WILLIAM Y., aged forty-two years, a labourer, was admitted at 11.45 p.m. on August 7, with a large hernia filling the right scrotum. He stated that he had been ruptured for about six or seven years, and had been obliged to wear a truss in consequence.

On the day of admission, as he was going home from work about six o'clock, his truss broke, and by the time he had walked home (a distance of two miles and a half) the rupture had come down and filled the scrotum. The swelling had never been so large before, and on previous occasions he had always been able himself to reduce it completely. This time he had had great pain in the tumour and in the abdomen from the first. He had had no hiccough, and had only vomited once. He had himself made several unavailing attempts to put back the hernia, and a medical man whom he had called in had also tried to reduce it, and had failed. On examination the tumour was found to be dull on percussion; it was not very tense, and yielded no impulse on coughing. As the symptoms were not very urgent, a cautious application of the taxis was made by the House-Surgeon without result, and patient was then put to bed with the legs elevated, and an ice-bag applied to the scrotum. During the following day the patient was very sick several times, the vomited matter being either curdled milk or bile-coloured fluid. Mr. Adams had the patient put under the influence of ether, and again tried to reduce the tumour, but without success. At 8 p.m. patient complained of a good deal of pain in the region of the stomach; the pulse was full, rapid, but not wiry; and he had vomited once or twice since the after

noon.

At 11.30 p.m., as the symptoms were not subsiding, Mr. Adams made an incision down over the neck of the sac

to the gut. When the sac was opened, the bowel (small intestine) was found to be red and deeply congested; it was gently returned into the abdomen, and, as its complete reduction was almost effected, there was a gush of thickish grumous fluid, which was recognised to be the contents of the intestines, and the aperture of escape was easily found. The bowel at this portion was somewhat thickened and very soft, and had flakes of lymph upon it. Another portion of the gut, close to the place of rupture, was also roughened, and looked as if it had been adherent to the sac. This appearance led Mr. Adams to doubt the history given by the patient as to the previous entire reduction of the tumour. It afterwards was found that, not content with the attempts of others to reduce the hernia, patient himself while in bed had tried by pressing the tumour between his thighs to get it back, and it was supposed that his violent and misdirected efforts had weakened the gut and caused it to give way. The edges of the ruptured intestine were brought together by catgut sutures, and the parts were returned into the abdomen. The external wound was stitched up, and a pad and firm bandage applied. A morphia subcutaneous injection was given.

August 9.-Patient has slept a little during the night, and has vomited once or twice slightly. He complains of pain, and begs that his abdomen, which is swollen, should not be touched. His face is flushed; pulse 108, full and bounding; temperature 101-2°. A grain of opium has been ordered, and he is to have milk and ice only. 4.30 p.m.: He looks less flushed and anxious, his pulse is not so rapid and the

swelling of the abdomen is not increasing. He has had a little vomiting. 9.15 p.m.: Pulse 100; temperature 101°. He is perspiring, but does not look anxious or in much pain. 10th.-11.30 a.m.: The skin is cool, not perspiring; pulse quiet and steady; temperature 98.6°. The wound looks healthy; there is no tension on the sutures and no discharge. The abdomen is less distended, and the wound has been dressed this morning. A brownish mark is present along the track of the lymphatics in the groin. 8 p.m.: The intestine has slipped back into the scrotum; most of the stitches of the external wound have been taken out, but no fæcal matter has escaped even on squeezing. The pulse is hard and wiry, about 100; skin perspiring; temperature 100-6'; the abdomen does not feel more tense than it was.

11th. This morning the patient does not complain of pain, and lies quietly in bed. He has not vomited since last night. Pulse is 98, full and incompressible; temperature 99.6°.

12th. The wound does not look clean, but patient seems no worse. Pulse is 84, steady and full; temperature 99-4°. The skin of the scrotum is hot and inflamed. The bowels were relieved yesterday for the first time, and were again open to-day.

13th.-Patient's aspect is much improved to-day, his face looking quiet and easy. The wound is being poulticed and is only very slightly painful. Patient can now bear percussion over the abdomen, which is less distended. The skin is cool; pulse 78; temperature 99°. There has been no return of the sickness, but he still takes ice and milk, and complains now of feeling hungry.

14th. He has had pain in the right side all night, and has slept badly. The abdomen is a little more distended. The skin is cool; pulse 96; temperature 100°.

15th. His face is a little flushed and moist, but he is in less pain than he was yesterday and the abdomen is less distended. Pulse 84; temperature 98°. The bowels were open last night.

16th.-Patient had a better night. The abdomen is less tense and he has only occasionally pain shooting across at the level of the umbilicus. The wound looks cleaner, but is still being poulticed. Opium is still being administered, and ice and milk and beef-tea are his only articles of diet. Pulse 80; temperature 99°. Bowels open.

18th.-Patient has had a good night's rest, and feels better. He is free from pain. Temperature at noon 99°.

20th. His nights are now good, and in every respect he is improving. The tension of the abdomen is diminishing, and he scarcely complains of any pain. The wound is still being poulticed.

24th.-Temperature is normal. The bowels have lately been rather constipated, but were open yesterday and to-day. The abdomen has decreased much in size, and the wound looks better.

26th.-Patient is now taking fish diet, and is going on well. The scrotum is still somewhat hard and inflamed, and the wound discharges pus, but the temperature is normal and pulse steady.

September 1.-He is now nearly well, and the wound has almost healed, a little zinc ointment only being applied to it. Patient now gets up for a few hours daily. He still keeps on fish diet.

9th. He has now obtained a well-fitting truss, which he wears, and during the last week has been on ordinary diet. Except that patient is emaciated and weak, he seems now to be quite well again.

ATROPHIC CANCER OF THE MAMMA.
(Under the care of Mr. ADAMS.)

Mary M., aged fifty years, a widow, was admitted on October 27, complaining only of pain and swelling of the left arm, which prevented her doing her work as a washerwoman. On examination there were found to be two or three small irregular ulcerated patches round about the left nipple, involving the skin only. The breast on the left side had entirely disappeared, the mammary region being there covered by a flat surface of red, hard, contracted skin, resembling the mark of a scar. The nipple was very large, hard, and prominent. The surface of skin involved was about as large as the palm of the hand, and its margins were marked by reddish nodules of advancing cancer. Hard minute cords could be traced running towards the axilla, where there were several enlarged glands. On the left arm, at the inner

aspect of the biceps, was a large, hard, irregular mass, which was considered to be due to phlebitis of the basilic or brachial vein, and to which was probably due the cedema of the hand and forearm. Patient was remarkably well as to her general health, and had never lost flesh at all. The pain in the parts she described as "lancing," but it was slight and only occasionally noticed. She had had seven children in all-the first when she was twenty-five years old, the last when she was forty-two. Fifteen years ago she had first observed a lump in the left breast, which she thought had followed an abscess; this lump gradually increased for some time, and was then followed by complete wasting of the breast. The ulceration commenced about a year ago, and had progressed very slowly. Patient remained in the hospital for about five days, nothing beyond constitutional treatment and the application of simple lotions being, of course, done.

ST. THOMAS'S HOSPITAL.

SARCOMATOUS TUMOUR AT BASE OF BRAIN. (Under the care of Dr. BRISTOWE.) [FOR the following notes we are indebted to Dr. W. B. Hadden, Medical Registrar.]

Alice G., aged thirty years, was admitted on October 25, 1878. It was stated that patient had been quite healthy until about three months before admission. About that time her sight began to fail, she became stupid, and at times seemed as if out of her mind. She was then pregnant, and about the middle of November her child was born. During the five weeks following her confinement patient lost flesh to a considerable extent and her other bad symptoms underwent no abatement.

ex

When admitted, patient was pale and had a stupid ex pression of countenance. She was constantly talking in a rambling way, but when questioned answered rationally enough. She had delusions connected with her recent confinement, and when questioned about it stated that she had been delivered of a baby that morning (Oct. 25), and had put him out in the yard. There was severe occipital and slight frontal headache. She was quite blind, and the pupils were dilated, the right rather more than the left; both were very slow in reaction to light. The optic discs were of a greyish white, but the vessels were not much altered in size or appearance. There was slight facial paralysis on the left side and some loss of power in the left arm, but there was no anesthesia in any part. The temperature was normal. On examination all the other organs and parts seemed to be healthy, and the urine was free from albumen. All the evacuations were passed involuntarily. Patient remained in the same condition, being always more or less drowsy and under delusions, until December 1, when she had a fit which lasted for a few seconds. In this fit the eyes were said to have been fixed and the head and limbs rigid.

December 11.-Patient appears to sleep a great deal. The evacuations are still passed involuntarily, and her delusions remain.

February 9.-There has been nothing of any interest recorded lately concerning patient. To-day she had an attack of unconsciousness which lasted about two minutes; there were neither spasms nor rigidity. The pupils were at first contracted, and afterwards became widely dilated.

March 28.-She has of late been less talkative than formerly; is very lethargic, and can scarcely be roused to take her food.

April 2.-She occasionally swallows a little food, but cannot be roused. She lies on her back, breathing stertorously. There is some loss of sensation in the conjunctivæ, and the left facial paralysis is very marked.

3rd.-To-day she seems to have regained consciousness, and to be aware of what is passing round about her.

4th.-Some râles are to be heard over both sides of the chest in front.

5th.-To-day the face and lips are dusky. She is conscious, but can hardly articulate, and moans occasionally and complains of pain. Her temperature this morning was 102.2°; in the evening it rose to 103.6°.

7th. She cannot be got to answer questions, but appears to be conscious, and moans frequently. Her general aspect

has not altered, and she appears to be sinking. Temperature, morning 102.2°, evening 104-4°.

8th.-Patient died to-day at 3.30 p.m. The temperature rose from 105.6" in the morning to 107 just before death. Post-mortem Examination.-On removing the calvarium, there was found to be great injection of the pia mater, but no meningitis. A tumour about as large as a small orange was found on the under and anterior surface of the right temporo-sphenoidal lobe of the cerebrum, the substance of which had been partly absorbed, so that the right middle cerebral artery was exposed all along the course of the fissure of Sylvius. The surface of the tumour next the brain was soft and covered by pia mater. On the side next. the base of the skull the tumour was closely adherent to the dura mater, and had caused partial absorption of the adjacent petrosal and sphenoid bones. The right optic nerve was flattened and soft, and the right crus cerebri seemed somewhat pressed upon. No other nerves apparently have been interfered with. On section, the tumour was. granular in structure, purplish in colour, and evidently very vascular. Microscopically examined, it was found to consist of fusiform and round cells, with numerous concentric aggre-gation of cells in a bird's-nest-like arrangement. The growth was considered to be sarcomatous.

THE NURSING AT GUY'S HOSPITAL. Nor long ago we considered, at some length, the very im-portant subject of Hospital Government, noticing in a general way the merits and demerits of the different systems of government adopted in our metropolitan hospitals, and entering with some fulness into the respective advantages: of government by committee, and government by a paid medical head, with, in large institutions, a lay head also. We did not comment directly on government by an autocratic lay head by a "treasurer,"-the form of govern-ment which obtains at St. Bartholomew's, Guy's, and St.. Thomas's, though we pointed out the dangers that must attend such a system, or any system of purely personal government. It may work very well, so long as the lay

autocrat has not only the necessary knowledge, industry, and business habits, but has also discretion, tact, and a considerate appreciation of the position, duties, and special responsibilities of the other officers of the institution. But should he be over-zealous and over-energetic, hasty and despotic in the remodelling of systems and in enforcing reforms, and over-persuaded of his own wisdom and judgment, he may work infinite mischief. We pointed out that any officer in such a position should remember that change is in itself, or may be easily made, an evil; that the law of custom is stronger than any command upon paper; and that it is easier far to destroy than to build up; and further, that before interfering with or attempting to remodel any part of the working of a hospital, he ought to take counsel with those who are especially interested in and know most about it. The present most unfortunate state of the nursing system at Guy's Hospital illustrates to perfection the evil that may be worked by a want of these governing virtues and a neglect of the precautions we spoke of.

Some months ago the Treasurer of that Hospital, Mr. Lushington, appointed a new Matron or Lady Superintendent, with a new, cut and dried "system of nursing"; and he did this without any consultation with the Medical Staff. This new system the Matron has insisted on carrying into practice at once, and fully, without any consideration for the old system or appreciation of its excellencies; and the result has been an entire disorganisation of the nursing in the institution. There has been an exodus of many of the oldest and most efficient sisters of the wards and of some of the most competent and perfectly trained nurses from the Hospital. So far as we can see, it would appear that the guiding principle in this lady's mind is that hospitals are made for the nurses, not nurses for the hospitals. Nurses have been shifted from surgical wards, where they had long worked, and had become thoroughly conversant with their duties and with the particular treatment and system of dressing of the surgeon, into medical wards, where they had to learn everything afresh; and those even who had been trained in special wards have been removed into general wards. And it is said that the Matron has ordered that patients who are not confined to bed all day shall get up and dress themselves at five o'clock in the morning. We need not point out how absolutely bad such changes must be for the patients. And numerous other changes, causing friction, discontent, and resignations, have been made.

We have not spoken of all this sooner, because we hoped that the disastrous effects produced, and the remonstrances of the Medical Staff, would lead to a satisfactory rearrangement before the matter became a public one. But we fear this hope is a vain one. All the House-Surgeons, HousePhysicians, Resident Obstetric Officers, Full Dressers, and Clinical Assistants memorialised the Treasurer and Gover. nors upon the subject, and were promptly snubbed; the Assistant Clerk to the Hospital curtly informing them, by order, that the Governors had entire confidence in the Treasurer, and would not interfere with the proceedings of the Matron.

The Medical Staff have also remonstrated with the "Treasurer, but in vain. He was courteous, and, of course, only anxious to do what was best for the patients, etc. But he summoned a meeting of the Governors, at which-by virtue of his office, we suppose-he took the chair. The meeting was, it is said, a very small one; no representative of the Medical Staff was invited to attend; and a vote of confidence in the Treasurer was passed. Thus the real reply of the Treasurer to the remonstrances of the Staff has been, that the Governors have entire confidence in the Treasurer, and the Treasurer has entire confidence in the Matron-and

HIP-JOINT DISEASE.

THE Clinical Society of London has recently been engaged in a prolonged discussion on hip-joint disease. Assuredly few subjects of greater importance and interest could have been selected for discussion. Not only on account of its social aspects is it important, but from the surgical standpoint it is a subject that affords ample material for discussion, and ample room for improvement; and the debate upon it has afforded the profession an opportunity of hearing the most recent views of Mr. Holmes, Mr. Hulke, Mr. Wood, Mr. Lister, and Mr. Bryant, among others.

The debate was excited by a paper from Mr. Croft, who, at the meeting on November 28, 1879, read notes of a case of excision of both hip-joints for femoral necrosis. The case, and the discussion on it, will be found fully reported in our issue of December 13. This case was a brilliant success. We must, however, regard it in the light of what can be obtained rather than as a sample of what is the usual outcome of this operation. Incidentally Mr. Croft mentioned that out of forty-five patients operated upon there had been sixteen deaths from one cause or another; and it was this statement which gave rise to the discussion, as it was subsequently carried on, on the evening of December 12. The bare figures were no doubt somewhat startling, but when the causes of death were analysed, and presented to the Society at their last meeting (vide report in our issue of December 13), they assumed a totally different aspect.

Mr. Croft then explained how these deaths spread over a period of fourteen years; that nine of them died of tubercular disease of the viscera, which could not be attributed in any way to the operation, all of them having lived for some time after it-the period of survival varying from about three months to four years. These valuable statistics had only been obtained by most sedulously following up the cases through many years. With less diligence and care the patients might have been entered in the case-books as "cured" or "relieved," and more misleading statistics would thus have been added to the mass with which we are already overweighted. It were to be wished that other surgeons had followed up their cases with equal diligencenot only their operations, but the cases of hip disease entered in their books as cured or relieved. A few critical analyses like this of Mr. Croft's would supply us with information which is very much needed at the present time. There yet remain, however, six other fatal cases, death being due "directly or indirectly to the operation," viz., one to septicæmia, three to pyæmia, one to suppurative arthritis of the knee following on erysipelas, and one to thrombosis and asthenia. There was also one death from diphtheria of the air-passages. This is no doubt a formidable array, and it leaves room for much improvement, as Mr. Croft seemed to suggest when he stated that "five of these 'deaths occurred from preventable disease."

Thus the entire subject of hip disease-its pathology, its treatment, and ultimate issue-was opened up by this paper. We do not propose in this place to repeat what has already been fully given elsewhere; but it may be useful to briefly summarise the points raised, and the lessons which are deducible therefrom.

It was stated by several speakers that rest, with extension, and perhaps counter-irritation, together with change of air,

especially sea air, sufficed, or would suffice in a large proportion of cases, to effect a cure, provided they could be brought to bear on the case at a sufficiently early stage of the disease. On the other hand, some cases were referred to in which the disease baffled all efforts, and continued to progress notwithstanding the most careful hospital treatment. From this it must be evident that there are cases the tendency of which is to disorganisation, but it does not prove that there are not a large number of cases which might also be benefited by the treatment just alluded to. Unfortunately hip disease is common in that class of life where this plan of treatment cannot possibly be carried out. Doubtless one of the speakers was right in saying that the child of a labouring man cannot receive adequate treatment at home. And as surgeons are obliged to refuse admission to the majority of patients suffering from hip disease, it is quite clear that a large proportion of the cases are doomed to progress to that stage of the disease at which, by common consent, surgical help is no longer possible. There can be little doubt, too, from what was said during the discussion as to the frequency of caries as the pathological factor in hip disease, that the cases which resist treatment are probably cases of caries of the neck of the thigh-bone. Caries is a very obstinate disease in young children, and a very common complaint too. In the hip-joint it is doubly dangerous on account of the secondary troubles to which it may give rise. We mean the epiphysial necrosis, cases of which were brought forward by Mr. Parker at the suggestion of the President of the Society. They are interesting, it seems to us, as confirmatory of the caries view; and we should expect them to occur even more frequently than actually seems to be the case. Perhaps the carious epiphysis has not been looked for, or it may perhaps have become absorbed in greater part owing to the late stage at which the operation is often performed. Once exfoliated, these epiphyses become foreign bodies, and by their continued presence they serve to keep up the disease indefinitely. It is of importance, then, to clear up this question, and by a careful study of the cases to differentiate this class, for the sooner such a sequestrum is removed the better.

Some remarks were made on the methods of operating. It may certainly well be questioned whether the usual method of opening the joint from behind does not unnecessarily involve the cutting through of structures which are important to the limb; but it will require a much larger experience than we at present possess to induce us to accept a new operation such as is proposed. At present, all that can be said is that the generally unsatisfactory results of operative treatment justify any attempt to render the proceeding as little destructive as possible. As to the utility of using Lister's antiseptic precautions, we presume that there will not be a single dissentient voice. Carefully carried out, a hip-joint which is the seat of disease, with or without pus, can, with these precautions, be opened without fear of evil consequences, and the question of caries, or necrosis, or epiphysial sequestra can then be settled with a certainty which will otherwise be impossible.

The subject of articular surgery within the last few years has undergone a remarkable development, and we confidently look forward to the time when hip disease will cease to be such an opprobrium to surgery as it undoubtedly is at the present time. We have no wish to advocate cutting into every hip-joint which is said to be a little painful or swollenindeed, we would especially protest against any such practice, but we hope that a more rational plan of treating this troublesome affection will be inaugurated as an outcome of this important discussion.

If it serve only to point out the necessity for a more ample accommodation where the subjects of this disease can receive

that rest and nursing which are said to effect an almost certain cure, it will have done much good; while if it brings about a more accurate knowledge of the right time to operate, and of the best method to adopt, it will prove of inestimable advantage to those who, having the disease, were not able to secure that attention in the early stage which, as has just been said, is so efficacious and yet so simple.

THE RELATIONSHIP OF BRIGHT'S DISEASE
TO OTHER DISEASES.

PART I.-THE SECONDARY FORMS OF NEPHRITIS.

THE subject of Bright's disease is one which is far from being exhausted as yet, and many points in its history still require elucidation. Professor Bamberger, of Vienna, has. therefore done good service(a) in utilising the vast resources. of the Allgemeines Krankenhaus to try and clear up difficulties and open up new paths of investigation into the pathology of this disease. His essay is founded on his own long clinical experience, but also on 2430 post-mortem examinations in which the anatomical diagnosis of Bright's. disease has been made in the Pathological Institute at Vienna during the last twelve years. The total number of patients of all kinds, excluding children, during this period was about 250,000, the total number of necropsies. 19,000. The cases diagnosed as Bright's disease do not include amyloid disease, or nephritis due to circulatory obstruction (Stauungs-Hyperämie) or to embolism or pyæmia, unless accompanied with true parenchymatous or inter-stitial nephritis. On the other hand they include the nephritis which occurs in acute infectious diseases, and especially in typhoid and puerperal fevers, this form being classed under the head of acute Bright's disease. The Vienna pathological classification arranges cases of Bright's disease under three heads, the acute, the chronic, and the atrophic. Those cases in which the kidneys exhibit the anatomical appearances of inflammatory swelling are under this system reckoned as "acute," though clinically they may be chronic cases with acute exacerbation. By "chronic" is meant that form of nephritis in which the epithelial element is chiefly involved (parenchymatous, or tubal nephritis); by "atrophic," that which is known in England as inter-stitial nephritis, where the bulk of the organ becomes gradually reduced by connective tissue proliferation and contraction.

With regard to this classification, we should say that Pro-fessor Bamberger recognises no abrupt line of demarcation. between the parenchymatous or tubular, and the interstitial or granular contracted forms of chronic nephritis. They shade insensibly into one another when a large number of cases of Bright's disease are examined post-mortem.

There

are marked examples of both forms, and endless interme-diate forms between the two extremes. The same is true of the clinical history when a sufficient number of cases are observed. We get typical examples of chronic Bright's disease where the symptoms of the classical descriptions of tubular and interstitial nephritis are found associated, each with their proper morbid appearances. On the other hand, as Bamberger points out, there are three other contingencies.. In the first place, cases diagnosed as interstitial nephritis during life turn out at the necropsy to be either cases of tubular (parenchymatous) nephritis, or combinations of the latter with interstitial changes or even with amyloid. degeneration; or, secondly, the symptoms may be very nearly those of tubular nephritis and the kidneys be in a. highly contracted state; or, thirdly, the symptoms may correspond partly (especially in the earlier stages) to those of

(a) "Ueber Morbus Brightii und seine Beziehungen zu anderen Krankheiten" (Volkmann's Sammlung Klinischer Vorträge, No. 178).