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and bas adopted several modes of treatment; he, with Astley Cooper, bleeding from the saphena when Sir Everard Home, applied the ligature, and with some necessary, and applying a well-regulated pressure and success for a time, when pblebitis occurring, and other palliative means. death resulting, it was discontinued. Mr. Abernetby, M. Breschet tried the plan of pinching the vein with considering that the ligature was the exciting cause of forceps, constructed for the purpose; this plan frequently the phlebitis, suggested the mere division of the vein; answered the end of obliterating the veia, but often and Sir B. Brodic and others appear to have availed produced sloughing and ulceration, which in time was themselves of the recommendation.' In many instances cured. The process was tedious. M. Sanson also irritable ulcers supervened, and in most the benefit was copstructed forceps, with blades so broad as to keep very transient. Sir Astley Cooper, in speaking of the the sides of the vein in contact for nearly an inch. ligature and division of the vein, remarks, _“It was He remarks that it is not necessary to compress the formerly the practice, when the veins were in a varicose vein with a force to induce adhesive inflammation; it state, to tie and divide them; this plan is pursued by is sufficient to compress the vessel so as to arrest the many surgeons, but it is one that I bare deprecated in Row of blood through it, when a clot forms, which my lectures for many years; it is bad treatment, very ultimately becomes absorbed, and leads to a permanent injudicious, and fraught with great danger. I have seen obliteration. tbis operation prove fatal twice, and if I were to state Sir Astley Cooper, in speaking of the treatment of all the cases in which I have known it terminate fatally, varicose ulcers, says, “ The first thing to be attended to I should recount at least a dozen. Another over- is the recumbent posture, in fact this position is indiswhelining objection is, that when it does not prove pensable;" he then recommends mercurial washes and fatal, its ultimate effects are perfectly nugatory.” bandages. He also recommends the opening of the Whereas Signor Rima, in giving the results of thirty- veins ;—“ indeed they are so distended that they may four operations, by the excision of an inch long of the be more properly termed lakes than rivulets." He vein above the first varicose swelling, states that there advises the veins to be punctured twice a week, and were
speaks of the little danger attendant on the operation. 10 ...... . radically cured. He farther remarks, " if the puncture, however, at any 13 ...i'... much relieved. time should not unite, but fret into ulcers, you must 6 · · · · · · · slightly relieved. apply Liquor Calcis." 2 . . . . . . . not relieved.
Lallemand, Davat, and Velpeau, applied needles in 2 · · · · · · · deaths.
the manner recommended by Mr. Phillips, of London, 1 ....... under treatment. for the obliteration of arteries, and with success so I witnessed this operation performed in St. George's far, rendering the vein impervious for some distance Hospital, where every precaution was taken, and the of its course; it is a painful operation, and not always operation done in a masterly style ; nevertheless successful. phlebitis came on, which proved fatal on the third M. Fricke adopted the plan of Sxing the veia ucder day. The subject was about twenty-five years of age the skin, passing through it a needle armed with a and in the height of good health at the time of its strong thread. This was done at intervals of a few performance. This was the only case in which I have inches, in every vein that it was thought necessary to seen the excision of a portion of the vein, and there- obliterate. The ihread was mored daily in the vessel fore do not feel myself in a position to speak decidedly to excite inflammation, and was removed on the third on its value, yet from the relation of several cases, and or fourth day. With M. Fricke this operation was the table quoted from Signor Rima, we may conclude successful, whereas with Velpeau it was very unsucthat it is far from being free from danger.
cessful, for out of twelve patients inflammation of the It was about the year 1818, that Sir B. Brodie vein took place in all ; in three of the cases the adopted a new mode of dividing the vein with the inflammation was so excessive that the patients barely intent of preventing the irritable ulcers consequent on escaped with their lives, and the twelfth patient died of the old method. The operation consisted in passing a phlebitis. thin-bladed knife for some distance under the skin, M. Vel peau's method of applying the ligature over the vein, then turning the cutting surface down. appears to have been so successful in his lands, that wards, draw it across the vein, and divide it. In a very | I quote his plan more fully. A strong sharp pin large majority of these cases much good appeared to with a large head, and a waxed thread, are the result, and the operation for some time was held in only instruments used. The patient is to be placed repute; but I believe in almost every instance after a in such a posture as will render the veins tumid and short lapse of time the disease returned, and Sir prominent. The trunk of the vein is now raised up B. Brodie bas given it as his opinion that the operation with the fingers, the pin is passed below the ends of is not attended with a benefit great enough to justify the nails, and underneath the vein. It is necessary ito performance, and now recommends, as did Sir to protect the finger with a thimble, for the tissues
under the varicose vein are often very hard and re- | favourably of the principle, that I determined to give sistant. This process must be repeated with regard the plan a trial the first opportunity. It was not loog to every dilated vein; eight, ten, twelve, or fifteen pins before one presented itself, as in the month of August, may be required from the foot up to the knee, but, 1834, a cook applied to me for an old ulcer dependent generally speaking, three or four are sufficient. When on varicose veins, whose case I will relate, as it will the veins are free and moveable under the skin, it is suffice to show the manner in which the caustic has easy to pass the pins under them; but when they are been applied by me, and will show also the usual course applied closely to the bones, this is sometimes im- in the treatment of these cases. possible; it is then necessary to pass a strong pin Mary Jackson, aged 53, a cook, of full habit of body, perpendicularly downwards, and then direct it obliquely has been afficted with varicose veins for seventeen or under the trunk of the vein. The pins being all eighteen years, and during the last eight years has placed, are fixed with threads, by twisting the thread suffered from a painful ulcer above the inner ankle. in a circular manner round the pins, taking care to This ulcer has been healed two or three times during that draw it tight. The pins and ligatures are not removed period; it frequently confines her to bed, and renders before the sixth or twelfth day, when the tissues her very inactive and unfit for her work. The ulcer is embraced between them have been destroyed; but about the size of a crown-piece; the skin surrounding even if the eschar be not detached at this period, it it is ioflamed and hard. After keeping Jackson in bed is well to remove them, as there can be no doubt but for two days, and prescribing low diet, I emptied the that the vein is obliterated. “The introduction of vena saphena by raising the feet, and passing my hand the pin gives very little pain, but the constriction along the inside of the leg. A piece of adhesive exercised by the ligature is excessively painful. Hence plaster on leather, with an aperture in it of the size of you should commence with the highest pin, in order a shilling, was applied over the vein on the inside, and to cut off the nervous communication as much as just below the knee. The potassa fusa was freely rub. possible.” The tissues embraced by the ligatures bed on that part of the integument seen within the mortify and are separated, leaving a sore, which soon aperture in the plaster, until it assumed a dark-brown heals up. M. Velpeau further states, "Of more appearance. A warm poultice was then placed over than one hundred patients on whom I have operated the whole. I was pleased to find that the patient did by this method, not one has presented any dangerous not appear to suffer inuch. On the third day after the symptoms; some slight external phlebitis, and the application the distension of the vein subsided, and the formation of some small abscesses, were the only con character of the ulcer improved. On the tenth day the sequences of any moment tbat ensued. Still I always slough came away, and by that time the ulcer began to dreaded that such constant success in this matter heal. On the patient assuming the erect position, a would be interrupted by an unfavourable result, and cluster of veins was still observable, a few inches above my apprehensions have been unfortunately realized. the ulcer. The caustic was applied a little above the The only fatal case occurred recently."
cluster, with the same result as before. The distension The plan so much extolled by Velpeau I have seen disappeared, and on the twelfth day the slougla sepatried on three occasions ; the subjects were young and tated. This case speedily got well, and two years afterbealthy; the operations were performed by my late col-wards, on my examining the leg, the ulcer continued league, Mr. Wainwright, in a most excellent manner. quite well, and the veins appeared more arborescentIn the first there were slight symptoms of phlebitis, but that is, the minute branches were more observable which required active treatment to allay. In the than natural. second case the symptoms of phlebitis were more acute, Io the case alluded to there was no untoward gympand it was with difficulty that the patient was saved. tom, and from the result I was induced to persevere in In the third case, a troublesome ulcer formed, the the plan, and have now treated upwards of forty casos varix re-formed, and the operation was not renewed. in this manner. I have generally succeeded in healing I would state that one pin only was applied in each of the ulcer in an unusually short time. My only applicathese cases, and that we never ventured on this tion to the ulcer itself has been a little wet lint; and I operation again.
have observed the ulcer produced by the separation of In the year 1834 a gentleman requested me to operate the slough, and the original ulcer, heal about the same on bis leg. He had been quartered in Dublin with his time. In two cases, at the time of the separation of regiment, and had consulted an eminent surgeon there the sloughs, hæmorrhage came on to a considerable for varicose veins, and a small painful ulcer. The extent. In both instances the patients refused to consurgeon suggested the propriety of having the vein fine themselves to bed; with these exceptions I never destroyed by an application of potassa fusa. ' As I had experienced any unfavourable symptom. In one case never seen the treatment adopted, nor did I at the time the caustic was applied in several different places before know that it had been tried, I put the patient of as I the patient quite recovered. In this instance the woman best could. On considering the subject, I thought so had suffered from varicose veins and a painful ulcer for
twenty-three years; the ulcer bad been healed several bave returned, if the disease had recurred. A few times during that time, but did not remain healed for weeks ago a man (one of the five before alluded to.) a month together. This was decidedly the worst case applied to me to use the caustic again; he had been. I ever treated on this plan. It is now nine years since under my care two years ago. He stated that the leg had the caustic was applied, and during the whole of that become painful, and that a small ulcer had formed period she has continued well with one exception, and above the inner ankle. On examining the leg I found then, after a very hard day's wasbing, and exposure several knots of veins, and the ulcer was looking to cold, she had an attack of erysipelas in the leg, irritable. An eschar was made above the highest knot, which terminated in abscess and ulcers, which were when the distension subsided, the pain disappeared, troublesome to beal. After a few weeks' perfect rest and the ulcer healed quickly. she got well, and has continued so. The varix bad But supposing that this mode of treatment only followed a severe burn, which occurred when she was acts beneficially for two or three years, is it not fifteen years old.
superior to any other? It is free from danger; The minimum age of the patients attended by me there is no difficulty in healing the ulcers; even those was 22; the maximum 78. Of the forty-three cases of many years' existence yield to it. Sir Everard the shortest time of cure was nineteen days; the longest Home found it necessary to discontinue tying the time 147.
veins, and Sir B. Brodie and others deprecate the 10 were cured in a period averaging from 20 to 30 days. removal of a portion of the vein. The application of 15
30 to 40 the needles, according to Phillips's plan, and needle 40 to 50
and ligature according to Velpeau's, has not answered, 50 to 60
without occasionally producing inflammation of the 60 to 70 70 to 80 ,
veins, and is acknowledged by its inventor as “very
80 to 90 , painful,” and not unattended with danger. Sir B. . . . . . . took 147 » Brodie acknowledges the inefficiency of his mode of In most of the cases one es char has been sufficient. dividing the vein, and with Sir A. Cooper, contented Occasionally the caustic had to be re-applied in conse bimself with using palliative measures,—such as the quence of the slough not penetrating deep enough, so elastic stocking and bandages. The great advantage as to destroy the vein, whicb can be always ascertained of the caustic, as a means of destroying the rena by the patient's rising from bed. In several cases the saphena, over every other method, is the safety with caustic had to be be applied in more than one place, wbich it may be used, the facility of its application, seldom more than in two places, in one instance in and comparative ease to the patient. When necessary pide places. I have met with one case only that it can be re-applied, and this too, in several parts of baffled this means, and that occurred in an old man, the vein's course. Cases in which there existed great who had gloried in a bad leg with varicose veins for pain from inflammation of the ulcer and indurated many years; he had travelled the round of several integument, after the application of the caustic became hospitals, and I suspect used means to irritate the easy and bealthy. ulcers, for invariably when it was about to cicatrize, Mr. Mayo published a case in 1834, in which he I found a greenish slough present itself, which rapidly cured a varicose state of the veins in the leg by the threw back our attempts. This man left the hospital application of caustic issues. Sir B. Brodie also upcured.
mentions having applied the caustic potass in a case of the cases enumerated there existed a larger without any bad symptoms; he does not state why proportion of men than women; they were of he discontinued its use. And M. Bonnet, surgeon to various ages, from 22 to 78; the stature was generally
the Hotel Dieu, Lyons, has been in the habit of using middle-sized, and their occupations varied. Of these the kali with great success. The rules he gives for cases only five returned to me with a recurrence of the its application are as follows :-ulcer, and enlargement of the vein, and then not until 1. Many portions of caustic must be applied on the after a lapse of two years, and in one instance not until course of the dilated vein, at intervals of two or three after the expiration of three years, although they were | inches. invariably requested to return, in case the leg became 2. The application should not be made, except in scaid affected. In several instances I have bad the I those parts of the veins which correspond to the means of knowing that the cure has remained good. muscles. The only places where it should be applied In hospital practice there is considerable difficulty in are on the superior half of the leg, and inferior half of retaining a knowledge of patients after they leave the the thigh. institution ; nerertheless, it is only reasonable to sup- 3. The caustic must be applied at least twice at the pose, that out of thirty-four cases treated there during same points, in order to reach the vein. This supposes thirteen years, all of whom appeared pleased with that it is necessary, in order to obliterate the veins, their recovery, a greater number than five would to reach and open them with the caustic. In no case
PHYSIOLOGICAL ACTION OF INHALED ÆTHER.
after the first application, which only destroys the in several quarters, as the discovery of discoveries of the skin, and a little cellular tissue, hus the flow of blood nineteenth century, and as one of the greatest blessings been found to cease in the veins ; and they are to suffering humanity. It is true that some cases have nerer found converted into a bard cord, impermeable
been reported unsuccessful, and a few others have been to the blood. It is only after being opened that these
candidly represented as either fatal in the result,
or followed by injurious effects. changes occur. M. Bonnet has not even once seen
Amidst all these generally favourable and exceptionable & tendency in the inflammation to propagate itself
reports, although mostly given with practical detail, I along the course of the veins, although three or four ha
our have, as yet, seen no scientific solution of the modus applications of the potass had been made on different operandi of this novel application of æther on the animal parts of their course, and in the greater number had and sentient organism, and scarcely any attempt at a opened their cavity; the inflammation was, therefore, rationale of the process. Some have stated that the phy. in all these cases, limited by the bands of adhesion, siological action is narcotic; others sedative; while the and perfectly circumscribed. These results prove majority of those who have touched the question, have that destroying the veins with caustic potass does not
compared the effects of inhaled æther with those of expose the patient to the danger of phlebitis, “and,"
| intoxication from alcoholic liquors, or the Indian hemp.
After so much practical experience of the visible says M. Bonnet, “ finding every-day proofs of the
effects of this remarkable process, it may not be con. Ĩ
sidered premature now to examine some of the essenthan that of confining my patients to bed.”
tial conditions of the question, to see whether we can It is a question for the consideration of surgeons
seration of surgeons approach to any fair physiological solution of it. whether it were better to make a sufficiently deep In the first place we have the chemical substance, eschar on the first application of the caustic, so as to rectified sulphuric æther, long known and used in destroy the vein, or to apply it a second time, as recom- medical practice as a quick diffusible stimulant and mended by M. Bonnet. I have found it necessary in a antispasmodic. It is a compound of carbon, oxygen, and few instances to apply the caustic a second time, but in
hydrogen, and has a specific gravily of 0.750 at 400, and a very large majority of them the eschar was suffi.
| 0.715 at 60°, according to Dumas and Brande. What is
| its more peculiar property is the density of its vapour, ciently deep by the first application to destroy the vein,
being at the mean pressure and temperature, as 2.58 to indicated by its becoming converted into a hard cord.
air, asrl. The elastic force of its vapour is another like substance. Whenever I found the vein continuing
property of most important consideration, being at 54', pervious, which is denoted by its continued distension, Fahrenheil = 10.3 inches of mercury, at 640=15, and I re-applied the caustic. I have only found it requisite at 960=30 inches, gradually increasing in tension, till in ten cases to use the caustic, as recommended by M. at 212° it has a force of 240, according to Dalton; Bonnet, at several parts of the vein; in five of these it it, moreover, boils under a pressure of 30 inches, at was necessary to use it in two places; in two it was | 989, Fahrenlieit. · applied in four places; in two in three places; and in
Let us next examine the conditions of the subjective one in nine places. I do not advise its application at part of the theorem--the animal lungs and body, to see intervals of two or three inches at several parts of the
if there is any physiological path for us safely to follow,
The human body has a temperature, varying from 989 vein, as adopted by M. Bonnet. Where the first appli
10 1000, and we may consider the lungs, immediately cation is sufficient to take in the vein, it is usually
after expiration, to be about either of these temperatures. found sufficient for the cure. It may be requisite to The temperature of the æther inhaled has been at various apply it in more than one place, but this forms the degrees, from what is called temperate, up to 75o. On exception to the rule. When the slough comes away, this difference of temperature depend greatly the phya healthy ulcer is left, which usually heals by the sical and other effects of the æther vapour on the tissue simplest means, and generally at the same time with
of the lungs, and its ultimate force on the sentient brain. tbe original ulcer.
According to Dr. Snow, air, saturated with the vapour, at 54', conlains about one third of its bulk of vapour, and
at 750 it contains more than one half. The simple result ON THE PHYSIOLOGICAL ACTION OF
then of inhaling this vapour, at whatever degree of INHALED ÆTHER.
saturation, will be to increase its elastic force or excen
tric pressure, from 15 to 30 inches of mercury, if it By J. BLACK, M.D., Physician to the Manchester is inhaled at a temperature of 64o. If taken at 75°, at the Union IIospital.
full point of saturation, the practical increase of elastic The remarkable, and, we may now say, the popular, | force will not be very much less. There can be no con. adminstration of æther, by inhalation, for producing densation of this vapour in the lungs, for even if imbibed insensibility to pain, during surgical operations, and in a liquid state, the heat of the body, at 98°, would some idiopathic afflictions of the body, has been put to soon throw it into vapour, that temperature being its a very general trial throughout the kingdom. The result, boiling point, which is a very curious coincidence. according to the numerous reports, has been, in the great. From these conditions, excentric pressure must be, majority of cases, declared satisfactory, and in many with greater or less force, made on the air-cells of the cases 80 successful, that the process has been pronounced lungs; it may be hazardous to calculate the amount
but it must be great. The question now is, upon what | Professor Christisop mentions two cases where isbalatissue is this increased elastic pressure expended to tion of sulphuric æther produced,mia one, intermitting produce the phenomena of ætherization, among which, lethargy for thirty-six hours, with depression of spirits insensibility to physical pain and suffering is the most and lowness of pulse ; and in the other apoplexy for some conspicuous? Is it chiefly or solely through the channel hours, and the person would have perished had he not of the blood-vessels or the nerves of the lungs, that this been discovered. Brande appears no farther acquainted exaggerated pressure or irritation is conveyed to the with its physiological effects than that "it produces a sensorium commune ? for it appears that the physiological remarkable species of intoxication when its vapour is climax is there exploded.
respired, mixed with air." To solve, in some approximative manner, this point, It is unneeessary to advert much to the actual pheand to see how far the law of endosmosis might be con- nomena that occur after inhalation, as corroborating the cerned in the first part of the process, I inclosed, at the views of excentric pressure and distension obtaining in the common temperature, some rectified æther, in a piece of heart and blood-vessels, with more or less corresponding recently killed lamb's small intestine, which, after being irritation. We witness, where the process has been firmly secured and made perfectly tight by ligature, was successful, frequency and softness of the pulse, swelling found to weigh two drachms, including the contents, and general fulness of the vessels of the neck, head, and which only filled one half of the cavity to allow of face, with laborious breathing, congestion of the eyes, safe expansion. This little sac of æther was, with the and dilatation of the pupils. It would appear that in assistance of Mr. Hallsworth, apothecary of the Union many cases, while there seemed to be perfect insensiHospital, immersed and kept down in a vessel, contain-bility to pain, and a suspension of all voluntary moveing about six ounces of blood, fredhly drawn from a ments, yet a consciousness of the surrounding objects and healthy adult, and which was placed in another vessel operations remained, rendering this state very similar to of water, kept at the temperature of 1000 Fahrenheit. that of the mesmeric trance. This appears to be the The sac of æther was gently kept under the surface of most difficult part of the question to solve, and requires the blood by a stiff feather, without agitation, and being the most refined analysis for explanation. . withdrawn after ten minutes, was washed clear of blood, Not to leave the solution of this very interesting point and cooled down to its temperature before immersion, altogether unattempted, might not the partial dislocation when it was found to have lost fifteen grains, or about of nervous function be occasioned by the newly imbibed one-eighth of its former weight. This loss was entirely pressure on reaching the encephalon, being at first and of the æther, for the gut-membrane was the same as for a time, expended on the base of the brain, which is before; it was still tight to liquid æther, and therefore more immediately in contact or connection with the artethe loss must have been by exosmose through the gut- ries that convey the blood directly from the heart. The membrane. Besides, the blood at the end of the ex. sensury ganglia are here also more exclusively located, and periment smelled strongly of æther.
will first suffer suspension of their functions; but if the This rude and simple experiment may be taken for as blood has taken up an undue charge of the elastic vapour, much as it is worth, but I cannot help considering it as or if inhalation be continued too long, or if the subject is very much countenancing the view, independent of a of feeble resistance, the whole parts and functions of the priori probability or reasoning, that the vapour of æther, brain will suffer, and enervation, apoplexy, or death, through the elastic pressure which it exerts, permeates may follow. the walls of the air-cells of the lungs, becomes absorbed Without intruding farther upon your columns at by the blood currents, is thence conveyed directly to present, I have only to say, that as the whole subthe heart, and so quickly carried in a direct stream to ject is full of interest, it is very desirable to withdraw the brain. All this may be done in less than ten seconds, it as much as possible from the domain of speculation. according to the experiments of Mr. Blake on the into that of science; and if the few observations which, transmission of poisons by the blood-vessels. After the have here been made tend to provoke some more vapour reaches the blood current, its elastic pressure is exact and experimental researches on this engrossing substill kept up, if not increased, by the heat of the heartject, the writer will feel gratified to see the physiology of and other internal tissues. This adventitious force will the matter placed upon a more satisfactory basis than it at most, only increase the reaction of the central organ, is at present. and distend, more or less, the elastic calibres of the Manchester, March 15, 1847. efferent vessels; but when the distending agent reaches the brain in the current of the circulation, this elastic force meets with a counter pressure in the resisting case
ON THE EMPLOYMENT OF NUTRITIVE of the calvarium; its tension will therefore become in
ENEMATA. creased, and the consequence will be, the cerebral mass will suffer pressure, even to paralysis of some of its
By KENRICK Watson, Esq., F.R.C.S., Stourport. functions. This adventitious pressure being, however,
The following cases may perhaps be interesting to occasioned by elastic vapour, and not by fluids, however some of the junior meinbers of the profession as allepuated they may be, as alcohol, it may not, and does sheving the confidence which may be placed in not seem in general to lead to any serious or permanent enemas in those cases, in which either from severe lesion; in most cases the brain soon becomes relieved injuries of the throat or fauces the power of swallowing. by the dispersion of the very permeating vapour through. is lost, or on account of irritability or exhaustion the out the tissues, if not by its decomposition,
stomach rejects whatever is swallowed. I am very