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administered that evening, and brought away much fæcal matter. In the course of the day the tumour became spontaneously much reduced in size; for some time subsequently a small swelling remained in the groin, and whether it ever disappeared completely I am unaware.

The second case occurred in the practice of my friend and partner, Mr. Allan, of Epsom, and I am chiefly indebted to him for the particulars. A woman, aged 70, suffering severely with a catarrhal attack, presented symptoms of obstruction of the bowels, and on examination a femoral hernia was discovered in the left groin. She said she had first perceived the swelling two or three months previously, and it had seemed within the last few days to increase materially from the violence of the cough. The taxis aud other remedial means were unavailingly resorted to, and the symptoms had existed 48 hours when Mr. Allan requested me to see the patient with him, that we might determine as to the operation. At that period I found the tumour the size of a large walnut, free from heat or pain, neither was there any abdominal tenderness. The tongue was somewhat furred and ary, but there was no great heat of skin; the pulse did not exceed 84, was regular and not deficient in tone. The woman's chief complaint was of intense nausea and violent sickness, coming on with the paroxysms of coughing; any movement or attempt to change her position would also occasion it, and on taking any nourishment, it was immediately rejected; with the continued vomiting stercoraceous matter followed in abundance. I applied the taxis some time, and with considerable force, but unsuccessfully. There could be no doubt as to the nature of the case, and the ultimate necessity for an operation seemed inevitable, but as the constitutional symptoms were not urgent, and the operation was strenuously objected to by the husband, we agreed to some farther delay. A large eneina with castor oil was administered, and, beyond a little gruel, no nourishment was to be attempted.

No favourable change had resulted the following morning, night had afforded no repose, and the retching and vomiting had been almost incessant. The enema had for the most part been retained some hours, but its evacuation had been unaccompanied by fæcal matter. The constitutional depression was more manifest, the pulse had become accelerated, and some pain and tenderness were experienced both in the abdomen and in the tumour. Mr. Allan proposed that the tobacco enema should be used, and in the event of its failure, that the operation should be had recourse to without farther delay. Bearing in mind the success which had attended opiate treatment on the former occasion, I suggested its adoption in the present instance, as there was still great aversion to the operation on the part of the patient and her husband. Mr. Allan acceding to my proposal, one

grain of opium in the form of pill was administered every hour.

When we met the following morning eight doses had been taken, and the narcotic influence was manifest, though the medicine was evidently well borne. The pain and vomiting had ceased, but the bulk of the tumour was not diminished, nor had the bowels been moved.

After the administration of four more doses the tumour was found to have diminished to one half its former size, the patient still continuing free from pain and sickness. A large injection of gruel with castor oil was then thrown up the rectum, and ample evacuation of fæces soon took place. The relief was permanent. A small swelling remained in the groin, and still continues, probably containing a portion of incarcerated omentum. In the words of Mr. Allan, "Thus was this patient saved the risk and pain of a serious operation, by a remedy, every dose of which brought relief and comfort."

I shall now venture on a few brief observations in reference to the modus operandi of opium in hernia, and my opinions on this subject have emanated rather from a long continued investigation of the action of the various narcotics and sedatives, than from a mere wish to clothe the above isolated facts with an appropriate and well-seeming theory.

The pathological elements of strangulated hernia are two-fold:—on the one hand those connected with the protruded bowel, and on the other those depending on the muscular and tendinous tissues which surround the opening through which the intestine protrudes. That the tendinous structure can only exert a passive influence is generally allowed, and that permanent spasm can under ordinary circumstances affect the fibres of the voluntary muscles, or even those which are instinctive or spinal-motor, would not on reflection seem probable; and yet on this latter assumption have all the theories of hernial strangulation been chiefly founded as far as I am cognizant thereof. Now, in a pathological point of view, beyond the visceral extrusion, through a narrow and unyielding opening, I believe the active cause of hernial strangulation to be essentially connected with the intestine itself. Suppose a portion of intestine forced into a cavity of which the neck is somewhat constricted. Now, we know that the general effect of superficial pressure on any portion of the body will occasion a greater obstacle to the venous part of the circulation than to the arterial. The balance of action of the two circulating media being disturbed, the afflux will incline to exceed the eflux, until such time as circulation is completely arrested, when gangrene must take place. In accordance with what I have stated above, any medical attempt to relax the external muscular structures would be unavailing; but on the other hand, if we can relax and.

ÆTHER-INHALATION IN TETANUS.

205

of a portion of intestine. The velocity of the capillary circulation is found to diminish on the application of opium; and where a person is under the poisonous influence of the drug, I need scarcely remark that blisters and sinapisms will fail to produce the slightest irritant effect, so completely is organic sensibility destroyed. In conclusion I may remark, that in my experience, the safest and most effectual method of bringing the constitution under the influence of opium, in ordinary cases, is by the repeated and frequent administration of moderate doses; and I am therefore inclined to advocate the same plan in hernia, care being taken to carry the administration to a sufficient extent.

Since writing the above, the influence of æthereal inhalation, in cases of hernia, has come to my knowledge; whether the medicinal action thereof is superior to that of opium remains to be seen; but be that as it may, the lately recorded facts support my view of the pathology of hernia. Mr. Tuson's case, published in the Medical Gazette, is especially remarkable. On the abdomen being opened, large masses of intestine escaped, but on æther being used, the bowel returned spontaneously, apparently collapsing rather than contracting under the medicinal influence.

reduce the bulk of the intestinal substance, we might then hope for advantage. Now, let us look at the influence of the various sedatives, and see how far any one of them may be expected to conduce to the desired end. Warm baths and bleeding may lower the general system, and relax the muscular structures, but the result of their employment do not sufficiently indicate a decided bearing on the local morbid state. Antimony exerts a special depressing cerebral influence; it diminishes the power of the heart, and lowers respiratory action; it also affects the contractility of the voluntary muscles, but it does not diminish the peristaltic contraction of the intestines in the first instance, neither does it immediately influence the capillaries; moreover, it is objectionable on account of exciting irritation in the mucous membrane of the alimentary canal. Belladonna exerts its chief influence on the voluntary muscles; so likewise does tobacco, which in its cerebral influence will subsequently determine to the heart; over that centre of the circulation, digitalis appears to exert a direct control, but it has no peculiar action on the capillaries. Aconite, on the other hand, seems to have a special relation to the sensitive power, and to exert no direct influence over contractile or motor structures. The diminution or even destruction of organic sensibility appears to result from the action of prussic acid, so as to destroy the connection between action and re-action. Now ON ETHER-INHALATION IN TETANUS, WITH opium is essentially one of the most powerful sedatives we possess, although undoubtedly stimulation may be primarily consequent on its administration under peculiar circumstances. Its action is very general. When freely administered it relaxes all the contractile tissues, and primarily and essentially those which are involuntary. It soon reduces the force of the circulation, and though at first it may tend to produce a state of capillary congestion, yet as soon as the balance of action between the centre and periphery of the circulation is restored somewhat, the capillaries of the surface and of the membranous viscera will be deficient ingested, amongst other diseases, that tetanus is one in their usual contents, and lose their natural irritability. Now, with emptied and inactive capillaries, and relaxed contractile fibre, is it not to be expected that the hernial tumour would become reduced in bulk, motionless, insensible, and flaccid?-the intestinal structure is in fact utterly paralysed, and the state which has caused strangulation being removed, as well as the undue internal pressure by which it was originally caused, may we not fairly hope for the spontaneous reduction of the protruded viscus, even as it seemed to occur in the instances which I have adduced?

Experimental enquiry supports the opinion I have advanced respecting the medicinal influence of opium. If the heart, while yet pulsating, be removed from the body of an animal, the muscular contraction will immediately cease on applying a solution of opium, and the same is the case with the vermicular motion

A CASE.

By W. H. RANKING, M.D., Norwich.

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A careful analysis of the recorded experience of the æthereal inhalation in surgical cases cannot fail to convince any unprejudiced person that a discovery has been made, no matter by whom, which is not surpassed in the annals of the healing art. We now know tolerably well what are the circumstances under which it may be exhibited in surgical practice, and when it should be withheld, but of its effects in medical practice we are comparatively ignorant. It has been sug

which the stupifying agency of æther would be of great service, but with the exception of myself, I believe as yet no one has had practical demonstration of its effects.* These effects were, as the subjoined case will indicate, not only not beneficial, but to all appearance injurious.

In a disease so uniformly fatal as tetanus, I regard experimentalism, even in the teeth of physiological deduction, as pardonable, otherwise I should not have ventured upon the inhalation of æther in the present case, for I am induced to believe, from a careful noting of the operation of the agent, that it has no power,

Since the above was written, two trials of æther in tetanus have been recorded,-one in this country, one in France. In the former some slight relief was thought to have been afforded; in the second death was indubitably precipitated by its use.

at all events, immediate upon that portion of the nervous system which we know to be engaged in the manifestation of tetanic symptoms-namely, the spinal marrow. I am aware that this opinion is at variance with that of some French physiologists, Longet among the number, who maintains that æther does induce insensibility of the spinal marrow as well as of the cerebral lobes, though only secondarily to the latter, and when carried to a degree in itself all but fatal; but I still consider, that therapeutically considered, æther cannot be employed in diseases of spinal origin, as granting that it is possible to influence that part of the nervous system, it can only be done at the risk of seriously prostrating the functions of the cerebral portion.

If the spinal marrow either cannot be affected at all by æthereal inhalation, or only as secondarily to the production of deeper cerebral insensibility, than most people would consider themselves justified in inducing, it must be obvious, on reflection, that it is not likely to act beneficially in tetanus, for we know that the functions of the true spinal marrow gain an increased intensity by the abolition of the controlling power of the brain. Such being the case, we might expect that the spasms of tetanus, so far from being mitigated, would be aggravated by the inhalation. This was not actually the case in the instance which I am about to record, for the plain reason that inhalation could not be carried on to the point of inducing insensibility. The mere attempt to insert the pipe into the mouth caused the spasms to reappear; and the first contact of the æther vapour with the bronchial membrane induced such fearful con

vulsions, that to proceed with it was out of the question. In recording this case, however, I would not omit to state, that the inhalation was attempted with a common bladder and pipe; as the more effective instruments which ingenuity has devised in such abundance, had none of them at the time been brought into existence. The case is briefly as follows:

being furnished, and two ounces of the purest æther we could obtain being put into it, the patient was got into a bath at 108°, and the inhalation commenced. The warm water had partially relaxed the board-like rigidity of the body, and the poor fellow expressed some relief, when the attempt to insert the pipe again excited a strong spasm. Being however, anxious to persevere, he contrived to push it into his mouth, but the first breath he drew aggravated the spasm in a tenfold degree, the body became perfectly opisthotonic, foam issued from the mouth, and the man altogether presented so frightful a spectacle that we might fairly have been excused had we desisted from that moment. We, however, after allowing the effects to subside, made one more attempt, when the recurrence of the same symptoms convinced us of the worse than uselessness of the proceeding.

The subsequent treatment need scarcely be alluded to, as my object is solely to point out the failure of the æther, but I may state that he was bled largely and continued the cannabis, with some amendment, and in the evening had a tobacco enema, (half a drachm to half a pint of water,) which acted effectually in relaxing the spasms. A warm perspiration ensued, the patient was enabled to open his mouth to the extent of an inch, and He expressed himself as in every respect better. remained quiet for nearly an hour, with a good pulse, when a sudden spasm seized him, in which he died.

OBSTINATE CASE OF CONSTIPATION.

By JOHN ELLIOTT WOOD, Esq., Surgeon, Rochdale.

Nancy Sladen, a married woman, the mother of several children, was seized on February 19th, 1847, with pain in the abdomen, vomiting, hiccough, and the subject of irreducible femoral hernia for several other symptoms of strangulated hernia. She had been years. The hernial tumour, however, though large, was not larger than usual, nor more tender to the touch than the abdomen generally. Pills of calomel with croton oil were administered, and injections used, without producing any discharge from the bowels. The symptoms gradually increased in urgency, and on February 21st the usual operation for femoral hernia was practised, the patient being at the time under the influence of ather. The bowel and omentum were found in a natural state, no strangulation existing.

Large doses of calomel were now administered by the mouth, and injections of castor and croton oils diligently persevered in, without any relief to the symptoms. The abdominal tenderness increased; the hiccough and vomiting continued; there was a remark, able anxiety of countenance.

A man aged about 60, of intemperate habits, but of remarkably fine and athletic proportions, ran a nail through his boot into the sole of his foot, near the ball of the great toe, while walking across some old timber. The accident gave him no uneasiness until the expiration of a week, when he complained of stiffness in the neck, and placed himself under the care of Mr. Coe, a surgeon of Bury St. Edmunds. The next day the tetanic symptoms were general, and my co-operation in the treatment of the case was requested. On visiting the patient, about eleven in the morning, I found the jaw completely locked, the spasms frightfully violent, and considerable opisthotonos; in fact, every symptom was present of tetanus of the most acute From this time to March 31st, a period of more than character. Our treatment was commenced with the | five weeks, croton oil, castor oil, compound extract of Cannabis Indica, full doses of which were with difficulty colocynth, large doses of calomel, jalap, injections of got down; but this medicine was for a period croton and castor oils, of turpentine, of tobacco infuomitted in favour of the ether-inhalation, which sion, of large quantities of warm water, friction to thewe determined to essay. A common bladder and pipe abdomen with castor oil, with turpentine, the cold:

On February 22nd, a solution of morphia was prescribed, which afforded the patient more relief than anything hitherto had recourse to.

HOPITAL DE LA PITIE, PARIS.

douche, every remedy, in short, calculated to produce a purgative effect, was tried without effect. The morphia was continued during the whole time with great benefit. Beef tea, jellies, wine, and eggs, were ordered, and taken with appetite.

On March 31st she felt an inclination to go to stool, and parted with a motion, perfectly natural in consistence and colour; this was followed by several others in the course of the day, till she had discharged a very large quantity of fæcal matter. There was no blood, or mucus, or scybalæ, and no portion of intestine voided.

The incision over the hernial tumour, it should be stated, healed in a week. The night before the re-establishment of the action of the bowels, the hernia became large and painful, but was reduced to its usual size by pressure without difficulty.

207

premonitory symptom; she did not receive any treatment, and was brought to the hospital at six o'clock the same morning. At present the patient lies upon her back, rolls her head from side to side, throws her arms about, and moans as if in great pain; the skin is moist and natural; the expression of the countenance is anxious, the lips and cheeks are florid; the respiration is hurried and laboured, fifty-five in the minute; she speaks interruptedly, catching her breath between each word. There is no cough, the physical signs of the lungs are quite natural. She complains of severe pain, (which has continued since one o'clock this morning,) shooting through from the xyphoid cartilage to the spine. She states that she feels a tightness about the chest, and a sensation as if she were being suffocated. There are no external marks of injury in the epigastric

The patient is now (April 3rd,) in a fair way for region. On auscultation, the heart's beat is found to recovery, though reduced in strength and flesh.

Rochdale, Lancashire.

Hospital Reports.

HÔPITAL DE LA PITIÉ, PARIS.

be slower than natural, there is a slight degree of harshness with the first sound, and the sounds are heard over a larger surface than usual. On percussion, the heart is found to be enormously enlarged, measuring from above downwards four inches and a half, and from base to apex five inches and a half; the dulness is very strongly marked; the aorta is also distended; the pulse is laboured and compressible, seventy in the minute. There is no nausea nor vomiting; the large

A CASE ОР ENGORGEMENT OF THE HEART AND intestines are filled with solid matter, and the stomach
INTERNAL ORGANS, PRODUCED BY A SEVERE
KICK UPON THE EPIGASTRIUM, AND FOLLOWED

is distended with gas; the bowels have not been moved for the last eight days; the liver is somewhat

BY SYMPTOMS OF INTERMITTENT FEVER, AND enlarged; the spleen is of the usual size; the urine is natural in quantity and quality; the catamenia are regular. ver

PERIODIC NEURALGIA, WITH REMARKS. (Communicated by SEPTIMUS LOWE, Esq., M.R.C.S.) History of the case: present attack; symptoms on admission.—Treatment: its effects; progress of the case; convalescence; cure.—Remarks: importance of percussion; nature of the attack; engorgement of the heart, lungs, and liver.—Cause: “anervismie;” benefit derived from bleeding.-After symptoms: “hypernervismie ;" intermittent fever; intercostal neuralgia; periodicity referred to the ganglionic system and spleen.

S. P., a female aged 18, admitted into the Hôpital de la Pitié, under Professor Piorry, March 19, 1847. She is a needle-woman, of the ordinary stature, sanguine temperament, and florid complexion. She is a native of Paris, and has resided all her life in the Rue Mouffetard, inhabiting a small ill-ventilated apart. ment, and sleeping in the same room with eight other persons. She has never suffered from rheumatism or bysteria. About three months since she had a severe cold, with pain in the epigastrium, and loss of appetite, but she was not put under any treatment. Her health has been generally very good. About six o'clock on the evening of the 18th of March, whilst restraining a patient during an attack of hysteria, she received a severe kick in the epigastric region; she suffered but little at the moment, and continued her usual occupations. About one o'clock in the morning of the 19th, she was suddenly seized with violent pain below the left breast, shooting through to the inferior posterior part of the chest on the same side, with very great difficulty in breathing, and considerable anxiety and restlessness; she had no shivering fit nor other

The extent of the heart being marked out upon the skin with nitrate of silver, Professor Piorry ordered the patient to be bled to the amount of thirty-two ounces; during the bleeding she experienced great relief, and at the conclusion she expressed herself nearly free from pain; the dyspnoea was almost entirely removed, but there still remained some degree of tenderness in the epigastrium. On again percussing the heart, it was

found to have diminished to the extent of an inch from | above downwards, and three quarters of an inch on its left border; the dulness was much less intense in its character; the aorta was considerably lessened, and the liver was also diminished about half an inch, both on its inferior and superior borders; there was no tendency to syncope, nor was there any sensible effect produced upon the patient's strength; the pulse mounted to eighty, and became firmer, and more natural. Ordered to abstain from all food, and to have a purging enema.

Vespere. About five o'clock she was again attacked with severe pain and dyspnoea. Ordered a grain and a half of opium.

At eleven o'clock the opium was found to have had not the slightest influence in subduing the symptoms, and they had, in fact, become almost as urgent as on her first admission; the heart was again enlarged to about midway between the first limitation and the one made after the bleeding. Ordered to be bled to the amount of thirty-two ounces. After the second bleeding the extent of the heart was found to be diminished considerably within the limitation made

after the former bleeding, and to be, in fact, almost in its normal condition. The distressing symptoms were again completely removed, and the patient obtained a few hours sleep.

20th. About three o'clock this morning she experienced a return of the pain and dyspnoea, but less intensely than before. The heart was found to be in its normal condition, so that a third bleeding was not deemed necessary. A warm bath was ordered, which succeeded in removing the distressing symptoms. At present she is quite calm and composed, but complains of tenderness in the epigastrium and left intercostal spaces; the pulse is regular, compressible, and 78; there is considerable tenderness on pressure over the sixth, seventh, and eighth dorsal vertebræ; the bowels have not yet been relieved. Ordered a warm bath, a mustard poultice to the epigastrium, and a purging

enema.

21st. The pain is greatly relieved; the bowels have been moved once; the tongue is slightly furred; no appetite; heart in its normal condition; pulse rather weak and compressible. Ordered low diet. Continue the warm bath and enemata.

22nd. The countenance is again anxious; there is considerable jactitation, interruption in speaking, and catching of the breath. There is not the same kind of dyspnoea which was observed on her admission. She complains of violent lancinating pain, darting through from the epigastrium to the left intercostal spaces and spine, so that she cannot fully expand the chest, or take a deep inspiration, without great agony. The heart continues in its normal state; there is no harshness with the first sound; the large intestines are still filled with fecal matter, and the stomach is distended with gas. Ordered thirty leeches to the epigastrium, followed by a large linseed poultice; friction over the abdomen with olive oil; a blister over the spine, to be dressed with a quarter of a grain of hydrochlorate of morphia; a purging enema, and

a warm bath.

the quinine and warm baths, and apply a blister to the epigastrium.

From this time until the 29th, the patient had an attack every day, but each day it became shorter and less intense; the tenderness in the epigastrium and spine continued, and she complained of some degree of feebleness.

31st. The tongue is clean and moist; the appetite has returned; she has not had an attack since the 29th. Convalescent. Full diet. April 2nd. Cured.

Professor Piorry, in remarking upon this case, observed, that if we consider the astonishing progress medicine has made within the last few years,-if we look at the rapid strides it has taken towards perfecof disease which is now obtained, we can have no tion, and the degree of certitude in the investigation difficulty in admitting it to be a "veritable science;" while chemistry and physics are limited by certain and peculiar laws, or carried away into abstract theory and speculation. Medicine has arrived at such an amount of accuracy and exactitude, that by the assistance of anatomy and physiology, on the one hand, and by that of auscultation, percussion, the use of the speculum, &c. &c., on the other, we can now measure and mark out the different organs with the greatest nicety and precision; and by reasoning upon, and comparing them with, the natural condition, we may detect the almost slightest lesion, and arrive at results the most positive and satisfactory.

The case before us illustrates most admirably the truth of these observations, and is another amongst the many proofs we have lately had of the utility and importance of percussion, and an "organo-pathological" investigation of disease, showing most clearly the surprising light they often throw upon phenomena apparently the most obscure.

This patient was admitted with most distressing symptoms of dyspnoea and troubled circulation, following a severe kick upon the epigastrium. On auscultation nothing abnormal was detected in the lungs, there was a slight harshness with the heart's first sound, and the heart's impulse was extended over a larger surface than natural, but there was nothing positive to point out the true nature of the case. On percussion

23rd. She had another attack of the same nature last night, which lasted several hours. The bowels have been freely relieved; the pulse is somewhat fuller, and quite regular, 80; there is still considerable tenderness in the epigastrium and spine. Ordered five grains of sulphate of quinine every six hours, in the heart was found to be greatly enlarged, and the dul

the intervals of the attack.

24th. The attack commenced last night about ten o'clock, with well-marked symptoms of intermittent fever; shivering, which contined about an hour; heat, which lasted about an hour and a half, followed by sweating. This was succeeded by the same kind of intense pain as before. Continue the quinine.

25th. She again had an attack last night of the same nature, and at the same hour as the former She was ordered ten grains of quinine, which immediately arrested the symptoms, and she remained free until the following day.

one.

26th. There is still considerable tenderness in the epigastrium and spine; the heart retains its normal condition; the bowels are regular; the appetite improved; the tongue is clean. Ordered to continue

ness more marked than usual, but it retained its ordinary form. Could it be effusion into the pericardium ? Certainly not; for, in the first place, the bruits were not distant or indistinct; 2nd, the rapidity of the attack, and gravity of the symptoms, prevented the supposition; and, 3rd, the shape was altogether different to what is observed in hydro-pericarditis, where, according to numerous experiments made by Professor Piorry, both upon the living and dead subject, the dulness is found to extend upwards and outwards to the left side, and to assume a figure totally different to what is observed either in the normal or the hypertrophied heart.

What then was the true nature of the case! Evidently engorgement of the heart and great vessels, and consecutive engorgement and congestion of the lungs,

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