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drawing back of the head occurs in cases of meningitis;but plainly, the best cases for investigation of regionallocalisation are cases of small tumour producing a chronicillness.

Occasionally we meet with other local tonic spasms, some-times of the jaws. Of the pathology of these cases I knownothing at all. I would suggest that the cerebellum shouldbe carefully searched as well as other parts in all cases oflocal tonic spasm, including ordinary torticollis.

I think there is evidence that in some parts of the cere-bellum there is a unilateral representation in the order fromtrunk movements to movements of the hands and feet. Ihave no doubt that Brown-Sequard is right in saying thattumour pressing on the crus cerebelli produces paralysis ofthe same side, and I believe this is mainly of movements ofthe trunk and those passing to the upper parts of the limbs.The erratic movements of the arm in some of these casespartly depend, I think, on paresis of muscles attaching thelimb to the trunk.There are indirect symptoms from tumour of the middle

lobe and large tumours under the tentorium. There is vastincrease of fluid in the lateral ventricles of the cerebrum insome cases. In children the head enlarges ; there is greathebetude of mind, a slow failure of mental faculties. ThisI used to suppose was caused by pressure, as the veins ofGalen. Stephen Mackenzie, in an admirable paper on Cere-bellar Disease, recently read before the Hunterian Society,suggests another explanation.

A MODIFIED CLOVER’S BOTTLE FOR THERAPID EXTRACTION OF DEBRIS

AFTER LITHOTRITY.

BY BERKELEY HILL,PROFESSOR OF CLINICAL SURGERY IN UNIVERSITY COLLEGE,

SURGEON TO UNIVERSITY COLLEGE HOSPITAL.

DR. BIGELOw’s bottle and tubes for exhausting debrisafter lithotrity are manifestly a great improvement on theapparatus previously employed for that purpose. The im.

provement consists, first, in providing a wider passage foithe current to and fro between the bladder and the exhaust.

ing bottle; and, secondly, in furnishing a more forciblestream than was possible with the small bottle of Clover.But as Bigelow’s bottle has considerable disadvantages inbeing costly, cumbersome, and especially in being muchlonger than is necessary, it occurred to me that Clover’sbottle might, by some small modifications, be rendered amore rapid exhauster of debris than that of Bigelow. Forsome time before Dr. Bigelow’s visit to this country I hadbeen employing urethral tubes for washing out debris largerthan those commonly used for this purpose, habitually em-ploying Nos. 24 and 26 French, instead of No. 22 or No. 23(Nos. 12 and 13 English), the customary sizes. Consequently,when Dr. Bigelow brought before the profession his rapidmethod of clearing the bladder of debris, I was prepared toappreciate the improvement he has effected in this depart-ment of surgery. By the apparatus which I have now usedon several occasions-the outcome of repeated alterations-I find I can exhaust a given quantity of debris more rapidlythan I can by Bigelow’s bottle. This advantage I attributemainly to the shorter distance the fragments have to travelfrom the neck of the bladder before they are securely lodgedin the trap below the current. The length of the tube fromthe beak to the interior of the receiver is only eleven inches,or twenty inches less than that in Bigelow’s apparatus.The woodcut shows the form of the apparatus very well.

A stout india-rubber bottle, holding ten ounces, with a neckone inch across internally, is fitted to a glass receiver, ortrap, blown into a discoid shape resembling that of a flatturnip or onion, having a transverse diameter of in. Themount of this receiver is closed by a cap, to which thewashing out catheters can be fitted in a joint fastened by abayanet-catch. The catheter is prolonged into the centreof the receiver by a short tube, in. (about No. 40 French)in diameter, to prevent the reflux of the fragments that have ealready been sucked out of the bladder. As the fragmentsissue from the tube they at first swirl about in the receiver,

then fall rapidly into the lower part, where they lie snugand still while the water is being injected again into thebladder to bring forth another quantity of debris. Probablythe main advantage of the apparatus is its shortness. Amoment’s reflection will show that when the outflow ceasespart of the debris sucked from the bladder lies in the tube,to be driven into the bladder again by the next inflow ofwater; consequently the nearer the trap or receiver can be

placed to the neck of the bladder, the more rapid will be theremoval of the fragments. In Bigelow’s apparatus, thereceiver is placed at the farthest extremity of the bottle.This large bottle is placed for convenience of working atthe end of 14 in. of flexible tube. Thus the fragments haveto travel 112 in. along the silver tube, then along 14 in. offlexible tube, making a total distance of 26 in., before theyreach the bottle itself, down which they gravitate during thepauses between each act of injecting and exhausting to theglass receiver placed at the further end of the bottle. Thusthe fragments do not reach the trap or resting-place, untilthey have traversed 31 in. of distance. The tubes I usehave an internal capacity equal to sounds Nos. 24, 26, and30 French (equal to Nos. 14, 16, and 18 English). They areprovided with large eyes, carefully bevelled off to preventtheir gaping edges from lacerating the mucous membrane.Some have the eye placed at the convexity of the beak,some have it at the concavity, and one tube (the largest) isstraight throughout. This I have seldom used, as it is rarefor the urethra to admit its introduction without a pre-liminary free incision of the meatus urinarius, which it isnot always expedient to do. Except in being shorter, andin the lesser sizes smaller, my tubes do not greatly differfrom Bigelow’s, and their mode of attachment to the wash-ing-bottle is copied from Bigelow’s pattern.The woodcut also shows the beaks of a powerful lithotrite

made for me by Mr. Coxeter, for breaking large hard stonethat cannot be safely managed by ordinary lithotrites. Itwas constructed for me in imitation of Sir Henry Thomp-son’s new lithotrite, and in some respect, like other imita-tions, advances beyond the first embodiment of the newidea. His recent alterations on former patterns Sir HenryThompson has already brought before the profession in thiscountry, and on the continent. They are chiefly two.First, the male blade is fitted to slide along the femaleblade until its heel comes flush with the outer surface ofthe beak of the female blade, which is cut away for thatpurpose. By this arrangement fragments cannot lodge norlock the blades, but are driven through the female bladebefore the advancing male blade. The second novel pointis, the knife edge form given to the beak of the male blade.This knife edge enables the male blade to penetrate a hard,bulky stone with facility, and split it into fragments, thatcan afterwards be readily comminuted by the usual litho-trites, which have more pulverising action. The beaks ofthe lithotrite depicted in the drawing differ from those ofSir Henry Thompson’s instruments in having a somewhatsharper knife-edge and a wider notching of the edge ; thereis also a slight jagging of the opposing edges of the femaleblade to afford a better hold of the stone before it is broken.Whether this increased sharpness of the knife-edge is anadditional advantage can only be determined by comparative

trial of the two instruments. Mine was simply an endeavour

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on the part of Mr. Coxeter to produce a lithotrite for methat should embody Sir Henry Thompson’s recent improve-ments, of the value of which there can be no doubt. BothSir Henry Thompson’s lithotrite and the repetition shownin the drawings, while being sufficiently powerful to dealwith the hardest stones, are far less bulky and heavy thanBigelow’s large lithotrite. This power is attained by bettermechanical concentration of the crushing force.Wimpole-street.

ON THE TREATMENT OF DIPHTHERITICOPHTHALMIA BY LOCAL APPLICATIONS

OF SOLUTION OF QUININE.BY JOHN TWEEDY, F.R.C.S. ENG.,

ASSISTANT-SURGEON AT THE ROYAL LONDON OPHTHALMIC HOSPITAL,MOORFIELDS.

TRUE diphtheritic ophthalmia is so rare in this country,and its treatment at all times and in all places so unsatis-factory, that no apology is, I hope, needed for the followingremarks.Until the beginning of last year I had, out of an aggre-

gate of many thousand cases of disease of the eye, seen butone unmistakable example of primary diphtheritic ophthal-mia, and that was in the year 1873. In February, 1876, Iwas consulted about a case of ophthalmia in an infant,which I suspected to be diphtheritic, but was deterred fromtreating it as such in consequence of overwhelming evidenceof its gonorrhoeal origin. More than three years and a half

after-namely, in October, 1879-I accidentally alighted onsome knowledge that tended to strengthen my suspicion, andhas indeed convinced me that, whatever may have been itsorigin, the case was really diphtheritic when I saw it.These were the only cases I had ever seen, either in myown practice or in that of others, prior to those hereinafterdescribed.

I deem it necessary to make this explanation, becausemany cases have been recorded in the medical newspapersand other periodicals of this country, under the nameof diphtheritic ophthalmia, which, in my opinion, were

not diphtheritic at all, but merely cases of purulentophthalmia, accompanied with the formation of pel-licular membranes on the surface of the conjunctiva. Ifthe confusion only involved a question of nomenclature,it would scarcely be necessary to do more than callattention to it in passing; but there is a more importantissue at stake. It unfortunately happens that the treat-ment that is appropriate for the membranous form ofpurulent ophthalmia is, according to the best authorities,highly injurious in the diphtheritic variety. Hence thedanger that lurks in the hypothesis that membranous oph-thalmia and diphtheritic ophthalmia are different phases ofthe same disease. If the caustic treatment, which isuniformly successful in the former disease, be adopted inthe latter, disastrous results will ensue. I cannot perhapscite a better illustration of the sort of case that has beenrecorded by British practitioners as diphtheritic ophthalmiathan that reported in THE LANCET " Mirror of HospitalPractice" for July 5th, 1873, as occurring in the practice ofMr. Streatfeild at Moorfields. This particular illustrationis especially apposite, because there is a long editorialcomment pointing out the essential difference between thecase in question and those described by von Graefe andother continental writers under the same name.l A likecriticism would apply to almost all the other cases that havebeen recorded in this country.My late lamented friend and colleague, Mr. Soelberg

Wells, who, while acting as assistant to Professor von Graefe,in Berlin, had many opportunities of witnessing the disease,used to say that he had never seen a genuine example ofdiphtheritic ophthalmia in this country. I regret that hewas unable to inspect any of those I am about to relateuntil they were nearly cured. It is, however, as I havealready hinted, a mistake to imagine that the malady neveroccurs in this country. At the fourth International Oph-thalmological Congress, held in London in 1872, Dr.

1 THE LANCET, vol. ii. 1873, p. 10.

Samelson, of Manchester, read a paper on some cases oidiphtheritic ophthalmia that occurred in that city during theyears from 1867 to 1871. Dr. Samelson was careful to ex.plain that by the term " diphtheritic ophthalmia " he didnot mean "the so-called membranous conjunctivitis as chaoracterised by the formation of a pellicular membrane andeasily removable recurrent exudation on the surface of a

mostly highly vascular mucosa," but " that specific affectionof the eye for the life-like delineation of which we are in.debted to von Graefe, and the chief pathognomonic featurEof which is the thorough solid infiltration of the parenchymaof the mucous membrane, so almost hopelessly unmanage.able, and so prone to destruction."2This is precisely the criterion by which all cases should b(

judged. Keeping these characteristics in mind, anyone whowill take the trouble to read the descriptions of the so-calledcases of diphtheritic ophthalmia recorded as occurring inthis country, will find that, almost without exception, theyfall into the former category, and that neither in severitynor gravity did they resemble the true form. The cases 1shall relate fulfil, I think, the conditions laid down by Dr,Samelson.On the 15th of February last a puny male child, fou]

months old, was shown to me at the hospital, suffering ap-parently from a moderate attack of purulent ophthalmia oiboth eyes. The lids were red and swollen, but soft andeasily evertible. A thin purulent discharge exuded fromthe palpebral fissures, and the conjunctival sacs contained aconsiderable quantity of the ordinary yellow muco-pus thalis secreted in purulent conjunctivitis of children. The pal.pebral conjunctiva of both eyes was of a bright-red colour,vascular, prominent, and spongy. Both corneae were smooth,bright, and clear. The mother, a small, delicate, and ill.nourished woman, stated that she first noticed the dischargethree days before, and that the child, who was breast-fed,had not previously had anything amiss with the eyes.The case was treated as one of simple purulent oph.

thalmia. The conjunctival sacs were gently but thoroughlycleansed with tepid water, and the surface of the mucousmembranes was lightly brushed with a ten-grain solution oinitrate of silver, and a lotion containing six grains of alumto an ounce of water was given to the mother to use everythree hours. When seen by Mr. Burnham, the junior house.surgeon, on the following morning, the eyes seemed better;although the swelling had in no degree abated, the dis.charge was diminished in quantity, thinner in consistence,and less purulent in character. On the l7th the case wasapparently doing satisfactorily; the lids were again lightlybrushed with a nve-gram solution of nitrate of silver.The child was not seen on the 18th, but on the morning of

the 19th I saw it myself, and was startled to find a markedchange for the worse. The lids were more swollen, andthey had become hot, hard, and shining, and of a reddish-purple hue. A thin, dirty-looking fluid, mingled withgreyish flakes and shreds, escaped from the deep, narrowchink between the upper and lower eyelids. The lids couldhardly be separated, and when they were everted the pal.pebral conjunctivas of both eyes were found no longer redand spongy, but pale, smooth, thick, and mottled with redand grey, the grey vastly predominating. Many smallecchymoses were scattered over the surface, and here andthere were larger or smaller bloodvessels, blocked withstagnant blood. The mottled patches of exudation had anirregular and an ill-defined margin, and extended laterallyalong the whole length of the lids from inner to outer angle,and antero-posteriorly from the free margin, where theywere most pronounced, to the oculo-palpebral fold, wherethey seemed to gradually fade away. They began againnear the periphery of the ocular conjunctiva, and continuedup to the corneal limbus. To the touch, and when com-pressed edgeways between the thumb and finger, theconjunctiva felt hard and resistent. In both eyes the upperlids were the more affected.Moderate friction with lint failed to remove more than a

few insignificant shreds, and left the appearance substantiallyunaltered; nor could fairly energetic friction detach thefalse membrane, which seemed to sink deeply into the con-junctival tissue. Even the forceps failed to strip it off, or toprovoke bleeding. Both cornese were rough and steamy,and had lost their transparency to such a degree that neitherthe iris nor the pupil could be traced. On the right corneathere was, in addition to the general haziness, a well-

2 Report of the Fourth International Ophthalmological Congress, heldin London, August, 1872, p. 127. London, 1873.