On chloroform and other anæsthetics: their action and administration

by John Snow

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.

Mr. Fergusson introduced a great improvement in this operation about seven years ago; instead of the incisions through the cheek or lip, or both of these parts, he merely slits open the lip exactly in the mesial line, as far as the columna of the nose, and then carries the knife along one side of the base of the columna into the nostril, next the tumour. He says: “By opening the nostril in this way as much relaxation was gained as if the knife had been carried from the root of the ala an inch up the side of the nose, and as much facility was given for the future steps of the operation, as if an incision three inches in length had been made through the lip and side of the nose, while a grand object was gained in leaving the slightest possible conspicuous appearance afterwards.”[^[146]] This plan has the further great advantage of avoiding the very copious hæmorrhage which arises from a deep incision in the side of the face.

In one of the operations which was performed before this improvement was introduced, the patient died of hæmorrhage. The case is related by Mr. Prescott Hewett in the Medico-Chirurgical Transactions for 1851. This operation was performed in St. George’s Hospital, in May 1848, with the consent of the surgical staff of the hospital. The patient was a man, aged twenty-five; the tumour was of nearly six years duration. For some time previous to the operation, he had suffered occasionally from hæmorrhage from the affected nostril, to an extent which had reduced him considerably. The vapour was given to him rather slowly, with the apparatus I commonly employ, and he became gradually insensible, without previous excitement or struggling. In about three minutes, the inhalation was discontinued, the narcotism having reached the third degree. The patient was passive, but the muscles were not relaxed. The breathing was not stertorous. Some teeth were now extracted without causing any sign of pain. A little more chloroform was then given to him, and when the inhalation was discontinued a second time, he was in the same state as before the teeth were drawn. The operation was immediately commenced. The superior maxillary and malar bones of the left side were removed. During the first part of the operation, whilst the flaps were made, the patient was perfectly quiet and silent; but afterwards he began to groan and move his limbs, and he was not again rendered altogether insensible; for although a few minims of chloroform were from time to time sprinkled over a sponge, which was, now and then, held near his face, yet, owing to the hands of the operator and his assistants being in the way, and the cavity of the mouth and nostril being laid widely open, he got very little of the vapour, and the only effect of it was partially to quiet him on one or two occasions. After the first two or three minutes of the operation, the effect of the chloroform never exceeded the second degree. The patient executed voluntary movements of his arms and legs; sometimes it was necessary to hold his hands, and at one time he appeared conscious, for he folded his arms as if making an effort not to raise his hands to the seat of pain. He coughed now and then, and seemed somewhat embarrassed with the blood in his throat. He was seated in a chair, but as there was no window in the operating theatre except the skylight, his head was obliged to be inclined rather backwards. He was leaned forwards once or twice, to allow him to get rid of the blood, and it appeared that he vomited some on one of these occasions. Towards the conclusion of the operation, and at a time when he was very little under the influence of chloroform, he fainted. He was laid down, and brandy was given to him. No more chloroform was administered after this time. He partially rallied from the syncope, but again became faint. The actual cautery was applied, but oozing of blood continued until the moment of death,—about half an hour after his removal into another room. During this interval, he was much exhausted; his pulse was small, and difficult to feel. He was tossing himself about in a restless manner, but there was no difficulty of breathing. He seemed quite conscious, doing as he was told, but, of course, could not speak, from the nature of the operation. I left a few minutes before the patient’s death. When he ceased to breathe, laryngotomy was performed, and artificial respiration exercised by the opening, with no beneficial result. In my opinion, this measure was not indicated, but of course it could do no harm.

One of the surgeons who was present when the patient died informed me that blood entered his windpipe from the wound, when he became moribund.

It was found during the operation that the tumour did not involve the superior maxillary or malar bones, but was situated behind them. In his address to the class immediately after the operation, Mr. Hewett estimated the loss of blood at sixteen ounces. It appeared to me to be much greater; besides that a great deal of blood would certainly be swallowed.

After death, portions of the tumour were found still remaining attached to the posterior and upper part of the cavity, and projecting into the foramen lacerum of the orbit and right nostril, as well as in other directions. The trachea and bronchi contained some frothy blood. Numerous small dark spots of congestion were met with in the lung, resulting from some of the small bronchi being filled with blood.

The late Mr. Liston lost a patient from hæmorrhage during the removal of a tumour of the upper jaw, before the prevention of pain by inhalation was discovered; and it is evident that the chloroform did not contribute either directly or indirectly to the death of Mr. Hewett’s patient. His symptoms were simply those of exhaustion from loss of blood; he recovered from the effects of the chloroform some time before he died; and the small quantity of blood which spotted the lungs, and was observed to enter as he was dying, would not have led to any immediate urgent symptoms if it had entered during the operation.

Tumours of the Lower Jaw. I have notes of twelve cases in which I have given chloroform during this operation. Eight of the operations were performed by Mr. Fergusson, and the others by Mr. Stanley, Mr. Tatum, Mr. Hancock, and Dr. Pettigrew. In some of the cases the jaw was divided on each side above its angles, and in most of the others it was disarticulated on one side, and divided near the symphysis. Three of the patients died within three days, from the hæmorrhage which occurred at the time of the operation, but the others all recovered.

The remarks which were made respecting the application of chloroform in the removal of tumours of the upper jaw are applicable here. After the operation has been commenced, one should endeavour to keep up the insensibility by means of a mixture of chloroform and spirit on a hollow sponge. In tumours, both of the upper and lower jaw, the operating table is preferable to an easy chair for the patient under chloroform. The head and shoulders must be raised by the movable flap of the table, or by some other contrivance if the operation be performed in a private house. I have, however, seen the operation performed on a sofa, and with the patient in bed. The blood does not flow into the throat so much in the removal of tumours of the lower jaw, as in those of the upper one.

Tumours of the Female Breast. I have memoranda of 222 cases in which I have given chloroform during the removal of tumours of the breast, or tumours which returned after the breast had been removed. I do not include with these a considerable number of small tumours, situated upon, and near the gland, but not involving it. By far the greater number of the tumours of the breast were looked upon as malignant, but I am not able to state the numbers which were believed to be malignant, and which were thought not to be so. I may state that there is no surgeon whom I am in the habit of assisting who does not occasionally remove malignant, as well as non-malignant, tumours of the breast. By far the greatest proportion of the above mentioned operations on tumours of the breast were performed in private practice. In a number of cases diseased glands were removed from the axilla, in addition to the mammary gland. It is desirable in the removal of large tumours of the breast that the surgeon should be well seconded, by assistants who are in the constant habit of assisting him, in order that the bleeding may be restrained and arrested as quickly as possible. I have not seen any case in which the patient did not go through the operation, and live, as far as I can remember, for two or three days. But a few of the patients have been very faint from bleeding during the operation, and faintness from hæmorrhage seldom takes place during the influence of chloroform unless the loss of blood is very great. The greater portion of the patients who have been faint during the operation have done well afterwards, but a few of them have not. In cases where there is a great loss of blood, and a very large wound remains, the patients are apt to sink and die in from three to five days. Most patients may recover from a considerable hæmorrhage, and most patients may be able to bear up during the healing of a large wound, but the combination of a great hæmorrhage and a great wound is apt to be fatal; especially to patients who are already reduced by illness. The largest tumour of the breast I have seen removed, was one on which Mr. Fergusson operated, in King’s College Hospital, on Feb. 26th, 1853; it weighed eighteen pounds and a half. On the 4th of June, following, the same patient had a small tumour removed from the same situation. It probably resulted from a portion of the large one which had been left behind.

There are a few surgeons who prefer to have the patient seated in an easy chair whilst removing a tumour of the breast; but it is more convenient, under the influence of chloroform, that the patient should lie on a table, or sofa, or in bed. I usually keep the patient unconscious till the wound is stitched up, and the plaster and bandage applied.

I have administered chloroform in four cases of tumour of the male breast. These tumours were all of them malignant, I believe.

Other Tumours. I have had to administer chloroform during the removal of several large and deep-seated tumours of the face, situated just in front of the ear, over the parotid gland, with which some of them were thought to be connected. These operations were generally extremely difficult and tedious, owing to the necessity of avoiding the division of the branches of the facial nerve which passed over the tumour. When the branches of the facial nerve are touched with the forceps, or back of the scalpel, during these operations, the muscles of the face to which the branches are distributed contract very freely, at a time when the patient is perfectly insensible. Mr. Stanley, Mr. Fergusson, and Mr. Tatum, are amongst the surgeons whom I have assisted in the removal of tumours of this kind.

I have memoranda of 41 tumours situated behind the angle of the jaw, in the removal of which I have exhibited chloroform. These tumours, which mostly consisted of diseased lymphatic glands, were often very deep-seated, passing near to the carotid artery, and it was necessary on that account to keep the patient quite insensible, to prevent his flinching during the operation. The greater number of these tumours were removed by Mr. Fergusson.

Seventy-one of the tumours of the removal of which I have notes, are stated to have been of the encysted kind. Sixteen of them were situated on the eyelids, sixteen on the scalp, three or four in the orbit, several in front, or at the side of the neck, and the rest in different parts of the body.

I have memoranda of 66 fatty tumours which were removed from different parts of the body. Some of them were of great size; one weighed fifteen pounds. One which Mr. Fergusson removed in 1855 from the arm of a lady, the patient of Messrs. Maurice and Harris of Reading, was situated beneath the biceps muscle, and weighed two pounds six ounces and a half. The diagnosis of it was very difficult. The fatty tumours were easily removed, except in a few instances, in which the fat was infiltrated in the surrounding tissues.

I have notes of the removal of 87 other tumours of various kinds, as fibrous, scirrhous, epithelial, melanotic, fungoid, etc.

On February 11th, 1854, Mr. Fergusson removed a large fibrous tumour, situated over the right scapula of a stout gentleman about forty. It weighed about three pounds. The tumour was very adherent to all the surrounding tissues, and the removal of it occupied five or ten minutes, and was attended with considerable hæmorrhage. At the time when the tumour was completely detached, the patient became pale, and the pulse could no longer be felt in either wrist or in the temporal arteries. He did not faint, however, for the breathing continued to be well and regularly performed. He partially recovered his feeling once or twice, whilst the vessels were being tied, and more chloroform was given to him. At the end of the operation he was quite conscious, and did not complain of being faint, although no pulse could be felt. The pulse had not returned when I left him half an hour after the operation, and I was informed that it did not return for about three hours. Four hours after the operation, when I called to see him, he had a frequent and very distinct pulse. He had some hot brandy and water just after the operation, and about ten minutes afterwards he insisted on going to the water-closet in the next room, and could not be persuaded to lie still. The moment he was raised on his feet, however, he fainted, but was immediately laid down again, when he as quickly recovered his consciousness, and was content to lie still. This was the only faintness he had. It is my opinion that the effect of the chloroform kept up the breathing and prevented syncope, whilst the smaller arteries of the exterior of the body contracted so as to confine the remaining blood very much to the vital organs. The patient seemed in some danger for two or three days, but was walking out quite well in less than a fortnight.

In April 1856, Mr. Paget removed a fibro-cellular tumour, weighing probably ten or twelve pounds, from a lady a few weeks out of her confinement. The tumour was situated over the sacrum and nates. Sir Benjamin Brodie was present at the operation. The patient recovered favourably.

Nævi. I have memoranda of 116 operations on vascular tumours, the greater part of them in infants. The operations have generally been performed by subcutaneous ligature, and have been extremely successful. The greater number of them have been performed by Mr. Fergusson and Mr. Bowman, in private practice and in King’s College Hospital. Some of the nævi on the faces of infants, which were operated on by Mr. Fergusson, were very large, and required a succession of operations.

Ligature of Arteries. I have administered chloroform in three cases of ligature of the carotid artery, by Mr. Bowman, Mr. Lane, and Mr. Haynes Walton. Mr. Walton’s patient was an infant six months old. The right common carotid artery was tied, on account of a tumour which pushed forward the eye to a great extent. On the child being brought under the influence of chloroform, the prominence of the eye diminished very much, as I was informed that it had done when chloroform was given for some reason on a previous occasion. On the ligature being placed under the artery, the chloroform was discontinued, and its effects allowed to subside before the ligature was tied. As the effects of the chloroform went off, the eye became as prominent as before; and the tightening of the ligature had no effect on this prominence whilst I remained, although it instantly stopped the pulsation of the temporal artery. I was informed that this child was cured by the operation.

I have also administered chloroform in three cases of ligature of the external iliac artery, for aneurism of the femoral. Two of the operations were performed by Mr. Fergusson, and the other by Mr. Henry Smith. One of Mr. Fergusson’s patients was a very stout gentleman; the external iliac artery was diseased at the usual situation of the ligature, and it had to be tied near to the common iliac. This patient died. Mr. Henry Smith’s patient recovered, as I believe did the other of Mr. Fergusson’s. It is necessary that the patient should be kept very insensible during the operation of tying the carotid or external iliac artery, to prevent the possibility of his flinching.

I have exhibited chloroform six times for the ligature of the superficial femoral artery, on account of aneurism in the popliteal space. Two of these operations were performed by Mr. Bowman on the same man with an interval of three weeks. He had an aneurism in the popliteal space of both limbs. There was a case of false aneurism of the radial artery, on which Mr. Fergusson operated by tying the artery above and below, and turning out the clot; and also a case in which Mr. Hancock tied the vessels for a false aneurism, situated between the metacarpal bones of the thumb and forefinger. There were two cases also in which the radial artery was tied for a recent wound; one by Mr. Henry Charles Johnson, the other by Mr. Henry Lee.

Tumours of Bone. I have administered chloroform in a number of cases of the removal of enchondroma, and other tumours of bone. In June 1849 I assisted the late Mr. Aston Key whilst he removed a bony tumour from a youth about sixteen, situated at the inner and anterior part of the femur, just above the knee; and I have seen two or three other tumours of the same kind, exactly in the same situation. I have no notes of the other cases; but one was a patient of Mr. Quain, and another, I think, of Mr. Fergusson. After an incision is made, the tumour can be clipped clean off at once with a pair of strong, curved bone nippers. Unless the bone nippers are curved, the operation is troublesome and difficult.

Hare-Lip. I have notes of 147 operations for hare-lip, for which I have given chloroform. A few of these operations were performed by Mr. Arnott, Mr. Cæsar Hawkins, Mr. Bowman, Mr. Henry Charles Johnson, and others, but nearly nine-tenths of the whole number were performed by Mr. Fergusson, either in his private practice or in King’s College Hospital. A great number of Mr. Fergusson’s operations were in children from three to six weeks old; and some were younger than this, one being only eight days. There used to be an objection against operating for hare-lip on very young infants, as it was said that they often died of convulsions, which I believe to be true. The convulsions were supposed to be caused by the shock of the operation on the nervous system, which I believe to be entirely untrue. I believe they were caused by hæmorrhage; and I would not recommend the surgeon to perform his first operations for hare-lip on very young and feeble infants. The great success of this operation of late years, in the first weeks of life, depends on the dexterity of the surgeon who performs the operation so quickly that scarcely any blood is lost. When Mr. Fergusson performs this operation, the infant is held by a nurse, who is seated opposite to him, whilst its head is placed in his own lap between his thighs. An assistant compresses the labial artery on the right side, by grasping the lip between his finger and thumb, just at the angle of the mouth; a sharp-pointed scalpel is pushed through the lip on the right side, just below the nose, and carried downwards so as to cut away the edge of the fissure; then the same performance is done on the left side of the fissure, while Mr. Fergusson compresses the labial artery on that side with the finger and thumb of his left hand. In about twenty seconds from the beginning of the operation, the hare-lip pins are introduced, and the cut edges of the lip being pressed together, the bleeding is at once entirely stopped. I have no doubt that many lives are saved by early operation, especially amongst the poor, as a child with a bad hare-lip cannot take the breast till it is operated on, and there is a very great mortality amongst infants brought up by hand.

The blood which escapes when the infant is laid on its back flows back into the throat, and it usually passes on each side of the epiglottis, and runs into the stomach without any act of deglutition. In a few cases of strong children, in whom the bleeding is rather free, the breathing gets embarrassed, and Mr. Fergusson turns the face of the child downwards for a moment to let the blood run out of its mouth. When the quantity of blood flowing into the throat is greater than can run down into the stomach, in the way I have mentioned above, the glottis closes and the breathing stops, which gives the indication for turning the face downwards. I have seen a few operations in the hospital for hare-lip, without chloroform, whilst the children were on their backs. In these cases they cried violently from the pain, set the blood in the mouth into violent commotion, and then drawing a deep inspiration, drew a little of the blood into the larynx, which caused a violent cough; so that there was usually much more appearance of choking than in the cases where chloroform was given. Moreover, in these latter cases, it is usually towards the end of the operation that the children sometimes become embarrassed with the blood; not because the quantity of blood is greater, but because the sensibility is returning. I have seen one case which shows that the effects of chloroform, when deep or long continued, will diminish the sensibility of the glottis. After an infant was made insensible some years ago for an operation for hare-lip, it was found that an instrument for dividing the projecting intermaxillary bone was wanting, and I kept the child insensible for several minutes, by administering chloroform occasionally, until the instrument was found; the bleeding was rather free, and some of it entered the windpipe and caused a tracheal râle. The child coughed it up on awaking, and no ill consequences followed; but the occurrence confirms the opinion previously expressed, that the insensibility should not be both deep and long continued at a time when copious hæmorrhage is flowing into the throat. The effects of chloroform pass off very quickly in infants, and it is not often that they last till the operation of hare-lip is finished, short as that operation is. In private practice, indeed, when the parents of the infant are close by, I usually have an opportunity to apply a little chloroform, mixed with spirit, on a sponge, in the course of the operation, when it is required to prevent crying; but in the hospital, the children sometimes cry a little before the operation is concluded.

Cancer of the Lip. I have memoranda of nineteen cases of cancer of the lower lip, and three or four of the upper lip, in which I have administered chloroform. As there is never an easy chair in the operating theatre of an hospital, and it is difficult to keep the patient in a common chair when he is under the influence of chloroform, it is better to place the hospital patient on the operating table, with his head and shoulders raised during this operation; but in private practice the patient may either be placed on a sofa, or in a large easy chair with a high back. The effect of the chloroform often lasts to the end of the operation, if it be completed within two or three minutes; but I always go provided with a hollow sponge, and a mixture of chloroform and spirit to apply during the operation, if required.

Division of the Sensory Nerves of the Face. I have notes of nineteen 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.

Hæmorrhoids and prolapsus ani are peculiarly prevalent in the upper 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.