"First,-In cases belonging to the first class, either mode is applicable; but extra-peritoneal division being attended with much less danger, is decidedly preferable.

"Secondly,-In regard to cases in which, independent of the stricture, an obstacle to reduction exists, it will be proper to consider what are the principal obstacles most frequently met with. These are adhesions of the protruding parts to the hernial sac, the natural means of connexion, in some rare cases; adhesions of the protruded parts to each other; and the large size of the hernia.

"For a description of these obstacles to reduction, the reader is referred to the section on irreducible hernia.

"If any of these conditions exist, and if the sac be not opened, reduction is in general impracticable. If the sac be opened, two of them may easily be overcome; namely, the soft recent adhesions formed by coagulable lymph, and the filamentous-the former can be broken down with the finger, the latter divided by the knife. Two of them present an insuperable impediment to reduction; namely, the natural means of connexion, and the close organized adhesions, if these be to a great extent, and the hernia large. With regard to the two remaining conditions, the possibility of overcoming them, and the propriety of attempting to do so, must depend entirely on the particular circumstances of the case; but frequently, it is more judicious not to interfere with them, unless they exist only to a limited extent, and in hernia of moderate size. Most of these conditions, however, are principally met with in cases of large and old hernia; and, on account of the risk of injuring the intestine in attempts at reduction, as well as that of inducing dangerous inflammation by much handling of the intestine, and the difficulty of maintaining the parts reduced, even should reduction be possible, the majority of surgeons seem now disposed to follow the advice of Sir Astley Cooper regarding such cases. His practice was, to divide the stricture, which fortunately in such cases is, for the most part, external to the sac, and to leave the latter unopened, and the hernia unreduced. The stricture being divided, the principal cause of danger is removed. The coverings of the hernia should be replaced, and proper means taken for promoting the healing of the wound.

"Thirdly,-There are certain states in which it would be extremely improper to attempt reduction; namely, when the hernia is gangrenous, or when the intestine has given way from inflammation having gone on to gangrene, or when it has been torn, or accidentally wounded in the operation. The two last-mentioned conditions can only result from unskilfulness in the mode of procedure; but, should they exist, the hernia ought not to be returned. When the intestine presents such an appearance as to render it doubtful whether its return may be followed by fæcal extravasation, the surgeon should content himself with carefully dividing the stricture. In all cases in which the intestine is gangrenous, or not entire from whatever cause, it ought to be allowed to remain, so that the fæces passing off by the wound may form an abnormal anus, and extravasation into the abdomen be thereby prevented. When omentum forms the hernia, and it is gangrenous, the gangrenous portion may be removed, and the remaining part returned to the abdominal aspect of the mouth of the hernial sac. The practice of removing a portion of omentum, when from growth it renders a hernia irreducible after division of the stricture, is a proceeding which, in some cases, may be adopted with advantage. For cases belonging to this class, extra-peritoneal division is of course quite unsuitable. These remarks, it is to be hoped, will be sufficient to point out the proper mode of procedure when the hernia is sound, and reducible after division of the stricture; when it is irreducible after such division-and when it is in any of the various conditions in which reduction would be dangerous and improper; and also to show, that to follow one method indiscriminately in all cases would be unwise; that intra- or extra-peritoneal division should be adopted according to the particular circumstances of the case; that in the majority of cases intra-peritoneal division is not only the more suitable mode, but the only one which is safe, or by which any good can be effected; and that the cases in which extra-peritoneal division is suitable are those of very short standing, where there is no reason to apprehend the existence of adhesions, or of an unsound condition of the hernia; and those also of large and old hernia, where the more judicious proceeding is to divide the stricture, and not to attempt reduction." (pp. 591-594.)

Our last extract will convey Mr. Pirrie's judicious cautions on the use of the taxis, which correspond with those given by some of our ablest metropolitan surgeons, and are justified by the success of his own practice.

"There can be no doubt that intestinal inflammation is the most frequent cause of death after the operation for strangulated hernia. Some of the advocates of Petit's method have assigned as the causes of that inflammation, when the ordinary proceeding is adopted, the exposure of the intestine to light and air, change of temperature and handling. I agree with Mr. Lawrence in ascribing it, not to these agents, but chiefly to the long-continued pressure of the stricture, owing to the operation being too long delayed, and to an injudicious and too frequent

use of the taxis previous to the operation. I remember being very much struck with an observation of Desault's; I have not his works beside me at present, but it is to this effect:-'Think well of that hernia which has been little handled and soon operated on.' The operation is justifiable and necessary, when the patient has been brought fully under the influence of chloroform, and the taxis has been fairly, fully, and skilfully tried without producing the desired effect. The conviction being thus produced, that by no other means than an operation is there hope of saving the life of the patient, it ought to be resorted to as quickly as possible. Much handling must not only give unnecessary pain, but also increase the risk of hurrying on the inflammation to results which, even though the operation should be performed, would render it unsafe to return the hernia. When therefore the taxis has been fairly and skilfully tried, on a patient fully under the influence of chloroform, no advantage can, but considerable injury may, result from the repetition of treatment already found to be unavailing. Many considerations show that the operation should be performed as soon as possible, after its inevitable necessity has been found to exist. Delay, like undue handling, increases the risk of inducing such a state of the hernia, in consequence of inflammation, as would render its return unsafe. From the circumstance that a hernia may speedily prove fatal, and from the depressed state which comes on in consequence of delay, rendering the patient less able to stand the shock of an operation, will be seen the importance of being as prompt as possible; but there is another and a very urgent reason-namely, that if the operation be delayed until intestinal inflammation has been induced within the abdomen, it is far from certain that this inflammation will subside on the removal of the hernia which caused it. I have performed the operation for strangulated hernia, according to the usual mode, a considerable number of times, I believe twenty-three in all, and (except in one case, where death occurred in consequence of an attack of phlegmonous erysipelas which commenced after the patient was considered out of all danger) in every instance with success. This success I attribute to two things-namely, avoiding all undue and useless handling, and performing the operation early. My decided impression is, that the reason why the operation is so frequently followed by death, instead of being one of the most successful of the great operations of surgery, is, too great delay in resorting to an operation, and the undue and injurious use of the taxis, even after its adoption has proved unavailing." (pp. 595, 596.)

We fear that our review may seem to have scarcely done Mr. Pirrie full justice; for though it is exceedingly easy to detect blemishes and short-comings, it is extremely difficult to convey an adequate idea of the merits of an elementary work, where those merits consist in method, condensation, and perspicuity. By far the greater part of Mr. Pirrie's book possesses these in a very high degree; and the author will find it easy, with a small additional expenditure of diligent care, to render the next edition of his work, which must, we feel sure, be required at no distant date, the best compendium of surgery in our language, if not the best existing treatise of its kind.

ART. XIV.

Researches and Observations on Scrofulous Disease of the external Lymphatic Glands. With cases, showing its Connexion with Pulmonary Consumption and other Diseases. By THOMAS BALMAN, M.D., M.R.C.S., &c., one of the Medical Officers of St. Ann's Dispensary, Liverpool.-London, 1852. 8vo, pp. 189.

"VERY nearly three years ago," Dr. Balman observes, "I suggested to one of my colleagues, that each of the honorary surgeons to the Dispensary should be at liberty to select some particular group or class of diseases as his speciality, and that the cases belonging to such group occurring in the practice of the other surgeons should, as far as might be agreeable, be transferred to the care of the surgeon who had adopted this particular speciality. In this request all my colleagues readily acquiesced: hence the origin of this inquiry." Dr. Balman was thus enabled to note the particulars of 141 cases of scrofulous enlargement of the external cervical glands, which he did according to a fixed form; and the results are presented numerically and generally in the volume before us.

The first chapter is headed "Histology of Scrofulous Affections of the External Glands," and inquiries into the temperament most commonly prevailing in the scrofulous constitution; the ages of the patients; the regions of the body most frequently

affected; the probable causes; the connexion between scrofula and phthisis; and "the diseases occurring in the parents and relations, some of which have been supposed to be sometimes associated with the strumous habit." This chapter contains, therefore, the etiology and pathological relations of the disease; consequently, we are puzzled as to what can have induced Dr. Balman to head it with the title "histology," unless he has thought that term and "history" synonymous. That he does not know the meaning of the word is obvious, however, or he would never have used it so mis. appropriately. We will give a brief summary of the facts arrived at. There were 90 males and 51 females; 34 per cent. of these had dark hair and complexion; 73.76 per cent. were aged from 2 to 15 years, and only 284 per cent. above 30. But about one-tenth of the whole were obtained from different charitable institutions or schools; and all those (comprising a greater number of adults than of children) who could not give the necessary information as regards their family history were excluded. This appears to us to have been a mistake on the part of Dr. Balman. The mere fact of occurrence at a certain age has no necessary connexion with the family history or with hereditary predisposition; we therefore think that he has restricted his numerical inquiries on the general points of age, sex, temperament, &c., very unnecessarily, by taking in the additional element of family predisposition. It is obvious, at a glance, how this circumstance wholly vitiates the general conclusions which might have been otherwise deducible from Dr. Balman's tables. As to the region affected in the 141, by far the greater proportion (83.69 per cent.) had disease of the cervical glands alone. The axillary glands were diseased (as well as the cervical) in 6.30 per cent., the inguinal in 4.20, and the glands above the elbow in 4.97 per cent. As to the causes ; in 55.45 per cent. they were not evident; infantile fevers were assigned in 23:40 per cent.; exposure to cold and damp in 14:18 per cent. Dr. Balman "purposely omits many of the external causes which are well known to act most injuriously in persons predisposed or otherwise to scrofula-such as bad air, deficient or unwholesome articles of food, defective ventilation, or deprivation of exercise, because "they have already been so ably discussed by Mr. Phillips, as to preclude the possibility of my adding anything to what he has already recorded"-just as if the play of Hamlet' were to be played with the Prince left out, because the character had been already so admirably represented by Kemble.

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. The hereditary connexion between scrofula and phthisis pulmonalis, is, in fact, the chief object of Dr. Balman's inquiries. This is shown in Table 5, from which it appears that in 9 cases (of 141) the father had died of phthisis, in 11 the mother; in 11 the paternal grandfather, in 17 the paternal grandmother; in 9 the maternal grandfather, in 20 the maternal grandmother; and in 99, uncles and aunts (on both sides) had died of phthisis. This table is interesting as far as it goes, but it is doubtful whether it shows the full extent of hereditary predisposition derived from the parents and collateral branches. The large proportion of young cases points to the probable circumstance, that the parents of some had still to become the victims of phthisis. Dr. Balman would have increased the value of his table very considerably, if he had had columns showing the numbers of cousins affected with struma or dying of phthisis. From inquiries as to the liability to phthisis (or "consumption") of persons born of phthisical parents, Dr. Balman found that in 20 instances in which the grandfather died of phthisis, it was transmitted in 13; and in 37 instances of the grandmother so dying, it was transmitted in 14. This result corroborates in some degree those arrived at from inquiries at the Brompton Hospital. As to consumption occurring in families as a companion-disease to scrofula, Dr. Balman found of the 141 cases he investigated, that in 30 there were no ascertained family deaths from phthisis; in 60, in one branch only; 40, in two branches; 9, in three; 1, in four; and 1, in five branches. The general infirmity of constitution renders the scrofulous liable to other diseases of a grave character. Thus in 27 there were 18 deaths of father or grandfather from apoplexy, paralysis, or epilepsy; out of 27 on both sides, 6 grandfathers and 1 grandmother died of insanity, 5 of the latter of cancer, 3 of the former of stone; in all instances a much larger ratio than occurs in the general population.

We pass from Dr. Balman's not very satisfactory statistics, to his more satisfactory pathology. On this head, his views are those of Phillips, Glover, &c. He has submitted blood taken from strumous persons to microscopic examination, and the only deviation from the healthy condition which he has been able to make out, is an unusual increase in the number of the normal colourless corpuscles. He has "very frequently counted as many as sixty and eighty in the field with a fourth-of-an-inch object-glass, whilst ordinarily only five or six are observable. They appeared very variable in size, some being less than half the size of the coloured corpuscles, whilst the majority exceeded the blood-discs in diameter." He has found the urine of the strumous to average about, sp. gr., 1.012, and "it had often a strong odour of cod-liver oil in cases where this medicine had been taken for any length of time." In 19 (of the 32 cases in which the urine was examined), he found octohedral crystals of the oxalate of lime, the average specific gravity being 1020. Of the 13 remaining cases, 4 showed the phosphates in excess; 2 of these had very large glandular swellings excited by syphilis; in the other 2 these glands had suppurated. With the laudable view of testing the value of the oxalate-urine as a pathological indication, Dr. Balman examined the urine in various other diseases. In 117 instances of this kind, the oxalates were present in 16, unmixed with any other deposit, in 26 mixed with lithates, in 3 with phosphates: 21 cases of phthisis gave 10 with oxalates; 12 "affections of the skin" gave 8, of these 4 were cases of impetigo. Dr. Balman did not find any unusual frequency of the oxalates in dyspeptic cases. From these researches it would appear that the oxalate of lime occurs more frequently in the urine of the strumous, than of those affected with other diseases. Dr. Balman makes the proportion to be 74 per cent. to 38 per cent.; but it is manifest that if phthisis and impetigo be deducted from the instances of general disease and added to the strumons, we should have a somewhat different ratio-namely, 64 to 32 per cent. Dr. Balman found the oxalate deposit showing itself in strumous cases, 'for weeks or more, commonly for months, uninfluenced by diet or medicines of any kind." This he ascertained by careful and repeated experiment and observation. He also found the oxalates more abundant in the urine passed at night, than in that of the morning. As the health became more and more deteriorated, and the powers of the system reduced, the earthy phosphates appeared, the oxalate of lime being then seldom met with. On the other hand, as the health became re-established, the urine ceased to exhibit traces of the oxalates.

Dr. Balman devotes his third chapter to the consideration of the "Symptoms, Progress, Duration, and Varieties of Scrofulous Tumours." His familiarity with the disease is well manifested by the truthfulness of his delineations. We make some prac tical excerpta.

"One peculiarity in these tumours, which I have repeatedly noticed, is the almost sudden variations in size which they appear sometimes to undergo. Thus, after excitement or exercise of any kind, as running or walking fast, they sometimes become distended to twice or thrice their usual size. The same thing, in a less degree, is observable in the morning on getting out of bed (arising, probably, from some temporary impediment to the return of venous blood from the head and face), which gradually subsides during the forenoon. One may sometimes notice, too, another feature of interest-that is, the reciprocal influence between it and the healthy and regular performance of the digestive and blood-making process, on the one band, and the partial arrest or temporary derangement of these functions on the other. Thus, suspend, vitiate, or impair by neglect of hygienic means, unwholesome or insufficient food, the process of digestion, and the disease either increases or remains stationary; remove the person from an unhealthy locality, and supply him with good and nutritious food, and the swelling will in all probability diminish, and the general health correspondingly improve." (p. 97.)

It has been remarked by various practical writers, that an external deposit of tuber. cular or scrofulous matter is apparently prophylactic, in its influence on the system, against the more serious deposit internally in the lungs or other viscera. In a clinical lecture, published a few years ago (1846), Dr. Laycock mentions this general fact as probable, from various circumstances. Referring to a case under the notice of his class, he observes:-"She is thin, meagre, and has enlarged glands in the axillæ and neck; and it is well for her that they are there, for I am inclined to think they will

be her defence against the tubercular deposit in the lungs; at all events, they will much delay the fatal termination. I have witnessed three or four cases of tubercular phthisis of this kind with the peculiar complexion-(a muddy grey)-the enlarged scrofulous glands in the neck and axillæ, and tubercular deposit in the lungs going on, but very slowly indeed, the patient lingering on from day to day in really a wonderful manner. I see that Dr. Glover, of Newcastle, in his recently published work on Scrofula-a work containing the result of original investigations,-states it to be a popular belief that scrofulous cervical glands prevent the internal disease becoming manifest; and he quotes an observation by Sydenham, somewhat like that I have just made. I certainly cannot say I have seen phthisical persons cured concurrently with these scrofulous glands; but I am sure their presence in good large masses (and if suppurating, so much the better) is the guarantee for a prolonged existence to your patient. I have such an example under my care at this moment. How this happens can only be theorized on, but it is not unreasonable to suppose that there is a derivation from the lungs to the glands; that what tubercular matter is deposited in the glands would have been deposited in the lungs had there not been glandular irritation to attract it there. With the humoral pathology the old terms of that pathology will come into use, and we may say, with regard to scrofulous diseases and deposits, ubi irritatio ibi fluxus. The old methods of treatment adopted by the old humoral pathologists will come again into vogue; and I cannot doubt that in the gouty and scrofulous cachexies, derivants, such as issues, setons, and perpetual blisters, may be, and are, of advantage."*

We have given this quotation at length, because it very accurately expresses the results of Dr. Balman's experience; active scrofulous tumours in the neck or elsewhere, serving, in his opinion, as a safety-valve to the lungs. He details one or two cases illustrative of the prophylactic efficacy of the external deposit, in cases of tubercular phthisis, and has found a seton below one of the clavicles attended with beneficial results, as regards both the local and general symptoms. Dr. Balman has a theory explanatory of the fact, which is based upon the probable functions of the lymphatic glands. Referring to the resemblance, on several points, between the latter and the thymus, he observes:

"If their function be, as is now very commonly entertained by physiologists, to elaborate and prepare nutritious matter to meet the additional requirements of the system during the active period of growth, when nature is employed in building up the structures, appears in my mind [sic in orig.] to go some way in explaining the reason why these glands should be more liable to be affected with strumous disease previous to the age of puberty and manhood, than at any subsequent period of life. The growth of the body being now perfected, the functions of these organs would be simply limited to the maintenance and support of the animal body; and those morbid and heterogeneous products which would otherwise be attracted to the surface in growth, have now a greater tendency to fix themselves in some internal organ, especially the lungs, causing pulmonary consumption. This view is, I conceive, strengthened by some of the remarkable phenomena before alluded to, as regards a certain amount of antagonism between two diseases: for example, external glandular swellings, either whilst gradually increasing in size, or in a state of suppuration, seem to protect the lungs from being invaded with tubercles; and, on the other hand, the presence of tubercles in the lungs is seldom followed by the deposition of a similar product in the external glands." (pp. 109, 110.)

Dr. Balman illustrates the causal relation between syphilis and scrofula by detailed cases, and then points out the influence of other circumstances on the progress of the disease. We do not here find, however, anything worthy of special notice; and we therefore pass on to Dr. Balman's chapter on the treatment of strumous glandular swellings, where we again find nothing novel. The tumours in the early stage should be" dispersed," if possible; and to this end, Dr. Balman recommends "pencilling the part lightly with the solid nitrate of silver a few times, at intervals of a week or ten days." When suppuration has taken place, an early incision is recommended, &c. We think Dr. Balman would find constant endermic medication of the tumours useful

* Dr. Laycock's Clinical Lecture on Scrofula, London Medical Gazette, Nov. 1846.