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-;an Anglo-Indian patient, aged about 50, who had avery faint nebula in the centre of each cornea due to axecent ophthalmia. Ophthalmoscopic examinationshowed that she was also suffering from cataract at- a very early stage. She told me that her vision hadbecome useless for anything distant or fine. I gaveher a subconjunctival injection of cyanide of mercury- in each eye, which I believed would clear up the cornealnebulae, and asked her to write and let me know after8ome weeks the condition of both near and distantvision. She wrote to say that both had recovered-and were as good as they had ever been.

It struck me, on thinking over the case, that thiswas impossible unless the hyperaemia (which I hadinduced) had also influenced the nutrition of the lens.In the railway class of patient and others who cameto me I was able to see many cases of early cataract,:and I treated them on the same lines, being agreeablysurprised at my success. I tried cases at differentstages and found that up to 6/10 we might expect to be.successful in almost every case. Even 6/12 may recoverto 6/6. But while the result in 6/10 and less lasts for’years 6/12 or more has a tendency to recur. (I do not’wish it to be imagined that dead tissue, such assand-like opacities, or minute opaque striae, whenpresent, disappear.) I have had many cases under,observation for years and am satisfied that the treat-ment is eminently satisfactory, both for the patientand for the surgeon.

The Z)6Kye?’-<S’?<yMo.As regards the future of the question, I hope that

- ’the general practitioner will learn to recognise that ifailing distant vision in people over 40 is the first sign of cata,ract, and that he would do well to send- the patient to an ophthalmologist for investigation. If-this is done in every case it seems to me that opera-tions for senile cataract will in the future be lessfrequently necessary, and that it will be found that the- early stage of cataract is more frequent in peopleover 50 years of age than is usually supposed.

Since I wrote my first paper on this subject I havelearnt that eye-baths containing iodide of potassiumand other agents have been tried over long periodswith success. I have tried iodide of potassium sub-conjunctivally and have found that from 15 to 18 gr..to the ounce give an efficient hyperamia, giving thesame result as 1 in 4000 cyanide of mercury injection.My opinion is that the agent (dionin included) doesnot matter; the result depends not on the agent but,on the hyper&aelig;mia. From my experience of malingererswho use nicotine to produce an ophthalmia I thinkthat drops of nicotine solution would be as effectiveas dionin or more so. I

Also, since the appearance of my first paper onthis subject I have learnt that many men have triedthis treatment; some have not found it successful,whilst others have found it satisfactory. Diagnosismust be carefully made ; failing distant vision fromother conditions than cataract is to be considered, andI suspect that the failures have been due to mistakendiagnosis.By what mechanism does this treatment affect the

nutrition of the lens, or the elimination of its waste,.or both ? If it be assumed that an atheromatouscontraction of the channels conveying nutriment tothe lens is the cause of cataract then results such ashave been obtained for years-from mere dilation of-these channels caused by a few weeks’ hyper&aelig;mia&mdash;would not be expected. One would expect theatheromatous condition to recur rapidly, as it does inother structures. It seems to me that to explain thesefacts we must assume that a special pabulum for thenutrition of the lens is metabolised by some of thecells in the ciliary region, and that cataract is due toa pathological condition of these cells and to the:pabulum issued by them, this pabulum being non-physiological and incapable of maintaining physio-logical nutrition of the lens.

Conclusion.The results of the treatment would imply that the

induced hyperaemia re-establishes the physiological

condition of the metabolising mechanism. I think theexistence of such a mechanism will not be disputed ;it is, of course, a matter of speculation, but the specu-lation has facts behind it. The influence of a hyper-camia in other regions of the body is beyond the domainof doubt, as is the influence of local blood-letting,which is very closely allied to that of artificial hyper-semia. The influence of local blood-letting over apainful and acutely congested liver is very marked.I have explored with a trocar a large and painful liverfor abscess a number of times and failed to find one.Four or five ounces of blood escaped and I was agree-ably surprised to find that the patient was quicklyrelieved of all his trouble and continued to be so.The question of cataract opens up a wide field for

the physiologist, and I hope that physiologists willdevote more attention to the nutrition of the lens andvitreous than they have done in the past.

Clinical Notes:MEDICAL, SURGICAL, OBSTETRICAL, AND

THERAPEUTICAL.

A CASE OF

LOSS OF SPEECH, MEMORY, AND HEARINGFOLLOWING INJURY: RECOVERY

AFTER OPERATION.

BY JOHN J. WADDELOW, J.P., F.R.C.S. ENG.,MEDICAL OFFICER TO THE WHITTLESEA WORKHOUSE INFIRMARY,

THE following case of loss of speech, loss of memory,and loss of hearing following an injury is of interest.The patient recovered after operation.W. S. G., aged 21, was admitted to the Whittlesea Work-

house Infirmary as a certified lunatic on Oct. 21st, 1921.When I first saw him he was sitting in a chair and wasperfectly quiet. I was unable to make him hear, but couldconverse with him in writing. He did not know his ownname or the name of his father or the name of the streetwhere he had lived in the town, and when his mother visitedhim he did not recognise her. On visiting days, however.he would write that he expected a friend ; up to the time ofhis injury his memory was a blank. On his arrival atWhittlesea he did not recognise the town, the road, theWorkhouse. or any person. His vision was unaffected. Hehad some scars on his scalp and a definitely tender spot2 in. behind the right external angle of the frontal bone,4 in. above the zygoma. I also learned that he had aninjury preventing him using his right arm and was taught tosew and write left-handed. This injury cleared up and hewas able to resume the use of his right arm.

I am indebted to Dr. J. H. Skeen, of the Fife andKinross District Asylum, for the following communica-tion dated Dec. 18th, 1921.

" While he was in the poorhouse here he was, I under-stand, X rayed, and the report, which I did not see, but heardof, was to the effect that there was a definite fracture at thepoint you mention, with depression. I mention this withsome diffidence as I neither saw the plates nor the originalreport. I sent him to Dundee to be operated on, but asthey insisted on an X ray report there, and as this tooksome time owing to their X ray expert being away for afew days, patient got rusty, kicked up a row, and, of course,the hospital would not keep him any longer, consideringhim a dangerous lunatic."

Operation.On Nov 5th I operated, turning down a flap making the

tender spot the centre, and trephined the skull with a inchtrephine. I saw no sign of the fracture or depression whichI had thought I could feel through the scalp. On removingthe disc of bone a large branch of the middle meningealartery crossed the opening which was occluded ; no pulsationwas visible or perceptible on pressing the dura. I nextincised the dura with a free incision and was met with agush of blood-stained fluid which I allowed to escape ; thebrain underneath was plainly visible, pulsating and normal.I closed the wound by continuous suture without replacingthe bone, and no drainage was inserted.

225

The operation was begun at 11.30 A.M. ; by 1.45 thepatient was conscious, and had recovered his hearing andspeech; he asked who had operated and when toldimmediately said, " Oh, I remember him," and gave a verygood reason. The wound healed by first intention, andwith the exception of some vagaries in temperature therecovery was uninterrupted. His own account of the injurywas that he travelled from London with a friend (?) onJune 21st, 1921, and left the train some 30 miles from wherehe intended to go ; his friend discovered that he had friendsin the neighbourhood and proposed to go to them. Bothbeing tired by the journey from London and the summernight being fine and warm, they decided to sleep in the open.The next thing he remembered was waking up in hospitalminus .618.

The man is now quite normal as regards speech,hearing, and memory.

SPONTANEOUS RENAL FISTULA.

BY E. F. GUY, M.B., B.S. LOND., B.SC. WALES.JUNIOR MEDICAL OFFICER, GRANGETHORPE HOSPITAL,

MANCHESTER.

SPONTANEOUS renal fistula is a rare occurrence, andthe following case in a pensioner is of interest.

J. B., aged 23, was admitted to Grangethorpe Hospitalon Nov. 8th, 1920, with a discharging sinus in the right loin.He stated that during physical training in August, 1918, hewas jumping from a board and slipped ; in falling, theright side of his back was struck by a support. The accidentwas followed by severe pain in the right loin, which almostprevented his walking, and kept him awake at night. Threeweeks later a swelling formed in this region. He had slightpain on micturition, but the urine was clear and containedno blood. An abscess apparently formed under the skin andhe was admitted to hospital. The abscess was openedwithout anaesthesia and a quantity of pus evacuated.Although scraped in December, 1918, the abscess failed toheal, and an operation was performed in April, 1919, thenature of which is not known. An X ray taken shortlyafter admission to this hospital showed indefinite shadows onthe right side at level of the eleventh and twelfth ribs,looking very like sequestra in a psoas abscess, and shadowsnearer the iliac crest, thought to be calcified glands. Patienthad no urinary symptoms or any kind.

First Operation.-On Feb. 10th, 1921, the sinus was

explored and found to pass deep to the twelfth rib, part ofwhich was excised. No sequestra were found. After thisoperation he had scalding at the end of micturit,ion and alittle pus in the urine for about a week. The urine wasexamined for tubercle bacilli but none found. The sinusremained open and further exploration was decided on.Second Operation.&mdash;On June 30th the sinus was followed

down, the operation necessitating removal of remainder ofthe twelfth rib. It was found to pass towards the upperpole of the right kidney with which it communicated. Witha probe renal calculi were felt at the bottom of the sinus ;three calculi were removed. There was no h&aelig;maturia afterthis operation and no obvious escape of urine from the sinus.As the sinus still failed to heal, a further X ray was taken,which showed a shadow in the right kidney.

Third Operation.-On Sept. 4th the kidnev was exposedby an oblique lumbar incision. It was felt to be verysclerotic and adherent to surrounding tissues and to thediaphragm. The capsule could not be stripped. One largeand two small calculi, apparently encysted in fibrous tissue,were removed and the wound closed around gauze plugging.Following the operation, the urine contained a trace of

albumin, but no blood, and again there was apparently noescape of urine from the wound. The sinus now slowlyclosed up and two months later was dry and soundlyhealed.

Remarks.&mdash;This case agrees with those previouslydescribed as to absence of renal and urinary symptoms,and this fact, together with absence of blood from theurine after operation, and of any trace of urine inthe discharge from the wound, is probably connectedwith the encysted condition of the calculi. At notime was there any suggestion of renal colic.The three operations described were performed by

Mr. Geoffrey Jefferson, to whom I am indebted forpermission to publish these notes.

LITERARY INTELLIGENCE.--Mr. Murray announcesthe forthcoming publication of "The Chemistry of theRadio-Elements," by Dr. A. S. Russell, and of a second(revised) edition of " Cancer of the Breast and its Treatment,"by Mr. W. Sampson Handley.

Medical Societies.ROYAL SOCIETY OF MEDICINE.

SECTION OF MEDICINE.

THE DIAGNOSIS OF GASTRIC ULCER.A MEETING of this section of the Royal Society of’

Medicine was held on Jan. 24th, Sir W. HALE-WHITF,the President, being in the chair.

Dr. C. BoLTON opened a discussion on the abovesubject. After a brief description, illustrated bylantern-slides, of the various types of acute andchronic gastric ulcer, he passed to the means of’recognition of the presence of an ulcer by (1) theaccidents of the disease : haemorrhage and perforation,the latter being outside the scope of the presentdiscussion; (2) the associated disorders of gastricfunction ; (3) X rays combined with a bismuth meal.

H&oelig;morrhage.Haemorrhage constituted the most valuable

diagnostic sign. The haemorrhage from acute ulcerusually occurred without any preliminary gastricsymptoms, and might take the form of haematemesisor melsena. In the latter case the patient not

infrequently sought advice on account of faintingattacks or anaemia. The haemorrhage might bemistaken for the bleeding consequent on certain non-gastric diseases-hepatic cirrhosis, anaemias, &c.There was also a form of gastritis which gave rise to’haemorrhage. Haemorrhage from chronic ulcer wasusually accompanied by a characteristic pain, andwhen it occurred might be said to clinch the diagnosis.Very occasionally chronic ulcers gave rise to melaenawithout symptoms, and such cases were very difficultto diagnose from cancer.

The Interpretation of Disorders of Function.These might be motor or secretory ; chronic ulcer,

by increasing the muscular irritability of the stomach,.gave rise to pyloric spasm with diminished rate ofemptying, or occasionally to spasm in other parts ofthe stomach. Acute ulcer had no such effect unlesssituated close to one of the orifices. Such motordisorders were recognised by the symptoms of pain,and by means of the X rays. Pain, of course, occurredin disorders of the stomach other than gastriculcer, but the pain of gastric ulcer had usually the-following very definite characteristics : it was

situated in the epigastric region, and accompanied bytenderness and muscular rigidity ; it was severe and-recurred frequently in more or less prolonged attacks ;-it had a constant relation to the taking of food andwas relieved by vomiting; and its characters appearedfairly constant in the same ndividual.The alterations which occurred iir the secretory

function in gastric ulcer might occur in other gastric-conditions, so that the results of a test-meal couldonly be of value when interpreted in conjunctionwith the other findings. The single test-meal giving-the total free and combined HCI was open to the-objection that the gastric contents varied constantly,. while the interpretation of the curves obtained by thefractional method had not yet been fully worked out.Rehfuss regarded the curves of free HC1 and of totalacidity as being secretory curves, and that typewhich rises to a higher level than normal, such as iscommonly found in pyloric ulcer, as a hyper-secretorycurve. With Dr. G. W. Goodhart Dr. Bolton haddone some experiments on this subject, and they hadformed the conclusion that the curve of total chlorides.more nearly represented the secretory curve, since the -HC1 curve was affected by regurgitation; of alkaline:duodenal contents when the pylorus was relaxed They therefore regarded the climbing type of HCtcurve, called by Rehfuss " the hyper-secretorycurve," to be due to hypertonus or spasm of pylorus.

In general, the finding of an excess of total HOrafter a single test-meal, or of the climbing type ofacidity curve by the fractional method, were in.