Source: Snow, John. London Med. Gazette, vol. 43,  Mar. 16, 1849, pp. 451-56 (part 10).

On narcotism by the inhalation of vapours

By John Snow, M.D.

Vice-President of the Westminster Medical Society.

Part X.

1. Ether and Chloroform in operations on the teeth; 2. on the eye; 3. on the anus; 4. on the back. 5. Inhalation to facilitate the reduction of hernia; 6. of dislocations; 7. to aid diagnosis; 8. to save the moral feelings of the patient. 9. Occasional sequelæ of inhalation-–sickness; 10. its treatment. 11. Headache. 12. Hysteria.

1. Chloroform is, I believe, not very generally employed in tooth-drawing in this metropolis. This is partly [451/452] owing to the circumstance, that the pain occasioned by the operation, though severe, is usually but momentary; but another reason appears to be, that the majority of dentists are not sufficiently acquainted with the application of the medicine to be satisfied that they can use it with perfect safety, and it is not always convenient to the patient to have another medical man present. It is only in the cases of children and very nervous persons, who have not resolution to keep the mouth voluntary open for the operation, that narcotism facilitates the work of the dentist; in other cases it adds to his trouble, and occupies more of his time. The introduction of ether and chloroform has been of service to the dental profession, having increased the practice of many of its members by relieving the springs of industry from the incubus of the dread of pain; for a number of the operations under these vapours would not have been performed except for their use. I allude to many of the cases in which the mouth is "cleared," as the term is, of a number of decayed teeth, and stumps of teeth, to make room for a set of artificial ones-–a process which is now generally performed at one or two sittings, without any pain, and which cannot fail to be, ultimately, of great benefit to the patients.

It is desirable not to carry the narcotism further than the third degree for the extraction of teeth, and in this stage there is generally some rigidity of the muscles of the jaw, but this can nearly always be overcome by pressing the chin down. It has been recommended that a wedge should be placed in the mouth before the inhalation, but I have never seen it necessary to have recourse to this plan, as I have always been able, with the assistance of the operator, to get the patient's mouth open. The few instances in which the mouth could not be at once opened were cases in which voluntary power was exerted under a dreaming condition of the mind, and in these cases the exhibition of a little more of the vapour enabled the desired object to be effected. There was one instance in which the addition to the dose of vapour was prevented by hysterical symptoms, till the lady recovered her consciousness, and then she had sufficient courage, and preferred to have her tooth removed without the repetition of the inhalation, which there is no doubt would have been effectual, as in every other case that I have seen. As it was, the pain was probably diminished. It has always appeared to me that there was a diminution of muscular power under the effects of chloroform and ether, in every variety of their operation; the voluntary efforts under excitement are much less powerful than those of an exasperated individual in an unnarcotised state, and the involuntary rigidity in the third degree is still more easily overcome. As there is usually less rigidity from the use of ether than chloroform, the former would be preferable in tooth-drawing, were it not for the strong odour that it leaves in the breath for the rest of the day. When teeth require to be removed from both jaws, those in the lower one, especially if they be molars, should be first extracted; otherwise, as the patient is unable to wash out his mouth, the blood will render them obscure. To clear the mouth of blood, whilst operating on the teeth of the lower jaw, it is sometimes desirable to use a sponge squeezed out of warm water. If the sensibility is found to be returning before all the teeth are extracted, the inhalation must be resumed for a short time before proceeding further. There is sickness after the use of chloroform in some instances of dental as of other operations, and it is here felt to be more annoying than after a great operation where the patient is necessarily an invalid. I shall have to speak of the treatment of sickness further on.

I am not an advocate for the use of chloroform in every instance of tooth-drawing, but I do not see how any rules can be laid down respecting its employment, as a good deal must depend on the wishes of the patient as well as on the presumed severity of the operation. One point, however, should be imperative, viz. that chloroform should not be given except by medical men who have made themselves well acquainted with its effects and mode of application. I have a strong feeling that severe pain ought not to be inflicted on children, since the means of preventing it have been discovered and act so favourably on them; and therefore, when a tooth is [452/453] to be removed that is firmly fixed, I think that a child should be made insensible whenever there is the knowledge requisite to effect this with perfect safety.

2. In most operations on the eye, narcotism is of essential service. In the operation for strabismus, the amount of pain to be prevented is considerable; and as the patients are usually children, who would offer all the resistance in their power, the proceedings of the surgeon are very much facilitated, as Prof. Miller, of Edinburgh, has recently remarked.* (*Surgical Experience of Chloroform.) Chloroform or ether may be given with advantage to children, in operations on the eye unattended with pain, merely for the purpose of keeping the patient and the eye motionless. I have given the vapour of one or other of these medicines several times for Mr. Cæsar Hawkins and Mr. George Pollock, whilst operating on congenital cataract by the method of drilling. Two or three of the latter gentleman's patients were only a few weeks old. The operation was facilitated in all the cases. In the excision of cataract, it is not advisable to administer ether or chloroform, for if vomiting should be induced it would be likely to cause serious mischief; and although vomiting is not a frequent result of inhalation, when precautions are taken to prevent it, yet it is impossible, I believe, to predict with certainty in any case that it will not occur.

3. Operations on the anus are frequently required, and they are of a very painful nature, on account of the great sensibility of the part. It was the practice of most surgeons before the introduction of inhalation, to have the patient standing on the floor, in a stooping posture, and leaning over a table or bed; but this attitude could scarcely be maintained in a state of insensibility, and therefore the practice now is to let the patient lie on his side with the knees drawn up towards the abdomen; or when that is more convenient to the surgeon, the patient can lie on his back, as for lithotomy. The chief operations on the anus are that for fistula, the excision of hæmorrhoids, and the cutting away of loose folds of integument from the verge of the anus, for the cure of prolapsus. It is necessary to have the patient completely insensible in operations on this part, more especially in that for fistula, as any involuntary flinching during its performance would be a serious inconvenience.

4. For the removal of tumors from the back, and the performance of any other operations in that situation, it is best to let the patient inhale whilst lying on his side, and when he is insensible to turn him over, in a great measure, on his abdomen, allowing his head to remain in its former position on the pillow: in this way the inhalation can be repeated, if required, during the operation.

It is unnecessary to enumerate other operations, as they do not require any special directions, as regards the chloroform or ether. There are some cases to be mentioned, however, in which narcotism is attended with signal benefits, in addition to the prevention of pain.

5. There have been several cases of strangulated hernia, in which the inhalation of ether or chloroform has enabled the bowel to be replaced by the taxis, after previous efforts had failed, and where an operation must otherwise have been performed. I am not aware how soon etherisation was employed with this happy result, but the earliest case that I find recorded is that of a patient of Mr. White, in the General Hospital, near Nottingham: it occurred on March 22nd, 1847, and the ether was administered by Dr. Sibson.* (*See Med. Gaz. Vol. xi. p. 1009.) On July 10, 1847, there was a similar case under the care of Mr. Stafford, in the Marylebone Infirmary.† (†Med. Gaz. Vol. xi. p. 115.) On March 6th, 1848, a man, James S., was placed upon the operating table, in St. George's Hospital, with a strangulated inguinal hernia: I administered chloroform to him at the request of Mr. H. C. Johnson, who had the treatment of the case; and when the patient became completely insensible, and the muscular system relaxed, the hernia was readily reduced 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 still insensible. In the case of another [453/454] patient, a woman with femoral hernia, who was placed on the table immediately afterwards, Mr. Johnson performed the operation as soon as she was rendered insensible, without employing the taxis, being deterred by the tense and inflamed condition of the tumor. This case ended favourably, as well as the former one. There are several other cases recorded in the medical journals of this and other countries, besides the three above enumerated, in which the use of ether or chloroform has enabled the surgeon to reduce a strangulated hernia without the operation.

6. Narcotism by inhalation facilitates the reduction of dislocations of the bones, besides preventing the pain of the process; and it has enabled the surgeon to reduce dislocations of long standing, which could not otherwise have been relieved. On June 24, 1847, Mr. Tatum reduced a dislocation of the shoulder of ten weeks' standing, with the aid of the pullies, in St. George's Hospital, whilst the patient, Richard R., aged 31, was under the influence of ether. The dislocation, which happened in the country, had been first overlooked, and when detected, could not be reduced. On February 7th, 1848, a dislocation of the femur into the ischiatic notch, which had existed for about three weeks, was reduced with the aid of the pullies, in the same hospital, by Mr. H. C. Johnson; the patient, Patrick C., an Irish labourer, being made insensible, and his muscles being relaxed, with chloroform. Three days afterwards, Mr. Tatum reduced a dislocation of the hip, in the hospital, of five weeks' standing; the patient, Joseph G., a working man, being put under the influence of chloroform. I have also given the vapour, in St. George's Hospital, in some cases of old dislocation, in which the position of the parts has been improved by the efforts made during the state of insensibility and relaxation, although their condition did not admit of complete reduction: two cases of dislocation at the elbow-joint were of this nature. Some cases of recent dislocation have been reduced under the influence of narcotic vapours, when previous attempts at reduction had been unsuccessful. Two cases of dislocation of the thigh-bone, in which Dr. Sibson administered ether, at Nottingham, were of this nature. One into the ischiatic notch, reduced by Mr. White, April 7th 1847; the other on the dorsum ilii, reduced by Mr. Caunt, May 31st, 1847.* (*See Med. Gaz. Vol. xi. p. 1009.) I assisted Mr. H. C. Johnson by giving chloroform to a gentleman with a recent compound dislocation of the last phalanx of the thumb backwards. The previous efforts at its reduction had failed, on account of the pain occasioned by them being more than the patient could bear. When he was rendered insensible, the dislocation was soon reduced.

Chloroform was given in many of the above cases because it was in use at the time, and could be employed without the delay that getting the ether ready would have occasioned. It answered very well; but it is my opinion that ether is preferable, both in dislocations and strangulated herniæ, as it induces relaxation of the muscles more easily, and with less previous rigidity.

7. The artificial production of insensibility is frequently of the utmost service in assisting the surgeon to form a diagnosis. I gave ether for this purpose at the request of the surgeons to St. George's Hospital, in February, 1847, to a little girl with disease of the knee and abscesses in the thigh. In this case, the great tenderness of the parts, and the nervous agitation of the patient, precluded every attempt to examine the state of the limb in the usual manner; but when the patient was rendered insensible, the condition of the limb was ascertained sufficiently to enable the surgeon to determine on amputation, which was performed on February 25th, by Mr. Henry James Johnson, the patient being again placed under the influence of ether. In several other cases of diseased joint and diseased bone, ether and chloroform have been employed in this hospital, to aid diagnosis in a similar manner. In sounding for stone, especially in children, it is of service to render the patient unconscious. I administered ether for this purpose in St. George's Hospital, as early as February 3rd, 1847, whilst Mr. Cutler sounded a little boy, aged four years. Dr. Thomas Smith, of Cheltenham, applied ether about this time, viz. on February 22nd, to [454/455] enable him to ascertain the state of the corneæ of a child labouring under strumous ophthalmia.* (*See Med. Gaz. Vol. xi. p. 676.)

8. There are many operations on the female which medical students could seldom witness except at the expense of some shock to the feelings of the patient. They are now generally conducted in the hospitals in this wise:--The patient inhales and becomes insensible whilst only one or two surgeons and the nurse are present in the private ward, or behind the screen with her: the students then come in and witness the operation, and go away again before the consciousness of the patient has returned. In some operations in private practice, where the surgeon requires two or three assistants, they are not brought into the room till the patient is insensible, or she is made insensible in an adjoining room, and carried to the place selected for the operation.

9. Narcotism by chloroform or ether, to the extent required in surgical operations, occasionally leaves some effects after the immediate influence of the vapour has subsided: these may be called sequelæ. I have not observed that they are more frequent after one of these agents than the other. The only after-effects of inhalation with which I am acquainted are sickness, headache, and hysterical symptoms in those predisposed to hysteria.

Vomiting is apt to occur during the narcotism, or just afterwards. It can be rendered less frequent by the precaution previously mentioned,† of not allowing the patient to inhale soon after a meal, and also not carrying the narcotism further, if possible, than the third degree,--thus avoiding stertor and complete relaxation of the muscular system; but I believe that it cannot always be prevented by all the care that can be used, more especially if the inhalation have to be repeated, in order to keep up the insensibility for more than a few minutes. (†Last Vol. p.1024) The vomiting no doubt depends on the action of the narcotic vapour on the brain, and is allied to that occasionally caused by opium and alcohol, and to that which occurs in some morbid conditions of the cerebrum. If the patient recover completely from the immediate effects of the vapour, without any feeling of sickness, he is not liable to it afterwards from that cause; and, in the greater number of cases in which vomiting does occur, the sickness goes off in a few minutes, and does not return; but in a few instances it continues for several hours, if nothing be done to relieve it, and in two or thee cases it has lasted, under these circumstances, for two or three days. I have met with more or less vomiting in about one-fifth of the patients operated on, under chloroform, during the last six months: many of them, however, had received no previous directions respecting their diet. The number of cases in which there has been troublesome sickness has been one in twenty-six operations during the same period. I have never found the sickness continue more than five or six hours when I have been taking measures to relieve it.

Diminished temperature of the surface generally accompanies the sickness: indeed, the depression of the respiration and circulation attending it has a tendency at all times to lessen the development of animal heat. But chloroform and ether, I am quite satisfied, have also the effect of diminishing the production of caloric, quite independently of their action on the respiration and circulation; and, when inhalation has been kept up for some time, I have remarked the patient to become rather cold in cases where no sickness was present.

10. When sickness has continued after the immediate effects of the vapour have subsided, and the stomach has been quite emptied by vomiting, I have generally found that a little wine or weak brandy and water has removed the sickness. When the patient is cold as well as sick, warm wine and water, or brandy and water, are preferable; and other measures to restore warmth should be resorted to, such as warm covering, drawing the sofa near the fire, if it be winter, or applying a feet-warmer, if the patient be in bed. In two or three cases these measures did not afford relief, and ten or twelve minims of Battley's solution of opium were given, with the effect of completely and permanently removing the sickness: these, of course, were adult patients, and I have not found sickness continue very long in children. The [455/456] horizontal posture should, if possible, be preserved till the sickness has subsided, and for some time afterwards. It is desirable, indeed, to let the patient remain, without being moved or spoken to, till the narcotism has completely passed off, in every instance where it is practicable. The necessary removal of hospital patients from the operating theatre immediately after the operation causes sickness in many cases where I believe that it would not otherwise come on. I have not perceived any appreciable benefit from effervescing draughts, and I have not had occasion to try hydrocyanic acid or creosote. The application of ammonia to the nostrils sometimes seems to refresh the patient, but internally I think it is not so beneficial as wine.

The wine and opium recommended above are not given to combat the direct effects of chloroform, and should not be administered till the immediate influence of the vapour has subsided, unless it be the former, when it is required to remove faintness from loss of blood, which, however, seldom happens during narcotism. The opium probably acts by removing irritability of the stomach, occasioned by the vomiting, which was induced in the first instance by the state of the brain.

11. Headache is not a common result of inhalation: few instances in which I have heard it complained of, occurred in persons in good health and inclined to plethora, and passed off spontaneously.

12. In describing the circumstances that modify the action of narcotic vapours, it was stated* that, in the hysterical diathesis, inhalation was liable to induce a paroxysm of the disorder, which might recur as the narcotism was diminishing. (*Last vol. p. 1022.) This usually soon subsides, but there are a few cases in which it remains troublesome for two or three hours. I have seen hysteria two or three times in the male, after ether and chloroform, in patients who had previously had the complaint. I have not found it to require any treatment, except in the case mentioned before;† and if it do, it should be treated in the usual way. (†Loc. cit.)

My own experience of hysteria, as a sequela of inhalation, is, that it forms no great impediment to its employment. Mr. Tomes,* however, has related three cases with which he had been made acquainted, where the disorder was more lasting and troublesome; and one case in which the use of chloroform was followed by worse effects than hysteria, viz. delirium, and subsequently an occasional vacancy in the patient's manner, leading her medical man to forbode insanity, sooner or later. (*See Review in Med. Gaz., last vol. p. 545.) In this last case, however, the patient had an overdose of the vapour, having been "almost pulseless-–scarcely breathing," with a ghastly countenance. The chloroform was given by a dentist who evidently did not understand its effects, having first asserted that the lady was "under its full influence," when she, in fact, heard what he said, and then having given an overdose. The case only confirms a maxim, now beginning to be better understood than when chloroform was first suddenly brought into universal notice-–viz. that it ought not to be used except by medical men who have studied its effects.

(To be continued)

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