Part 34

On June 18th, 1847, I exhibited, in University College Hospital, ether to a man, aged forty-two, with stricture of the urethra, caused by an accident. He passed his urine only in drops, and the attempts to pass a catheter had all failed. It was Mr. Liston’s intention to divide the urethra in the perinæum, but when the patient was placed fully under the influence of ether to the fourth degree of narcotism, a catheter (No. 1) passed into the bladder, and the operation was not required. Larger catheters were introduced in a few days, and on July 27th, the patient was discharged, being able to pass his urine in a good stream.

Ether was administered in many cases of midwifery by Dr. Simpson, who had first applied it in obstetric cases, and by a number of other practitioners. I only exhibited it in one case, and then only for a short time. Mr. Lansdown of Bristol used it in thirty cases. In one case, it was continued for eleven hours and a half, and fourteen fluid ounces of ether were used. He said that he invariably found the perinæum relaxed before the head came to bear on it, thereby not requiring the pressure of the head to force it open, in cases where ether was used. He says: “I find the uterus sending out the placenta immediately after the expulsion of the child, and there has been scarcely any hæmorrhage following.” Mr. Lansdown said that he had found the action of the uterus to be induced by ether, when in a sluggish state, but he had not found this effect from chloroform, in the cases in which he had used it.

Ether was used with great advantage in most of the kinds of medical cases in which chloroform was afterwards applied. In the summer of 1847, an infant, nine months old, was brought to me in a convulsive fit, which had lasted twenty minutes. I poured twenty minims of ether on a sponge, and applied it to its mouth and nostrils; in two or three minutes, the quantity was repeated. The spasm subsided, and the child fell asleep. It had no return of the fit. It was labouring under hooping-cough at the time, which had existed a week.

The inhalation of ether was employed in the treatment of asthma, hooping-cough, and tetanus, before it was employed in surgical operations. It has been already stated (page 14) that Dr. Richard Pearson administered the vapour of ether in consumption in 1795. Dr. Robert Willis sent an article to the Medical Gazette on February 2nd, 1847, in which the following passages occur.

“Ether, given by the mouth, has long been familiarly employed in the treatment of asthma. I have for many years been aware of the fact that it is vastly more efficacious administered directly in vapour by the breath. My plan of using it is extremely simple. I have had recourse to no kind of apparatus for this purpose, but have been content to pour two, three, or four drachms of the fluid upon a clean handkerchief, and to direct this to be held closely to the mouth and nostrils: a single short and difficult inspiration is hardly made before the effect is experienced; and I have occasionally seen the paroxysm ended in six or eight minutes, the respiration having in that brief interval become almost natural.

“It is not otherwise with hooping-cough: the paroxysms of coughing are positively cut short by having the ether and the handkerchief in readiness, and using them when the fit is perceived to be coming on.”

I have been informed of a case of tetanus which was treated successfully by inhalation of ether more than twenty years before this medicine was used to prevent the pain of operations, but I am not able at present to give a reference to the case. Mr. C. A. Hawkesworth, surgeon, of Burton-on-Trent, wrote me an account of a case of tetanus, which had recovered under the inhalation of ether in 1847. The patient was a healthy-looking butcher’s boy, about twelve years old, who had received a slight scalp wound, which was followed by general tetanus. Mr. Hawkesworth administered the vapour of ether to him during the greater part of one day. The spasm relaxed most completely whilst the influence of the ether continued, but returned in great degree when the inhalation was intermitted. He took no other medicine except calomel and jalap, with a view to purgation; the calomel, however, acted on his mouth. He recovered speedily and completely. Some other cases of recovery from tetanus under the inhalation of ether have been recorded in the medical journals.

In February, 1847, Dr. Sibson related several cases of facial neuralgia that had been greatly benefited by the inhalation of ether; and it has been used in many cases since.

The inhalation of ether causes an increased flow of saliva in many cases; quite as frequently, in fact, as chloroform. Vomiting also follows the use of ether quite as often as that of chloroform. The insensibility from ether lasts longer than that from chloroform without repeating the inhalation when the narcotism is carried to the same degree. When the narcotism from ether is carried to the fourth degree there is generally a complete absence of pain for three minutes, and a state of unconsciousness for five minutes longer, a period during which any pain there might be would not be remembered afterwards. On account of this longer duration of the effects of ether, it is better adapted than chloroform for certain operations on the face, as removal of tumours of the jaws, the operation for hare-lip, and making a new nose. The relaxation of the muscular system from the effects of ether seems greater in general than from chloroform, and ether therefore seems to be the better agent to employ in the reduction of old dislocations, and strangulated hernia.

Great safety of Ether. I believe that ether is altogether incapable of causing the sudden death by paralysis of the heart, which has caused the accidents which have happened during the administration of chloroform. I have not been able to kill an animal in that manner with ether, even when I have made it boil, and administered the vapour almost pure. The heart has continued to beat after the natural breathing has ceased, even when the vapour has been exhibited without air; and in all cases in which animals have been made to breathe air saturated with ether vapour, at the ordinary temperatures of this country, they have always recovered if they were withdrawn from the vapour before the breathing ceased. Even in cases where the natural breathing had ceased, if the animal made a gasping inspiration after its removal from the ether it recovered.

I hold it, therefore, to be almost impossible that a death from this agent can occur in the hands of a medical man who is applying it with ordinary intelligence and attention.

I am only aware of two deaths which have been recorded as occurring during the administration of ether, and it is not probable that the death in either case was due to the ether. The first of these cases occurred in France, at the Hotel Dieu d’Auxerre, on July 10th, 1847. The patient was a man fifty-five years of age, who had a cancerous tumour of the left breast of seven months duration. He was robust, and had no general lesion resulting from the cancerous disease. The ether was exhibited with the apparatus of Charrière. The patient had hardly inhaled two or three minutes when he became strongly excited. The trunk and limbs were agitated with violent starts and shocks. The breathing became frequent, and the face injected. He endeavoured to push away the inhaler, and babbled as if drunk. This state lasted for five minutes, and the prick of a pin showed that sensibility still remained. The apparatus was still applied, but in opening to the ether vapour an issue as large as the instrument permitted; for the tap which gave passage to it had hitherto been but half turned, and that progressively. At the end of ten minutes from the beginning of inhalation, the relaxation and immobility of the limbs was complete, the insensibility was not doubtful, the respiration was deep, gentle, but free from râle. The muscles of the face had ceased to be agitated, and it was of a violet red colour, as was also the skin in front of the chest; the pupils were turned upwards, dilated and immovable.

The apparatus was taken away, and the operation was commenced; but the incision had only given issue to a small quantity of black blood, when it was perceived that the features were altered and become entirely violet, and that the respiration was extremely feeble. The pulse, touched on this moment for the first time, was soft, full, and very slow. All at once it ceased to beat.

Twenty-four hours after death, all parts of the body yielded a strong odour of ether. The blood was deep black, fluid, and rather viscous. The blood which gorged the back part of the lungs had a consistence and colour somewhat like treacle. The mucous membrane of the bronchi, trachea, and larynx was very much congested. The spleen was so softened in its interior as to resemble the lees of wine.

This patient appears to have died rather from the want of admission of sufficient air to the lungs than from the effects of ether. The apparatus was applied without intermission, long after the face became injected, and was kept applied till it became of a violet colour. The pulse was not felt till the patient was dying. Artificial respiration was not attempted, although it would most likely have restored the patient.

The other death which happened whilst the patient was under the influence of ether took place at the Hotel Dieu de Lyons, on September 11th, 1852. The patient was a woman, aged fifty-five, but looking much older. She was affected with a tumour of the superior maxillary bone, and was weak and in a bad state of general health. M. Barrier was reluctant to remove the tumour, but yielded to the entreaties of the patient. The ether was administered from a sponge placed in a bladder, and the patient was quickly put to sleep. M. Barrier had made the incisions in the face, and had just divided the ascending process of the jaw, when the breathing stopped. There was no pulse at the wrist, and it was doubtful whether there was any at the precordial region. The patient was placed horizontally, and artificial respiration and other measures were applied, but without success.

This patient evidently died of hæmorrhage; the mode of death which M. Barrier must have been dreading, as we perceive from his reluctance to perform the operation. According to the result of my experiments on animals, ether is not capable of causing the kind of death which this patient died.

There were three or four cases in which ether was blamed by the operating surgeons for causing the death of patients, who recovered from its effects, and, died some days, or at least hours, afterwards. The nature and circumstances of the operation were sufficient to account for the fatal result in each of these cases, whilst the extended use of ether has confirmed the opinion that it cannot be the cause of deaths which occur days, or even hours, after its use.

On Friday, the 12th of February, 1847, Mr. Roger Nunn performed lithotomy, in the Colchester Hospital, on a man who, as it was found after his death, had disease of the kidneys. The ether seemed to act favourably. Mr. Nunn says: “There was neither difficulty nor loss of time in cutting into the bladder; but having done so, some little delay occurred in grasping the stone, which was small, very flat, and lying in the posterior part of the bladder; the delay was also increased by the extremely relaxed state of the bladder itself, which seemed to fall in folds on the forceps, and to cover the stone.” This delay in grasping the stone is attributed by Mr. Nunn to a collapsed state of the bladder caused by the ether, but it can only have arisen from the fact of the urine having escaped from the bladder, before the stone was seized. The small vessels divided in making the first incision showed much inclination to bleed, and Mr. Nunn secured them immediately after the patient was put to bed.

Speaking of his patient and the ether, Mr. Nunn says: “He recovered from its effects after a short time, and continued in a quiet passive state, but without decided reaction for twenty-four hours. At this period he had a chill, which lasted for nearly twenty minutes.” Stimulants were given, but without much effect. The patient seemed incoherent from eight o’clock P.M. of Saturday till nine A.M. of the following day. From this time he gradually sank, and died at five o’clock P.M. of that day, Sunday, being sensible to the last.

On March 9th, 1847, Mr. Wm. Robbs, of Grantham, removed an osteo-sarcomatous tumour from the back part of the left thigh of Ann Parkinson, a married woman, aged twenty-one, the mother of one child. Mr. Robbs tried to make his patient insensible with ether, but did not succeed. He says, indeed, that in about ten minutes its usual effects were produced; but these could not have been its full and proper effects; for he says, “she appeared quite sensible to the pain during the whole of the operation.” It is reported that she appeared to feel the first cut. Mr. Robbs says that during the early part of the operation, the patient “cried out much, complained, and writhed in great agony of pain.” The operation was begun by an incision commencing midway between the tuberosity of the ischium and the trochanter major, and extending about six inches down the thigh. The fascia was next divided, and the muscles were next separated with the handle of the scalpel, so as to expose the upper surface of the tumour. After this had been done, the inhaler was replaced to the mouth of the patient whilst the operation proceeded, but the ether appeared to take no effect. The tumour was “very adherent to the long head of the biceps flexor cruris, which nearly covered it anteriorly, while posteriorly it rested on the sheath of the great sciatic nerve. It took its origin from the common tendon of the flexor muscles, close to the tuber ischii, and was inserted into the short head of the same muscle just below its origin.” Mr. Robbs says: “The dissection was protracted longer than I expected, from the violent contractions of the muscles, and the struggles of the patient.” He estimated the time occupied in the operation at twenty-five or thirty minutes; and the sister-in-law of the patient, who gave her evidence at the inquest, expressed her opinion that the operation lasted an hour all but five minutes. At the end of the operation, the patient appeared very faint, and the pulse was very rapid and feeble. The patient remained much depressed, with a pulse of 140 in the minute, small, and without much power, having her intellect perfect; she died forty hours after the operation.

A coroner’s inquest was held, but neither the coroner nor any of the jury appeared to have any knowledge or suspicion that a surgical operation on the thigh could possibly be the cause of death. A surgeon who gave evidence stated, that “the shock from the operation was not simply the cause of death, as the seat of the disease was not essential to life.” The verdict was, that the death of deceased was caused by the inhalation of ether; and that no blame was attached to the surgeon, as ether had been used and recommended by eminent medical men.

I cannot tell whether Mr. Robbs would have undertaken the operation if ether had not been about to be used, but if he had undertaken it without ether, one may presume that he would have done what every surgeon does who undertakes a great operation, that he would have informed the patient and her friends that it would be attended with some amount of danger. In his communication to the Medical Gazette, Mr. Robbs complains of the friends of his patient having thought it necessary to obtain a coroner’s inquest; but he has himself to blame for that. After he had attributed the death entirely to a new agent, which had been given with a view to prevent the pain, and had entirely failed even in that, it was very natural that they should seek for a legal investigation of the affair.

Mr. Robbs makes no admission that the pain his patient suffered could be due to any defect in the administration of the ether. He states, that he “was quite unprepared for that perfect state of prostration of the brain and nervous system which it appears in this case to have induced”. The fact of the patient crying much, and complaining, and writhing in great agony of pain, and the contraction of the muscles, and the struggles which protracted the operation, do not look like a prostration of the brain and nervous system. At the end of the operation she was, to be sure, prostrated by its long duration, and the great loss of blood which must have occurred; but her brain and nervous system were not so much affected as the vascular and muscular system. She spoke of the operation as having been very severe, and she retained her mental faculties perfectly to her death. Ever since 1818 many of the students at lectures on chemistry had inhaled the vapour of ether to quite as great an extent as Mr. Robbs’ patient.

As a proof how far the feelings will suspend both reason and common sense, it may be mentioned that some of the medical men, who were strongly opposing the use of ether in 1847, did not hesitate to allude to the inquest in this case, as showing that ether had caused the death of a patient.

Mr. Eastment, of Wincanton, Somersetshire, related a case in which he attributed the death of the patient to ether. It was apparently the first time he had seen ether employed on the human subject; and with a larger experience of its effects, he would no doubt alter his opinion respecting the cause of death in the case he related.

A boy, aged eleven years, became entangled in the machinery of a mill, about eight A.M., on February 23rd, 1847, in consequence of which he sustained a very severe compound fracture of the left thigh, with great laceration of the soft parts, and a simple fracture of the right thigh. The surgeons in attendance waited till four P.M. for the boy to recover from the shock of the injury, and then performed amputation of the left thigh. Ether was given, but so badly, that the patient’s sufferings were so severe on the circular incision being made, that it appeared to be a complete failure. The inhalation was repeated, however, and the pain of the latter part of the operation was prevented. The patient died three hours after the operation, being in a state of great exhaustion, with occasional mental excitement, during the three hours.

This patient’s chance of life would probably have been improved if the ether had been more effectually given, so as to prevent all the pain of the operation; but I believe that his chance of recovery would have been most improved by administering the ether soon after the accident in the morning, which would most likely have removed the collapse, and enabled the surgeon to perform amputation at once, and thus have prevented the eight hours suffering and depressing effects of the great laceration of the thigh.