"Case illustrating the difficulties of diagnosis of morbid growths from the upper jaw. With remarks."

Medico-Chirurgical Transactions
(1851): 43-52
Hewett included a letter from Snow, who was the anesthetist during the operation.

By Prescott Hewett, Assistant Surgeon to St. George's Hospital, and Lecturer in Anatomy.

Read at the Royal Medical-Chirurgical Society on December 10, 1850.

. . . . . . . . .

A man, æt. 25, was admitted to St. George's Hospital, under my care, in the month of May, 1848, with a large tumour, of an irregular shape, occupying various regions of the left side of his face. [43] [There follows a detailed description of the presentation, that the disease had begun six years prior to his admission to the hospital, and previous efforts by other medical men to reduce the tumour.]

. . . . . . . . .

At a consultation of the surgeons, it having been decided that the removal of the upper jaw was justifiable in this case, I undertook the operation, the patient himself, before whom were laid all the dangers incident to it, being most urgent that something should be done for him.

Dr. Snow, to whom the surgeons of St. George's are so much indebted for the able manner in which he, for a long time, administered chloroform at the hospital, gave it on this occasion.

The patient being seated in a chair, the usual incisions were made, and the bones having been divided with a strong pair of cutting forceps, the superior maxillary and the malar were easily tilted out of their place; but it was then discovered that the disease was not connected with the upper jaw,--it was lying behind it. Hoping that I should, nevertheless, still be able to get away the whole of the tumour, I first removed the greater portion which was in view, dissecting it from off the pterygoid process to which it was attached. I then, by gently pulling, got out that part which was lying under the temporal muscle, where it was imbedded in loose cellular tissue; that portion which was in the orbit required some careful dissection, as it was partly attached to the conjunctiva. At this stage of the operation, as the patient became faint, he was placed in the horizontal posture, and a small quantity of stimulant was administered, by which means he soon rallied. I then proceeded to remove, with a pair of strong curved scissors, that portion of the tumour [45/46] which I found projecting into the nasal cavity. The pulse having again failed, the patient was at once laid on a bed, and carried into an adjoining room; different restorative means were made use of, and he appeared to rally somewhat: but shortly afterwards, observing that the breathing became difficult, Mr. Charles Johnson and myself thought it advisable, as a last resource, to make an opening into the crico-thyroid membrane, and, by means of a tube, to try and keep up artificial respiration. When the opening was made into the larynx, I observed that some frothy blood immediately made its escape; the tube was readily passed, but all our efforts were ineffectual, the patient continued to sink, and soon died.

Throughout the operation I met with but few vessels, and one only of any size; this, most probably the termination of the internal maxillary, was secured by a ligature; to the other vessels blue lint was applied: on the whole, no great amount of blood was lost, and there was no bleeding from the incision in the neck.* (*I have avoided entering into any details about the chloroform, as I prefer sending, with this communication, a letter which I received from Dr. Snow on the subject.)

[Before inserting Snow's letter, Hewett provides details of the post-mortem examination, and concludes with the following paragraph:]

Some of the appearances observed in the post-mortem examination naturally lead to a question of great practical importance in the present day. I refer to the blood which was found in the air-cells and bronchial tubes. In my mind there is no doubt that that blood found its way into these parts by passing through the glottis; and if this was the case, it may fairly be asked, whether such an occurrence would have taken place had no chloroform been used,--the probabilities are that it would not. It is, I believe, now generally admitted that one of the effects, both of chloroform and ether, is to suspend the irritability of the glottis, whereby in those operations about the mouth, in which there must be a certain amount of hæmorrhage, there is a risk that some of the blood may find its way into the windpipe, without there being any cough excited to expel it; and several eminent surgeons, both abroad and in this country, have not failed, of late, to condemn the administration of these agents in operation of this nature. Some surgeons being unwilling to submit their patients to all the pain incident to such serious operations have, however, adopted a middle course, administering the chloroform in the first steps of the operation only, hoping thus to avoid all risk; but it remains still to be proved whether, even with this precaution, there may not be danger in using anæsthetics in some operations about the mouth. [50/51]

Letter from Dr. Snow referred to in Mr. Hewett's Paper.

On May 18th, 1848, I administered chloroform, at St. George's Hospital, to a young man with a tumour of the superior maxillary bone. The vapour was given to him rather slowly with the apparatus which I generally employ; and he became gradually insensible, without previous excitement or struggling. In about three minutes, the inhalation was suspended, and some teeth were extracted without causing any sign of pain. A little more chloroform was given, that the operation of removing the tumour might commence, whilst the patient was under its full effect. When the inhalation was discontinued, he was in the condition that has been named the third degree of narcotism. He was passive, but the muscles were not relaxed, and the breathing was not stertorous. He remained quite silent and motionless during the early part of the operation, whilst the flaps were made, but afterwards he began to groan and move his limbs, and was not again rendered insensible; for, although a few minims of chloroform were sprinkled, from time to time, on a sponge, and held near the face, he got very little of the vapour, as the hands of Mr. Hewett and the surgeons assisting him were constantly in the way, and the cavity of the mouth and nostrils was laid widely open. The only effect, indeed, that I could produce, was partially to lull the patient, on one or two occasions. During this time, the effect of the chloroform never exceeded the second degree, or that state in which the mental functions are confused, but not suspended. He 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 seemed a good deal embarrassed during the operation with the blood which flowed into his throat. He leaned forward once or twice to get rid of it, and I thought that he vomited some blood on one of these occasions. [51/52]

In the course of the operation, and at a time when he was but little under the influence of chloroform, the patient became faint, he was laid down, and brandy was given to him. No more chloroform was administered after this time. When I left the Hospital, a little while after the removal of the patient form the operating theatre, he was much exhausted, but seemed quite conscious, and did as he was told. There was then no difficulty of breathing, and, in my opinion, the influence of the chloroform had altogether left him.