Part 28

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.

I have notes of nine cases of the drilling of cataract in which I have administered chloroform, and there were some other cases in 1848, of which I have no memoranda. Some of the early operations were performed by Mr. George Pollock, and the more recent ones by Mr. Bowman. Many of the patients were infants or children. There have been two cases of the removal of coagulated lymph from the interior of the eye, by Mr. Bowman and Mr. White Cooper; and six cases of the formation of artificial pupil, by the same surgeons, and Mr. Dixon; and in two cases lately, Mr. Bowman has removed a portion of the iris.

I have given chloroform in 25 cases of excision of the eyeball; 20 of the operations have occurred within the last two years, in addition to some in which I administered amylene. The whole of the operations were performed by Mr. Bowman, except one by Mr. Fergusson, and one by Mr. Hancock. The operation is of late years a much less formidable one than formerly, owing to the plan of commencing to dissect off the conjunctiva just around the cornea. After the eyeball is removed, the edges of the conjunctiva are drawn together by a fine suture, so that scarcely any wound is left, and the patient can generally begin to wear an artificial eye in four or five days. In cases of malignant disease extending beyond the globe, of course, the more formidable and extensive operation would still require to be performed.

I have administered chloroform for the removal of sparks of iron and other foreign bodies from the cornea, chiefly in cases in which the surgeon had previously tried without success. Under the influence of chloroform, the foreign matters were always removed very readily. There have also been operations for the removal of growths from the eye and granular growths from the conjunctiva, and also for staphyloma and pterygion.

I have memoranda of 54 operations for strabismus in which I have administered chloroform. The greater number of them were performed by Mr. Bowman, but several by Mr. Fergusson, and a few by other surgeons. One operation was performed by the late Mr. Dalrymple. Mr. Bowman generally operates on both eyes at the same time. A great number of the patients who have taken chloroform for this operation were children. They have nearly all been lying down during the operation.

There have been nine operations for ectropion and entropion, chiefly by Mr. Bowman. I have administered chloroform on four occasions whilst Mr. Bowman has performed a plastic operation for the formation of a new eyelid. On three occasions, the eyelid had been destroyed by a burn, and the material for the new one was taken from the integuments of the forehead. The operations were necessarily tedious.

Removal of Foreign Bodies and Polypi from the Ear. In May 1849, Mr. Henry Charles Johnson extracted a pea from the ear of a child, six years of age. The pea had been a month in the ear, and Mr. Johnson had endeavoured to examine the ear without chloroform, but could not do so. In May 1857, I administered chloroform to a child aged three years, a patient of Mr. Tuach, whilst Mr. Hewett extracted a glass bead with sharp edges from the ear. He got it out with a director. I have notes of four cases in which a polypus was removed from the ear by Mr. Partridge, Mr. Fergusson, Mr. Henry Lee, and Mr. Henry Smith; and I recollect giving chloroform more than once at Mr. Toynbee’s whilst he performed a similar operation, although I have no memoranda of the circumstances.

The Removal of Polypi and Foreign Bodies from the Nose. I have memoranda of fourteen cases in which I have administered chloroform for the removal of polypi from the nose. The operations were nearly all performed by Mr. Fergusson. The patient was nearly always seated in an easy chair, and the chloroform, in several cases, was repeated to keep up the insensibility till the operation should be completed. In one of the cases, the polypus caused a protrusion of the nasal bones; the nostril was slit up, and there was very great hæmorrhage as the polypus was brought away. The pulse became small for a time, but there was no syncope. The patient did well. In June 1852, I gave chloroform to a girl, five years old, and Mr. Fergusson scooped out some polypus growth from the right nostril, and also an oval softened body, rather bigger than a horse-bean, which was a young orange that the child had pushed up her nose in India. The case had given rise to a good deal of difference of opinion amongst medical men in India and Malta, who generally discredited the child’s account of the orange. In August 1856, Mr. Stanley removed a bean from the nose of a child.

Certain Operations in the Mouth. I have notes of six operations for cancer of the tongue, performed by the late Mr. Keate, Mr. Quain, Mr. Hancock, and Mr. Paget. Mr. Paget’s was a case of epithelial cancer, in a lady, about twenty-five. The operation was one of excision of the tumour, and I lately heard that the patient remained free from the complaint. The other operations were by ligature. Mr. Quain’s was a hospital patient, and I do not know the ultimate result of the case. The other patients had a return of the disease, and died after great suffering.

I have notes of ten operations for epulis, chiefly by Mr. Fergusson. The patient was generally on a sofa or the operating table, with the head and shoulders raised. As the operations were soon completed, the chloroform seldom required to be repeated. There have been some cases of cancerous disease of the gums and alveolar process in which I have administered chloroform. One of these was a patient of Mr. Bell, the dentist, on whom Mr. Hilton operated. I assisted the late Mr. Avery by giving chloroform in two operations for cleft palate. A large cork with a string to it was kept between the molar teeth on one side during the operation; and the inhalation was repeated from time to time. The surgeon, however, much prefers to have the patient awake during this operation, when he can get his assent.

I have administered chloroform four times for the removal of the tonsils. Three times in children, and once in the adult. In the case of a child on which Mr. Curling lately operated, he removed one of the enlarged tonsils very easily and very well, but just as he was beginning to remove the other, the child began to vomit its breakfast, and the throat was afterwards so filled with mucus and blood, that we thought it better to defer the remainder of the operation till another day.

Plastic Operations. I have memoranda of 50 plastic operations in which I have administered chloroform, in addition to those on the eyelids, previously mentioned. Eight of the operations were for the formation of a new nose. Five of them were by Mr. Fergusson, two by Mr. Critchett when Mr. Fergusson was present, and one by Mr. Samuel A. Lane. I made the patients insensible with the inhaler before the operation was commenced, and afterwards kept up the insensibility by means of chloroform, diluted with spirit, on a hollow sponge. No fewer than 24 of the plastic operations were for the remedy or mitigation of deformity caused by burns. In fourteen of these cases, the operation was performed on the neck, but often extended to the breast and lower part of the face. The other ten operations were for burns on the face and arms and other parts of the body. Nearly all these operations were performed by Mr. Fergusson. One of his patients was a gentleman from New York, who had a most severe burn in the face when a child. The operations, without the action of a narcotic, would be of the most painful nature; and the greater number of those at which I have been present would not have been performed, except for the discovery of narcotism by inhalation. The remaining eighteen plastic operations were for a variety of purposes, such as replacing the loss of a lip, the closing of artificial anus, and of openings in the cheek, and a variety of other defects, either congenital, or arising from injury or disease. They were nearly all performed by Mr. Fergusson.

Raising depressed Portions of Skull. In Dec. 1848, I administered chloroform to a gentleman in Norfolk, aged sixty-two, on whom the late Mr. Aston Key operated. The patient had been thrown from his horse four years previously, and probably kicked whilst on the ground. He believed that he did not lose his consciousness. There was a considerable depression of a portion of the right parietal bone, near its upper and posterior angle; but there were no symptoms of cerebral pressure or irritation for two years after the accident; but at that time he fell from his seat in some kind of fit, after which he had partial paralysis of the left arm, impaired vision, and a melancholy or apathetic state of mind. He was also subject to attacks of real or apparent suspension of breathing, and to occasional attacks of vomiting.

His ordinary medical attendant, Dr. Bell of Aylsham, objected to the chloroform, on account of feeble and irregular action of the heart, in addition to the above symptoms. The patient, however, became gradually insensible, without any unfavourable symptoms. After making incisions in the scalp, Mr. Key sawed out a good sized piece of the parietal bone with Hey’s saw. The insensibility was kept up gently during the operation, which lasted above half an hour. There was pus under the bone, and the dura mater was diseased, and gave way during the operation. Mr. Key immediately expressed a bad opinion of the case. The patient recovered his consciousness in about a quarter of an hour, and in a little time was in the perfect enjoyment of all his faculties, being very cheerful, and in a totally different state from the one of apathy and almost unconsciousness, in which he appeared when we first saw him. He was attacked with inflammation of the brain on the third day, and died on the fifth.

In May 1855, I administered chloroform in St. George’s Hospital to a young man who had been kicked by a horse. The frontal bone above the right eye was driven in to a good depth, and a little of the brain had escaped. Mr. Cæsar Hawkins cut a piece from the frontal bone, just above the depressed portion, with the bone forceps, to enable him to introduce the elevator. The depressed portion being quite loose, was removed, together with the roof of the orbit. The youth was partially comatose before chloroform was given, but made a resistance to the operation. A week after the operation, when I saw him, he was conscious, but feverish, and he died a week or two later.

Mr. Bowman, on one occasion, made an incision over the frontal sinus in a gentleman; and made an aperture in the outer table of the frontal bone, which gave exit to a quantity of pus which had been formed in the sinus.

In the summer of 1847 the late Mr. Liston performed a similar operation on a lady, the patient of Dr. Locock, who was present. I exhibited sulphuric ether on that occasion.

Operations for ununited Fracture. I have notes of seven operations by Mr. Fergusson and Mr. Bowman, for ununited fracture of the femur, humerus, radius, and ulna. The usual course has been to scrape and puncture the ends of the bones by subcutaneous incision, and where this has not succeeded, to cut down on the bones and saw off the ends; or to bore holes near the ends, and introduce ivory pegs.

The Reduction of Dislocations. I have notes of twenty-seven cases in which I have administered chloroform during the reduction, or attempted reduction, of dislocations. Only three of these were recent dislocations. One had existed a few days; and the other twenty-three for some weeks or months. Twelve of the operations were performed by Mr. Fergusson, and the others by Mr. Cæsar Hawkins, Mr. Cutler, Mr. Bransby Cooper, Mr. Partridge, Mr. Tatum, Mr. H. C. Johnson, Mr. Charles Hawkins, Mr. Hewett, Mr. Henry Lee, and Mr. Price. Most of the dislocations at the shoulder were quite successfully reduced; one of them by the late Mr. Bransby Cooper, as long as ten weeks after the accident. Dislocations of the hip were successfully reduced in three weeks and five weeks after the accident. At longer periods, dislocations of the femur were often benefited by the operation, but not completely reduced. The dislocations at the elbow were not successfully reduced except when recent, although the position and motion of the forearm were improved in several cases by the operation. Pulleys were applied, often for a length of time, in the old dislocations; and many even of the successful operations could not have been performed except the patient had been in a state of anæsthesia. A full dose of chloroform is required in the attempts to reduce old standing dislocations, in order to suspend, as nearly as may be, the resistance of the muscles.

Forcible Movement of Stiff Joints. I have given chloroform in twenty-two operations of this kind, within the last three years, for the restoration of motion in the knee, elbow, and hip, after the joints had become fixed in one position, generally by adhesions resulting from disease. The first operation of the kind in which I assisted was one performed by Mr. Brodhurst, whom I have since assisted more frequently in these kinds of operations than any other surgeon; but other operations have been performed by Mr. Fergusson, Mr. Cæsar Hawkins, Mr. Partridge, Mr. Bowman, Mr. Hewett, and Mr. Edwin Canton. These operations would evidently not have been performed except for the discovery of producing a state of anæsthesia by inhalation.

Tenotomy. I have memoranda of 78 cases of tenotomy in which I have administered chloroform. In some of the cases which have occurred during the last two or three years, forcible movement of a stiff joint has been resorted to, in addition to the tenotomy. I applied chloroform in St. George’s Hospital in tenotomy, when the agent was first introduced; and have also given it in King’s College Hospital for ten years. During these ten years I have also administered chloroform to a number of the private patients of Mr. Fergusson, whilst he has performed tenotomy, and to those of other surgeons occasionally. During the last three years, I have given it in several operations by Mr. William Adams. I understand that several orthopædic surgeons had, at one time, an objection to chloroform in tenotomy, from an impression that it would relax the muscles, and thus render the operation less easy of performance. But it is altogether unnecessary to carry the effects of chloroform so far as to relax the muscles. The pain of this operation can always be prevented without relaxing the muscles, which are indeed often more tense than if the patient were awake.

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.