Blood and Guts (8 page)

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 child, 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.

The invention of anaesthesia meant that surgeons had now
conquered the third barrier to successful surgery. This, allied with
a full understanding of anatomy and the ability to stem blood flow,
meant they could now attempt new and more daring operations.
People would seek treatment earlier. Women in particular might
see a surgeon to have a small lump removed from their breast
before the cancer took hold.

In theory, more lives than ever should have been saved. In practice,
more and more people were dying. One out of five patients
would probably end up in the dead house. In some hospitals, half of
those operated on would be expected to die. Disease would ravage
entire hospital wards. The disease even had a name: 'hospitalism'.
Admittance to some hospitals amounted to a death sentence, and
many people decided they would rather take their chances at home.
Despite all the advances in science and medicine, no one could
figure out why so many patients were dying.

Vienna, 1846

Childbed or puerperal fever was a terrible disease. Within days of
giving birth, the mother would start to experience discomfort, soreness
and a rising temperature. Abscesses and sores developed and
spread across the body, accompanied by a swelling of the abdomen.
As the infection spread, it devoured tissues and attacked the vital
organs. Meningitis – a swelling in the lining of the brain – might be
accompanied by fits and periods of unconsciousness. Few women
recovered. And while this was bad enough, in many cases their
newborn babies died too.

In one clinic in the maternity wing at Vienna General Hospital,
puerperal fever was killing hundreds of mothers each year. In
January 1846, out of 336 births, there were 45 deaths. In February
of the same year, 53 out of 293 women died. This was a death rate of
18 per cent – one in five patients.

There were two clinics at the hospital. In the First Clinic the
patients were seen by doctors – mostly medical students. The
Second Clinic was run entirely by midwives. When the authorities
divided the maternity unit into the two clinics, they expected to see
a rise in mortality rates in the ward where the midwives were in
charge. It was, they argued, only common sense: midwives received
less training, were less scientific in their approach and, of course,
less rigorous in their intellect (there were no women doctors).

But the opposite was happening. In the clinic run by midwives
there were far fewer deaths. In 1846 a total of 459 women (11.4 per
cent) died in the doctor's clinic compared with 105 (2.7 per cent)
in the midwives' care. It was a striking difference – and one that
soon became well known throughout the city.

The two clinics admitted patients on alternate days. The
changeover between the clinics was at four o'clock in the afternoon.
Women in the advanced stages of labour would delay admission as
long as possible so that they would be admitted to the midwives'
rather than the doctors' clinic. As a result, women were giving birth
in the street or in carriages. Others would run screaming from the
hospital or had to be dragged through the corridors when they
discovered they'd been put in the First Clinic.