are shaded, thus favoring the dilatation of the pupil, served without the ophthalmoscope; yet, the amber allowing more light to enter the eye. A mydriatic color of age contrasts strongly with the deep black pu (atropia) also enables him to see better. This is espe- pil of youth. Focal illumination, however, will reveal cially true of a nuclear cataract, whereas the reverse is any slight opacity of the lens and by use of it the lens observed in zonular or lamellar cataract in which the can be thoroughly searched. The illumination in order patient can see better when the pupil is contracted, or to bring out sharply any slight opacity should not be with the face to the light, the pupil being then moder too intense. ately contracted. In nuclear cataract the opacity is usually more con fined to the nucleus, while in the zonular it is the peripheral portion that is mostly opaque. Senile cataract is usually bilateral while juvenile as a rule is confined to one eye. DIAGNOSIS. In pre-ophthalmoscopic days the detection of cataract was somewhat difficult, the amber tint of the lens in advanced age was often mistaken for incipient cataract, whereas there was no opacity of lens. Thanks to Helmholtz, we are now able to assure ourselves The pupil changes in color from the normal black, quickly by means of the ophthalmoscope and converg varying from a slight grayish white to a more dense ing lens (Figs. 17 and 18) if there be the slightest greyish white opacity. The striæ of a hard or nuclear cataract are much more numerous and are finer than in soft cataract, and the nucleus is of an amber tint with a dense opacity (Fig. 16). opacity of any of the refractive media. When the opacity is considerable it can be detected by the naked eye. The pupil instead of being black as in the physiological condition will appear of an opaque, opalescent, greyish white. The physiological appearance in old age might be mistaken by the superficial or casual observer for cataract; especially is this the case in the negro, where, with a slight density of the lens and yellowish cast of the nucleus with the reflex from the ash color of the negro's fundus the appearance simulates cataract. However, the ophthalmoscope will immediately settle In incipient cataract scarcely any change can be ob- the question as to any real opacity of the lens; for if At the border of the lens occasionally we see opaque striæ extending all round, usually slightly more dense at the upper and lower portion. These can only be seen when the pupil is widely dilated. They may be the beginning of cataract although they frequently remain stationary throughout life. They are called gerontoxin lentis, or arcus seniles lentis. there is the slightest cloudiness of the lens it will ob struct the red reflex rays from the retina, and the shape and size of the opacity will be revealed. If the cloudiness or opacity is confined to the edge of the lens, as in zonular or lamellar cataract, it will be necessary to dilate the pupil in order to detect it. Occasionally, when the opacity is in the nucleus and very small it may be overlooked but as aforesaid by magnifying lens in front of the ophthalmoscope the slightest trace of cloudiness should be revealed. If the striæ appear opaque viewed at a certain angle and clear at another, it shows that the opacity is due to an irregularity in refraction due to the condition of the inter and intra-laminal spaces. To make a more search ing examination, a magnifying glass behind the mirror should be used, the observer, getting close to the eye. By this examination the slightest defect of the lens ought not to escape observation. If the opacity begins at the posterior surface, the eye should be carefully ex. amined as to its condition at the fundus; for this spe. cial primary seat is indicative of some disease of the back part of the eye, as choroiditis. Mature cataract is that form in which the lens is so completely opaque as to exclude light, the person being no longer able to distinguish objects; but no cataract is ever so dense the eye being otherwise in a healthy condition, as not to allow sufficient light for the person to discern objects when passed before the eye or to be able to tell the direction from which the light occurs; for instance, the light of a lamp or candle in a dark room. Anterior polar cataract can be easily recognized from the circular shape, small size, and its location. FIG. 19. Hard or nuclear cataract usually begins in the nucleus, occasionally in the cortical portion. If the affec tion begins in the nucleus and is limited to this part, the cataract develops very slowly. The nucleus be. comes more hard and dense, and after several years the entire lens may be involved. It is called nuclear, or senile cataract. We usually speak, however, of all forms of senile cataract as nuclear; for in all cases of cataract developed from old age the nucleus sooner or later becomes densely opaque. In soft cataract the converse is true, the nucleus never becomes hard or densely opaque, the opacity begins in the cortical or lamellar portion and is characterized by large, wide, opalescent centripetal stripes. These stripes and ab sence of the opaque yellow or amber tint of the nucleus constitute one distinguishing feature of the soft cataract when compared with the hard or nucleur cataract whose strise are fine and more numerous. Soft cataract de velops much more rapidly than hard cataract. Wide stripes always indicate a rapid development whereas narrow stripes indicate a slow progress. In early stage of senile cataract there may be more or less myopia, due to swelling of the lens. In the use of the ophthalmoscope in partially developed cataract there is more or less red reflex from the retina. In mature cataract the red reflex is entirely absent. In nuclear cataract where the opacity has not reached the cortical portion, a bright red ring will appear at the edge of the pupil. FIG 20. Posterior polar cataract is deeply seated, and so near the nodal point that when the eye is moved it does not change its position, or if so, very slightly (Fig. 19). This is the principal distinguishing feature of posterior polar cataract. It need not be mistaken for any other form, nor should it be mistaken for opaci. ties of the vitreous, the former being stationary, the latter floating. When viewed by the ophthalmoscope, the opacity is usually stellate and appears smaller than it does by the oblique illumination. Lamellar cataract in the young is frequently mistaken for myopia, or near-sightedness, as the little patient in order to gain a more distinct image brings the objects nearer to the eye; but glasses do not correct this defec tive vision. By focal illumination (Fig. 20) we can distinctly make out a clear layer of lens substance between the zone of opacity and the nucleus, the superficial layer of the lens being clear. Fluid cataract simulates soft, but does not always ex- distinguished by certain appearances of the pupil. ist in young persons; it may occasionally be found in Numerous fine opaque striæ indicate hard cataract. adults, and it should not be mistaken for hard and an Broad and less numerous striæ indicate soft (Fig. 22). extraction be attempted. It is characterized, by absence Where there are no striæ or patches and the lens ap. of striæ, either broad a narrow, and is more granular, pears amorphous, fluid cataract is indicated. In the a milky white color. latter frequently the nucleus of the lens may be seen gravitated to the lower part. PROGNOSIS. The opacity of the lens never disappears spontane The Morgagnian or black cataract is characterized by its dense color, a sort of a rusty iron red, and it is al most always secondary, the lens opacity being due to absorption of cholesterine from intraocular hemorrhage. Morgagnian cataract also is spoken of as that peculiar condition in which the cortical portion of the lens has ously. However, dense the opacity may be, it in itself become fluid and the nucleus had gravitated towards the lower part of the capsule of the lens. This is a semi-fluid cataract, and it always indicates other dis. eases of the eye. This form, as also the fluid cataract, may come under the head of hypermature cataract. will not produce total blindness. In mature cataract (provided that there are no complications) the person should be able to see a lighted candle or lamp in the room several feet away and tell the direction from which the light comes. Diabetic cataract has not the distinguishing features that many other secondary cataracts have. It is sup posed to be due to a deposit of sugar within the lenticular substance, and it may be soft or hard, usually hard. Glaucomatous cataract is hard cataract and is sequent to glaucoma. The pupil is always widely dilated and of a greenish hue the anterior chamber frequently is deep, and oftentimes there is a tremulous iris which indicates fluidity of the vitreous body. In this form of cataract, vision is usually destroyed, there being no perception of light. Traumatic cataract in appearance is similar to the cortical or lamellar cataract and comes on soon after the injury, varying from three days to as many weeks. It may be a partial or complete opacity of the lens. Senile or nuclear cataract (Fig. 21) is the most frequent form that we have to deal with, and appears usually after the fifty-fifth year of age, occasionally after the forty-fifth but never before the thirty-fifth. Its most frequent time of development is between the fiftieth and the seventieth years. The opacity usually begins in the nucleus. FIG. 22. Before giving the prognosis the field of vision should be taken by the perimeter (Fig. 28). If contracted this may indicate some disease of the fundus; such as scotomata, detachment of the retina, disease of the choroid or other parts, and, of course, bedim the prognosis. Cataract with a pre existing myopia does not promise well; frequently there is posterior staphyloma or even detachment of the retina. Usually, it is accompanied by opacities of the vitreous. The tension should be taken by slightly pressing upon the globe. An increased tension suggests glaucomatous complications; and if there is tenderness and soreness, or has been pain in or about the eye, and the eye is abnormally hard or soft, the prognosis must be guarded. A very yellow or a very white chalky lens, or one with many spots of opacity on the capsule signifies disease of the vitreous humor or some deeper part of the eye. If the lens is shrunken and cretaceous with a tremulous iris, fluidity of the vitreous and choroiditis To sum up the different forms of cataract are easily are indicated, which cloud the prognosis. A highly myopic eye does not promise such good results as the emmetropic or hyperopic eye. The pre existence of musca volitantes (floaters) does not necessarily indicate any serious disease and need not be taken as a bad omen. after extraction, the incision being free from any clots, shreds, or iris. A bad cough or nausea and vomiting militate against the results. The pupil should be active and respond freely to the stimulus of light as well as to the mydriatic. We should be wary of cretaceous and of fluid cataract. A tremulous iris (iridodonesis) bespeaks hyalitis and synchisis. Adhesions or synechiæ foretell a previ ous iritis and a damaged eye. We should consider well the gravity of operating on an eye that is above or below the normal tension, or on one with a widely dilated pupil. In these cases the per cent of success is low in comparison to those that are uncomplicated, the success in the former being perhaps not more than 5 or 10 per eent, while the failures in the latter should not be more than this amount. 2 3/0 A deeply seated eye with a prominent orbit makes the operation more formidable, and yet, it is thought that an eye that is prominent is more tardy in healing. [TO BE CONTINued.] Evil Results of Nasal Applications.-Bischof (Therapeut. Monatsheft., September, 1895), summarizes the occasional evil results of local application to the nose. Otitis media following the nasal douche may be avoided by attention to the following points: The douche must not be at too high pressure, nor too prolonged; no swallowing or coughing to be allowed dur. ing douche; head to be slightly inclined forward; douche to be administered through the narrower of the two nostrils; nose not to be blown in the ordinary manner just after douche, but patient to close one nostril while he blows out through the other; fluid used, to be at first lukewarm, then gradually cooler; nozzle of douche not to fit the nostril tightly; cotton-wool to be worn in the ears after douche. Neuralgia results some. times from allowing the stream of a douche to impinge on the roof of the nasal cavity; the nozzle of the douche should therefore be either horizontal or pointing down. wards. Impairment or even permanent loss or smell may result from the use of too strong solutions of zinc salts or alum. Nasal insufflations less often give rise to trouble, but powders should be used as weak as pos sible, for the mucous membrane is sometimes very sensitive to the stronger powders; prolonged lachrymation with swelling of the whole nose, neuralgia of the fifth nerve, and sometimes even membranous rhinitis following their use. Where chromic acid is applied to the nose, an alkaline douche should be used after the patient has blown the nose thoroughly; neglect of this has led to severe toxic symptoms due to swallowing of chromic Dr. Noyes, in speaking of the flap operation, acid. Adhesions between adjoining surfaces after use says that in 10094 cases by 35 different operators the of caustics or galvano-cautery are to be avoided by apfailures were 10.4 per cent, taking as a standard of suc-plication of ointments, and daily breaking down of adcess vision 1/10. In 10664 cases by 110 operations the failures were 5.8 per cent. These statistics were gath ered in 1879. FIG. 23. Since then with our more careful, scrupulous antisep tic treatment, the failures in senile, uncomplicated cataract should be less than 5 per cent with the standard of success vision / hesions. Many nervous disturbances have followed the use of the galvano-cautery, for example, headache, neuralgia, asthma, and in several cases more serious and even fatal results, especially pyemia and thrombosis of cerebral sinuses. The danger of septic processes is still greater in operations on the nose associated with much bleeding, for example, removal of polypus or growth, correction of septal deviation, etc. In view of such cases all instruments used for nasal operations should be sterilized, and the nasal cavities should be irrigated with antiseptic fluids after all such operations--Brit. Med. Jour. The elements of success are an obedient, hopeful, tractable patient; a cataract mature and uncomplicated; a smooth, correct incision; a delivery of the lens in toto without bruising the iris or contiguous parts during its transit; and a perfect coaptation of the lips of the wound to a great many others among which he also mentions two proteus forms. Dr. Jaeger draws the attention of Dr. Banti to the fact that in his article on "The Infectious Febrile Icterus" (Weil's disease) he (Jaeger) proved that the etiological factor is a proteus infection and he intimates that the bacterium found by Banti is a proteus form and that the many capsulated bacteria which Banti mentions as being similar to well known forms of bac. teria are simply evolutional phases of the same bacterium which he considers to belong to the proteus variety. In order to avoid confusion and the possibility of scattering the accumulated literature upon the subject by the suggestion of an entirely new form of bacterium Dr. Jaeger draws attention to his article which he thinks has been overlooked by the Italian savant. He agrees with Banti that the bacteria causing icterus must have an hemolytic action. He also supports Banti in the YEARLY SUBSCRIPTION, $3.50. SINGLE COPIES, 10 Cents. presumption that other varieties of bacteria not belong TO CONTRIBUTORS AND CORRESPONDENTS. All letters whether intended for publication or not must contain the writer's name and address, not necessarily for publication. No attention will be paid to anonymous com munications. Secretaries of medical societies will confer a favor by keeping us informed of the dates of the meetings of their respective societies, and of officers elected. Members of the profession who send us information of matters of general interest to our readers will be considered as doing them and us a favor, and we shall take pleasure in ing to the proteus group may have a similar hemolytic property. We notice in a recent article of the Deutsche Med. Wochenschrift, by Prof. Banti, that he refutes the propriety of classifying the bacterium found by him with the proteus bacillus found by Dr. Jaeger. The misunderstanding, according to Banti's explana. tion, is due to the fact that he aud Bordoni Uffreduzzi have designated two forms of bacteria respectively as proteus capsulatus septicus and proteus hominis capsu latus, on account of the pleomorphous properties of these organisms. The word proteus implying variability. inserting the substance of such communications. Communications, Medical Books for review, and all letters Banti asserts that there exists a decided difference becontaining business communications or referring to the pub-tween the proteus bacteria described by him and Borlication, subscription, or advertising department of the doni Uffreduzzi and those belonging to the proteus vul. REVIEW, must be addressed to O. H. DREYER, Publisher 112 N. 4th Street, St. Louis. garis and mirabilis (of Hauser) with which Jaeger clas sifies the bacterium of Weil's disease. Moreover, Banti states that he was well acquainted with Jaeger's article Entered at the St. Louis Postoffice as Second-Class Matter. and that the case which he subjected to a bacteriologi Infectious Icterus-The Banti-Jaeger Controversy. Although icterus is merely a symptom of a great variety of diseases, it has been found by H. Jaeger, of Stuttgart, that there is a febrile infectious form of icterus (Weil's disease) which is due to a proteus infec tion. The proteus is a pleomorphous bacterium of which there appear to be a great many morphological varieties some of which exhibit toxic properties of great intensity by the production of a proteid substance which possesses hemolytic properties. cal examination was not a case of Weil's disease but of an icterus levis. The above short sketch of the controversy between Banti and Jaeger is an exceedingly interesting and instructive one, particularly to those who have not the time or inclination to follow the various discoveries within the continuously growing range of bacteriology. It affords to the less initiated observer a view into some of the most difficult problems agitating the minds of original investigators in bacteriology. It is the variation in the morphology and biology of bacteria, which will necessitate their exact botanical classification, a problem, often, of the greatest difficulty. Recently Prof. Banti, of Florence, has described a Cases of febrile icterus in which the cause is obscure bacterium which he cultivated by inoculating culture create decidedly the impression of being due to a toxic tubes with the blood of the spleen taken from a patient infection. In how many cases this infection is suffering from an icterus infectiosus levis. Only one due to a toxin produced by bacteria is still an unsettled form of bacterium grew upon numerous culture-tubes. question; it is just as reasonable, however, to suppose Banti states that the bacterium found by him is similar that the absorption of bile into the circulation will |