Dr. Fenwick very properly remarks that other circumstances may have had an influence over the mortality of the various operations, as well as the fact of chloroform being used or not used: but his inquiry is very important, as it shows the result of operations in the same institution since the employment of ether and chloroform, and for a long period immediately preceding the use of those agents.
THE ADMINISTRATION OF CHLOROFORM IN THE DIFFERENT KINDS OF OPERATIONS.
General directions for the exhibition of chloroform have already been given, but it is desirable to say a few words regarding its employment in some of the individual operations of surgery.
Lithotomy. In this operation, it is advisable to have the patient placed on the operating table with his head supported by one or two pillows, and to administer the chloroform before the sound is introduced. This having been done, it is generally requisite to administer a little more vapour cautiously and gently, whilst the bandages are applied to the hands and feet, and the patient is drawn down towards the foot of the table. The bandaging should on no account be neglected in the adult patient. It would be an abuse of chloroform to carry its effects so far in every case that the slightest contraction of the muscles could not be excited by the use of the knife, merely to save the trouble of applying a bandage. In little children, the bandages are not usually employed; but in these cases, the person administering the chloroform should hold the head or shoulders of the little patient, just as the surgeon makes his first incision; for the two assistants who are holding the legs, and think they are doing a great deal of good, are really making a fulcrum to enable the child to push itself away from the surgeon, if it makes the least flinch, which it is almost sure to do, if the narcotism is not much deeper than there is any occasion for. In this operation the patient should be fully insensible when the surgeon makes his first incisions; and the chloroform must be repeated or not during the operation as occasion may require.
I have memoranda of fifty-seven cases in which I have administered chloroform in the adult, and thirty-four in children, down to the present time, the end of March 1858. It was my expectation that I should be able to give the result of these, and all the other important operations; but I have in a few cases either not ascertained whether the patient recovered or not, or have neglected to make a note of the circumstances at the time; and although the deficiencies might perhaps be made up by private correspondence, and by searching the books of three hospitals, I regret that I have not time at present for such an undertaking.
A large proportion of the above cases of lithotomy were performed by Mr. Fergusson, either in his private practice, or in King’s College Hospital, and the remaining operations were performed by a number of surgeons. On April 19th, 1855, Mr. Fergusson removed eight calculi, as large as pigeon eggs, from the bladder of a gentleman, aged sixty-nine, who had a favourable recovery.
On June 7th, in the same year, he removed fourteen calculi from the bladder of an elderly gentleman, who also recovered. In January 1857, he removed forty-two calculi from the bladder of a gentleman, aged sixty-six; twelve of them were nearly as large as chesnuts, and the rest about as big as hazel-nuts. This patient died, I think, within a fortnight. He had disease of the kidneys. A considerable number of the elderly men on whom lithotomy has been performed have had well marked symptoms of fatty degeneration of the heart; but the chloroform has acted favourably on all of them. In January 1853, Mr. Fergusson performed lithotomy in the country on a gentleman, aged sixty-four, removing a rather large calculus. The patient weighed eighteen stone; he had a pulse which was liable to intermit, some of his relations had died suddenly, and his usual medical attendant was very much alarmed about the chloroform; but its action was very satisfactory. The patient recovered his consciousness without sickness, or any unpleasant symptom; and he had a favourable recovery. On August 11th, 1855, I administered chloroform in King’s College Hospital to a man, aged seventy-five, whilst Mr. Fergusson performed lithotomy. The patient had suffered from apoplexy a year before; he was still paralyzed on one side, he had the arcus senilis well marked in both eyes, and the temporal arteries were very thick and rigid. He went through the operation well; the pulse being good all the time. He died on the fifth day, and the following appears in the Medical Times and Gazette respecting the appearances found after death. “At the autopsy, the cellular tissue of the pelvis was found infiltrated with pus. The kidneys were contracted, and occupied by many cysts; the ureters were inflamed and contained pus. The bladder was extensively sacculated, and its mucous membrane so much congested as to appear on the point of sloughing. There was no peritonitis. The heart was large and fatty, and its aortic valves diseased to a small extent. The brain was congested, and its bloodvessels extensively ossified.” On December 22nd, 1855, I administered chloroform in King’s College Hospital to a very fat man, aged sixty-one, with a soft weak pulse, and arcus senilis of the cornea. Mr. Fergusson performed lithotomy. He went well through the operation, and recovered promptly from the effects of the chloroform. He died on the seventh day, with purulent effusion into the left knee, and around the left shoulder. The heart was large and flabby, and the substance of the left ventricle was very friable. The right ventricle was dilated and thinned, and its walls were soft and friable, and encroached on externally by fat; at one place there seemed scarcely any muscular substance left.
I have memoranda of four cases of lithotomy in the female, in which the urethra was divided as well as dilated to extract the stone; and I recollect two other cases of the same kind of which I have no notes.
Lithotrity. I have memoranda of 155 operations of lithotrity in which I have administered chloroform. The number of cases of stone in which these operations took place was sixty, but some of the patients had operations performed, either without chloroform, or when it was administered by some one else. The earliest cases of lithotrity in which I administered chloroform were in St. George’s Hospital, and a great number of the patients to whom I have given it were the private patients of Mr. Fergusson, who is entirely satisfied of its utility in this operation. Speaking of this operation in his Practical Surgery (third ed., p. 800), he says: “I am of opinion that there is not any department of practical surgery in which anæsthesia has been of more service than in this.” I have administered chloroform in a few operations of lithotrity by Sir Benjamin Brodie; but I believe that he does not approve of it in this operation, as a general rule. The following are amongst the other surgeons whom I have frequently assisted by giving chloroform in this operation: Mr. Cæsar Hawkins, Mr. Cutler, Mr. Coulson, Mr. Charles Hawkins, and Mr. Henry Lee. Mr. Fergusson, in one of his operations, extracted some portions of gutta percha bougie round which a phosphatic calculus had formed. He was not informed of the presence of the bougie in the bladder, until it was extracted. On another occasion, a patient was brought from the country soon after a bougie of this description had broken off, and he extracted with the lithotrite the piece remaining in the bladder. It was between two and three inches in length.
It is generally desirable to make the patient quite insensible during the operation of lithotrity; and the patient sometimes groans during its performance, when he is in a condition that, so far as one can judge, he would show no sign of sensation under the use of the knife; but he, of course, has no recollection of the operation afterwards. The bladder is sometimes apt to expel the water which is injected, if the patient is not well under the influence of the chloroform; but when the vapour has been continued for a few minutes, and the narcotism is complete, the bladder will, I believe, always hold water as well as if the operation were performed in the waking state, and generally much better. There are some surgeons who occasionally raise the breech of the patient for a short time during this operation, so that the head becomes considerably lower than the body. Stout old men generally snore more loudly when in this position under the influence of chloroform; but I have not met with any ill effects, nor expected any, from the head being lowered for a short time. From ten to twenty minutes has been the most usual duration of the operations under chloroform at which I have been present.