451THE BRITISH MEDICAL ASSOCIATION.

and he proposed to touch on only a few points. Irregularand imperfect contraction of the stomach, as revealed byX ray examination after bismuth meals, was certainly presentin some cases of dyspepsia associated with pain and tendencyto vomit. In other oases the pain appeared due to irregularcirculation through the intestine consequent on binding downof the coils of intestine by adhesions. Dental caries, byleading to deficient mastication, and hurrying childrenthrough their meals, acted in the same way and led to

dyspepsia. Rest before meals and variety in diet were

important points in treatment.Dr. C. PAGET LAPAGE (Manchester) agreed with the

other speakers that congenital pyloric stenosis in infancyrarely caused symptoms of dyspepsia in later years. Diseasessuch as rheumatism and tuberculosis and also chronic under-

feeding led to general lowering of the bodily functions andwere a frequent cause of atonic dyspepsia. Treatment of the

general condition led to a rapid improvement in the digestivepowers. Many cases of dyspepsia were probably due totuberculous affection of the mesenteric glands, oftenunsuspected and undiagnosed, and cleared up when thedisease was overcome. In some cases which at firstsuggested periodic vomiting the attacks become more

frequent, and ultimately the underlying tuberculous conditionbecame apparent. Carbohydrate food had a bad influence inproducing dental caries and also led to bolting the food :foods should be prescribed that required mastication, so thatthe whole range of the digestive tract might acquire pro-ficiency through exercise.

Dr. F. C. EVE (Hull) considered that the atony of thestomach was often part of a pot-belly condition, and empha-sised the need of horizontal rest and abdominal massage.Many cases of dyspepsia were merely symptomatic of otherdiseases, such as phthisis, glandular tubercle, worms, con-stipation and nervous debility, and diagnosis was in con-sequence uncertain ; it was important to look for an under-lying cause.

Dr. JOHN HADDON (Hawick) emphasised the importanceof food, fresh air, and exercise in the treatment of

dyspepsia.Dr. C. RIVIERE (London) drew attention to a type of

children who suffer from the age of infancy with lack ofappetite. They were thin, pale, nervous, and restless, andhad no definite dyspeptic symptoms other than want of

appetite. He asked whether Dr. Hutchison would considerthese cases to be of neurasthenic origin and advise over-feeding, or to be due to an intestinal catarrh calling forlimitation of food. As a clinical type they were of

mportance.Mr. CORNER considered that overfeeding led to multiplica-

tion of micro-organisms, and these congregated particularlyin the cascum. He would suggest that appendicitis was anecessary corollary to such stasis, and that removal of theappendix would be of great benefit in many cases of

dyspepsia in children.Dr. R. B. MCVITTIE (Dublin) stated that rest in bed had a

very beneficial influence on these dyspeptic cases, and

suggested that this was the explanation of the benefit thatremoval of an appendix not obviously diseased might lead to.

Dr. F. CLAYTON (Leamington) and Dr. W. E. HUME(Newcastle) also spoke.

Dr. HUTCHISON, in replying, put in a strong plea forlogic and sanity in the discussion. The causes of dyspepsiawere manifold, and not all cases could be attributed toeither appendicitis, tuberculosis, or error in diet. He hopedthat X ray examinations on the lines Dr. Hutton had carriedout would throw much light on dyspepsia due to lack ofmotility. The cure of dyspepsia in children was usuallyeasy if the practitioner had a free hand. The use oflaxatives and a change of air and life were the chief itemsin treatment.

Mr. A. H. TUBBY (London) read a paper onA Method of Operating for Webbed Fingers.

The cases could be divided into four classes: (1) those in.which union was by skin only; (2) by skin and fibroustissue ; (3) the lattice form in which the fingers were sepa-rated proximally, but united distally; and (4) where thebones were fused together. Difficulties arose in those caseswhere the union was by soft tissues as well as skin, and inthose where some of the bones were joined. The number ofoperations that had been devised for the cure of this con-dition showed the difficulty of getting good results ; most

of them failed to fulfil all the postulates of success, namely-(1) the formation of a large permanent opening at the baseof the cleft (this opening must be lined throughout withepithelium, and be in the position and have the naturalinclination of the cleft); (2) the fissure so formed must be

stationary ; (3) when the fistula was completely healed theweb was dealt with in such a way that the lateral rawsurfaces became completely covered with skin ; (4) absoluteasepsis must be maintained from first to last ; and (5) thefingers when healed must be watched and if necessarysplinted to prevent lateral deviation ; they should be

massaged and moved daily. The operation planned bythe author and practised to carry out these require-ments was described as follows: Two triangular flapsof skin are cut in the situation of the normal inter-

digital cleft; one on the palmar aspect with the basetowards the tips of the fingers, the other on the dorsal

aspect with its base in the reverse direction and further fromthe fingers, to obtain the natural slope of the interdigitalcleft. The flaps are large and generous. The soft tissues atthe base of the web are cut out till a circular opening one-third of an inch in diameter is made. The flaps are drawnthrough the foramen and carefully adjusted with their

epithelial edges opposed and sutured in position. To preventcontraction the foramen is kept distended by a glass rod ; ifnot fixed firmly this would tend to move about and irritatethe parts, and further it had been found to work downgradually towards the tips of the fingers. To prevent this.Mr. Tubby has devised an apparatus which will fix the rod :the apparatus, which can be sterilised, consists of a

metal wristlet carrying two arms which hold the glassrod in place by means of two screws ; the palmararm is rather longer than the other, so that the

glass rod maintains the obliquity of the interdigital cleft.The rod is kept in for a week after the stitches have beenremoved, when the fistula should be dry and lined with skin.When the first operation is successful flaps are turned fromthe dorsal aspect of one finger and the palmar aspect of theother by Didot’s method, and the completion of the separa-tion is carried out. Complete apposition must be obtainedand no raw surfaces left either on the fingers or in the cleft ; ytension on the flaps should be avoided. A dressing ofsterilised tinfoil under the gauze prevents irritation and aidsrapid healing. The hand and arm are fixed in splints forthree weeks ; the wound should be found dry, and theresult satisfactory. Massage and movement are requireddaily, and lateral deviation is overcome by malleable fingersplints if necessary. (Full details of the operation andfigures will be found in the writer’s book on "Deformities,including Diseases of Joints and Bones.")Mr. CORNER congratulated Mr. Tubby on an operation well

designed to remedy satisfactorily these difficult cases.

OPHTHALMOLOGY.

THURSDAY, JULY 25TH.

President, Mr. EDGAR ATHELSTANE BROWNE (Liverpool).A discussion on the use of

Tuberculin in Diseases of the Eyewas opened by Dr. GEORGE MACKAY (Edinburgh), who saidthat he proposed first to examine the status of tuberculin asan aid to the diagnosis of ocular tuberculosis ; to considerthe preparation and method of application ; and, further,the importance of making a differential diagnosis betweenthe human, bovine, and avian varieties, and the means attheir disposal for discriminating between these. The sub-cutaneous injection of small doses of the original tuberculinhe thought highly of ; Calmette’s ophthalmo-reaction had amost restricted applicability, owing to its danger ; von

Pirquet’s reaction was safe, simple, but only moderatelyreliable ; whilst Moro’s was much less reliable. He did notthink it possible to distinguish between human and bovinetubercle by these means. He next dealt with the values ofthe opsonic index, or phagocytic index, as he preferred to.call the reaction. The method was undoubtedly difficult andtedious, the personal equation entering largely into theresults obtained, but these examinations had taught themmuch, and they were still of value in cases of difficulty indiagnosis. As regarded tuberculin in treatment, the safestpreparation appeared to be Koch’s New Tuberculin T.R.,whether human or bovine ; it caused the least violent reaction.Where more powerful effects were desired the bacillary

452 THE BRITISH MEDICAL ASSOCIATION.

emulsion (B.E.) might be employed. They had sufficient t’evidence to show that if initial doses were small the n

increase was gradually made, and the inoculations were not c

too frequent, the clinical condition and the absence of local treaction might be taken as guides without repeated observa- ttions on the opsonic index. No hard-and-fast rules of dosage could be laid down, the personal reaction of each c

patient had to be considered, and they must bear in mind r

that their aim was not so much to flood the patient with 1massive doses of antibacterial material, but rather to r

stimulate his own tissues to produce this material for chimself. The speaker then proceeded to consider illustrative tcases of tuberculous disease and his experiences in treating them ; this part of the paper was illustrated by a series ofbeautiful water-colour drawings shown by the epidiascope. l

Phlyctenular conjunctivitis was often associated with tuber- (

culous lesions of glands and bones, but he was diffident in i

assuming a phlyctenule was a pure tuberculous lesion. Some of them he had evidence to show were definitely staphylo-coccic lesions. Some, on the other hand, appeared to be due to mixed infections of tubercle with some variety of coccus, 1and this was particularly the case in patients who were liableto a series of ocular lesions of slightly different order.

Considering the deeper affections, interstitial and punctatekeratitis, he showed that certainly some of these cases weredue to tuberculous manifestations, the diagnosis and thetreatment on the lines described had been of the utmostvalue, and it was a distinct warning not too hastily to assumethat an interstitial lesion was syphilitic. Other cases againreacted to both tuberculous and syphilitic tests, so that therewas doubtless the double diathesis. He believed that intuberculin they had a valuable remedy, if judiciouslyemployed, both for diagnosis and for treatment.

Dr. L. C. PEEL RITCHIE (Edinburgh) dealt with themethods of blood examination employed in the investigationof cases particularly referred to by Dr. Mackay. First, theyhad to remember that while the blood might give evidence ofthe presence of some particular organism infecting the

system, that in itself did not necessarily furnish the cause ofthe eye infection. Further, there was the possibility of morethan one variety of infecting agent being present. The bestevidence could be obtained in cases in which the eye was

,apparently the sole seat of infection ; in many cases therewere other lesions which complicated matters. At first

they were compelled to make a large number of bloodexaminations for a variety of organisms, but with experi-ence the range of the examination became limited, andlatterly inoculation tests and treatment had been carried outon a number of patients without any examination of theblood. After detailing his methods of blood examination hewent on to show that the differentiation between the various

types of tubercle bacillus was of high practical importance ;in certain types of cases the bovine type of infection wasfound to be especially common, and evidence had beenobtained that treatment of such cases with the human typeof tuberculin was ineffective. As regarded the methods ofinoculation treatment adopted with tuberculin and othervaccines, their object was to avoid objectionable reactions,to permit of the continuance of the treatment over longperiods, and to make it suitable for outdoor patients. The

general principle was to keep the patient constantly underthe influence of small doses of fairly uniform amount, buttending to gradual increase, never to diminish the dose, toavoid hypersensibility by giving the earlier doses at shortintervals, while later, as the conditions tended to come undercontrol, to increase the intervals and also the dose.

Dr. A. HILL GRIFFITHS (Manchester) gave in illustrationof the successful use of diagnosic methods and treatmentwith tuberculin records of two recent cases, the one a healthyadult man suffering from tuberculous conjunctivitis, and theother a boy with multiple tuberculous lesions ; injectionswith tuberculin T.R. at intervals of 14 days had been mostsuccessful.

Dr. D. Louis DoR (Lyons) said that no doubt some remem-bered the enthusiasm of the whole assembly when in 1890 atthe International Congress, Berlin, Koch announced that hehad found a remedy for tuberculosis which he called tuber-culin. From then till 1893 nearly all physicians had triedit, but unhappily it was proved that the remedy was verydangerous and that in some cases the disease of the patientswas aggravated by its use. Lately Dr. Dor had treated agreat number of patients, 80 in four years. He considered

,hat in a great number of cases interstitial keratitis with anegative Wassermann reaction, phlyctenular conjunctivitis,;hronic scleritis, quiet iritis, and optic neuritis, were due totubercle, and in these the best thing was to try the action oftuberculin as a diagnostic agent. In the majority of cases.ocal and general reactions resulted, but many were atypical)ases. He used very small doses (100,000th part of a

milligramme) and every third day injected larger doses solong as no reaction resulted. As soon as a local or generalreaction was noted he injected the same dose until it pro-iuced no reaction. He never neglected local and generaltreatment. So far he had had no bad results, and therewas definite reduction of the lesions. The action was slow,and quite unlike the rapid action of salvarsan and iodides.It was absolutely necessary to treat a number of cases beforecoming to a definite conclusion, and the duration of a coursemust never be less than two months ; even after threemonths with a seeming cure he had had relapses necessitatinga second course. For the majority of cases he preferred theGerman bacillary emulsion (B.E.), which was a culture ofbacilli crushed and killed.

Mr. T. HARRISON BUTLER (Coventry) said that Calmette’sreaction was dangerous and useless. He had had violentreactions, with resulting interstitial keratitis and cornealulcers in previously normal eyes. Von Pirquet’s reactionwas positive in 90 per cent. of all adults, and so valueless,though for children it had some use. Injection of oldtuberculin was the only method of real value. A localreaction after an injection was proof of ocular tuberculosis.He used 0.001 c.c., followed up at an interval of a few

days by twice, and then four times, this dose. He had hada case which failed to react to human but did react tobovine tuberculin. In ,treatment he found tuberculin T.R.best. It was necessary to continue the treatment even upto a year. He questioned whether any good was obtained byincreasing the dose. He had had excellent results, especiallyin diseases of the uvea, and in phlyctenular conjunctivitiswhich he believed to be of tuberculous association. Scleritisand sclerosing keratitis were frequently tuberculous andoften susceptible to tuberculin therapy.

Dr. W. B. MARPLES (New York) said he was muchinterested in the cases of interstitial keratitis of tuberculous

origin. In his own experience, the majority of cases of thisdisorder gave a positive Wassermann reaction, and theremaining cases did not give a positive tuberculin reaction.He had had several cases of obsolescent tuberculous choroid-itis with a focus of recrudescence which gave positivetuberculin reactions. In some cases of recent tuberculouschoroiditis the " mutton-fat " exudation on the back of thecornea had quickly disappeared under treatment, but theopacities in the media and the choroiditis got well onlyslowly. In tuberculous iritis where tuberculin had been

given as a diagnostic aid three times at intervals of four daysno positive reaction except a slight rise of temperature wasnoted, but the nodules had gradually disappeared. He agreedthat small; gradually increasing doses were necessary, andthat the treatment should be continued for several months ora year.

Mr. N. BISHOP HARMAN (London) raised the point as towhether they were justified with their present state of know-ledge in using tuberculin by "rule-of-thumb" " methods-that was, without a preliminary exhaustive examination ofthe blood and the repetition of these tests during each stageof the treatment. He thought they were justified in doingso. The cutaneous tests for tubercle were at best dubious, andthe personal equation in making the blood tests was so greatthat in any event they were left mainly to their own clinicalacumen. He had found the use of tuberculin in selectedcases, given after the manner detailed by Dr. Peel Ritchie,safe and satisfactory. He relied on three guiding signs : theappearance of the local lesion ; the temperature of thepatient taken regularly; and lastly, the feeling of fitness onthe part of the patient. If a patient felt out of sorts noinjection was given that day. He raised the most emphatic

, protest against the assumption on the part of some that: phlyctenular conjunctivitis was always of tuberculous or. para-tuberculous origin. All the evidence tended to showthat the greater number of the cases-which formed a

large part of those seen at children’s hospitals-were; comparatively innocuous lesions due to local causes. Het had examined the case papers at the Belgrave Hos-t pital for 10 years with the following results : of

453THE BRITISH MEDICAL ASSOCIATION.

all the cases one-half were cured in one week, a further

quarter in the fortnight, only 5 per cent. dragged onfor months, and these were the cases of phlyctenularkeratitis occurring in children who were justly called" strumous " at sight. Next the cure was obtained by thesimplest means, yellow cintment ; in some cases he had

experimented with plain castor oil with equally satisfactoryresults. Further, the cases had an "age-peak," themaximum occurring at six years of age, a fact that had norelation to tubercle, but a very definite one to the decay ofthe first dentition and the eruption of the second. Lastly,the lesions had a " seat of election," one that had a specificrelation to the distribution of the fifth nerve to the teeth.These things led him to conclude that the common phlyc-tenular conjunctivitis of children was not tuberculous in

any real sense ; it was a herpetiform eruption due to irrita-tion of collateral branches of the fifth nerve. In a residuumof cases there were genuine tuberculous bases, particularlyin those lesions which occurred in later years of life ; andthere were the pustular lesions and the combined episcleraland corneal lesions, which were often, but probablyerroneously, called phlyctenules. " He felt that to assigna simple lesion to a grave cause and then claim cure forit by vaccine treatment when it was more easily curedby the simplest therapeutic measures was to discredit vaccinetreatment.A paper on

The Treatment of Word-blindness, Acquired and Congenital,was read by Dr. JAMES HINSHELWOOD (Glasgow), who saidthat the old idea was that nothing could be done for theeducation of persons suffering from these serious defects.Much, however, could be done if the treatment were con-ducted on proper lines, and he indicated what line, in hisexperience, was the best to adopt. Pure cases of acquiredword-blindness almost always came to the ophthalmicsurgeon in the first instance, as it was supposed that thedefect lay in the eyes. The lesion, however, was either inthe brain, in the angular gyrus itself, or it was due to theinterruption of the communicating fibres between it andthe ganglia. In right-handed people the lesion was onthe left side. He related the case of a man, aged 58 years,who awoke one morning with the power of readingquite lost. He had right lateral homonymous hemian-

opsia, but no other symptoms were discoverable. Hestarted to re-educate himself, learning letters and wordslike a child. After six months he was able to recognisethe letters of the alphabet, but never learned to read wordsby sight. He could read only by spelling words out letterby letter and thus stimulating his auditory memory. Aftera year he gave it up as hopeless ; still he had re-acquired thevisual memory of the letters and of a few short words.Another patient was a woman, aged 34 years, whohad been completely word and letter blind for 14 months ;she had right homonymous hemianopsia. A school-master took great interest in her re-education. Itwas found that the effort of eduction was very great, andcould not be continued for more than 10 minutes at a time.Ultimately she learned to read simple Bible texts by spellingout the words. Her progress has been steady but slow fromthat point of attainment ; but now, after an interval often years, she could read a newspaper fairly fluently, onlyoccasionally she was compelled to spell words. The thirdcase was that of a girl, aged 14 years, who had right-ided paralysis and loss of speech 18 months before.

Previously she had been a good reader. When first seen shewas completely letter blind and had right homonymoushemianopsia. Her auditory memory was unaffected. Re-education was started. After learning the alphabet she wasallowed to spell out words letter by letter. In four monthsshe had made considerable progress and could recogniseany letter and many small words. Longer words she hadto spell so as to get the aid of her ear. Two years later shecould read as well as ever but the hemianopsia persisted.Age evidently was a very important factor in the ability withwhich the patients were able to regain their lost powers.The cause in all these cases was cerebral haemorrhage. Insuch cases the process of re-education should be delayeduntil all signs of acute brain symptoms had disappeared.In these cases it could be accomplished only by bringinginto play the corresponding centre on the other sideof the brain. He argued from these cases of acquiredword blindness and the experience of re-education that

both in these and in congenital cases neither the old systemnor that known as the ’’ look-and-say method was suit-able for all cases. A great deal depended upon the degreeof defect in the visual memory, and upon the condition ofthe auditory memory. When the visual memory was verydefective and the auditory good, then the old system wouldgive the best results ; but when the auditory was not goodthe best results might be obtained by the "look-and-say"

"

system. Lastly, personal teaching was necessary in allcases, and a number of short reading lessons during theday was better than one long one, for the brain rapidlybecame exhausted.

Dr. F. W. EDRIDGE-GREEN (London) quite agreed withthe methods suggested for training the memory. He hadfound that it was of the greatest importance to put as littlestrain as possible on a weak faculty. It should be re-

membered that the retina was represented in the cerebrum,so that we might almost speak of a " cerebral retina."

OTOLOGY AND LARYNGOLOGY.

THURSDAY, JULY 25TH.

President, Mr. HUGH EDWARD JONES (Liverpool).On this clay the Otological Section combined with the

section of Laryngology under the chairmanship of Dr. J.MIDDLEMASS HUNT (Liverpool) to discuss jointly the

Education of the Specialist in Laryngology and Otology.In opening the discussion Dr. HOLGER MYGIND (Copen-

hagen) surveyed the education of the specialist on thecontinent, where there was no uniform system. Countries,he said, might be divided into three groups : (1) Those(Germany, Austria-Hungary, Scandinavia, Holland, Switzer-land, and Roumania) where the universities had chairs ofOtology and Laryngology (in this group were 44 such chairs) ;(2) those (Italy, France, Spain, and Belgium) in which someof the universities (19 in number) possessed such chairs ; and(3) those (Russia, Greece, and Portugal) where there was nosystematised teaching. This was not, however, the soleexpression of the state of education in Europe. The higheststandard was undoubtedly reached in Germany, but Austriawas not far behind. On the continent it was a

rare thing to find a man recognised as a specialist whohad not passed some time as an assistant in a specialclinic, and a man with a high reputation might remain asassistant for 12 or 14 years. In some countries an assistant-

ship, followed by the publication of a dissertation, qualifiedhim as " privat-docent," a valuable distinction, as it carriedwith it the right of teaching. Dr. Mygind then discussedthe defects of the continental system. He considered thatthe preliminary education of the student at the universityshould be the first stage of special training. The first faultwas a superficiality in the examination of the patient, due towant of time on the part of the teacher. The second wasthe laying of too great stress upon lectures. Text-bookswere plentiful now, and detailed instruction in practicalwork was most required. Thirdly, the course did notend in examination, save in Germany, where it was con-ducted by surgeons and physicians, and not by specialists.In the final stages the assistants had too scantytraining in general work, appointments were often of tooshort duration, and the great majority of the out-patientdepartments were overcrowded and experienced assistantstoo few in number. As a consequence, cases were badlyrecorded and were treated by too many specialists. Theremedies suggested by Dr. Mygind were the following : 1. Amore thorough and more individual teaching of the youngstudent, in classes of 10 to 12, with experienced assistants tothe professor. 2. Beginners to study every detail, to avoidsuperficiality, only ordinary cases to be demonstrated at

first, as a few cases examined thoroughly taught more thanmany badly gone over. 3. Compulsory final examination byspecialists for every student. 4. Free post-graduate coursessupported by the university or the State. 5. No appoint-ment of an assistant to be made without a year and a halfas a general assistant (nine months being spent in surgery),the minimum duration of special assistantship to be oneyear. 6. The provision of enough salaried assistants in

proportion to the number of patients. 7. The provision ofwards attached to each clinic. Dr. Mygind also discussedthe connexion between laryngology and otology which, in