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and duodenum. There was no stricture, the opening beinglarge enough to admit the three fingers and thumb easily, bythe side of the oesophagus and pyloric end of the stomach.The heart was pushed over to the right side, its apex im-pinging against the wall of the chest under the right nipple.Our examination was carried no further.The question arises, at what time in the history of the

case did this hernia of the stomach take place ? It couldnot have followed immediately upon, or taken place at, thetime of the aspiration, or symptoms of strangulation wouldhave shown themselves, and there were none ; on the con-trary, she was very much relieved by the operation. And itcould not have taken place while the tube was in the chest,or the purulent contents of the pleura would have escapedinto the abdomen, and excited peritoneal mischief there.There was no symptom of such during the progress of thecase, nor evidence of it at the post-mortem ; and, moreover,the frequent auscultations practised during the treatmentwould have at once detected so important a dislocation; andthe severity of the retching at the commencement of thefatal illness could not have caused it, for so far from therebeing any evidence of laceration or effusion within the chestto show that such an enormous hernia had taken placesuddenly, the stomach had made quite a smooth-walledhome for itself, and even bulged the chest-wall.Besides this, the evidence of patient’s mother, whosays that during the past year her daughter had constantlycomplained of severe pain in her left chest about an hourafter each meal, and frequently remarked upon strangegurgling sounds which she heard high up in her chest underthe collar-bone, and that also of the medical man who sawher at Torquay last winter, who noticed the fact of the dis-eased side not having fallen in, and said he considered it amarvellous result to find no deformity after the method oftreatment that had been adopted, would go to show that thestomach was then in the chest. The probability is that thefloor of the chest, thinned possibly by the ulcerative processwhich went on while pus continued to be discharged, andhaving no superincumbent lung to retain it in position, waspushed up before the distended stomach, gave way, andgradually permitted the hernia.

In conclusion, I hope the history of this case may not aidin deterring anyone from the treatment of empyema by thedrainage-tube, but on the contrary add to the numerousevidences of its efficacy, as the post-mortem appearanceshere showed how perfect had been the cure, everything inthe chest being quiet, disappearance of lung-substancealmost complete, no ponded-up collections of pus, and nosigns of any irritation whatever. Excluding the accidentalhernia the case had been a perfect cure.Bury St. Edmunds.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

Nulla autem est alia pro certo noscendi via, nisi qnamplurimas et morborumet dissectionum historias, tum aliorum, tum proprias collectas habere, etinter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proœmium.

MIDDLESEX HOSPITAL.THREE CASES OF STRANGULATED INGUINAL HERNIA;

OPERATION IN EACH CASE WITHOUT OPENING

THE SAC ; RECOVERY.

(Under the care of Mr. GEO. LAWSON.)AN operation was performed in each of the three cases of

strangulated oblique inguinal hernia here recorded, and theprotruded intestine returned without opening the sac. Whenthe hernia can be reduced by a simple division of theexternal stricture, and without exposing the intestine, thepatient is naturally exposed to far less danger than whenthe sac is opened; but, unfortunately, in a large number ofcases of strangulated hernia, and especially in the inguinalvariety, it is absolutely necessary to open the sac, either torelieve the stricture within the sac, or else to ascertain thecondition of the bowel, in order to decide whether it is ad-

visable or not to return it within the cavity of the abdomen.It is important to note that all the patients were taken tothe hospital at an early stage. In the first two cases thesymptoms of strangulation were most acute, but as only fouror five hours had elapsed from the first symptoms of strangu-lation, there was reason to hope that the bowel was not muchdamaged, and that if it could be returned it would soonrecover from the effects of the constriction to which it hadbeen subjected. These cases illustrate very clearly theadvantages of an early operation in all cases of strangulatedhernia.

In Cases 1 and 2 the symptoms were so acute that therewas reason to fear that if the operation were delayed somehours a fatal result would follow. In Case 2 the strangula-tion had existed only four hours, and yet the bowel was evi-dently considerably damaged, for pain, tympanites, andvomiting continued for three days after the operation, butgradually yielded to fomentations and opium. All thepatients recovered.CASE 1. Strangulated oblique inguinal hernia; operation

without opening the sac; recovery.—William K-, agedsixty-four, a labourer, was admitted on July 9th last, suffer-ing from a very acute strangulation of an inguinal hernia onthe right side. The hernia had existed since the previousSeptember, but was easily reducible by the patient himself.He had never worn a truss. On the evening of his ad-mission into the hospital, whilst walking, a large portion ofthe bowel suddenly came down into the scrotum. Painand vomiting quickly followed. When he reached homehe made many trials to return the hernia, but failed. Thepain and sickness increasing, he was taken to the hospital.Ice was applied to the tumour, a full dose of opium wasgiven by the mouth, and gentle taxis was applied by thehouse-surgeon. Although only four hours had elapsed sincethe descent of the hernia, the symptoms were most intense.The belly was tympanitic. The tumour, the size of thefist, was very tense and tender. There was severe pain in theabdomen, accompanied by stercoraceous and almost incessantvomiting. Mr. Lawsom was sent for, and determined atonce on operating. The patient having been put underether, a small incision, about an inch and a half in length,was made over the neck of the tumour, and the externalring, which was tightly girting it, was divided, but the sacwas not opened. With a little manipulation, the contentsof the sac were returned into the abdomen. The woundwas closed with two sutures, and a pad, with a little weakcarbolic acid lotion (one part in a hundred of water) was ap-plied, with a bandage, and the patient placed in bed withhis legs bent over a pillow. All symptoms ceased im-mediately after the operation. The bowels acted on theeighth day after a dose of castor oil, and on the twelfth daythe wound was completely healed, and a truss was ordered.CASE 2. Stranglated oblique inguinal hernia; operation

without opening the sac recovery.—William L agedthirty-eight, a coachman, was admitted on Nov. 8th last,suffering from an acutely strangulated inguinal hernia. Hehad been ruptured for over twelve months, but had neverworn a truss, and had been always able to return the herniahimself. About two hours before his admission he wasriding a horse, when the hernia suddenly descended, butthis time it was much larger than on any previous occasion.He went home and endeavoured to reduce the hernia, butwithout success. As the belly was very painful, and hebegan to vomit, he was taken to the hospital, where ice wasapplied to the tumour, a full dose of opium given in-ternally, and a little gentle taxis tried. The symptoms,however, rapidly increased, the pain in the belly becamevery severe, the vomiting stercoraceous and frequent, andthe tumour, about the size of an orange, very tender to thetouch, and tense. Mr. Lawson saw the patient betweenfour and five hours after the descent of the hernia, and asthe symptoms were urgent, at once decided to operate.

The patient having been put under ether, an incision wasmade over the neck of the tumour, upon the external

abdominal ring, which tightly gripped the hernia. Thering was nicked freely with a hernia-knife, and the intestinereturned into the belly without opening the sac. The woundwas closed with sutures, and a pad of lint, wet with a littleweak carbolic-acid water, was bandaged firmly over thewound. Half a grain of extract of opium in a pill was givenevery four hours. He was sick three times after the opera-tion, but next morning he felt easier, and the pain in thebellv was less.On the 10th he was still frequently sick, but vomited only

13

the contents of the stomach. Fomentations to the belly Iwere applied, and opium pills continued. The wound lookedwell, and was nearly united. On the llth the sickness hadceased, but there was still pain in the belly, which wasrather tympanitic. On the 12th the tenderness of the bellyhad, passed away, and the opium pills were omitted. Thepatient continued from this time to do well. On the 21st,twelve days after the operation, the wound was quite healed.A truss was ordered, and on the 30th the man left thehospital.CASE 3. Strangulated oblique ing2cinaccl hernia; operation

without opening the sac; recovery.—Edward W, agedtwenty-three, a porter, was admitted on Dec. 4th lastsuffering from a strangulated oblique inguinal hernia of theright side. He was ruptured last Easter for the first timewhilst liftin- a heavy weight. He had worn a truss eversince. On the morning of his admission, at about 6 A.M.,whilst coughing, the hernia again came down, and he wasunable to reduce it. Feeling sick, and having pain in hisbelly, he applied to the hospital, and was admitted at about8 o’clock, two hours after the descent of the rupture. Icewas applied over the tumour, opium given by the mouth,and the taxis was tried, but without success. As the sym-ptoms were not urgent, this treatment was continued until2 o’clock, when Mr. Lawson saw the man. By this time un-doubted symptoms of strangulation had set in; there wasthen a tense irreducible inguinal hernia filling the right sideof the scrotum. There was dragging pain in the abdomen,extending downwards from the umbilicus, together withregurgitant vomiting of dark-green bilious matter.As the symptoms were now becoming urgent, Mr. Lawson

decided to place the man under ether, and, if he did notsucceed in returning the hernia by taxis, to operate. Etherwas accordingly administered, and as the hernia would notyield to moderate taxis, a small incision of about one and ahalf inches in length was made over the tumour upon theexternal abdominal ring, which was apparently the seat ofconstriction. This was divided, and the bowel was returnedwithin the abdomen without opening the sac. The woundwas closed with two sutures, and dressed as in the othertwo cases.The patient received immediate relief from the operation.

The pain and vomiting ceased. On the fifth day after theoperation the bowels acted voluntarily. On December 20ththe wound was healed. On December 26th the patient left thehospital quite well, and wearing a truss.

LONDON HOSPITAL.PROGRESSIVE PERNICIOUS (OR IDIOPATHIC) ANÆMIA ;

RETINAL HÆMORRHAGES AND DOUBLE OPTIC NEU-

RITIS ; MICROCYTHÆMIA ; EPISTAXIS ;DEATH ; NECROPSY.

(Under the care of Dr. STEPHEN MACKENZIE.)THE following careful record of a rare malady will doubt-

less be read with interest.W. J-, aged ten years, a schoolboy, was admitted on

Sept. 5th last. His father and mother were alive and

healthy, and had several other children, who enjoyed ex-ceedingly good health and looked quite well. The patienthad scarlet fever, measles, and whooping-cough, previous tchis fourth year. He had had good health up to three monthsbefore admission, being, however, rather subject to coughsand colds. Had lived in fair-sized rooms in the east-end ojLondon all his life.Three months before admission, he began to get white,

like wax or a dead body. His father said at the same timehe began to feel weak, and could not run about. He wasdrowsy and giddy, the giddiness coming on especially ongetting up; it was not so bad when he lay down. He hada constant frontal headache, not severe, but graduallygetting worse. His head ached especially on getting up.His head used to perspire so much as to wet the pillow, butthe rest of the body was free from perspiration. He hadfrequent nausea, but did not vomit. Two months beforeadmission, he left school, but went out occasionally, thoughhe did not care for the exertion. He never felt warm. Hisappetite was good. One month before admission, had tctake to his bed, he felt so sick and giddy, and could notwalk about. He complained of earache, and had some

discharge from right ear. He had to go home from schooloccasionally, the pain in the ear was so great; it lasted onand off for about a month. His bowels were regular. Hisface was thought to be puffy in the morning, hut the handsand feet were never noticed to be swollen. His symptomsall became progressively more severe until admission.Though nausea was constant, his mother said he had onlyvomited once after some "oil."His condition on admission was as follows :-A dark-

haired boy with brown irides, somewhat wasted. Skineverywhere extremelv pallid, having a waxy or ivory-likeappearance. No oedema of face. Lips, gums, tongue,mucous membrane of nose, and conjunctivæ very pale.Chest well formed ; lungs normal. Cardiac impulse half aninch outside and an inch below left nipple, heaving ; a sys-tolic thrill over cardiac area; cardiac dulness extended fromleft margin of sternum upwards to third rib ; and to left halfan inch outside nipple line. Systolic murmur loudest atapex and bottom of sternum, but heard over aortic and pul-monary valves. Hepatic dulness from fifth rib to margin ofthorax. Splenic dulness not increased ; spleen cannot befelt. Lymphatic glands just to be felt in left axilla underjaw, behind right ear, and in groins; little, if at all, en-larged. Hearing in left ear good, and in right somewhatdefective ; has a little pain in vertex. Pupils dilated.

Ophthalmoscopic examination.—Right eye : There wasmuch swelling of the optic nerve. The edge was nowherevisible. Both arteries and veins distended, but very pale ;the latter very tortuous ; both lost in places in exudation.The centre of the disc, where the exudation was thickest,had a bluish tinge. There were one or two small ha-mor-rhages on the disc itself. Around the disc the retinaappeared uneven and irregular. At some parts it was verytransparent, and through it could be seen choroidal vesselsand pigment ; at other parts it was intranslucent, and thevessels were hidden. In the. left lower quadrant, beneaththe yellow spot, was a large, irregularly-shaped, sharply-defined haemorrhage of deep red tint, occupying the wholefield of the erect image in the almost fully dilated pupil. Itdid not appear to be connected with any vessel. Scatteredover the rest of the retina were other smaller haemorrhages.There were no white patches or glistening specks. Left eyein all respects the same as right, wanting only the verylarge haemorrhage. Microscopical examination of the bloodshowed great variability in the size of the coloured cor-puscles. There was a considerable number of small colouredcorpuscles not more than one-quarter the size of the normalones. Most of the small ones were spherical in shape, andof the same tint as the larger ones ; a few of them presentedtail-like processes. The remaining coloured corpuscles hadtheir natural tint. There was no excess of colourless cor-puscles. Urine 30 oz., acid, clear, sp. gr. 1015; no albumen;contained 7 per cent. of urea, or 6’72 grms. in twenty-fourhours. Pulse small and soft; temperature 99° F. ; respira-tion easy, not accelerated.

Sept. llth.-Vomited last night and this morning.16th.-Nose bled during night; handkerchief stained with

pinkish blood.18th.—Epistaxis; murmur very distinct, most distinct

over pulmonary artery.24th.—Murmur conducted well into axilla ; strongly-

marked pulsation of carotid arteries; loud bellows-soundover veins of neck.29th.-Tint of skin changing ; colour less yellow, more

white ; systolic murmur all over heart.Oct. 1st.—Nausea and vomiting this morning; felt giddy.

Could not sit up when his bed was made. Temperature,which yesterday was 98.8°, has risen to-day to 103°.4th.-Bleeding from gums ; blood very pink and watery;

feels lively.16th.—No sickness or headache; vision 20/20, reads 1½

Snellen with right eye; 20/40 and 1½ Snellen with left eye.Still marked optic neuritis, with haemorrhages in bothretinae. The large patch in the right eye but little altered.Temperature 99°.25th.-Sickness and headache.Nov. 12th.—Distressing vomiting, bringing up a good deal

of fluid.14th.-Nose bled this morning—half a porringer full.18th.—Very sick ; headache.21st.—Vomiting comes on if he takes much food; his

appetite has been failing for the last fortnight.27th.—Very sick ; brings everything up ; is very feeble.28th.—Distressing vomiting ; surface somewhat cold ;