amylene than in the use of chloroform; but this probably arose from the
circumstance that the effects of amylene were very frequently not
carried to that degree in which rigidity and struggling are liable to
appear. It is in the third degree of narcotism from narcotic vapours
that rigidity is met with in those cases in which it occurs, but the
greater number of the operations under amylene were performed in the
second degree of narcotism. The rigidity from amylene, when it occurs,
is of a somewhat different kind, and takes place in patients in whom we
should not expect it from chloroform. In the spasm and rigidity from the
latter agent, the head is more commonly bent forwards or turned to one
side, although it is occasionally thrown back; but under amylene, the
latter is the usual position it assumes when rigidity occurs,
constituting a brief opisthotonos. The rigidity under the influence of
chloroform is usually accompanied with struggling, while in that caused
by amylene the patient is generally quieter. The persons in whom
rigidity and struggling are most violent from the effects of chloroform
are lean, muscular men, who work at hard labour, or follow athletic
sports, such as hunting, and especially boating; while those who lead a
sedentary life, or are reduced by illness, seldom exhibit these
phenomena. Women and children seldom exhibit any rigidity under
chloroform, and fat persons least of all. Old people do sometimes,
especially if thin. Under the use of amylene, on the other hand, I have
most frequently met with some amount of rigidity in children and young
persons, while many robust men, in whom it would be almost certain to
occur under chloroform, have not shown any signs of it. The cause of
this probably is, that the operation has generally been performed
without carrying the narcotism beyond the second degree, while rigidity
does not take place till the third degree is attained. In every case
where rigidity and struggling have occurred in the employment of
chloroform, however violent these symptoms might be, I have continued
the vapour gently and steadily till they were subdued, either by
removing the tendency to these symptoms, or by carrying the narcotism to
the fourth degree, which is accompanied by relaxation of the voluntary
muscular system, and usually with some tendency to stertor. In the use
of amylene, on the contrary, I have not attempted to subdue the spasm by
continuing the inhalation, but have, with the exception of a case of
dislocation previously mentioned, withdrawn the vapour when the rigidity
appeared, and the operation has either been performed at once, or else,
if it was of a nature that the spasm would interfere with, I have waited
a short time, and exhibited a little more vapour very gently, so as to
get a state of anæsthesia without the recurrence of the spasm.
Mr. Jones, of Jersey, favoured me with the following account of a case
in which amylene acted much more favourably on his patient than
chloroform.
John D., æt. 41, stout and of very ruddy complexion, so injured his leg
that it was deemed advisable to saw off the fractured ends of the tibia.
Chloroform was at first given (March 16, 1857), but the effect it
produced, though administered with the utmost caution, was evidently of
so dangerous a nature, that it is more than probable that death would
have resulted had it been persevered in longer than five or six minutes
(the period it was employed). The patient became quite apoplectic, and
had two or three very severe convulsions. Amylene was at once
substituted, and with the happiest result. The patient appeared
conscious, but was not so, and the operation, which was a tedious one,
was commenced and finished without his experiencing the least pain,
indeed without his having the slightest knowledge that operative
measures had been resorted to.
Amylene differs widely from chloroform, and still more from sulphuric
ether, in the promptitude with which patients generally recover from its
effects. This is a character of amylene which might have been predicted
from its physical properties. I have many times observed how quickly,
and, indeed, almost instantaneously, small animals recover from the
stupor occasioned by certain permanent gases which are sparingly soluble
in watery fluids, as olefiant gas, carbonic oxide and carbonic acid
gases, nitrous oxide and the gaseous oxide of methyle. Now amylene is so
volatile as to approach to a permanent gas; at a temperature a little
above that of the human body it would be a gas, and the vapour is very
sparingly soluble in watery fluids, and consequently in the blood.
Sulphuric ether is, indeed, as volatile as amylene. I cannot remember
any other two bodies whose volatility is so nearly alike; but sulphuric
ether is very soluble in watery fluids, in comparison with amylene.
Water dissolves a tenth of its volume of liquid ether, or 23 volumes of
the vapour. Consequently a large quantity of ether is absorbed during
inhalation, and the blood has to pass many times through the lungs
before it is freed from it. The quantity of amylene which is absorbed
is, on the contrary, extremely small, as I have explained above, and
this, together with its volatility, is no doubt the reason why the
patient recovers so promptly from its influence. In about a minute after
the operation is concluded, and the inhalation left off, the patient
usually awakes from the influence of amylene, and completely recovers
his consciousness. The same quick recovery may take place after
chloroform, but more frequently it is a few minutes before the patient
is quite conscious. I have seen two or three instances in which a child
has slept for twenty minutes or half an hour after amylene, but it must
be remembered that children sometimes sleep for hours after chloroform
in cases where the operation has not produced a painful wound. The quick
recovery of the patient is a decided advantage in all minor operations.
In great operations, where the patient is obliged to keep his bed
afterwards, it is of less consequence whether he wakes promptly or not,
although, even under these circumstances, his friends are generally
anxious to see him recover his consciousness. The smarting of the wound
after an operation is often prevented longer when chloroform has been
employed than after the use of amylene, and this may be considered as a
slight advantage which chloroform possesses in certain cases. In some
instances, however, in which chloroform has been used, the patient
begins to show symptoms of suffering pain in the wound before he has
entirely recovered his consciousness, while after amylene I have not
seen symptoms of pain in the wound till consciousness had completely
returned. In any cases where the pain after an operation, either from a
wound or ligatures or caustic, is very great, the inhalation of the
agent which has been employed may be gently repeated at times until the
pain has a tendency to subside, or till an opiate shall take effect.
The patient generally seems surprised or confused on first recovering
from the effects of the amylene, but in a few seconds he becomes, in
most cases, completely conscious of his position, and feels that his
mind has been wandering. He often says he does not know where he has
been in his dreams, or that he has been a long way. Sometimes he does
not remember exactly what he has dreamed about; at other times he does.
All this is common enough after chloroform, except that the process of
recovery is generally much slower; but there is one condition of mind
which is very common after chloroform, which I have rarely met after
amylene, I allude to that condition in which the patient asserts that
the vapour has not taken effect, and that he has not been asleep at all.
Amylene appears to support the pulse under loss of blood at least as
well as chloroform. I have not found the pulse to fail, although there
was rather free hæmorrhage in some of the operations.
There has been a little headache in a few of the cases as the effects of
this agent were subsiding, but it passed off in a few minutes.
In administering amylene, the vapour must be given of such a strength as
will cause insensibility in about three minutes, or it will not succeed
at all unless the strength of the vapour be altered. In giving
chloroform, the vapour may be of less than half the desirable strength,
and by continuing more than twice the usual time, the patient may be
rendered insensible; and in using sulphuric ether, the vapour may be
breathed of one-seventh the proper strength, and by continuing it
constantly for seven times the usual period, _i. e._, for half an hour,
the patient might be rendered insensible; but in using amylene, time
will not make up for deficiency in the strength of the vapour. If the
vapour be not strong enough to cause insensibility in about three
minutes, it might be breathed for an indefinite period without causing
insensibility; and the patient is solely affected by what he has inhaled
within two or three minutes.
On account of the very rapid subsidence of the effects of amylene, it
requires to be very frequently repeated during the performance of an
operation. The patient generally requires to inhale a little of it every
half minute or so to keep up its effect. On this account, it is not well
adapted for certain operations on the face. I did, however, administer
it with complete success in several operations on the face in King’s
College Hospital. Amongst these, there were four operations by Mr.
Fergusson for making a new nose in which I administered amylene, and
succeeded in preventing the pain by holding a hollow sponge, wetted with
that agent frequently, near the mouth and nose.
In cases of tooth-drawing, in which a number of teeth or stumps have to
be taken out, the effects of the amylene are apt to pass off before the
operation is completed, and the inhalation has to be repeated once or
twice, but in cases when only one or two teeth require to be extracted,
amylene has a great advantage in the promptitude with which the patient
recovers from its effects. There is occasionally some difficulty in
opening the mouth with amylene, as with chloroform.
The patient has nearly always a very cheerful expression of countenance
when he recovers from the amylene, and the state of his mind, as
indicated by his conversation, corresponds to his look. Dr. Debout has
noticed the same circumstances. Speaking of the patients operated on
under amylene in Paris, he says, “A leur réveil et le premier moment de
stupeur passé, leur physionomie est épanouie.” The same state of
countenance and mind is met with after chloroform only now and then, and
is by no means the rule.
Hysterical symptoms occurred in a few women after operations under
amylene. They were met with about as frequently, I think, as after
chloroform. These symptoms generally subsided in a few minutes; but in
one or two young women in the hospital, they lasted nearly an hour.
The greatest advantage that amylene possesses over ether and chloroform,
is the great infrequency with which it excites sickness. I only saw
vomiting occur in two of the 238 cases in which I administered amylene,
although it occurred before I left the patients’ room in twenty-two
cases out of 100 in which I administered chloroform and kept an account
of this symptom, at the time I was using amylene. In the greater number
of the cases in which chloroform was exhibited, the patients had been
requested not to take a meal; whilst in the cases in which amylene was
administered, no directions regarding diet had as a general rule been
given.
I made subsequent inquiries respecting most of the patients who inhaled
amylene, and I was only able to hear of sickness in eight or ten cases,
and it was not distressing or troublesome in any of these. It generally
occurred three or four hours after the amylene, and subsequently to the
patient taking his first meal after the inhalation. In one of the two
cases in which vomiting occurred after amylene before I left the room,
there was retching for four hours; but I did not hear of so much
sickness after any other case in which I administered this agent; and
there was no faintness or depression either in this case or any other in
which amylene was employed, although faintness and depression often
accompany the sickness which is occasioned by chloroform. Some of the
patients who inhaled amylene without being sick, had previously suffered
from sickness after inhaling chloroform. I administered amylene, on
January 30th, 1857, to a lady, about twenty-five, whilst Mr. Bowman
operated for strabismus, and there was no vomiting or sickness, either
at the time of the operation or afterwards; but the same patient had
undergone a similar operation a week previously, when chloroform was
administered, and on that occasion vomiting commenced before the
operation was finished, and recurred every quarter of an hour, with
violent retching, for twelve hours.
I had the misfortune to lose two patients from the inhalation of
amylene. The following are the particulars of these cases.
Mr. Fergusson requested me to assist him on the 7th of April, 1857, in
the case of a gentleman on whom he was about to operate for fistula _in
ano_. The patient was thirty-three years of age, and was in good health,
with the exception of the local complaint, although he had lived
somewhat freely. Mr. Fergusson examined the patient’s chest the day
before the operation, and found the sounds of the heart to be normal. I
felt his pulse just before he began to inhale. It was natural, but
somewhat accelerated, as usually happens just before an operation. He
was lying on his side in bed. About six fluid drachms of amylene were
put into the inhaler (I never intentionally used all I put in, but added
more before the paper became dry), and he breathed steadily and gently.
The valve was gradually advanced over the opening in the face-piece till
it about three-quarters covered it, and the patient appeared to become
quietly unconscious in about two minutes. He breathed quickly for a few
inspirations just as he appeared to become unconscious. Just after this,
Mr. Fergusson came and felt the patient’s pulse, and he says it was very
good. I felt it also. I looked at my watch at this time, and it was two
minutes and a half or two and three-quarters from the beginning of the
inhalation. Mr. Fergusson commenced to use the probe, and, finding the
patient did not flinch, he began to use the bistoury. Mr. P. C. Price
assisted at the operation. I held the patient’s thigh with one hand, as
I often do in such an operation, lest he should flinch. He did not
flinch, however, but kept his limbs tense, without moving them. Just at
this moment, I observed that the valve of the face-piece, which I had
left three-quarters covering the opening, had moved so as to cover it
entirely, but I cannot say whether or not the patient had taken an
inspiration a little stronger than I intended, and thought nothing of
the matter, as I have frequently had to close the valve completely in
giving amylene. It could not, however, have been many seconds in that
position, for I paid no attention to the operation, except so much as
was requisite to guide me in what I was doing. The inhalation was
discontinued at the moment I have mentioned, and on looking round
directly after, I found that the operation, which had apparently been
but one incision, was finished. I now began to feel for the pulse, more
out of constant habit, and from a scientific curiosity, than from any
supposed necessity of doing so. Although it had been good only half a
minute before, I could not find it in the left wrist, and only a slight
flutter in the right one. His breathing was, however, good, indeed quite
natural, and he did not seem even to be very insensible, for there was
some motion both of his features and limbs, as if he were about to
awake. I watched the patient with great anxiety, thinking that surely
his good and natural breathing would restore the pulse, and feeling that
at all events this superseded any other measures at the moment. In two
or three minutes, however, he seemed to be getting more insensible; he
did not wink on the edge of the eyelids being touched, and the breathing
was getting slower and deeper. I called Mr. Fergusson’s attention to the
patient, and both he, who was preparing to go away, and Mr. Price, who
had all the time been standing by the patient, were surprised to find
that anything could be wrong, as they had seen the patient going on
apparently so well, not only during the inhalation, but after it was
discontinued. They dashed cold water in his face, which did not seem to
have any effect. His countenance was now livid, and his breathing of a
gasping character. It soon began to leave off, with the exception of
deep, distant, gasping inspirations, and we therefore began to perform
artificial respiration, by Dr. Marshall Hall’s method, placing him in
the prone position, and bringing him partly round, while Mr. Price kept
the mouth open. The air could be distinctly heard passing through the
larynx during this motion. We also tried pressing on the chest with the
head on one side and the mouth open, which answered very well as
regarded the ingress and egress of air. Inflation from mouth to mouth
was tried, but did not seem to answer so well. Although deep gasping
inspirations were made by the patient till fully ten minutes had elapsed
from the failure of the pulse, the measures used had no effect; I
believe that I heard a feeble motion of the heart even after this
period; and, as Mr. Fergusson perceived a slight pulsation at the same
time in the right wrist, I was probably not mistaken. There were no
further signs of life after this, although the artificial respiration
was continued for a long time. I am quite sure as to the length of time
respiration continued after the failure of the heart’s action. The pulse
ceased to be distinctly perceptible at ten minutes before five, and the
patient was still breathing at five o’clock. He had not taken food for
some hours, but drank a pint bottle of ale a little while before the
operation. A good portion of amylene remained in the inhaler after it
had been uncovered for an hour and a half.
There was an examination of the body forty-eight hours after death. The
body was rigid. There was a good amount of fat beneath the integuments.
The cartilages of the ribs were ossified. The lungs were large, and did
not collapse; they completely filled the cavity of the chest, and seemed
by their texture to be emphysematous, although there were no large cells
on the surface. There was a little congestion at the posterior surface
of the left one, otherwise they were not very vascular. There was a
little clear fluid in the pericardium. There was a good deal of fat on
the surface of the heart, which was somewhat larger than natural. It was
removed by cutting the great vessels before it was opened, and in
removing it three or four ounces of dark-coloured fluid blood escaped.
The right ventricle was somewhat dilated, otherwise the heart was
healthy; the walls of the left ventricle seemed very thick, but it was
contracted, so as almost to obliterate the cavity. The liver was
vascular, dark-coloured, and friable. The stomach was healthy, and
contained only a little mucus. The other organs were not examined. There
was no odour of amylene in the body.
I believe the patient had emphysema of the lungs. There was no such
force used in the artificial respiration as could permanently dilate the
air-cells, and the dilatation of the right ventricle indicates some
chronic obstruction to the pulmonary circulation.
The other death from amylene occurred in St. George’s Hospital on July
30th, 1857, in a case in which Mr. Cæsar Hawkins removed a small
epithelial tumour from the back. The patient, a short, muscular man, was
a tailor, twenty-four years of age, who had been in the Hospital several
months, and had had three similar tumours removed, by as many
operations, under chloroform; the last of these operations having been
performed three weeks previously. He inhaled the amylene without any
difficulty; in about two minutes he appeared to be unconscious, and, in
another minute, the sensibility of the margin of the eyelids was
somewhat diminished, and I told Mr. Hawkins that he might perform the
operation. For this purpose the patient, who had been lying on his side
on the table, was turned a little more on his face, or at least it was
attempted to turn him, when he burst out into a kind of hysterical
excitement, laughed loudly, and was with difficulty held on the table.
Nothing was done during this excitement, which lasted about a minute.
After it had subsided, I administered a little more amylene, although
the patient had not recovered his consciousness; and then Mr. Hawkins
performed the operation, which I believe did not last more than two
minutes altogether. During the operation, the patient was turned on his
face. He rested, I think, chiefly on his knees and elbows. He was
muttering in an incoherent manner, and making slight attempts to move,
but was easily restrained. I gave him an inspiration or two of amylene
now and then during the operation, with the intention of preventing his
waking prematurely; for this purpose, I turned the head a little to one
side, and raised the face a little from the table.[176] I had concluded
that the patient would not require any more amylene, and was expecting
that he would show signs of returning consciousness or sensibility
almost as soon as Mr. Hawkins had tied the suture which he was
introducing; but, instead of this, the limbs became relaxed, and the
breathing, though free enough, took on a noisy, snoring character.
This is a state which is common enough in the use of chloroform, and
excites no alarm whatever, but I felt that it ought not to occur in the
use of amylene, especially after it was left off. I therefore sought
again for the pulse at the wrist, and could perceive it only with
difficulty, if at all. I spoke to Mr. Hawkins, and we immediately turned
the patient on his back. His face had already become livid, and his
breathing was of a gasping character. Mouth to mouth insufflation of the
lungs was performed, and between the insufflations there were
spontaneous acts of inspiration, during which the air seemed to enter
the lungs freely. In a minute or two, the lips became of a proper
colour, and the countenance had altogether such a natural aspect that
the patient seemed to be recovering. The pulse at the wrist, however,
could not be felt. No one listened to the chest at this time, for fear
of interrupting the process of artificial respiration. After two or
three minutes, Dr. Marshall Hall’s method of artificial breathing was
substituted for the insufflation, and it was continued very perfectly by
the house surgeons and others for an hour and a half, with the exception
of two short intermissions, which will be mentioned. During
three-quarters of an hour of this time, there were spontaneous
inspirations, during which air entered the lungs, in addition to that
which entered during the turning process. Twenty minutes after the
accident, the process of artificial respiration was suspended for about
a quarter of a minute, to enable me to listen to the chest. I thought I
could hear the heart beating regularly, but very feebly, and certainly
there was a good vesicular murmur, and the air seemed to enter the lungs
by the patient’s own breathing, almost as freely as in health. At the
end of three-quarters of an hour, with the permission of Mr. Hawkins, I
introduced two hare-lip pins which had been connected with the
electro-magnetic battery, with the intention of performing
galvano-puncture of the heart. The needles were introduced to the depth
of about an inch and a half between the cartilages of the ribs, just to
the left of the sternum, and on a level with the nipple. They were
afterwards found to have penetrated the walls of the left ventricle,
near the septum, but without reaching the cavity. There was a quivering
contraction of the pectoral muscle when the needles were first applied,
but no effect on the heart. The needles ought probably to have been
coated with some non-conducting substance almost as far as their points.
There were no further efforts of inspiration after this time, but this
was probably only a coincidence. The electro-magnetic battery had been
applied in the early part of the treatment by means of the wet sponges
applied to each side of the chest, but it produced no effect.
An examination of the body was made by Mr. Holmes, the Curator of the
Hospital Museum, on the following day. A good deal of dark-coloured
fluid blood flowed from the right cavities of the heart, and the left
cavities contained but little blood. The heart was pale and somewhat
friable; but a microscopic examination by Mr. Holmes did not show any
fatty degeneration. The lungs were moderately vascular, and contained
some small epithelial tumours of the same character as those removed
from the back. There was a large cyst in one kidney; but, with these
exceptions, the organs were healthy. The vessels of the brain were not
distended, and that organ was altogether less vascular than is usual
after sudden death. No smell of amylene was perceived in the body.