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Mr. JOHN GRIln"TTH (London) read a paper onA Case of Melanotio Sarcoma 2ri.cing in tlee lletrotarsal Fold

of the Upper Lid, the Sclerot’i.o being 1’inrled Brorvn.The patient made a rapid recovery after free incision.The PRESIDENT of the section, Mr. TREACHER COLLINS,

and Mr. MARSHALL also cited cases, but not in the same

position.Dr. JAMES HINSHELWOOD (Glasgow) read a paper on

The Use of E1lphtltal1nin: a New Mydriatio.He described the advantages of euphthalmin as a mydriatic,two or three drops of a 5 per cent. solution effectingdilatation of three hours’ duration in 20 minutes, adding thatone drop of a 1 per cent. solution of holocaine previouslyinstilled quickened absorption. Only slight weakening ofaccommodation ensued and no other inconvenient effects.The PRESIDENT of the section mentioned mydrine as

having similar advantages but being very expensive, euph-thalmin being one-fifth the price of homatropine.

FRIDAY, AUGUST 4TH.Dr. BULL (Paris) described an adaptation of the stereo-

scope for the detection of insufficiency of ocular muscles(hyperphoria).

Mr. WATSON GRIFFIN (Brighton) read a paper on

Cases illustrating the Value of the Correction of Hyperphoria.He reported cases of hyperphoria in which binocular visionwithout eye strain was secured by an adaptation of prismsin the glasses worn for ametropia. Mr. W. Lang allowedhim to mention two cases in one of which the strength of theprism had to be periodically increased, indicating a develop-ment of previously latent hyperphoria.

Mr. TREACHER CoLLiNS said that more attention was paidto this matter on the other side of the Atlantic.

Dr. REEVE (Toronto) spoke of cases and of the verycareful adjustment of prisms necessary for correcting vision.On account of the great expense entailed by a triple com-bination of lenses he suggested an eccentric mounting of theordinary correcting glasses.

Dr. ARNOLD LAWSON read a paper on

The Value of Correctiny Befraetion Terrors in the Ireat’1lwntof Trackovia

and cited instances in which rapid improvement hadfollowed such correction though resisting ordinary treatment.He referred to the similarity between trachoma and adenoidgrowths in young people and the frequent dependence ofdiseases of the lids and conjunctival sac upon ametropia.

Mr. TREACHER COLLINS admitted the great influence ofcorrecting glasses in these diseases, though very difficult to Iunderstand in cases of trachoma.

Colonel DRAKE-BROCKMAN spoke of the frequent occur-rence of trachoma and other conjunctival diseases in theEast and of the beneficial effect of correcting glasses.

Dr. DE SCHWEINITZ also alluded to the parallel conditionsof the lids and conjunctiva, adding recurring meibomiancysts and styes and habit spasm of the eyes to the list.

Dr. JOHN HERN read a paper on

The Eye Symptoms in Hay ]ih’er.He described the symptoms and spoke of their removal byproximity to the sea. He mentioned cocaine in a from 2 to4 per cent. solution as affording temporary relief.

Mr. TREACHER COLLINS mentioned the relief affordedby dark glasses.

Mr. DEVEREUX MARSHALL stated that these symptomsoccurring in the early summer were as often induced by roaddust as by direct exposure in the fields.

Mr. KENNETH SCOTT (Cairo) described a case of

Extensive -Destruetii,e Uleeration of the Eyelidof two months’ duration in a man, aged 45 years, who com-pletely recovered under mercurial inunction and local appli-cation of europhen. Vision remained perfect and the globewas pretty well covered.Mr. TREACHER COLLINS spoke of the greater frequency of

phagedasna in the East.Colonel DRAKE-BROCKMAN said that syphilis was so

general in the East that the usual question was, " When didyou have syphilis?" This was certainly syphilitic gumma.He spoke favourably of the local effect of enrophen.

The following resolution was passed in the Section of

Ophthalmology on Friday and has been sent to the Board of £Trade :-That the Ophthalmolntgical Section of the British Medica.1 Association

hegto express their profound belief that, it would prove of great publiebenefit if the BOl1.rd of Trudo conjd see their wny to include in theirregulations the tweiftit recommeodtition of t,lie l{oyal Society Com-mission : "that in case of judicift) inquiries as to collisions or

accidents witnesses giving evidence as to the nature or position ofcoloured signals or lights should themseives he tested for colour andform vision, and suggest its application in every case of judicialinquiry upon accidents at sea."

.

This completed the business of the section.

DISEASES OF CHILDREN.

WEDNESDAY, AUGUST 2ND.

Ununited Fracture in Childhood.

The Presidential Address on this subject by Mr. EDMUNDOWEN appeared in abstract in THE LANCET of August 5th,p. 383.Mr. GEORGE MORGAN (Brighton) alluded to the case of

’

a child whom he had seen who was the picture of healthI and had been treated with the utmost care in hospital from

the occurrence of the injury and latterly had undergoneseveral operations without success. It was interesting tonote that the fibula was entirely absent ; so quite possiblythere was some congenital weakness of the tibia also.Mr. A. H. TUBBY (London) considered that osteotomy and

t osteoclasis were not such harmless operations as they seemedor were commonly thought to be and that some of thesecases, which were numerous, were due to those operations.

’

The bone was often noticed to be soft before the operation,L

so it would be a good rule to operate only on hardened bone.l In one such case everything possible had been done to secure

union, rabbit’s bone being used for the purpose, but to no.r

avail. The limb was in a state of fatty degeneration, before the fracture.

The PRESIDENT of the section briefly summed up the discussion, urging strongly that no operation should be

described as free from risk. He had tried puppy’s bone toinduce union, but without any result.

Dr. ROBERT MAGUIRE (London) then read a paper on

The Medical Treatment of Pleuritic Effusion in Childhood.He recommended putting an exploring needle into the

. cavity of the thorax to see whether it contained serum or

pus ; this was particularly important in children as empyema.E in them was more latent than it was in adults. As a note of

warning he said that the needle should be fairly large (or pu&E would not come through) and the suction power should be) fairly strong. He frequently used the aspirator for this’

purpose and then if considered right the fluid could be- evacuated forthwith. If there were much blood in the serum3 it would suggest the possibility of sarcoma. Pleuritic effusion

was an active secretory process of the irritated pleura, ands still more so in empyema; it was always encysted in the

latter, and was often encysted in serous effusion. He dwelt onthe resistance of the thorax ; the rib-spring in adults gavepositive tension, but not being developed in children itlessened the force of effusion. The heart could be displacedby a comparatively small pleural effusion. Of more importancewas the depression of the liver, stomach, and spleen; if withdyspncea, then aspiration should be performed. If the serum

) should be deeply bloodstained the aspiration should be

I stopped. If the amount of effusion was moderate and therewere no signs of peril the medical man should not aspirate. Heconsidered tubercle to be rarely the cause of pleuritic effusion;Sir W. Jenner said that it was the cause of purulent effusion.There was some tubercle occasionally in the lungs when therewas pleuritic effusion, hence the advice above given aboutnot aspirating unless there was urgent reason for doing so.It had been suggested that the pleuritic effusion in cases oftubercle of the lung might serve as some kind of antitoxin,

. and so should not be taken away ; there was no proof of this

. but it was well worthy of investigation. The general health3 of the patient must, of course, be attended to and Dr.

Maguire spoke highly of grey powder as acting very power-E fully in the removal of fluid. There were not generally any

reasons for absolute rest ; a judicious open-air treatment was) best. When the effusion was purulent the medical man should1 try to find out the course of the infective material. Most of. the cases of empyema were due to the pneumococcus; often

there was the septic staphylococcus or streptococcus as well.

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Operators on adenoid growths were not always sullicientlycareful either to remove all the vegetations, or to maintaincomplete asepsis, or to time their operations properly.Sometimes empyema had followed these operations directly.Even in empyema there might be no need for surgical aid.The chest might be tapped once or oftener and a cure mightresult. Occasionally no operation could be done as bothsides were affected. There was not quite so much risk inleaving empyemata in children as in adults, for they did notget perforation of the lung so readily. One other pointwas that in pneumothorax sometimes the fluid was serous.Mr. B. BETHAM ROBINSON (London) then read a paper on

Surgical Treatment of Ple7tritic"’Effusions in Children.He said that the presence of the surgeon was generallyrequested if the effusion was purulent. He discussed thebest situation for tapping the effusion. There need not be

complete withdrawal of the fluid and the vacuum shouldnot be too great. Aspiration should be stopped ifmuch bloodstaining came on. If the blood re-accumulatedit suggested sarcoma or tubercle. Opening the pleuralcavity for tuberculous pleurisy had been suggested on theanalogy of opening the peritoneal cavity in tuberculousperitonitis. Of this he did not approve and he described thepathological conditions. Aspiration alone might be effectivesometimes, but the fluid must be thin. He discussed thebest position for incision and drainage, saying that it shouldnot be lower than the sixth or seventh intercostal space, forotherwise the diaphragm would interfere. It was not truethat the lower down the better the drainage. He advisedresection of a rib, as it risked nothing. The finger couldexplore the cavity, find the amount of the compression of thelung, and clear out coagula, &c. Irrigation should not bemade a usual practice ; it should be done only with sterilisedwater or a boric acid solution and regularly, with an easy- exit, so as to produce no intra-pleural tension. He believedthat the lung expanded as well with a free opening as

under the precaution suggested by Dr. Robertson of Oldham.The tube was often left in far too long. It might betaken out if the temperature was normal and if therewas not more than one ounce of discharge per diem.Also if it was frequently found in the dressings, as

that indicated that the lung was filling up the space.It could easily be put in again. Failure of the cavityto close was not common in children as it was due tofailure of the expansion of the lung. If after three monthsthe cavity still existed a thorough examination should bemade and if necessary one or more ribs should be re-

sected.The PRESIDENT of the section said that he would

like more work done on the nature of pleural effusions.He had noticed a tendency on the part of physiciansto do surgical work. He asked whether an empyemacould be opened, drained, and shut up in any case

with safety. Sometimes the tuberculous effusion was appa-rently purulent. He discussed the choice of the placefor incision and would certainly resect a rib in childrenas the tube was apt to get nipped. Irrigation should only beresorted to in septic cases. In taking the tube out he wouldkeep in mind the possibility of having to re-introduceit as in the after-treatment of the tracheotomy tube. The

drainage-tube might get into the pleural cavity and be hardto extract. He recommended tubes with a large flange ofrubber sewn on in place of the safety pin.

Dr. MANSEL SYMPSON (Lincoln) said that in order to avoidthe danger which the President had mentioned he alwaysused where possible a Morrant Baker’s tracheotomy tube fora drainage-tube in cases of empyema.

Mr. A. H. TUBBY gave some interesting facts as to theeffect of irrigation in producing collapse. This varied withthe pressure and the nature of the fluid. Carbolic acid oriodine caused blood-pressure to go down; evidently therewas a sensitive pleural reflex acting on the vaso-motorcentre.

Mr. R. STERLING (Stoneyford) remarked on irrigation.Dr. G. F. STILL (London) described a case of albuminous

expectoration lasting for several hours in a child, aged 10years, who had had the chest aspirated. There should be no

delay in the removal of pus from the thorax, as any momentdissemination of the pneumococcus might occur. He relatedparticulars of a series of fatal cases of empyema, death being<due in several to suppurative pericarditis, meningitis, andperitonitis. The chest should be opened freely and all thicklymph, &,c., cleared away.

Mr. G. MORGAN spoke of the use of educating the child toblow out and inspire so as to expand the lung.

Dr. MAGUIRE and Mr. ROBINSON replied briefly.Dr. G. F. STILL then read an interesting paper on theChannels of Infection in the Tuberculosis of Children,

founded on post-mortem examination. In many cases ofgeneral tuberculosis it was hard to determine which partwas first attacked. The condition of the glands was helpfulin this matter. Children swallowed sputa and so infectedtheir intestine or mesenteric glands. There were 10 cases oftuberculous mediastinal glands without lesion of the lungand nine cases of diseased mesenteric glands without lesionof the intestine. It was doubtful whether the first classcould be due to extension from the glands of the neck.There were many more cases of affection of the right glandsthan of the left. Infection of the’intestine accounted for 63cases and infection by the lung for 138 cases, showing howvitally important purity of air was and that children shouldnot be exposed to the risk of tuberculosis by being in thesame room. Overcrowding was evidently responsible for

many of the cases.The PRESIDENT of the section inquired as to the effect of

digestion on the tubercle bacillus.Dr. STILL replied that tuberculous infection of the

stomach was very rare, though digestion did not kill thebacilli.

Mr. GEORGE MORGAN then read a paper onTuberculous Adenitis of the Head and Nee7z.

This condition was not so common now as it was 15 yearsago. He discussed the etiology with reference to acquiredscrofula, intermarriage of predisposed persons, infectionfrom mucous membrane, teeth, tonsils, adenoids, &c. Thelatter might be, with the tonsils, the seat of tuberculosis.For treatment all milk should be boiled, the children shouldbe kept out of phthisical rooms, their teeth should be

properly treated, adenoids and enlarged tonsils should beremoved, and iodide of iron with malt should be given.Plenty of fresh air was essential and residence at the seasidewas beneficial. Conditions of the skin or mucous mem-

branes on which the morbid state of the glands dependedshould be treated. The lower glands should be taken outfirst without pressing on the glands so as to infect theneighbourhood.

Mr. ROBINSON said that in a case of adenoids he wouldtreat the suppurating glands first and the adenoidsafterwards.

THURSDAY, AUGUST 3RD.Mr. JAMES GREEN (Salisbury), Vice-President, was in the

chair.Dr. A. M. GossAGE (London) read a joint paper by Dr.

J. A. COUTTS (London) and himself on theCausation and Treatment of Conmclsions in Infancy.

After defining convulsions they said that one form justpreceding death was really a form of dying and did not quitecome under the ordinary class. They attached great import-ance to predisposing causes, such as an unstable and irritablenervous system. The exciting causes were rickets, laryn-gismus stridulus, craniotabes. concussion or cerebral hoemor-rhage, birth palsy, meningitis, and uraemia, the latterbeing very rare in children under two years of age. Inacute diseases, such as pneumonia and the specific fevers,convulsions were not so frequent at the beginning as

in the course of the illness. Other causes were teething,severe surgical injuries or burns, and asphyxia, and per-haps this explained the convulsions of dying infants.With regard to pathology either no changes were foundor any that existed were the results of the convul-sions, coarse brain lesions excepted. For treatment theclothing should be loose and the child should lie on the backwith the head slightly raised. A hot bath with mustard init was useful. Inhalation of chloroform in severe cases orrectal injection of chloral hydrate and bromide of potassiummight be resorted to, also nitrite of amyl or half a grain ofmorphia to an infant of six months. The treatment would

vary according to the cause of the convulsions. Small dosesof bromide should be continued for some months and boraxshould be tried if bromide failed.

,

Mr. A. H. TUBBY read a paper by Dr. HUGH JONES(Liverpool) on

The Public Health Aspect of Convulsions in Children.: Dr. Jones considered that convulsions were a sign of under-

lying disease ; that they were beginning to be less frequently

460

assigned as a cause of death, though the certificates werenot capable of affording very accurate information at

present; that the largest proportion of deaths from con-vulsions was due to digestive troubles; and that there wasan increase of deaths from premature birth. He also sug-gested that the social condition of the children was largely responsible owing to the ignorance of mothers, under-agemarriages, and over-crowding.

Dr. EDMUND CAUTLEY (London) remarked that many ofthese cases were due to the feeding of the child and thatmal-nutrition of the nervous system caused fits. He gaveinteresting details of a case where the improper feeding ofa child had this effect. Excess of proteids induced fitseither from the formation of curds, or from irritation of theintestine, or from giving rise to products of digestionwhich were absorbed and which acted directly on thebrain.The CHAIRMAN asked if any relationship to fits would

explain the very numerous cases of overlaying, and he sug-gested that cupping and bleeding should be tried in urasmia. ;

Dr. GOSSAGE briefly replied.Dr. E. GRAHAM LITTLE (London) read a paper on

Night Terrors in Children,dividing them into those caused by digestive disturbancesand those due in neurotics to disordered brain functions.They were often associated with rickets, adenoids, or

enlarged tonsils, errors of refraction, and tapeworms. Theywere more common in rheumatic children and partook of thenature of dreaming, of somnambulism, and of epilepsy,and were associated with migraine by some writers. Theywere a central neurosis according to others. Dr. Little hadnoticed a large proportion of morbus cordis in his cases andwas inclined to place dyspnoea as the ultimate factor.

Mr. WRIGHT (Natal) associated night terrors with som-nambulism and praised bromide of potassium and chloralhydrate as useful in treatment.

Dr. CAUTLEY associated night terrors with somnambulismand with education.Mr. G. MORGAN (Brighton) mentioned the influence of

adenoids in this complaint.Dr. J. A. MASTERS (London) was inclined to think that

the bad treatment of children by their nurses in terrifyingthem was responsible for some of the cases.

The CHAIRMAN agreed that dyspnoea was the ulti-mate cause of these terrors.

Dr. MANSEL SYMPSON asked for further details oftreatment.

Mr. A. H. TUBBY read a paper on an

Operation for the Belief of Contracted Hand and Arm afterInfantile Hemiplegia.

He detached the pronator radii teres from its radial end

(leaving a bit of tendon on the bone for easiness of sewing)through the interosseous membrane, and round to its oldattachment, thus converting it into a supinator. The flexor

carpi radialis was divided at the wrist which diminished

pronation and also flexion of wrist. He would also dividethe flexor sublimis digitorum, the flexor carpi ulnaris, and ifnecessary the flexor longus pollicis. Thorough asepsis mustbe maintained during the operation. The wrist should be

gradually straightened.Mr. JACKSON CLARKE said that physicians generally were

against advising operations in these cases but he agreedwith Mr. Tubby as to the usefulness of doing them. He

elongated the tendons.Mr. WRIGHT related a case of Spastic Infantile Hemi-

plegia on which he had operated with success.Mr. C. H. PARKINSON (Wimborne) read a paper on the

Varieties and Causes of Cough in Children with especialreference to Practical Treatment.

Dr. CAUTLEY read notes of a case of

Abnormal Ossification of Both Parietal Bones in an Infant,

aged eight months, who died from marasmus, the rightparietal bone being divided into two, and the left into threeparts. The child had snuffles and a fit, a previous childhad rickets, and a later one congenital syphilis. Dr. Cautleysuggested that the sutures showed evidence of irregular newcentres of ossification and not any-linear tabes comparable tothe craniotabes so often found in rickety heads.

PHARMACOLOGY AND THERAPEUTICS.

THURSDAY, AUGUST 3RD.

The subject arranged for discussion was Intestinal Anti-septics and their Value. The discussion was opened byDr. BURNEY YEO (London).

Previously to the opening of the discussion Dr. GEORGEHERSCHELL (London) exhibited a New Combined Galvanicand Faradaic Battery. Among other advantages were an

automatic action for indicating in which direction thecurrent was running, while the cells were so arranged as tobe easily inspected in case renewal or adjustment was

required.-The PRESIDENT (1’rofessor J. B. BRADBURY ofCambridge) then called upon Dr. Burney Yeo to open thediscussion on

Intestinal Antiseptics.Dr. BURNEY YEO commenced by saying that intestinal

antiseptics and evacuants had for a long time beenin use without the rationale for their use being known.The old blue or calomel pill together with the blackdraught which dissipated the spleen and the vapoursfor our forefathers were instances to the point. Heintended to consider the subject under four headings:(1) What was the scope of antiseptics ? (2) What was

the scientific basis for their use? (3) Under what con.

ditions were they applicable ? and (4) What were the meansof applying intestinal antiseptics ? With regard to (1) themedical use of antiseptics was different to the surgical use.The surgeon nowadays aimed rather at asepsis than at anti.sepsis. But in medicine as concerned with the intestinalcontents asepsis was impossible. We must, if possible,prevent, cr, at any rate, antagonise, auto-intoxication-i e.,intoxication of the organism with the products of digestion.With regard to (2) it must be remembered that certainbacilli were only harmful in the presence of putrefactionor other abnormal condition. The bacillus coli, forinstance, was a normal inhabitant of the intestineand under ordinary circumstances was harmless. If, how-ever, the bowel became abnormal in any way owing tocatarrh, long-continued constipation, or sometimes injury thebacillus coli seemed to take on a virulent action. Whenassociated with the bacillus typhosus it had the power of

intensifying the virulence of the latter. Dr. Burney Yeocited the experiences of Dieulafoy upon the bacillus coliwhen taken from an appendix the cavity of which had gotshut off from the rest of the bowel and the same organismwhen taken from the normal mucous membrane of the bowel.The former was virulent, the latter was not so. As, then,the virulence of intestinal bacteria depended upon theirenvironment, so by modifying that environment it wasreasonable to suppose that we could modify theirvirulence. With regard to (3) intestinal antiseptics wereindicated in gastric catarrh and fermentative dyspepsia.Grange recommended in cases of summer diarrhoea the useof plain boiled and cooled water. He claimed that the useof this diluted the toxins. There were many other conditionsto which fermentative dyspepsia and auto-intoxication gaverise. Such were dyspepsia, chest pain simulating anginapectoris, vertigo, aphasia, and anaemia. Even perniciousanaemia had been considered by some observers to dependupon some toxin which exerted a htmolytic action. Therewere three other diseases in which the use of intestinalantiseptics was rational-namely, cholera, dysentery, andtyphoid fever. Of the first two Dr. Burney Yeo said thathe had no practical experience, but with regard to

typhoid fever he had for some years advocated and prac-tised the use of intestinal antiseptics. Typhoid feveroften exhibited symptoms of being due to a mixed infectionand this might explain the extraordinary variations in theseverity of cases. He cited some instances in which the useof a chlorine and quinine mixture given every two or threehours had been attended with most marked results for thebetter in cases of typhoid fever. So, also, in some cases ofindefinite febrile affections accompanied by rise of tempera-ture, furred tongue, and foul-smelling stools the use ofthymol by the mouth, together with irrigation of the largebowel by eucalyptol, olive oil, and soap-and-water ad-ministered in the knee-chest position, had rendered thepatients well. He was not able to say to what exactdisease this condition was due, but he thought that whether theoriginal infection had been by typhoid fever or influenza thatthe condition which he was called upon to treat was due tathe action of the bacillus coli in an abnormal environment.