OPHTHALMOLOGY.

351 and trituration of the lens, as recommended by Forster. The objection, I think, to the former method is the liability to retention of cortex and its consequences. In old people cortex left in the pupil is slow of absorption, and during that tedious process iritis is apt to occur, sometimes very severely. With a view to avoid irritation from retained cortex Mr. Tweedy ruptures the capsule at the periphery after making the iridectomy, so that if the cortex should be left behind it is retained within the capsule and is likely to be harmless. The main objection some surgeons have to trituration of the lens is the fear the operation may damage the eye by undue irritation and iritis and synechia, a condition of things which might militate against the success of the after-extraction. I have had a fairly good experience in both operations, sufficient, I think, to enable me to form an impartial judgment on their respective merits. Up to five years ago I was in the habit of extracting unripe cataracts in necessitous cases every now and again by the combined method in thd ordinary way, with this exception-to avoid as much as possible leaving cortex in the pupil. I made the section unusually long so as to admit an easy escape of the lens with the least possible amount of pressure. In some cases the result was all that could be desired, in others again the cortex found afterwards in the pupil often gave trouble and anxiety by iritis. Without troubling you with any statistics I may just say the results on the whole were not equal to those of extraction of a naturally mature lens. For the last five years I have adopted Forster’s method in about forty To give it a fair trial cases in hospital and private practice. I made a selection of what I thought were really suitable cases, following Forster’s recommendation as closely as possible. They were cases of uncomplicated senile cataract with I soft cortex in which cortical opacity more or less existed. thorough practical courses on (1) pathological anatomy, Forster considers it essential that cortical opacity must histology, and chemistry ; (2) bacteriology as applied have begun. The vision of these eyes varied from 10 to 20 to the study of infectious diseases; and (3) general clinical Jaeger, and the progress of the opacity was known to have medicine and surgery, with special courses in special been exceedingly slow, extending in some cases over some branches of clinical work, such as diseases of women and years. After making a small iridectomy well back in the - obstetrics, diseases of children, infectious diseases, mental sclera I massaged or rubbed the centre of the cornea with a vulcanite or tortoise-shell spoon for about two minutes, diseases, diseases of the eye, of the ear, of the throat, &c. should be to courses lectures confined on : Systematic exercising care and judgment in the amount of pressure. (1) etiology of disease and pathogenesis ; and (2) general con- Beyond a little hæmorrhage occasionally in the anterior siderations regarding the practice of medicine and of surgery, chamber nothing unusual happened in the operation. In no These courses should be as short as is compatible with a case did undue irritation follow ; nothing approaching iritisdear exposition of those principles which but very few the opacity was complete in most cases within a fortnight, students would be able to formulate for themselves from the in a few it was nearly a month ; no atropine was used before study of facts. Finally, I wish to say that if in expressing operation and seldom afterwards ; the after-extractions were my views I have wounded the feelings of any who have all normal, there was no escape of vitreous, the healing opinions differing from mine I will ask him to apply to me process went on favourably, there was no loss of the the words of Harvey: "II would not charge with wilful eye, and the ultimate results were on a par with extracfalsehood anyone who was sincerely anxious for truth, nor tions of a naturally mature lens. I have been much lay to anyone’s door as a crime that he had fallen into impressed with the safety and efficiency of the operation. If it be done with reasonable care and judgment error."6 I feel sure it is as safe as any operation can be and I shall continue to practise it and recommend it with OPHTHALMOLOGY. confidence. There are cases, however, in which perfect Address by the President of the Section. I doubt if it would answer. Cataracts of deep amber Dr. DAVID LITTLE, Lecturer on Ophthalmology, Owens colour, uniformly hard throughout and no soft cortex, with College, Senior Surgeon, Royal Eye Hospital, Manchester, a good deal of transparency, sufficient sometimes to enable in his observations on the treatment of certain forms of one to see the details of the fundus,-these cases, in my cataract said: My first duty, gentlemen, on taking this can be safely extracted at once and with excelexperience, chair is to tender my thanks to the Council of the Associa- lent results, and I have therefore never tried Forster’s method tion for the great honour that has been conferred upon me by in that class of case. I think triturition might possibly asking me to preside over this Section. cause undue irritation, or, what is more likely, it might fail In view of the important papers before us it is not my to complete the opacity. intention to occupy your time by a lengthened address, but In zonular cataract and in some cases of traumatic or soft I should like, with your permission, to refer very briefly to cataract in young subjects it is a favourite practice of mine some personal experience in one or two practical subjects to extract the lens with a Teale’s suction curette in prenot touched upon in our programme, and, first, as regards ference to linear extraction. I can it to clear a rely upon the treatment of immature senile cataract. When in- pupil more effectually than by linear extraction and I have it is not more generally used. It is said cipient cataract has advanced to a stage when vision often been is so impaired as to render the patient useless for any there is a surprisedof danger introducing septic matter through the occupation it is clearly our duty to relieve him if we have tube and of sucking iris and vitreous, but if the curette is reasonable means of doing so. To be kept waiting in a semi- made clean and aseptic, and kept within the area of the blind condition for long and indefinite periods-perhaps dilated and not passed too deeply, accidents of that pupil years-is a great hardship to those people in many ways and kind need not be feared. If I have reason to suspect a is very depressing and often injurious to health. There is of the hyaloid I do not use it. In zonular cataract I abundant evidence that such cases can be safely dealt with rupture have rarely found excision of a small portion of the pupillary by operation. The question appears to be what is the best margin of the iris improve vision, at least to any appreciable operation to perform, whether to extract the immature extent, and for many years I have given it up. I either leave cataract at once or mature it before extraction by iridectomy the case alone or resort to discission and suction. In cases of tough capsule obstructing vision after cataract operations, 6 Harvey: An Anatomical Dissertation upon the Movement of the fails to cut it or disHeart and Blood in Animals. Dedication 1628. Rendered into Englishif the needle or double needle operation a I scissors, and have Wecker’s for G. Moreton. Canterbury. 1894. employ place_it permanently with facts which necessitated chiefly powers of observation, and which could all be easily demonstrated. When we come to deal with causes of disease and with the way in which lesions are produced we must necessarily introduce into our work induction, deduction, and .experimentation. When a number of facts seem to indicate that two or more phenomena are correlated and due to the .action of a certain cause we feel generally when dealing with biological problems that we may have overlooked many factors, and therefore we have to test our views by experimentation. Experimentation is not, however, always guided by direct observation, for it often happens that the causation of certain lesions is inferred from what we know of the causation of other more or less analogous lesions. The nature, the duration, and the difficulty of many of the experiments which have been made for the purpose of testing theories touching the causation of disease and the production of lesions make it difficult to teach the whole of this part of pathology by means of demonstrations and practical classes, and it is in this case that systematic lectures or text-books are the most justifiable and, in fact, necessary. Etiology and pathogenesis cannot be put aside, for much of the advances which have been made in the art of prognosis, in the treatment, and in the prevention of disease are based -on our improved knowledge of these subjects. Bacteriology, however, lends itself specially well to practical work, and I believe it would be beneficial to most medical men to have a more practical knowledge of this subject than they are generally made to acquire in the course of their studies. The conclusion which I draw from all these considerations is that students would obtain a more -useful knowledge of medicine if they had fewer lectures and more practical courses. They should be made to attend

subject,

accurate

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352 found it

i used only by the time-discredited agitator. In England admirably, better than a cataract knife, for is the additional advantage that there will bewages have increased 40 per cent. since 1860. Under no dragging of the iris when adhesions are present. Wecker’ssuch an economic condition we should have looked for a < scissors is also best adapted in making a pupil when it is commensurate appreciation in the provident fees paid by partially closed and drawn up from iritis after extraction.workmen to medical men, instead of which we have been 1 face to face with the pretentious medical aid prinWe sometimes see an eye with a white irregular mass of brought shrivelled up calcareous-looking capsule and lens filling up ciple, the effect of which is to ever reduce the payments the whole pupil and presenting rather an unsightly appear- made for medical advice and to extend the principle of These people consult one for cosmetic reasons andsweating to our profession. This sweating has been aggraance. ask if it cannot be removed. I have operated upon severalvated by the claim seriously put forward by the promotera such cases in my time with good cosmetic effect. I makeand supporters of these medical aid associations that the the ordinary cataract incision with iridectomy above; if Legislature should be asked to enact that the medical pro. there are iritic adhesions I separate them; very often therefession shall be compelled to accept what these gentlemen are none. I then introduce a stout pair of capsule forceps choose to give their surgeons both in the way of work and (specially made for the purpose, ribbed on the inner side of remuneration. It is to the credit of the Oddfellows’ each blade), and by gentle traction draw the white mass out; Annual Movable Committee that they rejected in May sometimes I have had to pass one blade behind and the other last a resolution to this effect and affirmed the commonin front to get a firm hold. Sometimes vitreous escapes, sense position that the medical profession were as much sometimes not. It may not be bad practice to leave such justified in combining for the protection of their own cases alone in case of inflammation and greater disfigure- interests as any other class in the community. I congratument. In the few cases I have done nothing of the kind has late the profession on its awakening to what this medical happened. If the iris is healthy looking and the tension aid principle means and upon the concerted determination normal I have no hesitation in recommending operation. In it is showing to have none of it. Cooperative doctoring traumatic prolapse of the iris the best practice I have found of the type we get in some medical aid associationsis to slit up the sac throughout the whole length of the i.e, where the medical man is the exclusive servant of the wound with a Gi,tefe’s knife under antiseptics, and if iris committee, deprived of that liberty to practise privately remains in the lips of the wound to excise it. Rapid healing which his diploma gives him, and subject to a degrading takes place, and the result is a firm and flat cicatrix, with control-is opposed to the medical interests of the little or no synechia, and the eye is left pretty safe from public, and especially of the poor, and the profession future infection. Such good results are not by any means must not tolerate it. Nothing analogous is allowed for a always obtained by the other recognised methods, as ex- moment in the legal profession, and shall the medical pro. I have never found eserine or atropine fession, whose foremost care is the health of its patients, cision, bandage, &c. reduce a prolapse, even when it has been very small and have a lower standard of ethics ?? recent. Errors of refraction form a large proportion of I would give one important word of warning. The time is ophthalmic work nowadays. We have various ways of esti- rapidly approaching when there will be change of name mating refraction errors. In my own practice I rely on of these associations without change of the basis on which retinoscopy and testing the vision with Snellen’s test types. they rest. The name is an opprobrious one and will be My object in referring to this subject is to say that I para- changed. The profession must be watchful not to be misled lyse the accommodation with atropine in a large proportion by the simple dodge of substituting another name for either of young subjects in the first examination. I do not mean existing or new medical aid associations. At the seventeenth in every case, but in a large number of them, and it is annual conference of the Friendly Societies’ Medical Alliance astonishing how great the spasm that is often found to exist. last April a suggestion was made to omit the word "aid" By paralysing the ciliary muscle we ascertain the full amount from the titles of these associations. It appears to me that of error and are able to correct the defect most accurately. the time is ripe for the British Medical Association to ask These young patients on their first visit are often nervous the Legislature to take steps to prevent the use of the word and unreliable and atropine gives one independence ; "medicalin titles of concerns owned by persons who The use of the word has besides the examination can be made more easily and possess no medical licence. become altogether too loose and in many cases is now quite rapidly and time is saved. unjustifiable. Medical hall applied to a druggist’s shop is misleading; medical association applied to one of these associations for obtaining cheap doctoring is quite out of ETHICS. place. If it means anything it means an association of 29TH. WEDNESDAY, JULY medical men. This, however, is a minor matter. The vital Medical Aid Associations. distinctive feature of the movement, let it be called what Dr. LESLIE PHILLIPS read a paper on Medical Aid Asso- it will, is "farming." The time and services of a medical ciations. He said :-The civil responsibilities of medical man are wholly or in part farmed by a layman or a body of practice have been within the last few months very strik- laymen who make money thereby in one or both of two ways. ingly shown. If these responsibilities are to be gauged by There is made either a direct profit, as by obtaining, say, 4s. such damages as was the case in this cause it will behove from the patient and paying the medical man 2s. 6d., or, ad members of the profession to act in concert to see that all is more usual, by obtaining for about 6d. or ls. skill and labour work undertaken is adequately remunerated. Whether club for which on club terms 4s. was formerly contentedly paid. work has ever been properly remunerated is more than I have already stated my views that even this 4s. basis was, doubtful. I personally believe that the orthodox 3s. 6d. and is, totally inadequate. The importance of this warning or 4s. per year per member paid the clubs for medical with regard to names and principles is exemplified at the attendance and medicine is not only inadequate but absurd. present time by the case of the Bridgnorth Infirmary. Here a None but medical men would for a moment accept or be responsible hospital committee, in spite of the protests of content with such a sum as an insurance against a sickness the majority of the medical staff, employ a salaried house risk, and the profession will be well advised at the present surgeon, making it a condition of his appointment that he time to stand out with determination for a remuneration earns money for the committee by carrying on a provident adequate to what is expected from them and what is given branch, which is really a medical aid association. by them. I can understand that in poor agricultural districts The proceeds of this branch are used for the purpose the members may be unable to pay as much as in our manu- of supporting the hospital. Here the skill and labour facturing towns, where workmen earn good wages ; but in the of a medical man are farmed to run a medical aid latter case I believe something like 10s a year per member association for the purpose of supporting a charitable should be insisted upon by the surgeons, and I cannot see institution. Those who care nothing for the well-being that this would unduly press on the insured member. of our profession may say : " Here is a capital way for present point, however, is to remind you that years ago I the public to exercise their charity without putting their showed, and it has not been contradicted, that some hands in their pockets. So long as it can be done at the medical aid associations pay their surgeons a cash expense of the profession by farming medical men why salary at the rate of less than 6d. a year per member. should the public find the money ?? Never mind the proIt will be well for the profession to bear in mind that fession ; they are unbusinesslike men who will not notice statisticians. alike of Europe and America, are agreed that the sublying principle, or if they do they will as usual the poor are becoming richer, and that the argument that exercise their traditional self-sacrifice and be content to the masses of the people are becoming ever poorer and poorer submit to be farmed to run our up-to-date coöperative answer

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