Read at the Annual Meeting of the British Medical Association at Christchurch, 1923, by D. S. Wylie, C.M.G., C.B.E., F.R.C.S., (Eng.).

My reasons for bringing to your notice a subject which possibly some of us might consider somewhat stereotyped are the consclusions which have been forced upon one during the last two and a-half years as the outcome of having considered the details of each anaesthetic death during that period which ahs been the subject of a coroner’s enquiry.

In April, 1920, shortly after I undertook the duties of Inspect of Hospitals under the Health Department, I investigated the question of deaths under anaesthetics in New Zealand. On scrutinising, however, the figures supplied by the Registrar-General for the years 1913 to 1919, I found that in practically no case was the nature of the anaesthetic administered recorded, and, consequently, the figures for the period in question were of little or no practical value.

The matter was taken up with the various authorities concerned, and from June, 1920, until the present time, fairly full information has been obtained concerning each death under anaesthesia which has been the subject of a coroner’s enquiry. The figures are interesting. From 1913 to 1919 the number of anaesthetic deaths reported in New Zealand each year varied from 5 (the number recorded in the years 1914 and 1918) to 11 (the number recorded in 1919). In 1920 there were 11 deaths; in 1921,21; in 1922, 22. That is, we have a total of 54 deaths in three years, compared with 57 deaths in the preceding seven years.

The sudden increase in 1921 was striking, but in considering the matter it had to be remembered that greater attention was being paid to the matter of securing accurate returns, and that for the years 1915 to 1919 the influence of the war upon the population of New Zealand, and possibly upon the amount of surgical work which was done in the country at that time, had both to be taken into account.

It was considered that no definite good would have resulted from taking action at the end of 1921, having regard to the harmful effects resulting from the publicity which was given to the question of maternal mortality before proper enquiries had been made into that matter. It was resolved that, so far as the question of deaths from anaesthetics was concerned, proper enquiry should precede publicity. That this intention partly failed was not due to any action of the Health Department, but arose as the consequence of the use made of certain facts and figures, which were supplied by the Health Department to a medical practitioner for use in connection with a paper which he was reading, and details of which, I am informed, leaked out in an unfortunate way to the Press.

On considering in further detail the anaesthetic deaths for 1920,1921 and 1922, certain facts of interest and importance manifest themselves. In putting these before you I am fully aware of the danger of drawing conclusions from insufficient data, and especially so when dealing with small numbers. So far as statistics are concerned, we must all bear in mind the epigram of Sir Berkeley Moynihan, when he said: “Statistics may be made to prove anything—even the truth”.

I will now deal briefly with the various aspects of the case which scrutiny of the 54 deaths, which occurred in 1920, 1921 and 1922, compels one to consider.

GEOGRAPHICAL DISTRIBUTION

1. The deaths, as the attached table shows, have occurred pretty evenly in the North and in the South Islands, there being for the period we are considering 28 deaths in the North Island and 26 deaths in the South Island.

View Tables 1–6.

Included in the number of deaths occurring in private are four fatalities, which took place in dental surgeries.

Of the deaths in the North Island three occurred in the Public Hospital, Auckland, three occurred in private hospitals and one in private. The Wellington figures show one death in the Public Hospital and one death in a private hospital, making a total of 2. Three deaths occurred in the Public Hospital at Napier. 10 deaths occurred in public hospitals elsewhere in North Island and five occurred in private, including dental surgeries, making a total of sixteen anaesthetic deaths in the North Island outside Wellington, Auckland and Napier.

In taking the 26 deaths, which occurred in the South Island, it is found that their incidence is as follows:—5 deaths in the Public Hospital at Christchurch, one in a private hospital in Christchurch and one in private, making a total of 7. Seven deaths occurred in the Public Hospital at Dunedin, including in which figure is one death which took place at the Dental School. Two deaths took place in private hospitals in Dunedin and none in private, making a total of 9. Two deaths took place in the Public Hospital in Timaru, two in the various private South Island hospitals other than Christchurch and Dunedin.

2. The next question to consider is the number of fatalities induced by chloroform, by chloroform and ether mixtures, and by ether respectively—no deaths having been recorded from the use of nitrous oxide, ethyl chloride, the use of spinal anaesthetics or of local anaesthesia. The figures are as follows:— (view table 3)

Chloroform was responsible for 8 deaths in 1920-21 and for 10 deaths in 1922. Chloroform and ether mixtures were responsible for 16 deaths in 1920-21 and for 10 deaths in 1922. Ether was responsible for 33 1-3 per cent. of the mortality, chloroform and ether mixtures for slightly over 48 per cent., and ether for 18 ½ per cent.

Incidentally it is interesting to note that of the 22 fatalities in 1922 no fewer than 12 occurred either during the induction of the anaesthetic or just at the commencement of the operation. For the sake of comparison it is of interest to consider for a moment the figures supplied concerning 700 deaths occurring during anaesthesia in England, and which are quoted in the Oxford Loose-Leaf surgery. These are as follows:—Chloroform, 378; chloroform and ether, 100; ether, 28; nitrous oxide, 12; ethyl chloride, 6; spinal, 8; scopolamine, 2; local,6; not specified,160. Of these 233 died before the operation commenced. The comments made upon these figures are as follows:—“In analysing these figures one is at once impressed with the dominance of fatalities under chloroform, and it is difficult not to attribute them to the improper selection of the anaesthetic agent, although the inexperience of the administrators may have been a contributing factor. Fleming (who is responsible for the figures) is undoubtedly correct in his belief that the appalling death-rate would not have occurred if ether had been administered instead of chloroform. From a purely scientific point of view these statistics serve to show the great need of reform in the selection and administration of anaesthetics.”

I wish, however, to return to a consideration of our own figures, and desire now to direct your attention to the following 15 cases which occurred amongst the 18 deaths due to chloroform:— (view table 4)

Here are a series of 15 cases, the vast majority of which are of a comparatively minor character, in which I am of opinion, after reading the evidence given at the various coroners’ enquiries, that an appropriate, or wrongly-chosen, anaesthetic was administered. Who can defend the administration of chloroform for teeth extraction, or for the removal of tonsils and adenoids? Professor A.R. Cushny of the University of Edinburgh, in the latest edition of his well-known book on Pharmacology and Therapeutics, gives as a fair average the occurrence of one death in each three thousand cases where chloroform is administered, and one in ten to twelve thousand cases where ether is give. The Extra Pharmacopoeia gives the death-rate of chloroform as about seven times that of ether, which is said to have a death-rate of one in thirteen thousand.

Given two anaesthetics, one of which has a mortality at least three times as great as the other, some very specific justification for the use of the more dangerous must surely be brough forward and sustained before its use can be sanctioned. Here in a small group of eighteen fatalities we have chloroform given in no fewer than fifteen instances where the employment of other anaesthetics such as nitrous oxide, nitrous oxide and oxygen, ether, or local anaesthetics, would have been, to say the least of it, far safer, more in keeping with the deliberate opinion of recognised authorities, and more in consonance with the welfare of the patients to whom the anaesthetics were administered.

The group of fatalities occurring with the administration of chloroform and other mixtures can now be considered. These anaesthetic mixtures have been responsible for nearly fifty per cent. of the 54 fatalities we are now considering. I am sorry I cannot say how many cases are due to C(1) E(1), C(1)E(2), C(2)E(3), etc., as in many instances the exact proportions of the two drugs employed were not given in the evidence of the various medical men concerned. Among the 36 deaths occurring with the use of chloroform-ether mixtures are the following:— (view table 5)

Here again, is a group of ten cases, in which the use of an anaesthetic with admittedly a higher death-rate than ether was employed, where the use of another anaesthetic agency would have been infinitely safer. I feel sure again that in this group of cases insufficient care was given to the selection of the anaesthetic having due regard to the welfare and safety of the anaesthetist, or under his supervision. It is often used for induction purposes (admittedly the most dangerous stage of general anaesthesia), and its ease of administration in comparison with he additional trouble of giving ether, together with an exaggerated idea of its safety, makes its use, I feel certain, more frequent than should be the case.

We come now to the group of fatalities where ether alone was employed. They total 10 and I propose to give you particulars of each one. (view table 6)

Case No, 9 occurred in the induction stage, and Case No. 8 occurred just after the operation commenced. It is to be remarked, also, that four of the ten fatalities took place in Dunedin. It will be noted that seven out of the ten deaths occurred in association with the performance of operative procedure of a very definitely serious character in contradistinction to many of the fatalities which took place with the use of chloroform and of chloroform-ether mixtures in comparatively minor cases. In neither of the goitre fatalities was the use of local anaesthesia in combination with the ether mentioned.

I now come to the question of the purity or otherwise of the various brands of anaesthetics now in use in New Zealand. With reference to this the Dominion Analyst is engaged in the work of their analysis at the present time, but the results are not yet available for use. It has been stated in certain quarters, somewhat loosely, that the number of anaesthetic deaths in the years 1920,1921 and 1922, has some connection with an inferior quality of chloroform which was supplied by the Defence Medical Stores to various hospitals and medical men in this country. I have seen a return prepared by the Defence Medical Stores showing the quantities and the brands of chloroform and ether supplied to its various customers April, 1921, to September, 1922, and from the returns it appeared that the Wellington Hospital, which, of all the large hospitals in New Zealand, has the lowest number of deaths, has been supplied with the largest quantity of the chloroform in question, namely 84lbx., and that the other large hospitals, where the bulk of the deaths have taken place, have not been supplied at all by the Defence Department. This information should, I think, dispose of any misapprehension likely to arise on this point.

Deliberate consideration of the figures which I have adduced will show, I think, that (1) insufficient care has been taken of late years in the choice of an anaesthetic for operative purposes, (2) inadvertently, no doubt, the interests of the patient are not being considered enough, (3) in many instances very faulty judgment is being exercised regarding the choice and administration of anaesthetics. Of the 54 deaths which have occurred during the period we have under review I consider that between 40 and 50 per cent. might, and should, have been presented by a better choice of anaesthetic, and I am of opinion that this matter requires the very fullest consideration which this meeting can give to it, and not merely that alone, but the taking of definite action by the meeting to produce a happier state of affairs and one redounding more to our credit as a profession.

I have recently returned from a visit to America and Canada, where I visited many of the chief clinics and hospitals, notably those of the Mayo’s at Rochester, Minnesota, of Dr. Crile, at Cleveland, Ohio, the Peter Bent Brigham Hospital, Boston, which is the hospital of the Harvard Medical School,  the General Hospital, Toronto, the General Hospitals at Winnipeg, Vancouver, and many hospitals in New York. Among the many admirable things one saw I was much impressed with the general high level of anaesthesia used in the various hospitals I visited, with the care taken in the choice of anaesthetic—especially in the class of case known as “the bad risk”—with the use made of spinal anaesthesia, especially in bladder and pelvic cases, with the use of paravertebral anaesthesia, sacral anaesthesia and the increasing use of local anaesthesia. Local anaesthesia is very largely used in combination with nitrous oxide and oxygen analgesia, and very excellent results are being obtained with it. I was especially impressed with the very high standard of anaesthetic work at the Lakeside Hospital, Cleveland, where Dr. Crile does the majority of his operative work. At this hospital they have a record of 51,000 cases of nitrous oxide and oxygen analgesial anaesthesia, or nitrous oxide, oxygen and ether, in combination with local anaesthetics in practically all cases, with only a single death. At this hospital I saw many operations for the following conditions: Goitre, gastric ulcers, duodenal ulcers, infection of biliary tract, appendicitis, pelvic gynaecological cases, etc., done with nitrous oxide and oxygen analgesia and the use of a local anaesthetic. In some of the cases, especially in the upper abdomen, the use of ten to fifteen per cent. ether for perhaps 15 to 20 minutes was necessary to secur adequate relaxation. I saw the patients afterwards, not only on the day of operation, but on each subsequent day during my stay in Cleveland, and was impressed not only with their general comfort but with the comparative absence of the various so-called minor unpleasantnesses which occur when ordinary inhalation anaesthesia is alone employed. The use of nitrous oxide and oxygen as a routine general anaesthetic necessitates the employment of specially trained people for the work. At Cleveland there are trained nurse anaesthetists, and very competent they are at their work. At certain hospitals open ether or the nitrous oxide ether sequence is employed routinely but even in these hospitals, local, sacral, and paravertebral anaesthesia is being increasingly employed. This is especially noticeable at Rochester, where they have now a specially trained medical man who does all the sacral, spinal, and paravertebral anaesthetic work for the various hospitals in this town. Increasing attention is being given the question of ensuring not only the maximum safety for the patient, but of administering an anaesthetic with the minimum discomfort to be endured afterwards. I was tremendously impressed with this point and am sure that we can in New Zealand emulate to advantage in this respect our American colleagues. Nowhere in the States did I see chloroform used either alone or as a mixture.

The question arises now as to the nature of the steps which can be taken to improve matters. Personally I think that the following methods should be adopted:

1. KEEPING OF BETTER ANAESTHETIC RECORDS BY HOSPITALS.—Each hospital should, I consider, keep special records of the administration of anaesthetics, and should publish a summary annually of the administration of anaesthetics in their annual medical report, together with full details of any fatalities which occur. Only in this way will statistics worth having be produced and progress made possible.

2. THE APPOINTMENT BY EACH LARGE HOSPITAL IN NEW ZEALAND OF EITHER HONORARY ANAESTHETISTS, OR QF WHOLE-TIME PAID ANAESTHETISTIS.—During the last two or three years a special lecturer and instructor in anaesthetics has been appointed at the Dunedin Medical School. This was a most necessary proceeding, but in itself is not enough, and I am sure that the time is opportune for the appointment of special anaesthetists to our largest public hospitals, namely Dunedin, Christchurch and Auckland. Wellington has already an honorary anaesthetist in the person of Dr. Anson, and the sooner similar appointments are made at the other hospitals named the better for all concerned. If it is not possible to secure the services of medical men as honorary anaesthetists who are specialising in this work outside then I consider that the appointment of whole-time paid specialists should be undertake. Such appointments, with the co-operation of the surgical staffs of the institutions in question, should speedily procure results. The administration of anaesthetics by house surgeons would be properly supervised, and they would necessarily acquire a better knowledge of the art of anaesthesia than they do at present. The question of the appointment of special anaesthetists should be considered by the honorary staffs of our large hospitals at the earliest possible moment, and recommendations made by them to their respective Boards, who are only waiting for a lead in this matter.

3. The honorary medical staffs of hospitals, and especially the surgical portions of the staff, should consider at the earliest possible moment at their monthly staff meeting the anaesthetic problem of their particular hospital, with a view to effecting improvements where such are necessary.

4. The establishment by this meeting of a small committee to further consider the matter and to enquire into the practicability or otherwise of the various suggestions which will no doubt be brought forward, and to communicate their recommendations within all possible speed to: (a) The Director-General of Health, Wellington; (b) the honorary staffs of the various public hospitals; in New Zealand; (c) the medical superintendents of all hospitals; and (d) each medical man practising in New Zealand, whether he is a member of the British Medical Association or not.

In conclusion I wish to thank the Director-General of health for the permission he gave me to use various departmental files for the purpose of this paper, and also Mr. Clayton, the Librarian of the Health department, for the very careful way in which he has kept and summarised the abstracts which have been prepared from time to time by the Health Department.