class of society. That small portion of English people who dine in the
evening seem to furnish more cases of hæmorrhoids for operation than all
the rest of the population. And I am inclined to attribute the
circumstance to the habit of taking the greater part of the food towards
the close of the day, after a long fast; by which means congestion of
the liver, and obstruction to the return of blood from the bowels is
induced. Many of the patients with hæmorrhoids are ladies who are far
from luxurious in their habits, indeed many of them are abstemious; and
many of the male patients are the reverse of sedentary, as they spend a
great part of their time in hunting, and other field sports. Again, the
complaint cannot in my opinion be attributed to highly seasoned food, as
I think the working classes use more pepper than fashionable people. I
am inclined to believe that the habit of taking the chief meal of the
day at twelve or one o’clock, is the principal reason why bad cases of
hæmorrhoids are comparatively so rare in the working and middle classes,
many of whom live luxuriously, and are more sedentary in their habits
than the higher class of society.
Several of the patients operated on for hæmorrhoids were extremely
blanched, from the continued loss of blood arising from the disease; but
these patients underwent both the action of the chloroform and the
operation very well. The operation, it must be remembered, is not
attended with loss of blood.
_Fissure of the Anus._ I have notes of forty-four cases in which I have
exhibited chloroform in operations for the cure of this disease. Two of
them were performed by the late Mr. Copeland. The sphincter ani was
divided in the greater number of the operations. In addition to these
cases, there were some in which fissure existed, along with hæmorrhoids,
or fistula _in ano_. The patient was always placed on his side, in the
same position as in the operation for hæmorrhoids.
_Operations for Fistula in Ano._ The position of the patient in this
operation should be the same as in those for hæmorrhoids and fissure of
the anus, unless the patient is placed on the back, in the lithotomy
position, as I have seen in a few cases.
I have memoranda of 218 cases in which I have given chloroform in
operations for fistula _in ano_. In many of the cases the sinuses were
very numerous and extensive. It is necessary that the patient should be
quite insensible during this operation, to prevent the possibility of
his moving suddenly whilst the bistoury is being used.
_Operations on Ovarian Tumours._ I have notes of three cases in which I
gave chloroform during the removal of an ovarian cyst. The first of
these was in March 1850. Twenty-four pints of liquid were first
evacuated from the tumour. It consisted of four cysts united together,
two of which contained serous fluid of slightly different colour; the
third contained serum tinged with blood, and the fourth and smallest
cyst, a purulent fluid. An incision was made, twelve or fourteen inches
in length, extending from the pubes to midway between the umbilicus and
sternum. Some slender adhesions were removed at one spot. The tumour was
attached by a membranous pedicle, with the left iliac fossa, and the
fundus of the uterus. Needles were passed through the pedicle, and it
was tied in three or four portions, when the tumour was removed. After
the tumour was removed, the patient seemed to breathe entirely by the
ribs, the diaphragm remaining relaxed, and not contracting, whilst the
wound in the abdomen was being closed. Scarcely any blood was lost
during the operation. The patient died of peritonitis early on the
fourth day.
The next case occurred on August 27th, 1850, and is reported in the
_Medico-Chirurgical Transactions_ for 1851. Mr. Duffin was the operator,
and the patient made a favourable recovery.
The third operation was performed on the 31st of January, 1854. The
patient was a spinster, twenty-eight years of age, and the tumour had
not been tapped. It contained about two gallons of clear fluid, and was
removed through an opening in the median line above the umbilicus, about
seven inches in length. There was no depression when the patient awoke
after the operation. She died within three days.
I administered chloroform in two cases where it was intended to remove
an ovarian cyst. In one case the cyst was so adherent to the peritoneum
that it could not be removed; in the other case, there was no cyst, but
some serum in the peritoneal cavity, and a tumour growing from the
fundus of the uterus. This tumour was allowed to remain. Several medical
men, in addition to the operator, had diagnosed an ovarian tumour in
this case. These two patients recovered.
I exhibited chloroform in four operations in which an ovarian cyst was
opened, and the cut edges of it sewed to the wound in the abdominal
parietes. These four patients, I believe, all died. I am quite certain
as regards three of them.
On March 10th, 1852, I administered chloroform in St. Mary’s Hospital to
a woman, apparently about thirty-five, who had suffered from an ovarian
cyst about eighteen years. Mr. Isaac Baker Brown made an incision, about
six inches in length, into the peritoneal cavity, drew out a portion of
the cyst, tapped it, and removed several pints of clear serum. He then
cut away a piece of the anterior wall of the cyst, about as large as the
hand, and allowed the rest of the cyst to remain loose in the abdomen.
The wound in the parietes of the abdomen was stitched up. If I remember
rightly, the patient died, but I have no note of the result.
_Operations for Cancer of the Vagina._ I have notes of eighteen cases in
which I have given chloroform for operations of this kind by the knife,
which would have been extremely painful without the use of an
anæsthetic.
I exhibited this agent, in 1848, to a lady, whilst the late Mr. Aston
Key applied the actual cautery to malignant excrescence of the os uteri;
and I have administered it in several cases in which potassa and other
caustics have been applied to the os uteri. In operations on the vagina
or perineum, the woman should inhale chloroform whilst lying on her
back; and when insensible, should be drawn to the edge of the bed, or
the foot of the operating table, and have the knees held back and
separated.
_Operations for Rupture of the Perineum._ I have notes of fourteen
operations for this accident. Six of them were performed by Mr. I. B.
Brown, five by Mr. Fergusson, and the others by Mr. Paget, Dr. Protheroe
Smith, and Mr. Henry Lee. Mr. Fergusson has, in five cases, performed an
operation for prolapsus uteri, by paring the edges of the outlet of the
vagina, and stitching them together so as to diminish the orifice.
I have given chloroform in several operations for vesicovaginal fistula,
some of which were performed by Mr. Spencer Wells; and also for the
removal of warts and other growths from the labia pudendi, either by the
knife or caustics.
_Removal of the Testicle; Amputation of the Penis, etc._ I have
memoranda of twenty-seven cases in which I have administered chloroform
during the removal of a testicle, generally for malignant disease; and
six cases in which I have administered it for amputation of the penis,
always for malignant disease. There were six operations, also, in which
a part of the penis was removed for malignant disease; and eleven cases
in which warts were removed from the glans penis, generally with the
knife. In two cases in August 1854, Mr. Acton destroyed a number of
venereal warts on the glans penis and prepuce by a caustic composed of
potassa and lime. In all the operations on the testicle and penis, under
chloroform, the patients have been lying on the back.
_Operations for Phymosis._ I have memoranda of 76 operations for
phymosis, in which I have exhibited chloroform. The operations were
generally in the adult, although the complaint was, in most cases,
congenital. I have known two cases in which cancer of the penis was
produced by the patient’s suffering a congenital phymosis to remain to
about the age of fifty. The cancer commenced in the glans from the
irritation of the retained urine. One of the patients died of the
disease.
_Removal of enlarged Bursa._ I have notes of six cases in which the
bursa of the patella was dissected out by the surgeons of King’s College
Hospital for housemaid’s knee. The patients were charwomen and domestic
servants. In two cases a bursa was removed from the forefinger.
_Evulsion of the Nails._ I have notes of twenty-five cases in which I
have given chloroform for cutting down the nail of the great toe, and
tearing away the whole, or the two edges of it; and also of three cases
in which one or more finger nails were removed by a similar process.
This operation is one of the most painful of the minor operations of
surgery. It is better that the patient should be lying when it is done
under chloroform.
_Laryngotomy._ I administered chloroform to one or two infants in which
Mr. Henry Smith performed laryngotomy for croup. I also administered it,
on four occasions, to a patient of Mr. Partridge, a boy four years old,
who was believed to have a button in some part of the air-passages. The
larynx had been opened a few days previously to the first occasion in
which I gave chloroform, and I administered it on a sponge, held near to
the tube in the larynx. It was necessary to give the vapour gently at
first, just as if it was entering in the usual way. When it was given at
all strong, whilst the patient was still conscious, he showed exactly
the distress that a patient experiences when he says that the vapour
produces a choking feeling; which confirms my opinion that the feeling
referred to the throat, from the action of pungent vapours and gases, is
caused by their presence in the lungs. The chloroform was given to keep
the child quiet whilst Mr. Partridge searched for the supposed button in
the larynx and bronchi. When the child recovered from the chloroform,
before the operation was concluded, the explorations in its air-passages
embarrassed the breathing much more, and caused more apparent
threatening of suffocation, than they did when he was under the
influence of the vapour. This little boy remained for months in King’s
College Hospital; and at last the embarrassment in his breathing
subsided, the tube was removed from the larynx, and the wound allowed to
heal; and he left quite well, although the button, which was supposed to
have gone down his windpipe at the moment when his symptoms first
suddenly came on, was never found.
I have administered chloroform in a great variety of surgical
operations, in addition to those mentioned above, but as they required
only the usual management in the application of the vapour, I need not
allude to them, but shall, however, make a few remarks regarding dental
operations.
_Extraction of Teeth._ It is the custom in the medical journals and
medical societies, to object occasionally to the use of chloroform in
tooth-drawing, as if the operation were not sufficiently severe to
require it. I will say nothing of the wives and daughters of medical men
in connexion with this subject, but will only allude to the case of an
elderly lady, who had for thirty years been the private friend, as well
as the patient, of one of the Council of the College of Surgeons. After
she had had ten necrosed teeth extracted, and had awakened from the
effects of the chloroform, her friend and surgeon, who had been looking
on, discoursed eloquently on her case, explaining how the state of her
mouth was ruining her health; how impossible it would have been for her
to go through the operation without chloroform, and what a great
advantage it was.
Dr. Watson says in his Lectures:[148] “I am not at all sure that the
increased longevity of modern generations is not, in some degree,
attributable to the capability of chewing their food which the skill of
the dentist prolongs to persons far advanced in life.” I have seen at
least fifty cases in which the dentist has been able to exert his skill
in enabling his patient to masticate only by the aid of chloroform;
cases of feeble, aged, or debilitated persons, whose mouths contained
between twenty and thirty stumps of teeth or necrosed teeth; and who
were able to get rid of them all at two or three operations a few days
apart; but without the opportunity of being made insensible, would
undoubtedly have continued with the mouth in a tender and painful state.
It was in consequence of the relief afforded by nitrous oxide gas, in
pain caused by a tooth, that Sir Humphrey Davy suggested its application
in surgical operations; it was for the extraction of a tooth that Mr.
Horace Wells first carried out the suggestion of Davy; and it was in the
extraction of teeth that Dr. Morton first employed sulphuric ether as a
substitute for nitrous oxide gas. These circumstances seem to point to a
demand for anæsthetics in operations on the teeth; and when the great
frequency of these operations is considered, it is probable that more
pain may be prevented during their performance than in any other class
of operations.
I have notes of 867 cases in which I have administered chloroform during
the extraction of teeth, chiefly by dentists living in this
neighbourhood: amongst whom are Mr. Saunders, Mr. Cartwright, Mr. Samuel
Cartwright, Mr. Arnold Rogers, Mr. Thomas A. Rogers, Mr. Tomes, Mr.
Bigg, Mr. Crampten, Mr. F. W. Rogers, Mr. Alfred Canton, Mr. Woodhouse,
Mr. Lintott, Mr. Rahn, Mr. Vasey, Mr. Sercombe, Mr. Fletcher, and
several others; and there is one dentist in the City, Mr. West of Broad
Street, whom I have frequently assisted. The number of teeth, or stumps
of teeth, extracted in these 867 operations, has been about 3021. In
some cases in which several teeth have been removed, I have not been
sure of the exact number, but have put down about the number.
The number of teeth extracted at an operation has varied from one to
nineteen. The latter number was extracted by Mr. Canton on one occasion,
and on two or three occasions, Mr. Arnold Rogers and Mr. Samuel
Cartwright extracted seventeen at one sitting; but these gentlemen and
others, as well as myself, have thought it better, as a general rule, to
make more than one operation, when the number of teeth to be drawn
exceeded ten, in order that the mouth might not contain too many wounds
at one time, and that the loss of blood might not be very great. A great
number of the operations have been for the extraction of the four first
permanent molars, in children about thirteen, as these teeth are very
apt to decay at an early period.
I have on 181 occasions, of which I have memoranda, given chloroform for
the extraction of a single tooth. I exhibited it lately to a lady, aged
eighty-six, whilst Mr. Bigg extracted an abortive wisdom tooth, which
had recently come through the gum, and was giving pain. She awoke in
about two minutes after the operation, and was quite cheerful and well.
The patients have been seated in an easy chair in all the operations on
the teeth, except in a very few cases where a female patient was too ill
to sit up. In many cases, and always if there was any feeling of
faintness, the patient has been placed on a sofa, after the operation,
for twenty minutes or half an hour. I am not aware of any inconvenience
from the chloroform, in any of the cases of tooth-drawing, excepting
sickness and vomiting, which in a very few of the cases have been
troublesome for some time.
It is necessary in tooth-drawing to make the patient unconscious, and to
continue the chloroform a little while after unconsciousness is induced,
till the sensibility of the edge of the eyelid is very much diminished,
or almost altogether suspended, otherwise the patient will probably make
a resistance that will interfere with the operation, or scream out and
alarm his or her friends. I nearly always take about four minutes in the
inhalation. It is not desirable to take longer than five or six minutes,
as the patient would be slower than is desirable in recovering
completely from the effects of the vapour.
The patient is usually in the third degree of narcotism when the
operation is performed, and, in this degree, as was previously stated,
there is not unfrequently a contracted and rigid state of the muscles.
This state often affects the muscles of the jaws, and interferes with
the opening of the mouth, if it be closed. I generally tell the patient
to keep his mouth open whilst inhaling, and by that means it often
remains open when he is insensible. Not unfrequently, however, he closes
it on becoming insensible. One can generally open it by pressing on the
chin; but as the chin does not afford a very favourable hold, there are
a very few cases in which the mouth cannot be opened easily in this way,
at least not unless the effects of the chloroform are carried further
than is desirable for these operations. I therefore carry with me a
little instrument of two blades, made to open by means of a screw. The
ends of the blades are covered with leather, and, if introduced between
the teeth, at the corner of the mouth on the side opposite to that on
which the dentist is about to operate, the mouth can easily be
opened.[149] The power of the instrument is only such that I can
scarcely open it with one hand, when I hold the blades with the other.
It would not enable one to open the mouth of an adult if he were closing
it by voluntary power; but the spasm caused by chloroform is very much
less powerful than the action of the muscles when influenced by the
will. I never use the instrument for opening the mouth when the patient
is closing it voluntarily under the influence of a disordered
consciousness, but always wait till consciousness and volition are
entirely suspended. When the mouth is once opened, it can generally be
kept open with the fingers, and the instrument may be withdrawn.
The bleeding during tooth-drawing is never so free as to interfere with
the breathing; but when more than two or three teeth are extracted, and
especially if they be in the back part of the mouth, some of the blood
which escapes nearly always flows into the stomach; it flows down the
fauces and œsophagus usually without any act of deglutition; but the
evidence of its having gone into the stomach is obtained in those cases
where the patient vomits. In consequence of the blood flowing into the
stomach, vomiting cannot so generally be prevented by the precaution of
not taking a meal before the operation in tooth-drawing as in other
operations; but the sickness usually subsides as soon as the patient has
emptied his stomach.
The chloroform has occasionally to be repeated in tooth-drawing before
the operation is completed, especially in cases where several teeth
require to be extracted. When this is the case, I always reapply it as
soon as the patient begins to show signs of feeling the operation,
without waiting till he recovers his consciousness. In many cases,
however, a number of teeth are extracted without any repetition of the
chloroform; and in the instances in which as many as fifteen, seventeen,
or nineteen teeth were extracted at one operation, it was chiefly
because the first application of the vapour enabled the dentist to take
out such a number, otherwise, in most of these cases, a number of the
teeth would have been left for a succeeding operation. It has
occasionally happened, however, that the chloroform has required to be
repeated, once or twice even, for the extraction of a single stump. When
the chloroform is repeated once or twice, it is generally a longer time
before the patient is able to leave the dentist’s house. I always
request the patients who are operated on at the dentist’s, to drive
home, as it is not advisable to walk, or use any exertion for an hour or
two after the action of chloroform. Indeed, the patient is usually
disinclined for any exertion for twenty minutes or half an hour after
the influence of this agent, and sometimes for much longer; although I
have seen a patient mount the box of a sort of dog-cart, and drive
himself away, within five minutes after having several teeth extracted
whilst he was in a state of complete insensibility from chloroform.
I have administered chloroform in a great number of cases for the
destruction of the nerves of the teeth. The patient requires to be made
as insensible in this operation as in tooth-drawing.
_Secondary Hæmorrhage_ after Operations. The hæmorrhage which
occasionally comes on several days after an operation, from sloughing,
ulceration, or the non-formation of a coagulum in an artery, is probably
as liable to occur now as formerly; but I believe that hæmorrhage, a few
hours after an operation, is much less frequent since the practice of
narcotism by inhalation. Before this practice, it was extremely common
for the patient to faint during an operation, when the bleeding of the
smaller arteries stopped, and they escaped the ligature, to break out in
hæmorrhage occasionally afterwards; but under the influence of narcotic
vapours it is unusual for the patient to faint, and consequently every
vessel which is capable of bleeding is tied during the operation.
CHLOROFORM IN PARTURITION.
When the practice of inhalation in midwifery was first introduced by Dr.
Simpson, he very naturally adopted the plan which is usually followed in
surgical operations, making the patient unconscious at once, and keeping
her so to the end of the labour. It was soon found, however, by other
practitioners, that this is not necessary; and, indeed, it would not be
safe in protracted cases. Drs. Murphy and Rigby were, I believe, amongst
the first to state, that relief from pain may often be afforded in
obstetric cases, without removing the consciousness of the patient; and
I soon observed the same circumstance.[150] Some persons, indeed, have
alleged that the pain of labour can always be prevented, without making
the patient unconscious of surrounding objects; whilst others have
asserted that no relief can be afforded unless unconsciousness be
induced. But both these opinions are directly opposed to experience.
There are comparatively few cases in which the suffering can be
prevented throughout the labour without interfering with consciousness,
although there are very many cases in which it can be in this way
prevented in the early part of the labour. This difference depends, in
some measure, on the constitution of the patient, but chiefly on the
severity of the pain to be prevented. It is in accordance with what is
observed in medical and surgical cases, that the pain should be removed,
in some instances, without abolishing consciousness, and that in other
instances it should not; for, in certain cases of neuralgia, the pain is
so severe, that no material relief can be obtained by chloroform as long
as consciousness is retained; and in surgical operations, although it
now and then happens that the minor and concluding parts of an
operation, such as tying vessels and introducing sutures, can be
performed without pain, whilst the patient is consciously looking on, a
free incision in the skin can hardly ever be made, under similar
circumstances, without pain.
With regard to the cases of labour in which chloroform may be employed,
it will be readily conceded that, in cases where the pain is not greater
than the patient is willing to bear cheerfully, there is no occasion to
use chloroform; but when the patient is anxious to be spared the pain, I
can see no valid objection to the use of this agent, even in the most
favourable cases. The benefits arising from chloroform in severe cases
of labour are experienced in a lesser degree in favourable cases; and
the patient may be fairly allowed to have a voice in this, as in other
matters of detail which do not involve the chief results of the case.
The determination of the kind of labours in which chloroform should be
used, or withheld, is really a matter of not much importance, because,
as we pass from cases that are severe and protracted to those which are
short and easy, the quantity of chloroform that is used, and the amount
of diminution of the common sensibility, and of interference with the
mental functions, become so trifling, that very little remains about
which to hold a discussion. Indeed, from what I have observed of the
continued use of this agent in medical cases, and its use by healthy
persons for experiment, I believe that the quantity which is inhaled in
a short and easy labour might be continued daily for an indefinite
period, without appreciable effect on the health.