ner and to a degree which might reasonably warrant the suspicion of a circumscribed abscess in that organ.

CASE 2. Stricture- Effusion of Urine-Inflammation of the Kidney. Pollard Tate, æt. 33, admitted June 27th. He had suffered from stricture, with occasional retention of urine, for six years prior to his admission; but he had not adopted any treatment for the malady. Five days previous to admission, he felt, when in bed, a desire to make water; but merely a little dribbled away with much straining, and subsequently it was only voided in drops. On the following day, the penis began to swell, and on the next, the swelling extended to the scrotum; on this day he had rigors.

On his admission, the penis and scrotum, the perineum, and lower part of the abdomen, were enormously swelled, and of a vivid red colour: he was in very great pain, with some fever, and the bladder was much distended with water.

"Now, I told you, some time ago, when speaking of effusion of urine, that I liked, if possible, to pass a catheter into the bladder, and in making the necessary incisions, to let one of them reach the instrument in the urethra, near the usual seat of the stricture. I found, however, here that the catheter would not at first pass, from the tense state of the parts, and from the quantity of sloughs in which the point was obstructed, even near the end of the penis; I therefore made several incisions in the scrotum and penis of considerable depth and length, and another in the perineum, down to the usual situation of the effusion; which, last, in fact, gave exit subsequently to some urine, besides that which came through the catheter. I gave him fifty drops of laudanum, and had him placed in a warm bath as soon as the hæmorrhage ceased. Two hours afterwards he was much more comfortable; the swelling was not above half the size it had been previously; and after some little difficulty, the catheter now entered the bladder, and drew off the water which distended it."

The skin was prevented from sloughing by the incisions-sloughs of cellalar tissue came away-and though erysipelas supervened, it was mild: and all appeared to augur favourably for the patient. We should state that, four or five days after his admission, a calculus, like a grain of coffee in appearance and in shape, was removed from one of the incisions in the penis. It seems not unlikely that this was the indirect consequence of the stricture, and the immediate cause of the effusion of urine sticking in the narrowed passage, it might totally obstruct it.

On the 3d of July, an unfavourable change was noticed. The patient became affected with sudden and complete prostration of strength, a copious perspiration, and coldness of the hands and feet. Stimulants were of little or of no avail in removing these alarming symptoms. On the 6th, there was slight diarrhea, and a little tenderness of the abdomen, and on the day on which he died, the 8th, pain was experienced in one wrist-joint.

Dissection. "The bladder was nearly in the same state as Weighell's, much thickened, and reticulated, and inflamed, and contained a good deal of thickbloody urine. The ureters were very much dilated and inflamed, and both of them were twisted and obstructed near the kidney, as you may see, by other preparations in the museum, is often the case in stricture. The pelves of the kidneys, and infundibula, were much more distended than in Weighell; in a high state of inflammation; and the kidneys themselves were coated with thick yellow lymph; and all these parts were on both sides full of a dark, bloody purulent secretion, quite pulpy in consistence, and which had passed down in great quantity into the bladder. The structure of both organs was inflamed, but not yet condensed or diminished in bulk, as in Weighell. In the right kidney, where most lymph had been deposited, one or two of the infundibula looked like distinct abscesses. Subse-quent examination, however, shewed that this was not the case, the cavitiesall communicating with the pelvis of the kidney by continuous mucous surface."

Mr. Hawkins directs particular attention to three important circumstances: the absence of distinct symptoms characteristic of renal disease the abundant secretion of purulent matter from the mucous membrane of the kidney and ureter-the sudden supervention of symptoms of prostration, and the speedy occurrence of a fatal termination. The first should teach us caution-the second should enlarge and correct our opinions-and the third may diminish our surprise at the comparatively sudden manner in which some patients die after the operation of lithotomy, or during the progress of a case of stricture, when the local disease appears to be yielding in a satisfactory

manner.

III. REPORT ON HERNIA, CONSISTING OF CASES EXTRACTED FROM THE NOTE-BOOK OF MR. CESAR HAWKINS; with Clinical Remarks.

There are few subjects which on the whole present such a variety of interesting points for consideration, and in which the result of the surgeon's reflexions are of more serious importance than the treatment of hernia; for ourselves at least we can safely assert that we scarcely ever saw a case in which we did not learn something, or in which some interesting or novel point did not occur to strengthen or modify the opinions we had seriously formed. The most important point however in the whole subject is the conviction on our minds of the propriety of operating at an early period of strangulation; often have we seen a patient sink under the disease for want of an operation, either from the ignorance or timidity of the practitioner, but it is very seldom indeed that we have witnessed the death of the patient purely from the operation having been performed. Even in the practice of hospitals we can ourselves recollect a complete change in the treatment of these cases, most of which when presented at the hospital are already of considerable standing, and yet when we began our studies we can recollect repeated consultations being

held upon them after admission, before recourse was had to an operation; now on the contrary, if fair trials had been made beforehand, or if the strangulation has already lasted some time, no time is lost in what are then most probably only fruitless attempts at reduction, but the surgeon at once proceeds to the certain relief afforded by the operation; and nothing can be more striking than the comparative result of such cases. How little the system is affected by the operation when performed soon, the following case will shew.

Charlotte Kitter, æt. 34, admitted Feb. 19th, 1834. Catamenia present. Has had femoral hernia for some years, reducible till 10 o'clock, a. m., after which attempts were made to reduce it without success, and in the evening she was sent to the hospital. There was a femoral hernia of some size, turning over Poupart's ligament, very hard and firm at the ring, and the tumor itself tender and painful. The chief circum stance Mr. Hawkins said, in his opinion, to be attended to in strangulated hernia, is the state of that part of the protruded bowel or omentum which is embraced by the sac, for if that portion is very hard and tender, it is not very likely to be reduced, and the part below may be quite flaccid and unattended with pain, although mortification may be going on; a portion of tightly strangulated bowel being defended by omentum or by a quantity of fluid in the sac below the ring. For this reason Mr. H. thought it right in this case to proceed at once to the operation, without further trials to reduce it, which was done about twelve hours after the strangulation. The sac contained about five inches of intestine, which was dark coloured, but quickly recovored its proper circulation when the stricture was divided, which was very broad and tight. After the bowel was returned a large quantity of serous fluid came down from the abdomen. She was then left quiet for the night.

20th. An injection was given, and 1 afterwards three doses of Epsom salts

and infusion of roses, and the bowels still continuing confined, three grains of calomel, followed by some castor oil, were also given. In the evening the bowels had been freely open, and no pain whatever was felt.

22. Beef-tea was given, and the next day fish, the patient not having had a single bad symptom. On dressing the wound it was found to have almost united by the first intention. A small portion of skin, however, near the incision,looked as if it was going to slough from the force used in the taxis, which did actually take place. The patient however quickly got well.

2. Incarcerated Omental Hernia-no operation.

But while strangulated hernia cannot be operated on too soon, there are frequently occasions for the exercise of judgment on the part of the surgeon in determining whether strangulation is actually present or not. An old and large intestinal hernia for instance frequently causes attacks of severe pain, constipation, tenderness of the tumor, sickness and vomiting, and yet no operation may be necessary in such case, the bowel being merely incarcerated,i.e. its functions impaired by its confinement, (generally from some imprudence in diet,) and yet the stricture not being tight enough to endanger the circulation in the protruded viscera; in which case the symptoms may be combated by appropriate means, and the temporary obstruction overcome. It is in cases of this description too that the operation becomes really dangerous, from the size of the tumor, and from the adhesion generally formed, and hence the propriety of that line of practice recently again recommended by Mr. Key, though so often lost sight of, viz. when strangulation actually takes place, to divide the stricture without opening the sac. With omental hernia again, although an operation is sometimes as urgently required as for intestinal hernia, yet there is no doubt that as a general rule more room is afforded for the trial of such means as may succeed in removing the effects of the stricture without an operation. There is danger, indeed,

of a portion of bowel being concealed in a mass of omentum, so that if from the symptoms there appears reason to fear such an occurrence, the surgeon should not trust to the feeling only of the tumor, but rather operate unnecessarily than incur the risk arising from delay; if, on the other hand, the symptoms are mild, he may wait till more urgent necessity for operation arises, and so perhaps avoid it altogether.

Ann Tenison was admitted under the care of Mr. Hawkins, Nov. 15th, 1833, with femoral hernia. She had had rupture for six months, and the present tumor has continued down for the last fortnight, producing no pain or inconvenience till four days ago, when symptoms like the present came on, and after a few hours suffering again left her; they returned, however, a second time, last night. The tumor is not very large, it is moveable and circumscribed, somewhat elastic, and has a large gland over it; it receives a slight impulse on coughing; is very tender, and painful even when not handled,—she has also a good deal of pain in the back and around the umbilicus. The bowels have been open since the tumor has been down, and she has no sickness;-tongue whitepulse not very quick.

On her first admission she was placed in a warm bath, and had 20 ozs. of blood taken from the arm, and an unsuccessful attempt was made to reduce the tumor. Mr. Hawkins saw her in the middle of the day, and thought that the tumor was omental only-that the stricture was not very tight, from a slight impulse being still perceptible on coughing-that it was incarcerated, and not strangulated, and consequently that an operation would probably not be necessary; in which opinion the other surgeons who were in the hospital concurred.

A dozen leeches were applied over the tumor, an injection administered, and some aperient medicines given by the mouth. By this treatment the pain was reduced, and the bowels acted upon several times; she slept well during the night, and had no return of symptoms, and in a few days she was order

ed to wear a truss upon the tumor, with a not very forcible spring, and the pad not so convex as usual.

3. Wearing a Truss upon an irreducible Hernia.

In speaking of the propriety of wearing a truss over the omentum in the case just related, Mr. Hawkins said that if care was taken not to use too great pressure, nor at first to continue it for too long a time at once, there was no danger of producing inflammation or other mischief in the part, and that the truss served effectually to prevent further protrusion, even if it did not succed in reducing the hernia altogether. He then related the following case to shew that the same treatment was also applicable to intestinal hernia, and being an interesting one, we preserved notes of the account. A young gentleman, about 13 years of age, was under the care of a physician for some time, in consequence of great disturbance of the bowels, and consequent derangement of the whole system, the cause of which was not evident till the boy complained of pain on one side of the abdomen, when it was clear that the testes had not yet reached the scrotum, and the pain was found to be just above the ring on one side. I was then asked to see him, and ascertained that without having come through the external ring, there was an effort to protrude on the least coughing or other exertion, the bowel apparently filling the inguinal canal on both sides. I then directed a double truss to be worn not pressing upon the external ring, where the testis would have been compressed, but having a broad pad bearing upon the course of the inguinal canal. The boy immediately improved in health, and after wearing the truss for about a year, the testes had reached the scrotum, and the incipient double inguinal hernia was completely cured. Something of the same kind as this Mr. Hawkins said was very common about the time of puberty, but the same boy was about a year afterwards an example of a circumstance which is comparatively very He was observed to have very great irregularity in the action of the

rare.

bowels, which were sometimes obstinately constipated for several days together, resisting the strongest purgatives, and only yielding at last to repeated doses of castor oil; the attack of constipation being frequently succeeded by diarrhoea for some time, during which time the evacuations frequently shewed a good deal of blood. Being under the care of the same physician, he frequently examined the abdomen, and I also saw him with the same object, but it was evident that there was nothing now wrong in the inguinal canals, and no complaint was made which led us to suppose that any other hernia existed to account for the severe symptoms he occasionally laboured under, and which had a good deal affected his health. At last, however, he fortunately received an accidental kick in the groin from a child, which drew attention to this part, and then a very small body was felt quite deep under Poupart's ligament, which was soft and slightly tender, and in which it seemed that our patient had occasionally heard something like the noise of air. This immediately excited our attention, as perhaps a femoral hernia, although, if so, it must be a very small portion of one side only of the bowel, not including the whole calibre of the canal, and scarcely equalling a common gland in size, and therefore, as it seemed, scarcely sufficient to account for the symptoms he had laboured under for several weeks, as no pain whatever had been felt in this part. Mr. Brodie also saw him with me, and said that he had never seen anything of the kind before. We agreed, however, that he should wear a slight truss over the part for some time. The effect of this was quite surprising, for the action of the bowels directly became regular and the health better; in a short time, nothing could be felt in the part, and he soon after left off the truss without having since had any return of similar symptoms.

4. Rupture of Intestine by a Blow upon a Hernia.

The records of forensic medicine possess more than one such case as the

following, and shew the danger of leaving a hernia unreduced, and unprotected by a truss, however common such carelessness unfortunately is in all classes of life.

Henry French, æt. 55, admitted Jan. 11th 1834, under the care of Mr. Haw kins. This man had been leading a horse drawing a cart, when the animal took fright, and ran against some iron railings, by which means he was squeezed between the railings and the wheel. He had slight scalp-wounds in one or two places, and a severe contusion of one arm; but what he chiefly complained of was severe pain in the abdomen, especially on the right side, where there was an inguinal hernia, that he thinks was down at the time of the injury, and which came down also several times after his admission. There was no great anxiety or collapse when first seen, the pulse was 84, full and soft. Leeches were applied to the part, and saline and antimonial medicine ordered. The next day he seemed pretty comfortable, and said he was relieved by the leeches, though there was still some tenderness. Leeches repeated, with aperient medicine, as the bowels were not open. Pulse 90 and small. In the evening he felt better, though some distension of the bowels was perceived. Between 12 and 1 o'clock the housesurgeon was called up to him, and found him in very great pain over the whole abdomen, with exquisite tenderness to the least pressure-constant retching, much distention of the abdomen-the skin cold, and the pulse hardly perceptible-in short, the most acute peritonitis had evidently come on. continued much in the same state till about three, when he aroused himself, and asked for some warm gruel to drink, but before the nurse could procure it he had fallen back, and expired about forty hours after the injury.

He

On examination the next day, nothing was found in the hernial sac, but in the right iliac fossa a portion of small intestine was seen in a cavity formed by adhesion from recent lymph, and inclosing a quantity of lymph and pus and a little fæcal matter;-the bowel was slightly ecchymosed, and a small

rupture of its coats was seen about onethird of an inch in length. The whole peritoneum was inflamed and coated with lymph.

The hernial sac presented a curious complication, that in an operation might have caused some difficulty. Below the sac was a hydrocele, and behind the sac a large varicocele, and in front of it was a fatty tumor about 24 inches long, and surrounded by a smooth cyst, in which it lay loose like a portion of omentum in a hernial sac; so much so indeed, that it was thought at first there must have been a double hernia.

5. Hernia produced by a Blow. William Cooper, æt. 20, admitted July 29th, 1834, under Mr. Hawkins, with the following history. He said that a fortnight before, a person had kicked him on the groin and scrotum, and driven the testicle up into the abdominal ring, whence it did not return for an hour, and that then a rupture had come down with it; that the bowel was supposed by his medical attendant to have been slightly strangulated at first, as it did not go up again for two days, during which time he had a good deal of pain, and complete constipation, and that he had had much pain in the abdomen since that time. There had been no swelling whatever of the testis, so that a mistake as to the nature of the case could not have been made as to this point, and he said that whenever he walked since the accident the rupture had come down with some pain, and receded again on his lying down. On his admission there was a good deal of tenderness of the abdomen,especially on the right side, but without any hernial protrusion. This pain was increased by exertion, especially when he made water, which he did with more difficulty than usual-the spermatic cord seemed full and tender, but the testis was healthy. He had also some degree of fever.

A calomel purgative with castor-oil was given, and some leeches applied to the abdomen, by which he was somewhat relieved.

Sept. 1. Some pain complained of chiefly in the epigastrium-feverishness