Part 38

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.

I met with less rigidity and struggling during the administration of 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. 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.