ACCURACY IN ESTIMATING ERRORS OF REFRACTION.

1064 coated white.

Sleeps and takes nourishment well. Feels and has some relish for food. The medicinal treatment now consisted of fifteen grains of quinine and three minims of tincture of digitalis in an ounce of water thrice a day. A cold bath was again given, with a view to the prevention of rise of temperature; at 9.45 A.M., before the bath, it was 99-6°; just after it, 97°; at 5 r.M., 101°. On Feb. 3rd the temperature was 100’4°, and the cough was better. He continued to improve, and on the 6th the digitalis was omitted. On the 7th a mixture containing five grains of quinine and five minims of tincture of the pernitrate of iron, in half an ounce of infusion of chiretta, was prescribed; and iodine liniment painted on the chest. On the 8th it was recorded that the signs of pneumonia .&c. had nearly disappeared. On the 16th an examination ,of the chest showed only some slight hydrothorax, for which the painting of iodine was advised to be continued, with a little iodide of potash and squill internally. Rentarks.-The case is of interest in its diagnostic and therapeutic aspect. It is one of those cases in which it is ,difficult to pronounce a precise opinion as to whether the fever is a prmiary affection of malarial type, or symptomatic of pulmonary inflammatory disease. Therapeutically, it is of moment as indicating the value of the cold bath, as well as of digitalis, the modus operandi of the latter being, of course, due to stimulation of the inhibitory power of the vagus. The raison d’être of this paper, however, is the result of the microscopic examination of the blood. I had seen these spherical bodies before, and wondered what they were; this was previously to the publication of the most recent contributions on the subject. It struck me that there were two points to be considered-(I) the pigmented appearance, and (2) the amoeboid-like movements and change of form. I thought to myself whether the first-named characteristic might not be due to the hsematin after it had separated (by heat?) from the globin of the haemoglobin of the broken-up red corpuscles. This I viewed in the light of physiology, but I was puzzled about the movements. These resembled the amoeboid movements of living white cells. That the blood undergoes certain changes in all morbid conditions in which the temperature is raised cannot be gainsaid. It is this that we must look to in fatty metamorphosis which takes place in the heart &c. in hyperpyrexia, which I have some years back shown in an article or two published in these columns and elsewhere. But as yet we are in almost entire darkThe red ness as to the precise nature of these changes. corpuscles are doubtless destroyed by high temperature in disease, in much the same way as happens physiologically in health by prolonged residence in the tropics. Whether the iron in it becomes less by separation, or what else takes place, has to be determined by the joint labours of the biologist and the physician. Rabbits and dogs might well be experimented upon by raising the body hungry now,

to graduated heat, by acting upon the thermic nerve centre mechanically, through the agency of drugs, and by the action of septic virus. The results obtained by the opposite experiment of lowering the temperature must also be considered side by side. I should mention that these pigmented bodies were

temperature artificially by subjection

i

absent in this

case on

other occasions when the blood

was

examined, which was done when the temperature was above normal. They were present and absent in other cases of pyrexia-oftener absent than present-without any fixed rule, so that no reliable inference can be drawn from it.

The literature of the subject has been enriched of late years by but few additions. Proceeding on the track of TommasiCrudeli and Klebs, who discovered the bacillus malariae, now about ten years since, Celli and Marchiafava told us in 1884 or 1885 that the blood undergoes certain important changes in malarial fevers and the resulting cachexia. According to them, the haemoglobin of red discs is removed ’ by some process, presumably metabolic or chemical, and a hyaline material is substituted, and this new material cani be easily stained with methyl, whereas in health red corpuscles cannot be stained by any aniline dye; and they further hold that these corpuscles undergo softening and "crenation." However important these researches may’, be from a histological standpoint and aids to future I investigators, they throw little light on the path ofI the practical physician. Later on their researches received confirmation at the hands of Dr. Laveran, a m6deciii-major in the French army, who turned his opportunities at Algiers to very good account by studying malarial fevers there. Dr. Laveran appears to be inclined to regard what he calls

"leucocytes melaniferes"" (the spheroids larger than red corpuscles which I had myself seen and wondered what they were) as white cells pigmented and rendered melanotic. He is very likely right. And my reasons for thinking so are(1) the amoeboid movement of white cells, first demonstrated by our much-respected physiologist, Mr. Wharton Jones,

is

well-known characteristic; (2) there is no reason I believe, the separated colouring matter hsematin from globin escaping from the broken-up red discs and floating in the serum should not be taken up by the white ones, especially when the blood heat is raised. It would, I venture to think, be difficult for an adverse critic to controvert this contention, hypothetical though it may be. Then, again, Dr. Vandyke Carter, in his explorations of the vast clinical and pathological mines of the Jamsetjee Jeejeebhoy Hospital in Bombay, has got them to yield similar results.i He found certain micro-organisms in the blood in ague. Having examined the blood in about 120 cases of malarial and other fevers, it was only in but a small proportion of those more distinctly malarial (in this country I do not think we can very well separate the malarial element) that he found pigmented monads. Dr. Carter is cautious in not hazarding any very definite expression of opinion. The whole subject is of vast magnitude, and demands careful study. Bombay. a

why,

as

ACCURACY IN ESTIMATING ERRORS OF REFRACTION. BY A. ST. CLAIR BUXTON, ASSISTANT SURGEON TO THE WESTERN OPHTHALMIC HOSPITAL.

THE diagnosis and treatment of errors of refraction form large proportion of the work which falls to the share of an ophthalmic surgeon. This fact alone sufficiently emphasises the importance of the subject. It behoves the surgeon to estimate these errors, not merely approximately, but as accurately as is possible. It is not enough that a patient be able to read e. Many myopes, and more hypermetropes, That being an can do this without the aid of spectacles. admitted fact and beyond dispute, it follows that it is easy to find a lens which will enable many an ametropic eye to to read ; but it does riot follow that this lens represents a

the full measure of the error, nor that an over-correction has not been effected by it. When an ametrope readswith. out assistance, one of two things takes place: either the

types

are

not very

clearly seen (being only just sufficiently

well discerned to be recognisable), or else the vision is ren. dered clear at the expense, so to speak, of the ciliary muscle. Uncorrected errors of refraction are productive of many evils, of which it suffices to mention strabismus, spasm of accommodation, headache, and frontal neuralgia. The amount of evil effect is, cceteris paribus, usually strictly proportionate to the degree of error. And yet how fre. quently do we find that patients have been "fitted" with spectacles entirely on the strength of information supplied by subjective tests of the most incomplete kind. It is not surprising, therefore, that a certain number of these patients should acquire a lack of confidence in any gentleman who prescribes for them in this manner. As an act of common honesty, setting aside the higher dictates of humanity, it is the duty of the surgeon to do his very best for his patients. It cannot be logically argued that a man who does not take the trouble to ascertain the exact amount of, at any rate manifest, refractive error is in a position to prescribe the best possible remedy for that error; and, therefore, when an oculist is satisfied with simply finding the first lens which permits his patient to read he is falling short of his duty. It is, unfortunately, not a very rare occurrence to meet with cases of mixed astigmatism in which the myopic meridian alone has been corrected by means of a spherical lens, the hypermetropia being entirely ignored, and of course artificially increased in amount to a corresponding degree. That some patients thus treated can readIhave eon. vinced myself times out of number; and the fact may be easily accounted for on the supposition that the ciliary muscle is capable of what my friend Dr. W. J. Collins very aptly calls "meridianal accommodation." But the thrown on the ciliary muscle soon tells its tale to the t

overwork

1 Scientific Memoirs, part iii.

1065 to seek fresh assistance in other quarters. This is not calculated to elevate the dignity of our profession in the lay mind. To assert that the surgeon who thus treats a fellow creature is using his ability to its utmost in affording relief is either an absurdity I am aware or a grave reflection on his professional skill. that many hold that, because the human eye is but an imperfect piece of optical apparatus, it is sheer waste of time to attempt to correct minute errors. Surely two wrongs do not make a right. It is, of course, easy to understand that a doctrine of this kind is comforting to the conscience of a busy man, but it is none the less unworthy of a scientist. Others, again, affect to consider errors of refraction almost beneath their notice. It is a pity that they do not consider them entirely so. Another argument urged against the necessity for accuracy is found in the statement that" experience teaches us that it is not necessary to the comfort or well-being of the patient that these errors should be so minutely neutralised"; and some go so far as to say that the subdivision of the powers of the test lenses into quarter dioptres is superfluous and practically needless. This reminds one of the remark made by the rich man who wondered why farthings were coined. Let the point be referred to a patient suffering from a small amount of mixed astigmatism, and who uses his eyes many hours daily in the performance of delicate ’i work. I am content to abide by his verdict, provided he has had the opportunity of comparing the comfort afforded by accurately adjusted spectacles with that obtainable from ’, those which only approximately neutralise his error. I can give 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 thatis only arbitrary standard of emmetropia. So it is; and if we can get our patients to read so much the better. The employment of keratoscopy, more properly called the shadow test, should never be neglected in estimating an error of refraction. It offers good and reliable data, and really occupies no greater time than the rough-and-ready plan. While speaking of keratoscopy, I should like to dispel an idea which seems to a certain extent prevalentviz., that in the case of hypermetropes the latent as well as the manifest (i.e., the total) hypermetropia can be computed without paralysing the accommodation. This is not so while any accommodation remains. I admit that the + lens, which apparently accurately corrects the hypermetropia by keratoscopy, is probably a rather stronger one than could be used by the patient to read 6/6 But if the eye be subsequently placed under the influence of atropine, it may be found that a still stronger one is needed to obtain the same acuity of vision. The reason of this, I take it, is that light stimulates to a less extent than does the effort to read the distant types. In conclusion, I maintain that no pains, no time, and no patience should be economised in ascertaining, to the very utmost of our ability, the exact condition of the refraction when called upon to prescribe spectacles. Our motto should ever be : " Quicquid assequitur manus tua ut facias pro facultate tua fac."

patient, who is generally tempted

an

___

A Mirror OF

HOSPITAL

PRACTICE,

BRITISH AND FOREIGN. Nulla autem est alia pro certo noscendi via, nisi

quamplurimas et mor-

sides to

a

slight extent, but associated with a general tuber-

culosis, and not of itself producing symptoms. References

Fallopian

to this particular affection of the tubes are few. Dr. Kingston Fowler, in a paper read before the Medical Societyl in 1884, brought forward fifteen cases of disease of

tubes which had come under his observation, to their possible tubercular origin, considered it probable that in some the primary change was of that nature. Other cases are recorded in the Pathological Society’s Transactions and elsewhere,3 sometimes associated with tubercle of the uterus. Dr. Griffiths, in a paper read before the Pathological Society on Nov. 6th,4 on Tubercle of the Ovary, said that the most common seat of tubercle in the female generative organs was the Fallopian tube, then the uterus, and lastly the The other causes given for pyo-salpinx5 are : ovary. chronic catarrh of the vagina or uterus, gonorrhoea, exanthematic disease at puberty, inflammatory mischief in the pelvis in the post-puerperal state, infantile condition of the uterus, or stricture of the cervical canal. The complication which arose in consequence of the slipping of theligature in the second case was one which demanded and energetic action, and it is fortunate when such an accident, if it occurs, is recognised whilst the patient is on the operating table. The only procedure open to the surgeon is to secure the bleeding point at once, by the abdominal section in a case of femoral hernia, or by the enlargement of 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 disease of the left sterno-clavicular joint; arthrectomy was performed, the wound healed, the joint became ankylosed, and she had no further trouble for two years. At the end of that time a small abscess formed in the cicatrix, and was opened, leaving a discharging sinus, which never healed. Four months before admission the amount of discharge commenced to increase, and she began to suffer considerable the

Fallopian

and, with reference

prompt

pain.

On admission the patient was pale and careworn. There old cicatrix between the origins of the two sternomastoid muscles, and one inch and a half below this a red depressed scar, with an orifice discharging pus. There was slight swelling over and around the manubrium, but The left upper angle neither redness nor fluctuation. of the manubrium was wanting, and the sternal end of the left clavicle was irregular in outline. In the right iliac fossa was a painless swelling. This had been known to exist for fifteen days. At the beginning of that period she had considerable abdominal pain and a sharp attack of fever. The swelling referred to was semifluctuant ; it occupied the true pelvis and the inner part of the right iliac fossa, but it did not reach down to Poupart’s ligament. It could be swayed somewhat from side to side. On vaginal examination it was found to be connected -with the broad ligament. There was also a smaller swelling of similar character on the left side. On aspirating through the abdominal wall some thick pultaceous matter was extracted, which proved to be inspissated pus. There was no disease of the lungs. The facts obtained by the above examination, taken with the previous history, led to the conclusion that the patient was suffering from tubercular was an

pyo-salpynx. On May 2nd patient was placed under an anaesthetic and laparatomy performed. The great omentum was fixed by recent adhesions at its lower edge to the parietal peritoneum ; on separating it two tumours were exposed, that on the right being as large as an ostrich’s egg, the one on the left the size of a goose’s egg. The one on the right side was

borum et dissectionum historias, tum aliorum tum proprias collectas removed first; it was adherent in front to the omentum, habere, et inte"’ se comparare.__MORGAGNI De Sed. et Caus. Morb., , behind to the intestines, and on the outer side to the lib. iv. Procemium. j abdominal wall. The adhesions were gradually torn ST. MARY’S HOSPITAL. through, and as the tumour was very tense it was aspirated. ________

LAPAROTOMY

IN CASES OF DOUBLE TUBERCULAR PYOSALPYNX AND STRANGULATED FEMORAL HERNIA.

(Under the

care

of Mr.

PEPPER. )

TUBERCULAR disease affecting the Fallopian tubes to

an

extent sufficient to demand their removal is of extremely rare occurrence, and therefore the first case is an important one. It is not, however, an unusual experience for the pathologist to find the disease existing on one or both

This

done, and all

the adhesions

having been divided,

the

wound; it was attached pedicle by a narrowthis was

tumour was easily drawn out of the to the right upper angle of the uterus

(the undistended portion of the Fallopian tube); and divided, and the mass removed; attached;to

ligatured

5

1 THE LANCET, Vol.i., p. 800. 2 Ibid., 1885, Mr. Silcock, p. 303 ; 1886, Dr. Kidd, p. 857. vol. i., p. 800 ; 1888, vol. i., Feb. 3 Ibid., 1884, 4 Ibid., vol. ii., p. 914. Ibid., 1887, p. 777 : Tait, who refers to Sänger. New York Academy

of Medicine:

Wyllie.