198 ROYAL ACADEMY OF MEDICINE IN IRELAND.

best means of controlling the protrusion was by applying amoist (antiseptic) flat sponge folded in an envelope of gutta-percha tissue (over the protective) upon the hernia and fixingit in position by broad strips of adhesive plaster passinground the head. In this way a considerable amount of

support was afforded and the further increase of the herniawas effectually checked. In the early part of April thewound assumed a healthy aspect and cicatrisation fairly setin at the circumference, the protrusion gradually diminishingand receding till it had entirely healed over. This was com-

pleted in the second week in May. The patient was dis-charged on June 3rd. There was at that time a distinct

pulsation, but no bulging of the cicatrix ; it was quite on alevel with the scalp.Remarks by Mr. RAWDON.-There are three points pre-

sented by this case worthy of consideration : firstly, thelaceration of the superior longitudinal sinus, attended withcopious hæmorrhage at the time of the accident, and withan alarming recurrence on removing the depressed fragmentsof bone ; secondly, the supervention of the hernia cerebriand the vexed question of its appropriate treatment; and,thirdly, the defective eyesight, which was evidently due toinjury of the right posterior lobe of the brain. There can beno doubt that it was fortunate for the patient that the over-lapping bone had been sufficiently removed, as it permittedthe lacerated wound of the sinus being seen and dealt with ;for the rent was a large one and its propinquity to thetorcular Herophili added to the danger of the hæmorrhageending fatally. With regard to the treatment I believethat the prompt raising of the patient to a nearly sitting posi-tion was an expedient of great value, for by minimising theout-pour of blood it afforded the opportunity of closingthe rent with sutures. I find that Professor Nancrede, thewriter of the article on "Injuries to the Head" in "Ashhurst’sInternational Encyclopaedia of Surgery," in referring towounds of the sinuses says : "Warner, Pott and Lister

report cases where wound of this sinus (longitudinal) wasreadily recovered from " ; but he goes on to say : "In all suchcases either the application of the trephine or the elevation offragments has given free access to the wounded vessel-i. e.,sinus ; where the opposite conditions obtain a fatal hæmor-rhage does at times occur." In a footnote at p. 162 ofJacobson’s Surgical Operations " it is stated that Dr. Parkes3 3successfully "arrested a terrific haemorrhage from a rent inthe superior longitudinal sinus by introducing three fine

catgut sutures." My attention has been drawn to a shortpaper in the Medical Week of Jan. 13th, 1893, wherein it isstated (page 23) that Dr. Schede (a German surgeon) hadsuccessfully stitched wounds of large veins on several occa-sions, making mention of the successful adoption of this pro-cedure in the case of an accidental wound of the internaljugular vein during an operation and also in the case of awound of the inferior vena cava inadvertently caused duringthe extirpation of a kidney. He used the continuous suture ofthe finest catgut, employing very fine Hagedorn’s needles-sofine as to leave no holes through which the blood couldescape. He says that the needles may traverse the coats ofthe vein, but it is important that the two sides of the woundshould be accurately brought into contact. Dr. Schede hasmet with invariable success in all cases in which he hasadopted this course. With respect to the second point-namely, the hernia cerebri-I would remark that this com-plication is probably of less frequent occurrence since theadvantages of asepsis have become so generally recognised.When it does occur the best authorities, I observe, va.ryconsiderably in the directions and advice they give as toits repression and treatment. I am, however, satisfied thatin my patient’s case the support afforded by the spongeand plaster4 was of the greatest use. Had the fungus beensliced off or removed, as some suggest, in all probabilitythe lateral ventricle of the brain would have been opened.The third and last point I desire to remark upon is one ofspecial interest, as it affords evidence of the localisation ofthe cortical centre for vision. The defective eyesight ofwhich the patient complained continuing a month after shehad left the hospital, at my suggestion Mr. Charles C. Lee,surgeon to the Liverpool Eye and Ear Infirmary, under-took to examine her eyes. He reports that the patientis practically blind on her left side, the blindness beingcommon to both eyes. The ophthalmoscope revealed no intra-

3 Annual of Anatomy and Surgery, vol. viii., p. 118.4 The "Heftband," which only adheres to itself, proved the best, as

the plaster substance did not come off or stick to the patient’s hair.

ocular mischief in either eye, but on using the penmetehe found well-defined left hemiopia of both eyes, though notequally, the left being much the more seriously and extensiveaffected ; the area of blindness occupied the complete halffield and even passed considerably over the centre vertical lineto the right upper area of the field. The area devoid of sighin the right eye was less in amount than that which existed inthe left, but here it was continued across the centre to thright side to a small extent. The part of the brain which hadsustained injury was made out in this case by taking exac?measurements of the position of the cicatrix and afterwardson the cadaver by drilling the occiput at the correspondingspot. On the removal of the calvaria it was seen that thefirst annectant gyrus was the part which had been penetratedand to some extent destroyed. Judging from the characterof the blindness it may be inferred that the cuneus was alsoinjured along with the occipital lobe.

Medical Societies.ROYAL ACADEMY OF MEDICINE IN

IRELAND.

SECTION OF MEDICINE.Case of Pharyngeal Spasm.-The Diagnostic Value of the Dia:o

Reaction.A MEETING of this Section was held on May 19th,

Dr. WALTER G. SMITH, President, in the chair.Dr. H. T. BEWLEY related a case of Pharyngeal Spasm in

a man who, having enjoyed good health up to Sept. 27th,1892, woke up the next morning unable to swallow. This statecontinued until he was admitted into Adelaide Hospital onSept. 30th. He was a small-made and pale but not thin man.As he lay in bed he suffered constantly from hiccough. ’Whenhe tried to swallow anything the attempt excited much spasmof the pharynx and larynx. He was able to get food, especiallysolids, into his oesophagus, but he did not seem to be ableto swallow it wholly, and after a prolonged struggle the foodwas generally regurgitated into the mouth and expectorated.The struggle to swallow caused him much distress. Other.wise he was sound in body and in good health. He continuedto be unable to swallow for two days ; then Dr. Bewley passeda stomach-tube and introduced some milk into his stomach;the tube passed readily and caused no distress. About twohours after the patient suddenly died without a struggle. Apost-mortem examination gave negative results. The convolu-tions were slightly atrophic and some nuclei in the medulla hadvery pigmented nerve cells ; but with these exceptions everyorgan in the body was healthy, the pharynx, larynx andoesophagus being perfectly so. Dr. Bewley was inclined to thinkthat the case was one of paralysis of the oesophagus from func.tional causes, the food lying in the passage and excitingspasmsof the surrounding organs ; he was, however, unable to explainthe persistent hiccough and sudden death.-Dr. PURSER said ifthe movements of respiration stopped first it would probablvbe a paralytic lesion, whilst if the heart stopped first it wouldhave been probably an irritative lesion.-The PRESIDENTstated that he had at present under observation a woman inwhom attempts to take solid food caused intense pain aboutthe cricoid cartilage. He passed a bougie down the oesophagiunder the influence of an ansæsthetic, but no stricture couldbe felt.-Dr. BEWLEY, in reply to Dr. Purser, stated that thedysphagia had lasted for about five and a half days.

Dr. W. R. DAWSON said that the first observations on tieDiagnostic Value of the Diazo Reaction as applied to theDiagnosis of Disease were published by Ehrlich in 1882. The

present paper was based on examinations of the urine o[227 cases made in Cork-street Fever Hospital, comprehendforty-seven varieties of disease. Those which gave thereaction were all of a febrile nature, and it was particularlyfrequent in enteric fever (over 70 per cent. of the testsbetween the fifth and twenty-first days showing it), icmeasles and in tuberculous disease, whilst rather less thanhalf the testings in typhus fever yielded the reaction. Ita

presence was not indicated by any gross peculiarity in theurine, and experiment showed that neither free acetone norany direct product of Eberth’s typhoid bacillus was respon-sible. Upon the whole, its value in the diagnosis of enter.cfever seemed to be considerable, but negative rather thanpositive, and it might probably also be used to distinguish

199REVIEWS AND NOTICES OF BOOKS.

measles from rötheln, since the latter disease did not give it.-Dr. PURSER said that the test occupied a curious positionamongst urinary tests, because it was a test for something whichwedidnotknow. The test was empirical and so was the result.He was inclined to think it had some value in typhoid fever.If there was a case in which the diagnosis was very evenlybalanced between typhoid fever and something else and the re-action was absent he would be inclined to regard the case asnot one of typhoid fever. The reaction must show a blood-redcolour and the froth must be red when the liquid was shakenup. He remembered a case which was diagnosed as typhoidiever for a long time, but in which the reaction could not beobtained and the case afterwards proved to be one of acutetuberculosis. The sodium nitrite solution should be freshlyprepared at each time of testing as it was very unstable.-Dr. J. W. MooRE and the PRESIDENT also joined in the dis-cussion and Dr. DAwsoN replied.

SECTION OF OBSTETRICS.

Ovarian Tunioitrs.-Porro’s Optration.A meeting of the above Section was held on May 26th,

31r. A. H. HORNE, President, in the chair.The SECRETARY read for Dr. C. YELVERTON PEARSON

-notes of a case of Ovarian Tumour that had been successfullyoperated upon.

Dr. A. J. SMITH exhibited specimens of Ovarian Tumours.The first was a simple unilocular tumour. The second speci-men was one of great interest. The patient complained of,great pain in the right inguinal region, and Dr. Smithdiagnosed a small tumour in the right broad ligament. He

operated and removed a specimen of hydrops folliculorum.At the same time he examined the left ovary and noticedthat it was small and felt normal. However, the painwhich the patient complained of was never entirely re-

moved, and a month after the operation it became ofa boring character and was referred to the original place.The patient came to him recently and he had the assist-ance of both the President and Mr. M’Ardle in examin-

ing her. The left ovary seemed to be fairly normal, but hadbecome enlarged since the previous examination. They decidedto explore. Having removed the ovary they turned to thepedicle, which was left, and they found that it had becomeadherent to the intestine. They endeavoured to separate’it, but found that the adhesion of the pedicle to the anteriorwall of the intestine was so great that they would have toresect the intestine, so they determined to leave it alone.After the second ovary had been removed the pain dis-

appeared.Dr. MORE MADDEN exhibited: (1) An enormous Uterine

Tumour, together with Gravid Uterus, removed by the Muller-Porro operation; (2) a large Submucous Uterine FibroidTumour recently removed by Cæsarean section in which itwas necessary to deliver with the midwifery forceps, the

patient making a good recovery; (3) the Ovaries and Tubesrecently removed, as a result of hmmorrhage from fibro-

myoma ; and (4) an exceptionally large Multilocular OvarianTumour removed from a patient in the Mater MisericordiaeHospital.

Dr. COLAHAN (Galway) read a paper on a Successful Caseof Porro’s Operation. The case was one of pregnancyoccurring in a rachitic dwarf, in which it became necessaryto perform abdominal section, delivery being impossible pervias naturales. Porro’s Cssarean hysterectomy was the

proceeding adopted to complete delivery and was successfulin saving both the mother and child.-Dr. SMYLY said that itwas a matter of surprise to him that in this country of all thecountries in the world Porro’s operation should be such arare thing. He did not agree with Dr. Colahan that theresults of Porro’s operation were equally good as comparedwith Cæsarean section. However, it was not a question thatthey could dogmatise upon, as the really bad cases fell toPorro. Still, the mortality from Cæsarean section was onlyabout 5 per cent., and he did not think that Porro could showas good a result as that.-Dr. A. J. SMITH said the point towhich he would specially refer was whether a woman shouldbe sterilised or not in doing Cassarean section.-Dr. MOREMADDEN thought that it would add to the advantages of theAcademy if their fellow-members throughout the countrywould give them their experiences oftener. He thought theoperation which Dr. Colahan had done reflected great crediton his surgical skill. In cases of rachitic pelvis the Cmsareansection had been eminently successful in Scotland, and in thehands of Dr. Cameron there had been only about two deaths

in twenty operations, whilst the mortality of Porro’s operationhas, according to Sir Spencer Wells, been about 56 percent. Therefore he thought that the Cæsarean section wassafer for the women, in whose interest it should be performed.-Dr. COLAHAN replied.-In the discussion that followed Dr.COLAHAN, after thanking the President and other membersfor their very flattering remarks, stated that it was the firsttime, as far as he knew, that the operation had been performedin the west of Ireland, and not anticipating such an under-taking he found himself without a serre-nceud at the lastmoment; and although the use of them was quite successful,yet he would not for choice use silver sutures for the abdo-minal incision. In reply to Dr. Smyly, he said he quiteagreed that there were many women who would not wish tobe sterilised, and who would wish to have children in thefuture, but he was quite certain that this particular womandid not want to have future children, nor was it desirablethat she should. In reply to Dr. Smith, he said he hadDr. Macan’s case at the Rotunda Lying-in Hospital in his mindwhen he alluded to these dwarfs becoming pregnant a secondtime. Dr. Colahan was not aware until Dr. Smith mentioned itthat in Dr. Macan’s case the woman died of rupture of theuterus at the site of the former uterine section. In replyto Dr. More Madden, Dr. Colahan said that, with all

respect, he coincided with Mr. Tait’s opinion that Porro’soperation, if properly done and at the proper time, is a mostsuccessful operation and the mortality a mere bagatelle.Dr. Colahan believed that Porro intended that his opera-tion should be for the purpose of saving the mother andchild, and should be done on a sound uterus and a viablefoetus. He further believed that Mr. Godson’s classifi-cation of Porro’s operation should be followed in collect-

ing statistics ; in this way the true Porro’s operation wouldnot be confounded with operations done for a uterine

myoma or for removing a child from a ruptured uterus wherea fatal result was almost certain. If the true Cæsarean sectionwas mixed up in this way it would soon fall into disrepute. Inconclusion, he did not think that it was as yet very intelligiblewhy the tedious processes of suturing the uterus and thensterilising that organ should be preferred to a true Porro’soperation.

Dr. W. J. SMYLY read a portion of the Report of theRotunda Lying-in Hospital for the three years 1889-92. It was

proposed and carried unanimously that the report should beprinted and copies sent to the members (with the permissionof the General Council), and that the discussion should takeplace at an extra meeting of the Section, the date of whichwas to be arranged hereafter.

Reviews and Notices of Books.Diseases of the Skin. By H. RADCLIFFE CROCKER, M.D.

Second Edition. London : H. K. Lewis. 1893.

THE first edition of Dr. Radcliffe Crocker’s work on

Diseases of the Skin, published in 1888, has been out ofprint for a considerable time, and the second edition nowbefore us is certain to be warmly welcomed. The fact thatthe first edition of the work should have been so rapidlyexhausted means, of course, that it has supplied a real wantand that its worth has been duly appreciated. Dr. Crocker is

an acknowledged master of his subject, and those who areacquainted with his painstaking methods and mature ex-perience have not been disappointed in their expectationthat such a work from his pen would be well worthy of Britishdermatology.As a preliminary to the volume and to refresh his memory,

the reader is given a few diagrams and drawings of the minuteanatomy of the skin, mostly after Ranvier, and he is referredto ordinary handbooks on anatomy and to Unna’s article inZiemssen’s Encyclopeadia for a fuller description of the normalhistology of the skin. It is questionable, however, whetherdermatologists would not have appreciated a more completeaccount of this branch of the subject, or at any rate an epitomeof recent advances in dermal anatomy and physiology, many ofwhich are not yet included in the general text-books. In other

respects the new edition is well up to date, and good descrip-