on November 14, when the patient was discharged by his own request, he stated that he had a feeling of firmness in the ring which he had not previously. I have no doubt, however, that the hernia could easily have been made to descend. The conclusion from this small experience appears to me to be

That the operation by scarification and injection, being perfectly safe, is worthy of being practised to test the amount of its efficacy; but the fact that so many other methods, which, à priori, would seem more calculated to produce the same expected result, viz., the plugging the neck of the sac or ring with lymph, have not cured the disease, should suggest very great caution in the formation of an affirmative opinion from any but a large and long experience.

The operation, as practised by Dr. Wood of Cincinnati, also in my opinion offers many inducements to surgeons, to make it the subject of experiment; since, proposing as it does the approximation as well as agglutination of the pillars of the ring, it attempts to meet the objection that may be made against all the other methods, viz., that the tendinous opening remaining the same, but an imperfect barrier can be opposed to the re-descent of the hernia.-Edinburgh Medical and Surgical Journal, Oct. 1853, p. 353.

84.-STRANGULATED FEMORAL HERNIA-REDUCTION-SUBSEQUENT GANGRENE OF BOWEL-RECOVERY.

Under the care of E. STANLEY, ESQ.

[The patient, a female, aged 44, was admitted into St. Bartholomew's Hospital Dec. 29, 1852. The bowel had been strangulated eighteen hours.]

She was, on admission, in a condition of extreme prostration, with an anxious countenance and scarcely perceptible pulse. The tumour was very tense, and about the size of a goose's egg. Mr. Stanley did not deem it warrantable to again attempt the taxis, but without delay proceeded to the operation. On account of the feebleness of the pulse, chloroform was not administered. The sac of the hernia having been exposed by an incision along its inner side, and the stricture divided, ineffectual attempts were made to reduce the tumour without opening the sac, which was accordingly laid open. Together with a large mass of omentum, a strangulated knuckle of intestine, about the size of a walnut and quite black, was now brought into view. Its surface was tense, smooth and polished, and as it did not appear to be gangrenous, Mr. Stanley returned it into the abdomen, leaving the omentum in the sac to which it was adherent. The ordinary dressings having been applied, the patient was sent back to bed.

Dec. 30. She has passed a tolerably quiet night, undisturbed by vomiting, but this morning the abdomen is tender and tympanitic, and her aspect is sunken and very anxious. Pulse extremely feeble. Hirud. x. abdomini.

B. Pil. sap. co. c. opio. gr. v. 4tis horis.

Jan. 2. The pills have been regularly continued up to the present time (eighteen grains of opium in three days), and with apparently the best effect; the symptoms of peritoneal inflammation have gradually yielded, and her strength has much improved. To-day the bowels have acted twice quite spontaneously, for the first time since the operation.

4th. The wound has not yet commenced to close; to-day there is a discharge. from it of fluid intestinal contents. Her general health is improving; she takes a nourishing diet, with beef-tea and wine.

21st. The discharge of fæces from the wound, which continued profuse for two weeks, gradually declined, and has now quite ceased to flow, and the wound looks healthy. She has during this time had several evacuations per anum, but by far the greater part of the intestinal contents have passed through the opening in the groin. Feb. 9. The patient is going on extremely well, and the wound is nearly closed. The bowels act regularly by the natural passage.

On March 16 the patient left the hospital quite well in every respect, the wound being healed and a truss adjusted.

Inasmuch as the space of six days elapsed before the diseased intestine gave way, and as in the interval the bowels had acted naturally, it may fairly be inferred, that, at the time of the operation, the vitality of the strangulated portion was not hope

lessly reduced. We have noted that it was not collapsed, and that it retained its polished smooth appearance. Very possibly, had the restorative vigour of the patient been greater, the ulterior processes, which resulted in sloughing, might have been arrested, and the gut enabled to resume its functions, and taking this view the prolonged subsequent history would seem quite to justify the course pursued by Mr. Stanley. It is no light matter to needlessly puncture intestine because it is black, or even to leave it exposed in the wound,-a proceeding which will certainly increase the danger of gangrene. Looking, then, at all the various risks, and estimating fairly the various means of forming a correct prognosis, it is a thing quite to be expected, that, in some cases, the probabilities may be so nicely balanced, that the judicious surgeon may return portions of bowel, concerning which he does not feel absolutely certain that they are not irrecoverably damaged. Just such a case we believe the preceding to have been. To return gangrenous intestine is, of course, a proceeding replete with danger, on account of the probability of the escape of fæces into the peritoneal sac. If, however, time be allowed for the exertions of the vis conservatrix naturæ before the diseased parts separate, this accident may, as the result of the above case proves, be obviated by the preparatory glueing together of the intestine and the abdominal wall at the part nearest to the external opening, so as to provide means of free escape from the irritating fæcal matters. In addition to the above point of interest-the successful treatment of traumatic peritonitis by opium, and the spontaneous closure of an artificial anus-this case also illustrates the practice of leaving adherent omentum in the sac of the hernia. The mass left was of very considerable size, and, at the time of operation, much congested, though not in a condition at all approaching to gangrene. No sloughing occurred subsequently, but the whole sac suppurated very freely, a considerable portion of the discharge being probably derived from the exposed serous membrane. Under this process, the omental mass diminished much in size, and ultimately became consodated with the surrounding parts.-Med. Times and Gazette, April 30, 1853, p. 446.

85.-CASES ILLUSTRATING THE USE OF CHLOROFORM IN THE TREATMENT OF HERNIA.

By W. S. SAVORY, Esq., Tutor at St. Bartholomew's Hospital.

[The first case is one of oblique inguinal hernia, having the following appearances:]

A tumour, about the size of a common egg, extends from the right internal ring, along the canal, into the scrotum; it is firm and tense, and conveys a slight impulse on coughing. He complains of pain when the tumour is handled, but there is no tenderness in the neighbouring parts, or in the abdomen generally. A very small swelling in this region was accidentally discovered about two months ago; it soon disappeared under pressure, but has since repeatedly returned. He has never worn a truss. The present tumour appeared about 2 a.m.; he was making no exertion at the time. Not being able to return it as usual, he applied to a medical man. He was placed in a bath, and the taxis employed for fifteen minutes without success. Under these circumstances, it was determined to remove him at once to the operating theatre, and, while under the influence of chloroform, to repeat the attempt at reduction, and if unsuccessfully, to operate without further delay. Chloroform having been freely administered, the hernia was reduced without much difficulty. In a few days he left the hospital, wearing a truss,

[The second is a case of congenital inguinal hernia in a man aged 42. It is thus described :]

A firm and tense tumour extends from the internal ring, along the spermatic cord, into the scrotum, of irregular shape, and somewhat constricted about the middle. An impulse is distinctly felt on coughing, but the tumour and the parts around appear very tender. He has "had a rupture" ever since he can remember, but has always been able to reduce it. He has never worn a truss. About four hours ago, the tumour appeared of unusual size, without any apparent exertion, and all attempts at reduction failed. He was placed in a bath (temp. 100°), and taxis employed, without success. He was then removed to bed, and placed completely under the

influence of chloroform. The taxis being repeated, in about three or four minutes the hernia was reduced, the tumour almost suddenly disappearing with a gurgling sound. A bandage was applied, and he was discharged on the following day.

[The third case, one of oblique inguinal hernia in a man aged 31, by trade a smith, was admitted Nov. 1st, 1851, at nine p.m.]

A firm, elastic tumour, about the size and shape of a common pear, communicating an impulse on coughing, but not tender to the touch, extends from the left inguinal ring into the scrotum. He first perceived a swelling in this region nine years since, after great exertion, during which, he thinks, he strained himself. It disappeared under pressure. It was repeatedly returned, but he has never had any difficulty in reducing it. He has generally worn a truss. Yesterday, about seven a.m. (twenty-six hours ago), he incautiously lifted a heavy weight, not wearing the truss; the rupture descending, became suddenly larger and more tense than usual, and he was unable to return it. About twelve hours since, he took a dose of croton oil, which produced two scanty evacuations, the last occurring about three p.m. Previously to his admission, taxis had been persevered in for a considerable time by a medical man. He was at once placed in a bath (temperature 98°), and after remaining in it for fifteen minutes, taxis was employed for ten minutes without producing any effect upon the tumour. The symptoms not being urgent, he was placed in bed, and ordered pil. saponis c. opio gr. x.

Nov. 2, ten a.m. He has passed a good night, having slept comfortably.

There

are no fresh symptoms; the bowels have not acted. Having been placed completely under the influence of chloroform, the hernia was readily reduced. Nov. 6. He has been discharged, wearing a truss.

[In another case of oblique inguinal hernia, produced by slipping while carrying a load, although the warm bath and taxis failed in reducing it, yet after some time and trouble, it yielded under the influence of chloroform. A week afterwards the patient was discharged.]-Med. Times and Gaz., April 30, 1853, p. 458.

[The alleviation of pain is by no means the only recommendation for the use of chloroform in cases of hernia. In many now recorded, the use of the anaesthetic prevented the operation, by enabling the reduction to be effected.]

When a patient is fully under the influence of chloroform, he is in a condition very favourable for the reduction of an hernia by taxis. All the muscles are completely relaxed, and pain being suspended, no resistance is made to the necessary manipulation. We gain at once, indeed, many of the advantages belonging to other and older plans of treatment, e. g., tobacco ene a, venesection, &c., without any corresponding evils. The chief good effects of the warm bath are here also produced; and this is the more important, as this va uable adjunct in the treatment of hernia-except in hospital practice-is often only obtained with great difficulty, and after considerable delay. Indeed, it appears from numerous observations, that the use of chloroform in the treatment of hernia is attended with decided advantages over all other means which can be employed. For example, in three of the four cases related, chloroform succeeded after the warm bath (hitherto considered as our most useful auxiliary) had failed. Doubtless, the value of chloroform, under these circumstances, is mainly dependent upon the complete muscular relaxation induced; and this is a point to be particularly attended to. Every surgeon is aware how forcibly attempts at reduction by taxis are opposed by the violent, in some cases almost spasmodic contraction of the abdominal muscles; indeed, the same cause that expels the intestine from the abdomen, still acts to prevent its return. No means with which we are at present acquainted are equal to chloroform in producing complete muscular relaxation without danger or delay. But the objections to its employment in cases of hernia are not to be overlooked, and the more so, as by judicious management they may be often overcome. The two principal are (1) the violent muscular exertions which often occur during its administration, and (2) the sickness which sometimes accompanies returning sensation. The former of these evils may generally be avoided by the observance of due care in its administration. If given very gradually at the commencement, and if no attempts are made to compel the patient to inhale, in spite of alarm, and the chloroform be pure, and if, subsequently, when the muscular actions which generally precede total insensibility commence, its administration be effectually continued without intermission or delay, we shall generally succeed in producing the full effects of chloroform, without the severe struggling

which frequently occurs. The second evil, sickness, is much less within our control; the condition of the stomach is generally the cause, sickness usually follows when chloroform is administered shortly after a meal. We can only look to the quality of the chloroform; this and many other effects, as coughing, &c., often depending on slight impurities.

It has been stated, that the inhalation of ether produces more decided muscular relaxation, and is, therefore, preferable, in cases of hernia and dislocation, to the use of chloroform. Now, ether is much less powerful, and, therefore, much less rapid in its action, than chloroform; consequently, when inhaled, it enters the system more gradually. This may explain the more decided effects which are said to result from the use of ether; and it reminds us of the advantage to be obtained from the gradual and cautious administration of chloroform, more especially at the commencement of the process. The difference observed between the effects of ether and chloroform appears to be, in a great measure, due to their relative strength.

From the observation of a considerable number of cases, it appears to me, that many of the unpleasant complications, especially struggling, which often attend the administration of chloroform, are, to a great extent, dependent on the instrument employed. In this, as in most cases, the simplest plan is the best. It seems that chloroform can be administered in every respect most advantageously by means of a handkerchief or a piece of lint. All instruments appear to be more or less objectionable, perhaps in direct proportion to their complexity. The prejudice which generally exists against the use of the handkerchief arises from its supposed danger. In the hands of a careless or incompetent person, some of the instruments which have been contrived may possibly be employed with less risk of danger, but such persons are not justified in administering chloroform under any circumstances, and, with ordinary care, the use of the handkerchief is at least as safe as the employment of a more complicated instrument. These opinions are held by some of the most eminent surgeons. Another objection urged against the use of the handkerchief is, that chlo roform is wasted in this way. With a little care this may be in a great measure avoided, and even allowing this objection its full force, it is but a trifling one. It has been said, that when chloroform is administered on a handkerchief, so much escapes that the atmosphere of the room becomes unpleasantly impregnated. This may happen when the exhibition is prolonged for some considerable time, but under such circumstances the same objection applies to instruments. It has also been objected to the handkerchief, that we cannot estimate so exactly the quantity of chloroform inhaled, as some is lost by evaporation. This objection applies equally to all instruments from which the vapour of chloroform can escape. But the chief point to be attended to in the administration of chloroform is not the quantity consumed, but the effects produced. Women and children are often alarmed by the sight of any instrument; however simple it may really be, it appears to them mysterious. This is no trivial objection. They will readily inhale chloroform when merely dropped upon their handkerchief. So far as my observations extend, many of the disagreeable circumstances which often occur when an instrument is employed, such as struggling, shouting, coughing, congestion of the face, &c., seldom arise when a handkerchief is used. In cases of hernia, more especially, this is a great point to be attended to.

It is important that the administration of chloroform be continued till muscular relaxation is fully induced before taxis is employed. If attempts at reduction are made while the muscles are tense, more harm than good results from its use. On the other hand, we must be mindful not to continue our efforts at reduction, during the insensibility produced by chloroform, for an undue length of time. The patient, being unconscious, can give us no warning by his complaints that we are pressing our attempts at reduction too far, and, in our anxiety to succeed, we may overlook the time and force employed.

If such attempts at reduction are unsuccessful, should the operation, supposing it be deemed necessary, be at once performed without allowing consciousness and sensibility to intervene? The advantage of this plan is, that we spare the patient a second administration of chloroform; the objection to it is, that we must then prepare our patient beforehand for the worst, and thus sometimes needlessly alarm and distress him. Perhaps the circumstances of the case may be our best guide. When there is a fair chance of success we may attempt reduction under chloroform without distressing him by the idea of an operation; when, on the other hand, our

chances of success by taxis are small, we may prepare him at once for the worst, and employ chloroform as a preliminary to the operation, if that should become necessary.

The good effects derived from chloroform are not at an end when an operation is required. The pain and consequent terror of this proceeding is abolished by its use. But the preservation of life is more important than the annihilation of pain, and perhaps the happiest effects of chloroform in hernia are witnessed in the results which often follow its administration. It would perhaps be difficult to mention any event which the surgeon hails with greater pleasure, after an operation for hernia, than the supervention of natural sleep. Indeed, to procure sleep after an operation is often an indication of no mean importance to be fulfilled. Calm and prolonged sleep is often the precursor of a rapid recovery. It may be said, indeed, that sleep thus appears beneficial because it only occurs in the absence of any bad complication; but after making every allowance for this fact, many cases most unequivocally demonstrate the advantages of sleep, after an operation for strangulated hernia. Such sleep often follows when chloroform is employed. It is frequently promoted, nay, sometimes induced by it. The patient does not appear to awake from the effects of chloroform, and a natural sleep without the intervention of consciousness seems to succeed the artificial one.-Med. Times and Gazette, June 4, 1853, p. 586.

86.-Strangulated Femoral Hernia-Removal of a large Mass of Omentum— Peritonitis-Sloughing of the Sac-Recovery. Under the care of Mr. ERICHSEN.[This patient, a female, aged 67, was admitted into University College Hospital January 11, 1853, at 9.30 A.M. All efforts by the taxis, even with the aid of chloroform, failing to reduce the hernia, the sac of the hernia was laid open. A large lump of omentum presented itself, and, after a little search, a tight stricture was divided, surrounding a small knuckle of intestine, and the reduction accomplished: but the question remained as to what was to be done with the omentum.]

Conclusively opposed to the idea of returning it were the circumstances, that it was very large, much congested, adherent to the sac, and had probably been down for a long time. If left in the wound, sloughing would probably ensue, and induce great constitutional irritation. Mr. Erichsen accordingly determined to remove it, and to adopt, according to his custom in such cases, the plan of ligaturing the whole constricted neck of the tumour, rather than each vessel singly. For this preference he alleged as a reason, that it was very desirable to prevent the portion left behind from passing up into the abdomen, which might be much more easily accomplished by one large ligature than several small ones. A piece of whipcord was accordingly passed round it, as close as possible to the femoral ring, and the lower portion, having been cut off, was gently separated from the sac, to which it adhered, and removed. The end of the cord was turned up on to the abdomen, and there fixed by means of a strip of plaster, so as to retain the divided omentum in place. The sac, which was very large, was next plugged with sponge, and, the wound having been covered with wet lint, the patient was sent back to bed. Capt. vin. opii mxxv. statim.

The portion of omentum cut away was afterwards found to be six ounces in weight.

At two P.M., there were symptoms of commencing peritonitis; the belly was tympanitic, and slightly tender; pulse 90, soft; tongue moist, and thinly furred; knees a little drawn up. Hirud. xij. abdom.

B. Hydr. chlorid. g. ij.; pulv. opii gr. ss.; 4tis horis sumend.

Jan. 12, one A.M. Hirud. xxiv. The pain in the abdomen continuing with but little improvement, the same number of leeches were again applied at noon, and at midnight a blister was ordered to the abdomen. Tinct. opii m xxx. horâ somni sumend.

13th. Pulse 120, sharp and hard; abdomen tympanitic and tender; she is very restless, and appears to be in great pain. Hirud. xxiv. To continue warm fomentations to the abdomen.

16th. A profuse diarrhoea commenced yesterday; in other respects she is a little improved.