SURGICAL CASES.

10 first effect of arterial excitement in every secreting organ is to excite to an unnatural degree the natural function of th( organ. We know that mental emotion will cause a suddei determination of blood to other organs, which, according t( the part, will be followed or not by secretion. Blushing and erection of the penis are instances of sudder determination of blood to a particular part. And the lacryma

glands, salivary glands, testicles, prostate gland, gastric glands; even the kidneys often pour forth their secretions sc abundantly, and so suddenly, that the formative fluid, the blood, must have circulated through their capillaries in greatei quantity, and with greater rapidity, than when the glands I think that the were at rest, and their secretions suspended. periodic attacks of mania with which many of the insane are affiicted may be regarded in this light. The vessels which are especially the seat of this morbid action, I suspect, are those of the plexus choroides and one of the layers of the cortical substance. The choroid plexus is frequently found hypertrophied in the brain of epileptics, assuming an almost fleshy appearance. This hypertrophy would very probably be the effect of repeated action. It is also the seat of small tumours, generally like hydatids. The expression determination of blood to the head" is often made use of, but without any explanation of the manner in which this takes place. I doubt whether the profession generally have any distinct idea as to the exact condition of the vascular system that produces it. I would venture to offer the following theory, the first idea of which I certainly derived, many years ago, from that most truly philosophical work, the " Elements of Physic" of Dr. Arnott. It applies, not merely to the head, but everywhere else. The middle or muscular coat of the arteries, in a state of health, contracts, with each systole of the ventricles, just sufficiently to give a solidity to the wall of the pipe; so that the force of the contraction is not lost on a yielding surface; a much greater force is required to drive water through a leather hose than through a leaden tube. The middle coat and

"

contracts sufficient to assimilate the artery, physically and temporarily, to the leaden tube. Arteries with permanently rigid walls, like leaden tubes, would have interfered, by their rigidity, with the motions of the limbs ; and hence this

beautiful contrivance.

When this middle coat does not concontracts imperfectly, then the force of the heart dilates the tubes and produces congestion. I believe, then, that determination of blood to the head arises simply from deficient contraction of the muscular coat

tract,

or

only

of the capillaries of the brain, preceded by the excitement of the heart’s action. The throbbing of the carotid arteries may be considered as corroborative evidence in favour of this opinion. The throbbing cannot arise from action of the vessel; it is the action of the heart, felt strongly, and seen distinctly, because the tube yields to the impulse of the left ventricle, instead of resisting it, like a solid leaden pipe. If the throbbing arose from the action of the artery, it would not be synchronous with the heart, which it is. It is the same yielding of the coat of the capillaries, in an inflamed limb, which gives rise to the throbbing sensation which all of us have felt in some small spot or another. I think that it is not at all improbable, that the reason why these capillaries of the brain thus suddenly and unnaturally neglect to perform their duty is some defective innervation from the sympathetic nerves, whose office I hold to be the regulation of the coat of the arteries, so as to produce secretions &c. There are many circumstances attending organic disease of the brain which I think can only be accounted for on the supposition that the quantity of blood in the brain varies very much at different times. One of the most striking of these is the remission of pain and accession being produced by anything that would tend to accelerate the circulation. Most authors who have written on epilepsy, Esquirol among the number, agree in stating that the brain is in a state of congestion during the fit. The amazing benefit which I have seen derived from the This use of digitalis is strongly corroborative of this theory. powerful medicine was most serviceable when it kept the pulse down even below the standard of health. I believe that in all cases of fatal epilepsy, where there has been autopsy, the vessels of the brain and membranes have been found enormously distended, and in some there has been extravasation. The warning which many epileptics have-viz., a singing noise in the ears, I believe arises from the dilated carotid

artery vibrating in the carotid canal, close the internal

to the vestibule

o:

ear.

I regard it as analogous to the throbbing produced by the dilated artery in inflamed parts. Dr. Conolly observed that epileptic patients are occasion’ ally warned of the approach of paroxysm by mental excitement, their high spirits becoming to their friends the wellknown precursors of their sufferings. This must arise from arterial action. It is analogous to the mental excitement in. duced by spirituous liquors; no one doubts that this psychical effect is produced by a physical cause. Dr. Bright says—" I believe that almost always, during the epileptic paroxysm, either as a cause or an effect, sanguineous congestion takes place within the brain." Dr. Prichard’s and Dr. Alison’s opinions coincide with this. But I must not detain you longer on this branch of our subinto it in my work on the ject, as I have entered very brain. For a knowledge of all the medicines which have been used in the treatment of this formidable disease, I must refer you to Dr. Copland’s admirable and erudite article on this subject. In some cases, as, for instance, in the case which has called forth these remarks, there are general symptoms which call for especial treatment; but there are many cases of epilepsy which are clearly functional, and then your treatment must be, to a certain extent, experimental or empirical. In females suffering from amenorrhoea, I have seen the greatest benefit derived from the use of steel. But this mineral must be continued for months,-obstinately continued. In order to do this, you must vary the form of it, always giving it in small doses, or you will nauseate your patient, and disturb the digestive organs. The carbonate of iron, the iron mixture, the citrate of iron, the sulphate of iron, are all useful in their turn. I have lately had a successful case, by obstinately persevering in this plan of treatment, in the person of a young lady, who had suffered from this complaint for above five years, and who had been under the care of many of the physicians at the West-end. She has now been free from attacks for nearly two years. After administering steel for some time, great advantage is often derived from the combination of the sulphate of iron and sulphate of zinc. In young men with a florid complexion and irritable pulse, I have found the digitalis of great service, several patients recovering entirely under its use; but it is a medicine which requires great care and constant watching. The sulphate of zinc certainly possesses a decided power over the disease, and I have had three or four patients recover under its use. I seldom give it in larger doses than two grains, and as it is a medicine which may be given without danger, I generally prescribe it in the first instance. In old and chronic cases, when everything else has failed, I give the oxide of silver, which is one of the most valuable medicines we possess. It requires watching, to prevent its discolouring the skin. But if you do so carefully, and leave it off for about a fortnight at the end of every two months, there is very little danger. One of the worst cases of epilepsy I ever knew, independent of organic disease, got well under its employment. The patient had been ill fifteen years; he took the medicine for twelve months, and he has been quite well for above six years. I shall call your attention to this subject again, when I review the progress of our present patient’s case, which I hope, for the credit of medical surgery, may prove satisfactory.

freely

SURGICAL By JOHN

CASES.

ERICHSEN, ESQ., F.R.C.S.,

ASSISTANT-SURGEON TO UNIVERSITY COLLEGE

HOSPITAL,

ETC.

SELECT CASES OF HERNIA.

Strangulated congenital he2,nict in an adult; with large accunzulation of fluid in the tunica vaginalis ; operation; cure. CASE 1.—W. I-, aged twenty, admitted into University College Hospital, Sept. 8, 1849. He states that he has always felt the scrotum somewhat larger on the left than on the right side; a cord appearing to extend from the testis upwards. Nine months ago, in consequence of exertions, he noticed for the first time a distinct tumour in the left groin. This varied somewhat in size, but never disappeared entirely. Did not know that it was a rupture, and had never worn a truss. Yesterday evening was seized with cramp and pain in the stomach, with vomiting. He applied to a surgeon, who, treat-

11 of cholera, gave him some medicine, which vomiting, but the pain in the abdomen continued. He noticed, also, that the tumour in the groin had increased considerably in size to a much greater extent than it had ever

ing it as

a case

arrested the

attained before.

Sept. 8th.-Admitted at one P.M. Bowels had not acted since yesterday evening, when a small motion passed. Has vomited twice or thrice, since morning, a quantity of greenish grey fluid. There is much tenderness of abdomen, more particularly in the left iliac and umbilical regions, with occasional cramp. On examination, there is in the left side of the scrotum a tumour about the size and shape of a large pear, being round and uniform below, but constricted at the external ring, and continuous upwards into a broad elongated neck, which extends through the whole of the inguinal canal. It is soft and fluctuating, with no tension or hardness in any part of it, and is distinctly translucent in the scrotum, but no translucency can be detected near the ring, or in the canal, where it is constricted. The testis cannot be felt, but pain is complained of when the lower and posterior part of the tumour is compressed. On employing the taxis in the warm bath, the

tumour appeared to subside somewhat, becoming distinctly smaller and softer, with a sort of emphysematous crackling, but without any gurgling or sensation as if gut or omentum On taking off the pressure, the tumour rewere returned. gained quickly its original size and shape, but continued soft and fluctuating. Pulse 84, soft and compressible; tongue moist, red in centre and at tip, furred at edges; countenance -somewhat anxious, and much restlessness. What was the nature of this tumour? Did it contain intestine or not ? Four opinions might be entertained with respect to its nature. 1. It might be a case of acute hydrocele, the testis being situated near the ring or within the canal. 2. Encysted hydrocele of the cord, and some effusion into

the tunica vaginalis. Or, 3.

Hernia,

·cele of tunica

with accumulation of fluid in the sac, and

-

hydro

vaginalis. Or, Congenital hernia, with large accumulation of fluid in tunica vaginalis. With regard to the first supposition, though the pain in the abdomen and sickness might be the result of orchitis, and the soft tumour in the inguinal canal might be dependent on an inflamed testis in this situation of it, yet the effusion into the scrotal tunica vaginalis, and the pain experienced in compressing the posterior part of the scrotum, indicated the existence 4.

and some very dense adhesions tying down the bowel, were then separated with the bistoury and finger-nail. The testis, which was very small, was in its usual situation, separated by an interval of about a couple of inches from the coil of intestine. The bowel being then returned, four points of suture and a compress were applied. Patient was ordered two grains of opium immediately, and three grains of calomel, with a quarter of a grain of opium every third hour. 9th.—Nine A.M.: As the pulse rose, and increased tenderness came on in the night, he was bled to sixteen ounces, and had twenty-four leeches applied to the abdomen, and an enema of gruel and oil was ordered.—Eight P.lII.: Bowels have acted twice since the enema; tongue moist and clean; pulse 104, and soft; still abdominal tenderness. To continue the pills, and have eighteen leeches applied, and turpentine epithems. 10th.—Has passed a good night; bowels have acted once; pulse 102, full and soft; less tenderness of abdomen. As the opium made him very sleepy, it was discontinued, but the calomel continued. 11th.—Has passed a good night, bowels acting once; pulse 96, soft; tongue moist; much flatus and some tenderness in left iliac region. For this he was ordered one ounce of castor oil, in peppermint water, which acted three or four times, and gave him much relief. From this time he went on very well, as far as the hernia was concerned; but afterwards got abscess of the prostate, which was opened through the perinseum, by Alr. Arnott. The points of especial interest in this case were, the shape of the tumour, which was hour-glass or doubly pyriform, constricted by the external ring ; its soft and fluctuating character throughout, there being no tension whatever about it, though it contained strangulated bowel; its partial reduction in size, with a sort of emphysematous crackling, but quickly filling again when pressure was taken off; the quantity of fluid in the tunica vaginalis; and the fact that though the hernia was a congenital one, the testis could indistinctly be felt unsurrounded by bowel, which was separated from it by a distance of nearly two inches, being retained near the ring by old and firm adhesions.

Strangulated Oblique Inguinal Hernia;

unusual seat

of

Stricture; Operation; Death. CASE 2.-G. S-, aged twenty; admitted Sept. IS, 1849,

with

strangulated inguinal hernia of right side. This man ruptured on that side from birth, but has never worn a truss; nor has he experienced any inconof a testis in its normal situation; besides, in those cases of venience from the rupture until the night of the llth, when inflamed testis in the inguinal canal that I have seen, the he was seized with pain in the abdomen and vomiting. His tumour was hard, and but slightly, if at all fluctuating, with bowels acted for the last time on the morning of this day. On the 12th he was seen by a surgeon, who attempted the no translucency in the scrotum. 2nd.—Was it encysted hydrocele of the cord with acute taxis, but unsuccessfully; used fomentations; ordered enemata, On the night of the 12th the vomiting became faecal, and hydrocele of tunica vaginalis ? This explanation was untena- &c. the abdomen increased much. ble, as the fluid in the scrotum and in the canal communicated, the tenderness of at On admission, half-past four P.M., Sept. 13, there is a and the tumour was soft and not tense, like an encysted hydrohernial tumour on the right side of the scrotum, very tense cele. 3rd.-The same objection—the communication between the and tender, elongated, and about the size of a duck’s egg; the fluid in the tunicn. vaginal is and canal - presented itself to testis can be felt distinctly below it. It is therefore not conthe supposition that it was hernia, with dropsy of the sac, and genital, though it was said to have existed from birth. There is much tenderness of abdomen, with tympanitis, especially hydrocele. in the right iliac and umbilical region; dorsal decubitus, with in a was it 4th.-Lastly, congenital hernia, lying hydrocele knees drawn up; pulse 102, small; tongue moist and furred; of the tunica vaginalis ? The history of the case, the symptoms,-though somewhat frequent fostid eructations and occasional stercoraceous vomitobscured by the supposed attack of cholera,-and the character ing ; bowels have not acted for forty-eight hours. Altogether, of the tumour, pointed to this as the correct diagnosis of the the patient’s condition is most unfavourable; but as an operacase. The only points in opposition to this were, that the tion presented the only chance, it was performed at once, the testis could be felt, though very indistinctly, and was sur- taxis being first tried, under the influence of chloroform. rounded by fluid and not by intestine, and that a portion of the Operation.—An incision was made along the long axis of fluid could be squeezed out of the tumour. This might be the tumour, and the dissection carried down to the sac. This explained by the knuckle of intestine being small, situated was pinched up, and carefully opened, no fluid being internear the ring, and confined there by adhesions, through which posed between it and the contents. It contained a large =the effused fluid was partially squeezed back into the perito- piece of omentum, which was red and congested, but not næal cavity. The patient having been bled, put into a warm thickened, or otherwise unhealthy. To the inner side, and ’bath, and the taxis tried there, and under chloroform, without somewhat behind this, lay a coil of intestine, about four inches effect, the operation was proceeded with in the usual way. in length, of a dark purple or morone colour, and much disAfter dividing the integument and fasciae by an incision ex- tended with flatus. The seat of stricture was apparently at tending along the whole length of the tumour, a large sac, the external abdominal ring, which constricted the tumour which proved to be the tunica vaginalis, was exposed. This tightly: this was divided, so that the finger could readily pass was pinched up, and opened, when about half a pint of clear into the cavity of the abdomen. An attempt was now made straw-coloured, slightly sanguinolent serum escaped. It was to return the intestine, the omentum being held on one side by then laid open to its full extent, and a knuckle of intestine, an assistant, but it could not be got up, nor was there any about three inches in length, and deeply engorged, but shining gurgling. It was evident, therefore, that it must still be conand otherwise healthy, was exposed, lying at the ring, and stricted somewhere, but the stricture was not in the ring or within the canal. The stricture, which was situated deeply canal, as the finger could be freely passed into the abdominal at or near the inner ring and was ver tight was then divided cavity. It could not be in the sac as that had been laid openstates that he has been

-

.

12 with the other parts. Where was it, then ? The cut edges of the sac were now held apart, the tendon of the external

the centre. Vomiting excessive. On examination, a small tense femoral hernia was found in the right groin. oblique were freely divided, and the knuckle of intestine and Operation.—At half-past eight P.M., assisted by my friends, the omentum drawn downwards, when it was at once seen Dr. Sieveking, and Messrs.GreenhaIgh and Carver, I proceeded , that at a point corresponding to about the internal abdominal to operate in the usual way. The hernial sac was quickly exring, the intestine was tightly constricted by a very narrow, posed, and found to be covered by a quantity of firmly ad. cord-like band of fibres, firm, and of a pale colour, stretching herent granular fat. A tight stricture was found at Gimacross from the omentum to the mesentery, and tying down bernat’s ligament; this was divided, without opening the sac, the intervening breadth of gut, as with a string. It was quite so that the finger could be freely introduced around the neck unconnected with, and in no way adherent to,.the sac. The of the sac. Gentle attempts at reduction were now made, but intestine was much distended above this constriction, and without success. All stricture having been divided outside was of a dark chocolate colour, and much congested; below sac, it was evident that the obstacle to reduction existed the band of fibres the intestine was natural in size, and upon or within it. The sac was therefore well pulled down- . tolerably healthy in appearance, though somewhat congested, wards by an assistant, and the dissection proceeded with more the line of demarcation being abrupt, and corresponding to deeply around its neck. It was now found that it was here the string-like stricture. It was now evident why reduction constricted by a band of firm fibro-cellular tissue lying at the of the intestine had not followed the division of the tendon of bottom of a deep sulcus, and constricting it somewhat in an the external oblique, one side of the coil of intestine that was hour-glass shape. This band of fibres, which was very tough lying in the hernial sac having been prevented going up by and firm, was now carefully dissected off the sac, but without the band of fibres stretching across it from the omentum to opening into this by means of the scalpel and forceps, when, the mesentery. Had the protruded omentum not been help with scarcely any force, the contents of the sac slipped back down by an assistant at the time the reduction of the intestine into the abdomen. The patient was ordered one grain of opium was attempted; the whole would have slipped back together, immediately, and another in six hours. She got well without and no relief been afforded, for although the sac and its con- a bad symptom. tents were compressed by the external abdominal ring, this This case is interesting from its bearing upon an operation pressure would appear to have been expended on the mass of that has of late been recommended in cases of femoral omentum, which lay before and covered in the coil hernia-viz., the division of the stricture by a limited exterprotruded of intestine. The case was evidently one of internalstrangula- nal incision. That this operation may in certain cases be suction in an incarcerated hernia. cessfully practised admits of no doubt, but the case that has The intestine was now well drawn down, so as fully to ex- been related is one of those instances, of not very unfrequent pose the seat of constriction, and the band of fibres was dis- occurrence, in which the stricture is not situated in the sected off by the knife and forceps. As soon as this was done, crescentic margin of the saphenous aperture, in Gimbernat’s, the constricted part of the gut started up, becoming imme- or the ilio-femoral ligament, but is formed by a band of diately distended with flatus. The intestine was now returned fibres seated npon or within the sac; the sac appearing to without any difficulty, and the omentum put back after it. have been constricted bv some of the transverse fibres of that Sutures and a spica bandage were applied, and the patient of the sheath of the vessels that is derived from the portion ordered five grains of calomel, and one grain of opium, to be fascia transversalis. taken immediately, and to be repeated in three hours; as the Hydrocele of Hemaiad Scte. pulse rose in the course of the night, he was bled to eight CASE 4.-W. I-, aged forty-one, consulted me on the 10th ounces, and had thirty-six leeches applied. The peritonitis, however, increased in intensity, the countenance became more ’ October, 1849, for a large tumour of the scrotum. He states anxious, the pulse frequent, wiry, and small, and the patient that about twenty years ago he injured his right groin whilst died at eleven A.M. on the following day. riding, the consequence of which was an inguinal hernia in the right side, which rapidly attained a considerable size. About Examination, fours hours after death.-On laying open the ab- twelve months ago an inguinal hernia appeared on the left domen the intestines were seen to be tympanitic, and their side. He has worn a truss for the rupture on the right side coils glued together in all parts by recent lymph. There were since its first appearance, and latterly a double truss, but has two or three ounces of a dirty yellowish-brown fluid in the not for years been able to return completely the whole many cavity of the abdomen. The portion of the gut which had of the right inguinal hernia, though a considerable portion of been strictured was still deeply discoloured, but was not quite it goes back without difficulty. It remained stationary in size so dark as at the time of its operation, contrasting, however, for many years, but about two or three years since the scrotum strongly with the parts in its neighbourhood. It was found on the right side began gradually to increase in size, and lying close to the internal ring, and one side was still marked about a year ago the increase became suddenly much more by the pressure of the stricture, though this had been fully rapid than before, and the tumour attained its present magrelieved. On laying the strictured part of the gut open, the nitude. mucous membrane was found softened, and there were patches On examination, Ifoxnd the scrotum in tberiglitside occupied of coagulated blood in the sub-mucous cellular tissue. a tumour as large as a child’s head. This has an elongated This case is interesting, not only on account of the rarity by pyriform shape, being much broader below than above, and is of this peculiar kind of strangulation, but also from its bearing constricted about the middle. The upper part of distinctly on the operation for hernia without opening the sac. Had the tumour, that above the constriction, is occupied by the sac not been opened in this case, the constriction of the a the greater part of the contents of which external oblique merely being relieved, the intestine would arelarge hernia, and can readily be returned within intestinal, evidently have been returned, still constricted by the transverse the of the abdomen, but a portion, consisting of omencavity band of fibres, and the main cause of strangulation would not is being adherent to the neck and posterior have been removed. It was, in fact, a case of internal stran- tum, of irreducible, the sac. When as much of the hernia as can be repart gulation in an incarcerated hernial sac, there being double duced is put back, a large, soft, fluctuating tumour, about the strangulation, one stricture at the external ring, the other size of a cocoa-nut, can be felt below and in front of the adwithin the sac, across a portion of its contents. herent omentum. There is a distinct fluctuation in the tumour, which evidently contains fluid. Its walls can be felt without Femoral Hernia in a Female; Operation Strangulated o be thick, and it is not translucent. The lower part of the opening the sac; Stricture upon the sac itself. :umour is rounded and uniform, the upper boundary is not disCASE 3.—Mrs. S-, aged forty-five, a patient of Dr. Sieve. tinctly circumscribed, being apparently formed by the adherent king, by whom I was requested to see her at six r.M. on the md irreducible mass of omentum, and corresponds to the con27th of February, 1849. She is a stout, healthy woman; ha,s triction that exists about the middle of the scrotum of the been married two years; has had no children; has been the ’ight side. Below and somewhat behind the lowest point of the subject of femoral hernia of the right side for two years; which umour the testis can be distinctly felt of its natural size. It will thus be observed that the whole mass of the right occasionally comes down, but is easily reduced. The hernia crotal tumour may be divided into two parts by the central came down yesterday morning, early, without any very evident cause; vomiting came on shortly afterwards, and has horizontal constriction; that which lies above this line is comosed of omentum, which is adherent, and of intestine, which is continued ever since. There is much tormina and uneasiness in the abdomen, particularly around the navel, where there is educible; that below this line consists of a fluid, fluctuating, slight tenderness; the bowels have not acted since the morn- pake tumour, distinct from the testis, rounded below, with an ing of the 25th. There is much restlessness and anxiety; 1-defined margin above, soft when the hernia is reduced, tense. pulse 120, rather small; tongue coated at the root and down hen it is down, having a distinct impulse when the patient

the

13

coughs,

and not

being

reducible

on

pressure.

The

patient,

Who believed the tumour to contain fluid, and was greatly incommoded by its bulk, was anxious to have it tapped. But

on Midwifery, observes:" Those women are most predisposed to the disease (puerperal convulsions) who have had hysteria or epilepsy in early life, who have suffered from injuries of the head, or who have had violent attacks of fever,

tures

it became necessary to be satisfied as to the flui,l and the nature of the tumour. with severe affection of the brain :’ It was evident that the upper part was composed of reduDrs. Hardy and M’Clintock, in their excellent " Practical cible intestine, the middle, of adherent omentum, and the Observations ill Midwifery," express a different opinion. They lower, of fluid. Was this an encysted hydrocele, or a hydro- say :-It does not appear that females who are subject to epicele of the hernial sac ? It could not be a hydrocele of the leptic fits are more liable, on that account, to attacks of puertunica vaginalis, for the testis could be distinctly felt unsur- peral convulsions. On the contrary, it would seem that they rounded by fluid. enjoy an exemption, and that even the epileptic attacks occur The history of the case; the existence of an irreducible with less frequency, and with unmitigated severity, during omental hernia for many years; the rapid increase in size of pregnancy. This certainly was the case in three or four cases the tumour; its irregular, uncircumscribed upper boundary; its of pregnant epileptic females, who came under our notice." I varying tension, according as the hernia was reduced or not; believe I am right in referring this passage to Dr.M’Clintock, the impulse communicated to it on coughing; were all circum- and I shall hereafter have the pleasure of quoting his cases, stances that were irreconcilable with the supposition of its with the notes of which he has kindly supplied me. In his essay " On the Theory of Convulsive Diseases in being an encysted hydrocele, and which pointed clearly to the only other explanation that could be given of it-viz., the ac- Adults," Dr. Marshall Hall observes, respecting puerperal cumulation of fluid at the bottom of a hernial sac, the upper convulsion:—" There are many and most important questions portion of which was closed by firmly adherent omentum; in to be solved in regard to this and other forms of convulsion. Does it lead to subsequent attacks of epilepsy ? Do previous Other words, a hydrocele of the hernial sac. As the case was an obscure one, I requested the opinion of my attacks of epilepsy predispose to puerperal convulsion? In friend, the late Mr. Morton, who agreed with me that it was a this latter is there sphagiasmus, laryngismus, or odaxismus! What relation is there between puerperal convulsion and case of accumulation of fluid in a large hernial sac, the upper part of which was closed by adherent omentum, above which puerperal mania ; and between convulsion, or epilepsy, Thus the or insanity, and paralysis in general?" lay some coils of reducible intestine. As the patient suffered and mania,between much inconvenience from the large size of the tumour, I de- relations epilepsy and convulsions are involved in termined to tap it. The hernia was therefore reduced; the considerable obscurity, and I do not know that any collection cases has ever been made to determine the point upon patient lying on his back, and the tumour having been made of tense by being grasped posteriorly with the left hand, a tro- which such a difference of opinion exists. char was introduced at its anterior aspect. On withdrawing The two diseases, epilepsy and puerperal convulsion, are the stylet, about three ounces of clear yellow serum escaped, so alike in their general features, that any one reasoning nd then ceased to flow, the tumour not being sensibly dimi- à prioriwould be apt to say that epileptics must necessarily nished in bulk. On introducing a probe through the canula, be prone to the convulsions of the puerperal state, particularly a firm elastic membrane could be felt, against which the end ’, when the excited condition in which the entire nervous system of the instrument rested. The stylet was now re-introduced, is brought by gestation and parturition is considered. But and the membrane punctured, some force being necessary, upon reflection, it would become evident, that were this the when nearly three pints of a dark-brown serous fluid were case few married epileptics could survive the repeated shocks drawn off, the tumour being completely emptied of its fluid of the puerperal seizures during the era of child-bearings There are, too, certain points of difference between epilepsy contents. No ill effect followed the tapping. ’ If we limit the term "hydrocele of the hernial sac" to and puerperal convulsion, both in the attacks themselves, and those cases in which there is a slow and gradual accumulation in their antecedents and results, which, upon examination, go of fluid at the bottom of an old hernial sac, which has been cut far to establish the distinctness of the two diseases, convulsion always off from all communication with the peritonæum, either by the Epilepsy is generally a chronic, radical cure of the hernia, or by the adhesion of intestines or an acute, disease. Epilepsy is generally preceded by the con· omentum to the upper part and neck of the sac, it must be characteristic aura; this is never present in considered a disease of unfrequent occurrence, and but few vulsion. Puerperal convulsion is generally preceded by oedema of the extremities, a thing rarely observed in epilepsy. cases are recorded by surgical writers. Mr. Curling, in his work on the testis, states that during his connexion with the Epilepsy, when long continued, often leads to idiocy or wealc, London Hospital he has seen only one case; and the only ness of intellect, with occasional paroxysms of insanity. Puerothers with which I am acquainted are, two related by Pott, peral convulsion, when it affects the intellect, produces acute mania. The fits in puerperal convulsion are much more severe; two by Pelletau, one by Boyer, and one by Lawrence. This disease must not be confounded with the accumulation and asphyxia is more nearly approached. The fits are many in 6f fluid, in whatever quantity, in strangulated hernia or in her- number, following each other in rapid succession, and there nial sacs that communicate with the peritonæal cavity. Its generally is insensibility in the intervals; while in epilepsy, the by fits of one or two at a time, often at long indistinguishing feature is the accumulation of fluid in a sac that disease recurs has been cut off from all communication with the cavity of the tervals, with the speedy recovery of consciousness, after subsidence of the convulsion. Puerperal convulsion is peritonaeum. The case that has been just related was evidently the of this character, and was remarkable on account of the large a disease of days, or even hours! Epilepsy is a disease of years ! It is seldom that epilepsy terminates fatally, until the quantity of fluid thus accumulated. nervous system of the patient has been worn out by repeated seizures, while in the puerperal disorder the first attack may with the ordinary functions of the A MEMOIR ON THE RELATIONS AND DIFFER- kill. Epilepsy isatconnected the most occurring varying times, and from the most ENCES BETWEEN EPILEPSY AND THE PUER- body, varying causes, while puerperal convulsion belongs to an exPERAL CONVULSION. traordinary function, of limited duration. And after asking the question-Is epilepsy followed by puerperal convulsion? By TYLER SMITH. M.D. (LOND.) another question is suggested-Are the subjects of puerperal LECTURER ON OBSTETRICS, ONE OF THE PHYSICIANS TO QUEEN ADELAIDE’S convulsion predisposed to attacks of epilepsy ? If we examine LYING-IN HOSPITAL, HONORARY MEMBER OF THE DUBLIN OBSTETRICAL into actual cases we shall find the facts to be, that the SOCIETY, ETC. existence of epilepsy is by no means necessarily followed OBSTETRIC authors, when treating of Puerperal Convulsion, by puerperal convulsion on the occurrence of gestation very commonly speak of it as Puerperal Epilepsy, or they and parturition; and it would be difficult to prove that there is divide puerperal convulsions into the hysterical, apoplectic, in epileptics even a greater predisposition than usual, to the and epileptic varieties. The application of the terms epilepsy puerperal attack. In epilepsy, too, the exciting cause is end epileptic to the convulsion of the puerperal state, shows generrlly excentric, as, for instance, some irritation of the The circulating mass is not that these maladies have been thought related to, or closely stomach, bowels, ovaria, &c. resembling, each other; and I believe, from my own experience, vitiated as far as its examination has yet gone. In puerperal many persons believe in the existence of some actual con- attacks, there are unmistakable indications of toxsemia, bloodnexion between them, and that epileptics are more prone than poisoning, or centric irritation of the spinal marrow, the organ other women to puerperal attacks. It is this supposed con- upon which all convulsive actions depend. The treatment re nexion thatI wish to examine in the present memoir. quired in the two diseases is very dissimilar; in the one, the ’ Dr. Robert Lee, in his learned and comprehensive " Lec- time for treatment is in the intervals between the fits; in the

before doing this, the precise seat of

puerperal

puerperal

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