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facts were so varied and numerous, and even contra-

dictory, that he did not know how to make them fit withany one theory. He referred to the excellent results whichsometimes followed (especially in the practice of von Graefe)the subconjunctival or subscleral division of the ciliarynerves. His experience during twenty-five years led him tothink that indiscriminate enucleation of diseased globes wasa practice of doubtful value. Of late years he had notlargely recommended enucleation, and believed that he hadthereby saved many useful eyes.-Dr. biuZES thought thatsympathetic irritation and inflammation, though they hadsomething in common, ought to be separated. The formerdilated the lymph spaces, and so allowed the more easytransit of infective elements. With regard to the length oftime which sometimes elapsed, he thought that the bacterialhypothesis explained this condition. In reply to Dr.Brailey, he said that he was not prepared to say that bacterialelements might not arise in the body without a perforatingwound.-Dr. BRAILEY said that it was impossible to over-throw a hypothesis like that of Dr. Mules, which was sowide and comprehensive. In criticising the President’sviews, he did not think it necessary to advance anotherhypothesis. It would be sufficient if he could succeedin showing that the theory did not hold good. Howwere we to explain on the President’s hypothesis thefact that secondary sarcoma was so rare in the other eye?The commonest place for secondary sarcoma of the eyewas the liver. Again, suppurative panophthalmitis wasmore likely to be followed by purulent meningitis thana similar suppurative disease of the other eye; so that wehad instances in which cancerous or pus cells were taken upinto the circulation and caused similar disease in othertissues of the body rather than in tissues of the other eye.Though Dr. Brailey did not support any doctrine, yet hethought that the facts in our possession were more explicableon the theory of direct transmission. Snellen had shownhow, probably by direct transmission, the inflamed middleear might give rise to disease of the meninges, and so on tothe eye on the same side. Again, Deutschmann’s experiments,which ought to be verified, seemed to show that bacillaryinflammation could be propagated from one eye to theother. He thought there was no single pathological fact inconnexion with the eye which tended to support Mr.Hutchinson’s hypothesis. Propagation of mischief by thelymph spaces of the optic nerve appeared to him to bethe most likely explanation; but he did not give an un-qualified support to any theory.-Mr. NETTLESHiP said6hat of all the theories that of blood infection accounted forsome of the phenomena of the disease more easily than anyother-e.g., the simultaneous appearance of changes, suchas neuro-retinitis or iritis, in widely different parts of theeyeball. The difficulties in the way of accepting the theorywere, that upon it it was hard to understand how the incu-bation period could ever be so long as it sometimes actuallywas, or why it should break out in the sympathising eye ata considerable interval after the removal of the infectingeye. Two other questions might be asked, which wouldperhaps tell as much against as for the theory under con-

’ sideration. How could exceptional but well attested casesbe explained in which parts outside the eye, such as theeyelashes, underwent organic change in the course ofsympathetic inflammation? and how was it that the

exciting eye might be but slightly damaged, though thesympathising eye suffered profoundly, even to total

" blindness? The severity in the sympathising eye must

depend upon the number of germs which it contained;if these were bred in the exciting eye, why did it not sufferin proportion ? On the other hand, if they were not simplycarried by the blood, but multiplied in it, how did the othertissues of the body escape serious change? As regarded thetransmission theory, there were difficulties in regard to allthe paths along which the disease had been thought totravel. Deutschmann’s view that septic inflammation wasconducted along the optic nerves met with a certain amountof support from clinical facts. Failure of sight, papillitis, orpapillo-retinitis were, for instance, among the earliest pheno-mena of the disease, and in cases of traumatic inflammationof the eyeball it had been proved that inflammation couldtravel up the optic nerve. But iritis or keratitis punctatahad been present in all cases, or nearly all, which hadshown early retinal or neural changes, and all thesephenomena might be accounted for upon the supposi-tion of inflammation of the choroid. The clinical proofsthat were required in support of this theory were that

the changes should appear at the disc some time beforethey were seen in other parts of the eye, and that failure ofvision should precede the other visible alterations. Again,according to the transmission theory, basic meningitis oughtsometimes to be seen as a sequel. In mild cases too, on theoptic nerve theory, the disease should sometimes be confinedto the optic nerve, but, with the possible exception of Dr.Brailey’s case, this was hitherto unknown. Again, in retro-bulbar neuritis there was no evidence that the inflammationever spread upwards to the other eye, though it went down-wards to the disc on the same side. The chief objectionto the theory of transmission along the filaments othe fifth or sympathetic nerves was that the path wouldbe so very long and narrow; the nerve twigs were so verydifficult to examine that it was easily to be believed thatinflammatory changes in them might escape detection.-Mr. JONATHAN HUTCHINSON, in reply, said he perceivednothing in the arguments which had been brought forwardwhich led him to doubt that his hypothesis might not stillbe the correct one. He also said that he himself merelyadvanced the new theory in a tentative fashion. Theoccurrence of secondary periostitis, the phenomena of rheu-matic inflammation of joints, and other like instances, pointto the existence of a law of very general and wide appli-cation. Referring to Mr. Power’s criticism, he said thatthat surgeon seemed to hold two theories, one of reflexirritation, and another of direct extension of inflammation.He had no doubt of the occurrence of reflex irritation, andthe fifth nerve was the agency in this process. Accordingto some, it was dangerous to excise the exciting eye forfear of increasing the irritation; this was not, however,his view. With regard to the length and irregularityof the intervals, and the relapses of sympathetic ophthalmitis,.he did not think such facts were more difficult of explana-tion on his than on any other theory. In reply to Dr.Brailey, he urged that though symmetrical cancer and sar-coma were not common, still they were not unknown ; and,indeed, cases of secondary tumour of the eye had beenshown at the Society that evening as well as at recent

meetings. Moreover, the sequence of the development osecondary growths varied exceedingly, and there was !Ii

general law to that effect.-Mr. JESSOP asked whether itwere true that adults were as liable to sympathetic ophthal-mitis as children, or more so. He had been surprised tohear Mr. Spencer Watson controvert Mr. Power’s statement.Had Mr. Spencer Watson seen a case of sympathetic ophthal-mitis in an individual over sixty years of age ? The-President said his experience concurred with that of Mr.Power.-Mr. SPENCER WATSON said he had a general im-pression to the effect that wounds in the ciliary regions ofchildren were not frequently followed by sympathetic in-flammation.-Dr. NOYES added that there were about thirtywell-attested cases on record in which the operation for senilecataract had been followed by sympathetic ophthalmitis.,

ACADEMY OF MEDICINE IN IRELAND.

AT a meeting of the Pathological Section on April 17th,Dr. FINNY exhibited a typical specimen of Shekleton’s Dis-secting Aneurysm. It commenced in the thoracic aorta;.about 2 in. above the diaphragm, and dissected between thelaminae of the middle coat, along the anterior two-thirds ofthe vessel, its whole length, and down both common iliacswith the most exact symmetry to their termination, where,through a small aperture (in. in diameter), at the junctionof the external iliac branch, the sac again communicatedwith the normal arterial channel. The aorta and the iliacswere thus divided into double tubes, the aneurysmal tubebeing much the larger, and from it sprang most of theabdominal arteries-the right renal, the spermatic, and theinferior mesenteric. The aneurysmal sac was lined with asmooth membrane, which seemed continuous at eitherorifice with the lining membrane of the aorta. In additionto this dissecting aneurysm, two sacculated aneurysmssprang from the anterior wall of the sac : one in the thorax,2; in. long by Ii in. broad, which lay 2 in. above the primaryopening from the aorta into the sac; and the other, a verylarge one (31 in. by 2i in., and 5 in. in circumference), whichextended from below the coeliac axis to the bifurcationof the aorta. Both these aneurysms were firmly con-

solidated by layers of white fibrine. There was also atrue aneurysm of the trunk of the coeliac axis, which

69

was also completely blocked with. similar laminae ofilbrine, and but one branch of the axis -namely, thecoronary-was pervious for the transmission of blood.The specimen was removed from the body of a man, agedforty-three, who died in Sir Patrick Dun’s Hospital lastFebruary, of the effects of apoplexy and right hemiplegia,of which he had had two attacks-one in September, 1884,and the second in December. The patient had been underDr. Finny’s observation for a year and a half before hisdeath, and had been admitted to hospital in the first in-stance, in September, 1883, with the symptoms and signs ofsacculated aneurysm of the abdominal aorta. There wasno history of syphilis, rheumatism, intemperance, or of

injury to cause the disease, and the kidneys seemed to be’healthy at that time, as there was an absence of albumen,,or of other symptoms of Bright’s disease. The patient wasplaced on Tufnell’s treatment, and for four months main-tained the horizontal position. In a short time he ex-perienced relief, and then freedom from all the subjective.symptoms, and later on it was evident that the aneurysm was.cured by consolidation. The patient recovered sufficiently towalk about, free from all pain or distress; he gained in weightand flesh, and went back to his occupation, as a tailor,six months after the aneurysm was first detected and treated.There was no idea, however, that all this time he was the isubject of a dissecting aneurysm of very great dimensions, II.as neither during the time he was under observation wasthere any evidence of any disease other than the sacculatedaneurysm, nor before nor subsequent to that time werethere any symptoms to mark its advent in the first instance;and it is, therefore, quite unknown how long such a condi-tion may have existed.-The PRESIDENT asked Dr. Finnyif he considered that, in the case of a dissecting aneurysm,any grounds could present themselves for forming a

.diagnosis? According to his experience, cases of the sort

.generally turned up as pathological surprises.-Mr. TUFNELLmentioned two cases to show the permanent character ofthe consolidation of aneurysms that could be accomplished.-Dr. HENRY KENNEDY observed that pressure had been verysuccessfully applied for the cure of aneurysm. He wishedto ask Dr. Finny two questions-namely, had the patientCheyne-Stokes’ respiration, and were there any evidences offatty degeneration ?-Professor FINNY, in reply, said hebelieved, as a rule, dissecting aneurysms afforded no groundsfor diagnosis. He knew of only one case of the kind, inwhich a diagnosis was made and confirmed after death, andthat was the one described by Dr. Swaine where the lesionsuddenly occurred in the upper part of the aorta, close tothe termination of the left subclavian, and the patient wasaffected by shock and collapse. The aneurysm was a

dissecting one, and had made its way down in such a wayas to obstruct the course of the iliac vessels, so that thecirculation in the patient’s legs was stopped. The diagnosisthat had occurred was confirmed by a subsequent partialxestoration of heat and circulation in the lower extremities.As to Cheyne-Stokes’ respiration, it was well recognisedthat that affection was not connected with cases of fattyheart alone, but was frequently found in cases where therewas no fatty heart. It was neurotic in its character, andoccurred in various forms of fever, as well as in cases offatty heart and atheromatous disease of arteries. In the.case which he had just submitted to the section there wasno fatty disease of the heart or surrounding vessels.

ilr. KENDAL FnANES exhibited a Tumour, excised in theAdelaide Hospital on March 5th from a man aged fortyyears. The tumour, which was an epithelioma, was firstnoticed as a small sore at the root of the frsenum linguastowards the end of October last. By the end of Decemberit had extended downwards, so as to cause a hard lumpbeneath the chin, and in January the skin over it becameinvolved. About the middle of January it had extended tothe gum in front of the symphysis menti. The lower incisorteeth loosened and became very tender. The man, whenadmitted, was suffering acute pain in the jaw and teeth,and neuralgic pains all over the head. He had lost sleepand flesh, and urgently requested an operation to relievehim. Accordingly, on March 5th Mr. Kendal Franks excisedthe growth, and with it the involved skin, the middleportion of the lower jaw, from the facial groove on one sideto a correspoding point on the other, and the entire tongue,involving all its attachments, down to the hyoid bone. Thepatient made an uninterrupted recovery, and left the hospitalGn April 14th, with the wound nearly healed, and withoutany appearance so far of a return of the disease. There were

no glands involved. The tumour, which was the size ofan ordinary orange, presented on section a dense whitestructure, which the microscope showed to be an epithelioma.It sent fan-shaped processes upwards into the tongue, noneof which, however, reached the surface. In front it hadcompletely eroded the central portion of the lower jaw,so that the two sides were freely movable. Mr. Franksdrew attention to the rapid growth of the disease, to theunusual direction in which it had extended, and to thegreat relief afforded by operation, though he scarcelyhoped that there would not be a return of the diseaselater on.-The PRESIDENT asked if any power of speechremained to the man after the removal of his tongue-Mr.ABRAHAM observed that it was remarkable how little thegrowth had invaded the mucous membrane of the mouthand tongue. It seemed to have gone directly inwards,and formed a hard solid tumour in the substance of thebase of the tongue.-Professor STOKES said the patientwas for a considerable time under his care in the RichmondHospital, and he wished to know what was his actualcondition at present, and if there were any evidence of areturn of the disease.-Dr. FRANKS, in reply, said theman’s powers of speech were now decidedly bad-worsethan they were before the operation. They knew, how-ever, that in cases of excision of the tongue, when thepatients lived long enough, they often recovered theirspeech in a most marvellous manner.

Professor STOKES brought forward a case of SuicidalWound in the Throat, and exhibited the head and neck ofthe subject of it. The gentleman who had furnished him(Professor Stokes) with the specimen wrote, saying thatthe diseased was a "distant man, who did not care muchfor society, but, in fact, rather avoided it, while, at thesame time, he was not quarrelsome or a disagreeableneighbour." One of the remarkable circumstances of thecase was that, when his body was discovered, the penknifewas so tightly grasped in his fingers that it was only bypulling them out that it could be released. Another wasthe extraordinary magnitude of the wound, and the depthto which it was carried, without any injury being doneto the cervical vessels. The man must have made two orthree cuts on each side. He believed that death was notcaused by the hoemorrhage-though a great deal of bloodwas found--but by the falling down of the epiglottis onthe glottis, which caused asphyxia. Another point wasthe sudden occurrence of rigor mortis, and the marked extentto which it prevailed, as was proved by the extreme tenacitywith which the knife was found grasped in the hand.-The PRESIDENT observpd that it was generally found thatthe more sudden the occurrence of death, the more suddenand violent was the rigor mortis. In cases of deathfrom slow lingering diseases, like consumption, it came onslowly; after death from lightning it was very rapid. Ifthere was so much bleeding, he could not understand howthe thyroid artery could have escaped; and the influence ofhsemorrhage on the rigor mortis was also an importantpoint to determine.-Dr. FoY mentioned a case of a manwho cut his throat with a razor from ear to ear, dividingthe larynx completely, and also the superior thyroid artery.He (Dr. Foy) did not see him until an hour after the occur-rence, and yet he was then able to sit up and make violentbut ineffectual efforts to drink. In the great majority ofsuicidal wounds inflicted on the throat the carotid arteryescaped, probably because the first gush of blood weakenedthe suicide, so that he was then unable to carry the wounddeeper. -

At a meeting of the Surgical Section on April 24th,Mr. J. K. BARTON, speaking of the Surgery of the Knee-

joint, said some points of interest in the surgery of the knee-joint are illustrated by the following six cases: (1) Excisionfor advancing disease, (2) excision for deformity, (3) ampu-tation through the joint, (4) removal of an enlarged bursapatella, (5) removal of a loose cartilage from the joint, and(6) withdrawal of part of a sewing-needle from the joint.The patients upon whom the first three operations wereperformed were all present and exhibited. The first was asailor boy aged fourteen, the second a girl of eight, the thirda girl of about twelve. The first case of excision hadsuffered from periostitis of the femur, but the result (nowmore than a year since the operation) was satisfactory, theboy walking nimbly and firmly without a stick or supportof any kind. The second case was not so far advanced, butthere was very firm union, allowing the child to walk well,

70

but still with the help of crutches. The third case was oneof amputation through the knee-joint, in a case in which thelimb from the knee down was rendered useless by paralysis.The cartilages had been left; the stump was an excellentone. The fourth case was one of enormous enlargementof the bursa patella, of which a cast was exhibited. Theoperation which was undertaken for its removal consisted I,of’ the cutting of a very narrow eliptic piece of skin. fromthe front of the tumour, and a similar piece from the frontwall of the bursa, after which the contents, which were ofthe consistence and appearance of boiled sago, were allremoved, then the sides were laid down, a drainage tubeinserted at each end, and the edges united with carbolic gutsuture ; the dressing was by sero-sublimate (one per cent.)gauze; there was no supuration. Two dressings sufficientto completely heal the wound. In the fifth case a loosecartilage had been found under the tendon of the extensor,easily pushed out and back again. It was removed by afree incision under spray, and the wound was dressed withthe sero-sublimate gauze. The highest temperature markedwas 101° on the second night after the operation, afterwhich it speedily became normal, and the patient re-turned to the country quite well. The last of the serieswas that of a housemaid, who in kneeling on the stairshad got a needle into the knee, which, in endeavouring toextract, she broke. The pointed half was left deeply fixedbelow the patella and in the fibres of the ligament. A freeincision was necessary to find it; it was found directedstraight in towards the joint, and was safely drawn out. Therelation of the cases was accompanied by comments uponthe most interesting features of each.-The PRESIDENT dis-claimed credit for the splint exhibited, as being on the basisof that of Watson of Edinburgh. Although the mode offixing it might vary, the moulding was due to Patrick HeronWatson, as well as the credit for so great a success inexcisions at the knee-joint. While the author had dwelt onthe necessity of the long anterior flap, and such was gene-rally adopted, yet that flap was unsuitable in cases wheredisease existed on the front of the limb. About two orthree years ago, Hardy of Manchester published a paperrecommending, instead of the long anterior, the obliquecircular amputation. An opportunity occurring, in the caseof a woman aged fifty, he followed the procedure suggested,with one advantage, that he was not limited in frontfor coverings by the disease, which was lupus. A plain-cut surface, instead of being at right angles, was slopedat 45°. The procedure was a little more difficult than theusual method to carry out, but the covering was perfect.In that case he left the patella and the cartilages of thetibia in the joint, without any serious consequences fromdeath of cartilages said to result from that course.-Mr.STOKES emphasised as very important the method ofdealing with cases of excision of the knee-joint after theoperation. Speaking from an experience of twenty cases,he had tried different plans of treatment: (1) Placing thelimb in a large box; (2) fixing the limb by means of gypsumbandages or other immovable apparatus; (3) the plan ofP. H. Watson, in which the principal was not a posterior,but an anterior splint.-The PRESIDENT said he had usedboth.-Mr. STOKES, continuing, said he had also tried amodification of Watson’s plan, devised by his colleague, Mr.Thomson. Instead of strong brass or iron wire, such as inthe apparatus on view, a hoop-iron splint applied bothanteriorly and posteriorly, being fixed in position by meansof gypsum. But after due trial he had abandoned thegypsum, adopting, however, the plan of the hoop-ironanterior and posterior splints, affixed by broad belts, andthese fixed again on an inclined plane to give ample spaceanteriorly and posteriorly for the dressing of the wound.Quite as important as careful antiseptic dressing was theabsolute fixation of the limb during the healing of thewound. But in the apparatus Dr. Barton had brought for-ward he did not see adequate provision for ensuring thatessential in the after-treatment of excision of the knee-joint.—Dr. HAMILTON was puzzled from what he had heard to de-termine whether there was an absolute necessity for per-forming the operation so high up, as the leg was in a com-paratively healthy state. He would himself have hesitatedbefore amputating through the knee-joint, and would pro-bably have been satisfied with amputation below the knee,allowing the patient to rest upon the knee as the naturalpoint of support Of course, Dr. Barton would give reasonsfor preferring the upper operation; but it was a rule insurgery to cut away as little as possible of the living limb.

He had himself had an opportunity of trying almost everysplint, and he was perfectly satisfied with the resultsobtained from Watson’s splint, with a little addition. Heused a. back splint of exceedingly firm material, and heapplied to it a very strong iron bracket, which enabledhim to leave the limb perfectly undisturbed, and at thesame time to renew the dressing as often as he wished.Thus the limb was kept with that perfect rigidity which, asMr. Stokes remarked, was so important in the treatment ofthose cases. The splint was made of steel, and sufficiently wideto allow the dressings to be removed without disturbing fixa-tion.-Mr. THOMSON believed that almost as many splints andimodifications of them had been devised for the after-treat-ment of excision of the knee-joint as in fracture of the-patella, and that everybody who had had some experience ofa particular splint would probably modify it to suit his ownwishes. He had himself used two or three, beginning withWatson’s-the one in which the posterior splint was madeof scored wood, and there was an anterior metal rod

extending from the thigh to the foot. The posterior splintwas first padded with a considerable amount of cotton-woolto allow the limb to lie quietly and easily in it. Then theplaster-of-Paris was applied. He found after some weeks,when the limb had settled down into the splint, a great dealof looseness occurred, so that though in the early days a,considerable amount of fixation had been secured, yet this.was not so in two or three weeks before actual union tookplace. Next he tried the excellent splint devised by Dr.Hayes, of the Mater Misericordise Hospital, but it did notadmit of getting the retaining material sufficiently closeupon the limb. After that it struck him that by using hoop-iron, which was introduced in the treatment of morbuscoxse by Dr. Thomas, of Liverpool, he would, provided it was.of sufficient strength and thickness, obtain a splint thatwould answer his requirements. The hoop-iron splint hadcertain advantages to recommend it, being easily procurable.in the country, and capable of being shaped to the limb bybending across the edge of a table or across the knee. Heused a posterior splint of plain hoop-iron, and an anteriorone moulded in the same way. From the difficulty of cuttingthrough the plaster-of-Paris when once it was applied, heabandoned it, and now used an ordinary flannel bandage..The results from using the splint which he adopted wereexceedingly good, but a wire splint a quarter of an inchthick, such as Mr. Barton’s, was unequal to supporting alimb.Mr. M’ARDLE read the notes of a case of acute Traumatic

Tetanus, in which two-third grain doses of urari every fifthhour resulted in a cure, the more remarkable effects pro-duced by the above-named doses being relaxation of thecontracted muscles in from six to ten minutes after adminis-tration, very rapid and tumultuous action of the heart,.cyanosis, laboured breathing, and dilatation of the pupils.Once the patient was sufficiently under the influence ofurari, the evacuations from the bowels were regular. Mr.M’Ardle suggested the combination of urari and pilocarpin,.in the hope that the cardiac and respiratory trouble pro-duced by the former might be prevented by the latter. Healso showed that urari, to be of service, must be used in.large doses, and that the drug is cumulative.

Reviews and Notices of Books.Diagnosis of Diseases of the Brain. By. R. GowERSy

M.D., F.R.C.P. London: J. & A. Churchill. 1885.

THE present work is a companion volume to that on thespinal cord by the same author. It takes the form oflectures, which have been delivered at University CollegeHospital. The need of a work on the diagnosis of therdiseases of the brain has been strongly felt for some yearspast. The student cannot be expected to learn all that i-5

necessary about cerebral diseases from a descriptive treatisebefore he approaches their clinical study. He wants a guide-which shall direct him in the methods of diagnosis, andwhich shall tell him the value of different symptoms. As

there is no doubt of the need, so there is no doubt of ther

difficulty of supplying it. As the physiology of the brainis more complex and recondite than that of the spinal cord,