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years. The cyst was incised and drained by the late Mr.Leopold Hudson and the patient was now in’perfect health.-Dr. DE HAVILLAND HALL mentioned a case of pancreaticcyst in which jaundice was one of the first symptoms. Asthis did not clear up Mr. Pearce Gould cut down and found acyst of the head of the pancreas.-Mr. BATTLE asked if’therewere any facts showing what liability there was to relapseand as to the efficacy of drainage from the loin. He men-tioned a case that he had seen with Dr. Hector Mackenzie ofenlargement of the liver, probably syphilitic, in which aswelling appeared in connexion with the head of the pancreas.As this did not disappear under iodide of potassium heexplored and found a mass there the nature of which couldnot be ascertained, but it entirely disappeared and wasprobably gummatous.-Mr. DORAN, in reply, said that thehard material mentioned by one or two speakers as affectingthe head of the pancreas was probably pancreatitis, in somecases possibly traumatic. A posterior incision had beenadopted by Mr. Pearce Gould in his first case. He thoughtthat the cyst removed by Mr. Malcolm very closely resembledthe retro-peritoneal cysts, probably congenital, which weresometimes met with in front of the kidney.-Dr. ROLLESTON,in reply, said that in three fatal cases of acute pancreatitiswhich he had seen there had been localised effusion intothe lesser peritoneal cavity. Possibly if they had recoveredthis eff asion of fluid might have become encysted. Enlarge-,ment of the head of the pancreas might be due to malignantdisease, but it was also common in any cases of inflamma-tion about the pylorus or duodenum from localised pan-creatitis, and Dr. Hale White had shown that the head of thepancreas might be so much enlarged as to be palpable inconsequence of back pressure from cardiac valvular disease.- Mr. MALCOLM, in reply, said that the cyst in his case wasvery like the retro-peritoneal cysts referred to by Mr. Doran,but it was very closely associated with the tail of the

pancreas and large vessels entered it from that body, so thatlie had little doubt that it was a true cyst of the pancreas.

CLINICAL SOCIETY OF LONDON.

Acute , Intestinal Obstruction; ,. Deat7i from IntestinalTox6eq7tia.-Yesical Calculus as a Result of Injury of the

, Bladder during the Operation for Radical Cure ofHernia.- Cases of Intusszcseeption.A MEETING of this society was held on Dec. 10th,

Mr. LANGTON, the President, being in the chair.Mr. PEARCE GouLD read a paper on a case of Acute Intes-

tinal Obstruction relieved by operation in which deathoccurred on the ninth day from Intestinal Toxsemia. The

patient was a man, aged forty-three years, who developedsymptoms of acute intestinal obstruction after receiving astrain at his work. On the fourth day the abdomen wasopened and a coil of small intestine was found in the pelvisadherent and twisted on itself. This was liberated and atonce the fluid intestinal matter passed into the collapsedlower ileum and cæcum. Next day a small motion waspassed and two days later flatus passed freely and also alarge formed motion showing that the obstruction was

relieved. For three days after the operation intestinalmatter regurgitated- into the stomach and was removed bywashing out the’stomach’on three occasions. The patienttook fluid food well and there were no signs of peritonitis,but still the urine continued to give a very dark indicanreaction with nitric acid and gradually he passed into a con-dition of stupor, deepening into coma, accompanied by aslightly quickéned pulse, quickened, deep, and noisy respira-tion, a subnormal temperature which was lower in therectum than in the axilla, profuse diarrhoea, the motionsbeing of a peculiar odour and of a grey-green colour,and the skin was covered with a dark erythematous rash.These symptoms first reached their maximum on thesixth day after the operation; four pints of saline fluidwere injected into a vein and immediately all the sym-ptoms passed away. He relapsed next day and salinefluid was again injected with marked benefit. Two dayslater he again became unconscious and died comatose inspite of a third injection of salt and water. All this time the-urine contained a great excess of indican and Dr. P. A. Young,who analysed the urine, found that another chromogen waspresent which was converted into dark brown pigment byoxidation but was not melanin. Mr. Gould pointed out that!Jhe symptoms were toxic and their slow onset, coupled

with the marked instantaneous effect of saline infusionand the succeeding relapse, he took as showing thepoison was a chemical one which only exerted itsinfluence when in a certain degree of concentration.--Mr. A E. BARKER mentioned the case of a woman whoseabdomen was opened in consequence of intestinal obstruc-tion. The cause was a growth which could not be removed’and intestinal anastomosis was performed. A few daysafterwards she developed an erythematous rash, whichhe believed was due to poisonous substances absorbedfrom the bowel —Dr. P. A. YOUNG called attention to thetoxic substances contained in normal urine whichwhen injected into the blood caused acceleration ofthe heart, pyrexia, frequent micturition, and death.-Dr. COLMAN mentioned a case which was under the careof Mr. Grubb in which intestinal toxaemia caused notcoma, as in the preceding cases, but mental excitement.The patient was a woman, aged about forty years, who had alarge fsecal impaction in the ascending colon. Under treat-ment the mass became softer and she began to pass feacalmaterial in considerable quantity. But on the third-day shebecame delirious with no knowledge of her surroundings,with hallucinations of hearing and hallucinations of visionwhich took the form of animals running about her bed,which did not terrify her but amused her. Therewas no history of alcohol or of the administration ofbelladonna. Her temperature was low and her pulsewas quiet. By means of frequent enemata the bowel wascompletely emptied and the delirium entirely passed off.Dr. Colman remarked that erythematous rashes were notinfrequently met with in children after the administrationof enemata.-Mr. EASTES observed that in chronic casesthere was often ulceration above the seat of the obstructionand it occurred to him that toxic substances might beabsorbed through such a raw surface which would not pene-trate the normal intestinal wall.-Mr. MAKINS asked whetherthe urine or the blood had been examined for micro-organisms. He thought that the rash was more likely to beof bacterial origin than due to chemical products. It wasremarkable that the pulse should remain so steady if thecondition was one of toxæmia.—Mr. GOULD, in reply, saidthat neither the blood nor the urine had been examined formicro-organisms. He thought that the evidence as a wholefavoured the view that the condition was caused by achemical poison rather than by living organisms.

Mr. LOCKWOOD described a case in which he per-formed Lithotrity for the removal of phosphatic calculiwhich had resulted from an injury to the bladder somemonths previously. The patient had been operated on

in June, 1895, for the radical cure of a right inguinalhernia. He was, however, rejected for the army becauseof another incomplete inguinal hernia of the left side.In November, 1895, this was operated upon by Mr. Lock-wood. Soon afterwards the patient complained of dis-comfort in the bladder and it was ascertained that atthe first operation a finger-like extension of the bladder hadbeen opened in dissecting away a mass of fat near the neckof the hernial sac. The opening had been closed by silksutures. Pus afterwards appeared in the urine and a cysto-scopic examination revealed the presence of two phosphaticcalculi. Mr. Lockwood -removed these by lithotrityand the patient soon recovered. No remains of ligaturescould be found in the debris of the calculi. It was suggestedthat in future such injuries should be sutured with sterilisedcatgut inserted by Lembert’s method.-Mr. BARKER asked whether there were many cases on record in which calculi hadformed after ligature of the bladder in the ordinary way inconsequence of the ligature forming the nucleus of acalculus. He had difficulty in understanding how thesutures should find their way into the cavity of the bladder.-The PRESIDENT said that hernia of the bladder was morefrequent than was believed and was more common in menthan in women and usually occurred on the right side. Therelation of the peritoneum to the displaced organ was veryvariable. The etiology of the condition was obscure.-Mr. PEARCE GOULD relnted. the case of a woman on whomhe operated for a small swelling in the crural canal whichproved to be a subserous lipoma. He dragged firmly on it,ligatured it, and cut off the end. Extravasation of urinefollowed and no doubt when dragging on the fat he hadruptured the bladder wall. Mr. Pearce Gould remarked thatin this case the patient was a woman and the hernia was’on the left side.-Mr. MAKINS thought that there wasa tendency for any ligature in the pelvis to pass into the

1593

-bladder just as a ligature applied to the outside of theintestine usually found its way into the lumen of thebowel.—Mr. LOCKWOOD replied.

Mr. A. E. BARKER read a paper on Fifteen Consecutive’Cases of Intussusception in eight of which injection failed,.-and subsequent events showed that no less than twelve ofthe fifteen could not possibly have been reduced by injectionwhen first seen. He concluded, therefore, that except in the’rare instances in which the case was seen within a few hoursof the onset of the symptoms it is safest not to employ in-jections but to proceed at once to abdominal section.-Mr.LOOKWOOD said that after twenty-four hours the immediateperformance of laparotomy gave the patient the best chance;after that time injection rarely did good and might do harm.-’Mr. E. W. ROUGHTON said that his experience was limitedto one case and in that he was able to open the abdomenwithin twenty-four hours of the commencement of the

symptoms with a good result. The recorded cases appearedto show that the chances of recovery were in inverse pro-portion to the length of time that the symptoms had lastednd there were very few cases which recovered if thesymptoms had lasted more than two days, and more recoveredwhen operated on without previous injection than when injec-tion had been tried, perhaps because of the delay involved.-Mr. BARKER, in reply, said that any liability to ventralhernia might be minimised by adopting a very small incision.In most cases an incision large enough to admit a single fingerwas sufficient. He should hesitate to draw conclusions fromcollation of isolated cases from the medical journals as onlyselected cases were published. A consecutive series of caseswas more reliable and instructive.

OPHTHALMOLOGICAL SOCIETY.

Foreign Bodies lodged in the Eye and Orbit.-Mules’s Opera-tion for Ptosis.-Aon-rec2crrent Orbital Sarcoma.-SolidŒdema of the Conjunctiva.-Traumatic Cyclitis.-Speci-1nens of Pseudo-glioma.-Secondary Sareoma of the Orbit.-Chip of S’teel in the Vitreous for Eighteen Months.-Per-forating Wound of the Eyeball. -Reezirrent MerobranousOonjunctivitis.A CLINICAL meeting of this society was held on Dec. 9th,

’the President, Mr. H. R. SwANZY, being in the chair.Mr. HARTRIDGE showed a case of Laden Pellet lodged in

the Eye, with skiagraph. The patient was shot in the righteye by a pellet from an air gun. When seen two hours afterthe accident there was a large linear wound of the corneawith prolapse of the iris and hemorrhage into the anteriorchamber. There was no perception of light. Tension -1. Theprolapsed iris was cut off. Two days later, after the bloodin the anterior chamber had cleared up, it was found thatthe lens was wounded. A skiagraph was taken, the platebeing placed on the right side of the head and the Crookes’stube on the left so that the x rays passed through the headfrom left to right. The exposure was fifteen minutes. Theresult showed that the pellet was lodged about the middle ofthe orbit. The eye was excised as it was obviously lost,.-and the pellet was found lodged in the globe.-Mr. J. F.BULLAR also showed a Skiagraph of a Fragment of a

’Percussion Cap in the Orbit.-Remarks were made by thePRESIDENT, Mr. BICKERTON, Mr. JOHNSON, Mr. TAYLOR,Mr. POWER, and Mr. HOLMES SplCBE.Mr. W. J. CANT and Mr. A. S. MORTON each showed a case

of Ptosis treated by Mules’s operation which consists in theinsertion of a wire loop from the free edge of the lid beneaththe skin to the eyebrow. Mr. Cant’s case was one of con-genital ptosis of one eye. When the frontalis muscle wasput into action the lid was raised by means of the loop so asto expose the pupil. Mr. Morton’s case was one in whichptosis had been present in the right eye for twenty years andin the left eye for three years. Referring to the difficultyof tightening the suture Mr. Morton had had a communica-tion from Mr. Mules in which the latter said he used silverwire as stout as the lid would bear and before using it heheated it in a spirit lamp to make it less brittle. Afterinserting the suture from the free edge of the lid to abovethe eyebrow he allowed it to remain five or six days beforetightening it. In order to tighten it the wire near the endswas grasped with lead-lined forceps while the ends weretwisted. Mr. Morton had also heard from Dr. TathamThompson of his experience which was entirely favourable.In one of his cases after two months’ use a blow on the eye

caused the wire to snap but the ptosis was not so bad as ithad been before insertion of the suture, a certain amount ofcicatrisation of the subcutaneous tissue of the lid havingbeen set up.Mr. MoRTOrr showed a case of Non-recurrent Orbital Sar-

coma. The patient had had a sarcoma extending from theupper outer part of the orbit to its apex. The whole of thecontents of the orbit were removed and chloride of zinc pastewas applied. After fourteen months there was no sign ofrecurrence.

Mr. HOLMES SPICER showed a case of Solid (Edemaof the Conjunctiva. The patient was a woman, agedtwenty-one years. The condition was present in the right eyeonly ; it was confined to the ocular conjunctiva; it had beennoticed for about three or four months. The only apparentcause was an obstruction to the return of lymph from the eyeproduced by suppuration and subsequent cicatrisation inthe lymphatic glands of the neck two years before. Onthe affected side the preauricular and cervical glands hadboth suppurated, and on the other side the cervicalglands only. There was no proptosis of the eye; thevision was normal and the retina and its blood-vesselsappeared normal. There was no sign of disease in the nasalpassages.-The PRESIDENT thought the case was a veryrare one.-Mr. ADAMS FROST thought it was similar to twocases shown at the society some years before by Mr. DonaldGunn which were described as syphilitic infiltration of theconjunctiva. In those cases he thought the preauricularglands were also enlarged.-Mr. SILCOCK referred to a casewhich he had published in the Transactions of the societysimilar to this one ; he had incised the conjunctiva andscraped granulation tissue from Tenon’s capsule.-Mr. EALESspoke of a case of similar appearance which he had seen.Mr. MARSHALL showed a specimen of Traumatic Cyclitis,

in which the injury had been caused by a piece of wood;there was a dense cyclitic membrane dividing the eye intotwo cavities.

Mr. MARSHALL showed one specimen of Pseudo-Glioma,and Mr. ERNEST CLARKE another. In the former the childwas seven weeks old, there was a white mass seen behind thelens, and the tension of the eye was raised. After excisionthe case was found to be one of pseudo-glioma. Mr. Clarke’scase was one of bilateral pseudo-glioma, in which there wasa record of pseudo-glioma occurring in two other membersof the family.-Mr. TREACHER COLLINS said that he wouldhave been inclined, apart from the family history, to haveregarded this as a case of congenital membrane in thevitreous.Mr. RIDLEY showed a case of Secondary Sarcoma of the

Orbit. There were all the signs of a tumour of the orbit,and there were also tumours of the scalp, of the supra-spinous fossa, and of one fibula.-Remarks were made byMr. JESSOP, Mr. EALES, Mr. COLLINS, and Mr. NETTLESHIP.

Mr. LAws showed a patient with a Chip of Steel in theVitreous which had been there for eighteen months. Therewas no sign of irritation; the body in the vitreous was encap-suled ; there were several red streaks on the lens and finered particles all over the surface of the lens; the lensremained clear for fifteen months but had slowly becomeopaque in its posterior parts.

Dr. BRAILEY showed a case of Perforating Wound ofEyeball. The patient’s right eye had been struck by a pieceof wood. There had been a wound of the cornea and prolapseof the iris; the prolapse had been removed. Without anyapparent cause the vision of the other eye which hadremained quite good for two months and a half wasbeginning to deteriorate and had fallen from to 6/18. Therewas no sign of sympathetic inflammation and nothing toaccount for the defect.

Mr. BATTEN showed a case of Recurrent MembranousConjunctivitis. The membrane had been removed severaltimes but always recurred; it had the appearance of a

superficial burn. The bacteriological examination had notbeen completed.

NORTH LONDON MEDICAL AND CHIRUR-GICAL SOCIETY.

Exhibition of Cases and Skiagrams.A MEETING of this society was held on Nov. 11th, the

President, Dr. DAVID FAIRWEATHER, being in the chair.Dr. SCLATER JONES read the notes and showed Skiagrams