turbance, the inflammation rapidly increases, the distention is prevented by the rigidity of the tendinous aperture, or by the neck of the sac which contains the intestine-hence strangulation."

The author then goes on to state, what, however, has been stated by others; but the consequences which he deduces are his own, and important; that the strangulation and its symptoms are not produced by any altered state of the abdominal aperture, and that the inflammation and enlargement of the intestines are the essential points to be considered.

He then observes,

"From what has been stated, it appears that the indication of cure generally laid down, is not warranted by the nature of the disease, nor of the treatment, namely, to return the hernia through the apertures by pressure with the hands; because, as mentioned before, it is not the situation of the intestine, it is the enlargement of it, which occasions the symptoms; and that state should, in the first instance, forbid the attempt on account of its obvious impracticability."

These remarks lead the author to, and prepare the reader for, a very material alteration in the treatment of strangulated hernia in its first stages, which we shall state in his own words.

"With the view of affording a satisfactory explanation of the practice, which I think ought to be pursued, founded on the principles which I have endeavoured to establish, I shall des cribe my own manner of treating a case, and the order which I think ought to be followed, and which has succeeded under my arrangement in, I believe, more than 36 cases since the year

1796.

"I place the patient in a recumbent position, with his shoulders a little raised to relax the trunk, but the pelvis not raised, as that would put the fascia on the stretch; the knees are to be drawn up. If the parts have not been irritated by handling them, or the body disturbed by jolting it about, or by any such roughness, I proceed directly to apply cloths, wet with cold water, expose the entire body to the open air, the doors and windows

being open. This practice usually succeeds within an hour. If it does not, I surround the hernia with my hand, or hands, at about its middle, in the way that I would grasp a gum elastic bottle, to press out its air or other contents, by gently approximating its sides, always holding in view that the tumor is to be emptied, and not pushed up, and that a little assistance to the compressing force, which the coats of the intestine, (reacting from distention) are exerting, by lessening its area, even in a small degree, the air will be strongly impelled against the part of the tube which is closed, and through which it is only necessary that it should obtain exit, to effect our purpose. When it is small, as in femoral hernia, or in protrusions, which do not pass below the groin, or are elsewhere situated, it may be done with the fingers and thumb of one hand. Having applied the hands, I do not remove them for fifteen or twenty minutes, aware that reiterated impulses irritate, and that the effects of compression are lost each time that it is intermitted.

"Cases which have been long strangulated, and those which are accompanied with great pain and tension, are exceptions to this practice, so far as the employment of the hand, on the principle that the reaction of the intestine is at a pitch sufficient to propel the air through the coalesced tube, if its passage is possible, and that handling parts in such a state would endanger mortification or rupture of them. My chief reliance in such is on bleeding, proportioning the quantity by nearly the following scale:

"If the patient is young and robust, I take off sixteen ounces; if old, or weakened by previous illness, from six to ten ounces, should even debility+ take place if attended with

* In some cases where I could not immediately attend, I have directed that cold applications should be used until my arrival, and after an hour, they informed me that they were seized with a shivering; that they heard the wind rush out of the hernia; and that they were instantly relieved.

↑ I never press the hernia in any direction, or at all towards the aperture. It is very material in this, indeed in every disease, to discriminate between that debility which is the effect of pain, anxiety, and restlessness, and that which is the effect of impaired health or of original constitution. In the former, bleeding is advisable; in the latter it is generally improper to any

extent.

great pain, I repeat the bleeding after three hours; but if the pain yields, I omit it; all this time I apply nothing topically,. except cold water, and strictly avoid all attempts with the hand.

"I direct no medicine internally, and by these means I have succeeded in the instances before mentioned; and I am persuaded that they will scarcely ever fail, provided, that the taxis in the usual manner had not been practised, and that such other exasperating causes, as putting the patient with his head to the ground and his heels up, and jolting him about, had been omitted.

"Strangulated hernia, under this treatment, will in many cases continue several days without serious mischief; and in the event of the operation being required, peritoneal inflammation will be provided against.

"The tobacco clyster is the next remedy which I would advise; in a robust subject in the proportion of one drachm to a pint of water, which I would repeat of double that strength, if the first produced no effect; in an infeebled person, half a drachm should be first tried.

"In the event of failure in our efforts to remove the strangulation, the operation of enlarging the apertures by the knife must be had recourse to; the precise time at which we should lay aside all other means, and commence this practice, is not easily decided on.

"In a young and full person suffering great distress, I would' not defer it longer than six or eight hours, particularly if the hernia had been much handled, and also if bleeding had not been used; but where no mischief had been produced by external causes, and this evacuation had been premised, it might be deferred sixteen or twenty-four hours, always watching if the belly became sore to the touch, or much inflated, in which case to operate instantly. In an aged or debilitated subject it may be delayed longer. I have known it to continue in such, six, seven, or eight days, and afterwards to be removed without an operation."

Such is the treatment, and such the means which the author recommends in the strangulated hernia previous to operation. The points on which he differs from others are, chiefly, abstaining from violent attempts to reduce the gut, and objecting to the use of purgative medicines. He is the advocate of bleeding, of the application of cold, and, in short, of every antiphlogistic plan to reduce the size and inflammation of the intestine preparatory to its return. On the whole, we consider this commentary as a valuable addition to our information on a disease of great importance, both from its frequent occurrence, and the imminent danger which accompanies it; and we therefore strongly recommend the work to our readers.

THE following case having some time since fallen under my notice, I shall, without any apology, venture to submit it to the press, with a few observations necessarily resulting from it.

Having been called to visit a patient who was supposed to be in the fifth month of her pregnancy, but who for several weeks previously had been distressed with uterine hemorrhage, at first in a moderate degree, but gradually increasing in violence until it became truly alarming. Upon my first seeing her, I was convinced from the severity of the pains which had come on some hours before, with regular intervals of ease, that abortion would inevitably take place, and thought it most safe to ascertain her precise situation, by an examination; by which I found the os uteri dilated to about the size of a half dollar, and a substance presenting very similar, as regarded the touch, to the placenta. Presuming that this was attached immediately over the os uteri, I thought it best to separate or perforate it with my finger, expecting that the liquor amnii and fœtus would then be immediately expelled: but, to my surprise, instead of these, there was discharged a mass something resembling a small placenta verging towards putrefaction with half a common wash-hand bason full of transparent spherical vesicles, from the size of a pea up to that of a small walnut, full of water: after which the hemorrhage ceased. I could not detect any appearance of the impregnated ovum or fœtus. The vesicles were connected with each other, and to the surface of the more solid mass resembling the placenta, by short pedicles or necks; they were extremely delicate, and easily broke down upon being handled. The woman recovered happily and spee dily.

Mr. Home, in the second volume of the Medical and Chirurgical Transactions, relates the case of a young woman who died