PATHOGENESIS OF PTERYGIUM.

BY DR. A. C. ROGERS,

Late Resident Surgeon Manhattan Eye and Ear Hospital, New York City. My attention was recently directed to this subject by the report of a paper in the New York Medical Record of August 6, 1887, from the pen of Dr. Theabold, of Baltimore. He takes issue with Aldt as to the development of pterygium. Dr. Aldt believed that an ulcer at the sclero-corneal margin was the first step of progress. Dr. Theabold is of the opinion that errors of refraction, failure of accommodation and a disturbed balance of convergence cause a local congestion of the conjunctiva most frequently seen over the internal recti muscles, which condition, long continued, results in this dis

ease.

This will not explain to my entire satisfaction the greater frequency with which pterygium is observed in this locality compared with the East.

There the disease occurs, but it is not frequent. Here its manifestations come under the most casual observation. The usual location of the disease helps us in the most material way to understand a leading cause and method of development. It is found most frequently involving that portion of the ocular conjunctiva, not continuously covered by the lids.

The habits and business of the patient demand, in most cases, an exposure of the eyes to the irritation of wind, dust and the glare of light.

The disease may be frequently noticed among ranch-men, drivers and others who are especially exposed to the above mentioned influences. Persons following such vocations seldom suffer from eye strain, because their duties do not call for such accurate vision as the book-keeper, teacher or other professional man. If pterygium was a frequent result of eye strain we should find it more often among that class who require the most of the visual organs, the object of their investigations being within arm's-length. Accommodation and convergence being generally required only at such a distance.

Still further evidence is observed in the fact that few cases of pterygium are ever seen in females. They suffer more frequently than males from eye strain, but are less often exposed to local irritations of the conjunctival surfaces and are seldom seen with well developed pterygium.

As an illustration of my position on the topic, allow me to give the leading features of a few cases coming under my observation since I have been a resident of this city.

Mr. M., 40, a farmer, and had previously been a resident of Kansas for many years, sought my advice in August, 1887. He was found to have a well developed pterygium, reaching from inner canthus to corneal surface of left eye, a half developed one in a similar position on the right. Vision was normal in each eye and patient would accept no glass. The ophthalmoscope gave no indication of a marked error of refraction, while convergence and accommodation were quite up to the standard of a person at forty years of age.

Removal of the growth was advised and undertaken the following week. Local anesthesia was secured by the instillation of one drop of a four per cent solution of cocaine hydroclorate every five minutes for one hour. The method of removal was similar to that practiced at Manhattan Eye and Ear Hospital, New York city. The lids were separated by a Graefe speculum after the patient had been placed in a recumbent position. A strabismus hook was entered at the inferior border of the mass near the edge of the cornea, passing through the connective tissue to the upper border; it was assisted to emerge by the scissors, thus including the breadth of the growth on the hook, like the tendon of a recti muscle during tenotomy for squint. Gentle traction on the hook did not separate the apex from the cornea, as it will sometimes do, the scalpel being required to complete the division.

The patient was then requested to abduct the eye; the apex was firmly grasped by the forceps and the superior and inferior borders of the pterygium were successively separated from healthy conjunctiva by the straight scissors; next, the base of the cone was cut through as near the inner canthus as possible. The triangular gap left in the conjunctiva was filled by undermining the membrane above and below and aproximating the cut edges by two black silk sutures. Previous to and during the operation the eye was irrigated by a solution hyd. bichlor. 1-10000.

The after treatment consisted of keeping the eye covered with a thin layer of absorbent cotton, wet in a cool, saturated solution of boric acid. The sutures were removed in thirty-six hours and union was found complete. The case was seen two

months later; a slight redness and some opacity of the cornea alone remained visible.

The refraction, accommodation and convergence of three subsequent cases have been carefully tested and the results failed to indicate that eye strain contributed in any considerable degree to the formation of this disease in these instances.

The conclusions drawn from the above observations coincide with the opinion of Wells that local irritants, like wind, dust and glare of light, are ample cause for the development of this disease.

My object, Mr. President, in calling the Society's attention to this question is that I may ask the assistance and communication of the members in such cases as may come within their notice, to this end, that we may contribute one or more facts to the general stock of medical knowledge.

41 South Main street, Los Angeles, Cal.

TREATMENT OF TAPE-WORM.-Dr. Berenger-Férand, after enormous experience as chief of a large marine hospital and a trial of all known remedies, recommends the use of tannate of pelletierine given after the following method: On the day before the proposed treatment the patient is to be put on milk diet. On the day of treatment he is to keep his bed, and at 6 A. M. to take an infusion of senna. At 7 A. M. he takes seven grains of tannate of pelletierine in simple syrup, and at 7:30 A. M. he repeats the dose. He then lies with closed eyes, and without moving in bed, in order to avoid vomiting. At 8 A. M. castor oil is given, but the patient remains in bed till all nausea and nervous symptoms disappear. The disposition to stool is to be resisted as long as possible. If the patient does not feel like having a passage in a short time, an enema of senna and sulphate of soda is given. At stool a large vessel of lukewarm water is to be used, so that the worm, when partly expelled, will be suspended in the water and not easily torn.

In the last Egyptian campaign, says Keetley, in the Annals of Surgery, not a single man died from pyæmia, septicæmia, erysipelas, or hospital gangrene, a result unparalleled in the annals of war. So much for Lister!

SELECTED.

SACCHARIN.

UNDER this name Dr. C. Fahlberg describes a product of the coal-tar derivatives which has recently been introduced to medical use:

Saccharin is a white, irregular crystalline powder, with an acid reaction, soluble in 500 parts of distilled water, but dissolving readily in boiling water, from which it crystallizes out on cooling. It is readily soluble in alcohol and ether, and forms soluble salts with the hydrates or carbonates of the alkaline metals which separate from their solutions on the addition of acids. It melts at 220° C., and when fused with potassic hydrates it forms salicylic acid. Its most remarkable property, and which renders it chiefly valuble in medicine, is its intensely sweet taste, which is so great that when 1 part is dissolved and neutralized in 70,000 parts of water it can still be tasted, while cane-sugar can only be detected when at utmost one grain is dissolved in half an ounce of water. It is therefore about 300 times sweeter than sugar. Its taste closely resembles that of cane-sugar, with a peculiar by-taste like bitter almonds.

Saccharin, when given internally or subcutaneously, is excreted completely by the kidneys in unaltered state. It is therefore not decomposed in the body, nor do the saliva or the fæces contain any traces even after large doses. Unlike benzoic and salicylic acid, it is not converted into hippuric or salicyluric acid. It has scarcely any retarding effect on the digestion of either proteids or hydrocarbons, and in fact is said to increase the diastatic action of malt. When given either in large doses, fifteen to seventy-five grains in man, no injurious effects or even disturbance of the appetite are produced. The urine is not altered either in specific gravity, quantity, or the amount of urea and sulphuric acid; it, however, does not readily undergo fermentation. The amount of chlorides in the urine appear to be increased during its use, while the phosphates remain normal. Animals on full diet along with saccharin increase in weight, and frogs may be kept alive indefinitely in a neutralized watery solution of saccharin. Sac

charin, therefore, is not possessed of any toxic deleterious effects on the human organism. Its principal use in therapeutics is as a corrective for the taste of other substances, for employment in cases of diabetes mellitus, and in persons under treatment for the reduction of obesity. Dr. Dreschfeld has found that it relieved some of the troublesome symptoms of acid dyspepsia. One part of saccharin entirely corrects the bitter taste of two parts of quinine, with which it chemically unites. It may be used for sweetening the food or coffee and tea of diabetic patients, either by the direct addition of a grain or two of saccharin, or it may be used in the form of a sirup made as follows:

Dissolve 10 parts of saccharin and 11 parts of carbonate or 12 parts of bicarbonate of sodium in 1000 parts of distilled water, at a temperature of 40° C.

INTUBATION OF THE LARYNX.*-(By Dr. Joseph O'Dwyer, New York.) Intubation is apparently, but not really, a simple operation. With more than usual dexterity and coolness, and an easy case, it will be called by the physician who tries for the first time, a very simple thing. With less dexterity and a difficult case to manage, it will be called a difficult operation. When established, and perfected, and in common use, intubation can never be considered a satisfactory remedy, in view of the complications and the very nature of membranous croup. The first results, if good, will create enthusiasm; if bad, distrust.

In comparing tracheotomy and intubation, the question is not which will save most lives in a given number of cases submitted for treatment, but which operation can be performed or will be permitted in the greater number of cases.

Statistics will be of very little value in settling the question between tracheotomy and intubation until a very large number have been obtained. Aside from the question of saving life, intubation will be resorted to in the most hopeless cases, those in which tracheotomy would not be thought of, for the sake of securing euthanasia.

* From advance sheets of International Medical Congress.