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"Further remarks on amylene"

Medical Times and Gazette
(11 April 1857): 357-59
Part 2.

PDF of the original article is included with the PDF posted for part 1

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 water fluids, and consequently in the blood. Suphuric 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 explained in my paper in January, 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 [357/358] these circumstances, his friends are generally anxious to see him recover his consciousness. The smarting of the wound after an operations 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 possess 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 has completely returned. In any case where the pain after an operation, either from a wound or ligature 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 do not remember yet to have met with after amylene. If the patient, when he awakes from even a deep and prolonged insensibility, is in the same position as when he became unconscious, he often asserts that the vapour has not taken effect, he requests that the operation may not be commenced, and will not believe it is over till convinced by his own senses. It seems as if, in such cases, a piece has been snipped, as it were, out of the mental existence of the patient, and that not even dreams had occurred.

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. I have met with hysterical laughing and crying in three females after operations under amylene, which I think is not oftener than the same symptoms might be met with after chloroform. In one case where Mr. Fergusson amputated the leg of a young woman, the hysteria lasted about an hour; in the other two cases it subsided in a much shorter time, although the patients were very subject to this affection.

Amylene appears to support the pulse under loss of blood at least as well as chloroform. I have not as yet found the pulse to fail, although there was rather free hæmorrhage in one or two operations.

There has been a little headache in a few cases as the effects of this agent were subsiding, but it has passed off in a few minutes.

I have already administered amylene in many of the chief operations of surgery. There have been five cases of lithotomy in the male, three of them by Mr. Fergusson, in King's College Hospital; the young man and the child already alluded to in my former papers, and another child; and two cases in St. George's Hospital, one by Mr. H. C. Johnson, and the other by Mr. Pollock, both children. All the five cases have done well. In addition to the amputation of the thigh by Mr. Henry Lee, mentioned in the paper in January, I administered amylene in a similar operation by Mr. Tatum, in St. George's Hospital, and also in an amputation of the forearm by the same gentleman, and an amputation below the knee by Mr. Fergusson, in King's College Hospital. I have administered amylene in the removal of the head of the femur by Mr. Bowman; in the removal of three large tumours near the groin, two of them by Mr. Bowman, and one by Mr. Fergusson; in the removal by Mr. H. C. Johnson of a tumour deeply seated behind the angle of the jaw, and in the removal of six tumours of the breast by different Surgeons. There have also been three operations for stricture by perineal section, two by Mr. Fergusson, and one by Mr. Curling. The amylene has answered perfectly well in all these cases, so there can be no doubt of its general applicability in the great operations of surgery.

Amylene has succeeded perfectly well in operations of the eye. In the extraction of cataract it will probably have an additional advantage, in the almost entire absence of sickness after its use. I have exhibited it in two cases of extraction of cataract, performed by Mr. Bowman, and one operation for cataract by drilling. Also in six cases of excision of the eyeball for various diseases, by Mr. Bowman; one of these cases occurred in King's College Hospital, one in the Ophthalmic Hospital at Moorfields, and the others in private practice. There have been also twelve operations for strabismus, and a number of other operations on the eye and the eyelids, in which I have administered amylene chiefly for Mr. Bowman. I have given it in three cases of the forcible rupture of the adhesions in anchylosed joints, and it has answered perfectly in preventing the pain. Two of the cases were in King's College Hospital, and one in the Orthopædic Hospital, under Mr. Lonsdale.

I have employed amylene in two cases of dislocation of the humerus, both patients of Mr. French in the St. James's Parochial Infirmary. The first case was a dislocation downwards in a woman aged 68. She inhaled for three minutes, when extension being made, the bone slipped into its place with the utmost ease, although Mr. French had found a good deal of resistance in an attempt he made just before sending to me--not any serious resistance or pain, but so much of both as led him to think it would be a good opportunity for trying the amylene. In two minutes after the reduction of the dislocation, and five minutes after beginning to inhale, the patient was awake again, and said that she had felt nothing. The other case was a dislocation forwards in a man aged 72. No attempt to reduce it was made till the amylene was administered. The case was under the care of Mr. Buzzard. After inhaling two or three minutes, the old man got into a state of muscular rigidity, and did not get beyond this state, although I continued the inhalation nearly ten minutes until about two ounces of amylene were used. He was quite insensible, but the rigidity prevented the reduction of the dislocation. So I discontinued it, and sent for some chloroform, which I administered a few minutes afterwards. It produced muscular rigidity rather stronger than that which the amylene had caused, but by continuing the inhalation steadily for about two minutes, the limbs became relaxed, and the humerus slipped easily into place. This is the only case in which the amylene has not effected the purpose for which I have exhibited it; and I have no doubt, for reason which I stated before, that I could have produced relaxation of the voluntary muscles by increasing the strength of the vapour the patient was breathing; but there were one or two circumstances which at the moment stood in the way of this. The patient's face was so hollow from his loss of teeth that the face piece fitted badly, and as it was early in a frosty morning the water bath of the inhaler was colder than usual. These defects could have been remedied if necessary, but I thought it as well to use chloroform; and I am inclined to think that chloroform is the better agent to employ in those rare instances where relaxation of the voluntary muscular system is required. I remain also of the opinion, which I expressed years ago, and which I occasionally act on, that sulphuric ether is preferable to chloroform in the reduction of old dislocations, as it seems to produce complete relaxation of the muscles more readily and constantly than chloroform.

Amongst the minor operations in which I have administered amylene, have been eighteen operations of tenotomy, chiefly by Mr. Williams Adams and Mr. Lonsdale, in the Royal Orthopædic Hospital, and mostly in children and young people. An inhalation of about two minutes generally sufficed to prevent the pain entirely. I find that some surgeons have entertained an objection to use chloroform in tenotomy, lest it should cause a relaxation of the muscles, which would interfere with the operation. I have, however, been in the habit of exhibiting it for eight or nine years, both in King's College Hospital and in the private practice of Mr. Fergusson and some other surgeons. I never carried the effect of the chloroform so far as to cause relaxation of the muscles, and I have generally heard the tendons give way with a snap. With a small dose of amylene the tensions of the muscles not only remain, but is usually somewhat increased.

Amongst the more important and painful operations in which I have given amylene, and where it has answered perfectly, [358/359] I ought to have mentioned several cases of necrosis affecting various bones,--as the femur, lower jaw, tibia, etc. I administered it to an infant about six months old, in King's College Hospital on January 17th, previous to Mr. Fergusson operating for hare-lip. The child was insensible to the knife at the beginning of the operation, but began to cry before the incisions were finished, and cried very lustily as the hare-lip pins were introduced. The property, previously alluded to, which amylene possesses, of allowing the patient to awake so quickly, although an advantage in most operations, is not desirable in operations about the mouth, where the inhalation cannot very well be continued or resumed. This is more especially the case in young children, who awake, even from chloroform, more quickly than we wish in such operations. There have been four or five operations on infants for hare-lip since the one above mentioned, but I have given either chloroform or sulphuric ether. In all the other operations in this Hospital, when I have been present to administer any narcotic vapour, since the 13th of December last, I have exhibited amylene, in order to give it a fair trial. There have been several plastic operations on the face in patients of adult age, or nearly so. The amylene has always prevented the pain at the beginning of the operation, and has been continued on a hollow sponge afterwards for some little time. On two or three occasions it was so continued with success to the end of the operation; but two or three times the sponge became so cold by the continued evaporations of the amylene, as to make my fingers ache, and to limit the evaporation so much that the patient seemed about to awake. I therefore put a little chloroform on the sponge, and it answered the purpose desired. Chloroform absorbs much less caloric than amylene during its evaporation, as the patient inhales, on account both of the quantity which evaporate being less, and of the specific gravity of the vapour being greater.

In tooth-drawing, amylene has both its advantages and disadvantages as compared with chloroform. The prompt recovery from its effects, and the almost constant absence of sickness, are decided advantages, as also is the greater ease with which it is inhaled; but in cases where eight or ten teeth require to be extracted at once, as often happens, where my assistance is required, or where several stumps are in the alveolus, the effect of amylene does not last long enough to complete the operation, without one or more repetitions of the inhalation. A difficulty in getting the mouth open occurs about as often, I think, with one agent as the other.

I have only as yet had leisure to administer amylene in two cases of labour. One was under the care of Mr. Buzzard in the St. James's Infirmary, on January 20th. It was the patient's second labour, and was a lingering one, having lasted 35 hours. I administered the amylene only during the last 20 minutes preceding the birth of the child, the head being advanced so as to rest on the perinæum. The vapour was given well diluted at the beginning of each pain. The patient breathed very deeply, and got relief very quickly from each pain; the mind was quite clear between the pains, and I could not tell whether or not the consciousness was removed for half a minute or so, during each pain. Half a fluid ounce of amylene was used. The other case occurred in an out-patient of King's College Hospital under the care of Mr. Meadows, Dr. Farre's assistant. It was the patient's third confinement. I arrived three hours after the commencement of labour, and two hours before the birth of the child. The os uteri was almost dilated on my arrival, and the pains were very strong, recurring every three minutes or so. They continued to increase in strength to the last. The patient was probably unconscious for a brief period during the uterine contractions, while the amylene was administered, but between the pains she was quite conscious. Under the use of chloroform, in a labour with brisk and frequently recurring pains, as in this case, the patient usually sleeps on from one pain to another, but I offer no opinion at present as to which state of circumstance is preferable. The amount of amylene inhaled in this case was three fluid ounces. The quantity used in each of these cases must have been about half a fluid drachm in each pain, and this is the quantity I had previously recommended Dr. Tylor Smith to employ, when he did me the honour to ask me some questions about amylene before he employed it in a case of labour. The results arrived at by Dr. Tylor Smith, in the case in which he employed amylene, were similar to my own, viz.[,] relief of suffering during the uterine contraction, consciousness between pains, and no interference with the progress of labour. I look forward with some interest to a more extended experience of amylene in midwifery. Chloroform answers so extremely well that there does not seem much room for improvement; there are cases, however, in which chloroform has a tendency to retard the progress of labour, by diminishing the force, duration, and frequency of the uterine contractions, even when administered very moderately; and it remains to be ascertained, by observing a number of cases, whether amylene may not be free from this disadvantage.

In the concluding part of this paper I shall make some remarks on the mechanical means of administering amylene in the most efficient way, and on its relative safety as compared with chloroform and ether.

[Part 3 appeared in the 18 April issue.]

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