Source: Snow, John. Medical Times Gazette 4 (1852): 349-50. [ltr. to ed., 3 April 1852]
On the administration of chloroform in the public hospitals
(To the Editor of the Medical Times and Gazette)
Sir,--However trivial a matter the exhibition of chloroform may have been considered by many on its first introduction, I believe there is no one who does not now look on it as a subject requiring the utmost care and attention, together with a thorough knowledge of all the symptoms it may induce. The possible consequences of want of attention or skill are so serious, that the office of administering chloroform should no more be delegated to a dresser than the important operation of surgery, or even to a house-surgeon, where he holds the office for a limited period. While fully acknowledging the great attainments of the gentlemen who usually occupy the office of dresser or hours-surgeon in the London hospitals, I consider that there are grave objections to their having charge of the chloroform. As these offices are frequently changed, the duty has to devolve, every now and then, on an individual who is quite a stranger to it in practice, and, as the operation is about to begin, his eyes are directed to the proceedings of the operator, and no one is looking to the effects of the chloroform.
No person ought to administer chloroform without first making its action a subject of special attention; and, as there requires to be some one always on the spot to administer it on emergency in the public hospitals, it should be the duty of a permanent resident medical officer. This plan has been found to answer perfectly where it has been acted on. At St. George's Hospital, for instance, Mr. Potter was appointed to the duty of giving the chloroform, between two and three years ago; and I believe there has been no alarm or uneasiness respecting it in any case. In University Hospital, Mr. Clover has, I believe, performed this duty since the early part of 1848, with an equally satisfactory result. In St. Bartholomew's Hospital, the chloroform was long administered by Mr. Tracy, and all went on well; but since it has been entrusted to dressers, two accidents have happened--one a fortnight ago, which was fatal; and one a few months ago, in a case of Mr. Stanley's, which had well nigh ended fatally. Where accidents have happened in hospital practice, there has been no person regularly deputed to manage, or even to superintend, the inhalation; and, notwithstanding what has been said of the experience of the gentleman who administered it in the late fatal case at St. Bartholomew's, it appears that, when questioned at the inquest, he was unable to state what are the signs indicating danger during the administration of chloroform. The fact of deaths not occurring in the hands of persons who have given great time and attention to the subject, cannot be attributed to mere coincidence, for, when chloroform is administered by a uniform method which insures the sufficient dilution of the vapour with air, the results are so regular and so completely under control, as to afford proof that danger can be altogether avoided by care and skill.
I have heard it said that, although the person giving the chloroform may be inexperienced, yet there are able practitioners looking on; but the action of this agent, when not well managed, may be so rapid that there is not time to give directions, and it is necessary, therefore, that the thought and the action should be combined in the same person. Moreover, if supervision were sufficient, it would still be requisite to appoint a superintendent, for "what is everybody's duty is nobody's duty," and the attention of every one is generally absorbed by the surgical operation, if the chloroform [349/350] is not under the management of some competent and responsible person.
The best defence that can be made for entrusting the exhibition of chloroform to the advanced pupils of an hospital is, that they thereby gain practical experience in it previous to having to apply it in their own practice. But if it be thought necessary that they should have this practical experience, let them begin first (as indeed every one ought to begin) by using sulphuric ether; using it, however, under the guidance of a responsible superintendent, such as I have mentioned; and when they have become well acquainted with the various stages and degrees of narcotism, and can manage the ether properly, it will be time enough to try the more potent agent.
It is often said that chloroform should not be employed in minor operations; but, if it can be employed without incurring any danger, there is no reason thus to limit its use; and, unless a person feel confident that he can employ it without running the least risk, he ought not to use it in any case. For the truth is, there is never any greater reason for giving it than that of avoiding the slight pungency, strong odour, and other little inconveniences of sulphuric ether. It is much to be regretted, in my opinion, that chloroform was introduced before the greater number of the Profession had had time to become fully convinced of the great merits of the last-named agent, which, when properly applied, produces all the advantages of chloroform, and is at the same time as safe as a medical man could desire; for, if any agent safer than sulphuric ether should be introduced, patients and nurses would apply it, and it might degenerate into a domestic remedy, and be abused.
I shall not enter on the manner of giving chloroform, or the rules to be observed in its use, as I have treated these points on other occasions.*
I am, etc.
John Snow, M.D.
(* Medical Gazette, 1848, Vol. II., pp. 333, 412, 615, 840, et seq.; also Medical Times, 1850, Vol. II., p. 223; and present Vol., p. 253.)
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