SUBCUTANEOUS EMPHYSEMA DUE TO LABOR.Miller reports two cases of this condition (British Med. Journal, Dec. 12, 1885). Both the patients were primiparæ. In the first case the first stage was tedious. When the head came to the perineum the pains subsided, and patient gasped for breath. Face swollen and congested; respiration extremely rapid and irregular; pulse weak and fluttering.

Delivery was effected by the forceps.

In the second case the labor was normal and satisfactory until near its termination, when the face of the patient became much swollen. In both cases emphysematous crackling was obtained on palpation; the areas affected being the parietes of the thorax, the neck, face and forehead. No treatment other than strict rest was employed, and both cases made a good recovery.

OPHTHALMOLOGY.

M.

THE EXCHANGE OF LIQUIDS IN THE EYE-ExPERIMENTAL STUDIES.-Schick (Arch Ophthalmology) gives some experimental contributions to our knowledge of the laws regulating the exchange of liquids in the eye. He reaches the following conclusions:

3.

I. The solution of ferrocyanide of potassium injected subcutaneously in rabbits appears in the blood vessels of the eye in a few minutes. 2. No current of filtration can be shown to exist such as Ulrich has described as emanating from the choroid and passing through the retina, vitreous, zonula zinnii, posterior chamber, iris and anterior chamber into the cornea. The solution of the salt passes from the ciliary body and iris into the posterior chamber. 4. From the posterior chamber the liquid penetrates the capsule of the lens and through Petit's canal into the lens substance. 5. The salt passes through the zonula into the vitreous, enters its anterior layers and then spreads through the whole vitreous. 6. He could not determine whether the salt entered the retina from its own blood vessels or those of the choroid. 7. In the healthy eye no communication can be shown to exist between the anterior and posterior chamber at the pupillary margin. 8. The aqueous humor of the anterior chamber is furnished by the whole anterior surface of the iris; it probably comes from the blood vessels of the iris, at least by far the greater proportion. 9. The aqueous humor of the anterior chamber is carried off through Fontana's spaces. 10. The salt does not enter the cornea by direct filtration from the anterior chamber, but from the looped blood vessels at the corneal margin. 11. When injected directly into the vitreous and under pressure in the latter, the salt enters the choroid through the retina and is absorbed by the blood vessels of the former. 12. After injection into the

vitreous the salt passes through the zonula into the posterior chamber; here part of it enters the lens at its equator, while another part enters the ciliary body and posterior surface of the iris, where it is absorbed by the blood vessels of the latter. 13. A part of the liquid which had entered the iris passed out at the anterior surface of the latter into the anterior chamber.

14. The

salt, when injected into the vitreous, does not enter the cornea from its posterior surface 15. A solution of uranine injected subcutaneously into a rabbit appears soon afterwards in the blood vessels of the eye, passes through their walls, and penetrates into all parts of the eye through predetermined channels. 16. From the choroidal blood vessels the uranine penetrates the whole thickness of the choroid. 17. There is no current of liquid passing from the choroid through the retina into the vitreous. 18. The retina is nourished from its own blood vessels, and not from those of the choroid. 19. From the surface of the ciliary body the uranine penetrates the posterior chamber. 20. From the posterior chamber the uranine filters through the zonula into the vitreous, coloring first the anterior and then the posterior layers. The coloration of the vitreous is independent of that of the retina and choroid. 21. A portion at least of the uranine passes out of the eye by the same paths by which it entered. 22. From the posterior chamber the green liquid enters the capsule of the lens at the equator, and then the lens itself. It colors first the cortex and then the nucleus and leaves the lens in the same way. 23. The nutritive changes of the vitreous and lens take place much more slowly than those of other parts of the eye. 24. In the healthy eye there is no communication between the two chambers at the pupillary margin, the regeneration of the aqueous humor taking place entirely from the anterior surface of the iris. 25. The liquid coming from the iris does not filter in a fixed zone of filtration from the posterior chamber through the tissue of the iris into the anterior chamber, but comes principally from the vessels of the iris. 26. The first greenish tinge always comes from the sphincter of the iris. 27. The coloring matter does not penetrate from the anterior chamber through the epithelium into the cornea, the coloration of the cornea always taking place from the sclero-corneal margin.

ma.

FOLLICULAR INFLAMMATION OF THE CONJUNCTIVA. -Ræhlmann (Archives Ophthalmology) gives the results of a full discussion of the pathological history of trachoHe divides it into three stages, that of the development of the follicles, that of the destruction of the follicles and of ulceration, and that of cicatrization. There is an acute and chronic form of trachoma. In the latter, small, yellowish-gray dots are first observed on the conjunctiva of the lids, which gradually increase in size and develop into translucent granules of a gray or grayishyellow color, the size of which is the greater the nearer

they are to the fornix. This process is attended with very little inflammation. As long as the disease is still in the stage of granulation, absorption and therefore a cure is possible. This can be effected the more readily, the smaller the granules and the more superficial their position. When the disease is once fully developed its transition into the farther stages can generally not be prevented. The symptoms of irritation are due almost without exception to affections of the cornea, the latter taking the form of trachomatous pannus in more than half of the cases.

When the disease enters upon the second stage the swelling of the mucous membrane increases. The granules generally lie so close together that no free portion of the mucous membrane lies between them. Then ulceration begins and the epithelium of the conjunctiva is cast off. The ulcers thus formed can extend to the cartilage of the lid. True granulations like those of wounds, are the result. Finally cicatrices develop, arranged in spots and lines. In this stage the corneal complications are frequent and severe, and the ocular conjunctiva is greatly injected. The second stage is always followed by cicatrization and shrinkage. The lid is thus shortened, and thus entropium, trichiasis and districhiasis result with all their deleterious consequences.

In distinction from chronic trachoma there is a form of acute follicular conjunctivitis which may be called acute trachoma. Trachoma granules half the size of a pinhead and arranged in rows develop upon the conjunctiva of the lids, and especially at the fornix, accompanied with intense injection. They are round and slightly opalescent, and of a grayish-red or yellowish-red color. Curiously enough, there are always more at the lower than the upper fornix. Sometimes the affection is complicated with slight pannus or phlyctenular keratitis. Most cases recover, but the disease may become chronic and pass through all the stages of chronic trachoma.

rest may be strong convergence, and in spite of the presence of asthenopia.

6. The majority of hypermetropes do not squint on account of the strong inherent desire for binocular fixation, and because the power of accomodation in your youthful individuals is ample to overcome the disadvantages of hyperopia. They remain victorious in the struggle between binocular fixation and the position of rest just the same as emmetropes, though it costs the former more of an effort. In other words, the majority of hypermetropes have no inducement to squint, just as little as emmetropes have. As regards higher degrees of hyperopia statistics show that they are rare in the same proportion as cases of strabismus with corresponding degree of hyperopia. The same considerations hold good here as with hyperopic convergent strabismus in general. Highly hyperopic persons do not gain anything by squinting. They could emancipate themselves from the laws of accommodation, but the power of accomodation of the fixing eye would still be insufficient.

The answer briefly is: The development of inward squint depends in each case upon the position of rest. If it is divergence or parallelism inward squint cannot develop. If the position of rest is convergence the degree of squint and the rapidity of its development will depend upon the amount of this convergence and upon the strength of the internal recti muscles. The spontaneous cure of squint depends upon a change in the position of rest brought about by changes in the size of the globe and its annexa.

COCAINE; ITS ACTION ON THE CORNEA; EXPERIMENTAL AND ANATOMICAL RESEARCHES.-That in certain instances cocaine induces disease of the cornea is beyond question. Wurdinger (Klin. Monatsbl. f. Augenheilk.) by experiments shows that the corneal roughness produced by cocaine is greatly diminished if not prevented by closure of the cornea. The duration of the experiment rather than the strength of the solution or the frequency of the application seemed to produce the greatest roughness. This roughness was found to be due to a drying of the cornea. By the fluorescent method of Ulrich and others he studied the connection between this dryness with the conjunctival anæmia and diminished lymph supply to the corneal parenchyma. One eye of the animal only was treated with cocaine until the corneal roughness appeared. Both eyes were then treated with the fluorescent solution an equal period. In the cocaine eye the color appeared in the deepest parts, spreading thence and becoming very intense throughout the parenchyma; in the other eye the fluorescence appeared only in layers of the cornea, in slight degree and quite evenly throughout.

Again, he made similar scratches in both eyes, one of which was cocainized. On applying methyl blue to both eyes the following was observed. In the cocaine

eye the whole corneal substance became stained most intense at the defect in the epithelium. In the other eye only the part injured was stained.

From these data the writer concluded that under the influence of cocaine, the cornea receives a diminished lymph supply to the epithelium and parenchyma.

A microscopical examination of cocainized corneas showed that the uneveness of the surface was due to an irregular diminution of the thickness of the tissues. During the early stages the epithelium remains entire; its anterior layers then become thinned and flattened; a little later the deeper layers begin to shrink and ultimately the external cells are in places cast off at the spots where the cornea is most damaged. The shrinking of the corneal surface is so considerable that depressions are produced in its hinder surface.

The same changes are induced in the cornea by the hypodermic administration of the alkaloid.

Finally the experimenter found that weak solutions of corrosive sublimate, borax, boracic acid are apt in eyes energetically treated with cocaine to cause more or less intense opacity of the cornea. It is well to make these applications about half an hour before using the cocaine.

EYE DISEASES AS RELATED TO UTERINE AFFECTIONS.-Dr. T. R. Pooley (N. Y. Med. Jour.) gives a series of his observations bearing upon the above subject. From these he concludes:

In certain cases there is a direct relation between irregularities in function and diseases of the uterus and concomitant affections of the eye.

The eye affection may be merely functional, or there may be organic disease.

Asthenopia exists in cases where there is no ametropia, apparently due to only the reflex action of the uterine disturbance upon the organs of vision.

In many of these cases there is paresis of accommodation.

In other cases of asthenopia in which ametropia is present, and the existence of uterine disease as well, the former is not always relieved by correcting glasses.

Other functional anomalies than asthenopia may be observed, such as blepharospasm, diplopia, and functional irritation of the retina. Long continued reflex irritation from uterine disease may result not only in asthenopia, but, as already shown by Mooren, in atrophy of the optic nerve, and other organic changes.

in displacements, lacerations of the cervix, and other affections accompanied by congestion, and where the nature of the disease is such as to affect the normal process of menstruation.

The proper therapeutic measures to be adopted in such cases are: the rational treatment of the uterine disease; the correction of any existing ametropia; the temporary use of weak convex glasses where there is any feebleness of accommodation; in some instances galvanism for the relief of supra-orbital neuralgia, and the use of tonics, proper food and favorable hygienic conditions.

TRACHOMA TREATED BY Squeezing out the ConTENTS OF THE TRACAOMA FOLLICLES.-The modes of treating trachoma are legion. The failures from any or all modes are also legion. Any suggestion lending the hope of better results is cordially welcomed by all who have these cases to treat. Dr. F. C. Hotz (Archiv Ophthalmology, June, 1886,) supports Mandelstamm's plan of treating trachoma by squeezing out the follicles. For five years he says he has practiced the method with gratifying success. The manipulation is as follows: The upper lid is everted and held by the thumb or forefinger of the left hand. Then the thumb or forefinger of the right hand, palmar surface being turned toward the eyeball, is inserted under the everted lid. These two fingers are pushed towards each other and the finger of the right hand made to glide slowly forward from under the trachomatous conjunctival fold. By the pressure thus induced the contents of the trachoma follicles will be extruded. By repeating this manoeuver several times along the whole breadth of the eyelid, he removes at one treatment all the trachoma follicles.

With the lower eyelid he uses an old fashioned iris forceps with a slight bend and no teeth. By the open convex side of the forceps a portion of the conjunctival fold is engaged. The branches are closed and the forceps gradually moved upwards the caught-up conjunctiva is slowly run through the branches of the forceps and thoroughly squeezed, like wet clothes run through a wringer. The ocular conjunctiva, and the follicles of the plica semilunaris are treated in a similar

manner.

treatment is adapted to existing conditions. If it be found that any follicles have been neglected they must be attended to. This treatment has the advantage of saving the conjunctival folds, the movements of the eyeball, etc.

CATARACT EXTRACTION, GALEZOWSKI'S METHOD. Dr. Culbertson, in the June Amer. Journal of Oph

The eyelids are separated with a speculum, and the eye-ball secured below the cornea by fixation forceps, and the eye rolled downwards.

2. With a fine-pointed, narrow von Graefe knife, puncture is made at the corneo-sclerotic junction three mm. above the horizontal diameter of the cornea.

3. The point of the knife is passed to the lower border of the previously dilated pupil, and the capsule is divided with it from below upwards to the upper limit of the pupil by depressing the handle of the instrument, the point describing the arc of a circle; the blade of the knife is not turned on its axis; then the counter-puncture is made opposite the point of puncture.

4. The incision is carried upwards and slightly forwards, and completed wholly in the cornea, at two millimeters from the upper corneal margin.

5. The speculum and forceps are withdrawn.

6. The upper eyelid is elevated with the right little finger, and at the same time pressure is made upon the upper border of the sclerotic above the apex of the incision with the curette with the same hand.

7. With the thumb of the left hand pressure is made, through the lower lid, upon the inferior border of the cornea. The lens escapes without difficulty.

8. If the iris is within the wound, it is replaced with a silver stylet.

STRABISMUS TREATED BY THE ADVANCEMENT OF TENON'S CAPSULE.-Dr. Knapp (Medical Record, Aug. 18) says that he performed this operation ten times. within the past few months Dr. Wecker does it thus:

A piece of conjunctiva five millimeters long and ten millimeters high, is detached from the region of the insertion of the tendon, leaving a small band near the cornea. Tenon's capsule is then incised near the insertion of the tendon, and loosened alongside and under the muscle. The capsule is then stitched forward by two sutures, entering through the conjunctiva to the capsule at the lower and upper edges of the muscle, coming out in the conjunctiva above and below the cornea. Dr. Knapp himself leaves a broader conjunctiva flap, and uses a third middle suture.

In no case had there been alarming reaction. All cases were treated with antiseptic precautions. He had operated upon two cases of convergent strabismus, due to paralysis of the external rectus, two cases in which former tenotomies had not overcome the difficulty, and six cases of convergent strabismus of high degree with considerable amblyopia. The results have all been quite good. He preferred advancement of Tenon's capsule to

ESERINE AND COCAINE, THEIR RELATIONS AS DETERMINED BY EXPERIMENT.-Reus (Archives Ophthalmo'ogy) from a long series of experiments reaches the following results concerning the relations of cocaine and eserine:

When eserine or pilocarpine are instilled simultaneously, no mydriasis is produced; the beginning and duration of the myosis are either not at all or only slightly delayed. When eserine has produced myosis, the latter is not affected by the subsequent instillation of cocaine, no matter whether the quantity of eserine was large or small; pilocarpine acts similarly but not with the same energy. The maximum cocaine mydriasis rapidly disappears when eserine or pilocarpine is instilled; but the action of the myotics soon ceases when they are given in too small a dose. A more energetic instillation, however, completely overcomes the mydriasis; here, too, eserine is the more reliable. The spasm of the ciliary muscle produced by eserine or pilocarpine is not affected by cocaine, at least not so far as the far point is concerned. The power of eserine and pilocarpine to reduce the tension, particularly in glaucoma, is not influenced by cocaine; the latter may therefore be used in operations for glaucoma.

INTRA-OCULAR PRESSURE: EXPERIMENTAL INVESTIGATIONS.—Holtzke (Archiv. f. Anat. Phys.; Archiv. Ophthalmology), from experimental studies respecting intra-ocular pressure as related to remedies acting upon the iris, found:

I. Eserine at first markedly increases the pressure in the anterior chamber, but afterwards the pressure in the anterior chamber falls below the physiological

mean.

2. Atropine does not directly increase the pressure, but increases the pressure in the anterior chamber to a marked degree by its power of dilating the pupil.

3. In an eye not poisoned, the pressure in the anterior chamber rises when the pupil dilates, and sinks when it contracts.

4. Pilocarpine at first increases the pressure in the anterior chamber, though to a less extent than atropine.

5. There is no material difference between the pressure in the aqueous and vitreous chambers.

HOW TO OVERCOME DIPLOPIA WHEN PRISMS ARE NOT ENTIRELY SUCCESSFUL.-Dr. W. S. Little (Medical Record), in order to prevent the patient wearing prisms from looking under the glass and seeing double, suggests the following procedure:

The sphero-cylinder correcting the diplopia of the right eye has been ground opaque for one-sixteenth of an

as to obliterate sight eye. Then there is frame the wire net

inch above the horizontal plane, so in the lower field of vision in this attached to the lower portion of the word used in protection glasses. This is carefully adjusted to fit close to the face, the perforation in the gauze being stopped by painting. Vision is thus cut off below and under the spectacle. In this way the vision for the affected eye is only through the upper part of the myopic correction, and the necessity for a prism done away.

WHY DO NOT ALL MYOPES SQUINT OUTWARDS?— Dr. F. Stilling (Archiv Ophthalmology) answers this question as follows:

1. Some myopes squint inward because their position of rest is convergence, and there may be insufficiency of the external recti besides.

2. The position of rest of many myopes is convergence. If this be only slight, only relative divergent squint can possibly develop. The same holds good for parallelism as position of rest.

3. Even if all circumstances are favorable for outward squint, it will not develop if the individual cannot learn to relax one internal rectus muscle in order to give the eyeball a chance to assume its position of rest.

4. The majority of myopes do not squint because they have acquired the faculty of shifting the range of relative accommodation in the interest of binocular fixation so that the synergistic efforts of accommodation are reduced to a minimum.

THE AFTER-TREATMENT OF CATARACT OPERATIONS.-Dr. Chas. E. Michel (Archives Ophthalmology, Sept.,) says that after his cataract operations he dresses the eyelids by a piece of gold-beater's skin plaster closely applied to the lids only. The size of this plaster is a half inch by an inch and a quarter. He allows his patients to walk to their beds after the operation and attend to the calls of nature. But he restricts his patients in their movements. He has them lie upon their backs for about three days, the time necessary for a fair union of the lips of the wound. After this he permits them to rest themselves by lying on the side opposite the wounded eye. By the fifth day the corneal wound has generally healed pretty firmly but he still keeps the strips of plaster applied so as to leave a moderate opening between the lids of the operated eye.

A MUCH OPERATED OPHTHALMIC PATIENT.--Dr. L. F. W. Ring (N. Y. Med. Monthly) reports a case of a young lady that in a short time had the following operations done upon her eyes:

Three tenotomies of the externi, an enucleation, an iridectomy, two operations for entropion, and two operations for ectropium, and a cantholysis. Finally, Dr. Webster dissected out the entire palpebrarum ciliaris

muscle of the lower lid for the relief of the existing entropium. The result was a perfect restoration of the function of the lower lid; there was no contraction, no cicatrix, no epiphora.

LARYNGOLOGY.

THE EPIGLOTTIS: ITS FUNCTIONS.-Dr. Donaldson (N. Y. Med. Jour., August 7th) publishes a paper detailing a case of congenital defect of the epiglottis, and collates the literature relating to this organ. On the whole, he thinks he is justified in forming the following views:

I.

The epiglottis is not a valueless appendix to the mechanism of deglutition in the human subject, but is one of the agents for protecting the larynx from the entrance of food and drink.

2. Ordinarily, the lowest third of the epiglottis is the only portion which is needed for this function.

3. The other effective agents for the protection of the air-passages are the upwa d movements of the larynx in front, combined with that of the tongue behind, the occlusion of glottis, the exquisite sensibility of the mucous membrane of the glottic space, and especially the lower constrictor muscles of the pharynx.

4. All these different portions of the pharynx are protective of the larynx to a greater or less degree, and it is difficult to assign to any one of them a position of the greatest prominence. They ordinarily act together in protecting the larynx from the dangers connected with deglutition. In instances of disability of one or more of them, the others supplement their action.