precise nature of the case was not known during life, and no operative attempt was made to afford relief; and in each the post mortem examination discovered a hernial tumour in the neighbourhood of the internal ring, reduced through the abdominal parietes, but lying exteriorly to their general peritoneal investment. On opening the tumour, in each its fundus lay below the level of the ring, towards the cavity of the pelvis, the contents being found in a state of sphacelus, and strictured by the neck of the sac, in which they were enclosed.

The first case, which fell under my own treatment, occurred on a short, muscular stage-coachman, thirty years of age, who, while driving along one of the public thoroughfares of London, experienced the descent of a hernia through the left inguinal ring, but at the time not attended by any pain. He immediately applied pressure to the tumour, without descending from his seat, under which pressure it quickly disappeared.

He thought nothing more of the occurrence until his return home an hour afterwards, when he began to feel pain in the bowels, followed by sickness. Having obtained medical assistance, various remedies were used without relief to his symptoms. On the contrary, the severity of his sufferings became gradually augmented, until his admission into the London Hospital, in the night of August 30, 1839, upwards of three days from the commencement of his illness.

He was at this time suffering from severe pain in

the abdomen, and great prostration of strength. The abdomen was tympanitic and tense, attended by frequent vomiting of fæcaloid matter, and obstinate costiveness, which latter had not yielded to purgatives administered in the course of the previous treatment. The pulse was weak, and the countenance pale and anxious.

He stated, on being interrogated, that he had been the subject of a large rupture, on the left side, for many years, during the greater part of which he had worn a truss for its support. He also related the particulars of the descent and reduction already mentioned.

It was suspected by the gentlemen formerly in attendance, and by myself, that the hernia had been reduced with its contents still suffering from continued strangulation, and diligent examination of the inguinal rings and canal was made, with the hope of detecting some indication of a local character to guide our proceedings, but none was discovered. The inguinal rings of both sides were entirely free from every appearance of tumour, and the canal was devoid of all external evidence indicative of a hernial descent. Neither was there any fullness of the abdomen in the neighbourhood of the ring, nor more pain caused by pressure in that situation on the left side than on the right.

Amidst the doubts and uncertainties of the case, I determined to await the result of a consultation which I directed to be called for the next day, and in the interim prescribed some medicine, but which,

when taken, was quickly rejected by vomiting, without producing any beneficial effect.

August 31st. In the absence of clearer indications, it was considered, at the consultation, most prudent to abstain from any operative proceeding.

Subsequently to this decision, the treatment consisted of the occasional administration of calomel combined with opium. Being unwilling to leave the patient without an effort to save his life, I continued about the hospital, and visited him from time to time, devoting much anxious consideration to his case. After the lapse of about three hours I arrived at the determination to perform an exploring operation, especially as, during my consideration, it had occurred to me that such an operation might be performed without entailing any material new danger, until a hernial tumour should be made manifest to me, and be opened for the liberation of its contents by the course ordinarily adopted for that purpose.

This determination, on proposing the operation to the patient, was not acted upon, in consequence of the emphatic assurance which he gave, that at the time of his reducing the hernia he had employed but very little force, and that the reduction was not attended by the slightest pain; the reverse of two contingencies that might generally be supposed to precede or accompany the reduction of a strangulated hernia, together with its investing

sac.

Being, in the evening, under the necessity of

leaving London for a few days, the patient was left in charge of the assistant-surgeon, by whose directions the treatment was conducted during my absence.

On my return to town, September 4th, I found my patient still alive, but with all his symptoms of danger much increased. A local indication had also now arisen, by the formation of a tumefaction along the course of the inguinal canal, which induced me instantly to propose and perform as quickly as possible, the operation of exploration which I had before contemplated.

An incision was made over the seat of tumefaction, from which a quantity of highly offensive sanious fluid exuded, and by the infiltration of which into the cellular texture of the part, the tumefaction had been caused.

Continuing the incision towards the internal ring, a lustreless greenish membrane presented itself, the tense and rounded surface of which extended beyond the limits of the opening made by the operation.

This was at once recognised to be hernial sac, and therefore opened.

On examining its contents, they were found to. consist of a large quantity of intestine, sphacelated and reduced to a pulpy condition, so that it gave way under the pressure of the finger, introduced for the purpose of ascertaining the seat of stricture. This latter was reached by the finger with great difficulty, in consequence of its distance from the opening of the parietes. Being reached, the finger

was passed through it, and when withdrawn was followed by fæculent discharges, rendering further division unnecessary. A free vent for the dis

charges was made by enlarging the external wound, and the patient taken to bed. A bread-and-water poultice was applied over the part, and stimulants were administered by the mouth.

Copious discharges continued to flow from the wound for two days, at the end of which he died, his death taking place on September 6th.

The large hernial sac discovered during the operation, was brought more fully into view at the examination post mortem. It was found to occupy a considerable space just within the abdominal parietes in the vicinity of the internal ring. The fundus of the sac lay a little below its level, towards the cavity of the pelvis, while the neck (still contracted, so as obviously to have been the original seat of stricture) lay in an upward direction towards the umbilicus, and between three and four inches distant from the situation of the internal ring. The whole sphacelated contents were empty, collapsed, and in a pulpy state.

The second case occurred in a respectable baker aged 40, also a rather muscular man. He had been the subject of a large inguinal hernia on the right side for upwards of twenty years, and of a small hernia on the left side for about four years. About seven o'clock in the evening of January 6th, 1843, while removing some bread from the oven, he was suddenly seized by a severe pain, extending