Use of Sulfuric Ether and Chloroform during Civil War, 1861   Topic: Documented evidence of exactly what was known and when regarding the use of chloroform and/or ether for surgery during the first year of the Civil War.  In 1861, sulphuric ether was shown to be safe, whereas chloroform or a mixture with ether was not thought to be safe as a medical anesthetic.   Of particular interest is the fact Dr. C.T. Jackon's book on Etherization was excluded from the SGO library catalogue through out the Civil War.  The point being the Medical Department staff who maintained the library saw Jackson's book to not be worthy of inclusion in the catalogue of the library and the book was never included in the list of medical text books specifically printed for the U.S.A. Hospital Department distribution to the hospitals and surgeons.  On the contrary, evidence in the citations of the Medical and Surgical History point out the continued use of chloroform and ether mixture until the end of the war irrespective of the extensive study regarding chloroform and ether published in the Boston Medical and Surgical Journal in 1861.  Interestingly, the Boston Medical and Surgical Journal  was one of the few journals the Surgeon General's Office library maintained through the war years.  One would assume the information in the 1861 journal would have been widespread among the staff of the Medical Department and surgeons at hospitals. What follows is edited documentation of the report in 1861 by the Boston Medical and Surgical Journal, then a follow-up by C. T. Jackson in reply to the report, and citations from the Medical and Surgical History. Source: THE BOSTON MEDICAL AND SURGICAL JOURNAL VOL LXV, OCTOBER 24 1861; No 12 REPORT OF A COMMITTEE OF THE BOSTON SOCIETY FOR MEDICAL IMPROVEMENT ON THE ALLEGED DANGERS WHICH ACCOMPANY THE INHALATION OF THE VAPOR OF SULPHURIC ETHER By Doctors: R. M. HODGES; GEO. HAYWARD; S. D. TOWNSEND; C.T. JACKSON; J. BAXTER UPHAM Read before the Boston Society for Medical Improvement, October 14th 1861 and communicated for the institute of Medical and Surgical Journal. Any one who has observed the course of events especially the tone of journals and the published statements of late surgical writers as Erichsen Druitt Hamilton and others must have noticed a diminishing confidence in the safety of chloroform and an increasing willingness to allow the greater security of ether. Various influences have however prevented the disuse of the former even by many of those in whose hands accidents have occurred and it still remains the anaesthetic most in vogue When the subject of chloroform first came under discussion its dangers were commented upon and even then freely acknowledged It had not been two months introduced when a well developed girl of 15 died from its administration for the evulsion of a toe nail the process of inhalation operation and death not having occupied more than two minutes.  Since that time deaths from its use have repeatedly occurred.  On the other hand fatal results from ether although still figuring in the statistics of mortality from anaesthetics are everywhere admitted to be very infrequent.  Indeed the opinion has been expressed by various authorities both in America and Europe that a death really attributable to the inhalation of sulphuric ether is yet to be reported. The correctness of this opinion has however been repeatedly denied and the strong conviction of the absolute safety of this agent which exists in some localities in this country is thought to have its foundation rather in the desire that the fact might be established than in the proof that it was so. Of course no one intends to say that a person cannot be killed by ether the inhalation of its vapor without a sufficient admixture of oxygen destroys life by asphyxia. This may happen and unfortunately has happened but such an event cannot be laid to the anaesthetic since in such a case it is the method of administration and in no sense the ether which causes the fatal result. It is the purpose of this report to solve the doubt just implied with regard to the absolute safety of sulphuric ether and to investigate the dangers of its use as compared with chloroform. In pursuance of this object therefore we propose in the first place to consider what conditions and precautions are necessary in bringing about a state of insensibility by its use and what phenomena of etherization have an apparent or real danger.  The safe inhalation of medicinal ether requires proper attention to: 1st to the quality of the article used 2d to the method of administration 3d to the symptoms which present themselves while the patient is under its influence 1st Quality of Ether:  Ether for inhalation should be of unquestionable purity. A large amount of inferior ether is sold which cannot readily be distinguished from that which is pure except by its effects although an expert familiar with its properties may infer something from the odor and other sensible qualities The inferiority may be due to oxydation from bad corking the presence of alcohol sulphurous acid which has not been removed by thorough washing and volatile oils.  Either of these impurities may give rise to a tedious and imperfect inhalation and the latter of thorn by irritating the bronchial mucous membrane to such coughing struggles and resistance that the patient is finally etherized in a distressing and unsatisfactory manner. Accidents of this kind lead to a disparagement of the value and practical usefulness of ether. It is therefore an advantage for the surgeon to procure his own ether or to use from an original package of the character of which he has already assured himself.  There are two brands of ether in common use in this country viz that manufactured by Powers & Weightman of Philadelphia and that by Dr Squibb of Brooklyn NY.  These are uniformly of excellent quality.  The latter is remarkably anhydrous but possesses an odor more harsh disagreeable and intensely ether like than the former and in the opinion of those who have used it extensively produces more choking during inhalation. This may be remedied to a certain extent by moistening the sponge from which it is given in water enough of which will perhaps be taken up by the ether to diminish its unpleasant effects.  Ether may be made purer by simple agitation in lime water allowing the water to settle and then decanting and this washing is practically and for general application as good a method of purification as can be adopted without re distillation.  2d Method of Administration: Ether should never be given from any inhaling apparatus. The best medium of its administration is a bell shaped sponge large enough to cover in the nose and chin but it is difficult to find one of sufficient size and close enough in texture or without such numerous apertures at the root as to admit too freely the atmospheric air. A sponge of this sort moreover being as expensive as rare is seldom used outside of hospitals.  A still towel properly folded may be substituted and has the advantage of being always at hand as it may be left behind the surgeon does not carry away with him the annoying odor of an impregnated sponge.  It is desirable that the towel should be a new one and of pretty good size It is to be taken just as it conies from the laundry and not unfolded further than to display it in the dimensions of about ten inches by five by folding down two of the corners in such a way that they shall lap over each other a little and securing them by stout pins a cone will be made which fits the face admirably. The thick layers of towelling will hold sufficient ether and its texture prevent a too free dilution of the anaesthetic by the atmospheric air provided the apex and seam of the cone are carefully and tightly closed cither by pins or the fingers.  As the cone becomes collapsed by saturation it should from time to time be opened and kept in shape by distending it with the hand.  Unless these details are attended to and especially the closure of the apex of the cone the induction of anaesthesia will be uncertain and protracted In anything so porous as a towel or sponge the difficulty is to exclude enough air for while its adequate admission to the lungs during etherization is essential to the life of the patient its too free entrance not only delays anaesthesia but induces a condition of excitement both mental and physical. The importance of excluding the air as above stated is a point not generally appreciated but the necessity of it has long been known to those most accustomed to the use of ether as shown by the chemise with which in hospital practice a too porous sponge is often covered to expedite the etherization of a rebellious patient.  Ether should be poured lavishly on the towel or sponge an ounce or two at a time especially at the commencement of inhalation.  Although it may be wasted too much so far as safety is concerned cannot be used.  A small quantity poured on hesitatingly and timidly as is sometimes done has the same effect аs а too free dilution of the vapor with air producing simply intoxication and its accompanying excitement without anœsthesia whereas a large amount though the cough and choking sensation which the greater volume of vapor produces may cause the patient to resist and struggle is certain to bring about a satisfactory condition of insensibility. 3d Phenomena of Etherization:  A strong full blooded man is pretty sure to resist the approaches of anœsthesia under any circumstances.  This may sometimes be overcome by warning him before hand of such a possibility and inducing him to resolve not to struggle the last impression on his mind influences him even in his stupor.  The same thing is liable also to happen with almost all patients just before complete anaesthesia takes place but the ether rarely requires to be suspended.  Occasionally the respiration becomes embarrassed during the period of excitement partly from the strudle itself and partly perhaps from the increased flow of saliva which is a common phenomenon of etherization or from the position of the tongue or head of the patient and a condition may sometimes show itself characterized by lividity rigidity and convulsive motions of the extremities.  These phenomena are an observation of Dr H. J. Bigelow of this city are in reality the tetanic symptoms which Dr Brown-Sequard has shown precede the approach of asphyxia.   Although alarming to the inexperienced the state is in fact devoid of danger provided the ether be momentarily suspended this being done the refusal to breathe soon gives place to a long drawn inspiration and in most instances complete insensibility immediately ensues In such a case it is interesting to observe how readily the spasm yields and how complete is the muscular relaxation which follows the free respiration of air unmixed with ether.  It should therefore be borne in mind that when there is muscular rigidity with lividity the suspension of etherization will transform this into the relaxation of anaesthesia.  Persons of intemperate habits succumb to ether slowly and with greater reluctance and more opposition than persons unused to intoxication.  The pulse should be watched by a competent person from the outset and its failure either in strength or frequency lead to a more cautious use of the ether.  It must however be remembered that in experiments with anaesthetics upon animals the heart has been found to be the ultimim moriens the respiratory movements therefore should not be forgotten or neglected but any slowness or irregularity in their performance should at once receive attention.  Attention has been drawn by Dr H. J. Bigelow to the distinction between the effects of anaesthesia upon the pulse of the healthy subject suddenly reduced by accident and a similar or even stronger pulse in a person exhausted by long and grave disease.  In the former case the vitality is unimpaired and the pulse even when hardly perceptible rises with anœsthesia.  Ether therefore is not to be withheld from a patient to be operated on even in a state of collapse after severe accident but great caution is demanded in its use with patients who are near death from chronic and exhausting disease and who require operations.  The best test of complete etherization is the snoring of the patient and no operation unless slight should be undertaken until this symptom presents itself.  The relaxation of the muscles of the extremities may occur without insensibility The important distinction between snoring and stertor is however to be borne in mind.  Whilst the former is caused only by the relaxation of the muscles of the palate the latter arises from spasm ol the vocal cords and partial closure of the rima glottidis and thus becomes the immediate forerunner of the train of symptoms already referred to as indicative of partial asphyxia Stertorous respiration demands therefore a brief suspension of inhalation one or two inspirations of fresh air will аs already mentioned almost instantly dispel the symptom.  Ether may be administered to persons of all ages from the new born infant to the octogenarian There is however a condition prone to manifest itself with children especially those who are weak strumous or overgrown which is due to its cumulative properties.  It may show itself after almost any decree of etherization and is characterized by a feeble pulse and slow respiration not passing off with the readiness usually marking the phenomena of etherization.  With young persons a cautious inhalation of five minutes will often induce an anaesthesia of half an hour an effect wholly out of proportion to what the same amount of ether would produce in an adult.  This state is not a dangerous one and only requires time to dissipate its symptoms.  Compression of the chest will expel the fumes of ether being eliminated from the pulmonary surface and admit the entrance of a fresh supply of oxygen to stimulate the circulation.  The inhalation should therefore be suspended at short intervals with children and but little ether given at a time.  It should also undoubtedly be used with great caution with persons past the middle period of life of such a general obesity or constitutional condition as may lead to the supposition of a fatty degeneration of the heart In none of the alleged deaths from ether is there any mention however of valvular disease of the heart being found.  Of this then and of any bad effect upon pulmonary affections there need be no fear for we see it constantly administered without detriment to persons more or less advanced in phthisis for the common operation of fistula iu ano Its subsequent effects are rarely disagreeable.  The nausea and vomiting which follow the use of any anaesthetic may lie prevented or diminished by giving it upon an empty stomach.  Faintness although a rare event is occasionally noticed and demands the ordinary treatment by stimulants. Headache sometimes remains for a few hours but seldom persists into the following day. We now and then hear of delirium debility and the non return of a full use of the mental faculties as temporary accidents from the use of ether.  Such occurrences must be of extreme rarity and probably find their explanation as much in the idiosyncrasies of patients as in the effects of the anaesthetic. Having thus detailed what we conceive to be the conditions of its successful and safe administration we undertake in the second place to prove that these conditions being fulfilled sulphuric ether is of all anaesthetic agents alone worthy of unlimited confidence.  Confirmation of this assertion is to be found in what we know of the use of ether in other places.  It is true llmt thus far this has been limited to a few localities but wherever it has been adopted the confidence and freedom with which it is ad ministered is worthy of notice.  In 1857 it was stated that for about eight years ether alone had been used in the civil or hospital practice of Lyons in France and that during that time the necrology of anaesthetics so far at least as that city was concerned had remained closed.   And here in Boston where more ether has probably been inhaled during the last lifteen years than in any other place in the world from the time when Dr George Hayward performed the first capital operation under its influence Nov 1 1841 down to the present day no fatal result has ever occurred or been heard of in the vicinity though repeated deaths have happened from chloroform during the same period.  But to sustain the above conclusion with regard to the absolute safety of sulphuric ether your Committee place their chief reliance upon the histories of the recorded fatal cases thought to have been caused more or less by its inhalation and upon the result of their own efforts to obtain information of all others of the kind known to the profession any where.  With unequalled facilities to examine the literature of the subject under discussion with all the chief foreign and American Journals at hand and the results of a most extensive distribution of circulars before us no case of which we have knowledge can be cited as unquestionably and unavoidably fatal from the breathing of pure sulphuric ether.  The following two conditions must be considered essential to any case of death fairly attributable to the inhalation of an anesthctic account: 1st That the event should occur while the patient is actually in an anaesthetic state 2d That the circumstances of its occurrence should be inexplicable by any phenomena of disease or operation Such a death should be unavoidable by any precautions which might be adopted were the patient to be again rendered insensible under similar circumstances.  It must consequently be sudden and unexpected in manifesting its symptoms as well as rapid in its progress to a termination.  The unmistakeable deaths following the use of chloroform have usually been almost instantaneous out of 27 which occurred within 10 minutes.  15 took place in less than 2 minutes.  No conclusive light can be thrown on the subject by a post mortem examination it can only demonstrate a cause exculpating the anaesthetic there being no pathognomonic signs of death from the use of these agents.  It is clearly unreasonable therefore to attribute to anaesthetics deaths happening long after patients have recovered from their immediate and specific influence.  A man is etherized for lithotrity and dies of pneumonia a week later or a female anaemic and feeble suffering from the constitutional effects of a malignant tumor of rapid and large growth inhales chloroform for the bloody or tedious operation by which it is to be removed and dies twenty eight hours afterwards without rallying.  Events of this description are not so infrequent where no anaesthetic has been used as to require any other explanation than such as may be found in the operation or disease itself and are obviously liable to occur from accidental causes under any circumstances.  Yet this is the character of a large proportion of the facts cited by writers as evidence to prove the occasional occurrence of fatal results from the inhalation of ether.  Of the whole number of alleged deaths from sulphuric ether, 41 which has been collected by your Committee all survived the inhalation from 3 to 16 days and 8 from 3 to 50 hours.  In all of these deaths occurred after the peculiar primary effects of its use had subsided from a secondary set of symptoms which were either simply coincident or else such as arc well known frequently to terminate in death when no anaesthetic has been used and which moreover never show themselves in cases of inhalation for slight and trivial operations where the primary effects of ether have been just as well marked as in the severer operations after which they were alone noticed.  The statements of any author however distinguished in position not accompanied by proof in the form of piècts jimtijiaitka must remain of no value in face of the direct evidence of your Committee that their careful search of journals and monographs furnishes not a single conclusive case ot death from the proper inhalation of pure sulphuric ether. In contrast with the foregoing evidence how striking is the admission of the staunchest partisans of chloroform that no care on the part of the administrator nor intrinsic chemical perfection will in in1 the safety of the person breathing its vapor. Neither the skill of a Dr Snow nor the laboratory of Duncan Flockhart & Co appear to exempt those who inhale chloroform from the lethal calamities which sometimes ensue wherever it has been used.  In 1857 in a discussion before the Academy of Medicine M. Rieord spoke of the use of chloroform as an accident which complicated an operation and in 1859 the President of the Paris Société de Chirurgie M. llervez de Chegoin seriously proposed the question.  Whether its use had not better be actually suspended until some method of using it with constant security had been discovered or if it is to remain of so uncertain safety even renounced altogether.  In 1856 Dr Erichsen of London in a letter to Dr H. D Townseud of this city said that when a patient was fully under the influence of chloroform he was on the verge of death.  The epithet fleuu chloroformiquc is therefore not undeserved one for in any man's hands chloroform may indeed become a scourge whose blows shall fall so suddenly and mysteriously that before the surgeon's knife is taken up the patient's life may have passed away beyond resuscitation.  No such impressions have ever prevailed with regard to sulphuric ether.  No one can die from it as he may die from chloroform.   Dr John Snow declares that he holds it almost impossible that a death from ether can occur in the hands of a medical man who is applying it with ordinary intelligence and attention.  The more agreeable odor the more rapid result and the smaller benefit are the only compensations offered as an offset to the suspended sword which thus hangs over the surgeon whenever he invokes the aid of chloroform. The first of these advantages seems too unimportant to be serious nor are all people of one opinion as to the more agreeable smell of chloroform.  M Roux talks of its nauseating and sickishly sweet odor as being more painful to inhale than that of ether.  M Sédillot says that of patients submitted by him sometimes to the use of ether and sometimes to that of chloroform all have preferred ether.  Dr Snow esteems the odor of and the sensations produced by ether as much more pleasurable than those of chloroform. Then too as to rapid action a patient may be put by ether into a thorough anasthetic condition for the performance of a by no means short or trivial operation in one minute and a third.  Chloroform can hardly do more than that the rapid production of anaesthesia however a desirable thing.  It is an assertion based upon statistics that the early stage of chloroformization is the most dangerous.  The agitation and excitement of patients during the first moments of inhalation may explain this as the rapidity and intensity of anœsthesia are in proportion to the activity of respiration and circulation.  Such being the case a gentler and slower anœsthetic than chloroform ought to carry the patient more safely over this dangerous period by allowing the etherized blood gradually to penetrate the remotest parts of the system and tries to avoid the prostration of a sudden and violent impression upon the nervous centres.  The necessary duration of the anaesthetic condition when gradually induced must for the same reason be more satisfactorily ensured.  A rapid anaesthesia normally complete is apt to be of very short duration and the patient may recover his sensibility as suddenly as he lost it.  This does not occur so frequently when the anaesthetic has taken e flee t in a slower manner and may be explained by supposing that я volume of the blood first charged in the lungs passes to the brain and narcotizes the patient and that the blood which remains in the extremities not yet touched by the vapor will if the process be arrested in its turn flow through the brain and at once revive him.  On the other hand a more protracted inhalation such as is usually the case with ether ensures the gradual saturation of the whole circulation.  Here too is an additional illustration of the important statement before made that unless an operation is to be short the surgeon should not be content with the appearance of the first symptoms of insensibility but push the anaesthesia till the patient snores.  The advantages of chloroform in respect to portability arc of little consequence in civil practice.  But when an agent so much more compact than ether can be used in military hospitals and on the battle field the necessity of reducing baggage to its minimum demands it has been alleged that the less bulky anaesthetic be preferred and this argument is usually strengthened by a reference to the results of its use in the Crimea viz two death in 30,000 cases one in the French and one in the English army.  These statistics apparently so conclusive will not as your Committee believe stand the test of examination How was it possible to obtain accurate information from every battery rifle pit or trench where chloroform was given.  What surgeon would not under the circumstances in which it must constantly have been administered be liable often to attribute to the effects of an injury fatal results really dne to the anaesthetic especially if it is true as Dr Snow states in a communication to Mr Guthrie that to take 10 minims of chloroform into the lungs when insensibility is almost complete must be attended with danger.  The amount of ether required for army use if properly administered and economized is not very great. The quantity necessary for a regiment especially one with easy access to its supplies cannot add much encumbrance to the stores of the hospital department At all events it might be used to a certain extent and the soldier's life in a degree secured against the treachery of one foe not less dangerous than the bullets of the enemy. The objection to ether on account of its inflammability does not apply with any more force to its use in armies than in private practice and ordinary precautions will provide against accident from this cause The more trivial the operation for which chloroform is inhaled the more care should be taken in its use fully two thirds of the deaths from its effects having occurred during the performance of minor operations.  The very opposite of this is true of ether.  Only after long protracted inhalation during operations accompanied by great loss of blood or involving great prostration of the general system can any possible anxiety be felt The friends of chloroform admit that over 150 deaths have already occurred from its use.  The objections to chloroform apply with equal force to chloric ether which is chloroform diluted with alcohol to amylene and to the mixture of sulphuric ether and chloroform in whatever proportion.  The dangers of this last are well shown in a case reported in the Appendix where a boy 5 years of age died within three or four minutes after breathing a mixture of four parts of ether and one of chloroform.  The addition of chloroform to ether being unnecessary only renders dangerous an anaesthetic which is otherwise safe and is liable to lead to a carelessness in its administration wlrich would not occur with chloroform and might prove as dangerous as when that anaesthetic is alone used in an unadulterated state.  The general conclusions which have been arrived at by your Committee may be summed up as follows: 1st The ultimate effects of all anaesthetics show that they are depressing agents. This is indicated both by their symptoms and by the results of experiments.  No anœsthetic should therefore be used carelessly nor can it be administered without risk by an incompetent person. 2d It is now widely conceded both in this country and in Europe that sulphuric ether is safer than any other anaesthetic and this conviction is gradually gaining ground. 3d Proper precautions being taken sulphuric ether will produce entire insensibility in all cases and no anaesthetic requires so few precautions in its use. 4th There is no recorded case of death known to the Committee attributed to sulphuric ether which cannot be explained on some other ground equally plausible or in which if it were possible to repeat the experiment insensibility could not have been produced and death avoided.  This cannot bo said of chloroform. 5th In view of all these facts the use of ether in armies to the extent which its bulk will permit ought to be obligatory at least in a moral point of view. 6th The advantages of chloroform are exclusively those of convenience.  Its dangers are not averted by its admixture with sulphuric ether in any proportions.  The combination of these two agents cannot be too strongly denounced as a treacherous and dangerous compound Chloric ether being a solution of chloroform in alcohol merits the same condemnation. R. M. HODGES, M.D;  GEO. HAYWARD, M.D.; S. D. TOWNSEND, M.D.; C.T. JACKSON, M.D.; J. BAXTER UPHAM, M.D. The preceding  report was accepted and its conclusions were adopted by the Society FRANCIS MINOT, M.D., Secretary Post Publication comments by Dr C.T Jackson, one of the Committee, objects and excepts to the clause in this report in which all mixtures of ether and chloroform are denounced viz to the words the dangers of chloroform are not averted by admixture with sulphuric ether and to the terms treacherous and dangerous compound of ether and chloroform he believes that a mixture of four measures of ether and one measure of chloroform may be employed without danger or with very little danger and that the risks from chloroform are diminished more than four fifths by this combination.  He believes it to be necessary to use an anaesthetic agent of less bulk than ether and not so dangerous as chloroform for army uses and is satisfied that this mixture which he has employed and prescribed completely answers the purpose required. Jackson's book on etherization was not on the list of textbooks in the Surgeon General's Office Library during the Civil Warr and the above information may well be the reason it was excluded.  Jackson's objections to except the clause regarding the mixture of ether and chloroform being the point.  But, contrary to these facts the following citations in the Medical and Surgical History clearly point out that chloroform and ether were not only mixed, but that chloroform was widely used during the War. Written by the notable Charles T. Jackson. Jackson begins with a little history of a case he investigated 6 years prior , on a chloroform death. The blood from the victim was analyzed in 1855. Jackson then displays a vial of blood from the same victim that he has stored for the last 6 years. He then begins his chemical analysis and theory on what happens to the blood in such cases. He also discusses : CHLOROFORMIZATION , HOW TO DIMINISH DANGER , BATTLE-FIELD ANESTHSIA , CIVILIAN ANESTHESIA , ANESTHESIA USED IN THE AUSTRIAN MILITARY , IMPURITIES , MYSTERY OF CHLOROFORM SPONTANEOUS DECOMPOSITION , CHLORIC ETHER , HIS PUBLIC TRIALS OF WALDIE AND SIMPSON'S SUBSTITUTE FOR ETHER , ETC. Jackson then details his 8 approved tests for chloroform to test if the surgeon is employing pure agent. Jackson ends "I FEEL BOUND TO AID IN THE CALLING UPON THE MEDICAL PUBLIC TO RETURN TO THEIR ORIGINAL ANESTHETIC AGENT ; PURE WASHED ETHER". Pages 175-181. __________________ Following are excerpts from Tripler and Blackman's Handbook for the Military Surgeon, 1861 ON THE USE OF CHLOROFORM   ( From Macleod's Notes on the Surgery of the War in the Crimea as directly quoted in Tripler and Blackman) The advantages derived from the use of anaesthetics are perhaps more evident and more appreciated in the field than in civil practice The many dreadful injuries which are presented to us in war and the severe suffering which so often results from them soon cause us fully to appreciate the benefits bestowed by such pain soothers The vast majority of the surgeons of the eastern army were most enthusiastic in their anticipations of what chloroform was to accomplish It was expected to revolutionize the whole art of surgery Many operations hitherto discarded were now to be performed and many which the experience of the Peninsula said were necessary were henceforth to be done away with In the British army chloroform was almost universally employed but although the French also used it very extensively as we learn from Baudens still I do not think from what I saw of its employment in their hospitals that they had our confidence in it Baudens tells us that they had no fatal accident to deplore from its use although during the eastern campaign chloroform was employed thirty thousand times or more In the Crimea alone he continues it was administered to more than twenty thousand wounded according to the calculations of M Scrive In one division of our army it was not so commonly used as in the others from an aversion to it entertained by the principal medical officer of the division a gentleman of very extensive experience The only case in which with any show of fairness fatal consequences could be said to have followed ite use occurred in the division referred to The patient a man thirty two years of age belonged to the 62d regiment and was about to have a finger removed The chloroform was administered on a handkerchief as he sat in a chair Death was sudden and artificial respiration which  was the moans of resuscitation employed failed to restore him No pathological condition sufficient to account for death was found postmortem Some five or six other cases were brought forward by the small body of surgeons who were suspicious of the action of chloroform as having ended fatally from its effects but in none of these could I think the least pretext be found for the imputation further than that the anaesthetic had been administered at some period previous to death A man who had been dreadfully mutilated and who had lost much blood died shortly after having his thigh removed high up Chloroform had been used and to it was ascribed the fatal issue Death twenty or thirty hours after a capital operation rendered necessary by the most dreadful injuries must be attributed to the chloroform and so on and no note taken of the effects of severe injury plus a capital operation in shattering the already enfeebled powers I Death occurring under such circumstances when no chloroform was employed would not be thought to demand any special explanation nor does the fact that the injury was occasioned by a round shot introduce any new element into the calculation The objections nadc to the use of chloroform were restricted to two classes of cases trivial accidents in which it was thought necessary to run the risk of giving it and amputations of the thigh in which a fatal accession of shock was feared However this may be it certainly shows the little practical force of these objections that while with every indulgence in the interpretation of the law post hoc etc only some half dozen cases could be obtained throughout the whole army to illustrate the pernicious effects of this agent and that too when thousands upon thousands had been submitted to its action and hundreds of surgeons of equal experience to the objectors were ready to record their unqualified opinion in its favor as well as their gratitude for its benefits For my own part I never had reason for one moment to doubt the unfailing good and universal applicability of chloroform in gunshot injuries if properly administered 1 most conscientiously believe that its use in our army directly saved very many lives that many operations necessary for this end were performed by its assistance which could not otherwise have been attempted that these operations were more successfully because more carefully executed that life was often saved even by the avoidance of pain the morale of the wounded better sustained and the courage and comfort of the surgeon increased I think 1 have seen enough of its effects to conclude that if its action tion is not carried beyond the stage necessary for operation it does not increase the depression which results from injury but that on the contrary it in many instances supports the strength under operation Its usefulness is seen in nothing more than when by its employment we perform operations close upon the receipt of injury and thereby if not entirely at least in a great degree are able to ward off that embranlement of the nervous system which is otherwise sure to follow and whose nature we know only by its dire effects To men who had lost much blood it had of course to be administered with great care from the rapidity of its absorption in such persons but if wo do not act on broader principles in its exhibition than reckoning the number of drops which have been employed or the part of the nervous system which we may presume to be at the time engaged then we must expect disastrous results It is difficult to see how its use could favor secondary hemorrhage after operation as some said it did but it is on the contrary easy to Understand how the opposite result might follow.  That purulent absorption should prevail among men so broken in health as our men were need not be explained by the employment of chloroform and that Ice would prove more useful in the slighter operative cases in field practice few will be disposed to admit either on the ground of time efficiency or opportunity To Deputy Inspector General Taylor we owe the practical observation that chloroform appears to act more efficiently when administered in the open air In the prolonged searches which are sometimes necessary for the extraction of foreign bodies chloroform is useful not only preventing pain but also in restraining muscular contractions by which obstacles are thrown in the way of our extraction which did not oppose themselves to the introduction of the body Then much is gained in field practice by the mere avoidance of the patient's screams when undergoing operation as it frequently happens that but a thin partition a blanket or a few planks intervene between him who is being operated upon and those who wait to undergo a like trial Thus when as after a general engagement a vast number of men come in quick succession to be subjected to operation it is a point of great importance to save them from the depression and dread which the screams and groans of their comrades necessarily produce in them.   It is therefore my clear conviction that the experience of the late war as regards chloroform is uneqivocally favorable that it has shown that chloroform both directly and indirectly saves life that it abates a vast amount of suffering that its use is as plainly indicated in gunshot as in other wounds and that if administered with equal care it matters not whether the operation about to be performed be necessitated by a gunshot wound or by any of the accidents which occur in civil life. _______________________ The information from Tripler and Blackman absolutely agreed with the use of chloroform in their 1861 publication, based on English and French surgical experience in the War of the Crimea.  The following examples are reprinted from the Medical and Surgical History citations showing use of both agents through out the Civil War in direct contradiction to the findings and information published in the above Boston Medical and Surgery Journal article, a display of the lack of knowledge during the war which could be due to lack of circulation of current information...or regional isolation by the surgeon's themselves.  The endorsement of Tripler and Blackman would account for wide spread use during the war as their book was widely published and distributed by the U. S. Army Medical Department during the War. Medical/Surgical History--Part I, Volume I CCV. Extracts from a Narrative of his Services in the Medical Staff. By Surgeon G. G. SHUMARD, U. S. Volunteers. "Chloroform was freely employed in nearly all the serious surgical operations performed in the different commands to which I have been attached, and in no instance has it disappointed our expectations. I have neither seen nor heard of any bad results following its use. Sulphuric ether has, in a few instances, been employed as a substitute for chloroform, but from my own knowledge and experience, I would much prefer the latter." _______________________ Medical/Surgical History--Part I, Volume I CXCII. Extracts from a Narrative of his Services in the Medical Staff. By Assistant Surgeon JOHN BELL, U. S. Army. "While I was on duty at the general hospital at Hilton Head, the battles of James's Island, June 16, 1862, and of Pocotaligo, October 20, 1862, took place. The wounded from both of these engagements were nearly all sent to the general hospital in which I was. Those from James's Island arrived on the third day after the engagement, and those from Pocotaligo on the second day, having been brought by water conveyance. Sulphuric ether was usually employed as an anaesthetic. In a few cases in which this agent did not readily produce anaesthesia, chloroform was mixed with it in a small proportion. There were no deaths which could be fairly attributed to its use. I have assisted in its administration, I should suppose, sixty or seventy times since I have been in the army. I have probably had under my personal care from two hundred to two hundred and fifty cases of gunshot wounds received in battle, but have had no case of bayonet or sword wound. The proportion of deaths among the wounded at Pocotaligo was about three times as great as among those from James's Island. This fact, in my opinion, is only to be accounted for by the circumstance that the latter battle took place early in the season before the men had begun to suffer from malarious poisoning, while the case was was decidedly different at the battle of Pocotaligo." ______________________ Medical/Surgical History--Part I, Volume I XCVIII. Extracts from a Narrative of his Services. By Surgeon N. R. MOSELY, U. S. Volunteers. "The men brought to this hospital were mostly wounded by the explosion of shells. Several primary amputations were performed under the use of a mixture of equal parts of chloroform, and sulphuric ether. No deaths occurred. These wounded were afterwards conveyed in ambulances to Bristoe Station, from whence they were transported by rail to Washington." "When admitted to the Emery Hospital, Washington, on August 17th, 1864, he was feeble, and much exhausted from exposure on the field, and during transportation. On August 25th, bleeding profusely, chloroform and ether were administered, and the right common carotid artery, through an incision about two inches in length, was ligated by Surgeon N. R. Moseley, U. S.V. Cold water dressings were applied, and tonics and stimulants were administered. He died on August 30th, 1864, from exhaustion and constitutional irritability." _____________________   Medical/Surgical History--Part I, Volume I XXIV. Account of the Operations of the Medical Department at the Battle of Belmont, Missouri. By Surgeon JOHN H. BRINTON, U. S. V., Medical Director of the Troops under General Grant, stationed in the District of Cairo and its Dependencies. "In all of these operations anaethesia was previously induced. Washed sulphuric ether was the agent generally employed, and in no case was any untoward result observed. When the fact is considered that those of our soldiers who were wounded in the lower extremities underwent considerable privations and exposure, and were subjected to much rough transportation, the final results must be considered as exceedingly favorable." ____________________ Medical/Surgical History--Part I, Volume II Chapter V.--Wounds And Injuries Of The Chest. Section II.--Gunshot Wounds Of The Chest. "The cadets were again detailed to administer stimulants and to watch, and, in case of haemorrhage, to make compression. Observations by Acting Assistant Surgeon M. J. Grier; who administered an anaesthetic consisting of four fluid ounces of sulphuric ether and two of chloroform: "Pulse, at commencement of aetherization, 112, irritable, quick, and feeble, rapidly rising to 130, and becoming quick, thready, and almost imperceptible under the application of the anaesthetic; but upon the removal of which returned to its former condition. Sometimes, when the administration was prolonged, it reached the frequency of 160--always falling below 115 in a few seconds after the admission of the atmosphere. He was very susceptible to its influence, and was very easily controlled by the occasional application of the sponge. Toward the close of the operation, it was deemed advisable to administer brandy, under which the pulse changed from 115 to about 100, gaining in strength and volume." One hour after the operation, there was considerable reaction; the pulse 98, general expression better, and the body much warmer." "He was carried to the field hospital of the 1st division. Ninth Corps, where Surgeon W. V. White, 57th Massachusetts Volunteers, administered chloroform and ether and amputated the left arm at the junction of the middle and upper thirds by circular operation. ]h, died August 16th. 1864." "Corporal George M. Klechner, Co. D, 93d Illinois Volunteers, aged 23 years, received at Allatoona, Georgia, on October 5th, 1864, a gunshot wound of the left arm; the ball entering at insertion of deltoid muscle, lodged between the clavicle and first rib, over the tubercle of the rib. He was admitted to the general hospital at Rome, Georgia, October 8th, 1864, and, on October 13th, the subclavian artery was ligated behind the scalenus anticus and the ball removed; chloroform and ether were administered. At the time of operation, there was excessive infiltration of serum in all the parts involved in the operation, and profuse secondary haemorrhage, with extreme prostration therefrom. Stimulants were freely administered, but he died six hours after the operation. The case is reported by the operator, Surgeon J. H. Grove, U. S. V.   " The patient was anaemic and feeble from haemorrhage. On the 19th, Surgeon R. B. Bontecou, U. S. V., administered sulphuric ether, enlarged the wound of entrance, and passed a piece of bandage through and tied it over the ensiform cartilage, ligating the internal mammary artery. Simple dressings and cold applications were applied, and supporting treatment administered. The patient gradually sank, and died May 24th, 1864, from recurring haemorrhage and pneumonia of the right lung." "Private Thomas Kinney, Co. A, 17th United States Infantry, aged 36 years, was wounded at Petersburg, Virginia, September 30th, 1864, by a ball which entered under the inner third of the clavicle, one inch from the margin of the sternum, fractured the second rib, and lodged in the right lung. He was conveyed to the hospital of the Fifth Corps, and on October 7th was transferred to Harewood Hospital, Washington. When admitted, his constitutional condition was good. On October 11th, haemothorax was diagnosed. The right lung was compressed, there was dullness on percussion, an absence of the respiratory murmur, and dyspnœa. Surgeon R. B. Bontecou, U. S. V., administered ether and performed paracentesis thoracis on the right side, between the sixth and seventh ribs, in the linea axillaris; five quarts of blood and serum were removed." "Private Patrick F. W, Co. A, 33d Ohio Volunteers, received a penetrating gunshot wound of the chest at Chickamauga, Georgia, September 20th, 1863; the missile entered four inches below the right axilla, passed backward, and emerged at the lower angle of the scapula. He was taken prisoner and remained in the hands of the enemy until September 30th, when he was paroled and sent to the hospital at Chattanooga, Tennessee. Haemorrhage occurred several times during the night of October 4th; an examination on the next day showed the skin to be swollen with an accumulation of blood; the patient was exceedingly feeble and almost deadly pale. Surgeon I. Moses, U. S. V., administered ether, dilated the wound, turned out all the clots, and, after some difficulty, succeeded in ligating the intercostal artery." __________________ Medical/Surgical History--Part II, Volume II Chapter VI.--Injuries Of The Abdomen. Section III.--Complications "Private J. Z. Kivett, Co. H, 2d East Tennessee, was admitted to Jarvis Hospital, April 18, 1864, with oblique left inguinal hernia. He was convalescent from pneumonia, and presented symptoms of strangulation. The tumor extended well down in the scrotum. Symptoms of strangulation were very urgent, and ether being administered, and taxis unavailing. Acting Assistant Surgeon B g. Miles laid open the sac, May 11, 1864, divided the stricture, which was very tense, and replaced the protruding gut, which was indurated and congested." ___________________ Medical/Surgical History--Part II, Volume II Chapter VII.--Injuries Of The Pelvis. Section III.--On Injuries Of The Genital Organs. "he was sent to Cuyler Hospital, at Germantown. Assistant Surgeon H. S. Schell, U. S. A., states that this man was "well until March, 1864, when he fell astride the round of a ladder. This accident was followed by an abscess in the perineum, and difficulty in passing water. The cicatrix in the buttock became swollen and was lanced, and urine escaped from it. On June 1st, Dr. Dunton passed a large bougie through two strictures in the urethra, while the patient was under the influence of chloroform and ether. The instrument was not introduced into the bladder. The patient was much relieved, having had some difficulty in passing urine previously. June 2d, the same bougie was passed into the bladder while the patient was under the influence of the same anaesthetic." "on February 16th, Acting Assistant Surgeon W. F. Atlee made an incision about one inch long and extracted the piece of shell. There was but little haemorrhage, and no ligatures were used. The anaesthetic used was one part chloroform to three of ether." _______________   Summary: Medical/Surgical History--Part III, Volume II Chapter XIII.--Anaesthetics. It was impracticable to determine the total number of cases in which anaesthetics were employed during the war, but as near as can be ascertained they were used in no less than eighty thousand (80,000) instances. Time and clerical assistance did not allow of the examination of this enormous number of cases in detail, and in treating of this subject we must confine our remarks to the number of major operations in which the agents used were definitely ascertained. Of eight thousand nine hundred cases chloroform was used in six thousand seven hundred and eighty-four, or 76.2 per cent., ether in one thousand three hundred and five, or 14.7 per cent., a mixture of chloroform and ether in eight hundred and eleven, or 9.1 per cent. These percentages differ somewhat from the percentages given in the preliminary report,(1) where it was stated that chloroform wits used in 60 per cent., ether in 30 per cent., and ether and chloroform in 10 per cent.; but at that time the percentage of the different agents had been principally derived from the reports of general hospitals, and in which ether was frequently used. When, afterwards, the operations performed in the field hospitals were examined, where chloroform was almost uniformly used, the percentage of the cases in which the latter agent was employed increased to 76.2 per cent., as above indicated, while the number of cases in which ether or the mixture of ether and chloroform was used was proportionally decreased. The inestimable value of the use of anaesthetics in military surgery will hardly be denied at this date, although it has been claimed that the effect of anaesthetics in the treatment of shot injuries are deleterious, inasmuch as they add to the depression caused by the shock, and retard union by first intention, and predispose to haemorrhages and pyaemia. It is possible that in two hundred and fifty-four cases in which it was asserted that no anaesthetic was given the surgeons were actuated by such objections, as no reasons have been assigned why anaesthetics were not administered. How far the use of anaesthetics has contributed to the saving of life during the late war it is impossible to say, as we have no statistics to make this comparison. It may be stated, however, that their use has undoubtedly influenced the favorable percentages of mortality after major operations pointed out in different sections of this and the preceding volumes.   From the rapidity of its effects, and from the small quantity required--qualities which can only be appreciated at their proper values by the field surgeon when surrounded by hundreds of wounded anxiously awaiting speedy relief--chloroform was preferred by nearly (1) Circular No. 6, War Department, Surgeon General's Office, Washington, November 1, 1865. All the field surgeons, and their testimony as to its value and efficacy is almost unanimous, although all recommend the greatest care in its administration. It is, perhaps, best to allow the different medical officers to speak for themselves on this subject: Surgeon C. J. Walton, 21st Kentucky, administered "chloroform in every painful operation, but did not keep the patients under its influence longer than was absolutely necessary, withdrawing it as soon as the cutting was completed. While I could not dispense with chloroform, I must protest against the extravagant and indiscreet use of it. It is a most potent agent, and should be used with the utmost caution. In no case were we displeased with its effect." Surgeon B. B. Breed, U. S. V.: "Chloroform was almost universally employed as an anaesthetic, and without bad effect in any case. Whenever practicable, I employed ether in preference to chloroform, preferring, both from personal experience and observation, the delay and discomfort in its administration to the possible danger from the use of the latter. On the field of battle, however, chloroform is the safe and preferable agent." Assistant Surgeon C. Bacon, jr.: "The anaesthetic I have seen used has invariably been chloroform. Among the great number of cases in which I have witnessed its administration I have seen but one death resulting from its use. I have, however, frequently seen cases in which its use required extreme care, and, at times, have been obliged to desist in its administration in cases of great exhaustion consequent upon long-established injuries. I have frequently seen the use of chloroform attended with bad results when improperly administered. As an anaesthetic I think chloroform should be given in prompt and efficient dose. The desired effect being attained, its administration should be discontinued; in this manner less chloroform is required, thereby avoiding to a great extent its toxical effect." Surgeon D. P. Smith, U. S. V.: "I have in every instance but one, in the army, employed chloroform, and in but one case have I had reason to believe its use disastrous. In this instance it was given too profusely by an entirely incompetent person (since then dismissed from the medical corps) while I was amputating at the knee joint. The patient never reacted from the shock, but died about twelve hours subsequently." Assistant Surgeon J. T. Calhoun, U. S. A.: "I have always used chloroform as an anaesthetic, have given it, and have seen it given under my direction, and in the practice of other surgeons in an immense number of cases, and never saw a death from it, or, in army practice, even an alarming symptom. I am inclined to believe that in general practice the chief danger of chloroform is that in its administration care is not taken to let the patient inhale sufficient air with it (a fact often due to the desire to be economical in its use), and the patients die, not from the chloroform, but from the want of oxygen." Surgeon H. S. Hewit, U. S. V.: "Chloroform was used freely without any fatal accident,. But I conceived that those cases did not finally do so well who were kept under its influence for a length of time; and I am of the opinion that when used the patient should be kept under its influence merely long enough to last through the severest part of the operation. I believe that when a patient is kept under its influence for a long time his chances of recovery are thereby lessened." The serious results following the use of chloroform, when "improperly" or "too long" administered, or when administered by "incompetent persons," referred to by several of the operators, will hardly be charged to the agent itself. In the reports of the surgeons in charge of base hospitals, sometimes the use of ether, sometimes of chloroform alone, or a mixture of both, is advocated. The most convenient, and common form of administering anaesthetics was a cloth or paper folded in the shape of a cone, with a sponge in the apex. It was placed at some distance over the nose and mouth of the patient to allow the first inhalations to become diluted with air, and then gradually advanced to the nose until anaethesia was produced, when the inhalation was suspended. The method of Marshall Hall, by placing a double fold of muslin over the mouth and nose of the patient and simply dropping the chloroform on it drop by drop, was found to be tedious, and inoperative in the open air, where many of the operations were performed, owing to rapid evaporation. In the southern armies, where chloroform was scarce, Surgeon J. J. Chisolm, finding that much chloroform was wasted by these methods, employed a flattened cylinder two and a half inches long and one inch wide in its broadest diameter, having in one of its broadest surfaces a perforated plate. Attached to the cover are two nose pieces. When the instrument is not in use these projections can be pressed into the cylinder, thus diminishing the size of the instrument. In the interior of the cylinder is found a piece of sponge, or what is much better, a bent wire, over which is folded a piece of cotton cloth. The chloroform when dropped through the perforated plate is received upon the sponge or folded cloth, which offers an extended surface for evaporation. It has been stated that the nature of the anaesthetic employed was indicated in eight thousand nine hundred cases, viz: chloroform in six thousand seven hundred and eighty-four, ether in one thousand three hundred and five, and chloroform and ether in eight hundred and eleven cases. Of the six thousand seven hundred and eighty-four cases in which chloroform was used, death was ascribed to this agent in thirty-seven, or 5.4 per thousand;(1) of the one thousand three hundred and five cases in which the anaesthesia was in,luted by ether, four deaths, or 3.0 per thousand; and of the eight hundred and eleven cases in which a mixture of chloroform and ether had been employed, two deaths, or 2.4 per thousand, were charged to the anaesthetic. Deaths from Chloroform.--Thirty-seven cases were reported: (1) CHISOLM (J. J.). (A Manual of Military Surgery for the use of Surgeons in the Confederate States Army, Columbia, 1864, pp. 429-30) : "Of the many thousand instances of its administration since the war between the Confederate States and United States began, but two fatal cases from chloroform inhalation have been reported. In one, the patient died in a few minutes after inhalation was commenced. In the other, the patient did not die for several hours. The case was that of a healthy young soldier who had a minié ball embedded under the scapula, and who, while en route to rejoin his command, stopped at a hospital and desired its removal. The operation was very tedious, and he was kept under the influence of chloroform for one and a half hours. Although he regained his consciousness when the administration was stopped, his pulse never reacted, notwithstanding the liberal use of brandy. A few hours after the operation was completed there appeared an increasing disposition to sleep, which gradually ended in coma, the pulse becoming more and more feeble. He died thirty-two hours after the inhalation. As the operation affected no vital part and as the health of the patient was good, his death could be attributed to no other cause than the inhalation of the chloroform." Considering the great number of cases in which chloroform was applied, principally during and after the exciting circumstances of a battle, when expedition was a matter of necessity, it is remarkable that not more cases of death from this agent have been recorded. With what justice the fatal issues in the cases here cited are chargeable to the anaesthetic the reader must judge for himself.   Deaths from Chloroform and Ether.--Two cases were reported. In one case, although the patient's condition would appear to have been favorable, no efforts at resuscitation seem to have been made; in the other case it is doubtful whether death was due to the severity of the injury or the anaesthetic: Deaths from Ether.--Four cases were reported. In three cases death was probably due to the shock and the effects of the ether combined; in one an overdose was administered: The reports of the surgical operations of the war are very deficient in regard to the quantities of the anaesthetic used, the manner in which it was administered, the time required to produce insensibility, the period during which it was maintained, or the unfavorable symptoms following its application; the reports of the medical officers of the army after the war were somewhat fuller on these points.   There appears to have been some inconsistency regarding the reporting of the use of chloroform and deaths attributed to its use.  Given the volume of anesthetic provided during the war, it is possible post-mortem reports were either missing or inaccurate as to the cause of death which could be attributed to chloroform vs ether.  The post-war analysis seems to be defensive about its use.   Chloroform,  Ether, and the Civil War Article on anesthesia during the Civil War Article on chloroform during the Civil War Additional information on the Chisolm ether and chloroform inhaler