Source:  Snow, John. BMJ 1 (April 3, 1858): 279. [ltr. to ed., 27 March 1858]

Death from chloroform

Letter from Dr. John Snow, M.D.

Sir,--I am surprised to find that Mr. Prichard has taken offence at my late-communication on chloroform, and for a reason that is purely imaginary. He says that I referred to the two unfortunate cases which occurred in Bristol as if they were the only fatal instances on record. On the contrary, I referred to them only in comparison with all the other cases. Any one who has never heard of chloroform would perceive from my paper that there had been a number of other fatal cases, forty-nine of which, at least, had been recorded. I cannot perceive that there was any cruelty in referring to two cases which had been published in the Journal in which I was writing; but there would have been a cruelty in my neglecting to speak, on any suitable opportunity, of the advantages and perfect safety of chloroform, when properly and carefully managed, which I had witnessed almost daily for more than ten years. The proposal of Mr. Prichard to use anæsthetics only in a few great operations would almost abolish the greatest improvement that was ever made in surgery; for the fact of their application being so limited would make them a terror to the few patients who were allowed to inhale them.

I do not propose that any risk should be incurred by the administration of chloroform, but, on the contrary, that, unless a person is satisfied that he can give chloroform without risk, he had better use sulphuric ether. It was not merely because no one had recorded a death from sulphuric ether, that I spoke of its safety, but also because it will not cause those very sudden deaths in animals which depend on paralysis of the heart, and which chloroform can be made to produce at will. Only a small part of the dose of ether which it is necessary to inhale can be present in the lungs at one time; whilst a very large proportion, even the whole dose of chloroform, may be contained in the lungs at once. The question of the amount of vapour in the air under different circumstances is one of vital importance, and which every one must attend to who wishes to understand the action of narcotic vapours. Mr. Prichard must be wrong in supposing that it is the condition of insensibility that puts the patient in peril of his life. Hundreds of thousands of persons have been insensible without harm; whilst Mr. Prichard's own patient, and several others, died from chloroform without being made insensible at all.

I thought I had made my opinion sufficiently clear in my paper, that chloroform may be given with safety to every patient requiring a surgical operation; and that danger does not depend on the kind of patient, but on the way in which the agent is given. I am not aware of ever having written opinions which are inconsistent with each other. I have used the same kind of chloroform inhaler for upwards of ten years, with very slight alteration; and during the progress of operations on the face, when I cannot use the inhaler, I employ the mixture of equal parts by measure of chloroform and spirit, which I have thought it right to recommend to those who do not wish to study and adopt and inhaler. I use chloroform generally in preference to sulphuric ether, because it is more convenient, and can be made equally safe.

I admit that most persons who have written on chloroform are opposed to its use in cases of fatty degeneration of the heart; but they write without experience. I am opposed to the pain of the knife being inflicted on such patients; and I write from experience of the favourable action of chloroform on a great number of patients having all the symptoms of fatty degeneration well marked. In several cases, the disease was verified in patients who died a few days after great operations.

Mr. Prichard is welcome to his own opinion as to the cause of the death of the patient with fatty heart to whom I was administering chloroform; but he is wrong when he says that any one else than myself would come to an opposite conclusion from my own. The only medical man present besides Mr. Hawkins and myself when that patient died, was Mr. George Pollock. He had had great experience of the action of chloroform, and was well acquainted with the patient. He gave me his opinion, without being asked for it, that the patient died of his heart-disease, and not of the chloroform. That patient was benefited very much by previous inhalations of chloroform, and probably had his life prolonged by them. He was relieved of a stone in his bladder the year before his death, by lithotrity, under chloroform, when Mr. Hawkins was of opinion that he could not have borne the operation without being put in a state of anæsthesia.

I am, etc.,

John Snow.

18, Sackville Street, March 27th, 1858.

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