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came. The surgeon made a long incision over the tende

parts of the gum. He concluded that there had bee)some periosteal irritation of the left superior maxillaThe toxic effects of decaying teeth were well knownbut he did not think that this could have explained thsudden occurrence of the tetanoid spasms. Moreoverthis patient had neither teeth nor stumps in his head -Dr. ERNEST KINGSCOTE referred to a case which he had seeIin the Salisbury Infirmary in 1892 of a man who was broughtin with lockjaw. He complained of violent toothache ; thEtooth was removed but no relief was obtained. The next

day the gum was still very much swollen and when a longitu.dinal incision was made into this a few drops of pus escaped.This procedure relieved the spasmodic condition at once.He also referred to a case which he had seen in Billroth’sClinique. A man was brought in with lockjaw. There wasconsiderable swelling of the gum and when this was dividedright down to the bone the patient made a good recovery.

Mr. H. L. BARNARD exhibited two cases of SerpiginousUlceration involving the Eyelids and the Orbit Around. Oneof these cases was undoubtedly syphilitic. Not only wasthere a clear history of the disease, but several other typicallesions existed. There was a little ectropion of the upperlid. This case was rapidly recovering under treatment byiodide of potassium. The other case was more difficult ofdiagnosis. There was no history of syphilis or any otherindications of that disease. The ulcerated area had for themost part scarred over, but it had a raised edge and hadbroken down at intervals. Ectropion of the upper and lowereyelids existed and at one time the conjunctiva of the

upper eyelid was so prolapsed as to cover the cornea. A

plastic operation of the upper eyelid had reduced theectropion and the prolapsed conjunctiva had been cut away.Mr. Barnard intended to perform another plastic operationand to take the opportunity of examining the edge of theulcerated area.Mr. BARNARD also exhibited a boy, aged four years, with a

Central Dermoid Cyst over the Bridge of the Nose and a Con-genital Dimple near the Tip. This little cyst had existed overthe bridge of the nose since birth. The mother stated that it" formed and went away repeatedly." But this was explic-able by the fact that as a result of blows it became inflamed.It had been several times incised. The dimple was on thetip of the nose and a probe passed a short distance down it.It could not be ascertained whether it was connected with thecyst or not. Matter, apparently sebaceous, exuded at inter-vals from the aperture. The cyst had been excised and atthe operation its connexions appeared to be rather upwardstowards the fronto-nasal suture than downward towards the

dimple, but owing to the many attacks of inflammation theparts were matted and their relations obscured. Since th

cyst was excised a slight swelling had appeared below thscar and towards the dimple on the tip of the nose. Thimight possibly be the cut end of the fistula dilated b:secretion.Mr. BARNARD also showed a case of a very large Hernia

Cerebri due to Tumour, projecting from the right frontaand parietal area and overhanging the eye and zygomaThe patient, who was 21 years old, had complained of flashe:of light, headache, and vomiting for four years. One yeaago it was recognised that he was suffering from cerebra:tumour. His condition then became rapidly worse. He wasnever free from the most severe headache, attacks.of vomiting were frequent, and his sight rapidly faileduntil he was practically blind. At the suggestionof Dr. Cautley Mr. Barnard removed a large piecefrom the right frontal and parietal bones some five or sixinches in diameter. This aperture reached from the zygomaexternally to about an inch from the middle line and fromjust above the orbital margin in front to the Rolandicarea behind. The dura mater was opened and removedover the whole area. The cortical vessels were ligatured intheir sulci around this area. The brain bulged throughthe aperture, making a projection of the size of a penny bun.The flaps were drawn over this mass and although therewas great tension the wound healed by first intention.The result was very satisfactory. For seven months thepatient was entirely free from headache and vomiting. Hereturned home and so far recovered his sight that he wasable to go out walking in the parks alone. Quite recentlyhe had had pain in the right orbit apparently due to pressureand one or two attacks of vomiting. About a month ago hehad two fits. The hernia cerebri was at the present time twoor three times as large as it had been immediately after the J

r operation. Photographs were shown recording the sizet and increase in growth. Mr. Barnard remarked on the. beneficial result of the operation. He also wished to, refer to the long duration of the symptoms, and the

extreme thinness of the skull, which was as brittleas a piece of paper and perforated at one spot.-Dr.

. CAUTLEY also referred to the great benefit which the

. patient had derived from the operation. Symptoms had: existed since last December four years ; about a year before! the operation hemianopsia had appeared and this was; followed by double optic neuritis and complete blindness.But now he could go about by himself. The tumour wasthought to be behind, but it was inaccessible.-Replying tothe PRESIDENT as to the nature of the tumour Dr. Cautleythought that it was probably tuberculous. The patient hadtaken cod-liver oil almost continuously from the age of fouryears until he was 16 years old.Mr. F. C. WALLIS exhibited two cases of Fracture of the

Lower Extremity treated by Wiring. The first was in a man,aged 23 years, who was admitted to the Metropolitan Hos-pital on Jan. 10th, 1898, suffering from a simple comminutedfracture of the left tibia and fibula. The accident was causedthrough a boiler explosion. The tibia was broken near themiddle and the fibula somewhat lower, with great displace-ment and comminution. After ten days in splints the legwas much swollen and the ends of the bone were in an ex-tremely bad position. A long incision was made, blood-clotand several pieces of bone were removed, and it was necessaryto saw off three-quarters of an inch of tibia before theends could be brought together. Silver wire was usedfor adjusting the ends. The patient made an uninterruptedrecovery and now he could walk quite well, the shorteningbeing overcome by wearing a thicker sole to his boot.The other case was that of a man, aged 63 years, whohad slipped off a doorstep and fallen with his left foot underhim, causing a Pott’s fracture. When admitted to the Metro-politan Hospital on May 27th there was a great deal ofswelling and deformity. The patient was gouty and bron-chitic, the urine showing a cloud of albumin. The attemptsto get the foot into good position being futile, on June 2ndthe patient was anaesthetised and a curved incision four anda half inches long was made behind the internal malleolus anda flap of skin was turned forwards. The blood-clot waswashed out of the joint, the torn aponeurosis was removed,and the internal malleolus, which was almost within the joint,was then brought into excellent position by a silver suture.The fibula was not interfered with. The wound made an un-eventful recovery, but convalescence was retarded by attacksof gout and general bronchitis. Nevertheless, he left thehospital on July 14th with his foot in excellent position andwithout any lameness.-Sir ROBERT CRAVEN (Hull) re-

marked that in former times, when the displacement inPott’s fracture could not be reduced, he had been in thehabit of dividing the tendo Achillis and generally good ’results were obtained. But these cases showed that betterand more rapid results could be procured by wiring.

CLINICAL SOCIETY OF LONDON.

Aeute intestinal Obstr1lction due to an Intussusception ofMeckel’s Diverticulum -Primary Nephrectomy for com-plete Ruptnre of the gitlney.-Enlarge.d Spleen due to <

CongenUal VolV1&Ucirc;lls of the Stomach and Transverse Colon(sivtqtlatig2g ,ule7ic Anaemia).A MEETING of this society was held on Nov. 10th, Sir R.

DOUGLAS POWELL, Bart., the President, being in the chair.Mr. H. BETHAM ROBINSON read a paper on a case of

Acute Intestinal Obstruction due to an Intussusception ofMeckel’s Diverticulum which occurred in a healthy boy,aged five years. He had been quite well up to 40 hoursbefore being seen and operated on, never making any com-plaint except of an occasional pain in the abdomen. Afterbreakfast on Jan. 2lst he complained of nausea and feelingunwell, but his bowels were relieved naturally. Duringthe day he complained of pain in the abdomen, though histemperature was normal and there was nothing found onexamination to point to any serious lesion. Through thenight there were frequent attacks of bilious vomiting withcramping pains about the umbilicus, hiccough, and thirst.Next morning he seemed a little better, but he vomited afterswallowing anything. There was no distension ; no lumpcould be felt in the abdomen and nothing in the rectum.

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His temperature was 99&deg;F. and his pulse was 130. In theafternoon the pain, which hitherto had been intermittent,became more continuous and the abdomen was a little fuller.An enema was given but with no result; it was noticed, how-ever, that the returned flaid showed a little blood. Mr.Robinson saw him in the evening in consultation and foundhim with a distressed look and very restless, complaining ofthe pain across the abdomen at the level of the umbilicus.His temperature was 99&deg; and the pulse was 160. He wasvomiting a clear, watery, bile-stained fluid. No flatushad been passed during the day. His abdomen was

distended, coils of small gut being noticed in the upperpart. On palpation there was no rigidity and no specialtenderness ; an ill-defined lump could be felt just above theouter part of Poupart’s ligament on the right side, with com-parative dulness over it, but nothing else was to be made outand the rest of the abdomen was resonant. In the rectumthere was no mucous discharge and no lump, but in thefascal smear on the finger was noticed a little blood stain.Immediate operation was advised and proceeded with.Under the ansesthetic the increased resistance above

Poupart’s ligament disappeared, but per rectum a lump wasfelt in Douglas’s pouch which could be pushed up by thefinger and then grasped with the other hand above the innerpart of the ligament and to the right of the bladder. Itseemed firm and tubular and about three inches long. Its lowsituation and free mobility were rather puzzling. A mid-lineincision was made and on opening the cavity clear fluid

escaped but no lymph coagula Two fingers were passed downinto Douglas’s pouch, the lump was seized and drawn out ofthe wound. 16 was then seen that it was intussusceptedsmall intestine forming a tumour about four inches long.Without much difficulty the main part of the gut wasreduced, when a hardness could be felt with a cup-shapeddepression in its centre. A little further reduction showedthat the normal axis of the intestine was restored andthat the lump came from its free margin, proving it to be aninverted diverticulum. The reduction of this from itsthickened contracted neck proved impossible and so therewas no alternative but to excise it. The edges of thegap in the intestine were brought together by Lembert’ssutures, but owing to the doubtful state of the bowel at onepoint it was thought better not to entirely close it but to fixit in the abdominal wound. An additional reason for doingthis was that the boy’s condition forbade any lengthy resection.After the operation he revived for about two hours and thensomewhat suddenly collapsed and died.-Mr. CHARTERSSYMONDS remarked that he had had no personal experienceof intussusception of Meckel’s diverticulum ; such cases wereprobably very rare, but he had seen two cases of obstructiorfrom that cause. The first case was in a little boy who hacrepeated attacks of pain on the right side like that o:

appendicitis. The lad was seen on the fourth day and walextremely ill. He therefore operated and found a diverticulum of small intestine round which the bowel was twiste(and gangrenous. The second case was that of a man, agel26 years, who came in on the sixth day of an attack of acutintestinal obstruction. Un opening the abctomen ne touncta very wide diverticulum round which bowel was folded.In both cases the intervention was too late to save

life. He urged that the sooner these cases were broughtunder treatment the better for the patient. He had operatedon eight, only two having been successful. It was, how-ever, interesting to notice that one of the successful caseswas that of a child, aged 12 months, with an intussusceptionreaching from the csecum almost to the rectum, and theincision for the operation extended from the ensiformcartilage nearly to the pubes. The other was that of a childonly eight months old, and in this case he had made anopening over the cascum. The first case was seen within24 hours and the second within 48 hours and both madeexcellent recoveries.-Mr. ROBINSON, in reply to the PRESI-DENT, said it was difficult to speak with certainty on thequestion whether or not there would be any contraction afterthe operation. That would depend probably upon the size ofthe lumen at the base of the diverticulum.Mr BLAND SUTTON related the details of a case in which

Primary Nephrectomy had been performed for CompleteRupture of the Kidney. The patient was a man, aged 35years, who had been run over by a cab. On admission heshowed marked signs of internal bleeding and a large, tense,ill-defined swelling, dull on percussion, formed in the rightloin. There were no superficial traces of injury; the over-lying skin was not scratched, contused, or torn. Three hours

after admission the signs of bleeding and the collapse becameso marked, and so much blood appeared in the urine, thatthere could be no doubt that the kidney had been severelyinjured. Through an incision in the right linea semilunarisit was ascertained that the remaining abdominal viscera wereuninjured. On detaching the peritoneum overlying theswelling in the loin the kidney was found to be completelytorn across at the junction of the lower with the middlethird. The laceration had involved the renal vein andblood issued from it with some force. As it was hope-less to attempt to suture the two parts of the kidneytogether the fragments were removed with the surround-ing clot. The cavity was lightly stuffed with gauze andthe wound was secured with interrupted sutures of silkwormgut. The patient convalesced quickly and left the hospitalfor the convalescent home in four weeks from the date ofthe operation. Mr. Bland Sutton pointed out that theclinical features were so marked and the line of treatmentwas so obvious that he thought there could be no differenceof opinion as to the mode of treatment adopted. He

suggested that the term primary nephrectomy" " should bereserved for cases in which the kidney was removed within24 hours of the accident and that where it became necessaryto remove a kidney some days or weeks after such an injuryit should be called secondary nephrectomy. He furtherobserved that their home literature contained very fewrecords of primary nephrectomy for rupture of the kidneyand that a study of the Centralblatt fiir Chirtl’l’gie indi-cated that far too many cases were recorded from post-mortem observations, the patients often dying without

surgical intervention. This, he held, was very regret-table, especially as the signs of this grave accident werein a large proportion of cases very clear and obvious.A good number of the cases were in young persons betweeneight and 14 years of age. The evidences of rupture or

laceration of the kidney were threefold. First, there wasa history of a definite injury to the loin ; secondly, a tense,ill-defined swelling in the loin ; and thirdly, blood in theurine, though this was not quite always present. It wasmuch to be regretted that the operation should not be doneimmediately after the injury so as to check the hemorrhageat once.-Mr. G. R. TURNER related a very similar case in aman, aged 57 years, who fell from the top of an omnibus onto his right loin. He also presented a swelling in the rightloin with rapidly increasing dulness. He diagnosed ruptureof the right kidney and opened the abdomen in the same wayas did Mr. Sutton. The whole of the ascending colon andcaecum were black with extravasated blood. He incised theperitoneum to the risht of the ascendins colon and in themidst of much blood-clot found the kidney torn into severalpieces. It was too mangled to admit of suture, so heremoved it. The patient made a good recovery in spite ofan attack of acute bronchitis, the cough on one occasionbursting open the wound and allowing a foot of intestine toescape. Mr. Turner said he was led to operate in that caseforthwith by having seen a fortnight before a man who hadrupture not only of the kidney but also of the liver. The

patient, a man aged 24 years, was intensely collapsedand he had to wait until the third day before opening theabdomen. He found a slight laceration of the under surfaceof the liver with blood in the general peritoneal cavity, butnot of recent date. There was enormous retro-peritonealextravasation evidently due to rupture of the rightkidney. The patient vomited persistently and died in a

week. He suggested that the vomiting might have beendue to involvement of the semilunar ganglia in the clot.He quite agreed with Mr. Sutton in advocating primaryoperation in cases of rupture of the kidney unless the collapsewas very extreme. The amount of urea had been estimatedin one of his cases after the operation and it was found onthree occasions to be 2’45 per cent,, 2’6 per cent., and2’3 per cent.-Dr. COODE ADAMS did not think thathsematuria always occurred in cases of rupture or lacerationof the kidney. He remembered the case of a man, aged35 years, who had met with a buffer accident" on therailway. This had resulted in fracture of the femur and

ribs. Rupture of the left kidney was found after death, buti during life no hsematuria was observed. The rupturei measured half an inch and there was a small quantity ofblood in the capsule, but none had passed into the bladder., He had seen two other cases of injury to the kidney in youngt male adults and in both of these there had been extensive- haemorrhage in the bladder and urine. Neither case

was operated on and both recovered. In neither of

1371

these cases was the injury a very severe one, one

being a fall on to the back on jumping over a

bonfire, and the other resulted from a slip in the street.-Mr. T. H. KELLOCK asked why Mr. Sutton removed thekidney transperitoneally, seeing that it would have been somuch more convenient to have approached the kidney fromthe loin.-Mr. HOWARD MARSH remarked that it was sur-

prising how well the kidney would bear free handling andhe thought it might often be sutured instead of beingremoved. He also asked Mr. Sutton why he had proceededin that way at the operation. He thought it better to shutoff the peritoneum first and then get at the kidney frombehind, for if he had wished to suture the organ it wouldhave opened into the peritoneum. For the treatment of the

collapse he strongly advocated saline injections with a littlebrandy or whisky. It was remarkable how patients ralliedafter this treatment. In reference to the symptoms of rupturedkidney external evidences were often entirely wanting in themost severe visceral injuries. He remembered a boy who wasbrought in after being run over in whom there was no exter-nal evidence of any kind, but at the necropsy the left lungwas found to have been completely torn off the bronchus.-Mr. BLAND SLTTON, in reply, admitted that in adoptingthe course he had done he was treading on debateableground. He had been brought up as a " loin " surgeon buthad gradually come round to Mr. Knowsley Thornton’s wayof treating these cases by transperitoneal incision. He haddealt with 25 cases of operation on the kidney through anabdominal incision transperitoneally, and with a littlecare the peritoneum could be brought together so

as to shut. off the general peritoneal cavity, leavinga more convenient means of draining than that

through the loin. In this respect he dealt with eachcase upon its merits. He believed the good results ofsaline injections could be obtained by repeated injectionsinto the rectum. He used about three ounces at a time witha little brandy, but he preferred making these injectionsafter the operation because, if used before, they were apt togive rise to much oozing of blood. His experience with theinjections had been principally in the treatment of rupturedgravid tubes. He discussed the treatment of these cases bysuture of the ruptured kidney, which Bradford had shownwould readily unite if the rapture were through kidney sub-stance. But the main point he wished to insist on was thatthe operation should be done early.-Mr. TURNER, in replyto the PRESIDENT, said there was a post-mortem examinationin his second case bat no injury to the intestine was found.He concurred in the view that the incision through thesemilunar line was a good one.

Dr. NORMAN DALTON read a paper on a case of EnlargedSpleen with Congenital Volvulus of the Stomach and Trans-verse Colon (simulating Splenic Anasmia) occurring in awoman, aged 38 years. The spleen was painless and hadprobably been enlarged since the patient’s first pregnancy.It now reached to the right iliac fossa. There was nohistory of malaria, syphilis, or alcohol, and the liver was notenlarged. All the symptoms of an&aelig;mia were present andthe blood showed 21 per cent. of red discs, 20 per cent. ofhaemoglobin, no increase of leucocytes, and no abnormalcorpuscles. No hemorrhages had occurred. She hadnoticed the pallor and debility for one year and whileunder observation remittent fever was present. Deathoccurred suddenly. The stomach was found to be strangu-lated and extremely distended by gas, and there was a perfora-tion due to sloughing existing at the cardia. The enlargementof the spleen was such as would have resulted from obstruc-tion of the splenic vein. Two other abnormalities werefound. 1. The transverse colon lay above the stomach (in theanatomical position), and before it reached the left lumbarregion was bent in such a way as to encircle the insertion ofthe oesophagus into the stomach. This abnormality was con-genital because the apron of omentum attached to the Itransverse colon had not united with that attached to thestomach, a state of affairs which existed in foetal life.2. The pylorus lay almost behind the cardia, so that when-ever the stomach became distended the fundus, by rotatingto the right and forwards, would half intertwist the cardiaand pylorus, so as to narrow both orifices. The grip of thecolon round the cardia was apparently not tight enough ofitself to cause obstruction, but when the spleen became largethe drag of its weight on the gastro-splenic ligamentpressed the cardia tightly against the encircling colon.This could be demonstrated on the post-mortem tableby traction on the lower part of the gastro-splenic

; ligament. Finally, some extra distension of the stomach produced such a twist of the cardia and pylorus that fatal- strangulation of the involved tubes occurred. The position

of the parts at the cardiac end of the stomach was such thatthe splenic vein might have been compressed from the first,but from the history it probably became loosened from itsattachments at the first pregnancy and then increased insize from traction and torsion of its vein. The an&aelig;mia andfever could, Dr. Dalton thought, be explained by the con-dition of the stomach. As regards diagnosis, lymph-adenoma, leucocyth&aelig;mia, malaria, and other splenic affee-tions were discussed and eliminated and he had come to theconclusion that the large spleen was due to obstruction of thesplenic vein, although he was not able to discover any cause-for such obstruction. It would be noticed, however, that theblood condition (oligocyth&aelig;mia and chlorosis without leuco-cyth&aelig;mia), the large spleen, and the fever established a closeresemblance between this case and the disease called splenican&aelig;mia or splenomegaly, though there were some minordifferences, such as the absence of haemorrhages and theapparent long duration of the case. Dr. Dalton was

not quite convinced that Banti was correct in considering-that splenomegaly was a "pathological entity," becausewhile the total number of cases of this affection whichhad been recorded was still small, in several of thosewhich were most carefully observed during life no

post-mortem examination was obtained ; and, further, ina few of those in which a post-mortem examinationwas made it had been shown that the symptoms couldbe explained without calling a new disease into existence.-Dr. PERCY KiDD remarked that as regards the production ofan&aelig;mia he hardly believed that the condition of the stomachcould altogether account for it. He quite agreed with Dr.Dalton in his doubts about splenic an&aelig;mia. He hadobserved some cases of cirrhosis of the liver in which thespleen was very greatly enlarged and there was intense-ansemia, and he suggested that possibly some of these casesmight have been taken for a new disease, which he thoughtthey should be cautious in accepting. No case of splenican&aelig;mia should be so labeled without being verified by post-mortem examination.-Dr. DALTON, in reply, admitted thatit was difficult to explain the an&aelig;mia, the connexion ofwhich with stomach disease had not been thoroughly worked’out. He referred to a case which had recently been pub-lished of removal of the spleen for "splenic ansemia," inwhich it was mentioned, however, that post mortem extensive-lymphadenoma of the abdominal glands had been found, yetit was still labeled " splenic an&aelig;mia."

OPHTHALMOLOGICAL SOCIETY.

Primary Neoplasm of the Optic Nerve.-Iritis : a Sequel toGonorrh&oelig;a.-Exhibition of Cases.

AN ordinary meeting of this societv was held on Nov. 9th,Mr. G. ANDERSON CRITCHETT, the President, being in thechair.Mr. E. TREACHER COLLINS and Mr. DEVEREUX MARSHALL

communicated a paper on two cases of Primary Neoplasmof the Optic Nerve. They exhibited also four other speci-mens of this variety of new growth which they had collected.Their first case was that of a boy, aged five years, who-had come under the care of one of them at the RoyalLondon Ophthalmic Hospital, Moorfields. The right eye hadbecome more prominent than its fellow and although treat-ment with iodide was tried no improvement occurred and itwas therefore decided to explore the orbit. While under-observation the proptosis had become more markedand the eye more flattened in its antero-posteriordiameter, as was proved by the fact that the hyper-metropia increased from 4 D. when it was first seen

to 9 D. at the time of the operation. The movements.of the eyeball were but very slightly limited. Whenremoving the eye it was found that the nerve was verymuch enlarged; this was divided as far back as the optic-foramen. On examination the growth was seen to be chieflycomposed of the very much thickened pial sheath ; there wasalso a great increase in the fibrous tissue of the nerve, andthe nerve fibres had almost entirely disappeared, leaving-apparently empty spaces. The second case was that of awoman, aged 46 years, whose sight had been failing for ninemonths. H&aelig;morrhages covered the retina and the eye was