later stages, contrary to the rule in lobar pneumonia.

Resolution may also be delayed in broncho-pneumonia, and in this case there is a fibrous tissue deposit after the manner of all inflammations, leading to chronic fibroid pneumonia, to be considered very briefly.

CHRONIC FIBROID PNEUMONIA.

Chronic fibroid pneumonia, or sclerosis of the lung, is the formation of new connective tissue in the lung, the thickening of the septa, and closing or obliteration of the air cells. This connective tissue contracts, binds the air cells together, collapses and obliterates them,

and produces a hard sclerosed mass. Unresolved exudate in the bronchi and air cells becomes organized by the proliferation of embryonic connective tissue cells and helps in this process of sclerosis.

These sclerosed lungs are hard and elastic, contracted to surprisingly small sizes, and difficult to cut. The undiseased lung and lobes show excessive compensatory hypertrophy, even forcing the mediastinal contents, heart and great vessels out of their natural location. The chest wall over the affected area is sunken in and the lung itself is of a gray color. The pleural sac may be entirely obliterated, but if not, the pleura is greatly thickened and hardened.

It

The removal of an eye is a subject of grave consideration in the mind of the patient as well as the physician. ranks in the lay mind with the major operations, such as the removal of a limb, not only as a matter of sentiment, but also in the scale of damages allowed by accident insurance companies, and also by the courts in suit for the payment of damages.

The loss of visual range over a segment of approximately 60 degrees, and the resulting deformity, are factors in the production of the unwillingness of the patient to submit to the operation, and must be met by convincing reasons on the part of the medical attendants. As medical advisers, we must consider these important questions in all phases

*Read before the Upper Peninsula Medical Society, at Escanaba, 1906.

and endeavor to avoid error, either through being too radical or ultra conservative.

Enucleation may be performed for the relief of intolerable suffering in a hopelessly blind eye, to check the process of malignant intraocular growth, as glioma of the retina in a child, for cosmetic reasons, for freedom from discomfort caused by diseased eyes that have long been blind, and last and by far the most important, for protection of the other eye.

Herman Knapp reports the case of a patient who upon leaving the hospital after the removal of the second eye, stated he was now happy that he could experience relief from pain which had been unbearable for years from glaucoma, and in which case the pain was slowly but steadily sapping the patient's

strength. The removal of the worthless eye resulted in greatly increased physical comfort and general improvement.

Glioma of the retina, probably the most frequent intraocular malignant condition for which enucleation is performed, is met with most frequently in babes and young children, is often unilateral and the only treatment of service (and even this offers slight promise) is prompt enucleation. This condition I have met with but twice in my practice and I am not anxious for further experience. If seen when the pupil first presents the glistening pearly white reflex, the amaurotic cat's eye, enucleation and later evisceration may save the child, but the prognosis in these cases is always unfavorable-recurrence or metastases usually destroy the patient.

To those to whom the sacrifice of the eye for cosmetic reasons seems hardly justifiable, I wish I could present a picture of a former resident of Menominee,

an intelligent, fine looking young lady, excepting for the horrible disfigurement caused by bupthalmus or ox eye. A well fitted Snellen greatly improved her ap

pearance.

The possession of an eye, blind from disease, is often a great handicap to the artisan who wishes to obtain employment, as large concerns do not wish to incur the additional liability to which an employee with but one eye may subject them. The modern Snellen or the Shell, fitted after a Mule's operation, will often enable the unfortunate who hast lost one eye to conceal his deformity and thus save himself this handicap.

The real consideration of the subject. of the "Indications for Enucleation" resolves itself, however, into the consideration of the prevention and treatment of that most dreaded of all dread diseases to the oculist, sympathetic ophthalmia. The pathology, symptomatology and treatment of sympathetic ophthalmia is in itself sufficient for a symposium,

and I will not attempt more than a brief resume, but let it suffice to say that the disease steals upon its unfortunate victim like a thief in the night, and he is often not warned of the approaching danger by the premonitory symptoms of photophobia, ciliary congestion, lacrimation and asthenopia, despite the statements which are still contained in many text books.

Whether the disease is conveyed to the fellow eye through the optic nerve. trunks, via the chiasm through the intervaginal and subdural spaces, or along the vessels penetrating the eye and passing through the orbit to the cranial cavity, are open questions, but the concensus of opinion, at present, is that the disease is the result of the migration of the infection, probably bacterial, from the exciting to the sympathizing eye and not through irritation of the ciliary nerves. Gifford's three cases in which there were no other symptoms than impaired vision and deposits on the posterior surface of the cornea in the sympathizing eye, would argue strongly against the ciliary nerve theory.

Usually the entire uveal tract is involved, taking the form of a plastic. irido-cyclitis, serious irido-choroiditis or a choroido-retinitis. The prognosis is essentially grave and relapses are frequent, although one's efforts may be first rewarded with apparent partial suc

cess.

Gifford, at the Columbus meeting of the American Medical Association, reported six cases of true sympathetic. ophthalmia, the first symptoms of which were gradual loss of vision in the good eye and the presence of minute deposits. on the posterior surface of the cornea, the latter being apparent only to the skilled observer. Although these cases were seen under most favorable conditions, even these mild symptoms did not occur until too late for enucleation of the exciting eye to check the disease.

This indicates the importance, whenever possible, of daily testing the vision in cases in which there is danger of sympathetic ophthalmia, but in which it seems possible to avoid enucleation of the injured eye, or where it is refused.

Inasmuch as sympathetic ophthalmia, when once established, offers a very unfavorable prognosis, the principal hope is in prophylaxis, and the only prophylactic measure worth consideration is enucleation, or one of its substitutes, in cases in which there is danger of its development.

Concerning the substitutes for enucleation, I have of late years found little necessity for anything different from the operation as advised by de Schwinitz. This consists in the usual operation of excision, after which the ends of the tendons of the opposing extrinsic muscles are sutured together. A well fitted Snellen over such a stump gives as satisfactory a result as would be desired. Indeed Snellen's reform eye fills the orbital cavity so satisfactorily and moves. so easily that simple excision, saving all conjunctival and extra ocular tissue possible, gives a very satisfactory result.

There is, however, one exception to this rule, viz: when enucleation is necessary for a child. Where the eye of a young child is removed the intraorbital pressure and support necessary for the development of that side of the face is gone, resulting in slight asymmetry. To remove this objection it has been my custom recently, to perform the Mule's operation along the lines advised by Dr. F. C. Todd. This consists in complete evisceration of all intrascleral tissue leaving the sclera a hollow bowl shaped a hollow bowl shaped cavity with a white shining inner surface, after which it is thoroughly cleansed with a swab wet in pure phenol and then dried. A glass or gold ball is then inserted and the cavity closed by scleral and conjunctival sutures. Care should be taken in the selection of the

ball, as one too large, will crowd itself out, while one too small acts as a foreign body, by rattling about, as it were, in the scleral cavity and may be expelled. By placing the scleral and conjunctival sutures at right angles to each other, I have yet to have the annoying experience of expulsion of the ball as reported by some operators. Those who have done this operation for years are able to demonstrate that Mule's operation avoids that asymmetry of the face which is an objection to enucleation in childhood.

When there is any especial danger of sympathetic ophthalmia, I do not believe we are justified in considering for one moment any substitute for enucleation. Certainly none of them is safer, and if there is any possibility that they are not as safe prophylactic measures, we certainly cannot afford to take any chances.

The following indications for enucleation as prophylactic to sympathetic. ophthalmia are in general those of Swanzy, and represent the published opinions of most authorities.

(a) "An eye with a wound so situated as to involve the ciliary region, and so extensive as to destroy the sight immediately, or to make its ultimate destruction by inflammation of the iris and ciliary body reasonably certain should by all means be enucleated."

I was very much surprised during some post-graduate study in an eastern hospital, to watch the care with which they had tried for weeks to save an eye hopelessly blind from injury involving the ciliary region, and upon my return put the doctrines of ultraconservatism into practice somewhat to my sorrow. I was visited by a patient who had received a severe cut across the eye, but with such an instrument that there was little danger of infection. Against my better judgment I thought I would try this conservative treatment and sutured the scleral wound after excising all in

carcerated iris. Repair was by first intention and apparently complete, but the injury to the ciliary body so impaired the nutrition of the eye that it subsequently became atropic and a greater disfigurement than a well fitted Snellen, to say nothing of the longer time involved in treatment and the danger of subsequent sympathetic ophthalmia to which this child was subjected.

The case, which has aroused considerable public interest on account of a home newspaper's attitude in the matter, was of this type. The patient, a boy of five years, was cut across the eye from sclera-corneal margin on one side to the other, a very small portion of the ciliary body being involved, but there was extensive incarceration of the iris. The eye repaired from the injury and I did. not see the patient at all until the end of the fourth week. The area involved was such that in view of the fact that the child was hopelessly blind in this eye and the parents ignorant and indifferent concerning treatment, I urged enucleation. They did not accept this suggestion, and the next time I saw the child he had had sympathetic ophthalmia for almost two weeks. during which time there had been one or two days during which he had been practically blind. Enucleation was now insisted upon, and after a few days permission obtained. The remaining eye has subsequently cleared considerably, although there is great danger of relapse, as a plastic irido-cyclitis was already established, and with the iritic adhesions present there is constant irritation of the bound down iris. In this case there has been practically no treatment, but the enucleation, and although I do not approve of this course, removal of the exciting eye alone resulted in relief from pain and photophobia, with with greatly improved

vision.

It is not necessary that the wound be in the ciliary body to excite sympa

thetic ophthalmia. I recently saw a prominent citizen of southern Wisconsin, who is threatened with total blindness, and for whom the most that is promised is ability to get around and care for himself. In this case the sympathetic disease was the result of a perforating corneal ulcer. There had been considerable pain in the sympathizing eye, but the most important symptom was gradual and constant impairment of

vision.

(b) "An eye with a wound in the ciliary region, already complicated by severe inflammation of the iris or ciliary body, even if the sight is not wholly destroyed or the eye containing a foreign body which judicious efforts have failed to extract and in which severe iritis is present, even if the sight is not wholly destroyed, should be removed." I have had several cases under this subdivision, the most interesting of which was a farmer from Amberg, Wis., who, while chopping wood, was struck in the eye by a chip. This was immediately removed, but the patient became blind in this eye and suffered severe pain. A perforating wound could be readily seen through the cornea, iris and lens, and as the eye was totally blind and intensely painful, enucleation was advised. The small sliver seen in the anterior chamber in the specimen I present was found in the middle of the vitreous chamber, but unfortunately displaced from there to where you now see it, through manipulation in mounting. There are very few cases of this character on record, but it demonstrates the force with which so small a foreign body as a splinter of wood can be driven. I have had several cases of iron splinters in the interior of the eye, in which enucleation was ultimately necessary, but this is my only experience with so small a piece of wood.

I have at present under observation a miner who may, and I believe has, a

foreign body in his vitreous chamber, but I have not suggested enucleation. He has a traumatic cataract which is being removed by discission. Enucleation is contraindicated in this case because he has good light projection through his opaque lens. There is no inflammatory reaction in either eye; he has good vision in the remaining eye, and his physician is carefully watching the sight in the uninjured organ. Should vision become impaired it would be a signal for immediate investigation. Then should the injured eye be found tender over the ciliary body and there be punctate deposits on the posterior surface of the cornea of the better one, the safest course would be prompt enucleation of the injured organ, unless sympathetic disease is already established and vision in the sympathizing eye much reduced, in which event there is a difference of opinion as to the better course to follow. There is a case on record in which enucleation of the injured eye was refused after sympathetic ophthalmia had become established, and it ultimately had better vision than the organ involved secondarily. As Gifford states, this is no proof that the sympathizing eye would not have had still better vision had the one causing the trouble been promptly removed. These cases must be decided upon their individual merits, and I hope to be relieved of the responsibility of deciding upon the removal on an eye with some vision which has already excited sympathetic inflammation in its fellow.

(c) "An eye, the vision of which has been destroyed by plastic iridocyclitis, or one which has atrophied or shrunken, providing there are tenderness on pressure in the ciliary region and attacks of recurrent irritation, or even without waiting for signs of irritation, such an eye should be removed." This is true. not only because of the great danger of sympathetic inflammation, but also be

cause of the additional comfort a patient obtains from the removal of a permanently functionless, dead organ, a constant source of discomfort as well as risk to its fellow.

Some years ago I enucleated such an eye, which gave no evidence of sympathetic ophthalmia, but which was hopelessly blind and had been for several years. The patient remarked when he was leaving the hospital that he had no appreciation of the discomfort caused him by the blind eye until he was rid of it. and I have recently enucleated another such an eye for a patient who had been burdened with it for many years, simply because of his sentimental objection to sacrificing a useless part of his anatomy for the safety of a remaining pcrtion.

(d) "An eye whose sight has been destroyed, even though sympathetic inflammation has begun in the other eye, in the hope of removing the source of infection and thus rendering treatment of the second eye more efficacious, should be removed."

(e) "An eye in which the wound has involved the cornea, iris or ciliary body, either with or without injury to the lens, and in which persistent sympathetic irritation in the fellow eye has occurred or in which there have been repeated relapses of sympathetic irritation, should be removed, and an eye whether primarily lost by injury or in a state of atrophy, associated with symptoms of sympathetic irritation of the fellow eye, should be removed."

Lacrimation, photophobia, asthenopia, and pain on pressure over the ciliary body of the injured eye, while symptoms of irritation only, are sometimes precursors of inflammation and as such an eye as just described is useless at best as an organ of vision, it is the safe course to remove it for the safety of its fellow-at any rate that would be the treatment I would want were I the pa