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, The author unhesitatingly preferred to reduce the herniawithout opening the peritoneal sac in those cases in which thesurgeon would be justified in returning the protrusion by thetaxis, if it could be accomplished.

In the twenty-six cases the peritoneal sac was opened intwelve, and the causes which prevented the reduction of thehernia without so operating were the three following :-

1. The contents of the sac.2. The morbid condition of the contents of the sac.

, 3. The dimensions of the neck of the sac, and the unyieldingstate of its tisssue.

Six cases were related in which the author had reduced thehernia by a simple division of the fibrous tissues about the neckof the sac, and external to that covering of the hernia knownas the fascia propria. To this simple method of relieving theconstriction around the bowel the author gave the name of"The Minimum Operation." The causes of death in the fatalcases were shown, by post-mortem examination, to be referribleto peritonitis; injury of the bowel inflicted in the taxis; ex-haustion after fascal fistula ; phlegmonous inflammation ; col-lapse ; acute bronchitis; and perforation of the bowel. Ofthe cured cases, the minimum of time during which the bowelwas strangulated, was three hours ; the maximum was seventy-seven hours. Of the fatal cases, the minimum period of stran-gulation of the bowel was eleven hours ; the maximum seventy-nine hours. Of the cured cases, the average number of hoursduring which the bowel was strangulated amounted to thirty-three. Of the fatal cases, the average period of strangulationof the bowel was forty-six hours. The causes of death were

primary and secondary:-1. Prostration ; peritonitis ; gan-grene of the intestine; perforation. 2. Bronchitis : abscessbehind the peritoneum; phlegmonous inflammation and sup-puration. The circumstances by which they were broughtabout :--Age ; a journey ; the defective constitutional nutritionof the patient ; the morbid state of the canal above the stran-gulated piece of bowel; injury of the hernia caused by theconstriction of the ring, and by manual violence inflicted onit; the duration of the sufferings ; the intensity of the consti-tutional sympathies ; fæcal fistula ; neglect of the tumour; theadministration of purgatives ; the warm bath. The means bywhich they may be avoided are :-By care in manipulation; theearly relief of the bowel from constriction; the reduction ofthe hernia without opening the peritoneal sac: the exhibitionof opium; and the avoidance of all causes likely to induceexhaustion.Mr. HUNT referred to the great injury inflicted on the

patient by the taxis, when employed in a rough or impropermanner. When used with gentleness and perseverance-thetumour being regarded thereby as a bag of fluid-the taxis, inhis hands, had been always successful.

Mr. HIRD had originally opposed the operation for herniawithout opening the sac, but the success which had since at-tended the proceeding had induced him to alter his opinion.The practical point in Mr. Birkett’s paper was its advocacy ofoperating early, a necessity strongly insisted upon by the late

Mr. Hey, of Leeds. He agreed with the author of the paperrespecting the non-employment of purgatives both before andafter the operation, and on the use of opium after the proceed-ing. The strong objection to the use of the taxis referredrather to cases of femoral than to inguinal hernia: more rapidevils might ensue in the former than in the latter from the useof the taxis. In femoral hernia, the sooner the operation wasresorted to the better. He agreed, also, with the author ofthe paper as to the effect of shock, &c., in interfering with thesuccess of the operation.

Mr. HALE THOMSON observed that Mr. Hunt’s wonderfulsuccess with the taxis differed from that of other practitioners.No such boast could have been made by Cline, Abernethy, orCooper. He (Mr. Thomson) differed with the author of thepaper in his opinion respecting opening of the sac. He thoughtin all cases the sac should be opened. He thought in compli-cated cases it was undesirable to give opium after the opera-tion, as the symptoms might thereby be masked, and the prac-titioner misled. With respect to the taxis, he thought therule to guide us was, to desist from its use immediately that it i

gave pain; then we should operate at once.Mr. HENRY LEE related some cases, to show the necessity of

opening the sac in certain instances of strangulated inguinalhernia.Mr. DE MERrc spoke in high terms of the care and lucidity

with which the author of the paper had drawn up his tables,and of the patience and perseverance necessary for collectingso many cases. Mr. Birkett was known as an indefatigablecaterer of facts, and he deserved much praise for making such

splendid use of his opportunities at Guy’s Hospital. Mr. deMeric had been carefully watching the conclusion of the paperto hear what deductions the author felt authorized to drawfrom the cases of death and recovery after the operation forstrangulated femoral hernia which had been quoted ; and he(Mr. de Meric) certainly thought that some of the rules laiddown were fully worthy of being carried out, and very properlydeducted from the results of the cases. Time did not allowobservations on some of these rules, as the opening of the sac,the mode of incision, and the most advisable time for operating;but he would just mention that some of Mr. Birkett’s remarkshad reference to circumstances over which the hospital surgeonhad no control-viz., the constitution of the patient, and thefatigues which may have been endured during strangulation.Operations must, in extreme cases, and under very unfavour-able circumstances, be performed, and the rules could onlyapply to the after-treatment. Much had been said by theauthor of the paper, and some speakers, respecting the mischiefof reckless attempts at taxis; he (Mr. de Meric) thought thatsome of the epithets used were too strong, and that " imprudentattempts" were quite sufficient to characterize the practice ofsome surgeons who might be carried too far by the wish ofpreventing the necessity of a hazardous operation. Thegradual, gentle, and protracted taxis mentioned by Mr. Huntwas certainly valuable, and he (Mr. de Meric) quoted theopinion of Mr. Hilton, of Guy’s Hospital, who had been suc-cessful in this mode of reduction, and who gave it his fulladvocacy. It was well known that the elder Amussat, ofParis, considered no strangulation insuperable, and that he hadoften succeeded by persevering, and, perhaps, somewhat violentefforts, in returning the hernia without the use of the knife.That mischief might be done by unskilful and indiscreet handswas, however, but too true. Mr. Birkett had stated in his

paper, that in certain cases he divided a very small extent oftissues, so as to lessen the chances of untoward results. Thisthe author called his minimum operation-a term very happilychosen, whether referring to the minimum of cutting, or theminimum amount of danger. This anxiety of the author todivide as little as possible of the tissues, reminded him (Mr. deMeric) of a plan lately proposed by M. Seutin, the eminentBrussels surgeon. The latter, instead of cutting down uponthe strictured portion of the sac, introduces his finger, or nail,without having recourse to the knife, between the neck of thesac and the ring, by the side of the tumour and along the un-broken skin, and tears the fibres of the ring. The constrictionthereupon ceases, and the herniated intestine or omentum is

easily returned into the abdomen. Numerous experiments onthe dead body (which are too seldom performed in this coun-try), and successful cases, are brought forward by M. Seutinin the Belgian medical papers, the Brussels surgeon contendingthat the knife may henceforth be completely dispensed with,and strangulated hernia be relieved by a bloodless operation.’ Mr. BIRKETT, in reply, said that a case was rarely admittedinto a hospital in such a state as a prudent surgeon would feel

justified in applying the taxis. He had seen more than onecase of rupture of the intestine from the violent use of thetaxis. He still urged the necessity of operating early. With

respect to reducing the hernia without opening the peritonealsac, he could only say he had never seen any bad result from it.

PATHOLOGICAL SOCIETY OF LONDON.

TUESDAY, FEBRUARY 5TH, 1856.MR. ARNOTT, PRESIDENT, IN THE CHAIR.

Mn. ATHOL JOHNSON exhibited a specimen of

CYSTIC DISEASE OF THE TESTIS,

removed by him from a child, aged two years and two months,at the Hospital for Children. The testis was first seen to beenlarged when the child was three months old, but it wassupposed to have been congenital. Its size increased slowlyat first, and afterwards rapidly. At the time of the operationit measured seven inches in circumference. In other respectsthe child appeared healthy. On examination, the tumour pre-sented an infinite number of cysts, varying in size, and con-taining a fluid transparent and gelatinous. Some of the cystsnear the circumference were lined with pavement cells, butthe majority had distinct ciliated epithelium. A large mass ofbone, with lacunae and canaliculi, occupied the fibrous struc-ture between the cysts. There was no trace of cartilage cells.

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Mr. ERICHSEN read his report on Dr. Van der Byl’s case ofEXTENSIVE PLUGGING OF THE ARTERIES.

The case appeared to be one of acute arteritis associated withendocarditis, and illustrates very strongly some points in thepathology of these affections, more especially with reference tothe production of plastic matter within the arteries, as theresult of their inflammation, and the consequence of a diffusionthrough, and accumulation in, different parts of the vascularsystem. In acute idiopathic arteritis, the plastic matter thatis poured out by the inflamed part in the artery appears to bedisposed in four different ways :-

1st. It may be deposited upon, and become adherent to, thelining membrane of that portion of the vessel which is in-flamed. In such cases as these the artery will be found to beplugged up more or less completely by tough, leathery, buff-coloured fibrine, when it is so closely adherent to the liningmembrane as to be stripped off with difficulty from it. Thecalibre of the artery itself will be contracted at this point, sothat the contained plug is firmly embraced by it. (Theseappearances are well illustrated by the axillary artery in Dr.Van der Byl’s case.) If the plug occupy a considerable portion ’,of the vessel, and particularly if so situated in an artery of the ’,extremities as to occlude the mouths of the chief collateral ves-sels of the limb, gangrene will not improbably ensue. If to aslimited an extent as in Dr. Van der Byl’s case, the interruptionto the circulation will only be sufficient to cause coldness of theextremity, with deficient or absent pulse. In every instanceof this kind that has fallen under the notice of Mr. Erichsenthere has been, as in the case under notice, pains in thelimbs, sometimes of an extremely severe character, and occa-sionally associated with an exquisite degree of cutaneous sen-sibility.

2nd. The plastic matter, not completely blocking up theartery at the point originally inflamed, may be washed downby the current of blood still passing across it into the lowerportion of the vessel, and there accumulating in the form of afirm, maroon-coloured, cylindrical coagulum, may obstructthe terminal branches to such an extent as eventually to leadto gangrene of the limb. Between the two points so obstructeda portion of the artery will usually be found to be pervious.It is, Mr. Erichsen believes, this obstruction of the artery at asecond place, at some distance below the primary seat ofdisease, that causes arteritis so frequently to be followed bygangrene; the obstruction occasioned by the second or distalplug of lymph being so complete as to render it difficult for thecirculation to be carried on with the requisite amount of vigourto maintain the vitality of the part. This appears to be thestate of the femoral artery in Dr. Van der Byl’s case, in whichthere is a plug composed of the ordinary buff-coloured fibrine,then an interval of healthy pervious artery, and then a portionof the vessel plugged up in the way already mentioned; but towhat distance this secondary deposit extended it is impossibleto say, as the vessels have been cut off short. Although exist-ing to a sufficient extent to seriously impede the circula-tion, it was evidently, from the symptoms during life, notsufficient to arrest it entirely. The plug of lymph in theleft middle cerebral artery appears to have been of thesame kind, and the softening in the correponding hemisphereof the brain to have been dependent on the obstruction ofthe vessel.

3rd. The plastic exudation that is poured out by the inflamedvessel may be washed by the current of the blood into thecapillaries of organs beyond the seat of diseased arteries, espe-cially the spleen and kidneys, and becoming arrested in theultimate ramifications of the vascular system, accumulate in theform of light, buff-coloured, or reddish-yellow fibrinous con-cretions. These may also form as the result of endocarditis, ashas been especially pointed out by Hasse, and as the endocar-dium appears to have been inflamed in Dr. Van der Byl’s case.Mr. Erichsen thinks it most probable that the yellowish-whitefibrinous masses formed in the spleen, kidneys, and heart, pro-ceeded from this direct source rather than from the moredistant one of the inflamed arteries. The fibrinous con-

cretions found in the substance of the heart itself, probablyresulted from the exudative matter carried directly fromthe interior of that organ, through the coronary arteries,and, so far as his observations go, was a frequent form ofthis deposit.

4th. Fibrinous concretions may form in large and distantvenous trunks, as the result of arteritis, but as there is no evi-dence of its having occurred in Dr. Van der Byl’s case, it isneedless to pursue further this pathological condition.

Dr. HILLIER exhibitedA CANCE"ffOUS TUMOUR FROM THE BRAIN,

removed from a man, aged thirty-six. The history obtained ofhim is imperfect. He died in St. Pancras Infirmary, to whichhe had been admitted about three weeks before his death.When admitted he complained of headache and cold, for whichhe was ordered Dover’s powder. Nothing indicative of para-lysis was noted at the time. A few hours after taking thepowder he was suffering from symptoms like those of opiumpoisoning, and means were employed to keep him awake.There was no reason to suppose that more than ten grains ofthe powder had been administered. On recovery from thisstate he was found to possess little more power on the left sidethan on the right. He stated that he had never suffered fromheadaches. His intellect was dull, and he seemed half asleepconstantly. His sight was not materially affected. His appe-tite was generally moderate. Whilst in the Infirmary, he hadseveral comatose attacks, which lasted several hours, unattendedwith convulsions : at these times he could not be roused. Hegradually lost power over his bladder and sphincter ani, andthe feeling in both lower extremities was very deficient, thoughthe power of motion was not very much affected. He died ina state of coma. On post-mortem examination, the tumournow exhibited to the Society was removed from the anteriorlobe of the left hemisphere of the cerebrum, extending abovenearly to the upper surface. It is about the size of a goose’segg, and is enclosed in a complete cyst. The membranes ofthe brain were finely injected, but the brain substance aroundthe tumour did not appear much, if at all, altered in cha-racter. Microscopically, the tumour was found to consist ofcancer-cells and nuclei of ordinary character, some of themundergoing fatty degeneration. There were a number of cellswith nuclei and nucleoli, and numbers of so-called exudationcorpuscles.

Dr. HiLLlER also exhibited a specimen ofCIRRHOSIS OF THE LIVER, ACCOMPANIED WITH HÆMORRHAGE

INTO THE STOMACH AND INTESTINES,in a child, thirteen years of age, who had been from earlv lifeexposed to the weather and privation of all kinds. She sufferedfrom ascites and occasional attacks of jaundice some few yearsback. Her breathing was habitually short, and her complexionof an earthy tint. There was no history of her having hadrheumatism. Three days before death she was in her usualhealth, when she had a chilly sensation, and became drowsy.She passed a large quantity of urine; she did not complain ofpain. The drowsiness continued, and she lost her appetite’;the bowels acted several times. On the second day before herdeath she spat a few teaspoonfuls of blood, and on the day fol-lowing she was admitted into University College Hospital.She was then in a very drowsy condition, but, when roused,was capable of putting out her tongue a short distance. It wasbrown and clammy. Her pupils were large, equally actingunder the stimulus of light. She frequently uttered a lowmoaning sound, but could not speak. The skin was hot, of asallow tint, and slightly jaundiced; the pulse was 124; respi-ration 36. The patient passed urine in quantities. She hadpurgative medicines, which operated freely, and blood waspassed with the stools. She died the next morning. On post-mortem examination, the liver was found to be remarkablycirrhosed, being very nodular, presenting an appearance ex-ternally, something similar to the convolutions of a small brain.The lobules Spigelii appeared to be in the hypertrophiedstage, whilst the left lobe and part of the right had undergonecontraction. The liver weighed twenty-six ounces. Thestomach contained a large quantity of black coagulated blood,and the small intestines contained some also. The stomachexhibited a mammillated appearance to a very marked degreenear the pylorus. There was no alteration of the stomach orof the intestines, except in a very small point of one of Peyer’spatches, about an inch and a half from the ileo-ceecal valve.The rest of Peyer’s patches were a little injected, but notelevated. The lungs were slightly emphysematous, and theright side of the heart was a little dilated; the mitral valvewas thickened irregularly at the edges of the flaps, and thecordæ tendinæ shortened. The kidneys were not quite healthy.The spleen was large, weighing seventeen ounces. On section,the liver is seen to be made up of roundish lobes, subdividedinto lobules; between these are thick partitions of cellulartissue. The nodular bodies vary in size from that of a good-sized shot to that of a large bean; they are of an ochre colour,with but little vascularity, whilst the cellular partitions are ofa. light colour.