Death in Bristol

An exchange of views between Augustin Prichard (consultant anesthetist, Frenchay Hospital, Bristol) and John Snow

by R. M. WELLER

Source: Anaesthesia 31, 90-96, 1976.

In 1858, Augustin Prichard, FRCS (Fellow of the Royal College of Surgeons) (1818-1898), Honorary Surgeon to the Bristol Royal Infirmary, reported a death in a record of the transactions of the Bath and Bristol branch of the British Medical Association dated 25 February 1858 which was published in the British Medical Journal [1]. 

Case report

The patient, a man of 49 years, was admitted for ‘excision of the elbow for long continued disease of the joint’. ‘His health had suffered, inasmuch as he was greatly out of condition, from the discharge and constant pains; but he showed no sign of organic disease.’

On Friday, 12 February ‘he walked into the operating room... and got up without much help and lay down upon the table. Mr Powell, the assistant house surgeon examined his chest as he invariably does before administering chloroform, but he detected nothing abnormal. The patient had taken no food since breakfast: this rule is always followed, when possible, to prevent the chance of vomiting, and the danger of solid food impeding respiration by obstructing the glottis when the patient is insensible from the effects of chloroform. A drachm (one drachm = 3.4 ml) of chloroform (which had been obtained from Duncan and Flockhart of Edinburgh) was poured upon the center of a hollow sponge, and held over the patient’s nose and mouth. He asked whether he was to breathe it; and was, of course, told to do so. I then found that he still had his waistcoat on, and directed him to sit up and take it off, which he did, the sponge being removed for the purpose; and after he lay down, I again made him sit up and remove the shirt sleeve from the diseased arm, a process that took 2 or 3 minutes, in consequence of the pain produced by any sudden movements of the limb. He then lay down again, and continued to inhale a portion of the same drachm of chloroform which had been evaporating all this time. I turned round to speak to some of the surgeons of the Infirmary, who were standing near the fire, and in about 2 minutes, my attention was drawn to the patient by the assistant house surgeon saying "this patient does not bear chloroform well". He was then gasping but not breathing; his limbs were moving slowly and irregularly in the convulsive motion of death; the eyes were fixed, with dilated pupils; and his pulse had stopped; and he was, in point of fact, dead, as surely as, and more rapidly than, if he had taken a large dose of prussic acid.’

‘We tried every means of restoration. A powerful battery was at hand, and going, and was applied at once. I opened his trachea; and we kept up artificial respiration for half an hour, by blowing into the tube and pressing the abdomen alternately. The battery was applied with sufficient strength to contract forcibly the muscles of the face, neck and trunk, and to produce the movements of respiration, but without affecting the heart in the slightest degree; and at the suggestion of one present, I injected a warm saline solution into the cephalic vein, to try to stimulate the heart; but all our efforts were in vain, for the man was dead.’

Autopsy

The post-mortem examination showed nothing abnormal, except a heart much covered with fat, with the muscular structure generally pale, containing fat disposed in rows among the fibrillae.

Prichard’s comments

Prichard’s report continues with some remarks on the case which emphasized his lack of faith in anesthesia.

‘I need hardly say that to witness a scene of the kind which I have described impresses most forcibly upon us the grave responsibility we incur when we use chloroform for any but the most severe operation, and makes us realize the dangers which we have, up to this period, escaped.’

‘I may, perhaps, be allowed to record my present opinion respecting chloroform, and to repeat what I said when I had the honor of reading the annual address before the members of the Branch last summer. I then said, and still think, that "if we are in the constant habit of using any agent which destroys life once in the course of some thousand cases, it is a very grave matter", and that "we are not justified in using it in all trivial operations"; It should never be administered when the stomach is full; and it should be given, as has been recommended by others, diluted with alcohol or ether and, of the two, the former is to be preferred. The horizontal position should always be maintained; and I believe that the danger would be lessened were the patient to take, immediately before the inhalation of the chloroform, a glass of wine or brandy and water, or some other effective stimulus.’

Local discussion

Various suggestions were made to improve the safety of chloroform in a discussion that followed Prichard’s report. While we might agree that patients with fatty degeneration of the heart need less chloroform, and that it should be given slowly and well diluted with atmospheric air, the suggestion of a Dr Davey would perhaps no longer find favor. He, ‘considered that, in cases having such a fatal tendency, a stimulant applied over the solar plexus was the most effective remedy. A piece of tow or rag, dipped in brandy, placed on the epigastrium, and then set fire to, was a most effective stimulant of the solar plexus. Chloroform should be administered so gradually as to effect only the cerebro-spinal system. As fatal cases would occasionally occur, we must, beforehand, be prepared with remedies to relieve the otherwise fatal syncope. The more effective were stimulating enemata, cold affusion, and rapid vesication of the skin.’

The case was summed up by Dr Richard Budd, Physician to the North Devon Infirmary. He observed ‘that every member of the profession must keenly feel the importance of such cases... ‘. The patient ‘died from the primary action of the chloroform on the cardiac ganglia, whereby the action of that single muscle, on which all the functions of life depend, was instantaneously stopped. The fatal cases by use of chloroform must be divided into two groups: in one, death arose from prolonged use of the remedy, the whole tissues of the body being permeated by the poison; in the other group, it was fatal by the impression on the nerves of the heart.’ 

Dr. John Snow presents his views in Part 2.

Continue to Death in Bristol - Part 2

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