means for warming and ventilation have not always answered, and open fire-grates had to be built in their stead. Smoky chimneys or stoves must not, of course, be tolerated. FLOORS. I have not much to say about the floors, walls, and ceilings of hospitals. In Paris, where some hospitals had stone-floors, these have been replaced by parquet ones, les Cliniques, Charité, St. Louis. In English hospitals, some deal floors are now oiled and lacquered-King's College Hospital, Newcastle. In bath-rooms tiled floors are in their right place (Cambridge, Lock Hospital, Harrow-road). In France, every grocer sells the material which is used to lacquer the floors; walls, and ceilings, which are not coated with cement, want repairing or whitewashing about once a-year. FURNITURE. The furniture, which the wards contain, can easily be improved where necessary. The Paris Administration has nearly all other bedsteads replaced by such as are provided with spring-mattresses. They are more easily kept clean and free from vermin, the quantity of horse-hair contained in the mattress is only 18 kilogrammes, or 40 lbs. I saw some very useful hospital furniture in the Paris Exhibition -night-tables, contrivances to raise the patient, &c. All the London hospitals should gradually replace their beds by better ones. WATER-CLOSETS AND LAVATORIES. That the salubrity of a hospital is endangered by badly placed water-closets or latrines and drains is well-known, and it is therefore desirable where they are faulty to remove the nuisance. These things are better arranged in England than elsewhere. I have, however, pointed out in another place that we are not altogether free from blame. At the Oxford Ratcliffe Infirmary a nurse's-room is, or was till recently, squeezed between two water-closets. The Paris Administration is gradually replacing the latrines by waterclosets. The new ones of Lariboisière are quite on a level with English ones. La Charité, les Cliniques, the new part of Cochin, Beaujon, la Salpêtrière, are provided with new waterclosets. It will not be long before we will have to search diligently for the ancient latrines which everyone who sees thein for the first time contemplates with amazement. Low seats of stone with a small round opening, not fit to sit but to stand upon, as constructed more than 100 years ago, are still visible at the Charité and Salpêtrière. Earth closets I did not see in hospitals, but I noticed them in the Exhibition. They seem to me the next best thing to water-closets, especially in hot climates. Lavabos are not difficult to place where they do not exist. In France, they have generally marble-slabs, whereas the English are content with slate. Water-closets and the place where the lavatories are, are rarely warmed, it should become in future the object of architects not to overlook this. In Guildford Hospital, Herbert, New Leeds Infirmary, and the Brompton Hospital, the means for warming are found. In consumption hospitals especially they should not be overlooked. The best means are small chimneys or warm air, which has passed over hot pipes. OPERATING-ROOMS AND LECTURE-ROOMS. They are not always what they should be. Where they are not light enough, windows may be formed at the proper place. Some hospitals have had new ones added lately at a considerable outlay--viz., Guy's Hospital. The most ancient amphitheatre I saw recently is that of Bouilland in the Charité Hospital. It is of a round form, the chair in the centre, the seats rising steeply, the light sparingly falling through a round skylight above the chair. 300 students may be seated. THE POST-MORTEM ROOMS are badly arranged in many of the old buildings, and might be replaced by separate detached deadhouses, care being taken that the patients cannot see the funerals. THE BATHS are capable of much improvement in English hospitals. The more recent establishments are somewhat more satisfactorily arranged, but the older ones contain neither a sufficient number, nor are the baths of the proper material. Enamelled earthenware I consider the best material for the fixed baths. In Paris, a great many newly instituted baths are of enamelled cast-iron, and they look beautiful, but they are less durable than the former. Zinc-baths are not rare with us or on the Continent; copper-baths are much valued in Germany (Berlin). The finest baths are those of one piece of marble, as exhibited last year in the Italian gallery of the Exhibition, but they are very expensive. Hot air or Roman or Russian baths are rarely met with in British hospitals. I may mention they are to be found in Cambridge, Colney-hatch, and Herbert Hospitals; they will of course not be missing in the New St. Thomas's Hospital, French physicians are much struck with the deficiency in this respect, great value is attached to them in France. In Germany, the larger establishments (Charité, Rudolphstiftung, and others) usually contain these baths; and so they do in St. Petersburg. Occasionally a voice has been lifted in their favour in England, but as yet with little success. The same must be said of sulphur baths. Almost all hospitals in Paris, where skin diseases are common, have plenty of these. The famous baths of Barèges in the Pyrenées are much valued, and produced artificially in French hospitals. In the same manner the "Mother of find some favour with English Hospital Physicians. Lye" baths are used in Germany. Soda and sea-salt baths number of other artificial baths used in Paris, as seen from A London. The atomized baths of Mathieu de la Drôme the report of the administration, are almost unknown in seem not to find much favour with our French colleagues, as they are only instituted in St. Louis and another hospital. Appliances for fumigations for the cure of syphilis and skin diseases should be added to the baths in English hospitals. The hydro-therapeutic apparatus are brought to great perfection and used in Paris, but there is somnie caution necessary regarding their use, especially as respects the Douche. A plan of treating habitual constipation by shower-baths is not much known in England. There is some danger of falling into the error of treating too many diseases hydrotherapentically where the apparatuses exist. Portable hot air and vapour-baths may, of course, be easily acquired for an hospital, and I have reason to recommend them. There is some caution necessary to prewhich I found in several French Hospitals, may be introvent accidents with them. A new appliance, the bidet, duced in English ones. I was pleased to see it in the female lock-hospital. fluous. As an instance, I refer to the new Alexandra The warming of bath-rooms is often considered superwing of the London Hospital, opened only two years ago. Some of the bath-rooms are partitioned off the ward by an opaque glass partition, and are rather dark, but there is a gas-burner. No means of warming nor for the escape of steam are provided for, so the steam enters the ward. Such arrangements should be ameliorated. An apparatus for warming the linen must not be over-looked As it seems very difficult, and in some cases not possible, to provide London hospitals with the desirable Russian baths, appliances for fumigation, sulphur baths, &c., I suggest that a central establishment for medicated and other baths be founded; hospitals, infirmaries, and dispensaries to support the institution by becoming subscribers for tickets, the tickets to be distributed on an order from a medical man connected with the hospital. I know cases where patients with skin diseases have not been admitted into the public baths. An institution of the kind supported by the profession and well managed, would be an undertaking which might be taken in hand by a public company with the greatest success, and be an inestimable boon to the poorer classes of the metropolis. DINING-ROOMS OR HALLS new one in the Salpêtrière, stone floors, marble slabs, or slate, tiled walls, opposite windows, etc., ice in summer. Milk to be kept in enamelled slate tanks with air draught underneath (Brompton). Meat-safes, hot plates, tin boxes for the lifts, and many modern improvements of minor importance may be added. THE WASH-HOUSE. have found much favour with hospital authorities in this country, and there is no doubt that they often prove a desirable addition to many buildings. They are more necessary where the number of light cases is large, and may therefore not be out of place in many country hospitals where the privileged light cases are often largely admitted to the detriment of the real sufferers from disease. Those The plan of having the washing of several hospitals done patients who cannot leave their bed enjoy a larger cubic at one of them is a good one, and, of course, easily actedspace by the others vacating the ward; the attendants upon, where a central administration exists as in Paris. I are saved a great deal of trouble by serving a greater have found the washing attended to at the smallest institu number at one time; the patients do not get their dishes tion I visited-viz., at Windsor, an infirmary for twenty cold, and dine comfortably together. Therefore, notwith-patients-and, on the other hand, large hospitals do not standing some disadvantages which I know quite well, I undertake it for instance, the Brompton Hospital. It consider the addition of dining-rooms an improvement. may not be feasible to act upon the principle of co-operation in London, but there may be country towns more favourable for it. PATIENTS' LIBRARIES can be easily connected with the recreation rooms, and when libraries do not exist, the chaplain of the hospital should make it his business to form them. Such a library, recently founded, I noticed with pleasure at my last visit to the Sheffield Infirmary. LIFTS have been lately added to some establishments, for instance, University College Hospital. They serve to carry the dishes from the kitchen to the upper stories, and are very useful. Also, LINENSHOOTS can be formed where they do not exist, and it is wellknown that earthenware tubes deserve the preference. I need scarcely add that many other improvements are of more importance, and should therefore first be attended to. DISPENSARY. The place where the medicines are made up is often too dark, and in that event should be made lighter, or the dispensary removed to another part; for instance the dispensary of the Herbert Hospital is defective in this respect. A small gas-apparatus is very convenient for preparing infusions and decoctions, and might be added, a defective sink and lavatory might be replaced by an improved one. Medicine vessels should be provided with stoppers. The preservation of cod liver oil, especially in large establishments and consump. tion hospitals, makes some precautions necessary. The principal store is in a cool place in the cellar. A stone barrel with a tap should be kept for it in the dispensary. The objection is raised that such a barrel might be difficult to cleanse, their being only a small opening for filling it, but I think this is not the case. The next best things to be recommended are the glass vessels with double margin. For larger stores a slate tank, under which a current of air passes, is desirable. Poisonous drugs have to be kept always separately; distilled water kept in stone jars. KITCHEN. This is a much neglected department in English hospitals. Many kitchens are in the basement, and too low, badly lighted, etc. The ceiling may be carried higher (Sheffield), or the floors lower Windsor), but it is preferable, where possible, to build a new kitchen. The Berlin Charité Hospital is an instance of this improvement. A large kitchen was built attached to one of the wings of the old hospital a few years ago. Almost all the kitchens of the Paris hospitals are lofty, airy, and have opposite windows with vasistas for ventilation, the smoke flues are carried under the floors which are of stone. For fuel they use coke, formerly coals were used. A central range usually has four fires, Coke wants a little more time before it gets thoroughly heated, but is cheaper than coals. Steam I found employed for cooking, but in one establishment viz., St. Anne; in Germany they generally cook by steam. Gridirons for chops or steaks with side or downdraught can be instituted where not found. For storing the provisions which are to be consumed, I noticed in Paris, and recommend for imitation, airy meat rooms like the Only very small institutions should be without a steamengine, and no large amount of washing should be done without steam-power. It is true that the linen wears longer if only subjected to hand-work, but this is so much more expensive that it cannot be thought of. I am convinced that a great amount of labour and money might be saved in this country by better managing these matters, and adopting some of the continental principles. These matters are too much left to the ingenuity of the female mind, and time and labour is often wasted. I found washing byhand done before the things were put in the machines; in fact most things were washed twice over, which I should think only necessary in a fever hospital. The French way is far more expeditious, as hardly anything is washed twice. It is very singular how the different countries adhere to their own ways, and that, for instance, the modus operandi in France should be different from that of Germany, and both differ from the English one. In all the large French wash-houses-say, of Lariboisière, of the Salpêtrière, or the Incurables Femmes--I was told that the dirty linen, after being wrinsed in cold water, was not washed by hand, but at once thrust into the steamtubs, where the water was gradually raised to a high tem perature. The water, mixed with hot ley, percolates the linen for four hours, after which time it is ready for the washerwoman. The German procedure, as in the Berlin Charité, and many other establishments, is a little more tedious. The linen is wrinsed in cold water, subjected to the action of hot ley-the temperature being moderate-for twelve hours, removed into the steam-tubs, where it is steamed for three or four hours, washed in hot water, wrinsed, &c. This system was partly adopted from a French model, and the precepts of Bourgnon de Layre, but replaced in France by that of M. Bouillon. The tubs à arrosage are not exactly a new invention, but they are an improvement on previous apparatuses. I cannot describe all the washing-wheels and machines, the wringing ones and hydraulic presses; suffice it to say that the French plan deserves a trial in this country, and a good opportunity exists in the new St. Thomas's Hospital. THE OUT-PATIENTS' DEPARTMENT. It requires improvement in many English hospitals. Many of them were built without architects paying much attention to the subject, and we find the defects the more striking the more the number of out-patients has increased. The possibility of this department being used for purposes of medical education did not, of course, occur to the builders. The waiting-rooms are almost as a rule defective in the country and in London dispensaries. How often have I seen the patients, male and female, sitting together in the hall, blocking the way to the stairs or consulting-rooms, exposed to draughts, &c. The consulting-rooms have often insufficient light. The patients should have a separate entrance and exit, in order not to be in each other's way. The rooms should be quiet, and therefore separated by double doors or lobbies, from the waiting-room. Where the department is used for medical instruction, several consulting and private examination-rooms should be found near the principal entrance. The lecturer must be enabled to detach some of his pupils for examining the patients, and go on lecturing to the others. The names of the patients must, of course, be inscribed in a book kept for the purpose, and case-books for interesting cases be found besides; assistants and famuli, elected according to seniority and merit, should be trained to attend to these matters. The dispensing department should be placed in such a manner that the out-patients pass by it when they leave. NOTES ON SOME PECULIAR CASES OF SYPHILIS. BY ANGUS M. PORTER, M.D. (Read before the Ulster Medical Society). Case 1.-Mr. L., a young, unmarried Scotchman, of fair complexion, and free living habits, contracted the disease in Dublin about ten days before coming for advice. Had never suffered from syphilis previously. Five days after connexion he noticed an inflamed spot on the upper part of his foreskin. On September 22, 1867 (the date of his first visit), the appearance of the sore was so indefinite, that it was impossible to determine whether it was specific or not; a dry elliptic chafe being the form it assumed. Recommended rest, a mild purgative, and, locally, cold water dressing. 24th. The dorsal part of the foreskin was considerably inflamed. The sore, on being exposed, presented a suppurating surface. There was no constitutional disturbance nor any enlargement of the neighbouring glands. 26th.—The ulcer was covered by dark sanguineous matter, the edges raised and hard. The prepuce was much swollen, but the system remained perfectly tranquil. The strong nitric acid was carefully applied, and then water dressing. He did not come back till October 2, when, on examination, the surface of the sore was found clean, the margin, however, remaining high and indurated-there was complete absence of pain or irritation. The healing process did not seem to have commenced as yet. For the first time he appeared depressed, and had a bilious look. The various glands still remained unaffected. Prescribed one 5 grs. Plummer's pill, to be taken each night for a week, and large doses of decoction of sarsaparilla daily, the topical remedy being altered to blackwash. Next day he returned much better, the ulcer looking healthy. He continued to improve till October 9, when he complained of soreness and stiffness in his right groin, for which a spica bandage was employed, and rest recommended. The chancre had begun to heal rapidly, but considerable hardness remained around the edges. Some red oxyde of mercury was dusted freely over it. 16th. The chancre had disappeared, leaving a fine purplish skin behind it, surrounded by slight induration. The patient still complained of tenderness in the groin. He was continuing to take large quantities of the sarsaparilla decoction. He now left, promising to return as soon as convenient, which he did on November 5, when he reported himself as completely cured. There was no hardness remaining to indicate the situation of the chancre, and the abortive bubo had quite disappeared. Up to the present he has enjoyed excellent health. In this gentleman's case, which, from its persistency and difficulty of cure, was undoubtedly one of a specific nature, at least one feature of interest occurred, and that was the presence of induration unsupplemented by any form of secondaries. This hardness, as has been noticed, was not the result of a cicatrix, nor incidental, but evidently characteristic of the form of ulcer which it accompanied, inasmuch as it occurred a considerable time before the healing process commenced, and subsided on the disappearance of the sore. Case 2.-Mr. A. G., of Belfast, occupied as a clerk, of dark complexion, bilious temperament, regular habits, young, and unmarried. On October 2, 1867, he first sought advice for three nonindurated, flat, round, ulcers, two of which were situated on the mucous surface of the right side of his foreskin, and one on the left side. A large bubo had formed in the left groin; considerable constitutional disturbance was also present. He stated that he had not had connexion for six weeks, and that it was two since he first noticed the sores. He had never been the subject of venereal disease prior to this attack. On drawing back the foreskin he experienced intense pain; a good deal of smegma had consequently been allowed to collect, and keep the chancres in a foul condition. After the removal of all the secretions by warm bathing, the strong nitric acid was freely applied, followed by cold water dressing. Pressure, by means of a pad and spica bandage, was put upon the bubo, and perfect rest inculcated. The following day (Oct. 3) the chancres were looking clean and not so sore, the bubo, however, was causing him considerable inconvenience. He was now recommended to use blackwash as the local remedy, and the following internal medicines :B Hyd. bichloridi, gr. ii. Infus gentiane co., 3viii. M. Ft. mist. Sg. A teaspoonful at each meal, and 20 drops of the tincture of perchloride of iron three times daily. His diet to be plain and nourishing, and his mode of living regular. His bowels being confined, two teapoonfuls of the liquid extract of senna was prescribed to be taken at bed time. October 5th.-The aperient had acted freely, which gave him some relief. The chancres were looking better, and not causing much annoyance. The bubo, however, was intensely painful, and the system considerably dis turbed. His next visit was on October 11th, when the chancres did not seem to be doing so well, this it appeared was owing to his own dread of drawing back the foreskin to dress them. Some red precipitate was now applied to each of them. 14th. The change, which had taken place in the sores was most satisfactory, and the patient now felt less difficulty in applying the dressings himself. The bubo, which had pointed, was freely opened, and a large quantity of thin pus allowed to escape. The general disturbance of the system had greatly abated. 16th. The chancres were almost healed, but the bubo continued to discharge watery matter, and was still very painful, especially when walking. 19th. The chancres had quite disappeared, but the affected groin continued to resist all attempts to bring about a healthy condition. The diseased gland was reopened, and covered with a linseed poultice. A considerable quantity of thin serous matter subsequently drained away. 25th. The oozing had nearly ceased, so pressure was substituted for the poultice, by means of a sponge pad and close fitting truss. At this time his general health was unimpaired. November 3rd.-Mr. A. G. left to fill a situation in England, and had apparently quite recovered from the disease for which he was treated. He felt in excellent health, and had ceased to take the prescribed medicines. Scarcely any trace of the bubo remained. 26th.-A letter came from him, stating that the glands of his neck were swollen, and his throat sore. The general tone of his letter indicated despondency. In reply, the following treatment was recommendedB Pil Plummeri zi Div in pil duodecem Sg. One 3 times daily, with a wineglassful of decoction of sarsaparilla. Ten grains of chlorate of potass (in water) removal, one part of citrine ointment, in two of simple cerate, was directed to be rubbed on them each night. March 14th. The patient's general health had become very good. The skin affections were quickly disappearing, leaving the surface of the body covered with scales and crusts of various shades and sizes. The hair had ceased to fall out. 29th.--A vast improvement had taken place in every feature of the case. No ulceration of the throat remained, though on rising in the mornings a peculiar dryness was felt which a drink of cold water immediately relieved. The medicines were still continued. night and morning; and twelve grains of Dover's powder every second night, also a gargle containing astringents. December 4th.-There was another communication from Mr. A. G., to say that he was no better. In answer, I advised him to take two teaspoonfuls of cod-liver oil three times daily, and to persevere with the remedies already prescribed. Subsequently, finding no improvement in his state of health, he went under medical treatment in England. January 20th, 1868.-He returned to Belfast, having become impatient and discouraged by the obstinacy of his maladies. His face was now covered with pustule, while over his trunk and limbs a squamous eruption had become thickly developed; some of the spots were bright red, April 16th.-No trace of cutaneous disease remained others purple, and the remainder copper-coloured. His save some slight red marks on the face. The patient's ap tonsils and the back of his throat were extensively ulcer-petite and general health were good, and he appeared in ated. He was greatly dejected in spirits, and suffering excellent spirits. All medicines were now omitted. from a severe cough which, on examination of the chest, Mr. A. G. paid his last visit on April 20th, on which proved bronchitic. His bowels were pretty regular, his date every symptom of the disease had vanished. tongue clean, skin moist, and pulse normal. Whilst in In this case the plurality of the chancres, the absence of England, his medicines had been altered, with the excep- induration, and the late development of the roseolar rash, tion of the Plummer's pills. He objected to take any more are points of some interest, as well as the absence of ptyalmercury although he had never been salivated, nor other- ism during a lengthened course of mercurial treatment. It wise felt the unpleasant effects of this drug. Owing to his may be well to remember that cod-liver oil was adminispertinacity on this point, I thought I would give the tered throughout. terchloride of gold and sodium a fair trial. Accordingly, he was recommended to take one of Grötzner's pills,* with two teaspoonfuls of cod-liver oil three times daily; and, for the cough, an anodyne pectoral mixture containing the dilute mineral acids and muriate of morphia, together with expectorants. His throat was thoroughly cauterized with nitrate of silver, and a strong astringent gargle prescribed for frequent use. Feb. 3rd. He seemed in a somewhat better condition, as regarded his general health. The cough had become easier and less frequent. His appetite had improved, and he rested more comfortably at night. The pustular rash on his face had increased, especially on the chin and forehead; where any spots had died away, a deep purple stain remained. 8th. He was almost free of the bronchitis, and in better spirits, though he was somewhat alarmed at seeing a new form of rash present itself-viz., roseola of a very bright colour, principally situated on the chest and arms. The appearance of his face was very disagreeable on account of the confluent nature of the pustules, which in some places were discharging a yellowish matter. He had now taken 57 of the pills, or better than 2 grs. of the terchloride of gold and sodium (which quantity of corrosive sublimate I have seen remove equally severe cutaneous eruptions, and in a shorter time). Not having noticed any marked beneficial effects from this preparation, I deemed it judicious to adopt the following (without consulting my patient on the subject) : M. B Liq. hydriod hyd. et arsenici, ss. The cod-liver oil being continued. His hair had commenced to fall out in large quantities, for which symptom Erasmus Wilson's prescriptions were adopted-viz., R Ung. hydr. nit. ox., zi. Adipis odoratæ, Ziii. (To be continued.) Hospital Beports. RICHMOND SURGICAL HOSPITAL. ENORMOUS INCARCERATED AND SUBSEQUENTLY STRANGULATED INGUINO-SCROTAL HERNIA, PROBABLY CONGENITAL: DIFFICULTY OF DIAGNOSIS: OPERATION: VIOLENT PERITONITIS: RECOVERY. UNDER THE CARE OF MR. WILLIAM STOKES. (Reported by Mr. JAMES Ross.) FROM the very unusual and extraordinary symptoms and Thomas F., æt. 30, by occupation a cooper, was admitted into Mr. Stokes' wards in the Richmond Hospital on the 8th of last June. He stated that he had a hernia on the right side as long as he remembers, and that he was always able to reduce it until two weeks previous to his admission into hospital. He stated that when it was reduced, there was a great thickness of the scrotal coverings remaining which much smaller on the affected side. The symptoms of was not so on the left side, and that the testicle was always the day before his admission. There was frequent vomitstrangulation, however, did not appear to supervene until ing and hiccough, constipation, great pain and tenderness over the lower part of the abdomen, which were especially acute in the situation of the external ring. On examination a large scrotal tumour was found, of great weight, the upper half of which was tympanitic on percussion, the lower half absolutely dull. There was great tension of the skin over the tumour, which was somewhat lobulated and irregular on the surface. There was little or no impulse on coughing, and on moving the tumour sud Sg. To be rubbed well into the roots of the hair at bed-denly from side to side, or from before backwards a loud time: splashing sound could be distinctly heard, like that of hydro-thorax, indicating the admixture of air and water within the tumour. On examining it with reference to transparency, none whatever could be found. Shortly after his admission, he was put under the influence of chloroform, and the taxis carefully tried, and though Mr. Stokes failed to reduce the hernia, he thought he succeeded in diminishing the size of it somewhat. At all events, some of the symptoms of strangulation-viz., the vomiting and retching, and the violence of the abdominal pain, subsided after the taxis. In the evening, 8 P.M., the scrotum became again very much distended, causing much pain from the tension. There was also retching and hic cough. These symptoms, however, under the influence of anodynes, enemata, hot fomentations, and the warm bath, towards morning completely subsided. The same state of things recurred next day. June 12.-The bowels were moved slightly on the 11th. Pulse quiet. Patient able to take light food, and very little tenderness about the abdomen or scrotum. 13th. The symptoms of strangulation recurred with great violence. Mr. Stokes got the following message from Mr. Ross, his resident clinical assistant:-"The patient with hernia in No. 7 ward has been very ill during the night, vomiting set in at two A.M., and has continued at frequent intervals since then. He is perspiring profusely." On Mr. Stokes' arrival, he found that the alarming symptoms the patient had during the night and early morning, had greatly subsided. He was in a state of great prostration, perspiring profusely, but the vomiting had stopped, the constipation which had now lasted since the morning of the 11th continuing. The tenderness and pain over the abdomen and scrotum had also to a great extent subsided. The pulse was 76, and very weak. At this juncture, Mr. Adams kindly saw the case with Mr. Stokes, and was of opinion that although the patient's symptoms were decidedly alarming, and the prognosis unfavourable, yet, that under existing circumstances, the symptoms of strangulation having to a great extent subsided, immediate operation was not called for. It was then determined that a consultation should be held at 5.30 P.M., the patient to have in the meantime a full enema, and morphia and hydrocyanic acid internally. At 5.30 P.M., the patient was found considerably better. He had only had during the day two slight attacks of retching. The tumour was not nearly so tense, and the tenderness in the abdomen greatly better. He was still in a very weak and exhausted condition. The enema had come away, but there was no feculent motion from the bowels. Mr. Stokes then agreeing with his co leagues, considered it would be better again to defer any operative interference until he saw what course things were going to take, and accordingly it was agreed to meet again to see the patient at 10.30 P.M. In consequence of this unusual, and extremely interesting case, many other eminent surgeons in addition to Mr. Stokes' colleagues, came to see this case. Among them may be mentioned Mr. Porter, President of the Royal College of Surgeons; Mr. Fleming, Mr. Collis, Dr. Wharton, Mr. Croly, Mr. O'Grady, &c. The difficulty of diagnosis in this case as to whether namely, it was one of simple strangulated congenital hernia, or whether the case was one of a small hernia into a large previously existing hydrocele of a hernial sac, arose from the existence of the following symptoms and appearances:-1. The absence of all impulse in the tumour on coughing. 2. The intermittent symptoms of strangulation. 3. The great weight of the tumour. 4. The loud succussion sounds. 5. The absence of translucency in any part of the tumour. 6. The comparative freedom from pain in the vicinity of the ring. 7. Absence of all abdominal fulness. Many of these symptoms and signs were characteristic of the rare form of hernial complication, known as "Hydrocele of the hernial sac," which, as Dr. Fleming has remarked, occurs generally in adults in early life, with large not fully reducible scrotal hernia, or the rarer variety named "Congenital inguinal hernia." The chief difficulty, however, in determining the exact nature of the case, and, consequently, the line of treatment to adopt, arose from the intermittency in the symptoms of strangulation, and the loud succussion sounds. At 10:30 P.M. the symptoms of strangulation having again supervened, and with greater intensity than at any time previously, Mr. Stokes decided upon performing the ordinary operation for strangulated hernia. On making the usual incision over the external abdominal ring, and dividing layer after layer of fascia down to the sac of the hernia, the opinion which was given, in the first instance, by Professor R. Smith, was found to be absolutely correct. There was no hydrocele of the hernial sac, and the great mass of fluid and air which gave the succussion sounds, so unusual in hernial tumours, were within, not external to, the intestine, and the enormous scrotal tumour was composed entirely of a mass of intestines. On arriving at the peritoneal sac, Mr. Stokes passed his finger up to feel for the constriction which caused the strangulation, and found that it occurred at the external abdominal ring, and that it was caused, not by a narrow cord-like constriction, but, which is also unusual, by a broad, flat, riband-like constriction. Mr. Stokes was very anxious in this operation to reduce the hernial tumour without opening the peritoneal sac, in consequence of the large size of the tumour, and the recent and intermittent strangulation of the intestine. However, in passing his finger up to the constriction he must have pushed a portion of the sac before it, for a quantity of fluid came welling up from the bottom of the wound, the very moment the stricture was divided. After this a good view was obtained of the intestines. They were found considerably congested at the seat of the stricture, but everywhere else they appeared quite normal and healthy. Fully three feet, or perhaps more, of small intestines were in the scrotal tumour, and the reduction of this vast coil of intestines was not accomplished without very great difficulty. After the operation the patient got a powerful anodyne draught, and one grain of opium every third hour during the night. Also, strong beef-tea iced. 14th. He slept very well during the night, and at 8 P.M., this morning, his bowels were moved. He took some milk and egg this morning. Pulse 112. As the day advanced the pulse became full and bounding, and rose to 120 in the evening. Very violent spasms in the abdomen set in. When each spasm subsided, Mr. Ross could hear a loud gurgling noise, after which the patient expressed himself much relieved. There was great tenderness and pain in abdomen, especially above the right groin. The patient was put on calomel and opium, and twelve leeches were applied to the right side of abdomen. After the application of the leeches, the bleeding was encouraged for some hours by hot fomentations. 15th.-Pulse 112, compressible. There is persistent vomiting, but scarcely so much tenderness over the right side of abdomen. The right testicle is highly inflamed. The patient's countenance wears an anxious expression. He is in a state of great prostration, and lies with his legs stretched at full length. The abdomen is tympanitic and very tender. He passes urine freely, it is high coloured; bowels not moved since yesterday. Mr. Stokes ordered the calomel to be stopped, but a grain of opium to be given every third hour, and strong mercurial ointment to be rubbed into the axillæ and smeared on a large linseed meal poultice to be applied to the abdomen. Twelve more leeches to be applied to the abdomen. 16th. The spasms have diminished in frequency and intensity, and the patient slept pretty well during the night. The tenderness in the abdomen is somewhat diminished, but it is distended to a great extent. He frequently passes flatus, but bowels not moved since the 14th. There is great thirst, the tongue is now red, but moist. Pulse 100. The gums are slightly touched by the mercury. Although he has taken a grain of opium every third hour since the operation, it has not had any effect, except making him drowsy and taking away his appetite. The pupils are not contracted. 17th.-Pulse 90. Patient had a slight attack of syncope at 7 o'clock this morning. The distension of the abdomen is considerably less than it was yesterday, but there is a good deal of tenderness still. There is less vomiting now, and his appetite is returning. He took a little calve's-foot jelly and iced brandy this morning. Last night prussic acid was given to allay the vomiting, and it proved very efficacious. The mercurial inunction was ordered to be stopped. Opium reduced to half a grain, every third hour. Six leeches to be applied to the abdomen, close to the wound. |