Further experience will have to prove or disprove its useful

ness.

The Results. I have heretofore published in detail the reports of the first ten cases I operated upon. Since then I have not kept an exact history and daily record of the cases, but I have operated on altogether about 80 cases, comprising all kinds, stages and degrees of granulated lids. In a general way I will say that all of the cases progressed rapidly, and most of them got practically well in from one to eight weeks. A few of the cases, about half a dozen, proved to be more stubborn than the rest, the time required extending to 10 to 12 weeks. The latter class comprised mostly the cases where the lids were badly granulated and the balls were covered more or less with pannus. I find that it takes, as a rule, longer to get rid of the pannus than it does to cure the granulations. In a few of the cases the lids healed or cicatrized completely within a week. These cases were those in which the granulations had partly cicatrized or absorbed before the lids were brushed.

In all the cases the brushing operation was made at once, regardless of the condition of the cornea, and uniformly the keratitis and ulceration began to heal promptly and rapidly, and progressed till the healing was completed. In cases where the eyes were painful, the suffering promptly ceased. I now have a case on hand, who had not been able to sleep on account of severe pain caused by a large ulcer on the lower part of the cornea for five weeks; within two days the pain ceased, and he has lost no sleep since. This, too, in spite of. the fact that bluestone was applied daily, but lightly, to the lids. Had the lids not been brushed, I would not have dared to apply the bluestone to them at all.

The brushing of the lids, therefore, is not contra-indicated in heratitis and ulcers of the cornea. On the contrary, the brushing is the best means of getting the cornea to heal promptly. I have had a few relapses, but not nearly so many as I used to have in the old treatment of granulated lids. The relapses were mostly in the form of keratitis or ulceration of the

cornea.

The advantages of this surgical treatment over the old method of treating granulated lids will readily appear from a

moment's contrast. The surgical treatment promises with much certainty to get a bad case well in from three to 12 weeks, while the old treatment required from three to 12 and often 18 to 24 months to finish up a bad case, with a good deal of uncertainty at that. A corresponding saving in time and expense to the patient is the result.

In conclusion, I will say that in my judgment the surgical or brushing treatment for granulated lids is the quickest, surest and best. Heretofore I have rather shunned bad cases of granulated lids, but now I gladly undertake them, because I feel that I am able to make rapid progress in getting them well.

Finally, I wish to say that this method of treating granulated lids is still in process of development, and great improvement may yet be effected. What I have said gives the present status of this method of treatment.

CATARACT:

ETIOLOGY, DIAGNOSIS AND PROGNOSIS.

BY FAVEL B. TIFFANY, M. D., KANSAS CITY Mo.

There are many forms of Cataract, and the treatment that is applicable for one might not do for another.

ETIOLOGY.

Immediately posterior to the iris we have the crystalline lens in its capsule, supported by the suspensory ligament, vitreous body and ciliary processes.

Cataract is very frequently secondary to some disease of the uveal tract, and ofttimes we are able to trace it directly from iritis or choroiditis. Nearly all deaf mutes have choroiditis, and these people are sooner or later almost sure to be affected by cataract. In fact, it is a rule that people with choroiditis eventually become cataractous.

Cataract frequently follows iritis and cyclitis. It exists more frequently in the hyperopic than in the emmetropic, and if the myope has cataract the disease develops very slowly, extending over a period of many years before its maturity is reached. Consanguinity in some occult way is responsible for this disease. Children of parents of blood relation are frequently cataractous. I have had in my practice several large families where every child had cataract - one family of 11 children, all of whom had cataract. All were also hyperopic, with other complications.

I have also a vivid recollection of another family from a neighboring town (the father a bright, able attorney, and the mother with more than ordinary intellect and brilliancy), in which each of the four children was cataractous with choroiditis, and these children were absolute mutes, each having had fairly good hearing up to the second or third year, when they

gradually became deaf. These children otherwise were bright, with mental capacities to be admired. In this case the father and mother were first cousins.

At my clinic but a few days since, I had a large family of children, all now grown up and each one cataractous. The father and mother, as in these other families, are first cousins.

While in Berlin in the years 1878-9, I noticed that the rabbits kept in the laboratory for vivisection were nearly all blind from cataract. This blindness was attributed to the inter-breeding of these animals.

The eating of rye bread which contains ergot has been attributed as a cause of cataract-ergot producing a constriction of the blood-vessels at the limbus, thus interfering with the circulation and hence with the nourishment of the lens.

Diabetes and other systemic diseases cause cataract; diabetes from a deposit of sugar in the leus.

Anterior polar cataract may be congenital or infantile, usually infantile, and due to ulceration of the cornea.

Posterior polar cataract is usually the result of choroiditis or hyalitis, and is secondary. It may be congenital, or it may take place after birth.

Cataract occurs frequently in old age, and is evidently due to an arrest of or mal-nutrition, and it is no easier accounted for than is grey hair or a wrinkled skin, and is one of the evidences of senile decay.

In senile cataract the majority of eyes, aside from the cataract, seem to be perfectly sound, free from any disease, and when the cataract is removed the vision, by a suitable glass, usually approximates 20-20, or normal vision.

Soft or lamellar cataract is of early life, usually congenital, may be traumatic. Infantile is usually hereditary and very frequently due to consanguinity, to dissipation or excesses on the part of one or both parents. The sins of the progenitor are frequently visited upon the progeny in this way.

Congenital is brought about from an arrest of, or by malnutrition during the development in utero.

Lamellar or zonular cataract is another mark in the child evidencing some indiscretion or sin, committed either wittingly or unwittingly by the progenitor.

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.

By the ophthalmoscope, the slightest trace of opacity on the lens or its capsule can be readily seen, and if this 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 is mistaken by the superficial or casual observer for cataract; especially is this the case in the negro; where there is a slight density of the lens and yellowish cast of the nucleus, with a reflex from the ashy paleness of the negro's fundus, the appearance simulates cataract. However, the ophthalmoscope will immediately settle the question as to any real opacity of the lens. For if there is the slightest opacity it will obstruct 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, as a mere speck, it may be overlooked, unless the lens is carefully examined by good illumination. By a magnifying lens in front of the ophthalmoscope, the slightest trace of opacity may be detected.

Hard or senile cataract rarely occurs before the age of 45, and most frequently after the age of 55, never before 35.

Soft is that form of cataract which occurs in early life— rarely, if ever, after the 35th year of age, unless it be traumatic or secondary. Cataract of youth or infancy is always soft; hard or nuclear cataract usually begins in the nucleus, occasionally in the cortical portion. If in the nucleus, the central portion of the lens assumes a yellowish densely opaque appearance, and the opacity gradually extends to the periphery. Frequently, however, it begins at the margin and extends to the nucleus.

In fluid cataract, the color may be likened to ground white meal mixed in milk.

It is very essential that we distinguish one form of cataract from another, as the treatment must be modified according to the form and complication, and in some cases no treatment