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draw attention to the very definite presence of tumour,which was felt not only through the abdominal walls,but also with the hand in the peritoneal cavity. Fromfirst to last there was no doubt as to the tumour. Itwas owing to this tumour that the history was strained a

point, for the latter indicated a much longer duration of thedisease than was compatible with tumour. This difliciilty,however, was got over by supposing that malignant diseasehad started at the site of an old ulcer. This is said to occur.The sense of tumour was no doubt greater during life thanafter death, when vascular turgescence had subsided. Thehead.of the indurated pancreas formed one with the adherentand thickened pylorus, and I can only suggest in explana-tion of the undoubted mobility of the tumour during lifethat the movements of the stomach as it filled or emptied,continued through a period of years, had loosened theposterior attachments of the pylorus. This point was,unfortunately, not tested at the post-mortem. Dr. Brinton,speaking from his large experience, has stated that in afew cases he had found it impossible to decicle betweencancer of the stomach and gastric ulcer. This case mayserve as a commentary to this statement, and it will enforcethe danger in clinical medicine of relying too much on onesymptom or sign. The base of the ulcer and its edge wereexamined microscopically, but no evidence of malignantdisease was obtained. As to the treatment, I do not see inwhat it erred, for gastro-enterostomy is a recognised treat.ment both for new growth and ulcer of the stomach.

MANCHESTER ROYAL INFIRMARY.TWO CASES OF GASTROSTOMY FOR STRICTURE OF THE

ŒSOPHAGUS ; REMARKS.

(Under the care of Mr. SOUTHAM.)IN the following cases the operation of gastrostomy was

performed for obstruction of the oesphagus, which wasprobably of a malignant character. Although surgeons aregenerally agreed as to the advisability of performing thisoperation at an early stage, before the patient is exhausted,it is not often possible to gain the consent of the patientto the performance of the operation until a very late stage,when exhaustion is so extreme that much benefit cannot beexpected. Gross collected records of 167 cases of gastrostomyfor malignant disease, of which the mortality was 29’34per cent.; most of them died quickly, but forty-six survivedfor more than a month. Of 207 examples of this operationperformed for various conditions the mortality was 29 47,and the average prolongation of life was about eighty-two

days.CASE 1.—Edward T-, aged fifty-eight years, was

admitted under Dr. Steell, on Feb. 10th, 1890, suffering fromdysphagia of about six months’ duration. During the lasttwo months he had rapidly lost flesh, and about four weekspreviousiy he began to lose his voice. When admitted hewas unable to swallow solid food, and was much emaciated,weighing only 8st. lllb. On exploring the oesophagus, anobstruction was encountered nine inches from the teeth,and a second one about four inches lower down, throughwhich it was impossible to pass the finest bougie. Onexamining the larynx the left vocal cord was found to beparalysed. During the first fortnight after admission thepatient gained four pounds in weight. At the end of thisperiod, as he began to lose weight, and also to experienceconsiderable difficulty even in swallowing fluids, he wastransferred to the surgical wards to undergo the operation Iof gastrostomy. ,March 8th.-Gastrostomy was performed by means of an

incision three inches long, commencing at the outer edge ofthe left rectus and carried parallel with and about a finger’sbreadth below the margin of the ribs on the same side; thestomach was readily exposed. It was then drawn up andattached to the margins of the wound by six catgut sutures,which included, on the one hand, the entire thickness ofthe abdominal parietes, and, on the other, the serous andmuscular coats of the stomach, care being taken to bringthe opposed serous surfaces well into apposition. Two silksutures were then passed through the serous and muscularcoats of the stomach to act as a guide when the viscus wasopened. On the fourth day, the patient having meanwhilebeen fed entirely by nutrient enemata, a small puncturewas made into the stomach with a tenotomy knite, and apiece of a No. 7 Jacques’ catheter was passed through the

opening and secured. Through this the patient was after-wards fed, two ounces of warm milk being introducedevery two hours. On the sixth day the tube was removedand left out of the wound, being reintroduced every three orfour hours for the purpose of feeding. The patient left thehospital on the twenty-eighth day, being able to feed him-self through the gastric fistula, having gained twelvepounds in weight during the last three weeks. lie attendedseveral times as an out-patient, but eventually diedat home just three months after the performance of theoperation.CASE 2.-Thomas L-, aged forty-two years, was ad..

mitted on June 28th, 1890, in an extremely emaciated con-dition, weighing only 8 st. 21b. About six months pre-viously he had commenced to experience difficulty indeglutition, and at the time of admission could onlyswallow fluids in very small quantities. On exploring theoesophagus, an obstruction was met with at a distance ofthirteen inches from the teeth, which would not admit thesmallest bougie. During the first week, as the result ofcareful feeding, he gained 4 lb. in weight. During thesecond week, he was suddenly seized with complete inability to swallow, and though he was fed with nutrientenemata he lost 171b. in weight. It was accordinglythought advisable to perform gastrostomy without furtherdelay. The operation was performed on July 12th, in thesame manner as in the preceding case, and the stomach wasopened on the third day, as the patient was becoming ex-tremely exhausted from want of food. On the followingday, at the request of his friends and contrary to advice, hewas removed to his home, a small cottage in one of thepoor quarters of Manchester, where be was unable to besupplied with proper nourishment. Though he continuedto be fed through the gastric fistula, he gradually sank,death taking place exactly three weeks after the perform-ance of the operation.Remarks by Mr. SouTtiaiz,-Aceording to recent statistics

the rate of mortality after gastrostomy is still very high,being not less than 72 per cent. In a large proportion ofcases death takes place within the first twenty-four orforty-eight hours, and is due to shock, which is not wellborne by the subjects of stricture of the oesophagus, forthey are usually worn out by exhaustion and inanition atthe time of operation. As rapidity of operation is alwaysan important factor in lessening the effects of shock, thesimpler and the more speedy the method of attaching thestomach to the abdominal walls the greater is the pro-bability of a successful result. The simple plan adoptedin the preceding cases, where a single row of sutureswas employed, not only ensures sufficiently accurate

apposition of the serous surfaces, but it also has theadvantage of great rapidity, for in both instances theoperation was performed in less than fifteen minutes.Though the duration of life after operation was not verygreat in either patient, yet it was undoubtedly prolongedby the performance of gastrostomy, and in addition thepangs of hunger were relieved, and the comfort of thepatients was also increased. In neither case was thereinconvenience from regurgitation of food or escape of gastricjuice from the fistula, these complications being avoideclby the formation of a small opening and by not retaining thetube for a longer period than forty-eight hours. No post-mortem examination was obtained in either case, but fromthe rapid course which the disease ran there can be littledoubt that the strictures were of a malignant nature.

Medical Societies.OPHTHALMOLOGICAL SOCIETY.

Some Points in the Development of Cataract.—DiphtheriticParalysis of External Recti.—Paresis of External Recti.— Supposed Case of Sanguineous Lacrymation.AN ordinary meeting of this Society was held on Dec. 11th,

the President, Mr. Henry Power, F.R C.S., in the chair.Mr. W. A. BRAILEY read a paper on Some Points in the

Development of Cataract, in which he said that,excluding thecongenital and zonularforms, and also the cataracts secondaryto other conditions, whether local, following glaucoma oriritis, or general, as from diabetes, 7 per cent. of the total

21

cases seen in his private practice during the last two yearswere found to have some degree of opacity of the lens.But only one on the average out of these seven patients hadhis cataract sufficiently advanced to justify the operation ofextraction. From examination of the records of all patientswith immature cataract who had been re-exatnined withinthe last two years, it was found that 45 per cent. of themremained absolutely unchanged for the worse, the intervalsbetween examination and re-examination varying betweenthree months and eight years. Four other cases had evenbecome slightly better as regards vision, thus making 58

’’

per cent. in which the sight had not deteriorated. Twenty-three per cent. were decidedly worse, inclusive of 4 cases(13 per cent.) in which the cataract was sufficiently advancedto justify removal under ordinary circumstances. The slightimprovement of vision in 13 per cent. of the cases wasattributed to the hygienic measures adopted with regard tothe use of the eyes. h was ob3erved that the cataractswhich had remained stationary or improved were mainly ofthe cortical variety, as shown by the presence of peripheralstriae or fissures in the lens, whereas those getting slowly andsteadily worse were mainly nuclear. Other differences werefound between the two groups, the cortical variety beingattended, in about two-thirds of the cases seen, both at theonset and for long afterwards, with irritative symptoms, suchas conjunctivitis, photophobia, lacrymation, slight rednessof the optic discs, and by aching in the eyes and head,especially on use of the eyes. There was often also a slightincrease in the refraction, and some augmentation of thepower of accommodation, with occasionally slight spasm ofaccommodation. Finally it was suggested that while thesenile nuclear cataract was a degenerative change, thecortical exhibited often the characters of an inflammation.-The PRESIDENT said the remarks made by Mr. Braileywere in accordance with general experience. He men-tioned cases under his own care, and recalled the axiom ofSir William Bowman, " Never operate for cataract whilethe patient can see to read with either eye.’’ The rate ofdevelopment of cataract depended much on constitutionalcauses, but in come degree might be delayed, he thought,by hygienic precautions. He was unaware that any casehad been met with in which partial cataract had ever dis-appeared. With regard to laminar cataract, Mr. Powermentioned the case of a young man whose vision had beengood till eighteen years of age ; his sight failed after twoyeais of office work, and it was necessary to wait anotheryear for full development before operating. He did notknow that anyone could hold out any promise of recoverywithout operation.—Mr. SILCOCK said that such cases as thosedescribed by Mr. Brailey were familiar to most ophthalmicsurgeons, but he thought the association of symptoms metwith in one class of cases of which he had spoken might havebeen of value in prognosis.—Dr. W. J. COLLINS mentionedan instance of cataract which had been twenty-eight yearsmaturing, and was not now complete. The original diagnosisand a sketch had been made by Sir William Bowman.The primary striæ were posterior, and there was some

myopia. The latter might be referred to the increaseddensity, the refractive index increasing with the percentageof solids in, apart from swelling of, the lens.-Mr. WARENTAY was interested in Mr. Brailey’s account of the sym-ptom?, in addition to failing vision, which were present incases of immature cataract.&mdash;Mr. MCHARDY thought therewas insufficient evidence that free use of the eyes appre-ciably hastened the maturation of cataract, and that therewas therefore no advantage in recommending a limitation ofhe use of the eyes. In his experience there was usually a- change in the refraction of the eyes, in the direction of.myopia, which varied with the state of tone of the patient,<and was, he considered, chiefly dependent on the higherrefractive index of the altered media. He recognised thepossibility of improvement in vision, and cited the case of aman in official position who relinquished his employmenton account of defective vision through the development ofcataract, and was able a month afterwards to read thenewspaper regularly. He eventually died some time later,without any necessity for operation having arisen.Mr. DOYNE (Oxford) exhibited and read notes of a case

he had brought before the Society last session under thetitle of Paresis of the External Recti. He now thoughtthe condition was more correctly described as "spasm ofconvergence," The patient, a lad aged seventeen, had visionof with each eye separately, and Jaeger 8 when holdingthe types at three inches from his face. His eyes were usually

in a normal position, but as soon as examination was begunspasmodic convergence showed itself. The refraction wasalways myopic, though the degree varied; under atropine,however, a low degree of hypermetropia became manifest.Extreme restlessness and sighing and profuse perspirationwhen under observation were noticeable symptoms. Mr.

Doyne thought the case was one which might be classed asneurotic, but suspected also that there was deliberatemalingering.Mr. A, STANFORD MORTON read notes of four cases of

Paralysis of the External Recti due to the poison ofdiphtheria. Three of these patients came under hisobservation during the last ten months, and the fourth wasa patient of Mr. Tay in 1876. They all complained ofsomewhat similar symptoms, such as " crossing " of the eyesand "seeing double," together with more or less defectivesight, weakness of the limbs and staggering gait. From astudy of the cases it appeared that the paralysis of the ex-ternal recti came on in from four to seven weeks after thesore-throat. Its shortest duration was four weeks, and inone case it is still in existence, having been present twenty-six weeks. In addition to the paralysis of the external rectithere was in one case defective action of the superior andinternal recti. The pupils acted well to light and con-vergence in all the cases. The accommodation was affectedin three of the cases, being absolutely paralysed in one.Loss of the patellar-reflex was very marked. The shortestperiod in which this symptom was recovered from was threemonths. In two of the cases the reflex was still absentafter a period of twenty-six and sixteen weeks respectively.These cases were reported because of their apparent in-frequency.-Dr. SIDNEY TAYLOR (Norwich) referred to acase of paralysis of the external recti following an attack ofepidemic influenza.Mr. RICHARDSON CROSS read an account of a case of

Supposed Sanguineous Lacrymation, occurring in a ladyaged twenty-one, who was seen in June, 1889, on accountof slight follicular conjunctivitis of the left eye and somediscomfort referred to the inner pait of the upper lid. OnJuly 2nd she returned saying that a lotion of cupricsulphate and cocaine ordered at her first visit had causedconsiderable inflammation, and that on two or three occa-sions blood or a blood-stained tear had suddenly suffased theeye and fallen down the cheek. A cold douche for the eyeand an iron tonic were prescribed, and some days later thepatient again presented herself directly after a drop ofblood had fallen. There was a small red-stained fibre inthe canaliculus and a similar thread under the lower lid.No ulcer or h&aelig;morrhagic spot could be discovered, but theeyeball looked redder than before, and the plica semilunariswas swollen and congested. After the lapse of a year,during part of which period the symptom was absent, inspite of somewhat impaired health, the patient returnedcomplaining that one or more drops of blood-stained tearsor blood, such as might come from the nose, suddenlysuffused the eye and fell down on her book or her work, atall sorts of times, every two or three days, and even twoor three times a day. The tear had been observed to comeas if from under the inner part of the top lid, to run mainlyalong the plica and caruncle under the lower lid ; and lefta blood-stain on whatever it fell. Blowing the nose showedthat a mere tinge had passed through the lacrymal canal.Stooping seemed to encourage the blood flow. It had oftenoccurred while kneeling in church, and the mother had onseveral occasions taken little red films or clots from underthe lower lid or from the inner side of the eye. The bleed-ing continued in spite of treatment by large doses of ironwhich improved the general health. In October the patientcame again immediately after some blood-stained tears hadfallen; there was still a small red fibre or clot between theplica semilunaris and the caruncle, and another under thelower lid. The conjunctiva, especially at the plica, wascongested. At the end of the month the patient waswalking with her mother when she stooped down to tieher shoe-lace, and at once the eye bled. Within a fewminutes she was seen by Mr. Cross. The eye looked blood-stained, and a red film was in the conjunctival sac as

before. Several spots of blood were on her handkerchief,which were tested with guaiacum and hydrogen peroxide,and gave a definite blood reaction. The eye sac was care-fully examined; no spot could be detected from which thebleerling seemed to have occurred, the caruncle was slightlyswollen, the plica distinctly so, and its vessels congested.Mr. Cross said there could be no doubt of the accuracy of

22

the facts as stated by the patient. The symptom was a mostexceptional one, and the literature in connexion with it veryscanty. Has and De Wecker had alluded to it, the latterin connexion with scorbutus. There had been no tendencyto other h&aelig;morrhage, no indication of, hysteria, and thepatient was very anxious to get rid of the malady. Shehad been at times distinctly an&aelig;mic.&mdash;Mr. WAREN TAYinquired if a microscopic examination had been made ofthe blood spots.&mdash;M. HARTRIDGE asked if the lacrymalgland had been investigated from theconjunctival surface.-Mr. CROSS, in reply, said the spots had not been examinedwith the microscope, and that no abnormal appearancecould be detected beneath the upper lid. The patient wasnot a bleeder.The following living and card specimens were exhibited:-Messrs. CRITCHETT and JULKR: Microscopic Sections of

Epithelioma of Cornea and Conjunctiva.Mr. TREACHER CoLLINS: Rupture of the Posterior Capsule

of the Lens following a Blow on the Eye.Mr. BEAUMONT: Macular Coloboma(?).Mr. LAWFORD: A Case of Subhyaloid Haemorrhage.

MIDLAND MEDICAL SOCIETY.

A MEETING of this Society was held on Wednesday,November 26th, Mr. A. Messiter, President, in the chair.

Congenital Absence of Ribs on Left Side.&mdash;Mr. MESSITErshowed a most remarkable example of this condition.

Fractured Olecranon; Suture jor Fibrous Unioo.-Mr.BARLING showed a case of a man aged twenty-four on whomhe had operated after fracture of the olecranon nine monthsafter the injury. The fragments were separated by aninterval of 11 in., and the muscles were extremelywasted, the measurement round the injured arm being2&frac12; in. less than on the opposite side. The surfaces ofthe fragments were freshened and brought together by onemedian silver wire suture, and the arm put up in theextended position. Union by first intention followed, andnow, nine weeks after operation, the movements of theelbow joint are free in all directions, and the difference incircumference between the arms is only 1&frac14; in. Theunion between the fragments consisted only of some fibrousbands, and the upper fragment was so fixed by retraction ofthe triceps that it had been suspected that it was ankylosedto the lower end of the humerus. The suture remains insitu, and causes no inconvenience.Hydatid Cyst of Kidney.-Mr. CHRISTOPHER MARTIN

showed this specimen, removed from a lady aged forty-sixby Mr. Lawson Tait. The cyst was first noticed two yearsago, and the chief symptom was frequent micturition.There was no history of renal colic or of hydatid vesiclespassing in the urine. The cyst was as large as a man’shead, filling up the entire right costo-iliac space. It was

globular, tense, elastic, fluctuating, and painless. Theabdomen was opened by a lateral vertical incision9 in. long and the cyst enucleated, but the kidney wasso disorganised that it was also removed. The pedicle wassecured with a wire serre-noeud and treated extra-peri-toneally. The patient made an uninterrupted recovery.

Placenta Pr&oelig;via.&mdash;Mr. CHRISTOPHER MARTIN also showeda uterus at the seventh month of pregnancy containing aplacenta pr&aelig;via removed post mortem by Dr. Malcolmsonfrom a widow aged twenty-eight. No suspicion of pregnancywas entertained until the woman was found dead in bed lyingin a pool of blood. The uterus was opened from above, andthe child extracted. The cervix was partially dilated andthe placenta detached for about an inch round the osinternum.

Dr. MALINS showed the following specimens :&mdash;(1) FibroidTumour of Cervix; (2) Channelled Polypus of Cervix;(3) Fibroid of Uterus ; (4) Membranous Cast from Vagina.

Gall-Stones removed by Cholecystotomy.-Mr. F. MARSHexhibited nine gall-stones removed from a woman agedfifty-three. They were irregular in shape and of an averagediameter of five-eighths of an inch. The patient had a gooafamily history, and had always been temperate. Her lastpregnancy occurred eighteen years ago, and terminated bya miscarriage. Since then she has had prolapse of theuterus, and has suffered from pains in the epigastricregion, associated with flatulence and vomiting. Herbowels have generally been constipated. She has neverhad jaundice, though her complexion has often been yellow.

Eight months ago she noticed a lump in the abdomen whichwas tender on pressure Examination showed a roundedprominence extending for t few inches below the rightseventh costal cartilage of the size and shape of a kidney.Microscopically the urine showed a quantity of minute-crystal of oxalate of lime, with a few blood-corpuscles.The diagnosis lay between a distended gall-bladder, amovable kidney, and a renal tumour. An exploratoryincision was made over the most prominent part of thetumour, which proved to be a distended gall-bladder. It wasdrawn into the wound and four ounces of sero-purulent fluidevacuated. The opening was then enlarged and the stonesremoved. A drainage-tube was placed in the bladder andthe opening closed with a purse string suture and fixedto the sides of the wound. Bile flowed through the tubefor forty-eight hours, and was then replaced by a serousdischarge. On the third day the tube was removed andthe superficial edges of the wound brought together.The patient made a good recovery and is now quitewell.

Exfodiatioo of Mucous Membrane of Gall-bladder fromSuppurative Cholecystitis.&mdash;Mr. JOHN W. TAYLOR showeda specimen from a case of Suppurative Cholecystitis. Com-plete exfoliation of the mucous membrane of the gall.-bladder had taken place, and on opening the latter, whichcontained a pint of pus, a slough consisting mainly of themucous coat was found lying free within the gall-bladder,and was removed. Five or six gall-stones, black in colour,,were removed at the same time. As soon as the contents.of the gall-bladder had been discharged the ducts becamepatent, bile flowing freely from the day of the operation.The patient made a good recovery.

Mr. JORDAN LLOYD read a paper on Gonorrh&oelig;al Spermato-cystitis (inflammation of the seminal vesicle).

SHEFFIELD MEDICO-CHIRURGICAL SOCIETY.

AT a meeting of this Society, held on Oct. 23rd, 1890,Mr. W. Dale James (President) in the chair, Dr. MARTINshowed a Multilocular Ovarian Cyst, interesting fromthe rapidity of the growth, the increasing emaciation,and the very marked appearance of cachexia in thepatient from whom he removed it.&mdash;Mr. DALE JAMESshowed a case of Lupus Verrucosus of sixteen years’ stand-ing, and a patient with a Small Tumour, probably hydatid,at the lower part of the posterior scapular border.-Mr.GARRARD exhibited two specimens of Mulberry Calculi andone of Uric Acid Calculus, removed by lateral lithotomy.--Mr. R. FAVELL showed a specimen of Fibro-myoma of theVagina. The tumour, which he had removed from the-posterior vaginal wall, measured two inches and a quarter

transversely, and one inchand a half from before backwards.Dr. GWYNNE read a paper on the Epidemic of Pneumonia,which occurred in Sheffield during the first half of thepresent year. After reading notes of a dozen cases, all ofwhich presented features of special interest, he summed upby recording the following distinctive features of theepidemic as derived from a review of numerous cases thatcame under his care :-1. The tendency in the case of manyindividuals, attacked by influenza, for a slight patch ofpneumonia to appear suddenly, generally at the case of thelung, with very slight rise of temperature, and almost assuddenly to disappear. 2. The common occurrence ofblood-stained sputum. 3. The weak asthenic type of thedisease that prevailed, many cases being subacute from the-first and convalescence tedious, and many more assumingfrom the very commencement a typhoid character ; the

patient, in many instances, dying from the fourth to theseventh day of the disease. 4. The tendency to unusualcomplications; illustrated by cases where relapses, parotidi--tis, phlebitis, pericarditis, and abscess of the lung super-vened. 5. The fact that in some instances the attack couldbe traced to distinct infection. 6. The marked immunityenjoyed by children.At the meeting on November 6th the PRESIDENT exhibited

a patient suffering from Syphilitic Ulceration of the OuterSurface of the Nose, as well as of the Palate and Pharynx.The unusual situation, and a superficial similarity of appear-ance to lupus before the scabs had been removed, were thepoints of interest in the case.-Dr. SIDNEY ROBERTSshowed specimens from a case of Carcinoma of the Stomachand Liver. The patient, a soldier, aged fifty-four, the sub-