Anesthetics in The Civil War
Source for this article: "The Medical and Surgical History of the War of the Rebellion. (1861-65.) --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, W
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.
Fig. 424 CHISOLM'S Inhaler. Spec 4910
In reference to the propriety of giving alcoholic stimulants prior to the administration of ether and chloroform, the records of the war supply little definite information. They give simply the number of cases in which anaesthesia was induced, and frequently not even the name of the anaesthetic employed. In cases in which the effect of the anaesthetic was believed to have led to a fatal result special reports were made. These special reports throw little light on the question, since they include, in almost equal proportion, cases in which stimulants had, or had not, been administered prior to the inhalation of the anaesthetic. Some surgeons advise the use of stimulants prior to anaesthesia uniformly; others deprecate the practice except in rare cases, and others again discard it altogether. When there is extreme depression, alcoholic stimuli will of course be employed, in conjunction with other restoratives, to bring about reaction. But when the patient is in a fit state to undergo a major operation, a stimulant should not be given with especial reference to the anaesthesia about to be induced, as it would seem that in the practice of surgeons who habitually employed the stimulants the patients were less readily anaesthetized. It would be better to reserve the stimulant as a restorative in the course or on the completion of the operation, that it may aid in reducing reaction instead of retarding the induction of anaesthesia.
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
(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."
which a mixture of chloroform and ether had been employed, two deaths, or 2.4 per thousand, were charged to the anaesthetic. Brief abstracts of the fatal cases are given.
Deaths from Chloroform.--Thirty-seven cases were reported:
CASE 1233.--Surgeon M. K. Hogan, U. S. V., reports that Private Sylvester Anninger, Co. F, 147th New York, aged 27 years, received a shot fracture of the left; leg, at Spottsylvania, May 12, 1864. He was at once carried to the field hospital of the 3d division, Ninth Corps. He died May --, 1864, "under chloroform."
CASE 1234.--Corporal ---- Ballou, Co. E, 14th Pennsylvania Cavalry, fracture of bones of right hand, April, 1863. Operation for removal of fingers October 12, 1863. Chloroform inhaled without unpleasant symptoms; upon removing index finger pain was evinced; small additional portion given and operation recommenced, when patient struggled violently; arterial hemorrhage ceased to flow; tongue found to not have fallen back upon rima glottidis; usual means of exciting respiration applied; good current of fresh air; patient rolled from side to side; artificial respiration resorted to; spirit of ammonia applied to nostrils and cold water dashed on chest and face, without effect. In the opinion of Surgeon W. B. Wynne, 14th Pennsylvania Cavalry, the operator, the patient was not under the effects of the anaesthetic five minutes before life was extinct. At the autopsy the lungs were found to be perfectly healthy; the heart presented some appearance of slight ossification.
CASE 1235.--Private J. Bradley, Co. D, 25th North Carolina; slight wound of patella; admitted into Chimborazo Hospital, Richmond, June 25th; necrosis and gangrene. July 18th, amputation at junction of upper and middle thirds of thigh. There was but little blood lost, but the patient sank under the operation and expired a few minutes after its completion. It is remarked, upon an unsigned case-book, that "the chloroform may have, by its depressing effect, contributed to this unfavorable result, for it caused him to vomit freely, and he was unable to retain any stimulants in the stomach."
CASE 1236.--Private G. Budlinger, 76th Ohio, aged 30 years, admitted into hospital of 1st division, Fifteenth Corps, with a shot wound of hand; placed upon operation table and about a drachm of chloroform sprinkled upon four folds of patent lint applied to face, space being given for the free admission of air. After breathing it for a few moments quietly without any apparent effect, more chloroform was added and reapplied by a nurse in attendance (the surgeon having stepped aside for a moment), when, after six or seven respirations, the patient drew up his legs and arms convulsively, and heavy stertorous breathing came on. Chloroform removed immediately, and a few moments given him to resume his regular breathing, but the difficulty increased; frothy exudation from mouth not caused l,y excess of saliva; respiration became more and more incomplete, pulse small and imperceptible, veins of neck and face prominently distended; heart action ceased before respiration had entirely stopped. Friction to extremities, cold water dashed in face, jugular vein opened, artificial respiration, without relief. The surgeons of the hospital reported, as the result of an autopsy, that "being unable to discover any other abnormal condition, and its the absence of further evidence, it may be proper to conclude that this is a case of apoplexy induced by chloroform."
CASE 1237.--Private J. G. Clarkson, Co. A, 35th Massachusetts, age 40 years, is reported by Surgeon F. M. Lincoln, 35th Massachusetts, to have died in hospital at Falmouth, Virginia, "from the inhalation of chloroform administered for the performance of an amputation," January 20, 1863.
CASE 1238.--Private J. Conley, Co. A, 90th Illinois, aged 18 years; shot fracture left ankle joint, Mission Ridge, November 25, 1863; ball lodged; admitted into hospital No. 1, Nashville, February 4, 1863. Surgeon R. L. Stanford, U. S. V., reports that the patient "died from the effects of the chloroform at the time of the operation of extraction of the ball," and forwarded the specimen of the lower portions of the left leg, rite astralagus, and calcaneum; they constitute Spec. 3360 of the Surgical Section.
CASE 1239.--Private P. Conlin, Co. G, 11th New Jersey; shot perforation knee joint, popliteal artery cut; Ream's Station, September 17, 1864; considerable haemorrhage; patient in a very nervous state and having great fears of the result. Stimulants were given, and after he had rallied a little he was placed upon the table and chloroform administered. Plenty of fresh air was allowed during the administration and he passed through the usual stages necessary to insensibility, but died before the contemplated operation was commenced, having just reached the point of insensibility. The only observable symptoms which were unusual were the high state of nervous excitement while the chloroform was being administered and the very small quantity required to render him insensible. Methods for resuscitation freely used for half an hour without effect. A post-mortem examination revealed nothing abnormal in the size or appearance of the organs.
CASE 1240.--Sergeant S. Crumbaker, Co. A, 35th Virginia Cavalry, aged 44 years, was admitted into the Confederate hospital at Charlottesville in May, 1864, with a pistol ball perforation of the head of the humerus, received at the Wilderness, May 6th. On May 11th chloroform was administered and the head of the humerus was excised. He is reported to haw? died May 16, 1864, "from the effects of the chloroform."
CASE l241.--Private T. Donaldson, Co. E, 13th Ohio Cavalry, aged 19 years; shot injury left humerus, Poplar Springs, Virginia, October 8, 1864; admitted into hospital at Beverly, New Jersey. Necrosis of humerus. October 29, 1864, amputation of left arm at shoulder by antero-posterior flaps by Acting Assistant Surgeon J. C. Morton; chloroform used. Patient "died from the effects of the chloroform and nervous shock to the general system." The upper part of the humerus was forwarded to the Museum by Assistant Surgeon C. Wagner. U. S. A., and is numbered Specimen 3706 of the Surgical Section.
CASE 1242.--Private D. Flynn, Co. A, 18th Infantry, admitted into hospital No. 19, Nashville, January 5, 1863, with a compound fracture of fingers of right hand, received December 31, 1862. January 8th, chloroform administered with a due proportion of atmospheric air; patient was rather troublesome, struggled, etc. A relaxation of the muscles testifying to anaes-thesia, the chloroform was suspended and the operation commenced; just after the formation of the anterior flap the patient commenced to breathe stertorously, and at that instant the brachial pulse suddenly ceased; there was an up and down movement of the thyroid cartilage, a swelling out almost to bursting of the external jugular veins, blue lips, a pupil insensible to light, and an ashy paleness. Cold water dashed in face, aqua ammonia to nostrils and upon thorax, tongue drawn forward with tenaculum, artificial respiration kept up, and the principles of Marshall Hall's method of respiration put into requisition, but without effect; patient expired after one or two long-drawn sighs. Amount of chloroform expended was about two drachms. No autopsy possible.
CASE 1243.--Private R. Gormley, Co. I, 7th New York Artillery, admitted into McClellan Hospital, Philadelphia, June 13, 1864, with a shot wound of the lower third of the right leg; ball lodged. On November 29th chloroform was administered with a view of removing the ball. The anaesthetic was given with great caution, and inhaled with perfect facility until the operation was nearly completed. Acting Assistant Surgeon W. E. Ely slated that "the patient's pulse continued good, and nothing of unusual interest presented itself until the incision had been made, when I was suddenly deterred from proceeding in search of the ball by a spasmodic rigidity of the muscles, such as generally occurs immediately before the point of complete anaesthesia is attained. The patient, who had up to this time appeared perfectly sensible of external objects, suddenly threw his head back and almost immediately expired. Cold water was dashed into his face, ammonia was applied to his nostrils, his mouth was kept open, and his tongue drawn forward, while Hall's ready method of artificial respiration was kept up for nearly an hour, but only with the effect of producing three or four long inspiratory efforts, when life became entirely extinct." Dr. Ely was assisted by Acting Assistant Surgeon A. S. Uhler.
CASE 1244.--Private Thomas Hamilton, Co. A, 1st Maryland Infantry, aged 31 years, admitted into Patterson Park Hospital, Baltimore, June 25, l864, with a gunshot wound of the hand. September 3, 1864, patient placed on table to undergo an operation for necrosis of the carpal bones. A sponge wet with chloroform was carefully held at first some three or four inches from the face, and at no time less than two or three inches. The patient inhaled for about five minutes and still remained conscious frequently making some remark. He soon, however, commenced muscular efforts, such as are quite common with patients inhaling chloroform, except that the muscular contractions were more violent than usual. Before the contractions ceased the pulse grew feeble and the chloroform was withdrawn for two or three minutes; the breathing continued regular, only that the patient occasionally took a deep inspiration and expired forciblyf, then the muscles became relaxed; the operation was commenced; but the respiration soon commenced to fail and the pulse became imperceptible; the operation was stopped. All known means for resuscitation were resorted to, but life had fled. The friends of the deceased could only be persuaded to allow an examination of the heart. The organ was found of normal size and appearance; both auricles were distended with venous blood, but the ventricles were empty. A clot of white fibrin, streaked in some places with coagula of blood, was found in each auricle.
CASE 1245.--Private Robert Harris, Co. G, 132d New York, was admitted into Ward Hospital, Newark, New Jersey, May 4, 1864. Surgeon George Taylor, U. S. A., reported that the patient died on May 20, 1864, while under the influence of chloroform administered for the purpose of amputating the leg.
CASE 1246.--Private John Johnson, Co. B, 2d Pennsylvania Heavy Artillery, a patient in Mower General Hospital, near Philadelphia, expired suddenly on May 13, 1865, while inhaling chloroform preparatory to undergoing a surgical operation. The case is reported by Surgeon J. Hopkinson, U. S. V.
CASE 1247.--Private John Kroft, Co. D, 7th New York, shot fracture leg, Petersburg, September 16, 1864. Admitted into hospital at Beverly, New Jersey, September 28th. Amputation of leg October 8th. On November 16th a second amputation was found necessary; at the previous operation sufficient chloroform was administered to produce complete anaesthesia without unpleasant effect. On the latter date chloroform was administered on a sponge, from one drachm to a drachm and a half--in all not over an ounce was given. He had been upon the table about fifteen minutes when fatal symptoms were manifested, and he died in from five to six minutes. An autopsy revealed no pathological lesions sufficient to account for death. Assistant Surgeon C. Wagner, U. S. A.. reported the case.
CASE 1248.--William Laws, Co. E, 23d North Carolina, aged 24 years, shot wound of groin, fracturing tuber ischii; admitted into hospital No. 1, Frederick. October 28th, chloroform was administered to remove the fragments of the ischium. The chloroform was administered on a pocket handkerchief which was pressed firmly against the mouth of the bottle which was then inverted. Plenty of air was given, and the handkerchief was wet with chloroform but once. About a minute after the administration was begun almost complete relaxation was produced, and two stertorous respirations were observed, when the handkerchief was immediately removed. The pulse up to this time was undisturbed; the patient then took some ten or twelve deep and rather rapid inspirations, with quickened pulse, when respiration suddenly ceased; the pulse continued for six or eight beats, which were slower and feeble, and then suddenly ceased. Artificial respiration was immediately resorted to by Marshall Hall's ready method, which produced distinct respiration, but no pulsation. Having kept it up for about twenty minutes without result, the case was given up as hopeless. An account of the post-mortem appearances, together with other details of the case, will he found in CASE 703, page 242. Second Surgical Volume.
CASE 1249.--Colonel McGilvray, Chief of Artillery of the Tenth Corps, was slightly wounded in the forefinger of the left hand. at Flussus Mills. August 17, 1864. Excision of the joint was advised, and, on September 4th, chloroform was administered; about a drachm of the anaesthetic was poured on a sponge enclosed in a towel folded funnel-shaped. The patient came very kindly under its influence, about two drachms of chloroform in all being used. The period of excitement did not last over a minute and a half. The operation was commenced; the pulse was then beating steady and firm at about 65, respiration slow and regular; at the time the inhalation of the chloroform had been discontinued for at least two minutes; at the moment of the first incision the pulse and respiration at the same moment ceased without the slightest warning. The face flushed for a moment, and then became pallid; the eyes were fixed and not suffused. About half a minute after the cessation of respiration the patient made one or two spasmodic attempts at respiration and then was still. Artificial respiration was commenced and kept up for an hour, but in vain. The heart and lungs were examined on the next day, but did not indicate the cause of death. The particulars of the case were communicated by Surgeon A. M. Clark, U. S. V.
CASE 1250.--Sergeant George S. Moss, Co. C, 125th New York, received a shell wound of the penis, scrotum, and thigh, at Gettysburg, July 3, 1863; the missile lodged among the muscles of the back of the thigh. The patient desired to have the <ms_p3v2_892>missile removed, but positively refused to be touched without the administration of chloroform. On August 8th a stimulant was given and the anaesthetic was administered; in one minute the patient came under its influence, the shell fragment was removed in less than half a minute, and additional stimulant administered; pulse became suddenly weak, and the patient died almost instantly. It was the opinion of surgeons present that the patient died from valvular affection of the heart.
CASE 1251.--Private Patrick Murphy, Co. B, 111th Pennsylvania, aged 22 years, admitted into hospital at Murfreesboro', Tennessee, October 28, 1863, with shot wounds of right knee joint :and in centre of forehead, received at Brown's Ferry, Tennessee, on the same day. On admission patient was wild, delirious, and unruly, but a few hours afterwards seemed partially to recover his senses. On October 30th amputation of the thigh was performed. On loosening the tourniquet no blood escaped from the vessels, and the patient was observed to be in a state of collapse. Stimulants were freely given, but without avail. He died on the table soon after the operation, probably from the effects of chloroform. A section of the anterior portion of the cranium, showing a partial fracture and depression of the centre of the frontal bone, was forwarded to the Museum by Assistant Surgeon John C. Norton, U. S. V., and is numbered 2139 of the Surgical Section.
CASE 1252.--Private C. M. Odell, Co. I, 36th Wisconsin, received a shot fracture of the head and shaft of the humerus, at Cold Harbor, June 3, 1864. Amputation was deemed necessary; his pulse was good, and he walked to the operating table unassisted. Chloroform was given until complete relaxation of the voluntary muscles was produced; the amputation was performed, the arteries ligated, and the flaps were about to be closed, when respiration suddenly and quietly ceased. Artificial respiration was set up, but without success. The autopsy showed the heart much enlarged, without thinning of the walls, and distended on both sides with a grumous fluid and tough grayish clot, which extended into the great vessels.
CASE 1253.--Surgeon J. F. Patterson, 131st New York, states that "on June 11, 1863, the 114th New York was ordered to take a. position in front of our line, and while advancing to execute the order one of the privates shot himself in the foot and was carried to the field hospital for treatment. An amputation being deemed necessary, chloroform was administered by the assistant surgeon of the 1st Louisiana in such a manner that death almost immediately ensued. The surgeon of the 114th, whose name I believe was Wagoner, opened the chest of the cadaver about fifteen minutes after death, and finding the lungs lying on the back of the chest announced that death was occasioned by collapse of the lungs." The case of William Rathbone, Co. K, 114th New York, who received a gunshot wound of toe of left foot at Port Hudson. Louisiana, and who died, is reported by Surgeon L. P, Wagner, 114th New York, but no details of the case are furnished.
CASE l254.--Surgeon S. A. Richardson, 13th New Hampshire, in a special report of the surgical operations performed at Flying Hospital, Twenty-fourth Corps, March 30th to April 9, 1865, remarks: "Manuel Silver, Private, Co. F, 10th Connecticut, gunshot comminuted fracture of the left humerus by conoidal ball. Flap amputation left arm in middle third by Surgeon H. C. Levensaler, 8th Maine, April 2, 1865 (primary operation). Died during the operation, from effects of chloroform given by Surgeon De Landre, 158th New York. Was brought under the influence of chloroform with difficulty."
CASE 1255.--Sergeant Major Adolphus Spaeth, 9th Ohio, was admitted into Cumberland Hospital, Nashville, September 24, 1863, with a shot fracture of the right wrist. The ball passed upward on the palmar aspect of the forearm nearly to the bend of the elbow, but so deeply embedded as not to be found. He had violent erysipelas of arm and great constitutional disturbance. Three or four days afterwards the ball was removed from the deep layer of muscles opposite the upper third of the radius, palmar aspect. His general condition continued bad. On October 17th he was placed upon the table for amputation at the middle third of humerus. During the administration of chloroform death took place with scarcely a premonitory symptom. The post-mortem exhibited venous congestion of both lungs, evidently produced by the chloroform, the lungs being otherwise perfectly healthy. The quantity of chloroform inhaled did not exceed two drachms.
CASE 1256.--Private George E. Stannard, Co. G, 14th Connecticut, admitted into Finley Hospital, Washington, with a shot fracture of left ulna, received at Fredericksburg December 31, 1862. Patient was a perfectly healthy, robust man, of lively temperament, rather pale in color. On January 28, 1863, chloroform was administered for the purpose of removing the loose pieces of bone. About two drachms of the anaesthetic were sprinkled on a towel and placed to the nose; in about five or six minutes he came under its influence; the usual struggle came on just preceding complete anaesthesia, when he suddenly ceased to breathe and his pulse failed. Every effort to resuscitate him failed. The history of the case, together with the specimen of the lower extremity of the left ulna, was contributed by Surgeon I. Moses, U. S. V.; the Specimen is numbered 859 of the Surgical Section of the Museum.
CASE 1257.--Corporal C. F. Tarbell, Co. D, 21st Maine, aged 19 years, shot wound of left thigh, at Port Hudson, May 27, 1863. He was removed to the regimental hospital, where it was found necessary to amputate the thigh in the middle third. Surgeon G. E. Brickett, 21st Maine, reports that the patient died May 27, 1863, from the effects of the chloroform.
CASE 1258.--Private G. N. Titus, Co. G, 8th Vermont, was admitted into regimental hospital at Algiers. Louisiana, August 21, 1862, with a wound of one of his toes. Chloroform was administered by Surgeon H. H. Gillett and Assistant Surgeon S. H. Currier, 8th Vermont, for the purpose of amputating the injured toe. The patient expired suddenly, before the operation, was commenced. Assistant Surgeon L. C. Herrick, 4th U. S. Colored Cavalry, reports the case.
CASE 1259.--Surgeon Edwin Bentley, U. S. V., reports that a Confederate soldier, a large, robust, muscular North Carolinian, after the battle of Hanover Court House, May 29, 1862, underwent amputation of the thigh. The operation was performed in the open air and very little blood was lost. A large amount of chloroform had been administered without the patient becoming at all unconscious, when the surgeon forced him to large and free inspirations and he became immediately under its influence. Just after the completion of the operation the pulse sank rapidly, and he appeared to cease to breathe simultaneously with the effects of the anaesthetic.
CASE 1260.--Surgeon John A. Lidell, U. S. V., in his report of the operations of the medical staff of General Sedgwick's division of the Second Corps, at Fair Oaks, states: "A soldier of General Richardson's division was placed on the table and <ms_p3v2_893>chloroform administered for the purpose of amputation of the thigh for gunshot comminuted fracture of the femur in the neighborhood of the knee joint. While inhaling the chloroform he suddenly became pale, pulseless, and ceased to breathe, dying on the operating table while the amputation was going on."
CASE 1261.--Private J. W. Whitlock, Co. K, 111th Illinois, gunshot wound of left elbow joint, Dallas, Ga, May 31, 1864. Admitted into hospital of 2d division, Fifteenth Corps, same day; chloroform administered for the purpose of operating, but he died from its effects. An autopsy revealed extensive adhesions of the pericardium and hepatization of the right lung. The case is reported by Surgeon J. B. Potter, 30th Ohio.
CASE 1262.--Unknown soldier, with a shot injury necessitating amputation at the knee joint; chloroform, was administered, and the patient died while the operation was being performed. Surgeon D. P. Smith, U. S. V., the operating surgeon. states that the anaesthetic was administered too profusely by an entirely incompetent person, who was subsequently dismissed from the service.
CASE 1263.--Corporal A. Wilde, Co. H, 61st New York, wounded at Deep Bottom, August 19, 1864; distal phalanx of thumb shattered; admitted into hospital of 1st division, Second Corps. Assistant Surgeon C. Smart, U. S. A., reports that chloroform was given, and after about three drachms had been taken the patient became much excited and passed into a violent convulsion, in the midst of which he died. At the autopsy the heart was found small and firmly contracted, its walls being in contact and the cavities obliterated.
CASE 1264.--Private Lewis Winters, Co. I, 11th Michigan, aged 40 years, Atlanta, August 7, 1864; conoidal ball in lapper third right thigh. Admitted into hospital No. 8, Nashville, August 20th; gangrene. October 27th, preparatory to cleaning and burning the wound Acting Assistant Surgeon R. W. Forrest commenced to administer chloroform from a sponge surrounded with a napkin, plenty of atmospheric air being admitted. Not more than half an ounce of chloroform was poured upon the sponge. His pulse was good, and he was judged to be a healthy man. After inhaling the chloroform for about three minutes a very severe spasm came on; his head was thrown violently back, his body arched, resting on top of head and feet, the arms were drawn up, and the hands violently clenched. The chloroform was withdrawn; the spasm relaxed in a few seconds; his head and face became very much congested. Cold water was instantly dashed over his face and chest and ammonia applied to the nostrils, and every means that could be devised to resuscitate kept up for more than an hour without effect. Autopsy: Five points of cicatrization from scarification for cupping; considerable serous effusion under aracnoid and filling sulci; vessels on surface of brain much congested; pleuritic adhesions very firm on both sides; left lung deeply engorged with dark blood, frothy serum exuding from cut surface, and numerous small chalk-like deposits found near the surface; heart normal in size and appearance.
CASE 1265.--D. Zebriske, Co. I, 12th Alabama, admitted into hospital No. 5, Frederick, October 18, 1862, with a shot flesh wound left hip, traversing deep portion of gluteal muscles; Antietam, September 17, 1862; ball lodged. October 19th, chloroform, administered with a view of removing missile. No unusual symptom was observed; but while the operation was in progress and the patient not in the act of inhaling the vapor, it was discovered that he had ceased to breathe. The autopsy threw no light on the cause of death. The subject was anaemic, and exhausted by hardship and depleted by suppuration. The report of the case was made by Surgeon H. S. Hewit, U. S. V.
CASE 1266.--Private G. G. Allison, Co. A. 6th New York Artillery, aged 43 years, admitted into hospital at Beverly, New Jersey, July 7, 1864. On February 7, 1865, he was placed upon the table to be operated on for fistula in ano. Chloroform was administered in the ordinary manner; room was well ventilated and the vapor of the chloroform freely diluted with atmospheric air; full anaesthesia was produced, when the pulse rapidly failed, and in a very brief period death took place. The quantity of chloroform inhaled did not exceed two drachms. Every effort was made to restore life by artificial respiration, ammonia, stimulants, etc. An autopsy was made twelve hours alter death; the brain, thoracic and abdominal viscera were very carefully examined, but nothing detected sufficient to account for death; the brain was very slightly congested. Assistant Surgeon C. Wagner, U. S. A., reported the case.
CASE 1267.--Private Francis Heward, Co. F, 1st New Jersey, was admitted into Fairfax Seminary Hospital, April 5, 1862, with a dislocation of left humerus forward and inward of a few hours' standing. Surgeon Henry A. Armstrong, 2d New York Artillery, reduced the bone without assistance. On May 6th Acting Assistant Surgeon H. W. Ducachet discovered that the bone wits again out of place in the same direction. The patient was chloroformed and reduction attempted with the heel in the axilla, but without success. On the 9th pulleys and counter-extending hands were obtained and adjusted. Chloroform was again administered, a drachm being poured upon a piece of lint about two inches square and held about three inches from his face, a towel being thrown over the head of the patient and hand of the operator, and which was removed from time to time to admit air. Some time elapsed before the muscles became relaxed, when the chloroform was removed. There was no stertorous breathing, choking, or struggling, nor was there occasion to use force to keep him down, as at the previous administration. There was, as there always is, congestion of the conjunctiva and vessels of the neck, but not as much, certainly not more, than when the chloroform was administered on the 6th. Reduction was being attempted when symptoms of asphyxia were noticed; the pulleys were instantly relaxed, the tongue drawn forward, and artificial respiration resorted to, but everything failed. No autopsy was made. The report of the case is signed by Surgeon H. A. Armstrong and Acting Ass't Surgeon H. W. Ducachet.
CASE 1268.--T. A. Leaning, Co. H, 76th New York, a patient in Eckington Hospital, was troubled with stricture of the urethra. An attempted examination by the catheter was so painful that chloroform was administered on a handkerchief, pains being taken that the patient had plenty of air by holding the handkerchief far enough away from the face. In a few minutes the rigidity of the muscles yielded, but only partly, and two or three stertorous respirations were taken. The chloroform was immediately suspended and the examination by the catheter commenced. The instrument had only been introduced to about the membranous urethra when an involuntary evacuation of both bladder and bowels took place; the patient at that moment ceased to breathe and his face grew purplish. The action of the heart could not be observed at this time since the administrator had not his finger on the pulse. On being immediately observed, no pulsation could be felt at the wrist nor observed on auscultation over the heart. The tongue was immediately pulled forward with a tenaculum, but as no respiration succeeded, Marshall Hall's ready method of artificial respiration was immediately commenced. The temporal artery was also instantly cut, but only a few drops of blood escaped. Respiration incomplete and obstructed by eructation; passive vomiting, with friction of the surface by the hand and by a stiff brush, and stimulating injections of ammonia and turpentine were kept up for over two hours with no favorable result and the attempt at resuscitation was then given up. Acting Assistant Surgeon W. W. Keen, jr., who reports the case, remarks of the autopsy that "almost the only things strictly abnormal were the enormous congestion--probably passive--of the heart, fluidity of the blood, and the absence of rigor mortis."
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:
CASE 1270.--Private Henry Jefferson, Co. E, 19th Colored Troops, aged 20 years; shot fracture of femur two inches below trochanter major, August 14, 1865; doing well until October 16th, when the pus became rusty. November 17th, Acting Assistant Surgeon H. Raphael, at the post hospital at Brownsville, Texas, administered an anaesthetic of two parts of ether and one part of chloroform with the intention of excising the ends of the bone; hut after inhaling two minutes the patient began to sink pulse failed, spasms occurred, the head was drawn back and hands and feet were in a tremor; the sponge was removed, and the patient rallied; but upon re-administration spasms immediately returned, the pulse stopped, and the patient was dead.
CASE l271.--Lieutenant Colonel J. C. Hodges, 44th Indiana, was injured on the railroad, September 27, 1864. The right femur was fractured and the soft parts lacerated; the left os calcis was also fractured; considerable haemorrhage. At the patient's urgent request a mixture of chloroform and ether was administered. The pulse improved slightly, and amputation of the thigh was decided upon. Five minutes before the conclusion of the operation the breathing was noticed to be stertorous and soon intermitting, with flagging pulse. Artificial respiration was immediately resorted to by posture and by compression of chest at intervals, while the tongue was drawn forward by an assistant. This procedure gave much encouragement for a long time--indeed, for two hours the indications of returning vitality and consciousness seemed to depend entirely upon the vigorousness of the efforts at artificial respiration, but every effort failed to restore life.
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:
CASE l272.--Captain John Brennan, Co. A, 16th Virginia, shot wound, right thigh, lower third, Weldon Railroad, October 27, 1864. Admitted into Harewood Hospital October 31st. The condition of the wound was good, but haemorrhage occurred November 10th, from the popliteal artery, by which ten ounces of blood were lost. The artery was ligated in popliteal space, and the patient did well until November 21st, when the limb became dematous. November 25th, haemorrhage recurred to the amount of twelve ounces; it could not be controlled, and the limb was amputated; the patient died on the operating table from the shock and effects of ether. At the post-mortem no abnormities could be discovered, with the exception of slight venous conjestion of the right, lung and old adhesions of the left. The case is reported by Surgeon R. B. Bontecou, U. S. V.
CASE 1273.--An unknown soldier received, in 1862, a shot fracture of the condyle of the femur. The patient was stout and exhibited no symptom of exhaustion or severe shock; his heart acted with uniformity and strength; amputation was decided on and ether was administered, which produced insensibility in about ten minutes. As soon as the operation was begun the patient seemed to be regaining consciousness; but it required only a few seconds to restore complete anaesthesia. The assistant then removed the ether from the patient's face, but was ordered by the operating surgeon to renew the application. After one or two inspirations the patient ceased to breathe. The saw had not been applied nor the use of the knife been finished when death occurred. The case is reported by Dr. Walter Burnham.(1)
CASE 1274.--Private John Maxwell, Co. E, 159th New York, was wounded before Port Hudson, May 27, 1863, just below the knee, implicating the joint. He lay on the field of battle until midday of the 28th. His pulse was small and feeble and his
(1) BURNHAM (W.), (Death from the Effects of Sulphuric Ether [in an overdose.--ED.], in The Boston Med. and Surg. Jour., 1870, Vol. VI, p. 377.
nervous system much prostrated. He was fed on beef tea and stimulants. He was brought to the field hospital, and three hours later ether was administered to him with a view of amputating the wounded leg. After being partially anaesthetized he was removed from where he had been lying and placed upon the operating table. More ether was then administered, and as soon as the patient appeared to be sufficiently narcotized a circular incision was made just above the knee joint. The assistant holding the pulse remarked that the circulation was failing, and efforts were immediately made to induce restoration of the vital energies by drawing out the tongue, throwing back the head, artificial respiration, and dashing of cold water. All was in vain, and the patient died May 28, 1863. The case is reported by Surgeon C. A. Robertson, 159th New York.
CASE 1275.--Private Henry S. Ware, Co. K, 38th New York, aged 23 years, was struck by a shell in the upper part of the right leg. at the battle of Williamsburg, May 5, 1862, for which injury the limb was removed on the field, at the middle third of the thigh, He was admitted into the general hospital at David's Island, New York Harbor, on June 15th, and came under the care of Acting Assistant Surgeon E. B. Root on June 26th, at which time his general condition was bad. He was suffering from diarrha and a very large bed-sore. The wound had nearly united but the bone was denuded. The constant discharge from the stump necessitated the removal of the necrosed bone. On October 9th the patient was placed under the influence of ether and an inch of bone removed with the chain saw, and then two inches off the bone with its involucrum. During the operation the femoral artery was divided, but not much blood was lost. Altlough it was found that more of the shaft was involved, further operative interference was deemed unnecessary. The patient was removed to his bed, when severe vomiting commenced which continued to the time of his death, seventy-two hours subsequently. The post-mortem examination showed all the viscera healthy. Surgeon S. W. Gross, U. S. V., ascribes the death to the effects of the ether superadded to the previous exhausted condition of the system. The constant vomiting and retching could not be arrested.
A few instances are recorded in which suspended animation was restored by energetic and prompt interference. The following two may serve as examples:
CASE 1276.--Private A. Boyd, Co. C. 38th Georgia, received a shot fracture of the right elbow joint, at Gettysburg, July 1, 1863, and was admitted to hospital at Frederick five days afterwards. Water dressings were applied until July 18th, when considerable dema of the limb having become apparent, with redness about the joint, a resection of the injured parts was decided upon. The patient having been brought to the operating room, ether was administered by a Medical Cadet for fifteen or twenty minutes without producing anaesthesia, when from one and a half to two drachms of chloroform was added to the sponge and closely placed over the patient's mouth and nose. In the course of thirty or forty seconds stertorous breathing was produced, whereupon Assistant Surgeon R. F. Weir, U. S. A., in charge of the hospital, proceeded to operate and commenced the incisions. About this time, however, pulsation in the brachial artery was noticed to be running down rapidly, and the respiratory movements of the chest and abdomen were observed to have ceased, when one of the attending surgeons was instructed to examine the patient's tongue, and finding it had not fallen back, "Marshall Hall's" ready method was purposed and instantly applied. After this had been kept up for about half a minute and no respiratory effort had been observed, the operator immediately proceeded to open the larynx, when, after artificial respiration by means of compressing and relaxing the chest and abdominal walls for the period of about two minutes, natural breathing was re-established and pulsation of the radial artery could be felt. There was scarcely any haemorrhage from the incision, and none, perhaps, entered the trachea. The edges of the wound were drawn together by adhesive straps. It not being thought proper to proceed with the operation of excision, the patient was returned to his ward and stimulants ordered to be given freely, also generous diet. He rested fairly and took broth very freely the next morning; pulse 130 and quite feeble; respiration quite easy. During the next night and for several days afterwards the patient had a daily chill, and there was considerable cough, with well marked capillary bronchitis throughout the whole extent of the left lung; tongue coated and brown; wound of elbow but little disposed to suppurate. These symptoms continued to grow worse, and subsequently there were several slight haemorrhages from the incision over the olecranon process. During the last few days the patient's swallowing became very difficult, and beef tea and whiskey were administered by means of clysters. Death supervened on July 28, 1863. The post-mortem examination disclosed a small abscess on each side of the sternum, just beneath the pleura-costalis and about one and a half inches below the clavicles, and confirmed the existence of capillary bronchitis. The history of the case was furnished by Acting Assistant Surgeon W. S. Adams. The lower third of the injured humerus and a wet preparation of the upper portion of the trachea, the cricoid cartilage, and larnyx, showing the incision made, were contributed to the Museum by the operator, and constitute Specimens 3901 and 4080, respectively, of the Surgical Section.
CASE 1277.--Private S. R. Green, Co. A, 5th New Hampshire, was wounded in the leg, at Gettysburg, July 2, 1863, by a minié ball, which fractured the tibia and fibula. Amputation at the middle third of the leg was performed at a field hospital by Surgeon C. S. Wood, 66th New York, who made the following report: "Out of the hundreds of cases in which I have administered chloroform this is the only the accompanied by any unpleasant symptoms; here the patient sunk under its use, was apparently dead, and respiration and circulation both ceased. But by the continual use for some ten or fifteen minutes of Marshall Hall's ready method he was restored and the operation was proceeded with. The cause was evidently inattention on the part of the administrator." The patient subsequently died at the Seminary Hospital at Gettysburg on July 30, 1863.
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; but to make them as complete as possible, the following order was issued in 1876 from the Surgeon General's Office:
CIRCULAR ORDERS, NO. 2.
WAR DEPARTMENT, SURGEON GENERAL'S OFFICE,
WASHINGTON, October 2, 1876.
With a view of collecting precise data relative to the effects of chloroform and ether, Medical Officers are instructed to record, during the year 1877, the cases in which recourse is had to anaesthetics, noting the following particulars: Name and age of subject; nature of the anaesthetic; the quantity used in maintaining anaesthesia; the time required to induce complete insensibility; the time the anesthetic influence was maintained; the mode of administration; whether vomiting, excitement, or great prostration was observed during or after the administration. These memoranda will be transcribed and returned on the Quarterly Reports of Wounded for March, June, September, and December, 1877.
BY ORDER OF THE SURGEON GENERAL:
Assistant Surgeon General, U. S. Army.
As the number of cases in which anaesthesia was employed during the year 1877 was limited, the order was continued in force by the following:
CIRCULAR ORDERS, NO. 1.
WAR DEPARTMENT, SURGEON GENERAL'S OFFICE,
WASHINGTON, May 20, 1878.
Circular Orders No. 2, of October 2, 1876, from this Office, will be hereby continued in force until further orders. Medical Officers will render reports accordingly.
BY ORDER OF THE SURGEON GENERAL:
Assistant Surgeon General, U. S. Army.
The information thus obtained is here briefly given: The total number of cases since the close of the war, in 1865, in which anaesthesia was produced, is one thousand two hundred and ten (1,210). Of these chloroform was used in three hundred and fifty-five (355), ether in five hundred and eighty-seven (587), and ether and chloroform in two hundred and sixty-eight (268) cases. In the cases reported previous to the issue of Circular Orders No. 2, Surgeon General's Office, 1876, the data are, like those of the war, very incomplete, and we will therefore confine ourselves to the consideration of the cases reported since the issue of that order. They number five hundred and ninety-seven (597); in one hundred and fifty-seven (157), or 26.3 per cent. of these, chloroform; in one hundred and eight (108), or 18.1 per cent., chloroform and ether; and in three hundred and thirty-two (332), or 55.6 per cent., ether was administered. In three of the cases death was ascribed to the anaesthetic--to chloroform in one, to chloroform and ether in one, and to ether in the third.
The smallest quantity of chloroform used to induce anaesthesia was three-fourths of one drachm, of chloroform and ether one drachm, and of ether two drachms; the largest quantity of chloroform ninety-six drachms, of chloroform and ether one hundred and thirty drachms, and of ether two hundred and fifty-six drachms; the average amount of the agents used was chloroform eleven, chloroform and ether thirty-two, and ether fifty-one drachms. The average time in which insensibility was induced by chloroform was nine minutes, by ether and chloroform seventeen minutes, and by ether sixteen minutes, as shown in the following table:
Statement of Five Hundred and Ninety-seven Cases of the Employment of Anaesthetics, showing Quantities used, Time to induce Anaesthesia, and Period during which it was maintained.
CASES QUANTITIES USED TIME TO INDUCE
Chloroform 157 ¾ 96 11 ½ 35 9 1 180 22 Chloroform and Ether 108 1 130 32 1 60 17 1 130 26 Ether 332 2 256 51 1 55 16 235 26
The rapidity of the effects and the saving in quantity in the use of chloroform, so important to the field surgeon, especially after large battles, is at once apparent. There is hardly any difference in the average time required to produce anaesthesia by ether or by chloroform and ether.
Vomiting was recorded in twenty-three (23), or 14.6 per cent., of the one hundred and fifty-seven (157) cases of chloroform; in thirty-two (32), or 29.6 per cent., of the one hundred and eight (108) cases of chloroform and ether; and in ninety-eight (98), or 29.5 per cent., of the three hundred and thirty-two (332) cases of ether,--the relative frequency being nearly the same in the cases in which ether or ether and chloroform was used, and less in the cases of chloroform, as well as less copious:
Statement showing the Frequency of Vomiting, Excitement, and Prostration in Five Hundred and Ninety-seven Cases of Anaesthesia.
CASES VOMITING EXCITEMENT PROSTRATION
None Slight Copious None Slight Marked Violent None Slight Marked
Choloform 157 134 20 3 113 23 9 12 136 11 10 Choloform and Ether 108 76 25 7 68 24 10 6 95 11 2 Ether 332 234 83 15 202 85 31 14 295 24 13
Excitement was likewise reported less frequently in cases in which chloroform was administered than in those in which chloroform and ether or ether was used, the percentages being 28.0 in chloroform, 37.0 in chloroform and ether, and 39.1 in ether; but, as the figures in the table indicate, it seems to have been somewhat more violent in the cases of chloroform narcosis, although in one case in which ether was employed the excitement was so intense that the use of the anaesthetic was abandoned and the operation completed without anaesthesia. Prostration was reported in twenty-one, or 13.3 per cent., of the cases of chloroform; in thirteen, or 12.0 per cent., of the cases of chloroform and ether; and in thirty-seven, or 11.1 per cent., of the cases of ether.
In four of the one hundred and fifty-seven cases in which chloroform was used slight disturbance of respiration was noted, and in two cases respiration ceased and the pulse stopped, but life was restored after prolonged efforts. Pulse and respiration were likewise suspended in two instances in which ether and chloroform, and in one in which ether alone, had been used; they also were brought back to consciousness. In three cases death was ascribed to the anaesthetic. A case of death from chloroform is reported by Assistant Surgeon R. Barrett, U. S. A.:
CASE 1278.--Private A. L. Bruce, Co. G, 13th Infantry, aged 26 years, suffered from bleeding internal piles, and deriving no benefit from a palliative treatment it was decided to relieve him by operation. After abstaining from solid food for sixteen hours the patient was, on August 22, 1877, placed on the operating table and the administration of chloroform was commenced. The inhaler used was a towel folded cone-shaped, with an inch aperture at the apex. Fearing that this opening was not sufficiently largo to admit of the free access of atmospheric air, the inhalation was discontinued and the opening enlarged to twice its former size. The inhalation was then resumed, the patient at this time lying on the table and quietly observing the operations going on around him. I am thus minute as I wish to show that the patient was perfectly conscious when the second inhalation began. He took the anaesthetic kindly for about a minute, when he suddenly sat upright and asked if his piles were out. I replied "No, lie down;" he said "All right doctor, I have the utmost confidence in you." His head had hardly touched the table when his radial pulse ceased and his face became intensely congested; his breathing was stertorous and a large quantity of froth appeared on his lips. I directed the attendants to seize his heels and hold him up, head down, at the same time <ms_p3v2_898>applying aqua ammonia to the nostrils. His respiration was now reduced to an occasional gasp, and finding the Nélaton position of no benefit I had him laid on the table, and drawing forward his tongue with a forceps introduced a large gum catheter into the trachea and gently blew air into the lungs; this was repeated several times, the air being forced out after each inflation by pressing on the thorax. While attempting artificial respiration I ordered an enema of whiskey, which was retained, but was immediately followed by a copious discharge of urine. This was the last act of the patient's life, for he was now dead, and I reluctantly discontinued my efforts to revive him. I have estimated the quantity of chloroform used as about two drachms. Death no doubt occurred from paralysis of the heart, as there was no evidence of a pulse after it first ceased at the wrist. After the patient's death I learned that he had stated that he had heart disease and expected to die under the operation.
Assistant Surgeon C. E. Price reports a case of death from the administration of ether; the case was hopeless before the operation was begun:
CASE 1279.--A. J. Moore, aged 50 years, suffered for about six years from the results of a contusion of the knee. The joint became swollen and painful, and an examination in May, 1878, showed that the bone had become diseased. Amputation or resection was advised, but the patient refused to be operated upon, and gradually became worse until July 11th, when he finally consented to an amputation. He was then put on a generous diet with stimulants. However, he grew rapidly worse. The urine had only a trace of albumen, but there was dema of the lungs with evidence of great effusion in the pleural cavity. His breath began to be labored, and there were large, coarse, moist tales in both lungs, while the effusion almost destroyed all movement in the left lung and impaired that of the right. He became greatly alarmed, as in two or three coughing spells he was nearly strangled to death. He now begged me to operate, and said he was sure to die very soon if I did not. When I explained the dangers of the operation he said he knew it all, but that it gave him a possibility of life. Having no assistant of any kind, I called upon Lieut. Halloran, 12th Infantry, who had on several occasions attended to the administration of an anaesthetic for me. I read to Lieutenant Halloran and gave him to study the instructions as given in Ashhurst's and Erichsen's Surgery, and explained to him the importance of closely watching the effects of the anaesthetic. I had but six ounces of ether (Squibb's), so I took the bottle of chloroform for use in case the ether should prove insufficient. With Lieutenant Halloran to attend to the anaesthetic and two soldiers for assistants I began. At first I attended to the anaesthetic myself. After a few breaths of the ether I said: "Moore, do you feel it?" He said: "A little." A few more breaths and he said: "Wait a minute and give me a rest ;" I replied "all right," but kept along with the ether. After a few moments more I gave the sponge to Lieutenant Hal-loran and began applying an Esmarch's bandage. I had wrapped it up to the lower part of the swelling about t.he knee when I looked up and said to Lieutenant Halloran "take away the sponge," and noticed that his breath had stopped. Lieutenant Halloran replied: "His pulse is good," but by the time I felt it it had disappeared. I instituted artificial respiration at once, applied nitrite of amyl to his nostril, and injected ammonia into a vein of the arm. I kept up artificial respiration after Sylvester's method for three-quarters of an hour, but it was of no avail. In the chest a large effusion was found in the pleural cavity, with stringy pus and bands of adhesion in many places. The upper and middle portions of the left lung were thickly filled with points of caseous deposit, and in many of these spots were deposits which were as hard as and seemed to be solid limestones. The right side of the heart was dilated and nearly full of clotted blood; the left side was nearly empty.
The details of a case in which first ether and subsequently chloroform were administered are given by Assistant Surgeon P. J. A. Cleary, U. S. A.:(1)
CASE 1280.--Private H. D. Bradfield, Co. H, 19th Infantry, aged about 33 years, large and robust, addicted to liquor, was admitted to hospital December 3, 1878, suffering with an injury of the middle finger, right hand, resulting in gangrene of the second and third phalanges, and in consequence it was decided to amputate at the metacarpal articulation. For this purpose a mixture of equal parts of ether fortior and chloroform was administered. About ten minutes previously two ounces of whiskey were given. I examined his heart and found it normal in every respect. The anaesthetic was administered on a piece of lint, covered with a small towel, held square in contradistinction to cone-shaped. I personally administered the mixture while the steward observed his pulse. The cloth was held so as to allow a free admixture of air. He inhaled freely. About two drachms were first poured on the cloth, but had no apparent effect. Shortly after about the same quantity was poured on; he observed that "he did not feel it." After a time about the same quantity was again poured on, and, as I turned to look at some instruments, he requested me not to begin yet to cut him. A further quantity was now poured on the cloth, when he began to laugh; this was followed by attempts to articulate, then, as is common, by strong gesticulations of his arms, to stop which the steward forcibly pressed down one arm, holding him by the wrist, while an attendant did likewise with the other. He was now passing to a state of unconsciousness, and in reply to my inquiry the steward said he could not feel the pulse, but added that his arm was somewhat twisted, which prevented his perceiving the pulse. I therefore felt for the pulse at the other wrist, but could not perceive it. Just as I felt, the muscles of his arm and neck, which had been strongly in action, suddenly relaxed; his breathing, however, was very good and such as would in no wise have attracted attention. At once I removed the anaesthetic and dashed some cold water in his face. The pulse did not return. He continued to breathe freely for a little time longer, then his breathing became labored, and then suddenly stopped. The action of the heart had previously stopped, and the man was dead. I will add that everything I ever heard of, saw, or read, appropriate for such cases, was done, but to no effect. The mixture consisted of chloroform and ether fortior; amount used exactly one ounce; time in using it, fifteen minutes. Cause of death, paralysis of the heart. Of the entire amount used one-half only was chloroform, i. e., half an ounce. Of this amount a large proportion was wasted over the cloth and which he never inhaled; the inhalation of the remainder occupied fully fifteen minutes.
(1) The case has been reported in the Philadelphia Medical Times, 1879, Volume IX, age 280.
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