Part 6

Dr. Morton withheld at first the name of the agent he was employing, but its strong and peculiar odour revealed it so plainly that concealment was impossible. Dr. Bigelow, of Boston, having tried sulphuric ether, and found it to produce all the effects of the so-called letheon, he made the subject known, not only to his own countrymen, but also by letter to Dr. Boot of London. The first operation under the influence of ether on this side of the Atlantic, was the extraction of a tooth, at the house of Dr. Boot, on Dec. 19th, 1846. Mr. Robinson, of Gower Street, administered the ether and performed the operation. The patient was a lady, named Miss Lonsdale. The ether was quite successful in preventing the pain in this case, as well as in two operations performed at University College two days afterwards, by the late Mr. Liston. These operations were amputation of the thigh, and evulsion on both sides of the great toe-nail. The ether was given by Mr. Squire, of Oxford Street, with an apparatus which he contrived for the occasion.

Considerable opposition was made to the inhalation of ether in America, soon after its introduction, and it seemed likely to fall into disuse, when the news of its successful employment in the operations of Mr. Liston, and others in London, caused the practice of etherization to revive. Mr. Robinson, dentist, gave much time and attention to the exhibition of ether in London on its first introduction, and was on the whole very successful. This was not generally the case, however, with other operators during the first six weeks of the new practice. Owing to imperfections in the inhalers employed and in the method of using them, the ether often either failed altogether or only made the patient partly insensible; and Mr. Liston, and some other surgeons, were inclined to discountenance the use of it, in consequence of the struggles and cries of patients to whom it had been administered.

It soon became apparent, however, that the vapour of ether was capable of inducing a state of perfect quietude, with entire absence of pain, during all kinds of surgical operations. From the 28th of January the ether produced the desired effect in every operation that was performed in St. George’s Hospital, until the time when chloroform was introduced as a substitute for this agent.

Ether was employed in Paris a few days after its first application in London, and in a short time it was in use nearly all over the world.

On the 19th of January 1847, just a month after the first application of ether for the prevention of pain on this side of the Atlantic, Dr. Simpson of Edinburgh administered the vapour in a case of labour, and ascertained that it was capable of removing the sufferings of the patient without interfering with the process of parturition. Etherization was soon afterwards employed in the reduction of strangulated hernia and dislocations of the femur and humerus, some of them of long standing. It was also used with advantage in neuralgia, tetanus, and the convulsions of infants, and it became more and more general in surgical operations.

No great improvement in the practice of medicine was probably ever established so readily as the inhalation of ether for the prevention of pain. Yet it met with stout opposition in certain quarters, and when a serious operation in which ether had been used terminated unfavourably, there were those who attributed the patient’s death to the new practice, although numerous other patients had sunk in exactly the same manner long before ether was used. In one of these cases a coroner’s inquest was held, and the jury returned a verdict that the death of the deceased was caused by the inhalation of ether, although the patient had not even been made insensible by it, had felt all the pain of the operation, which was retarded by her struggles, and did not die till the third day. Notwithstanding a certain amount of opposition and mistrust, the inhalation of ether was becoming more general in the course of the year 1847, and there is every reason to conclude that it would very soon have obtained the complete confidence of the medical profession and the public, had it not been for circumstances which must next be considered.

A medicine called chloric ether has been in use since 1831. It consists of a solution of chloroform in spirits of wine. It is somewhat variable in strength, but usually contains about twelve per cent. of its volume of chloroform. Dr. Henry Jacob Bigelow of Boston tried this by inhalation, as well as other substances, when Dr. Morton first used sulphuric ether, but he did not succeed with it in causing insensibility to pain. Mr. Jacob Bell of London tried the chloric ether in the beginning of 1847, and succeeded in causing insensibility with it in some cases. After this time the chloric ether was exhibited occasionally in St. Bartholomew’s and the Middlesex hospitals, and in the private practice of Mr. Lawrence, but it did not come into general use, owing to its expense, and its frequently failing to cause insensibility.

The relation of chloroform to chloric ether is exactly the same as that of opium to laudanum, and no one acquainted with this circumstance could doubt for a moment that chloroform inhaled alone would produce the effects which it did when inhaled from its solution in spirit; the only uncertainty about the matter that could possibly exist would be whether it might not be too strong for use in its undiluted state.

The true nature of the so-called chloric ether was, however, known to very few persons. It did not enter into the pharmacopœias, and it was mentioned in very few of the works on materia medica. I examined a specimen of it, and found that its properties when inhaled were due to a volatile body containing chlorine, which evaporated first, leaving a great quantity of spirits of wine behind. I concluded that the volatile body was hydrochloric ether, and as this article is so volatile that it exists in the form of gas except in comparatively cold weather, and consequently could not be conveniently used for inhalation, I did not consider the matter any further. M. Flourens had indeed experimented on animals with undiluted chloroform, but was so struck with its great and dangerous power, that he was far from recommending its use in surgical practice.

It was left for Dr. Simpson of Edinburgh, who had already the merit of having discovered the use of inhalation in midwifery, to be the first to administer chloroform in an undiluted state, and to recommend it successfully for general use. Mr. Waldie, of the Apothecaries’ Hall of Liverpool, first mentioned chloroform to Dr. Simpson, as the latter states in a foot-note to his first pamphlet on the subject. Mr. Waldie has given the following account of the circumstance in a pamphlet on chloroform.

“When in Scotland, in October last, Dr. Simpson introduced the subject to me, inquiring if I knew anything likely to answer. Chloric ether was mentioned during the conversation; and, being well acquainted with its composition, and with the volatility, agreeable flavour, and medicinal properties of the chloroform, I recommended him to try it, promising to prepare some after my return to Liverpool, and to send it to him. Other engagements and various impediments prevented me from doing this so soon as I should have wished; and in the meantime Dr. Simpson, having procured some in Edinburgh, obtained the results which he communicated to the Medico-Chirurgical Society of Edinburgh on the 10th of November, and which he published in a pamphlet entitled—‘Notice of a New Anæsthetic Agent as a Substitute for Sulphuric Ether in Surgery and Midwifery.’”

Dr. Simpson’s first experiments with chloroform were made in the early part of November 1847, and his pamphlet on the subject, which was published on the 15th of that month, had a wide circulation, and created great interest. Chloroform was immediately used everywhere to a greater extent than ether had been. An impression became very prevalent that chloroform was safer than ether. This impression arose rather from the general tenour of Dr. Simpson’s essay than from any direct statement, for he had not treated on this point.

The great strength of chloroform as compared with ether, and the extreme care required in its use, were indeed soon pointed out; these precautions, however, attracted but little attention till the first death from chloroform occurred near Newcastle on the 28th January, 1848. Ether was exhibited by inhalation during eleven months in Europe, and about sixteen months in America, before chloroform was introduced. During all this time no death was occasioned by its use, if we except one at Auxerre in France, which appeared to be occasioned by want of air, owing to an imperfect inhaler, and not to the effect of ether. Chloroform had only been employed between two and three months when the above mentioned death occurred, and this was soon followed by others in nearly all parts of the world. These accidents have prevented many persons from inhaling chloroform, and they have prevented a still greater number from enjoying that freedom from anxiety and apprehension before an operation, which ought to be one of the greatest advantages of any plan for preventing pain. As chloroform possesses advantages over ether, in being more convenient and less disagreeable, it continues to be used, to the exclusion of the latter agent, in most parts of the world. In the Massachusetts General Hospital, however, where sulphuric ether was first employed, it was resumed three or four years ago, and the use of chloroform was prohibited by the governors, on account of two accidents from it. Ether is also employed out of the hospital, both in surgical and obstetric practice, in Boston and the neighbourhood; and I have been informed that this is also the case in Philadelphia, whilst in the state of New York both chloroform and ether are employed. I learned last year that ether was the agent employed for causing insensibility at Naples and at Lyons.

Several volatile substances have been tried in a few cases with the effect of causing insensibility, since the introduction of chloroform, but none of them came into use except amylene, which was first employed by me in King’s College Hospital in November 1856, after I had made several experiments on animals with it, and inhaled small quantities of it myself. I have administered it in a great number of operations already, and find it to possess certain advantages over chloroform in the greater number of cases. Although it has not yet been generally employed in this country, it has been used extensively in Paris, Strasbourg, Lyons, and other places on the continent, with very favourable results.

It is not improbable that, amongst the multitudes of new bodies which chemistry makes known every year, some agent may be found superior to those hitherto used; and besides the great practical advantages which are directly derived from the discovery of inhalation for the prevention of pain, the method of breathing medicinal substances in the gaseous state offers great facilities for the investigation of their effects, and cannot fail to hasten the time when the mode of action of medicines will be a branch of exact knowledge.

ON THE INHALATION OF CHLOROFORM, ETC.

GENERAL REMARKS ON INHALATION.

Inhalation is simply the act of breathing, or at least so much of it as consists of inspiring, or drawing the air into the lungs. The term is usually applied when any medicinal substance is added to the air which the patient breathes, and the process is altogether different from that called “smoking,” as practised by the nations of western Europe and of America, where the fumes of tobacco are merely drawn into the mouth and puffed out again. The eastern nations, however, always inhale when they smoke, as was stated before (page 12). This process of inhaling smoke, as I first witnessed it in a gentleman connected with one of the eastern embassies to this metropolis, is very instructive, as showing that the lungs become emptied of their contents by three rather full expirations and inspirations. When this gentleman took the cigar from his mouth to speak, the smoke could be seen issuing thickly with each word till there was a momentary pause as he took a fresh inspiration, then the smoke could be seen issuing with each word as before, only not so thick, and after another inspiration, the smoke could be still perceived in the expired air, but in a very diluted state; but after a third inspiration, it could no longer be seen till he had resumed the cigar.

The following are the chief reasons for resorting to inhalation.

1. Certain agents, as nitrous oxide and oxygen, being permanently in the gaseous form, cannot be administered in any other way.

2. By taking advantage of the immense surface of the air-cells of the lungs for absorption, a more sudden and profound effect may be produced by medicine than it would be safe, or, in some cases, even possible to produce in any other way. It is to this circumstance, and to the rapidity with which certain volatile medicines exhale in the breath, and leave the patient free from their effects, that the power of preventing the pain of surgical operations is due.

3. Many medicines which have a disagreeable taste—as turpentine, creasote, and camphor—are not unpleasant when inhaled in the form of vapour; and the process of digestion is less interfered with than by taking them into the stomach.

4. Medicines, such as benzoic acid, and some of the gum-resins, which are believed to exert a local action on the mucous membrane of the air-passages, may be expected to have a greater effect when inhaled, than when they are taken into the stomach in the same doses, and reach the lungs only through the circulation.

5. Some agents, as chlorine and ammonia, have a local action when inhaled, which they could not exert if exhibited in any other way.

In every kind of inhalation, the breathing should be allowed to go on freely, and in the natural way.

Medicines may be inhaled either at the ordinary temperature, or with the aid of artificial heat; and in the latter case they may be breathed with the addition of vapour of water, or with only so much of it as is naturally present in the atmosphere. The medicines in use for the prevention of severe pain, are always inhaled at the ordinary temperature.

CHLOROFORM.

History and Composition. Chloroform was first made in 1831 by two chemists who operated independently of each other. The liquid, which is formed by the union of equal volumes of chlorine and olefiant gas, and which is usually called Dutch liquid, was named chloric ether by Dr. Thos. Thomson (System of Chemistry, 6th ed., 1820). In consequence of a statement in Silliman’s Elements of Chemistry, that the alcoholic solution of this chloric ether was useful in medicine as a diffusible stimulant, Mr. Guthrie, an American chemist, attempted an easy method of obtaining it. He distilled together chloride of lime and alcohol, and he considered that the product he had obtained was an alcoholic solution of the chloric ether of Dr. Thomson, and it is still used in medicine under that name. About the same time, M. Soubeiran distilled together the above ingredients in France, and analysed the chloroform which he obtained. His analysis, which was incorrect, led him to name the liquid bichloric ether. In 1832, Liebig examined the liquid which has been since named chloroform, but as he failed to detect the hydrogen which it contains, he called the liquid chloride of carbon, a name which its alcoholic solution occasionally bore afterwards when used as a medicine. In 1831, Dumas examined this liquid. He proved that Soubeiran and Liebig had not obtained it pure, or had been incorrect in their analysis. He showed that it consists of two atoms carbon, one atom hydrogen, and three atoms chlorine.