Death after aneasthetic at circumcision operation - Michael Jowett

This case report is taken from the British Medical Journal, 28 April 1951

Whatever may be the merits of circumcision, a subject
discussed in this Journal just over a year ago,' the risks
inherent in administering anaesthetics to very young children
are illustrated by a recent tragedy in Yorkshire. On advice
received at the Halifax General Hospital, Mr. and Mrs.
Arthur Jowett, of Halifax, decided to have their son Michael,
aged 5 months, circumcised. On the day before that fixed
for-the operation Michael had a cold and cough, and his
mother took him to see their family doctor. Next day at
10 a.m. she took him to the Halifax General Hospital. She
told the sister with whom she left him that he had a cold
and cough. When she collected him at 3 p.m. that afternoon
he seemed to be listless, and on the following day she notice
that his breathing was wheezy. On the second day after the
operation he seemed to be so ill that Mrs. Jowett again
called in her doctor. Michael was taken back to hospital
by ambulance, and there, in spite of being given oxygen,
penicillin, and stimulants, he died early' next morning, two
and a half days after the administration of the anaesthetic.
At the inquest held before the Halifax Borough Coroner
on March 21 evidence was given by the resident anaesthetist
at the- hospital, who had given the anaesthetic. He had used
atropine 1/200 gr. (0.32 mg.) as premedication. This was
followed by inhalation of open ether in the dorsal decubitus
position, and administration had lasted 10 to 12 minutes.
He had found the child a normal healthy-looking infant.
He had not made a detailed examination of him before
giving the anaesthetic, nor had he taken his temperature,
examined his lungs, or sounded his heart. It was usual to
examine the chest before giving an anaesthetic. So far as
he knew rno one else had made a detailed examination of
the 'child. It was his responsibility as the anaesthetist to
see that the child was fit to have an anaesthetic. He said
that if he was satisfied that the lungs were not involved,
the fact that a child had a cold or cough would not prevent
him from giving it an anaesthetic, though to do so would
be dangerous if it was suffering from bronchopneumonia.
If he knew a child had a severe cold it might deter him
from giving it an anaesthetic.
Dr. H. V. Phelon, pathologist at the Royal Halifax
Infirmary, who made the post-mortem 'examination, said
the lungs showed widespread patches of bronchopneumonic
consolidation, and gave his opinion that death was caused
by bronchopneumonia. Dr. Phelon said that before a child
was given an anaesthetic it should have its temperature taken
and its heart and lungs tested. The administration of ether
to a child with a cough and cold would increase the risk of
infection of the upper respiratory tract. The administration
of ether was, in his opinion, associated with the
bronchopneumonia which had caused the-.death.
The verdict was recorded of death by misadventure.

So the Michael Jowett brought about his own death through "misadventure".

Keyword: Death after aneasthetic