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of the operation. I consider that such a case is of great im-portance, as showing how false hernia cerebri may form afteroperations on the brain. False hernia cerebri is supposed bymost surgeons to form from a septic condition of the wound,and I quite agree that a septic condition is probably the mostfrequent cause of false hernia cerebri, but it must berecognised as only one of the causes of irritation whichset up this condition. We have round most tumoursand cerebral lesions a limited area of softening or ence-

phalitis. If such an area exists, it requires to be con-sidered as one of the elements likely to give rise to herniacerebri, and therefore as one of the risks of the opera-tion. If those observers who have done so much in theway of diagnosing cerebral affections could give preciseindications which would enable us not only to say that atumour or other lesion existed at a certain part of thebrain, but also how much and to what degree the braintissue in the vicinity of this lesion was affected by inflam-mation, it would enable us to prognosticate whether herniacerebri would be likely to result from the operation, to antici-pate its formation, and to prepare the way for its treatment.It is clear, then, that we have two points to consider: notonly the lesion (tumour or syphilitic gumma, &c.), but alsothe amount of localised encephalitis existing at the time. Itis further clear that we ought to try to allay this secondaryirritation round the tumour or other lesions prior to perform-ing the operation. It may, therefore, be summed up thus :-In certain cases of acute encephalitis involving the surfaceof the brain, where the inflammatory action is sufficientlyfar advanced, false hernia cerebri will form, provided anaperture be made through the skull and the membranes topermit of this extrusion. Unless the inflammatory action inthe brain substance has taken place to a sufficient extent,false hernia cerebri will not form, even supposing oppor-tunity for extrusion be afforded by an aperture in the externalparts. Healthy brain tissue will not be extruded through anaperture in the skull except as the result of violence orpressure exercised from within. Operations on brain tissue,which is not in this state of acute and advanced inflamma-tory action with blood extravasation, will not produce herniacerebri, provided that after the operation the brain tissue is notirritated to a sufficient extent to induce this amount of inflam-matory action. The chief cause of false hernia cerebri, afterintra-cranial operations, is decomposition; and this cause canbe prevented by the use of antiseptics. If inflammation inthe brain exists at the time of the operation, hernia cerebrimay form, notwithstanding the use of antiseptics.

CASE OF FRACTURE OF LARYNX.

BY JOHN B. BERRY, M.D., C.M. EDIN.

DURING the afternoon of February 6th I was called tosee G. L--, aged twenty-one. He was reclining on a sofa,looking very pale. Extending from the tip of the chin tojust above the hyoid bone was a superficial wound. Thevoice was like that of laryngitis. The prominence of thethyroid cartilage was gone. Placing my hand over thethroat and requesting the patient to swallow, I detected un-mistakable crepitus of the moving larynx. A more carefulexamination revealed what felt like a separation of thewings of the thyroid cartilage. The history of the accidentwas briefly this. About twenty minutes before I saw himhe was working a circular saw, and was suddenly struck inthe throat with great force by a large piece of wood comingfrom below upwards. For a few moments he had a hardstruggle for breath, but managed to keep from falling byleaning against a bench. Water was brought to him, buthe declined it as he feared it would choke him. With thehelp of two men he walked home, a distance of about 500yards from his work. Having applied a warm-water dressingto the throat, the patient was put to bed, his head andshoulders being raised. An hour later I saw the patientagain in conjunction with Mr. Chaffers, whose help I

sought when 1 saw the case was of such gravity. Mydiagnosis was confirmed, and seeing the patient was

free from urgent symptoms, the breathing being quiet andfull and the condition of shock gradually passing off, weconsidered it best to continue the warm-water dressings andforbid anything being taken by the mouth except ice, leavingword that any change in the breathing should be imme-

diately reported to us. About 1.30 next morning I wascalled up, as the patient was reported to be choking. Aftersleeping for about an hour and a half, during which time hebreathed rather noisily, he woke up somewhat suddenly andat once began to struggle for breath. When I arrived hewas unconscious, the eyes were open and fixed, the pupilsdilated, the face pale, and the deep spasmodic efforts tobreathe were failing. Having sent for Mr. Chaffers, I atonce performed laryngotomy. Still no air seemed to enter,and’no mucus escaped from the tube. Having satisfiedmyself the tube was clear and that no blood was obstructingthe air-passages near the wound, I enlarged the opening andreplaced the tube, with no better result, death taking placeafter a few more respiratory efforts had been made. Half anhour after death Mr. Chaffers and myself examined the larynxand trachea as well as we could through the operationwound. Besides the separation of the wings of the thyroidoblique lines of fracture were made out on each side,through the wings themselves. Within easy reach of thefinger, hanging down the trachea by a mere shred of fibroustissue was a part of the left wing of the thyroid cartilageitself, the size of a finger-nail, apparently the lower frontangle; this was easily removed. I regret no post-mortemwas allowed, as I am still in doubt whether to attribute theasphyxia entirely to the one piece of cartilage found, whichwas not wedged in the trachea, but simply lying flat againstthe anterior surface, but it may have acted like a valveduring inspirar,ory efforts. During life, I may add, therewas no spitting of blood, and after death perfectly whitefrothy mucus welled up from the throat.Keighley.

______ ____

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. THOMAS’S HOSPITAL.SARCOMA OF THE KIDNEY; NEPHRECTOMY; CURE.

(Under the care of Mr. CROFT.)

Nulla autem est alia pro certo noseendi via, nisi quamplurimas at mor-borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se comparare.-MORGAGNI De Sed. et Caus. Morb.,lib. iv. Proœmium.

THIS case is a very interesting one, few cases for removalof the kidney for sarcoma being on record. In the Trans-actions of the Medical and Chirurgical Society, vols. 63 and 64, alist of cases in which the operation had been performed isgiven by Mr. Barker. Two of these were nearly the sameage as the patient who was under the care of Mr. Croft, butin one the disease had existed for two years and a half, andin the other for one year. In each the operation was success-ful, but in the latter recurrence had taken place in theneighbouring glands eight months after the operation. The

prognosis is more favourable in the following case, wherethe disease had produced symptoms for seventeen days onlybefore operation.For the following notes we are indebted to Mr. W. J.

Staddon, dresser.T. II——, a boy aged three, was admitted under the care

of Mr. Croft on Feb. 3rd, and left cured on March 17th, 1885.The family history was good. The patient had alwaysenjoyed good health, and was apparently quite well untilhe was noticed to have passed blood with his urine onJan. 21st of this year. He passed blood again on the 27thand on the 29th. On the 31st the medical attendant noticedswelling in the abdomen.On admission, the boy was looking very healthy and well

nourished. Examination of the abdomen showed a distinctprojection on the right side, which on palpation was foundto be due to a hard, somewhat elastic, movable tumour, notmoving with respiration, which extended into the rightloin, the surface of which was marked by large irregularbosses. Above, the free edge of the liver could be felt over-lapping it. Dulness extended from the liver to the crest ofthe ilium, backwards to the spine, and forwards to themiddle line, excepting in the position of the ascending colon,where there was resonance. The remainder of the abdomen

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appeared healthy; there was nothing abnormal in the chest.Urine: sp. gr. 1022, clear, of a light-straw colour, acid, noalbumen, no cells, no casts.Feb. 5th.-The patient was placed under chloroform and

examined by Mr. Croft. No stone was detected. There

appeared to be a rounded body of small size to the innerside of the growth, possibly an enlarged gland. Urine:

sp. gr. 1035; very acid; excess of urea ; no sugar.7th.-The patient having been placed under chloroform,

Mr. Croft removed the right kidney. A slightly oblique in-cision was made between the crest of the ilium and the lastrib, about four inches and a half in length, ending anteriorlyin the linea semilunaris; this incision was carried down tothe peritoneum, when all bleeding points were ligatured.This incision not being large enough to admit of the tumourbeing extracted, a vertical one was made along the lineasemilunaris about four inches in length, opening the peri-toneum to the extent of two inches and a half; the tumourwas then brought out of the wound as far as the pedicle,which was rather short, would allow. The pedicle was thenligatured in two sections: the first ligature (of silk) includedthe vessels, and the second ligature (of catgut) was placed onthe ureter. After removal of the tumour, the peritonealcavity, so far as it had been exposed, was sponged out, andthe edges of the peritoneum brought together with con-tinuous catgut sutures, after which the skin flaps werebrought together with silk, a drainage-tube being placed inthe most dependent part. The wound was dressed withoiled-silk protective, iodoform, iodoform gauze, and salicylic wool, gauze bandages being used, and over all a flannelbandage. The carbolic spray was used from the time thatthe peritoneum was exposed. The patient was very sicktowards the end of the operation. The parts removed formeda mass as large as an adult fist. Examination showed thegreater part to have been replaced by a large sarcomatousgrowth, there being only normal renal structure on the cir-cumference of the growth, above and below. The growthwas soft, elastic, bulging on section, presenting in parts analmost gelatinous appearance; in others there were smallhaemorrhages. The growth projected into the pelvis of thekidney to some extent at one or two points, and also intothe renal vein. Later microscopical examination proved thegrowth of round-celled character.9th.-Has been going on very well since the operation,

having had neither pain nor sickness. Pulse 144; tonguerather dry, slightly furred. Taking milk, tea, and toast.Wound dressed yesterday and looking well.10th.-Pulse 114; bowels acted after an enema. Wound

dressed.12th.--Pulse 116. He had retention of urine for several

hours during the night, and this morning there is someepididymitis on the right side.15th.-Wound redressed, two stitches removed and the

drainage-tube shortened ; very little discharge.23rd.-Pulse 127. Fluctuation having been felt in the

right side of the scrotum an incision was made, giving exitto a small quantity of laudable pus. The operation woundwas dressed; the granulations were found to be on a levelwith the skin, excepting where the drainage-tube had been.March 11th.-Nitrate of silver applied to granulations on

the right side. Most of the wounds have healed, as also thewound in the scrotum.14th.-Got up.16th.-Wound in right side almost perfectly healed, there

being only a few small granulations not quite skinned over;is dressed with zinc ointment. The patient left on thefollowing day, being very lively and looking remarkably well.The highest temperature after the operation was 1020 at

3 A.M. of the morning after the operation. For eight daysthere was an evening rise, varying from 996° to 101’4°;after that it became lower, rising, however, on more than oneoccasion to over 100° ; this was in all probability connectedwith the epididymitis. The average daily quantity of urinewas about 17 oz. after the operation. The patient continuesin good health.in good mcamu.

Remarks by Mr. CROFT.-The rapid recovery in this casewas partly due to the fact that the operation was performedbefore the growth had infiltrated or attached itself to

neighbouring structures. Its enucleation did not neces-sitate dissection or the use of any force. Authors onnephrectomy have not laid down any rule for the closing ofthe peritoneal wound when this membrane has been disturbed in the course of the operation. It is worthy of observationin this case that the peritoneal wound was sutured inde-

pendently of the rest of the wound ; thus the cavity wasclosed against any exudations from the section of theabdominal wall. It would have been impracticable to havetreated this according to the rules laid down for closingwounds in the median line. The occurrence of epididymitiswas not easy of explanation, as the structural connexionbetween the parts disturbed or ligatured in the loin is notdirect or obvious. Retention of urine came on with theepididymitis, and had not existed before it. It would be

interesting to know if other surgeons have met with thiscomplication.

NEWCASTLE-ON-TYNE INFIRMARY.PRIMARY SARCOMA OF THE RETRO-PERITONEAL GLANDS;

DEATH; NECROPSY; REMARKS.

(Under the care of Dr. PHILIPSON.)J. H-, aged fifty-six, an auctioneer’s clerk, was

admitted on Nov. 22nd, 1884, complaining of pain in theepigastric region of about six months’ duration. His fatherand a brother died of consumption, and another brother ofspinal disease. The patient has had to lift very heavyweights; he has had good food and lodging, and has beenfairly temperate; has had three attacks of rheumatic fever.About six months ago he first experienced a dull uneasysensation in his right side and passing across the lumbar

portion of his back. Pain became more decided and wasgenerally worse at night; it came on in paroxysms withintervals of several hours. Gradually the pain becameworse and the intervals shorter, till now he has seldom tenminutes’ freedom from it. He did his work up to the timeof his admission.When admitted the patient was found to be a man of

5ft. 7 in. in height, and weighing 9 st. 2 lib. (he used toweigh 10st. 71b.). He is slightly cachectic, and has theappearance of suffering acute pain. The tongue is foul,appetite good, but accompanied by great thirst; the painrarely crosses the back now, but starts on the right side,crosses the abdomen at the level of the umbilicus, and endsin the left side. The pain is intensified by lying down, butis relieved by sitting up; the greatest relief, however, is gotby kneeling before the fire with his elbows resting on a lowchair; deep inspiration brings on or aggravates the pain.There is visible pulsation in the epigastric and upper part ofthe umbilical region ; in the right hypochondrium andepigastrium a hard resistant body is felt, reaching in themiddle line nearly to the umbilicus, and in the nipple-lineabout three fingers’ breadth past the free edge of the ribs.This body moves with respiration. As far as can be madeout, its surface is smooth and its edge regular, and it is nottender, though there is pain on deep pressure. There is nopulsation on the right side of the mass, but on the left themass rises and falls with the aorta; there is no expansilepulsation. There is continuous dulness from the seventhrib downwards to the edge of the mass. At the apex ofthe left lung there are distinct signs of consolidation andsoftening.December 5th :-Has lost 1 Ib. since admission. The pain

has become so bad as to necessitate injections of morphia.Temperature varies between 99° and 102° F.31st.-Is still emaciating. Does not complain so much

of pain, but shows decided dementia.January 24th.-Death.Post-mortem examination.-The liver extends down-

wards as felt during life. Its surface is smooth, except onthe under side, where there are two nodules about the sizeof peas. The anterior margin is unusually thin and coversa tumour about the size of the foetal head lying on thespine. This tumour is evidently glandular, and has thepancreas attached to its left side, in front of it the pylorusand four or five inches of the duodenum, and behind it theaorta. The outline of the tumour is fairly regular, but witlaglobular projections at parts. On section it is pretty firm,but with soft portions here and there. On microscopicexamination it proved to be a spindle-celled sarcoma.Lungs: The left apex contained some tubercular depositsand small cavities, while the right had a slight tuberculardeposit. Heart: Mitral orifice narrowed and curtainsthickened. Brain: Considerable amount of subarachnoidfluid. Kidneys : Normal. No other deposits besides thetwo on the under surface of the liver.Remarks by Dr. PHILIPSON.-The chief interest of this

case was in the differential diagnosis of a tumour situated