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reflex being intact, and plantar titillation immediatelyevokes the usual muscular jerk. There is perfect controlover the sphincters, and the urine is voided in a fullstream. There is no lack of intelligence, the eyes are fullof expression, the head of normal size and shape, withno sign of hydrocephalus. Pressure on the tumour producesnot symptom of distress, nor does it alter materially the sizeor shape. It has a very broad bae, and the edges of thespinal aperture can be felt, the finger-tip detecting a largeirregular ovoid opening communicating with the spinalcavity. The size of its base indicates its non-pedunculatedcharacter. The measurement in circumference at base i-iseventeen inches, and across from side to side eleven inches.It is as transparent as a hydrocele. The case, when firstseen, did not encourage the idea of attempting a cure byinjection, and I may mention that it has been tapped fre-quently, but has rapidly refilled each time.The curious and interesting points about this case of

hydrorachis seem to me to be these: the size of thesac; the fall development of the lower extremities; thepower of progression; the absence of pressure on the spinalcord, and thus the sphincter integrity. While the sizeof the opeoing would point to the possible pressure on the-cord. If broad based tumours are more likely to press uponthe cord than pedunoulated ones, how is it there is no evi-dence of pressure here ? Suppose the nerve structures arecarried forward in front of the flUId, I think we mightreasonably on physiological grounds expect to find evidenceof nerve pres-ure, or malnutrition from nerve stretching, orrom nerve atrophy. There is no talipes in this case. Weare told not to puncture the front part of these tumours so asnot to injure the nerves, but is there any evidence that thepuncture of nerve structure in this part of the body by a fineneedle has been productive of permanent mischief ? Thiscase seems to me, if not unique, at least curious and

prompts the following considerations. If the subarach-noid fluid both of the brain and spinal canal normally- does not exceed two ounces, how is it that this tumouris so large? We know the fluid is reproduced rapidlywhen withdrawn, and the withdrawal when completeproduces symptoms analogous to plethora of the blood-vessels, and when it is in excess it also produces convulsionsand other evidences of pressure. There being direct commu-nication between the spinal subarachnoid channel, and thecerebral ventricles, how is it that when the fluid was alldrawn away in this case no convulsions ensued ? and thisprocedure has been observed several times without mishap.Does this part of the enveloping sac membrane from itslarge area alone secrete the fluid, or does the whole arach-noidal surface contribute its proportion ? and if so why insuch excess above normality ? The question may alsobe prompted, Why is there usually talipes in thes9cases ? Is that condition purely accidental or isit due to defective tissue growth dependent upon thespinal abnormality cutting off nerve-supply to a givenset of muscles ? I confess my inability to suggest anybetter method of treating, radically, hydrorachis ; but,except in the matter of injection, we have made no advancein our knowledge of it during the last fifty years. This is areproach to our modern surgery, which boasts, and withperfect justice, of feats so brilliant that they become almostincredible as compared with the surgery of the past halfcentury. Of this I am quite convinced, that something willdawn upon the intellect, as a more certain and effectivemeans of dealiog with this disease. An interest has sprungup which will eventuate in some satisfactory operation. Canwe in any way imitate s-loughing which produces spontaneouscure ? To say that hydrorachis is an incurable disease wouldbe considered unsurgical, but I am by no means convincedthat some better method may not yet be discovered than weat present adopt. The old plan of a seton must be con-demned, so I think must tapping and pressure, experienceteaching that no reliable good ensues from these measures.It is to be hoped every successful case of cure by injection,no matter what the agent used may be, will be published,so that tabulated results may lay the foundation of some-thing like a sound basis whereon to act, and which willinspire confidence in dealing with this bête noi1’e of surgery.

Southport.

ON Wednesday morning Dr. Edwardes, of Hounslow,was found dead in hi chair. It is stated that there wasevidence present of death having been caused by prus-ic acid.

CASE OF FEIGNED SKIN DISEASE.

BY T. COLCOTT FOX, M.B.LOND.

A. S-, aged nearly sixteen years, a furtive-lookinggeneral servant in London, presented herself at the SkinDepartment of the Nor:h-West London Hospital on the28th of November. The catamenia commenced at the ageof thirteen, but had since been irregular, and for the pastyear absent. She was fairly well nourished, but pasty-looking, and her finger-naih were mirkedly grooved. She

applied on account of three excoriated patches which ap-pedred on Nov. 21st, close together on the front of her left leg,and had, she stated, given her great pain, and caused her tolie awake sobbing at night, so that her mistress had no

longer the heart to keep her at work, The suggestion hadbeen made that the sores were caused by the dye from herblack stockings, and the girl said that she had dressed theplaces with "bToore’s ointment." One sore was perfectlyoval, another neatly heart-shaped, and the third triangular,with a hora at each angle at the base. The patches mea-sured about 14 in. by 1; in. to 2 in., and the long axis was inthe direction of the limb; they were simple uniform weep-i"g excoriations, with hardly any attendant inflammation.Su-pecting the nature of the lesion, I ordered a simpledressing and a saline aperient, and talked of admitting thegirl into the hospital if more sores appeared. On Dec. 5thshe returned with a transversly oval sore just above eachmamma (a very characteristic site in feigned cases, but notquite symmetrically situated. There were two others abovethe left ankle-joiut, and one on the outside of the right calf,all longitudinally oval simple excoriations, with a well-defined border, except on one sore, where the abrasion wasnot complete at one end, and only papulation existed, sug-gesting a cantharides application. There was a dark-brownblood scab on some. She was admitted to the wards. OnDec. 6th a transve1sdy oval patch appeared just below theleft mamma.; and another, longitudinally oval, covered witha slight scab, on the right hip. The girl from time to time,for twenty-four hours after admission, had prolonged fits ofhysterical sobbing. On the 12th a sore appeared on theright shin near the ankle, and another on the right mamma,between the site of a former excoriation and the areola.There was a remarkable uniformity in the size of the patchesthroughout. As to the agency at work, I never could detectany evidence of the formation of a bulla, and the patcheswere too superficial for causation by an acid ; moreover,repeated examination of the clothes, bedding, &c., at con-venient times and unbeknown to the patient, failed to fur.nish any clue. On the 16th, no more excoriations havingappeared, I taxed the girl with producing the eruptionartificially, and, after prolonged denials, she confessed thatshe had done so, partly by her nails, but mostly by con-tinued rubbing with the tops of her fingers. Probably themalingering was not altogether motiveless, and she desireda rest from her household labours. She proved to be verytroublesome and disobedient in the ward, and I learnt fromher father that she was an incorrigibly bad girl and a con-stant source of worry. The case is of iuterest as establishingan agency which has hitherto only been suspected as pos-sible. Whether the skin in these cases is peculiarly sensitiveto injury is a point for further investigation.

Harley-street.

LARGE ASYLUMS FOR THE INSANE.

BY H. RAYNER, M.D.,SUPERINTENDENT OF THE MALE DEPARTMENT OF THE HANWELL

COUNTY ASYLUM.

IT appears to me to be desirable to draw attention to a

danger which threatens the welfare of the insane poor ofEngland and Wales. This danger arises from the con-version of asylums of a size that is efficient and economic,into larger asylums that are less economic, and I fear lessefficient. Moreover, valuable opportunities are being lostby the building of large, cheap asylums for the detention oflunatics, in place of efficient hospitals for their treatment

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and cure. These errors are being committed from theprevalent belief that large asylums are the cheapest.The following figures abstracted from reports prepared

for other objects will, I hope, tend to correct this mistake,and prevent further mischievous consequences. The thirty-sixth Report of the Commissioners in Lunacy for the year1881 yields the following statistics in regard to the Englishcounty asylums. (The borough asylums are exclude,i asbeing under different conditions.) The asylums I havedivided according to their number of inmates into fourgroups: the first, in which there are less than 450, beingconsidered too small; the second, above 450 and under 600,being taken as the most favourable size for economy andtreatment; and the twu other divisions being made only toshow the increase of cost with the increase of size.

This table shows, as might be expected, that thoseasylums are dt-arebt which are not sufficiently large to

justify the necessari’y complex and expensive staff of suchinstitutions; aLd it also shows that beyond this is a classmuch more economic, and, if judged by the proportion ofmedical attendance supplied, much more efficient than thelarger asylums.A Parliamentary return for the year 1877 yields the fol-

lowing statistics:-

This report includes all the county asylums of which thereturns were available, and shows that the asylums of from450 to 600 beds are the most economic in construction, largerasylums being dearer in proportion to their size ; even

Banstead, constructed in the simplest manner, with a specialview to cheapness, being more costly.A second Parliamentary return for the year 1877 shows

that in-

In this respect the cost would seem to bear a direct relationto the increase of size.

Statistics are proverbially unreliable, and I have con.sidered these carefully, from other points than the one givenhere, with the result that, making all due allowances, Iconsider the above figures to approximate closely to thetruth. Assuming that they do so, we may make the fol.lowing summary of results, in comparing the moderate-sizedasylums (450 to 600 beds) with the large asylums (of 800beds and upwards). In the large asylums a patient costs6e?. more per week, and each bed costs JE44’7 more in con-struction and .61 ’06 annually in repairs. This is equivalentto saying that if 40, 000 patients (and the number for Englandis close upon this) were lodged in large asylums, they wouldcost 91,760,000 in construction of buildings, ,jE40,000 annuallyin repairs, and nearly .660,000 annually in maintenance,more than the same number in asylums of the size Iadvocate.The current economy is of small importance compared with

the question of efficiency, and this depends to a very greatextent on the personal influence of the medical superinten-dent, an influence which I believe cannot be delegated to ajunior officer, however efficient and zealous.The primary importance of the personal influence of thephysician was emphatically expressed by W. Tuke in 1792,and was fully recognised by the Commissioners in Lunacy intheir report for 1857, in which they point out " the evils ofvery large buildings on account of the loss of individual andresponsible supervision, the loss of the patient’s individuality,and the tendency of the rate of maintenance to run higher."I could quote many other authorities in support of thisopinion, but that I might appear to be proving a truism.Then arises the question, Over what number of patients

can an average superintendent exercise the maximum of per-sonal influence, and at the same time exert such a generalcontrol over the asylum that every detail of management maybe used to the greatest advantage for treatment and economy ?I answer that the number should be not more than 600, andthat the balance of advantage lies in a somewhat smallernumber than this.

I do not doubt that efficiency may be and is obtained inthe larger asylums, but, as the preceding figures show, at amuch greater cost, which must be still further increased ifthe number of medical supervisors in them is to be madeproportionate to that in the medium-sized asylums.

Believing as I do that the curability of insanity is in analmost direct ratio to the care bestowed on it, I cannot helpexpressing an emphatic protest against the enlargement ofasylums of useful size, or the building of large dementiarepositories in place of lunatic hospitals.Hanwell.

TWO CASES OF

INTRA-VENOUS INJECTION OF FLUIDSFOR SEVERE HÆMORRHAGE.

BY WM. COATES, M.R.C.S.,RESIDENT ACCOUCHEUR, LATE HOUSE- PHYSICIAN, LONDON HOSPITAL.

PROMINENCE having lately been given in THE LANCETto the subject of intra-venous injections for the purpose ofcombating the effects of severe haemorrhage, in connexionwith which Mr. Jennings has contrived a new instrument,I wish to supplement what has already been written bythe history of two cases in which I have performed thisoperation, both of them cises also interesting in theseparticulars, that the haemorrhage necessitating the opera-tion occurred a long time after delivery without any definitecause, and that they were the first occasions on which Mr,Jennings’ syphon has been employed.