ARTES
SCIENTIA
LIBRARY VERITAS OF THE
UNIVERSITY OF MICHIGAN
WIT
TCEBOR
41-QUE RIS-PENINSULAM AMENAM
CIRCUMSPICE
The
George E. Wantz
(UM Medicine 1946)
Collection




From Henry
Hancock

January 18596
ON
RUPTURE,
AND ITS MORE EFFECTUAL TREATMENT BY
A NEW FORM OF INSTRUMENT;
ALSO, ON
PROLAPSUS UTERI,
AND ITS TREATMENT,
BY THE SAME MEANS.
BY
M. W. HILLES,
FORMERLY LECTURER AT THE WESTMINSTER HOSPITAL
SCHOOL OF MEDICINE,
AND LATELY CIVIL SURGEON IN HER MAJESTY'S SERVICE IN
THE EAST.
HENRY RENSHAW, 356, STRAND.
ONE SHILLING.
70

TAUBMAN
RARE BOOK ROOM
RD
6271
#54

TO
DR. ANDREW SMITH,
-DIRECTOR-GENERAL OF THE ARMY AND ORDNANCE MEDICAL
DEPARTMENT.
SIR,
Having observed the zeal displayed by you in the
discharge of your duties, as head of the Army Medical Department,
I have been induced to believe that whatever tends to promote
Medical Science, or to alleviate human suffering, will meet with
your approval.
I beg leave, therefore, to inscribe to you the following
observations on a new mode of treating one of the most
serious disorders to which humanity is subject.
I have the honour to be,
Your
very
Sir,
obedient and humble Servant,
MALCOLM W. HILLES.
7, PERCY STREET, BEDFORD SQUARE.
London, April, 1856.

ad of united
oldbard

BEFORE proceeding to describe the means by which I propose
to treat and in some instances to cure Rupture, a brief description
of this disease will be serviceable, as it will put the patient in
possession of its nature, its leading characters, and the principles
on which its treatment is to be conducted to a satisfactory issue.
The patient will thus be enabled to assist, by his own efforts, in
the treatment, and will no doubt not only second but materially
assist his medical attendant in its management.
On this, as on many other affections, to which human nature
is subject, there is much misapprehension; many conceiving that
Rupture is comparatively a rare disease, requires but simple
treatment, and is by no means dangerous; whereas, the reverse of
all this is the case. Rupture is of frequent occurrence, shows
itself at all periods of life, and in both sexes, few individuals,
especially of the male sex, passing fifty years of age without the
disease appearing, or a strong disposition to its formation mani-
festing itself. As to its treatment, it is true that so long as the
protruding intestines may be returned with facility, it requires
but little skill in its management, but as this condition may be
changed at any moment, the disease may become thus in an instant
one of the most formidable which afflicts mankind, and which
calls for the attendance of the medical practitioner. It is suffi-
cient to state that Rupture has proved fatal in a few hours, and
that the operation necessary for its relief is one of the most trying
that surgeons have to perform.

6
Rupture generally appears, in the male sex, in the regions of
the groin, a little above and to the outer side of the pubes; it
first shows itself as a small colourless swelling, pushing forward
the abdominal parieties during any exertion, as coughing, sneezing,
&c., and then receding, especially on assuming the recumbent
posture. By degrees it increases in size, and descends lower,
until it finally makes its way into the scrotum. As it causes little
or no pain, it is frequently unnoticed by the patient himself; it
soon, however, begins to cause uneasiness, there is irregularity of
the bowels, sickness of the stomach, or nausea, and occasionally
colicky pains throughout the abdomen. The patient is often at
a loss to account for these symptoms, until at length he either
consults his medical attendant, or becomes aware of the disease
by the swelling and enlargement of the scrotum.
Although called Rupture, there is rarely any Rupture or
breaking of the parts in the formation of this affection; it is
indeed solely produced by the intestines or other part of the
viscera being pushed outwards along certain canals or passages
which exist naturally, in the parieties of the abdomen; of these,
the largest is the spermatic canal, and this, therefore, is usually
the seat of Rupture in the male sex.
The spermatic canal is an oblique passage in the abdominal
parieties, by means of which the spermatic chord descends to the
testicle in the male sex, and the ligamentum teres, an analogous
structure, in the female. Its commencement is about three inches
from the pubes, its termination close to the outer side of this part.
The obliquity of the canal, and the overlapping of the abdominal
muscles and other parts, prevent the escape of the viscera in the
healthy condition; it is only when these provisions do not exist
in a perfect state, or under unusual exertion, that a portion of
the viscera will escape from the abdomen, and thus form a
Rupture.
MIL

7
In the female, on the contrary, Rupture more frequently appears
in the upper and front part of the thigh, hence called Femoral
Rupture. This is owing to the greater breadth of the pelvis in
this sex, here the Rupture follows the course of the large blood
vessels into the thigh and descends with them. The female is,
however, subject to Rupture in the groin, or Inguinal Rupture,
as a similar canal exists in her, as already stated, conveying a
structure analogous to the spermatic chord in the male. The
Rupture takes a similar course, and descends into the labium.
These are the two principal forms of the disease, the one termed
inguinal from its occurring in the groin, the other femoral from
its position; but there are several others, such as umbilical,
ventral, &c. These are of comparatively rare occurrence, and
need not occupy our attention here.
Although, as I have said, Rupture may occur at any period of
life, it is usually met with in the more advanced ages. Many
circumstances conspire to cause this; in the more advanced
periods of life, the parieties becoming more relaxed, the muscles
less powerful, and the viscera generally fuller and more weighty.
As fat often accumulates, too, at this period, and especially in the
omentum, it follows that there is less space or room in the cavity
of the abdomen for the viscera; the most movable of these, then,
namely, the small intestines, are soon expelled from their proper
position, and thus form the Rupture. It is true that the pro-
trusion forwards of the abdominal parieties, so observable in middle
and advanced age, makes additional room, but this is gained by a
serious sacrifice, as the canals formerly alluded to become thereby
increased, and thus more favourable to the descent of the
intestines.
In like manner, the impregnated uterus in the female, asserts
its influence in this sex, and hence the formation of femoral and
other forms of Rupture.

8
Besides, we may add the wear and tear of life, the occurrence
of accidents, the using of violent exertion, or the receipt of
injuries, as all tending to the appearance of Rupture in the more
advanced ages.
Sir Astley Cooper, the celebrated surgeon, was the subject of
Rupture in early life; he was, however, unaware of it, until,
hearing a lecture on the subject from one of the surgeons of the
hospital, he felt certain that he was ruptured. He hastened home
as soon as possible, stretched himself on the bed, and raised his
legs upwards as high as possible, in which position his master, for
whom he had sent in all haste, found him. Gibbon, the historian,
was subject to a very large Rupture, which descended nearly as
low as his knee.
The treatment of Rupture consists in replacing the protruded
viscera in the abdomen, if possible, and then preventing their
future descent by artificial means. To replace the viscera, the
patient should be in the recumbent posture, with the head slightly
elevated, and the knees flexed towards the abdomen. The Rupture
should now be raised, if in the scrotum, and pressure applied upon
it in the inverse direction of the canal, through which it has
descended. Its return is usually accompanied by a gurgling
noise, caused by the motion of the intestines, and is followed by
much relief to the patient.
As the disease is sure to re-appear when the patient rises, or
makes any exertion, artificial means must be applied to prevent
this. Several instruments have been recommended for this pur-
pose, but the Truss is that which has been most frequently in use
for many years past. This instrument consists of a semi-circular
spring, which surrounds the body, and is fastened in its place by
a leather strap in front, and a linen strap underneath; on one of
its extremities is a convex pad, which is laid over the part where
the Rupture makes its appearance, and by its pressure here prevents
the return of the affection.

9
Although the Truss has been in use for such a length of time,
it has been found liable to many objections, and in some cases
cannot be worn at all. The presence of the spring round the
body is very inconvenient, the pressure of the pad in the inguinal
or femoral region causes excoriation of the skin, especially in
warm weather, and the linen belt which passes between the limbs
is also a source of constant annoyance.
In addition to this, the pad of the Truss is liable to slip out of
its place, during walking, riding, or taking other exercise, and
thus to allow of the descent of the Rupture; the spring, too, often
breaks, and the patient is thus liable at any moment to have his
life placed in danger from these several casualties.
The Truss also deforms the figure very much, and it is only by
the use of a loose dress that the deformity can be concealed.
So much do some patients suffer from the use of a Truss, that
they are obliged to discontinue it altogether and trust to bandages,
or other imperfect means, for the alleviation of their sufferings.
To remedy these evils many improvements in the Truss have
been suggested from time to time, and have been extensively
tried by the public, but none have been found effectual: in some
cases one form of Truss has given satisfaction, whilst in others the
same has been found wholly inefficient. So much has this been
the case, that many of the first surgeons of the present day are in
the habit of recommending the common Truss in preference to
all others.
With the view of remedying these deficiencies, I would re-
commend a new form of instrument for the treatment and cure of
Rupture. This, I trust, will be found effectual in most cases, and
to be free from the objections to which the Truss is exposed.
This instrument consists of drawers fitting closely to the figure,
and is provided with a peculiarly-constructed pad or pads placed
in their proper positions. The drawers differ but little from those

10
in common use; that part which encircles the body and pelvis is
provided in front and behind with means by which this part may
be drawn with sufficient tightness round the frame; there is one
aperture posteriorly and another in front, to admit of the functions
of nature being performed without inconvenience to the wearer,
and without removing the pressure of the pads from the parts
which require their support; a portion of the drawers is continued
between the limbs and rests on the perineum, by which the whole
is kept more firmly in its place. In most cases it will be necessary
to continue the drawers down the limbs, as far as a short distance
below the knees, where they should be secured in the usual
manner; in some, it may be more advantageous that they should
be continued to the ankles and there secured, whilst in others a
short pair, enveloping the thighs, may be found sufficient; much
depends on the shape of the limbs and the figure of the wearer;
the great object is to fix the drawers so securely on the person as
not to admit of being displaced in the motion of the limbs and
body.
Where the abdomen is more than usually prominent, it is
better that the Drawers should be secured round the ankles, but
when this is not the case, the shorter form may be found sufficient.
The pad or pads are of a peculiar construction, and will be
found to possess many advantages over the pads of the common
Truss: in these the pressure is uniform and constant in almost
every position; inasmuch as they do not possess any means by
which this can be regulated according to the will of the patient or
as circumstances may require.
The pads of the Rupture Drawers, on the contrary, are so con-
structed as to allow of the pressure being increased or relaxed as
may be necessary; for this purpose, each pad consists of a double
plate, or rather of two metallic plates, concave and convex, the
concavities being turned towards each other; they are held in

11
apposition by a screw in the centre, with a supporting rod on
each side; by means of the screw in the centre, these plates may
be separated or drawn together, as may be required, and thus a
sufficient degree of pressure maintained under all circumstances.
As the screw turns in a boss or projection on the concave surface
of the inner plate, the separation of the plates may be produced
without any unseemly or awkward projection of the screw, the
head or handle of this being the only part which appears externally.
This change of the plates may be produced without any trouble
and without disturbing the dress, all that is necessary being to
place the hand within the dress and turn the screw as may be
required. This will be found most agreeable in many instances,
as the degree of pressure required in the erect posture is not neces-
sary in the sitting or recumbent position, and will often give rise
to serious inconvenience in the different changes of the body.
The pads should be placed directly over the places or parts
where the viscera protrude from the abdomen, or in other words
where the Rupture first appears: this is most important in the
application of all instruments used for the purpose of preventing
Rupture. In Inguinal Rupture, this will be found at a short
distance above and to the outer side of the pubes, as it is here
that the spermatic canal commences, by which the Rupture de-
scends into the scrotum; if the pad be placed on the outer
extremity of this canal, the Rupture will still lie in the upper
part of the canal, and is almost as dangerous here as in the
scrotum.
The pads are contained in pockets formed in the Drawers for
their reception, and are here firmly secured.
In old cases of Rupture, and in that form which is named
direct inguinal, the pad or pads should be placed still nearer the
pubes, but so as to avoid pressure on the spermatic chord.
In Femoral Rupture the same kind of instrument will suffice:

1
12
here the pad must be placed on the upper and inner part of the
thigh. In this form of the disease the Rupture Drawers will be
found most agreeable, as the Truss is exceedingly inconvenient to
females, and by some cannot be worn at all.
Gun Shot wounds and other injuries of the abdominal parieties,
attended by a loss of substance, are almost invariably followed by
a Rupture, or a strong tendency thereto-the means necessary for
its prevention must be regulated by the nature and situation of
the injury.
Indeed there is no form of Rupture capable of being reduced
or returned into the abdomen in which this instrument will not be
found efficient.
The only forms in which it cannot be used are those which
cannot be returned, or which do not appear externally; in the
former, a bag must be used to suspend the parts, in the latter, no
instrument can be applied.
When in bed the patient may remove the Drawers altogether,
or only withdraw the pads, these being again replaced in sitû
before assuming the erect position.
As patients affected with Rupture are naturally anxious to be
cured of this disease, it may be asked if any reasonable expectation
of so desirable a result may be entertained? To this we would
reply as follows:-
Many cases of Rupture are capable of being cured; but many,
on the contrary, are incurable by any means at present known.
Where the disease occurs in early life, say before the age of
thirty, and has not been in existence for any serious length of
time, it may be reasonably expected that such will be radically
cured. All parts of the body are then more disposed to repair
the defects caused by accident or otherwise, and where this dis-
position is supported and promoted by adequate mechanical means
the happiest results may be attained.

13
Let us say, then, that such a patient presents himself for not
only temporary but permanent relief. The first thing to be done
is to reduce or return the Rupture, and when this is accomplished,
the Drawers should be carefully applied, and every care should be
observed to prevent the Rupture from again making its appearance:
so long as this is permitted to descend, even occasionally, we can
hope for no beneficial results. The object in view being to cause
the gradual contraction and restoration of the canal by which it
has descended to the natural or healthy state, it is evident that if
the Rupture be allowed to descend this cannot take place. But
if, on the contrary, the Rupture is never permitted to protrude,
the canal will contract by degrees, and will be ultimately restored
to its healthy state. In order to secure this, much depends on
the patient himself; he must be careful to wear the instrument
constantly on, to remove it only when in the recumbent posture,
replacing it whilst still recumbent; he must also avoid all violent
exercise, and pay such attention to the state of the bowels as will
prevent them from being distended with either an undue quantity
of food or by becoming constipated.
The pads will be found active agents in effecting a cure, as their
pressure tends to produce inflammation and consolidation of the
subjacent parts.
But in advanced life, where there is an unusually relaxed state
of the abdominal parieties, and where the same disposition to
recovery does not exist in the constitution, equally sanguine hopes
cannot be entertained. A successful result, however, may be
obtained by care and perseverance in some cases, and in all, the
disease may be prevented from becoming burdensome to the
patient, prejudicial to health, or dangerous to life.
It should be carefully borne in mind that where instruments
have been once used, it is more dangerous to lay them aside than
if they had never been resorted to. This is owing to their causing

14
partial contractions of the spermatic canal, by which the Rupture,
should it descend, is exposed to become strangulated.
Where the disease of Rupture exists only on one side, it is
usual to wear a single pad only; this I consider highly injudicious,
as the pressure of the pad on one side tends to throw the viscera
to the opposite one, and thus to induce a Rupture here; in all
cases I would recommend a double pad to be made use of, as by
this means a uniform support is given to the abdominal viscera.
The materiel of which the Rupture Drawers should be composed
is either silk or cotton, the former, although stronger and more
resisting than the latter, is not so easily cleansed. Two pairs
should be prepared, so that one may be always in wear.
The patient afflicted with Rupture should bear in mind that the
disease is always a dangerous one so long as the Rupture is per-
mitted to remain out of the abdominal cavity. Any unusual
exertion may cause a larger portion of the viscera to descend, and
all efforts may be ineffectual to their restoration. The intestinal
canal now ceases to act, the bowels become obstinately constipated,
and inflammation of the abdominal peritoneum ensues-too often
followed by death. In these cases, the use of all instruments is to be
laid aside until the Rupture is reduced; if this cannot be accom-
plished without professional aid, this should be obtained without
delay a few hours postponement may prove fatal. Larrey met
with a case which terminated fatally in two hours. Further
allusion to this condition of a Rupture is not called for here.
It must be evident from the preceding description that the
Rupture Drawers should fit exactly to the person, hence in most
cases, and especially where the patient is anxious on the matter,
it is desirable that the Drawers should be made by measure pre-
viously taken. For this purpose, I have instructed Mr. Blaise, of
the firm of Whicker and Blaise, 67, St. James's Street, London,
successors to the eminent firm of Savigny and Co. This gentleman

15
is in possession of my views on the subject, and from his great
mechanical skill and ingenuity will be able to meet any difficulty
which may present itself, where the figure is unusually corpulent,
or from any other cause. I andaluc
brod PROLAPSUS UTERI.
It has occurred to me that a modification of the Rupture
Drawers might be applied to that truly formidable and distressing
complaint, Prolapsus Uteri. The different forms of treatment
at present in use apply themselves to the protruded tumour,
whereas they should be used with reference to the cause of the
protrusion.
It is true that one cause of the formation of Prolapsus Uteri
is the relaxed state not only of the uterus itself, but also of the
inferior structures of the pelvis. After frequent pregnancies, and
especially where the labours have been difficult, the structures
which bound the lower apertures of the pelvis and prevent the
protrusions of the viscera in this direction, have become dis-
placed, more or less distended, and relaxed, the result of which is
that the uterus descends too far inferiorly into the pelvis, and
finally protrudes externally.quillo nor
But these are only the predisposing causes; the immediately
exciting causes are the gravity of the uterus, the pressure of the
superincumbent viscera, and the impulse of the diaphragm and
the abdominal muscles.lo
The present instruments operate against the first of these
causes only, and simply support the prolapsed uterus; the prin-
cipal object should be, however, to resist the action of the others;

ai
16
so long as these are allowed to act upon the uterus, this must
descend from its natural position.
The abdominal supporters at present in use assist to a certain
extent, but their action is not powerful enough where most
required; if we can succeed in preventing the superincumbent
viscera from being forced into the pelvis, the uterus will cease to
be protruded.
A modification of the Drawers recommended for the treatment
of Rupture will, I consider, be found to effect this object.
The Drawers should be made to surround the abdomen, and
should be furnished on each side with pads of a considerable
size, and made so as to press the viscera upwards, and prevent
them being forced into the pelvis by the impulse of the abdominal
muscles, or from descending by their own gravity.
I need hardly state that there are some cases of Prolapsus
Uteri in which it would be all but impossible to restore the organ
to its natural position; where the uterus has been long displaced,
and has become very much enlarged, and has contracted adhesions
in its new position, but little can be done to effect this object;
but much may be gained and much relief given to the patient by
the use of such an instrument.
ning sdl
LONDON:
PRINTED BY EDWARD AVERY MITCHENER,
DOGT. RUSSELL STREET, BLOOMSBURY.

Henry Hancochlig
13
pom the
an
A MEMOIR
ON
thin
STRANGULATED HERNIA.


A MEMOIR
ON
STRANGULATED HERNIA;
FROM
CASES OCCURRING IN THE LONDON HOSPITAL.
BY
NATHANIEL WARD, F.R.C. S.,
ASSISTANT-SURGEON TO THE LONDON HOSPITAL, AND DEMONSTRATOR OF ANATOMY.
www
Read before the Hunterian Society, May 24, 1854.
www
SECOND EDITION.
LONDON:
JOHN CHURCHILL, NEW BURLINGTON STREET.
MDCCCLV.

• АГИЛЯН ОТТАТОРНАЯТ 12
LONDON:
G. J. PALMER, SAVOY STREET, STRAND.
TESITE ZOTOLEWA
WHOL

I HAVE been induced to publish the following Memoir at the
suggestion of several Members of the Hunterian Society, and
in accordance with the wish of some of the Pupils of the
London Hospital.
1, Broad Street Buildings,
Sept. 2, 1854.
NATHANIEL WARD.


A MEMOIR,
&c.
THE consideration, that the results of experience which
have ensued either on recognized principles of action, or
on a deviation from them, apart even from the interest of
special description, should command as much attention as
any medical or surgical novelty, constitutes my apology
for bringing the subject of Hernia before the members of
the Hunterian Society, in the manner in which I propose
doing this evening. I shall do so also the less reluctantly
when I consider that the subject is a popular one, in con-
sequence of the varied character of the affection, the
necessary important nature of its details, the consequent
modifications of treatment that are called for, and the
good results which surgery has effected with a daily in-
creasing amount of certainty in this department of its
practice.
From the middle of February, 1851, to the middle of
May, 1854, a period of three years and a quarter, 69
B

2
cases of hernia have been operated on in the London
Hospital. Of this number 43 were femoral, 22 inguinal,
and 4 umbilical. The number not operated on during
that period amounted to 173, thus making a total of 242
that have been under treatment.
Of the 43 cases of femoral hernia, 39 have occurred
in the female, 4 only in the male. 28 cases have occurred
on the right,-24 of them being in the female, 4 in the
male; and 15 on the left side.
Among the 22 cases of inguinal hernia, 15 were on the
right, and 7 on the left side. These facts, as to the
greater frequency of hernia on the right than on the left
side, correspond with the experience of Sir Astley Cooper,
and may, as he remarks, possibly be accounted for by the
fact, that exertion is generally greater on the right than
on the left side of the body.
Of the 43 cases of femoral
birosla
hernia, the sac was not
opened in 29, and opened in 13. The average period of
strangulation in the former class of cases amounted to 34
hours and a fraction; in the latter to 58 hours.
Of the 29 cases of unopened sac, 4 died and 25 re-
covered, the shortest period of strangulation in the fatal
cases having been 39 hours, the longest 5 days; in the
recoveries, the shortest period having been 10 hours, the
longest 5 days.
to and one of atlueen boog
Of the 13 cases of femoral hernia, in which the sac
was opened, 6 died and 7 recovered; the shortest period
of strangulation in the 13 cases having been 24 hours,
the longest 7 days.
B

3
In the 22 cases of inguinal hernia, the sac was opened
in all but 3. 14 recovered, and 8 died. The shortest
period of strangulation was 3 hours, the longest 9 days.
Of the 4 cases of umbilical hernia, 2 occurred in the
male, and 2 in the female. 3 died, and 1 recovered.
The case that recovered was that of a female, who had
been operated on four years previously. In all the 4
cases the sac was opened.
21.
The aggregate mortality in the 69 cases amounted to
The operation in the cases of femoral hernia in which
the sac was not opened, was, in the majority of instances,
conducted according to the method detailed by Mr. Luke,
in his admirable and practical essay, in the "Medico-Chi-
rurgical Transactions."* In a few instances the mode of
*"It will be recollected that there is always a groove or depres-
sion of the integuments, which defines the upper limits of the
tumour upon the abdominal surface. Where no depression can be
seen, the boundary of the tumour may be ascertained by the pres-
sure of the finger in that situation. A fold of integuments is to be
pinched up at that part, and divided by transfixing it with a narrow
knife, so that the incision, when the skin is replaced, shall fall per-
pendicularly to the body of the tumour, with its centre opposite the
depression referred to. By a few strokes of the scalpel the tendi-
nous expansion of the abdominal muscles is to be laid bare; after
which a finger should be introduced as far as Poupart's ligament,
between the tendinous expansion and the tumour, when the latter
rises upon the former. The ligament being thus exposed, a hernia
director is guided under it by the finger into the femoral ring, the
margin of which may be safely and easily divided in an upward di-
rection with a common probed bistoury, and the taxis applied in the
B 2

4
operating recommended by Mr. Gay was had recourse to.
Whichever operation was selected, it was carried out with
as little delay as possible, and in the large majority of
cases after only a short and guarded attempt of the taxis,
associated with the use of the warm bath, and, in several
instances, of chloroform.
Of the relative merits of the two methods of operating
(if a wide view of the subject be taken, and if an opera-
tion is to be so planned as to embrace nearly every variety
of a femoral protrusion), the method recommended by
usual way. Should the margin of the ring have formed the stric-
ture, the taxis, for the most part, succeeds very readily, and the
operation is completed in a very short time. But should the stric-
ture be caused by bands of fascia propria, the director will have
passed over them, as it entered the femoral ring, in which case any
amount of division in an upward direction, will be of no avail.
When the taxis does not succeed readily, these bands of fascia may
generally be suspected to be the cause of failure. The fact may be
made sufficiently clear by introducing the finger on the neck of the
sac, under Poupart's ligament, while the body of the sac is pressed
between the finger and thumb of the other hand, when it will be
discovered that no impulse is communicated to it by such pressure.
By a little attention, the band may be detected crossing the neck of
the sac, from half to three-quarters of an inch below the ring, and
may
be divided by insinuating the nail of the forefinger of the left
hand under them from above, and by carrying the point of a probed
bistoury along the nail, with its blunt edge towards the sac.
division is made by the surgeon drawing the bistoury away from the
sac towards himself, a proceeding which, if properly performed,
avoids all danger of wounding the sac or its contents."-Medico
Chirurgical Transactions: Vol. xxxi.
The

5
Mr. Luke appears to me preferable to that recommended
by Mr. Gay, inasmuch as the latter is peculiarly applicable
to those cases in which the division of Gimbernat's liga-
ment is sufficient for the reduction of the swelling, which
division alone is usually found to be effectual only in
comparatively recent herniæ. Mr. Luke's incision, made
over Poupart's ligament, and the neck of the sac, so as to
command all the structures round about the latter, and to
interfere as little as possible with the fascial connexions
of the body of the tumour, can easily meet the require-
ments arising from impediments to reduction caused by
other fibrous and tendinous structures than Gimbernat's
ligament, and to the extent of its greater applicability is
therefore the preferable proceeding. An answer also
must be given in favour of the vertical incision in a large
number of cases in which, in consequence of the period of
strangulation, it has been reasonable to infer that serious
lesion has been inflicted on the mucous and other coats of
the gut. There would be much greater danger of in-
creasing this lesion by passing a director and bistoury be-
tween Gimbernat's ligament and the sac, in a line with
which ligament the amount of injury is always the great-
est, than by passing the instruments beneath Poupart's
ligament and relieving the impediment to reduction over
that part of the intestine, where frequent post mortem
observation has proved that the injury is the least. I
should mention, however, that the most rapid instance
of recovery that I have witnessed was one in which
the oblique internal line of incision of Mr. Gay had been

6
adopted, the wound having entirely healed on the fifth
day.
The various sources of impediment to the reduction of
strangulated femoral hernia, which are situated externally
to the sac, call for some observations, and I shall here
enlarge on those I made some time back in the "Medical
Times and Gazette."* It is curious and confusing to hear
and to read the various descriptions as to what is termed
the seat of stricture, or what, in my opinion, would be
more properly termed the impediment to reduction; for
the parts that surround the hernial protrusion can exert
no active tightening effect upon it, but are rather them-
selves rendered tense by the pressure of the rupture, and
its products from within, even, I imagine, although the
coverings of the hernia may be, as in some forms of in-
guinal, muscular in their structure. This distension of
tendinous and muscular structures, superficial to the rup-
ture and its sac, in consequence of pressure exerted from
within, is admirably illustrated in herniæ other than recent
in which the dimensions of the different hernial canals
and apertures are so far from normal as occasionally to
allow of the easy admission of three fingers, as occurred
in one among this collection of cases.
Sir Astley Cooper speaks of three sources of stricture:
1st, The crural sheath; 2nd, Posterior edge of the crural
arch; and 3rd, The mouth of the hernial sac. Lawrence,
of the thin posterior boundary of the crural arch as the
very part that constitutes the stricture; and he compli-
* October 10, 1851.

ments Gimbernat on the discovery. Mr. Hey speaks
strongly of the falciform edge of Burns; Mr. Key placing
much stress on a band of fibres above and behind Poupart's
ligament; and Mr. Luke pointing out the transverse
fibres that are occasionally found highly developed, and
strengthening the sheath of the vessels, as frequently the
seat of stricture, these being apparently identical with
the bands alluded to by Cooper, as the anterior columns
of the sheath of the hernial protrusion.
Now it would appear, à priori, from a consideration of
the anatomy of the femoral canal, that the sharpest and
most resisting structure would constitute the chief impe-
diment to the return of the bowel. Gimbernat's ligament
has this peculiarity, and, in post mortem examinations of
femoral ruptures, the bowel will be found to have expe-
rienced a greater amount of injury at that part where it
was in relation with Gimbernat's ligament, than elsewhere.
I had once an opportunity of being thoroughly satisfied
on this point, on examining an old woman who had suf-
fered from strangulated hernia, and had died without any
operation having been performed. The mucous and mus-
cular coats had entirely ulcerated where they were in
relation to Gimbernat's ligament, but not elsewhere.
In numerous cases of femoral rupture, particularly in
small and recent protrusions, an incision of Gimbernat's
ligament is quite sufficient to effect reduction, and, with
this object mainly in view, I conclude Mr. Gay introduced
his line of incision to the Profession.* It is worthy
* Since the above was written, Mr. Gay observes, in the "Medi-

8
of remembrance, that Gimbernat's ligament is in intimate
connexion with Poupart's ligament, and with Hey's liga-
ment or the upper part of the falciform edge of Burns,
and that they, by their blending together, constitute the
greater part of the boundaries of the femoral ring. An
incision of Hey's and Poupart's ligament could not conse-
quently be made without relaxing somewhat Gimbernat's,
as was illustrated in many cases in this series, in which,
after the incision of the former two, the hernia was readily
reduced. Now it is true that, after the incision of Gim-
bernat's ligament, or its relaxation by a division of
Poupart's and Hey's ligaments, a rupture cannot, in many
cases, be reduced, but returns easily on the further division
of the transverse bands strengthening the sheath of the
vessels. These bands are then spoken of as the seat of
stricture; but they clearly constitute mere secondary
impediments, no case having, to my knowledge, occurred
in which their division alone, without the previous incision
of Gimbernat's or Poupart's ligament, was sufficient to
allow of the reduction of the contents of the hernial sac.
I conclude, therefore, that Gimbernat's ligament is the prin-
cal Times and Gazette," of August 12, 1854, in his "Remarks on
the seat of Stricture in Femoral Hernia :" "The line of external
incision by which my mode of operating is carried out, was not
devised for the purpose of specially commanding Gimbernat's liga-
ment, but permits the knife to pass successively behind the falciform
process, the edge of the lower orifice of the canal, Hey's ligament,
and the fibres of the inguinal canal of Hesselbach, and is thus
made to command whichever may happen to be the particular seat
of stricture."

9
cipal impediment to reduction. In small and recent herniæ
it is usually the only impediment; but when the tumour
has existed for some considerable time, and has much
increased on its original dimensions, it distends the canal
into which it has descended, and presses on and renders
tense and hypertrophied different series of fibres in more
or less original intimate relation with the sheath of the
vessels, such as the deep femoral ligament, the transverse
fibres of the sheath and Hey's ligament, which structures
were, in the small condition of the hernia, lax in com-
parison with Gimbernat's ligament, and produced no in-
jurious effect on the tumour. These fibres, then, which
in the majority of herniæ of long standing have thus
become gradually hypertrophied, and brought to this
condition also partly by the pressure probably of a truss
from without, require division on the supervention of
strangulation, as well as Gimbernat's ligament, in order
to effect the reduction of the gut.
With reference to the transverse fibres of the sheath,
properly so called, I would hazard a few remarks. I am
not at all satisfied that the transverse fibres strengthening
the sheath of the vessels exist so frequently as some
surgeons imagine, and as one would be led to conclude
from a perusal of Mr. Luke's essay but that, on the con-
trary, they are, in many cases, artificially produced. I
have carefully watched the steps of the operation in
numerous cases of femoral hernia, and have observed,
that immediately after the exposure of the external oblique
tendon, the director has been glided down the tendon,

10
and insinuated immediately beneath the lower border of
Poupart's ligament, which has then been divided, when
the incision has been directed upwards, and together with
it, Gimbernat's ligament, when the incision has been
directed upwards and inwards. The result of this pro-
ceeding has been to detach Hey's ligament from its con-
nexion with Poupart's. An attempt has next been made
to reduce the hernia, but ineffectually. The left index
finger has then been passed behind Poupart's ligament
from above downwards, and, after having reached a vari-
able distance, ranging from almost immediately below the
ligament to three-quarters of an inch distant from it, the
nail of the finger has been arrested by some more or less
dense bands; a probe-pointed bistoury carried carefully
along the nail, and then drawn forwards, has divided these
bands, and the hernia has gone back without any further
difficulty. Now these bands have appeared to me, from
the manner in which the first steps of the operation were
conducted, to have been the detached upper part of the
falciform edge of Burns, and, if so, identical with the
structure which Hey, more than forty years ago, described
as the seat of stricture in femoral hernia.
The previous analysis has shown, that out of 29 cases
of femoral hernia in which the sac was not opened, 4 only
died; of 13 in which the sac was opened, 6 died, thus
leaving, one might say, a wide margin in favour of the
first proceeding. On reflection, however, a comparison
would not be just, and I hardly know how it would be
possible to arrive at an appreciation of the relative merits

11
of opening the sac or of not opening it in the practice at
an Institution where the latter proceeding is intentionally
the rule, the former the exception; the one undertaken
on conviction, the other by caution or necessity. In other
words, unless experiments were intentionally made on a
given number of cases, carefully selected as to points of
resemblance, similarity of treatment before, during, and
after operation, and the operation by opening the sac
performed in as many instances as by not opening it, I do
not see how, in the absence of most extensive statistics, a
logical conclusion can be drawn, however much a common
sense view of the question may appear to determine in
favour of not opening the sac in those cases of protrusion
that admit of it. Of this point, however, I am tolerably
clear, that the operation without opening the sac, in con-
sequence of the ease of its performance when the steps
for conducting it, the difficulties that may occur, and the
mode of meeting them, are distinctly impressed on the
mind of the operator, its comparative freedom from the
danger of wounding intestines, or bloodvessels of import-
ance, and the general rapidity of recovery, will lead to
one most desirable result, I mean the early surgical inter-
ference for the relief of a strangulated rupture. Thus,
by doing away as much as possible with the monstrous
habit of delay and expectancy-a habit forming too large
an element, even now, in the mortality of hernia cases-
the general adoption of the early operation without open-
ing the sac will justify the remark I made at the com-
mencement in reference to the progressive amount of

12
certainty in carrying out a hernial operation and insuring
its success.
Of the four fatal cases in which the sac was unopened,
the following are the brief particulars :-The first, a
woman, aged 73, died on the nineteenth day from ex-
haustion. The second, aged 73, died from a similar cause
on the sixth day. The third, a woman, aged 72, died on
the fourth day from a low form of peritonitis, and had
been suffering for many years from troublesome prolapse
of the uterus, which had much reduced her prior to the
operation. The fourth case was that of a woman, aged
56, who died on the third day after the operation, from
peritonitis and a perforating ulcer, strangulation having
existed for three days.
Among the cases that recovered, of those in which the
sac was not opened, two only out of the 25 require
notice :-
1. A fat, unhealthy woman, aged 69, died from pulmo-
nary apoplexy two days after the healing of the wound.
2. A man aged 64. Strangulation had existed for
fourteen hours on the right side, and he recovered on the
thirteenth day. He had had a strangulated hernia on
the left side a year or two before, and had been ope-
rated on in St. Bartholomew's Hospital. The right rup-
ture occurred shortly after leaving St. Bartholomew's in
consequence of a severe jerk while working. Since then
he had worn a double truss.
The above series of cases of femoral hernia, in which
Petit's operation was performed, although peculiarly satis-

13
factory to the surgeon in consequence of their general
favourable termination, lose much in interest when com-
pared with cases in which the sac was opened in conse-
quence of some individual peculiarity or complication not
existing in the first series, or, if existing, necessarily un-
observed and comparatively unimportant.
I proceed now to speak of those cases among the
femoral class, amounting to 13 in number, 6 of which
died. The following are the particulars of the 6 fatal
cases :-
1. A woman, aged 46, was at the time of the operation
convalescent from scarlatina, and died on the third day
from low peritonitis, strangulation having existed three
days before the operation.
2. A woman, aged 72, died exhausted thirty-five hours
after the operation, strangulation having existed five days
before it.
Lad
3. An emaciated female in-door pauper, aged 66, died
thirty-six hours after the operation, strangulation having
existed between seven and eight days before admission.
In this instance th woman was so weak that she could
give little or no account of herself; the skin over the
hernia was inflamed, and her hands were cold and
clammy. A large quantity of omentum was found in
the sac, concealing a knuckle of intestine at the back of
the sac, which was adherent to it by recent fibrinous
exudations. On the post mortem, the omentum was found
attached by old adhesions to the front, inner, and outer
part of the neck and body of the sac; the part of the

14
T
gut which had come down was much inflamed, and
interrupted by purplish spots, but not devoid of lustre ;
the mucous membrane much congested, particularly that
part which had been in contact with the inner boundary of
the ring. This case is interesting as showing that when
an omental hernia exists prior to the occurrence of an
enterocele, the inflammatory action on the bowel is much
limited in intensity. This circumstance arises from two
conditions, the first, the enlargement of the femoral
ring by the presence of omentum; the second, the pre-
sence of the omentum between the sharp edge of Gimber-
nat's ligament and the bowel, so that the sharpness of the
former, and its consequent injurious action on the latter,
are materially diminished, as in this instance, in which
though the symptoms of strangulation had lasted about
eight days, the mucous membrane had not ulcerated, nor
had the bowel lost its lustre. This result strikingly con-
trasts with the rapidity and severity of symptoms that
usually supervene in a case of simple protrusion of the
bowel (particularly in lean subjects), in which it is
brought into almost immediate contact with Gimbernat's
ligament, the mucous membrane frequently ulcerating
through, even in the course of less than forty-eight hours
after the descent.
4. A woman, aged 40, who had suffered from symp-
toms of severe strangulation six days before admission.
The nature of her affection had been overlooked for that
space of time, and a remarkably varied, and what is
termed palliative treatment had been adopted. The gut,

15
when the operation was performed, was found mortified,
and fæcal matter was extravasated in the immediate
coverings of the intestine. The patient died on the ninth
day after the operation; no discharge from the false anus
having taken place for three days previously, and the
symptoms shortly before death having been those of a
low typhoid type.
5. A woman, aged 65, who, when admitted into the hos-
pital, was very depressed, the tongue being dry and brown,
the pulse quick and feeble, and the hands clammy. The
hernia was very large, occupying half the space between
the front and upper spine of the ileum and pubis, measur-
ing three and a half inches in its long axis, and two inches
in the broadest part of its vertical diameter. The nature
of the case had been overlooked till within a short period
of her admission, and the patient had for several days
been under treatment for enteritis. During the operation,
which was performed without the application of the taxis
previously, the fascial structures were found highly deve-
loped, and six distinct layers were divided before the sac
was opened. The most superficial connected the tumour
so firmly to the tendon of the external oblique, that the
latter was incised in order to detach them. Half an ounce
of blood escaped on opening the sac, which contained
omentum, connected by old adhesions to the sac, and by
recent to a purplish, but not lustreless, knuckle of intes-
tine. Nothing appeared to stand in the way of the re-
covery of the patient but her great depression and her
determination to die, which made her refuse her nourish-

16
ment and medicine to a great extent. She sank six days
after her admission. On a post mortem examination no
trace of peritonitis could be detected; about six inches
of the intestine were of a purplish tint, the middle part
was darker than elsewhere, and the mucous membrane
interruptedly congested, and here and there ulcerated.
6. Was of the variety termed by Stephens "obstructed
hernia." A woman, aged 56, was admitted with symp-
toms of strangulation, which had been slowly developing
for a week, and came on without any perceptible increase
in a small right protrusion, which had existed, she said,
for nine or ten months. She had had on several occa-
sions, similar attacks of sickness and constipation, but
they had gradually gone off. After the incision of the
superficial fascia a dark layer of membrane was exposed,
on opening which out came a quantity of bloody serum.
Inside this sac was a globular mass of fat, hard and con-
densed, and of the form of a large walnut. On incising
this, its circumference was found a quarter of an inch
thick, and in close contact with, and enveloping another
sac,
which contained dark serous fluid, and a small por-
tion of gut, which had all but lost its elasticity, being
flaccid, yielding on pressure, and but slowly regaining its
form. It was not much larger than the tip of the middle
finger, and the coats were thick, and like soaked leather.
Its upper part, all round, was in most intimate union with
the sac, and to all appearances so structurally connected
with it, that it would have been impossible, I think, to
have separated it with the knife or otherwise, without

17
endangering its integrity. It was, therefore, left in situ,
as much tension having been removed as possible, by the
free division of Poupart's ligament at the angle of junc-
tion between it and Gimbernat's. The symptoms of
strangulation remained unrelieved; and, on the second
day, the gut was opened by a crucial incision; fæcal mat-
ter escaped. The patient died in four and a half days after
the operation. The neck of the sac was found firmly adhe-
rent to the neck of the gut, which was only a portion of
the entire calibre, by very firm close connexions girting it
all round, and which to all appearances had existed for
years.
Of this variety of incarcerated hernia, termed ob-
structed, Stephens relates several cases, in which the
uniting adhesions to the chronically inflamed and thick-
ened bowel were freely detached, the gut returned into
the abdomen, and a favourable result ensued. Could this
proceeding have been safely effected in the above case, it
is possible that a different result might have followed.
Among the 7 cases of hernia that recovered, of
those in which the sac was opened, I find several inter-
esting statements. Thus, in a woman, aged 60, who re-
covered on the thirty-ninth day after the operation, a
previous operation had been performed on her on the
same side ten years previously. A woman, aged 72, re-
covered on the thirtieth day, strangulation having existed
for forty-eight hours. In one instance the sac was
opened, in order to examine the nature of a tumour in
connexion with the sac, and which turned ont to be a
large dilated diverticulum appended to it.
C

18
I come now to a consideration of the particular points
of interest connected with the 22 cases of inguinal
hernia, of which 14 recovered, and 8 died, and, in all
of which, with three exceptions, the sac was opened.
The shortest period of strangulation was three hours;
the longest nine days before the operation. All, with
the exception of one, were of the oblique inguinal kind;
the exceptional case occurring in a man, aged 37, in which
the protrusion was a direct or internal left inguinal. The
sac contained a large portion of the sigmoid flexure of
the colon, the symptoms of strangulation were slight, and
recovery ensued on the fifteenth day, the operation having
been performed within twenty-four hours after the de-
scent of the gut, chloroform and the taxis having been
previously used without effect. Among the 14 recoveries,
there were 2 cases of reduction en bloc; and one of
marked hour-glass contraction of the neck of the sac,
which formed the impediment to reduction, and which
was placed more than half an inch below the level of the
outer ring, and very analogous to a case I witnessed ope-
rated on by the late Mr. Andrews, in which the neck of
the sac, which formed the impediment to reduction, was
one inch below the outer ring. In this case, as well
as in several others, Mr. Luke's strangulation test was
found of signal advantage; and I extract the following
description of it from the " Medical Gazette" of 1841,
as I do not think it is so generally known as its merits
deserve :-
"If the body of the hernial tumour be compressed by
the hand, an impulse is communicated to all its parts

19
below the seat of stricture; but, if the neck of the hernia
be grasped between the finger and thumb of the other
hand, above the stricture, while such compression is made,
there will not be any impulse felt. When, in the com-
mencement of the examination, the neck of the tumour
is first grasped, we may be always assured, that if an im-
pulse is felt on compression of the tumour itself, the seat
of stricture is nearer the abdomen; and by gradually
withdrawing the finger and thumb in that direction,
while renewed compression of the tumour is made, a
point will soon be reached at which impulse ceases to be
felt. The point at which impulse first ceases to be felt is
the seat of stricture. In like manner, if an impulse is
not felt when the neck of the tumour is first grasped,
we may be equally assured that the stricture is situated
nearer to the body of the hernia; and by a like gradual
approximation to it with the finger and thumb, an im-
pulse shortly commences to be felt. The point where the
impulse commences to be felt is the uppermost part of the
strangulated contents, which implies that the stricture is
immediately above it; and, on inquiry, it will be found to
correspond with the indications of an examination com-
menced from below."
The value of acting on the indications of this simple
proceeding when its application is practicable* is at once
apparent, as unnecessary division of the soft parts is thus
avoided. But to continue; I find that a man, aged 34,
* In very tense strangulated protrusions, I have found the test
inapplicable.
02

20
who had recovered on the eighteenth day (the symptoms
of strangulation having existed only three hours), had
been operated on on the same side ten months before, in
St. Thomas's Hospital, and that a large quantity of omen-
tum had been taken off. A case of sight oblique inguinal
hernia in a man aged 43. It belonged to the intermus-
cular, or ascending variety, described by Mr. Luke, in the
"Medical Gazette" of 1850. The tumour in this instance,
instead of passing down into the scrotum, had mounted
up in the cellular tissue between the external oblique ten-
don and the internal oblique muscle, considerably above
the level of the anterior superior spinous process of the
ileum. On the free division of the tendon of the external
oblique and the subjacent fasciæ, the sac was exposed;
it was drawn down, a free incision made into it, and the
intestine exposed. This was highly inflamed; no fur-
ther impediment to reduction was found, strangulation
having arisen in consequence of the peculiar position of
the body of the hernia, and the bending upwards on itself
of the bulk of the gut, a distinct indentation existing at
the angle of flexure. Strangulation had existed for four
days, but the symptoms had not been very severe till within
fifteen hours of the operation. This man had used for a
considerable time an ill-adjusted truss, which commanded
the outer but not the inner ring. The protrusion had, in
consequence of the resistance offered to its descent in the
former locality, mounted upwards, and had thus become
analogous to the upward course of a femoral protrusion,
the truss having acted in the same way in the inguinal

21
as the blending of the fascia transversalis below the saphe-
nous opening with the immediate covering of the femoral
artery and vein, does in the crural form of hernia.
Of the 2 cases of reduction en bloc, one occurred in
a lad aged 14, who had had a right inguinal hernia for
two or three days, with slight symptoms of strangulation.
On the application of the taxis under chloroform, the bulk
of the tumour disappeared, and could only be indistinctly
felt in the region of the inner ring. Symptoms con-
tinuing, an exploratory operation was had recourse to.
The body of the tumour was pulled down, and the neck
of the sac and inner ring divided. A recovery in fifteen
days resulted. The last cases worthy of particular note
are, a case of left congenital hernia, with orchitis and
empyema of the tunica vaginalis following the operation,
in a man, aged 27. Strangulation was of twelve hours'
duration. The sac was opened; it contained omentum,
and seven or eight inches of the large intestine. Orchitis
shortly supervened, and was followed by a large purulent
effusion into the tunica vaginalis, which membrane was
laid freely open on the eighth day. Two days previously
erysipelas had come on on the dorsum of the foot, termi-
nating in an abscess, which was opened on the ninth day.
Recovery ensued on the fifty-second day. A case of ob-
lique inguinal hernia in a male child, 21 months old. The
strangulation had not existed twenty-four hours, and he
recovered on the seventeenth day. And, lastly, a case of
strangulated inguinal hernia, in a male infant 9 weeks old.
The symptoms of strangulation had existed three days.

22
The sac was not opened, and the wound had healed on
the seventh day. The child was taken out of the hospital
contrary to the wish of the surgeon; erysipelas and death
supervened.
Among the 8 fatal cases of inguinal hernia, I find seve-
ral that are worthy of a more or less lengthy notice.
1. A man aged 51, subject to double inguinal hernia.
Seven days before admission, the left rupture came down,
and became larger than usual. He had been in the habit
of reducing it easily before. On this occasion, he suc-
ceeded in the taxis in five or ten minutes, but used a
much greater amount of force than he had been in the
habit of doing, kneading it and twisting it about. It gave
him great pain, which was relieved, however, when the
reduction had been accomplished. The bowels acted every
day till the day preceding his admission, when the
pain, which had never entirely ceased, became very
severe, increased on pressure, and was limited by a space
equal to the palm of the hand, which included the upper
part of the inguinal canal. Sickness had now come on,
No tumour could be detected in the course of the inguinal
canal, although there was an obscure swelling at its upper
part. The supposed enteritic character of the symptoms
not yielding to treatment, an operation was performed on
the following day. The neck of the sac was divided
deeply and internally to the inner ring: a good deal of
the exposed gut was sphacelated. The man sank in
thirty-six hours after the operation; and on a post
mortem, the neck of the sac was found over the border of

23
the inner and anterior part of the true pelvis, the body of
the sac occupying the iliac fossa. A case similar to this
occurred some short time before my record commences,
and is recorded by Mr. Curling, in the "Lancet," for 1850.
2. A case of double congenital hernia, partial reduc-
tion en bloc, remarkable malformation in the left tunica
vaginalis. A bailiff, aged 37, married, subject to a left
rupture for nine or ten years. He was not aware that
there was anything wrong on his right side, although
there existed there an irreducible omental hernia. Five
days before admission he fell out of a cart and was much
shaken. On the evening of the same day, the rupture
came down on the left side, his truss not being on. It
was reduced with great difficulty in about an hour and a
half. He was sick during the time it was down; on re-
duction he felt quite easy, but soon afterwards pain in the
bowels, followed by sickness came on. He had taken
lots of medicine, and had had, he said, about forty injec-
tions. Two days after reduction he had passed a small
quantity of fæculent matter. Sickness continued at in-
tervals, and injections returned as soon as administered.
These symptoms continued till his admission. An opera-
tion was performed on the left side three-quarters of an
hour after the patient came in. The canal was laid open
and, on pinching up the sac, prior to opening it, the bowel
appeared to recede and collapse. The sac was very thick,
and the intestine of a dark claret colour, but not lustre-
less. On passing the finger upwards, the impediment to
reduction was found at the neck of the sac, about half an

24
inch above the natural position of the inner ring. The
patient died on the third day, in consequence of a violent
attack of diarrhoea which terminated in fatal prostration.
On laying open the abdominal cavity, two contiguous por-
tions of small intestine were remarked in the upper part
of the left iliac fossa, placed obliquely one above the other,
and united by soft lymph. At the front part of the
upper portion was a dark mark, three-quarters of an inch
long, not prolonged on to the posterior surface. The
peritoneal coat had not given way in the line of this mark,
but the subserous tissue had, the muscular and mucous
coats not having ulcerated. A patch of the lower divis-
ion of the small intestine, equal in area to a shilling, was
covered over with lymph, and, on removing this, the gut
looked dusky and red; a corresponding surface internally
was similarly covered with plastic exudation. With this
exception, the mucous membrane, though dark was not
lustreless. On the right side there was a large congenital
hernia, containing nearly all the great omentum, so that
the transverse colon had been dragged much down, and was
distant only an inch from the inner ring. The omentum
was adherent to the sac, and the lower part overlapped
the testicle, thus verifying the diagnosis which had been
formed on the admission of the patient.
left hernial sac had been divided a little
The neck of the
above the inter-
nal ring. On laying open the sac by a vertical incision,
carried to within two inches of the scrotum, it was found
distended with sero-purulent fluid. The vas deferens-
five times its ordinary thickness, and covered over by a

25
dense layer of fat-was observed at the outer and back
part of the sac. The testicle was not seen, nor the epi-
didymis; but on passing the finger to the bottom of the
sac, the nail could be insinuated between the upper part
of the body of the testicle and the epididymis, and a
smooth dense ring in the bottom of the sac, as though the
tunica vaginalis had an opening below. On extending
the vertical incision to the bottom of the scrotum, the
body of the testicle was exposed. It was much altered
in position; the anterior and inferior border looking
downwards, backwards, and to the left side; the epididy-
mis looking in the contrary direction. On the outer and
back part of the body of the testicle, immediately below

26
the globus major, was a somewhat semilunar opening, the
size of half a sixpence, leading upwards to a cul-de-sac on
the outside of the cord, gradually contracting as it pro-
ceeded upwards, and one inch and a half in length. The
cavity in which was the somewhat atrophied testicle was
larger than sufficient to contain it, not glistening on the
surface, but covered over with layers of soft false mem-
brane. On cutting through the ring which girted the
upper part of the body of the testicle (and which ap-
peared at first sight to be the boundary of a perforation
in the lower part of the parietal tunica vaginalis), and
making slight traction of the structure which formed it,
it was found that the membrane could be stripped off
from the subjacent tissue, which latter, when thus exposed,
resembled that surrounding the body of the testicle.
Thus the cavity of the tunica vaginalis was divided into
two unequal portions by the developement in its upper
two-thirds of an adventitious sac, whch contained the
hernial protrusion and the spermatic cord, and by its
lowermost portion, completely encircled the testicle with-
out adhering to it. During life the hernia must have
descended into this false sac, above the body of the testi-
cle, which would have formed a distinct swelling below it,
and thus the diagnosis of its being a congenital form of
protrusion would not have been made. The accompany-
ing sketch illustrates the above description.
3. A case of right oblique inguinal hernia, with stran-
gulation of intestine, in consequence of its having pre-
viously passed through a ring in the mesentery. The

27
tumour occupied the upper third of the scrotum and in-
guinal canal, and occurred on the right side in a young
man. The gut had come down thirty-two hours before
admission, and symptoms of strangulation had supervened
in three hours after. During the operation the bulk of
the swelling, which was much below the outer ring, was
found to have arisen from bloody fluid, which had dis-
tended and rendered the sac tense. The upper part of
the swelling, which occupied about the upper third of the
inguinal canal, and extended somewhat beyond it, was
occupied by a highly congested knuckle of intestine.
There appeared to be no impediment to reduction at the
inner ring; but, one and a half inch beyond this, the
neck of the sac was reached, and was incised by a bis-
toury guided on the finger. From the direction of the
finger the neck of the sac appeared to be lying over the
brim of the pelvis. The patient died suddenly while
leeches were being applied to the abdomen, twenty-two
hours after the operation. On a post mortem, the neck
of the sac was found an inch and a half from the level of
the inner ring, just over the brim of the pelvis; and,
extending from the lower and posterior part of its cir-
cumference, was a delicate old organised band, tense, and
connected with a ring in the mesentery, which tightly
encirled three folds and a half of the small intestine
which was dark purple, with patches of deeper coloured
extravasation in the coats, and matted together by plastic
effusion. A large quantity of bloody serum was found in
the cavity of the abdomen. The part of the intestine
which had been in relation with the mouth of the sac was

28
evidently part of that which had passed through the ring
in the mesentery.
han Janco Inning
4. A case of strangulation of the small intestine in an
old irreducible hernia, containing portions of the ascending
and transverse colon, occurring in a man, aged 52, in
which the operation, without opening the sac, was per-
formed on the fourth day, and the recent protrusion re-
duced. Death, however, occurred from apoplexy on the
sixth day.
Thus I have endeavoured to bring forward a general
view of the important subject of hernia, as far as it can
be illustrated without tedium, by the number of cases of
strangulation I have had the opportunity, during the last
three years and a quarter, of witnessing, gaining informa-
tion upon from others, or of personally conducting the
necessary surgical proceedings; and I here tender my
best acknowledgments to my colleagues, who have unre-
servedly placed their Hospital experience during this
period at my disposal. I cannot, however, leave the sub-
ject without making a few brief observations on those
very important points concerning the treatment of stran-
gulated hernia preliminary and subsequent to the opera-
tion; the application of the taxis and the period of opera-
tion, on the one hand, and the medical treatment after
the operation, on the other.
My own experience has led me to the strong convic-
tion that the taxis, when employed, should be used with
the utmost caution; and, after having been so used, and
failing, the operation should at once be had recourse to, the
warm bath and chloroform having also proved ineffectual.

29
To quote from the chapter on hernia in Dieffenbach's
"Operative Surgery" (an essay of a highly practical cha-
racter, too little known in this country, but particularly
entitled to consideration, as emanating from a man who
had greater experience in strangulated hernia than any
surgeon, I believe, in Europe), "It is not too much to
say, that to see a surgeon postpone an operation, after
the ineffectual use of the taxis properly applied, is much
the same as the conduct of that man who, on going sud-
denly into a room, and seeing a fellow-creature who had
just hanged himself, quietly put his hands in his pockets,
seated himself before the unlucky individual, and instead
of cutting the cord from his neck, called for soap liniment
and began rubbing it into the soles of his feet."
In the perusal of my Note-book I find statements like
the following:-"Taxis employed for about an hour be-
fore admission; quantity of bloody serum escaped on
opening the sac; taxis used three times, each time last-
ing about a quarter of an hour; hurt him very much;
two ounces of bloody serum on opening the sac, and after
death a large quantity of bloody fluid in the abdomen;
ecchymosis of the connective tissue between the different
layers of abdominal muscles; patches of deep-coloured
extravasation in the coats of the intestine that had pro-
truded; taxis used for a considerable time before admis-
sion, sac found as black as your hat, looking like mortified
gut; longitudinal rent, an inch long, in the peritoneal
coat of the intestine. Death."
I might multiply extracts, but I forbear, for I have no

30
doubt, the experience of all those who have seen much of
hernia, either in public or private, has led to the conclu-
sion, that the ruthless application of the taxis has been
the cause of a lamentable amount of failure in hernial
operations. And if, in some cases, we remember, that,
even in the hands of the most experienced, the taxis,
although to all appearances judiciously used, has been
attended with serious and fatal consequences, extra cau-
tion becomes requisite. In illustration of this remark, I
bring forward the following case which has come under
my notice: An emaciated widow, aged 53, had a stran-
gulated hernia of thirty-two hours' duration; the taxis
was carefully and skilfully applied, no undue amount of
force appearing to be used. Very shortly after the in-
testine had been reduced, she gave a loud shriek, com-
plained of violent and excruciating pain, which lasted
about an hour, and was then followed by irremediable
collapse, and death in three hours after the reduction of
the gut. A careful post mortem examination, in nine-
teen hours, found the sac protruded through the
saphenous opening, the boundaries of which were very
tense, as also those of the femoral ring. On opening the
abdomen, a strong smell of garlic obtruded on the nose.
A small loop of intestine, which had been in the sac, was
deeply indented, and contracted at its upper part, the
indentation being covered by fibrinous deposit; the
corresponding part of mucous membrane had partly
ulcerated through. On the posterior part of the gut,
nearer the lower than the upper border, was a circular

31
opening, equal in size to the end of a small pencil-case,
with a clean cut border in the mucous membrane; a
corresponding opening of the serous coat was three times
larger, with a ragged circumference; and that of the
muscular was intermediate in size. An extravasation of
blood was in the subserous cellular coat. The entire
intestine partook of the general wasted character of the
body, was thin, and possessed little tonicity. In this
case the symptoms of strangulation were anything but
well marked. At the time of the application of the taxis,
or just before, the patient was sitting up in bed drinking
her tea; and she had been sick but once, symptoms bearing
no proportion to the serious organic lesions, independent
of the rupture, revealed by the after-death inspection.
The substitution for the operation of various forms of
medicine on the failure of the taxis appears equally re-
prehensible with the abuse of the latter, and can only be
comprehended by supposing that the surgeon, in conse-
quence of vague apprehension or ignorance of the danger
of delay, thinks anything better than the use of the knife,
setting up in his own mind the most irrational hopes of
the recovery of his patient, the realization of which would
be akin to miraculous. In illustration of this part of my
subject, I cannot do better than again quote from the
illustrious Dieffenbach; "I was called," says he, "once to
see a young man who had been suffering for two days
with acute strangulation. I found a surgeon in attend-
ance, who was leaning over the bed, and applying the
taxis. Thick drops of sweat were rolling down from his

32
forehead.
The patient was constantly screaming out with
pain, and the doctor in a louder tone bellowed out to him
to keep quiet, telling him that nothing else could succeed.
Shortly after I came into the room, he rose up exhausted,
wiped the sweat from his brow, and remarked that it was
tremendous hard work, and that he had been so employed
with but little rest ever since yesterday; but, thank
God,' said he, it's somewhat smaller. I've tried, sir,
numerous clysters, castor-oil, and croton-oil which is
thought so much of in these cases. Linseed-oil with salt-
petre he vomited up, but fortunately he has kept twenty
grains of calomel down. Cold applications, sir, I don't
think have done him any good; and yesterday evening
once, and to-day twice, I placed his legs over my shoulders
and used the taxis while he and I were in the hot bath
together. But it's all been of no use!' I had almost
added, You have not yet tried the wheelbarrow method?*
but I merely remarked, Why on earth havn't you per-
formed the operation? He immediately turned deadly
pale, and whispered in my ear, 'The artery, sir, the
epigastric!' I at once operated. The intestine was blue,
bluow
6
*A method introduced by a German Physician. It consists in
placing the patient on his back in a wheelbarrow, with his legs
hanging down in front over it, so that the thighs and trunk become
bent towards each other. Then, while the invalid is being wheeled
along a stone pavement, the operator runs backward in front of the
barrow, and manoeuvres on the hernia, under the idea that, by the
simultaneous application of the taxis and the shaking of the vehicle,
the hernia will be reduced.

33
and had been able to resist the tremendous violence that
had been used only in consequence of the large quantity
of fluid which was contained in the hernial sac. I have
related this case," quietly remarks Dieffenbach, " only to
show how dangerous, on the one hand, is a want of fore-
sight associated with timidity, and, on the other, how
much a patient can occasionally go through and yet re-
cover."
Of the medical treatment subsequent to the operation,
a review of that adopted in the above cases has led me to
the conclusion, that the simple, uncomplicated, solid opium
treatment is the best in the first instance; in combination
subsequently, or rather used at the same time, or not, as
circumstances may suggest, with enemata and castor-oil.
In the history of hernial strangulations, it will be found-if
any reliance can be placed on subjective evidence that a
great number of patients prior to the irreducible descent
of the bowel have had symptoms of intestinal irritability,
as evidenced by more frequent stools than natural, some-
times amounting to absolute diarrhoea, which affection
has afterwards returned (sometimes so severely as to
threaten death by prostration), without the administration
of any purgative, and has required sedatives to check it.
The use of opium is here at once apparent. In other
cases in which the bowels have been constipated, or
natural prior to strangulation, the drug is still called for,
as being one of the most powerful antiphlogistics we pos-
sess, in consequence of the tendency it has to restore the
disturbed balance between the nervous and vascular
D

34
forces, whatever that may be; and, by procuring sleep,
and tranquillizing the system, to renovate the powers of
the frame, and thus to give the best possible opportunity
for the establishment of a healthy reparative process.
The object of combining calomel with the opium does
not appear to me to be evident. When so used, opium
is looked on as a secondary remedy, and given in order to
keep a check on the baneful influence of the mercurial
drug, which, in the irritable or inflamed state of the gut,
is otherwise too apt to act as a powerful purgative. The
question may be fairly asked, If the opium assists the
action of the calomel, may not the calomel interfere with
the action of the opium? Traumatic inflammations of the
eye, the arm, or any other part of the body, might with
equal propriety, I think, be subjected to mercurial influ-
ence, whereas they readily yield to counterirritation, local
abstraction of blood, sedative and soothing applications,
and a judicious constitutional treatment.
In conclusion, I would remark, that by thus scrutinizing
what we have done, we come generally to know what to
keep doing, treatment conducted on sound principles
urging us to confidence, treatment deviating from them
warning us to caution.
THE END.
LONDON
G. J. PALMER, SAVOY STREET, STRAND.
From Henry Hancock by

January 1857)
REMARKS
ON THE
MODES OF PROCEEDING
IN REGARD TO
THE HERNIAL SAC
IN THE
OPERATION FOR STRANGULATED HERNIA,
65
BY WILLIAM PIRRIE, M.D.,
REGIUS PROFESSOR OF SURGERY IN MARISCHAL COLLEGE; ONE OF THE SURGEONS
OF THE ABERDEEN ROYAL INFIRMARY, AND FORMERLY LECTURER ON ANATOMY
IN THE UNIVERSITY OF ABERDEEN.
FROM THE EDINBURGH MONTHLY JOURNAL OF MEDICAL SCIENCE, MAY 1848.
EDINBURGH:
SUTHERLAND & KNOX, 58, PRINCES STREET.
MDCCCXLVIII.

WITHDRAWN
DATE
INITIALS

ON HERNIOTOMY.
Ir is a question of great importance, in reference to the operation
for strangulated hernia, which of the two following modes of pro-
ceeding in regard to the hernial sac is the more advisable; namely,
that of opening the sac, and dividing the stricture from within; or
that of dividing the stricture, and replacing the parts without open-
ing the sac. Of these two, technically called the intra-peritoneal
and extra-peritoneal modes of division, the former is that, which,
except in a limited number of cases, has received the sanction and
adoption of most surgical authorities in these islands. It appears
certain that, in the great majority of cases, it is by that mode
alone, that it is possible to accomplish the two grand indications
which it is desirable to fulfil by the operation; namely, the
removal of the pressure by division of the stricture, and the return
of the hernia. The fulfilment of the former, namely, the removal
pressure by division of the stricture, is essential to the safety
of the patient; and the latter, the return of the hernia, exceedingly
desirable when practicable and proper.
of the
That
With regard to the FIRST indication, when the stricture is exter-
nal to the sac, as is not unusual, it is possible to divide it by
adopting either mode; but if formed by the sac, or within it, it is
clear, that by intra-peritoneal division alone can the more impor-
tant indication be fulfilled, or any good effected. Cases belonging
to the latter class are by no means of unfrequent occurrence.
the neck of the hernial sac occasionally constitutes the stricture, is
a point regarding which surgeons are agreed, instances having been
recorded by the great surgical authorities of this and other countries,
and examples occurring frequently in the practice of many surgeons.
The sac, necessarily narrower at its neck than in other parts, is liable
to be still further diminished by effusion and organization of lymph,
either on its outer or inner surface, as well as by a thickened and

6
DR PIRRIE ON HERNIOTOMY.
indurated state of its own substance, conditions which, separately, or
in various degrees of combination, diminish the canal of the sac. For
eighteen years I have availed myself of every opportunity of ex-
amining the condition of hernial sacs, and from my dissections I
am led to conclude, that, in herniæ of considerable standing, thick-
ening of the neck is of frequent occurrence. Although constriction,
when sufficient to render a hernia irreducible, is usually at the neck
of the sac, yet it is not invariably so. This fact is of little practical
moment if a hernia be merely irreducible; but it becomes of the
greatest importance if it be strangulated, and require an operation,
as the paramount object of the operation is to divide the constriction,
in order to relieve the symptoms of strangulation.
The stricture is occasionally found within the sac. In a very
few instances it has been found to be occasioned by a loop of in-
testine; in some by a band of omentum; and in others by a band
of lymph effused from the serous coat of the intestine, and sur-
rounding and constricting it as by a ligature.
This last-mentioned condition has been described and delineated
by Sir Astley Cooper. It has also been met with by other surgeons;
and not fewer than four cases of it have come under my own
observation.
The first case was that of a female about sixty years of age, of a full habit
of body, and the subject of a strangulated umbilical rupture. Her medical
attendant, a surgeon of long standing in Aberdeen, found it necessary to have
recourse to an operation, and of that I was a witness. The hernia returned
very suddenly as soon as the margin of the umbilicus was slightly divided;
but the symptoms of strangulation continued, and the patient died in ten
hours after the operation. I was requested to conduct the post-mortem ex-
amination; and, on opening the abdomen, found behind the umbilicus a swelling
about the size of a small orange, formed of intestine, with a neck surrounded
by a band of lymph, which embraced and constricted the part, as by a cord.
The lymph had been effused from the serous coat of the intestine in con-
sequence of the inflammation excited by the pressure of the margin of the
umbilicus. In this case the hernia returned, but without the stricture having
been divided.
The second case was that of a female, a patient of my own, about the mid-
dle period of life, on whom I had occasion, with the assistance of Mr Paterson,
surgeon in Aberdeen, to perform the operation for strangulated femoral hernia.
On carrying up the point of my finger between the hernia and hernial sac to
feel for the stricture, I was struck with the circumstance, that the tightness of
what I supposed to be the stricture, bore no ratio to the extreme urgency of
the symptoms of strangulation, and that, after dividing some of Poupart's
ligament, by cutting from within the hernial sac, the intestine on being gently
pressed still remained as tense as formerly, and its contents did not seem to be
moved by the pressure. I therefore examined the neck of the hernia with my
finger, and perceived a band of lymph keeping the part tightly constricted,
and, in short, constituting the stricture. I gently drew down the intestine,
and cut the band in several different parts, when the contents of the intestine
could be easily made to move upwards. On being satisfied that all constric-
tion was removed by dividing the band of lymph in various parts, the intestine
was returned into the abdomen, and the patient recovered without an unfa-
vourable symptom. If the hernia had been returned without this band of
lymph having been discovered and divided, the object of the operation would
have been unaccomplished.

DR PIRRIE ON HERNIOTOMY.
7
The third case was that of a female, about sixty years of age, of a remark-
ably full habit, and who, about two days before I saw her, had been seized
with symptoms of strangulation. When I first saw her, the abdomen was
tympanitic to a great degree; the vomiting was most distressing; the bowels
had not been moved for five days, and she had every symptom of sinking very
rapidly. She stated that she had often on previous occasions had attacks of
what she believed to be colic, and imagined at first that the illness from which
she was suffering was only a return of that disorder, and, consequently, an-
ticipated a speedy recovery. I was also informed that, for a considerable time,
she had had a disagreeable feeling of tenseness in her left groin, though with-
out swelling, so far as she could perceive; and that, some hours before I was
called, while drawing up her limbs in a fit of retching, she felt, to use her own
expression, as if something had given way in her groin, and from that moment
was relieved from all feeling of tenseness. The symptoms of strangulation,
however, continued. I made a most minute examination of all the usual seats
of hernia, but could detect no symptom of such a lesion. I requested my col-
league, Professor Macrobin, to attend the patient along with me, which he did,
and he was also present at the post-mortem examination. On opening the ab-
domen, there was at its under part a small tumour of intestine seen, before any
parts had been disturbed beyond merely turning down the abdominal parietes.
It was of a livid colour, about the size of a walnut, and with a narrow neck,
tightly embraced by a band of lymph, by which it was so constricted as to
make it difficult to pass a probe from that part of the intestine which led to the
swelling, into that which constituted the tumour. The intestine was also
twisted over itself in form of a loop. On examining the femoral canal of the
left side, a hernial sac was found in it; and the tumour of intestine had, no
doubt, formed a hernia, but returned of itself. The stricture, however, formed
by a band of lymph, still remained. Sir Astley Cooper records a case in
which Mr Weston returned a hernia by the taxis without an operation; but
the symptoms of strangulation continued, and it was found that the stricture
was caused by a band of lymph which embraced the intestine. In the in-
stance of my patient the hernia returned without any assistance.
The fourth case was that of a female, whom I had never seen during life,
but at the post-mortem examination of whose body I was present, in conse-
quence of the request of a medical man who had seen her a short time before
death, and who had also often attended her on previous occasions, when in a
state of great suffering from disease of the womb. The symptoms, I was
informed, were those usually induced by a strangulated hernia; but the medi-
cal man could not detect any swelling in any of the usual seats of hernia. On
examining the left groin before opening the abdomen, I thought I felt a very
small swelling, which I suspected to be a hernia, and I therefore made a care-
ful dissection of the parts in presence of the surgeon, who requested me to do
so, and of one of my pupils. On cutting through Poupart's ligament from
before backwards, the contents of a small hernial sac returned into the abdo-
men without being touched, and were found to consist of intestine strangula-
ted by a band of lymph, embracing the neck of a small hernia. The hernia
was not much larger than a walnut. If it had been discovered during life,
and been made the subject of operation, there would have been great risk of
its returning into the abdomen without the real stricture being discovered or
divided.
From what is stated above, it appears very clear, that the extra-
peritoneal mode of herniotomy is quite unsuitable when the stricture
is formed by the sac or within it, whatever be the nature of the
stricture itself; and the above-mentioned examples of strictures
formed by membranous bands, suggest very strongly the propriety
of great caution in arriving at the determination of adopting the
extra-peritoneal division; as well as in those cases in which the sac

8
DR PIRRIE ON HERNIOTOMY.
is opened, of examining very carefully, before the hernia be returned,
whether membranous bands do or do not exist.
•
The second indication which it is desirable to fulfil by an opera-
tion, is the return of the hernia. With a view to facilitate the in-
quiry, as to which of the two modes of procedure is the more suit-
able, cases may be arranged into the three following classes :-
First, Those in which the stricture is external to the sac, in which
it is neither impracticable nor improper to return the hernia, and in
which no obstacle exists to that return after the stricture has been
divided. Secondly, Those in which an obstacle does exist after di-
vision of the stricture; and, Thirdly, Those in which the return of
the included intestine would be practicable, but improper.
First, In cases belonging to the first class, either mode is appli-
cable; but extra-peritoneal division being attended with much less
danger, is decidedly preferable.
Secondly, In regard to cases in which, independent of the stricture,
an obstacle to reduction exists, it will be proper to consider what are
the principal obstacles most frequently met with. These are adhe-
sions of the protruded parts to the hernial sac, the natural means
of connexion, in some rare cases; adhesions of the protruded parts
to each other; and the large size of the hernia.
Adhesions of the protruded parts to the hernial sac often consti-
tute an impediment to reduction. Of these adhesions there are
three varieties.
1st, The protruded parts sometimes adhere to the sac through the
medium of a layer of coagulable lymph. This form was described by
Scarpa as the gelatinous or glutinous adhesion; and as it is a condition
of parts which very quickly takes place, the surgeon should endea-
vour to return the hernia as soon as possible, in order to prevent the
slight inflammation which gives rise to the effusion.
2d, Adhesions sometimes assume a membranous or filamentous
appearance, varying greatly as to the number and length of the fila-
ments. As a general rule, adhesions of this form are only found
connecting moveable parts with each other, as the intestine with the
hernial sac, or with the omentum. They are precisely similar to
the bands we often find between serous surfaces in other parts of the
body, and are produced by the effusion of coagulable lymph, which
ultimately becomes organized. In this respect they differ from the
last-mentioned form. The lymph thus effused is drawn out into
bands or filaments by the movement of the intestine, which accounts
for the circumstance of their being found chiefly connecting move-
able parts to each other, and for their being more frequent at the
body and fundus of the sac than at its neck or mouth, where the
parts are in a more confined space and have less motion.
3d, The third form of adhesion, which usually receives the name
of the close organized, or the fleshy, is, like the gelatinous and mem-
branous-a result of inflammation; but differs from them, inasmuch
as the union is close and firm, so that the protruded parts and the

DR PIRRIE ON HERNIOTOMY.
9
sac cannot be separated from each other, but form a solid mass, the
vessels of which are continuous. In a case of strangulated hernia,
the subject of operation, this form of adhesion requires a very dif-
ferent method of procedure from the gelatinous or membranous, as
will afterwards be stated. This species of adhesion is very frequently
met with between the omentum and hernial sac; and then is gene-
rally at the body and fundus of the sac. When it is found between
the intestine and sac, which is a rare occurrence, it is usually at
the neck. Scarpa has described this form under the name of the
unnatural fleshy, to distinguish it from what he calls the natural
fleshy, which is of an entirely different character, as will presently
be shown. These three forms of adhesion agree with each other in
being caused by inflammation, and in being attended with effusion
of lymph; but they differ, inasmuch as the lymph in the first form
is not organized; while, in the second, it is organized and elongated
into bands or filaments; and, in the third, although organized, it is
not elongated, but effused between the sac and protruded parts, so
as to convert them into a solid inseparable mass, the vessels of which
are continuous.
errors may
The obstacle to reduction is sometimes furnished by the na-
tural means of connexion between the intestine before its de-
scent, and the peritoneum lining the surrounding part of the
abdomen. It is of the greatest importance that the surgeon
should have distinct ideas of this condition of a hernia; for, if it
be not understood, and an operation be necessary, the most fatal
be committed. Scarpa has given an exceedingly clear
and full explanation of this condition of a hernia. It has also been
described by Pelletan, Cloquet, and Hesselbock, and with great
distinctness by Mr Lawrence. The natural means of connexion of
the hernia with the surrounding parts, may form the obstacle on the
right side if the hernia be formed by the coecum or head of the
colon, or on the left if it be formed of the sigmoid flexure of the
colon. These divisions of the alimentary canal are covered by peri-
toneum laterally and anteriorly, but are in a measure destitute of
peritoneal covering behind; and the peritoneum is reflected from
their lateral aspects to the parietes of the abdomen in the ileo-lumbar
regions, with which parietes it is connected by loose cellular tissue
capable of great elongation. The natural means of connexion of
these divisions of the alimentary canal with the parietes are short,
and formed of the peritoneum extending between that portion of the
membrane which furnishes a serous coat to the intestines, and that
which lines the walls of the abdomen. If these portions of the ali-
mentary canal descend to form a hernia, they will drag along with
them the part of the peritoneum which naturally lines the parietes
of the ileo-lumbar region to form the hernial sac; and if the hernial
sac descend into the scrotum, and there form adhesions to the sur-
rounding parts, the portions of peritoneum which, within the ab-
domen, preserved the intestine in its natural relations to the walls of

10
DR PIRRIE ON HERNIOTOMY.
the abdomen, will now retain it in the sac; and as, through the me-
dium of these portions, the hernial sac and serous coat of the intes-
tine, which forms the hernia, are continuous with each other, it is
evident that reduction must be impracticable. It is as impracticable
under these circumstances to return the intestine, as it would be to
return the testicle into the abdomen; the intestine draws the peri-
toneum along with it to form hernial sac, and the testicle draws
peritoneum to form tunica vaginalis; and the serous coat of the in-
testine has the same relation to the hernial sac as the tunica vagi-
nalis propria has to the tunica vaginalis reflexa. Such a hernia,
when it becomes strangulated, and the subject of operation, re-
quires a particular method of treatment, which will afterwards be
explained.
Adhesions of the protruded parts to each other, often form the
impediment to reduction. The parts which form a hernia often
glide down separately and to a great extent into the sac; and
afterwards, by pressure and various accidental causes, adhere to each
other, and cannot in mass be returned through the opening by
which they separately left the abdomen.
A frequent impediment to reduction is the bulk of the protruded
parts in relation to the opening through which they would have to
be returned. The bulk is sometimes owing to the quantity of parts
which have come out from the abdomen, especially in neglected
cases, where means have not been used to give a degree of support.
Another more frequent cause is the enlargement or growth of some
parts constituting the hernia. The omentum and mesentery are the
parts which, when protruded, present the impediment to reduction
from growth, and their increase is occasioned mostly by deposition
of fat in the portions of these tissues external to the opening through
which they came out from the abdomen. Where they are embraced
by the opening, the pressure prevents enlargement in that situation;
but from the yielding nature of textures external to the opening, the
increase of volume is often very considerable. In old hernia, which
have been long irreducible, this condition is sometimes met with to
a great extent. Such are the principal conditions which, indepen-
dent of the stricture, offer an obstacle to the reduction of a hernia.
If any of these conditions exist, and if the sac be not opened, re-
duction is in general impracticable. If the sac be opened, two of
them may easily be overcome; namely, the soft recent adhesions
formed by coagulable lymph and the filamentous, the former can be
broken down with the finger, the latter divided by the knife. Two
of them present an insuperable impediment to reduction; namely,
the natural means of connexion, and the close organized adhesions,
if they be to a great extent, and the hernia large. With regard to
the two remaining conditions, the possibility of overcoming them,
and the propriety of attempting to do so, must depend entirely on
the particular circumstances of the case; but in many cases it is
more judicious not to interfere with them, unless they exist only to

DR PIRRIE ON HERNIOTOMY.
11
a limited extent, and in herniæ of moderate size. Most of these
conditions, however, are principally met with in cases of large and
old herniæ; and, on account of the risk of injuring the intestine in
attempts at reduction, as well as that of inducing dangerous inflam-
mation by much handling of the intestine, and the difficulty of main-
taining the parts reduced, even should reduction be possible, the
majority of surgeons seem now disposed to follow the advice of Sir
Astley Cooper regarding such cases. His practice was to divide the
stricture, which fortunately in such cases is, for the most part, ex-
ternal to the sac, and to leave the latter unopened, and the hernia
unreduced. The stricture being divided, the principal cause of
danger is removed. The coverings of the hernia should be replaced,
and proper means taken for promoting the healing of the wound.
Thirdly, There are certain states in which it would be extremely
improper to attempt reduction; namely, when the hernia is gangre-
nous, or when the intestine has given way from inflammation having
gone on to gangrene, or when it has been torn, or accidentally
wounded in the operation. The two last-mentioned conditions can
only result from unskilfulness in the mode of procedure; but, should
they exist, the hernia ought not to be returned. When the intestine
presents such an appearance as to render it doubtful whether its
return may be followed by focal extravasation, the surgeon should
content himself with carefully dividing the stricture. In all cases
in which the intestine is gangrenous, or not entire from whatever
cause, it ought to be allowed to remain, so that the fæces passing off
by the wound may form an abnormal anus, and extravasation into
the abdomen be thereby prevented. When omentum forms the
hernia, and it is gangrenous, the gangrenous portion may be removed,
and the remaining part returned to the abdominal aspect of the
mouth of the hernial sac. The practice of removing a portion of
omentum, when from growth it renders a hernia irreducible after
division of the stricture, is a proceeding which, in some cases, may
be adopted with advantage. For cases belonging to this class, extra-
peritoneal division is of course quite unsuitable. These remarks, it
is to be hoped, will be sufficient to point out the proper mode of
procedure when the hernia is sound, and reducible after division of
the stricture; when it is irreducible after such division-and when
it is in any of the various conditions in which reduction would be
dangerous and improper; and also to show, that to follow one method
indiscriminately in all cases would be unwise; that intra or extra
peritoneal division should be adopted according to the particular
circumstances of the case; that in the majority of cases intra-peri-
toneal division is not only the more suitable mode, but the only one
which is safe, or by which any good can be effected; and that the
cases in which extra-peritoneal division is suitable are those of very
short standing, where there is no reason to apprehend the existence
of adhesions, or of an unsound condition of the hernia; and in cases

12
DR PIRRIE ON HERNIOTOMY.
of large and old hernia, where the more judicious proceeding is to
divide the stricture, and not to attempt reduction.
The plan of not opening the sac, although practised in certain
cases by Franco and Paré, was first strongly recommended by Petit,
and consequently has been designated the method of Petit, to dis-
tinguish it from the mode in common use. Petit practised this
method as early as 1718. It was subsequently advocated by Ga-
rengeot; and, at a still later period, adopted and strongly recom-
mended by Bonnet of Lyons.
In this country it was introduced by the second Monro, who
advocated its adoption in cases of small and recent hernia, and men-
tioned four cases in which he resorted to that mode of proceeding.
In one of them, however, adhesions prevented the return of the
hernia, and in two of them he was obliged to cut the neck of the
sac. In later times, the same proceeding was adopted by Sir
Astley Cooper in cases of large and old herniæ, and strongly re-
commended by him as the decidedly preferable mode in cases of
that class. Mr Lawrence, in his valuable Treatise on Ruptures,
remarks, "The plan of removing the stricture, and returning the
prolapsed parts without opening the sac at all, ought, I think, to be
more frequently adopted than it has hitherto been, although it ap-
pears objectionable as a measure of general use, in the operation for
strangulated hernia." To Mr Key, however, the merit undoubtedly
belongs of having recommended a more general adoption of Petit's
mode than had previously prevailed in this country. In his admi-
rable Memoir on the Advantages and Practicability of dividing the
Stricture in Strangulated Hernia on the Outside of the Sac, published
in 1833, will be found much valuable information on this interesting
subject. Mr Luke of the London hospital strongly recommends
this mode, and his success is a decided testimony in its favour.
Out of nearly forty patients he has not lost more than two. In
October 1845, when I had occasion to be in London, Mr Liston
showed me a patient in the North London hospital, in whose case
he had adopted this mode; and, in a communication I afterwards
received from him, he informed me that he had practised it in a
few other instances, and felt convinced of its being the preferable
mode when the hernia is small and recent, and when there is no
reason to apprehend an unsound state of the intestine. And,
judging from the recorded statements of some other distinguished
surgeons, this mode seems to be meeting with deservedly increased
favour; and I have no doubt will continue to do so, if practised
under the limitations already mentioned.
There can be no doubt that intestinal inflammation is the most
frequent cause of death after the operation for strangulated hernia.
Some of the advocates of Petit's method have assigned as the causes
of that inflammation, when the ordinary proceeding is adopted, the
exposure of the intestine to light and air, change of temperature,
and handling. I agree with Mr Lawrence in ascribing it not to

DR PIRRIE ON HERNIOTOMY.
13
these agents, but chiefly to the long-continued pressure of the
stricture, owing to the operation being too long delayed, and to an
injudicious and too frequent use of the taxis previous to the operation.
I remember being very much struck with an observation of De-
sault's; I have not his works beside me at present, but it is to this
effect "Think well of that hernia which has been little handled
and soon operated on." The operation is justifiable and necessary
when the taxis has been first tried alone, and has then, in combi-
nation with such auxiliary means as seem advisable, been again
fairly and skilfully tried without producing the desired effect. The
conviction being thus produced, that by no other means than an
operation is there hope of saving the life of the patient, it ought to
be resorted to as quickly as possible. Much handling must not only
give unnecessary pain, but also increase the risk of hurrying on the
inflammation to results, which, even though the operation should be
performed, would render it unsafe to return the hernia. When
therefore the taxis, and also along with it the proper auxiliaries, have
been fairly and skilfully tried, no advantage can, but considerable
injury may, result from the repetition of treatment already found to
be unavailing. Many considerations show that the operation should
be performed as soon as possible, after its inevitable necessity has
been found to exist. Delay, like undue handling, increases the
risk of inducing such a state of the hernia, in consequence of in-
flammation, as would render its return unsafe. From the short time
in which a hernia may prove fatal, and from the depressed state
which comes on in consequence of delay, rendering the patient less
able to stand the shock of an operation, will be seen the importance
of being as prompt as possible; but there is another, and a very
urgent reason-namely, that, if the operation be delayed until intes-
tinal inflammation has been induced within the abdomen, it is far
from certain that this inflammation will subside on the removal of
the hernia which caused it. I have performed the operation for
strangulated hernia, according to the usual mode, a very consi-
derable number of times, and in every instance with success; which
I attribute to two things-namely, avoiding all undue and useless
handling, and performing the operation early. My decided im-
pression is, that the reason why the operation is so frequently fol-
lowed by death, instead of being one of the most successful of the
great operations of surgery, is, too great delay in resorting to an
operation, and the undue and injurious use of the taxis, even after
its adoption alone, and in conjunction with the proper auxiliaries,
has proved unavailing.

MURRAY AND GIBB, PRINTERS, EDINBURGH.
Nem Henry Man

January 18572
PROCEEDINGS
OF THE
WESTMINSTER MEDICAL SOCIETY.
SESSION 1848-9.
bas
No. 1.
October 21, 1848.
JOHN WEBSTER, M.D., F.R.S., President, in the Chair.
THE Society commenced its meetings for the season this evening.
The President, on taking the chair, delivered an inaugural address
on the present state of the Society, which, he reported, was in
every way prosperous. In the course of his remarks, Dr. Webster
made the following observations with reference to the health of the
metropolis, especially in regard to the recent epidemics of Cholera
and Scarlatina:-
"Before dismissing the subject of cholera, it must be interesting
for the fellows to know that, notwithstanding the anxiety now pre-
valent respecting that malignant disease, it hitherto has not made
much progress in the metropolis; and that if its present fatality be
compared with other epidemic maladies, we have as yet really not
much cause for alarm, for during the six weeks ending on Saturday,
the 16th of October, 1847, the number of fatal cases of this disease
in London was twenty-six; whilst the total number of deaths caused
by the same malady throughout the entire metropolitan population,
during the six weeks ending on Saturday last, the 14th instant,
amounted to sixty-seven, being, as yet, only a little more than
double the mortality by cholera during the same number of weeks
in the previous year. Compared with this, it is instructive to
mark the different results observed in another epidemic now pre-
vailing in London with great severity, but which, notwithstanding,
does not call forth much remark, or cause anxiety to the extent
it deserves-I mean scarlatina, also discussed last year in the
Society; but which, unfortunately, is now so malignant, that hun-
dreds of victims have been recently sent to an untimely grave,
according to the registrar-general's reports. In these tables it is
stated, that during the six weeks terminating on Saturday, the
16th of October, 1847, already quoted in reference to cholera,
B

2
302 individuals died in London from scarlatina; whereas, during
the six weeks ending on Saturday last, the 14th instant, as many
as 972 persons have sunk under that virulent complaint; or
upwards of quadruple the average mortality by the same disease in
the previous five autumns. Without undervaluing the importance
of the epidemic which at present attracts so much notice, I think
such a dangerous malady as scarlatina deserves even as great atten-
tion from medical men and the public as cholera-more especially
since the subjects of its attacks are usually children, or young
people just entering upon the morning of life; whereas the victims
of cholera are generally drunkards and persons of worn-out consti-
tutions, or those who have set every hygienic rule at defiance.
Although scarlatina is a disease of frequent occurrence in this
country, and although it annually carries off thousands of indi-
viduals, hitherto, no boards of health have existed; no quarantine
laws, and very few sanitary measures, have been put in force by
public bodies for preventing its approach, notwithstanding its
highly infectious nature. But this is only another illustration of
the prevailing disposition, in the minds of many persons, to view
whatever is familiar with indifference, whilst anything new or un-
common is sure to attract attention. It will also be instructive to
recall to our recollection the recent invasion of the epidemic
influenza, which was so fatally prevalent in the metropolis at the
early part of last winter, 1213 persons having died from that com-
plaint during six weeks ending on Saturday, the 8th of January
last. At the same time, the total deaths registered from all causes
were increased to an extraordinary extent, being so high as 2454
in one week, and 2416 in the subsequent-instead of 1046, the
ordinary weekly average of previous seasons. Contrasted with this
plague-like mortality, it must be gratifying to hear that London,
comparatively speaking, is not at present unusually unhealthy,
notwithstanding the actual presence of cholera, the great malignity
of scarlatina, and the prevalence of typhus, by which disease 424
persons have died in the metropolis during the last six weeks,
instead of 260, the averaged deaths by typhus of a similar period
during the five preceding autumns. Such facts are important;
and although the cholera now occasions considerable anxiety, the
total deaths from all causes, throughout the metropolitan popu-
lation, have actually diminished, especially during the last fortnight,
notwithstanding the prevailing epidemics. This satisfactory state
of the public health in London is proved by the mortality tables,
which show that instead of the weekly average of 1154 deaths, as
in the last five seasons, during the week ending on Saturday, the
7th October instant, 1005 persons died from all causes in the
metropolis, and only 991 in the week terminating last Saturday,
the 14th: thus making an actual diminution of not less than 312
deaths in the two weeks now referred to, being an increase of
fifteen and a half per cent. last year over the two similar weeks of
the present season. I now mention these important facts to the
Society not to paralyze exertion, but as useful statistical data, to

3
which reference should be made in order to arrive at correct con-
clusions when an epidemic like the cholera prevails in the com-
munity; and to show how far the average mortality is thereby
affected."
Mr. Hancock exhibited an apparatus for relieving the breast
when over-distended with milk.
It consisted of a very stout bottle, surrounded by a ring, with an
ivory shield, which firmly fitted the nozzle. The bottle having
been filled with boiling water, to heat it, was to be emptied, the
ivory shield replaced, and the mouth-piece placed against, but not
pressed upon, the nipple, which would be immediately drawn out,
as well as some of the superabundant milk.
Mr. I. B. Brown related a case of Prolapsus of the Funis at the
expiration of the third month of Utero-gestation.
The patient was thirty years of age, and the mother of three
children. She was threatened with abortion, and after two or three
attacks of hæmorrhage, attended with expulsive pains, the funis
was found to be presenting in a loop. The following day a severe
pain came on, and the cord burst. This was followed by profuse
hæmorrhage, and the expulsion of the foetus. The placenta, which
was adherent to the fundus uteri, was removed under the influence of
chloroform, by introducing two fingers within the uterus. Both
placenta and child were nearly bloodless.
Mr. Hird read a paper on the Pathology and Treatment of
Cholera.
He commenced his observations with a description of the leading
symptoms which characterize the disease, and dwelt upon the
differential diagnosis between the malignant or Asiatic cholera,
and the ordinary autumnal affection observed in this country. The
symptoms by which the malignant form may be recognised he
stated to be, the absence of bile, both in the matters vomited and
discharged from the bowels-the suppression of urine-the cold
breath-the veiled unearthly voice-the rapid sinking of the heart's
action-and the great fatality of the disease.
In speaking of the mode of invasion, the author stated that, as a
rule, the disease is preceded by an attack of diarrhoea, which may
continue for an hour or two, or may be protracted to one, two, or
three days, before the symptoms characteristic of the pestilential
malady develop themselves. He observed that this diarrhoea should
never be overlooked, and that the absence of pain was no proof that
it would not terminate in cholera.
He divided the disease into three stages-the first, diarrhoeal or
premonitory; the second, or algide stage, marked by great depres-
sion, and by the peculiar dejections, of a watery character, loaded
with flakes of whitish matter, which under the microscope appear
to be composed of cells, rather larger in size than exudation cor-
puscles, of scaly epithelium, of a few blood corpuscles, and of other
B 2

4
matters, differing in each individual case, according to the severity
of the symptoms; and the third stage, indicative of reaction.
When alluding to the question of contagion, the author stated
that, although the disease did not usually spread from person to
person so rapidly as scarlatina, small-pox, or measles, it was very
analogous, in reference to the mode by which it may be communi-
cated, to typhus fever, erysipelas, &c. A patient labouring under
typhus, when conveyed into a good-sized and well-ventilated apart-
ment, he stated, would rarely communicate the disease to the
attendants; whereas, the same patient, placed in an unfavourable
locality, and surrounded by poverty and distress, would very pro-
bably spread the disease to those persons in attendance at the sick
bed. Cholera he believed to be contagious, and that it had been
traced to spread in accordance with the ordinary laws of contagion.
The frequent immunity from the disease of the professional and other
attendants, he considered no proof of the non-contagious nature of
the disease, for the same objection might be adduced by every ex-
perienced practitioner against the contagiousness of any of the
acknowledged infectious diseases. The Central Board of Health
had acted, he considered, most injudiciously in issuing their mani-
festo for the information of the public, in which they state that no
danger is to be apprehended from cholera spreading in consequence
of the association of the healthy with the sick.
The leading symptoms of the disease, the mode of its fatal ter-
mination, and more especially the spontaneous favourable termina-
tion occasionally observed, under every variety of treatment, all
tend, in the author's opinion, to assimilate it to the effects of poisons
on the animal economy.
However great the obscurity may be which overhangs the ques-
tion respecting the generation or exciting cause of cholera, he
stated that most satisfactory evidence can be adduced to prove that
many circumstances predispose the human body to its influence,
and render it more than usually susceptible of the disease. Those
who exceed in spirits and wines-in fruits and unwholesome food-
the debilitated from any cause-the poor, who live in unhealthy,
badly-drained, and ill-ventilated residences-and especially those
who have suffered from previous diarrhoea, rarely escape when the
pestilence prevails.
The author next proceeded to detail the post-mortem appearances
which he had observed in several fatal cases of the disease. In
those who died during the algide stage, the body had undergone
great diminution in bulk, and become almost as emaciated as a body
in the last stage of consumption; the peculiar blue colour of the
skin frequently disappeared shortly after death; the temperature of
the surface of one or two bodies increased for a short time after
death; quiverings of the muscles, and sometimes even distinct
movements of the limbs took place for an hour or two after all
signs of animation had departed. The shrivelled appearance of the
hands resembled those of a washerwoman.
In the chest, in most of the cases, slight effusions of blood were

5
The
found on the heart, and on the pneumo-gastric and sympathetic
nerves. Dark viscid blood filled the cavities on the right side of
the heart; in one or two instances coagula were found.
cavities on the left side were generally nearly empty, containing
only a small quantity of thick, black blood. The aorta and its
large branches were also nearly empty. The lungs and pulmonary
arteries were gorged with very dark, treacly-looking blood, and
spots of ecchymosis were observed, in two or three of the bodies
examined, between the pleura and parenchyma of the lungs.
In the abdomen there was great venous congestion. In the
cava, iliac and portal veins, the blood was black and tenacious.
The liver was congested, and the gall bladder distended with green
or dark yellow bile, of a ropy character. The mucous glands of
the intestines stood out in bold relief; the agminated and solitary,
as well as those of Brunner, being enlarged; and the epithelium,
in many of the most severe cases, was completely stripped off the
mucous membrane. The kidneys, and the whole genito-urinary
mucous membrane, were vastly congested, and the bladder much
diminished in size.
On examining the brain, medulla spinalis, and their envelopes,
in the cases which terminated fatally during the algide stage of the
disease, with the exception of venous congestion, there was found
no particular morbid appearances; whereas, when death had occurred
subsequent to the establishment of reaction, great vascular tur-
gescence was observed, and in two cases in which coma had existed
for some time prior to death, serum was found effused into the
ventricles.
From the appearances observed after death, from the mode of
development of the disease, and from the peculiar character of the
symptoms in its successive stages, the author concluded that the
organic nervous centres are, if not primarily, at least consentaneously
affected with the blood, and that all remedies should be prescribed
with reference to this view of the pathology of the disease. He
considered it unphilosophical and irrational to apply our remedial
agents with a view to check one or other of the isolated symptoms
which manifest themselves in the progress of the disease.
In speaking of the treatment, the author reviewed the various
remedies which have been proposed, and stated his conviction that
no known therapeutical measures have any specific power of coun-
teracting the peculiar agency of the poison. In order to attain
even a moderate amount of success in the treatment, he considered
it essential that a comprehensive view should be taken of the whole
disease, and that special attention should not be directed to any one
particular symptom which may show itself during life, or to one
particular lesion which may be discovered after death. The dis-
ease should not be located in any particular organ, when all are
affected; but the leading symptoms during life, and the prominent
morbid lesions most frequently observed after death, should be care-
fully noted, and the effects of medicines in modifying the severity of
the symptoms watched most attentively.

6
Cholera being essentially a disease of depression, of collapse,
three grand objects are to be attained in the treatment-viz., the
rousing of the vital energies of the patients, so as to enable them to
resist the depressing influence of the morbific poison; the arrest of
the frequent evacuations from the bowels; and the restoration to a
healthy condition of the secretions and excretions of the body.
In the premonitory diarrhoea, the author had found scruple doses of
the compound chalk-powder with opium, combined with spirits of
ammonia and cinnamon, in the infusion of cusparia, of service.
This medicine, with small quantities of brandy at intervals, would
frequently prevent the further development of the disease. In
cases in which the evacuations were watery and contained little
bile, he recommended five grains of calomel and half a grain of
opium to be administered immediately, and followed up with a
grain of calomel, and two grains of cayenne every ten minutes,
quarter, or half hour, in proportion to the severity of the symptoms.
He considered that the secretions were more effectually restored
by these measures, than by the scruple doses of calomel and two
or three grains of opium, which some practitioners had recom-
mended, and that the rapid depression which frequently followed
the use of the latter was rarely observed under the former
treatment. When the symptoms increased in violence, and were
not checked after three or four doses of the above, and the charac-
teristic evacuations and other symptoms which denote the approach
of the algide state of the disease had set in, he found the greatest
amount of benefit from the use of stimulating emetics of mustard
and salt, the application of mustard cataplasms over the region of
the heart, and along the course of the pneumo-gastric nerves in the
neck; frictions to the extremities, chest, and abdomen; the free
use of diluents; turpentine epithems to the abdomen; and a liberal
supply of warm clothing and heated air.
After two or three full vomitings had roused the heart's action,
and in a measure overcome the disposition to internal congestion,
the author recommended the use of the acetate of lead, in doses of
two grains every half hour. His experience bore out the favourable
opinion formed of this remedy by Dr. Graves of Dublin, who
introduced it to the notice of the profession in 1832. In the
intervals between each dose he recommended ammonia in five
or ten grain doses to be given, or from five to ten drops of
chloroform on sugar. The vapour of chloroform had been recom-
mended by some physicians to allay the violence of the spasms.
The author stated that he had not had an opportunity of trying its
effects, but did not expect from its modus operandi on the healthy
body, that it could do more than simply allay the pain in cholera, and
might have injurious effects on the action of the heart and nervous
system, if given in a dose sufficient to produce anæsthesia.
By the above measures, the functions of the heart and lungs were
maintained-internal congestion, as far as possible, prevented, and
time thus afforded for the system to overcome the effects of the
morbific poison. The acetate of lead, he found, had more power in

7
checking the constant drain from the system of the elements of the
blood, than any other remedy that had been suggested. The
treatment by immense quantities of calomel, with the view of
forcing the action of the liver, he believed was founded on an erro-
neous view of the disease. The want of action in the liver was not
the cause, but the consequence of the disease, and the deficiency of
bile not more important than the deficiency of urine. Both of
these secretions, he stated, were restored so soon as the virulence
of the disease was overcome, and afforded most certain evidence
that the nervous force was returning, and that the vascular and
glandular apparatuses were resuming their functions.
During the stage of reaction, the treatment applicable to fever
was called for. Blood-letting, the author considered, required the
greatest caution in its use; the abstraction of blood, generally, was
almost equivalent to the abstraction of life, and ought never to be
resorted to except in young patients, who, previous to the attack,
had been in robust health, and when the blood had not been deprived,
by frequent and long-continued evacuations, of a large quantity of
its serous and saline constituents. Its beneficial influence, even in
the class of cases mentioned, was very questionable, and was purely
of a mechanical character. The subsequent management of the
disease, he stated, required the administration of quinine, and such
other treatment, as fevers arising from miasmata. The author
objected to the use of large doses of opium in every stage of the
disease, and also to large quantities of brandy and other powerful
stimulants. He believed that when given too freely, they interfere
with the restoration of the functions of the several depurating
organs, that they increase the liability to consecutive fever,-
and that coma is a much more frequent occurrence when they have
been largely administered.
-
November 4, 1848.
JOHN WEBSTER, M.D., F.R.S., President, in the Chair.
Dr. Willshire exhibited a pocket handkerchief which had been.
used by a patient labouring under phthisis pulmonalis, and men-
tioned that the handkerchiefs of two other patients under his care
for a similar affection, presented like appearances. These handker-
chiefs, into which the sputa were received, became worn very
speedily into round holes, as if acted upon by some corrosive sub-
stance. No quinine or sulphuric acid had been taken by these
patients, nor had these holes been caused by the use of scents.
From the form and other appearances these holes presented, and
from the inquiries he had made of the patients' friends, Dr. Will-
shire could not acquiesce in the opinion that they were caused by
friction in the process of washing. The sputa had not been
analyzed, but to the eye they were similar to the ordinary yellowish-
green, roundish sputa of tuberculous disease of the lungs.

8
Mr. Wade narrated the case of a man who shot himself in the
mouth with a pistol.
The lower jaw was fractured near its centre, and the lips and
cheeks cut into riband-like strips; the edges of the wound were
black and jagged, the two principal lacerations extending from the
angles of the mouth to the mastoid processes: the mucous mem-
brane of the whole interior of the mouth and fauces was black and
pulpy, and blood freely oozed out, but no open blood-vessels could
be detected. It was discovered that the pistol had only been loaded
with powder. The fractured ends of the jaw were secured in situ
by strong ligatures passed round the teeth, and the wounds of the
cheeks and lips were united by stitches; a light bandage was
applied and ice employed, and subsequently a piece was placed in the
mouth, which checked the hæmorrhage. The next day the patient
had considerably improved, and was received at the Westminster
Hospital, where, while taking some beef-tea, he fell backwards and
expired. Mr. Wade supposed that spasm of the glottis was the
cause of his death.
Mr. I. B. Brown read a paper on Scarlatina, with especial refer-
ence to its treatment.
He alluded to the great and increasing prevalence of this dis-
ease, and adduced statistical facts from the Registrar General's
Reports, to show its astonishing fatality.
The character of the disease the author believed to be debility,
dependent on the presence of an active morbid poison received into
the blood; and that this poison exerts its influence especially on
the skin, mucous membrane of the fauces, &c., and on the kidneys,
arresting their excreting functions, and causing engorgement, or
even inflammation. But although these organs are more par-
ticularly involved by the noxious principle, yet the nervous
system is remarkably disordered, and a state of nervous prostration
induced.
The author then proceeded to point out the treatment he
pursues:-His first care is to freely apply a stick of lunar caustic
to the tonsils and fauces, even though ulceration be absent, in
order altogether to check the formation of ulcers; or if they
are already formed, to arrest their progress and accelerate their
healing. At the same time he applies to the throat, externally,
some stimulating application, or poultices. The medicine first
given, is a dose of calomel, followed shortly by a dose of castor
oil. The bowels having been acted upon, a course of treat-
ment is commenced, which may be described as of a stimu-
lant character; and such as is indicated by the view of the
pathology of the disease entertained. The patient is strictly
kept in bed, and sponged with tepid vinegar and water, the
hangings about the bed and room removed to facilitate ventilation,
and the floor sprinkled with solution of chloride of lime, or with
Burnett's Solution. But the distinctive part of the author's treat-
ment consists in the administration of dilute acetic acid, in doses of

9
half a drachm and upwards, according to age, given in syrup
or other convenient vehicle. This medicine is followed by the
exhibition of stimulants, as wine or brandy, given with arrow-root,
gruel, or with any diluent, together with beef-tea, or veal, or
chicken-broth. These stimulant and supporting hygienic measures
are, as a rule, commenced on the second day of treatment. The
state of the throat is diligently attended to; the tonsils and fauces
being sponged two or three times a day with a strong solution
of nitrate of silver, (ten grains of the salt to one ounce of water).
This application induces a healthy action in the parts, and brings
away the viscid mucus which adheres to them, and impedes respira-
tion and deglutition. Not unfrequently, moreover, the caustic
solution is advantageously projected by a syringe, through the
nostrils, to the upper and back part of the pharynx, in order to
remove the acrid, and often sanious discharge which is thrown off
from that part and from the posterior nares.
Besides the above remedial measures, recourse to opiates or
sedatives is mostly necessary, to produce sleep or allay irritation.
Tonics, as bark, may be usefully combined with the acetic acid
mixture; and the exhibition of ammonia is indicated where great
depression exists.
Although unable to state the modus operandi of acetic acid,
Mr. Brown believes it to be a direct stimulant to the skin and
kidneys, tending to remove the existing congestion of their vessels.
As soon as these excretory organs can be made to act, he con-
siders the danger of scarlatina is passed-i. e., should no ex-
traneous accidental circumstance interfere.
When death takes place, it appears to the author to depend
either upon the deadly influence of the poison on the brain and
nervous system generally, as seen where coma and delirium super-
vene in the course of the first three days; or on a mechanical im-
pediment to respiration, from the condition of the fauces, together
with the consequent circulation of imperfectly aerated blood, and,
probably, the constant re-imbibition of the poison into the circula-
tion, by the necessary passage of the inspired air over the diseased
mucous membrane of the tonsils, pharynx, &c.
Coma, or delirium, when present, instead of indicating the employ-
ment of venesection, the author believes should be treated by the
administration of stimulants and sedatives; and he lays much stress
upon the necessity of maintaining an uniform temperature during
the whole course of the disease; as any check to the efflorescence
may give a fatal turn to the malady, or any exposure to cold, in an
after stage, may be followed by dropsy.
Of the last named sequela, not one case in 253 seen by him,
occurred. Desquamation was found to be favoured by the use of
the warm bath; and until that process is completed, the danger of
scarlatina cannot be deemed as past.
The author next proceeded to narrate some severe cases of the
disease, occurring in his own practice. The first he mentioned
was particularly severe, and desquamation so extensive, that com-

10
plete and thick casts of the skin of the feet and hands were de-
tached.
In each of the cases the plan of treatment above sketched, was
adhered to; the greatest precaution being taken to avoid change of
temperature, and to ensure the patient's having a sufficient allow-
ance of nutritious and stimulant substances, to sustain the failing
powers of life.
In a concluding observation, Mr. Brown remarked that the
specific stimulant influence, supposed by him to be possessed by
acetic acid over the skin, might be referred, perhaps, to the
chemical composition of acetic acid, an hydrated oxide of a radicle,
acetule, which in its chemical relations approaches nearly to ethule,
the hypothetical radicle of ether, and indeed belongs to the Ethylic
series.
November 11, 1848.
FRANCIS HIRD, Esq., President, in the Chair.
Dr. Woodfall exhibited a gall-bladder and kidney, and read the
following account of the case.
The patient was a female, aged thirty-eight, who had been sub-
ject, for many years, to disorder of the digestive organs. In
March last, she suffered very severely from headache and sickness,
but her health improved greatly during a subsequent residence in
the country. Early in September, soon after her return to London,
she was seized with a violent attack of epistaxis, which was with
difficulty controlled, and from which she never fairly rallied. Dr.
Woodfall saw her first on October 3rd, and found her very pale,
greatly emaciated, and suffering from obstinate vomiting and ex-
treme tenderness in the left hypochondriac region. The urine
was pale, clear, and acid, it deposited an abundance of albumen,
on the application of heat, and was of specific gravity, 1008. The
vomiting and tenderness were soon relieved, but a convulsive
attack took place shortly afterwards; the sensorium became affected,
the countenance assumed a peculiarly wild and anxious look,
though, on the attention being roused, she was able to understand
and answer questions. About ten days before death, the con-
junctivæ of both eyes became injected with blood; there was a
return of epistaxis, pale coloured blood continuing to ooze from
the nose for some hours; and there was hæmatemesis. The con-
vulsions recurred at frequent intervals, and after lingering for a
long period, death, preceded by coma, took place on October 29th.
The urine was usually not deficient in quantity, though, on two or
three occasions, none was voided for nearly twenty hours; it be-
came neutral, or even alkaline, but continued to deposit albumen,
on the addition of nitric acid; and the last time he examined the
specific gravity, about a fortnight before death, it had fallen to
1005. On examination after death, the kidneys were found to be
smaller than natural, pale and flabby; the left (the one exhibited)

11
was smaller than the right. The emulgent artery, where it
entered this kidney, was of cartilaginous hardness, and the vein
was partially blocked up by a firm mass of fibrine. The divided
arteries of the mesentery were rigid and gaping. The liver ap-
peared natural in structure. The gall-bladder was of a deep
purple hue, and firm and flesh-like to the touch; on slitting it
open, it was found to be filled with a firm coagulum of blood,
partially adherent, the source of which was extensive ulceration of
the mucous membrane of the fundus and body of the organ. The
other viscera of the abdomen presented no unnatural appearance,
and, unfortunately, time did not permit him to examine those of
the chest and the brain. On reviewing the case, there could, he
thought, be no doubt that the disease of the kidneys was of long
standing. Whether it was occasioned by the condition which
appeared to prevail in the arterial system, or whether both were
the common result of faulty nutrition, it is not easy to decide, but
he considered the latter the more probable explanation. The
hæmorrhagic tendency which prevailed during the last two months
of the patient's life was very remarkable.
Mr. Dunn exhibited a Placenta, which had presented in an
abortion, at about the six month of pregnancy.
Considerable hæmorrhage had prevailed for two months, which,
on the last occasion, was arrested by plugging the vagina with a
sponge dipped in vinegar. The os uteri having become dilated,
and the placenta and funis presenting, the child was delivered by
turning. It was to the condition of the placenta that Mr. Dunn
wished to direct the attention of the Society. The contrast be-
tween the detached and the undetached portions was most striking.
While the latter was blanched, and more pale than natural, the
former would be seen to be gorged with blood. The source of the
hæmorrhage, in such cases, was the great point of practical im-
portance.
Mr. Nunn exhibited a Cast of the lower part of the leg and
ankles of a woman suffering from Dropsy, dependent upon Cardiac
Disease.
The integument of the parts was studded with tubercles of about
the size of moderately large split-peas, while the whole of the leg
was oedematous, and very much distended with serum. The tuber-
cles secreted, or rather excreted, from their surfaces, a fluid in great
abundance, and it was observed that, when the discharge of this
fluid was copious, the chest symptoms remained in abeyance.
The case had been subjected to a great variety of treatments by
various medical men, and by some was considered to present an
example of a species of Elephantiasis.
Mr. Nunn put forward the opinion, that the tubercles were the
papillæ of the skin, hypertrophied and transformed into an excern-
ing apparatus, the office of which was to rid the limb of effused
fluid.

12
Dr. Ogier Ward related a case of sudden death, presenting some
unusual post-mortem appearances.
Mrs. H., aged fifty-three, stout, but not florid, and liable to
convulsive fits, had an attack resembling Angina Pectoris, while
walking home. She had had an attack in church three weeks
previously. Being taken to a medical man, her face was noticed
to be pale, the eyes staring, the neck distended, but the veins not
prominent; she complained of pain passing from her heart to her
back, and gasped for breath; clear froth flowed from her mouth;
she stretched herself out and died, the mouth being drawn to one
side.
The medical man attempted to bleed her, but from both arms
could only get a few tea-spoonfuls of thick black blood. On being
laid out, her stays were found so tight that the lace could hardly
be cut, but immediately this was done, the distortion of the face
ceased, the left arm burst out bleeding, the blood was red and
florid, and when, after great difficulty, the flow was stopped, the
right arm began to bleed; previously to this a slight flush had been
noticed on the cheeks, and the layer-out fancied that the woman's
hand closed upon hers; the countenance also became quite placid,
so that some doubts were held as to the real occurrence of death.
The body was, however, placed in a coffin, where the same ap-
pearances continued undiminished, and an inquest was held upon
it the second day after death, florid red blood continuing to flow
during both days. After the inquest the coffin lid was laid on,
which caused the cheeks to become more coloured, and a perspira-
tion to appear upon the cheeks and forehead. The right arm was
now stiff and cold, but the body had previously remained warm,
and the nose and lips never became stiff; frothy mucus continued
to flow from her mouth, and blood to trickle from her arms. The
coffin-lid was secured and the body buried three days after the
inquest.
While she lay in the surgery, the medical man listened to the
heart's action, but heard no pulsations, nor were any felt by her
friends subsequently.
November 18, 1848.
JOHN WEBSTER, M.D., F.R.S., President, in the Chair.
Mr. Canton gave a detailed account of certain morbid appear-
ances which he had met with in the examination of the bodies of
three children, two of which had been "overlain," and the third,
intentionally, suffocated. Each case had been the object of judicial
inquiry. The subjects were only a few months old.
Exterior of the body: Features placid; lips congested; eyes
not unduly prominent; conjunctivæ rather extra-vascular; hands
clenched; no blotches of ecchymosis to be anywhere detected.-

13
Head: Patches of effused blood, here and there, beneath the
pericranium; cranial bones engorged with blood. In two cases,
great congestion of the pia mater, in all its superficial extent,
accompanied by numberless subjacent sanguineous extravasa-
tions, varying in size from a pin's point to a silver penny: no
such effusion within the brain or its containing membranes; a
little clear fluid in the ventricles. In the third case, the intra-
cranial appearances were natural, whilst those of the skull bones
and pericranium were the same as described. A little clear
frothy mucus in the trachea and bronchi, with redness of their
lining membrane.-Thorax: No fluid within, or adhesions across,
the pleural cavities. Lungs much congested and crepitant, whilst
beneath the visceral and reflected pleuræ, blood had been every-
where effused, presenting numerous small bright red patches,
and fine points; all the blood of the substance of the lungs was
within its vessels. The pericardium contained some serum, and
was spotted in its whole extent after the manner described; the
vasa vasorum of the heart's great vessels and thoracic aorta were
minutely injected. In one case there was a large quantity of blood
extravasated posteriorly, and especially on the left side, in the
groove between the auricles and ventricles, as though the coronary
vein had been ruptured; this latter point, however, was not ascer-
tained. In this instance, too, the substance of the heart, particu-
larly its left ventricle, was so soft as to become readily pulpy on
slight pressure between the finger and thumb. The right cavities,
in all the cases, were replete with dark, liquid blood; the left ones
nearly empty; the tissue of the organ free from extravasation.
The surface only of the thymus gland was mottled like the heart.
No unnatural appearance within the abdomen. Mr. Canton inquired
if
any member of the Society had met with similar appearances in
these cases, as those relating to the ecchymosis were not, he believed,
mentioned by medico-legal authorities.
Mr. Hird exhibited a specimen of a portion of pericardium, on
the right side of which was a pendent cyst, communicating with
the cavity of that membrane by a slit-like opening.
The preparation was obtained from a dissecting-room subject,
aged sixty-five years, and no history was attached. Six ounces and
a half of fluid were contained in the pericardium and cyst together;
the latter containing about six drachms. The walls of the cyst
were composed of pleura externally, and serous pericardium within.
The surface of the heart was rough from an old effusion of lymph,
and the mitral valves presented vegetations.
Dr. Garrod read a paper "On the simultaneous Progress of
Gout and Phthisis."
99
He was induced to bring this subject before the notice of the
Society, as in a paper on phthisis, communicated during the last
session, it was asserted that a gouty condition of the system or
blood was inimical to the development of tubercular disease; and

14
it was suggested that, for the purpose of preventing or curing the
latter affection, an attempt should be made to produce a gouty dia-
thesis; and even the internal administration of urate of soda was
hinted at. Dr. Garrod first spoke of some recent researches he
had made on the subject of gout, and published in the last volume
of the Transactions of the Royal Medical and Chirurgical Society,
and described what he considered to constitute a gouty condition of
blood-viz., the presence of an excess of uric acid, before and
during the paroxysm, in acute gout; and as an almost constant
accompaniment in those forms of the disease where tophaceous or
chalk-like deposits take place in different parts of the body. The
author then stated, that if the gouty and tubercular diathesis were
antagonistic, phthisis would never become developed in the invete-
rate forms of gout above alluded to. To prove, however, the fallacy
of the idea, the following case was related:-A young man, aged
twenty-eight, a native of London, whose father and grandmother
had suffered from gout, applied for relief at University College
Hospital, and was admitted under the care of Dr. Williams. He
was a painter by trade, and for some years had been of very intem-
perate habits, but until the last few years had had a sufficiency of
food and clothing. From the age of seventeen, he had suffered
from what he termed "rheumatism," (gout?) but had no affection of
the heart with it. Formerly, he was of full habit, but about three
years since he began to lose both flesh and colour, although he did
not feel particularly ill, and had no cough at the time. He was
soon after seized with an attack of gout, both in his feet and hands,
tophaceous deposits formed, and he was confined to his bed for
twenty-eight weeks. About two months after his recovery, he was
again attacked, and then had a severe cough, with expectoration of
a greenish hue. The pectoral symptoms continued for about four
months; the gouty, two months longer. From this date until his
admission into the hospital he was constantly suffering from chest
affection and gout; hæmoptysis had occurred once, and deposits of
urate of soda frequently came away from his joints. When
admitted into the hospital, he was pallid and emaciated; com-
plained of pain in various joints arising from gouty inflammation;
also of pain in his side, cough, and expectoration of a muco-puru-
lent character. On physical examination, clear evidence was found
of the existence of tubercular deposits in both lungs, especially the
left, at the apex of which, a distinct cavity was indicated by the
production of pectoriloquy and cavernous respiration; during the
remaining month of his life, the gouty affection continued to pro-
gress-now appearing in one part, now in another, and occasionally
with the discharge of urate of soda from some of the joints. The
thoracic affection also continued to advance, accompanied with
hectic symptoms, increase of cough, and sharp pain in different
parts of the chest, until he fell into a state of stupor, and so con-
tinued for a day or two, when death took place. The post-mortem
appearances fully proved the accuracy of the diagnosis. At the
apex of the right lung a cavity was found, large enough to contain

15
a walnut; the rest of the lung being studded with scattered tuber-
cles in different stages of development. The apex of the left lung
was excavated to the depth of four or five inches, and the remain-
ing portion was sprinkled throughout with grey tubercles. The
heart was healthy; the liver had patches of soft tuberculous deposit
on its surface; the kidneys were small, and many of the tubuli filled
with a white matter, consisting of crystallized urate of soda and
uric acid; spleen enlarged. Mucous membrane of the colon ulce-
rated in patches. An examination of the blood was also made, and
it was found to contain a very large amount of uric acid, larger
than Dr. Garrod had ever before obtained. Some remarks were
then made on other cases, in which gout and phthisis existed
together; the rarity of the combination being easily accounted for
by the fact, that gout in general does not appear till after the
of forty, whereas tubercular disease is much more frequent before
that period. It also appeared very doubtful to the author whether,
granting the correctness of the hypothesis advanced in the paper
alluded to, a gouty condition of blood could be induced by the
internal administration of urate of soda.
age
November 25, 1848.
FRANCIS HIRD, Esq., President, in the Chair.
Mr. Canton exhibited a specimen of Cancer of the Clitoris, to-
gether with portions of this deposit in various tissues of the same
body.
The patient was upwards of sixty, and had suffered from the com-
plaint for several years. The labia minora and inguinal glands were
the only parts implicated, in the vicinity of the disease. The bones,
generally, were brittle, and some of the ribs especially so, where
masses of scirrhus, embedded in the lungs near their surface, had
become adherent to them. The latter were emphysematous, and a
little turbid fluid was found in the pleural sacs. The liver, kidneys,
and left crus of the diaphragm were the other parts affected.
Mr. Hancock exhibited a Model of a Surgical Bed.
At the head of the bed was a windlass, by which the patient could
be raised up, lying on a moveable platform, and made to assume any
position required without any effort on his part. At the foot of the
bed was a pivot, by which the platform could be fixed in any posi-
tion; and on the under surface of the platform was a sheet divided
into several pieces, so as to admit of the exposure of any part of
the patient's back requiring attention. Mr. Hancock had found
the bed of great service, in a case of a woman who threw herself
out of a third-floor window, and had in consequence sustained a
compound fracture of the thigh, and a severe laceration of the
back, denuding several bones of the flesh covering them.

16
Dr. Webster read a paper entitled "Remarks on the Statistics,
Pathology, and Treatment of Puerperal Insanity."
After a few prefatory observations in regard to the severe symp-
toms frequently characterizing this disease, and the anxiety it often
excites amongst relatives and attendants, when they perceive the
patient's mind begin to wander, or reason altogether to forsake its
seat, the author entered into several elaborate yet interesting state-
ments respecting the frequency of puerperal insanity compared with
other varieties of mental disease. To illustrate this point, he stated
that, in 1091 curable female patients recently attacked by insanity,
and admitted into Bethlem Hospital, during the last six years, 131,
or one-eighth of the whole, were puerperal cases; thus showing
that the malady is not so unfrequent as many may perhaps believe.
Again, as to the curability of this form of mania, more recoveries
were reported than in the other varieties of lunacy; 81 puerperal
patients having been cured, or at the rate of 61-83 per cent. ;
whereas the average recoveries during the last twenty years, in all
cases of insane females treated at this institution, was 53.67 per
hundred. Hence, three in every five cases of puerperal insanity
may be confidently expected to get well within a year. In regard
to hereditary tendency to mental disease, 51 of the 131 patients
were thus predisposed, or 39 per cent.; whilst 41 were suicidal,
being at the rate of 31 in every 100. Both these peculiarities are
of much importance in this malady, and materially influence the
disease, its progress, and result. Respecting the total deaths in the
131 puerperal patients, the author reported that they amounted to
6, or 4 per cent.; thus making the average rate of mortality
nearly the same as in other species of insanity, taken collectively.
The particulars of the fatal cases, and pathology, next occupied
attention, and on this point the author stated, that three of the
six patients who died were suicidal and hereditary; one was only
hereditarily predisposed to insanity, but not suicidal; whilst two, it
was reported, had neither of these peculiarities; and none were
insane previously. In addition to these facts, the author also men-
tioned, that half the deaths occurred in persons who were not
affected longer than fifteen days, the shortest period being eleven
days; and that all were attacked by insanity within seventeen days
after their confinement. In none of the dissections were any
morbid changes observed in the abdomen, but the lungs always
appeared to be diseased, as also the brain and its membranes. The
details of an autopsy were then described, as illustrative of the
diseased changes of structure frequently met with in puerperal
mania; the principal morbid alterations being, turgidity of the
blood-vessels of the brain and membranes; large bloody points on
cutting the cerebral substance; slight serous infiltration of the pia
mater, and considerable effusion of fluid into the fifth ventricle:
adhesion and purulent ulceration were noticed in the left lung, with
hepatization in other portions of that organ, and in the right lung
partial pneumonia in the congestive stage. Although this patient
had been delivered only twenty-six days prior to her death, no

17
corpus luteum could be discovered in either ovary, and no diseased
changes of structure were noticed in the abdomen. Notwithstand-
ing that it appeared rather a digression, the author remarked, that
although gangrene of the lungs is very rare in persons carried off
by bodily disease, but without any mental affection, sloughing of
that organ is not unfrequently met with in lunatics. This he said
from his own knowledge, and the same observation had been made
by others, especially in the continental lunatic asylums. Puerperal
insanity, in the author's opinion, is both more frequent and fatal in
the upper than the lower classes of society; the suicidal and here-
ditary cases being less tractable, and more destructive to life, than
the other forms of the malady. He also remarked, that the melan-
cholic cases proved more protracted, and less curable, than the
other varieties; and that, although over-lactation seemed to be a fre-
quent cause of insanity, it is then generally very amenable to cure;
and that, notwithstanding the malady may arise oftener from partu-
rition than from lactation, it comes on, relatively speaking, in a
greater number of cases after weaning than during the period of
suckling. Further, that the disease more commonly attacks females
from the age of twenty to thirty than at other periods; is more
serious in single than in married women, mania being the most
frequently observed; and that three cases in five usually occur
before the fourteenth day after delivery; whilst the danger is
always diminished, the later the period at which the attack comes
on after parturition. That formerly, the variety of insanity now
under discussion was comparatively less frequent, but that it proved
more fatal than recently. That Dr. Haslam, for instance, reports
that, during the time he resided at Bethlem Hospital, only 85
cases of puerperal insanity were met with in 1644 lunatic females
admitted into that institution, being at the rate of five cases in
every 100 admissions. Again, that Dr. Burrows records 10 deaths,
besides one suicide, in 57 cases which came under his immediate
observation, being more than quadruple the mortality mentioned by
the author in the first part of this paper; whilst, according to Dr.
Copland's experience, one out of every eight cases of puerperal
mania usually terminates fatally.
Dr. Webster afterwards alluded to the treatment of puerperal
insanity; and considering cerebral irritation, combined with great
exhaustion of the nervous system generally, to constitute the true
character of this disease, and that it rarely, if ever, proves inflam-
matory, he thought depletion, or the use of strong antiphlogistic
measures very seldom admissible. Leeches appeared in some cases
advisable; but even then they should be applied with great caution,
and their effects carefully watched. As a general maxim, the
author advised the same principles to be followed in the treatment
of this malady as in delirium tremens, since the nature of the two
diseases was somewhat analogous. Opium, camphor, ammonia, and
aromatics, with some of the diffusible stimuli, proved excellent
remedies, and ought to be chiefly relied upon. When opium fails
to procure sleep-so beneficial in this, as indeed in every form of
C

18
insanity-then conium, hyoscyamus, or Indian hemp, may be sub-
stituted. Mild purgatives, to open the bowels, and sometimes
cathartics, should be prescribed; but powerful drastic medicines
are seldom advisable. Enemata also are useful, conjoined some-
times with turpentine. When the disease assumes a more chronic
form, setons or issues may be made in the neck, and counter-irrita-
tion employed. The shower-bath, from its strengthening influence,
then acts beneficially; whilst tonic remedies, with more nutritious
food, become necessary, and prove advantageous: indeed, low diet
is very often prejudicial in insane patients, and it has been long
remarked in many asylums, that improved nutriment, especially in
lunatics who have previously suffered privations, frequently becomes
a powerful means for promoting recovery. In recent cases of puer-
peral insanity, when the circulation is accelerated, accompanied by
evident congestion of the brain, leeches to the temples and behind
the ears, or blisters, might then be applied, and afterwards cooling
lotions, with ice to the head; whilst tartar emetic, or ipecacuanha,
in nauseating doses, and digitalis, may be administered for the same
object. Besides medical treatment, moral means, with judicious
occupation and amusements, when proper for the patient, must not
be overlooked, as these very often constitute effective adjuncts in
the management of the insane. With the view of briefly illus-
trating the symptoms and treatment proper to be pursued under
ordinary circumstances, the author next narrated two cases of puer-
peral insanity, one being affected with mania, the other with melan-
cholia. In the first, or maniacal case, the patient, a single woman,
aged twenty-one, whose child did not survive, had hereditary ten-
dency to mental disease, but was reported as not suicidal. She was
very noisy, incoherent, often much excited, frequently very wild,
violent, exceedingly mischievous, used bad language, destroyed her
clothes, and paid no regard to personal cleanliness. She took food
voraciously, was very restless at night, and dirty in bed. Pulse
generally quick, and bowels constipated. The remedies employed
consisted of opening medicines, cooling saline mixtures, and croton
oil, on one occasion, with regulated diet. Subsequently, bodily
occupation and amusements were put in requisition, whereby the
patient soon became convalescent. The second case was an example
of the variety denominated melancholia. In this patient, a married
woman, aged thirty, suicidal and hereditary tendency to mania
existed. She was hasty in temper, but naturally cheerful. The
attack commenced a month after delivery, and her child was weaned
when six weeks old. She had been much debilitated by hæmor-
rhage after labour; appeared often very depressed and melancholic;
generally very desponding of her insane state, and had attempted
to injure herself. She took food very unwillingly; could not sleep
at night; would scarcely remain in bed, and endeavoured to escape
from her room. The pulse was of natural frequency, and the
bowels regular. Early in the disease, leeches were applied once to
the temples, and afterwards blisters to the neck on three occasions.
Opiates and camphor were prescribed, with purgatives, especially

19
the compound decoction of aloes. Latterly, the cold shower-bath
and tonic medicines were employed. The diet, at first light, was
subsequently more nutritious, and malt liquor was allowed; by
which means, and by proper occupation, conjoined with amuse-
ments, as the patient improved, she recovered. In concluding his
paper, of which the above report is merely an abstract, the author
made some observations respecting the employment of restraint to
persons labouring under lunacy in any form. Dr. Webster was
decidedly opposed to the use of any such severe measures; and
said that, if improper in ordinary cases of mania, mechanical
coercion was even more inapplicable to puerperal insanity, because
wherever the strait-waistcoat is adopted, lest the patient might
injure herself-the excuse commonly assigned by attendants-the
exasperation and excitement then exhibited, appear more frequently
as a consequence of, than a warrant for, such barbarous proceed-
ings. This is found to be especially true in respect of suicidal
patients, since experience amply demonstrates that the mechanical
restraint of insane persons so disposed, and even of individuals who
have never shown any propensity of the kind, often acts as a highly
exciting cause of suicide. The degradation which even lunatics
feel, when thus treated like criminals, frequently produces most
injurious effects upon their weakened minds; and if the insane
patient, subjected to such cruel treatment, be a female of delicate
constitution, susceptible feelings, high accomplishments, and of
education, the objections to strait-waistcoat, or similar mechanical
means of coercion, become much stronger, as the results, in all like-
lihood, will prove more disastrous.
December 2, 1848.
JOHN WEBSTER, M.D., F.R.S., President, in the Chair.
Dr. R. C. Golding exhibited a heart taken from a young woman,
a dress-maker, aged twenty-four, who died of acute pleurisy of the
right side, with bronchitis. The patient had been under Dr.
Golding's observation, and often treated for rheumatism by him
during more than three years. Dr. Child had attended her
during her last illness, and had invited Dr. Golding to the
autopsy. The cardiac disease had lasted for six or seven years, its
symptoms not having materially varied since she first came under
Dr. Golding's care. The health of the patient, when free from
rheumatism, was tolerably good; and as great caution in diet and
regimen was enjoined and punctually observed, her life was pro-
longed, till the accession of the pleurisy and bronchitis, for which
Dr. Child attended her. The physical signs indicated great hyper-
trophy of the heart, with double valvular disease of its left cavities.
Dulness was appreciable along the lower half of the sternum, as
high on the right side as the cartilage of the third rib, and on the left
to the second rib. The apex of the heart was felt beating between the

20
seventh and eighth ribs, three inches at least more to the side than
in health. The sounds were feeble; the rhythm, under ordinary
circumstances, not impaired; the impulse strong; and the pulse
full and bounding. There was a double murmur at the apex, and
a very loud and rough diastolic sound at the upper part of the
sternum, at its sides, and along the neck. The autopsy revealed
great thickening of the tricuspid, mitral, and aortic valves: the
two former formed perfect rings around the auriculo-ventricular
openings, which must have been patent during life; the pulmonary
valves were healthy; and the calibre of the aorta above the valves
was much contracted. The pericardium was thickened, but nowhere
adherent or unduly vascular. There was recent pleurisy of the right
side, great congestion of the lungs, together with a little emphysema
here and there. The gall-bladder contained a few small calculi:
nothing else was noticed as irregular or morbid.
Dr. Golding considered that the heart showed clearly that rheu-
matism was the cause of the valvular lesion in both ventricles;
that the same disease, influencing the valve in precisely the
same manner, and relatively in the same degree, existed in both
tricuspid and mitral valves; and that the perfect rings formed by
the adhesion from inflammation of the divisions of the valves
respectively, (together with the thickening, shortening, and adhe-
sion of their chordæ tendineæ,) must have been attended, during
life, with permanent patency of their orifices.
Dr. Wm. Merriman narrated a case, which presented many
symptoms of laceration or rupture of the uterus.
A woman, aged twenty-eight, in labour of her third child, was
found with the os uteri fully dilated, the bag of membranes dilating
the vagina, and the vertex presenting over the pubis. The mem-
branes having speedily ruptured, the head descended, but not so as
to occupy the whole brim of the pelvis; on the contrary, very violent
pains drove it rather against the pubis and fore part of the vagina.
After an hour's duration of unusual suffering, chloroform was exhi-
bited for two hours, in hopes of mitigating the suffering, while the
pains propelled the head gradually downwards; but this not ensuing,
three doses of ergot were given, without any pains succeeding.
Vomiting and tenderness of the abdomen came on about this time,
to relieve which the patient had forty minims of laudanum. After
some hours, it was found that the head had been completely
retracted, and the constitutional disturbance still continuing, Dr.
Chowne's advice was sought, and the woman was delivered by
turning, twelve hours after the cessation of the pains. The child
lay very high up, yet still within the uterus, and the hand was first
reached. The child was, however, dead; the uterus contracted
well. By careful watching, the patient had very much recovered,
and Dr. Merriman had considerable hopes of her complete recovery,
ten days having elapsed since the labour.

January 1857
3
PROCEEDINGS
OF THE
WESTMINSTER MEDICAL SOCIETY.
SESSION 1848-9.
No. 2.
December 9, 1848.
FRANCIS HIRD, Esq., President, in the Chair.
Mr. Harvey exhibited an Acephalous Monster born at the full
period of pregnancy.
Another child accompanied it, which was remarkable for its badly-
nourished condition; the funis was small and short; there were two
placentæ; that belonging to the monstrosity was very large. When
it was born, the integuments presented a dark blue colour above
the umbilicus, and below it a pale red. The exterior view presented
no head or upper extremities: the inferior extremities, large and
well-formed, terminated in club-feet; the left foot had three toes,
the right five, each furnished with a nail. On the fleshy substance
above and between the shoulders, representing the head, were
observed some slight tufts of hair, and two button-shaped fleshy
substances, the one in the centre and the other to the right side;
the external organs of generation were well marked as a female,
and the anal aperture communicated with the intestinal tube. An
incision was made through the centre of the body, with the view of
inspecting the parts within; it brought into view a cavity contain-
ing the base of the skull resting on the atlas on either side, bounded
by the ribs; neither clavicle nor sternum was present. The cavity
was filled with loose cellular structure and a sac, which would con-
tain about a teaspoonful of fluid; the internal layer resembled the
fibrous structure of the auricles of the heart. The connexion of
the sac with the umbilical vessels was made out, but no vessel
could be discovered running from it; perhaps this was in conse-
quence of decomposition. A large vessel, probably the aorta, took
the course of the vertebral column on each side, and terminated in
four distinct branches at the sacrum, two running to the anterior
part of the thigh, and two to the posterior. There was an absence
of all the viscera of the abdomen, excepting the intestinal tube,
D

22
which was closely adherent to the abdominal parietes. The urinary
organs and the internal organs of generation were also absent; the
spinal portion of the skeleton was greatly incurvated, and on each
side of the three upper ribs was a loose portion of bone resembling
a scapula. The spinous processes of the vertebræ were much
enlarged, and the vertebral canal was filled with spinal marrow;
the nerves arising from it were observed to be large and irregularly
distributed. Very little muscular structure was observed, the
anterior parietes of the abdomen being composed, solely, of common
integument and adipose structure.
A communication was read from Mr. I. B. Brown, stating that
he had used collodion with advantage in cases of sore nipples.
Dr. Lankester exhibited a fatty kidney, taken from a patient
who had died of phthisis, and who had been taking cod-liver oil.
He inquired whether any connexion was probable between the dis-
ease of the kidney and the medicine.
Dr. Lankester narrated a case of Poisoning by Opium.
An Irish woman, aged forty, was admitted into University Col-
lege Hospital, at eleven A.M., on April 8. She was supposed to
have taken opium, and had been brought to the hospital six months
previously, under the same circumstances. Her face and hands
were livid; there was no pulse perceptible at the wrist; the breath-
ing was slow, laborious, and accompanied with a loud mucous
rhonchus. The carotids beat irregularly, about fifty strokes in the
minute. The accompanying coma was profound. The stomach-
pump was applied, and coffee with ammonia injected into the
stomach. The patient was undressed, and several pitchers of cold
water were poured over her from a height. This had the effect of
slightly arousing her, but the surface became cold, and she was
wrapped in blankets, and her feet put in hot water, from which
she directly withdrew them. Some more warm coffee was admi-
nistered by the stomach-pump at half-past twelve, the coma still
continuing; the surface was cold; no pulse at the wrist; the
breathing stertorous. She was put into a hot bath, which had the
effect of causing a momentary return of sensibility; after this she
began to swallow, and more coffee was administered with ammonia.
At two o'clock the symptoms were worse; the pupils, which at first
were not remarkably contracted, now became so. The coma in-
creased, and the breathing became more stertorous and embar-
rassed; an enema of turpentine was administered, but no improve-
ment took place in the symptoms. The difficulty of breathing and
coma increasing, she was bled to six ounces from the arm. The
symptoms slightly improved. An attempt was made to walk her
about the ward, but no sooner was she placed in an upright position
than the respiration became embarrassed, and the coma increased.
Under these circumstances, the electro-magnetic battery was em-
ployed, and currents of electricity were passed through the shoul-
ders, chest, abdomen, arms, and legs. Under this treatment the

23
symptoms improved; the pulse became perceptible at the wrist;
the tendency to drowsiness continued to a greater or less extent till
ten P.M., but was effectually prevented by passing a weak electric
current through both arms. When recovered, she stated that, at
five o'clock the previous evening, she had taken a shilling's worth
(about two ounces) of laudanum. She had, therefore, been eighteen
hours under the influence of the poison before any treatment was
commenced. She was discharged from the hospital, but was sub-
sequently readmitted, with gangrene of the lungs, of which she
eventually died. The post-mortem examination revealed a tuber-
culous condition of the left lung, and a large cavity, produced by
gangrene, on the right lung.
The author drew attention to the following points:-1. The
condition of the patient when brought to the hospital. The
symptoms were of such a nature, that all who saw her despaired
of affording any relief, and only a sense of duty prompted them
to make an effort for the rescue of the patient. 2. The benefit
experienced in the use of cold affusion in this case would warrant
its application in similar cases, or wherever the same combina-
tion of symptoms was present. 3. From the effect of the ammonia
and the turpentine enema in this case, it may be inferred, that
such stimulants are amongst the remedies in cases of poisoning
by opium which should not be had recourse to but under the most
urgent circumstances. The condition of the nervous system is
very different in coma from narcotic poisons, and coma from
mere congestion. 4. The reaction which was observed at two
o'clock, and attended with more decided symptoms of narcotism,
may, perhaps, serve to explain the cause of death in cases where
persons have apparently recovered from the effects of narcotic
poisoning, and afterwards again sunk. 5. The evident advantage
of using the electro-magnetic apparatus as a means of arousing the
sensorium in cases of poisoning by opium, especially when, as in
the present case, other means cannot be well employed. 6. The
tuberculous condition of the lungs may suggest the question, as to
whether this was the result of the depression brought about by the
poisoning, or whether, rather, this condition was not present when
the poison was taken, and contributed to that congestion of the
lungs which was so remarkable a feature of the case, and brought
on the gangrenous condition of these organs, of which the woman
died. 7. The non-contracted condition of the pupils, and the want
of opium smell in the contents of the stomach, are points worthy
of notice in this case.
December 16, 1848.
JOHN WEBSTER, M.D., F.R.S., President, in the Chair.
Mr. Canton exhibited a preparation of an ununited, comminuted
fracture of the surgical neck of the humerus, accompanied by displace-
ment of the long bicipital tendon; also an example of unreduced dis-
D2

24
location of the radius forwards at the elbow, with partial luxation of
the ulna inwards.
Both specimens were removed from the right arm of an elderly
female, and no history of them could be ascertained. In the first
preparation a strong fibrous capsule was formed, enclosing the ends
of the broken bone, and in it were entangled the comminuted
fragments, one of which was coated with porcellanous material,
in a manner similar to that part of the surface of the shaft it
had played on. The shaft was drawn upwards and inwards; the
biceps tendon was well retained in its new situation on the lesser
tubercle of the humerus, and the articular surface of the bone was
directed unnaturally outwards. In the second preparation Mr. Canton
remarked, it was interesting to observe the great degree of mobility
Nature had established, though the accurately-fitting surfaces of the
ulna and humerus, no longer rightly corresponded with each other;
and this end had been obtained by a modification of the form of the
trochlea, and by extension inwards of its surface; so that, from
this latter circumstance, the projection of the internal condyle was
altogether lost. The head of the radius revolved freely in a broad
cavity above the capitulum humeri, and was retained in situ by a
strong coronary band passing from the external condyle to the
anterior edge of the lesser sigmoid cavity of the ulna. The coro-
noid fossa was obliterated, and the pit for the olecranon nearly
filled up.
Mr. Henry Smith related a case of perineal abscess, accompanied
by symptoms resembling quotidian ague.
The patient was a middle-aged gentleman, who had been
under treatment for a month when Mr. Smith first saw him, for
what was supposed to be quotidian ague, but had received no
benefit. On the third day after the first visit, the patient called
his attention to a painful sensation he had in the perinæal region,
and, on inspection, a tumour was discovered containing matter,
which was evacuated in large quantities, and on the following
day a stricture was discovered, and a small catheter passed.
The patient was greatly relieved, and recovered quickly, having
had no return of the rigors, or other feverish symptoms, since
the operation. The author observed, that although it was far from
uncommon to meet with cases in which symptoms simulating ague
accompanied diseases of the urinary apparatus, especially perinæal
abscess, at the same time he thought it was rare to meet with a
case in which the symptoms were so prominent and so strikingly
similar to ague, that they alone attracted the attention of the prac-
titioner who had attended him, and were treated as ague for about
three weeks, while the fons et origo mali had not been discovered.
The paper concluded by a few remarks upon the sympathetic effects
of stricture of the urethra.

25
December 23, 1848.
FRANCIS HIRD, Esq., President, in the Chair.
Mr. Henry Smith narrated the following case:-
He had been called to a case of Scarlatinal Dropsy, commencing
about ten or fourteen days after the eruption appeared, but as he
had not attended the case at first, he could not speak positively on
this point. The boy's age was sixteen. Mr. Smith was sent for,
as the boy was in a fit; he applied a blister to the neck, and
gave a strong purging dose; the convulsions, however, recurred
frequently, and in the evening he bled him to eight or ten ounces.
Immediately the convulsions ceased, but the respiration became
very difficult, from obstruction in the bronchi, and he died from
asphyxia, the next morning. Before bleeding, the pulse was
quick and sharp, and the pupils dilated; the urine was very scanty,
and of a deep red colour. Mr. Smith asked if the bleeding had
probably accelerated the death?
Dr. Snow read a paper on the use of Chloroform in Parturi-
tion:-
He said that the chief objections which had been made to the
use of anæsthetics in midwifery were of an à priori kind, but that
the question ought to be decided by experience. Some objections
had arisen from the supposed necessity of inducing a deep state of
insensibility, and he was of opinion that if it were requisite to cause
the same amount of insensibility in midwifery, as is required in
surgical operatious, this would be a valid objection, as he con-
sidered that this state could not be continued for two or three
hours without injury to the patient. But this amount of insensi-
bility was not required in obstetric practice except to arrest or
diminish strong uterine action for a few minutes to facilitate turn-
ing the child. The suffering, attendant on labour, might often be
greatly relieved, or even altogether removed, without suspending
the consciousness of the patient. Towards the conclusion of
labour it was usually necessary to carry the effect of the vapour a
little farther, but even then it should not exceed the second
degree of anesthesia, or that condition of the patient in which the
mental functions are not altogether suspended, but in which there is
a dreaming or wandering state of the mind; the patient, never-
theless, usually remaining silent if not spoken to. In labours
unassisted by manual or instrumental aid, the auxiliary action of
the respiratory, and even of the voluntary muscles, continued with-
out interruption when the chloroform was well managed. He con-
sidered that a medical attendant acquainted with the action of
chloroform, and the mode of applying it, might administer it with
propriety in all cases, in which the pain was either severe or pro-
tracted, whether they fell within the division called natural labours
He then related two cases in illustration of the beneficial
action of chloroform. He used an apparatus in administering it,
or not.

26
and gave a little at the beginning of each pain. He disapproved
of Dr. Simpson's plan of giving chloroform on a handkerchief, and
more particularly of his practice of putting three or four drachms
on the handkerchief to begin with. To show the danger of this
practice, he alluded to the fatal cases published, and read some
notes, furnished to him by Mr. Henry Smith, of a case in which
the patient very nearly lost her life from chloroform given in this
manner, preparatory to an operation. Chloroform was of great
service in removing rigidity of the os uteri and of the perinæum,
and it had relieved puerperal convulsions in two cases on record.
Dr. Snow concluded by remarking, that as all medical men were
actuated in their views only by a desire for the well-being of their
patients, the difference of opinion in the profession concerning the
employment of chloroform in midwifery ought not to be attended
with any acrimonious feelings.
January 6, 1849.
JOHN WEBSTER, M.D., F.R.S., President, in the Chair.
Mr. Hancock related a case, in which he had removed the os
calcis from a patient suffering from caries of that bone, a proceeding
which he believed had never been previously adopted; and although,
from the causes detailed, the case did not terminate so favourably
as could be desired, still the operation had succeeded in two instances,
related by Mr. Greenhow, at the Newcastle and Gateshead Patho-
logical Society, and was therefore worthy of consideration.
R. W, aged twenty-four, a butcher by trade, and of scro-
fulous diathesis, was admitted into the Charing-cross Hospital on
the 23rd of May, 1848. He was suffering from caries of the os
calcis of the right foot, with abscess; the bone was rough, but not
loose. His other leg having been removed some two or three
years before, for scrofulous disease of the knee-joint, Mr. Hancock
was anxious to preserve as much of the remaining foot as possible,
and accordingly decided, as the disease appeared to be limited to
the os calcis, to confine his operation to the removal of that bone
alone. Accordingly, on the 2nd of June, the patient having been
placed under the influence of chloroform, assisted by Mr. Avery,
and Mr. Canton, he removed the bone, by carrying a semilunar
incision from the posterior angle of the inner malleolus across the
sole of the foot, to the external malleolus, the convexity of the flap
looking forwards. The flap, thus made, was carefully reflected,
the tendo-Achillis divided, and the knife being carried from be-
hind, forwards, between the astragalus and the os calcis, the latter
was dissected out without any difficulty. Two or three vessels
were tied, and the flap being brought over, the edges were united
by sutures and strapping. The patient went on extremely well until
the 6th, when erysipelas came on, accompanied with severe con-
stitutional disturbance. On the 9th, a considerable portion of the

27
flap sloughed, and it eventually came away on the 16th, but suf-
ficient skin remained to cover the bones completely. He con-
tinued to improve until the middle of July, the external wound
being almost healed, and the foot becoming firm and of good shape;
but at this time he was again attacked with erysipelas; several ab-
scesses formed in the limb, both in the foot, above and below the
wound, and in the leg and ham; his strength gave way, he became
very low and weak, and it was evident that there was very little
probability of saving his limb; but being anxious to give him every
chance, Mr. Hancock determined to try the effect of the protein, so
highly recommended by Mr. Tuson, and this was accordingly given
in doses of fifteen, afterwards increased to twenty, grains, thrice
daily. For some time his general health improved, but the foot
did not mend, and at length, as the constitutional symptoms re-
turned, and further delay appeared dangerous, the leg was removed
at about five inches below the knee, on the 6th of October, just four
months after the former operation. Mr. Hancock was inclined to
attribute the want of success of the first operation to the state of
the patient's constitution, and the attacks of erysipelas, rather than
to other causes, and he was confirmed in this opinion by the suc-
cess which had attended the two operations since performed by
Mr. Greenhow, both of which were cases of accident and not dis-
ease. Mr. Hancock considered that this plan was well worthy the
consideration of the profession, and should be selected in patients
of good constitution, or in accidents, where the mischief was con-
fined to the os calcis, rather than the methods hitherto employed,
as thereby the ankle-joint is preserved entire, a matter of con-
siderable importance to the patient. In conclusion, he corrected
an error into which Mr. Greenhow had inadvertently fallen in
the relation of his two cases, in stating that "the operation had
never been performed before he did it." Mr. Greenhow had the
credit of the first successful case, but the dates of the several ope-
rations prove that Mr. Hancock was the first to introduce the
plan into the practice of surgery. His operation was performed
on the 2nd of June, above ten weeks before Mr. Greenhow's
first, which took place on the 15th of August, whilst his second
was performed on the 17th of October.
Mr. Henry Smith exhibited the pharynx and trachea of a child
aged eleven months, on whom he had performed the operation of
tracheotomy.
The child had suffered from chest affection for several days; and
three days before he saw it, symptoms of obstruction in the upper
part of the air-passages presented themselves. When he was
called, he found that immediate interference was requisite, and
therefore at once proceeded to open the trachea. This he did in the
usual way, with the loss of about an ounce and a half of blood. The
operation lasted about a quarter of an hour, time being taken over
it, as the little patient was very weak. The child lived six hours
after the operation, and on examination after death the trachea was

28
found healthy, the lungs being in some parts congested. The dis-
ease was confined to the pharynx and larynx, which had been
inflamed and thickened, the epiglottis and glottis being involved in
the mischief.
Mr. Nunn exhibited a bladder containing a small fungous growth,
taken from a patient in the Middlesex Hospital, into which he had
been admitted on December 6th, for hæmorrhage from the urinary
organs, then existing about four days. No disease whatever could
be felt by the hand applied over the pubes, or by the finger in the
rectum, or by the catheter, and the man gradually died from
hæmorrhage, losing from six to eight ounces of blood a day. He
had had gout, but not for five years. The microscope showed pus
globules in the urine.
Mr. I. B. Brown exhibited a Funis 38 inches long, which had
not been coiled round any part of the child.
January 20, 1849.
JOHN WEBSTER, M.D., F.R.S., President, in the Chair.
Mr. R. Greenhalgh read a paper on Ruptures of the Uterus and
Vagina.
He stated that out of 78,018 deliveries occurring under the
superintendence of Drs. Ramsbotham, Collins, Hardy McClintock,
Joseph Clarke, and McKeever, this accident occurred eighty
times, or once in 975 cases; out of 71 recorded cases by these
authorities, 66 were fatal to the mothers-five only having
recovered, or about 1 in 14. Out of 18 deliveries, 17 were fatal
to the children. He then gave the result of nine cases recorded by
Dr. Murphy in the seventh volume of the "Dublin Journal of
Medicine," all of which were fatal to the mothers; eight of the
children were still-born; one, a girl, was born alive; three mothers
were 36 years of age-two, 30-one, 46-one, 26-one, 21. Two
were in their tenth labour; two, in the first; two, in the third;
one, in the eleventh ; one, in the sixth; one, in the fifth. Eight
were delivered by the crotchet; one by the natural efforts. One
mother died eleven days after delivery; one, eight; one, six;
one, four; one, three; one, two; two in thirty hours; one in
twenty-four hours. In five cases the rupture occurred in the
anterior part of the cervix uteri ; two in the posterior; one patient
was not examined, and in another no spot is specified as the seat
of the accident.
The author then detailed a case to which he had been called.
The patient was 35 years of age, in labour with her sixth child;
the arm and shoulder presented, but this position was converted,
by one of the gentlemen in attendance, into the first position of
the head, about two hours after which she complained, during

29
a pain, that something had given way in her inside; vomiting,
fainting, extreme prostration, oozing of blood from the os externum,
together with recession of the presenting part, speedily followed.
While suffering from these symptoms, Mr. Greenhalgh was first
called upon to visit her. After giving her some brandy and laudanum,
he proceeded to turn the child, which he accomplished with some
difficulty in the space of about three-quarters of an hour, having
first removed the placenta from the vagina, where it was found
lying unattached. The child was still-born; the shoulder and arm
were much swollen and ecchymosed, and over the right parietal
bone was a distinct scalp tumour. She sank sixty hours after
delivery, from exhaustion, in spite of a frequent and liberal supply
of nourishment and stimuli. No circumstance had occurred during
her pregnancy to induce her to seek medical advice; although,
when closely questioned, she admitted that she had suffered more than
usual from sickness, pains in her breasts and in the left iliac fossa,
and that when the child moved it gave her an idea that it was
passing "over a sore place."
No post-mortem examination was permitted; but during the
operation of turning, a large rent was discovered, through which
the child had escaped into the abdominal cavity, extending from the
anterior and upper part of the vagina, through the os and cervix
uteri, and passing obliquely to the right side of the pelvis. Mr.
Greenhalgh drew the attention of the Society to the absence of
symptoms, during this patient's pregnancy, of softening and inflam-
mation; to the comparative immunity from this accident in women
who have complained of tenderness, pain, and other symptoms
usually regarded as indicative of uterine inflammation, which have
gone on unchecked by medical treatment; to the feebleness of the
uterine efforts in this case; and the very unusual circumstance of
the conversion of a shoulder and arm presentation unto that of the
head.
He then mentioned another case which occurred in a patient of the
Middlesex Hospital, of which he regretted that he had no record. The
patient was about thirty-five years of age-it was not her first con-
finement-she had been some hours in labour-the breech presented
-rupture of the uterus took place, followed by vomiting of a very
violent character, great exhaustion, partial escape of the presenting
part into the abdominal cavity, and more or less discharge of blood
from the os externum. After having given a dose of brandy and
opium, Mr. Greenhalgh brought down the feet of the child, which
he extricated without delay; the infant was still-born; the patient
sank shortly afterwards from exhaustion.
He then detailed two doubtful cases of rupture. One was a first
labour, the other an eighth-both female children. In the first,
the pains were irregular and spasmodic-in the second, perfectly
natural in recurrence, and above the average strength. In both the
head presented; one was of natural conformation, the other hydro-
cephalic; the first was expelled by the unaided efforts of nature,
the second by perforation; a sensation, as if something had given

30
way in the abdomen, during a pain, followed by a partial recession
of the presenting part, was present in both cases; also great pro-
stration, vomiting, but not of coffee-ground fluid, escape of blood
from the vagina, and subsequently acute peritonitis. Both mothers
recovered, and have since borne male children, without any unto-
ward occurrence.
The author concluded by stating that he considered this accident
more common than was generally supposed; that it far more
frequently occurred in patients who had had many confinements,
than in primiparæ; that the seat was usually found in the cervix
uteri and upper part of the vagina; that ergot of rye might cause
this accident, by increasing the action of an attenuated uterus, but
not by producing any structural change in that organ. Finally,
he drew the attention of the society to the various methods of
delivery in these cases-by turning, by the forceps, and by per-
foration; and concluded by stating, that he was disposed to consider
that the performance of the Cæsarian operation, in the case first
recorded, would have given the patient a much better chance of
recovery than the forcible attempts had recourse to for the
extraction of the child.
January 27, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Dr. Routh narrated a case of Scarlatina, followed by purulent
deposits.
The child was three years old, and was first taken ill on the 7th
January, with symptoms of general fever. On the 8th, the erup-
tion of scarlatina and an otitis made their appearance. The fever
progressed favourably, and lasted eight days, or till the 15th. On
the 17th, the mother noticed the desquamation of the cuticle. On
the 18th, feverish symptoms again appeared, the otitic discharge
having persisted throughout, and in no way diminished. Next
morning, the 19th, the face and body were swelled, but pale.
By accident, the mother noticed a swelling about the size of a
goose's egg, in the left side of the abdomen. On the 22nd, a
swelling about the size of a pigeon's egg appeared over the internal
condyle of the right humerus.
Dr. Routh first saw the child on the 26th instant. The
abdominal tumour was then about the size of two goose's eggs,
evidently situated between the parietes of the abdomen. A similar
swelling, about the size of a small hen's egg, was situated over the
inner condyle of the right humerus. In both, fluctuation was very
distinct. The surface of the skin was very pale. Over the
abdominal tumour, however, one tortuous and enlarged purplish
vein was noticed. The left humerus was swollen, and apparently
oedematous, but pale, and tender to the touch. There was no cedema
elsewhere. The aspect of the child was very unhealthy; the tongue
rather brownish; the pulse quick and feeble. A puncture being

31
made with an exploring needle in the swelling on the right humerus,
indicated the presence of pus.
The case was interesting as exemplifying a rare form of sequela
of scarlatina-the pus being effused external to, and not within
the joints, and also as being preceded by symptoms of renal
dropsy.
In regard to the treatment, Dr. Routh asked whether the pus
should be evacuated or not?
Mr. I. B. Brown exhibited two bandages, applicable in the treat-
ment of Ovarian Dropsy.
The
The first, intended for the treatment with or without previous
tapping, is made to lace up, and thus the amount of pressure can be
daily increased. It is fitted with pieces of whalebone, to keep it
smooth, and is secured round the thigh by straps. This bandage
is equally beneficial as an abdominal support in other cases.
second form of bandage is applicable where pressure is required for
a long time after tapping; it is simple in structure, and fastens by
straps and buckles, and contains an air-cushion, which being
emptied or filled lessens or increases the pressure as it is required,
without the necessity of undoing the bandage.
Dr. Murphy exhibited a Fibrous Tumour, and read a history of
the case, of which the following is an abstract:-
A woman applied to him, having the pelvis occupied almost
entirely by a firm tumour, so that the os uteri was beyond the
reach of the finger, and micturition impossible, except by the aid
of a catheter. After a few days he was called to her, and then
passed a gum elastic catheter to its full length, but obtained no
urine, although she was suffering from sensations of retention of
urine; she rapidly sank and died.
On opening the abdomen after death, a large tumour was found,
which had displaced the intestines, and reached upwards to the
umbilicus, and laterally to the iliac fossæ. The mass of the tumour
lay on the left side, and had nearly incorporated the uterus, which,
however, with the right ovary, was found projecting from its right
margin. The bladder was contracted and empty; but the ureters,
being compressed by the tumour, were enormously distended and
tortuous. The kidneys were enlarged and in an advanced state of
Bright's disease. The tumour proved to be fibrous, engaging the
whole posterior wall of the uterus, the cervix being stretched for
some inches along its anterior surface, and expanded over it. The
uterus had been drawn out of the pelvis by the growth of the tumour.
A small portion in its centre was softer and more friable than the
remaining parts.
The author drew attention to the unusual position of the tumour,
occupying the pelvis so completely as to displace the uterus entirely;
to the advisability, if practicable, of pushing such a tumour out of
the pelvis when small; and to the sensation of retention of urine,
produced apparently by the distention of the ureters, the bladder
being empty.

32
February 3, 1849.
JOHN WEBSTER, M.D., F.R.S., President, in the Chair.
Some cod-liver oil was exhibited, drawn from two livers pre-
sented to the Society by Mr. Wing. A discussion then took place
on the use of this medicine.
February 10, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Mr. Benjamin Travers narrated a case of Hæmatemesis from
ulceration of the Gastric Artery.
A widow, of middle age, and almost chlorotic in appearance, was
seized with vomiting of blood; she rallied a little, but in the night
was again attacked, threw up a large quantity, and shortly after-
wards died. On a post mortem examination, the stomach was
found to contain much grumous fluid, with a circular breech, like
an ulcer, directly over the gastric artery, which was laid open by
an orifice admitting the end of a blow-pipe. The peritoneum was
healthy. None of her medical attendants had ever suspected the
existence of ulceration in the stomach.
The audited abstract of the income and expenditure of the
Society, up to the 31st December, 1848, was read.
The nomination of Fellows to fill the vacant offices of Vice-
Presidents and Council then took place.
Mr. H. Smith Palmer read a case of Continued Fever, compli-
cated with attacks resembling Ague.
A nobleman, aged seventy-six years, of a remarkably active and
healthy character, yet suffering at times from bilious attacks, left
town on 29th November last, for the day only, but was prevented
returning home in the evening by an attack of illness resembling
English cholera, gradually passing into continued fever, of a typhoid
type, yet without delirium at any time. The urine became very
offensive, and both it and the foeces were passed involuntarily,
although not unconsciously. He was supported by wine and brandy,
and other nutriments, and treated with hydrargyrum cum creta, &c.
On the night of December 18th, a profuse perspiration broke out,
and all his symptoms were relieved; the tongue, instead of being
dry and brown, became moist and clean; the pulse was not above
the natural standard, and the urine much clearer. During the
following night, however, he became as ill as before, so that his
medical attendants conceived that he had ague. On Decem-
ber 22nd, he had a violent shivering fit, succeeded by heat, and
continued to get worse until the 24th, at which time he was not
expected to live many hours; but he rallied again surprisingly,

33
On
and on the 27th was very much improved in every respect.
the 28th, however, he had another rigor, and died during the
collapse. No post-mortem examination was allowed.
February 17, 1849.
JOHN WEBSTER, M.D., F.R.S., President, in the Chair.
Mr. I. B. Brown exhibited a Foetus, born prematurely, from
Prolapsus of the Cord, as he supposed.
The mother, aged thirty-eight, had borne nine full grown children,
and four prematurely. On most of these occasions she had had
retention of the placenta after delivery, from adhesions to the fundus
uteri. A fortnight since, Mr. Brown had been called to her, and
found her suffering from periodical uterine pains, attended with
considerable hæmorrhage: she declared herself to be six months
pregnant. On examination he could not pass his finger into the
cervix uteri. Opiates were administered, and the horizontal posi-
tion ordered, under which treatment the pains ceased, but the
hæmorrhage, to a slight extent, continued.
That morning he had found her suffering severe uterine pains,
the funis presenting externally in a loop, the os uteri dilated, the
head presenting, but no part of the placenta within reach; the latter
eventually proved to be adherent, as usual, to the fundus uteri.
The inner surface of the uterus where the placenta had adhered
was nodulated; the parts separated were quite free from blood, the
other parts black and congested. The liquor amnii had evidently
escaped some long time previously. The child had been dead about
four days.
Dr. Ogier Ward related a case of Ulceration of the Cocum,
with enlargement of the mesenteric glands, which formed a
tumour in the right iliac fossa of a girl aged nineteen, who had never
menstruated. The diseased parts were also exhibited.
66
The patient was of a sickly family, and had never been strong
herself, the only appearance of menstruation being a very slight
show," four months since. She had been anæmic for the last
three years, and during the last year had had wandering abdominal
pains, supposed to be the access of the menses, but subsiding on
fomentations being applied. The pains had been more frequent
since the "show," but she was able to do the work of the house
till January 13th, when Dr. Ward first saw her. Her bowels had
been costive lately, but were then opened by medicine. The face
had a slight hectic flush, the skin was hot and dry, the pulse 120,
the tongue, hitherto pallid, was of a natural redness and moist; no
appetite; no pain anywhere; no disease could be detected in the
chest. The abdomen was soft and compressible in every part
except the right iliac fossa, where a tumour existed, painful on

34
pressure, and of the size of an egg, defined upwards and towards
the median line, but not downwards or outwards. The symptoms
continued much the same till her death, on February 13th, but the
fever, which assumed a remittent type, was completely controlled
by quinine. Aphthæ formed in the mouth and peeled off in large
flakes the day before her death.
The head was not examined; the lungs contained many miliary
tubercles in the upper lobes; the stomach was large, and the lower
portion of the oesophagus covered with a ragged coat of epithelium,
like that on the tongue; the liver was enlarged, extending below
the ribs of the right side and far to the left of the epigastrium;
the lobuli were all tinged with bile, and appeared slightly fatty.
The spleen was about three times the natural size, and the kidneys
about twice as large, but apparently healthy. The omentum was
adherent to the brim of the pelvis, and dragged down the transverse
colon so as to conceal the small intestines. The lower portion of
the ilium was ulcerated in spots down to the cœcum, which contained
much fluid fœces and was enormously thickened by tubercular
deposit under the peritoneum. The mucous membrane was com-
pletely destroyed by a large ulcerated surface extending about ten
inches up the colon, and then terminating abruptly. The mesen-
teric glands were much enlarged by tubercular deposits. The
uterus was healthy. The ovaries resembled sparrows' eggs in size,
shape and colour, being enveloped in a cartilaginous membrane
half a line thick. The tumour was formed partly by the cœcum
and partly by the enlarged glands. Its want of definition down-
wards was caused by the diseased mass descending into the pelvis,
where it had contracted firm adhesions to the surrounding parts.
Dr. Ward noticed that this case confirmed Louis's observ-
ations, that tubercles in the lungs always accompany that deposit
in other organs.
Mr. I. B. Brown read a paper on Protracted Labour, induced
by the twisting of the cord around the neck of the Foetus.
He observed that obstetric writers had not mentioned these
causes of protracted labour, yet they were not uncommon. He
said, that where the cord is twisted round the neck of the child, it
exerts so much traction upon the fundus uteri, as to interfere with
the regular expulsive efforts,-that this is easily discovered by the
peculiar pains, which are of only half their natural duration, and
are cut short suddenly; the head receding after each pain, so that
the patient says that they have done her no good;-that in these
cases the child's head does not make "the turn" gradually, as
usual, from the termination of the first stage of labour to the
commencement of the second. The repeated expulsive efforts at
last separate the placenta from the fundus uteri; the head then
suddenly turns into the hollow of the sacrum, and the child is born
after one or two pains, thus rendering hæmorrhage probable. The
practitioner should, therefore, be in attendance, and grasp the uterus,
not leaving off till the placenta is expelled, and the uterus firmly

35
contracted. An increased length of the cord may obviate
any evil
from a single coil around the neck of the child, but in most cases
it is so much shortened by repeated coils as to produce the impedi-
ment alluded to.
The Ballot for the election of officers having closed, the following
Fellows were declared elected officers of the Society for the ensu-
ing year:-
President.
Francis Hird, Esq.
E. W. Murphy, M.D.
John Snow, M.D.
Vice Presidents.
E. Lankester, M.D., F.R.S.
J. F. Marson, Esq.
Treasurer.
Aug. Sayer, M.D.
Honorary Secretaries.
S. W. J. Merriman, M.D.
R. Greenhalgh, Esq.
Council.
C. Wing, Esq.
J. W. Woodfall, M.D.
I. B. Brown, Esq.
W. Harding, Esq.
W. R. Rogers, M.D.
W. D. Chowne, M.D.
A. B. Garrod, M.D.
F. R. Manson, M.D.
W. Harvey, Esq.
T. H. Tanner, M.D.
February 24, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Mr. Canton narrated the following case:-
A gentleman, aged 45, who had resided in a warm climate, had
been for several years afflicted with a swelling in the left side of
the scrotum, which had attained, by very gradual enlargement,
the size of a small melon, producing no inconvenience, however,
except from its bulk and weight. During its growth, it had
occasionally been struck by the pommel of the saddle, whilst
riding a restive horse. The tumour was oval, extending to
the external abdominal ring, and the spermatic cord was
obscurely to be felt behind; the testicle was nowhere to be distin-
guished; the surface was uniform, and the scrotum natural and
unadherent; freely handling the tumour produced no pain or un-
easy sensation; no impulse was to be felt on coughing; the patient
could not remember whether the swelling had commenced from
above or below; translucency and fluctuation were absent; pressure
at the back and towards the lower part elicited no pain. A small

36
portion of the anterior surface was found, on careful examination,
to be more yielding to the touch than the remaining part, and the
sensation experienced was that of softness and elasticity.
In consultation with Mr. Hancock, it was agreed that the
case was one of old hydrocele, with the tunica vaginalis con-
siderably thickened, and a trochar was consequently passed into
the tunic through the forepart of the tumour, as the least resisting
part.
There flowed, at once, through the canula, a thick, unctu-
ous, brown fluid, which coagulated by heat. The size of the
tumour, however, remained the same as before the operation. A
few days afterwards, a considerable amount of lighter coloured fluid
was drawn off, and at the next visit, Mr. Canton determined to lay
open the sac, and endeavour to promote the formation of granula-
tion by filling the cavity with lint. He accordingly made an inci-
sion from the upper to the lower part, through the cyst, the walls
of which were nearly an inch in thickness. The testicle was now
seen within, and situated lower down than in ordinary hydroceles,
and appeared to be in every respect healthy. The patient suffered
much from nausea, sickness, and constitutional irritation. At the
expiration of a few days, these symptoms having abated, and the
interior of the sac being found in a sloughy state, it was judged
advisable to remove, by the knife, the whole of the disease, a fear
being entertained that otherwise, from the indifferent state of the
patient's health, the sloughing might extend, and in so doing
involve other parts, whilst the low organization of the sac gave
little encouragement to the hope of obliteration being effected by
granulation-besides that the patient was urgent in his desire to
have every unhealthy part removed. Under these circumstances,
Mr. Canton carefully dissected the cyst, which was almost as con-
sistent as cartilage, from the fore part of the spermatic cord, and
from around the testicle, so as to leave the latter, which was quite
healthy, freely suspended by the cord. No part of the scrotum was
removed, and the integuments at the close of the operation were so
contracted that the testicle could scarcely be returned to its place
through the wound; this healed favourably, and the patient has
since remained perfectly free from
any inconvenience.
Sold by HENRY RENSHAW, Medical Publisher, 356, Strand.
Price One Shilling each Number.
From Henry Hanwell y

mary
1857
PROCEEDINGS
OF THE
WESTMINSTER MEDICAL SOCIETY.
SESSION 1848-9.
No. 3.
March 3, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Mr. Henry Smith exhibited a specimen of Ulceration of the
Larynx, which was taken from a child three years old. og
The patient had recovered from a severe attack of measles, com-
plicated with pneumonia, but had recently suffered from inflamma-
tion of the palate and fauces, accompanied with aphthous deposits,
and extending into the larynx. He was treated by nitrate of silver
to the fauces, and blisters externally, and improved very much;
but on the morning of his death suddenly became considerably
worse. When Mr. Smith saw him, the strangling fit was over;
and although the child breathed with difficulty, he did not think the
case sufficiently urgent to warrant the performance of tracheotomy,
but prescribed wine, and blisters to the part. The child died sud-
denly in the evening. A post-mortem examination showed the
rima glottidis to be obstructed by a tenacious mucus, and patches
of ulceration over the inner surface of the larynx. The trachæa
was healthy.
Mr. Smith observed, that in this case tracheotomy would pro-
bably have been successful, and he regretted its non-performance.
Mr. Hancock read a paper on the administration of Iodide of
Potassium in some cases of Strumous Corneitis, Hypopion, and
Syphilitic Iritis.
The author observed that he had employed this remedy very
largely in cases of strumous inflammation of the cornea, attended
with opacity from interstitial deposit; in interstitial abscess of the
cornea; in iritis, attended with effusion of matter into the anterior
chamber; in rheumatic inflammation of the sclerotica and iris
assuming the chronic form; and, indeed, in all cases of deep-seated
inflammation of the eye occurring in weak and debilitated or
E

38
irritable constitutions. He considered this medicine superior to
calomel, as exerting its absorbent powers more quickly and with
greater certainty, and without, in the majority of cases, producing
the ptyalism which is so distressing and injurious to the patient.
Calomel does not appear to act upon ophthalmic diseases until the
patient's system is completely under its influence, and this will not
usually be effected under eight-and-forty hours, whilst sometimes,
indeed frequently, it requires a longer time, on account of the purg-
ing it causes, or from certain idiosyncrasies of the patient's con-
stitution, &c. Even when the peculiar action of calomel is pro-
duced, it will frequently disappoint our expectations, and aggravate
instead of diminish the local affection, from its irritant action upon
the constitution. Mr. Hancock was induced to employ the iodide
of potassium freely, from observing the result of its administration
in some cases of deep-seated inflammation of the eye with hypo-
pion, occurring in persons of weakly constitution, and more par-
ticularly in cases of interstitial abscess, which are, for the most
part, to be met with in scrofulous patients, or where, from bad
living, excessive drinking, and hardships, the powers of reparation
are destroyed, and excessive irritability of the system exists. With
regard to syphilitic iritis, the author remarked, that he seldom
found it necessary to push mercury to any great extent, and usually
gave two grains of it every night at bedtime, combined with
opium; and at the same time the iodide of potassium mixture twice
a day. The form of the latter medicine employed is that recom-
mended by Lugol.
March 10, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
The President laid upon the table some elastic bandages made
by M. Bourgeaurd.
The principal advantage of these bandages, which were appli-
cable in the treatment of varicose veins, and of umbilical hernia,
consists in the spiral arrangement of the elastic web.
Mr. Gilbert attended the Society, and exhibited the chair in-
vented by him for facilitating the performance of operations upon
the teeth.
Mr. Canton related the following case of Chronic Rheumatic
Arthritis of the Shoulder and Hip joints. The preparations of
these articulations were exhibited.
James Harrison, aged seventy-nine, a tall, emaciated, and feeble
man, stated, that in the year 1805 he "got thoroughly wet
through," and the next morning suffered from rheumatism of the
right shoulder, but in no other part. This was the first attack of
the complaint he had experienced, and for it he was attended by
Dr. Hope, of Edinburgh, whose treatment relieved him of the

39
affection in a short space of time. From this period to the winter
of 1847 the joint had been free from any uneasiness, except in
damp or frosty weather, when a "sensation of gnawing" was com-
plained of in the part, and continued to trouble him whilst the
inclement weather lasted. This inconvenience, however, was not
of a nature to prevent him following his usual work-that of a
gentleman's servant. In unfavourable weather the pain was always
aggravated at night, or, as he says, "when warm in bed." In the
winter of 1826, whilst employed in dislodging snow from a house-
top, he caught a violent cold, through getting his feet wet, and
from that time the left hip was affected with rheumatic pains,
which, like those of the shoulder, were found to be invariably in-
creased in frosty or damp weather, and when in bed.
The pain
was always especially felt "the first thing in the morning," whilst
a sensation of cracking and grating in the joint was frequently
complained of; at the same time the sound emitted, particularly
when rising from a sitting posture, was audible to, and remarked
upon by, the by-standers. Nine or ten years ago he became, for
this complaint, a patient in the Middlesex Hospital, under the care
of Mr. Arnott. Various applications were employed without relief;
and at the expiration of a month, the nature of the disease and its
intractable character having been explained to him, he quitted the
hospital. At this time he walked lame, and was informed, after
admeasurement of the limbs had been made, that the left leg was
shorter than the right. When seen by Mr. Canton, no great dif-
ference was noticed, inasmuch as the opposite hip had become simi-
larly affected. No distinct attack of rheumatism occurred to the
shoulder since that above mentioned, but it continued the seat of
the same symptoms as those previously described during the last
twelve months. On applying the hand over the joint, and then
rotating and circumducting the humerus, a very well-marked
"articular crepitus" was heard, and the peculiar sensation charac-
teristic of it, also, was communicated to the touch. The crepitus
was most readily felt when, in circumduction, the arm passed for-
wards from the side of the chest; the movement producing, at the
same time, an indescribable uneasiness in the articulation; pressure
on the deltoid muscle, so as closely to approximate the joint-sur-
faces of the humerus and scapula, gave no pain, nor was any incon-
venience experienced when the head of the humerus was directed
against the under part of the acromion process. The arm could
with difficulty be elevated or directed forwards or backwards. The
deltoid of either side, in common with the muscles generally, was
much wasted; little if any difference was to be noticed, however,
between the two sides. Measurement did not show the right
humerus to be nearer the acromion process than it was on the left
side. An incessant dull pain, aggravated by motion, was com-
plained of in the joint, and extending thence down the front of
and along the inner side of the arm to the elbow. The acromio-
clavicular articulation presented a partial dislocation of the clavicle,
which was elevated, and appeared to be fixed near to the upper
E 2

40
edge of the articular surface of the acromion process. This joint
on the opposite side was in all respects normal.
On the post-mortem examination the joints presented the follow-
ing appearances:-1st. The shoulder: the glenoid cavity was more
shallow than is natural, in consequence of an expansion of its outer
part depending upon the deposit of new bone in the glenoid liga-
ment, whereby the surface for articulation with the humerus was
rendered additionally broad. The long tendon of the biceps, as it
passed through the joint, was considerably flattened, expanded, and
divided into four or five slips, placed side by side. This condition
of the tendon had permitted the head of the humerus to shift
upwards, and, thereby, to articulate with the under part of the
acromion process, in which situation was seen a broad surface,
against which the former played. The capsular ligament, however,
was intact. The great tubercle of the humerus was flattened, and
three of the capsular tendons at their insertion were, in part,
absorbed. In the opposite shoulder similar changes were in pro-
gress, but they had not proceeded to so great an extent as in the
fellow joint. 2nd. The hip-joint: this showed the ravages of
chronic rheumatic arthritis to have progressed to a great degree.
The acetabulum was much deepened, from bony deposit in the coty-
loid ligament; the encrusting cartilage was wholly removed, and at
the upper and outer part of the cavity, porcellaneous material was
present in a continuous sheet, and having a high polish. The
ligamentum teres was absent. Bony plates were lodged in the
capsular ligament. The head of the femur was mis-shapen, its
form being accommodated to that of the acetabulum. The car-
tilage was wanting, and ivory-like deposit was present, correspond-
ing in extent and situation to that in the cotyloid cavity. The
cervix femoris was short, horizontal, and, at the anterior part,
encroached upon by new bone, which sprang from the circum-
ference of the head, and adhered to it in this situation.
cortex was thin, and the medulla abnormally soft and red. The
fibrous structures, generally, of the articulation, were unduly vas-
cular.
The
Mr. Canton made some observations on the parallel changes in
these analogous joints, and showed another specimen of the disease
in the shoulder-joint, to prove that an extension of this morbid
action rendered the similarity of the changes in the two articula-
tions still more striking. Preparations (recent and dried) were
exhibited of the effects produced by the complaint in the knee-
joint. The outer condyle, in all of them, was expanded, coated
with enamel-like matter, and alternately grooved and ridged in a
vertical direction. The corresponding surface of the patella was
in the same condition, so that interlocking was effected, and gingly-
moid movement preserved. In one instance the patient was knock-
knee'd, from absorption of the external semilunar cartilage; and in
this case upwards of twenty loose cartilages were found in the
joint, some of them free in its cavity or loosely connected to the
tissues around. An illustration was shown of the disease in ques-

41
tion in a dried hand, which demonstrated the advance of morbid
action to a great extent, especially in the first joint of the thumb,
so that, before dissection, the part presented the appearance of a
dislocation of the metacarpal bone upwards on to the trapezium.
The other specimens exhibited were of the elbow, acromio-clavi-
cular joints and spine, in all of which the same order of changes
might be remarked as those more particularly described in the hip
and shoulder.
Resolved unanimously, that "The warmest thanks of the Society
be given to Dr. Webster, for the zeal, ability, and uniformly cour-
teous conduct evinced by him during the period of his presidency."
Dr. Rogers read a paper on a case of Anæsthesia and Paralysis
of the right side of the face occurring in a light porter, aged
twenty-seven, who, in the discharge of his duties during heavy
rain, got a severe wetting, which gave rise to giddiness, deep-
seated and shooting pain in the right temple, with deafness and
buzzing in the corresponding ear, and considerable tenderness of
the parts in front of it; these symptoms were accompanied by a
gradually increasing anæsthesia of the right side of the face, right
nostril and orbit, and the right half of the palate; the extent of the
affection accurately corresponding to the limits of the anatomical
distribution of the ophthalmic, superior maxillary, and temporo-
auricular branch of the inferior maxillary nerves. Under treat-
ment, this symptom began considerably to abate, and the patient,
feeling himself much improved, ventured to go out of doors for the
benefit of the air, but on his return, violent and deep-seated pain
was felt in the temple, the conjunctiva of the right eye was found
in an active state of inflammation, but quite devoid of sensation,
Loss of motion in the muscles of the face was now added to the
renewed anesthesia, both bounded by the before-mentioned limits.
These symptoms were also attended by high febrile excitement;
however, under treatment, (leeches, blisters, fomentations, &c.,) all
the symptoms were much alleviated; but the inflammation of the
eye still continued, and the deep tissues became involved, the iris
being severely affected. Mercury, which had been employed for
some time previously, was now administered more freely, but no
salivation followed, although the mercurial fœtor was strong. Mr.
Quain had visited the patient, and advised a continuance of the
treatment adopted, especially the mercury. Under its use, after
the lapse of a little time, sensation and motion began to return in
the face, but the inflammation of the eye continued; and three dis-
tinct spots of puriform deposit made their appearance between the
layers of the cornea, and gradually coalescing, engaged about two-
thirds of it, so as completely to interfere with vision. The mercury
was immediately discontinued, and in its place opium, quinine,
iodide of potassium, with a bitter, were substituted. About this
time the patient began to feel a dull pain in the brow, and could
slightly elevate the upper lid, which had been hitherto immovable,

42
though not from paralysis of the third pair of nerves; the eye could
also feel a hot sensation from a solution of watery extract of opium
dropped upon it. After three weeks' perseverance, the puriform
deposit, which was never surgically interfered with, discharged
itself externally, the iris became more natural, the pupil less
angular, and the cornea less hazy; these beneficial changes being
obviously connected with the return of sensation to the face, as in
many instances noticed by Bellengeri, Magendi, Bell, and others.
The patient from this time gradually recovered, and soon got well,
a slight haziness of the cornea and an angularity of the pupil only
remaining.ing fun
With regard to the pathological conditions, centric or excentric,
giving rise to the anesthesia which affected all the branches of the
first and second divisions, and the temporo-auricular branch of the
third division of the fifth nerve, and those giving rise to the para-
lysis of the muscles supplied by the superior division of the seventh
nerve accompanying the relapse of the anesthesia with inflammation
of the eye, the author considered that the morbid action was excen-
tric rather than centric; although aware that an inflammatory action
may be set up in one part or division of a nerve as it emerges from
the brain, and give rise to paralysis or anæsthesia, as the case may
be, in the parts to which it is distributed. Yet, as the inflam-
mation in the case related was diffusive in its character, he did not
think it probable that the fibres which ultimately emerge in front
of the ear, as the temporo-auricular nerve, should be so curiously
singled out from the other nerve fasciculi, composing the lower
division of the inferior maxillary nerve, by an inflammation having
a central situation, and engaging the origin of the fifth pair. And
he considered it unreasonable to suppose that the common trunk of
the seventh nerve should be affected centrically, and only give rise
to paralysis of those muscles to which its upper division is supplied.
He thought besides, that the acute pain felt on pressing the parts in
front of the cartilages of the ear, where a slight induration remained
still perceptible to the touch, would further support the conjecture
of an excentric origin to the symptoms; for the temporo-auricular
nerve in passing to the surface is enveloped by a portion of the
parotid gland in the back part of the glenoid cavity, and some lym-
phatic glands lie in the immediate vicinity of the upper division of
the facial nerve, so that it would be easy to imagine that inflam-
mation of those parts would involve the nerves just mentioned,
which are likewise connected with each other by distinct nervous
twigs; and that an extension of the morbid action, inwards and
upwards, by the cellular tissue in the zygomatic and pterygo-
maxillary fossæ might engage, first, the superior maxillary nerve
and Meckel's ganglion; and next, the ophthalmic nerve, which,
although it passes directly from the cranium to the orbit, neverthe-
less is uncovered by bone where it lies in the pterygo-maxillary fossa.
The external pterygoid muscle forming a septum or barrier between
the inferior maxillary nerve and the other divisions of the fifth, and
thus preventing the inward progress of the inflammation in that

43
direction, would fully account for the immunity of the inferior
maxillary nerve, admitting that its temporo-auricular branch was
superficially engaged in the inflammation.
The author stated, that in similar cases to the preceding it be-
comes of some moment, with regard to prognosis, to be able to dia-
gnose its centric or excentric origin; whether it can be traced to a
simple cold producing inflammation, as in the present case; or whe-
ther it arises from a tumour or other cause pressing upon the
origin of the nerve, or from disorganization in some part of its
course either within or without the cranium; the former class
being, usually, easily cured, the latter almost hopeless as to treat-
ment.
March 14, 1847.
JOHN SNOW, M.D., Vice-President, in the Chair.
Mr. Walton exhibited a Fibrous Tumour from the Patella, and
a cast of the knee, and gave the following history of the case.
The patient, a female, aged thirty-nine, applied to him with a
tumour situated over the left patella. It was moveable, being easily
pressed from side to side. The integuments, although much thick-
ened, were not adherent to it. His impression was, that it was a
solid growth, both on account of its density or firmness, and from
the history of the case-viz., that five years ago it commenced as a
very small, hard substance, which slipped from side to side when-
ever it was pressed on. It never inflamed, and had increased
gradually; and within the last few months any pressure occasioned
pain. Mr. Walton never suspected that it was an enlarged and
hardened bursa, but imagined it might be a sarcomatous growth.
He operated on the 12th instant, and removed the tumour exhi-
bited. While dissecting at its base, he opened a cavity, which
proved to be a large, healthy bursa, between the tumour and the
patella, and extending much beyond the limits of that bone. The
wound had united by the first intention. The tumour on being
divided displayed a fibrous character.
Mr. Henry Smith exhibited a specimen of Disease of the
Larynx.
He had removed the parts after death from the body of a gentle-
man, aged forty, who had suffered for more than six months from
symptoms chiefly referable to the windpipe. The irritation was so
great, and the general condition of the patient rendered so dange-
rous, that Mr. Smith was consulted, for the purpose of considering
the propriety of performing an operation. The operation proposed
was, to make an opening into the trachea, and afterwards to apply
a solution of nitrate of silver to the larynx by means of a piece of
sponge. The symptoms presented, however, by the patient, in-
duced Mr. Smith to suppose that tuberculous disease of the lungs

44
was present, and he therefore declined the surgical interference.
The patient gradually became worse, and died some months after-
wards from exhaustion. On examining the body, the whole of the
inner surface of the larynx and epiglottis was found to be in a state
of chronic ulceration; and on the right side there was great thick-
ening of the superior vocal chord, so that it projected into the
cavity of the larynx, and nearly blocked up the aperture of the
glottis. This accounted for the complete loss of voice the patient
suffered under for several months. The upper and posterior por-
tion of each lung were beset with tubercles in their first stage.
Mr. Harvey exhibited a preparation taken from a patient who
sank from the effects of perinæal Abscess. The morbid appear-
ances observed were, the thickened condition of the mucous mem-
brane about the bulbous and membranous portion of the canal, and
the elastic tissue about the prostate gland spoken of by Tyrrell.
The muscular coat of the bladder was very much hypertrophied.
The patient had long suffered from stricture, which doubtless
caused the abscess of which he died.
Mr. Harvey was desirous of eliciting from the Society the treat-
ment of abscess in this region of the body, and the propriety of
introducing the catheter while the abscess was discharging.
March 24, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Dr. Routh mentioned the cases of two children who had died
from Pertussis; convulsions-viz., opisthotonos, but no lock-jaw,
having affected one of them. In the first, the lung was found, on
post-mortem examination, to be ruptured, and air effused under the
pleura; the spinal cord was much hardened, and as much as an
ounce of fluid escaped from it. In the second case, miliary tubercles
were found, with the same appearances of air escaped from the
lungs.
Dr. Routh asked the Society whether large bleedings should be
practised in such cases, or what other treatment is appropriate.
Mr. Benjamin Travers read a case of prolonged retention of
Urine, caused by permanent stricture, in a young man, to whom he
was summoned for the purpose of giving the bladder some imme-
diate relief. No water had passed otherwise than by drops for
days previously, and the patient was dying rapidly from the local
distress and bodily exhaustion. Mr. Travers operated in the fol-
lowing manner. The patient's chest having been raised with
pillows, and the skin being incised in the median line, immediately
above the pubic symphysis, a straight dropsy trocar and canula was
next pushed into and through the anterior wall of the bladder. The

45
relief was very decisive, but so sudden, as nearly to produce a fatal
collapse. The patient was, however, presently restored by the
administration of stimuli. The canula was tied into the bladder
and stoppered, but after some days it was removed, as it no longer
hindered the escape of urine by its side, when the bladder became
full. In about a month the wound had become fistulous, a small
quantity of urine passing through it, the remainder flowing by the
urethra. The patient's health being much restored, and the stric-
ture not much enlarged by the use of bougies, Mr. Green, one of
the surgeons of the hospital, cut down upon the stricture in perineo,
and so introduced a catheter into the bladder. After this opera-
tion the patient gradually recovered.
The author remarked, that the first operation rescued the patient
from immediate death, at a time when loss of blood must have
proved fatal; and he quoted an instance wherein the patient died
under such circumstances, before the bladder could be relieved by
incising the perinæum. Puncture of the bladder has had many
able advocates from the days of Portean and Thiraud (1760) to the
present time. Home, Abernethy, and Hey of Leeds, were men-
tioned as having practised it repeatedly, and with great success.
The operation affords an interval of repose to the irritated ure-
thra by diverting the passage of the urine for a time, during which
that canal has been found so far capable of spontaneous restora-
tion that the patient has subsequently recovered without any inter-
ference on the part of the surgeon, beyond the occasional use of a
bougie. The circumstances of each case must determine the site of
the operation; but when it is admissible, and the relief desired only
temporary, puncture per anum is usually preferred. The author
referred to a case of puncture per anum recorded in the "Philoso-
phical Transactions" for the year 1776, which shows that the
canula may be withdrawn, with perfect impunity, immediately after
the evacuation of the bladder, and without risk of dangerous extra-
vasation. In the instance quoted the patient perfectly recovered.
The author did not insist upon the universal adoption of punc-
ture in preference to the incision in perineo, but recommended it in
cases of extreme urgency, and where there is great exhaustion of
vital power, and concluded by protesting against the very unscien-
tific and hazardous practice of forcing an instrument through the
substance of an enlarged prostate when that constitutes an insur-
mountable barrier to the onward progress of a catheter.
He also read a letter from Mr. Cock, approving of the operation
of puncturing the bladder per anum; he leaves the catheter in for a
time; and, if irritation supervene, he passes a gum-elastic catheter
through the canula, which is then withdrawn, whilst the catheter
is retained in its place.

46
March 31, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Mr. Abram exhibited a Stomach perforated by an Ulcer.
He had been called in the night to a maid-servant, aged twenty-
two, of short and stout stature, and not chlorotic, who had for some
time been subject to dyspepsia, the attacks having lately been more
frequent and severe than formerly. She was always more or less con-
stipated; the appetite generally good. The previous evening she had
taken two laxative pills, and eaten heartily of dry haddock for supper.
Two hours after she was in bed she was suddenly seized with
vomiting, accompanied with acute peritonitis. Mr. Abram not
being acquainted with her previous state of health, bled her to
twelve ounces, and prescribed calomel and opium every two hours,
hot fomentations, castor oil, and enemata, from which no evacu-
ation was procured though the pain was somewhat relieved. At
8 A.M. the pain had returned; the pulse was 120, the tongue moist,
the abdomen tympanitic; no hiccup, sickness, or nausea present.
Venesection was again attempted, but unsuccessfully; twelve
leeches were therefore applied. She died at six P.M.
The body was examined one hour after death. The abdomen
was distended with fluid, on which floated the castor oil; the peri-
toneum was extensively inflamed, and there were firm adhesions
gluing the stomach to the liver and adjacent viscera. No further
examination was allowed. The perforation in the stomach was
small and perfectly circular, as if punched out.
Dr. Snow read a paper on the fatal cases of Inhalation of Chlo-
roform.
He considered that no deaths had resulted from the use of ether,
unless, perhaps, one that occurred in France, and in that case the
accident was probably due in a great measure to defective admis-
sion of air. Chloroform is much more powerful than ether, and
this has been the chief cause of the accidents which have hap-
pened. The author detailed some calculations of the quantity of
chloroform contained in the blood in the different stages of insensi-
bility, and of the quantity that would cause death, and also of the
quantity of vapour that might be present in the lungs at one time,
the result of which calculations tended to show, that unless care were
taken to dilute the vapour of chloroform largely with air, there
might be so much of it in the lungs when the inhalation was left
off, as would cause death by being absorbed, and added to that
already contained in the blood. A handkerchief does not afford
the means of regulating the proportion of vapour in the air breathed
by the patient, and nearly all the fatal cases that have occurred
must be attributed to this employment of the handkerchief in
administering so powerful an agent as chloroform. When animals

47
are allowed to continue breathing air, containing vapour of chloro-
form, after they are completely insensible, they shortly cease to
breathe, but if there is not more than about five per cent. of vapour
in the air they were breathing, the heart continues to pulsate for
some time, and the circulation ceases only on account of the absence
of respiration; but if about ten per cent. or upwards of vapour of
chloroform is present, the respiration and circulation cease about
the same time, in consequence of the quantity of vapour present in
the lungs at the time the respiration ceased, being sufficient, when
absorbed and added to that already in the blood, to paralyze the
action of the heart. Under these circumstances artificial re-
spiration can be of no avail; and there is reason to believe that
these are the circumstances under which chloroform has been fatal
to the human subject.
The author then detailed the particulars of the fatal cases, which
he considered to be seven in number. He was of opinion that
these accidents might in every case be avoided by proceeding care-
fully, and by employing an inhaler which admits of the regulation
of the quantity of air to dilute the vapour.
At the conclusion of the paper Dr. Snow performed two expe-
riments, to show the difference of the action of chloroform according
to the quantity of air with which the vapour is diluted. In the
first experiment twelve grains of chloroform were diffused through
the air in a glass jar holding 100 cubic inches, and a linnet was
put in, which in half a minute was dead. In the other experi-
ment the same quantity of chloroform was mixed with the air in a
jar holding 600 cubic inches, and another linnet was introduced: it
became gradually insensible, and was taken out at the end of about
three minutes, and recovered in two or three minutes after its
removal.
April 7, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Mr. Canton placed on the table a Hydrocephalic Foetus, born at
the ninth month, after thirty-one hours of labour, the breech pre-
senting. It was the first child. From the appearance of the eyes,
nose, and mouth, it was supposed that there had been an arrest of
development at the third month, although there had been no arrest
of growth. The case was attended by Mr. Savery, of Hastings.
Dr. Webster read a paper, entitled, "Observations on the Health
of the Metropolis during last winter, compared with similar months
of the previous year."
Having adverted to the recent sanitary movement, which must
in time produce beneficial consequences, Dr. Webster observed,

48
that, so far from the fears entertained by timid persons, and even by
public functionaries, that the public health would materially suffer
by the re-appearance of epidemic cholera, the aggregate number of
deaths from all causes had considerably diminished throughout
London during the last six months, in comparison with the same
period of the previous year, particularly in regard to diseases of
the respiratory organs, usually so prevalent and fatal in this
country during winter and cold weather. In proof of this opinion,
notwithstanding the extraordinary severity of scarlatina, and the
presence of cholera, the gross mortality from all diseases met with
in London, during the last six months ending the 31st of March,
was 30,263; whereas, during the parallel six months of the previous
winter, the total amount rose to 36,060 deaths, being an excess of
5797 fatal cases of disease, or 18.82 per cent. in favour of the cur-
rent season. In regard to this important point, the author observed,
that the greatest difference occurred in diseases of the organs of
respiration, by which, including influenza, in the winter of 1847
and 1848 the deaths were 11,197; whilst during the same six
months, ending the 21st of March of the current year, only 5127
persons died from similar causes, being less than half the former
amount, or an excess of 118.39 per cent. more deaths under this
head in the previous than in the winter just terminated. The author
then alluded to some of the pectoral diseases, and stated, amongst
other interesting facts, that 1965 persons had died from pneumonia
this season, instead of 3159 the previous, thus giving an excess of
60.76 per cent. By bronchitis, 2047 died the last six months,
whilst the number was 2984 in the former period, being 45.77 per
cent. more than recently. Again: 3040 died from consumption
this season, against 3740 in the winter of 1847 and 1848, being
nearly one quarter of the deaths greater from the same disease than
in the present year. By influenza only 78 deaths occurred, in
place of the unusually great mortality of 1739, registered during
the former season. By measles, 391 persons died, instead of 1346,
which thus caused two and a half times more deaths in the previous
winter, than the one just terminated. Scarlatina formed, how-
ever, a very marked exception, in respect of its great virulence
and mortality, having proved far more fatal last winter than
for many years. It was, in fact, the chief epidemic of the season;
2546 individuals, principally under fifteen years of age, having
died from that virulent disease during the six months ending the
31st of March last, instead of 1362 during the parallel period of the
previous year, although the mortality from the same cause was also
then greater than ordinary. By typhus the deaths were fortunately
less this year than last, 1585 having died from that disease during
the present winter, in place of 2201 the previous, thus making an
excess of 38.86 per hundred more in the last than in the present
season.
The above fact respecting the great diminution in the mortality
of typhus, the author considered both important and instructive,

49
whilst he thought the greater or less prevalence of that form of
continued fever amongst the population of a country might be
viewed as a very fair indicator of their physical condition; or, as
Dr. Webster stated, in other words, that typhus constitutes, as it
were, a good noso-meter of the high or low health at the time
prevalent amongst a community.
The author subsequently alluded to bowel complaints, respecting
which class of maladies he remarked, contrary, perhaps, to expecta-
tion, that notwithstanding the existence of cholera, and the preva-
lent tendency to affections of the bowels, diarrhoea and dysentery
had actually proved less fatal during the last six months than in
the same period of the previous year. In proof of this opinion he
stated, that in the six months ending the 31st of March, 1849, the
deaths in London, by diarrhoea, were 554, instead of 644 in the
same months of the year before; whilst by dysentery, 135 then
died, in place of 116 recently. This contrast is curious, seeing
that cholera has prevailed more extensively than usual in the
metropolis, 984 persons having died in London by that epidemic
during the last six months, whereas only twenty-one deaths from
the same cause are recorded in the previous winter. The author
then observed, that great as the above amount of deaths by cholera
may appear, it is not by any means so considerable as the mortality
met with in the spring of 1832, when this malady also prevailed in
London epidemically. For instance, in the month of March and
the first week of April of the year above mentioned, as many
persons died from cholera in the metropolis, during these five
weeks, as throughout the entire six months ending the 31st of
March, 1849, according to the official report of the Registrar
General. Having now almost ceased to exist as an epidemic in
London, since only four deaths have been recorded by cholera
during the week terminating last Saturday, the 31st of March, Dr.
Webster believed little apprehension need be now entertained;
although likely, as in the year 1832, the disease may again become
common next summer, or in the autumn, when cholera usually
prevails in this country, but, for the most part, the disease then
prevalent is generally of a mild and less fatal description than the
type it exhibited last winter, or previously.
From the various data detailed to the Society, notwithstanding
the recent prevalence of cholera, and the unusually great mortality
by scarlatina, the author considered London had not become by
any means unhealthy, nor had last winter proved insalubrious, if
compared with previous seasons, especially with those of 1847 and
1848, when almost every class of disease was both more prevalent
and fatal than at any former period, even, he thought, since the
time that the plague was epidemic in the metropolis.
Dr. Webster subsequently discussed the diathesis generally
exhibited by the diseases he had now cursorily passed under
review. Speaking generally, from his own observation, as likewise
from the information of other physicians, the author believed that

50
almost every complaint recently met with assumed an asthenic
character-if not on the first supervention of disease, at least soon
afterwards; and even in those instances of acute complaints which
are in appearance, or even really, inflammatory, they very often
soon exhibited symptoms of great debility and exhaustion-similar,
in fact, to the peculiar type noticed when the influenza was so
prevalent last year in the metropolis, and in many parts of England.
Scarlatina, measles, and diseases of the respiratory organs, come all
within this category, and required, according to the author's ex-
perience, very different modes of management to the measures
formerly found beneficial by most medical practitioners.
This marked tendency of nearly every form of disease, not only
during the last, but even previous seasons, to assume an anti-
inflammatory character, merits special notice on the present occasion,
as the treatment best adapted under such circumstances is thereby
materially influenced.
Respecting cholera and typhus the author said that there could
merely be two opinions on the subject, as both diseases almost in-
variably exhibited asthenic symptoms of the most marked descrip-
tion. The same feature was also observed in scarlatina, and deserves
even more notice from the fact that during former epidemics of this
malady, much arterial excitement and decided inflammatory
symptoms were then of common occurrence. Recently, however,
the case has been quite otherwise; and frequently this fatal
eruptive complaint assumed an asthenic type, even from the very
commencement. Great debility and depression likewise charac-
terized diseases affecting the organs of respiration, and judging
from the cases which came under the author's observation, he
stated, that, unlike examples of the same kind of maladies formerly
observed, which were then really inflammatory, recently the great
majority of diseases assumed quite an opposite character, and often
required very different modes of management.
Dr. Webster then adverted generally to the remedies employed,
and the various methods of cure recently adopted, which, he said,
were generally tonic and stimulating. Exceptions might occur to
this rule, but they were rare, even in those diseases of the chest
which formerly required antiphlogistic treatment. The abstraction
of blood appeared seldom, if ever, necessary, it being now as un-
common to bleed any patient as formerly it was the reverse.
Indeed, the lancet, like the sword of the soldier in the time of
peace, might be considered as laid up in ordinary. The author
subsequently discussed the treatment pursued in the several diseases
alluded to in his paper, which it is unnecessary now to particularize
at any length, as the plans adopted seemed generally based upon
the symptoms manifested, and the principles now enunciated. It
may, however, be interesting to mention, that mercury in small
and alterative doses, conium, or even opium with ipecacuanha or
antimonials, diuretics, and mild aperients, when required, constituted
the chief internal remedies in the early stages, which were, in many

51
instances, followed by ammonia, quinine, and even occasionally wine
and brandy. Mustard poultices and blisters to the chest proved
also often beneficial, whilst the strength of the patient was sup-
ported by light nutritious food, such as warm beef-tea, mutton-
broth with arrowroot, and the like articles of diet, at the same
time that warmth was applied to the extremities.
In concluding the communication read to the Society, Dr.
Webster observed, that although scarlatina was really one of the
most prominent and serious epidemics prevalent during the last six
months, whereby nearly three times as many persons were carried
off as by cholera, still the latter malady occupied by far the most
public attention. With respect, however, to the management of
scarlatina, the author said it differed essentially from the method
other practitioners, like himself, had formerly found it expedient to
employ in that malady. In previous epidemics of this eruptive
disease, it was frequently necessary to resort to antiphlogistic
measures, low diet, active purging, and even to bloodletting, either
from the arm, or by leeches. During the recent epidemic in
London, however, so far from depletion being required, or admis-
sible, it was often found advisable to commence supporting the
system very early in the complaint; to give tonics, ammonia, wine,
and sometimes even brandy, where the symptoms, apparently, but
not actually, seemed inflammatory; debility, depression, and a
great want of tone in the system, being generally characteristic of
the malady, whilst the remedies best adapted under such circum-
stances were of the above description. Fortunately, this severe
complaint has recently considerably abated in virulence; and
although still above the average of previous seasons, the consequent
mortality is by no means now so great as it was about the latter
part of the last and the early portion of the current year.
ever, at whatever period the present epidemic scarlatina may
terminate, medical practitioners will not fail to remember its great
prevalence, rapid progress, marked symptoms of debility, and its
unusually fatal character; as, likewise, the tonic stimulating plan of
treatment, which the disease almost invariably required.
How-
April 14, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Dr. Cormack exhibited a left Kidney, taken from the body of a
male child, aged seven years and ten months, who had laboured
under Scarlatinous Anarsarca, and whose death occurred on the
fiftieth day from the attack of Scarlet Fever.
The urine had been intensely albuminous, and was, on one occa-
sion, suppressed for seventy hours. Some days before death, pus
was found in the urine. The left kidney contained a well-defined

52
circumscribed cavity at the lower part, which would admit of a
large hazel-nut; there was also a smaller cavity of the size of a small
pea, communicating with the other. Both cavities were chiefly
filled by dirtyish white matter, somewhat resembling cerebral
matter in a state of softening. Along with this, in the passage
between the cavities, and in the pelvis of the kidney, there was
fluid pus.
The dirtyish white matter examined under the micro-
scope was found to contain much epithelial debris. The whole
kidney was much diseased. The cortical substance was pale,
anæmic, shrunken, and horny, and the pyramids (as contrasted with
the surrounding tissues) looked red and turgid. This case is given
at length in the "London Journal of Medicine," May, 1849.
Dr. A. P. Stewart exhibited a greatly enlarged and flabby heart,
with an unusually extensive deposit of false membrane under the
endocardium of the left ventricle. There were also several dense
and cartilage-like, but not bulky vegetations, on and near the free
border of the mitral valve, which, however, completely closed the
auriculo-ventricular opening. The deposit, which was opaque, and
more than a line in thickness, covered the one-half of the interior
of the ventricle, being about three inches in length, and two and a
half in breadth. Two or three similar patches of small size were
seen on the outer surface of the heart. The patient had never had
rheumatism, and though above seventy years of age, had enjoyed
remarkably good health till the middle of last November. From
that time she was subject to bronchitis, with distressing cough and
dyspnoea, amounting, during the last six weeks of her life, to ortho-
pnoea. Colour peculiarly sallow, and expression habitually anxious.
From the indistinctness of the sound of the heart, especially the
second, from the absence of impulse, and from the existence of very
marked and circumscribed dulness over a conical space rather
larger than a man's hand, extending upwards from the xiphoid
cartilage, and rather more to the left than to the right of the
sternum, Dr. Stewart was led at first to suspect hydropericar-
dium. All around this dull region, and over the whole back of
the chest, respiration was heard mingled with sibillant and sonorous
rhonchi. During the last fortnight of life, when the oppression
was greatest, no examination was made, owing to the repugnance
manifested by the patient. She died suddenly while being shifted
in bed.
The whole amount of fluid in the pericardium did not exceed two
ounces. The quantity of clear serum in the pleural sac was so large,
as to have greatly encroached on the right lung, and to have com-
pressed the left into a flesh-like mass, completely exhausted of air,
and not larger than the middle lobe of the opposite lung. Dropsical
effusion went and came, during life, in the hands, and loose areolar
tissue around the eyes, and existed, to a large extent, in the abdomen
and lower extremities. The urine coagulated freely on the applica-
tion of heat. The substance of the kidneys was remarkable only

53
for its healthy appearance. The supra-renal capsules, however,
were much diseased.
Mr. O'Connor exhibited a specimen of perforation of the stomach.
It had been removed from the body of a girl who was seized with
great pain in the abdomen, and with vomiting twenty-five hours
before death. She had enjoyed good health, but four months
previously had suffered from pyrosis. Two ulcers were detected
near the pyloric orifice of the stomach.
Dr. Garrod read a paper on the Pathological Condition of the
Blood in Cholera. The author divided his communication into two
parts-in the first he spoke of the investigations which had been
made previously to the present year, and gave the results arrived
at by Dr. O'Shaughnessy, Dr. Thomson, of Glasgow, and Dr.
Clanny, in this country, and by MM. Rose and Wittstock, Lecanu,
and others, on the Continent. In the second part, he detailed the
post-mortem appearances, together with the examinations of the
blood and evacuations in those cases which had fallen under his
notice during the present epidemic. These, he observed, had been
limited in number, and the analyses attended with many difficulties,
from the fact that the blood taken after death had frequently to be
used for the purpose. After stating the various analyses, he gave
the following epitome of the different results.
Physical condition of cholera blood.-The blood was always found
more tenacious than in health, of a darker colour, and with less dis-
position to coagulate; its specific gravity also greatly increased-
viz., 1,068, 1,074, 1,076, 1,076, (the specific gravity in health
being about 1,062,) and 1,081 in adults; in children, also, it was
very high.
Water and solids.-The water was always found much less in
quantity than in health, and the solid portion increased in like pro-
portion.
Blood-globules.-These were found to be increased in amount.
Fibrin.-In many cases, this principle was not able to be deter-
mined, from its having lost the power of coagulation: when it was
separated by whipping, it was found not to be diminished in amount.
although deficient in tenacity.
Constituents of the serum.-When this fluid could be separated
from the cruor, it was found to have a specific gravity much greater
than in health. In two instances it had a specific gravity of 1,038
and 1,041, (healthy serum averaging 1,028.)
Albumen.-This principle was always in large excess, and to this
was due, in a great measure, the increased weight of the serum.
Salts of the serum and blood.-With regard to the amount of the
saline portion of the blood in cholera, the results arrived at by Dr.
Garrod differed considerably from those obtained by Dr. O'Shaugh-
nessy; and in place of finding a deficiency, they appeared, in many
cases, to exist in increased quantities. In several cases, the numbers
representing the amount in 1000 parts of blood, were as follow:-
F

54
10.7, 7.54, 7.50, 6.15, 6.02, and 5.72 parts, the mean proportion in
healthy blood being about 6.0 parts. In like manner the soluble
salts of the serum were found to be increased. Dr. Garrod noticed,
that in the blood of two children who had died of cholera, the salts
were in very large amount. Both the serum and blood were at
times found neutral, or even acid in reaction. The neutral condi-
tion before noticed by Dr. O'Shaughnessy was ascribed by him to
a loss of the soluble salts, especially the carbonate of soda; that such,
however, was not the true explanation, was demonstrated by the
fact of Dr. Garrod having found that the ash of an acid blood gave
an alkaline reaction as strongly marked as that obtained from healthy
blood, and that the amount of the soluble salts was not diminished.
Urea. This substance was often found in the blood in cholera,
and in many cases it might have existed in quantities larger than
in health, and yet escaped detection. In general, it was found to
exist in increased quantities, and the amount of this increase
depended much on the state of the patient at the time the blood was
obtained, or on the stage of the disease in which the individual died;
thus, in the stage of collapse it was found in but small amount; when
partial reaction had taken place, and had continued for a time, then
it was increased; and in the consecutive febrile stage its excess
became very great. Dr. Garrod explained this by supposing that
in the intense collapsed stage, the formation of urea became sus-
pended, as well as its excretion by the kidneys, thus accounting for
its amount being then but little augmented; but when reaction,
febrile or otherwise, took place, then the formation of this principle
ensued, and often the excretory power of the kidneys was not re-
gained; and hence its accumulation in the blood.
From the results obtained recently, together with those arrived
at in the former epidemic, Dr. Garrod drew the following conclu-
sions-viz.,
1st. That in cholera the physical characters of the blood are
altered, and that its tendency is to become thicker, tar-like, and less
coagulable.
2ndly. That the proportion of water is much diminished.
3rdly. That the specific gravity of the serum is very high, due
to the increase of the solid portion of the serum, and especially to
the albumen; that this fluid also tends to become less alkaline in its
reaction.
4thly. That in cholera the saline constituents of the blood are not
only not decreased in amount, but sometimes exist even in increased
proportions, and that the diminution of the alkaline reaction is not
due to the loss of salts, but to the diminished excretion of acid
matters which are constantly being formed in the system.
5thly. That urea usually exists in increased quantities in cholera-
blood, but that the amount differs considerably in the different stages
of the disease, being but small in quantity in the intense stage of
collapse, increasing during reaction, and in excess when consecutive
febrile symptoms occur.
Dr. Garrod stated, that although our knowledge of the changes

55
which occur in the blood during cholera were confessedly very im-
perfect, yet that sufficient was known on the subject to enable us to
distinguish this disease from any other, and to solve the following
problem:-"Given a specimen of the human blood to determine
whether it was derived from a cholera patient."
Dr. Garrod then showed the bearings of these researches on the
pathology of the disease, and alluded to some points in the treatment.
This paper is published at length in the "London Journal of Medi-
cine," May, 1849.
April 21, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Dr. Sibson made a communication on the Position of the Viscera,
the Configuration of the Body, and the Movements of Respiration
in Chest Disease, based upon, and illustrated by, a series of nearly
forty diagrams, which had been taken from the dead and living
body by himself, by means of a tracing-frame, suggested to him by
Dr. Hodgkin.
These investigations had been the subjects of his researches
during the last twelve years, and his object was to bring them
before the Society in a connected form, as the three subjects, appa-
rently separate, really and naturally combine to form a preliminary
method of examination in ascertaining the presence and nature of
chest-disease.
The following is an abstract of Dr. Sibson's communication:-
"It is self-evident, that the knowledge of the normal is essential to
that of the abnormal. In the healthy man, the important organs
are all so placed in relation to each other and to the parietes, that
there is a common centre, around which they all, as it were, cluster.
That centre is the lower end of the sternum, and the recollection of
it is at once easy and important. Just above the lower end of the
sternum is the lower boundary of the heart, and the lower margin,
coming to an angle, of the right lung; just below the part indicated
is the upper boundary of that portion of the liver which is imme-
diately behind the parietes. A line drawn from the lower end of
the sternum to the right, runs along the lower margin of the right
lung; a line from the same point to the left indicates the lower
boundary of the heart; the liver and stomach being immediately
beneath those lines. The configuration of the chest, happily, indi-
cates the size and outlines of the internal organs, so that they can
be distinguished by the ocular inspection of the body, the bulk and
size of the organs being made apparent by certain prominences, and
their boundaries by certain depressions. The lower margin of the
right lung and the lower boundary of the heart correspond to
depressions passing across the sixth costal cartilages to the right
and left of the lower end of the sternum. The costal cartilages
immediately in front of the heart are more prominent than those
F 2

56
over the middle lobe of the right lung. The ribs over the liver and
stomach to each side are more prominent than those over the right
and left lungs; the hepatic and gastric bulges are thus formed, the
existence of which was first pointed out by Dr. Edwin Harrison.
During inspiration, the position of all the viscera is changed, the
diaphragm, in its descent, drawing downwards the base of each lung
and the lower boundary of the heart, and pushing downwards the
liver, spleen, stomach, and, indeed, all the abdominal and pelvic
organs. At the same time, the costal area of the chest everywhere
enlarges. During a tranquil inspiration, the superior ribs, which
perform thoracic respiration, move forward from two to six-hun-
dredths of an inch, while the abdomen advances about three-tenths
of an inch, indicating diaphragmatic respiration; at the same time,
the lower or floating ribs move outwards about one-tenth of an
inch, their motion being greater than that of the superior ribs.
Their action is to expand the lower part of each lung simul-
taneously with the descent of the diaphragm, and they are truly
diaphragmatic ribs. During a deep inspiration, the descent of the
diaphragm and the advance of the whole of the front of the chest
and abdomen is about one inch; consequently, while the thoracic
respiration is increased twentyfold, the diaphragmatic is only
increased threefold. The base of each lung and the lower boundary
of the heart are about an inch lower, when the diaphragm is at the
lowest; at the end of a deep inspiration, the liver, stomach, and
spleen are pushed down to a like extent. To observe the respi-
ratory movements with greater nicety, Dr. Sibson devised the
chest-measurer, an account of which is contained in the last volume
of the "Medico-Chirurgical Transactions." If the organs be in the
position, and the chest be of the configuration indicated, and if the
respiratory movements be symmetrical and normal in extent, we
have the assurance, so satisfactory both to the medical man and the
patient, that there is no organic disease of the heart and lungs.
This important information can usually be gained with sufficient
accuracy by means of ocular inspection and percussion, by the
application of the hand during respiration, and, if needful, by the
use of the chest-measurer. When the stomach and intestines are
much swollen with flatus, they push up the diaphragm, and com-
press the lungs and heart upwards into the chest. The lower
boundary of the heart and the lower margins of the lungs are un-
usually high, being, in cases of extreme distention, about an inch
higher than usual. The form of the chest and abdomen is changed
in proportion to the distention, the abdomen being full, rounded,
and tense, while the chest is flattened in front, and widened side-
In cases of the class referred to, a chain of morbid sensa-
ways.
tions in the chest is often referred by the patient to disease in the
chest itself, though it is really due to the abdominal distention;
both dyspnoea and palpitation caused by the physical compression
upwards of the heart and lungs; and in the train of symptoms,
headach, dizziness, and even unconsciousness are often occasioned by
the difficulty with which the blood returns from the head to the

57
right side of the heart. If the stomach and intestines be unusually
empty, the diaphragm, instead of being raised, is lowered, and the
lungs and heart, instead of being compressed upwards and short-
ened, are lowered at their base and lengthened. In bronchitis, and
vesicular emphysema, the lungs and the heart, especially its right
cavities, are enlarged. In extreme cases they are larger, and their
lower boundaries are lower than they are in health during the
deepest possible inspiration; these boundaries being in some cases
from an inch to an inch and a half lower than they are in health.
The whole diaphragm being lowered, the liver, stomach, and spleen,
and indeed all the abdominal viscera, are correspondingly low in
their position. The configuration of the chest is at the same time
correspondingly changed. The enlarged condition of the lungs and
heart is indicated by the marked and barrel-like roundness and ful-
ness of the chest, especially at its upper part; for while that part is
prominent, the lower end of the sternum and the upper part of the
abdomen are unusually hollow. In the emphysema of boyhood,
the sternum is most prominent some little way above the lower end;
in that of manhood, the greatest projection is at the junction of the
two bones of the sternum; while in that of old age, the lower end
of the sternum and the xiphoid cartilage are the projecting parts.
The respiration of persons affected with emphysema is very cha-
racteristic; they are already, as it were, almost at the top of their
breath, and they breathe with labour. The motion of the upper
part of the chest is usually somewhat increased, but the lower end
of the sternum, and the adjoining cartilages, instead of advancing,
actually fall back. The same remarkable phenomenon is observed
in cases requiring tracheotomy, when the obstruction to respiration
in the larynx is extreme; in one case of that class, the whole of the
walls of the chest fell backwards, instead of advancing during
inspiration, at the same time that the abdominal motion was
unusually marked. The cause of this falling back of the walls of
the chest, during inspiration, is evident; the diaphragm, by its
descent, lengthens the lung, and, as air can only enter the air-cells
with difficulty, the lung collapses, and the costal walls over them
collapse also, being forced backwards by atmospheric pressure. In
extreme laryngitis, as in emphysema, the lungs are lengthened,
owing to the action of the diaphragm; but while the lungs are
amplified in emphysema, they are narrowed in laryngitis, and the
chest is consequently lengthened, flattened, and narrowed; at the
same time, the heart, being denuded of lung in front, comes into
extensive contact with the walls of the chest, and the heart's im-
pulse is therefore felt extensively; whereas, in emphysema, it is
only to be perceived behind and below the xiphoid cartilage.
When much fluid is effused into one side of the chest, (as has been
observed and well described by several authors,) the fluid neces-
sarily compresses the lung on the affected side, and all the neigh-
bouring organs are pressed aside from their usual position. If the
effusion be on the left side, the heart is displaced to the right of
the sternum, and the stomach, spleen, and liver, are displaced

58
downwards and to the right; at the same time, the ribs are pushed
outwards and separated farther from each other by the contained
fluid; consequently, the whole of the affected side is enlarged. The
respiratory movements are remarkably affected; while those of the
whole of the healthy side are exaggerated, those of the affected side
are either lessened, arrested, or reversed. When the effusion dis-
appears, it is interesting to notice the progressive return of the
viscera towards their normal position, as instanced in a case which
Dr. Sibson had seen with Dr. Hodgkin and Dr. Aldis. If, while
the fluid disappears, the lung does not regain its power of expan-
sion, but remains permanently condensed, the displaced organs will
return beyond their former position, and in part occupy the place
previously occupied by the condensed organ; consequently, the
margin of the healthy lung and the heart will be drawn abnormally
to the affected side, and the abdominal organs will rise unusually
high into that side of the chest; at the same time, while the oppo-
site side is enlarged, the affected side is narrowed and flattened.
The respiratory movements are at the same time restrained or
annihilated on the affected, while they are exaggerated on the
healthy side. If the upper lobe be the seat of tuberculous cavities,
while the lower lobe is comparatively healthy, the position of the
viscera is not materially changed; but the ribs over the affected
part are flattened, and their respiratory motion is diminished. If
the lower lobe be the seat of pneumonia, while the other parts are
healthy, the affected lobe is permanently enlarged; the thoracic
organs are not materially displaced; the walls of the chest on the
affected side are somewhat fuller than usual; and the respiratory
movements of the ribs, especially the diaphragmatic or lower ribs,
and of the abdomen on the affected side, are restrained, while those
of the whole opposite side are exaggerated.
"Dr. Sibson concluded his communication by indicating the
position of the viscera, the form of the chest, and the movements of
respiration in pericarditis; enlarged heart, without pericardial
adhesions; and enlarged heart with pericardial adhesions. He
afterwards exhibited before the Society two men, one healthy, the
other affected with tubercular disease of the whole left lung. In
the former, the position of the viscera, the form of the chest, and
the movements of respiration, were symmetrical and normal. In
the latter, (kindly brought forward by Dr. Burslem,) the inner
margin of the right lung encroached on the affected side, being
considerably to the left of the sternum; the whole of the left side
was narrowed and flattened, while the right side was unusually
developed; and the respiratory movements, both thoracic and
abdominal, of the whole of the affected side, were almost anni-
hilated, while those of the opposite side were, throughout, exagge-
rated. The respiratory movements in both of these cases were
observed by means of the chest-measurer."

59
April 28, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Mr. Henry Smith related a case of Acute Inflammation of the
Prostate, from injection of nitrate of silver.
W. C, ætat. 28, applied to him on the 4th, suffering from
extreme pain about the bladder, and very frequently passing a few
drops of urine, followed by great pain. About three weeks pre-
viously he had had gonorrhoea, for which he took medicine, and
afterwards used an injection of nitrate of silver, which stopped the
discharge, and caused intense pain and bloody urine. These symp-
toms had gradually increased until the present time, when Mr.
Smith, conceiving that there was merely some irritation or inflam-
mation about the neck of the bladder, ordered hot fomentations to
the part, and prescribed calomel and opium, and a draught contain-
ing copaiba, hyosciamus, and liquor potassæ, every four hours. As
no improvement followed, a closer examination was made, and the
prostate gland was found to be much enlarged, very tense, and
painful when touched. The patient was sent home to bed, and
leeches were applied, and calomel and opium given, the latter by
the mouth, as well as in the shape of a suppository by the rectum.
This produced relief of all the symptoms, and in a few days the
patient was enabled to attend to his business again.
The case was related with the view of showing how cautious
medical men should be in the use of injections of nitrate of silver.
The author did not deny the virtues of nitrate of silver as a means
of cure in gonorrhoea, but thought that great caution in its use is
necessary.
Dr. Tilt read a paper on Subacute Inflammation of the Ovaries
and Fallopian Tubes, as a cause of Sterility.
After dividing the causes of sterility into three-viz., those
which are self-evident, those which are disputable, and those which
are of a mysterious nature, the author drew the attention of the
Society to subacute ovaritis, as a frequent cause of sterility. He
commenced by establishing the paramount importance of the ovaries
in the hierarchy of our organs, showing that the anatomical phe-
nomena of ovulation are identical with those termed inflammatory,
and thus lead us to believe that, in morbid ovulation, the healthy
process may pass into the inflammatory, and furnish a satisfactory
explanation of the increase of pain and of heat in the ovarian
regions-symptoms so frequently met with in difficult menstruation.
He considered that subacute inflammation of the ovaries might
produce all those symptoms which are called by the common name
of dysmenorrhoea, although they depend on the disorder of different
organs. He also admitted that the symptoms of subacute ovaritis
might vary according to the nature of the patient's constitution,
producing hysterical symptoms in nervous and highly-excitable

60
females, and morbid products and sterility in those of a strumous
constitution.
The author then proved, by the testimony of authors, that
ovarian lesions often occur which cannot be accounted for, and as
these lesions are admitted by all to be the products of inflammation,
he drew, as an evident conclusion, that the ovaries and their peri-
toneal covering are frequently subjected to inflammation, though
not recognised as such during the patient's life, nor treated accord-
ingly. He admitted that, in some instances, all the symptoms of
Dysmenorrhoea are produced by subacute ovaritis, while in others,
as has been well established by Dr. Oldham, ovaritis determines
dysmenorrhoea by the inflammatory congestion of the ovaries to
which it gives rise, but he did not agree with Dr. Rigby that mem-
braniform exudations on the catamenia are always the proof of ova-
ritis. The author next observed, that dysmenorrhoea and sterility
being admitted as concomitant facts, depending on each other, or
on the same cause, he had a right to infer that subacute ovaritis is
a cause of sterility, and that this imperfection is the result-
1, Of morbid lesions of the stroma, or of the vesicles of the ovula
therein contained;
2, Of a false membranous deposit lining the ovaries so as to
preclude the exit of the ovula.
Of lesions in the tube destined to convey the ovules to their
uterine abode, he stated that sterility is sometimes produced by
the uterine extremities of the Fallopian tubes being blocked up by
a glutinous deposit, and asked whether there is any possibility of
doing for these organs what Mackintosh and Simpson have done in
similar cases of temporary occlusion of the neck of the womb. He
remarked, that as our knowledge of the physiology of the ovaries
is very recent, we need not be surprised if the pathology also is
in an embryotic state.
The author concluded by giving three cases in which the
diagnosis of the disease was fully confirmed by an accurate exami-
nation of the patient through the rectum, and in which the treat-
ment recommended brought on the cessation of sterility after it had
lasted five, six, and seven years. The remedial measures were
leeches, blisters, mercurial ointment combined with narcotic ex-
tracts and camphor, and medicated enemata.
This paper is published at length in the "London Journal of
Medicine," June, 1849.
Extra Meeting, May 5, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Dr. Tyler Smith exhibited an instrument that he had invented
for deobstructing the Fallopian tubes in cases of sterility, arising
from their obstruction or occlusion at the uterine extremities by
thickened mucus, or other impediments.

61
The instrument, in the use of which the speculum is always re-
quired, consists of a small silver catheter, bent like the uterine
sound, to adapt it to the curve formed by the uterus and vagina, and
having a sudden lateral curve at the distal extremity, to the right
hand, or to the left, so as to point, when in situ, to the uterine
mouth of the Fallopian canal, which it is proposed to examine.
Through the catheter, a fine flexible, whalebone bougie is passed
into the Fallopian tube. When the small bougie is thus passed so
as to project at its Fallopian extremity, the instrument represents
accurately the singular direction taken by the generative canal,
from the mouth of the vagina to the fimbriated extremity of the
tube. This novel operation proposes to bring an important organ
under treatment, which has hitherto been removed from all inter-
ference, but is one requiring extreme caution in its employment.
Mr. William G. Hunter exhibited a specimen of Aneurism of the
Thoracic Aorta, taken from a coalheaver, aged about forty-three,
who had always enjoyed good health, with the exception of occa-
sional attacks of gout.
On the morning of his death, he complained of pain in his chest,
accompanied with indescribable uneasiness; still he continued at
his work. His fellow-workmen left him, and returning a few
minutes afterwards, found him dead. He was brought immediately
to the Charing-Cross Hospital.
At a post-mortem examination, twenty-seven hours after death,
the left pleural cavity was found filled with coagulated blood, com-
pressing the left lung, which was very emphysematous. The
aorta, from its origin to the diaphragmatic opening, was studded
with atheromatous deposits; and opposite the fifth vertebra an aneu-
rismal pouch, about the size of an orange, projected into the left
pleural space, and as an offset from the aneurism was a sacculus
about as large as a walnut, which had given way by a vent from
half to three-quarters of an inch in extent. The edges of the
aperture were jagged. The opening by which the aneurism com-
municated with the aorta was circular, and about an inch and a
quarter in circumference, with a round and smooth margin.
The heart was larger than natural, firm in consistence, and its
left ventricle much hypertrophied, with the fibres of a darkish red
colour; the valves were perfectly healthy. The abdominal viscera
were entirely free from disease.
Mr. Wing related a case of Tic-Douloureux, of a very obstinate
character, occurring in a gentleman forty-two years of age, of a
vigorous constitution and temperate habits, but who, during sixteen
years, had overwrought the energies of both mind and body, being
employed incessantly, and especially at night, in connexion with a
leading daily paper. He came under Mr. Wing's care in the begin-
ning of February last, having suffered for upwards of twelve months
with most distressing neuralgic pains of the face and back part of
the head, implicating chiefly branches of the fifth pair and the

62
portio dura, and the suboccipital nerves. None of the remedies
employed had been of any real service; not even quinine, which
had been largely employed for many months. At this time he was
completely shattered; the mind was evidently losing its power,
memory was failing, and attention to objects and his duties was
painfully weakened; he was sinking under the apprehension of a
speedy dissolution. Indeed, the brain appeared to be in that con-
dition which leads to imbecility and paralysis. His pulse was 54,
and labouring; the tongue coated; the skin natural; the urine
plentiful, sometimes thick; the bowels generally regular; the appe-
tite defective; the countenance sallow and anxious; his nights
were restless, or rather restless at those hours when he was enabled
to retire to his bed. For upwards of twenty years he had been
subject to a peculiar compressive pain in the head on the approach
of thunder. The thoracic and abdominal viscera were healthy.
Counter-irritants were employed behind each ear, and the follow-
ing ointment applied over the affected parts night and morning,
veratria, thirty-six grains, spermaceti ointment, half an ounce;
though it produced no eruption, it gave immediate relief to the nose
and forehead. A purgative of jalap, calomel, and ginger was
administered, which acted freely; and seeing that the affection was
not one of periodicity, and looking at the languid state of the circu-
lation, Mr. Wing ordered him the following mixture:-
B
Tincturæ valerianæ ammoniat., f. ss.
Confect. aromaticæ, 3j.
Aquæ mentha piperitidis, f. 3vss.
Two table spoonfuls to be taken three times a day; a nutritious
diet; wine, and subsequently bitter ale, and the shower-bath were
prescribed. In ten days his hours of rest became quiet, and he
soon perfectly recovered his health. No mercury was given beyond
the dose of calomel.
Mr. Wing drew attention to the following facts:-1st. The
speedy relief afforded by the counter-irritants, in a case of so pro-
tracted a nature, and involving so weakened and disordered a state
both of the bodily and mental powers. 2ndly, The beneficial effects
of the diffusible stimulant combined with a cordial, and the utter
uselessness of quinine. 3rdly, The rapidity with which amendment
took place on the relief of the agonizing and depressing pain to
which he had been so long subjected.
The neuralgia did not arise from any overcrowding or disease of
the teeth.
Mr. Henry Smith read a paper on the Seat of Stricture in the
Urethra, and on the treatment to be adopted in some forms of that
disease.
He showed that it is a generally entertained notion, and one
inculcated in the works of most writers on Stricture, that the seat
of this affection is most commonly the membranous portion of the
canal; but he had been led to believe that there is some error in this

63
opinion, and for the purpose of ascertaining or disproving its cor-
rectness, he had made some investigations, and had looked over a
number of morbid specimens of Stricture of the Urethra, which
were preserved in the various museums of this metropolis. Of
ninety-eight specimens, he found that the seat of stricture was in
the membranous part of the canal only in twenty-one instances, whilst
in seventy-seven the obstruction was in front of the triangular
ligament, in various parts of the urethra, but most frequently at the
bulb, or just in front of it. He considered that he was warranted
in coming to a conclusion, from the examination of these cases, that
the general opinion respecting the seat of stricture is incorrect, and
that it is to be met with much more frequently in the bulb, or just
in front of it, than in the membranous portion of the canal.
An excellent anatomist (Mr. Hallet) had examined the speci-
mens in the Museum of the College of Surgeons with him, and
agreed with him respecting the seat of the disease. He was also
supported in his view by two celebrated surgeons, and accurate
observers, namely, John Hunter and Sir Astley Cooper, the first of
whom had found stricture most frequently in the bulb, the latter,
just in front of the bulb.
Respecting the causes of stricture, some persons consider that the
use of injections is liable to produce it; but the author could not
understand upon what principle an injection, used properly, and of
moderate strength, can cause a stricture. He believed that a proper
use of injections rather tends to prevent stricture, as they no doubt
overcome the chronic inflammation of the canal, which is the origin
of the disease.
He believed that the treatment of some forms of stricture, espe-
cially the painful and irritable, is rendered obstinate and unsatis-
factory by the too frequent introduction of instruments; and in
those cases where the obstruction is recent, and there is a tendency
to hæmorrhage, sufficient caution is not always used by the sur-
geon. Two cases which had occurred in his own practice, and in
which most profuse hæmorrhage ensued upon the introduction of
bougies, indicated the necessity of extreme care in the treatment
of these soft and bleeding strictures.
The author then made some remarks on the treatment of imper-
meable and undilatable strictures, and those accompanied with peri-
næal fistulæ. In such instances, it is necessary to resort to the
operation of urethrotomy; there are two modes of performing it:
the first, by dividing the stricture from within by means of a con-
cealed blade; and the second, by cutting through the perinæum.
The former operation might be useful in cases of stricture near the
orifice of the urethra, and those in the spongy portion, but it is a
dangerous measure to resort to in the cases of stricture situ-
ated at the bend of the urethra, as the surgeon is working in the
dark, and cannot be apprehensive of the mischief he may cause.
The operation of dividing a stricture from without through the
perinæum is that which appeared to him to be the safest and best.
He had lately seen several instances, in the public and private prac-

64
tice of Mr. Fergusson, when the operation had been undertaken
with great success and immense benefit to the patients. The after
treatment is very necessary to be well attended to. The use of the
bougie, or catheter, should be cautiously kept up for some time.
Extra Meeting, May 12, 1849.
FRANCIS HIRD, Esq., President, in the Chair.
Mr. Canton exhibited a preparation of disease of the left side of
the heart.
The patient from whom the specimen was removed was a spare,
delicate female, aged 37 years, who had, a few days previously,
dropped down suddenly and expired. When seven years old, she
suffered from a severe attack of acute rheumatism, and had occa-
sionally since then been affected, on change of weather or exposure
to cold, with pains in one or other of the large joints. Whether
there had been metastasis to the heart in the first attack or not
could not be ascertained.
—
Autopsy. The heart was larger than natural; the right side of
it healthy; the left ventricle was more than thrice its normal
thickness; the mitral valves of great consistence, with narrowing of
the auriculo-ventricular orifice; the semilunar valves were indurated,
stiffened, and puckered, so as to be diminished in their vertical and
transverse directions; their free margins were swollen and slightly
notched. The aorta above the valves, for the extent of an inch
and a half, was irregular on the inner surface from subjacent
deposit of atheromatous and bony matter: a well-marked undulating
line terminated abruptly this diseased appearance, whilst the whole
arch of the aorta was generally thickened, though the lining mem-
brane was healthy.
Dr. Routh exhibited the Kidneys of a Patient, and gave the
following account of the case:-
The patient had been under treatment at the Royal Free Hos-
pital for obstinate vomiting and constipation. He had taken
hydrocyanic acid and castor oil pills without effect, and gradually
became reduced to an extremity of weakness. Dr. Routh saw him
for the first time on the 9th of May. He had had an ulcer in the
thigh, which had healed about the beginning of the present attack.
He had been ailing, more or less, for twelve months, though still
able to follow his occupation as a painter. For twelve years back he
had suffered occasionally from what he called a stricture. He had
never had syphilis, gonorrhoea, or used injections. Sometimes he was
able to pass his water in a full, sometimes only in a scattered stream;
sometimes it would stop suddenly. The urine was sometimes very
dark: indeed, he stated that he had lately occasionally passed blood.
His habits were regular. The present attack began about ten
days ago, with nausea and vomiting with constipation, unrelieved

65
by medicine: his countenance was symptomatic of malignant disease
existing somewhere: his intellect was clear; he had no cough; was
sleepless: the heart's sounds were weak; the pulse was very feeble
and frequent. He was much troubled with hiccough, which came
on in paroxysms of half an hour to an hour, and were brought on
by any exertion in talking or attempt to swallow food. He could
not keep anything on his stomach, either liquid or solid: the
abdomen was soft, and somewhat tympanitic, except in the region
of the transverse and descending colon, where it was harder.
There was no pain in the epigastrium, or in the region of the
kidneys; although about a fortnight since he had complained of
some pain there, which had yielded to a mustard poultice. He was
ordered creosote, dilute Prussic acid, aa, m. iij., to be taken every two
hours in half a fluid ounce of water; a croton-oil pill every six
hours, and to take gruel or arrow root, with wine, by teaspoonfuls
at a time, and frequently. On the 10th, the hiccough was less, but
the sickness no better. He had had no motion: he complained of
great weakness, and was pulseless at the wrist: the heart's sounds
were regular. He was ordered to have wine and ammonia, and to
have a turpentine injection immediately. He became insensible
towards night, and died at 11 P.M., the bowels not having been
relieved.
Post-mortem examination, 33 hours after death. The arachnoid
membrane of the brain contained some fluid in the subarachnoid
tissue, and about half a fluid ounce of clear serum might be con-
tained in all the ventricles together. In other respects, the parts
were healthy-the spleen, liver, pancreas, and lungs were healthy:
the heart healthy, excepting the right auricle, which was exceed-
ingly thin. The cavities of the heart contained large polypi: the
intestines contained some fluid and solid fæces: the jejunum having
its villi very prominent, and somewhat softened. The left kidney was
larger than natural, the capsule tearing off readily and cleanly. On
section, the substance of the kidney was mottled white here and
there, especially in the pyramidal portion, which appeared striated,
and was hard, yet somewhat elastic. Here and there were other
patches of a tubular form, about the thickness of an ordinary quill,
very white, varying in length from two lines to half an inch,
containing granular and calcareous deposits. The right kidney
presented the same general appearances on section. In addition to
the preceding appearances, one or two pouches in the pelvis of the
kidney, somewhat dilated, and a small cavity about the size of a
pea in the substance itself, were observed, containing sanguineo-
purulent fluid. The ureters were healthy: the bladder was con-
tracted, and rather thickened in its coats, and contained about half
a tea-cupfull of clear urine, with a sanguineo-purulent sediment.
In addition, the posterior and inferior surface of the right kidney
was adherent to the psoas muscles, between which and it, and
extending in its breadth as high as the twelfth dorsal vertebra, and as
low as the pectineal line, and a portion superiorly infiltrated in the
muscle itself, was a collection of pus. The vertebræ were healthy:

66
the urine had a feebly alkaline reaction: the opening in the prepuce
was scarcely perceptible; between it and the glans there were a
little clear mucus and blood: no stricture could be detected in the
urethra. The case was important, inasmuch as the urgent
symptoms during life were rather those of intus-susception or
strangulated hernia, than of abscess around the kidney; nor did it
clearly appear how the secondary abscess had been produced, or
should have been so suddenly fatal. The cicatrix of the ulcer in
the thigh was examined, and found to be superficial, nor was any
pus or diseased bone found in the neighbourhood of it.
Dr. Skiers related a case of Imperforate Rectum, successfully
operated upon by M. Amussat.
A female child not passing any meconium, an enema was ad-
ministered, which all returned by the vulva. This singular
occurrence led to a close investigation of the parts, and it was
found that the anus opened, not into the rectum, but into the
vagina, which had thus two external apertures. The anus being
dilated so as to admit of the introduction of a finger, a soft pulpy
sensation was felt high up, which was supposed to be the termina-
tion of the rectum; accordingly it was seized by tenacula, and
gradually drawn down, so as at last to protrude beyond the anus.
Proving to be the rectum, it was now opened, the meconium eva-
cuated, and the cut edges fixed by ligatures to the outside of the
anal opening, so as to preserve a continuous mucous surface com-
pletely through the aperture. The parts healed kindly, the
sphincter ani recovered its natural state of contraction, and in a few
days the fæces were retained properly.
Dr. Skiers said that it had been discussed among the medical men
attending this case, how far the perinæum would yield kindly
during parturition, should the infant grow up.
Dr. Cormack read a paper on Renal Puerperal Convulsions.
He detailed three cases of Puerperal Convulsions which had
recently occurred in his practice, and proceeded to show that
Puerperal Convulsions are generally toxicological results of the
non-elimination of the excrement of the blood, and that in by far
the largest number of cases, this non-elimination depends on renal
congestion, caused by the pressure of the gravid uterus. He
considered that when structural renal disease co-exists with a gravid
uterus, the risk of Puerperal Convulsions amounts almost to a
certainty, as diseased kidneys are liable on slight causes to have
their functions disturbed, and are specially disposed to congestion.
He showed that albuminuria and dropsy are symptoms associated
with Puerperal Convulsions; and independently of pregnancy, are
sure signs of retardation of blood in the emulgent veins. First,
because ligature of these vessels in the lower animal induces rapid
renal congestion and albuminuria; and secondly, because the records
of clinical medicine inform us that this condition of the urine, and
likewise dropsy, are caused by aneurism, enlarged ovary, or any

67
abdominal tumour, producing a similar, even though less perfect,
mechanical impediment to the return of blood from the kidney.
When the urine is albuminous, there is congestion of the kidney:
when the kidney is congested, its emunctory office is inadequately
performed; and whenever the insufficiency of renal depuration of
the blood proceeds beyond a certain point, the blood becomes so
poisonous as to act toxicologically on the brain. This he con-
sidered to be the explanation of the frequency of convulsions coming
on in the course of Bright's disease, when slight causes may at any
time excite such an increase in the congestion as to induce con-
vulsions, stupor, or sudden death.
Dr. Tyler Smith, in the opinion of the author, has handled the
subject of Puerperal Convulsions more philosophically than any
preceding writer; but attributes them far too sweepingly to irrita-
tion of the extremities of the nerves, and attaches too little
importance to direct toxæmic impressions on the nervous centres.
The following quotation is given from Dr. Smith's writings:-
"Irritation of the kidney has been known to excite epilepsy, and
most probably it would act as a cause of Puerperal Convulsions.
Lamotte and others have recorded cases of this kind. It is an old
remark, that oedema of the face and neck forms a frequent pre-
monitory attack; and Dr. Lever has made the interesting and
important observation, that albuminuria is present in many in-
stances. These points," continues Dr. Smith, "require further ex-
amination, with special reference to the different modes in which
spinal action may be excited."
The author believed that Puerperal Convulsions rarely, if ever,
occur in women who are not oedematous to a greater or less extent.
Along with the dropsy there commonly exists an albuminous
condition of the urine. Many women have slight oedema and
albuminuria, and some have both to a considerable extent, and yet
escape convulsions. The frequent coincidence of albuminuria with
Puerperal Convulsions was first stated by Dr. John Lever. He
announced the fact, that in nine out of ten cases in which he had
examined the urine, it was found to be albuminous. Drs. Devilliers
and Regnault, in a valuable memoir on the Dropsy of Pregnant
Women (published during the past and present years in the
Archives Générales de Médecines), declare, as a remarkable and
essential fact, that "chez toutes les femmes éclamptiques, on trouve
de l'albumine dans les urines. Cette régle ne nous a pas encore
paru souffrir d'exceptions." If, then, albuminous urine and ana-
sarca-the characteristic signs of congested kidney-are so common
in Puerperal Convulsions as to be regarded, by the best and most
recent authorities, as their constant concomitants, it may, Dr.
Cormack thought, be inferred that the renal congestion is a common
cause of the convulsions; or, more precisely, that the convulsions
are direct toxicological effects on the nervous centres, produced by
poisonous substances which the unembarrassed kidney could throw
off with the urine, but which the congested kidney cannot excrete.

68
He remarked that in pregnant women blood-poisoning exists far
more commonly than is generally believed, for the gravid uterus,
or other tumour, pressing on the renal veins, or in any way seri-
ously impeding the return of blood from the kidneys, must induce,
more or less, inability, on their part, to perform their emunctory
office, and, when the pressure is great, a consequent condition of
toxæmia. Also, that the maternal blood, during utero-gestation,
notwithstanding the demands made on it by the growth of the
foetus, requires, in some respects, an extra degree of depuration,
and therefore the pregnant woman can ill bear an impediment to
the free return of blood from the kidney, as she probably requires,
for her preservation in health, to throw out an additional amount
of excrementitious matter from the blood, including the elements
of the milk.
Many of the distressing symptoms attendant on pregnancy
may, in the opinion of the author, be considered as resulting from
toxæmia, dependent on defective sanguineous depuration, and treated
accordingly. He did not wish to be understood as saying that
diminished renal elimination is the only cause, for the skin, the
lungs, the liver, or the kidneys, may one and all be at fault; but
from the pressure of the gravid uterus, the latter run the greatest
risk of having their functions impaired. If the kidneys be embar-
rassed from the congestion caused by the gravid uterus, urea will
remain in the blood, and likewise the elements of the milk. The
non-elimination of the lacteal elements is much less dangerous than
the retention of carbonic acid in the lungs, or of the poisonous prin-
ciples of the bile and urine; as the former, being oleaginous, saccha-
rine, and albuminous, are not very dissimilar to the constituents of
the blood. Milk-fever, however, which ought to be regarded as
truly a poison-disease, is sometimes pretty severe, if active deriva-
tive treatment be not adopted.
Dr. Cormack stated, that it generally happens that when the
uterus is emptied, the convulsions cease, and seldom recur after
delivery. When they do recur, we must suspect structural renal
disease. The explanation of this, he apprehends, is not so much
that the uterine irritation is lessened, as that the kidneys are re-
lieved from their hyperæmic condition, and thus become enabled
to resume the proper exercise of their function.
The individuals most commonly the subjects of Puerperal Con-
vulsions he stated to be strong healthy young women, pregnant for
the first time; that is to say, a class of patients in whom the abdo-
minal walls are the most unyielding, and least able to relax under
the pressure of the expanding womb. In proof he quoted the fol-
lowing passages from Dr. Collins-viz., that "Puerperal Convulsions
occur almost invariably in strong plethoric young women with their
first children, more especially in such as are of a coarse, thick make,
with short, thick necks;" and "in thirty cases which occurred
during his mastership, twenty-nine were in women with their first
children."

69
Dr. Cormack then showed, by means of a statistical table, taken
from various authors, that out of 145 cases of convulsions, 117
occurred in first, and 28 in subsequent pregnancies; and ob-
served, that in primiparous women there is, as a general rule,
a greater tenseness and rigidity of the abdominal parietes; and
therefore in them the gravid uterus is much more apt, by its inward
pressure, to cause dangerous renal congestion, an obvious expla-
nation why primiparæ are the most liable to Puerperal Convulsions,
and why convulsions in them are chiefly of a renal, and therefore
of a severe and epileptic-like character. He considered it probable
that albuminuria is associated with the cedema of the face and upper
part of the body, which is sometimes seen in many who escape con-
vulsions, for the albuminuria and oedema are simply signs of con-
gested kidney, and that congestion may exist-and indeed often does
exist to an extent quite sufficient to cause these phenomena, and
yet inadequate to produce toxæmia of sufficient intensity to cause
Convulsions. abbus aftwory i sot hoold arodor
An analysis of the history of those cases in which convulsions
occurred in subsequent pregnancies, shows that they may all (ex-
cepting non-toxæmic cases) be classed under four heads,-viz.,
1. Persons who, though previously pregnant, had never gone to the
full time, and in whom, therefore, there had been no relaxing of the
abdominal walls. 2. Persons of extreme muscular development,
whose rigid fibres do not readily yield to the augmenting womb.
3. Persons who, from organic changes in the structures of the
kidney, cannot adequately perform renal depuration of the blood;
among whom may be included those suffering from granular or
other structural disease of the kidneys; or who have some con-
genital anatomical peculiarity in these organs; or in whom some
morbid growth presses on the emulgent veins, or, indirectly by its
presence, impedes the free flow of blood through these vessels.
4. Excessive volume of the uterine contents, including twin cases,
and cases of superabundant liquor amnii. Dom bas
The first and second classes are very numerous.
The third class is not numerous but important, when it is recol-
lected how often, in the course of Bright's disease, after we have
greatly relieved the head symptoms, and reduced the cedema and
albuminuria by derivative treatment, convulsions or death abruptly
occur from exposure to cold or some error in diet. In such in-
stances, the author supposed that the coagulability of the urine had
returned to its former state of intensity. Thus, a pregnant woman
labouring under Bright's disease, even in an early stage, must run
a tenfold risk of convulsions. If she have an ovarian tumour, or
any other mechanical predisposing cause to renal congestion besides
the gravid uterus, her risks will also be great, and in her delivery
will hardly bring exemption from the danger of toxæmia from
renal non-elimination.
As examples of the fourth class, he refers to Dr. Collins, who
had, in 240 cases of twins, three cases of convulsions, though in
G

70
his grand total of 16,654 labours, he had only thirty cases of con-
vulsions.
Some authors having explained the fact of the unmarried being
more subject than the married to Puerperal Convulsions, by
assuming, that in the former were present greater emotional causes,
he argued that, allowing that emotion may often, both in the
married and unmarried, be concerned as an accessory cause, yet,
as regards those who have become pregnant out of wedlock, it seems
natural to infer, that the tight girding of the abdomen, which they
so often practise, to an extraordinary extent, to conceal their shame,
may act most powerfully, in producing extreme congestion of the
kidney and consequent intense toxæmia.
When the death of the foetus precedes the attacks of convulsions,
he considered that there is inevitable toxæmia, which may be looked
on as Nature administering a poison for the purpose of accomplishing
abortion. If the foetus die, the matters which were being taken
out of the mother's blood for its growth, suddenly cease to be
required: and the depuration by the foetus also ceases, producing
more or less toxæmia. When the supply of material for the fœtus
from the uterine vessels of the mother suddenly terminates, by its
birth at the full time, the lochial discharge comes to her relief, and
so long as it is in sufficient abundance, she has small hazard of
toxæmia, the use of the lochial discharge being to prevent poisoning
of the blood. When convulsions occur or recur after delivery, the
toxæmia most probably arises from imperfect excretion or complete
suppression of the lochia; but it may also depend on the kidney
being congested from structural disease in itself, or from pressure
on the veins caused by the morbid enlargement of some neighbour-
ing part.
The author referred all convulsions to toxæmia or anæmia acting
directly on the spinal column and medulla oblongata; or to irrita-
tion of the extremities of the nerves, acting in a reflex manner on
the spinal column and medulla oblongata.
The sources of toxæmia causing convulsions, he considered very
various, and thus succinctly arranged them:
SOURCES OF TOXEMIA CAUSING CONVULSIONS.
I.
DEFECTIVE DEPURATION
OF THE BLOOD.
II.
INTRODUCTION OF FOREIGN
MATTER INTO THE BLOOD.
(1. Non-evolution of carbonic acid by the lungs.
2. Non-elimination of the principles of the bile from
the blood.
3. Non-elimination of the principles of the urine
from the blood.
4. Non-elimination by the skin.
5. Non-elimination of accidental effete matters from
the blood, by the kidneys and other emune-
tories.
1. Inorganic poisons, such as acetate of lead, &c.
2. Organic poisons, such as strychnia, &c.
3. Morbid poisons, such as scarlatina, &c.

71
While the pregnant woman is not exempt from any of the above
causes of toxæmia, she is specially in danger from those comprised
under the third and fifth divisions of the first head-viz., non-elimi-
nation of the principles of the urine by the kidney, and non-elimi-
nation of the accidental effete matters from the blood by the
kidneys and other emunctories.
Toxæmic puerperal convulsions are mainly renal or lochial, or
they partake of both, along with other characters. The chief
object of the paper was to point out the importance of the former,
but in doing so, the author wished explicitly to recognise defective
elimination from any organ as a cause of more or less toxæmia: and
also to recognise non-toxæmic causes of Puerperal Convulsions.
1. RENAL PUERPERAL CONVULSIONS. The following diagram
shows how pregnancy of itself may cause Renal Convulsions; organic
disease of the kidney being always calculated to augment their
danger.
PREGNANCY
CAUSES
Increased necessity for Renal Depura-
tion of the Blood.
A tumour (gravid uterus) causing renal
congestion, which
CAUSES
Non elimination of poisonous excre-
ment from blood:-
ΤΟΧΕΜΙΑ,
WHICH CAUSES
-
Action on Brain, Spinal Marrow, and
Medulla Oblongata,
HENCE RESULT
CONVULSIONS.
The Prophylaxis of Renal Puerperal Convulsions was shown by
the author to embrace an avoidance of too long continuance in the
supine position; an easy corset, giving free play to the lungs, and
not pressing back the womb; moderate exercise; regularity and
sufficiency of the alvine evacuations, and a good state of the skin.
Mental excitement must also be avoided, as it might, even with a
moderately poisoned state of the blood, be the immediate cause of
Convulsions. When toxæmia is present, congestion of the nervous
centres must necessarily be more dangerous than when the super-
abundant blood is healthy.
The Treatment of Renal Puerperal Convulsions was indicated in
the following diagram:

72
TREATMENT.
1. Remove pressure
from Renal Ves-
sels, by interdict-
ing supine pos-
ture, by unloading
bowels, and (when
safe)
uterus.
emptying
2. Relieve Con-
gestion of Kid-
neys by purg
ing, cupping
in the loins, or
general bleed-
ing.
306
3. Venesection if
apoplexy be
threatened.
to
4. Calmatives
excited nervous
system.
REDUCING
ΤΟ ΧΑΜΙΑ
RELIEVING OR ARRESTING
CONVULSIONS.
This paper is published at length in the "London Journal
of Medicine," June, 1849.
Special Meeting, May 19, 1849.
EDWIN CANTON, Esq., in the Chair.
This meeting was called to consider a proposition of the Council,
in reference to the Festival; but after some discussion, the motion
was, by leave, withdrawn, and the meeting separated.
Extra Meeting, May 19, 1849.
FRANCIS HIRD, Esq., President, in the chair.
Dr. Routh exhibited to the Society two small maggots, which
had come out of the ear of a gentleman.
This gentleman held the office of Superintendent in some gold
mines in Brazil. Being engaged on a Thursday in October, 1846,
in reading, he was tormented by a fly, at which he struck with the
palm of his hand, and accidentally pushed it within the meatus
auditorius. He was not able to extract it till four or five minutes
after, when his daughter succeeded in doing so by means of a
small forceps. The fly came out entire, excepting one leg, and
alive, and was seen by every member of the family, and recognised
to be a musca carnaria, or flesh-fly. On the same evening the
gentleman began to feel an uneasy sensation in his ear, which went
on from bad to worse, until the internal ear became exceedingly
painful. The sensation was as if there was something like a
gnawing or rasping of the drum. The natives around him stated
that maggots had been found in the ear. An English medical
gentleman was sent for, who ordered a few drops of solution of
opium in dilute nitric acid, to be instilled into the ear. The pain
and gnawing, however, were in no way relieved. On the Saturday,
at 4 P.M., he was seized with a convulsion: he moaned terribly,
plunged his head in his pillow, bending forcibly the joints, and

73
rolling the eyes; the general character, however, of the spasmodic
movements was clonic: the convulsion lasted from seven to ten
minutes. The medical gentleman called the same evening with a
forceps, extracted a living maggot, and ordered a weak solution of
bichloride of mercury to be applied within the ear. The rasping,
gnawing, and pain continued. At 11 P.M. the same evening,
another convulsion occurring, further medical aid was called in, and,
on consultation, it was agreed to apply white precipitate suspended
in milk to the ear. This was done, and somewhat relieved the pain;
soon after, two other maggots came out alive. On the Sunday
morning another convulsion occurred, but much less violent; the
same day a fourth maggot dropped out, also alive. From this time
all the acute pain subsided, but slowly at first, as a purulent dis-
charge continued to flow from the ear, but which at last yielded to
injections and counter-irritants. The patient finally recovered in
about six weeks, but had remained deaf in that ear ever since.
The case related was very interesting: 1st, as showing the short
space of time in which the ova were deposited, the fly not having
remained in the ear more than five minutes; 2nd, as showing the
rapidity in which they were hatched in the ear; 3rd, as exemplifying
the non-poisonous quality of the cerumen to maggots of musca; and,
lastly, as indicating the danger of delay, and the efficacy of white
precipitate as a means of cure. Two cases only were recorded in
"Cooper's Surgical Dictionary," in one of which convulsions also
were present, but in neither was the history of the first deposition
of the ova given, which in this case was distinctly traced to a musca
carnaria.
Mr. Henry Smith exhibited the oesophagus and part of the liver
of a patient who had for the last fortnight suffered from pain and
difficulty in swallowing.
On examination of the body after death, the mucous coat of the
oesophagus was found to have been destroyed by ulceration, there
was also slight stricture of the part, and hardened cancerous masses
in the cellular tissue underneath. The liver was affected with
carcinoma; there was no resulting dropsy.
Dr. Snow placed on the table an apparatus with which he had
lately administered chloroform in some cases. It consisted of a
hydrogen balloon holding upwards of two thousand cubic inches,
which was provided with a tap, and attached to a face-piece con-
taining valves. He said that by means of this contrivance chloroform
could be given in a more exact way than heretofore, and that the
vapour was rendered much less pungent and irritating, owing to its
being uniformly mixed with the whole of the air. When used, a
measured quantity of chloroform was put into the balloon, which
was then inflated with air by a bellows; in this way, the exact pro-
portion of vapour in the air breathed by the patient was known, and
the effects produced were very uniform. The expired air escaped
by a valve, without returning into the balloon.

74
Mr. Nunn exhibited a Perineal Bandage, which he had found
useful in Prolapsus Uteri, and where the abdomen required support.
A band passes round the abdomen, and from each side there
descends a strap, which passes between the thighs, and is fastened
on the opposite side to the abdominal band. He had found it
supersede the necessity for a pessary.
Mr. Hancock read a paper on the Operation for Strangulated
Hernia.
The recommendation of not opening the sac, he stated, has
recently been brought prominently under the notice of the profes-
sion, and has at various times been ably advocated by Petit, Le
Dran, Monro, Sir C. Bell, Bransby Cooper, Aston Key, Luke, and
Gay, in whose hands it has been successful, particularly in those of
Mr. Luke; whilst the statistics advanced by the latter gentleman
certainly appear, at first sight, greatly to favour this mode of pro-
ceeding. On the other hand, it has also been as ably opposed by
men of eminence-viz., Dupuytren, Richter, Hey, Heister, Sir A.
Cooper, (excepting in old and large incarcerated hernia,) Law-
rence, Liston, and Lizars, and more recently by South. A closer
inquiry, however, into the statistics and arguments adduced in
favour of this operation, tends greatly to diminish its claims to
superiority, and proves that the mortality after operations for
strangulated hernia depends, in most instances, upon causes entirely
independent of the operation; that opening the sac does not, in
reality, increase the danger, but that, on the contrary, the advan-
tages of this method are so great, that, as a general rule, it ought
to be adopted as the safer mode, and as presenting the greater cer-
tainty of success.
It having been urged by the advocates of Petit's operation, that
by its adoption we avoid the following dangers-viz.
"Peritoneal inflammation consequent upon the exposure of an
inflamed or strangulated portion of the bowel, which, accord-
ing to Key, is the cause of death in the majority of cases;
Hæmorrhage into the cavity of the abdomen, should a vessel
be wounded;
"Risk of wounding the intestine;
"Opening the sac, and thereby laying bare the peritoneal cavity
of the abdomen;
"Immediate manipulation of parts so important to life; and,
according to Gay, inducing unhealthy processes in the ex-
ternal wound;"-
---
the author asks, in the first place, are these objections valid or
tenable? Have not the surgeons in question, in their anxiety to
support their own particular views, overlooked the real causes of
failure, and grasped at the shadow whilst they neglected the sub-
stance? The published records of strangulated hernia cause a
feeling of surprise in the minds of the readers; not that the mor-
tality has been so great, but that it has not been greater, as every

75
rule of good practice, of common sense even, appears to have been
violated in the treatment of these cases. When strangulation took
place, instead of early relieving the stricture, the patient was left
until almost dead; the surgeon, in the meantime, torturing him in
all manner of ways, in order to prevent the necessity of an opera-
tion, which was at last obliged to be performed under every dis-
advantage, the gut being bruised, inflamed, or mortified, and the
patient in a state of collapse, worn out by suffering, and the pro-
longed yet abortive attempts at reduction. When the intestines,
from the injury sustained, had lost their power of action, they were
still more irritated and injured by the exhibition of purgative
medicines, both before and after the operation; and yet those who
pursued this practice, would most strenuously have deprecated the
employment of purgatives in cases of idiopathic enteritis. Again,
notwithstanding the patient was almost in a state of collapse, from
the severe constriction exerted upon the intestine, his vital powers
were still more depressed by the exhibition of tobacco, either in
solution or in fumes, tartar-emetic, and other equally destructive
agents. These points have been all lost sight of; even mortifica-
tion and rupture of the intestines, and disease of vital organs, have
been overlooked; and deaths occurring under such circumstances
have been ascribed, not to their true cause, but to the opening of
the sac, and classified accordingly.
With respect to the remark made by Key, "that in the usual
operation, the majority of fatal cases are consequent upon the
exposure of the inflamed or strangulated portion of the bowel
caused by opening the sac," Mr. Hancock observed, that the history
of strangulated hernia proves, by every-day experience, that the
peritoneum may be cut with impunity. He is as willing to admit
that, if the healthy peritoneum is cut or irritated, peritonitis may
be induced, although this even does not always occur; but he
argued, if an inflamed peritoneum is cut, the inflammation does not
necessarily increase, especially when that inflammation results from
some exciting cause removable by the incision. The operation then
becomes a relief to the patient; whereas, when made in healthy
peritoneum, it inflicts a violence on the part. He is supported in
this belief by the observations of Sir Charles Bell, that a peri-
toneum, when diseased, may be cut with greater impunity than
when in health. The abdominal sections in ovariotomy prove this;
the removal of large portions of omentum prove it; the operations
of paracentesis abdominis prove it; and the success which attended
the author's case of cæcal disease also tends to strengthen the posi-
tion. Again, in reply to the question, is the general peritoneal
cavity laid bare by opening the sac? the author observed, that the
communication between the sac and abdomen is completely closed
by the protruding gut or omentum, and that, even when the intes-
tine is returned, it lies so close to the ring, that very little, if any,
air can gain access to the abdominal cavity, even should it prove
injurious in so doing, of which he had great doubts, having had
patients under his care who, from wounds, have had the abdominal

Ra
76
cavity exposed for a much longer time than would be required for
the operation for strangulated hernia, and have recovered without
any urgent symptoms.
The author then adduced arguments to prove that the chance of
wounding the intestine was not diminished by the performance of
Petit's operation, and objected strongly to the plan adopted by
Mr. Luke, of scarifying, in certain cases, the thickened neck of the
sac at different places, without penetrating its entire thickness.
The modification of Petit's operation, lately introduced by Mr. Gay,
was described; and Mr. Hancock remarked, that the neck of the
sac must be reached, whether the structure be got at directly or in
front, or on the inner side; the only difference being, that in the
one case the surgeon can attain his end directly, in the other, only
in a round-about manner and in the dark-a very objectionable
mode, as the operator should always, if possible, see what he is
doing. Neither can it be at all admitted, that there is more danger
of wounding the intestine in opening the sac in the ordinary opera-
tion, than in forcing the blunt-pointed bistoire caché (although
with the least possible amount of force) between the strangulated
femoral hernia and the pubic margin of the ring, at the very point
where ulceration of the gut takes place, from the pressure exercised
by the sharp edge of Gimbernat's ligament, as has been noticed by
Chevalier, Breschet, and indeed by all surgeons of experience. The
other objections to the usual operation, mentioned at the com-
mencement of the paper, were next commented on, with a view to
prove that they were not entitled to the large amount of considera-
tion ordinarily bestowed upon them.
out aimago vd beanD
In illustration of the advisability of opening the sac, in order to
ascertain, amongst other points, the presence of adventitious bands
within, or at the neck of the sac, which might be a cause of a con-
tinuance of stricture, and lead to a fatal result, were the gut returned
without laying it bare, the author related a case in which he had
assisted Mr. Canton in an operation for strangulated femoral hernia.
In this instance the gut was fairly returned into the abdomen, but
upon Mr. Canton's introducing his finger as a precautionary
measure, he ascertained that a distinct band passed over the intes-
tine, and, from its position relative to the gut, would most certainly
have led to an unfavourable result, had it not have been discovered
and divided. The patient recovered. Two other cases had also
occurred to the author, which proved, additionally, the great neces-
sity for opening the sac. is a vong dalolla ais tro
He concluded with a statistical account of a large number of
cases in which the operation was performed in the usual method,
and also in that proposed by Petit, and deduced therefrom addi-
tional arguments in favour of the former mode of proceeding in
cases of Strangulated Hernia.
bad quival
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