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internal plantar artery is frequently wounded in this littleoperation, but that no harm as a rule follows when firmpressure is applied. The cause of the aneurysm in this case,I believe, was due to the mother allowing the child to walkabout after he left the hospital and before the parts hadbecome consolidated by the pressure. An injury to theartery is best avoided uy using a blunt-pointed tenotomeafter the skin has been punctured, and keeping its point incontact with the fascia whilst passing it beneath the tenseband. The only point calling for remark with regard totreatment is the importance of avoiding too severe directpressure upon the aneurysm, for fear of sloughing of the skin.Mr. Adams mentions a case which occurred in his practiceof injury of the posterior tibial, where a small slough formedin consequence of the pressure not being relieved for fourdays from neglect of the mother to attend at the hospital.A copious arterial haemorrhage took place, the aneurysmbeing ultimately cured by the injection of perchloride of iron.

ROYAL SOUTHERN HOSPITAL LIVERPOOL

CASE OF "BULLOUS DERMATITIS" IN A NEWLY BORN INFANT;EXHAUSTION; DEATH.

FOR the following account we are indebted to Mr. F.H. Wigmore.

Alice C——, an infant ten days old, was brought to thishospital on the evening of Dec. 31st, 1887, suffering from alarge bulla extending under the chin from either angle ofthe jaw. The bleb had already burst, and the red surfaceof the cutis vera was observed beneath the rupturedepithelium. The mother stated she first noticed the " blister"the day previously; that it was situated beneath the chin,was white in colour, and not more than an inch in length.The bulla was dressed with simple boracic ointment, and themother instructed to come again the next morning. Thisshe neglected to do; and it was not until 3.30 P.3f. on

January 2nd that she again brought the child, which thenpresented a great extension of the disease downwardsover the chest, which was raw. The infant was at onceadmitted. The disease rapidly spread—spread, as it were,by a continuous and progressive exudation of the serum,with the formation of one enormous but flattened bulla, theperiphery of which, without any zone of redness, creptinsidiously onwards in all directions, while the centre,broken and torn, disclosed the surface beneath, until themouth, cheeks, abdomen, back, right thigh, half the leftthigh, and the left heel were involved, at which point thechild died of exhaustion. The temperature on admissionwas 99°. It then fell to 93.6°, but rose again on Jan. 3rd to1006°, which altitude was maintained without interruptionuntil 7 P.M. on Jan. 4th, when the thermometer only regis-tered 95°. It was shortly after this that the child died.Necropsy by Mr. DIXON.—The body has the appearance of

having been extensively scalded. In places it is vesicated,and in others the epithelium is peeling cff and a raw red-brown surface exposed. This condition extends over the rightside of the face, chin, and neck, the whole of the front andback of the chest and abdomen, the front of the arms, upperpart of the thighs from the calf of the right leg downwards,and the left foot. On the other parts the epithelium is inplaces loosened and raised, and at the borders of the rawsurfaces is hanging in loose shreds. The stomach is muchdistended, and the mucous membrane is of a purple colour.Intestines rather pale; other appearances normal. Heart,lungs, and spleen normal. The kidneys contain severalsmall hæmorrhages, for the most part in medullary portion ;some at junction of cortex with pyramids.Remarks by Mr. WIGMORE.—I think this case is worthy

of record, because had I not seen the infant when the singlebulla was present, I should have come to the conclusion thatit was suffering from the effects of a severe scald ; indeed, thedevelopment of the disease was of this nature, so that whenlooked at at any period of its course, without reference tothe condition preceding it, the tirst and almost only inferenceto be drawn was that some boiling, or nearly boiling, liquidhad been poured upon it. Pemphigus neonatorum is notuncommon, but I know of no description which tallies withthe condition observed in this case. In pemphigus there issometimes a history of syphilis, but in this the only factelucidated with reference to this point was that before mar-riage the father suffered from some disease which resultedin a bubo, and which, presumably, therefore was not sypbUis.The mother has one child, now two years and seven months

old; and this child, though small for its age, has neithersign nor history of any hereditary disease. The post-mortemappearance, I think, will be important. I have called thecondition observed bullous dermatitis " for the want of abetter and more accurate term; but I must not be understoodby that to preclude the possibility of its being due to somelocal irritation, though none was discovered, nor to put outof court some rare or anomalous form of pemphigus, whichhas not, within my knowledge, been previously described.

WEST OF ENGLAND EYE INFIRMARY.

ENUCLEATION OF THE EYEBALL, WITH INTRA-ORBITALINJECTION OF COCAINE.

(Under the care of Messrs. TOSSWILL, BANKART, and ROPER,)FOR the following notes we are indebted to Mr. A. Roper,

registrar.CASE 1.—Noah M-, aged twenty-two. The left eye

was lost from a blow with a stick a month ago. There was afirmly cicatrised wound extending across the cornea andinto the ciliary region on both sides. The cornea was flatand opaque. The conjunctiva having been anæsthetised bythe instillation of a 4 per cent. cocaine solution, Mr. Roper in-jected twelve minims of the same solution into the orbitwith the hypodermic syringe from four separate punctures,and after waiting for about three minutes enucleated in theusual way. The only pain which the patient felt was when,after division of the tissues, the eye was forced upwardsby the backward pressure of the speculum, when he com-plained of headache over the left ear, which ceased imme-diately the nerves were divided.CASE 2.-Mr. Bankart, who witnessed the operation in the

foregoing case, was so pleased with the result that he imme-diately repeated it on a patient of his then awaitingenucleation. The following is the case: William C--,aged sixty. Right cornea sloughed; eye contracting andpainful. Cocaine injected as before. The removal of theeye was most tedious from the great thickening of theorbital tissues. The patient felt scarcely any pain.CASE 3. - James C-, aged fifty-five. Old painful

glaucomatous eye, enucleated. Fourteen minims of a 4 percent. solution injected. Some pain was felt on attemptingthe division of the internal rectus, but this was relieved bya further and deeper injection of three minims of thesolution. With this exception there was no appreciablepain, but some faintness at the time of dividing the nerves(? faintness from the cocaine).CASE 4.-Francis B-, aged fifty-six. Right eye blind

from a cut across the cornea and the ciliary region nearlyfive months ago. Sympathetic ophthalmia in the left. Eyeenucleated after cocaine injection. Some slight pain wasfelt, but " not so bad as toothache " ; but the headache wassevere over the ear. It was thought that fifteen minims ofthe solution had been injected, but on cleaning the syringeafter the operation it was found that seven minims hadpassed back, owing to the dryness of the piston. Only eightminims was injected therefore, which was evidently notquite sufficient.CASE 5.-William L---, aged fifty-six (under the care of

Mr. Tosswill). Large staphyloma of right cornea followingslough from burn by hot iron. The patient wished to havethe eye removed, but was so nervous that Mr. Tosswill, whohad not seen the cocaine used, hesitated to try it. Mr. Ropercould not, however, anæsthetise the patient (a burly black-smith) in the absence of assistance to hold him down, hisstruggles being very violent, and so fourteen minims of the4 per cent. cocaine solution were injected. He was literallygasping from nervousness and fear of pain, but did notwince, save whFn the globe was forced forwards. He ex-plained afterwards that he winced because he felt something,and was afraid he was going to be hurt.CASE 6.-Frederick H--, aged seventeen, under the care

of Mr. Bankart, who removed the left suppurating eyeballafter a similar injection, with only slight pain to thepatient.CASE 7.-James F-, aged twenty-two (under the care

of Mr. Bankart). Staphyloma of sclerotic and cornea fromwound by a fork when a child. Eye irritable. V.R. shadows.Eye removed after injection of fifteen minims of 4 per cent.solution of cocaine. There was no pain.Remarks by Mr. A. ROPER.-It occurred to me in the

beginning of the year, when doing my colleague -Air. Toss-will’s work, that an intra-orbital injection of cocaine would

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be as effectual in preventing the pain of extirpation of theeyeball as a subcutaneous injection is in the extirpa-tion of tumours on the surface of the body, and thisI have found to be so, as the preceding cases show.I have found that the best way to administer the injections(for I have injected each orbit in four places) is to pass theneedle between the tendons of the recti muscles, as they arevery tough, and it is hard to drive the needle of the syringethrough them. Next, the injections must be as far into theorbit as possible and close to the globe, to do which it iswell to rotate the eye to the opposite in which you proposeto inject. For instance, to administer the upward and out-ward injection, I rotate the eye downwards and inwardsas far as I can, and then, pinching up the conjunctiva asnear the sulcus as possible, I pass my needle close to the

globe and well into the orbit. Lastly, the experience oftwo of my friends, who have tried this method withoutsuccess, goes to show that, if the conjunctiva is muchpuffed up by the cocaine, the injection is either not deepenough, or more probably is not sufficiently close to theeyeball to ensure its entering Tenon’s capsule.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

Tubercular Disease of Testis.- Intra-peritoneal Rupture of’

the Bladder.AN ordinary meeting of this Society was held on Jan. 24tb,

Mr. G. D. Pollock, F.R.C.S., President, in the chair.Mr. WILLIAM H. BENNETT read a paper on the Occurrence

of Tubercular Disease of the Testis as a local affection, par-ticularly with reference to the desirabiliiy of early castrationin certain cases. It was based on a record of five cases oftubercular disease of the testis which came under theauthor’s observation amongst his out-patients at St. George’sHospital. The cases were selected with great care from aconsiderable number of patients suffering from this disease,as they possessed the following important characteristics incommon : 1. An absolutely perfect family history, and anentire absence of evidence of privation, excess, or oi;her con-ditions predisposing to thedevelopment of tubercular disease.2. A perfectly clean bill of health up to the time of theonset of the disease in the testicle. In this respect excep-tion may perhaps be taken to the case of patient No. 5, whohad suffered from syphilis twenty-three years previously,but had never been troubled by any symptoms since. 3. Thecause of the original inflammation in the scrotal contentswas due in all the cases to direct local irritation, traumaticin four, gonorrhoeal in one. 4. In each case the spinalcolumn showed evidence of disease before the oppositetestis, epididymis, either seminal vesicle, or other parts inthe immediate neighbourhood of the testis originally in-volved. This spinal disease was so insidious that, withthe exception of Case 3, in which it was discovered acci-dentally, its existence was not suspected by the patient.5. In neither of the cases did the affection manifest itself inother parts until after the original disease had broken down.These points were fully discussed and the following pro-positions submitted :-(a) Inflammation of the testicle orepididymis, the consequence of injury or direct irritation,may result in tubercular disease of a purely local kind,which, if left to itself, tends surely to generalisation. (b) Thegreatest tendency to general infection is at a time subse-quent to the breaking down of the original disease. (c) Partsremote from the testis primarily involved may be affectedbefore the opposite testicle, epididymis, or either semi-nal vesicle. (d) The rational treatment of cases like ethose under discussion is castration, upon the appear-ance of disintegration about the original disease-i.e.,at the commencement of what the author terms, forreasons stated, the "dangerous period."—Mr. HOWARDMARSH said his general experience was opposed toMr. Bannett’s conclusions. He thought spinal diseasevery rare; he had never met with an instance in asso-ciation with tubercular testis. He asked whether therigidity noticed in some of Mr. Bennett’s cases might not bedue to reflex irritation caused by disease of the lumbarglands. In the large number of cases of local tubercularmischief, such as hip joint disease, general infection very

rarely followed, and he thought the tendency to the latter inthese cases had been greatly exaggerated.-Mr. II. H.CLUTTON said that in the majority of cases both testes wereinvolved, and for that reason they wera unsuitable foroperation. He related a case in which removal of testis andcord as far as could be reached was followed by a dis-charging sinus communicating with the stump of the vasdeferens. In his experience pulmonary lesions were

common in association with scrotal deposit.-Mr. BnucBCLARKE alluded to the difficulty of diagnosing tubercularepididymitis from cases of enlargement due to chronicinflammation.-Mr. BENNETT, in reply, commented on thedifficulty of being certain of the healthy condition of theveaiculse seminales. He felt sure that in his cases the spinalrigidity was due to carious disease.

Mr. W. J. WALSHAM brought forward a case of Intra-peritoneal Rupture of the Bladder, in which abdominalsection was performed and the viacus sutured. The patient,C. H--, aged twenty-two, was admitted on March lst,1887, into St. Bartholomew’s Hospital. He had been drink-ing the night before, and in a fight was butted by hisopponent in the abdomen, his bladder being full at the time.He passed a night of great agony, and was brought in a cabto the hospital the tollowing morning; but he was thensuffering very little shock, and walked into the surgery withthe assistance of two friends. He complained of pain inthe lower part of the abdomen, and of having being unableto pass any urine since the blow, although his bladder wasuncomfortably full at the time. The perineum was natural,and there was no history of stricture. On passing a catheterno urine flowed, although the point was ascertained to bein the bladder by the finger in the rectum. On depressingthe handle the catheter was felt to free itself with a jerk,and its point could be then felt more plainly than naturalthrough the abdominal walls. Bloody urine now escaped,the flow varying with respiration. About twelve hoursafter the injury Mr. Walsham opened the abdomen, andhaving discovered an intra-peritoneal rent in the posteriorwall of the bladder sewed it up with nine Lembert sutures.The sutures were passed through the muscular and peritonealcoats only, and one was placed above and below the upperand lower angles of the wound respectively. The bladderhaving been forcibly injected with eight ounces of boricacid solution and found water-tight, the peritoneum wasirrigated with about two gallons of warm boric acid solu-tion, and the abdominal wound closed as in ovariotomy.A catheter was left in the bladder for two hours, and thepatient subsequently reminded to pass his urine every fourhours. There was little shock, and the patient recovered.Daily notes were given at length. The author remarkedthat there had now been seventeen cases in which abdominalsection had been performed for rupture of the bladder, threeextra-peritoneal and fourteen intra-peritoneal. Of the threeextra-peritoneal cases two died and one recovered. In thesuccessful case the wound in the bladder was secured to theabdominal wall, but not sutured. In the fatal cases death wasdue to shock. The rent in one was found securely sutured atthe post-mortem examination; in the other the rupture hadnot been discovered on opening the abdomen. Of the fourteenintra-peritoneal ruptures, the rent in the bladder was suturedin eleven, and in three a drainage tube was placed in thewound, but no sutures employed. Of these three, one re-covered and two died, death being due to peritonitis andsuppression of urine respectively. Of the eleven caseswhere the rent in the bladder was secured by sutures, fiverecovered and six died, death being due in three cases toperitonitis, in two probably to shock, and in one tohemorrhage from a perineal incision employed for ex-

ploration. In the three cases of peritonitis the sutureshad given way in one, and a leakage had occurred in thelower part of the wound in the other two. In the fivesuccessful cases Lembert sutures were employed and theperitoneum was washed out, and in only one was a

drainage tube used. The author discussed (1) the advisa-bility of early operation; (2) the importance of using asuture which would not become softened too soon, and ofascertaining before closing the abdominal wound that therewas no leakage from the bladder; (3) the cleansing of theperitoneal cavity; (4) the unadvisability of a preliminaryincision in the perineum, or of a subsequent incision inthat region for the purpose of drainage ; and (5) the ques-tion of tying in a catheter after the operation, which hedecided in the negative. A table of the seventeen caseswas given, sixteen of which are in Sir William Mac Cormac’s