Blood and Guts

by Richard Hollingham

  * There have been several studies over the years that show the placebo effect is actually quite an effective treatment. If patients believe a drug is doing them good, they tend to recover more quickly.

  Nevertheless, and despite the scientific evidence, doctors were reluctant to abandon bloodletting altogether. At the turn of the twentieth century it remained a recommended treatment for high blood pressure (based on the 'common sense' argument that less blood meant less pressure). Even as late as the First World War, the technique of bloodletting was applied to the victims of gas attacks in the trenches.

  Aside from blood, there were plenty of other bodily secretions to worry about. Urine in particular was seen as a valuable diagnostic tool. Not its chemical composition – its protein or sugar concentration – but its colour. Much, it was said, could be read into the colour of urine. Some specialists made their diagnosis on urine alone. Flasks of urine would be sent to them by other doctors for a specialist opinion. Often, somewhat inevitably, the prescribed treatment for the patient's ailment would be bloodletting. And so it went on. Doctors seemed to be struggling to keep up with scientific developments. Surgeons, on the other hand, were as eager as ever to try something new.

  MR SIMPSON CONDUCTS SOME INTERESTING

  EXPERIMENTS

  Edinburgh, 1847

  * * *

  Ether was gaining in popularity, but the anaesthetic did have its drawbacks. It was a noxious gas to breathe, irritating the mouth and lungs. It had a tendency to induce vomiting in patients. The flask and tubes involved in administering it were awkward, and its effectiveness proved inconsistent. But the biggest problem was ether's high flammability.

  Ether was being used only inches from the naked flames of the gas lights hanging over the operating table. The slightest upset and the gas was likely to explode in a ball of flame. There was also no way of telling how the prolonged use of ether would affect the patient. Would it leave them permanently unconscious or even brain damaged? Surgeons were used to their patients dying, but this seemed an especially unnatural way to go. There was also the question of its pedigree: it had been invented by a maverick 'Yankee' dentist. This was deeply unsettling to British, scientifically trained surgeons.

  The only way the medical questions were going to be answered was to experiment on patients. Surgeons, of course, usually had no problem with this. Some, however, felt the drawbacks of ether were too great and started to look for an alternative.

  James Simpson was a young professor of midwifery at Edinburgh University. As a student under Robert Liston, Simpson had attended his first operation aged just sixteen (he qualified in medicine at eighteen). The horror of the experience had lived with him ever since. Now head of obstetrics, he realized that every day he was witnessing more pain than ever.

  Simpson was the son of a village baker, so to have risen to such a high position within the Scottish medical establishment was a remarkable achievement. He appears to have won the post through a combination of political persuasion (money may or may not have changed hands), public campaigning and, above all, an overwhelming sense of confidence and self-belief. It helped that he was also an excellent surgeon.

  During a visit to London, shortly after the first ether operation, he had the opportunity to talk to Liston and confirm what was involved in the procedure. Perhaps he could apply pain relief during childbirth to relieve the terrible suffering some women had to endure? But questions about ether's safety become even more important when childbirth is involved. The gas would not only have to be used over a long period – hours possibly – but there was no knowing what effect it could have on the foetus. Might the child be killed or born an idiot? Simpson would also have to contend with religious and moral objections to the use of pain relief. Surely the pain of childbirth was a natural process? Didn't Genesis state that woman should bring forth her children in sorrow?

  But Simpson was a driven man. He spent that summer trying out every chemical he could lay his hands on. He mixed a whole variety of substances together, drank and sniffed a cocktail of compounds. Every chemical that might prove a suitable candidate was inhaled or ingested. Then one day Simpson tried a new chemical that had been suggested by a Liverpool chemist. He woke up on the floor.

  The last substance Simpson had tried before he passed out was known as chloroform. A colourless liquid composed of alcohol and chlorinated lime, chloroform had been invented some fifteen years earlier and marketed both as a treatment for asthma and a stimulant. That it had quite the opposite effect was an early cautionary lesson to not always believe what the pharmaceutical industry puts on the bottle. After trying the chemical a few more times, Simpson decided that chloroform needed rigorous testing before he used it on patients. So a few days later he took the opportunity to experiment on friends and family.

  After dinner one night he served up tumblers of chloroform to some of the assembled guests. On breathing in its sweet, fruity aroma, they slipped into a magical state of relaxation. They laughed, they joked, the room started to spin, the conversation became distant and faint. The guests tumbled off their chairs or lay themselves down on the floor. Then everything went blank. 'This is better than ether!' exclaimed Simpson as he picked himself up off the rug some minutes later. 'A most pleasurable experience.' So pleasurable, in fact, that all the other guests were keen to try the thrill of chloroform for themselves. Simpson's niece had a sniff and presently declared herself an angel before passing out on the settee.

  His scientific trial now complete, Simpson concluded that chloroform was a great success, and was in no doubt that it would bring untold benefits to his patients.

  Four days later, Jane Carstairs is in the final stages of labour. Her screams following each contraction can be heard far beyond the delivery room. Bathed in a blanket of sweat, she is starting to become exhausted. Simpson knows he will have to intervene. He will probably have to use forceps, slipping the instrument – like a pair of long, wooden-handled serving spoons – either side of the infant's head. Then he will pull and it will hurt even more.

  Simpson sprinkles a few drops of chloroform on to a handkerchief and lays it across Mrs Carstairs' mouth and nose. 'Keep breathing deeply,' he tells her. Within a minute she is asleep. When she awakes she is handed a little baby girl. The first success for this marvellous chemical.

  This was the final proof Simpson needed that chloroform would transform nineteenth-century medicine. The charismatic surgeon saw it as his mission to spread the word. 'It was my duty,' he said, 'to teach all these people that they were wrong and I was right.' While taking every opportunity to try the drug out in his own practice (within a week he had used the new anaesthetic in an astonishing fifty cases), Simpson planned a marketing campaign to make sure as many people as possible knew about chloroform. Rather than publish his findings in a journal, couched in cautious scientific terms and possibly written in Latin, he took his results directly to the public. He drew up pamphlets that he sent out to other doctors. He gave talks and held demonstrations. He even took out an advert in the Scotsman newspaper, proclaiming this new miracle pain relief.

  Not only was chloroform a more effective anaesthetic than ether, it was also a Scottish invention, and soon became a source of national pride. Simpson's confidence was infectious, and surgeons across Europe began to adopt his technique. Others sought to refine it, looking at new ways of administering the drug. One of Simpson's friends, a certain Dr Smith, tried to administer the drug rectally. Filling a syringe with chloroform, he injected it into his back passage. He woke up some hours later in a pool of diarrhoea with the syringe still in place, and suffered severe anal burns.

  Apart from Dr Smith's misfortune, chloroform seemed to have few disadvantages. Patients were comfortable taking chloroform; it was easy to use and, unlike ether, involved no cumbersome equipment. As Simpson put it, 'No special kind of inhaler or instrument is necessary for its exhibition. A little of the liquid, diffused upon the interior of a hollow-shaped sponge, or a piece of li
nen or paper, and held over the mouth and nostrils, so as to be fully inhaled, generally suffices, in about a minute or two, to produce the desired effect.'

  For the first few months everything seemed to be going well. Then, on 28 January 1848, fifteen-year-old Hannah Greener of Winlaton, near Newcastle upon Tyne, went to see surgeon Thomas Meggison for the removal of a toenail. She had undergone a similar procedure a few months earlier under the influence of ether, so was less fearful than she might otherwise have been. Nervous nevertheless, she was reassured by her uncle that everything would be fine. Mr Meggison would be using this new anaesthetic, chloroform. She would not feel a thing.

  Hannah is seated in a chair. Meggison drips a teaspoon of chloroform on to a cloth and holds it to the girl's nose. She takes two deep breaths and pulls Meggison's hand away. He asks her to try again, this time breathing naturally. Half a minute later the muscles of Hannah's arm become rigid and her breath a little shorter. Meggison puts his hand on her pulse. It seems somewhat weaker but has not altered in frequency.

  Meggison asks his assistant, Mr Lloyd, to begin the operation. Using a knife, Lloyd makes a semicircular incision and carefully prises off the toenail. Hannah starts to struggle and jerks forward. Meggison believes this is because the chloroform has not had sufficient effect, but he does not administer any more. Hannah's eyes are closed, but when the surgeon reaches forward to open them, they remain open. He starts to become concerned. Her mouth is also open, and her lips and face are suddenly pale.

  Meggison calls for water and throws some in the girl's face. She does not move. He tries to give her some brandy. He holds it to her lips and, he later claims, she swallows – albeit with difficulty. Increasingly desperate, he lays her on the floor, cuts her arm with a lancet and tries to bleed her. When only a few drops come out, he tries bleeding her from the jugular vein in the neck, but manages to get only a spoonful of blood. Three minutes after Meggison administered the chloroform, Hannah Greener is dead.

  An inquest before a jury was opened four days later and Meggison gave his account of Hannah's final minutes. The inquest heard from the doctors who conducted the post-mortem examination. They reported that the girl's lungs were in a 'very high state of congestion'. The coroner, J.M. Flavell, also included in the record an account of a chloroform experiment on mice. The mice had also died from congestion of the lungs. The jury concluded that Hannah 'died of congestion of the lung produced by chloroform'.

  Simpson rejected the findings of the inquest, claiming that the death was more likely caused by the water and brandy. Subsequent studies have found it very unlikely that chloroform had a direct effect on Hannah's lungs. But it seems certain that it was at least partly to blame for the girl's death. And although she was the first to die under the influence of chloroform, she would not be the last. As surgeons started to use the drug for everything from ingrown toenails to major amputations, more and more people were dying. The deaths were sudden and dramatic as if, one surgeon reported, 'the patient had been shot'.

  Curiously, the people who died were generally young and fit. Chloroform also seemed to kill a higher proportion of those who were more afraid of the procedure. Perhaps inevitably, deaths were higher in Scotland, where chloroform was the anaesthetic of choice, than in England, where ether was still preferred. Not that Simpson was experiencing any problems himself. All except one of his patients survived chloroform anaesthesia, but as the woman was quite frail anyway he was able to dismiss (in his own mind at least) any link to the chemical. A substance that had started out as a party trick, and was being used successfully on a daily basis, was also turning out to be a killer.

  What the chloroform anaesthetic lacked up until now was any science. No proper studies had been done into what effect the chemical had on the body, or the doses that should be used. Simpson's advice to use 'a little of the liquid diffused upon a pocket handkerchief' was beginning to reveal its shortcomings. Should less be used for a young girl than an old man? How long should the handkerchief be held over the patient's face? These were fundamental scientific questions that no one had bothered to ask. Fortunately, someone else was already working on the problem.

  In London Dr John Snow had been following the development of anaesthesia with great interest. He had already devised a number of improvements to administer ether, including a new type of vapour inhaler, and had drawn up tables to help surgeons calculate the correct (and safe) concentration of gas required.

  Snow was the complete opposite of Simpson. He was a quiet, calm, diligent man given to careful scientific study. In 1848, as well as trying to save lives by improving anaesthetics, he was studying the outbreaks of cholera that were killing tens of thousands of people in the capital.*

  * Snow worked out that cholera was spread through contaminated water rather than being carried in the air. Unfortunately, thousands more Londoners would die before his findings were accepted by the city authorities.

  In his publications on anaesthetics, Snow was very careful not to criticize Simpson 'in conferring on us the benefit of chloroform'. However, Snow was convinced that surgeons and doctors were using too much of it. He studied the effects of different concentrations of chloroform and divided them into 'degrees of narcotism'. In the first degree the patient was fully conscious, aware perhaps of the agreeable feelings felt when inhaling the chemical. The second to fourth degrees referred to various stages of insensibility or unconsciousness. Experiments with frogs suggested that a patient in the fifth degree of narcotism might stop breathing or suffer complete heart failure.

  Snow concluded that chloroform had an effect on both respiration and the heart, and that there was a terribly fine line between insensibility and death. A third of a teaspoon of chloroform was enough to knock a patient out, but half a teaspoon could kill them. He reasoned that different people needed different doses. Young, fit patients might need more chloroform to render them unconscious, but this pushed them closer to a fatal dose. As for those who were 'fearful', it was probably because they were holding their breath for as long as possible. When they finally took a breath, they inhaled enough chloroform to stop their heart.

  After applying his study to different classes and sensibilities, Snow took his conclusions further:

  Those persons whose mental faculties are most cultivated appear usually to retain their consciousness longest whilst inhaling chloroform and, on the other hand, certain navigators and other labourers, whom one occasionally meets with in the hospital, having the smallest possible amount of intelligence, often lose their consciousness, and get into a riotous drunken condition, almost as soon as they have begun to inhale. There is a widely different class of persons who also yield up their consciousness very readily, and get very soon into a dreaming condition when inhaling chloroform. I allude to hysterical females.

  On Chloroform and Other Anaesthetics: Their Action and Administration (1858)

  Of course, the effect of chloroform had nothing to do with intelligence, educational attainment or class, but there was clearly some sense in controlling and regulating the dose. For those, such as 'hysterical females' who 'yield up their consciousness very readily', Snow advised using lower doses of chloroform. Whatever the subject's susceptibility to the drug, it was obvious to Snow that splashing a few drops on a handkerchief was downright dangerous. Just as he had devised better means of delivering ether to patients, he now set about designing an inhaler for chloroform.

  A measured amount of liquid chloroform was added to a flask. This was attached to a tube, and a mask was placed over the patient's face. When the doctor cupped his hands around the flask this warmed the liquid, vaporizing some of the chloroform to a gas that the patient could comfortably breathe in. Even hysterical females. Snow's method was safe, easy to use and reliable. He administered chloroform to more than four thousand people. Only one of them died, and that was probably from other complications.

  By 1853 Snow had become one of the physicians to Queen Victoria. During the birth of her eighth c
hild, Prince Leopold, Snow administered chloroform. There were no complications with the birth and it is likely that he used only a small dose for pain relief. However, when the medical establishment found out, the Lancet published a furious editorial chastising Snow (although not by name) for putting Her Majesty's life at risk. The editorial spoke of the 'deplorable catastrophes' that were referable to the 'poisonous action' of chloroform, and the 'awful responsibility' of advising the administration of the drug to the queen.

  Not that this controversy deterred Snow; after all, he had a genuinely fine track record. He employed chloroform again during the birth of Princess Beatrice four years later. Had Simpson been overseeing the birth, there might have been more cause for concern. That Snow, rather than Simpson, bore the brunt of criticism from the Lancet for risking lives with anaesthesia seems hardly fair. But then Snow was never to receive the recognition he deserved for any of his medical or public health achievements.

  James Simpson died, aged fifty-nine, in 1870, a Scottish hero. He was the first man to be knighted for services to medicine. A huge state funeral was held in Edinburgh, the largest in Scottish history. Flags were flown at half-mast and thirty thousand mourners lined the streets. Statues and memorials were built. Hospitals were named after him.

  John Snow, the man who had made Simpson's discovery safe, had died ten years previously. His great work on anaesthetics was published after his death. Snow's small grave was paid for by friends and colleagues. He also has a pub named after him.

  Chloroform would continue to be used as a popular anaesthetic well into the twentieth century. In the end, Simpson's method of putting a few drops of chloroform on a piece of cloth became the most popular method of application. However, thanks to Snow's efforts surgeons used a lint mask and measured the chloroform using charts and a specially designed 'drop bottle'. Now (relatively) safe, chloroform could be used in the most difficult of circumstances and was the favoured anaesthetic in battlefield hospitals. Still, not everyone was convinced: some older surgeons were still suspicious of pain relief, preferring to hear the 'lusty screams' of soldiers as they went under the knife, a sure sign that the men were fighting for survival.