310

were no adhesions around the bit of intestine and the serous csurface was perfectly smooth. This patient had died from s

ulcerative colitis, wholly unconnected with the illness for 1which the operation had been performed some years before. (

He wished to refer to the advantage of sewing up the aabdominal wound layer by layer. He quite agreed with the importance of emptying the bowel at the time of the opera- tion and he saw no harm in , the use of a mild aperientafterwards. In gastro-jejunostomy he had been equally l

impressed with the advantage of direct suture. lMr. A. PEABOE GOULD read a paper on a case of Bullet

Wound of the Abdomen, with four wounds of the smallIntestine and two of the Mesentery; Operation; Recovery.The patient was a young man, aged 20 years, who wasaccidentally shot with a small revolver on the evening ofOct. 30th, 1899. A medical man who was called to himfound him in great pain and at once administered a hypo-dermic injection of morphia, and then took him to theMiddlesex Hospital where he was seen by Mr. Pearce Gouldabout an hour after the accident. The wound in the abdo-men was two inches below the navel and one inch to the leftof the middle line. There was still some pain, the respira-tion was easy, the abdomen moved freely, and the pulsewas 96. The liver dulness was not obliterated and there was nodulness in either flank. There was no paralysis. Six ouncesof clear normal urine were drawn off by catheter. Under ananaesthetic the wound was explored and was found to extendinto the peritoneal cavity. This was freely opened and bloodflowed out from it, but neither gas nor intestinal contentswere observed. The intestine was examined and four woundsapparently in the jejunum were found; three of these wereperforating and the other involved the serous and muscularcoats only. There was no visible escape of intestinalmatter. These wounds were closed with Halsted’s suturesof sterilised silk and two wounds of the mesentery whichwere close by were also sutured. No other lesion was found.The peritoneal cavity was cleansed, the bowel was returned,and the abdominal wound was closed. The man made an un-interrupted recovery and left the hospital well on Dec. 4th.The bullet was found lying deep in the left buttock and wasallowed to remain. In commenting on this case Mr. PearceGould drew attention to the following points: (1) the multiplelesions produced by a single bullet; (2) the absence of serioussymptoms ; and (3) the necessity for exploration, even inspite of the absence of all symptoms, to determine whetherthe wound was perforative, whether any viscus or largevessel was injured, and, if so, to treat them. He emphasisedthe importance of the hypodermic injection of morphiaimmediately after the accident, both in relieving painand shock and in controlling the movements of theintestine, and so lessening the chance of fouling of theperitoneum with germ-laden intestinal contents. The caseillustrated the necessity for careful and thorough explora-tion of the abdomen (by operation) in all cases of perforat-ing wound and severe contusion of the abdominal wall.-The PRESIDENT, referring to the use of opium in abdominalinjuries and wounds, said that although it had been discarded,not without reason in these cases, it was ont; thing to giveit before diagnosis and another to give it after the diagnosiswas made. The morphia syringe might be of great use onthe battle-field. When gangrene of the intestine had beendiagnosed there might be no harm in giving morphia. As tothe absence of symptoms in Mr. Gould’s case this waspossibly due to the narcotism of morphia.-Mr. ARTHURBARKER remarked that there was no more difficultclass of case to deal with than that narrated. Theamount of shock in such cases varied very considerably,and he mentioned the case of a patient shot throughthe abdomen who walked downstairs and professedhimself as feeling quite well. In another case with the samekind of wound there had been great shock. As to the pro-cedure adopted that must vary with the time which hadelapsed since injury. If seen early the abdomen should besearched, but if not seen till later it might be well towait. The velocity of the bullet was another factor. If the

speed was great then the intestinal wounds would be verysmall. In general an operation might well be undertakenin any doubtful case. He quite agreed with the remarksmade on the value of opium.-Mr. HOWARD MARSHreferred to the possible absence of symptoms even withvery grave internal lesions and mentioned a case

in point of ruptured colon. In another case of injuryin the hunting field the patient went to the city and waswell for two days. Then he passed into a state of shock and

died. The necropsy revealed rupture of the super-mesentericartery as a consequence of which part of the small intestinehad become gangrenous. He certainly thought it well tooperate more freely. An exploratory operation was notattended with much risk. He believed in saline injections asa most valuable method for the treatment of shock.-Dr.NEWTON PITT referred to the remarkable way in which a" cow-doctor" would puncture a distended intestine with alarge trocar. He inferred from this that small bullets with

high velocity would not do great damage to the intestine.-Mr. PEARCE GOULD, in reply, said that the patient was notnarcotised but he was only relieved from pain by themorphia. The amount of shock in such cases seemed to

depend very much on the parts which were damaged. If thegreat sympathetic plexuses were injured then probably therewould be great shock. In his case the shock at the end ofoperation was not great enough to call for saline injection.His main object in bringing forward this case was to

emphasise the importance of operation in all perforating

injuries of the abdomen.

OPHTHALMOLOGICAL SOCIETY.

Experimental Exophthalmos and Enophthalmaos.-CicatrixHorn growing frona the Cornea.-Glau.coma following theuse of Homatropine.-Exhibition of Cases and CardSpecimens.AN ordinary meeting of this society was held on Jan. 25th,

Mr. G. ANDERSON CRITCHETT, being in the chairDr. WALTER EDMUNDS read a paper on Experimental

Exophthalmos and Enophthalmos in which he remarked thatthere were three ways in which prominence of the eyescould be affected experimentally: (1) by acting on thesympathetic, either stimulating it or dividing it; (2) bythe administration of certain preparations or drugs ; and(3) by operations conducted on the thyroid gland. Withregard to the first, stimulation of the cervical sympatheticproduced: (1) prominence of the eye; (2) widening of thepalpebral fissure; (3) at first increase and later decreaseof the intra-ocular tension ; and (4) erection of the hairsof the head. Division of the sympathetic produced theopposite effect. Cocaine was one of those drugs whichproduced proptosis, widening of the palpebral fissure, dilata-tion of the pupil, and decrease in the intraocular tension.Cunningham had shown that feeding a healthy animal onthyroid extract produced similar results. Dr. Edmunds thenshowed photographs of monkeys and rabbits both before andafter feeding on this substance. Exophthalmos after theadministration of thyroid had once been observed in man byBeclere, where it appeared after excessive doses had accident-ally been taken by a patient suffering from myxoedema. Thethird method of effecting the prominence of the eyes was byoperations on the thyroid. Removal of the thyroid might pro-duce either exophthalmos or enophthalmos, but in the monkeyusually the latter. Numerous lantern slides were shownof animals in which this had been done, as well as drawingsof animals in which the sympathetic had been divided.Dr. Edmunds summed up his results by saying that the dis-cussion of these phenomena was particularly interesting inits bearing on the pathology and treatment of Graves’sdisease ; the fact that the most important eye symptom ofGraves’s disease could be produced by the administrationof thyroid preparations certainly suggested that the eyeaffection was secondary to the goitre. He had not triedthe effect of division of the sympathetic in feeding withthyroid extract, but with the administration of cocaine itdiminished the effect produced. It therefore suggesteditself that the exophthalmos might be benefited by divi-sion of the cervical sympathetic, and, indeed, the opera-tion had been tried several times in man. The resultswere said, however, not to be very satisfactory, at leastas far as the general disease was concerned.-Mr. J. B.LAWFORD referred to a case reported by him in whichexophthalmos had resulted from thyroid-feeding in a woman.aged 34 years, who had suffered from myxcedema for fiveyears. She was treated with the extract with great benefit ;but relapsing four and a half years later the treatment wasresumed, this time with the development of severe exoph-thalmos. Her subsequent history was unknown.-Mr.G. MACKAY described a case in which exophthalmosfollowed an operation on the cervical glands in which thesympathetic had evidently been divided. He also quoted a

311

case of extreme exophthalmos benefited by the removal ofhalf the thyroid gland.-Mr. W. H. H. JESSOP cited a casein which death followed division of the sympathetic.-Mr. H. E. JuLER stated that he had seen in Paris a caseof glaucoma in which division of the sympathetic had pro-duced many unpleasant symptoms without enophthalmos.-Dr. W. A. BRAILEY also spoke on the subject and Dr.EDMUNDS replied.

Dr. ARNOLD LAWSON read a paper on a case of a CicatrixHorn growing from the Cornea. He said that a carefulsearch through ophthalmological literature had failed todiscover another example of this curious condition. The

patient was a female child, aged eight years, a hydro-cephalic idiot. The history given was that about one yearpreviously a white spot had appeared on the right eye andthat the eye began to project. Six months later a growthwas first noticed on the right cornea and this had constantlyincreased in size. Latterly a white spot had appeared on theleft eye. On examination of the eyes there was seen alarge conical tuberculated excrescence protruding betweenthe lids of the right eye. It was half an inch in lengthand its base attached to the cornea covered aboutfour-fifths of its surface. The left cornea exhibited a

yellowish infiltration just below the pupil over which thecornea was bulging; the anterior chamber was deep, theiris was immobile, the tension was slightly raised, and the eyewas quite blind. Both globes were very anaesthetic and therewas considerable muco-purulent discharge from a chronicinflammation of both conjunctival sacs. The growth uponthe right eye was accidentally detached a few days afteradmission into the hospital and it was then seen to havebeen attached to the cornea at the apex of a central staphy-loma which was left covered by a fleshy soft core which hadformerly been embodied in the centre of the growth. Thecornea was entirely opaque and the eye was quite blind. Afterremoval of the right eye a few days later examination of theglobe revealed a co-arct retina with evidences of chronicdegenerative changes in all the various structures. Theanterior chamber was completely abolished, the iris through-out its extent being firmly adherent to the back of thecornea, which was bulging centrally. The apex of thecorneal staphyloma had evidently been the site of a largeperforation which was closed by the fleshy granulations whichformed the core of the growth. The growth itself measuredhalf an inch from apex to base and one and a half inchesround its base. The interior portion was soft and crumbling,but the external layers were hard and horny and cut withdifficulty. A wedge-shaped piece was cut away from thegrowth and specimens were cut and stained with carmine.The microscope showed that the external layers consisted ofseveral faintly fibrillated strata of a dense homogeneousnature. The layers occupied about one-quarter of theentire thickness of the walls, the rest being entirelycomposed of small nucleated cells, those most external

being stratified. Adopting Mr. Bland Sutton’s classifica-tion of human horns, this growth would be an exampleof a cicatrix horn, the rarest of all varieties of horn,and one which had been usually found in connexion withthe cicatrices of burns and scalds. The probable etiologyin this case was an overgrowth of granulation tissue

closing the perforation in the cornea, which, owing toan unhealthy condition of the wound and eye, which wasanaesthetic and atrophic, had become exuberant, simulatingexactly the condition known as "proud flesh" elsewhere.By a process of accumulation and heaping up the granula-tions gradually formed a cap over the cornea, whilst theexternal layers gradually became stratified and horny fromthe pressure of fresh growth from the central core and by theaction of the air. The nature of the growth was evidencethat the corneal epithelium bore no share in its productionand discounted the possibility that it might be due to a hugecrust of inspissated conjunctival discharges.—Remarks weremade by Mr. TREACHER COLLINS and Mr. DEVEREUXMARSHALL.Mr. C. H. B. SHEARS read notes of a case of Acute

Glaucoma following a Single Application of Homatropine. Awoman, aged 52 years, went to the Liverpool Eye and Ear In-firmary in October, 1899, for reading-glasses. With her hyper-metropia corrected her distant vision was nearly two-thirdsof normal. One or two drops of homatropine, four grainsto the ounce, were put into the right eye. When she cameagain to the hospital a week later she had all the signs ofacute glaucoma in this eye and she could only just countfingers. Pain and vomiting and great loss of sight

came on the same evening that the homatropinewas used. Eserine and leeches were tried for two hoursbut without benefit. Iridectomy was then performed,with the result that the tension and sight were quiterestored in ten days and had remained satisfactory up tothe present. Mr. Shears was of opinion that no mydriaticshould be put into the eyes of persons over 30 years of agewithout careful consideration; that if homatropine wereused it would be well to instil eserine before the patient leftthe hospital ; that cocaine followed by eserine was usuallyquite sufficient for ophthalmoscopic examination ; or the newpupil dilator-euphthalmine-would be found very satisfac-tory for this purpose. Very few cases were published ofglaucoma after homatropine and the accident appeared to be,very rare.

The following cases and card specimens were shown :-Dr. E. E. HENDERSON: Microscopic Sections of Growth

from the Upper Palpebral Conjunctiva.Mr. A. Q. SILCOCK : Persistent Hyaloid Artery arising

from a Central Coloboma of the Choroid.Mr. W. T. HOLMES SPICER: (1) Detachment of the

Choroid; and (2) Primary Optic Atrophy associated withDiabetes Insipidus.

Mr. L. V. CARGILL: Fibromata in the Eyeidls.Mr. R. W. DOYNE: (1) Peculiar Appearance in the Cornea ;

(2) Extreme Cases of Essential Shrinking of the Conjunctiva ;and (3) Unusual Case of Striated Keratitis.

Dr. G. F. STILL: Infantile Cerebral Degeneration withSymmetrical Changes in the Macula,Mr. H. E. JULER: A case of Pemphigus of the Conjunctiva.

SOCIETY OF MEDICAL OFFICERS OFHEALTH.

The Application of Bacteriology to Public Health.

A MEETING of this society was held on Jan. 12th, Dr. A.NEWSHOLME, the President, being in the chair.Mr. WALTER PAKES read a paper on the Application of

Bacteriology to Public Health. This, he said, had alreadyresolved itself into two branches, the pathological and thetechnical, each demanding long study and practice ; indeed,there was no department of research in which a little

knowledge was so dangerous a thing or so prone tolead to the grossest errors. He felt this very strongly inconnexion with the bacteriological examination of water,milk, and even of pathological secretions by the publicanalysts, who, though rightly required to be highlyqualified chemists, if not Fellows or Associates of theInstitute of Chemistry, are not required to have the

knowledge and training essential to the exercise offunctions which, if not committed to professed bacterio-logists, should be jealously retained by the medicalofficer of health, This officer if he had undergone a courseof laboratory instruction, might easily become an adeptin the examinations required for purposes of public health.These examinations were-(1) diagnostic and (2) preventive.Perhaps the most important of the former was the identifica-tion of the tubercle bacillus in milk, the more so sinceit appeared to acquire greater virulence in the bovineorganism, and infants were far more susceptible thanadults. With proper precautions as to the completedecolourising of the tissues or the milk residue, it couldbe identified with certainty and distinguished even fromthe smegma bacillus which most nearly resembled it both inappearance and in its behaviour towards stains, and hadbeen found in the sputa, urine, and milk. Mr. Pakesdescribed the precautions to be observed in taking samplesof these secretions and of fasces, and the details of a modi-fication of the Ziehl-Nielsen and Honsell’s staining pro-cesses. Next in importance was the diagnosis of diphtheria.He had examined the secretions from nearly 3000 sore-throats,of which 1836 during the last five years bad been systemati-cally examined for the different microbes, with results whichhe exhibited in tabular form. The Klebs-L6ffier had beenfound alone in 289 and associated with Hoffmann’s in 18,and with strepto- or staphylo-cocci in 36, making 343 of truediphtheria, Hoffmann’s alone in 89 and with cocci in 13,strepto- or staphylo-cocci or both in 339, while the restshowed other forms or none. Hoffmann’s gave rise to an