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and communicated it in a virulent form to his mother andsisters, who died from it.

Dr. LACK, in reply, said that the throat was affected aswell as the nose in his cases. In describing true nasal

diphtheria he had drawn his picture from cases associatedwith faucial diphtheria. There was membrane on the nasalmucous membrane in his cases. This could only be seen oncareful examination with a mirror as it did not affect thevestibule.

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MEDICAL SOCIETY OF LONDON.

Abdominal Section for External Injury.-Venesection inAcute Pneumonia.

A MEETING of this society was held on Oct. 24th, Dr.KINGSTON FOWLER, Vice-President, being in the chair.

Mr. MARMADUKE SHEILD read a paper on four cases ofAbdominal Section for External Injury not accompanied byWound. After referring to the extreme difficulty of decidinghow to act in this class of cases he related firstly the case ofa boy, eleven years of age, who was run over by a cab andshowed all the signs of grave abdominal injury, with seriouscollapse, which did not pass off. The abdomen was opened andfound to be distended with blood, like a ruptured extra-uterinegestation. The source of haemorrhage was found in a tearof the mesentery, which was repaired. The patient made arapid and complete recovery. The next case was similar-aboy was run over by a heavy vehicle. The abdomen wasfound full of blood and the jejunum was torn quite across. Aresection of intestine was rapidly done, end-to-end anasto-mosis being employed, and the mesentery was repaired. Thecase proved fatal and after death a second rupture whichhad escaped observation at the operation was found in thetransverse duodenum, which was the source of the fatal

peritonitis. The resected intestine had joined and heldwater under considerable pressure. The third case was adesperate one of ruptured liver in a boy, sixteen years ofage, and was related to show the success of the treatmentof the haemorrhage in these injuries by plugging withiodoform gauze. The last case was very interesting. A

woman, sixty-one years of age, was run over across the lowerabdomen and showed grave signs of injury, together withhsematuria. The bladder, however, held injected boric fluidand the diagnosis was made that it was intact. Blood,however, returned with the injection. The collapse andserious symptoms rather got worse than better and theabdomen was opened. There was some blood-stained fluidin the pelvis. The source of bladder trouble was apparent ina large ecchymosis of the size of a halfpenny on the posterioraspect of the fundus, just where rupture so commonly occurs.Careful examination showed that no actual perforationexisted. The liver, spleen, and renal regions were palpated,but nothing more was found. After the operation the

patient became feverish and maniacal. The symptomswere of the most puzzling nature and pointed to some

pyaemic process, though its cause was not even guessed at.After death a faecal abscess was found tracking up in theretro-peritoneal tissue towards the right kidney. This

originated in a small rent on the posterior surface of thecascum. It was peculiarly unfortunate that this had not beendetected during life as it admitted of such easy repair. Inconclusion Mr. Sheild discussed the indications for these

operations. The symptoms of ruptured kidneys and bladderwere generally to be demonstrated and the rules of treatmentwere tolerably clear. It was in ruptured intestine andmesentery, injuries of the liver and spleen and of the

sympathetic nerves, that the greatest difficulties arose.

As a general rule, when, after a severe abdominal injury,the symptoms were progressively grave, and especially if

vomiting and abdominal distension began to come on,exploration was indicated. The mortality would be indirect proportion to the gravity of the injuries ; thefatal operations are merely failures to save a life other-wise certainly cloomed. It was of the utmost importancethat these cases should be related. Only by accumulatedexperience could rules of practice be formulated.-Dr. KINGSTON FOWLER said it was interesting to notice thatin several of Mr. Sheild’s cases there was more than onelesion, a circumstance which made a full diagnosis extremelydifficult. In cases of chronic obstruction it was also oftenfound that there was more than one growth or other causeof obstruction. He asked whether in the cases of rupture ofthe intestine there was obliteration of the liver dulness. He

iad formerly thought that after perforation of a chronicalcer the disappearance of hepatic dulness was alwaysEollowed by a fatal issue, but he mentioned a case in whichapparently perforation of a chronic ulcer occurred. Aftersome hours the liver dulness became obliterated, and bothhe and a surgical colleague were quite convinced that perfora-tion had occurred. The patient refused operation and thenormal dulness gradually reappeared, recovery taking place.-Mr. G. R. TURNER mentioned a case of traumatic volvulus

occurring in a boy who fell 12 ft., striking his abdomen

against the pole of a boat. There was no wound, but theabdomen was explored twenty-four hours later. The volvuluswas found and released and the boy made a good recovery.Since then he had seen several cases of injury of the viscerawithout external wound. In the first there was abundant

haemorrhage from a small rent in the under surface of theright lobe, which was plugged, but the condition of the

patient was already very grave and be did not survive. Inthe second case a man who was carrying a heavy weightreceived a blow on the abdomen rupturing the smallintestine. This was found and repaired, and a herniafrom which he suffered was operated on at the sametime and he did well. Another patient was admitted

suffering from severe collapse and vomiting. He im-proved for a time but the vomiting returned and theabdomen was explored. A small tear was found in theunder surface of the liver, and in addition there was

enormous extravasation of blood in the retro-peritonealtissue. Vomiting persisted and he died from exhaustion caused’by vomiting ten days later. The kidney was found at thenecropsy to have been crushed to a pulp. A week lateranother man was admitted with symptoms of rupture ofthe kidney. The abdomen was opened in the linea semi-lunaris. There was no blood in the peritoneal cavity, butthere was again extensive retro-peritoneal haemorrhage. Thekidney was found to be extensively torn and was enucle-ated, the patient making a good recovery. Although heheld strongly the view that in cases of grave injury surgicalexploration should be resorted to the surgeon should exercisesome caution in coming to a decision, remembering that inthe old days some patients did recover under expectanttreatment, as was shown by specimens exemplifying repairafter injury of various organs to be seen in all museums.-Dr. F. LUCAS BENHAM mentioned the case of a boy whofell striking his abdomen against the kerb. There was painabout the caecum and severe peritonitis, with symptoms ofobstruction and stercoraceous vomiting. He was treated byleeching, the free administration of mercury internally andexternally, and afterwards with small doses of turpentine..He recovered without surgical assistance.-Mr. F. C..WALLIS said it was interesting that no gangrene of theintestine had resulted in the case of rupture of a mesentericartery. The influence of injury of the solar plexus incausing part of the condition of shock must not be over-looked. He mentioned a case which occurred in Germanywhere haemorrhage from the liver from a stab was

successfully treated by suturing. In cases of rupture,however, he was afraid the walls would not hold.-Mr. W. H. BATTLE insisted on the importance of watchingcases of abdominal injury from hour to hour, as gravesymptoms were often delayed and came on suddenly. Nogroup of symptoms could be relied on to indicate particularlesions. In cases of rupture of the intestine sometimes thesymptoms were clear and unequivocal, but often they weremasked. He mentioned such a case in which a man wasadmitted after being run over. He was free from pain,anxiety, and fever for four days, and then the temperaturesuddenly ran up and he died in a few hours. At the

necropsy a rupture of the small intestine was discovered.The amount of shock afforded little guide as to theseverity of the visceral injury. He asked Mr. Turnerhow long had elapsed after the injury before he

operated on the case of ruptured intestine.-Mr. TURNERstated that he operated about eight hours after theaccident.-Mr. SHEILD, in reply, agreed as to the

necessity for caution in deciding to explore. But if thecollapse did not pass off, vomiting continued, and theabdomen became distended, delay was dangerous. Hethought that Dr. Benham’s case might very well be one ofappendicitis lit up by the injury. In contrast to that case hementioned one in the practice of another surgeon where awoman fell and bruised the right side of the abdomen.There were symptoms pointing to injury of the cæcum, butno operation was performed. She improved for a time but

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a faecal abscess formed, no doubt the result of a small

rupture, and she died from pymmia. He did not place verymuch reliance on examining for dulness. The abdominaltenderness usually precluded careful percussion, and evenwhen fluid was present, unless it were encysted or in greatquantity, its presence was often masked by the distension ofthe intestines. The disappearance of the hepatic dulnessmight, he thought, be brought about by intestinal distension.as well as by free gas in the peritoneal cavity.

Dr. F. LUCAS BENHAM read a paper on the Advantages ofVenesection in Acute Pneumonia, with Cases in Illustration.It was based on the report of 19 cases in which venesectionhad been successfully performed. All these cases were

severe ones and in several life was undoubtedly saved bythis means. The series included some cases of pneumoniacomplicating influenza and phthisis. Reference was alsomade to the beneficial employment of leeches in some formsof pneumonia in children, particularly that which com-plicates whooping-cough, and is very apt to be fatal.Additional cases were mentioned where death occurrednotwithstanding bleeding or where death might have been.averted if recourse had been had to blood-letting. The

guiding principles laid down were that though venesectionaffords great relief in most cases of acute pneumonia fromthe earliest stages, and if performed in moderation neverdoes the slightest harm, yet that, as cases of moderate.severity recover by simple means only, venesection is

indispensable only in severe and dangerous cases, the objectaimed at being to convert a severe form of the disease into amild one-i.e., to subdue the over-intensity of the morbidprocesses, the chief indications to follow after noting theseverity of the initial rigor being a rapidly-increasingfrequency of the pulse and nervous disturbance marked bysleeplessness and wandering. As pneumonia is a disease thesymptoms of which increase in intensity from day to day untilthe crisis, the progress of this intensity may be checked or.stayed by blood-letting if it is advancing too fast and thusbetokens danger. It was possible that greater good mightbe done by bleeding at the very beginning of the disease,which might be cut short thereby ; but it was generally use-less to delay it till the last moment, when the patientwas dying from the formation of clots in the heart.-Dr. KINGSTON FOWLER said that it was now half a centurysince the antiphlogistic pathological theories had been laid.aside. It was possible that the pendulum had swung too farin the other direction. But personally, while he quiterecognised that venesection had a definite value as a thera-peutical weapon, he did not go as far as Dr. Benham in hisrecommendation of its use in pneumonia, although headmitted that his experience of its employment in that con-dition was limited. The condition which called for it wasdistension of the right side of the heart, especially in cases ofchronic bronchitis with emphysema. He mentioned such acase in which a patient was greatly relieved by freehemorrhage from the dorsalis pedis artery which was

unintentionally included in an incision intended torelieve the patient’s anasarca. It was also of undoubtedvalue in relieving for a time the pain of aneurysm.-Dr. B. B. JOLL said that he had practised formerly in adistrict where periodical bleeding during health was thecustom and where venesection was the routine practice inpneumonia and other fevers. The results were almostuniformly good.-Dr. Lucas BENHAM agreed as to the valueof venesection in cases of bronchitis, but he had intentionallyconfined himself to the treatment of pneumonia in his paper.He thought that venesection would be valuable in severalgrave diseases such as plague, hydrophobia, and the severerforms of malaria.

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OPHTHALMOLOGICAL SOCIETY.

Glioma of the Optic Nerve.-Tension of the Eye in Iride-cyclitis.-Exhibition of S’pecimens.

THE first ordinary meeting of the session was held onOct. 20th, Mr. H. R. SWANZY, President, being in the chair.

Mr. J. F. BULLAR and Mr. C. DEVEREUX MARSHALL com-municated a paper on Glioma of the Optic Nerve. The caseupon which it was based was that of a woman, aged thirty-seven years, who noticed nothing the matter until 1889, whenthe left eye became more prominent than natural. It con-tinued to become more and more pushed forward until 1895,when Mr. Bullar operated and removed the tumour with theeyeball attached. Immediately behind the globe the optic

nerve was of normal size for a distance of 15 mm. It thusformed a pear-shaped swelling 50 mm. long and 20 mm. wide.A cyst-like cavity was found inside this which containedstraw-coloured fluid. On opening it the interior was

found to be rough and vascular and had a fatty appear-ance. The tumour was encapsuled. The optic nerve wascompletely lost as soon as it entered the tumour, and itwas not again seen at the posterior part, as the growthextended at least as far as the optic foramen and was cutacross behind. The patient did quite well and hadsince married and was in good health. The tumour was

proved by microscopic examination to have originated in theneuroglia; Mr. Bullar and Mr. Marshall have thereforetermed it a glioma of the nerve. The eye was normal. Inthe literature on the subject 130 cases of growths of the opticnerve were recorded, and the results of these showed thatthese tumours were of slow growth, but should be classedas malignant, as they were liable to extend into thebrain, although metastases had not been found in anycase. The question of growths of all sorts found in the

optic nerve was discussed, and although the differentterms applied to them were legion, yet Mr. Bullarand Mr. Marshall were strongly of opinion that the

majority of them would fall into three groups: (1)those originating in the neuroglia, which should be termed"gliomata"; (2) those originating in the dural sheath,"sarcomata"; and (3) those originating in the pial sheath,endotheliomata. " Mr. Bullar added that there had beennu difficulty in removing the tumour. As soon as the con-

junctival sac was opened the finger passed readily into theorbit and the tumour was easily defined; it was not necessaryto clear out the orbit. The posterior section of the growthwas made as close to the apex of the orbit as possible, butthe tumour was cut through so that some portion of it musthave been left behind. It would have been quite easy toremove the whole of it, leaving the eye behind, but in thestretched condition of all the parts he had not thought thisadvisable.-The PRESIDENT remarked upon the rarity oftumours of the optic nerve. He only remembered seeing onecase.-Mr. J. B. LAWFORD referred to a case published byMr. Rockliffe in which part of the tumour had been left in theorbit without ill consequences.-Mr. TREACHER COLLINS com-mented on the great variety of names which had been givento this form of tumour. He thought the best classificationwas the anatomical one-those originating in the sheaths ofthe nerves and those starting in the nerve itself. The opticnerve was a prolongation of the brain substance and gliomataof the optic nerve resembled those of the brain in structurerather than those of the retina, which approached theembryonic type in their round-celled formation.

Captain H. HERBERT, I.M.S., made a communication onthe Tension of the Eye in Irido-cyclitis based on observa-tion of 144 eyes affected with the disease. In the majorityof attacks, more especially in the milder attacks, thetension was, as in simple hypersemia of the iris andciliary body, reduced, the reduction lasting, as far as

the evidence went, at least as long as any ciliary injectionremained. In other cases a period of high tension of veryvariable duration came on. The high tension appearedto be due to blockage of the normal outlets from theanterior chamber, and the eyes chiefly affected were (1) thosevery severely attacked with copious exudation ; and (2) eyesperhaps lightly attacked but predisposed to glaucoma, asshown by shallow anterior chamber in the sound fellow eyeand by more or less advanced age of the patient. In these

high tension cases the anterior chamber was deepened andthe pupil slightly dilated. In the most intense inflammationsthe plus tension rapidly gave way to a softening, which mightbe permanent and which indicated atrophy of the ciliary body.The mild attacks, which were little removed from primarysubacute glaucoma, were of interest because of difficulties indiagnosis and in treatment. There were no grounds for

attributing high tension to cyclitis as distinguished fromiritis.-Mr. PRIESTLEY SMITH said that the principlesenunciated by Captain Herbert were now generally accepted.There were two processes, mutually antagonistic, concernedin the regulation of tension in irido-cyclitis : one was thesuppression of secretion reducing the tension, the other wasthe formation of an albuminous exudation hindering filtrationand raising the tension. He had been glad to hear in thispaper of the value of the tonometer he had introduced ; afterlonger experience he thought it very valuable if its limita-tions were recognised. He had made some experiments ontension some years ago in which a perfectly limpid