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urine drawn off. To take nothing but ice, and to have onegrain of opium evey four hours.6th.-Not sick until this morning, at 6.30, when vomit was

stercoraceous ; no pain in abdomen ; is breathing comfortably;pulse good. Taking ice, and ordered one drachm of Brand’sessence every two hours.7th.-Wound dressed ; looks quite healthy ; has healed at

lower part ; slight tenderness and tympanites, but no pain ;breathmg chiefly thoracic; sick once last night (fseeal) and this morning vomited a little watery fluid ; pulse 66 (regular, ’,soft) ; tongue moist.

’

8th.-Sick three times (fseeal); feels well ; no pain ; less z,tenderness over wound, and less tympanites ; tongue clean ; ’,pulse good.9tb.-Sick once (faecal) ; passed flatus yesterday for the I

first time; feels well ; no pain over abdomen ; tympanitesvery slight; tongue moist ; pulse good. He was put on beef-tea.10th.-Sick twice (fseeal); wound dressed and looking

well; there is very slight tenderness over it and at theupper end is a little localised hardness, probably the stumpof omentum ; the remainder of abdomen quite flaccid, andpalpation does not cause any pain ; passes flatus ; has beenordered some milk and soda-water, which he fancied verymuch ; looks well ; pulse good ; tongue slightly dry ; sleepswell.llth.-Sick three times yesterday (faecal) ; a little pain

and tenderness over the upper part of the wound; passesflatus ; has a somewhat anxious expression; pulse quickand feeble; tongue dry and brown. The milk was discon-tinued, and he was ordered to take beef-tea and six ouncesof brandy.12th.-Sick once (faecal), but a smaller quantity ; passing

flatus ; no pain or tympanites; tongue moist; pulse quickbut stronger; feels hungry ; sleeps well.13th,-Sick once (faecal); passing flatus; tongue furred and

moist; pulse good ; no pain ; feels hungry ; sleeps well;wound dressed; lower two-thirds healed ; upper third nearlyhealed, and hardness can still be felt at the upper part.l4th.-Not sick at all; feels better; passes flatus; no pain;

BO action of the bowels, but feels a desire to have an action;pulse good; tongue furred, moist.15th.-Not sick; still passes flatus.16th.-Very sick once (fsecaJ) ; enema (soap and water)

given yesterday was returned unchanged; tongue moistand clean; pulse good; slept well ; says he feels well;passes flatus; no pain; wound nearly healed ; antisepticdressing left off.17th.-No sickness ; passes flatus.18th.-Sick once (faecal) ; opium reduced to two grains a

day.19th.-No sickness.20th, 21st, and 22nd.-Sick once (fseeal); soap and water

enema with an ounce of castor oil given on the 25th, broughtaway a few scybala.24th.-Sick twice (faecal) ; is looking ill; pulse small and

quick ; tongue dry ; no pain ; sleeps well. To be fed withhalf an ounce of milk every hour by the mouth, and thefollowing nutritive enema every three hours : two ounces ofessence of beef, half an egg, half an ounce of brandy, tendrops of tincture of opium and ten grains of pepsin.25th.-Was fed yesterday with enemata as above ;

retained them all; was slightly sick this morning (faecal) ;passes flatus ; tongue clean, a little dry ; pulse regular,small.26th.-Retained all the enemata; was sick three times

yesterday (fca)) ; milk discontinued ; to have nothing bythe mouth except a little ice; abdomen since yesterdaymorning a little swollen and tense ; no pain ; pulse regular,quick and small; tongue clean and dry ; passes flatus. Tohave one grain of opium every four hours by the mouth, andopium in enema reduced to three minims.27th.-Retained all the enemata; no sickness; abdomen

more distended ; no pain ; tongue clean and dry; pulseregular, quick (100), small; passes flatus. Taking half anounce of milk every hour.18th.-Returned one enema; was sick once yesterday

(f?eca)); abdomen distended; no pain ; passes flatus ; pulsestill weaker ; tongue furred, moister.29th.-Retained all enemata ; no sickness; abdomen verytense; no pain; almost pulseless ; hands and feet cold. i

Gradually sank and died at 12.30 P. M. ’Necropsy, twenty-fours after death. - On opening the J

aladpmen; the omentum, devoid of fat, was seen stretched 1

tightly across the intestines, and was attached by the pedicleto the abdominal wall in the situation of the upper angle ofthe wound made by the operation. On cutting through theomentum, there were some signs of recent peritonitis, theintestines having lost their lustre and a few flakes of lymphbeing seen, but there was no fluid. Attached to this pedicleof omentum was a tumour the size of a small hen’s egg,which corresponded to the patch of hardness felt thereduring life, and appeared to be a knuckle of intestine boundthere by adhesive inflammation. On starting with therectum and tracing the intestine backwards, the large intes-tine was found to be fairly normal ; but the small intestinecollapsed up to the point, a distance of two feet from theileo-esecal valve, where it entered the tumour mentionedbefore, while on emerging from it the remainder was enor-mously distended. A ligature was put round each portionof the gut emerging from the tumour, the gut cut througb,and the tumour removed from the abdominal wall. Onexamination it was found that the finger passed quite easilydown each end of the gut, but could not get past the pointwhere the gut was bent on itself, the angle of curvaturebeing a very acute one. On cutting open the gut, it ap-peared simply congested. There had been adhesive inflam-mation going on between the peritoneal surface of the gutand the omentum, and it was difficult to separate them atthis point, the omentum covering the gut by about a quarterof an inch in thickness.Remarks by Mr. WEBBER.-The chief interest in this case

lies in the fact that the patient lived for twenty-four daysafter the operation with almost continuous faecal vomiting.The necropsy showed that he had obstruction caused by thebinding down of a piece of gut with the pedicle of omentumto the external wound, but until then there was no certaintyof diagnosis, as up to the last three days of his life theabsence of all pain, the cheerful expression of countenance,the flaccidity of the abdomen, and the continual passage offlatus, all pointed to a state of paralysis of the gut ratherthan anything else. The continuous faecal vomiting, how-ever, was looked upon with suspicion, and I think in caseswhere this symptom goes on for more than ten days after anoperation for strangulated hernia it should be an indicationto open and thoroughly explore the abdomen, as obstructionafter that length of time is not probably due to a continuanceof paralysis of even an intensely congested piece of gut, andshould be attributed to some other cause.

DUNDEE ROYAL INFIRMARY.ACUTE CHOREA; EXTREME DEGREE OF JERKING ; NIGHTSCREAMING ; INCONTINENCE OF URINE ; CHLOROFORM

INHALATION ; ADMINISTRATION OF CONIUMJUICE ; RECOVERY ; REMARKS.

(Under the care of Dr. SINCLAIR.)FOR the following notes we are indebted to Dr. D. J. Reid,

late house-surgeon.D. F——, aged twelve, was admitted on Aug. 31&t, 1883.

A year ago he had a mild attack, which lasted three months.The present attack was attributed to a fright from hishaving been put into a dark hole by some boys. Before thejerks came on he had some pains in his limbs.There was a decided rheumatic family history, though the

father and mother never had rheumatism. A sister, nowtwenty-five years of age, had acute rheumatism with cardiaclesion when fourteen years old. The paternal grandfatherand a paternal uncle had rheumatic fever. The maternal

other suffered so much from chronic rheumatism thatshe had great dimculty in managing her own children. Thepresent attack came on six weeks before admission, and sincethen he had had no control over his limbs, and his speechhas been affected. For nearly six weeks before admissionhe had been under treatment, and had been taking arsenicand bromide of potassium, but without any improvement.. On admission, and when first seen in bed, he was tossingabout and did not seem to be able to lie still for a moment.His upper and lower limbs were in constant movement,especially the latter. The head was at times jerked to theone side and at times to the other, and occasionally bark.ward. The whole body was from time to time bent back.ward like a bow. If asked to protrude the tongue he jerkedit out, sometimes to the one side and sometimes to the other.1’he muscles of expression also participated in the move-ments, the eyebrows being raised from time to time, but on;he whole the face was placid. There was an auriculo-

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systolic murmur at the apex. Pulse weak. Temperature99’8°. The patient was ordered a draught containing tengrains of chloral hydrate and fifteen grains of bromide ofpotassium.On Sept. lst four drops of arsenical solution were ordered

to be taken four times a day, and, being restless at night,the draught was repeated. Temperature normal. At mid-night, the patient having been for some time in a fearfulcondition, tossing about and screaming at the very pitch ofhis voice, twelve grains of chloral were given ; he, however,spat it all out. Chloroform inhalation was then tried, untilhe became quiet.2nd.-Attrr the chloroform inhalation he remained quiet

until 2 A.M., when he again began to toes about and screamas before To-day one drachm of succus conii was orderedto be given four times a day, along with the four-drop doseof arsenical solution. Evening temperature 99’8°.3rd.-Evening temperature 98 4°, Patient has been a

good deal quieter to day.4th.-Morning temperature 98’4° ; evening temperature

98’40.5th, -Has not had a draught since the night of the 2nd.

Choreic movements less.6th.-Nurse states that he has had incontinence of urine

since the 3rd. The arsenic was stopped to-day, and he wasordered to have ten drops of tincture of belladonna alongwith the drachm of succus conii four times a day.

14th. — Choreic movements diminishing. Incontinencecontinues.26t.h.-Jerks almost stopped, but incontinence continues.

The dose of belladonna tincture was increased from ten tolifteen drops four times a day.

27th.—Incontinence less.Oct. 3rd.-No incontinence for the last five days; scarcely

any twitching except to a slight extent about the mouth.To get up to-day.22nd.-No purring tremor over the heart, and no cardiac

murmur. The apex beat, however, still displaced down-wards ; no jerks. Discharged well.Remarks by Dr. SINCLAIR -It will be observed that on

both the paternal and maternal side, but especially theformer, there was a well - marked rheumatic tendency,although the patient himself never suffered from any rheu-matic affection beyond the pains in the limbs complained ofbefore the onset of the attack for which he was under mycare. This case was without exception the most aggravatedattack of acute chorea it has been my lot to see. The poorboy’s sufferings were most painful. Arsenic and bromide ofpotassium in full doses had been tried before I saw him, butwithout any effect. It will be observed from the clinicalrecord that although he was so ill as to require the adminis-tration of chloroform on the day after admission he imme-diately improved after four one-drachm doses of coniumjuice, and he continued to improve steadily under its use.It was not found necessary to resort to the enormous dosesrecommended by some authors, and derided by others. Ten-minim doses of tincture of belladonna appeared to have noeffect on the incontinence of urine, which rapidly ceased onthe administration of fifteen minim doses four times a day.The cardiac murmur also disappeared under treatment. OnOctober 21st, 1884, the patient’s mother stated there hadbeen no return of the disease since the boy left the infirmary.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

Lumbar Nepltrectomy.AN ordinary meetirg of this Society was held on Tuesday

last, Dr. George Johnson,F.R.S., President, in the chair.The discussion on Mr. Morris’s paper lasted the whole even-

ing, which was prolonged for half an hour beyond the usualtime.

Mr. HENRY MORRIS read a paper on a successful case ofLumbar Nephrectomy for Renal Calculus. A labourer, agedthirty-five, who had suffered from well-marked symptoms ofrenal calculus of the right side since the end of 1881, andhad been under the care of Dr, Douglas Powell at theMiddlesex Hospital, came again under treatment in October,1883. In November, 1882, Mr. Morris had explored the

kidney digitally and with the probing needle, but did notdetect the stone. On October 24th, 1883, the explorationwas repeated, but again failing to detect the stone the kidneywas removed through the lumbar incision. The patientmade au uninterrupted recovery, and at the present time isat hard work as a charcoal-burner, and " is as well as everhe was in his life, and able to work without the slightest in.convenience." The kidney excised was ot normal size andappearance, and the secreting structures were found by Dr.Coupland on microscopical examination to be quite healthy.The organ, however, was harder and tougher than usual,and contained a rounded rough calculus about the size of amarble. Careful daily examination was made of the urinehy Mr. Paul, both before the nephrectomy and for more thansix weeks after the operation, so that the rapidity and powerwith which one kidney can take on the whole of the excre.tory function was shown in a table which formed part of thepaper. The results are equivalent to those of a simple phy.siological experiment, because a healthy kidney (so far asits excreting substance went) was removed, and a healthyone was left behind. A comparison was made between thelumbar and the peritoneal methods of nepbrectomy. It wasshown that the arguments which have been used in favourof the peritoneal operations were more theoretical thanpractical, and that if logically followed out they were likelyto lead to pernicious results. The conclusion arrived at wasthat lumbar nephrectomy is, as a rule, the better operation,though there are exceptional circumstances and certaindiseased conditions in which the abdominal method is prefer.able. In nephro-lithotomy the lumbar incision, and thatonly, ought to be employed. In judging of the condition ofthe opposite kidney to the one to be removed, we have todepend upon the general symptoms of the case and upon theamount of urea daily excreted. But it is not correct to inferthat the kidneys are diseased because they excrete a dailyaverage quantity of urea even less than half the standardquantity. Persons who have long been living an invalidlife, and who have lost much flesh, may, with perfectlysound kidneys, only pass from thirty to thirty-five ouncesof urine a day, and eliminate not more than from ’8 to 1’8per cent. of urea in this quantity of urine. -The PRE-SIDENT supposed that the chief points for discussionwould be the relative merits of the peritoneal and lumbarmethods of nephrectomy.-Mr. THOMAS BRYANT thoughtthe case a valuable addition to the surgery of the kidney,and presented many interesting points for discussion. Itwas, no doubt, a physiological experiment as to the value ofa kidney, and proved that one kidney, if good, would verysoon take on the action of both kidneys. The question ofdiagnosis was very important; careful manipulation andexploration had failed to detect the stone on two separateoccasions. In all cases of suspected stone the operation ofnephro-lithotomy would be undertaken as one of an explo.ratory kind befoe e it could be anything more, for the surgeonwas perfectly justified in exploring the kidney when thesymptoms pointed to a calculus. The suggestion of incisingthe pelvis of the kidney for the purposes of searching was agood one, and not much harm could come even if incisionbe practised through the parenchyma of the kidney. Hehad no doubt whatever that the lumbar operation was cer.tainly the operation for nephro-lithotomy, for the reasons thatthe pelvis of the kidney could be better got at from behindthan from the front, and a most thorough investigationcould even be carried out at this site. His feeling wasgreatly in favour of the lumbar incision from all points ofview. Where the diseased kidney is greatly enlarged theemployment of the peritoneal section was perhaps called for.In a measure the removal of a kidney had been an accident,as in cases where other organs were supposed to have beenthe cause of the abdominal tumour, for which the abdo-minal section had been practised. It was a questionwhether in pyoephrosis or hydronephrosis removal ofthe kidney was required. Would not drainage andwashing out effect all that was necessary? Woulda discharging i-inus, continuing for years, justify theoperation of nephrectomy ? He referred to three cases inwhich he had respectively removed eigbty-eight ounces ofpus, one quart of matter, and thirty-six ounces of pus, allof which were in a favourable state, although the ultimaterecovery was slow. He had not yet removed a kidney, anddouhted whether he ever should do so.—Mr. WHITAKERHULKE said that, like Mr. Bryant, he had not practisednephrectomy, but had some experience of nephro.lithotomyand cutting into the kidney. He felt sure that the lumbar