XI.

FEMORAL HERNIE IN THE MALE
SUEJECT.

THOS. STEERS, æt. 54, a labourer, was admitted, 12th July, under Mr. Green, with a small, circumscribed, and slightly elastic swelling in the right groin; no impulse was given to it by coughing, but it lay as if folded over the falciform process of the fascia lata, to its upper and outer side. His history is clearly, that, three weeks ago, during an attack of vomiting which ushered in a typhoid fever, he felt a sudden pain in his groin, as if something had given way; this excited his alarm for a little while, but soon was forgotten, either giving no longer pain, or vanishing altogether: yesterday, however, a renewal of the vomiting, which lasted until this morning at 12, brought the swelling into notice again, by an excessive pain. His medical attendant had tried the taxis and bled him to syncope, but without effect. About two hours after admission he was placed in a warm bath, and the taxis again was fairly applied, his pulse not yet having perfectly rallied from the effect of the venesection. Mr. Green was now sent for, and arrived at half-past six. After obtaining the

above history from the patient, and the treatment adopted by the dresser, he proceeded to examine the patient, and found that the belly was somewhat tender on pressure, and that the tumour was irreducible; and notwithstanding the elasticity in the tumour, the compressible pulse, the absence of vomiting, or any anxiety of the countenance, he immediately proposed the operation, which was consented to.

The operation was commenced by an incision through the integuments drawn across the tumour parallel to Poupart's ligament, and by another meeting its middle at right angles. The flaps thus produced, being reflected, the cellular and fascial coverings were carefully divided, which exposed an unusual layer of fat surrounding the sac, on opening which a small quantity of serum escaped, and the intestine appeared greatly discoloured. The bistoury was then introduced upon the director, and the stricture, which was found to be Poupart's ligament, was divided, when a very large quantity more of serum escaped from the cavity of the abdomen. The intestine was returned, and the edges of the wound brought together by a suture and dressed with adhesive strap-two small bleeding vessels were secured during the early part of the operation. On his being replaced in his bed, we found him relieved, his pulse larger and more expanded, and pressure, even, gave no pain. Mr. G. left directions that, should the pain continue, fomentations were to be applied, or even leeches, according to the judgment of the dresser; but, if the pulse indicated it, venesection was to be had recourse to.

13th. No pain left-pulse soft and expanded—has had no relief in his bowels. R. Magn. sulph. 3ij. ex m. m. omni hora ad sedes.

14th. Towards the evening, his bowels were relieved-in every respect, he is doing well.

On the 15th, the wound was dressed, and found to be adhering in part, and the rest granulating well.

On the 17th, he was allowed the house diet, no symptom having appeared by which meat is counter-indicated.

From this period, he got progressively well, no alteration either in symptoms or treatment having occurred. Now, the alertness of Mr. Green will serve as an

example of its importance in all cases; no less than an opportunity for specifying his reasons for adopting it. Let me first ask, what is gained by delay in these cases? Did we know the changes which are going on within the sac, so as to calculate on them with certainty, we might, perhaps, be borne out in waiting the result of other means for its reduction; for, although a spontaneous reduction has often occurred, after all artificial means have failed, and, as in the present case, the inflammatory action will subside upon withdrawing the cause, yet, from the recollection that the symptoms of inflammation are sometimes extremely insidious, that the most powerful remedies have been applied without effect, and that the operation is neither a painful nor a dangerous one, we may safely conclude, that its proposition ought speedily to be made. The present case will shew how fair this view of the subject is, for effusion had taken place to a considerable amount, as the most probable effect of inflammation, although the existence of symptoms, beyond a slight pain on pressure, could not even induce its suspicion, and the protruded intestine was discoloured far beyond the expectation of Mr. Green, and those around him. If irreducible, then, by the powerful remedies of bleeding, and the warm-bath, carried to a proper length, Mr. Green considers a hernia but aggravated by subordinate measures; and, indeed, we cannot know when we are safe, except by such a rule.

EDWARD TAPNER, æt 47, was admitted 29th July, under Mr. Travers, with a painful swelling in the right groin, about the size of a large walnut. It lies below Poupart's ligament, upon the fascia lata, and receives some impulse upon coughing, at its lower and inner part-it is circumscribed, and rather tense. The patient states that it appeared suddenly upon a fit of coughing, about 20 hours previous to admission, and has continued to give pain ever since. There is pain in the abdomen, aggravated by pressure, an anxious countenance, occasional vomiting, and a small, quick pulse.

On his admission, he was placed by the dresser in the warm-bath, and the taxis was applied, without effect, the tumour not yielding in the least. At 9 o'clock, Mr. Tyrrell arrived, and, in the

absence of Mr. Travers, determined on operating immediately, as the only chance of relief to the patient. Consent was gained, and the operation was conducted in the ordinary way, no variety or difficulty presenting itself.

On being put to bed, Magn. sulph. 3ij. T. opii, m vj. ex Aq. menth. pip. were given, and desired to be repeated every two hours: but the bowels became very much relaxed, and the dresser gave 40 minims of laudanum; this had the effect of lessening their action. We afterwards learnt, however, that a diarrhoea had existed on him previous to the descent of the intestine.

The wound has healed without interruption, those symptoms having yielded immediately after the operation which had been urgent or indicative of inflammation. A diarrhoea has constantly been upon him, and some attention has been requisite to his general state of health, since he coughs, with a pain in his chest, and has done so for nearly two years.

The difference in the after-treatment of these two surgeons, is remarkable. It is a practice with Mr. Tyrrell, to stimulate the intestines by purgative medicines, immediately after the stricture is divided, although the intestine is inflamed

indeed, it is Sir A. Cooper's plan of treatment, to carry this to a surprising length, and many reasons are said to support it; but Mr. Green endeavours only to soothe the part until inflammation has subsided, and, even then, is reluctant to give purgative medicine, unless the bowels have not been relieved; for if inflammation exists, he considers stimuli but calculated to increase it. Reasoning, however, will hardly decide the question, when practice has proved the success of both parties. A preference can only be given after an accurate comparison of the two, which I am incapable of establishing in the present reports.

JAMES SCISSON, æt. 34, was admitted, 31st May, 1827, under Mr. Green, with a wound in his leg. He informs us, that, 14 years ago, when a soldier in Spain, he received a musket ball in his leg-he did not perceive any pain for many minutes, but was afterwards disabled from using the limb.

Hard labour has been much interrupted, and almost entirely prevented ever since. For the two first months,

/bone was continually coming away, amounting to a dozen pieces at least.

There is a sore at about the lower third, with irregular edges, exposing a metallic body, nearly an inch deep-there is a constant discharge, and great swelling above and below the sore, which neither pits on pressure, nor is painful. Ordered cat. lini, and rest.

15th June. The swelling has subsided in great measure, and was considered by Mr. Green, in a fit state for the extraction of the foreign body. Mr. G. commenced, by making a crucial incision over the wound, and reflected back the four flaps, so as to expose the whole of the body; it appeared imbedded in a cartilaginous substance, which was connected with the bone. Sufficient of the ball being exposed to afford a firm purchase, Mr. Green grasped it with a stout pair of rough forceps, and, with a long, firm, and steady effort, succeeded in dislodging it. On examination, it was found to be very irregular, its rounded form being by no means preserved. The wound was lined, as it were, with cartilage, and bled pretty freely. A dossil of lint was laid upon the wound, and the patient conveyed to bed. Bleeding continued for some short time, and the leg, above and below the wound, became extremely painful: this, however, in a few days, subsided, and a slough came away of those integuments which were divided. The wound granulated, and the limb became stronger, when gentle motion was first permitted, and afterwards the full use of the leg.

XII.

sense of suffocation-his cough is a croaking, metallic sound, attended with occasional difficult expiration-his lips are livid, skin cold, tongue brown and moist, bowels costive, pulse quick and small. Ordered, V. S. ad 3xvj. Liq. antim. tart. 3 ss. 2dâ quâq. horâ.

13th. He was relieved by the bleeding, and vomited the antimony three times only. Symptoms but little altered.

14th. 4 P. M. Complains of intense pain round the right side-his breathing is very difficult-his feelings he described to be of suffocation, and his appearance is the same,-a cold and cadaverous skin -an almost vacant stare-aggravation of the mucous guggle-slow and feeble pulse-he complains of lightness in the head, a singing in his ears, and dimness of vision. Mr. Whitfield saw him, and ordered V. S. ad 3 xiv. and a blister to the side. He was speedily relieved, as soon as a few ounces of blood were drawn-he coughed up some frothy mucus, which rendered his breathing much easier-the surface of the body became warmer, and the pulse expanded.

11 P. M. The symptoms returned. C. c. ad 3 xiv. which relieved him. Continue the antimony.

15th. Improved in every respect,though the symptoms are far from being subdued. The antimony has not been rejected since the first day,. V. S. ad 3xx. Vini ant. tart. 3 vj. 2dâ q. h. Ung. ant. tart. pectori infricand.

19th. But little alteration. M. s. c. statim; increase the antimony to a fluid

ounce.

21st. He is now decidedly worse. There is excessive pain, which he describes as diffused and deep-seated-the cough is

WITH TARTARIZED ANTIMONY.

T. CARLTON, æt. 40, a sailor, was admitted under Dr. Elliotson, 12th July, 1827. He states, that, six weeks ago, he was thrown overboard, and nearly drowned, since which his present complaint has, more or less, troubled him. He has been constantly exposed to wet, to which he attributed the continuance of the symptoms, if not the prevention of their cure. His breathing is quick and labouring, accompanied by the mucous guggle-he complains of no pain, but a tightness and

tearing sensation; pulse quick and small; skin dry. Hydr. submur. gr. v. 6tâ q.h. Omit the antimony.

24th. Symptoms much lessened; mouth sore. C. c. parti solent. ad. 3xvj. Hyd. submur. b. d. only.

27th. Complains again of increased pain, while there is great difficulty of breathing, and scarce power to articulate. Vini ant. tart. 3ss. M. s. 3j. Tinct. digitalis, m xx. 8is horis.

30th. Relieved in some measure, but, from inability to expectorate, the mucous guggle is very great; he lies upon his

back, scarce observing surrounding objects, and a cold sweat is upon his skin. Emp. canth. larg. pectori.

He died on the 5th of August, without any material alteration of symptoms. Unfortunately, no effort was sufficient to prevail upon the friends to permit an examination of the body in this interesting

case.

JOHN CHITTENDEN,æt. 20. was admitted, 21st July, under Dr. Elliotson, with pain, and increased rotundity of the left hip. On examination, the inflammation was clearly external to the joint. Pulse 100, and firm-skin hot and dry-thirst -bowels confined. C. c. coxæ sinist. ad 3xx. Lot. ammon. acet, Liq. antim. tart. 3ij. 2dâ q. h.

24th. Has borne the antimony without even nausea, after the first dose, which he rejected. Emp. lyttæ; Liq. antim. tart. 3iij. 2dâ q. h.

He rejected the antimony on the following day, and it was withdrawn for 24 hours. It was afterwards given again, and retained upon the stomach for several days, when matter was supposed to be formed, and the patient was seen by the surgeon. The antimony was withdrawn, and the case became of no farther interest to require its detail in these reports.

In the former case, it is clear that the large doses of antimony were borne with perfect impunity, after a while, but they had no control over the complaint. 'Tis true that the symptoms were mitigated at first, but repeated blood-letting was exercised at the same time, and I think may fairly be deemed the more efficient remedy of the two; for the benefit received immediately from one bleeding, was not at all assisted until it was repeated; and, indeed, we may as fairly conclude that, if the antimony had not been given, but some more powerful remedy, as afterwards was had recourse to, such delay, and even the life. of the patient, might have been spared. Now Dr. Elliotson is endeavouring to learn, whether inflammations of the chest alone are conditions repugnant to the violent impressions of antimony, as asserted by Continental writers, who would use drachms for our grains; or whether the same state of any other part of the body is not equally opposed to its effects; or even whether antimony, in large and continued

doses, is not, as many medicines are, almost inert, when the system is totally undisturbed by disease: and, as a first step to this, Dr. E. has given it in an inflammatory disease of the hip, where, likewise, it was borne, without inconve nieuce. for some considerable time. This idea, however, has already been suggested to the public; and M. Velpeau has gone some way to decide the question, a short account of which appeared in the Med. and Phys. Journal. He relates several cases of rheumatism, where a trial was given to this remedy in doses of from 20 to 30 grains, and his opinion of its effect, after witnessing 30 cases of its use, is, "that, in some, it produced not the least amelioration." But in a female, where bleeding and leeching had been used without benefit, 12 grains of the tartar emetic, dissolved in orange-flower water, and given in the 24 hours, such relief followed, as not to require its repetition. Now the condition produced by the antimony is not mentioned; for we must all have seen larger doses even than these given, to produce nausea—a favourable state for the cure of almost any inflammation.

Hence, we have reason to conclude, that inflammation of the chest is not the only condition of the body repugnant to the effects of antimony; while it remains to be proved, whether the body, in its natural state, can endure it without inconvenience, and whether its asserted deleterious effects are suppositions merely, or the result of experience and observation.

XIII.

LITHOTOMY.

EDWARD ROWE, æt. 24, a spare young man, with blanched skin, which he attributes to his late debauched habits, was admitted under Mr. Green, 9th August, with stone in his bladder. He had been aware of its presence two years, and Mr. G. had sounded him previous to his admission. Some opening medicine was given him; and, on the following day, the sound was introduced, and readily heard to strike against some hard body. The operation was performed in the ordinary way, and the gorget used.

No