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patient, who is generally tempted to seek fresh assistancein other quarters. This is not calculated to elevate thedignity of our profession in the lay mind. To assert thatthe surgeon who thus treats a fellow creature is using hisability to its utmost in affording relief is either an absurdityor a grave reflection on his professional skill. I am awarethat many hold that, because the human eye is but an imper-fect piece of optical apparatus, it is sheer waste of timeto attempt to correct minute errors. Surely two wrongsdo not make a right. It is, of course, easy to understandthat a doctrine of this kind is comforting to the conscienceof a busy man, but it is none the less unworthy ofa scientist. Others, again, affect to consider errors ofrefraction almost beneath their notice. It is a pity thatthey do not consider them entirely so. Another argumenturged against the necessity for accuracy is found inthe statement that" experience teaches us that it isnot necessary to the comfort or well-being of the patientthat these errors should be so minutely neutralised";and some go so far as to say that the subdivision of thepowers of the test lenses into quarter dioptres is superfluousand practically needless. This reminds one of the remarkmade by the rich man who wondered why farthings werecoined. Let the point be referred to a patient sufferingfrom a small amount of mixed astigmatism, and who useshis eyes many hours daily in the performance of delicate ’iwork. I am content to abide by his verdict, provided hehas had the opportunity of comparing the comfort afforded by accurately adjusted spectacles with that obtainable from ’,those which only approximately neutralise his error. I cangive copious examples of cases of this kind in which 0’25D, more or less, makes the greatest difference as regards both vision and comfort. It is sometimes pleaded that is only anarbitrary standard of emmetropia. So it is; and if we canget our patients to read so much the better.The employment of keratoscopy, more properly called the

shadow test, should never be neglected in estimating anerror of refraction. It offers good and reliable data, andreally occupies no greater time than the rough-and-readyplan. While speaking of keratoscopy, I should like todispel an idea which seems to a certain extent prevalent-viz., that in the case of hypermetropes the latent as well asthe manifest (i.e., the total) hypermetropia can be computedwithout paralysing the accommodation. This is not so whileany accommodation remains. I admit that the + lens,which apparently accurately corrects the hypermetropia bykeratoscopy, is probably a rather stronger one than could beused by the patient to read 6/6 But if the eye be sub-sequently placed under the influence of atropine, it may befound that a still stronger one is needed to obtain the sameacuity of vision. The reason of this, I take it, is that lightstimulates to a less extent than does the effort to read thedistant types.In conclusion, I maintain that no pains, no time, and no

patience should be economised in ascertaining, to the veryutmost of our ability, the exact condition of the refractionwhen called upon to prescribe spectacles. Our motto shouldever be : " Quicquid assequitur manus tua ut facias profacultate tua fac."

___

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. MARY’S HOSPITAL.LAPAROTOMY IN CASES OF DOUBLE TUBERCULAR PYO-

SALPYNX AND STRANGULATED FEMORAL HERNIA.

(Under the care of Mr. PEPPER. )

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor-borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inte"’ se comparare.__MORGAGNI De Sed. et Caus. Morb., ,

lib. iv. Procemium. ________ j

TUBERCULAR disease affecting the Fallopian tubes to anextent sufficient to demand their removal is of extremelyrare occurrence, and therefore the first case is an impor-tant one. It is not, however, an unusual experience forthe pathologist to find the disease existing on one or both

sides to a slight extent, but associated with a general tuber-culosis, and not of itself producing symptoms. Referencesto this particular affection of the Fallopian tubes are few.Dr. Kingston Fowler, in a paper read before the MedicalSocietyl in 1884, brought forward fifteen cases of disease ofthe Fallopian tubes which had come under his observation,and, with reference to their possible tubercular origin, con-sidered it probable that in some the primary change was ofthat nature. Other cases are recorded in the PathologicalSociety’s Transactions and elsewhere,3 sometimes asso-

ciated with tubercle of the uterus. Dr. Griffiths, in apaper read before the Pathological Society on Nov. 6th,4on Tubercle of the Ovary, said that the most com-

mon seat of tubercle in the female generative organswas the Fallopian tube, then the uterus, and lastly theovary. The other causes given for pyo-salpinx5 are :

chronic catarrh of the vagina or uterus, gonorrhoea, exan-thematic disease at puberty, inflammatory mischief in thepelvis in the post-puerperal state, infantile condition of theuterus, or stricture of the cervical canal. The complicationwhich arose in consequence of the slipping of the ligaturein the second case was one which demanded prompt andenergetic action, and it is fortunate when such an acci-dent, if it occurs, is recognised whilst the patient is on theoperating table. The only procedure open to the surgeon isto secure the bleeding point at once, by the abdominalsection in a case of femoral hernia, or by the enlargementof the wound in hernia in the inguinal region.CASE 1. Double tubercular pyo-salpynx laparatomy;

removal of uterine appendages ; recovery.-Emily L ,aged thirty-one, a nurse, was admitted on April 15th, 1888.She was in the hospital four years ago for strumous diseaseof the left sterno-clavicular joint; arthrectomy was per-formed, the wound healed, the joint became ankylosed, andshe had no further trouble for two years. At the end ofthat time a small abscess formed in the cicatrix, and wasopened, leaving a discharging sinus, which never healed.Four months before admission the amount of dischargecommenced to increase, and she began to suffer considerablepain.On admission the patient was pale and careworn. There

was an old cicatrix between the origins of the two sterno-mastoid muscles, and one inch and a half below this a reddepressed scar, with an orifice discharging pus. There wasslight swelling over and around the manubrium, butneither redness nor fluctuation. The left upper angleof the manubrium was wanting, and the sternal endof the left clavicle was irregular in outline. In theright iliac fossa was a painless swelling. This had beenknown to exist for fifteen days. At the beginning ofthat period she had considerable abdominal pain and asharp attack of fever. The swelling referred to was semi-fluctuant ; it occupied the true pelvis and the inner part ofthe right iliac fossa, but it did not reach down to Poupart’sligament. It could be swayed somewhat from side to side. Onvaginal examination it was found to be connected -with thebroad ligament. There was also a smaller swelling ofsimilar character on the left side. On aspirating throughthe abdominal wall some thick pultaceous matter wasextracted, which proved to be inspissated pus. There wasno disease of the lungs. The facts obtained by the aboveexamination, taken with the previous history, led to theconclusion that the patient was suffering from tubercularpyo-salpynx.On May 2nd patient was placed under an anaesthetic and

laparatomy performed. The great omentum was fixed byrecent adhesions at its lower edge to the parietal peri-toneum ; on separating it two tumours were exposed, thaton the right being as large as an ostrich’s egg, the one on theleft the size of a goose’s egg. The one on the right side wasremoved first; it was adherent in front to the omentum,behind to the intestines, and on the outer side to theabdominal wall. The adhesions were gradually torn

through, and as the tumour was very tense it was aspirated.This done, and all the adhesions having been divided, thetumour was easily drawn out of the wound; it was attachedto the right upper angle of the uterus by a narrow pedicle(the undistended portion of the Fallopian tube); this wasligatured and divided, and the mass removed; attached;to

1 THE LANCET, Vol.i., p. 800.2 Ibid., 1885, Mr. Silcock, p. 303 ; 1886, Dr. Kidd, p. 857.

3 Ibid., 1884, vol. i., p. 800 ; 1888, vol. i., Feb.4 Ibid., vol. ii., p. 914.

5 Ibid., 1887, p. 777 : Tait, who refers to Sänger. New York Academyof Medicine: Wyllie.

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it was the ovary. On cutting the latter open, it was foundto be of a dark-red colour from recent hæmorrhage. Thetumour on the left side was next removed in the same way;there were very few adhesions, and, as on the other side,the inner part of the Fallopian tube was not dilated. Theleft ovary was cystic. The abdominal cavity was thencarefully cleansed with 1 in 3000 perchloride of mercurysolution, and the wound closed. Silk ligatures and sutureswere used ; no drainage tube was inserted. The operationlasted two hours and a half; it was rendered tedious by theextensive oozing from the adhesions, some of which wereold and fibrous, but the greater number consisted of vascu-larising lymph.The patient slept fairly well the night following the opera-

tion, having had the third of a grain of morphia adminis-tered hypodermically. She made a rapid recovery, thewound healing by first intention and the temperature neverreaching 100°. On June llth she got up, and was dis-charged, wearing an abdominal belt, on July 19th. Sinceleaving the hospital the patient’s general condition hasgreatly improved.CASE 2. Strangulated femoral hernia; herniotomy ; hamor-

rhage into peritoneal cavity,’ laparotomy ; recovery.-Jane B-, aged fifty-three, was admitted on June 19th,1888. She had suffered from a right femoral hernia forfifteen years, but had never worn a truss. The hernia hadalways been easily returned. On the 17th she commencedto have pain in the abdomen and to vomit, the hernia be-coming irreducible. She gradually got worse, the vomitbecame stercoraceous, and she was brought to the hospital.On admission, there was a large femoral hernia on the

right side; taxis failing to reduce this, the patient wasplaced under an anaesthetic, and it was again tried, butwithout success. Herniotomy was therefore performed, andthe sac opened; it contained a small piece of congestedintestine, which was returned, and a large mass of omentum.The latter was ligatured in two pieces with catgut andremoved. On completing the division the stump seemed tospring back into the abdominal cavity, and one of theligatures separated. This was followed by welling up ofblood in the wound. The patient became blanched. It

being impossible to find the retracted omentum, the abdomenwas opened in the median line below the umbilicus by anincision four inches in length; the omentum was now easilyfound, drawn out of the wound, and the three bleedingarteries secured with silk ligatures. The abdominal cavitywas then rapidly but thoroughly sponged dry, and themedian wound entirely closed with sutures; the wound inthe groin was partly closed, and a drainage tube inserted.With the exception of the formation of a small abscess atthe lower part of the abdominal incision, the case pursuedan uninterruptedly favourable course, both wounds werehealed at the end of a month, and the patient was dischargedwell, wearing an abdominal belt, on Aug. 9th.

Mr. Pepper, in his remarks on the case, said that in futurehe would never again use catgut ligatures in abdominaloperations, and he related several instances in which acalamitous ending had resulted from the slipping of gutligatures. He insisted on the necessity of at once grapplingboldly with such an emergency as the one under notice,and deprecated the practice of resorting to external pressureand internal haemostatics.

CALCUTTA MEDICAL COLLEGE HOSPITAL.LARGE VENOUS ANGIOMA OF ARM; OPERATION; RECOVERY;

REMARKS.—TRAUMATIC VENOUS ANEURYSM;OPERATION; RECOVERY; REMARKS.

(Under the care of Dr. K. MCLEOD, Brigade Surgeon.)THE following are cases of considerable importance as

illustrative of rare conditions of disease of the veins, andthe account of them will be attentively perused by theprofession. The notes were taken by Assistant SurgeonA. K. Shah a.

Extensive venous angioma of left arm; partial excision ;suppuration.. primary abscesses of left arm, forcarm, andhand; secondary abscess of right knee joint; recovery.-Suresh Chunder D-, a healthy-looking male child, agedtwo years and nine months, was admitted into the firstsurgeon’s wards on March 9th, 1888, with an extensivemævus involving almost the whole of the left upper extremity.The child was born with a purple spot over the left pectoralis

major muscle and a soft swelling of the index and middlefingers and palm of the left hand. These swellings increasedand extended until they attained the present dimensions.At nine months iron was injected into the palm withoutbenefit, and during the last year several severe bleedingshad taken place from the chest swelling-one to a dangerousextent.On admission the child was apparently healthy; liver

somewhat enlarged ; no sign of anaemia. There was a soft ft

doughy swelling about the size of a hen’s egg under theleft clavicle, which collapsed on steady pressure. The skinwas very thin, and of a purple colour over the most

prominent part of it. (It was from this spot that thebleedings took place.) Around this patch the skin was thin,adherent, and blue, and several large blue veins were seenin the neighbourhood. The swelling passed down to thearm in the course of the cephalic vein, and occupied thewhole of the flexor aspect of the arm and forearm, causingconsiderable increase of circumference, and presenting adull-blue colour. The palm and dorsum of the hand weremuch swollen, and the index and middle fingers greatly in-creased in size, soft, blue, and separated from each otherand from the other digits. The first three metacarpal boneswere separated from each other by the swelling. The musclesof the extremity appeared to be wasted.

After consultation with Dr. D. O’C. Raye, the propriety ofremoval of the whole extremity by amputation at theshoulder joint was pressed on the child’s father; but hewould not consent to this measure; and, as an alternative,immediate excision of the oldest, most isolated, and mostdangerous portion of the tumour--namely, the pectoral-was proposed, leaving the remainder to be dealt with after-wards as might appear advisable. To this proposal consentwas obtained. Accordingly the skin was carefully dissectedoff the surface of the tumour, with the exception of the centralpatch; the nsevus was isolated, and its base transfixed bycatgut ligatures, which were firmly tied. The tumour wasthen removed by scissors. A ligature was passed belowthe prolongation of the tumour downwards about half aninch from the margin of the wound and tied tightly. Thewound was dressed antiseptically for granulation, and thehand, forearm, and arm carefully bandaged. Very littleblood was lost, every bleeding point being secured by aSpencer Wells’ pressure forceps as the operation proceeded.The child was detained seventy-eight days in hospital,

during which time the following local events occurred.The discharge was moderate, and no bleeding took placefrom the wound at any time. The tissues, which had beenligatured, sloughed, but the sloughs separated and thewound healed slowly but kindly by granulation. Theloop which had been placed below the wound causedsuppuration, and a sinus resulted, from which a little bloodcame one day, but it eventually healed. The arm and forearmbecame more swollen and firm, also tender, and it appearedas if thrombosis had occurred throughout the tumour.About the fourteenth day this swelling subsided and theextremity had a shrivelled look. On the eleventh day theright knee was observed to be painful and swollen. Thiscondition grew worse, and on the twentieth day thejoint was found to be full of pus, and a free incisionwas made into it, a drainage tube inserted, and anti-

septic dressing applied. On the thirty-second day a

fluctuating swelling was discovered at the lower end ofthe forearm, on the flexor aspect, at the site of the mevus.It was explored. Pus was discovered, an incision made,and a drainage tube inserted. On the thirty-ninth day asimilar abscess was discovered above the elbow, and simi-larly treated. On the forty-eighth day a large abscess wasopened below the right knee. On the fifty-flist day twoabscesses of the arm were opened which had formed in thesituation of the original swelling. On the fifty-third dayanother abscess of the forearm was discovered and opened.Subsequently three small collections were found and opened,one on the ball of the thumb, one on the back of the handbetween the first and second metacarpal bones, and one onthe left arm. All these abscesses formed where the tumourhad been. They were thin walled, and their cavities werelarge, and collapsed very readily. When the patient wasdischarged on May 26th they had all healed with the excep-tion of four-one of the axilla, one of the arm, one of theforearm, and one of the right knee, which were small, short,and discharging very slightly. During this time the patientunderwent severe constitutional disturbance. Pvrexia of aremittent type set in early and continued throughout,