Bull. Ind. Inst. Hist. Med. Vol. XIX. pp. 47 to 61

HISTORY OF ANAESTHESIA&

HYDERABAD CHLOROFORM COMMISSIONS

MOMIN ALI* & A. RAMACHARI**

ABSTRACT

Man's endless pursuit for finding nature's hidden treasures andsecrets had rewarded him with countless discoveries in every field.The study of the development of anaesthesia is also very interestingand stimulating in the field of medicine. Today it can be said that theuse of ", ugs to produce anaesthesia is a boon to humanity, but in1840 this was not so. James Young Simpson discovered the anaesthe-tizing properties of Chloroform and put the agent to use in November1847, which proved in his hands a great success. But the dangers ofthe chlorcform were realised quickly and different committees ofinvestigation were appointed. In the late 1880's Edward Lawrieentered the argument and persuaded the Nizam of Hyderabad to giveail the necessary assistance for a scientific investigation on safety ofchloroform, which was known as the First Hyderabad ChloroformCommission - 1888. Then came Second Hyderabad ChloroformCommission in the following year 1889. Reports of both the Commi-ssions were later published in a book form in 1891.

"The True past departs not. No truthor goodness realised by man everdies, or can die but all is still here,and, recognised or not, lives andworks through endless changes."

T. Carlyle

"Shall those arts which have discov-ered a thousand instruments for infli-cting pain on suffering and civilisedman, never discover any new meansof making him happy. Shall the fruitof the tree of knowledge always

* Research Officer. lie, Indian Institute of History of Medicine,OMC Buildings, Putlibow!i, Hyderabad-500 195.

** Chief Anaesthesist, E.S.1. Hospital, Sanatnagar. Hyderabad.

48

continue bitter, shall it never beripened by the radiance of the Sunof benevolence. Are there any suffi-ciently cold hearted to believe this,let them be idle. To us hope whichthough it should be vain is yet aneternal source will remain. It will forever prompt to actions which thoughthey should deserve no laurels oftriumph from mankind will never haveraised them by watering the earthwith blood".

Humphry Davy

The history of medicine and thehistory of human race are one andthe same. It is like a story havingits threads so intervoven that it isdifficult to pickout individually anddistinguish separately each of thethreads.! Man's endless pursuit forfinding nature's hidden treasures andsecrets had rewarded him with count-less discoveries in every field. Thestudy of the development of anaesth-esia is also very interesting and stimu-lating in the field of history of medi-cine. Nothing new in the way ofagent or method had been discoveredfor hundreds of years except themethods used prior to 1E45 - opium,water of nightshade, henbane, lettuce.medicated wines, mesmerism. strap-ping. compression of nerves and bloodvessels and nosie etc which mig:ltbe considered a sad indication of thestate of the practicing surqcon'scuriosity. Today it can be said that

Bull. Ind. Inst. Hist. Med. Vol. XIX

the use of drugs to produce anaesth-esia is a boon to humanity, but in the1840's this was not so. One of theprincipal obstacles in the way of thetechnical development of surgeryprior to the discovery of anaesthesiawas the need for unnatural speedand skill. Surgery technically at thebeginning of the nineteenth centurywas limited to surface and reparativemanipulations and was resorted toonly in extreme cases. Prior to theuse of anaesthesia all the hospitalswere containing separate rooms torsurgery. so that the shrieks of agonywould not be plainly heard by others.

In 1795 the anaesthetic proper-ties of laughing gas (Nitrous-oxide)were found by Sir Humphry Davy(1778-1829). On inhalation of thegas, his pain due to the cutting ofwisdom tooth had disappeared. Hisdisciple, Michael Faraday, whileworking on ethers, noticed its sopo-rific effect and suggested its use asan anaesthetic. In 1824 Henry HillHickman (1800-1830) made signifi-cant contribution to the knowledgeof anaesthesia by conducting experi-ments on animals with carbonic acidgas According to him throughinhalation of the gas surgical anaes-thesia can be produced in man. In1842 ether was successfully adminis-tered by Crawford Williamson Long(1815-1878) to two persons. but thissuccess also could not Q"t r quired

1. 'The English PIO"eerS of Anaesthesia' hy F. F. Car tw ighl (1952) pub. by Br istoi : John Wflghl

& Sons Ltd. London. Simpkin Marshall Ltd. p.No. 166. 30R & 330.

History of Anae sthesie - Momin Ali, Ramachari 49publicltv.! In 1844 a dentist, Horace Owing to the irritating andWells (1815-1848) observed a demo- unpleasant odour of ether, searchnstration of gas by Gardner Quincy was made for other volatile agents.Colton (1815-1898) in which, a Chloroform was discovered in 1831person was unable to feel the injuries by three independent persons- Eugenereceived due to fall. after the inhala- Soubeiran (1793 - 1858) a Frenchtion of Nitrous oxide. Horace Wells chemist, Samuel Guthrie (1782-1848)tested the effects of the gas, on himself of America and Justus Von Liebigfor extraction of his tooth, and felt (1803-1873) of Germany by distillingno pain. Charles Thomas Jackson Chloride of lime and alcohol. Chloric(1805-1880) suggested the use of ether, a solution of Chloroform andSulphuric ether for deadening pain by alcohol had been used by Jacob Bellsprinkling it over the skin and mucous <1810-1859) and by William Lawrencemembrane surface. His pupil William (1783-1867) in 1847 as an anaesthe-Thomas Green Morton (1819-1868) tlc.? There is no doubt that, truetook up the suggestion and in a case anaesthesia was occasionally attained,where excess of ether was used, it but the cases were few and farran over the face producing numbness between. It is likely that, anaesthesiaof the entire face, which gave him can never have been produced withthe idea of using ether for inhalation.> complete certainty until the introduc-Morton tested on himself success- tion of chloroform by James Youngfully on September 30, 1846, he was Simpson (1811-1870). He discoveredunconscious for about 8 minutes by the anaesthetizing properties of chlo-the inhalation of ether vapour. In roform and put it for use in 1847,this year he administered ether succ- which proved to be a great success.essfully in a case of tumour of the Chloroform became very popular dueneck, operated by John Collins to its potency, sweet odour andWarren and the Massachusetts Gene- smoothness in administration inral Hospital. With the support of comparison to the drawbacks of etherWarren and Henry Jacob Bigelow, such as its explosiveness, irritancyetherisation was accepted and widest and its tendency to produce vomitingpublicity was also accorded to it. etc. But the dangers of its use wereSince then there has followed a tale realised soon and some were convin-of human endeavour which has given ced that chloroform was an inherentlyus drugs and yet more drugs, methods dangerous agent capable of causingand yet m0re methods. death by stopping the heart. Hence,1. History of Anaesthes-a by Thatcher, P.Nos. xiii (introduction) 6. 14. 15. & 16.

2. Evolution of Anaesth -sia by Dr. Hari Rao. Ind. Journal of the Hist. of Med,Vol. 2 No.1. P. Nos. 29 to 32.

3. History of Anaesthesia by Thatcher. P. No. 13.

50

research work in physiology andpharmacology and for the establish-ment of basic principles of anaesthesiacontinued. John Snow (1813-1858)lead the anaesthesia from handicraftto science, based on physiologicalprinciples. The actual cause of deathfrom chloroform was not known, andtherefore, this became the subject ofgreat controversy which was settledby the valuable findings of A. Good-man Levy in 1911.1

In Enof snd the number of deathsdue to the inhalation of chloroformhad reached upto 123 by 1863, apartfrom the deaths in other parts of theworld due to its use. So, the RoyalMedical and Chirurogical Society(now the Royal Society of Medicine)appointed a special committee ofinvestigation in 1864. The committeereported that as an anaesthetic, etherw~s far safer than chloroform,because when overdose of ether wasgiven, the respiration stopped beforethe heart and it was possible to revivethe animal through artificial respirationwhereas due to overdose of chloro-form the action of the heart stoppedbefore the respiration and theanimal could not be revived.Ether anaesthesia was irnnrr.ctic ableon account of its immoderate slow-ness in produci ng the anaesthetic stateand the frequent turbulence, during

Bull. Ind. tnst. Hist, Med. Vol. XIX

the introduction period of the subjectbeing etherized. The Commitee sugg-ested that, chloroform should bediluted by mixing it in various propor-tions with ether. Since then ether hadrarely been used in England.

Then in 1877, came the GlasgowCommittee doing no more than,reassuring both, those who usedether and those who usedchloroform. For those. who in 1870adopted ether considering it saferthan chloroform found it still superiorto chloroform and the length of timerequired to obtain its required effectwas immaterial for them. On the otherhand, those, who had adopted chloro-form in spite of the very generalre-adoption of ether found that, noadditional deterrent to its use hadbeen discovered since 1864 exceptthe paralyzing effect of chloroformupon the heart and this deterrent wasnot so importa nt to the chlorotormists."

In 1880, Edward Lawrie (Fig.1)entered the argument. He was inIndian Medical Service, appointed asthe surgeon in the British Residencyin Hyderabad. He very soon becameprincipal of the Medical School ofHyderabad and also the personalphysician of Nawab Mir MahboobAli Khan, the Nizam VI (Fig.2). Hehad been a medical student and house

1. Evolution of Anaesthesia by Dr. Hari Rao. Ind. Journal of Hist. of Med. P.No. 32.

3. The development of inhalation Anaesthesia'bv Barbara M. Duncum p. nos. 21, 22. 253, 428 & 429.

History of Anaesthesia - Momin All, Ramachari

surgeon of Prof. James Syme (1799-1870) at Edinburgh. He used chloro-form anaesthesia in thousands ofpatients without any incident in themanner of his teachers who hadtaught that death during chloroformanaesthesia primarily was due toraspiratorv failure, not to heart failureand that consequently, if the respira-tion were carefully watched the pulsecould be ignored. He believed thatchloroform was absolutely safe, ifadministered by the method of Edin-burgh School. He pursuaded theNizam to pay for the scientific researchwork on safety of chloroform, whichcame to be known as the 'FirstHyderabad Chloroform Commission',which was carried out in early 1888.'

First Hyderabad ChloroformCommission - 1888 A.D.

This commission consisted of1. Surgeon Patrick Hehir, as President,2. Dr. A. Chamaretes - member and3. Dr. J. A. Kelly - member (Fig.3).A series of experiments were perfor-med on dogs to determine the exactcause of death due to chloroformanaesthesia, to test the effects ofpoisonous doses of chloroformon dogs, with the aim that,the experiments should have animportant bearing 0 n the way inwhich the administration of theanaesthetic ought to be conductedin the human objects. The experi-ments of the commission lead themto conclude that "Chloroform can begiven to dogs by lnhalation with

51

perfect safety, and without any fearof accidental death if only the respi-ration - and nothing but the respira-tion - is carefully attended to throu-ghout,'-

Dr. Lawrie, while forwarding thereport to the Government, stated that"the results of the experimentswith the principles necessary for thesafe administration of chloroformtaught by Mr. Svme, who never hada fatal case and with my own expe-rience, which is founded upon thesame principles. I have killed scoresof dogs with chloroform and in everyinstance death has resulted fromfailure of respiratory function. I havealso given chloroform in surgerywithout a death for more than twentyyears and for as many as five to tentimes a day during the last fifteenyears I have never seen Syncope orfailure of the hearts action producedby it". He lost no time in publicisingthe result.

On the occasion of the distribu-tion of prizes to his students by theRoyal Highness the Duke and Duchessof Conn aught, Dr. Lawrie gave ashort speech on February 23, 1889saying that .... he had made experi-ments with reference to the effect ofchlorofcrm and had never seen theheart injuriously or dangerouslyaffected by chloroform. Reacting tothis statement of Dr. Lawrie, comme-nted the Lancet on March 2, 1889that the result of the research made

52upon pariah dogs was that theseanimals were killed from respiratoryfailure, and in no case did cardiacsyncope occur directly. UnfortunatelyMr. Lawrie contents himself withbare statements of results, addingthat these results tally with his ownexperience, which he believes to beuniquely large. Mr. Lawrie, as adisciple of Simpson and Syme arrivesat conclusions consonant with theteaching of those great clinicians,but utterly, at variance with theexperience alike of experimentand practice as carried out inEurope. We should require more thanthe scanty statements of experimentsperformed upon dogs - notoriouslynon-susceptible to chloroform syncope- before we could accept the conclu-sions of the Hyderabad Commissionwhen they appear to go in the veryteeth of those at which the commi-ssion appointed by the Royal Medicaland Chirurgical Society and by theBritish Medical Association (TheGlasgow Committee) arrived, andfurther, are opposed to the carefuland painstaking experiments of suchscientific observers as Snow, ClaudeBernard, Mc Mendrick and others toonumerous to mention. All thosewho are familiar with chloroform arewell aware that syncope, whenprimary, as a rule supervenes in theinitial stages of inhalation, whilesecondary syncope due to respiratoryembarrassment in the result of accu-mulation of chloroform in the bloodleading to paralysis of the medullary

Bull. Ind. lnst. Hist. Me d. Vol. XIX

centres, and occurs in a late stageof the administration. The primarysyncope it is rarely. if never, possiblyto induce in dogs, although, unfortu-nately, it is this form of chloroformheart failure which does occur inhuman beings, and which it is almostimpossible to remedy. While welco-ming the attention paid to the subjectby the Hvderabad Commission, wecannot but feel that, should thecommission inculcate a disregard ofthe heart as a factor in chloroformdangers, it will do harm and provokea slips hop carelessness in the use ofthat valuable anaesthetic, which mustin the long-run do damage to thecause the commission has espoused"(Lancet 1889, i,438).

Lawrie accepted the Lancet'schallenge. In a letter to that journal,published on May 11, 1889, he wrote"there is no such thing as chloroformsyncope. It is conceivable that syn-cope may occur in the initial stagesof inhalation of chloroform, but inthe course of a very large experienceI have never met with a single ins-tance of such an accident, and if itever does occur it cannot be due tochloroform poisoning though it mightbe caused by fright or shock. Owingto the numerous accidents that havehappened with chloroform to thediscussions prevalent in the profes-sion, and to the mistaken notionthat the risk of heart failure is insepe-reble from its use, the public dreadits administration much more than

History of Anaesthesia - Momin Ali, Ramachari

they dread surgical operations, andfainting from mE!fefright in the earlystages of inhalation is no less intelli-gible that it is easy to prevent. incase where it is likely to occur by apreliminary dose of alcohol. On theother hand, it is equally intelligiblethat syncope may be induced if anoperation be commenced in the ini-tial stages of chloroform administra-tion, before the patient is renderedinsensible to shock by being broughtfully under its influence. In poison-ing by chloroform the heart failsVIi hen t he respiration ceases, andnever before . the her rt rapidly orgradually stops beating as a directre sult of the: s t oppaqe of respiration,and as an irc!irect effect of the poi-soning with chloroform. The Lancetasserts that the statements made inmy address are utterly at variancewith the experience alike of experi-ment and practice as carried out inEurope The Lancet would trust tothe heart and circulation for signalsof danger in 'chloroform administra-tion" Our contention is that if theadministration is ever pushed farenough to cause the heart to showsigns of danger, the limits of safetyhave already been exceeded and a fatalresult must almost inevitably ensue..... But we say. further, that therespiration invariably gives warningswhen a danger point is approached,and consequently t hit it is possibleto avert all risk to the heart by devo-ting the entire attention to the respi-ration during chloroform administra-tion (Lancet. 1889, i. 852).

53In reply to this letter from Law-

rie, the Lancet said " Mr. Lawriehas contended himself with meredogmatic assertion and iteration ofhis former statements. Whatever maybe the value of the work done bythe Hyderabad Commission - andMr. Lawrie seems inclined to acceptthe conclusions arrived at, ratherthan those of well-known and triedscientists-it is quite impossible forthose who have neither seen theexperiments to which Mr. Lawrierefers, nor received an authoritativestatement as to the methods emplo-yed and precautions taken, to acceptas evidence the results to wh'ch herefers .. concerning the depressantaction of chloroform upon the heart(Lancet 1889, i, 949).

Due to the Lance t's dismissivereaction Dr. Lawrie persuaded theNizam of Hyderabad to pay for asecond more extensive study in thisregard and in 1889 in a further letterLawrie stated that "he was directedby his highness the Nizam to offerLancet.. .... the sum of one thousandpounds to send out a representativeto repeat the experiments of theHyderabad Chloroform Commission".In response to this offer, the Lancetproposed Dr. T. Lauder Brunton as itsrepresentative in this matter (He wasan authority on the action of drugson the heart and had published bookson this subject) who accepted theoffer (Lancet, 1889, ii, 601, 606.1351-2).

54

Second Hyderabad ChloroformCommission 1889

This new commission, under thepresidency of Dr. Lawrie, of whichMr. Lauder Brunton was one of themembers, came to be known as the'Second Hyderabad Chloroform Com-mission'. The other members weresurgeon Major Gerald Bomford andand Dr. Rustomji. The President andmembers of the First Commissionwere also associated with this com-mission.

For three months, the commis-sion performed various kinds of expe-riments on some six hundred animals,the first telegram sent by LauderBrunton from Hyderabad was "Fourhundred and ninety dogs, horses,monkeys, goats, cats, and rabbitsused. One hundred and twenty withmanometer. All records photogra-phed. Numerous observations onevery individual animal. Resultsmore instructive. Danger from chlo-roform is asphyxia or overdose, nonewhatever heart direct".

In December 1889 its report wascompleted with the same conclusionthat, on administration of chloroformby inhalation the respiration stops firstfollowed by the heart One of themost significant findings of thesecond commission was that theadministration of chloroform causesa fall of blood pressure and dilatationof the ventricles of the heart. Thereport of this commission was first

Bul!. Ind. tnst. Hist, Med, Vol. XIX

published in instalments in the Lancetbetween January and June 1890(Lancet 1890. i, 149-59,421-9,486-510, 1140-2, 1369-88).

The conclusions of the SecondCommission provoked numerous ad-verse comments in England's leadingmedical journals. Typical one ofthese was that from Leonard Hill, thedistinguished physiologist, who saidthat "the doctrine that Chloroformkills by paralysing the respiratorycentre propounded by the findingsof the two Hyderabad ChloroformCommissions, and the prejudicedenthusiasm of Surgeon-Major Lawrie,is one of the most pernicious anddangerous doctrines ever put beforethe medical profession". He alsofound many of the conducted expe-riments faulty. Such as, chloroformanaesthesia was started, with theanimals in 'induction boxes'. No lessthan 60';' of the animals were foundto have died. unobserved, in theboxes during induction with chloro-form before any of the experimentson them had been set up 'In this'Hill said. "the commission givesaway their whole case. They neverobserved these accidental deaths".He was right, Lawrie, Brunton andtheir colleagues had ignored thesedeaths, and had glibly ascribed themto the slip-shod techniques of theirunqualified assistants whose taskwas to render the dogs unconsciousprior to the commission's experiments.

History of Anaesthesia-Momin Ali, Ramachari 55

Similarly, after the publication ofthe results of the careful researchesof Dr. E. H. Ernblev, the editor of the'British Medical Journal' said of thesecond commission that it had .•.....looked upon respiratory failures asthe primary cause of death, mostother researchers look upon this assecondary to the failure in the circu-latory apparatus. The commissiondeserves much credit for pointing outthe importance of 'the respirationbut from the scientific point of viewno impartial observer can maintainthat thay proved its main contention'".

Such as, by far the most prevalentmethod of administering chloroformwas 'poured on a handkerchief and indescending order of frequency onlint, on a towel, a napkin, into anextemporized cone, or on a spongeetc. (Fig.4). The recorded deathsresulting from chloroform beingadministered without an inhaler arerather more than double those occu-ring when an inhaler is used ..... Asto the determininq causes of deathby chloroform, the answers to theLancet's questionnaire bore out thefindings of the Chloroform Committeeof 1864 and the Glasgow Committeeof 1880. The larger proportion ofdeaths were reported as having resul-ted from initial heart failure, in oppo-sition to the view of the physiologicalresearches of the Hyderabad Commi-ssion. A possible explaination of whythe observations of the HyderabadCommission differed from those madeduring the above survey by Lancetwas suggested that, the conflictingviews are reconcilable and seems to

A careful prepared questionnaire be possible, atleast in many cases. Thewas sent to individual members of reports of numerous cases refer tothe British medical profession and failure of the pulse, as occuring beforesimilar information was sought in a that of respiration, and it is undoub-more detailed form of questionnaire tedly true that although the pulsefrom the hospitals at home and does fail, yet the actual heart actionabroad. The material thus gathered continues for sometime after pulsewas analysed and many interesting failure. This explanation howeverobservations were made by 1893. seems hardly to apply to those cases

1. Edward Lawrie and the Hyderabad Chloroform Commission, by A. Ramachari & A. Patwari.published in the lnter+ationa l Congress and Symposium Series - 134 (July 1987) entitled"The History of Anaesthesia" published by Royal Society of Medicine Service Ltd. -London in 1988. P.no 236.

Inspite of all the above experi-ments, Lawrie's personal assurancebased on his vast experience that hehad never seen a death from heartfailure due to the direct action ofchloroform and Lauder Brunton'sconversion to Lawrie's beliefs, theLancet remained to some extentdoubtful regarding the authenticityof the results.

56of sudden death which occur at thecommencement of chloroform anaes-thesia, nor can these deaths beexplained ..... as being due to fright,and not to the anaesthetic (Lancet1893. i, 29.693, 761,899,97',1111,1236,11.79).1

Edward Lawrie gave convincingreplies to all these criticisms and hefinally believed the results of both

BIBLIOGRAPHY

1. Anonymous (1988) Souvenir, Hyderabad Chloroform CommissionsCentenary (1888-1988), pub. by the Centenary Celeb-rations Committee of Afzal Gunj Hospital (1886-1986)& Diamond JUbilee Celebrations Committee OsmaniaGeneral Hospital & Osmania Medical College,Hyderabad-A.P. (1926-1986).

The development of inhalation Anaesthesia withspecial reference to the years 1846-1900pub. by The Wellcome Historical MedicalMuseum - New York.

The English pioneers of Anaesthesia,pub. by Bristol: John Wright & Sons Ltd.London; Simpkin Marshall Ltd.

Evolution of Anaesthesia - Pub. in the IndianJournal of the History of Medicine Vol. II, No.1.

Edward Lawrie and the Hvderabad ChloroformCommissions pub. in the International Congress andSymposium Series - 134 (July 1987) entitled "TheHistory of Anaesthesia", pub. by Royal Society ofMedicine Service Ltd. - London in 1988. o. no. 236.

History of Anaesthesia with Emphasis on the NurseSpecialist - pub. by J. B. Lippincott Co. London.

2. Barbara M. Duncum(1947)

3. Cartwright, F. F.(1952)

4, Hari Rao, D.(1957)

5. Ramachari A &Patwari A (1988)

6. Virginia S. Thatcher(1953)

Bull. Ind. Inst. Hist. Med. Vol. XIX

the Hvderabad chloroform commis-sions were right, up until his deathin 1915.

Reports of both the commissionswere later published by His Highnessthe Nizam's Government in a bookform in the year 1891 A. D. Thismemorable event has given Hyderabadand India a permanent place in theHistory of Medicine.?

1. The deve'opment of inhalation Anaesthesia by Barbara M. Duncum, P.Nos. 21, 22 & 423 to 441.2. Souvenir. Hyderabad Chloroform Commissions. Centenary. 1888·1988.

History of Anaesthesia - Momin Atl, Ramachari 57

AFZAlGUNJ HOSPITALVenue of the Hyderabad Chloroform Commissions

/'

58 Bull. Ind. Inst. Hist. Med. Vol. XI X

Surgeon-Major Edward Lawrie(Fig. 1)

History of Anaesthesia - Momin A ti, Ramachari 59

Nawab Mir Mahboob Ali KhanNizam of Hyderabad

(Fig. 2)

60 Bull. Ind. Inst. Hist. Med. Vol. XIX

HYDERABAD CHLOROFORM COMM ISSION

Seated (L-R) Dr. Rustomji, Dr. T. Lauder Brunton, Surgeon Major Edward Lawrie,Dr. P. Hehir, Dr. Gerald Bomford.

(Fig. 3)

\

History of Anaesthesia - Momin Ali, Ramachari 61

Hyderabad Chloroform Cap in use

62 eou. Ind. Inst. Hist. Med. Vol. XIX

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