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OPHTHALMOLOGICAL SOCIETY.

Melanotic Sarcoma of the Choroid with General Metastasis -New Operation for Squint.-Security ot Sutures for I tSquint Operations.--Disease of the Pi!ecatary Body without sAcromegaly.--Fusion Pictures.-New Method of Cataract eExtraction.

THE May ordinary meeting of this society was held in the (

theatre of the Royal Dublin Society on May llth, Mr. J. B.LAWFORD, the President, being in the chair. :

Dr. H. A. LEDIARD read a paper entitled "MelanoticSarcoma of the Choroid with General Metastasis." It was acase in which metastases were seen in the liver and intestine,occurring in a woman aged 55, who came under treatmentin the Cumberland Iafirmary with symptoms of gall-stone.During operation it was seen that the liver was diseased, andon incision a black tumour was discovered. Three yearspreviously the patient had had the left eye removed in theManchester Royal Eye Iafirmary. on account of intraoculargrowth, correctly diagnosed. Vision had been failing fortwo years, and when the eye was removed there were pain,blindness, cataract, increased tension, and shallow anteriorchamber. The secondary growth in the liver showed massesof spindle-celled sarcoma, parts of which were pigmented,and others free from granules of melanin. There was alsoan invasion of the mucous layer of the intestine by pigmentbearing sarcomatous cells lying between the gland follicles.The chief tumour within the liver was as large as a

small-sized orange and absolutely black. The gall-stoneremoved was a single large one weighing lc)9 grainswhen dry, and measuring 1 in. by 1 in.-Mr. W. H. H.JESSOP asked whether members really thought there was sucha thing as a leucosarcoma ; he had always been able to detectpigment microscopically in every choroidal sarcoma, no

matter how white they appeared to be.-Dr. W. B. INGLISPOLLOCK and Mr. C. DEVEREUX MARSHALL said that theyhad never seen a true leucosarcoma ; a certain amount ofpigment was always present.-Mr. ARNOLD LAWSON ex-

pressed the belief that sarcoma of the choroid was reallyn)t a very malignant disease, and that many caqes were

cured if the eye was removed early enough.-Sir HENRY RSWANZY agreed with Mr. Lawson -Mr. D. A. HILL GRIFFITHsaid that, of the cases he had reported about 50 per centwere well three vears after the primary growth was removedand he doubted whether removal of the eye made muchdifference to the possibility of general metastasis. Somecases removed in quite an early stage proved generally verymalignant, while others remained for years and produced nometastasis at all.-Mr. W. T. HOLME3 SPICER Mentioned thecase of a patient whose eye he removed in 1898 andwho still showed no further signs of the disease. Healso mentioned another case where the patient refusedtreatment ten years ago, and he was still well.-Mr.G. A. BERRY doubted if a growth which appeared tenyears after removal of an eye for melanotic sarcoma was

really a metastasis at all. He believed that leucosarcomadid occur, and the sooner all these cases were operated uponthe better was the chance of life.-Mr. N. BISHOP HARMAN

thought that the younger the patient was the more

malignant was the growth.Mr. BISHOP HARMAN read a paper entitled "A New

Operation for Squint-Conjunctival Reefing and Advance-ment." He said that despite a growing condemnation oftenotomy the operation still lived in out-patient practicebecause of its facility. To secure reasonable prospects ofsuccess with the operation of advancement, with or withouttenectomy, the patient had to be put to bed with both

eyes bandaged. His aim in devising this new operationof reefing-advancement was to avoid these difficulties. Hebelieved that he had succeeded in this. The operation hedescribed was comparatively easy to perform and expeditions.Of the 34 patients he had operated on only one had beerkept in bed, all the others had been outdoor patientswith only the one eye bandaged. The results up to dat(were distinctly gratifying, both to patient and surgeonBriefly, the operation consisted in exposing the edges of thetendon to be shortened, then with special forceps foldingor reefing the tendon, very much in the same fashion

that the laundry-maid treated linen frills in the process o

goffering. The operation could be varied according to th

degree of squint : (1) the extent of the reefing or shorteningof the tendon could be varied by the adjustment of thereefing forceps ; and (2) in high degrees of squint the suturesused to secure the reef were carried forward so as to advance.the reef. The steps of the operation (say for convergentsquint) were : 1. Securing the eye by the insertion of an.anchor stitch at the limbus ; this avoided fixation forceps,and the stitch was used to fix the eye in abduction at the endof the operation. 2. Locating the tendon. It was pointedout that there were distinct colour differences in the can-.junctiva, according as tendon or Tenon’s capsule was beneathit. These differences were marked in the young 3. Twobutton-holes were cut through conjunctiva right to the scleraabove and below and parallel to the edges of the tendonbetween the insertion and the canthus. 4. The surfaces ofthe tendon were rasped with a squint hook, the edges ofwhich had teeth. This stimulated the production of adhesionswhen this part of the tendon was folded. 5. The reefiogforceps were applied to the tendon. The forceps were likesquint hooks whose short flat handles fitted together andwere adjustable, so that the hooks coincided or separated by

, varying widths. Working from the outer canthus one blade, was slipped beneath the tendon, and the ether blade. above the tendon and under the conjunctiva. When3 the forceps were turned from the outer canthus to

, lie across the nose the tendon was folded over or

reefed. 6. The base of the reef was then fixed byappropriate sutures. If the squint was of low degree theoperation was then finished. If it was of high degree thesutures were carried forward and fixed into the sclera at thelimbus, so that tying the sutures advanced the reef andfurther abducted the eye. 7. Finally, the eye was completelyabducted by means of the anchor stitch ; this was fixed tothe skin of the canthus with strapping. By this meansrelaxation of the antagonist of the operated muscle wasproduced, and it protected the reef from too early strain.The eye was bandaged, the spectacles worn with a blinkerbeside and half covering the open eye, so as to cause thpatient to look towards the operated muscle. The anchorstitch was removed the third day and the reefing stitches on the tenth day.

Mr. BISHOP HARMAN also gave an account of "Some

Experiments to Ascertain the Security of Sutures for Squint

0 perations." He said that in squint operations four modes

of placing the scleral sutures were possible. The part thattraversed and gripped the sclera might be placed (1) in linewith the axis of the tendon and at right angles to the

limbus ; (2) across the axis of the tendon or parallel to thelimbus. Further, each of these sutures might be made witha single or a double thread. To find out which of these

possible modes gave the greatest security Mr. Harman hadmade experiments with artificial materials and their tearingchrain under weights The conclusion was thai; a. rlntihlp. silk

thread placed in the sclera across the axis of the tendon, andtherefore transversely to the strain of the suture, had a

carrying power from 12 to 18 per cent. greater than the otherthree modes. He had found these experimental data con-firmed in practice. For that reason he inserted his stitches,as above described, in advancement operations.

Dr. Louis WERNER read a paper on Disease of the

Pituitary Body without Acromegaly. He gave a short

history of the discovery of the disease, and described wbathad been ascertained by experimental evidence and clinicalfacts. He discussed the course and symptoms, and gave theviews of various observers. A series of photographs wereshown on the screen depicting animals and X ray photo-graphs of patients suffering from the disease, as well as

micro-photographs of the pituitary body in health anddisease.

Mr. H. H. B. CUNNINGHAM read a paper on FusionPictures. He emphasised the importance of training thefusion sense in young children, but thought that stereo-scopes, &c., were too complicated and too expensive forgeneral use. He had devised a series of pictures drawn intwo colours, which could be seen through a coloured screen.One part of the picture could be seen with one eye and onewith the other. Those for very young children were of a veryelementary character, but for older children they were rathermore elaborate. In this manner, as in the case of an

ordinary stereoscope, binocular vision could be developed andeducated.! Mr. J. STROUD HOSFORD, in describing a New Method

1411

of Extraction of Cataract in the Capsule, said that the opera-tion of cataract extraction was justly looked upon as a major Ioperation, and the premier operation in ophthalmic surgery.Very serious dangers could be avoided if removal of the lens inits capsule could be done with safety. Daring the present year- he had performed nine cataract extractions by a new method,which consisted of entering a discission needle into the lensand then rotating the lens on an antero-posterior axis. Thiscaused the zonule of Zinn to be torn, after which the lens, inets capsule, could be removed without the loss of vitreous.The lens could be thus rotated either before or after the

making of the section. If this method were adopted incom-plete lerses could be removed, and it had all the advantagesof Smith’s operation, besides being safer and not so com-.nlicated.

UNITED SERVICES MEDICAL SOCIETY.-A meet-ing of this society was held at the Royal Army MedicalCollege on May 8th, Major E. B. Waggett, R.A.M.C. (T.),the President, being in the chair.-Lieutenant-ColonelJ. F. Donegan, R A.M C., gave a demonstration of his

Operating Table for use in the Field. The table is made ofaluminium and tubing ; it is 41b. lighter than the present.pattern, and is so designed that all the requisites for an

operation are contained in the table itself. There is pro-vision for heating the table when necessary, and all theusual positions can be arranged for.-Major F. E. Fremantle,R.A.M.C. (T.), read a paper on the Sanitary Service of theTerritorial Force. He pointed out that the regimentalmedical officer of the Territorial Force was not a trainedsanitary officer, as in the line ; consequently there was muchgreater need for the activities of divisional sanitary officersand of sanitary companies. The efficiency of theregimental medical officers might be much increased

by their being allotted definite sanitary duties whilein camp and by the issue of a small manual of instruc-tion for their special use. The unattractive nature ofthe duties of regimental sanitary squads made it very diffi-cult to obtain recruits for these posts, and he suggested thatit was only possible to secure men for the sanitary squads byoffering special inducements in the way of extra pay andquicker promotion. The water duty men had no functions ina camp in peace time and were not likely to be needed inwar time in this country, where water-supplies were usuallygood and only needed proper protection from pollution byordinary military measures. He thought that each divisionshould have a sanitary company under the divisionalsanitary officer, who should preferably be a countymedical officer of health in the area from which thedivision was drawn. Every effort should be made to keep inclcse touch with the civil sanitary authorities, so as to getthe advantage of their local knowledge.-Major P. Caldwellsmith. R.A.M.C. (T.), read a paper on the Duties of Sani-tary Companies of the Territorial Force. After describingtheir organisation, he urged that the number of non-com-missioned officers should be increased so as to allow of the

company being split up into eight sections for the purposescf their duties in the various parts of the area under their- charge. The non-commissioned officers should be recruitedfrom among civilian sanitary inspectors. He then proceededto describe the methods of instruction adopted in his com-pany. Great stress was laid on lectures and practicaldemonstrations in care of water, infectious diseases and theirprevention, camp conservancy, and the inspection of food.He thought it was probable that on mobilisation the Terri-torial Force would establish large concentration camps, andthat the sanitary companies would find their chief functionsin the sanitary care of such camps. He recommended that adistinction should be made in the uniform of the men of thesanitary companies so as to prevent their being taken awayfrom their proper duties.-The President, Brigade-SurgeonJ. F. Beattie, A.M.S. (retired), Colonel J. Harper,R.A.M.C. (T.), and Lieutenant-Colonel B. M. Skinner,M.V.O., R.A.M.C., took part in the discussion.

BRIGHTON AND SUSSEX MEDICO-CHIRURGICALSOCIETY.—The final meeting of the session of this societywas held at the Queen’s-road Dispensary on May 8th,Mr. T. H. Ionides, the President, being in the chair.-The following were among the cases and specimens ex-

hibited :—Dr. L. A. Parry : A boy with a Fracture of theLower End of the Humerns, which he had wired on account

of the difficulty of getting the broken ends in accurate apposi-tion by the usual method of treatment-i.e., fixation in thefully flexed position. There had been some musculo-spiralparalysis after the operation, but this had now cleared up, andthe result was quite good, the boy having almost perfect move-ments in all directions.-Dr. C. F. Bailey : A woman aged30, who was probably an early case of Disseminated Sclerosis.She had nystagmus, tremors, and left lingual paralysis.-Dr. Walter Broadbent: 1. A case of Morbus Coeruleus inan undersized boy aged 12. He had a blue appearance, verymarked on exertion, and his finger-ends were much clubbed.There was hypertrophy of the heart, mainly of the rightventricle. On auscultation there was a loud, rough systolicmurmur in the third left space. The condition was probablypulmonary stenosis with patent foramen ovale. 2. TheHeart and Brain of a girl aged 12, who during an attackof acute endocarditis developed a right hemiplegia fromembolism, and some weeks later suddenly became comatose.There was retraction of the head, conjugate deviation ofthe head and eyes to the right, and loss of knee-jerks.Post mortem was found a large subarachnoid haemorrhageon the under surface of the medulla, pons, and crura. Thelateral ventricles also contained blood, the left more than theright. In the heart only the mitral valve was affected andabout a square inch of the auricular wall above the valves.-A discussion, adjourned from the last meeting, took placeon the Therapeutics of Vaccines.-Dr. Broadbent read apaper on Influenza.

Reviews and Notices of Books.Modern Theories of Daet; and their Bearing upon Practical

Dietetics. By ALEXANDER BRYCE, M.D. Glasg., D. P. H.Camb. London: Edward Arnold. 1912. Pp. 368.Price 7s. 6d. net.THIS is a valuable volume for general practitioners, for in

these days there are so many devotees of diverse cults indiet that it is essential to the physician to have his ideas onthe subject as far as possible formulated and arranged.The views expressed are distinguished by a sober impartiality,which almost errs at times by being too impartial. Two

introductory chapters on modern theories of metabolism havebeen revised by Professor Fraser Harris, of Halifax, N.S.,and give an admirable survey of such speculations as thoseof Pfluger, Voit, and Folin.

Vegetarianism in theory and practice is considered fromall the standpoints usually occupied by its advocates-the11 humanitarian " point of view, Major McCay’s investigationsinto the physical capacity of the natives of Lower Bengal,and the Irving Fisher experiments at Yale are passed underreview, as well as a large number of allegations constantlymade by vegetarians, such as the influence of flesh food inthe production of cancer. In the preparation of this difficultresunae Dr. Bryce, who was himself at one time a residentat Battle Creek, has had the advantage of criticism andassistance from Dr. J. H. Kellog, the head of the largestvegetarian establishment in the world. The chapter is

useful and interesting, but the conclusion to which theauthor arrives is that " the only infallible argument in

favour of vegetarianism to-day that has the slightest valuefor the individual is the personal one to which there is

no answer." A well-balanced section on low-protein theoryand practice introduces Professor Chittenden’s admirablywork, coupled with Fletcher’s well-known experiments, anda further and fuller commentary on McCay’s inter-racial

observations on food. In his account of purin-free diet Dr.Bryce does not spare the dogmata of Dr. Haig, and hefurnishes a valuable epitome of the points of variancebetween this writer and Professor Folin.The subject of excess-feeding is introduced under the name

"hyper-pyræmia," applied to it by Dr. Francis Hare, whosetwo valuable volumes are well criticised and carefully com-pared with the ’’ Salisbury treatment"; and the chapter