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dicted, and the milk given with lime-water. Next morningcalomel and magnesia were given, which relieved the con-stipation that had lasted four days. On the 4th, as the foodseemed to induce vomiting, nutriment was entirely adminis-tered by enemata every four hours, a few drops of laudanumbeing added to ensure their retention. On the 5th a sina-pism was applied to the epigastrium, and on that day thevomiting was certainly less, and the pain easier, an ameliora-tion which continued throughout the following day. Onthe 7th bismuth and hydrocyanic acid were prescribed, andthe sinapism to epigastrium was repeated. The vomitingdid not cease, although the quantity ejected was less, andon the 9th a blister was applied locally, and a small quantityof beef-tea allowed by the mouth, which was discontinuednext day, as the sickness recurred violently, and hypodermicinjections of morphia (one-sixth of a grain) were commenced.On the llth she was allowed a little egg and brandy by themouth, and the carbonate of bismuth given in place of theliquor. There was no abatement of the vomiting however,and the nutrient enemata were still continued. On the 13thice caused pain, and vomiting still persisted. Oxalate ofcerium was prescribed on the 14th, and on the 15th she wasfree from sickness for twenty-four hours, but under the sametreatment the vomiting recommenced on the 16th.From May 18th to June 8th the vomiting still continued,

and the quantity of vomited matter was compared with theamount of urine excreted every twenty-four hours-viz. :

* Passed under her.

The treatment during this period varied as much as before,the chief measure being hypodermic injections of morphia(6 gr.), and atropia (12 gr.) every six hours, until the 5th ofJune, when they were finally discontinued; ice was appliedto the epigastrium on May 24th, and an ice-bag to the spineon the 29th. On the 25th some fish and jelly were given bythe mouth, the enemata still being continued. Most ofthis food was retained ; and on the 2nd of June it wasdecided to discontinue the rectal alimentation entirely,especially as it was likely that, after a course of fourweeks’ uninterrupted administration, the absorbent powerof the mucous membrane must have been somewhat ex-hausted. The fish diet, with beef-tea, milk, and an egg,was therefore given on the 2nd, with the addition of custard-pudding on the 5th, when also the hypodermic injections wereleft off. The result of this change in treatment proved verysatisfactory. On the 8th only two ounces were vomited,and from that date the sickness ceased. She was allowed toget up, encouraged to exert herself, having during the wholetime lain in an apathetic inert condition. Meat was allowedon the 10th, and she had no return of pain. Throughoutthe temperature had been normal or subnormal, and thepulse rate from 84 to 96. The urine was free from abnormalconstituents. The patient left the hospital on June 27th.

Remarks.—In spite of the resemblance of the symptomsto those of chronic gastric ulcer, which led to the measuresemployed in the first instance, it became obvious after atime that the vomiting was of a neurosal character. Theaspect and well-nourished condition of the patient, the oc-currence of vomiting independently of taking food (even whenno food was taken by mouth) ; the character of the vomitedmatters, from first to last free from blood ; and the act of

I vomiting itself-all combined to favour the hysterical hype-thesis. Indeed, it could hardly be called vomiting ; it wasoften little more than a simple regurgitation or fluid eructa-tion, not accompanied or preceded by straining, or notablecontraction of the diaphragm or abdominal muscles. Anote made on May 22nd illustrates this point :-" Pressure

. over the epigastrium causes a sense of nausea, and at timeseven actual sickness. Whilst the abdomen is being pal-pated very gently, without manifest pain, some clearfluid is ejected from the mouth without any effort or

the usual mechanism of vomiting being brought into play."The result of allowing her solid food, of calling into playher dormant volition, and of ceasing to regard herself as anincurable invalid, seem to place the purely functionalcharacter of the affection beyond a doubt. At the ClinicalSociety last year Dr. Graily Hewitt recorded a remarkablecase where vomiting had continued persistently for tenmonths, unalleviated by all measures of treatment. Thepatient was reduced to an extreme degree of emaciation,and the vomiting ceased after measures had been taken torectify a malposition of the uterus. In the present case

there was no evidence of any uterine derangement,and, in spite of vomiting (which before admission had oc.curred intermittently for some months), her general nutri-tion was unaltered. - __-

COUNTY HOSPITAL, LINCOLN.GUNSHOT INJURY ; DESTRUCTION OF RIGHT KNEE-JOINT

AND AMPUTATION OF THIGH ; ANEURISM OF LEFTFEMORAL ARTERY TREATED BY DIGITAL PRES-

SURE AND ESMARCH’S BANDAGE.

(Under the care of Mr. SYMPSON.)FOR the following notes we are indebted to Mr. ’BV. J.

Cant, house-surgeon.J. T-, aged forty-six, was admitted on August 22nd,

1880, with a severe gunshot injury of right knee, left thigh,and both hands, caused by the discharge of a fowling-pieceat a distance of about twenty feet. The tissues were notmuch torn, but there were marks indicating the entrance ofnumerous shots. The patient suffered from severe shock,soon followed by well-marked inflammatory reaction. The

knee-joint was poulticed and fixed immovably on a McIntyresplint. Both hands, after suppurating freely, graduallyhealed. Numerous abscesses formed round the knee-joint,which were opened, allowing the escape of large quantitiesof laudable pus. The temperature was always more or lessabove normal, and on two or three occasions reached as highas 103°. There was continuous intense pain, radiating fromthe knee-joint, with increasing formation of pus, which discharged from numerous sinuses. Symptoms of exhaustionwere setting in. On Oct. 2nd a consultation was held, whenit was decided that the thigh should be removed at thejunction of the middle and lower thirds.On opening the knee-joint after its removal it was found

to be extensively damaged, the cartilage over the head ofthe tibia was torn and ulcerating; both condyles of thefemur were denuded of cartilage, and the cancellous tissuewas broken up. The operation was performed under theantiseptic treatment.On the day before the operation a small pulsating swelling

was found connected with the femoral artery ot the leftthigh, which, on careful examination, was proved to be ananeurism. The tumour was rapidly increasing, and onOct. 3rd, was found to have reached the size of a smallorange. At two o’clock of the same day digital compressionof the femoral artery at Scarpa’s triangle was commencedand continued for two hours, when Esmarch’s bandage wasapplied from the toes up to the aneurism, and then to thethigh above the aneurism, thus leaving the tumour exposed.

Digital compression was continued, as the pressure from theEsmarch’s bandage was not sufficient to stop the pulsations(ether was not administered). The bandage and pressurewere continued for eight hours, when on their removal thepulsations had ceased, and the tumour consolidated.The thigh-stump healed completely in about three weeks,

without any formation of pus, showing a firm and linearscar. The aneurism gradually diminished in size, and onNov. 8th, when the patient was discharged cured, scarcelyanything could be felt of it ; the femoral artery pulsatedabove and below the tumour.

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CUNNINGHAM HOSPITAL, ST. KITTS, WESTINDIES.

CASE OF ELEPHANTIASIS OF THE LEG ; AMPUTATION;SECONDARY HÆMORRHAGE ON THE TWENTIETH DAY ;

LIGATURE OF FEMORAL ARTERY ; DEATH.

(Under the care of Mr. A. BOON.)S. G-, a delicate-looking negro labourer, forty-five

years of age, was admitted into hospital on Oct. 27th, withelephantiasis, and an extensive ulcer of the left leg. The

elephantiasis extended up to the knee, and slightly aboveit; the ulcer occupied the lower third of the leg ; it was

deep and foul, discharging profusely, and of many years’duration. The right leg was not affected. Urine normal.Had had syphilis and dysentery several times. As the ulcerwas very large and incurable, and therefore a great drain onhis strength, and as his general health was better than ithad been for some time, it was determined to amputate,which was accordingly done on the 30th, by the circularmethod, the bones being sawn through at a line about oneinch below the tuberosity of the tibia. The elastic tourni-quet, on being applied before the operation, broke, the india-rubber having been spoiled by the climate, so an ordinarytourniquet was put on. The venous haemorrhage was prettysevere, which is often the case; several large veins andabout a dozen arteries required ligature. The stump wasswabbed with a solution of chloride of zinc, and envelopedin carbolised tow. Carbolised catgut ligatures and horse-hair sutures were used. After the operation all went well.By the end of the first week the flap had united, except attwo points. At first there was the profuse watery dischargethat is always seen in such cases ; afterwards a small quan-tity of inodorous pus was found on the dressing which wasrenewed every two or three days. The patient’s generalhealth improved steadily; his temperature and pulse re-mained at normal; his appetite good ; his bowels regular ;his sleep unbroken. So things progressed ; he was far inadvance of a man in the next bed, whose leg had beenremoved a week before his for traumatic gangrene of thefoot.

’

On the evening of the twentieth day the patient foolishlygot out of bed on to the floor : frightful hæmorrhage cameon; the alarm was given, and the resident assistant, Mr.Winter, was speedily on the spot and applied a tourniquet,which effectually controlled the bleeding, but in the fewminutes several pounds of blood had been lost. Mr. Boonwas sent for, and on his arrival found the man in a state ofcollapse. Stimulants were given, and he rallied to someextent. Mr. Boon then, with the assistance of Dr. Waldron,opened up the flaps, which were very firmly united except atthe two points mentioned above, and sought for the vesselfrom which the haemorrhage had come, but was unable tofind it; the man was in such a condition that it was not safeto relax the tourniquet. It was, therefore, decided to tie thefemoral artery in Hunter’s canal, which was done. Thoughthe vessel was empty, in consequence of the tourniquet beingstill on the limb, and the operation had to be done by lamp-light, there was not much difficulty in finding the vessel andapplying the ligature. But the loss of blood had been toogreat, and the patient died shortly after.The next day a careful dissection showed that the

hæmorrhage had come from the popliteal artery ; the vesseltapered a little at the cut end, which was patent, thediameter of the opening being equal to about one-third ofthat of the vessel. It was evident that the catgut hadbehaved much in the same manner as an ordinary silk liga-ture. The artery itself seemed to be healthy except at apoint about one-fourth of an inch from its extremity, wherethere was an irregular opening of about the same area as thlèone already mentioned, which had the appearance of beingthe result, of an ulcerative process in the coats of the vessel.Finally, there was merely a slight trace of an internal plug,a few shreds of blood-stained tissue adhering to the sides ofthe vessel and in no way obstructing its calibre.Remarks bn Mr. BOON.—Though the questions of the

advisability ot operating, and the method of operation, iisuch cases of elephantiasis may be discussed at anothertime, this case is of interest from the fact that the carbo-lised catgut ligature was used, and secondary hæmorrhageensued at an unusually late date. I am satisfied, however,

that there was no connexion between the form of ligatureand the hæmorrhage. No doubt the patient getting out ofbed was the immediate cause of the catastrophe, but I aminclined to think that, sooner or later, the vessel would havegiven way. It is not so clear what was the cause of thealmost complete absence of the internal plug. Probably thesyphilis, the haemorrhage at the operation, and the generalcondition of the patient, all three, had something to do withit. I may add that the carbolised catgut was above sus-picion, having been procured from Weiss.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

Congenital Truncation of Forearm.—Tubercular Disease ofJoints.—Abscess in the Liver.

THE ordinary meeting of the Pathological Society ofLondon was held on Tuesday, Feb. 15tb, Dr. Wilks,President, in the chair. The chief subject considered wasthe presence and influence of tubercular growths in the syno-vial membrane and bones of diseased joints, introduced byMr. Croft and illustrated by microscopical preparations. byDrs. Greenfield and Mercer and Mr. Makins. Dr. AndrewClark brought forward a case of Abscess of the Liver whichpresented features of considerable interest.Mr. BARWELL showed two living specimens of Truncated

Malformation of the Forearm. This deformity has latterlybeen consideredto be due to intra-uterine amputation by shredsof indurated fibrin. No doubt intra-uterine amputation doesoccur, for in some few rare cases the amputated portionshave been born. He had found of such cases only three onrecord-in one, the foot was amputated and born afterwards;a second, in which the foot was born hanging to the am.putating thread; and a third, in which the foot was bornsome days before the child. Simpson speaks of the littlefinger-like growths at the end of the stump as the results ofsecondary reproduction. Both the women shown had atruncated forearm; the younger one has four small digitsand a little depressed pucker ; the elder one has four fingersand thumb andapalm, all rudimentary; no pucker; no nails ineither case. There is considerable voluntary movement ofadduction and rotation of these fingers as a whole. We can-not believe that these muscles and nerves are formed by rudi-mentaryreproduction, and, therefore, inmost of these cases thetheory of intra-uterine amputation also falls to the ground.Most of these cases are really lack of development. He had seenmany cases, and in all of them but one there had beenrudi-ments of fingers.-Dr. N. MOORE thought the view of ar-rested development fully borne out by facts. These caseswere most interesting in comparison with the sirenia-aquatic herbivora-in which the hind-limbs are not de-veloped ; these animals are probably descended from ter-restrial herbivorous animals, with perfect hind-limbs. Inall the instances of undoubted reproduction of amputatedlimbs, as in amphibia, the new limbs are perfect.-Dr.WILTSHIRE bore testimony to the accuracy of Mr. Barwell’sstatements. He had never seen a case of true intra-uterineamputation. The rudimentary digits in the cases shownwere of the size of a foetus of four months, and this factsuggested that the developmental error occurred at thattime. Cretinoid foetuses show well a condition of truncatedarms and legs, which, if carried further, would simulateMr. Barwell’s cases. It is an arrest of development, and veryrarely amputation.Mr. CROFT showed a series of microscopic specimens to

illustrate the occurrence of Tnbercle in Bone and SynovialMembrane. He premised that by tubercle he meant asmall-eellecd growth surrounding epithelioid cells, withgiant cells, and a fine reticulum, non-vascular, and

tending to caseatioil in its older forms. The patientsfrom whom the specimens were obtained were all in delicatehealth ; their joints progressed very tediously ; there wasgreat hyperplasia, and abcesses with cations pus. Case 1,aged twenty, had effusion iu knee-joint for three months ;the leg was amputated ; tuberculosis of synoyial membranewas found ; he subsequently died of intestine phthisis; hi