By Experiments 36, 37, and 41, we find that with ether, as with chloroform, a quantity of vapour in the air, somewhat greater than suffices to induce complete narcotism, has the effect of arresting the respiratory movements.
In treating of chloroform (page 74), the average quantity of serum in the adult human subject was estimated at 410 fluidounces. In order to find the quantity of ether in the system, we may multiply 410 by 0·000875 for the second degree of narcotism, and by 0·00175 for the fourth degree, when we shall obtain 0·358 and 0·71 of an ounce, i. e. f. ʒii. ♏︎l in the first instance, and f. ʒv. ♏︎xl in the second. In the third degree of narcotism, in which surgical operations are usually performed, the quantity is intermediate, or a little over four drachms.
On the Administration of Ether. About a fluid ounce of ether is usually inhaled by an adult patient in becoming insensible; fully one-half of this is, however, thrown back from the lungs, windpipe, nostrils, and face-piece, without being absorbed. I usually put two fluid ounces of ether into the inhaler above described, at the beginning of the inhalation, and this quantity often lasts to the end of the operation, if it is not a protracted one. The inhaler is connected, by means of a wide elastic tube, with a face-piece similar to that described and delineated in treating of chloroform. It is necessary that the inhalation should commence, as in the case of chloroform, with the expiratory valve of the face-piece turned on one side, for the admission of air which is not charged with ether, and that the vapour should be admitted to the air-passages by degrees, to avoid the irritation that would arise from suddenly inspiring any considerable quantity of the vapour. The vapour of ether is very much less pungent than an equal quantity of the vapour of chloroform; but as the patient requires to breathe about six times as much of it in the inspired air, it feels quite as pungent as that of chloroform, and, perhaps, a little more so. Whilst the patient never requires to take in more than four or five per cent. of vapour of chloroform in the inspired air, he requires to inhale about thirty per cent. of vapour of ether, in order to be rendered insensible in a convenient time. The air-passages, however, soon get accustomed to the presence of the vapour of ether, and in a minute and a half or two minutes after the patient begins to inhale, he can usually bear the valve to be closed so far as to charge the air with as much vapour as is necessary speedily to cause insensibility. The inhaler yields quite sufficient vapour when the water-bath is at 50° Fahr.; and at the seasons of the year when the temperature of the water is higher, the expiratory valve of the face-piece can be left more or less open to admit a portion of air which has not passed through the inhaler.
I prefer the flavour of ether vapour to that of chloroform; and the sensations I experience from the inhalation of ether are more pleasurable than those from chloroform. Many persons agree with me on both those points; but some prefer chloroform. The quantity of ether expended in causing insensibility is eight or ten times as great as that of chloroform, but the quantity used in a protracted operation is not so disproportionate; for, owing to the great solubility of ether and the large quantity of it which is absorbed, it is much longer in exhaling by the breath, and when the patient is once fairly insensible, it does not require to be repeated so frequently as chloroform.
In administering ether, I usually rendered adult patients insensible in four or five minutes, and children in two or three minutes. A somewhat longer time was occasionally occupied in cases in which the air-passages were irritable, or where there was much rigidity and struggling. I never failed to make the patient insensible in any one instance in which I administered ether. I have notes of 152 cases in which I administered ether, before chloroform was introduced, and twelve cases in which I have exhibited it since.
Nearly all the great operations of surgery were included several times amongst the cases in which I administered ether. Amputation of the thigh was performed in nineteen cases; fifteen of the patients recovered, and four died. Amputation of the leg was performed eleven times; eight of the patients recovered, and three died. The arm was amputated three times; one of the patients died, and two recovered. There were thus thirty-three of the larger amputations with eight deaths, being a mortality of twenty-four per cent. There were two amputations of the forearm, and both patients recovered. There were nine operations of lithotomy; seven of the patients recovered, and two died. Five of the patients were children, who all recovered; the two deaths occurring amongst the four adult patients. Eighteen female patients had the breast removed for tumour, and they all recovered except one.
On July 1st, 1847, Mr. Cutler amputated the leg of a man, aged forty-four, in St. George’s Hospital, who had suffered from disease of the tibia and ankle, which had existed thirty years, and was caused by an accident. This patient died on the seventh day, of sloughing phagedena, which was present in the hospital. It was then found that he had disease of the heart. Its structure was soft and easily lacerable; much fat was mixed up with the muscular structure. The aortic valves were much thickened, and almost cartilaginous in structure. Two of them were so much contracted that they were together about the size of a healthy one. The left ventricle was dilated, and the right ventricle still more so; its walls being extremely thin. The ether had acted quite favourably on this man.
I administered ether repeatedly in infants and old people. Some of the infants were operated on by Mr. George Pollock, in 1847, for congenital cataract by drilling; and two of them were operated on, in 1857, for hare-lip, by Mr. Fergusson and Mr. Bowman. A gentleman, one of whose toes the late Mr. Liston amputated in 1847, was said to be subject to apoplectic attacks. The ether acted very favourably. Amongst the operations which Mr. Liston performed on patients to whom I administered ether, was the tying of the external iliac artery in a man, aged forty, for an aneurism of the groin, situated partly above Poupart’s ligament. The patient lay perfectly still in this, as in all the other important operations in which I administered ether. He recovered.
On June 18th, 1847, I exhibited, in University College Hospital, ether to a man, aged forty-two, with stricture of the urethra, caused by an accident. He passed his urine only in drops, and the attempts to pass a catheter had all failed. It was Mr. Liston’s intention to divide the urethra in the perinæum, but when the patient was placed fully under the influence of ether to the fourth degree of narcotism, a catheter (No. 1) passed into the bladder, and the operation was not required. Larger catheters were introduced in a few days, and on July 27th, the patient was discharged, being able to pass his urine in a good stream.
Ether was administered in many cases of midwifery by Dr. Simpson, who had first applied it in obstetric cases, and by a number of other practitioners. I only exhibited it in one case, and then only for a short time. Mr. Lansdown of Bristol used it in thirty cases.[[162]] In one case, it was continued for eleven hours and a half, and fourteen fluid ounces of ether were used. He said that he invariably found the perinæum relaxed before the head came to bear on it, thereby not requiring the pressure of the head to force it open, in cases where ether was used. He says: “I find the uterus sending out the placenta immediately after the expulsion of the child, and there has been scarcely any hæmorrhage following.” Mr. Lansdown said that he had found the action of the uterus to be induced by ether, when in a sluggish state, but he had not found this effect from chloroform, in the cases in which he had used it.