ON THE USE GENERAL RETROSPECT. AND ABUSE OF MERCURIAL Dr. Sichel gives the following cautions as necessary in the exhibition of mercurial preparations : 1. The diet must be in no-wise stimulant, and as little nourishing as possible. If this is not attended to the plasticity of the blood becomes augmented. 2. All notable change of atmospherical temperature should be avoided. Unless this rule be observed, numerous disappointments will occur, and premature salivation is especially likely to be induced. 3. It is a general law that the special physiological action, or the toxical effect of a medicinal substance, only manifests itself after its action upon the pathological condition has become exhausted. The operation of this law is well seen in the employ. ment of narcotics in those affections of the nervous system which afford distinct indications for their use, as neuralgia and tetanus. This last, we know, demands large doses of opium, but the point of saturation must be carefully watched so that the drug may be laid aside when the precursors of narcotism begin to replace the tetanic symptoms; unless we wish to see, as I have often seen in the hospitals, the patient cured of the tetanus to die by opium. The physiological action of mercury is exerted upon the salivary glands, and with the earliest precursory symptoms of salivation, the blood has already lost some of its morbidly plastic character. It is indeed remarkable to what an extent acute inflammation becomes relieved, upon the appearance of the precursors of salivation, and how long these are in making their appearance in intense and essentially erudative inflammations, as iritis, peritonitis, and especially puerperal peritonitis. In this last we are sometimes surprised at finding the abdomen, which the evening before would not endure the weight of the clothes, supporting next day firm pressure of the hand, the precursory symptoms of salivation having manifested themselves in the interval. These are indeed the signs of the system having become sufficiently saturated with the mineral, which must be left off as soon as they appear, our object not being, save in very rare and obstinate cases, to excite actual salivation. Instead of then pushing on the mercury, if the disease does not yield, we must, in the case of inflammation, bave recourse to other antiphlogistics; and in the case of syphilis, to iodine, sudorifics, &c., carefully limiting the regimen, and avoiding exposure to cold. When, however, the precursory symptoms are dissipated, and the disease has not yet yielded, we may turn again and again to the mercurial treatment. In syphilis this is almost always necessary. It is from the non-observance of the above rules, that so much mischief has been caused by this remedy, and so much prejudice has been raised against it. The excitement of profuse salivation is especially mischievous. The anti-plastic action of the drug may, after long use, so diminish the coagulability of the blood, as to produce a mercurial scorbutus, very difficult to care. Marasmus may likewise be produced, especially in children and aged persons, if mercury be employed sufficiently long to induce ptyalism or diarrhea, or 79. the two conjointly. Calomel, particularly, must be given to such subjects with great care. It is not sufficient to withhold it when salivation or purging already exist; but at every visit the condition of the salivary organs and digestive tube must be carefully enquired into. From neglect of this precaution, infants often suffer severely from the prolonged use of calomel.-MedicoChirurgical Review, Jan., 1847, from the Revue Médicale, Nov., 1846. SURGERY. OPERATION OF MYO-TENOTOMY. [There can be little doubt that in this, as in all other new operations, there is some risk of abuse, from the want of a due consideration of the cases to which it is safely applicable. It must therefore be a matter of interest to the surgeon, to know what are the veritable indications for its performance, and what are the cases in which mechanical means alone will prove sufficient.] A man According to Neumann there is but one pathological condition which is indicative of the propriety of the section of tendons; this is muscular retraction. When this is not present, whatever be the state of the parts, the operation will not be followed by its expected results. The muscular retraction referred to manifests itself in general, by a tension and hardness of the tendon or its muscles, which cannot be accounted for by the state of the affected limb. We must be careful not to confound the retraction of a muscle, with a shortening of its fibres. To shew the importance of a due distinction of these conditions, it will suffice to glance at one of the affections for which tenotomy is most frequently employed, pes equinus. in perfect health is able, at pleasure, to induce such contraction of the gastrocnemii muscles as shall elevate the heel as much as is commouly seen in pes equinus. There is no proof, therefore, that the tendon is shortened in this affection; it is only retracted, and tenotomy destroys the morbid retraction and rigidity of the fibres, without necessarily causing the elongation of the tendon. And even if it did so, the elongation would be inconvenient, for although the patient would be able to place his heel on the ground, he would walk defectively. Again, it is necessary to separate morbid retraction of the muscles and tendons from that which occurs in the aponeurosis and ligaments, forming a real shortening. Among the diseases which require tenotomy, and which depend upon muscular retraction, the author establishes two classes,-those which are general, or those which may appear indiscriminately in any part of the body, and those which are confined to particu. lar localities. The first class includes paralysis and anchylosis, when these are accompanied by permanent retraction of the muscles; certain accidents to which the joints are subject, and which are always accompanied by muscular retraction, such as insensibility, sensation of cold, &c. In the second class he comprises strabismus, ptosis, tortuosities, club-foot, and articular retractions. Another important question is whether, when several muscles are simultaneously retracted, they should be operated upon at one or several different times. On this point the author is opposed to M. Guerin, and affirms that it is better to divide several muscles at once if they belong to the same region. If another articulation or limb requires an operation, it should, he observes, be always at an interval of a week at least from the former one. The author farther states, that tenotomy should never be performed on infants under a year old. The operation for strabismus ought not to be recommended before the age of eight or ten years, as up to this time the resources of nature may prove sufficient. So also for club-foot, we ought never to operate before the age of twelve years, because previously to this age a cure may be accomplished by mechanical means alone. After the age of sixty the author thinks tenotomy useless. Inflammation of a retracted articulation is a potent contra-indication to an operation in all cases.— Casper's Wochenschrift. minds of the bystanders. I applied cold to the head; gave some brandy and water, for his hands were cold; and admitted fresh air freely into the room. Soon the cataleptic symptoms disappeared, and were succeeded by severe hysteria, with about the same degree of consciousness as is usual in that disease. With some difficulty I led him to the outer door, when he exclaimed"Cover my chest," "cold, cold, cold." He was then removed to the sofa, when he was seized with severe cramp in the legs, the difficult breathing still con| tinuing. I gave more brandy and water; applied hot flannels to the feet, and cold water to the head; admitted fresh air freely, and watched the progress of the case with no little anxiety; for these distressing symptoms continued for more than an hour, during which time I had to contend against the most fearful apprehensions of the mother, as well as to administer reljef to a near relative who had voluntarily taken a poison, the effects of which I had not before witnessed, and the probable result of which I could not from experience determine. At last a few deep inspirations ushered in a state of OBSERVATIONS ON THE INHALATION OF semi-consciousness, the patient raised himself to a SULPHURIC ÆTHER. By E. COPEMAN, Esq., F.R.C.S., Coltishall. Amongst the novelties of the day nothing has excited a greater or more universal degree of interest than the performance of surgical operations without pain. The reason for this is so obvious that it is needless for me to refer to it. Through the instrumentality of the press, both medical and general, facts are daily brought before the public which prove to demonstration, that by means of the inhalation of æther, the pain of a surgical operation may be avoided; and it is very probable that the wide diffusion of these interesting facts may lead to a trial of the effects of the vapour of æther, not only by surgeons, but also by some who are not educated to the medical profession. But it seldom occurs that a great good is unmixed with evil; and I believe it to be as much a duty on the part of surgeons to represent and warn against danger, as to relieve suffering, and cure disease. Upon this principle I lose no time in communicating the circumstances attending a trial of the inhalation of æther, on the evening of the 23rd instant, in my presence. The experimenter was a medical gentleman, who requested me to extract a tooth for him, provided he could make himself insensible to pain by means of æther. He breathed the vapour for several minutes without any apparent effect, but soon afterwards thrust the apparatus suddenly from him, exclaimed that he could bear it no longer, staggered about the room, and was assisted to a chair. His breathing became very difficult; his arms were stretched out; his fingers extended; and he was perfectly cataleptic. I would then have attempted to draw his tooth, but he showed some resistance, and his breathing was so exceedingly laboured, that it would have been almost impossible to perform that or any other operation. Each expiration was accompanied with a loud Hah! his eyelids were closed; his head was hot; pupils not altered; conjunctivæ much injccted; pulse 120; and his appearance altogether was so distressing as to excite great alarm in the sitting posture, and looked about him with a vacant stare, the conjunctivæ being very red and suffused. He attempted to rise, but tottered like a drunken man, and suffered a degree of exhaustion and giddiness which lasted until he was taken to bed. He slept well, but next morning complained still of languor. I should mention, that while he was lying on the sofa I applied strong ammonia to his nose, without its producing any visible effect, and he had afterwards no recollection of the circumstance. The description afterwards given by the patient of his sensations whilst under the influence of the æther, was as follows:-He felt nothing for several minutes, but on a sudden appeared to lose all muscular power. He seemed to take leave of the external world, but experienced a dreadful sensation of universal tremor, and yet a perfect fixedness of the limbs. He felt irresistibly disposed to lie down, and get his head upon the ground; was much distressed with a sensation of cold, also of tightness across the chest; and although he seemed to be aware that persons were talking to him, had no consciousness of what was really passing around him. He said his sensations were so dreadful that he would rather undergo any amount of pain than submit to the same again, which he could compare only to a state of utter helplessness and impending dissolution. The impression on my own mind was, that I would on no account willingly produce a similar train of symptoms; and that, if such were to be the frequent effects of the æther, there would be few who would wish to exchange for them the pain of a surgical operation. The apparatus employed was a glass jar, with openings at the top, into one of which was inverted a flexible tube for inhalation; and into the other a funnel, containing a piece of sponge, saturated with æther. About an ounce of æther, and several pieces of sponge, were in the jar. The patient was 23 years of age, spare, and of nervous temperament, with a brain very active and excitable. The time at which the inhalation was performed was soon after dinner; I presume, INHALATION OF ETHER. therefore, that neither was the constitution of the patient suited to the exhibition of æther, nor the time for the performance of the operation judiciously chosen. Certain I am, that it would have been extremely difficult to perform any operation requiring steadiness or delicacy in its execution during the presence of such symptoms as were produced in this instance by the inhalation. It is clear that great judgment is required in the selection of cases, and that the inhalation of æther ought on no account to be practised by any but competent medical practitioners. The object for which it is employed is so desirable, that in all probability it will become general in the profession; but in order to be useful, it must be safe, and I trust the above narrative will prove, as it is intended to be, a warning against the indiscriminate employment of a powerful agent, which, in incompetent hands, or under unfavourable circum. stances, is capable of producing very disagreeable if not dangerous effects. Coltishall, January 25, 1847. AMPUTATION PERFORMED UNDER THE TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SIR, The result of operations performed upon patients under the influence of æther, will, for a long time to come, be regarded with peculiar interest both by the medical profession and the public; and it seems desirable that the practice of reporting all the cases which occur, whether favourable or otherwise, should be continued, as affording the best means of enabling us, in due time, to obtain a correct knowledge and form a just estimate of the real value of this highly interesting and, I hope, most happy discovery. I am consequently induced to send you a brief report of a case which I had at the Northampton General Infirmary, on Thursday, the 21st inst. My patient, a little boy 12 years old, had for two or three years been the subject of scrofulous disease of his left knee. Treatment had proved useless, and his constitation had begun to feel the effect of local disease. Amputation therefore became the only chance of saving life, and to this both the parents and the patient were at length induced to consent. The means so happily discovered for preventing the pain of surgical operations not having been tried at this Infirmary, I determined to avail myself of this case for the experiment, and had arranged to call upon the parents and request their consent, but fortunately the mother, anticipating my wishes, waited upon me, and requested that either this or any other measure might be adopted if it could afford a chance of relieving her child from the agonies of the operation. I thought it expedient to try the effects of inhalation the day before the operation; and I am inclined to attach some importance to this, believing that some cases of failure, which have been reported, might possibly have been successful, had such a measure of precaution been used. The little boy was at first rather alarmed, and, from the effects of agitation and apprehension, not able to breathe the vapour well, but by a little gentle persuasion and encouragement he soon succeeded in doing 81 He so, and in about two minutes the stupifying effect of inhalation was full and satisfactory. By various little means we assured ourselves that he was unconscious of pain. He was pleased when he awoke, and talked about his nice dreams, and, the next morning, when I went to him, a little before the time appointed for the operation, I found him quite cheerful, and apparently feeling confident that he should not suffer any pain. said he should not be afraid this time, and that he would breathe it well. He did so, when plaeed upon the table, without any agitation; but the effects on this occasion were not produced so soon as the day before, which I attributed to his seeing so many gentlemen in the room, together with other feelings which might attend the occasion; but in about four minutes the state of unconsciousness appeared to be complete, and I proceeded with the operation,-amputation above the knee. The limb was removed in about two minutes, during which time not the slightest motion nor sign of sensation was observed; afterwards he became partially awake, and capable of conversation, but still seemed to suffer no pain from tying the vessels and dressing the stump. As on the day before he talked about his dreams, but most distinctly assured us that he had not been conscious of any suffering. All the medical officers of the Infirmary were present, and, with one or two exceptions, all the surgeons of the town, and some others, and every one was satisfied that the power of the vapour had been most fully and satisfactorily shown. I attach no particular value to the apparatns I made use of, not doubting that many better ones are already in use, and that farther improvements will probably still be made; I merely mention, therefore, that it is a common wide-mouthed bottle, holding about one and-a-half pint, fitted with a cork, which is perforated by two glass tubes. One of these, the breathing tube, goes in no farther than just through the cork; the other goes nearly to the bottom of the bottle, its lower end being immersed in the æther, of which about half a pint is required. This tube admits fresh air into the bottle as fast as it is drawn out by the breathing tube; and the said air passing through the æther, becomes strongly impregnated by its vapour. A piece of sponge is fixed at the upper part of the bottle above the æther; an elastic tube is attached to the outer orifice of the breathing tube, and to the other end of the elastic tube, a tin mouth-piece of two parts, one for inhaling out of the bottle, the other for exhaling, the latter tube requiring a simple valve. I have pleasure in stating that my little patient, is going on in all respects perfectly well. I am, Sir, Your obliged and obedient servant, H. TERRY. OBSERVATIONS ON THE INHALATION OF The introduction of a new remedy into the practice of medicine and surgery, at all times attracts great attention; and I am inclined to think many useful remedies often fall into disrepute and disuse, in consequence of the indiscriminate application of them. Those members of the medical profession who have I have thought it worth while to communicate the particulars of this case, and to make these observations on the use of this new discovery, and I hope the members of the Provincial Medical and Surgical Association will give a candid statement in the Journal of the effects of the remedy under consideration. Many I know have already operated under its influence, and it is very desirable we should have their experience faithfully recorded. had an opportunity of testing the efficacy of the inhala- | morphia; in the evening he was free from pain. He tion of the vapour of sulphuric æther, in rendering informed me that although he felt no pain during the patients insensible to the pain attendant on surgical operation, he was not altogether unconscious. operations, appear to have pronounced unanimously a verdict in favour of the discovery of Dr. C. J. Jackson, and Dr. Morton, in America. Such appears to be the case, if we may credit the accounts lately promulgated by the daily press. Dr. Bigelow, in the Boston Medical and Surgical Journal, has given a detailed account of the effects of this discovery in numerous cases. I have read carefully some extracts from his paper in the last number ef the British and Foreign Medical Review, and I cannot consider the symptoms which accompanied the inhalation of the vapour altogether free from danger. In some, alarming cerebral symptoms occurred; one patient became excited, and required to be confined in the chair. "Young subjects are affected with nausea and vomiting, and for this reason Dr. Morton has refused to administer it to children." A short time since, I witnessed the effects of this remedy on the person of a young medical man, of spare habit. He requested my attendance late in the evening to restrain a profuse hæmorrhage, consequent on the application of two leeches to his gum. I succeeded by the use of pure tannin. He informed me, that two days previously, the crown of a tooth had been broken off, in the attempts made by a dexterous dentist to extract it; this operation was followed by great inflammation, aggravated by exposure to cold; the pain he suffered was almost intoterable. The next day, contrary to my advice, he determined on having the stump removed. I cannot imagine a more painful proceeding, considering the state of the parts on which the operation was to be performed. He requested that I should be present, as he was about to inhale the vapour of æther previous to the attempt being made. A bladder, with a suitable mouth-piece, &c., was prepared by Mr. Ruck, of the Montpellier Baths, in this town, and the sulphuric æther put in it. The patient proceeded to inhale the vapour; in two or three minutes he became quite unconscious; complete relaxation of the muscles ensued; the pupils were dilated; the pulse small and quick. The dentist, with an elevator, proceeded to eradicate the stump, which broke in the attempt. About one minute was occupied in performing the operation, when he started from the sofa, and commenced dancing and singing, placing himself in a pugilistic attitude, and made a desperate attack on a vapour bath which was standing in the room. The face and neck were much congested, and far darker than I have ever witnessed under any circumstances, the pupils enormously dilated. I must say I was relieved from much anxiety, when I saw the countenance restored to its natural state. I should think the whole period occupied in inhaling the vapour, and the return to consciousness, was not more than five minutes. The pain returned with great violence, and he again attempted to inhale the vapour, which proved a failure. Farther attempts were made to eradicate the offending stump in vain. I recommended him to go home and take a grain of muriate of Dr. Ware, of Boston, in his letter to Dr. Forbes, in the British and Foreign Medical Review, says, " objections may arise, of which we do not dream, and evils may be found to follow which we do not now perceive," The violent gesticulations that ensuedin the instance I have detailed, although of no great importance in an operation unattended by hemorrhage, would have been of serious consequence in one in which it was requisite to divide large vessels. I feel it would have been almost impossible to restrain the muscular exertions of my friend, who informed me that similar effects follow the inhalation of laughing gas. If I were desirous of performing an operation under the influence of the vapour of æther, I should certainly make a preliminary experiment on the patient some days before the operation was to be done, and in the present state of our knowledge I should decline using it in cases of accident requiring amputation, &c. In plethoric subjects and in those who have a disposition to cerebral congestion, I should consider the use of the remedy wholly inapplicable. REMOVAL OF A STEATOMATOUS TUMOUR Eliza Morris, a patient of the Chichester Infirmary, aged 29, the subject of a steatomatous tumour, situated deeply in the left lumbar region, and about the size of a goose's egg, was operated on on the 29th instant, in the presence of several members of the profession, whilst under the effect of sulphuric æther, by Mr. Abraham Duke, senior Surgeon of that Institution. The patient having been placed in a proper position for the operation, and the nose being closed by an assistant, the inhalation was commenced, and in about six minutes it was quite evident that the vapour had produced the desired effect, (this was indicated by the turning up of the eyes, falling of the eye-lids, a fixed but dilated state of the pupils, the lowering of the pulse, and the total unconsciousness of the patient,) when the fingers were removed from the nose for a few seconds. Mr. Duke then began his first incision, and in three minutes the tumour was dessected out, without the patient evincing the least sign of pain, or any unpleasant effects supervening. At the commencement of the operation she moaned occasionally, and says she felt a slight prick, but not anything like pain; in fact she was not aware of having undergone the operation when placed in bed, twenty minutes after it had actually been performed. It was necessary to make use of six sutures, and although PERSPIRATIONS IN FEBRILE DISEASES. so many were inserted no pain whatever was then experienced; this was the more extraordinary as she was then talking with those standing around her. No vapour was administered after the removal of the diseased part. Numerous expensive and complicated apparatus have been invented for the inhalation of the vapour of æther, but in this case nothing but a common inhaler, with that portion of Reed's enema syringe containing the valves, introduced between the vessel and the tube, with an India rubber covering for the mouth, was used, and with the most perfect success. This is another very satisfactory instance of the great benefit to be derived from the use of the vapour of æther, and its valuable assistance to the surgeon in difficult and painful operations. PERSPIRATION IN FEBRILE DISEASES. TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SIR, In your number of January 27th, you report the proceedings of the last meeting of the Bath and Bristol Branch of the Association. In the discussion on fever which then took place, I am made to observe, "that the peculiar odour emitted in cases of fever was given out by the perspiration." This certainly was the first observation I used, but I employed it merely as the test to introduce to the notice of the meeting, a more important one, to which a long experience in the treatment of febrile diseases had led me,-namely, that the period of infection in fevers and febrile diseases was that in which the perspiration was offensive in its odour. The exanthemata plainly prove the part performed by the skin in the relief of fevers; we use a portion of the secreted matter to convey their infection; while in continued fever, as I maintain, this infection is propagated by the diseased perspiration, sensible by contact, insensible by inhalation. I then took a wider range, and in relation to phthisis pulmonalis, said I had seen many cases where relatives previously healthy, and by no means predisposed, had become diseased in consequeace of their sleeping con. stantly with those affected by it, more particularly relating instances of husbands and wives, sisters, &c. The night-sweats in this disease have always had offensive odour, and are a diseased secretion; and the disease is infectious under this condition-namely, by contact, and not by inhalation, for nurses and others rarely receive it, and it is from this circumstance that it has neither been considered neither infectious nor contagious. I proceeded farther to remark, that in rheumatism (a specific disease of a febrile character, attended with offensive perspiration,) I had seen relatives in close attendance attacked with febrile symptoms, complete in every respect excepting the specific characters of rheumatism, while hired nurses altogether escaped. This subject, an interesting and highly important one, is worthy of farther investigation, more particularly in relation to the health of the community, and the prevention of disease. I am well aware that many theories have been put forth to account for the contagion 83 of fever and diseases of a febrile character; into these I have no time now to enter; but I would reiterate, that when diseases are accompanied by unhealthy cuticular exhalation, they are more or less contagious, that the skin is the organ from which infection is received. Leaving the subject for further inquiry, anxious only, that what appears a trivial and tyro-like observation, should be explained by its sequence of practical remarks, I am, Sir, your obeedint servant, JAMES TUNSTALL, M.D. Bath Hospital, January 30th, 1847. Medical Entelligence. OPERATIONS PERFORMED UNDER THE Among the more remarkable operations performed at the metropolitan Hospitals under the influence of the vapour of sulphuric æther since our last, are one of Cæsarean operation, by Mr. Skey, at St. Bartholomew's Hospital; and one of lithotomy, where the bladder was diseased, and in an extremely irritable state, by Mr. Arnott, at the Middlesex Hospital. The following are some of those which have been performed in the provinces :— At Liverpool, at the Northern Hospital, by Mr. Stubbs, amputation of the thigh, for diseased knee-joint; at the Eye and Ear Infirmary, by Mr. Neill, for hard cataract by depression, in two cases, for soft cataract by breaking down the cataract, and for strabismus. At the Northampton Infirmary, by Mr. Terry, amputation of the thigh. At Cheltenham, by Dr. Brookes, removal of the breast. At Sheffield, by Mr. Beckitt, removal of the middle finger and a portion of the hand. At the Suffolk General Hospital, Bury St. Edmunds, At Maidstone, at the Kent Ophthalmic Institution, by Mr. Woolcott, removal of a tumour from the back of the neck; fistula lacrymalis; and strabismus. At the Newcastle Infirmary, by Mr. Potter, for fistula; and in a case of diseased bone. At Bristol, by Mr. Lansdown, removal of a cancerous tumour from the lip; of a portion of nail from the great toe; and amputation of the leg. At Laxfield, Suffolk, by Mr. Beales, for lithotomy. Mr. Cotton, of Lynn, has employed the æther vapour in private practice. He says,-"In one case the most perfect composure and serenity was preserved, during a painful operation; whilst in a second case, the most boisterous, hysterical-like spasms (as observed by Professor Parker,) followed, requiring all the force of the by-standers to hold the patient; a farther inhalation, however, effected the required degree of unconsciousness, and the operation was completed without the patient's knowledge, or the slightest indication of pain." In Edinburgh the inhalation of the vapour has also |