On July 21st, 1861, the city of Washington D.C. was full of movement. It was a Sunday morning, which was the only day off for most people, so this would typically be a relatively lazy day. But with the knowledge that a grand battle was going to occur, many people decided they wanted to observe history in the making. Only a handful of citizens had already set up before McDowell's movement from Centroville, Virginia, but more civilians would trickle in over the next several hours, eventually amounting to upwards of 500 spectators. After the battle, their presence would be a scandal. One of the spectators was a relatively famous British journalist named William Russell, and his account of one woman has been the basis for much of the critical perception of the people. He described the woman as using her opera glasses to observe the battle, and in response to some explosion, she exclaimed, quote, that is splendid. Oh my, oh my, is not that first rate. I guess we will be in Richmond this time tomorrow, end quote. It's likely that Russell's account was an embellished truth. Historians have argued that the citizens were not there to just be entertained. They wanted to observe what they expected to be an historical personal event. And they were there because they felt responsibility for some of the soldiers. Some of the spectators were politicians, and one of them, Senator Henry Wilson from Massachusetts, actually brought a bunch of sandwiches to hand out to Massachusetts volunteers. Some of the spectators had children or spouses in the battle, and one set of parents had a son in William Sherman's brigade, and they actually followed the brigade until they crossed Bull Run. Their son, Sam, wrote a letter to a friend saying, quote, mother was the only woman around for miles, end quote. Part of the scandal, especially in historical memory, is the fact that most of the people brought food with them in picnic baskets. But that imagery suffers from some presentist bias, where we think of picnics as being strictly recreational, but these people were just being practical knowing they could be out of the city for a long time, and they had to bring food with them. Some of the women among the spectators brought food to sell. The reality about the observers is probably a combination of all of these elements. It is certainly true that some people were there because they had people they felt responsible for in the battle, and the idea of being part of history was absolutely appealing as well for many of them. The idea that some people were there out of union pride or even just to watch the festivities is probably also partially true. It's likely Russell embellished his story of the woman with opera glasses, but it's unlikely he fabricated it. And if you remember from the episode on Fort Sumter, Charlestonians also set out picnics to observe the action. People are fascinated by the macabre. That's evident throughout human history, so I think the historians who reject this out of hand are probably dismissing this element too readily as well. But the notion that the spectators were there for entertainment value is the narrative that would create scandal in both the union and the Confederacy. For this and other reasons, those who showed up to watch the first battle of Bull Run would come to regret their decision. I'm Chris Calton, and this is the Mises Institute podcast, Historical Controversies. Before we get into today's episode, I want to let you all know that to celebrate the one year mark for the podcast, I will be in the Mises Institute studio to do a live Q&A on August 6th. We're taking questions ahead of time, so please submit any questions you would like to have answered at Mises.org slash QA. I'll also be taking questions submitted live through the chat, but the questions submitted ahead of time are more likely to get answered, so please send me your questions. Mises.org slash QA, and join us on August 6th at 2 p.m. Eastern Time to watch live, and you'll also be able to watch later on YouTube. The first battle of Bull Run, also called the first battle of Manassas by the Confederacy, was not the largest battle of the Civil War, but it was the first large-scale battle of the war, and certainly can be identified as among the most significant battles in the direction the war would take, especially in the early years. Casualty counts for this battle are far from perfect. We're left with estimates and generalizations, but it is safe to say that the amount of deaths that resulted from this conflict would amount to more than half the total American deaths during the entirety of the Mexican-American War, the most recent military conflict in people's minds. This battle would be a turning point in the minds of many people as the point in which the war lost its romance and adventurer appeal and became something much darker. In the previous two episodes, we looked at the early part of the campaign leading up to the first Bull Run, which included the small skirmishes at Hoax Run in Blackburn's Ford. In the next three episodes, we will look at the actual battle of Bull Run that took place on the 21st with the events divided into three parts. The morning of the battle would center on Matthew's Hill, which will be the subject of today's episode. The early afternoon would be fought on Henry Hill, and the final part of the battle will focus on Chin Ridge and the final retreat. We will also devote some time to the aftermath of the battle, which is important not to overlook, as it tells us a great deal about the mood of the country and the politics that followed, and this is often overlooked by the greater interest in the action of the battle itself. I'm also going to give my one and only warning for the rest of the season. I know this is not a visual medium and any imagery is limited by my ability to describe it, but nonetheless, I want to say up front that one of the reasons that I chose to do the Civil War is specifically because I wanted to underscore the absolute carnage and horror that the people living through it suffered.  Obviously, it's not going to be fully conveyed here either, as that's impossible, but when I describe the carnage of the battlefields, I won't be pulling any punches here, and some of the stuff can be uncomfortable to listen to, just as it was uncomfortable for me to read about. McDowell's goal in the battle was to bring his army down to Manassas Junction and destroy it. The problem was figuring out the best way to get past Beauregard's army, which meant trying to predict the most vulnerable areas to cross Bull Run. To try to give you a very brief description of the geography, the main road going east to west was the Warrington Turnpike, which crossed Bull Run at the Stone Bridge. South and southeast of the bridge were various fords that could potentially be crossed, including the fords discussed in the previous episode, like Blackburn's Ford and Mitchell's Ford. North and northwest of Stone Bridge were two other fords, Poplar Ford, and then farther down the river was Sudley Ford. McDowell thought this would be the best place to focus his primary attack. His strategy was to feign two attacks elsewhere to divert Confederate forces. One feigned attack would be at the southeast around Blackburn's Ford, conducted by Richardson, who already engaged in battle there on the 18th. Richardson's brigade was part of the division commanded by Brigadier General Daniel Tyler. Tyler's other three brigades would handle the other feigned attack along Stone Bridge, which would effectively look like a frontal assault, and it would be led by Tyler himself. One of these three brigades, by the way, was commanded by Colonel William to come to Sherman. The idea was that Tyler's assault would look like the main attack, with the intention of crossing Stone Bridge along the Warrington Turnpike, and then moving south toward Manassas Junction on the primary north-south road, which was the Manassas-Sudley Road. But the real attack would come from two other divisions who were instructed to follow Tyler along the Turnpike before turning northwest. This would be the division led by Brigadier General David Hunter, who had two sizable brigades, and the other division was led by Colonel Samuel Heitzelman, whose division included three smaller brigades. These two divisions together amounted to about 13,000 soldiers and more than 20 cannons, making it the single largest attack force the country had ever seen up to this point in American history. This was the flanking column that was to travel wide around the battlefield and cross Bull Run at Sudley Ford, where Heinzelman would stop following Hunter after the crossing, but Hunter would continue pushing on the confederate left, while Tyler moved forward across Stone Bridge, pushing on the confederate front, and Richardson was distracting confederate forces in the southeast. Tyler reached to the Stone Bridge at some time around six in the morning. The three brigades with him were led respectively by Colonel Erasmus Keys, Brigadier General Robert Schneck, and Colonel William Tecumseh Sherman. Schneck and Sherman set up on either side of the road while Keys' brigade held the rear, and Tyler called out his artillery to the front to open the battle. The artillery commander was Peter Haynes, and his pride and joy in this battery was this giant 30-pound cannon, which his men had nicknamed the Baby Waker. Getting the gun over the Virginia Hills was a feat in and of itself. The thing weighed about 6,000 pounds, and its purpose was more to make a demonstration of strength than anything else. It was too large to have practical battlefield mobility, but it certainly made for an impressive first shot of battle. Haynes had the gun aimed at the house of Abraham Van Pelt, which he believed must be the headquarters of some confederate officer. At about 615, he ordered the firing of the cannon, which one reporter present described, quote, the reverberation was tremendous, shaking through the hills like the volley of a dozen plebeian cannon and the roar of the revolving shell indescribable, end quote. The cannonball crashed into Pelt's house, according to Haynes' account, but it was harmless to confederate soldiers. Two more shots followed, one of which took out the tint of Beauregard's signalman, Captain Edward Porter Alexander, though Alexander was not inside at the time. The hope was that the frightening boom of the giant cannon would scare off the confederates across the bridge, but Tyler was disappointed. The other side of Stonebridge was protected by Beauregard's seventh brigade, led by Colonel Nathan Evans, who actually had been using the Van Pelt house as his headquarters, so Haynes' assumption on that count was not incorrect. Evans's brigade consisted of just over 1,000 men, and the only artillery he had was two smoothbore six-pounders on loan from another regiment. The three regiments under him consisted of one regiment of Virginia Cavalry, the 30th Virginia, and then two regiments of infantry, the 4th South Carolina under the command of Colonel John Sloan, and a battalion of Louisiana volunteers nicknamed the Louisiana Tigers, under the command of Major Chatham Roberto Wheat, who you may remember as having been a character in the filibustering episodes I did on Cuba and Nicaragua. He had also spent some time in Italy serving the revolutionary Giuseppe Garibaldi, but he didn't stay long because he wanted to return to Louisiana after its secession. Needless to say, this guy enjoyed military adventuring. Evans had been prepared for the coming attack across Stonebridge since around five in the morning. He acted quickly by splitting his men into small groups and settling them at different locations around the bridge, having them hide behind trees around the river, and the others to hide behind a small hill where they wouldn't be seen. This would prove to be quite clever, as it would prevent Tyler from ever having knowledge of the size of the force he was facing across the bridge. Tyler had nearly 7,000 men on the other side of the bridge, and he'd have even more once Kies' regiment rejoined him. They were lagging behind to cover the flanking column until they started to move north, so Evans' decision to keep his force hidden was wise. Over the next hour after the firing began, the two forces exchanged gunfire from either side of the river. This amounted a little more than minor skirmishes, and when Tyler realized that the Confederates were neither going to flee nor offer a vigorous response, the Union forces settled in to continue sending cannonballs, but mostly to wait for the battle to progress. Some of the men climbed trees to get a better view of the battle, and some even took naps, which is hard to imagine given all the noise from the cannons, but these men had been on the march since the middle of the night, so they were certainly exhausted. Beauregard's plan was similar to McDowell's in that he also wanted to send a flanking force to his right, which would be the Union left. This was where Richardson was already exchanging similar casual fire with James Longstreet and Millage Bonham, who were still covering Blackburn's Ford and Mitchell's Ford respectively, just as they had been three days prior when they first faced Richardson. Just like Evans at Stone Bridge, they would not take the bait by responding with any kind of energetic attack. For the first hour or so, fighting at Stone Bridge and the South East stretch of Bull Run was relatively uneventful. Beauregard saw no cause for concern for McDowell's faint attacks, but Johnston was a bit more uneasy. He wanted to send more troops to Stone Bridge to reinforce Evans. At 7 in the morning, he gave Beauregard orders to send Thomas Jackson, Bernard B., and Francis Bartow, the first three brigades in the Army of the Shenandoah, to start moving to the Confederate left towards Evans. He also sent the recently arrived unbrigated troops from South Carolina under the command of Wade Hampton III, who was the richest man in the South and owned nearly 3,000 slaves. Beauregard was in charge of the battle plan since he'd been placed at Manassas Junction, but Johnston was the superior officer, and this was definitely a source of tension between the two generals. Bernard B. was particularly upset at those orders since he was convinced that all the action was going to take place on the Confederate right. Accompanying his force were four artillery guns under the command of John Imboden, and on the way Imboden made the mistake of complaining that his men hadn't eaten in more than 24 hours to which Bea angrily responded, quote, you will have plenty of time to cook and eat to the music of a battle in which we shall probably take little or no part, end quote. In a little while though, Bea would come to find himself in the most heated part of the battle. But Beauregard was still set on his plan to attack the Union left, and included in his 7 a.m. orders were instructions for James Longstreet to cross Blackburn's Ford, where his men had to step over the water bloated corpses of Union soldiers from the battle that took place three days earlier and confront Richardson's brigade. At McLean's Ford, southeast of Longstreet, David R. Jones led his brigade across the river as well. Once across, the Confederate soldiers held tight under Union artillery, awaiting the orders to attack. Further southeast from McLean's Ford was Union Mills, which was protected by Richard Ewell's brigade. Beauregard had also dispatched orders for them to cross. Beauregard's plan was to have Ewell cross at the furthest corner of the battlefield and initiate the attack. And upon seeing Ewell's brigade attack, Jones would initiate his attack, which would signal Longstreet to initiate his. But the courier sent to deliver the orders to Ewell, for reasons lost to history, never arrived. Ewell was left on the Confederate side of Bull Run, waiting for orders that were supposed to have been delivered shortly after 7 a.m., and since they never came, he never crossed. And Longstreet and Jones were left facing enemy fire without ever receiving the signal to respond. So just because we don't have the benefit of maps like you do when you're reading a book or watching a video lecture, I just want to clarify what's going on. The Confederate front is facing east across Bull Run, the Union front is facing left. The Union flank is moving north and then west and then south to cross Bull Run to hammer the Confederate left. And the Confederate flank, their right flank, is in the southeast to hit the Union left. So they're kind of sending the attacks in a circle around each other, except for because of the failed orders, the Confederate flank in the southeast never actually initiated their attack. Ewell's undelivered attack orders certainly delayed the combat from the Confederate flanking force, but the Union flanking force on the far other side of the battle was also delayed. McDowell's information about the terrain the flanking force was expected to follow was incomplete, so he impressed a local into his service to head Hunter's division to Sudley Ford. But on the way, this scout said that the originally planned route would subject the Union troops to hidden batteries of artillery, and he offered an alternative, but longer route. Hunter felt he had no choice but to heed the advice of his guide, but his trek towards Sudley Ford was pushed two hours behind schedule. To compensate for the lost time, Hunter and Heinzelman had their men march double time, which meant that they would be even more exhausted by the time they actually saw combat. On the way, the Union troops passed Southern spectators who yelled abuses at them as they marched. One woman they passed came out of a rundown log house and was described by one soldier as having, quote, a very frowsy and dirty personage, end quote. She taunted the soldiers, saying that they were on their way to meet a huge Confederate army, her husband among them. The soldiers laughed at her, but one soldier later admitted, quote, despite her disreputable appearance, it must be conceited, she had fine military judgment, end quote. So two hours after the battle officially started, both the Union and the Confederate plans were falling apart. But back at Stonebridge, Nathan Evans was holding out well by holding fire and not revealing to Tyler how outnumbered he was. One other crucial advantage he had was the Van Pelt House where he had access to a signal station. Edward Porter Alexander, the man whose tent got destroyed by the giant Union cannon, provided a pivotal turning point for the battle. Alexander was a West Point graduate who graduated third in his class in 1857. Two years later, he went to work for an army surgeon named Alfred J. Meyer, who had once studied how deaf mutes communicated with each other. After this, Dr. Meyer spent some time in the West where he observed the signaling system of the Comanches in the New Mexico territory. They would communicate with each other over long distances by using lances, and Meyer thought he could adapt this system for the U.S. Army that would be able to communicate even more complex messages. Together, Dr. Meyer, employing the recently invented telegraph communication system concocted by Samuel Morse, invented a way to use Morse code to deliver messages over long distances by waving cloths attached to poles. He also adapted his system to torches so that the signaling system could be used at night. Shortly after this, he met Porter Alexander, and the two men perfected the signaling system, and they got so good at it that the United States Army ended up adopting the system. When Porter Alexander joined the Confederacy, Beauregard instructed him to take 12 volunteers and teach them the signaling system. At Bull Run, he was Beauregard's chief signaler, and he set up several signaling stations around the battlefield, including the one at the Van Pelt House. The morning of the battle, Alexander ate breakfast with Beauregard and Johnston along with the rest of their staff. Around 8 a.m., after Beauregard issued his orders to the right fling, they all started to move casually toward Nitchell's Ford, which is where Beauregard expected most of the fighting to break out. But on the way, Beauregard ordered Porter Alexander to go to his signaling station at the top of Wilcoxon Hill, which Alexander was not very excited about because, kind of like Bernard B., he thought he was going to miss all the action. But he followed his orders, taking couriers with him, and once he arrived, he sent signals to the other station to let them all know he was in position. Then he began to scope out the region with a spyglass. Shortly before 9 a.m., he spotted something to his north. He couldn't quite make much out, but he could see the glittering of the sun, which he recognized as the sun's reflection from a brass cannon. He kept his gaze in this direction, and soon he could make out the reflections of bayonets and muskets. He moved quickly, sending the signal to Van Pelt Station, alerting Evans, quote, look out for your left, you are turned, end quote. Then he sent a word to Beauregard with one of his couriers to inform him of the Union flanking force. The message read, quote, I see a body of troops crossing Bull Run about two miles above the Stone Bridge. The head of the columns is in the woods on this side. The rear of the column is in the woods on the other side. About a half mile of its length is visible in the open ground in between. I can see both infantry and artillery, end quote. This proved to be an absolutely crucial moment in the battle. At about the same time that Evans received the warning from Alexander, he received word from one of his outposts of the same danger. This confirmed it, and his decision to keep his men hidden throughout the morning would now pay off. Out of his 1100 men protecting Stone Bridge, he moved 900 of them, taking all of Wheat's Louisiana Tigers and much of the 4th South Carolina. He left behind only the 200 man skeleton force of South Carolinians to guard the bridge, meaning that Tyler could have easily overpowered them, but because he had not let Tyler see his force, Tyler would not realize that the bridge was virtually undefended for several more hours, so Evans effectively used 200 men to hold off more than 7000, since Keyes was just behind Tyler at this point. Historian John Hennessey says that this move by Evans was probably the single most important move made by any of Beauregard subordinate officers during the entire battle. Evans moved his men about a quarter mile down the road and set up a position near Pennsylvania, that's P-I-T-T-Silvania just in case my enunciation isn't clear. He also sent word to Colonel Cock, who was protecting Lewis Ford just to the south of Stone Bridge, that he was leaving the bridge virtually unprotected. Evans underestimated the enemy's route though in stopping at Pennsylvania. He expected the Union flank to move towards Stone Bridge, but when they continued moving south along Sudley Road, Evans realized that they would soon outflank him. He started moving his men again, this time toward Edgar Matthews Farm. Wheat sent a group of his Louisianans known as the Cata Hula Gorillas ahead to act as skirmishers, meaning they were to keep an eye out for potential ambushes and batteries. But Colonel Sloan, the leader of the 4th South Carolina Regiment in Evans Brigade, also sent some South Carolinians out ahead of the rest of his troops, and they moved in a different direction than the Cata Hula Gorillas. Shortly afterward, the South Carolina skirmishers saw one of the men not far from them and they opened fire. The men they shot out returned fire. Then the South Carolinians realized that the men they were shooting were the Cata Hula Gorillas, two of whom had been mortally wounded. Even once the Louisianans realized that they were fighting other Confederates, some of them still fired back out of anger at their injured comrades, and the fighting only ceased after Wheat rode through the men and put a stop to it. This would not be the last instance of friendly fire and troop confusion during this battle. Finally, Evans set up a new position on Matthews Hill at around 930, where they waited for Lincoln's horde of northern barbarians as one of the soldiers called to them. He set up his two small cannons on either side of the hill. But his position wasn't great. Fortunately, shortly after he set his men, Barnard B arrived to reinforce him. B set his force a few hundred yards to the left toward the nearby Henry Hill, along with the four pieces of artillery he brought with him under the supervision of John Embedon. B was much happier now, saying to Embedon, quote, here is the battlefield and we are in for it, end quote. Despite his worries about missing the fight, it now looked like B would get to see the first real battle of the day. Wheat led his Cata Hula Gorillas to the crest of Matthews Hill, where they encountered actual Union soldiers this time, being members of the Second Rhode Island, marching near the front of Hunter's Division. The skirmishers charged the Yankees and let loose a single volley which sent the Rhode Islanders to the ground to take cover from the bullets. But once more Union troops started showing up, Wheat and his men quickly scurried back up the hill. As the Yankees advanced and reached to the top of the hill, the Confederates on the hill opened fire as well, and the Second Rhode Island took the brunt of the first volley. One Union soldier described it as, quote, a perfect hail storm of bullets, round, shot and shell, tearing through our ranks and scattering death and confusion everywhere, end quote. But the New Englanders didn't back down and the fighting broke out at the top of the hill. The Second Rhode Island held out alone for a few moments, but they were shortly reinforced by a battery of six pieces of artillery under the direction of Colonel Ambrose Burnside, which set up only 150 yards from the Confederate forces. Close range artillery was a Napoleonic strategy, but when Napoleon was conducting artillery charges, he was only facing short range, smoothbore muskets. Many of the men fighting at Bull Run had rifled muskets, which made artillery more vulnerable at such a short range, and Burnside's men quickly learned the difference. The Confederates let out a volley against the Artillerists, shooting horses out from under the men riding them. The Artillerists had never faced such gunfire before, and they were finding it much more difficult to do their job with bullets flying over their heads. Men from both sides started dropping, but the Union men lost a handful of their officers. The commander of the Second Rhode Island, Colonel Slocum, took a bullet through the skull while he was climbing over a fence, yelling for his men to show the Confederates what Rhode Island can do. One of his men wiped the blood from his face and, with the help of some others, carried him to the Regiments Ambulance that took him to the nearby Matthews' house, where he lingered in a coma for two days before he finally died. Major Sullivan Ballew had his leg ripped off by an artillery shell, killing both him and his horse. The most significant casualty was the Division's commander, David Hunter, who took a bullet to the neck. He would survive the wound, but it was enough to take him out of the battle. Before he rode off the field, he put Ambrose Burnside in charge of the Division in his stead, but Burnside passed the commander, Andrew Porter, commander of the First Regiment in Hunter's Division. The governor of Rhode Island, William Sprague, was also part of the battle, riding a beautiful white horse named Snowdrop. Snowdrop was killed, but Sprague quickly mounted another horse. He was soon shot off that horse during the battle, which was decapitated by a shell fragment, and then he had to get on a third horse for the battle, still being uninjured himself. Horses were all over the battlefield, by the way, because they were commonly used to pull artillery, but they were large targets. And if you want to fully understand the carnage of battle, you can't leave them out. I had a friend who went to film school and he took a screenwriting class where the teacher told him it was a lot less common for animals to be depicted being killed in movies because audiences have stronger emotional reactions to seeing animals killed than they do humans, presumably because animals are seen as being entirely innocent. I think that's probably true for a lot of people, and in this case it certainly adds to the horrors of war. The gruesome scene from Matthews Hill wasn't just the bodies of the soldiers, but it also included the entirely innocent bodies of horses littering the battlefield, twitching from their wounds, some of them having limbs ripped off by artillery. The horses didn't care about unionism or secession, and many soldiers wrote about them after the battle, many of the men holding the view that of all the deaths that took place, the horses were the most innocent victims. Out of the 130 horses pulling the Rhode Island battery on Matthews Hill, only 65 made it out. But the Confederates did not have the advantage of numbers here, and more Union regiments started climbing up Matthews Hill from other sides. They were swarming on the Confederates. At about 10 a.m., though, Evans and Wheat thought they saw a vulnerability in the Union line. Wheat ordered his 400 Louisiana Tigers to charge. One of the men wrote of the charge, our blood was on fire, life was valueless, the boys fired one volley, then rushed upon the foe. They were charging at a line of Union Marines manning a few cannons under the command of Major Reynolds, taking out their cannons, horses, and artillery crew. The Tigers didn't have bayonets, or at least many of them didn't, and that isn't entirely clear to me, but they either used their muskets as clubs or drew bowie knives as they passed the Marines and moved toward the second Rhode Islanders. But this time, the Rhode Islanders were dealing with guns dirtied with gunpowder residue, making it increasingly difficult for them to reload, and some of them were out of ammunition altogether, forcing them to check the corpses lying around them for extra rounds. But they held their ground against Wheat's charging Tigers, and those who could fire unleashed a devastating volley against the Louisianans. They fell back to their original position, much to the delight of the canoneers they crippled on the way. At this point, Evans rode to Henry Hill to ask Barnard B to reinforce him. B, who'd been observing the combat on the adjacent hill, told Evans to retreat to Henry Hill instead. Evans declined. He wanted to halt Matthews Hill and said he could do it if B backed him up. B gave in, eager to join the fight. The largest regimen in B's brigade was the 4th Alabama led by Colonel Egbert Jones. They led the charge, but when they came under Union fire, they ran back and found cover, moved around Matthews Hill, and started up the other side, where Matthews Hill combined with another smaller hill, called Buck Hill. As the Alabamians reached the top of Buck Hill, about 300 yards from the center of the battle, they faced more Union bullets, so they took cover in the woods to their right, stepping over the Louisiana Tigers who'd been dropping during Wheat's charge, and then they started up toward the Union center, stopping 100 yards away. There, Jones told his men to lie down and open fire. This wasn't a good position for the Alabamians, and they could see more Union forces taking position on the hill. B sent word to the other regiments in his brigade, the 7th and 8th Georgia, and the 2nd and 11th Mississippi, to back them up. Technically, just for those who might be confused if they know of the history before I tell it, the Georgians were part of Francis Bartow's brigade, but at Henry Hill, the higher ranked Barnard B had essentially taken command of both brigades, superseding Bartow's authority for the moment. With the Confederate reinforcements coming up Buck Hill to join the Alabamians, Reynolds turned his six cannons on them and opened fire. This was good motivation for the Georgians and Mississippians to pick up their pace as they climbed Buck Hill, but more Union troops, the 71st New York, joined Reynolds, bringing two Howitzers with them to add to the artillery aimed at B's Confederates. They couldn't even get horses to pull the Howitzers, so the New Yorkers had to drag the cannons up the hill themselves. One of the New Yorkers described the scene, quote, the cannonballs were plowing up the earth all around. Shells were bursting and crashing through the trees, directly in our rear, and the mini balls were battering and humming in all directions, end quote. The Alabamians took the worst of it. They were cut to pieces. Their leader, Colonel Jones, was sitting on top of his horse yelling out orders when he was shot off his mount, injured, but not killed. To the right of the Fourth Alabama, the two Georgia regiments were not faring much better. They dropped like flies under a hell of Yankee bullets, but they held their position and returned fire. The Confederates were outnumbered on Matthews Hill at this point, even with B's men joining the fight, but they held the Union soldiers at bay. The battle had turned to chaos. One Rhode Islander said, quote, shells were exploding and the cannon roaring made such a noise that the cry of the wounded could not be heard, end quote. Another soldier said that he felt something between his legs, only to look down and find one of his comrades lying on his belly, firing his gun from between his legs of the other soldier. Another man had his leg ripped off by a cannonball, spraying blood on everyone nearby. Soldiers watched as their friends fell around them. One man from New Hampshire left this account, quote, a cannonball passed between myself and the man next to me, and struck a man just behind us and killed him instantly. Another man near me was facing the enemy, and someone said something which made him laugh.  Another Union soldier sent a letter to his sister, Libby, about the horrors he encountered, quote, since I left home, the awfulest sight I ever saw was at the battleground. It is a sight that never can be forgotten. To see the men slaughtered, some of them dead, some of them with their legs off, one in particular with a cannonball, through his body, there was a hole through him big enough to stick your head in. Oh Libby, it is awful, but I fear it not all through, end quote. The captain of one of the Mississippi regiments tried to give a battlefield speech. Shouting over the cannon fire, he yelled to his men that they were facing, quote, a most bitter and damaging enemy, and one that does not only propose to rob you of your property, but to deprive you of your constitutional rights and privileges for which your ancestors fought, bled, and died. He wasn't done with his speech, though, when a shell exploded right above his head, causing him to dive for cover. When he stood back up, he wiped the dirt from his mouth and said, quote, I will finish my remarks when this thing is over, end quote. A South Carolina volunteer described a similar scene for his wife, quote, the cannons, although they make a great noise, were nothing more than pop guns compared to the tremendous thundering noise of the thousands of muskets. The sight of the dead, the cries of the wounded, the thundering noise of the battle can never be put on paper. It must be seen and heard to be comprehended, the dead, the dying, and the wounded, friend and foe all mixed up together, friend and foe embraced in death, some crying for water, some praying their last prayers, some trying to whisper to a friend their last farewell message to their loved ones at home. It is heart-rending. I cannot go any further. My eyes are damp with tears, end quote. The Eighth Georgians pushed forward, coming to face the Second Rhode Island, who was still holding out on top of the hill. Each regiment saw dozens of men go down, and these two regiments would suffer some of the highest casualty rates of the battle. The leader of the Eighth Georgians, Colonel Gardner, was one of the casualties. He took a bullet to the ankle, barely managing to limp away. Only a few minutes after he was hit, his adjudant, John Branch, took a bullet to the chest, mortally wounding him. Branch was serving in the regiment along with his two younger brothers, Sanford and Hamilton. Even after the rest of the Georgians retreated, Sanford stayed on the field with his dying brothers, allowing himself to be captured by the Yankees. Later, when writing to his mother from a union prison, he wrote quote, I thought I would look behind me to see if any of my company had fallen, but mother, just think of my horror to see John, dear John, real and fall. I dropped my gun and ran to him. I got there just after Dr. West, and who, dear John, asked whether there was any chance or not? When told he must die, he replied, very well. He would die like a soldier and a man. I cannot write any more now, as I was taken prisoner standing by his body, end quote. These weren't the only siblings to suffer in such a way. One young Alabamian, George Anderson, took a bullet to the skull, killing him instantly. His younger brother, only 14 years old, was next to him. And when his brother fell, he ran to him and threw himself over his brother's body sobbing. The captain of a small company, the Koneku guards, tried to encourage him, telling him to stand up and avenge the death of his brother, but the young boy couldn't do anything but continue to cry and hold on to his brother's corpse. As the Georgians and Alabamians were being cut down, some of them started a retreat. As one Georgian was taking off, an officer rode up on a horse and angrily asked how Georgians could be running while South Carolinians were staying to fight. The soldier threatened to shoot the officer off his horse, whoever he was. The officer, as it happened, was the South Carolinian officer, Barnard B. As other Georgians started yelling similar curses at B, he said, quote, I must admit that you are ready enough to fight. I withdraw the words I should not have used, end quote. As the Georgians scattered, their leader, Francis Bartow, picked up the regimental flag dropped by one of his men who'd been killed. He waved it above his head and yelled, on my boys. Right then, he took a bullet to the chest, and according to the men who witnessed his death, his dying words were, quote, they have killed me by brave boys, but never give up the ship. We'll whip them yet, end quote. While all this fighting was going on at Matthews Hill, General McDowell sent orders to Tyler to finally push across Stonebridge to reinforce the Union flanking column. Tyler was hesitant, still unsure of how many Confederates were on the other side of the bridge, but his subordinate officer, General Sherman, was aching to join the fight, and he'd spent the morning scouting out for a place to cross Bull Run, which he discovered around 9 a.m. So when McDowell sent his orders, Sherman didn't hesitate to lead his five regiments, nearly 3,500 men, toward Matthews Hill. One of his subordinates, the leader of the 69th New York, was Lieutenant Colonel James Hagry. He'd been reported as killed during the Battle of Blackburns Ford three days earlier, and as he was leading the way, he commented that he, quote, felt very warlike for a dead man, end quote.  But Sherman's brigade made it to the battlefield, and there was no way that the Confederates were going to keep their position. The Louisiana Tigers had already been decimated, and now their leader, wheat, took a bullet as well. Evans and B finally ordered the retreat. As they left, Colonel Jones, the wounded leader of the 4th Alabamians, yelled out, men don't run. Some of the histories I've read made it sound like he was worried his men were leaving him, but others say that he simply failed to hear the retreating order, and that does seem more plausible. When the Union came and took Jones prisoner, he said, quote, Gentlemen, you have got me, but a hundred thousand more await you, end quote. He would not survive his wound. At this point, the Union soldiers had upwards of 18,000 men watching 3,000 Confederates retreat. They started to wave their hats in celebration, shouting, they are running, victory, the day is ours, and thanks of this nature. It was shortly before noon, one of the Union soldiers, Charles McCook, joined the crowd of spectators where his dad, Daniel McCook, was watching the battle, and they had lunch together. A Union officer also wrote up to the crowd of onlookers and said, quote, We've whipped them at all points. We've taken their batteries, they are retreating as fast as they can, and we are after them, end quote. With the Union victory on Matthews Hill, the battle looked to be coming to a close, and McDowell would be able to claim credit for a quick and easy win over the rebels. But instead of retreating completely, the Confederates were regrouping on Henry Hill, and as more of Johnston's army of the Shenandoah continued to arrive at Manassas Junction, fresh Confederate soldiers would give Beauregard a much-needed edge in the afternoon. The battle is far from over, and we will pick up the story here in the next episode. Historical Controversies is a production of the Ludwig von Mises Institute. If you would like to support the show, please subscribe on iTunes, Google Play, or Stitcher, and leave a positive review. You can also support the show financially by donating at Mises.org slash SupportHC. If you would like to explore the rest of our content, please visit Mises.org. That's M-I-S-E-S dot O-R-G.


It's quite good to see Interpol, first of all, in India in terms of interacting with the police and the customs officials because Interpol being an international agency which is usually not in any controversies, which is a good thing, can be a very instrumental force in binding and getting coordination together between the customs and the police officials, which is not yet there. They all are working very well in their own spaces but that coordination needs to be built up. And these kinds of occasions can bring them together in the same room to exchange their problems and their learning at the same time. So I would sort of encourage and look forward to Interpol working more and in different regions of India. In India, the problem is quite widespread and it's across almost every sector. In our preliminary research, we saw there were around 27 sectors that we could actually identify very quickly and easily. The top being automotive components, pharmaceuticals, fast-moving consumer goods, mobile, hardware, and then we're talking about tobacco, liquor, which is quite rampant. But having said that, even lubricants, pesticides are all, it's everywhere, let's put it that way. Astrophigures, they've been floating around, we're talking about 36% in the automotive components. We're talking about around 5% in the pharma sector, which has been actually accepted by the government officially when they were doing WHO negotiations on that controversial issue. But it's all floating. It's not backed by a model which has been statistically proven or anything like that. There's a lot. And we in Cascade have identified that problem and in December we're going to be coming out with some kind of reliable data to expose the extent in these sectors that I just talked about. It's really, really important to make the people aware. It's not about awareness generally within the police or the customs only. It's about the general consumer to be aware that whatever they are picking has a chance of being a counterfeit. And the fact that it is going to be consumed by them in some way, maybe as a food product, maybe as a skin cream and the kind of impact it can have short term or long term on their health is really crucial. And in that sense, we at Cascade have worked with the Ministry of Consumer Affairs to come out with a full-grown campaign and our ongoing activities are really on an outreach focus.


Creating a bibliography for men not online. Select Format and Bibliography. Choose the references you want to create and the style which you want to deliver them in. Select the file format. I suggest RTF. Click Save and save the file somewhere memorable. Open the file and you've successfully created a bibliography in a particular style. That is the end of this demonstration.


This is Doctimer 11127. We're here at Summit Automotive in Fond du Lac, Wisconsin. You're new and used RAM and light-duty truck headquarters. Today we are checking out this super clean 2016 RAM 1500 Crew Cab Short Box Rebel Mopar 16 Edition. This vehicle has the 5.7 liter V8 Hemi motor. It has been fully-safety and inspected by our service shop. It has a fresh oil and filter change. All the fluids have been checked and topped off and this truck is 100% ready to go. Brilliant black crystal pearl is the color we shoot all of our videos in 1080p 60 frames per second so if you have HD capabilities on your computer, tablet, or smartphone device turn them on right now because it is definitely your best way to check out the quality and condition of the truck before seeing it in person. And if you'd like to check out all the photos on this truck in the upper right-hand part of your screen is a link to our website click that and check us out there. It comes with Ultra Motor Sports painted alloy rims and it has Open Country Toyo LT28570R17 tires and these tires look like they have right around 50 to 60% of the tread left on them. Front fender is in excellent condition. This is a numbered vehicle. This is number 124 of 500 trucks made with the Mopar 16 edition. Front bumper is kind of a flat metal finish, projector lamp headlamps, LED running lights. You get the hood decals on there and the sport hood, the ram stamped front grille and of course the tow hooks on the front. Headlight lenses are nice and clear. Passengers side front fender is in excellent condition. I didn't see any dents or dings on that and the passenger side rim no scuffs or scrapes. As you go down this side of the truck take note of how clean the body is, how reflective and mirror like that paint is. We take these HD videos so if you are far away or even if you're close by and you just cannot make the trip down but you're still interested in purchasing the truck you can see the truck, hear the truck and have confidence in what you're looking at before you even get here. So that when you do get here there's absolutely no surprises and that is why we offer the Summit Auto Fast Pass option in the upper right-hand part of your screen. A link right to our website where you can apply for financing, get pre-approved, see a payment quote, even appraise a trade all from the comfort of your own home so when you get here all you got to do is drive the truck, love it and you'll be all set to go. Back room is a nice shape and the back tires have about 50% of the tread left. Not as much as the fronts but still pretty decent. Has the plastic wheel well liners which keeps your frame and underbody looking as clean as this one does. Very very nice very little corrosion as all the remaining factory exhausts lower rockers all look really good you got those nice Mopar Ram step bars on the back there comes with a truck's port soft tonneau cover from Truxedo rear bumpers in pretty nice shape you get the dual tipped chrome exhaust only thing I saw is one little ding on that bumper there get the full towing package with the receiver hitch four pin and seven pin wiring the tailgates in pretty nice shape does have one little ding right there but other than that not too bad has the shock down assist tailgate and you do get a very nice spray in bed liner the bed itself is in really nice condition as well that shuts nice and solidly as you go down the driver's side just as clean as that passenger side no denser dings on the box and for full disclosure this back rim is in excellent condition as well down the rest of the side the truck looks really good I didn't see any dents I didn't see any dings very nice condition it does have the heated power mirrors inside the rebel package gives you the black and red it's kind of a almost like a rubber type finish to it and then you get the cloth on the inside with the tire tread pattern no rips or tears on the seats really nice condition both these front seats are heated we have the mopar rebel all-weather floor mats in here auto headlamps power windows power locks power mirrors you get all that red trim around the doors and the dash and on the seats and then on that floor mat there as we hop inside the vehicle turn the ignition on so you can check out the miles and everything can see that this one has 59,942 miles you get a digital speedometer outside temp and compass display has the leather wrapped heated steering wheel cruise controls on the right gear selector on the right bluetooth and information center controls on the left it does have audio controls on the back of the steering wheel you get the five inch you connect touchscreen radio AM FM and Sirius XM radio capabilities you get the eight-speed automatic transmission push button four-wheel drive and you do get the four-corner air suspension on this vehicle you can actually raise the vehicle up and I don't know if you can see it but we're raising up right now see it goes about two inches and once it stops flashing then you're at your max off-road height we'll leave it up for that so you can check that out when we get out of the vehicle does have a 115 volt 150 watt plug-in here's your mopar 16 badge and you can see that it is number 124 of 500 so absolutely a numbered vehicle passenger side format and seat are in excellent condition no rips or tears on there you get the rebel rebel stitched into the side there and the ram on the headrest the headliner is in really nice shape I didn't see any rips or tears on that you got map lights power siding rear window and then your mirror is where your Bluetooth sets up we'll take a quick look at the back seats and then we'll start it up and check out under the hood back seats are just as clean as the front seats no rips or tears back here it does have the latch child safety system for any child car seat needs power sliding rear window you get that tread pattern on the back seats as well you do get a load floor which is really nice if you put those down you put both sides down you got a nice flat place if you got pets they have a nice flat place lay if you got muddy boots or tools put them on there you're not going to get your nice cool rebel seats dirty underneath there there is more storage you have the all weather floor map back here and then you do have in-floor storage with removable containers for easy cleaning you can put ice and drinks in there dump them out it's like you got too many coolers wherever you go you can see those seat backs are all red as well get the red trim on the doors notice the red stitching and the white stitching the theme throughout the vehicle and then you get the child safety locks on the back doors we'll start up and take a quick look under the hood and see there are no check engine lights or anything started right up and I would personally like to thank you for checking out the video today and hopefully from this HD video you will have been able to tell just how clean this truck is all the way around inside and out under the hood we have the 5.7 liter V8 Hemi motor engine today is very clean runs very smooth this truck has been fully safe and inspected by over service shop has a fresh oil and filter change all the fluids have been checked and topped off and this truck is 100% ready to go see more pictures of this truck or one of our other 450 new and used cars trucks SUVs minivans Wranglers half tons three-quarter tons one tons you name it we got it go to our website www.summitauto.com full pictures and descriptions of every single vehicle from two locations all at www.summitauto.com and if you'd like to check out more HD videos you can go to www.youtube.com slash www.summitauto.com remember to like subscribe and share on this video and all the videos that you see there in fact in a second you will see a link to subscribe to our YouTube channel on your left you link to more Ram 1500 truck videos like this one on your right you've not been to our website on the bottom link to this vehicle on our website click those check us out and we're super excited to be offering this really clean 2016 Ram 1500 crew cab short box rebel Mopar 16 edition number 124 of 500 thanks again for checking out the video


Morning everybody. We're going to go ahead and get started. Thank you Jeff So this morning We have a presentation on the ocular surface by Dr. Michael Duffin from the Moran Eye Center and That should be the only presentation Welcome Good morning. Good to be with you this morning What I'd like to talk about is the ocular surface, but near the topic to talking mostly about dry eye disease practical approach and treatment to that My wife and I were missionaries in Panama between 2004 and 2007 We noticed down there our eyes didn't give us any trouble at all But we came back to Salt Lake City a few years ago all of a sudden at least my eyes began to burn and sting a lot And I started thinking you know, I haven't paid a lot of attention with my dry eye patients to Humidification and control of the environment and I started paying more attention to that and found that it actually did work a little bit This is us a few years ago in the Sun Bloss Islands 95% humidity and more like a hundred percent humidity and 95 degrees all year round Dry eye disease as all of you know is a very prevalent condition and about five million adults in this country have a preponderance of women The cost of dry eye disease is significant was estimated in a recent study Published a few months ago in the cornea journal that the cost to the patient direct cost with co-pay and Coinsurance was about eight hundred dollars a year. Then if you look at the total cost What insurance companies pay the government pays and even lost to employers approaching 11 or $12,000 a year So the financial burden is significant No matter what specialty or subspecialty we happen to be in in ophthalmology We're finding that it's more important now that we used to realize before to pay attention to the ocular surface particularly with refractive surgeons premium Iowals But ocular plastic surgeons of course have to pay a lot of attention to the ocular surface with blink abnormalities retina surgeons with neurotrophic carotopathy with diabetics and Certainly glaucoma specialists with the amount of topical medications and preservatives that are placed on the eye We all know that it's a multifactorial problem with pharmacology neurology Allergy immunology Blepharitis infections trauma all kinds of different factors can have an effect on the ocular surface and dry eye I've come to realize especially after coming to Salt Lake Where it's much drier than even in the desert where I practice in Southern, California That I was really quite weak in my approach to dry disease and my patients in California One of the weaknesses I had was taking an incomplete history not really talking to the patient about their lifestyle Failure really to look at the whole patient Maybe not noticing their face that they had rosacea or looking at their hands to see that they had rheumatoid arthritis Sometimes we have the weakness of just approaching everybody that says my eyes burn and sting and giving them artificial tears instead of looking at some other modalities that may be more helpful and Failure to address the basic cause of dry eye and not educating our patients correctly in 1946 Eugene Wolfe put forth the the theory of the three separate layers of the tear film the lipid the aqueous and the mucous layer and later in 1965 alers noted that these three separate layers actually worked in unison When a pressure was placed on the lower eyelid it seemed the tear film seemed to move on block a few years ago and in Australia Ivan share coined the term dachroon Which emphasized the integrated body of the tear film and here's a an illustration from his paper which shows Interpalpebral tear film and the retropalpebral tear film which Probably does not contain much of any lipid concentration Here on the on the right in this diagram. We see the corneal epithelium In immediately adjacent to the corneal epithelium. We have a glycol calyx, which is a slippery layer of glycol proteins that Decrease the friction when we blink That's secreted by the corneal epithelial cells then immediately to the left of that We have the mucin layer the aqueous layer and then the lipid layer here to the left What we've learned in recent years is that the aqueous and the mucin layer are not completely separate It's actually called the muco aqueous layer now because the mucin Molecules are interspersed in the aqueous layer with a concentration that decreases as we go toward the external tear film Steven Flugfelder and others have popularized the notion of the lacrimal functional unit recognizing that the tear glands don't act in an isolated manner, but are Linked together with the neural network and the ocular surface to work together as is a unit And this will have an effect as we'll see both in the pathology as well as the normal physiology of the tear film There's been a lot of different terms that have that have been used in the literature to describe dry eye disease One of the terms that was popularized I believe by the Delphi panel a few years ago was dysfunctional tear syndrome Which doesn't use the term dry eye that terminology is not really caught on because dry Eye the term dry eye is so ingrained in the literature But the rationale for using dysfunctional tears syndrome is to recognize that not all tear film abnormalities are dry eye But as we read the recent literature the most common term is either dry eye disease or dry eye syndrome currently in the literature There have been several attempts to define and classify dry eye One of the main ones a few years ago, which was published in corny in 2006 was the Delphi panel now a Delphi panel is simply a consensus of experts. There are 17 External disease experts who are brought together to try to classify and define what dry eye is And they concluded that the terms that we've used in the past and still use aqueous Deficiency dry eye and evaporative dry eye really inadequate because they seem to imply there's two separate categories When really they're not most of our patients have a combination of evaporative and aqueous deficient dry eye most cases of significant dry eye will have an inflammatory basis Diagnostic tests such as the Schermer test have limitations and they proposed a stage classification which will help to direct treatment a year or two after that the in the ocular surface journal the The dry eye workshop study the do's study was published and in this study a definition was put forward stating that dry eyes a multifactorial disease Consisting of symptoms visual disturbance instability of the tear film and Then they use two terms one is increased osmolarity hyper osmolarity and inflammation which Help us to understand the pathophysiology of dry eye syndrome There are many anatomic and physiologic Factors that impact dry eye whether it be decreased blinking ectropion decrease in aqueous tear production my bomean gland health corneal epithelial health Neurotrophic keratopathy and immune system In addition to these factors, there are many other factors such as age gender hormonal changes Pharmacology vitamin a deficiency, etc. That Many of these will take their effect through a common pathway to destabilize the tear film causing hyper osmolarity damage to the ocular surface and discomfort We're all aware of many lifestyle Factors that affect dry eye. There's actually a syndrome called computer eye syndrome And it's amazing how many patients will see today that they ask him how many hours a day do you spend on the computer? They'll say eight ten sometimes twelve hours on the computer And it's been shown in several studies that that has an effect in exacerbating the symptoms long commutes in the car Especially if people have the vent directed toward their face Airplane flights and other environmental recreational and occupational Factors and perhaps even diet may play a role as we'll see in a minute. There are many clinical tests for dry eye I don't do the Schurmer test near as much as I used to in the past. It doesn't correlate It's not as reproducible. It doesn't correlate with the symptoms is not as helpful as other tests such as The tear breakup time or corneal epithelial staining so generally In a busy clinic, it's very helpful to put a drop of fluorescein in the eye Technically if a person is doing research, they should quantify the volume and the concentration of fluorescein Maybe 50 microliters of 2% fluorescein, but in practice it is not really that practical to do So a little drop of fluorescein in the eye and one can check epithelial staining although it's best to wait Three or four minutes if you can do that because sometimes epithelial staining will not be present within 10 or 15 seconds But might show up after a minute or two or even four or five minutes We can also check the tear meniscus with the fluorescein stain and then of course check tear breakup time Other tests such as tear osmolarity and impression cytology are primarily reserved for research applications So vital dye staining besides fluorescein we have rose bengal and lysamine green Fluorescene will stain of course corneal epithelial defects and defects in the tight junctions Whereas rose bengal and lysamine green both will stain Devitalized epithelial cells even though there are no defects and also areas where the mucin layer is deficient Rose bengal will sting quite a bit. Lysamine green stings a little bit less than that and Rose bengal and lysamine green are better for staining conjunctiva Here we see lysamine green here on the lower right. Whereas the fluorescein is better for staining the corneal epithelium A study by a Korean group in this month's issue of cornea Reported their results and actually combining lysamine green with topical fluorescein to stain both at the same time Their conclusions were not really that surprising These are not photos from the study, but they saw both corneal epithelial staining as well as conjunctival staining and concluded that Symptoms were better correlated with conjunctival staining for some reason Whereas corneal staining correlated better with the tear breakup time The tear breakup time Consists of simply putting fluorescein in the eye Asking the patient to blink a few times and then having using the cobalt blue filter having them Stare straight ahead without blinking and checking to see how long it takes to see the fluorescein layer Begin to break up this presumably is due to the lipid layer the outer lipid layer becoming disrupted which allows the muco aqueous layer to begin to evaporate now the the Patients generally will blink every few seconds, maybe every five to ten seconds if the tear breakup time is Sooner than the the blink rate then there's a problem with the evaporation leading to symptoms If the breakup time is longer than the Inner blink interval then there shouldn't be as much problem Irradiator light reflex can also be seen at the slit lamp. Here's a photo Post-lasic patient sewing some epithelial changes, which are quite common, especially in the lower cornea after lasik I don't know if this instrument is available yet. Does anybody know if the hyper The the tear lab instrument for measuring osmolarity is available Did they okay I haven't I haven't seen it yet But I believe it cost about $6,000 and the kit is about 40 or $50 for measuring the osmolarity of the tear and this Holds a lot of promise because it could be a very good marker for helping with dry eye studies with with new medications and clinical trials They're coming Coming forward to help us to better evaluate the efficacy of medications Yes Yeah, well basically if the patient symptomatic I think it's perfectly reasonable to treat to treat them anyway You treat them at least with artificial tears and see That certainly wouldn't hurt anything You know if if you if you know really why do the test? I told I totally agree very expensive tests And really what's it going to add? You know is it in the in the final analysis were basically going to treat symptoms and signs anyway And probably not pay a lot of attention to whatever that osmol out so I think primarily this probably will help in as a research tool to To help in research studies because it can be a marker for because it's well It's well accepted generally accepted that hyper osmolarity is correlated with the pathology and in dry disease We all know that dry a disease can affect the visual acuity this hasn't always been well understood the reason most likely is because the the differences in their refractive indices between air and The liquid of the tears is greatest of that Transition interface that it is in any other Transition interface in the ocular system There are also studies showing opaque corneal epithelial cells by confocal microscopy and other pathology That could occur certainly when you look at a Light reflex such as this here below. It's it's easy to see why visual acuity could be affected a Study a couple of years ago in the ocular surface journal by an optometrist I Addressed the correlation or lack of correlation sometimes between signs and symptoms He concluded that generally there's a positive relationship between the amount of the severity of the signs and the severity of the symptoms But the association is always is not always that strong And he found that higher correlations actually exist among questionnaires than among objective tests What causes symptoms in dry eye? Most likely it's due to irritation or stimulation of corneal nerves either due to the cytokines hyperosmolarity pH changes or or trauma And we've all seen patients that come in with symptoms, but we don't see anything wrong on the examination or Have Significant signs on the examination but not really complaining very much the former here on the left symptoms without signs It can be a little perplexing. We wonder if we just have a complaining patient, but it may be a just a hypersensitive eye There was a study by Belmonti that Postulated that in some cases there may be a micro neuroma or something wrong with one or more nerves that could be causing some pain In the absence of any visible symptoms on the ocular surface The a scenario of signs without symptoms is more dangerous In our situation because if you have somebody with neurotrophic keratopathy, they can have significant problems even corneal melts Impending perforations with very little symptoms may not even come to see us. So it's always important to Take a careful look at the ocular surface, especially before surgery Even if a person is not complaining of dry eye symptoms There's several entities that can masquerade is dry disease with similar symptoms such as blepharitis particularly posterior blepharitis and conjunctival Colases which I know that I have not paid much attention to in the past and probably still miss a lot of cases Most of our older patients will have redundant conjunctiva especially in the lateral portion just over the above the lower eyelid and The symptom the main symptom of conjunctiva chelases is a burning or a stinging sensation of fleeting Stinging sensation when they blink so during the blink mechanism if it stings then and after when they're not blinking It doesn't sting that could be conjunctiva chelases is probably due to the redundant kind of type of being Moved across the ocular surface especially with a deficient ocular tear film which will cause friction and Simulation of corneal nerves this can be treated generally pretty well with Artificial tears some people have used procedures such as caudary Conjunctival resections to tighten the conjunctiva with some good results So as we look at the pathophysiology of dry eye what was actually happening on the ocular surface What is the cause hyperosmolarity is the main driving force that leads to activation of various? inflammatory cytokines That in turn will cause goblet cell reduction Loss of mucin on the ocular surface and epithelial damage and apoptosis This will destabilize the tear film which in turn exacerbates the tear hyperosmolarity leaving leading to a vicious cycle these core mechanisms are Driving force this Diagram taken from the Dew's report are a driving force that will stimulate the nerves and initially in the early stages Increase the reflex drive to the lacrimal gland increasing aqueous production However with the passage of time nerve injury can occur in chronic dry eye Which will lead to a reflex block which decreases aqueous production? and That will lead to worsening of the hyperosmolarity now Also as we look at the eyelids with my bomean gland dysfunction Decrease film lipid film layer from my bomean gland dysfunction which leads to increased evaporation especially with environmental changes dry air and low humidity which will lead to high evaporation and increased hyperosmolarity and Other factors we see here on the periphery surgery the aging process Low androgens which accounts for the fact that the predominant The majority of people that have dry eye are women and other factors systemic drugs such as antihistamines Estrogen replacement and postmenopausal women and other factors which will exacerbate this condition So we see a disruption of the mucin layer here with goblet cell loss Decrease in the aqueous layer by reflex block of the lacrimal gland and decrease in the lipid layer from my bomean gland dysfunction Which are the pathophysiologic? elements that drive the dry eye disease pathology My bomean gland dysfunction is not necessarily synonymous with posterior blepharitis, but it consists of hyperviscous secretions in the my bomean glands Leading to an inadequate tear lipid layer and bacterial lipases can act on the discretions the waxes and esters to Convert them to triglycerides and fatty acids which will lead to a Suponification process and little micro bubbles or froth that we can see along the eyelid margin and that is considered to be Pathognomonic when we see that froth at the slit lamp on the eyelid margin Pathognomonic of bacterial growth that perhaps some antibiotic ointment on the eyelid margin and I might be beneficial An article last year in cornea entitled non obvious obstructive my bomean gland dysfunction presented several cases where There was no obvious inflammation. There was no obvious whitish secretions from the my bomean gland orifices and one our initial inspection might say well the eyelids look fine There's no posterior blepharitis the only way to diagnose this non obvious mgd would be to try to express The my bome from the glands and if one tries to do that They could see that the glands at least some of the glands are obstructed and that can lead to the same problems of decreased lipid layer and evaporative dry eye So even though we probably don't generally at least I don't routinely try to express sometimes at the slit lamp We can certainly put some digital pressure on the on the eyelids just to see what happens With the myvim at the orifice to see if there is obstruction The treatment for my bomean gland dysfunction is well known starting with warm compresses The warm compresses probably should be kept on the eye for at least four or five minutes to really be effective It's not the one or two minutes. It's not sufficient If you really talk to your patients about this compliance is probably very low most people I mean, I don't know how many of you have tried to do warm compresses It's not the easiest thing or funnest thing to do you're tired want to go to bed and putting warm compress on your eye People probably don't do this as much as we would hope they would but following the warm compress I live massage and expression of the the secretions Lid margin hygiene is needed antibiotic application We've talked about now oral doxycycline can probably be used in doses lower than what we've been accustomed to in the past For example, 100 milligrams BID a maximal dose is is often not needed In fact even 20 to 50 milligrams of doxycycline a day or BID Can be a very good maintenance dose for many patients We'll talk in just a minute about the possible benefit of dietary omega-3 supplements Topical asus site and also my bomean gland probing We can teach our patients how to digitally massage the my bomean gland that the eyelids after hot compresses To help express some of the secretions and then clean them off with an ice scrub pad or with the washcloth itself in the office we can express the my bomean glands secretions such as this and This is a picture showing them a strata paddle, which is just an instrument that can be used to do the same thing And then tear science has produced this instrument. I'm not sure if this is available yet, but it's called lipoflow Where if you look here at this diagram I'm not sure I'd want to have one of these put in my eye, but Good luck trying to talk your patients into the volunteering for this But the internal aspect that goes again There's a corneal protector and then an internal warmer that heats up the adjacent to the my bomean glands heats up the the glands And then a an eye cup on the outside that puts external pressure on the Eyelids expressing both the upper and lower eyelid at the same time Now the question comes comes up. Does it really do any good to try to express my bomean glands this? article from last month's issue of cornea by RC and aga They did baseline studies of tear evaporation rates, and then they looked at evaporation rates both in a relatively dry and a relatively relatively humid environment and Looked at it at about six minutes 12 minutes and 24 minutes, and they found that the tear evaporation rates did decrease at the six and twelve twelve minute marks, but 24 minutes there is really no Change at all in the evaporation rate. So from this study anyway, there's not we wouldn't expect a lasting effect By expressing my bomean glands in the office One of the reasons for that is that if you have a completely occluded gland which many of our older patients do Expressing is not going to do a bit of good for that. So that leads us to Steve Maskin's Procedure that he presented at Arvo two and a half years ago my bomean duct probing which seemed rather barbaric at the time Who would want to have little needles or probes stuck into their eyelids 20 times? But his results were really very good have been reproduced by others at least anecdotally The rationale behind probing the ducts is that they can be obstructed there can be obstruction of the orifices by surface Metaplasia there can be fibrotic destruction and my bome plugs within the glands themselves And these probes are currently available through Ryan medical Maskin published his studies a year ago in cornea 25 patients were treated Just about all of them reported immediate improvement in the symptoms and all of them had symptomatic relief at four weeks and This seemed to the symptomatic relief seemed to last with 80% of them within Within a year for a year. So this Actually going in and probing the gland can be much more longer longer lasting than the expression No, no, yeah, and that probably would be a little difficult to I see a sham probing just being Going through the procedure. We're not actually probing. Yeah. He did. I don't think he did that That's a good. I I've been doing this in a few cases over the last year and I've noticed that We do one eye first and every patient except for one that I've done Immediately notices an improvement, but a lot of that could be placebo effect also So it's really hard to tell hard to I think might be a little hard to do do a control But I don't he didn't do that in this particular study This is a video in bypassing the two millimeter probe through the orifice You may need a fine router movement to find the opening especially in setting of orifice metaplasia if Epithelium has grown across the orifice the probe may still be able to pierce through if not in top Galactica may be used to de-epithelize the orifice if the orifice is scarred You may be able to penetrate by cutting the tip with a barred Parker blade Cut it on an angle to achieve a more pointed tip Be sure to visualize the gland before attempting to penetrate an orifice to avoid the completely atrophic non-existent gland So the first patient I did with this last year He had probably 75% of his glands. I couldn't even enter they were there It is a very advanced case and either because of surface metaplasia or fibrosis within the gland and maybe my Inexperience, I just couldn't get in most of the glands and he didn't notice any improvement But subsequent patients have I've only done three or four, but they've all noticed some symptomatic improvement and every single one of them is noticed improvement On the treated eye versus the control was the eye that wasn't treated, but of course that could be placebo The these probes come in two four and six millimeter lengths and generally the two millimeter is sufficient to Relieve the symptoms and what's what's happened before? Anecdotally in going to meetings and talking to people across the country. There's several Ophthalmologists that are doing this at the present time. I'm not aware of any other published study yet Maybe somebody else is but time will tell whether this is really beneficial or not Theoretically it does make sense if obstruction is a problem and expression is not really relieving the my bomeans The my bome obstruction then perhaps probing probing will be helpful Here's another video from Steve mask and showing a different approach Penetrating the orifice of the two millimeter use the four or six millimeter depending upon the length of the gland to achieve complete Patency of the ductal highway you may encounter resistance Respecting the length of the gland will prevent extending the probe too far Therefore if you obtain resistance, you may be up against a fibrotic band Check to ensure that you are colinear to the gland and then provide additional force to pop through the introductory scar It will give way similar to popping through a thin lacquer more punctile scar from thermal quarry At times you will notice a drop of heme at the orifice this may occur as you pass through a fibrotic neovascular scar or simply a Neovascular membrane Here's an example of a plug of my bum Freed up from behind a neovascular membrane Notice the my bum being released and here into the probe and a drop of heme at the orifice At times a trace amount of perilangular subconcentival heme may be noticed from opening a membrane Maskin describes a popping Popping sensation which which he could feel when he introduces these probes which I've noticed also in fact My technician that helps me do these at Rocky AJ even he can feel the popping sensation when I'm going through there He's holding the eyelid for me with his finger and I can actually feel the resistance as we're going through with the with the probes so Just an idea that may be beneficial for the future but remains to be Seen whether it is whether it's going to be helpful. I Yes There there isn't yeah, there is a code for a not it's a non-reimbursed code that's used I think it's a v code and Apparently at the Medicare carriers if they get enough of these v codes will eventually decide to so what we currently do I charge I think 250 or 275 per eye being both upper and lower eyelid It takes about a half hour to 40 minutes to do both eyelids and and just have the patient If they want to they need to pay for it cash pay up front As far as anesthetic mask and does this with topical lidocaine gel generally I found that about half my patients Will tolerate that although there is some pain involved and the other half require a block of the eyelid with some Xylokane to tolerate the procedure This is a study reported by Flugfelder's group at Arvo a couple of years ago Let's say a laboratory study with cultured corneal epithelial cells showing Apparently showing that topical Azithromycin or incubation with azithromycin Maybe beneficial in decreasing inflammation on the ocular surface they found that When these epithelial cells were incubated with My probe my microbial components inflammatory mediators were released However, when they added a zithromycin that blocked the release of inflammatory mediators Here are two clinical studies one by Gary folks and the other by Jody Luke's studying patients in The past few years with topical Azocyte drops and as you know many people are using these as an off-label treatment of posterior blepharitis In folks study He measured both the transition temperature of my bum, which is essentially the melting point and notice that that Decrease making it easier for the my them to melt and flow out when Azocyte was used for one month He also noticed a difference in the lipid pattern approaching that of of my women an increase in the tear film breakup time which seems to Imply that Azocyte might help with the my bone flow and might help with evaporative dry eye Jody Luke's found essentially the same thing mostly focusing though on symptomatology Treating one group with a zithromycin and warm compresses and the other just with warm compresses alone symptoms were better when the Azocyte was used another approach the common approach with dry eyes of courses with to use artificial tears and it makes sense to Target our use with artificial tears depending on the particular need for example if someone Seems to have a deficient lipid layer with a short breakup time We might want to use a lipid containing products such as refresh and Dura or products such as sustained balance which is formulated for Unstable tear film If we're looking to replenish the aqueous layer products such as their tissue refresh might be good for glaucoma patients and other patients that have significant inflammation on the surface of their eye Reducing the preservative load by using preservative free or disappearing preservatives such as found in theratheers and gentile or Refresh would be good if we want to try to reduce osmolarity Theratheers aqua tears and hypoteers will do that We should keep in mind though that hypoteers has benzalconium as a preservative one of the few tears that do so It's probably not a good idea to use too much of that because benzalconium is not good for the ocular surface There's several different techniques also that have been Explained in the literature one is saturation dosing where an individual if they're using Preservative free artificial tears that may have about six or eight drops in it Put a drop in each eye and instead of throwing it away wait a couple minutes and do it again And wait maybe five minutes and do it again till the vial is gone Putting several drops in each eye over a five or ten minute period and that should help to may help to decrease the frequency That the person needs to put the tears in during the day Combo dosing is something I've used with several of my patients and some of them will notice the benefit If you have somebody that's used finding they need to use artificial tears every hour ask them instead to use cysteine gel or theratheers liquid gel Initially and then about 30 seconds later chasing it with the regular artificial tear like cysteine ultra or theratheers Regular theratheers and that will help to clear the vision that's caused by the the gel and Many patients can go from every hour to maybe every three or four hours instead and save some time Then preventative maintenance rather than waiting until eight o'clock at night when you've been on the computer for several hours And your eyes are stinging using the idrots before they begin to cause symptoms Many years ago the thought of using steroids for dry eye was considered not a good idea But now the days it is accepted if it's used judicially a lot of max is a good drop But rather costly and even fml is really quite expensive. There was a study recently. I forget where I think it was last year Looking at very dilute a topical dexamethasone instead of 0.1% using 0.01% Dexamethasone and that seemed to relieve symptoms if used even twice a day What about restasis Topical cyclosporine of course is gained a lot of popularity. It's the only medication. It's been approved by the FDA for use in dry eye It's an immunomodulator that acts by Suppressing the expression of inflammatory markers and also reducing the number of activated telemphasis this action is primarily in the lacrimal gland and the Oculosurface so even though it's applied to the oculosurface one of its main actions is remotely at the lacrimal gland because of the telemphaside action, so it increases aqueous production and increases goblet cell population and In Perry's study a few years ago Recommended that perhaps we should consider using it a more mild to moderate cases as opposed to the severe cases because it seemed to be More efficacious The problem is that most treatments are probably going to be more efficacious have used in the milder cases and one of the concerns I have with Restasis is that it costs a lot. I mean this is the Walmart cost in Salt Lake City just a few days ago $135 and Somebody has to pay for that it is a good medication But somebody has to pay for it and and the cost actually will go up to even 180 $190 per One month supply, but restasis I can be very great beneficial especially if we're dealing with a An inflammatory component to dry such as Shogun syndrome But not all experts in the field agree that it doesn't a good in fact most patients that I ask who are on restasis the majority I ask them do you think it's helping you and most of them really can't tell me and that doesn't mean it's not helping it just means that the Pathology is so complicated. There's so many factors. We really can't control for all of them In fact when the study was done to approve restasis. It didn't The FDA study restasis did not meet the primary efficacy guidelines for approval They'd only met one secondary efficacy guideline, which is increasing the Schumer test and also Improving symptoms in a subset of the patient. So just barely squeak by But it's the only medication that has been approved today In the past I didn't pay a lot of attention to Humidity but once I moved to Salt Lake. I got a little humidity gauge I was wondering why my eyes were bothering me so much And so I measured the humidity and found that it was really only about 20% inside So I got humidifiers from my house and found That I needed to put one on the furnace as well as in the room in order to get the humidity up to a Reasonable level of 45% This is a chart showing the water holding capacity of air and this is something we don't learn in medical school But it's something we probably all ought to be aware of If you look at air at zero degrees Fahrenheit cold outside air in the winter here in Salt Lake It holds very little water If you bring that into your furnace and heat it up to room temperature It will hold 16 times as much water Now what that means is you can take this cold outside air even if it's 100% humidity Relative of course to the temperature Bring it into this into the house heat it up if you don't add water to the air You're going to end up with less than 10% humidity now in practice if you get a Hygrometer and measure the humidity here It'll generally be in the wintertime about 20 to 25 percent indoors in a commercial environment in the summer time It's more like 35 percent, but that's one of the reasons why our patients will complain of dry eye because the air is just very dry Which will increase evaporation the other factor is that we live in a relatively high elevation here and of course with higher elevation the vapor pressure is Is increased relative to the atmospheric pressure which will increase evaporation also So here's some photos just showing the room humidifiers and furnace humidifiers and Hygrometers which are inexpensive and I have a lot of my patients Buy one of these because otherwise it's really hard to tell whether the humidifier is doing any good now taking a turn to talk about dietary supplementation with Omega fatty acids the rationale behind taking Omega-3 or omega-6 fatty acids are the following There has been a study showing that it may change my bomean gland oils and the tissue levels are Inversely related to the severity of dry eye disease, but most importantly the long chain Omega-3s are Anti-inflammatory and they tend to block the gene transcription of pro-inflammatory cytokines Which related to the pathogenesis of chogren syndrome? So if we look at the metabolic cascade with omega-3s and omega-6s Flaxseed oil is about 50% alpha linolytic acid which is not Which is not anti-inflammatory okay, our bodies do not Metabolize alpha linolytic acid to icosapentanoic and docosahexanoic acid very well Only about 5% of that goes to icosapentanoic and less than 1% to DHA in our bodies So taking flaxseed oil is not going to do a whole lot for anti-inflammation compared to fish oil Fish oil is much higher in EPA and DHA the Omega-6s Will produce both anti-inflammatory DGLA as well as pro-inflammatory Arachidonic acid and so they're not as good as the Omega-3s The potential clinical benefit of essential fatty acids are to number one try to restore the lipid layer of the tear film and block the inflammatory cytokines now here is a Here's a summary of Recent studies that were that were done some are clinical studies some one is an epidemiologic study and others are animal studies that look at either systemic or topical Omega-6s and Omega-3s one of the problems with these studies is that most of them used either Just Omega-6s or a combination of Omega-6s and Omega-3s But in spite of which are not as anti-inflammatory as Omega-3s Nevertheless, they still most of them found some symptomatic relief We talked about this before that the fish oil is actually preferred over plant sources because there's more anti-inflammatory Effect in EPA and DHA than there is on the Omega-6 side Now, I think this will hold true for use of these products with macular degeneration as well as cardiovascular disease If you tell your patient just to go to the store and buy some fish oil, what are they going to buy? they probably should have some guidance because Generally, if they go to most stores a 1,000 milligram capsule of fish oil will have about 300 milligrams of totally EPA DHA But some products have much less than that even close to 100 milligrams and others will have Almost 700 milligrams of course, Levesa, which is the prescription medication will have has the most but it's also very expensive Thorne research is a company up in Idaho, which sells a high quality fish oil only online It's more expensive than the Costco variety What I recommend for most of my patients is to go to Costco and get the 1200 milligram and tarot coated Which has almost 700 milligrams of EPA DHA and the cost of that is even less than Walmart It's very very low cost. It's the cheapest available and is readily available for our patients So that is a good buy for And they make their fish oil out of Small fish so the PCB and mercury contamination is probably pretty low Now a couple of clinical studies. This is one that was published a few months ago in cornea Oral omega-3 supplementation using fish oil They gave a total of just one fish oil capsule per day, but it contained 750 milligrams of DHA and EPA and they found That there was no difference in the mybom composition or the tear evaporation rate So the effect of this oral fish oil didn't seem to be affecting the mybomian gland Mybom composition or the tear lipid layer the best they could tell what it did affect was the tear production and Another study published just this month in in cornea using plant Omega-3s Also found no difference in mybom composition So Wrapping this up additional therapies include punctal plugs one thing about punctal plugs if we use them We probably should not place them in the presence of ocular inflammation because of the ocular surface and the lid margins are inflamed We're also making the eye retain these inflammatory Mediators and debris from the inflammation along with the tears. So it's best to treat the inflammation first and then place the plugs I actually take more plugs out nowadays than I put in for that reason patients coming in with symptoms And sometimes they do better without the plugs lack research have been Reintroduced but are rather expensive and not not always tolerated secretogogs such as oral Sevemaline can be used Just as a cholinergic agonist, but that also stimulates the GI system and and sweat glands Autologous serum moisture chamber spectacles and others The moisture chamber spectacles I found to be really good These are advertised seven eyes and why the X are advertised in the motorcycle Magazines for people are outdoor enthusiasts and riding ATVs etc. Quite helpful for those sports and some of our patients these can be purchased with Clear or even prescription lenses for use of our dry eye patients I find these to be quite helpful especially with lagothalamus and patients with eyelid abnormalities and neurotrophic care top of thing These will cost one or two hundred dollars You can also go down to Walmart and get something almost as good with shooting glasses They cost about four ninety seven about five bucks and protect the eyes really quite well from draft and may even increase the humidity So in summary, I've presented a practical clinical approach in approaching dry disease taking a good history Considering lifestyle activities focus the examination using fluorescein to examine the breakup time effectively educating the patient Keeping an eye on compliance because they often don't really comply with what we asked them to do These are some environmental and lifestyle factors that can have an effect Smoking sleeping with pets overhead fans swimming and cycling long hours on the computer I use a handout that I developed for my patients that I After I explained to them once or twice what I like them to do Check off on the handout and give them in printed form so they can take home and digest it And I think this will help compliance. It also gives them information where they can buy Hygrometers and get humidifiers On the horizon they're coming up with some next-generation lubricants To reconstitute the mucin and lipid layer new medications in office measurement of tear cytokines in the current dry eye research is focused on mucin secretogogs Mucomimetics and immunomodulators similar to cyclosporin and others that can help with the inflammatory problem One of the main problems with these studies is that it's very difficult to pass FDA scrutiny and It's impossible ready to control all the different variables one of the challenges with the FDA approval is that It's impossible to control the variables the efficacy endpoints are Relatively strict and because of all the variables for example, how are you going to control? What a person eats so the relative humidity in their home or how much time they spend on the computer or drive in their car Or other lifestyle factors and even the seasonal variations here in Salt Lake City the relative humidity Changing from season to season as the study progresses You really can't control for all those things so these that those who are designing the studies are looking for different endpoints and different environmental conditions that can test the Efficacy of the medications in a more rapid way So in summary, we've looked at the pathogenesis with the core mechanisms the effect on the lacrimal gland and and the eyelid and learned that Inflammation is a key element in dry disease hyperosmolarity and instability of the tear film or principal forces Aqueous deficiency is often immune mediated Understanding the history and lifestyle can be very helpful a patient can have minimal symptoms and significant signs Which means that we need to always examine the patient even if they're not complaining and Punctal plugs if they use should be used after controlling inflammation Corticosteroids are allowed and if used wisely can be tolerated and helpful to improve inflammation over a few days or weeks Topical cyclosporinate can be very beneficial Lephoritis needs to be controlled Lower doses of doxycycline are often effective Dietary supplements may or may not play a role in the future the initial studies are not conclusive, but it need to be substantiated, but It appears that possibly oral ingestion of omega-3s may be beneficial particularly fish oil high in EPA and DHA We can decrease economic burden by focusing on the causes of Dry disease and not being too quick to write a prescription The ocular surface should be examined and managed pre-op particularly with refractive surgery and cataract surgery and Obtaining FDA approval for new medications is incredibly difficult Which is one of the reasons why we've had only one approved medication in the last several years any comments or questions Yeah, so the question is how do I select patients to probe? As with any other treatment it probably would be more effective if we didn't wait till the end stage But generally what I'll do is I'll take the patients that I've Treated with pretty much everything else that they will tolerate for example We have them on artificial tears preservative free Beyond doxycycline warm compresses massage lead lead hygiene and maybe even a trite asa site And it just didn't seem to help and they're still having a lot of symptoms Then if I look at the my bomean glands and try to express them and notice that there's some obstruction Those are the patients that all tend to do so it's kind of a last resort with me right now simply because they have to pay More money for it and it takes some time and it's not not my favorite procedure to do but it has helped the patients I've been really quite impressed I had one patient that I I checked his tear break at time before the procedure. It was it was four seconds And then I hadn't come back a week later was 10 seconds and he was saying wow I really feel a whole lot better and I had that that that sign is significant just one patient, but It seems to be beneficial Jeff. I haven't know That would be That would be nice to have those particularly for the patients that are not able to blink and having significant cornea problems Short of doing a tarsorophy on them. Bala. Thank you. Is that DHE is that topical or systemic topical? Thank you