Part 29

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.

Operations on Ovarian Tumours. I have notes of three cases in which I gave chloroform during the removal of an ovarian cyst. The first of these was in March 1850. Twenty-four pints of liquid were first evacuated from the tumour. It consisted of four cysts united together, two of which contained serous fluid of slightly different colour; the third contained serum tinged with blood, and the fourth and smallest cyst, a purulent fluid. An incision was made, twelve or fourteen inches in length, extending from the pubes to midway between the umbilicus and sternum. Some slender adhesions were removed at one spot. The tumour was attached by a membranous pedicle, with the left iliac fossa, and the fundus of the uterus. Needles were passed through the pedicle, and it was tied in three or four portions, when the tumour was removed. After the tumour was removed, the patient seemed to breathe entirely by the ribs, the diaphragm remaining relaxed, and not contracting, whilst the wound in the abdomen was being closed. Scarcely any blood was lost during the operation. The patient died of peritonitis early on the fourth day.

The next case occurred on August 27th, 1850, and is reported in the Medico-Chirurgical Transactions for 1851. Mr. Duffin was the operator, and the patient made a favourable recovery.

The third operation was performed on the 31st of January, 1854. The patient was a spinster, twenty-eight years of age, and the tumour had not been tapped. It contained about two gallons of clear fluid, and was removed through an opening in the median line above the umbilicus, about seven inches in length. There was no depression when the patient awoke after the operation. She died within three days.

I administered chloroform in two cases where it was intended to remove an ovarian cyst. In one case the cyst was so adherent to the peritoneum that it could not be removed; in the other case, there was no cyst, but some serum in the peritoneal cavity, and a tumour growing from the fundus of the uterus. This tumour was allowed to remain. Several medical men, in addition to the operator, had diagnosed an ovarian tumour in this case. These two patients recovered.

I exhibited chloroform in four operations in which an ovarian cyst was opened, and the cut edges of it sewed to the wound in the abdominal parietes. These four patients, I believe, all died. I am quite certain as regards three of them.

On March 10th, 1852, I administered chloroform in St. Mary’s Hospital to a woman, apparently about thirty-five, who had suffered from an ovarian cyst about eighteen years. Mr. Isaac Baker Brown made an incision, about six inches in length, into the peritoneal cavity, drew out a portion of the cyst, tapped it, and removed several pints of clear serum. He then cut away a piece of the anterior wall of the cyst, about as large as the hand, and allowed the rest of the cyst to remain loose in the abdomen. The wound in the parietes of the abdomen was stitched up. If I remember rightly, the patient died, but I have no note of the result.

Operations for Cancer of the Vagina. I have notes of eighteen cases in which I have given chloroform for operations of this kind by the knife, which would have been extremely painful without the use of an anæsthetic.

I exhibited this agent, in 1848, to a lady, whilst the late Mr. Aston Key applied the actual cautery to malignant excrescence of the os uteri; and I have administered it in several cases in which potassa and other caustics have been applied to the os uteri. In operations on the vagina or perineum, the woman should inhale chloroform whilst lying on her back; and when insensible, should be drawn to the edge of the bed, or the foot of the operating table, and have the knees held back and separated.

Operations for Rupture of the Perineum. I have notes of fourteen operations for this accident. Six of them were performed by Mr. I. B. Brown, five by Mr. Fergusson, and the others by Mr. Paget, Dr. Protheroe Smith, and Mr. Henry Lee. Mr. Fergusson has, in five cases, performed an operation for prolapsus uteri, by paring the edges of the outlet of the vagina, and stitching them together so as to diminish the orifice.

I have given chloroform in several operations for vesicovaginal fistula, some of which were performed by Mr. Spencer Wells; and also for the removal of warts and other growths from the labia pudendi, either by the knife or caustics.

Removal of the Testicle; Amputation of the Penis, etc. I have memoranda of twenty-seven cases in which I have administered chloroform during the removal of a testicle, generally for malignant disease; and six cases in which I have administered it for amputation of the penis, always for malignant disease. There were six operations, also, in which a part of the penis was removed for malignant disease; and eleven cases in which warts were removed from the glans penis, generally with the knife. In two cases in August 1854, Mr. Acton destroyed a number of venereal warts on the glans penis and prepuce by a caustic composed of potassa and lime. In all the operations on the testicle and penis, under chloroform, the patients have been lying on the back.

Operations for Phymosis. I have memoranda of 76 operations for phymosis, in which I have exhibited chloroform. The operations were generally in the adult, although the complaint was, in most cases, congenital. I have known two cases in which cancer of the penis was produced by the patient’s suffering a congenital phymosis to remain to about the age of fifty. The cancer commenced in the glans from the irritation of the retained urine. One of the patients died of the disease.

Removal of enlarged Bursa. I have notes of six cases in which the bursa of the patella was dissected out by the surgeons of King’s College Hospital for housemaid’s knee. The patients were charwomen and domestic servants. In two cases a bursa was removed from the forefinger.

Evulsion of the Nails. I have notes of twenty-five cases in which I have given chloroform for cutting down the nail of the great toe, and tearing away the whole, or the two edges of it; and also of three cases in which one or more finger nails were removed by a similar process. This operation is one of the most painful of the minor operations of surgery. It is better that the patient should be lying when it is done under chloroform.

Laryngotomy. I administered chloroform to one or two infants in which Mr. Henry Smith performed laryngotomy for croup. I also administered it, on four occasions, to a patient of Mr. Partridge, a boy four years old, who was believed to have a button in some part of the air-passages. The larynx had been opened a few days previously to the first occasion in which I gave chloroform, and I administered it on a sponge, held near to the tube in the larynx. It was necessary to give the vapour gently at first, just as if it was entering in the usual way. When it was given at all strong, whilst the patient was still conscious, he showed exactly the distress that a patient experiences when he says that the vapour produces a choking feeling; which confirms my opinion that the feeling referred to the throat, from the action of pungent vapours and gases, is caused by their presence in the lungs. The chloroform was given to keep the child quiet whilst Mr. Partridge searched for the supposed button in the larynx and bronchi. When the child recovered from the chloroform, before the operation was concluded, the explorations in its air-passages embarrassed the breathing much more, and caused more apparent threatening of suffocation, than they did when he was under the influence of the vapour. This little boy remained for months in King’s College Hospital; and at last the embarrassment in his breathing subsided, the tube was removed from the larynx, and the wound allowed to heal; and he left quite well, although the button, which was supposed to have gone down his windpipe at the moment when his symptoms first suddenly came on, was never found.

I have administered chloroform in a great variety of surgical operations, in addition to those mentioned above, but as they required only the usual management in the application of the vapour, I need not allude to them, but shall, however, make a few remarks regarding dental operations.

Extraction of Teeth. It is the custom in the medical journals and medical societies, to object occasionally to the use of chloroform in tooth-drawing, as if the operation were not sufficiently severe to require it. I will say nothing of the wives and daughters of medical men in connexion with this subject, but will only allude to the case of an elderly lady, who had for thirty years been the private friend, as well as the patient, of one of the Council of the College of Surgeons. After she had had ten necrosed teeth extracted, and had awakened from the effects of the chloroform, her friend and surgeon, who had been looking on, discoursed eloquently on her case, explaining how the state of her mouth was ruining her health; how impossible it would have been for her to go through the operation without chloroform, and what a great advantage it was.

Dr. Watson says in his Lectures: “I am not at all sure that the increased longevity of modern generations is not, in some degree, attributable to the capability of chewing their food which the skill of the dentist prolongs to persons far advanced in life.” I have seen at least fifty cases in which the dentist has been able to exert his skill in enabling his patient to masticate only by the aid of chloroform; cases of feeble, aged, or debilitated persons, whose mouths contained between twenty and thirty stumps of teeth or necrosed teeth; and who were able to get rid of them all at two or three operations a few days apart; but without the opportunity of being made insensible, would undoubtedly have continued with the mouth in a tender and painful state.

It was in consequence of the relief afforded by nitrous oxide gas, in pain caused by a tooth, that Sir Humphrey Davy suggested its application in surgical operations; it was for the extraction of a tooth that Mr. Horace Wells first carried out the suggestion of Davy; and it was in the extraction of teeth that Dr. Morton first employed sulphuric ether as a substitute for nitrous oxide gas. These circumstances seem to point to a demand for anæsthetics in operations on the teeth; and when the great frequency of these operations is considered, it is probable that more pain may be prevented during their performance than in any other class of operations.

I have notes of 867 cases in which I have administered chloroform during the extraction of teeth, chiefly by dentists living in this neighbourhood: amongst whom are Mr. Saunders, Mr. Cartwright, Mr. Samuel Cartwright, Mr. Arnold Rogers, Mr. Thomas A. Rogers, Mr. Tomes, Mr. Bigg, Mr. Crampten, Mr. F. W. Rogers, Mr. Alfred Canton, Mr. Woodhouse, Mr. Lintott, Mr. Rahn, Mr. Vasey, Mr. Sercombe, Mr. Fletcher, and several others; and there is one dentist in the City, Mr. West of Broad Street, whom I have frequently assisted. The number of teeth, or stumps of teeth, extracted in these 867 operations, has been about 3021. In some cases in which several teeth have been removed, I have not been sure of the exact number, but have put down about the number.

The number of teeth extracted at an operation has varied from one to nineteen. The latter number was extracted by Mr. Canton on one occasion, and on two or three occasions, Mr. Arnold Rogers and Mr. Samuel Cartwright extracted seventeen at one sitting; but these gentlemen and others, as well as myself, have thought it better, as a general rule, to make more than one operation, when the number of teeth to be drawn exceeded ten, in order that the mouth might not contain too many wounds at one time, and that the loss of blood might not be very great. A great number of the operations have been for the extraction of the four first permanent molars, in children about thirteen, as these teeth are very apt to decay at an early period.

I have on 181 occasions, of which I have memoranda, given chloroform for the extraction of a single tooth. I exhibited it lately to a lady, aged eighty-six, whilst Mr. Bigg extracted an abortive wisdom tooth, which had recently come through the gum, and was giving pain. She awoke in about two minutes after the operation, and was quite cheerful and well.

The patients have been seated in an easy chair in all the operations on the teeth, except in a very few cases where a female patient was too ill to sit up. In many cases, and always if there was any feeling of faintness, the patient has been placed on a sofa, after the operation, for twenty minutes or half an hour. I am not aware of any inconvenience from the chloroform, in any of the cases of tooth-drawing, excepting sickness and vomiting, which in a very few of the cases have been troublesome for some time.

It is necessary in tooth-drawing to make the patient unconscious, and to continue the chloroform a little while after unconsciousness is induced, till the sensibility of the edge of the eyelid is very much diminished, or almost altogether suspended, otherwise the patient will probably make a resistance that will interfere with the operation, or scream out and alarm his or her friends. I nearly always take about four minutes in the inhalation. It is not desirable to take longer than five or six minutes, as the patient would be slower than is desirable in recovering completely from the effects of the vapour.

The patient is usually in the third degree of narcotism when the operation is performed, and, in this degree, as was previously stated, there is not unfrequently a contracted and rigid state of the muscles. This state often affects the muscles of the jaws, and interferes with the opening of the mouth, if it be closed. I generally tell the patient to keep his mouth open whilst inhaling, and by that means it often remains open when he is insensible. Not unfrequently, however, he closes it on becoming insensible. One can generally open it by pressing on the chin; but as the chin does not afford a very favourable hold, there are a very few cases in which the mouth cannot be opened easily in this way, at least not unless the effects of the chloroform are carried further than is desirable for these operations. I therefore carry with me a little instrument of two blades, made to open by means of a screw. The ends of the blades are covered with leather, and, if introduced between the teeth, at the corner of the mouth on the side opposite to that on which the dentist is about to operate, the mouth can easily be opened. The power of the instrument is only such that I can scarcely open it with one hand, when I hold the blades with the other. It would not enable one to open the mouth of an adult if he were closing it by voluntary power; but the spasm caused by chloroform is very much less powerful than the action of the muscles when influenced by the will. I never use the instrument for opening the mouth when the patient is closing it voluntarily under the influence of a disordered consciousness, but always wait till consciousness and volition are entirely suspended. When the mouth is once opened, it can generally be kept open with the fingers, and the instrument may be withdrawn.