On chloroform and other anæsthetics: their action and administration

by John Snow

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.