ment of true bone; it may be a calcification. It has not yet been examined microscopically, but the sensation it gives to the finger is that of bone. As regards calcification, that part of the eye which is most frequently the seat of this change is the lens. Frequently as a result of an injury, a cataract develops or is present, perhaps, from birth; there is a shrunken condition of the lens, it is smaller than normal; there is a thickening of the anterior and posterior capsules and between them a calcareous deposit.

DR. HILSCHER read a paper entitled:

A Capsulo-Tenectomy: The Most Accurate and Dependable Operation for Certain Cases of Squint or Insufficiency of External Eye Muscles.*

DISCUSSION.

DR. HENDERSON said that insufficiency of the ocular muscles is the "bete noir" of our specialty. Innumerable operations have been devised, and every one of them has at times been found wanting. Vision can often be improved by the proper correction, by putting on proper glasses. In the great majority of cases of internal strabismus, if the eye is hypermetropic, vision can be improved by putting on a hypermetropic glass. In an eye that is amblyopic, having a vision of 6-100ths-or, as measured by meters, six meters after putting on the proper correction as with a convex lens, the vision may improve and may be brought up 6-50ths, or better. After getting that correction with the glass, he has never had a great amount of success in improving the vision by exercise, as blindfolding the other eye every day and having the child use only the amblyopic eye.

He asked the essayist if the eyes are brought into exact parallelism at the time of the operation, or if he overcorrects with the view of losing some of the correction and then getting a condition of suitable equilibrium eventually. He did not know just how much of this trouble was dependent on the weakness of the muscle itself. In these cases the muscle is able to pull the eye in every direction, and it is not altogether due to a weakness of the muscle that prevents the parallelism of the eye; it is more likely that there is a defect in central innervation, which cannot be materially assisted by shortening or by tenotomy. In these cases he has found that stereoscope exercises for fusion of the images have been very beneficial in such cases, even after tenotomy or after an advancement. gives his patients a stereoscope and has the figures so arranged that there will be an effort made two or three times a day, at a given time, in fusing the images. He thought the operation suggested

*See page 341, this number.

He

a good one, but did not believe that it has much advantage over a dozen others that have been suggested for accomplishing pretty much the same thing; it is rather similar to the effect Reynolds gets with the buried kangaroo stitches. He picks the muscles with the capsule and conjunctiva, draws them together with the fixation forceps, stitches through, punctures the conjunctiva and lets the kangaroo stitch bury itself under the muscle. There are innumerable operations; one that has been lately advocated by Reber in a monograph on this subject seems to meet the indication about as Dr. Hilscher's does. Tweedy has done ten operations to correct an over effect where he had done one primary tenotomy. In the operation he has made a strong point, and an essential one, in advising that in the advancement of the tendon of the muscle to be shortened, the sclera should be irritated in order to produce adhesions. If the sclera is left unirritated the tendon will slipback, and we have to trust to its attaching itself just where it happens to lie. Tweedy makes a

raw surface on the sclera so the tendon will attach itself in the position in which it is stitched, which is a good practical point.

In regard to the amount of residual squint which is left after the operation, or the exact effect to be arrived at in the operation, most authorities believe, as in the case of an internal strabismus, in leaving a certain amount of residual squint, because the subsequent effect is to correct this. If there is an internal strabismus, the operator will correct it possibly four degrees, claiming that in time this effect will increase. He quoted a leading ophthalmologist of this city, who said that this is all a matter of guess, and he always tries to get perfect parallelism at the time of operation and trusts to luck; sometimes he would win out and sometimes not. His own experience has been pretty much the same; sometimes it goes out and sometimes in; it is a hap-hazard business at best.

DR. BALL said he did not take quite so pessimistic a view of our ability to control these conditions. He had tried all sorts of operations, including the one mentioned by the essayist, which is a modification of an old operation. Whether an attempt should be made to obtain, at the time of operation, an absolute parallelism or to produce an over or under effect, he is guided entirely by the age of the patient. In the case of a young person, he always makes it his aim to make an under correction. In the case of an adult, if the eye is turned markedly in or out, he makes a tenotomy of the internal rec

tus and at the same time advances the externus

and obtains an outward deviation of four or five degrees at the time of the operation, and within a week has praticully obtained parallelism. The objection which the essayist urges against

tenotomies he thinks is not well taken at the present day. The objection would be a good one as applying to certain men who claim to be ophthalmologists, and who are ground out in the specialty in six or eight weeks' study and who tenotomize every case of squint; but among men who study their cases and try to select the operation that will suit each particular case, or the treatment that will benefit each particular case, he believes that the objection to tenotomy does not obtain. In making a tenotomy, whether the muscle is left in a weakened condition depends entirely upon whether the operator dissects extensively the accessory fibers which run from the capsular tendon upwards and downwards from the lateral muscle. If the central portion of this tendon is cut only, and the accessory fibers are left, as they always should be, the patient immediately after the operation is able to move his eye just as far inwards and outwards as before. Something was said about the application of the operation to insufficiency. An insufficiency of the ocular muscles is one in which the patient has a lack of balance, but it is not pronounced enough to be operated on as a squint. In the treatment of insufficiency there are a great many things to be taken into consideration. Attention to the general health is of first importance.

Secondly, in a great many cases of insufficiency of ocular muscles, simply correcting the error of refraction will suffice to produce a cure. He did not agree with the essayist that in every case of squint there is an error of refraction; he had met with bad cases of squint where there was absolutely no error of refraction. The treatment of squint unfortunately is not appreciated by the family doctor. Time and again it happens that a father takes the child to the family doctor and says my little girl has cross-eyes; the patient is perhaps four or five years of age-what shall we do? And a great many times the family physician says wait till the child is ten or fifteen years old, and then go to an oculist. This is the worst sort of advice, because a great many of these cases of strabismus in children, if treated properly, can be cured, or wonderfully improved, by the constant use of glasses; and even if some deformity is left under the treatment by the use of glasses, the resulting "condition of the eye when the case is brought to us for operation is much better as regards the visual acuity. During the five or ten years that the patient is waiting in order to get old enough to be taken to an oculist, the eye which deviates is losing its sight, and no matter how carefully the error of refraction, if it be present, is corrected, and no matter how carefully an operation is performed to correct the deformity, the eye which deviates almost invariably suffers in the matter of sight. A case of squint should have glasses put on it, if there

be an error of refraction present, just as soon as the child is old enough to keep a pair of glasses in place-that is, about the third or fourth year. Sometimes children younger than three years of age will wear glasses. The whole subject of the treatment of muscular errors, as regards the eye, is unfortunately at the present day in a mixed-up condition. Almost everyone has his own peculiar view on this subject, and almost everyone expresses his views in print. As regards surgical operations in these cases, the simpler operation is the better one as a rule. He first practiced making a folding operation, making a tenotomy whether or not there was convergent squint; making a tenotomy of the internal rectus and advancing the external by folding it upon itself, and in some cases obtained good results and in others bad ones. The next operation was a more simple one, and it is practically the operation that the essayist has described, only he prefers to attach the tendon to the cornea by sterilized silk. There is no danger in doing this. It has been done a good many times, fastening with the needle to the corneal tissue.

Dr. E. SAXL thought that a very distinct line must be drawn between the divergent and convergent strabismus, if it is purely strabismus. All oculists will agree that the result in operations on convergent strabismus has been considerably better than in divergent. He agrees with what has been said about the necessity for getting these cases in children under proper treatment early. Perhaps it is not advisable to operate on them before the twelfth or thirteenth years, but a great deal can be done for them before any operation is undertaken. The trouble is more frequent among children in thickly settled countries, where the schools are not properly lighted and where the children have a good deal of work to do, especially in the evening. There should be a State law passed providing for an examination of the eyes of children in order to protect their eyes.

DR. C. SHATTINGER is led to believe that the operation which the doctor has described is a good one. He desired to say a word in defense of the family physician. The remark was made, and with justice, that the family physician very coLImonly errs with regard to the advice given in regard to eye diseases. The ophthalmologists are themselves to blame for this state of affairs in a very large degree. The way ophthalmology is taught in medical schools is a disgrace to this nation. No doubt there are medical colleges where the subject is properly taught, especially if the best graded courses are given. But in the ordinary medical school the eye is held up to the student in such a way that he gets a confusing picture of it, and he likely gets the idea that he is incapable, or that it is probably impossible for him to

aspire to the height of touching this delicate organ. The ophthalmologist is responsible for such condition of affairs. A thorough understanding of the eye should be demanded by every family physician, and an appreciation of the fact that the eye, far from being a touch-me-not, is an exceedingly tolerant organ, and that many operations performed by ophthalmologists present much less risk than do the operations which the general surgeon has to perform as regards the medical treatment of the eye, and particularly errors of refraction, etc. It is a mere routine mechanical procedure, such as any physician of ordinary intelligence, and who takes the proper interest in the subject, can acquire if he has an opportunity to do so.

Dr. HILSCHER said a great many eye diseases are very simple and can be treated very readily by the family physician, who should post himself at least on the errors of refraction, strabismus, conjuncivitis, iritis, and the simpler things. He can certainly do a large part of refraction work. He was misunderstood in regard to the question of every case of strabismus involving an error of refraction; he said the most cases. Donders was the first to call attention to the fact that convergent strabismus especially, and divergent, also, was usually due to errors of refraction; he estimates that about seventyfive per cent of these cases are due to errors of refraction. Noyes, in his book, reports the results of some forty cases; binocular vision resulted in 11 cases. The orthoptic exercises that Dr. Henderson mentioned with the stereoscope are very good, but the experience of the writer has been that patients will not be diligent enough to prosecute these exercises and it is extremely hard to get them do it. He agrees with Dr. Ball as to the general treatment of the patient, and also uses largely a method of Dr. Gould, of Philadelphia, which is a sort of gymnastics for the weakened muscles, and with very good results. There are, however, a certain number of those cases which will not yield to treatment for correcting the error of refraction; and in those cases the operation for the correction is in order. Dr. Stevens, of New York, has done a great deal of work in this direction and has been criticised a great deal on account of his corrections not lasting. He thinks the reason for this is very plain. Stevens makes a button hole in the tendon, according to how much is necessary to make the eyes parallel. If he could stop the operation when the eyes are parallel, and keep them that way, he would do wonderful things; but there is the trouble; for if there is a cut in any tissue, that cut will fill up and grow together again, and therefore these partial tenotomies, which are very uncertain, have brought the operation into disrepute to a certain. extent, although a great many of them are permanently successful. In regard to Reynold's ruffle

operation, the weak muscles are pulled up a little bit, then relaxed, and the little fold is doubled upon itself. This is all right as long as the suture is in, but take the suture out and the same thing occurs again in a little while. There will be, of course, a little cicatricial tissue holding it in place along the track of the suture; when the suture is removed the cicatricial tissue gives way, and by-and-by the operation is undone; wherefore his operation, or any operation of the kind, is worthless. The operation which Dr. Henderson and Dr. Ball describe is really a modification of Critchett's advancement operation, in which the tendon is cut off very much as in tenotomy, and it is split and sewed further forward. In regard to the amount of correction, of course that depends, as Dr. Ball says, on the age of the patient and various other things. As a general thing, in operating on a young patient for convergent strabismus, it is best to leave it slightly uncorrected. It is better to get a little undercorrection than overcorrection, especially in convergent strabismus.

MEDICAL SOCIETY OF CITY HOSPITAL ALUMNI.

Sanitary Inspection of Schools and Municipal Medical School Inspection.

DISCUSSION (CONTINUED).

DR. B. M. HYPES: Every member of the medical profession of St. Louis should receive a copy, and all of the members of the school board, and all the editors in St. Louis should also receive a copy, so as to arouse interest in sanitary work and the benefit of medical inspection of the schools. By attracting the attention of the public, and especially the thinking part of the community, to the subject he believed a great advance would be made in making the inspection of benefit to the schools, and in assisting the physicians in carrying out their plans. The expense, of course, was obviously the great difficulty in maturing and carrying out any plan, and the only way to overcome that would be by getting at the people-the voters-those who decide as to the taxes which shall go to the benefit of our schools,. so that the public as well as the medical profession should be in line on this subject; and, as has been found in political campaigns, nothing educates the people up to anything like literature.

DR. A. H. MEISENBACH thought that the general public would not have an opportunity of becoming conversant with the matter unless presented in some such way; the facts as brought before the society had been patent to the profession probably, but never were so cogent as now. The question

was of such general public interest that the committee should be empowered to place these reports at the disposal of the public press and some means adopted for the publication of such portions of the papers as would be of interest to the general public. The speaker said the papers were excellent ones, and showed a great deal of work and thought on the part of their authors. They showed, too, that this society was a working society and that, young as it is, it is bound to make its mark.

DR. CHAS. J. ORR recalled a point to which he wished to call attention, if it was not presented by the essayist (he had not heard all of Dr. Shattinger's paper). While engaged in the inspection work he had been impressed with the enthusiasm some of the children manifested. We are prone to become prejudiced as we grow old, he said, and hesitate to accept and take an interest in the progress of affairs in some things. The fact that the children took an active interest in the work and talked with their parents about it out of school, was potent for good, he thought, because it would be only a few years until these same children would themselves become citizens and have a voice in these matters. He believed the work would be advanced and interest increased if the subject could be brought before the people.

DR. BENNO BRIBACH said he thought this subject was one of great interest to every practitioner. Every one knows what an important factor the schools are in the disssemination of disease. There is no doubt that communicable diseases are increased three and four times with the opening of the schools, as mentioned in Dr. Sharpe's paper. He thought it would be impossible to have these measures adopted unless the people became interested, and he believed the only practical way to do this was to have the matter agitated in the public prints. He believed it to be a matter of vital importance to have the system introduced in St. Louis, and did not believe it could be brought about in any other way.

DR. FRANCIS REDER: The recent introduction in the schools of vertical writing was an advance step in the direction of preventing disease which might come from a faulty position. It is possible that deformity could be largely prevented by the position assumed by the pupils, especially in the practice of vertical writing. The continued and prolonged contact of the chest with the desk would in time show in the growing child. Another matter, and it was of no little importance, was in a certain book used in the schools, called the "Health Primer." During the last four or five months it had come to his notice that some children were affected by the study of this book. Two girls, aged nine and ten years, he had found to

have been suffering from extreme nervousness, and to such an extent as to compel them to leave school. This "Health Primer" was of such a kind as to interest small, susceptible pupils, probably more than was intended. It was possible that the fault may rest to a certain extent with the teacher, who may not confine himself to what is in the book, but dilate upon the complications which might arise from such a subject. The older of these two children complains that the blood rushes to her head; she will go to her mother and say that he has ruptured a blood vessel. In looking up, the matter, it was found that this "Health Primer" gives instruction upon the bones of the head, blood vessels, etc. The other girl, who was but nine years old, one day went to her mother and said she had cancer of the stomach. The mother, of course, said she did not, but the child dwelt upon that ailment to such an extent that she had to go to bed. I think that as soon as any of these signs were manifest in the pupil, the child should be excused from any further recitation on the subject until she was older and could more easily comprehend the teachings of this book.

Dr. G. C. CRANDALL said he thought nothing could be accomplished until laws upon the subject could be made and carried out. The society might discuss the matter and formulate plans, and yet no result would be seen unless laws were made to govern the subject. In the East, he said, an effort was made to introduce the system, yet nothing could be done until public laws were made. That, he said, was the reason why it failed in London.

DR. SHATTINGER, in closing, replied to the question as to whether a child should be excluded from school as long as diphtheria bacilli persisted in the throat, though perhaps no longer virulent; that he recognized the fact that the diphtheria bacillus, like other micro-organisms, may lose its toxicity in whole or in part, and regain it. He said he supposed the doctor would agree with him in holding that such non-virulent bacilli in one throat might regain their toxicity if transferred to another. Taking cultures until the bacilli were found absent was the only practical method of ascertaining when a child might safely be allowed to return to school. Should an exceptional case be encountered where the bacilli persisted for an unreasonable length of time, animal inoculation could always be resorted to as a test of their virulence.

There was one point which he had not touched upon in his paper, and which, he noticed, Dr. Sharpe had also avoided, and that was when the inspecting physician should visit the school. The practice here and elsewhere was to make the visit in the morning. The idea was that by visiting the school as early as possible, cases would be discovered early and thus do less harm than if they had

remained in school all day. But he believed it would perhaps be better to make the call later in the day, because then those ill would be more apt to show symptoms, and the teacher would have had more time to observe the pupils. We know fever will be more manifest in the afternoon than in the morning. He inclined strongly to the opinion that an afternoon visit would detect the largest number of cases of sickness.

In the German city of Göttingen, they have introduced baths for school children. After a very short time the children became very enthusiastic about them, and the parents took greater pains to send them to school cleaner and better clad, being ashamed to have their children found dirty or wearing soiled clothing.

The question of the inspectors looking after the hygiene of the schools had been brought up and very wisely, for he thought it of equal importance to that of the children themselves. The improved school furniture found in our newer buildings, was an outcome of the agitation here and in Europe with reference to preventing near-sightedness and spinal deformities among school children. In this, as in so many other matters affecting the public welfare, the medical profession has just cause to be proud of its influence.

Regarding the legal aspect of medical inspection, the speaker had obtained information from both the health commissioner and the city counsellor to the effect that no special enactment would be necessary if the service were undertaken by authorrity of and with funds controlled by the board of education. An appropriation by the city council, however, could only be obtained as part of an act establishing and regulating such service. The principal difficulty would be to secure the means. Pay ing $50 per month, which the speaker thought was not one dollar too much, and employing the minimum number of fifty-one inspectors would necessitate an annual expense of $25,500 for salaries. Eighty-two inspectors would bring the amount up to $41,000. Adding $100 for supplies, etc., the cost then would be from $25,600 to $41,100 according to the extent and efficiency of the service. To obtain this money the speaker said there were three ways: One, by taking it from existing funds belonging to the school board. In order to do this, Superintendent Soldan says, it would be necessary to stop building or to curtail the salaries of teachers. This, of course, could not be done, because we need more schools, and it would certainly be wrong to reduce the salaries of the teachers. This source, therefore, is cut off. Another way would be to impose an additional tax upon the tax payers of the city. This would have to be done by a general vote of the people. Whether that could be obtained would depend

largely upon a successful agitation of the issue. The board of education has repeatedly tried in this way to get means to erect a library building for the public library, and failed. The speaker thought the daily press was largely to blame for this. If half the space devoted to partisan politics were given to the discussion of questions of vital interest to the people, library buildings, sanitary supervision of schools, and much more, would follow. He did not believe that our citizens were so stingy as to begrudge a small extra tax, if the good to be derived therefrom could only be explained and assured to them. Still a third way existed, viz., to move the city council to make an appropriation. To do this it would be necessary to convince its members of the need and importance of the measMoney is the key to the whole situation. The question as to whether sanitary supervision can be secured for the schools of St. Louis resolves itself into this-can the board of education afford the outlay, or can the city council be prevailed upon to make an appropriation, or can the taxpayers be induced to vote an increase of their rates?

ure.

DR. MEISENBACH said he would like to offer a resolution, in order to bring the matter in proper shape before the society, that the gentlemen be authorized to make an abstract or synopsis of the work done, to be at the disposal of the committeein charge, with the view of bringing it to the attention of the public press, both German and English. He thought it necessary to get the matter before the people, and the necessary means. would be a question for latter decision. He said there were many people among the laity whowould take the matter to heart if it were presented in a proper manner.