SELECTIONS FROM OPHTHALMIC SURGERY.
By Surgeon
J. B. SciUVEN,
Principal,
Lahore Med. School. 1
Extraction of Cataract.?So much attention of lute years has been paid to the diagnosis and treatment of cataract, and
by the best observers and best operaday, that it may seem strange there should bo anything to add, from so distant a province as the Punjab. Disease?, however, the constitution of the persons they affect, and consequently the treatment, vary in different parts of the world. Cataract forms no exception to this rule, nor do I see any other way of accounting for the various success of different operations for its relief, in the hands of different very skilful so
much has been written
tors of the
operators. Dr. C. Macnamara
tematically extensively
in
Bengal,
was
the first to practice extraction sys-
Dr. Archer
the Medical
was
the first to carry it out
in
Calcutta, and in the year 1860, I also had a few successful cases at the Bhowanipore Dispensary. Before Drs. Archer and Macnamara, Drs. Martin and Bedford only performed it in exceptional cases, and did not consider it applicable to natives of India. Later experience has proved that it is in many instances, no less necessary to extract the lens, in natives of this country than in natives of Europe, though the operation perhaps may The method of oblique illumination has not be borne as well. supplied the means of diagnosing the kiad of cataract, with tolerable accuracy, so that, in the present day, the judgment of the surgeon may be fully exercised as to the kind of operation that gives the best promise of success in each individual case ; and it appears to me, that solution is the safest remedy for soft cataract, and extraction the only one for hard. For the latter class of cases, depression was the old remedy, and even this, I bolieve, has still its advocates: it is said that half the cases used to recover. I am not acquainted with any careful statistics on this point, but if the statement be correct, I very strongly suspect that the half that recovered, if they re covered permanently, were cases, not of hard cataract, but soft, in which the manipulation of depression was perhaps performed ; resulting however, not in displacing the entire lens? but in breaking it up and effecting its solution. I believe it impossible to depress a soft cataract without breaking it, and, at
College
if inflammation do not supervene, it rapidly dissolves ; whereas a a depressed hard lens nover dissolves, but always remains as foreign body in the eye. I have occasionally extracted these
depressed hard lenses, months and years after the operation, and found them of their full size; and though numerous cases ^ come before me of total blindness following on depression, do not remember to have seen a
restoration of sight,
single
case
of
permanent
October 1, It
seems
than in
FROM OPHTHALMIC SURGERY.?BY J. B. SCRIYEN.
1870.] SELECTIONS
ine, therefore, that, in natives of India, no less of other countries, hard cataracts ought to be But how ought they be extracted? This is the imand one to which it is more than probable
to
people
extracted.
portant question, ? hat a different answer ought to be given, for the inhabitants of different climes ; indeed, it is exceedingly likely that one rule would not apply to natives of all parts of India. The remarks, therefore, which I have to make, I wish it to be understood, apply to the Punjab people, amongst whom to
justify
my
writing
on
I
was transferred to the adopt it in suitable cases, when 1860. in Punjab At that time, I only knew the flap extraction, which I always performed by the upper section, without chloroform. On turning over my records, I find that I performed this operation fifteen times, between October 1860 and April 1865. Of these fifteen cases, ten did well, though one of them had to undergo a secondary operation; in some the vision was exceedingly good and the pupil nearly central; in others, the pupil was distorted, and the vision less perfect, but in all the ten the result was satisfactory. One of these occasionally pre? sents himself at the hospital now, the best case I ever saw. One eye only was operated on, and its vision is so good that the man pursues his occupation, as a farrier, with perfect
to
comfort and without spectacles. Were it not for the inconnot have believed testible evidence of this patient, I should four failed from this possible. Of the other five cases, supthe eye; one had prolapsus puration and total destruction of but obtained vision, sulicient to recognize people and
iritiis,
find her way about. These results perhaps
ought not to have been discouraging that much depended beginner. Nevertheless, I was conscious few instances was the patient quiet upon chance. In very with perfect satisfacenough for the operation to be performed tion to the operator; loss of vitreous and prolapsus iridis to
a
and I could not but feel that there was great need of some mode of dealing with hard cataracts, which should be attended with more certainty, and less risk to the
were common,
organ of vision. In 1865 I went to England, and attended the ophthalmic and learned the new mode practice at the Moorfields Hospital, the distinguished surof operating there adopted ; for even abandoned the old that institution had
flap geons of certain and less dangerous. extraction for some thing more extraction. I carefully This was the now well-known scoop of the operation, as performed by noted the various steps consisted of first incising the Bowman and Critchet't, which the full size of the a portion of iris, cornea, next removing anterior capsule, and lastly, introwound, then lacerating the behind the lens, and extacting it. So favoura ducing
scoop on my return the results of this at Moorfields, that, it at the hospital, and to Lahore in 1867, I at once introduced almost exclusively adopted, this mode of operating has been until, in fact, the cases for hard and mixed cataracts, ever since, me to form an idea of had been sufficiently numerous to enable far behind the old been has it its merits. Unfortunately, been performed, it is true, flap extraction in success. It has was expected, at the in numerous cases in which no benefit in glaucomatous times some urgent request of the patient, the lens had previously been in which in sometimes eyes eyes, of the most sucessful depressed; on the other hand, somo have beon those in which the soft cortical substance, able
were
cases
surrounding
the hard nucleus, hud been
by a needle operation. For my present purpose, however, it is necessary to consider only the results of the treatment on cases of uncomplicated cataract, which had not been operated on before, and, of such I find 31 recorded up to the end of 1869, of whom 10 only got useful vision. Scoop extraction, therefore,
previously dissolved,
the Medical School
at
Hospital, has met with only flap extraction met with previcauses may possibly have combined
half the success that the old ous
to
to 1865.
Wow three
this remarkable difference
produce
:
?
1st.?Chloroform has been
the
experience only subject. small practice at the BhowaniHaving learnt from my own as well as from Dr. Archer's and Dr. Macnapore Dispensary, inara's cases that extraction was not an operation to be entirely thrown aside as inapplicable to natives of India, I determined I have sufficient
j
203
of cases since has been
1867,
administered in the majority but never before. Vomiting however
rare, that I cannot attribute much to chloroform, and the harm that it has done, in some cases, has perhaps been
so
more
than counterbalanced
2nd.?The
sanitary
by
the benefit in others.
condition of the
hospital
has
deteriorated,
from the increase of patients, without adequate improvement in
ventilation, or sufficient increase in cubic space : this deterioration indeed is much to be deplored, but, in my opinion, it has not been sufficient to produce so a difference in great
results.
3rd.?I believe the principal cause to have been the introduction of a scoop to remove the lens, so that, while the danger of loss of vitreous has been diminished by the smaller incision required in scoop extraction, and the risk of prolapse prevented by removal of a portion of the iris, the chance of has been inflammation increased, by the introduction of an instrument into the interior of the eye. My unsuccessful cases of scoop extraction have failed by inflammation, beginning at the wound of the cornea, infiltrating its tissue with lymph, and filling up also the coloboma of the iris.
The inflammation sometimes has run on to destructive sometimes ha3 simply destroyed the pupil, and
suppuration,
rendered the
cornea
permanently opaque. This, at once, sugthing specially affecting the corneal wound. Now, numerous cases occur at this hospital, in which iridectomy is performed, for various disorders, often on eyes much less healthy than in these cases of cataract; and yet the wound very rarely fails to heal favourably, though the operation is the same as extraction, miuus the use of the pricker, and the introduction of the spoon to extract the lens; while destructive inflammation of the eye was vastly less frequent in the cases of the old flap operation, in which the iris waa but no spoon, was used. The not touched, and the pricker, use of the pricker, therefore, being excluthe and iridectomy, ded, the final process of removing the lens with a scoop gests the idea of
some
must be the cause of the mischief. It appears to me that the iutroduction of the scoop, however carefully managed, is, of that does some violence to the corneal a
necessity,
proceeding
The lance-shaped knife is introduced parallel to the coats obliquely, not iris, and therefore cuts the corneal wound.
the scoop, to get' perpendicularly to the surface; whereas behind the lens, must be passed directly backwards, pushing of the section up, the flap of cornea down, the posterior edge some amount of and scraping both in its way. Moreover, is unavoidable, in the extent of the corneal inci-
uncertainty sion, which,
care, sometimes proves too outward passage of the lens and perfectly easy together. All operators, I believe, agree that the width of the knife is not to be depended on.- it may with
the
greatest
small for the scoop
simple
or the other, after introduction, have to bo pressed to one side, I certainly find a diffiin order to enlarge the wound. Now, to the full extent I require, because the culty in doing this, held only by a single point below the cornea, rotates eye, being axis before the knife, which thus on its anteroposterior cuts its way out sooner than is intended. Mr.
occasionally Streatfield invented a forceps for grasping the eye at two this difficulty; but it creates another, points, which remedies for in most eyes, it raises the conjunctiva, ia a fold, around
THE INDIAN MEDICAL GAZETTE.
204
the upper half of the coriiea, ?which conceals its edge, and so interferes with the cut. Happily, a new operation has been devised by Yon Graefe, in ?which the scoop is unnecessary, and which, already, bids fair to produce better results in my hands. I refrain from giving numbers, as my cases as yet have been too few. The section, with Yon Graefe's knife, leaves nothing to be desired, in the way of certainty ; while, by cutting directly out, in a direction perpendicular to the coats of the cornea, it leaves no projecting
ledge,
to
interfere
with the escape of the lens, which thus
presents its edge in the wound, after the capsule is lacerated, on the application of little pressuro to the front of the cornea,
and so escapes, without the introduction of the scoop. For the details of Yon Graefe's operation, I must refer the reader to Mr. Soelberg Well's lecture, in the Lancet of December 11th,
Suffice it to say here, that I introduce the long narrow knife at the point A in the
1869, page 798. 7
A
C
horizontally
figure,
and pass it
through
the anterior
chamber in the direction of point 13; has reached the further margin X-? B when it of the dilated pupil, the blade is turned across the eye, made to counter-puncture at point
C, and finally, the cutting edge being turned forward, it completes the section through the upper margin of the cornea. There is another advantage in \on Graefe's mode of section. The narrow knife at first passed obliquely downwards, across the cornea, may be made to lacerate the anterior capsule of the lens, from one margin to the other of the dilated pupil; thus making an ample opening for the escape of the nucleus, -while the anterior chamber is full, and every thing can be distinct'y seen, before the iris contracts, as it always does when
the aqueous humour escapes, and before a drop of blood has been effused. Who, that has performed the scoop operation frequently, ha3 not been considerably perplexed, from time to the delay, necessary to clear the eye of blood, after time,
by iridectomy, before
the anterior capsule could bo lacerated, the scoop introduced ? a period during which the patient often begins to recover from the chloroform, requires more to be administered, perhaps, and by his struggles destroys the eye. If the operation be performed, aa I now propose, the operator may press out the lens as soon as the bit of iris has been removed, this proceeding, at the same time, emptying the the
or
and very commonly preventing its further this, there are cases in which the previous laceration of the anterior capsule obviates the necessity of removing a bit of iris, for, in tho case of morgagnian cataract, chamber of
effusion.
blood,
Besides
the nucleus will often at once escape into the anterior chamber the opening, and the fluid parts bo washed away by the escape of the aqueous humour. This washing away of the softer substance, I think, would always occur, more or less, in
through
of mixed cataract, and much of tho trouble and danger removing soft remnants of the lens, after tho extraction of
cases
of the
nucleus,
measure
so
frequent
avoided.
in scoop
extraction,^be
"
empty,
Laticet, December 11th, 1869, page 798.) The operator steadily fixing the eyeball with the forceps, next proceeds to lacerate the capsule freely, with the pricker, by successive incisions. The one is to commence at the lower edge of the pupil, or even a little behind it, beneath the iris, and extend upwards along its inner side; tho other, passing to the same extent, along tho cuter margin of tho pupil. Both incisions should reach quite up to the periphery of the lens, exposed by tho iridectomy. 1 inally the capsule should be lacerated at its periphery, in a line corresponding to tho section." This is a very simplo direction to give, but one, I imagine, very seldom carried out, with the
and the lens and iris in contact with
suppose these incisions to have been the result would be an ample opening truly, but with a the cornea. detached
But,
membrane, flapping
effected,
partially
about at the bottom of the
cavity;
or, if this be still further torn in the after-steps of the operation, a number of wholly detached fragments, sometimes very
perplexing to the operator, because and yet, if they remain, liable to set
very difficult to remove, up iritis or obstruct the
field of vision.
experiments on the dead body, moreover, the having been removed, I havo found the pricker to be a very ineffective instrument; the first application of it, only, incising the membrane, the others simply stripping it off, and rolling it up; and this I believe to be the result most commonly obtained by its application on the living body. It appears to me that a better end is gained by making an ample opening across the centre of the capsule, such as Yon Graefe's knife would make, which would be further enlarged by the escape of the nucleus, and which, passing across the centre, In
several
cornea
and iris
would correspond to the axis of vision ; while there would be tendency to detachmcnt of fragments, and no loose flap of
less
membrane would be left.
Capsule, if not abnormally thickened,
harm within the eye, provided it retain its natural attachment, and does not obstruct the field of vision. A considoes
no
quantity of capsule is continually left, in very successof solution, which sets up no irritation, and in no way interferes with vision, provided there be an ample opening in the centre. Such an opening, in fact, wo often make with two needles, after solution of the lenticular substance is complete. Now just such an opening is secured, by the passage of the blade of Yon Graefe's knife obliquely across the centre of the capsule, enlai-ged, as it afterwards is, by the escape of the nucleus. It is Dr. Macnamara's practice to lacerate the cap* sulo with the lance-shaped knife, in making the section of the cornea, in his scoop operation. This instrument, however, makes by no means so large an opening, and the deviation of the knifo from its course, parallel to the iris, in order to effect the laceration, seems to me somewhat likely to endanger the regularity of the corneal incision. A similar danger, I imagine, prevents operators for flap extraction, from lacerating the capsule, as they pass the knife across the anterior chamber, and, as this operation is generally performed with the pupil undila* ted, the attempt would endanger the iris, without insuring a sufficient opening in the capsule. Query, might not the dilfi* culty bo removed by dilating the pupil ? This brings me to the last procedure in an operation for extraction, viz., the bandaging. Bowman and Critchett always apply a knitted cotton baudage, having first padded the eye carefully with Von Graefe's compress ; a good bandage is still greater importance to the restless inhabitants of this pr0" vinee, who have never been accustomed to lio quietly in bedThe Moorfields bandage is of this pattern:?b, the baudage that derable
ful
cases
in a great
Moreover, the laceration of tho capsule itself is thus more effectively performed than otherwise. How are we told to do it with tho quote from Mr. Soelberg Well's lecture,
pricker? (I
anterior chamber
1870.
[October 1,
a.
a>.
=C
covers both eyes; c, a circlo of tape at one end of it, the upper half of which passes over the vertex of tlio head, and tl'e lower behind the occiput; tho two terminal tapes, a. a., ara tied together at the sido of tho head. J brought somo of thes? from homo, and used them in my first few cases ; but I found that one pattern by no means answered for every body, ^l0 shape of the head varying so much, that in one case the bandage would ride up, in another down, and it was further inconvenient for persona with long hair. 1 therefore now adopt
October 1, the
DARJEELIXGr.?BY T. MATHEW.
1S70.]
following plan.
Before I
I tie
operate,
a
piece
of broad
tape tightly round the head, passing below the occiput, close After the operbehind the ears, and just above the forehead. ation? having placed the com-
p
press
on
bandage
the eye, I apply a of this kind, the side
fitted with the double strings being uppermost. These serve to fix the bandage to the tape already round the head. Of
passes below the ear, strings on the other side, the long looped ever the tape, below the occiput, and, coming round the remaining short again under the other ear, is tied to string. This bandage keeps remarkably firm, and is particularly useful hair whose long plaited behind, forms a among the Sikhs, considerable obstacle to the application of any less complicated on the third or apparatus. I generally remove the bandage fourth day, if the case does well, and allow the patient to wear a shade afterwards; but, in cases in which the wound does not unite immediately, the bandage ia of immense use, in keeping up a constant even pressure on the eye, and it should not be dispensed with until the anterior chamber is full. the
one
is
J
205
By Surgeon
J. B. SciUVEN,
Principal,
Lahore Med. School. 1
Extraction of Cataract.?So much attention of lute years has been paid to the diagnosis and treatment of cataract, and
by the best observers and best operaday, that it may seem strange there should bo anything to add, from so distant a province as the Punjab. Disease?, however, the constitution of the persons they affect, and consequently the treatment, vary in different parts of the world. Cataract forms no exception to this rule, nor do I see any other way of accounting for the various success of different operations for its relief, in the hands of different very skilful so
much has been written
tors of the
operators. Dr. C. Macnamara
tematically extensively
in
Bengal,
was
the first to practice extraction sys-
Dr. Archer
the Medical
was
the first to carry it out
in
Calcutta, and in the year 1860, I also had a few successful cases at the Bhowanipore Dispensary. Before Drs. Archer and Macnamara, Drs. Martin and Bedford only performed it in exceptional cases, and did not consider it applicable to natives of India. Later experience has proved that it is in many instances, no less necessary to extract the lens, in natives of this country than in natives of Europe, though the operation perhaps may The method of oblique illumination has not be borne as well. supplied the means of diagnosing the kiad of cataract, with tolerable accuracy, so that, in the present day, the judgment of the surgeon may be fully exercised as to the kind of operation that gives the best promise of success in each individual case ; and it appears to me, that solution is the safest remedy for soft cataract, and extraction the only one for hard. For the latter class of cases, depression was the old remedy, and even this, I bolieve, has still its advocates: it is said that half the cases used to recover. I am not acquainted with any careful statistics on this point, but if the statement be correct, I very strongly suspect that the half that recovered, if they re covered permanently, were cases, not of hard cataract, but soft, in which the manipulation of depression was perhaps performed ; resulting however, not in displacing the entire lens? but in breaking it up and effecting its solution. I believe it impossible to depress a soft cataract without breaking it, and, at
College
if inflammation do not supervene, it rapidly dissolves ; whereas a a depressed hard lens nover dissolves, but always remains as foreign body in the eye. I have occasionally extracted these
depressed hard lenses, months and years after the operation, and found them of their full size; and though numerous cases ^ come before me of total blindness following on depression, do not remember to have seen a
restoration of sight,
single
case
of
permanent
October 1, It
seems
than in
FROM OPHTHALMIC SURGERY.?BY J. B. SCRIYEN.
1870.] SELECTIONS
ine, therefore, that, in natives of India, no less of other countries, hard cataracts ought to be But how ought they be extracted? This is the imand one to which it is more than probable
to
people
extracted.
portant question, ? hat a different answer ought to be given, for the inhabitants of different climes ; indeed, it is exceedingly likely that one rule would not apply to natives of all parts of India. The remarks, therefore, which I have to make, I wish it to be understood, apply to the Punjab people, amongst whom to
justify
my
writing
on
I
was transferred to the adopt it in suitable cases, when 1860. in Punjab At that time, I only knew the flap extraction, which I always performed by the upper section, without chloroform. On turning over my records, I find that I performed this operation fifteen times, between October 1860 and April 1865. Of these fifteen cases, ten did well, though one of them had to undergo a secondary operation; in some the vision was exceedingly good and the pupil nearly central; in others, the pupil was distorted, and the vision less perfect, but in all the ten the result was satisfactory. One of these occasionally pre? sents himself at the hospital now, the best case I ever saw. One eye only was operated on, and its vision is so good that the man pursues his occupation, as a farrier, with perfect
to
comfort and without spectacles. Were it not for the inconnot have believed testible evidence of this patient, I should four failed from this possible. Of the other five cases, supthe eye; one had prolapsus puration and total destruction of but obtained vision, sulicient to recognize people and
iritiis,
find her way about. These results perhaps
ought not to have been discouraging that much depended beginner. Nevertheless, I was conscious few instances was the patient quiet upon chance. In very with perfect satisfacenough for the operation to be performed tion to the operator; loss of vitreous and prolapsus iridis to
a
and I could not but feel that there was great need of some mode of dealing with hard cataracts, which should be attended with more certainty, and less risk to the
were common,
organ of vision. In 1865 I went to England, and attended the ophthalmic and learned the new mode practice at the Moorfields Hospital, the distinguished surof operating there adopted ; for even abandoned the old that institution had
flap geons of certain and less dangerous. extraction for some thing more extraction. I carefully This was the now well-known scoop of the operation, as performed by noted the various steps consisted of first incising the Bowman and Critchet't, which the full size of the a portion of iris, cornea, next removing anterior capsule, and lastly, introwound, then lacerating the behind the lens, and extacting it. So favoura ducing
scoop on my return the results of this at Moorfields, that, it at the hospital, and to Lahore in 1867, I at once introduced almost exclusively adopted, this mode of operating has been until, in fact, the cases for hard and mixed cataracts, ever since, me to form an idea of had been sufficiently numerous to enable far behind the old been has it its merits. Unfortunately, been performed, it is true, flap extraction in success. It has was expected, at the in numerous cases in which no benefit in glaucomatous times some urgent request of the patient, the lens had previously been in which in sometimes eyes eyes, of the most sucessful depressed; on the other hand, somo have beon those in which the soft cortical substance, able
were
cases
surrounding
the hard nucleus, hud been
by a needle operation. For my present purpose, however, it is necessary to consider only the results of the treatment on cases of uncomplicated cataract, which had not been operated on before, and, of such I find 31 recorded up to the end of 1869, of whom 10 only got useful vision. Scoop extraction, therefore,
previously dissolved,
the Medical School
at
Hospital, has met with only flap extraction met with previcauses may possibly have combined
half the success that the old ous
to
to 1865.
Wow three
this remarkable difference
produce
:
?
1st.?Chloroform has been
the
experience only subject. small practice at the BhowaniHaving learnt from my own as well as from Dr. Archer's and Dr. Macnapore Dispensary, inara's cases that extraction was not an operation to be entirely thrown aside as inapplicable to natives of India, I determined I have sufficient
j
203
of cases since has been
1867,
administered in the majority but never before. Vomiting however
rare, that I cannot attribute much to chloroform, and the harm that it has done, in some cases, has perhaps been
so
more
than counterbalanced
2nd.?The
sanitary
by
the benefit in others.
condition of the
hospital
has
deteriorated,
from the increase of patients, without adequate improvement in
ventilation, or sufficient increase in cubic space : this deterioration indeed is much to be deplored, but, in my opinion, it has not been sufficient to produce so a difference in great
results.
3rd.?I believe the principal cause to have been the introduction of a scoop to remove the lens, so that, while the danger of loss of vitreous has been diminished by the smaller incision required in scoop extraction, and the risk of prolapse prevented by removal of a portion of the iris, the chance of has been inflammation increased, by the introduction of an instrument into the interior of the eye. My unsuccessful cases of scoop extraction have failed by inflammation, beginning at the wound of the cornea, infiltrating its tissue with lymph, and filling up also the coloboma of the iris.
The inflammation sometimes has run on to destructive sometimes ha3 simply destroyed the pupil, and
suppuration,
rendered the
cornea
permanently opaque. This, at once, sugthing specially affecting the corneal wound. Now, numerous cases occur at this hospital, in which iridectomy is performed, for various disorders, often on eyes much less healthy than in these cases of cataract; and yet the wound very rarely fails to heal favourably, though the operation is the same as extraction, miuus the use of the pricker, and the introduction of the spoon to extract the lens; while destructive inflammation of the eye was vastly less frequent in the cases of the old flap operation, in which the iris waa but no spoon, was used. The not touched, and the pricker, use of the pricker, therefore, being excluthe and iridectomy, ded, the final process of removing the lens with a scoop gests the idea of
some
must be the cause of the mischief. It appears to me that the iutroduction of the scoop, however carefully managed, is, of that does some violence to the corneal a
necessity,
proceeding
The lance-shaped knife is introduced parallel to the coats obliquely, not iris, and therefore cuts the corneal wound.
the scoop, to get' perpendicularly to the surface; whereas behind the lens, must be passed directly backwards, pushing of the section up, the flap of cornea down, the posterior edge some amount of and scraping both in its way. Moreover, is unavoidable, in the extent of the corneal inci-
uncertainty sion, which,
care, sometimes proves too outward passage of the lens and perfectly easy together. All operators, I believe, agree that the width of the knife is not to be depended on.- it may with
the
greatest
small for the scoop
simple
or the other, after introduction, have to bo pressed to one side, I certainly find a diffiin order to enlarge the wound. Now, to the full extent I require, because the culty in doing this, held only by a single point below the cornea, rotates eye, being axis before the knife, which thus on its anteroposterior cuts its way out sooner than is intended. Mr.
occasionally Streatfield invented a forceps for grasping the eye at two this difficulty; but it creates another, points, which remedies for in most eyes, it raises the conjunctiva, ia a fold, around
THE INDIAN MEDICAL GAZETTE.
204
the upper half of the coriiea, ?which conceals its edge, and so interferes with the cut. Happily, a new operation has been devised by Yon Graefe, in ?which the scoop is unnecessary, and which, already, bids fair to produce better results in my hands. I refrain from giving numbers, as my cases as yet have been too few. The section, with Yon Graefe's knife, leaves nothing to be desired, in the way of certainty ; while, by cutting directly out, in a direction perpendicular to the coats of the cornea, it leaves no projecting
ledge,
to
interfere
with the escape of the lens, which thus
presents its edge in the wound, after the capsule is lacerated, on the application of little pressuro to the front of the cornea,
and so escapes, without the introduction of the scoop. For the details of Yon Graefe's operation, I must refer the reader to Mr. Soelberg Well's lecture, in the Lancet of December 11th,
Suffice it to say here, that I introduce the long narrow knife at the point A in the
1869, page 798. 7
A
C
horizontally
figure,
and pass it
through
the anterior
chamber in the direction of point 13; has reached the further margin X-? B when it of the dilated pupil, the blade is turned across the eye, made to counter-puncture at point
C, and finally, the cutting edge being turned forward, it completes the section through the upper margin of the cornea. There is another advantage in \on Graefe's mode of section. The narrow knife at first passed obliquely downwards, across the cornea, may be made to lacerate the anterior capsule of the lens, from one margin to the other of the dilated pupil; thus making an ample opening for the escape of the nucleus, -while the anterior chamber is full, and every thing can be distinct'y seen, before the iris contracts, as it always does when
the aqueous humour escapes, and before a drop of blood has been effused. Who, that has performed the scoop operation frequently, ha3 not been considerably perplexed, from time to the delay, necessary to clear the eye of blood, after time,
by iridectomy, before
the anterior capsule could bo lacerated, the scoop introduced ? a period during which the patient often begins to recover from the chloroform, requires more to be administered, perhaps, and by his struggles destroys the eye. If the operation be performed, aa I now propose, the operator may press out the lens as soon as the bit of iris has been removed, this proceeding, at the same time, emptying the the
or
and very commonly preventing its further this, there are cases in which the previous laceration of the anterior capsule obviates the necessity of removing a bit of iris, for, in tho case of morgagnian cataract, chamber of
effusion.
blood,
Besides
the nucleus will often at once escape into the anterior chamber the opening, and the fluid parts bo washed away by the escape of the aqueous humour. This washing away of the softer substance, I think, would always occur, more or less, in
through
of mixed cataract, and much of tho trouble and danger removing soft remnants of the lens, after tho extraction of
cases
of the
nucleus,
measure
so
frequent
avoided.
in scoop
extraction,^be
"
empty,
Laticet, December 11th, 1869, page 798.) The operator steadily fixing the eyeball with the forceps, next proceeds to lacerate the capsule freely, with the pricker, by successive incisions. The one is to commence at the lower edge of the pupil, or even a little behind it, beneath the iris, and extend upwards along its inner side; tho other, passing to the same extent, along tho cuter margin of tho pupil. Both incisions should reach quite up to the periphery of the lens, exposed by tho iridectomy. 1 inally the capsule should be lacerated at its periphery, in a line corresponding to tho section." This is a very simplo direction to give, but one, I imagine, very seldom carried out, with the
and the lens and iris in contact with
suppose these incisions to have been the result would be an ample opening truly, but with a the cornea. detached
But,
membrane, flapping
effected,
partially
about at the bottom of the
cavity;
or, if this be still further torn in the after-steps of the operation, a number of wholly detached fragments, sometimes very
perplexing to the operator, because and yet, if they remain, liable to set
very difficult to remove, up iritis or obstruct the
field of vision.
experiments on the dead body, moreover, the having been removed, I havo found the pricker to be a very ineffective instrument; the first application of it, only, incising the membrane, the others simply stripping it off, and rolling it up; and this I believe to be the result most commonly obtained by its application on the living body. It appears to me that a better end is gained by making an ample opening across the centre of the capsule, such as Yon Graefe's knife would make, which would be further enlarged by the escape of the nucleus, and which, passing across the centre, In
several
cornea
and iris
would correspond to the axis of vision ; while there would be tendency to detachmcnt of fragments, and no loose flap of
less
membrane would be left.
Capsule, if not abnormally thickened,
harm within the eye, provided it retain its natural attachment, and does not obstruct the field of vision. A considoes
no
quantity of capsule is continually left, in very successof solution, which sets up no irritation, and in no way interferes with vision, provided there be an ample opening in the centre. Such an opening, in fact, wo often make with two needles, after solution of the lenticular substance is complete. Now just such an opening is secured, by the passage of the blade of Yon Graefe's knife obliquely across the centre of the capsule, enlai-ged, as it afterwards is, by the escape of the nucleus. It is Dr. Macnamara's practice to lacerate the cap* sulo with the lance-shaped knife, in making the section of the cornea, in his scoop operation. This instrument, however, makes by no means so large an opening, and the deviation of the knifo from its course, parallel to the iris, in order to effect the laceration, seems to me somewhat likely to endanger the regularity of the corneal incision. A similar danger, I imagine, prevents operators for flap extraction, from lacerating the capsule, as they pass the knife across the anterior chamber, and, as this operation is generally performed with the pupil undila* ted, the attempt would endanger the iris, without insuring a sufficient opening in the capsule. Query, might not the dilfi* culty bo removed by dilating the pupil ? This brings me to the last procedure in an operation for extraction, viz., the bandaging. Bowman and Critchett always apply a knitted cotton baudage, having first padded the eye carefully with Von Graefe's compress ; a good bandage is still greater importance to the restless inhabitants of this pr0" vinee, who have never been accustomed to lio quietly in bedThe Moorfields bandage is of this pattern:?b, the baudage that derable
ful
cases
in a great
Moreover, the laceration of tho capsule itself is thus more effectively performed than otherwise. How are we told to do it with tho quote from Mr. Soelberg Well's lecture,
pricker? (I
anterior chamber
1870.
[October 1,
a.
a>.
=C
covers both eyes; c, a circlo of tape at one end of it, the upper half of which passes over the vertex of tlio head, and tl'e lower behind the occiput; tho two terminal tapes, a. a., ara tied together at the sido of tho head. J brought somo of thes? from homo, and used them in my first few cases ; but I found that one pattern by no means answered for every body, ^l0 shape of the head varying so much, that in one case the bandage would ride up, in another down, and it was further inconvenient for persona with long hair. 1 therefore now adopt
October 1, the
DARJEELIXGr.?BY T. MATHEW.
1S70.]
following plan.
Before I
I tie
operate,
a
piece
of broad
tape tightly round the head, passing below the occiput, close After the operbehind the ears, and just above the forehead. ation? having placed the com-
p
press
on
bandage
the eye, I apply a of this kind, the side
fitted with the double strings being uppermost. These serve to fix the bandage to the tape already round the head. Of
passes below the ear, strings on the other side, the long looped ever the tape, below the occiput, and, coming round the remaining short again under the other ear, is tied to string. This bandage keeps remarkably firm, and is particularly useful hair whose long plaited behind, forms a among the Sikhs, considerable obstacle to the application of any less complicated on the third or apparatus. I generally remove the bandage fourth day, if the case does well, and allow the patient to wear a shade afterwards; but, in cases in which the wound does not unite immediately, the bandage ia of immense use, in keeping up a constant even pressure on the eye, and it should not be dispensed with until the anterior chamber is full. the
one
is
J
205
