On chloroform and other anæsthetics: their action and administration

by John Snow

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.