office at 7:30 P.M. The membranes filled the pharynx and nasal cavities, protruding at the nares; acrid dis. charge from the nose, hoarseness, croupy cough, marked enlargement of submaxillary glands, flushed face, temperature 103 5. In about thirty hours after the injec tion of the serum the membranes had been detached. In forty hours I found her free of fever, with good appetite, free respiration, some troublesome epistaxis. No vestige of membrane was visible anywhere. Two days later she was practically well.

CASE 3. March 26, 1895. Martha B, age 2 years, W. Davis Street. Sick three days. Membranes on tonsils and uvula, enlargement of submaxillary and deep cervical glands, high fever. Forty honrs after the injection I found the throat clear, no fever, good appetite, the child lively and playful, the glandular engorgement entirely disappeared.

The specific effect in a given time of the remedy, has been so invariably unfailing that I confidently look for it in every case. I have repeatedly injected cases, and not seen them again for two days, when I found them well. Four patients, living at a distance were treated at my office with order to report again in two days.

The rapid change from profound sickness to good health is no less a proof of the specificity of the serum as a true diphtheria antitoxin. The foul tongue, fetid breath and anorexia, which seem to cry out for mercur. ial treatment, disappear in practically all cases in two days without any other than the serum treatment, and in a day or two later there appears to be no trace of illness left, except perhaps hoarseness in the laryngeal cases. Only two of the cases required subsequent treat ment for prostration and anemia; they had been sick five and six days respectively before injecting.

In the laryngeal cases, the sudden change from an exceedingly critical condition to perfect safety is intensely striking and gratifying. Before the days of antitoxin the mere diagnosis of diphtheritic croup in the sixteen cases which recovered would have been equivalent to a fatal prognosis; to-day I feel certain, that, had the three fatal cases been injected twenty-four hours sooner, there would not have been a single death among the forty-eight. Emil Behring's claim, that there is no death in any case injected during the first two days of the disease, I believe to be founded on truth.

There has been no untoward effect resulting from the injection, except some local soreness and swelling, which always passed off in two days without treatment. Two injections of 2 cc. of Behring's serum, used for immunizing purposes, were followed next day by a gen. eral erythematous rash, resembling scarlatina, which passed off in a day without having caused any constitutional disturbance.

While many of the cases are of too recent date to confidentially state, that no one was followed by paraly. sis or heart failure, I have had none of these sequela so far, nor do I fear them to supervene, from the fact that the duration of the disease has been so short that severe toxic symptoms developed in no case.

CASE 12. Lulu S, age 20 months, 116 W. Marceau; sec ondary laryngeal diphtheria; succumbed in a few weeks to cerebral meningitis. She had made a rapid recovery after a threatening condition, was in perfect health for uine days, and then developed a typical case of meningitis of which she died in a few days. A careful analysis of the case convinces me that this death can not be attributed to either diphtheria or antitoxin.

A second injection was resorted to in three cases. While I have not deemed it necessary to inject the large doses which Dr. Saunders has given, I fully concur with the Doctor's advocacy of a full initial dose, graded to the severity of the case. Second or third injections after a day or two are probably inefficient.

The diphtheria epidemic in this locality during the last three months differed from any preceding ones I have witnessed by the great preponderance of laryngeal and tracheal cases. I have not seen in it a single case of the intensely septic type, so disastrously fatal in 1885 and 1886, characterized by gangrene of the throat, cervical adenitis and cellulitis, and death by blood poi. soning. I believe that antitoxin, promptly and freely administered, will prove as beneficial in this as in the other forms of the disease, and that many of my cases this year would have assumed a like septic character had the disease not been cut short early.

Until five ar six weeks ago, I treated mild cases of tonsillar diphtheria without antitoxin. Nearly all those patients would convalesce slowly, often presenting for weeks the familiar anemic condition sequent to the dis ease. One of these slow, mild cases was followed in five weeks by paralysis of the palate.

CASE 10. October 6. Henry B., age 21 years, 8116 Ivory Ave., is one of four cases occurring simultaneously in the same family. Three younger children had tonsillar diphtheria of a mild type, and were treated with. out serum. The case in question developed after two days an extension of the membrane into the nares, with high fever, great prostration, intense glandular swell. ing, and was treated by serum. A few weeks later be was in excellent health, while the three other, milder cases, after a slow convalescence, showed all evidence of having passed through a serious illness. At present I treat every case of diphtheria with serum as soon as the diagnosis is made, refuse to take cases when this is objected to, and am convinced that no supplementary treatment is required, excepting perhaps antiseptics topically in gangrenous cases, and intubation to ward off impending asphyxia.

For immunizing purposes I injected the serum in about forty cases, of which I have kept no record. None of the children so protected have since had diph theria; although isolation in most cases was not practi cable, and was not insisted on.

There was, then, in these forty-eight cases of undoubted true diphtheria, not a single failure of the curs. tive effect of the serum. The three deaths, occurring in one, three and five and a half hours after the injec tion, can not be called failures, since we know that the

effect of the remedy can be looked for only in from abdominal ostium of the Fallopian tube was closed and twenty to thirty-six hours. After the official collective the fimbriated extremity was filled with a brown fluid investigation by the German Government, covering producing a cyst as large as a hen's egg. Some parts of many thousand cases, and with my own experience, the the cyst wall were still lined with coulmnar epithelial question of the value of the serum is for me no more cells, weile others were not. At the lowest part of the debatable. Objections to the antitoxin treatment, sack (b), a mass of connective tissue was present, in whether based on theoretical grounds, dogmatic obsti- which no ova could be found. The specimen was a nacy, or ignorance, are silenced by the "brutal force of hydrosalpinx.

CASE I.-HYDRO SALPINX. Mrs. R, white, age 32, CASE II.-UNILATERAL LACERATION OF CERVIX AND married housewife. This patient gave birth to a child ENDOCERVICITIS.-Mrs. D., age 42, married, housewife. about three years ago. Eight months ago she had a This patient had good health until June, 1895, when miscarriage, after which headache, pain in the back, and in the right side of the abdomen frequently oc curred. Her menstruations were irregular, sometimes scanty, other times profuse.

On October 18, under the influence of chloroform, a bimanual examination revealed a growth in the right ovarian region, as large as a hen's egg and movable to a certain degree. Its consistency was about the same as that of an ovary. The uterus was in the normal position, enlarged, and the uterine cavity was three and three fourths of an inch deep. Diagnosis-Cystic ovary.

During the past twelve hours the abdomen was covered with an antiseptic pack. The bowels were moved by a saline cathartic and an enema. The vagina was thoroughly cleansed with soap and water and then irrigated with 1-2000 solution of bichloride of mercury.

metrorrhagia and pain in her back and limbs began and persisted until now, making her very weak and nervous. On October 9, under the influence of chloroform, bimanual examination revealed the uterus to be enlarged, softer than normal in consistency and movable. The cervix was lacerated on the left side. The laceration extend. ed into the cervical canal about three-fourths of an inch and outward to the periphery of the cervix.

The laceration had a red granular appearance. October 15. During the past twelve hours her bowels were moved by a saline cathartic and an enema. Her vagina was thoroughly cleansed with soap and water and irrigated with 1-2000 bichloride of mercury solution. Under the influence of chloroform the uterine cavity and cervical canal were thoroughly curetted. The cervix was then brought into view by three tenaculum forceps. One forceps was placed on the anterior lip, one on the posterior lip and one at the outer angle of Under the influence of chloroform an incision three the laceration. With a scalpel all of the cicatricial tisinches long was made between the umbilicus and the sue was removed. The denuded surfaces were then ap symphysis pubis in the median line. The uterus was proximated and sutured with three chromic catgut suin the normal position. On the right side was found a tures. On the right side was found a tures. The vagina was lightly packed with iodoform tumor as large as a hen's egg bound down in Douglas' gauze. No febrile reaction followed. A section of the cul de-sac. After some strong efforts the mass was cicatricial tissue removed gave the following appearance. loosened and brought into view. A silk ligature was The red granular surface (a) consisted of adenomathen placed around the uterine end, and another around tous tissue while the outer section (b) was covered with the infundibulo pelvic ligament. The mas was then a layer of squamous epithelial cells. (Fig. 2). removed. The abdominal wound was closed with silk sutures.

Her temperature ranged between 99 and 101 until November 1, when it returned to normal and remained

80.

CALE III.-ENDOCERVICITIS AND FUNGOUS ENDOME. TRITIS.-Mrs. O., age 28, widow, stenographer. This patient had one child and one miscarriage. Her menstruations have been regular. During the past ten years she has been suffering with leucorrhea, a bearing down senation in the region of the uterus, headache and backache.

An examination of the mass revealed a complete obliteration of the lumen of the tube at (a). No trace of epithelial cells was found in the tube. Inflammatory On October 22, under the influence of chloroform, biconnective tissue replaced the mucous coat. The circu manual examination revealed the uterus to be mobile, lar and longitudinal muscular coats were present. The in the normal position, the body enlarged and thickened

anteriorly and posteriorly. An abundant muco puru thoroughly curetted and irrigated. Then an application lent discharge was present. Both ovaries were normal of Churchill's tincture of iodine was made to the uterine cavity; no febrile reaction occurred.

Cataract.

BY DR FLAVEL B TIFFANY, KANSAS CITY, MO.

[CONCLUDED.]

Let us now consider the steps in the two operations of extraction, the simple and that with iridectomy. In each operation the incision is made at the limbus, embracing corneal tissue throughout. As in di-cission, we should enumerate the different steps, laying out the instruments (Fig. 34) necessary for each, taking care that all are at hand before proceeding to operate. First, lay out speclum; second, fixation forceps; third, rat toothed forceps, (in case that it is necessary to steady the eye before fixing); fourth, von Graefe's bi-concave, narrow, linear knife, taking care that it is in perfect order; fifth, iris forceps; sixth, iris scissors; seventh, capsular forceps; eighth, cystitome; ninth, two

CASE IV-CORPOREAL FUNGOUS ENDOMETRITIS.-Mrs. curettes. These instruments should always be at M., white, age 32, married housewife. This patient had good health until the birth of her last child two and a half years ago. Since then she has been afflicted with backache, headache, pains in the abdomen, impaired digestion, and has menstruated irregularly.

hand whether the simple operation or that with iridectomy is to be made, we can not always foretell whether it would be expedient to make iridectomy or not until after the knife has entered the eye. The instruments should be passed into boiling water imme. diately before using. My custom is to have a gas stove by means of which boiling water is secured at any and all times. In the boiling water I dip the instruments before and after all operations. The boiling water is preferable to any antiseptic solution as it does not affect the edge nor rust the instruments. The operator as well as the assistant should cleanse his hands and finger nails by means of soap and nail brush, and should The be scrupulously careful as to his personal toilet, remov. ing his coat and operating in clean shirt sleeves, or better, immaculate surgeon's gown.

On October 16, under the influence of chloroform, bimanual examination revealed the uterus to be enlarged, softer than normal and retroverted. The right Fallopian tube was thickened. The right ovary somewhat fixed. A piece of the mucous membrane was removed from the cavity of the uterus by the curette. A section gave the following microscopical appearance. (Fig. 4). October 17. During the past twelve hours her bowels were moved by a saline cathartic and an enema. vagina was thoroughly cleansed with soap and water and irrigated with 1-2000 bichloride of mercury solution.

After the instruments have been dipped into the boilUnder the influence of chloroform the uterus was ing water, pass them into boric acid solution, then lay

learn, if possible, to operate with the left hand as well is kept well to the border of the chamber (Fig. 39), as with the right, and this can be acquired by practice. there is less danger of wounding the iris than when the When I first commenced to operate I dared not trust point is thrust deeply into the center of the chamber. my left hand and was obliged to resort to the awkward position when operating on the left eye. I now operate with the same assurance with the left as with the right, always taking the position at the head of the patient.

The pupil having been dilated, the nose and face must be scrupulously washed with soap and water, and spe cial care taken to cleanse with the brush the brow and lashes. The eye anesthetized and again flushed with boric acid solution, we make the operation in the following manner:

о

FIG. 38.

If the knife should have been introduced too deeply the point may be withdrawn; however, it is not advisable to withdraw the knife, for the aqueous humor escaping allows the iris to come forward which is very liable to wrap around the edge of the knife and interfere with the steps of the operation. Some operators, as for instance, Galezowski, are in the habit of going to the cen

First separate the lids with the speculum, taking care that the instrument does not press upon the eyeball. Noyes' (Fig. 37) is one of the best forms that we have, as it separates the lids without pressing upon the ball, and hugs the temple so as not to interfere with the opter of the pupil, and with the point of the knife incising erators' finger or with the instrument.

G.TIEMANN-CO

FIG. 37. NOYES' SPECULUM.

The second step is to fix the eye with the fixation forceps, which we do by grasping the conjunctiva near the limbus about in line with the inferior rectus.

the capsule before making the counter-puncture, thus securing capsulotomy at this stage of the operation. Care should be taken in making the counter-puncture at the limbus that it be slightly within the cornea; the tendency is always for the beginner to misjudge the distance or depth, and dip too deep so as to pierce the sclera instead of the cornea. The incision should be made at first by the point of the knife urged forward and kept all the time at the limbus, being cautious not to withdraw the knife until as much of the incision has been made as possible with the point, thus preventing

The place of the incision is preferably the upper part of the cornea rather than the lower and very few operators of to-day make the incision at the lower part, although some of the German operators adhere to the lower incision, claiming that this is the most simple, and gives the most promise of vision to the patient, and as that is the main desideratum, they don't take into consideration in the least the cosmetic effect. I noticed while at Halle that even Graefe himself made all his incisions at the lower part and invariably employed iridectomy The difficulty of the delivery of the lens from an incision made at the upper part compared with that at the lower part is so slight and the other advantages so great, that the upper is the one that should be selected, other things being equal. Of course, in case of complications, for instance, opacity of the cornea, then the incision with the escape of the aqueous, for as soon as the knife iridectomy should be made so as to bring the artificial (which has up to this stage acted as a wedge), is with. pupil opposite the clearest portion of the cornea, and as drawn, the incision gapes, and there is an escape of the near the visual line as possible. The incision should be aqueous with an advancement of the iris. Should the made to embrace from one-third to two-fifths of the iris fold over the knife it may be replaced by making perimeter of the limbus. The puncture and counter- slight pressure with the finger on the cornea; but if it puncture should be at the sclero corneal juncture and can not be easily disengaged, the incision should be com about 3 mm. from a horizontal line tangent to the upper pleted by a to-and-fro movement of the knife severing the borders of the cornea (Fig. 38). If the simple opera- fold of iris. In completing the incision, care must be tion is made, it is safer to pass the knife directly through, not entering deeply into the anterior chamber as is rec. ommended in most text-books. If the point of the knife

FIG. 39.

taken not to drag upon the eye, allowing the knife by its own virtue to cut its way out; and the incision should also be completed very slowly without traction, lest by