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Dr. Jones (closing the discussion): Dr. Duncan has said that I did not explain the cause of normal vesicular murmur. I did not undertake to do it in the limited time at my disposal, and particularly to dwell upon the various theories as to the cause of the normal vesicular murmur, among which are muscular contraction and a number of others. I was simply endeavoring to explain my views as to the location of the crepitant râle.

ON SOME OCULAR DISTURBANCES OF GENERAL INTEREST.

BY ALEX. W. STIRLING, M.D., C.M. (Edin.); D.P.H. (Lond.); ATLANTA, GEORGIA,

Mr. President and Gentlemen:

I propose in the following paper to confine myself to a few words concerning one or two of those ocular lesions which for some reason or another are likely to be of general interest.

Of conjunctival affections I may mention one-sided hyperemia, which should always suggest a foreign body in the conjunctival sac or on the cornea. Few of the minor operations of surgery will better repay the practitioner than a dexterous manipulation of the eye in such cases, and one should not be hurried in excluding a foreign body. Besides numerous cases in which, by the concentrated light of a lens, one has found small particles of dust of various composition when these had already been definitely excluded, I have notes of two cases which have come under my own observation, from the sulcus of the conjunctival sae of one of which there was removed a hazel catkin half an inch in length by a quarter of an inch broad, which had lain there for two years, causing a disturbance stated by the physician in attendance to be of no consequence; and from a similar position in the other case, a piece of copper nearly as large, which had passed through the lid several years previously.

A question, especially for skin specialists, is whether the disease called pemphigus of the conjunctiva is generally

associated with pemphigus of the skin. In the half dozen or so ocular cases which I have encountered I have seen only one in which the skin was also affected; but whether by pemphigus or not is uncertain. On the other hand, the affection of the conjunctiva has usually been associated with bulle on the palate.

I need only say a few words in connection with ophthalmia of the new-born, and these to remark that this is a disease which will brook no trifling, but yet one which, if promptly and energetically treated, will generally respond with remarkable rapidity to proper remedies. Nothing is better than thorough and constant cleansing, painting once daily the well everted lids with fifteen to twenty grains to the ounce of nitrate of silver, and the application of boric ointment to the lashes to prevent their gluing together. An abrasion of the cornea may prove fatal to the eye, and there is no doubt that a considerable amount of skill is required to make the silver application thoroughly and yet gently. The child's head should be held between the knees of the physician while it lies on the nurse's lap and is firmly controlled. Considering the large amount of blindness produced by ophthalmia neonatorum, it appears to be a suitable question for discussion in this society whether the good example set by certain other States in connection with the compulsory reporting of such cases should not be followed here.

To pass to the cornea:-Our chief interest there to-day lies with ulcers and with foreign bodies. The latter are often difficult to find, and when found may be deeply imbedded in the corneal tissue, and not always quite easy of removal. The point to which I wish to draw attention, however, is that even after the simplest abrasion by the foreign body or by the instrument used in its removal, the protecting epithelium is destroyed, and not infrequently, as I have myself seen on more than one occasion, germs thereby

gain access to the corneal tissue, and severe ulceration, with or without hypopyon, results. Strict antisepsis is therefore advisable; frequently, also, a bandage for twenty-four hours, and sometimes atropine. Corneal abscesses and ulcers have a very various etiology, and are often dependent upon general ill-health. They usually demand shade, atropine, and antiseptic applications, but when near the periphery eserine may replace atropine in the absence of iritis. Should the ulcer perforate, there is then less likelihood of prolapse of the iris into the wound. Some of the severest forms of ulcer may be rapidly cut short by certain destruetive agents, notably the electric cautery, the sharp spoon, strong solutions of perchloride of mercury in glycerine or alcohol, and frequently very prompt treatment in them also is required to save the whole eye from destruction. Poultices should in this, as in practically every other ocular disease, be carefully eschewed.

The watery eye, produced by obstruction in the lachrymal duct, should be of interest mainly for two reasons: First, that it arises probably most frequently from nasal catarrh, one of the reasons which make it advisable that even slight nasal complaints should not be neglected; and the second, that in the presence of duct obstruction the simplest ocular abrasion becomes serious. It is only the direst necessity which brings a surgeon to operate upon an eye whose duct is so affected, and yet it may be the lot of any of us to be called upon to remove a foreign body from the cornea, or to treat another traumatism in such an eye. The dangerous germs with which the conjunctival sac is swarming in this condition explain the necessity for its

cure.

While cataract is looked upon as usually a purely local disturbance, except in the rare cases in which it is associated with certain diseases, as diabetes, there is one form of opacity in the lens which is believed to have important relation

ships to conditions of general health. This is called zonular or lamellar, and sometimes congenital, cataract, and is by far the most frequent type of lenticular opacity met with in children. It affects a varying amount of the lens, and the opacity produced by it may be so slight as to interfere but little with vision, or so great as to disqualify its owner for ordinary work. The opacity is usually figured as an oval ring of varying thickness surrounding and concentric with the nucleus or center of the lens which it separates from the healthy periphery; but as a matter of fact in most zonular cataracts, the nucleus is also more or less affected. The lens grows by the superposition of new layers upon its exterior, formed from epithelial cells lining its capsule. At one time, therefore, the opaque ring in zonular cataract may have been the exterior of the lens directly beneath the capsule, and the point of interest for us lies in the questions: Why and when did the opacity arise? By comparing a series of measurements of the normal lens in fetal life and in infancy with measurements of the opaque ring in these cataractous lenses, it has been shown that if this ring were the external layer at the time of its unhealthy change, this change must have taken place, at least in some cases, during intra-uterine life. But among the few theories which have been advanced to account for zonular cataract, one which has gained much credence is that the condition is the result of rickets during the first two years of infancy. The fact just stated, that the size of the opaque ring supposed to have been the external layer during the formation of the opacity may be smaller than the lens at birth, does not actually prove that the lenticular disease may be intra-uterine, because it has not been positively shown that this layer must then have been the most external, and it may in reality have been deeper. That zonular cataract is frequently associated with the teeth said to be peculiar to rickets is held to sustain the proposi