ON THE INHALATION OF ETHER-VAPOUR. fracture; no pulse at the wrist. A long splint was adapted to the arm, and the patient allowed to leave his bed. 18th. Much headache and feverishness; arm uneasy; splint removed. Low diet and house medicine. 19th. Erysipelas supervened, involving the whole arm and shoulder. Limb to be exposed. Potassæ Nitratis, Potassæ Bicarb., utrq., gr. x.; Vini. Antim. Tart. m. xx.; e Mucil. Acacia, tertiis vel quartis horis. 24th. Erysipelas subsiding; skin efflorescing; a serous discharge escapes from the wound and two or three small abscesses have formed in the adjoining soft 129 or rather perhaps its defects, whenever there is reason and probability in its favour. In the instance of this novel plan for diminishing human suffering, whatever may have been stated on other occasions, sufficient has occurred to redeem the character of the profession, and to prove the readiness of its members to adopt any new suggestion, when supported by facts, and by the slightest colouring of reason. Whatever hints may previously have been given upon this new application of ethereal inhalation, we are undoubtedly indebted to our Transatlantic brethren for effectively starting it in practice, " Palmam qui meruit ferat." Not he who tamely offers a suggestion, but he who with energy and spirit forces his ideas upon the public, and starts them into practical life and activity, deserves the credit of an invention. In 28th. Erysipelas disappearing. A small piece of the short space of a few weeks the æthereal inhalabone has come away. October 24th. The force of the collateral circulation quite perceptible at the wrist; can slightly flex the fingers but cannot raise the arm without assistance. There still continues a discharging sinus, from which an additional portion of bone has exfoliated; the surrounding soft parts are becoming more healthy looking, although still ædematous and swollen, particularly about the elbow. Apply light pressure by means of a bandage, and make him an out-patient. December 26th. Regaining a useful, though somewhat shortened arm; can raise it without assistance; flexion at the elbow still much limited; can grasp pretty strongly with the hand; pulse established at the wrist. Ordered to use the limb, and to be discharged, cured. (To be continued.) PROVINCIAL tion has been tried in our own country in many hundreds of instances; in all parts of the provinces, as well as in the great centres, the metropolis of each division of the kingdom; employed for avoiding pain, not only in the slighter matter of teeth-extraction, but in all cases of the great amputations and other capital operations, and even to strangulated hernia, extirpation of the eyes, ovariotomy, the Cæsarean section, &c. In a small proportion only of these cases, of whatever description, has the process failed to take effect; and although to a few patients it has proved inconvenient, to none is it reported to have proved fatal, and very little has yet been written upon the cases to which the new measure is inapplicable. Such is the usual course of a novel plan launched upon the wide ocean of practice under popular favour. All appears fair for Medical & Surgical Journal. a prosperous voyage; but it is a voyage of dis WEDNESDAY, MARCH 10, 1847. covery; the quick-sands and dangers are at a distance, and we must wait the navigator's return ere we can learn the whole issue of the undertaking. The inhaling for the production of narcotic or intoxicating effects is not new, but the extensive The process of inhaling æther for the avoidance of pain during surgical operations, has taken so fast hold of almost every professional man in this country, that it behoves the jour-adoption of it, in the manner we are considering, nalist to look to the subject, and from his focus of information scatter a few useful remarks and cautions on the employment of this new process. How often has accusation been made by enthusiasts of various descriptions against members of our profession generally, for their incredulity and prejudices in respect to the several delusions with which this age of quackery teems. Yet was censure never less justly applied. The profession are commonly eager enough to embrace any new proposal, and give a laudatory report of its application; too often indeed, at first, without due regard to its effects, may still render a new term convenient, and even necessary. The instrument employed, of whatever construction, has received the appellation of "the Letheon," and from this root is readily to be derived all the terms required. The phenomena which a letheonized patient presents, are very similar to those of intoxication, varying in degree from hilarity to half consciousness, complete narcotism, total insensibility to external impressions, failure of pulse, syncope,—may we not add death. The most striking, if not notice of the occurrence of a fatal case, which will be Since the preceding observations were written, a found narrated in another column, has been received, the peculiar circumstance, is the rapidity with which the effect is produced, the shortness of its duration, and its equally rapid subsidence. The brain is the organ acted upon, and in proportion as external impressions are shut out, internal ideas seem to be generated. A letheonized patient is a sort of Ryp Van Winkle; he dreams away twenty years of his past life in a minute, but with equal surprise, and unlike his predecessor, on awaking to the world again, finds it much as he left it. These psychological phenomena will doubtless furnish a fine study for the physiologist and the metaphysician. fear, find these to be numerous and grave, as, judging from the examination we have made, in referring to names well known in our larger towns, and not unknown also in the great metropolis itself, scarcely that care which is requisite would seem to have been employed. Certain of these errors are, no doubt, to be attributed to gentlemen applied to by circulars, having neglected to forward the information asked for; others to the unfortunate scrawls in which too many of our brethren are wont to render themselves unintelligible. But what shall we say for sundry errors of omission and commission, in cases where the information sought for has actually been supplied? Possibly a portion of this may have.been thought too trivial for insertion; and had a line of exclusion been drawn, by adherence to which equal justice might have been dealt out to all, in the giving or withholding of titles, appointments, and other claims to consideration, there would have been little cause for complaint; but when we find to some gentlemen ascribed, in addition to genuine qualifications, obscure appointments of which Nothing is more remarkable than what every one who sees half-a-dozen letheonized patients will be sure to witness,—a state of half-consciousness, with eyelids open, a congested countenance, a frightened stare. The patient is sensible of persons present, and talking, and because he is still in a degree sensible, protests against the operation, whilst it is actually being performed; and on the letheonic influence subsiding, which it does in two or three minutes, he reports the nobody ever heard, or the publication of some brief trial a failure, and waits the operation, which is already completed without his being conscious of it. How are such opposite states of the sensorium compatible? May we conjecture that the succession of ideas is so rapid, that they seem coincident or synchronous, though really successive and alternating? But we pass to the less speculative part of the subject, as more immediately applicable to our purpose, and we urge our provincial brethren to emulate those of the metropolis in helping to elucidate the use of the Letheon, and particularly to giving us an account of any unfavourable result of the trial, any cases that may seem unsuited to it. We can scarcely persuade ourselves that the pain naturally attendant upon all mutilating operations upon the human frame, is to be quite annihilated by this discovery, although nothing could be more congenial to the wishes of both the patient and the operator. It will probably turn out that there are cases to which the measure is wholly unsuited, wholly improper. When next we dip pen" in æthereal fluid, we shall endeavour to write a few cautions, and give a guarded prognosis, as to past or prospective events; meantime, let the incautious Letheonizer beware, remembering that "all is not gold that glitters." Reviews. The London and Provincial Medical Directory. 1847. In an undertaking of this description, especially on the occasion of its first publication, the occurrence of errors is unavoidable. Our provincial friends will, we epistle which nobody ever read, "Behold Dalhousie, great God of War! "Lieutenant-Colonel to the Earl of Mar!" while from others, all mention of long services as medical officers, whether civil or military, is withheld (due information fsuch services having been supplied,) we are at a loss to devise a palpable excuse for the omissions. With the question which is attempted to be raised, as to the degree of estimation in which the license of the Apothecaries' Society, and the diploma of the London College of Surgeons, are respectively to be held, we do not feel disposed here to intromit; but we may observe that we find the term General Practitioner,' by which it is professedly intended to designate the possessor of the former, sometimes misapplied to those who hold only the diploma of the latter. But with all this, the publication is one which is calculated to be of great utility. Even in its present imperfect state it affords much information which can nowhere else be met with; and if the errors åre duly corrected, which can only be fully and effectually accomplished by individual medical practitioners communicating the requisite information, the edition of another year will prove most acceptable to the entire medical profession. A Tabular view of the Physical Signs and Diagnosis of the Diseases of the Lungs; with a Synopsis of the Signs which occur in each Disease. By JAMES TURNBULL, M. D., Physician to the Liverpool Northern Hospital. London. We notice this work simply with the view of directing the attention of our readers to a very useful summary of the diagnostic symptoms and characters of diseases of the lungs. The table is folded in a royal octavo BIRMINGHAM PATHOLOGICAL SOCIETY. size, and bound up with the accompanying synopsis, with which it admits of convenient consultation and comparison; but it may be also detached and mounted for setting in a frame, and hung up in the consulting room for more ready inspection and reference, as called for. In either way it affords at a glance much valuable information, which it would require the pages of a goodly octavo to set forth. Proceedinys of Societies. BIRMINGHAM PATHOLOGICAL SOCIETY. January 2nd, 1847. FREDERICK RYLAND, Esq., in the Chair. RUPTURE OF THE LEFT VENTRICLE OF THe heart. Dr. Fletcher presented a specimen of rupture of the left ventricle of the heart, and read the following letter which he had received from Mr. Savage, of West Bromwich, who had kindly forwarded the specimen to be exhibited to the Society : "Dear Sir, I send you a report of the case connected with the specimen of rupture of the heart I gave you to-day. "Samuel Allden, of Birmingham, was brought to my surgery about 7 a.m., on Monday last. He was quite dead. It appears he left Birmingham about 6 a.m. of the same day to walk to West Bromwich, to see his son, who resides here. He was overtaken by a coal cart about mid-distance between Birmingham and this place. He asked the man to allow him to ride with him to West Bromwich; he complied with his request. The deceased got into the cart, and sat with the driver on a board put across the cart from side to side. They conversed together on the way cheerfully; the deceased made no complaint whatever. On getting within half a mile of this place the deceased suddenly fell over into the body of the cart, never spoke after, gave one or two gasps, and appeared dead. The man drove at once to my surgery, where on seeing him I found him dead. I have heard from his son that his habits for the last thirty years have been very intemperate. “Post-mortem eight hours after death. He was of nervo-lymphatic temperament; rather full habit of body; no appearance of external injury. On opening the chest and abdomen the cellular tissue was somewhat loaded with fat. We found the pericardium very much distended, and on opening it discovered it to be filled with black blood, both fluid and coagulated, at least amounting to thirty ounces; the left ventricle of the heart we found ruptured; the lungs healthy; no adhesions. The mucous coat of the stomach was inflamed and softened; the liver enlarged, otherwise healthy; the intestines healthy; the bladder and kidneys nor. mal. I did not open the head. There was, in fact, almost the entire absence of any disease except the rupture of the heart." The heart was enlarged to about half above its natural size, which consisted of a general and equal dilatation of all its cavities, and a corresponding 131 hypertrophy of their parietes. The rupture, situated on the inferior portion of the anterior surface of the external laceration left ventricle, consisted of an about an inch and a half long, extending from about an inch from the septum upwards and outwards, at the inner terminus of which was a round aperture about the size of a large swan quill, which communicated with the interior of the cavity of the left ventricle. In the interior was another laceration or extended ulceration, by which one of the columnæ carneæ had been divided, lined with lymph, and crossing the direction of the external laceration, so as to form a St. Andrew's Cross. The inferior portion of the left ventricle was very much softened. The mitral valves were thickened at their edges; the aortic valves natural. The aorta was dilated, its lining membrane studded with a few patches of atheroma and one of ossific deposit. The apertures of the coronary arteries were dilated, and these arteries themselves much dilated and ossified, particularly the branch of the left coronary running down to the softened and ruptured portion of the left ventricle. The heart was very much coated with fat. Microscopic examination with a Powell's microscope of Dr. James Russell's, in which he kindly assisted:-In a portion of muscular structure taken from the upper part of the ventricle, where the structure seemed healthy, the muscular fibres were healthy, and the striæ complete; a few fat-globules floating around the edge. In a portion taken from the lower part of the ventricle, where the structure of the ventricle was softened, the fibres of the muscular structure appeared under the microscope smaller than natural, and the striæ in most parts totally absent; in some few portions the striæ were slightly to be perceived when out of focus, so that it is presumed, quite the superficial surface of the muscular fibre was brought into view; there were numer. ous fat-globules. In a portion taken from the ruptured part of the heart, the muscular fibres were very indistinct, and the striæ, as in the second portion examined, only seen in some parts feebly, and when out of focus; there was abundance of fat-globules. Dr. Fletcher said that this appeared to be a case of rupture resulting from ossification of the coronary arteries, having caused softening and disorganization of the muscular structure of the left ventricle; the internal laceration must have been caused first, and whether this commenced by laceration or ulceration it is now impossible to determine, but the deposit of lymph shews it to have been of some standing. The microscopic examination is interesting, as shewing the alteration of the structure of the muscular fibre to correspond with the ruptured and softened portion of the parietes of the left ventricle. ABNORMAL ATTACHMENT OF THE FUNIS. Dr. Fletcher exhibited a placenta, membranes, and funis, which had been brought for exhibition to the Society, by Mr. Wright, who gave the following description of the case : After delivery the membranes came away separated from the placenta and attached to the cord, and contained. so much clotted blood that it appeared as if the placenta itself was come away, which, on examining the cord and membranes was found not to be the case. On examination per vaginam, the placenta was found within the os uteri, and brought away in the hand, and no trace of attachment of the cord to any part of its surface could be discovered. OPERATIONS PERFORMED UNDER THE INFLUENCE OF ETHER. By WILLIAM PHILPOT BROOKES, M.D., M.R.C.S., Surgeon to the General Hospital and Dispensary, Cheltenham. Since reporting my former case, I have successfully performed the following operations under the effects of the inhalation of æther : Ann Weston, aged 69, living at No. 1, Burton Street, had been suffering for the last twelve months with fistula in ano, and had been during the whole of the time confined to her bed. She was of a very nervous debilitated habit, aud would not give her consent to the performance of an operation, but upon hearing of my former painless case, she sent for me, and desired to have the operation performed. On examination I found the whole verge of the anus in a state of ulceration, accompanied with great pain. The probe discovered a fistulous sore, extending full four inches into the rectum, the walls of it of some thick. ness. Having put her in train for performing the opera. tion, it was done in two days afterwards. The patient was laid on her back, with the head elevated, (so as to have no difficulty with the ether,) the buttocks raised, knees drawn up, and held apart. I then passed up my finger, inserted the director, when the inhalation of the æther commenced, (with merely a bladder and elastic tube,) and she was in a complete state of uncon. sciousness in two minutes. The bistoury was then introduced, and the fistula divided in its whole length without the patient showing the least symptoms of pain or uneasiness. When it was over I asked her if she had quite made up her mind to have the operation performed. She said, "Yes, please go on with it as quickly as possible." When told it was over she uttered great surprise. At this operation the following gentlemen were present:-Drs. Wright, Bagnall, Bree, Smith; Messrs. Eves, Ocrell, Peart, Alix, Tibbs, Rowe, Norman, and Churches, and all agreed and expressed themselves perfectly satisfied with the result. The next case was that of Ruth Monk, aged 21, who wished to have the last molar tooth extracted under the æthereal influence. She is of full, plethoric, and excitable having had nine out before, she could judge of its effects, and said, "I will never loose another tooth except I am prepared in a similar manner so as to have no pain." were February 1st, 1847. The following cases operated on to-day, in the presence of fifteen gentlemen, most of them members of the profession : John Coombes, aged 56, a labourer on the roads, residing at Charlton, of a strong plethoric habit of body. Whilst at work he met with an accident (three weeks back,) to the middle finger of the right hand; mortification took place, and the first joint sloughed away; still he would not consent to the loss of the finger, and the disease extended to the metacarpal bone. Having heard he could have it taken off without suffering any pain he applied this morning to have the operation performed. The ether was inhaled and the man under its effects in six minutes. He remained so for five more, and the finger was taken off by a V shaped incision, opening the metacarpal bone half way down with Liston's bone nippers. The patient did not shew the slightest sign of pain, and stated that he heard the bone cut, but positively asserted he felt no uneasiness of any kind, and grumbled much at the suffering we gave him when taking up the arteries afterwards. I allowed this case to remain for half an hour before I dressed it, as I am inclined to think secondary hæmorrhage will often occur after the effects of the other have passed away; reaction does not until then become perfectly established. Small arteries often escape untied if we dress immediately, and union will not take place so well on account of extravasation of blood. The pulse in this case was before the operation 84, and during the ethereal process it varied from 60 to 70. William Guy, aged 21, residing at No. 44, Duke Street, of a pale exsanguineous habit of body; has had phymosis from syphilis for several months, and wishing to have the glans penis liberated, submitted to the operation. The ether was inhaled, and produced its effects in three minutes. The skin was then divided down to the end of the glans without any sign of pain, and he states he did not feel anything of it. Pulse when in the ethereal state was 75, and soft, and before that time 90. A servant, aged 30, had four stumps extracted without giving her the slightest pain, by Mr. S. Tibbs, The ether was inhaled surgeon-dentist of this town. from a modification of Dr. Snow's apparatus, and she got under its influence in less than two minutes, and remained so nearly five. Positively states she felt nothing. habit. In one minute and a half she was in a state of unconsciousness from the æther and became quite unmanageable, her face flushed, and she required two Lot Organ, aged 36, residing in Grove Street, of persons to hold her. I lanced the gum without any spare habit of body, has had a disease of the left elbowsign of pain, and she recovered her sensibility imme-joint for the last year or two, and would not consent to diately. As she was very anxious to have the tooth extracted, she again inhaled it, and when under its influence some excitement returned, and on drawing the tooth with the claw she cried out, "Oh!" but on -coming to herself stated she had had no pain; and its being amputated before, but the general health becoming injured, he now consented. The æther was given with Snow's apparatus, and after its inhalation for nearly four minutes, he appeared quite unconscious; the healthy arm dropped involuntarily to the side when INHALATION OF ETHER. raised, eyelids closed, and all the usual signs of insensibility to pain. The circular incision was now made through the skin, and he cried out most lustily, and continued doing so through the whole stage of the operation. After it was all over he stated he felt the first cut, and also the bone sawed, but he was in a dream, and smoking a pipe, which some one tried to take from him. I can only view this case as a failure, and I think it right alike to report all, whether failures or not. The other cases were decidedly successful. I may state in the above operation the mouth-piece did not nicely fit the mouth, and he appeared to have inhaled fresh air by its side. Albion House, Cheltenham, REMOVAL OF THE GREAT TOE AND PART 133 I thought it desirable that my patient should be previously tutored in the process of inhaling, and for that purpose induced her to inhale the æther the day before the operation, which she did, to the entire satisfaction of both of us. This appears to be a matter of some importance, and likely to contribute to the success of the process, for there are several precautions which are better thus explained beforehand, and the patient will be less likely to be affected by timidity at the time of the operation. The points which appear to require particular attention are: 1. To tutor the patient beforehand in the process of inhaling. 2. To give charge of the inhaling apparatus to a trustworthy assistant, who should keep the mouth-pad in firm contact with the lips. 3. To allow two or three inspirations to be made before removing the small stopper, and applying the nasal spring, otherwise the full volume of the vapour will be likely to excite coughing and a sense of suffocation. 4. To cut off the supply of vapour for a time, by By T. HEREFRT BARKER, M.B., M.R.C.S. Emma Rawlins, aged 23, of Cople, near Bedford, had turning the stop-cock and removing the nasal nipper, when deep insensibility has been produced. been labouring under strumous disease of the great toe, involving the phalanges and part of the metatarsal bone, during the last five years, and was anxious to have the diseased parts removed by operation. Desirous of giving her the benefit of inhaling the vapour of æther, I procured the apparatus constructed under the directions of Dr. Boott and Mr. James Robinson, and sold by Mr. Hooper, of Pall Mall, London, and yesterday removed the parts in the following manner, with the kind assistance of Mr. Hurst, and in the presence of Messrs. C. W. Hyne, W. Bailey, Anthony, Birch, Cox, and Ravenscroft: Having succeeded in about four minutes in getting her thoroughly under the influence of the vapour, a flap of good size was made, with a scalpel on the inner side of the foot, the metatarsal bone being laid bare beyond the extent of the disease. A strong bistoury was then passed through the space between the metatarsal bones of the first and second toe, in close contact with the former, and brought out anteriorly; the flexor and extensor tendons were divided, and the metatarsal bone nipped through with Liston's forceps. The exposed surfaces were sponged, and the flap secured by three points of interrupted suture. The morbid effects of the inhalation of æther have yet to be made out, and good service will be rendered to the profession and humanity, by any one who will investigate the precise effects of this powerful agent, when administered in cases complicated with pulmonary, heart, and a strong predisposition to cerebral disease, cardiac, or cerebral mischief. Some affections of the will probably be found to be the morbid conditions more particularly contra-indicating its employment. Bedford, February 16, 1847. REMOVAL OF THE NAIL FROM THE GREAT On Monday, January 18th, Mr. Rudall, surgeon, of Sheepwash, North Devon, in the presence of J. G. Maxwell, Esq., performed the operation of removal of the great toe nail with part of the toe, on the person of an athletic farm-labourer, aged 22 years, the patient being put under the influence of the æther vapour. The result in the most satisfactory manner, confirmed During the operation, which lasted but a short time, all that has been reported of this extraordinary means the supply of vapour was cut off by means of the stop-of subduing pain in the performance of surgical operacock; she did not in the least shrink from the knife, nor tions. The vapour was administered by means of an did she manifest in any way the slightest sign or expression of pain. On regaining her consciousness, she inquired when the operation would commence, and on being told that it was all over, stated that she had been asleep and dreaming. The testimony of so many operators has already been recorded of the efficacy of the inhaled æther, in completely deadening the sensibility of the system, during severe and protracted operations, that there cannot be a doubt that this is one of the greatest discoveries of the age, productive as has been that age of great discoveries. apparatus extemporaneously constructed, and consisted of a large-sized bullock's bladder, to which was connected a tube of half an inch in calibre, and two and a half inches in length, this was attached to a bulb capable of containing about eight ounces of fluid; continued from this was a tube seven inches in length, and a quarter of an inch in calibre. The æther (six drachms,) being put into the bladder, which was afterwards inflated, and the tube being introduced into the patient's mouth, the inhalation was commenced. In rather less than one minute perfect insensibility was produced, a gentle tremulous motion of the lips, |