140

HERNIA INTO HARTMANN’S INFERIOR

ILEOCÆCAL FOSSA

BY J. A. MAXWELL CAMERON, M.D. Manch.,F.R.C.S. Edin.

LATE RESIDENT SURGICAL OFFICER, JERSEY GENERALHOSPITAL

A DOCK labourer aged 17 was first admitted to theGeneral Hospital, Jersey, on May 18th, 1937, com-plaining of bouts of pain in the right lower quadrantof the abdomen for the preceding three months.There were no other symptoms, and diet, exercise,and posture bore no relation to the pains.He was a fit young man and there were no abnormal

signs anywhere. A " bubbly caecum " was felt inthe right lower quadrant. No hernise were found andrectal examination did not help. There were 10,000white blood-cells per c.mm. The urine on generaland microscopic examination did not show abnormality.A barium meal and follow-through were normal.The patient was kept in bed for four days, and asduring this time he remained free from symptoms heasked to be discharged.He was readmitted on June 18th, 1937; he had

still been having bouts of similar pain in the rightlower quadrant of the abdomen. For the past twodays they had been more severe ; he had vomited

twice, and looked ill. There was deep tendernessin the right iliac fossa, but no mass could be felton abdominal or rectal palpation. The temperaturewas normal.At operation under open ether anaesthesia a right

paramedian entry was used. The caecum was normalin appearance, but as it was being withdrawn ashort loop of lower ileum was released from a peri-toneal pouch in the ileocaecal region. This loop andthe terminal six inches of ileum were injected anda little swollen. Three inches from the end of theileum there was a kink due to the pressure ofthe loop pushing forwards from behind against theterminal ileum in front. The inferior ileocaecal fossaof Hartmann was well demonstrated. Anatomicallyit is a peritoneal cul-de-sac formed by Treves’sbloodless fold anteriorly, and the mesentery of theprocessus vermiformis posteriorly. It extends upwardsto the ileocaecal junction. After removal of theappendix the fossa was obliterated and the ileumallowed its freedom again.

It is noteworthy that the diagnosis was not madebefore operation, a feature shared by most publishedcases of internal hernia. 1 In the first instance thepatient came with symptoms that were vague, andit required a subacute intestinal obstruction to bringhim back for operation.My thanks are due to Mr. A. C. Halliwell who

presented me with this case.

MEDICAL SOCIETIES

OXFORD OPHTHALMOLOGICAL CONGRESS

THE twenty-seventh annual meeting of the congresswas held at Keble College on July 7th, 8th, and 9th.The Master, Mr. C. E. Russ WOOD presided. Prof.HUGH CAIRNS (Oxford) opened from the neurosurgicalstandpoint a discussion on the setiology, diagnosis,and treatment of

Ocular Palsies

He said that the lesions causing ocular palsies aremostly expanding lesions within the orbit and cranium,the clinical picture depending to a remarkable extentupon the speed with which compression or stretchingis produced. He stressed the need of considering allfactors in an individual case and of making full useof accessory methods, especially radiology. Amongorbital lesions, orbital haemorrhage did not, he said,usually produce ocular palsy. This resulted from

injury to muscles and nerves in the orbit and to

damage to the pulley of the superior oblique, thelatter causing diplopia of short duration. In orbitalabscess all external ocular muscles were partly orcompletely paralysed. After evacuation of theabscess prompt recovery of movements ensued.

Slow-growing orbital tumours produced little dis-turbance of ocular movement. Tumours spreadinginto the orbit from without disturbed ocular move-ments very little when they were benign and of slowgrowth, but of malignant ones ocular palsies were aprominent and often the first symptom. Metastatictumours in the roof of the orbit might lead to squintand diplopia, but these conditions were usuallyassociated with pain in the distribution of one orother branches of the 5th nerve. Prof. Cairnsreferred to the work of Russell Brain on exophthalmicophthalmoplegia, a progressive condition often follow-ing thyroidectomy but also developing spontaneouslywithout thyroid changes. Decompression of the orbitgave partial and temporary relief. Ophthalmoplegiadue to aneurysm in the cavernous sinus usually

recovered after ligature of the carotid. In pituitarytumours the most important feature of ocular palsies,from the point of view of diagnosis, was often theirsudden onset with pain in the eye and impairment ofvision. It might be necessary to perform cerebralarteriography to decide whether the lesion was a

tumour or an aneurysm. Oculomotor palsy was oftenassociated with aneurysm of the posterior communi-cating artery, coming on either gradually or associatedwith severe pain on the corresponding side of thehead and neck. Prof. Cairns described and illustrateda group of ocular palsies with trigeminal pain due to(1) carotid aneurysm, demonstrated by X rays or

arteriography; (2) tumours of the middle fossa;(3) cyst of sphenoidal sinus ; (4) polyneuritis cranialis ;(5) Gasserian ganglion tumour ; (6) Schuller-Christian’sdisease, a condition characterised by deposit of cellscontaining lipoid in long bones, skull, and base of thebrain. In conclusion he said that many lesions

affecting the oculomotor nerves were incompletelydefined. There was no short cut to the mapping ofthis fascinating field, which could be further exploredby the use of radiography, ventriculography, and

arteriography, and in appropriate cases by surgicalexploration.Dr. BERNARD CHAVASSE (Liverpool) spoke of the

clinical sequelae of ocular palsies. He described thecauses and results of over-action of muscles andthe effects of over-action on the muscle itself and on thefasciae of the orbit. He pointed out that contractureitself had some paralytic effect. Palsy arising fromdisease affected convergence in two ways : (a) byproducing squint, alternating according to thedistance ; and (b) by effecting aesthetic cure of

amblyopic accommodational convergence. This typeof palsy was progressive and Dr. Chavasse accountedfor nearly all cases of divergent strabismus, exceptthose due to congenital convergent palsy. Palsyfrom disease also affected the contralateral antagonist

1 Rowlands and Turner, The Operations of Surgery, London,8ED, vol. ii, p. 362.

141

of the paralysed muscle. It produced secondarydeviation and past-pointing as well as secondaryconcomitance ; and secondary functional palsy of thecontralateral antagonist led to new primary and

secondary deviation which opposed the original ones.Congenital palsies differed from those due to diseasein the absence of amblyopia, diplopia, past-pointing,and excess of secondary over primary deviation.Dr. Chavasse discussed the aetiology of congenitaltorticollis and the diagnosis and treatment of

congenital palsies.Mr. F. A. WILLIAl18oN-NOBLE (London) gave an

address onContact Glasses

from the clinical standpoint with a survey of resultsobtained. Only recently had it been possible to

produce contact glasses which could be worn withcomfort for any length of time by a reasonable

proportion of the people who would be benefited bytheir use. The indications for contact glasses wereoptical, occupational, and cosmetic. Optical indica-tions included (a) high myopia, (b) conical cornea,(c) after-effects of mustard-gas burns, (d) hyper-metropia and astigmatism, (e) macula disease,(f) faceted cornea. Any surface irregularity in thepupillary area of the cornea might produce grossinterference with vision irremediable by ordinaryglasses, but subject to great improvement when theirregularities were filled in by the normal saline

separating the anterior surface of the cornea from theposterior surface of the contact lens. Persons in

occupations which made ordinary glasses liable to beclouded by steam or rain found contact lenses a

great convenience ; and especially in certain myopesthey had manifest cosmetic value. A questionnaireaddressed to a large number of patients showed that50 per cent. of myopes could wear contact glasses forsix hours or more. Conical cornea patients toleratedthem better still and excellent results were obtainedin the mustard gas and pemphigus cases. Somepatients reported discomfort during the first hour,after which these glasses became progressively morecomfortable. Tolerance to them was roughly propor-tional to the benefits which they conferred, suggestinga psychological element in the matter of tolerance.Dr. I. A. VAN HEUVEN (Utrecht) read a paper on

PapilloedemaHe reviewed modern writings on the venous pulsationon the optic disc and explained how he had checkedthe figures of Bauermaun and others on the relationbetween venous pulsations and intracranial pressure.Lack of retinal venous pulsation was an importantearly sign of papilloedema. Hydrostatic experimentsseemed to confirm his views that the conditiondeveloped when intracranial exceeded intra-ocularpressure. As to the genesis of papillcedema mechanicalfactors played an important rôle, but that they couldnot account for all the phenomena. The colloidchemical conditions of the optic nerve and surroundingtissues also influenced the development of papill-cedema.-Prof. HANS LAUBER (Warsaw) describedthe effect of compression of the optic nerve in dogsand local compression of the brain in human subjects.Compression of the vein but not of the artery causedrapid development of papillcedema.—Mr. THOMPSONHENDERSON (Nottingham) attributed papilloedema todissociation at the lamina cribrosa between intra-cranial and intra-ocular pressures.-Prof. HUGHCAIRNS (Oxford) produced experimental evidencethat concentration of C02 in the cerebral bloodincreased intracranial pressure.

Cataract

The Doyne memorial lecture was delivered byDr. A. VON SZILY, emeritus director of the UniversityEye Clinic of Miinster. His lecture was concernedwith the contribution of pathological examinationsto the elucidation of the problems of cataract ; alsothe morphological findings and changes in the

chemistry of the lens in different cases of cataract,including their primary role, temporal sequence, andlocal combination. The study of many ancilliarysciences-embryology, heredity, biology, the develop-ment of slit-lamp microscopy, and biochemistry-had contributed to our changing views on the vitalfunctions of the lens. Discussing histology, thelecturer showed a number of slides demonstrating thedisplacement of the nuclear corona and other featuresof normal and abnormal development of the lens.Some adult peculiarities of the lens arose from innatefaults in the layers of the embryonic lens, others frominjury or disease at various stages of life. The youngerthe lens tissue the more liable was it to be affected

by injury. He traced histologically the developmentof punctate, lamella, and nuclear cataract, and con-trasted them with the condition observed during theformation of hard and soft senile cataracts, of

Morgagnian degeneration of the lens, and of " com-plicated " cataracts. Calcium deposits were thecommonest of the chemical changes in cataract ; lessoften cholesterin crystals were found. Iron and

copper were deposited in the capsule and deposits offat and ossification in the lens. On the biochemicalside lack of vitamin C influenced the producing ofcataract. Lens tissue was especially sensitive to theintermediate products of metabolism which were

influenced by endocrine disturbances, notably indiabetes mellitus. The lecturer modestly forbore toshow how much of very recent knowledge of thissubject was derived from his own laborious work.At t the conclusion of his address the Master

presented him with the Doyne memorial medal.

Intracranial Blood Pressure and Intra-ocularTension

Prof. HANS LAUBER delivered an address on therelationship between intracranial and retinal bloodpressure and intra-ocular tension, and on the treat-ment of tabetic optic atrophy. He showed that thevenous diastolic pressure in the retina gave a measureof intracranial pressure. The normal relation betweenvenous and arterial pressure in the retina variedwithin the limits 1 :1-8 to 1 : 3. So long as thisrelation was preserved no papilloedema occurred inspite of high intracranial pressure, and if intra-cranial pressure was raised the central retinal veinwas compressed by the cerebro-spinal fluid as it

passed through the intravaginal space. The effects oflow arterial pressure would be to favour the develop-ment of papillcedema whilst high arterial pressuretended to prevent its occurrence. Prof. Lauberreviewed the theories on the origin of optic atrophy,especially in tabes. Changes in the ganglion cells ofthe retina and interstitial neuritis in the optic nervedid not explain satisfactorily the development of thiscondition. He described the influence of generallow blood pressure in accelerating the progress of

optic atrophy, and pointed out that the retinalcirculation differed from that in other tissue in thatthe intra-ocular tension acted on the vessels, especiallyon the capillaries. If the normal difference betweenintra-ocular tension and diastolic blood pressure inthe retinal arteries was less than 20 mm. of mercury,circulation was interfered with and nutrition of the

142

retina, especially oxygen supply, was insufficient.Glaucoma was an instance of this disturbance of thebalance of pressures. Hypotonia was often found intabetic optic atrophy after loss of large quantities ofblood, in Leber’s atrophy, and in retinitis pigmentosa.Dr. Lauber noted that the treatment of optic atrophymust aim at raising the general blood pressure andlowering intra-ocular tension. It followed that anti-luetic treatment in tabetic optic atrophy was dan-gerous in so far as it lowered the general bloodpressure, but such treatment could be carried out

safely if the precaution was taken of lowering intra-ocular pressure. This could be achieved by continuousinstillation of pilocarpine (2 per cent.) which reducedthe normal intra-ocular pressure by as much as

10 mm. Hg. More permanent relief of intra-ocularpressure was obtained by cyclodialysis. Prof.Lauber showed charts illustrating remarkable improve-ment in fields and acuity of vision in tabetic atrophyand retinitis pigmentosa. He concluded that hydro-dynamic disturbances were among the most importantfactors in the formation of tabetic and some othervarieties of optic atrophy.

Anaesthesia in Ophthalmic SurgeryA discussion was opened by Dr. H. M. TRAQUAIR

(Edinburgh). He described the methods used at

Edinburgh and traced the, technique of local anaes-thesia in eye work from the crude use of cocaine dropsto the production of akinesia by injection. Totalanaesthesia had now been achieved by injectionround the lids over a wide area, by applying cocaineto the eyes and by subconjunctival injections aboveand below the cornea.-Prof. R. R. MACKINTOSH(Oxford) commented on the advantages of premedica-tion by Spasmalgin and by a combination of Luminaland aspirin.-Prof. LAUBER had found that cocaineinstillation was insufficient for removal of deepcorneal foreign bodies of some days’ duration.-Mr. HARRISON BUTLER (Birmingham) described hismethod of doing squint operations under local anses-thesia.-Dr. MARGARET GALBRAATH (Birmingham)gave statistics of post-operative vomiting withdifferent methods of anaesthesia.—Mr. LINDSAY REA(London) detailed his technique of orbital injectionswith a specially made curved needle.-Mr. KEITHLYLE (London) recorded some of his experienceswith Evipan sodium and showed how undesirablesequelae could be avoided.

Some Other Communications

Mr. HARRISON BUTLER, speaking on CapsularGlaucoma, showed drawings to illustrate detachmentof the zonular lamella from the lens in traumaticand pathological conditions. In glaucoma differentobservers found separation of the lamella in propor-tions varying from 5 to 90 per cent. of all cases, andhe appealed to members of the congress to make slit-lamp observations so that the true frequency of thiscondition might be established.-Mr. OTTO BARKAN(San Francisco) recorded his experience that the angleof the anterior chamber was often not blocked in

glaucoma and that when cases were examined withthe gonioscope shreds of capsule were often found inthe angle of the anterior chamber.

Mr. FREDERICK RIDLEY (London) described an

Active " Substance in the Tears. Previous researchhad shown a histamine-like substance in the aqueousof glaucoma cases but not in the normal aqueous.Mr. Ridley suggested that in glaucoma there mightbe a lack in the aqueous of some substance antagon-istic to histamine-like bodies. His own work showedin normal tears a substance similar to histamine; it

was not destroyed by boiling or by blood or serum.It passed readily through a cellophane membrane.It was not acetylcholine. It produced the wheal andflare reaction in the skin and caused a rise in intra-ocular pressure through vascular dilatation.Dr. CzUKRASz IDA (Debrecen) described Hungarian

plastic methods, particularly those employed byProf. Blaskovics and Prof. Kreiker, showing photo-graphs of the excellent cosmetic results obtained inreplacing large areas of diseased skin in the region ofthe lids.-Mr. PERCIVAL HAY (Sheffield) confirmed thevalue of Blaskovics’s method, emphasising the impor-tance of keeping the flaps dry with a dressing ofboric acid and iodoform.

ROYAL MEDICO-PSYCHOLOGICALASSOCIATION

Tiiis association held last week its ninety-seventhannual meeting, at Ilkley, under the presidency ofDr. J. R. GILMOUR of Scalebor Park, Burley-in-Wharfedale. His address on the Private Patient andSome Changes contained the fruits of his longadministrative and clinical experience in a hospitalmaintained for private patients by a local authority.The first meeting was concerned with the study

of thePhysiopathology and Treatment of

SchizophreniaThe opening paper was given by Dr. R. GJESSING(Oslo), whose work on somatic function in certaintypes of catatonia is widely known and appreciated.He has chosen to work on catatonics whose illness hasa periodic course, which form a very small proportionof the total schizophrenic group. In circumstancesso carefully controlled that they correspond almostto laboratory conditions he has carried out manydetailed metabolic investigations over a considerablenumber of years. His most significant results, whichhe described, were those which showed the time

relationships between nitrogen retention and excretionon the one hand and mental and motor disturbanceon the other. Dr. Gjessing himself pointed out thesmallness of the group with which he works and the

folly of drawing wide conclusions from his findings,but a study of his methods suggests that along suchlines may in time be found some explanation of theaetiology of mental disorder in general and perhaps ofschizophrenia in particular.

Of the papers on treatment, the most notable wasthat by Dr. A. SAKEL (Vienna and New York) on theinfluence on the psychoses of pharmacological shocks.He described the development and the results of thetherapy associated with his name and better knownhere by the original term which he applied to it-hypoglycaemic shock treatment. The results whichhe quoted were based upon the records of 1500treated cases from the New York State Hospitalservice. The figures were supplied by the superin-tendents and staffs of 25 hospitals and were interpretedand analysed by the statistical office of the mentalhygiene department of the New York State. Threegroups of patients were studied : those treated byhypoglycaemic shock, those treated by Cardiazol(Metrazol), and those not treated by either method.It was pointed out in the discussion that the figuresfor remissions in the control (untreated) group wereso far below the usual remission figures for suchcases in this and in some other countries that a

possibility arose of some factor which made thebasis of assessment different from that generally