WEBSTER: Thirty-five aCzses of Cataract Extraction. 497 the sutures, and on the following day he was obliged to remove them under great difficulties. His experience had been that no wounds heal more kindly than those resulting from enucleation of the eyeball. More recently his assistants, after enucleation, have been in the habit of filling the orbit wTith boracic acid. DR. BULLER thought the suture prevented the formation of button-like granulations, which sometimes occur after enucleation. With reference to hemorrhage, he had always applied a sponge compress in the manner mentioned by Dr. -Mittendorf, and had not had any trouble from secondary hemorrhage.
REPORT OF THIRTY-FIVE -CASES OF CATARACT EXTRACTION. BY DAVID WEBSTER, M.D., NEW YORK.
I HEREWITH present, in tabular form, the records of thirtyfive cataract extractions, comprising all that I have done, good and bad, from the beginning. All these operations were performed at the Manhattan Eye and Ear Hospital. Some of them will bear a fuller report than can be put into a table; I beg leave, therefore, to enter more fully into the details of some of the cases, with such cursory remarks as may seem relevant. Case III. was that of a man who had long since lost his right eye, which was now in a state of phthisis bulbi. This was followed by detachment of the lower portion of his left retina, but he was still able to see to get about alone until his vision was entirely obscured by cataract. I operated. upon him with the understanding that, in the most favorable eVent, he would see only well enough to find his way about alone. But we .were disappointed in this, iritis set in, followed by closure of pupil. A subsequent iridectomy gave him a clear pupil, but no sight, and as nbthing could be seen through
498
WEBSTER: Report of Thirty-five Cases
the pupil but darkness I concluded that the whole retina had become detached. Case VI., a most unfortunate one in its results, was reported in detail to this Society in my paper on " Sympathetic Inflammation following Operations for Cataract," and will be found on page 21 of the "Transactions" for i88o as " Case IV." In Case X. the operation was without accident, the only indication of the probability of a bad result being the thinness and flaccidity of the cornea, and the inelasticity of the coats of the eye. Upon opening the eye two days after the operation the pupil was found blocked up by a whitish mass, and there was some redness of the globe, with considerable catarrhal secretion. Two days later sloughing of the cornea began at the wound. The incision was reopened with a probe, and a few drops of a straw-colored fluid escaped. Soon after the anterior chamber became filled with pus, the whole cornea sloughed, and the result was phthisis bulbi. In Case XVII. while lacerating the periphery of the lens capsule, vitreous began to escape, and as the least pressure upon the eye, instead of causing the lens to present in the wound only increased the loss of vitreous, I was compelled to remove the lens with a Daviel's spoon. As the patient complained of considerable pain on the second day, the bandage was removed and a good deal of chemosis and swelling of the lids were found to exist. Twenty grains of calomel were given at once, two leeches were applied to the temple, and iced cloths were used upon the eye. On the third day it was noted that the chemosis was less, that the pain had ceased, that the iris was yellow and the pupil opaque. Onethirtieth of a grain of pilocarpine was given hypodermically. On the fourth and fifth days one-eighth of a grain of pilocarpine was in like manner administered. On the sixth day two more leeches were applied to the temple and ten grains of calomel were given. From this time on, there was gradual improvement, and the eye recovered with the iris " drawn up," causing complete closure of pupil, with normal tension and good perception of light. Two months later I per-
of Cataract Extraction.
A99
,formed an iridectomy downward. On seizing the iris with forceps at about its middle, and making a little traction it easily broke away from its attachment in the region of the wound, and upon drawing it out and cutting it oft I found I had niade a narrow vertical pupil extending all the way across the eye. The eye recovered quickly from this operation, and with it the patient still sees sufficiently well to read diamond' type. Case XIX. was that of an old man with dense leucomata of both cornea, upon both of whose eyes iridectomy had been' performed by another surgeon, as he said, for the cure of his corneal ulcers. Subsequently to the healing of his corneal ulcers cataract had developed. The lens was removed without difficulty, and a subsequent needling was performed. The resulting vision, r, was as good as could have reasonably been expected. C4ses XX. and XXII. are the two eyes of a German woman who had suffered much from photopsiae, and floating " black spots" and " clouds " before her eyes. An iridectomy had previously been done upon both eyes at the Homeopathic Hospital, corner of Twenty-third Street and Third Avenue. She had also been subject to severe attacks of hemicrania. The lens was successfully extracted, without accident, from one eye on September 17, I879, but an opaque capsule and some soft lens matter remained in the eye. She had iritis during convalescence, and the eye healed with a dense membrane and partial closure of pupil. I learned that this eye was afterward operated upon at Charity Hospital, but what the result was I do not know. I operated upon the second eye on October I, I879. The lens popped out very suddenly and vitreous presented at the wound, but none escaped. Panophthalmitis set in on the fourth day and destroyed the eye. It is noted in her case that " the dense opacity on the anterior capsule was probably due to the inflammation-which occurred at the time of the iridectomy, or, possibly, for which the iridectomy was performed." The history seems to show
500
NEBSTER. Report of Thirty-five Cases
that hers was a complicated case of caitaract, and should not be brought in with uncomplicated cases to vitiate statistics. In, Case XXVIII. the patient died on the 27th day after the operation, which is a good reason, I think, for reporting the case in full. J. B-, aged sixty-five, was received into the hospital from a country poor-house, and was operated upon December 7, I88I. Perception of light good, but projection doubtful in parts of field. Cataract of six years' duration. General health poor. Under the left eye is a peculiar growth, which seems to be cancerous or epitheliomatous in its nature. He said, however, that it had not increased in size for several years. Ether was given, and the lens was extracted through a modified Graefe's cut without much difficulty. Small membranous looking opacity still visible in pupil. A few minutes after the -operation, when the nurse's attention was diverted. he suddenly tore the dressing from the eye. December 8th.-Considerable swelling of lids. Bandage removed and iced cloths applied. Calomel, gr. xv., given, followed by saline cathartic. December gth.-Swelling of lids somewhat diminished. December I ith.-Patient again unmanageable. He tore the bandage from his eyes and roamed about the building during the night. Notwithstanding this, the eye seemed to be doing well. December I 2th.-Patient again found out of bed, and wandering around the building. Administered chloral hydrate, gr. x. December I4th.-Patient has been quiet during last few days under influence of chloral. December i6th.-Some iritis. To have atropine applied. December i8th'.-Patient again unmanageable. Got out of bed and crawled under it. December 3Ist.-An attack of dementia. January I, I882.-Patient very weak; acts like one insane. Pulse weak, and signs of failure of heart. January 3d.-Died very suddenly last night. Autopsy the following day by Dr. T. Mitchell Prudden,
of Cataract Exttadtwn.
50I
the pathologist of the hospital: "1 CEdema of lungs and brain,; kidneys much atrophied; extensive degeneration of the arteries." Although this patient's vision does not appearon the books I frequently tested it with my fingers, which he counted readily, and I have no doubt that had he lived his resulting vision would have been very good. Case XXXII. was that of a prematurely old man, aged sixty, whose right eye had been the subject of a severe attack of inflammation some eight months before I saw him, leaving the upper two-thirds of the cornea covered with a dense leucoma while the lower third was quite hazy. He had mature cataract of both eyes, but was anxious to have the eye with the corneal opacity operated upon first. I accordingly extracted the cataract from this eye on September 25, 1882. The eye did well until the fourth day, when, being allowed to sit up, and groping about in the absence of an attendant, he struck it against the top of a chair-post in stooping. The next day a well-marked panophthalmitis had set in, and the result was an atrophic globe. Had this accident not occurred, the chances are that he would have recovered with sufficient sight in the eye to get about alone. As this patient had but one eye left I thought that perhaps his chances would be better were I to do a preliminary iridectomy for him. Accordingly ether was administered to him, on April 13, I883, and when he seemed to be well under its influence I proceeded to operate. While the iridectomy knife was in the anterior chamber, however, the patient suddenly raised his head and at the same time contracted his orbicularis with great force. I instantly withdrew the knife from the eye, removed the fixation forceps, and took out the speculum. After more ether was given I excised the prolapsed iris. His aqueous leaked away until the fifth day, when, the wound having closed and tht anterior chamber having been re-established, we found that ,the lens had been dislocated into the anterior chamber. As Drs. Agnew, Pomeroy, and others, concurred with me
502
WEBSTER: Report of Thirty-five Cases
in the opinion that the sooner the dislocated lens was removed the better it would be for the eye, I proceeded to extract it one week after the preliminary iridectomy. As the iridectomy wound was still only partially healed I thought it would be safer to make the cut downward. This I did without difficulty, avoiding the lens, and enlarging the wound at one end with fine probe-pointed scissors. I then introduced a small, sharp hook beneath the lens and assisted it out of the eye without loss of vitreous. A very small piece of iris prolapsed and was cut off. Considerable cortical matter was left in the eye, but I thought it prudent not to meddle with it. The eye was not opened until the sixth day, but the dressing was removed daily and the lids washed with a saturated solution of boric acid. As the anterior chamber did not fill up quickly eserine was used several times, and on the tenth day the wound closed. The pupil was filled with cortical matter, which was slowly absorbed until the twenty-third day, when a considerable portion of it fell down into the bottom of the anterior chamber, and the patient suddenly saw. He improved rapidly from this time on until he was discharged on the forty-second day with vision f, with + s.2+ , c. ax. i8o0. Case XXVII. was interesting on account of the patient's having mucocele of both lachrymal sacs. Having seen disastrous results in several cases where a dacryocystitis had been treated by slitting up the canaliculus, and passing probes for some time before extracting the cataract, I concluded it would be better to let the tear-passage alone lest, by operating upon it, I should change a mucous into a muco-purulent discharge, and thus the more readily infect the wound. At Dr. Pomeroy's suggestion I washed the eye with a weak solution of carbolic acid immediately before operating, and on the first few occasions of opening the eye duringr convalescence. The eye was opened by the house surgeon several times daily, and the contents of the sac pressed out with the thumb and carefully wiped away. The recovery was unattended with inflammation. Thirty-one different patients were operated upon, four of
of Cataract Extraction.
503 them having the second eye operated upon after a short interval. Males, 20; females, ii. Total, 31. Their ages ranged from 30 to 83. Under 40 years of age ........ ............ 2 From 40 to 50 years of age ................ 3 From 50 to 6o years of age ................. 9 From 6o to 70 years of age................ 9 From 70 to 80 years of age ................ 6 Upward of 8o years ...................... 2
3' Twenty-eight eyes were operated upon while the patient was under ether. Of these twenty-three were successes, two partial successes, and three failures. Seven eyes were operated upon without the use of an anesthetic. Five of these did well, and two were failures. The method of operating known as " von Graefe's modified" was used in all cases in which it was practicable. Where a preliminary iridectomy was done, the incision for extraction of the lens was made in the same position as in the other cases. Preliminary iridectomy was performed in six cases, four by myself, and two by another surgeon. Both the eyes of the patient who came to me with preliminary iridectomies did badly; the other four did well. In only one case out of the whole thirty-five was there loss of vitreous. The same was the only case in which a scoop was introduced into the eye for removing the lens. In one case there was dislocation of the lens into the anterior chamber during the preliminary iridectomy. In one case irido-dialysis was produced during the operation, though so obscured by blood as not to be recognized until later; and in one case the iris fell before the knife, owing to premature escape of the aqueous, and was cut through. In all these cases in which accidents occurred during the operation the eyes recovered with good sight. In three cases the cornea was found thin and flaccid, and became wrinkled, or collapsed, on evacuation of the lens. In eight cases there was hemorrhage from the iris imme-
WEBSTER: Report of Thirty-five Cases 504 diately following the iridectomy, showing an undue vascularity of that membrane, or an atheromatous condition of its blood-vessels. In four cases a considerable quantity of soft lens matter was left in the eye. In one case " some inflamnmatory reaction " was noted during recovery. This eye did well. In four cases there was iritis. Closure of pupil resulted in three of these, and in one the result was good. In another the result was made good by an iridectomy. Sloughing of the cornea occurred in one case, panophthalmitis in two cases, and in one case there was irido-cyclitis with sympathetic inflammation of the fellow eye. Comparatively few secondary operations were required. Iridectomy was performed in two cases, in both resulting in a clear pupil, but in one failing to restore sight on account of deeper disease. Keratonyis for pupillary membranes was performed in seven cases, and was in all cases successful. If we take the results of all the cases, complicated and uncomplicated, they will stand as follows: In 2 eyes, vision was -; in 3 eyes, 20; in 6 eyes, ; in 8 eyes, -U; in 3 eyes, 2A; ~~~202 4 2 0 in i eye Figers in 4 eyes, 2; in I eye, Fingers; in I eye, OT in i eye, perception of light; in 5 eyes, 0. I shall reckon the case which is recorded as counting fingers at twenty feet as a good result, as the patient did not know her letters; and the case of perception of light as a loss, although sight may have been restored by a subsequent operation. We will then have: successes, 27 = 77+ per cent.; partial successes, 2 = 54 per cent.; failures, 6 = 17+ per cent. I believe, however, that in justice to myself and to, cataract statistics, I ought to exclude the two cases of extensive corneal opacity, the case of detachment of the retina, and the old German woman with vitreous, and perhaps deeper complications. The figures would then be very materially changed. We would have: successes, 27 = 90 per cent.; partial successes, I = 341 per cent. ; failures, 2 = 6j per cent.
of -Cataract Extraction.
505
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WEBSTER: Report of Thirty-five Cases 0
of Cataract Extraction.
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5o WEBSTER: Report of T4ry-five Cases REMARKS.
DR. HEYL said that the case of sloughing cornea referred to by Dr. Webster recalled a clinical experience which is suggestive of the thought that sloughing cornea following cataract extraction may sometimes be due to diphtheritic infection, and should be treated accordingly. He had noticed in one instance that a short period, perhaps a couple of days, after a Graefe extraction inflammatory action was developed in the eye. The pupillary space became filled with a whitish mass which projected between the lips of the cut. On the lower half of the cornea a yellowish semicircle formed, perhaps, a millimetre in breadth, and distant from the limbus perhaps two millimetres. The cornea was steamy. Encircling the limbus was a girdle of conjunctiva elevated by subconjunctival infiltration. The upper- lid was cedematous; there was no false membrane. The symptoms, with exception of the whitish mnass blocking the pupil, correspond to what he had observed a number of times in cases of subacute conjunctival diphtheria. The semicircular infiltration of the cornea was rather peculiar, the opening of the ring corresponded with the cut. In his experience usually the corneal affection is in the form of an opaque area, which breaking down forms a deep ulcer. He had, however, once seen an opacity similar to the one above mentioned, except that instead of being a semicircle it was a complete circle. The pupillary mass must, he thought, have been a bacterial formation. In confirmation of the view that this was a case of traumatic diphtheritis, a patient in the same ward, and but a few beds distant, on whonm extirpation of the orbital contents for malignant disease had been performed, was attacked by traumatic diphtheritis; also two attendants in the hospital at the same time were attacked with pharyngeal diphtheria. Another point was suggested in this connection. The secondary operations in Dr. Webster's cases had been followed by no unpleasant result. Dr. Heyl had a year ago extracted a cataract, and subsequently divided the capsule without unusual reaction, with the effect of giving the patient sight sufficient to pursue his occupation, that of a clerk. A hole of good size had been made in the capsule, surrounded, however, by a margin of thin veil-like tissue. At the solicitation of the patient he was induced to try if he could not further improve sight. After doing the best that.could be done by glasses, he advised that the veil-like margin of capsule be divided. There was apparently no irritability of the eye. The extrac-
of Cataract Extraction.
509
tion cut had been a little peripheral, and in one corner a prolapsed portion of iris had healed in the wound. The second division of the capsule was performed without any difficulty. On the third day after the operation cyclitis was developed, followed by total loss of sight. Whether the engagement of the iris in the corneal cut had placed the eye in a condition favorable for the development of cyclitis, whether an unsound condition of the eye previous to the extraction was the cause, or whether this was a case of traumatic inoculation is not known. DR. STRAWBRIDGE asked, first, was ether used, and if so why; second, was atropia used in the after-treatment; third, were antiseptic dressings used in the after-treatment. DR. WEBSTER replied that he gave ether in most of the cases, and because the patients wished it. Atropia was used in forty-eight hours after the operation in most cases, but not always. Antiseptics were only used in the case of mucocele, and there the eye was simply washed with a solution of carbolic acid. DR. THEOBALD would like to ask Dr. Webster whether, in the case in which the patient became irrational, he noticed any connection between the instillations .of atropia and the appearance of the mental aberration.' He had seen one case where the use of atropia was followed by mild symptoms of dementia. DR. WEBSTER replied that he did not think that the mental disturbance was attributable to the atropia at all, and most of the gentlemen who saw the case thought that the ether had something to do with it, as the patient had Bright's disease.. DR. CARMALf, with reference to the assumption that mental disturbance might follow the use of ether, mentioned a -case in which active delirium came on the third or fourth day after the operation without ether. He believed the delirium to be mainly due to the confinement in bed in a blinded condition, in which state the patients- " lose their bearings " altQo. gether. He had not infreqfiently met the same thing, in patients blinded by accident and put to bed immediately'afterward. THE PRESIDENT remarked, that it was well established that symptoms of dementia can be produced by atropia. He did not believe that the ether had anything to do with the development of these symptoms, and that in Dr. Webster's case the condition was more -likely due to anoemia or- some general condition of the patient; at all events, he did Inot think that the ether had anything to do with it.
REPORT OF THIRTY-FIVE -CASES OF CATARACT EXTRACTION. BY DAVID WEBSTER, M.D., NEW YORK.
I HEREWITH present, in tabular form, the records of thirtyfive cataract extractions, comprising all that I have done, good and bad, from the beginning. All these operations were performed at the Manhattan Eye and Ear Hospital. Some of them will bear a fuller report than can be put into a table; I beg leave, therefore, to enter more fully into the details of some of the cases, with such cursory remarks as may seem relevant. Case III. was that of a man who had long since lost his right eye, which was now in a state of phthisis bulbi. This was followed by detachment of the lower portion of his left retina, but he was still able to see to get about alone until his vision was entirely obscured by cataract. I operated. upon him with the understanding that, in the most favorable eVent, he would see only well enough to find his way about alone. But we .were disappointed in this, iritis set in, followed by closure of pupil. A subsequent iridectomy gave him a clear pupil, but no sight, and as nbthing could be seen through
498
WEBSTER: Report of Thirty-five Cases
the pupil but darkness I concluded that the whole retina had become detached. Case VI., a most unfortunate one in its results, was reported in detail to this Society in my paper on " Sympathetic Inflammation following Operations for Cataract," and will be found on page 21 of the "Transactions" for i88o as " Case IV." In Case X. the operation was without accident, the only indication of the probability of a bad result being the thinness and flaccidity of the cornea, and the inelasticity of the coats of the eye. Upon opening the eye two days after the operation the pupil was found blocked up by a whitish mass, and there was some redness of the globe, with considerable catarrhal secretion. Two days later sloughing of the cornea began at the wound. The incision was reopened with a probe, and a few drops of a straw-colored fluid escaped. Soon after the anterior chamber became filled with pus, the whole cornea sloughed, and the result was phthisis bulbi. In Case XVII. while lacerating the periphery of the lens capsule, vitreous began to escape, and as the least pressure upon the eye, instead of causing the lens to present in the wound only increased the loss of vitreous, I was compelled to remove the lens with a Daviel's spoon. As the patient complained of considerable pain on the second day, the bandage was removed and a good deal of chemosis and swelling of the lids were found to exist. Twenty grains of calomel were given at once, two leeches were applied to the temple, and iced cloths were used upon the eye. On the third day it was noted that the chemosis was less, that the pain had ceased, that the iris was yellow and the pupil opaque. Onethirtieth of a grain of pilocarpine was given hypodermically. On the fourth and fifth days one-eighth of a grain of pilocarpine was in like manner administered. On the sixth day two more leeches were applied to the temple and ten grains of calomel were given. From this time on, there was gradual improvement, and the eye recovered with the iris " drawn up," causing complete closure of pupil, with normal tension and good perception of light. Two months later I per-
of Cataract Extraction.
A99
,formed an iridectomy downward. On seizing the iris with forceps at about its middle, and making a little traction it easily broke away from its attachment in the region of the wound, and upon drawing it out and cutting it oft I found I had niade a narrow vertical pupil extending all the way across the eye. The eye recovered quickly from this operation, and with it the patient still sees sufficiently well to read diamond' type. Case XIX. was that of an old man with dense leucomata of both cornea, upon both of whose eyes iridectomy had been' performed by another surgeon, as he said, for the cure of his corneal ulcers. Subsequently to the healing of his corneal ulcers cataract had developed. The lens was removed without difficulty, and a subsequent needling was performed. The resulting vision, r, was as good as could have reasonably been expected. C4ses XX. and XXII. are the two eyes of a German woman who had suffered much from photopsiae, and floating " black spots" and " clouds " before her eyes. An iridectomy had previously been done upon both eyes at the Homeopathic Hospital, corner of Twenty-third Street and Third Avenue. She had also been subject to severe attacks of hemicrania. The lens was successfully extracted, without accident, from one eye on September 17, I879, but an opaque capsule and some soft lens matter remained in the eye. She had iritis during convalescence, and the eye healed with a dense membrane and partial closure of pupil. I learned that this eye was afterward operated upon at Charity Hospital, but what the result was I do not know. I operated upon the second eye on October I, I879. The lens popped out very suddenly and vitreous presented at the wound, but none escaped. Panophthalmitis set in on the fourth day and destroyed the eye. It is noted in her case that " the dense opacity on the anterior capsule was probably due to the inflammation-which occurred at the time of the iridectomy, or, possibly, for which the iridectomy was performed." The history seems to show
500
NEBSTER. Report of Thirty-five Cases
that hers was a complicated case of caitaract, and should not be brought in with uncomplicated cases to vitiate statistics. In, Case XXVIII. the patient died on the 27th day after the operation, which is a good reason, I think, for reporting the case in full. J. B-, aged sixty-five, was received into the hospital from a country poor-house, and was operated upon December 7, I88I. Perception of light good, but projection doubtful in parts of field. Cataract of six years' duration. General health poor. Under the left eye is a peculiar growth, which seems to be cancerous or epitheliomatous in its nature. He said, however, that it had not increased in size for several years. Ether was given, and the lens was extracted through a modified Graefe's cut without much difficulty. Small membranous looking opacity still visible in pupil. A few minutes after the -operation, when the nurse's attention was diverted. he suddenly tore the dressing from the eye. December 8th.-Considerable swelling of lids. Bandage removed and iced cloths applied. Calomel, gr. xv., given, followed by saline cathartic. December gth.-Swelling of lids somewhat diminished. December I ith.-Patient again unmanageable. He tore the bandage from his eyes and roamed about the building during the night. Notwithstanding this, the eye seemed to be doing well. December I 2th.-Patient again found out of bed, and wandering around the building. Administered chloral hydrate, gr. x. December I4th.-Patient has been quiet during last few days under influence of chloral. December i6th.-Some iritis. To have atropine applied. December i8th'.-Patient again unmanageable. Got out of bed and crawled under it. December 3Ist.-An attack of dementia. January I, I882.-Patient very weak; acts like one insane. Pulse weak, and signs of failure of heart. January 3d.-Died very suddenly last night. Autopsy the following day by Dr. T. Mitchell Prudden,
of Cataract Exttadtwn.
50I
the pathologist of the hospital: "1 CEdema of lungs and brain,; kidneys much atrophied; extensive degeneration of the arteries." Although this patient's vision does not appearon the books I frequently tested it with my fingers, which he counted readily, and I have no doubt that had he lived his resulting vision would have been very good. Case XXXII. was that of a prematurely old man, aged sixty, whose right eye had been the subject of a severe attack of inflammation some eight months before I saw him, leaving the upper two-thirds of the cornea covered with a dense leucoma while the lower third was quite hazy. He had mature cataract of both eyes, but was anxious to have the eye with the corneal opacity operated upon first. I accordingly extracted the cataract from this eye on September 25, 1882. The eye did well until the fourth day, when, being allowed to sit up, and groping about in the absence of an attendant, he struck it against the top of a chair-post in stooping. The next day a well-marked panophthalmitis had set in, and the result was an atrophic globe. Had this accident not occurred, the chances are that he would have recovered with sufficient sight in the eye to get about alone. As this patient had but one eye left I thought that perhaps his chances would be better were I to do a preliminary iridectomy for him. Accordingly ether was administered to him, on April 13, I883, and when he seemed to be well under its influence I proceeded to operate. While the iridectomy knife was in the anterior chamber, however, the patient suddenly raised his head and at the same time contracted his orbicularis with great force. I instantly withdrew the knife from the eye, removed the fixation forceps, and took out the speculum. After more ether was given I excised the prolapsed iris. His aqueous leaked away until the fifth day, when, the wound having closed and tht anterior chamber having been re-established, we found that ,the lens had been dislocated into the anterior chamber. As Drs. Agnew, Pomeroy, and others, concurred with me
502
WEBSTER: Report of Thirty-five Cases
in the opinion that the sooner the dislocated lens was removed the better it would be for the eye, I proceeded to extract it one week after the preliminary iridectomy. As the iridectomy wound was still only partially healed I thought it would be safer to make the cut downward. This I did without difficulty, avoiding the lens, and enlarging the wound at one end with fine probe-pointed scissors. I then introduced a small, sharp hook beneath the lens and assisted it out of the eye without loss of vitreous. A very small piece of iris prolapsed and was cut off. Considerable cortical matter was left in the eye, but I thought it prudent not to meddle with it. The eye was not opened until the sixth day, but the dressing was removed daily and the lids washed with a saturated solution of boric acid. As the anterior chamber did not fill up quickly eserine was used several times, and on the tenth day the wound closed. The pupil was filled with cortical matter, which was slowly absorbed until the twenty-third day, when a considerable portion of it fell down into the bottom of the anterior chamber, and the patient suddenly saw. He improved rapidly from this time on until he was discharged on the forty-second day with vision f, with + s.2+ , c. ax. i8o0. Case XXVII. was interesting on account of the patient's having mucocele of both lachrymal sacs. Having seen disastrous results in several cases where a dacryocystitis had been treated by slitting up the canaliculus, and passing probes for some time before extracting the cataract, I concluded it would be better to let the tear-passage alone lest, by operating upon it, I should change a mucous into a muco-purulent discharge, and thus the more readily infect the wound. At Dr. Pomeroy's suggestion I washed the eye with a weak solution of carbolic acid immediately before operating, and on the first few occasions of opening the eye duringr convalescence. The eye was opened by the house surgeon several times daily, and the contents of the sac pressed out with the thumb and carefully wiped away. The recovery was unattended with inflammation. Thirty-one different patients were operated upon, four of
of Cataract Extraction.
503 them having the second eye operated upon after a short interval. Males, 20; females, ii. Total, 31. Their ages ranged from 30 to 83. Under 40 years of age ........ ............ 2 From 40 to 50 years of age ................ 3 From 50 to 6o years of age ................. 9 From 6o to 70 years of age................ 9 From 70 to 80 years of age ................ 6 Upward of 8o years ...................... 2
3' Twenty-eight eyes were operated upon while the patient was under ether. Of these twenty-three were successes, two partial successes, and three failures. Seven eyes were operated upon without the use of an anesthetic. Five of these did well, and two were failures. The method of operating known as " von Graefe's modified" was used in all cases in which it was practicable. Where a preliminary iridectomy was done, the incision for extraction of the lens was made in the same position as in the other cases. Preliminary iridectomy was performed in six cases, four by myself, and two by another surgeon. Both the eyes of the patient who came to me with preliminary iridectomies did badly; the other four did well. In only one case out of the whole thirty-five was there loss of vitreous. The same was the only case in which a scoop was introduced into the eye for removing the lens. In one case there was dislocation of the lens into the anterior chamber during the preliminary iridectomy. In one case irido-dialysis was produced during the operation, though so obscured by blood as not to be recognized until later; and in one case the iris fell before the knife, owing to premature escape of the aqueous, and was cut through. In all these cases in which accidents occurred during the operation the eyes recovered with good sight. In three cases the cornea was found thin and flaccid, and became wrinkled, or collapsed, on evacuation of the lens. In eight cases there was hemorrhage from the iris imme-
WEBSTER: Report of Thirty-five Cases 504 diately following the iridectomy, showing an undue vascularity of that membrane, or an atheromatous condition of its blood-vessels. In four cases a considerable quantity of soft lens matter was left in the eye. In one case " some inflamnmatory reaction " was noted during recovery. This eye did well. In four cases there was iritis. Closure of pupil resulted in three of these, and in one the result was good. In another the result was made good by an iridectomy. Sloughing of the cornea occurred in one case, panophthalmitis in two cases, and in one case there was irido-cyclitis with sympathetic inflammation of the fellow eye. Comparatively few secondary operations were required. Iridectomy was performed in two cases, in both resulting in a clear pupil, but in one failing to restore sight on account of deeper disease. Keratonyis for pupillary membranes was performed in seven cases, and was in all cases successful. If we take the results of all the cases, complicated and uncomplicated, they will stand as follows: In 2 eyes, vision was -; in 3 eyes, 20; in 6 eyes, ; in 8 eyes, -U; in 3 eyes, 2A; ~~~202 4 2 0 in i eye Figers in 4 eyes, 2; in I eye, Fingers; in I eye, OT in i eye, perception of light; in 5 eyes, 0. I shall reckon the case which is recorded as counting fingers at twenty feet as a good result, as the patient did not know her letters; and the case of perception of light as a loss, although sight may have been restored by a subsequent operation. We will then have: successes, 27 = 77+ per cent.; partial successes, 2 = 54 per cent.; failures, 6 = 17+ per cent. I believe, however, that in justice to myself and to, cataract statistics, I ought to exclude the two cases of extensive corneal opacity, the case of detachment of the retina, and the old German woman with vitreous, and perhaps deeper complications. The figures would then be very materially changed. We would have: successes, 27 = 90 per cent.; partial successes, I = 341 per cent. ; failures, 2 = 6j per cent.
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5o WEBSTER: Report of T4ry-five Cases REMARKS.
DR. HEYL said that the case of sloughing cornea referred to by Dr. Webster recalled a clinical experience which is suggestive of the thought that sloughing cornea following cataract extraction may sometimes be due to diphtheritic infection, and should be treated accordingly. He had noticed in one instance that a short period, perhaps a couple of days, after a Graefe extraction inflammatory action was developed in the eye. The pupillary space became filled with a whitish mass which projected between the lips of the cut. On the lower half of the cornea a yellowish semicircle formed, perhaps, a millimetre in breadth, and distant from the limbus perhaps two millimetres. The cornea was steamy. Encircling the limbus was a girdle of conjunctiva elevated by subconjunctival infiltration. The upper- lid was cedematous; there was no false membrane. The symptoms, with exception of the whitish mnass blocking the pupil, correspond to what he had observed a number of times in cases of subacute conjunctival diphtheria. The semicircular infiltration of the cornea was rather peculiar, the opening of the ring corresponded with the cut. In his experience usually the corneal affection is in the form of an opaque area, which breaking down forms a deep ulcer. He had, however, once seen an opacity similar to the one above mentioned, except that instead of being a semicircle it was a complete circle. The pupillary mass must, he thought, have been a bacterial formation. In confirmation of the view that this was a case of traumatic diphtheritis, a patient in the same ward, and but a few beds distant, on whonm extirpation of the orbital contents for malignant disease had been performed, was attacked by traumatic diphtheritis; also two attendants in the hospital at the same time were attacked with pharyngeal diphtheria. Another point was suggested in this connection. The secondary operations in Dr. Webster's cases had been followed by no unpleasant result. Dr. Heyl had a year ago extracted a cataract, and subsequently divided the capsule without unusual reaction, with the effect of giving the patient sight sufficient to pursue his occupation, that of a clerk. A hole of good size had been made in the capsule, surrounded, however, by a margin of thin veil-like tissue. At the solicitation of the patient he was induced to try if he could not further improve sight. After doing the best that.could be done by glasses, he advised that the veil-like margin of capsule be divided. There was apparently no irritability of the eye. The extrac-
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tion cut had been a little peripheral, and in one corner a prolapsed portion of iris had healed in the wound. The second division of the capsule was performed without any difficulty. On the third day after the operation cyclitis was developed, followed by total loss of sight. Whether the engagement of the iris in the corneal cut had placed the eye in a condition favorable for the development of cyclitis, whether an unsound condition of the eye previous to the extraction was the cause, or whether this was a case of traumatic inoculation is not known. DR. STRAWBRIDGE asked, first, was ether used, and if so why; second, was atropia used in the after-treatment; third, were antiseptic dressings used in the after-treatment. DR. WEBSTER replied that he gave ether in most of the cases, and because the patients wished it. Atropia was used in forty-eight hours after the operation in most cases, but not always. Antiseptics were only used in the case of mucocele, and there the eye was simply washed with a solution of carbolic acid. DR. THEOBALD would like to ask Dr. Webster whether, in the case in which the patient became irrational, he noticed any connection between the instillations .of atropia and the appearance of the mental aberration.' He had seen one case where the use of atropia was followed by mild symptoms of dementia. DR. WEBSTER replied that he did not think that the mental disturbance was attributable to the atropia at all, and most of the gentlemen who saw the case thought that the ether had something to do with it, as the patient had Bright's disease.. DR. CARMALf, with reference to the assumption that mental disturbance might follow the use of ether, mentioned a -case in which active delirium came on the third or fourth day after the operation without ether. He believed the delirium to be mainly due to the confinement in bed in a blinded condition, in which state the patients- " lose their bearings " altQo. gether. He had not infreqfiently met the same thing, in patients blinded by accident and put to bed immediately'afterward. THE PRESIDENT remarked, that it was well established that symptoms of dementia can be produced by atropia. He did not believe that the ether had anything to do with the development of these symptoms, and that in Dr. Webster's case the condition was more -likely due to anoemia or- some general condition of the patient; at all events, he did Inot think that the ether had anything to do with it.
