employed ten hours each night at his work on the newspaper, and was rather pallid, but speaking generally he was a wellnourished and muscular individual. About four weeks previous to his visit to hospital he experienced at work certain attacks which he described as fainting fits. These were transitory; but immediately afterwards he felt a severe pain in the left frontal and temporal regions. His sight also began to fail him, and images appeared double. Feeling himself incapacitated for work, he consulted Dr. Nelson, the ophthalmic surgeon at the Royal Hospital, Belfast. I am indebted to Dr. Nelson for his kindness in sending me the particulars of the early appearances upon ophthalmoscopic examination. On the 19th January, 1888, there was observed “a suspicion of blurring at the inner margins of both discs. The vessels were normal." On the 27th distinct optic papillitis was recognised in both eyes, and on the 31st a small hæmorrhage was detected in the left fundus between the two ascending vessels. At this time he came to Birmingham, his native place, and on the 14th of February he was again examined by the aid of the ophthalmoscope in my out-patient room at the Queen's Hospital. The right disc exhibited marked swelling, with increased vascularity and complete obscuration of its edge. In the left fundus oculi the disc was much paler and the vessels were diminished in size. The motions of the eyeballs were good; the pupils responded to light and accommodation; sight was defective in both eyes, and I observed that there was considerable peripheral contraction of the field of vision in the left. He complained also of seeing sparks and diplopia. His headache now troubled him less, but he suffered from vertigo, and in staggering he fell to the right side. The patient himself, on being questioned, exhibited obvious defect of intelligence. At his first visit to hospital he could speak rationally enough, except that he was much troubled in recollecting the names of things and past events and circumstances. Subsequently his amnesia, which at first was merely verbal, developed into an absolute word-blindness and word-deafness. I admitted the patient into hospital on March 7th. I then observed that his superficial reflexes were normal, the patellar tendon reflexes exaggerated, especially on the right side, and ankle clonus was present on the right side. His respiratory, alimentary, and circulatory functions were apparently healthy. He had never vomited. On the 9th the patient became very drowsy, passed his urine and fæces in the bed, and had an attack of twitching in the right side of his face, neck, right arm and leg. His pupils no longer reacted to light. On the roth the patient, after some severe convulsions, limited to the right side of the body, became comatose. The right hand twitched occasionally, the conjunctival reflex was abolished, the patellar reflex and ankle clonus were absent. On the 13th the patient recovered consciousness, the reflexes returned, and he recognised his friends and was able to answer questions. He took his food well and began steadily to recover ground, when on the 23rd he relapsed into a semi-comatose condition, occasionally grasping at imaginary objects. His urine became albuminous and contained blood-cells and casts, also bile-pigment. In this state he remained until the 30th, when he died after several hours of profound coma. Autopsy, March 31st, made by Dr. Hogben twenty-four hours after death. The brain: The vessels of the cortex were engorged; there was also arachnoid thickening and opacity; no sign of tubercle. On opening the left lateral ventricle there was found a large yellowish glue-like tumour arising from the posterior end of the optic thalamus, involving the upper limit of the hippocampus major and the anterior end of the hippocampus minor. It extended upwards through the roof of the ventricle, and downwards to the convolutions of the cerebrum below. Externally it reached to within 4-in. of the angular and supramarginal convolutions. Towards its external part the tumour was excavated and contained some yellowish fluid; numerous large new vessels were running into the growth. Both ventricles contained a considerable amount of fluid. The tumour was rather firm, and had no distinct capsule. The kidneys were large, red, and congested; liver and other organs appeared normal. The early symptoms of the above case pointed to involvement of the sensory centres, and more especially of the visual apparatus. It is interesting to remark that failure of sight should have been the earliest phenomenon in a case in which there existed a lesion of the optic thalamus and neighbouring parts, as well as of the fibres of the posterior end of the internal capsule, and of the corona radiata proceeding from the angular gyrus. I may say that hemianopia was not observed. The motor phenomena which occurred later in the progress of the case and consisted of convulsion of the right side of the body, pointed to a lesion in or near the left cortical motor area. I have prepared microscopic sections of the tumour. It is a glioma, and at its periphery it merges gradually into healthy brain tissue. I have also obtained crystals of hæmatoidin from the fluid in the cystic portion of the growth. A CASE OF GANGRENOUS FEMORAL HERNIA: WITH REMARKS ON THE TREATMENT OF GANGRENOUS BOWEL AND OF FECAL FISTULA. BY JORDAN LLOYD. M.S., F.R.C.S. ENG., ON April 23rd, 1887, I was asked by my friends Mr. Oakes and Dr. Purslow to see a case of strangulated hernia. The patient, Miss F., aged 45 years, a well-nourished albino, was in her usual health a week before my visit. On the 17th she was taken somewhat suddenly with pain in the belly and vomiting. She noticed also that a swelling in her right groin-which had been present for more than five years, and which had varied in size from time to time-was more painful than usual. Symptoms continued with increasing severity until the 21st, when she sent for her medical attendant. The bowels were slightly moved on the morning of the first day of her illness. On the evening of the 21st her general symptoms were much better, and on the following morning the skin over the groin-swelling was faintly red and oedematous. At the time of my visit the abdominal pain was slight and paroxysmal ; vomiting of a yellow brown fluid occurred every ten or twelve hours; constipation was unrelieved; the abdomen was moderately distended and tender to pressure; the tongue was furred, with red edges; the pulse was fast and small. In the right groin was a diffuse soft swelling, extending along the inner half of and below Poupart's ligament; the skin was mottled-red and oedematous; fluctuation was evident, and coarse crackling emphysema could be indistinctly felt on light pressure; there was no impulse on coughing; the tension of the swelling was less than that of the abdomen. Miss F. volunteered the statement that she had been subject to attacks of spasms and biliousness for the past five years; she had no idea that she was ruptured. A diagnosis of strangulated femoral hernia with inflammation and probably suppuration about the sac was made, and immediate operation suggested. Dr. Purslow gave an anesthetic of two parts of methylated chloroform and one part of methylated ether, a combination I have used in nearly all my operations during the past five or six years, and with the best results. A two-inch oblique incision was made over the position of the neck of the hernia. The tissues were slightly oedematous and were divided until the sac, which appeared as a dirty looking brownish layer, was exposed. This was freely opened; it contained a small quantity of dirty fluid and was otherwise filled with a greyish raggedlooking unrecognisable mass, which on close examination turned out to be a 31⁄2 inch coil of gangrenous small intestine : there was a strong fæcal odour but no distinct fæcal contents were seen. Before any further step was taken the whole was thoroughly washed with warm water until it was absolutely clean, and then Gimbernat's ligament was freely divided by several notches with a herniotome. A large opening was made into the gangrenous gut and its edges stitched with thin silver wire firmly to the skin. A large drainage tube was then passed into the bowel and pushed on until fæces escaped through it in enormous quantity. The wound was lightly covered with absorbent wool and all nourishment withheld for twenty-four hours. The details of the after progress from this operation are unimportant. The wound cleaned in ten or twelve days, and then presented two open intestinal ends, from the inner one of which the whole of the fœces escaped. Nothing passed per rectum. The skin around the fistula was excoriated and painful; it was much irritated by the flow of many ounces of a rich golden yellow fluid (bile chiefly) coming on always about three or four minutes after a meal. This state of things existed until August 9th, when the éperon was divided by the following means:-Without any anesthetic the blades of an ordinary nasal polypus forceps were passed— one blade in each channel-their whole length along the spur, and the handles were tied together as tightly as possible so as effectually to crush the tissue which lay in the grasp of the instrument. The particular forceps chosen is known as Lennox Browne's. The blades are 238in. long, about in. broad, slightly curved, roughened in their whole length, and come closely together from heel to point when closed. The handles are held together with catch similar to Spencer Wells' artery forceps. Before the blades were introduced they were covered with a single layer of lint, held securely in position by wrapping with fine surgeons' silk thread. To avoid the possibility of nipping a coil of gut between the blades-as is said to have occurred where Dupuytren's énterotome has been used they were made to nibble their way, little by little, along the spur until they were introduced in their whole length, the blades never being more widely separated than was necessary to allow them to slip along the septum. No pain whatever was felt either during the introduction nor at the time of closure of the instrument. The outlying part of the forceps was secured |