"On the employment of chloroform in surgical operations "

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By John Snow, M.D.

I have now been very much occupied in the administration of chloroform for a period of nearly eight years; and I am quite confirmed in the opinion which I long ago expressed, that this agent may be exhibited with propriety in every case in which the patient requires, and is in a condition to undergo, a surgical operation. If it were simply a question of giving chloroform or not giving it, there are, indeed, some patients to whom one would prefer not to give it; but the question lies between exhibiting chloroform or inflicting the pain of an operation, and, according to my observation, the former is always the lesser evil of the two. The affection which is generally thought to be most opposed to the inhalation of chloroform is fatty degeneration of the heart; but from all that I have been able to observe, it is of great advantage, in such cases, to prevent the pain of an operation.

Patients with fatty degeneration of the heart are liable to die suddenly in two distinct ways: first, with the cavities of the heart empty; and, secondly, with the cavities of the heart full of blood. In the latter case, death is caused by the inability of the weakened heart to propel the blood; but, in the former case, where the patient dies by ordinary syncope, such as that occasioned by loss of blood, and where the cavities of the heart are empty, death must be caused by some undescribed condition which accompanies the disease of the heart, and not by that disease itself; for the most healthy heart would be unable to maintain the circulation when the blood no longer reached its cavities from the veins.

The pain of a surgical operation has a tendency to produce both those conditions of the cavities of the heart which are liable to prove fatal, when that organ is affected with fatty degeneration; whilst, on the other hand, chloroform has the effect of keeping the circulation in a more equable state. The ordinary kind of syncope, in which all the cavities of the heart are probably empty, was very common during surgical operations, before the introduction of ether and chloroform, even when the patients were apparently strong, and the operation of a trifling nature. Under the influence of chloroform, however, syncope is extremely rare, even in operations attended with considerable loss of blood. The pain of an operation has a tendency also, in many cases, to cause over-distention of the right cavities of the heart, owing to the patient straining violently, and holding his breath. The following instance, in which I had an opportunity of witnessing a similar operation, in the same patient, both with and without chloroform, shows this effect of pain, and the favourable effect of anæsthesia, in a remarkable manner.

On January the 6th, 1855, Mr. Fergusson performed lithotrity in King's College Hospital, on a man aged fifty-one. He generally directs chloroform to be administered in lithotrity, but in this instance he omitted to do so, as he thought that the bladder was not very irritable, and that the patient would not suffer much. I began to feel the pulse just when the patient saw the lithotrite about to be introduced. It was 120 in the minute. As soon as the instrument was introduced, the pulse increase to 144, and immediately afterwards it became uneven, irregular, and intermitting. I could not count more than three or four beats at a time, and, occasionally, when the pain seemed greatest, and the man was straining and holding his breath, the pulse at the wrist was altogether absent for four or five seconds at a time. In order to ascertain whether the absence of pulse might not depend on the pressure of the muscles of the arm, caused by grasping the table, I applied my ear to the chest, and found that there was no sound whatever to be heard during the intervals when the pulse was imperceptible. It was evident that the patient held his breath till the right cavities of the heart became so distended as to stop the action of that organ till the respiration returned. The man did not complain, or cry out, during the operation. A week afterwards the lithotrity was repeated, but on this occasion I administered chloroform. The pulse was about 120 in the minute, when the patient began to inhale; but it became slower as he was made unconscious, and it was regular and natural during the operation. It was only towards the end of the operation, when the effect of the chloroform was allowed to diminish, and the man began to strain a little, though not yet conscious, that the pulse intermitted slightly, passing over a single beat occasionally. There were none of the long intermissions of the pulse which were observed on the former occasion.

It is very evident, that if this patient had been the subject of any affection of the heart which weakened or embarrassed its action, he would have run a much greater risk from the pain of the first operation than from the inhalation of chloroform in the second one.

I have given chloroform with a favourable result to a great number of patients having all the symptoms of fatty degeneration of the heart, as a weak, intermittent pulse, arcus senilis of the cornea, and liability to faintness. The only patient, indeed, whom I have had the misfortune to lose whilst inhaling chloroform had very extensive fatty degeneration of the heart, the symptoms of which were well marked during life; but I am by no means sure that this patient died from the effects of chloroform, although I thought it best at the time to designate the death as one from this agent. The patient, a gentleman aged seventy-three, died just as he probably would have done, at no distant day, if no surgical or medical interference had taken place. He was making a straining effort, as if he was beginning to feel the pain of the operation, and I was commencing to give him a little more chloroform, when he suddenly expired; and I am quite unable to tell whether it was the effort of straining, or the influence of the chloroform, which caused death to take place at the moment when it did. The quantity of chloroform he was taking at the time was very small indeed, and largely diluted with air, and he had inhaled it several times before. But if it be granted that this death was caused by the chloroform, when I take into account the number of other patients with similar symptoms, to whom I have given it with a favourable result, I do not consider that it furnishes any argument against the use of this agent in such cases. Patients with fatty degeneration of the heart in an advanced stage are, no doubt, very undesirable subjects for a surgical operation under any circumstances; but when it is absolutely necessary to perform one, I am of opinion, both from what I have seen of the effects of pain on the circulation, and from what I have seen of the effects of chloroform in patients of this kind, that it is desirable to let them have the advantage of its administration. Patients with symptoms of fatty disease of the heart sometimes become faint after the conclusion of an operation under chloroform if they are kept in a sitting posture, but I have always found the faintness to subside on placing them horizontally. [361/362]

Out of the entire number of deaths from chloroform which are recorded, there are very few in which any considerable disease of the heart was found. In fact, the majority of those who are dead from chloroform were healthy persons in the best period of life--that is, from fifteen to thirty-five or forty, and it is most likely that they had, on the average, a sounder state of the heart than the multitude who have inhaled chloroform with impunity. It was not very uncommon occurrence for patients to die on the operating table before the introduction of anæsthesia, either just before the commencement of an operation or during its performance. Dr. Simpson, writing in 1852, says that two deaths had occurred on the operating-table in Edinburgh since the discovery of the effects of chloroform, in cases where the agent was not used. One died directly after the first incision through the skin, in a case of hernia, and the other instantly after the use of an abscess lancet. He also alludes to a case which occurred in Edinburgh just before the introduction of chloroform. Dr. Robertson had shaved the groin of a patient, and was proceeding to perform the operation for hernia, when the patient fainted, and died before any incision was made.

We have no information respecting the state of the heart in the patients who died suddenly on the operating table before the introduction of ether and chloroform, but it is extremely probably that many of them were affected with fatty degeneration of this organ; and I believe that by the careful administration of chloroform during operations on such patients, we not only prevent pain, but may in some cases save life.

The sudden deaths which occasionally took place on the operating table, before the introduction of anæsthesia, have sometimes been alluded to as affording an explanation of the deaths that have occurred during the use of chloroform; but, with a very few exceptions, this is not a correct view of the subject. In the instance at Mr. Robinson's, and in that at St. George's Hospital, the patients appeared to die suddenly from mental emotion, without being affected by the chloroform, which they were only just beginning to inhale; and in three cases on the Continent, where the patients died suddenly, just after great operations, loss of blood was probably the cause of death. With these, and perhaps one or two other exceptions, the deaths that have taken place under the influence of chloroform have nothing in common with those which happened on the operating-table before its introduction. In these latter cases, if the death did not arise from hæmorrhage, it was occasioned either by pain or mental emotion; but as the patient neither feels nor thinks when fully under the influence of chloroform, he cannot die from either of the two latter causes. In speaking of the benefits of chloroform, it is quite allowable to bring forward the sudden deaths which occasionally happened in operations, as a set-off against the deaths from this agent; but to suppose that the patients who have died during the employment of chloroform are the same that would have died without it is undoubtedly a mistake. The late Dr. Richard Mackenzie related a case of sudden death, which, he said, narrowly escaped being imputed to chloroform. He reduced a fracture of the radius, about an inch above the wrist, in a case where there was a good deal of swelling and displacement. He would have used chloroform, but he had none with him. Within five minutes after Dr. Mackenzie left the house, the patient died instantaneously, whilst he was talking freely to those about him. He was a corpulent man, from sixty-five to seventy years of age, who had lived freely, and Dr. Mackenzie thought it probable that he had fatty degeneration of the heart, but there was no examination of the body. The cause of death, in this case, was probably the pain to which the patient had been subjected, and it is not unlikely that the employment of chloroform might have saved his life for a time. At all events, there is no reason to conclude that the patient would have died in the manner he did if chloroform had been administered.

Surgical operations are, I believe, never performed during acute disease of the lungs, and chronic affections of these organs, as phthisis and chronic bronchitis, form no objection to its use. I have administered this agent in a number of operations where one or other of these diseases was present, and there have been no ill consequences in any case. The mucous membrane of the air-passages is always irritable, both in consumption and bronchitis, and the chloroform is apt to excite coughing at first. It is therefore necessary to begin by giving the vapour very gently in these cases, and in a little time the irritability of the mucous membrane is allayed, and insensibility can always be induced in a few minutes. The cough is afterwards relieved, in nearly all these cases, for a time--often for two or three days, in cases of chronic bronchitis.

Affections of the head offer no obstacle to the exhibition of chloroform in surgical operations. I have given it in many cases where more or less paralysis remained, from previous attacks of apoplexy, and no ill effects have followed. In a patient on whom Mr. Robert Wade lately operated--removing a scirrhous tumour of the labium pudenda--there was probably disease of the heart, as well as the remains of an apoplectic clot in the brain. The age of the patient is seventy-two; she is partially hemiplegic, from an apoplectic seizure two years ago; and her pulse, when I saw her, was irregular in the strength of its beats, and also intermitted. She went through the operation very well, and readily recovered her consciousness. I saw Mr. Wade eleven days after the operation, and learned that his patient was going on well. There is often some trouble in giving chloroform to insane patients, for when they cannot be persuaded to inhale it, it has to be given by force. When once they are under its influence, however, the surgeon is enabled to make examinations, and to perform operations that would otherwise be impossible.

I have given chloroform to a number of patients who were reduced to a state of extreme debility, from chronic disease of the large joints, and from various other causes. Chloroform agrees extremely well with such patients; they do not require to inhale so much as stronger persons, but that forms no difficulty, as the administration of this agent does not consist in giving a dose, but in executing a process, and the effects produced are observed as the process goes on.

An objection was raised in the Crimea last autumn to the use of chloroform in operations immediately succeeding to severe gun-shot wounds; but this objection seems to have given way before further experience. According to the letter of a medical officer, quoted in the medical journals, this agent was used with very good effect in such cases in particular where the soldier had the left thigh shattered to pieces, the right hand and wrist joint in the same condition, and a compound fracture of the other arm. Amputation of the thigh and forearm was performed, and, when sent to Sentari, two days afterwards, the patient promised to do well. The writer was of opinion that the soldier could hardly have borne the shock of his wounds and the operation without chloroform. I have not had occasion to give chloroform in operations immediately after gun-shot wounds, but after severe compound fractures from other causes, I have found its action very satisfactory, as well as in strangulated hernia, where there was excessive exhaustion.

I have often administered chloroform during pregnancy and no ill effects have followed in any case. Mr. Fergusson, Mr. Bowman, Mr. Henry Charles Johnson, and Mr. B. Travers, jun., are some of the surgeons for whom I have given chloroform to patients undergoing operation during pregnancy.

Chloroform may be given with propriety to patients of all ages. I have exhibited it to several infants aged from ten days to three weeks, and to one patient nearly ninety. I have notes of the cases of 145 infants under a year old, to whom I have administered this agent. A great number of them were operated on for hare-lip by Mr. Fergusson, who performs this operation at the earliest period of life, if the children are healthy. Chloroform acts very favourably on infants and children. There has, I believe, been no death from chloroform under the age of fifteen years. Chloroform was, indeed, blamed for the death of a child, in Germany, during the removal of a very large nævus on the side of the face, but there is no doubt that the cause of death in that case was hæmorrhage.

The only direction which it is usually requisite to give beforehand to the patient who is to inhale chloroform, is to avoid taking a meal previous to the inhalation; for chloroform is very apt to cause vomiting if inhaled when there is much food in the stomach. The sickness is not attended with any danger, but it constitutes an unpleasantness and inconvenience which it is desirable to avoid. The best time of all for an operation under chloroform is before breakfast; but the customs and arrangements of this country do not often admit of that time being chosen, and it is not advisable to make the patient fast beyond his usual hour. It answers very well to perform an operation about the time when the patient would be ready for another meal, or, if the time of the operation fall two or three hours after the usual time of eating, to request the patient to make only a slender repast at that time, so as just to prevent this feeling of hunger. It is impossible to prevent vomiting, in some cases, with best precautions, for the stomach occasionally will not digest when the patient is expecting a surgical operation, and the breakfast may be rejected in an unaltered state hours after it has been taken. In other cases the patient does not vomit, even when he inhales chloroform shortly after a full meal. [362/363]

The most convenient position in which the patient can be placed whilst inhaling chloroform, is lying on the back or side, as he is then duly supported in the state of insensibility, and can be more easily restrained if he should struggle whilst becoming insensible. The semi-recumbent posture on a sofa, also, does very well; and there is no objection to the sitting posture, when that is most convenient to the operator. In that case, however, the patient could be placed in a large easy chair with a high back, so that the head as well as the trunk may be supported without any effort, otherwise he would have a tendency to slide and fall when insensible. It has been said, that it is unsafe to give chloroform in the sitting posture, on the supposition that it would, in some cases, so weaken the power of the heart as to render it unable to send the blood to the brain. Observation has proved, however, that chloroform usually increases the force of the circulation; and although the horizontal position is certainly the best for a patient under an operation in all circumstances, I consider that the sitting posture is by no means a source of danger when chloroform is given, if the ordinary precaution be used which would be used without chloroform, that of placing the patient horizontally if symptoms of faintness come on. I have preserved notes of 647 cases in which I have given chloroform to patients sitting in a chair, and no ill effects have arisen in any of these cases.

The person who is about to inhale chloroform is occasionally in a state of alarm, either about the agent itself or the operation which calls for its use. It is desirable to allay the patient's fears if possible before he begins to inhale, as he will then be able to breathe in a more regular and tranquil manner. In a few cases, however, the apprehensions of the patient cannot be removed, and they subside only as he becomes unconscious from the inhalation. It has been said that chloroform ought not to be administered if the patient is very much afraid, on the supposition that fear makes the chloroform dangerous. This is, however, a mistake; the danger, if any, lies in the fear itself. Two cases were alluded to above, in which the patients died suddenly from fear, whilst they were beginning to inhale chloroform, and before they were affected by it; but the probability is, that if they had lived till the chloroform took effect, they would have been as safe as other patients who have inhaled it. If chloroform were denied to the patients who are much afraid, the nervous and feeble, who most require it, would often be deprived of its benefits. Moreover, the patients would either be prevented altogether from having the advantage of surgery, or they would be subjected to the still greater fear of the pain, as well as the pain itself; for whatever undefined and unreasoning fears a patient may have when the moment comes for inhaling chloroform, he has only chosen to inhale it on account of a still greater fear of pain. The practice I have always followed has been to try to calm the patient by the assurance that there was nothing to apprehend from the chloroform, and that it would be sure to prevent all pain; but where it has been impossible to remove the fears of the patient in this way, I have always proceeded to remove them by causing a state of unconsciousness. As soon as this is induced, the pulse, which just before may have been extremely frequent and small, from the effects of fear, generally falls almost to its natural frequency, and resumes its full volume and force.

As a general rule, it is best to place the patient in the position in which the operation will be performed before he inhales the chloroform; but in cases of disease of the large joints, and other instances where motion causes pain, it is an advantage to give the chloroform to the patient in bed before he is removed to the operating-table. It is often desirable also to give it to children in another room, that they may not see any of the preparations for the operation.

[Part 2 appeared in the following issue.]