DR. F. J. VAGER, Campbellsburg: This is a subject upon which I desire to say a few words. I am glad Dr. Beeler has agitated the subject. His remarks are good and pointed. I have gone over the ground of which he speaks myself. He has told you that with our old-time treatment we were generally tolerably successful. But while I would make these statements with a great deal of confidence and assurance, still I have cases in which it is difficult to effect a cure, and I am glad we have specialists to send them to and let them shoulder the responsibility. In my early practice I have applied salt water to scrofulous eyes, and various other little common things, which, along with the vis medicatrix naturæ, have helped to effect favorable results. These specialists are capable of throwing new light upon these subjects. If they do not take these cases in hand and assume the responsibility they would be in a worse condition than they are to-day. If they do not cure every case, I am satisfied they benefit a great many, and the country at large is far better off now that we have specialists.

DR. DABNEY (closing the discussion): I desire to express my appreciation of the remarks of Drs. Beeler and Yager. I value their opinion most highly as general practitioners, especially with such long experience as these gentlemen have had. We appreciate very intimately the relationship between diseases of the eye and those affecting the general health, and on that special relationship they have given us most valuable instruction.

In regard to the word catarrh, the cases called catarrh in our text-books on diseases of the eye will be found to have their origin in those soft growths that exist between the nose and throat-the naso-pharynx. You put your forefinger up there and you feel them like a bunch of worms; that is the source from which the discharge comes, runs from the nose, and irritates the nostrils. When these growths are present, unless we resort to curetting or remove them with the forceps, we must expect considerable irritation or trouble from them.

In regard to atropia, I would take issue a little with Dr. Beeler on that point. I think most of you have seen cases of little children or grown people who have an intense sensitiveness to light, accompanied with pain, who would lie awake and rub their eyes and experience a great deal of trouble. In such cases atropia helps to allay those symptoms. In addition to that there is a tendency to involvement of the iris, and atropia removes the danger from that source.

As regards sensitiveness of the eye to light, by dilating the pupil of the eye it allows more light to enter, but we must counteract this effect by smoked glasses. Twenty-per-cent cocaine, as mentioned by Dr. Taylor, would be likely to do harm. The ordinary solution which I use is a fourper-cent one, and although at rare intervals a twenty-per-cent solution might be useful, I should hardly think of using it habitually. Dr. Ray spoke, and I believe Dr. Beeler agreed with him, in regard to the routine

use of cocaine. I do not approve of using it in a routine way. It is a valuable agent for examination as well as for treatment. Little patients, as we know, have an intense blepharospasm. The old practice was to dip the head in cold water until they gasp for breath. This allays the spasm of the lid. Cocaine may be used for the same purpose effectually.

I was interested in the point Dr. Ray made in regard to the relation ship of this disease to eczema. Prof. Horner, in Zurich, had an enormous experience with this form of strumous ophthalmia, considering it a form of eczema. The race proclivities are interesting. It is a well-known fact that the negro race are much more prone to the disease, and when it occurs it does so in a much more violent form than in whites.

ACNE ROSACEA INDURATA PUSTULOSA: A CASE.*

BY J. W. O'CONNOR, M. D.

Realizing the difficulty the average general practitioner has in recognizing many forms of skin disease, and believing that this form of skin disease is rather rare in this country, and with the hope that it may be of interest to this Society, I report this case.

On November 28, 1894, Mrs. I. W., a widow, aged thirty-two years, white, a native of Kentucky, the mother of two children, called at my office to consult me in regard to a skin disease of the face. She said she had consulted and had been treated by several physicians, but the disease was gradually growing worse.

She gave a history of dyspepsia and constipation. The skin disease commenced about two years ago, soon after the death of her husband. She first noticed a few pimples on the nose, which gradually spread over the nose and both cheeks, with a few on the forehead. Previous to this she would often have a flushing of the face, or hot flashes, as she called them, and the skin of the face was always greasy.

At this time she was very much below par and quite nervous. Her face was covered with bright-red indurated pustules, varying in size from that of a pin-head to that of a small bean, many resembling a bean in shape, nearly all containing some pus. The integument generally was very much thickened, and pressure upon it would move the entire cheek. The capillaries were enlarged, congested, and tortuous. I commenced treatment by opening the pustules with a sharppointed bistoury and squeezing out the contents, then inserting a

*Read at the June meeting of the Kentucky State Medical Society, 1895.

pointed stick dipped in Monsel's solution as a cautery and germicide. After opening all the pustules, I would sponge the face with five-percent carbolized water. I interdicted the use of all soap and recommended bathing the face in hot water night and morning, after which rub in with a piece of flannel a three-per-cent alcohol solution of salicylic acid. At first this is to be mixed with three parts water and made stronger and stronger until it was used pure. I gave internally 1-10 grain doses of calomel every hour for a few days, with a pill of aloin, strychnia, and belladonna at bedtime. I would alternate this every few days with sulphur tablets, one grain every two hours, and tablets of iron, one grain, arsenic 1-20 grain, and strychnia 1-30 grain, every four hours. My patient gained rapidly in flesh, the dyspepsia and constipation was relieved, but the eruption yielded very slowly. There was a pretty good crop of pustules to open two or three times a week for about eight weeks, when they gradually began to disappear, and after about six weeks longer they were all gone.

The thickened integument and new growth of connective tissue also disappeared with the indurated pustules. The redness of the skin was slow to yield on account of the varicosed condition of the capillaries, but finally left under the continued treatment of hot water and massage.

There are many other remedies recommended, and many others I have tried for the treatment of this disease, but none so efficacious as those given above.

According to Fox, Heitzman, and others, different terms are used to designate the different forms of this disease, but I think there are no hard and fast lines that can be drawn, except perhaps between the simple acne of youth and the chronic form of middle life, as described in this case. I think a term should be used to describe as accurately as possible a certain disease, hence I use the term "Acne Rosacea Indurata Pustulosa."

It is a chronic inflammation of the face, made up of acne spots, periglandular inflammation, erythema, and new growth of connective tissue growing independently of the glands. An excessive amount of sebum is secreted, and the skin feels greasy (Seborrhea). The connective tissue round and about the glands hypertrophies. The acne spots become indurated and hard. The color of the redness is bright red; the vessels become varicosed and ramble freely over the surface of the diseased parts, suppuration is quite marked, and the integument is generally thickened.

According to Fox, this disease occurs in women of middle age who suffer from dyspepsia or uterine disease, and is aggravated by trouble, stimulating food, and by alcoholic drinks.

It must be remembered that the circulation of the face is sensitive to irritants; it is liable to great fluctuations; it is very active when the glands are particularly well developed in the face; they are therefore likely to become permanently deranged. All debilitating causes, all local causes of irritation and disorder of those organs which have a reflex relation with the face, for example, the stomach and uterus, as well as want of cleanliness, cold winds, the use of cosmetics, etc., may induce glandular congestion and also acne. The treatment must consist in removing the cause of reflex irritation of the stomach or uterus, personal hygiene, tonic and local treatment, as given in the above case. The after-treatment consists in the exhibition of a general course of tonics, the mineral acids, or arsenic, or iron, or cod-liver oil, as seems best suited to the individual case in hand.

ELIZABETHTOWN, KY.

NON-OPERATIVE TREATMENT OF INTERNAL HEMORRHOIDS.*

BY W. O. GREEN, M. D.

Can internal piles be cured without an operation? This question more frequently than any other must be answered by the surgeon who is often consulted for rectal disorders. It may be confidently asserted that in carefully selected cases appropriate treatment employed in a scientific manner will relieve a large proportion, probably a majority, of patients without recourse to operative interference.

There is a deeply rooted idea, unfortunately too often entertained by the legitimate practitioner, that few cases of this disease can be relieved by non-operative measures. Such beliefs, in the present advanced state of our knowledge, must appear prejudicial and unprogressive and are often harmful not only to the physician but to the patient.

The reaction that has appeared from the many distressing accidents of the quacks, together with a prevalent desire for brilliant and more remunerative surgery, seem to have caused the pendulum of scientific modes to pass the point of conservatism and swing to the extreme limit

* Read at the June meeting of the Kentucky State Medical Society, 1895.

of radical measures. It is true that when judiciously operated upon few. cases fail to reach permanent recovery, but it does not follow that such satisfactory results should justify this method of treatment alone. Many cases of piles reach an equally satisfactory end by much simpler means, and it would be not only undesirable but unjustifiable for the surgeon to attempt to relieve them by operation. The following case may serve to illustrate the point:

Mr. X, a lawyer, came to my office in September, 1892, for consultation. He stated that for five or six years past irregular hours and sedentary habits, incidental to his professional duties, had occasioned periodical attacks of constipation. About eight months before, during one of these attacks, he took a strong purge and noticed that following the action of the bowel there was slight pain in the anal region and a few drops of blood were passed. In the course of a day or two these symptoms disappeared and he felt no more discomfort until the onset of the present attack. About two weeks before consultation another attack of constipation came on, as a result of excessive smoking and late hours, which required the free use of purges, and when the bowels began to act there was considerable irritation about the rectum. After each action there was a sensation as if the bowel had not been relieved, which brought about violent and prolonged straining.

In the course of a day or two a protrusion appeared at the anal orifice, which at first returned spontaneously, but later remained outside, became swollen and tender, and bled freely when the bowels moved. The bleeding and pain annoyed him so much that he consulted a physician, who diagnosed his trouble piles, and advised an immediate operation. The patient had a very great dread of any surgical procedures, and, being compelled to keep at his work, declined operation at

once.

He came to me for consultation the next day. I examined him and found a mass of six edematous piles that had come outside the anus on the previous day. The sphincter muscles had become very irritable, and constricted the protruding mass to such a degree that he was unable to return it. The parts were exceedingly sensitive, and walking or sitting or any manipulation gave him considerable pain.

A diagnosis of internal hemorrhoids was made, and it appeared that he might be relieved by judicious treatment without the intervention of operative interference. Accordingly the piles were painted with a local anesthetic, anointed, and reduced. This gave him almost instan