Use of Sulphuric 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."
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
