case has some important bearing upon all the points connected with tracheotomy in croup, and is reported because it so forcibly demonstrates, the now very generally accepted idea that tracheotomy is proper to be recommended in membranous croup when it becomes evident that recovery is highly improbable without it. Authors properly caution against too long delay and most certainly there is great danger from delay. Positive diagnosis is not always obtainable, and the careful physician watches the condition and progress of the case, thus requiring often valuable time. It is far better to operate upon a case which might possibly recover without it, then to delay operation until death is inevitable in cases certainly fatal unless operated upon. The facts of the following case are sufficiently suggestive to the experienced, thoughtful physician and need little comment:

On the morning of May 10th, I was called in the absence of Dr. M. G. Potter, the attending physician, to the Buffalo Orphan Asylum, to see S. C., aged six years, who had been taken sick during the preceding night, and the symptoms present being different from those of spasmodic croup, awakened in the mind of the experienced matron, Mrs. McPherson, a suspicion that the child. had membranous croup. I will state in this connection that four weeks before this a bright little girl of the same age, and of a good constitution, had died of membranous croup after an illness of three days duration, and from the beginning of March to the present time, June 15th, there have been about twenty cases of spasmodic croup. It is very unusual in the history of the institution that there should be such a large number of cases of disease of any form, as during the ten years intervening between 1864 and 1874, there was but very little sickness and only one death. A thorough cleaning of the house and premises has been ordered, with a view to the prevention of this epidemie of eroup.

I found the patient with a pulse of 120, temperature 102° F., tongue with a white cream-like coating, respiration 30 per minute, absence of voice, considerable difficulty in breathing, and the characteristic cough of croup, percussion over the chest normal, but auscultation showed sonorus and sibilant rales over both lungs. Inspection of the throat showed a general conjestion of the

pharynx, but without much swelling, and the absence of any deposit. The diagnosis was membraneous croup, and the following prescription made:

R Calomel grs vii.

Pulv. James, grs. vii.

Pulv. Dovers, grs. xv., M.

}

Ft Pulv. No. xv.

Give one powder every fourth hour; also two grains of quinine every second hour. The temperature of the room to be kept at 75° F., and the air moistened by water vaporized. Inhalations of steam from hot water poured on unslacked lime were given every second hour; the bowels kept open, warm applications to the throat, and an emetic of ipecacuanha night and morning during the first two days of treatment. On the afternoon of the 12th inst., the third day of treatment, I called Drs. Miner and Rochester in consultation. At this time the condition of the patient was as follows: Pulse 120, tongue thickly coated, and somewhat dry. considerable difficulty in breathing, the condition of the throat unchanged. The nurse informed us that at times the child would be taken with what she called sinking spells, and that at such times the pulse would become weak and very frequent with increased embarrassment of respiration. The treatment above detailed was continued with the addition of stimulants, with the understanding that if the breathing became more difficult, tracheotomy would be indicated.

On the morning of the next day, the 13th inst., the patient was every way worse; the nurses reported that they had been unable to give either medicine or nourishment by the mouth since 12 o'clock midnight, and had ceased attempting to give anything, thinking it better to let the child die as easily as possible. While I was examining into his condition he was suddenly taken with a severe paroxysm of choking, which was somewhat relieved by the coughing up of a false membrane, about two inches in length, a complete cylinder, shaped to the interior of the trachea below the larynx.

Our diagnosis was now confirmed, but the respiration was still very difficult, more difficult in fact than before the expulsion of the membranous cast, and at the request of the father of the

child and the matron of the asylum, I made preparations for the performance of tracheotomy, Drs. Miner and Rochester again very kindly met me in consultation, and the propriety of the operation was concurred in. At my request Dr. Miner proceeded to operate. Drs. W. W. Miner, Brush and Barnes assisting; the anesthetic being administered by Dr. Rochester. The operation was successfully made in the usual manner, below the isthmus of the thyroid gland, and after a large amount of mucous was expelled through the opening, a curved double tube was passed into the trachea and secured by tapes. The patient now breathed very freely through the tube, the external opening of which was covered with gauze, and after the effect of the anesthetic had passed off, was removed from the operating table to his bed. From this time forward in the treatment of the case, all medicines were withheld, excepting a Dover's powder at night, and the diet consisted exclusively of milk. The inner tube was removed and cleaned frequently on account of the large quantity of mucous which was present in the lungs and coughed out through it. The general condition of the child began at once to improve, and on the eighth day the tube was removed from the trachea, the opening being left open to close by granulation. On the fourteenth day after the operation the wound in the trachea was closed, so that respiration was naturally and easily performed, and the voice sounds were perfect. The patient was discharged cured.

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ART. III. Syphilitic Hydrosarcocle. By B. J. PRESTON, Rochester, New York.

Among the various forms manifested by syphilitic disease that of Syphilitic Hydrosarcocele is not without considerable interest. It is the object of this paper to relate briefly, the history of an interesting case of this form of syphilis. According to established authority this variety of disease usually attacks the individual after the development of the tertiary form as recognized by excavating ulcerations of the mouth and throat, iritis nodes, etc.

The subject of these remarks, a young man, aged 27 years, applied to me for treatment for a painful swelling affecting his left

tibia, which I found upon examination to be in a red, swollen and very painful condition, so much so as to interfere with his ordinary business that of market gardener, and it was upon this account that he was led to seek medical advice. Upon close inquiry I ascertained that he had some four years before contracted a chancre on the penis for which he had been treated, and was, as he supposed, cured.

Believing this to be a true tertiary node, I prescribed a poultice to be applied to the swelling until the inflammatory symptoms had subsided, afterwards local applications of tincture iodine, alternating the iodine and poultices as the circumstances seemed to require. I ordered internally five grain doses of iodide of potassa three times a day combined with vegetable tonics.

Improvement followed rapidly, and although the pain and other inflammatory symptoms soon disappeared he, according to my advice, continued to take the iodide of potassa for about eighteen months, suspended only for intervals of a few weeks.

During the early stage of this treatment he complained of a slight inflammatory symptoms in his left testicle which I directed to be suspended in a suspensory bandage, and heard no more of it until December, 1872.

The patient then complained of his tongue which was nearly perforated by an excavating ulcer nearly two inches in length and very painful. Frequently repeated applications of a strong solution of nitrate of silver put a stop to the destructive process, and the ulcer was healed in a few weeks. It was about this time that he again called my attention to his testicle which, upon a re-examination, I found to present the appearance of an ordinary Hydrocele, and in the course of three or four weeks I operated for the palliative treatment, and drew off about fourteen ounces of a transparent yellowish fluid. After the operation I observed a considerable hardness and some enlargement of the testicle itself, expecting, however, to see him again in a few days I paid but little attention to it. The next interview I had with my patient was about four weeks afterwards when I tapped his scrotum a second time. There was discharged but little fluid, not more than three ounces, and with but small decrease in the size of the tumor.

But upon a third operation the amount of fluid obtained was equal to that at first drawn off. Now for the first time I was able to ascertain the true character of the tumor which, upon deep pressure, seemed to be hard and irregular, there being three distinct nodules. In view of this, and of the previous history of the case, I deemed it necessary that there should be more thorough surgical interference, and therefore called upon Dr. B. L. Hovey, who coincided with me in the opinion that the removal of the organ was necessary. Accordingly on June 7th, 1873, Dr. Hovey, assisted by Dr. C. S. Starr and myself, removed the affected organ.

The weight of the tumor was seventeen ounces. It was ovoid in shape, and smooth and regular on its surface.

Upon laying it open with the scalpel we discovered three distinct sacs containing serum of a slightly yellowish color. The largest of these contained about six ounces of the fluid; the next smaller, three ounces, while the smallest contained only about one ounce.

Within the centre of the substance of the testicle itself there was found a deposit of yellow granular matter about the size of a large robin's egg, together with small points of like deposit at the outer edge of the testicle.

A point of interest in the operation is treatment of the cord which was all included in the ligature and without any unpleasant results, such as might be feared from pressure on the spermatic

nerve.

This corroborating the experience of Dr. Erichsen may serve as an encouragement to those who have read the cautions and dread the results described in the surgical work of Dr. Syme.

The case progressed favorably. There was but slight constitutional disturbance, the wound suppurating freely, granulation soon filling up the incision.

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Correspondence.

Through the kindness of Prof. White, we are placed in pos-ession of the following letter, which gives the history of three interesting cases of inversio uteri. The means proposed for the cure