981

extreme nsemia, with pulsating tumour in epigastrium,rather to Lift of middle line. During the progress of thecase the patient progressively emaciated, and finally diedfrom hsemor;hage into the stomach. Absence of persistentvomiting was the only, irregular symptom in the case, sick-ness only occtjring on one or two occasions to a very slightextent. It is noticeable that this absence of marked vomit-ing was associated with an unusual portion of the ulcer-viz., in the anterior wall near to the greater curvature.-Dr. HABERSHON fu3ked whether there were any more decidedsymptoms in the case. The ulcer could hardly have been onthe anterior wall ae its base was formed by the pancreas.-Dr. ROUTH referred to a case where the limited pain causedby a galvanic current to the epigastrium determined adiagnosis of ulcer, when other symptoms were deficient. Thepatient, a gentleman, died after profuse haemorrhage, andthe ulcer was found after death.-Dr. WILTSHIRE asked ifmelxna had been observed. It was a valuable symptom, andoccurred often without haematemesis. Vomiting was moreapt to occur when the ulcer was seated near the pylorus.-Dr. ALLCHIN said there was no history of hasmatemesis, butmeleana occurred. Although mainly on the anterior wall thebase of the ulcer adhered to the pancreas.

Dr. HABERSHON then showed a specimen in which aCancerous Cavity in the Left Lobe of the Liver communicatedwith the Stomach, and an abscess between the liver and thediaphragm communicating with a second cavity in the rightlobe of the liver. There was extreme anaemia, and acancerous growth in the lung had produced local pleuro-pneumonia. The gastric symptoms were comparativelyslight, the orifices were free, and the rest of the gastricmucous membrane was unaffected. The anasmia and thesecondary affection of the lung masked the primary disease.- Dr. THOROWGOOD mentioned the case of a gardener whocame under treatment in the morning, made a good meal;was afterwards taken with sudden collapse, and died thesame evening. A large perforating ulcer of the stomach wasfound.-The PRESIDENT inquired as to the etiology of ulcerof the stomach, and whether this disease was so common asDr. Brinton supposed.-Dr. HABERSHON, in reply, saidthese cases may be very slow in their progress, but when theulcer is seated over a large vessel the case may be veryquickly fatal. He mentioned a case where symptoms, afterlasting forty years, subsided, probably from healing of the

Dr. HABERSHON then read notes of a case of Obstruc-tion of the Intestine from great contraction of the MucousMembrane of the Ileum. The patient, aged thirty-five,was seen in consultation with Mr. F. E. Webb. He hadbeen subject to attacks of colic and diarrhoea from boyhood,but had otherwise good health. In the autumn of 1878 hebegan to suffer from weakness, and paroxysmal abdominalpain recurring at shorter and shorter intervals ; emaciationslowly taking place. The bowels were open but motionswere pale. On August 3rd, 1879, there was great distensionof the abdomen, visibility of coils of intestine, constantattacks of pain, especially in upper part ; motions some-times loose, sometimes forced. No tumour could be detected,and it was evident there was not complete obstruction. Hedied in December, and examination showed adhesion of acoil of small intestine to the transverse colon, with greatnarrowing of the ileum less by thickening of the mucous mem-brane, whilst above this point the coats of the bowel were muchhypertrophied and ulcerated, but small and contractedbelow. This was no evidence of cancer. Dr. Habershonthought the contraction had existed for many years, andwas probably of inflammatory origin-an intussusception inarly life being suggested as an hypothetical explanation.He discussed the question of diagnosis, and reviewed thevarious causes of intestinal obstruction. The clinical history

pointed to disease of the mucous membrane rather than tobands of adhesion, volvulus, or tumour; but it was thoughtprobable that the disease had assumed a malignant charac-ter. The difficulty in distinguishing between obstruction ofthe large or small intestine was referred to, and in thiscase the symptoms pointed to the colon as the seat of dis-ease. The adhesions to the -colon probably caused the painin this region. Prognosis was unfavourable from the first,and the treatment only palliative. Colotomy would havebeen of no use, but if the obstruction had become complete,an operation would have been resorted to, hencethe importance of precisely localising the disease. -The PRESIDENT asked whether any attempt had been madeto discover the seat of obstruction by means of abdominal

section. In all cases it was essential, if possible, to deter-mine the nature of the seat of obstruction.-Mr. RoYES BELLalluded to the frequent impossibility of diagnosing the exactseat of an internal obstruction. He related a case whereobstruction was thought to be due to an inguinal herniawhich was operated on. The patient dying soon after a

stricture of the small intestine was found a short distanceabove the hernia ; and had it been detected at the time ofoperating an artificial anus might have been made in thebowel above the stricture.-Dr. DE HAVILLAND HALL relatedacase with symptoms of diarrhoea treated for several days withchalk and opium, when signs of obstruction set in, and hewas admitted into the hospital in a sinking condition. Colo-tomy was performed at once, but patient died a few hoursafterwards. The obstruction was due to cancer of the rec"tum.-Dr. HABERSHON agreed as to the obscurity of thesecases. In the case he had read, the obstruction was notcomplete. Mr. Birkett had had a case under his care inwhich were three distinct sorts of obstruction. Dr. Haber-shon deprecated too early surgical interference, because insome of them all symptoms disappeared in the course of afew days.

____________

OPHTHALMOLOGICAL SOCIETY OF THEUNITED KINGDOM.

Opacities in Vitreous Humour, following injury.-RetinalHcemorrhages and Degeneration in Scurvy, and in Idio-pathic Anoinia. - Congenital Absence of Eyeball.-Paralysis of Cranial Nerves with Hemiplegia.—Peri-tomy.-Eye Symptoms in Locomotor Ataxy.THE ordinary meeting of this Society was held on the

9th inst., W. Bowman, Esq., F.R.S., President, in the chair.There was a good attendance, and many interesting caseswere exhibited, and papers read by Mr. Critchett and Dr.Hughlings Jackson. "

Mr. J. E. ADAMS exhibited and described a case of pecu-liar Opacities in the Vitreous Humour, following Injury.Within two weeks of receiving a blow on the right eye witha chestnut numerous minute shining bodies, like cholesterin,were detected in the vitreous. At first the pupil was weakand excentric, but it is now (two months after injury)normal, the vitreous remaining as before. The case wasremarkable for the short time elapsing between the injuryand the appearance of the bodies in the vitreous. Knapphad recorded a somewhat similar case.-The PRESIDENTthought it difficult to explain if it were due to the accident.Might not the bodies have been long present ?

Dr. S. MACKENZIE described a case of Scurvy, withRetinal Haemorrhages and Degeneration, in a young ladwho had lived in Whitechapel, and had not been deprivedof vegetable food. The gums were spongy; there werenumerous purpuric spots on the skin; and whilst underobservation haemorrhages began to appear in the retina ofboth eyes, becoming more and more abundant, so that theynow present the appearance of severe albuminuric neuro.retinitis. He is very auaemic ; there is no leucocythaemia.—Dr. BUZZARD doubted if the case were one of truescurvy, for if so it would be the first case he knewin which that disease had appeared whilst taking vege-table food. He had examined many cases of scurvy forretinal haemorrhages, but without success. The case wasrather one of purpura.-Dr. GOWERS asked if there was anyconsiderable reduction in the number of red corpuscles.-Dr.MACKENZIE said the case was regarded by many as one ofscurvy, although he admitted the force of Dr. Buzzard’s argu-ments. He had hitherto failed to find retinal haemorrhagesin scorbutic cases. The red corpuscles were about twenty tothirty per cent. of the normal, and the haemoglobin was verydeficient. Dr. Mackenzie then mentioned a case of Idiopa-thic Anaemia in a man in whom retinal hemorrhages werepresent, but had disappeared under treatment. It was usualfor such haemorrhages in anaemia to come and go. The cor-puscular richness was at first only 20 per cent.

Dr. A. D. DAVIDSON showed a case of Congenital Absenceof one Eyeball, a small rounded button lying beneath the con-junctiva at the bottom of the orbit, which was of natural depth.At birth there was a slight discharge from this orbit, but inanswer to the President, Dr. Davidson said there was no

. appearance of inflammation.

982

Dr. ALLEN STURGE exhibited a man, aged seventy-two,who was admitted into the Royal Free Hospital five weeksago in an attack of apoplexy. There ensued paralysis of boththird nerves, partial paralysis of the levator palpebrse on theright side, slight on the left; dilatation of pupils, especiallythe left ; right facial paralysis and deafness on the right side;and left hemiplegia. Recovery began in the arm first, and onthe upper part of the arm before the hand. The facial para-lysis, complete in degree but not in extent, improved in threeweeks, and the ocular condition remained unaffected. Therewas a possibility of syphilis in the case (there was some oldchoroido-retinitis in the left eye), but the history pointed infavour of a haemorrhage in the anterior part of the pons.The following cases were exhibited, but for want of time

not described. Mr. MCHARDY : Case of Recent Rupture ofthe Choroid.-Mr. WORDSWORTH : Case of Rupture of bothEyeballs with subconjunctival dislocation of the lenses, bya single injury ; recovery of good sight. Case of peculiarGranular Calcareous-looking Opacities upon the Iris afterneedle operations for soft cataract, in a boy.Mr. CRITCHETT then read a paper on Peritomy, and gave

the following reasons for introducing the subject to thenotice of the meeting : First, that during a long career manycases of vascular opacity with granular lids had come beforehim in which the disease had remained for many years unre-lieved, although the patients had been under treatment forconsiderable periods at various institutions; and secondly,because the operation of peritomy had fallen into unmeritedneglect, and was seldom practised. He then proceeded togive a brief sketch of the leading symptoms of the disease,and alluded to the type of patient in whom it most frequentlyoccurs, he having found that it is most prevalent in youngadults who had been ill-nourished and neglected ; and thatit is frequently propagated by direct transmission, so thatconstitutional defects and local causes contribute in varyingdegrees to its development. It often exists in a more or lessaggravated degree for many years ; and the treatment is, asa rule, directed to removing the granular condition of thelids. This may be partially effected by the application ofcaustics and astringent lotions, but such treatment is ratherpalliative than curative, and not unfrequently during itsprogress the case will relapse and the symptoms become evenmore intensified. Mr. Critchett recommended-although itmight seem contrary to the pathology of the disease-thatcurative treatment should in the first place be directedto the vascular web, which in these cases covers the upperthird or upper half of the cornea, since he believed that theexciting cause of the relapses lay rather in this morbid con-dition, and that the granular state of the lids was kept inactivity by the existence of the above-mentioned vascularmembrane. He, therefore, in every case initiates his treat-ment by performing the operation of peritomy, since he findsthat when sufficient time has been allowed (usually fromfour to six months) for the resulting cicatrix to becomedense, white, and atrophied, thus cutting off the vascularsupply to the partial pannus, the web gradually disappears,the cornea becomes transparent, and the granulations eithertake their departure or become much more amenable toordinary treatment. He was anxious to dwell upon thislast point, because for a certain period after the perform-ance of the operation no benefit, but rather the contrary,would usually be observed, and it is only on the completionof the last atrophic stage of the cicatrix that the curativeinfluence is established. He earnestly commended theoperation to the attention of his colleagues. Three caseswere shown illustrating the effects of treatment at differentstages.-In reply to the President, Mr. CRITCHETT said thathe extended the peritomy beyond the pannus-i.e., right roundthe eye.-Mr. HIGGENS had performed peritomy in manycases without result, and had therefore abandoned it. Possiblyhe had not observed the case long enough afterwards, and afterMr. Critchett’s advocacy he would again perform the operation.Mr. STREATFEILD asked whether any treatment was adoptedfor the granular lids ?-Mr. CRITCHETT said all the caseshad granular lids, but he began by the peritomy, and in alarge number of cases the granular condition subsides whenthe vascularity of the pannus is cured. In other cases thegranular lids require additional treatment.-Mr. JAMESADAMS had long been in the habit of performing peritomy,and was satisfied with the benefit resulting from it. Hethought the cases should be selected. He had found thatthe pannus was not always dependent on granular lids, butthe cornea was vascular from the first.

Dr. HUGHLINGS JACKSON then read a paper on the Eye-

Symptoms in Locomotor Ataxy, of which an abstract is: given elsewhere. (See p. 968.)-Mr. SPENCER WATSON

asked whether the optic atrophy of ataxies was peculiarand a special form.-Dr. JACKSON said that he had longago pointed out its special features ; and it was now gene-rally admitted to be due to grey degeneration, and was cha-racterised by limitation of the field of vision and loss ofcolour-perception.-Dr. GOWERS regretted that time hadnot allowed Dr. Jackson to read the whole of hispaper. He had examined a number of cases of ataxywith myosis and loss of reflex action to light, and hecould confirm Erb’s statement that, in this condition thepupils did not dilate on stimulation d the skin. Hethought, however, that we must hesitate in regarding thisphenomenon as strictly analogous to the loss of other reflexactions in the disease, which were due to a lesion of thesensory structures or reflex centres. It might be the resultmerely of the motor paralysis of the sympathetic fibres forthe dilator pupillse. This view was confirmed by one casewhich lie had seen, in which, although there was loss ofreflex action to light, there was not myosis, and the pupilsdid dilate on cutaneous stimulation.

Reviews and Notices of Books.St. Thomas’s Hospital Reports. New Series. Vol. X.

Edited bv Dr. ROBERT CORY and Mr. FRANCISMASON. London : J. & A. Churchill. 1880.

St. George’s Hospital Reports. Vol. X. Edited by T. T.WHIPHAM, M.B., and T. P. Pick, F.R.C.S. London :WHiPHAM, M.B., and T. P. PiCK, F.R.C.S. London:J. & A. Churchill. 1880.

THESE volumes, which each contain full statistical tablesand summaries of the cases treated in the hospitals duringthe year 1879, have appeared with commendable punctuality.They present certain points of difference in the manner inwhich they are drawn up, but each is excellent in its way.Far greater space is allotted to the actual "reports in theSt. George’s volume, but we miss any general statisticaltable of the medical cases similar to that furnished in theSt. Thomas’s Reports. In the St. George’s Reports eachdisease is treated separately, and references are given to thecases in the hospital registers. In the St. Thomas’s volumesome diseases are analysed in a tabular form, others bymeans of brief abstracts. But in both the amount of informa.tion is considerable, and the labour entailed upon the

registrars in the compilation of the reports must have beenvery great. The medical report in St. George’s is byDr. Isambard Owen, in St. Thomas’s by Dr. W. B. Hadden ;the surgical in the former by Mr. W. H. Bennett, in thelatter by Mr. H. P. Potter. The St. George’s volume con-tains also two extended reports from the curator, Dr. Ewart,giving an account of the work done in the post-mortem roomduring the years 1878 and 1879. There are also reports fromthe various special departments, more or less full.Preceding the analytical summary, and occupying the

main part of the book in the St. Thomas’s Reports, areseveral original memoirs by members of the staff. Dr. Pea-cock analyses critically 161 cases of rheumatic feverunder his care from 1872 to 1876, in continuation ofa previous paper dealing with cases before that period, andmaking a total of 394 cases, of which 205 were males and189 females. Of this number 32’7 per cent. exhibited someform of recent cardiac disease ; the total average of cardiaccomplications, old or recent, being 42’8 per cent. or one in2’3 cases. The mortality was only 1’5 per cent. Mr.

Nettleship writes upon Diphtheritic Ophthalmia and Con-genital Day Blindness with Colour-blindness. In the firstof these papers he includes all cases of membranous ophthal.mia, which, he points out, is rare in association with pha-ryngeal diphtheria, but more common during, or after,measles and other exanthemata. Its greater prevalence inVienna and North Germany is suggested to be to the