Source: Snow, John. London Med. Gazette, vol. 43,  Feb. 9, 1849, pp. 228-35 (part 9).

On narcotism by the inhalation of vapours

By John Snow, M.D.

Part IX

1. Condition of patients subsequent to amputation under chloroform. 2. They are not more liable to secondary hæmorrhage. 3. Statistics of result of amputations under ether and chloroform. 4. Their administration in minor amputations. 5. In lithotomy. 6. Results of cases of lithotomy. 7. Chloroform in lithotrity. 8. In the treatment of stricture. 9. In operation for necrosis. 10. In the removal of tumors of the female breast. 11. In the removal of tumors of the maxillary bones, and other large operations on the face.

1. In amputations under chloroform, the patient is not only saved the immediate pain of the operation, but generally, also, the greater part of the subsequent smarting; for the common sensibility usually remains more or less blunted for some time after the return of consciousness, and the smarting is often not felt at all for half an hour after the operation, and then but slightly. In a few cases, however, pain is felt in the wound as soon as consciousness returns. In two or three cases in which the smarting was distressing, I have exhibited a little chloroform, from time to time, with complete relief, during the first hour or two that followed the operation; [228/229] after which the pain shewed no tendency to return. I have tried the local application of chloroform over the wound, in one or two instances, but it was applied external to other dressings, and not much effect was observed from it. The nervous system is tranquilized by the chloroform inhaled during amputations, and the spasmodic starting [jerking] of the stump, that without its use would generally be distressing, hardly ever occurs.

2. One of the reports in circulation, soon after the inhalation of ether was introduced, was, that it gave rise to secondary hæmorrhage--probably some surgeon met with it in one or two cases. Secondary hæmorrhage, however, is by no means common after either chloroform or ether. Although I have administered one or other of these vapours in fifty-seven case of the larger amputations, there has not been secondary hæmorrhage of any consequence, except in two instances, and it has been equally uncommon after other operations. As inhalation prevents the fainting that would otherwise often attend an operation, and generally also stimulates the circulation more or less, we might expect that it would facilitate the tying of all the vessels, and thus be a means of preventing secondary hæmorrhage; and experience seems to confirm this view.

3. Preventing the severe pain of the larger operations may reasonably be supposed to have some effect in diminishing their danger: and as the result of the larger amputations had previously been made the subject of statistical inquiry, they at once suggest themselves as a means of comparing the present with former practice. But a statistical inquiry is evidently incapable of shewing what is the direct effect of the use of chloroform and ether on the mortality resulting from operations. For, if a slight difference should be found, it might be supposed to depend on the altered circumstances under which operations are sometimes performed since the introduction of anæsthetics; as, on the one hand, patients are occasionally induced to submit to them earlier, and when the circumstances are more favourable than they otherwise would be; and, on the other hand, an amputation is now and then undertaken, when the patient is so reduced, or his prospect of recovery from it so bad, that it would not [be] performed if the pain had to be inflicted. Still, it is proper to make a statistical inquiry, as it would be interesting to know whether the use of those agents has any appreciable affect, direct or indirect, on the mortality; and it may assist to dispel the fears of those, if any such remain, who think that the inhalation of them would be attended with notable ill consequences. With this view, I will here give the result of all the large amputations in which I have administered chloroform or ether. Although the number of cases I have to furnish is not large enough to determine this question, it will serve as a contribution towards that object.

The amputations in which ether was the substance employed , were 32 in number, and took place in 1847; those with chloroform were 25. Of these 57 amputations, five occurred in private practice; three of the thigh, of which two ended fatally; one of the leg, and one of the arm, both followed by recovery; 39 were performed in St. George's Hospital; 22 were amputations of the thigh, amongst which were six deaths; 13 of the leg, followed by three deaths; two of the arm, with one death; and two of the fore-arm, both ending in recovery. Eight of the amputations took place in University College Hospital; five of the thigh, all ending in recovery; two of the leg, in one of the which the patient died; and one of the arm, which terminated fatally. Four amputations of the thigh occurred in King's College Hospital, with one death; and there was one amputation of the leg in the Hospital of the Fusilier Guards, performed by Mr. Judd: the patient recovered. The deaths were each occasioned by some well recognized cause, which the inhalation could neither induce nor prevent: generally erysipelas of inflammation of the veins.

The following table shews the result of all these cases together. None of them remain under treatment; and all the patients who did not actually recover are included in the deaths, by whatever cause decease was occasioned: [229/230]

Seat of Amputation            No. of Cases            No. of Recoveries            No. of Deaths            Deaths per cent.
Thigh            34            25            9            26
Leg            17            13            4            23
Arm            4            2            2            -
Fore-arm            2            2            0            -
Total            57            42            15            26
If the two cases of amputation of the fore-arm be withdrawn, the total mortality will be 27 per cent. instead of 26. None of the above amputations were performed immediately after an accident, but were all either for disease or injuries sustained some time previously.* (*There have been eight amputations in St. George's Hospital performed immediately after injuries, in which ether or chloroform has been administered by one of the resident medical officers. Five of the patients recovered, two died, and one remains under treatment, going on favourably.)

The mortality in the above cases is a little higher than shewn in a return by Dr. Lawrie of the amputations (primary ones being excluded) at the Glasgow hospital a few years ago,† (†Med. Gaz. vol. xxvii. p. 394.) but is much lower than a similar return by Prof. Malgaigne, form the Parisian hospitals.‡ (‡ Archiv. Gén. De Médecine, tom. lviii. p. 40.)

In a collection of cases of amputation, from various hospitals, under ether and chloroform, in the Monthly Journal of Medical Science, April 1848, by Dr. Simpson, the morality appeared much lower than in any previous tables; but as Dr. Simpson gave no instructions in his application for the return of amputations, that cases still under treatment should be excluded, there is reason to apprehend that he may have included such cases in his table, some of which may have since ended fatally. The return I furnished to him of operations under ether at St. George's Hospital is not correctly inserted in his table. Against the seven cases of amputation of the leg, there is a cipher in the column for deaths, where the number 1 ought to stand. This death arose from sloughing phagedena of the stump. I conclude that the discrepancy was occasioned by some mistake, and that, as I have mentioned it to Dr. Simpson, it will be corrected in his future tables; for I cannot suppose that it was intentionally withdrawn from the deaths, on account of the disease under which the patient succumbed.

4. In amputations at the ankle-joint, or tarsus, it is of course as needful to give chloroform as when the limb is divided higher up. Amputation of the finger or toe is an operation in which it is generally very desirable to inhale the vapour, as the pain of an amputation by no means diminishes in the same proportion as the size of the part on which it is performed. No particular directions are required respecting the mode of giving chloroform in the minor amputations, as what I have said concerning the larger ones is equally applicable to them.

5. Lithotomy is an operation in which I believe that every surgeon now considers it desirable, if not almost a duty, to have his patient made insensible. The practice of tying the hands and feet together with a bandage, to retain the patient in the required position, is still very properly resorted to. It is better to give the chloroform, so as to remove consciousness, before either the bandaging or introduction of the sound. This is especially desirable in the cases of children, and it is also the best plan in adults, as they begin the inhalation more at their ease. During the bandaging and sounding the effect of the vapour partially goes off, and therefore the inhalation must be resumed for a short time, so as to insure complete insensibility when the incision is made. The symptoms of insensibility were described in the last paper treating of the larger amputations. The patient should not be allowed to recover either consciousness or sensibility till the operation is completed by the extraction of the stone; and therefore, except when the operation is concluded in an unusually short time, it is necessary to give a little vapour from time to time, whenever the eyes shew that the patient is about to wake, or any slight shrinking or moaning indicates the beginning of [230/231] uneasy sensations. It must not be supposed when there are obscure indications of sensations from time to time during an operation, that there is severe pain of which the patient is unconscious, for the truth is, that sensibility returns gradually, as we learn, by actual observation, in those cases where complete consciousness returns before the common sensibi[li]ty. Under these circumstances, the patient, when first beginning to feel, describes as something pricking or pinching, measures that would without anæsthesia cause intense pain, and does not yet feel what at another time would be attended with considerable suffering.

6. The cases of lithotomy, in which I have administered ether or chloroform, are nineteen in number, of which fourteen ended in recovery, and five in death. Eight of the operations were performed at St. George's Hospital, the patients being all children. They all recovered but one, and in that case there was extensive disease of the bladder and kidneys, one of which was dilated so as to form a pouch. Five of the cases occurred in University College Hospital, under the late Mr. Liston; two of the patients were children, and recovered, and one--a very old man--died. Two of the cases were in King's College Hospital, both in children, and ended in recovery. And there have been four cases in private practice, all those of adults, three of whom died a few days after the operation, and one recovered. The three patients who died were far advanced in life, and their disease was of long standing. The patient who recovered could not have got through the operation had it not been for the chloroform: such was the opinion of Sir B. Brodie and Mr. Coulson. I alluded to this case in a paper I read last winter.* (*Lancet, Feb. 12, 1848.)

It will be observed that twelve of the above cases were those of children, and that all of them recovered but one, who had a mortal disease at the time of operation; and that of the seven adults, four died. This difference between the mortality of lithotomy in childhood, and in the later periods of life, is in accordance with the usual experience of surgeons. I may remark of the cases that were fatal, that death was the result of causes quite independent of the narcotic vapour, as in all the other cases that I have seen in which operations have ended unfavourably.

7. Chloroform is generally given in St. George's Hospital in lithotrity. As the pain of this operation is usually not excessive, inhalation would not be employed if the surgeons did not feel quite satisfied of its perfect safety, and freedom from all ill effects. I have always seen the operation very satisfactorily performed under chloroform, both in this hospital, and on two occasions when I assisted Mr. Henry Chas. Johnson with it, in private practice. Besides preventing what pain there would be, the surgeons find that the chloroform has the further advantages of preventing the straining efforts of the patient, and enabling them to seize and crush more fragments at one operation than they otherwise could.

The chief suffering from lithotrity is often in passing the fragments; and in dismissing this subject I may allude to the opinion of the late Mr. Liston, expressed to his class in 1847, that the discovery of etherisation would be a reason for choosing lithotomy in some cases, where otherwise crushing th calculus would be preferred, as the former operation at once frees the bladder from irritation, and is now stript of its greatest terror.

8. In the division of the urethra in the perineum, chloroform or ether is of course as necessary as in lithotomy. I have assisted with the inhalation in several such operations. One case may be alluded to here, on account of its important bearing on the treatment of stricture. It was a case in which this operation was about to be performed by Mr. Liston in University College Hospital, but was not required, owing to the relaxing effects of ether on the stricture.

John Willis, aged 42, had stricture of the urethra, caused by an injury twelve years before. He had passed his urine in a very small stream for the last three years, and latterly only by drops, and no catheter could be introduced, although it had been frequently attempted. When the patient was got fully under the influence of ether, a Number 1 catheter was introduced with the intention of passing it down to the stricture, preparatory to dividing it, by an incision in the middle line of [231/232] the perineum; but it passed right on into the bladder, and the intended operation was not required.

This took place on June 18, 1847; the catheter was retained in the bladder till the 23rd, when No. 2 was substituted for it, and subsequently larger catheters, and the patient went out cured on July 27th, being able to pass his urine in a good stream.

9. There are no operations in which the utility of narcotic vapours is greater than in those for necrosis--operations that are generally of considerable duration, and which are amongst the most painful in surgery, on account of the great sensibility of the inflamed bone surrounding the sequestrum. I have given ether and chloroform in nearly thirty operations for necrosis in St. George's Hosptial, besides a number elsewhere. The action of the vapour has always been quite effectual in preventing the pain. The majority of the patients were children, and during a great part of the time occupied in the operation narcotism generally did not exceed the second degree; that is to say, there was a dreaming or wandering condition of the mind, and not a state resembling coma.

10. The extirpation of tumors is perhaps the most frequent operation in surgery; but tumors differ so much in size, situation, and every other respect, that there would be no advantage in stating the general result of their removal. Operations for the excision of tumors of the female breast, however, sufficiently resemble each other to admit of such a statement being given.

The number of cases in which I have had to give ether or chloroform, for the removal of tumors of the female breast, involving the gland, is thirty-four. Nineteen of them were in private practice, in seventeen of which the patients recovered from the operation, and in two cases the patients died--one of them of pleurisy, and the other, apparently, of exhaustion. The other fifteen patients were in St. George's Hospital: thirteen recovered from the operation, and two died--one of peritonitis twenty-four days after the operation, the other of erysipelas.

By far the greater number of these tumors of the breast were of malignant nature. There has not yet been time to ascertain the ultimate effect of the operation on the disease; and, indeed, I am not able to give the results to the present period. The patients in the hospital leave when they have recovered from the operation, and generally are not heard of again; and I only hear now and then, through their surgeons, of some of those in private practice. I am able, however, to state that some of the patients are now in pretty good health, who must long since have died a lingering and painful death if no operation had been performed. Any objection that existed to the removal of malignant tumors must have been greatly diminished by the introduction of narcotic vapours. Each case must, of course, be judged on its own merits; but the number of cases in which an operation may be properly recommended, and in which it will be submitted to, when the whole question is laid before the patient, must be considerably increased by the discovery of the means of rendering it devoid of pain.

11. The only surgical operations that present any difficulty to the total prevention of pain during their performance, are operations of considerable magnitude and duration, which involve the cavity of the mouth or nose, such as the removal of tumors of the maxillary bones. The patient can be rendered insensible before the operation, in the usual way, as easily as in other cases; but the difficulty is in repeating the inhalation so as to preserve the immunity from pain till its conclusion. It is best, in operations of the face, to exhibit the vapour well diluted, so that insensibility may be induced gradually, by which means the fluids of the body get more thoroughly impregnated, and its effects are more permanent. When inhalation of chloroform extends over three or four minutes, and the third degree of narcotism is well established, with insensibility of the conjunctiva, it is generally about three minutes before there are distinct signs of pain from the use of the knife. The effects of ether are, I think, a little more lasting, and therefore it would be preferable in such operations, were it not that chloroform can be more easily reapplied during the operation. To effect this, I drop a few minims of it, from time to time, on a sponge that has been squeezed out of cold water, and as soon as the patient evinces any sign of pain, [232/233] I apply it near to his mouth and nostrils for a moment, whenever the position of the surgeon's hands, and those of his assistants, will permit. In this way, if the pain cannot all be prevented, the patient can generally be kept so unconscious that he afterwards says that he felt nothing. It is only in protracted operations that the use of the sponge in this way is required, for the greater number of operations are concluded in two or three minutes.

There are some surgeons who think that chloroform in operations involving the mouth, and attended with considerable hæmorrhage, is not altogether free from the danger of blood getting into the trachea. This point requires to be very carefully considered, for whilst it would be improper to run a risk of this occurrence, the pain of large operations on the face is so frightful that the inhalation ought not to be interdicted on mistake grounds. There are good physiological reasons for believing that the sensibility of the glottis would last, under the influence of narcotics, as long as respiration continued to be performed; but the evidence will be that derived from experience. I have seen a great number of operations attended with considerable hæmorrhage into the mouth, in which ether or chloroform has been given, and no ill effects have followed in any case. The result of my observation consequently is, that there is no danger of blood getting into the air passages when these agents are carefully given, and the same attention is paid to the patient's position and breathing that would be in the absence of insensibility. There was one operation at which I assisted last summer, where the patient died soon after it was performed, and as I have heard that a report got abroad, in some parts of the medical world, that death was occasioned by blood entering the air passages, it may here be mentioned:--

The patient was a young man, with a large fibrous tumor in the maxillary bone. For some time previous to the operation he had suffered occasionally from haemorrhage 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. I took no notes of the method in which it was performed, but can state that 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 nostrils 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 [233/234] 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, tracheotomy 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.

After death, portions of the tumor 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.

It is evident that the chloroform did not contribute, either directly or indirectly, to this patient's death, for the following reasons:--1st. That the tracheotomy and artificial respiration sufficiently account for the small quantity of blood found in the bronchial tubes. (An eminent physician-accoucheur has informed me that in cases of still-born children, in which he has performed artificial respiration by an incision in the larynx, he has always found blood, after death, in the bronchi.) 2nd. If there had not been this reason for blood in the lungs, it would be more likely to have entered when the patient was moribund, or during the syncope, than at an earlier period. 3rd. That the symptoms did not indicate any impediment to respiration, but were such as I have seen in uterine hæmorrhage, and such as were met with after the removal of the superior maxillary bone by a very eminent operator in this metropolis, before the introduction of ether. 4th. That if the judicious use of chloroform caused a liability to the entrance of blood into the bronchi, there would have been some symptoms of it in the numerous patients who have recovered from similar operations in the narcotized state; but such is not the case. And 5th. That the quantity of blood met with in the lungs was not enough to cause rapid death.

In dismissing this case, I wish to state my belief that the operation was a very proper endeavour to cure the patient of a disease that must inevitably have been fatal in a short time; and that my reason for alluding to it is, that if I should leave it unnoticed, in treating of chloroform in operations on the face, I might be suspected of keeping back a material fact.

I will now enumerate the other operations, for the removal of larger tumors of the jaw, in which I have exhibited narcotic vapours.

In May 1847, Mr. Liston removed a large tumor of the lower jaw, in a young lady, dividing the bone far back, near the rami, on each side. He was assisted by Mr. Morton, Mr. Cadge, and others. The patient took ether.

On December 23, 1847, Mr. Henry Charles Johnson removed one of the superior maxillary bones of a young man, in St. George's Hospital, for a large tumor. This, and the remaining patients, inhaled chloroform.

A few days after the last operation, Mr. Fergusson removed a large tumor of the lower jaw , occurring in a gentleman. Sir B. Brodie was present.

Early in January 1848, Mr. Fergusson also removed a large tumor of the upper jaw of a middle-aged woman, in King's College Hospital. The tumor has been removed once before, but had returned.

In May last, Mr. Tatum removed a very large tumor of the lower jaw of a Spanish gentleman, in St. George's Hospital, dividing the bone near its symphisis, and disarticulating it on one side.

In November last, Mr. Fergusson removed a tumor of the superior maxillary bone in a little girl, in King's College Hospital.

In the same month, Mr. Fergusson also removed a tumor of the lower jaw in a young man, a patient in the same hospital.

The above patients all recovered favourably from the operation.

I have seen chloroform and ether employed, also, in a number of other operations in which a good deal of blood flows into the mouth and throat; such as operations for epulis, and [234/235] polypi of the nose. Sometimes the patients can be observed to swallow the blood, with an act of deglutition; but usually it seems to flow down the pharynx and esophagus without distinct muscular effort; and if the quantity of it is not very large, it does not in any way interfere with the glottis.

When infants are laid on the back, during the operation for hare-lip, the blood is swallowed, whether they are narcotized or not; and when they are insensible, it goes down with less appearance of choking than when they are crying from pain.

 

(To be continued)

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