Another method by which haziness is produced is by the contact of the ulcers and granules of the upper lid with the cornea, which is equally as destructive to the sight.

Still another phase vastly important both as to the vision as well as the lid itself, is the matter of cicatricial contraction of the lining of the upper lid. As the old ulcers repair, the scar tissue formation under the lid may cause the margin of the lid to turn inward. With this complication of entropion the eyelashes irritate the eyeball to the extent of ulcer formation and otherwise great annoyance to the individual. In other instances the cicatricial deposits in the lining of the lid cause it to turn its inner surface outward, or ectropion. In such a case the eye is frequently the receptacle of foreign bodies, and owing to the eversion of the lid the tears cannot reach the tear duct, their only outlet being their overflow across the face.

Without laying too much stress upon the more fatal cases of trachoma, it is astonishing to what extent the vision may be impaired by a corneal haziness so slight that it is scarcely perceptible to the average examiner. It is not uncommon for such unfortunate individuals to show only one tenth the normal vision.

The treatment of trachoma varies almost in proportion to the wide variation and complications of the disease. In severe and well advanced cases nothing short of operative treatment is indicated. With the aid of the roller forceps the granules may be successfully expressed. In case the granules are pronounced enough, a very good method is to puncture each granule with a small knife. When located in obscure regions of the lid, they may be scraped with the sharp blade of a knife. In other instances I have had good results from brushing the lids with a tooth brush after having cut the bristles short and smooth. With anything other than the forceps, however, it is difficult to reach those granules located far back under the tarsal fold. Following such procedure it is well to apply a weak solution of trichloracetic acid, nitrate of silver or mercurial ointment. Cases complicating corneal involvement should be influenced by a mydriatic, and so far as possible be protected from the light.

The use of simple eyewashes serves as a splendid adjunct to the treatment by keeping the secretions washed away and by adding to the patient's comfort. However, too much dependence in such treatment alone is not safe. lest the patient by believing his condition to be no worse, allows it to drift on into the chronic stage. Hoping eventually to affect a cure by these methods many a person comes to the sad realization later that he has "sinned away his day of grace," and that

To accomplish

now there is no cure for him. the most, then, prompt, frequent, and persistent treatment is urged.

Such then is the general course of a disease prone to wreak such unmerited vengeance upon its innocent victims. It must not be inferred that the progress of the disease is in all cases uniform. It is peculiarly treacherous and hazardous to the patient because of its remissions and exacerbations in many cases. Many patients grow weary of the slow progress of recovery and take it upon themselves to dispense with the treatment too early, only to find that later it has returned in a more violent and destructive form than

ever.

Statistics show that about 75 per cent. of untreated cases result in blindness sooner or later, and it is because of this deplorable fact that war is being waged upon the dreaded disease. If it appears in the child he is debarred by municipal regulations from the public schools at an age when the mind is most receptive. When it occurs in early manhood, the door of professional study is practically closed. When defective vision or blindness result he is prevented from laying up in the storehouse of his mind those mental pictures derived from the study of art, science and literature among which his imagination could run riot to the solace of his declining years. Indeed his lot is most pitiful.

An eminent ophthalmologist has stated he would prefer that his child would have smallpox rather than trachoma. In the one case he either dies or recovers, in the other his life is inevitably made miserable.

Bringing the matter closer to us in whose hands rests the responsibility of the health and well being of Scott county in a professional way, this malady is present among us probably in a more prolific form than the casual observer would scarcely believe. It has come under the writer's personal observation from practically every section of the county. It being a disease contagious in all its stages, the innocent in many homes are continually being subjected to its contagion through the careless use of the towel, the wash basin bed clothing and many other ways by which the secretions may be carried from one eye to another. In the schools an undetected case of trachoma may infect an innocent little deskmate.

Just at this season of the year the epidemic seems to be unusually active among us, and several cases quite recently have come under my observation severely affected. I do not wish to appear as an alarmist, but as one having recognized impending danger. Trachoma is a preventable disease. Its spread could be and should be largely controlled. The public

has a right to the knowledge of the habits of the disease and how to protect themselves.

For the purpose of relieving the situation, Governmental inspection has been invited and obtained in other sections of the state around us, and public sentiment therefore is doing much to prevent its spread and to release the innocent from its dangers. People in other sections of the State of Kentucky are being enlightened along this line and are taking are taking steps to prevent its spread. Also, the laity has joined with the profession in these sections to make the effort more effective. It is easier to prevent trachoma than to cure it. And in no other condition is the old adage more applicable than here, that, an ounce of prevention is worth a pound of cure. Many cases are entirely incurable, and if it is within our domain to prevent it. governmental inspection might not be out of place in our own county.

RENAL TUMOR: REPORT OF CASE.*

By J. T. REDDICK, Paducah.

I was called to see Mrs. Lula D., age 27, on June 6th, 1914, for what seemed to be a nervous, hysterical condition, her mother having been buried that day, having died of tuberculosis, at about fifty-two years of age.

In the course of the examination I detected an abdominal tumor. (my attention not having been called to it) which I diagnosed as an ovarian cyst, it being in right ovarian region.

She called at my office about two weeks ago for further consultation and advice as the tumor had much increased in size and was giving considerable pain.

She is now twenty-eight years old, has two children, aged five and two, is a small, anemic woman; her father died at about the age of forty, of some trouble the result of measles and her mother as before stated, last June, of pulmonary tuberculosis, aged fifty-two. She first noticed this enlargement in abdomen about five years ago, and said it was in right ovarian region. It had every appearance of being an ovarian cyst. I advised an operation at once. She entered hospital February 14th, and I operated February 16th.

Drs. Blythe and Kirkpatrick were in operating room as she went under the anaesthetic and both expressed themselves as believing it to be an ovarian cyst, from inspection.

On opening the abdomen, to my surprise, it had no connection with pelvic organs, but found it to be a tumor connected with the right kidney. The omentum and intestines were firmly adherent to anterior, inferior surface of the tumor, and the kidney, healthy in

*Read before the McCracken County Medical Society.

appearance, but much reduced in size, perhaps from pressure atrophy, firmly adherent to tumor. The tumor was enveloped in a thick fibrous capsule, almost as thick and hard as sole leather, and seemed to have originated from the hilum of the kidney. With considerable difficulty it was enucleated, and there was quite a good deal of hemorrhage from the hilum of the kidney which I could not control until I sutured the capsule, making good pressure over the denuded kidney tissue. The thick, fibrous covering which was stripped off, was removed, drainage put in, and the patient at this time, nine days after the operation, is doing well.

Renal tumors are relatively rare. The new growths of the kidney are best divided into three classes-granulomatous, parasitic neoplastic. The first includes isolated tubercules, gumma, and actinocotic foci. As regards the relative occurrence of tumors of the kidney Kelynack, in an analysis of 306 cases of primary renal growths, found 115 sarcomata, 22 myosarcomata, 145 carcinomata, 15 fibromata, or lipomata and 12 adenomata. In this series the author failed to consider the hypernephroma, which probably formed a considerable proportion of the tumors listed as sarcoma or carcinoma.

The true neoplasms of the kidney are most conveniently classed as innocent and malig nant. The benign tumors of the kidneys are of relatively little importance and there is surprisingly little general or local disturbance following their development in the renal tissue. Named in their relative order of occurrence, the chief innocent tumors of the kidney, are fibroma, lipoma, myomata and angioma.

Fibromata occur most commonly in the cortical portion of the organ, less frequently in the capsule. They are usually round, and appear in small, rarely large masses of connective tissue fibrils arranged usually in whirllike bodies.

Lipomata are growths from the capsule in practically all instances. practically all instances. They may be of considerable size, and though well differentiated from the renal tissue, they may cause considerable pressure or erosion of the renal tissue.

Myomata are of two classes-leiomyoma and rhabdomyoma. The former growth is commonly found in the capsule and is of small size. Rhabdomyomata, or striped muscle tissue are most frequently found in infants, and they are associated in most cases with sarcomatous or teratomatous neoplasms. They are often of large size, and infiltrate the renal tissue diffusely so as to make enucleation impossible without total nephrectomy. They are usually more or less malignant, and

in most of such cases they grow rapidly and set up fairly early metastases.

Hypernephromata are said to be the most frequent primary growths that occur in the kidney. They are said to spring from bits of fetal tissue originally intended to develop into adrenal bodies, but which become detached and incorporated in the anlage for the kidney." Green and Brooks, Diseases of the Genito Urinary Organs and the Kidneys. Third Edition, 1912.

The tumor which I exhibit, from its appearance, does not belong to any of the above mentioned classes, neither is it sarcomatous or carcinomatous. It measures now 15 inches in circumference and I am sure it was six inches in diameter before removal.

It is no doubt a simple cyst of the kidney. I have a special work by Green and Brooks on Diseases of the Genito Urinary Organs and the Kidney, and Bryant & Buck's American System of Surgery, besides several other works on surgery and I cannot find a description of a case to fit this. In an article by Clarence Arthur McWilliams in Reference Handbook of Medical Sciences I find this quotation:

"Simple or serous cysts are not very frequent, Brachel having collected twenty-one cases out of the whole literature from the year 1865 to 1899. They are usually solitary and may grow to large size. They cause no symptoms except those due to pressure. They arise from the cortex and project from its surface, the reminder of the kidney being healthy and functionating actively. Their contents are various, thin, clear, blood or colloid.

Women seem to be more affected than men, in the proportion of about four men to six women. Their exact mode of origin is uncertain. The diagnosis is very difficult, as they may be mistaken for a number of other kidney conditions. Treatment consists in tapping them when they become so large as to cause discomfort. If they refill they may be laid open and the edges of the cyst stitched to those of the wound. This course, however, involves a greater loss of time before healing is completed than if the plan is adopted of totally removing the cyst and its wall, the cavity of which may then be obliterated by sutures."

Exercise and Competition-Physical exercise, it it is to be of real hygienic service, has an object quite different from the preparation of a specially equipped individual trained for a game. Exercise is intended to benefit all the muscles and all the pupils. Its aim is to advance the bodily equipment of the great number of our youth; otherwise our so-called physical education fails to serve the communty at large.

CROUPOUS PNEUMONIA.*

By J. E. WILSON, Butler Pneumonia is an inflammation of the lungs, pneumonitis, lobar pneumonia, or lung fever. It is an acute infectious disease, characterized by an inflammation of one or more lobes of the lung, the affected parts becoming consolidated, owing to the exudation of cells and fibrin into the air vesicles. The exciting cause is usually the diplococcus pneumonaie of Frankel, but other microorganisms may produce it. The disease sets in with a chill which is followed by a rapid rise in temperature, hurried respiration, cough, and expectoration of peculiar rust-colored sputum. The fever remains high until about the ninth day when it falls by crisis. The disease generally involves the lower lobe of the right lung, and is accompanied by a fibrinous pleurisy. In the early stage the lung is intensely congested, soon there is an exudation into the vesicles causing solidification of the lobe. The lung in the beginning of this stage. is dark red and resembles liver tissue; later it becomes gray. In favorable cases the exu

date becomes absorbed and expectorated.

The characteristics of pneumonia are the sudden onset with a chill, pain in the side, cough, delirium, high and regular fever, full and bounding pulse with increased rate; and respiration becoming very rapid, 60 to 80 in a child, with expiratory grunt, and the alae of the nose dilating with each inspiration. The face is flushed and there is often a circumscribed redness on the cheek of the affected side. The tongue is furred, and there may be nausea and vomiting. The bowels are usually constipated, and tympanites is often present. The urine is scanty and high-colored. The picture is completed by the physical signs, the rust-colored sputum, with the diplococcus. Inspection reveals increased motion in the affected side. Palpation discloses increased vocal fremitus over the affected ed dullness over the affected area. Auscultapart. In percussing, ordinarily there is marktion in the early stage shows the breath sounds to be often weak. As engorgement advances into consolidation, the breath-sounds become broncho-vesicular and, finally, bronchial. During the second stage friction sounds are often heard. During the third or stage of resolution, small moist crepitant, and later mixed moist rales of all kinds may be present. The patient often lies on the affected side. The fever may be very slight, or absent in old persons. In children the fever may abate gradually. A rise just before or just after the true crisis may occur. Delayed resolution may cause some fever of an irregu

*Read before the Pendleton County Medical Society.

lar type for weeks. Cough may be absent, especially in children. Expectoration varies much in character and quantity. Pain is slight or absent, if the pleura is not involved, as in the deeper lung-tissues. In children abdominal pain is an early symptom. Tympanites is common and may lead to a mistaken diagnosis. The pulse in severe cases may be dierotic, or small and rapid, and followed by serious heart weakness. Because of the obstruction of the pulmonary circulation the right heart may have an excessive amount of work thrown upon it. And the character of the pulse is no indication of the manner in which the right ventricle is standing the strain. A closer guide is the pulmonary second sound. If this is accentuated the lesser circulation is being maintained. A disappear ance or a weakening of this sound is an indication of right-heart weakness and dilatation. In children convulsions are a frequent and early accompaniment. The clinical varieties we meet depend in part upon the location, and extent of the pulmonary lesion, but mainly upon the difference in the virulence of the affection, and the resisting powers of the individual.

In the aged and debilitated we often have a type of low adynamic so-called typhoid pneumonia. There are symptoms of more or less profound blood-poison indicating the involvement of the nervous mechanism which presides over the most important functions of the body. Physical signs may be slight. There is delirium, or stupor, early and severe prostration, cyanosis, and some jaundice. The tongue is dry and brown, and the pulse and respiration rapid. This form of disease may be a mixed infection. (A pneumococcus plus a streptococcus.)

The successful treatment of pneumonia does not depend upon the number of drugs you leave in the room; but, rather on environments and intelligent application of the nurse. The patient must be warm and comfortable. The air to breathe must be cool and pure. There must be moderate light and no noise. The temperature of the room must be regular. The nourishment must be fairly rich, and easily digested. The patient must have a daily warm sponge bath. The face may often have a cool sponging. Very high temperature in young and sthenic cases may be controlled by cold bath, semi-solid and liquid foods may be given, especially plenty of water. The digestive tract must have attention. Pain may sometimes be controled by strapping. Nerve sedatives may be needed. Antipyretics may be used in sthenic cases in the first stage. Later the circulation is best equalized by warm baths and other external applications. If breathing becomes very difficult stimulants are indicated, especially

about the time of the crisis. Heart tonics used with care may do good. Convalescence

calls for rest, air food and digestants and iron tonics.

CATARRHAL PNEUMONIA.*

By S. M. HOPKINS, Demossville.

An inflammation of the minute bronchi and air vesicles is known by the terms: broncho pneumonia, capillary bronchitis and catarrhal pneumonia. Age is a predisposing factor, as this is the form of pneumonia usually seen in young children. Also often seen in the aged. Also the secondary pneumonias of older children and adults are of this type. The primary type is much more prevalent in winter and spring months. The same may be said of the secondary type. as pneumonia is oftener seen to follow epidemics of measles, pertussis and other infectious diseases of chil

dren in winter than in summer. This form of

pneumonia is often of a tubercular origin. In the primary cases the pneumococcus is nearly always present, and in a large proportion it is found alone or associated with streptococcus. Pneumonia following influenza may be caused by the specific organism of influenza. The secondary cases are due to a mixed infection. The pneumococcus is usually present and is associated with one or more of the following, viz: streptococcus, staphylococcus, Klebs-Loeffler bacillus, typhoid bacillus or the specific bacillus of the disease to which the pneumonia is secondary.

Catarrhal pneumonia is seen in many different forms. There is no typical form. About one third of the cases are of the primary variety. They present usually the symptoms of acute bronchitis of severe grade. The temperature is 102-105, pulse is usually fast and full. The respirations are hurried. If the patient is not old enough to complain of pain it will be evident that pain is present. In some cases the cerebral symptoms are most prominent, convulsions, restlessness and delirium may mark the pulmonary symptoms for a few days, making a diagnosis impossible or at least doubtful. In what is termed the congestive form the symptoms are more severe, the course is irregular, cough may be absent, temperature high, breathing very rapid, nervous symptoms very prominent. This class of cases may prove rapidly fatal or run a pretty severe course.

Other cases will begin very much as a typical lobar pneumonia, from which they are sometimes pretty hard to diagnose.

The secondary pneumonias are more common, the symptoms are marked by the primary disease, and the disease is often entirely

*Read before the Pendleton County Medical Society.

overlooked. An increase in fever, cough, respirations, etc., occurring during the course of most any of the acute infectious diseases, especially measles and whooping cough, should lead us to suspect pneumonia.

In the beginning of an attack the physical signs are usually those of a general bronchitis. We will notice sub-crepitant and sibilant rales, soon larger or smaller areas of consolidation are present. At first rapid breathing, then cyanosis is observed. Palpation shows defective expansion over the consolidated areas. Small areas of dullness is present or the dullness is greater if several small areas have coalesced.

The diagnosis from acute general bronchitis is often difficult and sometimes impossible in first few days. In pneumonia the fever, cough, cyanosis and prostration continue and in a few days we should get the characteristic physical signs of localized consolidations. A primary lobar pneumonia with small area of consolidation in a child under two years of age, might put the diagnosis in doubt, but we usually would not have to wait long, as a lobar pneumonia in a child of this age usually runs a very short, favorable course.

A diagnosis from the tuberculous form of broncho-pneumonia is only made positive by microscopical test of sputum and a tuberculin test. The prognosis is grave except in the very mild cases.

Much may be done in a prophylactic way and any abnormality of nose and throat should receive appropriate treatment. Every child with acute bronchitis, measles, pertussis and other infectious diseases should be protected from exposure to cold. In primary cases there seems to be little danger of contagion, but cases secondary to measles and other of the infectious diseases are contagious. In one of my families of four children with measles, three of them had pneumonia with one case fatal.

The secondary cases, especially, should be isolated. The sick room should be large and well ventilated, kept at a temperature of 68 to 70 degrees F.

It is cumtomary to use oil silk or flax seed meal poultice on chest. A light flax-seed meal with a little mustard seed makes good application. A calomel purge in the beginning is in order. High temperature calls for frequent tepid baths in young children, cold sponging is proper in older children or adults if the tepid baths fail, nervousness may be quieted in the beginning with a small dose of phenacetin, but would not give it except early. A fever mixture of citrate potassium and spirits mindererus may be employed, Dover's powder in small doses is best form of opiate for troublesome cough, but should be used very sparingly in small children. The

diet should be light, milk, eggs, albumen, broths, etc.

Muriate of ammonia is best expectorant. when an expectorant is indicated, but is so likely to disagree with stomach that it is of ten better to use the carbonate or aromatic spirits.

The cardiac stimulants, alcohol, strychnia, etc., should be used when indicated, should the serums be used a bacteriological examination of sputum would be necessary to the proper use of them.

GRIP.*

By H. W. WATT, Pembroke.

When our Honorable Secretary at our last meeting asked me to prepare you a paper for to-day's meeting, I began at once, like the proverbial fish, to flounder in an attempt to select a subject that would be both entertaining and instructive. However recognizing my limitations and knowing myself to be one among the least of you I soon came to the conclusion that it was beyond me to either instruct or entertain you, therefore I have chosen for your consideration the commonplace subject of Grip.

Grip is an epidemic disease, marked by depression, fever, catarrhal inflammations and neuralgic and muscular pains. It is a very old disease possibly having been described by Hippocrates in the year 412 B. C. It has been no respector of place or person, frequently occurring in pandemic form the world over. is from Russian, hence one of its names RusOur earliest authentic history of the disease country and if I may be permitted to add not sian fever. It is a direct import from that a very desirable one.

The first great outbreak of the disease in the United States in the winters of 1889 and 1890 and since that time it has been con

stantly among us, and like the poor, it seems that we are to have it amongst us for always.

The cause of grip was a mooted question for years. Pfeiffer in 1893 discovered in the expectorations a minute bacillus which has been accepted as its true cause. But by way of parenthesis if you will allow me will say that I am still a little pessimistic as to its cause. To explan partially and briefly, only recently I have been through a mild epidemic which had its beginning on the west bank of a water course, traveled west for about two miles and in twenty-four hours I was as busy from one to half a dozen in each family. In as a doctor needs to be, the disease attacking one family the man of the house was the first to develop it, he had not been from home for three weeks, having been kept there on ac

*Read before the Christian County Medical Society.