10

fore argues that the disposition of these muscles is not suchas to allow them to compress the globe of the eye: " Hadthey been so disposed as to embrace the globe in the form ofa ring, their contraction might then have squeezed the eyeinto an oblong form." Having repeatedly dissected the eyeof the jack, the author is enabled to assert positively thatthe oblique muscles have the very disposition whichDr. Porterfield is here contemplating. His assertion respect-ing their decussation below the eye has evidently arisenfrom his mistaking the inferior rectus for one of the obliquemuscles.A case, indeed, has been quoted in text-books in which

all the muscles supplied by the third pair of nerves wereparalysed, and a good accommodation remained.4 An infer-ence is drawn from this case that the recti and obliquimuscles have really very little power in producing thisaccommodation. But in this case the fourth nerve was notparalysed; and inasmuch as the peculiar function of thefourth nerve is to regulate the degree of compression exer-cised on the eyeball by the superior oblique muscle, thecase affords additional evidence of the real function of thisnerve. In seals the fourth pair of nerves is well developed.The visual focal length would be different in them in the airand in the water for correct vision, and yet a seal cancatch a fish as accurately out of the water as in it.The development of the fourth pair of nerves here corres-ponds with its power of adaptation of the eye to accuratevision under different circumstances. In the monkey, again,where accuracy of vision, in jumping from branch to branch,is so necessary, the fourth pair of nerves is well developed.In the cat, which measures its distance accurately beforemaking its spring, the fourth pair of nerves is also welldeveloped. But here, as in other animals which have atapetum lucidum, the nerves and the muscles which theysupply have another function. They not only regulate theantero-posterior diameter of the eye for the reception oflight entering the eye, but also focus the light reflected fromthe tapetum lucidum.5 The power of concentrating reflectedlight accurately upon an object must give the animal thesame knowledge of distance as the focus obtained inordinary vision. In the flaccid eye of a dead cat the raysof light reflected from the tapetum are nearly parallel. Ifthe antero-posterior diameter of the eye were altered in aliving cat, as by the action of the oblique muscle, the raysof reflected light after they had left the eye would con-verge as they do in the larger eyes of the sheep and the ox;the degree of the action of the oblique muscles in bringingthe reflected rays to a focus would then afford an indica-tion of the distance of the object looked at. The amountof convergence of the two optic axes in binocular visionplays, no doubt, a much more important part in the measure-ment of distance. But by far the larger majority of animalswhich have a tapetum use one eye only at a time. Wherethe two eyes are used together the degree of convergence isunder the control of the external rectus, which, like thesuperior oblique, is supplied by a separate nerve.6Those who have called a policeman’s lantern a " bull’s-

eye have never realised the analogy that exists betweenthe lantern and the real eye. The glare from the anteriorsurface of the cornea may have originated the name. In theliving eye the rays of light reflected from the tapetum may,within certain limits, be concentrated upon any given spot,and the light thus concentrated, as may be illustrated by aslightly concave mirror, is very much more intense thanthat produced by ordinary scattered rays. If a policeman’slantern were constructed with a slide so that the distancebetween the light and the reflector could be regulated, theanalogy would be more perfect. The rays of light mightthen be brought to a focus instead of always being directedin paralleled lines.In ordinary carriage lamps the light is thrown straight

forward, which, no doubt, is an advantage to the driver;but for the horse itself the light is required where theirnatural reflectors throw it-namely, in front of their feet.

4 Power on the Eye. p. 592. 5 Med.-Chir. Transactions, vol. lxix.

In the transmission and reflection of light through thetransparent parts of the eye some light is necessarily lost.If the whole of the light were reflected from a concavemirror three inches square, and concentrated in a focus of’one inch, that inch would receive its natural proportion ofordinary light and nine times the amount of light falling,upon each square inch of the mirror.

Savile-row.

ON DR. BERGEON’S NEW METHOD OFTREATING CONSUMPTION.

all the muscles supplied by the third pair of nerv es were

paralysed, and a good accommodation remained.4 An infer- BY ARTHUR HILL HASSALL, M.D. LOND.,ence is drawn from this case that the recti and obliqui FOUNDER OF, AND CONSULTING PHYSICIAN TO, THE ROYAL NATIONAL

muscles have really very little power in producing this HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST.

accommodation. But in this case the fourth nerve was notparalysed; and inasmuch as the peculiar function of the WITH a view to greater precision and uniformity infourth nerve is to regulate the degree of compression exer- carrying out the treatment of consumption by Bergeon’scised on the eyeball by the superior oblique muscle, the method, I have had some analyses made, the results of whichcase affords additional evidence of the real function of this I will now detail. The analyses were undertaken at mynerve. In seals the fourth pair of nerves is well developed.The visual focal length would be different in them in the air request by Mr. Edwy G. Clayton, F.I.C, F.C.S., assisted by Mr.and in the water for correct vision, and yet a seal can F. T. Knott, and they had for their object the determinationcatch a fish as accurately out of the water as in it. of the quantity of sulphuretted hydrogen contained in theThe development of the fourth pair of nerves here corres- mineral water or other sulphurous compounds used in theponds with its power of adaptation of the eye to accurate process, both before and after injection.vision under different circumstances. In the monkey, again, The analyses of the Eaux Bonnes water used by Drwhere accuracy of vision, in jumping from branch to branch, The analyses of the Eaux Bonnes water used by Dr.is so necessary, the fourth pair of nerves is well developed. Bergeon furnished the following results:— In the cat, which measures its distance accurately before 1. On the gallon.making its spring, the fourth pair of nerves is also welldeveloped. But here, as in other animals which have a a. One gallon of the water containedtapetum lucidum, the nerves and the muscles which they 0.60816 grain of H2Ssupply have another function. They not only regulate the =25.94 cubic centimetres

antero-posterior diameter of the eye for the reception of = 1.58 cubic inch.

light entering the eye, but also focus the light reflected from b. After passing carbonic acid gas, one gallon containedthe tapetum lucitlum.5 The power of concentrating reflected 0.095 grain of H2Slight accurately upon an object must give the animal the = 4.04327 cubic centimetressame knowledge of distance as the focus obtained in = 0.25 cubic inch.ordinary vision. In the flaccid eye of a dead cat the rays 2. On the bottle.of light reflected from the tapetum are nearly parallel. Ifthe antero-posterior diameter of the eye were altered in a a. One bottle (700 cubic centimetres) containedliving cat, as by the action of the oblique muscle, the rays 0.00608 gramme of H2Sof reflected light after they had left the eye would con- = 0.093814 grain of H2Sverge as they do in the larger eyes of the sheep and the ox; = 3.997 cubic centimetresthe degree of the action of the oblique muscles in bringing = 0.2436 cubic inch.the reflected rays to a focus would then afford an indica- b. After passing carbonic acid gas, one bottle containedtion of the distance of the object looked at. The amount 0.000952 gramme of H2Sof convergence of the two optic axes in binocular vision = 0.014689 grain of H2Splays, no doubt, a much more important part in the measure- = 0.623 cubic centimetrement of distance. But by far the larger majority of animals = 0.003836 cubic inch.which have a tapetum use one eye only at a time. Wherethe two eyes are used together the degree of convergence is 3. On the half-bottle.under the control of the external rectus, which, like the a. Half a bottle containedsuperior oblique, is supplied by a separate nerve.6 0.00304 gramme of H2SThose who have called a policeman’s lantern a "bull’s- = 0.046907 grain of H2S

eye " have never realised the analogy that exists between = 1.9985 cubic centimetrethe lantern and the real eye. The glare from the anterior = 0.1218 cubic inch.surface of the cornea may have originated the name. In the b. After passing carbonic acid gas, half a bottle containedliving eye the rays of light reflected from the tapetum may, 0.000476 gramme of H2Swithin certain limits, be concentrated upon any given spot, - 0.0073445 grain of H2Sand the light thus concentrated, as may be illustrated by a = 0.3115 cubic centimetreslightly concave mirror, is very much more intense than = 0.001918 cubic inch.that produced by ordinary scattered rays. If a policeman’slantern were constructed with a slide so that the distance These results show that the amount of sulphurettedbetween the light and the reflector could be regulated, the hydrogen contained in the bottled water corresponded closelyanalogy would be more perfect. The rays of light might with that present in the water taken at the source, accord-then be brought to a focus instead of always being directed ing to the best analyses. This amount is, however, extremelyin paralleled lines. small, it being only 0.1218 of a cubic inch in the half-bottleIn ordinary carriage lamps the light is thrown straight of the water, the quantity usually employed by Dr. Bergeon

forward, which, no doubt, is an advantage to the driver; for a single injection.but for the horse itself the light is required where their After 3 litres of carbonic acid gas had been slowly passednatural reflectors throw it—namely, in front of their feet. through it, the time occupied being twenty-three minutes,

the amount of sulphuretted hydrogen in the half bottle was4 Power on the Eye, p. 592. 5 Med.-Chir, Transactions, vol. lxix. found to have been reduced to 0.001918 of a cubic inch. This6 The advantage of judging of distances in binocular vision has pro- result IS so far satisfactory, since it shows that the greater

bably some compensation in animals, which use only one eye at a time. part of the sulphuretted hydrogen was carried over by theThe more perfect grasp of the eye by the transverse muscles must enable carbonic acid. No combined sulphuretted hydrogen is con-them to focus the rays of light more perfectly than in animals in which the muscles are oblique. The owl, unlike other birds, has its eyes placed tained in the Eaux Bonnes water, and this being so thereforward. This disposition enables it to direct both eyes to the same is no necessity for the employment of an acid, mineral orobject at the same time. It has therefore the advantage of binocular organic, for the liberation of the gas.vision. In common with other animals which seek their prey at night, The first published results of Bergeon’s method of treat-it has within a limited distance the power of judging of the position ofobjects by the angle at which the visual axes meet. ment were all founded upon the employment of the Eaux

WITH a view to greater precision and uniformity imcarrying out the treatment of consumption by Bergeon’smethod, I have had some analyses made, the results of whicbI will now detail. The analyses were undertaken at myrequest by Mr. Edwy G. Clayton, F.I.C., F.C.S., assisted by MrF. T. Knott, and they had for their object the determination-of the quantity of sulphuretted hydrogen contained in themineral water or other sulphurous compounds used in theprocess, both before and after injection.The analyses of the Eaux Bonnes water used by Dr

Bergeon furnished the following results :-

1. On the gallon.a. One gallon of the water contained

0-60816 grain of H2S=25-94 cubic centimetres= 1’58 cubic inch.

b. After passing carbonic acid gas, one gallon contained0-095 grain of H2S

= 4-04327 cubic centimetres= 0’25 cubic inch.

2. On the bottle.a. One bottle (700 cubic centimetres) contained

0-00608 gramme of H2S= 0-093814 grain of H2S= 3-997 cubic centimetres= 0-2436 cubic inch.

b. After passing carbonic acid gas, one bottle contained0-000952 gramme of H2S

= 0-014689 grain of H2S= 0-623 cubic centimetre= 0-003836 cubic inch.

3. On the half-bottle.a. Half a bottle contained

0-00304 gramme of H2S= 0-046907 grain of H2S= 1-9985 cubic centimetre= 0-1218 cubic inch.

b. After passing carbonic acid gas, half a bottle contained0-000476 gramme of H2S

- 0’0073445 grain of H2S= 0-3115 cubic centimetre= 0-001918 cubic inch.

These results show that the amount of sulphuretted’hydrogen contained in the bottled water corresponded closelywith that present in the water taken at the source, accord-ing to the best analyses. This amount is, however, extremelysmall, it being only 0’1218 of a cubic inch in the half-bottleof the water, the quantity usually employed by Dr. Bergeonfor a single injection.

After 3 litres of carbonic acid gas had been slowly passedthrough it, the time occupied being twenty-three minuteo,.the amount of sulphuretted hydrogen in the half bottle wasfound to have been reduced to 0-001918 of a cubic inch. Thisresult is so far satisfactory, since it shows that the greaterpart of the sulphuretted hydrogen was carried over by thecarbonic acid. No combined sulphuretted hydrogen is con-tained in the Eaux Bonnes water, and this being so thereis no necessity for the employment of an acid, mineral ororganic, for the liberation of the gas.The first published results of Bergeon’s method of treat-

ment were all founded upon the employment of the Eaux

11

;Bonnes water. More recently, however, recourse has beenhad to other sources of the sulphuretted hydrogen. Thus,,as we learn from Dr. Burney Yeo’s recent lecture, Dr. Bardethas employed a definite solution of sulphide of sodium.This is made by dissolving 10 grammes of the salt in100 cubic centimetres of distilled water. One cubic centi-metre of this solution contains 10 cubic centimetres of

sulphuretted hydrogen, which is set free by the action oftartaric acid. Of this solution 10 cubic centimetres in200 grammes of water, = 3036 grains, are employed for eachinjection, so that if the whole of the gas were liberated, thequantity injected would amount to 100 cubic centimetres,equal to no less than 6’10 cubic inches. Here is an enor-mous difference in the amount of sulphuretted hydrogenintroduced into the system: in one case less than a quarterof an inch, and in the other over 6 cubic inches.

Dr. Coghill has lately employed a saturated aqueous solu-tion of sulphuretted hydrogen, using It oz. to 2 oz. of thisin 12 oz. of water; and this quantity, he states, has beenwell borne by every patient on whom it has been tried.Now I oz. of such a solution should contain-if the waterwere really saturated at 150 Centigrade and 760 millimetresbarometric pressure (these happening to be the temperatureand pressure at the time the analyses were made)--3’117cubic inches of the gas, and 2 oz. 4’156 inches.

Another substance which has been employed is bisulphideof carbon, but I have not seen any statement as to the.quantity of this reagent that has been used. Its volatility,however, even at ordinary temperatures, is such that a com-paratively small quantity of the liquid reagent (which boilsat 46 6° Centigrade) yields with facility a large volume of.carbon bisulphide vapour.

It is thus seen that there is a great difference in the.amount of sulphuretted hydrogen injected, and yet the.results of the treatment have been reported as equally’favourable in all cases ; the varying amount of the gas usednot appearing to nuke any difference. According to thereports, the frequency of the pulse has been reduced, thetemperature lowered, the night sweats relieved, the expec-toration diminished, the nutrition greatly improved, the I

weight rapidly increased, and a great and surprisingamelioration in every respect has ensued.

Lucerne.

A CASE OF

PERFORATING ULCERS OF BOTH FEETASSOCIATED WITH DIABETES AND

ATAXIC SYMPTOMS.

BY T. DAVIES PRYCE, M.R.C.S.,SENIOR RESIDENT SURGEON, NOTTINGHAM DISPENSARY.

A. D-, aged fifty-six, framework knitter and hawker,was admitted as a home patient on May 27th, 1886. He hadenjoyed fair health up to eighteen months previous to hisbeing treated at the dispensary, with the exception of anoccasional winter cough. For eighteen months past he hadpassed large quantities of urine, and had suffered from greatthirst. He was never of temperate habits, and was addictedto " drinking bouts." He was stated to have led a wild life.No history of gonorrhoea or syphilis could be elicited, butstrong presumptive evidence of venereal taint was presentin the form of two scars, one in each groin, and varioussuspicious-looking marks on both legs. Eight monthsprevious to admission he complained of pain in his legs,and stated that his feet felt dead. At Christmas, 1885, hecaught cold, and suffered from an aggravation of thefoot symptoms, together with abdominal pain and vomit-ing. He was described at this time as walking on hisheels. In February, 1886-i.e., three months and a halfbefore his death - the ulcers of the feet first appeared.When first seen by me the patient was suffering frombronchitis and symptoms of commencing diabetic coma.

The heart sounds were feeble and occasionally intermittent.The arteries of the upper limbs were evidently diseased.The pupils reacted feebly to light. There was diminishedcutaneous sensibility of both feet and also of the lowerthirds of both legs. The knee-jerk was totally abolished.The skin over the legs and feet was of a livid hue, andbelow the normal temperature. A fetid odour emanated

from both feet. The ulcers commenced as corns. One ulcerof the size of a two-shilling piece was situated over theplantar aspect of the metatarao-phalangeal joint of the rightgreat toe. Its outline was sinuous and ragged. The bonesentering into the formation of the joint could be felt at thebottom of the sinus, the metatarsal bone being eroded. Asinus of the same character but of smaller size was situatedover the plantar aspect of the head of the fifth metatarsalbone of the opposite foot. Carious bone could be detected.There was also the remains of a partially healed ulcer on theinner aspect of the left great toe. The patient’s urine wasacid, sp. gr. 1030, contained sugar and a trace of albumen,but no peptone. He died on June 1st (fourth day of treat-ment).of diabetic coma.There was no history of gout, rheumatism, or injury in

this case. The patient had, however, been exposed to allweathers, and in following his occupation of hawker hadwalked a great deal. The spinal cord and the nerves of theright lower limb were examined. The only naked-eyechanges which could be detected were: (1) the posteriortibial nerve presented considerable enlargement in the lowerthird of the leg, and was here partially surrounded by in-flammatory material, in which was also embedded theatheromatous posterior tibial artery; and (2) the plantartermination of the nerves were discoloured, and diminishedin size.The cord and peripheral nerves have been examined by

Mr. Bowlby, of St. Bartholomew’s Hospital, who has demon-strated the following changes. In the lumbar region of thecord there is marked atrophy of the cells of the grey matter,which are granular and have lost their processes. In thedorsal region the change is more advanced, most of the cellshaving completely disappeared. There was no cell exuda-tion in either the white or the grey matter. In the peri-pheral nerves the changes are most marked in the posteriortibial trunk, where the white substance of Schwann is

replaced by granular material which does not stain blackwith osmic acid. Some of the axis cylinders are normal,but many have atrophied and undergone a fatty change.The anterior tibial nerve shows a similar degeneration, butin a lesser degree, and in the sciatic the bulk of the fibresare normal. There appears to be a slight increase of theconnective-tissue basis.

I wish also to mention that Dr. Byrom Bramwell, ofEdinburgh, also describes similar changes in the peripheralnerves in this case, with the addition of well-markedvascular disease. He also found vascular changes in thespinal cord, but no ataxic lesion. It will be seen that thechanges in the peripheral nerves differ from those recordedby Messrs. Savory and Butlin1 in the greater amount of truenerve degeneration, and in the much smaller increase of theconnective-tissue basis.The comparatively frequent occurrence of perforating

ulcer in locomotor atax is well known, but it remains tobe shown whether the ataxia in all these cases is due to atypical tabetic lesion of the cord, or, as is probable in theabove case, to a peripheral neuritis or nerve degeneration.It is abundantly evident that in the case just recorded theactual cause of the perforating ulcers was a peripheral nervedegeneration. It will be seen that a good many of thecauses which have been believed to produce perforatingulcer and peripheral neuritis were also present—i.e., cold,alcohol, diabetes, vascular disease, and continued pressure.It is probable that all these played a part in the causationof the disease, but I would venture to assign a considerableshare to diabetes and vascular disease. Vascular changes havebeen found in a number of cases of perforating ulcer, and havebeen especially insisted upon by M. Pean and other observers.It also appears to me that diabetes may of itself be a causeof perforating ulcer, and this belief is induced by thefollowing considerations: 1. That it is not uncommonlyassociated with locomotor ataxy, in connexion with whichdisease perforating ulcer occurs comparatively frequently.2. That there exists a marked similarity between perforatingulcer on the one hand, and the destructive process of gan-grene on the other, which latter is peculiarly liable to occurIn diabetes. 3. It has been shown that diabetes does occa-iionally produce peripheral neuritis. 4. That another case)f perforating ulcer has been recorded as occurring with

1 Transactions of the Royal Medical and Chirurgical Society of London,vol. lxii., p. 373, 1879.

2 See cases related by Professors Ball and Thibierge (Transactions ofthe International Medical Congress of London, vol. ii., p. 520); Treves(THE LANCET, Nov. 29th, 1884).