fact, though, that if we could make a smooth, clean opening in the drum-head, and keep that opening from healing, it would be possible to medicate the middle ear more thoroughly and intelligently. For this so eminent an authority as Burnett, with others, still advocate the introduction of an eyelet through an incision made in the drum-head, in order that the aperture may be retained, but it is a procedure difficult to carry out, and the results thus far have not been satisfactory, plausible and attractive as it may seem in theory.

It has long been known that where a considerable opening existed in the drum of the ear, not only did the person hear perfectly well for practical purposes, but it was noticed that in many cases where suppuration occurred, and such an opening did remain in one ear, the amount of hearing was greater than that remaining in the other ear, where practically the same process had gone on, except as regards the opening. This surgical procedure of nature. had long ago taught aural surgeons that such an opening is not only desirable, but a necessity to hearing in certain cases, and it is not too much to expect that they will soon be able to maintain such an opening in the membrane as to treat the middle ear with astringents and other proper solutions as readily as such applications are made to the inner surfaces of the eyelids.

Another procedure which gives promise of most satisfactory results is the so-called mobilization of the bones-especially the stapes. An article like this can make only the merest reference to this step in advance. In another place I hope to discuss this method of treatment more in detail. The fact is evident that immobility of the bones of the ear is a very important factor in the production of imperfect hearing, and the problem before us is very similar to that which confronts the general surgeon in the case of a stiff-jointed knee or elbow. In that case, he institutes forcible motion and the bones move upon each other with more or less freedom afterwards. In the ear the problem is to move these adherent bones one upon the other, and especially to lessen the adhesions which in most instances the stapes has had formed about it. The brilliant results obtained in some cases and the many instances of decided improvement in others, give us strong reason to hope that this operation is one destined to bring relief to many in the future. Even a small experience with it justifies this conclusion. As for the entire removal of the stapes, as advocated by Jack, this operation, it must be admitted, is still

to be held as under trial, and considered as applicable to only a small class of cases. In general, I think nearly every practitioner of experience will agree with me that when he compares his results during the last four or five years with those in the earlier years of his practice, he sees that the advances made in operations on the middle ear have done much to warrant encouragement in a class of cases which before we saw go from bad to worse, while we confessed with shame our ignorance and inability to give the relief so much desired.

183 DELAWARE AVENUE.

SOME AFFECTIONS OF THE EYE ASSOCIATED WITH AND DEPENDENT UPON THE SCROFULOUS

DIATHESIS.1

BY ALVIN A. HUBBELL, M. D.,

Professor of Ophthalmology and Otology, Medical Department of Niagara University,

Buffalo, N. Y.

THE theme as here stated involves, according to present pathological conclusions, an erroneous assumption. It presupposes the existence of a condition of the human system heretofore defined as scrofula, whereas scrofula is known no more in the newer pathology. It has figured most prominently in the past; but its foundation has been narrowing more and more, till within the last few years it has been removed entirely. Those lymphatic enlargements and other conditions which were formerly regarded as scrofula are now known to be forms of tuberculosis. Today scrofula is tuberculosis. And without scrofula there can be no "scrofulous diathesis." But in losing a name we do not lose a disease or its predisposing conditions. The "thing" is still with us, but has only been newly labeled.

There may be some objection to the word "diathesis." Indeed, there are some who deny such a condition. Perhaps "vulnerability" or "tissue-vulnerability" is a term more in harmony with our present knowledge. But I like the word "diathesis," signifying to me, as it does, a condition, either congenital or acquired, in which there is found a weakened vital or cell-resistance to morbific agents, and, therefore, in a sense, a predisposition to some particu

1. Read before the Buffalo Academy of Medicine, February, 1894, and the New York State Medical Association, Fourth District Branch, at its meeting held in Buffalo, May 8,

lar constitutional or local disease. It seems to me very expressive to speak of the "gouty" diathesis, "scorbutic" diathesis, "hemorrhagic" diathesis, and the like. For the present purpose, therefore, I will retain the old name, but with its modified signification.

The so-called scrofulous or strumous diathesis is peculiar, and is, generally speaking, easily recognized. It exhibits a proneness to inflammations of the skin and mucous membranes, especially inflammations of a chronic nature, and a susceptibility to tubercular infections leading to glandular enlargements, bone and joint disease, "cold abscesses," pulmonary phthisis, and similar affections. This diathesis might with propriety be called tuberculous, as it offers most fertile soil for the propagation of the tubercle bacillus.

It is a condition both inherited and acquired. It is seen in children of tuberculous parents, or of ill-nourished, over-worked or greatly debilitated parents. It may be acquired from insufficient or improper food, impure air, insufficient light, uncleanliness and unhealthy surroundings. It is peculiarly a condition of young life, and is found alike in both sexes. It may be seen, generally speaking, in two types of individuals, one of which possesses the so-called "sanguine temperament," the other the "phlegmatic (Treves on Scrofula). The one type is also said to be erethistic, the other torpid (Keen's American Text-book of Surgery). In 1881, Dr. Mahomed and Mr. Galton exhibited, at the museum of the International Medical Congress held in London, a series of "composite" photographs which admirably illustrated the general physiognomy of these two types as found in phthisical patients. In the first," the face is oval, the lower jaw small, the features delicate and regular, the lips thin, the eyes are bright and covered with long eyelashes." In the second type, "the face is broad, the lower jaw large, the smaller bones often prominent, the features coarse and irregular. The nose is generally thick, the lips tumid, the lobes of the ears large and the neck unshapely. Individuals of the first type "are tall, slight and graceful, with well-formed limbs, hands and feet, a fine clear skin, usually a fair complexion, and the hair is often remarkably fine and silken." The disposition is sprightly and excitable. Those of the second type are, as a rule, short and burly, with coarse limbs, large hands and feet. The skin is coarse, harsh and thick. The amount of subcutaneous cellular tissue is considerable. Persons of this class appear flabby and heavy-looking; they are apathetic, have little muscular power and are soon tired." (Treves on Scrofula.)

Sir Richard Barwell (Heath's Dictionary of Surgery, Vol. II., page 297,) also recognizes two types of this diathesis, the one corresponding, he says

To fineness and paucity, the other to coarseness and abundance of connective tissue. The former is marked by refinement and definition of the features. The curves of the lips, the nasal, aural and tarsal cartilages are finely modeled. The conjunctiva and sclerotic are so thin that the pigment of the choroid, partially seen through them imparts a bluish or pearl-grey color to the white of the eye; the skin clear and pure of tint, with cool-toned, ash-grey shadows, is so translucent that the bluish wavy course of subjacent veins is plainly marked, as on the upper eyelid, the temple, the angle of the jaw, etc.; the luscious redness of the lips testifies to the same condition, the eyelashes are abundant and a fine down, often rather long, extends from the margin of the scalp-hair some way down the forehead, the temples and The whole aspect is of refined but fragile beauty.

nape.

The other type is coarse and ugly. The head large and lumpy, bigger before than behind, is flanked by large, red, puffy ears; the jaws are prominent and lips thick, ill-defined, and often cracked, sway clumsily apart. The nose is lumpish, the origin of the alæ ill-defined, the eyelids thick and clumsy, often, when not inflamed, bordered with red, and are frequently lined with dried Meibomian secretion clinging to the roots of the sparse, irregular lashes. The dull, unclean-looking skin is marked by large orifices of sebaceous glands. The figure is unusually ungainly, the joints and extremities large, the belly prominent; the hair coarse, either of a dull, sandy color or lusterless black.

This somewhat rhetorical description applies to the two extreme types. Between these there are various mixtures and combinations. Whatever description, however, may be given to this condition, one thing is certain: the vital resistance of tissues is weakened, especially that of the skin and mucous membranes, and the lymphatic circulation is sluggish. Thus morbific agents find lodgement, and with insufficient antagonism become operative, producing chronic inflammations of the skin and mucous membranes, especially of those mucous membranes most exposed to the air— lupus; eczema; tuberculosis of the glands of the neck, mesentery, joints, bones and lungs, and other similar diseases. Such subjects are particularly prone to naso-pharyngeal, laryngeal and bronchial catarrhs, to enlarged tonsils, adenoid vegetations, hypertrophies over the turbinated bones and to inflammations of the lachrymal passages and conjunctiva.

That this diathesis is an important factor in disease not to be lost sight of by the physician is further proved, not only by the prevalence, but by the fatality, of those diseases which are engrafted upon it. Not that every person who has catarrh of the nose or throat, or inflammatory affections of the eyes, or tuberculosis in some of its manifold forms was originally "diathetic," as here described, but that very many such were.

The affections of the eye which are liable to develop upon this tissue-state or diathesis are eczema of the lids, inflammation of the margin of the lids, some forms of inflammation of the conjunctiva and cornea, inflammation of the lachrymal sac and of the iris and choroid, lupus of the lids and conjunctiva, and tubercular disease of nearly every structure of the eyeball and its appendages. In this discussion but little detailed consideration need be given to lupus and other tuberculous affections, as they are rare. The inflammatory affections are most frequent and will engage our attention at this time.

It is generally accepted today that all inflammations are due to some chemical or toxic substance which is inimical to cell- or tissueintegrity. Such substances may be derived from various sources, both within the body and without, from the vital processes of the body itself, from microbic or vegetable life, from other living bodies or from inanimate nature. Indeed, these products are so numerous, and obstacles to experiment and observation so great, that their extent has not been determined. It is certain, however, that no inflammation can arise without the presence of some specific irritant; and science has gone far enough to demonstrate that, in most cases, such irritant is the product of microorganisms. Senn (Principles of Surgery, page 67,) says: "True inflammation is always caused by the presence of one or more kinds of pathogenic microbes." I do not think this definition is altogether true. Leber (Trans. Oph. Soc. United Kingdom, Vol. XII.), who has most indefatigably studied the causes of inflammation by careful and extended experiment, has proved that certain chemical substances absolutely sterilized cause inflammation. He says:

Among the pus-producing chemical substances quicksilver stands in first rank. A single drop, rendered absolutely sterile by heat, antiseptically introduced into the anterior chamber of the eye of an animal, always gives rise to a circumscribed collection of pus in its immediate neighborhood, which, in the course of time, can even lead to purulent infiltration and softening of the inner layers of the cornea. This puru