partly from concussion of the nervo-muscular fibres producing a change in their nervous relations.

The good effects of friction are not confined to the mere relief of pain, as will be seen under the succeed ing indication of treatment.

means resorted to in labour. The only one which will be here noticed is the secale cornutum, or ergot.

The Ergot or Ergotine. This singular parasitical production of the rye, and also of some few other plants, as the glyceria fluitans, although long known to botanists, and for its effects in parturition, was little used until within the last thirty years. The history of this medicine, its presumed effects as a specific exciter of uterine action, the mode of administering it, as well as the objections it is liable to, and the precautions required in its use, are all so well known. that it would be superfluous here to detail them; what is of more consequence, is to endeavor to determine how far it really merits the high opinion so

f. Pressure. This is an important adjuvant to friction. The advantage of pressure is well illustrated by the anxiety the patient so often expresses to have her back held; and it is an interesting confirmation of it that the side on which she lies is comparatively little. if at all, affected by the pain. The pressure may be made with the hand, and in immediate cooperation with the friction, the hand alternately rub bing and pressing, or champooing, as it were, the part affected. Another mode of application is a firmly-generally entertained with respect to it. The author adjusted bandage.

was one of the first in this country to give it a trial. C. Another and important indication of treatment having administered it to various patients in the is to promote uterine action. The present subject is years 1822 and 1823, and since that period to the naturally involved in the preceding indications; for present time he has frequently used it, particularly whatever relieves the painful actions will necessarily in consultation with other practitioners; and he retend to throw back the parturient energy on the ute-grets to feel bound to say, that, although administerrine muscles. There are still other means of fulfil- ed in large and repeated doses, and with every anxiling the indication, the majority of which have al-ety to do it justice, it has invariably proved appaready been alluded to, but which deserve farther no-rently inert, and disappointed his expectations. That tice in the present place.

in the hands of many it has frequently been followed a. A late eminent practitioner once observed to the by more propitious effects, he by no means doubts: author, that if you pulled a woman in labour by the but it is to be recollected that it is not unusual, where nose, and made her believe it would do her good, the neither ergot nor any other means have been resorted action of the uterus would strengthen, and the case to, that unexpected and felicitous changes are met become more propitious. A useful inference may be with; it is also to be noticed that this particular remdrawn from this facetia-the importance of influenc-edy is generally administered in warm infusion or ing the mind of the patient so as to induce rational decoction, or in the form of spirituous or æthereal confidence; for however assured the practitioner may tincture, and which by their warmth and stimulus be of the correctness of his principles and treatment, may tend to relieve the spasmodic pain, and induce he is not to be surprised at their failure if the mind more powerful uterine contraction, or even operate of his patient continue materially depressed. through the medium of the mind. Under this supposition, the author has occasionally made the patient drink one or two cupfuls of hot water, and he conscientiously declares that it has proved equally, or more efficacious, in altering the character of the succeeding pain. His friend, Mr. S, of Brydges street, Covent-garden, doubtless well recollects an instance of this kind. It will be unfortunate if a remedy, which many think "helps so marvellously." should eventually prove to possess little more real virtue than "an eagle's feather placed under the left foot of the patient;" which John of Gaddesden says, "facit parere statim."

b. An important mode of increasing uterine action is to apply a direct and determinate stimulus to the orificial parts, which may be accomplished by bandaging the abdomen, which will have the effect of producing increased pressure on those parts: also by pressure with the hand, accompanied by friction, as has so lately been described; an addition to the above is to combine with it stimulation of the os uteri, by means of a finger introduced per vaginam; the effect of these means, used in conjunction, will often induce powerful contraction, and the most satisfactory progress. The rupture of the membranes, if they be rigid, and fail to break spontaneously when the os uteri is becoming well dilated, should also not be neglected.

2. The second head of reflex action in labour, is where it influences the heart and circulating system, so as to give rise to fever, local determination or conAn important advantage may occasionally be at- gestion, syncope or convulsions; of these effects, it is tained when the finger is within the vagina, which, if purposed in the present paper only to notice the latit does not positively increase uterine action, not un-ter, generally known as puerperal convulsion. frequently serves as a substitute for it; this is, to em- It is conceived that convulsion generally is the reploy it in a cautious attempt to dilate the os uteri.sult of a determination to and congestion of blood in The practice may be censured; but it is in fact only effecting by art with ease and facility what nature has rendered necessary, and would otherwise accomplish with comparative distress and delay.

some portion of the cerebral or spino-cerebral system; that it takes place at the time of labour in consequence of those parts being associated with the uterine organs, by virtue of metastatic or reflex action, c. The ancients, from Hippocrates downwards, and was for the first time enunciated by the author in his the mediaval practitioners. have recommended va- "Treatise on Midwifery." so frequently adverted to rious means, medical and otherwise, for promoting or (see first edition, p. 239, second edition, p. 141.) "provoking" labour in cases of protraction. Many Many facts may be adduced to render the correctness of these are absurdly ridiculous, and yet they were of this view more than probable; thus, the convulreputed to " help marvellously." It is worthy of re- sions, together with their occasional precursory mark that the best of them are antispasmodic or ano- symptoms, as pain in the head, giddiness, &c., are dyne, which would have the effect of relieving pain; generally preceded by severe pain, either uterine or or sternutories, the tendency of which was to induce extra-uterine; they also come on and go off in parpressure on the orificial parts so as to promote ute-oxysmal form with the regularity of labour-pains, so rine action; while others were calculated to give con- as to appear to be a modified substitute for the latter, fidence to the patient. The modern practitioner has and have the same effect as extra-uterine pains, in generally abandoned the use of the whole of them suspending the expulsive action of the uterus; and and there are now comparatively very few medica after delivery, in a similar way, they either go off en

tirely, or are materially alleviated;-in fact, they ap- events to render them compatible with the continupear entitled to be regarded as depending on addi-ance of life. tional links or nervous arcs in the chain of the excito-motory nervous actions. The predisposition and the exciting causes are precisely the same.

in quantity. The physical signs were the extraordi- | colic valve was completely closed, and symptoms of nary appearance presented by the abdomen, and the strangulation were produced in consequence of the evident presence of a solid body occupying the epi- contents of the small intestines not being able to pass gastric region. The left hypochondrium and umbil into the colon. Upon three or four ocaasions I have ical region were also unusually dull on percussion, met with a similar difficulty in returning the protrudand there was total absence of resonance over the ed intestine, after all the steps of the operation had been successfully passed through, up to the division spot generally occupied by the stomach. This difficulty probably arose from of the stricture." the distension of the viscera within the abdomen. In one case I found it quite impossible to return the bowel, and I made a slight puncture into it, with the object of setting any gazeous matter at liberty, but I failed in producing the intended effect, as the mucous membrane closed the aperture, which I dared not enlarge. The patient died of peritonitis, and I made up my mind never to try such an experiment again. In a similarly difficult case, I had the patient put to bed, after trying ineffectually to reduce the hernia, and covered the protruded bowel with a large thin poultice. In a few hours the patient had a motion; the bowel was then easily returned, and he recovered. I consider this treatment far safer and more likely to be successful than long-continued attempts at reduction by taxis, puncturing, or any other violent means.

The autopsy, performed twenty-two hours after death, revealed a large fleshy tumour, connected with the liver, and represented in Fig. 2. The pressure of this morbid growth had obliterated the vena cava inferior to the extent of two inches. There was a small quantity of fluid in the sac of the peritoneum. The vena azygos was somewhat enlarged; the spleen was of enormous size, and almost black from congestion; the right kidney was soft, pale, and flabby; the left was enlarged; the cortical portion mottled and compact; the heart and lungs healthy.

Fig. 1. will sufficiently illustrate the mode in which the blood, diverted from its usual course by so terrible an obstacle, at last reached the centre of the circulation. Of course, the impediment had come on

gradually, and so time was given for the development of the collateral supplementary veins. Anomalies of form in hernia will often produce The symptoms during life were therefore in accord-serious difficulties in the diagnosis. A bubonocele ance with what we should expect from the presence occurring in an invividual in whom the external ring of such a growth. The hematemesis, I should sup- is abnormally small, may, for instance, develop itself pose, may be attributed to obstruction in the branches of the portal system. The gorged spleen may be not only in the inguinal canal, but also upwards and outwards as high as the anterior superior spinous process of the ilium, so as to present a most unusual appearance for a hernial protrusion.

referred to the same cause.

CASES OF HERNIA.

By BRANSBY B. COOPER, Esq., F.R.S.

[Concluded from Sep'ember No., p. 195.]

WHATEVER may be the experience of a surgeon in the treatment of hernia, I think he will be obliged to admit that he has seldom seen two cases exactly resembling each other; there is almost always some difference in the symptoms, some peculiarity in the form of the tumour, or some anomaly in the concomitant circumstances; so that, when at length compelled to resort to the operation, it is generally set about rather as a step of exploration than with confidence as to the physical conditions of the case being perfectly understood. Although the anatomy of the outlets of the abdomen is well known, the course of hernial protrusions frequently deviates from that of the natural channels, so that it is often difficult to ascertain by which outlet the viscus has passed from the abdomen. The difficulties arising from anomalous circumstances attendant upon cases of hernia, are often productive of so much trouble and anxiety to the practitioner, and interfere so materially in forming the diagnosis, that I have thought the following cases may prove useful, as they are illustrative of some of the points most likely to mislead and confound the judgment.

Mr. Potter, of Dublin, related a case of strangulated hernia to me, in which he had lately operated. Upon opening the hernial sac, and dividing the stricture, he was unable to return the protruded intestine into the abdomen. He sent his patient to bed, covering the intestine with linen dipped in warm water, to maintain as nearly as possible the natural temperature of the protruded bowel. Notwithstanding the stricture had been freely divided, all the symptoms of strangulation remained unabated, and in three days the patient died. In a post-mortem examination it was found that the ascending colon had protruded beneath Poupart's ligament into the crural sheath, passing over the ilium, which was so firmly compressed just at the point of its entrance into the cæcum, that the ileo

A servant of Dr. Babington was admitted into Guy's Hospital, with a large tumour occupying the whole space between the anterior superior spinous process and the symphysis pubis, overlapping Poupart's ligament, assuming the appearance of a large femoral hernia; indeed, it was a somewhat doubtful point whether it was femoral or oblique inguinal hernia. The patient was suffering from symptoms of obstruetion rather than of strangulation; he was put into a hot bath, and Mr. Morgan succeeded in reducing the hernia, using considerable force in the taxis. The patient perfectly recovered.

I have mentioned that Mr. Morgan reduced the hernia by somewat forcible taxis. This gentleman was in the habit of employing considerable force in the reduction of hernia; and although I must say that I should not myself adopt this practice, I confess that I have seen Mr. Morgan succeed in returning the intestine in cases in which the amount of force ordinarily employed would have completely failed. Sir Astley Cooper also rather leaned to this comparatively violent treatment. Some time ago Sir Alexander Crighton told me that in Russia it is an almost universal practice to force herniæ back by the taxis: and although by such measures they occasionally rupture the intestine, the general success is very considerable. Personally, however, I should never recommend such a practice, and should always prefer resorting to the operation in cases were a moderate amount of force is insufficient to secure the return of the protruded bowel.

A woman, aged seventy-two, the mother of several children, was admitted into Guy's Hospital, with severe symptoms of strangulated hernia, which had commenced three days before. She had had a rupture for several years. When she was examined, a tumour was found in the left inguinal region; it had all the appearance of a bubonocele, and the finger could be placed on the spine of the pubis under the tumour, which circumstance might in itself almost have been considered a conclusive proof of its being an inguinal hernia. Upon close examination, how

ever, the tumour could be felt issuing from the saphe- It had the appearance, and was about the size of a nous opening of the fascia lata, showing its femoral calf s bladder, partly filled with fluid. By pressing origin the anomalous appearance of the hernia was, the fingers deeply into the tumour, a substance very however, manifest to all who saw it. The operation similar to intestine or omentum could be felt. This was immediately proposed in this case; but the pa- could be traced under Poupart's ligament. I could tient would not submit to it until the next day, when not succeed in reducing the swelling by the taxis. I operated; the sac could not be emptied without being The patient stated that the hernia, which had existlaid open, when a large quantity of omentum was ed for about five years, was sometimes twice as promfound in it, with a knuckle of intestine behind, en-inent. There was a second tumour, of small size, tangled in the omentum. This was probably the rea- above Poupart's ligament. This was pendulous. and son why it was necessary to open the sac. Upon of the size of the end of the little finger. It had the passing my finger to the stricture, I could feel the epigastric artery beating forcibly immediately across it. In consequence of this I was enabled to divide the stricture without wounding the artery, which I could not have done had I not felt the vessel pulsating. After dividing the stricture, I easily returned the intestine; a portion of the omentum was removed, and the patient was put to bed. It was two days after the operation before any motion passed, but the patient recovered without a bad symptom.

appearance of a ventral hernia, protruding between the separated tendinous fibres of the external abdominal oblique muscle. I ordered a large dose of opium, ice to be applied to the tumour, and a castor-oil enema to be given. The next day the sickness was less urgent, and there was no aggravation of the other symptoms. I, however, recommended the operation, but to this the patient would not consent. On the following day she still remained much the same; but as there had been no relief to the bowels, I urged On the 30th of October, 1846, a woman, aged for- that the operation should be performed immediately. ty, (mother of eight children,) was admitted into the As the patient now began to feel that her situation hospital with acute symptoms of strangulated femoral was critical. she agreed to submit to it. I commenced hernia. She had had hernia for four years; it had my incision from the upper tumour, continuing it frequently come down, but she had always been able downwards below Poupart's ligament, as far as about to return it. On the 28th instant, the hernia sudden- the centre of the lower swelling, cutting through the ly descended as she was coming down stairs. She was skin and superficial fascia, exposing the free edge of immediately seized with vomiting and a sensation of Poupart's ligament, as well as the protrusion of the tightness across the scrobiculus cordis. The tumour upper tumour through the tendon of the external obwas peculiar in form: instead of being of the usual lique muscle, as I had expected. I next proceeded to shape of a femoral hernia, it was much elongated explore the upper swelling, and for that purpose outwards, running under and parallel with Poupart's opened the sac. I could see nothing but omentum. ligament, reaching almost as far as the anterior su- I then divided the opening through which it had perior spinous process of the ilium. The elongated passed, and Poupart's ligament; this showed that the portion was extremely moveable, and felt as if it were upper swelling was merely a portion of the lower, as immediately under the skin, but it could not be press- they were now rendered quite continuous. I opened ed towards the crural ring. It was difficult to be- the sac of the femoral tumour, and found a large lieve that the coverings of the hernia could have so quantity of omentum, and, lying behind it, a knuckle prolonged themselves, and it was, indeed, doubtful of four or five inches of intestine. I then divided if there were not some adventitious swelling uncon- the stricture, and as the intestine, with the exception nected with the hernia. As the symptoms were very of slight congestion, was quite healthy, I returned it urgent, I proposed to perform the operation imme- into the cavity of the abdomen, leaving the omentum diately. The patient consented, and I commenced within the sac; the edges of the wound were brought with a vertical incision in the seat of common femo- together by suture. and the patient put to bed. She ral hernia. I made a second incision at right angles said that she was relieved from all sensation of conto the first. On dividing the skin and superficial striction. On the 16th, she had a free evacuation of fascia, I exposed the internal abdominal fascia, (the the bowels, the sickness had entirely subsided, and fascia propria of Sir Astl y Cooper.) The incision the pulse was quite natural. On the 17th, purging was continued outwards over the prolongation of the came on, she was very much flushed, and symptoms, swelling. I divided the fascia in the same direction which were almost those of mania rather than delias I had previously divided the skin. The hernial rium. supervened. This might perhaps have arisen sac was thus exposed; and it was continuous with from an hereditary tendency, her mother having died the whole of the swelling. I next divided the stric-mad. I have observed, in other cases, that delirium ture, and the sac became immediately quite flaccid. followed upon omentum being left in the sac; but in In consequence of the anomalous form of the tumour, those the omentum sloughed, which did not happen I determined, however, upon opening the sac, in in this case. After the 17th, the patient went on imorder to ascertain the nature and condition of its con- proving; the wound healed rapidly, almost entirely tents. I found in it a knuckle of intestine, elongated by first intention; and on the 27th I left her quite in the direction corresponding to the tumour; it was cured. quite healthy and fit to be returned into the cavity of the abdomen. A few hours after the operation, the patient had a free evacuation, without the use of a purgative. This patient also speedily recovered.

Oct. 15th, 1851.- was called to a case of hernia by Mr. Thornton, of Museum-street. The patient was housekeeper to a lady in St. James's-place. She was fifty years of age, and when I saw her had been suffering for three days from strangulated hernia. She was very sick, but there was no other urgent symptom; no pain nor swelling of the abdomen; the countenance not distressed; and the pulse full, soft, and compressible. Upon examining the tumour 1 found it large and flaccid, extending down the thigh.

Anomalies in the form of a hernia may, as I have said already, render it very difficult to diagnose with accuracy the nature and direction of the protrusion, but anomaly of form is not the only source of difficulty; the circumstances concomitant with the hernial protrusion are sometimes sufficient to mislead the judgment very materially. I have selected the following cases to show how far accompanying symptoms may interfere with the diagnosis of hernia.

In May, 1838, Mr. Callaway was sent for to a ca e of inguinal hernia, on the right side of a lady, aged 36. The hernia had descended only the day before, but it had existed for nine years. The symptoms being urgent, Mr. Callaway determined upon operating

immediately. On opening the sac he introduced his quantity; unfolding this, an adventitious cord of finger through the internal ring, and returned the protruded intestine, which was quite healthy. As soon as the intestine was returned, a fluid escaped by the opening in so large a quantity that it was thought at first that the bladder had formed the protrusion, and had been wounded; it was soon, however, seen that this was not the case, for the fluid coagulated on the sponge used in wiping it away, and when a portion was collected in a wine-glass it separated into a clot, which precipitated, and a serum which remained on the top it also coagulated by the application of heat. These circumstances seemed to show that it was an ovarian cyst which had been opened. Soon after the operation the bowels were relieved, and the patient recovered.