their final results, and my own experience with cataract extractions, I am convinced that the surest and best vision will follow a religious observance of the following practical details.

After having decided that the patient and the eye are in the proper condition for operation, the surgeon must choose the place for its performance. A wellappointed hospital, private or public, affords the best control of the patient and his surroundings. In many cases it is best to refuse absolutely to do this operation at the patient's house-where chances are taken as regards cleanliness and proper nursing. In no case and under no possible circumstance is it justifiable to perform a cataract operation in the surgeon's office, as has been advocated and actually done. From the very nature of the operation and the condition the eye is in after the extraction of the crystalline lens, the patient cannot, without chance, get as perfect results by such a procedure, by which the dangers of infection are increased. Infection is not an impossible occurrence in any case, for, as yet, this deplorable accident is not unknown to our very best operators working under the most favorable conditions; hence to neglect any precaution against infection, in every case, is reprehensible.

The room in which the operation is done and in which the patient remains must be rendered as nearly aseptic as possible. There must be good natural light and reliable artificial light at hand, for, in case of certain accidents incidental to cataract extraction, artificial illumination is immediately required. One thoroughly competent assistant should be present, as in some occurrences his aid may be invaluable.

The patient is prepared in a general way as for any surgical procedure. This operation should be invariably done with the patient in bed. If the right kind of a bed be chosen it is quite as convenient for the operator as a chair or table. Any movement of the patient after the operation may be detrimental to his eye. The bed should be narrow and high, the height can be adjusted by additional mattresses, and with no head-board, or the head-railing should be removable. After the patient is in bed a drop of a four per cent solution of cocaine is put into each eye; then the eyes and surrounding regions are fully cleansed with soap and warm bi-chloride solution, giving especial attention to the lashes and eyebrows. Large wet pads of cotton should be placed over the patient's eyes, and his head wrapped in a moist bichloride towel, and the face surrounded with similar towels. The anesthetizing of the eye for operation is continued with either cocaine or holocain. All the solutions and all the dressings must be sterilized. The hands especially, of the surgeon and his assistants, should be beyond reproach. The cutting instruments should lie in alcohol. and then be held in boiling water; all others are boiled. The instruments are then placed in a sterilized tray and covered with a bichloride towel. The instrument

table should likewise be covered, and upon it, in addition to the instruments, are placed a basin of bichloride solution for the hands, and warm boric acid, saline and bichloride solutions in undines or bulbs" in basins of warm water.

The patient should be instructed and practiced in looking up, down, etc., and told what is expected of him, and what he may expect. The speculum should then be introduced and the conjunctival sac washed out with a warm solution of bichloride, 1 to 10000.

After the operation is completed, the toilet of the eye is performed in a most painstaking manner. Every little shred of blood, lens-matter, etc., should be removed from the eye, and the lips of the wound very carefully adjusted. This is done to facilitate healing, decrease the reaction, and lessen the amount of resulting astigmatism, whereby precious vision is gained.

Both eyes should be closed with a light dressing. First a thin layer of absorbent cotton dipped in a weak bichloride or boric acid solution should be carefully applied to each eye, which, when dry, acts similarly to a splint; then a small pad of dry cotton, and over this a flannel or cotton roller-bandage. And finally a Ring's ocular mask should be adjusted by the surgeon, as shown in the illustration. This mask thoroughly protects the eye from injuries from without.

The room should be darkened and no unnecessary conversation permitted. An attendant should always promptly answer the bell placed at the patient's bedside, for the patient should not be permitted to call, or wait on himself for anything.

The patient is required to lie flat on his back for twenty-four hours, after which time he may turn on the unoperated side, and may be raised and supported by a bed-rest for comfort and to receive his nourishment. At first the patient should receive only liquid food. Unless there be pain or considerable discomfort of the eye, it should not be opened for forty-eight hours after the operation. The eye is then dressed by the light of a candle. The bandage should be cut through

over each temple, and the unoperated eye receive the first attention. Then the operated eye is uncovered and gently bathed. Caution the patient not to squeeze his lids together or to open his eyes. A drop of cocaine is instilled between the lids, and the patient is told to open both eyes gently. After inspection, atropine is used and a double bandage applied.

The eye is now dressed daily, and on the third day one eye is given. The next day it may be permissible to allow the patient to get out of bed. Very soon the bandage may be left off during the day, but the mask must be worn constantly for ten days or so, windows being made therein, as per dotted lines in above illustration, and bent upwards.

The patient must ever be cautioned against straining any part of his body during his recovery. By following this routine in all cases of cataract extraction, a history of uneventful recovery" may very often be recorded and perfect vision more often obtained than by any other method of handling these classical cases.

The history of the following case is appended as an illustration of the technique of the operation for senile cataracts and the results we should get in favorable

cases.

For the privilege of operating on this case of double cataract I am indebted to Dr. Peter A. Callan, Surgeon to the New York Eye and Ear Infirmary, Ophthalmic Department.

Mrs. Helen McW., aged 61; general health only fair: low spirited.' Diagnosis: Mature senile cataract in each eye.

Left Eye. Duration of cataract three years, V. 1 projection normal.

November 15th. Operation under cocaine. Simple extraction upwards. Section of limbus, peripheral capsulotomy, speculum removed and lens expressed with my fingers. Iris replaced with spatula, pupil becoming round and central. Ten per cent cocaine instilled. Double bandage and Ring's mask.

November 16th. Patient restless last night and eye uncomfortable. Opening the eye, I found slight reaction, but a large prolapse of the iris. Under cocaine anesthesia, I replaced the iris with a spatula: showing no tendency to re-prolapse, the eyes were again bandaged.

December 18th. Healing uneventful. Pupil is round and clear. Vision of right eye is 38 with 10. s. c. 2. axis 180°. She reads Jaeger No. 1 at 20 cm. with 4. s. added.

Thus we observe that on November 15th this patient was blind in both eyes, and on December 18th following she had absolutely perfect vision in each eye. This satisfactory result is attributable as much to the management of the case, for which this paper contends, as to the smoothness of the operation.

Some of the Essential Features in the Diagnosis and Treatment of Idiopathic Epilepsy.-W. M. LESZYNSKY* believes that epilepsy can usually be diagnosticated without difficulty; it begins in the form of isolated attacks, which become more frequent; mild attacks must be distinguished from hysteria, though occasionally both occur in the same person; when hysteria is suspected, stigmata should be sought for during the interval between attacks. Attacks of petit mal often pass unnoticed and exist for a long time, and all suspected cases must be constantly observed. The real nature of the attack should be determined in each case before a specific plan of treatment is instituted; the physical and mental status of the patient should be investigated, and all abnormities, whether of the eye, naso-pharynx or uterus and its appendages, and bad habits corrected; since in many the persistence of attacks appears to be due to auto

November 19th. Eye quiet, pupil reacts to light. Patient allowed to get out of bed.

December 13th. The eye is entirely healed, lens capsule occluding the pupil. Operation under cocaine, discission done with Knapp's knife-needle. Bandage applied.

December 14th. No reaction, large clear space in pupil.

December 18th Vision of left eye is 28+ with

stricted if necessary. General hygienic management is of the first importance; that by drugs secondary. The drugs of most merit are the bromides, chloral, atropine, nitroglycerine and digitalis. In the use of these, judgment and vigilance on the part of the physician are required and the patient must be seen often. Bromides are not required in all cases, and in many the attacks are prevented by hygienic management alone.

*N. Y. Medical Record, May 20, 1899.

Miscellany

THE following is the program for the St. Louis Medical Society of Missouri, Saturday evening, June 10, 1899: A Report of Actual Cases Demonstrating the Relief, by Modern Methods, of Patients Hopelessly Afflicted for Many Years with Deafness from Catarrh, Running Ears, Low-Speaking Voice, Dizziness, Noises in the Head and Ears, Worse Hearing in Quiet Places, Aural Distress, etc.," by Dr. Robert Barclay.

It is reported that leprosy is spreading at an alarming rate in Russia, especially in the provinces of Livonia and Courland. The difficulty of dealing with the disease is the same that has been encountered in Norway. The Russian authorities feel a good deal of anxiety over the frequency with which the disease is found in the military examinations of conscripts for the Russian army. It is stated that more than five thousand cases are now known in Russia.

THE AMERICAN ELECTRO-THERAPEUTIC ASSOCIATION. The ninth annual meeting of the American Electro-Therapeutic Association will be held in Washington, D. C., on September 19, 20 and 21, 1899, under the presidency of Dr. F. B. Bishop, of Washington. Several papers of great scientific value have been promised and the committee on arrangements has arranged for a trip to Mt. Vernon, one to Arlington, and several other social features. The headquarters of the Association will be at Willard's Hotel, where special rates will be given to members and their families.

A MEDICAL Council is proposed for the Dominion of Canada, cast upon somewhat similar lines to that of Great Britain. It is suggested that the body be appointed, one from each province, to be named by the Governor General; one from each province, to be appointed by the medical council, and the presi

dent of each council to be ex-officio a member of the larger body. This would give twenty-four members. It is determined that the formation of such a governing body would be exceedingly difficult, but the difficulties are thought not to be insuperable. functions of the council would be to examine candidates for admission to the profession, and the license of this larger body would permit the holder to practice in any part of the Dominion.

The

THE surprising assertion is found in the recent issue of the Medical News, made by S. O. Golden, in which he reports a case of chloroform anesthesia, pushed to the surgical degree and lasting for forty minutes, in which the patient remained conscious throughout. The case differs so much from the usual run, that we can only regret that it is not reported more fully. The

question of hypnotism is by no means excluded and it is easy to understand that analgesia may be present as the result of anesthesia, but without complete loss of consciousness on the part of the patient. Hypnosis implies a partial consciousness, and it is possible that a partial degree of anesthesia induced by ether or chloroform might favor the development of a hypnotic state.

PROF. NICHOLAS SENN is announced as a candidate for governor of Illinois. Having conquered the entire surgical field, his entrance into the arena of practical politics, if pushed by his usual energy and determination, will carry him to a splendid success. Why not a physician for governor? The suggestion is met with a smile by many persons, based on the feeling that the occupation of a physician has something peculiar about it, that sets him apart from other men. It is time that the profession assumed its proper relation in public affairs, a position accorded to it in foreign countries. There is no reason why all of our statesmen should be recruited from the ranks of the legal profession.

THE International Congress of Gynecologists and Obstetricians is to be held at Amsterdam from the 8th to the 12th of August, 1899. The leading questions for discussion will be: The surgical treatment of fibroid tumors; the relative value of antisepsis and improved technique in gynecological surgery; the influence of posture on the form and dimensions of the pelvis; the indications for Cæsarian section, symphysiotomy, craniotomy and premature labor. The names of those who will take part in the discussions include a number of the leaders in gynecological surgery of the world. The official languages are English, French, German and Italian.

THE following cases of small-pox have been reported to the Surgeon-General of the U. S. Marine Hospital Service during the week ending June 3, 1899:

United States.-Louisville, to date, 475; Philadelphia, 29; Swampscott, 20; Savannah, Cleveland, 13; St. Louis, 12; Fall River, 10; New Orleans, Newport News, 9; Morgan City, Norfolk, Portsmouth, 7; Spokane, 4; Los Angeles, West Tampa City, Emporia, 3; Frankfort, Mt. Sterling, Pittsburg, 2; San Fran cisco, Jacksonville, Omaha, Massillon, Johnstown, Seattle. 1.

Foreign.-Sierra Leona, 40; St. Petersburg, 22; Athens, 24; Formosa, 19; Mexico, 16; Odessa, 8; Moscow, 6; Bahia, 3; Prague, Rio de Janeiro, Montivideo, 2; cases reported from Breslau.

Deaths.-Rio de Janeiro, 9; Athens, Mexico, 8; St. Petersburg, 5; Louisville, 4; New York, Odessa, 3; Cairo, Calcutta, Nagasaki, Constantinople, 2; Washington, Swampscott, Norfolk, Prague, London, Madras, Nuevo Laredo, Warsaw, 1.

Yellow Fever: Numerous cases and deaths in Brazil and Mexico.

Plague: Present in India and Japan, with numerous deaths at Tamsui.

MEDICAL REVIEW

A WEEKLY JOURNAL OF MEDICINE AND SURGERY

CONDUCTED AND EDITED BY

H. W. LOEB, M. D., 3559 OLIVE ST., ST. LOUIS, MO. H. N. MOYER, M.D., 103 STATE ST., CHICAGO, ILL.

AND A CORPS OF ACTIVE COLLABORATORS

YEARLY SUBSCRIPTION, $1.00

Entered at the St. Louis Postoffice as Second-Class Matter

ANTISTREPTOCOCCIC SERUM IN LANDRY'S

PARALYSIS.

A recent article says that Landry's paralysis is an infectious disease, with which we think most students will agree. It is accompanied by enlarged and softened spleen, disturbances in the digestive track and more or less albuminuria, a symptom complex pointing to bacterial infection. Occasionally streptococci and staphylococci have been found in some of the organs, but whether they bear a primary or secondary relation to the development of the disease is uncertain. In view of the very rapid and almost invariably fatal course of the infection, it is proposed to employ antistreptococcic serum in its treatment, especially as animals when infected with the pus germs or poisoned by their toxins occasionally show clinical pictures strikingly like those of progressive spinal paralysis. To our mind this is a wide departure from correct scientific principles. The enthusiasm of the admirers of serum therapy may bring the entire principle into disrepute. When a germ is accurately identified as a cause of a disease and a serum is prepared that is of undoubted efficacy in overcoming the infection in animals, then its use is justified in human beings. The wonderful results achieved in certain infections, notably diphtheria, by the use of serum therapy does not justify any ill-directed and unscientific application of the principle in diseases whose germs have not been identified.

Such an application of the principle savors too much of the explanation of the young sportsman, who had leveled his gun at an inoffensive cow under the impression that it was a deer, that he intended to hit it if it was a deer and to miss if it was a cow.

THE SURGICAL TREATMENT OF GOITRE.

THE surgical treatment of goitre has not received as extended consideration in this country as has been given it abroad. Operators like Kocher and Roux number their operations by hundreds or even thousands.

We believe that one reason is the fact that

goitre, in all of its forms, is much less frequent in this country than it is abroad. There are, of course, no figures which one could quote to support such an assertion, but we think it is generally so believed by those who have extensively studied the subject, both in this country and in Europe. Many cases of simple enlargement of the gland are not accompanied by constitutional disturbances, and the patients go through life with a moderately enlarged thyroid, without inconvenience. Moderate goitres, again, in early life and for a considerable period, do not present constitutional symptoms. Later, however, progressive weakness, nervousness, local sweatings, and rapid heart develop a clinical picture varying very much in different cases. A close distinction between ordinary goitre and Basedow's disease cannot longer be maintained, as many transitional forms are found.

In a goitre of moderate size, without symptoms, there is no occasion for operation, but when it is accompanied by disturbances of the general health which cannot be attributed to other causes, or when some other disorders originating in this gland are present, such as exophthalmos, tachycardia, or when the enlargement of the gland is so great as to seriously embarrass respiration, then surgical intervention should be resorted to. Of course, a complete extirpation of the gland is not to be thought of, but a resection or an enucleation of cystic areas can be performed with a surprisingly low mortality. Roux claims that the mortality of enucleation is about one per cent, while that from resection is from one and one-half to three per cent. The after-results of operation are certainly very favorable and far exceed those of the non-surgical treatment.

PROGRAMS OF MEDICAL SOCIETIES.

At a recent meeting of a State medical society, which was divided into three sections to meet alternately, the total length of the meeting being three days, one section contained sixty-four titles of papers to be read. The time limit was reduced from twenty

to fifteen minutes, and it was tacitly understood that but very little discussion should be indulged in. After each paper the president of the section announced formally that it was open for discussion, and with a pause of not more than a second or so, announced the following paper. The meeting to which we refer is not different from many of our State and National gatherings. For several years there has been an enormous increase in the size of the programs of the American Medical Association which has furnished a serious embarassment in the conduct of the meetings, for a reduction of the time which is commonly given to papers means a most inadequate presentation and the limiting of many writers to a mere fragmentary presentation of the subject. It is true

that a comparatively small number of papers that appear on the program are actually read, and this mars not a little the pleasure of attending these meetings. It is not an unusual circumstance to have eight or ten papers called before one is reached in which the writer and the paper are both present. It is no uncommon experience to have titles sent in year after year by members, and the paper and member be conspicuous by their absence. These evils have become so considerable that if medical society meetings are to retain their usefulness and interest, some adequate means of limiting the number of titles and of appropriately presenting the subject will have to be devised. In earlier years when writers were comparatively few and listeners more numerous, there was little difficulty in disposing of the accumulated material within the time of the meeting.

Many papers are read at medical societies which should only see the light through publication. Not that these are devoid of value; on the contrary many of the most signal advances in medical science do not admit of profitable presentation to a medical body. Those which are highly technical, which involve experimental work, largely belong to this class. The papers which should be read in medical meetings are those which deal with unsettled topics within the experience of the members. Subjects that are of interest to the entire membership, and upon which most of them have already formed opinions or have had experience, should be heard. If papers were largely restricted to communications of this character and the programs were reduced in length so that they would be reasonably certain that the paper would be read and sufficient time allowed for the discussion, it would greatly enhance the interest of medical meetings.

Fewer papers would admit of the preparation of a program some time before the meeting and the publication of a synopsis of each paper to facilitate discussion.

A form of program that has been growing in favor is termed the symposium. Instead of the members drinking and making merry together, as would be implied by the meaning of this word, a topic is selected which is divided into sub-parts which those best qualified are appointed to discuss. This plan carefully worked out often furnishes admirable results in sustaining and developing the interest of a medical gathering. It, or other means, must be adopted more extensively in the future if the attendance and interest of medical meetings is to be sustained.

At the last meeting of the Wisconsin State Medical Society a plan was adopted to meet some of the evils of the redundant program. It was decided to limit the whole number of papers to fifty, onehalf of which should be written by members selected by the committee and the other half furnished by volunteers on a competitive basis. This reduced the

number of titles upon the program to forty-three, while the year before there had been ninety-three, and in 1897 ninety-four. The plan is said to have worked very well in producing excellent communications from those who were assigned to prepare papers on special topics, but the result as to the volunteer papers was somewhat disappointing. The secretary of the society, who has had the matter in charge, thought that the difficulty with the volunteer papers was due to the fact that the plan was tried for the first time, and that its details were not well understood by the members.

A MAL-PRACTICE SUIT BASED UPON INJURIES FROM THE X-RAY.

There has recently been tried in Chicago a damage suit against Dr. O. L. SCHMIDT for injuries inflicted by the x-ray. Three x-ray pictures of the ankle and foot were made, and varied from forty to forty-five minutes. It was claimed by the plaintiff that the exposures were too long and that the tube was too close to the foot. Sometime before the x-ray pictures were made, he had sustained a fracture, with perhaps a partial dislocation of the bones about the ankle joint. As there remained some stiffness, and more or less pain following the fracture, an x-ray picture was made for obtaining exact information of the bones and joints about the ankle. The exposure was followed by an x-ray burn, with some ulceration, which led to amputation of the foot. The defendant claimed that this amputation was probably unnecessary, and there was evidence which supported this contention, and led to show that if the foot had been properly treated after the burn had been inflicted, the conditions would not have been such as to make amputation necessary.

Wide-spread interest has been excited by this case, and while the verdict has been adverse to the defendant, there is little doubt that when it reaches a higher court, if it ever does, the verdict will be reversed. There is nothing in the evidence produced by the plaintiff to sustain a damage suit, and nowhere was it shown that due diligence and care were not exercised in making the exposures. In fact, at the time the pictures were made there was no general knowledge on the part of the profession that exposures to the x-ray would cause burns or inflamma. tion of the skin. Up to that time there had been but one article published, and that in German, calling attention to the fact that exposures to the x-ray did produce such results. Unless the rule of law is to be changed by which the physician and not the patient is to assume the unknown and unavoidable risk attending an examination, then we do not see how the plaintiff in this case can recover.