To the Editor:-Ether was the main anesthetic in the American Northeast during the second half of the nineteenth century. [1–4]Chloroform enjoyed a few months of popularity in Boston in 18483 but was quickly discarded after several deaths were reported on both sides of the Atlantic. The American preference for ether rested on its safety, chauvinistic pride, and the influence of Boston and Philadelphia on American medical practice. [1–3]The European objection to ether's slow action was overcome in the United States by the practice of “pushing” or “forcing” ether to hurry the induction. Like Snow, most European surgeons judged ether to be safer than chloroform but were seduced by the latter's potency and resulting fast and smooth action. [1–3]They believed that vaporizers delivering low concentrations and close observation of the patient's pulse and breathing reduced the dangers of chloroform. The “Transatlantic Debate”[2,3]lasted until the 1890s, when ether slowly replaced chloroform, first in England and then on the Continent.
Even in the 1850s, chloroform had already become suspect to several English authorities alarmed by the many fatalities in young, healthy patients undergoing minor surgery. [3,6]Several committees were formed to study the causes and the prevention of such accidents:the Royal Medical-Surgical Committee in 1864, the Glasgow Chloroform Committee in 1880, and the two Hyderabad Committees in 1888 and 1889. The conclusions of the Hyderabad Commissions exonerating chloroform were rejected by the Lancet's editors, who encouraged eminent British physiologists to study the problem. Shore, Gaskell, McWilliam, Sherrington, Sowton, Embley, and Waller reported that chloroform depressed the respiration and was a powerful, occasionally lethal, myocardial depressant. [3,7]Their conclusions were adopted in the 1892 and 1901 reports of the British Medical Association Committees on Anaesthetic. 
Chloroform came under further attacks in the late 1890s when A.G. Levy and L. Hill found that light chloroform anesthesia could produce ventricular fibrillation and when L.G. Guthrie reported late liver failure in children after chloroform anesthesia. Guthrie's findings prompted animal research on the hepatorenal toxicity of chloroform in Germany and in Baltimore, where G.H. Whipple's findings of hepatic toxicity further discredited chloroform. His reports and the statistics of the AMA Committee on Anesthetics (1905–1912) led to the condemnation of chloroform by the AMA in 1912. 
In England, the concern over chloroform led to a search for safer mixtures and new anesthetics, the development of vaporizers and anesthetic machines, and the return of N2O and ether. On the Continent, despite Gult's statistics on anesthetic deaths in Germany and Central Europe, which clearly showed the greater safety of ether, the latter's return was delayed for another decade by controversies over the severe pulmonary complications attributed to its inhalation. Thus, at the turn of the century, many European surgeons had recognized the soundness of their American colleagues' choice [2,3]and were returning to ether.
Ether remained the main anesthetic in the academic hospitals of the large North American cities around 1900. [13–19]Ether was vaporized with oxygen and N2O from an anesthetic machine after morphine premedication. Its administration was often preceded by N2O-O2, ethylchloride, or small doses of chloroform. [13–19]Ether by open drop with added oxygen, N2O-O2, and morphine and regional anesthesia were also common techniques. Small concentrations of chloroform vapor in oxygen were occasionally used for short procedures or to speed up or deepen a difficult ether anesthesia, [13–19]except in Boston and Philadelphia, where chloroform was banned. [1,3,14,18]“Open drop” chloroform in air as sole anesthetic was thought to be the most dangerous of the 10–12 anesthetic techniques then in use and was to be avoided. [10,13–19]
We were thus surprised to read that one of New York's best known academic surgeons around 1900 still used chloroform by open drop in air for 75% of his operations. John A. Wyeth was one of the most eminent surgeons of his era. [20,21]He pioneered operations, which until then had had a prohibitive mortality: carotid surgery, hip disarticulations, major procedures on the spine and large joints, and extensive plastic procedures. He published numerous articles and several books on surgical topics; his “Textbook of Surgery” went through four editions between 1887 and 1909. He was a leader in many surgical societies and vice president and then president of the AMA. His main contribution to US medicine was the creation, aided by his father-in-law, J. Marion Sims, of American postgraduate medical education. He founded the New York Polyclinic Medical School and Hospital for the postgraduate teaching of medical specialties and was its Surgeon-in-chief and Chair of its faculty. The institution still exists as the French and Polyclinic Medical School.
Dr. Wyeth's article explains why after exclusively using ether during his first 10 years in New York, he had returned to chloroform for the next 25 years of his busy practice. He had become unhappy with ether's slow and stormy inductions and their episodes of asphyxia from secretions and glottic and bronchial spasms. He also thought ether to be too irritant in those with pulmonary or renal diseases. Like many of his contemporaries, Dr. Wyeth believed that ether was largely eliminated through the kidneys.
Dr. Wyeth's patients received preoperatively 15 mg morphine and 0.5 mg atropine subcutaneously to relieve their anxiety and thus prevent arrhythmias. Fifteen minutes later, an experienced assistant closely supervised by Dr. Wyeth slowly dripped chloroform on an Esmarch's mask. Surgical depth was reached in 15–20 min. If the patient developed arrhythmias, facial pallor, or dilated and fixed pupils, the mask was immediately removed, the patient placed in head-down position, and the induction continued with ether until chloroform could be safely resumed. Once the induction was over, Dr. Wyeth proceeded with his surgery.
Dr. Wyeth believed that chloroform was riskier than ether in inexperienced hands but that it could be safely used by an expert aware of his patient's physical status and by doing a slow, well-monitored induction. He preferred chloroform in patients with lung or kidney disease, in alcoholics, or for abdominal surgery. He chose ether for debilitated children or for patients with heart disease, especially for those with rheumatic heart disease. His views on both anesthetics closely resembled those of Snow 50 years before him. 
Dr. Wyeth used chloroform as a preceptee in North Alabama and as a medical student in Louisville [20–22]and had witnessed several chloroform deaths. Chloroform was preferred in the southern states at the time because of the strong influence of the New Orleans surgeons, many of whom had studied in Paris. The South's hot weather and rural conditions also favored chloroform. [1,14,15,18]By 1900, however, its use in the South was decreasing. [14,15]
We know of no comprehensive survey of the anesthetic techniques in New York around 1900, although US statistics of the time [10,15,17,19]include several New York academic hospitals; they and the writings of J.T. Gwathmey, a contemporary New York anesthesiologist, [13–19]suggest that ether and N2O were the main agents used in the city at the time. Ethylchloride and chloroform vapors were occasionally added to help a difficult anesthesia. Oxygen was generally delivered with all the anesthetics. [13–19]“Open drop” chloroform in air was believed [10–12]to be the most dangerous of the techniques then in use and was strongly condemned by Gwathmey. [13–19]
Dr. Wyeth's use of plain chloroform in air on an Esmarch's mask seems to conflict with the existing practices of the New York academic hospitals. His article, however, raised no objections from JAMA's editors or, to our knowledge, from his colleagues. His reputation and surgical skills may have granted him this privilege. His paper reported no chloroform fatalities.
We do not know whether Dr. Wyeth continued to operate or use chloroform after 1900 because after that date he stopped publishing medical articles and turned to the history of the Civil War and his participation in it. [21,22]He, however, remained active at the Polyclinic Medical School until his death in 1922, at the age of 77 years. [21,22]
Ray J. Defalque, M.D.
A.J. Wright, M.L.S.
Department of Anesthesiology; UAB School of Medicine; 619 South 19th Street, JT845; Birmingham, Alabama 35233–6810
(Accepted for publication September 8, 1997.)