servator of uterine dynamics" and who says that it is especially valuable and serviceable during the first stage of labor, because it relieves excess of suffering without causing prostration. It has been my practice for many years to give anesthetics (and by that I mean chloroform) from the beginning of the second stage of labor until the termination of that stage, but I believe it is scarcely ever justifiable to employ an anesthetic during a prolonged and tedious first stage. Of course such cases need relief, and in the use of opium the progress of the labor, instead of being interfered with, is actually encouraged, while the strength of the patient is conserved.

In reference to the position taken by the last essayist concerning the use of forceps, I would say in my experience (and of course that is quite limited) I have very seldom had occasion, indeed, so far as my memory serves me, no occasion to use forceps during the first stage of labor, and with an os uteri undilated or undilatable it is, in fact, almost impossible to consider anything like using forceps. It is as a rule safe, therefore, in cases of that kind, unless contingencies arise which do not suggest themselves to me now, to wait and allow labor to progress to such a degree that it will be safe to apply the instruments.

CHAPTER VI-OPHTHALMOLOGY

Neuroparalitic Keratitis

By THOS. F. KELLER, M. S., M. D., Toledo

The gravity of neuroparalitic keratitis is apparent to all experienced ophthalmic surgeons, and in passing I wish to preclude any apprehension that something new is being photographed upon the canvas of histologic research which is not known to the liturgy of the profession.

While the management was somewhat unique when compared with the teachings of some of our ablest ophthalmologists like Graefe, Hutchinson, Gudden, Magendie, Fuchs, Leber, Hippel, Ebert, Böckman and others, no preeminence is claimed in accomplishing the desired result, as the same etiologic conditions would have appealed to any student of pathology.

If by giving a brief synopsis of this one particular case, which came under my observation within the last year, should interest anyone engaged in the healing art, then the object of this paper will have accomplished its purpose.

Charles R., American, aged 26 years, a farmer by occupation, applied for relief August 10, 1901, macroscopic examination revealed a cloudiness in the center of the cornea of the left eye and the absence of sensibility and lacrimal secretion led me to suspect trophic and latent physiologic disturbances. The patient admitted having contracted syphilis in January of the same year, with the accompanying initial sclerosis in the months of March and April.

Nothing unusual occurred (save an occasional attack of diplopia and vertigo) from this time until August 7, when he was kicked by a colt on the left temple, rendering him unconscious for several minutes, resulting in an ecchymosed

condition of the eye and seat of injury. Having a specific and traumatic history of his maladies, as well as a dull surface of the cornea, which indicated a recent affection, I concluded to resort to heroic prophylactic treatment with a hope of arresting any further destruction of the epithelium of the cornea, especially if the paralysis of the trigeminus was secondary to a lesion at the nucleus or origin in the brain, hastened possibly by the trauma inflicted.

Having good digestion, and never addicted to the use or abuse of liquors, he began taking 15 drops of saturated solution of iodid of kalium in compound syrup of cinchona and milk immediately after eating, increasing the amount six drops daily, until he was taking 120 grains a day. This maximum amount was decreased in the same relative proportion as it was increased, and continued in this way for a period of three months.

I also gave him daily hypodermic injections of bichlorid solution into the gluteal muscles for 90 days, at which time lacrimation and sensibility of the eye fully reestablished themselves. Subconjunctival injections of corrosive sublimate, 1-5000, was resorted to every second or third day, until the blood-vessels began forming around the limbus nearest the ulcer.

The eye was constantly protected from the elements with a perforated shield, and the ball was kept moist and as aseptic as possible with a mild solution of boracic acid. Hot compresses and a solution of atropin completed the therapeutic measures.

The result from this form of treatment was a retention of the contour of the cornea, a translucid opacity in the center of the eye of two and one-half m.m. in diameter, and a complete restoration of all the physiologic and anatomic functions of the eye, save the one specified exception.

Neuroparalitic keratitis is sometimes confounded with two other forms of keratitis, viz., lagophthalmia and keratoalacia.

If you will permit me to digress for a moment, I will try to point out the principal diagnostic symptoms, differentiating one from the other.

In lagophthalmic keratitis, the cornea becomes dessicated, owing to an inability to close the lids, due to protrusion of the ball, contraction of the lids, or paralysis of the orbicularis palpebrarum muscle, and the ulcers are usually on the lower quadrant or limbus of the cornea, as this part is exposed most of the time during the day, as well as at night, for the eye is always turned upwards during sleep.

In keratomalacia, our attention is directed to a whitish substance like deposit on the conjunctiva on each side of the cornea, which cannot be moistened with lacrimal fluid, and has the appearance of being touched with some unctious preparation.

Again, this form of keratitis exists only in impoverished and illy-nourished children, and never was known to occur in adults. Many other symptoms might be given in describing the various features which are not common one with the other, but I hope sufficient stress has been given on the essential points to aid one and all in making a diagnosis of this, one of the gravest forms of keratitis.

DISCUSSION

Dr J. H. McCassy, Dayton: Along about November, 1899, a patient came to me at Dayton. He was a man aged 82 years, suffering with an epithelial cancer of the face, located on the right side between the eye and the ear. He was unable to close his right eyelid, there was a paralysis of the right side of the face, and he had an ulcer of the cornea extending toward the edge. This was a case of neuroparalytic keratitis due to an involvement of the trigeminus nerve. The facial nerve was also affected, which, together with the involvement of the trigeminus, produced a complete facial paralysis. The trigeminus is, as you know, a nerve of special sense of motion and common sensation. The eye also lacked lacrimation and sensitiveness, which are always present in a paralysis of this nerve. I think that in the case recited by

the doctor the kick of the horse was the cause of the paralysis of the nerve, and not the syphilis.

Of course the treatment of my case did not amount to much. A simple antiseptic, boracic acid with hot compresses and some atropin were used. The process of ulceration on the cornea was arrested in about eight weeks, but the patient died in about two months afterward from the general cancerous condition of the face.