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was of a headstrong disposition and impatient of control.On more than one occasion he got out of bed and it was onlythe skilful management of the house surgeon, Mr. JohnMcClean, that carried him through the danger of the firstfour or five days. The difficulty attending the diagnosis ofabdominal lesions directly after the infliction of the injuryis again demonstrated by this case. All abdominal injuriesshould be admitted to hospital when they apply, and itcannot be too strongly emphasised that the most serious

injury may be present without any apparent damage tothe abdominal wall or any excessive shock. The diagnosiswas very clear at the time I first saw the patient andI had no hesitation in preparing for immediate operation.In addition to the history of injury the abdominal painwas then very severe and the aspect of the patientindicated great anxiety. The vomiting which had beenthought to have been possibly the result of drink con-tinued and was frequent and distressing. Examination ofthe abdomen showed great rigidity of the abdominal walland much tenderness. The percussion note was not impairedanywhere. As a rule there is, I should say, no dull area incases of ruptured small intestine over the part affected bythe injury unless there is associated with the ruptured gut ahsemorrhage from ruptured mesentery. If there were muchcontusion of the intestinal wall with hsemorrhage into it onecould imagine some impairment of note, but it is not easy tounderstand how gut which has been paralysed by injury canproduce a change in the percussion note sufficiently pro-nounced to be of use in the diagnosis of these lesions,though possibly this might be due to want of tone in thewall of the gut-compare the dull note obtained by slackingdown a drum. French surgeons have expressed an opinionthat it is little use operating for ruptured intestine if morethan fifteen hours have passed since the injury, but it is to behoped that this will not be accepted generally, otherwise weshall certainly lose cases which might have been saved. Dr.

Wiggins successfully operated on a boy thirty-six hours afterthe injury.

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ANCOATS HOSPITAL, MANCHESTER.A CASE OF IRREDUCIBLE HERNIA ; ADHESION OF INTESTINE,

SEPARATION OF MESENTERY ; RADICAL CURE; RECOVERY.

(Under the care of Mr. STANMORE BISHOP.) THE special point of interest in the following case is the

accidental separation of the mesentery from a portion ofthe small intestine. It is often stated that the bowel is

liable to slough if this occurs and many instances of thisserious result have been recorded, but generally this happensonly when the separation has been much more extensive thanin the case recorded below.A man, aged fifty-one years, was admitted into Ancoats

Hospital on Jan. 10th, 1898. He was stout, flabby, andof rather coarse build; he had an irreducible scrotal herniaon the left side which he declared he had observed onlyfor nine months; he had never worn a truss. After restin bed for three days it became somewhat smaller but noattempt at reduction appeared to have any effect upon it.It was of about the size of a cricket ball and gave a clearnote on percussion, apparently containing only intestinewithout any omentum. When the patient first noticedthe swelling, about nine months before admission, it wasof the size of a duck’s egg, his attention being directed toit by some hypogastric pain. He had suffered from

cough but he did not attribute the swelling to the

coughing nor did he think it resulted from his employ-ment, in which he had to lift heavy bags of coal. OnJan. 14th the operation for radical cure was performed.The veins of the spermatic cord were varicose, the cord itselfbeing much thickened, elongated, and convoluted, but it waseasily separable from the sac. On opening the latter a

U-shaped coil of intestine was found; it was intimatelyadherent laterally; and while this adhesion was beingseparated by means of scissors it was found that the mesen-tery itself was being separated from the gut. The mistakewas recognised almost immediately and the adhesions werethen attacked nearer the neck of the sac and behind where agap was found and from this point the work was easy. Thebowel itself at the apex of the loop was shrunken andnarrowed in calibre, looking indeed as though it had been

1 Allingham: THE LANCET, May 5th, 1894.

compressed in the neck of the sac. At first resection of this.

portion was thought of, but the idea was rejected partlybecause the bowel retained its normal colour and gloss and,partly because the patient showed signs of commencing col-lapse. The neck of the sac was divided upwards, the bowel was.reduced, and the neck of the sac was tied, the remainder beingcut away. The ring and canal were then sewn up by threemattress sutures, applied as Noble suggests, so as to drawthe conjoined tendon behind Poupart’s ligament, leaving onlyenough room for the passage of the cord. The wound was,closed by horsehair sutures and sealed by celloidin. The-patient was greatly collapsed on the same night and verysick, the vomiting lasting until the evening of the next day.The first motion was passed on the second day. Recoverywas uneventful and the sutures were removed on the tenth.

day, the wound having healed by first intention. The.patient was kept in bed for six weeks and left the hospital,perfectly well on March 8th.Remarks by Mr. STANMORE BISHOP.-This case indicates,.

I think, the amount of reliance which may be placed upon.the anastomoses of vessels on the bowel wall, since in,the process of separation several of the direct smallersupplying vessels were divided.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

Lesions of tlte Pineal Body.A MEETING of this society was held on Dec. 6th, the

President, Dr. PAYNE, being in the chair.Dr. CYRIL OGLE exhibited two cases of Tumour of the,

Pineal Body. The first was a pigmented mixed-celled sar-coma about 1-21 in. in diameter associated with melanoticsarcoma diffused all over the cortex of the cerebrum and,invading brain substance along the fine vessels. The appear-ance of the brain was as if it had been painted with darksepia or black lead. Dr. Ogle referred to instances of diffuse’sarcoma in the pia mater described by Ziegler and to a.similar appearance due to melanotic sarcoma depicted inBramwell’s book on "Intracranial Tumours." The other-specimen was a mass about 1 in. in diameter, limited te.the region of the pineal body but pressing on and causingatrophy of part of the optic thalami and corpora quadri-gemina, the rest of the brain, including the pituitary body,being healthy. On microscopic examination it proved tobe of complex character, partly composed of vasculartissue like hyperplasia of the normal pineal body, but alsoof collections of exceedingly large cells with vacuolatednuclei and of cystic spaces lined by cubical epithelium,The whole, perhaps, was to be regarded as alveolar sarcoma.or endothelioma. with a tendency to revert to structures.found in birds in the pineal body. The symptoms in this;case included rapid blindness with dilated inactive pupils,no paralysis of the third nerve, but loss of the external move-ment of each eye. There was no other paralysis or loss of sensa-tion, but there were staggering gait and stiffness of themuscles of the back, vomiting, and fits, great enlargementof the penis and almost continuous sleep for from five to six.weeks or longer. Dr. Ogle referred to 8 other cases of pineal-tumour, 2 being hyperplasia or glioma, the remainder eachof a complex constitution, some containing hair, cartilage,and fat, others containing spaces lined by epithelium sug-gesting glandular tissue, most of them containing cysts andsarcoma tissue. Dr. Ogle pointed out that the pineal bodydeveloped as a hollow outgrowth of the fore brain, elabo-rated as in certain lizards, as shown by Baldwin Spencer,into a median eye of very perfect elements, but in mammalia.remaining in a rudimentary or rather a degenerate condition.as a solid body containing compartments filled with.reticulum and cells, processes of which appear to form the-reticulum. It had been suggested that the body might havenervous functions, its appearance being somewhat like that.of the granular layer of certain parts of grey matter ofcerebrum or cerebellum, but the appearance was morelike that of masses of neuroglia. Dr. Ogle thenconsidered whether the body had any metabolic func-tion comparable to that of the pituitary or thyroidbodies, although not representing, as they do probably,.

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glandular, secretory, or excretory structures in earlier

types of animals. He considered that it was fair to con-clude that the symptoms in the uncomplicated case of pinealgrowth could be well explained by pressure on the corporaquadrigemina, hence the rapid blindness without chokeddisc, stiffness, staggering gait, loss of conjugate movementof eyeballs. But possibly the precocious development of

penis might have some relation to disease of the pineal in- the same way as pituitary tumour appeared to cause enlarge-ment of the extremities, although apparently this was notborne out by the scanty clinical details of other cases. Inthe same way the excessive sleepiness, with perfect intellectwhen aroused, might be an effect of pineal disease. Thiswas found in several of the other cases collected and wasmot readily explained.- Mr. T. W. P. LAWRENCE exhibited a specimen of Glioma-of the Pineal Body. The organ was slightly enlarged,.circular in outline, and compressed from above downwards.It measured 14 mm. in diameter and 7 mm. in thickness,and showed slight signs of lobulation on its surface. Histo-logically the tumour consisted of a dense reticulum ofdelicate fibrils with scattered cells of small size, scantyprotoplasm, and of round or triangular type. A large propor-tion of the tumour had undergone degeneration and consisted-of granular material. The substance of the pineal body wasdisposed as a narrow zone at the periphery of the new’growth and was divided up into distinct areas by the latter.’The pineal body was free from adhesion to surrounding parts.The specimen was taken from a boy, aged sixteen years,who was under the care of Dr. Bradford at UniversityCollege Hospital. The patient died from tuberculous

meningitis of ten days’ duration ; his previous history wasgood and he had been free from illnesses, and there wereno symptoms referable to the presence of the enlarged:pineal body.

Mr. J. R. LUNN exhibited a specimen of Syphilitic Hyper--trophy of the Pineal Body which was found post mortem inthe brain of a demented female epileptic who had been in anasylum for ten years. She had had marked symptoms ofacquired syphilis and ultimately died from tuberculosis. Shehad left hemiplegia and frequent fits, but owing to her mental-condition accurate investigation of her symptoms was

,difficult. At the necropsy the pineal body was found greatly’hypertrophied, it being affected with fibrosis evidently of a- syphilitic nature. There were also two gummata in thebrain, one in the tip of the left occipital lobe and the other- in the right Rolandic region.

Dr. A. E. RUSSELL showed a Cyst of the Pineal Body found- in the body of a man, aged twenty-three years, who wasadmitted into St. Thomas’s Hospital comatose suffering fromfracture of the base of the skull the result of an accident.The pineal body was found to be distended by a thin-walled cyst containing clear albuminous fluid. No otherlesion was found. Careful inquiry from his friends failed tohdiscover that he had shown any symptoms during life.

Mr. S. G. SHATTOCK showed an exactly similar cyst fromthe Museum of the Royal College of Surgeons of England.’The history of the specimen was not known.

Dr. A. W. CAMPBELL (Rainhill) exhibited two specimensof Dilatation of the Central Canal of the Pineal Body. The’first case was that of a female epileptic, aged thirty-threeyears, who died from phthisis. The only marked intracraniallesion was enlargement of the pineal body, 13 mm. in length,10 mm. in width, and 8 mm. in depth, with a cyst-like dilata-’ tion of its central cavity, the contents being a glairy, brownishfluid. The wall of the cyst was composed of two layers; theouter was composed of normal pineal tissue, the inner stainedindistinctly and contained several large, pale, or faintly,granular cells, the nature of which was not evident. Therewere also scattered cells containing brown pigment. At theposterior part of the cyst these pigmented cells were

.arranged in a definite stratum. Possibly these might behaematoidin collections, but it was also possible that they-were pigmented cells analogous to those found in the choroid:and retina, and would confirm the view that the pineal bodywas a rudimentary organ of sight, and would also explainthe origin of a primary melanotic sarcoma in that body.’The second specimen was also taken from an epilepticfemale and was similar except that the dilatation was

.greater. Unfortunately no microscopic examination was

made.Dr. GARROD showed a specimen of Cyst of the Pineal

Gland taken from the body of a boy, aged sixteen years, -,who died from diabetes. The necropsy was made thirty-fivE

Hours atter death. The pineal body contained a small cystcavity of the size of a pea with smooth walls. It containedno hasmatoidin crystals. The fourth ventricle appeared to bequite natural and no other cysts were found in the brain. Thepancreas was small and was found on microscopic examina-tion to be markedly fibrotic. The liver and kidneys werefatty. It was probable that the cyst was of the same natureas those shown by Dr. Russell and Dr. Campbell.

Dr. VOELCKER showed a specimen of a Pineal Body inwhich there was a calcareous deposit. There was a similar

deposit in the choroid plexus on each side and extensivecalcareous degeneration in the arterial walls. There were no

symptoms during life pointing to an intracranial lesion.The PRESIDENT remarked that the pathological importance

of the organ was evidently small, as was to be expected fromthe fact that in the higher animals it seemed to be of a

merely rudimentary character. As Dr. Ogle had pointed out,it was recognised as having been (far back in the scale) aneye, but that must date back to the time when the tissueswere transparent. After opaque substances began to be

deposited in the tissues a central eye would become uselessunless brought up to the top of the head, as in certainreptiles. Cyst formation, such as had been illustrated, wascharacteristic of rudimentary bodies. The occurrence ofpigment was interesting as in the early days of the organthere must normally have been pigment present. The casesquoted had shown that the symptoms were those ofmechanical pressure on adjacent parts and did not atall suggest that the pineal body had any functionsanalogous to those of the pituitary body in forming substances which entered the blood.

ULSTER MEDICAL SOCIETY.

Ulceration following Scarlet Fever. -Larygeal Diphtheria.-classification of the Colon Group of Micro-organisms.

A MEETING of this society was held on Dec. lst, Dr.NELSON, President, being in the chair.

Dr. T. S. KIRK showed a child with extensive Ulcerationfollowing Scarlet Fever and producing a curious deformity ofone foot, the toes being covered by a fold of skin. A radio-gram was exhibited of the deformity.

Dr. A. B. MITCHELL read a paper on the Influence ofAntitoxin on the Mortality of Tracheotomy for LaryngealDiphtheria, with special reference to the results of operationin Ulster. Attention was first drawn to the prevalence ofdiphtheria in the north of Ireland, this being illustrated by amortality of 3402 from this disease in Ulster during the pasttwenty years, while during the same period in all therest of Ireland the deaths from the same cause were

only 3320. The annual death-rate per 100,000 inBelfast and the surrounding district was 14, while asimilar rate for Dublin was only 7. The beneficial effect ofantitoxin in the treatment of diphtheria and the consequentreduction in the mortality from this disease was referred toand it was then pointed out that the benefits to be derivedfrom its use were still more striking in those cases wheretracheotomy became necessary. The recovery rate aftertracheotomy in the hospitals under the Metropolitan AsylumsBoard, which was 28 per cent. without antitoxin, hadrisen to 63 per cent. since the introduction of the serum.For years there had been a firm conviction in the mindsof the profession in Ulster that tracheotomy in diphtheriaoffered no reasonable prospect of saving life and it wastherefore only performed on rare occasions and, indeed,rarely recommended. Dr. Mitchell communicated with theleading surgeons throughout the province of Ulster andsucceeded in collecting a series of 82 operations performedfor this disease previously to the introduction of antitoxin.Of these only 6 recovered, equal to a recovery-rate of7’3 per cent., a record sufficiently gloomy to justify thefeeling of the profession in regard to it. A similar listsince the introduction of antitoxin yielded a total of 20operations with 15 recoveries, equal to a recovery-rate of75 per cent. Though the number of cases was comparativelysmall it was contended that the figures were convincingand the attitude of the profession in the North of Irelandtowards tracheotomy must be reconsidered. The value ofartificial respiration after the trachea had been opened inthose cases in which respiration had suddenly been sus-

pended was particularly insisted upon, and records were