Some few points of interest not having been noted in the foregoing letter, Mr. Crowfoot subsequently added, "that the communications between the cyst and the bronchial tubes were numerous but not large. There was no disease or ulceration of the mucous lining of the trachea, which we, in common with all his medical friends, had been led to expect, owing to his constantly referring his pain and uneasy sensations to that organ."

Mr. Beales, of Halesworth in Suffolk, the kind and intelligent medical friend with whom L. B. resided, subjoined the following particulars :

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"The pulmonary artery was so large, as at first to be taken for the aorta, for it had a complete curvature to the right, as high up, and upon a line with the clavicle of the left side. The opening into the abscess, it is probable, was the result of the coats of the artery giving way, rather than the effect of the ulceration of the abscess; as the opening from the artery was funnel-shaped, and terminated in the smallest possible aperture."

This case is submitted to the consideration of the Medico-Chirurgical Society, as one abundantly interesting in its details, and as affording an unequivocal instance of the communication of a large artery with the cavity of an abscess. The dilatation of the pulmonary artery may perhaps be attributable to pressure of the cyst upon one of its main divisions, and whether the communication between it and the abscess be due to the ulceration of its coats from pressure, or from bursting of its dilated and thin

parietes, is a matter of far less moment than the establishment of the fact, that no vessel in the body is exempt from the consequences of pressure, and of the disintegrating influence of suppurating cavities in their immediate neighbourhood.

Abundant examples of the ulcerations of arteries of the systemic system have now been published, and Mr. Bloxam's paper shows that the large veins may be similarly circumstanced. This interesting case of Mr. Crowfoot completes the deficiency in the chain, by exhibiting a fatal hæmorrhage from the communication of a large branch of the pulmonary artery with a chronic abscess of the lungs.

CASES

OF

STRANGULATED HERNIA,

REDUCED "EN MASSE."

WITH OBSERVATIONS.

BY JAMES LUKE, Esq.,

SURGEON TO THE LONDON AND ST. LUKE'S HOSPITALS, AND LECTURER

ON SURGERY.

COMMUNICATED BY SIR B. C. BRODIE, BART.

READ APRIL 25TH, 1843.

AMONGST the numerous and ever-varying occurrences in the progress of cases of hernia affected by strangulation, there is occasionally to be met with, one so little expected by the generality of surgeons, yet of so dangerous a character, if not detected and met in a proper manner at an early period, that I hope, by directing the attention of the Society to it by the relation of cases, followed by some observations, intended to be of a practical nature, I shall not be considered to have entered upon an unnecessary or superfluous undertaking.

The occurrence to which I allude, takes place during the application of the taxis, mostly, when

used by patients themselves for their own relief, but is also liable to take place in the hands of the surgeon, when too much force is applied under certain contingencies favourable for its production.

It consists in the reduction of the hernial tumour through the aperture of the abdominal parietes, together with its investing sac, whereby the hernial contents continue still subject to strangulation, in the same degree and by the same cause that existed previously to the reduction, and demand, no less imperatively, liberation from constriction by an operation, than when presenting the more obvious guide of external tumour. French surgeons have called this kind of reduction "réduction en masse,' or "réduction en bloc." But British surgeons appear to have considered the occurrence to be of such rarity, as hardly to have any influence upon the general course of practice. We, therefore, find the surgical records of our own country almost wholly barren of cases of this description, and our best and most approved writers upon the subject of hernia are altogether silent, or refer to examples taken from the records of other countries, where the occurrence of "réduction en masse" has excited greater attention.

Although, from these circumstances, we must admit that the reduction alluded to is an event of some rarity, yet I am induced to think, that it is one of less rarity than is generally supposed, and that at least it is so frequent, that it should be held constantly in view as an occurrence within the

range of ordinary probabilities, and as requiring only favouring circumstances for its development.

I am led to the above conclusion, by the occurrence of five cases of reduction en masse under my own notice; a conclusion the more desirable to be adopted, as an error of omission during the actual existence of such reduction will prevent the use of the only means likely to be available to the safety of the patient.

One of the above cases occurred in a patient about fifty years of age, who had been admitted into the London Hospital for an ulcer of his leg. He had been the subject of inguinal hernia on the right side, for many years-which, under the influence of some exertion, descended, and became strangulated, after his admission. The attention of the housedressers being called to him, the hernia was quickly reduced, and the symptoms of obstruction ceased. After the lapse of a fortnight, the hernia again descended, and became strangulated. Upon this occasion it was reduced by himself; but the symptoms of obstruction continued, and increased in severity up to the period of his death, which took place some days afterwards, immediately subsequent to an effort made to force an evacuation from the bowels. Two other cases came under my examination only post mortem.

A great similarity of circumstances appears to have attended the whole of these cases. Thus, in each case the hernia was oblique inguinal-and reduced by the patient's own efforts. In each the