The papillary layer is notably enlarged and the scales result from hyperplasia of the cells of the rete mucosum. HERPES ZOSTER. A man, 22 years of age, comes to us on Believing the present case to be depend-account of an eruption in the axilla and ent upon a rheumatic condition we shall order the treatment upon that basis. In the first place, as the patient's tongue is badly coated, her intestinal tract shall be thoroughly cleansed by the use of a mer curial cathartic. After this object has been accomplished she shall be placed upon the following preparation: R Salolis, gr. iij. Calcii sulphidi, gr. 1/ The rash is of a typical aspect and consists along the border of the pectoral muscle. of a series of vesicles. These also extend down the right arm. The disease has been in existence for four days. The first symptom which drew his attention to the parts He then examined his person and found was the occurrence of sharp, shooting pain. the eruption in the situations named. There has been no disposition to amelioration, but rather the contrary. The pain M. et ft. capsul. No. j. Mitte tales No. shoots down the arm to the elbow. There XXX. Sig.: One capsule four times a day. is also a burning sensation in the skin. The vesicles present a linear arrangement and some of them are bluish in color. The scales are unsightly and troublesome. When, as in this case, they are situated upon the face they are a source of mental distress to the patient. It is, therefore, highly desirable to effect their removal and, if possible, prevent their reproduction. Detachment of the scales is facilitated by the use of oil dressings or poultices. When the affected surface is large the warm bath is an efficient method. When the surface has been cleared a mildly stimulant application is generally of service. Among the agents which may be employed are salicylic acid, carbolic acid, creasote, naphthol, thymol, tar, chrysarobin, etc."shingles," which is a corruption of the Tar itself may be objectionable on account of its color and smell, and may be more acceptably used in the form of oil of cade. Chrysarobin is a favorite with many, but has certain disadvantages. It stains; it is very apt to create too much irritation, or even cause dermatitis, and it is capable of producing constitutional symptoms by absorption. In the present case, after the surface has been cleared, we shall make use Whenever you see a line of vesicles, ac-. companied by pain, think of the anatomy of the parts and note whether the eruption does not follow the course of a superficial nerve. In the case now in your presence the rash corresponds to the situation of the pectoral and brachial nerves. This anatomical arrangement is characteristic of. herpes zoster. In this case the eruption occurs in an unusual locality, but the disease may manifest itself along the tract of any superficial nerve. Very commonly it is in relation to the intercostal nerves and hence has originated its common name of of the following ointment: Acidi salicylici, 3ss. Sulphuris sublimati, 5ss. Unguenti zinci oxidi, j. M. et ft. ungt. Latin word cingulum, a girdle or belt. This patient is ignorant of the cause of the disease, although he fancies that it may be the result of cold. Its sudden development would seem to lend probability to that supposition. Herpes zoster is an acute disease. According to its severity, it may last one or usually small and discrete, but in some intwo weeks, or even longer. The vesicles are stances they run together and form bullæ. After a duration of three or four days the contents become opaque and at the end of one or two weeks they concrete into brownish crusts; these fall and leave exposed a . surface which may be normal, pigmented, or scarred. In exceptional cases the vesicles contain blood, and in other instances the inflammation may be so aggravated by friction of the clothing and scratching as to cause actual ulceration. As a rule, herpes zoster does not attack. a patient a second time. The neuralgic. pain generally lessens or disappears with the advent of the eruption, but it may remain unabated during the course of the rash or may persist for an indeterminate period after the skin has regained its normal aspect. This lingering of the pain is very apt to occur in old subjects. On the other hand, the neuralgia is less severe in children than in adults. In the aged, anæsthesia and other nervous disturbances may succeed to the neuralgia. Zoster, or zona, as it is also called, of the orbital region may attack the eye and give rise to very serious consequences. It should not be difficult to diagnosticate herpes zoster. Its vesicles are larger than those of eczema and tend to dry up, while the neuralgic pain is entirely peculiar to herpes. Its anatomical disposition is also an essential feature. Herpes zoster is due to irritation or inflammation of nervous ganglia or peripheral fibres. The eruption upon the skin is, therefore, a secondary matter. This patient's general condition is good and his appetite is normal. The bowels are regular. He is a moderate drinker. In treating herpes zoster we wish to relieve the local inflammation and assuage the pain. It is better, if possible, to avoid resorting to opium. Dry, antiseptic and somewhat astringent applications are usually beneficial. In the present case shall make use of: R Salolis, Acetanilidi, of each, gr. v. M. et div. in chart. No. xx. we Sig.: One such powder every hour or two until the pain is relieved. GENTLEMEN: We have had the pleasure of many interesting talks together, and when I was a student I always felt that up to the holidays the winter was very long; after that, the time until graduation day was very short. double duty: first, to the Professors; and second, to your State; and I am sure by this time you are probably becoming annoyed by hearing so much about the State Board of Examiners; but we all feel very much interested as to the outgrowth of next spring's examination, and every Professor in this College is trying to make you the banner boys of all that go before this Board of Examiners; and we do not want it said that there is a man of you who cannot answer the practical questions that will be asked of you. I am glad to say, and it is with the greatest degree of pride, that of all this class who have handled the Graefe knife, I believe every one will be able to You have before you a Clinical Lecture delivered at the Medico-Chirurgical College tell about the practical operations which | folds appear a little thicker than normal. will take place on the eye. I must say, as There are slight ridges, the color changing. a certain Professor said long ago, "It is In the gray and blue eye it assumes a marvelous the way the Americans handle greenish tint-in the dark eye a mouldy the knife." I do not know whether it is appearance. Upon exposing to a strong simply because we are natural mechanics, light, the iris of the good eye contracts imor whether it is our natural adaptability to mediately, while the iris of the diseased eye circumstances, but the number of students will not move. Care must be taken to who have taken this practical course in break up the adhesions before the iris adthe operations on pig's eyes have shown a heres to the crystalline lens. degree of skill that is really most gratifying, and I feel sure that when you get to the end of these opportunities and when you become masters in your field you will be ready to follow out all the various operations which will give sight to the blind. It is important that you know something about the various practical operations on the eye, at least, to be able to diagnose them, and I believe you are a set of students who will embrace every opportunity to advance your future career. Inflammation in rheumatic iritis begins at the uveal tract, which you understand is that one containing the pigment, rich in blood vessels, lymphatics and nerves. It is the coat that carries the circulation to the inner part of the eye. When inflammation extends from back forward, the iris is limited in its action, the same result taking place as in specific iritis; but the intense pain you get in rheumatic iritis is probably more characteristic of that disease than the specific. In specific iritis you may have inflammation and plastic adhesions and yet not have a particle of pain, whereas in rheumatic iritis it is entirely different: there is severe orbital along the side of the head upon which the inflammation exists. These pains are somewhat vague, last for an hour or two, and fly off into the different parts of the body. First, we will speak of the intraocular diseases of the eye, demonstrating them as much as possible with cases. We shall show you a case of inflammation of the iris. This coat, the iris, the "window cur-pain, along the nose, back of the head, and tain of the eye," which gives it color, is very rich in blood vessels and is situated posterior to the cornea. It is also a continuation of the choroid and ciliary bodies, and wherever the lymphatics act together they become very rich in inflammatory products, and the reproduction of exudative tissue is very active. These processes are intensely rich in food for the eye,that is to say, plastic material is easily produced, easily thrown out and easily absorbed. Another duty of this coat is to guard the retina. The iris is composed of three layers, external, internal, and posterior. The various causes which enter into plastic destruction of the iris are,-specific, rheumatic, and gouty diathesis. In specific iritis you will find slight congestion around the ciliary region, and as the inflammation increases this increases. When you examine the iris carefully the Iritis is amenable to treatment in the young and middle age, but hard to cure in the old. Treatment. In the treatment you have three or four things to carry out. In the first place use atropia, locally, 1 grain to 3 drachms, which may be increased to 1 grain to 1 drachm. If the iris is engorged to such an extent that the fibres cannot pull it apart, you can increase it still more. The atropia dilates the pupil; pulling off this part of the iris distends it as far as it possibly can. At this point, referring to the case before us, the iris has grown fast to such an extent that the dilating is lost, and you get these irregular conditions of the pupil. I do not wish you to be misled and think that in iritis you have irregularly dilated pupils: it is only the result of the mydriatic. You have seen the irregularly dilated pupil because you have seen this after we have administered the drug which did the work. Daturine may be used after atropia where there is inflammation. Mercury is given internally in the form of calomel, 1/10 grain, every hour until 3 grains have been taken. In rheumatic iritis I am fond of prescribing salicylate of sodium, 10 grains, three times daily, and so far have met with excellent results. Then follow with the iodide of potassium without regard to the character of the iritis. cific iritis. This eye last week had a very different appearance, the cornea was dim, the iris dilated, and the blood vessels engorged and thickened. To-day you notice the eye is clear and white. Beside the treatment I have given you, we used in this case the ung. hydrargyrum to its fullest extent, rubbing different parts of the body with the ointment. If all other remedies fail we then perform an iridectomy. I am lingering over this line of cases because they will probably come under your care more than any other, and therefore I want you to be thoroughly well versed For pain and congestion use leeches, in the diagnosis as well as the treatment to about one-half inch from the outer canthus, be carried out. From time to time, whenthus relieving the blood vessels of engorge-ever the opportunity occurs, I shall bring ment and establishing proper circulation, these cases before you. and the lymphatics are allowed to carry away this deleterious material. Then, too, hot water application is very efficacious. Our next case is a divergent squint, and many of you know exactly what is to take place. This young woman has come to me for a purely cosmetic purpose. We can readily understand that feeling in woman which will cause her to make any sacrifice to improve her personal appearance, and rightly so. Now my duty is to take away this squint, which mars the beauty of her face. We have before us a young man whom I have examined carefully and find it a case of specific iritis, without a doubt, notwithstanding the history he gives refutes this. You note the virulency with which it attacks the eye, the red discoloration of the sclerotic coat, the irregular-shaped pupil which shows that the iris has thrown This operation was a very disappointing out plastic material. The iris, instead of one to the older surgeons and a tedious being perfectly round, is bound down with one to the present-day surgeon. Since its little tags and various growths, showing introduction by Professor Guérin it has the adhesion between the posterior part of undergone various modifications at the the iris and the anterior capsule of the hands of Von Graefe, Critchett, Bowman, lens. Wherever you have inflammation of Knapp, and others. For a slight degree of the iris the tendency is to contraction. The divergence I prefer snipping the external pupil narrows itself in a measure to give re-rectus and advancing conjunctiva and lief to the eye, and in giving that relief it Tenon's capsule. This. is best done by does injury. The plastic material which is taking out an oval piece of conjunctiva thrown out contracts, draws itself together, and Tenon's capsule (DeWecker's operaand you will have the condition we have tion) with T-shaped forceps, and then here complete occlusion of the pupil-uniting the edges of those tissues together. myosis, as it is called. This young man will be placed on the treatment as above outlined and will be brought before you next Friday, that you may see the action of the drugs. This is the young man that I presented to the class last week with an attack of spe In pronounced cases I follow the operations suggested by Richard Williams, of Liverpool: "An incision is made in the conjunctiva and subconjunctival tissue over the tendon of the internal rectus, extending from near the margin of the cornea for about half an inch toward the inner can thus. The edges of this incision being sep- perform the Mules operation. The conarated and an aperture having been made junctiva is dissected from its corneo-scleral in the capsule, the strabismus hook is in- attachment, back to about the equator of serted under the tendon in the usual way, the eyeball, no attention being paid to the and then confided to an assistant. A cutting of the muscles-they are separated curved needle, armed with a suitable silk from the eyeball in every instance, uniting thread, is then inserted in the conjunctiva again in the process of healing. The cornear the margin of the cornea and car-nea is excised, this being done with a ried between the sclerotic and conjunctiva large Beer knife,-as in performing a flap toward the muscle behind the hook. It operation for cataract; the lower half of is then passed through the tendon, from the cornea is then removed with curved edge to edge at right angles, to the course scissors and the contents of the globe taken of its fibre, and brought out at the opposite out with a small scoop devised for the purside of the conjunctival wound. The edge pose. We must exercise care in removing of the conjunctiva at this side of the in- the ciliary bodies, choroid and the head cision is now raised with a pair of forceps, of the optic nerve, leaving a clean, white and the needle is inserted between it and sclera. the sclerotic, and brought out near the margin of the cornea at a point corresponding to the point of entrance. At this juncture the external rectus may be divided or not, according to the requirements of each individual case. The tendon of the internal rectus is divided at a safe distance from the ligature and the hook is removed. By now tying the two ends of the loop together the margin of the cornea is brought into apposition with the cut end of the tendon and the eye brought into a position of more or less squint. Finally, the edges of the conjunctival incision are brought together by means of a fine suture." This operation is much shorter and simpler than the usual method. Next week you shall see the result of this operation. Dr. Stevens, of New York, has gained more success in strabismus operations than any other man in the profession, and to him we are indebted for much of our knowledge on the question. This young colored girl has glaucoma and staphyloma of the cornea, due to an ulcer eight years previously. After the cavity has been thoroughly cleansed a glass ball is inserted, with an instrument devised for the purpose. The sclera is split so that the edges may be drawn together and held by stitches of black silk, thus completely hiding the ball. Thorough antiseptic precautions are taken and the eye bound with sterilized bandages. I have given you a very hasty description of this operation, as it has been performed before you so many times that I feel confident you are thoroughly familiar with the modus operandi. EXOSTOSIS OF THE LOWER POR- BY ERNEST LAPLACE, M.D., LL.D., GENTLEMEN: I present to you to-day a There is but one thing to be done, and that is, removal o the eye. must be removed why not give the patient the advantage of the improved appearance of the artificial eye? To do this we shall 1 Delivered in the Clinical Amphitheatre of the MedicoChirurgical Hospital, Philadelphia |