DEATHS UNDER CHLOROFORM

'DEATH under Chloroform' is only too frequent a heading to a newspaper paragraph. The statement is usually appended that according to the medical evidence death was owing to failure of the heart's action, and the cause of such failure is always assumed by the public to have been the chloroform acting directly upon a weak heart.

This is undoubtedly the inference that the administrator desires should be drawn, and it is encouraged by the silence of the medical profession-an inexcusable silence for men who know what the facts are in such cases. The elaborate and painstaking labours of the Hyderabad Chloroform Commission in 1889, and of Drs. Gaskell and Hare in 1893, cannot be unknown to the members of the medical profession, though the public perhaps has rarely heard of them, and they have apparently borne little fruit in England. As I write, I have before me an article on the Report of the Chloroform Commission, written in January 1890, and the letter from the Prime Minister of Hyderabad, written in January 1894 to the four medical men-two of them English physicians and two American-who had subsequently made independent researches on behalf of the Nizam's Government with the view of further testing the conclusions arrived at by the Commission-conclusions which they emphatically endorsed.

The Report of the Commission is of the deepest interest to the public, as any one of us may have to take chloroform some day, and on the way it is administered will depend our ease or our suffering, and possibly our lives. I have myself been under chloroform twice in England, and yet oftener in India, and it is my own personal and painful experience of the difference in the manner in which it is administered in India and in England that impels me to write, in the hope of arousing sufficient interest to stir up a revolt against the method of administering chloroform too commonly practised in England, and thereby save others from suffering as I have done. Public feeling is curiously apathetic in the matter. It is too generally looked upon as a question for the medical profession only. This is a view I cannot take. To my mind it is a question so personally, so vitally affecting us all, that it seems to me the lay world has a

right to make its voice heard-the voice of those who have suffered. It is too late when they have been silenced for ever.

So far from being surprised at the number of deaths that occur in England from chloroform, I, like the Chloroform Commissioners, am only surprised that they are not far more numerous. The percentage, I am aware, is small, but the annual tale of victims is nevertheless large far larger than is generally known-and, according to the report of the Medical Commissioners, it should be nil.

It is the custom of many practitioners in England (I speak only from my own experience) to administer chloroform in direct opposition to the principles laid down by the Hyderabad Commission, and to the way practised in India. There the primary consideration is that nothing shall in any way impede the patient's breathing, and the operator consequently takes care never to place the pad or handkerchief very close to the mouth, holding it invariably at a distance of some inches, so that the chloroform may be freely diluted with air. In this way I have taken it some half-dozen times, and, far from having experienced the slightest distress, I found the sensation exceedingly soothing and agreeable as long as consciousness lasted.

In England my experience has been far otherwise, and my dread of taking chloroform is now almost as great as the dread of being smothered or drowned. Having suffered great distress the first time, I entreated the administrator on the last occasion to allow me air the whole time, telling him how greatly I dreaded the feeling of suffocation I had experienced. He merely answered, somewhat testily, that I must allow him to act as he thought best, and those present assured me in chorus that he was one of the best-known chloroformists in London. I was helpless, and I submitted. At first he held the hollow pad some inches from my mouth, and I inhaled the fumes with perfect ease and comfort, drawing deep and regular inspirations; but no sooner was I half unconscious than he clapped the pad over my nose and mouth in the way I had so dreaded. I struggled furiously for breath, but could inhale nothing but the burning, choking fumes of the chloroform, that felt as if pure alcohol were being poured down my throat, and made me gasp and choke in an agonising manner. I became frantic in my efforts to obtain air, and the few moments that elapsed before unconsciousness came to my relief were to me a prolonged agony. I am perfectly certain that had I not been physically strong, and my heart and lungs sound, I must have succumbed, in which case I should have furnished another paragraph to be headed Death under Chloroform,' and the public would have heard that my death was owing to failure of the heart's action.' Dead men tell no tales, and my frantic and futile struggles for air would never have been known.

The memory of that struggle for life will never leave me; it sets

my heart beating violently at night sometimes when I merely recall it, and it is in the hope of saving others from such an experience that I now refer to it. That this is a common mode of administering chloroform seems certain, as it is improbable that I should have met with the only two men, both chloroformists of repute, who administerit in this way. I know also of another case in my own family in which it was given in a precisely similar manner to a young girl, whose terror and horror of chloroform are now as strong as my own.

of it is that of having been done to death by suffocation.

The memory

As to the medical view of the danger thus incurred, a few extracts may be quoted from the two sources previously mentioned. If any reader wishes to obtain the Report of the Hyderabad Chloroform Commission, I have no doubt it can be procured in England. If it were published in a cheap pamphlet form and widely disseminated, it would do much towards preventing the barbarous mode, too prevalent in England, of administering one of suffering humanity's greatest blessings.

The objects of the Chloroform Commissioners, kept in view throughout their experiments, were to test the safety of chloroform as an anæsthetic and compare it with ether, and with the mixture of alcohol, chloroform, and ether known as the A.C.E. mixture; to persevere with these anæsthetics till death resulted; to note the different effects produced by the drugs and by asphyxia; and to investigate especially the alleged liability of chloroform to produce stoppage of the heart. To this end no fewer than 588 experiments were made, principally on dogs and monkeys, who passed from unconsciousness to a painless death. The Report gives the fullest scientific details of each case, and embodies the results of the most lengthened and most carefully tested series of experiments with anææsthetics ever made Its keynote, recurring over and over again with added emphasis, is that chloroform anasthesia is entirely free from risk as long as the breathing is in no way interfered with; and that in death from chloroform the respiration always stops before the heart does.

Two conditions modify the effect of chloroform in the most important manner; these are struggling and holding the breath. The ultimate effect of struggling is to cause acceleration of the respiration and circulation, and therefore to increase the intake of chloroform into the system, especially if the administrator holds the cap or inhaler down tightly over the nose and mouth. . . . When the inhaler is held close to the mouth, the patient involuntarily holds his breath; but when this is no longer possible, deep respirations follow, and the heart and circulation are violently accelerated. If the chloroform is still held to the face by an ignorant administrator, an overdose is taken in and may destroy life with the greatest possible rapidity. As chloroform has been given on wrong principles for over forty years by an immense number of chloroformists, it is amazing that deaths have not been more numerous. . . . When chloroform is given continuously by any means which ensures its free dilution with air, it causes a gradual fall in the mean blood pressure, provided the patient's respiration is not interfered with in any way, and

he continues to breathe quietly without struggling or involuntary holding of the breath, as almost always happens when the chloroform is insufficiently diluted.

Those surgeons who, dreading heart failure, attend to the pulse and overlook the signs of approaching danger which are invariably given by the respiration, have deaths; while those who are guided entirely by the respiration and watch it in such a way as never to allow it to be interfered with, give chloroform with unbounded confidence and freedom, and such absolute safety as to preclude the possibility of doubt as to the soundness of their principles.

The Commission has been able to demonstrate conclusively that chloroform has no direct action on the heart, . . . and has proved that the sudden effects on the heart's action are not really due to the chloroform at all, but are the result of asphyxia or suffocation.

. . The pulse is never appreciably affected by chloroform except through interference with the breathing or by over-dosing, which is practically the same thing. . . . The heart can only be affected under chloroform by interference with the breathing. It can make no difference as regards the direct effect of the anaesthetic whether the heart is sound or unsound, strong or feeble. Provided the breathing is in no way interfered with, chloroform renders a surgical operation in the case of a patient with heart disease infinitely safer than it would be if it were not employed.

The clinical statistics put forward by the late Professor Syme presented an unbroken record extending over forty-two years, from 1847 to 1889, and still unbroken in 1894, of chloroform administered on his principles in England and India without a death.

The researches of the Commission and the subsequent experiments devised by Drs. Gaskell and Shore have placed the proofs that chloroform does not directly affect the heart on an unassailable basis. At the Hyderabad Hospital, chloroform is given by students with uniform and perfect safety, solely because the inhalation is never allowed to interfere with the patient's breathing, and the heart is entirely disregarded as a factor in the administration.

I may refer those who wish for fuller information on the subject to the Report itself. Enough has here been quoted to show how absolutely at variance with the conclusions of the Medical Commission is the manner in which chloroform is often administered in England, and how full of danger it must be, not to speak of the terrible misery it inflicts on the patient.

When this paper was originally written I was not aware that the editor of the Hospital had been drawing attention to the frequency of deaths from chloroform, and had, since the beginning of 1897, been collecting and tabulating the newspaper reports of inquests held on persons who had died under the influence of anæsthetics. The result of his inquiry supports my own personal experience very strongly, and is sufficiently startling to rouse even the apathy of the lay world, since none of us can tell how soon we ourselves may be compelled to place our life in the hands of a chloroformist.

On the 27th of March the Hospital published its first article on the dangers of anæsthetics, and said: We find that already in this year, not a quarter of which has yet passed, twenty-two deaths from chloroform have been recorded. It is a ghastly list of catastrophes

to happen from the same cause in the course of three months in a country the size of England.' On the 24th of April, and again in subsequent numbers of the Hospital, the editor gave lists of inquests collected from the general press; and he wishes it to be understood that these lists, having been drawn entirely from the published reports in newspapers, constitute, therefore, the very minimum of fatal cases. He adds that there are circumstances which make him feel somewhat doubtful if all the deaths that have occurred from this cause have ever obtained publicity. Even should there be no room for such a doubt, and if this list might be accepted as an exhaustive one, it is sufficiently terrible. No fewer than eighty-eight inquests were held in the past year on persons who had died from anæsthetics, seventy-five of them from chloroform. Nor does this constitute the whole mortality from this cause, as when the editor began to collect the data he confined his attention to chloroform alone, and only in the second half of the year included deaths from ether.

He points out a marked difference between the deaths under ether and those under chloroform. Most of the deaths under ether occurred some time after the anesthetic had been administered, and in some cases were clearly due to the severity of the operation and not to the effects of the ether. In the deaths under chloroform it was very different. No single fact,' he says, 'is more striking than the frequency with which death took place at once, apparently as the direct result of the action of the drug. It seems impossible to avoid the conclusion that in these cases the dose was too great.'

Nowhere is any reference made to the Report of the Hyderabad Chloroform Commission, and the question is spoken of throughout as if it were quite an open one, and as if the Commissioners' patient investigations and weighty conclusions were unknown. If this were not so, a passage in their Report, already quoted, might have been mentioned as authoritatively confirming the editor's own conclusion. The heart can only be affected under chloroform by interference with the breathing or by over-dosing, which is practically the same thing. He goes on to say:

Then comes the great question-Is this overdose the result of certain patients being peculiarly susceptible to the influence of chloroform, so that a very small dose becomes with them an overdose; or is it the result of faulty methods of administration, which allow the vapour to be administered in too concentrated a form? The experience of the laboratory, as well as the fact that in some of these cases the patients had previously taken chloroform without any difficulty, all points to the conclusion that it is the accidental absorption of too concentrated a vapour that is the cause of death.

Now, the Medical Commissioners assert distinctly that when chloroform is administered without being freely diluted with air it is accompanied with great danger. Those whose hearts are strong will live to battle through the struggle for air, but those with weak