Part 39

The continuance of the respiration so long after the heart was paralyzed in these two cases, and especially in the second one, is a remarkably curious event. The respiration continued after the heart had ceased to act in several cases of death from chloroform, but not for so long a time as in these deaths from amylene. It is probable that there must have been some little circulation going on through the brain whilst the respiration lasted, and in fact, the slight fluttering pulse and feeble sounds of the heart, once or twice perceived, indicate that the circulation was not absolutely arrested. Under these circumstances, we may inquire why the action of the heart does not recover. If the circulation were going on in the coronary arteries, it might be expected that the blood from the lungs, which has been aerated by respiration, and freed from the narcotic vapour, would restore the action of the heart. But it is probable, for the reasons stated at page 262, when treating of accidents by chloroform, that the circulation through the coronary arteries is arrested.

The accident clearly commenced at the heart in both these cases, and I believe that the brain was never more than partially under the influence of the amylene in either of them. In the Medical Times and Gazette of July 25th, 1857, M. Devergie is related to have expressed an opinion in the Academy of Medicine of Paris, that the first of the above deaths from amylene was caused, in great part, under the influence of true asphyxia, using that term in its modern acceptation. Now that is altogether an error, arising, probably, from M. Devergie not having seen any original account of the case. There was no cause of asphyxia, either internal or external; the patient breathed well until after his heart had ceased to beat, unless in the most feeble and doubtful manner. The valve which was closed only altered the direction, but not the amount of air. In fact, the patient was throughout supplied with as much air as could enter through a tube twice the size of his windpipe.

I had scarcely any hope of the patient in St. George’s Hospital from the very commencement of the accident; for I felt that if he could be recovered by artificial respiration, his own breathing would have remedied the accident, even before it was discovered. From what has been published respecting the pulse sometimes stopping and commencing again, during the inhalation of chloroform, it is probable that many accidents, in which the heart has been nearly paralysed, have happened, and rectified themselves, without attracting much notice.

I have no doubt that in each of these accidents the patient must have taken into his lungs at one moment air containing upwards of thirty per cent. of vapour of amylene. And there is no doubt that the cause of this was the unsteady boiling point of the agent. If the amylene with which I was supplied had boiled steadily at the same temperature, there is no doubt that the means which I was employing, and which had enabled me for ten years, whilst exhibiting chloroform, to give four per cent. of the vapour, probably without ever allowing the quantity to exceed six per cent., would have enabled me to give fifteen per cent. of vapour of amylene without permitting the quantity to exceed twenty per cent.

The alteration in the boiling point of a specimen of amylene from 86° to 115° Fah. would cause it to give off more than twice as much vapour in the beginning of its evaporation as towards the end; and, moreover, the different specimens of it did not always possess the same amount of volatility.

The temperature of the external air as it influenced that of the water-bath of the inhaler would have some influence over the evaporation of the amylene, but I altered the amount of evaporating surface of paper according to the season of the year for amylene, as I was in the habit of doing for chloroform. The highest temperature of April 7, the day on which the first accident happened, was at Greenwich, according to the Report of the Astronomer Royal, 62°; and on July 30, the day on which the second accident happened, was 78·7°. After the first accident, I had reduced the surface of bibulous paper in the inhaler to one-half of what it had previously been.

The first of the above accidents happened in the 144th case in which I administered amylene, and the second in the 238th case. In the ninety cases and upwards in which I administered amylene between these two accidents, I never had occasion to feel a moment’s uneasiness about it.

In the future cases in which I employ amylene, it is my intention to administer it from a bag or balloon, putting in so much of the liquid as will make fifteen per cent. of vapour when the bag is filled up with air. In this manner, the variability in the boiling point of the amylene can have no influence whatever on the amount of vapour which the patient breathes; and if the vapour be breathed over again, within certain limits, in the manner of nitrous oxide gas, there will be a great saving in the amount of amylene consumed.

In my first paper on amylene, which was read on January 10th, 1857, I said: “While I cannot venture to predict for it the absolute safety which seems to attend sulphuric ether under all circumstances, I trust that it will be perfectly safe with careful management” And I added further on, “It is my opinion that the cold produced during its evaporation would, in all the ordinary methods of inhalation, prevent the air from taking up a quantity of the vapour which would be dangerous.”

Although amylene was largely used in Paris, Strasbourg, Montpelier, and Lyons, soon after I published my first account of it, and although I have lately heard that it is still employed in Paris and Berlin, nearly eighteen months after its first use in these places, I am happy that I have not heard of any accident from its use except the two which happened in my own hands.

M. Giraldis, of Paris, who was present at the operating theatre of St. George’s Hospital when the accident happened at that institution, had already employed amylene in 100 cases in children, and I believe that he continues to use it. Given on a handkerchief or sponge, I believe that amylene is safer than chloroform, owing to the greater cold produced during its evaporation, and the limit thereby put to the amount of vapour which is given off; but I have seldom given it in this manner, as I do not think it would be certain and regular in its action, and any doubt on these points would, with me, have quite overbalanced its other advantages. In applying amylene on a sponge, M. Rigaud of Strasbourg used 100 grammes (between four and five fluid ounces) in making an adult patient insensible, although half a fluid ounce suffices with the inhaler I employed.

Mr. Clarke, of Bristol, in a paper which he published on amylene, says: “It seemed impossible to get too much into the system, and with this I have been greatly impressed; it is this fact that appears to me to promise an immunity from danger.... It requires to be given almost unintermittingly, and requires the same amount of attention to keep up its effects as chloroform does to keep the patient safe. The direction of the attention, however, is one less calculated to give anxiety.”

Dr. Debout stated, as the result of some experiments on animals, in which he was assisted by M. Duroy, that if it sufficed to double the quantity of chloroform in order to transform the anæsthetic dose of that agent into a poisonous dose, it was necessary to quadruple that of ether, and to quintuple that of amylene, in order to arrive at the same result; and that, therefore, the innocuousness of the new agent was still greater than that of sulphuric ether.

In a paper which Professor Tourdes, of Strasbourg, read before the Academy of Medicine of Paris, he came also to the conclusion, from a series of experiments and observations, that “amylene was evidently much less dangerous than chloroform, perhaps even than ether.”

According to my experiments, amylene ought to be placed between chloroform and ether in respect to its comparative safety by the ordinary methods of administration; and by breathing it from a bag, in the manner previously mentioned, it would be absolutely safe, so long as the right quantity were put into the bag.

Papers on amylene were read to the Academy of Medicine of Paris by Dr. Debout and M. Tourdes, and were reported on favourably. M. Giraldis afterwards presented a paper in which he stated the very favourable result of seventy-nine cases in which he had employed it. The Academy on this occasion recommended the disuse of amylene on account of the accidents which had happened in my hands, apparently overlooking the circumstance that M. Giraldis himself had been much more successful in the use of amylene than in that of chloroform. M. Jobert de Lamballe, the reporter of the Commission, stated that amylene deprived the blood of its red colour and that chloroform does not. But there is no difference between these agents in this respect; the blood retains its proper colour under the use of either of them, unless the effects are carried so far as to interfere with the breathing.

THE MONOCHLORURRETTED CHLORIDE OF ETHYLE.

This substance was discovered some few years ago by M. M. G. Regnault. It is made by exposing to the sun’s rays a mixture of the vapour of chloride of ethyle (muriatic ether) and chlorine gas. One equivalent of the hydrogen of the chloride of ethyle is replaced by an equivalent of chlorine. Its composition is four atoms carbon, four atoms hydrogen, and two atoms chlorine. It has the same composition as Dutch Liquid, which is made by the combination of olefiant gas and chlorine gas; the specific gravity of its vapour, 3·42, is also the same as that of Dutch liquid, which it resembles also in taste and smell. The boiling point is however different, and it differs from Dutch liquid in not being decomposed by an alcoholic solution of potassa.

I tried several times to make the monochlorurretted chloride of ethyle in 1849 and 1850, but did not succeed in procuring more than a drachm or two at once, owing to the constant over-action of the chlorine and the production of other chlorurretted products. In 1851, however, these products which result from the decomposition of muriatic ether by chlorine gas were recommended in Paris as local applications in rheumatism and other painful affections, and Mr. Mason was kind enough to obtain for me from that capital a pint bottle of a liquid consisting chiefly of the monochlorurretted chloride of ethyle. It was mixed with a certain portion of the bichlorurretted and terchlorurretted products, but I was able to separate by distillation as much of the monochlorurretted product as enabled me to administer it to twenty-two patients. Mr. Mason was, however, not able to obtain any more liquid containing any of the monochlorurretted chloride. What he afterwards was able to obtain had a very high boiling point, and consisted chiefly of chloride of carbon; carbon four atoms, chlorine five atoms.

The monochlorurretted chloride of ethyle resembles chloroform very much in taste and smell, and in its physiological properties. Its boiling point is 149°, whilst that of chloroform is 140°; the specific gravity of its vapour is also lower; for these reasons, it is considerably less volatile than chloroform, and it is therefore pretty certain that it would not be liable to cause the sudden deaths which have occasionally been produced by the administration of chloroform, even if it were given freely and with no great care. The difficulty of procuring it in a state of purity is, however, a barrier to its introduction into practice.

I first administered this preparation in King’s College Hospital, on June 20th, 1851, to a young woman, whilst Mr. Wm. Hewett, the house surgeon, repeated the operation of paring off venereal warts and applying nitric acid. The patient breathed it very readily without appearing to suffer from the pungency. She was a little longer in becoming unconscious than on former occasions from the chloroform, but soon after becoming unconscious, the sensibility of the conjunctiva diminished, and the operation was commenced. There was some flinching, so that she required to be held, but there were no cries or other signs of sensation. Consciousness returned almost immediately, and she seemed more exhilarated than after chloroform. She had had her dinner just before the operation, and at one time, soon after recovering her consciousness, she said that she felt rather sick, but this feeling passed off without vomiting, and she did not remember it afterwards. She did not begin to cry out from the smarting till twenty minutes after the operation, when she had been quite conscious, collected, and rational for a quarter of an hour, although on the two former occasions, after chloroform had been inhaled, she began to cry immediately after the operation, and almost before consciousness had returned. Next day she was very well.

On the following day I administered the same preparation to three patients on whom Mr. Fergusson operated in King’s College Hospital. The first was a boy seven years old, who had the forefinger removed, together with part of the metacarpal bone, on account of a large enchondroma. The second was an infant three months old, which was operated on for hare-lip; and the third was a woman about thirty-five, who had some venereal warts removed from the pudenda. There was no sickness in either of the cases, although the little boy and the woman had taken their dinners just before the operation.

On June 25th, I administered the preparation with the chloroform inhaler, as in all the other cases, to a muscular young man, about 25, whilst Mr. Henry Lee removed some piles, and applied nitric acid to the raw surface. The patient was six feet three inches in height, and weighed fourteen stone. He became insensible rather slowly, with low muttering and a good deal of rigidity. The operation lasted about ten minutes, during which the inhalation was repeated two or three times. There was no pain. He recovered his consciousness in two or three minutes after the conclusion of the operation; he said that he felt drunk, and he appeared so for a few minutes. He was very cheerful, and had no sickness, although he had had his dinner just before coming to the hospital to have the operation performed. Half a fluid ounce of the monochlorurretted compound was inhaled, being about the same quantity as would have been consumed of chloroform.

The other operations in which I administered this preparation, consisted of the removal of a tumour situated below the angle of the jaw in a young woman, by Mr. Fergusson; an operation on the tibia and fibula of a little boy, for ununited fracture, by Mr. Bowman; trephining the tibia of a young man, and giving exit to a collection of pus, by Mr. Henry Lee; an operation for necrosis of the tibia, by the late Mr. Avery; two operations for hare-lip; two operations for fistula in ano; one for nævus on the forehead; one for tenotomy; and one for removal of a fatty tumour, by Mr. Fergusson.

THE END.

INDEX.

Absorption of vapours by fluids, 59

—— —— —— by the lungs, formula of, 59