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TRANSACTIONS

OF THE

American Homceopathic

Ophthalmological, Otological and

Laryngological Society.

TWELFTH ANNUAL MEETING.

ATLANTIC CITY, N. J.

June, 1899.

S2SZ

OFFICERS, 1897-
PKES/DEArr:

A. R NORTON. M.D...., New York City.

VICB'PRESIDENTi

WM. R. KING. M.D Washington, D. C.

SECRETARY:

ELMER J. BISSELL. M.D Rochester. N. Y.

TREASURER •
HAROLD WILSON, M.D Detroit, Mich.

CENSORS:

W. A DUNN, M.D Chicago. Ilu

F. PARK LEWIS, M.D ,. ^ Buffalo. N. Y.

W. A. PHILLIPS. M.D v^oO-N • M B^?^h^- Cleveland, O.

WM. R. K.INv7, M.D. • • •! A*D*D* * X\' * *l M)C * 'XT^* 1* * * * ■^ASHUfGTON^ D. C>

THOMAS L. SHEARERxit.D .'.^./ Baltimore. Md.

HOWARD P. BELLOWS>MDt.y.w ^...^yT Boston. Mass.

SECRMU ^^rk^S i^R:
CHARLES H. HELFRICH, M-DTTT: 777. New York City.

CENSORS:

E. W. BEEBE, M.D Milwaukee, Wis.

E. J. BISSELL, M.D Rochester. N. Y.

R. S. COPELAND, M.D Ann Arbor. Mich.

A. B. NORTON, M.D New York City.

GEO. H. QUAY. M.D Cleveland, O.

OFFICERS. 1899.
PRESIDENT:

ELMER J. BISSELL, M.D Rochester. N. Y.

VICE-PRESIDENTS:
E. W. BEEBE, M.D Milwaukee, Wis.

C. GURNEE fellows. M.D Chicago. III.

5iffC^^rrf^ K.-
HERBERT D. SCHENCK, M.D Brooklyn, N. Y.

TREASURER:

CHARLES H. HELFRICH. MD \ New York City.

CENSORS:
EDWARD B. HOOKER. M Pf 1 ■ ■ , Hartford, Conn.

D. A. MacLACHLAN, M.D. . J — GA*T-A{-0O<iif*^* --'l Detroit, Mich.

GEO. B. RICE, MD I .?h .?.4^.?. . . /. Boston, Mass.

THOMAS M. STEWART, M.t)wu n rr • v /• Cincinnati. O.

ISAAC C. SOULE. M.D J.hr.H,,!^., l&G.S Freeport, III.

OFFICERS F« 'R YEAR ibcjo

I preSi^MT' I

PREJI ^I^T:

HOWARD P. BELLOWS, M.15T?:'. . .■.TTrTrrr;-..*. Boston. Mass.

VICE-PRESIDENTS:

C J. SWAN. M.D Chicago. III.

E. L. MANN. M.D St. Paul. Minn.

SECRETARY:
HERBERT D. SCHENCK, M.D Brooklyn. N. Y.

TREASURER:

CHARLES H. HELFRICH, M.D ' New York City.

CENSORS:

J. H. HARVEY. M.D Toledo, O.

G. H. QUAY. M.D Cleveland, O.

P. C MORIARTY. M.D Omaha. Neb.

C. L. RUMSEY, M.D Baltimore, Md.

O. L. SMITH. M.D Chicago, III.

PROCEEDINGS

OF THE

TWELFTH ANNUAL MEETING OF THE AMERICAN HO-
MOEOPATHIC, OPHTHALMOLOGICAL, OTOLOGICAL
AND LARYNGOLOGICAL SOCIETY, HELD IN ATLANTIC
CITY, N. J., JUNE 19TH AND 20TH, 1899.

First Day. — Morning Session.

The society met in the Hotel Dennis, and the first session was called
to order at 10.40 A.M., Monday, June 19th, by tlie President, Dr.
Elmer J. Bissell, with the following remarks : Previous to giving my
Annual Address, I wish to say that I concluded after looking over the
long program that you came here to hear each other rather than to
hear me. I have, therefore, reduced my address to very small pro-
portions, in order that you may have a longer time for the exchange of
thoughts among yourselves.

Dr. Bissell then presented the President's Address, and followed it
by declaring the Society open for the transaction of business.

Dr. Bushrod W. James: I have been much pleased with this ad-
dress. It seems to me that it strikes right at the foundation of the
usefulness of this Society. The thoughts therein contained are valua-
ble, and I think we ought to have a committee of five appointed to report
further upon this address, and bring out any other points which he
has suggested in his remarks. I, therefore, move you, sir, the appoint-
ment of a committee of five to take into consideration the address and
report further. Amended to make the committee consist of three in-
stead of five members, and then carried.

The President then announced that through Dr. King of Wash-
ington a photographer had agreed to make a picture of the society on
the hotel veranda at the close of this afternoon's session. That
a room had been set apart a short distance from the meeting-room for
the exhibition of instruments, specimens and photographs, in charge
of Dr. Hoyt of Rochester, who requested the members to assist him in
getting all their exhibits early in place. He also announced that the

6 TWELFTH ANNUAL SESSION.

first three papers on the program would be transferred to the first ses-
sion on June 20th, and that "Aural Massage" would be the first subject
considered, in order to accommodate one of the authors. For the same
reason the paper upon "Diseases of the Frontal Sinuses and Anterior
Ethmoidal Cells" would be transferred to the session this afternoon,
where two of the announced papers were not to be presented. The
President also said that where papers had been prepared upon "Aural
Massage and Strabismus," which were special subjects arranged for
this meeting, that it would break up the continuity not to have all the
papers read, and he would therefore depart from the usual rule and
have the papers prepared upon these subjects by authors not present
read, unless there was some objection offered now, as he believed it
would be to the advantage of the Society to hear these particular papers.
No objection was made, and it was so ordered.

REPORT OF THE SECRETARY.

Mr, President and Fellow Members:

Your Secretary begs leaves to submit the following report of his
work for the past six months :

Soon after assuming office the corresponding members selected at
the last meeting, Drs. C. Knox Shaw and Dudley Wright of London,
England, and Dr. Parenteau of Paris, France, were each notified of
their election. Dr. Parenteau did not reply to his letter of notification
or to one sent by the President later. The following replies were
received from Drs. Shaw and Wright :

19, Upper Wimpole st., W., London, Feb. 16, '99.
Dear Sir : I have much pleasure in acknowledging the honor con-
ferred upon me by your society, in electing me one of its corresponding
members. I have never yet visited America, but am hoping, each year,
to be enabled to do so. Unfortunately, I do not see my way to getting
over this year, but I hope one day to get to one of your interesting
meetings. I am, dear sir, yours sincerely,

C. Knox Shaw.

19, Upper Wimpole st, W., London, March 13, '99.
Dear Dr. Bissell:

It is with great reluctance that I have to reply to your very kind
invitation by saying that I shall be unable to get over to your meeting

TWELFTH ANNUAL SESSION. 7

this year at Atlantic City. I have a very great longing to pay your
country a visit, and to meet some whose acquaintance it has been my
pleasure to make in this country, and to see more whom I do not know
personally, but whose fame is so well known over here. I am sure I
should much enjoy the visit: the many kind letters I have received
make my regret the more keen. With kind regards, I am yours fra-
ternally, C. Knox Shaw.

55, Queen Anne Street, Cavendish Square, W., May 17, 1899.
Dr. Herbert D. Schenck :

My Dear Doctor: I should have acknowledged before this your
kind note of February i8th last, acquainting me that the Ophthal-
mological, Otological, and Laryngological Society of America had done
me the great honor of electing me a corresponding member, only I
have been waiting until I had written a paper which might be presented
to the congress.

Having now accomplished this, I am sending it to you under separ-
ate cover, and would beg you to be so good as to convey to the society
my sincere thanks for the honor which has been thus conferred upon
me.

It is much to my regret that I am unable to join you all in your
meeting, and to have the pleasufe of becoming personally acquainted
with yourself and your colleagues, but it unfortunately happens that
our British Homoeopathic Congress falls in the same week as your
own, and as I am one of those who has promised to speak on one of
the papers, I must be present at the meeting.

With my kind regards and sincere good wishes, believe me yours
very truly, Dudley Wright.

In March a circular was issued, notifying the members of the time
and place of this meeting and asking for papers, with a request that the
titles be in the hands of the Secretary by April ist and the completed
paper by May ist. The first request was very generally complied with,
but the second was more generally honored in the breach than other-
wise, only four of the forty-seven papers which were finally put in the
program being at hand before May 5th. Your Secretary would sug-
gest that much expense to the society, some misunderstanding, as well
as a very large amount of extra labor, would be spared your officers
if the members, in this respect, would in future more carefully arrange
their work for the Society.

8 TWELFTH ANNUAL SESSION.

On June Sth a circular announcing the methods of obtaining re-
duced railroad rates for this meeting and other information wfis sent
to all the members with the program of the meeting, which is herewith
presented.

At present the society has 134 active members, 3 corresponding
members, and one honorary member. Eleven applications for member-
ship have been received up to the present time.

Respectfully submitted,
Herbert D. Schenck, M.D., Secretary.

The President : This report will be placed on file, unless otherwise
ordered.

Dr. J. L. Moffat : I move the minutes of the last meeting be adopted
as published. Carried.

The Treasurer next presented his report.

treasurer's report.

Mr. President and Gentlemen of the Society:

I have the honor to make the following report :

American Homoeopathic Ophthalmological, Otological, and Laryngol-

ogical Society,

In account with

Dr. Chas. H. Helfrich, Treas.

Dr. Cr.

To balance $160 74 By stenographer $65 00

To dues received 421 00 By stenography and printia|:. . . 37 32

By printing bills 475

By cut 5 00

By printing, bindicig, ma Ling,

etc., Annual Transa:tions 154 97

By mailing bills 4 62

By mailing programs 11 40

By stationery 4 ^

By postals 3 80

By transportation committee. . . 6 00

By printing 43 5o

By treasurer's sundries 9 25

By secretary's sundries 25 48

By balance 206 15

$581 74 fc^' 74

Balance on hand $206 15

TWELFTH ANNUAL SESSION. 9

On motion the report was referred to an auditing committee.

The President: Under the head of Appointment of Committees, I
will announce that several months ago I asked Dr. J. B. Garrison to
act as a Committee on Transportation and Local Arrangements, and I
now take pleasure in regularly appointing the man who has done the
work. I also announce that I asked Drs. King of Washington, Bellows
of Boston, and Rumsey of Baltimore to act as a Press Committee, and
I now regularly appoint them.

As a Committee on Attendance Drs. Bates of Hamilton, Haywood
of Rochester, and Rumsey of Baltimore are appointed. As an Auditing
Committee, Drs. Haywood of Rochester, Suffa of Boston, and Leavitt
of Minneapolis. Drs. Shearer of Baltimore, Townsend of New York,
and Moriarty of Omaha are made a Committee on President's Address.

Dr. A. B. Norton : I would like to call attention to an action of the
Medical Society of the State of Pennsylvania, that has probably been
sent to all members of this society, in regard to the relations between
the medical profession and opticians. I think we should take some
similar action and move that this matter be referred to a committee of
three to report at to-morrow morning's session. Carried. Drs. Nor-
ton, Moffat, and Vilas were appointed such a committee.

Dr. P. C. Moriarty : In regard to the nomination of officers of this
society, I have a standing resolution to offer providing for a standing
committee for the nomination of officers. I have had the experience
of seeing two societies apparently dying early, dragged into innocuous
desuetude, simply because the officers elected were not qualified, capa-
ble, and pushing men. I think few of us are as capable of selecting
officers as the ex-presidents of the society, who have seen the work of
the various men, and know to whom the interests of the Society should
be intrusted. The experience of the late war of appointing volunteer
officers by the election of companies, has been a very strong argument
in favor of selecting men for such positions as are fully qualified for
them. As every society depends largely on the caliber of its officers,
and as our ex-officers are best capable of passing judgment in this
respect, I think we have sufficient reasons for having the ex-presidents
nominate our future officers. I, therefore offer the following as a
standing resolution:

Resolved, That the committee on the nomination of officers shall
consist of all the ex-presidents of the society present at any meeting,
provided that in any case less than three be present that the President

10 TWELFTH ANNUAL SESSION.

shall appoint from the members present a ntmiber sufficient to make
the committee consist of three members.

Dr. A. G. Warner: I heartily second this motion of Dr. Moriarty
as it seems to me eminently fit that the ex-presidents of this society
should form such a committee. They certainly are in a position to
know the members and to gauge the necessities of the case better than
any other members. Carried.

The President: As there are only two of the ex-presidents here,
this resolution imposes upon the President the appointment of a third
member of the committee.

Dr. Vilas : Mr. President, there are a good many more than two ex-
presidents here.

The President: I was not a member' in the early days of the society,
and I am very glad to have this matter brought to my attention and
corrected.

The Secretary then presented twelve applications for membership
which were referred to the Censors for report at first session on June

20th.

The Treasurer presented the resignation of Dr. J. M. Schley of New
York, who resigned on account of illness, on motion this was accepted.

The Secretary: Last year notice was given of an amendment to
section i of article v of the by-laws, which is now offered, to insert,
after the word "physician," "endorsed by two members." The section
will then read: "Any regularly qualified and reputable physician, en-
dorsed by two members, may be elected to membership in this society."
Adopted.

The Secretary: It is suggested that section i of article vi be
amended by inserting, after the word "In," "Roberts Rules of Order" :
The section will then read : "The rules governing the deliberations of
this Society shall be those found in Roberts' Rules of Order." The
latter work is substituted for "Cushing's Manual," which is entirely out
of date. Adopted.

The Secretary: It is suggested that section 2 of article vi be
amended by inserting, after the word "Secretary," "by April ist of
each year, and completed paper not later than May ist." The section
will then read "No report or paper shall be received by the society in
an incomplete or unfinished condition, and the title of any proposed
paper shall be forwarded to the Secretary by April ist of each year,
and the completed paper by May ist." Adopted.

The Secretary: It is suggested that an additional section be added

TWELFTH ANNUAL SESSION. 11

to article vi, as follows : "The time allowed for the presentation of any
paper shall be twenty minutes. The leading discussion shall not exceed
ten minutes, and all other discussions five minutes for each speaker."
Adopted.

Dr. Moffat: Mr. President, I notice that the application-blank
specifies only the graduation of members. In many of the States the
diploma does not license a person to practise medicine. In some it does.
I think it would be well for this society to know under what license our
applicants are practicing. I, therefore, move to add to the application-
blank, after the words "in the year 189..," "and practising under a

license of , dated 185. .." The application-blank would then

read : I, , residing in , State of

, a graduate of , in the year 189. ., and practising

under a license of , dated , hereby apply for mem-
bership in the American Homoeopathic Ophthalmological, Otological
and Laryngological Society, and, if elected, agree to comply with its
by-laws, rules, and regulations. (Name in full, with all titles.) Ad-
dress, Date, 189. . .

If the applicant is living in a State where the diploma is all the

license that is necessary, he will just state, "I am a graduate of

college, in the year , and practising under the license of a diploma" ;

or, he may state, "I am practising under the license of law,"

and sign the date on which he registered. In New York the first
license was simply a requirement that every physician go to the G)unty
Qerk's office and sign his name in a book. Now applicants must be
licensed by the Regents.

Dr. James : I would amend as follows : "Or a certificate from the
Examining Board of the State in which he resides." We don't have a
license in our State, except that the law compels a man to pass an
examination before he is entitled to practise. The passing of that
Examining Board entitles him to that privilege, and should be men-
tioned in the blank, because some of the other States may have the same
method we have in Pennsylvania.

Dr. Moffat: As I understand, that is practically a license. They
cannot practice without that examination. Applicants may just recite
that in the blank line.

Dr. James : You want the words there to make it clear.

The amendment was lost. On the original motion of Dr. Moffat
a division was called for. The motion was carried by a vote of 12 for
to 10 against it.

12 TWELFTH ANNUAL SESSION.

The President : The first paper will be on "Aural Massage," by Dr.
Henry C. Houghton of New York.

Dr. Henry C. Houghton: You will excuse me for prefacing my
paper with an apology : First, that I should be the means of a change
in the program, which is giving you some inconvenience. It was a
matter of positive necessity, beyond my own control, that I should be
at Mt. Holyoke College to-morrow morning, which obliged me to make
this request. That I may not be misunderstood, allow me to say, also,
that before this paper was complete and I was aware of the circum-
stances, I had already given a promise of this paper to the editor of
the Journal of Ophthalmology, Otology, and Laryngology, If I have
made an error, I feel as though the pledge stood, and I shall be obliged
to abide by my word, and hence make this statement before I begin read-
ing the paper.

Dr. Norton: I move that Dr. Houghton's paper be read and
accepted by the society, even though it is to be published in other than
the official organ of the society.

The President: It is certainly a matter of error.

Dr. Houghton: An error of the head and not of the heart. The
motion was carried.

Dr. Henry C. Houghton then read his paper, and followed it with
a demonstration of the use of the instrument mentioned.

Dr. Norton then moved that throughout this meeting the courtesies
of the floor be extended to all visitors to take part in the discussion
of the papers. Carried.

The remainder of the morning hour was taken up with the reading
and discussion of the first five papers upon the program, as amended at
the beginning of the session.

After this the Secretary presented two additional applications for
membership, which were referred to the Censors, after which an ad-
journment was taken to 2.30 P.M.

First Day. — Afternoon Session.

The meeting was called to order by the President at 2:50 P.M.,
who announced that the executive committee had decided that it was
best to begin this session with the presentation of the remainder of
the papers on the program for this morning's session before proceeding
with the regular program for this afternoon. The whole session was
occupied in the reading and discussion of five papers. At the close of

TWELFTH ANNUAL SESSION 18

the session the President announced that the exhibits were now all in
place, except Dr. Boynton's colored plates illustrating various intra-
ocular conditions which would be in position to-morrow morning. An
adjournment to 8 P.M. was taken at 6 o'clock.

First Day. — Evening Session.

The evening session was called to order by the President at 8.15
o'clock, and was wholly occupied with the reading and discussion of
nine papers. An adjournment was taken at 10.48 P.M. until to-mor-
row morning at 9 o'clock.

Second Day. — Morning Session.

The meeting was called to order by the President at 9.25 A.M.

The Secretary presented three applications for membership, which
were referred to the Censors.

The report of the committee appointed to draft a resolution regard-
ing the relation of opticians to the medical profession reported,
through Dr. Norton, the Chairman, the following resolutions which
were adopted without debate.

Resolved, That it is the opinion of the American Homceopathic
Ophthalmological, Otological, and Laryngological Society that opticians
are not qualified either by education or training to perform the work
of the oculist which deals with the function of the eye and the health
of the patient

Resolved, That until opticians have fitted themselves by a medical
degree to treat disease, all physicians are reminded of the danger to
their patients in consulting tradesmen and are requested to discoun-
tenance the growing pretences and assurance of the opticians.

Dr. Norton then moved that the resolutions just adopted be referred
to the American Institute and to other societies throughout the country
for action. Carried.

The President: The report of the Auditing Committee, is now in
order. No member of the committee was then present, but later the
committee reported that the Treasurer's accounts had been examined
and found correct, and the report was accepted by the society.

Dr. T. L. Shearer, the Chairman, then read the report of the com-
mittee upon the President's address.

The committee appointed to report upon the President's address

14 TWELFTH ANNUAL SESSION.

were greatly impressed not only by the able way in which his views
were placed before the society, but also by the tremendous import to
future generations if his suggestions are carried out in a practical
manner. Human beings as a class are not observant, although very
curious by nature about things that are novel. Why should parents,
who have naturally no reason to be on the watch for diseased condi-
tions involving the organs of the special senses, when they have not
even heard of such possibilities, be expected to care intelligently for
their children? And yet, in the address, this is the point of chief value ;
for children, as a rule, are not brought to the physician until months,
at least, if not years, of valuable time is lost — a time of life when early
impressions and normal mental development are dependent upon a
healthy state of the special organs. The only way to accomplish this
satisfactorily is for the physician to instruct the parents, to warn them
of diseased conditions possible in childhood, in order that they may
protect the interests of their offspring. The committee feel that this is
a subject which deserves widespread attention, and, therefore, recom-
mend that the address be published in reprint form for distribution
among the members of the American Institute of Homoeopathy dur-
ing the coming year.

Thomas L. Shearer,
p. c. moriarty,
Irving Townsend,

Committee.

The report was adopted without debate.

The report of the Board of Censors was then presented by Dr. E.
B. Hooker.

There have been referred to the Board of Censors fifteen applica-
tions for membership. These applications come from gentlemen, who,
for the most part, are unknown to us, and they are not recommended
by anyone, as it has not been required ; therefore we have had to take
them largely on faith. I think there is no doubt but that they are all
ladies and gentlemen whom we wish to haveas members. In the
absence of further information, if they come from a straight, reputable
college, we have simply passed them. I say this in explanation, because
we do not stand personally responsible for these applicants. We, there-
fore, recommend all the following applicants for membership :

Charles C. Boyle, M.D., 49 W. 37th st. New York.

Herbert A. Church, M.D., 601 S. Warren St., Syracuse, N. Y.

Charles Deady, M.D., no W. 48th St., New York.

TWELFTH ANNUAL SESSION, 15

Neidhard H. Houghton, M.D., 867 Boylston St., Boston, Mass.

Charles H. Hubbard, M.D., 8th and Madison sts., Chester, Pa.

Edward Humphries, M.D., Somerton, Philadelphia, Pa.

Ella G. Hunt, M.D., 608 W. 8th st., Cincinnati, Ohio.

Gilbert J. Palen, M.D., 6043 Germantown ave., Philadelphia, Pa.

Thomas Parsons, M.D., 33 S. Clinton St., Rochester, N. Y.

Isaac G. Shallcross, M.D., 1617 Arch St., Philadelphia, Pa.

Zuber N. Short, M.D., 428 Central ave., Hot Springs, Ark.

Richard K. Valentine, M.D., 190 Lincoln place, Brooklyn, N. Y.

Frank P. Warner, M.D., 304 Main st, Canandaigua, N. Y.

Harry S. Weaver, M.D., 1621 Chestnut st, Philadelphia, Pa.

David W. Wells, M.D., 391 Boylston St., Boston, Mass.

These were elected by the Secretary casting a ballot for all the
applicants.

Dr. Hooker : In accordance with our by-laws we have the privilege
of electing to honorary membership any lady or gentleman whom we
think fit for such honor, who has been recommended by the Board of
Censors. We recommend the election to honorary membership of a
gentleman well known to us all — known throughout the country — ^a
gentleman, who, by character, by attainment, by long years of service,
merits the position of honorary membership in our society, and I take
great pleasure in nominating for that position the gentleman whom we
had the pleasure of listening to yesterday, Dr. Henry C. Houghton of
New York.

The question being asked whether the doctor was not now a mem-
ber, being an ex-president of the society, the Secretary stated that his
name had not appeared among the members since the reorganization, as
he had not taken any steps to comply with the requirements.

Dr. Moffat: Would honorary membership debar him from service
upon committees?

The Chair stated that honorary members had all the privileges of
active members except voting and eligibility to office, and that they were
exempt from dues.

Dr. Houghton was then unanimously elected an honorary member.

Dr. W. R. King, Secretary of the nominating committee, then re-
ported the following nominees for officers for the coming year :

President, Dr. Howard P. Bellows, Boston, Mass.; First Vice-
President, Dr. C. J. Swan, Chicago, 111.; Second Vice-President, Dr.
E. L. Mann, St. Paul, Minn.; Secretary, Dr. Herbert D. Scfienck,
Brookl)m, N. Y. ; Treasurer, Dr. Charles H. Helfrich, New York;

16 TWELFTH ANNUAL SESSION.

Censors, Drs. J. H. Harvey, Toledo, Ohio; G. H. Quay, Cleveland,
Ohio ; P. C. Moriarty, Omaha, Neb. ; C. L. Rumsey, Baltimore, Md. ;
O. L. Smith, Chicago, 111.

On motion of Dr. Norton, Dr. King was instructed to cast a ballot
for all these nominees, which he did, and they were declared elected as
officers for the ensuing year.

Dr. Bellows was then called upon and said :
Mr. President and Members of the Society:

I am deeply sensible of the honor which you have conferred upon
me in choosing me for this office. I am afraid you have overrated
my ability to fill such a position, and I know that I do not deserve it as
much as other members among you, by reason of their age or their serv-
ice in a wider field of work than my own. It only remains for me,
however, to attempt to deserve your confidence in a most faithful effort
to discharge the duties of the office. I thank you from my heart for
the chance which you have given me to serve."

The remainder of the morning hour was occupied with the reading
and discussion of six papers.

At 12.40 an adjournment was taken to 2 P.M.

Second Day. — ^Afternoon Session.

The meeting was called to order by the President at 2.15 P.M., and
the Secretary presented a report from the Censors recommending for
membership George S. Wells, M.D., Wells Block, Sistersville, W. Va.,
and John Storer, M.D., 1007 Columbus Memorial Bldg., Chicago,
111. The Secretary was instructed to cast a ballot for these applicants,
who were declared duly elected to membership.

During this session ten papers were read and discussed.

The Secretary then moved that all papers that had not been read
be considered as having been read by title, and be referred to the
Executive Committee for publication in the Transactions. Carried.

Dr. J. B. Garrison moved that a vote of thanks be extended to Joseph
H. Borton, proprietor of the Hotel Dennis, for his courtesy in extend-
ing to the society the use of his Music Hall for our meetings, a room
for the display of the exhibits, and for furnishing so generously elec-
tricity for the use of exhibitors, and that the Secretary be instructed
to inform him of this action of the society. Carried.

TWELFTH ANNUAL SESSION 17

Dr. F. D. Bates, Chairman of the Committee on Attendance, re-
ported the following attendance at each session :

Members. Visitors. Total.

June 19, morning session 35 28 63

June 19, afternoon session 46 32 78

June 19, evening session 54 48 102

June 20, morning session 59 107 166

June 20, afternoon session 58 7 65

The report was accepted, and the committee discharged with thanks.

Before adjoining the society the President said :

"Before declaring this twelfth annual meeting of the society
closed, I wish to express to you my appreciation of the honor you have
conferred upon me by electing me to this office, and to thank you most
sincerely for the assistance rendered not only during this session, but
through all the months of preparation for this meeting.

"I wish to extend my thanks to the Secretary for his valuable,
efficient aid, to the other officers and members of committees for their
untiring efforts, to the authors of papers and their disputants for their
thoughtful preparation, to each and every member of the society who
has contributed to the success of this meeting : for it is due to the co-
operation of the many, rather than to any individual, that this our
twelfth annual meeting has come so auspiciously to an end. I now
declare the twelfth annual meeting of the American Homoeopathic
Ophthalmological, Otological and Lar)mgological Society closed.

The adjournment was taken at 4:55 P.M.

Herbert D. Schenck, M.D.,

Secretary.

OUR SPECIALTIES AS RELATED TO MENTAL DEVELOP-
MENT AND MODERN EDUCATIONAL METHODS-
PRESIDENT'S ANNUAL ADDRESS.

By Elmer J. Bissell, M.D.,

Rochester, N. Y.

MEMBERS of the Society and Friends: We as physicians
specially engaged in studying and treating the eye, the
ear, the nose and the throat, seats of four of the five special
senses, hold an important and most unique position, not only among
physicians, but among psychologists and educators. Dealing as we do
so exclusively, and under such varied conditions with the most essen-
tial means by which the human organism may know what is external
to it, we should be students of, and contributors to, the domain of
physiological psychology. The very knowledge and experience which
we possess regarding these special organs of sense, so necessary in
acquiring an education, places a responsibility upon us in matters per-
taining to the education of the young, and should enable us to speak
authoritatively on pedagogic methods as influencing the mental and
physical health of students.

I have, therefore, selected as the theme of this brief address "Our
Specialties as related to Mental Development and Modem Educational
Methods."

Through the four avenues of sense which are within the field of
our work, sensations from the outer world pass to the brain cells, and
that marvelous something we call the mind is aided in its development.
The cognative mind is therefore quite largely the elaborated, accumu-
lated information gathered by the senses. These sense perceptions form
the basis for, and naturally precede the higher mental operations of
logical thought, reason and imagination. Consequently this sense
material should be transmitted to the brain accurately, and without an
undue expenditure of nerve force.

It is a matter of common observation that the interdependence of
the physical and mental life is intimate and intricate. Bodily fatigue,
ill health, malformed or diseased eyes or ears, obstructed nasal respira-
tion, lessen intellectual power and contribute to mental dulness. On
the other hand, prolonged and severe mental work, overstimulation of

PRESIDENTS ANNUAL ADDRESS, !•

the brain, especially in the growing child, and the expenditure of ex-
cessive nerve force at the brain centers devoted to the reception and
storing of impressions received by the special organs of sense mean
not only lessened mental efficiency and brain fatigue, but a general im-
pairment of nutrition and a disturbance in the normal functional activity
of some, or even all, of the organs of the body. Nerve force is as
truly something to be reckoned with as gravitation, although both are
subtle in character and hard of satisfactory definition. The former is
almost as definite in its limitations and mode of operation as the latter.

Nerve force is expended in every act, every thought, and the
amount at the command of any individual is relatively fixed, and any
overdraft must be settled for in full, and usually with interest. With
these general statements of facts before us, and which time will not
permit of further elaboration, let us now more closely analyze the in-
timate relationship between the special organs we treat and the develop-
ment and operation of the intellectual faculties.

If specialism necessarily imposes a certain narrowness of thought,
yet within the domain of our specialty we should be broad and ever
ready to carefully consider anything which is vitally related to it. Such
a vital relationship exists between our work and the intellectual life,
for we are dealing with means necessary to the attainment of great
ends. Concurrent with physical development there is supposedly in-
creased mental power. This mind development is from the simple to
the complex, from the mere reception of material by the senses to the
inner and higher impression, as expressed in thought, feeling and
imagination. No period of life is entirely given up to any one form
of mental development, for we are ever moving further and further
from the life of the senses. Up to ten or twelve years of age both the
emotional and cognative minds are largely receiving and differentiating
sense impressions. This then is the period when our opportunities are
greatest for far-reaching results. Not a physician present but what is
consulted almost daily by patients in middle life with conditions long
uncorrected, which, if relieved earlier, would possibly have changed the
whole character of their lives.

As the mind influences the states of the body, and the mmd is
influenced unfavorably by abnormalities of the organs of sense, and
the mind expresses itself in feeling as well as in knowing, therefore
is it anything less than a statement of fact to say, that such patients
might have been healthier? Yes, but also happier and wiser. Have we
kept clearly before us this threefold effect of our work? It is good to

20 ELMER /. BISSELL, M,D.

have made our patients healthier. Is it not of greater or equal im-
portance to have made them happier and wiser? Man is mind, not
body. The fact that we by our skill influence the feelings, emotions,
imagination and intellectual power of our patients, gives added dignity
and importance to our efforts. If we accept these facts in psychology,
it is a matter of no small moment that a patient comes to us irritable,
or cross, or melancholy, or ambitionless, or forgetful, or intellectually
dull, for we may possess the skill to so transform these abnormal mental
states that life, that which is more than body, that which is eternal, is
worth living.

If these far-reaching effects may most surely be secured by correct-
ing abnormalities of the eye, ear, nose or throat early in life, should
the beneficent results be limited to the comparatively few children who
come professionally under our care? This suggests the broader rela-
tionship of my subject to educational work.

If we could but accurately know the number of children with im-
paired sense organs who are counted as forgetful and stupid, scolded
because they are restless and inattentive, and actually punished because
they are nervous and irritable, we who have had extended opportunities
for observation would be startled and keenly aroused to our duty. We
are citizens as well as physicians, and owe something to society.
Knowledge of such a vital and practical character imposes a responsi-
bility which I trust none of us are anxious to escape. How, then, can
these truths be best brought to the attention of the thousands going
through life fighting against unnecessary odds ? The practical solution
is through the teachers of our land. They by their intelligence, oppor-
tunities and interests are best qualified to extend this knowledge to those
most in need of it, the children and youth of our schools. Some teach-
ers have already grasped the relationship between abnormal sense or-
gans and impaired mental activity, and are ever zealous in searching out
those pupils who are laboring at a disadvantage from this cause. How-
ever, there are many directly and indirectly engaged in educational work
who do not understand or appreciate the beneficent and threefold eflfect
which may follow the correction of such abnormalities. To such teach-
ers, normal classes and boards of education we should direct our atten-
tion, and as opportunity is oflFered, point out to them in a clear, practi-
cal, yet scientific manner, the importance of giving careful thought to
the relationship which exists between the organs of sense and mental
development. The need of educating the educators of our land
upon this subject is so great that it would not be beyond the bounds

PRESIDENTS ANNUAL ADDRESS. 21

of propriety to even ask for the privilege of addressing educational
societies anl teachers' associations upon this theme. Such efforts, in-
telligently directed, may favorably change the life history of many
individuals. This work then is worthy of the earnest and thoughtful
endeavor of every member of this Society.

INFLATION.

By Sayer Hasbrouck, M.D.,
Providence, R. I.

WERE the question asked. What do you consider the so-
called cornerstone of aural treatment, it is safe to say that
the answer would be inflation.

On the other hand, how many who daily use this method could give
a clear explanation of the reasons for so doing or the results to be
expected. It is true that the student of to-day is being better trained
in the theory and practice and theoretically has a better understanding
of the fundamental principles of practice, but for many years to come
the student of the past will be in the active field and, if he wishes to
keep abreast of the times, must work on more scientific principles.
Much of his experience was acquired by the rule of thumb which in
its day seemed adequate for all demands.

The old methods of inflation no doubt did more good than harm
although many times harm was done or little good accomplished — ^both
unnecessary with a clear understanding of the possibilities and limits
of the methods used. Inflation has its sphere and its limits and these
should be thoroughly understood by every one who pretends to its use.

It is not my intention to go into the details of this subject as this
is fully treated of in the text-books of aural disease. At the same time
I desire to protest against the too frequently careless use of this valua-
ble means of treatment. Especially should one be more careful in
placing it in the hands of our patients for self-inflation. Too fre-
quently the patient who has been instructed in the use of a Politzer
bag believes that he has at his command all that is necessary for the
treatment of aural disease thereby neglecting other and essential meth-
ods of treatment which, if given in time, might have accomplished the
desired result, and too late he is forced to realize that his efforts have
been in vain and the time for successful treatment ha^ passed.

Inflation as first practiced was for the purpose of opening the
Eustachian tube by direct application of compressed air through a
hollow tube now known as a catheter. Later this end was gained by
a more general inflation by the method known as Politzer's, where both

INFLA TION. as

ears were inflated at the same time, compressed air being the means
used. This was further supplemented by an attempt not only to open
the passage but at the same time, by means of a volatile medicament, to
directly treat the tissues themselves. This was a great advance in the
treatment of aural disease, but still more was desired and, with the
adoption of nebulized fluids, another and more valuable method was
added. With a better understanding of drugs to be used and the
methods of application I believe great good may be expected.

There are two objects for which inflation is intended — ^the first,
diagnosis, and the second, treatment

For the purpose of diagnosis the catheter is to be preferred although
much in this way may be learned by means of Politzer's and Valsalva's
methods. The latter is especially useful if we desire to make a personal
inspection of the drumhead at the time of inflation.

Of the relative values of the different methods of treatment much
may be said and each has its advocates. The method of Valsalva as
usually practiced is rarely advocated on account of the attending con-
gestion of the cerebral vessels that it occasions and the liability of harm
following its too frequent use by over-distention and subsequent relax-
ation of the membrana tympani. This last objection is easily overcome
by a simple method that seems little known. It was suggested by Dr.
Houghton in a short paper before the New York Homoeopathic Medical
Society in 1887, at which I was present. He directs the patient to close
the external meatus with the middle finger of each hand and at the
same time closing the anterior nares with the thumbs, then exhaling acs
usual. I have at times suggested this method to those recovering from
acute catarrh of the middle ear to the great comfort of the patient, and
I have explained its importance to those patients who have been using
this method in the old way, but all such cases should be cautioned
against its too frequent use.

In speaking of the relative value of the catheter and Politzer's
method much can be said but to my mind neither should be discarded
for the other as both have their places and at times one is preferable to
the other. Politzer's method should always be used in children and in
acute diseases as the passages are more easily made patent and there
is less liability to injury where the tissues are acutely inflamed.

In the case of children inflation can be more easily performed by
means of a piece of rubber tubing much like a diagnostic tube with a
mouth piece on one end to be inserted in the surgeon's mouth and
another suitable tip on the other end for the child's nose. Inflation is

24 SAVER HASBRO UCK, M.D.

accomplished by forcible expiration on the part of the surgeon. It is
obvious that this should not be attempted by a person suffering from a
disease of the air passages.

A similar arrangement has been recommended by Dr. Dundas Grant
for auto-inflation, the mouth-piece being inserted in the mouth of the
patient, when by forcible expiration the vault of the pharynx is closed
and air is forced into the Eustachian tubes by means of a dilated nose
piece in which cotton, medicated with a volatile medicine, can be placed.
The added effect of the vapor is gained by this means.

I have also a bent glass tube that is intended for the same purpose.

The catheter, in all cases of long standing where adhesions exist, is
the most serviceable though its use may be supplemented usually by
Politzerization to advantage.

Last year at a meeting of this Society, in a paper on the use of
nebulized fluids, I described what I saw fit to call a modified method
of Politzerization. This is accomplished by the use of a nebulizing
apparatus under compressed air, the pressure of which is under the
control of a regulator, as in acute cases much judgment should be used
as to the pressure needed. It is evident that much force will be lost
in passing the air through the oily fluids used. To obviate this and to
obtain known pressure, I have tapped the air-supply previous to its
entering the nebulizer and again joined the two before using it for infla-
tion. This method of inflation not only opens the air-passages but at
the same time suffuses the tissues with such medicaments as we desire.
A full description of this method with an illustration of the apparatus
can be found in the Transactions of this Society and also in the October,
1898, number of the Homceopathic Eye, Ear and Throat Journai^

I supplement this treatment in the hands of the patient by means
of the aseptic hydrocarboline atomizer made by George C. Frye. It
is the cheapest and most convenient hand atomizer I know of and,
what is more, does not get out of repair. After a little practice the
patient is able to use it for Politzerization as well as the nebulization of
fluids.

In the use of the catheter great care should be taken not only for
the comfort of the patient and that no harm is done. In sensitive cases
cocaine applied on cotton to the nasal passages facilitates matters.
Since using suprarenal extract in my practice I have found it of great
assistance in making the proper examination of the nasal cavity and
also in passing the catheter. Its use bids fair to be a boon second only
to cocaine in operative work about the nose, and I am not sure but that

INFLA TION. 25

its therapeutic field will embrace many diseases of the eye, ear, nose
and throat.

Previous to the passage of the catheter the nasal passages should
be inspected and, if necessary, cleansed, points of obstruction noted,
and the catheter passed by the aid of reflected light if necessary also,
the patient at the same time being directed to breathe through the
mouth, as this keeps the soft palate as far as possible out of the way.
The orifice of the Eustachian tube being found, a gentle current of air
should be used and its eflEect noted by means of the diagnostic tube.
If the passage is found patent, you may continue the inflation, using a
nebulized current if necessary, but never under too great pressure, as
where this is necessary it is doubtful if any permanent good can be
accomplished and the liability of harm is greatly increased. Death is
said to have been caused by this. At times an alarming emphysema in
the surrounding tissues occurs. I have met with this accident two or
three times but have never seen any harm follow. I have had haemor-
rhage of the middle ear occur once and have known of its occurring
in two other cases. It is indicated by quite acute pain and inspection
of the driunhead plainly shows a dark fluid mass behind it, and in my
case I could plainly see the middle ear slowly fill. The pain lasts some
twenty-four hours, but absorption took place in a few days without
further discomfort. This accident is illustrated and described in the
De Schweinitz-Randall "American Text-Book on Diseases of the Eye,
Ear, Nose and Throat" just issued. I once ruptured the membrana
tympani while using Politzer's bag, the patient being an old gentleman,
but as it evacuated some pent up fluid in the middle ear there was a
marked improvement of the hearing.

During the past winter I accidentally stumbled upon an interesting
and, what seems to me, a valuable aid to the more satisfactory inflation
with the catheter of many if not all cases. While inflating an old
gentleman whose ears I had never been able to satisfactorily inflate I
was greatly surprised to note that the air was passing freely and, on
looking at the patient, I noticed that his mouth was widely open. On
mentioning to him that at last we had succeeded in opening the tube he
closed his mouth and I was again surprised to find the current of air
was cut off. I asked him to again open his mouth widely and the air
passed as freely as before. I have repeated this observation many times
since then with equal satisfaction, especially in cases of relaxed mucous
membrane where no doubt we push some of the membrane in front of
the mouth of the catheter thus obstructing it.

8S SAVER HASBRO UCK, M.D.

In many cases where I have no difficulty in passing air into the pas-
sage it has not seemed to materially assist matters, but in many others
it has been of great assistance. There is no doubt that opening the
mouth widely has a tendency to contract the tensor palati mollis muscle
whose action opens the Eustachian tube. We have all had frequent
demonstrations of this as we note how the air rushes into the middle
ear during the act of yawning.

In this day of aural massage, with its multiplicity of mechanical
appliances for its accomplishment it is well to remember that they can
accomplish but little of permanent value unless the Eustachian tube is
patent and, when patent, massage of the membrana tympani can be most
satisfactorily accomplished by an appliance that interrupts the air cur-
rent from our compressed air apparatus, either by means of the
Eustachian catheter or by my so-called modified Politzer's method of
inflation aided by external atmospheric pressure, causing the membrana
tympani to move from within out and without in at the same time that
we are applying our nebulized fluid.

DISCUSSION.

Dr. Gustave A. Mueller: Inflation is of such every day importance
to the otologist and is a diagnostic and therapeutic agent so often
employed that scarcely too much can be said on the subject. The
essayist, however, has treated the subject so thoroughly that little can
be added that will shed much light on the matter. He says that
"Inflation is practically the comer-stone in the treatment of aural dis-
ease." And this is true for very logical reasons. Unfortunately the
cases in which inflation is markedly the means by which to effect a
cure come into the otologist's care so late that it is only after long
continued and persistent treatment that it is possible to bring about
relief and then frequently, only too frequently, but partial relief.

I will say nothing of the relative value of the various methods
employed, as each has its own sphere of emplo3mient, and even in each
sphere the skill acquired by different operators in following different
methods must influence the individual operator. I believe that fully
ninety-five per cent, of all the cases of defective hearing with all their
attendant train of local manifestations, such as the retraction of the
drum, perforation of the drum, thickening of the drum, otorrhoeas,
mastoid involvement, &c., could be avoided if an intelligent care were
given at the proper time to naso-pharyngeal growths and diseases
which have a tendency to irritate and assist in bringing about a
catarrhal condition of the Eustachian tubes, in this way interfering
with the natural inflation of the tubes and thus destroying the equality
of the atmospheric pressure within and without the drum. If in the
beginning of these troubles the irritating cause be removed and the

INFLATION. 27

patency of the Eustachian tubes be maintained by inflation I believe
we can avoid in most cases the h)rperplastic conditions, stenoses, &c.,
which are usually the forerunners of middle ear disease. The affec-
tions coming witiiin the otologist's domain have been in the past the
most difficult in which to bring about satisfactory results. The deli-
cate, intricate anatomy of the parts has made us fearful at times, but
in these later days I believe we are arriving at a better knowledge of
ways and means of reaching them. The inflation of the Eustachian
tubes with air saturated with medicaments opens a wide field for
research and observation and I believe the immediate future is preg-
nant with discoveries along this line, which will make the coming
decade an important era in the treatment of aural disease. The essay-
ist has mentioned an experience which I am able to verify by several
experiences of a like nature in my own practice. In several cases,
where I found it impossible to properly inflate the tube through the
catheter, although it seemed to be in proper position, on directing the
patient to open 3ie mouth the obstruction, whatever it might be, seemed
to be removed, and there was no further bar to the admission of air.
My attention was first called to this little point by Prof. Schech of
Munich. In other cases where the tube seemed to be occluded by
tough tenacious mucus it was impossible to inflate properly until I had
passed an Eustachian bougie, and so to a degree cleared the way.
With regard to the method of inflation in the case of children by
making forcible expiration through a rubber tube on the part of the
operator, I must confess I cannot agree. The idea of using the breath
for any such purpose is obnoxious to me, or rather would be, were I
the patient. I have found but little difficulty in bringing about the
desired result by the use of the Politzer bag. Almost invariably
children cry, and tlie very act of crying raises the soft palate and closes
the pharyngeal vault in the same way that the act of swallowing does.
So far as the danger of rupturing the drum is concerned, in adults, I
believe the danger is much overestimated. Personally I am in the
habit of using a fourteen-ounce Politzer bag, and, as I have a strong
right hand, am able to use considerable force, but I have yet to see any
unfavorable result. Our individual experiences are our best teachers,
hov^ever, and there is an acquired, as well as an intuitive knowledge,
of the amount of pressure to exert, which cannot be taught in words.

A BURN OF THE CORNEA.
By John L. Moffat^ M.D.,

New York (Brooklyn}.

MISS E., an intelligent girl fifteen years old, dropped a hot
curling iron upon her open left eye (the face was up-
turned) at about two P.M. on Sunday.
Her father, a physician, at once instilled cocaine and
atropine, gave Aconite 3c hourly, applied heat locally and telephoned
me; I ordered the heat changed to an ice bag and called two and a
half hours later. At that time I saw just below the visual axis a hori-
zontal superficial wrinkled white eschar two millimeters wide extend-
ing six millimeters across the cornea. The pupil was well dilated,
there was ciliary injection, pain, and some redness of the lids and
cheek that had been caused by the hot applications.

I ordered the Aconite continued, instillations — ^whenever the pain
should recur of a 0.25 per cent, solution of holocain hydrochlorate
and iced linen cloths which were to be changed as soon as they ceased
to feel cold. These directions were faithfully carried out, the cloths
being changed about every half-minute except from one to 6 A.M.,
and the holocain instilled a number of times.

The next afternoon, twenty-four hours after the accident, I found
the patient lying comfortably in bed with an iced cloth upon the eye.
To my astonishment a careful examination could detect no evidence of
the accident, beyond the mydriasis and pinkish coloration (externally)
of the lid ! Five days later the ophthalmoscope revealed hyperemia of
the disk; otherwise the eye was normal except for the mydriasis.

Was the eye really burned ? Yes. It was evidently a slight super-
ficial bum causing white swelling of the anterior epithelia. The
prompt re-establishment of their normal condition was doubtless due
principally to the early and continuous application of the cold cloths,
but I doubt if this would have been so effectual without the Aconite.

For such prolonged treatment iced cloths are safer than the ice bag,
and holocain less dangerous than cocaine.

Did the holocain have any but its anodyne effect? Would the
cure have been as prompt and complete under cocaine, even granting
immunity from systemic poisoning by it?

Although holocain smarts more than cocaine it does not desiccate
the cornea, and I believe this desiccating action of cocaine would have
tended to lower the vitality of the anterior epithelial cells hindering
rather than helping the rccstahlishmcnt of their noriTja! condition.

A BURN OF THE CORNEA. 2»

DISCUSSION.

Dr. H. B. Ware : It seems to me that Dr. Moffat prescribed a correct
treatment in this individual case, as is proven by the remarkably quick
recovery ; but as I am to discuss this paper, I must look at the treatment
in a general way in the abstract.

I cannot question the propriety of the ice water applications when
he first saw his case; but I should have used some antiseptic in the
water, such as boric acid, preferably. As to an)rthing else dropped into
the eye, I should have had it sterilized first. He used holocain. This
drug is not capable of being treated to the sterilizing point and retain
its anaesthetic properties, as eucain and cocain can be treated. I agree
that holocain is less dangerous to a corneal abrasement than is cocaine,
when neither is sterilized, for the latter seems to retard granulations,
especially when the deeper structures are involved. In this case, if the
pain was not relieved by the ice applications, I should have used a
eucaine solution first having had it thoroughly sterilized; but I think
I would have used a mild opiate before any local anaesthetic. I should
be induced to think the ciliary injection and h)rperaemic disc were due
more to the mydriasis rather than the injury.

In regard to the questions as to whether holocain had any but an
anodyne effect, I should say no, as no healing properties are accorded to
it. The question as to whether the cure would have been as prompt
had cocaine been used, I have already answered. But why, in such a
case, is it necessary to choose between two evils, for a superficial bum
will heal almost of itself without any treatment when the congestion of
the blood is controlled by the early use of ice applications. A burn from
lime, which often happens to plasterers, must be treated differently.
Oils should be used, such as castor oil or linseed oil, but these should al-
ways be borated, and never use cocain or holocain. Sterilized eucaine
I have used with no bad after effects in these cases. I will state here
that it has been my observation that even eye men are at times careless
in making thorough examination of the eyes of plasterers when burned
from lime. They find a bum on the cornea and treat that without
looking further. In two cases I have found a symblepharon which
should never have been allowed to occur, owing to their location, had
proper care been exercised by the oculist in his examination at the time
of the injury.

Dr. B. W. James : I am not surprised at the action of this case in
healing so promptly ; because, as we know, the application of thermo-
cautery to some of these ulcerations of the comea rather stimulates the
growth, or, at least, the repair of that structure. I have seen the red
hot, or intensely hot, thermo-cautery swept across with beneficial results
and the ulcer has healed very promptly under this treatment. I do
not doubt that many of the members here have adopted such a plan.

Dr. Chas. Deady: About ten years ago, in my clinic in the New
York Ophthalmic Hospital, I had a case in which hot lead had been

80 JOHN L. MOFFA T, M.D.

dropped into an eye. The entire cornea was covered with one large
eschar. It looked bal for the patient. In trying to do something to save
some vision, I put him on the operating table, and very carefully
cleaned off the eschar until the cornea was clear over its entire sur-
face. That man was discharged in a week with an entirely clear
cornea. I have a case in the hospital now, with a bum from a hot
coal which stayed in contact with the eye longer than the lead did, in
which I followed the same treatment, with nearly as good a result,
although in one place the bum was too deep to get a perfect result.
The first case was absolutely perfect, and I was very much astonished
as I had never treated a case similarly before. The treatment was
like Dr. Moffat's : iced cloths, and Aconite, but I did not use holocaine.

Dr. Geo. W. McDowell: Nearly five years ago I had two cases
occurring within a month of each other in the left eye, in which the
cornea had been burned by a curling iron. In one the entire surface
of the cornea had been scorched so that it looked like a case of intersti-
tial keratitis. In both cases healing was very prompt and the cornea
became entirely clear in three days, cocaine being used to relieve pain,
and Aconite given in both cases. The eye was bandaged afterwards
and atropine was instilled to prevent possible trouble in the iris. I
think the bums of the cornea need no antiseptics, as Doctor James
has pointed out, the cautery being itself an antiseptic, and hence we
need no antiseptic solutions, which rather interfere with the healing
of cases of this kind than otherwise. The superficial layer of the
cornea sloughed off in about twenty-four to forty-eight hours in my
cases.

Dr. Sayer Hasbrouck: I have had a unique experience in the
curling-iron business. I have seen the cornea burned I don't know
how many times by ladies themselves, and had it always heal with the
same result as Dr. Moffat, showing that evidently the iron did not
remain in contact very long with the surface. Two years ago I saw
a case where a curling iron was used by a nurse upon a child, and in
some way she burned the child's cornea. That was a very different
condition of affairs. There we had severe ulceration for some three
weeks, showing that though she pulled the iron away very quickly from
her own eye, yet, when she had touched it on someone's else eye, it
might do serious damage. In other words, the eye is safe in the hands
of the patient, but if in the hands of the second party, you are liable to
do just as much damage with the curling iron as any other application
of heat.

Dr. F. H. Boynton: Something should be said of the influence of
fee on the healing process. Superficial bums of the cornea yield
promptly whether you put on ice or not. The eschar remaining de-
pends upon the depth of the bum — ^how deep the tissue is involved. It
would not be safe, in my opinion, for the impression to prevail that
ice is a good thing to apply to the cornea. Our experience at the
hospital (I think Dr. Deady and the other gentlemen present will bear
me out) for several years has taught us to give up the use of ice as

A BURN OF THE CORNEA. 31

soon as an ulcer forms in the course of disease of the cornea. These
superficial wounds heal well with ice. That agent will heal trauma-
tisms from many causes.

Dr. Chas. Deady: Ice does more than relieve pain. The reaction
from a bum of the cornea is often very great. If you prevent that re-
action with ice, I think you help and hasten your case. If you do not
use anything, the reaction in my opinion is often a great deal more than
if you use the ice.

Dr. John L. Moffat : Of course it was my duty to dilate the pupil ;
atropin was the best mydriatic under such circumstances, although I
wanted to give Aconite internally. Whether either would have acted
better had 1 not given the other cannot be said, probably the action of
the atropin was practically local and the Aconite mainly constitutional.

What impressed me was the prompt recovery after so threatening
an aspect. I have not tried to sterilize holocain; have used it for
cataract extraction and foreign bodies, but prefer eucain B except for
the latter when I do not mind its irritation.

THE MICRO-BIOSCOPE FOR THE MINUTE STUDY OF

LIVING STRUCTURES.

By F. Park Lewis, M.D.,

Buffalo, N. Y,

ONE of the most profound of our modern scientists has said that
to see the dead tissue under the microscope is to see the
fireworks the day after the show. The energy which has
actuated the thing and made it what it was has gone — ^and what is left
is simply the empty shell. There has been a growing feeling, there-
fore, that, if the obscure problems in the life history of living structures
are to approach solution, these structures must be studied while they
yet live. Hence it is that biological research has progressed even more
rapidly than microscopy and while making use of the latter has not
been wholly dependent upon it for its most important conclusions. It
has been apparent, therefore, that if an instrument could be devised by
which an insight might be got into Nature's laboratory while she was
at work — if she might be caught, so to speak, in flagrante delicto —
that she might be led to betray some of the secrets which up to the
present time she has so carefully guarded. Her most vulnerable point
seemed to be the eye, one of the most vigilant sentinels of the nervous
citadel ; so sensitive that the intangible light rays will cause the normal
pupil to respond with the delicacy and certainty of a finely attuned in-
strument and probably more delicate and more responsive under the
best conditions than the most accurate artificial instrument ever made.
If, then, it were possible to observe this mimosa plant as Thoreau is
said to have seen Nature, as with the eye of a microscope, what possi-
bilities of biologic function might not be opened up to the inquiring
mind and the observing eye? What are the differences in the result
when the eye is stimulated by the lower red and the upper violet of the
spectrum? What, is the effect upon this sensitive instrument of the
ten or a dozen octaves of invisible light far up in the actinic field, be-
yond that recognized by conscious perception, or down through the
caloric rays that bolometric measurements have shown to exist in the
infra-red portion of the' color field ?

It is unnecessary to take the time of this Society to outline the

THE MICRO-BIOSCOPE, 33

multitude of fascinating problems that obtrude themselves for solution,
but the impelling desire to know more made necessary an instrument
by which more could be seen. Many atempts to secure such an instru-
ment were met by failure, until the problem was presented to H. L.
De Zeng, Jr., to whose broad knowledge of optics together with his
skill and ingenuity I am indebted for this instrument. To Mr. De Zeng
a like problem had suggested itself and he had already constructed
some instruments which might be readily applied to this kind of inves-
tigation. The demands to be met were a compound microscope with
suitably balanced lens systems, the objective being of sufficiently wide
angle to give a flat field, and the whole being so placed that it could
readily be approached to the tissue to be studied.

With De Zeng's aid these requisites were met and, as a result, I
have the pleasure of exhibiting to you what I have designated as the
micro-bioscope, an instrument, as the name implies, for the micro-
scopic study of living structures. It consists of a brass tube lo^
inches long, and having a draw tube giving almost double that length
when completely extended. It is mounted on a round rod, which may
be fixed by a set-screw at any height. It may also be rotated on this
rod at any meridian. The rod is attached to the tube by a hinge joint
so that any angle or position may be readily obtained. The tube is
placed upon a rack-and-pinion adjustment, so that the working dis-
tance of the lens system — about t^/t, inches, may be quickly covered.
While the brass mechanism is exquisitely made — ^the — correction and
adaptation of the lenses is a triumph of optical skill that reflects very
great credit upon Buffalo workmanship. I have never seen more
beautiful lenses than those employed in this instrument.

The objective is a five-inch achromatic lens corrected for the
cornea, iris and interior lens surface. It has an angle or aperture of
35 degrees and this, with a 2j4-inch eyepiece gives an amplification
with the draw tube in of 20 diameters ; with the draw tube out, of 50
diameters, with the one-inch eyepiece which may be used, we get an
amplification* of 50 diameters, as a minimum, and 125 diameters as a
maximum enlargement. Any point between these may, of course, be
obtained by extending the tube to a lesser distance.

In the few weeks that I have been using this instrument Ihave
had opened to me a wholly new vista in biologic and pathologic study.
The groups of vessels surrounding the corneal margin have presented
a beauty and an interest never recognized before. It is now possible
to follow the new vessels as they make their way in corneal inflamma-

34 F, PARK LEWIS, M.D.

tion into and through the transparent structures, the study of corneal
reflexes will take on a new value since they may be studied in such fine-
ness or detail. But the fascination of the micro-bioscope is in the won-
derful view which is obtained of the iris and pupillary margin. This
exquisitely sensitive orifice is never quiet — in the normal eye. It is
tremulously feeling for the stimuli by which it is affected. The effect
of the fluttering of an unsteady light may be watched in the responsiv*
action of the swelling and contracting pupil. A mental start, a sudden
word, shows its effect under the micro-bioscope.

I shall not attempt to outline here its possible range of usefulness,
as this is merely a sketch of the instrument and any elaboration is out
of place, but I wish to say that its possibilities in the investigation of
life problems grow upon one as the beautiful pictures are brought in
view, and I shall be surprised if the micro-bioscope does not prove a
valuable aid to the student in many lines of scientific research.

BLOOD POISONING IN A CASE OF EMPYiEMIA OF THE
ANTRUM FOLLOWING ACUTE MIDDLE EAR CATARRH
—RECOVERY ON THE USE OF LACHESIS.

By Leigh Y. Baker, M.D.,
Washington, D. C.

WHILE cases of antral empyaema of a chronic nature are
frequently met with in both medical and dental practice,
the acute form is less often noted, but when seen, the
cause of the trouble can generally be easily referred either to carious
teeth or to extension of post-nasal trouble; the former being by far
the more frequent cause of both the acute and the chronic form.

In reviewing this subject, I could not find recorded a single case
Adhere middle-ear catarrh was even suspected as being an etiological
factor, nor can I find a case of empyaema where Lachesis was either
used or suggested as a remedy, so that on both points this case seems
to stand alone, and this being so I can cite no cases in reference.

Under Zuckerkandl and Hajek of Vienna, one is taught that the
first procedure in the treatment of this condition is to obtain drainage
by going through the wall of the nostril or by tapping the antrum
through the socket of an extracted molar or bicuspid, and possibly this
is the only rational course to pursue; in fact, I had determined upon
this procedure, when, to my great surprise, and I may say, satisfac-
tion, my case showed signs of improvement, so that the idea of opera-
tion was first postponed and then abandoned.

Case. — On Nov. loth I was called to see a case of "earache" in a
girl of about ten years who was anaemic and poorly nourished. I
found considerable pain in both ears but more marked in the right.
The discharge, which was more profuse from the left ear consisted
of a thin, yellowish fluid, excoriating, and with very little odor.

There was a history of chronic otorrhcea, and the parents did not
comprehend the gravity of the condition for I had only been called
on account of the pain. I learned that the discharge had been present
for some days before I saw the patient.

I cleaned the canals with dry cotton and found perforations of both
drums, the larger being of the left. There was not as much evidence
of inflammation as I had expected to find, and although the pain had
been great during the night, it had diminished to a considerable extent,
and there was very little at the time of my visit. I gave Capsicum 3x
and Pulsatilla 3x every half hour.

86 LEIGH V. BAKER, M.D.

On the next day, Nov. nth, the pain had been much less and
there had been no discharge from the right ear, while that from the
left was markedly less. I repacked the external canals with calendu-
lated boracic acid and continued Capsicum and Pulsatilla as before.

Nov. I2th. — No discharge from the right ear; had had a good
night until early in the morning when she was awakened by a darting
and throbbing pain in the right side of the face which had increased
in intensity as the time passed. Gave Aconite 3x and Hepar sulph. 6x.

Nov. 13th. — The pain had increased and was then intense. The
right side of the face was swollen and flushed while the left side was
of a peculiar, waxy appearance. She could not open the mouth very
widely, and such examination of the tongue as could be made showed
it to be swollen, dry and brown. There was a discharge of a yellowish
semi-fluid substance from the right nostril when the patient sat up in
bed, which, in fact was the only comfortable posture she could asstime.
I redressed the ears and gave Belladonna 3X Hepar 6x.

Nov. 14th. — ^The infiltration of the tissues had increased, but the
pain was somwhat less and the patient was much more comfortable.
Discharge from the nostril still profuse and had changed to a muco-
purulent character. — Continued Belladonna and Hepar.

Nov. 15th. — Patient had had a succession of chills with a rise in
temperature. Pain was more intense and throbbing. Discharge from
nostril had considerably decreased. Teeth separated about a quarter
of an inch and jaw could not be moved. The mouth was dry. The
face, nose and lips were swollen and blue and the tissues around the
right eye were so infiltrated as to nearly close the lids. Gave Lachesis
6x one grain every quarter hour and went out to consult with a
dentist, leaving with the understanding that if the conditions were not
materially improved by the next day, an operation through a tooth
socket should be done. In the evening the patient was a little more
comfortable and the nasal discharge seemed slightly increased.

Nov. i6th. — The pain was much less and, although the swelling had
not diminished, the patient could move the jaw slightly — she was
brighter and complained of being hungry, which was the first indica-
tion she had given of any appetite whatever. Continued Lachesis.

Nov. 17th. — Pain was decreasing and she had passed a fairly com-
fortable night. Complained of soreness and stiffness of the neck but
she could open the mouth better and had more appetite. Lachesis con-
tinued.

Nov. i8th. — Pain almost entirely absent. Some swelling of cervi-
cal glands. Blue color fading but face still considerably swollen.
Discharge from nostril continues, but less purulent in character.
Stiffness of jaw considerably less, but lips are quire sore. Gave Mer-
curius corr. 6x, Lachesis 6x.

Nov. 19th. — All conditions are much improved. Patient expressed
a desire to leave the bed and dress. Glands seem normal. Continued
Mercurius corr, 6x, Lachesis 6x.

Nov. 21. — Had a slight chill and temporary rise in temperature

BLOOD POISONING. 37

but local conditions seem improved. Appetite still on the increase, but
gave orders to lessen the amount of food given. Lachesis 6x.

Nov. 23d. — Swelling of the face rapidly diminishing. Mouth,
throat, tongue and nostrils feel and appear in good condition. Both
ear drums thickened around perforations but otherwise normal. Lache-
sis 6x.

Nov. 26th. — Patient still improving. Lachesis 6x one tablet every
four hours.

I continued treatment of the ears and the perforations ultimately
healed and hearing became nearly normal. On Dec. 28th I saw the
patient. She was in a very good condition, in fact, was in better health
than before her illness.

An examination of the teeth revealed no condition which could
have incited an attack of pyaemia, they being in a perfectly sound
state, and the nares were in a healthy condition both before and after
the attack, so that the ear seems to have been the only possible source
of infection.

My prescription of Lachesis was made principally on the blue color
of the tissues, but its good work continued after every Lachesis symp-
tom had subsided, and I relied on it to the end of the treatment.

DESTRUCTIVE DISEASES OF THE NOSE.
By Edward Beecher Hooker, M.D.,

Hartford, Conn.

WHAT I have to say on this subject is so simple and brief
that I hesitate to put it on paper and were it not of
practical importance, in a class of cases of common occur-
rence and at the same time difficult to handle in a satisfactory manner,
I would noi have ventured to lay it before you.

Destructive diseases of the nose are malignant and benign. I have
had a very limited experience with cancer of the nose and if I at-
tempted to tell you anything about it I should simply state what I have
read in the text-books and as I propose to do nothing of the sort I
shall not speak of cancer at all. I have never seen a case of lupus
of the interior of the nose, therefore I shall not weary you with an
account of something about which I have no original knowledge. This
plan of elimination that I am following is a good thing for me, for it
lets me out of a lot of second-hand composition, and it's a mighty good
thing for you — for you do not have to hear it.

The destructive diseases that I have in mind are atrophic rhinitis
and syphilis, the ulceration and bony necrosis of the later stages. All
diseases of the nose attended by destruction of tissue have certain fea-
tures in common, whatever the cause of the disease and whatever the
degree of destruction. The turbinated bodies, and the mucous mem-
brane covering all the interior of the nose have several functions, which
are, to warm the inspired air, to free it from floating impurities and to
render it moist. The upper third of the nose is also endowed with
the sense of smell. In order to perform its functions the
mucous membrane must itself be soft, pliable and moist.
With the loss of membrane, be it only the superficial epi-
thelial layer, such as we find in dry catarrh or in the destruction «^f
syphilitic ulceration, comes loss of function and we have the first im-
portant symptom^-drjmess. Such secretions as there may be are thicker
than normal, dust collects on the membrane, scabs or crusts form and
adhere and a foul odor follows. This odor may be something really
horrible in a case of atrophic rhinitis and the stench from a syphilitic
nose in process of caries is beyond description. The secretions them-

DESTRUCTIVE DISEASES OF THE NOSE. 39

selves are ordinarily but little offensive, but when they are retained
beneath the crusts they undergo decomposition and the odor arises.
If the formation and retention of crusts can be prevented there will
be little or no odor, even in cases of deep ulceration. The problem is
then how to keep the nose clean. I believe it to be impossible to re-
store to normal functional activity to the mucous membrane in advanved
atrophic catarrh, but it can be kept clean, odor prevented and a high
degree of comfort afforded. The same may be affirmed in regard to
syphilitic ulceration. I was led to adopt the method of treatment,
about to be described, during the course of a most obstinate and offen-
sive case of syphilitic ulceration and necrosis. I did not at first believe
the case was one of syphilis, although the patient was a man of disso-
lute habits, for I could get no history of an initial lesion or of the
ordinary secondary symptoms. There was already partial destruction
of the septum and turbinated bodies when he came to me, yet there were
certain unusual features which made me suspect cancer. No improve-
ment following the remedies at first administered, I put him on Potas-
sium iodidt', in medium doses, five grains four times a day, and he soon
began to improve. But after awhile he neglected to follow it up and
left me for several months. When he came back there was greater
destruction. Treatment was resumed for several weeks and improve-
ment again occurred, but for a second time he tired of it and left me
for three or four months. Finally the unspeakable odor forced him to
return for treatment, with the determination to stick to it until som.e
permanent relief was afforded. His condition was then as follows:
the septum was almost wholly gone, a small portion suspended from
the roof of the nose alone remaining, all of the turbinated bodies were
destroyed and there remained one great reeking nasal cavity, whose
surfaces were covered with adherent scabs and crusts, beneath which
bloody secretions were festering. The stench was such that no one could
live in the same room with him. There were but two ameliorating
circumstances — he could smell nothing himself and the nose did not
cave in. Every day for weeks I carefully picked off the crusts and
cleaned the surface as thoroughly as possible, finishing with generous
spraying with bichloride of mercury, formolyptol, or hydrogen dioxide.
At home he used a nasal douche of salt water and antiseptic spray$.
Internally he took Potassium iodide. The condition of the nose im-
proved, but very slowly; the odor was lessened, but still rank, and
every day I found the surfaces covered with crusts that had accumu-
lated since the previous treatment. Moreover the crusts adhered so

40 EDWARD BEECHEk HOOKER, M.D.

firmly that their removal irritated and caused bleeding of the tissues
beneath. Powerful sprays had but little effect in cleaning the nose,
but were useful for disinfection afterwards. One day on beginning
treatment J took an ordinary hard-rubber post-nasal syringe, inserted
it into the nasal cavity through the nostrils and forcibly syringed the
whole interior of the nose with a pint of 1-2000 bichloride solution,
part of the liquid going backwards into the pharynx and escaping
through the mouth, the rest of it escaping forwards through the nostrils
into the basin which the patient held. When I examined his nose I
was surprised — there was hardly a crust to be seen and what little
remained was so soft that I easily wiped it off with cotton on probes.
The solution had dissolved and washed out practically the entire mass
of scabs and crusts, and the tissues were left clean and unirritated.
I had the patient get an ordinary hard-rubber syringe and use salt
water several times a day, with the result that the crusts ceased to
form, the odor became barely perceptible, ulceration ceased, and the
interior of the nose became comparatively healthy. For a time I
kept up the treatment with the bichloride wash every few days, but the
nose was so clean that there was little for me to do, except that the
necrosis had destroyed the bone between the nasal cavity and the
sphenoidal sinuses and it was necessary for me to wash out this acces-
sory cavity with a long, straight tipped syringe.

Acting on the suggestion derived from this case I began treating
all cases in which there was loss of tissue and formation of crusts witn
the syringe and salt water, with excellent results. Sprays are useful
for disinfection, nasal douches will wash, clear the floor of the nose,
but when there is destruction of tissue (and consequently plenty of
room) and formation of crusts high in the nose, the surfaces must be
kept clean, to prevent odor and to allow repair, and I know of no means
to be compared in simplicity and effectiveness with frequent, persistent,
and vigorous use of a syringe and salt water.

DISCUSSION.

Dr. G. M. Ha)rwood: Like Dr. Hooker, I have had no experience
with cancer or lupus of the nose ; my experience with destructive dis-
eases of the nose being limited to atrophic rhinitis and syphilitic ulcera-
tion and necrosis. A case of the latter, which I reported to our State
society, was of so interesting a nature that a few of the principal points
may be of value. The patient, a man of thirty, had contracted syphilis
six years before; his nose had been troubling him a year before he
came to me, but he had received no treatment for it. The nose was so
sore and sensitive he was unable to blow it — with cracks and fissures Li

DESTRUCTIVE DISEASES OF THE NOSE. 41

ala, and a large ulcer at upper junction of ala nasi with triangular car-
tilage; the cavity was full of crusts and scabs, which on removal
showed almost entire destruction of the cartilaginous as well as the
bony septum. Also entire destruction of the lower and middle tur-
binated bodies, the hiatus semilunaris in full view so that a probe could
be carried into the antrtun of Highmore without difficulty. There was
no odor, nor had there been any.

This patient, like Dr. Hooker's, treated a few weeks then stopped
all treatment; more gumma formed, broke down, and when he r-r-
turned for treatment, despite Kali. iod. and Mercury a gradual de-
struction of the tissues took place, until all the septum, both cartilagin-
ous and bony, was gone ; the nostrils and antrum of Highmore of right
side was one reeking filthy cavity — ^the tip of the nose was broadened
and flattened, but as the bones forming the bridge of the nose remained
intact there was not much deformity.

My method of cleansing was a little different from Dr. Hooker's.
I used Marchand's Peroxide solution with a post-nasal syringe, fol-
lowed by a Seiler solution ; until all crusts were removed ; all ulcerated
surfaces were then treated with mercuric nitrate 3 per cent., argentum
nit. 2 per cent., or comp. tinct. of benzoin ; also the cracks in ala were
treated, followed by a thorough application of nosophene, which I have
found the best powder for all ulcerated surfaces of the nose, throat
or ear, as it has all the good properties of iodoform without any odor
at all.

I had the patient cleanse the nose night and morning with a Success
syringe (which is a soft-rubber bulb with a perforated tube six inches
long attached, and is the best thing of the Icind I have ever seen for
self use in atrophic syphilitic rhinitis or pharyngitis), followed by a
spray of hydrastis oil, which prevents the crusts from sticking so
tenaciously.

In atrophic rhinitis the same local treatment is beneficial, with the
addition of a permanganate solution, or one of sanitas oil if there is
much odor.

Dr. Rice: I have had some success in the use of the Shoemaker
nasal syringe. I was led to its use in a case similar to Dr. Hooker's
and found it more satisfactory than a straight syringe; and it is an
instrument that any patient can use with safety. It is similar, I pre-
sume, to Dr. Hooker's. It has a rubber bulb with a shaft about three
inches long, with numerous openings on the sides and on the end.
The patient introduces it into the nose and forcibly presses the bulo,
slowly drawing it forward. In this way the crusts are washed off and
the nose thoroughly cleansed.

Regarding the medicinal treatment of syphilis, we should as hom-
oeopathists. apologize to ourselves if we depart from the line of treat-
ment of giving the indicated remedy in small doses unless we do so
in a perfectly open way : and yet I do not personally believe that we gel
very marked, quick or lasting effects from remedies given according to
strictly homoeopathic methods in the third stage.

The third stage of gummatous formation and ulceration is sometimes

42 EDWARD BEECHER HOOKER, M.D.

very rapid in its destructive processes: for instance, adhesion to the
soft palate, perforations of the hard palate, destruction of the septum,
etc., occur : and it seems to me that if one given line of treatment, no
matter whence its source, is efficacious and will control those destruc-
tive processes, it is our duty to use it; but I do not believe that we
should call it treating the case homoeopathically.

What we want is the truth regarding the efficacy of our therapeutic
methods, and this cannot be obtained by attributing cures to homoeo-
pathy which are performed in other ways entirely. It has been argued
that iodide of potash is homceopathic to syphilis in the third stage. I
do not believe that we have half the evidence of its homoeopathicity to
the disease as in the case of the bichromate, yet the latter drug is of lit-
tle benefit here. These points should be freely and fully discussed.

Dr. Fred. D. Lewis : In regard to the internal treatment of syphilitic
conditions, I noticed in Burt's Physiological Materia Medica several
years ago that copper sulphate had been given and a series of fifty cases
were reported at a meeting of the Paris Academy of Medicine where
they administered ^/^^ to Ve ^^ ^ grain a day. I had two years ago a
case referred to me, where the uvula was entirely destroyed and the
soft palate was in process of destruction. The case had been treated
for some time by his physician receiving the regulation treatment. 1
put him on a */io of a grain of cupric sulphur a day. The disease was
checked and there has been no recurrence of any syphilitic conr'ition
for two years. In several cases since, I have given */jo-grain doses a
day with marvelous results. I do not pretend to say that that !S
homoeopathy. I do know, however, that I get results from it.

Dr. Hooker: In conclusion, I desire to say that I instruct patients
with atrophic catarrh to consider their nose as much a part of their
person to be taken care of as they do their teeth, or their finger-nails,
or their ears. They have got to keep it clean if they have atrophic
catarrh, or they will have the formation of these crusts and there will
be odor. Therefore, with one kind of syringe or another, they must
wash out these accumulations and do it persistently and faithfully, or
there will be accumulations and odor. It must be a part of the toilet.

I sympathize and feel just as Dr. Rice does, in the treatment of
sjrphilis. When I get a case of syphilis, I have to give mercury in
appreciable doses, or iodide of potash, perhaps, in the later stages. I
have made a number of faithful attempts to follow out what we call the
indicated remedy in small doses, and I have had to stop because I did
not dare allow the destruction to go on. That is all there is to it.
Portions of the pharynx disappeared before my eyes till I began to give
some of the remedies which I do not consider homoeopathic, but which
I find more effective than those which are purely homoeopathic, there-
fore I use them, and I want to put myself on record as being, first of
all, a physician. I am a homoeopathic physician, I am glad to use
homoeopathic remedies if 1 can ; but I want to use any means that are
useful to cure my patients, and I dp not consider that I am a mongrel
or anything of the kind. I consider that I am an honest man, doing
the best I can with the knowledge that is given to me.

ATRESIA PHARYNGIS.
By Charles E. Teets, M.D.,

New York.

ADHESION of the soft palate to the pharyngeal wall may
be congenital or the result of an ulceration of these parts.
Where the soft palate becomes adherent to the pharyn-
geal wall as the result of ulceration, it is either due to the carelessness
of the patient or to the lack of proper treatment. Therefore before
discussing the operative treatment, I wish to call to your attention
the treatment for preventing adhesions of this part of the pharynx.

Usually these ulcerations are due to syphilis, and involve not only
the pharyngeal wall but the posterior edge of the soft palate. During
the healing process, the parts are not only apt to become adherent, but
as cicatrization occurs there will be a strong tendency to contraction
and closure of the opening from the ora-pharynx to the naso-pharynx.

By systematic dilatation this can be prevented. The patient should
be seen every day if possible; the parts cleansed with a post-nasal
syringe and after applying cocaine, the physician himself should dilate
the opening. At the same time the patient should be taught how to
use the post-nasal syringe and the dilator and instructed to make
traction on the soft palate with the post-nasal syringe and dilator.

The symptoms are similar to those resulting from adenoids and
different forms of nasal obstructions. Nasal respiration is obstructed
compelling the patient to breathe through the mouth air which not
being warmed, moistened or purified of its irritating elements, inter-
feres with the functions of the pharynx and larynx. The pharynx
is dry and the voice altered, having a muffled sound or non-resonant
quality. The sense of smell and hearing is also impaired and the
patient experiences great difficulty in clearing the nose.

There may be a complete or incomplete closure of the opening, but
this makes but very little difference in the treatment because the dif-
ficulty usually met with is not the division of the adhesions but main-
taining the artificial opening after it has been made.

Different methods have been devised to prevent re-adhesions and
contraction. Some operators acting on the theory that re-adhesion was

44 CHARLES E. TEETS, M.D.

the main difficulty in overcoming these deformities have after the in-
cision applied to the cut surface trichloracetic or monochloracetic acid.
This establishes a superficial slough which is maintained in position a
sufficient time to allow the edges to granulate beneath.

Dieffenbach after separating the adhesions passed a strip of linen
through the nose and allowed it to fall below the free border of the
palate so as to prevent re-adhesions. Dzondi packed the opening with
charpie for the same purpose while Vemeuil suspended in the pharynx
a series of drainage tubes, strung on a thread, which was passed
through the nose. Vemeuirs object in using drainage tubes was not
only to guard against a re-adhesion of the parts, but also to permit of
the passage of air. In addition to this he instructed the patient to
dilate the opening daily by means of a small rubber bag, acting on the
principle of Barnes' uterine dilators.

Cook's device which is said to have been successful, consisted of a
quadrilateral lead plate, suspended in the pharynx. After severing the
attachments this was suspended in the pharynx by means of threads
passed through the nose and worn for six weeks. Championniere con-
structed a curved silver tube which was passed from below upward
between the palate and pharynx and held in position by arms attached
to the third molars of the upper jaw. This device seems to have been
worn with comfort and followed with excellent results.

One case came under my observation in which a seton had been
used to make an artificial opening, but this was a complete failure as
contraction and re-adhesions soon closed the opening. Lieven after sep-
arating the adhesions powders the parts with europhen and packs the
naso-pharynx with europhen gauze for ten days. Then a rubber bag
is passed into the naso-pharynx with a tube extending through the
nares by which the bag is distended with air. This is worn for several
hours each day.

Nichols method for the relief of adhesion of the velum palati to
the pharyngeal wall is as follows : The pharynx having been cocain-
ized, the thickness of the adhesion is ascertained by passing a curved
steel bougie through the nostril into the naso-pharynx and palpating
the end of it by means of the finger. An incision is then made in the
medium line upon the end of the bougie. The next step in the process
is the same as if the closure were only partial. An ordinary staphy-
lorrhaphy needle curved to the right or left, as required, is armed with
four or eight strands of coarse suture-silk. It is then passed through
the center opening into the naso-pharynx and carried as far as possible
directly outward ; turning the handle it is then brought into the ora-

ATRESIA PHARYNGIS, 45

pharynx, cne end of the suture is grasped, the needle withdrawn
and the ends of the sutpre tied near the central opening, leaving the
loops loose enough to play freely through both perforations. If neces-
sary, the same procedure is applied to the opposite side. The suture is
moved slightly every day, and in from ten to fourteen days healing takes
place, a smaU canal remaining, slightly larger than the diameter of the
suture. Traction is now made upon the loop toward the medium line,
in order to stretch the canal, and inco it is introduced a staphylorrhaphy
knife curved on the flat, the tissue between the two openings is then
cut through and the parts kept dilated until healed.

GriflBin reports a case which was successfully operated upon for the
relief of adhesion of the soft palate to the posterior wall of the pharynx.
He first dissected an opening into the upper pharynx by the aid of a
sound passed through the nose. This was kept open by the habitual
use of a dilator by the patient himself. Duncan had the blades of a
pair of blunt-pointed scissors bent at a right angle, their points slightly
curved forward to avoid the roof of the pharynx, and their outer edges
converted into cutting blades. The parts being cocainized, the scissors
were introduced, and by firmly opening them an incision was made
over an inch wide. This was kept from re-uniting by using the scis-
sors, their blades protected with cotton, as dilators, and occasionally
severing the commencing adhesions at the angles of the wound with
the naked instrument.

Dieffenbach and Lesser's plastic operation, where the adherent
portion of the palate is turned about, in such a way as to form a palate
whose healthy membrane faces the pharynx, and the raw surface pre-
sents anteriorly does not overcome the main difficulty.

From the different methods that have been employed to correct this
deformity it is seen that it is a difficult matter to maintain the artificial
opening and prevent contraction. It demands constant attention to
obviate this and preserve a sufficient opening for functional purposes.

The method which I have found to be sucessful in maintaining the
opening is as follows : Where an opening already exists it is enlarged
by separating the adhesions as far as possible with a blunt angular
knife and then applying to the cut surface trichloracetic acid to pre-
vent re-adhesions. During the healing process contraction takes place
with wonderful rapidity and closure of the opening can only be pre-
vented by systematic dilatation. Therefore the patient is kept under
daily observation and after anaesthetizing the parts with cocaine the
opening is dilated. The patient is furnished with an angular dilator

46 CHARLES E. TEETS, M.D.

in the form of a blunt hook and taught to use it himself. He is in-
structed to use it several times a day not only while the healing process
is going on But for several weeks after the healing is complete, passing
it through the opening and moving it from side to side making at the
same time traction upon the soft palate.

Where there is complete closure of the opening an oval piece is
removed as near the pharyngeal \^all as possible and the upper edge
that is the portion looking towards the naso-pharynx and the lower
edge that portion near the ora-pharynx brought together with a con-
tinuous suture. During the healing process and for several days fol-
lowing, the after treatment is the same as previously described for
partial closure.

I furnish the patient with an angular dilator which I have had made
for this purpose. Bosworth considers the ordinary flexible oesopha-
geal bougie, the best instrument we possess for dilating purposes.
This is passed from above downward through the nose, or inserted
through the mouth, the patient easily acquiring sufficient dexterity to
carry out this manipulation successfully.

A METHOD OF CONTINUED IRRIGATION IN CASES OF
PURULENT OPHTHALMIA, WITH INSTRUMENT DE-^
VISED.

By E. Elmer Keeler, M.D.,

Syracuse, N. Y.

IN February, 1898 I gave before the Onondaga County Homoeo-^
pathic Medical Society, a more or less extended review of the sub-
ject of ophthalmia neonatorum, its history and treatment, both by
the old school and the new. This paper subsequently published in the

HOMCEOPATHIC EyE, EaR, AND ThROAT JOURNAL, of April, 1898, gaVC

a very encouraging report tending to show most conclusively that as a
school both among the specialists, and the general practitioners our
results compared most favorably with those of the dominant school.

In the preparation of this paper I took occasion to correspond with
many of the leading oculists of New York State in our school, inquiring
as to the frequency of ophthalmia neonatorum, their treatment, and
the results obtained. I also secured the statistics from many of the
larger hospitals, where of course every precaution is taken against its
occurrence, and in this way I was enabled to make a fairly accurate
comparison of results in the two schools, both in private and hospital
practice. I also mailed a somewhat similar list of questions to all of
our local men who had enjoyed a large maternity practice. As a result
of these letters, as then reported, I gathered reports from over 2,00a
cases in private practice, and in that number there had not occurred a.
single case of total blindness following ophthalmia neonatorum, where
the physician had delivered the mother.

Of these cases, i per cent., or 20 cases had developed the disease.

In studying the reports from both general physicians and oculists.
I was impressed with the unanimity of treatment which had been fol-
lowed. In reply to the query, "What has been your customary treat-
ment in these cases?" the invariable reply was, as a first requisite,,
"absolute cleanliness." This was followed by different physicians, with
such drugs as boracic acid, argentum nitrate, calendula, listerine,.
&c.

As the result of this treatment, as has already been stated, not a
single case of blindness had occurred in private practice covering over
2,000 cases, and the report came from Drs. Bissell, Norton and Deady

48 E, ELMER KEELER. M D.

that in their special practice they had never lost the sight of a single
eye, where the case had been seen before opacity of the cornea had
occurred. At this time the attention of the profession in New York
was turned to this subject by the action of the old school who proposed
to introduce a bill to the legislature which would make it a misde-
meanor, if in every case, the physician or midwife in attendance, did
not at once upon the birth of the babe, drop into the eyes a two per cent,
solution of argentimi nitrate. This was to be enforced by a fine of
$200.00 or imprisonment not to exceed six months, or both. To make
the need of such a law appeal to the public, statistics were offered, from
old school institutions of course, showing that ophthalmia neonatortmi
was responsible for anywhere from 3 to 70 per cent, of all cases of
blindness ; their own authorities varying to that extent.

However, the percentage may arrange itself, there were two facts
brought out by my correspondents. First, the absurdity of a law com-
pelling the instillation of a drug in the eyes of each and every infant
when only two out of each hundred were liable in ordinary private
practice to contract the disease, and in 2,000 consecutive cases, none
lost their sight ; and second, that it was to methods as closely as possi-
t)le approaching absolute surgical cleanliness, that we as a school owed
our success in its treatment, and also in the treatment of other purulent
diseases of the eye. It became very evident that the majority of our
school looked upon the unnecessary use of a caustic in the eye of ever}'
babe as cruel, and unscientific to the last degree.

That surgical cleanliness was all that was needed, in the majority
of cases became apparent, and to overcome the evident difficulty attend-
ing the treatment of purulent ophthalmia occurring at any age, I was
lead to devise the instrument here shown.

It consists in brief of a hollow lid retractor made of hard rubber,
having along its lower free margin three rows of minute openings com-
municating with the main tunnel inside, one directing its spray upward,
one downward, and one inward.

The instrument is inserted under the upper lid with little difficulty
on the part of the attendant, and causes very little discomfort to thj
patient, even when there is great chemosis.

When once in position, the tube of a fountain syringe is attached
to the tunneled end, and a thorough cleansing is instituted, such as is
quite impossible in any other way with which I am acquainted. Of
course where treatment is not commenced until there is epithelial abra-
sion of the cornea, or actual sloughing of its tissues, the introductioti

IRRIGATION IN PURULENT OPHTHALMIA. 49

of this instrument should only be intrusted to skilled attendants, but
in any other condition it may be used by any one, to whom the usual
cleansing of the eye would be intrusted. Following this method I find
that the accumulated products, auto-inoculable in character, may be
easily removed, and imdoubtedly the greatest difficulty in the successful
treatment of cases of purulent ophthalmia has been the thorough re-
moval oi this purulent infective material. Where the discharges are
frequently and thoroughly removed, strong caustic injections are very
seldom found necessary. The attendant usually finds great difficulty in
cleansing every portion of an infected conjunctiva in an adult, and in
children this is well nigh impossible, by the ordinary methods of even-
ing the lids and attempting to remove the discharge. Also in many
instances the lid was so tense from the inflammation that it was quite
impossible to reach the most important part, the retro-tarsal fold. With
this little instrument this is easily accomplished. It is a self-evident
fact that unless a removal of all the purulent material is accomplished,
that the disease process is sure to continue, and yet this was almost
impossible, owing to pain caused by the necessary manipulation, and the
swelling of the bulbar and palpebral conjunctival surfaces. Now the
sulci may be cleansed with sterile water as often as necessary without
causing the patient any suffering. Any antiseptic may be used as
needed with the same instrument.

My attention has been lately called to the fact that a Dr. Pyle of
Philadelphia has made use of an eye douche constructed upon some-
what the same principles. This is however more like an ordinary lid
retractor, and would fail I believe to as thoroughly and comfortably
irrigate the sulci as the one herewith presented. However this may be,
the use of this instrument has demonstrated the fact that thorough
and frequent irrigation is of the utmost value in the treatment of
purulent ophthalmias.

DISCUSSION.

Dr. F. P. Warner: Dr. Keeler's paper is worthy of commendation
as it brings the treatment of this disorder up to the most modern way of
treating this disease.

The paper shows that the doctor has made a good deal of original
research in investigating the treatment, both in the old school and that
of our own, he having sought his knowledge from over two thousand
cases, as reported by hospitals and physicians in general and specif 1
practice.

These statistics are, however, obtained from cases where the oph-

50 E, ELMER KEELER, M.D.

thalmia neonatorium occurring m only one per cent, of the two thou-
sand cases, has been under the care of a specialist, or in a hospital prac-
tice. Were these statistics gathered from the country districts the
report would not be so flattering. Specific diseases from which this
ophthalmia is generally contracted is not as prevalent in the country dis-
tricts as in the city and larger towns ; nevertheless, many cases of this
disorder occur in the rural districts and the general practitioner
throughout the country, knowing very little about eye diseases, does
not impress upon the mother (many of them not being able to have a
nurse), the importance of absolute cleanliness. Consequently a much
larger percentage would occur in these country cases and more eyes
would have to be reported "permanently damaged."

The paper of Dr. Keeler should be put into the hands of every
practitioner outside of the cities especially, and much emphasis put
upon the point of absolute cleanliness.

The instrument which the doctor has devised is no doubt a good
one and evidently meets all t he requirem ents in cases which have not
gone on to ulceration or d^ajnc^ij^P^ecornea. In this condition
the doctor states that thM^igktion snolftd/Miv be left to experienced
hands. True! but is J^ra good treatment^^ot so serious a disease?
Here every precautio/ snoi||^^e ^m.tg pl'l^^nt any wounding or
abrasion of the sensafty^ tissu&. ^his ''condition comes from a loss
of nutrition to the cornea or from a pressur#[^om the chemosis, and

all manipulation which otrN;;^^^^?!^^^^}^^^^^ ^^ ^^^ inflamed parts
should be avoided. Here itse Cnjs t o iiicr abetter plan is to cleanse the
eye with bits of sterilized cotton wet in some disinfectant, and after-
wards steaming of the eye with an ordinary steam atomizer as was
commonly used for the throat for the purpose of increasing the nutri-
tion. This offers a more rational treatment.

The instrument devised by the Doctor, though I have not seen it,
could be easily used by a physician, but in some cases of nervous chil-
dren it might trouble a nurse or the mother to adjust it. In such cases
a small tube like the vaginal bent pipe of the Goodyear rubber syringe
attached to a fountain syringe offers an easy insertion under the lid
and accomplishes all that is necessary in the way of cleansing.

Some authors state that in former years a large proportion of all
cases of blindness have resulted from this disease, varying all the way
from twenty to seventy-nine per cent. But with the attention paid to
cleanliness the percentage has been much less of late years ; still more
could be done along this line by absolute cleanliness at the time cf
parturition. A disinfectant douche before the delivery would prevent
much of this disease as well as puerperal fever. No eye of a child
should be bathed in the same water as its body, nor with the same
cloth. Bits of absorbent cotton, using only one piece at a time, and
dipped into a disinfectant wash, is the only proper way to cleanse the
eye at birth or thereafter.

The original research of the doctor is much to be commended, and

IRRIGATION IN PURULENT OPHTHALMIA. 51

the invention of the new irrigator adds another instrument to the suc-
cessful treatment of this purulent disease.

Dr. Pajme: I would like to inquire of Dr. Keeler how his instru-
ment is held in position after the insertion, and whether the eye toler-
ates the use of this instrument without the use of cocaine? Can it
be kept in position any length of time and be tolerated by the eye ? It
seems to me, that the shape of the instrument would demand a right
sided and a left sided instrument.

Dr. Moflfat: I noticed at once that this instrument is made for
the right or left eye. This may prove valuable because the essen-
tial of treatment is cleanliness of the conjunctival sac, but I hesitate
to have any nurse or hospital interne introduce this or any other instru-
ment.

I suggest the stem of this instrument be in the middle and prolonged
into a handle so as to make an irrigating Desmarre's lid retractor — tfiat
could be used for either eye, and we could see what we are doing; it
would be necessary to avoid the orifices along the edge having the
effect of saw teeth.

Dr. Schenck: Not long ago in the Brooklyn Maternity Hos-
pital with which I am connected, they had a large number of cases of
ophthalmia neonatorum, some of them very destructive. Then they
began to use Crede's method, which is still practiced, with the result
that it has almost annihilated the disease from the institution. No
purulent cases have occurred in five years, and no eye has been lost in
that time. This method is strictly carried out there, and I think in
institutions this method is very desirable. In private practice it proba-
bly may not be necessary.

Dr. Keeler: I should have stated that the instrument is made in
pairs, one for either eye. It is light, easily used, and, conforming more
or less perfectly to the curvature of the cornea, makes its introduction
almost painless. In fact, comparing it with the ordinary process of
everting the lid and cleansing it with pellets of absorbent cotton, this
method is entirely painless. You simply raise the lid and this instru-
ment slips into place very readily. After it is in position, there is no
irritation following its use at all. If the child is very young it will
lie very quietly and allow the irrigation to be continued half an hour.
With the use of sterile water, at such temperature as you may see fit,
I can see no possible objection that can be made against its use. We
are certainly enabled to cleanse the conjunctival surfaces in a way that
I never before have been able to do by any other method.

MYCOSIS TONSILLARIS.
By Fred. D. Lewis, M.D.,

Buffalo, N. Y.

IN reporting my case of mycosis tonsillaris it is with the intention
of placing it on record, rather than of establishing any new facts
in regard to the disease or its treatment. The disease is of ex-
ceedingly rare occurrence ; its etiology is uncertain, and the treatment
has varied with almost every reported case. The literature is very
scanty, while the microscopical examination of the growth has shown
a variety of organisms; being constant only in the presence of the
leptothrix buccallis. My case is peculiar in the fact that this sup-
posedly essential element is so nearly absent that it can not be con-
sidered as the cause.

Case. — The child, eleven years of age, was brought to me by her
father December 20, 1898, who gave the following history : About ten
days previous to coming, the child had complained of a slight soreness
of the throat, probably due to cold; the mother, always fearful of
diphtheria, examined the throat and was alarmed to see both tonsils
covered with a yellowish white deposit. She took her daughter to the
family physician, who assured her that the disease was not diphtheria,
but frankly admitted that he did not know what it was. He prescribed
per-oxide of hydrogen as a spray, with no evident result at the end of
a week. The father then asked him if he had any objection to the case
being submitted to some one who could diagnose it ; the physician said
he would be glad to have this done, so I was consulted.

Looking through the meagre literature on the subject, I concluded
that the disease was mycosis tonsillaris, and assured the parents that
there was no danger, but that the cure would probably be very slow. I
obtained a culture and also a portion of the growth for bacteriological
and microscopical examination, with results as follows :

The bacteriologist to whom the culture was sent reported by tele-
phone that the tube contained what resembled thrush. This I knew
could not be the diagnosis of the case, as there were none of the
characteristic thrush symptoms. The thrush aphthae was absent ; there
was no soreness or difficulty in swallowing, no diarrhoea, absolutely no
discomfort or constitutional symptoms. The thrush parasite is fre-
quently found, however, in the mouths of healthy children, so I attached
no importance to this report.

The flake, about the size of a silver five-cent piece, taken from the
tonsil, was submitted to another bacteriologist for microscopical exam-

o-e^ZMa-u cue/

MYCOSIS TONSILLARIS. 63

ination. After about six-weeks' delay, the following report was sent
to me:

"Dear Doctor : Examination of sections made from membrane in
case of suscepted mycosis, proves it to have been diphtheritic in charac-
ter. The prevailing organism present is the B. diphtheriae, associated
with a few cocci. Yours truly, ."

Here again I concluded the diagnosis in error, as I had been in the
South for over a month, and on return had found the case unchanged,
with the exception of a decided diminution of the amount of the growth.
The only explanation of the mistake that I could arrive at was that in
the beginning the disease may have been associated with a mild form
of diphtheria, and the spraying for a week with per-oxide of hydrogen
had destroyed the B. diphtheriae, while unaffecting the mycotic growth.

There still being a specimen obtainable, I sent a supply to a third
bacteriologist, with the following result :

"The portion of the growth removed from the tonsil is a milk-white
substance, soft and easily spread between cover-glasses, and after hard-
ening in absolute alcohol, very brittle and easily crumbled.

Methods of Examination Used. — Portions of the fresh substance
were teased in,

1. Caustic potash 2 per cent, solution,

2. In iodine solution,

3. Macerated in Ranviers' alcohol and teased in iodine, Farrants'
solution.

Cover-Glass Specimens. — ^These were made by pressing a small por-
tion of the fresh substance between cover-glasses and then quickly
sliding them apart, fixing three times in the flame and staining in,

1. Gentian violet,

2. Picro-carmine,

3. Gram's method.

Sections. — ^The material was hardened in absolute alcohol imbedded
in parafine and sectioned. The sections were fixed to cover-glasses and
the parafine removed and then stained, in,

1. Hsematoxylin, and eosin,

2. Methylene blue,

3. Gram's method.

The specimen showed the presence of numerous bacilli ; the most
numerous being a non-liquefying, non-chromogenic bacillus, resemying
the diphtheria bacillus. Some threads of a leptothrix and some speci-
mens of what was presumed to b^ some form of an ascomycetes.

The sections showed the presence of various tissue elements in a
more or less state of necrosis, but not either the leptothrix or ascomy-
cetes in such quantity as to say that either was the cause of the growth.

The clinical features of the case show it undoubtedly tojbe a case of
mycosis, but in the present state of our knowledge of both leptothrix
and ascomycetes it is not possible to say which is the cause in this case
— probably both being instrumental in its formation."

54 FRED* D, LEWIS, Af.D.

The drawings made from these examinations are herewith attached,
showing the leptothrix and ascomycetes.

This case was of so much interest to me, and I was so anxious to
arrive at the proper conclusion as to its nature, that I took the girl to
the meeting of the Western New York Homoeopathic Medical Society
in January, and exhibited the throat to its attending members, about
fifty in all, none of whom could positively diagnose it, but not one
suggested diphtheria.

The parents of the child are both American of Grerman descent,
both healthy, and having several healthy children. The little patient
was not strong as a baby, being only five and one-half pounds' weight
at birth, but now is quite as strong and active as most children of her
age.

The growth had none of the appearance of the diphtheric membrane.
Instead of being smooth and of one piece, it is rough, uneven, and
fungus-like, in appearance.

The growth, when most plentiful, came away with the forceps m
flakes ; later, when somewhat reduced, it was as if pulling out tufts of
moss. Portions of it could be removed at any time without bleeding.

My treatment consisted only of the application each night, to each
tonsil, of powdered borax. With this the growth gradually diminished
until May 20th, when but a small spot on each side, springing evidently
from a deep crypt in each tonsil remained. The child was not suffer-
ing, nor had at any time suffered in the least, from the presence of the
growth, yet as the parents were anxious to have it cured, I applied
deeply trichloracetic acid. A week later finding that the one applica-
tion had not entirely destroyed it, a second application was made, and
this finished it up.

The only cause to which I could attribute the growth was the pres-
ence of a decaying tooth, which I advised the parents to have attended.

The following descriptions of the disease led me to a diagnosis :
Ivins : "Mycosis is a painless and rare affection. Its favorite site
is the crypts of the .tonsils, during chronic lacunar inflammation. . . .
They appear as white or yellow deposits, not unlike diphtheria, when
uncomplicated, are devoid of pain or inflammation, and impart a sensa-
tion of hardness."

Bosworth : "When the spores of this plant lodge upon the mucous
membrane of the fauces, these small thread-like bodies, augmenting
rapidly by fusion, multiply themselves, gradually building up the plant-
like mass of spores which is easily recognized on gross inspection,
standing out from the surface of the mucous membrane as small,
pointed, wart-like projections of a clear milk-white, chalky color. The
presence of this growth in the faucial mucous membrane seems to be
tolerated with almost entire impunity, for it excites no inflammatory
changes whatever in the membrane proper, the symptoms being of a

MYCOSIS TONSILLARIS. 55

ipurely mechanical character. It usually occurs in individuals in the
enjoyment of perfect health, and its presence seems to give rise to no
general disturbance."

Bishop: "This is a very rare parasitic disease of the superior
pharyngeal space, including the tonsils. Small white or yellow
growths appear, projecting above the mucous membrane, instead of
occupying a recessive position, as is the case with tonsillar concretions.
. . . It has, in some instances, a fungoid appearance. ... Its
diagnosis is easily made, since the S3miptoms of inflammation character-
izing pharyngitis, tonsillitis, etc., etc., are wanting.*'

Other authors might be quoted to establish a diagnosis, but I think

these are sufficient.

The conclusion I have drawn from the case is that the bacteriolo-
gists, owing to the rarity of the disease, did not recognize the presence
of the leptothrix, in the first examinations, or that mycotic growths
may exist independently of its presence in sufficient quantities to be cer-
tain that this form of growth is an essential factor in mycosis.

DISCUSSION.

Dr. George H. Quay : In the oro-pharyngeal cavity we find mycosis
presenting in two forms, (i) Small, white points, the commoner va-
riety ; (2) plaques of a yellowish color, somewhat resembling diphtheria
patches.

When appearing on the tonsil it is to be distinguished from lacunar
tonsillitis. In the later condition the exudation appears at the mouths
of the cnrpts, and it is easily raised oflf with a probe, the small white
points 01 mycosis are not apt to spring from crypts, but from the
mucous membrane between the crypts. It is to be distinguished, from
the various form of acute angina, which give rise to general symptoms ;
from diphtheria, where cultivations will confirm the diagnosis. Again,
the small points stick tenaciously to the epithelium, after the top is
pulled off it persists in growing unless its sub-mucous portion is de-
stroyed. Frequently the surrounding tissue has a healthy appearance,
at least there is no surrounding inflammatory areola.

The first case of mycosis to come under my observation was some
seven years ago ; since then I have had three other cases, all presenting
under the microscope the characteristic rods of leptothrix. All four
cases were of the first variety mentioned — i. e., small white points.

Regarding the treatment, I have used the bichloride, hydrogen di-
oxide, alum, iodine, and the iron salts, with negative results. I do not
believe that we possess an agent that will destroy the fungus, except the
cautery.

One writer claims that tobacco-smoking cured a case. It is
more probable that it was a case of spontaneous recovery, as it is well

56 FRED. D. LEWIS, MM.

known that mycosis frequently disappears without any treatment what-
ever. In the first case to come under my observation the patient
smoked at least twelve cigars a day. If there is any efficacy in tobacco
to destroy the fungus, certainly that man smoked enough to floor it.

Regarding the case presented by Dr. Lewis, I am of the opinion that
if it was mycosis, it was the second variety mentioned — *. e., presenting
as plaques of a yellowish color, and furthermore that diphtheria was
also present. I believe that the reports of the bacteriologists will sub-
stantiate this view. The first report is not to be considered as it is too
indefinite: the second one reports, "The prevailing organism is the
bacilli diphtheria" ; the third and altogether the most satisfactory re-
port says, "The specimens showed the presence of numerous bacilli.''
The most ntunerous resembling the diphtheria bacillus. Also various
tissue elements in more or less state of necrosis, but not either the lep-
tothrix or ascomycetes in such quantity as to say that either was the
cause of the growth.

In view of the reports quoted it seems to me to be very clear that
the opinion above expressed is maintained, that if the case was mycosis
there was also present a mild form of diphtheria.

Dr. Ha3rwcod : I want to report a very similar case. A young man
of twenty-five, whom I saw a few months ago, had what at first I took
for a very simple case of tonsillitis, and prescribed the usual remedy
without benefit. When he came back, I made a more careful examina-
tion, diagnosed it as mycosis, used the galvano-cautery. Later the tri-
chloracetic acid was used, and in a few days' time he was entirely cured.

Dr. Lewis : I wanted to get all I could from microscopic examina-
tions, and I was not anxious to cure the case too quickly. If I had
another case, I should bum the tonsils with the actual cautery.

THE INFLUENCE OF HYGIENE UPON THE UPPER AIR

TRACT.

By Herbert W. Hoyt, M.D.,

Rochester, N. Y.

IS it true that specialists are inclined to lose sight of the fact that
the human body is composed of many members all more or less
interdependent ?

Dr. Sheppegrell recently said: "The nose and throat specialist
should avoid the tendency of becoming narrow in his views, and of see-
ing the patient only through the nasal speculum and laryngoscopic mir-
ror ; he should be as familiar with matters of general medicine as the
general practitioner, and should make it his motto not to know less of
general medicine, but to know more of rhino-laryngology."

This is not laying out an easier field of work for the specialist, but
a harder one. It seems strange that there should be any question as
to whether the condition of the abdominal organs influences the upper
air tract. But so eminent an author as Bosworth says, in his text-book,
"The mucous membranes of the different portions of the air tract are
in exceedingly close sympathy, and a morbid process in one portion is
very likely to be followed by a morbid process in another, but that there
is any sympathy or connection between the mucous membranes of the
air tract and the mucous membranes of the food tract I do not believe."
Later, in a discussion in the American Laryngological Society, he par-
tially retracts, and says : "Constitutional state has very little to do with
diseases of the nose, but very much to do with the naso-pharynx."
Every one else in the discussion took the ground that the whole air tract
was influenced by the other organs.

The anatomical nature of the upper air passages, with their abun-
dant supply of blood-vessels, makes them physiologically and patholog-
ically very susceptible to congestion. The lymphatics, so prodigally
supplied in the naso-pharynx and phar3mx, make a nidus for auto-
intoxication surpassing any other portion of the body. General practice
teaches one to know that indigestion and constipation cause congestion
of the portal circulation. Obstruction in this large venous system
causes congestion in more remote regions. By inquiry it is nearly al-
ways found that constipation or indigestion is a characteristic of those

58 HERBERT IV. HOYT, M.D.

troubled with hypertrophic rhinitis. It is commonly known that one
often takes cold after a very hearty dinner or late banquet, but the
portal obstruction or congestion is not the only factor in such cases.
The intestinal tract is a very fertile source of auto-intoxication, if the
fermenting matter is not readily passed off, and, when produced, how
can this poison be thrown out of the system, except by the kidneys and
mucous membranes of the respiratory tract ?

Another interesting reflex relation is that of the genital organs upon
the upper air passages. Dr. J. N. Mackenzie has given some very
valuable information on this subject in a paper entitled, "The Physiolog-
ical and Pathological Relations between the Nose and the Sexual Ap-
paratus of Man." An immense amount of research is displayed in this
paper; and plenty of evidence is given to show that the venous and
nerve supply of the nose are markedly influenced by the generative or-
gans in either sex. Excessive venery has been the direct cause of hay
fever, asthma, hypertrophic rhinitis and perversion of the olfactory
sense.

The text-books on general medicine speak of the nose and throat
manifestations of the exanthemata, typhoid, scurvy, rheumatism,
eczema, syphilis, tuberculosis, diphtheria, &c. Bishop lays considerable
stress on the uric-acid diathesis being at the bottom of many catarrhal
conditions.

Wells has gone very thoroughly info the relations of the skin and
the upper air tract, and shows conclusively that the nose suflFers severely
when the skin is not doing its duty. Hajek, of Vienna, said : "Unless
one has devoted a certain amount of time to dermatology, he is not
competent to intelligently diagnosticate the diseases of the nose and
throat."

With this partial review of the relations of the general system to
the upper air passages, what path is shown to the specialist in this line?
To quote from an editorial in The Laryngoscope: "The fact remains
that surgery should be employed to as little an extent as is compatible
with the abnormalities present in the case ; then local constitutional and
hygienic treatment must be depended upon to remove the cause of the
disease. Removal of the result does not materially affect the cause,"
Diathesis cannot be eliminated in a day.

Attention will be called to some of the directions in which hygienic
measures will assist in relieving troubles in the upper air tract, where
surgical interference will not cure. From the public point of view this

THE INFLUENCE OF HYGIENE 69

takes up the questions of ventilation, sewage, heating, dust, noxious
weeds, pure foods, &c.

Many public and private buildings are very poorly supplied with
fresh air. Nothing is so trying to the mucous membrane of the nose
as its attempt to render superheated and foul air fit for entrance to the
lungs. Hypertrophy is produced and greatly aggravated by such ef-
forts. Many children with slight adenoids are in excellent condition
during their summer vacation, with its out-door life, but as soon as they
are shut up in the poorly aired schoolroom they find difficulty in free
breathing and, in consequence, have headaches and kindred symptoms.
Our modem houses are an improvement over those of European na-
tions, but there is a great danger in having the living-rooms too warm
and the air too dry.

Another source of much discomfort is the large quantity of dust and
soot in the street air, especially in the cities. It is the duty of every
community to have its streets as clean as possible, and oblige manufac-
turers to prevent the smoke nuisance. When the automobile replaces
the horse, the main source of our uncleanly streets will be obviated.

It is generally believed that the rag-weed and golden-rod are the
chief causative factors of hay-fever in the predisposed. These weeds
are of no value in the human economy and the day should come when
legislation will compel the public to destroy, in so far as possible, any
weed apparently injurious to health.

The food question is both of public and private interest. It ought
to be possible for one to obtain pure food products, and the laws should
be so rigidly enforced that a label on any food should tell the exact
truth as to its purity.

As before suggested, obstruction and congestion in the portal cir-
culation bears a direct and marked relation to the congestion in the
mucous membranes of the nose and throat. Pure, healthful foods
properly prepared and thoroughly masticated, will prevent and cure in-
digestion and its accompanying ills, other things being equal. Pork,
veal, fried foods of all kinds, pastry, hastily cooked cereals, condiments,
coflfee, tea, and new bread are not good foods for any one. A number of
students coming under the writer's care have found their catarrhal ten-
dency much lessened by rejecting some of the articles on the boarding-
house menu and by taking more time for eating. Of course, a man
who works hard out of doors will digest almost any food, but in the long
run it is at the expense of his stomach and its helpers. The Jewish
race is proverbially a healthy one, and there is no shadow of a doubt

80 HERBERT W. HOYT, At.D.

that it is due, to a very large extent, to their custom of not eating poric.
Tuberculosis, which claims so much attention from the nose and throat
specialist, is rare with the Jews. There is absolutely no other ground
for argument why the Jews are so exempt from tuberculosis, than on
that of abstaining from the use of pork, for a large class of them are
otherwise unhygienic. Tobacco and liquors dry and engorge the mem-
branes of the upper tract both directly and reflexly. A man who is
engaged in a sedentary occupation must be more careful in eating than
one who has plenty of exercise. Meat once a day for any indoor man
is enough. Beans and peas contain the same kind of nourishment, in
larger proportion, as meat, are cheaper, and, if well cooked, more easily
digested.

Exercise is a prime factor in aiding digestion and keeping all the
eliminative organs in active condition. The writer has a patient who is
a teacher. Throughout the school year he suffers greatly from conges-
tion of the nasal mucosa, but during his vacation of hunting, fish-
ing and camp life, he throws off his catarrhal condition entirely. Mul-
hall tells of two prize-fighters who were subject to hypertrophic rhinitis
when not in training. After a course of work in preparati(Mi for a
match, their bowels become regular, the skin soft and smooth as satin
and all congestion in the nasal mucosa disappears, leaving no trace of
the former need of hawking and spitting. The same author recom-
mends sawing wood, in the old-fashioned manner, as a most excellent
form of exercise. This gives the kneading action to the diaphragm
and bowels, which relieves the portal, and reflexly the nasal congestion.
Next in importance to exercise is bathing. Some one has said that
the skin is the external organ of respiration, and if it is healthy and
active, there is less likelihood of taking cold in the varying changes of
weather. By the cold bath the system is made more tolerant of
draughts and sudden exposure, by teaching the arteriols to expapd and
contract readily. The skin is not really toughened by the bath, but the
glands are kept sweet and clean and the eliminative function is given
free play. A pair of loose, thumbless mittens, made of heavy Turkish
toweling, are most convenient for a cold bath. Then with both hands
quickly and thoroughly go over the whole body. This should
ediately done upon getting out of bed and followed by a brisk
; whole process not occupying over three minutes. If one is
:nough to enjoy it, a shower or plunge is excellent. The cold
)uld be begun in early life,
[tis connection might be mentioned the great benefit of cleanli-

THE INFLUENCE OF HYGIENE, 61

ness and antisepsis in some nasal diseases, as hay-fever. The writer
has had very satisfactory results in a violent hay-fever by daily
thoroughly cleansing of the nose with a mild antiseptic during the
period of attack. Nothing else ever gave this patient such relief. Hol-
lopeter cites two hundred such cases with astonishing results.

No hard and fast rules can be laid down about clothing. Some
cannot wear wool, while others do better with it. According to the
variations in the weather the clothing should be changed. Regularity
in eating, sleeping, and exercise is the salvation of many men.

This paper was not written to decry necessary surgical work, but
rather in the hope that it might diminish the reckless destruction of the
mucous membrane of the upper air tract. The turbinated bodies are
very useful, when not maltreated by disturbing influences in other parts
of the body. Homoeopathic remedies will help restore crippled func-
tions, when combined with proper hygienic living. Would that it
might be said of the members of this Society that they make it their
first business to correct the wrong methods of living, and that they
resort to surgery only in cases where it is needed.

DISCUSSION.

Dr. Townsend: This subject is, in my opinion, the most im-
portant one that we, as specialists, have to consider, and it behooves us
all to give it careful attention. When a specialist loses sight of the
fact, that the organs to which he has given his thought and attention,
are only a part of the most intricate combination of vital elements ever
associated together, and that in addition to the physical, the mental
and spiritual elements are essential to form the complete human organ-
ism, he is liable to see things from a standpoint, which shows only a
glimpse of one side, rather than the broader view, which takes cog-
nizance of everything that a careful analsyis of the case reveals, before
arriving at a conclusion.

The doctor refers to most of the predisposing causes of inflamma-
tions of the respiratory mucosa, and, in the main, I would indorse his
conclusions.

The nervous and digestive systems play most important roles in re-
lation to catarrhal inflammation of the upper air tract, as every observ-
ant practitioner knows, and it is sometimes diflicult to decide which is
responsible, and to what degree either may assume the relation of cause
and effect. Nervous relation is largely reflex, and assumes a variety
of manifestations.

I would emphasise very emphatically the influence of impaired di-
gestion and assimilation, together with diminished elimination of waste
products, as a predisposing cause of these troubles. This is beyond

62 HERBERT W. HOYT, M.D.

doubt the chief cause in a majority of cases, if we include the phenom-
ena of sub-oxidation, or, in other terms, a disproportion between assim-
ilation and elimination.

Lithsemia is a phase of this same condition.

Haig's work on "Gout and Its Cause" throws much light on this
subject, and contains valuable information regarding the action of uric
acid and other waste products when retained in tihe body. Lack of
exercise and overeating tend to cause a sluggish action of the liver and
kidneys, and unless the skin assumes an increased share of the burden,
there will be trouble.

The cold bath in the morning, is a boon to such patients. Simple
calisthenic exercises, and message are invaluable. Riding on horse-
"back is a great aid in overcoming the evils of sedentary living.

My observation does not confirm the statement that the Hebrew race
«njoy a large degree of immunity from tuberculosis. Without refer-
ring to the records, I am inclined to think that they furnish a fair share
of tfie tubercular cases treated in my clinic.

The suggestion that peas and beans furnish the same nutritive ele-
ments as beef, is incorrect, and probably not intended. That they are
a good substitute for beef is very doubtful, as the overfed patient
usually suffers from intestinal indigestion, and does not tolerate starchy
foods. Milk foods, fruit, green vegetables, pure water, and exercise
are a panacea for such patients.

Neurasthenics furnish us many patients, some of whom are found
to have the cause of their infirmity in a nose or throat lesion. Others
may be free from local trouble, and affect, or perhaps feel, some irrita-
tion in the nose or throat, A slight operation often relieves them, but
only temporarily as a rule. They are impressionable and influenced by
suggestion, and probably many of our brilliant cures (?) are due to
that fact, instead of the other treatment.

A very valuable adjunct to treatment (particularly in women pa-
tients) is the regular practice of breathing exercises, at stated intervals
and according to strict orders. In sedentary patients, this usually pro-
duces marked results, improving the circulation and the digestion, as
well as having a favorable effect on the local condition.

Dr. Hoyt: I was persuaded to attack this subject by seeing the
careless way in which hygienic matters are treated in many of tlie
clinics that I have attended. They take patients and give them some
medicine, or make a local application, cut off a spur, cauterize some-
thing, and say nothing about hygiene. That is especially applicable to
the tenement-house class, who greatly need hygienic instruction. At
one of our Western New York meetings within the past year, the ques-
tion of pork came up as meat food, and one of the Doctors arose and
said : "Who ever saw a Jew who had tuberculosis ? It is because they
do not eat pork." Of course, there are Jews who have tuberculosis ;
but there are very few, and you will so find in an examination of the
statistics. As for beans and peas, according to our laboratory experi-
ments, they contain in proportion to meat about seven times, I believe

THE INFLUENCE OF HYGIENE. 63

it is, as much of the proteid element If they are thoroughly cooked
and that means a number of hours' boiling if they are boiled, or a very
long preparation in otherwise cooking them, because a bean partially
cooked is very hard to digest. Once thoroughly cooked they will take
the place of meat. If you want further information in that regard,
read some of the experiments at Battle Creek, Mich. I know some of
you may think it a sort of fad referring to Battle Creek — ^but they have
put out some good work.

SUBCONJUNCTIVAL INJECTIONS IN THE TREATMENT

OF OCULAR DISEASE.

By Charles Deady, M.D.,

New York.

MY attention was first directed to this subject during the fall
of 1892, when I made the acquaintance of a young physi-
cian who had been an assistant in the clinic of Dr. Darier,
of Paris, France, and who was returning to his home via New York.

He brought me an article on subconjunctival injections, which had
shortly before been read by Dr. Darier before the Societe Fran5ais
d* Ophtalmologie, and which was published in the Journal of Janu-
ary, 1893.

My visitor explained the modus operandi of the treatment and was
so enthusiastic over some of the results obtained, that I became inter-
ested and began to look the matter up.

In the paper referred to, Dr. Darier presented 18 cases in which
the injections had been used, furnishing a brief history of each case,
with plates showing the condition of the fundus. Of these cases, 11
were either central choroiditis or chorio-retinitis, 4 were disseminated
choroiditis, i each of the pigmentary form of choroiditis with atrophy
of vessels, of syphilitic chorio-retinitis with atrophy of the nerve, of
general chorio-retinitis and of neuro-retinitis.

Case No. i was of central chorio-retinitis of 15 days' standing,
which failed entirely to respond to mercurial frictions continued for 8
days. Here the vision was improved from J4. to i by a series of injec-
tions of sublimate, the lesion clearing up so that there was no trace of
it one year later.

Case No. II. of central chorio-retinitis of three-months' duration.
After two-months' trial of mercurial friction and iodide of potash with-
out effect, vision was brought up from J^ to i by six injections of
sublimate and the anatomical lesions almost disappeared.

Case III., central chorio-retinitis, vision was raised from 54 to i
by eight injections.

While the results obtained were not so excellent in other cases as
in those quoted, vision was very much improved in all the macular
lesions, including those due to myopia. In disseminate choroiditis, the
improvement was less marked but still considerable, and the only case

THE TREATMENT OF OCULAR DISEASE, 65

in which the treatment failed entirely was that of neuroretinitis.

From that time on, as suitable cases presented, I began to use the
treatment. The method adopted was to cocainize the eye with a 4
per cent, solution, then by means of an ordinary hypodermic syringe
made entirely of metal, and capable of being rendered absolutely sterile,
an injection of one drop of a solution of bichloride of mercury i-iooo,
which had been previously filtered, was made beneath the conjunctiva.

It soon became manifest that the amount of reaction varied accord-
ing to the site selected for the injection. If made too near the ciliary
border of the cornea, or too far away from it the reaction was increased.
If it was so entered as to strike one of the small vessels, there was con-
siderable ecchymosis, with resulting increase of inflammatory action and
often pain lasting from 12 to 24 hours. After a time it was demon-
strated that the best site for the injection was midway between the
corneal border and the cul-de-sac, avoiding, so far as possible, the ves-
sels. One thing which was beyond control was the tendency to wound
the sensory nerves supplying the part. This would result in immedi-
ate and sometimes severe pain, which soon subsided in some cases and
in others lasted until the inflammatory action aroused by the injection
wore off, which was usually in 48 hours, at most, and on experimenting
it was found that the period could be shortened by the use of the ice-
bag.

Occasionally, when fortunate enough to avoid all vessels and nerves,
the reaction would be very slight, and with perhaps no pain at the time
of the injection.

A few cases cited from a number treated, will be sufficient to show
the results obtained.

Case One. — Miss O., aet. 43. Myopia et choroiditis centralis O. D.
et staph, post. O. D. V200 — 16 Ds C — 3.50 Dc axis 15"*

•V

100-

After six injections, with the same glass, vision O. D. **/,o.
Case Two. — Mr. L., at. 20. Amotio retinae O. U.
R V — "/ L V — •/

XV. V . / 200> ■■-'• ^ • ""• / 200*

After 3 injections R. V. = ^V2oo-

After 4 injections L. V. = V2oo-

Case Three. — Miss K., aet. 19. Astig. reg. myopia et staph, post.

O. D. V. = V200 — II Ds C — 2.50 Dc ax I5^ V. = •7,0-

O. S. V. = V200 — 13 Ds C — 2.50 Dc ax i8o% V. = ^V^oo.

After 4 injections R. V. with same glass = ••/g^ ? ?

After 5 injections L. V. with same glass =*^/8o ?

Case Ponr. — Geo. W., aet. 9. Chorio-retinitis cent. O. D.

R. V. = ^V^o. After 3 injections R. V. = ^V^o ?

66 CHARLES DEADY, M.D.

Patient was then lost sight of.

Case Rvc. — Henry B., aet. 47. Chorio-retinitis cent, et myopia.

O. D. 20/2^^ ? eccentric — 1.50 Ds V. =*Vioo?

O. S. 'Vaoo ? eccentric — i Dc ax 90° V. =*Vioo?

After 4 injections in each eye, V. = *®/ioo easy, each eye with same
combination.

Case Six. — Miss D., aet. 24. Myopia et staph, post.

O. D. V. = I J^Aoo with — 22.50 Ds V. = ^V^oo.

O. S. V. = iJ^/200 with — 20 Ds V. = "Ao.

After 7 injections, R. V. = "/12 ?? with same glass.

After 5 injections, L. V. = ^V^a ?? with same glass.

About 18 months later this patient again presented and upon ex-
amination I found that vision had deteriorated in the interval, the status
praesens being as follows :

O. D. with — 22.50 Ds V. = "Ao-

O. S. with — 20 Ds V. = "Ao-

The treatment was again resorted to and after three injections, vision
was raised in each eye to ^'^/ao* when the patient discontinued her visits.

Case Seven. — Mrs. C, aet. 50. Amotio-retinae O. S.

O. S. V. = fingers i ft. After four injections vision *Aoo letters,
no further improvement

Case Eight. — Mr. B., aet. 50. Sclero-choroiditis post, et myopia.

O. S. Vaoo — 16 Ds C — 2.50 Dc ax 165% "Ao-

After one injection, with same glass glass, V. = **^Ao-

The case was lost sight of as patient ceased his visits.

These experiments certainly seem to indicate that there is something
in the treatment if carefully used in selected cases. I have used it on
a considerable number of patients besides those above noted, and my
conclusions as formulated in my own mind are that it should be bene-
ficial in some cases of disseminate choroiditis, if used early enough;
I have seen very little benefit in this type of disease when the stage of
confirmed atrophy of the choroid has been reached. In the exudative
stage I should look for some improvement, and if I am not mistaken,
Darier has reported two or three cases of this stage which were
benefited.

In central chorio-retinitis, several good results have been obtained
and Darier has published a number of cases in which the treatment
accomplished all that could be desired, as in his cases Nos. I. and II.,
quoted at the beginning of this paper, where vision was not only re-
stored, but the ophthalmoscopic signs of the lesion also disappeared.
These cases, however, were both of recent origin. No. I. being of only
iS-days' standing and No. II. having had a course of three months.

In this type of disease, therefore, the injections should be given a

THE TREATMENT OF OCULAR DISEASE, 67

fair trial, more especially as these cases do not readily yield to the action
of internal medication. In the Recueil d'Ophtalviologie of May, 1892,
Darier among other things says that he has had excellent results from
the injections in cases of simple amblyopia, other than those of toxic
origin, and it has been in something akin to this that I have had the
best success. We are all familiar with the fact that in certain cases of
myopia, even where there is comparatively little posterior staphyloma,
there is sometimes a considerable difference between the best vision
obtainable by glasses and the normal. It is just here that I am able
to recommend the bichloride treatment. By its use in a number of such
instances, vision was increased to a greater degree than has ever been
possible by any other method, at least in my experience, and I look
upon them at the present time with much more equanimity than for-
merly. Some of them, it is true, fail of relief, but in a number the
results have been gratifying. Other observers seem to have had equally
good results in this form of trouble, as is instanced by the reports of
Gepner (Centralblatt fur Praktische Augenheilkunde, Leipzic, Jan.,
1894), of 20 cases of myopia with choroiditis, which he put on the
treatment and in which not one failed to derive some benefit. Three
of the Darier cases, published in the Journal, were myopic-choroidal
affections, all of which were materially helped, and Sidlossy (Arch, d'
Ophtal., July, 1898), recommends it for "high myopia" among other
conditions mentioned.

The sublimate* injection treatment, like many other new remedial
measures, seems to have been tried by old-school ophthalmologists on
nearly ever)rthing that presented and with results which vary widely.
Thus Darier, Briggs, Lagrange and others, seem to consider it specially
useful in syphilitic forms of disease, while Galezowski has abandoned
the treatment in such cases on the ground that it is useless and dan-
gerous.

A number of investigators recommend this method especially in
diseases of the uveal tract, but Terson (Annates d' Oculistique, May,
1894), takes the opposite position, and claims that deep involvement
is a contraindication. This writer, by the way, having noticed that
vascularity around the cornea, commonly followed the subconjunctival
injection of the bichloride, began to use it in conditions where circiun-
comeal congestion was present, and the cure of a case of episcleritis as
a result.

This seems to the impartial observer to be a dangerous tendency
toward Homoeopathy.

I
I I

68 CHARLES DEADY, M,D.

Veasy {Therapeutic Gazette, Jan. 15, '94) claims a good result in a
case of scleritis, and to those who are acquainted with the slow and im-
perfect results of ordinary treatment in this tedious disease, the state-
ment will be welcome. In a second case, however, the result was nil.

The method has been used upon most of the diseases of the con-
junctiva, cornea, iris, ciliary body, choroid, vitreous humor, retina, and
optic nerve. So far as can be gathered from the mass of contradictory
report, it appears to be of good service in iritis, irido-cyclitis, choroiditis,
irido-choroiditis, and choroido-retinitis, whether syphilitic or otherwise,
being apparently especially useful in those affections of the macular
region, which are so destructive to vision. Next, it would seem to have
been effective in the hands of some practitioners in superficial lesions
due to infection. Abadie claims to have aborted sympathetic ophthal-
mia by this means. It is reported to be of little or no use in diseases
of the optic nerve and retina proper.

The dose varies from the careful use of a single drop of the 1-2000
solution to De Wecker's massive dose of a whole syringe full of the
same; a majority, however, inclining toward one or two drops of a
solution of i-iooo.

Respecting its local effects Bull (iV. Y. Med. Jour,, Jan. 19, 1895),
states that it always causes severe pain, notwithstanding careful and
persistent use of cocaine, and that the reaction is apt to be severe and
sometimes very severe.

Mellinger (Archiv fiir Augenheilkunde, Wiesbaden, Nov., 1894)
says that the injection of a 1-2000 solution is very painful and causes
an adhesive inflammation which obliterates the subconjunctival space,
and he believes that a normal salt solution is equally efficacious, without
these objections.

Darier has repeatedly denied the latter statement, and is corroborated
by Wilder {N. Y. Med, Jour., Nov. 28, 1896), who is equally positive
in this respect.

Personally, I have never used the treatment except in choroiditis,
chorio-retinitis and the single case of detachment of the retina (in which
it failed), for the reason that I felt that we had better means for the
relief of the other forms of disease. The pain, as before stated, has
been found to depend on the site of the injection. The obliteration of
the subconjunctival space by adhesive inflammation is, I think, a com-
mon though not invariable result, but it is confined to the parts imme-
diately affected by the operation. Where a number of injections are

THE TREATMENT OF OCULAR DISEASE. 69

made in the same eye, however, this adhesion may extend over a con-
siderable portion of the membrane.

As to the reaction, I have never seen it so severe that it was not

relieved inside of 24 to 48 hours by the icebag, and in many cases it
has been very slight. Possibly my good fortune in this respect may
be due to the fact that I have always allowed a period of at least five
days and often a week or two, to elapse between injections. In other
words, no second injection has been made until the eye was entirely
recovered from the previous one.

In all the cases which have been under my observation, there has
been no serious result of any kind. In the Archiv fur Augenheilkunde,
Wiesbaden, Apr., 1895) Darier says that both the adhesions and the
severe pain are caused by making the injections too deep in Tenon's
capsule or too near the border of the cornea.

Mellinger and Bossalino (Archiv fur Augenheilkunde, Wiesbaden,
June, 189s), as the result of an experimental investigation, conclude
that the injected fluid follows the large lymphatic spaces over the whole
surface of the bulbus and optic nerve, entering also the supra-choroidal
spaces and under the sheath of the optic nerve. They agree with
Zehender that the beneficial effect is a result of stimulation of the lymph
circtilation, and consequent acceleration of the removal of infectious
material.

E. H. Bernstein (Jour. Am. Med. Ass., Sept. 12, 1896) advises the
use of the cyanide of mercury rather than the bichloride, claiming that
it is more quickly and completely absorbed. He claims to have had
excellent results and he is supported in this statement by Lagrange and
Fromajet, by Chavellereau, Dunn, and others.

DISCUSSION.

Dr. R. S. Copeland : Dr. Deady has succeeded, as he always succeeds,
in giving a clear-cut, interesting description of a comparatively recent
method of treatment. In outlining its field of usefulness, the essayist neg-
lects to state another possible use for the subconjunctival injections.
This is in the absorption of blood from the anterior chamber and
vitreous. Mellinger calls attention to the great value of four-per-cent.
salt solution in these cases. My own experience leads me to accept his
statement that the absorption under this treatment is much more rapid
than when left to itself.

When I last/visited DeWecker's clinic he was using bichloride injec-
tions for every abnormal eye condition from fundus to cornea. I felt
then, as I now feel, that, in the light of DeWecker's results, the homoeo-

70 CHARLES DEADY, M.D.

pathic specialist has no occasion to apologize for his internally adminis-
tered treatment.

In certain conditions the subconjunctival injection has an undoubted
value. Salt, with its affinity for water, takes it from the tissues and
hurries the nutritive processes. Mercury is a remedy many times useful
in certain forms of eye diseases. But, in my judgment, the indis-
criminate use of this method of treatment is bound to be productive of
more harm than good.

With no desire to criticize this most excellent paper, written by a
man of undoubted faith in our law of cure, I do wish to inquire why we
need spend much time on the uncertain therapeutic whims of the domi-
nant school ? When it has demonstrated in any disease a method of cure
equal to our own, that method deserves our consideration. When it can
show results superior to ours, we fail of our duty if we neglect to adopt
it. But as I have compared the results of our remedies with the results
of this method, I am more than ever convinced that similia gives the
patient a hope of cure that is denied the victim of the subconjunctival
injection.

In the absence of clear definition of the end sought in any given case
and without well marked indications for it, I do not believe in the use
of the subconjunctival injection. The greatly harmful results in some
cases are but modified in many others. To some extent the essayist has
indicated these unpleasant effects. He has not told us of the cyclitis,
the panophthalmitis and the S3rmpathetic ophthalmitis which have fol-
lowed injections made under the strictest aseptic precautions. We must
be fair with ourselves and not seek to build up a system of treatment on
cures alone.

I hope I offend no one by the positive expression of my convictions.
The essayist, I am sure, holds the same opinions.

Dr. Moffat: I g^ve my homoeopathic medicine hypodermatically
whenever that method of administration is the best. Corrosive sul>-
limate may, eventually, prove to be homoeopathic to these cases that it
cures. We know it has a marked action upon the fundus as well as
the iris, even when given by the mouth.

Dr. Deady: In answer to Dr. Copeland, to whose criticism
I do not take the. slightest exception, I have only to say that my ex-
perience does not tally with his. I have formed my views of subcon-
junctival injuries from observation of fifty or sixty cases. I have never
seen a result which was much out of the common, or which caused me
any anxiety. I have never seen a case of iritis or cyclitis. Possibly I
may have been more careful than some others who have used it; al-
though it is supposed to be always used under the strictest aseptic pre-
cautions. If DeWecker uses whole syringefuls with good results and
without any untoward results, we should not be afraid of a drop or two.
I have never used more than two drops — ^usually one drop—and the
reaction to my mind depends almost entirely on the site of the injection,
and whether you happen to strike a nerve or not. The very small sen-
sory nerve it is impossible to avoid, and the pain is more or less severe

TREATMENT OF OCULAR DISEASE, 71

for twenty-four to thirty-six hours. I have only used it in a limited
number of diseases, because, as the doctor says in his discussion, we
have better means; but there are two conditions, particularly, where I
think it is worth a trial : One is in amblyopia with myopia, in which it
does its best work, and the other is in choroiditis. These conditions, if
we can help them by any means, should have the benefit of a trial of
subconjunctival injections because they affect vision very seriously. I
have no thought of taking offense at Dr. Copeland's honest opinion^.
This is not a personal matter. I have simply tried something that has
been brought up, and whether it is good or bad is not for me alone
to say.

SECONDARY CATARACT.

By Chas. M. Thomas, M.D.,

Philadelphia.

ANY Opacity remaining in the pupillary area after the removal
or absorption of the lens, is commonly designated as sec-
ondary or after cataract. Even where the lens capsule has
been completely emptied of its contents, vision may, with the lapse of
time, be interfered with, either by a wrinkling of the remaining cap-
sule or by a gradual opacification of the epithelial cells within its folds.
More commonly the secondary opacity will result from retention of
some portion of the opaque lens during the operation of extraction, or
of clear lens matter which sooner or later becomes opaque. Finally,
the pupil may become occupied by membranous deposit, the product
of inflammatory action within the capsule itself, or the structures lying
in contact with it.

While either one of these causes may be sufficient to the production
of secondary cataract, as a matter of fact, a large proportion of cases
arise from a combination of all.

The least disturbing form of after-cataract is that found in the
first of the above-mentioned classes, and usually does not make itself
evident for months, sometimes for years after the extraction. The
impairment of vision in these cases is always very gradual and out of
proportion to the slight objective changes in the pupil. Indeed, the
appearance of the pupil is often so little altered, even after sight has
been lowered so that the patient can no longer read ordinary type (say
V. = **/ioo)» that an obstruction can hardly be made out except under
very bright illumination ; and a very fair view of the fundus can still
be had with the ophthalmoscope. On careful inspection the pupil is
found to be occupied by a surface not unlike that of watered silk.

When some portion of the lens is left behind after the extraction,
the pupil will very soon be seen to be filled with a more or less dense
white mass, which may render the immediate result of the operation
almost entirely nugatory, and will offer a most discouraging outlook
to the patient. Experience, however, shows that if inflammatory com*
plications remain absent, the process of absorption will often bring
about in time a most satisfactory clearing of the pupillary space. The

SECONDARY CATARACT. 78

most troublesome cases are finally those in which during the progress
of an iritis or what has been called capsulitis^ or both, the pupil be-
comes occupied by a more or less dense white or pigmented membrane
of plastic material, which may show itself promptly after the extraction,
or from slowly progressing irido-choroiditis may not develop for many
weeks subsequent. Here there can be little or no hope of later im-
provement by any natural process.

It is thus apparent that, while a certain proportion of secondary
cataracts may be looked upon as dependent upon processes beyond our
control, a very considerable class will always be found where the opa-
city might have been prevented or modified by attention to means which
will limit the amount of traumatism or inflammatory action accompany-
ing our operative manipulations, and further by so planning our ex-
traction method so as to secure the most perfect dearing of the pupillary
space.

The relative frequency of the necessity for secondary operation will
certainly be considerably less in proportion to the care which is exer-
cised in canning out the steps required for securing these ends.

That the discussion of the question of avoidance of conditions liable
to entail the necessity for subsequent operation interference is a matter
of much importance goes I think, without saying even though the risk
attending the secondary operation were less than that acknowledged
by those who have the largest experience therein, and those therefore
who might be expected to have the best results from its performance.

One of the first requisites for securing complete removal of the lens
from its capsule is that the opacity shall be as nearly as possible com-
plete, that is, that the cataract be ripe.

While I do not believe that one should invariably wait for extrac-
tion till no transparent cortex can be seen, till the patient can no longer
see objects, and there is no red reflex to be made out with the ophthal-
moscope, I am nevertheless inclined to think that many of us are too
much disposed to operate before the cataract is quite ripe and this,
either from inattention, or perhaps a desire to secure the case, or a lack
of firmness in resisting the appeals of the patient. In at least the
ordinary cortical variety we should certainly make sure that the opacity
is complete before extracting, either by patiently waiting out the time
for entire ripening, or by resorting to one of the operative methods for
hastening maturity.

While there may be some risks in the artificial ripening, my experi-
ence, mainly with the Foerster method lead me to believe that they

74 CHAS. M. THOMAS, M.D.

are far less than those met with in attempting to extract immature
cataracts particularly of the cortical variety ; and the results, while not
always so prompt or certain as one would desire are occasionally most
brilliant in shortening the trying period of waiting.

In the purely so-called nuclear cataract occurring in people well
advanced in life, the process of opacification we know will often go on
slowly for many years ; the cortex becoming hard or sclerosed without
actually losing its transparency, while the large opaque nucleus filling
the greater part of the pupil, obstructs vision almost as effectually as
a ripe cataract. In such cases although the fundus is perhaps visible,
we need not postpone interference till the ripening is complete, for with
a generous section, the delivery can commonly be made surprisingly
clean on account of the tough cohesive character of the cortex.

I have long been fully convinced, that one of the most important
factors in not only securing a pupil free of cortical remains, but proba-
bly also in lessening the risk of plastic inflammatory action, lies in the
performance of a preparatory iridectomy.

Supposing this to be done, I cannot conceive of a more simple, safe
and complete operation than the removal of cataract.

The manipulative steps are certainly thereby reduced to the
minimum — viz,, section of cornea, section of capsule, and expulsion of
lens. The iris is hardly an element to be considered, it is never in the
way of the knife, it need neither be cut nor bruised, and practically never
prolapses. The iridectomy need never be done under unfavorable
conditions (hours or days after extracting) and finally the intangle-
ment of the iris with its various risks need never be given a thought
The steps of the capsulotomy and delivery of the lens may certainly be
conducted with greater ease and precision, there being no bleeding to
obstruct the view, as is so often the case with immediate iridectomy,
and no necessity for groping under the iris with the cystotome as in the
so-called simple extraction. The only important obstacle to the expul-
sion of the lens has been removed, and the coloboma furnishes a free
road-way, not only for clearing away cortical remains, but, if desired,
for the introduction of irrigation instruments.

As further contributing toward the prevention of secondary cata-
ract, I think we should include certain points in the operative technic,
and, by limiting the traumatism, reduce the risk of formation of in-
flammatory pupillary deposits.

Foremost among these is the placing of a generous section of the
cornea. When the corneal incision is limited, the natural inclination is

SECONDARY CATARACT, 76

to force the delivery through the msufiicient opening at the risk of
scraping off cortex and leaving it in the anterior chamber, rather than
attempt the somewhat awkward manoeuver of enlarging the section
after the lens has started into the opening.

A careless or insufficient capsulotomy will often not only add ma-
terially to the traumatism by necessitating harmful pressure and ma-
nipulation in delivery but will invariably result in retention of more or
less cortex between the capsular layers. While in my earlier experience
I opened the capsule at the periphery, I have of late years satisfied
myself that the most complete clearing of the pupil is accomplished by
starting the capsulotomy with a vertical cut from well below the centre
or axis of the lens, and ending at the equator and finishing by a free
horizontal cut at the equator following the line of the corneal wound.
Whenever there is the slightest tardiness in the movement of the lens
through the section I add to the pressure of the spoon from below, a
backward pressure on the sclerotic lip of the wound, and have the
assistant, prepared to lift the lens through by gently sinking a sharp
hook into the nucleus. Absolute quiet of the patient and of the eye
during the first days of healing must certainly add their influence in
securing freedom for inflammatory pupillary deposits; and this it
seems to me is much more surely accomplished by previous iridectomy,
which does away with all necessity for replacing or excision of iris
prolapse, perhaps under the disturbing effect of a general anaesthetic.

Finally, after the healing process is complete, it is, I think, an im-
portant question as to whether we do not often favor the development
of pupillary opacities by too early an adjustment of the glasses and the
use of the eyes. I am in the habit of continuing the use of the mydriatic
for two or three weeks after the patient is discharged, and when possi-
ble, make no correction of the refraction for from four to six weeks
after the healing.

Of the immediate division of the posterior capsule at the time of
the extraction as a preventive measure. I can say nothing having had
no experience with it, nor have I seen a case in which it had been done.
Personally, on theoretical grounds, I should think its risks from vitreous
prolapse and infection greater than those attending the secondary opera-
tion, and so far as I know, the expectation that it would remove the
necessity for subsequent capsulotomy has not been realized.

I have ventured to consider rather at length some of the means by
which the frequency of secondary cataract may be lessened, believing
as I do that we can never be justified in looking upon even the least of

7« CHAS. M. THOMAS, M.D^

the operations which we are accustomed to do for its relief, in the light
of a trifling or harmless procedure; though I cannot accept the state-
ment of Wecker and others that the discission is an operation of greater
gravity than that for extracticm of the lens. On the other hand, I
would be quite as unwilling to follow the practice of even so great an
authority as Knapp who does not hesitate to operate for the improve-
ment of a * V40 vision.

While in a general way, the risk of operation is greatest in dense
membranes, and more particularly when they have followed iritic or
irido-cyclitic processes, we have to bear in mind that fatal glaucoma
and panophthalmitis have been known to result from the simple needling
of very innocent appearing thin membranes. Although the percentage
of these evil results is small, I question whether we are justified, unless
under exceptional conditions, in risking such a misfortune, when the
visual power already obtained is as good as say ^^/^o or **/yo with the
ability to read ordinary print with fair ease.

In considering the question of operation, I will premise by saying
that cet par a needling may be undertaken at any time after the sub-
sidence of the irritation following extraction, and after the time at
which we expect patients to attain their greatest visual acuity say 4 to
6 weeks.

The age of the membrane counts but little in the prognosis, pro-
vided its formation has not been the result of an iritis or irido-cyclitis.
The amount and character of such complicating inflammation neces-
sitating a greater or less variation in the operative technic.

It may be said in general that the same care and precautions are
required as to asepsis, etc., in the operation for secondary as in that
for primary cataract, even when it consists only in the mere needling
of a non-inflammatory opalescent wrinkled capsule.

The larger the pupillary space, the more readily can the operative
manipulations be carried out, hence, when the iris is not extensively
attached to the capsule the pupil should be well dilated for some hours
previous to the operation. Here again a pupil with a moderate colo-
boma often presents a distinct advantage over the central round pupil of
the simple extraction, especially when adhesions are not entirely absent

An enumeration of the various operations for secondary cataract
or a detailed descriptian of technic would be superfluous before this
society and I shall therefore limit myself to a brief and rather personal
consideration of the subject.

If there be a moderately large pupil, and the membrane is apparently

SECONDARY CATARACT. 77

not very thick or dense, or even m the latter case, if there are thinner
portions so located as to justify it, I think there can be no question that
the method to be preferred above all others, is that which has been so
extensively practiced, and so often described at length by Knapp — viz,,
the cutting not tearing, of the membrane by means of a straight delicate
knife needle.

Too great care cannot be exercised in illuminating the anterior
chamber, particularly if the membrane be thin ; and as a rule the light
will come best from a point opposite the operator and fnxn the side
toward which the needle points.

The lids should be kept closed for some minutes just before the
operation, as, specially where cocaine has been freely used, the steps of
the capsulotomy may be annoyingly obscured by a sudden dulling of
the corneal epithelium. I always also flood the front of the ball with
pure water just as the needle is introduced.

The direction to enter the needle not farther than 3 mm. from the
edge of the cornea, is most important, as the nearer the puncture lies
to the centre of the cornea, the more difficult it is to make a sufficiently
long clean capsular cut. Further, I believe it should always be intro-
duced at the temporal edge of the cornea, otherwise the bridge of the
nose may interfere with depressing the handle in tilting the point of
needle towards the comer in passing from the horizontal cut to the
vertical ones.

Finally as to the shape of the incision, I have to confess that I have
often found it difficult to make it a crucial one, owing to the shallowing
of the anterior chamber from loss of aqueous before the third cut
could be made ; and as a matter of fact, a T incision is commonly all
sufficient.

When the membrane is not readily cut by the single needle, I be-
lieve one will rarely do better by attempting to tear it with the double
needles of Bowman.

In all dense membranes, and those of inflammatory origin, opera-
tive measures shotdd be approached with great caution and only after
the eye is perfectly quiet, and particularly sfiould methods be avoided
which will cause traction on the iris and ciliary body.

When one is in doubt and fails to cut with the needle on moderate
effort, it is surely much better practice to open the anterior chamber
and divide the membrane with the Wecker scissors or draw out a por-
tion and abscise it as advised by Knapp.

Any of the disastrous or unpleasant reactive processes which follow

78 CHAS. M. THOMAS, M.D,

the primary operation, may attend the secondary, though their occur-
rence in these days of aseptic surgery must be rare. Irido-cyditis,
irido-choroiditis and destructive suppuration have very occasionally
been reported ; personally I have no knowledge of them.

"Glaucoma," in the words of Knapp, "is the only consequence of
discission which may be fairly considered as inherent to the operative
procedure."

This unpleasant sequel I have met with twice in my own practice
and though I was fortunately able to control it in both cases by free use
of myotics alone. I believe that the latest words of Knapp on this sub-
ject, viz., "All cases of ever so slight glaucomatous cyclitis should be
treated with iridectomy without delay" are deserving of most serious
attention.

DISCUSSION.

Dr. J. H. Buffum : In the reading of Dr. Thomas' paper I am struck
with the coincidence of his experience in secondary cataract with that
of my own and I should have been pleased on that account to have had
the principal discussion of his paper fall to some of our colleagues
whose experience may have been different from that of either Dr.
Thomas or myself.

The various forms of secondary cataract and their causes have been
fully described in the paper before you. There is no doubt that the
early operation for cataract is the cause of a large percentage of subse-
quent opacity of the capsule, and it is undoubtedly true that a much
ereater need for secondary operation in the last few years is due to the
fact, that we do not time our primary operation, as well as we did ten
years ago.

The advancement of ophthalmic surgery which has kept pace with
rapid strides in general surgery and enables us to obtain better and
surer results than before, has however tended at least to lessen our
conservatism, and perhaps to affect our judgment as to the best time
for the primary operation.

It is true the demands of patients for early operation as well as the
fact that there are many operators who encourage the laity to believe
that cataract can be operated upon at any time after vision has begun
to fail, sometimes causes us to make an operation earlier than we other-
wise would.

It is a fact that a cataract may be ripe for operation and yet not
opaque throughout and may bring at times a brilliant result to one who
undertakes the operation but subsequent operations based upon a case
of this kind, are usually fraught with loss of the eye or vision to the
patient and of reputation for judgment or skill of the operator.

A careful study of cases which show an individual tendency to

SECONDARY CATARACT. 79

sclerosis of the lens fibres as evinced by the condition of the other tis-
sues of the eye is necessary to form a proper opinion as to time of opera-
tion to obtain the best results.

As to the best method of operation for cataract for the avoidance of
the necessity of a secondary operation, it is impossible for any surgeon
to say, each operator is inclined to think his own is the best and so it
should be if he gives to his cases the careful analysis he should and
finds his results as satisfactory as that* of others. Our patient's ex-
pectation is vision and is unable to appreciate the brilliancy of our
operation if it leaves him more blind than he was before it. To this
end nothing contributes more than a preliminary iridectomy which
may be made at any time after the opacity has become marked and
which in my own experience is the best ripener of immature cataract.
Its objections have been thoroughly discussed but the advantages are
obvious. A full capsulotomy is without question of the greatest im-
portance. The use of atropine with cocaine for three or four weeks
after the operation is in my experience a valuable aid in the prevention
of capsular opacity and I fully agree with Dr. Thomas that the time for
the fitting of lenses should be delayed until the eye has fully recovered
from the operation. In the majority of cases I believe six to eight
weeks should elapse between the extraction of the cataract and the use
of corrective lenses. I have never thought it was wise to perforate
the posterior capsule at the time of operation. As to the time when a
discission should bemadefor secondary cataract my experience has been
that better results are obtained by waiting four montihs, than making
what would seem a simple operation at two months when the patient
has a vision of ^^/jo or ^^/jo- With vision of that value the puncture of
the posterior capsule may or may not give our patient better vision.

As Dr. Thomas states, simple as the operation may appear, there is
a certain element of danger to the already existing vision and in many
cases the condition of the fundus of which we may have had no knowl-
edge, may preclude the possibility of obtaining better vision and again
be such as to be readily incited to take on an inflammatory process
which will destroy the good results obtained by the primary operation.

The reaction following the operation is usually trifling but after a
few days a glaucomatous condition is not infrequently set up and de-
mands the immediate use of myotics or the performance of an iri-
dectomy and when the condition is recognized at once and the proper
treatment applied the vision is often saved.

Dr. Anderson: This is a very important paper. There are one
or two questions I would like to ask I>r. Thomas, and one is, why he
tiiinks atropine necessary after the operation to dilate the pupil, where
there is no sig^ of any iritic trouble ? I formerly did it, until, in several
cases, I got acute mania, as I thought, as the result of atropine, and
tmless there are indications of iritic trouble I do not use any mydriatic.
My last experience was with a woman 95 years old, from whom I had
successfully removed a cataract. In a moment of haste I gave her a
weak solution of atropine which brought on glaucoma and she lost the

90 CHAS. M. THOMAS. M.D.

use of the eye. I do not believe in the use of atropine where it is not
necessary, and I do not believe it is necessary unless there is some sign
of iritis.

Dr. Vilas: I do not think a paper as valuable as this should
be passed over in a light manner. No paper presented here to-day is
more entitled to careful consideration; and there are no subjects more
interesting to those operating much. I was particularly impressed with
the conclusions in regard to his operating, and I could say much in
cordial approval. His remarks in regard to the capsulotomy were ex-
cellent. The opening of the capsule nas been a subject discussed in a
voluminous way ; but, after all, the way to open it, as I believe, is the
way that the author of the paper prefers. I suffered in my early prac-
tice from fear of something that was going to happen about the time
that I opened the capsule, but I never saw bad results when it was
opened properly. I think the various devices that have been invented
have nearly all been abandotted for the method described so carefully
in the paper.

The second point was regarding the needling operation. I was not
aware of the danger of this operation until I had done it so many times
that I was beyond fear. I never saw serious results, and I never hesi-
tate to needle any case which has yielded unsatisfactory results ; and
by unsatisfactory results I mean where the patient has been unable to
read. It has not always happened that a person has been able to read
after needling; but I have seen no imfavorable results from this opera-
tion, and I believe that the reason is that I have used needles that have
been sharp so there has been dean cutting, without any drag^ng on the
tissues. I do not use an ordinary needle, but a knife needle.

My third point is with reference to the use of atropine. I use it as
Dr. Thomas does, and have never seen any serious results follow from
its use.

Dr. Norton: I would like to endorse what has already been
stated about the value of this paper. The reason that so little discus-
sion can be had upon this paper is because there is no room for dis-
cussion: the subject has been so well and thoroughly covered. Not
ing had as an extended experience as the author of the paper, and
ing so far met with but one unfortunate experience from discis-
1, I do not look upon the operation with the same caution. From
own experience I should not feel as if I had done my full duty to
patient with no better vision than **/i«> did I not advise a needling
ration. I have always used the Knapp knife needle and
only complication ever met with was in one case in
ch I had, following the operation, a panophthalmitis and
the eye. I presume I have made the needle operation hundreds
imes and have never seen any bad result whatever except in this one
ticular instance. This was a case in which the extraction had been
le by another. There was a very dense capsule remaining and evi-
tly no discission had been made. The operation was made with
ipp's capsulotomy knife in the usua' manner. I can conceive of do

SECONDARY CATARACT. 81

reason why the eye should have been lost except, possibly, as the capsule
was very dense and tough and the first knife did not seem to cut well, I
used a second knife, which I called for in a hurry, and it may not have
been sterilized before insertion. That is the only assignable reason I
could give for losing the eye ; but, with the exception of that one in-
stance, out of hundreds of discissions I have never seen any bad results.
In my opinion the operation is not as frequently made as it should be.

Dr. Hasbrouck: I wish to thank Drs. Thomas and Vilas, who
have spoken on this subject, as I believe with Dr. Thomas that the
preliminary iridectomy is the only safe and true operation in cataract
extraction. I have operate with the simple operation and with iri-
dectomy at the time of the operation ; but I never forget the words of
Dr. Story, of St. Mark's Hospital, when he said that if he had a cataract
of his own, he would never have it operated on without a preliminary
iridectomy. The needle operations I have done many times, and never
but once have seen any bad results. That time I had glaucoma follow
in four or five days. There had been no immediate irritation apparently
the first two or three days after the operation and the eye did well but
the case developed glaucoma; and, even though I did an iridectomy
almost immediately, she lost the sight. I operated upon the other eye
later for cataract, and also needled this second eye but with no bad
result. There were no apparent inflammatory results to make me think
I had poisoned the eye, and why glaucoma occurred in that case I could
never tell. In the glaucomatous condition the local irritation was slight,
but the tension went up and the pain increased. I did the iridectomy
right opposite to the one I had previously made. I don't think in this
case that atropine had been used. I now prefer using atropine from
the beginning but at that time I was one who did not believe in atropine
after an operation until necessary, but I have changed my mind and
now always use atropine in the manner Dr. Thomas advocates.

There is one other instrument I have not heard mentioned here and
have not seen except once or twice in the hands of doctors in this coun-
try — that is, Ferguson's scissors for the very tough capsules which we
do not succeed in cutting with our needles. They look like DeWecker's
scissors, but the cutting edge is on the outside and they cut from within
outwards so there is no strain upon the ciliary region. I have seen
them, in cases where there has been an exudative iritis, do splendid work,
where the pupil was all closed after an operation. It is an instrument
that you should all have.

Dr. Suff a : My attention was first called to an ingenious intra-
ocular scissors, invented by a Dr. Prentice, I think, and made by Geo.
Teimann & Co. These scissors have blades that c ut both on the outer
and inner edges, and are introduced through the cornea closed, making
their own puncture, rather than an incision, and are of a size to close the
opening made in the cornea, thus preventing any loss of aqueous.
When the blades are in the anterior chamber they are opened, one blade
penetrating and passing beneath the thickened capsule, the other blade
passing above the capsule, and, when closed, making an incision in the

a CHAS. M. THOMAS. M.D.

capsule as well as dividing the iris if necessary. I had occasion to use
these scissors in one case following an iritis, after a tardy closure of the
cornea, where the iris was nipped in the lips of the wound, and drawn
upward, leaving a shallow anterior chamber, and dense capsule to which
the iris was adherent. The anterior chamber being shallow, leaving
barely room to manipulate the blades, made this a difficult case for
this instrument; yet one snip of the scissors divided the capsule and
part of the iris, giving a clear pupil.

I consider the instrument a valuable one, and the operation far pref-
erable to the MK requiring DeWecker's intra-ocular scissors, being no
more dif&cult of execution, and with far less danger of loss of vitreous
and a smaller corneal cut to heal.

Dr. Hasbrouck: The scissors I speak of were made by Tie-
mann & Co. Dr. Ferguson is iiom New Zealand. I knew him in
London, and have always been interested in his work, I saw the
description of the scissors in the Ophthalmological Review.

Dr. Thomas : In reply to the question of Dr. Anderson in
reference to the use of atropine I would say that I consider its employ-
ment imperative after extraction, on account of the disposition for iritis
to appear (even after clean operations) between the third and ninth
day, and sometimes as late as the fourteenth. As to the intimation that
atropine should be withheld until symptoms of iritis present, I can only
say that in my experience extensive iritic adhesions and plastic deposits
will occasionally occur, entirely without sympbMns — that is, as the
result of the so^alled "quiet iritis."

SEPTIC THROMBOSIS OF THE LATERAL SINUS SEC-
ONDARY TO PURULENT OTITIS MEDIA.

By Dudley Wright, F.R.C.S.,

London, Eng.

THROMBOSIS of the cranial sinuses is of two kinds. The
first, or non-inflanunatory type, which occurs in patients suf-
fering from marasmus or other wasting diseases scarcely
concerns the surgeon. The second, the infective inflammatory form, is
of the greatest importance, for prompt action based upon a knowledge
of the nature of the disease and of the parts involved will enable us co
save many a patient from certain death.

It is impossible to enter fully into the pathology of the complaint in
this paper, suflice it to say that, of all the sinuses, the lateral is the
one most frequently affected, the exciting cause being suppuration in
the middle ear.

In such a case the organisms invade the sinus and cause disinte-
gration of its endothelial lining. This eventually leads to thrombosis
and the clot may then tmdergo organization which finally leads to the
obliteration of the sinus; or, as more commonly happens, the clot
breaks down into a suppurating mass, loaded with septic organism, gets
washed into the general circulation, and sets up a fatal pyaemia. An
inflammatory fluid, which eventually becomes purulent, usually collects
around the inflamed sinus, and forms a sub-dural abscess.

The symptoms of this affection have been dealt with in a masterly
manner by Macewen in his work on "Pyogenic Diseases of the Brain
and Spinal Cord." He divides them into two groups, viz., general
symptoms, and local ones, which are determined by the anatomical
position of the sinus affected.

The general symptoms are ; headache which may be generalized or
only over the part affected: vomiting; very rapid pulse; temperature
of a remittent type, and very often rigors. According to his experience
the symptoms take on a more or less definitive form, such as (i) the
pulmonary, in which after the disease has existed a week or two lung
signs, such as dyspnoea and stabbing pain in the chest, possibly due to
infarctions, occur. Secondly, the typhoid type, in which, at the end of
the second week, there is abdominal pain, meteorism, and diarrhoea;

M DUDLEY WRIGHT, F.R.C.S.

the stools often being pea-soupy and very offensive. A dark measly
rash not raised above the surface, nor disappearing on pressure may
also occur. And, thirdly, the meningeal form, in which symptoms of
meningitis are present.

The local symptoms vary according to the sinus affected. In the
case of the longitudinal sinus, oedema of the scalp, swollen veins in the
occipital and frontal regions, epistaxis owing to venous circulation 'n
the nose and convulsions followed by coma and death usually complete
the picture. In the case of the cavernous sinus, exophthalmos, and
cedema of the lids and surroimding parts tc^ther with ptosis and
squinting are present

If the lateral sinus is involved, swelling and tenderness along the
course of the internal jugular vein, with enlarged cervical glands, may
be found. CEdema over the mastoid is often present, it is, however, a
mistake to suppose that this always accompanies the sinus disease, or
even is present in every case of mastoiditis, for one of the narrated cases
will show, both present without any mastoid dwelling.

If the clot breaks down, or becomes puriform, micro-organisms are
carried on by the circulation into the lung, and pysemic abscesses are
set up at the site of the lodgment of each particle of thrombus. It is
only by as early recognition of the nature of the case, and prompt and
energetic treatment that such an accident, usually fatal in its result
can be avoided.

In dealing with these cases it should be our aim first of all to ren-
der healthy those parts which are the fotites et origines of the disease.
That is to say the mastoid cells and antrum and the middle ear must be
thoroughly attended to. This having been done, the next thing is to
open up the groove which lodges the lateral sinus. This can be easily
offiv-tBd by removing some of the bone behind the original opening into
istoid antrum.

le sinus having been laid bare, we must note whether its normal
ions are present or not. These pulsations are most marked with
ct of respiration, but arterial pulsations are also communicated to
: no pulsation be present we may suspect that it contains a throm-
[lough this is not a certain sign of clot. We may make sure of
esence of thrombus by inserting a hypodermic needle — ^needless to
reviously sterilized. If we now aspirate, we may obtain no re-
r a puriform clot may come away. In many cases, where the clot
tic, and often before it has broken down within the sinus, a col-
i of matter will have formed around the sinus, or even, as in the

SEPTIC THROMBOSIS OF THE LATERAL SINUS. 86

second case narrated, gas may have formed and escape on removing
the bone. In any case, where we have ascertained the presence of a
dot, and where symptoms of septicaemia are present, and more particu-
larly if pyaemic symptoms are noted, I deem it by far the best treatment
to immediately ligate the internal jugular vein in the midlle of the neck,
or lower if the clot be found to have extended lower, and then to op**n
the sinus freely and remove the infective material that lies within.

I much regret that I did not do this with the first case; but it
occurred so long ago as 1891, and in those days this operation was
scarcely introduced. In the second case occurring in 1894 I proceeded
as above, and with a successful result; though the patient passed
through a very anxious period before we were sure of her recovery.
Since that time I have operated upon many scores of mastoid cases, but
I have not been called upon to deal with any presenting signs of sinus
thrombosis. I believe this points to the fact that the profession as a
whole are more alive to the baneful results of neglected mastoiditis, and
are careful to apply to the surgeon early whenever mastoid symptoms
arise in the course of an otorrhcea.

Case One. — Florence F., aged 12, first seen on October 20, 1891, was
at that time complaining of severe pain around the right ear, radiating
over the whole right temporal region ; slight, oflfensive, brown-colored
discharge from the ear, and general feelings of malaise. The discharge
had been present three years ; one year ago the patient had an attack of
scarlet fever, after which the discharge slightly increased.

The pain came on for the first time three days ago ; two days ago
the patient vomited once and had a slight fit, but nothing definite was
noticed about it beyond that the arms "twitched" a great deal, and that
there was no loss of consciousness. On the day that she was first seen
the temperature was 101.6*. The mind was quite clear, though the
child was evidently suffering great pain. Skin dry, and tongue coated ;
pupils equal. There was no redness or oedema over the mastoid proc-
ess, but this and the right temporal region were tender to pressure.

The next day, October 21st, the patient was admitted to the hospital,
the above S3miptoms remaining about the same. Examination of the
meatus showed it filled by florid granulations, which completely
obscured all view of the drum, and bled readily when touched with a
probe.

In spite of treatment the patient grew rapidly worse. The pain in-
creased; the temperature varied between 103** and 99.6**; the pulse
became very frequent, at times reaching 150 per minute; there was
great restlessness; the patient grew dull and was constantly sighing
and moaning involuntarily; and there was photophobia. Ophthalmic
examination revealed a commencing double optic neuritis.

On the third day after admission (October 24) the mastoid antrum

S6 DUDLEY WRIGHT. F.R.C.S.

W3S opened by means of a small trephine. About a drachm of foetid
pus was removed, and the granulations and polypi were removed by
means of a curette. Iodoform emulsion (glycerine and iodoform)
was then instilled through the mastoid wound, and a drainage-tube and
iodoform gauze- dressing applied.

The operation had the effect of relieving the pain for about twenty-
four hours. There was a free discharge from the wound, necessitating
a change of dressing twice daily. The pulse, however, did not diminidi
in frequency, and the temperature showed oscillations.

On the morning of the 26th, the patient had a rigor, and the pain
returned, and the optic neuritis was found to have increased. A con-
sultation was held, and it was decided to explore the brain for an
abscess. The spot selected for trephining was ij4 inches behind the
center of the meatus, and i>^ inches above Reid's "base-line" (a lire
prolonged backwards from the lower and outer angle of orbit through
the center of the bony meatus). At this spot a J^-inch trephine was
applied, the bone removed, and dura mater incised. An aspirating
needle was then passed into the underlying temporal lobe in various
directions, but no pus was found. The wound was, therefore, closed.
A few small pieces of the bone removed were replaced, and the usual
dressings applied, the pericranium and the skin-flaps being sutured
separately.

The patient recovered well from the immediate effects, and passed
a good night, the temperature having fallen considerably, but the fol-
lowing day the symptoms returned, and the patient grew rapidly worse,
being at times unconscious, and having daily rigors up to the 29th, the
temperature on one occasion rising as high as 107.°

At midnight on the 2Qth it was decided, as a last resort, to explore
the surroundings of the lateral sinus. To effect this, an incision was
made at right angles to the previous mastoid wound, and the bone re-
moved just behind the mastoid process with a chisel, until the sinus was
brought to view, and a further enlargement of the opening was th?n
made with bone forceps. A probe passed backwards, separating the
sinus from the bony groove, gave exit to foetid pus. This was done
several times, both upwards and backwards, and in the direction of the
superior petrosal sinus, and along the posterior surface of the petrous
bone ; and weak carbolic solution used to wash away the pus, which
ly in fair quantity. The lateral sinus pulsated, and therefore
to have fluid contents, but it was not opened to ascertain this.
s were rough, and covered in parts with inflammatory lymph,
emperature fell to 97° after the operation, and during the next
not rise above 102°. The following day — October 30 — the
ad another rigor. Temperature 102.4°, Th* general condi-
fair. The wounds looked fairly healthy, and the discharge
ely lost its offensive character. The patient suffered no pain,
.ind took food well. Dressings were renewed twice a day,
intiseptic lotion was syringed for a considerable distance Iw-
dura mater.

SEPTIC THROMBOSIS OF THE LATERAL SINUS. 87

On November ist the patient became worse. A cough developed,
and she had pain in the left side of the chest, where a distinct friction
sound was heard. This continued, and the strength gradually failed,
and temperature fell, on one occasion going as low as 95.2°, and finally
the patient died, on November 5th, a week after the last operation.
Bryonia, China, Aconite, and Lachesis were all used during the progress
of the case, but without avail.

At the autopsy, extensive thrombosis of the lateral sinus of the right
side was found, the clot extending downwards in the internal jugular
vein as far as the level of cricoid cartilage, and upwards as far as the
torcular herophili. The veins leading from the lateral and petrosal
sinuses were extensively thrombosed. There was no abscess in any
part of the brain, and no appreciable meningitis.

The roof of the mastoid antrum was necrosed and carious, and the
ulceration had spread up to the petro-squamous fissure, thus effecting
a conununication between the tympanum and the sub-dural space.

A septic infarct was found in the right lung, the left lung was col-
lapsed, and the pleural cavity contained about Ji. of pus. The other
organs were fairly healthy. The trephine wound over the tempero-
sphenoidal lobe had entirely healed up.

Criticising this case in the light afforded by the post-mortem exam-
ination, we are able to follow the train of events which led to the fatal
issue, and, at the same time, can form a fair conclusion concerning the
most suitable treatment.

We see that a chronic inflammatory disease, apparently originating
in the tympanic cavity, had caused a carious process to be set up in a
localized part of the surrounding bone, effecting thereby a communica-
tion with the extra-dural space situated over the upper surface of the
petrous bone.

This having taken place, the pus, in time, found an exit, and hav-
ing, we may presume, collected to a certain extent at this spot, gravi-
tated towards the sulcus lateralis on account of the normal incline down-
wards and backwards of the upper surface of the bone.

Having once reached this situation it found a convenient resting-
place for itself, and, at the same time, set up an inflammation of the
coats of the adjacent sinus, which probably soon exerted its injurious
effects upon the blood contained within.

It was at about this stage that the case came under treatment. The
almost hourly fluctuations of the temperature were an index of the
extent to which the blood was being poisoned by the absorption of the
accumulated septic products, and the pain, optic neuritis, and frequent
pulse denoted the meningitic irritation. The mastoid was now opened,
and the release of the pent up pus, together with the depletion of the

S8 DUDLEY WRIGHT, F.R.CS.

vascular turgescence, effected by the loss of blood during the operation
resulted in a temporary amelioration of the symptoms. The most im-
portant seat of the disease, however, remained untouched, and, there-
fore, further complications ensued; the sudden appearance of rigors
probably betokening the occurrence of secondary septic inflammation in
other regions and development of a pyaemic state.

Case Two. — Sarah C, aged nine years, was admitted into the Lon-
don Homoeopathic Hospital on January 27, 1894, suflFering from in-
tense pain behind the left ear and swelling in the neck below the left
mastoid process.

The patient had scarlet fever two years ago, followed by a bad-smell-
ing discharge from the left ear, which had continued up to about three
months ago. Three days before admission, the pain in the head fir:>t
came on; it rapidly increased in severity, and the night before admis-
sion the patient was delirious. There had been no rigors or convul-
sions.

On Admission. — The child was very pale and cold and almost col-
lapsed. Pulse 136 and temperature 100**. She was deaf in the left ear
and had some swelling of the tissues below the mastoid process, and
there was tenderness to pressure there, but there was no redness of the
skin and no swelling whatever of the mastoid itself.

There were no abnormal physical signs in the lungs or heart. Was
ordered Belladonna and Plantago, On the day after admission (28th)
the patient vomited three times and was still in great pain, the tempera-
ture varying between loi** and 102.8**. Veratrum viride be. On the
29th January there was marked drowsiness ; the patient was continually
lying on her left side, with the knees drawn up. Pain and tenderness
over the mastoid region remained about the same, and the swelling in
the neck was still present, but there was no redness or swelling over
the mastoid itself. The knee-jerks were absent, no ankle clonus, pupils
dilated. Ophthalmoscopic examination, made by Mr. Knox Shaw,
showed the discs swollen and edges indistinct but not striated and con-
siderable congestion of the vessels. Examination of the ear showed
a perforation in the drum, through which some thin offensive pus was
discharging.

A consultation was held, and it was decided that an exploratory
operation was advisable. The patient was put under the influence of
A.C.E. mixture, and an incision was made behind the ear and the bone
covering the mastoid antrum, was removed with a chisel and forceps,
the lining of the posterior wall of the external meatus being detached
and held forward. A considerable thickness of bone was removed be-
fore the antrum was opened and the foetid pus which it contained then
escaped. Finally the opening was much enlarged by removal of the
greater part of the mastoid process, and the cavity well scraped out
and flushed with antiseptic lotion and packed with iodoform gauze. At
the close of the operation some air of foetid odor was noticed escaping

SEPTIC THROMBOSIS OF THE LATERAL SINUS. 89

from a small opening in the posterior part of the cavity. The patient
was rather collapsed after the operation.

On the next day (January 30th) the following notes were made:

"The patient had some pain in the night and vomited once. This
morning the patient had a rigor, the temperature going up to 105.4.
The dressing was changed, a fair amount of discharge having come
away. Hot boracic fomentations to the ear had given considerable
ease to the pain, and the patient seemed better in the afternoon after
the rigor."

The occurrence of a rigor in spite of the exit already given to the
pus pent up in the mastoid antnmi, made it highly probable that septic
matter was present around the lateral sinus. It was, therefore, deemed
advisable to open up the sulcus lateralis. This was accordingly done
under an anaesthetic the same afternoon.

By prolonging backwards the incision made on the previous day, the
bone was laid bare and removed, and the lateral sinus exposed. It was
found covered by a thick layer of adherent pyogenic membrane. This
was removed, and a hypodermic syringe used to ascertain whether the
sinus contained fluid blood. None was, however, obtained, it being
evident that the venous channel was obstructed by a thrombus. The
wound was accordingly temporarily plugged with gauze, and an in-
cision was made along the anterior border of the stemo-mastoid at
about the middle of its length. The external jugular, which lay in the
line of the incision, was divided between two forceps, and a mass of
enlarged glands removed, the internal jugular being thereby brought co
view. It was found to contain clot as far down as the entrance of the
middle thyroid veins, and a double ligature was placed around the vein
below the lower extremity of the thrombus, and the vein divided be-
tween the ligatures. The lower extremity of the upper divided end
was then opened, and stitched to the skin, and some of the contained
clot removed. The lateral sinus was next opened, and clot mixed with
pus removed from it, both from its lower and upper part, whereupon
free haemorrhage took place. This was easily controlled by plugging
with gauze, and the usual dressings completed the operation.

The pulse was rather weak towards the end of the operation, but
was much improved by an enema and hypodermic injection, of brandy.

The patient rallied well and slept a good deal through the evening
and night, and the pain was much less. Liquid food was taken well,
together with small doses of brandy. Three doses of Strophanthus Ix
were also given during the night. The temperature varied during the
following two days between normal and 102.8®. The dressings were
changed dailv and a stream of lotion made to wash out the vein from
its upper to its lower opening, thus removing the septic coagulum.

On February 2d (the third day after the operation) the patient
complained of pain in the left side and the respirations were accelerated.
A loud pleuritic rub was heard in the infra-axillary region. (Bryonia
Ix ordered.)

The following day impaired resonance and harsh breathing was

90 DUDLEY WRIGHT, RR.CS.

found at the left apex in front ; and at the base the percussion note was
dull below the angle of scapula, and tubular breathing was present here.
The friction sound was not so loud as before. Phosphorus.

On February 4th the left lung remained about in the same condi-
tion, but the harsh breathing was present at the right base. The head
and neck wounds were progressing well, the disclutrge having lost its
offensive character, and healthy granulations appearing.

On February 7th the whole of the left base was dull to percussion
with weak breath sotmds. Above the angle of scapula there was
aegophony. Aspiration of the pleura with a h)rpodermic syringe gave
a negative result.

There was a small slough in the neck wound, which together with
the stitches uniting the vein to the skin was removed. The patient
had been taking food and brandy well. There was only a slight cough
and no expectoration.

On February 9th expectoration had appeared in the form of slightly
foetid yellowish lumps. There were signs of redux crepitation at the
right apex, and considerable dulness at both bases.

The dulness at the left base had considerably diminished by the 14th
of February, and small crepitations were heard at the right base; there
was also impaired resonance and harsh breathing at tihe right ape<.
Since the last note on the temperature the daily variations had been con-
siderable, the maximum being 104.4** (on one occasion) and the mini-
mum 97°. (Arsenicum iod. 3X.)

February 19th. — Since the last note the temperature has been fall-
ing steadily, and during the last two days it has not risen above 99".
Left lung is clearing well. In the right lung crepitations are heard
as high as the mid-scapular line. Expectorations of yellowish offensive
sputum continue. Both wounds are closing, though there is some puru-
lent discharge from the left ear.

February 26th. — The patient is improving rapidly. The dulness is
disappearing from the bases, and the patient is sitting up in bed and
appears much stronger. The temperature keeps normal, and expectora-
tion has now nearly ceased.

March 12th. — The patient has now been getting up every day for
the last ten days, and is in very good health, though still somewhat
anaemic. There is only a very small wound behind the mastoid and the
neck wound has healed. The temperature remains normal. There is
still a slight discharge from the ear.

Shortly after this date the patient was discharged from the Hospital
quite well, and went to a convalescent home. She has lately been seen,
five years since the operation, and is quite healthy, the ear never having
given her trouble since she left the hospital.

DISCUSSION.

Dr. George W. McDowell: The recital of the two cases of sinus
thrombosis to which we have just listened are exceeding instructive.

SEPTIC THROMBOSIS OF THE LATERAL SINUS. 91

The first shows the almost inevitable result when the condition Is
not recognized, or when operative measures are undertaken too late to
prevent secondary infection of remote organs. The second illustrates
the triumph of modem surgical methods when applied in time, in avert-
ing what would otherwise be a fatal termination of the disease in
question.

Certainly no blame can attach to Dr. Wright's failure in the first
instance to reach the site of infection, by opening the lateral sinus, as
was done in the second, for at the time of the first operation eight years
ago, but little was known on this subject. Burnett, in his edition of
1884, does not even mention the lateral sinus, of so little interest was it
to aurists of that day. Politzer, in his edition of 1894, the year of Dr.
Wright's second case, says : "The prognosis of otitic-sinus diseases was
very unfavorable until within a short time, but owing to the great
progress of modem surgery it has proved more favorable in so far, that
results have been obtained by the operative treatment which were
scarcely anticipated a few years a^o."

The question of diagnosis of smus thrombosis is of the greatest im-
portance to every aurist, and is not as yet absolutely settled. One of
the most important symptoms for diagnostic purposes is the tempera-
ture curve, which may show great variations from hour to hour, reach-
ing 104° to 106** and then dropping to nearly normal spontaneously.
The sudden rises of temperature are thought to be due to the passage
into the general circulation of septic material, which is thrown oflf by
the breaking down of the disorganized clot in the sinus. In order to
detect these sudden changes, the temperature should be taken every two
hours when such a condition is suspected. Another characteristic
symptom is the presence of rigors in a patient suffering from mastoid
disease. This, however, is not always present, but when it exists, is
almost pathognomonic. In some of the cases when the thrombus ex-
tends into the internal jugular vein the latter may be felt like a tense
cord running along the anterior border of the stemo-cleido-mastoid
muscle. In the second case reported this probably could not be felt,
as the author states that a mass of enlarged glands had to be removed
before the internal jugular was reached.

There has been some difference of opinion among operators as to
whether it is necessary to ligate the vein before the sinus is opened.
Some have claimed to have attained as good results when they have left
the jugular untouched as when it was ligated, getting more or less
secondary infection in either case. The method adopted by Dr. Wright
in his second case, in which he cut the jugular between the two liga-
tures, slit the upper portion to remove the clot, and then sutured it to
the skin, thus permitting a thorough cleansing of the sinus from above
downward, is certainly to be commended. The successful outcome
of the case, in spite of the secondary infection which existed at the
time of the operation, is a matter for congratulation, and will aflford
hope to others under similar circumstances.

THE TREATMENT OF TRICHIASIS.
By E. W. Beebe, M.D.,

Milwaukee.

THE aflfection of the eyelids known as trichiasis, and upon which
I have the honor to report upon this occasion, is seldcMn seen
in such severity as formerly, when trachomatous disease was
more prevalent, yet the milder cases are encountered sufficiently often
to make the subject of more or less interest to the surgeon.

It is a topic which, from its fancied simplicity, is seldom discussed
by an association of this character, and I feel like apologizing for bring-
ing it before you at a time when there are so many more important ques-
tions to engage your attention ; but it is a condition which is exceedingly
annoying to patients, and the treatment which is generally employed for
its relief, partakes so much of the crudity of ancient surgery, and so
at variance with the experience of the writer, that I trust I may be
pardoned for calling your attention to a more humane, conservative,
and I doubt not quite as effectual a method of managing these cases as
any now commended.

It is a condition which has been recognized since surgery had an ex-
istence and with but very little improvement, if any, in its treatment
since the days of Celsus.

It is not my purpose to enter into any discussion of the causes or pe-
culiarities of the affection, our reference books being so complete as to
its etiology and characteristic descriptions as to leave nothing to be de-
sired in that respect; but a variety of opinions exist as to the most de-
sirable treatment, and this, therefore, becomes a question of importance
to the specialist, and may, I trust, be discussed with advantage by the
members of this society.

Of the management of the graver forms of this affection, as when
complicated with entropium, or incurvation of the tarsal cartilages,
there is perhaps a greater uniformity of opinion, but in the milder varie-
ties, or where only a few cilia are involved, a variety of methods are
employed for its relief, each of which has its supporters.

In the treatment of trichiasis two important considerations should
be taken into account :

THE TREATMENT OF TRICHIASIS. 9S

1st. The patient must be relieved permanently of the annoyance;
and

2nd. The treatment must be attended by as little suffering as pos-
sible, and without any injurious or undesirable cosmetic eflfects as se-
quels.

After a somewhat lengthy experience with the various accepted
methods of treatment, the writer is forced to the conviction that many of
the operations for the relief of this condition which are commended
should be condemned, as they have no place in the practice of conserv-
ative surgery. Any operation which has for its object the removal of
the hair follicles, either by the knife, electrolysis, or otherwise, must be
considered unscientific, and open to objection.

The use of the electric needle now so generally employed for the re-
lief of this condition, is not infrequently attended by severe pain, and a
high degree of nervous erethism in timid patients; this renders it ob-
jectionable, particularly as it is exceedingly difficult to accurately insert
the needle in such cases, thereby rendering it necessary to resort to
general anesthesia or a second or third operation before success is at-
tained.

Experience has taught me that of all the methods which have been
commended for the relief of this condition the one most applicable to
the majority of cases, is a modification of that introduced by Celsus,
which has now become obsolete, and is seldom mentioned in surgical
works. This is due, probably, not so much to its inefficiency, as to the
difficulties attending its practical application.

In the earlier years of my practice a modification of this method —
first suggested by Snellen — was not infrequently used, and was known
as the "stitching up process,"the modus operandi of the procedure be-
ing as follows : A fine curved needle, armed with a double silken thread,
was passed through the edge of the lid from within outwards, the open,
or cut ends, of which were withdrawn from the wound and the needle
removed, leaving a loop of the thread remaining, through which the
offending cilia was threaded and the whole withdrawn, leaving the
free end of the eyelash in the wound, in which position it continued to
remain, and of course gave no further annoyance.

This little operation, which is so simple to describe, and apparently
to put into practice, is nevertheless attended by more difficulties than is
at first apparent, a fact which will be recognized by those who are
familiar with the details. The results, however, when successfully
carried out, are all that could be desired. Realizing this fact many

U E. IV. BEEBE, M.D.

surgeons have experimented with modifications of the method, with a
view of simplifying it, but only to cast their devices aside as impracti-
cable, or no improvement on that of the needle and thread.

Knapp conceived the idea of threading a curved needle with the eye-
lash while engaged in the wound, but abandoned it from the difficulties
attending its application.

Wecker devised a needle with a hook in the end in place of the eye,
which was also thrown aside as impracticable for various reasons.

The writer's early attempts to simplify this method were attended
by the same or similar successes, but my latest or improved device
promises to supersede my earlier efforts, and it is my pleasure to pre-
sent it to you for your consideration.

Among the most serious objections to the use of the needle and
thread was the size and depth of the wound necessarily made in pass-
ing the double thread, the difficulty of placing the cilia in the loop, and
the retention of the same in the wound after the adjustment, particu-
larly with shortened lashes.

In the instruments here presented an attempt has been made to have

them constructed as small as practicable, to make their application as
nearly painless as may be, as well as to prevent injury to the hair folli-
cles and glandular structures bordering the lids, and to better retain
the readjusted lashes in the normal position. The needle is slightly
curved, and flattened upon its anterior, and ridged upon its posterior
surface, and is made with cutting edges. This enables the operator to
make a superficial puncture without its tearing out, as is frequently the
case when the needle and thread are used, which is one of the objections
to that method. The hook also has a slight curve to facilitate its use in
overhanging eyebrows.

The use of these instruments is very simple : the needle being first
inserted as close to the root of the cilia as possible, is carried from
within outwards sufficiently deep only, to prevent breaking the skin,
and should be from puncture to exit from two to three millimetres in
extent, depending somewhat upon the location of the in-growing lash.
The hook is then inserted from the outer side and the cilia engaged
and withdrawn. The hook should not be regularly curved, but should
be elongated somewhat, in which shape it engages the cilia better, and
is less liable to be disengaged if the instrument is rotated slightly, as is
necessary sometimes to facilitate its withdrawal.

The operation of readjusting displaced cilia by the aid of these

THK TREATMENT OF TRICHIASIS. 96

instruments is but momentary, or probably less than one quarter of
the time necessary for their removal by destroying the hair follicles.

In my experience the relief is not only prompt but has been per-
manent, and the objection whicli some have made that the life of the
cilia is of but a few month's duration, and that a recurrence of the an-
noyance takes place with the new growth, I have found to be without
foundation. The sufferiiig of the patient is very slight as compared
with that of the removal of the follicle by caustics or electrolytic action ;
and the method is efficient in all cases, except those accompanied by
entropium, or where there is incurvation of the tarsal cartilage after
trachomatous disease, which, of course, requires a more severe opera-
tion for its correction.

It is unnecessary for me to expatiate on the advantages of correct-
ing the abnormal direction, or growth, of the eyelashes over that of the
more severe methods of splitting the lids, extirpation, or transplanting
of the hair follicles, by the aid of the knife, or destroying them by elec-
tro-cautery, electrolysis, etc. The deformities of the lids which are
most certain to follow such measures, and of which there are numerous
examples, are sufficient to condemn their use except in the most extreme
cases.

DISCUSSION.

Dr. A. G. Warner : I wish to thank Dr. Beebe for his ideas upon the
treatment of this troublesome disease. Certainly the methods of the
past have been very unsatisfactory in my hands. Fortunately, I have
very few such cases to treat now-a-days; and I am very apt to wish,
when I see one, that I might never have another. With the new instru-
ments which Dr. Beebe has devised and which I had the pleasure of
seeing this morning, I should attack the next case with some degree of
interest. Of course, the proof of the pudding Is in the eating of it.
Whether I shall succeed as well as Dr. Beebe has, I can only tell by
trying.

OPHTHALMIC AND OTIC USES OF SOME ANIMAL EX-
TRACTS.

By Isaac C. Soule, Ph.D., M.D.,

Freeport. 111.

THIS title is not strictly correct, in that the substances herein
spoken of, are, perhaps, more properly designated, animal
products or derivatives, as they are, with one exception, used
exactly as found in the anatomical state, having* only been dried, the
better to preserve them, and none having received and chemical treat-
fnent,

Protonuclein. — This is said by its makers to be the active or life
principle, the nuclein, of every gland in the body together with that of
the brain. The extraction, is mechanical, after which it is dried. It is
furnished in two strengths, the "Special," being full strength, intended
for local use only, while for internal use a triturate in sugar of milk is
provided.

The active principle is freely soluble in water heated to 98° F.
but as there is also present some insoluble organic matter, the solution
must be filtered or allowed to stand until this has settled, and then
decanted. This solution will, if made with distilled water, keep satis-
factorily in cold weather, but in summer it is more satisfactory to make
a fresh one each day. They must never be boiled, as heat over 103^ F.
renders the active principles inert. To make the solution, add to i dram
of distilled water, previously heated, 10 or 15 grs. of the special powder,
shake well for a few moments and filter. Personally, the only use I
make of the solution, is to occasionally give it to the patient for home
use, the powder being more satisfactory for ofiice use, and is the form
used in these studies unless otherwise specified.

My study of this remedy was begun something over five years ago,
I have endeavored to make it thorough, as exhaustive as possible, and
accurate. Each and every clinical result herewith presented has been
verified many times over, a written history of each case made at the
time, and the cases kept under observation for from one to three years
after discharged as cured. No selection of cases has been made for this
report, but they were, on the contrary, taken at random from my case-
books, only having been arranged in certain order, the better to illus-

USES OF SOME ANIMAL EXTRACTS. 97

trate certain phases of action, which are, "A," those cases where a
stimulant or nutrient is clearly indicated, and **B," those illustrative
of its peculiar action on morbific growths or organizations.

"Class A." — Case One. — Miss Z. V. H., age i8. First seen
September 19, 1895. When four years of age the cornea of right eye
was torn by being accidentally struck with the sharp point of an iron
hand-sled runner, while at play with a younger sister. Three weeks
after the accident happened the patient was placed under the care of
Dr. J. H. Buffum, who succeeded in saving the eye, but gave no en-
couragement to their hopes of useful vision. Present condition — Right
eye inflamed and painful, sensitive to pressure, worse from use of the
other eye, if she catches cold or for any reason feels worse than usual.
Apt to be inflamed and always painful at each menstrual period. No
increase in tension. Patient very nervous, slightly hysterical, some
choreic symptoms present. Great deal of headache, which always set-
tles in nape of neck and between shoulders. Sore, tender spot, size of
half-dollar, on the spine of fourth dorsal vertebra. General ansemia.
Under atropia and very dark glasses, continued for two weeks, many
of most distressing symptoms disappeared or grew very much better.
Right eye still sensitive to touch but not inflamed, tension normal. On
account ot extreme irregularity of cornea, no view of fundus was pos-
sible. For the same reason failure was met with in the attempt to use
/aval and the Placado disk. Under oblique light cornea is seen to be
much more convex than the left, and to contain several irregular-shaped
scars. Vision — Cannot count fingers nor find way about the room.
Sees ten duplicates of candle-flame. With stenopaic disk at ax. 50° with
— 9 D. lens, only three images are seen. Vision — Counts fingers fairly
well, at six feet. Left eye, slight amount of Has. Advised opaque
glass for right eye and corrections for left. Patient refused to wear
such correction, and would only consent to wear a broad, black velvet
ribbon to exclude right eye during near work at home. Some improve-
ment resulted from this, but it was very unsatisfactory. Patient was
now seen by two well-known oculists of the old school, at my request,
who both advised enucleation as the best treatment and only safe
course. Consent to this was emphatically refused by both patient and
parents. Referred patient for general treatment and began the use of
Protonuclein locally. Cornea was liberally covered with the powder
and then direct massage with a silver spatula practised for five minutes
Treated three times per week. Treatment continued regularly for
three months, when the massage was discontinued, except at rare inter-
vals, but the Protonuclein was used with more or less regularity until
April 28, 1898, when a second attempt at correction under Scopolamine
(2 drops, refraction at 60 minutes) was made. Right eye — Javal Ax
1.30**, = 44.5 D, Ax. 40^ = 51 D. against rule. Images in these
meridians are clear, regular and sharply defined, a variation of 2** either
way, however, will render them so distorted as to be almost unrecogniza-
ble. Full correction as obtained by skiascopy was ordered. Vision un-

V8 ISAAC C. SOULt, Ph.D.. M.D.

corrected, fingers at 8 ft. with — i. D. sp. C 7- D- cy. ax 40° = "/^ — 3
letters, sees two faint images of candle-flame, one on either side of the
bright flame. These were evidently only reflections due to prismatic
effect of heavy concave cylinders, as they soon disappeared, unless she
looked for them. Left eye — Javal ax 180° 43. D. ax 90° 43.8 D.
Skiascopy + .63 D. cy ax 90°. Evidences of old choroiditis. V. =:
^'/jo. In right eye, no evidence of the scar-tissue can be discovered
with + 24 D. lens and reflected tight. Comea clear and smooth. This
patient has recently been examined with the result of obtaining V. O. D.
= 'Y„ and Jaeger No. 5 at 10 inches. Reads music and newspaper
readily, only an occasional headache, eye never painful nor inflamed.
Sore, tender point on spine and ache between shoulders entirely gone, is
fleshy, pretty and consequently happy.

Case Two. — Miss J, S., age 40. Referred by Dr. B.
History. — Has been troubled all winter by something on right
comea; been under care of old-school oculist for past four months,
with varying, but wholly unsatisfactory, results. Never better than at
present time, June 15, '96. Inflammation and infiltration of comea is
so extensive that a careless examination might lead one to pronounce
the trouble keratitis, instead of what it really is, an extensive superficial
ulcer, measuring 2j4 m. m. in diameter, with ragged edges and numer-
ous small vessels extending to the limbus; extreme lachrymation and
photophobia.

Treatment. — Curetted entire ulcer thoroughly, flushed it with solu-
tions of formaline i-io.ooo, gave patient solutions of i-io per cent, of
scopolamine to be used every 2 hours and Kali mur. 30X every four
hours. In five days ulcer had healed and comea almost clear. This
improvement only lasted a few days, when she returned with eye in
almost as bad a cwidition as when first seen. I now learned from Dr.
B. that patient is addicted to the use of morphine. Judging that there
was a lack of nutrition to comea, ulcer was again curetted and flushed
as before, comea entirely covered with Protonuclein powder, and light
pressure bandage applied. Ulcer entirely healed in thirty-six hours,
slight haziness of comea alone remaining. Treatment was continued
every day for eight days, then every other day for two weeks more,
Kaii tnur. 30 x was given twice a day for the first ten days. At end
of treatment comea was clear and brilliant. Patient has had no return
of trouble up to present time.

Case Three. — Delayed union following extraction of cataract.
Mr. G.. age 80. In good health and vigorous as a man of 70, Has
been a drinking man for thirty-five years, but for past five or six years
rt drank any at all. The wound made for preliminary iridectomy
, promptly and, apparently, solidly. Six weeks later I extracted
aque lens. The wound being entirely in the comea, capsulotomy
one with forceps, and entire operation frran start to finish very
ictory. Edges of wound coapted nicely. Eye closed with ad-
plaster, and protecting wire mask applied. No pain, inflamma-
>r untoward sympttKns at any time present, yet at end of ten days

(/S£S OF SOME ANIMAL EXTRACTS. 99

wound remained open as freely as when made. Dusted wound very
plentifully with Protonuclein powder, and closed as before. At end of
thirty-six hours anterior chamber established for first time since opera-
tion. Dressing was reported twice, when patient was dismissed, with
very faint gray line marking site of line of incision.

"Class B." — Case One. — ^Trachoma Pannus.

Daisy D., age 19. Referred by Dr. W., July 7, '97. Contracted
trachoma in infancy and in spite of several active courses of treatment
has steadily grown worse. Present condition — Right vision can see
movements of hand but cannot count fingers, at 2 feet. Left vision,
fingers at 6 feet. Lids considerably contracted. Palpebral fissure so
short that lids cannot be everted. Considerable ectropium in both
eyes. Cornea uniformly densely infiltrated throughout entire surface.
No light reflex possible. July 17th, under A. C. E. anaesthesia, did a
free canthoplasty on each eye, together with thorough expression of
trachomatous bodies, with Knapps* roller forceps. Only the upper lids
were treated, as patient did not take the A. C. E. well. Dressing fol-
lowing operation ; the lids were cleansed of all traces of blood, by spong-
ing (cotton) with hot formaline ^/looo solution, dusted with Proto-
nuclein powder, and the powder well rubbed in, again plentifully dusted,
together with the wounds at the angle, lids closed with adhesive plaster,
dusted over again, covered with light pledgets of absorbent cotton
(which had been previously thoroughly impregnated with Protonuclein
powder), all held in place by wire masks and tapes. Dressing
remained in place for forty-eight hours. Wounds healed by first in-
tention. No swelling of the lids. From this time until September ist
ty^s were treated every day, first cleansing well with formaline, ^/looo
solution, then applying Hodge's argentum iodinum mixture (see
Note L) considerable force being used in rubbing same into lids. Eyes
were closed and massaged for five minutes through lids.

At- the end of ten days, the corneal condition not improving, Proto-
nuclein was substituted for the Hodge !l^ every other day, using it
liberally and massaging through closed lids for five or ten minutes.
Cornea began to clear almost immediately, continuing to improve until,
when dismissed, only by using a -f 26 D. lens could any fine dots be dis-
covered. The upper lids were smooth, covered with healthy con-
junctiva, and free from scar-tissue. In the lower lids the trachoma-
tous bodies, following the use of Protonuclein powder, were noticed to
become more prominent, that is they seemed to become more like small
round grains resting on the healthy conjunctiva, at the same time grad-
ually growing smaller as treatment continued, until they entirely dis-
appeared. Corrected vision of this case when dismissed, was, right

NoTs I. — Hodge R consists of two solutions. No. i, Arg. Nit. 5i« Glycerine
3ii, Aqtia, 3ii, mix. Na 2, Potass, iodidi, 5ii, Glycerine, 3iv, Aqua, 3iii mix*
Sig. To 5 gtts. of No. I on a clean watch-glass, add 10 g^ts. of No. 2. Apply
resulting yellow precipitate to lid with cotton-covered applicator. Ophthalmic
Record, Vol. I., page 85.

100 ISAAC C. SOUL^ Ph.D., M.D.

eye ^°/o4, left eye ^^/gg. Jaeger No. 4 at 10 inches. Duration of treat-
ment nine weeks.

Case Two. — Leucoma, — Mr. Paul W., age 2y, Referred by Dr.
W., July 27, '98. Some time ago while a medical man was attempting
to cauterize a small nodule on the upper right lid, a granule of the
mitigated stick became loose and dropped into the eye. A dense white
leucoma, triangular in shape, covering the lower temporal quadrant of
the cornea, apex nearly in the center, was the result. Treatment — The
scar was covered well with Protonuclein powder and massage applied
direct to it, with a silver spatula, again covered with the powder, the
eye closed and an exclusion bandage applied, to be retained two or three
hours. Patient was directed to apply an ointment of i gr. of Mercury to
the oz. of Vaseline, to the eye at ni^ht and massage for ten minutes
through the closed lid. In the mommg to bathe the eye for ten min-
utes in very hot water, and immediately follow with a bath of iced water
for an equal length of time. At end of six weeks patient discharged
with only a small spot, of light gray, near the comea-scleral junction in
lower temporal quadrant. Remainder of cornea clear. Vision *V«o*
Old choroidal changes precluding any better.

Case Three — Suppurative Otitis, — Mrs. A., age 38. Referred by
Dr. A., whose wife she was and under whose care she had been up to
time she came to me. History — Something over two months ago she
was attacked with La Grippe, then prevalent, during which, the middle
ear became implicated. Both ears were attacked but only the right ear
suppurated, the discharge which was very acrid, excoriating and plen-
tiful, had existed for nine weeks. There was a small perforation of
Shrapnell's membrane while almost the entire lower half of the mem-
brana tympani was destroyed. Within the tympanic cavity and on the
edges of the perforations were numerous granulations. The ear was
thoroughly cleansed by spraying it with Hydrozone, 3 per cent., and
wiping out with absorbent cotton. Some Hydrozone was next dropped
into the external canal, and, by means of a tip fitted to the compressed
air cut-off, forced through the Eustachian tube into the post-nares.
Protonuclein powder was now blown into the middle ear, using com-
pressed air and sufficient force to get the powder distributed to all parts
of the cavity. Patient was directed to cleanse the ear, by dropping in
Hydrozone, with a dropper until all bubbling ceased. Making the appli-
cation every two hours. Patient was treated every day, and although
five days were lost on account of a crop of small boils, on February 3,
two weeks after the first visit, only a slight bland discharge remained,
which entirely disappeared during the next three days. Treatments
were continued three times a week until February 27th, when patient
was dismissed, hearing distance increased to 36-120 from 3-120 and
perforations in membrane both completely repaired. Duration of
treatment, six weeks.

Supplied Blood. — Studies were first made with fresh bullock's blood,
but had to be abandoned on account of inability to preserve the blood.
Later defibrinated bullock's blood, known as Bovinine, was used, with

USES OF SOME ANIMAL EXTRACTS. 101

perfect satisfaction. I will cite two of the many clinical cases in which
it has been successfully used.

Case One. — Lupus of upper left eyelid. Miss C, age 20. This
case came from a general surgeon of undoubted ability, who had two
microscopical examinations made confirmatory of the diagnosis. It
had received the usual treatment for three months and although at one
time almost healed has broken down again, and is now i c. m. long
and 15 m. m. broad. Very angry. General health not good, much
emaciated. Treatment — ^Ulcer was curetted and cleansed by spraying
first with Bovinine and then with Hydrozone, 3 per cent., washed oflF
with Listerine solution, sprayed with a 5 per cent. Hydrozone, and
washed again with Listerine. Edges of ulcer cauterized with electric
cautery, and gauze dressing applied, which was kept moist with Lister-
ine for thirty-six hours. Ulcer was now clean and not nearly so angry
looking. It was a^in cleansed with Hydrozone 3 and 5 per cent., and
same dressing applied for forty-eight hours longer. At end of this time
ulcer looking much better, and patient complaining very much of the
severe pain in ulcer, it was determined to commence the use of supplied
blood. After cleansing ulcer, it was sprayed with the blood, covered
with eight layers of gauze, thoroughly saturated with the remedy, a
sheet of rubber placed over the gauze, the rubber covered by two layers
of dry gauze and the whole painted with collodion, except at the
upper edge, which was left unfastened. Bovinine was applied by
means of a dropper at this unfastened edge, every two hours, thus keep-
ing the dressing saturated constantly. The remedy was also given
internally, in tablespoonful doses, every three hours at first, soon in-
creased to a wineglassful every four hours, with a wineglass of old
Port wine, night and morning. The dressing was not disturbed for one
week. The pain disappeared at the end of twenty-four hours, never to
return. Wound steadily improved, until at end of four months patient
was dismissed cured, the site of the former ulcer being covered by a
soft, smooth, pink scar. Patient had gained nine pounds while under
treatment. Two years later patient is plump, healthy, and happy, cure
apparently perfect.

Case Two. — Mrs. A., ag^e 38. Traumatic Necrosis of Left Mastoid.
Necrotic bone was thorou^ly scraped and chiselled away, cavity mop-
ped out with Hydrozone, 25 per cent., packed with gauze, which had been
soaked in Iodoform- Bovinine ; dressing was kept saturated by dropping
on fresh Bovinine every hour. Dressing was changed every twelve
hours for first three days, the cavity being cleansed with Hydrozone, 5
per cent., each time. On the fourth day plain Bovinine was substituted
for the lodoform-Bovinine, and the dressing changed only once in
twenty-four hours. At end of six weeks the cavity was completely
filled with new bone, and the edges of the flesh-wound having been
freshened and brought together, healed nicely, leaving scarcely any
scar, instead of the usual unsightly condition.

Suprarenal Capsule. — ^The preparation used was that of Armour &
Co., and is the dried gland of the sheep, powdered. Much difficulty was

102 ISAAC C. SOULJ^ Pk.D., M.D.

experienced in preparing a satisfactory solution, owing to its ease of
putrefaction. This has been to a degree overcome by the following
method. Ten grains of the powder are added to i^ dram of freshly
boiled distilled water contained in a large test-tube. The mixture is
well shaken, corked with cotton and allowed to stand for an hour or
two, occasionally shaking it. It is now boiled for ten minutes, and fil-
tered into a clean glass-stoppered bottle. Scrfutions prepared in this
way will, in moderate weather, keep for ten days to two weeks. The
boiling does not seem to interfere in any way with the peculiar action of
the drug. For use in warm weather a solution of formaline ^/looo
may be substituted for the distilled water with some advantage. How-
ever, solutions prepared with formaline, while they seem to act in all
other ways the same as other solutions, lose, I think, somewhat in their
power as haemostatics. Solutions so long as they remain clear and
retain their peculiar "fresh" odor have not deteriorated. Even when
the odor becomes quite pronounced they still remain efficacious.
Studies intended to demonstrate the remedial action of this gland have
uniformly been failures, if we except slight inflammations and injec-
tions of the membrana tympani and conjunctiva. It is however a
highly useful drug to the oculist and aurist, owing to three peculiar
properties which it possesses — i. e., (a) that of blanching mucous mem-
branes, whether they be actively inflamed or only slightly injected;
(fc) of controlling, even to the point of often preventing entirely,
haemorrhages; and (c) aiding, strengthening, or increasing the absorp-
tion or penetration of certain drugs. It has proven itself useful in cases
of abraded cornea, foreign substances in the eye, trachoma, and all con-
ditions which give rise to intense injection, and where it is desirable to
for any reason produce cocaine anaesthesia, which, under those circum-
stances, is so difficult of proper accomplishment. If the inflammation
be very great it is desirable to invert the lids and allow a few drops to
flow gently down over the inverted surface into the eye, wait a few
moments and apply the cocaine (4 per cent, to 10 per cent.) in the same
way,and in a short time make a second application of the Suprarenal solu-
tion. If very profound anaesthesia is required, it is necessary to make two
or more applications of the cocaine or use the stronger ( 10 per cent, to
15 per cent.) solutions. Under anaesthesia produced in this way I have
performed iridectomies, extractions, advancements, curettements, cau-
terizations, Knapp's operation with the roller forceps, excision of mem-
brana tympani, and several minor operations within the middle ear, all
entirely painless and surprisingly free from haemorrhage.

Thyroid Gland or Thyrodine. — ^The source, and method of prepar-
ing the solutions are the same as already given for suprarenal. An
unexpected and protracted sickness renders this report, unfortunately,
very unsatisfactory, and it is incorporated at all only in the hope that
it may induce some of the Fellows of this Association to take up, and
complete the study of what I think will prove a useful adjunct to our
art. Unlike suprarenal, this gland seems to have a decided remedial

USES OF SOME ANIMAL EXTRACTS. 103

action. It was used successfully in tumors of the conjunctiva and lids,
pterygium, exophthalmos, and follicular conjunctivitis.

Summary. — Protonuclein, has a decided action upon the nutrition
of the cornea greatly aiding it. It also appears, to in some way, affect
the growth and continuity of tumors, etc., as is instanced in its action
in trachoma. It produces decided and marked ear symptoms, when
given in large doses. These symptoms closely resemble those of China
sulph. with which remedy they are here compared.

Protonuclein. — Deafness in both ears, unaccompanied by any par-
ticular headache or symptoms. Tinnitus, ringing of bells, buzzing, ill-
defined ringing in both ears, cannot hear sounds because of it. Per-
sistent ringing of small bells. Nervous, weak, and unsteady heart,
rapid increased action. Pulse, full, strong, bounding.

China Sulph. — Deafness in both ears; full, confused feeling.
Headache accompanies. Ringing almost always in left ear, very rarely
in right. Nervous, weak, and unsteady heart, rapid, increased action.
Pulse, small, weak, easily compressed.

Used according to these few s3rmptoms in anaemic patients, suflFering
with tinnitus, results have been uniformly good. The active principle
of Protonuclein is destroyed by all solutions containing alcohol, mer-
cury, chlorine or bromine, their salts, acids or alkaloids. It is not
affected by iron, strychnine, quinine, arsenic, iodine, phosphorus, or
their salts. While it must not be used in combination with or closely
following the use of its incompatibles, it will very materially enhance
their action if used two or four hours before them.

Supplied Blood. — ^This was found to be frequently successful, in
ulcers where Protonuclein had failed. It has a very decided antiseptic
and deodorising action. Is an excellent anodyne, patients invariably
experiencing a relief from pain in a short time after its use. It aids
vitality greatly. It has been successfully used in the dressing of opera-
tive wounds, ulcers, bums and scalds; in the treatment of necrosis
and skin-grafting. As it is necessary that the part under treatment be
kept constantly bathed in it, it is only applicable where a dressing can
be used, thus almost precluding its use within the eye or middle ear.

DISCUSSION.

Dr. Piatti : I think it must be admitted by all the members of this
Society that Dr. Soule has contributed a very timely and interesting
paper, even though we may not agree with him fully as to some of the
conclusions contained therein. It is with temerity that I discuss this
paper, since my use of the remedies in question has been limited to the
treatment of diseases of an entirely different character, hence my dis-
cussion is more from a theoretical than a practical standpoint.

I have used protonuclein considerably in my practice and have fol-
lowed the literature pertaining thereto very carefully for some time
past, but I have never seen it recommended locally, in the eye, as sug-

104 ISAAC C. S0UL£, Ph.D., M.V>

gested in the Doctor's paper. The Doctor has certainly met witli
phenomenal success in some of his cases, and it is only to be regretted
that he did not report failures in the use of the protonuclein (that is,
if he had any) for it would have been a more certain way of demon-
strating the true estimate of its value in ophthalmic practice.

Case I. — as reported would lead us to suppose that the protonuclein
certainly had the power to bring about the absorption of cicatricial tis-
sue and infiltrations of various kinds in the cornea.

The Doctor states in the first examination, he was unable to see the
fundus owing to the irregularity of the cornea. At the last examination
of the eye, the Doctor succeeded in getting such a good test, I would
like to ask him if he obtained a view of the fundus at this or any future
examination.

We must not lose sight of the fact, that the Doctor massaged the
eye for five minutes on each application of the protonuclein and this, in
itself, if persistently carried out, will often causew the absorption of
corneal opacities.

Cases 2 and 3, 1 pass without further comment, as they depend upon
the same power of the drug as the preceding case.

Qass B. Case i. — This case does not to my mind demonstrate posi-
tively that the protonuclein has any effect on trachoma.

The methods used by the Doctor (Knapp's roller forceps operation
and the use of Hodges' Argentiun-Iodium Mixture,) would have gfiven
him the same result without any use of the protonuclein whatever.

I recall several cases of trachoma where the upper lid only was
treated and in which absorption of the trachomatous bodies took place
in the lower lid, without any further treatment, so that the disappear-
ance of the dii eased tissue in the lower lid, after the operation does not
to my mind, demonstrate that the protonuclein was the cause of the
absorption; although I must admit that the pannus disappeared very
quickly. It is to be regretted that the Doctor did not treat some of his
cases of trachoma with the protonuclein alone, instead of using in con-
junction therewith other methods, either one of which will cure this
disease. Of course I do not mean to detract from the value of the
protonuclein, for I firmly believe that it has a specific action on the
cornea as the cases reported by Doctor Soule show. What I object to,
is the treatment of cases, by "Mixed Methods" where one wishes to
demonstrate the action of a remedy, comparatively new.

The only use I have made of the protonuclein in ophthalmic prac-
tice has been in a case of epithelioma of the face involving the lower
lid.

Mr. H , aged 38, mechanic, has had growth on side

of nose and cheek for about five years, which has increased gradually
and steadily, until at present time, it is about an inch in diameter and
involving about Vs of ^be lower lid. Has been under treatment during
most of this time, but notwithstanding, the disease has steadily pro-
gressed. After a careful examination, the growth was removed, except
that portion involving the lid, which was curetted. A flap taken from

USES OF SOME ANIMAL EXTRACTS. 106

the cheek, a dressing of protonuclein powder special applied and re-
moved in two days. Wound healed by primary intention, lower lid
very much swollen and upper lid also much infiltrated, was thoroughly
cleansed with hydrogen-dioxide, followed by hot salt solution, this treat-
ment repeated daily for one week, at which time the swelling was re-
duced and wound re-dressed with protonuclein which again caused
great swelling of the lid, which however disappeared after three days,
and thereafter the protonuclein was applied every third day for three
months.

Protonuclein was also given internally, no other drugs being used.
At the end of five months, patient discharged as cured, nothing re-
maining of the growth, but a small scar and a slight eversion of the
punctum lachrymali which was afterwards slit.

I would like to ask the Doctor, in applying the powder to the cornea,
if he found it necessary to produce anaesthesia? My use of the remedy
In suppurative otitis has been limited to two cases, but the result was in
no way, more brilliant than those cases in which I cleansed with ^JC>t
and give the remedy indicated generally Viola odorata 30, which is my
sheet anchor in these cases.

Supplied Blood. — ^This remedy I have used in the form of bovinine,
I have used it in ulcers of the cornea ; result — ^nil.

I treated one case of necrosis of the tibia successfully after all other
remedies failed, keeping it constantly moistened, as suggested in the
paper. Dr. Soule states that it is only applicable where a dressing can
be applied and I fully agree with him ; such being the case, I fail to see
its relation to ophthalmic or otic practice.

Supra renal capsule ought to prove a very valuable remedy on the
lines laid down by the author and I trust that at the next meeting of
this Association, we will receive reports on its use, especially from those
members who are connected with large clinics and who thus have an
opportunity of having a large numbier of cases under observation.
With this remedy I have had no experience.

Referring again to protonuclein, I mic^ht state, that I have given it,
in a nimiber of cases of typhoid, internally, but have never noted any
symptoms attributable to the drug, even when given in large doses.

ON THE DESIRABILITY OF EXAMINING THE INMATES
OF OUR BLIND AND DEAF ASYLUMS.

By C. H. Vilas, M.D.,

Chicago.

A BRIGHT, healthy boy, about twelve years of age, was brought
to me for examination, having been taken from a blind asy-
lum for that purpose.

For a number of years during the lectures which I have given In
connection with the annual course at the Hahnemann Medical College
and Hospital, of Chicago, it has been my custc»n to call the attention of
those about to graduate to the desirability of examining into the condi-
tion of the blind and deaf in the various asylums throughout the coun-
try, and this lad came as a result.

He proved to have a posterior polar cataract in each eye. We all
know how intractable such cataracts are under a needle operation, and
hence after exploration of the lenses, I iridectomized each eye in the
inferior nasal quadrant, the iridectomies proving exactly symmetrical,
as desired. The boy quickly learned to read, and repeated visits to me
have confirmed the excellent results attained.

This case demonstrates that it is possible, despite the care now so
generally exercised by our institutions, for an unfortunate to be found
within them who could be not alone raised to a higher plane, but re-
stored to active life. It is possible therefore that a re-examination of
those already admitted to our asylums might disclose others who could
be similarly benefited by like operations or a careful course of treat-
ment, means perhaps unknown at the time or in the district from which
the inmate came. Were but a single case so found materially benefit-
ed, sufficient would be gained to make the reward ample. How many
more might be successfully treated could only be told by trial, though
it is not unlikely a number of such might be discovered, judging from
the reports of the ntunbers there immured.

Asylums for the deaf should also receive our attention for similar
reasons ; and especially those cases therein where ear troubles are asso-
ciated with mental derangement. Fortunately the excellent care such
persons now receive usually provides for their treatment in this respect
But re-examination of these and of those declared blind can do no harm
and may yield excellent results.

Practitioners who are located in the neighborhood of asylums will.

EXAMINING THE INMATES OF ASYLUMS. 107

I am sure, be cordially aided in investigation by those in charge, and
results may be attained quite as valuable as were secured in the crusade
waged for the examination of the eyes of school children for refractive
troubles. Moreover, such labors will lead to the examination of State
laws and such corrections suggested as may be necessary to provide
against errors in admission, and correction of any already made.

DISCUSSION.

Dr. Shepard : We are all in sympathy with Dr. Vilas' paper, and
I have very few words to say, except that I would advise that all our
institutions, not only those for the blind but those for poor children
generally should have an examination of the eyes ; that is, of the vision,
by a specialist. A number of these children have come into my hands
which have been looked upon by their teachers as dull and of very poor
mental capacity, where a careftd examination of the vision has revealed
a very high degree of refractive error. A few weeks ago, one was
brought to me with nine diopters of hyperopia. The fingers were
counted at five feet without a glass, and with the correct glass, vision
of 'Vso was obtained. That boy of ten or eleven years of age, although
showing some bright ideas, was looked upon as being peculiar, and was
of little use to himself or any one else ; but when I put the glass on, he
said, "Now I will learn to read." It seems to me that the consulting
oculists of our institutions should be made to look more carefully after
some of the hidden troubles in the eyes — ^not simply be called in when
there is some acute inflammation.

Again, as to the deaf. Our work among the deaf children and deaf
people should begin, really, before the deafness occurs; and it may
very often be averted by carefully looking after the throat and nose.
I am sure that a very large percentage of the bad cases of deafness
and suppuration could be averted, if every child, upon entering our
charitable institutions, could be brought under the practiced eye of
the aurist, and attention given to the diseased condition of the vault of
the phar3mx and Eustachian tubes.

RESULTS OF CASES TREATED BY PHONO-PNEUMO

MASSAGE.

By Benj. S. Stephenson, M.D.,

Lowell, Mass.

A YEAR ago I had the pleasure of reading a paper on this sub-
ject at the Chicago meeting of our society, and showed you
a very crude machine for producing it. After returning
home I received a number of inquiries as to what it would cost to get
out a practical instrument. For the next six months I caught it from
all sides as relying on the statements of my electricians, I made promises
as to the time of delivery and the perfection of mechanism, etc.

I was at last compelled in oraer to redeem my promises given in
good faith on my part to manufacture them under my own supervisicm^
and to-day I am able to show you a practical instrtunent which has been
able to accomplish results in my own and the practice of others. As our
President said to me last year give us statistics that are tangible, and if
you can do one-third that you claim we want it to. You know it is an
old saying that an inventor can obtain results when no one else can, so
if you will allow me I will quote you extracts from letters received
from Drs. Findley of Des Moines and Bates of Hamilton.

"Dr. Findley says: First. It paid for itself the first month.
Second, my patients are all enthusiastic over it. Third and most im-
portant of all I have been able to improve the hearing in cases that I
have failed in before."

"Dr. Bates, says, in regard to a case that he had had in his care for
the past five years and who had a severe relapse following a cold that in
one months treatment he had obtained better hearing than he had in
any of the past five years and for a long time previous to that."

Now I shall not take up but a little of your time and will present a
list of five cases covering in age, condition, and various phases of deaf-
ness, those which ordinarily present themselves in our practice.

Case One: — Miss C, age 23, light complexion, robust in appearance,
general health good. Complains of ringing noises in the head, worse on
left side at night after retiring. Hearing on the right side for watch
six inches, over the mastoid distinctly, C2 fork heard at fifteen inches
for five seconds, low tone of voice speaking slowly at six feet. Left
side, watch at seven inches, distinct over mastoid, C2 fork at 16 inches
for 8 seconds, low tone of voice at six feet.

liL^-

PHONO-PNEUMO MASSAGE. 10«

On inspection, canals clear, slight thickening of drum, poor response
to suction with otoscope, on each side. Eustachian tube easily dilated
with air at lo lbs. pressure. Mucous membrane of pharynx congested
and thickened, nares clear. First noticed noises about eighteen months
before, but paid no attention to them until she found her hearing was
being affected. The treatment pursued in this case was fifteen minutes
of sound massage beats at i8o per minute, followed by sound and pneu-
matic massage for ten minutes using suction two to pressure one and
ending by usmg direct suction for five minutes. This was followed for
five weeks, three times a week at first and then twice a week for the last
two, with the following results. At the end of first week, a gain at the
end of treatment of two inches for watch but this only lasting for two
or three hours, no difference in tinnitus. End of second week watch
heard at twelve inches lasted longer and tinnitus not as constant or loud,
also said that people were talking louder than necessary. In this case
there was steady gain and at the end of five weeks the hearing was
normal and tinnitus had ceased I looked the case up last week and she
said that her hearing was all right and there had been no return of
tinnitus, this case was treated last August.

Case Two: — ^An English woman, Mrs. S., been in this country five
years, age 43, says she has been deaf for 20 years, and has had plenty
of experience with quackery both in this country and England. Has
had continuous tinnitus for the last three years. Hearing on the right
for watch pressed close against the auricle, not heard over mastoid, for
the C2 fork at three inches when struck a metallic blow, the voice in a
full loud tone at three feet. The left side slightly worse. On inspec-
tion the cansd dry and scaly, drum white and pearly, retracted and the
malleus very prominent, no movement with otoscope, throat dry and
glazed in appearance, inflation of Eustachian easy with pressure at
ten pounds at which I use it for inflation. This case had been told by
Blake of Boston that nothing could be done except an ossiculectomy and
could not promise success with that.

In this case sound massage at 180 beats per minute was used for
15 min. and then sound and pneumatic for 10. No suction was used on
this case for the first two weeks on account of the parchment like condi-
tion of flie membranes. She came 3 times a week for two months and
although the improvement was slow there was an increase and she
could then hear the watch at three inches, could hear the dishes rattle
when using. She continued coming for two months more and gained
so that she could hear ordinary conversation at five feet, the drum had
a healthier color and was movable with the otoscope, the tinnitus stopped
after the loth week, but would return at times when very tired or
nervous.

Case Three: — Miss R., age 34, complained of a chronic discharge of
the left ear which had followed an attack of scarlet fever when she was
20. Her hearing for the watch was at 3, and C2 fork at 6 inches, but
was lost after 3 seconds. On the right side the hearing was 7 inches for
watch and the same for fork continued for 10 seconds. On inspection

110 BENJ. S. STEPHENSONr M.D.

the left showed canal filled with a thick foul smelling discharge, after
removing which I found shreds of dnun, absence of malleus and por-
tion of incus, the attic filled with discharge and necrosed tissue, the
right, drum retracted, and but slightly movable with otoscope, decided
thickening and the malleus handle prominent. In this case all the
necrosed tissue was removed and the parts cleansed with a solution of
alcohol, borax and water used as warm as possible, then used suction
on the left side each time first and cleansed with dry cotton, then used
the sound massage and pnetunatic massage for fifteen minutes each
followed by ten minutes on the suction for both ears.

The discharge ceased in three weeks, and the hearing came up to
normal on the right and to twelve inches for watch on the left

Case Four: — Mr. K., age 56, hearing has been poor for years, very
annoying tinnitus for which he had the drum and malleus removed on
the right side without relieving the condition. Hearing for the watch
not at all on the right, C2 fork heard at 2 inches when first struck, also
by mastoid. Left ear, watch not heard at all, fork at six inches when
first struck, voice heard by making a trumpet of hand. The drum on
inspection retracted, malleus prominent, membrane parchment like and
no reaction to otoscope. Difficult to inflate Eustachian even with
chloroform. This case was the most difficult one I have come in contact
with and been able to obtain what he considered good results. He was
under treatment for six months, using sound massage 180 beats at first
and later 240 per minute and the sound and pneumatic for fifteen
minutes each, as the drum became more pliable on the left side using
the suction for five and then ten minutes. At first improvement was not
noticeable but the tinnitus began to lessen at the end of the first month
and at the end of three months was not noticeable, the hearing improved
so that he could talk with one person ff there was not much collateral
noise as he found it hard to separate sounds.

Case Pivc: — A little girl, age six, chronic discharge of two years
standing, following measles, thin acrid foul smelling and making the
meatus raw where it touched. This case was under the care of my
wife as it came while I was on the west coast.

Membrana tympani gone in lower third, on each side. Hearing for
the watch 6 inches, clearly over mastoid, C2 fork heard by air conduc-
tion at 10 inches, also over mastoid, voice at 4 feet speaking slowly and
distinctly. Treatment consisted of dry cleansing and use of suction
followed by sound and pneumatic massage. The discharge ceased
within three weeks, and the drum gradually filled in, and within seven
weeks her hearing was normal. Of course this last is what would be
considered an easy case and yet these cases are the ones that lead to
permanent impairment of hearing.

Now as a summary of results, I find that my experience continues
this year the same as it has for the last four. There are but very few
that cannot be helped. About 40 per cent, of cases can be given good

PHONO-PNEUMO MASSAGE. Ill

serviceable hearing, and the others improved to a greater or less degree
dependent on condition, age, duration of disease and health of patient.

From what I can learn from inquiry from those who are using mas-
sage in this form better results are being obtained than have been
possible before, and I think the reason for this is that while the nutrition
and mobility are increased, the thickening lessened, at the same time a
nerve whose perceptions are slow and feeble is being trained. That
this enters into the case can be easily proved as almost without exception
a person who is deaf will hear without raising the voice if you speak
slowly separate your syllables and give the nerve filaments time to con-
vey one sound impression before the next is uttered.

I was talking with one of the prominent aurists of this country a
short time ago in regard to the treatment and he said ''Doctor I have no
faith in it at all, I experimented with massage twenty years ago and
proved it a failure." I then asked him if at that time he ever used more
than one form of massage at the same time, and he acknowledged he
had not I then told him about experimenting a year or two ago and
finding that each form of massage would do a certain work and then a
limit was reached beyond which it was impossible to go, but take the
same patient who had been using phono massage alone and it took but
a comparatively short time by using pneumo massage to bring about a
good result, and the same with pneumo massage. Both have got to be
used singly and in combination at the same treatment to get a good
result.

I wish to call your attention particularly to the action of the pneu-
matic apparatus on a U tube partly filled with water. I think the bene-
fit of massage comes largely from the slowness of the beat — ^allowing
the muscles to act themselves on the return stroke, not doing the whole
with the instrument. Time should be given after the direct suction to
allow the action to exercise the muscles and ossicles connected with
them.

DISCUSSION.

Dr. Bates : I don't know that I can do more in discussing the paper
of Dr. Stephenson than give my own experience in the use of his phono-
pnetmio-massage apparatus.

Some years ago, when I first read Dr. Garey's article on the massage
treatment for catarrhal deafness, it struck me as being the most feasible
method of producing mobility of the bones of the ear, that had yet been
introduced. I immediately purchased a phonograph and the cylinders
devised by Dr. Garey, together with some musical cylinders, and com*
menced experimenting with the same. I could see nothing particular

Hi BENJ. 5. STEPHKNSOS, M,D.

to guide me as to the number of vibrations which would be applicable
to certain cases, so tried various instruments on the phonograph, <A
high and low tones — in cases where there was tinnitus, trying to get as
near the sounds heard by the patient as possible. In some cases I was
able to stop the tinnitus (even in cases of long standing) almost im-
mediately, in others, (even in cases of short standing) I was not; but
wherefore, I know not as yet. One thing is certain, I have had better
results in treating catarrhal deafness since I have been using the mas«
sage treatment than ever before; so much so, that I know no one in
Canada to-day has a better reputation for treating the same than I have.
A short time ago a patient was sent to me by an allopathic physician
whom I did not know, in one of the larger cities in Ontario, who, he
said, told him I was the best man in Canada on the treatment of deaf-
ness. I mention this simply to show the superiority of the massage
treatment over the old method ; for I know by my own experience, tlwt
no method of treatment for catarrhal deafness has ever been introduced
as yet, by which any specialist can compete successfully with one who
uses the massage treatment. I have used various instruments : viz., the
phonograph, vibrometer, vibrophone, telephonic connection with the
raradic current of electricity, and also the galvanic current in con-
nection with the phonograph; but of all the instruments I have used
up to within the past few months, I have had better results from the
old "saw mill" of Dr. Carey's, followed by a comet or piccolo solo on
the phonograph, than from anything else. Since then I think I have
had better results from Dr. Stephenson's instrument than from any.

But to mention a case in point. Something over six years ago Mr.
J. E. A., aged 42, came to me for treatment. . He had been more or less
deaf for thirteen years, and had been under treatment most of the time
during that period. It was the hypertrophic form of catarrhal deafness.
He had been under the care of four specialists of the best reputation in
Canada, two in Montreal, one in Toronto, and one in Hamilton, and
also one in London, England, and one in the United States. He told
me that none of them had ever improved his hearing, diough he had no
doubt that he would have been much worse without the treatment he
had received. When he came to me, his hearing for the watch was
pressure on the left side, and about ten inches on the right. If any one
spoke to him on the left side, he had to turn his right ear to them itt
order to hear what they were saying, and when he went to church he
had to get near the front and turn his right ear to the preacher. Tin-
nitus had been a constant S3rmptom in his case from the beginning,
changeable in its character, sometimes being of a rushing sound, at
others a high-pitched singing noise. I treated him for four montiis
every day ; at the end of which time he could hear the watch tick four
feet away from both ears, in the room I use for treating ear cases, wher*
the normal distance for hearing the watch I use for that purpose is ten
feet. I tried to increase it beyond that, but could not do so. However >
his hearing was practically good, so that no one in speaking to him
would suspect that it was at all impaired. He heard equally well with

PHONO^PNEUMO MASSAGE. 113

both ears, and when he went to church could sit in the back seats and
bear well enough. The tinnitus was entirely stopped, only having
returned a few times since when he has had a cold. Dur-
ing the past six years he has ccMne to my office about once
a month for treatment, and, when he caught cold, would
come three or four days in succession, with the result that
for the six years I have been able to keep his hearing up to the
four feet for the watch in both ears. About three months ago he caught
a very severe cold, which affected his ears to such an extent that he could
hear the watch only about two inches from each ear. I then com-
menced the treatment with Dr. Stephenson's instrument, which I was
using at the time. I treated him every day for a few days, and then
three times a week for six weeks ; at the end of which time he could
hear the watch tick seven feet away from the right ear, and six feet from
the left, and the last time he was in, he told me that the night before he
bad heard the fire bells ring down town — ^about a mile away from his
house — ^and sat up in bed and listened to them. He said he heard each
stroke distinctly, and had never been able to hear them before. This is
the only case I have had, which has led me to believe that this instru-
ment is superior to any others I have used, though I have had just as
good results from it in many other cases as from the use of the phono-
graph. I have not, however, given up using the phonograph ; as after
using the phono-pneumo-massage instrument, I usually end up with a
musical cylinder on the phonograph, believing it has a good effect. The
massage treatment for deafness, is in its infancy as yet. I have believed
from the beginning that there were great possibilities in it ; and as time
goes on I am more convinced than ever, that it is the proper method of
producing mobility of the bones of the ear. I trust that the members
of this society who have not used the massage method, will do so ; and
those who have used it for a short time and cast it aside (as we are all
too apt to do with any new thing when we do not see quick results) will
take it up again.

The data upon which to apply the massage treatment; i. e., the
sounds or numbers of vibrations to use in each particular case, is very
difficult to get at ; but if we all work together with that one end in view,
and when an idea strikes us, let it be known through our Journal we
will no doubt one of us, some of these days, strike a happy thought that
will lead to a solution of the difficulty.

There are many things about deafness we all have to learn as yet ;
but when our knowledge is more complete regarding the causes of
various symptoms connected with certain cases and not with other, such
as tinnitus, aural vertigo, paracusis Willisii, and others in which certain
sounds are heard much better than other sounds, we will know better
how to apply massage treatment. I have one young lady under my care
at the present time, who is so deaf that she can only tell what a person
is saying by watching their lips, and still she can hear my watch tick
two feet away from either ear. This is an extreme case, but we all
meet the same occasionally to a lesser degree, as well as the opposite.

114 BEN J. 5. STEPHENSON, M.D.

where they can hear ordinary conversation readily but cannot hear the
watch tick at all. An accurate knowledge of the pathological condition
in these cases, together with their cause will aid us in the application of
the massage treatment.

Dr. Houghton : I trust that you will all give your attention to one
point. I think if we can determine that, it will be a very great advan-
tage, certainly to the patient, and it is this — ^to make a careful attempt
at a diagnosis of the conditions existing in every case when the treat-
ment is undertaken and when there is apparent failure. If the re-
searches of our European colleagues are correct, it would seem that it
would be practically useless to apply for any length of time aural mas-
sage in a case of ankylosis of the stapes at the fenestra ovalis. We
meet there a barrier which is apparently next to impossible to break
through. All the other relations are somewhat modified by massage ;
and I have come to question, in my own observation of cases, whether
such an osseous union may not exist in these cases that do not exist
in those cases that yield within the limits of ordinary treatment It is
very difficult to settle all these points to-day. Those of you who are
familiar with the subject, of course know Dr. Roosa's views as to the
shading of this diflFerential diagnosis. If we could follow out our
German colleagues' practice of comparing the clinical case with the
post-mortem result, we could thus learn something more about it. That
is one thing which I hope our observers will try.

MASSAGE OF THE MIDDLE EAR BY ALTERNATING IN-
TERNAL AND EXTERNAL PRESSURE.

By Francis B. Kellogg, M.D.,

Los Ans;eles» Cal.

THE development of massage as applied to the middle ear, has
been an interesting study. Pneumo-massage, with the
Siegel speculum and Delstanche masseur represent the early
steps in this direction. Then came "vibro-massage/'suggested and ap-
plied by members of our own school: Following this, the idea of
pneumo-massage was still further developed by Chevalier Jackson, who
secured uniformity and rapidity of the suction-pressure action by means
of an electric motor attached to what was practically a Delstanche
masseur. Still later the two ideas were combined in an apparatus for
phono-pneumo massage, described before the last session of. this so-
ciety by Dr. Benj. S. Stephenson, of Lowell, Mass.

With the recent invention and perfection of the multiple comminu-
tor, or nebulizer has come the suggestion of massage of the middle ear
through the Eustachian catheter. By connecting the escape tube of
the comrainutor with the catheter in situ the medicated vapor is forced
into the t)rmpanum under pressure. Massage is secured by means of a
needle valve, which simply interrupts the current of vapor at the will
of the manipulator. Thus the middle ear and membrani tympani are
subjected to a series of impulses, all coming from the same direction,
viz,, from within out.

It occurred to me that this was an inadequate and incomplete form of
massage, and that to be effective in securing mobility of the parts there
should be an alternating of corresponding degree from without inward
in the external canal.

This was secured in the following manner: The Eureka nebulizer,
which was used, has two escape tubes, one for nebulizing medicated
oils and the other, with a cut-off, for use with the spray tubes. After
introducing the catheter, it was connected with the nebulizing tube by
means of a sliding hard-rubber connection, while the cut-off tube was
connected with the external canal by means of a tight ear-piece and a
piece of rubber tubing. After introducing and connecting up the
catheter, effective communication with the middle ear was assured by

116 FRANCIS B. KELLOGG, M.D.

turning on the current of medicated vapor and using the otoscope. The
patient then held the catheter in position with the thunrib and second
finger of the hand of the opposite side, the first finger resting on the
nose. Test again with the otoscope, remove same, and have patient in-
sert the ear-piece with hand of corresponding side. The operator now
turns on the medicated vapor, and grasps the tube which conveys it
with the left forefinger and thumb, while working the shut-ofF with the
right hand.

By making simultaneous pressure with both thumbs the air is turned
into the external canal through the shut-oflF, and the vapor prevented
from entering the catheter by compressing the vapor tube. Upcm re-
leasing the pressure, the opposite condition supervenes, viz.: the vapor
rushes through the catheter and the air is shut oflF from the external
canal. Thus we have the pressure applied alternately upon opposite
sides of the drum membranes ; which would seem to be more effective
than upon either side alone.

The lumen of the external tube is much greater than that of the
catheter, and the access to that side of the membrane much more direct
For this reason the patient should be instructed to insert the ear- piece
at first somewhat loosely, and at no time to make the connection tight
enough to occasion pain or discomfort. I have at no time used over
seventeen pounds pressure (the degree of water-pressure in my auto-
matic pump), and for one of my patients I have found it best to reduce
the pressure to five or six pounds.

I have not used this method of massage sufficiently long to speak
with any degree of confidence in regard to its eflFectiveness, neither do
I claim that the method of application is other than crude and elemen-
tary. If it has been previously suggested it has not come to my notice.

In three of my cases I have given it a trial of from one to two
months. They are all cases which had been under treatment for sev-
eral months, and had ail shown improvement as the apparent result
thereof before being subjected to the treatment under consideration.

Case One. — Mrs. S., catarrhal deafness of several years' duration.
Preliminary examination showed hearing R. E. for watch, o: hoarse
whisper, i meter. L. E. watch 5 in. Tinnitus, constant in R. E., in-
termittent in L. E. Up to the time I adopted the masage I had suc-
ceeded in improving the hearing to the following degree : R. E. watch J4
in.; hoarse whisper, 6 meters. L. E. watch, 12 in. This was accom-
plished by daily treatment of middle ear with vapor inflations ; reduc-
tion of hypertrophic inferior turbinated membrane; enucleation of a
submerged tonsil and cauterization of enlarged lingual tonsils. After

MASSAGE OF THE MIDDLE EAR. 117

adopting massage, I also dilated the tubes, using a "D" violin string as
bougie. This measure contributed definitely to the improvement. The
final test, after using massage twice a week for a month showed R. E.
watch, 5 in. L. E. watch, 24 in. These results were constant for the
last two weeks of treatment.

Case Two. — Mrs. N. Had been annoyed by increasing tinnitus in
R. E. for six months. Hearing in that ear, watch 12 in. The first
step in the treatment consisted in removing from the nares correspond-
ing to the affected ear a long septal ridge which nearly occluded the
passage. From that time up to two months ago she was treated two
or three times a week by the usual methods. The tinnitus was aggra-
vated by the air-bag and the catheter, and none but the most gentle
local measures could be used. The intmal administration of Cimici-
fuga tincture seemed to have a modifying effect upon the tinnitus. I
tried the massage upon this case. She could only bear about five
pounds pressure without bringing on an aggravation. I finally aban-
doned it, and at present am using inflation through the nose with the
nebulizer. The tinnitus fluctuates. Is at times much better, and then
returns, but in a modified degree.

Case Three. — Mr. J., railway mail clerk. Car gets very hot, and
then he has to open the door to throw out a bag. Consequence : fre-
quent colds affecting the ears. L. E. has been deaf for years. R. E.
recently affected. He had been under treatment for several weeks with
encouraging results when he contracted a very severe case of La Grippe,
which especially affected the upper respiratory tract, and left him de-
cidedly deaf. Upon resuming treatment he could only detect the acu-
meter at three inches with either ear. His business is such that it
prevents his coming for treatment except every otiier week. For two
months he has received massage regularly, three or four times every
other week. In the past week his progress has been encouraging. He
now hears the acumeter four feet with R. E. and one foot with L. E,

DISCUSSION.

Dr. Houghton : The essential features of functions of the middle ears
involved in a study of this paper, have been fully considered in the paper
just read by me; hence let us turn at once to the practical side of the
subject. I said in my haste "Solomon was in error; there is something
new under the sun, and Dr. Kellogg has found it, but a few days later
one of my colleagues told me that a physician in Cincinnati, O., had de-
vised a method of doing just what we have proposed to do, by slightly
diflFerent technique. It would seem to argue that modem psychology is
correct when it claims a common source of knowledge ; original work is
merely drawing from that source. Three students may tap the fountain
at different points at or about the same time.

Dr. Kellogg's technique strikes me as admirable in dealing with re-
cent cases. I shall make a comparative study of his method and of that
suggested in my paper. There is one fact that will militate against the

118 FRANCIS B. KELLOGG. M.D.

adoption of the practice suggested in these two papers. When Mr,
Wappler showed the apparatus presented to us to-day, to a member of
the so-called regular school, he said it was a good thing, but it was a
pity that it came from our school; the particular form of words used
was more pungent than pious. This is in keeping with history as re-
gards internal remedies, such prejudice must yield because of the merit
of aural massage, but due credit will hardly be given us, on surgical
lines when it has been denied for over a century on medical ores.

There is only one other ground on which adverse criticism can be
made, and that the author has guarded ; these methods are so new that
we must be watchful; the catheter and Politzcr's method of inflation
have been abused. I have come to be very cautious in their exhibition,
having seen merabrana tympani made lax, beywid hope of restoration
by inflation, hence, I never allow Valsalva's method practiced without
closing the external meatus.

While there is a gain by applying the force directly to the mouth of
the Eustachian tube, in some cases, there is also a loss in another sense;
because the massage of the nares, and vault of the pharyr-x is elim-
inated; this is a very important factor in treatment as the catarrhal
disease of accessory areas, is the basis of the middle ear disease. An
active condition induced by the massage will give new symptoms for our
study, and the internal remedy will be one indicated by these very
symptoms. A paucity of symptoms has been the bane of chronic aura)
catarrh. > I , | f

AURAL MASSAGE.
By Henry C. Houghton, M.D.,

New York.

DEFINITION. — Massage is the act of manipulating the body in
such a way as to modify its function in part or as a whole.
The word is from the Greek "to knead," through the French
(ma sazh'), masseur, (ma ser'), masseuse (ma sez'), terms applied to
persons who practice the art. Sometimes incorrectly applied
to a machine. General massage is produced by kneading, striking,
vibrating, rubbing, and other modes of moving the tissues of the body
so that the arterial nerves, lymphatic circulation, is changed, as the
ganglia and terminal nerve filaments are stimulated, thus affecting the
entire nervous system.

Nature and Scope. — ^Aural massage is of the same nature, has the
same purpose, and, in a limited sense, the same scope. A brief study
of the anatomy, physiology, and pathology of the ear, will convince
the unbiased mind that it is as valuable locally as it is generally.

Audition is the function of reception, conduction, and perception
of sound force ; the perfection of this function depends on the integrity
of the external ear for reception and synthesis, the middle ear for con-
duction, the internal ear for perception. Pathology shows us that it
is the function of the middle ear that is specially increased by massage.
Catarrhal disease of the middle ear, either alone or leading to suppura-
tive disease, is the cause of the great majority of cases of deafness.
Alone, it causes in the hypertrophic form of disease such thickening
of mucosa, and increase of secretion, that sound-waves cannot reach
the internal ear ; in suppurative disease the mechanism of the middle
ear is so changed in its relation, that the same is true of the function.
Even if suppuration cease and the condition come to be classed as
catarrhal again, the consequences of suppuration are like in kind with
those of simple atrophic catarrh, adhesions, pseudo-anchylosis, etc.

Toynbee was the first writer to do any extensive work in showing
the actual condition existing in these cases, and his collection of prepara-
tions of the middle ear are his best memorial. During the last quarter
of a century a more advanced step has been taken by our English and
Continental aurists, by joining the clinical history with the post-mortem

120 HENRY C\ HOUGHTON, M.D.

•

study and preserving the specimen for our study. From these, we can
draw general conclusions as to the probable mechanical conditions exist-
ing in the mechanism of the tympanum of any case with similar clinical
history.

Not to dwell on this item, we find in atrophic cases either simple
or complicated by a history of suppuration, dense adhesions between
the drumhead and the ossicula, between the ossicula themselves, or
between the drumhead and the inner wall of the tympanum ; threads,
bands, dense masses of scar-tissue, etc. Hence, the sound-waves can-
not reach the internal, save in a limited degree. Aural massage does
for this mechanism what general massage does in a similar anatomical
relation — the shoulder, arm, forearm, hand. Place the first at the
shoulder on the same side and you have a parallel relation. What
passive motion does for the greater, aural massage does for the lesser.

History. — Aurists have sought for some means of causing passive
motion of the drumhead and ossicula. Siegel's otoscope, designed for
diagnostic purposes, came to be used by many, Lucae's pressure-probe,
Delstanche's pump. I, myself, used Siegel's otoscope with alternate
action from a breast-pump, and made a series of trials of apparatus for
massage, devised by the late Geo. H. Taylor, M.D., well-known in this
city as an advocate of the Swedish system. No special advance was
made till Dr. Maloney, of Washington, D. C, devised his otophone.
Even then, the device was not appreciated till Dr. Garey, of Baltimore,
gave a wider use to a vibratory diaphragm, using a stethoscope with
the phonograph. In March, 1892, 1 visited Dr. Garey at his clinic, and
have given, in a previous paper, my views of the matter.

The phonograph served well its purpose, and still gives, in a limited
way, more than any one instrument, as one can get great variety of
vibration from it by changing cylinders. Dr. Garey turned from it
to his vibrometer, in the attempt to combine tones and noise, but my
experience is in keeping with those who abandoned it for an instrument
capable of producing tones. Dr. Wilson, of Meriden, Conn., Dr. Bis-
sell, of Rochester, N. Y., utilized the guitar with uniformly good
results. I turned my attention to the organ, and succeeded to my satis-
faction, till now I have four, illustratmg the doctrine of evolution ; as
well as dispersion of filthy lucre. By the use of single tones, chords
and simple harmonies, one can bring the auditory nerve to perfect
function, as the function of the middle ear improves.

Since the utility of aural massage has been demonstrated, instru-
ments have multiplied, and there is no doubt that by united eflFort, some

AURAL MASSAGE. 121

device more simple and effective will be devised. In another place, I
have given results obtained by combination of faradic energy combined
with diaphragm vibrations. Dr. W. R. King, of Washington, D. C,
devised a similar apparatus. In the April number of the Journal of
Ophthalmology, Otology, and Laryngology, I offer my colleagues a
somewhat limited experiment at widening the use of the pump as a
means of doing the pioneer work in aural massage, specially in very
difficult chronic cases. In 1895, Dr. H. E. Waite made for me a pump
to be run by a small electric-motor ; the rapid condensation and rarefac-
tion of air was communicated to the drumhead by a stethoscope, as in
similar efforts at massage, the effect being very much like that produced
by Siegel's otoscope or Delstanche's instrument. Later, a similar
instrument was brought out by an aurist in Pittsburgh, Chevalier Jack-
son. Dr. Waite afterward improved liie plunger, and I found it valu-
able in suppurative cases, but it was not until last September that I
realized my ideal in a plant built upon specifications given to Mr.
Wappler, of the Wappler Payer Co., of New York.

Since the above-mentioned articles were written, my attention has
been called to the instrument devised by Dr. Stephenson, of Lowell,
Mass., which is similar in character, and from the use of which Dr.
Stephenson and others have obtained excellent results.

Methods. — Whatever devices have come to be used in the seven
years covered by the history just given, the method has been to cause
vibration of the drumhead and ossicula by sound force conveyed to
the tissues of the canal and membrana tympani by the column of air
contained in an ordinary stethoscope. The only exception, so far as
I know, is that of the direct application of force by a pressure-probe
(Lucae) or some rapidly vibrating probe, having a lateral motion such
as is used in massage of the pares. There is nothing specially new in
this direction.

Last autumn, soon after my plant was put in by Messrs. Wappler
and Payer, while using the blowing action to force an insufflation, I
was able to open the Eustachian tube by a succession of gentle im-
pulses. This led me to the study of phonation as I had done with the
organ tones, the idea being suggested by Dr. Lowenberg, of Paris, in
an essay on the "Physiology of Vocal Tones," which he kindly sent me.
By using a suitable nasal tip, one can convey to the entire tissues of
the nares, naso-pharynx. Eustachian tube, and middle ear, the vibra-
tions of the column of air in the tube attached to the pump, and can
modify the same as the pharyngeal muscles are brought into action by

122 HENRY C\ HOUGHTON, M.D.

vocal sounds; ah, oh, e, ou give a different vibration, the first two
acting to produce the vibration more in the nares, the second two cause
vibration back and into the middle ear.

I have been surprised at the uniformly favorable testimony of pa-
tients to this entirely new departure. I do not think it is psychic. I
trust my colleagues will make reports on their observations, that the
truth may be reached ; one observer may be biased.

fiesnlts. — In another relation I have given my views of the eflEects
of massage. I need not go into that matter now, as we shall not dis-
agree as to the effects, or how they are produced, but there are one
or two points on which it may be well to enlarge. It is my conviction
that simple noise does not suffice to restore audition to normal standard ;
it does the rough preliminary work, but must not be pushed too far.
There is too much noise in the world, too little harmony. We need to
have modulated tones, and musical tones follow noises with good effects
leading to the perception of the modulated tones of human speech.
While this is true, passive motion by some device, which acts as does
Siegel's otoscope, is more effectual in overcoming rigidity of the middle
ear mechanism, than is sound alone ; still, the sound made by a pump,
run at a high degree of speed, is not a disadvantage, but rather other-
wise.

In the earlier study of aural massage, the aim was to secure succus-
sion of the mechanism, and when the pump came to be used, we dealt
with the catarrhal form of disease, finding the instrument valuable in
cases in which there was a history of previous suppurative disease. In
my own experience, the fact of its great value in suppurative disease,
was rather a surprise, from observing cases in which there was suppura-
tive disease of one ear complicating the catarrhal disease in the other
ear. Later the pump has been used in all suppurative cases. When
Dr. Winslow told us at Deer Park of the unique results gained by
suction in a case of suppuration involving the attic we little thought
of the wide scope of that simple act ! Massage by suction giving more
brilliant results than any other phase of this treatment, transforming
a chronic, indolent condition into an active repair in a few days.

Dangers. — Every force for good may be turned to evil uses, so of
aural massage. The advice of the great artist was good, "mix your
paint with brains"; exercise caution in all cases. I am positive that
one may cause concussion of the auditory nerve by long-continued, fre-
quently repeated noise produced by some machines used for aural mas-
sage; indeed, the deep organ tones may be used to excess. Heroic

AURAL MASSAGE. 123

dosage is to be avoided in bringing to action upon the ear any form of
energy whatever; this is true of galvanism, faradism, the static, and
it must be true of sound force. Any pump that is capable of doing the
work needed in very rigid tissues may do harm. This is true especially
in suppuration ; in a number of cases slight haemorrhage has been pro-
duced, even while watching the effect, and the result was all that we
could desire, because measures were taken to keep the tissues clean, and
a remedy g^ven which controlled the condition. In one case,
a patient whose cerebral gray matter must be more dense
than his mucosa, disobeyed directions while under close watch
and care, and I was obliged to remove the stethoscope from
his ears with my own hands. Ecchymoses of slight area
were made in the cutis of the external meatus; but the drumhead
was only slightly congested, and the middle-ear condition was made
better by this radical treatment. One can infer what might occur in
dealing with slight neoplastic tissue. Hence, be very careful that your
pump is adjusted before starting. The same is true of my method
of massaging the middle ear via the Eustachian tube. As the air
pressure that forces the tissues of the anterior nares apart may be
stronger than is needed to force the Eustachian tube during phonation,
one must be careful not to be in haste to force air through the nares ;
let the action there be continued ; it is very beneficial ; it is quite as
important to reduce the mucosa of the nares, as it is to fire open the
Eustachian tube ; other things being equal, if the nares are well open,
we have no trouble at the Eustachian tube.

Therefore, let the vibration of the middle ear be gentle, except per-
haps in old cases with very rigid mechanism.

The following cases illustrate some of the later phases of aural mas-
sage ; the earlier experiences are undoubtedly familiar to all my present
audience, and need no comment as to technique.

One of each of the usual types of disease will be enough to illustrate
my new method.

Case One. — Mrs. S., age 50.

Diagnosis, Otitis media cat, chron. First seen, Sept. 29th, 1873.
R. failed one year ago. H.D. watch, R. ^/z^o, L. ^^/jo, canals clear. R.
Mt, depressed, adherent; L. normal. Pharynx, thin tissues, but not
specially abnormal ; slight secretion of thin white mucus ; subjective puff-
ing. Unded faradic current and auto-inflation, she gained in six months
to, R. ^®/2o» L. normal. During the next two years she kept nearly that
degree of function, then became discouraged. I saw her only occasion-
ally during the succeeding years. Sickness, loss of her husband, a hard

124 HENRY C HOUGHTON, M,D.

struggle in life, were factors that kept her depressed till she became very
deaf for voice.

Feb. 17th, 1899, she came on one of her occasional experiences of
headache from acute catarrh, with increased subjective noises, and was
induced to come for treatment regularly. The result has been remark-
able. The perception of all noises has increased, so that she hears them
promptly, and at a distance ; also musical tones, but modulated tones are
not as well recognized; some tones are clear, others seem muffled, and
the mental concept of tones that are not clear, is very tardy; later, it
dawns on the patient. Certainly, the present status is one not anticipated
at the outset of the treatment, four months ago.

Case Two. — Mr. W. M. C, age 22, Oct. 19, 1895.

Diagnosis, Otitis media sup, chron, — History, measles when a little
child. Both ears discharged ; then healed ; since then deafness has come
on with colds.

Present state. H.D. watch, R, ^/zio* L. ^/24o- Canals clear. Mt.
scarred, irregular, immobile. Pharynx adenoid. Nares hypertrophic.
Ett. dilatable. Has been suffering for days with acute catarrh, but the
ears have escaped.

Under Ferrum phos. for acute conditions and Hepar for suppurative
exacerbations; he made good progress. Four months later, R. V2o»

i-*. /20'

June, 1898. He was seen only from March to June and maintained
good condition.

Nov. 17, 1898. He was seen, having got cotton too deep in meatus,
while cleaning the left ear; but could not be made to realize the need of
attention.

Jan. 23, 1899. He came and followed up treatment with more regu-
larity, the secretions being removed by suction, as before.

Feb. 1 6th, R. Mt. came forward and L. Et. opened, and tissues were
quite free from moisture.

March 24th. Perf . clearly defined ; masses of white cheesy pus were
dislodged from pockets. Tissues more normal.

May 1 8th. Canals and memb. tymp. quite clean, slightly moist, but
not purulent. Perf. (L) a mere pin-point, H.D. watch ^Vgo R. and L.
diff.

Case Three. — Mr. J. A. B., age 52.

Diagnosis, Otitis media cat. acuta. — History, ten years ago had ab-
scess in L. from cold. Two years ago, similar attack. Perfect recov-
ery, which I question.

May 17th, 1899. After riding on a bicycle when weary, had sudden
pain in left ear. Telephoned for afternoon appointment, and came in
pale, depressed, in intense pain. L. canal bathed with bloody serum.
Mt. congested to an extreme. Pharynx angry red, thick tissues.
Ferrum phos. 2x every J^ hour and Gelsemium 7c, when pain lessened.

May 18. Better before midnight; same appearance, and slight perf.
same remedies. Seen daily for one week, when the rapid improvement
warranted an outing over Decoration day.

AURAL MASSAGE. 125

On May 2Sth, I was able to massage the ear by suction as well as
blowing, and on May 31st, the perforation was closed; it did not yield
to quite forcible massage.

June 4th, the congestion had nearly disappeared, and the outlook
is that the ear will become better than for years before this attack.
Lesson Treat acute cases with the purpose to secure better conditions,
before the tissues return to their former rigidity.

Case Four. — Mr. C. S. P., age 50.

Diagnosis, Otitis media sup, acuta, — May 15th, 1899. History,
strictly classed, this is a case of chronic suppuration presenting symp-
toms of a more active sort, due to neglect. Patient was first seen Feb.
loth, 1881 when, after head cold, acute otitis set in, affecting both ears.
When a child, scarlet fever was complicated by otitis.

Some weeks since was called at night to see the patient at his resi-
dence, and gave relief; now another alarm, at finding the right ear
closed, precipitates a call for relief.

The present state is soreness and tumefaction of R. canal, and entire
cartilage extending into soft tissues, before and behind the auricle. The
canal is nearly closed by a mass of tissue, cellular, bleeding easily and
mobile on a base which seems to be posteriorly secured. The canal was
cleared as fully as possible, and equal parts of vaseline and ether applied,
after touching the granulation mass with sulphuric acid. Hepar sulpK
was given internally. Three days later the mass was curetted and the
base touched with acid ; the next day the ear was thoroughly syringed
and massage by suction and blowing used, with immediate relief ; but no
opening of Et. since then three treatments each week have been given.

To-day, June 5th, the drumhead is nearly free from moisture and
becoming more clearly defined ; the air passed freely to both tympana,
and the patient says he hears better than he has been able to do for
many years. As he proposes to make a trip to Europe July ist, to be
absent three months, I shall make an exact record of the degfree of acute-
ness of function just before his sailing, to compare with the future
reports.

Relief from acute conditions was the impelling motive for treatment
not increase of function.

The adage of the new broom is not out of my mind. This is an age

of fads. But I am free to admit that this latest phase of massage, has

more of promise in it, than any form of local treatment which has come

to my hands, since 1867.

DISCUSSION.

Dr. King : I have been interested more or less of late in the experi-
menting and using new instruments. I have not gone very ex-
haustively into experiments in the line of what is quite properly called
pneumatic massage. The method of massage by sound waves, the so-

126 HENRY C HOUGHTON, M.D.

called phono-massage of Dr. Stephenson, has been a little more in my
line because my past experience was with the otophone, of which Dr.
Houghton has just spoken, and the phonograph and later with the
vibrometer. Other matters have taken precedence of this with me of
late, but Dr. Stephenson and Dr. Houghton are continuing the experi-
ments, I am glad to note, and are advancing. I have not lost my inter-
est, however, in the matter ; and, from what we have seen to-day, I be-
lieve that massage by phonation and air force are both necessary,
at least in some cases. Either one may be necessary in any single case ;
both combined in some. I think that the advances made are going to
be permanent at least to a degree. I think we are progressing in the
right direction, and are obtaining some relief. There are certain cases
that nothing else, in my experience, has been able to benefit one particle,
that have been benefited in varying degrees by some form of massage.
I do not believe we will ever find a method that will be applicable to all
cases, any more than we will find any one remedy applicable to all cases.
All these experiments and this practical study in the line of aural mas-
sage is of undoubted benefit and will aid us along a line that has been
the bugaboo of every otolc^ist — ^the treatment of these chronic cases of
deafness, particularly of the catarrhal t)rpe as well as in chronic sup-
puration. I had the pleasure of seeing this instrument demonstrated
at The New York Medical College and Hospital the early part of the
last month. Dr. Houghton presented there a patient, one of the cases
which he has reported who has been through the line of treatment with
the older instruments for quite a while and had obtained practically no
benefit during the twenty-five years, the doctor tells me, that the case
had been under observation. The patient reported to him for an acute
exacerbation. Under the treatment with this new instrument through
the outer ear and the Eustachian tube (as suggested in the last remarks
of the doctor) the amount of improvement gained was quite remarkable.
With the instrument of Dr. Stephenson, I am not so well acquainted.
The instrument is now in a much more perfect condition than it was
when presented before this Society last year. The doctor is practically

everyone is. There is no question but what we are helping many cases
we could not before benefit. We are failing, to be sure, in some cases
to get the relief, we desire, but mechanics are going to be of consider-
able assistance here, because as the result of the original cause of these
conditions, we have mechanical difficulties to overcome. I understand
from Dr. Stephenson that the Section on Otology of the American
Medical Association took up the matter of aural massage quite ex-
tensively at its recent meeting, and that some of the men are doing a
good deal of experimental work in this direction. For a long while
they did not do anything in the way of massage because the first prac-
tical application of this idea came from our school, and they are a little

AURAL MASSAGE. 127

chary about taking up even mechanical methods of treatment that we
advance.

Dr. Houghton : For cautery work in the nares, larynx or for use in
general surgical work this is a most excellent cautery. The unique
thing about this apparatus is that any electrician could put it in shape as
an office plant. It is the pump, however, which is the unique feature.
I came to be satisfied that I could get better results by what is ordinarily
known as a 3-way pump and drew a sketch of one which is not at hand
now, in which I purposed to shut off the current on one side by a
stop-cock, and let the current through from the other side. There was
also a third stop-cock at the Y to be reversed : that is, I arranged it just
as one would for a three way service. I went to Mr. Wapper, and he
constructed this pump, which is one of the very best arrangements I
have ever seen. By changing the bed-plate into either one of three
different positions you get three different actions. In this position (it
is now moving in the middle position) it alternately flows and exhausts,
and it may be so regulated that the action is very rapid, as high as 800
movements per minute in the middle position or even faster, but it is not
necessary to imperil the instrument by such rapid action. The motor
is on a rheostat, and by a simple motion the pump can be stopped. All
the gradations desired can be made by the regulator. In fact, the mis-
take is often made, I think, by running it too rapidly. This illustrates
the three movements you can get from the instrument, ist that through
the stethoscope — ^the suction — 2nd the blowing action, and 3rd the
alternate suction and blowing action.

In using the blowing motion, with the ^paratus here shown, you
have the instrument by which the phonatiort, of which I spoke in the
paper, is utilized. This is a separate device connected when the
stethoscope is used. The air is driven through the same tube which is
put into the anterior nares. Then, as the patient phonates, the air
passes through the nares and Eustachian tube to the middle ear, as I
will be able to demonstrate to anyone interested in it after the session.

THE POINT OF VIEW.
By John L. Moffat, M.D., O. et A. Chir.,

New York, Brooklyn Borough.

NOTWITHSTANDING the opposition usual to all advances
in the world's progress the makers of microscopes were at
last induced to use a common screw-thread.

It is the purpose of this paper to suggest that every illustration of
the fundus oculi be accompanied by a note indicating its amplification,
or, better, the distance at which it should be held from the eye in order
to give the proper sized retinal image.

A landscape photographed with a twelve-inch lens appears best
when viewed with one eye at the distance of a foot, that taken with an
eighteen-inch lens from a foot and a half; similarly, the student will
derive most benefit from lithographs, etc., of the fundus if they appear
to him the same size as if he were looking into an eye — especially is this
so in regard to estimating the caliber of the blood-vessels.

Comparing half a dozen or more of our leading text-books, I found
the horizontal diameter of the optic disk measuring all the way from
7 mm. to 30 mm. ; frequently on the same page one drawing was upon
twice the scale of another. These differences are not due to physiolog-
ical variations, nor to the fact that the small were inverted, and the
large erect images, but are attributed to thoughtlessness.

Let us, hereafter, have uniformity ; it certainly is practicable to make
each drawing of the fundus appear in detail, and in toto the size of the
inverted or of the erect image when we view it through our ophthal-
moscope with its correcting lens held as during examination of the eye.

Thus would give accurate uniformity in the caliber of the blood-
vessels make the lithographs doubly valuable to the specialist, refresh-
ing his memory for cases of doubtful dilatation or constriction.

A material help in the accomplishment of this end will be for every
reviewer to commend this feature, if present, and to criticise its lack, in
future atlases and text-books.

A CASE OF OSSIFIED CHOROID, WITH PATHOLOGICAL

SPECIMEN.

By John N. Payne, M.D.,

Boston.

HE case that I present to-day is to me a most mteresting one ;
and I believe it to be an unusual one on account of the ex-
tensive pathological alterations that have taken place. I
have found mention of such possibilities in several text-books, but a
report of only one individual case in the current periodical literature
that I have at my command. Dr. T. H. Wood of Nashville, Tenn.,
describes a similar case in the Archives of Ophthalmology, Vol.
XIX., No. 4 (1890). The late Dr. H. W. Williams in his book on
"Diseases of the Eye," published in 1886, says, following a short de-
scription of "Osseous formations in the choroid," that he has in his
possession a completely ossified choroid which he encountered in oper-
ating for the removal of the anterior part of a staphylomatous globe,
and which he extracted with forceps, subsequently bringing the cut
edges of the sclera together with sutures so as to form a good stump.
My case seems to differ from both of these in the involvement of the
lens, as well as the choroid and ciliary body, in the calcareous degenera-
tion.

I speak of it as a degenerative change, because there was no evi-
dence of the choroid remaining in this case, but simply the sclera on one
side, and the retina on the other; the ossified plate having apparently
taken the place of the choroid. Dr. George A. Berry of Edinboro
describes it in his text-book as an exudative choroiditis, involving only
the inner or capillary layer. He says, "it appears certain that the bone
forms in the exuded matter, and not in the original tissues of the
choroid," also that "it does not in any way differ from the development
that takes place from periosteum," and that the formation always
"ceases at the border of the ciliary body, in which ossification never
takes place.'' This case that I have here to-day, together with its
pathological specimen, would seem to have involved the ciliary body as
well.

Dr. Berry (and I quote him particularly, as he seems to have given
more space to the consideration of this subject in his text-book than

130 JOHN N. PA YNE, M.D.

others, with the possible exception of Norris and Oliver), says, further-
more, that he has "always seen an aperture left at the position of en-
trance of the optic nerve, but it is said sometimes to be bridged over."
You will notice in this specimen of mine a minute circular aperture of
a little less than one mm. diameter just at the point of location of the
optic disc, which I believe was left open for transmission of the retinal
vessels, thus not completely bridging over the optic disc space. He
mentions a case recorded by Lacquer, where, "After the extraction
of a dislocated calcareous lens the media were found to be sufficiently
clear to admit of ophthalmoscopic examination." "In this case," he
says, "no trace could be seen of the optic nerve or retinal vessels, and
the appearance altogether seems to have been very remarkable, while
the diagnosis of ossification of the choroid was confirmed by palpation."
It was impossible to make an ophthalmoscopic examination in this case,
as the pupillary opening was obstructed completely by the ossified lens,
which I was unable to remove.

This condition seems to be in most cases a result of irido-choroiditis
that has caused a shrinking of the whole globe, with subsequent osseous
formation. My case presented no such evidence of shrinkage, but
rather it appeared as an ordinary eye with moderately contracted pupil
and calcareous lens, and with some conjunctival injection.

Believing that the history of such a case with exhibition of the
pathological specimen, might be of interest and instructive to many of
you, I have ventured to present both to-day.

Case. — My patient was a man of forty years of age when he first
called to consult me. May i8, 1894. He was absolutely blind, and gave
the following history : His right eye was injured by a base-ball when
twelve years of age, April 10, 1866, and its sight was immediately lost
His left eye became inflamed through sympathy two days later, and
gradually lost its vision until it was reduced to a mere perception of a
point of light by January of '67. On the seventeenth of that month
his sight returned suddenly to his right eye (the one injured), so that
he could read a book, and could tdl colors and objects for about two
hours, until he went to bed. The next morning he found it reduced
again to a perception of large objects by sunlight, whereas he was
almost absolutely blind by artificial light. This continued until July
of the same year, when his vision suddenly disappeared for good.

When he presented himself for examination, I found the following
condition: Right eye of normal size and free from outward evidence
of inflammation, except for a circum-comeal injection such as is seen
in iritis; the anterior chamber somewhat shallow; the pupil dilated
and adherent posteriorly; and the pupillary space filled in by a dense,
yellow-white, evenly distributed, mass that was evidently a calcareously

A CASE OF OSSIFIED CHOROID. 181

degenerated lens. Its tension was a strong plus, and it was rather
sensitive to pressure, I thought, though the extreme over-sensitive
condition of the whole nervous system made it doubtful as to whether
his shrinking from contact was due entirely to the local irritation. His
left eye was blind, pupil contracted to pin-head size, completely ad-
herent, and blocked by exudation. The tension of this eye was some-
what below par, but it presented the same circum-corneal injection.
He complained of a constant, intense pain in one eye or the other almost
crazing him, and had for this reason sought consultation. I advised
enucleation of the right eye as the only possible remedy, but he begged
me to try first extraction of the lens, so that he might have a chance
for his vision, and I consented with the understanding that I should
be allowed to enucleate if I found the condition hopeless. He was put
into the hospital and the usual incision made through the cornea under
general anaesthesia, and an attempt made to extract the lens, which, as
I anticipated, was futile. I passed a probe under the lens to loosen it
from its attachment, and to lift it out, but found that it rattled against
a bony plate all around, and evidently was in contact with an ossified
ciliary body. I enucleated the eye, and on section of the sclera found
the pathological condition that I present to you to-day, and that I
have embodied in this paper in a series of photographs that represent
an enlargement of about four times the original specimen.

You will notice that the ossified shell is thicker in parts than in
others but represents an average of about i m.m., and that it involves
nearly the whole choroid, and all of the ciliary body, and all of the
cribriform plate with the exception of a circular aperture just large
enough to admit the arteria centralis retinae and its vein, and that the
crystalline lens is also completely ossified. I have said "nearly the
whole choroid," and by that I mean with exception of the large open-
ing that you will notice on one side, and which measures lo m.m. in
transverse diameter, and 5 m.m. in perpendicular diameter. This I
have explained by a possibility of the choroid having been ruptured at
the time of the blow, and that this represents the rent made then.
The vitreous had become liquefied, and the retina still remained as a
lining membrane of the choroid, but the latter had entirely disappeared.
The enucleation was followed by a great amelioration of the pain in
each eye, but not an entire cessation. I have seen him within the past
three months, and have found the left eye looking just the same with
the exception of the circum-corneal injection which has disappeared,
and a little more chalky appearance of the pupil, and with tension still
minus. He has an occasional attack of pain in the stump of his right
eye, though it does not look inflamed, and this pain will also extend
to the left eye at times. Says it seems to him like a very much modified
and expurgated edition of the old pain. No sense of light except when
he is feeling particularly well. Smokes a great deal and is nervous
and intense, but otherwise well. Is slightly rheumatic, and once had
rheumatic fever years ago. Has occasional attack of pain in right
shoulder, and numbness and powerlessness of three first fingers of right

132 JOHN N. PA YNE, M.D.

hand, soon disappearing, but leaving for a long time numbness of right
index-finger. Carpal joints somewhat enlarged but freely movable,
and not over-sensitive. I have no record of having made an examina-
tion of his urine.

I have no explanation to offer of the cause of this peculiar condi-
tion, but have simply presented the facts, hoping that some one of you,
who has had a similar experience, may have found the true ex-
planation.

DISCUSSION.

Dr. T. P. Wilson: Dr. Payne's paper is certainly full of interest.
It is a rara avis; and may well be placed amcng the curiosities of
medical literature. It does not admit of much discussion for, unlike the
fabled shield, it has but one side. "The extensive pathological altera-
tions that have taken place" are stated with admirable clearness but I
do not share in the hope of the author, that any one has found or will
find "a true explanation" in the sense intended by that phrase.

As related to general pathology, the xrase it seems to me takes its
place among the many recorded cases of so-called ossific deposits in
various parts of the human body. As to their relative frequency in
the different tissues, I have no means at hand for judging. It does
not matter, however, as we are concerned only in the fact, that some
of the tissues of the eye are prone to this form of degeneration. That
such cases are rare I judge only from the fact, that I have seen only
two such and they were confined to the lens.

The separation of the various salts of the blood, is an ordinary
physiological process, as we know in the case of urinary products.
Under pathologic conditions, they escape into tissues and build up
concretions without special form. In other cases they follow the laws
of nutrition and displacing normal tissues, assume their form. I do
not know of any reason for this.

Such cases have been successfully treated, when occurring in parts
of the body other than the eye. I mean various concretions have been
removed by internal medication. If we could detect the diathesis
which leads to these results, might we not hope for something from
preventive measures ? If left to surgery, the treatment is plain enough.

Dr. Hasbrouck: I have had a similar case to that of Dr. Payne
with a very interesting history of the early conditions. He first ap-
peared to me applying for a pension, claiming that he had lost the
sight of his right eye from moon blindness without the history of any
wound. On examining the eye, I noticed a calcareous lens, and feeling
of the tension, found the globe like a stone. He was complaining of
severe pain in the eye, extending to the back part of his head. It
looked like a case of old irido-choroiditis that had run its course with-
out treatment. I removed the right eye. On seeing the title of Dr.
Payne's paper, I tried to find the specimen but it had been lost. It

A CASE OF OSSIFIED CHOROID. 133

was so like Dr. Payne's that I wish it could have been presented at this
meeting.

Dr. Moffat : I would like to ask if there was any probability of these
patients having lived in a region where the water for drinking was
lime-water?

Dr. Hasbrouck : Possibly. My patient is a colored man at present
driving a coal-wagon, and previous to this he lived in the South. I
believe there is considerable lime-water in the South.

Dr. Pa)me: I regret very much that I neglected to have a urinary
examination made. The patient's joints are somewhat outgrown, but
they are movable and this seemed to be the only trouble he had had
so far as I could judge, being perfectly well otherwise, and I regret
very much not having had an examination made to determine the
lithaemic state. ^ i '

WAS IT A CASE OF SUB-RETINAL CYSTICERCUS?

By E. H. Linnell, M.D.,

Norwich, Conn.

THE occurrence of a cysticercus, the larval stage of a tape-
worm, in the human eye is of rare occurrence. It is more
often seen in Germany, where raw pork is eaten, than
anywhere else, and an idea of its frequency may be had from
the following statistics: for instance. Von Graefe saw eighty
cases in eighty thousand patients, or one in one thousand. Hirsch-
berg saw, during the short space of six months, two thousand
one hundred new patients, of whom five had a cysticercus, or one
in four hundred and twenty. Mauthner saw none in thirty thousand
patients. In the United States it is almost unknown. Loring in his
"Text-Book of Ophthalmoscopy" alludes to one case reported in the
Medical Record for December 27, 1889, by a Dr. Minor, as the first and
only case noted in this country. In view of its exceeding rarity, there-
fore, the record of a case is of interest even though the diagnosis is
not entirely positive, and I offer the following history as unique in my
experience and as probably a case of cysticercus. I do not say of
cysticercus cellulosae, because the beef-worm or the taenia sagginata is
much more common in this country and therefore the cysticercus bovis
would be more likely to infest the eye of an individual than the
cysticercus cellulosae of the taenia solium. The latter is the only one
of which I have been able to find a description in ophthalmological litera-
ture, although it has been claimed that the former has been found in
the human eye. Probably the description of the one would not vary in
essential details from that of the other, as the larval stage of all tape-
worms that are found in man is said to be very similar, and to pass
through the same stages of growth and development Therefore
whether mine was a case of cysticercus cellulosae or of cysticercus bovis,
I was unable to determine, but as will be evident, it resembled in
essential features the appearances described as characteristic of the
former.

Before narrating my case, it may not be unprofitable to review the
etiology and development of the affection.

A peculiarity of the life of all tape-worms is that they do not

IV AS IT A CASE OF SUB-RETINAL CYSTICERCUSf 135

attain maturity until they inhabit a "second host." The hog, for in-
stance, or the steer swallows the mature segments or the embryos of a
worm. These embryos are minute vesicles armed with hooks. They
do not develop into worms, but by means of the booklets, they penetrate
the walls of the stomach and the larval stage or cysticerci develop from
them in the intermuscular tissue and other organs. Now if an in-
dividual eats this "measly pork" or infected beef, the cysticerci develop
in his intestinal canal into the mature tape-worms. If, however, in any
one of various ways which it is not necessary to allude to here, he
swallows the embryos, they do not develop into the worms, but the
growth ceases with the larval form as in the case of the hog, and occa-
sionally this larva or scolex, bladder-worm or cysticercus as it is vari-
ously designated, lodges and grows between the retina and choroid and
perhaps penetrates into the vitreous chamber. It is said to be found

twice as often in the former location as in the latter. At first it re-

mains quiescent for a time and then, after losing its booklets, its
growth commences and progresses slowly for a period varying from
several weeks to four months. The mature bladder-worm in the
vitreous, is thus described by Mauthner :

"At the posterior end is a round cyst-like formation serving as a
receptaculum scolicis, into which the animal can withdraw, presenting
when in this position the appearance of a round whitish body. A
small fold marks the mouth of this receptacle. When the animal pro-
trudes his head and neck, the body appears to be sprinkled here and
there with calcareous deposits, and presents sometimes a smooth and
sometimes a wrinkled appearance. The body decreases in size towards
the neck, to which is attached the head, with four flattened down angu-
lar projections. A round-shaped snout can be projected from the
center of its head, and this latter is provided at its base with a double
row of hooklike tentacles which are capable of retraction. Each of
the angular projections is provided with a rounded sucking apparatus."
This full development can of course only take place in the vitreous.

Becker, in Mauthner's work on the ophthalmoscope from which
the previous quotation was taken, describes the earlier subretinal stage
as a "transparent cyst-like swelling of a bluish color. Its walls could
be seen to bend backwards with a convex surface and to be distinctly
separated from that of the retina. A critical examination led to the
conclusion that the retina at that point was lifted up from the choroid
by an independent bluish but depressed body with rounded contours,
the walls of which contained no vessels. This lack of vessels speaks

1B6 E, H. LINNELL, M.D.

against a diagnosis of a new growth and in favor of an entozoon."

Of course the animal may die and development cease at any period
of its growth, and thus its size and appearance are influenced by its
age and the fact of its being alive or dead and undergoing degenerative
changes. With these preliminary remarks, I offer for your considera-
tion the following history and hope for a free expression of opinion as
to the diagnosis.

Case. — Miss T., aged seventy-five, consulted me May 7, 1895, on
account of failing vision of the right eye, which was found to be ^^/^^
dif . After dilating the pupil with homatropine the vitreous was found
to be fluid and somewhat cloudy, with floating opacities. At the inner
side and a little above the optic disc a clearly defined bluish-white vesicle
was seen, and within it a dark object. The surrounding retina was
detached for about one disc diameter toward the median side. The
outlines of the vesicle were distinctly separated from the surrounding
retina and no vessels were noticed upon it.

The lady was not seen again until May 22nd when the vitreous was
still more hazy, and the outlines of the vesicle were indistinct. No
other details of the fundus could be made out.

On June 8th I saw the patient for the third time. The vitreous
was then a little clearer and the vesicle had sunken to the lower median
part of the retina. I thought it seemed a trifle larger than at first, and
what appeared like another smaller cyst was noticed at its median
lower edge. I was never again able to see anything behind the pupil.

Iritis developed soon afterwards, and later a keratitis, followed by
a glaucomatous attack and finally a cataract.

Such is the meager history of what was to me a very interesting
and unique case. I regret very much that the vitreous so soon became
too cloudy to admit of a careful study of the ophthalmoscopic appear-
ances, and that even at the first examination it was not perfectly trans-
parent. I feel reasonably sure, however, of the presence of a cyst with
dark contents behind a detached retina, from which it was distinctly
separated.

It did not give me the impression of a neoplasm, and although not
conforming eiltirely with the classic description of a subretinal cysti-
cercus, I know of no more plausible diagnosis.

DISCUSSION.

Dr. Jas. A. Campbell: Dr. Linnell's paper has been of more than
ordinary interest to me for two reasons. First, because it discusses
in a very attractive manner, one of the rarest diseases of the human
eye, for in this, and in several other lands, cysticercus in the inner

IVAS IT A CASE OF SUB-RETINAL CYSTICERCUSf 137

eye may be regarded as an ophthalmological curiosity of greatest
rarity, as stated in the paper.

' Again, to me, it is a most interesting topic, for it brings back to
me, most vividly, early experiences and observations of my student
life, years ago, which I have always regarded as unique. During six
months in Berlin, in the Fall and Winter of 1872, it was my good for-
tune to have seen seven cases of sub-retinal cysticercus cellulosae, in
the clinics of Schweigger, and in the private hospital and large clinic
of Dr. Ewers, formerly presided over by Von Graefe. Having full
notes on these cases, I do not trust entirely to my memory for comment
now. In each of these cases, while they were in different stages of
development, the leading well-known characteristics, outlined by Dr.
Linnell, were present. In five of them distinct movements of the
cysticercus could be made out. Three of these cases were operated
on (von Graefe's method), resulting in absolute failure and subsequent
loss of the eye. In another case the eye was enucleated, as a painful
iridochoroiditis had set up.

The point for discussion in Dr. Linnell's paper is necessarily upon
the correctness of his diagnosis. In reference to this, we labor under
the great disadvantage of not having had the opportunity to examine
the case. Under these circumstances, it would seem almost presumptu-
ous to offer criticism, especially since the doctor, himself, almost dis-
arms criticism by his frank suggestion of possible doubts. However,
one or two statements may be considered.

Our colleague, following the views of Becker, states that oi>e ground
for his belief that his case was not a sub-retinal neoplasm, was because
the walls of the cyst-like swelling contained no blood-vescels. This
in either case, would depend, somewhat, upon the length of time the
elevation had existed, and possibly its position in the fundus. I have
seen subretinal exudations and growths, in their early stages, where no
blood-vessels were apparent. And, I remember very well, in one or
two of the seven cases seen in Berlin, small blood-vessels could be made
out running over the cyst-like elevations. And Dr. Schobl, in his
article on the subject in Norris and Oliver's "System of Diseases of
the Eye" (Vol. 3, p. 574), describes and pictures one case of a triple
cyst, where such a condition is plainly seen. From time to time I
have seen small elevations in the fundus, where it was impossible for
me to decide, for the time being, just what the nature of the sub-
retinal trouble was — a beginning colloid degeneration,. tubercular de-
posit, subretinal effusion, or primary neoplasm. Progression of the
case and subsequent observations, will generally decide these questions,
but not always.

It will be remembered that while cysticercus cellulosse in the eye is
most frequently subretinal, it is not a rule or a law, for it has been
found in the orbit, in the vitreous, in the cornea, in the lens and subcon-
junctival, as well as elsewhere.

Cysticercus in the eye, is especially prevalent in North Germany,
and is seldom seen elsewhere. During six months in Vienna, not a

138 E. H. LINNELL, M.D.

single case appeared, and I could hear of but one case, which had been
seen there. Prof, von Jaeger pictures and g^ves an account of one
case in his "Atlas." In Paris and in London not a case was seen during
a prolonged stay there, and Schobl states that in Prague but two cases
occurred in 130,000 patients.

TREATMENT OF SOME AFFECTIONS OF THE THROAT
PECULIAR TO SINGERS AND PUBLIC SPEAKERS.

By George B. Rice, M.D.,

Boston, Mass.

IMPAIRMENT of the voice (and the term is used in its highest
sense), is occasioned by so many and so varied conditions that no
attempt will be made to even summarize the causes. There are,
however, special pathological states of the throat which are of particular
interest, and to those your attention is asked. In this class may be
mentioned the so-called singer's node, to which Tiirck gave the name
"Trachoma" ; Rice, of New York, "Chorditis Tuberosa" ; while Curtis
has adopted the term "Nodules of Attrition."

The affection consists of a small, ovoid projection on the edge
of one or both vocal bands at about the junction of the anterior and
middle thirds. The nodule may, as has been said, be unilateral, the
opposite band presenting a small indentation at the same relative point.
The literature regarding the etiology of this affection is meagre in
the extreme. Curtis^ describes the condition as primarily consisting
of a bulging of the vocal bands, due to faulty tone production. He
claims that long before the nodules appear a tendency can be observed,
when the upper voice is used, for them to touch at the junction of the
anterior and middle thirds, this spot being marked, on the bands
separating, by a small bead of mucus.

Sabrazes,^ Fuche,* Kanthack, and Rice* have examined specimens
of these nodules and find largely increased epithelial elements, Kan-
thack finding cornification in one specimen. It has been my good
fortune to see a number of these neoplasms, some of them well developed
and others in the incipient stage.

Case One. — Miss H., a public singer, consulted me, June 3rd, 1895,
for hoarseness after singing with inability at all times to sing the upper
notes of the voice softly, this trouble dating some six months previously.
The general health was good. The larynx appeared slightly congested

> Voice Building and Tune Placing, page 130.

* Internationales Centralblat fiir Laryngologie, 1890.
» Ibid. , 1893.

* Transactions of the American Laryngological Association, 1890.

140 GEORGE B. RICE. M.D.

{
in a general way. The right vocal band was reddened, the edge hav-
ing a roughened appearance. The bands did not adduct perfectly
except by considerable muscular effort. (No note is made of bulging.)
As the patient was dependent upon what she earned by her singing,
complete rest of voice was impossible. I did, however, insist upon the
abandonment of all vocal exercises and the use of great care at all times
in the explosive use of the upper tones. After three months of quite
constant treatment the inflammation subsided to such an extent, that a
single distinct node could be distinguished on the right vocal band.
The singing voice was much better than formerly, but the upper notes
were still husky. I became satisfied that the patient was using the
voice improperly, but found it difficult to convince her of the fact.
She did consent to give up all engagements for the summer months
and to allow me to keep her under observation during that time. The
node did not grow materially smaller under the rest treatment. In
the fall the patient married and removed to a distant city. She wrote
me, eight months later, that under a new singing teacher her voice
had so improved that no trace of the former difficulty in singing existed.

Case Two. — Miss C, a public singer, consulted me for recurrent
attacks of hoarseness. The nose, naso-pharynx and larynx were nor-
mal in appearance. The vocal bands were slightly reddened and
catarrhal. It was noticed that on abduction of the vocal bands a bit
of tenacious mucus stretched across from one edge to the other. After
a few days of treatment and rest, the bands on adduction could be
seen to touch at a nearly central point before the edges were made
parallel. This remained about the same for a number of weeks. An
interval of three months then elapsed, during which time the patient
did not come to me. On her next visit, some four months after the
first examination, a small nodule could be seen at the junction of the
middle and anterior thirds of the right vocal band. This, at first,
looked like a small bead of mucus but it could not be brushed away
and the voice was persistently husky. After this examination, the
situation was discussed and my opinion plainly expressed, with the
result that the patient became persuaded that she was using her voice
improperly. She consented to change her method of tone production
under a competent teacher. The result was extremely satisfactory.
Although still obliged to do church and concert work constantly, yet
the voice improved from the first and up to the present time the old
huskiness and relaxation have not returned, nor is there the slightest
trace of a node existing.

Case Three. — Mr. W., age forty-eight, a teacher of singing in the
public-schools of an adjoining city, consulted me, January i8th, 1896,
for a recurring hoarseness of three-months' standing. It was found
that the anterior portion of both vocal bands were congested, the left
ventricular band was puffy in appearance, while at about midway on
the edge of the right vocal band was a small, hard, pale projection.
The nose and naso-pharynx were nearly normal. In this, as in the
other cases, rest of voice was impossible. The patient admitted forcing

TREA TMENT OjF SOME AFFECTIONS OF THE THRO A T 141

his voice and promised to follow my direction in all respects. Cer-
tain light vocal gymnastics were given to be followed daily, and the
patient was cautioned against pushing his upper tones. By the internal
administration of Mercurius biniodtde — followed by Hepar sulphur —
and with mild local applications, the congested condition of the larynx
quickly disappeared ; but the node remained unchanged in appearance.
March 6th the larynx was cocainized and the growth touched with a
50-per-cent. nitrate of silver solution. The 6x was also given inter-
nally. April nth, node much smaller. Another application of silver
nitrate made, and on May i6th a similar treatment was given. July
17th, growth hardly perceptible and patient says the voice is in better
condition than for a long time. For the month previous to this one,
complete rest has been possible. A period of nearly three years has
now elapsed. The patient was seen on the 4th of March, 1899, and
no trace of the growth was apparent.

Case Four. — May 27th, 1895, Miss B., one of the principals of the
Grau Grand Opera Company, consulted me for hoarseness of some
months' duration. On examination I found nose, naso-pharynx and
pharynx apparently healthy. The vocal bands presented two small
projections at the junction of the anterior and middle thirds, the pro-
jections being covered with small dots of tenacious mucus. On ad
duction these diseased portions were quickly brought in contact.
Mezzo-voce singing was impossible in the upper voice, but the full voice
was not much impaired. I was unable, in the three weeks of observa-
tion, to give her any relief. I did, however, succeed in persuading
her to discontinue her operatic work, to rest three months and then
begin rudimentary vocal exercises again under a good instructor. She
fulfilled her promise, went to Paris and in the fall wrote me that her
voice was in fine condition. She did heavy work all the following
winter with unimpaired powers.

Papilloma of the larynx is not so distinctly an affection peculiar to

public voice-users as the preceding disease, yet past observations would

seem to show that these classes of patients are more subject to this form

of growth than those in other walks of life. My own limited experience

would surely indicate that laryngeal neoplasms are more likely to be

found in the throats of those who use their voices in public. It must

not be forgotten, however, that this class of patients are more quickly

conscious of vocal defects and so come under observation with greater

frequency. At any rate local laryngeal inflammation is recognized

as an important element in the etiology of papillomata. Children are

not exempt from the disease — two cases having come under my own

observation. The nature of a papillomatous- formation is that of

epithelial proliferation and it has been called by one observer a benign

epithelioma.^

* American Text-Book of Ear, Eye, Nose and Throat, page 1 106.

1« GEORGE B. RICE. M.D.

Case One. — Mr. A., public singer, consulted me on October 24th,
1896, for hoarseness. I found both vocal bands congested slightly.
At the junction of the middle and anterior thirds was a small red tumor.
The larynx was cocainized and the growth easily removed with a guillo-
tine. The microscope revealed the growth to be a papilloma. No
reaction followed the operation, the voice quickly improved and there
has been no recurrence of the trouble. The after-treatment consisted
of extreme care in the use of the voice and in prompt attention to
laryngeal colds.

Case Two. — Mr. D., auctioneer, consulted me for hoarseness, Sep-
tember 5th, 1894. Examination showed a deviation of the septum
sufficient to interfere with nasal respiration. There was considerable
congestion of the pharynx, while both vocal bands were reddened. On
the anterior portion of the right band was a growth of considerable
size, attached by a small pedicle. The throat was extremely sensitive
and it was impossible to do anything in an operative way until Septem-
ber 2ist, when the larynx was cocainized and the growth removed.
October 5th, the deflected nasal septum was straightened under ether.
The restoration of normal nasal respiration did much toward controlling
the pharyngeal and laryngeal congestion; but the forced use of the
voice did not allow the complete cure of this inflammation. September
3rd, 1895, about a year later, the patient returned with the voice as
husky as before. It was found on examining the larynx that the
growth had recurred on the original site. September 12th, the papil-
loma was removed again. The patient decided to change his business.
October 5th, 1896, he again presented himself for examination. This
time the larynx was in a healthy condition and the voice has been
normal ever since.

Case Three. — Mr. F., tenor singer, consulted me for hoarseness

October 25th, 1893. The trouble had existed for some two years and

he had been under treatment by different physicians during a greater

portion of the time. I found the larynx to be inflamed considerably.

On the anterior portion of both vocal bands were two pale growths.

They did not have the appearance of papillomata which I had seen

before and I felt in doubt as to the condition present. The throat

was treated locally and the apparently indicated remedy given for some

months without the slightest improvement being manifest, I then did

not see the patient for some time. He consulted me again October

4th, 1894. On this visit he was completely aphonic and the two

growths first noted had increased very materially. The larynx was

cocainized and the tumors removed. They proved to be multiple papil-

iHiata, that is, the surface of the growths were surrounded with many

)unded projections, each one apparently being an individual papilloma.

1 this case there were constant recurrences of the growths after

imoval. From October 4th, 1894, to April 12th, '99, twenty-five were

:moved at different times, and almost every portion of the vocal bands

as at one time or another occupied by the neoplasms. Most of them

■ere removed during" the years of '95, '96 and '97. In '98 four very

TREA TMENT OF SOME AFFECTIONS OF THE THRO A T. U3

small growths were taken away and the last operation was made April
1 2th, '99. At present the speaking voice is fairly good (though sing-
ing is impossible). The general health is very good. The vocal
bands present numerous flattened elevations and, of course, the larynx
is far from healthy in appearance. The patient has been under close
observation during this time. Local applications of thuya, of absolute
alcohol — as suggested by E^elivan* — ^also weak solutions of zinc chloride
and silver nitrate were used from time to time without the slightest
eflFect; but I feel confident that the Mercurius biniodide 3X
did have a favorable influence, and that the improved condition of the
larynx, in the past two years, has been due in a great measure to the
drug. The remedy was not given originally for the condition of the
lar)aix but for other symptoms referable to the phamyx, which were
only temporary. It was found, however, that the larynx improved
while the remedy was being taken, and so it was administered from
time to time in different potencies, the 3rd (three times a day) proving
the most efficacious way in which to give it. These few cases of
singer's node, selected from quite a number of a similar nature
which have come under observation, during the past few years, would
seem to support the conclusions of other observers, that singer's nodes,
notwithstanding the denial of one writer,^ do exist; and that they are
caused by improper tone production. The treatment is obvious. The
nose and naso-pharynx must be rendered as healthy as possible by treat-
ment directed to these parts. Rest of voice is not sufficient for a per-
manent cure so long as a return is likely to the original faulty method
of tone production. It is the physician's duty to call the patient's
attention to this wrong method and to induce a change in the manner
of voice production. It is not always easy to determine what is the
right method of voice production. So-called methods are as numerous,
almost, as the sands of the sea, but almost every throat specialist has
on his list the names of teachers of singing, or of elocution, whom he
knows to possess the requisite knowledge. Musical quacks there are
as well as medical quacks, and the one should be avoided as assiduously
as the other. Believing these nodes to be due to mechanical causes, I
do not think that, so long as the cause exists, the internal remedies can
influence them favorably other than to, perhaps, control, to a certain
extent, any laryngeal inflammation which may be present.

The papillomatous formations must also receive similar attention
as far as the use of the voice is concerned. Operative influence is-
also indicated. The case of a laryngeal tumor cured with Conium by
Dr. Custis' and the apparent influence of Mercurius biniodide in my
own case, are sufficient evidence of the efficacy of the homoeopathic

» American Medico Surg. Bull., June 18, 1896, page 870.
• Musical Courier, '97.

> Case of laryngeal tumor, cured with conium. By J. B. Gregg Custis, M.D.
Homoeopathic Eye, Ear, Nose, and Throat Journal, June, 1896.

144 GLORGE Ih f<ICE. ALD^

remedy in this class of cases to make a trial worth while. Perhaps in
time a sufficient number may be collected to enable us to form some
definite conclusions regarding the influence of the homoeopathic remedy
on these affections.

DISCUSSION.

Dr. Fred. D. Lewis: Dr. Rice's paper covers the ground so com-
pletely that there is little left to add in the way of discussion. I would
like, however, to draw attention to the fact that the general handling
is on the lines of the most advanced teaching of to-day, viz. : the deter^
mination of the cause in any given case and the cure effected by the
removal of the cause. The singers' nodes are undoubtedly due in
many, if not in all cases, to faulty vocalization, and so long as this is
persisted in no treatment, either local or constitutional, will render any
permanent relief. An operation may be called for, but the physician's
duty to his patient has not been performed by simply removing the
result of an error, without instructing the sufferer in the only way of
gaining the most relief, the avoidance of the cause.

I would have been pleased had the Doctor gone a little more fully
into the medical considerations of the conditions presented, for it is not
only in that direction that our school differs from all others, but fre-
quently in my opinion, it is the means of attaining brilliant results.
The case of frequently recurring papillomata that responded so beau-
tifully to Biniodide of Mercury might have gone on recurring in-
definitely, but that the constitutional discrasia that permitted their de-
velopment was corrected by the indicated remedy.

I do not mean to imply, however, that the indicated remedy alone
is sufficient, but it may play a most important part. A case I have in
mind might do to illustrate. The man came under my care some years
ago, referred to me by his family physician. The trouble he complained
of was considerable throat irritation; examination with the laryngeal
mirror showed a great deal of congestion of the pharyngeal and
laryngeal mucous membranes. The patient was over-fat and the
throat was in consequence narrowed. No growths of any nature were
present, the nasal cavities were in fairly good condition, no deformities.
Sprays, gargles, and the remedies apparently indicated by the appear-
ance of the membranes were given, with temporary relief; the patient
remaining away for a few months to return again with as bad a throat
as ever for several more weeks of treatment. Convinced at last that
there must be an underlying cause for the trouble, I made a careful
study of my patient's general condition, had examination made of his
urine, and found a uric-acid diathesis. Treatment along the lines of
the modern treatment of rheumatism, regulation of diet, keeping the
skin in good condition with frequent Turkish baths, advising him to
buy a bicycle to ride to and from business instead of taking the cars,
and I lost a patient, but made a friend. He has not required my
services now for his throat for over a year.

TREAIMENT OF SOME AFFECTIONS OF I HE THROAT. U&

Another case that stands out clearly in my memory is that of one
of our prominent public singers. She, for several seasons, when in
my city, always had me treat her throat before each performance.
Here was likewise only general congestion with some huskiness of
voice. Her singing was always made easier by an application of a
solution of aluminum aceto-tartrate. Her general health was good.
For some time I had urged her to have instruction in the proper use
of her voice, which I presume she did during her rest last summer, as
in her engagement in Buffalo last winter I heard her and could see
she was obtaining the same result as formerly v;ith much less effort,
and she did not need my attendance.

These are suggestions that I think Dr. Rice would do well to con-
sider; his paper is excellent as far as it goes, but it does not, in my
opinion, go far enough.

Dr. Hoyt: I had a case come into my office the day before I
left, which I called a case of singer^s nodules, although in a young
woman who was not a professional singer but who tried to sing some
in church and at home. She received a severe shock last January by
running quickly for a physician in the night, without hat or shawl.
Her throat pained her very severely for some days after that, with
considerable of a spasmodic condition, and she had been hoarse ever
since. She is an intelligent young woman, a college graduate. In
examining the larynx, the only thing I could see wrong was a little
nodule in the centre of the right chord, and a very tiny thickening in
the centre of the left. That would correspond to what Dr. Curtis
calls "Nodules of Attrition." I could not account for those nodules
appearing, unless as a result of inhaling the very cold air which so
irritated the larynx that this spasmodic condition followed and pro
duced a sudden strain upon the vocal chords. Would Dr. Rice con-
sider this a case of singer's nodules ? When she is not using her voice
any more than one does in ordinary conversation, what treatment
would he advise?

Dr. Rice: It is very difficult to answer Dr. Hoyt's question. I
don't think I could give him any suggestions.

Dr. Weaver: I was very glad to hear Dr. Rice mention Thuja,
especially for growths in the larynx. I believe it is a remedy very
well indicated for these conditions. I have seen five cases of recur-
rent papillitis in the larynx cured by the local application of Thuja,
where operation after operation in three of the cases seemed to give
but temporary relief. After removal they started immediately to recur.
It took considerable persistency in applying the Thuja locally. First,
I used the alcoholic preparation, but, later on, simpl> the aqueous
Thuja. At the same time I gave it internally. I think it should be
used in these cases, especially where you have them recurring; so fre-
quently, but it must be persisted in' a considerable length of time to
get the required results.

Dr. Rice : Let me say in answer to Dr. Weaver's argument in favor
of Thuya that about a year ago, a gentleman consulted me, suffering

146 GEORGE B. RICE, ALD.

from hoarseness. I found a large papilloma on one of the vocal bands
apparently easy to remove, but I found it impossible to anaesthetize his
throat; cocaine had no effect; eucaine was useless; neither of these
drugs even quieted the reflexes. So after repeated attempts I gave
up in despair.

I told him that if he was unable to control it by local applications or
by internal remedies (and it grew so as to interfere with respiration)
that I did not see any other way than external operation.

He was averse to an operation. For nearly a year he has been
receiving applications of Thuja, beginning with the lo per cent, aque-
ous solution and gradually raising it to a 50 per cent, solution. These
applications have been used three times a week by his family physician
who was taught to apply it properly.

For the first three months he apparently got some relief; the
growth was smaller, more pale and I thought that we were to reach
the desired end in a simple way. After this there was no change at
all in the appearance of the growth and at the present time I cannot
see that it is doing anything towards reducing tiie size of the tumor.

REPORT OF MY LAST SERIES OF FIFTY CONSECUTIVE

CATARACT EXTRACTIONS.

By a. B. Norton, M.D.,

New York.

THE present series of fifty consecutive extractions were made
between February 12th, 1896, and January 31st, 1899. The
report haq been limited to a series of only fifty cases, because
the large majority of my cataract operations are made at the New York
Ophthalmic Hospital and unfortunately the system of records of opera-
tions kept previous to about this time makes any reliable data or results
very uncertain. My general impression would be that my previous
experience in cataract extractions, covering a period of fifteen years,
would give practically as favorable results and I regret that the lack
of positive data for these preceding years prevents the reporting of a
much larger series.

Of these fifty cases, 32 were simple extractions, 14 extractions
with preliminary iridectomy; in 2 cases an iridectomy had been made
fourteen years before for iritis, and in 2 other cases a short time before
the extraction, for glaucoma. The selection as to the method of operat-
ing, whether with or without an iridectomy, depended upon the individ-
ual case to be operated. The operation preferred in ripe uncompli-
cated cataracts, is the simple extraction without an iridectomy. In
the thirty-two cases operated by this method, in this series, an iri-
dectomy at the time of the operation was required in none. In pre-
vious simple extractions I have had two or three cases in which the iris
would not remain in place and an iridectomy would have to be made
at the time of the extraction. Prolapse of the iris occurred in six out
of thirty-two cases. In three the prolapse was cut oflF and in others
not. Five of these cases had a final vision of '^/jo or better. The other
was one of the three where the iris was cut oflf and the vision finally
lost from opacity of the cornea. As this result was in a patient 82
years of age very unruly and mentally unsound the bad result should
hardly be attributed to the method of operation.

The duration of treatment, i. e., the time from the operation until
discharged, averaged in the simple extraction nearly 21 days, while
in the extraction with preliminary iridectomy it was a fraction over

A. B. NORTON, M.D.

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FIFTY CONSECUTIVE CATARACT EXTRACTIONS. 163

i8 days, a difference in the length of time of three days in favor of a
preliminary iridectomy, but as the iridectomy itself usually requires
three or more days there was no gain. The average duration of treat-
ment in the simple extractions was greatly increased by the cases of
prolapsed iris as in cases 7, 21, 45, 46 and 47. With these omitted the
average is a little less than that where an iridectomy had been made.

A comparison of the results as to ultimate vision gives us no relia-
ble data. The difference in the cases, the complications, the total loss
of vision in two cases of simple extraction, viz,, 17 and 21 which in
either case could not be chargeable to the method of operation, and 4
other cases where no discission was made, prevents any comparative
figures. The results in all cases of ultimate vision of ^^/g© or better
give about the same percentage to the total number of cases operated
by either method.

The good vision obtained in these cases I attribute to my almost
universal rule to make a discission on every case, and to repeat the
needling as many times as it is necessary to get a perfectly clear pupil.
In fact I do not consider my cataract operation as finished until after
a successful discission. In my experience it is much better to wait
six weeks or more, where it can be done, before needling as the capsule
becomes more tense the longer it is left after the extraction and gaps
open and rolls out of- the way better after it is divided. As a rule,
however, these patients are too eager to again use their eyes to wait for a
sufficient period to elapse before needling. This is, of course, especially
apt to be the case in a large hospital practice, for as a rule their living
depends upon the use of their eyes.

The relative gain in vision from the discission operation after catar-
act extraction has been shown by Knapp in his "Report on a third
series of one hundred successive cataract extractions without iridec-
tomy'^ to be as follows. "The average visual result of extraction is
**/7o> which by subsequent cystotomy is converted into ^^/s©-" While
our records are not sufficiently full to give positive data in this respect
still I am strongly of the opinion that the value of a cystotomy is not
overestimated by Dr. Knapp.

Another factor contributing to the particularly favorable ultimate
results I believe to be the extreme care taken in the final adjusting of
glasses. Fully eight-tenths of my cataract cases are given cylindrical
lenses. The amount and axis of the astigmatism being very carefully
determined both with the ophthalmometer and the trial lenses. This
point is referred to because in a recent report of sixty cases a cylindrical

164 A. B. NORTON, M D.

lens is recorded as being used in but three cases. Another author re-
ports a series of twenty-five cases with astigmatism in five. As it has
long since been shown by measurements that the shape of the cornea is
altered to quite a degree by the section of a cataract extraction, the
vertical meridian becoming flatter, it would seem to the writer that
many operators do not pay sufficient attention to the correction of the
corneal astigmatism which is always present in a higher or lower de-
gree. Pfingst in the Archives of Ophthalmology, Vol. 25, reports the
measurements of the cornea after cataract extraction in 59 cases
operated upon by Dr. Knapp with an average astigmatism two weeks
after the extraction of 7.7D.

Very few reports of cataract operations record the refraction and
the glasses ordered, but I am convinced that mucli better results could
be obtained by careful attention to the correction of the resulting astig-
matism. It is at all events an important subject which we hope to pay
more attention to in another article.

Method of Operating, — It is my rule to always have the patient
admitted to the Hospital twenty-four hours before the operation. The
patient is then given a bath and the head and face thoroughly washed
with soap and water. Just previous to the operation the face is
thoroughly scrubbed with corrosive sublimate i to 4000, great pains
being taken with the eyebrows and eyelashes. The eye is then flushed
with a bichloride solution i to 8000 and instillations of a 4 per-cent
solution of cocaine used. In operating I use a knife made
for me by Tiemann and Co., the blade of which is broader and shorter
than the usual Graefe knife. The speculum and fixation forceps are
always used until after the division of the capsule, then both are dis-
continued and while the assistant draws down the lower lid, a firm hold
of the upper lid at the ciliary border is taken with the index finger of
the left hand. A hard rubber spoon is then applied to the lower border
of the cornea and pressure made downward and backward to tip the
lens on its axis and as it presents at the wound is gradually followed
up with the spoon, the pressure growing less as the lens advances.
All the cortical substance that can be easily coaxed out is removed but
in simple extraction it is not my practice to manipulate too long or
too strongly to remove it. Where an iridectomy has been made you
can remove the cortical substance much easier and safer than in the
simple extraction.

As to the section in simple extraction, it has always been made
wholly in the cornea. I have varied it at times from just at the corneal

FIFTY CONSECUTIVE CATARACT EXTRACTIONS. 156

margin to about midway from the corneal margin to the upper edge
of the pupil. The great drawback to the simple extraction is the
liability to prolapse of the iris and I am sure that the danger of the
prolapse increases as the section approaches the corneal margin. The
objection to a more central section seems to me to be a higher degree
of corneal astigmatism and oftentimes a slower union of the wound and
a more tardy restoration of the anterior chamber. As these latter fac-
tors are of much less gravity than a prolapse of the iris it seems to me
as though a less peripheric section is to be preferred.

In the extraction with the iridectomy on the other hand I continue
to make the old Graefe linear section, the puncture, counterpuncture
and the section all being in the corneo-scleral margin.

The opening of the capsule or cystotomy is made with the cystitome
introduced under the upper part of the iris and scratching the capsule
at its periphery.

Before the dressing is applied care must be taken in the simple
extraction to see that the iris is not only back in place but that the pupil
is perfectly circular. If it does not readily go back of its own accord
it can be gently stroked into place with a spatula. The eye is then
flushed with a boracic-acid solution and a piece of sterilized gauze wet
in a I to 4000 solution of the bichloride is applied over the closed eye.
Upon this is placed a small piece of absorbent cotton soaked in the
same solution which molds itself to the eyeball making gentle and uni-
form pressure to all parts. Over this a second and sometimes a third
pad, but dry, is placed and the whole held in place by two strips of
adhesive plaster. This dressing I have adopted as very much lighter
and more comfortable than the old roller bandage, and as better than
the gold-beaters' skin applied to the lids because easily removed with-
out disturbing the wound as the latter dressing when stuck to the lids
is apt to do. The patient is then carried to the bed and instructed to
keep on the back or the unoperated side for the first forty-eight hours.
It has been my practice of late to examine the eye the day after the
operation in order to cut oflF any prolapse that may have occurred, but
as I have so frequently found no prolapse on the first examination and
then to have it occur on some subsequent day that I shall try the
method advocated by Galezowski of not opening the eye until a week
elapses. He claims that by this method he scarcely ever finds a prolapse
of the iris.

This paper has been presented with the hope that it will result in a

156 A. B. NORTON, M.D.

free discussion by the members present for the subject is one of interest
to all of us.

DISCUSSION.

Dr. Moffat: I would like to ask Dr. Norton how he makes his
capsulotomy, and the comparative results of the different methods.

I prefer the old way of describing the corneal cataract incision,
t. e., the distance of its apex from the apex or limbus of the cornea;
the edge of the pupil is too variable.

Formalin is perfectly satisfactory as my antiseptic. I have had
two eyes broken open after operation by a blow, so now protect the
eye with a cage or, better, Ring's mask held in place with adhesive
strips beside a bandage ; under this I have only a strip of gold-beater's
skin-plaster from the upper lid to the cheek, leaving room for the escape
of tears.

Dr. Norton spoke of astigmatism. In the Annales d'OculisHque,
Dec, 189s, Dr. Georges Martin, of Paris, called attention to Wherrell's
error when coining this word. The Greek irrt^fia — ar<9 means a
point in the sense of a prick or sign, but a mathematical point is trans-
lated by tnqr/ni — 1^9. Therefore we should say astigtnia for astigmatism,
and astigmic instead of astigmatic. I plead with the members of this
Society to exert their influence for this reform in the name of scholar-
ship and accuracy; especially let each secretary and each editor make
this correction as he would any other lapsus lingiuF.

Dr. Payne : It seems to me that the question of opening the capsule
is a very important one, and, of the different methods that I have tried,
my experience has been that a "T"-shaped section has been less pro-
ductive of trouble and leaves less liability to a necessity for a needle
operation later. The opening of the capsule is accomplished simply by
passing the instrument down to the lower extremity of the capsule,
drawing it up over the middle of the capsule, and then following the
superior border with a cross-section. In that way two large cuts are
made which, on extraction of the lens, are apt to divide and leave an
opening that demands less attention later in the way of an operation.
At times, in using the cross-section, I found the flaps fell together,
and that they interfered very greatly with vision afterwards.
Since the adoption of this method, I have had very much less
trouble. In the method of treatment of the eye after the
extraction as to dressing, I find it very much better to use isinglass
plaster instead of gold-beater's skin. I have preferred to use that as
I found that the lachrymation sometimes followed and was very apt to
wash off the gold-beater's skin and hence I have adopted the silk
isinglass, getting the very thinnest possible, that put up by Johnson, &
Johnson. I make two strips for each eye which start from above the
superior border of the eyebrow, running down the cheek and crossing
each other opposite the eye. I have had no trouble after having used
this method for several years, and imagine that by its use I have had

FIFTY CONSECUTIVE CATARACT EXTRACTIONS. 167

less astigmia to correct later. These have been the expedients which I
have adopted for the last few years with most satisfactory results.

Dr. Suff a : I would like information in regard to stitching the cornea
after cataract extraction, whether any members have had experience in
that line, and if so the results. Vol. XXVIL, No. 2, i8g8, Archives of
Ophthalmology J contains an excellent article on a series of experi-
ments on stitching corneal incision on the rabbit after removal of the
lens. The author, Dr. W. H. Bates of New York, gave good reasons
why stitching of the cornea should be employed after cataract extrac-
tion in the human being, and the method of application. I have one
case to report, where a stitch was necessary and gave quick and good
results. It was after a simple extraction, in a traumatic case, where
the anterior and posterior capsule had been ruptured. As soon as the
corneal incision had been made, before the forceps and knife could be
laid aside, the patient had a spasm of the lids, forcing out the lens, and
apparently one-fourth of the vitreous. The speculum was quickly re-
moved, the eye closed, and dressings adjusted. No undue reaction '
ensued, but a bead of vitreous persisted in separating the edges of the
wound, and as the patient was very unruly during dressing, having
no control over his lids, I decided to bring the edges of the wound
together with a stitch. This was done under anaesthesia eight days
after the extraction. One central stitch was sufficient to dose the
gaping wound, and replace the bead of vitreous. Union was unevent-
ful and rapid, and there was no further trouble in doing the dressings.

Dr. Thomas: Since the early years of my practice I have done
cataract extraction almost exclusively with a preliminary iridectomy,
and, with few exceptions, have not felt that in the interest of my
patients, or of my own comfort, I had the right to depart from this
method. It seems to me if we look into the matter very carefully that
there can be little doubt as to the greater safety in the extraction of
cataract with preliminary iridectomy. Indeed, I think I can recall
reading a similar statement over the signature of Dr. Norton himself.
I believe we are all agreed that when a case is a complicated one, and
perhaps where there is but one eye, the extraction should be done in this
way: no chances, no risks are here to be taken. This statement is
repeated over and over in our writings, and yet if the preparatory
iridectomy is advisable under such conditions, why not in all cases?
Our great desire I take it is to remove the cataract in the simplest
possible way and with the greatest safety to the patient.

Supposing iridectomy to have been done, (and I doubt if there
are many of us who will claim that this little operation is productive
of danger, or adds to the complication, if done as a preparatory one,)
I can conceive of nothing more simple than the removal of the cata-
ractous lens. We have simply to incise the cornea, open the capsule
and press out the lens; and as to the healing process nothing can be
more simple or sure. I may say briefly that I g^ve next to no thought
to my cases after extraction — they cause me no anxiety.

I am never called upon hours or days after the extraction to

158 A. B. NORTON. M.D.

examine for or replace a prolapse, or do an iridectomy under very
unfavorable conditions, perhaps under a general anaesthetic. The heal-
ing goes on uninterruptedly, provided the extraction has been done
according to the rules of the art.

On the third or fourth day the unoperated eye is uncovered, and
four or five days later all dressings may be removed.

The case is discharged about the twelfth day. As to the cap-
sulotomy, the invariable practice in my clinic is the T-shaped incision.
We at one time did the peripheric capsulotomy of Knapp, but have of
late years added to it the vertical cut. The dressing is very much
the old one of Graefe — i, e., the binocular roller, excepting that we
use a wet compress in place of the dry one, dipping it into the soda
water for boiling the instruments.

This is left on without change for three or four days, when a drop
of a 6 to 8-grain atropine solution is instilled and repeated with each
daily dressing thereafter. I notice that Dr. Norton speaks of occasional
difficulty in removing the cortex. .With a preparatory iridectomy this
most important part of the operation is certainly much more easily
accomplished than where the simple extraction is done. Is it not most
desirable that we secure as much as possible of the cortex at the time
of the operation in view of the subsequent difficulties in the needling?

It seems to me the preparatory iridectomy affords us a decided
advantage in this particular. I want to thank Dr. Norton for his most
practical and valuable paper.

Dr. Deady : There is one point in this matter, I think, which has a
bearing on the method of dressing. It has been my experience for a
good many years, both in my own cases and those of others, to notice
that where the skin covering was used instead of the pad that, other
things being equal, there was less redness and the time of the redness
was shortened. In reference to that matter, I have another thing to
speak of, and that is, that in a recent case where the patient very
strongly objected to having the second eye covered, I allowed it to
remain uncovered, and had one of the quickest results I ever saw. It
is the first time, I think, I ever operated a cataract without covering
both eyes, but there was not the slightest difficulty from one end to
the other in the case. I do not know whether the gentlemen present
are in the habit of doing this sort of thing, but I thought I would men-
tion it for what it was worth.

Dr. Beebe: Will Dr. Norton give us the average length of time
which his patients were in the hospital after the extraction? I came
to the conclusion several years since, that the use of the bands^,
however applied, was a damage and an injury after cataract extraction
and that the simple court-plaster was tlie best after-dressing as it is, in
fact, in almost any disease of the eye. I am aware that the dressing
which Dr. Norton suggests is the one which Professor Knapp now
uses and that he has greatly modified his former methods of dressing,
but I am convinced that had Dr. Knapp resorted to the use of the plas-

FIFTY CONSECUTIVE CATARACT EXTRACTIONS. 169

ter dressing years ago, his average results would have been much better
than they are now.

Dr. Stephenson: I would like to ask if any have used the rubber
dam in place of either isinglass or roller for a bandage. That is to
say after the dressing following the operation, place a moist pad and
then a dry one over the eye, fill out the opposite side with dry cotton,
then place your strip of rubber two inches wide and five long with a
tape in each end to tie with. I learned of this dressing from a Doctor
in Salt Lake City, and since that time I have used it, and find that
four days after, on removing the first dressing, the cotton is moist, that
it comes away easily from the lids, and has not become stiffened as
other dressings do. I have found it very successful in my work.

Dr. Norton: I am glad to have stirred up some discussion. In
regard to the matter of capsulotomy, Dr. Knapp, of course, is the man
in this country who makes the greatest number of cataract extractions.
I have simply followed his lead in making a peripheral incision. As
to the method, it is to me easier to just sweep the cystotome around
the periphery that it is to go down to the bottom and draw up and then
across from side to side ; and the simplest methods are the best. In the
secondary operation he first split the capsule in the shape of T, later
changed to a + incision, which he says is the ideal operation giving
a clearer pupil than any other. The occurrence of glaucoma in i per
cent, of his cases of discission led him to return to the T incision. I
have had glaucoma in one case which was relieved at different attacks
by eserine and sclerotomy. As to the use of holocaine, referred
to by Dr. Moffat, I do not use it at all in extractions; be-
cause holocaine does not give any dilatation of the pupil, or
very little, and I use no mydriatic in simple extractions. I
get all the dilatation I care to from the cocaine, using that
in preference to holocaine for this reason and because it is less
irritating. As to the method of dressing which has been referred to by
several. The ideal dressing is that which keeps the lid in perfect appo-
sition and is as light as possible. My objection to the gold-beater's
skin or any dressing applied directly to the eyelid is that in drawing
off the gold-beater's skin, you have to make more or less manipulation
upon the eye before the wound is perfectly healed ; and I think a great
many have found that they have had opening of the wound from
removal of the dressing when applied directly to the eyelid. The use
of cotton as I use it is very light and soft : it is not hard and rolling as
has been suggested. I do not believe in applying the rubber dam sug-
gested by Dr. Stephenson : I think we would get too much heat by the
use of the rubber as a cap — it would act too much in the nature of a
poultice as suggested by Dr. Moffat. I simply use a thin layer of bi-
chloride gauze and a little thin pad of cotton, a pad about two inches
round, and not more than one-half inch in thickness, lightly soaked In
water, laid in its wet condition directly over the eyeball. It molds it-
self to the shape of the eye, is light in weight, and then I apply over it
a light piece of cotton to fill out the shape a little more. That dressing

160 A. S. NORTON. M.D.

has, in my experience, proved very light, soft, comfortable to the pa-
tient, and very easily removed without any disturbance to the eye-ball.

In answer to Dr. Beebe I would say that I expect to discharge my
patient from the Hospital on the 14th day, and as a rule do so (or
before) in the large percentage of cases of perfectly smooth healings,
with no complications. The protracted cases, however, as pointed
out in this paper have made the total average 21 days in the simple ex-
traction and 18 days when made with the preliminary iridectomy.

As to Dr. Thomas' su^^stion that I have previously stated that
preparatory iridectomy is safer, I think I must acknowledge the cor-
rection. If I had but one eye I should prefer to have it operated with
preliminary iridectomy. Dr. Thomas' argument that if the extraction
with an iridectomy is the safest operation it should be used at all times
is unanswerable. It would perhaps be best to confine the simple ex-
traction to those rare cases that decline to submit to two operations,
the preliminary iridectomy and the extraction to follow. I have only
made the simple extraction in uncomplicated cases. When we have a
patient with but one eye, or any complication such as adhesions from
iritis or other trouble, I always use the old method of preliminary
iridectomy, believing that, perhaps, it is the safer; but a great many
patients object to two operations — the iridectomy followed by the ex-
traction later on; and where we get a perfectly matured case of simple
cataract, I find no more difficulty in removing it by the simple method
than by preliminary iridectomy.

Dr, Thomas has also referred to the removal of the cortex. I stated
in my paper that it can be removed much easier and more thoroughly
in the operation with an iridectomy, but as most of this cortical sub-
stance will become absorbed I do not believe we should take any
chances of accident by too much manipulation for its removal.

AN UNUSUAL TUMOR OF THE EYE AND MALFORMA-
TION OF THE ORBITAL STRUCTURE, WITH ABNOR^
MAL DEVELOPMENT OF THE CRANIUM.— OPERA-
TION.

By George A. Suffa, M.D.,

Boston, Mass.

CASE. — Agnes Graham. First seen January 9th, 1896, when
five weeks old. Presented the following condition which was
present at birth. A fleshy-appearing tumor, approximately
one and one-quarter inches long horizontally, three-quarters of an inch
wide vertically and one quarter of an inch thick occupied the right
palpebral opening. Under general anaesthesia this growth was found
to be firmly attached to the sclera from above the cornea, which was
displaced downward beneath the lower lid to the integument above with
which it was continuous. The cornea could only be seen by retracting
the lower lid, was opaque throughout, and the lower border was contin-
uous with the inferior cul-de-sac, the eye being firmly fixed in this posi-
tion. The lower lid was normal in all respects, but the upper lid was
apparently cleft and the division filled with integument with which the
growth was continuous; the lid and lashes were displaced outward, ex-
ternal to the ttunor, and a shallow superior cul-de-sac existed at this
point. The lashes were turned upward close to the skin and a wart
occupied the external canthus. The growth dipped toward the equator
beneath the ocular conjunctiva, at the outer canthus; and the conjunc-
tiva at this point did not seem healthy, and was reflected directly to the
canthus. The frontal bone was, perhaps, slightly flattened on the right
side, as well as the frontal sinus, and a depression, almost an opening
through the skin, was present just below the normal position of the
supraorbital notch or forearm, beneath which depression a freely
movable spicula of bone could be felt. A similar condition, to a less
degree, exists on the left side, although the eye-ball is placed normally,
and is capable of movement, somewhat limited in certain directions.
The upper lid margin is divided by a wart, the under surface of which
is continuous with the ocular conjunctiva, practically obliterating the
cul-de-sac at this point, and to a considerable extent outward. There
is not only obliteration of the cul-de-sac at this point, but also an ab-
normal amount of tissue extending to the cornea, which is opaque in
its outer half, vision being possible only through the inner half. The
whole cranium shows marked irregularities and lack of development.
The forehead or frontal bone protrudes on the left side, bulging in the
right temporal region; antero-posterior diameter is enlarged; and ver-
tex pointed longitudinally ; in fact, the whole cranium is enlarged, sug-
gesting hydrocephalus. The fontanelles were large, especially the
posterior; they were connected by a separation of the parietal bones,

162 GEORGE A. SUFBA, M.D.

a non-union of the sagittal suture. At the posterior fontanelle the
brain protruded, causing a very perceptible bulging, and the scalp ap-
peared thin, almost ready to break through a space fully half an inch
in diameter; throughout this area, and considerably beyond on the
right side there is an entire absence of hair. At the present time the
area has become somewhat smaller, but there is still a bald, glossy area
entirely devoid of hair follicles and subcutaneous fat. The condition
can more readily be understood than is possible to convey by pen, by
examining photographs of the child when about one year of age; al-
though at that time the saggital suture had closed, the fontanelles were
much diminished in size and the bulging at the posterior fontanelle was
less marked. In addition to all these irregularities, of which there
were already a sufficiency to satisfy the most avaricious, a tumor de-
veloped on the right lower g^m, which absorbed the bony wall between
the two alveoli, extending fully half an inch into the inferior maxillary
bone. The growth was .very soft; macroscopically it had every ap-
pearance of being malignant, and microscopically was pronounced a
round-celled sarcoma, and a serious prognosis given. About six
months later another tumor appeared on the upper jaw which had the
same general characteristics, though somewhat firmer in consistence.
Both tumors were thoroughly removed and the cavities curetted and
cauterized with the actual cautery by Dr. Ha)rward. Neither recurred
and up to the present time there is no evidence of further trouble.

On January 30th, 1899, the ocular tumor was removed, the sclera
incised vertically, the cornea and contents of the sclera removed and a
Mule's glass sphere inserted. On removing the tumor it was found
firmly adherent to the sclera, though not continuous with it ; in no part
of the growth was there any evidence of the levator palpebrarum or
superior or external recti muscles, although the mass covered the
region normally occupied by these muscles. Removal was begun at
the superior inner portion, and the incision continued along the integu-
ment, where twelve spurting arteries were cut across. The outer free
portion of the growth was covered with what appeared like conjunctiva.
It was thought best to save this conjunctival tissue for future use, as the
tumor at this point graded into normal orbital tissue. Removal of the
growth was continu^ to the equator until normal orbital tissue was en-
countered, to be sure that all abnormal tissue had been removed, and
to form a cul-de-sac, as at this point the orbital tissue was excessive.
The lacrymal rfand was encountered at the outer edge of the growth,
being abnormally placed under the ocular conjunctiva, superiorly. The
tumor collapsed fully one-half as soon as removed, the reason for which
is readily seen by its richness in blood-vessels. The cornea, as pre-
viously stated, was opaque but normal in size, perhaps slightly thick-
ened. The iris, lens, vitreous, retina and choroid appeared normal.
The retina converged to form the optic nerve, which was placed in the
sclera below and anteriorly, near the equator, on account of the ex
treme downward rotation of the eyeball. The nerve itself was placed
in its normal orbital position. At this point the reason was found for

Side view before operatiot

t before operation.

AN UNUSUAL TUMOR OF THE EYE. 168

the fixed position of the eyeball, the apex of the orbit being filled with
bone and cupped anteriorly to receive the posterior third of the eye, to
which it was firmly adherent. At the termination of the cup, superi-
orly, the bone shelved upward, which shelf received the attachment of
the triangular piece of bone previously mentioned.

Diagram No. i shows in profile a vertical incision through the
tumor, centers of the eye, the spicula of bone, and the bony apex, and
explains itself.

After bleeding had ceased, which was no more than is usual during
evisceration, a small glass sphere was inserted and the sclera closed with
silk sutures. An incision was made vertically through the integument
to the point of the spicula of bone, a small triangular piece of the in-
tegument removed outwardly, the piece of bone removed and the opera-
tion completed by closing the gap in the skin and stitching the con-
junctiva, saved at the outer angle, into place. With the exception of
the cutting out of the lower suture in the lid healing was rapid and
without undue reaction, soft granulation soon covering the denuded
area.

On February 12th the granulations over the site of the tumor were
removed, and when bleeding, which was profuse, had ceased, the area
was covered with the ocular and palpebral half of a jack rabbit's con-
junctiva and fastened in place by a continuous suture. For the benefit
of those who have not grafted large pieces of conjunctiva I will
describe, somewhat in detail, the steps of the procedure. No difficulty
was encountered in separating the ocular portion of the rabbit's con-
junctiva, but not so with the palpebral and third lid region, so that
when these portions were reached no effort was made to remove only
the conjunctiva, but connective tissue and conjunctiva were removed
together. To remove this connective tissue and the third lid proved a
difficult task, as the conjunctiva persisted in rolling up into a string
and could only be kept from doing so by turning it over the index
finger. When the task had finally been accomplished it was difficult
to tell which was the outer surface, and, had not a stitch been placed
both in the ocular and lid portions, it would have been even more
difficult. The next problem was how to hold it in place for suturing.
This was accomplished by again stretching it over the left index finger
and holding it as near as possible to its final resting place, inserting*
two loops of the continuous suture into the conjunctiva of the lower
lid and graft before drawing it into place, then spreading the graft
over the denuded area, where it remained by its own adhesiveness un-
til fastened into place.

Dressings were first oiled silk, covered with sterilized gauze pads,
held in place by adhesive strips, and the mother and nurse were in-
structed to exercise care that the dressings should not be disturbed.
The child passed a restless night, and I found on my visit that the
dressings had been displaced, so that it was deemed wise to examine
the graft and adjust a new dressing. This was done under anaesthesia,
and the following interesting condition was found. Four pink points

164 G^RGE A. SUFFA, M.D.

one-eighth of an inch in diameter and fully one-quarter of an Inch
apart were symmetrically placed around a centre, the upper two, cir-
cular, were pink throughout; the two lower, somewhat larger, were
striped vertically; the rest of the conjunctiva appeared just as it did
after removal from the rabbit. This certainly was very encouraging,
and shows that union begins very quickly, within twenty-four hours.

In order to avoid displacement of the graft, should the child again
rub the eye, a suture was placed in the outer third of the lids and the
dressing replaced. The dressing was not disturbed for two days, and
then only the integument around the eye washed with a boracic solu-
tion. Five days after the operation, the stitch in the lid was removed
and the graft carefully inspected. The pink spots had increased in
size, and the whole graft was glossy except a small part in the centre,
which was white but seemed firm, showing no tendency to slough;
even the edges of the graft were adherent. As considerable secretion
was present under the oil silk it was discontinued. The future dress-
ings were gauze and absorbent cotton held in place with adhesive
strips.

A third operation, on February 23d, was for the purpose of form-
ing an artificial upper lid and superior cul-de-sac. In order to accom-
plish this end, an incision was made through the skin horizontally,
outward, from the outer angle for an inch and a half. An incision
was carried through the conjunctiva in the small portion of the su-
perior cul-de-sac, and continued into the inferior cul-de-sac fully one-
quarter inch and the integument undermined from the temporal end
of the incision to the bridge of the nose, fully one inch above the brow.
The lower lid margin was split for one-quarter of an inch to connect
with the incision in the inferior cul-de-sac. This splitting of the lower
lid was for the purpose of furnishing conjunctival lining for the por-
tion of skin to be slipped over from the temple to form the outer half
of the upper lid, and also a denuded area for the purpose of narrowing
the palpebral fissure. A triangular skin graft, except a pedicle at the
inner part, was removed above ; the incision beginningat lid margin, just
inside of cilia, extending upward and inward for fully one-half an inch,
then downward and inward to pedicle, and continued below the pedi-
cle to lid margin near the inner canthus. This skin graft was then
moved slightly outward and fastened with sutures above the conjunc-
tival graft to form the ocular portion of the superior cul-de-sac in this
region. The opening in the lid was brought together with three su-
tures, one below the pedicle near the edge of the lid, and two above the
pedicle. The conjunctiva, separated from lower lid, was reflected and
stitched to the outer portion of the upper lid. Four sutures were in-
serted to close the temporal incision, and a suture buttoned at each
end was placed horizontally above the brow to relieve tension. The
different steps in the operation caij be more readily understood by ex-
amining Diagram No. 2.

A piece of oiled silk, doubled, was placed between the skin graft
and the conjunctival lid surface, and the lids were covered with gauze

Front view after operation with artificial eye in position.

AN UNUSUAL TUMOR OF THE EYE, 165

pads and cotton as after the former operations. With the exception
of the cutting out of the suture below the pedicle, healing was perfect
and rapid, the skin graft healing throughout with no tendency to ad-
here to the conjunctiva of the upper lid.

The fourth and last operation was done on March 6th to com-
plete the inner portion of the lid and the superior cul-de-sac. After
severing the pedicle the incision was extended downward through the
ocular conjunctiva, previously grafted from the rabbit, underrunning
a flap which was left adherent to the lid margin. The skin was under-
mined above and towards the nose, the conjunctival flap inverted, a
looped stitch passed through the conjunctiva and skin to hold the for-
mer in place. The denuded ocular area was again covered with rab-
bit's conjunctiva, the gap in the lid margin denuded, brought together
with a suture, and reinforced with an adhesive strip. But, even with
this precaution, tension was so great that the stitch again cut out on
the fourth day, leaving a shallow gap in the lid, which nearly filled
in during the healing of the other sutures. Dressings were the same
as after the former operation and the result was all that could be de-
sired. A superior cul-de-sac, a quarter of an inch in length, was ob-
tained throughout, with a healthy looking conjunctiva over the site
of the tumor. Secretion was no more marked than after enucleation
at the same stage; the swelling of surrounding tissues was subsiding;
and the upper lid was becoming pliable and drawing into position.
Patient was discharged from the hospital March i6th with instruc-
tions to flush the eye twice a day with boric acid solution, and to pass
a probe under the upper lid daily, to prevent adhesions, should they
tend to form.

The child was not seen again until March 31st, when a very satis-
factory state of affairs existed. The swelling of the lid was subsid-
ing, and it was becoming quite pliable ; the scars were less perceptible ;
the gap in the lid left by the tearing out of the lower stitch had nearly
filled in, so as to be only noticeable, not objectionable; the mucous
membrane appeared glossy and healthy, but was still secreting exces-
sively. The superior cul-de-sac was sufficiently deep to allow the inser-
tion of an artificial eye after it had been ground down to one-eighth
of an inch above the upper corneal margin, and to a considerable ex-
tent in other directions. Instructions were given to insert this arti-
ficial eye twice daily, leaving it in place for one hour at a time, and to
gradually increase the time until it could be left in all day.

On April 21st the mother reported that the eye had been left in all
day, after the first few days; that the secretion was much less when
this was done ; and that it in no way seemed to irritate the parts or to
annoy the child. Photograph No. 2, taken at this time, does not accu-
rately represent the condition at the present time, as the photographer
attempted to improve the work of the camera by removing the wart
from the left upper lid.

Fully twenty negatives were taken to obtain this result, as it is

166 GEORGE A. SUFFA, M.D.

next to impossible to keep the child quiet sufficiently long for even a
snap shot, making his effort to beautify the child even more repre-
hensible, a subsequent sitting failing entirely.

The following report was received from Dr. S. C. Fuller, who pre-
pared and mounted a large number of slides :

"The growth received for examination was 20 mm. long, 6 mm.
wide, and 5 mm. thick. Microscopically its external surface is rough
to the touch, and while not distinctly hard, suggests a warty growth.
(This latter condition may have been due to the fact that the tissue
had been partially hardened in formalin.)

"Microscopically the external surface is covered with epithelium
which suggests the papillary layer of true skin and which in all prob-
ability it is — except that the epithelium is more luxuriant in its growth
and the papillae more villous in character. The stratified epithelia
which overlie the papillae in true skin are absent in this case. There
is no invasion of the underlying tissue by the epithelium which is
apparently proliferative in an outward direction except at the external
angle of the growth where there is evidence of invasion of the under-
lying tissue ; and what appears to be a beginning epithelial degenera-
tion. Beneath the papillae the connective tissue is in parts infiltrated
with leucocytes which suggest inflammatory areas. Here and there
may be seen alveolar tissue in some cases containing fat. The alveolar
tissue does not constitute a distinct layer, but lies in the midst of mus-
cular fibres which together with other connective tissue make up the
most of the growth. Throughout the connective tissue relatively large
blood-vessels are quite thickly interspersed. Here and there in the
outermost end about 4 mm. from external end of growth small gland-
ular structures may be seen. No mucous membrane was observed.
The portion of the cornea examined gave no evidence of inflammation.
In fact it was normal."

From this report and from the history of the case it seems reason-
able to assume that the growth was an accumulation of embryonic tis-
sue belonging to the ectoderm and the mesoderm, or in other words
there was an utter lack of differentiation of these layers in this region,
with excessive development. What caused the departure from the
normal would be an interesting study for the embryologist, but it would
hardly be proper to discuss that point in this paper.

Microscopic section through the ciliary body proved it to be normal,
and as the other intra-ocular structures appeared normal, microscopic-
ally it can be assumed that the abnormality involved the extra-ocular

PLATE 4

Vertical section through lids, eye, tumor, and orbital structure.

Dotted lines, ^, outlines of tumor. Continuous lines, B, lids; Q cornea; D,
optic nerve ; £, superior orbital wall ; F, inferior orbital wall. Shaded per
tion, H, spicula of bone before removal; I, after removal; iC, bony forma-
tion at apex of orbit.

r*s2.

Dotted lines. A, indicate original position of lid edges after removal of tiiinor;
B, skin ^^ft; interrupted line, C, incision through conjunctiva in superior
and inferior cul-de-sacs ; F, wart at outer can thus. Continuous line, D, present
position of lid margins; E, temporal incision. Connected {portion of dotted
line, H, at outer canthus, where lid was split to give coniunctiva to form
outer port of superior cul-de-sac. Crosses, position of stitches.

AN UNUSUAL TUMOR OF THE EYE. 167

tissues only. Although much could be said of the cranial irregularities,
I will dismiss the subject by stating that the child does not show any
signs of idiocy but is merely very backward in talking ; but as the child
is of the female persuasion this need cause no anxiety.

DISCUSSION.

Dr. Helfrich: The Doctor has presented a very unusual and in-
structive case. Unfortunately, however, the nature of the growth is
such that a dear description of it in a paper is very difficult, and on
the surface hardly shows the amotmt of care the Doctor has taken in
Its preparation. Fortunately, the photographs which you will see as
they are passed around, very thoroughly show the good results follow-
ing the operation. To make four operations, removing the growth
and supplying a new lid lined with conjunctiva, is a result the Doctor
certainly should be proud of. It is instructive also, inasmuch as the
conjunctival grafts from the rabbit were unusually large and thick, and
therefore less liable to thrive. Those of us who have had any experi-
ence in plastic operations will appreciate some of the difficulties the
Doctor had to overcome and did overcome so successfully. It is mar-
vellous that he succeeded in doing all this without the formation of any
symblepharon or anchyloblepharon. To criticise any certain plastic
operation is like making a good homoeopathic prescription: you must
see and individualize the case ; and not having seen the case, we can-
not very well criticize the methods adopted in securing the result he did.

Personally, I do not think it is advisable to perform Mule's opera-
tion. These cases heal very satisfactorily, but after a time the sclera
is apt to slough, and the glass ball come out, thus defeating the object
sought for.

RATIONAL TREATMENT OF "HAY-FEVER."
By Pierre Colon Moriarty, M.D., O. et A. Chir.,

Omaha, Neb.

THE name "Hay Fever" is a misnomer and its use is excusable
only on the ground that, through common usage, it conveys
the impression of a given condition. The name suggested
by Bishop is acceptable and the only available proper one : — ^"Nervous
Catarrh."

The history and varying theories of etiology and pathology of this
distressing fashionable ailment are well known to the profession, as is
also the fact that the consensus of opinion declares the condition to be
a neurosis.

Dr. S. S. Bishop's excellent little work on the Ear, Nose and Throat
presents the best essay on nervous catarrh which I have seen, and to
this writer we are indebted for the valuable suggestion of the relation
of uricacidaemia to nervous catarrh. While admitting with Dr. Bishop
that many cases of nervous catarrh have been cured by the removal of
spurs from a nasal sptum, hypertrophies, etc., still I agree with him
that the preponderance of evidence points to uricacidaemia as the un-
derlying cause in by far the majority of the cases, and is usually to be
found to some extent in all cases. Where we have local points of irri-
tation, their obliteration must generally be accompanied by treatment
directed to the uric acid diathesis as well. On the other hand, cases
treated constitutionally only (where local interference has been posi-
tively objected to) have been materially modified in spite of the local
condition. The rational treatment assumes not only the removal of the
main, but any and all contributing and exciting causes.

Under aetiology I would place first, uricacidaemia resulting in a
h)rperaesthetic state of the sympathetic nervous system ; and a neurotic
temperament. In many cases it is possible to trace back in the in-
dividual, and often in the family history, the uric acid diathesis as
manifested in a long train of rheumatic and gouty affections and not
infrequently choreic phenomena. This latter condition is becoming
recognized as a manifestation of a rheumatic diathesis, some authors
now claiming that such a source is demonstrable in over fifty per cent,
of the cases of chorea.

RA TIONAL TREA TMENT OF '*HA Y^FEVER." 169

Next in importance in aetiology I would place as contributing causes
the local lesions, such as h3rpertrophies of the middle and inferior
turbinals; spurs, especially when in contact with turbinals; hyperaes-
thetic areas; polypi; in importance in the order named.

Lastly the exciting causes are to be found extraneously in dust of
any kind, though the pollen of plants, especially the wild weeds, takes
first rank as an excitant. An immediate exciting cause is to be noted in
the vaso-motor disturbance from the use of ice-cold food or drink. I
have noted several instances of the immediate precipitation of an at-
tack after indulgence in ices, etc.

General directions to sufferers from nervous catarrh, such as
insistence upon an out-door life, freedom from mental strain, and
change of climate at onset of attack, are indeed good and valuable sug-
gestions, but decidedly impracticable in a great majority of our cases,
A treatment offering amelioration of suffering, without temporary
change of residence, is the treatment sought by the business man and
by many who, though participating in the gaieties of a reputed fash-
ionable malady, are still too poor in time as well as purse to avail them-
selves of the relief offered by the more expensive remedy of prolonged
vacations.

Dr. Jonathan Wright* while crediting Bishop's argument with
much force, still thinks it too early to judge of the merits of the theory
of uricacidaemia being causative in nervous catarrh.

The treatment which I am about to outline is the result of an ac-
ceptance of Bishop's theory after careful investigation, and what is
still more encouraging, practical application.

The results have been by far better than under any form of treat-
ment hitherto in use, and though not entirely satisfactory in all cases,
I have felt justified in casting the blame for failures, in most instances,
upon the patients themselves, owing to their refusal to accept in full
the rigid rules laid down. In some cases not materially benefited we
will learn that some point of contributing irritation has evaded our
search and complete relief will not be had until such point be discovered
and remedied.

The treatment according to the theory of uricacidaemia as the prime
cause, will in my opinion and experience practically cure a majority
of the cases and materially ameliorate all ; add to this a radical treat-
ment for all discoverable or probable contributing causes and the re-
sults are gratifying.

^American Text-book, Eye, Ear and Throat

170 PIERRE COLON MORIARTY, M.D., O. et A. CHIR.

In merely suggesting an anti-uric acid treatment in addition to the
local treatment, I do not feel that I would be fairly presenting the rea-
sons for my confidence in results, and therefore ask that you permit a
little reference to detail, especially as to specific anti-acid treatment in
these cases, the value of which has been fully demonstrated.

In no instance do we see more gratifying results of detailed and
faithful observation of the minutest directions, or more discouraging
and lamentable failures by ignoring of same, than in nervous catarrh;
and my first suggestion to a patient is the absolute necessity to implicitly
follow all directions.

To such as will assure us of a willingness to observe these rules, we
are almost justified in promising practical immunity.

When possible it is best to examine patients about three months
prior to usual date of onset. Get a full history, individual and family,
for guidance in individualizing treatment. Any probable contribu-
ting causes such as hypertrophies, spurs, sensitive areas, etc., should be
attended to at once and in some cases local use of sprays, etc., may be
used with benefit. In other words, prepare to have the seat of local
manifestation in as nearly normal a state as possible before the onset
of the s)rmptoms which mask so eflfectually underlying conditions.

Dieting is best begun at same time, gradually becoming more rig^d
as date of expected onset approaches. Taking for example a case un-
der favorable conditions : During the first six weeks I order a rather
liberal anti-acid diet, but with a material increase in use of water, and in
general avoiding sugars, fats, starches, fermented liquors, sweet wines
and malted drinks.

The patient's task really begins after this, as for the next four weeks
they are allowed no meats except white meat of chicken and occasion-
ally a mutton chop. Vegetables, mostly of the fresh g^een varieties, no
peas, beans, com or beets, and potatoes during this period are to be
eaten not more than twice a week and then only if thoroughly baked.
Farinaceous and bread stuffs in very small quantities. Of fruits the
acid varieties only. If patients desire wines, the light sour wines are
permissible. Fish and eggs at all times, properly cooked. It seems
hardly necessary to say that fried food is absolutely to be avoided, as
are made dishes, fresh bread, pastry, etc. Most foods must be warm;
none ice-cold. No iced drinks except lithia waters, and then only be-
tween meals. Ice cream and ices positively prohibited.

Dating two weeks prior to expected attack food is reduced to eggs
and milk only, with occasional toasted bread and acid fruits. Eggs

RA TIONAL TRRA TMENT OF ^'HA Y-FEVERr 171

may be served in any form, except fried. This limited diet is continued
throughout period of usual attack and made less stringent only after
first indications of frost, which always relieve local manifestations.
Then for a few weeks diet gradually becomes more liberal until re-
strictions are entirely removed. Patients fear that they will become
thin as shadows under such diet rules, but I have yet to see a single in-
stance of a person losing materially in flesh or strength, and in many
cases they feel decidedly stronger and even gain in weight.

A rather liberal experience has been productive of preferences with
me for certain waters, etc., and these I mention merely as being my
favorites: Sparkling Londonderry Lithia has been very satisfactory
as a general water. I depend mainly, however, upon Alkalithia, which
has a prompt and efficient action and is one of the best effervescent
salts I know of or tablets of tartarlithine, used in the morning in hot
water, the balance of the day in drinking water; the charged water
being used ad libitum. However, do not fail to have your patients
drink a great deal of water, at least two quarts during twenty-four
hours. To meet the inevitable temptation to join in a glass of soda, a
good root beer sour, with a little acid phosphate added, is permissible, or
sour lemonade. Another useful adjunct to the general treatment is a
thorough sweating, either by bath cabinet at home or in public baths,
once a week.

In the majority of cases where patients live up to the rules the at-
tack does not come, but if it does, immediately order a tablespoonful
of Horsford's acid phosphate taken at bed time in abdut six or eight
otmces of water to be continued nightly during attack. During at-
tack patient is to have local treatment daily ; my routine being a thor-
ough cleansing of the nares and naso-pharynx with a solution of benzo-
lyptus or similar antiseptic washes, and then carefully drying with cot-
ton, the application of a little carbolic acid, or iodine solution, followed
by a thorough spraying with campho-menthol in oil. The use of
cocaine must be avoided absolutely, as the slight temporary relief af-
forded is quickly followed by a reactionary congestion which is far
worse than original condition. The cleansing treatment, furthermore,
gives more marked immediate relief than cocaine and is lasting, even
being of benefit in cases that have not had the advantages of preliminary
treatment and diet.

In the beginning of preliminary treatment I have found Psorinum
and Lycopodium more frequently indicated than any other remedies,
and during the attack Mercurius corr,, Arsenicum and Euphrasia,

172 PIERRE COLON MORI ARTY, M.D., O. et A. CHIR.

The necessity for absolute observance of directions on all lines must
be insisted upon, and though much of it may seem to be drawing the
lines unusually stiff, you will note that every specified rule has its ma-
terial bearing upon the starting point of uricacidsemia. During the
first year it is indeed difficult to secure in full the cooperation of the
patient, but they approach the second year's task with a confidence
which is encouraging and willingness to comply with rules in full.

A dozen cases treated under full observance of these rules by pa-
tient and physician alike, will demonstrate that uricacidsemia is the
prime factor for consideration in the treatment of nervous catarrh.

DISCUSSION.

Dr. W. E. Deuel: I have read Dr. Moriarty's paper with much
interest and I hope with profit, because we are all interested in that
popular disease "hay-fever." I like the old name the best.

Dr. Moriarty refers to Dr. Bishop's theory of uricacidaemia as the
principal cause of this periodic distressing disease. I read Dr. Bish-
op's papers at the time they were published and always recall it when
I have a new patient (which is frequently in central New York), but
I am unable to accept the theory as fully as Dr. Moriarty does. There
may be no doubt about its being what might be called an auxiliary pre-
disposing cause, but I cannot accept it as the principal cause. The
main objections to the uricacidaemia theory is the periodicity of the
disease. If this theory is correct, how can this periodicity be accounted
for? Why is it that it appears each year with the regularity of time,
on the same day and you might almost say the same hour. Why is
it that one patient will be attacked in June, another in July, and an-
other in August or September, and continue for a definite time, many
times regardless of treatment or no treatment? Why will an August
or September catarrh persist until there is a good frost, in spite of all
efforts to subdue it? Why will a change of location be it near or
far many times control the whole train of symptoms?

I have one patient that if he would live about three miles from his
present home during the summer would never have an attack. When
he is taken if he will go to this place, a sulphur spring, he will be re-
lieved in twenty-four hours, only to be again afflicted if he returns
home.

It would seem to me that if this theory of Dr. Bishop's is correct
and that uric acid is so important a factor, why is there such a period-
icity in the diseases? Why do we not have it at other times of the
year besides three or four months in summer? Why not in winter?
Certainly people have uricacidaemia in winter as in summer, and do
they not have more in the former season. Since Murchinsen first gave
us the uric acid diathesis and the latter was more fully demonstrated

JiA TIONAL TREA TMENT OF • 'HA Y-FE VER^ 178

by the experiments of Hay, it has been assigned as the causes for many
diseases, hay-fever being the last.

I have not been able to accept the theory of Dr. Moriarty, and I
have brought these questions forward to open the discussion, that I
and possibly others may be enlightened.

I am still a believer in the old original pollen theory. I may be a
back number but I cannot make the conditions I see every year recon-
cile with any other theory, why one person has hay-fever and his wife
does not I cannot always tell any more than I can tell why one person
in a family has typhoid fever and the others do not under the same
condition. If I say personal idiosyncrasy I again expose my ignorance.
There may be many auxiliary causes, as constitutional conditions,
nasal spurs, and hypertrophy and sensitive sections in the nose, which
predispose one to an attack, or be good soil on which the poison of the
pollen may develop. As to the name, I do not seen why hay-fever is
not as good and intelligent as nervous catarrh. It certainly designates
the time of year when you can expect the disease and certainly there
is much fever during the attack. The former may not be as scientific
as the latter but as surely indicates the form of disease.

As for treatment that is as varied as are the subjects. I have used
most every remedy in the materia medica. At one time I would get
brilliant results, but the next year the same remedy would have no
effect.

Dr. Moriarty's preliminary treatment is very excellent but it is
difficult to get patients to continue it any given time. In fact there
have been so many failures that many people have given up trying to
get any relief, except by change of location. As people of the leisure
class are more afflicted than workmen, they can enjoy the remedy as it
is easy to take.

The intensity of the disease varies each year. Last year we heard
of many brilliant cures. This year it may be all failures. This I have
noticed many times. I have had best results from Naphthalin 3X
of any single remedy — Aresenicum alb, Cepa. Arum try. Euphasin
and, many others are good remedies. For local spray, I have relied on
hydrochlorate of quinia i to 100, and menthol combined with borolyp-
tol. Of course I have done such surgical work as I thought necessary
before giving remedies.

Dr. Moffat: In several cases my patients have obtained marked
relief from erythroxylon coca in one or other of its preparations — "ex-
tract," fluid extract, chewing the leaves, or "maltine with coca wine."

Dr. Shearer: I have been experimenting lately with a solution of
supra-renal capsule as a local application in cases of rose cold. One
may prepare the solution by adding ten grains of the desiccated suprar
renal capsule to one ounce of distilled water, shaking it well and filter-
ing. The preparation is then sprayed into the nostrils night and
morning, affording great relief from the constant flow of watery
mucus and the frequent use of the handkerchief. It is necessary to
prepare the solution freshly every third day, as at the end of that time.

174 PIERRE COLON MORI ARTY, M.D., O. et A. CHIR.

it becomes turbid and putrescent changes occur, rendering it unfit for
use. Various agents such as alcohol, boric acid, etc., have been added
as preservatives, but they irritate the nasal mucosa too much. The
results obtained were excellent and no doubt the solution would work
just as well in hay fever. No deleterious local or constitutional effects
were observed.

Dr. Palmer: Dr. Shearer having spoken of a solution of supra-
renal capsule, I recall that I saw about three weeks ago a short article
by Dr. Lederman of New York, in which he said he had made several
experiments and found a way to keep the supra-renal solution, that is by
dissolving it in a 25 per cent, solution of glycerine and distilled water.
He said he had tried different ways of using corrosive sublimate and
carbolic acid, and he had been unable to retain the good effects of the
supra-renal capsule until he had made this solution with the glycerine.
My experience has been that I can keep a solution of this kind for a
littie over two weeks.

While on this subject, I will mention that I obtained relief in six
cases of hay fever last summer from the insufflation of orthoform used
in a 50 per cent, mixture with lycopodium powder, which gave relief
for anywhere from 36 to 72 hours. I see in the journals now and
then the terms "orthoform old" and "orthoform new ;" and, apparently,
the action of new orthoform does not last as long as the old.

As to this uric acid theory: I have lately read a book on the uric
acid diatheses, in which the Doctor noticed, I think, that there were
only two drugs that caused uric acid in the body from poisoning.
Those are phosphorus and plumbum. I think if we, as homoeopaths,
bear this in mind, we might be able to work out some symptomatology,
or it might direct our minds to those two drugs in these cases of uric
acid condition affecting the nose. I have had some cases in which
relief has been secured, though it has not been long enough to make any
report on.

Question: Have you used formaline?

Dr. Palmer: Yes, I have used formaline, but not with satisfaction.
About all the anti-acids that could be used were tried, but failed.

Dr. Moriarty : The paper mentions only my general diet. In indi-
vidualizing it is sometimes necessary to give a boiled meat and hot
water diet, etc., in accordance with specific individual requirements.
These other forms of diet are not frequently called for and so have
given details only of most general. I have had no experience with the
supra-renal solution but could see where it might be of service. The
thorough cleansing, with drying of membrane has been very satisfac-
tory even in cases where preliminary diet rules had not been inaug-
urated.

EYE-STRAIN AS A CAUSE OF DISEASE.
By Frank D. W. Bates, M.D.,

Hamilton, Ontario.

WE are all familiar with the various discomforts of the eyes,
headache, etc., arising from errors of the refraction and
insufficiencies of the ocular muscles; but a question of
great importance to us at the present time is, — ^are these anomalies
capable of producing disease in organs remote from the eyes? From
my own observation during the past four years, I am firmly convinced
that such is the case.

I have no new theories of my own to bring forward in this paper,
but only wish to present this subject for discussion, that we may have
the benefit of each other's views.

Some four years ago I ran across a little book written by a certain
Chicago physician, in which the author claimed to have cured various
cases of consumption, diabetes, insanity, etc., by performing tenoto-
mies for various forms of beterophoria. His reasoning seemed very
plausible to me, and I determined to look into the matter and see
whether there was anything in it or not. The first case I looked into
was that of a case of diabetes, which he claimed to have cured, and
which had previously been under the care of a reputable physician of
Brantford, Ont., for four years, without result. I wrote to the physi-
cian mentioned, (whom I knew to be of good standing) and received
a lengthy reply from him, affirming that it was a true case of diabetes
mellitus; that he had been under his care for four years without re-
sult, and that after the operations upon his eyes, he had made a com-
plete recovery, and was at the present time (a year or so after the
operations) apparently in perfect health, there being no evidence of
diabetes remaining. This physician became very much interested in
the theory, and wished me if I made any further experiments in that
line to let him know the results. I also wrote to several others upon
whom he claimed to have operated successfully, and received confirma-
tory replies from all of them. I then determined to experiment a little
for myself.

Case One. — The first case that came under my care was one of dia-
betes of nine years' standing in a prominent allopathic physician of our

176 FRANK D. IV. BA TES, M.D.

city. I first saw him on the 22nd of March, 1896. He was in bed,
and never expected to be about again. The physicians in attendance
said he could not live three months. I let him read the little book re-
ferred to, and he being favorably impressed with it, asked me to un-
dertake the treatment of his case on those lines. On examining his
eyes, I found left hyperphoria, and put on prismatic glasses, as much
as he could overcome, divided between the two eyes, and his condition
immediately improved. Within a few days he was able to be out of
bed and to go downstairs. The specific gravity of urine, which had
been from 1036 to 1040, went down below 1030, and the quantity di-
minished. Within a few days he was able to go out of doors, and con-
tinued to improve, gaining somewhat in flesh (though he was very
much emaciated). During the summer months he remained fairly
well, being able to attend somewhat to his office practice until Septem-
ber, when as the result of a long drive which tired him very much, he
was compelled to take to his bed, from which he never rose again, —
more than to sit up for a few moments at a time, — although he lived
until the following June, — ^fifteen months from the time I first saw
him.

I should have said that symptoms of tuberculosis had set up in this
case before I saw him, which increased after he finally took to his bed.
I was not permitted to operate upon his eyes, as the physicians who at-
tended him, assured him there was nothing in the theory. For a day or
two before death he saw double, objects appearing one above the other,
and on examining his eyes after death, I found one, (the left) turned
fully 10° above the other.

Since then I have treated four cases of diabetes in persons aged re-
spectively 52, 40, 31 and 10 years of age. The first of the four has
hyperphoria, and the other three had exophoria. On the first I was
not permitted to operate, as the friends were all opposed to it, but from
the use of prismatic glasses which she has worn for nearly two years,
she has very much improved, so that from not being able to do her own
work at all, she is now, and has been during all the time I have treated
her, able to attend to her household duties. She cannot go long with-
out her glasses, without the symptoms becoming aggravated.

Case Two. — ^The case of the little girl of 10 years, was a very bad
one. I first saw her in August last. Her physician (one of the most
prominent in the city of Hamilton) had said to the parents a few weeks
previously, that she could only live for a few months, that there was
no use in giving her medicine as there was absolutely no hope for her.
He regulated her diet, and told them to make her as comfortable as pos-
sible while she lived. She was quite tall for her age, but slight, —
weighing something over sixty pounds, and had been losing weight for
some weeks. The specific gravity of urine had ranged from 1046 to

EYE-STRAIN AS A CAUSE OF DISEASE. 177

■

1052 ever since they first discovered her trouble. Her mother kept a
urinometer and tested it night and morning. On examining her eyes,
I found marked exophoria. She could overcome 20 degrees of prism,
base in, on first trial, which was soon increased to 30®. I performed a
full tenotomy on the external rectus of the O. D. — ^told them to let her
have plenty of fresh air, all the exercise she could take short of be-
coming tired, and to give her a liberal diet. In addition to this, I put on
prismatic glasses as strong as she would take, base in, which was about
10** at first, and gradually increased strength as she would take it, up to
20®. After the first few days, she commenced to improve. The
specific gravity of urine gradually went down until, at four months
after the first operation, it ranged from 1030® up to 1034**. She gained
in weight, up to 70 lbs., looked better, had more color in her face,
which had at first been very pale, and felt better in every way, and the
acetone which was very strong at first, had entirely disappeared from
her breath. About four weeks ago, I operated upon the other external
rectus, — ^making a full tenotomy as before, — with the result of showing
about I** of esophoria immediately after the operation. After she had
recovered from the effects of operation, I paralyzed the accommodation
and prescribed for a compound h3^eropic astigmatism of -|-5o
D.3«+75 ^-C- ^^^s 90 O.U. the correcting glasses which she is wear-
ing now. Upon last examination all tests, including Maddox rod,
phorometer, and tropometer, showed muscles perfectly balanced. The
specific gravity now rarely reaches 1030 and she is feeling better and
stronger than at any time before, — ^being able to take long walks and
join in the plays of other children without becoming tired, neither of
which she could have done six months ago. I have every reason for
believing that this girl is going to make a complete recovery.

The other two cases of diabetes I have operated upon were both
supposed to be hopeless cases, one being pronounced so by a great
English specialist in London. Symptoms of tuberculosis had ap-
peared in his case, — ^tubercle bacilli being found in the sputa ; but since
operation I have learned by letter that the cough has entirely disap-
peared, — ^though the diabetes still remains. Patient is in England now,
and is still wearing glasses I prescribed for him. I hear from him oc-
casionally, indirectly, but have not much hope of his recovery, though
he has lived longer now than it was supposed he would live when I
first saw him. The other case is also one of long standing (13 years)
and far advanced, though her symptoms have improved since opera-
tion. I cannot say what the result will be.

Now as to the plausibility of diabetes being caused by eye-strain.
We cannot fmd an article written on diabetes, within the last thirty
or forty years, that does not mention various asthenopic and accom-
modative troubles of the eyes, resulting from the disease. Is it not pos-

178

FRANK D. W. BATES, M.D.

sible that during all these years, we have been "putting the cart be-
fore the horse" and that the eye troubles, instead of being the result of
the disease, have been the cause of it? I have failed to examine a case
of diabetes since my attention was called to the matter, in which there
has not been either marked exophoria or hjrperphoria.

We all know that irritation of the floor of the fourth ventrical of
the brain, artificially produced, will cause sugar to appear in the urine.
We know that all the nerves supplying the muscles and acconmioda-
tion of the eyes arise in, or near, the floor of the fourth ventrical ; and
also that the pneumogastric nerve arises in the floor of the same. Now,
if irritation of the floor of the fourth ventrical, artificially produced,
will cause sugar to appear in the urine immediately, why will not irri-
tation produced by continuous strain upon the muscles of the eyes pro-
duce diabetes ? Or, why will not the irritation produced by continuous
strain upon the eyes cause disease of other organs of the body, — of the
heart, lungs, stomach, liver, bowels, ovaries, etc., by the irritation being
communicated to the nerve centers controlling these organs, ac-
cording to their susceptibility by hereditary predisposition, — ^the nerve
centers of all these organs being clustered around the base of the brain?
or, putting it in another way, would not the extra amount of nerve
force required to overcome strain upon the eyes, be taken from the nerve
force required for other organs of the body, thereby in time undermin-
ing the system to such an exten(t as to render the person more suscepti-
ble to the various germs of disease?

Case Three. — One of the first cases that came under my care in this
line, was that of a case of phthisis pulmonalis in a girl of i8 years of
age. Some ten years previously, a brother of this girl had died of the
same at the age of i6. I knew of the case at the time, and wondered
why he should have phthisis, as the father and mother were robust,
healthy Scotch people, the rest of the children, (of whom there were
eight or ten) were apparently perfectly healthy, and they could not
trace consumption on either side of the house. This girl had been to
several physicians who had pronounced it consumption, said that one
lung was entirely gone, and that she would probably not live more than
three months.

I examined the case, and found her in the following condition. She
was small in size, being 4 ft. 11 in. in height, had run down in weight
from 113 to 78 lbs., had had profuse night sweats for months, coughed
and expectorated a great deal, apparently did all her breathing with
the right lung — ^the left side of chest not expanding at all, — ^breathing
at the rate of sixty respirations per minute, with pulse at 120. She was
very weak and ate very little, and the least exercise tired her out I

EYE-STRAIN AS A CA USE OF DISEASE. 179

•

asked her if her eyes troubled her, and she said they did not. She read
considerably, with very little discomfort except an occasional head-
ache. The vision was *y,o ^^ ^sich eye, with a slight astigmatism.
Upon examining the muscles by the covering test, when the left eye
was covered and she looked at a given point with the right eye, the left
eye remained in line, but when the right was covered and she looked
with the left, the right eye turned up fully fifteen degrees. I put on
prismatic glasses of fifteen degrees, dividing it between the two eyes,
base down before the right, and up before the left eye, and told her to
report in two days.

She returned the third day with a marvellous change in her condi-
tion. Her night sweats had entirely stopped, she was breathing at the
rate of 26 respirations to the minute, instead of 60, and taking ap-
parently as much air into the left lung, which was supposed to be gone,
as into the right one, was feeling better and stronger in every way, and
appetite had increased. I had her continue with the same glasses and
report every few days. Things went on in the same way for about six
weeks, — ^night sweats did not return. She gained in flesh, so that at
the end of six weeks her weight was 82 lbs., — ^a gain of four lbs. Still
her cough continued about the same. I knew that something more
was to be done, but did not know exactly what to do. I examined the
eyes again, and found some esophoria. Having no combination prisms
I took off the prisms up and down, and put on prisms with the base out,
telling her to report again in two days. Did not see an)rthing more of
her for two weeks, then met the sister on the street and asked her how
Janet was. She said "Oh ; poor Janet is done for, I guess." I think
she must have caught cold the last time she was up town, for when
she went home she had to go right to bed. The cough came back as
bad as ever, the night sweats returned, her legs became swollen, and
poor girl, we think she will never get up again." I asked why they did
not let me know before, and she said they had thought it was no use.
A pair of glasses was a pair of glasses to them, and they saw no dif-
ference between the glasses she had been wearing and those she was
wearing then. I told them she had probably not taken cold at all, but
that it was probably the change in glasses, that had caused the change
in her condition. I told her to send those glasses back, and that I
would send her another pair. The next morning by first train, the
glasses came back, and I sent her the same glasses she had had at first,
with the result that in two days she called at my office again, as well
as before, night sweats gone, cough diminished, swelling gone from
her legs, and feeling as well as before the change in glasses.

This patient lived for thirteen months after I first saw her. I was
not permitted to operate upon the eyes, as kind friends had said to the
family that I would ruin her eyes, and the family physician had as-
sured them that there was nothing in the theory, and that the fact of
her being better after wearing the glasses was merely a coincidence.

IW FRANK D. W. BA TES, M.D.

and due to the fine weather and the medicine he had given her. But
I am strongly inclined to believe that had I operated upon that superior
rectus muscle, the final result might have been diflFerent. Another sis-
ter in the family is now showing sjrmptoms of consumption, and I ex-
pect to have her under my care before long. The mother has assured
me that if the S3rmptoms develop, I may operate upon her eyes if I think
best to do so. I know that she has muscular trouble, as I discovered
the same when prescribing glasses for her some two years ago.

Case Foxur. — Another case on which I operated successfully was that
of an unmarried lady of 29 years. She had been running down in
health for some six years. Had been examined by several physicians,
but none of them had been able to diagnose her case, said there was
no organic trouble discoverable, but a tendency to ovarian trouble.
One physician had suggested a removal of the ovaries, if she did not
improve before long. Six years previous to the time, I saw her, she
had been a robust, healthy girl, weighing 145 lbs. from which she had
gradually run down to 107 lbs. could do no woric about the house
without being used up, could not walk any distance or go out to spend
an evening without being used up for several days thereafter; in fact
was practically an invalid. Her bowels were constipated, she had con-
siderable pain in the back, and a tenderness in the ovarian regions,
which at first was during her menstrual periods, but latterly sdl the
time. Upon examination of the eyes, I found marked exophoria, so
much so, that within a few days she could overcome 25** of prism,
base in, and wear glasses of that degree with comfort. I performed a
full tenotomy of one external rectus, showing slight esophoria imme-
diately after the operation, which disappeared within a few days.
She commenced to improve immediately after the operation, — among
the first evidences being a relief of the constipation and tenderness in
the ovarian region; within three months after the operation, she had
increased in weight to 123 lbs. was able to take long walks, and do
work about the house without becoming tired ; wrote me that she felt
better than she had for six years, though still had some pain in her
back. Her father, who is a clergyman, called at my office about this
time, and thanked me for what I had done for his daughter, saying
that no medicine she had ever taken for her trouble had done more than
give her temporary relief. Last month she came down and spent four
weeks in the city under my care, and I performed a partial tenotomy on
the other external rectus. Have not heard the result of last operation.

I have performed several other similar operations during the past
year with more or less beneficial results, and have interviewed a num-
ber of persons who have been operated upon by Dr. George T. Stevens
of New York, and others, where the results have been very brilliant,
but have not time to enter into details now, as my time is limited, and

EYESTRAIN AS A CA USE OF DISEASE. 181

this paper is already longer than I intended it to be. But I may men-
tion in reference to the claim made by Drs. Stevens and Ranney of New
York, tfiat a large percentage of insanity is caused by strain upon the
eyes, that during the past year I have examined after death the eyes
of all the inmates who have died at a certain large insane asylum in our
city, where there are from 800 to 1000 inmates, and have failed to ex-
amine a single case where the eyes have been in line, though they had
been perfectly straight during life. In the majority of cases, the eyes
have been turned outward, in others one above the other, but never
convergent. I have also examined the eyes in several cases of suicide,
and have found them out of alignment. Some may say that the eyes
are often out of alignment after death. Even so ; if the muscles were
well-balanced they would not be so, and we cannot say that the ex-
penditure of nerve force required to keep them in line during life, was
not the cause of the person's death. Dr. Ranney in his book, very
aptly likens the expenditure of nerve force to a child being bom into
the world with a capital of $100,000, saying that if he does not encroach
upon the capital more than at the rate of $1000 a year, he will live to
be 100 years old before he will become bankrupt. But if he en-
croaches upon the capital at the rate of 5000 a year, before he reaches
his majority bankruptcy will be staring him in the face.

Drs. Hansell and Reber, in their book, take exception to the claims
of Drs. Stevens and Ranney, that a large percentage of various dis-
eases are due wholly to eye strain, saying that the theory is dangerous
and unsound. But facts are stubborn things; and if in a large per-
centage of said diseases, the patients have been cured by relieving the
eye-strain after medical treatment has failed to cure them, it seems evi-
dent that the relief of eye-strain has removed the cause of the dis-
ease. I am not one of the "Tenotomy Enthusiasts'* mentioned by Drs.
Hansell and Reber. I know there is a tendency in all specialties to
exaggerate anything in their line as being a cause of general disturb-
ance to the system, and this of course must be guarded against; but at
the same time, we know that the eyes do more work than any other
organ of the body. When we sit down our body is at rest ; but the eyes
are continually at work from the time we open them in the morning
until we close them at night, — and we have reason for believing that
latent muscular troubles are at work even when we are asleep. If
the refraction is at fault, or the muscles unbalanced, it must require an
extra amount of nerve force to overcome the same; and where an extra
amount of nerve force is required in any direction continuously, it

in FRANK D. H^. BA T£S, M.D.

must in time undermine the S3rstem so as to make the person more sob^
ceptible to disease. Now, in closing I wish to suggest an experiment
in reference to the insane. If the eyes are out of alignment after death,
why would they not be so during life under the full influence of anxs-^
thesia? I am going to try the experiment the first opportunity that
offers. There are two cases I have in view now, of persons who have
been in an insane asylum for several years, and are supposed to be
hopeless cases. If I am permitted to do so, as I think I shall be, I in*
tend to put them under the full influence of anaesthesia, and if I find
the eyes out of alignment, operate upon the muscles until I get them
as nearly in line as possible. I hope to be able to do this before the
meeting of O. & O. Society in June, and if so, will report the result.

DISCUSSION.

Dr. Norton: I hardly know what to say in regard to this paper.
It certainly has opened a field to us that is probably new to the majority,
as it certainly is to me. The results he has secured seem somewhat
miraculous to those who have not worked in this field ; and it certainly
is a subject that seems to me worthy of careful thought and investiga-
tion by the members of this Society. While I am not prepared to go
on and endorse the theory that we can cure diabetes, phthisis, and every-
thing else under the sun by operating the muscles of the eyes, or cor-
recting them with prisms — ^at the same time, I believe there is a possi-
bility that the eyes may have a great deal to do with it. I do not be-
lieve there is any one in the room working in the eye line, but has seen
a great many interesting and peculiar results from the correction of
muscular deviations or correction of astigmia. I have myself noticed
a number of cases of epilepsy where the attacks have certainly ceased
after the use of proper glasses correcting the muscular trouble and the
astigmia as well. I have seen a number of cases — I say a number —
perhaps a half dozen women at different times, who, after putting on
proper glasses, had several months later told me that since wearing the
glasses, they had been entirely relieved from menorrhagia from which
they had suffered for several years, and for which they had had all
kinds of treatment; and that while wearing the glasses they had not had
treatment of any kind. Whether these things are coincidences, or
whether it is due to correction of the nervous loss, I cannot say. My
opinion is that the nerve strain from the errors of the eye was the cause,
and after their correction they have been relieved. I recall one case of
a gentleman who had been examined by such eminent men as Spitzka
and Seguin at least ten years ago, and told that he was going to be con-
fined in an asylum in six months. That case was referred for exami-
nation. I found but a slight shade of astigmia, but proper glasses were
prescribed, not anticipating that the eyes had anything to do with hit

EYE-STRAIN AS A CA USE OF DISEASE. Ill

mental condition. The man is now well and able to do his work as
banker and broker, and has never had any of his old symptoms tend*
ing toward insanity since wearing the glasses. I could
go on and mention innumerable cases of reflex disturbances that havt
certainly disappeared after the correction of eye-strain, and I am not
prepared to say we cannot go on in this same line and expect results
in these more serious conditions. Who can say that long continued
strain upon the nervous system from any cause may not &ially result
in organic diseases that could be obviated and relieved by proper cof»
rection of the cause? I have not been an enthusiast upon the cutting
method of treating these cases. I have done my share of it, perhaps, in
the earlier years, but I now believe better results are had from correct-
ing it with prisms, either in systematic exercising of the muscles, or by
wearing prisms together with the glasses for refractive error; and I
do not see the necessity of going on to so much operative work. Dr.
Bates records one or two cases that he was not permitted to operate.
I do not understand why he should want to operate when he was able
to correct the trouble with prisms. If we can bring the eyes to ortho-
phoria by a prism glass, I do not see why we are not getting just as
good results and can expect to receive the same benefit as when cor*
recting the trouble by an operation. It has been a very interesting sub«>
ject to me, and if I get an opportunity with any of those diseases (which
I probably shall not) I shall try to follow out some of Dr. Bates' princi-
ples and see whether there is anything in it.

Dr. James : I have seen frequently these deviations pass away under
the wearing of a glass that would correct a very small amount of
astigmia. It is so in nervous temperaments, especially in young ladies
at a period when they are extremely nervous, where the correction of
a very small amount will soon relieve all the nervous ssrmptoms, and
thus you cure the case and the beginning of muscular deviation will
pass away, as I have seen time and again under a small error of re-
fraction which one can easily correct. Not only that, but I think we
must not only give the correction by glasses, but for the reflex symptoms
present (and many of them are very persistent after they begin,) we
must not forget our homoeopathic remedy. I have seen S3miptoms pass
away under the action of properly selected remedies, especially those
acting particularly upon the nervous system and brain — ^the more deli-
cate nerves of the eye and the ciliary regions. I have seen quick action
from some remedies in clearing up all the balance of the symptoms
that do not pass away under a proper correction of the refraction.

Dr. Moffat : It is an old story that the slighter degrees of astigmia
or heterophoria are more prolific of reflex disturbances. If Dr. Bates
had carefully re-examined his patient at the time the latter grew worse
he would possibly have afforded further relief by a change in the
prisms. Prismatic glasses should be but a temporary expedient to be
carefully watched and frequently changed. Their curative effect de-
pends upon bringing the visual axis so near the macula lutea that the
proper extrinsic muscles make the two coincide in the effort for

184 FRANK D. W. BA TES, M.D.

monocular vision. Otherwise the prism only confirms the distortion
of the eye.

Eye-strain may well be a contributing factor in the causation or per-
petuation of diabetes. The successful tenotomies are mainly in cases
of malformation. It is ridiculous to cure a weak muscle by weakening
its opponent. We should never operate without first thoroughly meas-
uring each muscle's strength and correcting any error of refraction.

Dr. Thomas : I have to confess to a feeling of skepticism with re-
gard to this subject. In diabetes, we have as we all know, to deal with
a disease that is extremely variable in its course; its natural history
shows it as such, and it is therefore difficult to say how much these
cases are really influenced by the various measures Uiat have been pro-
posed for their relief.

I happen to recall an extreme case of diabetes in which apparently
^ suggestion had a most beneficial influence. This gentleman, who
was confined to his bed hopelessly ill with this disease was told of a
similar case cured by eating molasses candy.

He immediately invested largely in the remedy, and was soon most
remarkably improved. With reference to epilepsy, I feel very much
the same. I doubt whether true epilepsy has been cured by the ad-
justment of either the refraction or muscular errors — though "con-
vulsive attacks" may have. There is certainly a difference between
epileptiform seizures and true epilepsy — ^but the resemblance is often so
close as to lead to error.

As I understand it true epilepsy is usually a very slow disease, be-
ginning with widely separated convulsions, and complete loss of con-
sciousness; the patient feeling perfectly well in the intervals. While
in convulsions from reflex causes, there is almost always a constantly
existing impairment in health in some direction or other, depending on
the seat of the reflex; frequent attacks, and commonly but partial loss
of consciousness.

Such cases have been relieved or cured by the greatest variety of
measures, both mechanical and otherwise, depending, again, upon the
seat of irritation, and it is my opinion that it is to this class of cases
that the so-called cures of "epilepsy" by treatment of ocular errors be-
long.

Dr. Anderson : I, too, with Dr. Thomas was a doubting one some
time ago. My attention was called in this direction shortly after or
about the time Dr. Bates was, and I can confirm very much of what
he said in regard to his experience in curing such nervous troubles, by
the operations upon the recti muscles. As one lady said to me, as I
explained the matter to her, "Well, Doctor, that is too good to be true,
— ^that a person can be relieved of diabetes and these other troubles by
relief of the eye muscles." I have operated several times along the
lines of Dr. Bates' paper, and I must confess with most uniformly satis-
factory results. One case of a young man that came to Toronto from
Chicagfo, who was broken down in health from asthma with fainting,
and dizzy attacks, so that he would fall down at his desk in the bank

EYE-STRAIN AS A CAUSE OF DISEASE. 186

in Chicago, where he held a very responsible position. He had to leave
his business and come to his friends in the city where I live. He
would have these attacks periodically. Then he would have so much
congestion, apparently, of the brain, that for hours the only relief he
could get would be from ice applications to his head. He had one of
the best preseribers in our school prescribe for him with no practical
result. He had tried the old school physicians also, and they came to
the conclusion that he had a tumor of the brain, causing brain pres-
sure somewhere. Some one suggested that perhaps he might have
some trouble with the eyes ; and he went to a specialist who examined
them and said they were all right. He went on with these distressing
symptoms rather increasing, until he was subject to attacks in the
street. He had to catch hold of a building, fence, or tree or some-
tliing to keep from falling, not being able to work at all. Finally he
came to me. I examined the eyes, and found he had about ij/^ diop-
ters of hyperopia and apparent esophoria. I found that it was a case
of reverse strain of the internal recti muscles, and by testing with the
various appliances I found that he had really exophoria. In a few
days he was able to overcome a prism of about 30 degrees, with the
base in, and, as I turned his eyes out, his symptoms began to be re-
lieved. As the result of the treatment along those lines, he entirely
recovered from all his untoward symptoms, and is apparently a well
boy to-day, a result due entirely, I am sure, to the treatment of his eyes.
Another case that was very interesting to me and which turned out with
very satifactory results, was a lady with chronic eczema. This may
seem entirely foreign to this trouble, but her physician thinking, per-
haps, it came from defective assimilation — some digestive trouble pro-
ducing a uric acid condition (and we know that this condition often
produces eczematous conditions) she was sent to me. This lady also
had gone the rounds of the schools and had had everything done for
her, both abroad and at home. I found a very similar condition to the
above mentioned case, viz., very marked exophoria. I explained to her
and her friends, and her physician, that I would not say that the re-
lief of these muscles would cure the eczema ; but I did not believe that
with that manifest nerve strain, she would get well without it. I
tenotomized the external rectus muscles of the right eye. She came
to see me about three weeks ago, and I found her almost entirely well.
Dr. Hasbrouck : I am hardly prepared to believe all that Dr. Bates
has stated. Personally, I know that diabetic cases are very erratic.
At the present time I have under my care a patient with exudative
iritis who has suffered with diabetes for twenty-five years. She has
had a diabetic coma time and time again, and when I saw her first her
family physician thought that she would not live the week out. At my
first visit the anterior chamber was muddy, and the iris bound down.
It was utterly impossible to get a retinal reflex. She could hardly
tell daylight from darkness. I saw her again yesterday morning; that
is, five days after my first visit. The pupil was nicely dilated, and we
could get a good retinal reflex, and she could distinguish objects in the

im FRANK D^ W. BATES, MJ>.

room. Inside of two or three dajrs from the time of my first visit
physically she wan ready to get up and do her house work she said.
Time and time again, in the last twenty-five years, she has had such
severe attacks that everybody has given her up. She has had Doctors
from New York, Boston, Geneva, and London, and all at the time of
her severe attacks said she could not live any length of time; but she
is still alive and active after twenty-five years of diabetes.

In speaking of nervous cases, we all have seen and have cured diese
where there was a low degree of astigmatism, or hyperphoria, by the
use of glasses.

I have had one case that insisted that he had eye trouble, even^
though Doctors in Boston, New York, and even Stevens said he didl
not have any eye trouble; but he insisted that all his nervous symp*
toms came from his eyes ; and he finally got a pair of absolutely plain
glasses which he has been wearing, to my knowledge, for eig^t years;,
and, so far, he has been able to do his work and has not lost a day..
Whereas, previous to this time, for three years he was laid up witih
headaches, and had to give up his work two or three times a week, and
would have lost his position if his father had not been one of the di-
rectors in the bank. He was a bank clerk, too, and to-day he is wear-
ing absolutely plain glasses. I saw him within three or four months
time and he wanted to know if it was not time for him to have presby-
opic glasses. I told him no, because the plain glasses had cured him
and kept him well for eight years : whereas,, all the oculists and opticians
in the country had not succeeded in finding any eye trouble. I also re-
member well, some ten years ago, a man came to my office, after hav-
ing consulted two or three other physicians in our city, suffering with
the worst kind of hysterical nervous symptoms: he would fall down
in the streets and be carried home in the express wagon, or the ambu-
lance would be sent for him. This meant all kinds of hyperphoria, eso*
phoria and various other things from different doctors, and each had
been corrected by prisms. I don't know whether anybody ever operated
on his eyes or not. I corrected his astigmatism and hyperphoria with-
out result. He went to Boston where Dr. Derby put him in his private
hospital, and told him he had a severe form of treatment to give him.
He was put in a dark room and told he could not leave until he went
through a systematic treatment. The doctor blistered his eyelids and
he said he was no better and begged to home, but the Doctor said "No,
you can't go : I have got to leave this on. The only way is to apply it
three different times." At the end of the second process of blister-
ing he left the hospital, and that man has continued to do his work for
the past ten years without wearing glasses. It was a case of hysteria
and was cured when he gets a good blistering; or, in other words, a
first class spanking was the only thing needed.

Dr. Philips : I do not believe we have any subject of more interest
than this. There has been opened by the writer of the paper a very
strong point, and that is this : It has been found that the irritation of
certain parts of the brain produces certain results in different parts of

EYESTRAIN AS A CAUSE OF DISEASE. 187

the body. As the writer says, if that be true, and an irritation here oc-
curs from some other cause, why not the same result? It is a point
that is a very strong one. In regard to diabetes, I do not know but
all may be true that he has said. My experience in that line has been
limited to one case. The error of refraction had not been corrected
until I saw him. He had no further trouble in that regard: but it
made no difference whatever as regards die s]rmptoms of the disease,
and he subsequently died. It would not seem to be reasonable to ex-
pect any great modification of the symptoms from relieving the eye-
strain after the disease had become well established, as it was in this

Dr. Bates: Regarding the matter of diabetes I would say to all
these ''doubting Thomases" and skeptics that I meet a great many of
the same in Hamilton. A certain allopathic physician said last week
to a patient of mine that ''a man who would think of curing a case of
diabetes by operating upon the eyes must be a fool." At the same time
I believe that the theory is right; and shall continue to believe it until
convinced to the contrary. The very ones who oppose the theory can-
not and will not even attempt to tell us what is the cause of the dis-
ease. Why should we throw aside without investigation, the most
plausible theory as to its cause that has ever been brought forward?
I expect to see a number of cases of diabetes during the next year, and
shall do my best to ascertain the correctness or incorrectness of the
theory. I trust that every one belonging to this society will do the
same, for it certainly is a matter of great importance to all of us.

STRABISMUS: CAUSES OF AND METHODS OF TESTING

FOR.

By William R. King, M.D.,

Washington, D. C

IN the division of the general subject of strabismus, I opine that I
have been assigned the portion most easily disposed of and yet
the most difficult one upon which to present any original thoughts
regarding it.

I have not I believe discovered any new causes for this trouble-
some ocular defect, neither have I devised any new methods to be used
in testing for strabismus. This paper then will be largely a brief review
of the subject, designed to refresh in your minds the important require-
ment preliminary to undertaking the treatment of a case of strabismus;
namely, the proper diagnosis of each individual case.

Strabismus, or squinting, is described as an inability to bring the
visual axes of both eyes to bear simultaneously on one point, the axis
of vision of one eye always deviating in a certain direction from the
object. (Foster.)

As to causes, before considering these, it may be well to speak
briefly of some of the more important varieties.

Convergent strabismus is the variety in which one eye deviates in-
ward toward the nose, so that its visual axis when prolonged crosses
that of the other eye in front of the point of fixation.

Divergent strabismus, in which one eye deviates outward toward the
temple, so tliat the optic axes never meet.

Strabismus deorsum vergens, in which the squinting eye turns down-
ward below the point of fixation of the other eye.

Strabismus sursum vergens, in which the squinting eye turns up-
ward beyond the point of fixation of the other eye.

These forms are again divided into numerous other varieties and
which are designated according to character and cause.

Concomitant strabismus is that in which the movements of the
squinting eye accompany those of the normal one. When the affected
eye is used for fixation the associated deviation of the eye generally used
for fixation is equal to the usual deviation of the squinting eye.

Unilateral strabismus is that in which the transfer of the squmt from

STRABISMUS: CA USES OF. 1«9

one eye to the otlier never occurs spontaneously, but is induced by
covering the eye ordinanly used in fixation.

Paralytic strabismus is due to paralysis of an ocular muscle. It is
distinguished from the concomitant form by the fact that the deviation
occurs only when the eye is turned in the direction in which the para-
lyzed muscle would normally turn the eye, and that this deviation in-
stead of being constant, increases more and more as the eyes are turned
in this direction; later on it is increased by spastic contracture of the
antagonist of the paralyzed muscle.

Dynamic strabismus is a tendency to convergence or divergence
which under ordinary circumstances is overcome in the interest of
binocular single vision, but which can be detected by the use of ver-
tically refracting prisms. This practically describes a condition of so-
called heterophoria.

There have been described a number of other forms of strabismus,
such as apparent, intermittent, spastic periodic, etc., but the above de-
scribed divisions will suffice for the objects of this paper.

The causes then of strabismus may in a general way be stated as,
(i) The weakness of some one of the extraneous ocular muscles, (2)
Paralysis of one of these muscles, (3) A faulty insertion, or (4) the
result of an over action of one of the ocular muscles. Apparent strabis--
mus is not considered in this class as the muscles are not at fault but the
cause lies in a retinal incongruence.

Nerve energy for the ocular muscles we must remember, is furnished
as follows. The internal, superior and inferior recti, also the inferior
oblique as well as the levator palpebrse and the sphincter pupillae and
the ciliary muscles derive their innervation from the oculo-motor nerve.
The external rectus is supplied by the abducens and the superior ob-
lique by the trochlear nerve. All three of these nerves originate at a
point on the floor of the fourth ventrical ; the oculo-motor in front, the
trochlear just behind it and the abducens, quite well back.

The muscles are divided into pairs which have an antagonistic action
to one another during their contraction. The internal and external recti
rotate the eyeball in different directions around an imaginary vertical
axis.

The superior and inferior recti rotate the eyeball around a horizontal
or frontal axis. The superior and inferior oblique muscles rotate the
ball around the so-called sagittal axis, (antero-posterior).

The internal and external muscles are the only ones which are per-
fect antagonists. The superior and inferior recti, owing to the general

1» WILUAM R. KING, M^D^

direction taken by the muscle in its course from the apex of the orbit to
its insertion tend to slightly adduct the eye.

The oblique muscles owing to the point of their insertion being pos-
terior to the axis of rotation, tend to slightly abduct the eye by draw-
ing the posterior segment inward, thus rotating the cornea outward
a trifle. These facts should always be considered in testing, especially
for es- or exophoria.

It must of course be remembered that in the normal state the eyes
exhibit a perfect muscular equilibrium. This state of perfect equi*
libritun is the result of the varying amount of innervation or nerve
force given to each muscle in proper proportion one to the other.

A normal muscular equilibrium is necessary to accomplish normal
binocular vision. It may be said by way of reminder that the ability to
see singly with both eyes directed toward an object, does not of neces-
sity indicate binocular single vision. In this latter state the patient
fixes correctly with both eyes, and the impression of the object seen is
made upon identical points on the retinae. Single vision is also present
when one of the two eyes fails to see, either being blind or it suppresses
the received impression; this is actually monocular vision.

To differentiate, we direct the patient to gaze steadily at an object,
a lighted candle some metres distant. If it be seen that one of the
eyes is somewhat deviated, binocular single vision is not possible. If
single vision does not exist, however, it must be that one eye is am-
blyopic, or that the image is suppressed in the deviating eye.

Frequently manifest deviation cannot be demonstrated on inspection*
In this case we test for binocular single vision as follows. While the
patient watches a given point intently we cover one eye and then the
other. If normal position is maintained after covering we have prob-
able binocular vision. Supposing, however, the right eye deviates out-
ward when the object is fixed by the left eye; should we now cover the
right eye the left would remain immovable in the act of fixation, whilst
if we cover the left one the right will be seen to move inward to a posi-
tion of fixation by a motion of adduction. This movement of adjust-
ment is still visible when it is impossible to demonstrate any devia-
tion by ordinary inspection. Another practical test to determine
whether single vision is due to a normal fusion of the images or to the
fact that but one eye sees this g^ven object through suppression or
neglect, is as follows. A prism, base downward, is held before one of
the eyes. If there was binocular vision before, two images would now
be seen situate one above the other. If, however, there still remains

STRABISMUS: CAUSES OF. IM

singk vision it can only be $o because the image in csie eye is suppressed

or neglected.

Binocular single vision presupposes also solid or stereoscopic vision.
Thus we may test with stereoscopic pictures, special varieties having
been made for this purpose.

We have binocular double vision then when one of the two eyes
leaves the correct position of fixation. This is most frequently due to
disturbances in the muscular apparatus such as contractures, relaxation
cr paralysis of some of the ocular muscles. The eye, however, may be
forced out of its normal position mechanically by means of pressure
from orbital tumors or localized extravasations. Double vision is also
found where the excursions of one eye are limited as compared with
those of the other by external mechanical obstacles, as symblepharon
or by pterygium.

Double images interfere with vision and are abhcrent to the eyes,
thus every one tries to avoid them. This is done by an effort to bring
the eyes by suitable muscular effort into such proper position that the
images coalesce. This function of the eyes is termed the tendency to
fusion.

In a case where the right eye is covered, an object fixed and the
oover then removed displaying an inward movement of this eye it indi-
cates that tlic external rectus muscle is the more powerful and while
with both eyes opened the internal rectus was able to overcome the
tendency to deviation to prevent the abhorent diplopia, it is accom-
plished only by an extra mnervation of the fibres of the internal muscle
to oppose the preponderance of the external. This disturbance of equi-
librium of the ocular muscles constitutes what is known as insufficiency^
This may occur in any direction according to the muscle most involved.
When still existing in a degree wherein diplopia can be prevented by
extra effort of the relaxed muscle, we have no true strabismus, but what
kas been turned heterophoria, or latent or dynamic squint.

High degrees of insufficiency often pass into strabismus proper.
The impulse for the transformation of this latent strabismus into the
manifest form is often furnished by the fact that in one of the eyes the
visual power is reduced so that binocular vision is of less use or may
be actually abolished. For this reason blind eyes are often found to
deviate more or less in some one direction.

In paralysis of an ocular muscle the movements of the eye toward
the side corresponding to the paralyzed muscle are diminished or ab-
rogated. If the external rectus of the right eye is paralyzed completely

192 WILLIAM R.KING, M.D.

that eye can be brought only to the median line and not beyond it to the
right

When paralysis is of less degree the motor disturbance is of course
less marked but according to the same mechanical rule.

The result of this limitation of motility is a lagging behind of the
eye when an associated movement is initiated within the sphere of
action of the paralyzed muscle. This squinting takes place only when
the eye is turned in the direction of the sphere of action of the affected
muscle and is more pronounced the farther the eye is moved toward
this side ; but in all other directions in which the paralyzed muscle does
not have to act the eyes stand in their proper relation. By this fact
paralytic squint is distinguished from ordinary or concomitant squint,
which is present in all directions in which the eye is turned and always
in the same degree.

In strabismus concomitants we have true squint, and the simplest
method for testing and measuring the same as follows. The patient
is made to fix his gaze upon a given object placed in the median line
between the two eyes, several meters distant. Suppose the left eye
fixes the object properly while the right eye squints or deviates inward.
We may now mark by an ink dot upon the border of the lower lid the
position of the external margin of the cornea in both eyes. We next
cover the left eye which has been fixing the object with a screen, telling
the patient to find the object again. To do so he must use the right
eye for fixation, and this brings it into correct position by a distinctly
visible movement of redress. We again mark the position of the outer
margin of the cornea of this eye by an ink dot upon the edge of lower
lid; the distance between the first and second dot gives the linear
measure for the deviation of the squinting eye; this is the primary stra-
bismic deviation.

As the right eye is being brought into position of fixation the left
eye moves inward behind the screen and is now In a position of second'
ary deviation. While in this new position the location of the outer
margin of the cornea of this eye is marked by an ink dot and the dis-
tance between the first and second dot gives the magnitude of the sec-
ondary deviation. In this instance the primary and secondary deviation
are equal whilst in paralytic squint the secondary deviation is always
greater than the primary.

In the beginning of strabismus there is present more or less diplopia ;
this soon disappears and afterwards can only be evoked by all sorts of
artifices or frequently cannot be evoked at all.

STRABISMUS: CAUSES OF. 193

In paralytic strabismus the diplopia remains a very annoying symp-;
torn.

A patient with concomitant squint fails to see double because he
learns to suppress the impression conveyed by the squinting eye. This
act of exclusion is a physical one as the squinting eye really does see but
the visual impressions set up by it are suppressed involuntarily. As a
result of this the patient has monocular vision; he does not therefore
have stereoscopic sight in the proper sense of the word.

The visual acuity of the squinting eye is of course diminished. In
fact the function was most likely enfeebled before the eye squinted and
this enfeeblement is frequently the primary cause of the squinting.
The visual acuity lessens more and more with the length of time the
strabismus exists until we have a complete amblyopia exanopsia ex-
isting. Such an eye has lost or forgotten its ability to perform fixation
and there is no motion toward iixatioa of the object when the sound
eye is covered.

When the same eye squints at all times we have monolateral strabis-
mus. When the two eyes squint alternately it is termed alternate stra-
bismus. In the latter class of cases it is usual that one eye fixes for
distant objects while the other fixes for near points. One eye always
fixes, it never happens that both squint at once. Occasionally we find
squinting occurring only at intervals or it may be present at all times;
thus we have periodic and constant strabismus.

Strabismus develops from insufficiency and is really insufficiency
or latent strabismus become manifest. This transformation of an in-
sufficiency into a strabismus is effected by such circumstances as re-
duce the desire for binocular single vision; that is such as render
diplopia less annoying, as for instance, any reduction of the visual
acuity in the affected eye. Thus we see a patient who has all along had
an insufficiency become strabismic when corneal opacities are left as a
result of a keratitis in one eye.

The most frequent causes of strabismus through loss of visual acuity
are: (i) Errors of refraction present in one eye alone, or to a higher
degree in the affected eye, in conjunction with tl:is error there fre-
quently exists a congenital amblyopia. (2) Opacities in the refracting
media, especially the cornea and lens. (3) Intra-ocular diseases, as
choroiditis, retinitis, etc.

Strabismus is therefore the result of two general factors, diminu-
tion of visual power of one of the eyes and a pre-existing disturbance
of the muscular equilibrium. According as the latter factor consists

194 WILLIAM R. KING, M.£K

of a preponderance in the internal or the external rectus muscle^ a con-
vergent or a divergent squint is produced.

Convergent strabismus occurs especially in hypermetrope^. Bon-
ders was the first to claim this and explains as follows, briefly, hypef^
metropes are forced to a strong effort of accommodation to see dis-
tinctly and as the relation existing between accommodation and con*
vergence is so intimate that the contraction of the convergent muscle
accompanying efforts at accommodation produces a preponderance of
contraction upon the internal rectus muscle. This preponderance of
the internal muscles of the eyes develops into a strabismus; if one of
the eyes from the time of birth has a more feeble vision than the other,
as for instance, on account of higher degree of h3^rmetropia or hyper-
opic astigmatism, or if through subsequent disease the visual power
is impaired. Convergent strabismus usually develops between the age
of two and six. Usually it is first noticed only when fixing for near
objects (periodic squint). This may remain the case but usually it
develops into a constant squint.

Very rarely it occurs that children with strabismus gradually cease
squinting as they grow older, and lose their strabismus about the age of
puberty. Thus they "out grow" their squint. The eye, however,
which has squinted never regains normal vision; thus accurate binocular
vision is never restored.

In divergent-strabismus myopia plays the part of a causative factor
instead of hypermetropia. The myope in viewing near objects uses
little or no accommodation, thus the reflex impulse for convergence is
too weak ; there is functional insufficiency of the intemi. To this are
added mechanical impediments, which interfere with convergence as for
instance the elongated eyeball of myopia.

As young children are never myopic, divergent strabismus does not
form until later on, during youth when myopia itself develops. As the
myopia increases the accommodative strain and with it the impulse for
convergence steadily decrease while the demands made upon con-
vergence increase in proportion owing to the approximation of the
near point. Ultimately the weakened power of convergence must
fail to answer the extraordinary demands made upon it and
we have a consequent divergence of one of the eyes. A spott*
taneous cure such as is sometimes seen in convergent squint never
occurs in the divergent variety ; on the contrary it will usually increase
with age.

I sincerely hope that this brief review of this subject will serve its

STRABISMUS: CA USES OF. !•»

tmdoubted purpose and refresh the minds of those present as a preface
to more original work in the line of treatment of this quite prevalent
affection.

DISCUSSION.

Dr. H. I. Jessup : After Dr. King's very thorough paper it seems
superfluous to make any further remarks regarding the causes of
strabismus and the method of testing for it.

A discussion of a paper as I understand it, has for its object tlie
bringing out from the different men present their individual opinions.
I will therefore venture to give mine on the above subject, preceding
them however by the statement that I know myself to be very fallible
and will be glad to be set right by the rest of you, whenever I have
formed any wrong conclusions.

In all that has been said by Dr. King on insufficiency (heterophoria)
as a cause I agree most heartily and would like to add to the factors
which may correct an insufficiency into a strabismus; the wearing
of a bandage over one eye for a number of days. I have seen this
occur twice in Dr. Thomas's clinic — ^both times in children who were
being treated for corneal ulcers. In both cases a convergent strabismus
developed which only subsided after the discontinuance of the bandage
and the atropia. There are cases on record of permanent strabismus
being developed in this way. Here of course the only possible explana-
tion was esophoria which became a manifest squint through the eye
being turned in so long under the bandage, i. e., excluded from use for
days. I believe we must also add as a factor in such cases the poor
vision from paralysis of the accommodation. In speaking of apparent
strabismus, Dr. King refers to it as a retinal incongruence. With this
view I cannot agree, as I consider the apparent convergence or di-
vergence to be due to a change in the size of the angle A. (the angle
bound by the optic axis and the visual axis) produced by the length
of the eyeball. Thus in H. the angle A. is larger than in E. and in higher
degrees of H. we will appear to have a divergent squint. The cause
of this occurs in some cases of myopia.

Regarding the measurement of the degree of squint, I have found it
very convenient in cases in which diplopia existed, to find what degree
of prism would produce fusion. If no diplopia exists I have found the
perimeter and a lighted candle to be the most accurate method for de-
termining the amount of deviation from the normal. I would have liked
very much to hear from Dr. King what has been his individual ex-
perience regarding the causes of paralytic strabismus and I hope in
the following discussion that this point will not be forgotten. In my
work in this line syphilis has certainly been at the bottom of the paraly-
sis in a large majority of the cases. In every case that I can remember
excepting one, it has been intracranial syphilis. In the one exception
it was probably a gumma of the orbit. I have seen but 3 or 4 cases
of paralytic strabismus due to catching cold (the so-called rheumatic)

196 WILLIAM R. KING. M.D.

but have seen several following injuries upon the head, principally upon
the vertex and in the mastoid region. Upon the subject of concomitant
strabismus the Doctor has left me nothing to say, unless I strain a point
and bring in the subject of paradoxical diplopia, i. e., a crossed diplopia*
with a convergent strabismus and an homonymous diplopia with diver-
gent strabismus.

This condition I have come across several times and each time I
have applied all the tests I could to deceive the patient, thinking it might
be malingering. In every case however the answers were correct and
consistent so that I am convinced of its genuineness and forced to
accept the explanation of the formation of a new macula. May we
not hope to hear of the experience of others in the same line?

Dr. Bates: About two months ago I was called to see a case of
paralytic strabismus in a man about sixty years of age. About three
months previously he had been knocked down by a bicycle, and struck
on the left side of his head. Was picked up unconscious and carried to
his home; but recovered after a few days so as to be able to attend
to business. Two months later was taken with lagrippe, and had been
confined to the house up to the time I saw him. For some days he had
suffered considerable pain in the left orbit, the left eye was turned in,
and he was quite dizzy most of the time. A counsel of physicians had
decided that there was some brain trouble (I did not learn what) and
gave an unfavorable prognosis. I was called in to examine tlie eye;
and concluded that it was the result of the accident (though three
months previous) and due to fracture of the apex of petrous portion of
temporal bone; with effusion producing pressure upon abducens nerve
and Gasserian ganglian. On covering the left eye with a pad the ver-
tigo disappeared. He recovered gradually, and is now attending to
business, his eyes being perfectly straight.

Dr. King: I am gratified that Dr. Jessup was able to make such
able remarks upon my paper. It is hard to discuss papers which are
practically based upon known facts, indeed proven facts — ^at least many
of them for a good many years. As to the suggestion he makes with
reference to my experience in paralytic squints, I must confess to have
had very little experience. In the few cases I have had, as compared
with the concomitant form, the cause has been, in most instances,
directly or indirectly traceable to a blow or shock to the cranium, as
has been suggested in the case just reported by Dr. Bates. I recall
particularly one instance of a young sailor lad in the late war, who fell
down a hatchway and injured his head very seriously. From the results
of that injury complete blindness has ensued, and he is a pensioner now
on account of it. An acute concussion with a scalp wound had been
the result of the fall. There was no fracture, and he was sick only a
short time. Very soon, however, a strabismus developed, markedly
paralytic in character. His history dates back too long for me to have
personal knowledge of it, but was handed down by the naval records of
that time. I found there was glaucomatous degeneration with com«d
degeneration and the man is totally blind. Suggestion of Dr. Jessup

STRABISMUS: CAUSES OK 197

that syphilis is an important factor in the production of this condition
is true. Intra-cranial syphilitic lesions would, when properly located,
unquestionably produce these conditions, and frequently do. In fact,
ether intra-cranial lesions other than specific, are undoubtedly at the
bottom of true paral3rtic squint. The cause must emanate somewhere
between the base of the brain and the distribution of the nerves in the
ocular muscles.

THE OPTICAL AND ORTHOPTIC TREATMENT OF STRA-
BISMUS.

By Walter Strong, M.D.,

Philadelphia, Pa.

THE subject of strabismus is certainly a most important one for
this society to consider, it being one of the mooted points in
ophthalmology. Even a most casual glance over our text-
books and journals will serve to verify the truth of this statement, for
here we will discover that a wide diversity of opinion exists upon this
subject. We will also note that this difference of opinion is not limited
to any particular portion of the disease, but embraces strabismus from
beginning to end. In fact it appears to the writer to be one of the least
understood subjects in the entire domain of ophthalmology.

Under such circumstances it is not at all strange that I should hesi-
tate about accepting the responsibility of presenting to this learned body
a paper upon so important a subject as the non-operative treatment of
strabismus. But my objections were all brushed aside by our Presi-
dent who informed me that all he desired was my experience with, and
views upon the non-operative method of treating this disease.

In this brief paper it is not my intention to occupy your valuable
time with any lengthy resume of this subject. I am not going to bur-
den you with the theories and opinions of others, but rather to give
you my own personal experience with the treatment of strabismus.
This I do with the sincere hope that my methods may materially differ
from those employed by some of the other members present and thus
lead to a thorough discussion of this most important subject

My first awakening to the possibilities and advantages offered by
the non-operative methods of treating strabismus occurred about ten
years ago while visiting the various European eye clinics. Here I was
forcibly impressed with the fact that while they operated less frequently
than we at home, they secured results which were superior to ours. So
impressed was I with this fact that after further observations I returned
home firmly determined to give those methods an impartial trial in my
own private and hospital practice.

Having been firmly wedded to the prevailing practice of that period,
of operating upon nearly every case of strabismus, I did not take kindly

TREATMENT OF STRABISMUS. 10»

to this innovation, I was both skeptical and impatient. But having
seen the results in the hands of others I felt certain that the sought for
results must be accomplished, and they have been, with results which
were satisfactory to both myself and patients. So after a lengthy trial
in quite a number of cases I am firmly convinced that we operate far
too frequently in strabismus, and that the non-operative treatment has
a much wider sphere of usefulness than is usually conceded it.

The most important factor in the successful treatment of strabismus
is a careful correction of the refractive error. It has been said that
we are all practically agreed upon this question (Priestly Smith in
Bowman lecture), but I seriously doubt the correctness of the state-
ment. Many oculists are not even theoretically agreed upon this point,
and hundreds absolutely neglect to carry it into their actual daily prac-
tice in a thorough and proper manner.

Correcting lenses are only valuable when scrupulously correct, con-
sequently a cycloplegic is absolutely essential in every case. Under the
influence of some such agent, preferably atropin, we determine the exact
state of the refraction, being especially careful in our examination not
to overlook any low defect or slight degree of astigmatism. In young
children and in amblyopic eyes this examination is best carried out by
means of the ophthalmometer and retinoscopy. As the result of such
an examination we prescribe for constant use those lenses which will
most thoroughly correct the full refractive error.

In the vast majority of these cases a refractive error is present and
in my opinion plays a very important part in the etiology of the disease
and unless fully and carefully corrected we cannot expect to successfully
reestablish binocular vision. Unfortunately a great many oculists are
content to consider their work finished when these correcting glasses
are ordered, and should there be no improvement in the strabismus
after a few weeks' trial immediately resort to operative interference,
unconscious of the fact that they have not given the non-operative
methods a thorough trial.

Correcting lenses having been secured, it is of the utmost importance
that they be frequently changed and the adjustment carefully watched,
so that the patient may derive the greatest possible benefit from their
use. The absolutely proper glasses, applied early enough, will often
prevent an operation and permanently cure the squint. By early enough
I mean as soon as the squint manifests itself, which in many cases is
very early in childhood. In such cases we are met by the objections
of the parents, who strenuously oppose us in ordering glasses for such

9pQ WALTj^R STmNC^ M.p.

young childrep, but it is in just 3uch cases wher^ we derive the most
benefit from a correction of the refractive error. Personally I have
Upon more than one occasion prescribed glasses in children as young
as three years with the best of results and with little or no incon-
venience to the child. In fact my experience fully substantiates the
statement of Lang and Barrett, that the effect of this treatment is in
direct ratio to the youth of the patient. Gk)uld recently reports having
employed glasses in children under two years of age, experiencing no
trouble and securing most excellent results.

Another very important step in the successful treatment of strabis-
laus is the prolonged use of some cydoplegic, as atropin, dubosLi. scopo-
lamin, or any other such agent according to the caprice of the surgeon*
This is of the utmost importance in cases of convergent strabismus,
here we are enabled to silence the abnormal stimulus to convergence
always consequent upon the unconscious but unceasing overaction of
the hyperopic ciliary muscle. In such cases I am in the habit of em-
ploying a weak solution of atropin (two grains to the ounce) which is
instilled into the eyes twice a day, and under the influence of such
treatment I have upon more than one occasion seen a permanent cure
pf the squint brought about. It may be employed with or without
correcting lenses, and should always be used in children who are too
young for wearing glasses. In divergent strabismus it may also be
of benefit, for here a very weak solution might have the effect of stimu-
lating the ciliary muscle and incite the adductors to action, and hence
be of service in the early stages.

Under the influence of correcting glasses and the judicious use of
some cycloplegic a very large number of our strabismus cases will be
very much improved, these cases will usually comprise those cases of
convergent strabismus in which there is no amblyopia present. The
results in such cases will as a rule be speedily obtained and permanent,
resulting in a correction of the deviation and the reestablisliment of
binocular vision.

In those cases where amblyopia is present in one eye other methods
of treatment will usually be required in connection with the measures
just referred to. This naturally brings us to a consideration of the
question of amblyopia, a subject which is inseparably connected with
strabismus and one upon which there is a wide diversity of opinion.

In nearly all cases of monocular esotropia amblyopia is present in
the squinting eye, and opinions differ as to whether the amblyopia
is the cause, or result of the strabismus. Much has been written upon

TREATMENT OF STRABISMUS. 20i

this question, so much in fact that I hatdly think it would be either
wise or profitable for us to enter into a discussion of the subject, fot
we would soon find ourselves involved in a mass of theories upon which
we could not possibly agree. Then, too, amblyopia as employed at the
present time is a very indefinite and elastic term, simply signifying in-
di£Ferent or doubtful vision, and unless qualified by an adjective means
very little. So that I think we may v/ith propriety omit the theoretical
portion of the question and pass on to the more practical one, as to how
we may best restore the function of a squinting amblyopic eye.

Perseverance scientifically applied to an amblyopic eye will often
be rewarded by a decided improvement in its vision, and frequently
result in a correction of the squint. Upon this point I have no doubts,
for I have frequently observed it in my own practice, although such
a happy result is only secured after persistent and long continued ef-
forts upon the part of the oculist and patient. Our first step in the
treatment should consist in an accurate correcting of the refractive error,
the full correction being ordered for constant use. Then we instruct
the patient to use the poor eye for reading large print for several
minutes each day, this being accomplished by the use of a shield or
blinder to cover over the good eye, thus gradually bringing the eye
into use. Where the occupation of the patient will permit, a most
satisfactory method is to instil atropin into the good eye, thus com-
pelling the patient to depend upon the amblyopic eye. Under such a
course of treatment there will be a decided improvement in most
amblyopic eyes, and with or even before it there will be a marked im-
provement in the squint. In my experience the use of the blinder in
connection with correcting glasses has given most gratifying results
and cannot be too highly recommended.

The orthoptic treatment of strabismus deserves more than a passing
mention, introduced by Javal in 1871 it received but little attention until
quite recently when it was introduced into practical ophthalmology
and now promises to take a very prominent part in the educative treat-
ment of strabismus. This method is so well known to all of you that I
will not take up your time by a description of it, but simply remind you
that it is useless unless the ametropia has been fully corrected. It re-
quires an intelligent patient with considerable perseverance to properly
conduct this treatment, but well repays the patient for the trouble.

Prisms may also be employed to advantage in the form of a sys-
tematic training of the ocular muscles, a sort of a gymnastic exercising
of the muscles which are deficient in their action. Such a course of

902 WALTER STRONG. M.D.

treatment is most conveniently earned out by means of a prism battery
as devised by Noyes and Gould, but for home use a simpler and less
expensive apparatus is usually desired. In such instances an ordinary
trial frame for prismatic lenses and a couple pairs of prisms answer
the purpose fairly well. Equipped with such the patient is enabled to
carry out exercises according to the oculist's directions, which direc-
tions will of necessity vary with the variety of the squint, but usually
consist of an attempt upon the part of the patient to overcome the
diplopia caused by the prisms in looking at a candle flame held at dif-
ferent distances. Such efforts repeated a couple of times a day will
result in strengthening those muscles which are deficient and thus be
of much assistance in treating some cases.

Regarding the practice of ordering prisms for constant use much
might be said, both for and against. Personally I never order such
lenses unless it be to give temporary relief, and look upon them as being
palliative ratlier than curative. Where a prismatic correction is ordered
for constant use it is usually found necessary to frequently change the
strength of the prisms and each change being to a stronger prism, until
finally we reach a point where they become absolutely useless and our
patient is in a far worse condition than when we commenced treat-
ment.

In conclusion permit me to say that I fully realize that the methods
which I have advocated are not new, but I am also well aware that in
this country at least, the non-operative methods of treating strabismus
are but seldom employed. I am not narrow minded enough to say that
tliis method of treatment is to be used to the exclusion of operations, but
I am firm in the belief that we are often too impatient with our
surgery, especially so in the treatment of strabismus.

DISCUSSION.

Dr. F. Park Lewis: As the writer of this excellent and thought-
ful paper has truly said there are few ophthalmic subjects about which
we have less exact knowledge than of the nature and cause of strabis-
mus. A generation ago, the subject was considered settled when
Donders pointed out the relationship existing between hyperopia and
ocular convergence; but broader knowledge and more careful study
has emphasized the fact that there is still a wide gap to be filled in
when we have recognized that Convergence and the accommodative
effort are mutually co-related.

The studies of Stevens, for example, have shown that muscular im-
balance may exist in high degree and yet be not visibly manifested;

TREA TMENT OF STRABISMUS. 20S

that disparity in strength of the superior ocular muscles may throw
out of balance the external or internal recti; and that there may be a
wide deviation from the normal in these lateral muscles without there
being an ostensible squint; we have learned that the combined action
of fourteen muscles inervated from several centers, is an exceedingly
complicated process — ^and that the analysis of any special problem in
this class of cases is not determined by any permanent set of factors, but
that each case is an individual, one and must be studied by itself. It
is doubtless within the experience of all of us that the most pronounced
instances of eye-strain are not those accompanied by squint but that
on the other hand the exclusion of the one eye from active participation
in binocular vision is a conservative acknowledgment on the part of the
eye that it is unequal to the contest; and the struggle is given up at
the expense of a visible deformity — ^the weaker organ, turning its sen-
sitive and acute point of direct vision to the one side or the other,
bringing in the line of direct fixation a less sensitive point and resting
the nerve centers by this action. If we are taught an3rthing by these
lessons it is that there is at least two distinct elements directly concerned
in this process. The effort of accommodation directly affects the co-
ordinate action of the muscles, and the action of the muscles react upon
each other.

We will premise another point, in which, I think, all will be agreed.
All individuals are not equally affected by an equal amount of eye-
strain. In some, peculiarly predisposed, small refractive errors will
excite marked nervous disturbances ; in others a defect of like kind and
degree will be wholly unnoticed and be in no way inimical to normal
and comfortable use of the eyes, with complete freedom from the small-
est evident sympathetic irritation.

Now especially in those of the first class, indeed in all, if refractive
correction is attempted — ^the focal correction must be exact. Especially
provocative of trouble are those forms of astigmatism in which tlie
meridians of least or greatest curvature are not S3rmmetrical or S3m-
chronous and in which the cylindrical lenses are of unequal value— or
in which together with the cylinder, a spherical lens is required before
one eye and not before the other — or if in both of unequal focal values.
In other words, in order that the eyes may be made to converge upon
the same point — ^they must be made to have exactly equal foci. This
retinoscopy has made possible even in the very young. If this relief
be applied at an early age the effect i^ often surprisingly satisfactory.
This is not always however, possible — a corneal scar may occasion an
incorrigible amblyopia, and in such case — ^the difficulty is greatly in-
creased. But assuming that all accommodative strain has been re-
moved, the condition of the extrinsic muscles, must be as carefully
analysed; As inequalities of the two sides of the bodj are not of un-
frequent occurrence, as one eyeball is occasionally smaller than the
other, it is not unreasonable to believe that in a proportion of cases, be
it greater or smaller like disparity in the position of attachment of the
ocular muscles may exist and in such when it can be demonstrated no

20i tV ALTER STRONG, M.D.

measures other than surgical can be expected to give more than teni-
porary relief.

There is, however, yet a third class of cases — ^and they are by no
means uncommon, and to them, I have as yet seen no reference made by
any authority — ^although they constitute in my judgment, one of the
most important with which we have to do. In these the defect lies in
the co-ordinating nerve centers themselves.

I took occasion, recently to direct attention, to a peculiar conforma-
tion of moutli and jaw accompanying l3rmphoid hypertrophies in the
naso-pharynx, obviously a condition of interrupted or perverted de-
velopment. I have noticed in many cases of convergent squint a co-
incident imperfection of speech— certain sounds are made with diffi-
culty, or not at all. In some, the sibilants cannot be sounded — m others,
the sound of th is pronounced as if it were / so that **tvith** is enun-
ciated as if it were spelled *'wif/*

It has been stated that twenty-four muscles are co-ordinated in
English speech. In the cases to which I refer there are no physical
imperfections which render clear enunciation impossible. This I have
tested in individual cases. Stammering is another phase of the same
peculiar lack of control over muscles that should smoothly work to-
gether or supplementally.

Now while eye-strain may so confound the nerve centers, that they
are unable to send out a distinct and discrete afferent impulse, con-
versely — ^the confusion may have a cerebral initiative and the brain cells
may lack that development that gives them power to co-ordinate mus-
cular activities; and as we discover that some children find difficulty
in catching a ball— or walking on a fence — or speaking plain English;
so they, or others having a like deficient cerebral development are un-
able to converge the eyes at will upon a fixed point; to the student of
pedagogy this fact has value. The co-ordinated centers are nearly
allied in the brain. The association and commissural fibres make it
impossible to develop the cells in one point without also influencing
favorably those with which they are connected. Training, therefore,
valuable as it is in co-ordinating the eye muscles, should be supple-
mented by making other muscular activities co-ordinate in producing a
certain result. Balancing, catching, etc., should supplement prism ex-
ercises, and the result will not alone, produce a harmonious action of the
muscles of the eyes, but as well — and of even greater importance —
that brain balance upon which the whole individual functional activity
depends.

As this is a discussion merely and not a paper — ^this can be only
suggestive, for I have already filled my alloted time ; but I hope some-
time to demonstrate this theory in fuller and more conclusive detail.

. Dr. James : I am very glad that Dr. Lewis spoke of that last point
The action of the brain in these cases through the nerve fibres originat-
ing from the motor area is not enough appreciated. We do not know
that in that way we get certain effects manifesting themselves in these
muscles, and unless we can secure medicinal curative action in the motor

TREATMENT OF STRABISMUS. 2o4

areas we do not cure our case. We may correct the symptoms by the
method which he has suggested and which Dr. Strong has recom-
mended ; that is, by the systematic training of these muscles — ^by mak-
ing a weak muscle gradually increase its power until it comes up in
strength to the other muscle, or until it is able to help co-ordinate these
muscles into harmonious action in both eyes. The system of training,
of course, is left to each individual ophthalmologist. I have found
very excellent effects from the KroU's system of cards. They are now
obtained so cheaply, about $2.00 for a set including the apparatus and
the cards, that after working with a case for a while and showing them
how to use it for a few weeks, I get them to purchase one of these sets.
1 keep these patients on this training for weeks and months, keeping
them reporting to me about once a month, or once in two or three weeks.
J have been rather astonished to see how I could train up the weak
muscles in some of these cases. There are a good many cases I have
examined, where the simple working out of the refraction in its fineness
— working out every available point that one can find in the way of
astigma, or of hyperopia, or any refractive error, corrected the devia-
tion. One cannot always obtain this on the first examination, and, with
a child, if the eye becomes fatigued while under examination, I stop at
once and make the patient come back another day. Let them come
several times, until you have worked out the case thoroughly in all
its refraction defects, and then ^ive them the proper glass. I have
seen many of these cases of deviation straighten by this method, but
not all, however, will work out this way. One or more of the muscles
may be so weakened that you must train it up or else you must give
the remedy that will correct the trouble in the motor area in the brain,
in order that those nerve fibres which supply those muscles may be
stimulated and the muscles balanced.

Dr. Rumsey: I was very much interested in the reading of Dr.
Strong's paper.

I usually use prisms, put in a frame, to strengthen the weak muscle
by looking at a candle at a distance of twenty feet with the prism-
frame one-half minute and then without the frame. There is an al-
ternative contraction and relaxation of the muscle. It is practically a
gymnastic exercise. This exercise is prescribed, on the average, twice
daily and for ten minutes at each seance. I have thus been able to pro-
duce orthophoria in many cases. The remarks made by Dr. Lewis
in the training of the centers of the brain are most advisable and very
helpful.

Dr. Bissell : If I may be pardoned a word, a point that has greatly
impressed me of late is the work along the orthoptic line that we are
to do after we have operated. There are cases in which binocular vision
is secured after operating. They are more numerous, perhaps, than
we have realized. Two cases I specially call to mind, which had the
symptoms after marked strabismus was corrected which are apt to
follow heretophoria, and which were overcome by the use of Kroil's
exercise cards, referred to by Dr. James. I am taking more and more

a06 WALTER STRONG. M.D.

pains in trying to develop binocular vision, and some of the amblyopia
at times will disappear. We must not be satisfied in dismissing our
patients simply because they look better.

Dr. Linnell : In the development of these muscles after an opera-
tion tliere is one point worthy of attention, and that is, electricity. I
have recently had an experience in a case of very marked divergent
squint following a tenotomy for convergent strabismus some years pre-
viously. I made an advancement of the internal rectus with a tenot-
omy of the external. When I got down to the internal rectus, I found
it only about one line in width and attached only by two very small fila-
ments to the sclerotic. I felt rather discouraged at the thought of
getting much result from the operation ; but under the use of systematic
exercises, with prisms and electricity, I have had very gratifying suc-
cess with the case. The eyes are straight and she has very nearly the
normal amount of adduction, overcoming a prism of 40** with the base
out before either eye. I think electricity will often be found helpful
in such cases where there is a lack of development of the muscle. I
used first galvanism for a few days, the negative to muscle and the
positive to the forehead.

Dr. Moffat: As for prolonged use of a cycloplegiae, we must not
forget that young children are very susceptible to drugs. We must not
forget that the prisms arc curative only of the influences that bring the
visual axis so dose to the macula as to stimulate the desire for smgle
vision. I know that a large number of practitioners will order prisms
temporarily to give relief to the patient.

Dr. Deady: In treating strabismus, I always before thinking of
operating, fit the case very carefully with glasses under a mydriatic,
allowing them to wear glasses for a time to ascertain whether they will
be benefited thereby. It frequently happens that for a time the patient
will do very well ; then the symptoms will recur and the patient return.
The first thing to do in a case of that kind is to examine the glasses and
see if they are perfectly in line — see if the lenses are exactly as they
were ordered. It is of the first importance to know whether the glasses
are accurately centered. It is useless to test very carefully for refrac-
tion, and give a glass for the full correction of the hjrperopia, if the cen-
ter of the lens fall so far external to the pupil that the patient is looking
through a prism with the base outward, exactly defeating what you
are trying to do. I have seen a number of cases where the patient was
apparently getting worse, where sending them to the optician to have
the frames straightened would cause the attack to pass off. In asti^ia
the axis will be changed by a little bending of the frames, sometimes
by exceedingly small amount, which produces a spasmodic effect on the
ciliary muscle.

Dr. Walter Strong: I would like to emphasize in conclusion the
opinion expressed in the paper that it is possible to secure improvement
in amblyopic eyes. I am firmly convinced that most excellent results
can be obtained with proper treatment, and I have not only repeatedly
observed it in my patients, but I have also had some personal ex-

TREA TMENT OF STRABISMUS. 207

r'rience with it. When I started into eye work, some 12 years ago,
was compelled to use the ophthalmoscope almost exclusively ^ith my
left eye, my right eye being amblyopic with vision of less than one-
third ; but with perseverance with an accurate and full correction of the
refractive error, together with the use of a blinder over my good eye,
I have been able to bring the vision in the right eye up to normal, so
that it is just as useful to me as the other. While I have not thoroughly
established binocular vision, it is most useful for both distance and close
work, when used independently of the other eye. I think that what we
want in these cases is an intelligent patient and a great deal of persever-
ance, such a happy combination coupled with intelligent treatment will
secure marked improvement in a large proportion of our cases of
amblyopia.

THE OPERATIVE TREATMENT OF STRABISMUS.

fiv Hasold Wilson, M.D.,

Detroit, Mich.

FOR our present purposes, we shall accept the division of
strabismus into two classes, i, superable, or latent, and 2,
insuperable or manifest, and the further division of each of
these classes into a, comitant (non-paralytic), b, incomitant (paralytic).
Further, three classes of factors are to be considered, i, anatomical, 2,
physiological, 3, mechanical.

Anatomical Factors. — ^The orbits or bony sockets in which the eye-
balls lie, naturally diverge outward and downward, giving to the eyes
an average inter-central distance of about 64 mm. If the divergence
of the orbits becomes excessive, the distance between the eyes increases
also, and unless there is a corresponding increase in the volume and
power of the internal recti muscles, the near point of convergence neces-
sarily recedes beyond the normal point, and a condition of convergence-
insufficiency results, or, a previously existing convergent squint may be
spontaneously cured.

The extrinsic ocular muscles have their fixed origins upon the orbital
walls. Variations in the shape and position of these walls may be ac-
companied by variations in the size and position of the attached muscles.
These muscles have their motor insertion upon the eyeball. The place
of these insertions is subject to many variations. These variations
give rise to many cases of squint, both manifest and latent. They are
also important in the performance of operations for squint.

The muscles may be said to have three attachments, i, fixed; 2,
elastic ; 3, motor. The fixed attachments are those to the orbital walls,
and constitute the so-called "origins." The elastic attachments com-
prise the connective tissue investments and connections, (capsular in-
sertion). The motor attachments comprise the insertions upon the eye-
ball, (scleral and capsular insertions). The fixed attachments have no
surgical importance, but it is far otherwise with the elastic and motor
connections. An accurate knowledge of these is essential to the proper
conduct of operative measures. Time will here permit no more tlian
a brief reference to their anatomical relations.

OPERATIVE TJ^^TJtfJs^T OE STRABISMUS. m

The motor attachments of the muscles consist of their direct con-
^^M^ctions with the globe by means of their tendinous extremities^ (all
the recti, and the superior oblique), or muscle fibres themselves (in-
f^or oblique) and of their indirect copnections with the globe by means
9{ various fascial extensions. From the fact of this double connection
it follows that either the fascial or tendinous insertion may be severed
without destroying the motor action of the muscle to which they belong.
Also, that the tendon being divided and a certain impairment of the
motor ftmction being secured, this may be increased by the further
division of the fascial extensions from the muscle to the globe.

Or, a certain effect may be secured by the division of the fascial
attachments alone. (Parinaud.)

The aponeurotic or capsular investments of the muscles have been
described with complicated minuteness by various authors. The fol-
lowing description is rather simple, and, I think, not difficult to under-
stand.

All of the structures within the orbit are invested with connective
tissue sheaths, which are mutually connected. At about the level of
the equator of the globe, these sheaths thicken, particularly those of the
piuscles, and extend away from the eyeball toward the orbital walls,
to which they are attached, forming a wall or septum supporting the
globe, and dividing the orbit into two parts, an interior and posterior.
This wall is sometimes called the "orbital septmn," and those portions
lying over and about the muscles are so much more developed than the
inter-muscular portions, even containing muscular fibres, that they have
received special names, "tendon of Tenon," "orbital muscle of Sappey,"
"check ligaments." These constitute what I have called the ela5tic at-
tachments, and their function is to support the structures of the globe
and to moderate muscular action.

Anterior to this septum, these sheaths descend upon the eyeball and
muscles, forming the "anterior capsule." It is the connections of this
capsule with the muscles and adjacent tissues which is of the greatest
surgical importance. The external face of the muscles lie under the
capsule more or less naked and free from adhesions. At the borders of
the muscles, however, two sets of adhesions are to be noted : first, what
ve called "pre-muscular." These fibres extend from one border of the
9iuscle to the other, arching over its external face, and forming there
? small serous cavity, called the "pre-muscular serous cavity." Second,
from each border of the muscle fibres extend laterally to join the inter-
muscular portions of the anterior capsule, and to be inserted upon the

210 HAROLD WILSON, M.D.

sclera in the space between the insertions of the musde tendons. These
are called the "lateral adhesions" (Boucheron). The inferior face of
the muscles is usually free.

Fhysiologioal Factors. — ^The first physiological factor to be noticed
is the fact that the movements of the eyes are regelated by certain
binocular innervations. There are twelve primary associated move-
ments of the eyes as follows :

1, Both eyes to the right— dextroversion,

2, Both eyes to the left — laevoversion,

3, Both eyes upward, — sursumversion,

4, Both eyes downward, — deorsiunversion,

5, Both eyes outward, — divergence,

6, Both eyes inward, — convergence,

7, Right eye up, left eye down — right sursumvergence,

8, Left eye up, right eye down, — ^left sursumvergence,

9, Torsion of both eyes to the right, — dextrotorsion,

10, Torsion of both eyes to the left, — ^laevotorsion,

11, Torsion of both eyes outward, — distorsion,

12, Torsion of both eyes inward,— contorsion.

Whether the impulse for each of these movements originates in its
own special center is not yet known. Those for convergence, sursum-
deorsum-, dextro- and laevo-version are generally admitted and recog-
nized while the existence of a divergence innervation is admitted by
some and denied by others. It is quite possible that each one of these
associated primary movements has its own innervational center.

The convergence innervation is most intimately connected with that
of accommodation, and hence with reiractive conditions, so that optical
considerations become of great importance in the treatment of many
cases of strabismus.

The movements of the eyes are conditioned by four (or more) physi-
ological laws, which may be called i. The Law of Definite Concert; 2»
The Law of Identical Sensation ; 3, The Law of Identical Position, and
4, The Law of Least Effort.

The law of definite concert is illustrated in the various innervations
referred to above. Two simultaneous impressions of a single object
must be harmonious in order to give the (mental) impression of single-
ness. The two eyes together should act as one. It is as if the nervous
innervational impulse started from one point, traveled along one path to
a certain other point and there divided, part of it going to one eye, part

OPERA TIVE TREA TMENT OF STRABISMUS. ill

to the other. Thus under the influence of the dextroversional impulse
both eyes turn to the right with perfect harmony .

The law of identical sensation. Identical visual relations between
the visual subject and the object, whenever occurring, give rise to
identical visual sensations, and conversely, identical visual sensations,
whenever occurring, determine identical visual relations between the
visual subject and object

The repetition of identical visual sensations determines the visual
recognition of external objects. The complex and varying relations
between the visual subject and object are, perhaps, never identically
repeated in every particular, but certain essential or grosser relations
often recur. Thus we come to know the features of a landscape as
familiar, and to recognize the features of our friends.

I believe that the laws of visual projection are in part, to be de-
duced from this law.

The law of identical position, (Bonder's Law). This is a conse-
quence of the converse of the preceding law. For any definitely fixed
(identical) relation of the visual fixation line and the head (body, posi-
tion of observer, etc.), the torsion of the eyeball, (or more generally,
its position in space), must be fixed, (identical). Otherwise, varying
visual relations between the visual subject and object would giye rise
to identical visual sensations, contrary to the law of identical sensation.

The law of least effort, (Listing's Law). Although Listing's law
was originally enunciated as a law of mechanical equivalents merely,
it seems capable of a wider application as a physiological law. At
least, the facts of ocular movement to which it applies are related by a
general law, and although this law has not yet been stated, it might be
tentatively formulated as follows : In passing from one position to an-
other, the eyeball seeks to traverse the path of least effort.

Motor limotions. — We must recognize three states of the motor
functions: i, over-action; 2, under-action ; 3, irregular action*

(Duane.) Each of these may be i, structural; 2, innervational.

Thus, an inward deviation of the eyeball may be due to

I. Structural

over-action of adductors

or
(Anatomical) ( tmderaction of abductors.

r .• t ( over-action of adductors (convergence)

2. Innervational 1 \ & /

\ y 6* ; I under-action of abductors, (divergence)

^% HAROLD WILSON. M.D^

3. CpmbiQe4 structural and inner/ational causes.

Heohanioal Faoton. — The motion of a mobile body under the in-
fluence of several forces applied to it, is the resultant sum of the com-
l)ined action of those forces.

In the eye we have forces called "tractions," of two kinds : i, muscu-
lar tractions; 2, resistant or elastic tractions. These may result in i,
translations; 2, rotations; 3, twists. Translations are linear displace-
ments of the eye as a whole. They exist only to a slight extent, (en-
and ex-ophthalmos) and may here be disregarded. For similar reasons,
twists, which are combinations of rotations and translations need no at-
tention in this connection. The movements of the eyeball to which at-
tention will be limited are then

Rotations. These are the result of several simultaneous pulls tend-
ing to spin the eyeball, each in a different direction, and in general, to a
diflFerent degree. Our knowledge of these several forces is still imper-
fect, so that we are able to establish the dynamics of the eye with only
approximate accuracy.

Rotations of the eyeball occur about an imaginary axis or line
passing through a certain point within the globe called the center of
motion, and situated about 13.5 mm. behind the summit of the cornea.
This point is supposed to remain the same for all movements of which
the eyeball is capable.

The axes of rotation for the several muscles of the eye have been
determined by a number of observers with approximate agreement
These observations suppose that each muscle is free to act upon the
globe without restraint, although practically, the movement of the globe
When a single muscle contracts is the resultant of the pull of the muscle
plus the pull of the various resistances, elastic and otherwise, so that
the axis of rotation of any single muscle cannot really be determined
until the amounts and directions of the resistance pulls are known.

In the normal activity of the eye, its movements, in general, cannot
be eflfected by the contraction of any one muscle acting alone. There
are several reasons for this statement.

I. The position of the several muscular axes, so far as known, is
such that in general, the rotation of the globe about these axes would
bring the corneal meridians into positions inconsistent with the law of
Listing.

During the contraction of any muscle having an antagonist, this
antagonist is usually innervated so as to act as a means of controlling

OPERATIVE TREATMENT OF STRABISMUS,

213

the extent and rapidity of the resulting movement. Thus, if we as-
sume a contraction of the external rectus muscle, a corresponding con-
traction of the internal rectus is necessary to regulate and check the
outward movement of the globe, and to permit the line of fixation to be
carried to any particular point desired. That we have the power of
directing the gaze very accurately in any direction, with various rates
of speed and to any desired point, is a matter of universal and constant
experience. The existence of a regulating mechanism is therefore evi-
dent.

In general then, all rotations of the eyeball are the result of the
simultaneous contraction of several muscles, together with the tractions
of the several associated elastic tissues.

The extent and direction of the resultant rotation in any case is
dependent upon i, the place of origin and insertion of the muscles rela-
tive to the co-ordinate axes of the globe; 2, the size and strength of
the muscles ; 3, the direction and amount of the associated elastic ten-
sions; 4, the degree and amount of the muscular contractions (in-
nervations) ; 5, the nature of the visual act performed, e. g., whether in
parallel or convergent binocular vision ; rotation from the primary to a
secondary position, or from one secondary position to another.

Hechanics of Strabismus. — ^The essential objective feature of strabis-
mus is the fact that the visual lines do not meet at the point of fixation.

Suppose we have a case of convergent squint of the right eye of
4 mm. If the globe is 24 mm. in diameter, this is equal to about 19^ of
angular deviation. According to the measurements of Volkmann, the
eye being in the primary position, the following averages obtain ;

Insertion

from

cornea.

Rectus intemus 6 mm.

Rectus extemus 7 mm.

Total length

muscle.

40 mm.

49 mm.

Length in
contact

with globe.

7 mm.

13 mm.

Now, if a convergent squint of 4 mm. exists, the above relations are

altered as follows :

Insertion

from

cornea.

Rectus intemus 6 mm.

Rectus extemus 7 mm.

Total length

muscle.

36 mm.

53 mm.

Length in
contact

with globe.

3 mm.

17 mm.

Now suppose that in such a case of squint the tendon of the rectus
intemus muscle be divided so as to produce a wound which gapes in a
horizontal direction 4 mm. The equilibrium of the eye being dis-

214 HAROLD WILSON, M.D,

turbed, two important mechanical changes occur: the divided muscle
being opposed by a reduced traction, retracts, or tends to retract until
its elastic tension is again opposed by equal and opposite counter-trac-
tions, and the elastic tension of the external rectus muscle and the other
counter-tractions being opposed by a diminished resistance, by con-
tracting (elastic) rotates or tends to rotate the eyeball outward. Tht
4 mm. of wound space represent the limit of the sum of these two move-
ments. If the elastic pulls outward and inward are equal, then the
former rotate the eyeball outward 2 mm, and the latter draw back the
posterior border of the wound by the same distance. In other words,
the correction of the squint produced by a wound 4 mm. in extent, the
outward and inward elastic tractions being equal, is just half this
amount, and to obtain a full correction, the other conditions remaining
the same, the wound would have to gape 8 mm.

If on the other hand the .elastic pull of the internal rectus muscle
were greater or less than that of the externus, the corrective rotation of
the eyeball following the operation would be correspondingly more or
less than half the gaping of the wound. Practically we find, I think,
that these differences in elastic tension do exist, so that the amount of
correction following a given operation is not always the same ; a moder-
ately gaping wound producing greater correction in some cases than
in others.

Similar considerations obtain in operations advancing a muscle or
Tenon's capsule, the amount of correction secured depending not only
upon the amount of advancement (that is, not only upon the point at
which the sutures are introduced, or the amount of muscle or tendon
exsected) but also upon the relative elastic tension of the opposing
muscles and fascia.

If, in such a case of strabismus as we have supposed, the rectus in-
temus has a maximum power of contracting 15 mm., its length would
then be 36 — 15=21 mm. We may further suppose that with a tenot-
omy producing a wound 6 mm. in extent, the retraction of the divided
muscle equals 2 mm., and the corrective rotation of the eyeball equals
4 mm. The intemus now measures 36 — ^2=34 mm., the externus
54 — 6=49 mm. If now, there had been no change in the resistant
tension of the capsule (check ligament) of the intemus muscle, or of
the outward elastic tractions, they would equal the retractive tension
of the muscle when this had reached a length of 21 mm., but 21=
34 — 13 n^ni. Thus 13 mm. would represent the extent of the adduction
after the operation, or in other words, the adduction would be reduced

OPERATIVE TREATMENT 01* STRABISMUS, 216

by just the amount of retraction of the divided muscle. But when the
intemus had reached a length of 21 mm. the eyeball would be 4 mm.
less in adduction than before the operation, and the outward traction of
the extemus and the elastic tissues would be just so much less tense,
opposing so much less resistance to the inward rotation of the globe,
and permitting so much more contraction to the intemus, providing that
the check ligament had not already reached the limit of its extension.
Hence the amount of adduction remaining after the operation would
actually be somewhat in excess of 13 mm., though less than 15 mm. If
there were no corrective rotation of the globe following the tenotomy,
the entire gaping of the wound would be produced by the retraction of
the divided muscle and the adduction would be reduced by this whole
amount

In advancement, the elastic capsular tension opposing the muscular
tension is increased somewhat, but the contractile power of the muscle
is also increased, and in proportion to its length, so that generally, there
is an increased power of duction on the part both of the advanced
muscle and of its antagonist. In some instances however, what is
gained by the advanced muscle is lost by its antagonist.

Previous to operating for strabismus, the following facts should be
noted in the record of the case :

1. Age of patient.

2. History of the case.

3. Nature and amount of the deviation, expressed in millimeters or
in degrees of angular deviation, for the nine principal areas of the motor
field.

4. The power of abduction, adduction, surstunduction, deorsum-
duction, convergence and divergence.

5. The visual acuity and refraction.

6. The nature and extent of the double vision that can be elicited
by means of prisms or colored glasses.

Indioations for Operation. — In children, orthoptic methods of treat-
ment and the use of atropine or glasses in appropriate cases are to be
preferred to operative measures. Some forms of squint have a tendency
toward spontaneous cure, and the most conservative surgeons prefer to
wait until the patient has reached puberty before resorting to its sur-
gical cure. However, since the cure of strabismus by orthoptic methods
is, in any event, a prolonged, tedious and more or less expensive matter,
it will be rejected by many parents as either impracticable or impossible,
and an operation may become desirable at an earlier age. Almost

216 HAROLD WILSON, M.D.

never, however, should a radical operation be advised in patients tinder
seven years of age. In appropriate cases, particularly where some form
of orthoptic training can be undertaken, a partial correction of the
squint may be undertaken at an early age.

Any operation for the relief of strabismus can be very much better
performed under cocaine anaesthesia, and a more satisfactory result
secured than where a general anaesthetic is given. This is an additional
reason for delaying the operation until the child has reached a manage-
able age.

A simple tenotomy of the rectus intemus muscle with the division
of the lateral and pre-muscular capsular attachments, will g^ve a maxi-
mum correction of about 4 mm. (i9°-20°). The same for the rectus
extemus muscle will give a maximum correction of about 2 mm. (9**-
10° ) . When the correction after tenotomy is insufficient, if the corre-
sponding duction of the two eyes is about the same, the corresponding
muscle of the other eye may be divided, if sufficient effect may be se-
cured thereby. If the duction of the squinting muscle is restricted, its
opponent should be advanced. Where the effect of a tenotomy is too
great, it should be reduced by a suture involving the conjunctiva, sub-
conjunctival tissues or muscle, more or less, depending upon the amount
of reduction desired. In alternating squint, the operation should be
divided between the two eyes.

Where the retraction of the divided muscle is great, the correction
will be small. It may result in getting no corrective effect at all. In
such cases, a temporary external suture or guy, producing a forcible
rotation of the globe into position, may be employed. (Knapp.)
Where the squinting eye is amblyopic, and the tenotomy fails of effect,
it may be combined with muscular or capsular advancement of the an-
tagonistic muscle of the same eye. If the vision of the two eyes is
equal, or approximately so, and if following the operation, orthoptic
treatment is to be given, it is necessary so to regulate the operation that
the duction of the two eyes in various directions (abduction, adduction,
sursumduction deorsumduction) is maintained, or made as nearly equal
as possible, e, g,, right and left adduction should be equal. Where the
squint is compound, that is, where the eye deviates out of the primary
vertical or h9rizontal plane, (e. g,, hyper-esotropia), in general, two
series of operations are necessary: i, to correct the vertical deviation;
2, to correct the horizontal deviation. In some cases of latent squint
particularly, the correction of the vertical deviation is all that is neces-
sary, the horizontal deviation spontaneously disappearing after the first
operation.

OPERATIVE TREATMENT OF STRABISMUS. 217

In divergent squint, the combined tenotomy of the rectus extemus
muscle and advancement of the intemus of the same eye is usually
necessary. Sometimes the advancement alone suffices. The primary
correction should exceed that eventually desired, and in ordinary cases,
there is little or no danger of making a permanent over-correction.

The nature of the operation to be undertaken in any case of squint
is determined by the nature and cause of the squint itself, the power of
duction or version in various directions, the power of convergence and
divergence, the anatomical peculiarities of the special case, the extent
of vision and the purpose for which the operation is undertaken.

The complete purpose of the operation for squint is :

1. To correct the deformity as entirely as possible.

2. To secure a proper equilibrium in the static and dynamic actions
of the ocular muscles

3. To render possible in suitable cases, by subsequent training, the
acquirement of binocular vision.

These points are stated in the order of their practical importance.
The most notable consideration is to correct the deformity. This re-
sult although it realizes only part of the purposes of the operation, will
be all that can be done for many patients, and all that is desired by
others. The second consideration above noted, is important first, to
obtain a correction of the squint over the entire motor field if possible ;
second, to render the subsequent acquirement of binocular vision most
likely.

Results of the Operation for Squint. — In the majority of cases of
squint, the immediate results of surgical treatment are satisfactory, that
is to say, the squint is removed, either wholly or in part. The remote
effects are not always so satisfactory, a squint which has been re-
moved for years, sometimes returning, or being followed by a squint
of the opposite sort. Statistics or detailed reports to show the ultimate
results of these operations are scanty. The following statements are
generally admitted :

1. After tenotony of the rectus intemus muscle, the effect may
diminish slightly for a few days, and then increase for an indefinite
period of years, even to the extent of producing an opposite squint.

2. After tenotomy of the other recti muscles, the effect may increase
for a few days and then slowly diminish. This is particularly true
after tenotomy of the rectus externus.

3. The effect of advancements usually diminishes for an indefinite
period.

918

HAROLD WILSON, M.D.

In respect to these changes there are no fixed rules, great differences
existing in different cases.

Some cases of squint appear to be incorrigible, though it is not possi-
ble to predicate the fact in advance. I beljeve as we progress in the
knowledge of ocular movements and all that these imply, we shall be
better able to effect a cure in all cases. Thus, the effect and treatment
of torsional defects are at present imperfectly understood, but their
influence in the production or maintenance of squint seems undeniable.

In general, an over-acting muscle should be tenotomized, and an
under-acting muscle advanced. The following table represents the
commonly appropriate procedures in affections of the various separate
muscles, and although it is not to be taken as absolute or invariable, it
may properly be adhered to in most cases :

Explanations — ^The letter A in the table means advancement; T,
tenotomy. Without brackets they are to be taken as expressing the
commonly necessary operation; enclosed in brackets, they refer to
operations which may be required, or may be omitted as the circum-
stances of the special case may indicate. The table is largely compiled
from Duane, Motor Anomalies of the Eye.

Motor Anomalies of the Eye.

OPERATION ON

Musde or Function.

Affected

\f 11 col A

Corresponding
Muscle of

Antagonist
of

Associated
Antagonist

HE lia%«AV

Other Eye

Same Eye

of Other Eye

Rgctus Intemus —

Under-action

Over-action

Rectus Exttmus —

Under-action

(A)

(T)

Over-action

Rectus Superior—

•

Under-action

(T)

Over-action

Rectus Inferior —

Under-action

(T;

Over-action

Obliquus Superior —

Under-action

Over-action

(T)

Obliquus Inferior —

Under-action

Over-action

(T)

Convergence —

Under-action

(T)

Over-Action

Divergence —

Under-action

(T)

Over-action

OPERA TIVE TREA TMENT OF STRABISMUS. 219

In convergence deficiency, where an operation becomes necessary,
both intemi should be advanced : If divergence excess is also present,
the external recti may be divided, and conversely. Convergence excess
may require tenotomy of the intemi, and if divergence insufficiency is
present, advancement of the extemi also. Divergence deficiency and
divergence excess are to be similarly treated.

Methods of Operating. — ^There are numerous methods and varia-
tions in methods of operating, the discussion of which, space will not
now permit. It is of much less importance however, in what precise
manner the conjunctiva is divided, the tendon severed or sutures intro-
duced, than that the proper species of operation be selected, and per-
formed with a due knowledge and appreciation of the complex anatom-
ical and physiological factors which enter into the problem which the
operation attempts to solve

DISCUSSION.

Dr. Boynton : The subject of strabismus has excited more comment,
the operations for its correction have been followed by more disap-

e>intments, probably, than any other branch of our special surgery,
ature's wise provision of the sensorium objecting to double imager,
provides for the suspension or suppression of one image. Were this
not true, the regrets and failures, the monuments that would be put
up to our incompetency would soon drive us out of the profession.
Happily we cannot, in the majority of cases, re-establish binocular
fusion.

According to the methods of operation in practice when I began the
study of the eye, nearly every muscle operated was followed by in-
sufficiency ; but it did not make much difference to the patient, because
all such operations are undertaken for cosmetic effect, and if there
was an insufficiency of one muscle, they soon learned to rotate the head
and adjust the eyes so that the defect was not seen. They looked
better, and it was only when more definite methods of measuring the
individual strength of the muscles and their relative balance were de-
vised, that we realized our incompetency. We are astonished at the
old instruments when they are compared with our modem appliances.
When we see the big Plunkett scissors used twenty-five or less years
ago, the big hooks that were introduced under the tendons and the
recklessness with which adhesions between the globe and Tenon's cap-
sule and the other investing membranes of the orbit were tom, we are
not surprised at the insufficiencies that resulted. We have indus-
triously tried to educate our conception of our eyes and to acquire a
ddicate touch. We are excluded from considering insufficiencies other
than those manifest in this discussion, and have no right to go into

220 HAROLD WILSON, M.D.

«
the field of heterophoria ; but the field of strabismus overlaps the field
of phoria where alternating strabismus exists.

Orthoptic exercises, ocular gjrmnastics, development of muscles
through ordinary appliances, in the interest of producing binocular
vision, may be compared to making a whistle out of a pig's tail. Life is
too short and the result too unsatisfactory to adopt such treatments as
a whole. I have rarely seen a case where binocular vision was pro-
duced, and that is a good thing. Every case of strabismus is better
for amblyopic vision. The attempts at correction by operative inter-
ference fail to produce binocular fusion, and it is happily so; because
those cases where binocular vision is obtained in alternating strabis-
mus, and the visual lines are made approximately parallel, cause the
most trouble. Strabismus cases do not suflfer except in the beginning
of the trouble and then when they attempt to use the eyes at the near
point. Then reflex disturbances like vomiting, nausea, cold sweats,
confusion, enuresis occur. All or any of these symptoms come to the
little children who are just learning to suppress the vision of one eye,
but after they have accomplished that they do not suflFer. It is the
cases where the visual lines are approximately parallel that have trouble
and hence comes the danger of parallelism.

All these faults are congenital or acquired. Congenital faults we
must confess, are anatomical differences in length. Now whether the
case is wide between the eyes, has large eyeballs, small eyeballs, short
intemi, or short extemi and correspondingly long antagonists does not
matter. They are anatomical faults, and all the results of heredity.
They are all evidences of degeneration. They occur in the higher
classes, the more highly educated, the wealthier people the more they
degenerate. In the lower classes it is due to other causes, like inter-
marriage, excessive diet, stimulants, poor environments and improper
opportunities for development.

After having gone through all the orthoptic exercises recommended
you will still almost always have the strabismus. A few cases will be
corrected by correcting the axial faults or the faults of curvature in
the eyeball, but they are few in my experience, and we must resort to
surgical interference. Shall we hack off the muscle with the old fash-
ioned scissors, the big hook, and tear off all the adhesions between the
tendon and the eyeball, and between the check ligaments, between the
sub-con junctival tissues and the conjunctiva, and loosen the con-
junctiva up to the fornix so as to get a depression over the insertion
of the muscle? This method has been an invariable failure. All have
left it in disgust and gone to optic appliances and orthoptic exercises.
I have had many failures; but I have earnestly tried to educate my
hand, to get some ideas into my brain, and to school my eye to com-
prehend and to appreciate as well as my hands to correct, and I believe
the only way to correct a short tendon ; viz., to make it approximately
of the length of its antagonist, is to set it back. But we may cut off
the whole tendon and get no correction. Those cases in which the
operators carelessly sweep the big hooks around with a horizontal or

OPERATIVE TREATMENT OF STRABISMUS, 221

a vertical movement, it does not matter which, so that it is away around
the insertion of the tendon which is all hacked off obliquely (always
obliquely as cannot be done any other way), have the check liga-
ments about the muscles destroyed. These expansions of Tenon's cap-
sule, which are sometimes called the tendinous muscle, go to the bor-
ders of the septi dividing the orbit into anterior and posterior portions
and restrains the muscular action. As a rule they hold back on the
muscle; but sometimes they hold forward. All these adhesions between
the tendon and the eyeball are elastic, and aid in motility of the eyeball.
I would try to save all these adhesions possible and to do so I would
make a little buttonhole in the conjunctiva if I were operating the
internal rectus about 6 millimetres from the cornea although no two
cases are alike. I would just cut a little buttonhole in the centre of
the tendon. When the eye is strongly rotated outward your button-
hole will gape and in that depression with your fine forceps you can
pick up the middle of the internal rectus right close to the insertion by
gliding the forceps back and forth. If you have cut a little too far
back or a little too far forward, you can find where the tendon takes
up fat freely, and then incise just in front of it, make a buttonhole
in it. Now you are in command of the situation. You have not dis-
turbed any adhesions, above, below, outside, or anywhere around the
tendon ; and then you may snip up or down till you get what you think
you want. This applies more to phoria than to strabismus, but in the
latter you have to go right on and cut off all the tendon, which you
will soon learn to locate. Then you incise the capsule till you have
cut as much as is advisable and still you may only have' half the cor-
rection. Then you measure the rotation of the eyeball, supposing that
you have done so before operating as well as having measured the
strength of the individual muscles. If you still have too little move-
ment, incise the check ligaments carefully, so you may not lose the
motility of the muscle and produce insufficiency. When you have done
half of the correction on one eye, which you can easily do in this way,
you will get increased abduction and have sufficient adduction remain-
ing. If the effect is not sufficient, then do it in the other eye, which
should be done in all cases, so as to divide the operation between the
two eyes, in order to get proper rotation.

Dr. Suffa: I have listened with a great deal of pleasure to Dr.
Boynton's lurid description of graduated tenotomy, but cannot agree
with his opinion of their efficacy, and I would like the opinion of others
in regard to this matter. I have met with invariable failure when
following the operation according to Dr. Stevens' method, even in
moderate degrees of heterophoria, and consequently have modified the
operation by separating the conjunctiva slightly beyond the edges of
the muscle, according to the amount of displacement desired. Then
I buttonhole the muscle and introduce the small hook, and cut both
halves of the muscle. Even with this liberal cutting, I have often
found it necessary to separate lateral attachments. In these operations
it has always been my intention to remove fully. one-half of the devia-

222 HAROLD WILSONy M.D.

tion from the squinting eye, and the balance from the other eye. I am
not always successful, usually under correcting, even with their free
division according to graduate tenotomists. I pursue this same
method in heterophoria, but to a more limited degree.

Dr. Phillips: There is a theoretical and a practical side to these
questions. I apprehend that the reason why failure has been so fre-
quently experienced among oculists in this operation is because we have
been unable often to accomplish two things ; viz., ( i ) To get binocular
vision : (2) To get, even approximately, perfect optical correction. We
know very well that in cases of amblyopia of one eye, that it is often the
case that the patient will see with the best eye and pay no attention
at all to what is seen with the other eye, whether it is standing straight
or is standing diverted one way or the other, or whether the deviation
is corrected by a prism. You cover the eye that he is seeing with, and
he will see nothing at all with the other eye until something attracts his
attention and he finds out that the best eye has been stealthily covered.
The first and the most important point, then, is to induce a disposition
to use the eyes together. If that can be brought about, we find that
the matter of an operation is far more satisfactory. The second thing
is, to get as perfect correction as possible of whatever error of refraction
may be present. If there is a disposition to use both eyes together, by
any sort of practice whatever, and approximately perfect correction of
the error of refraction is made, the operation will be satisfactory.

Dr. T. F. Allen : It has been a surprise to some of the gentlemen
to meet me here; but I came on purpose to attend this meeting, and
almost purposely to listen to this discussion. Since I was an ophthal-
mologist, I have become a general practitioner, and I am obliged, with
the recent progress of the science and art of ophthalmology, to g^ve
up all my special work, and largely advise on such matters with you
specialists. I want to say just here, that I have been exceedingly
g^tified and was last evening at the manly stand each of you gentle-
men took, especially Dr. Hooker, who took the bull by the horns and
disclaimed any reliance on or intimacy with homoeopathy. That is the
right position for you gentlemen to take as specialists. I am speak-
ing from the standpoint of the general practitioner altogether. I came
here to learn how I should give advice to patients whom I recommend
to oculists and who come back to see me and say "The oculist advises
me to have my muscles cut, what shall I do? Shall I have my muscles
cut, or not?" I want information on that subject, and all general prac-
titioners want this information. You do not know how widespread
the interest in this subject is. The ignorance is very widespread, and
the inability to give proper advice to our patients on this subject is very
general. We do not know what to do. A member of one of my fami-
lies recently went to a celebrated oculist in New York, who said, "You
want your eye muscles cut." It was cut. It was cut again. Then
the opposite muscle was cut. The upshot was that almost every rotat-
ing muscle in the eyes was cut. Then advancements were made of first
one, then the other until advancements of nearly all the muscles had

OPERATIVE TREATMENT OF STRABISMUS. 228

been made. That young man has had his health almost completely
mined by these successive operations, his prospects in life have been
greatly injured, perhaps impaired beyond recovery. It is a very sad
case. The advice to cut was bad ; the advice to advance was bad ; the
whole business was bad. And we practitioners have become afraid of
you gentlemen advising to cut muscles, until we are apt to say, "Damn
the oculist!" I tell you, this sentiment is very general and wide-
spread. There is a great deal of careless advice given to cut. I have
learned something here this mommg. I was very glad that this paper
was first read, which advised a more careful examination of the visual
acuteness of the eyes. The correction of these visual amblyopias and
attention to the cerebral conditions of the patients suffering from
adenoids and the general s3rmptoms which the patients suffer from who
have these adenoids and defects of speech, etc., have a bearing upon the
eyes. I fancy you will have to pay a great deal of attention to this. I
am frequently asked by patients, "Doctor, the oculist says I must have
my muscles cut : what shall I do ? I am afraid of him." And they say
farther that "Mr. So and So's son or daughter had their muscles cut
and were worse than before, constantly getting worse and worse. Now
the oculist says I must have my musdes cut. What shall I do?"
There is great danger of the oculists losing their hold upon the pro-
fession by this indiscriminate advice "to cut the muscles." I know
perfectly well that it is advisable in many cases to give such advice,
but it is a very serious matter I assure you. In my opinion this is a
most serious aspect of these cases, and I hope it will be discussed fully
and frankly to some purpose. It is needed by the whole profession. I
wish evey one could hear the whole discussion and profit by it.

Dr Rumsey: I do not know of any subject over which I have
burned the midnight oil as the study of the muscles of the eye.

First of all, I secure the refractive error of both eyes and then I
secure the muscular strength of each muscle of the eyes and note their
relationship. In securing the refractive error, I am particular to
acquire the exact angle for the axis of the cylindrical glass. There is
no machine or organ that can lose its balance so easily as the musdes of
the eye. Small deviations may produce severe pain.

Where the phorometer shows esophoria in the far and near tests and
an adduction of 40** or more, it is advised to give a full correction of
the hypermetropia, thus curing the pseudo-esophoria. What remains
may be cured by a tenotomy. Should the adduction be below 40**, pris-
matic exercises should be given. And where the low adduction is asso-
ciated with low abduction, I strongly advise against tenotomy. De-
vdop both the internal and external recti musdes by carefully pre-
scribed exercises.

Where the phorometer shows exophoria in both the far and near
test with an abduction of more than 8**, partial tenotomy of the external
recti should be performed. Where the abduction is less than 8°, pre-
scribe exercise. Where the abduction is 8°, I advised against operating

224 HAROLD WILSON, M.D.

on the external recti muscles, but these prismatic exercises to develop
the internal recti muscles and let the advancement of this muscle be
the dernier resort.

I have known of cases where a tenotomy was performed to make
either a normal or weak muscle equal its weaker opponent.

I always advise conservatism in the treatment of strabismtis.

Dr. Norton: The remarks of Drs. Phillips, Allen and Rumsey, I
wish to most heartily endorse. I am glad to see that within the last
few years more and more of our leading oculists are abandoning the
promiscuous cutting of the ocular muscles. I have been on record since
the first edition of the "Ophthalmic Diseases and Therapeutics," in
'92, and in fact a number of years before that, as in opposition to the
too general cutting of the muscles of the eye. I fully recognize the
advisability and even the necessity of operative measures in a certain
few cases.

I regret that through the craze of some men to cut the eye muscles
for every ill that flesh is heir to, we have to listen to such words of
wisdom and advice from the general practitioner as Dr. Allen has
spoken this morning. It is certainly a grave reflection on our specialty
when the general practitioner is unable, from sad experiences, to
recommend his patients to follow the advice of the oculist. The time
for operation in heterophoria should, in my opinion, be only after all
other methods of cure had been thoroughly carried out.

My records show that I can find some form of muscular disturbance
in over 90 per cent, of all cases that consult me for their eyes. I do not
believe that the human race are as a rule created with abnormal ocular
muscles in order that the oculist may correct the same. In my judg-
ment, the cause of heterophoria is oftentimes due primarily, as Dr.
Phillips has said, to uncorrected refractive errors. Another important
cause is undoubtedly the over and improper use of the eyes. By im-
proper use of the eves 1 mean, use by poor light, while convalescing
from illness, while in improper positions, etc., etc.

The operation of weakening a stronger muscle to cure hetero-
phoria does not seem to me either rational or physiological. I believe
our aim should always be to first strengthen the weaker muscle, by
prism, exercise, etc., in every case possible — failing to restore the bal-
ance in this way, we may next try to relieve by allowing the patient to
wear prisms partially or wholly correcting the trouble. As a last re-
sort after these methods have failed we may turn to operative meas-
ures.

Dr. Bates : I believe that when we can get binocular vision with-
out putting strain upon the eyes, it is all right, and we are doing a good
thing. If in getting that binocular vision we have got to diange a
case of strabismus into a case of heterophoria, I believe we are doing
more harm than good ; that is, if there is anything in the theory that
my paper advocates.

Dr. MoflFat : I agree emphatically about the necessity of establishing
binocular vision first if we hope for a permanent cure; it seems to me

OPERATIVE TREATMENT OF STRABISMUS. 225

an argument for early operation in children. I would like to hear the
judgment of those present about the ages at which it is wisest to operate.
The writer would never operate under seven years old; I have heard
others fix the age at eleven. I also hoped to hear about g^duated
tenotomies; these do not seem to be practiced as much as they were.
There is another operation for squint that has not been spoken of ; I
have relieved squint by circumcision, and always examine the prepuce
of every boy brought to me with squint.

THE USE AND ABUSE OF THE ELECTRO-CAUTERY IN

NOSE AND THROAT WORK.

By Irving Townsend, M.D.,

New York.

DURING the past five or six years, my use of the electro-
cautery has gradually diminished, and given place to what
I believe to be more discriminating and successful methods.

This has not been a conscious effort to make practice accord with
preconceived theory, but rather a process of evolution, by which each
new operation or remedy finally reaches its proper sphere of useful-
ness. There is no question that the electro-cautery is a very efficient
instrument for certain kinds of work in the nose and throat, and it is
equally certain that its injudicious use in unskilled hands is producing
disastrous results. More than ten years ago the most dire effects were
predicted from cauterization, by one branch of the profession, while the
other, (including most of the specialists) enthusiastically advocated it.
While each gave an exaggerated idea, both were in error, although
it is due to the former to state, that their criticisms have been justified
too often, by the subsequent history of the patient and apparent ill-
effects from this treatment.

This is not surprising, when we consider the fact that the preceding
fifteen years had been the experimental stages, inaugurating the use
of cocaine and the electro-cautery and giving an impetus to the work,
which carried it much further than was safe, or expedient.

This easy and painless method of restoring nasal breathing was
employed extensively, by specialists as well as by others, with varying
degrees of success. As time has progressed and our clinical knowledge
increased, we are learning to lose our dread of the " ancient bugaboo,"
scar tissue, and to know that in the right place it is a beneficent thing.

I will endeavor to formulate briefly some general rules, which I
trust will be of service to some one when undecided what particular plan
of treatment to adopt in a given case. From the statements made by
some writers, and what I have observed, to be a common practice, it is
quite evident that the electro-cautery is regarded by many as the best
method of relieving most of the impediments to nasal breathing. I do
not think that this view obtains, to any large degree, among rhinolo-

USE AND ABUSE OF THE ELECTRO-CAUTERY. 227

gists, most of whom are probably in accord with the sentiment of the
article.

The following are a few of the conditions, in which the use of
caustics and electricity, is not simply useless but injurious and even
dangerous, and with the few exceptions noted, should never be
employed, viz. —

I. On the septum narium (except to stop bleeding or destroy a
vascular growth). /

II. In reducing growths of a bony or cartilaginous nature.

III. In atrophic rhinitis.

IV. In destroying synechiae.

The process of repair in cartilage, (being due to a proliferation of
pre-existing cells, instead of exudation) is, much retarded by the
inflammatory effects of thermo-caustic applications.

This intolerance to heat is shown by the difficulty in getting these
wounds healed, and covered with a healthy membrane.

Perforation of the triangular cartilage is a common result and
synechiae often follow the careless use of the cautery.

This argument would be unnecessary but for the fact that there are
still rhinologists of experience who bum the septum with impunity, and
justify themselves by clinical reports of a satisfactory character, but
which are not in accord with the common experience of others.

Of the many cases of various forms of nose and throat disease,
treated by the electro-cautery I venture to express the belief that from
one-half to three-fourths, would have shown better results if other
methods had been employed.

For my own guidance I have relegated the electro-cautery to a
field, which is gradually narrowing and the following list includes all
the conditions for which it is ever used. Epistaxis, vascular tumors,
turbinal hypertrophies involving the soft tissue only, hypertrophy of
lingual tonsil and hypertrophy of the faucial tonsils if slight, if haemor-
rhage is feared, or when the consent to the cutting operation is with-
held. Mycosis of tonsils and pharynx, and small posterior growths,
located so as to be inaccessible by other means, may require the cautery.

In some of the above, the electro-cautery is preferred, but in many
it is only an adjunct to some other operative measure.

There is much to be said on this subject from the pathological
standpoint, but it was only intended to include in this brief paper a few
ideas which have suggested themselves to me from time to time and
which I believe are worthy of thoughtful consideration.

228 IRVING TOWNSEND, M.D.

Discussion.

Dr. T. M. Strong: I am sorry that I did not have a chance to
read Dr. Townsend's paper, and that I came into the room too late to hear
it, so that what I may say may be a partial repetition. There is not the
slightest question that the electro-cautery is as easily abused an instru-
ment as any we have in our hands, especially in rhinological work. I
do not think it can be abused as much in the throat as in the nose. It
is abused there, of course, but we have more protective conditions
there, tissues which will take care of themselves in better ways. In
cutting off the tonsils with the snare or cautery, you leave a certain
aseptic state, and the parts heal kindly. It would be a pretty severe
mutilation which any man would give the tonsils that could cause
lasting trouble. But when you go to work in the nose, and particularly
in deformed or narrowed nares, it is a different question. Its use
on the septum itself is almost prohibitory, I think, with the exception,
perhaps, of persistent haemorrhage, where the fused nitrate of silver,
or chromic acid, et cetera, will not control it. I have seen one or two
such cases, in which the touching with the cautery point at a light red
heat, used quickly, seemed to set up curative repair. It was used in
a limited space. It may be of service in some cedematous conditions
which occur upon the septum, high up, in some forms of hypertrophic
rhinitis, provoking spasmodic sneezing. For small septal spurs it is
useful, as a single application may remove them. I have never used
the cautery upon the middle turbinated. I have used it quite freely on
the inferior tubinateds, and in my own paper have referred to another
technique to take the place of the general use of the cautery, and the
advantages of it. Cases are reported where meningitis had followed
the application to the middle turbinateds, due to the intimate anato-
mical relationship between the cerebral sinuses and the ethmoidal
venous plexuses. It hardly seems possible that such results would
follow other than the abuse of the cautery. In pharyngitis, of the folli-
cular form, and where we have the enlargement of the tissues on the
lateral walls, behind the posterior pillars, in the post-nasal space, the
application of the cautery gives good results. Used within its proper
limits the electro-cautery is of valuable service, and without it we
would be seriously handicapped in our attempts at successful results.

Dr Hooker : For a number of years I have used electrolysis in the
contraction of soft tissues, no matter where situated — whether it be
to remove a mole from the face, or a hypertrophy from the nasal
cavity. I think I have not used electro-cautery in three years. I use
nitric acid and chromic acid very seldom. I restrict the use of those
acids almost entirely to the very soft hypertrophies of young children.
There a touch of chromic acid that acts very well indeed. The surface
of the mucous membrane is covered with delicate epithelial cells, whose
function is very important. This mucous membrane of the nose is
very precious to the patient, and that method is most successful which
will give you the largest amount of space with the least destruction

USE AND ABUSE OF THE ELECTRO-CAUTERY. 239

of tissue. I brought forward this method of treatment to this society
at Buffalo, and last year at Chicago, as I prefer it to any other in
the reduction of hypertrophies. I have been intending to use it in
nasal pol3rpi, particularly in those cases which are difficult to snare where
they are flush with the surface from which the growths spring, but
I have not got at it vet. I do not see why you cannot introduce the
point of the needle at the root of the polypus, and cause absorption,
destroy the tissue in this way and have your polypus drop out just
as you would destroy a wart on the hand with it. I have used the
single negative pole, and one of the questions I would like Dr. Strong
to answer is, what advantage the bi-polar method has? It is the
negative pole, as I understand it, that does the business ; hence, I have
the patient apply the positive pole on the back of the hand, thoroughly
moistened and I put the negative pole, attached to the needle, in the
place where I wish the contraction to occur. The disinteg^tion
of tissue takes place entirely beneath the mucous membrane. All the
damage you have done is a minute puncture of the membrane, and I
get far better shrinkage — z. greater amount of room — following the
application, practically without the unpleasant reaction afterwards,
than I had by using acids, or the galvano-cautery. I am very favor-
ably impressed with this method of reducing hypertrophies. One
treatment cannot do it all, several treatments are needed; but that,
as the doctor says, is true of chromic acid. I have found that four to
six milliamperes are ample, and two to three minutes length of time is
sufficient. I do not know but I will try a longer time, since the doctor
has gone as far as five minutes with ten milliamperes, but with the
smaller dose I have got very satisfactory results in these h)rpertrophies.

Dr. Rice: I wish to speak of a method, the results of whidi are
quite similar to those advocated by Drs. Strong and Hooker, for
reducing excessive hypertrophies. It consists of the use of a long,
small trephine propelled by a small electric motor. This trephine is
introduced into the inferior turbinate and slowly pushed backward
as far as may be necessary; then a little pressure is applied outside
of the turbinate against the mucous membrane by means of a cotton
pledget. The result is extremely satisfactory in the majority of such
cases. There is very little haemorrhage, apparently very little pain,
and it seems to me that in many cases it is much to be preferred to the
use of tfie electro-cautery against the mucous membrane. I believe,
as Dr. Hooker says, that the mucous membrane is very precious and
should be spared whenever possible.

Dr. F. P. Warner: The last remarks of Dr. Garrison ought to
be remembered where he laid special emphasis on the indicated
remedy in the treatment of these diseases. I have been wondering
of late whether there is any such thing as a primary hypertrophic
rhinitis, or catarrhal condition of the nose. Many of us have
removed the sub-lingual tonsil and seen it reappear. We have also
applied our acids to hypertrophy of the turbinated, too, and seen the
enlargements return. We have also applied the acid treatment for

9ie IMVING TOWNSEND. M.D.

hypertrophic rhinitis in children and have seen that condition rettnu;
and, it seems to me, that we are dealing here with more of a constitu-
tional condition than a local one. Hypertrophic rhinitis and catarrhal
diseases are an indication of something wrong with the system at
large. It may be with the food, a tendency toward glandular enlarge-
ments from scrofula, or from some other cause. I have noticed also
that in the treatment of these diseases, they improve much faster
and more permanently, when I have associated with the local treat-
ment the remedy for the constitutional condition.

Dr. A. W. Palmer : There is one method which is a little different
from Dr. Garrison's that has not been mentioned to-day. This is
the transfixion of the inferior turbinated, which may be done in two
wiiys. The turbinateds being anaesthetized by eucaine or a combina-
tion of eucaine and supra-renal, which leaves the tissues quite con-
tracted, you may then either first use the sharp-pointed electro-cautery,
introduced at the anterior portion of the inferior turbinated and passed
along the lower edge of the turbinated bone, between the bone and the
mucosa. Secondly, you may as Dr. Delafield advises very strongly,
transfix it by a sharp-pointed canaliculus knife, which inflames the
periosteum at the lower edge of the inferior turbinated, and which
also inflames and breaks up the little venous capillaries in the turbin-
ates, causing an adhesion of the tissues. This is usually done at the
lower portion of the inferior turbinated, ri^ht along its edge. I have
done it with the canaliculus knife along the inner surface. There does
not seem to be tissue enough to pass the cautery knife between the
turbinated bone and the mucosa on the inner side. I have had very
good results with this method, and prefer it to cauterizing the outside
of the turbinated body for the reason that Dr. Hooker has given.

Dr. E. W. Beebe: I formerly used the cautery, acids, and the
punctures, but the results were not satisfactory. I found that in
course of a few months those cases came back to me with the same
conditions they had formerly. Nothing has proved so efficacious in my
hands as the removal of the hypertrophies by the use of a saw, and I
remove sufficient tissue to insure a perfectly free opening of the nasal
passages. This treatment has given me better results than anything
else I have used.

Dr. Hoyt: I have had very satisfactory results from punctures
with the galvano-cautery after die method mentioned by Dr. Palmer.
Some of die turbinates are quite fat, and the cocaine will shrink them
down so that it will be hard to make a sub-mucous puncture, but with
eucaine it may be done and have just as profound anaesthesia. There is
another form of h)rpertrophy which has not been spoken of very much ;
that is, the posterior hypertrophy. We all know that the posterior
opening of the nostril is about the same size as the anterior while the
interior of the nose is quite large. We cannot get any more air
through the posterior end of the nose than through the anterior.^ Even
with a large hypertrophied bone there is a good deal of space in most
cases about them for die air to pass ; but, with a plug acting like a coxic,

USE AND ABUSE OF THE ELECTRO-CAUTERY. 2«1

sticking in the choans so as to fill the space two-thirds ftill, the air
cannot pass through. It is as though you had a cork partially in a
bottle. In these cases a snare can be applied very easily under eucaine,
better than under cocaine. That treatment seems to have a more bene-
ficial eifect in reducing hypertrophy of the inferior or middle part of
the turbinates, than to cauterize or shrink the middle part and expect to
affect the posterior.

Dr. Townsend: I have just a word to say in regard to Dr. Strong's
statement that he considered the dectro-cautery could be used with
considerable freedom in the throat. I do not think it can any more
than in the nose. Possibly it may be less liable to abuse ; but I have seen
cases of quinsy originate in patients who had never had quinsy pre-
viously, and who had been treated with the electro puncture. I have
seen quite painful inflammatory conditions arise where the cartilages
of the larynx had bee touched with the electro-cautery. The cartilages
there are quite as intolerant of the cautery, as they are elsewhere. I have
also seen a great deal of dryness and discomfort whenever the electro-
cautery has been used to destroy the enlarged pharyngeal tonsils, and
naso-pharyngeal adenoids, which was practiced quite extensively at
one time.

Dr. T. M. Strong : The bi-polar method seems to be a little easier,
quicker to use. You have everything right under the control of one
hand and one foot, whereas you have got to manipulate the wet elec-
trode on the patient.

TOBACCO-ALCOHOL AMBLYOPIA ; WITH PECULIAR-
ITIES OF COLOR VISION. ARE THE LATTER CERE-
BRAL OR RETINAL IN ORIGIN?

By Joseph T. O'Connor, M.D.,

New York.

THE title at the head of this paper has been deliberately selected
notwithstanding the use in ophthalmological literature of the
terms "retrobulbar neuritis" and "axial neuritis" to express
the abnormal conditions herein descibed.

My objection to the term retrobulbar neuritid as a synonym for
tobacco-alcohol amblyopia is that the former term includes at times
conditions not present in the tobacco-alcohol optic nerve affection; and
the designation axial neuritis is verbally incorrect since the affection
is at best para-axial and that in a short portion Only of the retrobulbar
course of the optic nerve.

In my opinion enough pathological data have been gathered to
justify the use of the term papillo-macular fascicular ascending optic
neuritis.

The history of the case which forms the basis of this paper is as
follows :

Case One. — Mr. , aged a little over 50, of marked neurotic

heredity, has always enjoyed fairly good health, some amount of
catarrhal dyspepsia being the chief of his ailments.

He has always enjoyed the pleasures of the table, has been a moderate
user of wines and spirits as beverages and has been a devotee to the use
of tobacco for many years.

Some five or six years ago one morning after a late night dinner
with plentiful accompaniment of stimulants and tobacco he noticed that
the outside world, the atmosphere, the sky, the buildings and people
appeared strange to him ; he was unable to describe the sdtered appear-
ance beyond saying that everything was too bright. Exercise in the
open air for an hour or so relieved the condition and things again
seemed normal.

This manifestation appeared later after other "good times" but
it took a longer period of open air exercise to dissipate the effect.

Late in the Summer of 1898 the patient was struck by the extreme
brightness of the blues and purples in the materials of Udies' dresses
or in their hat adornments. Upon inquiry, however, he found that such

TOBACCO-ALCOHOL AMBLYOPIA. 233

colors at that time were extremely bright in tint Nevertheless, any
material of blue color cotild be recognized by him at a distance far
beyond that at which he could distinctly perceive black or brown as
such.

In October he began to notice that yellows seemed intensified, or-
dinary yellow paint becoming of a golden tint while the gilt signs seen
over the shops had become like luminous amber.

A little later while reading and accidentally closing one eye, to the
open eye the type at the outer (temporal) side of the field of vision
appeared blurred as if the printing-ink had been rubbed over while still
moist. Then becoming somewhat alarmed he came under treatment.

Ophthalmoscopic examination late in October showed marked pale-
ness of both disks, perhaps more to the temporal side of each, while the
veins were enlarged and tortuous, the arteries narrow.

Perimetric examination showed the existence of a scotoma in each
eye for red and green. The scotoma was spindle shaped in outline,
placed nearly horizontal, extending in the chart from just without the
fixation point to a point beyond and including the blind spot.

His refraction, with glasses that had been prescribed some months
before, was 20/20 if the reading was done slowly.

The trouble gradually advanced, the scotomata increased in breadth
chiefly and extended below and to the inner side (as apparent on
chart) of the fixation point, by degrees invaded the latter first in left
eye and later, by April, the right. By this time reading a newspaper
became impossible except the large type in the head-lines. The patient
becoming really alarmed stopped the use of alcohol absolutely but con-
tinued that of tobacco in a lessened amount.

Ceasing the use of alcohol seemed to have no influence on the difii-
culty in seeing; the air at a distance of 200 feet and beyond, seemed
hazy or dusty and at a distance of thirty feet faces could not be surely
distinguished.

One peculiarity of the case noticed in October was that the faces
of those whom he met on the street were corpse-like and yellow, as if
of those who had died of yellow fever. The yellow tinge of the faces
of passers-by gradually disappeared until by December the tint was
simply ashy-white.

The scotomata were rarely positive, although at night when reading
they would appear and were then of a faint rose-purple tinge and were
relative, as the letters could be seen through them.

One peculiarity worthy of note appeared about December and con-
tinued until late in March, only occasionally after the latter date.

This peculiarity was the appearance in the scotomata when reading
of groups of fine lines arranged as arcs of concentric circles. The draw-
ing (Fig. i) illustrates this. In my opinion this was a shadow effect
due to the invasion of masses of nerve fibers of the papillo-macular
bundle becoming opaque and casting shadows appreciated by the per-
cipient elements of the retina as yet uninjured.

The disappearance of these lines from the page might be accepted

JOSEPH r. ircofmoft. «r.^.

ftft "tTitfence xii ixnprovcnmit in the troubte wcpc it not {or 4tc cCNOtiii-
aous increase of tiie smoky appearance of the atmosphere and tlie
faicreasing dimness m liie outlines of even large objects at a rektttvdy
short distance.

A variation of this symptom is the ** projection " of these lines on
die faces of passers-by, especially women wearing small-meshed veils
or men having a day's growth of beard evident; or even in looldng at
the sky. Here the lines are much longer, apparently five or six inches,
wavy and parallel. I use the term " projected " but am unable to under-
stand how the enlargement is produced. A similar case is mentioned fft
the end of this paper.

One symptom that has annoyed the patient is the guivering of the
sky or of a diffuse light when looking at it. A similar condition is men-
tioned among the other cases recorded herein but according to W. F.
Norris it is seen in cases of neurasthenia, especially of sexual type.

Red, if seen at a distance of more than a foot or ao, is dingy if it be
a dark red or flame-colored if rt be light red. When seen within two or
three inches of the eye the rays enter at a wide angle and affect portions
of the retina outside the scotoma and then are properly perceived.
Green acts similarly but there is no confusion of the dingy red and die
dingy green.

Within the scotoma both blue and yellow appear prie, that is
diluted with white, a very puzzling occurrence under any theory of color
vision.

A gas flame or the light of an incandescent filament gives a pan-
doxical result according to the distance at which it is seen. If seen at
a considerable distance, 250 ieet or more, such light appears as a hmii-
nous mass of amber; if seen at a distance of a foot it is plaiidy outlined
and is of a dense ghastly-white appearance.

When seen close at hand such flame ought to affect elements of <he
retina beyond the scotoma and hence should have its normal ydlow-
white color, while when seen at a long distance, chieflj' the yellow spot
and its neighborhood in the scotoma being aif ected, it ought to appear
diluted with white as does the yellow object in the perimetrical exami-
nation. Of course the narrowing of the pupil resulting from the prestii C R
of a bri^^ht light at close range may account in part for the contradictiHy
results just mentioned.

Without attempting to enter deeply into the theories of color vision
it would seem that the peculiarities of this case cannot be accounted lor
*y the Young or Young-Helmholz dieory which considers Ite recogni-
tion of what we call yellow to be a composite effect of the influence <A
the red and green rays, thus not admitting a physiological baas for the
independent existence of yellow as a primary color.

The Hering theory does admit the necessity of the latter, bnt^mi
4lien "we cannot readily account for the nmba: Xkak ci many ydlows

Fig. I. — Showing the scotniiia of left eye in reading a newspaper. The
inner lirukcn outline is that of the seolonia as it was in Dcceniher. 1898: ihe outer
contimioiis line is that nf the scotoma at the time of scndine this paper to ihe
press (November, 1899). Fixation point is marked by a cross; Ihe blind spot
i>y ihe heavy circle. The groiijis of curved lines are mo large and the lines them-
selves much too thick. These lines appear to be unci>nsciciusly suppressed when
the patient is trying to read, but when his attention is directed 10 his trouble
they appear to him.

Flc. II.— Showing the apjiearani-e. as near as may be. "f the line- nhi-n
seen in li)oking at the sky or a rough wall. etc. The figure only shows the gen-
eral effect of the curves; the lines sliould be very nmcli closer together and ot
extreme fineness.

TOBACCO-'AJLCQBQL AMBLYOPIA.

tsBctpt by the over stimulation of the green perceiving elements since
amber is only a yellow tinged with green.

Without searching the recent literature of the subject of color vision
it seems to me that our knowledge of it will be (as has been the case
in many departments of neurology) advanced more by continuous and
careful records of alterations in color perception in disease than by
investigations of the normal eye alone.

With the intention of following out the subject as far as lay in my
power I have questioned several sufferers from optic nerve atrophy as
to the alterations in color perception first noted by them when vision
began to fail and limiting the questions to this point.

Case Two. — ^Mr. A. Locomotor ataxia; has been under my observa-
tion for two years. Disks both atrophic and bluish gray. Vision as if
in a fog, large objects but dimly perceived when near. This patient's
vision began to fail some six years ago and he then noticed that the
faces of acquaintances and passers-by were '' chalky " in color, and at
the same time all the faces appeared wrinkled. In this case the same
appearance of tint in the faces of others existed as in the first, while
his statements as to the wrinkled appearance of faces was undoubtedly
the shadow effect of the projected lines seen by my first case.

This patient although having undoubted primary atrophy of the
optic nerves states that for years before the beginning of ocular symp-
toms he had used both brandy and tobacco to great excess, and this fact
leads me to the view that his optic nerve trouble mav have begun as a
tobacco-alcohol amblyopia implicating first the papilfo-macular bundle.

Case Three. — Patient in Dr. Boynton's clinic. Middle age. Optic
nerve atrophy of primary variety. Vision ; sees outlines of large objects
as through a fog. The first knowledge of his failing sight occurred
three years ago when he remarked upon the extreme whiteness of his
nephew's face. His remark was greeted with derisive laughter and he
was told that the boy had an exceptionally ruddy countenance. This
patient has had no appearance of lines either on the printed page or
upon other objects but he is even now sensitive to blue, and white causes

tain r photophobia). This patient denies any excessive use of tobacco
ut admits that for two or three years preceding the first symptoms of
visual disturbance he had associated with a '' fast set " in London who
drank a great deal of spirits. I think it is not assuming too much to
consider this case like No. 2, the optic nerve atrophy beginning, as the
result of alcohol-tobacco poisoning, in the papillo-macular bundle.

Case Four. — Patient in Dr. Shepard's clinic. Optic nerve atrophy
of right eye; left eye has fairly good vision and disk appears normal.
This patient has had syphilis and at first the trouble in right eye was
%8criVied to that cause. Subsequent examination revealed a wide spindle-
shaped scotoma for red and green with great loss of general perception
of form. He sees with right eye as in a fog but of a face near at hand

we JOSEPH T. (yCONNOR. M.D.

the features are obliterated. This patient has used tobacco extensively^
by chewing, and liquor as well. He has not noticed changes of tint in
the faces of others or the appearance of the lines, but as he is not edu-
cated his statements in this regard cannot be taken as conclusive. The
right disk appears atrophic but both veins and arteries are small.

This man when looking at the sky sees its light quivering and
trembling. His is the only one here recorded, except the original case,
in which this symptom appeared.

Case Five. — Dr. Shepard's clinic. Youn^ woman, aged 26, unmar-
ried. Atrophy of both disks; no cause discoverable. No scotoma;
fields concentrically narrowed, yet as she notices marked paleness of
people's faces it must be assumed that there is loss of perception of red
in the central region of the retina.

Case Six. — Dr. Boynton's clinic. Patient has double optic nerve
atrophy undoubtedly following a papillitis as there are still evidences
of exudation. This patient sees as in a fog. His only color-symptom
noted at the beginning of his visual loss was the appearance of '' sparks
falling from the eyes.'' The case is not to be included with those of
papillo-macular origin anatomically.

Case Seven. — Dr. MacBride's clinic. Negro, aged 26. From the
West Indies. Has had syphilis. Complete optic nerve atrophy. Loco-
motor ataxia. Has never used tobacco nor any form of alcohol. His
visual weakness began as a misty appearance of the atmosphere and
has increased until now all before him is in a thick fog. Has had no
alteration in color sense nor any appearance of the lines. The case is
not to be classed with Nos. i, 2 and 3.

My purpose in offering this paper is not to assert any new principle
in the subject of what we know as the color-sense but to elicit discus-
sion among the members of this Society who have many more opportu-
nities than fall to me to observe the course of tobacco-alcohol ambly-
opia.

I therefore do not attempt to draw any conclusions from the facts
as recorded but feel justified in offering as tentative propositions the
following suggestions :

I. That possibly a series of closely observed cases may give a basis
for a new theory of color vision.

n. That such a series among locomotor ataxics, paralytic dements,
or those having cerebral syphilis (presumed or proven) may show the
beginning of optic nerve atrophy when present to have been in the
papillo-macular bundle and with some or all of the changes of color
perception characteristic of the so-called tobacco-alcohol amblyopia. If
this proposition can be established in those previously addicted to the
use of tobacco and alcohol it will explain the hitherto unexplained
occurrence of optic nerve atrophy in those cases.

TOBACCO-ALCOHOL AMBLYOPIA.- M7

III. As a corollary to the latter proposition ; that the toxic amblyopia

mentioned when occurring in a patient who has had syphilis, has a

greater tendency to extension as a general optic nerve atrophy than in

one who has not been infected with syphilis.

I wish to record my obligation to the Surgeons and Assistant Sur-.

geons of the New York Ophthalmic Hospital (some of whom are herein

named) in placing at my disposal material from their clinics.

DISCUSSION.

Dr. Harold Wilson: In the title of this very interesting paper
occurs a query which the paper itself does not attempt to discuss. It
seems to me that when we have pathological changes in the eye or along
the optic tract with associated abnormalities of color-vision, the infer-
ence is more than justifiable that the former include the latter. The
perception of color, in common with other perceptions is a mental act,
but the mechanism of the sensation is primarily retinal. I think we
hardly need to look beyond the retina and optic nerve for the immediate
pathological explanation of acquired color-vision abnormalities.

Since receiving this paper for discussion, I have had no opportunity
of making any observations along the lines suggested by its author,
but I am very much in accord with him in the belief in the desirability
of a searching study of the color-vision in pathological cases as a
promising aid to a better understanding of the theory of color-vision.
We have not reached a perfectly satisfactory theory up to this time,
so that it is a field worth cultivating.

If any refinement in nomenclature is necessary, the author^s sug-
gestion is a good one, but even at the risk of losing some accuracy, I
question whether we might not generally prefer a short name like
^ papillO'tnacular neuritis" rather than a long one like " papillo^
mdcular fascicular optic neuritis ascendens"

IMPORTANCE OF BACTERIOLOGICAL STUDY.
By Charles Leslie Rumsey^ M.D.,

Baltimore, Md.

SOON after the invention of the microscope in the latter part of
the sixteenth century, minute organisms were founds by its
aid, in decomposing substances. Various workers in this field
began to associate these organisms with disease. The means at their
disposal were insufficient to prove any theory until Lowenhoeck of Delft,
Holland, about 1700, perfected the microscope. In his youth, Lowen-
hoeck had learned the art of grinding lenses by which he deducted
sufficient optical laws to construct a microscope. It was not, however,
until 1863 that any positive advance was made in identifying a bacte-
rium with a disease.

Bacteriology has now become a science in itself, and hundreds of
earnest investigators have so perfected this branch of study as to bear
an important relationship to both medicine and surgery.

Within the last decade, bacteria have laid a very strong hold on the
imagination and thought of the scientific world, and have come to be
looked upon as playing a most important role not only in the production
of disease and in fermentation but also in many every day processes
hitherto supposed to be dependent on very different causes.

In the last twenty years, however, owing to the vast improvements
that have been made in the methods of cultivating these organisms
and especially in obtaining what is known as a pure culture, that is, a
culture that contains only a single species of organism, most valuable
data as to the function and biological chemistry of these minute organ-
isms have been rapidly accumulated. Once a pure culture became
available, it was an easy matter to determine the conditions under
which a special bacterium would grow, for example aerobic or anaerobic.
The appearances under the microscope can give us no information on
many of these points and it is only by a most careful study of the life-
history of these organisms that any accurate information has been
obtained. It is evident from the consideration of all these facts that
bacteria must be looked upon as being governed by much the same laws
which govern other plants and animals. They are composed of proto-
plasm and their idiocyncrasies are always in the direction of their
specialization. Through this branch of study, thousands of valuable

IMPORTANCE OF BACTERIOLOGICAL STUDY, 23»

lives have been saved in our surgical wards. And only when we extend
this study into the formulation of the best sanitary laws that should
govern a municipality can we estimate therefrom the benefits to
humanity.

The claims of bacteriology must certainly merit our consideration.
They involve questions of prophylaxis and diagnosis which mark the
beginning of a new era in medicine, and discoveries in bacteriological
pathology have extended the field of therapeutic measures. It demon-
strates that a physician's chemical laboratory should be a part of his
required outfit.

We, as a distinctive school, must not stand idly by with closed eyes,
contentedly holding on only to a symptomatology of one century ago.
Had Hahnemann anticipated, his followers would be averse to all
progress and search after truth, the writer believes he would have
deplored the day he laid the foundation for our school. As it is believed
that Homceopathy is founded on an immutable law of nature, every
natural principle revealed will tend to elucidate our law of cure and
aid in its practical application. With this conviction we should fear-
lessly investigate every department of medicine and hail every principle
discovered as an ally of our own. Let the human organism suffer a
breach of the integrity of its protecting surfaces — the skin and the
mucous membranes — we can have a favorable nidus for the develop-
ment of bacteria. Reduce the power of resistance of the cells by an
unusual expenditure of nerve force in excesses of functional activity,
we shall find invading armies of micro-organisms in active struggle
with internal resisting structures, resulting either in the destruction of
the invading bacteria or their hosts. Prevent the entrance of these
germs and no infection will occur. This must assure us the need for
absolute surgical cleanliness in all surgical operations.

Plastic operations about the eye involving the use of large flaps
either with or without a pedicle are undoubtedly much more successful
now than formerly. And no one will deny that this increased success
is due in large measure to the more vigorous exclusion of bacteria from
the field of operation.

Gonorrhoeal conjunctivitis, acute catarrhal conjunctivitis, trachoma,
phlyctenular conjunctivitis, phlyctenular keratitis, serpentine ulcer,
hypopion, foreign bodies in the globe, sympathetic inflammation have
all been the subject of laboratory experiments with reference to
bacteria. If we do not concur in all the theories which have been

S40 CHARLES LESLIE RUMSEY, M.D.

evolved, the large number of recorded facts cannot but have a perma-
nent influence upon future opinion.

In the dust and crusts of mucus and dibris in the nose deposited
among vibrissae of healthy subjects, micro-organisms were alwajrs
found in abundance. On the Schneiderian membrane the reverse is
tfie case.

The close relationship existing between the eye and the nose and

the adjoining cavities allows the migration of organisgis from the nose

to the eye or conversely. It is thus true that diseases of the lachrymo-

. nasal duct and lachrymal sac are most frequently caused by pathological

conditions of the nose.

The mucus within the nose was most carefully examined for bacteria
in twenty consecutive cases. No attempt was made to identify the
various forms of cocci and bacilli except to search for streptococci and
staphylococci. There were only two cases out of the whole number that
contained the streptococci and in these cases there were nothing special
to report in the condition of the nose. The mucus was found sterile
when taken from the Schneiderian membrane in rabbits. It was deter-
mined, from these experiments, that the mucus membrane of the nose
had marked antiseptic properties.

Mycosis may be observed clinically and microscopically in any
situation in the air tract — ^phar3mx, base of tongue, faucial pillers
tonsils, nose — and, also, in the ear. Except one case, mycosis of the
ear, it has always been found in the female sex in my practice. Bacte-
riological examinations were made in four cases, in each one of which
was found the organism.

My colleagues have told me the Klebs-LoefHer bacillus has been
reported by the Health Department in cases attended by them where
there has been a malignant type of diphtheria and where there has
eventually formed no diphtheretic membrane.

The writer recognizes the importance of the study of bacteriology
and is assured of its scientific value in both surgery and medicine.
There are many queries, however, which perplex him. They can be
deducted from the statements herein made, together with the experi-
ments made by the writer himself and other citations.

Are diseases less malignant or less severe or less protracted or cures
more frequent by the knowledge of the germ theory? Mankind has
certainly not conquered germs. Influenza, a disease epidemically un-
known to Europe and the United States before the advent of the germ
theory, is to-day a horrible reality. The deaths directly attributable to

IMPORTANCE OF BACTERIOLOGICAL STUDY. S41

this q>idemic are innumerable. Otitis media suppurativa still accom*
panies scarlet fever. Hay fever gives as much misery to a patient as
previous years. Crede's prophylactic measure has diminished ophthal-
mia neonatorum ninety per cent, but gonorrhceal conjunctivitis or
ophthalmia neonatorum is as destructive a disease as before Crede's
discovery.

The conclusions are:

First: The germ theory has spurred men to the necessity to use
the microscope and perfect themselves in diagnosis.

Second: It has not promoted more cures but made the doctor
more cautious in his treatment.

Third: By Koch's rules the bacteria must cause the disease, but
the bacteria may be in existence without the production of the disease.

DISCUSSION.

Dr. Hoyt: I agree with Dr. Rumsey that the subject of bacteri-
ology is approaching a transitional stage. There is a good deal of what '
is commonly called chaff in bacteriology : that is, there has been a great
deal written and a great many investigations made, which are of no
practical use. It is a very interesting study. It is very interesting to
know whether we have staphylococci, or streptococci ; but they are not,
as a rule, of any practical benefit. For those connected with this section,
there are three forms of bacteria, which are of real, practical importance.
They are the tubercle bacilli, the diphtheria bacilli, and die gonococci.
Of course, the germ of glanders is of importance, but we run across this
disease so very rarely here, that it is hardly worth considering;
although, as we saw by the paper, only last week, the man who has done
more in the study and development of glanders than anyone else, died
as the result of infection while engaged in his work. It is very
important to know when we have a case of tuberculosis. There is
nothing that will give us a more absolute diagnosis of tuberculosis than
finding the tubercle bacillus, either in the sputum or in the encrusted
tissue, according to the form of tuberculosis we may have. In the cases
of diphtheria, the Board of Health has taken an immense weight off the
|;eneral practitioner's shoulders by assuming the responsibility of declar-
mg whether a case is diphtheria or not. It certainly helps the public
when the Board of Health says that a case is diphtheria, to take more
active precautions in prophylaxis than they would if the physician alone
said so. I think it is very important, in every case of a suspicious tonsil-
litis, to have a culture made. In diseases of the eye and sometimes of
the nose, the result of gonorrhceal poisoning, I think it is necessary to
have a bacteriological examination made, f am p^lad Dr. Rumsey said
that he thought Hahnemann would have believed in bacteria if he had
lived now. I think he would have been a progressive man, instead of
one staying in the same rut as some think he might have done. Some

14a CHARLES LESLIE RUMSEY. M.D.

day in the near future we are going to know and be able to differentiate
the germ of syphilis. Then we will be able to diagnose syphilis much
better. I heartily believe in bacteria : I think that the bacteria are the
cause of the disease and not the result, in most cases, especially in the
three I have named, of tuberculosis, diphtheria and gonorrhoea.

Dr. Rumsey : I cannot concur with Dr. Hoyt in the expression that
gonococcus is rather the result of gonorrhoea, not the cause of it. This
is contrary to the experiment I have made with gonococcus in the con-
junctival sac of a rabbit's eye.

Before a bacterium can be said to be the cause of a disease, Koch
states :

First: It must be found in the tissue or secretions of the animal
suffering from, or dead with the disease.

Second: It must be cultivated outside of the body on artificial
media.

Third : A culture so obtained must produce the disease in question
when it is introduced into the body of a healthy animal.

Fourth : The same germ must then again be found in the animal so
inoculated.

But I cannot understand, for instance, why Klebs-LxDeffler bacillus
could be found in the throat without the production of a diphtheritic
membrane. The best solution, that I can give for this and other queries
in my paper, is the soil must be congenial to the bacteria for the produc-
tion of the associated condition. And the Homoepathic remedy can
give greater resistance to the tissue which prevents the latter from
becoming a favorable nidus for their growth or can abort the disease.

ELECTROLYSIS IN HYPERTROPHIC RHINITIS.

By T. M. Strong, M.D.,

Boston. -^

WE only desire in this paper to add a word in regard to the
use of this agent in those conditions which are so fre-
quently met with, and where more or le^s destruction of
the mucous membrane is the result of the usual treatment by caustic
and electro-cautery. It is applicable to all except tUt youngest chil-
dren, and possibly very nervous patients. I have used it in children
as young as ten years of age, and failed with those much older. This
is a disadvantage, but the electro-cautery offers very little, if anything,
more in the same class of cases, to say nothing of the possibility of
burning extraneous tissues. Dr. W. Scheppegrel, in his recent work
on "Electricity in Diseases of the Nose, Throat and Ear," refers to this
method with rather a favorable bias. Dr. Morris J. Asch, in the
"American Text-Book of Eye, Far and Throat," says that "electrolysis
has been recommended by some authors; but the uncertainty of its re-
sults, and the slowness of the method, have prevented its being used
extensively."

While the uni-polar method has been used with some beneficial re-
sults, the best, and only, method, is with the bi-polar electrode, which,.
as compared with the former, is said to possess the following advan*
tages : "More rapid application, less painful, more definite in its action."

In the cases in which we have used this method, some twenty in
all, the results have seemed certainly as favorable as with the moderate
use of the electro-cautery. The most important point being the pres-
ervation of the mucous membrane practically intact, for the needle
punctures heal at once. Other advantages are the absence of any
slough, and avoidance of the danger of synechiae. With some there
is very slight reaction, while in others it is more severe, the pain of a
dull, nagging character, lasting for several hours, while the nostrils
feel full or stuffed up. This reaction, however, is not as severe as
seen in some cases, where the electro-cautery has been used, while in
the majority of cases it is less. The application may have to be re-
peated several times, but as the pain is only at the moment of puncture,
this is not a serious objection, and the same thing holds good with the

244 T. M. STRONG, M.D.

cautery. By puncturing at different points, antero-posteriorly, at the
several sittings, the whole length of the inferior turbinated may be
treated. We have not had occasion to try this method on the middle
turbinated, but do not see any reason why it should not be as satisfac-
tory as on the inferiors, and where, as a rule, the use of the cautery
is contra-indicated. It is said that the shape of some nostrils may
prevent its use, but under those circumstances the cautery would hardly
be more serviceable.

We have used the Nosmas cells, with an electro-motive force of a
little over one volt to a cell. The application was made with the bi-
polar electrode, using six to eight cells, with a current of five to ten
milliamperes, for five minute^.

My patients, as a rule, rather prefer the electrolysis to the cautery,
where a trial of each has been made.

The fact that the mucous membrane of the nose is so well-pre*
served ought to make this method the preferred one in hypertrophic
rhinitis, especially when no harm can result from failure to relieve,
whereas, with the cautery, as we know, to our chagrin, the harm done
has been a serious protest against its use. Very little oozmg of blood
follows the removal of the electrode, very seldom is it necessary to
leave in a plug longer than while the patient is in the office. Some^
times if the needle is not fully buried in the tissues, oi protected with
a shellac coating, you may get a slough at the point of entrance, but
it is of a minor degree of severity. We have not been able to use a
current of over ten milliamperes, nor is it usually necessary, in cmly a
few cases, the average patient objecting to the stronger current

DISCUSSION.

Dr. Townsend : I have just a word to say in regard to Dr. Strong's
statement that he considered the electro-cautery might be used with
impunity in the throat. I do not think it should any more than in the
nose. In the throat, perhaps, it may be less liable to abuse ; but I have
seen cases of quinsy develop in patients who had never had quinsy
previously, after the electro puncture. Have also observed quite paiiH
ful inflammatory conditions arise where the cartilages of the larynx
had been touched with the electro-cautery. The cartilages here are
quite as intolerant of cauterization as they are elsewhere. A great
deal of dryness and discomfort where the electro-cautery has been
used to destroy pharyngeal and naso-pharyngeal adenoids (as
quite extensively done at one time) is commonly observed.

HYPERTROPHIC RHINITIS.
By John B. Garrison, M.D.,

Kew York.

HYPERTROPHIC RHINITIS is a chronic inflammation of
the nasal mucous membranes, where the blood-vessels bo-
come permanently dilated and there is thickening of th^
deeper tissue sufficient to produce a stenosis of the nasal canal.

By many it is supposed to be a continuation of a catarrhal process,
primarily caused by taking cold; other authorities contend that thii
chronic condition sets in in the beginning, ante-dating the colds them-*
selves, and the contention seems with good show of reason. Trau-
matism is, no doubt, one of the most frequent causes of the hyper-
trophic condition in the nose, and injury to the septtun, causing devia-
tions, is most frequent, especially during childhood, when falls and
bumps are common and the face so often comes in contact with chairs,
doors, and floors. The softness of the bones and cartilages during
an early period of life causes many injuries here to go practically
unnoticed, so that it is entirely within the bounds of probability that
these injuries may produce conditions that are the startmg point of
nasal stenoses later on. Other causes are due to the surroundingSt
as constant working in an atmosphere laden with dust or noxious gases,
which cause the mucous membrane to become irritated and' finally
inflamed.

A rheumatic habit seems to be the direct cause in some cases, and
we have frequently seen a distressing nasal condition pass rapidly away
under a treatment directed to the cure of a local rheumatism without
thought of the nasal hypertrophy.

Under, normal conditions the nasal mucous membrane secretes %
pint or so of serum, which is all taken up as we breath so rapidly that
we are not conscious of its presence. Under diseased conditions, how*?
ever, when the membrane becomes thickened, the passage of the serum
is interfered with, and the amount given off is less than usual, which
causes the blood-vessels to become overloaded, and distention ensues.
The discharge from the nose then becomes thicker, and has a tendency
to become lodged in the canal or drops back into the pharynx, to bt
hawked therefrom.

M6 JOHN B. GARRISON, M.D.

As the hypertrophy increases, nasal stenosis is more apparent, and
mouth breathing becomes necessary upon exertion, and at night in
cases where it is not noticed in the day-time, the mouth-breathing is
frequently a prominent feature.

As the secretion becomes thicker, the accumulation at night is
larger, and becoming more or less inspissated, it often requires con-
siderable effort in the morning to dislodge it, and irritation of the
pharyngeal mucous membrane, and a constant sensation as of some-
thing in the throat that must be cleared away, is a constant annoyance.
As a result of the breathing through the mouth so much we have a
dryness of the mucous membrane, and a troublesome cough is fre-
quent; elongation of the uvula is said to be the result of nasal in-
flammation. Deafness is a frequent result of hypertrophic rhinitis.
Headaches are frequent, particularly in the frontal region, and from
the pressure of turbinateds against the septum and consequent im-
perfect drainage, the accessory sinuses frequently become the seat of
inflammation.

The mental powers may become impaired, incapability of atten-
tion to business from the mental dullness may occur, and sometimes
even intelligent speech may be almost impossible. In all severe cases
the general tone of the system is much below the proper standard,
owing to the lack of proper oxygenation of the blood.

Diagnosis. — Using a nasal speculum and having the patient in a
good light we see the mucous membrane to be of a pinkish-red color,
and we notice the thickened and swollen membrane, particularly over
the lower turbinated bone and at the prominence of the deviation of
the septum, if one occurs. There is usually a viscid, stringy secre-
tion covering much of the mucous surface. Sometimes we may find
almost total occlusion of one of the nares from the hypertrophy of the
inferior turbinated.

A posterior examination will reveal, when we look at it with the
aid of a rhinoscopic mirror, a peculiar appearance.

Lying on one, or both, sides of the septum will be seen whitish,
rounded masses, looking very much like grub-worms.

The middle turbinated^ are not usually very much enlarged posteri-
orly, but the inferior turbinateds are frequently so much hypertrophied
at their posterior ends, being roughened so as to look seedy after the
manner of a raspberry, as to nearly, or quite, fill the oval openings of
the posterior nares.

Now make an application of a four per cent, solution of cocaine to

HYPERTROPHIC RHINITIS. 247

the whole of the nasal mucous membrane; using for the purpose a small
pledget of cotton on a metal applicator, and in a short time there will
be a shrinkage of the swollen parts that will permit a much more ex-
tended view and will enable a calculation as to the amount of true hy-
pertrophy that exists.

Normally, under cocaine, the turbinateds would present a very
thin line, but there will be more or less thickness and roundness to the
edges now, in proportion to the amount of connective tissue hyper-
trophy that obtains. The changes seen posteriorly after the applica-
tion of cocaine are not so great as they are anteriorally, but there will
be some.

Treatment. — Keep the nasal cavities free from all accumu-
lations of mucus. In some cases it will be advisable to use a small
application of a four per cent, solution of cocaine or supra-renal ex-
tract to contract sufficiently to cleanse the cavities thoroughly.

Where there is contact between the septum and the turbinateds
some surgical interference is usually necessary. If the septum pre-
sents any deformity, that must be corrected. The hypertrophied tur-
binateds may be treated by means of the knife, forceps or scissors, but
it should be borne in mind that the object of any treatment must be
to produce a lessening of nutrition by the contraction of the blood-
vessels and a regaining of their healthy tone.

Any operative measure that is likely, by the removal of too much
tissue, either by cutting it away in mass or by producing too much of
a cicatrix, to produce a condition of atrophy, is to be condemned, and
the use of cutting instruments is thought by some to be unscientific,
while others, equally skilful, claim for them the most beneficial re-
sults, being able to see with accuracy just what they are doing. The
treatment should be to conserve tissue where possible, however and
whatever form of treatment the individual operator finds best suited
to his uses from practice should be used.

Excellent results have followed the author's use of chromic acid
and the galvano-cautery, both used with the view of accomplishing the
same end. The tissues are first well contracted under cocaine or
eucaine or supra-renal extract after the application of the latter;
if chromic acid is to be used a few crystals are fused on a probe and
applied carefully to the part most prominent, and a retaining scab will
result. If the galvano-cauter>' is to be used the knife should be heated
to a dull-red heat and applied by passing it flatwise slowly over the
hypertrophy, the result being the same as in the former method. A

ta JOHN B. GARRISON, M.D.

few treatments at intervals of perhaps a week wiU generally g^ve grati-
fying results.

The posterior hypertrophies can best be removed with a cold wifie
snare.

Medical treatment, the remedy being chosen homocopathically,
should never be neglected, and in the earlier stages particularly cures
can and will undoubtedly follow.

DISCUSSION.

Dr. Isaac Soule: The distinguished author has, along with many
others, found it next to impossible to discuss hypertrophic rhinitis
without to a certain extent including the much broader subject of nasal
stenosis. The one great fault, it would seem, with the paper is that
its author has given us too many generalities and far too little of his
personal experiences, too much aetiology and not enough treatment.
As to the much discussed point of whether the hypertrophic condi-
tions follow or precede the acute conditions, careful observations would
seem to pve credence to both propositions. Where the causes produc-
ing the h)rpertrophies are purely, or very largely, local, the hypertrophy
in all probability follows the numerous, neglected, closely successive
acute inflammations. This will, however, account for but a comparar
tively small per cent, of our cases, the remaining number being due
to constitutional conditions which, acting through the vaso-motor and
sympathetic nervous systems, become manifest in the nasal mucosa,
preceding the acute inflammations, being only aggravated thereby.
In the diagnosis much aid may be obtained from using the extract of
supra-renal capsules, the tissues becoming exsanguinated under its
action much more fully and rapidly than under cocaine, while, as it
may be sprayed into the nose, without fear of troublesome after-effects,
it can be much more readily and thoroughly applied. The necessity
of making the observation, as to color, etc., of the mucosa becomes evea
more imperative when using supra-renal extract, as the blanching is
even greater than that of cocaine. There is one point in connection
with the diagnosis of a certain form of hypertrophy of the inferior
turbinate which the author has not mentioned, and which I have never
seen in print, that I remember. I refer to the hypertrophy of the in-
ner edge, that portion of the scroll, if I may be allowed the expression,
of the bone which lies between the body or main portion and the exter*
nal wall of the nose. This Is not visible by either anterior or posterior
rhinoscopy, and can only be discovered by inserting a probe withia
the space described and pressing downward toward the floor of the
nasal cavity. I have frequently encountered cases where, to all ap-
pearances, the lower meatus was perfectly free, yet the patients com-
|>lained of a full, stuffy feeling, especially at night llie procedui^
just described would bring into view a roll of hypertrophied tissue, the

HYPERTROPHIC RHINITIS. a4»

removal of which gave immediate relief. The treatment must, if suc-
cessful, be based upon the removal of the exciting cause. If our pa-
tient suffers from a chronic indigestion, constipation, kidney or liver
trouble; if afflicted with rheumatism, gout or uric acitf diathesis; if a
woman and suffering from some disease peculiar to her sex, our great-
est hope of curing our patient must lie in the careful, painstaking selec-
tion of the Homoeopathic remedy, according to the totality of the symp-
toms obtained from the entire body, and not merely those of the nose
alone. Those of us who have tried the experiment of taking plenty
of time to study our case, and materia medica for just the one remedy
for that case, instead of making an off-hand haphazard guess at what
it should be, have been more than repaid by the cures obtained. It
takes constant work to practice good homoeopathy, for the nasal spe-
cialist, as well as the general practitioner. Locally nothing has g^ven
me the same amount of satisfaction as the scissors or knife and the
electric cautery. Where the hypertrophy is localized, cut it off; if
general sub-mucous electro-puncture, using a long, thin, narrow,
sharp-pointed electrode, has given entire satisfaction. I think less lia-
bility to inflammatory reaction follows the use of the point heated to
nearer a white heat, than that advocated by Dr. Garrison. The same
treatment is advocated for posterior h)rpertrophies where treatment of
any kind is necessary. In the majority of cases when there is a large
anterior hypertrophy, the enlargement posteriorly is largely comple-
mentary hypercemia, with only a small amount of hypertrophy, which
usually disappears rapidly, under the action of the homoeopathic rem-
edy, when the anterior hypertrophy is reduced. For hypertrophy of
the middle turbinated the snare or some of the cutting instruments
is the safest treatment.

CANCER AFFECTING THE EYE AND NOSE.

By J. H. Harvey, M.D.,

Toledo, O.

CANCER is a term applied to an infiltration or growth, chronic
infectious in character, with sharp lancinating, paroxysmal
pains, infiltration of the adjacent lymphatics, a peculiar dis-
tinct diathesis in which anaemia, cachexia, constipation and prostra-
tion are prominent symptoms.

Its stage of incubation is usually long, in some cases extending
over many years, during which time it is seldom thought of as being
cancer.

It is of protozoic or parasitic origin, and is dependent upon the
defects and vices of civilization that tend to produce cerebral and
sympathetic depression and exhaustion, such as worry, grief, monot-
ony, sleeplessness, struggle for existence, over-work and use of neu-
rotics. In such conditions of impaired vitality and lowered body
resistance there is little difficulty for the evolution of the cancer neo-
plasm, which, it IS fair to presume, has its birthplace from degener-
ated bioplasm, probably in the pink bone-marrow, where it has easy
access to the circulation, and in which it may be overcome and die,
or find lodgment in some weakened tissue or gland that has been the
seat of irritation or injury, with relaxed blood-vessels, collection of
infiltrations and partial death of tissue making a condition favorable
to the proliferation of the protozoic parasites. These parasites, as
described by Plimmer, are round bodies varying in size from .04 to .004
of a mm. in diameter, with a nucleus surrounded by protoplasm en-
closed in a capsule. They are looked upon by many as simply de-
generated forms of tissue, but they have none of the reactions of any
known degeneration, and are seldom if ever found in degenerated por-
tions of the growth, but in nearly all cases are found in abundance
in the zone of its periphery, the developing portion of the growth or
tumor.

The line of differentiation between healthy and diseased or in-
fected tissue is very uncertain because of the migratory power of
these micro-organisms.

CANCER AFFECTING THE EYE AND NOSE. 261

The toxic product of these active bodies is responsible for the
systemic infection of the later stages.

Constipation is present in the great majority of cases, and dates
back among the earliest S3rmptoms. This is certainly due to the de-
pression of the great sympathetic v/ith damage to the solar plexus,
causing inactivity of the bowels. In every case of cancer of the eye,
antrum, nose, or ear, there is a premonitory stage often long associ-
ated with chronic inflammation and irritation, producing conditions
favorable for the colonization of the parasites where they proliferate,
grow and flourish.

Cancer is at first apparently a local disease, but all admit its ulti-
mate malignancy and certain death if let alone. It is in this early
stage that the condition should be dia^osed as cancer and treated
energetically. The time has passed when we should wait until the
patient is forty years of age before we dare to diagnose a condition
as cancer. In these days of nervous exhaustion, the stage of incuba-
tion is many times passed at the age of 30 years. The frequency and
malignancy of cancer have been in pace with the progress of civiliza-
tion. Among the savage and semi-barbarous it is almost unknown.
While nearly all other infectious diseases have grown less niunerous,
cancer is doubling its victims every ten or fifteen years.

We have been too long treating effect and not cause of the dis-
ease. There is too little attention paid to the conditions favorable
to its evolution, and the patient is allowed to go on until reaching a
stage where only an operation will give any hope for life. It has
been his only hope, and he is slow to accept its horror until death
stares him in the face.

The curative treatment of cancer must begin in its early stages
by both local and constitutional measures upon an antiparasitic and
germicidal basis. The patient must be relieved of his condition of
impaired vitality, revive the bodily resistance, build up the system,
relieve the constipation, promote the action of the skin, vitalize the
great sympathetic. And when this is done the local condition will
many times disappear.

Locally I use paste in preference to the knife, with few exceptions.
A paste that penetrates quickly and effectively pves greater certainty
of success, requires the removal of less tissue, and leaves less deform-
ity, with little scar tissue.

The inflammation set up in surrounding tissue by the applica-
tion of paste is sufficient to break up and destrov any scatter-

teS /. H. HARVEY, M.D.

\tig pdirasites for a distance nearly as ^eat as the radius of the
surface covered by the paste. Herein lies the secret of the success
of the paste treatment, but unless used early it fails if you do not
eombine with it the general tonic treatment. I keep my patients oa
a constitutional treatment for about five months after the local condi-
tion is apparently well.

To use paste successfully requires just as much skill and experience
ins does the use of the knife. You should have a knowledge of the
form, location, rapidity of growth, stage of degeneration, and extent
of invasion of each case. You must also know the effect of your paste
hi each stage to be able to get the desired effect without unnecessary
tnutilation of tissue.

Removal should be rapid and complete, or should not be under-
taken, as application of mild means simply acts as a stimulant and does
more harm than good.

DISCUSSION.

Dr. Wells : I only had an opportunity to see this paper about half
an hour ago, and so have not been able to write any discussion of it.
The subject is certainly one of the greatest importance, and I con-
fess that I am hardly enough of a pathologist to properly enter into
all the details which ought to be considered. It seems to me that the
name "Cancer" is rather an indefinite one for us to use, among our-
selves at least. We should have a more specific term. I assume that
the writer, under the term "Cancer," means neoplasms of both a carci-
nomatous and sarcomatous nature. In dealing with this subject —
one of so much importance — ^we ought to use terms that would be a
little more diagnostic and specific. The pathology of Weichselbaum
recognizes two forms of malignant neoplasms: the carcinomata being
those of epiblastic origin, divided into those starting in the skin, called
the epitheliomata or flat-celled, and those forming in the mucous mem-
brane of the glands, called adenomata or cylindrical-celled. The other
form, which I assume the writer includes under this name "Cancer,"
is the sarcomata, which always start from the mesoblastic layer, or,
rather, from those tissues derived from the mesoblast, like the con-
nective tissue. If some such division as this be followed, we will be
able to discuss the question of what a growth really is, and the value
of the therapeutic measures employed.

With regard to the etiology of any or all these forms, I think that
the parasitic nature is not proved; and it seems to me that Koch's
law that there are certain things necessary to prove the parasitic ori-
gin of a disease, must be insisted upon, viz., that a healthy animal must
be inoculated with the germs of the disease, and the disease be pro-
duced in some similar form in the healthy animal in which those same

CANCER AI'FECTING TtiE EYE AND NOSE. 263

germs must be again found, to prove the causative relation. Until
that is done, I do not think we have any right to claim that a dis-
ease is caused by a certain specific micro-organism. Neurasthenia
has been spoken of in connection with the etiology. By some recent
writers it has been claimed as a direct cause of various growths of this
sort, especially the carcinoma. It has been defined by some as "tissue
gone mad" — this lack of nerve control over the proper cell develop-
ment leading to the invasion of surrounding tissue, which is the diag-
nostic sign, I believe, of malignancy. Speaking of malignancy, an-
other point which ought to be considered is, I think, the question of
the juiciness of the growth. In just so much as it is a succulent
growth will it invade the neighboring glands and metastasis take place.
Another point about which the doctor is not sufficiently explicit is the
diagnosis. Especially in the early stages, I know of no way by which
a diagnosis may be made except microscopically; and I see no reason
why this cannot, in a large majority of cases, be done by simply remov-
ing a portion of the growth, if it be large, or the whole of it if it be a
small growth, and making sections for a microscopical examination. In
judging of the therapeutic value of different measures and deciding
as to which are the most successful, the question of diagnosis must be
definitely settled, and it is the question about which all the arguments
will naturally arise. Unless that matter is definitely determined, we
shall never know that it was a malignant growth that was treated.

The doctor does not tell us about this paste. I should like very
much to know what it is and also his mode of application. I assume
that it must be some form of arsenical paste. He also states that
the scar tissue will be less. I confess that I have had no experience
with the paste treatment, but it seems to me that a clean wound, when
a growth has not advanced any farther than it need to in cases of this
sort, leaves very much less scar than any large application of a local
paste ; and, certainly, it must be a much cleaner method of treatment.
He also says that this matter must be taken in hand with the "inten-
tion of eradicating it, that mild measures do more harm than good."
In this very fact, it seems to me, lies the danger of the paste treat-
ment; and I confess that, theoretically, I can see no reason why this
sort of treatment would not tend to disseminate the poisonous matter
of the growth ; and, from my limited knowledge of the subject, I should
feel very much safer in removing all the tissue of any suspicious
growth that looked dangerous, by clean surgery. It seems to me
that that treatment is, theoretically at least, a much better treatment.
I do not know what success has attended the injections of erysipelatous
toxine. I have read some account thereof, but have not had any per-
sonal experience in the matter. Certainly it is a subject demanding
a great deal more time and ability than I have to offer in considera-
tion of it.

Dr. Hoyt: I think with Dr. Wells that the paper lacks a proper
method for the diagnosis of cancer. No foreign growth can be diag-

254 y. //. HARVEY, M.D.

nosed exactly withoiKt a microscopic examination. Symptoms do not
go for an exact diagnosis, and all the symptoms of cachexia may be
present with growths that are not malignant, which tmder proper
treatment will all disappear. The examination microscopically of that
same growth will prove that there is no malignancy. And the ques-
tion of "cancer," which used to apply to almost any growth which
might take on an apparently malignant character, is now accepted as
only applying to carcinoma. The New York State Legislature has
appropriated quite a large sum of money to establish a laboratory
under the direction of Dr. Park of Buffalo, to examine into cancer,
and find the cause and cure, if possible. I think he would be very
glad to know that we had a paper here which told us all about can-
cer, and how it originated, and what it consists of. In regard to the
paste, the doctor said it left very little scar. I never saw any case
in which there was not a very bad scar in proportion to the size of
the tissue removed, from the little papillomata which appear on the face
to the cancer of the breast.

Dr. Haywood : On a patient upon whom I operated a few months
ago, I am sure the paste would not have had any effect She was 68
years old, and had what was called a "'tumor" removed from her eye
four years before. It returned, and she consulted the same oculist
He told her that she had cancer of the eye, and he would have to take
the eye out. She dreaded such an operation, and came to me. I
told her that there was no doubt of its being a cancerous growth, and
I thought the growth could be removed and possibly the eye retained
for some months, possibly another four years. I removed the growth,
which was the size of a good-sized pea, attached at the comeo-sclera
margin, with the base extending down to the lids and a little on to the
lower lid. I removed that under cocaine, cauterized the base with
nitrate of silver, and in a few days everything was all right, excepting
a little symblepharon which, of course, I explained would be expected.
I saw no more of the case for about eight months, when she came
back, and I found the growth had returned not where I had removed
it, but a little further around toward the outer angle of the eye. The
caruncle also had become involved, and was as large as a smaJl
cherry. The lid was also becoming thick and showing involvement
I told her then the only thing was immediate enucleation. The first
of January of this year, just six months ago, I removed the eye, to-
gether with the caruncle and all the inner portion of the lower lid.
The eye healed beautifully, and she was discharged from the hospital
in a week. There has been no sign of any return of any pain or un-
pleasant feelings in any way from that day until now. Of course I
told her friends that as she was 70 years old that th^. growth would
no doubt return either in the orbit, or, possibly, in the other eye, as
at that time there was a slight growth the size of a pin-head at the
comeo-sderal junction. The growth was a sarcoma, and I look for
die involvement of the other eye in the course of time, if she lives long

CANCER AFFECTING THE EYE AND NOSE 266

enough. I am sure a paste, in that case, would not have been of any
avail at all.

Dr. Phillips : I have had two cases in my private practice of what I
diagnosed as epithelial cancer. No microscopic expminations were
made. In one of these cases before I saw it thc^ growth had been re-
moved, but at this time was as big as a cherry and had broken down
at one point and begun to discharge. The case healed up fairly well
under the use of Arsenicum, but in the course of a few months it re-
appeared and I extirpated it. In six months the growth reappeared
again, and a suppurative process commenced. She then refused to
have any further operating done. I don't recollect, in fact, that I
urged it, but I made use of Arsenicum again, the second trituration,
dusted onto the raw portion of the tumor twice a day. The result has
been that the tumor gradually disappeared. It is now between five
and six years ago, and there has been no return of the growth. In
another case I made use of Arsenicum in the same way, and the result
has been that the progress of the trouble stopped. The scar is a
healthy one along the edge of the lid, and the man has had no fur-
ther trouble. I have also treated three other cases in the clinic similar
to the last. They all occurred upon the lower lid. The one that
was the largest was, perhaps, the size of a small pea. There was a
raw surface in each case, and I made use of the Arsenicum in the same
way and the cases healed. I believe that the late Dr. Mitchell of
Chicago was the first to suggest this line of treatment; and the cases
that I have had under observation have seemed to do so well under
this line of treatment I would like to inquire whether any of the mem-
bers of the society have had a similar experience.

Dr. Keeler: I have given the Mitchell treatment a very thorough
trial in my practice. I well remember at the time it was first presented
to the profession I had on hand a case of epithelioma of the lower lid
at the outer canthus that had been diagnosed as such without
any doubt. This involved more or less of the mucous membrane,
although it seemed to prefer the skin to the mucous surface. I speak
of that because, later on, you will see that in my experience it has
followed that where the growth has come upon the skin I have had
little or no effect ; if it has come upon mucous membrane, I have had
very good results. This treatment was continued faithfully for some
two or three months, without any diminution in the size of the growth
or relief of the symptoms. I then removed it by an operation. That,
I think, was nine or ten years ago, and the man is well to-day. The
next case that I had was one upon the vermillion border of the lower
lip, where the malignancy was such that I had no appreciable results
with the arsenic treatment. I removed the entire lower lip, making
a V-shaped incision, going down to the base of the chin. Then I per-
formed a plastic operation on the chin, bringing in new tissue from
either side to form a new lip, and was delighted with results. To-day
the patient is in perfect health. The next case I used this remedy in

266 /. H. HAR VEY, M.D.

was an eye case, where the growth seemed to be favoring the mucous
membrane. In this case I had very fine results. A professional
friend, upon my suggestion, used it in a series of cases of undoubted
epithelioma of the cervix uteri. Under his treatment I have watched
these cases and seen remarkable effects, but not in the large growths,
or those that were far developed. Where there was not a great amount
of sloughing, ulceration, or anything of that kind, but in the incipiency
of these growths, where, perhaps, there would be in some cases a
growth the size of a large cherry. In those cases I have seen the best
of results. Whether it has been merely a coincidence or not, it has
been the case certainly in my practice, using this form of treatment
in at least twenty cases, that I have found it of little or no value in
cases where the growth has confined itself to the skin, while where the
mucous membrane has been involved I have secured the most satis-
factory results.

Dr. Harvey : I use several kinds of paste, of different strengths, de-
pending upon the condition. Arsenical paste, composed of equal parts
of arsenious acid and gum acacia, is very good for small and super-
ficial conditions, or the destruction of a large amount of diseased
tissue, which should be removed rapidly. I use either the chloride
of chromium, chloride of zinc, chloride of mercury, or ozone paste.
Sometimes caustic potash is used, though it is very severe and re-
quires great care and attention. Some of these pastes will penetrate
diseased tissue one inch in twenty-four to thirty-six hours. The
paste should be applied once or twice daily, depending upon the loca-
tion and general condition of the patient. Where it is necessary to
penetrate deeply, it is well to cut away the dead tissue every second
day. There is some pain, which can be nicely controlled by the in-
ternal use of papine or the local use of eucaine with the paste. After
the diseased tissue has been penetrated and killed, nature throws it
off by the sloughing process. The cavity is then packed for twelve
to twenty-four hours with cotton saturated with HjO,, which is fol-
lowed by the continuous application of a stimulating ointment that
protects the granulating surface from the air, and in a short time it
skins over with very little scar tissue. All my patients are kept upon
a constitutional treatment from two to six months. The system should
bie toned up and the bodily resistance brought to normal, if possible.
Herein lies the mistake of many operators, whose cures would be more
numerous if they would give as much attention to the patient as to the
operation.

MYDRIATICS, MYOTICS, AND LOCAL ANAESTHETICS.

By Bushrod W. James, M.D., LL.D.,

Philadelphia, Pa.

THE development of medical and surgical science and the sped*
alties, gradually demanded not only more elaborate methods
by which to diagnose peculiar and complicated cases, but
more merciful plans by which to search deeper into the human system,
which, while often requiring painful and sometimes prolonged examina-
tion, compelled the patient to offer physical resistance by reason of his
vision of surroundings, together with an involuntary resistance tliat
results even while the brain is perfectly cognizant of the stem necessity
for quietness and while being entirely willing to submit to the opera-
tion, yet is unable to control muscular action.

Of all the organs of the anatomy the eye perhaps is the most acutely
sensitive, while vision is so important as to be very dear to every indi-
vidual. The eye, unfortunately, is very subject to injury, to disease, to
hereditary defects and more likely to be affected by senile changes with
advancing age than other organs of the body. Many physicians have
been led to devote their entire medical lives to this specialty, for the
object of ameliorating suffering and averting blindness, or endeavoring
to restore the sight. Formerly the extreme sensitiveness of the organ
made even simple examination painful and difficult with even the most
stoical patient, while operations were many times unsuccessful from
such cause.

It is not marvelous then, that ophthalmologists hailed with keen
appreciation the knowledge that there were certain agents that pro-
duced anaesthesia and others that caused dilation of the pupil and tem-
porary paralysis of the ciliary muscles, enabling an examination of the
refraction to be more clearly made.

MYDRIATICS.

Mydriasis, amydriasis, platycoriasis or coromydriasis or medicinal
dilatation of the pupil, being the narnes given to this desirable condition
by the older writers, the preparations from drugs producing this re-
sult are now named mydriatics, the most important of which I will
herein enumerate, and briefly summarize their properties.

258 BUSHROD W. JAMES, M.D., LL.D.

Atropine. — Atropine was the first, and for a number of years the only
true mydriatic known to ocular science. It is an alkaloid obtained from
the plant atropa belladonna. It is also present in datura stramonium to
a limited amount. It is such an active agent as to cause enlargement of
the pupil and paralysis of the ciliary muscle by its local application to
the conjunctiva, in solution of one drop of the sulphate to one hundred
and twenty parts of water. The usual preparation by oculists at the
present day for refraction work is a one per cent, solution, and the
action of this strength lasts for seven or eight days. But the effect
differs in individuals, the eyes of adults and older patients requiring a
much longer time to secure the full effect than those of more youthful
subjects.

The discovery of the power of this drug, of dilating the pupil and of
paralyzing the ciliary muscle without injury, and thus holding this
n]usclc and the iris in complete subjection for days, was a great boon
to oculists, who found themselves permitted to make acquaintance with
the optic nerve and the retina and fundus generally, under mydriatic
influence, which it was impossible otherwise to gain. In the use of this,
and other drugs afterward discovered to have the same power, it was
also found that certain dangers attended the use of these toxic solutions.
If used in quantity or in great strength, they were liable to flow into the
canaliculi and thence into the nasal duct, nasal cavity and mouth, or
pharynx, and trickling down the throat, thus being swallowed, pro-
duced great disturbance of the digestive organs and nervous system,
with the possibility of a fatal result if used in great quantities or the
use maintained for a considerable time by frequent instillations. It is,
therefore, alwa^ys advisable to maintain pressure and hold the canaliculi
closed during the lengthy administration of any strong solution ox a
toxic mydriatic, myotic or local anaesthetic when used in the conjuctival
sac.

The consensus of opinion is, that atropine is the most desirable of
all the mydriatics in spasm of the accommodation or where long mydri-
asis is required, because added to its length of influence it is the least
dangerous. Some individuals, however, are very susceptible to its
action, and I have seen the ocular pupils dilated and the throat very red
and dry from the continued use of a belladonna plaster to the skin, with
unmistakable ciliary irritation, while I have also seen the face deeply
flushed with such use. Then again, where small portions have touched
the fauces I have marked the throat assuming a very dry, red and

MYDRIATICS, MYOTICS, AND LOCAL ANAESTHETICS. 26»

irritable appearance, these latter symptoms giving a positive denotation
of local belladonna intoxication and congestion.

Daturine. — Daturine is an alkaloid from the plant datura stramo-
nium, abundant in this locality, otherwise known as "J^n^^stown Weed'*
or "J^"^son Weed" in America, and as "Thorn Apple" in the British
Islands. The sulphate is generally used, and it is almost identical with
atropine in its action, many of the properties of which it possesses. It
is also' closely allied in its nature to hyoscyamine.

Eyoscyamine. — It is the alkaloid from the plant hyoscyamus niger,
the sulphate being in the form of clear needles, soluble in alcohol and
slightly soluble in water. It is, if anything, more prompt in its action
than atropine, and it has been claimed to be less dangerous than this
preparation from belladonna. I have seen serious cerebral disturbances
caused by the use of both datura and hyoscyamus, and I am, therefore,
led to express a little cautious timidity regarding the use of the alkaloid
of either of these crude drugs.

Dnboiaine. — Duboisine is an alkaloid obtained from the duboisia
myoporides. Used in the sulphate it acts more powerfully and quickly
than many other preparations, but it is not durable in effect, being,
therefore, quite unsuitable for protracted examinations. This drug is
considered by some practitioners as useful in mental diseases if admin-
istered hypodermically; but even then its action is evanescent, though
it may be quite advantageous in diagnosing certain cerebral conditions.

Scopolamine. — Scopolamine, the alkaloid of scopolia atropoides, is in
some sense more effective than atropine, but it requires as much, if
not more, care in its administration. Scopolamine resembles a prepara-
tion obtained from scopolia japonica, or Japanese belladonna, and called
scopolenine. Scopolamine is preferred in the form of the hydrobromic
salts, and is, indeed, adopted by some oculists as their standard mydri-
atic. This drug is also used as a sub-cutaneous remedy in the treatment
of insanitv.

Oelsemine. — Gelsemine is a resinous concomitant of gelsemium sem-
pervirens. It is not only doubtfully variable in its influence upon the
eye, but it is also liable to produce a serious disturbance upon the
human system, particularly upon the heart. It should be used with
extreme caution ; indeed, except in special cases I should avoid its use
entirely, other drugs being less dangerous and equally as well suited to
the attainment of the end desired.

Kydrine. — Mydrine or mydrin is a combination of one part of
homatropine hydrobromate to one hundred parts of ephedrine, as pre-

160 BUSHROD W. JAMES, M.D., LL.D.

pared by the eminent chemists Merck & Co. It acts quite rapidly, the
pupil expanding in eight minutes, the full effect passes off in about six
hours, the diminution requiring only twenty minutes in most cases.
Mydrine does not act to any appreciable extent upon the ciliary muscle;
its value, therefore, lies simply in its power as a pupil dilator for
ophthalmoscopic examination. Ordinary refraction examinations can
proceed very satisfactorily while the pupil is under the influence ol
mydrine, one of its most desirable qualities being that it leaves no un*
pleasant after effects.

Hyoscine. — Hyoscine, really isomine with hyoscyamine, is one of
the drugs which need not be called upon imless in the absence of its
complementary mydriatics. It is otherwise administered hypoder-
mically to produce sleep or to quiet the nervous excitement of insane
patients.

Ephedrine. — Ephedrine is the alkaloid of Ephedra vulgaris. It is
a mild mydriatic, but when combined with homatropine hydrobro-
mate it produces better results than when employed alone. The mydri-
asis of ephedrine is quite ephemeral ; it is, therefore necessary to carry
on the refraction examination while both drugs are working at maxi-
mum intensity, to obtain their full value.

Cocaine. — Cocaine, the alkaloid of er)rthroxylon coca, is not an effec-
tive mydriatic when used alone, but when combined with other drugs it
produces more decided dilatation than can be obtained by any one alone.
It is considered particularly desirable in many instances because of its
anaesthetic quality. It is very frequently used by oculists in conjunc-
tion with homatropine in varying strength, according to the judgment
of the operator, most oculists asserting that it intensifies the action of
the latter.

Homatropine. — Homatropine is an alkaloid derived from tropine,
which is sometimes used as a mydriatic. It is rapid in dilating and safe
from after results. As a mydriatic I am quite fully satisfied with homa-
tropine hydrobromate, preferring to use it alone, since I have found in
long experience with it that even cocaine admixture does not greatly
aid its mydriatic influence. In fact I have discovered that it seemed
sometimes to retard or change the action of the homatropine. The latter
I have of late years quite adopted as my standard mydriatic. I prefer
to use it in a sixteen grain solution recently prepared before application,
because the drug loses its intensity with age. My manner of using it
to my own satisfaction is by drop instillations, two minutes apart, until
I have used three drops. I allow my patient to wait at least one hour

MYDRIATICS, MYOTICS, AND LOCAL ANjESTH£T/CS. 261

before beginning the refraction examination. If the drug has been
applied several hours, the full action of the preparation upon the ciliary
muscle begins to diminish, and in such cases I observe that I do not
obtain nearly as fine results as those accomplished when I have pro-
ceeded with my examinations an hour, or at most two hours, after
the instillation of the drug.

Muscarine. — Muscarine is the alkaloid of agaricus muscarius, fly
fungus or poisonous mushroom. It is soluble in both water and alco-
hol ; the aqueous solution, as in the case of all drugs that are thus solu-
ble being most desirable when in use as either mydriatic or myotic. The
mydriasis of muscarine is rapid and intense ; but the condition passes off
quickly. Muscarine is a direct antidote to atropine, and when it is
desirable to suspend the action of atropine the injection of a small
quantity of muscarine solution produces the desired result in a short
time.

MYOTICS.

Myotic is the name bestowed upon drugs which produce myosis, or
contraction of the pupil. While mydriatics have the effect of inter-
fering transiently with the vision, myotics rarely cause inconvenience,
being capable of making objects appear distinct and clear. This effect
is not applicable to the drug itself, however, but to the power of intensi-
fying vision for the near point by contracting the ciliary muscle. The
principal drugs possessing myotic power are :

Pilocarpine. — Pilocarpine, an alkaloid prepared from the leaves of
jaborandi, by the joint action of hydrochloric and nitric acids. It is
claimed by many oculists to be the best of all myotics, being mild though
decided in its action, and having no evil symptoms succeeding its
use, though it produces great contraction of the pupil and peculiar
accommodation.

Arecaline. — ^Arecaline is the active principle of the betel nut, areca
catechu. The hydrobromic salts of the alkaloid is the preferable prep-
aration in use as a myotic. It is very satisfactory substitute for pilo-
carpine, the greatest objection to its use being the very ephemeral
character of its effect, which from its first action upon the iris until
complete recovery requires but seventy minutes, and sometimes less
time.

Fhysostigmine. — Physostigmine is an alkaloid of physostigma
venenosum, ordinarily known as the calabar bean.

Eserine. — Eserine is isomeric with physostigmine, both being used
as myotics. When first used upon the eye, these preparations were

802 BUSHROD W. JAMES, M.D.. LL.D.

found to have the power to produce very rapid contraction of the pupil,
in some cases the dilating power never returned. It was found also that
care must be taken in the use of the drugs, because of their action upon
the heart and spinal cord.

Calabarine. — Calabarine, another alkaloid from the calabar bean, is
also used in ophthalmological practice, but the sulphate of eserine has
thus far been regarded as preferable. In my own practice I find it an
admirable remedy in approaching glaucoma when used in quite a weak
solution and not too often repeated according to each case.

Muscarine nitrate. — Muscarine nitrate when taken internally pro-
duces contraction of the pupils, and is a rapid and efScient antidote to
atropine in relieving the extreme dilation of the ciliary muscle. Except
for that I would not resort to its use in ordinary examinations.

Morphine. — Morphine, the well-known alkaloid of opium, and
opium itself, have been resorted to by some oculists as myotics, but I still
prefer to use the less dangerous and equally efficacious eserine, the drug
which I have found in active experience a useful remedy for the relief
of the ocular tension in most cases of glaucoma and especially useful
in recurring attacks of this disease by the continued use of a very weak
solution of the drug. When I mention weak solution I mean ten drops
of a 4 per cent, solution of eserine to one ounce of distilled water.
This may be applied once, twice or even three times a week in one to
three-drop applications. I have often found one application a week
producing relief without manifesting any uncomfortable action upon
the very sensitive nerves of the eye, which this drug will produce if
used in strong solution. In other words, I thus gain a medicinal influ-
ence upon the eye rather than the full myotic effect, which I believe to
be in some cases the cause of the pain and aggravated symptoms attend-
ing glaucoma when the strong preparation has been used continuously.

GENERAL REMARKS.

Mydriatics possess more powerful action upon the iris and ciliary
tract than do the myotics, overcoming to a great extent any myotic
influence, and when applied producing each their characteristic dilating
results in a very short time. I have found in practice that there is one
thing to be said in favor of the myotics that should be well understood.
It is that when a strong mydriatic has been used and very susceptible
patients have complained of local distress, cerebral disturbances or
capillary hyperemia, that a myotic, such as eserine, locally applied in

MYDRIATICS, MYOTICS, AND LOCAL ANjESTHETICS 263

possibly one or two per cent, solution, will counteract to an appreciable
extent the action of almost all mydriatics, and relieve the aggravating
symptoms produced by their instillation.

On the other hand atropine, or any of the more powerful mydriatics,
will effectually retard myosis, the two antagonistic drugs producing
^rtain spasmodic actions of the iris, thus making examination of
refraction utterly impossible.

In the use of any and all of these preparations unabated care must
be practiced to prevent the drugs from entering the digestive tract, no
two patients being exactly alike in their acceptance of the remedy in
operation.

LOCAL ANAESTHETICS. '

The very uses for which anaesthetics are required give voice to the
possible danger of their action. At the same time local anesthetics, at
their worst, are far more desirable in most cases to the total anaesthesia
produced by inhalation.

No conscientious practitioner will positively assert that there is no
danger in their administration, though he is confident that he can make
the danger less by great care in administering and by skillful diagnosis
of the case in view while the internal anaesthetic is progressing in its
eflFect.

The early risk attending the utilization of chloroform and sulphuric
ether gave rise to a strong desire to produce an anaesthetic that would
minimize pain without producing unconsciousness. Naturally such an
agent must act upon the more external parts of the body instead of
through the alimentary tract or the lungs.

Cocaine. — Cocaine was of later years discovered and thought to be
the most desirable agent for the eye, and it is invaluable and has be-
come the leading local anaesthetic. But some risk in its free application
to persons with weak hearts or lungs, or of a very nervous temperament
or of the individuals disposed to tamper with the drug because of its
soothing action in relieving pain, have tended to make its use carefully
watched and restricted.

Bromide of ethyl. — Bromide of ethyl, hydrobromic ether, has been
accepted by many excellent authorities as a safe substitute for cocaine,
but it is safe only when it is extremely fresh and pure. Even then it
may sometimes have very adverse influences upon the heart, and it
has been pronounced quite as dangerous as chloroform to some classes
of patients. .

364 BUSHROD W. JAMES, M.D., LL.D.

Bromoform. — Brotnoform, generally accepted as an antiseptic, has
also qualities which name it as a local anaesthetic, its action being quite
benign in the relief of pain, but it is quite toxic, requiring considerable
care in its administration. It is a preparation of bromtun, a non-metallic
element of sea-water and saline springs.

Antipyrine. — Antipyrine is an alkaloid produced by distillation from
pine tar ; it is antiseptic as well as useful as a local anaesthetic. This
drug is considered safer than many others of its class, and in normal
conditions it is so, but there may be undeveloped maladies or organic
defects upon which it may produce deleterious effects. It is for tliis
reason that physicians have seemed to antagonize the use of the drug,
while some have been particularly successful with it.

Formanilid. — Formanilid, rather more decided in action than anti-
pyrine, is also used with considerable benefit in some patients, but with
tliis drug as well as antipyrine there is sometimes an evidence of general
intoxication, always very undesirable. They are effective particularly
as local anaesthetics.

Gnaiacol. — Guaiacol is obtained from pix liquida, and forms one of
the principal ingredients in creosote. It is more generally recommended
for sub-cutaneous injection, having very much the same effect as
cocaine. It is quite satisfactory as a local anaesthetic in dental surgery
and in other operations requiring but a short time for their perform-
ance, but it is not beneficial in ophthalmological examinations or opera-
tions.

Carbolated Camphor. — Camphor, carbolated camphor, or a prepara-
tion of camphor and carbolic acid and naphtholated camphor, are named
as among local anaesthetics by some practitioners, but I do not consider
that camphor is quite safe or as efficacious as many other preparations
and its sometimes precarious action upon the heart and brain would re-
quire extreme care in its administration.

Creosote. — Creosote is a preparation made by distillation from pix
liquida, poisonous and requiring peculiar care in its use, or preferably,
the strictly medicinal creosote from fagus sylvatica, beech tree. This
drug is sometimes used sub-cutaneously simply for the relief of pain.
I have never resorted to it in case of operation, but should suppose it
both too weak and too transitory to make the operation painless. Its
antiseptic qualities are certainly most desirable in any event when used
sub-cutanecusly.

Engenol. — Eugenol or eugenic acid is a pure extract from cloves,

and its properties are powerfully narcotic when locally administered.

MYDRIATICS, MYOTICS, AND LOCAL ANAESTHETICS. 266

In dentistry it is useful in relieving pain in a carious tooth or when the
dentine is painfully sensitive during excavation.

Tropococaine. — Tropococaine hydrochlorate is a substitute for co-
caine and considered safer than that drug and equally effective. An-
aesthesia is of longer duration and hyperaemia much less than after the
use of cocaine.

Orthoform. — ^Orthoform, a preparation of acidum salicylicum, has
both antiseptic and anaesthetic properties, but its application is rather
palliative than curative. It relieves pain of wounds and allays the suf-
fering from bums. As an operative application it is not useful, as it
is not thoroughly able to prevent feeling in parts to be operated upon.

There are some minor yet important local anaesthetics that I will
mention, having tested them in numerous cases.

Chloral hydrate. — Chloral hydrate is peculiarly effective in the tem-
porary relief of haemorrhoids and other rectal pains, if used in smalt
quantities, while larger applications are followed by general narcosis.

Carbolic acid. — Injections of a weak solution of carbolic acid into
painfully inflamed hemorrhoidal vessels sometimes gives temporary
immunity from the pain.

Water Hypodermically. — The hypodermic injections of distilled
water is found quite effectual in the immediate though transitory relief
of local or general pain. This is due to the pressure of the water upon
some of the peripheral nerves and not to any real anaesthetic or curative
power in the water.

There are many remedies which, though not strictly curative are
yet quite useful in alleviating pain, by injection, as in haemorrhoids or
by direct application to ulcerated surfaces. These are the opiates,
chloral, cocaine and similar drugs. Though they are not useful in sur-
gical operations, the palliative influence they possess gives rest to over-
taxed nervous endurance.

I have said nothing of h3rpnotism because of its producing general,
instead of special, local effects.

Anaesthesia by Cold. — ^Another form of local anaesthesia is produced
by applications which cause extreme cold, sometimes called the "freez-
ing process." It is generally produced from spray formed by putting the
drug into a bulb and directing the spray from it upon the parts to be
operated.

It can also be produced by the application of ice, or salt and ice
mixed and applied directly to the part, contact being retained from one
to two minutes, when the sensibility to pain will lie briefly suspended.

«66 BUSHROD W. JAMES, M.V., LL.D.

Chloride of Ethyl. — Chloride of ethyl is considered an excellent local
anaesthetic; it is furnished in glass tubes hermetically closed. When
required, the small end of the tube is broken off when the warmth of the
hand will force the liquid in a very fine stream upon the surface to be
frozen. This is very useful in short, superficial operations, such as
opening abscesses, removing small tumors, cutting out foreign bodies,
stitching lacerated wounds. I have found Dr. Bengue's patent spray
and stopper very convenient. It comes all ready for use in a neat case,
very convenient for pocket or medicine case.

Bhigolene. — Rhigolene, a very volatile product of petroleum, is also
very effectively used in producing local insensibility to pain. It is used
as a spray by forcing it from the bottle by means of a bulb and tube
with perforated nozzle. This is very useful in short operations, and
was once regarded with great favor in extracting dentistry, but it has
long since been abandoned.

Cymogene. — Cymogene is a drug nearly isomeric in its action with
rhigolene though I have abandoned the latter and now chloride of ethyl
is my preference, as I have used it with great satisfaction.

Menthol. — Menthol, oil of peppermint, can be applied to the surface
with a brush or used as a spray. It is very benign in relieving pain by
both outward application and internal doses. It relieves neuralgia
and rheumatic pains when they are superficial or peripheral, and one
or two eminent physicians afHrm that it can control incipient or even
slightly advanced inflammation without any subsequent return of the
attack to the surface treated.

Eacaine. — Eucaine, alpha hydrochlorate, resembles cocaine in its

action, but is intended specially for application to mucous surfaces.
Eucaine, beta hydrochlorate, also analogous to cocaine in its effects,

is recommended in ophthalmological research, but it often causes a

burning sensation when applied to the conjunctiva.

Eolooaine.-— Holocaine hydrochlorate is another companion to co-
caine, and is recommended for treatment of eye inflammations. These
three preparations being so nearly allied to cocaine that I do not use
them, feeling in every way fully satisfied with my standard ophthal-
mological assistant drug, cocaine itself.

Onethol. — Guethol, guaiaco ethyl, is considered as an antitubercular
agent, taken either externally or in internal doses. Its action is much
like that of guaiacol.

That there may be counter results in the use of any preparation of
cocaine, no one of experience will gainsay. Experience is ever the best

MYDRIATICS, MYOTICS, AND LOCAL ANAESTHETICS. 267

teacher, and I doubt not that every practitioner who has resorted to any
mode of anaesthesia, whether local or otherwise, has found certain
peculiar effects in the action of each upon individual cases. All will
agree with me that a thorough diagnosis of the general physical condi-
tion of a patient is necessary before applying anaesthetics, even for
slight operations.

It is a well known fact that creosote and its numerous concomitants
will preserve flesh, but a careless administration of any of them will
more rapidly destroy fibre and tissue beyond repair.

Even in the use of cold producing agencies, particular care must be
practiced because the intensity of the freezing process, if not limited,
may cause subsequent inflammation and sometimes sloughing of the
tissues that have been destroyed by the prolonged application of the
cold-producing agent.

There has been considerable discussion regarding the true action
of these freezing drugs, some claiming that the cold is the result of very
rapid evaporation. Doubtless in several drugs this is the case, but
menthol, ethyl and such extremely pungent drugs have a property pecu-
liar to themselves, which, though transient in effect is strikingly analo-
gous to the results procured by the spray application of other prepara-
tions.

That time may be saved I will give a summary of the remedies
herein mentioned with their antidotes and the quantities usually admin-
istered ; taking them alphabetically for further convenience :

THE MYDRIATICS.

Atropine, usual quantity, one drop of solution of one part sulphate
of atropine to one hundred and twenty parts water. Antidotes, before
absorption, charcoal or tannin; after, emetics, pilocarpine, muscarine
nitrate or morphine by hypodermic injection. The physiological in-
compatible drugs are the three mentioned, aconite and muscarine. The
chemicals are salts of mercury, tannin and the alkaloids.

Cocaine, hydrocUorate, usual quantity, solution two to five per cent
Antidotes, ammonia, digitalis, alcohol, chloral, caffein, amyl nitrate
or morphine-h}rpodermic.

Datnrine, nearly analogous to atropine; quantity, one to one-htm-
dred and sixty thousand per cent. Antidotes, same as atropine.

Dnboiiine nilpliate, quantity— 0.2 to 0.8 per cent, solution for eyes.
Antidotes, same as atropine. This drug is hypnotic and sedative. It

268 BUSHROD W. JAMES, M.D„ LL.D.

tomes as a yellow powder, deliquescent and soluble in alcohol.

Oehemine, quantity — seldom used. Small white crystals, soluble in
ether, chloroform or alcohol. Antidotes are in early stage emetics of
either atropine or strophanthin, external stimulants and artificial respira-
tion.

Homatropine hydrobromate, quantity — one per cent, solution or
stronger for eyes. Small white crystals, soluble in 133 parts alcohol,
in 10 parts water.

Hyoscine hydrobromate, quantity— one drop of solution of one to
three hundred. ' Perfectly transparent crystals soluble in either alcohol
or water.

Hyoscyamine, silklike white crystals, soluble in either chloroform,
water, acidulated water or alcohol. This drug is not only sedative but
hypnotic. Its antidotes are the same as for atropine or daturine. Quan-
tity same as hyoscine.

Uuscarine, sulphate and muscarine nitrate are practically about the
same. (Merck.) This appears in a deliquescent mass of brown color,
soluble in either alcohol or water. It is antispasmodic, antihidrotic and
is used also in treatment of incipient diabetes and night sweats. This
is one of the principal antidotes to atropine, daturine and hyoscyamine.
Dose 1/32 to 1/16 grain.

Hydrine, quantity — ^ten per cent, solution for eyes. It is a white
powder soluble in water, not dangerously toxic ( ?)

Scopolamine hydrobromate, quantity — one-tenth to one-fifth per cent,
solution for eyes.

It is a colorless hygroscopic crystal, soluble in alcohol or water.
Antidotes, stomach pump, emetics, tannin, muscarine, charcoal (ani-
mal) cathartics and other heroic remedies.

MYOTICS.

Arecaline ItydrobTomate, quantity — one per cent solution in ophthal-
mic examinations.

It comes in pure white crystals soluble in either water or alcohol.

Eaerine^ physostigmine salicylate, quantity — ^five per cent, solution
for eyes.

It is a yellowish crystal, soluble in 150 parts water, which solution

turns red after a short time. Besides its myotic influence it is used in

tetanus, toxic convulsions, strychnine poisoning and in relief of spinal

depression.

MYDRIATICS. MYOTICS, AND LOCAL ANAESTHETICS. 269

Morphine, a crystal, is almost insoluble in water. It is seldom used
as a myotic except as antidote to atropine, daturine, etc., or through
hypodermic injection. Antidotes, heroic emetics, stomach pump, per-
mangnate of potash, picrotonin, atropine, paraldehyde, strychnine, co-
caine, caffeine, violent exercise, electricity. Its incompatibles are the
alkalies, potassium permanganate and kindred drugs.

Opinnii much the same as morphine, used in ophthalmic research
more as antidote to antagonistic drugs.

Hnsoarine nitratei antidote to atropine, contracting pupils.

Filooarpine hydrochlorate, as a myotic and antidote to atropine.
Quantity — one drop of solution of one to one thousand or twelve hun-
dred. As a remedial agency it is sialagogue, diuretic and diaphoretic,
being used in doses of one-eighth to one-fourth grains in water to be
administered either by the mouth or hjrpodermic injection. The mala-
dies so benefited are coryza, bronchitis, asthmic dyspnoea, laryngitis,
croup, pneumonia, uremic convulsions, the maximum dose at any time
being one-third grain. Antidotes, emetic, stomach ptunp, ammonia,
atropine, brandy, etc. Its opposite drugs are alkalies, iodine, nitrate of
silver, and corrosive sublimate.

LOCAL ANiESTHETICS.

Camphor, monobromated, quantity — two to five grains in emulsion
or pill, the latter being objectionable because of its insolubility in the
stomach.

It is a beautiful semi-transparent crystalline gum, soluble in oil or
alcohol, but slightly so in water. Its order is pungently aromatic and
fragrant, its taste peculiarly cool, slightly bitter, and the mass is quite
volatile, disappearing without residuum when exposed to the air. It is
diaphoretic, sedative and narcotic, and as a local anaesthetic rather
soothing and narcotic than in any manner a true anaesthetic. Antidotes,
emetics, opium, morphine.

Cocaine hydrochlorate, quantity two to five per cent, solution. Color-
less crystals soluble in alcohol and water. Antidotes, amyl nitrate,
morphine, caffeine, chloral, alcohol, ammonia, digitalis.

Creosote, is a colorless oily fluid with disagreeable odor, greasy to
touch, inflammable and destructive to skin. It mixes with water or
alcohol, the solution turning red on exposure for any time or even when
not exposed to light if kept long. It is antiseptic and palliative rather
than truly anaesthetic in its action, being used to allay toothache and

270 BUSHROD W. JAMES, M.D., LL.D.

Other acute pains. Antidotes, alkalies, milk. But beechwood creosote
has very little, if any toxic qualities, and it should be the only kind used
except in rare cases for outward application. Merck, in his manual
says, ''Wherever creosote is indicated for internal medication, creosote
from beechwood should be dispensed and under no circumstances should
'creosote from coal tar' be given, unless explicitly so directed."

Wood creosote and coal-tar creosote differ very widely in their
action on the human body; wood creosote is comparatively harmless;
while coal-tar creosote is decidedly poisonous. Merck's beechwood
creosote is absolutely pure and free from any coal-tar poison.

Ether spraji used externally only. Spray from ether, sulphuric add
or ether fortior. Not poisonous thus used.

Ethyl chloride sprayi outward application only. A colorless liquid
soluble in alcohol. Used in dental surgery and in minor operations. It
also relieves neuralgic and rheumatic pains. Non-poisonous but highly
inflammable, and most efficacious if held from six to ten inches from
sturface to be frozen.

Enoaine, for local anaesthetics, sub-cutaneous six per cent, solution.
White powder soluble in water. Antidote same as cocaine.

Eugenol, eugenic acid, local anesthesia in dentistry particularly.
Used externally also for eczema and other cutaneous eruptions. It is
a colorless oleaginous liquid with spicy odor and pungent taste, soluble
in alcohol, chloroform, ether or a solution of caustic soda. It is anti-
septic and antitubercular, applied outwardly.

Erythrophleine hydrocUorate, a colorless crystal soluble in acetic
ether, water, alcohol and amylic alcohol. It is narcotic and astringent,
producing numbness in the spot affected by it..

Onaiacol— externally applied pure, with glycerine or with oil. It
is a clear colorless liquid with aromatic odor, soluble in alcohol, ether,
or two hundred parts water. It is considered antiseptic, antitubercular
and antipyretic. It is analgesic and antipyretic in external use. Not
actively poisonous.

Guethol, ethyl, used particularly as substitute for guaiacol. It is an
oily liquid, easily affected by cold, soluble in alcohol, ether or chloro-
form. It relieves the pains of neuralgia, tubercular cystitis and other
local diseases, used with a brush after mixing with chloroform or in
ointment of ten to twenty per cent, guethol.

Holocaine hydrochlorate, used as an anaesthetic in the same manner
as cocaine and eucaine. It is furnished in thin white needle-like crys-

MYDRIATICS, MYOTICS, AND LOCAL ANAESTHETICS, 271

tals, soluble in forty parts water. It is also used in diseases of the eye
in one per cent, solution.

Menthol, used in outward therapy as a freezing or deadening agent
It is a greenish colored oil, very pungent and aromatic and immediately
upon application, either external or upon the tongue, there is a peculiar
sensation of cold. It is soluble in equal parts of alcohol, but crystallizes
conveniently. One crystal placed in the cavity of an aching tooth pro-
duces first a very acute pain, which instantly yields to the extreme cold
and gives quick and sometimes permanent relief.

Methyl chloride, oil of wintergreen, almost isomeric with menthol
in its action. Colorless liquid with chloroformlike odor.

Orthoform, methyl ether of para-amido-mebi oxybenzoic acid.
White inodorous powder, slightly soluble in water. Applied pure or in
ointment or trituration for the alleviation of painful wounds and bums.
It is palliative, antiseptic and can be used internally as an anodyne.

Tropacocaine hydrochlorate is a clear crystal soluble in water, used
in place of cocaine, eucaine and holocaine. It is claimed that anaesthesia
fs of longer duration with this drug than any of its substitutes, and its
effects are less injurious to the system. As a local anaesthetic the dura-
tion of its power renders superficial and minor operations possible.

ANAESTHESIA BY INFILTRATION.

The possible difficulties attending total anaesthesia has always been
the source of much study and research. Resulting from this we have
local anaesthesia by outward application, by spraying and by sub-cuta-
neous injection. There is still another mode of producing immunity
from pain by infiltration, a certain quantity of plain water forced into
the tissues being able to render the part momentarily insusceptible. A
solution of cocaine, morphine and salt water will produce oedema of
still longer duration ; these results being caused by the pressure of the
foreign fluid upon the nerves, and by the action of the drugs upon the
nerves, if any drugs are employed the latter being responsible for the
greater duration of the anaesthesia.

An eminent physician and surgeon gives the following formula as
a superior agent for anaesthesia by infiltration, Cocaine Hydro, gr. iss.
Morphia Hydro, gr. J^. Sodi Chloridi, gr. iij. Aqua. Jiijss. This
to be first injected into the skin, and then into the tissue to be rendered
insensible. Doubtless any and all of these modes of preventing or
relieving pain have each their valuable properties, as also has the

272 BUSHROD W. JAMES, M.D., LL.D.

administration of nitrous oxide gas in the extraction of teeth. But
there are so many considerations to meet that there can be no better
plan than for every physician, oculist and surgeon to make careful
studies, not only of the drugs but of the individuals upon which they
intend them to operate : for where one may be harmless to a certain case
it may cause serious complications in another. I have ascertained that
there are very few drugs that are altogether and universally harmless.
Not because of their special properties always, but in their relation to
the systems upon which they are employed. Therefore it is the bounden
duty of the profession to take every precaution in the diagnosis of each
case under his practice and to use the most benign as well as the most
accommodating remedy.

DISCUSSION.

Dr. Keeler : The wonderful advances made in the ophthalmological
field during the past decade are most admirably suggested by Dr.
James' paper.

The doctor has done more than to present for our instruction this
very complete list of mydriatics, myotics, and anaesthetics ; he has given
us in the fewest possible words their dosage, characteristics, and com-
parative values. His paper might with propriety be termed a "com-
parative materia medica" of the drugs named. The subject has been
most ably handled, and in the discussion I only hope to niake emphatic
some few points.

To prove that the work of the oculist is scientific, we must show
that thoroughly effective work is being done by us. This is the
true test of success. In order that we may accomplish effective work
we must use drugs with which we are not only familiar, but upon
whose results we may place implicit confidence. With "perfection as
the goal" we have neitfier time nor inclination to become "faddists."
We must not be too ready to try experiments. Some ambitious phar-
macist assists a new-bom drug into the medical world every day in
the year, and in the majority of instances had there been a miscarriage
the world of therapeutics would not have been the loser. For each
of these new-comers a brilliant future is predicted; we are all ex-
pected to give them a thorough trial in our practice, and the result
in the great majority of cases is that within six months we are using
the old remedy, tried and true, or have been induced to discard the new
for one still newer. One of the best therapeutic rules with which I
am acquainted is

"Be not the first by which the new is tried.
Nor yet the last to lay the old aside."

Among those drugs comparatively new cocaine must be credited
with altering the whole professional life of the oculist. It has proven

MYDRIATICS, MYOTICS, AND LOCAL ANAESTHETICS. 278

itself invaluable. As Dr. James has intimated, it should not be used
without judgment. A great number of deaths have been reported
following its use, in some cases almost instantly, but they are mainly
where a large amount has been injected hypodermically or a strong
solution used locally. The smallest fatal dose recorded is where two-
thirds of a grain was injected into an eye, with the result that im-
mediate unconsciousness followed, and death occurred in two hours.
One grain injected into the gums by a dentist produced death in a
few minutes. The application of a lo per cent, solution to the larynx
with a brush was also fatal, unconsciousness following almost at once,
and death in three hours. Also cases have been reported where the
instillation of a 6 per cent, solution into the eye have been followed
by an alarming depression, unconsciousness, and delirium.*

When a few drops of a two to four per cent solution of cocaine will
enable the operator to accomplish everything necessary, the query
at once arises: Why use a stronger solution capable of possible harm?

Also when cocaine is so uniformly satisfactory when properly
used, why the anxiety to find something to supplant it? I doubt not
that to all of us it is, as has been expressed, our "standard ophthalmo-
logical assistant."

As has been recently pointed out,* it may be abused by physi-
cians who forget the injurious local effect of cocaine upon the nutri-
tion of the cornea. In cases where it has to be applied for a consid-
erable time, as in conjunctivitis, corneal ulcers, and other forms of
eye pain due to inflammation, it becomes decidedly hazardous. The
practice is common among general practitioners to prescribe a solu-
tion of cocaine for almost any eye pain. When used thus for any
considerable period of time it causes dr^'ness of the cornea, and loose-
ness of the epithelium. Not only is there this danger, but its appli-
cation deceives the physician by creating the impression that a very
serious condition may be trifling, because the pain is removed. In-
deed, I have found that so generally has the fact become known that
cocaine will relieve eye pain, that the laity frequently will resort to
its use.

Orthoform has been used with flattering results in some cases
where cocaine has proved of little or no value.

M. Boisseau reports that in several instances he has secured re-
lief in ulceration of the cornea, with intolerable pain, photophobia, and
lachrymation, by the use of an ointment composed of six grains of
orthoform and one dram of vaseline. And the fact is recorded that the
painlessness continued for some twelve hours.

Other cases are reported with results as above outlined. The con-
clusions drawn are that orthoform is perfectly inocuous, even when
its emplo3rment is prolonged, and that it possesses remarkable anal-
gesic power in diseases of the eye where cocaine has little or no effect.

♦ A. R. Baker, M.D. in American Journal of Ophthalmology.

• * •Southwestern Record," Vol. 4. p. 80.

274 BUSHROD W. JAMES, M.D„ LL.D.

Dr. James' opinion as to the value of homatropine has been empha-
sized in my practice. I have also had the best of results from the
use of duboisine. With either of these drugs we get the full mydri-
atic effect in an hour, and the patient is enabled to resume his usual
avocation in as short a time as with any other mydriatic with which
I am acquainted.

Dr. F. P. Warner: Is it safe to use cocaine? While I have not
had any bad results from cocaine, yet I have had quite a few cases
where my patient has become faint and I have had to stop using it,
and allow them to lie down for a time. I think now I can judge pretty
well of my patients, where 1 can expect to have good effects or be on
the lookout for ill effects. Those cases that do not bear it well are the
thin, anaemic individuals, not especially those who have any difficulty
with their hearts, but those who are bloodless, or highly nervous. In
this class of cases I am always on the lookout about using any strong
preparation of cocaine. I have never seen any fainting occur in
plethoric people, in strong, robust individuals, or in children. I think
a 4 per cent, solution sufficiently strong.

Dr. Bates : About ten years ago I was called to see a very bad case
of iritis in a man sixty years of age. He had been for six weeks
under the care of an allopathic oculist of two or three years' experi-
ence. The oculist had suggested an operation as a last resort, and
wanted counsel. He would not have me, as I was a homoeopath, but
wanted to send to Toronto for a specialist of his own school. The
patient objected on account of the expense, and the case came into
my hands. I took in the situation. The doctor had used atropine;
S3miptoms of glaucoma had then been set up, and he had used eserine.
He then thought the only resort an iridectomy. He evidently did
not know that while atropine increases the tension, some mydriatics
do not. I put hyoscyamine in the place of atropine, and tension di-
minished and patient got well.

Dr. Boynton: I wish to take exception, with all respect to Dr.
Bates, to his statanent regarding the influence of mydriatics over
tension. Any mydriatic, except, possibly, scopolamine, increases or
augments intra-ocular tension. It is a perilous thing to dilate the
pupil with any of the drugs given where the balance between the se-
cretions and excretions is delicate. With your permission we come
back to the old stand-by, atropine, the standard mydriatic for paralyz-
ing the accommodation, and for inflammatory conditions; but I am
afraid of it in cases past middle life, where the tension should be
carefully taken, and if there is any augmentation or tendency for it
to increase the atropine should not be used. Scopolamine is prob-
ably the safest mydriatic, and, so far as we know, is not followed by
increased tension. It has been used steadily and systematically in
cases of glaucoma in the ophthalmic hospital, and I do not know of
any case where the tension has been increased when used in one-quar-
ter of I per cent, solution. The one-half per cent, knocks them out.
It is just as paralyzing as that other solanae, hyoscyamine, with which

MYDRIATICS, MYOTICS, AND LOCAL ANESTHETICS. 276

it is almost identical, but it does not produce so much paralysis of nerve
centers as this last drug. I am using a one-quarter of one per cent,
solution, which is strong enough to paralyze the accommodation in
an hour, and satisfies me as to the amount of refractive error, helping
me in the selection of a suitable glass. I think it is the best mydriatic
known, except for inflammatory conditions.

Dr. Deady: I am obliged to take exception to some remarks of
the last speaker. I have used atropine in the New York Ophthalmic
Hospital and a limited private practice for twenty-three years, with
the exception of the last five years, during which time I have not
used it at all. In my opinion scopolamine is superior to atropine in
health and in disease as a mydriatic for any use to which a mydriatic
can be put. I have tested it in my clinics side by side with atropine
on the same cases and on different cases. The i to 200 solution of
scopolamine used once would paralyze in an hour the accommoda-
tion considerably better than atropine would do it. I have had the
same case use atropine, and when that had passed off in a week or
ten days, used scopolamine and have found the refractive anomaly
greater and have seen the second drug go deeper into the case. I
did that on case after case in our clinic four or five years ago, when
the drug first came out. I have never seen any dangerous action
from a one-half of one per cent, solution. Dr. Bo)niton states that
he has. That is a matter of the personal equation. Although I have
never seen anything dangerous from the i to 200 solution I can very
easily imagine that dangerous S3rmptoms could arise, though I have
never seen any such effects from either homatropine or scopolamine.
In one case of glaucoma I had remarkably beneficial effects from sco-
polamine — a case in which we tested the drug freely. With eserine the
tension would gradually rise, but by the use of scopolamine it would
come down gradually in twenty-four hours or less. We did it re-
peatedly. I had another case in which the result was not so emphatic,
but the general result was the same. My impression is that scopola-
mine, except in rare cases, is not a dru^ for glaucoma. It is perhaps
the least dangerous drug to use for mydriasis, for the reason that it
is least apt to produce glaucoma ; but I think, with a tendency to glau-
coma, which we cannot know in advance, any drug which dilates the
pupil may precipitate an attack at any time. My experience with
scopolamine (and it has been a very large one for the last three or
four years) has made me think it the best all-round mydriatic that
we can use. Homatropine I have no use for — it does not go deeply
enough. Dr. Boynton's statement that we get all necessary aid
from homatropine or atropine in the prescription of glasses, I differ
from, in that I think that the use of a mydriatic of the most profound
character is of the first importance in these examinations. It is not
th \ hyperopia that we want to get at, it is the exact degree of astigma-
tism — the exact axis. I have seen a change of 5 degrees in the axis
of a lens of the strength of a quarter of a diopter plus, make all the
difference between happiness and misery on the part of the patient.

are bushrod w. james, m.d.. ll,d.

Dr. Anderson: Since my one experience with scopolamine I have
been very chary in its use. Perhaps this case was one of those unfor-
tunate susceptible ones, but for about five or six hours I was exceed-
ingly anxious.* I called in consultation an allopathic neighbor living
next door, and we worked over this case I think about five or six
hours before we thought he was out of danger. I used scopolamine
in about the ordinary strength in this case, and for some time after-
ward I did not use it at all, but I am going back to its use again now.

Dr. Boynton: Was it a one per cent, solution you used?

Dr. Anderson: Somewhere along there, perhaps; I am not just
sure. I have had very satisfactory results from scopolamine as a
mydriatic, using it since that experience very carefully.

I have found the use of Gelsemium a preventive against the poison-
ous effects of cocaine; and, if I see any marked poisonous effects
coming on, I give them in addition inhalations of amyl nitrate of about
10 per cent, strength in alcohol and let them inhale it. By this means
the poisonous effects of cocaine pass quickly away.

Dr. Suffa: When scopolamine was introduced into ophthalmology
it was claimed for it that it would not produce or precipitate glau-
coma. I have seen two cases where decided hardness of the eyeball was
brought about, and in one case very intense increased tension. In one-
half of one per cent, solutions I have noticed toxic effects in probably
so per cent, of cases, vertigo, staggering gait, paleness and nausea. In
one-fourth of one per cent, solutions toxic eflfects are small, but still
more than desired. It has failed to paralyze the accommodation in
several cases, and that after their instillation twenty or more minutes
apart.

Dr. Deady : Who made your solutions ?

Dr. Suffa : The solutions are obtained at large drug-stores ; the same
solutions producing the proper actions in subsequent cases.

Dr. Norton : I wish to thank Dr. James for his most excellent digest
of the subject, and for having brought out a most interesting discus-
sion, I wish to add a word of warning as to the use of scopolamine.
When the drug was first brought before the public it was claimed that
it did not increase tension. This statement was evidently untrue, as
since then quite a number of cases of glaucoma have been reported by
competent observers as having been caused by scopolamine, and in pro-
portion to its frequency of use as compared with atropine, I believe it
to be as fully liable to cause glaucoma as is the latter drug. Glaucoma
is supposed to be due to the mechanical obstruction of the filtration
passages. I believe the best authorities to-day claim that any drug
causing an equal amount of dilatation or pushing the iris over into
these filtration passages is equally liable to cause glaucoma. I think
the statement that scopolamine does not increase the tension is wrong,
and a very dangerous one to make.

Dr. Vilas: I dislike to differ from my friend, Dr. Boynton, but I
wish to add a word on the use of atropine. I do not doubt but that
he has had the experience that he stated, as there seems to be a certain

MYDRIATICS, MYOTICS, AND LOCAL ANAESTHETICS. 277

number of cases that will result badly under the use of atropine; but
I have used it many years with no serious results. I have tried the
other drugs mentioned, but still prefer atropine, believing that it is
the most reliable of these remedies. But it should be used on persons
of, say, forty-five years and upwards with great caution*

I never allow a patient to use it the first time, and I never allow
my patient to go away until I am satisfied that the effect is good. I
have seen bad effects from daturine, but never serious ones. Sum-
marized, I believe if care is exercised in the use of atropine that, though
unfortunate results occur, it is the best remedy of Ae kind that we
have at present.

Dr. Moffat: I am disappointed in this paper; I had hoped to learn
from it and its discussion the relative effects, merits and dangers, in-
dications and counterindications, of these remedies. I understand the
disadvantages of cocaine are : dangers of constitutional poisoning, and
of dessicating the cornea even to exfoliation.

That holocaine is more painful but does not dilate the pupil, while
it is free from tlie above dangers ; that eucaine B. can be sterilized ; I
know of no objections or limitations to its especial use.

I have not been able to make up my mind about the effect of scopo-
lamine upon tension ; have used it satisfactorily in place of atropine.

I would choose atropine if I wanted the patient to have belladonna
— ^and were not afraid of glaucoma ; but would be on my guard against
it in the latter case and also on "belladonna patients." I have had
one death following cocaine: A plethoric old Englishman, apparently
healthy, came into hospital a couple of days before operation — extrac-
tion of cataract. This went oflf smoothly under formalin antisepsis;
four drops of 4 per cent, cocaine mur. solution were instilled at five
minute intervals, and another drop during the operation after the cor-
neal incision. Upon sitting up to get off the table his face became
very red, but he said : "I am all right." Two hours later he developed
acute mania, from which he died in a couple of days ; autopsy showed
intense cerebral hyperaemia and congestion of the circle of Willis. He
had been deprived of alcoholic stimulants, which he had been accus-
tomed to take daily. This was doubtless the main factor in the case,
but to my mind he had marked secondary action of cocaine as an ex-
citing cause.

I understood the writer to recommend eserine to the eye if cerebral
symptoms develop from a mydriatic; this does not appeal to me as ra-
tional. If we want to constrict the dilated cerebral vessels antipathi-
cally I do not believe this the best way to go at it ; first, will eserine so
act in the brain? Second, how much must we drop into the eye to
get other than merely local effects ? As Homoeopaths we have scientific
remedies for cerebral hyperaemia, or anaemia caused by drugs as well
as if the conditions were idiopathic. Medicine can be just as homoeo-
pathic in large as in small doses, in its primary as its secondary action.

Dr. Hooker : It is exceedingly common to have patients turn pale
and faint in the examination of the head or the chest, inspecting the

278 BUSHROD W. JAMES, M.D., LL.D.

ears or examining the eyes, or in merely examining the nose. It is
especially common for yoimg and scrawny, thin-blooded people to turn
faint during slight operations. I think we should discriminate be-
tween the faintness which occurs under those conditions, and the
faintness which is supposed to come from cocaine. I find two effects
from cocaine: the first is, stimulation like coffee, the brain is more
active, the patients are to some extent garrulous and talk to you in a
free way that they would not do when not under the influence of co-
caine. Another effect is in the direction of drowsiness — ^they become
drowsy and stupid and feel numb. I thing the cold sweat, the weak
pulse, and fainting are not the effects of cocaine. I think it is simply the
faintness which is induced by being examined and by going through
the operation ; and I believe it very probable that many of the so-called
poisonous effects which are attributed to cocaine are not due to the
drug at all.

Dr, Linnell : It seems to me the way in which we use these drugs
is important. I have used scopolamine a great deal with satisfactory
results. I drop a very little on the upper surface of the cornea, allow-
ing it to trickle down over the surface ; at the same time 1 incline my
patient's head toward the opposite side and close the tear passage.
I think a little precaution of this sort will avoid the danger. I have
had a somewhat similar experience to that mentioned by Dr. Suffa:
that is, scopolamine has sometimes failed to paralyze the accommoda-
tion, which I have attributed to the solution being perhaps a little too
old. I would like to ask Drs. Bo)mton or Deady whether they find
it decomposes rapidly, and how long a solution should be kept before
being renewed.

Dr. Boynton: You have all had failures in the use of mydriatics.
From idiosyncrasy you have seen alarming cases of poisoning, even
from the instillation of J4 per cent., a quarter or even a fiftieth
per cent, solution of atropine. One case occurred under my observation
within three weeks, where a woman of 25 years with progressive myo-
pia, which had alarmingly increased recently. I had had her under
observation since she was ten years old, and, finding an alarming in-
crease after an absence of several years, one drop of atropine was used.
She left after being an hour in the office, and did not reappear for a
second examination. Instead, a note from her physician said she was
alarmingly ill from atropine poisonin^^ I never use a mydriatic with-
out pressing on the tear passages. I must have done so, although
I do not recall positively, but as it is my rule, I presume I
pressed on her lachrymal sac and prevented the passage of the tears
into the nasal passages. That woman was violently ill, with delirium
and eruption in the fauces and over the body, and prostration, for more
than four days from one instillation.

Some years ago the Ophthalmic Hospital had its solutions made
up by the students, who acted as apothecaries. I used then to have
almost every case of delicate women and men where scopolamine, sup-
posed to be J4 per cent., was used, suffer from prostration, vertigo,

MYDRIATICS^ MYOTICS, AND LOCAL ANAESTHETICS, 279

and disturbance of equilibrium. I am aware that they used to sub-
stitute hyoscyamine for the scopolamine, which is a stronger
paralyzer and disturber of equilibrium than the scopolamine. We now
have a regular pharmacist make up all the solutions of the mydriatics
used, and have absolute accuracy, so far as we can get it. I have
adopted the % per cent., which I think is strong enough, while the
J4 per cent, is dangerous.

Dr. Harvey : No one having mentioned in this discussion the mini-
mum dose of scopolamine that will produce complete paralysis of ac-
conunodation, I wish to say that in children under ten years' I use a
^Ao of oiic per cent, solution, two drops in each eye at intervals of
fifteen minutes, and for those over ten years a ^/j© of one per cent
solution in the same manner. It never produces toxic symptoms, and
has never failed if the solution is prepared fresh every four weeks.

Dr. James : I feel amply repaid for the work I have put in upon
this paper. I put it in purely as a sort of firebrand, and am glad it
roused up some little disturbance in the society in the way of debate.
I have obtained just what I wanted, and that is the consensus of opinion
of the members of the association on these agents. The paper has

' brought out the experiences of many of the members of the associa-
tion, and of the profession in our school, and I am very glad to have
all these thoughts in regard to these agents. We have to constantly
use them, remembering that they are dangerous. There are patients
that are extremely susceptible to the use of any and each individual
remedy named, and we are going to find out, by throwing out these
ideas, just where the danger lies. I remember a case that occurred
several years ago — a very stout man subject to attacks of inflammation
about the face — ^localized erysipelas, and sometimes the whole side of
the face would be affected. He was very susceptible to Rhus tox., and
the symptoms were very acute. He told me of this susceptibility,
and that he had been poisoned with it several times. He said : "You
will please not give Rhus in my case." His S)rmptoms one day were
so thoroughly Rhus that I thought I would take my own judgment and
not his. I gave him a dose of Rhus tox. 30X. The next day when
I went in he said to me : "You gave me Rhus toxicodendron yester-
day, and I told you never to give it to me." He said : "I now have
all the s)miptoms of Rhus tox," The preparation was made by
Boericke & Tafel, and I presume it was truly the 30th. That is the
effect of one remedy upon one man, and we all have seen similar suscep-
tible effects of these mydriatics on individual cases. I have time and
again insisted upon the peculiar temperaments of individuals being
tsJcen into account — that we must individualize the temperament in
selecting every remedy that we use. We have to in the application
of the Homoeopathic remedy to symptoms, so we certainly ought to do
so in any mydriatic, myotic or other such remedy of this character,
which is known to be poisonous in its general action upon the system.
We apply them simply for local use. We do not expect to get general

/ symptoms from them at all, but in temperaments of a peculiar char-

280 BUSHROD W. JAMES, M.D.. LL.D.

acter we do get the general symptoms. We ought to look out for that.
We get poisonous symptoms that we do not want in individual cases,
and yet in those individual cases I do not see why we should not use
these local special remedies in specialty practice. You take the case of
chloroform. Certain individuals will die under its use, yet the next
10,000 cases will not

SOME CASES OF CARIES OF THE EXTERNAL AUDITORY

CANAL.

By Howard P. Bellows. M.D.,

Boston, Mass.

I^BERE is a class of cases, which is rdatively common, which
presents a carious destruction of a portion of the superior
wall of the external canal, close to Schrapnell's membrane.
These are chronic suppurative cases with much destruction of tissue,
including not only the dnmi-head bat also the loss of the malleus and
incus. The carious process may have reached the canal wall, originally,
by extension from a carious spot upon the neck or head of the malleus,
communicated by the contiguity of the parts. It is not my intention
to cite any cases of this class because they are too common. We have
all had them and to write of them would be wasted time.

Case One. — Related to them, but of more interest, is a case which I
have now under observation. The ear has discharged, at intervals,
for seventeen years, following measles. The drum-head is not absent
but is very cicatricial; with broad adhesions to the promontory of the
tympanum, and the hammer strongly bound in cicatricial tissue. In
the superior wall of the canal, just exterior to Schrapnell's membrane, is
an irregular carious opening, which admits a view directly into the
attic space when the head is strongly flexed towards the opposite side.
The discharge is very variable, sometimes nearly absent and at other
times profuse, bloody, and even offensive, coming at present, of course,
from the attic and tlie adjacent bone. The variation is due to the
degree of carelessness on the part of the patient in cleansing the ear.
This young man managed to elude the military examiners and enlist
in tiie army at the beginning of the recent war. He saw service in
Porto Rico and was altogether happy until there was no prospect of
further fighting. When that time arrived he allowed his disability to
be discovered by his regimental surgeon and promptly received his dis-
charge. It is to be hoped that his adventurous spirit will not lead him to
"take chances" with this disease.

Case Two. — ^Another case with caries in this same region is that of a
young man whose dnmi-head and ossicles are intact. There is no his-
tory of suppurative disease of the middle ear at any time. This case
first came under my observation nearly fourteen years ago. There
was then an otitis externa diffusa with a pol)rpus dependent from the
superior wall of the canal near the drum-head. There was absolutely
no perforation-sound, nor tympanic rale of any sort, upon catheterizing.

182 HOWARD P. BELLOWS, M.D.

and I had no reason at the time, or afterwards, to suspect the middle
ear of complicity. I removed the polypus and restored the external
canal to an absolutely normal appearance in three treatments, covering
about six weeks time, the patient living at too great a distance to come
more frequently. After a lapse of four years the patient again came
to me and I then had his ears under oi)servation and treatment, at
intervals, for a term of about three years — ^the condition upon both
sides being simply catarrhal. At the end of this time there appeared a
small, dry scab upon the superior wall of the left canal, at tlie point
where the polypus had existed seven years before, near tfie margin of
the dnun-head. This scab I removed. Six weeks later I found slight
moisture at that point, and five weeks after that the patient presented
himself with a gelatinous discharge and small polypus. The local use
of a boric acid and alcohol solution, with Calcarea carbonica internally,
corrected this condition in about a month's time, so that the polypus
entirely disappeared and the canal became again hard and dry, and so
remained, without further sign of disease, for three years and a h^f.
He then presented himself with a discharge from the same ear again,
which had continued for three weeks. Upon examination of the old
spot I found two small polypi already developed. These I removed with
a curette and directed the patient to again use the boric acid and alcohol
solution, systematically, after careful cleansing. In five weeks he re-
turned with the ear foul, through carelessness. I tried to frighten him
and taught him how to cleanse his ear with hydrogen dioxid. A month
later he returned with the canal dry but the diseased spot sealed in
with a little hard crust. Removing this, with some difficulty, I found a
slight accumulation of thick, greenish, offensive pus underneath, and
my probe, entering the little bowl shaped cavity, readily detected carious
bone. All this time the middle ear was not affected by any suppurative
process. Although the carious spot enlarged I could never pass a probe
into the attic space, but I could hook it outwards into the cancellous
tissue between tihe lamellae of the superior wall. The position precluded
any forcible use of the curette except most superficially. For one year
we worked away, therefore, as best we could, removing the cap which
persistently sealed in the cavity, once or twice a month, as the patient
could come to see me, and depending upon the hydrogen dioxide the
balance of the time. As the patient became expert and thorough in the
use of this agent the progress became more satisfactory, and Silica,
given internally, seemed to be of further aid, so that for some mondis
past the cure has seemed to be complete — ^the probe encountering only
smooth, hard bone and no exudation nor any capping being present.
The patient continues to come from time to time for inspection.

Turning now from the superior wall I would remark, in passing,

that, in my experience, I have never known a single case in which

the anterior wall of the canal has been affected by carious disease.

With the inferior wall, however, the condition is not so rare. I will cite

a case.

CARIES OF THE EXTERNAL AUDITORY CANAL. 288

Case Tbree. — ^The patient, a professional man of middle age and
poor general health, with tuberculous tendency, had been under my
treatment for chronic catarrh of the middle ear for about two years.
There occurred at the end of this period a small ulcer on the floor of
the external canal, just at its point of greatest elevation. There was
nothin|^ very marked in this. I cleansed and disinfected it and gave
him Silica internally and at his next visit, two weeks later, it was ap-
parently entirely healed, and so remained for about two months. At
the end of that time I discovered at this same point, on the inferior
wall of the meatus, a thin, dark colored scale. On pressure I
fancied it felt boggy underneath and so I worked under its edge, ele-
vated it and removed it entirely. My probe, with a sharp curve in the
end, then sank into a rounded hollow in the bone containing a thick,
cheesy secretion and on clearing this out the surface of the bone ex-
posed was gritty and carious. This was curetted and hydrogen dioxid
applied thoroughly. For four weeks the patient used this hydrogen
dioxid daily at home and took Silica internally. Once a week I ex-
amined with the probe and at the fourth treatment found the bone hard
and smooth and the trouble at an end. For nearly a year longer I con-
tinued to treat the catarrhal condition and there was no recurrence
whatever of the caries. The patient then sought a more favorable
climate for residence than that of New England and I saw him no
more.

I do not know why this particular spot, on the floor of the canal
at the junction of its inner third with its outer two thirds, where the
elevation is greatest, should be especially liable to carious disease —
unless it is that in 'efforts to cleanse the ear, or to allay itching or
irritation, any accumulations which may be present in the canal would
be pushed inward to about this point and there left to become a source
of further irritation. A marked roughness of the bone at this particular
point, which I have observed in a number of temporal bones which
I have examined, would seem to favor the development of such a
superficial condition, in certain cases, into one involving the deeper
structures. Certain it is that, in my own experience, I encountered a
second case very similar to the one I have just described — and not very
long afterwards.

Case Four. — ^This patient had also been under my observation and
occasional treatment, for a catarrhal aflfection of the middle ear, for a
long period of time — ^nearly seven years in all. The canal had never
exhibited any unhealthy state until, one day, I observed, in this same
location on the inferior wall, an irritable and softened area of the
skin. In the light of my former experience I carefully cleansed this
and gave my patient Silica. A week later I again cleansed it and ap-
plied calendula cerate. At the end of a second week the spot was hard

284 HO WARD P. BELLO IVS, M.D.

and dry and so remained for six weeks, at the end of which time, the
hearing having come up to normal, the visits were discontinued. Eight
months later, the catarrhal trouble demanded another course of treat-
ment, and at my patient's first call I explored the site of the former
local trouble to see if there had been any recurrence. I fotmd small
evidence of any on the surface, and my patient was conscious of none,
but upon a careful use of the probe I got down through a softened spot
to gritty underlying tissue. Opening up the surface I turned out a
scale of necrosed bone from underneath. Curetting the cavity, cleans-
ing with hydrogen dioxid, filling it with calendula cerate and giving
Silica internally I found the healing apparently complete at the end of a
week's time.

Case Eve. — ^The most interesting case which I have to report in this
series is one which involved the posterior wall of the external canal,
establishing an opening, for a short time, into the mastoid cells, which
were not diseased. The patient, a man about thirty-five years of age,
thin, nervous, overworked and aifflicted with chronic nephritis, came to
me in a pitiable condition from the effects of pain, loss of sleep and
the excessive use of opiates and whiskey.

Two years before a large bug had entered his ear. He filled the
ear with water and did nothing further about it, although it never
from that time seemed normal. For two weeks the condition had been
getting more and more painful, with distressing autophony. For the
past three nights the pain had been so severe that he had sought relief
by deluging the ear with various mixtures, notably one of sweet oil,
laudanum, aconite and chloroform; and had obtained no sleep except
after heavy doses of opiates. Examination showed great tenderness of
all the soft parts about the ear but none over the mastoid. The gentle
removal of cheesy dibris from the canal revealed a large mass of hard-
ened wax. Further exploration brought to view a polypus on the pos-
terior wall of the canal and a general condition of keratosis. Removal
at one sitting was considered imperative, under the circumstances,
and was accomplished, but with very great difficulty and the expendi-
ture of a couple of hour's time; the patient often turning faint and
having to rest and be braced up with hot bouillon. When the large
mass was finally separated and removed it was found to consist of a
mixture of wax and horny epithelial ribbons, and in the center of all
lay the wing-plates, legs and various anatomical remains of the de-
cayed bug, which had been the cause of the diseased canal walls and
the whole painful condition. The odor of this mass, when it was
opened, was sickening in the extreme. A week passed, in the treat-
ment of this case, before the violent inflammation of the canal walls
subsided sufficiently for me to attack the polypus. I then removed
it with a ring knife, powdered the stump with aristol and packed the
canal lightly with gauze. Three days later the spot was nearly dry.
A week later there was a dry scab, but I found moisture beneath it. At
the end of a second week there was the same dry scab, but under
it a little point of fresh granulation tissue that aroused my suspicion.

CAKIES OF THE EXTERNAL AUDITORY CANAL. 285

Exploring with a fine probe, bent at right angles at the tip, I discovered
a small sinus, in carious bone, running through the posterior wall of
the canal directly into the mastiod cells. The mastoid region itself
revealed no sign of disease. After curettement and the daily use of
hydrogen dioxide, with Silica internally, no further secretion was ap-
parent after a week's time and my patient started upon a much needed
vacation. Eight weeks later I fotmd the ear entirely healed and sound,
and the hearing distance 41/40. Six months have passed since then
and I am sure the absence of news from this patient means good news,
so far as the ear is concerned.

I am perfectly aware that this posterior wall of the canal is pecu-
liarly liable to be affected by caries and to give way to an opening
between the external meatus and the mastoid cells, but this process is
almost invariably inaugurated from the inside, the products of inflam-
mation within the mastoid process finding a natural egress in this
manner.

Case Six.. — I have recently had a case of this description which
followed scarlet fever in childhood and exhibited, in conjunction with
an empty tympanum, a large, irregular, carious opening in the posterior
superior wall, through which one could gaze upon the cancellous struct-
ure of the mastoid cells, with the intervening cell walls white and
glistening and totally devoid of their natural covering.

I have shown in this series of cases how the external auditory canal
can be invaded by carious disease from either the attic of the tympanic
space or from the mastoid cells; how such disease may originate in the
canal walls themselves; how treacherous its development may be in
this location; and how it may be successfully dealt with in its in-
cipiency, before the degenerative process has become a serious menace
to the patient or a permanent injury to the parts involved.

DISCUSSION.

Dr. Shearer: In reading Dr. Bellows' list of cases, one is struck
by the fact that as all of his patients exhibited* clearly defined caries
of the external auditory canal, one should find so little mention made
of this pathological state in treatises upon the ear. It is quite true that
caries affecting the walls of the tympanic cavity and the ossicles are
always described by writers on aural diseases; also caries involving
the external auditory canal when secondary to diseased mastoid cells
is referred to, but primary necrosis of the canal seems either to have
been considered an impossible affection or one unworthy, of a place
in a text-book. By primary necrosis, I mean a condition which has
not been in any way associated with changes in the middle ear, by a
process of direct extension, from one part to the other. Personally, I

286 HO WARD P. BELLO WS, M.D.

am inclined to think that such apparently localized instances ol.
must be comparatively rare. Possibly some cases ax« a^erlooked in
the haste to examine the membrana t3rmpani and "fwtien one is not ex-
pecting disease in such a locality, it is ¥ttf ^asy for it to escape one's
notice. The most interesting oabits in the paper are those concerning
the site in which we floay find the lesions, the simplicity of the treat-
ment ^ad Ae seemingly specific action of Silica, It is not unreasonable
to believe that, underlying some cases of constantly recurring f urun-
cular inflammation of the external auditory canal (and in which
diabetes mellitus is not present), we may have at least a superficial
tendency to caries of the subjacent bone. Women employ hair pins
so frequently to dig at their ears that septic inflammatory processes
are apt to occur on the inferior wall of the canal just at the point where
caries is sometimes found — at the junction of the inner witfi the outer
two-thirds. A sharp little finger nail is also capable, when repeatedly
applied to the ear to relieve itching, of causing abrasion of the cutane-
ous layer in the canal and if persisted in, could readily, through infec-
tion, set up a carious process in the deeper osseous portion. In short,
I believe that the majority of such cases of localized caries occur as
the result of local irritation in people whose constitutional conditions
are below par, such as victims of tubercular states or whose surround-
ings, bad food, poor digestions and generally diminished resisting
power predisposes them to disease. Another point of great interest
in these cases is the presence of a pol3rpus in some and of granulation
tissue in others. Now, in the year 1887, Briggs, referring to aural
polypus, stated that "there is nothing peculiar in the nature of their
origin, which is usually a suppurative inflammation. Histologically,
they are primarily the same as wound granulations, except that occa-
sionally they exhibit an epithelium which adds much to their growth.
In the older polypi we find a mixture of granulation and mature con-
nective tissue, the latter increasing with the age of tlie polypus. These
growths are liable to so many accidents that large ones are seldom seen.
Even in minute ones the microscope reveals degeneration of the tissue
and extensive alteration in the blood-vessels. Granulation tissue pre-
ponderates, large round cells with large nuclei lying within a delicate
alveolar framework. These cells are closely packed together with but
little intermediate tissue. The transformation of the connective tissue
begins in the axis of the growth, in the root first and extends outward.
The most common form of degeneration is that of the myxomatous
type. It is a good plan after the removal of either aural granulation
tissue or a polypus, to explore for any evidences of caries, in the region
from which such tissue has grown. If the underlying bone be diseased,
reproduction of the growth is almost certain to occur. It is, of course,
most important to ascertain as accurately as possible the condition
of the middle ear in a case that presents signs of caries of the external
auditory canal at any point. The chief charm in Dr. Bellows' paper is
the clear cut narrative of each case, the concise yet complete descrip-

CARIES OF THE EXTERNAL AUDITORY CANAL, 287

tion and last but not least, the practical nature of the subject. It ought
to afford us all an opportunity for deep reflection and study.

Dr. Shepherd : I have one case to report which may not have been
primary caries of the canal, and yet may have been. About four
months «g)Op a child of five years was brought to me. She had been
sickly since birth, tif scrofulous tendency, large glands, swelling of both
knees, etc. The history of the tms trouble was very imperfect, parents
being simply able to say that there had been a dwrhaiy from the ear
only a few weeks. The appearance presented, when I first saw her,
was like that of a canal apparently occluded by a tumor, which was
very near the orifice and springing from the posterior wall. On pres-
sure it seemed soft and I could distinguish marked crepitus. By
passing the probe into the canal about one-quarter of an inch beyond
the swelling, it came to the end of the skin and touched dead bone.
By putting in a retractor and drawing out the skin-covering of the
tumor, a button of bone, twice the size of a pea, was disclosed. This
was removed with the forceps, leaving a hole directly through into the
mastoid cells. Finding that the cells were themselves considerably
involved, and the opening through the canal small, I laid the auricle
forward and cleaned out the mastoid cells, which were entirely ne-
crosed. The inner extremity of the posterior wall of the membranous
and bony canals were perfectly healthy. Apparently the disease had
not been a direct extension from the middle ear, even though a small
perforation in the membrane showed that the tympanum was some-
what involved. The case, as far as the caries of the canal is con-
cerned, has practically recovered.

Dr. Schenck: The relation of one of Dr. Bellows' cases
where the necrosed spot was near the membrana tympani, recalls a
case I treated last Fall with very satisfactory results in a somewhat
similar position. The previous June she had a severe attack of sup-
purative otitis in both ears. The left ear, the one in which the necrosis
occurred, had been almost useless as regards function since she
was a child. The membrane was tough, and it had broken down
with difficulty, the discharge continuing for the past three months, but
not sufficiently profuse to attract her attention much. She had severe
vertigo from the start, which persisted for several weeks so that she
was confined to her bed. She was treated by her family physician, who
did not recognize the case as aural vertigo from disease, and therefore
treated her on general principles. It was three months afterward,
when she was so that she could travel that I saw her. Curiously
enough, she came to me not for the treatment of her ear, but for relief
from a paralysis of the left side of the face and of the lower lid which
made it impossible for her to close the left eye. After I inquired into
this and found the vision perfect with almost no error of refraction
and no intraocular disease, I told her I thought this paralysis was due
to her ear and had nothing to do with the eyeball. Inspection re-
vealed the canal one-quarter filled with very offensive pus, and near
the posterior wall, at the junction of the membrane, was a spot covered

988 HOWARD P. BELLOWS. M.D.

with a small polypoid growth. It was some days afterward before
I was able to get things in a condition so that I could remove the
granulation. It was finally removed and the probe could then be passed
two or three millimeters into the bone which was found to be roug^
and divided into small shallow cavities. It could also be passed mto the
attic. The condition remained about the same for several weeks,
cleansing and antiseptic fluids having very little effect, and I had told
her that I thought the only possible way we could get the necrosed
bone removed from the facial canal where the pressure was apparently
causing the trouble with the facial nerve was to open the mastoid, to
which she and her family were all greatly opposed. It then occurred
to me that possibly I might get rid of the dead bone by using some
digestive agent. I communicated with Fairchild Bros. & Foster of
New York, with the view of using their pepsin. They called my at-
tention to Enzymol, as a preparation of the digestive ferment especially
designed for such uses — as a solvent of pus, morbid tissue, necrosed
bone, etc. This was used persistently for several weeks at the
office and by the patient, with the result that improvement began very
speedily and continued until all the carious tissue was apparently de-
stroyed and the spot healed. As the recovered spot healed, the paralysis
of the face improved, and she is not troubled on that account or from
vertigo at present.

Dr. Bellows : There is not much further to add upon this subject.
It would be very interesting, in the case Dr. Shepherd spoke of, to
ascertain whether the carious disease was due to a local cause or
whether it originated in the middle ear, extending through the mas-
toid.

The case of Dr. Schenck is one he may well be proud of. The
action of those agents, which is a recent use of them, is, by his case,
exemplified most happily. There has appeared since my paper was writ-
ten, a report of a series of cases of caries and necrosis, treated by a Nor-
wegian physician. Dr. Ole B. Bull, with a 4 per cent, solution of hydro-
chloric acid, which, so far as I know, is the most recent mode of
treating such affections. The results which he obtains are very en-
couraging, but his report refers almost wholly to caries of the tympanic
cavity, or the extreme inner end of the canal. He had, I think, only
four cases, out of a long series, which concerned the external canal.
In the tympanic cavity he succeeded best, but he ends his summary by
a statement that in caries of the external canal, the use of hydrochloric
acid is not to be recommended. So far as I know, then, the treatment
of carious spots in the meatus, which I have advocated, that is, the
curette, when admissable, the hyxlrogen dioxide and the homoeopathic
Silica internally, still remains the best.

NASAL FIBROMA— A CASEr-OPERATION AND AUTOPSY.

By Thos. M. Stewart, M.D.,

Cincinnati, Ohio.

HOWEVER interesting it might be to preface the report of
this case with a review of the latest facts regarding fibroma
as it occurs in the nose or naso-pharynx, that phase of the
subject must be passed over for the present. At a future time I shall
hope to take up the subject when I can command more leisure than
has been possible since the case first presented itself to my notice. I
have much of the literature of the subject, but it would not profit this
assembly, nor would it coincide with my desire to present a hurried re-
view of so important a subject.

Therefore I shall cling closely to my subject and simply render a
report of the case.

Case. — ^The patient was a little colored girl aged eleven, badly nour-
ished and living amidst unhealthf ul surroundings and in an unsanitary
manner.

She was first seen by me on October ii, 1898, among the patients
at the regular Saturday eye clinic in Pulte Medical College, bhe had
attended the clinic some little time before, but had not been referred to
me for class instruction until on October 11.

History. — Five months previously the left eye was first noiiced to
be protruding from its socket. No medical attention was given the
child until after the condition had lasted three months. There had
been no pain at any time. Post nasal haemorrhages had also been no-
ticed at about the time the exophthalmos was first noted.

Nasal respiration was good before the eye protruded, but it was
less free, progressively, after the protrusion of the eye. The patient was
one of four children (all girls), one sister died in infancy. The mother
is a large woman and has had considerable trouble with frequent en-
largement of the cervical lymphatic glands. Father is a large, strong
man, and his personal history was good. There had been frequent
haemorrhages from the nose, which Phosphorus and Geranium, pre-
scribed by the clinical assistants, controlled nicelv each time.

Examination. — ^Left eye protruded straight forward; restricted ex-
cursions in all directions; no abnormal external appearance of eye;
fundus examination showed a white nerve, small arteries and large,
tortuous veins.

The left orbit felt free to the finger except at the inner side, where
a hard protuberance was detected ; the protuberance extended back as

290 THOS, M, STEWART, M.D.

£ar as finger could reach. Needle passed into it, excluding a bony
growth.

The left nostril was then examined, and a large, hard, smooth,
pinkish growth was found filling that nostril from front to back, push-
ing the septum into and occluding the right nostril.

The growth bled easily; cocaine had no reducing effect upon it; no
attachments to septum were found. Pieces of growth removed for
microscopic examination. The post nasal space was free — ^the nasal
growth could be felt in the nasal passage; none of it could be detected
in the post nasal space — either before or after the autopsy.

The specimens were examined by Dr. L. D. Meader and pronounced
fibro-myxoma. Specimens from the deeper parts showed more of the
fibrous tissue, hence the diagnosis as fibroma of the nasal cavities.

Operation, — The parents reluctantly consented to an operation only
after seeing the horrible frog face develop. No hope was held out to
them. On December 15, 1898, the patient was brought to the operating
table in the Ohio Hospital for Women and Children — ^having been in
the Hospital some twenty-four hours previously.

The left nasal cavity was opened by the Bruns operation, the tumor
was removed by the wire ecraseur. Haemorrhage was controlled very
largely by the actual cautery. As the operation was about completed,
the patient gasped and never returned to consciousness, though strych-
nine hypodermically, artificial respiration, sphincter dilatation and the
electric current were tried in vain.

Nothing was to be done but to inform the parents who were wait-
ing in an adjoining room. They were anxious to know the full extent
of the trouble, and a post mortem was held.

In addition to the mass completely filling the left nasal cavity, push-
ing the septum into and occluding the right nostril, and pushing the
nasal bones out, thus giving the frog face appearance, we found the
cribriform plate of the ethmoid raised up and as thin as tissue paper,
so that a portion of the growth one-half inch in diameter projected, in
a rounded mass into the cranial cavity, not as yet having caused any
cerebral inflammation. The orbit was also filled by a pushing out of
the OS planum of the ethmoid.

DISCUSSION.

Dr. A. W. Palmer : The author is to be thanked for the report of
such an interesting clinical case.

I wish to compliment him upon his independence for reporting a
case which does not at all appear to be a brilliant success. All cases
are not successful. And we frequently learn as much from similar cases
as from very successful ones.

This IS the more instructive because of late fibroma of such magni-
tude are becoming more rare in this vicinity of the body — for the rea-
son, that as rhinology and laryngology advances they are recognized
earlier, when small and amenable to intra-nasal surgery.

Dr. Stewart's Case of Nasal Fibroma.

NASAL FIBROMA. 291

As I agree with the author's opinion that if we should enter into
a discussion on fibroma in this body, it should be very thorough — such
would be lengthy and it does not seem a fit time now; therefore will
call attention to but two points.

The operation — Brun's — spoken of is the laying to one side, of
the whole external nose. The incision in the sott tissues is com-
menced below the ala in one side and carried horizontally across under
the nose, carry down to bone, but with care that the mucous mem-
brane of the gingivo-labial fold be not cut through. Make a second in-
cision across the narrowest portion of the nasal bridge, just above the
canthus. Then connect the corresponding ends of the above incisions
by a third one, parallel to but a little beyond the nasal furrow.

Now with a small saw commence at the outer lower comer of the
anterior nasal opening in the skull, beneath the commencement of the
first incision in soft parts — saw downward about % in., then hori-
zontally to about a J4 in. beyond the lateral margin of the bony opening,
saw upward parallel to such margin to a point just above the canthus,
then make a horizontal cut to Sie opposite side through the upper
portion of the nasal process of superior maxillary and nasal bones.

Finally incise the septum narium and the whole external nasal
organ can be laid over onto the cheek.

In this manner a strip of bone ]/i to % in. wide can be cut away
from the border of the anterior nasal opening in the skull, thereby
giving a very large opening through which to operate in the nasal
cavities. No large blood-vessels are encountered.

A circumstance that I have noticed of late which has interested me,
is, that although fibromata are tumors of approaching adolescence, still
in the literature of the past two years, there have been four or five times
as many cases reported occurring in individuals over 45 years of age
as below 30 years.

Believing that these tumors will frequently spontaneously disappear
at about 25 or 30 years of age by retrogressive tissue metamorphosis,
a "let alone" treatment is often advised.

Now on account of these tumors being so frequently found in older
persons I think it behooves us to be more careful in such prognosis and
keep strict supervision of such cases.

INTERNAL REMEDIES IN EYE AFFECTIONS.

By Wm. a. Phillips^ M.D.,

Cleveland, O.

I WISH to say, preliminary to the reading of the paper, that I have
said nothing at all in regard to the subject of bacteriology as
having relation to the use of internal remedies, as the status of the
subject is indeterminate. The systematic proving of medicine, and
keen clinical observations are the two grand steps that indicate the
direction in which we must conduct our researches to sustain the claims
of our law of cure.

The possibilities arising out of these two steps and the interminable
amount of careful investigation demanded in order to develop all the
virtues of medicines are features which are more and more fully appre-
ciated as clinical work is multiplied. The field of minute anatomy, of
physiology, of pathology, and of the peculiarities of diseases, is grad-
ually broadening and this means to the specialist as well as to the
general physician an ever widening circle of study. We know that no
two cases can be absolutely alike — ^they may be near enough alike so
that the same remedy will commonly cure : but for all this we know that
each case has certain peculiar symptoms and hence each individual case
is a problem in and of itself and should consistently be solved sepa-
rately. If time, sharp discrimination, the best diagnostic appliances,
and profound culture for the work, could always be brought to bear, it
is no doubt true that we could more nearly approach the aim in view.
It is fair to assert that it is the failure in one or more of these par-
ticulars that all possible cures are not made, rather than because our law
is not strictly applicable in the whole realm beyond the purely physio-
logical. We cannot keep it too well in mind that there is no such a
thing as a specific, in the sense that any one medicine will cure any one
disease in all people who may be attacked. A medicine is specific in so
far as it cures in any given case. Naming a disease and naming a
medicine, that has been known or thought to cure, are but a small part
of really scientific treatment. But it is so much easier to do this, and to
exhibit medicines in doses to produce physiological effects and thus
give the greater appearance of doing something tangible, that many
physicians have failed to devote the time and study necessary to make

INTERNAL REMEDIES IN EYE AFFECTIONS. 2W

a discriminating prescription. We must ever bear in mind, that both
objective and subjective S3rmptoms are quantities, so to speak, whose
absolute and relative value we can never put down as constant. There
are astonishing modifications of symptoms strictly within physiological
limits that give no particular trouble, while there are exceedingly
minute changes in the pathological field which often give no end of
trouble; thus showing that the relation existing between physiological
an,d pathological disturbances cannot always be exactly determined.
We have a live machine to deal with whose horse power cannot be
accurately put in figures — a machine in which the significance of the
symptoms depends primarily upon two things: i. The physical con-
dition of the visual apparatus ; and 2. The power and constancy of the
nerve supply. It is here that we as oculists see somewhat clearly de-
fined our therapeutic limitations. If there is, in any given case, a mal-
formation of the eyeball disturbing normal refraction, there is at once
a foundation for the development of symptoms, which from the nature
of the case, cannot be cured by internal remedies, however perfect
the correspondence between the "totality of the symptoms" and the
pathogenesis of any drug. Palliation, if even that can be obtained, will
mark here the limit of therapeutic measures. In those instances, how*
ever, in which well defined diseases have been developed in conse-
quence of the strain resulting from imperfect refraction, and in which
the error has been corrected, there will be found a more distinct sphere
for the exhibition of internal medicines, on account of the fact that the
physical cause of the disease is practically removed. We thus have
thereafter symptomatology and patholc^ to deal with and not at the
same time the direct influence of malformation. But in addition to any
inflammatory diseases that may occur from the above cause (error of
refraction), there sometimes develop a series of cases immediately re-
sulting from an inadequate power and constancy of the nerve supply.
This like the malformation may be congenital, or acquired because of
tlie long continued depressing effect of the muscular strain. Here is a
field for sharp discrimination in selecting the right prescription, for
we must know first, whether there is perfect optical correction ; second,
whether the symptoms are directly acquired through in-coordination ;
and third, whether they are due to reflexes from other parts of the
body. These points being settled it may be found that nothing more
than a purely physiological disturbance, so far as we can determine,
remains as a target for our prescription. It is clear, that the symptoms
arising from imperfect refraction do not offer the same opportunity for

2»4 IVAf, A. PHILLIPS, M.D.

the genius of the materia tnedicist as do those symptoms arising
idiopathically and which are uninfluenced by physical causes. Here
is a cardinal point for the general practitioner that he may know why
it is that oculists have to resort so frequently to lenses, ocular gymnas-
tics, and to the scissors to the harmless exclusion of "attenuations" in
the immense majority of optical and muscular defects. The reason why
oculists have been taken so much to task for not giving something more
specific in the use of medicines, is because physicians have not, and do
not, understand the real character of this large class of cases. But our
therapeutic limitations do not cease here, and that is due principally to
the peculiarities of the anatomical structure of certain parts of the eye.
The optic nerve, for instance : almost before we have an opportunity to
make a diagnosis grave pathological changes occur there in cell infil-
tration of the interstitial connective tissue and before its influence upon
the delicate nerve fibres can be arrested the initial steps of atrophy have
placed the case beyond certain restoration. Our clinical experience as a
school has not enabled us to treat these cases successfully : and as for
the old school a high authority says: "diaphoresis or mercury and
iodide of potassium may be tried." Furthermore, it is not at all proba-
ble that provings can ever be conducted in such manner that they will
materially help us in inflammation of the optic nerve. Only a long con-
tinued, painstaking course of discriminating clinical observation can
aid us in this line. The same may be said of the choroid : the same of
the structures implicated in glaucoma; the same in affections of the
lachrymal apparatus ; the same in regard to trachoma and other diseases
of the lids. On the other hand, most satisfactory results are obtained by
the use of internal remedies in inflammation of the retina, the iris, and
the cornea notwithstanding in the latter two certain local measures are
at the same time demanded. These specifications might be carried out to
considerable length, but the above is enough to indicate in a general
way what I wish to urge. In view of the fact, now, that the progress of
medicine has not reached that state of perfection where we can indicate
to others, or to ourselves even, definitely what is to be administered in
all known conditions, the leading question for us as a society is : What
is to be done to forward our specialty? Before we can designate
anything more definite than what we already have to rely upon respect-
ing the range of our law of cure, we must be

/. Strictly Systematic. — This clearly relates to (a) An accurate
record of the symptoms of each case from first to last, (b) The
instruments used as an aid in making the diagnosis, (c) What medi-

INTERNAL REMEDIES IN EYE AFFECTIONS. 296

cines were given and the attenuation, (d) What palliative measures,
if any, were employed.

//. — We must discriminate sharply between purely functional
symptoms and those of pathological import.

Under this head it must be conceded that we labor under a cloud
of uncertainties.

Not until the study of pathology reveals to the physician the true
and full significance of all functional disturbances in the real bearing
they have upon each case; not until we can know the full significance
of every S3miptom that points to the destruction of function or of tissue;
not until we know more of the true character of all the diseases attack-
ing the eye directly or indirectly ; and not until we have the most per-
fect provings possible of the medicines used ; not until all this illumines
the realm of practical medicine can we expect to attain to that degree
of success in all diseases which we now enjoy in the treatment of a
few. For, as already intimated, it is directly along this line of distinc-
tion between symptoms that have pathological import and those having
only a purely functional character that we arrive at a diversity of opinion
concerning diagnosis and treatment. One physician attaches an im-
portance to a single symptom or to a group, which another physician
may regard as incidental and of comparatively little value. Not until
well informed physicians can consistently and uniformly arrive at the
same conclusion in diagnosis and treatment of any given number of
cases, will we be able to rejoice in the happy thought that ophthalmology
is an exact science.

DISCUSSION.

Dr. Moffat: We must never forget that we are homoeopaths and
have a debt to pay in the advancement of homoeopathy ; we have an ad-
vantage over some physicians in that we can fairly see the pathological
condition underlying some of the subjective symptoms — ^it is our duty
to incorporate this into the materia medica by annotated verifications.
I take issue with Dr. Phillips if he says our remedies cannot help in-
cipient atrophy of the optic nerve; Nux., Strychnia phos., and Zinc
phos. have done good service here.

As to his point of defending ourselves against the general prac-
titioner for not prescribing more, I reply that we are removing the
cause — in obedience to Hahnemann ; when that does not suffice to cure
the S3miptoms we prescribe the indicated remedy.

Dr. Boynton : I am reminded of two cases causing me a great deal
of anxiety, which went from good vision to blindness, notwithstanding
my careful selection of the single remedy, given in attenuated form and
according to the law of similars. The first case was a man who ac-

aoe H^Af. A. PHILLIPS, Af.D.

quired S3rphiliSy of which I was not aware at the time of treatment.
He was sent to me by his physician for an examination to explain if
possible the cause of his recently impaired vision in one eye. I found
nothing. No ophthalmoscopic changes were observed at the time of
examination, but he had quite a high degree of hypermetropia with
astigmatism. In attempting to correct that I found he had amblyopia.
Either the changes were so slight or my powers of observation were
so limited, that I found no abnormal condition in the left fundus.
Four days later that man came in with pus in the anterior chamber.
Then the ophthalmoscope revealed some trouble in the vitreous humor
and some choking in the disc. Of course I was alarmed and put him
to bed. I saw that eye become totally blind, the second one become
involved in a similar manner, and the patient so blind he could barely
distinguish light from darkness. Meanwhile, the nurse had informed
me of mucous patches in the mouth and in the pharyngeal space which
explained the cause of his disorder. I had been religiously giving
Hepar sulph,, Gelsemium, Bromium and similar remedies. But now
we put him upon the orthodox single remedy according to Dr. Moffat's
definition — 2 grammes of the unguentum hydrargyri rubbed into the
skin daily, morning and evening. I had the satisfaction of seeing that
eye clear up and the patient recover perfect vision, notwithstanding
dense opacities in the vitreous humor. I do not think I am any the
less of a homoeopath for this selection of the single remedy.

The other case is one of sympathetic ophthalmia, where the right
eye was injured by the bursting of a lamp from having a stone thrown
into it, involving the sclerotic and half the cornea. The wound had
healed and I thought I would save the case just a few days for the
students who were about having their annual altunni day reunion. I
saved him just a few days too long; the fatal period passed; and I
think it was four weeks to a day when he developed sympathetic oph-
thalmia of the other eye. I had never seen a s)mipathetic ophthalmia
with total destruction of one eye from injury in the ciliary region
arrested by enucleation, but this eye was removed. Notwithstanding,
it went on. There were no external evidences at first. He claimed he
had got some sand in the second eye. I had him report every two or
three days, but here was the only case of neuritis of this peculiar
character that I have ever seen. He went on with a choked disc and
neuritis until vision was reduced to mere perception of light. Should
I give Gelsemium? I did, and I gave Bryonia and all the remedies
that presided over that class of tissues, until in despair, I gave him the
unguentum religiously rubbed into his lymphatic spaces and saw him
get perfectly well. And there is a case of sympathetic ophthalmia cured
by the inunction of the hydrargyrum. Did it not kill the same thing
that caused the inflammation?

Dr. Phillips: The only remark I wish to make in dosing, is in
regard to the unfortunate circumstance that some of these cases are
apparently cured by the use of crude drugs; whereas, according to
homoeopathy, they ought to be cured by attenuations. The point is,

INTERNAL REMEDIES IN EYE AFFECTIONS. Wt

whether bacteriology comes in as a matter of any importance. It is a
question whether there is septic material communicated, or whether it is
purely a nerve influence that produces the disease. If it is purely nerve
mfluence, then our attenuated remedies should cure; if germs have
anything to do with it, then it is possible that we will have to use the
remedies locally or in massive doses. They must get to the point
where the bacteria are in order promptly to destroy them, instead of
waiting for them to starve to death.

SOME OBSERVATOINS CONCERNING THE SURGICAL
TREATMENT OF NASO-PHARYNGEAL ADENOID
GROWTHS.

By Thomas L. Shearer, M.B., CM. (Edin.)

Baltimore, M.D.

ACCORDING to tradition, there once was a lad — one of those
half idiotic specimens without which no Scotch village is
supposed to be complete — ^who was found sitting by the road
side, engaged in cutting away with a pair of scissors, all of the hair
about his forehead. On being asked what he was doing, he quietly
replied, "Oh, just making all face that will be face." Now as the
tendency of modem naso-phar3mgeal surgery seems to be of the same
order, viz : to make that space as large as possible, it is opportune that
we consider briefly some of the points in connection with the subject;
for, in Maryland, adenoid operations are as common and as popular
with the medical profession as 'coon and 'possum hunts are with the
A.*scendants of Ham in Virginia. Young and old — experienced and
inexperienced — ^all are at it and victims are plentiful. Such being the
case, one of two things must follow ; either the necessity for such wide-
spread surgery exists or some unjustifiable operating is going on. Un-
doubtedly adenoid hypertrophy is a very common condition in childhood
and one that calls for thorough, careful handling. As this paper deals
only with the surgical part of it, no reference can be made to that most
important factor — ^the medical or constitutional treatment.
In order to be systematic, let us consider,

/. Diagnosis,

In very pronounced cases there can be no difficulty in recognizing
the presence of adenoids, as the well-known symptoms — which are now
almost classical — ^are very clearly marked. The peculiar facial appear-
ance: the broad and flattened nasal bridge, the anaemic and ill-nour-
ished condition, the drooping upper eyelids, the mouth partly open
with mouth breathing, the evident difficulty in hearing, the half stupid
and inquiring expression — ^all make up an extraordinary picture, one
not easily forgotten or overlooked. When to these symptoms are added
the absence of deviated septum or marked turbinate hypertrophy, the

NASO^PHARYNGEAL ADENOID GROWTHS. 299

Iristory of repeated attacks of bronchitis, persistent nasal discharges,
ear-ache, restless nights with snoring or snuffling respiration; occa-
sionally night terrors, with sensations of suffocation the result of de-
ficient air supply, we have further confirmation. In many instances
the patient's voice undergoes a curious change in resonance as the
sound waves impinging upon the post-nasal growths are thrown back
and produce a deadened quality, which varies according to the size of
the space and the degree of the hypertrophy. In saying "3, 2, i." the
one becomes "wudt" in severe cases and all shades of modified tone
may be encountered between the normal and the extremely dead quality ;
"m" is pronounced "eb" and "n" as "ed." Owing to interference with
the proper cerebral circulation, children with adenoids are often in-
clined to be slow at their studies and have not power of mental con-
centration — ^a condition to which Guye has applied the term "aprosexia."
In a case in which doubt exists concerning the presence of adenoids a
good plan recommended by Dr. Eugene S. Younge* is "to wrap a fold
or two of handkerchief around the proximal phalanx of the forefinger
of the right hand, care being taken that the folds are not voliuninous
enough to prevent the finger being inserted in its whole length. Then,
standing on the right hand of the patient (who is seated), with the left
hand resting lightly upon his head, so as to grasp it firmly if necessary,
the surgeon passes his finger rapidly backward, palm upward, not to
the uvula, as is frequently done, but behind the right posterior pillar
of the fauces ; the finger, on being rotated upward will then slip behind
the velum. The surgeon should now feel for the septum, and pass
the finger upward until the growths are impigned upon, when the
sensation will be akin to that of varicocele and on withdrawing the
finger, the presence of blood will confirm the diagnosis."

When one has made many examinations the peculiar sensation im-
parted to the finger when touching the Eustachian tubes, is easily dis-
tinguished from the soft adenoids which yield so readily to pressure.
If the digital examination is inconvenient, any of the post-nasal forceps
may be introduced to obtain a sample ; or, a Munger curette can be used
as a sound, for if growths are present, it sinks into them and resistance
is felt when one attempts to push it downward ; if no increase of tissue
has taken place, it slips easily over the smooth pharyngeal surface.

//. AncBSthesiih

Whenever possible, I think that surgical measures for the relief of

* Medical Brief, April, 1899.

aOO THOMAS L. SHEARER, M.B., CM. {ED IN.)

adenoid hypertrophy of lesser degrees should be carried out without
an anaesthetic. That the growths should be removed, in a number of
sittings, in one's office. When, however, we find that the amount of
the tissue is very large and that too many sittings would be necessary
for its removal; when the patient is being greatly upset by nervous
shock; when the subject is an unruly child, whose entire time is occu-
pied in keeping the teeth firmly in apposition, in planting his feet in
your epigastric region and in entertaining the waiting room with heart
rending screams ; when the patient will not consent to office treatment,
and lastly when, after such treatment, the tissue persists in causing re-
turning symptoms, the subject should be anaesthetized and the post-
nasal space properly cleared. In England, nitrous oxide gas is em-
ployed for the lighter cases. Until recently chloroform, which is con-
sidered the anaesthetic for children, has been largely used both in
Europe and in America for these as well as for tonsillar operations.
Dr. Hinkle,* however, has collected the records of i8 deaths following
the administration of chloroform for the removal of naso-pharyngeal
adenoids, hypertrophied tonsils or both. In 4 of these cases, death
occurred before the operation was begun ; in 3, from a few moments
to an hour after the operation was completed. In 1897, during a dis-
cussion of this subject in the British Lar3mgological Association, both
Wyatt Wingrave and Dundas Grant referred to the high mortality
under the use of chloroform in such surgical cases and strongly ad-
vocated the employment of some other anaesthetic. In Vienna, Pal-
tauf, Kolisko and others have made a number of observations which
may assist us in understanding the extraordinary mortality under
chloroform in this operation. They foimd, post mortem, in a num-
ber of cases of sudden death from slight causes that there was present
hypertrophy of the lymphoid tissue throughout the body, including the
tonsils, the lymphoid structures at the base of the tongue and the naso-
pharyngeal adenoids. The th)mius gland was persistent and often very
large, and the intestinal follicles were markedly hypertrophied. In
addition there were frequently present a dilated heart, not dependent
on valvular lesions and at times a narrowing of the aorta with small
size of the peripheral vessels. This condition which has been called
the habitus lymphaticus, was 'found among others in a number of cases
of death during chloroform administration. Persons so constituted
seem to have little power of resistance to comparatively light shocks.

• N.Y. Medical Journal, Oct. 1899.

NASO-PHARYNGEAL ADENOID GROWTHS. 801

Brickner,* commenting upon Kolisko's report of habitus lymphaticus,
says : "It would seem, therefore, that in anaesthetizing patients of the
lymphatic temperament, or in whom lymphatic enlargement or adenoid
vegetations exist, chloroform should be rigidly excluded." Statistics
as well as pathological studies certainly appear to confirm this view
and we are forced to the conclusion that the administration of chloro-
form in the removal of hypertrophied pharyngeal and faucial tissue
is attended by grave risk. This view so impressed itself upon me that,
for some time past I have employed ether for all adenoid operations
where a general anaesthetic was necessary. The objections to ether
are that, in operations about the face, the patient comes from under
its influence very quickly and as the cone is frequently removed while
operative step^ are being carried out, surgeons are annoyed by occa-
sional delays in completing their work. To avoid this, take plenty of
time and proceed only when the patient is properly anaesthetized ; not
when barely under its influence and when the nerve centres, in conse-
quence, are extremely sensitive to shock. Ether, when inhaled, is ac-
cused, in some instances, of causing profuse secretion of bronchial
mucus and thus increasing the difficulty of respiration during the use
of the anaesthetic. To overcome this complication never give ether to a
child when it is suffering from a marked case of bronchitis ; treat the
latter medicinally and when bronchial symptoms have subsided, any
secretion occasioned by ether is not apt to interfere seriously with its
use. Ether sometimes produces retching or vomiting. To guard
against any accident during this period, do not allow the patient to par-
take of any food or drink within six hours of the time set for opera-
tion. Chloroform is a cardiac depressant and renders any possible
chance of nerve shock much more apt to be fatal. Ether is a stimulant
and rather combats the effect of surgical shock. But to still further
assist our patient, it is a good plan to administer h)rperdermically ^/^
grain of strychnia sulphate, ten minutes before beginning the anaes-
thetic ; to give the ether only when the patient is in bed — ^not on the op-
erating table — ^and where no evidences of any surgical preparations can
be seen or heard. These measures go far towards producing that
mental quietude so useful in those about to undergo any surgical opera-
tion. When, therefore, neither the bromide of ethyl or nitrous oxide
are employed, ether should be given the preference ; upon no account
should the use of chloroform be considered for one moment in any

♦ Op. cit.

S09 THOMAS Z. SHEARER, M.B., CM. {EDIN.)

of these cases, as there is a growing feeling among medical men that
it is the most treacherous of all an<BSthetics.

III. Position of the Patient,

Every operator naturally adopts that position for his patient which
experience and convenience have apparently shown him to be the best
In my own sanitarium, the patient when thoroughly anaesthetized, is
placed flat upon the back on the operating table, the head and part of
the shoulders are allowed to hang well over the edge of the table, but
the occipital portion of the head rests upon the knee of the anaesthetist
The gag is now introduced and the operation is begun, stopping only
when more ether is necessary or when the blood is mopped from the
pharynx. This posture of the patient permits a flood of light from the
sky-light to fall into the oral cavity and enables the operator to watch
carefully the soft parts about the uvula in order that they may be free
from any injury. It also permits the blood to flow easily from the nos-
trils and thus diminishes the amount of blood and mucus that one
usually encounters in the oro-phar)mx. In addition to these advantages,
the anaesthetist is in such a position that he is also able to render great
assistance during the operation, by keeping the anterior nares clear
of blood, by occasionally mopping the pharynx with a piece of gauze
grasped by forceps and by altering the angle of the head when re-
quested to do so by the surgeon. The nurse attends to the instruments
and particularly sees that a number of gauze sponges are always ready
for instant use, in the event of sudden profuse haemorrhage taking
place. A good assistant and anaesthetist is worth his weight in gold
and can be a source of great comfort to the operator, while an incom-
petent one is capable of rendering one's life a burden. When the pa-
tient is a female, it is best to encase the hair in an oil silk or thin rubber
cap and thus keep any blood from trickling on to the scalp and be-
coming matted with the hair. After the operation the head aind
shoulders are allowed to rest on the table, the gag removed and the
face well cleansed. In the position just described, it is rarely necessary

to turn any one upon the side to permit the discharge of blood or mucus,
excepting, of course, occasions when vomiting is taking place. Some

surgeons advocate the Trendelenburg posture for these operations, but
personally, I have not been inclined to try it as one would naturally ex-
pect a greater degree of local blood pressure as a result of the exces-
sive body elevation and proportionately greater tendency to haemor-
rhage.

We come now to.

NASO^PHARYNGEAL ADENOID GROWTHS. 803

IV. The Operation for Adenoids.

(a) Office operation without an anaesthetic.

If the child is under five years of age and the growths only mod-
erate in amount, they may be removed by using the finger to clear out
the space; if five years or older the hypertrophy is very pronounced,
one may employ the Lowenberg or Schultz forceps to sieze the tissue.
Many operators apply a solution of cocaine to the naso-pharynx be-
fore the introduction of the forceps — a preliminary step that seems both
useless and absurd, when we consider that it is not the mere presence
of the instrument in the space that hurts the patient, but the sensation
as if "the inside of the head were being torn out," when part of the
tonsil is grasped and bitten off. Cocaine cannot possibly reach this
portion of it and consequently does not actually prevent the much-to-
be-dreaded feeling. The use of the powerful curette, without an anaes-
thetic, when the operator must necessarily work very rapidly, when
the little patient submits to the most severe pain merely because he is
overcome by superior force, is a disgustingly brutal performance and
from a scientific standpoint reprehensible. It is like a blindfolded man
who is armed with a sabre and turned loose in a small room, full of
people, to cut and slash at random.

(b) Operating under General Anaesthesia.

There can be no doubt that, after all, the most satisfactory and only
thorough way to remove adenoids is when the patient is under general
anaesthesia ; when one can quietly make a complete digital examination
and then introduce the instruments, guided by the left forefinger, which
also prevents any tendency towards denuding or stripping the bone of
its mucous membrane, or injuring neighboring parts. As indicative
of the necessity for this precaution, I examined recently a young lady,
whose adenoids had been removed by a leading laryngologist of Bal-
timore. The posterior border of the nasal septum had at least four
deep scars — the result of vicious bites from post-nasal forceps — some-
thing that should not happen when the instrument is controlled by the
forefinger. With the patient's head well over the table, the posterior
border of the septum nasi lies in an oblique direction, the sphenoid end
pointing towards the floor of the room.

It is absolutely necessary that we bear this in mind and keep the
forceps blades approximately parallel to the posterior pharyngeal wall.
If we should happen to grasp the edge of the septum, there is a pecu-
liar sensation imparted to our hand; there is a feeling of something

304 THOMAS JL SHEARER. M.B., CM. {EDIN.)

firmer in consistence than adenoid tissue and which does not seem to
3rield in the least to moderate tension. If such be the case, let go at
once as most surely we have bitten the sphenoid end of the septum.
Operating with the curette, when the patient is in this position, requires
that the assistant elevate the head for a few moments until it lies in
the same plane as the body ; this change enables us to have a more in-
telligent and clear use of the instnmient. The Eustachian orifices are
also sometimes injured but usually escape because they are rather slip-
pery and are placed in their peculiar lateral position — ^no thanks to
the efforts of the operator. It is well to introduce instruments as sel-
dom as possible as the degree of shock will naturally be in proportion
to the number of such assaults upon the region.

The digital exploration is of the greatest importance, as upon the
character of the tissue, and the space in which we have to work will
depend the choice of instruments. Only during the present year New-
comb,* of New York and Dundas Grant, of London, have related cases
in which an exaggerated prominence of the anterior arch of the cervi-
cal vertebrae has so altered the conformation of the post-nasal space that
only a special variety of forceps (Quinlan's) and Golding-bird's
curette could be used. In the regular adenoid work it is convenient to
begin with a large pair of forceps, then to follow with small forceps,
then the curette next to clear away fragments with forceps again and
lastly to remove shreds with the index finger. The early morning hour
is an excellent time for these operations and whenever it can be man-
aged they should be performed in a sanitarium or hospital — ^as private
houses are apt to be greatly upset by the preparations which are neces-
sary to render the home operating quarters as aseptic as possible. It
has been my rule to have assistants, nurses and operating room as thor-
oughly surgically clean as if for an abdominal section — for the removal
of adenoids is entitled to just as much care as any other more serious
surgical cases. After the operation the patient is placed in bed for
twenty-four hours, kept on milk diet and the naso-pharynx sprayed
twice daily with any of the ordinary antiseptic solutions, such as Do-
bell's or Seller's. In some instances, children do not make use of their
newly acquired power of nasal respiration but continue to breathe
through the mouth until brdcen of the habit by the constant watchful-
ness of their parents.

In conclusion, let us consider the question.

*N. Y. Academy of Medicine — Section of LaryngoL, December, 1898.

NASO'PHARYNGEAL ADENOID GROWTHS. 305

V. When is the Operation for Adenoids Indicated? . . . .

There are many cases of moderate hypertrophy in which hygiene,
diet and the persistent use of suitable internal remedies, such as Cal-
carea iod, Calcarea phos, and Baryta iodatum are all that is necessary
to bring about a normal condition of the naso-pharynx, but when they
do not respond to these measures and present the following symptoms,
surgical interference is justifiable:

(a) When there are repeated attacks of earache, suppurating ears
or merely deafness — the result of adenoids.

(b) When the child is inclined to aprosexia, provided the physical
signs of growths are well marked.

(d) When constantly recurring attacks of bronchitis, laryngitis and
nasal discharges are kept up by the growths.

(e) When nocturnal eneuresis of a severe type, is associated with
adenoid hypertrophy. Operation may or may not relieve the annoying
symptom.

(/) When the child suflFers from suffocative seizures during sleep
— ^the result of deficient air supply— oxygen hunger.

(g) When the voice is very much deadened in resonance.

(h) All cases presenting a family history of tuberculosis and in
whose childhood days, above all other children, the great necessity for
a normal breathing apparatus is most essential.

(i) When batting of the eyelids, ponstant sniffling and twitching
of the facial muscles is indicative of reflex irritation; which may de-
velop into a true choreic condition.

These are some of the most important indications for operation,
and while I am a staunch advocate of prompt surgical interference in
many of these cases, in all of them I recognize the great and absolute
necessity for careful constitutional treatment.

DISCUSSION.

Dr. J. B. Garrison: Dr. Shearer, in his able production, has left
but little that I am able to criticise, his ideas and methods being so
nearly in line with my own ; I cannot award him too much praise for
his labor in presenting this subject in such a clear and comprehensive
manner, making it, indeed, a classic.

I believe that in the majority of cases, it is best to make a digital
examination in order to accurately determine the location and character

306 THOMAS L. SHEARER. M.B., CM. (EDIN.)

of the growths to be removed, a proceeding which can, by practice, be
done quickly and at the same time satisfactorily almost before the child
has an idea that anything is being done. I have never found it neces-
sary to protect the finger at all, but I may sometime wish I had.

I think that the cases that are best operated in the office making
more than one sitting of it, are rare and I should not advise it. I be-
lieve that it is better for both the surgeon and the patient, as a rule, that
a general anaesthetic be given ; and I fully agree with the author that
a hospital oflFers the best facilities for good work. Personally I have
never seen any unfortunate results from the administration of chloro-
form, but in view of the deaths that have occurred, we should, if we
use it all, be careful to assure ourselves that those upon whom it is to
be used are not of the hypertrophic disposition spoken of in the paper.

The use of ether takes a little more time, but that is a factor that
does not count when the safety of life is at stake.

The author truly says that the position of the patient during opera-
tion which is best, is the one with which the surgeon is most familiar.
My habit is to place the patient on the right side and a sand-bag of
two feet long by four or five inches in diameter placed along the back
will greatly help to retain the position, permitting the nurse to devote
her attention to other things.

In this position it seems very easy for me to introduce my left index-
finger back of the palate and to introduce the forceps and grasp the
growths, while the blood flows readily out of the mouth.

The early morning, while the patient is quiet, is by all odds the best
time to operate upon the little ones.

Dr. Hooker: This is a most admirable paper we have just listened
to from Dr. Shearer. His experience and his methods are almost
identical with mine. It is a number of years since I have operated in
such cases under chloroform. When I give a general anaesthetic it is
invariably ether. My method differs from his in only one particular,
and in just one way from Dr. Garrison's also. It seems to me that we
get the best position — at least for me — in putting the patient on the
left side, with the head just over the edge of the table; and then the
assistant can give the anaesthetic and hold the head in such a position
that the blood will drain out of the nose and out of the mouth. That is
the only way that I differ from Dr. Shearer at all in regard to the opera-
tion. In all his other conclusions I am with him heartily. It is rare,
I think, that we find, in so few words, so much said as we have heard
in this paper.

Dr. Rice: I was extremely interested in Dr. Shearer's paper. It
covers the ground completely and brings to the front the different points
upon which there is difference of opinion, thus giving us the opportu-
jiity for a discussion which I am sure will aid us in our future work.

Regarding the use of an anaesthetic, my experience has been similar
to that of Drs. Shearer and Hooker. I did use chloroform at one time,
but, seeing the articles mentioned by Dr. Shearer, gave up this anaes-
thetic and performed all my operations with the aid of ether.

NASO-PHARYNGEAL ADENOID GROWTHS. WI

I have had some experience with the diflferent instruments in use
for this operation and at one time used forceps, but after a time was
compelled to give them up almost altogether in favor of curettes. It
seems to me that by using diflferent forms of curettes of diflferent sizes
of fenestrae, that the naso-phamyx can be cleared out safely and quickly
— ^much more safely and quickly than by the use of the forceps.

This instrument is not a safe instrument in the hands of all opera-
tors. Dr. Shearer has spoken of a case where injury occurred and I
have recently seen a case where an Eustachian orifice was nearly de-
stroyed, cicatricial contraction following as a result of the careless use
of the forceps.

In position of patient I agree with Dr. Hooker ; it seems to me that
with the patient on the side, with the head hanging over the edge of
the table, held by an assistant who also supports the mouth gag, the
position is almost perfect for both the operator and the patient. The
blood and discharges drain away rapidly from the nose and the mouth,
and one soon becomes able to work surely and expeditiously on the
faucial as well as the Luschka's tonsil.

Dr. Haywood: One or two points I would like to refer to not
spoken of, — that is, the holding out of the soft palate. I usually intro-
duce a catheter to which I have attached a small piece of bandage,
one-half inch wide by a foot long, pass that through the nose and out
through the mouth, and in that way tie forward the soft palate. I be-
lieve in this there is no danger at all of touching the uvula or the soft
palate. I never use anything except the Gottstein curette and never
have any bad eflfects. For my first operation I used forceps and did
have a little trouble with the ears ; but with the Gottstein curette and
going in afterwards with my finger nail I "find that is all that is neces-
sary.

Dr. T. M. Strong: I used chloroform exclusively in these opera-
tions for a long time, until I had a patient in whom the breathing and
pulse stopped completely for a few moments only, but it seemed an
hour. It was about this time that articles began to appear calling at-
tention to the danger of chloroform in operations for adenoids. That
there seemed to be a predisposition in some of these patients to be
seriously aflfected when under this anaesthetic. It was the first time that
my attention had been called to the possibility that, contrary to the
usual theory, chloroform was not safe for children, suflfering in this
way, however it might be in other conditions. This had been rather
the general working rule with surgeons. Since then I have stopped
the primary use of chloroform, although in this instance the fault
might have been with the anaesthetiser. I very frequently, however,
follow the ether anaesthesia with chloroform, if they are a little rest-
less, as you can work under the chloroform mask, where you cannot
under the ether cone.

The instruments mentioned by Dr. Shearer I have found advan-
tageous, and I have used in addition, with youth and adults, the Farlow
Guillotine, with which you can remove the pharyngeal tonsil in the

808 THOMAS JL SHJiARER, M.B., CM. (EDIN.)

same way as the faucial. The instrument can be used in the office, or
at the home, without an anaesthetic. I do not believe any child should
be operated upon with the end of the finger, except as a temporary
measure, and no operation at any child age, without an anaesthetic. I
should hate to attempt the curette operation, even in an adult, without
anaesthesia. With the guillotine, however, as a rule, you can remove
the hypertrophied mass very completely with one cut.

Dr. A. W. Palmer: I should like to emphasize the constant use
of the finger, — ^the digital examination of the pharynx. It is a thing
that I have found is not used as much as I think it should be. It is a
good idea, not only in examining for adenoids, but when you become
accustomed to it, the position of the parts and of the septum, can be
made out as can also Luschka's tonsil and the prominence of the Eus-
tachian eminence. You can get inferior turbinated hypertrophies,
which frequently accompany these cases. With children especially, I
think, it is easy, their mouth being rather shallow. You often find quite
a little difficulty in getting a postero rhinoscopic view with the mirror,
so I depend almost entirely upon digital examination in these cases,
finding it saves a great deal of time. After a little practice it is not
so disagreeable to them.

Dr. F. Park Lewis : Dr. Shearer seems to have covered the subject
entirely, as far as children are concerned ; but during the past year, I
have been led to adopt the exploratory diagnostic test in those of more
mature years than the children in whom we often find adenoid growths.
In manv of the most intractable forms of chronic middle-ear catarrh
I have found obstructions of lymphoid hypertrophies in the vicinity
of the mouth of Jhe Eustachian tubes. I have very materially helped
cases that have previously resisted all manner of treatment by remov-
ing these hypertrophies with the curette, or forceps. It was a new
experience to me. I had not until recently learned the necessity of
msiking an examination in this connection. While the fact that there
were obstructions at the mouth of the tube of one kind or another had
been recognized, it was impossible to see them with the laryngeal mir-
ror. It not infrequently happens that the surface appears to be smooth
in the mirror, and that the ocular appearance is not sufficiently char-
acteristic to indicate that there are hypertrophies ; but the delicate fin-
ger-ends recognize at once that there are hypertrophies at the Eusta-
chian tubes, which can be readily removed by the finger.

Dr. Mueller: This is a most interesting topic. We are all of us,
perhaps, taught by our own experiences rather than by anything else.
In a series of over 700 adenectomies I have made use of nothing but
Gottsteins' curette and I have yet to find any particular difficulty in re-
moving the growth. With regard to the anaesthetic, my preference is
chloroform. It is not necessary to induce deep anaesthesia and children
seen to rally more rapidly from its effects. I have in three cases,
where there was an acute otitis media, operated for adenoids. I first
did it in sheer desperation. There were repeated attacks and as I be-
lieved the adenoid growth to be the exciting cause I finally operated

NASO-PHARYNGEAL ADENOID GROWTHS. 309

with the immediate result of relieving the ear symptoms. On another
occasion I had, what I considered at the time, tie misfortune of oper-
ating on a little girl aged 8 years, who, on the day following the opera-
tion developed a very violent attack of scarlet fever. I consoled myself
with the thought, however, that an infection of the curetted surface
certainly could not be any worse than an infection of the adenoid mass
would have been, and subsequent events proved I was right, for the
throat symptoms were very mild, and while the attack of scarlet fever
was very severe the child made a good recovery. I am of the opinion
that if the naso-pharyngeal region were clear and in a normal condi-
tion, the various exanthematous diseases would seldom be followed by
the serious disturbances that we so often see.

Dr. Shearer: Last year I attended a fourteen-year-old boy, that
presented very marked symptoms of adenoids, the most prominent feat-
ures being mouth breathing, suffocative attacks at night and slightly
altered naso-pharyngeal resonance. He was so nervous that he would
not allow me to even properly examine him ; objected to any anaesthetic,
and finally, after close study of his case, I told his people that he was
suffering from hysterical relaxation of the uvula and the neighboring
parts of the pharynx, which simulated nasal obstruction. As he became
suddenly worse during my absence from the city, another laryngologist
was called to see him. He said that the boy had adenoids, etherized
him and on operating found his naso-phar)mx perfectly free from any
growth, thus confirming my opinion of hysteria. It is well to look out
for such cases.

THE USE OF HOT AIR IN THE TREATMENT OF MIDDLE

EAR DISEASES.

By H. H. Leavitt, M.D.,

Minneapolis, Minn.

I WISH to call attention to a method of treatment which I consider a
decided advantage over the ordinary cold air douching of the mid-
dle ear. Nearly a year ago it occurred to me that if hot air was a
good thing in the treatment of joint affections, rheumatism, and kindred
diseases, it would be equally as useful in treating the Eustachian tube and
tympanum. Dry heat stimulates the circulation, relieves hyperaemia,
and promotes absorption — ends desirable to obtain in all chronic inflam-
mation.

In order to test my theory I had constructed an air chamber of cop-
per about five inches in height, and about the same in diameter. In
one side near the bottom a quarter inch pipe is inserted and a similar
one near the top. From the roof of this chamber a piece of pipe capped
at the lower extremity is suspended for the thermometer. This cham-
ber is enclosed by an outer casing of sheet iron, nickel-plated. By a
gas flame underneath, the air in the chamber is heated to two hundred
or three hundred degrees F. By means of the Politzer air-bag, or the
current from an ordinary air-condenser connected with the lower
opening or inlet, the air in the heated chamber is forced through the
upper opening or outlet. This is connected by a piece of rubber tubing
to the Eustachian catheter. One or two drops of the medicament
which it is desired to use are dropped into an opening in the tube near
the chamber. The medicine is quickly volatilized and carried with the
hot air through the catheter into the Eustachian tube and the middle
ear.

The advantages evident by a few months' use of this apparatus are :
First, increased comfort to the patient compared with the use of cold air
douching. Second, increased efiiciency, the hot air relieving congesticHi
and promoting absorption, much more rapidly than the cold air. Third,
the superior effect of the medicines, their penetration being much more
marked. One drop of medicine in the tube is volatilized so rapidly and
so completely that its effect in the ear is almost immediately felt, and
endures for a longer time. I think the use of hot air will bring about a

tustAckiao CatUf«r

Pole tjer Air Baa
or ^

Coinbrc3>«d Air

3 3ooo

Cab For H^dicafiei)

DR. LEAVITT'S APPARATUS FOR TREATING MIDDLE-EAR DISEASES WITH HOT AIR.

THE USE OF HOT AIR. 811

given relief of a pathological condition in less than one-half the time that
it takes by the cold air method. The remedies that I have used mostly
are menthol in refined oil of pure tar; menthol and camphor in
alboline, and iodine in glycerine or ether — ^the same remedies that I
have been accustomed to use in the Dench vaporizer. The cases in
which I have used it have all been chronic middle ear catarrh. The
apparatus which I have used and the method of using it can be seen here
and may be freely discussed.

DISCUSSION.

Dr. Hasbrouck : Dr. Leavitt, in calling our attention at this time to
the value of hot air in the treatment of middle ear diseases, has brought
up a much neglected subject and one that I believe deserves greater
attention than has been given to it of late. It is a means that gives
promise of good results if properly applied. There is no question but
that hot air is more desirable than cold air as a means of inflating the
middle ear, and for a long time heated medication Has had many advo-
cates among the best thinking men of the profession in the treatment
of diseases of the respiratory tract and, though its use in the treatment
of aural diseases is by no means new, I believe it has received but little
attention and if Dr. Leavitt, in presenting this subject to us anew, is
the means of creating a new activity for its use he deserves our thanks.

While Dr. Leavitt makes no claims for originality in adapting this
method of treatment still he makes no mention of its use by others,
leading us to infer that it is original so far as he is concerned.

Personally my attention was called to the subject some two years
ago while considering the advisability of purchasing one of G. B.
Underwood & Co.'s Improved Universal Pulmonary Inspirators, an
apparatus that no doubt all of you are familiar with and which many of
you have used. So far as I know it is the best one of its kind on the
market to-day though I have had no personal experience with it and
only speak from the testimony of friends in whom I have the greatest
confidence. At this time I looked carefully over a pamphlet compiled
by them entitled "A Treatise on the Cure of Diseases of the Pulmonary
and Respiratory Organs by the Inhalation of Heated Medicated Air,"
a copy of which I have if you desire to inspect it. Among the many
uses for which they claim their apparatus is of value I noticed this state-
ment on page 5 : "Heated medicated air can be used in diseases of the
ear, etc., by means of compressed air. A short rubber tube to connect
the air cylinder and inspirator is all that is necessary for the purpose.
Proper rubber attachments are of course required to suit each case."
The natural inference is that in case of the ear it was their intention of
connecting this apparatus to the Eustachian catheter. As I did not then
purchase the apparatus the subject slipped from my mind and I made
no practical application of the suggestion, but on reading Dr. Leavitt's

3W H, H.. LEA VITT, M.D.

paper which was sent me by your President for discussion I was re-
minded of the fact that somewhere this subject had been suggestd to
me before and in looking up the subject I came across the remarks I
have just quoted. I have been forcibly impressed with its value as a
means of treatment and hope at an early date to put it to practical use,
and I desire to again thank Dr. Leavitt for bringing it to my attention
and trust others like myself have been so impressed. I believe it is a
good thing and should be passed around.

Having been convinced of its value as a therapeutic agent one de-
sires to know what is the best method of its application, for much de-
pends upon our future success with its use in having the best apparatus
where that is necessary for its application. Dr. Leavitt has shown us
his and has asked us to discuss it freely, though at the time of preparing
this discussion I had not seen his apparatus, still I was able to consult a
very careful drawing of it and I believe I understand the method of its
use. It is apparently simple in its construction and adequate for the
application of heated air but I question whether it is the best one for the
application of medicated heated air. It strikes me that his method of
volatilizing or vaporizing his medicaments is too sudden for the proper
diffusion of the volatile elements, a point upon which Underwood & Co.
lay great stress, and it seems to me that their argument is well taken and
worthy of our consideration. They claim a gentle gradual admixture
of the volatile elements. I trust there are members present who have
used their apparatus and will give us their views as to its adaptability
for the treatment of the middle ear diseases.

Since writing this I have to-day seen the heating apparatus in con-
nection with Dr. Houghton's pumps, and it seems to me that the entire
apparatus could be utilized to very great advantage in the treatment of
middle ear diseases with medicaments. It can be easily attached, I
think, to the catheter, and can be used under pressure or can be attached
to the new pneuma-chemic nebulizer by a system of Y's. While looking
up this subject, I wrote to the pneuma-chemic company of Cincinnati,
and it seems to me that they have an apparatus already on the market by
which they treat all their medicaments with heat under compressed air,
so that there is a number of apparatuses that one can select if they wish
to use this treatment.

Dr. Stephenson : I was much interested in the paper of Dr. Leavitt
because I have beeen using the same myself, perhaps in a very crude
way. I take the ordinary air-condensing tank, pass the air through the
nebulizer, then into a copper coil such as is used in distilling, having
it long enough so that the air becomes thoroughly warmed in passing
through; then with an ordinary Davidson's shut-off attached to the
nose piece, you have perfect control of it. I find my patients like it
as it is so pleasant, and I think that it is going to produce good results,
although I have not used it long enough to state with certainty.

Dr. Linnell : I discarded the Underwood inhaler because in one case
I got a pulmonary haemorrhage from using it. The haemorrhage fol-
lowed the use of it, and I attributed it to the effect of the hot air. I be-

THE USE OF HOT AIR. 313

lieve there is an element of danger in using it in some cases where the
mucous membrane is sensitive, especially if there is any tendency to
this trouble. I think there might be some such danger in otitis. I used
in this case a temperature of 300 degrees, which is not excessive.

Dr. Leavitt : There are two points I wish to speak of in conclusion.
Dr. Hasbrouck speaks of the advantages of slowness of medication.
This is a good point, but must not be carried too far, as theEustachian
catheter remains in the tube but a short time; — ^less than a minute under
ordinary conditions. An apparatus in which volatilization takes place
slowly enough for a twenty minutes' pulmonary treatment, would not
be as suitable for the short period that would be necessary for the
middle ear treatment. The fact that the silver catheter often be-
comes uncomfortably warm is an additional reason for not keeping it
in position for too long a time. A hard-rubber catheter would be more
suitable for this purpose were it not for the fact that it straightens out
from the heat. The ideal instrument would be a silver one, covered
with hard rubber.

Dr. Stephenson speaks of heating air by means of a coil. This
method has the disadvantage of great variations in the temperature of
the air, as so small a quantity is heated at one time. There is danger,
also, during the interval of changing the catheter from one nostril to the
other that the air in the coil will become superheated, and when it is
driven into the tympanum it may alarm or even burn the patient. There
is not this danger in an air chamber of greater capacity.

It is true that there are instruments on the market which are
represented to be adapted to the treatment of the middle ear. I am
sure the devisors of these instruments could never have used them for
this purpose, for those that I have seen are not air-tight. This is neces-
sary. If the instrument leaks we cannot get sufficient pressure with a
PoHtzer air-bag, or, if compressed air is used, we may overestimate
the leak and use too much force.

Dr. Hasbrouck has suggested medicating the air with a nebulizer,
and heating it afterwards. This suggestion strikes me as a valuable
one, and when developed may give us the most scientific and accurate
method of all.

ACTIVE MEMBERS.

Abbott, R John 929 Marshall Field Building, Chicago, 111.

Anders jn, Jeremiah N 5 College street, Toronto, Ont

Angell, Augustus 372 Main street, Hartford, Conn.

Baker, Leigh Y 916 Fourteenth street, Washington, D. C.

Baldwin, Edward Hill looi Broad street, Newark, N. J.

Barbee, B. I Ruggery Building, Columbus, Ohio.

Bates, F. De W. 34 James Street, Hamilton, Ont

Beebe, E. W. 175 Wisconsin street, Milwaukee, Wis.

Bell, Willard N 6 Green street, Ogdensburg, N. Y.

■^Bellows, Howard P 229 Berkeley street, Boston, Mass.

Bissell, Elmer Jefferson 75 South Fitzhugh street, Rochester, N. Y.

Blair, William W 406 Penn avenue, Pittsburg, Pa.

Boice-Hays, Emma L 3236 Monroe street, Toledo, Ohio.

Boynton, Frank H 36 West Fiftieth street. New York City.

Brooks, E. D 28 Main street, Ann Arbor, Mich.

Brown, Christian H. 1824 Diamond street, Philadelphia, Pa.

Buffum, J. H 905 Venetian Building, Chicago, 111.

Campbell, James A. 1729 Washington avenue, St. Louis, Mo.

Church, Herbert A 601 S. Warren street, Syracuse, N. Y.

Qark, Byron G 162 West I22d street. New York City.

Cooley, Helen no West Eighty-fourth street. New York City.

Copeland, Roy S 46 Catherine street, Ann Arbor, Mich.

Covert, N. B 415 Main street, Geneva, N. Y.

Custis, J. B. Gregg 912 Fifteenth street, Washington, D. C.

Custis, Marvin A 634 East Capitol street, Washington, D. C.

Davis, John E. L 743 Madison avenue. New York City.

Deady, Charles no West Forty-eighth street. New York City.

Delap, S. C 1214 Main street, Kansas City, Mo.

Deuel, W. Estus Chittenango, N. Y.

Dowling, Joseph Ivimey 214 State street, Albany, N. Y.

Fawcett, John M 1116 Market street. Wheeling, W. Va.

Fellows, C. Gurnee 70 State street, Chicago, 111.

Fiske, E. Rodney Nostrand avenue and Hancock street, Brooklyn, N. Y.

Foster, Frederick H 34 Washington street, Chicago, 111.

French, Hayes C Y. M. C. A. Building, San Francisco, Cal.

Fuller, Charles Gordon 39 Central Music Hall, Chicago, 111.

Gage, Frances M 91 12 South Commercial avenue, Chicago, 111.

Garrison, John B in East Seventieth street, New York City.

George, Edgar J 801 Marshall Field Building, Chicago, 111.

Gibson, F. M 608 Nicollet avenue, Minneapolis, Minn.

Hallett, George De Wayne 132 West Eighty-first street, New York City

816 ACTIVE MEMBERS.

Harvey, J. H 735 Spitzer Building, Toledo, Ohio.

Hasbrouck, Sayer 117 Broad street, Providence, R. I.

Ha3rwood, George M 830 Granite Building, Rochester, N. Y.

Hazeltine, Burton D 100 State street, Chicago, 111.

Heath, Gertrude Emma 164 Water street, Gardiner, Me.

Helfrich, Charles H 542 Fifth avenue, New York City.

Hills, Howard B 31 West Wood street, Youngstown, Ohio.

Hooker, Edward Beecher 721 Main street, Hartford, Conn.

^■^Horr, Albert W 7a Beacon street, Boston, Mass.

Houghton, Neidhard H 867 Boylston street, Boston, Mass.

Hoyt, Herbert W 7$ S. Fitzhugh street, Rochester, N. Y.

Hubbard, Charles H Eighth and Madison streets, Chester, Pa.

Humphries, Edward Somerton, Philadelphia, Pa.

Hunt, Ella G 608 West Eighth street, Cincinnati, Ohio.

Irving, Walter W 121 Wisconsin street, Milwaukee, Wis.

James, Bushrod W Eighteenth and Green streets, Philadelphia, Pa.

Jessup, Halten 1 1829 Arch street, Philadelphia, Pa.

Keeler, E. Elmer 452 South Salina street, Syracuse, N. Y.

Kehr, Samuel S 600 California Building, Denver, Col.

Kellogg, Francis B 420 West Sixth street, Los Angeles, Cal.

King, William R 1422 K street, N. W., Washington, D. C.

Kreider, W. B Goshen, Ind.

Leavitt, Henry H 909 Fourth street, S. E., Minneapolis, Minn.

Lewis, Frederick Daniel ^ 188 Franklin street, Buffalo, N. Y.

Lewis, F. Park 454 Franklin street, Buffalo, N. Y.

Lewis, Joseph Davidson 48 Germania Bank Building, St. Paul, Minn.

Linnell, E. H 45 Broadway, Norwich, Conn.

MacLachlan, Daniel A Majestic Building, Detroit, Mich.

Mann, Eugene L 681 Endicott Arcade, St. Paul, Minn.

Mann, Jesse E Louisville, Ky.

McDermott, George C Odd Fellows* Temple, Qncinnati, Ohio.

McDowell, George W 542 Fifth avenue, New York City.

Moffat, John L 1036 Dean street, Brooklyn, N. Y.

Moriarty, Pierre Colon Bee Building, Omaha, Neb.

Mueller, Gustave A 400 Pennsylvania avenue, Pittsburg, Pa.

Munson, Edwin Sterling 16 West Forty-fifth street, New York City.

Nelles, A. B 198 East State street, Columbus, Ohio.

Newberry, Frank J 8 North Qinton street, Iowa City, la.

Norton, A. B 16 West Forty-fifth street, New York Qty.

Paine, Howard S 148 Ridge street. Glens Falls, N. Y.

Palen, Gilbert J 6043 Germantown avenue, Philadelphia,, Pa.

Palmer, A. Worrall 138 West Eighty-first street. New York City.

Palmer, John B 122 East Twenty-fourth street. New York City.

Parsons, Thomas 33 South Qinton street, Rochester, N. Y.

Patterson, Joseph M Commerce Building, Kansas City, Mo.

^ayne, John H Pierce Building, Copley square, Boston, Mass.

Pearsall, William S 128 West Seventy-eighth street. New York City.

ACTIVE MEMBERS. 817

Peterson, A. C 319 Geary street, San Frandsco, Cal.

Phillips, William A. 89 Euclid avenue, Qevdand, Ohio.

Piatti, Virgil C Greenwidi, Conn.

Quay, Geo. H 122 Eudid avenue, Qevdand, Ohio.

Reed, Robert G. 20 West Seventh street, Cindnnati, Ohio.

Reilly, William F. 1008 Madison street, Covington, Ky.

Rice, George B 229 Berkdey street, Boston, Mass.

Rldiardson, George H Patton, Cal.

Rhoads, George 4 Chestnut street, Springfidd, Mass.

Rumsey, Charles Ledie 819 Park avenue, Baltimore, ' Md.

Rust, Edwin G. 29 Eudid avenue, Qevdand, Ohio.

Sdtz, Frank B 33 North Pearl street, BuflFalo, N. Y.

Sdiendc, Herbert Dana 241 McDonough street, Brooklyn, N. Y.

Shallcross, Isaac G 1617 Arch street, Philaddphia, Pa.

Shearer, Thomas L. 345 North Charles street, Baltimore, Md.

Sheets, Charles A

Shddon, Floyd P 223 West I22d street. New York Qty.

Shdton, George G. 521 Madison avenue. New York City.

Shepard, George A 1672 Broadway, New York City.

Sherman, Le Roy B 355 West Fourteenth street. New York City.

Short, Zuber N 428 Central avenue. Hot Springs, Ark.

Smilie, Nathan 249 East Logan square, Philaddphia, Pa.

Smith, J. W. Main street, Vevay, Ind.

Smith, Orrin Ldroy Forty-seventh and Kenwood avenue, Chicago, Bl.

Soul6, Isaac C. Kiansas Qty, Mo.

Spahr, Charles E. 10 West Market street, York, Pa.

Spencer, William 1820 Chestnut street, Philaddphia, Pa.

Steams, William M 813 Marshall Fidd Building, Chicago, HI.

Stephenson, Benjamin S 49 Kirk street, Lowell, Mass.<

Sterling, Charles F. 32 Adams avenue, W., Detroit, Mich.

Stewart, Thomas M 704 Elm street, Qncinnati, Ohio.

Storer, John 1007 Columbus Memorial Building, Chicago, 111.

Strickler, David A 705 Fourteenth street, Denver, Col.

Strong, Charles H 915 Madison street, Toledo, Ohio.

Strong, T. Morris 176 Huntington avenue, Boston, Mass.*

Strong, Walter 2049 North Thirteenth street, Philaddphia, Pa.

Su£Fa, George A. 229 Berkdey street, Boston, Mass.*

Swan, Charles J 34 Washington street, Chicago, 111.

Talbot, George H 306 Walnut street, Newton, Mass. <

Teets, Charles K 37 West Thirty-ninth street. New York City.

Thomas, Charles M 1623 Arch street, Philaddphia, Pa.

Townsend, Irving 67 West Forty-sixth street. New York Qty.

Valentine, Richard EL 190 Lincoln place, Brooklyn, N. Y.

Van Mater^ George G. 354 Macon street, Brooklyn, N. Y.

Vehslage, Samud H 117 West Forty-third street, New York City.

Vilas, Charles H 2811 Cottage Grove avenue, Chicago, IlL

Ware, Horace B Scranton, Pa.

Wvnor, Akoa G. 194 Schermerhoni street, BanMyM, 9L C

Wainei;, Ftsak P. 304 Main street, CuamSmgaa^ & VL

W^Tcr, Hjury S. 1621 Chestnut street, FUlsMphia^ 1^

-Wdls, D90M W 301 Boylston street, Bosto*^ Mnft.

WeUs, Grove S, Wells Block, Sistersiille, W- V^l

Wflbertoii, UwreaceG. Model Block, WincM, MiM.

WUder, Guert £. ^15 College avenue, Snwteriky, Ofan.

Waiard, Henry S. 102 Washington street, PaterMO* H. J.

Wilson, HMold 32 Adams avenue, W., ideferdit, Midk

Woodkom. WiUiam.... 609 Walnut stredt, Des Mouies» io«i.

Wiivht, JosqMi £. 26 High street, MosrialoM, N. h

HONOl^ARY MEMBERS.

Wilson, T. P 15 Archwood avenue, Chmtaid, fMtk

Botiglaxm, Hemy C 7 West Thirty-trinth street, New TafkCSt!^

€0&R£SFONDIKG MEMBERS.

Daniel. 73 rue de Rocher, Pmis, FoMioe.

Shaw, C Knox 19 Ufptr Wimpole street, London, Kngiend

Wright, Dudley 55 Queen Anne street, Loadoq, Kngland.

CONSTITUTION.

ARTICLE L — ^NAME AND QBJSCX.

This Association shall be styled the American Honu£Opathic Qph-
thabnotogical, OtoI<^cat and Laryngologicat Society, and its object
Ae study of the eye, ear, nose and throat, with particular reference to
Homoeopathic therapeutics.

The Socifity shall be. composed of those physicians who are already
mooiherSft and of such others a& may be hereafter chosen in confocmitjr
with tihe By-Laws.

ARTICLE IIL— QUORUM.

At any meeting of the Society eleven members shaft constitute a
qu o rum .

Axncui nr.— *omcBis»

The offioera of the Society shall be a President* two Vice-Presidenta,
a Secretary^ and a Treasurer^ who shall also constitute aa Executive
Committee of the Society.

ARTICLE V: — ^AHEKDICSNTS.

This Constitution may be altered or amended by a vote of two-thirds
of all the members present at the r^^ar annual meeting, provided that
notices of such alteration or amendment shall have been given in writing
at a previous annual meeting of the Society.

BY-LAWS.

L— 1

TUa Societ]^ shall hold at least ooe seaskm in tmh year, at such time,
and place w wMf ht detefmiscsd upoi ftom time to time.

no CONSTITUTION AND BY-LA WS.

ARTICLE n. — SELECTION OF OFFICERS.

Section i. The officers shall be elected by ballot at each annual
meeting of the Society, and shall enter upon their respective duties the
first day of January following.

Sec. 2. The regular chosen officers of this Society shall OMistitute
an Executive Committee, which shall arrange the business of the ses-
sion, attend to matters of business not otherwise specially provided for,
and perform such other duties as may by vote of the Society devolve
upon them.

ARTICLE III. — DUTIES OF OFFICERS.

Section i. The President shall preside at the meetings of the
Society, and perform such duties as may by vote of the Society be de-
volved upon him. He shall deliver an address at the opening of each
annual session, upon such subject as he may select.

Sec. 2. The Vice-Presidents in their order shall perform the duties
of the President in his absence or disability.

Sec 3. The Secretary shall keep a record of the proceedings of the
meetings, conduct the correspcmdence of the Society, issue notices of
meetings, and notify members of their election.

Sec 4. The Treasurer shall receive all money belonging to the
Society, shall make all disbursements under the recommendation of the
President, and he shall furnish at each annual meeting a written report
of the condition of the finances.

ARTICLE IV. — CENSORS.

There shall be a Board of Censors, consisting of five members, who
shall receive and examine the credentials of candidates for membership,
and report to the Society for election such as may be found properly
qualified. The members of said Board shall be elected by ballot at each
annual session to serve for one year from the first day of January next
succeeding said election.

ARTICLE v. — MEMBERSHIP.

Section i. Any regular qualified and reputable physician, endorsed
by two members, may be elected to membership in this Society.

CONSTITUTION AND BY^LA WS. 821

Sec 2. The admission fee of each member of the Society shall be
two dollars.

Sec 3. Members shall pay amiually the sum of three dollars toward
defraying the expenses of the Society.

Sec. 4. The election of no member shall be considered completed
mitil he shall have paid his admission fee and annual dues ; and his mem-
bership can only be continued by the annual payment of these dues ;
until they are paid he may not participate in the active work of the So-
ciety. He may at any time within three years, however, complete his
membership by paying his dues for the current year, tc^ether with any
back dues that may have accumulated against him.

Sec 5. Members neglecting the payment of dues for three years
after proper notification from the Treasurer, shall have their names
dropped from the roll of membership. Any person thus dropped shall
have the privilege of reinstatement by paying all arrearages, on recom-
mendation of the Board of Censors.

Sec 6. Any physician of eminent attainments in the special fields
of medicine with which this Society is concerned, may be elected an
Honorary Member on recommendation of the Board of Censors at any
annual meeting of the Society, and shall be exempt from dues and shall
have all the privileges of members, except voting and eligibility to
office.

Sec 7. Any foreign physician may be elected a Corresponding
Member of the Society at any annual meeting, on recommendation of
the Board of Censors, and shall have all the privileges of members, ex-
cept voting and eligibility to office.

AKnCLE VL — rules OP ORDER.

Section i. The rules governing the deliberations of this Society
shall be those found in Roberts' Rules of Order.

Sec. 2. No report or paper shall be received by the Society in an
incomplete or unfinished condition, and the title of any proposed paper
shall be forwarded to the Secretary by April ist of each year and the
completed paper by May ist

Sec 3. The time allowed for the presentation of any paper shall
be twenty minute. The leading discussion shall not exceed ten min-
utes, and all other discussion five minutes for each speaker.

COifSTZTUTIQN Aim MV-ZA WS^

ARTTCLB Vtl.

Tkese By-X«aws may be alfeered er amewkdl hy a Tele of tvo*1bird8

of the members present at the meeting.

STANOINtS RESOLUtlOK.

IttsoFU€(l, That the Committee on tite Noniinatton of Officers shali
consiist of all the ex-Presidents of the Society present at any meeting,
provided that in any case less tfian three be present the P^iesident shaU
appoint from the members present a ntmber sufficient to make the
Committee consist of three members.

CONTENTS.

i«

H Bum of the Comea. By John L. lioffiU, MX) 28

A CsM of OMifiad Choroid, with ftiihutyi|ifciil SpMineB. ly fohm H. FHyiMb

>L©.^ - -- 129

Mkn^T.F.. MJ). Discussion ....^ 9W

A Method of Cootiaued inigation in Csms oI Porolciit OpMteAnftii, «ith

Instrument Devisod. By E. BawBr K s dw^ MlX iff

AfldecBon, J. W., MJX THuli— Jun. 7^ 184, «f§

Aft Unusual Tumor of the Eye and Malformattemof this OrMal Stractwe, wMh
AbnoimalDevehqMeMt«f theCsmtumH-Qpsnrtiatt. % GMtcft A. ScMh,

BC.9...* •

Ateesia PhaiTngia. By Charies £. I^asli, HCi^ 43

AandMsssafe. By Henry C. Hou^^hton, ILD .*. tl^

Bakes Lsigh T., JAD, B]ood^^BiBoni«(iaaCflse«f Snpymnia«lllMJI»<nim»
loUowing Acute Middle Ear Catarrh— itewvwy «• 4lie Ute of L a c iMs ll .^v. 35

F.Oa W^M.D. Discussion xii, aSy, «9(, #24, S74

^o Strain as a Cause of Disease %« ,.....««« IH

Beeba,& W., UJD. Disoaseisft 158, 230

«< The Treatment of Trichiasis 93

BelofPS, Howard P^M.D. Discussion aSf

Some Cases of Carlsa of tiM.EKt«malAMKlitaryGtaal flSo

BiMeU, EhnerJ^ M.D. Discussion ..«*.... 005

«« PresidettfaAMtmlAdArMi x8

Hood Beisoning in a Case of Empyasmia of the Anlram Mfowinf AoAeJtiddle
Bar Catsnrh— iteoo««i]r on the ybe of LMliesis. By Leigii Y^ leimr, ILD. 35

Beyntim, £raak H., M.D. Discussion 30, aip, df4, 0^9 «f4

Bn£Eum, J. H., M.D Discussion 78

^^Uetm «.^ 3H

Campbell, James A., M*D. Discussiim.,.. «,••«•• ^^..>.... 136

OancerAiEBcting the Eye and Hose. By J. H. Harirey, M.D. « . « tjo

Cmstitntion ....« «.^... 3>4

Capeland, R. Sw, M.D. DisoussJon.. ...* ^

Dead|(, Cfante. M.D. P is c assh m 89, 51, yo, t5S, joA, af$

«* Subconjunctival Injectiona in the Treatment of QciAar P i i sa w is. 64

Destmctiii«e Diseases of the Nose. By Edward Bee ch sr Hooher^ UX> 3!

Oauel, W. E., M.D Dfscussion tfB

Btactionof NbwMemlbem.,., 14

Bectionof Offioess.^,. , 14

BiBCtrelysisJn Hypertrophic Rhinitis. By T,1L Strong, U.D,.. .«,.,.... ...,, a^)

Bya Stnin as a Cause of Disease. By FrsaikD. W. BatM|M.D««..« 175

Qarrison* John B., M.D. Discussion 304

HrpentnepUc RMnitli HIS

asrvem J.H., MJ>. Discussion >. 95A, a8A

OanosrAftdllngdie%>eandJ<bsa. .*.. «f»

ibmdg Sfl|«E, M.D. Discussion ....30,81^ Aa, <S3» ^^S* 11^

•* isifltfltau >.......«•.>. ...**.«..*,*.'^... aa

Haywood, George Bl, M.D. Discussion 40,56,2341 306

-«t

m CONTENTS.

Helfricfa, Charles, M.D. DiieuMion 167

Hooker, Edward Beecher, BCD. Diacuaaion 42, aaS, 378, 305

•* DeatnictiYe Diaeaaea of theNoae 38

Houghton, Henry C. » M.D. Aural Maaaage 119

«* Diacuaaion 114, 117, 127

Hoyt, Herbert W., M.D. Diacuaaion 62, 145, 230, 241, 253

** The Influence of Hygiene upon the Upper Air Tract 57

H y pe r trophic Rhinitia. By John B. Garriaon, M.D 245

Importance of Bacteriological Study. By Charles Leslie Rumsey, ]d.D 238

Inflation. By Sayer Hasbrouck, M.D S2

Internal Remediea in Bye Afifectiona. By Wm. A. Philllpa, M.D. 291

Jamea, B. W., BLD. Discuaaion 29, 183, 204, 280

** Mydriatica, Myotica and Local Anaesthetics 257

Jessup, H. I., M.D. Discussion 195

Keeler, £. Elmer, M.D. A Method of Continued Irrigation in Caaea of Purulent

Ophthalmia, with Inatrument Deviaed 47

** Diacuaaion 51, 255, 272

Kellogg, Francia B., M.D. Discussion

•< Maasage of the Middle Ear by Alternating Internal and External

Pressure 115

King, William R., M.D. Diacussion 125, 196

•• Strabismus : Causes of and Methoda of Teating for 188

Leavitt, H. H., M.D. Diacussion 312

•• The Use of Hot Air in the Treatment of Middle Ear Diaeases 309

Lewia, F. Park, M.D. Diacussion 202, 307

<* The Micro-Bioscope for the Minute Study of Living Structure 32

Lewis, Fred. D., M.D. Discussion 42, 56, 144

< < Mycosis Tonsillaria .^ 52

Linnell, E. H., MD. Discussion 206,279, 311

« WaaitaCaaeof Sub-retinalCjrstioercus? 134

Llat of Active Membera 3x0

•• «< Honorary Members 313

** " Correaponding Membera 313

Maaaage of the Middle Bar by Alternating Internal and External Preaaure. By

Francia B. Kellogg, MD 1x5

McDowell, Geo. W. , M. D. Discussion 30, 90

Moflht, John L., M.D. A Bum of the Cornea 28

«• Discussion 31, 51, 70, 133, 156, 173, 183, 206, 225, 278, 294

«• ThePointof View 128

Moriarty, Pierre Colon, M.D. Discussion 174

** Rational Treatment of Hay.fever x68

Mycosis Tonsillaris. By Fred. D. Lewis, M.D 52

Mydriatica, Myotica and Local Anaesthetics. By Bushrod W. James, M.D 257

Mueller, Gustavo A., M.D. Discussion 26, 307

Nasal Fibroma— a Caae— Operation and Autopsy. By Thos. M. Stewart, M.D. . 288

Norton, A. B., M.D. Diacuaaion 80, 159, 183, 224

" Report of My Laat Seriea of Fifty Consecutive Cataract Extractiona. 147

CONTENTS. 826

O'Connor, Joseph T., M.D. Tobacco-Alcohol Amblyopia ; with Peculiarities of

Color Vision — ^Are the Latter Cerebral or Retinal in Origin ? 232

On the Desirability of Examining the Inmates of our Blind and Deaf Asylums.

ByC. H. Vilas, ILD 106

Ophthalmic and Otic Uses of Some Animal Extracts. By Isaac C. Soul6, Ph.D.,

M.D 96

Palmer, A. Worrall, M.D. Discussion 174, 230, 289, 306

Payne, John H., M.D. A Case of Ossified Choroid, with Pathological Specimen. 129

*< Discussion 51, 133, 156

Phillips, W. A., M.D. Discussion 186, 222, 255, 295

** Internal Remedies in Eye Affections 291

Piatti, Virgil C, M.D. Discussion 103

President's Annual Address— Our Specialties as Related to Mental Development

and Modem Educational Methods. By Elmer J. Bissell, M.D 18

Quay, Geo. H., M.D. Discussion 55

Rational Treatment of Hay-fever. By Pierre Colon Moriarty, M.D., O. et A.

Chir 168

Report of Committee on Attendance 17

Report of Committee on President's Address 13

Report of my Last Series of Plfty Consecutive Cataract Extractions. By A. B.

Norton, M.D 147

Report of the Secretary 6

Report of the Treasurer 8

Resolutions Referring to Opticians 13

Results of Cases Treated by Phono-pneumo Massage. By Benj. S. Stephenson,

M.D 108

Rice, George B., M.D. Discussion 41, 145, 229, 305

** Treatment of Some Affections of the Throat, Peculiar to Singers and

Public Speakers 139

Rumsey, Charles Leslie, M.D. Discussion 205, 223, 242

*< Importance of Bacteriological Study. 238

Scbenck, H. D., M.D. Discussion 51, 286

*• Secretary's Report 6

Secondary Cataract. By Charles M. Thomas, BLD 72

Septic Thrombosis of the Lateral Sinus Secondary to Purulent Otitis Media.

By Dudley Wright, F.R.C.S 83

Shearer, Thomas L., M.B., CM. (Edin.). Discussion 173, 284, 308

** Some Observations Concerning the Surgical Treatment of Naso-
pharyngeal Adenoid Growths 297

Shepard, George A., M.D. Discussion 107, 286

Some Cases of Caries of the External Auditory Canal. By Howard P. Bellows,

. M.D 280

Son^e Observations Concerning the Surgical Treatment of Naso-Pharyngeal

Adenoid Growths. By Thomas L. Shearer, M.B., CM. (Edin.) 297

Soul6, Isaac C, M.D. Discussion 248

•* Ophthalmic and Otic Uses of Some Animal Extracts 96

Standing Resolution Concerning the Nomination of Officers 9

896 CONTENTS.

Stephenton, Benj. S., M.D. Discusiion I59» 3i>

«< ResullB of Cases TVeatad by Phono-pneomo MasMge io8

Stewart, Thos. M., M.D. Naaal Fibroma— a Case— ^Operation and Autopsy. . . . aSS
Strabismus : Causes of and Methods of Testing for. By William R. King, M.D. i88

Strong, T. BC, M.D. Discussion saS, 231, jo6

•* Electroljrsis in Hypertrophic Rhinitis. 243

Strong. Walter^ M.D. Discussion so6

•* The Optical and Orthoptic Treatment of Strabismus 199

Subconjunctival Injections in the Treatment of Ocular Diseases. By .Charles

Deady, M.D 64

SufGn, Geo. A., lf.D. Discussion 81, 157, 221, 277

** An Unusual Tumor of the Eye and Malformation qf the Orbital Structure,

with Abnormal Development of the Cranium — Operation i^i

Teets, Charles E., M.D. Atresia Pharyngis 43

The Influence of Hygiene upon the Upper Air Tract. By Herbert W. Hoyt,

M.D 57

The Micro-Bioscope for the Minute Study of Living Structure. By F. Park

Lewis, M.D 32

The Operative Treatment of Strabismus. By Harold Wilson, M.D aoB

The Optical and Orthoptic Treatment of Strabismus. By Walter Strong, M.D. . 198

The Point of View. ^ John L. Moffiit, M.D., O. et A. Chir 128

The Treatment of Trichiasis. By E. W. Beebe, M.D 91

The Use and Abuse of the Electro-Cautery in Nose and Throat Work. By Irving

Townsend, M.D 296

The Use of Hot Air in the Treatment of Middle Ear Diseases. By H. H.

Leavitt, M.D 309

Thomas, Charles M., M.D. Discussion 82, 157, 184

<* Secondary Cataract 72

Tobacco-Alcohol Amblyopia ; with Peculiarities of Color Vision. Are the Latter

Cerebral or Retinal in Origin? By Joseph T. O'Connor, M.D ^32

Townsend, Irving, M.D. Discussion 61, 231, 244

** TheUseand Abuse of the Electro-Cautery in Nose and Throat Work. 226
Treatment of Some Affections of the Throat Peculiar to Singers and Public

Speakers. By George B. Rice, M.D 139

AHlas, C. H., M.D. Discussion 80, 277

** On the Desirability of Examining the Inmates of Our BUnd and Deaf

Asylums 106

Ware, H. B., M.D. Discussion 29

Warner, Alton G., M.D. Discussion 95

Warner, F. P., Bf.D. Discussion 49, 229, 274

Was it a Case of Sub-Retinal Cysticercus ? By E. H. Linnell, M.D 134

Weaver, H. S., M.D. Discussion 145

Wells, David W. , M.D. Discussion 252

^RHlson, Harold, M.D. Discussion 236

*' The Operative Tk«atment of Strabismus 208

Wilson, T.P., M.D. Discussion 132

Wright, Dudley, F.R.C.S. Septic Thrombosis of the Lateral Sinus Secondaiy

to Purulent Otitis Media 83

If/ c /f^ /

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