have fluctuated in their flow from time immemorial, and that their present state is due to other conditions than their pumping, possibly to there being a number of wells unsealed and uncovered in different parts of the village, which would influence the natural flow of other springs. They further say that if the wells which have ceased flowing were cleaned out, they would flow as formerly.

Many of our citizens (the writer among them) do not accept this version of the cause of the new water level of our springs; but they believe the failure of the springs to flow, as in earlier years, is due entirely to the enormous quantities of water pumped by these gas companies, which exceeds in quantity the former normal flow of our springs by many hundred thousand gallons daily. Accordingly, there was formed a Citizens' Committee, their object being to preserve and restore the original condition of the springs of our village. Through the efforts of this Committee, the last legislature passed an enactment prohibiting the pumping of mineral water. While this measure was before the Legislature, many hearings were had and much feeling and acrimony resulted.

The gas people held that the springs had long been inert, and were "doctored," that is, the mineral qualities of the waters were added, and Saratoga had been marketing an artificial product. Statements were presented to the Legislature, attempting to show that this was so, hoping it would influence the members of the Committee and prevent the measure from becoming a law.

While individual springs may have failed to flow as formerly, or perhaps, as charged, may have been tampered with, as a whole the mineral springs of Saratoga are unchanged, and their virtues and characteristics are as they always have been. A forceful illustration of the absurdity of the statements made by the gas companies, is the fact that these companies obtain. their product from the natural mineral waters of Saratoga. As a matter of fact, the water that is wasted after the gas has been extracted, contains about 400 grains of total chlorids to the gallon, which corresponds closely with the analyses of the original springs, which it is alleged were doctored.

This version of the controversy was published in the press generally. Thus it was heralded over the country that "the springs at Saratoga had failed"-an unfortunate, unnecessary and untruthful statement. Eventually, the measure prohibiting the pumping of the waters of our springs became a law, the constitutionality of which was at once attacked, and is now being tried in the courts. The result of this suit will in no manner influence the supply or the value of the waters of Saratoga, the point at issue. being the present level of the spring waters, which are not pumped, and the gas pressure.

I believe this plain statement of the con

troversy necessary, if the medical profession is to have continued confidence in the waters of Saratoga. If, in individual cases, confidence in them has been shaken by such statements, I unhesitatingly affirm that the waters of Saratoga, as a whole, are all they ever were, in their physiological or therapeutic action. My observations as to the value of these waters were expressed in a monograph in 1898; and with increased experience, I have learned to have a still greater appreciation of their value.

For the general information of the profession who are not familiar with the mineral springs of Saratoga, I would suggest the original classification as being the best, which is as follows: saline or cathartic waters, alkaline, or as they are often called, table waters, and the chalybeate waters. Repeated analyses of the various springs do not show material deviation in their constituents from time to time. Thus each glass of water, having a definite quantity of chemicals, has a uniform action, which may be anticipated when taken into the economy, the same as any other combination of drugs. Naturally it is modified in its action, as are other drugs, by the combination of many chemicals, also the general condition of the system and the daily regime, such as food, exercise, bathing and environment. Each above-mentioned condition is of material value as a synergist to the water, in considering a cure at Saratoga.

This has

Often our visitors, and occasionally their physicians, expect that these waters will be the essential factor in the betterment of their condition while at Saratoga, overlooking the necessity of a regulated, methodical life during their stay. In the past, I am sure many guests who have been sent to our village to convalesce or recuperate have been disappointed. been so, because they have not appreciated the necessity of having been directed just how and what to do while here. Some of our visitors come to the town and simply drink the waters, ignoring important conditions which must be considered, if they are to be benefited. Others use the different sorts of waters indiscriminately, drinking them at irregular times and in inordinate quantities, and also dissipating in food, drink and pleasure.

Frequently, patients have told me that they have drunk from twenty-five to thirty glasses of water in the course of the day, from the different springs; often the termination of such excess is a temporary indisposition. Thus it would seem that the patients are not aware of the importance of professional advice; and, on the other hand, I do not believe that the local profession realize the value and possibilities of the remedy which is at our very door.

To prescribe mineral waters properly, presupposes a familiarity with their action. Mineral waters are medicines, composite in character, and without doubt are potent both for good and evil. Because they are a mild medication, and

generally palatable, this fact is often overlooked. They all possess two characteristics as remedial agents; first, the immediate action; and second, the remote result. The latter is so slow that it is often not appreciated until the termination of one's course of treatment; even then the general well-being is not attributed to the cure. This thought I would emphasize, as my patients often express their views of the value of the spring water, which generally depend upon the immediate action observed, whether it be catharsis or diuresis. Naturally, after the stimulation of the gastro-intestinal tract, the liver and kidneys, from the use of the mineral waters, there must be an immediate feeling of well-being; but I assure you, it is more than this. The continued use of the water, through constant stimulation, causes a more positive reaction in the circulation, and in all glandular organs, and an improved physical condition is the result.

The saline waters, as a class, contain about 500 grains of total salts; of this amount, approximately 400 grains are total chlorids.

The alkaline waters contain, as a class, about 300 grains of total salts, of which 150 grains are total chlorids.

The analysis of a chalybeate water is not available, but it contains markedly more bicarbonate of iron than the others. As Thorn said: "Analyses of these waters, made at different times, show practically no deviation in their composition. Thus the amount of salts in each glass is readily determinable (it is about one dram); and it would, perhaps, seem simple to deduce the probable physiological action. But, as one observes the effect of those waters, one concludes that the action is greater than one would naturally expect, and that their activity has been materially augmented by nature's combination of

chemicals.

The therapeutic action of the saline waters, when taken in quantities of a pint or more before breakfast, is to stimulate the mucous membrane of the alimentary tract, increasing the natural secretion, and exciting peristalsis, producing a copious, watery evacuation. Whether the result on the bowels is aperient or drastic depends upon the quantity taken.

The alkaline waters possess, in a measure, the qualities of the alkaline salts when well diluted. They stimulate the liver, increase the flow of bile, and often modify its character. They stimulate the secretions generally, and have a particularly marked effect on the glandular systems. When taken before meals, they stimulate and increase the acid secretion of the stomach. On the contrary, if taken at meals or immediately after, the carbonate neutralizes some free acid. Personally, I believe that the carbonic acid gas, which is present in our mineral waters, acts as a stimulant to digestion, prevents putrefaction, and serves to establish a general good feeling. If this class of waters is taken two or three hours after meals, they have a marked effect

in augmenting the secretion from the kidneys, particularly in cases of high arterial tension.

In the chalybeate springs, the iron exists as a bicarbonate, and is a wonderful reconstructor. The effect is particularly quick and happy, and this is due, I believe, to the fact that all iron preparations are more quickly beneficial if the glandular systems are active and the bowels free. It is a delightful method of giving iron, and never seems to nauseate or constipate. It is most remarkable how quickly a patient responds to the almost infinitesimal quantity of iron found in these waters. If it had not been repeatedly verified, one would question if the result were not due to other factors.

The therapeutic effect of all classes of waters is modified, according to the method prescribed, the temperature, the quantity, the amount of exercise at the time of drinking, the time in relation to food, as well as the habits, diet, exercise, rest, etc. For patients generally, no directions are possible. Each case should have the same careful, painstaking observation as if other more potent remedies were to be employed. Generally, the saline waters are taken in quantities of from two to four glasses before breakfast, either hot or cold; and I believe they should always be drunk slowly, or even sipped; and that a moderate amount of exercise (say ten minutes), should be taken between each glass, and that a half-hour should elapse between the last glass and breakfast. The breakfast should be light. Usually, after taking a cup of hot coffee, the bowels will move. As a rule, this class of waters is only taken in the morning; though a marked diuresis will be the result if four or six ounces are taken every two hours during the day.

The alkaline waters are taken before, at, or after meals, according to the result desired. They should never be taken in large quantities, as is done by so many. Two glasses should be the maximum quantity taken at one time. The iron waters are best taken after meals, in quantities varying from four to six ounces, eight ounces being the full dose; and even this quantity will often produce headache. It is best to direct the use of a saline water, before breakfast, in conjunction with the iron water.

While we do not assume that the Saratoga waters are in any way superior to those of foreign spas where cures are taken, yet we do maintain that the springs of Saratoga are equally efficient; and that they are within the reach of many who could not afford either the time or the money for an extended trip abroad.

While the waters at Saratoga have a distinct therapeutic value when used internally, they also possess the advantages of the foreign waters for bathing.

Saratoga enjoys a moderate elevation, a dry sandy soil, associated with one of the most delightful, bracing atmospheres to be found anywhere. Notwithstanding all these advantages, if our visitors expect to receive the same benefit

March, 1909

as at a foreign spa, they must come prepared to submit to the same general regulation here as there. While our local municipality is not controlled as are those of foreign countries, yet our local physicians must exact of their patients the same attention to detail as is required in taking a cure abroad. Thus we must advise each patient as to the particular spring from which he is to drink and the time at which the water is to be taken. Every detail of the baths must be arranged, including temperature, time, period of rest, etc.; and if massage or exercise is prescribed, it must be done definitely. The habits of the patient must be regulated, as well as the diet, amount of exercise, rest, sleep-in fact, the entire cycle of twenty-four hours must be planned, if the outcome is to be what it may.

A careful history, a physical examination, an examination of the urine and of the arterial tension, are all essential before attempting to outline a regime. All of these, when taken together, constitute a cure. No medical man would ever believe that it was the waters at Nauheim that have made the Drs. Schott famous; on the contrary, it was their wisdom, acumen, and painstaking observation of the effect of the waters, that enabled them to acquire the knowledge of heart, circulatory, and kidney trouble, and gave them an international reputation.

Patients who sojourn at Saratoga, under the conditions just mentioned, will be benefitted in nearly all functional diseases and many chronic ones. Time does not permit me to go into the detail of my individual cases; but they have been many in number and diverse in character. In fact, as I formulate my data in relation to cases in which the mineral waters of Saratoga have been a factor in improving the condition of the patient, it reads so much like quackery that I modified what I originally intended to present here to-day. The fact remains, however, that the relief is obtained, and is due to the use of the waters, internally and externally, and to a systemized, simple life-free from irregularities, aided by a perfect climate and general sanitation. Here an out-door life is natural, and can be as free from the excitement and bustle of the city as one desires.

The more common conditions which improve under a course of mineral waters at Saratoga are constipation, functional derangement of the liver and gall-bladder, and perverted digestion, with their concomitant conditions, such as fermentation, autointoxication, anemia and chlorosis; also many inflammatory conditions of the urinary tract, gout, chronic rheumatic conditions, functional nervous trouble and obesity.

In closing, I would again call your attention to the fact that the mineral waters of Saratoga possess the same natural medicinal qualities as formerly; and those who visit Saratoga in search of health may derive the same benefit from a regulated life and the use of the waters as they could at a foreign spa.

IMPROVEMENTS IN THE TECHNIQUE
OF THE EXTRACTION OF
CATARACT.

By LUCIEN HOWE, M.D.
BUFFALO, N. Y.

The object of this paper is to describe two modifications, which seem important in the operation for the extraction of cataract and two very simple instruments whose practical use has been proved by repeated trials.

The first point to which I wish to call attention is a new principle in the fixation of the globe, and to a pair of forceps for accomplishing this.

Practically every operator when extracting a cataract, finds it necessary to fix the globe in a position which will facilitate the making of a satisfactory corneal incision. It is true a few surgeons try to avoid this fixation, depending upon the ability of the patient to look down, when told to do so, thus exposing the upper half of the cornea. The practical fact is, however, that the majority of patients, especially the ignorant, and those who have but slight selfcontrol, find it impossible to look just then in any desired direction-no matter how much they wish to do so. Therefore, although the operator may have commenced with the intention of not fixing the globe, he finds it absolutely necessary to do so, in order to complete the corneal incision.

Now we have all found that the fixation of the globe is attended with difficulties. It is easy enough, of course, to catch the conjunctiva below the cornea with the ordinary fixation forceps. But the trouble is that the conjunctiva is apt to tear. It is especially brittle in old age, and in such persons, of course, most cases of cataract occur. In order to obviate this difficulty forceps have been constructed long ago which have two branches. These afford a double chance of holding on to the conjunctiva.

But the practical fact is that in old persons the conjunctiva is apt to be so brittle that these forceps with two branches also tear away as promptly as any others.

It occurred to me, therefore, that it would be a good plan to find some other point for fixation. besides the conjunctiva. When making dissections of the ocular muscles, it was easy to see that it would be possible to hold the globe in place if a pair of forceps could be made, the teeth of which would bite not into the conjunctiva alone, but into the tendon of the external and of the internal rectus muscles. Accordingly, I had such a pair of forceps constructed. Various modifications have been necessary in them as the imperfections in the original model were shown by trial. But the pair which is now presented seems to serve the purpose in quite a satisfactory manner. They are practically double tendon fixation forceps.

Their use is so simple as to be evident at a glance. After using the ordinary five per cent.

solution of cocaine, I am accustomed to apply one or two drops of a ten per cent. solution. Then, the speculum having been introduced, these tendon fixation forceps are first placed nearly over the position to which they are to be applied. Sometimes it is necessary to spring the two points of fixation a little nearer to each other or to separate them from one another to suit the globe as it lies in the orbit of that individual. This preliminary fitting having been done, the branches are first opened wide and then pressed firmly down, to catch not only the tendon, but even to reach partly onto the belly of each muscle. The teeth are closed, the spring clamped, the handle depressed and the eye is then ready for the corneal incision. The advantages of these forceps briefly stated are: First, They hold the eye in position, keeping it from rolling upward. Second, They prevent its rolling from side to side. Third, This obviates the twisting and distortion of the globe so often noticed, with its probable ill effects on the ciliary region. It also enables the operator to make a smooth incision free from ragged indentation.

It is evident that these forceps are useful not only in the extraction of cataract but in all other operations requiring fixation of the globe, such as cauterization or puncture of the cornea, iridectomy and the like. One of the most embarrassing situations in which the ophthalmic surgeon finds himself, and one unfortunately not uncommon, is with a case of acute glaucoma as usual in an elderly person, with perhaps valvular lesions sufficient to make general anæsthesia not altogether safe. In these cases also the double tendon forceps are a real boon.

A second point to which attention is called by this paper is the method of extracting the lens in cases in which the corneal incision has proved too small in proportion to the size of the cataract. The usual methods employed for this complication are well known to every operator and are also rather dreaded for the reason that they are either difficult or dangerous. To make much pressure on the globe, results often in loss of vitreous, to lift the lenses out with a spoon is equally dangerous, and attempts at enlarging the wound with scissors give additional opportunities for infection, besides interfering with the smooth wound which heals easiest and quickest.

In order to overcome these difficulties, attempts have been made by suction and otherwise to apply a vis a fronte instead of the usual vis a tergo. But these have not proved satisfactory in spite of the fact which every operator knows, that when the lens is in this position, only a slight touch to it, applied in the right direction, will cause its prompt delivery.

Therefore, when the lens thus presents in the wound, but sticks there, I have found the procedure is much facilitated by a pair of forceps especially adapted to that purpose. These for

JOURNAL OF MEDICINE

ceps are nothing more than what we have long known as the straight iris forceps, only a curve has been given to each blade near its termination of such a form that when the two points approach, they close upon each other in an arc whose chord is less than the length of the minimum incision made for a cataract extraction. That means practically that when in the course of the extraction the operator thus finds the lens caught in the wound, the eye is rotated down with the left hand, the operator taking the cataract forceps in the right hand gently tips the. lens sideways and with equally gentle traction, disengages it from its entanglements. Experiences of this kind, now several times repeated, have prompted this description of this very simple, but apparently useful little instrument.

Every surgical procedure of to-day is the result of a gradual evolution as one part after another of the technique has been gradually improved. The time required for that evolution depends on the complexity and delicacy of the operation. I venture to call attention to these two apparent improvements in the technique of the extraction of cataract, with the hope that they may advance a little further, the evolution of an operation which is, beyond question, one of the most complex and delicate in the whole ranges of surgery.

THE FIRST INTERVIEW WITH THE PATIENT.*

By WILLIAM 8. ELY, M.D.

HERE is often a tendency in the prelim

Tinary examination of patients to overlook

details which might help to a fuller comprehension of the case, and determine the best plan of treatment or management. A prominent consultant in a central city of this state recently said that it was common for him to see patients whose physicians had not thoroughly examined them before calling him in consultation. Hence, erroneous or inadequate diagnoses were submitted to him. It is this that suggested the subject of this paper-too little dwelt upon in text-books under the head of anamnesis-a word which has never come into general use.

The first interview with the patient-has its significance impressed you? Often you meet as strangers. The patient is in an attitude of distrust, suspicion, reserve-studying you as intently as you are studying him. It is high art to overcome this reserve, suspicion, distrust, while you are making your examination, and to compel the patient's confidence and belief that you understand him and his disease, if you really do, and are the most competent person to treat him and to tell him what he can know, what he ought to do, and what he has to hope for. To this end experience, address, training and knowledge of human nature in health and sickness con

*Read before the Medical Society of the State of New York, at Albany, N. Y., January 27, 1909.

March, 1909

tribute, and though it is no discredit to fail at times in winning your patient, success is highly satisfactory.

Every physician evolves his own method of examination and may excel in some particular. If time permitted, it might be interesting to compare and criticise different methods of investigating the problems of disease.

Of the many phases of our subject which deserve attention on the first interview with the patient, we can only refer to four that are at times overlooked:

1. The search for the causes of numerous disturbances that frequently receive only symp

tomatic treatment.

2. The correct estimate of nutritive changes. 3. The significance of heredity.

4.

The psychical aspects of many disorders. From the study of these factors comes a large part of the satisfaction attaching to our calling. We should consider every case as a problem to be solved, or a riddle to be answered. Without this interest and satisfaction our work would be monotonous. To those content with mere symptom treatment the practice of medicine must often be irksome.

I. Voltaire made an important contribution to accurate diagnosis in his little work called "Zadig," but "the method of Zadig" is yet unknown to the majority of physicians. The Sherlock Holmes of the sixteenth century was Zadig. He saw a thousand differences in nature which appeared to the untrained eye and mind as uniformity.

Perhaps lawyers could give physicians points in the investigation of their cases. Have you

noticed the minute details into which lawyers go in tracing the doings of a witness-every movement of his life for days or weeks? While much of this evidence may seem to us irrelevant, it is often of the greatest value in making the diagnosis of a criminal.

Now the sick man has frequently violated some natural law, and in that sense is a criminal. He may deem it disreputable to be sick, and may conceal essential symptoms. Hence the doctor must at times be a detective to search out the causes of disease. If he combine the astuteness of the lawyer, the shrewdness of Sherlock Holmes and the method of Zadig, it may be possible on the first interview to solve the mysteries of many obscure conditions.

He may find that the illness has resulted naturally and inevitably from a mode of living certain to bring on serious disorders. When such information is obtained, and the cause of the sickness for which patients consult us is traced back to errors in food or drink, to overwork, or to excesses of various kinds, it is obviously our duty to have such patients understand that if they would prevent a recurrence of similar or more serious troubles leading to structural, incurable, lifeshortening disease, their habits must be radically changed. This seems at times difficult so strong is the force of habit.

In most cases of sickness the appetite is more or less disturbed. A patient's statement that his appetite is good, bad or indifferent should sometimes be questioned. It may be wise to draw out specifically what he has eaten or drunk in the last 24 hours. Write down his answers. They may show that his judgment about the quality or quantity of his food and drink was misleading.

I have records which give in hundreds of cases the number of cups of tea or coffee, and the number of alcoholic drinks taken daily, and the number of cigars smoked. Very often when the patient sees in writing the total of his admissions on these points, his surprise equals that of his physician.

On the first interview with a patient it might be wise to learn the routine activities of his entire day, to determine the hours of work, the sanitary condition of the bedroom and the time given to sleep, the amount of food and fresh air taken, the nature of the occupation, and in the case of working people, the conditions as to fresh air, sunlight and so forth under which their work is carried on. The anæmia, headache, anorexia, constipation, depression, for which the physician is often consulted, may thus be accounted for. Frequently conditions that predispose to tuberculosis will be discovered,

The

2. All doctors do not have scales in their offices. I should as soon think of practicing medicine without a microscope as without an instrument for determining by weight the gross nutritive changes in patients of all ages. macroscopic changes in disease should receive as much attention as the microscopic, and the scales are the certain test of the effect of treatment in many cases, especially in that large class marked by defects in nutrition.

3. In the first interview with the patient few physicians pay adequate attention to the factor of heredity in explaining predisposition to disease and susceptibility to disturbing influences, both moral and physical. We should endeavor to determine the degree of responsibility for both physical and moral disorders, which attaches to the ancestry of the individual. "Who did sin, this man or his parents, that he was born blind?" It is not enough to investigate merely the immediate progenitors of a patient-atavistic tendencies may go back a thousand generations.

Oliver Wendell Holmes says: "The body in which we cross the isthmus between two oceans is not a private carriage, but an omnibus." In this omnibus are crowded the elements of a diverse ancestry. If it be axiomatic that every disease has its adequate cause, then in so far as the cause is not in the individual, or his environment, it must be in his ancestry. The weaknesses and sins of one's progenitors may leave marks upon descendants that are indelible.

At times hereditary defects can be modified or removed. There are other times when we bear them through life as burdens, infirmities or limitations, constantly reminding us that in certain directions we are by inheritance weighted, weak