EFFECT OF CHLOROFORM ON THE RESULT OF OPERATIONS.
Besides the great benefit conferred by chloroform in the prevention of pain, it probably confers still greater advantages by the extension which it gives to the practice of surgery. Many operations take place in children which could not be performed in the waking state; excisions of joints and tedious operations for the removal of necrosed bone are often performed on persons who would be altogether unable to go through them except in a state of anæsthesia; and the moving of stiff joints by force is an operation now frequently performed, although it would probably not have been thought of if narcotism by inhalation had not been discovered. The surgeon also obtains the ready assent of his patient to a number of other operations, where it would either not be obtained at all, or not at the most favourable time, if the patient had to suffer the pain of them.
The effect of chloroform cannot fail to be favourable, to a certain extent, in large operations. The patient is in a more tranquil and cheerful condition after the operation, than he would be in if he had suffered the pain of it. His pulse is usually of the natural frequency; and after an amputation, there is generally an entire absence of the starting of the stump, which was formerly so distressing. After all the minor operations in which chloroform is used, and which according to my experience comprise at least one-half of the cases, there is never a death; and the only inconvenience is a troublesome sickness of stomach in a very few instances. Moreover, when patients die after the more formidable operations, they succumb to causes which are well known, and were in operation before the practice of anæsthesia. I only know of a very few instances where there has been a reasonable doubt on the mind of the surgeon, whether the chloroform may not have had some share in preventing the recovery of the patient, after a severe operation. These were cases in which the sickness, which occasionally follows chloroform, continued for three or four days, indeed till the death of the patient. This is a point which it would be difficult to decide, for the latter part of the sickness might depend on the sinking state of the patient, and might have come on if chloroform had not been used. Moreover, as sickness is seldom very prolonged after chloroform in minor operations, except in persons who are not in a good state of health, it is most probable, that the patients who died after a great operation with continued sickness, would not have done well if no chloroform had been used.
Some attempts have been made to determine, by statistical inquiry, whether the result of operations has been more favourable since the introduction of anæsthesia. These attempts have been confined to the larger amputations, as they are the only operations which sufficiently resemble each other to admit of the application of statistical inquiry; and even in the case of these operations, the inquiries which had been made previously to the introduction of etherization differed widely in their results.
Dr. Simpson took great trouble, in the early part of 1848, to collect the account of the amputations of the thigh, leg, and arm, which had been performed under the influence of ether or chloroform in forty-nine of the hospitals in Great Britain; and for comparison, he collected from thirty British hospitals the results of the same amputations, for the two or three years preceding 1847. He found that the mortality in the period preceding the use of ether was 29 per cent. in these amputations, and the return of patients whose limbs had been amputated under the use of ether and chloroform gave a mortality of 23 per cent.; and he concluded that 6 per cent. of the lives of those who had undergone these amputations had been saved by the use of these agents. In his application for an account of cases, however, Dr. Simpson merely asked for the number of cases, and the number of deaths. Nothing was said as to the time when the amputations had been performed; and there is reason to believe that a number of cases still under treatment may have been included; some of which may have ended fatally after the returns were made. The cutting part of a large amputation is of very short duration. The loss of blood is not great; and patients hardly ever died during the performance of an amputation, but some time afterwards, of diseases which ether and chloroform have not been found capable of preventing. It was therefore not to be expected that these agents should save the lives of so many as 6 per cent. of those who underwent the larger amputations.
In the early part of 1849, I published an account of fifty-five amputations of the thigh, leg, and arm, in which I had administered ether or chloroform, and the mortality was 27 per cent.[[141]]
Dr. James Arnott has lately been investigating this subject in a very persevering manner. During the last three or four years, all the cases of amputation performed in the London hospitals have been reported in the Medical Times and Gazette, together with their results; and Dr. James Arnott has stated that the average per centage of deaths, after the three kinds of amputation above mentioned, is 34·4 per cent. There is obviously no means of ascertaining what was the mortality after amputations in the hospitals of London before the use of ether and chloroform, but Dr. James Arnott brings forward four papers, which state the mortality for a short period, in four hospitals, a little time before the introduction of etherization. The number of cases in these papers is 174, and the number of deaths 41. Dr. James Arnott states the per centage of deaths to be 21·9,[[142]] although it appears to me that it would be 23·5; and it may be remarked that the four papers from which these numbers are taken might probably not have been published if the numbers they contain had not been favourable. Dr. James Arnott, in a second table, gives the number of amputations and deaths from the several hospitals in London which are named. The cases are said to have occurred “during eighteen months from June 1855 to June 1856, inclusive;” here being obviously a mistake. The number of cases is 204, and the number of deaths 61; which would give a mortality of 29·9 per cent.; almost exactly the same as that which Dr. Simpson had obtained from thirty provincial hospitals before the use of ether. The numbers in Dr. Simpson’s table are 618 cases, and 183 deaths, or 29·6 per cent. Dr. James Arnott does not, however, mention the per centage of deaths in his second table, but gives another table, for a different period, in which the names of the hospital are not given. The numbers he gives in this table are 430 cases and 148 deaths, giving a mortality of 34·4 per cent. Dr. James Arnott therefore concludes that chloroform causes the death of upwards of 12 per cent. of those who inhale it for the purpose of undergoing amputation. It is evident that he can have had no experience of the effects of chloroform, or he would have perceived at once the error of his conclusions, for this agent is given for a much longer time than in amputations, in numerous operations of which the entire mortality is less than 12 per cent. In the removal of tumours of the female breast, for instance, more chloroform is generally administered than in an amputation, and the loss of blood is also much greater, yet the entire mortality after this operation is considerably less than that which Dr. J. Arnott supposes that chloroform adds to the ordinary mortality after amputations.
Dr. J. Arnott stated that the pyæmia, of which many of the patients died after amputation, had probably been rendered more prevalent and fatal by the use of chloroform; but Mr. Thomas Holmes, in one of his able replies to the remarks of Dr. Arnott, points out that pyæmia had been prevalent also in cases of compound fracture, and others in which the patients had no chloroform. He stated that this complaint had been more prevalent in St. George’s Hospital during the three years in which Dr. J. Arnott’s statistics of amputations had been collected, than in the previous five years, in which chloroform had been used.[[143]]
A very valuable paper on the result of operations performed in the Newcastle Infirmary, before and since the use of ether and chloroform, was published last year by Dr. Fenwick.[[144]] He says, respecting his tables, “in the first series are included the operations registered in the operation books of the Newcastle Infirmary from 1823 to 1843; but, as the record is imperfect, the actual period embraced is seventeen and a half years. In the second, are the operations registered since the first employment of ether; and as the use of anæsthetic agents has been general in all the more important operations since that time, these figures may be used to show any disadvantages likely to arise from the employment of chloroform.” Dr. Fenwick continues:—“Before the use of chloroform, there were registered 225 amputations of the thigh, leg, and arm, of which 54, or 24 per cent., died. Since the use of anæsthetic agents, 149 cases of similar operations have been recorded, of which 36 died, showing also a mortality of 24 per cent.
“Before, however, we can draw any conclusion from such facts, we must carefully exclude all those circumstances which are already known to produce an effect upon the mortality of amputations. It is, for instance, well known that amputations performed on account of accidents are, on the whole, nearly twice as fatal as those required for long standing disease. Now, if we divide the foregoing numbers into these two classes, we shall find that before the introduction of chloroform there were 144 pathological amputations, with a mortality of 19 per cent.; while since its employment there have been only 61, of which 13 per cent. have died; and while of 81 traumatic amputations which took place in the former period 32 per cent. died, only 31 per cent. perished in the latter period. The equal mortality obtained from a general average of all amputations is thus seen to have arisen from the smaller comparative number of operations performed for diseases.”
After giving a table which shows the result of each kind of amputation 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.