Part 27

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.

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.

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.