medicine is greatly overtaxed. There are at least three physicians where there should be only one. The business done by three would make a fair living for one were it equally distributed. But this, of course, cannot be done, for a few, as in all occupations, do the lion's share-the majority of the business. These few, as a rule, I am sorry to say, consider themselves superior beings. In their own estimation they absorb and control the superlative Heaven. They look down upon and spurn the young physicians, and do all they can to prevent them from getting into practice. They may have more than they can themselves do, but will let their patients suffer and even die from lack of proper attention rather than recommend some one else, particularly a young physician.

We have too many medical colleges and too much competition between them. Great efforts and concessions are made to induce students to attend these colleges. Hence we are annually having two or three times as many M.D.'s turned out as are actually necessary. They are graduated and sent out to practice, or try to practice and starve. Extending the course of study to four years and requiring some education before entering will, to a certain extent, curtail the number of new doctors. We are a city, I suppose, of about two hundred thousand, and have seven medical colleges. This is just five more than required. But should there be but two, how in the world could fifty or sixty doctors get their names before the public?

I think we may say it is a fact that the practice of medicine does not pay, and a fewer number obtain a competency than in any other business or profession. This, however, the young man or boy cannot be made to believe, and he will go on studying for a doctor ad infinitum.

To be a successful physician requires more than knowledge obtained from books. There must be an aptness for the business. We must have good judgment, quick comprehension, sympathy, kindness and good business qualifications. I do not believe a physician has

ever made a competency in the practice of medicine who could not have made more money in some other branch of business. How true it is, and how lamentable, that probably a less number of doctors are financiers than are to be found in any other business. Why this is so I cannot explain. It may be that they have less time and inclination to attend to the business of making money than they have to the relieving of suffering and the cure of the sick. These absorb all their faculties, and business is not attended to. Or it may be that those who study medicine have less natural business business qualifications than

others.

At any rate, it is a fact to be deplored that few physicians save any money. Even those who do the greatest amount of practice frequently die without having a very large bank account.

That physicians are more charitable than any other class of people I actually believe. They are so often brought into the presence of suffering, accompanied with poverty and want, that they would have a hard heart indeed if their hands did not frequently find their pockets to contribute to necessity. This is one means of keeping physicians poor.

There is no profession or people who do so much work where they receive no remuneration as the physician. They are constantly giving their time, wearing themselves out physically and mentally, for the benefit of the sick poor. I think I would be safe in saying that at least one-third of the practice of medicine that is done in this country is gratuitous. This, of course, is a means of reducing the physician's revenue.

Therefore, taking everything into consideration, I think I am perfectly safe in saying, in closing this paper, that it does not pay financially to be a physician.

GUAIACOL applied locally seems to be a safe and efficient remedy in relieving the pain of arthritis deformans, acute articular or muscular rheumatism, sciatica, orchitis and epididymitis. One part of guaiacol to ten or fifteen parts of vaseline or lanolin should be applied to the painful parts. - Journal of

Medicine and Science.

OPHTHALMIC MEMORANDA.

BY DAVID DEBECK, Sc. B., M.D., CINCINNATI,

OPHTHALMIC SURGEON, ST. MARY'S AND GOOD SAMARITAN HOSPITALS.

Cataract

Nutrition of the Lens and Formation. (Abstract of a paper by Dr. Louis Stricker, read before the Ophthalmological Section of the American Medical Association, at Columbus, June, 1899.)

The crystalline lens undergoes its successive changes of development, progression and retrogression, although devoid of bloodvessels, nerves and lymphatics. Its nutritive supply is derived from the vitreous (possibly, also, the aqueous), both likewise devoid of these structures. The lens is thus practically immersed in its nutritive supply, which permeates its interlamellar and interfibrillar interspaces; more perfectly, however, in the cortex than in the nucleus.

The lens responds in a purely passive manner to the influence of the zonula fibres, hence with each accommodative effort the fluid in the interfibrillar spaces changes its position, thus producing currents by which this fluid is forced onward, while fresh nutritive material enters the capsule by osmosis. Later in life, after the nucleus has become less resilient and no longer gives to the same degree as does the cortex during accommodative efforts, splits and fissures develop. In these the nutritive fluid stagnates, depriving the neighboring fibres of fresh nutritive fluid; chemical and degenerative changes follow, and thus the first cataractous changes are set up.

From this the conclusion has been drawn that the vitreous gives the lens an abnormal or deficient nutritive supply. The albuminous increase in the aqueous is derived from the lens, being not a cause, but a result, of the For it has been shown that the senile cataract contains a less amount of albumen and more water than the senile non-cataractous lens from the same period of life.

cataract.

The epithelial cells which line the anterior capsule are the principal factors not only in the production of the lens fibres, but in the protection of the lens as a whole. They also exert a selective power in the assimilating of nutritive material, and serve as a barrier against the entrance of abnormal fluids which would exert a detrimental chemical action on the lens fibres, or which would change its

index of refraction and so cause it to become opaque. It is a well-known fact that direct contact of normal aqueous or vitreous with the lens fibres in the living eye causes these to swell up and dissolve-an ordinary observation in traumatic cataracts and in needle operations. Hence there must be something present in the aqueous or vitreous which, while the integrity of the lens remains perfect, is prevented from entering the capsular sac. Even where there is but a partial destruction of the epithelium lining the capsule, fluids inimical to the lens gain entrance and cataract results. The entrance of pathological fluid, or of normal fluid which under proper conditions should not pass through the capsule, leads to a solution of some of the cortical substance; some of the constituents of the lens are removed; the intra-capsular pressure is reduced; various forms of pathological cells develop; hyperplasia of the epithelial cells lining the capsule takes place, and capsular cataract results.

It has been assumed that the entrance of the nutritive supply is between the zonula fibres, but this is still a matter of doubt. Its accepted exit is a circular area around the anterior pole. The vis-a-tergo from behind, and the suction power in the anterior chamber produced by the absorption along the line of the canal of Schlemm, must keep up a continuous circulation of nutritive material, and this is undoubtedly assisted by the changes in the shape of the lens during accommodative efforts.

The cataract developed in glaucoma is an instructive illustration of these points.

Post-cortical cataracts of chorio-retinitis or retinitis pigmentosa are the result of the osmosis posteriorly of a defective or abnormal nutritive supply from the vitreous, the lens having no epithelial protection posteriorly.

All varieties of cataract (excepting the congenital) may be explained on the basis of chemical change. The interchange of fluids in the lens is purely passive-entirely chemical or physico-chemical. The variety of cataract depends upon the character of the nutritive fluid and the intensity of its action, these being modified by the time of life; the only physical conditions which might have an influence being possibly temperature and electrical action. The chemical constitution and index of refraction of both aqueous and vitreous in the normal eye is practically the same. In the cataractous eye the aqueous contains

more albumen. The vitreous during cataract formation has not yet been analyzed, but opacities in it have been clinically noted.

In all constitutional diseases, as diabetes, albuminuria, gout, anemia, cholera, etc., a defective or abnormal nutritive supply gradually leads to death of the epithelial cells at given points; pathological fluids may thus gain access, and these resultant effects upon the lens fibres follow. Such conditions may even occur during intra-uterine life. In congenital cataracts there is possibly a defective or tardy development of the capsule, thus allowing the above process to occur before the protective covering of the lens is complete and effective. In those hereditary cataracts in which in each succeeding generation the cataract occurs at an earlier age the explanation must be sought in some sort of reduced viability of the original germinal cells set apart to form the lens germ. It is difficult to understand why these cells should show a progressively failing power of endurance; but we are forced to regard the fragile connection of the lens with its sources of nutrition, and the extreme sensitiveness of its epithelium to nutritive disturbances, as contributing to this, and resulting in a structure that more rapidly succumbs when later nutritive conditions become less favorable.

Etiology of Senile Cataract.—(The following was intended as a contribution to the discussion of Dr. Stricker's paper, but I arrived too late to take part in it.)

The views [given in the full paper] regarding the nutrition of the lens and the functions of the capsule are not new, but are presented there in a concise and convenient resumé.

The views as to the chemical origin of cataract are most interesting, although to my mind he leaves the question just at its most suggestive point.

The view that senile cataract is merely a result of the lowered nutrition of old age, and is itself an expression of this mal-nutrition, has never seemed conclusive. It is not found particularly (and certainly not exclusively) in the extremely weak and feeble. Diseases or cachexiæ resulting in profound and longcontinued mal-nutrition or marasmus show no tendency to the development of cataract; neither do cases of slow or chronic starvation. On the other hand (and this is very suggestive), cataract does sometimes develop in

certain sorts of chronic poisoning, like ergot and naphthalin poisoning.

The semi-mechanical theory (noted in the paper), that with the loss of the elasticity of the lens the continued accommodative attempts may cause clefts or fissures between the peripheral cortical fibres, with resulting stasis of the interfibrillar fluid and degenerative changes in the neighboring fibres, has not seemed to me conclusive. For these are really the conditions (with probably much the same effects) in all senile lenses. I admit that those cases of little equatorial cortical striæ we so frequently see, and so often observe to remain stationary for years, are best explained in this way.

The chemical theory is much more enticing. There are no patent, indisputable facts that bluntly oppose it, while it has the strongest sort of a buttress in the well-known diabetic cataract. To be sure, my own chemical examinations in one such case have been negative (which, however, carries little weight when my lack of special chemical skill is considered); but there seems to be little question but that the diabetic cataract is caused by the chemical action of the sugar in the circulating fluids. Possibly it may be due to some secondary product, and even if not acting directly this may cause an insidious cyclitis or anterior choroiditis. But the chemical theory may be carried, to my mind, much further than has heretofore been done.

Old age is not, strictly speaking, so much the period of mal-nutrition as it is the time of altered, or inefficient, or defective metabolism. It is pre-eminently the period of the uric-acid diathesis; we often meet with the lactic-acid diathesis, while we frequently see transient albuminurias and glycosurias. In such cases the blood will contain the chemical and more or less toxic products of faulty disassimilation, and arterio-sclerosis is a common result. It is the time of gout and glaucoma; of chronic rheumatism and chronic nephritis; of atheroma and apoplexy. Such cases will often put on fat, and fatness coming on in old age is probably never purely physiological. If one will review in memory the pictures of any considerable series of cataract cases, one will be surprised at the large proportion that will be remembered as of plethoric habit, with ruddy complexion or enlarged capillaries, and with a more or less rheumatic or gouty disposition.

Another condition has not received attention in this connection, and one that, I believe, is of considerable importance. Chronic constipation is one of the most frequent conditions of old age, so common as to be regarded as almost a natural weakness of this period of decline. The retained feces must give rise to more or less constant re-absorption, and a sort of chronic (even if slight) stercoremia must result. We know little or nothing of the chemical nature of these absorbed products, but must regard them in a general way as ptomaines, and, of course, as more or less toxic in character.

We may again recall how almost constantly we are under the necessity of freeing a chronically constipated bowel prior to our cataract operations.

We may also be justified in regarding in the same light some possible re-absorption from the long-retained urine in the cases of old men with enlarged prostate. We know that the retained urine undergoes some chemical changes, but as to what amount of reabsorption may really take place, and of its true chemical character, we know very little that is definite.

I have become more and more of the opinion that this metabolic insufficiency, and possible auto-intoxication, conditions very common to the period of decline of the human mechanism, are the real etiological factors in the development of senile cataract.

I think it probable that our better hygienic conditions, more varied diet, more careful personal habits in some respects, greater activity, and in general more normal social relations, may be the reasons why cataract is relatively much less frequent in America than elsewhere. As these conditions become less and less favorable we see cataract becoming more and more frequent, reaching the climax in countries like India and China. Purely mechanical hypotheses will not account for such differences; in fact, they should give the greater ratio to countries in which the eyes are more taxed.

Such views have a wide and important practical bearing. Let the family physician look carefully after the systemic condition, and the little neglected chronic ailments of the man or woman starting on the down grade of life, and cataract will probably become even less frequent.

In other words, if we could prevent the entrance into the tirculation of these toxic

products of faulty metabolism, and prevent the re-absorption of toxic products from excreta ready to be cast off, we possibly could largely or almost entirely do away with senile cataract.

Cataract and Glaucoma.-An interesting case of these conditions associated has recently come under observation.

Mrs. Mary A. B, æt. 54. Woman with a rheumatic history. She entered the wards of St. Mary's Hospital on January 15, 1899, with chronic rheumatic trouble of the lower limbs. About this time sight began to be impaired in both eyes. About the middle of May, the rheumatic trouble having been quieted, she was transferred to the eye ward. By this time there was a well-developed cataract in each eye. The cataracts seemed to be large and practically mature.

About this time there was a sudden attack of acute glaucoma in the left eye. The symptoms were classical. An iridectomy upwards was made at once. The course was uneventful, and the glaucomatous symptoms subsided completely. There has been no sign of any During the latter part of July there was a sudden outbreak of acute glaucoma in the right eye. An iridectomy upwards was made at once. The outcome here was also uneventful, and the glaucomatous symptoms entirely subsided.

recurrence.

On August 29 an extraction was made in the left eye. The nucleus proved to be unexpectedly large for this age, and quite soft, so that it was broken up in assisting its escape with the spoon. There was some cortex left, so that the recovery has been somewhat slow, but with no exceptional features. The time is too short to predict the final outcome.

This case gives occasion for some interesting surmises. Had this glaucoma come on immediately after the examination under the atropine it might most naturally have been charged up to this drug. But in one eye it came on nearly a week after, and in the other two months after. Had the extraction (simple) been made the attack of glaucoma may not have followed, but had it come on at the same time that it did it would most naturally have been accepted as a case of post-operative glaucoma. The iridectomy quieted the glaucoma, at least for the time; but it will be instructive to note whether the extraction may not, after all, cause another recurrence of the glaucoma.

Retinal Thrombosis During Erysipelas. -This ocular complication during the acute stage of facial erysipelas is, fortunately, one of the rarest. The ordinary involvement of the eyelids, leading to such swelling as prevents their opening, is common enough. The formation of abscesses in the eyelids, and even of orbital abscesses, is not so very rare.

The occurrence of blindness after erysipelas was formerly thought to be the result of pressure purely. The orbital edema or abscess, by pressing for days upon the optic nerve, mechanically destroyed its functionating power. Most of these cases, if not all, were first examined after the subsidence of the acute symptoms and the disappearance of the palpebral swelling had made an ophthalmoscopic examination possible. Under these circumstances a white atrophic disc was found, and white filiform lines wholly or partially replacing the retinal vessels. All the retinal vessels might not, however, be involved, or be involved equally.

One case of this character has come under observation, and was of special interest because the ophthalmoscopic appearances so exactly copied one of the classic cases.

Chas. F. S, æt. 43. Seen in October, 1890. He had had erysipelas, beginning some four weeks before. The swelling had been most marked upon the right side, completely closing that eye. The ordinary methods of treatment had been employed by the family physician, and the swelling had slowly subsided. No abscesses had pointed, or at least none had been opened. Upon first opening the eyelids it was discovered that vision was lost. An ophthalmoscopic examination was ordered at once.

The disc was found gray and blurred; the fundus was veiled or clouded about the disc and over the macula region. The vessels running downwards were nearly normal, the veins being somewhat large, the arteries slightly smaller than the normal. The vessels above had practically disappeared, a few fine red streaks passing out from the disc and being continued as white lines. At an examination made a month later these vessels above were entirely replaced by filiform white lines; the disc was white, and the fundus had nearly its normal tint. V-nil.'

The picture is such an exact copy of Jaeger's figures (if they be inverted) that a drawing would be really superfluous.

Jaeger reports (Pathologie des Auges, Plate

XVI, and Ophthalmoscopischer Hand-Atlas, Pl. X, Fig. 51) the case of a woman with erysipelas, affecting most severely the right side of the face. Ophthalmoscopic examination made five weeks later showed the superior vessels little affected; the lower vessels were filiform, and largely replaced by fine white lines.

Knapp studies a case (Archives of Ophthal mology, p. 94, Pl. A and B, xiii, 1884) that gives some interesting information.

Man, æt. 40. Facial erysipelas, with swelling of the lids and protrusion of the eyeballs. Examined ophthalmoscopically on the fourth or fifth day.

The ophthalmoscope showed the fundus white and sodden; disc invisible; black-red tortuous vessels, some at places almost varicose; and numerous hemorrhages scattered over the fundus. Later the hemorrhages were absorbed; the vessels showed a beaded appearance, and some showed intercalary portions of pure white. Still later the vessels showed as white lines crossing the fundus, and particularly marked and numerous around the macula region. But one artery and one vein (below) were intact, and they were small; two small veins showed a red streak over only part of their course.

The appearances would be explained by the occurrence of thrombosis in the retinal vessels. The compression causes stagnation in the retinal vessels. This acting mechanically, and aided by the infectious irritation, gives rise to proliferation of the endothelium and the formation of thrombi. These finally organizing give rise to the white lines of the obliterated vessels.

ACCORDING to Professor Loeffler, of Greifswald, congenital tuberculosis is extremely rare, and that in all such cases tuberculous disease of the mother's generative organs has been found. He does not believe that the tuberculosis of the father has any part in the heredi tary transmission of the disease. And as far as immunity is concerned, there is no proof as yet of immunity to the disease, nor of congenital or hereditary disposition to it, but that there is great probability that other diseases of the respiratory or digestive organs, as well as disturbances of nutrition, favored tuberculous infection.-Med. Age.