500

not retracted and Kernig’s sign is not so marked. A little twitching inleft arm and leg is present. Plantar reflex is extensor on the right side.For two to three days the patient has been drowsy. 31st: Athetosis ofleft hand started. The arm is abducted and the forearm flexed and theathetotic movements take place on the left side of the head. June 1st:Patient became very cyanosed at 1 r.M. and died at 3 P.M. Just beforedeath lumbar puncture-two test-tubefuls of fluid removed. Veryfew lymphocytes-much albumin.Necropsy.-Basal meningitis, exudation of yellowish lymph at base

not spreading into Sylvian fissure but spreading a little over uppersurface of cerebellum. Brain odematous, ventricles contained muchfluid. Direct examination of lymph showed a diplococcus, but therewas no growth in broth. Collapse of lower portion of right lung. Theright bronchus was filled with a thick white material. No sign oftuberculous disease anywhere in the body.CASE 4.-Girl, aged 10 years, under Dr. Humphry. Admitted on

June 3rd, 1911; died on the llth.- Hs<or}/.&mdash;No history of consumption in the family. Patient had

measles 11 months ago and left pleuritic effusion eight months ago.The present illness started with sickness ten days ago and the childbecame constipated. There has been some headache. She has beendrowsy five to six daye. Of late she has wasted. There has been no rash.Examination. -Temperature 990 F., respirations 20, pulse 80. The

child is unconscious and lies curled up on her side, but she can take herfeeds. The pupils are equal and dilated and react to light. The righteye is turned outwards. Tache cerebrale is present. There is no facialparalysis and no retraction of the head. Kernig’s sign is well marked.Knee-jerks are absent and plantar reflex is flexor. There is the scar ofan old perforation in the left tympanic membrane. There is animpaired note over the back of the left side of the chest. The heart isnormal. The abdomen is retracted; the liver and spleen are notpalpable. Lumbar puncture-fluid under pressure, two test-tubefulsremoved ; fluid clear, contained a little albumin, slight reduction ofFehling on prolonged boiling. Meningococcus cultivated from thefluid. Centrifugalisation-very few lymphocytes; no tubercle bacilli.June 4th: Patient unconscious, divergent squint present at times;

now and then there are nystagmoid movements. Slight retraction ofhead; abdomen not retracted. The margins of the optic discs are

blurred. 6th: Child a little conscious; she speaks sometimes. Theright pupil is larger than the left. 8th : Child is not so well. Thepupils are widely dilated and do not react to light. Kernig’s sign justpresent. Patient has a flushed face. Lumbar puncture-half test-tubeful removed. Many lymphocytes and a few polymorphonuclearcells present in the fluid; diplococci seen in fluid. 9th: Lumbar punc-ture-two drops of fluid removed. 10th: Child deeply comatose.Pulse and respiration irregular. Retraction of head and Kernig’s signabsent. llth : Death.Necropsy.-Brain: The pia arachnoid in the interpeduncular space is

greenish yellow and gelatinous and thickened. This condition passesinto the Sylvian fissures over the cerebellum and medulla. There isan increase of fluid in the ventricles. No sign of miliary tubercles.Lungs adherent to the chest wall. Two bronchial glands containedsmall caseo-calcareous areas. Adhesions between upper surface of liverand diaphragm ; on the latter were numerous white nodules.CASE 5.-Boy, aged 11 years, under Dr. Humphry. Admitted on

Feb. Ilth, 1911; death on the 12th.History.-Thirteen days ago patient fainted in chapel. He came

home and was sick. The sickness continued for three days and he hadgreat headache for a day or two. Soon after this he became deliriousand lately has been noisy. He has had no retraction of the head. A

cough has been present for a few days. During the past fortnightthe bowels have been opened twice with enemata. Three roundworms have come away.Examination.-The patient has a flushed face, he lies in bed uncon-

scious with his head a little retracted and knees drawn up. He isintolerant of light and is generally irritable. There is a scatteredmacular rash behind the ears and over the chest and back and down theback of the thighs. The hands are a little cyanosed. The eyeballswander independently of one another, the pupils are rather dilated.The tongue is protruded to the right ; it is very furred. Knee-jerksare absent. Plantar reflex is extensor on the right side. Kernig’s signis present. There is no aural discharge and no joints are painful. Non-consonating rales are present all over the lungs. The liver and spleenare not palpable. A lumbar puncture was performed. There were noorganisms in the fluid and no growth took place on cultures.

Feb. 12th: Patient died.Necropsy.-An exudation of greenish-yellow lymph beneath the

arachnoid in the interpeduncular space passing forward over theolfactory lobes, laterally into the Sylvian fissures, and posteriorly onthe superior surface of the cerebellum. Increase of fluid over thevertex. The brain was examined microscopically by Dr. L. Cobbett,who said the disease was not due to tubercle. There was a largecaseous gland at the bifurcation of the trachea and a few small nodulesin the lungs which on examination were found to be tuberculous.

I wish to thank Professor Bradbury and Dr. Humphry,under whom the patients were in this hospital, for permittingme to publish these notes.Cambridge.

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A CONVENIENT METHOD TO TEST THEVISUAL FIELDS FOR COLOUR WITHOUT

THE USE OF A PERIMETERFOR APPLICATION IN CASES SUSPECTED OF INCREASED

INTRACRANIAL TENSION.

BY TOM A. WILLIAMS, M.B., C.M. EDIN.,MEMBRE CORRESPONDANT DE LA SOCI&Eacute;T&Eacute; DE NEUROLOGIE DE PARIS, ETC.

IT was formerly supposed that inversion of the visualfields for blue and red was pathognomonic of hysteria,especially when a contraction of the -field for form was

present in addition. Not everyone is yet acquainted with

the work of Babinski,l which has clearly shown that theperimetric examinations of hysterical patients as ordinarilyconducted are redolent of suggestions, and that these veryoften influence the patient, so that the findings are notreliable except as indices of suggestibility. Thus, there isno characteristic visual-field type in hysteria.But there are certain affections in which the visual field

is characteristically inverted or interlaced. This happenswhenever the intracranial tension is increased to the pointwhere there is an interference with the functions of theneurons which conduct visual impressions. This manifestsitself most particularly, clinically speaking, towards the

periphery of the retina, where the sensibility is feeblest; sothat, as Bordley and Cushing 2 have shown, the red is

perceived even sooner than the blue on approaching thecentre of the visual field of cases where the intracranial tensionis increased by cedema of the brain, whether this is producedby a tumour within the cranium, by haemorrhage therein, orby some constitutional condition resulting from chronicnephritis, diabetes, or other modification of the blood.To measure this inversion or interlacement of the colour

fields accurately a perimeter is, of course, required, but Ihave found that the inversion may be ascertained roughly bythe following method: The patient sits with his back to agood light looking fixedly at a point in the distance. He isdirected to signal as soon as he perceives any movement.The visual field is then approached by the observer’s hand,which holds alongside and parallel two objects coloured ofan intense pure bright red and blue respectively. After the

patient signals, he is asked to signal again as soon as heperceives any colour, while the centre of the field is veryslowly approached. The observer then stops the movementand asks what colour is seen. To corroborate, the movementis then continued until the other colour is also seen. Innormal persons blue is always seen before red. If this is notthe case increased tension may be suspected. In two recentcases, one of tumour and one of albuminuric retinitis, thismethod has been as positive as that with the perimeter.

If the techique is carefully performed, the test is quite areliable one and is a useful addition to clinical methods.Indeed, Cushing believes that when inversion of visual fieldsappears in the case of a tumour operation should not befurther delayed.Washington, D.C.

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Clinical Notes:MEDICAL, SURGICAL, OBSTETRICAL, AND

THERAPEUTICAL.

THE CURIOUS HISTORY OF A SWALLOWED PIN.

BY WILFRED BALGARNIE, M.B. LOND., F.R.C.S. ENG.,SURGEON TO THE COTTAGE HOSPITAL, FLEET.

THE following case, where a pin was swallowed, probablysome years previously, perforated the stomach, and becameembedded in the peritoneum, seems of sufficient interestto be worth recording.The patient, a woman, aged 35 years, consulted me in

January of this year, complaining of symptoms of acute

indigestion. She stated that she had had slight troublesince her " teens," but during the last five years her life hadbeen more or less a misery to her. She had been treated ina hospital for gastric ulcer, and though she improved some-what whilst lying in bed, her symptoms speedily recurredwhen she resumed work. The pain at times was so acuteas to cause her, so she expressed it, to writhe on thefloor, and she had frequent attacks of vomiting on

taking food. When first seen she was struggling on withher work, though only able to swallow small quantitiesof milk, anything else causing much pain and vomiting. Ioffered to take her into the hospital, but she demurred atthis, as her previous hospital experience, where the treat-ment consisted of rest and diet, did not encourage her to

1 Ma Conception de l’Hyst&eacute;ri&eacute;, Paris, 1906. See also various articlesof the writer: New York Medical Journal, January, 1909; Inter-national Clinics, August, 1908; American Journal of Medical Sciences,August 1910, &c.2 Observations on Choked Disc, Journal of the American Medical

Association, Jan. 30th, 1909.