general condition occurring in the course of other diseases. At one time quinine was lauded as a specific-some explaining such property on the ground of its control of migration of white blood corpuscles; others that it was an antipyretic, and yet others that it was a germicide. Equal benefit is claimed by different observers from small and large doses. Probably if the large doses are ever of value, it is in the sthenic type, and the small tonic doses in other cases. Tincture of iron has been regarded as of specific value, and has been so used by many, in large, frequently repeated doses. Others have prescribed it with apparently equally good results in very small doses, such as would amount to thirty drops in twenty-four hours. Some attribute whatever virtue it possesses in this disease to its tonic and astringent properties.

At the two extremes of life treatment of any kind is very apt to be of little or no avail.

When the typhoid condition is marked, the indications may be met by the use of alcoholics and opium or coffee and quinine. Stimulating nutrients, serpentaria, ammonia, camphor, etc., may be valuable adjuvants.

In the ordinary sporadic cases such as we generally see now, I have come to think that indications are for protection, antisepsis and support.

Local treatment may be simply protection, or may also be somewhat antiseptic. Internal treatment antiseptic and supporting. The disease being essentially septic, I believe the antiseptic and supporting measures to be the most important in really severe cases.

For protective I like an ointment or lotion.

I have used acetate of lead and belladonna in ointment with considerable satisfaction, but for several years have largely used ichthyol in five to ten per cent ointment, smearing the inflamed part well, and covering it over with cotton or ichthyol collodion. I believe that the ichthyol has some virtue under the second indication, that of antisepsis.

I very often give minute doses of a mercurial, generally the bichloride. I believe it to be in such cases tonic and antiseptic. Sometimes have used it as lotion instead of internally. Usually at the outset I give a cathartic (unless the bowels are already acting freely) to clear out the alimentary tract and stimulate the secretory organs. I give internally small doses of tincture of the chloride of iron, quinine, perhaps some alcohol, more usually strychnia sulphate and concentrated nutrients.

Other than this I try to meet any special indication as it arises.

I occasionally give an opiate to quiet delirium and restlessness. I have seen a full, strong pulse with a rapidly advancing inflammation yield promptly to tincture of aconite after other

treatment had proved futile. But the rare idiosyncracies make no rule and establish no principle.

THE CATARACT OPERATION.*

By H. McI. Morton, M. S., M. D. Ophthalmologist and Otologist to the St. Barnabas Hospital, Minneapolis.

It is not my purpose to discuss with you today the ætiology, pathology or diagnosis of cataract to any greater extent than is essential to a lucid understanding of its treatment alone. The catract operation is one that affords much interest, as well as the most brilliant results, and is one of the most ancient operations known to the history of surgery. As early as thirty-five hundred years before the Christian era the Egyptian oculists performed an operation to relieve sufferers with this condition. Not with the methods or technique of today, of course, yet presumably with occasional success. During the middle ages this operation was unfortunately relegated to the quack who infested those dark times, and was executed in the most barbaric manner, with the result that the victim lost all chance of ever regaining his vision. It is, however, to this century that we owe the perfect technique and brilliant results of the present operation for the extraction of cataract.

With this exceeding brief rèsumè, we will proceed at once to consider the treatment of cataract under the following headings:

First, Uncomplicated senile cataract.
Second, Congenital and juvenile cataract.
Third, Posterior polar cataract.
Fourth, Traumatic cataract.

It is proper before speaking of the surgical treatment, to digress briefly to refer to the socalled medicinal treatment, and it is but to emphatically emphasize the fact that there is absolutely no proper treatment for opacaties of the lens but timely surgical interference. At the present we know of no drug which, administered locally or internally, will absorb the opaque lens.

When we have involvement of the nucleus alone mydriasis commonly improves vision. It is not uncommon for patients to be deceived by charlatans in this manner, and wonderful cures reported, without surgical intervention. As the cataract develops the deception is discovered. We will now consider, first UNCOMPLICATED SENILE CATARACT.

In these cases we have usually to deal with patients fifty years of age or thereabouts, al

*Read before the South Dakota State Medical Society at Mitchell, June 10, 1897.

though it may occur in much younger people. The patient has noticed a gradual diminution in the visual acuity, and oftimes observes many images of one object (polyopia). I am able to recall a patient who insisted that she saw thirteen distinct moons. As any disturbance in the vision is alarming we usually have these cases present themselves for examination before the opacity has completely involved the lens. If the patient is over fifty years of age, and we find considerable lenticular involvement, although not complete, it is not imperative or necessary to have the patient wait, oftimes for several years, until this is complete, as the results attending the removal of immature cataract are very satisfactory. Boettman, of Chicago, performs what is known as "artificial maturation" by stroking the anterior portion of the lens through a corneal incision with a spatula. After this has been done the lens becomes completely opaque in a short time, from one to three weeks, and is removed as a mature cataract.

unnecessary,

Many operators deem this since, in their judgment, should the cataract be so far progressed as to attract the attention of the patient, it can easily be removed without the ripening operation.

The operation should be performed under cocaine anææthesia, as the assistance of the patient is of great aid and one avoids the retching attending anæthesia, which may interfere with the steps of the operation, or result in a loss of vitreous humor. My method of operation is as follows: | 21

The patient receives a hot bath at the hospital and is then put to bed. The side of the face is thoroughly cleaned with green soap, rubbed with alcohol, and then douched with 1-5000 bichloride of mercury solution. The cul-de-sac is irrigated with a 1-10,000 solution, and a dry gauze bichloride pad is placed over the eyelids and cheeks, and is held in position by a light gauze bandage. Preceding the operation one-tenth of a grain of calomel is administered hourly until one grain is taken, and then one ounce of the sulphate of magnesia is administered.

The instruments and cocaine solution are sterilized. After the eye is cocainized, it is douched thoroughly with warm sterilized water. No antiseptic solutions are used after the eye is unbandaged just previous to the operation, as I think such solutions retard the healing by irritating the delicate flaps. After introduction of the speculum the eyeball is steadied by gentle pressure of the thumb and forefinger, and with the knife held gently in the other hand an incision is made at the corneal margin, or slightly to the inside, and involving the upper third of the cornea. I prefer to avoid the use of fixation forceps by the use of the thumb and forefinger as described. The iris is grasped with delicate

forceps, drawn well out of the incision, and a good broad iridectomy made with the scissors. An opening is then made into the capsule of the lens by several crossed incisions with the cystotome. With a rather long and narrow cataract spoon or scoop, the upper edge of the lower flap is depressed, while with a somewhat broader scoop gentle pressure is made on the globe just below the end of the vertical meridian of the cornea. The cataract will slide out of the wound and fall into the lower spoon. With the spatula the edges of the iris are replaced, and dèbris, as bits of iris, small blood clots or other foreign matter removed from the wound. By gentle rubbing of the cornea upwards small particles of lens matter may be floated from the anterior chamber and out of the wound and a clear pupil obtained.

Ordinarily these steps follow one another without interruption, yet it is proper to speak of some of the possible accidents that may occur.

In the first place it is possible to introduce the knife with the cutting edge turned the wrong way, a thoroughly inexcusable error. The knife must be withdrawn and the operation delayed until the anterior chamber refills. It is unfortunate to make the corneal incision too small, as difficulty may be experienced in expelling the lens, and we may have loss of vitreous, or injury to the flap, in the endeavor to do so. If this mistake has been made it is best to enlarge the incision with probe pointed scissors. It sometimes occurs that the iris falls in front of the knife during the making of the section, in which event it is best to continue the section and make the pillars of the coloboma as regular as possible by trimming with the iris scissors. If, during the operation, the cataract should be dislocated into the vitreous we may use the wire scoop of Levis to remove it.

It is not uncommon in old patients to have collapse of the cornea, due to a relaxation of the corneal tissue. The cornea may be made to assume its proper curve by gentle pressure below the vertical meridian.

The most unfortunate and most serious accident that may occur during the extraction is interocular hemorrhage. In cases where from the age of the patient and condition of the vessel walls, I am led to suspect weakening of the arterial coats, I always make my incision as far away from the corneal limbus as possible. In case of prolapse of the iris, if discovered within a few hours, we may attempt to replace it, or failing to do so, may cut off as much as possible. If not discovered until the removal of the bandage-I allow it to remain on before the first dressing for three or four days-it is preferable

not to interfere.

THE TREATMENT OF CONGENITAL AND

JUVENILE CATARACT.

Congenital cataract is probably due to a foetal iritis, and may pass unnoticed for many weeks. The lens being very soft the proper treatment consists in tearing the lens capsule with discission needles, thus admitting the aqueous humor which absorbs the soft lens matter. The point I desire to lay stress upon is that these cases should be operated upon at the earliest possible time, since the child cannot learn to coördinate the movement of the eyes until operated upon, and nystagmus, or amblyopia, or both, may develop. Two weeks is not too early to attend to these cases. The child's head may be held firmly, and, after a drop of cocaine has been placed in each eye, the capsule may be lacterated, the eye being held firm by fixation. forceps.

In considering juvenile cataracts we have largely to deal with children suffering from malnutrition or rickets. In these cases we find certain layers of the lens opaque, the nucleus not being involved. These cases are treated best by discission, as done in congenital cataract. When the layers lying nearest the nucleus of the lens. are involved, and the more peripheral layers remain clear an iridectomy oftimes gives us satisfactory results. If after dilatation of the pupil by a mydriatic vision is markedly improved, it is proper to perform an iridectomy in place of tearing the capsule by the discission needle.

THE TREATMENT OF POSTERIOR POLAR CATARACT.

In this form of cataract the posterior capsule and adjacent lens fibres only are involved. In this class of cases we find usually serious disease of the eyeground, as choroiditis or opacity of the vitreous humor, which are in truth the cause of the opacity in many cases. Persistent hyaloid artery may also be a factor in causation as well. The treatment is of no avail as a rule. The globes are not uncommonly, abnormally small and nystagmus present in cases of posterior polar cataract.

I will now, finally, discuss with you, fourth, THE TREATMENT OF TRAUMATIC CATA

RACT.

Probably no other ocular cases require more judgment on the part of the oculist than injuries to the anterior ocular segment and lens. There are those who, in cases of severe laceration of the globe of the eye, advise hasty removal, while many prefer less haste.

I think no greater mistake can be made than the too hasty removel of an injured eyeball.

It is surprising what happy results may follow what may appear on first sight a hopelessly injured eye. If the iris is prolapsed through a

corneal wound, I cut it off if it cannot be replaced. If the wound is central the iris is drawn away by atropine, if peripheral we use eserine.

If we are dealing with a punctured wound due to a needle or piece of steel, in which there is much swelling of the lens, I do a broad iridectomy and by cold compresses hasten recession of the inflammation. Where the lens capsule is badly torn and a great deal of lens matter protrudes into the anterior chamber, after doing the iridectomy, I proceed to remove the lens. Bv gently irrigating the anterior chamber with warm sterilized water, the small particles of lens matter may be washed away and we may obtain a good clear pupil.

The reasons given by those who remove the globe in severe cases of this nature is the danger of sympathetic ophthalmitis. While this is a grave disease, I do not think the immediate danger is such as to warrant us in removing the globe until we have exhausted all plans to save the injured eye.

315 New York Life Building.

Creasote in Chronic Constipation.—One of the most. difficult conditions to treat is that of chronic constipation. The objection to massage of the abdomen and electricity is that they are expensive and require much more time than many patients can give to them. Drugs are usually too powerful, and, once their action is exhausted, are apt to leave the patient more constipated than before. A physician residing in Paris, Dr. Vladimir de Holstein, claims that a satisfactory result may be obtained by administering creasote. This drug should be given pure, and not, as usually is done, in alcoholic solutions or in pills. Seven or eight drops should be given twice daily, after a meal, in a glass of water or any other liquid. If the dose is found not to act, it should be increased. Inasmuch as the patient may complain at first of the burning caused by the creasote, it is often well to begin by a smaller dose-say, one drop daily-increasing daily by one drop until the desired result is obtained. Not only is constipation done away with, but the appetite increases and the general condition is imroved.

This treatment should be continued for several months. Dr. Vladimir de Holstein thinks that creasote does not act as a purgative, but neutralizes some intestinal toxin which causes paresis of the intestinal tube.-Paris Letter to Therapeutic Gazette.

Mondeville, writing in the fourteenth century, said: The surgeon must ask without measure from the rich and get out of them as much as he can; provided, however, that he spend all the surplus in dressing the poor.

the state by the cargo. Mushrooms and olives belong to the luxuries of the table and a knowledge of and a taste for them is not to be ex

Northwestern Lancet.

MUSHROOM POISONING.

A taste for the edible fungi is increasing in this community as people become aware of the fact that Minnesota produces in the wild state a great variety of mushrooms, many of them of fine flavor. Already the shops are doing quite a little business in the sale of mushrooms gathered in the vicinity and find an increased demand for the cultivated variety. The indications are that the use of this food will spread widely when. once people get hold of the idea of eating it. At the present time it is probable that only a small percentage of the population of this state ever tasted a mushroom. A few years ago the same thing could have been said of the olive; country stores would have been searched in vain for one, while now they abound every where in the northwest and are imported directly into

With the free use of the mushroom will undoubtedly come cases of poisoning, such as have been noted in other places, although there is as yet perhaps no record of serious poisoning by mushrooms that have grown in Minnesota. It will be well then for the medical men of the state to be on the lookout for this accident and to be prepared not only to make the diagnosis, but also to administer the proper treatment. If the doctor shall also happen to have a knowledge of good and evil as related to mushrooms and can tell the safe from the dangerous it will make his management of the case much more successful, and his advice profitable to his patients in a prophylactic as well as a curative way.

There is only one rule to be followed in avoiding poisonous mushrooms and that is to know that the particular variety is safe because it has been eaten with impunity. That is the one who picks mushrooms should be able to say that he knows a kind to be good, not because it has this or that characteristic, but because he recognizes it as one that he has tried. He should know it in the same way that he knows he is picking blueberries or whortleberries and not the berries of the deadly nightshade. Those who go by any rule of thumb such as the color of the gills or the presence of rings on the stem, or still more by such crude tests as the discoloration of a silver fork cooked with the mushrooms will be likely to come to grief sooner or later.

It is to be remembered first of all in dealing with the subject of mushroom poisoning that these fungi are easily decomposed, and being largely nitrogenous may readily become the cause of ptomaine poisoning. Murrell warns particularly against this and urges that great care should always be taken that mushrooms are fresh when cooked; to warm them over he considers a dangerous practice. Ptomaine poisoning from mushrooms would be like that from the development of tyrotoxicon in milk products and would take the form of an acute gastro-enteritis beginning within a few hours after the ingestion of the poison.

Quite different from this is the typical mushroom poisoning, whose cause as far as is known

is muscarine, first described by Schmiedeberg, a colorless, syrupy mass, without odor or taste and easily soluble in water or alcohol. An account of six cases of this form of poisoning was given last summer by Dr. Caglieri, of San Francisco; it illustrated well the peculiar delay in the action of the poison. The six cases all occurred in one family and three were fatal. The mushrooms were eaten at about six in the evening. The first symptoms appeared in all the cases during the forenoon of the following day, and took the form of vomiting and diarrhoea. În most of the cases these symptoms were slight. All felt dull and stupid on awakening, and there was a feeling of dyspnoea which led them to seek the fresh air. One patient, a child, died during the evening of this day with convulsions. The two others who died (also children) showed no serious symptoms until the morning of the second day. At this time there was mental dullness, increasing to stupor, rapid, empty pulse, contracted pupils, irresponsive to light, rapid respiration, suppression of urine and free perspiration. One died on the second, one on the third and one on the fourth day after the poisonous meal. The fatal dose in all of these cases was but a small one, in two cases but one-half of a medium sized mushroom, and in the third case but one-sixth. The members of the family who escaped ate as much or more of the mushrooms, and it is supposed that there were but one or two poisonous fungi in the dish; that those who died ate these, while the others ate good mushrooms that were rendered somewhat poisonous by being cooked together with the bad. Muscarine is present in the dry fungus of the commonest poisonous variety (the amanita) in the proportion of only one-fifth of one per cent., so that the fatal dose, which has never been accurately determined, must, in the light of these cases, be a small one.

The physiological antidote of muscarine is atropine, which should be given in full dose, say one-sixtieth of a grain, and repeated if the pupils are not dilated by the first dose. With this should be given strychnine and such other stimulants. and heart tonics as are usual in the treatment of poisoning by depressants.

REPORTS OF SOCIETIES.

MINNESOTA ACADEMY OF MEDICINE. R. O. Beard, M. D., Secretary. Stated Meeting, December 1, 1897, at the West Hotel, Minneapolis, the President, Dr. J. W. Chamberlain, in the Chair.

Dr. J. Warren Little, of Minneapolis, presented a specimen from a case of extrauterine

pregnancy. The patient had never before been pregnant. She menstruated last on October 5; Dr. Little was called November 27; she was then suffering severe pain on the left side; her temperature was 97° F., pulse 160, respiration 41; the surface of the body was cold; she was in a profuse perspiration; the abdomen was distended. The diagnosis was clear; operation was performed immediately; the abdomen was found filled with clotted blood, some three pints being removed; the tube was tied off and removed. The next morning, the patient's pulse, temperature and respiration had markedly improved and she had since done well.

Dr. A. W. Abbott, of Minneapolis, presented a specimen of a double cyst and gave the following history of the case:

Miss S., æt. 38, nullipara: a generally strong woman; had been a hard worker up to two years ago. She had always suffered with severe dysmennorhoea; the pains lasting through the four days of menstruation. They were of an intense colicky nature and were accompanied by severe sacral and anterior crural pains. In addition, she had had pains of a severe griping character in the region of the umbilicus and radiating thence to the left. These occurred daily and sometimes several times each day. They were most severe at night. Physical examination showed the uterus antiflexed and retroverted; the ovaries and tubes were normal. In the right groin, just below Poupart's ligament, was a tumor of the size of a pigeon's egg, quite movable, excepting at its narrow base which could be located at about one inch from the pubic spine. It received some impulse on coughing. It was not tender to the touch and the patient had never vomited or shown any signs of intestinal obstruction. The diagnosis was uncertain. A cyst of an inguinal gland or possibly a cyst arising in the canal of Nuck was suspected.

An incision was made from the pubic spine, parallel to Poupart's ligament; the intention being to shorten the round ligament and remove the tumor through the same incison. The tumor was reached in the plane of Poupart's ligament. It was then seen that it protruded from beneath the ligament through an opening one-fourth of an inch in diameter. Through this opening the second portion of the double cyst was drawn and following it the peritoneum. This was cut off and the peritoneum closed, the margins of the opening being sutured with catgut; as the tumor was constricted between Poupart's ligament and the pubic bone, the reason of the impulse on coughing was apparent. The fluid contents were forced from the smaller portion into the larger. There has been no umbilical pain during the five days since the operation. The sac of the tumor was in direct continuity with the peritoneum, although on the larger por