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astringents is also an offshoot from an erroneous pathological theory; and now that the theory in question has been shown to be untenable, it necessarily follows that the mischievous practice which has been based upon it has become indefensible.
Such, we believe, is a correct exposition of what we must venture to consider the most valuable and original work which this publishing season has added to medical literature - British Medical Journal.
EMPYEMA OF THE LEFT PLEURAL CAVITY; CURE EFFECTED IN A
NOVEL MANNER. On August 2nd, 1862, Mr. J. B. Malcolm was called to see a man, aged 26, who had been ill for a fortnight, and had been attended by a club doctor. The man was suffering from a violent cough, with little sputa, and great difficulty of breathing. On a careful examination, Dr. Malcolm diagnosed extensive inflammation of the left pleura, with effusion into its cavity. He treated him in the usual manner; but although the cough became less frequent and troublesome, and the febrile symptoms began to subside, the breathing became not less difficult, and the extensive dulness on percussion of the side increased instead of decreasing. About the end of August, after a violent fit of coughing, the poor fellow expectorated a quantity of pus, and continued daily to do so; but still there was no real improvement. In fact, all the symptoms began to be worse.
He continued to suffer from night-sweats. The sputa smelt more and more disagreeably, and what little appetite he had was failing. The click of the aortic valve was clearly to the right of the sternum, and on measuring the respective sides of the chest, Mr. Malcolm found the left about three inches more in bulk than the right. On August 31st, after consultation with Dr. McGrath of Castlemaine, it was decided not to risk tapping, but to trust to nature. Day by day the symptoms became more urgent. It was manifest that the entire of the enlarged pleural cavity was filled with pus; also that there was an outlet from it, leading through the upper and front part of the lung, was equally apparent. The
, patient could remain for any length of time only in the sitting posture, but if he desired to rest he first leaned forward for a short time, and in this position he expectorated profusely. Afterwards he could lean backwards and rest for an hour or so without coughing or spitting. The idea occurred to Mr. Malcolm of turning the man upside down and allowing the pus to escape through the opening which the progress of the disease had already made, and which seemed to be a safe and sure means of exit. The patient was simply made to hang his head downwards over the front
of the bed, he being meanwhile held for fear of his falling, when about a quart of horribly offensive pus ran out of his mouth. This simple plan being followed night and morning, perseveringly but cautiously, the pus was gradually drawn off, the heart began to return towards it normal position, the lung to expand, and the appetite to improve. On Sept. 22nd, every bad symptom was gradually disappearing, except a slight cough, with a moderate expectoration which was no longer offensive. On October 21st he drove over to Mr. Malcolm's residence (twelve miles) a wonderfully improved man. The heart had regained nearly its natural position,. The side had fallen in very little.-(Australian Med. Journal.
THE ANÆSTHETIC SPRAY PRODUCER. When the toy for diffusing eau de cologne in fine vapour over the skin, in the form of spray_which some time ago found its way into our drawing-rooms—first came before me, it struck me at once that it might possibly be applied to the produetion of local anæsthesia; and I set to work to try its applicability in this respect. I was soon afterwards assisted largely in my labours by taking advantage of Siegle's apparatus, with the hand-ball spray-producer invented by my valued friend, Dr. Andrew Clarke, and supplied by the manufacturers, Messrs. Krohne and Sesemann, of Whitechapel-road.
With this apparatus I set myself to determine the degree of cold that could be produced by the vaporisation of all the known volatile liquids, and I determined the fact that the intensity of the cold produced, held a definite relationship to the boiling point of the fluid used; the rule being that the lower the boiling point the greater was the amount of cold exhibited. In these inquiries I employed a very delicate thermometer,
Ι directing the spray upon the bulb from half an inch to an inch and a half from the point of the jet. By these means I learnt that with rectified sulphuric ether I could bring down the thermometer within 10 degrees Fabr. of zero, and that by directing the jet on the skin I could produce a certain definite and marked degree of local insensibility, but not sufficient for surgical purposes.
I next got Mr. Krohne to construct for me a hollow cylinder of thin metal, six inches long and three inches in diameter. In the circumference of this cylinder was a chamber one-eighth of an inch in diameter for containing ether. The ether communicated with a tube which wasjoined to an air-tube, as in Siegle's apparatus, and the centre of the cylinder was filled with ice
and salt mixture. In this way the ether was reduced to zero, and when vaporised gave spray which brought down the thermometer six degrees below zero, and produced on the skin such entire insensibility that I could pass a needle through the part without sensation. On the 11th of December, 1865, I applied this process for the first time on the human subject for an operation. The patient was a lady, who required to have five front teeth extracted. I had previously administered chloroform to this lady for a tooth extraction, but the inhalation had produced so much irregularity in the action of the heart and other disagreeable symptoms that I considered it inadvisable to repeat chloroform, and she herself was only too ready to give the local measure a trial. The extraction was performed by my friend, Mr. Peter Matthews. On directing the ether
spray first at a distance and then closely upon the gum over the first central incisor on the left side, we observed, at the end of fifty seconds, that the gum had become as white as the tooth itself, and quite insensible. I then directed the vapour upon the tooth for twenty or thirty seconds more, and on the patient intimating that she did not feel, I suggested to Mr. Matthews to proceed. He extracted a very firm tooth without the slightest expression of pain. The process being continued in the same manner, he extracted three other teeth with the forceps. The fourth gave way, and had to be removed by the lever ; but in all cases the result was equally good. Not a drop of blood was lost; there was no painful reaction; and the healing process proceeded perfectly. Our patient, who was exceedingly intelligent, was specially requested to note every step of the operation, such as the applying of the forceps, the insertion of the blades beneath the gum, the loosening process, and the removal. She told us that in two of the extractions she felt nothing; that in one it seemed as though the jaw altogether were being pulled downwards, but without pain ; that in another she was conscious of a kind of wrench or loosening, but without pain, and that the introduction of the lever was attended with a momentary dull ache, just perceptible. On the whole, the process was quite as painless as when she took chloroform.
On December 13th, I applied the local anæsthetic to the same lady for the further extraction of nine teeth, Mr. Peter Matthews again operating. The results were equally good with the first seven ; at which point, unfortunately, the apparatus partly ceased play. At the eighth tooth pain was felt, and at the pinth, the apparatus being out of play, the operation caused great pain. We regretted this mach, although it gave us the information of the perfect action of the process when no mechanical obstacle interfered with it. The reason why the apparatus stopped
play was very singular, and could hardly have been foreseen. It arose from the condensation of water derived from the air in the air tube, and from the blocking up of the fine jet with a little portion of ice.
In the next step of research I got Mr. Krohne to make for me an apparatus with two spiral tubes, one the air tube, the other a tube for ether; and I immersed these spirals in a closed chamber filled with ice and salt. The degree of anæsthesia at first produced was most intense, and Mr. Spencer Wells was good enough to allow me the opportunity of applying the process in a case where an operation was required for closing a perineal rupture. Unhappily the apparatus, from the very same cause as before, ceased to yield a current; water condensed and became frozen in the air-tube. The apparatus itself was also found to be too cumbersome for practical purposes; I therefore, in this trial, failed to obtain any
By this time I had been led, very reluctantly, to the fact that the use of ice and salt for reducing the ether was a failure when the plan came to be tried in practice, nor could I see any ready way of preventing the difficulties that were brought before me. Added to these difficulties there was another, which has always attended my friend, Dr. Arnott's plan, viz., that of getting the ice and salt readily for operation. To succeed, therefore, it was requisite to dispense with ice and salt altogether.
In considering how this object could be achieved, it occurred to me that if a larger body of ether than is supplied by Siegle's apparatus could be brought through the same jet, by mechanical force, in the same interval of time, and with the same volume of air, a proportionate increase of cold must necessarily be produced. The theory was one of pure physics, admitting even of arithmetical demonstration, and running parallel with the lessons which had been taught me with respect to the cold produced by liquids having different degrees of boiling point. The theory was put to the test at once, and proved correct to the letter. By driving over the ether under atmospheric pressure, instead of trusting simply to capillary action-or to suction, as in Siegle's apparatus—the spray evolved brought the thermometer within thirty seconds to four degrees below zero-the result that was desired.
Ascertaining this truth, I instructed Messrs. Krohne and Sesemann to construct a very simple apparatus.
The apparatus consists simply of a graduated bottle for holding ether; through a perforated cork a double tube is inserted, one extremity of the inner part of which goes to the bottom of the bottle. Above the cork a little tube, connected with a hand bellows, pierces the outer part of the
double tube, and communicates by means of the outer part, by a small aperture with the interior of the bottle. The inner tube for delivering the ether runs upwards nearly to the extremity of the outer tube. Now, when the bellows are worked, a double current of air is produced, one current descending and pressing upon the ether forcing it along the inner tube, and the other ascending through the outer tube and playing upon the column of ether as it escapes through the fine jet. By having a series of jets to fit on the lower part of the inner tube, the volume of ether can be moderated at pleasure; and by having a double tube for the admission of air, and two pairs of hand bellows, the volume of ether and of air can be equally increased with pleasure, and with the production of a degree of cold six below zero.
By this simple apparatus, at any temperature of the day, and at any season, the surgeon has thus in his hands a means for producing cold even six degrees below zero; and by directing the spray upon a half-inch test-tube containing water he can produce a column of ice in two minutes at most. Further, by this modification of Siegle's apparatus he can distribute fluids in the form of spray into any of the cavities of the bodyinto the bladder for instance, by means of a spray catheter, or into the uterus by a uterine spray catheter.
When the ether spray thus produced is directed upon the outer skin, the skin is rendered insensible within a minute; but the effects do not end here. So soon as the skin is divided the ether begins to exert on the nervous filaments the double action of cold and of etherisation; so that the narcotism can be extended deeply to any desired extent. Pure rectified ether used in this manner is entirely negative; it causes no irritation, and may be applied to a deep wound, as I shall show, without any danger. I have applied it direct to the mucuous membrane of my own eye, after first chilling the ball with the lid closed.
I have now employed this mode of producing local anæsthesia in four cases on the human subject. The first case was the extraction of a tooth from a lady, the operation being performed by my friend and neighbour, Dr. Sedgwick, on January 24th of this year. On the 29th of the same month I used it again on the same lady, for the extraction of three very difficult teeth, Dr. Sedgwick again operating. The results were as satisfactory as in the previous case, where the ice and salt ether apparatus was used.
I have used the apparatus also in connection with my friend, Mr. Adams, who had a case at the Great Northern Hospital of deep dissecting abscess in the thigh of a young woman.
In the abscess there was a small opening, which just admitted the director. I first narcotised