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found necessary to remove two inches of the internal jugularvein which the growth had invaded. When dissecting outthe pneumogastric nerve the patient’s condition becamesomewhat critical, and it was found advisable to substituteether for chloroform till the end of the operation. Afterthe patient had been removed to bed the effect of the irri-tation of the pneumogastric was evidenced by syncope anda pulse of only 44. Stimulants of various kinds wereadministered, and he gradually regained consciousness, butit was not until five hours later that it was considered safeto leave him. It is certain that the symptoms were thedirect effect of the pneumogastric irritation, as he lostscarcely any blood, and no spray was used which mighthave added to the shock. The pathological specimen wasinteresting as showing the little resistance the coats of avein offer to the inroads of cancer, compared to those of anartery when equally exposed. The growth had not onlypenetrated but filled the lumen of the vein at one point,whilst clotting had taken place above and below. Thesheath of the carotid artery had to be taken off, but theproper coats of the vessel were uninjured. After the firsttwelve hours there was never any anxiety as to his

recovery, which was complete in a fortnight. Beforeleaving he insisted on having the old painful cicatrix inhis lip re-excised, and this was done under the influenceof the subcutaneous injection of cocaine.

WEST HERTS INFIRMARY.CASES OF SURGICAL INTEREST.

(Under the care of Mr. F. C. FISHER.)THE following cases are a continuation of those of last

week :-CASE 3. Gunshot wounds of shoulder and of face.-

A. N---, aged twenty-four, married, was admitted onMarch 26th, 1887. At 5.30 A.M. on the day of admission shewas fired at by her husband ; she was lying in bed, and hestanding by her on her right side. On attempting to shoother she grasped the barrel of the pistol with her right hand ;he, however, fired, and the bullet ran up parallel with thearm and entered the lower and anterior margin of thedeltoid muscle. She then let go, and turned her head awayfrom him, when he again fired, and hit her j just in front of thejunction of the helix and tragus of the right ear. She did notlose her consciousness, and walked to the infirmary, which wasabout a mile distant. On examining the patient at 9 A.M.,the right hand between the forefinger and thumb wasblackened by powder, the right cheek was swollen andshiny, and she presented wounds one-eighth of an inch indiameter at the above-named sites. She was seven monthspregnant.

Operation.-On examining the wound in the head, theprobe travelled downwards, forwards, and inwards throughthe tissues of the temporal fossa, and struck on thetuberosity of the superior maxilla. From that point thebullet had evidently bounded into the cheek. On the insideof the mouth there was a small bruise, evidently caused bycounter-pressure against a tooth. An incision was madeover that spot, and the bullet was believed to have beenstruck, but the soft parts overlapped it, and it could not beremoved. On examining the shoulder, the probe passed fourinches and a half upwards, backwards, and outwards, andlodged in the head of the humerus, which was splintered.The sinus was slit up sufficiently to allow the finger toexamine the parts. Several small loose fragments of bonewere removed, and then the bullet was seized with forcepsand extracted. It was firmly wedged in the bone, andrequired some little force to be used. A drainage tube wasinserted, and the wound treated with the usual Listerianprecautions.During the operation labour pains set in, and she was

delivered of twins the next morning. A good deal of feverfollowed, the temperature gradually rising to 104 4° F. onthe sixth day. Uterine discharges natural, no abdominalpain. Cheek much ’swollen and fluctuating. An abscesswas opened externally on the cheek, but the bullet couldnot be struck by the probe. Shoulder wound healthy. Thetemperature rapidly fell after this, being 99° on the eighthday. From this point she went on steadily improving. On

April 29th, thirty-three days after the occurrence, the bullet,now being plainly felt, was cut down on and levered out oithe wound. The wound rapidly healed. On June 9th thE

patient was discharged, with the sinus in the shoulder not

quite healed. One month afterwards she returned, theshoulder being quite sound and with good movement.Remarks by Mr. FISHER.—I am inclined to think that the

fever she had was the result of the abscess in the cheek. Itcertainly was perplexing to know how to deal with awoman in the parturient state and with two bad bulletwounds, accompanied by a temperature of 104:’4°. The wayin which the loose tissues of the cheek kept rolling over thebullet was most annoying. It seemed impossible to fix it,

especially as I did not want to leave a large scar on thecheek. The resulting scar is not more than half an inch inlength, and is not puckered. The bullets demonstrate bytheir markings the course they travelled: the one with a deepcut in one side, but otherwise fairly preserving its shape,being the one from the humerus where the hard cancelloustissue cut the bullet like a chisel; the other, with a long,.smooth side, caused, I take it, by gliding past the innersurface of the zygoma or else the temporal fossa.CASE 4. Genu valgum on both sides; osteotomy on the left

side; cure.-G. 0--, aged nineteen, was admitted onMarch 31st, 1887. Three years ago he was an in-patient atthe infirmary for genu valgum, but declined treatment.The legs becoming worse, he reapplied to have them operatedon. On admission, he presented a condition of well-markedgenu valgum, the inside measurement between the heelsbeing ten inches. The deformity was greater on the leftside. On April 15th, after consultation, it was decided tooperate on the left femur by Macewen’s method; this wasdone under antiseptic precautions, and the limb broughtstraight. The case ran an aseptic course, finally leavingan elongated ulcer at the site of incision. This was healedby May 16tb, when the limb was put up in plaster-of-Paris,He was discharged, walking with the help of a stick, onMay 26th. He returned in six weeks’ time, and had theplaster removed. The joint required a little passive motion,and then all the ordinary movements returned.

Medical Societies.ROYAL ACADEMY OF MEDICINE IN IRELAND.

Trephining in Brain Disease.-Serious Brain Symptomsfollowing Pyæmia.

THE opening meeting of the Surgical Section of tha

Academy was held on Nov. llth, A. H. Corley, M.D., President,in the chair.The PRESIDENT delivered an inaugural address outlining

the history of surgery for the past fifty years.Mr. J. DALLAS PRATT read a paper on a case of Alastoid

Disease with Discharge of Pus from the Middle Ear, in whichhe had successfully trephined, the trephine being applied onthe spot indicated by Mr. Wheeler, so that the crown of theinstrument was anterior to a line bisecting the mastoidvertically and the lower border of the crown, on a level withthe external auditory meatus. The membrana tympani wasperforated, and there were pain and tenderness in the mastoidregion, with deafness. After the operation, which openedthe mastoid cells, the middle ear, and the cranial cavity, the-patient’s temperature only rose above normal on one evening.The pulse never exceeded 80. The patient made a goodrecovery. The discharge from the ear ceased, and themembrana healed up; the deafness also disappeared. Mr.Pratt drew attention to the statistics, thirteen cases havingbeen operated on in this manner with only two deaths, or84 per cent. of recoveries; whereas the operation of gouging,drilling, or opening the mastoid cells by means of a bitproduces a mortality of about 27 per cent. He advocatedthe use of the trephine, even if the mastoid cells alone wereto be opened, as being more manageable and safer than theother instruments, and drew attention to the fact that ofeight cases in which no operation was done, there had notbeen a single case which recovered. He advocated th&performance of this operation in cases of prolonged otorrhœa,where milder measures had failed, even when no bone diseasewas present.Mr. MAYNE (Longford) read a paper on Serious Brain

Symptoms following Pyaemia. A. B-, aged twenty-seven,who had a slight scratch on her finger, had been dressing awound. A few days afterwards the finger got sore; the

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glands in the axilla also became enlarged and inflamed.These symptoms passed off, but after some days the throatgot sore and an abscess formed in the tonsil, which wasopened, when a quantity of pus escaped. Soon after thisthe parotid gland inflamed, suppurated, and burst into theeternal ear, through which pus freely escapad. After sittingat an open window in a draught, paralysis of the left side ofthe face set in, which was cured by counter-irritation andgalvanism. She complained, after some days, of severe painin the right side of the head, and was very irritable.Anodynes were given, which had very little effect in

relieving the pain or procuring sleep. The vision of the

right eye became impaired; she complained of tears flowingmto the right eye, preventing her seeing, and the pupil wascontracted. After a drive in a very easy carriage, she becamemore irritable, and could not sleep. She had a severe rigor,and declared she could not bear the pain of the right sideof her head. There was paralysis of the right side of the face,tingling of the left arm, she dragged the left leg, the rightpupil was dilated, and she misapplied words. For some daysthe symptoms became more marked. Mr. Fitzgibbon tre-phined the left mastoid, but on removal of bone there wasno sign of pus. For several days all the symptoms appearedaggravated, the paralysis being well marked, and thesphincters also paralysed. After some days the paralysispassed away, but was succeeded by noisy delirium, whichcontinued for several weeks. Counter-irritants were appliedto the head. Tonics, iodide of potassium, and iron, withcod-liver oil, were given internally. Eventually health wasrestored, and the mind became normal. Mr. Mayne was un-favourable to the trephining of the mastoid, although thepatient had had in early life otorrhœa after scarlatina, butthe discharge had not been present for years, and as duringthat time she had not been troubled with any brain symptoms,he saw no grounds for believing that trephining the leftmastoid would benefit the case. All the symptoms pointedto brain trouble on the right side, probably about the fissure,3fR31ando. Had there been any evidence of mastoid trouble,such as Mr. Wheeler records on p. 61, vol. i., of the Academy’sTransactions, he would not have been so opposed to theoperation.-Mr. HENRY FITZGIBBON regretted the want ofnotice of Mr. Mayne’s paper, as he would have liked to con-sult his notes of the case, it being the subject of a paper whichhe himself read before the Academy last session; but speakingfrom memory as to the condition of the patient at the timeof the operation, he was satisfied the disease had originatedfrom inflammatory action extending from the left mastoidregion. It seemed to him that the lady had had otorrhoeamore recently than Mr. Mayne mentioned. At any rate, herstate appeared to Mr. Wheeler and himself to be perfectlyhopeless, except, as the only chance of recovery, by givingrelief to some pent-up intracranial matter. While admittingthat trephining the mastoid process was not unequivocallyindicated, all he proposed to do was to trephine where hethought trephining would give relief.-Mr. BENNETT sub-mitted that diagnosis should be carried forward to a greaterdegree of certainty than was at present attained beforeadopting Mr. Fratt’s rule, that the trephine should be appliedm almost all cases of otorrhoea where the discharge wasmaintained a considerable time and did not yield to othermeans. He had investigated two or three cases in which thepath of fatal inflammation proved to be along the auditorynerve to the base of the brain.-Mr. THOMSON said Mr.Ilayne’8 case raised some interesting points, as being one ofpyaemia. The lady, from Mr. Mayne’s version, seemed to besuffering from left hemiplegia, and the trephining took placeon the left mastoid process, or in that region. He wished toknow from Mr. Wheeler, who consented to the operation,why, having regard to the localisation of functions, thatparticular position was selected; and whether he consideredthat the removal of a piece of bone from the left mastoidregion was calculated to improve hemiplegia occurring onthe same side. It appeared from Mr. Henry Fitzgibbon’sstatement that no pus appeared until the fourth day, whenit was manifest. There was nothing remarkable in that. Ifa piece of bone was removed and the case allowed to go onfor four days, unless the wound was strictly aseptic, it wasnot an unlikely condition that there should be pus. Thesymptoms produced by pressure were explained by the puspent up in the wound for a certain time.-Mr. WHEELER,îike Dr. Fitzgibbon, regretted he had no notice of Mr. Mayne’spaper, which was similar to a case operated on sixteenmonths ago by Dr. Fitzgibbon, who had communicated thedetails already to the Academy, It was difficult after so

long an interval to recall in a moment the particularcondition of the case. He concurred in the remark thattrephining should not be used indiscriminately for the cureof otorrhoea. There were cases which could be satisfactorilytreated by other means. But, in cases of prolonged dischargepressing through an opening in the membrane, the operationwas indicated ; as also in cases associated with bone disease,and where cerebral symptoms supervene from continued orsuppressed discharge.-Mr. FRANKS said the impression leftby Mr. Henry Fitzgibbon’s paper was, that Mr. Mayne’s casewas probably a pyæmic one, and there was no reason whythe patient should be trephined on the left any more thanon the right. He entered a protest against wholesaletrephining of the mastoid process. Dr. Myles had calledattention to a skull upon which he showed that Mr.Wheeler’s method would open the lateral sinus. He, too,had another skull himself, which would show that operatingin the same place the trephine would go into the middle ofthe lateral sinus.-Mr. PRATT, in reply, said he would under-take to trephine by Mr. Wheeler’s method the skulls referredto by Dr. Myles and Dr. Franks, without going into thelateral sinus at all. It should be remembered that the lateralsinus was not opened in any of the cases in which thatmethod was adopted. The treatment was iodoform andboracic acid; injections of perchloride of mercury andboracic acid. He disagreed as to the desirability of waitingfor intracranial symptoms, believing that by so waiting nine-tenths of the cases would die. No insurance company wouldgrant a policy where there was otorrhoea, and hence thedisease was looked upon as more serious than Dr. Franksthoughr. He did not regard abscess of the ear as a rarecomplication.-Mr. MAYNE also replied.

MIDLAND MEDICAL SOCIETY.

A MEETING of the above Society was held on Dec. 7th,Mr. Ross Jordan, President, in the chair.Compound Fracture of the Femur.-Mr. A. F. MESSITER

showed a boy aged fifteen, who was admitted to the Queen’sHospital on March 31st, under the care of Mr. Bennett May,with a bad compound fracture of the femur. The lower endof the upper fragment was protruding through a largewound on the outer side of the limb; the ends of both frag-ments were stripped of periosteum for about two inches.Under an anaesthetic the fracture was reduced, an extensionapparatus applied, the trunk and limb firmly fixed on aThomas’s hip splint, and a free incision made through themuscles and skin at the back of the thigh to provide fordrainage. At the end of fourteen weeks union was firm.Two sinuses led down to the necrosed bone, of which fourfragments were removed at the end of five months fromdate of accident. After another two months all woundshad healed, and the patient was getting about with one inchof shortening.

Unilateral Facial Atrophy follozving Puerperal Eclampsia.Dr. BARWISE showed a woman, aged forty-three, whohad been perfectly healthy until confined of her fourthchild eighteen years ago. After the confinement she hadconvulsions, and her husband noticed that she was lookingold; the hair on the right side came off in considerablequantity. She became subject to fits, which she continuedto have for two years and eight months, when she wasdelivered of a son. This boy was an epileptic imbecile; nofits have occurred since his birth, but her face has continuedto atrophy on the right side. Dr. Barwise considered thatthe cause of the lesion is probably pressure upon anddestruction of part of the fifth nerve (as it passes from thepons along the base of the skull) by an effusion which tookplace during the puerperal convulsions.

Dr. SAUNDBY read a paper on Hoematuria.

Epiphysitis of Femur.--Air. BARLING showed a boy, agedsix year, who had suffered from epiphysitis with acuteinflammation of the knee joint. When admitted to hospitalthe knee was hot, swollen, and very painful, but there wasonly a small amount of fluid in the joint; the evening tem-perature was 102°. The limb was fixed on a McIntyresplint and the joint was kept cool, but the constitutionaldisturbance was severe, the temperature reaching as high as104°. Ten days after admission some thickening wasdetected on the outer side of the femur immediately abovethe joint; two days later, the skin over this being red andcedematous, an incision was made. No pus was found, only