36 Under Chloroform (1860)

Most people take an interest in any authentic account of the mode in which important surgical operations are performed, whenever opportunity is offered of gratifying their very natural curiosity. Such opportunities are however somewhat rare. The columns of the newspaper press not unfrequently supply brief, and sometimes curiously incorrect, particulars of the injuries resulting from “an appalling accident” of the night previous, to some unfortunate workman who has fallen from a scaffold, or been mutilated by a railway train. Scraps of hearsay are eagerly gathered up by the penny-a-liner,^[1] who, like the fireman’s dog of notorious ubiquity, is always first on the spot after the occurrence of a catastrophe; and a remarkable combination of technical phrases culled from the brief remarks of the surgeon in attendance, and from the slender stock which has accumulated in the reporter’s brain from previous experiences, makes its appearance in to-morrow’s daily journals, and is certain to be reproduced in all the weeklies of Saturday next. Then it is the great public learns with profound horror that some poor victim’s shoulder-joint has been dislocated in three places, that the carotid artery was pronounced (surgeons are invariably said to “pronounce”) to be fractured, or that there was great contusion and ecchymosis^[2] (always a trying word for the compositor) about the spine, and that amputation would probably be necessary.

But sometimes it happens that an over-prying public, with a curiosity not much in this instance to be commended, peeps within the pages of the medical press, hoping to unravel some of the mysteries of professional craft. Ten to one that it gets nothing but error for its pains. The technicalities which medical men must necessarily employ when writing for each other, are instructive only to the initiated, and are pregnant with blunders for the simple reader. And few people make more mistakes than our medical amateur who, on the strength of a weekly perusal of The Lancet at his club, sets up as an authority in the social circle on questions of physiology and physic.

Occasionally, moreover, after dinner, when the ladies have left the table, and the men alone remain to empty decanters and derange a dessert, one has the gratification of meeting some very young gentleman, who, the week before last, presented his proud father with the diploma of “the college,” elegantly framed and glazed, in return for an education which has cost five years and a thousand pounds, and who astonishes his elderly associates with a highly-tinted sketch of some operative achievement, in which perchance he assisted at the hospital. As he surveys the auditory, silent and absorbed by his heart-stirring description, and complacently witnesses the admiration which such evidence of his own familiarity with harrowing scenes, and of his apparent absence of emotion, elicits, it is to be feared that its influence, associated with that of the port, a beverage appreciated by our young friend, if one may judge by the quantity he imbibes, tends to render the information obtained, as one may say almost at first hand, not so absolutely trustworthy as a man of fact is accustomed to desire.

After a due survey then of the varied sources from which most people obtain information respecting the topics in question, and after some observation of the character and quality of the knowledge so acquired, we have formed the deliberate conclusion that they possess very erroneous, and very inadequate notions about the nature of a surgical operation. No doubt all admire the sang-froid and skill, possession of which is necessary to make a good surgical operator—qualities, by the way, which are perhaps more frequently developed by training, than found already existing as a natural inheritance. But it is germane to our purpose to remember that everybody has a direct practical concern in the existence of an available supply of the necessary talent to meet a certain demand on the part of the body politic, for no one knows how soon his own personal necessities may not be such as to give him the strongest possible interest in its exercise: a demand that is absolutely inevitable;—for be assured that, without any wish to alarm you, gentle reader, Mr. Neison will, if requested to make the calculation, inform us at once what the numerical chances are that your own well-proportioned nether limb will, or will not, fall before the surgeon’s knife, or that that undoubtedly hard and well-developed cranium may not yet be scientifically explored by “trepan” or “trephine.” He will estimate with unerring certainty the probability (to nine places of decimals, if you demand it) that your own fair person may become the subject of some unpleasing excrescence; and also what the chances are that you must seek the surgeon’s aid to remove it. While Mr. Buckle will stoutly maintain, and you will find it hard to gainsay him, that, given the present conditions of existence, a certain ascertainable number of tumours, broken legs, and natural-born deformities will regularly make their appearance every year among the human family. And he will probably add, that it is perfectly within the province of possibility to calculate, if we had all the required data, the exact number of individuals who have the requisite courage to submit to operation; as of those who will not have heart to do so, and who will inevitably die without benefit of surgery; together with the exact percentage to the population of those who will, and who will not, put faith in the blessed boon of chloroform.

It is a blessed boon; and in olden times the possessor of such a secret would have been the most potent wizard of which the earth has yet heard tell. What miracles might not have been performed by it! What dogmas might not have been made divine and true by its influence! Happy was it that those great powers, the magic of chemical and electrical discovery, have been brought to light in a time when they can be used mainly to enlighten and bless, and not to darken and oppress mankind!

But that word chloroform is happily significant that it is to no scene of suffering that we would introduce our readers. There is no need to shrink, or to question the taste which exhibits the details of a surgical operation to the vulgar eye.^[3] It is not designed, even in this stirring time, after the fashion of ancient Rome, to deaden our sensibilities, or to accustom our youth to witness deeds of blood and violence without shrinking. No trace of suffering will be visible in the picture which shall pass before us. So great is the triumph which modern surgical art displays, so great the boon which it has conferred upon humanity! It is this which we propose to illustrate, by describing the single and simple process involved in cutting off a leg.

Permit us first, however, to cast a passing glance, by way of contrast; to the established and orthodox fashion of performing that operation some centuries ago. Bear with us but a moment, and in imagination hope that then, when painless surgery was unknown, no patient lacked support in his hour of trial (long hours then, in truth!) from that great and never-failing source which flows, unmeasured and unfathomable, for all humanity, alike in every age.

Until the last three or four hundred years, amputation of a limb was very rarely performed, except when, from injury or disease, its extremity had begun to mortify; and then, few surgeons ventured to make incisions in the sound portion, but limited themselves to an operation through the tissues which had already lost their vitality. This timidity was due to the fact that they were unacquainted with any effectual means of stopping the bleeding from the larger arteries divided by the knife. Certain and easy as is the control of such bleeding now, by the simple process of tying a piece of thread or silk round the extremity of the bleeding vessel (as we shall hereafter see), it was unknown, at all events as applicable to amputation, to any surgical winter from Hippocrates, 400 B.C., or from Celsus, who flourished in the first Christian century, to the fifteenth. Consequently, the numerous instances of injury and disease, in which life is now saved by a timely resort to amputation, were then always fatal. Hence, also, arose the various expedients which the more adventurous operators of the time resorted to, in order to stop fatal bleeding, with the effect only of increasing the patient’s torture, and with the attainment of no good result. Thus the incisions were performed with a red-hot knife, that the divided vessels, seared and charred by the horrible contact, might contract, or become plugged, and so be prevented from bleeding (Albucasis, 11th century). Effective for the instant, the force of the circulation quickly overpowered the slender obstruction, and fatal hæmorrhage, sooner or later, took place. Yet this plan continued more or less in vogue down to the discovery of the ligature in the 16th century, and was practised even later in Germany by the celebrated Hildanus (1641); although he subsequently adopted the new method. According to another fashion, the surgeon, after making a tedious division of the flesh down to the bone, with studied endeavour not to divide the arteries until the last moment, relied on applications of red-hot irons, or of some styptic fluid, usually a powerful acid or astringent, to arrest the bleeding. If these were not successful, a vessel of boiling pitch was at hand, ready prepared, into which the bleeding stump was plunged. Between Scylla and Charybdis, the patient rarely escaped with life; either he died from loss of blood in a few hours, or less; or if the dreadful remedies succeeded, he survived a day or two, to die of fever or exhaustion. After an earlier method, that of Guido di Caulico (1363), a bandage of plaster was made to encircle the member so tightly that mortification attacked all the parts below, which then, after the lapse of months, dropped off, a horribly loathsome and offensive mass. Another surgeon, Botalli (1560), invented a machine to sever the limb in an instant by a single stroke; and it was not uncommon at this period to effect the same purpose by the hatchet, or by a powerful mallet and chisel.

It is to Ambrose Paré, the great French surgeon, who flourished in the 16th century, that we owe the application of the ligature (used long before in ordinary wounds) to the bleeding arteries in amputation. He discarded the use of the red-hot cautery, and of all the frightful adjuncts already described; and accomplished his purpose by carrying the thread round the vessel by means of a needle passed through the soft parts adjacent—a method of adjustment which, although still in use, is now employed only in exceptional instances. Richard Wiseman, sometimes styled the father of English surgery, who practised about the middle of the 17th century, is believed to have been the first to employ the ligature in our own country, and to relinquish the application of heated irons. At this era also, the circulation of the blood was discovered by the renowned Harvey, and the distinction between arteries and veins being thenceforth clearly understood, the value of the ligature was rendered more than ever obvious.

But enough of this: let us soothe our ruffled nerves by seeing how the thing is done to-day. We will take a quiet post of observation in the area of the operating theatre at one of our metropolitan hospitals, in this year of our Lord 1860. Notice is posted that amputation of the thigh will be performed at 2 o’clock P.M., and we occupy our seat ten minutes before the hour.

The area itself is small, of a horse-shoe form, and surrounded by seats rising on a steep incline one above another, to the number of eight nine tiers. From 100 to 150 students occupy these, and pack pretty closely, especially on the lower rows, whence the best view is obtained. For an assemblage of youths between eighteen and twenty-five years, who have nothing to do but to wait, they are tolerably well-behaved and quiet.. Three or four practical jokers, however, it is evident, are distributed among them, and so the time passes all the quicker for the rest. The clock has not long struck two, when the folding-doors open, and in walk two or three of the leading surgeons of the hospital, followed by a staff of dressers, and a few professional lookers-on; the latter being confined to seats reserved for them on the lowest and innermost tier. A small table, covered with instruments, occupies a place on one side of the area; water, sponges, towels, and lint, are placed on the opposite. The surgeon who is about to operate, rapidly glances over the table, and sees that his instruments are all there, and in readiness. He requests a colleague to take charge of the tourniquet, and with a word deputes one assistant to “take the flaps,” another to hold the limb, a third to hand the instruments, add the last to take charge of the sponges. This done, and while the patient is inhaling chloroform in an adjoining apartment, under the care of a gentleman who makes that his special duty, the operator gives to the now hushed and listening auditory, a brief history of the circumstances which led to an incurable disease of the left knee-joint, and the reasons why he decides on the operation about to be performed. He has scarcely closed, when the unconscious patient is brought in by a couple of sturdy porters, and laid upon the operating table, a small, but strong and steady erection, four feet long by two feet wide, which stands in the centre of the area. The left being the doomed leg, the right is fastened by a bandage to one of the supports of the table, so as to be out of harm’s way; while the dresser, who has special charge of the case, is seated on a low stool at the foot of the table, and supports the left. The surgeon who assists, encircles the upper part of the thigh with the tourniquet, placing its pad over the femoral artery, the chief vessel which supplies the limb with blood, and prepares to screw up the instrument, thus to make sure that no considerable amount of the vital fluid can be lost. The operator, standing on the left side of the corresponding leg, and holding in his right hand a narrow, straight knife, of which the blade is at least ten inches long, and looks marvellously bright and sharp, directs his eye to him who gives the chloroform, and awaits the signal that the patient has become perfectly insensible. All is silence profound: every assistant stands in his place, which is carefully arranged so as not to intercept the view of those around.

The words “quite ready” are no sooner whispered, than the operator, grasping firmly with his left hand the flesh which forms the front part of the patient’s thigh, thrusts quietly and deliberately the sharp blade horizontally through the limb, from its outer to its inner side, so that the thigh is transfixed a little above its central axis, and in front of the bone. He next cuts directly downwards, in the plane of the limb, for about four inches, and then obliquely outwards, so as to form a flap, which is seized and turned upwards out of the way by the appointed assistant. A similar transfixion is again made, commencing at the same spot, but the knife is this time carried behind the bone; a similar incision follows, and another flap is formed and held away as before. Lastly, with a rapid circular sweep round the bone he divides all left uncut; and handing the knife to an assistant, who takes it, and gives a saw in return, the operator divides the bone with a few workmanlike strokes, and the limb is severed from the body. A rustling sound of general movement and deeper breathing is heard among the lookers-on, who have followed with straining and critical eyes every act which has contributed to the accomplishment of the task; and some one of the younger students is heard to whisper to his neighbour, “Five and thirty seconds: not bad, by Jove!”

The operator now seats himself on the stool just vacated by the dresser, who has carried away the leg, and seeks in the cut surfaces before him the end of the artery on which to place a ligature. There is no flow of blood, only a little oozing, for the tourniquet holds life’s current hard and fast. Only five minutes’ uncontrolled flow of the current from that great artery now so perfectly compressed, and our patient’s career in this world would be closed for ever. How is it permanently held in check? and what have we to substitute now for the hissing, sparkling, and sputtering iron, and the boiling pitch? The operator takes hold of the cut end of the artery with a slender, delicately made pair of forceps, and draws it out a little, while an assistant passes round the end so drawn out a ligature of exceedingly fine whipcord, fine but strong, and carefully ties it there with double knot, and so effectually closes the vessel. A similar process is applied to perhaps six or seven other but smaller vessels, the tourniquet is removed, and no bleeding ensues. Altogether the patient has lost little more than half-a-pint of blood! The flaps are placed in apposition, the bone is well covered by them, a few stitches are put through their edges, some cool wet lint is applied all around the stump, and the patient, slumbering peacefully, is carried off to a comfortable bed ready prepared in some adjacent ward. Half an hour hence that patient will regain consciousness, and probably the first observation he makes will be, “I am quite ready for the operation, when is it going to begin?” And it takes no little repetition of the assurance that all is over to make him realize the happy truth.

So it is that he who loses the limb knows less about the process than any one concerned; infinitely less, my gentle reader, than you who have shared with us the quiet comer, and have seen all without losing consciousness, or fainting. It was an early day in the medical session, and many new men were there; one at least was observed to become very—very pale, and then slowly disappear: no one knows how or where, for neither we in the area nor those elsewhere had leisure or care to inquire.

What might have happened to somebody else had he been witness before these blessed days of chloroform, can, in the nature of things, be only a matter for speculation. It may even be surmised by some theorist, and without hazarding a very improbable guess, that a similar catastrophe might, perhaps, under such aggravating circumstances, and at a greener age, have rendered utterly futile, on his part, any attempt to describe what modern skill and science now accomplish in cutting off the leg of a patient Under Chloroform.