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"Case of death from amylene"

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Medical Times and Gazette
(8 August 1857): 133-34

I regret very much that I have to detail the particulars of a second death from amylene. It occurred in St. George's Hospital on Thursday last, July 30, 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, 24 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. (Less than an ounce of amylene was poured out, and it was not all used.). 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. Hawkings 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 excited 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 [133/134] 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 a 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 accident in this case, as in that which I related in the Medical Time and Gazette of April 18, clearly commenced at the heart. This has also been the fact, I believe, in all the well-recorded instances of death from chloroform. In the Medical Times and Gazette of July 25, M. Devergie is related to have expressed an opinion in the Academy of Medicine that the former instance of death 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. The length of time the patient continued to breathe after the above accident from amylene is very remarkable. I believe the brain was never more than partially under the influence of that agent, and that its fatal action was undoubtedly exerted on the nerves of the heart.

After the former accident which I recorded, I gradually reduced the power of the inhaler by withdrawing some of the bibulous paper, till I had diminished the evaporating surface to less than one-half; and in upwards of ninety cases in which I had administered amylene--from the latter part of April till the above accident--I never had occasion to feel a moment's uneasiness about it. Whilst I have been very successful in avoiding accidents from chloroform, I have been very unsuccessful in avoiding them from amylene. I do not think, however, that we have evidence at present to show which of these agents is least dangerous, in the way in which they are generally used. M. Giraldès, of Paris, who was present at the operating theatre of St. George's Hospital when the above accident happened, has employed amylene in 100 cases in children, and I have been informed by several Medical men newly returned from visits to the Continent, that amylene is very extensively used in the public Hospitals; yet no accident has been recorded from its use abroad, although accidents occurred very soon after the introduction of chloroform. Given on a handkerchief or sponge, I believe that amylene would be even safer than chloroform, owing to the greater cold produced during the evaporation; but I have seldom exhibited it so, as I did not think it would be certain and regular in its action, and any doubt on these points would, with me, have quite counterbalanced its other advantages.

As regards the position of the patient, I have several times given amylene, and chloroform very often indeed, to patients placed on the table with the face downwards, and have seen no ill effects; and I do not see how this position could interfere with the action of the heart.

If I were to set the accident down to some peculiarity or idiosyncrasy in the patient, many Medical men would, I believe, be ready to agree with me; but I am inclined to the opinion that the patient took one or two inspirations of vapour a little stronger than I intended, and was using my best endeavours to regulate. I had determined the principle, that the air which the patient should breathe should not contain more than about fifteen per cent of vapour of amylene, and I was employing the same kind of means to accomplish this, which I have used for many years, in trying to limit the vapour of chloroform to about five per cent. Although this plan has answered sufficiently well as regards chloroform, I do not conclude that it is so exact as to prove that the patient, whose case I have related, was an exception to the usual rules which govern the action of amylene. I still believe, that if the amylene were exhibited, by measured quantity, in a balloon or bag of known size, a sudden accident would not happen, except by measuring a wrong quantity; but I had every reason to trust that the plan which had succeeded so well with chloroform would succeed also with amylene; and to introduce a troublesome and cumbrous method would hardly be practicable with a new agent, when it is not required for one already in use.

M. Tourdes, of Strasburg, arrived at the conclusion that accidents would not happen from amylene; because one may continue it for an indefinite period on animals, without ill effects, while continuing the application of ether or chloroform causes death. This would be true, if accidents happened by administering these agents too long, and not by their sudden action. In giving sulphuric ether, one gives the vapour seven or eight times as strong as would cause death, if continued for an hour or two; in giving chloroform, one gives the vapour twice as strong as would have the same effect if continued; but in administering the vapour of amylene, to be on the safe side, we must exhibit it of such strength that it would produce no ill effects if continued indefinitely. According to my calculations, the patient requires to absorb about eight minims of sulphuric ether into each pound of his blood, in order to be rendered insensible by that agent; while he requires to absorb only two-thirds of a minim of chloroform, and one-tenth of a minim of amylene, to produce a like effect. This circumstance will help to explain how sudden accidents may happen with the last two agents more readily than with the first.

Sackville-street, August 1, 1857

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