remained sufficiently dilated to admit my hand, on passing which, the first thing I perceived was a quantity of coagulated blood, the greater part of which I brought away before I proceeded any farther. I then felt for the cake, which I discovered firmly adhering to the fundus uteri, By inserting my fingers between it and the uterus, and using gentle force, I soon completely separated it; and now grasping it in my hand, I cautiously withdrew it. The hæmorrhage at first was considerable, but soon became moderate. After a few minutes I again introduced my hand, to find whether any pieces had been left detached; but not finding any, I withdrew it, bringing away a considerable quantity of coagulated blood. I judged this precaution the more necessary as the placenta was in so putrid a state that it séparated even by its own weight. Thus she was freed of the secundines just twelve hours after the birth of the child, since which the lochial discharge has been but small, and she appears quite easy and composed. She continued in a very favourable state since the delivery of the placenta on Wednesday morning until Friday afternoon, when she was attacked with a violent rigor, succeeded by pain and tension of the lower part of the abdomen. She was now ordered a dose of castor oil, and fomentations to the hypogastric region, with an anodyne in the evening.

Saturday morning much better; has had several stools ; pain of the abdomen considerably abated. She has slept pretty well during the night; has had several slight rigors; appetite good, pulse rapid and full, with foul tongue and pain of the head; she was ordered a saline mixture and to abstain from all stimuli, In the evening every symptom recurred with redoubled violence, pulse rapid and strong, breathing difficult, pain excruciating, great restlessness, a continued diarrhoea, and complete obstruction of the lochia. Being thus seized with extensive inflammation, she was ordered to lose six ounces of blood, which although a small quantity, had nearly induced syncope, When she recovered she took a draught of opium and antimonial wine, which gave her some rest, and produced a gentle diaphoresis during the night; when she awoke in the morning she again seemed much revived, drank a cup or two of tea, and only complained of a general soreness and stiffness all over the abdomen, extending down the thighs,

On Sunday evening she became much worse: no appetite, debility so great that she was unable even to turn in bed countenance became pale; the diarrhoea which had continu

ed

i

ed for two days now ceased. She was ordered to continue ber saline mixture, and another sudorific draught was administered. The pulse had now sunk considerably, and putridity had much increased, so that not only the people about her, but even she herself, could scarcely support the foetor, although the fumigating lamp was still kept at the bed side. I may just observe, that the weather was extremely warm during the whole time of her indisposition. At this time she was much harrassed with frequent retchings and vomitings. A large blister was now applied over the hypogastric region, and the antiseptic plan was now adopted instead of the antiphlogistic. With this view she took a desert spoonful of yeast every two hours, with an anodyne draught. Monday morning she appeared again much better, her retchings and vomiting having entirely subsided. Shé drank a cup of tea this morning, her appetite being much better than yesterday morning, which I attributed to the salutary effects of the yeast. The blister had not drawn, and it was therefore renewed. She gradually became worse during the day, so that nothing could now be taken but some porter, which was used as her common drink. All her pains having ceased, she appeared quite easy and slept a great deal. I now left her, not thinking she would survive till morning. Calling on Tuesday morning, I found her in a similar state. She was quite sensible at intervals, when the stupor subsided. She continued in a comatose state during the day, and survived till Wednesday morning, retaining her senses to the last, when she calmly passed into the extended arms of death.

Thus terminated this melancholy case on the eleventh day from its commencement. The membranes broke thirty two hours after labour began; the child was born sixty-eighty hours after, and thirty-six from the rupture of the membranes; placenta delivered twelve hours after the birth of the child, and about fifty-two before the fever commenced.

There is no doubt but the latter part of this case was the disease termed puerperal fever, which became epidemic in London in 1770, and which, I believe, was first particularly treated of as an original disease by Dr. Hulme, He describes it as a disorder which most commonly attacks the patient on the second or third day after delivery, when the belly becomes painful, tense, and sore to the touch, succeeded by rigors, pain in the head, heat, thirst, inquietude, and a quick pulse with difficult respiration and often retching and vomiting. Having inspected several

14

bodies

bodies who died of this disease, he found the omentum and intestines in a highly inflamed state. He therefore very properly attributes the cause to inflammation. In his indications of cure he places much more reliance on cathartics and diaphoretics than venesection, which he cautiously recommends.

Ipswich, June 10, 1810.

1 am, &c.

W. HAMILTON.

To the Editors of the Medical and Phyfical Journal.

GENTLEMEN,

SINCE

INCE my last communication to you, on the subject of reducing Strangulated Hernia by the Taxis, I have met with five more cases, where gentle and long continued pressure has been practiced. In two of these, I succeeded, but in the rest I failed. These cases, though possess ing neither novelty nor interest, much different from those formerly sent you, I have given you in detail. One of them, where the taxis failed, was so uncommonly circumstanced, as to entitle it more particularly to a place in your widely circulated Journal."

Hannah North, a married woman, aged 33 years, but who never had children, applied to me in the year 1806 for a swelling in her right groin, which she first discovered fourteen years before, and had in this interval applied to many surgeons, but without obtaining relief, or any satisfaction, as to its nature or probable consequences. One surgeon, a man of eminence, did actually salivate her for it, and declared her case venereal. Several others, from their manner of treating her, seemed to have similar suspicions. On the other hand, there were some who suspected it to be hernia, but acknowledged there was something mysterious in the case. From anxiety arising from this state of uncertainty, as well as by the imputation cast on her character as a modest woman, (for she then was single) from the supposition of her case being venereal, her life had become extremely unhappy.

On examination of the swelling, I could perceive two distinct tumours bordering on each other, and nearly in the same horizontal plane. The one situated exteriorly was hard, more circumscribed and prominent; the other inte

riorly

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riorly was softer, more diffused, and had a larger basis. This latter tumour frequently lessened when in a recumbent posture, but never entirely disappeared. She also made frequent attempts to reduce it by the taxis, but does not recollect she ever succeeded.

Being satisfied that one of these swellings, at least, was a hernia, notwithstanding the intricacy of the case, I recommended her to apply a steel-truss to this tumour only, but I believe this advice she neglected, for on the evening of the 7th of February, 1807, she was seized with symptoms of strangulated hernia. I saw her the following morning, when she complained of sickness and frequent Vomiting, constipation of the bowels, and pain in the abdomen, which shot upwards towards the stomach, and downwards towards the vagina. Her belly was neither swelled, nor very painful to the touch; her pulse was 92 and soft, and her tongue a little, though slightly furred. She said the interior swelling in the groin was somewhat painful, had been down some days past, and was now at its largest size.

I made gentle pressure on this tumour for three hours, having previously ordered her five drops of the tinct. vpii to be given every eight minutes. This remedy, and the manner of giving it in such cases, had been recommended to me by a friend. The aq. litharg, acet. c. was applied in the form of stupes, and pressure the rest of the day and the following night was continued at intervals. By midnight, from mistaking the directions that were given her, she had consumed half an ounce of her drops, but after the first hour of taking them, her vomiting and other distressing symptoms abated.

On the morning of the 9th, the vomiting and pain, attended with hiccough, returned with increased violence. Fifteen grains of the vitriolated magnesia were given her in a dissolved state; but this seemed to increase her sickness, The opium was again had recourse to in the same manner, and with nearly similar effects; and two drachms and a half of it were taken, before it was ordered to be discontinued, and pressure was again applied as before.

The pulse, during all this time, continued to increase in velocity, without any diminution of force; her thirst had likewise increased, and her tongue had become rather more furred; yet, notwithstanding, there did not appear any symptoms of considerable local inflammation. Her belly was neither tense nor much painful, and the tumour bore handling well.

On

On the morning of the 10th, she was evidently worse. Her pulse was at 120, but not weak, and her vomiting was frequent and distressing. Her thirst was also considerable, and her belly rather tense and somewhat painful; but still I could not perceive so much of that languor and deprivation of vital energy, which too often characterize and attend this affection. The tobacco-clyster was now administered, (a drachm and a half of tobacco being boiled in a pint of water ten minutes.) This caused considerable sickness, during which, pressure was again made on the tu mour for half an hour, but without the desired effect. After the influence of the clyster had subsided, the operation was performed. The incision was begun a little above the upper verge, and carried down below the inferior margin of the tumour. The fascia was next carefully divided; after this, I was surprised on the hernial sac coming in view, to discover a substance attached to the inferior and exterior portion of the sac, thus 8. This primâ facie appeared to be glandular, and adhered to the sac so firmly, as to render it impossible to ascertain the point at which they were united. This appendage was of an eliptical shape, resembling a moderate sized walnut, both in form and magnitude, and was somewhat flatted on its anterior and posterior parts. An incision was made better than half through it transversely, which discovered its texture, and some blood-vessels apparently enlarged, passing into it, convinced me it was one of the inguinal glands in a diseased state.

Having previously exposed the bottom of the sac by dissection, I desired an assistant to draw it a little exteriorly, and I gently passed the fore-finger of my left hand upwards between the sac and aponeurosis. The adhesions, which were only partial, and extended upwards about three-quarters of an inch, gave way by very little force. Having passed the tip of my finger within Gimbernat's ligament, I with the bubonocele-knife divided it upwards, and a little inclining towards the pubes. The incision, as nearly as I could ascertain, was about one-third of an inch in length; and the act of making it, gave me a sense of feeling, as if the knife were dividing something ligamentous. This being accomplished, in a few seconds the sac became less and flaccid, borborigmi ensued, and the patient expressed herself greatly relieved. In order, however, to be certain that the hernia had entered the abdomen, I pushed up the sac as far through the aperture as possible, without violence, but found the gland, as well as the adhesions of

the