were seven cases of lithotomy; six of the patients were children, and
the seventh a young man of seventeen. They all recovered. Five of the
operations were performed by Mr. Fergusson, in King’s College Hospital;
and two were performed in St. George’s Hospital, by Mr. H. C. Johnson
and Mr. George Pollock.
There were five cases of resection of the knee; three of the patients
got well, and two died. These operations were performed in King’s
College Hospital, one of them by Mr. Partridge, and the other four by
Mr. Fergusson. Of the seventeen cases of resection of the knee,
mentioned at page 280, in which chloroform was administered, I know the
result only in thirteen of the cases. Of these, eight recovered, one of
them after undergoing subsequent amputation at the thigh; and five died.
Some statistics of this operation have been gathered by collecting the
cases which happen to be reported in the medical journals, but such
statistics are likely to be extremely erroneous. The cases that are
reported are probably far more favourable than those that are not
reported. A surgeon undertakes an operation of this kind with no other
view than the benefit of his patient, and without thinking of the
medical journals; and, if his first or second case is unsuccessful, he
is probably not inclined to repeat the operation. If the cases should be
successful, however, he is inclined to repeat the operation when
opportunity occurs, and may ultimately give the result of his experience
to the profession.
Mr. Bowman removed the head of the femur in two little boys to whom I
administered amylene; they both recovered, as did a girl who inhaled
amylene whilst Mr. Fergusson performed resection of the elbow. I
administered amylene in four cases of amputation of the thigh: one of
these operations was performed by Mr. Henry Lee, on January 7th, 1857,
on a girl aged twelve or thirteen, who underwent resection of the knee
on the 1st of November previously. That operation was performed by Mr.
Bowman, and the girl inhaled chloroform. At the time of the amputation,
she was suffering from pyæmia, was extremely weak, and had a pulse of
150 in the minute. The vapour was exhibited to the patient in bed,
before her removal to the operating table. There was an examination of
the knee before the operation; and the anæsthesia was kept up till the
dressings were applied, which was twenty-five minutes from its
commencement, and nearly three fluid ounces of amylene were used. She
went through the operation extremely well. There was no sign of pain,
and the pulse remained the same throughout the operation, and there was
no depression. The patient recovered.
There was one operation of amputation below the knee by Mr. Fergusson,
in which I administered amylene. The patient was a woman of twenty. The
operation was performed on account of paralysis of the muscles of the
leg and foot. She recovered. There was an amputation of the forearm; two
amputations of the great toe, with its metatarsal bone; and two or three
of toes and fingers: four cases of operation for stricture of the
urethra by perinæal section—three of them by Mr. Fergusson, and one by
Mr. Curling. There were three operations of lithotrity, two for
hæmorrhoids and prolapsus ani, and four for fistula _in ano_. There were
nine operations for the removal of tumours of the female breast; there
were seventeen operations for necrosis of the tibia, femur, lower jaw,
and other bones.
I administered amylene in several operations on the eye. There were two
operations for cataract by extraction, and one by drilling, performed by
Mr. Bowman; eight cases of excision of the eye by that surgeon, as well
as some operations for artificial pupil, for the removal of foreign
bodies from the eye, for staphyloma, and one for the separation of the
eyelids from the globe. There were also twelve operations for
strabismus, eleven of them by Mr. Bowman, and one by Mr. Fergusson.
I exhibited amylene in forty-eight operations of tenotomy. Several of
them were performed by Mr. Fergusson, but the greater number were
performed by Mr. W. Adams and the late Mr. Lonsdale, in the Orthopædic
Hospital. The narcotism was scarcely carried beyond the second degree in
any of these cases. The eyes were open, and the features generally had
an expression as if the mind was active on some subject or other. The
muscles were nearly always in a state of tension, at least they were not
relaxed in any case. Many of the patients were children, and a number of
them only inhaled between one and two minutes. There were five
operations for the forcible extension of stiff joints, and two for
dislocation of the humerus: the latter were treated in the St. James’s
Parochial Infirmary. The first case was a dislocation downwards in a
woman aged sixty-eight. She inhaled for three minutes, when, extension
being made, the bone slipped into its place with the utmost ease,
although Mr. French had found a good deal of resistance in an attempt he
made just before sending to me—not any serious resistance or pain, but
so much of both as led him to think it would be a good opportunity for
trying the amylene. In two minutes after the reduction of the
dislocation, and five minutes after beginning to inhale, the patient was
quite awake again, and said that she had felt nothing. The other case
was a dislocation forwards in a man aged seventy-two. No attempt to
reduce it was made till the amylene was administered. The case was under
the care of Mr. Buzzard. After inhaling two or three minutes, the old
man got into a state of muscular rigidity, and did not get beyond this
state, although I continued the inhalation nearly ten minutes, until
about two ounces of amylene were used. He was quite insensible, but the
rigidity prevented the reduction of the dislocation. So I discontinued
it, and sent for some chloroform, which I administered a few minutes
afterwards. It produced muscular rigidity rather stronger than that
which the amylene had caused; but, by continuing the inhalation steadily
for about two minutes, the limbs became relaxed, and the humerus slipped
easily into its place. This is the only case in which the amylene has
not effected the purpose for which I have exhibited it; and I have no
doubt that I could have produced relaxation of the voluntary muscles by
increasing the strength of the vapour the patient was breathing; for I
have always been able to produce relaxation of the muscular system of
animals with it; but there were one or two circumstances which at the
moment stood in the way of this. The patient’s face was so hollow from
his loss of teeth that the face-piece fitted badly; and, as it was early
in a frosty morning, the water-bath of the inhaler was colder than
usual. These defects could have been remedied if necessary, but I
thought it as well to use chloroform; and I am inclined to think that
chloroform and ether are better agents to employ in those instances
where relaxation of the voluntary muscular system is required.
Sixteen tumours of different kinds were removed from different parts of
the body, in addition to the tumours of the breast previously mentioned,
in cases in which I administered amylene; and there was also a number of
miscellaneous operations which I have not mentioned.
One of the patients of the late Mr. Lonsdale at the Orthopædic Hospital
was a girl of seventeen, who had the scapula drawn up in an
extraordinary manner by the action of the muscles. When she became
unconscious from the amylene the shoulder came into its right position,
with hardly any pressure, although her muscular system was not in the
least relaxed from the action of the vapour; and the deformity remained
absent for three days. The amylene was repeated three or four times with
the same temporary benefit, and chloroform was given on one occasion
when I was not present with a similar result. I have not heard of the
subsequent progress of the case. I cannot suppose that the direct effect
of amylene would remain three days on the nervous system, and I conclude
that the result was brought about by some change in the emotions of the
patient.
I gave amylene in twenty-four cases of tooth-drawing, including those
which were previously mentioned. One of the cases was that of a lady
under the care of Dr. Oldham. She was suffering from a large ovarian
tumour, and was unable to rise from the sofa. Mr. Bell extracted four
teeth whilst she was under the influence of the amylene. She became
insensible without the least excitement, was perfectly quiet during the
operation, and recovered in a minute or two, feeling quite cheerful and
well.
I have administered amylene in seven cases of labour. The first patient
was under the care of Mr. Buzzard in St. James’s Infirmary, on January
20th, 1857. It was the patient’s second labour, and was a lingering one,
having lasted thirty-five hours. I administered the amylene only during
the last twenty minutes preceding the birth of the child, the head being
advanced so as to rest on the perinæum. The vapour was given, well
diluted, at the beginning of each pain. The patient breathed very
deeply, and got relief very quickly from each pain; the mind was quite
clear between the pains, and I could not tell whether or not the
consciousness was removed for half a minute or so during each pain. Half
a fluid ounce of amylene was used. The next case occurred in an
out-patient of King’s College Hospital, under the care of Mr. Meadows,
Dr. Farre’s assistant. It was the patient’s third confinement. I arrived
three hours after the commencement of labour, and two hours before the
birth of the child. The os uteri was almost dilated on my arrival, and
the pains were very strong, recurring every three minutes or so. They
continued to increase in strength to the last. The patient was probably
unconscious for a brief period during the uterine contractions, while
the amylene was administered, but between the pains she was quite
conscious. Under the use of chloroform, in a labour with brisk and
frequently recurring pains, as in this case, the patient usually sleeps
on from one pain to another. The amount of amylene inhaled in this case
was three fluid ounces. The quantity used in each of these cases must
have been about half a fluid drachm in each pain, and this is the
quantity I had previously recommended Dr. Tyler Smith to employ, when he
did me the honour to ask me some questions about amylene before he
employed it in a case of labour. The results arrived at by Dr. Tyler
Smith, in a case in which he employed amylene, were similar to my own,
viz. relief of suffering during the uterine contraction, consciousness
between the pains, and no interference with the progress of the labour.
On April 28, 1857, I administered amylene in Brownlow Street, Drury
Lane, to a woman in her sixth labour, attended by Mr. Ponsonby R. Adair,
one of Dr. Farre’s assistants. She had been in labour since three P.M.
the previous day. The os uteri was fully dilated, and the amylene was
commenced at 5·25 A.M., and continued till 5·50, when the child was
born. The placenta was expelled in a few minutes with very little
bleeding. The amylene was exhibited with the inhaler at the beginning of
each pain, which it soon relieved, although the patient did not become
unconscious. The pains came on every two minutes or so, and kept
increasing in force till the birth. About six drachms of amylene were
used.
On May 1st., I administered amylene to another woman in her sixth
labour, also attended by Mr. Adair. The vapour was commenced at 9·30
P.M., the patient having been in labour a few hours. The os uteri was
not fully dilated. The pains came on regularly every three minutes, but
were not very strong; they, however, gradually increased, and the child
was born at half-past eleven. The cord was round the neck, and the child
was nearly asphyxiated in the birth, but it was restored readily by Dr.
Marshall Hall’s method. The placenta was expelled a few minutes after
the child with very little hæmorrhage. The patient inhaled with every
pain, which was very quickly relieved. The last quarter of an hour, she
seemed to be altogether unconscious. About three fluid ounces of amylene
were used.
On May 14th, I exhibited amylene for about an hour to a woman in her
third labour, attended by Mr. Adair. The os uteri was nearly dilated
when I arrived, and the patient had been in labour about ten hours. The
pains occurred every three or four minutes, but were not strong. Amylene
was inhaled with each pain for about an hour, when the pains almost
ceased, just as the os uteri was fully dilated. I waited for half an
hour without giving amylene, and then left to attend to another
engagement. Mr. Adair informed me that the pains returned soon after I
left, and that the child was born in about half an hour. The patient was
hardly rendered unconscious by the amylene. Between two and three fluid
ounces were used.
I exhibited amylene for an hour and ten minutes, on May 25th, to a woman
aged 20, in her first labour. She was attended by Mr. Adair. She had
been in labour since three P.M. the previous day, and the os uteri was
not fully dilated. The amylene was commenced at 9·30 A.M., and inhaled
with each pain, which it relieved in a very manifest way. The pains
recurred every two minutes and a half. I left off giving the amylene at
10·40 to attend to other business. Mr. Adair informed me that the labour
was concluded at one P.M.
On July 1st, I exhibited amylene to a woman in labour with her third or
fourth child. Labour commenced at midnight of June 27th, and continued
during the following day till the os uteri was dilated to the size of a
crown piece, when the pains subsided on the evening of that day, and did
not return to be effectual till the evening of July 1st. The amylene was
commenced at 10·25, the os uteri being almost dilated, and the pains
recurring every three or four minutes. The uterine contractions
increased in force and frequency, and the child was born at 11·45. There
was a gush of blood two or three minutes after the birth of the child,
and Mr. Adair introduced his hand and removed the placenta, which was
only partially detached. The hæmorrage immediately ceased. The patient
was feeble and emaciated, and had suffered repeated beatings by her
drunken husband. She recovered favourably, as did the other patients.
The action of the amylene was very favourable in these obstetric cases.
The pains were relieved very promptly by it, generally by the time the
patient had taken two or three inspirations, and the effect of the
vapour passed off in most cases between each pain.
The great ease with which amylene can be breathed, owing to its entire
want of pungency, is a decided advantage which it possesses over both
ether and chloroform. Insensibility can always be induced with amylene
in as short a time as is desirable, namely, in from three to four
minutes in the adult, and about two minutes in young children. It is not
desirable to cause insensibility in a shorter time than this with any
agent. If narcotism is induced too quickly, the symptoms are not uniform
or in regular order, owing, no doubt, to the circumstance that the
narcotic vapour is not equally distributed through the blood, which must
convey it to the nervous centres. Insensibility can, indeed, be
generally induced with chloroform in the time above mentioned, but there
are many cases in which there is considerable delay at the commencement
of inhalation, owing to the pungency of the vapour, especially in
nervous and in sensitive patients, and in persons with irritability of
the air-passages from chronic bronchitis, phthisis, or any other cause.
In the use of amylene, absence of pain has been obtained with less
profound coma than usually accompanies the employment of chloroform and
ether. There are some cases, indeed, in which the minor parts of an
operation, under these latter agents, may be performed without pain
while the patient is in a semi-conscious state, or even altogether
conscious, but they form an exception; while in the use of amylene, the
patient has very often been half-conscious during the operation. In
operations under chloroform, the patients usually indicate the necessity
of repeating the inhalation by a tendency to flinch or cry, without
showing any signs of consciousness; but in the use of amylene, they have
more frequently begun to look about and to speak before showing any sign
of pain. There are some patients who will not lie still under the
surgeon’s knife while chloroform is being used, unless its effects are
carried so far that the breathing is on the borders of being stertorous,
but I have not met with any such case in using amylene.
The greater number of the operations under amylene were performed while
the patient was in the second degree of narcotism, being apparently
awake, although not really conscious of surrounding objects. This usual
absence of coma in the employment of amylene cannot be looked on
otherwise than as an advantage. It must conduce to the safety of the
agent when the proportion of vapour in the air is properly regulated.
The reason why no accident is known to have happened from chloroform, in
the practice of midwifery, when superintended by a medical man, is no
doubt due to the circumstance that it is only requisite to induce a
slight effect, in comparison with the effect required in surgical
operations.
The best indication that the patient will quietly bear an operation
under chloroform, is the more or less complete absence of sensibility of
the ciliary edge of the eyelid; but during the inhalation of amylene the
patient is often entirely regardless of the surgeon’s knife, whilst the
edges of the eyelids retain their full sensibility, and the slightest
touch causes strong winking. In operations on the eye, however, and in
all other cases where great steadiness on the part of the patient is
required, I have thought it best to continue the amylene till the
sensibility of the margin of the eyelids was almost abolished; and to
effect this it has usually been requisite to carry the influence of the
vapour as far as the beginning of the third degree of narcotism, or that
condition in which there is no longer voluntary motion of the eyes, or
any other part, and in which the eyelids are usually closed, and the
pupils inclined upwards. But even in these cases the patient has usually
reverted to the second degree of narcotism before the end of the
operation, and has shown signs of ideas by the voluntary motion of the
eyes and eyelids, or in some cases by speaking. In several cases,
however, the sensibility of the eyelid has been removed in the second
degree of narcotism; and important operations have been commenced before
the patient was “off”, to use an expression familiar on these occasions.
One instance of this kind was the operation of lithotomy by Mr.
Fergusson, on the 14th of March, 1857, in a young man, aged 17, in
King’s College Hospital. The sound was first introduced, and the stone
being detected, the assistants were requested to tie the patient up; and
finding his limbs somewhat rigid, they requested me to give him some
more vapour. If I had been using chloroform I should have done so
without any request, in order to cause relaxation; but I allowed the
effect of the amylene to partially subside, and in less than a minute
the bandages could be easily applied. I then proceeded to give a little
more amylene, but soon found that the margin of the eyelids was
insensible; so the operation was performed whilst he was calmly looking
about, as if awake; but he showed no sign of pain, and knew nothing of
the operation. I never saw a capital operation performed on the adult,
under the influence of chloroform or ether, whilst the patient was in
this condition; but I once administered chloroform in St. George’s
Hospital to a child of three or four years old, which was cut for stone
whilst lying calmly with its eyes open, and holding a toy in its hand,
all the time of the operation, without letting it fall.
The pulse is almost always increased in frequency and force during the
inhalation of amylene,—especially during the early part of the
inhalation, and to a greater extent than happens with chloroform. The
respiration is very often accelerated during the inhalation,—about as
often, I think, as with ether, and more frequently than with chloroform.
In many of the early cases in which I administered amylene, the pupil
was dilated for a short time; but I consider that this arose from giving
the vapour rather stronger than is desirable. I afterwards gave it more
gently, and very seldom observed the pupils to be dilated. They
remained, as nearly as I could tell, of the natural size, and also
sensible to light, in the cases where I made an observation on that
point.
The colour of the countenance is generally heightened more or less
during the whole period of the inhalation, and in a few cases there was
sweating,—a symptom met with now and then under the influence of
chloroform and ether. Amylene does not cause the great increase in the
flow of saliva which is so often met with during the inhalation of
chloroform, and especially of ether.
There is a tendency to laugh during the inhalation of amylene much more
frequently than during the use of chloroform. It occurs just after the
patient has lost his consciousness, but is soon subdued by the
increasing effect of the vapour. I only met with strong mental
excitement in a very few patients, chiefly females. It subsided in half
a minute in one case, on leaving off the vapour, and did not recur when
the inhalation was resumed. In the other cases it was subdued by
continuing the inhalation.
The expression of the countenance generally remains calm and cheerful
during the action of amylene; but in a few instances there is a
singular, and even unpleasant, aspect of the face for a short time,
arising apparently from a brief spasmodic action of the muscles.