn2e4i5oqq