fectly comfortable; as soon as this disappears, which is usually in two or three hours, the itching recommences. In the last three weeks the diagnosis has cleared up considerably; a nodule has developed just below the margin of the ribs. At first I thought it was a case of passive congestion dependent upon the weak condition of the heart. He has never been addicted to the use of alcohol. While he appears to be well nourished he has lost considerable flesh.

Reports of Cases. Dr. Cornelius Skinner: I want to report a case that I saw this week in a young man seventeen years of age convalescing from measles. On Monday he had pain in the abdomen, and I found an enormously distended bladder; he had passed no urine in two days. I withdrew three pints of urine, and have catheterized him twice a day since. The urine is normal; he has had no fever since Monday. At the time the bladder was so distended he had a temperature of 103°; after withdrawing the urine temperature went down to normal; he has no other symptom. On Monday there was some weakness and trouble. in standing, but this has disappeared.

Dr. J. W. Irwin: I have seen very little recorded on the subject. A short time ago there came under my observation a young man having a very severe attack of measles, and on the seventh day he developed a paraplegia with loss of control over the sphincters. For four or five days his urine had to be withdrawn. Mild cathartics acted on him violently, and he could not control his stools. After a few days he regained control of the sphincters without any special medication or the use of strychnia.

Dr. S. G. Dabney: In the last two days I have seen two cases of internal strabismus in young ladies who were annoyed by a symptom that is not common. They both complained of a feeling as if the eye which they used most was being drawn in toward the nose, and it has been a source of much discomfort. In one of the cases the strabismus had decreased in the last few years, and operation was not demanded for the improvement of appearance, yet the sensation of tension over the insertion of the internal rectus was so great as to be a source of serious annoyance. Yesterday I made a cautious tenotomy of this muscle. Of course it is too soon to say what the permanent result will be, but the patient expresses herself relieved entirely.

To-day I saw another case presenting the same symptom, but with more decided squint, and more positively needing operation for its correction.

Another recent case illustrates the danger from seemingly slight wounds to the eye, and the importance of a thorough immediate examination necessary under an anesthetic. On November 3d a little girl was stuck in the eye with a pin. The mother noticed shortly afterward that there was a drop of fluid on the coat of the eye, and sent for a physician, who did not then discover much the matter. The child became more and more sensitive to light, and suffered increasing pain. Twenty days after the injury she was sent to the city. The child was between three and four years old, and it was impossible to examine the eye without anesthesia. I placed her in one of the infirmaries, and under chloroform found that the pin had evidently gone through the center of the cornea and penetrated the crystalline lens. The result was traumatic cataract, which had produced irido-cyclitis, now gone so far that the pupil was entirely occluded. Remnants of lens matter filled the anterior chamber and the tension was increased. I opened the anterior chamber and removed what remained of the lens; used atropine, hot applications, and moderate doses of mercury. In spite of these measures, five weeks after the child's arrival in the city the eye was soft, somewhat shrunken, and blind. The question of enucleation arose. To my mind it is better to have a glass eye than a shrunken, blind one, that will be a source of danger to its fellow forever, and more unsightly than an artificial substitute.

The case illustrates the urgent importance of a complete examination of all wounds of the eye if necessary under complete anesthesia, and as soon as possible after their reception.

Dr. J. M. Ray: I have seen not only cases of squint but cases where there was a high degree of hypermetropia complain of seeing the nose. Correction of the error of refraction will materially lessen this sensation. I would like to say something while the question of squint is up about a case of divergence recently operated upon. After cutting both external recti muscles I used a nose guy. I got almost a complete correction of the external squint. She complained of double sight before being operated upon, and since the operation it has been more annoying, and instead of the displacement being lateral it is vertical. I believe now, to get complete relief, I will have to cut the superior rectus so as to let the eye down to correspond with the other.

With reference to the case of injury to the eye, we all see these unfortunate cases. I had a child in the office yesterday from whom I had to remove the eye some three months ago. The unfortunate thing

about removing the eye in children is that the face on the side from which the eye has been removed does not develop. This is especially noticeable in the muscles about the lid, and there is a decided want of symmetry. For that reason in children I am more inclined to try evisceration than enucleation. The features seem to develop more when evisceration is done, and there is left a better stump for an artifical eye later in life. And recently good results have been reported from Muhl's operation.

Dr. Dabney: A part of Dr. Ray's remarks were called forth because I did not report the first case as fully as I should have done. Of course, the error of refraction had been most carefully corrected, examination having been made both under homatropine and atropia.

As to Muhl's operation, it is not a new one, and has been subject to some criticism from the danger to the other eye it involves, two cases: of sympathetic ophthalmia having been reported as following it.

In operations for divergent strabismus I have several times been tempted to use the Gruening suture, and am sure it would help to correct the divergence, but it has seemed to me very likely to produce just such a vertical deviation as Dr. Ray reports, though the final result in his case promises to be very satisfactory.

The essay was read by Dr. William Cheatham; subject, The Socalled "Antitoxine" in the Treatment of Diphtheria, with Four Cases. [See page 1.]

Discussion. Dr. J. A. Ouchterlony: I have been deeply interested in the paper just read by my friend Prof. Cheatham, not only on account of the subject of which he treats, but because of the merits of the essay and its exhaustive character.

We are naturally rejoiced at the prospect of obtaining a new and promising method of treating a disease so grave and the mortality attending upon which has been so great. Yet I am not disposed to be oversanguine, having so often been disappointed in discoveries that promised fully as much, and after a while fell into disuse and oblivion. The analogy between this new treatment of diphtheria by antitoxine. and the antipneumotoxine of pneumonia encourages one to hope that in this direction will be achieveu a great practical advance in therapeutics.

Prof. Cheatham's report dealt mostly with laryngeal diphtheria, and in the treatment of this form of the disease there seems to be urgent need of improvement.

In the management of tonsillar, pharyngeal, and nasal or nasopharyngeal diphtheria, especially of recent years, the success has been quite satisfactory; especially when active treatment has been persisted in at every stage. My own success has been quite good.

But it would seem that the antitoxine may have the effect of greatly shortening an attack of diphtheria, and if this be so then it would seem a decided improvement upon previous methods.

The possibility of preventing by means of antitoxine the unpleasant sequelæ of diphtheria, if it proves to be a fact, would give additional value to the method. I have not looked over my records, and therefore can not say with what frequency post diphtherial paralysis occurred, but my recollection is that in the majority of cases it does not ensue. In almost all the cases of this paralysis the patient recovered.

The antitoxine has no effect upon the staphylococcus and streptococcus infection, and we all know that in diphtheria there is a mixed infection-that the frequent nephritis is not due to the diphtheria poison but to the former.

It seems to me that the attitude for us to assume at present is one of prudent skepticism, making use of the remedy sufficiently to ascertain its real value without being carried away by the unreasonable enthusiasm with which the common people are apt to take up whatever new thing of this kind is announced.

Dr. Ray: No doubt many of you have read the reports which have been appearing in the medical journals and lay press for several weeks. These did not strike me as much of an improvement over the old plan of treatment. I can recall only two cases in the last two years where the disease was limited to the nose and naso-pharynx that have not gotten well. My experience with the antitoxine is limited to two cases, and in only one of these did I have control. The cases recovered. There was a membrane on one tonsil and one or two small patches on the back part of the pharynx in one case; the other case was a child nineteen months old, which was taken sick on Sunday with sore throat, and on the next day a diagnosis of tonsillar diphtheria was made by Prof. H. A. Cottell. Monday night there was some evidence of obstructed breathing, which increased on the following day, when I introduced a tube. The child had a temperature of 103° when tubed. The result of intubation was of course complete relief to the obstructed breathing. That afternoon the temperature was 102°, and we injected into the inner side of the thigh during a few hours a vial of the No. 1 Behring

solution. No other treatment of any kind was used. On Wednesday afternoon we injected another bottle. The child showed less systemic disturbance than any I have encountered for some time. On Sunday morning the membrane had disappeared from the tonsil and pharynx. The child coughed up the tube and we left it out. No trouble in breathing was noticed, and the child rapidly recovered.

It seems to me that the last five or six cases I have seen were not so severe as those seen in October, and this may have something to do with the recovery. Epidemics vary in malignancy at different times.

With reference to the diagnosis and the value we can place upon the microscope, in my experience the microscopical has invariably agreed with the clinical diagnosis. I am getting more and more chary of my ability to tell diphtheria by inspection. I have met recently two or three cases where there were only two or three spots on the tonsil, and a diagnosis of follicular tonsillitis was made, yet after five or six weeks paralysis of the soft palate and muscles of accommodation came on.

I am not in a position to give any decided opinion in regard to the value of antitoxine, but hope there is something in it. Dr. Cheatham has collected from recent literature a number of statistics, but my experience has been that the results we get here by old methods of treatment, recognized by all, are as good or better than those collected as a result of the antitoxine treatment in foreign countries. No one has treated enough cases in this country to be able to give authoritative results.

Dr. Dabney: I have very little to say about the antitoxine. Of course it is only what we have personally seen that is of service now. I have had two or three diphtheria cases since the antitoxine was brought to Louisville. They were mild cases and readily yielded to ordinary treatment.

I must say that I have seen cases which did not seem to be true diphtheria, and yet a competent bacteriologist reported finding the germ of diphtheria. And when he told me the same germs were found in the mouths of healthy persons, I was still more skeptical, and doubt, in view of this fact, the wisdom of taking the bacteriological examination as proof positive of diphtheria in the entire absence of the clinical symptoms which usually develop as the case progresses.

Dr. F. C. Wilson: I have not had an opportunity to use the antitoxine yet. The only cases I have had since its introduction here were of a mild type, and the delay in making a bacteriological examination