never be disregarded; and if he be seen to steady his abdomen with his hand as he walks, the sign is a very suspicious one. When the patient is seen at a later period of the disease, and after the symptoms have become severe, it has still to be decided whether the inflammation be simple or be due to tubercular disease. This question can only be answered by a reference to the history of the child. A history of general failure in nutrition preceding the onset of the disease is in favour of the tubercular origin of the peritonitis; but the strongest and only trustworthy evidence is to be derived from the character of the local manifestations and their mode of beginning. Simple peritonitis comes on suddenly; the symptoms are severe from the first, and vomiting is common and distressing. In tubercular peritonitis the beginning is slow and gradual, the symptoms at first are slight, and vomiting is rare. The more severe the early symptoms, and the more acute the course of the disease, the greater the probability of the absence of tubercle.

(To be continued.)

ORIGINAL COMMUNICATIONS.

OPERA CLINICA.

ON BLOOD-LETTING AS A POINT OF SCIENTIFIC PRACTICE.

By BENJAMIN W. RICHARDSON, M.D., F.R.S.

(Continued from page 258.)

EFFECT OF BLOOD-LETTING IN CASES OF UREMIC COMA. In my last paper I recorded certain instances in which bloodletting had proved of service in the treatment of uræmia, to the extent of saving life. I have yet before me the record of another case, in which, although life was not ultimately saved, an abstraction of blood caused a return of consciousness from deep insensibility which was singularly striking. The case was that of an aged man, who was subject to albuminuria and who had occasional attacks of diarrhoea, a compensatory action for the imperfect function of the kidneys. For one of these attacks he was treated with grey powder and Dover's powder, by which, as is common during albuminuria, he was mercurialised. He recovered, but twelve months afterwards, having been exposed to wet, and taking what he called a cold, he was once more attacked with diarrhoea, was treated again with mercury, and again suffered from the effect of that drug. The ptyalism was this time attended by profound coma and frequent paroxysms of uræmic convulsion. At this period of the case the patient first came under my observation. His skin was warm, at times hot; the coma was profound, the breathing heavy, the pupils slightly dilated and fixed, and the pulse full and slow. The gums were swollen; the teeth were loose and saliva was constantly exuding from the mouth. About every two hours the repose of the patient was broken by a violent convulsive seizure. This convulsion lasted full fifteen minutes, and then subsided, the coma continuing throughout. The bowels were constipated, but a little urine was occasionally passed, and was found to be richly charged with albumen. The symptoms being urgent in the extreme, I advised, with the practitioner who was in attendance with me, the free abstraction of blood. This was agreed to. We first cupped freely over the loins, and, the coma still remaining, we drew off twelve ounces of blood from a vein in the arm. While this blood was flowing, the patient, for the first time in seventy hours, became sensible, sat, propped up by pillows, recognised all his friends, remained conscious several hours after the venesection, partook of beeftea, and arranged certain business matters which had been waiting for his decision. On the evening of the following day this patient relapsed into the comatose state, and died the next morning in one of the convulsive seizures.

I note this case as specially valuable in showing the immediate useful action of abstraction of blood, even when the conditions favourable to death are persistent in their course. EFFECT OF BLOOD-LETTING FOR RELIEF OF SEVERE PLEURITIC PAIN.

The ancients discovered that by the abstraction of blood acute pain, especially pain in the membranes, was speedily and effectively cured. Galen, seized with severe pain near the diaphragm, opened the artery between his thumb and fore

finger, drew off a pint of blood, was instantly relieved, and, he believed, saved. He cured a priest, he says, of a desperate pleurisy by the same method. The following cases bear out this practice::

(▲) A young, spare man, a shoemaker by trade, was suffering from what was called a sharp pleurisy. He said it came on like "a stitch" during a time when he had taken cold. I found him in bed, with his skin hot, his face anxious, his pulse hard, and his breathing short and difficult, from the severe darting pain which every attempt to fill the chest produced. On the right side, on a level with the nipple below the axilla, there was a sharp friction-rub with every inspiration. At the man's own request-for he had been bled some years before -I tied up his arm and drew blood from a vein until he showed slight signs of faintness. He was completely relieved of his pain at the moment, and had no return of it. With the reaction from the bleeding, there was free secretion by the skin, by the urine, and from the pleuritic membranes, for the friction-sound ceased; afterwards recovery was steady until it was perfected. This man resumed his work in a week after the bleeding, and although he seemed a very unlikely person to bear the loss of the blood that was abstracted from him (sixteen to eighteen ounces), he never appeared to feel the loss or to experience any effect, except the slight temporary faintness and the removal of the pain.

(B) Mr. Beresford, of Narborough, whom I assisted some months in my early life, reminded me the other day of a case similar to the above, in which I took blood with the same good effect. The patient in this instance was also a young man, who suffered from acute pleurisy, with extreme pain in the chest, friction-sound, and minute crepitation. There was high fever, hard pulse, and slight delirium. I may call the case one of pleuro-pneumonia in its first stage. When I reached this man's bedside I found that some leeches had already been laid on the chest, and that a linseed-meal poultice had been applied, but that no relief had been obtained. I thereupon tied up his arm, and drew off twenty ounces of blood, with direct relief to the pain and to the oppressed breathing. A simple saline treatment was all that was added to complete the cure of this man, who is still, I learn from Mr. Beresford, alive and well.

EFFECT OF BLOOD-LETTING IN PLEURO-PNEUMONIA WITH

PHRENITIS.

In 1854 I attended during her labour the wife of a man who acted as coachman to a nobleman of very eccentric and irascible nature. The husband of my patient (the coachman) was a steady man, anxious to do his best, but was the victim of his master, whom he could never by any ingenuity or service satisfy. The labour of the poor woman was long and severe, extending through the whole of the night, and I noticed that her husband, whom I will call M., was all the time unusually anxious and miserable. Whenever I went downstairs from the small bedroom where the patient lay, M. was sitting before the fire, with his head buried in his hands, and saying he was so cold. He complained bitterly to me of his service, declared he were better dead than alive, and wondered why men were made to be such slaves as he, and why such tyrants as his master were permitted. The cries of his wife when her pains came on agitated him greatly; he affirmed he could not stand them, and that he thought a doctor who had to hear much of them was as bad off as a coachman. I tried to soothe him, and, in order to divert him, got him to make me some tea: but I did not succeed as I wished, and altogether I thought him to be in a strange way. After his wife was delivered he was more cheerful, and I left him to go home to bed. I had not been asleep many hours when I was called in great haste to the residence of the master of M., and, arriving there, I found the man in the kitchen of the mansion, held by a rope in a Windsor arm-chair. I learned that a little time before, in a fit of maniacal excitement, he had rushed into the house, armed with a knife, declaring he would kill his employer. Happily, he was disarmed in time, and placed in the position in which I found him, the belief being that he had gone out of his mind. When I got to him he was to me as gentle as a little child, and agreed to go to bed; but as he sat he coughed a hard dry cough, and spat some rusty sputa, which made me suspect that he might be suffering from that form of pneumonia which is sometimes accompanied with symptoms of phrenitis. On examination I found fine crepitation in the posterior part of both lungs, a pleural friction-sound in the right lung, an injected condition of the

conjunctivæ, a hard pulse, hot skin, and suppressed function of the kidney. Without waiting to do anything less active, I took from a vein in the arm of the man twenty-two ounces of blood. The loss produced no faintness, but a subdued calm state both of body and mind, with a desire for sleep, which, under a full dose of Dover's powder, was soon obtained. From this time the severely acute symptoms passed away, and the disease resolved itself into one of ordinary pneumonia, which ran a course of about seven days, and from which the recovery was as effective as could be desired.

I heard of this man (M.), long afterwards, that he remained in good health, obtained a situation that suited him, and was considered a good and trustworthy servant. I remember no example in which the immediate and direct effect of removal of blood for the relief of vascular tension was more significantly demonstrated. If blood-letting had not been an old remedy, and if in such a case as this any physician had discovered its application and gained the same results, he would thereby have won a place in the history of his era.

(To be continued.)

THE INTERNAL ADMINISTRATION OF ABSOLUTE ALCOHOL.

By JOHN C. LUCAS, L.R.C.S.E.

THE internal use of alcohol in the anhydrous form, or as rectified spirit, has hitherto been unknown in therapeutical literature. Rectified spirit, as we are aware, contains 84 per cent. of absolute or anhydrous alcohol; it enters into the preparation of most of our tinctures, and is largely employed for external purposes. But when given internally in properly regulated doses, it should always be freely diluted, and properly disguised with peppermint, and perhaps coloured with tincture of lavender, not only to conceal its disagreeable taste, but likewise to prevent the patient from knowing that he or she is taking alcohol, the dose being adjusted in accordance with the demand of each individual case. The advantages gained in this mode of exhibition are great over ordering brandy, etc., as a portion of nourishment, in cases where we have hitherto employed the latter for virtues possessed by the former, without the evils and uncertainty attending the usual mode of administering alcoholic stimulants. I shall briefly state the objections to ordering brandy, gin, etc.

First and foremost, the quality of the brandy, etc., plays the most important part, especially as it is our main object to regulate the quantity of alcohol taken by our patient, not to speak of the impurities and adulterations, so that if we prescribe it in the form mentioned above we are positive as to the quantity, and that our patient does not have the noxious ingredients contained in bad brandy, gin, etc.; the former when good ought to contain a little more than half its weight of alcohol. Secondly, when it is dispensed and labelled in the ordinary way as medicine, the friends of the patient, and nurses, are more likely to give it at specified and regular intervals as desired by the practitioner than if brandy, etc., were ordered in the form of nourishment. Thirdly, the patient, if conscious, takes medicine more readily than food. Fourthly, and lastly, we know that in lower-class patients, the friends who nurse the sick are too often tempted to help themselves out of the stock which ought to be consumed by the patient. Unfortunately, this evil we sometimes, though rarely, witness in hospital practice, where the nurse, addicted to drink, robs the sick of the important alcoholic portion of nourishment. Of course this is neither expected nor seen in tolerably good-class practice, nor in well-governed institutions.

In the few cases in which I have adopted this method (originally inculcated by Prof. Parkes, of Netley), I have found every good derived. The stimulating effect, when desired, seemed to me to be more marked, more rapid, and more lasting than when an equivalent of brandy (good) was allowed. If we watch the patient after he

has taken three drachms of absolute alcohol-an amount equivalent to six drachms of brandy,—we notice almost immediately the pulse beccming fuller and stronger, and the limbs, which may have been previously cold, become warmer. The patients themselves have told me that they felt revived almost immediately after swallowing it. But given in larger doses (even two drachms) in debilitated and cachectic subjects, it produces a pulsating sensation in the limbs felt by the

Before concluding, I may add that

patients themselves. after convalescence from acute affections has been established, especially in the young and in females, the bad habit of drinking, so often cultivated, is easily avoided.

REPORTS OF HOSPITAL PRACTICE

IN

MEDICINE AND SURGERY.

ST. PETER'S HOSPITAL.

-

LARGE STONE IN THE BLADDER LATERAL LITHOTOMY-DEATH ON THE TWELFTH DAY AFTER THE OPERATION.

(Under the care of Mr. TEEVAN.) MATTHEW Y., aged 64, labourer, was admitted into the hospital on September 25, 1873, suffering from stone in the bladder.

History. Twelve years ago he began to pass gravel for a short period. Five years ago his urine got thick, and remained so for some time, and about the same period he began to suffer from pain at the end of the penis when he made water, and to pass blood occasionally. Four years ago he noticed that he had to make water every quarter of an hour, but was better at night. The patient and his parents are natives of Cambridgeshire. One of his sons was cut for stone when four years old. Has suffered from gout and rheumatism.

Present Condition.-Patient is a hard, sincwy-looking man of healthy aspect. Suffers great pain when urinating, and towards the close of the act the penis becomes erect, and blood escapes from the urethra. The urine is sometimes thick, at other times clear, but there is not much albumen in it. The patient was kept quiet in the hospital until the day of the operation, with much comfort to himself.

On October 6, at 3 p.m., he was put under the influence of ether by Mr. Daws, who used Professor Morgan's apparatus for the purpose. Among those present was Mr. T. Gutteridge, of Birmingham, who took much interest in the case, and visited the patient on several occasions afterwards. Mr. Teevan passed a rectangular catheter staff, and, having demonstrated the presence of the stone, he gave the instrument to Mr. W.J. Coulson to hold. The bladder having been opened with a probe-pointed knife, the stone was at once grasped with a slender fenestrated forceps, and the extraction commenced very slowly, on account of the large size of the calculus. As, however, the stone was pear-shaped, Mr. Teevan exercised gentle traction, with the hope that it might come through the opening already made, without any further extension of the incision. In this, however, he was disappointed; and, as he did not consider it prudent to exercise any more force, he inserted a probe-pointed bistoury and slightly enlarged the aperture, so that the stone now glided out. It measured two inches and a quarter long, four inches and a quarter in circumference, weighed two ounces, and was composed of lithic acid. Very little blood was lost at the operation, and the patient's pulse was good, and face florid after he had quite rallied from the eflects of the ether. 5 p.m.: No blood or urine had passed since the operation, and the patient had hardly expressed his great desire to pass water when there immediately gushed out about one pint of clear urine, followed by about a handful of clots. A few minutes afterwards he looked pale, and said he felt cold and inclined to shiver. His pulse was fair in volume, but soft. Hot-water bottles were put to the feet, bot blankets next the skin, and warm milk given internally. At 6 p.m. the patient had got warm again, but he complained of a desire to make water, and instantly there was another gush, but not so large as on the former occasion; and it was followed by the expulsion of a few small clots. As the patient looked pale, pieces of ice were put in the wound, and an ice-bag above the pubes. At 7 p.m. he said he felt comfortable; colour had returned to his cheeks; had not experienced any sickness. At 9 p.m. urine, slightly tinged with blood, began to trickle through the wound. The patient's pulse was 68, very little faster than it was before the operation, when it was 64; tongue foul and dry, but it had been so ever since he came into the hospital.

October 7.-6.30a.m.: Patient has had some sleep during the night; urine has dribbled away quite clear; tongue cleaning.

1

Patient says he feels quite comfortable and free from pain. The expression of his countenance is calm and cheerful. Complains of thirst. 10 p.m.: Bowels have been opened. Feeds well on milk, beef-tea, and toast. Tongue foul, but moist; is thirsty.

8th.-9.30 a.m.: Pulse 70, and, although soft, still very steady; temperature 101-3. Patient looks well, but has had no sleep, on account of rheumatic pains flying about both legs, and attacking the right knee especially. Tongue very dry and rather brown; feels parched. Face pale and fatiguedlooking. Patient has not had the slightest hypogastric tenderness, neither is there any tenderness in any of the joints. Ordered to be wrapped in hot blankets. 8 p.m.: Patient more comfortable. Tongue not nearly so dry. Pulse 78. Still complains of thirst.

9th.-2 p.m.: Pulse 78; temperature 102°. Tongue rather dry.

10th.-10 a.m.: Pulse 88; temperature 102.3°. Tongue furred and dry. Has slept a little. Suffers a good deal from pains in the legs of an erratic character, but there is no pain on pressing any of the joints, neither is there any fulness or redness. Patient says he would like to sit up. Ordered quinine. 10 p.m. : Pulse 92; temperature 103°. Looks flushed. Wound healthy. No abdominal tenderness.

11th.-7 a.m.: Pulse 88; temperature 102-4°. Tongue moist, but furred. Has slept fairly. Complains of thirst. 8 p.m.: Pulse 107; temperature 103.2°. Very thirsty. Cannot move on account of pains in knees. Looks flushed.

12th.-11 a.m.: Pulse 92; temperature 101.4°. Much less pain in knees. Slight excoriation over right hip, evidently from irritation of urine. Wound looks rather dry. Tenderness along left saphena vein is less. 10 p.m. Pulse 102; temperature 102-3°. Patient says his legs are almost free from pain.

13th.-2 p.m.: Pulse 95; temperature 101·1°. Patient is very comfortable.

14th.-Much better. Moves about well. Shaved himself to-day. Feels he could walk about. At 9 a.m. temperature was 1004, and pulse 95. Bowels relaxed. Tongue rough, dry, and brown. Ordered catechu and chalk.

15th.-5 p.m.: Patient looks pale, and he says he feels "low" to-day. Bowels not so loose. Pulse 126; temperature 102.3°.

16th.-10a.m.: Pulse 126; temperature 98-3°. Looks thinner, but the tongue is not so dry or brown. 6 p.m.: Pulse 130; temperature 101.2°. There are two small bedsores over hips. Has eaten a mutton chop. Is not so thirsty.

17th.-6 p.m.: Pulse 127; temperature 100.1". Patient looks pale and anxious, and he cannot articulate clearly. Pulse feeble and thready. Has rambled from time to time. Takes food pretty well.

18th.-5 p.m.: Pulse 136; temperature 98-4°. Is covered with a cold clammy sweat. Eyes glassy; can just recognise people, but can hardly speak. Is evidently sinking fast. 8 p.m. Much worse. Pulse 144, can just be felt. No diarrhoea since 15th. Death took place at 10.30 p.m. Permission was given to examine the abdomen only.

Post-mortem, thirty-six hours after Death.-Kidneys healthy; ureters of normal calibre. Peritoneum free from any inflammation. Rectum enormously distended with fæces, filling up nearly the whole of the pelvis. Bladder greatly thickened, fasciculated, contracted, and containing some muco-pus. The mucous membrane was inflamed, and there were many veins standing out from the wall of the bladder. The prostate was not much hypertrophied, but its plexus of veins was enlarged, inflamed, and filled with clots. In its roof there was a rent clearly made during extraction, completely splitting the gland in two at that part, the halves being held together by bands of the fibrous capsule. The differences between the incision made by the knife, and the laceration caused by extracting the calculus were very manifest, for the former was clean-cut and had evidently been repaired in part, whilst the latter was sloughy and irregular. The rectum was wounded at the operation just inside the anus, the slit communicating with the wound in the ischio-rectal fossa.

Remarks.-Mr. Teevan said that in this case he had rather departed from his usual method of removing a calculus through an aperture made entirely by cutting, because the stone was pear-shaped, and just such an one that would dilate a prostate, if dilatation were possible. Now, although the extraction was conducted very slowly and gently, aided by a slight notching of the wound with the knife when the thicker part of the

stone was passing, yet, after death, the prostate was found completely split in two, thus demonstrating the fact of the non-dilatability of that organ, although the contrary was affirmed in nearly all surgical works. Now, all facts prove the accuracy of Professor Ellis's doctrine regarding the nondilatability of the prostate, and this case added one more to the many which went to show that the so-called dilatation of the gland was complete laceration.

BRISTOL GENERAL HOSPITAL.

CASE OF ABDOMINAL ANEURISM.
(Under the care of Dr. BURDER.)
[Notes by J. H. THOMAS, Esq.]

A. L., AGED 31, admitted May 26 into the Bristol General Hospital under the care of Dr. Burder. Patient is a labourer, and has done a great deal of hard work. Has never had rheumatic fever. There is a history of syphilis. Has had occasional attacks of sickness, but on the whole has been a very healthy man all his life. Present illness began eleven weeks ago with a severe pain in his stomach and back. He was obliged to leave off work, and has not done any since. The pain keeps him awake at night. He states that when the pain came on first he was not lifting any weight or making any very great exertion, but it came on suddenly.

Present Condition.-There is a very anxious expression on the man's face. He complains of a severe pain in his epigastric and left hypochondriac regions. He has a severe pain in his lumbar region; there is also some tenderness in this region. The pains are constant. He moves freely about the bed, and does not complain of any weakness. No appetite. Tongue dirty. Bowels very costive. Is sick occasionally after his food. Pupils are about the usual size; there is no difference between them. Optic discs normal; the vessels are somewhat congested.

Chest.-Lungs: Anterior-hyper-resonant; respiration harsh, feeble. Posterior-wooden at apices, but resonant all over the rest of the back. Respiration is harsh all over the chestwall. Heart: Dulness normal; second sound somewhat prolonged. Liver and spleen: Dulness normal. Urine acid; no albumen; specific gravity 1016; phosphates. There is a distinct swelling to be felt in the epigastric and left hypochondriac regions. It is situated slightly out of the median line and is a few inches above the umbilicus. There is well-marked pulsation and bruit, an impulse heaving and radiating from the centre.

Treatment.-An ice-bag was applied.

May 29.-Pain very severe, so that an injection of one-third of a grain of morphia was given.

30th.-Ordered half a grain of extract physostigma three times a day, with a view to retarding the circulation.

June 1.-6.30 p.m. : Patient was sitting up in bed talking; he had just taken some food. About a quarter of an hour afterwards he began to vomit; whilst doing so he suddenly fell back on the bed, and died in a few minutes.

Autopsy (June 2).-Body fairly nourished. On opening the skull the brain and membranes were found to be healthy. The basilar artery was atheromatous. Chest: Lungs were congested, but otherwise quite healthy. Heart weighed ten ounces and a half; left ventricle empty and contracted; traces of commencing atheroma to be seen in the aorta. Abdomen: Liver weighed 2 lbs. 9 oz., fatty; spleen and kidneys normal. The peritoneal cavity was full of blood. An aneurism about the size of a large orange, and springing from the front of the aorta about an inch or two below the diaphragm. The part of the aneurism which had given way, and through which the blood had flowed, was about the size of a shilling. The interior of the aneurism was lined with organised fibrine.

THE ROYAL NATIONAL HOSPITAL FOR CONSUMPTION, VENTNOR.-The executors of the late Miss Hannah Brackenbury have contributed £200 out of the sums at their disposal in aid of the funds of this Hospital.

CONSTIPATION.-The following pill has been found very serviceable in correcting constipation:-R. Aloes soc. pulv. gr. vj., ext. belladon. gr. iij., confect. sennæ q. s.; M. et divide in pil. xij. One night and morning.-Medical Record, Aug. 1.

HOSPITAL CONSTRUCTION.

We are glad to see that the Norwich people are not inclined to rest under the dilemma which was made public at the late meeting of the British Medical Association. They had flattered themselves that their Hospital was a place where the sick poor might recover their health; they learn that, on the contrary, it is a place where some of them find their death. The evidence on this point is overwhelming. There is first of all Dr. Copeman, who, in his Inaugural Address, confesses and laments the frequent occurrence of deaths from bloodpoisoning after accidents and operations. Then we have the unanswerable statistics of Dr. Beverley, which agree with the statement made months before by Mr. Cadge, at the Clinical Society in London. Mr. Cadge leaves no doubt whatever that the deaths after operations are due to the Hospital, and nothing else. It is true that Dr. Copeman has since come forward on the wrong side with an attempt to show that the general death-rate of the Hospital is no worse than it was fifty years ago. But Dr. Beverley has challenged Dr. Copeman's figures as incorrect; and, even if correct, they furnish no argument one way or the other. The general death-rate of a hospital depends upon a thousand causes. severe winter or spring might send in cases of fatal pleurisy or rheumatic fever, and so forth. What we are concerned with now is not the general death-rate, but the rate of deaths from blood-poisoning after wounds and operations during the last ten years; and on this point Dr. Copeman agrees that Dr. Beverley's figures are unimpeachable.

A

The numerous letters on this topic which have appeared in the Norwich Mercury are highly interesting and creditable to the writers and to the city. The Norwich people feel that there is something wrong with their Hospital, and desire to amend it; and as they are not singular in this respect, we venture to throw out some general suggestions.

Now, the vice of most hospitals is, that they are made to combine under one roof and government two, three, four, or more departments, which are utterly incompatible with each other. Let us see what these are.

First of all, the hospital receives patients affected with that class of illness that comes under the general medical head-such as rheumatism, pneumonia, diseases of the nervous system, and the like—to which may be added such surgical cases as are not attended with wounds or with any particular taint of the atmosphere.

Secondly, there are the severe surgical cases, attended with some wound, whether the result of disease or of surgical operation-such as compound fracture, amputation, abscess, and the like. These cases have two elements of danger. They are attended with discharges which are liable to become tainted, and with open wounds from which tainted and poisonous matters can enter the veins, and poison the whole blood, bringing about the condition named pyæmia. Now, such cases taint each other; and the more of them there are, the more risk is there. Instances are known without number, in which a set of wounded patients are doing well in a ward, when there is brought in some patient whose wound is attended with profuse and fetid discharge, such as a very severe burn, or a case of sloughing phagedæna. Immediately, case after case does amiss; either hospital gangrene or erysipelas or pyæmia spreads and infects the whole hospital. The medical patients who have no wound are liable to erysipelas of the scalp. Space and ventilation and antiseptics lessen the risk, and may prevent it perhaps indefinitely.

Thirdly, there are the infectious fevers-especially scarlatina -which, if introduced into a general hospital, will spread as elsewhere.

Now, we say most positively that modern experience has most amply proved that surgical patients with suppurating wounds, and after operations, should not be received into a general ward: they poison each other, and in time the medical patients. And, since if one such patient in any ward goes wrong, it fares ill with the others, the chances of each are made much worse by massing them together. As for the patients with infectious fevers, what more cruel than to put them into a general hospital ward ? to let a child, admitted for a trivial accident, die of scarlet fever, taken from a patient admitted into the same ward?

Although, therefore, the severe surgical cases, and those of infectious fever, may share the benefit of the same medical attendance, nursing, and diet, still it is most cruel to put them under the same roof with the medical patients, or with each other. There may be a central block of good architectural proportions for the administrative offices, board rooms, chapel, and the medical wards; but into this no case of wound or operation or infectious fever should be admitted. These last should be treated in small, detached, single-floored huts or rooms, isolated from each other, though within the same grounds.

The out-patient department, which represents a fourth institution, should be utterly separated from the main building and from the surgical wards. Patients with all sorts of maladies, and with foul clothes, should not be allowed to contaminate the air. We believe that the Radcliffe Infirmary at Oxford was reconstructed, by Dr. Acland's advice, so as to avoid this source of mischief.

A fifth kind of institution—namely, the lying-in hospital— is rarely put under the same roof with the other already discordant elements of a general hospital. But women at this critical time are liable to the same contingencies as patients with wounds and operations-whatever taints the one will taint the other; and when an attempt was made, at King's College Hospital, six or eight years ago, to accommodate