547MEDICAL SOCIETY OF LONDON.

short); chronic cases by intramuscular injections ofcarbon bisulphide products of diethylamine or con-tramine. At the female climacteric a distinctive formwas met, accompanied by arthritis in the knees andphalangeal joints of the fingers ; this was metabolic inorigin, corresponding with gout in the male, had agood prognosis and responded well to injections ofthiol-histamine. The fibrositis of older people wasnever seen alone, being one of the clinical manifes-tations of a general fibrosis; the cause was notascertainable, and the treatment rested betweeninjections of contramine, insulin, and milk.

Dr. OLIVER HEATH described two personal experi-ences of lumbago, one following a gumboil, the otheran injection of typhoid bacilli. The onset and courseargued in favour of a bacteriological causation.

Dr. C. E. SUNDELL was of the opinion that thesoil was of greater importance than the seed. Thetemperature on the whole was subnormal, the skininactive, and the sweat, when induced, was stronglyacid with lactic acid. Treatment should be directedtowards flushing out the backwaters of the circulationwhere fibrositis was liable to occur ; exposure to warmmoist air for half an hour produced abundant sweatingand the excretion of large quantities of acid. Reliefwas produced, but cure could not be pronounced untilthe sweat had been rendered neutral.

Dr. M. B. RAY said that during the war " fibro-sitis" had much the same connotation as " I.C.T.,"" P.U.O.," and " N.Y.D." He described the chemicalprocesses occurring in a contracting muscle whenthere was perfect harmony between nerve stimulationand muscular response. Fibrositis occurred whenthere was some clogging in the minute lymphatics ofthe fibrous connective tissue, the treatment was tostop this lymph stasis, and give the digestive systema chance to return to normal.

Dr. HIGGINTS referred to the work of continentalinvestigators, and remarked that their results werestatistically as good as ours, although they paid littleor no attention to focal sepsis. Among their methodswere the surgical removal of perithecal fat com-

pressing the lumbar cord and the restoration of thelymphatic circulation, particularly in the region of thesacrosciatic foramen, by massage and calisthenics.Dr. PARKFS WEBFR expressed his agreement withthe observations of Sir William Willcox and Dr. Ellis.in which he saw no essential contradiction. ’

MEDICAL SOCIETY OF LONDON.

A MEETING of this Society was held on March 9th,Dr. EUSTACE M. CALLENDER, the President, beingin the chair.

THE FUNDUS OCULI IN GENERAL MEDICINE.Mr. ERNEST CLARKE opened a discussion on this

subject. He said that ever since the ophthalmoscopewas invented medical men had increasingly realisedits help in diagnosis and treatment ; and its use inmedicine had been enormously advanced since theintroduction of the luminous ophthalmoscope, whichhad brought ophthalmoscopy practically withinthe reach of all. As this instrument could be broughtso near to the eye that it almost touched the cornea,it was not necessary for the examiner to have adarkened room, and the patient could be examinedin any posture. In addition the reflection of lightfrom the cornea was much lessened, enabling theobserver, sometimes, to see through a pin-pointpupil, and even inspect the macula. The normalfundus showed a great number of variations, henceit was only by much practice and by looking at everyavailable fundus that the observer acquired thecapacity of recognising an appearance which wasabnormal. Otherwise he would become alarmedneedlessly when he saw such gross changes as opaquenerve-fibres or colobomata, which were of no clinicalsignifieance, while he might miss the importantfine changes which ushered in the onset of arterio-sclerosis.

,

Picture Records oj the fundi8.Mr. ("larke said an important further advance in

the subject had recently been made. At the sugges-tion of Dr. Rayner Batten, Messrs. Hamblin hadrecently opened a studio, staffed by trained artists,for making accurate colour-drawings of ocular fundi.The aim was to avoid wearying the patient andkeeping the eyes lighted up too long, and thereforethe artists had been trained to memorise what wasrapidly seen until it had been drawn. At a few minutesnotice a patient could be given an appointment andthe picture taken while the eye was still under amydriatic. A great advantage of this was that repeatedpictures could be taken, so that a record of progresscould be kept in a successful case ; or if it were notfavourable, the record showed in what directionthe disease was advancing. Colour drawings possesseda great advantage over black-and-white ones.

Mr. Clarke showed a number of instructive pictureswhich had been made in the way described, and gavethe histories of the conditions they illustrated. Onewas that of a woman, aged 12, who was being treatedfor rheumatiEm and pyorrhoea. Vision was hyper-normal, 6/5 in each eye. Pa,pillitis and haemorrhageswere present in both eyes. There was swelling ofthe disc in the right eye to +2, and of that of the leftz 3. Her teeth were attended to, she was auto-inoculated, she gradually improved, and the mannerin which the eyes indicated the progress was plainlyshown by the pictures of the fundus. In contrastto this was the case of a man, aged 48, who had6/9 vision in each eye, but it was recently becomingworse. He was suffering from pyorrhoea and intestinaltoxaemia. Papillitis was present in both eyes, anda serious view of the case was taken. A few weekslater there were choked discs, but the man had noheadache or sickness, though the fundus appearancespointed to brain tumour. After consultation with aphysician, a decompression was decided upon, butthe patient died on the table. Post mortem, a fairlylarge glioma was found on the right side at thejunction of the occipital and temporal lobes. Oneof the large series of pictures he showed had referenceto a case of veronal poisoning. A woman, aged 6], wasmuch worried and suffered from insomnia. To securesleep she took a very large dose of veronal. Whenthe speaker saw her she had marked papillitis andretinitis, with haemorrhages in both eyes, particularlythe left. The appearances were such as to suggestcerebral tumour, but under treatment she graduallyimproved, and a month later the papillitis and hwmor-rhages had disappeared, leaving only a slight post-neuritic blurring of the disc, and this subsequentlyceased leaving both fundi normal. Another seriesshowed gradual improvement of diabetic retinitisunder insulin treatment.

In conclusion, Mr. Clarke said it would be generallyagreed that a collection of fundus pictures, accuratelydrawn-many pictures referring to the same case-formed into a permanent library, would be ofenormous use. Copies of these pictures and lanternslides of them could be obtained with the consentof the doctor, and they would be a great aid in educa-tional work. As the names would never appear,the patient’s consent was not necessary.

Disc2cssior.Dr. JAIVrF,-, CoLLiKR said an ophthalmoscopic

examination should be made in every case of illness,whatever its nature. It could be done very quicklyand afforded valuable information. To the beginnerevery fundus was of interest, and he should practiseon normal people, to enable him readily to detectthe abnormal. In his own wards every student wall’,

obliged to use the ophthalmoscope on every patient.and he criticised what the students reported they saw.In this country much more attention seemed to bepaid to ophthalmoscopic examinations than in America.In many diseases the first svmptom might be oculai-Even more important, than positive findings in general Imedicine were indications that the ocular fundi

548 BRIGHTON AND SUSSEX MEDICO-CHIRURGICAL SOCIETY.

were normal. In the presence of such symptoms asheadache, giddiness, and transient blindness it wasimpossible, without an ophthalmoscopic examina-tion, to treat the condition without a lurking suspicionthat a serious organic condition underlay the sym-ptoms. On two occasions he had ’been called to caseshaving severe symptoms and the patient expiredalmost immediately ; yet the ophthalmoscoperevealed intense papillitis and proved the existenceof a cerebral tumour. But there had been no complaintof headache. Often examination of the’ fundusoculi settled the diagnosis in otherwise doubtfulcases. In one case a little girl was admitted tohospital with urgent symptoms of meningitis ; shewas unconscious, and had head retraction andvomiting. Lumbar puncture resulted in a largequantity of blood-stained fluid being withdrawn.Twenty minutes later she was sitting up and playingwith toys. After recovering from her unconsciousnessshe was found to have asteriognosis down the rightside, showing the probability of a lesion in the parietallobe. His diagnosis was that she had had a sub-arachnoid haemorrhage, which had torn up partof the parietal lobe, probably arising from a congenitalaneurysm. An alternative diagnosis of poliomyelitiswas offered by a colleague, but in one eye, just roundthe disc, there were three small groups of fine super-ficial haemorrhages, and these had never been reportedin association with poliomyelitis, but were a frequentaccompaniment of subarachnoid haemorrhage.

Dr. PARKES WEBER referred to ophthalmoscopicappearance as a clinical sign of recent death, Hesaid his attention was directed to the subject bychance when he was house physician in 1892, by acase in which the heart ceased to beat while he wasexamining the patient’s optic disc with the ophthalmo-scope. In the same year he was called to a patientjust after death had occurred, and he found thecolumns of blood in the retinal blood-vessels inter-rupted by small spaces, looking like the segmentationwhich sometimes occurred in the mercury columnof a manometer. He found that by exerting pressureon the chest these small spaces could be movedbackwards and forwards. In one case a singlespontaneous inspiration took place after he had foundthis ophthalmoscopic phenomenon of segmentationwas already present. He gave references to observa-tions of a similar nature which had since been made.by others, both on the continent and in America.-3-1. H. Kahn, in his most recent paper on the subject,1924, entitled "A New Vascular Sign of Death,"said that in vitro segmentary coagulation could beproduced, but not without difficulty, and concludedthat segmentation in the venules and arterioles wasa definite sign of death and that it should rankequally with the other clinical signs of death. Dr.Weber said it should not be inferred, in the absence ofthis sign, that the person was not yet dead.

Dr. RAYNER D. BATTEN showed a series of con-secutive drawings of fundi illustrative of the changeseen in association with various diseases, includingthe macular changes seen in mental degeneration.A record in words, he said, failed to convey a properimpression of the condition seen, and hence consecu-tive pictures were the only means to this end. Heurged that medical men should be willing to supplya note of the clinical features of cases of which fundusdrawings were made.

Fundus Changes in Toxœmic States.

Sir WILLIAM WILICOX agreed as to the greatimportance of ophthalmoscopic examinations inordinary medical work. In every case the fundusought to be examined, and if that were done morewould be known about the relationship of the eyechanges to general diseases, and diagnoses wouldbe more accurate. He said he had recently beeninterested in the changes in the fundus oculi in associa-tion with toxaemic cases. Until comparatively recentlyit was taught that fundus changes were either due todiabetes, or to Bright’s disease, or to high blood

pressure. But it was quite common to find hæmor-rhages and other changes in the fundus in cases showingno increased blood pressure and whose renal functionwas normal. In such cases it was most importantto search for every avenue and channel of infection.When such were found and put right, it was surpris-ing how soon the fundus changes cleared up. lieusually included among the measures in such casesPlombières treatment, as there was often a secondaryseptic involvement of the colon. Some drugs seemedto show a special affinity for retinal tissue, and agood example of that was atoxyl; in certain peoplequinine had a similar special effect, and he related acase in which a large dose of quinine given mistakenlyfor malaria produced temporary blindness. Withregard to veronal poisoning, he said a number ofnervous symptoms were recurring to-day-usuallyattributed to other causes--which seemed to be asequel of medicinal treatment by veronal at someprevious date. He asked why certain patients witha focal infection had retinitis. Was it because retinaltissue was specially sensitive to the toxin ? Orwere the patients sensitised to the toxin, which wasusually a streptococcal one ? When retinal changeswere present he thought special care should beexercised in the use of vaccines, and said that his ownpractice was to start with only 5000 or 10,000. insteadof the usual millions because of this sensitisation,which was akin to asthma and angioneurotic oedema.The PRESIDENT spoke of the value which a book

consisting of a collection of pictures of fundus appear-ances associated with various diseases would be tothe general practitioner, who had sufficient experienceto recognise from what he saw that something waswrong, but often he was not familiar enough withthe changes to base his diagnosis upon them.

Mr. CLARKE briefly replied.

BRIGHTON AND SUSSEX MEDICO-CHIRURGICAL SOCIETY.

A MEETING of this Society was held on March 5th,Dr. E. F. MAYNARD, the President, being in the chair.

Mr. H. N. FLETCHER read a paper on some pointsin connexion with the

Painful Dyspepsias and their Diagnosis.After remarking that the old view of hyper-acidityas the cause of pain had been discarded, except inso far as it might be so indirectly, he described theexperiments of Hardt, Carlson and others, and theirevidence that increased intragastric tension was thetrue cause. The recent views of A. F. Hurst as tohow this increased tension was brought about bythe reflex influence of diseased states within andwithout the stomach were referred to, and the needfor further knowledge of the neuro-muscular apparatusof the stomach, the exact part played by the vagusand sympathetic nerves, and their possible controlthrough Keith’s nodes was emphasised. Mr. Fletcherthen described in detail the salient characteristics ofthe common causes of painful dyspepsias, gastricand duodenal ulcer, gastric cancer, cholecystitis,chronic appendicitis, visceroptosis and " nervous

"

dyspepsia, and laid stress upon the paramountnecessity of a detailed history and physical examina-tion of the patient-the important differential pointsof which, in making a diagnosis, he described.

Discussion.The PRESIDENT in his remarks agreed with iafr.

Fletcher in his statement regarding the time incidenceofpain, as a differentiation between gastric and duodenalulcer. As regards vomiting, this is not at all charac-teristic of gastric ulcer. If, for instance, epigastricpains and vomiting are present one would think atonce not of gastric ulcer but gall-bladder or duct.The pain in the gall-bladder radiates up to the rightshoulder. We must not, he said, lose sight of the fact