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short attacks of clonic spasm. Towards four A.M. on the fol.lowing day, he became very quiet and pale, and died abouthalf-past four A. M.A marked symptom presented by the patient from the time

of his admission until death was constant vomiting of biliousfluid, and also expectoration of thick, frothy, and blood-stainedmucus, of which more than half a pint was thrown up.

Autopsy, twenty-two hours after death.-The body was thatof a strong, healthy, and well-developed man. On carefulexamination of the outside of the head, a patch of ecchymosiswas found on the left side of the occipital protuberance ; andafter the soft tissues had been carefully dissected away, asimple linear fracture was observed, which commenced abouthalf an inch below the left limb of the sagittal suture, and ex-tended downwards and outwards. The skull-cap was sawnoff and the brain removed, and the fracture was then seen toextend from the vault of the cranium into the posterior fossa,passing from above downwards and inwards across the leftinferior occipital fossa ; within an inch of the foramen mag-num it divided into two branched fractures, which extendedinto the foramen, and cut off a wedge-shaped piece of bone,the sides of which were bounded by the two lines of fracture,and the base formed by the free margin of the foramen mag-num. This piece of bone was removed by simply dividing thesubjacent soft tissues. On the right side of the foramenmagnum, extending from its margin, was another linear frac-ture, which passed directly outwards for a distance of threequarters of an inch. A third fracture extended from theanterior margin of the foramen along the basilar processes ofthe sphenoid and occipital bones as far as the sella turcica.The surface of the brain was much congested, and the super-ficial vessels were distended with blood. On the right anteriorcerebral lobe there was a flattened layer of dark-colouredcoagulated blood, and this reached forwards and downwardsto the under surface of the brain. Here the cerebral tissue wasfound extensively lacerated, and broken down into a soft massmade up of nerve-structures and coagulated blood. The otherparts of the encephalon were unaffected. There was consider-able effusion of blood at the base of the cranium, and the rightlateral sinus seemed to have been ruptured near the posteriorforamen. There were no signs of fracture in the middle andanterior fossæ. The lungs were crepitant over the lower lobes,and the surfaces of both organs presented a healthy appear-ance. On section, an immense quantity of brown frothymucus exuded. At the apices of both lungs were observedlarge claret-coloured patches of congestion. The stomach wasempty, with the exception of some thick, tenacious, and bile-stained mucus. Mucous membrane much congested over thewhole of its extent. Liver of a dark-brown colour ; the veinswere filled with dark fluid blood. The remaining viscera,both of thorax and abdomen, were healthy.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

TUESDAY, JAN. 28TH, 1868.MR. SAMUEL SOLLY, F.R.S., PRESIDENT, IN THE CHAIR.

ON A CASE OF VESICO-INTESTINAL FISTULA, FOR WHICH COLO-TOMY WAS PERFORMED; WITH REMARKS.

BY THOS. BRYANT, F.R.C.S.,ASSISTANT-SURGEON TO GUY’S HOSPITAL.

THE case was one which Mr. Bryant was asked to see byDr. Habershon in Guy’s Hospital in March, 1867. The patientwas forty-nine years of age, married, and the father of tenchildren. Twenty-seven years previously he had been in theWest Indies, where he had yellow fever and ague. He re-turned home after five years in good health, and remainedwell for twenty-one years, or till two years before his admis-sion, when he was seized with a violent attack of purging,and the passage of a quantity of blood. From that time hehad passed at uncertain intervals slime and blood in smallquantities with his motions. Eight or nine months since hepassed some ounces of blood from the bowel, and seven monthssince he began to have pain across the hypogastrium and aboutthe anus. Six weeks after noticing this pain, he observedflatus and a small quantity of blood and feces pass with hisurine. Of late he has suffered from difficulty in defecation,

and frequent desire ; but the act has not been associated withpain. His motions have, however, never been well formedsince his illness. He has never had syphilis.When coming under observation, his abdomen was natural;

no swelling or tumour could be detected in it. Urine wasloaded with feculent deposit, and the act of micturition wasmost painful. On making a local examination of the rectum,extensive ulceration of the lower bowel was readily made out,and an apparent stricture high up. This ulceration was, how-ever, free from all adventitious deposit.As the case appeared to be one of simple ulceration of the

bowel, with a fistulous communication with the bladder, colo-tomy was suggested and performed on April 27th, with theview of affording a free outlet for the intestinal contents abovethe seat of the disease, and the hope that the fistulous vesicalcommunication would subsequently close, and the ulcerationof the bowel heal; the certainty existing that relief to thepatient’s suffering would be afforded for a time, if not per-manently secured. The operation was performed withoutdifficulty, Mr. Bryant making an oblique incision from abovedownwards and forwards, its centre passing across the middleof the external border of the quadratus lumborum muscle; theobject of this incision being to give plenty of room. Immediaterelief was experienced by the patient. In two days the urinebecame clear, and was passed without pain.An abscess subsequently formed in the perineum, which was

opened by a deep incision; but this soon healed, and every.thing went on well till June 20th, when a change took place,Abdominal pains appeared in the region of the bladder, andsome constitutional disturbance. On June 25th these symp-toms were relieved by a sudden rush of faeces into the bladder,and their passage with the urine. The faeces were thin, andevidently from the small intestine. From that time the man’spower gradually gave way, and he sank on August 27th, fourmonths after colotomy had been performed, and two after thereappearance of faeces in the urine.

After death it was discovered that the bladder, large intes-tine, and small intestine communicated with an abscess at thebase of the bladder, and that all signs of ulceration of theintestine had disappeared, with the exception of the fistulousopening into the abscess. The left kidney was completely dis.organised, and was full of thick greenish pus, as were the ureterand bladder.Mr. Bryant, in his remarks on the case, said it would be

read with interest by those who had studied Mr. Holmes’s paperin the last volume of the Society’s "Transactions," for ittended to support the conclusions which Mr. Holmes haddrawn from the consideration of his own and other cases.It supported the conclusion "that ulcerated openings some-times take place between the bladder and either the large orsmall intestine, many of which have no connexion with pre-vious stricture of the gut, still less with disease; that in thosecases in which the fasces discharged into the bladder camefrom the lower gut, and are consequently more solid, greatsuffering is produced;" and "that in such cases as are not de-pendent on malignant disease, colotomy, by diverting the fascesfrom the fistulous channel, may enable the latter to close, andthus relieve the patient’s sufferings, and restore him to a con-dition of health and of comparative comfort." For in Mr.Bryant’s case all these points were well supported: relief tothe patient’s sufferings was afforded, and the healing of theulceration in the bowel followed the operation. Mr. Bryantclosed his paper by making some remarks on the value of theoblique incision over Amussat’s transverse and the vertical ofother surgeons. He believed it gave more room for manipu-lation in cases in which there is a strong probability the colonis empty, and may have to be looked for towards the pelvicbrim ; it takes the line of the nerves and vessels which passfrom the lumbar region ; it follows the ordinary integumentalfold of a patient when assuming the recumbent position, andpossesses all the advantages of any other line of incision.The PRESIDENT thanked Mr, Bryant for bringing this opera-

tion again before the notice of the profession. It had beentoo long neglected; in itself it was neither dangerous nordifficult. He thought that the oblique incision suggested byMr. Bryant added much to the value of his paper. The greatmistake in these cases was putting off the operation too long.

Dr. HABERSHON took the opportunity of correcting a slightmistake in Mr. Bryant’s paper as to the condition of the man’slungs: there was in reality slight flattening and imperfectresonance at their apices. He could bear testimony to thegreat amount of relief afforded the patient by this operation.Mr. MOORE said that he did not rise to speak of the opera-

tion, which was now proved to be slight and satisfactory, but

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rather to make some suggestions as to the mode in which the and carrying her with it to the ground, where it rested uponopening into the bladder was produced. He had encountered her. She was stunned at the time, but soon recovered her re-certain cases which tended to illustrate this point. He thought collection. On assistance arriving, and the door being removed,there was first a small adhesion at one spot which subse- she was totally unable to raise herself, being numbed all over,quently became the seat of ulceration. Examples were completely paralysed, and suffering fromdiniculty of breathing.frequent. When raised from the ground, it was observed that her headMr. CHRISTOPHER HEATH said that matters were surely was bent forward, and slightly to the left side; and although

quite the reverse-that the ulceration came first, then the herself aware of this, when totd to lift it up, she had no poweradhesion. This adhesion was merely a provision of nature for to do so. A chair having been procured, she was placed in it,preventing death. Eighteen months ago a case came under and upon her fellow-servant endeavouring to raise her headhis care in which, although the urine passed into the bowel, for her, she felt and heard something go into its place with athe fæces did not escape into the bladder. He used the rectal snap, soon after which she so far recovered herself as to move

endoscope, and was surprised to find the large extent of gut with assistance, though with great difficulty, into the house,thus displayed. Still no mischief could be seen even by it. when she became faint, and vomited slightly, but was ableIn some cases the instrument might be of service, as in the after a short interval to retire up-stairs to her bed. The faint-

application of the actual cautery. ness and nausea continued more or less during the night, withMr. NUNN referred to the interesting case of a sweep who pain in the head and neck, and inability to move without

suffered so much from the pain of a similar opening into his assistance. The recumbent position was so painful that, withbladder as to cut off his penis to relieve it. The case was the help of her fellow-servant, she was moved into an arm-brought before the Pathological Society. Mr. Nunn declined chair, where the head was supported by pillows, affordingto operate. great relief.. Mr. J. Woon would ask a question. The patient was She was seen for the first time about noon the followingclearly strumous, yet there was no account of looking for day. The countenance was pale, the expression somewhattubercle. Was it the origin of the ulceration ? As aiding the stolid, and the features were swollen. She complained of paindiagnosis of the site of ulceration, the nature of the discharge in the head and neck ; but what was most noticeable was awas important ; this also bearing on the propriety of per- feeling of alarm lest the head should be moved. The surface

forming any operation. Colotomy at best was only a palliative; of the head and neck, especially on the right side beneath themost died after it. There was a patient now under his care angle of the jaw, was morbidly sensitive, and there was awho had been ill two or three years, and by the constant and dread of even a hair being pulled. She was perfectly con-skilful use of the rectum bougie he had been able to secure scious, and, though exposed to a very strong light, there wasclosure of the opening. If the opening was low down, this no intolerance; the pupils were natural; the skin soft andprocedure was best ; if it was high up, it was a question cool; pulse 84, soft and regular; numbness of the right handwhether colotomy should be employed. As to the method, he and arm, with partial inability to move them ; slight ptosis ofthought that the oblique incision was likely to expose more the right eyelid ; dittielilty in opening the mouth, being onlyof the kidney than the whole one. This it was advisable to able to protrude the tip of the tongue ; could only swallowavoid. In other respects the incision was good. He attached liquids. To be kept perfectly quiet; the head and neck to beno great importance to the cutting of nerves; they soon re- well supported ; the hair to be removed, except just in front;united, as in one of his cases where there was perfect union of to apply an evaporating lotion to the head, and fomentationthe cut ends of the median. to the neck by means of spongio-piline.Mr. T. HoLMES remarked that Mr. Bryant’s case greatly re- When seen again towards the evening she was rather more

sembled his, the patient dying in much the same way. There comfortable, free from constitutional disturbance, and had hadwas no connexion with tubercle in other parts of the body so a short nap. The necessity of supporting the head and neckfar as he was aware, but the post-mortem examination had been by means of a gutta-percha splint was considered, but aban-made out of town. Mr. Heath’s observations were strictly doned, in consequence of the excessive tenderness of the sur-borne out by his case, as there was a third ulcer in the intes- face, the heat it might produce, and its interference with thetine without adhesion. Mr. Wood remarked on the diagnostic local application of the fomentation, which afforded greatvalue of the discharge. In his case this’was well shown by relief.the discharge of urine. He (Mr. Holmes) did not think much The night following the accident she retired, contrary toof the endoscope in such cases. The diagnosis was usually toler- directions, to her own bed, but was obliged to resume the posi-ably clear, but a reserved opinion ought to be given as to the tion in the chair, as she found the recumbent posture coulddanger of operation. One of his cases had done well ; in not be borne. She continued gradually to improve from dayanother the patient died in forty-eight hours. He was willing to day, although it was not until the 3rd of August, five daysto try the oblique incision, as he did not fear exposing the after the accident, that she was able to obtain rest in bed, andkidney. then only when well supported by pillows. The position inMr. BRYANT, in reply, thanked the Society, and the Presi- the chair was still the most comfortable, and she was accus-

dent in an especial manner. He said the surgeon was often tomed for some days after to rise as early as four A.M. to re-called too late to do any good. He thanked Dr. Habershon sume her place in it, retiring to bed at night for the sake of £for his correction, and Mr. Wood for his criticism. There was change. She was always most careful in raising herself, andno appearance of tubercle near the diseased spot; and if no refused assistance, for fear of having the head jerked.greater objection could be brought against his incision than Her improvement was progressive throughout, with the ex-the fact of the kidney being thus exposed, he was rather ception of a return of headache on the 14th of August in con-pleased to see it than otherwise. He considered it important sequence of some excitement, but which soon disappeared.to separate cases of cancerous disease from those of simple On the 21st, three weeks after the accident, she so far re-ulceration, as colotomy was most likely to succeed in the latter covered as to be allowed to go down-stairs, and walk in thecase. garden towards the cool of the day. The ptosis of the rightThe PRESIDENT thought men should not be deterred by eyelid had then disappeared, and the countenance had resumed

tubercle, the relief afforded was so great. its natural expression. The power over the right arm, althoughstill imperfect, was gradually improving, and the only thing

CASE OF RECOVERY AFTER SUPPOSED PARTIAL DISLOCATION noticeable was that she carried her head in a stiff and formalOF THE NECK, CAUSED BY THE BLOW OF A FALLING manner, with a drooping forwards, a condition which con-BARN-DOOR. tinued more or less until the beginning of October, when it

BY J. B. MARTIN, M.R.C.S., VENTNOR. gradually passed off, and she recovered by slow degrees con-(Communicated by SAMUEL SOLLY, F.R.S., President.) trol over the motions of the head. The morbid sensibility of

Emily M-, aged twenty-four, nurse, a stout, healthy the surface of the head and neck, with pricking of the skin,country girl, of active habits and intelligence beyond the and occasional pain under the jaw, continued more or less foraverage of her class of life. Returned home on the evening of a fortnight, and there was likewise up to that period a sense ofMonday, July 29th, with the children under her charge, be- falling backwards, if unsupported, or any attempt made totween eight and nine o’clock, and having placed the little raise the head.pony-chaise they had been using away in the barn, was in The treatment consisted in keeping the patient perfectlyact of closing the doors, when she perceived the left-hand door quiet, in the upright position, with the head well supportedwas falling, and likely to crush one of the children. She beat by pillows, low diet, an evaporating lotion to the head, andthe child back with her hand ; but before she could escape her- fomentation to the neck by means of the spongio-piline.self, the door (an oak one, 11 ft. high by 5 ft. 4 in. in width, The author concluded the history of the case by some re-weighing 480 Ibs.) fell, striking her on the side of the head, marks as to its precise nature, accounting for the skull not

195

having been fractured by the blow causing the accident on thesupposition that the head must rather have been violentlypushed aside than directly struck; and he alluded especiallyto the interesting physiological phenomena announcing tem-porary pressure or injury of the spinal marrow-namely, thedifficulty of breathing, the exalted sensitiveness of the scalpand integuments of the neck, the general numbness, incom-plete palsy of the right arm, and ptosis of the right eyelid, allof which symptoms gradually disappeared, leaving the patientfree from any trace of injury, eleven weeks after the accident.The PRESIDENT said that he wished to encourage the read-

ing of single cases, and remarked on the value of the presentone as bearing on the question of cutting down and trephiningthe vertebræ in fractutc or dislocation.

Dr. INGLis narrated a case he had seen in Australia. A boywas thrown against a tree; he remained insensible for someweeks, and when seen by him certain of his vertebras seemedto be slightly displaced. When he tried to twist his neck hefell down in a convulsion. He only saw him once.

Mr. HoLMES remarked that the evidence as to displacementin the case before them was rather weak. He had seen onewhere the last dorsal was separated from the first lumbarvertebra. No great force was needed for their reduction, butthe patient died of gangrene. He held to extension, ratherthan to operation.The PRESIDENT said his observations applied rather to cases

of fracture than to those of dislocation.

Reviews and Notices of Books.Neligan’s l6fedieoaes, their Uses and ITocle of Administration.

By RAWDON MACNAMARA, Licentiate of the Royal Collegeof Physicians ; Licentiate, Fellow, Member of Council, andProfessor of Materia 1Bledica, Royal College of Surgeons inIreland ; Surgeon to Meath Hospital, &c. Including acomplete Conspectus of the British Pharmacopoeia, an

Account of New Remedies, and an Appendix of Formulae.Seventh Edition. Dublin, Fannin and Co.; Edinburgh,Maclachlan and Stewart; London, Longman and Co.

ONLY two years elapsed between the publication of thesixth edition of this work and its being out of print. A more

complete justification for the issue of another edition couldnot well exist. But there did exist a reason for the entire re-

casting of the work of 1864 in the issue of the 1867 edition ofthe British Pharmacopoeia, which, as our readers are aware,was an entirely different work from the previous British

Pharmacopoeia.Mr. Macnamara’s version of Neligan is now a very valuable

one, including the substance of the British Pharmacopoeia, anaccount of all recent medicines not admitted into the Pharma-

copoeia, with such explanations of pharmaceutical processesand preparations as are not given in the Pharmacopceia itself,and such comments on the action of medicines as might beexpected from the chosen associate of the lamented Neligan,and the Professor of Materia Medica of the Irish College ofSurgeons. In various ways, more than two hundred pageshave been added to the former edition. Two entirely newchapters have been added-one upon Waters, the other uponthe Administration of Medicines : the one including a mass ofmost valuable information frequently needed by the intelligentpractitioner ; the other abounding in practical hints for thebest use of medicines, upon which our utility as medical mengreatly turns.The established reputation of this work, and the fact of this

edition being the seventh, make it unnecessary for us to expressany criticism other than may tend to perfect the successiveeditions of this work which may be expected. We should liketo see the plan of describing medicines under the head ofcertain alleged actions, physiological or therapeutical, aban-doned. It has two great disadvantages. It involves the re-

peated introduction of the same substance, and so swells thesize of the book. Moreover, it leads to the necessity of adogmatic statement of the therapeutical doctrine of the action

of medicines, which in the present state of therapeutics ismost undesirable. We have got a new and simple Pharma-copoeia. Our leading writers on Materia Medica, such as

Mr, Macnamara, should take the opportunity to liberate

therapeutical theory from its old ruts. But with an adhesionto the old terms expressive of the action of medicines this is

scarcely possible. And this conservative use of old thera-

peutic terms leads to the appearance of a more conservativetherapeutism than probably the author himself practises. Anillustration of our objections may be found in the case of car-bolic acid, a medicine now deservedly attracting great atten-tion. Mr. Macnamara of course makes reference to the use ofit by Mr. Lister. But it is classed among astringents ; for thesimple reason, we presume, that it must be classed somewhere,and that there is no word-except, perhaps, the word antiseptic- which would express our present notions of its mode ofaction. An alphabetical arrangement of medicines would bemuch the shorter one, and would permit a simpler, and, by somuch, a more scientific statement of our present imperfectknowledge of the uses and modes of action of medicines.Among the merits of this work are to be mentioned the ex-

cellent description of the action of medicines which have oflate come into general use, such as cerium, atropia, nuxvomica, cannabis Indica, and of medicines which have beenpeculiarly used by the Irish school of physicians. Of the

latter class is cannabis Indica. Mr. Macnamara’s wholeaccount of the action of this remarkable drug is good, andwill be endorsed by those who have experimented with it;and his allusion to a use of it familiar to men who have passedthrough the Dublin obstetric school, shows how observing anddiscriminating the author is :-"My friend Dr. Maguire, of Castleknock, has directed

attention to its value in small doses in menorrhagia, a state-ment confirmed by Dr. Cliurchill’s and my own experience. Inthree cases of this class in which I employed it, it producedcurious symptoms, resembling mania, the patient in one in-stance being fortunately arrested in the very act of precipi-tating herself from a high window. The attempt to get outof the window in this case was not attributable to a suicidalmotive, but to that peculiar feeling of exhilaration of spiritsalready alluded to as evinced by persons under the action ofIndian hemp, which is sometimes so intensified as to lead theindividuals to imagine themselves possessed of an etherealnature, and to be independent of material support."

In leaving this book in the hands of the profession, wewould state that we know no other work which treats so fully,and withal so practically, of our present materia medica.

An Inquiry into the Suitableness of Certain Articles of ArmyHospital Equipment for India. By Surgeon-Major CHARLESR. FRANCIS, M.B. Lond., H. M. Indian Army, Bengal.OF the benefits resulting from the late Exhibition in Paris

the army will naturally derive a fair share. The Prussian

Government, impressed with the importance of having its

army hospitals fully prepared for the field, sent over modellersand draughtsmen with a view to the ultimate ’construction ofsuitable articles of army hospital equipment ; and ProfessorGurlt, of the King’s University at Berlin, will shortly publisha volume for the Prussian Government on the subject. Pro-fessor Longmore was also deputed, on the part of England, toexamine the sanitary collections ; and Dr. Francis, MedicalExaminer to the Government in Bengal, has done similarservice for India. Indian army hospitals are very imperfectlyequipped in certain respects. For example, there exists butone mode of transporting the wounded from the field ofbattle to the field hospital-viz., the inevitable dooly. This isa valuable conveyance, inasmuch as it surmounts the difficul-ties of the roadless regions of India, and a wounded man neednot be removed from it on arrival at the field hospital. The

dooly, after detaching the pole and upper framework, be-comes his permanent bed. Constructed as it now is, it is

heavy and cumbersome, requiring four men for its transport,