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after securing the pedicle by an old pile clamp, withscrews at either end. When the cyst was emptied of its,contents (clear limpid serum) the growth was removed bythe knife. The edges gaped too much for a continuoussuture to be used, and three harelip pins with twistedsutures were passed through, with the double object ofapproximating the edges and preventing the clamp slippingoff. In the centre of the cut surface a small channel wasfound, which admitted the end of a fine probe down to thepoint of compression by the clamp. The middle harelip pinwas made to transfix the walls of this channel before passingout again on to the skin surface. The total quantity offluid withdrawn was six ounces. On examination thetumour was found to be a meningocele, the membranesbeing collected into a rope-like body at the pedicle, with thesmall channel above referred to in the middle. There wasno oozing of fluid or bleeding after the operation. Thestump was washed over with boroglyceride.

Feb. 1st.—Clamp removed twenty-two hours and a halfafter operation.3rd.--Two lateral pins removed, but the central one left

in. The child was sleeping well and taking the breast. Inthe afternoon the anterior fontanelle was noticed to beraised, and the child was more restless. Some puffiness,too, was observed at the back of the neck.4th.-Child more lively. Swelling in neck less, and

fontanelle less tense. Ordered bromide and iodide of potas-sium, one grain of the former to an eighth of the latter, threetimes daily. 9 P.M. : Eyes staring ; vacant expression.5th.-Some cerebro-spinal fluid oozed away. The orifice

of the channel was painted over with collodion. The woundsurface, which was grey and sloughing, was dressed withoil of turpentine (1 in 6).6th.-Slight oozing of fluid.7th.—Last pin cut out.8th.—Medicine omitted; child brighter and better in

every way; anterior fontanelle flat.14th.-Left the hospital. The mother lived in the country,

and unfortunately missed her omnibus, and the child wastherefore exposed much longer than was necessary on acold day.18th.-The child was brought into hospital, the mother

having noticed twitchings of the face and limbs the nightbefore, and the breast was refused. 5 p M.: Had a convulsion;medicine returned to, every three hours. The child wasplaced in a dark room and fed with mother’s milk by aepoon.

19th.—Occasional twitchings of the face and limbs, andthe head drawn backwards; bowels relieved by enema.20th.-Mother’s milk disappeared; cow’s milk and water

’used as food. Child much better; slept well all night;medicine given less often.21st.-Jerking of trunk backwards; eyes open. 3 P.M.:

Vomited milk in curds.24th.—Vomiting ceased. 6 P.M.: Shrill scream; return of

twitchings; swallowed with difficulty; face and neckflushed; eyes fixed ; anterior fontanelle very tense; headnoticed to be larger. Medicine as before.27th.-Died to-day, having slowly and steadily become

worse.

Necrops ’y.--The wound nearly healed. On removing thescalp an opening, half an inch in length by a quarter of aninch at its broadest point, was found three-quarters of aninch behind the posterior fontanelle, communicating withthe interior of the skull, but closed by membranes whichwere welded together into a rope and attached to the cere-bellum, a portion of which was torn away on removal of thebrain. On cutting through the parietal bones the left late-ral ventricle of the brain was opened, and a large quantityof fluid escaped. The surface of the brain was coated withlymph, and showed everywhere evidences of recent inflam-mation. Both lateral ventricles were very much distended,the left markedly so. The fluid in the left ventricle wasclear, that on the right side was opaque and milky. Thethird and fourth ventricles were distended with flui,-4, andtheir boundaries softened and disorganised.

Remarks.—In this case there appeared to be legitimategrounds for adopting, with a fair prospect of success, themeasures suggested by Mr. Holmes in his Surgical Diseasesof Children, although these means had not, at the time hiswork was written, been put to the test by him. From thesymptoms there was no evidence of existing internal hydro-cephalus; but this condition is stated to be usually presentto a greater or less degree in all cases. There was clear evi-

dence of the absence of brain matter, and that the channelof communication with the inside of the skull, if one existed,was small. The child’s general health was also exceptionallygood. A tubercular history was made out on the father’sside, yet not pronounced. In any future case with thesame favourable prospect, the operation as done here mightagain be attempted with a different result.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

Excision of Cerebral Tumour.AN ordinary meeting of this Society was held on Tuesday

last, Dr. George Johnson, F.R.S., President in the chair.Great interest was manifested in the proceedings, thoughthere were but few who joined in the discussion.

Dr. HUGHES BENNETT read a paper on a case of CerebralTumour, the surgical treatment of which was managed byMr. Rickman J. Godlee. The chief features of interest in thiscase were, that during life the existence of a tumour in thebrain was diagnosed, its situation localised, and its size andshape approximated entirely by the signs and symptomsexhibited, without any manifestations of the growth on theexternal surface. This growth was removed by a surgicaloperation without any immediate injurious results on theintelligence or general condition of the patient, who livedrelieved of his former symptoms for four weeks, and who atthe expiration of that time died, not from any specialfailure of the nervous centres, but from the effects of asecondary surgical complication. The case, however, taughtimportant physiological and clinical lessons, and suggestedpractical reflections which might prove useful to futuremedicine and surgery. In the communication the historyand condition of the patient on examination were detailed.The diagnosis arrived at was stated with the reasons for thesame. The surgical operation and subsequent treatmentwere described with comments thereon. The progress of thecase, its termination, and the post-mortem reports wererecorded. Finally a commentary was added in which allthe important clinical, physiological, and pathologicalpoints of interest were discussed. (For further particularsof this case, vide THE LANCET, 1884, vol. ii., p. 1090, and.p. 23 of the current volume.

Dr. HuGHLINGS JACKSON congratulated Dr. HughesBennett on the accuracy of his diagnosis. The operationMr. Godlee performed showed that Dr. Bennett was right insaying that a cerebral tumour might, so far as the operationitself goes, be safely removed. The patient, most unfortu-nately, died, but he died of a secondary surgical complica-tion. Dr. Hughlings Jackson also warmly congratulatedDr. Ferrier from whose valuable researches the tumour waslocalised. Speaking more generally of localisation of cerebraltumours with regard to trephining, Dr. Hughlings Jacksonsaid that there was a kind of monoplegia, often passing intohemiplegia, which was almost certain evidence of cerebraltumour; a paralysis beginning very locally, for example, in thethumb and finger and spreading very slowly week by week. Insuch a case he should not advise trephining, since there wouldbe great probability of a large tumour in the centrum ovale,not certainly, for he had seen such hemiplegia in a case oftumour of the dura mater pressing down on the cortex. Theconvulsive seizures of localising value were not cases ofepilepsy proper, but epileptiform seizures, convulsionsbeginning one-sidedly and only locally in the hand, cheek,or foot. Whilst these seizures pointed with certainty todisease of the opposite cerebral hemisphere, they did notalways occur from such gross disease as tumour. In somethere was local softening. When, however, there was alsodouble optic neuritis, such gross disease as tumour might beconfidently predicted. Even yet there is not evidence ofexact position. Dr. Hughlings Jackson had not yet seen acase of epileptiform seizure caused by disease outside Ferrier’smotor region. But such cases were recorded by great autho-rities, so that, repeating in effect what Charcot and Pitreshad urged, we required also some local persisting paralysisof the part convulsed-persisting, since temporary paralysisafter a seizure was no further help towards localisation. Sofar, then, three things were required: local persisting para-lysis, epileptiform convulsion, and double optic neuritis.

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Dr. Hughlings Jackson mentioned the case of a man whohad had convulsion and paralysis of one arm; a tumour,a cubic inch in bulk, was found involving the hindermostpart of the uppermost frontal convolution. This was beforeHitzig and Ferrier’s researches; the exact position was notdiagnosed. That tumour might probably have been got outwith safety, yet there was considerable softening; more-over, there was a tumour in each lateral lobe of the cere-bellum, although there had been no cerebellar symptoms.Another case in which a woman had very many convulsiveattacks of one arm (later wider seizure was mentioned). Inthis case Dr. Hughlings Jackson correctly predicted tumourof the hindermost part of the uppermost frontal convolutionand adjacent ascending frontal convolutions, but not withthe confidence he should have done had Ferrier’s researchesthen been made. The tumour was about an inch in diameter,and, had it been removed, very likely the woman’s life wouldhave been saved. She had not double optic neuritis, but,making an exception to a former statement, were he toobserve a case of repeated convulsions nearly always limitedto one arm, exactly alike at each recurrence, he should, evenwithout double optic neuritis, consider them to be due in allprobability to a tumour in the region mentioned. In anothercase he had diagnosed correctly tumour of the same region,but there were also other tumours in that half of the brain.Admitting difficulties-that the tumour might be very large;that there might be softening about it; that, besides thetumour localised, there might be others,-yet in a case wherethe tumour was evidently going to kill the patient, whenthere was intense pain, and when, as sometimes happened,the patient had twenty or thirty fits daily, the patient wouldconsent to risk something, and a surgeon might justifiablyoperate. Dr. Hughlings Jackson remarked that, after opera-tion in such cases as he had mentioned, there would, hethought, be the serious drawback of some permanentparalysis ; but this was little in comparison with themisery of pain, torment, repeated fits, and great dangerof death. In conclusion, he said that in a case of con-vulsion limited to one arm, or beginning in one leg, withsome persisting local paralysis and double optic neuritis, heshould diagnose tumour or other such gross disease of theupper part of the Rolandic region, and should seek surgicaladvice as to the propriety of trephining, not forgetting tostate prominently the three difficulties mentioned.

Dr. FERRIER congratulated the authors on their success,which was gratifying both to Dr. H. Jackson and to himself.He had watched the case with the greatest interest, andwas present at the operation, which was entirely successful;although the patient had been under the influence of theanæsthetic for two hours, yet at the end of that time hebecame conscious and was able to answer by gesture simplequestions put to him by Dr. Ferrier. So that the patientbore the operation without any great shock to the nervoussystem, and he might say without danger to life, forthere could be no doubt that death was due to an inflamma-tory complication, such as could only come under the chapterof accidents. The operation, if performed strictly anti-septically, need not be attended with any risk of encepha-litis. Some authors had said that operations on the brainof monkeys were free from risk of encephalitis, but this wasnot the case. Monkeys were quite as difficult of surgicalmanagement as human beings. If antiseptics be employedinflammation need not result. In his earlier series ofexperiments on monkeys antiseptics had not been used, andthen every animal suffered from encephalitis. During theexperiments made with Professor Gerald Yeo, in which bothfrontal lobes or both occipital lobes, or other parts ofthe brain, were removed, this was done without anyinflammation resulting because antiseptics were employed.He made reference to a case which had been under his careat King’s College Hospital, because it illustrated importantprinciples. The patient was a man who for two years hadsuffered from cerebral symptoms. He was admitted withcoma and left-sided paralysis, and suffered from pain in theright frontal region when the coma lessened, as it did attimes. The right eyeball was feebler than the left, and hehad all the symptoms of cerebral tumour. At his instiga-tion an exploratory operation was carried out by Sir JosephLister. The skull was trephined at the right frontaleminence. The frontal lobe of the brain was found to bedistended by what at first was thought to be a cyst, butturned out to be the distended lateral ventricle. Theknife, passed downwards, led to the escape of a gush offluid ; nothing further was done. The paralysis was relieved

and the coma diminished by this procedure, but the patientdied eight days later. At the autopsy a new growth wasfound to spring from the sphenoidal fissure, and had pressedupon the corpus striatum, and so caused the paralysis; the.bulging of the eyeball was due to this new growth. This.tumour would have been doubtfully removable, even,

supposing that it had been detected by the exploratoryoperation ; but in order to verify a diagnosis exploratorymeasures should be adopted, for the disease if left alone-would prove fatal. He felt confident that the future wouldyield more favourable results.

Dr. MACEWEN contributed an account of some cases whichhad been under his care, and which are being publishedseparately in our columns.

Dr. H. BENNETT referred to the important cases of Dr..Macewen, which had been attended with such brilliantsuccess; yet he considered that his cases were scarcelyanalogous with the one brought forward; for a limited’.lesion of the brain had been diagnosed entirely by sym-ptoms, whereas in Dr. Macewen’s first case there were otherindications to guide the surgeon. Then there was paralysisof a more extensive character than obtained in his (Dr.Bennett’s) case. He then exhibited to the Society a braintaken from a patient who had been under the care of Mr..Davy. This patient had been trephined, and from the sub-stance of the cortex as many as eight pieces of bone wereremoved; the bone had been forced there by an accident.The operation left behind it a large hole in the brain, whichwould take a pigeon’s egg. There were no antiseptics usedin this case, and yet the boy made an uninterruptedrecovery. Death ensued some time later from acute double,pleuro-pneumonia. The autopsy showed no trace of injuryto the brain, except a hard dense cicatrix, the site of theformer operation.

Mr. V. HORSLEY said that in this last case, which hadbeen done without antiseptics, the conditions were hardlyparallel with those which obtained in cases in which thebrain had sustained no previous injury. In this case ofdepressed fracture, no doubt adhesions would be producedall round the injury, and effectually shut off the wound fromthe rest of the cavity of the arachnoid. Some practicalsurgical points in experiments and operations on the brainwere alluded to. There was no doubt that morphiadiminished the tendency to haemorrhage, and the vigorouswelling up of blood from numerous arterioles was seen toa less extent in his and Schafer’s experiments. The morphiawas hypodermically injected, about two-thirds of a grainbeing the dose employed. As to the kind of dressing, hepreferred the dry permanent dressing, for he had beenastonished to see how rapidly the effused serum was ab-sorbed. In only five out of forty experiments had he-aspirated with a view to diminish the tension of the effusedserum.

Mr. GODLEE congratulated Dr. Macewen on his successfuland brilliant results. He ventured to think that there wasnot so much haemorrhage in opening into an abscess cavityas in cutting the unaltered brain. Moreover, he had employedthe actual cautery partly no doubt to arrest haemorrhage, butalso with a view of destroying the deeper parts of thetumour, the boundaries of which were indefinite in the-downward direction. In his opinion the inflammatoryaction was the cause of the hernia cerebri; inflammationwould probably not occur without some putrefaction havingbeen set up. In removing the deep part of the growth, whichappeared to extend downwards in a conical fashion, he hadused a Volkmann’s sharp spoon, but some instrument ratherlarger and blunter like a salt spoon would probably haveanswered the purpose better. Large wounds in manhad not in his experience been well treated when the’wound was completely closed, and he considered thatwounds in lower animals were not perfectly analogous towounds in man. So that he agreed with Dr. Macewen thata drainage-tube should be used; otherwise there would beno opportunity for an extensive effusion of serum and bloodto make its way out. As to the cause of the disaster in his.case, he had no doubt that it was due to putrefaction, whichwas probably the result of imperfect purification of thescalp. He remembered that blisters had been employed inthe occipital region, and had not healed; the serum fromthese sores might have contaminated the wound. Atanother time he should have the head shaved all over andthoroughly washed first with soap, and then with corrosivesublimate, and finally soaked in a strong solution of carbolic-acid.