hernia, in young and robust subjects, in which bleeding from the arm was practised previous to an peration being done, and the patient recovered without a bad symptom; perhaps they might have recovered equally well if the venesection had not been practised; nevertheless, I attribute the recovery, in a great measure, to the plan of treatment adopted. In Cases I, II, and VIII, it was practised with apparent advantage. The treatment after the operation in the present age differs materially from that used in former times. I There remark that the cases first related were subjected to a different plan of treatment to that pursued in the absequent ones. Aperients were given in a few hours after the operation with a view to procure evacuations from the bowels, but seldom succeeded, and it is very questionable whether they were even beneficial. Surely at is more common-sense practice to allow the system time to recover from the combined effects of a disstressing disease, and a painful operation, and to give ime for the re-establishment of the circulation in the Antestine, than to irritate an already irritable and perhaps amed intestine, by the exhibition of aperient medicines, which can scarcely fail to excite vomiting sand nausea. The opportunities afforded me of wit. sessing the effects of the one plan as compared with the other, are such as to impress my mind with the superiority of the soothing and sedative method. Purgative medicines and enemata are seldom required ring the first thirty-six or forty-eight hours after the performance of an operation; as a general rule the less we do the better. In Cases VIII and XIV it will be observed that the descent of the testes was incomplete. When called on to operate under such circumstances, it becomes a matter for consideration what course ought to be adopted in regard to the removal of the testicle. In Case VIII, the organ was partly within and partly without the external abdominal ring; and in Case XIV, it was completely within the inguinal canal; in both the pressure of a truss could not be borne, consequently the patients were exposed to the dangers of the hernia becoming again strangulated. Although this form of rupture has been noticed by Pott, Cloquet, and Lawrence, and more recently by Mr, Teale, I am not aware that any of these able surgeons have pointed out the line of practice which ought to be adopted when the operation is requisite. I conclude none of them could recommend the extirpation of the gland. In Case XIV, although neither testis was in the scrotum, the man informed me he was the reputed father of children. Case X was a very interesting and embarrassing one; the symptoms were not such as are usually observed in cases of strangulated hernia. This case, with the succeeding one, will more properly come under the head of obs'ructed irreducible hernia; in both the contents of the sac were omentum and colon, and the symptoms resembled those of ileus, and were probably produced by the irritation and inflammation of the contents of the sac, for in neither instance did the symptoms undergo any alleviation after the performance of the operation. In fact the gut was not much constricted; nevertheless, if either had died without any operative proceeding being attempted, I should not have acquitted the surgeons of blame. Whether the exhibition of the pure mercury was really useful I am unable to determine; certainly the effect which followed was truly marvellous, and the bowels were immediately relieved. short. It would be far more to the advantage and the welldoing of our patients, if we were, in this as well as in other diseases, content to look on and watch them with a jealous eye, and imitate and assist the efforts which nature makes for the reparation of disease, than as too often happens, frustrate her operations by injudicious While I was preparing this paper for publication, and meddling interference. The treatment generally Case XIII presented itself, and the subject of the operaost appropriate is to give a full dose of calomel and tion was the oldest patient I ever saw submitted to the sopivan, and repeat it according to circumstances, and knife; it turned out perfectly successful, and the time af the bowels do not act spontaneously within forty-occupied for the healing of the wound was unusually eight hours after the performance of the operation, if The stomach will bear it, to give a dose of castor oil'in a suitable vehicle. If this does not operate in the course of twelve hours, a common enema seldom fails to produce the desired effect, provided no inflammatory action exists in the abdominal cavity. Under such circumstances to persevere in the use of purgatives would be useless, our energies should be directed towards reducing such inflammation. Venesection to any extent is seldom required, and is not well borne after this or any other operation. Leeching the abdomen, freely followed by efficient fomentations, will answer better than the abstraction of blood from the arm. In great proportion of cases calomel and opium are Ladispensable. CASE OF LARYNGISMUS STRIDULUS ; IN- By W. E. IMAGE, Esq., F.R.C.S., Surgeon to the Master J, aged one year, a very fine healthy child, but of full habit and teething, had suffered for several days with repeated attacks of crowing inspiration. On my first visit I found him apparently perfectly well; before I left the house, however, he bad a very severe attack. The paroxysms were produced by the slightest inental irritation, and were sometimes so severe that he appeared quite exhausted and in a dying state for a considerable time after the cessation QUEEN'S HOSPITAL, BIRMINGHAM. of the paroxysm. The severity of the attacks daily increased. The crowing breathing was now succeeded by a state almost approaching to asphyxia. The gums were well and repeatedly lanced; the bowels well relieved by purgative medicines; leeches and blister to the nape of the neck, mustard to the legs, hot baths, and cold water to the head at the same time, with other remedies, were used, but without advantage. The attacks increased in frequency and severity. At length he had so severe a paroxysm that he remained two minutes and a half quite unable to breathe. His lips and face were purple ; pupils dilated. The body became covered with cold perspiration, and he appeared to be dying. His recovery from this frightful attack was very prolonged. His intellect was not restored till the following day. It was now agreed to apply æther to the nose and mouth on the slightest approach of spasm. Two days after this attack he began to crow as before, and every appearance of a severe attack pre sented itself. Æther, poured on sponge, was instantly applied to the nose and mouth. The spasms increased for a few seconds, and then perfectly subsided, and the child was well again. For four days the spasms recurred, but were instantly overcome by the æther-vapour, and from that period the child has remained free from an attack, and is perfectly well. I will not offer any remarks on the foregoing facts, but merely state my conviction, that the æther was greatly influential in preventing a recurrence of the dreadful paroxysms which had so nearly deprived my little patient of life. Bury St. Edmunds, May 22, 1847. Hospital Reports. QUEEN'S HOSPITAL, BIRMINGHAM. CLINICAL REPORTS OF SURGICAL CASES UNDER THE TREATMENT OF WILLIAM SANDS COX, ESQ. By PETER HINCKES BIRD, one of the Resident (Continued from page 237.) CARBUNCLE. Mary Ann Moss, aged 42, housewife, married, admitted August 11th, 1846, into the Queen's Hospital, under the care of Mr. Sands Cox. She states that about three weeks ago she first perceived a circumscribed, livid, red swelling on the back, she opened it with a needle, but no matter came out; a hard immoveable scab formed over it; it gradually increased in size, and caused her much pain; pain described as gnawing, pulling, "as if the flesh were torn from her;" when it had attained the size of her fist, which was about a week since, it broke into a number of small holes, which discharged a large quantity of whitish thin matter, the pain being considerably relieved. Her health has been very indifferent lately; she has been in a weak condition for some time; has had ten 295 children, four of whom are living; had difficult labours with them all, especially with the last; she lost a considerable quantity of blood in her last labour; has been much troubled with headache, described as if "something was hammering in her head," accompanied with singing in the ears and palpitations; has frequently "turned faint;" is not subject to cough. Has had poultices applied lately. Present State.-There is a large ulcer, rather larger than the bottom of a wine-glass, situated in the right lumbar region, about three inches from the spine; it contains a mass of mortified cellular tissue, of a brownish grey colour; the integument round the edges of the ulcer is of a dusky-red colour, and has a peculiar feel, like that of brawn; the ulcer discharges a thin brownish matter, mixed with strings of a yellowish colour; she complains of but little pain in it now; it is present at times as a slight gnawing pain; she has a pale anæmic look; pulse 90, very weak, easily compressible; tongue moist, of a whitish colour; she complains of a nasty bitter taste in the mouth; appetite indifferent; bowels open; sleeps pretty well at night; also complains of beating pain in the head; the urine was of a light colour, and of natural quantity; it was examined for sugar by the usual tests, but not a trace could be discovered. Ordered to have a large linseed poultice applied three times a day, and the following mixture :-R. Decoct. Cinchon., oz. viij.; Tinct. Cinchon., oz. ss. M, Sum, oz. iss, ter die, 14th. A large mass of mortified cellular tissue was discharged in the poultice yesterday; the ulcer discharges a thin, lightish-brown, not offensive, matter; she feels better; appetite improved. To have extra diet. 16th. The ulcer is quite free from mortified cellular tissu, and presents an uneven deep excavation. ave it filled up with dry lint, and covered ion. Ordered to by strips of adhesivester, so as to bring the edges of the wound in rather closer appos... *''., dr. j ; R. Quinæ Disulph., gr. xij; Acid. Sulph. a... Aquæ puræ, oz. viij. M. Sum., oz. iss, ter die. Con tinue the extra diet. 18th. Feels stronger; appetite very good; bowels regular; tongue clean; sleeps well. Continue medicine. 21st. Improving; tongue clean; pulse stronger; bowels open; complains of dull pain over the eyebrows. Continue medicine. 24th. Getting stronger; no pain in the head; is not troubled now with palpitations; the wound looks healthy, and is filling up. September 1st. Doing well; the granulations are rather indolent; health good; feels stronger. To have the ulcer dressed with lint dipped in a solution of sulphate of zinc. 12th. Much smaller since last report, but it has not made much progress towards healing within the last few days. Ordered to be dressed with the Lotio Nigra. 18th. Improving rapidly. 26th. Quite well; health much improved; no palpitations nor headache. Discharged cured. Anthrax, or common carbuncle, resembles furunculus in being attended with gangrene of the subcutaneous | lowest in the summer, quarter. In the summer cellular tissue; it is remarkable for constituting a quarter of 1846, the reverse was observed; dark, red, or livid swelling, accompanied by burning heat, pain and stiffness in the part. It most frequently occurs in those parts of the body where the skin is thickest, and abounds most in those processes of cellular tissue which are described by Dupuytren* as extending between its areola. Thus the nape of the neck, the back, the spaces over the scapula, the sides of the chest, and the nates, are the most frequent situations of anthrax. In this case its seat was in the lumbar region, which is of rather rare occurrence. According to Dr. Carswell,† the great accumulation of blood, and the still greater and rapid effusion of serosity which takes place in the circumscribed, acute, iuflammatory affections, produce a state of extreme induration of the cellular tissue, a greater or less portion of which, being thus as if strangulated, dies from want of nutrition, becomes separated from the living parts, and is expelled in the form of a grey or straw-coloured spongy or pulpy mass, through an opening made in the skin by a similar process, by ulceration, or by a surgical operation. Besides the production of gangrene and disorganization of the subcutaneous cellular tissue, there is sometimes a destruction of even the subjacent muscles and deeper textures. Carbuncle is mostly seen in persons beyond the middle period of life whose constitutions have been seriously impaired by some cause. In this case the patient was past 40 years of age, and had been enfeebled by the number of children she had given birth to. The carbuncle also was here of tolerable size; but cases have occurred in which it was as broad as a dinner plate. As this disease most frequently occurs in persons of a bad constitution, a tonic plan of treatment must be pursued; bark, wine, and a nourishing diet, must be given. With regard to the local treatment, it consists in affording a free escape to the sloughs and matter; a crucial incision is to be performed, but in this case an opening sufficiently large existed for the escape of the mortified cellular tissue. "Clin. Chir.," Vol. iv, p 109. the mortality was greater than it had been in any quarter of the seven preceding years; and in the last winter quarter, ending March 31, 1847, fifty-six thousand one hundred and five persons died in the districts which make the returns; a number greater than has been registered in any corresponding quarter, and six thousand and thirty-five above the corrected average." It will be recollected that the winter of 1845-6was remarkable for its mildness, as well as for the smaller amount of its mortality; and a comparison of the winter quarter (January to March,) of the two seasons, 1846 and 1847, will place the effect of cold on the mortality in a still more striking point of view. We have seen that the excess in the number of deaths in the quarter just ended, above the calculated average is 6.035; the decrease in the corresponding quarter of the year 1846, was 5.359. The difference between the two therefore amounts to 11,394, or upwards of one fifth of the entire mortality of the selected districts. Whatever effect, however, the severity of the weather may have had in producing this large increase in the mortality, the number of deaths cannot but have been greatly augmented by the want of sufficient nourishment for the poorer classes. The high price of provisions must have operated, both directly in a diminution of the supply of food, and indirectly in putting it out of the power of the necessitous to procure sufficient clothing, fuel, and other comforts, necessary to protect them against the inclemencies of the season. This indirect action of the scarcity has perhaps been more immediately felt than the deficient supply of food itself, as the increased mortality appears very generally to have been owing to imflammatory affections of the lungs + "Illustrations of the Elementary Forms of Disease," p.7. and bronchial mucous membrane, the effects of cold on the aged, on children, and on weakly persons, &c. PROVINCIAL Medical & Surgical Journal. WEDNESDAY, JUNE 2, 1847. The Quarterly Return of Health and Mortality lately issued by the Registrar General, contains, as usual, much valuable information connected with the public health. The effect of severe weather is strongly marked, and, together with the high price of provisions, has tended greatly to increase the mortality. "Winter," it is observed in the report, "appears to be the season in which it is most natural for man to die. For many years the number of deaths in England has been highest in the winter, and One of the causes of a high mortality dwelt upon at considerable length in the Report, is the great sacrifice of life, and of infant life especially, from the want of sufficient sanatory regulations in the larger towns. The injurious effect of an impure atmosphere on the health of the metropolis is especially dwelt upon, and the distribution of this atmosphere, “not a gas, but a sort of atmosphere of organic particles, undergoing incessant transformation; perhaps like malaria, not odorous, although evolved. at the same time as putrid smells; suspended like dust, an aroma, vesicular water in the air, but invisible," hanging like a “diseasemist," in various degress of density over different. REVIEW. parts of the vast city and its extended suburbs, is forcibly marked out. "This disease-mist, arising from the breath of two millions of people, from open sewers and cess-pools, graves and slaughter houses, is continually kept up and undergoing changes; in one season it is pervaded by cholera, in another by influenza; at one time it bears small-pox, measles, scarlatina, and hooping-cough among young children; at another it carries fever on its wings. Like an angel of death it has thus hovered for centuries over London." And though this disease-mist is not, perhaps, to be altogether "driven away by Legislation," as affirmed in the sanguine language of the Report,-its density, its manifold noxious impregnations, may undoubtedly be lessened, and its health-destroying influences circumscribed. "The poisonous vapour may yet in part at least, clear away from London, and from all the other towns of the kingdom;" and "some of the sunshine, pure water, fresh air, and health of the country" become also the portion of the inhabitants of towns. Before concluding these observations, we would direct attention to the valuable remarks on the weather by Mr. Glaisher, of the Greenwich Observatory, appended to the return. The severe cold experienced in the week ending the 14th of February, and the extreme degree of this on the 12th, in certain districts only, was, according to the Report, confined to a zone, the southern limit of which was in latitude 50° 45, and the northern limit, in latitude 52°. This cold was most severe at Uckfield, the thermometer falling there, according to the observation of Mr. Prince, as low as 1o ; at Blackheath, the lowest point of the thermometer on the same day was 6o, at Beckington, in Somersetshire, 5°, and at Romsey, Hants, as appears from Mr. Buckell's report, published in this Journal, it was 6°. It is worthy of remark that the lowest point of the thermometer observed during the month, both at Sidmouth and Honiton, was on the same day of the month, the 12th, though the amount of depression, as recorded by Dr. Cullen and Mr. Rogers, was very different, being in the latter place to 18°, and in the former not lower than 21° 5. Review. The Construction and Government of Lunatic Asylums and Hospitals for the Insane. By JOHN CONOLLY, M.D., Fellow of the Royal College of Physicians of London, and Physician to the Middlesex Asylum at Hanwell. London: 1847. 8vo. pp. 183. This is a small and unpretending volume, but at the same time, one of those rare productions which 297 leaves little of material import unsaid on the subject of which it treats, and contains no redundancies, either of matter or expression. The enlightened views known to be entertained by Dr. Conolly, on the subject of. the management of the insane, the deep attention which he has paid to the subject, and the genuine benevolence which his published sentiments, his public acts, and his private intercourse alike evince, render such a treatise as the work before us a work of no ordinary interest. The interest is not confined to the physician, but must be equally participated in by the general philanthropist, the magistrate, and the public at large. Happily it is unnecessary in these days to dwell on the general truth and practicability of those humane principles in the management of the insane, the working of which, the labours of Dr. Conolly have so much centributed to advance; but there are numerous minor points which yet require consideration connected with the best mode of carrying these principles into operation, and on these the present work affords much valuable information and instruction. By those to whom the general and medical treatment of the insane is confided, the opinions of Dr. Conolly cannot but be perused with great interest, and the correctness and applicability of his views will be tested by the results of their own experience. But there are persons whose duty it is no less to investigate the several questions connected with the management of asylums for the reception of insane patients, who have no previous instruction on the subject, neither from practical experience nor education. To county magistrates particularly such information as is here conveyed is of great importance, and we trust that the valuable observations of the author will have extensive circulation among the magistracy of the country, that while all due economy in the appropriation of public funds to the care of the insane is practised, no miserable parsimony may be suffered to cripple the efficiency of a system of general management, which has converted the receptacles for lunatics from gloomy and desolate prisons, into cheerful habitations, into hospitals for the curable, and into places of refuge and homes for those whose mental condition admits not of restoration to health. The following eloquent passage in which the duties of the Superintendent are briefly summed up, glowes with the purest sentiments of humanity and benevolence, and in every sentiment will be recognized by our readers the impress of the author's mind : "None," says Dr. Conolly, "but those who live among the insane can fully know the pleasures which arise from imparting trifling satisfactions to impaired minds; none else can appreciate the reward of seeing reason returning to a mind long deprived of it; none else can fully know the value of diffusing comfort, and all the blessings of orderly life, among those who would either perish without care, or each of whom would, if out of the Asylum, be tormented or a tormenter. Constant intercourse and constant kindness can alone obtain their entire confidence; and this confidence is the very keystone of all successful management. "Thus living, and thus occupied, the director will learn to love his people, with all their infirmities, which are their afflictions. The Asylum is his world. The patients are his friends; humble, but not without even delicate consideration for others; wayward, but not malignant, except when cruelty exasperates them; capricious, but not ungrateful; distrustful, but to be won by candour and truth; disturbed and grievously afflicted, but not dead to some of the best and purest affections. He will almost regard his patients as his children; their cares and their joys will become his; and, humanly speaking, his whole heart will be given to them." Proceedings of Societies. BIRMINGHAM PATHOLOGICAL SOCIETY. Dr. FLETCHER in the Chair. Mr. F. Elkington presented to the Society a specimen of tubercular disease of the peritoneal coat of the stomach, and gave the following history of the case :Margaret Robins, 65 years of age, a native of Wales, came to England when 16 years of age. Her mother died in a fit at the age of 23. Her father died when she was about four years of age, of an acute disease. Has been married twice; her first husband died eight years after their marriage. In 1813 she was married to her second husband, who died of lupus, in March, 1846. From her account it appears that she had during early life, an attack of pleuritis, and two large abscesses just above the crest of the right ileum, the cicatrices of which are still remaining. Has never had scarlet fever, typhus fever, small pox, &c. August 1st. 1846. She considers the present complaint to be of about six years' standing, during which period the following symptoms seem to have been gradually increasing in severity:-Violent spasmodic pain in the side (sometimes the right, and at others the left,) on the slightest exertion, or on taking certain articles of food; a sensation of pain after eating, and sometimes vomiting; violent palpitation of the heart, constipation, and depression of spirits. Present appearance is as follows:-Countenance exhibits great anxiety of mind; cheeks depressed; features contracted, with slight hectic flush upon the malar bones.-Tongue coated with a deep white fur in the cen're, and a brownish one round the margins, tremulous.—Pulse 100, small and compressible.-Chest-sound, healthy; no cough nor pain over the region of the chest; heart's action quick but natural.-Abdomen: no tumour to be discovered by the hand; complains of violent pain over the whole region of the stomach, increased upon pressure; constipated bowels; scanty high-coloured urine. Treatment. I ordered eight leeches to be applied over the region of the stomach, and after their removal a blister, a saline mixture every four hours, with two At the particular request of her friends, the abdomen |