On chloroform and other anæsthetics: their action and administration

by John Snow

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.