Part 26

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.

I have administered chloroform six times in female children whilst Mr. Fergusson performed lithotrity. The patients were three in number. I think the calculus all came away after the first operation, and the second was only an examination of the bladder. I administered chloroform also, on one occasion, to a lady whilst Mr. Spencer Wells repeated the operation of lithotrity.

Section of the Urethra in the Perinæum. I have notes of 56 cases of this operation. A great proportion of them were performed by Mr. Fergusson, either in King’s College Hospital, or in private practice. Amongst the other surgeons whom I have assisted in this operation were the late Messrs. Guthrie, Bransby Cooper, and Avery. In a great number of the cases, it was impossible to get a catheter into the bladder until after the incision was made in the perinæum, and many of the operations were very tedious; several of them lasting above an hour. It is very desirable to apply the bandages in this operation, as in that of lithotomy, especially if the assistants are not numerous.

Other Operations for Stricture, etc. I have notes of four operations in which the stricture was divided internally by a urethratome; and of two operations in which the orifice of the urethra was enlarged; and of nine plastic operations to restore deficiencies of the walls of the urethra, congenital or otherwise. I have memoranda of 66 cases in which I have administered chloroform for sounding the bladder or the introduction of a catheter. In catheterism under chloroform the patient, of course, lies on his back, which is indeed the position in which he ought to be during this operation, when chloroform is not administered.

Amputation of the Thigh. This operation is often performed for disease of the knee, when the joint is in such a state of tenderness that the least motion causes great pain. In such cases, I have administered the chloroform to the patient in bed, before his removal to the operating table, and given a little more chloroform just before the operation was commenced. In King’s College Hospital, I have several times given the chloroform in the ward in such cases, before the patient was removed to the operating theatre; but in St. George’s Hospital, the passages and doors being wide, the patient has been carried on his bed into the theatre, where the chloroform was administered just before his being lifted on the table. In those cases in which the tourniquet is applied, in preference to pressure with the fingers, it should be adjusted as the patient is getting under the influence of the chloroform, and tightened just before the operation begins. It is desirable to keep the patient quite insensible till the limb is removed, and the femoral artery is tied; after which a little chloroform may be given whenever the patient shows by a slight flinch, or contraction of his features, that sensation is returning. A few patients have recovered their consciousness during the tying of the smaller arteries, and have entered into a conversation without feeling the pain, but this condition is quite the exception. I have notes of 49 cases of amputation of the thigh in which I have administered chloroform. Some of the patients, who were almost grown up to the adult age, did not know that the limb was removed till three or four days had elapsed.

Amputation of the Leg. I have notes of 31 cases in which I have administered chloroform during this amputation. The remarks made above with regard to amputation of the thigh are applicable to this operation.

Amputation of the Arm. I have only administered chloroform five times in this operation, and only in one case during the last seven years. This case was that of a boy, aged sixteen; Mr. Hancock was the operator, and the patient recovered. I have no note of the disease for which the operation was performed, but in two or three of the remaining cases, the arm was amputated on account of malignant disease of the forearm. In one of the operations, the patient was seated in an easy chair, but in the others, the patients were lying on a sofa, or operating table, with the head and shoulders a little raised.

Amputation of the arm has apparently been much less frequently performed of late years, owing to the increasing practice of performing excision of the elbow; and it appears to me that all the great amputations are much less frequently performed now than they were a few years ago. During a little more than nine months of 1847, I administered sulphuric ether in 32 amputations of the thigh, leg, and arm; and in the last ten years and four months, I have only administered chloroform in 85 of the same operations; in the last three years, indeed, in only 16 cases; so that the practice of amputation is still diminishing. This is due to the practice of anæsthesia, which enables the surgeon to explore and to remove diseased joints and portions of diseased bone by operations that would be too long and too painful to be endured in the waking state. This circumstance confirms the remark of Dr. Fenwick, previously quoted, that the mortality after amputations may be expected to become greater, as they will cease to be performed, except after accidents, or in very desperate cases.

Amputation of the Ankle. I have notes of 15 cases of amputation at the ankle. They were chiefly performed by Mr. Fergusson, and generally in the manner recommended by Mr. Syme, or nearly so; but latterly Mr. Fergusson and Mr. Partridge have, in three or four cases, adopted the modification of this operation introduced by Prof. Pirogoff, by which a portion of the os calcis is left.

Other Amputations. I have notes of nine cases of amputation of the forearm; four of these operations were performed in 1850, and only three since that year. I have memoranda of twelve cases in which I have given chloroform whilst Chopart’s or other partial operations of the foot were performed. Also of three cases in which Mr. Fergusson performed amputation at the knee, and three cases in which he performed amputation at the wrist in King’s College Hospital. I have notes also of 65 cases in which I have administered it during the amputation of one or more fingers or toes.

Operations for Necrosis. Anæsthesia is of the utmost service in these operations, which are often tedious, and would be of the most painful nature. The operations are of the most successful kind of any in surgery; they usually relieve the patient from a very painful affection, and leave no mutilation. I have administered chloroform in many cases of necrosis in which an operation could not have been undertaken without its assistance; and in a still larger number, in which the operation could not otherwise have been satisfactorily completed. I have memoranda of 197 cases of necrosis in which I have given chloroform. In 70 of these, the tibia was the bone affected; in 15 cases, the femur; in 24 cases, the humerus; in 14 cases, the radius, or ulna, or both of these bones; in 29 cases, the bones either of the carpus or tarsus, or metacarpus or metatarsus. I have notes of six cases of necrosis of the sternum; in five of these the operation was performed by Mr. Fergusson, and in one case by Mr. Solly. Great care was required in some of the cases to avoid going through into the chest with the bone nippers. There have been nine operations for necrosis of the os calcis. In one of these, Mr. Wm. Adams lately removed, along with the necrosed bone, a small bullet which had been in the bone for six years.

The other cases of necrosis comprise the upper and lower jaw, the parietal bone, the edge of the orbit, the scapula and clavicle, the sacrum, the ileum, and the phalanges of the fingers and toes.

Excision of the Head of the Femur. I have notes of five cases of this operation. They all occurred in children from eight to thirteen years of age. Three of the operations were performed by Mr. Fergusson, one by Mr. Bowman, and one by Mr. French; I also recollect assisting Mr. Henry Smith in a similar operation in a child in 1848, at a time when I did not keep any account of the operations in which I administered chloroform. In one of Mr. Fergusson’s operations, he removed some diseased portions of the acetabulum.

Excision of the Elbow. There is every reason to conclude that this excellent operation has been performed more frequently in consequence of the inhalation of narcotic vapours than it otherwise would have been. I have memoranda of 19 cases of this operation in which I have exhibited chloroform; 18 of them were performed by Mr. Fergusson, and the remaining one was performed by Mr. Coulson, whilst Mr. Fergusson was present.

Excision of the Knee. I have notes of 17 cases in which I have given chloroform during the performance of this operation. Thirteen of the operations were performed by Mr. Fergusson, two by Mr. Bowman, one by Mr. Partridge, and one by Mr. Henry Smith.

This operation had been rarely performed till within the last seven years, and there is every reason to believe that it never would have been frequently performed, if the practice of producing anæsthesia had not been introduced. I shall speak of this operation again in treating of amylene.

Excision of Wrist. There have been two cases of this operation performed by Mr. Fergusson in King’s College Hospital.

The Removal of Tumours of the Upper Jaw. Mr. Syme, Mr. Lizars, and some other surgeons, expressed an opinion at one time that chloroform could not be safely used in this operation, as the blood would be liable to flow into the lungs. This is not the case, however, as the glottis retains its sensibility apparently unimpaired, if the influence of the chloroform is not too deep or long continued. It is only necessary to hold the head forward now and then, when the throat is very full of blood, in order to allow the patient the same opportunity of breathing that he would require if he were awake. A good deal of blood passes into the stomach in great operations about the mouth under the influence of chloroform; and if a few drops pass into the windpipe, they are coughed up again, as they would be in the waking state; there is, however, less appearance of suffocation in operations where the blood flows back into the throat, when the patient is insensible, than when he is awake. The glottis appears to retain some sensibility as long as a creature is capable of breathing, for I have placed the head of more than one cat under water after making them thoroughly insensible with chloroform, and the action of the respiratory muscles lasted more than two minutes, but no water entered the lungs.

I have always made the patient insensible in the usual way, with the inhaler, before the operation of removing tumours of the jaw, and have kept up the insensibility during the operation by means of a mixture of chloroform and spirit on a hollow sponge; or in cases in which I have not been provided with this mixture, I have put not more than fifteen or twenty minims of chloroform on the sponge at one time. Owing to the hands of the surgeon and his assistants being very much in the way, I have not always been able to keep the patient quite insensible throughout the operation. He has sometimes struggled or cried out, but there has been hardly any case in which the patient afterwards remembered any considerable part of the operation.

I have notes of twelve cases of removal of the upper jaw in which I have administered chloroform, in addition to four cases to which I alluded in the Medical Gazette, in the early part of 1849. In some of the cases, the malar bone was removed, as well as the superior maxillary. Eleven of these operations were performed by Mr. Fergusson, and the others were performed by Mr. Partridge, Mr. Henry Charles Johnson, Mr. Hewett, Mr. Henry Smith, and Mr. Haynes Walton.

Mr. Fergusson introduced a great improvement in this operation about seven years ago; instead of the incisions through the cheek or lip, or both of these parts, he merely slits open the lip exactly in the mesial line, as far as the columna of the nose, and then carries the knife along one side of the base of the columna into the nostril, next the tumour. He says: “By opening the nostril in this way as much relaxation was gained as if the knife had been carried from the root of the ala an inch up the side of the nose, and as much facility was given for the future steps of the operation, as if an incision three inches in length had been made through the lip and side of the nose, while a grand object was gained in leaving the slightest possible conspicuous appearance afterwards.” This plan has the further great advantage of avoiding the very copious hæmorrhage which arises from a deep incision in the side of the face.

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.