1558 NAZI REMOVAL OF CYSTIC TUMOUR OF SUPRARENAL BODY. [3uN3 27, I5so.

were present in the crude product substances for whichthe acid had incomparably gre'ater attraction than it hadfor water. When purified from these substancer, it isindeed sioluble In water, but only in small amount; andbeing so feebly held by water, it is free, when in waterysolution, to act upon other matters for which it hasstronger attraction. Thus was explained the remarkablegermicidal energy of a lotion containing only a twentiethpart of carbolic acid, as illustrated by the foul sore in thehand before referred to.With linseed oil, on the other hand, the acid -could be

mixed in any proportion, and being firmly held by the oil,it was mild in action, though present in the large propor-tion of 1 to 4, as used in the carbolic putty. The 1 to 4carbolic oil is bland when applied to the tip of the tongue,whereas the 1 to 20 watery solution is intolerablypungent.The acid in the watery solution, while potent in action

when applied, is soon dissipated, whereas It is slow inleaving the oil. Hence the watery solution, powerful buttransient iA operation, was admirably adapted for applica-tion to a cut surface as a detergent, while the carbollcputty, bland in action and serving long as a store of; theantiseptic, could be used with good effect not only forabscesses, but also as an external dresaing, for. operationwounds; and for that purpose I long employed it. Theputtywas ued in a layer spread on calico, freely over-lapping the skin around the wound, and.covered with'afolded cloth to absorb the serum.that flowed from beneathits edges. Although this mode of dressing gave place intime to others which were more conventent, the changeeffected under its uise at that early.period was of. the moststriking.character: healing without suppuration, pain orfever, instead of being the rare exception, became therule, and operations were safely performed which hadpreviousrly been utterly prohibited on account of thedanger that attended them; while pyaemia and hospitalgangrene, which had before been disastrously rife, werebanished from my wards.Epidermls is a substance for which carbolic acid has

special attraction; and this, coupled with the facilitywith which the acid blends with oily mattere, renders itpeculiarly fitted for purifying the skin about the seat ofoperation and the surgeon's hands. Another propertywhich aids its action as a detergent, Is its great penetratingpower, not limited by the products of Its chemlcal actionupon organic substances.

I used the 1 to 20 watery solution. for renderlng thepatient's skin and the hands of myself. and my aesistantsaseptic tbroughout the forty years durlng which I prac-tised on the antiseptic princlple, and I never had: anyreason to doubt its efficacy. No long time:is requiredfor Its action. In my private practice the purification ofthe skin was as a rule not begun till I) entered thepatient's room to perform the operation. The, part con-cerned was then thoroughly washed with the 1 to 20 car-bollc solution, and was kept covered with lint soaked withthe same lotion while the instruments were -being attendedto and the anaesthetic administered; the whole processoccupying only about a quarter of.an hour. Yet experienceshowed that this brief period was. sufficient.

It may perhaps be argued that under the carbollc puttyor any other dressing contatning' carbolic 'acid, thatvolatile agent was perpetually- acting- on the skin' andmay have made up for deficiencies in- the original purifica-.tion. But during several years belore I gave up practlce,the dreesings did not owe their virtues to any volatileantiseptic.

I may mention In Illustration one of my latest opera-tions. The-patient was a lady advanced in years, with alarge ventral hernia below the umbilicus. It was -pro-ducing serious - symptoms ; and attempts to reduce ithaving failed, her condition had become exceedinglygrave. I only began to disinfect the skin when she wasalready partlyunder the Influence of the anaesthetic. Theumbilicus contained some drops of opaque liquid of ahighly offensive character. I cleansed- Its, folds carefullywith the I .to 20 carbolice'solution sand washed the skinover and around the sac with the same lotion. The sacwas opened by a median incision,1 the upper end of whichextended to the umbilicus. Into further details of theoperation I need not enter. On changing the dressing (ofcyanide gauze) it appeared that, in her frail=condition, themargins of the sk!on at the upper end of the incision had

lost their vitality over an extent of about i in. in lengthand -jty in. In breadth at each side. I afterwards left thedresstng unchanged for several days, when I found that,the sloughs, the upper ends of which encroached on theumbillcus,ao foul before the operation, bad been replaced;by new living tissue, and complete cicatrization hadoccurred without the formation of a particle of pus.

I cannot but think it a happy circumstance that the'substance which I employed firat In endeavouring to applythe antiseptlc principle shouId have been so admirablyadapted for detergent purposes. And it has grieved me to-learn that many surgeons have been led to substitute.needlessly protracted and complicated measures for mea'nsso simple and efficient,*As an instance of trouble misapplied in this matter,may

be mentioned preliminary washing with soap and water.If carbollic acid is the disinfectant used, Such washing isnot. only wholly unnecessary, but is, I believe, posltivelryinjurious; as it must tend to check the penetration of the-germicide into the -substance of the epidermis, by satu-ratingit with water for which carbolic acid has so littleaffinity. That this practice is superfluous Is, I venture to-think, proved by my experience, as I never in any caseadopted It.The incomparably greater attraction of carbolic acid for-

epidermis than for water was strikingly illustrated by an-experiment not hitherto published.Here my letter was broken off, in consequence of other

engagements. But I afterwards wrote to Sir Hector Cameronwhat I had intended to say on this subject and he was goo&enough to incorporate my remarks in his second lecture (sew'BRITISH MEDICAL JOURNAL, April 6th, 1907, p. 799).

* The fear sometimes expressed of poisonous effects from carbolfic-acid, as used in antiseptic surgery, is, so far as my experience goes,AntMrAlv DrnoundleRR.

CYSTIC TUMOUR OF THE SUPRARENAL BODYSUCCESSFULLY REMOVED BY OPERATION,WITH NOTES ON CASES PREVIOUSLY PUBLISHED4t

BY ALBAN H. G. DORAN, F.R.O,S.,SENIOR SURGEON, SAMARITAN FREE HOSPITAL.

INTRODUCTORY REMABKS.MARY observations have recently been published aboutthe pathology, diagnosis, and treatment of tumours ofthe suprarenal body and of new growths developing inother organs from " rests," as they are termed, of adrenaktissue. An instance of the latter type of tumour wasreported by myself last year. In the autumn of 190&I removed a kidntey subject to "hypernephroma," thepatient surviving the operation for three months, but there-were secondary adrenal depositv, one appearing as a.vaginal polypus. Eleven months later I removed a tumoursituated in the left lumbar region. It proved to be a cyst ofthe suprarenal body itself, unilocular and full of a bloodrfluid., Henschen would rank it as a 8truma suprarernmicyatica haemorMagica. I will now relate my case andafterwards. make some mention of previously reportedinstances of cystic tuniour of the suprarenal body largeenough to be of clinical and surgical interest.

THE CASE.C. L,- aged 62, was admitted into my wards in the Samaritan,

Free Hospital.on .October lst, 1907, on account of an abdominal-swelling and pain.She had been married for thirty years, and had borne nine,

children, the last' confinement occurring eighteen years beforeadmission. There had been no abortions. All the patient'slabourswere normal exoept the last, when the forceps waw.applied. She had never suffered from any puerperal com.plication, but enteroptoiss developed during the laterpregnancies.In 1897 she was laid up with influenza, which leff her very

weak and liable to bronceltis ; at the same time she suffered-from frequent attacks of pain after food and vomiting. Theinfluenza troubled her again several times; on the lastoccasion, which was in 1904, she became deaf in tbe left ear.History of the Present IltIness.-The dyspeptic rttacks,

which had never ceased entirely, became severe Jest summor.

t Readiat a meeting of the Burgical Section of the Royal Society otMedikine, June 16th. 1908.

t Malignant Vaginal Polypus, secondary to an Adrenal Tumour ofthe Kidnevs. Trans. Obst. Soc., vol. xlix, 1107, p. 182, and Journ. ofOb8t. and Gyn. of Brit. Emp., vol. xi (June, 1°07), p. 449.

REMOVAL OF CYSTIC TUMOUR OF SUPRARENAL BODY. x - 1559

-nd to them were added sharp abdominal pains, whioh were at I pushed up the kidney and sutured the out edges of thethir worst durling'the night,- and were referred to a Jump In peritoneum with continuous catgut, uniting the muscole and

-the left side., Sheo was under the oare of Dr. Alexander integument -withL Interrupted silkworm-gait sutures. The-Davidson of Cornwall Road. patient was troubled with oungh, and suppuration of the lower

Oondiftion ons Admtaafon.-The patient was fairly well end of the wound occurred, but there was no evidence of anyniourished., The abdominal walls were thin and, below the effsionn or suppuration In the deepefr structures whence theumbilicus, extremely lair, forming a flaccid swelling tympanitic tumour had been removed.on percusision. There was no evidence of separation of the On November 21st the left kidney could plainly be defined.reoti. It was not enlarged, and was qutte -free from tenderness. 'It'A firm, oval b3dy, freely movable, occupied the leftI loin, lay almost entirely below the level of the last rib, and could

When the patient lay In bed It be pushed for about 1 In. up-retreated for the greater part wards. The urine was clear,under the ribs, Its lower per- pale yellow,and slightly tur--tion rotating upwardsi into the bid, with a little 'mucous,epigastrium., It*. could be deposit containinwz renal cellspushed downwards and- in-- but no casts. The specific

wad1o the extent of over, gravit was 1010, and thereZ,In., unltil itsi lower pole lay was no albumen. The dailybelow the lirvel of -the unmbili- "~'secretion was rather scantycoue. When held downwards D r. Davideion has kpthethere was always more or less patient under obsevaIon,resonance on -percussing Its since her -discharge from hos-Lsuterior surface. . 5 pital. SI~e sulThred badly fromn..!The right kidney could not 25 cough, In the winter mQnjhs,'be felt. The urine was re- K. which caused frsshtrouble wIth,peatedly exmnd hr > the cutaneous 'part of the sb-was no-history of haematuria dominal c!catrix. By the mid-asnd I never -found any trace :2 ~dle of Fabruary the cough hadof 'blooid, but there was always "25 subsided, and the patient's gen--a 'little, rather dentse, mucous 5 eral condition was satisfactory.

-deposit. TusceonwsI once more Saw thi paitient.scanty, une'5o.i wny t the hospital on March 12th,-four hours, -and the specific 1908, five months aifter 'the.gravity low as -a rule, ranging oeaIon. She was In veryfrm10B to 1022. gocd condition, the abdominal'On Ootober 7th I made- a ~ -- ~-~-*--cicatrix was strong, and the

-cystoscopic exaMInation Of - left kidney had .almost r'0'the bsadder with the kind' ~ gained its normial positiodi;-assistance of Mr. Malcolm. "' the lower end could be readilyThe mucous membrane was defined below the last rib.pale, the right ureteric orificenormal, whilst slightly turbidi DescrjptIon of the Tamour.,urine was seent iesuing from Bafore the tumour .wpis-the orifice of the left ureter. These appearancses are worth taken to the Collega of Sargeons, It was accidentally droppedrecording as they naturally led me to isuspecot that the left on to the floor of the operating theatre, so that''it burst, andkidney was the seat of the tumour-which was not the case. its contents, which consisted of about j pint of bloody -fluId*The tongue was clean, the appetite good, and the bowels mixed with broken-down tissue, were lost. When fresh, the

regular. The pulse was 72, small and regular. The maximum surface of the tumour was of a deep purple-bronze colour. Ate1mpDerature during the first week after admiissiou wai 98 80. the College It was put Into a forms in sjolution, which becameThe uterus had -undergone senile changes; the menopause deeply blood-stained, and was repeatedly. -changed. Three

was9 complete by 45. No part of the tumour inthe left loin months after the operation it was placed in a glycerine soiri-,could be pushed down to the leval of the pelvic brim. tion, which soon assumed a pale red' tint. Mr. ShattockThe nature of the tumour was somewhat obscure; but removed a plees of the cyst wall at the line of, rupture., and

altogether It appeared to be prepared sections for thev-enal. microscope.

The Operation. Naked-eye A~parne-On October 15th, 1907,. I The tumour had shrunk con-

.removad she tumour, assisted- siderably after rupture, butby Dr. Wlilliam Griffith, Mr. N,.I Its walls were from the firstMorley adminisitering' the distinctly rigzid, so that .' It.anaesthetic. The patient was became s'maller without ab-,plaeed in the horiz,ntal peel-t solutely collapsing. When Ition. A vertical incisiion was examined It three months andmuade through the left rectus fortnight after Its, removail.muscle near its outer border, Its vertical measfurement wais,beginning about 2 In. below 4 in., the horizontal 4j in.,the costat cartilages and ex- and the anteroi-pnoterior 3 in.tending 4 In. downwards, I . It had lost Its purplish tint,passed my hand Into the ' and assumed the dull1 reddish-

peionsal cavity as fair as the .brown colour of at cricket-ball.right loin; the right kidney -, The surface was fairly smooth.was In Its normkal position ard except where some tracts -ofwas not enlarged. The splenic condensied connective tissjue,fi~xure of the colon lay In front -~were adherent to It. The walls'ofthe-lower part ofthe tumor,were from I to ~ In. thick, andwhich was drawn downwards4 of tough consistence. The cut-and exposed by au incision fsurface wAs dull reddish-made through thLe peritoneum brown, -as though uniformly

ocn the ctrsd ofhestained with.blood, being odescending colon. precisely the saLme tint as the*The tumour lay in a capsule -nuto!r surface of the tumour.

-made up of connective tissue No fibrous or musoular struc-whence it was esimaly enucisated ture could be detected, eventin frcont, outside and behind, by the aid of a hand -lens, nbrwithout any subsiequent were any- yellow spOts, eat-..oozing., There were severe 1 Fig. 2. cuffed patchses, minute cysts,.large vessels running into tue iu nour Internally and from or l,acunae exposed by the section ; I could not even detectabove. The tumour now proved to be athick-walled cyst: the a blood vessel. The inner wall was rough from deposits of oldleft kidney lay entirely behind and mostly below it. The tail clot on its surface. At dne or two points the clot was very.of the pancreas, which I could feel did not touch the tumour. pale, but there were no yellow patches or tuberosiles. TheI secured the vessels wlth No. 4 dhina twlst close to the c) st cyst-cavity was absolutely single, nots traoe of even a rudi-wall, and fixed on a Doyen's clamp in two places, as the mentary septum could be foand on the inner wall. Thus, -totumour was heavy and threatened to tear Itself away from its thp naked eye, the out surtfoe of the cyst wall did not showconnexions. On dividing the vessels and surroundinig con- the appearanoesobaraeteristic of a blood cyst of the suprarenal-seotive tissue, it was set free. and the tissue included in the two body. -There was, In fact, no macrosoop1o indication of adrenalolAmes wascaretally tied. By the above manceuvres no large tisse;* yet, by the aid of the mieroscope, such tissue wavessels were.endangered by the application of clamps and liga- readily distlngulshed.

-4Aure to parts not thoroughly exposed, andno oozing ococurred. Mfcroscopic Appearanceas.-On February 14th I examined

*UNZ 27, Iga'.]

31,5460 TimULJ. REMEOVAL OF CYSTIC TUMOUR OF SUPRARENAL BODY. [JUNE 27, IO&

with Mr. Shattook some sections of theayst wall which he hadprepared for the-mieromope,The cyst wall proved to be mauch less homogeneous than we

suspected. There was a stroma of fibrous tissue without anyplign mnupole. Some large veins were detected, but there wasno indliatton of angiomatous or of lymphomatous tissue. Anodule of adrenal tissue was seen imbedded in the stroma'towards the outer surface of th6 wall, whilst deeper in the cystwall lay a plexas of cells of the-adrenal-tissue type arranged Inshighly atypical manner (Fige. land 2). There was no spitheliallining .to the inner wall of the cyst, but a distinct layer ofhomogeneous tissue, apparently old coagulum, was observed.Under this tissue was another layer of fibres somewhat denser:than in the deeper part of the cell wall. This appearance didnot, in Mr. Shattock's opinion, favour the view that the?tumour was originally a solid cancer of the suprarenal body,snd thatthes Interior had broken down.

CYSTIc TUMoUns 0 THE SUPRARE;AL BODY.I will now make some mention of cases of this kind of

tumour already published. By "c ystic tumours" I meancysts or new growths of more than purely pathologicalitterest, mostly blood cysts, more rarely lymphomas oradenomas, which are trpe new growths. Several cases*hlch I will relate have already been collected byHenschen and by Terrier and Lecbne, but I have madesome corrections after reference to the original reports,nd added other cases. The first and second areinteresting, because they were originally published in dayslong past by able observers who had not the resources ofziodern science at their disposal. I will therefore relatethem -at some length. A briefer abstract of each of. theremaining cases will be sufficient, as they are recorded byurgeons and pathologlits quite recently In publicationsto be found In most medical libraries.

CAsE I (Grelsellus).The original report of this ease, headed " Ren Succentauri-

atus monstrosus cam Ulcere," is to be found In a work pub-lished in Leipzig In 1670, entitled Mimecllanea CurioeaAfedico Physica Academias ncaturae curfosorum, 8iv8Ephemertdum Medico Ph&yeicarum Germanicarum, etc.,Observstlo lvi, p 152 (Rayer misquotes the page). A copy ofthis work preserved in the Library of the Royal College ofSurgeons of England.Greisellus of Vienna seems to have been a good anatomist

and evidently conducted the post-mortem sxamination of thiscaose with much care.Contemporary French and German writers presently to be

quoted seem justifisd in admitting this case as a genuineinstance of the new growth under c-onsidaiowIn-. There canbe little doubt that the tumour bad developed in the isupra-renal body, and it was, as in several recent cases, filled withbloody fluid.Nobilis quidam 45annorum tesiperamenti sanguinee-biiosi,

post diuturnam colicam, eamq; oontumactssimam, genero-sissimaq; remAdia respuentem imortuus, me apertes fult,ubi Intestini Coll exteriorem tunfeam absumtam, et quasisphaoelatam inveni, ex ilA nercpe parte qu Reni sinistroadjacebat. Ben vero sinistcr tantus erat, ut figuram Lienisdestruxerit, quli multis tunicis et membranis involutus erat,quibus resectis Ren verus In debita figura et situ inventusfait: Ben yerosuccentauriatugs tantus erat, ut totam ll1amquasi regionem a Disphragmate (quod una cum Liens ex illaparts elevaverat altius) usq; ad musculum Psoas deorsumocoupaverit. In hoc Rene suooentauriato erat ulcus, Iaquidemapertum, ut integro pugno transitus pateret. Materia ex hooulcere rupto effluxa, erat Aqua rubra ac si boloarmeno tinotafuisset ad libras xii quasi, intas -vero adhbu haerens erat densaet glutinosa vald 6, fuitlginemoq; redolebat ad instar carbonumterrae cum sumin nausea et horrore. Haseo massa sinemateria jam dum effluxa, et particula abrupta ponderabatliber(ic)2. unoias iii. Notandum penes set, quod Nobill hula jamdum fili sodem putatitio Colioo morbo mortul fuerint.-[D. Grafte. comm. Vienna# Dn D. Jung.]

Thus this patient, "a certain nobleman," aged 45, diedafter daily attacks of colic, which trowblsome symptomhis lordship neglected, rejecting with grat' oontempt thevery best remedies. Colicky pains have-been noted Inseveral recent caes; the history of colic in the patient'sfamily of little value. The report of the necropsy isclear; the leftsuprarenal body was converted into a big,tumour which filled the left aide of the abdomen, pushingup the diaphragm and the spleen, and extending down-wards to the psoas. In its wall was an ulcu, evidently arupture, big enough to admit the fist; 12 lb. of red fluidand over 2 lb. of fetid clot, had mostly escaped into theperitoheal cavity. The left kidney was distinct from thetumour.

Trammatim seems highly probable In this case.

CAsE II (Rayer).This case has often been quoted, for It was published by a.

distinguished French physician over seventy years ago, an*the tumour is figured in his (Rayer's) fine atlas illustrating his.TraWte des Maladies de RBine. Plate 54 and Plate 55, Fig. 3.The surgeon inspecting Plate 54 will note how closely thetumour was assoolated with several inches of the vena aeva..The history of injury and pain was very clear.A woman aged 75 was admitted into the Charit , Paris,ifor

violent pains in the region of the rzlght kidney. Since 2 yearsEof age she had been lame in the right leg. Within the five yersprevious to admission she had fallen five times on the rightside, writhuI 4ny immediate ill-effects. Five years beforeadmission she uffneed from an attack of agonizing pains inthe rlght loin, rammng down to the pelvis, so that uterine,disease was suspected. It is not stated whether this attawkoccurred before or; afer,the first fall. A few milder seizures.of the same kind fia d, and another as bad as the firstcame on three monthsbere admission. There was vomiting,which persisted and beeme very obstinate, and the painsextended to the right thigh. & tumour was observed abouta month before the patient came under Dr. Rayer's aewe1an&the lower extremities became oedematous.The patient's skin was of a greenish yellow tint. There wBas

a large tumour in the right flank, hard in Its upper part,where it seemed continuous with the liver and fluotuating:below. There was no tenderness on pressure. The patientdied in hospital, long before the days of renal surgery.The tumour weighed 4 lb.; it pushed up the liver -and

descended Into the right isiao fossa. It contained 1f lb. (unse'Uvre at demit, not Ittre as in some second-hand reports),ofblack liquid blood. The kidney, greatly flattened and alteredin shape, was found entire and adherent to the posterioraspect of the tumour; th"ensl tissue and ureter were normal.The left suprarenal bl4y showed no sign of disese, -the'corresponding kidney'Waf the seat of Chronio inflammatorychanges.The above acoountlis from Rayer's " Reaherohes anatomico-

gathologiques eur lese apsules surrdnales (Cavsulse strL--Milarae)," L'IsP{rfeia, vol. 1 (November 10th, 1837), p. 17.

CASE II (Chiari).A man " over 60 years of age,"* and very corpulent, died ot

heart disease. The place of the right suprarenal capsule wasoccupied by a spherical cyst nearly 6 In. in diameter. It con-tained old coagulum, its walls were thin and ineluded cirunm--soribed oDllections of the cortioal tissue of the suprarenal.body ; no elements Indicating a neoplasm could be found In thecyst, wbiah was separated from the kidney by loose connective'tissue. The left suprarenal body showed no signs of any change,save senile degeneration. There was no bronzing of the skin.and the existence of the tumour had never been suspeote&during life.

CASE IV (Routier).Woman,- 35. -Thse, ears, epigastric pain and vomiting.

Sixt months, tumeir observed in left hypochondrium, ex-tending from under rlbsdown to lilac fossa dull on peroussion,.fluctuating at one point. Operation: Medfan inoision. 'Retro-peritoneal tumour discovered holdiDg 1,600 grams of browibfluid. Rlaltions not4definable, deep adhesions, drainage, c*etwall tense, its sutures tore away; fatal peritonitis. uyst;found replaoing supraremal body, villous-like growths on innerwall oomposed of adrenal tissue.

CASE V (Pawlik).Woman, 40. Two years, fall from a ladder followed bbr

abdominal swelling. Spherical, tense, elaistio, fluctuating:tumour,- descending colon in front. Operation: Incision to'left of umbilicus. Cyst containing 17 pints of bloody fluidenucleated excepting a small piece left on a kind of pedic)eclose to vertebras. Kidney seen on inner side of lower pole of"the cyst. Recovery. A small piece of unaltered suprarenakcapsule ranOn to cyst wall. The tumour was defined as a largehaomor-rhagic yost of the left suprarenal ocpsule. Its *ilincluded islets of adreniattissue.

OAsn VI (Triepeke and Biert).Woman, 69. Tmourstize of adult head right side of abdo-

men. oInsteinclag outer edge of reotus; cyst tapped,3S pints of turbid fI&d wIth coagula; drainage of cyst caity,which was first saraped with the ourette; death soon afteroperation from " sbhok." The cyst, which proved after dethto be easily enuesble, occupled place of right suprarenas'body; kidney pushed downwards Into iliac fossa. In oytOwall adrenal elements asdeolated with mioracyrstle i,e-generation.

CASE VII (Oberndorfer)Man, 34. No symptoms, death from intestinal obstruotion.

Bound tumour, size of small apple, replaced greater part-ofleft suprarenal body, the unaltered part oappiDg the tumounr athin-walled cyst, which contained clear, pale yellow fluid;*Misprinted "68" in some second-hand reports.t" Six" in the original report, misprinted "dix" in Terrier andc

Lecene's monograph.Triepoke, Ueber Blutcysten in Nebennierenstraumen I have not been

able to procure or see a copy of this,thess ; the above is qute htMrzHensclen, and Terrier and7Lecene.

2REMOVAL OF CYSTIC TUMOUR OF SIIPRARENAL BODY. [7=CB'm ISX I

lymphangieotasis* of remainder of suprarenal body; rightsuprarenal body normal.

CASE viii (blarohetti).Woman, 50. Died in hospital of purulent peritonitis; un-

certain origin, but not connected with tumour, whioh wastense, elastic, fluotating, and situated in region of rightkidnesy. Autopsy: Oyst, biobed, remains of rigbt suprarenal*body,ran Into its wall above; vertical diameter of oyst 4j in.,contents thok, pale yellow fluid; a complete fibrous-septumduternally. Cyst adhered to vena cava. Adrenal tissue incyst wall and septum. Compensatory hypertrophy. left supra-s-rnal body.

CASE iX (Hensohen).Woman, 41. Twenty years pleurisy, from then attacks of

pain in left hypoohondrium, with vomiting. Three years,,puerperal thrombosls. During attaok of acute rheumatism,big, tense, smooth tumour discovered extending from lefthypoohondrlum to loin, and pushing ribs outwards. Opera-tion (Kronlein): Left pleura tapped, much chocolate-colouredullid; oblique incision Under border of ribs to loin, tapping of

cyst, chocolate-coloured fluid as in pleural oavity; complete.enucleation; adhesions to diaphragm and tall of pancreas,Anferior mesenteric vein damaged and ligatured. Left kidney-iay Internal to cyst. 'Gauze drainage. Death fith day, fromsevre thoracic complications. Tumour a unilocular cyst;,on inner Wall opaque yellow deposits consisting of adrenal4issue.

CASE x (Terrier and Lec6ne).Woman, 52. Four years oonstipatlon and attacks of pain

in umbilical region, mostly to right. Oval, smooth, distinctlydlotuating tumour, size of ostrich's egg, in left loin. Opera-tion (Terrier) : Median incision above umbilicus. Peritoneumexternal to descending colon incised. enucleation of tamour'easy; only half of It removed, being take'n for a pancreatic-AystI base drained. Left kidney found to be distinot fromcyst. Contents of cyst, lemon coloured fluid. Walls thin,-contained suprarenal tissue. Right parotiditis fifth day;eooovery; no fistula in cicatrix.

CASE XI (Bosanquet).Woman, 56. In hospital for carcinoma of stomaoh. Freelym-movable, firm, rounded tumour below left costal oarlilages,not tender on pressure. Fatal haemorrhage from malignantuloer (spheroidal-oelled carcinoma ventrioull). Tumour an,lmost spherical oyst, over 3 in. in diameter, in front of leftkidney, desoending colon on its outer side. IIThe left supra--renal body was attaohed to the upper and back part of thetumourand looked normal." Author defines tumour as "c ystic-sdenoma ofthe adrenal." [[ will return to this interesting pointfurther on,] Cyst wall taick and fibrous, lined with cells ofthe adrenal type; contents a semi-fluid, turbid, orange jelly,evidently mucoid degeneration of the adrenal tisfsue. RIght'euprarenal body bore small white nodule, an adenomatousgrowth showing fatty or early mucoid degeneration.

CASE xii (MoCosh).Woman, 45. Three years dull pain radiating from left loin.8evere attacks of lancinating pain. Blight bronzing of skin.smooth, globular, elastic, fluatuating tumour in left side ofabdomen, pushing out ribs;- colon on its inner side. Opera.tion: Oblique inoision, complete enucleation of universally'adherenot cYst, attached to aorta and bodiesof lumbarvertebras -'contents, 9 pints of dirty yellow fluid. Left kidney muoh dis-plaeod downwards. Foropressure and drainage, reoovery;lbronzlng of skin disappeared. Wall of cyst thick, containingdistinot adrenal tissue.

CAaE XIII(Author, related above).DOUBTFUL CASE (Lockwood).Woman, 20. Two years, painless swelling, slow growth.'reely movable tumour size of ostrich's egg, hard, tense, Inleft hypochondrium, reachingdownwardsto level of umbilicus;coilon defined to its outer side. Operation: Incision outsideleft rectus, easy enucleation ater incision through descendingmesoOolon; end of duodenum adhered to innerside of tumour.dlreter- lay behind tumour. "Recovery" (private correspon-'denoe). Thlok-walled cyst, fibrous tissue, inflammatoryChanges; "no glandular structure of. any kind could bediscovered." Contents, altered blood clot.

Renat'ke osnLockioood's Caae.-Considered from a clinicaland surgical standpoint this cySt remlnds us of severalof the blood cysts In th3above Series. In outward appear.-ame It closelyresembles the tumour which I removed andwhich Is preserved in the Museum of the Oollege ofsurgeons, and It lso seems -very like that described and'figured by Henechen. I may refer the pathologist andKeugen to Mr.LockWood'g specimen.,which is to be foundUn.the: Museum of St. Bartholomew's Hospitsl, Pathologicale3eries, No. 3,372a. The thick wall, bloodstained as in myease, and the slgle cavity contatning "a chocolate-coloured semi-fluid mass," are features very distinct in

*Bos,d, reports a easeof lymphapgtomacysticuwiof the rishtmupt!arqn id discovered atan xtopsyona woman, aged.2.-See.Hewu,cke

the "haemorrhagic suprarenal cyst." Lockwood himpellireferring to the researches of. Weldon, Janosil axdRolleston, implies that his cyst might have priginated i.the suprarenal body, which organ is probably developedfrom, and is certinly down to a late period of intra-uterine life continuous with, the front part of the Wolffilanbody. I cannot help suspecting that there may be, ln thewalls of Lockwood's cyst, some adrenal tissue which has,been overlooked. The pathologist, doubtful about thehomologies of Lockwood's important cae, should studythat surgeon's original report in conjunction withHenschen's well known monograph.Mr. Lockwood informs me that about a year ago he

removed a similar tumour which adhered to the lower endof the right kidney. The same authority describes In thereport above quoted a case of muliilocular retroperitosealcyst removed by Mr. Bowlby, who tells me, that thepatient was free from recurrence nine years after theoperation. It resembles a case of a similar cyst presentedby Dr. Bantock to the Museum of the College of Surgeons(Path. Berles, 303a). The splenic flexure and descendingcolon lay on its surface. The patient is living, twenty-two years after the opfration for Its removal. Mr. Shat-tock has kindly examined sections from the wall ofBantock's multilocular cyst, but cannot find any adrenalelements. This case and Bowlby'sareeven more doubtfuIas to their nature than Lockwood's, as far as origin fromthe suprarenal body is concerned.t

SUMMARY.Surgical Pathology.-The blood cyst li not a true new

growth; it owes its origin to haemorrhages Into themedullary substance of the suprarenal capsule. Therewas a history of injury In Rtyer's and in Pawlik's cases,which was very probably the cause of haemorrhage Ineither one or both; perhaps some pathological changewithin the organ contrlbuted to the development of theblood cyst. Such changes, on which it is not necessaryto dwell, are probably the sole cause in the majority ofcases. The operator, should he recognize the true charac-ter of the tumour during the operation, need not searchfor any extension of disease in Its vicinity, and when hecan make slure that it Is a blood cyst he need not fearrecurrence.

It is certain that adenoma, lymphoma, and other newgrowths seldom convert the suprarenal body into a cystictumour of interest to the surgeon. Henschen gives In ilsmonograph a good synopsis of the pathology of thesecysts, of which there is In the above series one instanceof lymphangioma (Oberndorfer) and one of cysticadenoma. Marchetti's bilocular cy it and Terrier andLec6ne's big cyst might have owed their origin to oldhaemorrhages, as pale yellow fluid is often seen In veryold blood cysts elsewhere.Those who are interested In the genesis of cysts of the

suprarenal body will find much valuable information inthe writings of H. D. Rolleston, Ogle, Raymond Crawlurd,and Charlewood Turner. The latter writer reports aninstance where there were also cysts in the cerebellum,livar, and kidney; the adrenal tumour was, I must add,of the size of a fist, but the patient died of the cerebellardisease, and the primary seat of cyst formation was notclear. One point very much to our purpose was ,lear-the cyst In the suprarenal body was certainly not due tohaemoirhage.

Lastly, I may turn the reader's attention to a prepara-tion which is to be seen in tbe Museum of the College ofSurgeons (Path. Series, 3 517), taken from a womanaged 55, who died alter ovariotomy. It shows " a supra-renal capsule in section, with a large, rounded mass in Itssubstance. The remainder of the capsule is dilstendedinto a cyst. The enlargement is due to a hypertrQphy ofthe cell columns of the suprarenal capsule with fatty,,degeneration of the contained cells." I may add that thisreport was made by Dr.- Goodhart. The preparation may,I think, explatn how, in a case of cystic disease of thesuprarenal body, the greater part of that organ may bofound on the cyst wall, as in t4e tumour, included. in the,above series, described by Bosanquet.Symptons axd Diagnosis - The number of cases of cystie

tumour of the suprarenal body remains small, yet tLbet I have recently published a clinical report of these two cases, withnotes on Monprofit's account of the r#moval ot a&WolWan cyst(Crses

of Multilocular RMtroperodai& (ysts ih Women, Journ. t Obst6et. andGn. of Brit. gmpire, vol. xiii, 1908, p. 257).

JMW 21. 1909.)

S62 2 REMOVAL OF CYSTIC TUMOUR'OF SUPRARENAL BODY. [30NU 279 1901.

above- records show that it gives rise to fairly definitesymptoms. I have already noted that a htstory of ipjaryhas beea obtained in more than one case. Pain appearsto be the rule; it usually assumes the cbaracters ofdyspepsia or fits of colic, and leads to the discovery ofa tumour. In my own cse it was very definite, and theabove abstracts fhow that distinct pain was specified Inthose reported by Greisellas, Rayer, Routier, Henschen,Terrier and Lec6ae, and McOosh, making in all seven, towhich we may safely add as an eighth Bosanquet's case,where, as the original report explains, this subjectivesymptom seemed mally, though not entirely, due tocoincident malignant disease. The tumour in this respectdiffers from a simple hydronephrosis, although attacks ofrenal colic may be associated with the latter. Fluctua-tion seems far less marked than in hydranephrosts, nordoes the cys' descend so readily, as the auprarenal bodyis more firmly supported than the kidney or, we mustadd, the spleen. In my own case the cyst was, I admit,freely movable, but it always slipped up again whendrawn down, and did not naturally lie well below theribs under the abdominal wall, after the fashion of renaland splenic tumours of its own size. The eystoscope mayaid in diagnosis, as will be seen In the original report ofPawlik's case. The descending colon is usually anteriorto the cyst, but this point is not always accurately indi-cated.. Other symptoms seem far less marked, whilstone, so familiar in association with another diseaee ofthe suprarenal body. deserves special notice.

Bronzing of the kkin.-This well-known symptom ofAddtson's disease was only observed in Mciosh's patient.It was slight, yet distinct, and disappeared soon after theoperation. McCosh's experience seems to be unique.Henchen, who wrote before the case was publisbed,declares that this "classical symptoms" is always wanting(itnnerfekdte) in cases of benign cystic suprarenal tumours,and is absent "almost wlthout exception" In patientssubject to other tumours of the Fame organ. I may addthat in my own case of malignant vagtnal polypusseoondary to an adrenal tumour of the kidney there wasdistinct bronzing of the skin during the patient's lastdays three months after the operation. The left supra-relial body was found to be free from new growths or anyother visible morbid condition. The state of its fellowremains uncertain; it was not found at the autopsy.I mention this case because it shows that cutaneousbronzing, which Dr. W. T. Evans informs me was muchmore distinct in this instance than my own report wouldlead the reader to believe, may be present in a subjectwhere one suprarenal body is healthy atd wbere there iano evidence of Addison's disease. None of the cystictumours described In this communication were bilateral.

Surgical Tteatment: Results of Recorded Operatiosu.-Without doubt, the rlght treatment for a cyst of this kindis removal by operatton. It should be enucleated fromthe kind of capsule of connective tissue In which it lies.The suprarenal body is normally- kept in its place byfamcia which separates it from the capsule of the kidney,and holds It well up, far back In the loin. Hence thesuprarenal body does not descend with the kidney whenthe latter becomes movable. When the suprarenal body,on the other hand, becomes converted Into a heavy cystictamcour, it descends along the outer border or anteriorsurface of the kidney, stretching Its supporting connectivetissue, which forms a capsule. The operation essentiallyconsists In the enucleation of the cyst from this capsule.

Diagnosts is difficult; It the cyst be taken for a renaltumour and exposed through- a lumbar incision, enuclea-tion might be effected with ease and safety, but in someof the above cases that incision would have proved veryunsatisfactory. Therefore the cyst Is far more safelydealt with if exposed by a vertleal incision through theouter margin of the rectus, as Mayo Robson reoommendsin operations onl solid tumours-of the suprarenal body.It allows of effiflent exploration, and the above serles ofoperative and po8t mwtem experiences teach us that Indealing with a tumour of this kind exploration should bevery efficient, seeing that the cyst may adhere to thevena cava, aorta, or p tncreas.

.I,scuiu and .Drai,s#e.-Experience teaches us thatthis incomnplete procedure is unsatisfactory. The cutedges of the cyst have been fixed to the edges of the abdo-minal wound (" marsupialization "), unfortunately the cystwralls, though thick, are not tough likce those of the more.

fmilar pelvic and renal cysts. In Boutier's case thesutures cut through the tissues, so that the cyst retracted'and some of its contents escaped Into t}e peritoneal cavity,with fatal results. In Triepcke and Biet's caFe, It waafound after death that enucleation would have been easy..Terrier encountered no difficulty when he eniucleated theanterior portion of his cyst, but suspecting that It waspancreatic he zefrained from completing the process and-"marsuplalized" the base. The pattent recovered, buttconvalescence was retarded by inflammation of oneparotid.

Complete Removal by Esuc'eation should always be under-taken if possible; it may be attended with dangerouscomplications. I have related how Kr6nleln, In the case-reported by Henschen, bravely completed a very diffieultoperation; but the patient was the subject of pulmondisease of very long standing, with fatty degeneration ofthe heart and sclerosis of the coronary arteries, so that.the fatal result was not surprising. McOosh's tumour wasattached internally to the wall of the aorta. When theconnective tissue capsule was incifed to allow of enuclea-tion very large vessels were divided, some lay so deeplTthat they could not be ligatured; three long artery forceps,were applied to them and left on for a time. We are notInformed how long after the operatton the forceps wereremoved. The patient recovered. The dangerouis prox-imity of the aorta in McCosh's cass reminds us of the,.observations of Rayer and Marchetti on subjects in thepost-mmen room. Both these writers publish drawingsof their cysts, which were in the right suprarenal body;.they were closely connected with the vena cava.Pawlik had to deal with a kind of pediele which ran

lnwards towards the lumbar vertebrae. I was not secured.without much difficulty, and when It was divided afterligature a piece of cyst wall as big as a shilling remainedon its proximal portion, which receded so far that theoperator feared to draw it down in order to excise the-fragment. The patient recovered. The afterhlstory ofthis case and of Terrier and Lectne's-where still more ofthe cyst wall was left behind-would be of interest.

In my own case enuoleation was unattended by anydifficulty; I was careful to apply the pressure forceps to-all large vessels within sight, avoiding the dangerous-practfce of pinching tissues In the dark.. The surgeon.operating on a tumour in the lumbar region is lIable toassume that It is renal, and this assumption may Inducehim to fix a clamp forceps on a part of the aorta, vena.cava, pancrese, or intestine, when he Is under the im-pression that he Is simply securing the renal vessels. Lock..wood found no difficulty In enrucleating his cyst of doubtfuloligin, although the emall intestine adhered to its wall.ln conclusion, I may observe that the pressure-forceps,

that invaluable invention of Koeberl6 gemeralized bySpencer Wells, must be the sheet-anchor of the surgeomengaged in enucleatieig a cyst of the suprarenal capsule.

BIBLIOGRAPHY.Bosanquet: Cystic Adenoma of the Adrenal. Trans. Pathol. Soc.;.-

vol. lli, 1901, p. 64.Chiari: Demonstration eines Haematoma glandulae suprarenalis

dextra. Wiener med. Presse, 1880, p. 1406.Crawfurd, Raymond: Cvstic. Disease of the Suprarenal Gland.

Trans. Path. Soc, vol. 1. 18S9, p. 212.Henschen: Ueber Struma suprarenalis cystica haemorrhagica.t

Bitrdge cutr klin. (,ihirurgie. vol. xlix, 1903, p. 217.Lockwood: A Retroperitoneal Cgst supposed to have originated in

Remains of the Wolffian BodY. Trans. Path. Soc., vol. xlix, 1898, p. 182.McCosh: Cystq of the Suprarenal Gland. Annals of Surgery,

vol xlv, 1906, p. 878.Marchetti: Degenerationseyste der Nebenniere mit cempen--

saterisebe hvpertrophle. Virchow's Archiv, vol. clxxii, p. 472.Oberndorfer: Mlittheilungen aus dem pathologischen Institiut in

Genf. Ziegler's Betirdge zur Pathol. Anatonme, vol. xxix, p. 516.Ogle: Cyst with Semi-transparent Parietes occupying about a-

quarter of one of the Suprarenal Capsules. Trans. Path. Soc., vol. xvi,1865, p. 252.Pawlik: Casuistischer Beitrag zur Diagnose urod Therapie der-

Geschwixlste der Nierengegend. Archiv. f. k1^in. Chirurgie, vol. liii,1896 (Case iv, p. t82).Robson, A. W. Mayo: Three Cases of Removal of the Suprarenal

Capsule. BRITISH MEDICAL JOURNAL, VOL. ii. 1899. P. 1100.Rolleston * Adrenal Tumours. A lloutt's System of Medicine, vol. iv.Routier: Kyste hdmatique volumineux de -la capsule surrdnale,

Bull. et 11dm. de la Soc de CAir., vol xx. 1894, p. 813.Terrier end Lecdne : Les Grands Kystes de la capsule surrdnale,

Revue de Chirurgie, vol. xxxiv, 1906, D. 321.Turner, Charlewood: A Case of Cystic Growths In the Cerebellumn.

and Right Adrenal. Trans. Path. Soc., vol. xxxix, 18&88 p. 9.

ADDENDUM^.';[Since I prepared this report the patient came once-

more under the care of Dr. Davidson for attacks of venuS.lng, which were suicosuiully cured by the end'of April b7

JiUIU 27, 1900S] LATERAL SINUS THROMBOSIS. I JTVJWAZ 1563

small doses of lpecaouanha, and the constipation anddistension associated with the 'vomiting also aubsided.On April 27th I examiaed the patient. I found that theleft kidney was tender to toncd, and all of -it, except theupper pole, lay below, the level of the last rib. There wa3no tumour nor hardening in the left loin, abiomen, orpelvic cavity. The enteroptoals had rather increased.Dr. Davidson saw the patient at the end of May, In verygood health.] _I_I

TWO CASES OF LATERAL SINUS THROMBOSIS.BY EDWARD HARRISON, M.A., M.D., F.R.O.S.,

HONORARY SURGEON, HULL ROYAL INFIRMARY.

CisEs of lateral sinus thrombosis are not yet so commonbut that instruction may ba obtained by the narration ofIsolated cases. The two following have recently beenunder treatment, and ahow the need for earl.y operation.The first case, which was the most eventful, recovered,while the second, no less instruptive from the surgicalpoint of view, died.

CASE I.-E. F., aged 12, was admitted into the Hall Royal Infirmary

on September 14th, 1906,Hi8tory.

For three weeks before admission he had suffered froman aural diEcharge and earache, and for a week had beenvomiting. Brome glycerine had been instilled Into the ear,and the disobarge bad ceased. This history was, however,only obtained some days atier admission, and was of no useln formiDg an early diagnosie.

Condition on Admiaaon.The boy was obviously ill he complained of headache and

pain in the right knee, which was slightly swollen. He onlyvomited once after admission, and this conslsted of food hehad just taken. Hfs temperature was only 990, but on theeVening of the day of his admission it roee to 1030, and on thefollowing day to 1040. Some tenderness over tte mastoid wasthen elltted, his Intelleot was qulte clear, but he had a greyopaque complexion, and was evidently very ill.

Fir8t Operation.On the third day after admission the mastoid was opened,

and a l1ttle sanions flaid evafuated, and on the foliowingiorning he appeared to be relieved, but the same evening histemperature again went up to 1020, and the disoharge from themastoid beoame purulent. The fluid in the right knee-jAintwas absorbed.

Second Operation.His temperature gradually fell till, on September 22nd, It

was normal ; but his condition was far from satisfaotory, soa oomplete mastoldectomy Wts perfor'med. The temperaturefell for a day or two, bat only to riis again, and he becameslightly jaundiced and oomplained of pain over the sterno-mastoid, which made one suspicloas of sinus thrombosis.

Third Operation.This susplclon was intensified during the next few daye, as,

with a slightly raised temperature he had sudden axacerba.tions to 1040, and, on September 26th, to nearly 1050. Thesewere, however, unsacompanied by rigors, so that I wasreluctant to open what might prove to be a normal sInus inthe close proximity to tbe disoharaiog mtstoid. The mastoidwas accordingly again ecraped and a quantity of foul grey puslrem3ved.

Fourth Operation.On the following day he had a rise of temperature to 1040,

this time aooampanied by a rigor. There was now no doubtthat the sinus was affected, so this was opened and found tocontain foul pus. This was temporarily plugged and thejugular vein cut down on, and as this contained fluid blood itwas divided botween two ligatures, and the wound In theneck closed and sealed to prevent Infection from the woundabove. The opening In the sinus was then enlargtd and thecavity scraped out till blood flowed freely. A plug of gauzewas inserted, which easily stopped the bleeding.

Operation on Knee.The next day his condition was much Improved, but this was

not maintained, and in a few days his temperature rose again asbefore. It wasthen found thathe had effusion in the left knee,so on Oatober 2nd this was opened and drained. The fluidwas opaque but searcely paruient, and a cullure from Itshowed sereptocooiec Infection.

Aftdr-history.EHe now rapidly improvbd in his general condition he took

his. food well and gained flesb, though his temperature stillremained above the normal.On Oatober 22nd the drain was removed from the knee and

ba was put on the baloony for open-3ir treatment. On October25th -Dr. Eve was good enough to give him an lnjeotion ofstreptocoool, after whlch his temperature fell somewhat, butno marvellous effeot was produced.His condition now gradually Improved, so that on November

15th he. had a.normal temperature, and the wounds In theknee and mastold were healed. The ligaments of the jointwere very lax, and I anticipated that he would require somefarther surgical treatment for the knee, but he was sent tothe convale.cent bame and then diecharped. He was shown at ameeting of the East York Branch of the Association InJDnuary, 1908, wnen the movements of the joint were quiteperfect, and he walked without any limp.

CASn II.P. M. N., a male aged 34, was admitted on November 23rd,

1907, with a diagnosis of mastoid disease. I saw him shortlyafter- his admission he had a temperature of 100. 40, no pain,tenderneEs, or swelling over the mastoid, and no auraldischarge. He was very deaf.

History.The history was very iLdefinite he seemed, however, to

have had a chronic aural discharge which had recently ceased.On the followiog evening his temperature rose lo 103.40,and was about the came the nxt morning. He now developeddecided tenderness along the course of the internal jugularvein, and there was some swelling. The mastoid region wasnot tender even on deep pressure, and he had no rigor.Lateral sinus thrombosis was diagnosed, and he was taken tothe theatre.

Operation.An incisilon was made over the jigular, and the margin of

the sterno-mastoid sought for. Tnls was so inflamed that anincision was made through the muscle. An enlarged glandwas removed, and a searoh made for the vela. This was foundto be represented bya thick solid cord. The facial vein wasseen running Into this, and was greatly distendad; it was liga-tured aed divided. The inclsion was then prolonged nearly tothe clavicle and the jugular vein tracad downwards, when thelower third of it was found to contain fluid blood. Ananeurysmneedle was passed csrefully under it, and the vein divldedbetween two ligatures. The descendene noni was Eeen,but notthe vagus. The vein was then dissested up to the angle of thejaw, the superior thyroid, and other branches, which weregreatly distended, being,tled and divided.The lower half of the woand was then satured, the lincslon

prolonged upwards behind the ear, and the mastoid regionlaid bare. - An opening made with a burr in the lateral sinusshowed this to contain clot of a friable character. The holein the bone was enlarged so as freely to excose the sinus, thecontents of which were seraped out unti fluid b'ood flowed.A small plug was then placed to control the bleeding, and thejugular vein opened and soaped out up to the base of thecakull, when I could wash out the sinus an -vein thoroughly.The vein was cut off as near the opening of the jugularforssmen as possible.The mastold antrum was tban explored and found to con-

tain grumous material, whit h was scraped and washed out.While dolng this it was noticed that there was pulsation Inthe fluid it the antrum, which suggestrd-a petforation intothe cranial cavity. Gauze plags were placed in the openingsin the bone, and one at she upper part of the wound in theneck, which was then closed. Rather over 2 in. of the jugularvein was exclsed..The operation, owing to the matting of the tissues around

the vein making the dissection difficult, was tedloup, lasltigan hour and a halt, and there was much trouble wlth thesmall oongested veins. The bone, too, was very hard andthick.

Progress of the Case.On November 30th the temperature had again ricen, and pus

was found in the neck; the wound was ropentd up and thesinus again soraped. Satures were not again Inserted, but theupper part of the incision left freely open; efficient drainagewas thus assured.For the next twelve days he had a temperature of pyasemic

character, but no rigors, and his condition was otherwise good.He took food well, and was given quinine in full dosee,purgativs, and rectal iDjections of saline.On Dec3mber 15th the temperature had become subnormal.

and the wound ILoked clean and healiby, bat there was stillsome pulEation in the mastold antrum. The temperatureremaibed subnormal for six days, when the pulsation in themastoid had ceased, the wound was granulating, and hisgeneral condition seemed satisfactory. He wa,, however,rather apathetic, which misht have been acocunted for by hisdeafneEs, but I was disposed to suspect cerebral abscess. He,however, deolined any further operatiob, and as the pertlooked now so well I did not feel inolined to press thematter.During the next ten days- the temperature regained the

normal, and he Was UP and about the ward, and tookr aninterest in his surroundings, so that I came to regard him assafely convlsesnt.To my dismay, en January 2nd, 1908, he had a sudden rise of

temperature accompanied byr vomiting. This was reptated,onthe next day, and on January 4th he died euddenlyr.