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of the blood in any veins had occurred, but since no acci-dent followed the former injection, and as the nsevus wasfar away from the veins of the face and neck, I am ofopinion that death in this instance was not the result ofembolism, but took place from spa,sm of the glottis, inducedby mental emotion. A fatal result would, I believe, havefollowed had any other mode of operation been employed.Holloway-road, N.

,

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

UNIVERSITY COLLEGE HOSPITAL.CASES OF HERNIA.

(Under the care of Mr. BERKELEY HILL.)

Nulla autem est alia pro certo’nos’ endi via, nisi quarnpJurirnas et morborumet dissectionum historias, turn aliorum, turn proprias collectas habere, etinter se compa.rare.—MoBGAatfi De Sed. et Dau8. Morb., lib. iv. Proaeminm. ’,

THE following is a continuation of the series of herniacases commenced at p. 128. It is well known that surgeonsdiffer very greatly in their opinion as to the advisabilityof performing operations on phthisical subjects. Some areso opposed to any surgical interference in these patientsthat they refuse to operate except in cases of extreme

urgency; while others do not consider a phthisical conditionof the system to be any contra-indication to the use of theknife in any case that appears to them to require it; others,again, only operate when by interference it may be reason-ably hoped that benefit will accrue to the patient by reliefof surgical affections which irritate or exhaust the generalsystem. In the subjoined case the indications were suffi-

ciently clear. There existed a strangulated hernia, which un-relieved would almost inevitably have speedily destroyed thepatient. But the immediate result of the operation exceededthe most sanguine anticipation. Not only was the stran-gulation relieved, but the general symptoms were amelio-rated, and for a time a material improvement took place.Unfortunately, however, the patient eventually succumbedto the malignant disease which had fixed itself in the lungs.Herniotomy in advanced phthisis; recovery, with normal

temperature.-W. C-, a man aged thirty-nine, was ad-mitted into Sir William Jenner’s wards on June 27th, 1873,with rapidly advancing pulmonary phthisis, having cavitiesat both apices, great emaciation, and constantly high tem-perature-I00° to 103° F. On July 10th, arupture that hadexisted for eighteen months, and till that day had beenreducible, became fixed. The next day pain in the bellyand severe vomiting led to examination of his groin, andthe strangulated hernia was detected. He was at oncetransferred to a surgical ward. By this time the belly wasdistended and tender at the umbilicus, the hernia itself ivery painful and tender ; the patient being also extremelyprostrate and feeble. Herniotomy was performed in anatmosphere of carbolic water spray. It was necessary toopen the sac to liberate the constricted gut. When thiswas done, a large quantity of straw-coloured fiuid issuedfrom the sac, with a few flocculi of lymph in the first gush.As the fluid escaped, the belly-wall collapsed completely.The gut was then seen to be detained by a few bands acrossthe interior of the sac, which were easily divided, and thebowel, which was smooth, though of a dark-claret colour,was returned into the abdomen. The wound was dressed

by Lister’s method, and the patient given one-third of agrain of morpbia under the skin. During the first twenty-four hours after the operation the patient vomited two orthree times, and spat up some blood.On July 14th the patient was very comfortable, belly

flaccid, free from pain, and tongue clean. Some flatus hadpassed. Temperature 98°. On the 16th there was naturalaction of the bowels. On the 19th the upper two-thirds ofthe wound had closed. On the 28th the patient, beingcured of his surgical affection, was returned to the medicalwards. The temperature had been normal since the opera-

tion. At the latter end of September the patient, who hadnever left the hospital, died of his lung disease.Post-mortem e:M[MMMHoM.—The peritoneum was found quite

free from inflammation or old adhesions. The mouth of thehernial sac at the internal abdominal ring was patent andunpuckered, and readily admitted the forefinger. The sa&was empty, and showed a scar opposite the cicatrix in the

skin, but otherwise, in its smoothness and absence of con-gestion, resembled the abdominal peritoneum. The part ofthe small intestine that had been strangulated could not bedistinguished from the rest.

This case shows how readily the operation of herniotomymay be recovered from in even very advanced lung disease ; 9indeed, the patient’s general condition was improved by hisoperation. The temperature fell, and the patient gainedflesh and strength while his wound was healing, which itdid with almost no suppuration. The condition of the sacpost mortem two months after the operation shows that ad-hesion of the walls of the sac, or shrinking of the mouth,is by no means a necessary consequence of operation andinflammation in it.

WESTMINSTER HOSPITAL.AIR ENTERING THE PLEURA, NOT FROM THE LUNG ;

HYDRO-PNEUMOTHORAX; PARTIAL RECOVERY.

(Under the care of Dr. STURGES.)THE following case appears to be an example of an un-

usual result of ulcer of the stomach-viz., perforationthrough the diaphragm into the pleural cavity :-George S--, discharged soldier, aged twenty-eight, was.

admitted into Burdett Ward (by the kindness of Dr. Anstie)on November 21st. He had been discharged from the armyfor ,chronic dyspepsia," now of three years’ duration, andof which the most prominent sign was vomiting after themorning meal. This vomiting, it was stated, had occurreddaily for the last six months. He had but little pain afterfood. No blood had been vomited, nor had the patientwasted much. He was of temperate habits, and had neversuffered from syphilis. For the last seven months he hadhad cough, and on one occasion during the summer, whenat work, spat a little blood. At the time of admission therewas still some amount of bronchial catarrh, evidenced bymucous spitting and irritable cough. Percussion elicitedcomparative dulness over his left chest posteriorly, a con-dition probably due to an old attack of pleurisy of whichhe spoke. No physical abnormality could be discovered inconnexion with the abdominal organs. The man was ableto get about and to take exercise out of the hospital. Undercareful dieting and routine medication the vomiting alto-gether disappeared, but the cough and spitting continued.He had some pain after food, and much flatus.On the 6th December, on his return from a short walky

the man was seized with violent shivering, a catching painin the left side, and considerable dyspnoea. His aspect atthis time denoted anxiety and active distress, and he be-lieved himself on the point of death. On the day succeed-ing the rigor, and for three days after, the morning tem-perature varied from 102° to 103v°. Respiration was shortand catching, never more than 24, but the sense of dyspnaea,was extreme, and the countenance very anxious. No par-ticular position was assumed, but the patient lay half-re-cumbent. On careful auscultation of the chest there wasnoticed at the base of the left lung, high, almost tym-panitic, resonance on percussion, with total absence of breath-sounds in that situation, the vocal fremitus remaining thesame for both sides; neither was there any perceptible dif-ference in the voice-sound. Upon the evidence of thesephysical signs, taken in connexion with the character ofthe acute attack and the continued severity of the generalsymptoms, it was conjectured that, from some source otherthan the lung, air had suddenly burst into the pleura. Thatview received further support from the negative evidencefurnished by further physical examination of the thoracicorgans.

Dec. 12tb.-Condition of the left chest as to high reso-nance and loss of respiratory sounds remains the same.The heart-sounds are heard plainest to the right of thesternum, where also, immediately below level of nipple, andequidistant between it and the right margin of the sternum,the impulse is best felt. The cardiac sounds are distinctly