1297OPHTHALMOLOGICAL SOCIETY.

extremities, abdominal wall, and back pit deeply on

pressure. The face is u,dematous, and presents more theappearance of an erysipelatous swelling of renal oedema.Upon examination of the mouth, deep-coloured ecchymosesare visible beneath the mucous membrane of the softpalate, gums, and cheeks; the gums are spongy and re-tracted from the tpeth; the breath is very foul; tonguedry and brown. There has never been any haemorrhagefrom the nose, gums, bowel, or bladder. The examinationof the chest shows signs of bronchitis and emphysema,and the physical signs of fluid in the pleurse, reachingas high as the inferior scapular angle. Respiration 40.The area of cardiac dulness is diminished; a soft systolicmurmur, with a maximum intensity at the xiphoid cartilage.Pulse 60, feeble, but regular. By examination of the Iabdomen the liver dulness is found to be normal. Theintestines are distended with flatus; and dulness in the iflanks and to within an inch of the umbilicus, with awell-marked thrill on percussion, prove the existence of aconsiderable amount of fluid in the peritoneal cavity.Urine: sp. gr. 1030; acid; deposits urates; no albumen orsugar. Temperature 101°. There is a peculiarly offensiveodour given off from the body. The patient takes foodwell. Bowels regular.May 7th.-Fresh ecchymcses have appeared, most abun-

dantly on the lower extremities. The older patches, parti-cularly those which have coalesced, have developed smallsloughs in the centre, or excavated ulcerp, which dischargesmall quantities of fetid semi-purulent secretion. Sloughshave also appeared on the gums. Pulse 100, weaker; tempe-rature 100 2° ; respiration 30. Patient takes fluid nourish-ment freely, but is more feeble. Voice husky; speechhesitating. The smell from the breath and skin is so over-powering as to render isolation necessary.9th.-The nurse reports that the patient has passed a

restless night. Some muttering delirium. Food is takenbadly. The cough is more frequent. Expectoration scanty;no blood in it. Pulse 120, small and compressible; tem-perature 994°. Tongue dry, brown, and tremulous. Nochange in the urine.During the next twenty-four hours a large slough appeared

upon the scrotum; urine was passed unconsciously ; thepulse became weaker and quicker; delirium more constant,passing into coma; and the patient died on the aftcrnoon ofthe 10th.Necropsy.-Body generally aedematous. Axillary glands

enlarged. Peritoneal cavity distended with blood-stainedserum. Subperitoneal haemorrhages generally. No hae-morrhage under the pericardium or pleurae. Left lungadherent to chest wall. Some clear fluid in pleurae. Bothlungs in a state of general bronchitis and emphy-sema. Heart : catities enlarged, and ventricular wallthin and flabby ; mitral cusps puckered ; other valvesnormal. Both kidneys small and pale; some ecchymosesbeneath the capsule of the right. No ecchymoses under themucous membranes of the bladder or intestine. Spleenlarge and friable. Liver normal. Glands in the mesenteryand splenic glands enlarged and hard. No infarctions inthe organs or staining of the vessel walls.-Remarks by Dr. CURETON.-The diagnosis made on admis-

sion by me was the one accepted by those who saw thecase subsequently. The man’s illness appears to have com-menced with weariness and aching in the lower limbs,followed by no swelling at first, but, on the contrary, areddish rash, developed on the calves of the legs, accom-panied by cough with shortness of breath-that is, a

bronchial catarrh attacking a man the subject of depressedvitality. The chief point of interest in this case arisesout of the ulceration-in fact, sloughing-which tookplace in some of the patches, and at the necropsy wefound blood-stained serous membranes, the latter observa-tion being a common post-mortem sign in scurvy. Anotherpoint of interest was that we had no extensive haemorrhage,such as epistaxis, during life. We also found no infarctionsor staining of bloodvessels as pointing to septicaemia. Icannot find anywhere recorded a case where purpuricpatches have been observed to slough.

WEST HAM HOSPITAL.-The ceremony of layingthe foundation stone of this hospital, in West Ham lane,was performed recently by the Duke of Cambridge.The building is estimated to cost ae5000, and will provideaccommodation respectively for twelve men and women,and two small wards with beds for four boys and four girls.

Medical Societies.OPHTHALMOLOGICAL SOCIETY.

Paralysis of Fifth Nerve, associated with Cataract.-EXO8tO8iS of Frontal Bone and Orbit with an Intra-cranial Growth. - Optic Atrophy in Three Brothers(Smokers).

All ordinary meeting of this Society was held on June 14th,Mr. J. W. Hulke, F.R.S., President, in the chair.Dr.W. J. CoLLINS showed a case of Paralysis of all parts

supplied by the sensory branches of the right fifth nerve;on cles of mastication unaffected. No history of syphilisand no cerebral symptoms. The patient had suffered fromsevere pain in the anaesthetic parts for eight months, andthe sight of the right eye had failed. There had been noherpes and no conjunctival or corneal affection whatever.There was diffuse opacity of the right lens; the left eye andside of the face were normal, and vision was good. Heconsidered that the lesion was located somewhere betweenthe root of the nerve in the pons and the subdivision of theGasserian ganglion. This case conflicted with the views ofSnellen and others respecting trophic nerves. Here thelens, non-innervated, and protected from foreign irritants,suffered, while the highly innervated and anaesthetic cornearetained its pellucioity, notwithstanding eight months’habitual exposure.-Mr. T. PRIDGIN TEALE mentioned acase of cataract in which puncture of one lens was followedby suppuration of the globe. The patient died shortly after-wards with aphasia, due to cerebral haemorrhage, whichwas not entirely recent, but partly resulted from an accidentmany months previously. He suggested that the disastrousresults to the eye might have been the result of the nervouslesion.-Dr. COLLINS briefly replied.

Dr. EnzRys-JoNES mentioned a case, and showed speci-mens, of a large Orbital Exostosis associated with a Myxo-matous Tumour in the Anterior Lobe of the Brain. Therehad been some epileptiform attacks, the existence of whichthe patient denied on account of his anxiety to havethe growth removed. The attempt at removal had to beabandoned, and the patient died five days later from septicmeningitis.-Mr. JONATHAN HuTCHINSON had seen severalcases of exostosis of the frontal bone. In one case of a youngman the exostosis grew into the frontal sinus on the leftside, and was removed by trephining. Later on there grewanother exostosis from the right side, which was early re-moved, but septic inflammation and death followed. Inanother case, that of a young woman. the exostosis was verylarge, and a long time was spent and many saws were usedin attempting to remove the growth, but only with partialsuccess, a raw surface with bony base being left ; thissuppurated and remained open for twelve months, when

L further surgical interference led to the shelling out of theremainder of the exostosis. A deep cavity was left, at thebottom of which some mucous material was seen, but thedura mater remained sound; the eye had been previouslylost. Ultimately the case did well and the wound healed.-

, The PRESIDENT said these cases pointed to the great risk ofinterfering when the cranial wall was perforated. He re-ferred to two cases where the inner table was only involved,,the roof of the orbit being free, in which removal of the

: exostosis was quite easy., Mr. EDGAR BROwNE (Liverpool) read a paper on Opticl Atrophy in three brothers (smokers). In the first patient,! aged forty, vision had failed at the age of twenty-seven. A, diagnosis of tobacco-amblyopia was made. The patient

reduced smoking gradually, but continued to chew. Vision. had steadily failed to shadows, but the pupils were three-. millimetres in diameter, acted to light, and the patellar,, reflexes were good. Previously, vision was good; generals health always good. Optic discs, topical skim-milk atrophy,[ with attenuated vessels. He could see a flame or bright; reflection from white at periphery of fields. The second,

patient was aged thirty-three ; sight became very bad six. months before; he also both smoked and chewed tobacco ;

he could see a little in twilight. The knee jerks were good.! Pupils, three millimetres in diameter, acted to light. The, optic discs showed a general appearance of atrophy; vessels. pervious, but rather small. He could see white paper test

in lower temporal (right) and lower nasal (left) fields, but, not at all centrally. In the third patient vision had failed. for two years, patient being aged twenty-three; could read

1298 CAMBRIDGE MEDICAL SOCIETY.

Jaeger 10. This patient continued smoking when warned.Pupils sluggish, but acted to light. Peripheral fields forwhite ; both eyes normal; central scotoma for white andred in left eye, for red only in right; colour vision withwools good. Optic discs very white and smooth; veinsperhaps a little large. The original assumption thattobacco could cause atrophy had been rather discreditedsince the significance of axial neuritis had been understood.These cases were closely related to the hereditary opticatrophy of Leber (though occurring rather late), but theterm hereditary should not be adopted till our informationwas much more exact. In all three cases tobacco wasprobably the determining cause of the atrophy. In all,perception of light was better towards periphery thancentre; none had visible neuritis; none had cerebral or

spinal symptoms. The father, mother, and two sisters hadgood sight; a collateral relative had suffered. These casesmight be taken as types of one group-namely, those inwhich an axial neuritis, being once established, tended tospread to the periphery fibres, involving both sets in thesubsequent atrophy. Exactly the opposite occurred in

ordinary neuritis, in which the central fibres (and vision)might escape for a time. The following grouping of caseswas suggested: 1. Ordinary tobacco-amblyopia, involvingonly central fibres; transient, and recovery on removal ofthe cause. 2. A class beginning with central negativescotomata, which progressed downwards till central defectbecame positive (or nearly so), and axial atrophy might beassumed, peripheral vision being unaffected. The partplayed by tobacco in these cases required investigation.3. Cases like those under consideration, where retro-bulbarneuritis, beginning centrally, spread peripherally, givingrise to more or less pronounced atrophy. Here the personalproclivity was shown in young persons, members of thesame family. If similar groups were found among non-smokers, search would not be required to discover theexciting agent. Beyond these were (4) consecutive atrophy,and (5) atrophy accompanying spinal degeneration. At

present the two last groups were not understood, but casesillustrating the second and third groups should be collected.--Mr. HuTCHINSON mentioned a group of three, consisting oftwo young males who smoked and the mother of one ofthem (and aunt of the other) who did not smoke, allaffected with optic nerve atrophy. In the case of thewoman the inherited predisposition to nerve lesion musthave been very strong. Eventually she became quite blind,but had very good health. Perhaps abuse of tea or coffeemight have had a share in bringing about this effect; hewas sure that they sometimes caused deafness. He thoughtthe Society might investigate the very rare group of womenaffected with this form of atrophy who did not smoke atall. Mr. Browne had mentioned that his first patient wasa total abstainer. This, in his experience, rather led to theproduction of the atrophy than the reverse; those whoindulged in alcohol as well as tobacco were less liable totobacco atrophy than were abstainers. These cases occurringin families were much more severe, more liable to end inblindness, and much less easily cured than the otherforms.-Dr. EMBYS-JoNES mentioned the case of a familyof nine children, but only five living, in which two childrenhad atrophy of the optic disc without definite cause, thegirl at the age of seventeen and the boy aged nine; totalblindness ensued.—Dr. HABERSHON referred to his paperread at a former meeting of the Society, dealing withhereditary cases of optic atrophy; in some a sexualcause appeared to operate.-Mr. BV ALRER thought thatgreat losses of blood and a numerous family in themother and grandmother might be a cause of opticatrophy in children.-Mr. BROWNE hoped an investigation,as suggested by Mr. Hutchinson, would be undertakenby the Society. Subjects of tobacco-amblyopia had oftenbeen drinking heavily; if they left off alcohol and tobaccothey did well.The following card specimens and living patients were

shown :-Mr. SiLCOCE: (1) Sarcoma of Frontal Bone ; (2) Sarcoma

of both Orbits.Mr. Jassop: Case of Symmetrical Pigment Ring on

Anterior Capsule of Lens.Mr. J. HUTCHINSON, jun.: Two Cases of Cicatrices on

Vitreous and Retinas.Mr. G. E. WALEBB,: Case of Recovery from Occlusion of

Pupil without Iridectomy.Prof. BERGER: (1) Sarcoma of Cornea; (2) a Refraction

Ophthalmoscope.

CAMBRIDGE MEDICAL SOCIETY.

A MEETING of this Society was held on April 6th, Mr. Stear,M.RC.S., President, in the chair.

Urethral Calculus.--Mr. BALDING exhibited a calculuswhich he had removed by perineal section from the urethraof a’man, aged twenty-four, who came under the notice ofMr. F. Davey in consequence of a fistulous opening in thescrotum, about one inch from its perineal margin, dischargingpus and urine. This had existed for about ten days, and thepatient then attributed all his symptoms to bruising hisperineum when getting over a stile about three weeks pre-viously. The calculus, which caused induration and swellingof the whole perineal region, was easily reached through thesinus, and removed by enlarging it sufficiently backwards.The wound healed favourably and has since closed. The mannow considers himself well. The calculus when dry weighed624 grains, and was two inches and a quarter in length and aninch and a quarter in breadth. No satisfactory history couldbe obtained from the patient himself, but that procured fromothers established the fact that from about two to four yearsof age he had constant urinary troubles, and was consideredto suffer from "gravel." Neither the man himself nor any ofhis friends knew of any subsequent symptoms till quiterecently. It would therefore appear that a calculus existedin the bladder during childhood, and that it then passed intothe urethra, where it remained for twenty years withoutproducing any serious trouble, till the perineum was injuredand suppuration followed.A Peculiar Rectal Case.-Mr. STEAR said that one day last

year he was sent for four miles from home to see a patient,a strong, healthy farmer. He stated that he felt quite welluntil atter breakfast, when during the act of defecation hewas suddenly seized with acute and almost unbearable painin the rectum, which turned him very faint. He made hisway into the house and sent for help. The pain was not sosevere then, but was increased on sitting down. He had notbeen costive, and the bowels had been comfortably relieveddaily without any previous pain or discomfort. Except forthe pain, he felt quite well; the temperature, pulse, andtongue were normal. He gave him some laxative medicinecombined with a sedative, and saw him again two daysafterwards, when the pain was much less, though increasedwhen sitting down. On making an examination, he feltabout an inch up the rectum something like a large bentpin. With very little trouble he extracted the substance,which he found to be a bone. It was a rib bone of a rabbitof which he had partaken the day previously.Hydatid Cyst of the Liver.-Mr. C. LUCAS (Burwell)

described this case. Mrs. C-, aged forty-five, who hadhad a previous attack, was seized suddenly, on Dec. 23rd,with pain in the right side, quickly followed by vomitingand prostration. Examination of the abdomen revealedgreat enlargement of the liver, which extended to six inchesbelow the ribs, its outline being visible to the naked eye.Its surface was smooth, and appeared of a stony hardness;there was no fluctuation anywhere; but at a spot four inchesbelow the costal arch in the right nipple line, apparentlyover the gall-bladder, it was exquisitely tender. Dulness onpercussion extended over the right chest in the dorsal andinfra-mammary regions. Breath sounds were faintly audibleover the upper half of the right lung, but absent over the lowerhalf. Heart sounds normal, weak. Pulse 90, weak and com-pressible. Temperature 100°. Tongue slightly coated andsomewhat dry down the centre. Urine scanty, high-coloured,slightly tinged with bile. Bowels relaxed. No jaundice.—Dec. 24th: Jaundice pronounced; pain in side very acute;sickness and vomiting less.-Jan. 26th : Vomiting and painoccurred again with rigors.-Feb. 1st: A circumscribedswelling, about the size of a tea-saucer, was visible overthe region of the gall-bladder, which distinctly fluctuated.-3rd : An exploratory puncture was made with a hypodermicsyringe, and some yellow purulent fluid drawn off; a smalltrocar was then introduced, and twenty ounces of the samekind of fluid evacuated ; the opening was then closed, and aflannel roller applied firmly round the abdomen.-4th: Liverenlargement slightly diminished, but still of a stony hard-ness.—llth : Fluctuation being detected over the right halfof the abdomen, an incision was made three inches below thecostal arch, in the right mammary line, and a large trocarintroduced, being directed upwards and backwards, andabout two quarts of yellow purulent fluid were drawn off;the cavity was washed out with a solution of sublimate (1in 500), and a drainage tube inserted. Under the micro-