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I cannot conceive that the public has a right to demand any-thing more. There may be other things which are desirablein a doctor, but they are things which in my opinion are un-necessary for the protection of the public, and it is the pro-tection of the public which is the basis of medical examina-tions. It may be very desirable indeed for the medical manto be a scholar, but the public has no right to demand thathe should be one. It is far more needful that he should bea gentleman than a scholar, but you cannot put that into anexamination.The physiology the medical student requires is an

acquaintance with its fundamental and elementary rules,but it must be a real acquaintance with them. He mustknow, for instance, thoroughly the laws which govern themovement of the blood, from the small arteries through thecapillaries into the veins. And to know physiology reallyand truly he must be able to judge of the way in which itsconclusions have been reached ; he must understand itsmethods, and he must know the instruments, the resultsobtained by which are the foundation of a large number ofthe theoretical views. And although you do not want muchphysiology for an understanding of the principles of medi-cine and of the nature of disease, yet as wise men youwould do well not to present yourselves at the examinationloaded simply with just the necessary amount of physiology;you should always leave a margin for accident. I believethere are sometimes accidents in examinations. I know afriend of mine who was floored by the morning paperbecause he had eaten too hearty a breakfast, and I take itthat in an evening examination a too hurried dinner willdraw a veil between the examiner and the real ability of thecandidate.But there is another reason why you should go beyond

that minimum. A medical examination, as I have said, isonly a preliminary selection. It only says that this man is,on the whole, fit to take charge of the sick; your ultimatesuccess in life will be the result of a struggle for existence,and your income will depend not merely upon your havingsatisfied the examiner, but upon the amount of skill whichyou will display in your life afterwards. Have you anamount of physiology beyond that minimum required bythe examining boards to help you in this struggle ?For if it will not help you, I, as a physiologist, haveno right to ask you to take the trouble to learnit. But I am sure that it is in your interest tolearn a fuller physiology, and though much of whatyou learn may be compared to scaffolding which mustsooner or later come down and be displaced, yet at thesame time there is a great deal of "real house," of firmbasis, which will remain for all time. These real physiolo.gical truths require careful and prolonged attention in orderthat the student may lay hold of them, and he does this allthe more readily if he carries on practical work in the

laboratory. The latter work carries with it no specialvirtue of itself, for it is astonishing how much time thestudent may spend in the laboratory and yet remain quitefree from any taint of physiology. The work to be donemust be done not only with the hand, but with the mind,and he only will gain by it who, working in the laboratoryat the things themselves, while looking at them reads inthose things the lessons which they teach. The physiologywhich can be of use to medical men afterwards is the samephysiology which is required of the candidate at examina-tion-a real acquaintance with fundamental physiologicalnotions; but the value of it will depend upon the way inwhich it is used. And let me here say how not to use it.You must not take the latest results of the laboratoryand apply them direct at the bedside; for physiology is onlyas yet in its infancy; and in our notions of the nature ofdisease things are only at the same level. Nothing is tomy mind more dangerous than the practice of taking, so tospeak, "raw" physiology at once into clinical work ; andif you look back on the history of the profession you willfind that these attempts to take physiology straight off into Ipractical use have proved delusive, and to my mind a greatdeal of discredit has been thrown upon physiology by theseattempts. When I last addressed this Society eleven yearssince, I took as my subject the absolute identity betweenpathology and physiology, and I tried to lay beforeyou the opinion that these two sciences were funda-mentally the same ; that they were only, so to speak,the two sides of one sheet. The great use of physiologyto a medical man is to supply him with ideas whichwill help him in pathological and clinical investigation. Let

him in practice use his physiology as a working hypothesisand let him combine with this pathological and clinicaobservation, and out of it will come a true theory whiclwill go far to cure the disease. Think for a moment of thalgreat discovery of antiseptic surgery. Lister started as Ephysiologist, and the commencement of the antiseptic theor3was a physiological idea worked out on pathological, clinical,and experimental lines. Take, again, the surgery of th(brain; physiology has gone hand-in-hand with clinicalsurgery and post-mortem observation, and brilliant resultshave been attained. But though you may say you haveneither time, opportunity, nor ability to make these medicalinquiries, yet you can and must be critics and judges. I amastonished and gratified by the amount of physiology whichI find has been introduced into practice, the amount ofphysiological knowledge now found common to the medicalprofession. But not all the physiology so found is good ;much of it, indeed, is bad. Let the student, therefore,so train himself that he may be able to detect the bad-those physiological wolves in pathological sheepskins,which make their way into the medical fold and doso much damage. The greatest use of an adequatephysiological training is to enable a man to detectin after-life with tolerable readiness those theories whichare worthy, and to separate them from those whichare worthless. To attain that faculty, and to let thatphysiological judgment get into your minds, you must giveserious attention to its study. One great evil in life is thatit is apt to be dull; the life of a doctor who takes no livinginterest in his profession is apt to be dull. Nothing will bringbrightness to your life-not music, not even good dinners-ifyou do not find brightness in your daily task; but brightnessmay be got if you lay hold of your old physiological learning.Physiology has a mystery in her own right and a future ofher own; physiology has not only to do with the mending,but with the making of men. If, in the intervals ofleisure, you study it, you will find pleasure in it whichwill always prevent your life from being dull.

Clinical LectureON

MASSAGE SCOOPS AND IRRIGATION IN THEEXTRACTION OF CATARACT.

Delivered at the Ulster Eye, Ear, and Throat Hospital.BY DR. McKEOWN.

GENTLEMEN,—We shall consider to-day the most delicateand critical stage of the operation of extraction-viz., theremoval of residual cortex. I may add also that it is themost uncertain, notwithstanding the accumulated expe-rience of nearly two hundred years ; for though a com-petent operator with a steady patient can make the sectionwith absolute precision in every case, the most experiencedcannot in many cases say whether he can or cannot removethe cortex by the ordinary methods of massage and scoop.It may surprise you when I say that these methods, whichhave been so long in use, are in a broad sense unsuited forthe object in view, and therefore unscientific. You havehad no opportunity of seeing in this hospital the use of thescoop at all, and massage has only been used in a very mildway, being only regarded and used by me occasionally asan auxiliary to irrigation. I shall try, however, to proveto you what massage is capable of doing and what it is not.To this end you must look at the physical character of thestructures, and consider the conditions involved in theproblem of extraction-a matter, I fear, which has not hadsufficient attention.You have now before you a rough drawing of the eye with

pressure on the cornea exercised after expulsion of the nucleus.(Fig.l.) This figure will explain to you better than I can doby words the inherent difficulty of removing cortex in anydegree resistant. The soft, jelly-like vitreous (D) is thepoint, or rather cushion, of resistance; the force is appliedat E, and causes a depression of the remains of the lens (A)and of the vitreous at F, with a corresponding bulging of

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the vitreous at C, opposite the wound. It is obvious that,whether the remains of the lens (A) will be expelled or, onthe contrary, the bulging vitreous at c, depends on therelative resistance of the remains of the lens (A) and thehyaloid membrane at C. If the cortex (A) be soft or, if notsoft, be separated from the capsule, it may be rubbed andpressed out; but if neither of these conditions exist the

FIG. 1.

A represents cortex imprisoned in capsule a,fter expulsionof the nucleus. B, Cornea.1 section npin on pressureexercised at E. C, Hyaloid membrane bulging towardswound. D, Vitreous. E, Cornea depressed by finger orscoop.

chances are that, notwithstanding all efforts, it will ingreat part remain in the eye a source of probable mischief.As you have never seen me perform an operation trustingto pressure and massage, you can have no adequate idea ofthe trouble and prolonged manoeuvres often necessary andoften fruitless. Whilst Fig. 1 is before you I show you nowa sketch of the conditions in irrigation afterexpulsion of the nucleus, with the nozzleof the syphon irrigating bottle inside thecapsule (Fig. 2). There is no pressure onthe cornea, no pushing back of the vitreous

FIG. 2.

no squeezing of the hyaloid membrane towards the section.The current of water, under the control of the surgeon,flows inside the capsule to the periphery, and returns alongthe anterior and posterior capsule, searching every cornerand bringing with it fragments of cortex from every part

I of the capsule. The force is equable and gentle, and actsnot only on the parts we do see but on those concealed bythe iris, and quite as well on the parts concealed as on theparts visible. In both cases an iridectomy is supposed tohave been performed. With these two figures before you itmust be clear that the complete extraction of cataract issimply a question of physics, of relative resistance andrelative well-directed and suitable force; and, if I may pro-phesy, the method which will prevail is that which most,accords with physical laws and conditions.

I now come, a little out of order, perhaps, to the use ofscoops. The history of scoops is one of which the ophthalmicdepartment of the profession has no reason to be proud. Itillustrates very well indeed the tendency of the mind to getinto a groove, to adopt views and practice without adequateinquiry and stick to them for generations, though warnedof their general unsoundness by daily experience. St. Yves.was the first to use a scoop. He removed by it a dislocatedlens through a corneal section. For this sort of operationit was a proper instrument, and at this day for a like casei it holds its ground. But when Daviel applied cornealsection to remove cataracts, not dislocated but remainingi in situ, he, probably following St. Yves in a way, used a! scoop to remove, not the body of the lens, as St. Yves did,but fragments of the lens in the pupil after extraction ofthe nucleus. I cannot help thinking that, useful thoughthe scoop of St. Yves was, and useful though the curette of’Daviel may have been in isolated cases, this use of the scoophas dominated the surgery of cataract not to its advantage.Surgeons have not used enough the critical faculty, but.have been too much led by a regard for names and authority.indeed, from the time of St. Yves till quite recently ophthal-mic surgeons have had fitful periods of a mania for scoopinvention. They have followed St. Yves and Daviel, and,I think, without any satisfactory reason. I will nowexamine in a few words, as I did in the case of massageand friction, what the scoop can and cannot do as regards.removal of cortex. I will begin with the old classical napextraction, for a time recently under a cloud, but now happilyrevived. You know iridectomy was not performed, there-fore, after expulsion of the nucleus, the only part of thelens area under view was that of the natural pupil-that is,about one-eighth or one-tenth of the anterior surface of thelens; and as the scoop could only be used to remove frag-! ments seen by the surgeon, it could have any possibleI armlication on onlv the one-eighth or one-tenth of the field.

I must speak quite plainly about this ; and I say theuse of the scoop was inapplicable for about nine-tenths of the field of operation, and even uncertainfor the remaining tenth, and therefore was radically-bad. But some may think that the combined opera-tion of iridectomy with extraction remedied this tosome extent. This is quite true, but, on the most.favourable view, just about in proportion to theenlargement of the pupil. If iridectomy enlargedthe pupil so as to expose one-fourth of the area ofthe lens, then the scoop might be used on one-fourthof the field, but on the other three-fourths it couldnot be used at all. All scoops, therefore, no matterby what distinguished names they may be called,must be condemned as inefficient on the ground Ihave stated. There are other objections to scoops,but it is a cardinal point in dealing with any question,that if you have an unanswerable objection you shouldnot trouble to discuss minor points.

In view of what I have told you of the physicaldefects of the methods of pressure, massage, and;scoops, you will not be surprised to learn that thebounds of legitimate operations for cataract have beencomparatively limited. For the cataract should be ofsuch a character that it could be removed by themethods of massage and scoop-that is, it shouldeither be so firm from centre to capsule as to comeout completely at once, or so soft all through, or onthe surface, that all the lens could be removed. Infact, conditions were required which left little ornothing for massage or scoop to do. The surgeonjudges by appearances, and if he determine that a.cataract is ripe, he operates, and the accuracy of his.diagnosis can be determined by the operation. So.

we have this important information, that operators ofexperience know that the diagnosis of ripe cataract is.in a considerable percentage erroneous, and that theoperation is attended with unforeseen difficulties. The-

consequences of such a mistake are very serious for the

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patient, and the surgeon with only massage and scoop issimply powerless. On the other hand, when the surgeondiagnoses a cataract as unripe, he rarely operates, and in

FiG. 3.

Syphon irrigating bottle

cases of such a character there is therefore no means ofknowing whether his diagnosis of unripeness is right orwrong. To sum up : when a diagnosis of ripe cataract ismade, there is a varying percentage of error as regards the- ease of perfect removal and a consequent risk to the patient;land when a diagnosis of unripeness is made, the patient isnot subjected to the risks of an operation, but is put asidefor months, and often for many years, with the prospectof a miserable life, and perhaps dependence on friends or onthe doles of parochial charity.

I think you have seen so much here that you know thesedifficulties are all faced. With intraocular irrigation aspractised here, I do not fear unexpected difficulties in theordinary cases, and do not hesitate to operate on cases oftransparent and sticky cortex-in other words, of unripe’cataract. And why? Because I have a well-tried method,.at least well tried in this hospital since 1884, and one whichmakes the surgeon, in a general sense, the master of circum-stances. I cannot impress on you too strongly that forsuccess in surgery the surgeon should be armed to meet alleventualities. I need not tell you, though I am sure itwould be interesting, of the various stages of developmentof the method of irrigation and injection. I have devisedand used various instruments of various degrees of effi-and of varying defects, but this I have always hadbefore me, that the force of pure water was the proper forceto clear out the residue of the lens, and I have never seenany reason to change my opinion.

I show you now the instruments I have used since thespring of 1884, but I ask your special attention to the lastone-the syphon irrigating bottle (Fig. 3). It is fiat andholds about four ounces. In the inside of the bottle thereis a bent tube, the bend reaching nearly to the top, whilstone end reaches to the bottom of the bottle, and the otherend passes through the screwed-on cap at the lower end of

, the bottle. To the lower end of the tube is attached aindiarubber tube on which are a clamp to stop the flow o

liquid and a ring with a, screw to press the sides of thtube together and diminish the initial force of the flowI do not know that the latter is of much use, but a.

i it is figured in the diagram I allow it to remain. Yoi

see I have a horizontal bar moving up and down 01

an upright attached to the operating table, and I intended to have the syphon bottle suspended on th(upright bar, but I have found it is better to have th(syphon bottle held in the hand of an assistant at a suitabl(elevation. You see also a hole in the top of the bottle foa thermometer, but I have discarded the thermometer. simply after charging the bottle with water of a tempera-ture a little above blood heat, before I begin irrigating theeye, let the water flow on the back of my hand till it feelscomfortably warm ; then grasp the indiarubber tube betweenthe forefinger and thumb just above the nozzle, and thusstop the flow, and introduce the nozzle into the eye ordepress the lip of the wound and, relaxing my grasp, letthe water flow, and stop the flow when I think it necessary,observe the effect, perhaps use slight massage, and renewthe irrigation, being guided as to continuance and repetitionby the appearance of the pupil.

I wish you to note specially that until the bottle is filledabove the bend of the tube the water will not begin toflow; but once it has commenced it will go on until thebottle is emptied unless stopped by pressure, and no matterhow often the clamp is applied the water will at once beginto flow again on its renewal.

You may have observed the care which is taken to haveeverything aseptic. A solution of perchloride of mercury(1 in 2000) is passed through the syphon bottle, then the

bottle is rinsed with distilled water previouslyboiled, then the bottle is charged with distilled

. water likewise previously boiled and above bloodBB heat, and the water allowed to flow through the

tube before use. The tube in the bottle being- of silver and the nozzle being likewise of silver,

they are tarnished by the mercurial solution. Ido not think that of importance in relation tothe tube in the bottle; but I have the nozzlepassed through the flame of a spirit lamp, rubbed,and washed by the flow of water before intro-ducing it into the eye. The aseptic precautionsdescribed to you may seem unduly troublesome;but I cannot impress on vou too much that

cleanliness and attention to minute details are of thevery essence of surgical success.

(To be continued.)

NOTES ON SOME CASES TREATED BY

SUSPENSION AT THE NATIONAL HOSPITALFOR THE PARALYSED AND EPILEPTIC,

QUEEN-SQUARE.BY J. S. RISIEN RUSSELL, M.B.,

AND

JAMES TAYLOR, M.A., M.B.,HOUSE PHYSICIANS TO THE HOSPITAL.

, By permission of the physicians, under whose care thevarious patients were, we are able to publish a list of someof the cases in which the suspension treatment as recom-mended by Charcot was tried at the National Hospital forthe Paralysed and Epileptic, Queen-square. The cases hererecorded are, it will be observed, all cases of tabes dorsali-with the exception of two-one of lateral sclerosis, appasrently primary, and the other of postero-lateral sclerosis,the "ataxic paraplegia" of Dr. Gowers. The apparatusused was the ordinary Sayre’s apparatus, consisting of tripodwith head and arm pieces suspended on a pulley. Sus-pension was done every other day, and in all the casesrecorded here was the only treatment employed. Half aminute to a minute was the time allowed for the first sus-pension, and this was increased as rapidly as the patientcould bear it, up to four minutes, which may be taken asthe time of the last four-fifths of the suspensions in eachcase. In only one case (No. 10) were the suspensions done