Joseph Lister, Professor of Surgery in the University of Glasgow and Surgeon to the Royal Infirmary, was invited to contribute the section on general anaesthesia to a four- volume textbook, A System of Surgery, edited by Thomas Holmes and published in 1862. Lister’s chapter appeared in volume 3, and occupied 16 pages. It contained some statements that were remarkable even in his own times. For example he asserted that anyone could give chloroform safely as long as they followed a few simple rules. Specialist anaesthetists were quite unnecessary, and had the disadvantage of investing the administration of chloroform with an air of needless mystery. Preliminary examination of the chest was, by alarming the patient, more likely to induce the dreaded syncope that to avert it. These opinions have been subject to much criticism, notably by Stanley Sykes, but Lister’s circumstances should be understood.
Lister was concerned that general anaesthesia, by which he meant chloroform, “was scantily used in parts of Europe and even in the United Kingdom because of fear of fatalities.” He wanted to increase this use, because, and here he was ahead of the field, he thought it protected against surgical shock. His purpose was to bolster the confidence of his medical students, so that when they entered practice they would not be afraid to administer a general anaesthetic. Hence his dismissal of Snow’s 300 page textbook as unnecessary.
“The notion that extensive experience is required for the administration of chloroform is quite erroneous, and does harm by weakening the confidence of the profession in this invaluable agent.” Mr. Syme (his father-in-law) had administered 5000 chloroform anaesthetics without one fatality. All that was necessary was to follow some simple instructions.
However Lister was very concerned to avoid airway obstruction, and seems to have been the first to publish about it. He appears to have regarded strongly stertorous breathing as “a sign of overdose in chloroform anaesthesia, which, if not recognised and dealt with, will become aggravated until it passes into complete obstruction to the entrance of air into the chest, though the respiratory movements of the thoracic walls still continue.”
The whole condition is very dangerous, because “it would seem that when chloroform is given in an overdose, the cardiac ganglia are apt to become enfeebled; and on this account asphyxia produces more rapidly fatal effects than under ordinary circumstances. But if the obstructed state of breathing is noticed as soon as it occurs, and the cloth is immediately removed from the face, and the tip of the tongue seized with a pair of artery forceps* and drawn firmly forwards, the respiration at once proceeds with perfect freedom, the incipient lividity of the face is dispelled, and all is well.”
*In a footnote Lister added that “The artery forceps are the most convenient means of drawing the tongue forwards. The puncture which they inflict is of no consequence; the patient, if he notices it at all, supposes that he has bitten his tongue under the chloroform.”
Lister continued to press the point. “I am anxious to direct particular attention to the drawing out of the tongue, because I am satisfied that several lives have been sacrificed for want of it. In order that it may be effectual, firm traction is needed. I have, more than once, seen a person holding the end of the organ considerably beyond the lips without any good effect, and, placing my hand on his, have given an additional pull, that has re-established the respiration.”
To emphasize the point he described a simple experiment “which anyone may perform on himself.” It is easy to produce stertorous breathing at will but not if the tongue is gripped with a handkerchief and pulled out sufficiently to cause decided uneasiness.
Lister continued to investigate stertorous breathing, and noted that it could be of two kinds, palatine, caused by vibration of the soft palate, and laryngeal. Just lifting the tongue off the back of the throat would not relieve the latter, nor would the increased second traction, so he concluded that a reflex must be involved. To elucidate this he examined his own larynx, by the indirect method, using the laryngoscopic mirror to reflect bright sunlight, and concluded that true laryngeal stertor resulted from the vibrations of the mucous membrane at the apices of arytenoids cartilages. He observed that drawing the tongue forward forcibly caused the membranous folds to separate, so allowing free passage of air. Hence the forceful drawing forward of the tongue is of the highest practical importance. Gentleness will waste a golden opportunity of rescuing the patient from death.
Lister concludes that if the above is correct, and the first sign of too deep chloroform anaesthesia is respiratory obstruction, it follows that the attention of the administrator “ought to be concentrated on the breathing, instead of being, as it too often is, diverted by the pulse, the pupil, or other matters still less relevant.”
Hence the rationale for the Scottish technique.