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dose of strychnine he had subcutaneously injected. For manyyears he had been accustomed to puncture by trocar and tomake incisions into distended gut, but he had not carried outthese measuies by a detailed method. Looking back on hisprevious work, he felt that in none of his cases had he beensufficiently careful to protect the patient from chill, shock,and prolonged exposure. The combination of puncture withincision and the protection of the patient from shock werethe essential features of the treatment recommended. Hehad long recognised that distension of the intestine was themost dangerous feature; as was also the septic material spreadover the surface of the gut ; the latter rendered thoroughirrigation absolutely necessary. If free evacuation of theintestine by incision followed the puncture of the gut, thecollapse of the intestine which followed such evacuationwould render the puncture less dangerous, even though theintestinal wall were softened by inflammation.Mr. HARRISON CRIPPS said that he would rather have

called such cases as bad been related "simple diffuse peri-tonitis," and he proceeded to give some illustrations of whathe meant by this term. He divided diffuse peritonitis intotwo great classes-first, those which he termed mechanical,such as resulted from a twisted ovarian pedicle ; and, secondly,diffuse septic peritonitis, which might follow after childbirthor erysipelas, or was occasionally the after-result of opera-tion. In the latter class of case he did not believe that anygood could be done by operation, for the cause of death wasthe actual poison which had been absorbed into the system,and which had thus got beyond the reach of surgery. He con-gratulated Mr. Lockwood upon his paper and upon his successwith cases which had been the bane of abdominal surgery.He thought that by showing how successfully to deal withthem he was conferring one of the greatest boons upon theprofession and upon humanity.

Mr. ALBAN DORAN went even further than Mr. Cripps anddivided cases of diffuse peritonitis into three classes-thefirst deadly, the second coming on in about three days andbeing those with which the paper was concerned, and thethird the truly pyasmic cases, which came on in about the thirdweek and might some day be cured by surgical interference.In this third class the excretory viscera were almost alwaysaffected with pysemic deposits, and he would like to ask Mr.Lockwood if he thought it justifiable to perform abdominalsection in such cases or whether they should be consideredhopeless.

Dr. NORMAN MOORE did not agree that the presence ofplastic lymph excluded septic peritonitis. Some of the

collapse present might be due to the size of the opening inthe gut, and he quoted the case of a man whom he sawwithin two hours of the bursting of a gastric ulcer, deathoccurring seven hours later. At the necropsy there werevery few signs of peritonitis. The operative measures recom-mended might be of use in the desperate cases of peritonitiswhich very rarely occurred in the course of acute rheu-matism, especially if unaccompanied by ulcerative endo-carditis.Mr. 1lZAlazAnuxE SHEILD had punctured the gut through

the abdominal wall on many occasions for chronic intestinalobstruction, but such punctures frequently leaked and hadset up peritonitis. It was of immense importance to usea very fine trocar and cannula, which should not be largerthan the calibre of a sewing needle and which should bepassed obliquely through the muscular coat so as to producea valve-like opening and thus render leakage almost impossible.He suggested that the peritoneum should be treated, likeother foul septic cavities, by continuous irrigation or bymultiple flushings.

Mr. HULKE added that he was under the impression thatBillroth fifteen years ago advocated continuous drainage inthese cases.Mr. BARKER had found by experience that a very con-

venient method of flushing the abdomen was to use a canwith three taps to which tubes of large calibre were attached,and thus the abdomen could be flushed from several pointsat the same time, the fluid flowing out of the originalincision. He thought that a better temperature for the fluidwould be 1050 F. He was in favour of free incisions intothe intestine rather than punctures on account of the imme-diate relief to the distended intestine, and that it was

practically almost as easy to stitch up an incision three-quarters of an inch in length as one only a quarter of aninch long. He entirely agreed with Mr. Lockwood that thebest way to secure patients from chill was to wrap themup in cotton wool from head to foot.

Mr. A. BOWLBY dealt with the best means of washing out-the peritoneal cavity ; an incision below the umbilicus wouldnot necessarily empty the peritoneal sac, for in one case.,after incising and flushing out below, he found a largequantity of gas as well as fluid remaining in the peritonealsac above. He considered that when the peritonitis was dueto duodenal or gastric mischief two incisions, one above andone below the umbilicus, were necessary to ensure completeflushing.Mr. LOCKWOOD, in reply, said that if odour was a test of

septicity then his cases possessed that attribute in a remarkable degree. 14e agreed that there were almost as manydifferent kinds of peritonitis as there were organisms thatcould get inside the peritoneal cavity. He remarked that allrecent researches on this subject had been done by cultures,but this was a fallacious method, because some of the.

organisms might not grow in the cultivating media used.He had been in the habit of using a trocar of the size of alarge Southey’s tube-that is, having a diameter of one anda half to two millimetres. He agreed that the bayonetpuncture was the best. He flushed out the peritoneum ina methodical manner with a large single tube. He agreedalso that in cases of perforation high up a second incision.lower down should be made for the purpose of flushing. Theobject of his paper was not to bring forward anything new"but to advocate the methodical use of known methods.

MEDICAL SOCIETY OF LONDON.

Laparotomy for Perforating Ulcer of the Duodenum.-Additional Cases of Perforating Ulcer of the Duodenum.AN ordinary meeting of this society was held on Oct. 22nd;.

the President, Sir WILLIAM DALBY, being in the chair.Mr. MARMADUKE SHEILD read a paper on Ulcerations of

the Duodenum, with special reference to the Latent Per-forating Dlcer of that part of the intestinal canal. He relatedtwo cases where he had performed laparotomy for acute-.abdominal symptoms in young men suffering from this affec-tion. The patients were respectively under the care of Dr.Thomas Green and Dr. Whipham. Other cases were referredto, especially those recorded by Mr. Lockwood in last year’s.Transactions of the Medical Society of London. The generalliterature of ulcerations of ’the duodenum was extensivelyreviewed, and Mr. Sheild argued that the ulceration of theduodenum after burns was due to septic infarction of thevessels of the duodenum, the gastric juice then acting uponthe parts cut off from vascular supply. Duodenal ulcerafter burns was rare in the present day, on accountof the care with which antiseptics and cleanliness wereemployed. The predisposing causes of ulceration of the:duodenum, especially chronic albuminuria, tuberculosis, andmalignant disease, were carefully reviewed. As regardedlatent ulcer of the duodenum, it was shown to be morecommon in men than in women, and generally to be situatedon the anterior surface of the first part of the duodenum. Noexplanation could be offered for this curious fact beyond the-possibility that when ulcers occurred in the back of theduodenum they might heal; but when they occurred on theunsupported front aspect of the gut they usually perforated.-Mr. Arthur Latham added an important mass of infor-mation to this paper by reviewing in conjunction withMr. Sheild the cases of perforation of the intestine atSt. George’s Hospital for the last thirty-one years. In8192 post-mortem examinations there were 116 cases

of death from perforation of the intestines, and 12 ofthese were due to perforation of the duodenum. Ten ofthese occurred in males and 2 only in females. In 9of the 12 cases the ulcer was on the anterior surface ofthe duodenum. Ulcerations of the duodenum which hadnot perforated were present as follows: those with slightulceration or congestion, 7 cases ; associated with renaldisease, 6 cases; tuberculosis, 2 cases; malignant ulceration,1 case ; in association with scirrhus of the pancreas, 2 cases ;and 5 cases without any very obvious cause. The symptomsand diagnosis were next considered, and cases quoted to showthe similarity of the affection to lead colic and intestinalobstruction, while the sudden collapse and death which hadbeen found in some of the cases had led to the suspicion ofdeath from poison. Great stress was laid upon the symptomsbeing primarily epigastric, and on the fluid and flatus in theperitoneal cavity being devoid of fsecal odour. The re-action to litmus should be acid, but this was not always

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the case, since the peritoneal exudation would neutralisethe contents of the duodenum or stomach. The situationof an exploratory incision was finally considered, andvarious methods of finding a perforation were mentionedand criticised. Stress was laid upon a method used byMr. Sheild in abdominal surgery of passing stout silkloops through the abdominal opening on either side andholding the edges asunder. This gave freer access tothe cavity of the abdomen than any other method,while traction upon the loops would greatly facilitate thereturn of distended intestine. The following conclusionswere arrived at :-1. That perforating ulcer of the duode-num was a rare affection, and far more common in youngadult males than females. 2. That in a considerablenumber of cases the symptoms were primarily epigastric orreferred to the right hypochondrium, or there was a previoushistory of epigastric troubles. 3. That in perforative peri-tonitis occurring suddenly in a male, if the symptoms were notvery typical of implication of the vermiform appendix, thesurgeon should turn his attention to the duodenum, where thelesion would most generally be found. The absence of faecalgas or odour in the abdominal contents pointed to implicationof the duodenum or stomach. Acidity of abdominal con-tents pointed to the same conclusion. A small exploratoryincision below the umbilicus would clear up the nature ofthe abdominal contents. 4. The success of the future layin cleansing the peritoneum by repeated hot-water flushingsand drainage of the pelvic cul-de-sac.

Mr. C. B. LOCKWOOD contributed an account of someAdditional Cases of Perforating Ulcer of the Duodenum.His communication is published in full in another part of ourpresent issue. Mr. Lockwood afterwards remarked that hehad recently seen a case of perforating ulcer of the stomachdealt with by laparotomy, and the fluid in that case wasfound to be neutral. All the cases of perforative ulcer whichhe had seen were small, with sharply cut edges, and all couldhave been closed by suture through a median incision abovethe umbilicus.

Dr. RECTOR MACKENZIE saiu. that bwo cases came unuer uis

notice some time ago. The first was sent to St. Thomas’s Hos-notice some time ago. The first was sent to St. Thomas’s Hos-

pital for intestinal obstruction, and perforative peritonitis ofthe appendix was diagnosed. Laparotomy was performedand a general diffuse peritonitis discovered, but there was noaffection of the vermiform appendix. As the patient becameextremely collapsed the abdomen was closed withoutfurther search. At the necropsy a perforating ulcer ofthe duodenum was discovered, though during life there wasneither localising pain in the right hypochondrium nor othersymptom suggestive of duodenal ulcer. The second casewas one of peritonitis and the patient lived nine days after theonset of acute symptoms. There was nothing in this casealso to suggest ulcer of the stomach or duodenum, but postmortem an ulcer was found in the first part of the duodenumon its anterior surface. In none of the cases of perforativeulcer of the duodenum at St. Thomas’s Hospital could adiagnosis be made. Symptoms of peritonitis of severe onsetmight suggest a perforation of the duodenum; but thesesymptoms might also be due to perforation of the stomachor of the vermiform appendix. If one relied too much onthe region in which pain was first felt one might easily fallinto the other error and mistake what was really a perfora-tion of the vermiform appendix for one of the stomach orduodenum. In cases of gastric ulcer guiding symptomsmight be present beforehand, but in duodenal ulcer thesymptoms were usually absent.

Dr. ROUTH said that in cases of abdominal inflamma-tion electricity might be of use in localising the area firstaffected ; it would be found that intense pain would becaused by passing the positive electrode over the spot oppo-site the perforation. Apostoli had succeeded in this wayin detecting trouble connected with the stomach and withthe ovary.

Mr. HOWARD BARRETT referred to a case which occurredin his practice in the early part of the summer of this year.A man aged thirty-five, who was the subject of dyspepsia,was suddenly seized at the theatre with extreme agony andcollapse accompanied by vomiting. Abdominal section wasperformed later by Mr. Godlee, and fluid of fæcal odour wasevacuated from the peritoneum. The abdominal cavity wasdrained and the patient recovered. It was the opinion ofthose who saw the patient that the case was one of duodenalulcer. Before the acute attack he had been frequentlytroubled with right hypochondriacal pain.Mr. SHEILD, in reply, said that in his two cases the

fluid found in the abdominal cavity was sweet, and hethought that if early laparotomy were resorted to in thesecases the fluid evacuated would generally be found to besweet and distinctly different from the fluid present in theperitoneal sac when the cæcum or lower bowel was per-forated. The fluid might be acid at first, but it was rapidlyneutralised in the peritoneum. He agreed that when explora-tory laparotomy was performed in these cases a secondseparate incision should be made above rather thanprolong the original laparotomy wound upwards. Thecollapse in these cases was very striking, and was, hethought, significant of perforation of ulcer high up. Hebelieved that the method suggested by Dr. Routh might beuseful in the case of a tender ovary, but it could be of littlevalue in instances like those under discussion, where theabdomen was often distended with intestinal gases and thepatient too collapsed to describe where he felt pain. Hehad seen cases of subphrenic abscess in which the fluid wasoffensive but not feculent. Where the communication ofthese abscesses with the stomach was direct the patientsseldom recovered, and it was therefore better to performlaparotomy immediately than to wait for the chance of asubphrenic abscess forming. In these cases it was neces-

sary to carry out an elaborate purification of the peritonealcavity.

OPHTHALMOLOGICAL SOCIETY.

Filaria Loa.-Tuberculous Keratitis.-Equatorial Rupture o,fthe Choroid.-Cataract.THE first ordinary meeting of this society for the present

session was held on Thursday, Oct. 18th, the President,Dr. D. Argyll Robertson, being in the chair.

Dr. ARGYLL ROBERTSON read an account of a case ofFilaria Loa. The patient, a woman aged thirty-two years,had spent eight years at Old Calabar, with the exception oftwo visits to England after attacks of intermittent fever. Shereturned to England in January, 1894, after being laid upwith dysentery and remittent fever, and the worm was firstnoticed in the February following. It affected both eyes,but chiefly the left, being felt in the lids and conjunctiva.The worm was most lively when the patient was sitting in awarm room, especially before the fire, disappearing to deeperparts in a colder atmosphere. In July and August, while thepatient was much in the open air, the worm was not felt, andwas thought to have disappeared, one having been passedper rectum. When moving about the creature producedirritation which prevented work or reading but set up nosevere inflammation. When examined in June no trace ofthe worm could be found, but on Sept. 12th it was feltmoving. The eye was covered with a warm cloth toretain the creature in situ, and on examination it wasobserved to be passing in a wriggling, tortuous manner underthe conjunctiva, about 5 mm. from the cornea, and causingsome lacrymation and injection. A finger was pressed uponthe globe to retain it during cocaine application, afterwhich a fold of conjunctiva was raised and snipped withscissors, one end of the worm was seized with iris forceps, andthe creature withdrawn. It was like a piece of fishing-gut:round, transparent, and colourless, about 25 mm. in lengthand mm. in breadth, blunt at one extremity and taperingat the other. Twisted around it was noticed a finer coil,which proved to be the alimentary canal protruded. Theworm became still when immersed in boracic acid, and wassubsequently mounted in glycerine jelly. It was a maleand was exhibited under the microscope. Sketches werealso shown. The creature was well known to the nativesof Old Calabar, and was believed to gain access to the eyeswhile bathing. They were accustomed to use salt-and-waterto "scare them away." Mosquitoes were plentiful in thedistrict but the dracunculus medinensis was unknown.He quoted other cases which had occurred in the same

region. A woman who had lived in Old Calabar from 1860to 1863 subsequently suffered from the worms’, which wereremoved in 1875 and 1876. Trouble was only experienced inwarm weather and ceased entirely after their removal. Dr.Thompstone of Opobo had described two cases in natives, thecoiled-up worm at the inner can thus resembling dachryo-cystitis. In all about twenty-six cases had been reported, ofwhich the earliest were by M. Bajon, a French surgeon, in1768 and 1771, on the occasion of his visit to Cayenne.Subsequently M. Morgan described a case, and in 1777M. Guyon did so, others being added by M. Clobe and