used in approximating the pillars of the ring seems doubtful,eurgeons still differing as to the advisability of using wire,catgut, or silk.CASE 1.R. J---, a bricklayer, aged forty-four, was
admitted on May 10th, 1887. For nine years he had had aright scrotal hernia, which had been strangulated two yearsago, but was reduced by taxis.The right half of the scrotum was as big as a mans fist,
and very tense; the hernia had been down for fourteenhours, and all the signs of strangulation were present. Taxishaving failed, herniotomy was performed. The sac beingopened, about two feet of congested small intestine wereexposed; the strangulation was divided at the neck of thesac. An atrophied testis was seen at the bottom of the sac.The neck of the sac and the spermatic cord having beenseparately tied with strong catgut, the testis and the sacwere removed together. Four strong wire sutures were
then deeply passed through the pillars of the external ringand the conjoined tendon, and the inguinal canal was thusobliterated. The wound was washed with a 1 per 1000mercuric solution, a drainage tube was introduced, and theedges of the wound were brought together with wire sutures.The patient was kept on iced water for twenty-four hours,and quarter-grain doses of morphia were administered.There were no febrile symptoms. (The epididymis was sub-sequently examined by the microscope for seminal filaments,but with a negative result.)On the eighth day the wound had healed throughout, the
sutures were removed, and the dressings were left off. Thetube had been withdrawn at the end of twenty-four hours.Thirteen days after the operation the patient was allowedto get up, there being a large plug of dense tissue filling upthe inguinal canal and surrounding the external ring. Onthe eighteenth day, however, some pus was detected beneaththe scar; this was let out and the dressings were reapplied.On the thirty-fourth day the man was discharged. But at theend of two months he was readmitted, as some suppurationcontinued. The four deep sutures were therefore removed ;two of them were found firmly embedded in fibrous tissue;the two others were loose. The wounds at once healed bygranulation, there being a mass of hard new tissue soundlyfilling the canal and covering the external abdominal ring.The patient was discharged cured, and was directed not towear a truss.CASE 2.--F. L, aged eighteen, was admitted Aug. 16tb,
1887. His right inguinal hernia had tirst appeared sud-denly, nine years before, whilst he was pushing a truck.He was greatly collapsed, though the bowel had been downand strangulated only three hours ; taxis was unavailing.The details of the herniotomy closely resembled those of thepreceding case. An atrophied testis was found in the sac;the neck of the sac and the cord were ligatured separately,and the testis and the sac were removed. The external ab-dominal ring and the inguinal canal were obliterated bymeans of sutures, which included the conjoined tendon,together with parts of the aponeurosis of the externaloblique, strong chromicised gut being used instead of silver.
After twenty-four hours the tube was removed. On theseventh day the dressings were left off, as the wound hadhealed completely. On the eighth day the patient wasallowed to sit up. On the fifteenth day he was discharged.There was abundant firm material blocking up the canaland surrounding the external ring, but it was not soplentiful as in the last case, where silver sutures had beenused. About three weeks after leaving the hospital theman returned to show himself, soundly healed. There wasstill plenty of hard material in the canal and around thering. The deep sutures had caused no discomfort what-ever, and nothing more has been heard or seen of them.Remarks by Mr. OwFN.-Not infrequently an atrophied
testis is found associated with an inguinal hernia; oftensuch a testis is imperfectly descended, and generally it is ofmore than doubtful physiological value. It might be con-sidered a good rule to remove such an imperfect gland whenoperating on a strangulated hernia, as by so doing thesurgeon is then enabled completely to blockade the inguinalcanal. The strong silver sutures which were used (asadvised by Sir Wm. Stokes) demanded subsequent dis-interment, whilst those of chromicised gut in the secondcase served their purpose perfectly. If suppuration occursabout deep sutures, the sooner the deep sutures are removedthe sooner the wound will heal.An important point is that neither of these men was
allowed to wear a truss after the operation. If the work of
the surgeon has been efficiently done no truss should b&wanted; if a truss be applied, its pressure huriies on theabsorption of the plastic material which consolidates theweak region, and its application may thus militate againstthe success of the operation.
I have the pleasure of saying that the second case wa&operated on by my house surgeon, Mr. J. J. Claike, whilst Iacted as his assistant.
BOROUGH LUNATIC ASYLUM, PORTSMOUTH.GENERAL PARALYSIS OF THE INSANE; ONSET IN FORM OF
STUPOR; APPARENT RECOVERY; RELAPSE, WITH EX-PANSIVE DELIRIUM AND SPEEDY DEATH; REMARKS.
(Under the care of Mr. J. D. MORTIMER, Assist, Med. Officer.)
J MR. MORTIMER expresses his obligation to Mr. W. C. Bland,medical superintendent, for permission to publish thefollowing notes.W. J. A----, aged forty-four, married, boiler-maker, was
admitted on Dec. 19th, 1885, with the following history. Hehad always been a steady hard-working man; was secretaryof a trade association, and had taken an active part in arecent Parliamentary election. No family history of anyneurosis. On Nov. 27th he had fallen, apparently accidentally,downstairs, striking the back of his head. On Nov. 30th, hewas first noticed to have a peculiar vacant look, and began totalk and act strangely, expressing an unfounded belief thathis accounts were " all wrong," turning out the gas at un-seasonable times, &c. He gradually passed into the stateseen on admission. He was then described as a tall, gauntman, bald-headed, with a red beard; face sallow; expressionof vacant bewilderment; pupils equal, rather sluggish;. ,tongue slightly tremulous. No definite signs of thoracicor abdominal disease, but pulse small and weak. Totters inwalking; knee jerk brisk on both sides. No special rigidityor flaccidity of muscles. When questioned, he staredstupidly, giving no response, except that, when asked if hewas in pain, he said his " head was bad," and passed hishand over it. He spoke slowly, but otherwise normally.Two days after admission it was noted that the man had
slept well and fed and dressed himself (but slowly). "Sitsmotionless and silent, replying to questions tardily andbriefly. He generally answers those as to facts correctly>but for some time persisted that the present year is1865."Four months after admission there had been no marked
change, but he was in all respects rather worse, being moredull and confused, more vacant in look and unsteady in gait,and often " wet and dirty" in habits. From this time(April, 1886) he steadily improved, at first in bodily, then inmental condition. At the end of May he was able to workin the garden, and at the end of June he was in good generalhealth, his pulse and gait being normal and the tremor ofthe tongue hardly perceptible. He conversed rationally andintelligently, the only noticeable fault being a slight slow-ness of mental operation.He was discharged on a months trial, which he spent in
the country, returning apparently well in all respects. Hewent back to work,.and for two months, according to thestatements of his wife and of those under whom he served,there were no signs of relapse. He seems, however, to havefretted rather unreasonably at having lost promotion by hisabsence, and not to have displayed much of his formeractivity of mind, At the end of this period he became rest-less and excitable, ordering expensive articles at shops andotherwise behaving insanely. After a few days he wasreadmitted to the asylum on Sept. 27th, 1886. He wasthen very boisterous and extravagant, wanting a specialtrain to meet the Prince of Wales, proposing to make alarge fortune by raffling watches, &c. His pupils wereequal, gait unsteady, knee jerk brisk, tongue slightlytremulous, and there was well-marked hesitation and thick-ness of speech, which had only been noticed a few days.He continued in a state of acute excitement, often violentand destructive, sleeping but little; and although eating
I voraciously, he grew very thinand anaemic. On Dec. 1st. he had a slight attack of diarrhoea, and on the evening of.
the 2nd suddenly passed into a state of collapse. No, treatment had any effect, and he died on the morning of, Dec. 3rd, 1886.
Necropsy, twenty-four hours after death.-Calvaria of! normal thickness and densitv. Vessels of dura mater, shrunken. Sinuses contained fluid blood. Arteries at base