On chloroform and other anæsthetics: their action and administration

by John Snow

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.