cases in which I have administered chloroform during this operation.
They were chiefly performed by Mr. Fergusson, but a few of them by Mr.
Bowman. The operation is of so painful a nature, that I believe it was
seldom performed before the practice of inhaling narcotic vapours was
introduced. It is done subcutaneously, by means of a small sharp-pointed
bistoury, by which the affected nerves are chopped up by twenty or
thirty incisions, at and near the points where they issue from their
respective foramina. In operating on the mental branch of the fifth
nerve, the bistoury is sometimes introduced from the face, and sometimes
from the interior of the mouth. The pain continues for two or three
days, till the inflammation caused by the operation subsides, when there
is usually a complete absence of pain for three or six months, at the
end of which time the operation has often to be repeated. I am not aware
whether the relief has been permanent in any case, but it has often been
very complete for a time. One patient, on whom Mr. Fergusson operated in
King’s College Hospital, looked like an old man at the time of the
operation, but this was the effect of his severe suffering; for a week
or two afterwards he looked his real age, which I think was less than
forty. This operation is not performed for the milder cases of
neuralgia, or for cases that can be cured by quinine or iron; but only
for the more terrible forms of the complaint, which fortunately are
somewhat rare. Rare as they are, however, they occur sometimes in near
relatives.
_Division of other Nerves of Sensation._ I have notes of nine cases in
which nerves in other parts of the body were divided, and a portion cut
out, for neuralgia. On four occasions the nerve was situated in a stump
following amputation; and on two occasions a tumour of the nerve was
removed. The operations were performed by Mr. Fergusson, Mr. Solly, and
Mr. Paget.
_Operations on the Eye._ The operations for cataract are frequently
performed without chloroform, when the patient has sufficient resolution
to keep his eye steady. I have, however, administered chloroform
fifty-three times during the extraction of cataract; thirty of the cases
occurred in the private practice of Mr. Bowman. On November 25th, 1851,
I administered chloroform whilst Mr. White Cooper extracted a piece of
flint from the interior of the eye; and on February 7th, 1852, whilst
Mr. Bowman extracted the capsule of the lens. On February 17th of the
same year, I assisted Mr. White Cooper with chloroform whilst he
extracted a cataract from the eye of an elderly lady; and I assisted him
in eleven other cases during that and the following year. I assisted Mr.
George Pollock in two operations of the extraction of cataract in June
1852; and Mr. Lawrence in three operations in 1853. Eighteen of Mr.
Bowman’s operations were performed in the summer and autumn of 1854, and
were of the usual kind; but in six out of the twelve cases in which I
have since assisted him, the cataract was first drilled and then
removed, in a softened state, through a small opening in the cornea, by
means of a small scoop. I have assisted Mr. Alexander in two cases, and
Mr. Critchett also in two. Several of the patients were over eighty
years of age.
The operation for the extraction of cataract is said not to be a painful
one, but the patient requires to be as insensible during its performance
as if he were about to undergo lithotomy, or a great amputation; without
this, the eye and eyelids will not be steady. The insensibility must be
kept up completely until the cataract is extracted.
It is necessary that the stomach should be empty when the patient
inhales chloroform for this operation, in order that vomiting may, if
possible, be avoided. There was a little vomiting in a very few of the
cases in which I administered chloroform, but it was not attended with
straining, and I believe it did no harm in any case. Mr. Bowman informed
me of a case of his in which chloroform was administered in the
Ophthalmic Hospital for the extraction of cataract, and the woman
vomited violently afterwards, and the eye was destroyed. She, however,
was a person of bad constitution, and the vomiting might have occurred
without the chloroform. The patients were lying on a sofa in all the
operations, except, I think, one by Mr. Alexander.
I have notes of nine cases of the drilling of cataract in which I have
administered chloroform, and there were some other cases in 1848, of
which I have no memoranda. Some of the early operations were performed
by Mr. George Pollock, and the more recent ones by Mr. Bowman. Many of
the patients were infants or children. There have been two cases of the
removal of coagulated lymph from the interior of the eye, by Mr. Bowman
and Mr. White Cooper; and six cases of the formation of artificial
pupil, by the same surgeons, and Mr. Dixon; and in two cases lately, Mr.
Bowman has removed a portion of the iris.
I have given chloroform in 25 cases of excision of the eyeball; 20 of
the operations have occurred within the last two years, in addition to
some in which I administered amylene. The whole of the operations were
performed by Mr. Bowman, except one by Mr. Fergusson, and one by Mr.
Hancock. The operation is of late years a much less formidable one than
formerly, owing to the plan of commencing to dissect off the conjunctiva
just around the cornea. After the eyeball is removed, the edges of the
conjunctiva are drawn together by a fine suture, so that scarcely any
wound is left, and the patient can generally begin to wear an artificial
eye in four or five days. In cases of malignant disease extending beyond
the globe, of course, the more formidable and extensive operation would
still require to be performed.
I have administered chloroform for the removal of sparks of iron and
other foreign bodies from the cornea, chiefly in cases in which the
surgeon had previously tried without success. Under the influence of
chloroform, the foreign matters were always removed very readily. There
have also been operations for the removal of growths from the eye and
granular growths from the conjunctiva, and also for staphyloma and
pterygion.
I have memoranda of 54 operations for strabismus in which I have
administered chloroform. The greater number of them were performed by
Mr. Bowman, but several by Mr. Fergusson, and a few by other surgeons.
One operation was performed by the late Mr. Dalrymple. Mr. Bowman
generally operates on both eyes at the same time. A great number of the
patients who have taken chloroform for this operation were children.
They have nearly all been lying down during the operation.
There have been nine operations for ectropion and entropion, chiefly by
Mr. Bowman. I have administered chloroform on four occasions whilst Mr.
Bowman has performed a plastic operation for the formation of a new
eyelid. On three occasions, the eyelid had been destroyed by a burn, and
the material for the new one was taken from the integuments of the
forehead. The operations were necessarily tedious.
_Removal of Foreign Bodies and Polypi from the Ear._ In May 1849, Mr.
Henry Charles Johnson extracted a pea from the ear of a child, six years
of age. The pea had been a month in the ear, and Mr. Johnson had
endeavoured to examine the ear without chloroform, but could not do so.
In May 1857, I administered chloroform to a child aged three years, a
patient of Mr. Tuach, whilst Mr. Hewett extracted a glass bead with
sharp edges from the ear. He got it out with a director. I have notes of
four cases in which a polypus was removed from the ear by Mr. Partridge,
Mr. Fergusson, Mr. Henry Lee, and Mr. Henry Smith; and I recollect
giving chloroform more than once at Mr. Toynbee’s whilst he performed a
similar operation, although I have no memoranda of the circumstances.
_The Removal of Polypi and Foreign Bodies from the Nose._ I have
memoranda of fourteen cases in which I have administered chloroform for
the removal of polypi from the nose. The operations were nearly all
performed by Mr. Fergusson. The patient was nearly always seated in an
easy chair, and the chloroform, in several cases, was repeated to keep
up the insensibility till the operation should be completed. In one of
the cases, the polypus caused a protrusion of the nasal bones; the
nostril was slit up, and there was very great hæmorrhage as the polypus
was brought away. The pulse became small for a time, but there was no
syncope. The patient did well. In June 1852, I gave chloroform to a
girl, five years old, and Mr. Fergusson scooped out some polypus growth
from the right nostril, and also an oval softened body, rather bigger
than a horse-bean, which was a young orange that the child had pushed up
her nose in India. The case had given rise to a good deal of difference
of opinion amongst medical men in India and Malta, who generally
discredited the child’s account of the orange. In August 1856, Mr.
Stanley removed a bean from the nose of a child.
_Certain Operations in the Mouth._ I have notes of six operations for
cancer of the tongue, performed by the late Mr. Keate, Mr. Quain, Mr.
Hancock, and Mr. Paget. Mr. Paget’s was a case of epithelial cancer, in
a lady, about twenty-five. The operation was one of excision of the
tumour, and I lately heard that the patient remained free from the
complaint. The other operations were by ligature. Mr. Quain’s was a
hospital patient, and I do not know the ultimate result of the case. The
other patients had a return of the disease, and died after great
suffering.
I have notes of ten operations for epulis, chiefly by Mr. Fergusson. The
patient was generally on a sofa or the operating table, with the head
and shoulders raised. As the operations were soon completed, the
chloroform seldom required to be repeated. There have been some cases of
cancerous disease of the gums and alveolar process in which I have
administered chloroform. One of these was a patient of Mr. Bell, the
dentist, on whom Mr. Hilton operated. I assisted the late Mr. Avery by
giving chloroform in two operations for cleft palate. A large cork with
a string to it[147] was kept between the molar teeth on one side during
the operation; and the inhalation was repeated from time to time. The
surgeon, however, much prefers to have the patient awake during this
operation, when he can get his assent.
I have administered chloroform four times for the removal of the
tonsils. Three times in children, and once in the adult. In the case of
a child on which Mr. Curling lately operated, he removed one of the
enlarged tonsils very easily and very well, but just as he was beginning
to remove the other, the child began to vomit its breakfast, and the
throat was afterwards so filled with mucus and blood, that we thought it
better to defer the remainder of the operation till another day.
_Plastic Operations._ I have memoranda of 50 plastic operations in which
I have administered chloroform, in addition to those on the eyelids,
previously mentioned. Eight of the operations were for the formation of
a new nose. Five of them were by Mr. Fergusson, two by Mr. Critchett
when Mr. Fergusson was present, and one by Mr. Samuel A. Lane. I made
the patients insensible with the inhaler before the operation was
commenced, and afterwards kept up the insensibility by means of
chloroform, diluted with spirit, on a hollow sponge. No fewer than 24 of
the plastic operations were for the remedy or mitigation of deformity
caused by burns. In fourteen of these cases, the operation was performed
on the neck, but often extended to the breast and lower part of the
face. The other ten operations were for burns on the face and arms and
other parts of the body. Nearly all these operations were performed by
Mr. Fergusson. One of his patients was a gentleman from New York, who
had a most severe burn in the face when a child. The operations, without
the action of a narcotic, would be of the most painful nature; and the
greater number of those at which I have been present would not have been
performed, except for the discovery of narcotism by inhalation. The
remaining eighteen plastic operations were for a variety of purposes,
such as replacing the loss of a lip, the closing of artificial anus, and
of openings in the cheek, and a variety of other defects, either
congenital, or arising from injury or disease. They were nearly all
performed by Mr. Fergusson.
_Raising depressed Portions of Skull._ In Dec. 1848, I administered
chloroform to a gentleman in Norfolk, aged sixty-two, on whom the late
Mr. Aston Key operated. The patient had been thrown from his horse four
years previously, and probably kicked whilst on the ground. He believed
that he did not lose his consciousness. There was a considerable
depression of a portion of the right parietal bone, near its upper and
posterior angle; but there were no symptoms of cerebral pressure or
irritation for two years after the accident; but at that time he fell
from his seat in some kind of fit, after which he had partial paralysis
of the left arm, impaired vision, and a melancholy or apathetic state of
mind. He was also subject to attacks of real or apparent suspension of
breathing, and to occasional attacks of vomiting.
His ordinary medical attendant, Dr. Bell of Aylsham, objected to the
chloroform, on account of feeble and irregular action of the heart, in
addition to the above symptoms. The patient, however, became gradually
insensible, without any unfavourable symptoms. After making incisions in
the scalp, Mr. Key sawed out a good sized piece of the parietal bone
with Hey’s saw. The insensibility was kept up gently during the
operation, which lasted above half an hour. There was pus under the
bone, and the dura mater was diseased, and gave way during the
operation. Mr. Key immediately expressed a bad opinion of the case. The
patient recovered his consciousness in about a quarter of an hour, and
in a little time was in the perfect enjoyment of all his faculties,
being very cheerful, and in a totally different state from the one of
apathy and almost unconsciousness, in which he appeared when we first
saw him. He was attacked with inflammation of the brain on the third
day, and died on the fifth.
In May 1855, I administered chloroform in St. George’s Hospital to a
young man who had been kicked by a horse. The frontal bone above the
right eye was driven in to a good depth, and a little of the brain had
escaped. Mr. Cæsar Hawkins cut a piece from the frontal bone, just above
the depressed portion, with the bone forceps, to enable him to introduce
the elevator. The depressed portion being quite loose, was removed,
together with the roof of the orbit. The youth was partially comatose
before chloroform was given, but made a resistance to the operation. A
week after the operation, when I saw him, he was conscious, but
feverish, and he died a week or two later.
Mr. Bowman, on one occasion, made an incision over the frontal sinus in
a gentleman; and made an aperture in the outer table of the frontal
bone, which gave exit to a quantity of pus which had been formed in the
sinus.
In the summer of 1847 the late Mr. Liston performed a similar operation
on a lady, the patient of Dr. Locock, who was present. I exhibited
sulphuric ether on that occasion.
_Operations for ununited Fracture._ I have notes of seven operations by
Mr. Fergusson and Mr. Bowman, for ununited fracture of the femur,
humerus, radius, and ulna. The usual course has been to scrape and
puncture the ends of the bones by subcutaneous incision, and where this
has not succeeded, to cut down on the bones and saw off the ends; or to
bore holes near the ends, and introduce ivory pegs.
_The Reduction of Dislocations._ I have notes of twenty-seven cases in
which I have administered chloroform during the reduction, or attempted
reduction, of dislocations. Only three of these were recent
dislocations. One had existed a few days; and the other twenty-three for
some weeks or months. Twelve of the operations were performed by Mr.
Fergusson, and the others by Mr. Cæsar Hawkins, Mr. Cutler, Mr. Bransby
Cooper, Mr. Partridge, Mr. Tatum, Mr. H. C. Johnson, Mr. Charles
Hawkins, Mr. Hewett, Mr. Henry Lee, and Mr. Price. Most of the
dislocations at the shoulder were quite successfully reduced; one of
them by the late Mr. Bransby Cooper, as long as ten weeks after the
accident. Dislocations of the hip were successfully reduced in three
weeks and five weeks after the accident. At longer periods, dislocations
of the femur were often benefited by the operation, but not completely
reduced. The dislocations at the elbow were not successfully reduced
except when recent, although the position and motion of the forearm were
improved in several cases by the operation. Pulleys were applied, often
for a length of time, in the old dislocations; and many even of the
successful operations could not have been performed except the patient
had been in a state of anæsthesia. A full dose of chloroform is required
in the attempts to reduce old standing dislocations, in order to
suspend, as nearly as may be, the resistance of the muscles.
_Forcible Movement of Stiff Joints._ I have given chloroform in
twenty-two operations of this kind, within the last three years, for the
restoration of motion in the knee, elbow, and hip, after the joints had
become fixed in one position, generally by adhesions resulting from
disease. The first operation of the kind in which I assisted was one
performed by Mr. Brodhurst, whom I have since assisted more frequently
in these kinds of operations than any other surgeon; but other
operations have been performed by Mr. Fergusson, Mr. Cæsar Hawkins, Mr.
Partridge, Mr. Bowman, Mr. Hewett, and Mr. Edwin Canton. These
operations would evidently not have been performed except for the
discovery of producing a state of anæsthesia by inhalation.
_Tenotomy._ I have memoranda of 78 cases of tenotomy in which I have
administered chloroform. In some of the cases which have occurred during
the last two or three years, forcible movement of a stiff joint has been
resorted to, in addition to the tenotomy. I applied chloroform in St.
George’s Hospital in tenotomy, when the agent was first introduced; and
have also given it in King’s College Hospital for ten years. During
these ten years I have also administered chloroform to a number of the
private patients of Mr. Fergusson, whilst he has performed tenotomy, and
to those of other surgeons occasionally. During the last three years, I
have given it in several operations by Mr. William Adams. I understand
that several orthopædic surgeons had, at one time, an objection to
chloroform in tenotomy, from an impression that it would relax the
muscles, and thus render the operation less easy of performance. But it
is altogether unnecessary to carry the effects of chloroform so far as
to relax the muscles. The pain of this operation can always be prevented
without relaxing the muscles, which are indeed often more tense than if
the patient were awake.
_Operations for Strangulated Hernia._ I have notes of only nineteen
cases of operations for strangulated hernia in which I have administered
chloroform since the end of 1849. This operation is, I believe, often
performed without the use of this agent. Fifteen of the cases in which I
have exhibited chloroform were inguinal or femoral hernia, and four
cases were umbilical hernia. In these latter cases, the patients all
died.
In one of the cases, there was a complication, in addition to the
hernia. The patient was an old gentleman, and the surgeon had directed
him to apply ice and salt, and had either given no directions respecting
the time it was to be applied, or the directions were misunderstood. The
patient was a scientific man, and applied the ice and salt most
effectually for about four hours. When we arrived, a portion of the
integuments around the umbilicus, larger than the palm of the hand, was
as hard as a board, and of a dull white colour. The surgeon said that he
could not turn back the flaps of the integument, if he made them whilst
it was in that hardened state. The part thawed whilst the patient was
inhaling chloroform, and when the incisions were made some fluid blood
of a light crimson colour flowed. Iced water was applied to the part
immediately after the operation, for a short time. The integuments which
had been frozen sloughed two days after the operation. The patient had
peritonitis, and died on the fifth day.
On March 6th, 1848, a man was placed on the operating table in St.
George’s Hospital, with a strangulated femoral hernia. I administered
chloroform to him at the request of Mr. H. C. Johnson; and when he
became completely insensible and the muscular system relaxed, Mr.
Johnson readily reduced the hernia by means of the taxis, although it
was previously quite incapable of reduction. If the taxis had not been
successful, the operation, for which the instruments were arranged
ready, would at once have been performed whilst the patient was
insensible. I do not think that chloroform has been sufficiently
employed of late years during the application of the taxis to
strangulated hernia.
In every case in which sickness was present, it was relieved by the
chloroform. And vomiting returned in scarcely any instance, after the
chloroform, so long as I remained in the room.
_Operations for Hæmorrhoids and Prolapsus Ani._ I have memoranda of 171
operations for these affections in which I have administered chloroform.
A great number of these operations have been performed by Mr. Fergusson
and Mr. Salmon; but I have also assisted Mr. Cæsar Hawkins, Mr. Bowman,
Mr. Quain, Mr. Erichsen, and a number of other surgeons, whilst
performing this operation. The patient always lies on one or the other
side during this operation, with the knees drawn up towards the stomach.
The chloroform should be inhaled till the patient is quite insensible,
that is, till the edge of the eyelid can be touched without causing
winking, otherwise he is apt to stretch out his legs, as soon as the
operation is commenced. Ligatures always, or nearly always, introduced
with a needle, have been applied to the mucous membrane in every case
both of hæmorrhoids and prolapsus ani, except in two or three in which
Mr. Henry Lee applied nitric acid and the actual cautery. In a great
number of the cases, however, folds of redundant and diseased skin were
cut away from around the anus, with a pair of large curved scissors,
after the ligatures had been applied to the mucous membrane. It is the
rule in these cases never to cut the mucous membrane, and never to tie
the skin. It is desirable to get the patient to protrude the hæmorrhoids
by bearing down at the night stool before he inhales the chloroform, and
they always remain protruded during the operation; indeed, there is
generally a good deal of bearing down during the operation under
chloroform, and if the bowels have not been entirely emptied, they are
apt to act as the operation is being performed. It is customary, and
very desirable, to give a full dose of opium almost as soon as the
patient wakes from the chloroform, to diminish the pain caused by the
ligatures. I have, in a few cases, continued to administer the
chloroform at intervals for an hour or two after the operation, till the
opium began to take effect; and I consider that it would be useful, in
some cases, to give the opiate two or three hours before the operation.
I administered chloroform to two ladies, one a patient of Mr. Bowman,
and the other of Mr. Wm. Adams, whilst hæmorrhoids were removed by the
écraseur. The operations lasted rather more than half an hour; but the
chloroform, after the commencement of the operation, required only to be
kept up to a moderate extent. There was no hæmorrhage in either case;
and it seemed to me that the great pain which is caused by the presence
of the ligatures would be prevented by this means of operating.