Dr. McDonald.-The bills of mortality were commenced by the Parish "How hard was poor Tom Wormald's lot He all the work and honour got, Mr. Coleridge.-Yes. Mr. J. H. Green, of St. Thomas's Hospital, delivered the Hunterian Oration on two occasions-viz., in 1840 and 1847. They were subsequently published under the titles of "Vital Dynamics," and "Mental Dynamics." Mr. Clarke, who delivers the next, is Consulting Surgeon to the same hospital. You will find an amusing account of the circumstance to which you allude in Clarke's "Autobiographical Recollections," page 270. PERIODICALS AND NEWSPAPERS RECEIVEDLancet-British Medical Journal-Medical Press and Circular-NaturePharmaceutical Journal-Northampton Mercury-Daily TelegraphAllgemeine Wiener Medizinische Zeitung-Berliner Klinische Wochenschrift-Centralblatt für Chirurgie-Gazette Médicale-Gazette Hebdomadaire-Gazette des Hôpitaux-La France Médicale-Le Progrès Médical-La Tribune Médicale-Bulletin de l'Académie de MédecineParis Medical Record-The Science of Health-The Phrenological Journal-The Illustrated Annual of Phrenology and PhysiognomyStudents' Journal and Hospital Gazette-Revue des Sciences MédicalesKnaresborough Post. COMMUNICATIONS have been received from NERVOUS; Dr. J. C. MURRAY, Newcastle-on-Tyne; Dr. H. FINCH, Colchester; Dr. EDIS, London; Mr. G. C. COLES; Mr. J. B. BLACKETT, London; Mr. D. COYDER, Bradford; Mr. E. ELPHICK, Adelaide, S.A.; Dr. BRINSLEY NICHOLSON, Red-hill; Messrs. KINLOCH and Co., London; Dr. EDWARDS-CRISP, London; Mr. J. WICKHAM BARNES, London; the REGISTRAR-GENERAL, Edinburgh; Mr. W. CROSS, Clifton; Mr. E. M. KIDD, Nottingham; Dr. LAWSON, Wakefield; Dr. J. E. POLLOCK, London; Mr. J. CHATTO, London. BOOKS AND PAMPHLETS RECEIVED The Annual Discourse before the Massachusetts Medical Society, by Dr. Nathan Allan-Lecture on Public Health, delivered in the Lecture-hall of the Royal Dublin Society-Tables of Materia Medica-Dickinson on Tropical Debility-Tyrell on the Use of Strychnine in Epilepsy-Alford's Hints on Public Health-Ballard on Hereditary Syphilis-Blake on the Connexion between Isomorphism, Molecular Weight, and Physiological Action-Nicholson's Indian Snakes, second edition-Blake on Sulphur in Iceland. APPOINTMENTS FOR THE WEEK. July 25. Saturday (this day). Operations at St. Bartholomew's, 14 p.m.; King's College, 2p.m.; Charingcross, 2 p.m.; Royal Free, 9 a.m. and 2 p.m.; Hospital for Women, 9 a.m.; Royal London Ophthalmic, 11 a.m.; Royal Westminster Ophthalmic, 14 p.m.; St. Thomas's, 94 a.m. 27. Monday. Operations at the Metropolitan Free, 2 p.m.; St. Mark's Hospital for Diseases of the Rectum, 2 p.m.; St. Peter's Hospital for Stone, 3 p.m.; Royal London Ophthalmic, 11 a.m.; Royal Westminster Ophthalmic, 14 p.m. 28. Tuesday. Operations at Guy's, 1 p.m.; Westminster, 2 p.m.; National Orthopedic, Great Portland-street, 2 p.m.; Royal London Ophthalmic, 11 a.m.; Royal Westminster Ophthalmic, 14 p.m.; West London, 3 p.m. 29. Wednesday. Operations at University College, 2 p.m.; St. Mary's, 1 p.m.; Middlesex, 1 p.m.; London, 2 p.m.; St. Bartholomew's, 14 p.m.; Great Northern, 2 p.m.; St. Thomas's, 1 p.m.; Samaritan, 2 p.m.; King's College (by Mr. Wood), 2 p.m.; Royal London Ophthalmic, 11 a.m.; Royal Westminster Ophthalmic, 14 p.m. 30. Thursday. Operations at St. George's, 1 p.m.; Central London Ophthalmic, 1 p.m.; Royal Orthopedic, 2 p.m.; University College, 2 p.m.; Royal London Ophthalmic, 11 a.m.; Roval Westminster Ophthalmic, 1 p.m.; Hospital for Diseases of the Throat, 2 p.m. 31. Friday. Operations at Central London Ophthalmic, 2 p.m.; Royal London Ophthalmic, 11 a.m.; South London Ophthalmic. 2 p.m.; Royal Westminster Ophthalmic, 14 p.m.; St. George's (ophthalmic operations), 1 p.m. 0.00 0.00 30 84-0 510 63.7 17.61 0.08 0.20 77 0.04 0.10 0.04 0.10 29 85 2 47-5 66.5 19.17 169 82.0 49-6 63 4 17-44 ...3400701 45 1 2323 120436 26 8 73 82257 11.0 30 192889 43.3) 126 70896 20-9 44 360892 43 0 261 106202 33-2 91 62 80-3 500 64.7 18:17 0.04 0.10 90894 45.5 62 41 80-9 49 7 64-0 17.78 0.01 0.03 510640 98-0 346 285 82-3 55 0 64 1 17-830-81 2:06 ... 355339 82-8 251 189 85 5 51 9 66-7 19-28 0.72 1.83 133068 25.7 107 79 85 4 49 9 65 1 18.39 0.68 173 86281 18'5 68 45 163056 226 111 75 79-2 53-9 62.2 16.78 0.34 C-86 278798 12.9 150 177 79-0 52 0 63 1 17-28 0.59 1.50 261029 13:3 197 120 83.5 50.5 64.3 17.94 0.08 0.20 130996 360 92 45 780 46-0 60 2 15'66 C'18 0'46 104378 31-6 46 41 80 5 51-0 63-8 17.67 0.07 0-18 Newcastle-on-Tyne 135437 25 2 90 67 77 0 53.0 61.5 16.39 0.13 0.33 211691 47.8 135 87 81-4 44-3 62.5 16-940-43 1:09 508109 100-4 400 251 79-8 48.3 63.0 17.22 0.57 1.45 314666 31-3 190 124 81-8 48 0 63.4 17.44 0.15 0.38 in United Kingdm 7618655 36 6 5193 3570 86-7 44 3 63.8 17.67 10.26 0.66 At the Royal Observatory, Greenwich, the mean reading of the barometer last week was 29.97 in. The lowest was 29'79 in. at the beginning of the week, and the highest 30 10 in. on Friday evening. The figures for the English and Scottish towns are the numbers enumerated in April, 1871, raised to the middle of 1874 by the addition of three years and a quarter's increase, calculated on the rate which prevailed between 1861 and 1871. The population of Dublin is taken as stationary at the number enumerated in April, 1871. ORIGINAL LECTURES. A CLINICAL LECTURE ON FACIAL NEURALGIA WITH HYSTERIA. DELIVERED AT WESTMINSTER HOSPITAL. By FRANCIS E. ANSTIE, M.D., F.R.C.P., Physician to Westminster Hospital, and Lecturer on Medicine in Westminster Hospital School. GENTLEMEN,-A girl, whose tedious case is at last approaching cure, affords me the opportunity of comparing and contrasting neuralgia of the fifth cranial nerve with neuralgia of the sciatic, on which I was lecturing the other day. There are also various other points of great interest in the case. Emma T., aged 21, was admitted to Tillard ward on January 18, the statement of her friends being that she had had no less than five fits in twenty-four hours. We made as careful inquiry as was then possible, and it really appeared as if she had been attacked with genuine epilepsy, for according to the accounts given she was perfectly unconscious and foamed at the mouth in each attack. I desired the House-Physician to watch her very narrowly, and the nurses had orders to call him to her immediately if a convulsion should come on. At the time of her admission the girl was, as she is now, very stout and florid. The left eyelid was completely closed, yet scarcely with the blank smoothness of simple paralytic ptosis, but rather as if spasm of the orbicularis had the chief part in the matter. She declared, however, that she could not open it in the least. It appeared that this closure of the eye had come on some eight months previously immediately after a fall, in which she cut the left side of the head severely; and on this account, as well as to investigate the remote possibility of constitutional syphilis, I asked Mr. Holthouse to look at the patient. He pronounced decidedly that there had been no serious injury from the fall; and as regards syphilis, he pointed out the spasmodic rather than truly paralytic character of the closure of the lid, and the great improbability that of all the branches of the third only that one should be paralysed which supplies the levator palpebræ superioris. He pronounced the whole train of phenomena to be probably "hysterical." In one important respect Mr. Holthouse's diagnosis was soon verified. The fits, which recurred at uncertain intervals, and sometimes happened several times in a day, were at first treated by us as genuinely epileptic, but there was a strange fatality in the way in which they would persist in happening just when the House-Physician was out of reach. I may so far anticipate matters as to mention what was the end of this part of the case. After she had been in the hospital for three or four weeks, the House-Physician got the opportunity of seeing her in a convulsion, and watching her narrowly. He came to the conclusion that she was not really unconscious, and that the attack was, in fact, hysterical, and not epileptic in character. I determined to deal with this in a vigorous manner, and I carefully explained to the nurses, in the patient's hearing, that the moment she went into a fit a large quantity of cold water was to be thrown over her. Thereupon she at once ceased to have fits in the daytime, but continued to have them frequently at night, when she knew very well there would be more trouble and difficulty for us to insure her a prompt ducking. We were determined not to be beaten, however. Mr. Heale, the then House-Physician, exerted himself enthusiastically, and managed to give her two or three effective duckings, even at the most inconvenient hours, after which she gave up the fits altogether. It is not often that I deal with hysterical cases in this way, and I do not wish to give you the idea that most, or even many, subjects of hysterical convulsion ought to be treated in such a manner. Our patient was a hysteric of a special type. She was very fat, and, in muscular development, up to a fair average; there had been no chronic illness such as might have impaired her constitutional tone; and it seemed, on the whole, as if she were merely a girl of originally weak will and limited self-control, who had allowed herself to be frightened by the fall which she had sustained into the idea that she must be very ill. Had she been really delicate and feeble, as very many hysterical patients are, I should not have ventured to inflict a severe shock upon the system; but as she seemed to possess sufficient strength to make it probable that there would be a healthy reaction, it appeared worth while to make VOL. II. 1874. No. 1257. a vigorous attempt to rouse her from a state of feeble volition which was evidently fast tending in the direction of moral enfeeblement accompanied with a good deal of imposture. Our experiment, as you have seen, was successful. The remaining symptoms proved far more intractable; and I wish distinctly to acknowledge that our diagnosis was too partial, and led to an unnecessary delay in the completion of the cure. She had complained at frequent intervals since her admission of severe pain in the left side of the forehead and face, but I did not at first identify the neuralgic character of these pains. The reason of this was that she not only spoke of them in a tone which appeared exaggerated (as well as we could judge from her appearance), but varied greatly in her description of them from day to day, and, moreover, exhibited such an extreme hyperæsthesia to touch as seemed much more like that which belongs to the hysterical temperament than the more limited and definite tenderness which characterises the genuine neuralgias. Under these circumstances, I allowed the idea of hysteria to take too exclusive possession of my mind; and, indeed, there were still various symptoms about her that obviously belonged to that category. For instance, she frequently vomited, and this vomiting had no definite connexion with the attacks of pain in the head; nor, on the other hand, was there any appearance of the tongue which would countenance the idea of a genuine dyspepsia. She also professed a complete inability to retain solid food on the stomach, which, in the absence of any morbid appearance of the tongue, was strongly suggestive of a half-delusion, half-imposture, which we very frequently observe in hysterical females. It may be as well here to record the various measures which we adopted during the first nine weeks of her stay in the hospital. For some days after her admission I thought it right to give a fair trial to anti-syphilitic remedies, because, although the hypothesis of syphilis was a very improbable one, it was not impossible, and had that malady really been the root of the mischief, the symptoms would have indicated dangerous lesions, and anti-syphilitic treatment would have produced decided and speedy relief. Neither iodide of potassium, however, nor small doses of hyd. bichlor. had any effect either upon the fits, the affection of the eyelid, or the pain in the head. From January 26, the hysterical character of the complaint being now strongly impressed on my mind, I gave her, in succession, bromide of potassium in full doses (on account of probable ovarian excitement), bismuth, hydrocyanic acid, creasote (for the vomiting); then quinine for two days only and in small doses, which, however, she declared made her immediately sick; then again bromide of potassium in large doses. On March 10, as she complained of great weakness, we allowed her a little wine, but the hysterical symptoms seemed rather aggravated by this; and on the 13th I gave her an exceedingly nauseous mixture of assafoetida, chloride of ammonia, and tincture of valerian, omitting the wine. On March 18, by which time the fits and the vomiting had ceased, and the patient was beginning to take and retain some solid food, I addressed myself in a more particular manner to the pain in the head and the closure of the eyelid. Still impressed with the hysterical aspect of the whole case, I determined to try the effects of faradisation, which often speedily cures hysterical hyperesthesia, paralysis, and spasm. The interrupted current was therefore applied, at firstly mildly and then pretty sharply, daily during nine days, to the forehead, the eyelid, and the cheek; but no good effects were produced. On the contrary, while the eyelid remained wholly and spasmodically closed, the pain, according to the patient's account, became much worse. From March 27 we frankly gave up the idea that the facial pain and the closed eyelid were at all specially due to hysteria. That the girl was of that temperament was obvious, but the active manifestations of hysteria had subsided, her general self-control was greater, while at the same time she gave a much more definite and coherent description of the pain. She described it as centreing in, and radiating from, the following points-(1), supra-orbital, just above the notch of that name; (2), opposite the infra-orbital foramen; (3), on the malar bone; (4), in front of the ear, upon the aurico-temporal nerve. The pain was also described as much more regularly paroxysmal than at first, recurring several times daily with great intensity for some minutes at a time. Thus we had very clearly before us the picture of a neuralgia affecting large branches of the first and second divisions, and a smaller branch of the third division of the fifth cranial nerve, otherwise called the trigeminal or trifacial, of the left side; and it was open to more than suspicion that the spasmodic closure of the left eye was a symptom parallel to the neuralgia, and analogous to the far more severe and generalised spasms of the facial muscles which occur in the worst forms of tic douloureux. At this point we noticed a phenomenon which either had not previously existed or else had been overlooked. On one or two occasions I saw the patient immediately after an unusually long and severe attack of pain; I then noticed a very obvious tumefaction, and bright redness of the cheek and temple. Now this, equally with the palpebral spasm, is a characteristic example of the secondary phenomena which frequently attend severe neuralgias: it was a condition of localised vaso-motor paralysis. I am afraid we must admit that our last remedythe faradic or induced current--had aggravated the neuralgia and its dependent phenomena. Having made up our minds to deal with the facial symptoms as truly neuralgic, we commenced (March 27) with the use of a powerful local sedative-extract of belladonna one part, glycerine two parts, rubbed into a thick smooth liniment. This afforded no relief whatever. On the 31st we ordered a blister behind the ear; and this decidedly, though but temporarily, relieved the pain: and I may mention that on many subsequent occasions we resorted to flying blisters in the neighbourhood of the various foci of pain (not exactly upon them), and always with considerable benefit; indeed, the girl would always ask for a blister when the pain had been worse than usual. We tried the bromides again, but they were useless; hypodermic morphia also, chloride of ammonium, and cannabis indica were tried, with perfectly negative results. We then determined to give a fair trial to quinine, and gave five-grain doses three times a day. This made an immediate impression; and from that time she never seriously relapsed. It has taken, however, full four weeks of the treatment to completely arrest the paroxysms. At present (July 2) she has been completely free from pain for some time, and the spasm of the eyelid is more than half cured. She speaks quite cheerfully about herself, and says she feels well. [She had some partial relapses, but on July 13 left the hospital quite well.] The case which has just been narrated to you is of a rather uncommon kind. It is not often that you get a true and severe neuralgia so completely masked in its early stages by the phenomena of hysteria. Still, there is nothing to prevent hysterical persons from having true neuralgia if the necessary conditions be present; and, in fact, a good many hysterical women-though far fewer than is generally supposed-suffer from neuralgia of perfect type. As regards the immediate or exciting cause of the neuralgia in our patient, I am inclined on the whole to trace it to the severe blow on the left side of the head which she had received some eight months previous to the occurrence of the series of "fits" for which she was admitted to the hospital. It is true that the neuralgia did not at once develope in complete form after this blow, but she spoke of having had very frequent headache, and much depression of mind, though strong enough in body. It is evident that there was considerable shock to the nervous centres, sufficient to set up the hysteric state; and it is probable that the same influence operated, more slowly, to produce the trigeminal neuralgia. I have several instances in my mind in which a shock of this kind was undoubtedly the precipitating cause of a neuralgia which might otherwise never have occurred, although weeks or months elapsed before the full development of the typical pain. But in such cases there is mostly a family predisposition to neurotic diseases, and I therefore carefully interrogated our patient on this subject. Her ascertainable health genealogy does not go very far back, but she positively stated that no blood-relation, that she had ever heard of, had had any of the graver nervous disorders, adding, however, that her own mother was the most "nervous person she ever knew, and apparently had been so all her life. It is quite possible that there have, in reality, been more and graver nervous diseases in the mother's family than our patient is aware of. However, we have no proof of this, and must content ourselves with the knowledge that from her mother she may have inherited a certain instability of the nervous system. Neuralgia of the face is a tolerably common disease in young females, but, for the most part, neither its form nor its history are what they were in this case. The form which is most frequently seen is that of migraine, or periodical sick-headache, commencing spontaneously some time between puberty and the age of twenty-five, but usually before the age of twenty. Indeed, it may occur from the very first development of sexual function, and in rare cases even precedes this. I am not going to repeat the minute description of this malady, because I have recently written so much about it, and made it the subject of a clinical lecture here, which you can read in the Practitioner for 1872 (vol. ix.). But I may remind you that I spoke of migraine, and of the allied clavus, which for the most part occurs in chlorotic girls, as diseases essentially belonging to the period of bodily development, tending to change their form in later life. What was migraine in the growing girl (or boy) becomes ordinary trifacial neuralgia in the adult whose frame is consolidated-without sickness, with little or nothing of the lengthened and perfectly regular intervals of migraine,—and finally, in most cases, dies out in middle age. Our patient has no such history, for it does not appear that she has at any time been liable to periodical sick-headache, nor (up to the time of the blow) specially to headache of any kind. It therefore becomes important to consider how far the improvement which has now taken place will endure; and for this purpose we require to take a careful view of the probabilities as to the nature of the injury which she received some months ago. I have already mentioned that Mr. Holthouse could find no mark of the blow on the left side of the head, and no unevenness of the bone; and it is therefore certain that there was no serious scalp wound, and no fracture of the skull. She probably sustained a severe bruise on the part, and the main shock would probably be directed (as in contrecoup) towards the base of the brain. This is a kind of shock that has become rather common of late years, owing to railway collisions; and it is instructive to note that the full effects are often only slowly produced. Provided, indeed, that there is no coarse lesion of structure, such as the rupture of a blood vessel of considerable size, or a rent of nervous substance, this slow development of results is more probable than not. There is at present little or no positive evidence as to the anatomical changes which take place in such instances; indeed, the most singular fact is that the patients, after passing through a phase of really serious illness, for the most part ultimately That the mischief done has been real, however, and not merely imaginary, is proved by the fact that the symptoms occasionally proceed to the development of a clearly organic paralysis, and sometimes even to a fatal softening of the brain or spinal cord. recover. In the present instance, I am inclined to hope that the girl may shake herself free from her attack altogether,. although it is discouraging to observe that the palpebral spasm is by no means cured even yet, and she has occasional attacks of pain at night. But as regards the future, it will be necessary to speak with much reserve. The neuralgic state, when once it has been established for so long a time in any particular nerve, is apt, even after apparent cure, to return to the same nerve repeatedly in after life. As our present patient seems to be a very sober and respectable young woman, she will escape many of the influences which might tend to reestablish her neuralgia. Still, if she marries and becomes pregnant she is likely enough to suffer severely during gestation. Whether the tendency to neuralgia will continue beyond the climacteric (should she live so long) must remain very doubtful; but if she is right in her belief that her family generally-with the one exception of her mother-have been quite free from all nervous diseases, it is quite possible that she may lose all tendency to the complaint at that epoch in her life. At present the symptom of worst augury is the persistence of the palpebral spasm. It looks as if the nucleus of the portio dura--which, as you know, is very closely united (in the medulla oblongata) with the nucleus of the fifth-had received a considerable concussion and a somewhat lasting injury. Traumatic neuralgias are of very different prognosis, according as the injury has been inflicted on the branches or the nucleus of the nerve. (I am putting aside all those cases in which the injury to the nerve is produced by the growth of a tumour or the spread of some other morbid process which, beginning in non-nervous tissues, comes more and more to involve a nerve by means of pressure or of ulcerative processes.) A bruise or a cutting wound, which injures a peripheral nerve, may set up a neuralgia of very obstinate character, especially if the patient be neurotically predisposed; but it is nothing like so apt to produce a lasting tendency to easily provoked neuralgia, as is a material shock inflicted upon that portion of the central nervous system in which the nerve is implanted. Were there time, I could tell you a terrible history of a gentleman who consulted me some years ago, and in whom the whole mischief originated in a violent blow on the head with a book which a spiteful usher gave him at school, because he a nervous lad-made some stumble in his lesson. The migraine which was immediately set up by this physical shock was complicated later in life, and under the pressure of unfortunate external circumstances, by epilepsy and facial spasm; and I have no doubt at all that a serious injury was inflicted, par contrecoup, upon the medulla oblongata by the blow received in youth-an injury which set up continuous organic changes. As regards the treatment, also, which appeared to be successful in our case, I have to remark that it is in some respects peculiar. In my lecture upon sciatica I informed you that in the general way, except for malarious cases, quinine was by no means a frequently successful remedy in neuralgia. There is one rather decided exception, in the case of neuralgias which affect only or chiefly the ophthalmic division of the fifth nerve. This is a purely empiric observation, unexplained by any knowledge that we at present possess; but it has been made independently by several of the highest authorities. Failing, then, to make the desired impression by the more usual remedies, such as hypodermic morphia, chloride of ammonium, and the external application of belladonna, we tried the effect of fivegrain doses of quinine. I cannot absolutely tell you that the cure was not partly spontaneous, but there could be no doubt that a very rapid subsidence of the pain took place almost immediately after the quinine was begun. The uniformly good effect of blistering in this case is nothing peculiar, for, as I told you, this is one of the most generally useful remedies in neuralgias of every kind and situation. It is not every lady, however, who will submit to have her face repeatedly blistered. Let me conclude by drawing another contrast between facial neuralgia and sciatica. The latter, as I told you, is preeminently a disease of middle and advanced life; it is excessively rare at the age of twenty-one, and when it occurs so early is always provoked by very special causes, which I mentioned to you in my lecture on that disease. Facial neuralgia, it is true, also sometimes commences quite in advanced life-and a terribly severe and intractable disease it then is apt to prove. But the great majority of cases of the commoner type of facial neuralgia begin between fifteen and thirty, and very often (as I have mentioned) they commence in the shape of migraine or of clavus hystericus. It is seldom that facial neuralgia, in a young girl, takes so decided and localised a form without a long preliminary period of migraine; and I have little doubt that the traumatic origin of the present case was the reason for this peculiarity. Let me say, finally, that if the case had continued intractable much longer, it was my intention to have applied the constant current from some eight or ten cells of Weiss's instrument. Note.-The amount of oxygen required to oxidise the organic matters nitrites, etc., is determined by a standard solution of permanganate of potash acting for three hours; and in the case of the metropolitan waters the quantity of organic matter is about eight times the amount of oxygen required by it. The water was found to be clear and nearly colourless in all cases but the following, when it was more or less turbid-namely, in those of the Grand Junction, the Southwark and Vauxhall, the Chelsea, and the Lambeth Companies. The average quantity of water supplied daily to the metropolis during the preceding month was, according to the returns of the Water Companies to the Society of Medical Officers of Health, 125,689,091 gallons; and the number of houses supplied was 510,499. This is at the rate of 36.9 gallons per head of the population daily. Soft nuclear cataracts .. 2 Needle operations.. 2 5 Needle operations. 10 Suction operations. As a comprehensive statement of the cases is given below, it will be unnecessary for me to make any lengthened remarks upon them. The traumatic cases were mostly treated as out-patients, after a day or two of confinement to the hospital or to their own homes; and I find as a rule that the cases do very well under these circumstances, if the patients are temperate and careful persons. Here I may state that these are by no means all the cases of traumatic cataract which presented themselves at the Eye Infirmary; they are, so to speak, selected cases, for, looking at the somewhat doubtful good which is practically obtained, even after a most successful operation for traumatic cataract, rarely press the matter, unless a swollen lens is producing pain or is threatening a destructive inflammation. When I speak of the doubtful good, I allude to the inconvenience which arises in the most perfect cases from the difference in the refraction of the two eyes-a difference which it is impossible to equalise with glasses, and which nature not unfrequently resents by giving a cast to the injured eye, which disturbs its harmonious action with its fellow, and renders it useless for binocular vision. In a large proportion of traumatic cataracts (if no untoward circumstance arise, such as I have mentioned above) the best results are obtained by allowing the lens to undergo absorption, and then performing any secondary operation that may be necessary upon the opaque capsule. If a primary operation is determined upon, it should be performed before severe pain and acute inflammation are thoroughly established, for in these cases interference with the eye, although imperative, is badly borne, and there are usually warning signs before the more acute symptoms are established. I do not wish again to reopen the question of the best operation for senile cataract. In eyes of a suitable form and otherwise healthy I still continue to perform flap extraction, with or without the administration of anaesthetics, according to the patient's desire or his power of self-control. Unquestionably a more simple operation, and one of easier and safer performance in the large mass of cases, is the operation known as Warlomont's when performed in the upper segment of the cornea, and Liebreich's when performed in the lower. I greatly fear, however, that if a large number of cases were examined, the optical results would be found to be much inferior to the results of flap extraction or Graefe's operation, owing to the astigmatism which must almost of necessity result, and the troublesome anterior synechia which frequently follow this form of operation. And here a question arises, so to speak, in the ethics of cataract operation which has never been, so far as I know, fully discussed. What are we to look for in the result of cataract operations-the greatest number of eyes saved, or the best optical results? because in accordance with the view we take of this question so will our selection of the operation be guided. Are we justified (the case being otherwise a suitable one) in submitting a patient to an operation which, though having a slightly higher average of failures, gives a much higher average of optical results? In answering this question we should, in my opinion, be guided by two circumstances-the patient's position and degree of education, or in other words the necessity which exists in his case for a high visual power; and the fact or not of his having a second eye which, though cataractous, is sound in other respects. The demand for great acuity of vision is not necessary in many occupations, such as labourers, porters, agriculturists, and the like, and for this class of cases the simplest operation is the one to be adopted, there being no other cause to contraindicate it; for persons who require a high degree of acuity, and who are rendered unhappy and comparatively useless without it, such as the higher kinds of artisans, literary and professional persons, the operation should be performed which gives the very best optical results, regardless of the fact of its having a higher rate by 2 or 3 per cent. of failures, especially, as I before said, if the patient has a second eye which is sound, and upon which we can fall back in the case of failure. These, then, are the points which guide one in influencing a patient for or against one or the other operation. If both eyes are cataractous but otherwise healthy, their form being suitable, and the patient's circumstances such as require the most perfect sight that can be obtained, I strongly recommend flap extraction to be performed on the one eye. If both eyes are cataractous, and the patient's circumstances are such as do not require the most perfect visual power, I recommend Warlomont's or Von Graefe's operation. If the eye, however, seems in other respects suitable for flap extraction, I explain the slightly increased risk, and leave it to the patient to decide, and in nine cases out of ten they prefer the operation which will give the best optical results regardless of the risk. If the patient has only one eye to be operated upon, I do not recommend flap extraction. I know that many will meet my arguments by stating that it has not yet been proved that the results of flap extraction, optically speaking, are more favourable than the results obtainable by Von Graefe's operation, and many could no doubt produce ably compiled statistics to show that it was not so. There is, I think, too much want of uniformity in reporting ophthalmic cases to make statistics very valuable in this department of surgery. My own impression, after 'seeing a considerable number of cases operated upon by different operators according to different methods, is, that the optical results of a good flap extraction (to say nothing of the cosmetic effect) far exceed the results of any other form of operation. That this impression is shared by other ophthalmic surgeons, I can have no doubt, when I see the efforts that are being made to produce the same results by somewhat modifying the form of incision, as in Warlomont's, Liebreich's, and Taylor's operation. The cases of congenital cataract call for but few remarks. In Case 22, the result of which was sufficiently perfect to enable the child to thread the finest needle, the absorption proceeded so rapidly as to leave no vestiges of the lens or capsule at the end of one month. In Case 24 the absorption was less rapid, and two operations were necessary, the second having for its object the removal of a piece of opaque capsule which partially occupied the area of the pupil. Case 25 was of unusual interest. The cataracts were of a pearly white, and had a glistening look, the opacity seeming to be chiefly towards the posterior portion of the lens, and from the appearance I suspected that there might be some calcareous degeneration of its substance. Absorption was slow in the right eye (which was operated upon first). No less than three operations were performed with the needle, and finally at a fourth some opaque capsule was withdrawn with the canula forceps. The result upon this eye was all that could be desired, and the mother states that the child's sight is perfect. It was now determined to operate upon the left eye, and I proceeded as before-at the first operation breaking up slightly the anterior portion of the lens occupying the centre of the pupil. One month after this a second operation was performed, as absorption was progressing very slowly. This time the deeper portions of the lens were broken up with the needle. This gave exit to a number of fine calcareous particles which dispersed themselves over the anterior chamber. An attempt was made to remove them, and some were successfully extracted, but many of them became impacted at the angle of the junction of the iris and limbus corneæ, and the aqueous being lost, it was found impossible to remove them all. The next day but little disturbance was present, and I was in hopes the fragments might dissolve and disappear, but on the third day inflammatory symptoms supervened, and on the sixth there was slight hypopion. A free exit was given to the matter, and gradually the inflammation |