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Medical Societies.

OPHTHALMOLOGICAL SOCIETY OF THEUNITED KINGDOM.

ANNUAL CONGRESS.

THE annual congress of this Society was held inLondon from April llth to 13th under the presidencyof Mr. CHARLES HOWARD UsHER. The first contri-bution was a paper on

Formative Fibro’us Tissue Reaction in the Eye,by Mr. E. TREACHER COLLINS. His purpose, he said,was to describe the form of reaction in the tissues ofthe eye which resulted in a new formation of fibroustissue. He classified as follows the conditions givingrise to this reaction: (1) Encapsulating fibrosis. Thefirst of the conditions under this head was in connexionwith foreign bodies ; the second in connexion withneoplasms, the third in connexion with parasiticcysts. (2) Post-fibrinous fibrosis in connexion withblood-clots. (3) Reparative fibrosis: (a) in connexionwith developmental defects ; (b) in the healing ofwounds ; (c) as a sequel of granulomatous inflam-mation.

In order to explain the conditions observed, Mr.Collins formulated the following general propositions :(1) That a formative fibrous tissue reaction was oneof the means which the tissues of the body used forcounteracting deleterious influences in their environ-ment. (2) That such a formative fibrous tissuereaction might be excited, apart from any exudationof leucocytes, though at times associated with it.(3) That an aseptic foreign substance implanted in thebody, exciting no exudation of leucocytes, might giverise to a formation of fibrous tissue which encapsuled.and fixed it. (4) That all neoplasms when they cameinto contact with tissue of mesoblastic origin excited.a formative fibrous tissue reaction, this tending tocheck their extension into surrounding parts. Withslowly growing neoplasms it succeeded in encapsulat-ing the new growth. With rapidly growing neoplasmsthe cell proliferation outpaced the formative fibroustissue reaction, and the growth took on malignantcharacteristics. (5) That any remedial treatment ofneoplasms should aim not only at checking theproliferative activity of the cells composing it, butalso at promoting the formative fibrous tissue reaction.(6) That parasitic cysts coming into contact withtissue of mesoblastic origin excited a formative fibroustissue reaction, an encapsulement in a fibrous tissuecovering. (7) That coagulated blood in some situationsin the body might act like a foreign substance andexcite a formative fibrous tissue reaction. (8) Thata formative fibrous tissue reaction might be excitedin the repair of lesions in the tissues of the body, dueto either defective development, traumatism, or a

destructive inflammation. (9) That the new formationof fibrous tissue in the conjunctiva in trachoma was asecondary and reparative process which persisted,tending to replace the fibro-adenoid layer which wasdestroyed. (10) That the new formation of fibroustissue in the conjunctiva in spring catarrh was a

secondary reaction excited by the proliferation anddowngrowth of the epithelium, and that it entirelydisappeared when the disease came to an end.

Mr..f. A. WILLIAMSON-NoBLE read a paper on

Graded Squint Operationsin which he described his procedures for advancementof muscle according to the result of measurements.A point to remember was that if a convergent squinthad lasted some time the external rectus became;atrophic. He had been satisfied with the results ofrecession, or recession combined with tenectomy ; hehad not operated upon the external rectus alone.For measuring the angle of deviation he used the

Maddox tangent scale or the Priestley Smith tape ; -,but a better method was with the Maddox rod andprisms, graduated according to their angle of deviation.Mr. Williamson-Noble did the operation under generalanaesthesia, as it was better for the patient and allowedof greater deliberation on the part of the operator.Of 16 cases which he had traced all but two weresuccessful, and one of the failures could scarcely becalled such, as she had 45° convergent squint beforethe operation, and it was reduced to one of 28°. Thereal failure was due to under-estimating the effect ofWilkinson’s resection advancement.

Mr. M. L. HEPBURN read a paper on

Some Unsolved Problems in Connexion with Diseasesof the Choroid.

His first contention was that primary pigmentarydegeneration of the retina was not due, as had beencontended by Treacher Collins and others, to nervedegeneration (known as the abiotrophy theory), butto defects in the choroidal circulation. The nextproblem he attacked was that of the reason for thevariations in the visual field defects found as a resultof inflammatory deposits and scars in the choroid.He considered that main arteries supplying definiteregions were isolated, and that an inflammatorydeposit might block one of these main channels, andso produce the sector-shaped defect in the visual field.Next he dealt with the question why some diseases ofthe choroid terminated in secondary optic atrophyaccompanied by a diminution in size of the retinalvessels, while in others, although the greater part ofthe choroid was involved, the disc and retinal vesselsremained normal throughout. His impression wasthat vascular diseases of the choroid were more likelyto end in optic atrophy than were the inflammatoryforms. A further question which he discussed was thesignificance of the variations in amount and distribu-tion of pigment in diseases of the choroid, and whetherthe appearance of this pigment bore any relation todiagnosis and prognosis. He thought it could safelybe said that when pigment appeared away from itsnormal situation, in most cases one was dealing witha disease of the choroid, probably of inflammatory orvascular origin. Prognosis was not much helped bythese appearances.

Mr. TREACHER COLLINS discussed the paper atlength.

Mr. CLARK SOUTER reported a case of Uveo-parotidFever, with Autopsy Findings. The patient was aman 40 years of age. and in addition to the generalphysical signs he had cycloplegia, dimness of vision,and facial paralysis. There was congestion of theconjunctiva and ciliary region, and permanent depositsof keratitis punctata were found all over the cornea.The latter persisted to the end.

Thursday afternoon was devoted to a debate onHETEROPHORIA.

Dr. E. E. MADDOX (Bournemouth) said thatorthophoria, from which heterophoria was a departure,could be defined as " a tendency for the eyes to setthemselves truly for the object of fixation." Hetero-phoria could well be compared to the slackness in thesteering-gear of an old motor-car, which in moderatedegree was of no consequence, but in larger amountmade too great a demand on the subconscious atten-tion of the driver. It was a corresponding tax onattention which gave to heterophoria its importance.Concentration of attention implied active inhibitionof every conflicting neuron, Sherrington’s " reciprocalinnervation " in the motor sphere finding its counter-part in the psychic. The discomfort arising fromheterophoria was apt to hover about the occipitalregion, whereas that of refractive errors was felt atthe back of the eyes, in the temple, and the brow.Sometimes a wandering eye suppressed its visioninstantaneously, so that no diplopia appeared; but,even so, the suppression made no difference to theeffect of the wandering on the aim of the other eye.In one well-marked case, good binocular vision was

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enjoyed until the object came within two or threefeet; then the right eye instantaneously suspendedits vision and deviated without diplopia. There were12 species of paretic heterophoria and 12 comitant.The measurement for the paretic was on the sameprinciples as for frank paralysis. It was importantto keep the disc of rods perpendicular to the linebetween the eye and the light; therefore he hadstrung one on a kind of gallows, so that it mightremain quite vertical, however much askew thehead might be placed. The comitant heterophoriaswere due, he said, to slackness of one of the higherconjugate innervations. Exophoria for distance was,nearly always, due to either subsidence of muscletone or to convergence deficit. It was very rarelydue to divergence excess. Division of the restiformbody was said to cause conjugate version of the eyesto the opposite side, combined with elevation of oneand depression of the other, confirming the see-sawinnervations which the speaker had described in acase. Cyclophoria, if constant, was due to relativeinaction of either incyclovergence (in which the twoupper poles of the eyeballs approached one another)or excyclovergence (in which they separated). Dr.Verhoeff (of Boston) did not believe in cyclophoria,stating that the fusion of skew images with oneanother was effected by psychical means only. Thatwas true, Dr. Maddox believed, within certain limits,but many tests showed that the eyeballs could rotateabout their visual lines. He would like to see a casein which, in nystagmus, the eyeballs cycloverged inand out, as that would afford a further confirmationof the innervations he was referring to. The versionphorias were less easily measured. Dextrophoria andIsevophoria were due to imbalance of two innerva-tions ; in these conditions there was a tendency forthe eyes to look parallel-wise to the right or to theleft when at rest. Anaphoria and cataphoria meanta tendency for both eyes to look upwards or down-wards, and were due to imbalance of the innervationshe called surversion and deorversion. Students wereoften perplexed as between the terms " duction,"" version," and " vergence." Whenever an eye wasthought of monocularly one could speak of duction ;it meant that an eye was led by its muscles, and themind did not travel beyond the orbit. Version wasa conjugate parallel motion of the eyes effected byconjugate innervations. Vergences were contraryreciprocal motions effected by conjugate innerva-tions. Hence when measuring the amplitude offusion by prisms it was better to speak of prismvergence tests than of duction tests.

Dr. Maddox then spoke of the tests for hetero-phoria. Since no refraction was complete withouttesting for heterophoria, it was desirable to have aspeedy method to single out cases requiring moreaccurate measurement. It was convenient, he found,to have a hand trial frame which could be held infront of the ordinary trial frame, the former havingrods on one side and a rotating prism or pair ofprisms on the other. The prism could be rotated aftertelling the patient to say " snap " when the redstreak and the light met. For accurate measurementa tangent scale was best, and if there was any suspicionthat fusion was not completely suspended, one eyecould be screened and then suddenly exposed to seewhere the streak appeared at the first moment ofexposure. The wing-test he regarded as better, asit did away with the prism and ensured accommoda-tion at the required distance.

Exophoria, by the wing test, was generally oftrivial account, but esophoria called for a sphericalcorrection which reduced it to nil. To give a weakprism for a large exophoria was often of greatvalue, as it was the last degree of stretch of thefusion reflex which was most fatiguing. An approxi-mate rule was, lenses for exophoria, prisms forexophoria.

Treatment.

It was impossible, said Dr. Maddox, to make rigidrules for the treatment of the condition, as it was a

symptom not a disease. The person must be treated,not the phenomenon. Most minor heterophorias didnot need treatment, though exceptions could beadmitted in the cases of aviators, sportsmen, andothers, as it might have importance when’ thenervous system was tired. The counsel of perfectionwas to ascertain the cause and, if possible, remove it.Errors of refraction were by far the most commoncause, but septic foci in nose, teeth or tonsils, lack offresh air and exercise, and anæmia could not be leftout of account. If refraction treatment failed, thechoice lay between exercises or relieving prisms.The former were more suitable for the young, prismsfor the old. Any neurasthenia should be treatedfirst. The effective value of a prism was less atreading distance than for a far object. Also, onemust make sure that the hyperphoria was not anafter-effect of wearing spectacles askew. If presentonly with the spectacles on, the fault lay with theglasses ; if vice versa, the fault which had been inthe spectacles was transferred to the eyes. Or thepatient might have skewed his spectacles to correct it.For esophoria, prisms were less useful than lenses ;the latter were curative. In exophoria, constitutionaltreatment was more often needed than in the othervarieties ; it was also the most suitable for training,especially where there was subconvergence. Weakprisms were often helpful; strong ones caused’meta-morphopsia, robbing the accommodation of thesupport it was accustomed to receive from con-

vergence. Operations were very suitable in selectedcases of heterophoria ; in neurotic people there effectwas not permanent.

Mr. CHARLES GOULDEN followed. He first describedhis routine examination of the muscle balance ofpatients who came with apparent or real refractiveerrors. Such an examination was obviously neces-sary. It was important to be certain of the type ofdeviation-i.e., whether it was concomitant or

paralytic. The most important heterophoria washyperphoria, a want of muscle balance betwean theeyes in the vertical direction ; this form caused mostinconvenience, because one had little power over thevertical deviation of the eye. Only when a verticaldeviation caused symptoms should it be treated.Among the symptoms were persistent headache, oftenoccipital, confusion of print, sometimes a complaintthat lower lines of print surmounted upper lines.The treatment consisted in the use of prisms. If a.low degree prism was necessary, this should be placedwith the base down before the eye which tended todeviate upwards. If the prism needed was 2°, or

more, it should be equally divided between the twoeyes-i.e., one prism base down before the upwardturning eye, the other base upwards before the down-ward turning eye. When of high degree, hyperphoriamight call for operation ; then advancement of eithersuperior or inferior rectus should be done. Hereferred to four cases he had seen of torticollis due tohyperphoria. There were patients who, immediatelythe examination was commenced, had a spasm ofconvergence ; these cases were probably hystericalin origin, and needed a careful correction of refrac-tion, probably under atropine, and then such treat-ment as the hysteria might call for. He had neitheroperated nor supplied prisms for this condition. Incases which resisted treatment by exercise, especiallythose in whom an exophoria became a squint-i.e.,when the patient was fatigued-operation might be-necessary. Here tenotomy was not usually regardedas sufficient, there must be advancement of aninternal rectus muscle.

Group-Captain E. C. CLEMENTS (R.A.F.) spoke ofhis experience in connexion with flying men, pointingout that in the case of an aeroplane in space, thestrains and stresses differed from those in people onthe ground. He analysed the results of spinning inthe Barani chair 10 times in 20 seconds in the caseof 118 men. Almost all flying men had good vision.He believed that a big percentage of cases of torti-collis would be found to be suffering from hyperphoria-

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Mr. ERNEST CLARKE did not think it was fair totake as normal the kind of case met with in the AirForce. In the ordinary population he regarded hyper-phoria as very common indeed, but as it was usuallyof a minute degree, it was not important. Formany years he had advocated the correction oflow errors of refraction. When minus glasses werenecessary there might be a small exophoria. Thelatter always lowered the amplitude of convergence,and when exophoria was present the fusion supple-ment required was always bigger, whereas it was forthe ophthalmic surgeon to make- the fusion supple-ment as low as possible. When low refractiveerrors were corrected, the hyperphoria usually dis-appeared in a short time. One should not becontent with a single test. He objected to the useof prisms for young or middle-aged people ; tosupply these at this stage was a confession of

weakness, and the strength had to be progressivelyincreased.

Mr. H. B. GRIMSDALE spoke of the people occasion-ally seen who were greatly helped by a 0-25 cylinder.and by a 1 prism. Could rules be laid down, he asked,for dealing with the condition ? Probably not. Forexophoria he usually advised exercises. He did notthink the r6le of hyperphoria in the production ofstrabismus had been given sufficient attention.Cyclophoria rarely gave trouble.

Mr. HUMPHREY NEAME agreed that in hyperphoria,to relieve the discomfort, the smallest possible prism-should be used.

Mr. HARRISON BuTLER said that often, when order-ing prisms for elderly people with convergenceinsufficiency, the relief afforded tended to allow themuscles to repair, after which the prism could bediscarded.

Mr. WILLIAMSON-NOBLE described this methodof testing for cyclophoria by means of tiltedmirrors.

After further discussion the openers replied.

On Friday morning Mr. W. S. DUKE-ELDER contri-buted a paper, illustrated by the epidiascope, on the

Nature of the Vitreous.He said the vitreous was ordinarily conceived,of as made up of a framework of fibres forming.a close network, in the meshes of which was afluid, the whole being kept in by a hyaloidmembrane which surrounded the vitreous body. Thefibrillar framework could be seen with the slit-lamp,

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though this could only show the optical appearances,the result of the heterogeneity of the tissues throughwhich the light passed. The slit-lamp findings mustbe elucidated by an unequivocal source, and this wassupplied by the ultra-microscope, which was firstutilised in this study in 1923. Its magnificationsshowed the individual molecules, and no fixative wasneeded. The vitreous was found to be a pure homo-geneous gel-i.e., of the consistency of gelatin. Ina gel the water became absorbed by or combined withthe colloid molecules ; it had a high viscosity. Onthe surface of the vitreous were forces which aggre-gated together the micelle in close formation. Inmost cases the chemical composition of the vitreous’was the same as that of the aqueous in regard tonitrogen and salt content; but in addition there waspresent a muco-protein to keep it transparent, and akerato-protein to keep it gelable. Vitreous was

derived largely from the ectoderm in the vitreouscavity. If the gel swelled glaucoma should occur ; if itshrank there would be a tendency to retinal detach-ment. The sclerotic swelled in both alkaline and acidsolutions, largely owing to its contained collogen.If the sclerotic swelled the volume of the eyewas much diminished and the eye pressure rose

enormously.Sir JOHN PARSONS expressed high praise for this

piece of research.

Among other papers at this sitting was one byMr. EUGENE WOLFF on the

Pathology of Orbital Hcemorrhage and Inflammation.Haemorrhage into the orbit, he said, took a longertime to absorb than did bleeding into most other partsof the body, usually held to be because the orbitalfat was relatively poorly supplied with blood-vessels.There was, however, another side to the questionwhich had not received much attention. Clinicallyabsorption of haemorrhage was accompanied byswelling, but in the orbit the contents could onlyexpand anteriorly, resulting in a pushing of the eyeforward, thus manifesting itself as a proptosis. Whenthe muscles of the eye had yielded to the full extentof their elasticity the orbit could be regarded as aclosed space, and the cedema following absorption ofhaemorrhage would cause venous obstruction, and,later, increased transudate. This would explain whyorbital inflammation cleared up after a simple incisioninto orbital tissues without evacuation of pus. Therapid onset of blindness in many cases of orbitalcellulitis was probably due to pressure exerted on theoptic nerve or on its blood-supply. The indication inthese cases therefore seemed to be to relieve thetension in the orbit, while doing a minimal injuryto important structures. This thesis Mr. Wolffelaborated and quoted cases. *

Mr. MAURICE WHITING read a paper on

Optic Atrophy following Hcemorrhage from theAlimentary Tract.

He said that Harbridge found that 240 cases of thekind had been reported up to 1924. The presentcontribution consisted of records of three cases whichhad come under Mr. Whiting’s own notice, and twoothers for which he was indebted to Mr. Hepburn andMr. Doyne. The following could be taken as illus-trative of them all.A man, aged 40, was admitted to hospital in a semi-comatose

condition. He had had abdominal pain, had two fits, andwas very confused mentally. On admission he was verypale, the mucous membranes were blanched, and therewas some jaundice. Soon after admission he passed twohard, black motions, but at the time the man was notthought to have melaena. Next day the motion showed atrace of blood. On August 14th the haemoglobin index was0-6, the red cells 15 per cent. ; on the 30th the red cellswere 19 per cent., and a month later the figure was 43 percent. Both discs were pale and blurred, and there weresmall scattered patches of exudate round the discs. OnSept. 4th there was no perception of light in either eye.The condition, said Mr. Whiting, might follow

haemorrhage from any source, but it was most com-monly a sequel of bleeding in the alimentary tract orfrom the uterus. Many cases had occurred afterchildbirth or miscarriage, and only rarely aftertraumatic haemorrhage. He did not believe the firstocular state was an optic neuritis; it was probablydue, in his view, to sudden death of the nerve fibres.

Friday evening was devoted to a discussion on the

Diagnosis and Treatment of Ocular Tuberculosis.Sir ARNOLD LAWSON, in opening, said the differ-

ential diagnosis of tubercle in the eye might be saidto rest on one or more of the following considerations :The presence of active tuberculosis elsewhere.In the eye tuberculosis was essentially a surgicalrather than a medical condition. Ocular tuberculosis,as an accompaniment of phthisis, was very uncommon.Up to, and even after puberty, bovine, as opposed tohuman, tuberculosis was very common. Bovinetubercle needed a bovine test, as a negation of humantuberculosis did not exclude the bovine form. Thepossibility of mixed infection should never beforgotten ; there was no reason against activetubercle coexisting with active mixed infection. Inocular tubercle there was an absence of subjectivesymptoms comparatively with objective signs. Thesecases were insidious in onset, destructive in character,slowly progressive, and intractable ; there was a

notable absence of severe pain. He opposed the use of

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Calmette’s local conjunctival test as being toodangerous. Tuberculous affections of the eye mightbe either extra-ocular or intra-ocular, the first of thesebeing so-called primary or secondary. He doubted,however, whether tubercle, even of the conjunctiva,could ever be primary; it was certainly difficult toinfect the conjunctiva unless a local abrasion waspresent. Intra-ocular tubercle was always a secondaryinfection ; it might occur in any part of the uvealtract. The most common tuberculous inflammationof the eye was irido-cyclitis. Perhaps choroidaltubercle could not be diagnosed clinically at first sight.Tuberculous masses sometimes reached a great sizewithout causing much trouble. They might disappearunder the use of tuberculin. Treatment of oculartuberculosis must be considered from the general andthe local points of view, the former especially in thecase of children with phlyctenular disease. In a largenumber of these benefit could not be expected untilsuperabundant adenoids and enlarged tonsils hadbeen removed. Of a series of 42 cases treated withtuberculin only 10 per cent. showed no improvement;in 45 per cent. healing followed its use. As, however,it might be a dangerous remedy, it should not be usedunless it was quite clear that the case was suitable.Probably the value of bovine tuberculin was not yetfully appreciated. Much good had followed photo-therapy for these cases, and he was able to endorseMr. Duke-Elder’s findings in this respect in the casesof children with phlyctenular disease. Sir Arnoldhad not found it of equal value for adults. Thistreatment should not be regarded as a substitute for,but rather as a supplement to, other methods. Thequestion of the value of local ultra-violet rays wasstill sub judice.

Dr. R. A. YOUNG read a paper on the generalsystemic aspect of the disease. He said that if medicaltuberculosis coexisted with the ocular condition thetreatment of the latter must wait on the former. Hewas cautious in his treatment by tuberculin, using itin his lung cases only when the pulmonary lesionswere stabilised and were not causing general symptoms.In the active stage of the disease both tuberculin andartificial sunlight could do harm.

Mr. S. H. BROWNING spoke on the subject firstfrom the pathological aspect. As to treatment, he saidhe had been using bovine and human tuberculin forthe eye for 15 years.Mr. A. L. WHITEHEAD emphasised the importance of

a thorough search of the whole body for tuberculouslesions when that disease in the eye was suspected.Many of the cases of vitreous haemorrhage seen inwhich the cause was not very obvious he suspectedof being tuberculous. He was a great believer intuberculin, which should be begun very gradually.

Mr. DUKE-ELDER said he regarded phototherapy asmerely an adjunct to ordinary treatment. It wasextremely good in phlyctenular disease and othertuberculous diseases of the eye. In 33 cases atMoorfields in which the treatment was employed, theaverage period of treatment before phototherapywas adopted was two and a half years (75 per cent.had tuberculin injections also). In the period afterthe introduction of phototherapy 85 per cent. had aquiet eye after an average of five months’ treatment;6 per cent. were very much improved. In 9 per cent.the disease was still active at the end of that time,though there were hopes of much improvement.

Dr. G. MACKAY and Mr. M. S. MAYOU also took partin the discussion, and Sir ARNOLD LAWSON replied.On Saturday morning Mr. BERNARD CRIDLAND

opened a discussion on thePrevention of Minor Eye Injuries in Industry.

He first spoke of the Departmental Committee on thesubject in 1922, which gave an excellent surveyof the whole question of accidents in industry.Four surgeons had supplied careful notes of eyeinjuries sustained in the course of occupations in426 cases, the four being Mr. J. Evans (Birmingham),Mr. A. J. Ballantyne (Glasgow), Mr. R. J. Coulter

(Newport, Mon.), and Mr. Cridland. The cases were-divided into three main groups: (a) Occupationsinvolving exposure to small flying particles, such asworkers at grindstones or emery wheels. 51 per cent.of the cases were in this group. Risk of seriousinjury here was small, the trouble being mainly a,foreign body in the cornea. (b) Occupations involvingexposure to flying chips of metal, 26 per cent. of all.(c) Miscellaneous, including such occupations as

mining, road-making and repairing, painting, plaster-ing, general labouring, 23 per cent. In 70 per cent.of eye accident cases no form of protection to the eyewas available-a fault of employers. In 19 per cent.protection was admitted to be available, but was notused. In the remaining 11 per cent. goggles ormachine guards were used, therefore accident seemedto prove them inefficient. After pointing out theeconomical loss of failure to adopt measures ofprotection, Mr. Cridland said there were three mainlines of prevention-namely, those based upon(1) mechanical guarding ; (2) education on the subjectof workmen and foremen ; (3) engineering revision.Good goggles, he said, gave 100 per cent. protection,shields 90 per cent. protection. The great obstacle tosuccess in all these efforts was the objection of theworker to the wearing of goggles, many regarding themas effeminate.

Mr. J. H. FISHER pointed out that the Council ofBritish Ophthalmologists had been actively interestedin the same subject. Mr. TREACHER COLLJNS thoughta visor on the lines devised by Sir Richard Cruise for-war purposes, with a very fine mesh, might be used ;it would be better ventilated than glass goggles. Mr.JOHN ROWAN, Mr. CYRIL WALKER, Mr. J. F.CUNNINGHAM, Mr. M. HINE, Dr. G. MACKAY, and Mr.A. L. WHITEHEAD also discussed the subject, and SirJOHN PARSONS pointed out that American employersin engineering shops took a stronger line than Britishemployers in insisting on workmen using adequateprotection.On Friday afternoon clinical cases were inspected

and discussed at the new premises of the RoyalWestminster Ophthalmic Hospital. During thecongress two rooms were set apart as a museum ofophthalmic appliances, drawings, and literature, theexhibits including goggles damaged during use atvarious trades.

LONDON ASSOCIATION OF MEDICAL WOMEN’SFEDERATION.

AT a meeting on March 26th Miss F. M. HUXLEYtook the chair, and an address onPain in Relation to Lesions of the Upper Urinary Tractwas given by Miss E. C. LEWIS. She distinguishedthree varieties of abdominal pain caused by lesions ofthe kidney and ureter : (1) colic; (2) pain in the loinand midaxillary region, due to lesions of theparenchyma; and (3) pain at the outer edge of therectus abdominis, at the umbilical level, caused bydistension of the pelvis. Colic in its most severe formwas caused by a stone in the renal pelvis or ureter-Some writers thought that it was due to tension of the-kidney capsule, others that it was a spasm of theunstriped muscle. Legueu’s work on pyeloscopyseemed to support the view that there would be painfuland vigorous contractions behind an obstruction,just as in the alimentary canal. Oddly enough, stonesin the calices did not cause pain. Renal colic.,however, did not always indicate the presence of astone ; similar attacks, though usually less severe,were caused by the passage of other foreign bodies,such as blood clots from a malignant growth, debrisfrom a tuberculous kidney, or " showers " of crystals .,also by irregular spasms in acute pyelitis, andureteritis, and in Dietl’s crises, and crises of nervousorigin. The differential diagnosis included biliaryand appendicular colics and those of intestinal and