Part 37

When mice are placed in air containing 30 per cent. and upwards of vapour of amylene, they usually recover, as in the following experiment, if the breathing has not entirely ceased on their removal; whilst if they are placed for a quarter of a minute in air containing 8 or 10 per cent. of vapour of chloroform, they generally die, although they may be breathing well, and hardly insensible, when they are removed.

Experiment 53. Eighty grains of amylene were introduced into a jar holding 330 cubic inches, and when it had evaporated, a white mouse was introduced. In about five seconds it was quite insensible, and in about a quarter of a minute the breathing appeared to have ceased. The mouse was quickly withdrawn, and immediately began to gasp. After a few gasps the quick breathing returned. In half a minute after its removal the mouse was recovering, and it was soon quite well. There was 32 per cent. of vapour of amylene in the air in this experiment.

I administered amylene with the inhaler which I had used for several years in exhibiting chloroform, and which I have described in treating of that agent. In administering chloroform it is desirable that the patient should breathe 4 or 5 per cent. of the vapour in the air he inspires; and the air, when saturated with vapour of chloroform at 60°, contains 12 per cent., or nearly three times as much as the patient ever requires. In administering amylene for surgical operations, it is desirable that the patient should take in 15 per cent. of the vapour with the air he breathes; and air, when saturated with this vapour at 60°, contains 465. per cent., or fully three times as much as the patient ever requires. It therefore seemed reasonable that the inhaler which had answered so well with the former agent, might be employed in the same manner, and used successfully with the latter agent. Vapour of chloroform, when inhaled of twice the proper strength, i. e., of 8 or 10 per cent., is capable of causing sudden death by over-narcotism of the heart; but amylene is required to be of nearly 40 per cent., or more than twice the proper strength, before it could produce this result: and it seemed, therefore, reasonable to expect that the inhaler which had been employed for so many years with chloroform, might be employed in exhibiting amylene with an equally satisfactory result. And if the amylene furnished for inhalation had been a constant and uniform product, boiling steadily at the same temperature, like chloroform, there is no doubt that these expectations would have been fulfilled.

I first administered amylene, in King’s College Hospital, on the 10th of November 1856, to two boys, about fourteen years old, previous to Mr. Samuel Cartwright extracting some teeth. I had but a few drachms, and being very sparing of its use, it did not entirely remove consciousness in either case, and the pain was not altogether prevented: the effects, however, as far as they extended, were so favourable as to encourage a further trial, which was made in the same institution, on December 4.

On this occasion I exhibited the amylene to four patients—two men, a young woman, and a girl of ten years old: it occasioned complete unconsciousness and absence of pain in each case. The first man was about thirty-five years of age. Half a fluid ounce of amylene was put into the inhaler, and he inhaled for three minutes. At first the valve of the face-piece was about one-third open, but it was gradually moved till it was almost closed. The man breathed readily, without coughing, and in a very little time seemed to be unconscious. The pulse became quick and slightly irregular; the skin became flushed; and in about two minutes there was a rather free sweating of the forehead; the eyes did not turn upwards; the conjunctivæ did not become insensible; there was no relaxation of the limbs, and, on the contrary, no struggling. The patient sat well, supporting himself, without any tendency to slide out of the chair; the mouth was partly open, and there was a tendency to laugh, just as the amylene was discontinued. The tooth was extracted by Mr. S. Cartwright, without making him flinch or cry in the least. In less than a minute he awoke. He looked a little strange at first, but immediately remembered all the circumstances of his situation, but knew nothing of the operation; and, three minutes after the extraction of the tooth, and six minutes after entering the room, he went away feeling, as he said, quite well. The amylene put into the inhaler was nearly used.

A young man, about twenty years old, next inhaled the same quantity, in exactly the same manner, for just three minutes; there was no irregularity of pulse, and no sweating; otherwise the symptoms were exactly the same. The tooth was extracted without his knowledge, and without causing a cry or flinch. He awoke, and was able to go in three minutes.

A young woman in bad health, an out-patient of one of the physicians of the hospital, next inhaled. She breathed the amylene for four minutes, and about three drachms were used. The effect was carried to the commencement of the third degree of narcotism; and the eyes were inclined to turn up, but did not do so persistently. The edges of the eyelids also remained sensible. There was a little trouble and delay in getting the mouth open, as the muscles of the jaws were rather rigid; and when the tooth was extracted, she flinched, and cried out a little. She did not remember the operation. She said she had had a very unpleasant dream, and she was dizzy and uncomfortable for about ten minutes, after which she was better.

A little girl ten years old inhaled for four minutes, and between two and three drachms were used. The eyes were turned up for a short time. She did not flinch or cry as the first tooth came out, but did both as two others were afterwards extracted. She did not, however, know anything afterwards of the operation. She recovered her consciousness in a minute or two, and quite recovered from the effects of the vapour in a few more minutes. There was no sickness, and no increased flow of saliva, in any of the cases.

On December 11th, I administered the amylene again in five more cases of tooth-drawing, with very similar results to those obtained in the previous cases; and on December 13th, I exhibited it in some more important cases.

Mr. Fergusson performed an operation for fungus of the testicle; Mr. Bowman removed some diseased glands from the groin; and there were two cases of tenotomy, in one of which forcible extension of the knee was made.

From November 1856 to July 1857, I exhibited amylene in 238 cases. There 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.