Chapter XVII: Preface (17)

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.[176] 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.

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”[177] 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,[178] 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.[179]

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.”[180]

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.[181]

THE END.

INDEX.

A.

Absorption of vapours by fluids, 59

—— —— —— by the lungs, formula of, 59

Academy of Medicine of Paris, reports by, 132–4

Accidents from chloroform, treatment and prevention of, 248–62

Age, influence of, on effects of chloroform, 49, 50

Age in fatal cases from chloroform, 230–1;
from amylene, 401–2

Air, saturation of, with chloroform vapour, 68, 123;
with amylene, 376

—— amount of, in lungs, 108

—— respired during chloroform, 108

Allen, Mr., on a fatal case from chloroform, 195–6

Alleged fatal cases from chloroform, 201–12

Ammonia, use of, after chloroform, 104

—— use of, during accidents from chloroform, 258

Amputations under chloroform of thigh, 276–7;
of leg, 277;
of arm, 277–8;
of the ankle, 278;
of other parts, _ib._

Amylene, first application of, by author, 23

—— applications of, in Paris, Strasbourg, and Lyons, 24

—— discovery of, 372;
preparation of, _ib._

—— chemical and physical characters of, 373–7

—— volatility of different specimens of, 416

—— experiments with, 378–86

—— administration of, for operations, 386, 400

—— administration of, in parturition, 394–7

—— mode of administration of, 386–7, 405–6, 416

—— symptoms produced by, 399, 400

—— spasms and rigidity from, 401–2

—— does not produce vomiting, 406–7

—— effects of, on different persons, 401–2

—— effects of, on author, 384

—— amount of, required to produce insensibility, 384

—— effects of, on the heart, 384

—— time of inhalation of, to produce insensibility, 397

—— effects of, on consciousness, 398–403

—— promptitude of action of, 403

—— effects of, on respiration and circulation, 400

—— —— —— on the salivary glands, 400

—— chloroform, and sulphuric ether, effects of, compared, 403–5

—— after-effects of, 406–7

—— fatal cases from inhalation of, 408–16

—— amount of vapour of, inhaled in fatal cases, 415

Amylene, author’s prediction regarding safety of, 417

—— mode of administration of, by M. Rigaud, 417–18

—— Mr. Clarke’s remarks on, 418;

—— Dr. Debout’s remarks on, _ib._

—— Professor Tourdes’ remarks on, _ib._

—— author’s computation of safety of, _ib._

—— M. Giraldis on use of, 419

—— M. Jobert de Lamballe on use of, _ib._

Anæsthesia, modes of production of, 40–1

Anæsthetics, definition of, 34–5

Ancients, views of the, 3

Animals, various, experiments on, with narcotic vapours, 60 to 73

Anus, operations on, under chloroform, 307, 308–9

Animation suspended by chloroform, treatment of, 251–62

Apuleius on effects of mandragora, 2

Apoplexy, administration of chloroform after, 57

Aretæus’ description of mandragora, 3

Arnott, Dr. James, statistics of operations before and after
introduction of etherisation, 265–7

—— on pyæmia following chloroform, 267

Arteries, coronary, circulation of the, 262

Artificial respiration, value of, 121, 251–7, 260

—— —— applied in cases of death from chloroform, 139, 144, 151, 156,
159, 163, 166, 167–8, 173, 179, 181, 183, 185, 187–8, 190–1, 194,
196–7, 207, 210

Artificial respiration applied in case of death from amylene, 410–413

Arteries, ligature of, under chloroform, 289–291

Aschendorf, Dr., on alleged fatal case from chloroform, 204–5

Asphyxia idiopathica, 226

Asphyxia, death from, 235

Asthma, treatment of, with chloroform, 331

Athletics least susceptible of chloroform, 50

Augustus of Poland, operation on, without pain, 8

Aurelianus Cælius on mandragora, 3

B.

Balard, Professor, discovery of amylene, 372

Balloon for inhalation of chloroform, 80

Barlow, Mr. W. F., report on case of alleged death from chloroform, 208

Barrière, M., case of alleged death from ether, 364

Bath warm, use of, in fatal case from chloroform, 159

Beddoes, Dr., administration of gases in disease, 14

—— —— his pneumatic institution at Bristol, _ib._

Bell, Mr. Jacob, on chloric ether, 20

Belladonna, effects of, 4

Berthé, M., discovery of amylene, 378

Bickersteth, Mr., on supposed effect of surgeon’s knife on pulse, 240–3

—— —— on the pulse during inhalation of chloroform, 249–50

—— —— cases of resuscitation from over effects of chloroform, 253–6

Bigelow, Dr., use of sulphuric ether as an anæsthetic, 18

—— —— administration of chloric ether by, 20

Birds quickly affected by chloroform, 70

Black, Dr. Patrick, on asphyxia and syncope, 222

—— —— on closure of the glottis by chloroform, 236

—— —— on modes of inhaling chloroform, 236–7

Blood, serum of, absorption of chloroform by, 69

—— absorption of amylene by, 382–4

—— quantity of, in body, 73;
amount of serum, 74

—— chemical examination of, in alleged case of death from chloroform,
211

—— condition of, after death from chloroform, 247

—— saturation of, with ether, 354–5

Blood-letting in accidents from chloroform, 261

—— from external jugular, tried in case of death from chloroform, 151,
159, 168, 174

Body, temperature of, falls under chloroform, 70

Bolton, Mr. Andrew, case of puerperal convulsions treated with
chloroform, 338

Bone, removal of tumours of, under chloroform, 291

Boot, Dr., first operation in England without pain, 18

Bouisson, M., on a case of supposed death from ether, 369

Bowman, Professor, removal of pus from frontal sinus after inhalation
by chloroform, 302

Breathing modified by chloroform vapour, 69, 70

—— conditions of, under chloroform, 89, 90, 91, 92

Breast, tumours of, removal under chloroform, 285–7

Breton, supposed death of, from chloroform, 199–200

Brodie, Sir Benjamin, on use of chloroform in lithotrity, 274

Buck, Mr. Gurdon, report of death from chloroform by, 136–8

Bullock, Mr. Lloyd, manufacture of amylene by, 374–8

Bursa, the, operations on, under chloroform, 311

C.

Cahours, M. Auguste, invention of name of amylene, 372

Cancer of the lip, operation for, under chloroform, 294

Cases dangerous from chloroform, 258–60

—— of death from chloroform during labour, from neglect, 328

Cases, fatal, from inhalation of chloroform, 120–200

Case 1, of Hannah Greener, Winlaton, Newcastle, 123–7;
2, of Martha G. Simmons, Cincinnati, 127–30;
3, of Patrick Coyle, 130–1;
4, of Mdlle. Stock, Boulogne, 131–5;
5, of a woman at Hyderabad, 135;
6, of Charles Desnoyers, Hôtel-Dieu, Lyons, 135–6;
7, of a young gentleman at Govan, 136;
8, of John Griffith, New York, Hospital, 136–8;
9, of J. Verrier, Hôtel-Dieu, Lyons, 138–141;
10, of Samuel Bennett, Westminster, 141–2;
11, of Mdlle. Labrune, at Langres, 142–3;
12, of John Shorter, St. Thomas’s Hospital, 143–5;
13, of Mrs. Jones, at Shrewsbury, 145–6;
14, at Berlin, 146;
15, of William Bryan, Kingston, Jamaica, 147;
16, of an artilleryman, Mauritius, 147–8;
17, at Seraphim Hospital, Stockholm, 148–50;
18, of a boy of seven, Glasgow Infirmary, 150–1;
19, of Alexander Scott, Guy’s Hospital, 151–2;
20, of James Jones, Cavan Infirmary, 152–3;
21, of John Holden, Stepney Workhouse, 153–5;
22, of Mdme. Simon, Strasbourg, 154–5;
23, at Seaman’s Hospital, Greenwich, 155–7;
24, of Elizabeth Hollis, Chipping Norton, 157–8;
25, of Thomas Hayward, of Bartholomew’s Hospital, 158–61;
26, of Mdme. W., at Ulm, 161;
27, of Mr. John Atkinson, Melbourne, 162;
28, of Mr. Martin, at Melrose, 162–3;
29, of Henry Hollingsworth, Manchester Royal Infirmary, 163–4;
30, of Caroline Baker, of University College Hospital, 165;
31, of a French soldier, Hôtel
Dieu., d’Orléans, 165–6;
32, of John Mitchell, at Royal Infirmary, Edinburgh, 166–70;
33, of E. R., at University College Hospital, 170–2;
34, of Ann Smith, at St. Bartholomew’s, 172–4;
35, of a young man in Vienna, 174;
36, of a young girl at Neustedt, 174–5;
37, of Jane Morgan, Bristol Infirmary, 175–6;
38, of a woman, Hôpital St. Antoine, 176–7;
39, of Mrs. Harrup, Sheffield, 177–8;
40, of Walter Hollis, Lock Hospital, 178–80;
41, of a man, at Middlesex Hospital, 180–2;
42, of George Sands, University College Hospital, 182–4;
43, of a woman, in Guy’s Hospital, 185–7;
44, of John Cannon, Royal Ophthalmic Hospital, 187–8;
45, of a lady, London, 188–9;
46, of Mrs. H., Edinburgh, 189–90;
47, of a sailor, St. Thomas’s Hospital, 190–2;
48, of a boy, recorded by Mr. Paget, 192–4;
49, of a man, Liverpool Infirmary, 195–6;
50, of Ann Stoner, King’s College Hospital, 196–9;
cases, supposed, of death from chloroform, 199, 200;
case, fatal, during labour from neglect, 328

Cases, alleged fatal, from inhalation of chloroform, 201–12;
of Mr. Walter Badger, 201;
case reported by M. Malgaigne, 204;
of a woman, in Paris, _ib._;
of a child, in the hospital, Madrid, _ib._;
of a child, by Dr. Aschendorf, 204–5;
case by the author, 205–9;
case at St. George’s Hospital, 209–12

Cases, alleged fatal, from ether, 362–8

—— medical, inhalation of chloroform in, 329–44.
_See Medical Cases_

—— surgical, use of chloroform in different kinds of, 271–318.
_See Operations_

—— fatal, from inhalation of amylene, 408–16

Cats, experiments on, with chloroform, 61, 66, 109, 110, 111

Cat, experiment on, with amylene, 380–1

Cataract, operations for, under chloroform, 296

Cause and prevention of death from chloroform, 107–120

Causes, supposed, of death from chloroform, 228–45.
_See Death_

Cerebral diseases and chloroform, 56

—— —— treated by chloroform, 56–7

Chaffinch, experiments on, with chloroform, 73

Charrière, M., inhaler for chloroform by, 85

Chassaignac, M., on tolerance of chloroform, 92

Chevalier, M., on asphyxia idiopathica, 226

Chinese, use of Indian hemp by, 5

Chloroform, first experiments with, by Glover, 112;
first experiments with, by Flourens, 21

—— recommended by Dr. Simpson, 21

—— rapid introduction of, 22

—— first death from, 22

—— disused in Boston, Massachusetts, Philadelphia, Naples, and Lyons,
23

—— history and composition of, 27

—— analysed by M. Soubeiran, and named bichloric ether, 27

—— examined by Liebig, and named liquid chloride of carbon, 27

—— examined by Dumas, and named chloroform, 27

—— called chloroformyl in London Pharmacopœia, 28

—— mode of preparation of, 28–9

—— chemical and physical properties of, 29–30

—— adulterations of, 30–2

—— effects of, mixed with alcohol, 31

Chloroform, how to be preserved, 32

—— properties of vapour of, 32

—— quantity of vapour of, taken up by air at various temperatures, 33,
68

—— effects of inhalation of vapour of, at different temperatures, 34

—— physiological effects of, 34

—— a narcotico-irritant, 34

—— degrees of narcotism from, 35–43

—— symptoms during first degree, 35–37;
second degree, 37–38;
third degree, 38–42;
fourth and fifth degrees, 42–43

—— effects on the heart of a sudden overdose of, 43

—— produces post-mortem rigidity, 43

—— effects of, on pulse, 43, 44, 77, 89

—— action of, on the nervous system, 44–45

—— effects of, during an operation, 45

—— varying effects of, on patients, 45–8

—— circumstances which influence or modify its effects, 48

—— influence of age in modifying effects of, 49–50

—— effects of, as regards strength or debility, 50

—— effects when given slowly, 50

—— effects of, in hysteria, 50–2

—— effects of, in epilepsy, 52

—— effects of, during menstrual period, 53

—— effects of, during pregnancy, 53

—— effects of, in cases of disease of the lungs, 53–4

—— effects of, in case of phthisis described, 53–54

—— effects of, in cases of heart disease, 54–56

—— effects of, in cerebral disease, 56–57

—— effects of, on the insane, 57

—— effects of, on hard drinkers, 57–58

—— amount of vapour of, absorbed to cause the various degrees of
narcotism, 58–74

—— is absorbed into the circulation during inhalation, 58

—— is exhaled in the secretions, 58

—— experiments on inhalation of, 59–74.
_See Experiments_

—— absorption of, by blood serum, 69

—— proportion of, required to arrest respiration, 69, 70, 74, 115, 116

—— action of, on frogs, 71–73

—— action of, on chaffinch, 73

—— action of, on animals of warm and cold blood, 70–73

—— preparations for administering the, 74

—— should not be administered after a meal, 74

—— vomiting in relation to administration of, 74–75

—— position of patient during inhalation of, 75

—— fears regarding the, 76–77

—— and fear, relative effects of, 77

—— removes fear as it destroys consciousness, 77

—— prevents syncope from fear, 77–78

—— mode of administering the, 78

—— amount of, required to produce insensibility, 78, 107

—— Dr. Simpson’s administration of the, 78

—— objections to administration of, on handkerchief, 78–79

—— may cause death without producing insensibility, 79, 133

Chloroform, effects of, not modified by idiosyncracies, 79

—— inhaled from a balloon, 80

—— inhaler for, the author’s, described, 81–84

—— diagram of, 82

—— amount of, used for inhalation, 84

—— how to be administered with inhaler, 86

—— use of, in obstetric cases, 87

—— use of, in surgical operations, 87

—— signs of insensibility from, 87

—— effects of, eyelid test, 88

—— effect of, on breathing, 89–93

—— effect of, on pupil, 93–94, 158

—— on position of the eyes, 94

—— accumulation of, in lungs, 91

—— rigidity and struggling under, to be subdued by continued
inhalation, 91, 92, 93

—— on tolerance of, M. Chassaignac, 92

—— how long to be inhaled by patients of different ages, 94

—— always takes effect, 95–96

—— repetition of, during operations, 97

—— recovery from, 97–100

—— sequelæ of inhalation of, 100–107

—— cause and prevention of death from, 107–120

—— effect of prolonged inhalation of, 109

—— experiments illustrating mode of dying from, 109–120

—— paralyzing effects on the heart from large doses of, 112

—— fatal cases of inhalation from, 120–200

—— alleged cases of death from inhalation of, 201–212

—— danger of rapid inhalation of, 126, 127

—— the mode of administration of, in fatal cases from, 124, 127, 130,
131, 135, 137, 138, 142, 143, 144–5, 146, 147, 148, 149, 150, 151,
153, 154, 155, 158–9, 161, 162, 164, 165–6, 167, 170, 172, 174, 176,
177, 178, 180, 183–4, 185, 187, 189, 190–1, 193, 195, 197

—— mode of inhalation of, in alleged cases of death from, 201, 205,
207, 209–10

—— symptoms in the fatal cases of inhalation of, 212–17

—— mode of death in accidents from, 217

—— table of fatal cases of inhalation of, 218–22

—— supposed causes of death from, 228–45,
_see Death_

—— state of the chief organs after death from, 245–8

—— further remarks on the prevention of accidents from, 248–51

—— rules in administration of, 250–1

—— treatment of suspended animation from, 251–62

—— the effect of, on the results of operations, 263–70

—— benefits conferred by, in operations, 263–4

—— administration of, in the different kinds of operations, 271–318,
_see Operations_

—— in parturition, 318–29

—— introduced by Dr. Simpson into obstetric practice, 318

—— need not produce unconsciousness during labour, 318

—— cases of labour in which it may be employed, 319–20

—— period for its administration in labour, 320

—— mode of administration in labour, 320–21

—— does not influence the duration of labour, 323

Chloroform, its use in operations during labour, 324–6

—— its use in peculiar cases of labour, 327–8

—— death from, by neglect during labour, 328

—— in relation to puerperal convulsions, 329

—— inhalation of, in medical cases, 329–44

—— frequent and long continued use of, 343–4

—— and ether, analogous action of, 349

—— and ether, combination of, 369–79

—— sulphuric ether, and amylene, effects of, compared, 403–5

Chowne, Dr., cases of hysteria treated with chloroform, 339–41

Circumstances which influence or modify the effects of chloroform, 48

Clarke, Mr., on amylene, 418

Clement, Mr., on case of death from chloroform, 145–6

Clover, Mr., his mode of administering chloroform, 184