OPHTHALMOLOGY.

OPHTHALMOLOGY.

315 The test had had considerable usage and was found of great value in testing defective children, for it required the minimum mental response. The t...

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315 The test had had considerable usage and was found of great value in testing defective children, for it required the minimum mental response. The test card is made by Messrs. Curry and Paxton of London. Mr. BISHOP HARMAN also showed

given sign by holding out its fingers.

A Typo)neter for 1’lleasecrind Print. the He said report of the British Association on school books had necessitated some simple mode of making small measurements with ease. The instrument shown gave a high magnification of the print and a quarter millimetre scale simultaneously. It was made by Messrs. Dixey and Wingate of London. Mr. BISHOP HARMAN also showed

Mr. PARSONS thought that post-operative epiphora was in to the duration of the dacryocystitis. Mr. BISHOP HARMAN said he had demonstrated that this epiphora was in some cases due to the canaliculi acting He made a as test tubes for the breeding of microbes. routine practice of destroying these channels as the final step of the operation. The insertion of a probe into the sac formed the best guide during incision. Mr. DEVEREUX MARSHALL said that concretions due to streptothrix were a frequent cause of trouble, and these wereeasily cured by expression and washing with mercurial

proportion

solutions. Dr. S. E. WHITNALL

described the anatomical sac, and said that it of bone within it; there might.

(Oxford)

arrangements of the fascia covering the

was not rare to find a spicule Presbyopes who Habititally wore Distance even be a bony bridge. Mr. CHARLES WRAY (London) maintained that local Spectacles. It consisted in two small D-shaped lenses set in a frame with anaesthesia was quite sufficient for these operations; hea double bridge, the whole so arranged as to be slipped agreed with Mr. Harman that a probe placed in the sac between the distance glasses and the face and provide formed a valuable guide in operating. The PRESIDENT said that in his opinion the routine temporary bifocal glasses. It had no hooks or handles and could be put in position and removed by one hand. This excision of the sac was wrong. It was a confession of failure on the part of the surgeon. He detailed his methods was also made by Messrs. Dixey and Wingate. of using styles, which afforded complete relief without any THURSDAY, JULY 24TH. persistent epiphora such as was confessedly common afterexcision. Dr. HARRISON BUTLER opened a discussion on the Dr. F. W. EDRIDGE-GREEN (London) read a paper on Treatment of Chronic Dacryocystitis. A Critieism of the Board of Trade Eyesight Tests, He said that it was a remarkable fact that the treatment advocated by Anel and Percival Potts in the eighteenth and moved the following resolution:"That the sight tests century was for the most part the best-known treatment of of the Board of Trade are not satisfactory, and that an to-day-i.e., regular syringing. Later on this excellent inquiry is urgently needed in the interests of the mercantilepractice was forgotten, and there were introduced crude modes marine and of the nation." He said that the tests both for of treatment that had only recently been done away with. form and colour were defective ; they allowed defective men He distinguished between the causes and treatment of to pass and failed men who should pass. They were so lacrymal obstruction in infants and adults. The former was uncertain that men never knew their position. He said that nearly always due to incomplete patency of the duct, which experience showed that at least 50 per cent. of thecould be remedied by the use of the probe once and one or dangerously colour blind could pass the official wool test two syringings on subsequent occasions. In adults it was even in its modified form. Mr. DEVEREUX MARSHALL seconded the resolution. He probable that very many cases were due to chronic inflammation of ’the ethmoidal cell. In the East it was commonly said the facts were proved ; the Board was convicted out of due to trachoma, and then the only treatment was excision ; its own mouth, for the inefficient lantern test which they badprobing or syringing was dangerous. He deprecated the introduced, apparently as a last resource, increased their practice of slitting up the canaliculus; it destroyed the percentage of rejections from 8 to 6.2 per cent. natural action of the punctum ; also styles were of doubtful Mr. BISHOP HARMAN said that he had experimented, with utility. He discussed Toti’s operation for producing an the three-colour lantern test of the Board and found that artificial communication between the sac and the nose, and colour-blind persons could distinguish the colours by the said that though ideal it was very difficult and tedious. The variations in luminosity. method of excising the sac was discussed. Dr. HARRISON BUTLER said that seeing an officer had to Lieutenant-Colonel R. H. ELLIOT, LM.S., said at his name colours at his work it was ridiculous that this naming clinic 900 cases of excision had been done in the past nine test was practically barred in the official tests. The PRESIDENT congratulated Dr. EDRIDGE-GREEN on his. years with the best of results. 78 per cent. had been removed entire, and in only 0’ 55 per cent. had a second operation persistence in his excellent work. In his view "incombeen necessary. Any form of prolonged treatment, such as prehensible" and Board of Trade" were interchangeable terms. Their failure was due to the fact that the testinglavage, was impossible in India. Mr. C. HIGGENS (London) said that he had done Toti’s was done by ignorant laymen who would fail to appreciate: operation and thought it excellent, but it was certainly very efficient tests. Mr. PARSONS thought jeers at the Board beside the mark;lengthy. Dr. J. McREYNOLDS (Texas) had seen good from the he maintained that the criticisms levelled at the modified’ tests were made in ignorance of their real nature and of the judicious use of large probes. Mr. S. H. BROWNING (London) spoke of the use of report thereon. He agreed that medical men would provide bacterial vaccines. Pneumococci were the most frequent the best examiners, but expense was a consideration. Dr. W. H. BRAILEY (Brighton) said that the argument invading organism, and for these vaccines were of little value ; but for cases of streptococcal and staphylococcal that appeals against rejections were few was no argument in favour of the Board’s tests, for the men had to pay the costs origin vaccines were often of great value. Dr. ELLETT (Memphis) described a method of rapid of the appeal. dilation of the duct at a single sitting. The resolution was passed with one dissentient. Professor WEEKS said cases of tuberculous origin Dr. INGLIS POLLOCK read a paper on the were not common in his experience. In excision the Persistence of the Nerve Plexus of the Iris after Excision of main difficulty was the haemorrhage ; it could be checked by the Ciliapy Ganglion and of the Superior Cervical Ganglion. local use of adrenalin provided the tissues beyond the The fact that there was this persistence argued that the area of the were not Troublelegitimate operation injured. plexus was of the same nature as the plexus of Auerbach some epiphora might remain, which was serious with private and Meissner in the intestines. but not serious with Sometimes patients, hospital patients. it was necessary to remove part of the tear gland. FRIDAY, JULY 25TH. Mr. R. J. WHITING (London) spoke of the difficulty of Discussion on the Question of Excision in Cases of distinguishing between diverticula of the sac and cysts of Injury to the L’ye. the ethmoid cells. Tapping the latter had produced fatal

An AttaoAment for



meningitis.

Dr. INGLIS POLLOCK said that it was not commonly necessary to excise the sac in private cases because these came for treatment early, when they were still amenable to

lavage.

-

Mr. M. L. HEPBURN (London) opened with a paper on the Clinical Aspects. After detailing the variety and degree of injuries met with, he said that the question of excision was a wide one irrespective of the question of the liability to sympathetic disease. Even if there were no perception of

316 in the injured eye it was justifiable to try to save the eye, for a blind eye was better than an artificial eye in that it presented less deformity and caused less bother. He attached no importance to the so-called dangerous area " for wounds. Penetrating wounds were the most dangerous and the most liable to be followed by sympathetic symptoms. He considered the limit of temporising before excision in these cases was six or eight weeks ; if irritation persisted to that time excision was necessary. He knew of no real distinction between sympathetic irritation and ophthalmitis ; it was merely a question of degree. Mr. R. AFFLECKGREEVES (London) followed, dealing with the Pathological Aspects. He had examined the eyes excised for injury at Moorfields for several years and found that the pathological features described by Fuchs were present in all those in which there had been a definite suspicion of sympathetic trouble. The pathological changes were typical and different from any other form of uveitis. The earliest date of the appearance of these changes was one week after injury ; once it was as late as four years, and Itwice 24 years after. The really dangerous clinical condition ’he believed to be incarceration of the iris, lens, or vitreous. ’The injury need not necessarily be extensive ; it might be in xthe cornea only. The true features of the disease were not )-found in cases of sympathetic irritation, and it was noteworthy that these symptoms were immediately checked on excision of the injured eye. Mr. S. H. BROWNING (London) dealt with the Blood ConEditions in Sympathetic Disease. There was a definite assouciation of an increase in the large mononuclear cells with >’sympathetic ophthalmitis, a fact that suggested a protozoal origin for the disease. Acting on this indication, salvarsan had been used in treatment with good, even striking, success l in-some cases. Full and repeated doses were necessary. ’Mr. BISHOP HARMAN dealt with the Case as Regards ’Children. He said that one’s views were the effect of experience. His views were largely affected by the experiences - of cases seen in the Blind Schools of London. As many as 16 children had come there blind from this one cause, and he maintained that there was no "conservative surgery" ,in permitting children to go blind for the sake of the uncertain benefit of saving an injured eye. With such an < experience as these cases afforded he felt that they should ,take for their guide a variation of a Bible passage : " If thine eye offend thee pluck it out ; it is better to enter into life ,with one eye than, having two, to be cast into the hell of

light

.

Fblindness."" Dr. MADDOX considered there was a real importance in 1’the "dangerous area "; 90 per cent. of the bad cases were ’due to injuries to the ciliary region. The extent of the injury was no guide to the liability to sympathetic trouble. -En his experience it was most likely to appear in eyes that ’a’emained soft, and he suggested that raising the tension in ’such eyes might fortify them. Lieutenant-Colonel ELLIOT deprecated an excess of surgical interference in injured eyes. Antiseptics, atropine, and rest afforded the best treatment. Further, if there was serious damage the eye should be excised ; they had no right to throw the risk on the patient. Excision was difficult in the East owing to religious prejudices, and evisceration of the
glaucoma. HARRISON BUTLER discussed the connexion of sympathetic irritation and ophthalmitis, and quoted a case that indicated that they were the same in nature. He disagreed with Mr. Harman in the seriousness of the prognosis in injuries to the eyes of children ; they recovered well. Mr. DEVEREUX MARSHALL said that in his experience .children with injured eyes were very bad patients and caused :great anxiety. He considered the treatment of sympathetic - symptoms with salvarsan distinctly hopeful. Professor REEVE paid a tribute to the work on the blood done by Mr. Browning. So far he had not had similar success with the method, but he hoped for better results. He agreed children suffered badly. Mr. H. H. TAYLOR (Brighton) asked what the advocates Dr.

of "conservative surgery" felt when they had a case of sympathetic and resultant blindness. It was far better to excise early than to take these serious risks. Dr. BRAILEY gave an account of his method of checking the He always fixed a piece of results of X ray examinations. material of the same nature as to supposed foreign body to the eyelid. This gave a valuable check to the findinge. Lieutenant-Colonel PRIDMORE expressed agreement with Mr. Harman’s views on injuries to children’s eyes, and urged that no risks should be run. Mr. WHITING detailed the case of a girl who had an eye grievously wounded 13 days before she was seen. Excision was done, but irritation was apparent in the other eye ten days later. Two injections of neosalvarsan checked the trouble. The PRESIDENT said that injuries to the back of the eye had been described as free from the risk alluded to, but he had experience to the contrary. Perchloride of mercury he thought a bad antiseptic in any sufficient strength, for it was far too irritating. A paper by Dr. A. F. MACCALLAN (Cairo) on An Operation for Ectropion of the Lower Lid in Trccchnnrrz was read by the Secretary. Dr. HARRISON BUTLER read a paper on Holt7i’s Punch Operation for Glcccconacc, and showed an improved punch made to his design. He detailed the steps of the operation, and maintained it was easier and superior to trephining. Dr. BRAILEY said he had done a similar operation for some time, using Harman’s" twin-scissors " and snipping off the resulting scleral flap. He found it very successful. Lieutenant-Colonel ELLIOT said the danger of the operation lay in the use of the keratome and the fact that the shelving incision weakened the eye. Mr. BISHOP HARMAN said that, like Dr. Brailey, he had done a similar operation with the twin-scissors as his routine practice. He denied that there was ever any sign of weakening of the eyeball as suggested by Lieutenant .Colonel Elliot, and failed to see that in proper hands the keratome was dangerous ; in fact, he found it an invaluable instrument. Trephining had the defect that pressure was put on the eye. Dr. McREYNOLDS said he was accustomed to fix a thread in the sclera and excise the piece with a knife ; no special instrument was necessary. Mr. HEPBURN said that the keratome was a dangerous instrument in case of shallow anterior chamber. The PRESIDENT said he was grateful for Elliot’s trephining operation ; he now did no other for chronic glaucoma. He acknowledged there was a danger from pressure during the cutting. As for the keratome, the danger lay in its wrong usage ; when properly used it was a valuable instrument and capable of fine work. The meeting concluded with a vote of thanks to the President and the officers. ___

DERMATOLOGY.

WEDNESDAY, JULY 23RD. President, Dr. J. H. SEQUEIRA (London). In his introductory address the PRESIDENT drew attention to Sir Malcolm Morris’s appeal in THE LANCET and to the subsequent petition signed by 40 eminent physicians and surgeons for a Royal Commission to investigate venereal disease. He also alluded to pellagra and the recent work

showing the presence of that hitherto unsuspected disease in Britain. Dr. H. G. ADAMSON

(London) read a paper on

F,a?igotts Infeetioits 0/ the Glabrous S’kin. He said that fungous infections of the skin and its appendages included various forms of ringworm of the scalp, the beard, and the nails ; several varieties of favus; several forms of ringworm of the glabrous skin; ringworm of the groin and the extremities ; tinea versicolor and erythrasma ; the serious diseases-actinomycosis, blastomycosis, and sporotrichosis. Fungous infections of the glabrous skin were considered under four headings: (1) Tinea circinata and pityriasis versicolor ; (2) ringworm of the groins and extremities and erythrasma; (3) favus ; and (4) actinomycosis, sporotrichosis, and allied diseases. Photographs of the various types of tinea circinata and ringworm of the skin were exhibited.