in the two periods, he adds, “It is plain from the above table that
since the employment of chloroform there has been a diminution of
mortality; thus in amputations of the thigh for disease there has been 5
per cent. less death, while after accidents 17 per cent. have been
restored to health, who formerly would have perished. In the
pathological amputations of the leg there is a difference of 8 per cent.
in favour of chloroform; and while one out of three died after the
removal of the forearm for accidents in the former series of cases, no
death had occurred out of eight in the latter. The only exceptions are
to be found in the traumatic amputations of the leg, and in the
pathological amputations of the arm. In the former there is an excess of
deaths since the introduction of chloroform amounting to 5 per cent.;
and in the latter, the cases, being only two in number, do not warrant
us in drawing any deduction from them.”
Dr. Fenwick found that the mortality from lithotomy had been greater
since the introduction of chloroform than before, but that the increase
was confined to the cases occurring in adults; and he justly attributes
this to the fact of the more favourable cases having been operated on by
lithotrity. He says, “However paradoxical it may appear, I believe that
as surgery improves the general average of mortality, both after
amputations and lithotomy, will increase; in the former, from the
operation being confined more and more to those suffering from
accidents, and in the latter, from those with a healthy condition of the
kidneys and bladder being selected for the action of the lithotrite, and
the worst cases only submitting to the knife.”
Dr. Fenwick gives a table showing the causes of death in the fatal cases
of lithotomy before the use of chloroform and afterwards, by which it is
seen that, in the latter set of cases, a larger proportion of the
patients had been afflicted with organic disease, in addition to the
stone. He says:—“This table shows that the relative proportion of deaths
arising from the operation in healthy persons has diminished since the
use of chloroform, 58 per cent. having died in the former, and only 47
per cent. in the latter.”
Dr. Fenwick inquires into the result of a considerable number of
operations in the Newcastle Infirmary, before and after the use of
chloroform, in addition to those mentioned above; and gives the
following summary towards the end of his paper.[145] “We find that there
has been a decrease in mortality since the introduction of chloroform in
the following operations:—
Per cent.
Pathological amputations of the thigh 5
Traumatic amputations of the thigh 17
Pathological amputations of the leg 8
Amputation at the shoulder joint 7
Traumatic amputation of the arm 5
Pathological amputation of the forearm 33
Traumatic amputation of the forearm 16
Ligature of the brachial artery 20
Ligature of the arteries of the forearm 25
Amputation of the penis 11
Amputation of the testis 14
Excision of the elbow 30
Tumours of the axilla, etc. 8
Tumours of the bones, etc. 4
“There has been an increase of mortality in:—
Per cent.
Traumatic amputation of the leg 5
Pathological amputation of the arm 41
Lithotomy 10
Herniotomy 12
Amputation of the breast 1
Tumours of the head, etc. 5.”
Dr. Fenwick very properly remarks that other circumstances may have had
an influence over the mortality of the various operations, as well as
the fact of chloroform being used or not used: but his inquiry is very
important, as it shows the result of operations in the same institution
since the employment of ether and chloroform, and for a long period
immediately preceding the use of those agents.
THE ADMINISTRATION OF CHLOROFORM IN THE DIFFERENT KINDS OF OPERATIONS.
General directions for the exhibition of chloroform have already been
given, but it is desirable to say a few words regarding its employment
in some of the individual operations of surgery.
_Lithotomy._ In this operation, it is advisable to have the patient
placed on the operating table with his head supported by one or two
pillows, and to administer the chloroform before the sound is
introduced. This having been done, it is generally requisite to
administer a little more vapour cautiously and gently, whilst the
bandages are applied to the hands and feet, and the patient is drawn
down towards the foot of the table. The bandaging should on no account
be neglected in the adult patient. It would be an abuse of chloroform to
carry its effects so far in every case that the slightest contraction of
the muscles could not be excited by the use of the knife, merely to save
the trouble of applying a bandage. In little children, the bandages are
not usually employed; but in these cases, the person administering the
chloroform should hold the head or shoulders of the little patient, just
as the surgeon makes his first incision; for the two assistants who are
holding the legs, and think they are doing a great deal of good, are
really making a fulcrum to enable the child to push itself away from the
surgeon, if it makes the least flinch, which it is almost sure to do, if
the narcotism is not much deeper than there is any occasion for. In this
operation the patient should be fully insensible when the surgeon makes
his first incisions; and the chloroform must be repeated or not during
the operation as occasion may require.
I have memoranda of fifty-seven cases in which I have administered
chloroform in the adult, and thirty-four in children, down to the
present time, the end of March 1858. It was my expectation that I should
be able to give the result of these, and all the other important
operations; but I have in a few cases either not ascertained whether the
patient recovered or not, or have neglected to make a note of the
circumstances at the time; and although the deficiencies might perhaps
be made up by private correspondence, and by searching the books of
three hospitals, I regret that I have not time at present for such an
undertaking.
A large proportion of the above cases of lithotomy were performed by Mr.
Fergusson, either in his private practice, or in King’s College
Hospital, and the remaining operations were performed by a number of
surgeons. On April 19th, 1855, Mr. Fergusson removed eight calculi, as
large as pigeon eggs, from the bladder of a gentleman, aged sixty-nine,
who had a favourable recovery.
On June 7th, in the same year, he removed fourteen calculi from the
bladder of an elderly gentleman, who also recovered. In January 1857, he
removed forty-two calculi from the bladder of a gentleman, aged
sixty-six; twelve of them were nearly as large as chesnuts, and the rest
about as big as hazel-nuts. This patient died, I think, within a
fortnight. He had disease of the kidneys. A considerable number of the
elderly men on whom lithotomy has been performed have had well marked
symptoms of fatty degeneration of the heart; but the chloroform has
acted favourably on all of them. In January 1853, Mr. Fergusson
performed lithotomy in the country on a gentleman, aged sixty-four,
removing a rather large calculus. The patient weighed eighteen stone; he
had a pulse which was liable to intermit, some of his relations had died
suddenly, and his usual medical attendant was very much alarmed about
the chloroform; but its action was very satisfactory. The patient
recovered his consciousness without sickness, or any unpleasant symptom;
and he had a favourable recovery. On August 11th, 1855, I administered
chloroform in King’s College Hospital to a man, aged seventy-five,
whilst Mr. Fergusson performed lithotomy. The patient had suffered from
apoplexy a year before; he was still paralyzed on one side, he had the
arcus senilis well marked in both eyes, and the temporal arteries were
very thick and rigid. He went through the operation well; the pulse
being good all the time. He died on the fifth day, and the following
appears in the _Medical Times and Gazette_ respecting the appearances
found after death. “At the autopsy, the cellular tissue of the pelvis
was found infiltrated with pus. The kidneys were contracted, and
occupied by many cysts; the ureters were inflamed and contained pus. The
bladder was extensively sacculated, and its mucous membrane so much
congested as to appear on the point of sloughing. There was no
peritonitis. The heart was large and fatty, and its aortic valves
diseased to a small extent. The brain was congested, and its
bloodvessels extensively ossified.” On December 22nd, 1855, I
administered chloroform in King’s College Hospital to a very fat man,
aged sixty-one, with a soft weak pulse, and arcus senilis of the cornea.
Mr. Fergusson performed lithotomy. He went well through the operation,
and recovered promptly from the effects of the chloroform. He died on
the seventh day, with purulent effusion into the left knee, and around
the left shoulder. The heart was large and flabby, and the substance of
the left ventricle was very friable. The right ventricle was dilated and
thinned, and its walls were soft and friable, and encroached on
externally by fat; at one place there seemed scarcely any muscular
substance left.
I have memoranda of four cases of lithotomy in the female, in which the
urethra was divided as well as dilated to extract the stone; and I
recollect two other cases of the same kind of which I have no notes.
_Lithotrity._ I have memoranda of 155 operations of lithotrity in which
I have administered chloroform. The number of cases of stone in which
these operations took place was sixty, but some of the patients had
operations performed, either without chloroform, or when it was
administered by some one else. The earliest cases of lithotrity in which
I administered chloroform were in St. George’s Hospital, and a great
number of the patients to whom I have given it were the private patients
of Mr. Fergusson, who is entirely satisfied of its utility in this
operation. Speaking of this operation in his _Practical Surgery_ (third
ed., p. 800), he says: “I am of opinion that there is not any department
of practical surgery in which anæsthesia has been of more service than
in this.” I have administered chloroform in a few operations of
lithotrity by Sir Benjamin Brodie; but I believe that he does not
approve of it in this operation, as a general rule. The following are
amongst the other surgeons whom I have frequently assisted by giving
chloroform in this operation: Mr. Cæsar Hawkins, Mr. Cutler, Mr.
Coulson, Mr. Charles Hawkins, and Mr. Henry Lee. Mr. Fergusson, in one
of his operations, extracted some portions of gutta percha bougie round
which a phosphatic calculus had formed. He was not informed of the
presence of the bougie in the bladder, until it was extracted. On
another occasion, a patient was brought from the country soon after a
bougie of this description had broken off, and he extracted with the
lithotrite the piece remaining in the bladder. It was between two and
three inches in length.
It is generally desirable to make the patient quite insensible during
the operation of lithotrity; and the patient sometimes groans during its
performance, when he is in a condition that, so far as one can judge, he
would show no sign of sensation under the use of the knife; but he, of
course, has no recollection of the operation afterwards. The bladder is
sometimes apt to expel the water which is injected, if the patient is
not well under the influence of the chloroform; but when the vapour has
been continued for a few minutes, and the narcotism is complete, the
bladder will, I believe, always hold water as well as if the operation
were performed in the waking state, and generally much better. There are
some surgeons who occasionally raise the breech of the patient for a
short time during this operation, so that the head becomes considerably
lower than the body. Stout old men generally snore more loudly when in
this position under the influence of chloroform; but I have not met with
any ill effects, nor expected any, from the head being lowered for a
short time. From ten to twenty minutes has been the most usual duration
of the operations under chloroform at which I have been present.
I have administered chloroform six times in female children whilst Mr.
Fergusson performed lithotrity. The patients were three in number. I
think the calculus all came away after the first operation, and the
second was only an examination of the bladder. I administered chloroform
also, on one occasion, to a lady whilst Mr. Spencer Wells repeated the
operation of lithotrity.
_Section of the Urethra in the Perinæum._ I have notes of 56 cases of
this operation. A great proportion of them were performed by Mr.
Fergusson, either in King’s College Hospital, or in private practice.
Amongst the other surgeons whom I have assisted in this operation were
the late Messrs. Guthrie, Bransby Cooper, and Avery. In a great number
of the cases, it was impossible to get a catheter into the bladder until
after the incision was made in the perinæum, and many of the operations
were very tedious; several of them lasting above an hour. It is very
desirable to apply the bandages in this operation, as in that of
lithotomy, especially if the assistants are not numerous.
_Other Operations for Stricture, etc._ I have notes of four operations
in which the stricture was divided internally by a urethratome; and of
two operations in which the orifice of the urethra was enlarged; and of
nine plastic operations to restore deficiencies of the walls of the
urethra, congenital or otherwise. I have memoranda of 66 cases in which
I have administered chloroform for sounding the bladder or the
introduction of a catheter. In catheterism under chloroform the patient,
of course, lies on his back, which is indeed the position in which he
ought to be during this operation, when chloroform is not administered.
_Amputation of the Thigh._ This operation is often performed for disease
of the knee, when the joint is in such a state of tenderness that the
least motion causes great pain. In such cases, I have administered the
chloroform to the patient in bed, before his removal to the operating
table, and given a little more chloroform just before the operation was
commenced. In King’s College Hospital, I have several times given the
chloroform in the ward in such cases, before the patient was removed to
the operating theatre; but in St. George’s Hospital, the passages and
doors being wide, the patient has been carried on his bed into the
theatre, where the chloroform was administered just before his being
lifted on the table. In those cases in which the tourniquet is applied,
in preference to pressure with the fingers, it should be adjusted as the
patient is getting under the influence of the chloroform, and tightened
just before the operation begins. It is desirable to keep the patient
quite insensible till the limb is removed, and the femoral artery is
tied; after which a little chloroform may be given whenever the patient
shows by a slight flinch, or contraction of his features, that sensation
is returning. A few patients have recovered their consciousness during
the tying of the smaller arteries, and have entered into a conversation
without feeling the pain, but this condition is quite the exception. I
have notes of 49 cases of amputation of the thigh in which I have
administered chloroform. Some of the patients, who were almost grown up
to the adult age, did not know that the limb was removed till three or
four days had elapsed.
_Amputation of the Leg._ I have notes of 31 cases in which I have
administered chloroform during this amputation. The remarks made above
with regard to amputation of the thigh are applicable to this operation.
_Amputation of the Arm._ I have only administered chloroform five times
in this operation, and only in one case during the last seven years.
This case was that of a boy, aged sixteen; Mr. Hancock was the operator,
and the patient recovered. I have no note of the disease for which the
operation was performed, but in two or three of the remaining cases, the
arm was amputated on account of malignant disease of the forearm. In one
of the operations, the patient was seated in an easy chair, but in the
others, the patients were lying on a sofa, or operating table, with the
head and shoulders a little raised.
Amputation of the arm has apparently been much less frequently performed
of late years, owing to the increasing practice of performing excision
of the elbow; and it appears to me that all the great amputations are
much less frequently performed now than they were a few years ago.
During a little more than nine months of 1847, I administered sulphuric
ether in 32 amputations of the thigh, leg, and arm; and in the last ten
years and four months, I have only administered chloroform in 85 of the
same operations; in the last three years, indeed, in only 16 cases; so
that the practice of amputation is still diminishing. This is due to the
practice of anæsthesia, which enables the surgeon to explore and to
remove diseased joints and portions of diseased bone by operations that
would be too long and too painful to be endured in the waking state.
This circumstance confirms the remark of Dr. Fenwick, previously quoted,
that the mortality after amputations may be expected to become greater,
as they will cease to be performed, except after accidents, or in very
desperate cases.
_Amputation of the Ankle._ I have notes of 15 cases of amputation at the
ankle. They were chiefly performed by Mr. Fergusson, and generally in
the manner recommended by Mr. Syme, or nearly so; but latterly Mr.
Fergusson and Mr. Partridge have, in three or four cases, adopted the
modification of this operation introduced by Prof. Pirogoff, by which a
portion of the os calcis is left.
_Other Amputations._ I have notes of nine cases of amputation of the
forearm; four of these operations were performed in 1850, and only three
since that year. I have memoranda of twelve cases in which I have given
chloroform whilst Chopart’s or other partial operations of the foot were
performed. Also of three cases in which Mr. Fergusson performed
amputation at the knee, and three cases in which he performed amputation
at the wrist in King’s College Hospital. I have notes also of 65 cases
in which I have administered it during the amputation of one or more
fingers or toes.
_Operations for Necrosis._ Anæsthesia is of the utmost service in these
operations, which are often tedious, and would be of the most painful
nature. The operations are of the most successful kind of any in
surgery; they usually relieve the patient from a very painful affection,
and leave no mutilation. I have administered chloroform in many cases of
necrosis in which an operation could not have been undertaken without
its assistance; and in a still larger number, in which the operation
could not otherwise have been satisfactorily completed. I have memoranda
of 197 cases of necrosis in which I have given chloroform. In 70 of
these, the tibia was the bone affected; in 15 cases, the femur; in 24
cases, the humerus; in 14 cases, the radius, or ulna, or both of these
bones; in 29 cases, the bones either of the carpus or tarsus, or
metacarpus or metatarsus. I have notes of six cases of necrosis of the
sternum; in five of these the operation was performed by Mr. Fergusson,
and in one case by Mr. Solly. Great care was required in some of the
cases to avoid going through into the chest with the bone nippers. There
have been nine operations for necrosis of the os calcis. In one of
these, Mr. Wm. Adams lately removed, along with the necrosed bone, a
small bullet which had been in the bone for six years.
The other cases of necrosis comprise the upper and lower jaw, the
parietal bone, the edge of the orbit, the scapula and clavicle, the
sacrum, the ileum, and the phalanges of the fingers and toes.
_Excision of the Head of the Femur._ I have notes of five cases of this
operation. They all occurred in children from eight to thirteen years of
age. Three of the operations were performed by Mr. Fergusson, one by Mr.
Bowman, and one by Mr. French; I also recollect assisting Mr. Henry
Smith in a similar operation in a child in 1848, at a time when I did
not keep any account of the operations in which I administered
chloroform. In one of Mr. Fergusson’s operations, he removed some
diseased portions of the acetabulum.
_Excision of the Elbow._ There is every reason to conclude that this
excellent operation has been performed more frequently in consequence of
the inhalation of narcotic vapours than it otherwise would have been. I
have memoranda of 19 cases of this operation in which I have exhibited
chloroform; 18 of them were performed by Mr. Fergusson, and the
remaining one was performed by Mr. Coulson, whilst Mr. Fergusson was
present.
_Excision of the Knee._ I have notes of 17 cases in which I have given
chloroform during the performance of this operation. Thirteen of the
operations were performed by Mr. Fergusson, two by Mr. Bowman, one by
Mr. Partridge, and one by Mr. Henry Smith.
This operation had been rarely performed till within the last seven
years, and there is every reason to believe that it never would have
been frequently performed, if the practice of producing anæsthesia had
not been introduced. I shall speak of this operation again in treating
of amylene.
_Excision of Wrist._ There have been two cases of this operation
performed by Mr. Fergusson in King’s College Hospital.
_The Removal of Tumours of the Upper Jaw._ Mr. Syme, Mr. Lizars, and
some other surgeons, expressed an opinion at one time that chloroform
could not be safely used in this operation, as the blood would be liable
to flow into the lungs. This is not the case, however, as the glottis
retains its sensibility apparently unimpaired, if the influence of the
chloroform is not too deep or long continued. It is only necessary to
hold the head forward now and then, when the throat is very full of
blood, in order to allow the patient the same opportunity of breathing
that he would require if he were awake. A good deal of blood passes into
the stomach in great operations about the mouth under the influence of
chloroform; and if a few drops pass into the windpipe, they are coughed
up again, as they would be in the waking state; there is, however, less
appearance of suffocation in operations where the blood flows back into
the throat, when the patient is insensible, than when he is awake. The
glottis appears to retain some sensibility as long as a creature is
capable of breathing, for I have placed the head of more than one cat
under water after making them thoroughly insensible with chloroform, and
the action of the respiratory muscles lasted more than two minutes, but
no water entered the lungs.
I have always made the patient insensible in the usual way, with the
inhaler, before the operation of removing tumours of the jaw, and have
kept up the insensibility during the operation by means of a mixture of
chloroform and spirit on a hollow sponge; or in cases in which I have
not been provided with this mixture, I have put not more than fifteen or
twenty minims of chloroform on the sponge at one time. Owing to the
hands of the surgeon and his assistants being very much in the way, I
have not always been able to keep the patient quite insensible
throughout the operation. He has sometimes struggled or cried out, but
there has been hardly any case in which the patient afterwards
remembered any considerable part of the operation.
I have notes of twelve cases of removal of the upper jaw in which I have
administered chloroform, in addition to four cases to which I alluded in
the _Medical Gazette_, in the early part of 1849. In some of the cases,
the malar bone was removed, as well as the superior maxillary. Eleven of
these operations were performed by Mr. Fergusson, and the others were
performed by Mr. Partridge, Mr. Henry Charles Johnson, Mr. Hewett, Mr.
Henry Smith, and Mr. Haynes Walton.