,^:z-: .O. ^;J2eo^.,.^/e iitJu m^i«Mif^k!te vKsmkii. Tie TW asm •«L B?»a«wi«- ■«. _riL ^ 1^ 4«IB- JOEb tfl^^L L INTRODUCTION At the time' this work was first contemplated, the intention was to make a translation of Otto Beclcer's Palhologie und Therapie des Linsen- sytems," Graefe-Saemisch Handlmcli, Vol. V. 1877, but as the work pro- gressed it became evident 'that many oi' the ideas therein expressed were not in accord with the teachings of modern pathology. The introduction of more delicate and accurate methods for pursuing microscopical investiga- tions, the use of the refracting opthalmoscope, the introduction of cocaine, the application of antisepsis, later of asepsis to eye surgery, have all added their share to the elucidation of this subject. No one who has carefully read Becker's great classic on the Crystalline Lens could possibly fail to be impressed with the keenness of his observation and the clearness and sim- plicity of his style. His historical references are so accurate, and his clin- ical pictures so vivid and concise, that uj) to the present time they have not been excelled. In 1883 he supplemented this work by another classic, "Zur Anatomie der Gesunden und Kranhen Linse,^ the results of further histological and pathological investigation. These two great classics, which to the great majority of the English-speaking opthalmologists are as a sealed book, together with a most careful and critical review of all that has been published on this and kindred subjects since that time, form the basis of this work. 1 Unter mitwlrkiing von Dr. J. R. DaGama Pinto und Dr. H. Schafer. Weis- baden, 1883. GENERAL CONSIDERATION In taking up the study of the Cri/slalliur Lom Si/slrin. one can not properly consider the Ci-ystalliiu' Lcii^ witlioiil al the same tiiiu' studying its suspensory ligainent. Tlir Zotnihi of Zimi {/ji(/tniieiilnni Suspensorium Lentis). By means of this Hgameni the lens is suspended, supported and I'etained in its proper ichition to the remaining structures of the eye. The gi'eat importance of this systiMu of fil)i-ilhie can only be fully realized after a careful study of its congenital malformations, its con- dition both in health and disease, and its physiological relation to the lens. Tlie Zonula of Zinn is the anatomical medium by means of which the ciliary muscle and the lens, which are ivol in direct contacl. are brought together. Without a pei-fect and regulai- (h'velopment of this structure, perfect power of accommocUition can not exist, 'i'he proper centering of the lens in its relation to the coi'nea. likewise in how far the axis of the lens and the cornea coincide, will he dependent on the al)ove fact. The visual axis is greatly influenced by the ])osition of the lens in the eye. The lens system is an integral portion of the so-called refracting media of the eye, and since the index of refraction of the aqueous humour in front of it, and the vitreous humour behind it, are both nearly equal to that of distilled water, and less than that of the lens: hence even in a physical sense, the Crystalline Lens is a lens.^ It differs from the ordinary lens in- dependent of any asymmeti-y of its surface in that, in the first place, it is not a homogeneous body, but consists of concentric lamellae which are most closely packed near the center, and in the second ])lace has the abilit}' of changing its form under influence of Ihe ciliai'y body. As a result of con- traction of this muscle, the lens becomes tiiicker, the radii of l)()th its .«iur- faces, and in all probability thi^ e<|uatorial dianu'ler also becomes less. During this change the i)()slerior pole keeps il> position, whereas the an- terior pole, as can be ])i'oven. nears the cornea. Tlie power of accommoda- tion is dependent on this ability of the lens to change its form. Our more advanced methods of making a functional examination en- able us to demonstrate changes of a histological nature, the senile included, even before they can be recognized by the microscope. This is fully con- sidered in works on Accommodation and h'efraction. In the interest of 1 Heluiholtz's Physiological Optic, p. 63. i6 undisturbed function of the lens system, considering only the physical side of the subject, it is necessary that the index of refraction, and the elasticity of each individual fibre should remain unchanged, for as is demonstrated by even the slightest senile or other pathological change, they become mat- ters of the very greatest importance, not equaled by like changes in any other tissue of the body. As regards their transparency, the elements of the lens, likewise those of the cornea, have following every pathological change a cloudiness, hence functional disturbances. In order that the lens may perform its functions normally, it is nec- essary that it should be transparent, that its separate parts should be mov- able one upon the other; that each lamella should have a different index of refraction regularly increasing toward the center of the lens; that the sur- face of the lens should have an almost spherical curvature, and be almost centered in the corneal axis, and that the lens in its entirety be freely mov- able, and be in no pathological manner adherent to neighboring structures, more particularly the iris. The lens is an epitlielial structure. It consists of the ordinary epith- elial cells, and so-called lens fibres, which are simply epithelial cells which, have taken on an extraordinary development and become elongated. Ex- ternally the lens is covered by a structureless membrane, the lens capsule, which encloses it completely. Notwithstanding its apparently simply construction, the study of its more minute structure, and the various processes which take place in the lens, has been connected with the very greatest difficulties. This was de- pendent not only on the proper recognition of the nature, and the function of the individual elements of the lens, but here more than in any other structure of the body was the difficulty encountered, of understanding the manner in which the individual lens fibres are laid down and connected with neighboring fibres. Only after the embryology of the lens, had been studied, was a definite and clear idea of its architecture and histological structure understood. The proper understanding of the wonderful reg- ularity in the arrangement, and the peculiar manner in which the fibres are adherent to each other, has only been attained by a study of the devel- opment and growth of the foetal lens. The importance of this knowledge will become apparent at once, when it is known that a dei)arture from this regular development, even the slightest interference with this absolute con- nection between the individual fibres, is followed by an interference with the function of the lens as a transparent body which refracts the light in an absolutely regular manner. Every departui'c Iroiu the normal is to be sought in an interference 17 with the normal devehipniont of the leii^;, or i]i ;iu anomalous growth, as the result of an ahnonnal nutrition, or conditions which persist in consequence of an interrupted physiological progression. Hence the study of the de- velopment, progression and growth of the human lens are not only of scientific interest, but are of the very greatest practical importance. The study of the embryology will elucidate many of the seemingly difficult to understand malformations and anomalies of position and at- tachment, and aid us in fixing the most probable time of the development of certain congenital pathological conditions. The lens being fully developed, we shall follow it through its period of physiological growth and retrogression, note the changes which the individ- ual fibres, as well as the lens, as a whole, undergoes. Further, the mode of entrance and exit of the nutritive fluids into the lens. Lastly, consider the chemistry of the lens and its surrounding fluids. It has been hoped, and not without good cause, that the investigation of the mode of nutrition and chemistry of the lens, and the chemistry of its surrounding fluids, would throw some light on the aetiology of cataract — more especially the con- stitutional forms such as occur in Bright's Disease and Diabetes. The pathological processes which play a part in the pathology of the lens are, on the one hand, those of proliferation and degeneration of its intracapsular cells; on the other, sclerosis, separation and softening of the fibres of the lens, together with all the secondary changes which follow these conditions. The lens may secondarily be affected either as a result of disease of other structures in the eye, or as the result of inequalities in the development of the Zonula of Zinn, or as the result of pathological conditions of the same. As a result of these pathological changes the full functions of the lens are modified in the following manner: 1. The single lamellae gradually become changed into a homogene- ous mass (Senile Sclerosis). The refracting power of the lens is reduced and the far point is removed from the eye, Acquired Ifj/permetropia (H. Acqui- sita). 2. The moveableness of the separate elements and lamellae againsi each other is gradually diminished and finally abolished, at the same time the ability of the lens, as a whole, to change its shape, becomes gradually reduced and finally abolished (Senile Sclerosis). The near point gradually becomes removed from the eye, and, as a consequence, the amplitude of accommodation more restricted, until finally there is an entire loss of ac- commodation (Presbyopia). 3. Though its form n>m;uns uuchanoed, the lens suffers in its trans- i8 parency. As a result, tlifiv i- a gfueial (liiiiimttiou in tlie ability to .seii accurately, until finally only a quantitative difference can be distinguished on throwing light into the eye. This condition is recognized as cataract, and is the most generally recognized pathological condition of the lens. The various diseases and pathological conditions of the crystalline lens system, the causation and clinical description of the same, the malformations associated vith anomalief' of the hijaloid arteri/ or the rasnilar capsule of fJie lens, those due to vn.si/m metrical development of the Zonnia fibres {Ectopia Lent is); likewise the acquired anomalies of position not due to malforma- tions: (LiLvatio Lentis) also the independent malformations of the lens will be successively taken up. all of which, as will be seen, excepting the congen- ital, and the traumatic, are the result of nutritive disturbances. An altered chemical constitution of the nutritive supplji is the initial step toirard the formation of cataract. The formation of a nucleus is a perfectly physiological process, and no sharp line of demarcation, either histological or in point of development, exixst between the nucleus (Xucleus Lentis) and the cortex of the lens {Sub- stantia Corticalis). An interference with the regular sclerosis of the nu- cleus has been said to be the initial cause of the development of senile cat- aract. The chemicaUi/ altered fluid which flh the interspaces between lamellae gives rise to an abnormal interchange between this rheinically altered fluid and contents of the lens fibres. This i7i its turn leads to an altered condition of the cortex, the cvpression of which is an altered refractive condition and loss of transparency which ire designate as cataract. These changes once having set in, it is apparent how useless all at- tempts at restitution by thei-a]ieutic measures must be. The various methods of removing the interference with sight (cataract; will he successively discussed. It would be useless to consider in detail all the minute changes which the various operators have introduced; only such will be considered as have a general bearing on the subject, and which il- lustrate the fundamental principles on which the various methods are based. In no department of surgery does the personal equation of the operator play so prominent a role as in the extraction of cataract. Tlio eyeball being a globe, the moment it is incised the relative position of its various struc- tures is changed, and the intraocular pressure is alteK'd. Further, since the successful extraction of a cataract in and of itself, does not insure a suc- cessful restoration of sight, the study of all those processes which take place during the period of healing, and sul)seq\i('nt thereto, likewise are of th-.' very greatest importance. Ht-ncc. a definite uiidcrstMnding of all these conditions is essential to the |)i-o|t('r management of tlic iiidividnal case. Finally the snl)jcct of apliakia will be eonsidered. THE NORMAL LENS SYSTEM. PART I. CHAI'l'KU I. TIIK l)K\I-:L()l'Mi:N'r ol- TJIK LKXS. ••Td-diiv all iiivesti*iator.s agree tlial tlu- tir>t dispos^ition to the forma- tion of tlie lens eonsists in a thiekening of the eetoflenn. This original gronp of cells undergoes an invagination: later on these cells are cut off and a hollow vesicle is formed. Kollil-er acepts this mode of development for the cuttle fish. Reiuak and Barhiii for the frog. Iliisrld-e, Remak. Henle and J I Is for tli^ chick, and Kessler and KoUik-er for mammals."* ••Hi>' accepts this involution of an open vesicle in the formation of the lens in the human einbrvo. and >o illustrates it. Kessler agrees with him, having had the opportunity i)f examining a human embryo expelled three weeks after the last menstruation, and with a loup he observed in this the funnel shaped involution. Bambeke^ states that in an embryo in the fourth week, which lie examined, he found the lens still connected with the cuticular epiblast. by a short, thick, pedicle which showed a funnel shaped opening. Kitter^ declares that in a five weeks embryo which he examined, the i)edicle had no lumen, and the lens seemed to contain a small hollow space."" VV/f prsi pn-hxl »f dcvclopnienl of the lens is enni- plch'd irilli III!' rliisiiir uf III is irsirli'. The time when this occurs ha> been but partially determined. Accord- ing to KoUilrr^ in the chick the lens vesicle is cut off by the third day. and this is in ai-c-ordance with an illu>tration by Kessler of a hatching egg of three davs and >e\i.^n hours. Kollihrr ([). (i;U) observed in a rabbit a lAnatoniie nienschlicher Enibryoueni. I.eipsij: Bd. I n.it Atlas. 1S80. Bd. II. 1882. pajre 49. Bk. 1. 2 Contribution a la historie du devoloppeiiK'iit de Toeil huiuain. Gjiud. lSi!>. 3 Zweiter Beitrajr zur Ilistosencse des Aujres. p. 145. 4 Eutwit-kehmgsgeschichte des Mensolieu iMul hoheren thiere Leipsig. 1870. p. «32. 20 thickening of tlie cnticiilar ))l;Ho on ilie tenth day, and hy the twelfth day the vesicle had already been cut oii". His fixes the age of a human embryo 22 ram. in length, and in which the optic vesicle was not even recognizable at from twelve to fonrteen d;iys, the age of one 7-T..") nnn. in length at four weeks. He illustrates one 4 mm. in length in which there is a thickening of the Epiblast. even before the primary optic vesicle could be discerned. Surely from the above we could not be far from wrong in attributing to au embryo 4 mm. in length an age of about three weeks. This would, bring (lie completion of the first period ahont in the FOUBTH WEEK. Bambeke and Kessler's observations quoted above agree with this, likewise with those of Kolliker. (P. 637). But, as Becker states, it is well to bear in mind the fact that the processes of development may go on more quickly in one indi- vidual than in another, hence exact statements as to the age of Human Embryoes can not be determined according to certain fixed laws. During this period of development, the eye is devoid of the so-called '•form-giving coverings," especially the cornea and sclera.^ THE SECOXD PEKIOD OF DEYELOPMEXT OF THE LENS. In its further development, the cells at the proximal wall grow in a distal direction, in man is a saggital direction, pushing in between each other, so that on meridional section they appear to be arranged in rows. The cells in the centre grow more rapidly, hence are larger than those at the sides. Since the nuclei of all the fibre cells are found in the anterior fifth, they will form a convex zone which is almost parallel to the anterior wall of the Lens. Meanwhile, the cells at the anterior wall arrange them- selves in a single layer, but show no signs of growing lengthwise. These distal cells assume the appearance of Epithelial cells. Kessler gives the following description for the chick: — "Even before the lens is cut off. signs of growth begin to manifest them- selves, more especially in the median (proximal) portion of the leus germ, cor- responding to the region of the subsequent capsule. Simultaneously, with a gen- eral increase in the enlargement of the organ, the cells arrange themselves closely together, and each individual cell increases in size and volume. They .assume spindle sliapes, and their sharp points force their way in between the neighl>oring lamellae. Meanwhile, tlie cells of the inner lamellae grow more rapidly backAvard. lliose :it Iht- sides iiutre anteriorly, while those nearer the axis of the organ grow niore rai)idly Hian any of the others. Every individual cell readies tlie posterior limit of tlie lens (the capsule of the lens), whereas 5 See Rilter, p. 82, p. 141 anteriorly, to the distal coll wall, and thus tlu- hollow space disapiifars up to a just appreciable space, whidi on cross section ii ohsorved lo oloiijjnto in the onibrvo of a Triloii ^i.') iiiiii. in Iciiulli jiikI tlic liollow space eiilirelv filled up in on? 4.. J mm. in len^lli. In ilie cliick. this stajie is completed on the fourth day. (Kessler). Tiiis luillow space was found still present in the embryo of a calf o cm. in len>ith. but entirely filled out in one 1 cm. lons heoins on the thii'teenth day and is com])leted on the cii^hiccnth day. possibly a little sooner. (Kolliker). The tinu' has not been exactly determined for man. hut imdoulitcdiy takes jtlace dui-inti' the xccnnd III on III II f foetal life. Tiii^: Till HI) ]m:ri()J) of development of the lexs is |)i'incipaJly occu])ied in the multiplication of the cellular elements, lens c<'lls as well as lens fibres. The former increase by direct cell division, and are distributed over the entire distal wall; the latter by mean.s of the growtii of the epithelial cells, wliicli lie along the Equator and somewhat behind ir, into lens fibres. This successive transition of tin- e([uatorial epithelial cells into the outer layers of nucleated lens fibi-es can be demonstrated in all Yertebi-ates. and tliis alone is suificient proof to demonstrate the fact, that these new lens fibres are derived from the Fi)ithelial cells and further that in the gnming lens, the identity (»f epit heli;il-likc and fibre-like cell> is to be maintained. At the close of the secoiul period of develo|)nient, the lens has attained the form from which it takes its iiame, as the rcsidt of the growth of fibres in an axial dii'cctiiui, these assume a slight cui'vatui'e with the concavity toward the edge of the lens, in contradistinction to those which, developing later on, do so meridionaliy. From now on, owing to the development of new fibres, at the Aequalor, these embn'onal fibres are gradmilly pushed away from the line of contact with the antei-ior epithelium, and the poste- rior wall of the capsule. (Ilenle). even at this time, the shortest: hence the youngest fibres continue lo nud\e a curve with the coiu-avity outward. I'ut as soon as they have made their way into the ca|)illary space between the anterior ends of the distally growing embryonal fii)ics. and tli(> distal epitheliuui. and posteriorly between the posterior ends of I he end)ryonal fibres, and the postei'ior capside. they take on a cuivatuiH' with tlu> con- cavity towai-d the axis of the lens. The moi'c this condition progresses, the more llie lihres of the second period ai'c pushed away IVom the capsule and the I'pilhelium. and finally they b)rm the centre of the <'omplete organ, which is concentrically siirniuude.l hy the libre> of llu' third permd. 23 TIIK S'rKM'CrrifK of TIIK LKNS .an onlv l)c iin.l.T-il animal-^ tliis is less tjian one-half. The -implcst strueture is found in ihc ;:lol)iilar lcii>e> «d' -omc fishes, ampliihia and reptiles, such a> llic ••>lo(k-ri>li."" niton, salamander, frog and lizard. In these animals the hhivs of each lamella i^o from pole to pole. each llhrc encircles one-iialf of the len>. each two form a complete circle. Their arran.iienicnl iiresujiposes that the lihre.- are hroader at the Aefpiator and hi'come more pointed toward the pole, so as to form a point; or. speak- ing more eoi'rectly. come together in a circle of irregular limits. 'I'his has l)een proven hy II. ^hilk'i''' to he the case in the l.aceria. and has been -nhstantiatt'd hy Ki'>sler. Lenkart. Sernotf and r.ahiicliin. In a large proportion of li-he>. amphibia and a feu animab (dcdphin. rahbit. s(piii-rel) the lens hhres of one sheath regularly meet each other anteriorly and posteriorly in a short seam (a segment of a circle) and the direction> of these cut each other at I'ight angle-. If at the anterior pole, this line lies horizontally, at the postei'ior it lies vertically. At the same time it becomes imiTOSsible for the fibres to entirely snrround one-half of the lens. For instance, if a fibre l)egins anteriorly at the end of the seam, it will end as it proceeds meridionally backward, posteriorly about the middle of the seam, hence in the axis of the lens at the posterior pole. Tu doing this, the fibres describe a cnrve anteriorly and mie posteriorly in order to gain a point of attacbnient to the >eam. Hence excry lihre describes a double curve. The fibres of each layer, hown'ver. po^so.- about the sanu. length. In several fisb.es. such as torpt' been observed, all the hhres coming together ac the posterior pole, whereas anteriorly they come together in a straight; seam. In most niammalia the fibres of each sheath meet each other so as to form a regular t hice-rayi'd star figure, the central point of which lies at the pole and the rays of thi> >tar. corropoiiding to the seams, forming with each other angles of IV'O degrees. The level- of these rays do not lie in the same jilane anteriorly and posteriorly, but are turned from each other at an angh' of (id degrees, -o that each ray of the anti'rior -urface falls within the open angle of the posterior. I'Acn in tlii.- form of arrangement. rt (iesanniielte mid liinterhisseiie Sciuilten lienuisgeg. vou Otta Becker. 1872. Bd. I. p. 74. 24 in order that the fibres may attach themselves to the seam or ray, they make two slight curves in opi)osite directions. However, all the fibres iu one lamella are of equal lengtli. We know absolutely nothing as to the cause of these various types. "Woinow "' has studied the manner of the manner of tlie f(u-iiiation of this seam for the second type, and the third type can be understood from Arnold's illustrations. Possibly, the above-quoted observations of Kessler concerning the lens of the sheep belongs to this category. If after the close of the second period of development new fibres are only developed in the Aequatorial region, a stage comes on, in which these fibres force their way along tlio inner surface of the capsule toward the axis, without, however, reaching those which are making their way in from the opposite side. As a consequence, the fibres cf the second period are de- tached from the capsule, pressed toward the centre of the lens, and these growing fibres come together behind them. Hence for a time, on merid- ional section, one will find a triangular space, filled Avith tissue fluid; this space, as a result of the continued growth of young fibres, becomes filled up by these, and in very thin sections can only be recognized as the line at which the fibres meet each other.'' It is especially interesting to note that Kolliker was able to show this three-rayed lens star present in a five months' human embryo. The pres- ence of the three-rayed star, on the anterior and posterior surface of the lens, simply signifies that at least the first layers of lens fibres which have taken their origin along the Aequatorial region, have attained their full growth, the fibres of the one side anteriorly and posteriorly, touching those coming from the opposite direction. Hence the third period of develo])ment lasts from about the middle of the second month up to such a time, which for man has not yet been ex- actly determined, but which, however, at the very latest falls within the first half of the period of foetal life. At this time not all, but only those which form the first layers of lens fibres, have attained their full length. The fibres extending from aequator to seam, both on the anterior and posterior surfaces of the lens, are arranged 7 Uber die enstehimg der bipolaren anorduug dor liuseu-faseru. Wiener Sitzungsbericlite, 18G9. Bd. LX^ 2 Abtli., p. Lll. a Tliose ob.servatioiis have been beautifully Illustrated by Arnold. (Beitrage zur eutwickelnngsgescliichte des Auges. lleidleberg, 1874. Die Kittsi;bstance der Eudotludien. A'ireliow Arch. Bd. LXVI. ]». 77.1 His ligures 13 and 14 correspond exactly with figures :'. of Woinow. Figure 15 shows a similar proceedure for the anterior half. In tigures 18 and lit ilie three-rayed star is already present. 25 like the tiles on a roof, so that the broad ends of Iho tlljres form an uninter- rupted mosaic at the inner surface of the i)osterior capsule and the anterior epithelium. Only those libres wlucli arc sonic distance removed from the surface reach to the seam. These seams or rays are therefore simply the optical ex- pression of imaginary lines along whicli the ends of the lens fibres touch each otlu'v. And on meridional sections. Ilicv ciin We Inllowcd almost to the centre of the lens; never, however, along a straight line. The nearer we get to the centre, the smaller is the encompassed space. As a necessary result it follows, that though all the fibres in a single layer are of equal length, in the various layers from without inward, their length regularly diminishes. Each fibre is developed from an cpilliclial cell at the equa- torial region. As the cell elongates, the nucleus, which was originally near the centre of the cell, gradually moves farther and farther away from the capsular end, until, finally, as the posterior end of the fibre grows to excess, the nucleus again comes to lie in the anterior third of the fibre. Hence, on meridional section the nuclei of all the fibres, in their various stages of growth, present a very beautiful ])icturc. the optical expression of all the nuclei being a double curve, this being another mode of demonstrating the natural curve which the lens fibres describe. In the beginning, the con- cavity of the curve faces .anteriorly, and finally the convexity is almost; parallel Avith the surface of the lens. Since this curve is not an absolutely regular one, Becker ^ suggested that the name "Kernbogen'' NUCLEAR CURVE, would be better than that adopted by H. ^Meyer. KERX ZONE, NUCLEAR ZONE.^ Kolliker was the first to recognize this gradual transition of the epi- thelial cells into lens fibres, and Yon Becker ^^ gave to the picture which these cells and their nuclei present on meridional section the name which it has since retained, "Linsenwirbel" — LenstrliorL THE DEVELOPMENT OF THE CAPSl LE OF THE LEXS has given rise to endless discussion, and the importance of this subject will become more apparent when the subject of capsular ciatrices and capsular cataract comes under consideration. One group of observers. Reinol; sUber den Wirbel und den Ivprnbogpii in der Mensohlitlien Linso. Arch. f. Ausenheilkunde, Bd. XII. 1. 1883. 9 Beitrag zu der Streitfra^*^ ubor di.- Knist.-himR dor I.inson fascrn. Midler's Areh.. 1851, p. 202. 10 Uutersuchungen uber don Ban dor Liiise bei an excretive product of the cells of the lens vesicle, heiu-e of I'U "!'( > I) !<: I! M I ( ' oii-in. Srhinitcr}^ as the result of his histoloo-ical and more special l.v his chemical investigations of fresh eapsule.v. capMdai- cicairico and ca|)sidar cataracts, joined the adherents of the later view, iiamelv. that they are not to be looked upon as of connective tissue origin. Availing himself of Kwald and Kuhne's dis- covery, that the capsule of the lens, as well as structureless niemhranes, arc easily digested h\ means of trjjsin. acids and alkaline solutions, whereas connective tissue i-euuiins totally undigested, he hnally concluded '"that there is a large pi'eponderance of proof in favor of the view, that hoth the capsule and its pathological fornuitions are derived from the same source, being products of the PZpithelium of the Capsule." Babuchin.is j„ examining Sernoff's preparations, claims to have seen nuclei in the cajjsule of the lens, in the embryo of a chick. IJerger i'' states that he made similar observations in the human embryo. i>ut Schirmer, basing his views on his histo-chetnical investigations, logically questions the accuracy of their ohsei'vatio))s, Kessler claims to have seen the capsule present at the clo.se of the Second Period of Development, as does also Arnold. The latter, however, at the same time leaves the (juestion undecided, as to how the formative cells, at the ])osterior capsule, which at that time have already l)ecome elongated into lens fibres, could jn'oduce an exudative substance to form the posterior capsule. Kessler tried in vain to prove that the capsule was formed simultaneously with the lens vesicle. Becker^' took a position between the two. and states that he l)elieves the structure of the capsule of the lens to l)e a complex one. and that it is only important to' prove its presence at the beginning of the Third Period. "For withont this closed 11 Znr Kntwiekelunf? des AujiV der Wirl.ellliiere. L«'ii)siff. 1877. 1-' Zur Entwickellunji' des (Jlaslcoi-pers. Aicli. fur Aiiatomie and TMiysioloiiie. Ant. Al)tli.. r. and ft H.'ft.. ISSU. 13 Ucclierclies sur le developi.cnient dii cristallin. (Jeneve. ISS.'.. Ueferale Hirscld.erji's Centralhlatt. ISS.",. p. 2.-,.-.. 14 Histolofiisclie und II istociieniisclic luitersucliun.iien ulier Kapselniarlte und Kapsel Cataract neltst lienierl^uiiucn uliei- das pliysioloyisclie Wachsthuni und die Structure der vodern Iansenllaiuc lo llic yoiiii-- lcii> lihivs wliidi |mi>Ii ihcir wav ill l)('t w ecu tlif pi'Dxiiiial (il)r('s on the (Uic liaml. and llic caioiili' and ita cpilliclinni on the ollicj-. one could not conipivlicnd the rc.Linlaril y l)oth in ihc I'oi-ni and arran-zcnicnt of llic lens lihro uliicli \\c >o niiicli adiniro. * ScliiMHci-. liowcvc!'. conlcnd.- llial llii- ca|(>ulc is dcvclojicd al llic liiiu? when the e|iitheliiiiii is still |ii'e>ent alon^- the iiostciaor ca|)-ule. hence dniaii";- tlie l-"irst I'ci'iod of 1 )e\ elopinenl and al the -aiiic liiiie. when as a result of the elongation of the pi'oxinial cell>. tlicii' |io\\er to foi-ni capsular snhstance is not entirely lost, lie even attril)iite> lo the yoimu •■fll> ii^ tliey develop aloniin. .lulius Arnold.'"^ reviewini('nt . anion^ them Fcrrciii. I'dlliici and SoIoiikhi . consid- ei'cd the zonula as a continual ion of ihe retina. A third, aiuon.u- them L'inlolplil. Polllin/ci: l/cssclhorli and Wchcr. considered the /(Uiula a> en- tirely independent formation. Ileiile (l-:iiio-ewei(l lehre ISdC.) joined in the views of the lir>t ,i:roup with this difrcrence. ihat lliouuh he looked upon the zonula a- derived from lhe hvaloid. he considered ihe latter a coiitiniiatiou of the limitau> in- terna retina. Lieher-kuhn (Cher Au.uv ^Wv Wirhelt hieivn. Marhur- isr.raefe Saemiscli Handlmcli. Vol. I. i). .".n.-. 1S74. 28 1872), liowever. jn-oved that tlie hyaloid liad nothing to do witli tho retina, and that it is the limiting membrane of the vitreons, hence derived from the mesoderm. SrJnralhe^^ coincides with Lieber-kuhn as to the origin of the zonula from the vitreous. He does not accept a splitting of the hyaloid at the orra sei-rata. hut contends that a thickening takes place at the orra serrata. and that the entire nicruhrane extends forward to form the anterior wall of Tetit's Canal, the ])osterior wall heing due to a thickening of the vitreous. A. Hannover -^ otl'ered a still more complicated view, stating that after the splitting into two leaves, the anterior again split into two leaves, one extending over the ciliary body and its processes and then going over to the anterior surface of the lens, whereas the posterior of the first two together with the posterior of the original division should form a second canal posterior to Petifs Canal known as Hannover's Canal. Arnold gives us the following explanation: "At an early period of foetal development, the lens is imbedded in a delicate tissue derived from the mesoderm, which is pushed in between the lens and the secondary ocular vesicle. This tissue gives off processes which, spreading around the lens, gain its anterior surface. Later this tissue goes to form the choroid, processus ciliare and the iris. That portion posterior to the lens forms the vitreous, the part anteriorly forms the membrano-capsulo-pupillaris. The portion aloug the equator forms the zonula. At a certain time no more intimate connection than this exists between vitreous and retina, or be- tween zonula and the ciliary pori;ion. Later on, a more intimate con- nection is established between zonula and ciliary body." He concludes that the limiting membrane of the vitreous, as also the portion from which later on the zonula is developed, are totally independent of the retina in their origin and that the zonula is simply a "peculiarly arranged and specialized part of the vitreous," originally solid in its construction and of mesodermic origin. This, he states, "does not preclude the possi- bility of softening or fluidity of the intercellular cement substance so as to pennit the formation of fibrillae, as we see them in the posterior part of the zonula." Merkel (Die Zonula Ciliaris Leipsig, 1870) was the first to doubt the existence of Petit's Canal, and that the zonula was a continuous membrane. He looked upon this space as the result of the elements of the zonula. Czermak -^ investigati-d this subject very carefully, and his views agree with those expressed by Gerlach, (Beitrag zur normalen anatomie des Auges. 19 Graefe Saomisch llandbuch, Vol. I, p. 458. 20 Entdeckuns dos Ban des (Ilaskorpers. Muller's Arch., 1845. 21 Zur Zonula Frago-Graef Arch., Vol. XXXI, Bd. I. p. 74-134. 1885. 29 Leipsig, 1880), who believed lliat the Zdiiula consisted of a syslcin of mcrid- ionally placed fibres, wliicli take tlicir ori.yin froin the ciliarv Ixxly and the orbicularis ciliaris, and thai thcv ai'c iiidcpciidciii of ihc vitrc(>ii.- hody. and he further denies the existence of I'ctits Canal, l.aler investigators, Schoen " and Top(danski,23 agree almost in lalo willi C/.ci-niak. As the result of liis investigations, Czermak states thai in cai'ly ro<'tal life the space between cihary body and lens is filled up by a large number of foetal cells, which aiTange themselves in rows, leaving spaces between them. These cells elongate, forming fine threads or fibrillac arranged nieridionally, hence the zonula is not a membranous structure, hut a complicated system of fibres from the beginning. In a six and one-half montli foetus he found the entire posterior eliamber oceujiied l)y the zonula, and a eondilitm pres- ent never seen in a fully develo])ed eye. namely, pencils of these rays of fibrillae extending from the peripheric portion of the iris and the most anterior part of the ciliary body. Later on, as the result of rarefaction, these fibres are restricted to the posterior portion of the posterior chamber, and the pupillary membrane disappears at the same time. He looks upon the zonula as of mesodermic origin, derived from the portion of the em- bryonal vitreous which fills up the space destined to become the posterior chamber, and that this tissue is "modified both physically and chemically so as to serve its function." Others again, as Abey ^^ and Kuhnt and Berger.--^ return to the view that the zonula is a membrane, the fibrillae Berger considered as fibrillae wdiicli support the membrane. Finally, E. Treacher Collins,^^ as the result of the examination of an eye, enucleated from an infant three months old under the supposition that it contained a new growth, and which was found to contain a persistent hyaloid and exhibited; fibres of the suspensory ligament in all stages of their development, and the subsequent examination of several foetal eyes, formu- lated the following idea as to the development of the zonula. "For a long time, the primitive lens remains in contact at its sides with the portion of the secondary ocular vesicle destined siibsequently to become 22 Zonula und Grenzehaut des Glaskorpers. Graefe's Arch., Vol. XXXII, R 2. 1). 149, 1886. 23 Uber den Ban der Zonula unbst bemerkungon ubor das Albinotische Aiige. GraetVs Arch.. Vol. XXXVIIl. B. 1. 1801. 24 Der Canalis Petit und der Zonula Zinnil l)eini Mensch und bei Wirbel- thieren. Graefe Arch.. Vol. XXXVIIl. H. I. ISS'J. 25Beitrag zur Anatomie der Zomda Zinnii Aich. fur Opth. XXVIII. B. II, 1882. 26 On the development and abnormalities of the Zonula of Zinn. The Koyal London Opth. Hospitiil Reports. Vol. XIII, Vol. I, p. SI. 30 the eiliarv body. Tlie leii> lK•(•()lllt■^; encircled hv w hat is terined its fibfo- vascular sheath, derived in part from the central artery of the viireous and in part from the vessels growing in between tlic lens and the cornea. The portion of the inner layer of the secondary optic vesicle still in contact with the lens — that is, the pars ciliaris retinae — acquires adhesions to this sheath. Then, as the eyeball enlarges, it does so at a greater late than the lens, so that a portion of the ciliary body which was in contact with the lens grow^ awav from it and the adhesions which liave formed between them become stretched, and the cells forming them much elongated, imtil only fibres with nuclei lying on them can be distinguished, and ultimately the nuclei go. leaving only the delicate fibres of the suspensory ligament as we see them in the adult eye." As a result of the tension of these elongating fibres, the antero posterior diameter of the originally almost globular lens takes on its lenticular form. He also suggests that this mode of development may throw light on some of the congenital abnormahties. Collins, however, raises the whole fibres which take their origin at the Equator, conipletely sui-round the pro.ximal fibres which, as we have seen, grow in an axial dirc'ction and form the original nucleus. Ilir lens hody of ilie second period, and press them awav from the distal epithelium and the posterior capsule. Erom this tinu\ up to birth, this production of fibres, which oiu' after the other elongate to reach a seam, goes on. During this i»eriod. the lens is almost globular, but owing to the Drestuice of many fibres which have not attaint'd their full length, all of which ci-o>> the e(|uat(.r. the e(|nalofial diamet.'r mu. ommiI i;il ly a font iruia- tion of tlie first poiiod, with ilii> (lilVcrciKc. ii;iiiicl\. ;i (lijimctric-ally oppo- site i)nK'es? beo-ins. which we will dcsi-iniilc ;i,- oiic of I' II Y SI OLOdJCAL nETHOanKSSlOS. Thoc .liain.'ti-icnllv op|.o>itr coiiditions diviih- tli. e\ti-ii-iitci-iiu' period into two i^rcal periods, one (d' extra-uterine growth, Ujt to its complete development: the other, ihat of retrogression to^^etlier wit'i the chan^'es incident to a i-ednction in v(diinie. How ureat the inci'ease in volnnie is. may he jnd,i:-e. at hirlh. in an eye having an ocular axis of 1^ mm. the lens wciuhed 0.10 grammes, ( l)ecker),;ind Sappey I'stimates the average weight of an adtdt lens at O.^IS grni. 'I'hi- increase in volume is accompanied hy a very natural increase in the e(iuato]'ial diameter of from ■") mm. to 10 mm., whereas the saggital diam- eter, the axis of the lens according to Sappey, remains almost unchanged, -t to 4.M mm. The lens of the human foetus and of tlie new-born child is almost glol)ular. whereas in an adult the surface has a much sharper curva- ture. In tlie following' table the absolute weight ajjrees exactly with the state- nieuts of Sappey. AVeisht and volume (with but one exception) increase steadily with ajre. The speoitic jtiavity varies slightly from the average. The extremes, however, bear no close relationship to the age. Some slight doubt is cast on the accuracy of these results, because the lenses had been in Muller's fluid for various periods, some for several years; and further, because the number of examinations is not large enough. All the lenses were obtained post mortem. Absolute Volume. Specific Weight. Gr. Cu. Ctm. Gravity. \ Foetus 070 •> 0.10 3 20 yrs. O.IS 0.155 1.1B129 4 20 " 0.185 0.159 1.18352 S 22 " 0.215 0.177 1.1315S 6 40 " 0.190 0.163 1.24248 7 49 " 0.225 0.194 1.15979 8 49 " 0.240 0.198 1.21212 9 54 " 0.246 0.214 1.1448(5 10 54 " 245 0.214 1.1448ti 11 60 " 0.251 0.217 1.15668 Average . . . 0.219 0.198 1.16946 Priesthey Smith i has verified all Becker's statements, at the same 1 Oph. Society. 1883, p. 79. reprinted in his monograph. '"The Pathology and Treatment of Glaucoma." 1801. time avoiding his sources of error. siiK-c all the eyos which he used were removed one hour after death, and at unoe immersed in viti'eous fluid, in order to prevent gain or loss in bulk. He states (Page 84), "15G eyes were removed from ^ " iy2 " lyz " lyz " i>^ " 1^ " 1^ " IK " 13/ " 62 66 62 74 84 64 (52 82 70 65 64 68 74 76 74 62 72 71 66 7.8 6.9 7.6 8.0 80 8.1 8.0 8.0 8.1 8.3 7.5 8.0 8.2 7.4 7.8 7.8 8.1 8.1 7.9 2.6 9 5 . . . 1 . . . 6 7 8 9 10 11 '. '. '. - 2.5 2.6 2.9 2.6 2.8 . . . j . . . • • • 12 ■ ■ : z ^ 13 14 15 16 17 18 19 20 8.3 6.9 ; : : 7.87 i.6 2.2 2.4 2.6 2.6 2.5 2.8 2.6 2.6 24 2.9 2.2 . . . i . . . . . . j . . . ...... 2.57 21 22 ...... ...... 23 2 " 2 " 2 " 2/ " ^ 76 82 78 68 8.2 8.4 7.9 8.3 ■8;4' 7!9' . . . i 2.6 '. . . i 2.5 8.2 ■ 2.8 . . . , 3.0 24 25 26 '3I0 2!5 "2.72 27 28 29 3 " 3>^ " 70 86 80 8.6 8.6 8.2 '8!6' '8!2' ... 2.8 8.46 2.9 ... 1 2.8 . . . 1 . . . 2.9 ; 2.8 '2.83 30 4 " ■5/2 " 7 " 12 " 84 100 85 129 7.8 8.4 8.2 8.8 . . . 3.1 3.2 2.9 3.4 '.'.'.'.'.'. 31 32 33 . . . "Finally, Treacher Collins 3 examined a series of foetal eyes from the fourth to the ninth month. This table also shows that the axial or transverse diameter of the lens, which at the fourth month is only a llttlo more than the antero- posterior, in the adult is nearly three times as nmch. Also, that in adult life the antero-posterior diameter is somewhat less than in foetal life. No. OF Eyes Examined. Diameter of Eyeball. Diameter of Lens. Age. Antero Posterior. i Lateral. Vertical. Antkro Posterior. Equatorial OR Transverse. fe 4 mths. 3 5 " ^ 6 " < 7 " w 9 " ^ Adult. 3 1 4 8 3 Merkel. 8.1 mm. 11.75 " 12.50 " 14.30 " 16.75 " 24.3 ♦' 1 7.8 mm. 1 11.5 " 12.0 " 13.2 " j 16. " 23.6 " 7.5 mm. 10.5 " 11.1 " 12.6 " 15.3 " 23.4 " 2.8 mm. 3.5 " 3.8 " 4. 4.3 " 3.7 " 3.3 mm. 4. 4.5 5. 5.55 " 9.00 " Thus, if we arrange a table from the foregoing, showing the growth of the equatorial and axial diameter of the lens from the early period of 3 Abnormalities of the Zonula of Zinn. The Royal London Opth. Hospital Reports, Vol. XIII, p. 86, 1893. foetal lift' up to the exti-ciiic auc it at once l)eeoines evident how extremely rapid the growth of tlic lens is in intrauterine life, as; eoni|)ai-('(l with th(^ extranterine. Furthei-. that in earliest, life the lens i.s almost filobular, bni as life advances liecomes Hatter. lyCATOKIAI Antero Diameter. 4th month, 3.3 mm. 2.K mm. COIJJNS. Foetal oth " Hth " 4.0 4.5 3.5 " 3 8 " Life. 7th " 5.0 4.1 9th 5.7 4.2 9th to 12th " 7.46 •• 2 46 " 1 to 2 years, 7.87 " 2.67 " 2 to 8 S.2 2.72 " Dub. After Hto 4 " S.4(5 " 2.83 " Birth. 4 to 6 " 7.S 3.1 5 to (> K.4 3.2 7 " S.2 " 2.9 12 " 8.8 " 3.6 " 20 to 29 8.67 " :Wto39 " 8.90 " PRIESTI.V After 40 to 49 " 50 to 59 9.09 " 9.44 " Smith. Birth. * (50 to (59 70 to 79 KO to S9 9.49 " 9.64 " 9.62 " The following average measurements for the lens in the new born are quoted in a recent publication by E. V. Hippel (Uber das Auge des Xeugel)(»renen. Graef Arch.. Vol. XLV, Part II. p. 29.S. 1898): Antero Equatorial Diameter. Posterior. V. Yager, 4.5142 6.3628 Huschke, 5.18 6.76 Sommering, 4.28(54 5.188 Krause, 4.512-4.737 6.768—7.219 IVIerkel & Orr, 5.0 9.6. For both Ant. and Post. Surface.- Radius of Curv- Dieckman, 5.1 (5.29 [ature, 3.3 mm. Treacher Collins, 4 3 6.76 E. V. Hippel, ( 3.76 14.00 6.00. (Two absolutely fresh Eves.) 6.6 .\s we have seen on page •*:'). the tri-star figure is accepted as the type at birth, with the star on the p(i>terioi- sui-facc of the lens lui-ned at tiO degrees lo the (»iie on the anlcnor .-urfacc. i'.ut in its furthrr dcvclopmenc after l)irlli. a more coinpliciilcd figure is foi-med bv the foruialioii of sec- ondary rays. Near the pole, each primai-y ray diviih's into two I'ays forming equal angles of 60 degrees, or each lay divi«h'- into three lays. thus forming equal angles of 40 degrees, or four rays, forming angles of ;!0 degrees. But. as Beel]). "'rhis does noi c.\hauntniss dor Laajio \uu\ Anonlnung der Augen liusen- fasren. Central), f. d. nied. Wiss, 1882, No. 27. 3 7 ;uul iiiiddlf third nf tlu' cunc-iMHidiiii;- radius iiirct. 'I'lie siicfceding fibres (111 llic aidcrioi- siiil'acc arc all successively i-eiiioved one fibre's breadth from. the |)ok'. and on the iiosicrioi- surface aloii^" tlio corresponding radius, all (he lil)res reach t)iie libi'e's hreadlh successively nearer to tlic pole, so that finally the lihi-c whicli linds its point of attaclinicnt on the anterior surface at the junction of tlie anterior and middle third extends posteriorly to the pole." .\cc(.r(lin,<:' t n\' a new-horn infant measures o..') min. Meas- uremenis of tlio lens fibi'cs of adults, as compared will) the increase in the size of the ('(jiiatorial diameter of the lens, did not show a relative increa,<5e in sizcand. aside from this. I hey varied greatly (2.74^" to 4.0(r") 7.17 to lO.fii nim. ITence the fibres are neither of equal length, nor can they reach from one pole to the junction of the outer and middle third of the corresponding radius of the opposite side. Direct observation has shown that they end in the outer third of the corresponding radius. The length of the fibres vary- in each lamella, and this variation is all the greater, the more complicated the star figure. If one will make a sketch of both the anterior and posterior surface of the adult lens, showing the lens star, one will see that if the number or rays is the same on both surfaces, all the fibres will be of equal length, jusi as in foetal life. But if this complicated type is difl'erent on the two sides, as a necessity the fibres must vary greatly in length. Since, with the single exception mentioned above, this latter type is the one always met with, the fibres of a single lamella in a human lens, and which develop in extrauterine life, will not only be shorter, as compared to the portion of the lens which they encompass, but they will no longer possess an equal length as com- pared with each other, as they did in foetal life. This inequality in the length of the lens fibres is to be looked upon as the cause of the great in- crease in the radii which go to make up the star figure and the production of the variety of types seen on both surfaces. In lieu of a more plausible explanation of this unequal gi-owth of th'^ lens fibres in extra-uterine life, one might be permitted to seek it, in the functional activity of the lens, and in its uninterrupted formation. The position of the nuclei of these fibres is dependent on the above described in-egularities in the length and the laying down of the new-former! lens fibres. In embryonal lenses, even in the new^-born, the Nuclear Zone of nuclei form a convex curve on section. This is not the case in older lenses. Von Becker ^ drew attention to the fact, that at first the fibres 9 ITntersnf'hunjren ubpr den Ban der Linse bei den Mensehen and den Wir- belthiertni. Arch. f. Opth., Bd. IX, 1873. p. 10. 3S grow only at their anterior extremity, as one is justified in concluding from the position of the nuclei, soon, however, the posterior extremity also grows. Thus it happens that in the hoginning the nuclei form a limited, and later on, a somewhat hroader curve, which is open anteriorly and which then merges into the larger anteriorly convex curve. According to Von Becker, from now on, the growth of both ends of the fibre is almost equal. Since the proportion of each fibre which is on the anterior and posterior surface is dependent on the arrangement of the radii, or, more properly speaking, on the part which each separate fibre plays in the formation of these radii, therefore their nuclei must also occupy a variety of positions, depending on the above circumstances. Though the general law, that the nuclei are always found in the posterior portion of the anterior half of the fibres, is almost universally accepted, on section the curve formed by all the nuclei which form the IMeyer's nuclear zone will always be found in the outer por- tion and with the concavity of the curve turned toward the anterior surface of the lens. Whether this curve will in certain portions of the lens extend anteriorly, or more toward the centre, or even backward, vn]\ depend on the variety and even the condition of the rays of the lens star. Von Becker very properly concludes, that one should not picture to one's self this nuclear zone as though it passed through the e(|uatorial plane of the lens, as though it were a diaphragm, but rather as though it were a sheet attached at the periphery and which extended through the substance of the lens, iu a wavy manner and equidistant from the radii of the lens star. If we can thus explain certain departures in the position of the nuclei, as we find them in very thin sections, aside from these, we do meet with well-preserved nuclei in the deeper layers, dispersed in the most irregular manner. This rule, therefore, has its exceptions. In very thin sections of the lens one may observe still other abnormal- ities. Henle (Zur Anatomic der Krystallinse Gottingen. 1878)- has pointed out one which is of great importance, namely, that the lamellae do not in- crease regularly in thickness, as we go from without inward. Such a con- dition indicates that the growth of the lens is not a perfectly regular and continuous one, but that it is influenced by the same fluctuations in tho general nutrition of the body, as are other organs, as per example, the skin, the hair, more especially the nails, on which, subsequent to a long-continued fever, one can observe a line of ^demarcation. There can hardly exist a doubt but that during the time in which a child is well nourished, the lens fibres grow rapidly, become broader and more succulent; whereas, in anaemic children, the growth is interfered with or possibly totally arrested. Such an irregular interference with the growth of the lens fibres will mani- 39 fest il.-v tt'acliiii;^- ihat thi- is to be looked upon as Iluniour Morgagni. also leaves behind it, when it coagulates, de- pressions of an analogous character on the inner surface of the E]ntheliuni. These figures are often mistaken lor AVcdIV Vesicular Cells." THE FOR:\rATI()N 01-' X KW LKNS FIliRES. As has already been indicated, on |)age 'i'L the laiuelhie of the lens are devi'loped hy t!ie forma- tion of new lens fibres along the equator. As these new fibres develop, they gradually press those already formed away from the surface. As long ago as 18.51, Herman Meyer,ii in order to uphold this view, drew attention to the changes which the nuclei of the fibres undergo as they gradually become removed from the surface, and he considered this as an indication of the gradual death of the nuclei. An incidental utterance, of II. Mulleri- ^lakes it probable that he also Ijelieved that the new fibres are found at the whorl. Kolliker (p. 731) believed that cellular divisioii took place along the Equator, thus constantly replacing the cells which had been changed into fibres, and Von Becker claimed that he observed this cellular division going on along the same line. Frey ^^ even mention- nuclear division in the lens fibres of an eight months' human foetus. Whereas, Sernoff, Iwanott* and Arnold did not observe these karyokinetic figures, Henle attempted to explain the assertions of Kolliker and Von Becker, who claim to have seen conglomerations of small cells along the epithelial border, by demonstrating that this appearance of a number of layers of small cells was due simply to the close packing of the cells which had become elongated into fibres, and the swellings at the points where the nuclei lay, were located at various heights so that the fibres could accommo- date their positions to each other. To this general description, Becker adds, "that in the calf embryo, as in young pigs, he found a broad zone, in which the nuclei wer^ smaller, closer together, almost touching each other, and taking the analine and haemotoxylin stains with avidity. The nuclei which in the center of the anterior capsule of the ox are perfectly round and have a diameter of 0.0047' mm., whereas the cells theniselves have an average diameter of 0.00(57 mm., at the Equator have a diameter of 0.0025 mm., with a diameter of cell equal to 0.0029 mm. At the same time the nuceli increase in height from 0.004T to 0.009 mm., and the cells elongate from 0.00G7 to 0.0174 mm. One can easily understand that such a change in shape will be very apparent where the long axis of the nucleus is exactlj 11 Beitrag zur der Streit frage uber die Entstehung der Linsen-fasern. Mul- ler's Arch.. 1851. p. 202. 12 Gesamelte und Hiuter lassene Schriften lierausgegebeu von Otto Becker, 1872. Bd. I. 13 Handbuch der Histologie uud Histochemi, 2 Auf., p. 287. 4.2 perpendicular to tlie surface of the capsule. From all that has been said, it seems to be higlil}- probable, that these peculiar pictures stand in close re- lation to the nuclear and cellular increase, and that the large cells are to be looked upon as "mother cells." Becker also coincides with Heule's views, namely, that tliere are no so-called Formative Cells (Von Becker) along the Equatorial Zone. When Henle (Zur Anatomie der Krystallinse, 1878) published his Monograph, he left the question as to how the new fibres are formed on the surface of the capsule, an open one, but since that time, he has published some successful studies which have elucidated this subject. In a thesis styled "Zur Entwickelungsgeschichte der Krystallinse und zur Theilung des Zellkerns." he recites his observations on the larvae of Frogs and Tritons, in which lie found cells interspersed between those at rest, and often at a considerable distance from the place at which the cells become elongated into fibres undergoing karyokinetic changes. He states: "In the lenses of these animals, as in all other globular lenses, the epithelium extends beyond the Equator on to the posterior surface. Along the Equa- tor the cells still have their polygonal shape, as on the anterior surface; then folloAv a number of rows of elliptical, almost quadrilateral, cells: next to these, as long as the lens continues to grow, rows of longer cells, which run parallel to the fibres, and so arranged as to lap over each other, like the tiles on a roof. In the pol3-gonal cells, which lie near the region of the equator, one observes these karyoldnetic changes going on. At times these changes are noted siugh^, then in numbers; but I could not find that their number stood in any relation to the age of the larvae. Xcither are the cells nearest the Equator always the ones in which the changes are farthest advanced. One finds cells undergoing division dispersed everywhere, and it is absolutely impossible to state, what it is in the individual case, which gives the initiative to these changes." Henle finally states tliat he never observed these changes in a fully developed frog (without a tail and with feet). It was not until after "indirect nuclear division" had been fully proven by Strassburger for the plant cell, by Fleming for the aninutl cell, by Arnold for pathological cells, that the subject of how the cells of the lens capsule increase, both in the normal and pathological conditions, could be definitely settled. It was then shown that these nuclear changes are pretty evenly distributed over the entire surface of the capsule. Thev are, however, only demonstrable when the specimen is hardened in Fleming's Solution. There wei'c two ])ossibilities as to where these karyokinetic changes take place; either, as Muller thought, they occur near the Equator along 14 Arch, fur Mikr. Anat, Bd. XX, p. 418. 43 the Ions whorl, or tlie iucroase takes place all unci- llie anterior capsule, thus gradually forcinfr all the epithelial cells towai'd the Ecjuator. Ilenle and Becker believed in this latter mode of increase. Tleide says: "Just as ac- cording to Ehert, the posterior epithelium (?) of the cornea grows over the surface, not as the result of the addition of cells al llie edges, but by the interposition of new cells over ihe entire surface, as the result of karyoki- nesis, the cells push themselves in ht'twcen the oM ones." The observations of Eberth and Leber are of especial interest, owing to the great importance which this subject of the movements of the epi- thelial cells across the surface of the capsule bears to a proper explanation and understanding of the pathological processes. (Capsular Cataract, etc.) Eberth ^^ has shown that where there is regeneration of the corneal epithe- lium, this prolifei-ation is not confined to the edge of the defect,but occurs at a considerable distance from this s])ol. and in cells interspersed between those at rest. Leber ^^ has shown that during the healing of capsular wounds the karyokinetic figures develo]) in a zone which is at a consider- able distance from the defect. Between small cells, with small nuclei, others are found which are considerably larger and clearer, showing all the vai'ious stages of karyokinesis. In the embryoes of calves and children, Becker found these karyokinetic tignres all over tlio capsule, without a special activity being noticeable in any jiarticular zone. Such an increase of cells presumes that these new cells force their way in between thoso already formed; the latter are compelled to change their position, and in a centrifugal direction, that is, from the pole towards the Equator. Thus it has been shown by direct observation that the cells multiply over the growing capsule, and that they change their position over the surface of the capsule, and it is also very probable that the entire epithelium in turn replaces those cells which are changed into lens fibres. THE CAPSULE OF THE LENS.— It is generally conceded that the capsule of the lens grows during extra-uterine life. According to Eitter,^^ in the new born, the capsule of the lens at the anterior pole measures O.Olti mm. in the thickness, whereas in the adult it ineasures 0.0 Ki mm., at the equator, 0.005 to O.OOT mm., and at the ])osterior pole. 0.0075 to 0.008. As has already been indicated on ])age '.^(i. to Schinnci- (ref- erence on page 26), who proved that the I'apsulc of the lens is an excre- tory product of the epithelium of the lens, are we indebted for the most isuber Kern und Zelltliciluug. Vircliow-s Atfh.. LXVII. p. 523-525. 16 Zur pathologic der liiise Zehcnders Klin Monats blatt. beilajj hoft. p. 33. 1878. 17 Anat. du cristallin— Wecker Traite des Maladies des ycux. 2il VA. II. p. 3. 44 modern and generally aec'e])ted views regarding this structure. In the course of his investigations on Capsular Cicatrices, Schirmer observed that 1lie new formed vitreous lamella behind the cicatrix increased in thickness \\ itli tlie age of the capsule, and to a degree equal to that of the surround- ing true (•a]»su]('. At the same time the everted edges of the ruptured cap- sule appi'ared continuously to decrease in thickness. This, he concluded, must be a physiological process. In order to gain more accurate data as to the rapidity of both this increase in tliiclaiess. and tlie diminution in thiclvn«>ss of the outer lamellae, he measured all tlie cicatrices produced in his experiments on animals, also the new lamellae. He estimates .Tnlia Sinclair's (Experimentelle T'ntersnchunjren zur Genese der erworbenen Kapsel cataract. Inaug. Diss Zurich. 1876) measurements as un- doubtedly too large. The anterior capsule e(iuals 0.022—0.0.30; whereas his own measurement of normal capsules of small rabbits at anterior pole e»iual 0.007.5 — 0.009 mm., and in a large rabbit 6.J years old. equals 0.018 mm. In the fol- lowing table the relative thickness of capsules is taken as one. and though some slight errors may exist, tlie general results can not be entirely ignored. They show that tlie thickness of the new lamellae steadily increases with the age of the cicatrix, whereas the old lamellae steadily grows thinner. Further, tlie in- crease is greater in the beginning than later on. and similarly, the old lamellae diminish more rapidly in the beginning than later on. Age of the Cicatrix. weeks 10 ^Yz months. (5 ]0>4 " ;^ years. 3 " " £ntirh Cai'SULE. 0.028 0.0094 0.0188 0.012 O.OOW 0,01 ];? o.oist? 0.013 0.034f) 0.013 Absolute Thickness. Old. New. Punctured with a Dis- ci.sion Needle. 0.026 mm. 10.002 mm. jO.0177 " 10.0017 " Punctured with 1 a Knife. 0.0155 mm. 10.0033 mm 0.009 " 0.002 " 0.0004 " !0.003 O.OOHI) " 0.0047 " 0.0117 " 008 " 0.0065 " 0.00(55 " 0.0075 " 0.030 008 " 0.035 " Relative Thickness. Lamellae. Old. New, Punctured with a Dis- cision Needle. 0.93 mm. j 0.07 mm. 0.82 " ! 0.18 " Punctured with a Knife. 0.82 mm. | 0.18 mm. 0.75 ". : 0.25 " 0.69 " 0.32 " 0.59 " 0.41 0.60 ' ' 0.40 0.50 " 0.50 0.20 •• 0.80 0.19 " 0.81 Schirmer says: "Either the anterior surface of the cajisule undergoes a steady resorption, or it undergoes a steady shrinkage: liem-c. every ca])- sular lamella whicli is excreted witliin a certain lengtli of tinu", in its turn, with advancing age. becomes thinner." Tlie lii'sl supposilion rec|uires that witliin a certain periodoftime, a certain (|nanlity of caiisulai- suhstanceshould be restored, and in a conlinnoiis and icgiilai- manner, niiiil linally it in turn entirelv disappcais; bul lliis can nd l>c proven, 'i'lie theory of shrink- (ii. proven where fine sec- tions of fresh capstde. obtained by the freezing microtome, were exposed to the digestive process. Jii both alkaline and acid solutions the capsule invariably turned up outwardly, and it was iuij)ossible to be mistaken, the epitheliuiu being an accurate guide. During this process of digestion, he ob- served (under high powers of the microscope) exceedingly fine and closely arranged striations. running parallel to the surface, in the beginning con- fined to the innermost portion of the ca])sule. Gradually minute inter- spaces began to develop in the inner lamella, due to se])aratiou of the mi- nute lamellae, and this process gradually extended more antei-iorly. After a time these interspaces grew so coarse as to give the impression of a verita- ble network, and thus slowly the inner layers were digested before the outer were affected by the digestive i)ower of the t^py^^in. Similar pictures were obtained by placing the capsule in nitric acid, and then heating wth per- manganate of potash or lime water. This also will explain the figures which Bobinski ^^ observed on surface preparations treated with nitric acd, and which he described as ''L'Capsule Corpuscles." and as analogous to those found in the cornea. E. Bergeri^ demonstrated the lamellar construction of the lens cap- sule before this time by a difterent method. He satisfied himself by "teas- ing" the capsule, and by maceration in permanganate of potash, that the torn edges are not like straight lines, but zig-zag or step-like, lie observed that we must distinguish at least three lamellae, although many sections led him to believe that there were more. Schirmer states that he got his best results after macerating for several days in a one-tenth ]>er cent, solu- tion, or in a ten per cent. XaCl solution. He succeeded in this way in dem- onstrating at least five lamellae, and does not coincide with Ik-rger's view that the outer lamella is a zonular lamella. He says: '•Certainly the zonular fibres are only attached to the outer lamella, since they can be followed for 18 Tntersuchnnsen ubor die Au.c;on llnsenkapsel. Berliner Klin. Wochen- schrift. ISSC. Bd. No. 12, p. 71. 19 Bemerliungen uber die Linseii Kapsel Ilirschlterjr's Contralblatt fur Prak, Augenli., 1882. Beitrage zur Anatoniie der Zonvd:i Zinni. iiraete Arcli.. 1882. Vol. XXVIII. Alth. 2. p. 28. 46 a certain distance into tlie substance of the capsule; but this is not a rea- son for looking upon it as something essentially different from the other lamoUac, and it does not seem justifial)le to attribute to it a different struc- ture. \']\vn Meeker-^ states tliat "he iiever succeeded in determining by a striation the exact point at which the the zonula fibres are inserted into the capsule." "Hence, if we must abandon this view, the other two lamellae can demand no further consideration as preformed structures." Schirmer looks upon the nuicoration experiments as pointing to the same conclusions as the digestive experiments; namely, "that these delicate lines indicate a previous solution of continuity, or that the epithelium, as tlie result of some external iniluence, has suffered a serious interference in its excretory power, of which these lines are an expression, and that these lines move more anteriorly the longer the time since the injury. Disturbances, as per example a wound, the formation of a capsular cataract or a widespread de- generation of the epithelium in consequence of a contusion, lead to an ir- regularity in the disposition of the excretory substance, the optical expres- sion of which, on cross section, is fine lines. The older a lamella of cap- sular sul)stance becomes, the more these irregularities sink in the back- ground, and the entire capsular substance forms a compact mass, and it is only after long reaction by the above method that these striations are dis- closed. This explanation excludes the assumption of a chemically different lamellar cement substance." Schirmer does not attempt to give the causes for these irregularities in the life of the epithelium, but suggests that it is a continuous process, repeating itself innumerable times, like the alteration of day and night, or sleeping and waking. He says he has observed not less than seventy-five lines in the inner fifth. The capsule also has the property of elasticity. Even Becker drew at- tention to tliis. in cases of luxated lenses, stating "where the equatorial diameter of the lens is reduced, no folds appear." As the lens grows, the capsule, which originally encompassed a smaller space, increases in size by expansion, and adapts itself to a greater surface. Even after the lens has attained its full size, the individual capsular lamellae as they are pushed forward expand, since the outer surface of the capsule is greater than the inner. This curling up outwardly of the capsule is an expression of dif- fei-ence in Ihe elasticity of the various lamellae. Tlir cheinical conditious of the ])osterior ca]isule are siuiilar to those of the anterior. Schiniicr r»'ii<)rts mii intcicslinf;- (-aso. in which :i iiiuce of tlii> :interior o:ii)sule 20 Anatomie, p. 43. 47 ■was i'Xlract«'d lliiv*' years lu-fore tlu- I'xaiiiiualioii. In iliis h-ns ho foimd a wound of the posterior capsule, which the coudltlons present led him to believe was an old one, dating back to the time of the operation. Here he found no sijrn of new formed posterior capsule, nor had cicatricial tissue formed, there beinji: no epithelium coveiinj; posteriorly. At tlic present dav the Zonula of /inn is generally conceded to con- sist of a system of nicridianally placed lil)res. which take their origin in the vitreous lamellae, which cover the par> ciliaris. ihc ciliary body and ita processes, as far forward as to where these latter go over to form the root of the iris. The fibres are made up of innumerable, very fine and exceed- ingly delicate fibrillae, wliich arc iiitc ilacc(| in the most complex manner, and it is this intricate structure which forms the suspensory ligament of the lens. It is no longer looked upon as a membranous formation, con- sisting of two plates enclosing "Petit's Canal;" hence, this latter has lost its identity, and is now looked upon as a part of the posterior chamber. Henle 21 believed that these fibres were held together by a cement substance, which could not be demonstrated after death. But as Czermak has so aptly remarked, the interspaces between the fibres are everywhere much wider than the thickness of the fibres, and further, no sign of a membrane has ever been observed under the microscope; therefore, he considers thia a network and not a membrane. Secondly, if the fibres w^ere held together by a cement substance; does it not seem strange that it should disappear so completely, especially since cement substances everywhere else in the body are acted upon entirely different by hardening fluids; as, per example, the neuralgia which becomes hardened? Czermak (page 28) has done more to elucidate this subject than any other investigator.22 He describes the origin and insertion, in substance, as follows: "The delicate fibrillae take their origin in the ^dtreous lamellae, and run together like pencils of rays to form coarser fibres; these in their turn form bands, and in their course, as they proceed toward the capsule of the lens, they give ofl' to and take up fibrillae from neighboring bands, so that the bands do not grow smaller. The points of origin and insertion vary. They begin to develop posteriorly about l.-") mm. from the orra ser- rata, and as they proceed forward they form acute angles, the convexity of the course facing anteriorly: but before the fibres reach the ciliary body they begin to split up again, some of tlie fibrillae inserting themselves again into the vitreous lamellae of the orbiculus ciliaris; others proceed onwaixl, insert themselves into the vitreous lamellae covering the ciliary body; others 21 Handbuch der Anatomie. 1866. 22 Zur Zonula frage Graefe Arch., Vol. XXXT. B. T. 18S5. 48 again go to the ciliaiT processes, while tlic niiijority pass onward to the capsule of the lens. At the same time fibrillae originate along' all theso respective parts, each in its turn sending out fibrillae to neighboring parts and to the main bands, which are on tlieir way to the capsule of the lens. This explains why it is that on nieridianal section one sees fibres crossing in all directions. He has divided these fibrillae into three groups:"' First. Those which spring from the orbiculus ciliaris and from the ciliary body and extend to the anterior and posterior capsule of the lens, the OrUcvlo and Cilio Capsular Fibres.'' "Second. Those fibres which spring from the orbicularis ciliaris and again become inserted more anteriorly; others again wliich insert them- selves into ciliary processes, the Orhinilo Ciliari/ Fibres." "Third. Those which spring from the interspaces lietween the ciliary processes on their w^ay to Join others, and those which extend from one ciliary process to another, the Inter and Intra Ciliary Fibres.'' Hence, each of the coarser fibres contain fine processes from each oC the other varieties, more especially of the first two, whereas the forme- give off' the fibrillae to neighboring bundles. Thus a most intricate and perfect network is formed. As the fibres approach the lens, they again split up into the very finest fibrillae, which are gradually lost as they be- come merged in the outer lamellae of the capsule. A partial crossing of fibres takes place, some of the most anteriorly situated giving off fibrillae which go to the posterior surface of the lens, and vice versa. The fibres have peculiar sharp contours, are smooth, and appear like hyaline or glass threads." Not alone do these fibres form a suspensory ligament, by means of which the lens is supported in its proper position and relation to neighbor- ing parts, but owing to its peculiar construction, it exerts an equal degree of tension in all directions. This network of fibres is the intermediate member which ])crmits of the, })roper inci'case or reduction of tension dur- ing the act of accommodation. CHAPTER III. THE PHYSIOLOGK AT; IJl^TROGKESSION Ol-; THE LEXS AND ITS ELEMENTS. The phenomena and changes which take place during the physiolog- ical retrogression of the lens, are not I'cstricted to any special period. Strictly speaking, they begin as early as the third ])t'riod of foetal life, and undoubt- edly can l)e demonstrated as soon as physiological growth begins. They take place in tlu' cells as well as in the fibres. They are subject to the same 49 laws, as art' tlu- (^|)iliiclial crlU ol' ihc ~kiii and iiiii((iii> iiicinbraiies, which likewise, in iiit raiitei-iiie life. Idse their iniclei. are east olV aiul are I'ound in llie veriiix (•ase()>a and aiiiiiiolie lliiid. In llie lens, however, since the capsule is a closed sac. the cells are not east oil'. l)ui (juite the contrary, the young growing fibres press tlie older ones toward the center. There they are subjected to various physical and chemical changes, which lead to the formation of a nucleus and the cortex. As soon as the intelligence of the child is siitruiently developed to permit of making the ])roper experiments, it can l)e shown that there is a gradual decrease in the accommodation, wiiich is a functional proof, that a ])rocess of hai-dening is going on in the center of the lens, whicli influ- ences the power of the lens. These changes in the lens are of a chemical. ])liysical and morpho- logical nature. The MORPHOLOGICAL changes have been the subject of the mo^t exhaustive studies, and have been most beautifully described in the so often quoted monograph of Henle. His examinations have been made amongst all the various classes of vertebrates. In reptiles and birds and most fishes he found that the fibres gradually diminish in width. In other classes he found that the width of the libres gradually diminish from with- out inward, but this process does not proceed as regidarly as. in birds; and aside from this there is frequently a reduction in the number of fibres, ow- ing to the gradual merging together of entire rows. In his observations on the len^ses of man aiid many animals, Henle ol)sevved ^ that the fibres could be divided into three groups. ''Whereas, as a rule, the fibres dimin- ished in size towards the center, there is pushed in between an outer and an inner layer of prismatic fibres, a layer of ribbon-like cells, so that at some distance from the perijjhery. the thickness of the fibres is considerably and rapidly reduced, and then again as they ap])roach the center again in- creased." Henle looks upon this as a constant condition found in the len^ of man, and states that "it is not the result of an irregular growth, but due to subsequent alteration in the full grown fibres." But he gives no reason for such a regular condition. Xot only the width and thickness of the fibres diminish, but the edges a])pear serrated. If we were to peel off layer after layer of an adult lens, until it were reduced to foetal size, one woidd expect to find all the fibres resembling those which are on the surface of a foetal lens: this, however, is not the case. Even in the foetal lens one meets with the same successive changes as observed in the mature lens. According to Henle, these serrated edges fit into those of neighboring iZur Anatoniie der Krystalline. p. ;VJ. (Jottingon. 1.ST8. 50 cells and those serve to hold the individual layers together. He supposes that these serrations are outgrowths from the fihres. Becker suggests that this is rather an evidence of the death of the cell corresponding to similar changes in the cells of the Kete Malphighi of the skin and in the corneal epithelium, in which the younger cells rarely or never show any signs of serration. This seems to indicate that these serrations are due to shrink- age. It has been proven that as we proceed towards the centre, the cells diminish both in width and in thickness, hence what wotild appear more natural than that these serrated edges are the result of shrinkage of the fibres. DEATH OF THE XUCLEI OF THE LEXS FIBRES. As has already been stated, as the cells elongate along the equator, the nuclei also gradually change their shai)e from the circular to the elip- tical. They become longer and flatter, so that it does not become necessary to assume an increase in the volume of the nuclei. The form and size re- mains about the same in all grown fibres. They all show tJie karyokinetic changes when preserveil in the proper fluids. As we proceed towards the centre, the structures begin to fail. The chromatic substance runs together into one or more clumps, until finally it entirely disappears, lentil the fibre has attained its full length the nucleus retains its life-like appearance. Bui as soon as a fihre extends from one ratlins of the star figure to another, the nucleus legins to shoio signs of death. This can be observed in the lens of the new-born infant, and is true of every ])eriod of life. THE PHYSICAL CHANGES which tJie individual (iln-es undergo with increasing age, consist of an increasing hardness and yellowish color, and an increasing index of refraction. The hardness becomes manifest by the resistance ofl'ered to pressure when a specimen is under the cover glass. The yellow color becomes evident when a number of lamellae are super- imposed one upon the other. All these changes are due to the giving up of water, leading to greater dryness and friability of the inner layers, partly however, also as a result of chemical conditions of the older fibres. That there is a ehcniical difference between the inner and the outer portions of the lens seems to be attested by a fact which, though known for a long time and frequently discussed, has been variously accounted for; namely, that in the lenses of all vertebrates and young animals which dur- ing life have been ])erfec11y transjiarejit, immediately after death, as soon as the animal jjecomes cDld, the inner portion of tlu' lens becomes cloudy. Michel 2 drew attention to the fact and showed thai the cloudiness in the 2 "Uber naturliflu' uiid ktinstliclic Liiist'iitiul>un.ineuV" Ft>stschrift znr Feier des 300 Yaliri.iffii Brstchcii dcr .Iiiliiis Mnxiiiiilius UniviTsitatc zur Wurzliurg, 1S82. 5' colli IV of the Ions of oats, ])iK>. inid oalvo.-, would (li>n|)|.oar again if they wore v.arniod up to L", to 20 do.uroos C. This could bo repeated a>; often as desired, and each time the lens would clear up again. This cloudiness is produced by the presence of innumerable roundish, highly refracting droi)iots in the central portions of the lens, and is not in any way <-on- nectod with the decomposition of the contents of the lens, such as is pro- duced by freezing (/. c, p. ()2). In these experiments there can not ari^e any (luestion as to the separation of the water from the albumin. These droplets become less numerous as we go from within outward. Treated with alcohol and ether, their number becomes less, and they are reduced in size. Hence it appears that they must consist of a fatty substance, which has a very low melting point, though it is impossible to state anything more def- inite at this time. The interest which the appearance of these bodies at h low temperature arouses is duo loss to their })rosenco than to the fact that they occur in the inner lamallae of the lens, that their numl)or varies in different species of animals, and that their deposit ceases a few months after birth. From this ^t follows that in the chemical formation of the lens, especially in the older layers of the same, very pronounced changes take place. Since, according to Kuline and Laptschinsky. the amount of fat is greater in the old than in the young, hence it can not be due to a quanti- tive but rather to a qualitative, change. Various authorities have drawn attention to the fact, that the,?e de- scribed changes in the lens keep pace with the physical and morphological changes which take place from the center toward peripheiy. Some of the pecuharities of the peripheric lamellae are in accord with this. From year to year the nuclei in the nuclear zone become less numerous; the nuclear zone comes loss near to the axis, its curvature grows less; in other words, the number of smooth, non-changod lens fibres which roach to the lens star, grows less year after year. In the capsular epithelium the cliangos (\\\q to the age are less marked, luiuinu'rablo moasuroments have shown that the diam- eter of the base of the oi)itlielial cells remains almost the same during life, at least as long as thoy rolain tlioir sliapo. Xot so. however, with the height of the cells. Beginning at a point corresponding to the pole, the ])ase of the coll gradually grows loss, whereas at the begin- ning of the whorl the cell is about three times as high as it is wide. In course of time the height of the cell at the pole, as well as along the equa- torial region, gradually diminishes, and sections taken from very old people show the height of the cell to be that of the niulous. whereas the protoplasm between the nuclei is shrunken to an almost immoasural)le thickness. In 52 some sections some of the luu-lei ;ire round wanting and some cells ai-e en- tirely -wanting. Xothing conld he moi'c wonderful than the regularity with which the perfectly circular. O.UO.j mm. in diameter nuclei are found in the epithelium dispersed over the capsule of young lenses. Examinations of unstained spcciiiit'iis show iK-nutifully the nndcai- fij;ures at rest: whereas staiiunl witli Ilaciiioti.x.vliii and I-:(>siii. tliese liiiiires show less distinctly: with .Vluni ("ni-niiu lliey are somewhat more distinct. The (nitlines of the cells are likewise more distinct in the unstained sections. The proto- plasmic bodies touch and limit each other, as most exact liexagoual figures. In some exceptional cases tlie contours of the cell bodies take the stain as do the nuclei, reminding one of Arnold's "indigo-carmin ledges." Wlien the stain- ing is done rapidly witli a concentrated Haemotoxylin solution, some of the nuclei take on a darker, more pronounced stain tlian others. These always are a measureable trifle longer than the paler nuclei, or they sliow a tendency to form star figures. Fre(iuently tlie nuclei, in the vicinity of one of these darker cells, form a circle around it, or the dark nucleus appears as the head of a spiral whicli is formed on succeeding 10-15 nuclei. As a result of this ai'- rangement the surface of tlie capsule covered witli tlie epithelium assumes a perfectly regular, almost life-lilve appearance. It is more than proijal)le that these nuclei, which take the stain more deei)ly, were just al>out to undergo nuclear division at tlie time the sections were placed in Muller"s fiuid. .\s we approaeli tlie eiiuator tlie niU'lei grow smalli'r. ai'e jiacked closer to- getlier, take the stain more deeply than tlie surface preparations. In older in- dividuals Hearing the fortieth year, the picture changes, in so far that the deeply stained cells grow less in number, as do also these peculiar circles and spiral figures. From noAv on tlie distinctly stained nuclei and cells grow less and less, but never entirely disajipear. In extreme old age it often happens that on pieces of capsule the epithelium is found wanting for certain distances; here undoubtedly either the epithelium remained adherent to the lens or dropped off during the manipulations incident to staining, dehydrating, etc. " AVhere cap- sules hai-dened in :Muller's fluid are sliaken in water, whole sections of capsular epithelium may lie detaclied, ;nid liere frequently tlie capsule sliows the im- pressions wliere tlie cells w<'re adherent. Tliis is due i>r(>l>:ihly to the cement substance of the ejiitliellal cells, 1 »eu1schm;urs subcaiuilar layer, which has re- mained adlierellt to tlie ca]>sule. Again, here and there, cells are found wanting or changed into \'esicular Cells. At times Iliey form veritable nests. It is remaiUalile how little coloring matter is taken up liy llie nuclei of tlie cells and by Ihe c:ii)suie. irres]iective of .■ig<'. .Xevertlieless, Die nuclei tjikc uji Ihe st;iin in a more regul:ir manner tlian do these distended cells. If tliese latter .-ire to he looked upon .-is dying or de.-id cells, then we mu.st accejit :i second v.iriely of death of the nucleus. In other sections, at tinii^s one Muds large numliers of nuclei Just about to die. just as noted ill tiie lens tibres. ,\g:ii]i. one notes cells of ihe cajisular epithelium which arc still pcrfoct in contour, showing: nuclei un-catly rcihiccd in volume, and which take the stain <1.m'i»1.v. as noted in tihres in wlij.li tin- nuclei :ire just about to disappear. CIIAPTHli IV. TIIK IMIVSiUl.()<;Y OK Til JO I.KXS SVSTKM. THE M'ANXER OF ITS XOUKISHMENT IN IIK.M/I'll AXD DISEASE. TIIK DIRECTIOX AXD COURSE OF TIIK XUTRITIVE STRF.\:\[ IX TIIF EEXS. Tlie 1oti.< is ciKloscd in a structure- less meiii1)raiie. wliicli under normal conditions, is not permeabk' to formed elements. Fntil near tiie close of embrj'onal life, a vas- cular membrane is closely applied to this structureless capsule. Be- yond a doubt, the vessels of tliis membrane serve, during the developmental period, to supply the nutritive material to this hyperplasia and increasing,' growth of the cells and the fibres within this capsule. After tlie degenera- tion of this vascular capsule, we are confronted by the peculiar condition, namely, that the lens is only indirectly, by means of the zonula fibres, held in connection with the firm portions of the eye. And, further, since the zonula fibres contain neither nerves, blood vessels nor lymph-channels, the lens must receive its nutritive supply either from the aqueous or vitreou.=, possibly from both. These media likewise possess neither nerves nor blood vessels. It is just possible that the iris stands in relation to this interchange of fluids, since the pupillary edge is merely separated from the anterior capsule by a capillary layer of fluid. Such being the conditions, the question to be determined was, along which lines does the nutritive fluid gain entrance to the lens? In his Pathologic and Therapie. p. 2ru, Becker expressed his belief that "the nutritive stream gained entrance in the equatorial region, between the two leaves of the zonula, because pr()l);ibly along this line, under normal circum- stances, the new formation of cells and ])ositively the growth of fibres ^'progressed most actively." Deutschman ^ investigated this subject more closely. He gave a rabbit one gnu. of pot. iodide in solution and three hours later killed the rabbit. The lens, enclosed in its capsule, was placed in a palladium-chloride solution and was proven to be impregnated with the pot. iodide and most intensely along the sub-capsular albuminous layer of the posterior ca])sule. as well as along its entire eijuator. to a less degree 1 Cataracts Senilis, 3879. Graefe Arch.. Bd. XXV. L'. p 54 the siib-nipsuliu- layer xmdev The anterior capsule, but disclosed no sign of impreo-nation in the nucleus or anterior corticalis. Here should be inci- dentally menlioned tliat he- also observed that if he opened the lymph sac in salt-water frogs and in this lymph sac placed crystals of chlor natrium, the cataract which resulted was due to the extraction of water. Hence Deutschnian considered it as very probable that the nutritive stream entered along Petit's Canal. Ulrich ^ arrived at the siime conclusion as the result of the following experiments. He injected ferro-cyanide of potash sub-cutaneously and subsequently placed the eyes in a solution of chloride of iron alcohol, lie states: "The line along which the ferro- cyanide of potash gained entrance to the lens could only be detected by the stain along the line of the equator; the posterior capsule of the lens re- mained unstained. The experiments which Schoeler and Ulitlioff mada according to Ehrlich's methods^ by using fluoresein, led them to gven a more advanced conclusion, stating, "Under physiological conditions (by sub-cutaneous injection) the fluid reached the equator of the lens, ex- clusively through Petit's Canal. Xever, however, does the fl.uid go directly through the vitreous to the lens. Further, the colored fluid which has once been taken up by the lens is never given off again througli the vitreous." Samelsohn came to a positive opinion as to the line along which the interchange of tissue fluids occurs, by observing the changes which took place in three lenses, in each of which a minute spicule of iron had become impacted in the lens. In all of these he observed that the particles of rust always changed their position in the same manner. In summing up his conclusions, he states,^ "It appears that the principal direction of fluids i>i directed from behind forward and on reaching Petit's Canal becomes 'dammed up' (Ulrich) along this line: it also gains entrance to the lens along the lino of the equator. I'rom here on it traverses the entire lens centripetally and comes together again at the antei'ior pole; from here it again goes out centrifugally toward the insertion of the Zonula fibres, where it leaves the lens and enters the posterior chamber." Along the line where the nutritive fluid is supposed to leave the lens, Samelsohn assumes the presence of special pores in the capsule, which offer 2 Deutschman— riitcisueliungou zni- rathogenese dor ('ataract. Arch. f. Ophthal., Bd. XX 11 1, p. 117. 3 Uber die Kninln-uug dcs Angcs Cnicfc's Arch.. Bd. XXVI. ?,. p. ;'.:^-82. 4 Das Fluoresein in seiner Bedoutinig fur den Flussiiilvcitswccliscl dos .\uges, Yahresbor der ScholtM-isclien Augon KJinik, 1S81. 5Zur Fhissig-kcitssln.inuiig in dcr Linsc Zclicnd.Ts Mon.Mtshl.. I'.d. XIX. p. 282. 55 the least j)ossil)lo liiiulraiiee to the I'scape of the used lliiid uliirli. Iiuw- ever, are not sufficiently wide to jiermit the passage of formed elements. The pores are the same as those which Morano *• believes he saw, l)ut which no one else up to the })ivsent time has seen. riilricirs ("Stauuii,i;s thcoi-ic") "(laimiiin^- hack" tlicorv.'^ on which Saniclsohii ])ascs hi> slatciiicuts. reads as foHows: "'rhc most intense hhio color of the vitreous (and in fact the most intense in the entire globe which can be attained l)y the use of sub-cutaneous injections of ferrocyanide ot potash) develops in the region of the ecpiator of the lens. The liltration of tissue fluid out ol' the vitreous proceeds from tiie vitreous honler into Petit's Canal aiul on reaching its anterior wall it again meets with a de- taining filter, the free portion of the Zonula of Zinn, which likewise shows a blue discoloration. As a natural result of the placing of two parallel filters in the region of the equator of the lens, there must naturally follow a damming back of the streams of fluid. This detention is more favorable to the nutrition of the lens, since it takes place at the eqmitor, where the space is very limited, and, further, since the iris, which will receive further consideration later on, acts as a third i^arallel filter." Without going any further into Uhlrich's views concerning the individuality of the posterior chamber as compared with the anterior, and his views concerning the passage of fluid through the iris from behind, forward, it is nevertheless proper to refer to the investigations of Deutschman,^ in which he states "that in a certain sense, or under certain conditions, the iris acts as a pro- tective organ to the periphery of the anterior surface of the lens." In all that has so far been stated, attention has only been drawn to Those experiments in Avhich coloring matter was given the animal, either per os or subcutaneously. Only these seem to possess demonstratable proof. But this is not the only reasons why Knies' investigations have not been cited before this. In his critical studies relative to the Nutrition of the Eye lo he arrives at anatomical conclusions, with whicli Becker does not agree. Knies states (page 340*): A form of cataract which begins in the Equator shows to us as a neces- sity that there is an affectation of a portion of the Uveal tract, which is situ- ated anteriorly to the Orra Serrata and posterior to the anterior lamellae of the Zonula of Zinn, namely, of the pars eiliaris choroideae and the processes ciliares. einterno agli stomi dell end otlialio della capsula del cristallino Atti dell associar. Ottal Ital Rianione di Napoli, Settembre, lS7i>, p. 61. 7Uber die Ernahrung des Auges. Graefe's Arch., Bd. XXVI. 3. p. 41. 8 Die Veranderungen der I>inso in Eiterproceoson im Auge. Arch. f. Opth., Bd. XXVI, 1, p. 144. 9 Becker says, page 92. 10 Arch. F. Augenlieil-kunde, Bd. VI 1. p. 320. 56 Tliis is true of the ordinary senile cataract, and at the bottom of pajre 341 he says: "Let us consider the lens and ciliary processes as far as the nutrition physiologically is concerned as a single organ, etc." These ciliary processes, however, are external and anterior to the Zonula Zinii, and the latter is be- tween the ciliary processes and the e(iuator of the lens, which even Knies concedes to be the line of entrance for tlic nutritive stream of the lens. The ciliary processes form the secretory organ for the ;i(iutM.us humor. .Mud. as it appears, have nothing whatevci- to do with the nutrition of the lens, or at most only secondarily. Becker, in his essay on the nuclear zone of the lens, drew attention to a heretofore not mentioned condition of the lens capsule of youthful individuals, wliich he tries to l>ring in conui'ctiou with the entrance of nutritive fluid. He states: "The capsule is materially thickened at a particular point which lies posterior to the Equator." I have formerly observed a similar thickening of the capsule in secondary cataracts, which I also attributed to this swelling, and which I have attempted to bring in connection Avith the rapid increase in the size of the cells during the formation of the Crystalline Pearl. This would seem to indicate that the abnormal conditions which had resulted from an operation had caused an especially active nutritive stream to pass through the capsule, and thus cause the capsule to SAvell up. It is possible that analogous changes could occur in uninjured, rapidl.v-growing lenses, but as to whether this change takes place during life must remain an unanswered question. Assuming this to be a post mortem swelling, occtirring after the specimen has been placed in harclening fluid, this observation Avould not be without interest, since one is justified in concluding that a different condition existed in the capsule at this point, even during life. "This point of thickening,"" he states with great cer- tainty, '"is j)osterior to the i)()sterior limit of Petif s canal." How long after birth this peculiarity of the capsule of the lens i»ersists. and whether it is in any way connected Avith the retrogressive formations of the vascular capsules of the lens, I can not state, owing to lack of available material. It was still per- ceptible in the capsule of a seven-weeks' old child. Even in fully developed cataracts one ma}^ demonstrate the existence of a nutritive stream. This was proven long ago by the beautiful experi- ments of lienee Jones ^^. In a number of experiments on animals to whom a large variety of substances were given via the digestive tract and by sub- cutaneous injection, at a later date he deiuojistrated beyond a doubt tlieir presence in the lens. TJkewise. in a number of experiments on human beings and animals, whicli were given carbonate of lithia, in a few minutes this could be found in every part of the body, but it required thirty to thirty-two minutes before it appeared in the lens. Cataract patients to 11 Proceedings of the Tloyal Institute of ({real r.rit:iin. Vol. IV. Part VI, No. 42, October. 57 whom 'iO ui'iiiuiiics of lilliia \v;is jiivcii in Wiilci'. niid w lio wci-c hilcr operated on by P)o\vma.n and Critelictt, llic lilliia was loimd in cvci} |iai-t of the lens, when the extraction was done Iwo and a lialf to three hours after ihe infjestion of tlie lithia water. Allei- foni- (hiys lilliia was still found in all parts of the lens: after live days it het^an izradiially to disappeai'. and after seven days it was scarcel\ pos>il)le to denion>lrate a trace of lithia in the extracted lens. The attempt has heen made to prove by this and a W'w iie<;ative experi- ments, that the interchange of nntritive fluid is an e.\ceedin>:ly slow one. Ulricli has, as it appears with jierfect j'ight. di-awn attention to the fact that this conclusion is not Justifia])le. if one will only sto)) to compare the nutritive conditions of tfie non-vasculai- lens with other vascular tissues. Schlosser '- looked upon the spindle-sha|)ed intersiiaces around the nucleus of the lens as a veritable system of lymph channels. His investiga- tions were all made where pathological conditions were present, and, as we shall see further on, these splits are a pathological production and therefore invalidate his conclusions. He states. "In the normal lens these peri- nuclear spaces are few and very narrow, whereas in cataractous lenses they are widely dilated." "The spaces," he says," follow the direction of the iibres." He bases his conclusion on the above-quoted views of Samelsohn, stating ''that the nutritive stream enters the lens along the equator, thence proceeds to the center of the posterior cortical substance and to the posterior star figure and reaching the peri-nuclear canals, flow toward the anterior star figure, finally converging toward a circular area l)eneath the anterior capsule," which he considers the line of exit. At the time the Xaphthalin experiments were first ]u"actieed. it was hoped that they, by the pathological processes which followed in the lens, would shed some light on this still interesting question.- but this hope has not been realized. A large number of investigations were made by Bouchard and Chnrrni}-- Paniias}'^^ Dor}^ ('. Hcss^^^ Mdi/iiiis.^^^ Kol- Unshi,^"^ and Prof. Hugo Magnus. i-"^** The last named concluded that the 12 Uber die Lymphbalnien der Linse. Munclieiier Med. VVochenschrift, No. 7, 1889. 13 La semanie medicalle. 1880. No. .",2. 13a Ktudes sur la nutrition de I'oeil dapres des exiuTiences faitos avec la flourescine et le Napthalin Arch. Opth.. 1887. Mars Avril. 14 Bulletins et memories de la societe Francaise d Optli. 1887. p. 150. Ha Berichte idier llttli \'ei-saiuluuK der Opth. (Jes.'l. Hci(icll)erjr. 1887. lib Therapeutische .Moualschi-ift, October. 1887. 15 Zur lehre von der Wirkins des Naplialins nwf das .Vnuc uiid uber den Sogenanten Napthalin staar. r.raefe Arch.. XXX\'. H. L*. issii. 15a Experimentelle Stndien niter die lOriialiniui;- der Ki'ystalline uiid uber Cataract Bildung. 5« nutrition of the lens could be interft'ivd witli as the result of interference wilh the eirculation of nutritive iiiiids in tlu' leus or l)y clianges in the ehemieal condition of tlie nutritive fluids of tlie lens. Ife concludes "(1) that the nutritive ])roeesses ) The e(|uator of the lens itself does not take u]) a separate nutritive stream, but is dependent on the two zones anterior and posterior and removed from it. (7) The manner in which the nutritive fluids escape from the lens is still unknown." THE PHYSICAL CHANGES which the lens undergoes as the indi- vidual advances in age. and under pathological conditions, affects its vohni/c and ircif/hf. its hardness and dn/ness, its r(dor]pssness. its transpa- rriici/. and it.< iitdox of refraction. The gradual increase in iveight and volume is a necessary result, due to the continuous formation of new fibres at the equator, which, under normal circumstances, is scarcely ever interrupted, even up to advanced age. Thi? is beautifully illustrated in Priestly Smith's table on page 31. The exce]> tion to this rule he found in lenses which began to show even slight cata- ractous cloudiness. Having weighed these with especial care, he found that at the beginning of the process the cataractous lenses had a reduced volume (and weight) as compared with non-cataractous lenses of the same age. Therefore, we are indebted to Priestly Smith for the valuable knowl- edge relative to the study of the cataract, namely, that a reduction of volume precedes the formation of calaracl. Owing to the giving off of water from its innermost lamellae, and which process gradually progresses toward the periphery, the lens becomes dryer and harder from within outward. Nucleus and cortex are prin- cipally difl'erentiated by this difference in hai-dness. Loss of colorh'fut Becker states that he has not been able to find an experimental demonstration of the fact that the difference in the index of refraction of the individual lamellae of the lens is less. Priestly Smith ^^ gives a different explanation' of this reduction of re- fraelion in the aged. He states: "The continuous growth of the lens suf- ficed to explain the acquired hy]>ermeiroi)ia of old age, witlKuit assuming that the lens changed its form. 16 Donders— Anomalies of Refraction and Aooommodatioii. 180(5. 17 Growth of the Lens. Mod. Times and Gaetto. .January 20. 1883. 6o This subject has ivci-ntly been investigated by L. Heine.** He used the eyes of liimian corpses, in which the refractive conditions were deter- mined by skiasopy before death. Subsec^uently, he found that the radkis of curvatiire of the anlei'ior surface of the lens had not changed; but, on severing all the zonular fibres, the radius of curvature at the anterior pole was increased to such a degree, that the radius in the latter condition was to the former as 6 to 10. Similar experiments in old people did not show an increase in the radius of curvature. In the eye of a corpse the radius of curvature at the anterior pole of the lens is 13 to 14 mm., whereas, after severing all the zonular fibres, the radius is reduced to 8-10 mm. In determining the index of refraction of the lens, an Abbe's refracto- metre was used: and the estimates were based on Matthiessen's ^^ general formula, that the tofol index of refraction of a lens, consisting of equally centric lamellae, is as much greater than the index of the centre of its nucleus, as the difference between the latter and the index of its cortical substance. In other words, the total index of refraction is obtained by find- ing the index of the substance at the anterior pole; also of the nucleus; and adding the difference between the two to that of the nucleus. The index of refraction found in the lens held tense by zonula fibres was looked upon as the ?ion-accommodating lens; whereas, with all fibres cut, this was con- sidered as the accommodating lens. The index of refraction of substance obtaiued at iuiteriov i)()lf 1.390—1.395 Tlie index of refraction of isolated accommodntiug lens 1.380—1.385 The index of nucleus 1.408—1.410 Estimated from these figures: The index of refraction of entire lens during act of acconnnodatiou. .1.435—1.440 The index of refraction of entire lens at rest 1.42.5—1.4.30 iVs long as the zonula is held tense, an albuminous body is found at the anterior pole of the lens, which has a lower index of refraction. This produces an increase in ihc total index of refraction. As a result, during the act of accommodation, the refractive coiulition is in part covered (1-3 D). The change in the coutour of the lens is. nevertheless, the main factor in producing an ahered relVai-tive condition. It was noted that the older the individual, tlir liiglicr the index of re- fraction at the anterior jioh — the values gnulually iiureasing fnuu 1.395 to ].I0."). The index of the nucleus likewise iiu-reases. hut not to such a aKeitrage /nr rhysiologie und I'.ithologio der Ivinse. Graefe Arch., Vol. XI.VI. Part 3, r. 52.-.. 189S. 18 Zehender. Matthiesen and .Tacobson. IJber die Breehuugscoetficient Kat- aractoser Liusen substanz. Zeliendor's Klin. Monatsbl., Bd. XV, p. 237-311. Ze- hender's Klin Monalsblntter, Kd. XVII, p. 307. 6i (loo-roo. (at most. O-OOo). 'riicri'loiv. tlif total index of llic -ciiilc Icii- is iimcli less than in the yoiillirul lens. The valiio of senile len> i-an.i:c' rroin 1.415 to 1.425 — and hence it innst appeal- evident thai thi> ivdnced index of refraction causes the hy|iei-ii|)ia >>[' did a,i:e. .No donhl the general increase in tliic-kness of the lens may compensate for this, within certain limits. 'I'Ih' I'olh.win-- is a Schematic tahle nf the avera-e total indices of re- iVaction: Senile hyinn-opia 1.41."i rresbyopia. doi)en<]in.ii- on the ajio and lliickuess of lens 1.420 -1.42.J Youthful lenses 1 .480 Leuses during act of aceoniniodation 1.440 N. r>.— In the schematic eye a chanji-e of (ine in the second decimal i>laco chans'os the total index of refraction Vjl> (equals iL> mni. difference in optic axi.s). In cataraetons lenses the indt'x of refraction is nearly always found increased. This may be due to various causes: First, the anterior pole may disclose an ahnormally low index: this would increase the total index. Sec- ond, the nucleus may be very markedly sclerosed, and Hius the index may be increased. Third. l)oth conditions may he combined, in the first group belongs, possibly, the mature catai-act. the ^lorgagni's and soft cat- aracts in which the nucleus is sclerosed: in the second group aiv found mature cataracts and certain forms of diabetic cataracts, in which irregular sclerosis and softening has not as yet destroyed the structure of the lens. Thus can be explained the clinical observation, thai at times during the in- cipient stages of cataract formation, myopia develo[)s. THE CHEMISTRY OF THE LENS AND THE FLUID MEDIA WHICH SUEKOHND IT. With the exception of the increase in weight and volume of the trans- parent lens, all the above-described changes are dependent on the chemical changes which take place in the lens. These in their turn will he largely dependent on the constitution of the nutritive supply which is ol)tained from the vitreous. That very marked chemical ditl'ei'ences exist hetween the lens of the young and those advancing in age has already heen pointed out. (on page 51), on the evidence of anatomical proof. Our knowledge of the chemical constitution oi the crystalline lens is inseparable from the nann^ of J'x'iv.clius. In the o\"s lens he found an albuminous substance like his glohulin. which he mimed Kri/slallinr. It appears that human lenses were not sulnnitted to a (piantitative analysis. 62 According to Kuliiie.-*^ Ihc lens coiitiiiiis water (iO per cent., albuminous material 37.5 per cent., fat and traces of cholesterine 2 per cent., and ashes at niost 0.5 per cent. Later analyses are from the laboratories of Hoppe Sevier. Laptschinsky,^! as the average of the analysis of four cahes' lenses, gives the following: Water 03.51 per cent., albuminous material 34.93 per cent., lecithin 0.23 per cent., cholesterine 0.23 per cent., fat 0.29 per cent., soluble salts 0.53 per cent., insoluble salts 0.29 per cent. Whereas Kuhne, like Simon, Alex. Schmidt, Liebei-kuhn and Vintschgau. states that, after careful trituration in sand, extraction in water and filtration, he obtained a faint opalescent fluid, in which he found at least three albuminous bodies, globulin, kali albumin, and serum al- bumen, Lapiscliinsl-ij ol)tained no precipitate from the clear filtrate of the precipitated globulin which he dissolved in a weak acid, whereas the solu- tion became cloudy at 55 degrees and at 70 degrees showed a flaky coagu- late. Therefore, according to the latter, the lens does not contain a potas- sium albuminate, but merely a globulin (24. G8 per cent.) and serum al- bumen (10.31 per cent.). Cahn ^^ triturated fresh animal lenses (accordin'^ to Hammarsteu's method) with crystallized magnesium sulphate and after- wards washed this out with a saturated soda magnesium solution, during which process more of the albuminous substance was taken up by the solu- tion. l^\om this he concluded that the entire lens was made up of a globuline. He adds: "Whether or not this is a single one is yet to be de- termined." Prof. Michel and Henry Wagner ^s investigated this subject again. They concluded that at least in the pig's eye, also in the ox's eye, we find lento-glohuline and lento-albumim. To digress here for a moment. Michel 24 has made some very interesting experiments relative to the tem- perature within the eye-ball, and with special reference to its action on the crystalline lens. With a peculiarly constructed electrical thermo element he made a series of investigations in the eyes of rabbits. The temperaturr., 1880. 24 Die Temperature Topogiaphi«' des Auges. Graefe Arch., Vol. XXXll, B. 2. 1886. 63 peratniv in llio viti-cuus. A^inin. in tlio vitreous (lie tcniperaUiro iiuTeaseO as the instiiuiirm ncarcd \hv coals of the eve. and attained the hody tem- perature when ilii'v wei-e loiiclitwl. 'I'lic tciii|icrai lire increased 2.3 defrree> when the lids were elosed and on llif apjilicaiion of an iec bag the tem- perature fell 13 to 1.') degrees ( '. in tlie e(Uir.-e ot one and a half minutes. The relatively low teini)erature of the anterior chamber may be due to the rapid dissipation of lieat by the cornea; also due to the fact that the blood vessels are relatively far removed. This latter cause may also explain the low temperature in the centre of the vitreous. From a physiological standpoint these temperature conditions appear to be especially important, since undoubtedly they exert a very decided influence on the albuminous bodies in the eye, especially in the lens. Michel gives the following experi- ment. If a small ice bag is laid on the eye of a cat. a total cloudiness of the lens will follow in a short time, which will again disappear shortly after the ice bag is removed. It would hardly seem necessary to remind one of the therapeutic value of the above experiments, which show the rapid changes in the temperature due to closure of the lid, or the application of an ice bag. Laptschinsky found that the amount of the cholesterine varies greatly, ranging from 0.06 per cent to 0.49 per cent. He also found that the normal transparent lens contains lecithin. Our interest is especially directed toward discovering the differences in the quantities of water, albuminous material, also lecithin, found in the senile 7ion-cataractous and in the senile cataradous /e/(.spv. Water. Deutschman ^s demonstrated for the no/i-cataractous lens, that which up to this time had been accepted, but which never had been experi- mentally proven, by weighing human lenses removed from the body shortly after death, and then permitting them to dry out completely, and in this w^ay he succeeded in demonstrating as a fact, that though there is a general increase as age advances, there is a diminution both absolute as well as rela- tive to the weight of the entire lens (from 70.8 to 64.6 per cent.) of the amount of luater contained, whereas the amount of ilrij constituents increases. Naturally, there were differences in the weight of the different lenses, as well as in the relation between the amoimt of water and the dry constituents of the lens. The weight of five senile cataracts, four of which had been extracted by H. Pagenctacher, and the fifth was a cataracta incip- iens and had been taken from a corpse, showed (p. 216) that the senile cataractoiis lens contained considerably more water (r6.23 per cent, as op- posed to 69.06 per cent.) //m/i the non-cloudy senile and that they were poorer 25 Cataracta Senilis, 1879. Graefe Arch., Bd. XXV. 2. p. 214. 64 in solid conslilucnts, especially the alliuniinou.-. products. Both features were less developed in C. incipiens. Jacobson's stateuients -^ are at variance with these, who fouiul just the opposite. iKiiiu'ly. that (■(thuutclniix ]rns(>s could in less water ((!;?. 45 per cent, as oppose^] to 7;i.ti per cent.) than the normal. This, liowever. is due to the fact that Jacobson made his estimates from lenses which had Ijeen extracted without theiv capsules, and hence there can be no doubt but that a part of the watery cortical substance remained behind in the eye. Unfortunately, Deutschman failed to state how his lenses were preserved while being trans- ported from A\'iesbaden to Goettingen in order to protect them against alterations in their watery constituents. Both Priestly Smith and J. Treacher Collins -" agree with Jacobson. The latter examined six fresh eyes one houi' after enucleation: also ten cataractous lenses, with following re- sults: — Fresh Eves, 10-64 yrs. Average Total Weight, 0.204 Water, . . 0.1446= 71 per cent. Solid Constituents, . 0.059 =29 Ashes, . . . 0.0013=0. (5 10 Cat AR A 0.113 0.073 = fio per cent 0.040 = 35 0.0014=1.57 Le.nsks, 46-80 yrs. Collins states: "The weight of the cataractous lens is far below that of the normal." The cataractous lens is not to be looked upon as the result of excessive changes due to age, but rather the result of nutritive disturbances of an entirely different nature, chemical, 7iot morphological. Albuminous Substances. Calin-^ analyzed cataracts which had been extracted by Laquer without their capsules and been subsequently preserved in alcohol, and he has compared his results with those of Laptschinsky which the latter made in normal calves' lenses. Since these are the only qnantitive estimates of human lenses, they are quoted here aud will be referred to again later on: — 100 Parts of Solid Constituents Contain In Cataracts. In Normal I. 1 II. Ox I^ENSES. .\lbunien, . 81.48 86.87 94.71 Cholesterine, , 6.22 4.55 0.62 Lecithin, . 4.52 0.803 0.63 Fat, 1.19 (t.79 .\lcoholic Extract, 0.83 1.45 0.71 Watery Extract, 3.94 2.76 1.52 Solualjle \ c„itc Insoluable i °^"^' " 1.81 2.41 1.36 1.14 1.45 0.46 26Uber die Brechungs-coefficienten iind uber die Chemische BeschaCfenheit Kntaraktoescr Liusensnbstauz. Zehcnder's Klin. ^lonatsblntl. Bd. XVII. p. 307. 27T1IO Composition of the Human Lens in Health and in Cataract, etc. Opthalmie Rfview, November. 1880. 2S Zm- IMiysiol. and Pathol. Chemie de.s Angos. Strassbm-g. p. 18. 1881. 65 According to tlic (wo jiiialysos. tlic avcra^u ahsulute decrease of albumen equals 0.95 to 0.84 ])er (ciii. Calm, however, also had llu' t)|)|)()rtuiiii v <>f ajialy/.ini: a iiiiiiiIkt of freshly extracted senile cataracts, lie preserved tlieni in quite a concen- trated sol. of coninion salt until he had a sufficient number, and then util- ized them to determine the niiidiinl of all)iiininous material in senile catar- acts by comparing the results of that wliicli is insoluble in water and CO, to that; which is soluble. The absohilc aiuoiuil of albuminous material soluble in wafer and CO was found to be diminished. Both the soluble and the in- soluble albumines were then dried, and the average analysis of the two analyses showed tliat the propoi-tion of the solubh^ to the insoluble albu- mines Avas to that of the noinial ox lens as 24, C)-i: 10, -81: that is, as 3.38: 1 is to 15.09: 1. Xow, since as we have seen all alt)uiniuous substances which are present in the normal lens are globuline, and that the apparent incomplete elimination of serum albumen is dependent on the abnormal quantities of water and CO^ Calm draws the conclusion from this fact, that irhere cataracts are treated with water and CO, a much greater portion of al- buminous substance is eliminated, and llial during life a portion of the albuminous substance has been so modified as to hare become insoluble. It is not difficult to assume that this rery circumstance adds to the cataractous cloudiness. Cahn does not decide what this modification is. Becker,^^ reasoning by analogy, expresses the belief that since the lens, like the skin and hair, is derived from the ectoderm, keratine might be found in the nucleus of the senile or cataractous lens. Knies, by means of Kuhne's digestive meth- od, proved that this assumption is not true.so He also examined senilo cataracts which had been extracted without their capsules: hence, essen- tially their nuclei. The result was a fluid which gave all the reactions of peptone, and did not in any way differ from a peptone fluid which resulte.l from digestion of alb^imcn. According to Knies, the substance of the nu- cleus of cataract is albuminous in its nature, though it did show certain difference in its chemical relation to other albuminous substances. This digestive method has in other ways proven its importance to the anatomy and chemistry of the lens.^^ By this means it has been shown that since the capsule of the lens, like Descemet's membrane, can be completely di- 29 Patliolosie Tlu'nipic. p. 109. 30 Knies Zur Chemie dor Alters veranderunfren der T.inso. T'ntersncli a. d. Physiol. Inst. d. Univ. Heidelberg, Bl. 2. p. 114. siKulme and Ewald die verdauuns als Histolosisclie Mothode. Yerhand dor Naturhistor Med. Verein in Heidelberg. Bd. 1. 66 gested, it is not an elastic membrane. It seems to coincide very much with the cement substance of tlie U'us. In fact, tlie entire lens may he digested, leaving hut a slight residue. f'holesierine ami Fat. The various authorities seem to coincide as to the amount of cholc-tcj-iiu' in cataractous lenses. Kuhne^^ found in senile (human) lenses wliicli Iiad assumed an amber color a greater amount of fat and cholesterine than in the normal lenses. Laptschinsky (cited above, page 639) could only reiterate this statement as to the amount of fa.t found in cases of amber colored lenses in oxen. It is however questionable whether Ave can imisiih'r the lenses of slaughtered animals as senile, in tlie sense wliich we consider lenses in old people suffering from senile cataract. A\'e are indebted to Jacobson for the most thorough investigations con- cerning the amount of cholesterine contained in the human lens during the various periods of life. This analysis was made at the instigation of Zo- hender and ]\Iatthieson. He found (cited above, page 315) that the lens of a new born infant does not. contain any cholesterine, and in the lens of a young woman of 20 years, he found but slight traces. He was the first to draw attention to this increase in the cataractous lens (page 313). Though he had to make a partial retraction in a latter publication (2d paper cited, page 309), he nevertheless states: "'//( i/oung individuals, as a class, ilie amonnt of choleslerine is much less titan in individuals wore advanced in life, and, as a ivhole, cataractous lenses are richer in cholesterine than nor- mally transparent lenses. Jacobson (p. 308) found in (U lenses taken from individuals under 60 years of age, that 3.11 per cent, of the dry substance consisted of cholesterine, and in 27 transparent lenses taken from indi- viduals over 60 years of age, 2.36 per cent., and in 86 cataracts taken from individuals over 60 years of age, 2.68 per cent. Both of the analyses of Cahn are in accord with these figures. As compared with the 0.(i2 per cent, cholesterine (100 parts of solid substance) in the normal .cortical sub- stance, he found in the centre of the cataract 5.38 per cent, cholesterine Jacobson was further able to show that the nucleus of the cataract contains three times as much cholesterine as the cataract substance. Therefore, he considers it as prohabk that cholesteriiie is not a foreifjn substance, which 1$ carried to the lens by the natritire fluid, hut that it is rathe v the result of a change in the allmminous substance contained in the lens. Lecithin. Laptschinsky found lecithiu in the cortical sul)stauc-e of the normal lens, as did also Cahn in both his analyses, and in the last very much increased in quantity. He does not attempt to draw any conclusions from this. 32 Physiologisfho Clioniic, ISOS. p. 400. 67 //■ ire ntnr hrir/h/ iiidhr ii rcsiinir of llir dhorr. wr liiid llnit Dciilsrlniiait inrciTcd tVoiii the rcdnctioii of llic aWxilutc (Hiaiil il \- nl' dried cortical sub- stance ill cataracts, an al)S()liitc rcdiiclidn of I lie alhiiniinoiis substance in cataract; ./dcuhsoii stalc> that a ixu'lion of I lie alhniiien lias hccn cliaii-i-ciE into cli()lc>tcrinc. w licrca.- Caliii. as tin' roiilt (if lii> cliciiiical invcsli^'^ations of n(in-cata!act()n> lenses aiul senile liiinian len>es. state> that in cataract there is a reduction of alhiiiiiinons material, partly chan.iicd into an iusol- uhlc substance, with at tlu' same lime foi-mation of cholestei-ine (and loci- Ihin. inci-ease of tlie extractive and anorganic substances). '.I'hough C-'ahn states that he is not able to draw any <'onclusion fi'om his i-esults couceru- ing the cataractous |)rocess. liecker draws this very im|iortant conclusion, that "Ihiiuijh (ill (ii/rrr as la llir phi/sicdl coinlilidd. l/irn: lids nererUiclcss been /inircii llidt llicrr d rr ilniidiisl nildhlt' cliniiical (liffrrriin's hclirren llir niiiieii^ of llir noii-rloiiih/ a ml llic inirlriis of llir raid nicloiis snillr Irns." A suhstance which has been occa>ionally noted in the lens, and w hicli does not occur under noi-nial conditions, is siujar. Its presence in tlie len>* iu cases of diabetic- cataract has attracted the greatest attention. Its pres- ence bere bas been utilized as tbe basis on wbicb to l)ui!(l a theory for tbc (b'velopnu'iit of tbis ])artic!ilai- foi'ui of cataract. There may be various reasons why its i)resenc-e is not a constant one. which will he touched on again, in order to ;ivoid doiihts wbicb niigbt arist' in tbe minds of tbe reader as to tbe accuracy with w bich tbese tests were made, Trof. Kulme kindly permitted the publication of the metbods pursued in bis laboratory. On Marcli !t. ISSl. Kuluie exaiiiincd for Be<-lver a cataract. Avliich the latter had .lust extracted. His h'tt<>r reads as foUows: "Tlie cataractous mass Avhich I received on .March Utii was nilihed ui> niinutel.v in water heated to the boilinjn point, sntticient acetic acid a(hled to liive it a weak acid reactlou. Altered while still hot. and the liltrate washed in hoilin.ii' water, and the clear filtrate dried over a water batli. The colorless lirni residue was tlien boiled witli alisoluti- alcohol, and this tittered after coolini: left nolliiny- to 1>." reduced. After this mass, which was insoluble in ab-ohol. had been furllier extracted in etlier. this was dissolved in a f<'W drops of water, lo wln<-ii were added a few drops of over-proof alcoliol: tliis was lieated: after cocdini; tiltered. an color was retained on heatinc. In tlie meanwhile, tliere had been such a rich deposit of reddish crystals of oxidt> of copper, that it was possible to determine 68 that, there was a very coiishU'rahle cNjiiKU-iiicd lo ((Hiiiilcic di'viicss. iinJ tlie iviiiniiis wci-c lakcii up in alcoliol (1). Tli.-it which the idcohol hd'l in- solul)U' was taken up in So pci- ccnl. ah'dhol CJ). And the Hiird in-(.lnl)le rcinaindci- was taken up in water (;!). 1 and '! were e\ap(irate(| and ehaiiji'eJ lo a. watery xdntinn. and in the rednelion lest L;a\c a negative ie>idt. as did also .">. All thfee jjortions were next just lui-ned pereei)t ihle liliie by the addition of hydrate of soda and snlpliaie of copper solution, and heated over a water hath I'oi- a considerable len.uth ol' time at a lein]ierat nre of 100 degret's (', dui-in.i:- which the cohjr did not clian,i:e. Later on tiie eoh)r was made decidedly hhu' by addition of inoi-e Cn. and then thoroujihly heated over a (lame; ])ut at the end of iweidy-four hours none of these tests showed a preeij)ilate in which the oxide of co|)])er could In; tletecled microscopically. These lenses. Ilwn-forc. did nut contain anij sugar, and in fart, notliiii;/ irhich coutd l)e reduced. Armaignae -^^ observed in a cataracla ni^uni. small, globular granules, which he considered haematoidin. The only speetroscopieal analysis so far reported was made hy Gillet de Grandmont.^^^ He extracted a very laro-e black cataract. The fundus disclosed a general chorio retinitis. The spec- troscopic examination proved that tlie hlack color was due to liver pigment. The occui'rence of the fundus disease explains the pathogenesis of the form of cataract. Pykalt believed the color was due to the choroidal pigment, for dilute sulphuric acid easily dissolved the pigment of the blood, and he made similar observtions when he treated sections of cataracta nigra with dilute sulphuric acid. H. Meyer stated that he believed there were two forms of cataracta nigra, one due to the taking up of the pigment of the blood, the other diu' to the general sclerosis. Vitreous and .[(jueinis. For reasons e.\])lained on pages 53 and 54, analysis of the vitreous and aqueous assume great importance, especially so owing to tlieir relation to the pathological conditions of the lens. It is ;. matter of regret that we |)ossess but few analyses of sufficient accuracy. The investigati(ms of Calm (1. c., j). U) have settled this question beyond a doubt. 'I'he humor aqueous has a somewhat strong alkaline reaction, and has a specific gravity of 1.009. It does imt contain any mucin, but a globu- lin and serum albumen. The former simulates blood serum as to the point at which it coagulates. 'I'he aqueous has this qualitative difference, "that in cooking the faintly acid solution, the all)umen becomes slightly flaky and is precipitated, leaving a clear fluid: whereas, the vitreous always re- main cloudv, and only gives a clear filtrate witli great difficulty, a condi- 33 Note sur la cataraote noire— Journal de :Med. de Bordeaux, Bd. IX. p. 357. 33a Extraction de Cataraote Noire. Society d Opth. d Paris, April. 1893. tioii uliicli Loll mover cnipliasiyA'd and whieli Dcutsoliinan misinterpreted, supposing this to be due to larger quantity of albumen. All quantitative estimates coincide. The average of six estimates showed the vitreous to contain 0.0T38 pel- cent, of albumen; the aqueous. 0.081 ])er cent.: hence, a somewhat greater amount. An analysis made with a larger quantity of vitreous (280 cc.) showed the albumen equal to 0.0907 per cent. Lohmeyer found it to be 0.053; Deutschman. O.l-^—O.li;] per cent. The following is Cahn's complete analysis: Humor Humor Vitreous. Aqueous. Albumen, 0.074 0.082 Remaining Organic Substances, 0.071 0.148 Ashes 0.971 0.993 Water 98.884 98.777 INORGANIC SUBSTANCES K„SO„ . . . . 3.74 6.99 Kcl, . . . . 5.57 2.92 Na cl, . 74.43 78.11 PO,H Na„ . 1.82 1.99 {FO^)^Ca„ . 0.44 0.62 (POjjMgj, 0.22 0.40 Na^Co, 12.67 8.72 "According to this the watery fluids of the eye are very similar to the cerebro-spinal fluid, and the transudates which are weakest in albumen." The material from which these analyses were made was taken from animals. In older analyses made by Berzelius and Kletzinsky, the aqueous used was taken from human eyes, but none has been made from the vitre- ous. One should judge, that since the index of refraction of both fluids is the .same under normal conditious, any abnormal addition leading to a changed constitution of the one or the other of the two fluids ought to bo demonstratable. Fleischer^-* fixed the indices of refraction by means of Abbe's refracto- meter. The value for distilled water (Line 1), 18 ])or cent.) being 1.3340, he found that of the luiueous equal to 1.3373, ami of the vitreous equal to 1.3369; hence, somewhat less. Notwithstandins the difficulty of uialvin.s estimates witli Abbe's Refracto- iMCter of the sinnll (iiiMiil ii ii's ot .-Miiieoiis or vitreou.-; wliicli can lie ohraiued from man, wc can nevcrtliel(>ss deterniinc to a des-ree the index of refraction (tf the fluids, and ixn'm comparatively accuratt> knowledge, as to whether the fluids are normal in their constitution, or Avhether they contain abnormal sub- stances. Cor ( vjinii'lc: 'Che index (-1 refraction of a three-(iuarfcr per ceiil. .Na. (11 solution, ].3;i50; Avliereas that of water e. IV. i-t-r criit. ill ;i tlirf<'-(Hi;ii-t.T per cciii. Xii. CI solution oiiiimI.-: I..".: !<;.".; ( u-- ."iiniiiicii. (i.ir.r. per cent. ('(|ii;iis i.:;:".f;s: (i.:;:; per cfin.. i.."!:;T(t O..") |»«M- cent.. 1.:;:!7:t. »>!<•. If llic .nitrrior cli.-iinlx'r of ;i iionii.-il cy.- is piiiiciuiM-d. a fluid will be (>i)1;iiiif(l siiowiiii; .-in index oT rcli-.-iction (MpiMl to 1. .■;:;<;:.'. If the .•interior cliMiulifr is punctured :i^:iiii. ten niimiles l:iter it will lie found 1.;1389. From c.rjK'riinnils iiniilc nii (niiiiiiils. it is a ircll hniiirn Ijiiil, that irith each siiccess- irc iHUiitini . ihi iilhiniiiiKnis /mrtidii uf llir uiiiiiitiis iiicrrd.sfs. 'I'lu- vitreous of an intensely icteric p.-itieiit. t.iken hut ;i few hours after death, liad an index of re- fraction eipial to l.:i.S71>. whereas, on hoilinjr. it showed Imt a alight opalescence. If \\r will now hold litsi lo tlic j'iict that hot h aijiirous and vitreous are poof ill alhtiiiu'ii. and that the anioiint of organic as well as inorganic con- stituents scarcely dilfer from each other: hence, any addition of substanct^s which arc normally jjrescnt. or any other substances whieli do not occur in tliem under iiornial circinnstances. will lead to the following important conclusion concern ing the nutrition (d' the lens: In (jofiprnl am/ inrirase or ahuoriiHil coitlcnls in l/ir rilmins, he Ihnj nrt/nnir or inorf/anic. irlll cause abnornidl nnlrilirr condillons in the lens, and liirr rondifions occurring in the mpienvs arc flir rrsull of an inlrrferenri' willi the proper inlerchange of fluids in the Jens. Lohmeyer •'•' succeeded in demonstrating the presence of sugar in vit- reous, taken from two human l)eings who had died of diabetes. The acid reacti(m of the fluid media (hictic acid) of the eye, which he claimed he had found, and which he also claimed passed through the lens, Leber ^^ Avas not able to find in the aqueous taken up with a pipette from the con- junctiva during a cataract extraction done on a diabetic patient. Hence^ Leber assumed that the acid reaction which Lohuu'ver obtained, was due to post mortem change. Deutschman ^^ proved the presence of sugar in the aqueous and vitreous of the corpse of a diabetic, which did not contain a cataract, and whose lens did not contain sugar. The aqueous was highly alkaline, and contained O.o per cent, the vitreous 0.3G per cent of sugar. We know as yet absolutely iu)thing concerning a change or increase in the amount of albnnien in tlu' vitreous in cases of senile cataract. The first analysis i^'lative to the amonnt of albunu'ii in the a((Ueous, in cases of senile cataract, are to lie found in h'dward Yager's work. **Ubor die Einstellung dcs dio|)tr. Aj)|)aratn>. eat." (|). 1 l"^) and were made by Kletzinsky. The aqueous was taken from the living eye by puncture of 35 Keitra.U' /ur Ilistoloiiie und .Vetioloiiie der erworl)eiieii Linseiistaare. Zeit- sohrift. f. rat Medicin X. I\. Hd. X'. j.. !>!». 1S.-.4. 36TTber die Erkranliun- des Au.iics Itei der I>i:il)etes Mellitus Arch, fur Opth., Bd. XXI. .3. 3VZur Refreneration des Iloiuor Aqueous. Arch. f. Optlial.. Bd. 26. p. 1)9. 72 the cornea. Xolwitlislaiuling the slipht (juantity wliieh he could ohtain (0.2 — O.o gr.), Kletzinsky estimated tlie amount of albumen in a normal eve to be 0.0456 per cent., and that of three cataractons eyes to l)e 0.3G18 0.0764 and 0.0899 per cent. Hence, the cataraclons eyes showed a great increase of albumen over that fonnd in the normal eye. Leber (1. c. p. 301) fonnd a very considerable increase of the albumen (on heating a thick pre- cipitate occurred), together with a 1 pro mille of sugar, in a patient who had diabetic cataract, removed two and one-half hours after death. This observation incited Deutschman to examine the aqueous in senile cataracts for albumen. He found during the process of ripening of senile cataract a greater amount of al])unien in the aqueous than under normal conditions; hence, he coincided with the Yager-Kletzinsky statement. In a case of acute nephritis, with exceptionally excessive albuminuria, the lens being transparent, no increase of albumen could be found in the eye. From this together with several other investigations. Deutschman concluded that tlie iiicn'ttsc of alhuiiien ii-JiicJt is found in the aqiieoii.s iii rases of cataract, is derived from the tens, tint lliat tlic cataract i snot due to an inceased amount of attmnien in the Icumor aqueous. Aside from the fact whether the tests made by Kletzinsky, with such small quantities, and the so-called optical tests of Deutschman, are of suf- ficient accuracy to give definite results, which could he of service in de- termining this important question as to the causes of cataract, they never- theless coincide fully with those with which we are acquainted, concerning the direction of the nutritive stream in the lens. Hence, we can understand the reason for the constant presence of a greater amount of albunum in the aqueous, in cases of advanced senile cataract, which must have been derived from the lens, and passed out by diffusion. One could account for the presence of sugar in the lens and a([ueou5 by a similar mode of reasoning. PART II. 'I^JIK l'.\'ni()I.(»(ilC.\l. LKXS SVSTK.M. CHAPTER I. THP] PATH0L0C4Y OF THE ZONULA OF ZTNX. Even at the present day but little is known concerning the patholog- ical anatomy of the zonula of zinii. on the noiiual integrity and develop- ment of which the lens is so prominently dependent, not only for its proper position, but also for its ability to properly perform its function during the act of accommodation. It might also be com])ared to the hairspring of a watch. Becker 1 states that at times there is such a complete (ifropln/ of the zonula fibres that one can not recognize a trace of its fibrous construction. This may lead to a spontaneous detachment of the lens in its capsule, par- tial or complete. This condition in all probability agrees with one de- scribed by Wedl and Bock - as senescence of the zomda. They describe the zonula fibres as taut, ap])arently closely packed together, and easily torn from their attachment on the application of a certain degree of force. When detached they are tense and friable. This condition is taken advantage of when the lens is extracted in its capsule (Pagenstechers operation). Again, Becker states ^ that it is not at all uncommon in cases of disor- ganized eyes, more jjarticularly in cases where cataract has developed, to find a marked inm-dse of the zonula fibres. These, he states, may be ob- served in the fresh as well as in hardened specimens, as chmdi/, thickened fibres, adherent to the ciliary body and the capsule of the lens. Wedl and Bock (p. T< ) state that in eataractous eyes the connective tissue corpuscles. which are normally ])resent at the time, are greatly increased, and lead to a cloudiness of the zonula. In the great majority ol;' disorganized eyes, such as phthisical 1)ulhi. those which have snlVered I'l'oin iridocyclitic pro- cesses, the infiammatory products lill up the posterior chamher. and the zonula fibres likewise become iinmersed in the exudate, ivatei' on these inflammatory products organize; tense bands develop, and as they undergo cicatrical contraction lead to dislocation of the lens, even to detachment of irathologie and Therapie. Graefo S.-ieinisch Vol. p. KH. No. 11. 2 Pathologisclio Anatomie des Aujres. Wieii. ISSO. p. 177. 3 Pathologie and Tlierapie, p. 102. 74 the entire cilinrv body. No doiibt ;it iiiiics iliesc Imiuls have l)een inistakeu for thickened zonular fibres. Move as the rcsidt of clinical observation than of anatomical examination it has been obsci-ved. that in cases of si/nrhifiis corporis rihri, the zoniihn- fibres are also alfected. loose their consistence, and are totally dissolved. This is evidenced in c;ises of s|)ontaneons lux- ation of the lens, where at the bejiinninu- there is iiidodonesis, with the leiis still propei'ly centered. Latei' on. due to the continuous niovenu'nts of the eyeball, and conse(|uenl oscillation of the lens, as a natural ivsult of the continuous tension, the zonula tibi-es finally rn|)ture. Owin.ii- to the inti- mate genetic relation existing between the zonula fibres and the vitreous (as pointed out on i)age 27), one might assume that the sauu' causative agent which leads to the pathological destruction of the vitreous, or its chemical decomposition, acts exactly in the same manner on the zonular fibres. Solution of conliniiili/ can always occur as the I't'sult of the application of mechanical foi'ce. hut tjie manner of its j)roduction may be brought about in vai'ious ways. Two causes have already been cited above. Trac- tion which the shiinking capsular cataj'act exerts on the zonula, or the dragging which it e.\pei'iem-es where the acpieous is suddenly evacuated, due to a corneal ruptui'c. the result, either of a trauma or operative pro- ceedure. may produce this disaster, the lens moving anteriorly a distance equal to its axial dianu'ter. Mcu'e fre(pu'ntly, however, the zonula does noi j-upture at oiu'c. but the lens I'cmains adherent at the point where the |)er- foration occurred; ami it is only after the anterior chambt'r is re-estab- lished, and the aqueous accumulated, that the zcuiula teai's. I']ctatic ]>ro- cesses. hydi'opt haliiius. cornea, globosa. staphyloma iutei-calare: in fact, all forms of staphylomata of the anterior segnicnt of the globe, lead to p;irtial or entire ru|)ture of the zonula, due to the continually increasing tension exerted on the zonula fibres by the gradual distension of the anterior seg- ment of the globe. Whci-e the eye is struck by a blunt foi'ce and suddeidy flattened out. and a.-sunu's ag;iin its normal shape, mit infre(puMit ly the lens is found luxated, and this is only possible where there is at least a par- tial teai' of the zonula. The >ame re.-ult is noted of a contusion, and as is well known: this latter coiuliti(ni most fresocialed with aiionialicx in llir forninlion of Ilir -.oniilo. In all the varielie> of colobomata (coloboma of ii'is, ciliary body, choroid, and I'ctina), supposed to be due to 75 laic closim' of the ot-iilar lissiwc. otic IIiuU. a> one would iialiirally I'xpect to find, a failiiiv of perfect dcvclo|)iiiciil of the zonula fibres, especially along the line wlici'c the closure look place, and in these [)laees the lens follows the tension from aho\e. 'rrcacliei- Collins (see page 2^)) explains cases of colol)onia lentis as due to want of proper adhesion between the ciliary portion of ihe retina and capsnie of the lens at a very early period of (1evelo])nient. heforc the expansion of the eyeball begins. Mctopia lentis. he e.\|)lains in a siniilai- manner, as due to a lac-k of development of the zonula iibres. lie further states: "If, a.s a result of persistence of the hya- loid artery, the tibro vascular sheath around the lens persists and becomes thickened, it may occui- that the lens be forced forwaid between iris and ciliary processes, without leading to adhesions laterally: as a result, there will be no traction and no -jiniilar /ihrt's. simply an epithelial deposit on the posterior capsule, and the lens then assumes an almost globular form." CHAPTEK 11. THE P.\THOL()(;i('AL CHANGES IX TIIF. LHXS. LENTirULAI? CATAlJAl T. "During the ])resent century the pathological anatomy of the lens has been the subject of a great many, and in part very accurate, publications. Hundreds of years ago, owing to the extreme importance which opacities of tlie lens bear to those so aflflicted. the operations for cataract awakened an interest which was not alone confined to the jihysician. Hence, it is easy to umlerstand why every effort has been made to clear u)). by accurate anatomical investigation, the cause of cataract." It is only since the early part of the last century that we know that grey cataract has its seat in the len.s, and it is only during the past fifty years that we know anything at all concerning its histological structure. The past twenty-five years have been ripe with a succession of ])ublications. nu)re especially the past fifteen years, owing to the rcHnement in tlu' techni(pie in the preparation of specimens and in our possession of l)etter nn'croscopes: ami as a result, our knowledge of the pathology of the lens has gradually been placed on a solid founda- tion. And at this point it seems no more than just and ])roper to again draw attention to the great efforts made in this direction by Otto liecker. whose masterly descriptions are the basis of the following: "The impetus to study the pathological anatotny of the lens was given by :\lalgaigne. and corresponds with the time when histology in geiu'i-al was undergoing i'evi>ion by Sehwan. Malgaigne contended (lie. Section 80, p. 182. 77 to the compiict condition, and hence icduci'd volume of ihe n\icleus. there necessarily follows a certain anioiini of traction on the more peripheral portictns of the lens. Those jiortioiis of the cortex in the region of the an- terior and ))osleii()r ])ole and tlie cai)suie. since they are not fixed hy the zonula, can give to this traction. I'.ut in the e(|uatonal region tlie condi- tions are difl'oreiit. To heuin with, here the connection between the la- melhie is less intimate, since it is here that the youngest lens fibres aro found. 1'hen again the zonula tixos the cap.-iile. and prevents the equa- torial ])()rtio)i of the lens from Ix-coniing fnrthci- removed from the ciliary body, and ap]ir.)aching the axis of the eye. Hence, it can not be such a matter of surprise tliat in senile cataract, the equatorial portion of the lens is the first to sutler a loosening up and separation of its cortical lamellae {geronfo.von lenli!<). and that this is subsequently followed by a true cloudi- ness of the lens fibres, and a molecular disintegration (cataract formation). Foerster^ appears to have been uncler the impression that "the firsi indication of a cataj-act ohra!/.'< makes its first appearance around the nu- cleus of Ihe lens, as a result of interference with the gradual sclerosis," and states "that a very delicate but .aces.a> iiuui- ifostatioiis (if (levelopin.u- cataract at a time wlieii the lens was apparently per- fectlynoniial. ••/•'/';•>■/; pear-shaped iiitei>paees aiTaiijicd concentrically around the equator. JSerotid, lare are found tlirou. recognizable I'adial arrangement of the lens tihres. For the further retrogressive metamorphosis, we are forced to assume entirely different changes in the lens. Hither the cortical substance be- comes more and luore thickened, accompanied hy the fonnation of caji- sular cataract, or the cortex gradually hecomes a fluid pasty mass, in whicli So is found an abundance of eholesterine and chalky dcj)osits. and in wliicli the nucleus finally sinks to the bottom (Cataracta Morgagni). On microscopical examination, these splits and inters'])aces are found to be filled with coagulated albuminous glolndes. Innumeraljle direct observations have settled this as an unassailable fact, and this has been especially demonstrated in lenses which, during life, had shown signs of cataracin 'uuijnens. and have conclusively proven, that it is these forma- tions which are the cause of the first opacities in the cortex of incipient cataract. These are the so-called "Moir/tu/ni's globules," and have long ago been observed in posterior cortical cataract. It must, however, remain an undecided question as to whether this fiuid coagulates into globules during life, or whether this is simply the result of a cooling ofl' of the body after death, or due to the action of the hardening fluid, or due to both the latter. Due to the influence of the changed fluid in these interspaces, the fibres undergo a variety of changes, all the various degrees of which can be observed without any difliculty under the microsco])e, beginning ^nth the punctate molecular cloudiness of the fibres u]) to highly refracting drop- lets, from the irregularly serrated borders of the fibres up to the transverse striations: from the tumesence to the gradual transition into cylindrical tubes. The first stage of disintegration, the dislocation of the lamellae one against the other, the breaking down, disintegration and total destruction of the individual fibres, the formation of albuminous globule^, molecular pasty masses, calcareous granules, fat, eholesterine crystals, can all be ob- serA'cd under a low power of the microscope. If a nucleus has formed, the cataract as a rule must develop in those portions of the lens which are not yet sclerosed. The older the individual at the time the cataract begins to form, the larger, generally speaking, will be the nucleus which is surrounded by the cataractous ma^s; whereas the younger the individual at the time the cataract begins to forni, the easier will it be ft)r the entire lens to become cataractous. But no sharp line be- tween nucleus and cortex can be drawn, estimated by the age; it is an exceedingly rare occurrence to find the centre of a lens undergoing cata- ractous changes after a nucleus has once formed. In those cases where the centre of the lens is first attacked, it is still an undecided question whether the cataractous |)rocess had been preceded by the formation of a nucleus, or whether it had occurred as a result of the failure of a nucleus to properly foi-iii. CATAiJA( '1' IX VOI'IMIKIL LENSES. The causation of the spontaiu'ous (lcvelo].uient of soft cataracts in youthful individuals is still wrapped in llic deepest darkness. Anatomical investigations arc enlirely wanting, and our knowledge is therefore en- tirely restricted to the results of clinical investigation. The only case which Becker was enabled to examine anatomically was obtained from a diabetic patient, a girl nineteen years of age. II is a well-set tU'd fjict. tlial a devel- oping diabetic soft cataract of a youthful individual differs in no way in its appearance from any other soft cataract of yonth. The lens is tumescent, shows the well-known ])ciii-ly grey, radially-arranged silky opacities wliicli aitl us in recognizing the ai-rangement of the lens fibres around the an- terior pole; between these are the dark striations which are to he looked upon as the interspaces filled with the transparent fluid. The IniiDnntic cataract has exactly the same appearance when it occurs in a youthful in- dividual. Examination of such traumatic cataracts and the diabetic cata- ract has shown that they have this in common, that the interspaces and splits are especially pronounced and numerous, between the lamellae and the fibres, and that they are undoubtedly the cause of the opacities. It is worthy of special emphasis that the dark striations between the silky stria- tions which seem to be due to splits, on anatomical examination of trau- matic cataracts were found in reality to be due to splits. It is further worthy of note, that if one takes a lens denuded of its capsule and exposes it to the air until it is perfectly dry, it will split up similarly into small sectors. Eobinski '^ makes mention of the same fact. Hence, in the de- velopment of soft cataract of youthful individuals, we are likewise dealing with a splitting up of the lens, and in these cases the- peripheric lamellae are first attacked, the more centrally located, later on. Here the cloudiness of the lens, as it appears to the one making the examination, as well as the impermeability to light in the eye so affected, is caused by the differ- ence in the index of refraction of the lamellae as they are superimposed one over the other. Undoubtedly the individual lens fibres, and the lamellae composed of these, possess a greater index of refraction than the fluid which has accumulated between them. Though it be true that the fluid which accumulates in the interspaces in incipient senile cataract is simply tissue fluid which is normally present, hut in increased ((uantity, it is equally true that in the soft cataracts of youthful individuals the fluid which oeeu])ies these interspaces has fi'oiu the very beginning gained entrance in an abnormal way, namely, by dilfusion, from without into the capsule sac. This seems to be attested l)y the fact, that the substance which occupies these interspaces has an index of i-etVaction about equal to that of the aqueous. In traumatic cataracts the source of this fluid is 7 Augen Linsen Staare der Menschen nnd der Wirbelthiere Ceutralblatt f. d. Med. Wiss., 1877, Nos. 3 and 4. 82 evident. It enters through tlie wound in the eapsule. Subsetjuently, streams of diffusion between the fluid which has entered and the contents of the lens fibres, as well as between the lens and the aqueous through the capsule will take part. 'J'his liypotliesis seems necessary because at times we find the capsule closes again, and still the opacities increase. Fi'om the very beginning we have assumed streams of dift'usion to explain the development of diabetic cataract. Kveii in the consecutive cataracts of youthful individuals, the appear- ance is exactly that of the foregoing. Under such circumstances there de- velops, even in veiy advanced old age, as the result of the rapid taking up of water, a cataract with a soft cortex, and it appears that it may even .soften u]) a sclerosed nucleus. In these cases, no other explanation seems possible than that the addition of a pathologically changed nutritive fluid lias led to this splitting up. The taking up of water, the stage of tumesence in the soft cataract, just as in the senile cataract, is to be looked upon as the second stage of the formation of cataract. The subsequent changes are almost identical with those of senile cat- aract: oidy that we find appearing in the fibres of youthful individuals, especially after discission or a trauma, the well-known and frequently described raciiules in large numl)ers. The wavy contours of the tumescent peripheric fibres are very striking. Finally, the entire lens seems to take part in the cataractous degeneration, there being no hard nucleus. It seems much easier for calcareous deposits to take place in this final stage than in cataracts occurring in old age. CHAPTKll III. TPIE PATIIOIJXJJCAL (TIAXGKS IX TIIH IXTKACAPSULAR CELL'S. (JAPSULAR CATARACT. A. THE DECENERA^riVE CHAXGES. The degenerative processes are sharply differentiated from the phe- nomena of physiological retrogression already described. If oiu' may be ])ermitted to so express himself, the latter consists of an atrophy of the nuclei and cells, whereas we are luM-e dealing with a metamorphosis begin- ning in the nucleus, then atlVcting the entii-e cell; as a result the cells be- come changed into a |)ath()logical s\d)stanee, the chemical nature of which Jias not been as vet t'ullv detei'niiiu'd. 83 II. Miill.'i-. ill lii> llr>t t'^iiv on tlii> >iil)Jcct.'" (IcscrilM- iwo kiii of deposits oil the iiinci' >iirt;i(r of the jiiitcrior capsule He states, "Some of these exteiul over I lie >iirt'a(c and seem in prolilc as striations which are easilv (litVcrentialed fr.nii \\\r cap-nle: tor a crilaiii (li>tan(c tliey may sliow a reu-ular (h^uivc of lhi(knc». On tin' oilier hand, they may form ))la(pies with no evident connection with one anolhci'. I'litliei' llicv aiv adhcivtii by a hroad Hat i)ase. or they form ^lohnlo oi' icnpin-likc strnctnro. wlnc'.i show .ureal similarity lo the papillae of the iiescenieti> or the isolated "Drusen" (warty, hyaline excrescences) of ihe vitreous lamellae of the choroid." The substance which forni> tlie>e structures is very much like the capsule itself is transparent, and refract> the liuht. Ao-ain. it may not show >ucli a perfectly i-e.uiilar. liomo.-ieiioiis sti-iicture. but show yellowish li,i>hter and darker spots, even iiranular masses. This latter lonii of (iei> llie I Museii of Tlie elioroid. Becker states, lie was enabled to study from its very ineipieiiey. The cataract was preserved five weeks iu a 4'. per cent, solution of alet>h(»l. the capsule was stained with haemotoxylin. and a portion was then imbedded and cut: the larger portion was put up in glycerine. The specimen haviiit; u'rown pale in course of time, it was .stained again with l.aemotoxylin and eosin. aii.l tli.'U i.ut up in Canada balsam. This .specimen .showed long stietcli.'s of widl i.reserved ei)itiielinm and beautiful nuclei, nearly Jill the imclei l)einj: at rest. .\t otlier i)lawn. liiglily refracting substance, so that but one portion has taken up tlie blue .-oloring matter. Due to this change, the chromatic substanrusig" (h.valinet figures, which assume the most characteristic forms, and frequently extend over large areas. In th.'se globular, at times t1attem>d "nrusen." 1 have found stained nuclei enclosed. In all cases liiey are siirrouiKh'd at tlieir edges by nuclei, show- ing .'vidi'iues of karyokiiK'sis. Soinet lines the nuclei are smaller, tlieii again larger, and can lie plainly seen to surroiiiHl th.-se excresences. This capsule sliowed ili.-se formations in all their various stages, beginning la Untersuchimgen uber die (Jlasluite d.-s .\uges. etc.: und Uber die Anato- mische Verhaltnisse des Kapselstaars. Wttrzburger Sit/.ungsberichte. 1850. p. 254. 84 with the isolated nuclei just begiuuing to show ohaugcs up to the complicated formations 1.5 mm. in length, 1 mm. in width, and 0.5 mm. in height. At times this colloid (V) substance is covered with stained nuclei; again but a few are scattered around the base and edges; again, the interior of the hyaline mass is perfectly free, with but a few nuclei scattered around the edges. It is not often that one has tlie opportunity of observing, as in the above specimen, so distinctly, through all its stages of development, thv^ development of these hyaline masses out of the nuclei of the epithelium. There is, however, scarcely a capsule, covering a senile cataract which has existed for any length of time, on which one can not discover various stages in the develoi:)ment of tliese hyaline excresences. The frequency of this anatomical condition corresponds to the round, white, light reflecting .spots frequently observed on the inner surface of the anterior capsule, in over-ripe cataracts, mention of which was made above. B. NEW CELLULAR FORMATIONS WHICH DEVELOP FROM THE INTRACAPSULAR CELLS. a. REGENERATIVE NEW CELLULAR FORi\L\TION. ' In close proximity to the above-described hyaline excresences (Dru- sen), one always finds a greater or less numl)er of luu-lei which take the stain with avidity, are small, and show karyokinetic figures. Not infre- quently one finds perfect nests of these nuclei. On focusing these very carefully, one discovers tliat they are no longer in the same niveau as th'; capsular epithelium, bnt seem to ascend on the sides of these excresences. In cases in which these Drusen are very extensive on the inner surface of the capsule, these new-formed cells often take on great dimensions. They not only completely cover these excresences on their inner surface, but they seem to project into its very substance. JJoii-rrrr, it stIJJ iriiiains a question, whether these excresences. surromuted as llieij tire l)j/ strands of cetts. are nut from ttteir reri/ betjinainn forniat from othrr celts irhic't these enctuse. Tlius onr form of capsatar catdract is described. J). TIIF PIJOCESSFS AND PJfODl'CTS OF ATROPHIC XFAV ( ' IvL 1 .ULA R FORMATIONS. Aside fidiii tlic above-described cellular new formations around the hyaline cxci'esonccs. lU'cker states that lie was siicccssriil in finding on the inner siii-racc of cvci'v senile cataract wliich lie cxaiuinod. itcir ccttiitar formations. As they lia\c e.xci'ptionally been (it)ser\e(l in lenses which showed no i-loudiness. they can ]iot he looked u|)on either as the cause of cataract formation, or as one of its sc(|nences. Wo ralliei- suggest;- that the same cause which, dui'ing the senih' >ch'rosi>. is acli\(' in pi'oilucing the ■S5 leiiticuhii- catiirjicl.. lilc iiiducis lliis new cflluhii- roniial ion. Ho further makes the emphatic statement, that (ill >inr fnnndlidtis of rxlls ivilliin l/ir II II ill/ II red cd/isiilr iilinii/s hilrr llirir (irhjiii fnuii llir rellular ('h'liii'iils irliicli lire iKiniidlli/ prrsriil. Iluil is. fnnii llir found a layer of irregular cells on the postcjior ca])sule." lie refers to this again in his following publications (pp. -iiil, •^(iO, 'i::. -i^o). IwanolV studied this condition of the epithelium in eyes which had been enucleated on account of disease. He states/ '"The cells which are most sensitive and earliest affected by IBeitrag zur Path. Anatoniie des HernhaiU uud Linsen Epitliel. racren- stechers Klin Beobachtungen, Bd. III. p. 12(!. 86 irritation are the formative cells of the h'ns." Every time one of the above diseased conditions begins to act, tlic lens swells and the formative cells are affected. Tlie piodiict of these formative cells is normally epithelial cells arranged on the innci- surface of the anterior ca])sule. as new lens fibres and as r/iillirli iiiii on Ihe /los/rrinr r more swollen, the nuclei easily nndei'go fission, and in fact ap- pears to ])ossess but little viability(?). The ei)ithelium on the posterior cap- sule easily undergoes degeneration, (colloid, mucoid), hence one so often sees these large, transparent, variously shaped vesicles, containing a nucleus which has been pushed to one side." II. Mil Her made all his investigations on cataractous lenses. Ifence it is of interi'st to note that he likewise drew attention to the ra])id disintegra- tion of the nuclei of these new-formed epithelial cells, and he likewise looks u])on the equatorial zone as tlieii- source of origin. (Jayet- likewise investigated the question. He believed that as a result of the formation of these vesicular cells, which are altei'cd epithelial cells, the neighboring normal epithelial cells are pushed aside, and as a i-esult are found alon.r the posterior c^apsule. Becker states that he is satisfied that "the epithelial covering of the posterior capsule is derived from the surface growth of the antiM'ioi' epi- thelium. This, however, can only begin to act when the lens whorl, as such, has ceased to exist." He denies the existence of the so-called fnniKt- tive cells m the sense in which von Keeker used them: he states, however, that "the pathological ])roduction of new cells takes ]>lace. nevertheless, from that region where m)rmally the growth and regeneration of the epi- thelium takes ])lace. The cells, howevei-. as they are forced backward, are not changed into lens fibres tlir(nigh tlu' medium of the lens whorl, since either the lens whorl no longer exists, or since the meebanii-al condition-- themselves are changed. As a result, the cells are pushed past the positioti of the whoi'l. far backward, and thus to a gicater or less extiMit cover the innei- surface of the posterior capsule. On this account, changes along the lens whoi'l in catai-acts are of great imporlaiice. In fact, it st'cms that whenevei- a cataract has advanced to atiy degi the whorl and the capsule, also with the youn The mechanical conditions are changed need no loiigei' o\erconie >o much pres>ui'e. and ih themselves on the one hand in between the cji 2 Sin- nil I'oiul d"! listolu-ie dc la ( ':it:ira<-t( XXXUl. 1). ir.. Ihc connection between libl e>. is loose lU'd up." far. that the 1 lew cells hu> can pu-li ; n.l fonv eliui n and the posterior 87 capsule, aiul the lens lihi-cs, on I lie oilici- liiind, i-clativcl v >|»c;ikiii^-, willidiit any hiiulranee wliatevei-. and iiiidci- imicli less pressure, lieiicc tliey develop into the lai'uc vesicular cells dii'cclly to he descrihed. or. as epilhelial cells, perniil themselves to push hackward lo the posterior capsule. In eonipli- oated cataracts one can often accuratelv follow the direction which thev take. As t-onipart'd with ihe epithelial cells on the po>lei'ioi- capsule which disclose departures from the normal, we fri'(pieiitly meet with vesicular cells in the region of the whorl. Thei'e can be nt) doubt but thai these new cells again produce cells. Xot only are tlie^e large vesiculai- cells formed, but in rare cases, structures whicli are identical with the so-called capsular cataracts of the anterior capsule. r>orh the pseudo-epithelium on the postei'ior capsule, as well as those vesiculai- cells along the i's changed into a vesicle, in which the nuclens atrophies, and gradnally nndergoes a fatty defreueration. These greatly enlarged vesicular cells, owing to pressure against each otlier. assume polyhedral shapes, and press those cells which have not undergone such a change into characteristic angular shapes; they then become granular, and tiually disappear. This vesicular de- generation of the epithelial cells necessarily leads to a surface enlargement of the entire epithelial layer, and according to Gayet explains the cause for the spreading of the epithelium to the posterior capsule." Becker denies that lie has ever noted such changes during the forma- tion of these vesicular cells, and states that we do not as yet possess a satisfactory explanation of this peculiar change. Is this hyaline or colloid, or is it a peculiar hydropsie of the individual cells? The vesicular changes are most easily studied along the equatorial line of secondary cataracts, and in all probability a study of their development here will aid us in clearing up the processes which form the basis of this change. Since the days of Yrolick and Sommering we know that after a reclination or extraction the cells along the lens whorl remain in the cap- sule. After the operation the production of cells springs up anew. How- ever, the mechanical conditions being changed, these cells become flat, and on cross section are no longer six-sided lens fibres, but assume irregular polyhedral shapes, similar to the vesicular cells found in cataracts within uninjured capsules. The pressure being removed, the lens fibres along the equatorial region, those which have remained dormant for years, become active again, and now being developed under a reduced pressure, do not form fibres, but assume polyhedral shapes. Becker describes a second mode of development. A peculiar change of the protoplasm around the nucleus occurs in the cells at the equator. It becomes thickened, more highly refractive, inA^olves either the entire thickness of the fibre, or leaves a portion of the substance of the fibre to one side, and thus seems to be- come constructed at first into an ellijitical, finally iuto a globular disk. All this time the nucleus appears to be at rest. Xotwithstanding the great dif- ference which exists regarding the mode of development of the vesicular cells, the question must still remain an unanswered one. as to whether they possess anything more in common than their form. Concerning the rela- tion of these cells to cataract formation, these di (Terences are of but littlo moment, since the cells developed according to the second method are very few. '^i'he large cells are especially ])r(uie to dcgeiuM-ation. Their nuclei show all the evidences of a gradual death. The hordcrs of the cells become indistinct and the conteiils (»!' ncighhoring cells i-un togclher. rorniiug a homogenous jnass. JwanolT (b'signated this change as colloid or ntucoid. •S9 Since the occurroiiee of mucin in llic capsule sac lias nur been jn'oven and since this chanii^ed product does not give the reaction of colloid material, both names are improper. Becker states that it would he more correct to speak of them as hydropsical cells. Tlie supposition that the disintegra- tion of the vesicular cells aids in l)i'iimiii,i;- iihout the tlnidily in cases ot cataracta ^lorgagni has uiuch in il> favor. Becker's view, tliat all ca|)>ular cataracts are the result of a h3'per- plasia of the capsnlar epiiht'linm. is today accepted. He believed (Anat- omy, p. 7«i) that the hyahiie processes of the newly developed cells in some manner softened up the ca])sule. worked their way in between the layers (?) of the capsnle. thus splitting it. and that the capsular cataract then de- veloped in this sijace. As long ago as 1S.5S, H. ^lullcr di'ew attention to the great similarity between capsular cataracts and connective tissue, and np to within a few- years this formed one of the nicest questions in the whole range of the study of ocular |)atliology. (leneral patluilogy teaches that connective ti.ssue structures must he forjned from cells of tlu' mesoderm, and hence can not be derived from the ectoderm. Manfredi ^ attempted to overcome the difficulties in the way, by declaring that a capsular cataract could only form after an injury to the cajisule, and where it had been made possible for cells of the mesoderm — that is, connective tissue cells — to gain entrance, and thus further produce connective tissue cells; and thus he positively asserts that capsular cataracts is a connective tissue structure. Leber ^ bases his utterances on examination made on capsular cataracts experimentally ])roduced. He expressly states, that he excluded all elements which might have entered from without. Notwithstanding this, he designates the tissue of a "true" or "genuine" ca])sular cataract as connective, Ussne-lil-e. and states that he verified to his own satisfaction "that from a tissue which originates from the ectoderm, hence which is a true epithelial tissue, a substance can be produced which has the structure of connective tissue." Becker struck the pro])e]- chord, when lie pointed out. that this question would eventually he settled as the roult of chemical investigation. The question presents different features when there has been a solu- tion of continuity of the capsule. Here one can not so easily exclude the entrance of foreign elements. Nevertheless, as the result of two series of i "Discussion sur la Cataraete Capsulaire." Compte rendu du Congres Pe- riodique Internat. d Opthal. de Milan, 1881. 5"Zur Pathol, der Linse." Zehender's Kliu. MonatslMatt. Beilaslioft. p. 33. Verb, der Heidelberg Gesell, 1878. 90 experimental iiivesti^^ations piir.-ucd uiidei- the direction of Prof. Leber, R. Wengler,^^ and II. Soluichard.-''^ the |)osition was taken that capsular circatrices are due to a liyperj)hasia of ca])sular e[)ithelinni. whereas in a later work by ('. Scldosser •'''■ tlie old \iew is asserted that the cicatrix is of coiinective tissue ori>rin. He states that tiie ca))suhir cicatrix is made up of connective tissue fibres, tbe only portion which is of epitbelial origin being the layer of epithelial cells and tlie structureless membrane which separates the cicatrix from the lens proper. Uut he ignores entirely the question, from whence these connective tissue cells may come. This whole subject has finally been most scientifically investigated by Otto Schirmer.^ He first studied the formation of artificially produced capsular cicatrices in i-abbits* eves. CAPSULAR CICATRICES. Immediately upon rupturing the capsule, the aqueous acts on the lens fibres, c-auses them to swell up. and unless the rupture is very great, the opening is soon plugged up by a thin, fibrinous covering which clothes the point where the defect in the capsule exists. Examinations made dur- ing the first few days show present in this fibrinous exudate two kinds of nuclei: first, degenerated forms of epithelial and lens fibre nuclei, and sec- ond, a few leucocytes. Schirmer states that he found a fully formed cicatrix as early as the third day. He looks upon this regenerative process as the result of a liyi)erphasia of the capsular epithelium because: First, the defect heals from the margin: second, the cicatrix gradually goes over the nonnal capsule; third, because at the beginning the cicatrix has a j)e euliar structure consisting of spindle cells without the presence of an intercellular substance: fourth, because of the possibility of demonstrating all the gradual, internu^diate steps between epithelial and s])indle cells: hfth. the epithelial a])pearance of the nuclei in the cicatrix: sixth, the lack of pigment: and. linally, seventh, because of the relatively small number of cells found in the fibrinous membrane which have a different appearance from the general mass of cells found in the cicatrix." Following the formation of the cicatrix, the filu-inous veil on the sur- face is absorbed by the a(|Ucoiis. and no doubt the cells which it encloses are destroyed at the same tiuu'. In the courst' of the next few weeks thi- 5a L'ber die Helhuifrs Vorjranjre nacli Verlctznniicn dcr Vodcvn I>iuspnkaps«'l. Inaug:. Dissert. (Joettiuficn. 1.S74. 5b "Zur Path. Anatoiiiic der Discission." Inaiij.'. Dissert. (Jocttiiijjjeii. 1ST8. 5c Experimentellc Studi«' uber Trauniatische Cataract. Mnnchen. 1887. 6 "Histolojrisclic und IlistoclK'niisclie rntersuchungen uber das IMiysiolo- jjische Wachstlmiii und (lie Structure d.>i' N'odcrii Linsenl^apsel." Otto Scliirnicr. <5raef Arch., XX.W. I'.. 1. iss'.i. I 91 ciciiti'ix ,i:ivcs diic tlic iiiiprosioii kF Itccdiniiii: >iii;illci-. Alxml the middle ..r the (ii'st iiKUilli, (MIC ohxM'vcs tli;il llic ('|iil licli iini -r;i(lii;i lly cxh-nds ;is ;i .-inylt' liivci- nwv the iniifi- siirrjicc (if the citiiliiN. iiiiljl it liiuillx i'iitii-('Iv coNci-.s ill llic cicjitrix. At once the cpit licliiiiii l)c,i;iii> lo cxcrcU' a vitrctMis laiiiclla (if new capsular siil)>tancc. wliicli i^radiially increases in lliickiios. and in cvcrv case this new -formed >iil)>taiice can lie followed for a cei'tain distance on to the old ca|isiilc. In the he-inning- we are dealin,u- with spindle cells, later they arc imheddcd in a livaline substance which the >piii(lle cells excrete.' in course of lime the nuclei all disap- pear and thei'c i> left a homo.yeiious cicatrical tis>iie. covered hy a layer of epithelial cells and the vitreous lamella, and with this sta.ue. the process of the formation of a capsular cicatrix is coni|)leled. As a rule, the injury causes a minute, circumscript area of disinte.yral ion of lens tissue, siir- rouiuled hy transparent lens substance, and as the new lens fibres develop and increase in lcii,i:th and extend toward the anterior pole, they force their way between the cicatrix and the mass of detritus, so thai a "cavity of detritus" is formed which is gradually forced towai'd the centre of the lens. THUE CAPSULAR CATAliACJ'. Here there has never been a rupture of the capsule, hence tliere can be no ([uestion as to the origin of tlie new structure, it being the result entirely of the hyi)erplasia of ei)ithelial cells. It is immaterial whether this be a congenital formation; that is, developed during foetal life; whether it develop during childhood, be the residt of a blenorrhoea neonatorum or otherwise caused corneal perforation, a primary cataract formation, or secondary to senile cataract, or whether it l)e a partial phenomenon of a rafanirht nuisrciil I ra or the principal portion of a ralfinirhi s(rundaria(M\\\ to l)e considered) or of a traumatic cataract (as has been demonstrali'd above), (ill (itr llw result of a InuMT/ilntsid nf llir rd psiiJar ('pilhcliinii. lU'cker states (Anatoinie. p. l.")). ••Depending on some cause as yet unknown to us, this byperpla>ia may at once undergo a retrogressive metaiiKU'phosis. and as a result of a repetition of the m'iginal process lead to the formation of a capsular cataract of a greater (U- less thickness." The original hyper])Iasia of e])ithelial cells may be looked upon as the first stdfic Next, thcsi- cells elongate and take on spindle shapes, not roniwrlire tissue), and imbed themselves in a peculiar hyaline s\d)stance which they themselves excivte, and this forms the seroud sifuje. This is followed by a surface growth across this new formation of the normal capsular epi- 7 Leber— "Znr Patholofrie der I.iiise." Bericlit der lltli Opth. (lesellshaft, ITeidelbcrs. ISTS. 92 tlieliuin. till' third sIikjc. and finally tliis normal ('})itlR'liuiu excretes a livalinc siil)staiice. cwaetly like llu' true capsular substance, the fourth sldf/e. If the causative factor continues, a second capsular cataract may develop from this epithelial layer, etc. Becker tried hard to prove that the membrane which covers the capsular cataract is derived from a splitting of the true capsule. Schirmer, however, showed that this theory is not tenable, because, first, ''this is an excretion -of the capsular epithelium; secondly, why should it be possible for cells to get in between the layers and split the vitreous lamellae from within, when it has been shown to be an impossibility to do so from without? Further, these splits could only be followed as fine lines, but no one ever observed a veritable se])aration. nor has anvone ever recorded the observation of the beginning of such a split."* The fact that one seldom finds the capsular cataract completely covered with epithelium is possibly due to the growth of the cataract. The age of the patient may play an important role, for Schirmer noted that in senile- cataracts the epithelial covering of the capsular cataract is not so com- plete as in the complicated cases which occur most frec[uently in younger individuals. The structure of the true capsular cataract bears a striking likeness to connective tissue. Teased specimens morphologically were shown ti have the same structure as the capsular cicatrices. Schirmer, using Ewald and Kuhne's digestive method (referred to on ])age ^(i) as his main stay, chemically tested capsular cicatrices and cap- sular cataracts and found them both to consist of identical tissue, whicli does not give the same reaction as connective tissiie. Both gave the same reaction as the capsule, a not inconsiderable proof that the capsule, as well as its pathological formations, are derived from the same source, namely. prodncts of the epittudliiiii of the nutorior capsule. Schirmer, usins a very simple apparatus, made liis experiments in the fol- lowing manner: Two small dishes, one a little larj;er than tlie otlier, were placed on top of each other, so as to form a wet chamber. A third smaller one was placed inside of these, and this latter was covered with a glass slide. Dur- ing the experiments just sufficient fluid (salicylic acid solution, 0.5 per cent.) was placed in tlie wet chamber so as just to toncli the glass slide. The digestive process was either carried on in the small dish, or more frequently on the glass slide. In the latter method, the cover glass was supported on the one side by a piece of glass fastened to the slide, tlius forming a triangular chamber, in which the object to be tested was itlaced. .md here it could likewise be ob- served under liigli poweis of the luicroscope. 'I'he digestive solution was made from the extract of llic i»aiirreas of the calf, to wliich was added five times its weight of a (>.."• per cent, solution of salicylic acid, and then l ilc.iii-t'cs. ('(.nlrol cxiici-iiufiiis were iii;idc ;il ilic smmic tiiur wiili normal capsular substance. XoniiMl cniisulcs of iiius" and raiiliits" Icuses were easily di.uested in from five lo six liours. Allowing ilicm to i-i'inaiii in aicoliol for eiirlit days did not alter this power, wlicrcas. if .iliowcd lo i-ciiiaiii for several montlis. tile tissues were decidedly more resisieul. .-lud always leli a liaky mass behind. If llie sections were imbedded in celloidin. they could be iefi foi- days in the dificstive fluid without beinj;- aeled on. Since alcohol and etlier did not delay the dijjestion, one must assume tliai the celloidin penetrated the rjssue and made it indijrestablc. If tlie capsule was previously treated witii 1 per cent, osmic acid solution, ilieii waslied out in watei-. the capsule l»ec;imc more resistant, and all tlu' more so the louder the capsule had remained in tlie osmic acid. Capsular cicatrices and capsular cataracts nave identically the same reac- tion to trypsin as did tlie normal cai)side. 77/r HoiliiKj Experiment.— It is well known that boiliii.u will lead to a solution of tibrillae. and on cooling lead to the formation of a .jelly. Accordinii' to Arnold and Ritter.s after boiling for several houis. a solution does take place, but no jelly forms on cooling. One centimeter of water is sufficient to dissolve the anterior capsule. Capsular cataracts and capsular cicatrices showed the same properties, but did not form a .ielly on cooling. Thin pieces of connective tissue allowed to. swell up in a 1 per cent, sidution of sulphuric acid; here the fibrillae dissolve in water at 40 degrees C. and the floccnli M-hich remain consists of elastic tissues and cells. The capsule, capsular cicatrices and capsular cata- racts do not dissolve in similar treatment. The slight resistance of the capsule to strong acids is well known, especially to nitric acid, which in but moderative concentration, can bring about solution. The same is true of capsular cicatrices and capsular cataracts. The reaction is especially characteristic as compared with elastic tissue. Schirmer's conclusions, which are eeiierally accepted today, are as follows: "First. Capsttlar cataracts and capsular t-icat rices devclo]i front the anterior capsular epithelium without the aid of otlier tissues. '\Secon(L Both are a tisstie sui tjeneris. morphologically like con- nective tissue, chemically diifering from this, but both capsular cicatrices and cataracts are alike. ''Third. Chemically, a.^ide from the cells. ])oth are identical with the capsular substance. Morpholooically. both forms of capsular cataracts 8 Die Linse und das Strahlen Platchen. Graef Saemisch Handbuch. Bd. 1, S. 288 and 21G, 1874. 94 consist of elon- ,sule by (liapedesis. I )eutsclnnau '" (piotes Floi'iani " as expressing himself in favor of the endogenous fmiuation of pus. Ihuitscliiuan. however, do- 9 Anatomie, p. 77. 10 "Dio ViM-anderunfrcn in der T>inse bei Kiterprocessen im .\n.i:e." .\rcli. f. Opth.. B(l. XXVI. 1. p. l.U. 11 Studio Kxperinieiitelle Sulla IiUlainnial ione del Crista'lino. Anna di Otial, ]S71. p. ]4.-)-1S is always pi'ccfdcd liy dcsl iMict ion fif llic capsnlc Since the lens is an epithelial stiaictni'e. the \)\\> eelU iiiiisl come IVoni without. In cases whoiv thei-e had heen an injiirv lo the ca|)>ule. their |>i'e.-.ence was easily oxi)laine(l. hut it has heen known U)V a l(ui>:- time that there are cases of spontaneous purulent inllanimation in which the presence of the |)us cells could not he so easily explained. The (pieslion to be decided was. did the cells wander throu>;h the capsule hy diapedesis. or was the capsule first destroyed as the i-esult of a "meltinj:- away" of the tissney in his experimental investigations. Dentschman ((pioted as above) demonstrated that a local perforation and softenin,i|- of the cajtsule did occnr, and that entrance to the pus cells was thus jiivcn. and he concluded that before this occurred not a sin<,de pus cell conld enter. tbou«ib the len.s be imbedded in |)us. Both Leber ^- and Wao-enman ^^ corroborated these investigations. Leber states: "Aside from the larger holes, numerous microscopical perforations are observed, in which solitary- or groups of celL are found, and between these cocci.'" Wagenman suggested that it ap- ])eared as though the cocci first entered the capsule, and that the ])us cell- then follow^ed. Otherwise, he states, it w^ould be difficult to ex|)lain whv these perforations should occur in circumscribed areas, rather than attack the entire surface of the ca])sule to an equal degree. Thus there still re- mained to be explained, what it is that i)r()duces this softening and *'melt- ing down" of the ca])sule. This Leber has done in his exhaustive, critical and experimental work. "Die Entstehung der Kntzundung und der AVirkung der Entzundung erregenden Schadlichkeiten," Leipsig. 1891; and he has made it the subject oH s])ecial observation and criticism in the 38th chapter. "Purulent softening and 'melting down" of tissues." IJe states (p. rrl'^) that "a purulent exudate free of nncrobes contains an niziini which has a fluidifying eflt'ect on tibrin. gellatin and dead animal tissue: that this enzym is produced hi/ llir leucoci/tes, l)ut acts independently id' them (m surrounding tissues. In puiulent inflammations this enzi/iii is the prin- cipal factor in dissolving tibrin and animal tissues, and also in pivventing the coagulation of fibi-in. The prt'vention of t'oagulation is due to the fact tliat the fibrinogen in the exudate or the alivady coagidated tibi'in is con- \'.'rted into a non-coagul)le pepton-like substance by the action of the llaKxperiuieiitelle fntersiiclnniiien ur (Jeiiese der Erworbeiien Kapsel Cat- aract. Inau.u-. Dissert. ISTC lliBericht nber die XX Vers, .roi.th. (;essel, ISS'.t. Zeliender-s M.. R 1. XXYII. Beila.sh Heft.. 8-45. 13 "Uber die von Operationsnarbeii und Vernarltten Iris vorlalleii aii-elionde 01asl. 96 euzyiii prodiKi'd l)y tln' pus cells." lie fni'tlici- cxpicsscs tlu' Ix'licf tliat the solution of organic substances iakcu up in ilic cells, which Metschiiikoif designates as intracellular digestion, i.v possibly due to the action of the same enzyni as the above-desci-ibed. in the extracellular processes of solu- tion. Leber uses the expression liisfali/sc to designate' Ibis purulent soft- ening and melting down of tissue, 'i'his he ascribes to cheiincal changes similar in tlieii- action to the pi'ocesses of digestion. The changes, he con- tends, are essentially chemical in their nature and dependent on the action of a I'crmeiit. "(hemical. not nu'chauical forces ha\e the power of con- verting lirm oiganic- substances into the fluid state, and the microscopical examination of tissues undergoing jjurulent iniilt ration demonstrates thac its elenumts are undergoing a chemical change." .Xunu-rous investigators contend that the enzyui is ])roduced by the micnj-organisms. but Leber contends that though the microbes may take part in hastening the disin- tegration of tissues, the essentially active principle is derived from the leucocyte^. 1'hough the suljject is not as yet absolutely settled, nor as yet fully explained, we nury nevertheless look u|)on this ferment, this enzym, as the essential factor, which, acting on the capsule, digests it and thiis prepares the way for the pus cells to gain entrance into the lens. CHAPTER IV. THE GEXEEAL PATHOLOGY AXD PATH0GE:NES1S OF THE LEXS. I. THE PROGRESSIA^E GHAXGES IN THE LENS. Becker states, "In all the non-traumatic cataracts which he examined he observed a new celluhir formation, exceeding the normal, which was derived from the caj^sidar epithelium." Exceptionally, he observed this condition in the lense> of individuals, which during life had shown no signs of cataract. If we will now cojisider this as the most important fact so far settled, the duty remains 1o discover the cause, which incites this hyperplasia of capsular cells during Ibe formation of a cataract. .\s we have seen, this abnoj'mal cellular pi-oduclion discloses itself. Iii-sl. as a hypi'r- phasia of the cai)sular epithelium, which is added to the foi-mation of hya- line excresejices: second, as a byper|)hasia of the capsular epithelium, lead- ing iinally to Ihe formation of a capsular cataract: Ihii'd. in the formation of large vesicular cells: fourth, in the formation of an epithelial-like cover- 97 ing wliich clothes the imicr .-iirrnrc of the i.oslci-ior (iiii.-iilc. All vjirii'tk-s of new cellular t'di'inations aiv observed in ilie ditVereiit i'orius of grey cata- ract, though in various degrees and under vaiidiis eunditions. ft is a renin d'ahle fact, hoirrrrr. Iliat nillirh/ Jijji-rrtil en uses irilliiii find milsifJe of the lens lead to similar format Ions. 1. CAUSES OF TlIK ABNORMAL NEW CELLULAIJ I'Oh'Al A'JMOXS IN SENILE CATARAl'T. Tu the early chapters of this work, special stress was laid on the pressure which the closed lens eapsnle exertg on the form and size of the individual lens fibres, as well as on the entire architecture of the lens. As age advances, the lens gradually becomes more rigid and the capsule less elastic, and in consequence of the increasing ]>ressure. tliis at lirst, impedes and gradually leads to entire cessation of increase in its volume. After tlie pressure reaches a certain degree, the cells lose their power of undergoing cell division. The degree of intracapsular pressure is dependent on the relation which two processes bear to each other, during the entire period of growth of the lens. These are the actual processes of physiological groirth; as seen in the increase of the capsular epithelium, the formation of new lens fibres, and the resulting increase of surface space of the capsule and the total in- crease in the volume of the lens; and subsequently the physiological retro- gression of the lens fibres^ which as soon as they have reached the rays of the star figure of the lens and have completed their growth, begin to undergo retrograde changes in all three dimensions. The first process pro- duces an increase in volume, whereas the second produces a reduction in volume. As age advances, the phenomena of growth become less active, whereas those of retrogression become more a])parent. the nuire the ele ments are affected. From this it must follow, generally speaking, that a period will be reached, when both processes, relative to their influence on the lens, will be evenly balanced. Priestly Smith, basing his statement on a series of weighings, found that under normal conditions this period is only reached in very advanced life. T^p to the ninetieth year, he always found a number of lenses which showed a steady increase both in weight and volume. This is in accord with the anatomical examinations, also with the steady and gradual de- crease in the ^vidth of accommodation. The former, as well as the latter, indicate that there must be a true balance between these two antagonistic processes, though in fact this is oidy reached in very extreme age. Priestly Smith also found a less nuud)er of senile lenses, as compared with other lenses taken from individuals of the same age which were more 98 or less i-;itai-;u-(()ii>. or dilVcrcntly expressed. !ie I'oiiiid tliat all rhiiKhj Irnaes, ercii lliosr ir/iicli irrrc hiil /Kiiiidlli/ cIduiIji Inul a red need vol nine. After thai w liicdi has been said in a |)re\ioiis chapter, ire enn on/i/ seek for III Is en use iif red ml Inn In ml nine In I lie elieinleni enndlllnns nf Ihe n miens id llie enlnrnel ns eonijxired irilli llinl nf Hie mm-ehindi/ lens. (I'a,ux-(i:.) The eapside and its adherent peripheric lainelhie as fa]- as the ehisticity of the capsnh' and its connection witli the zoinda will peiMnit. will foUow the ui'adua) decreasint push themselves in between the older and force these more toward the (Mpiator. l)ut the young cells are either forced inward and swell u]). forming lai-ge vesicles, or they undergo hyper- plasia, forming a capsular cataract. Finally, after destroying the whorl and loosening up the tibi-es from the posterior caj^sule. these new-formed celk are pushed over the posterior capsule, thus forming a soi-t of epithelial covering for th,. same .Xotwithstaiuling the gi-eat morphological ditl'er- ence, vesicular cells may secondarily be developed from these cells; also Irue capsular cataracts. I>eckei- ' di'ew attention to the peculiar cii-cumstance that in the forma- tion of Sommering's crystalline pearl, the secnndnri/ enlnrnel was formed from tlu' epithelial cells derived from the wlun-l. These cells, after having remainc'd almost t(»tally inactive for many years, suddeidy undergo active repi'oduction again. One might almost suppose that the impetus to the i-egeiu'ration is due to the enti'ance of foi-eign elenu'uts. which gain en- trance aftei' Ihe capsule i> opened. The nbsVnre nf prnper relnllnns nf pressvre. is cei'taiidy one n\' ihe causes of ihe hyperplasia of cells and the formation of a st'condarv cataract. 1 "Krystalwulst." Zehendor's Klin. .Mount shin tier. 1875. j). 445. 99 The contents of the lens capsule can never be made up of cells other than epithelial cells, except when the capsule has been ruptured. Tlie secondary cataracts may be divided into two classes: First, the simple secondary cataract, in which the cataract is the result of a hyper- plasia of the epithelial cells which line the anterior capsule. Tliis is a true epithelial structure. Second, the acute and inflammatory secondary cataract is one, which, per example, follows an iritis in which anterior synechia form, large num- bers of leucocytes are thrown out, fibrin is formed on the capsule; this gradually undergoes a formative process, and as a result a membrane is formed on the external surface of the anterior capsule. This is a con- nective tissue formation. 2. THE CAUSES OF THE XOEMAL NEW CELLULAR FORMA- TIONS IN CONSECUTIVE CATARACTS. As consecutive cataract, we designate every variety of cataract which can be diagnosticated both clinically and anatomically as a disease of the eye, and which, with a eertiain degree of regularity, occurs as a complication of some general disease process of the body, and which has also been shown to occur as a complication of disease in other portions of the eye. Hence all cataracts occurring in both eyes of an individual due to constitutional diseases (diatheses), also all total cataracts due to chronic or acute diseases of an eye, and all partial cataracts which occur subsequent to the local action of a disease of the eye, belong to this category. All of these diseased conditions lead to an abnormal production of cells inside of the capsule. -4. CONSTITUTIONAL CATARACT. a. CATARACTA DIABETICA. Of all the cataracts said to follow a diathesis, the one said to occur during diabetes mellitus has been most positively determined. By the demonstration of the fact, that sugar is present in the vitreous and in the lens, the abnormal condition of the nutritive supply to the lens has been proven. The formation of the vesicular cells which have been observed in diabetic cataract can only be ascribed to this abnormal nutritive supply. However, since, in all cases of diabetic cataract, a large increase in the volume of the lens has been observed clinically, and since it has been shown this is due to the taking up of water, it would be possible for this unusual condition to lead to a softening and swelling up of the capsule and also to a passing reduction of the intracapsular pressure. We would lOO then have as favorable conditions for the hvperphisia of cells, a reduction of hindrance to growth, and an increased amount and abnormal constitu- tion of the nutritive fluids. At the same time, attention is drawn to the fact, that a large part of the fluid contained within the capsule does not enter with the nutritive supply in the physiological way, but by diffusion through both the anterior and posterior capsule. h. CATAEACTA CHORIOIDEALIS. The total cataracts which occur subsequent to disease of the posterior segment of the eyeball are especially prone, as Iwanoff ^ noted, to the formation of enormous intracapsular hyperplasias, both in those cases in which the lens is surrounded by the fluid media, as well as in those in which abnormal connections have been formed as the result of detach- ment of the retina*, intraocular tumors, cyclitic, iridocyclitic or iritic bands of new-formed tssue, or as the result of simple iritic adhesions. Since the final result of all these cells is the same in all the above- named conditions, it might be correct to seek the cause in a pathologically changed nutritive material, which is carried to the lens and which is the real cause of the hypei-plasia of the cells. In cases of extensive adhesions, interference with the exchange and the giving off of products of decomposi- tion must likewise be considered. Contact with the capsule may lead to softening and thus permit of an abnormal entrance of nutritive fluid, and thus lead to a hyperplasia of the intracapsular epithelium. Often but a few days are requisite for the entire posterior capsule to become covered on its inner surface with a layer of epithelium. c. CONSECUTIVE PARTIAL CATARACT. ANTERIOR POLAR CATARACT. For the present let us ignore the congenital forms of anterior axial cataract. In the acquired form of anterior polar cataract, the conditions are such, that following a perforation of the cornea and evacuation of the aqueous, the pupillary portion of the anterior capsule comes in contact with the surface of the ulceration. A relatively short time is sufficient to arouse the cells lying at this point inside the capsule to undergo a hyper- plasia. The localized extent of this new formation permits us to conclude that this has resulted from a localized cause. Further, it is certain that at this point, we are dealing with a nutritive flow which is both abnormal in its direction, and in its constitution. There can be hardly a doubt, but 2 "Beitrag zur Pathologischen Anatomie des Hornhaut und Llnsenepithels.' Pagensteeher's Klin. Beobachtungen. Bd. Ill, p. 12G. lOI that the contact with the pathological secretion of an ulcer, softens th*; capsule in a circumscribed area, (Muller), that it becomes less resistant and places the cells on its inner surface in a condition of reduced pressure. The change of form which the capsule assumes, in the formation of a cataract a pi/ramidaUs seems to be favorable to this theory. However, the increased and pathological condition of the nutritive fluid will surely take a greater part in the cause of this hyperplasia, than the reduction of tension. Further, one must not forget that this form of cataract is most frequently seen in youthful individuals, in whom undoubtedly the cells more easily divide and increase! Those eases of pathological hyperplasia of the intracapsular cells which develop after corneal ulcers and chronic inflammatory processes of the whole eye, especially in its posterior segment, if they lead to capsular cataracts which can be diagnosed, are known as inflammatory, in contradistinction to the non-inflammatory, which develop in senile cataract during the stage of over-ripeness. After the identity of both had been anatomically established, Becker attempted to characterize the hyper- plasia, as the result in part of an "atrophic hyperplasia" partly due to an increased nutritive supply. At the present day we are in a position to recognize the fact that both conditions are identical, though incited by a variety of different causes. In the more restricted sense, we can not today look upon the acquired anterior capsular cataract as an inflammatory hyperplasia or new cellular formation. If, for clinical reason, it may appear desirable to retain the expression, '^inflammatory capsular cloudiness," or "inflammatory capsular cataract," it should only be used in the sense, that there are capsular cataracts, the formation of which are due to inflammatory processes occurring in other parts of the eye. REGENERATIVE CELLULAR HYPERPLASIA. On page 84, a form of capsular epithelium was briefly referred to, which must once more be briefly reconsidered. In the neighborhood of the hyaline excresences, the epithelium almost invariably show a great tendency to divide and in- crease. Here the principle of "atrophic hyperplasia" can not be applied, because the increase is confined to a limited area, in the immediate neigh- borhood of the hyaline excresences. For this very reason it seems most probable that this is a regenerative process. As the result of the colloid metamorphosis, a part of the epithelium having been lost, the effort to re- produce this, leads to cellular fission and increase. Another fact which demands an explanation is the localized growth of the capsular cataract. We have seen that it most frequently begins in the centre of the anterior capsule; at times it covers large surface areas, and in exceptional cases the entire capsule. Undoubtedly, this is in some manner influenced by the direction of the stream of normal and pathological nutritive fluid. Ex- ceptionally, the cai>sule is from 1 to 2 mm. in thickness, whereas, under normal conditions it is not over ^ mm. The abnormally large and thick capsular cataracts are nearly always found in the consecutive and compli- cated cataracts. Certain varieties of shrunken cataracts, which appear to be congenital or acquired during early life, consist simply of a thickened capsular cata- ract enclosed in a folded capsule. Here there has been a very active hyper- plasia of the intracapsular cells; the new formation of cells, however, has not been sufficient to fill the entire space enclosed by the capsule, but has rather exhausted itself before going so far. To explain this fact one, might be permitted to quote a remark made by Ziegler.2 He draws attention to the fact that, Just as in the fermenta tion of alcohol, the increase of the yeast plant ceases, when the amount of alcohol has readied a certain quantity; similarly, the increase of both con- nective tissue and epithelium become restricted in their fomiative powers by their own products. For the former, it is the formation of an inter- cellular substance; for the latter, it is the intimate relation, brought about by the cement substance, which restricts the further growth. Vice versa. the solution of the intercellular substance, and the loosening up of the epi- thelium can again start up this hyperplasia. If we will now apply this idea to capsular cataract, one would say, that it is the change of tlie body of the cell into a dense, thicl-, intercellular substance, which there acts as the limit- ing factor. This explains the reason, why it is that we fail to find the evi- dence of the cellular hyperplasia which has taken place, in fully formed capsular cataracts or in the congenital membranous cataracts. In this is also to be found the reason, that one never finds a hyperplasia of cells which becomes greater than the size of the lens, and why it is that there are no tumors of the lens. II. KETR0GKES8IVE CHANGES. a. THE LENS FIBRES. While studying the sclerosis of the lens and the formation of a nucleus, we noted changes which we designated as those of simple atrophy. Owing to the present state of our knowledge, the chemical changes, which take place in the lamella which surround the nucleus, are not definitely known. The most we can say is, that this is 3 Lehrbuch der Aljiemeinen uud Speciollfii ratli. Aii:i(. mid Pathogonose, 1882, 2 Auft, 1 Thlel, p. 124. I03 partly a Tatty nictamorphosis, iiia-;miicli as oliolcstcriiic and inargarin (?) crystals are found. Knies described this cataractoiis disintooration of the lens fibres, as changes which he comi)ares to those of so-called "cloudy swelling.'" (Virchow). Becker points to the fact that even Knies drew attention to the fact, that nothing positive is known concerning the resorption of albuminous cloudy lens fibres and the coincident clearing up of the cloudi- ness. ]jikewise, the idea that the formation of a cataract is a parenchy- matous inflammatory process can not be looked upon as a "•ha|)py thought," since, in order to prove this, its nourishing vessels would of necessity be involved, an experiment which even Knies admits he could nut carry out. As we have seen^ the inlracapsular cells may show signs which can be ascribed to atrophy. An almost constant accompaniment of the over-ripe senile cataracts, is the change in the nuclei of the cells which have been designated as the products of colloid metamorphosis. Finally, the so-called vesicular cells which develop both from the preformed epithelium of the posterior capsule, are in all probability to be looked upon as Injdropsical cells. All cells which are found within an uninjured capsule, both the cells which are normally present on the anterior capsule, more especially all new-formed cells, possess to a high degree, the common tendency of under- going soon and quickly retrogressive change. Thus one constantly finds in the tissue of a capsular cataract a portion of the cells from which the structure is formed, imbedded in a colloid mass. Finally, a deposit of lime salts is at times found in the tissue of a capsular cataract, which is known as a petrifaction, a condition similarly noted in other tissues. All the assumptions, excepting possibly the last, are wanting in chem- ical proof. Thus it still remains an open question whether this is really a colloid metamorphosis or a hyaline degeneration. IWii. assuming that our assum])tions are true, it certainly nnist seem astounding, that such a variety of "known changes, both progressive and retrogressive, can take place within an uninjured closed capsule. But only as long as one fails to recognize the fact, that all these processes are likewise observed in other epithelial structures, as the resuH of a disturbed nutrition, hence one would expect, since the lens is a pure epithelial structure to find them here with a certain degree of regularity. PART III. ANOMALIES OF TKANSPARENCY. In the following section the various forms of cloudiness of the lens will be considered. Since departures from the normal, both in size and form of the lens, occur but seldom congenitally, whereas, when acquired, are always accompanied by cloudiness of the substance of the lens, hence it will be unnecessary to devote a special section to their consideration, but they will be considered together with the opacities of the lens. CHAPTER I. THE GEEY CATARACT. DEFINITION. Every opacity of the lens system is called a grey cataract or "staar.''^ SYNONYMS. Glaucoma, glaucosis, glaucosies; hypochyma, hypo- chysis; suffusio, s. aquae, aquae descensus; catarrhacta, cataracta; cataracte; cataract; cataratta, star or staar. "The expressions, 'staar' and 'cataract' were in common use at the time Brisseau and Maitre Jean conclusively proved, that the cause of the interference with sight, which for hundreds of years previously had been removed by depression, was not due to a new-formed membrane in the pupil, which the cataract was supposed to be, but that it was due to a cloudiness of the lens. Although in ancient times a diseased cloudiness of the lens had been known, and called glaucoma, one was nevertheless justified in retaining the name 'cataract' for the new conception of the disease, as the possibiUty of restoring vision by operative interference still remained as a mark of difference between glaucoma and cataract." "The arguments used against Brisseau by the French Academy were essentially those of Galen. The latter's medical knowledge, however, was but that, as it had been developed since the time of Hippocrates." "In Greek literature are found the following expressions: yXavxc^ff'^^ (yXavxf^(^i^) 0^ yXavxx^^^ ^^^ vTToxvjua or V7r6xv(^i'>. ^^ these expressions, the Latin writers only retained glaucoma; they trans- lated, however, vttoxvGi? as 'suffusio/" 1 There is no English translation for the word Staar other than Cataract. Its derivation will be considered further on. I05 ''It is diftieult to determine at the present day, which I'oftiis of disease the ancients designated by these names, owing to their great lack of ana- tomical knowledge and sufficiently accurate methods of examination, which but in recent years have been perfected to such a degree as to admit of a proper understanding of the various forms of this disease.- It is very prob- able, however, that every disease leading to a discoloration of the {)upil re- ceived the same name, at one time being designated as glaucoma, at anothei' as hi/pochi/sis. Then difl'erentiations began to be made, but having no accurate anatomical basis, were but poorly kept apart. Gradually they became accustomed to speak of 'suffusio' where an iritis, pupillary mem- brane and primary cloudiness of the lens existed, which, however, w-as looked upon as a new-formed memhrane, but they designated every con- ceivable form of complicated cataract as glaucoma, aside from the dis- ease, glaucoma, as we understand it today." "The only expression known to Hippocrates was yXavxoJ(^t£''. This is evident from Aphorism, XXXI. , 3, in which he enumerates the diseases of the aged, and uses the word yXavxcoffte? to designate cataract, and with the occurrence of which he must have been very familiar. Celsius, how- ever, quite contrary to the above, uses the word "svffusio,' and thus shows that he located the disease in a place other than in the lens: rather in front of it, 'qua parte pupilla est, locus vacuus est.'^ At the same time, Plinius used both expressions successively without defining them. He, however, suggesti?, from his very rich therapeutic treasures, different remedies for each, so that one is led to believe that he looked upon them as two separate and distinct diseases.* Oribasius has saved for us, the opinion of Kufus, who lived some time after Plinius: 'Glaucoma humoris glacialis, i. e. crystal- lini qui ex proprio colore in glaucum convertatur et mutetur, morbum esse putavertunt, suffusionem vero esse effusionem humorum inter uveam et crystalloidem tunieam concrementium,' and he adds, that all cases of glaucoma are incurable, but that vTToxvjua is; but strictly speaking, not every case.^ We find that Galen expressed the same opinion. According to Kuhn's translation,^ Galen says, 'Suffusio est concretio aquosi humoris quae visum magis minusve imi)edit. Diflt'ert suffusio a glaucomate tum quod suffusio concretio sil dilute humoris, glaucoma vero naturalium mutatio humorum in caesium colorem, tum quod glaucomate baud prorsus in suf- fusione aliquantuhim cernant.' " 2 Von Graefe Glaucoma. 1858. 3 Lib. VII. cap. 7. 18. 4 His. Nat. XXVIII, 8: XXIV. (J; and XXXII. 4. 5 Morgagni, I. e. Synops. Libr. VIII. ca{>. 47. p. 1.30. ed. Stephen. 6 Vol. XIX, S. f. Med. 303 Lips. 1830. p. 4:JS. io6 "One may .«ay. that these words give a comprehensive account of the knowledge which the medical world possessed on the subject up to the beginning of the eighteenth century." "According to the Latin translation by Emerius. the teaching of the physician and philosopher, Leo, who lived about 800 B. C, (p. 146), reads 39 follows: 'Suffusio (vTToxvOt?) est cum inter membranum uviformam et corneam humor pituitosus et crassus quasi returbidus coagulatus est et pupillam obfuscat nee semere sinit: qui hoc morbo laborant initio culices vident. Curator vero punctione, non principio sed postquam aliquamdiu perstiterit.' A few lines below he says: 'Glaucosis est ubi crystallinus humor veluti coagulatus est et albidior f actus et visum impedit: fit autem semper in senibus malumque sanari nequit.' " '•'About the year 1150, the Salernian Physician Matteus Platearius speaks of cataract as one of the diseases of the eye, and defines it as fol- lows: 'Cataracte visus inter conjunetivam et corneam tunica nascuntur et uveam tunicam subalbidam reddunt.' Four hundred years later, we find the celebrated Ambrose Pare, the first physician who wrote in French, speaking of a 'suffusio,' 'cataraeta' or 'coulisse,' a 'concretion d'humeur' placed between cornea and lens; and this, along wdth glaucoma, hetero- glautis, leucoma, aygrias and acatastasia crystalloidous; the last of these was already being. spoken of as a luxation of the lens." "Not that during all these years the correct view had not time and again been expounded. In 1673 Werner Wolfing of Hamburg, Professor at Jena,'^ is said to have shown that the cloudiness in the pupil, which is amenable to operative interference, has its seat in the lens. In Gassendi ^ one finds the following: 'Since Lasnier^ has shown that an animal without a lens can see, it is not necessary to seek for further proof to demonstrate that the power of vision does not depend on the lens.' He has shown that the cataract is not a membrane between uvea and lens, which can be torn away mth a needle and depressed into the depths of the eye, but that it is the crystalline body itself, which is shrunken, is separated from the ciliar\'' processes, and is depressed into the vitreous. The celebrated Franz Quarre, as Morgagni tried to prove, expressed the same opinion even before Lasnier. The great physist, Mariotte;!^ also Jacques Kohault ^^ and Borrelll 12 were of the same opinion as the above-named investigators. Eohault says: "Que 7 Dissert Anat. Lib., b. c, p. 73. 8 Physic III, Lib. 7, D. B., 1G60. 9Remy D. Paris, 1650. 10 Nouvelles decouvertes touchant la vue Paris. 1668. 11 Tractus Physics I, cap. 35. 12 Historiore et observations medico-physicae, IV, Paris, 1657. I07 la cataracta n'est pas une taye qui se fonne del humeur cristalline, comme on la cm long temps, mais bien une alteration de cette humeur me me qui a enteirement perdu sa transparonco.' According to Heister, in 1707 the great Boerhaven taught the same idea in his clinic, before he had read the ^Y^it- ings of Brisseau and Meister Antonius, but these few voices were but little heeded by their contemporaries. To the two last-mentioned gentlemen fell the task of overcoming the opposition of the Paris Academy of Medi- cine, and of gradually introducing to the incdical profession at large the correct solution of this question." "On the 6th of April, 1705, in the hospital at Doorniek, Brisseau operated on the eye of a soldier who had died of the flux, and who had a simple ripe cataract. He made a depression, and after he had removed the membrane, which he held it to be, and the pupil was black again, he dissected the eye, and found that the opaque lens was not in its proper position, but that it was depressed into the vitreous. On the 17th of No- vember of the same year, he reported his observation to the Academy. The Academy, however, totally ignored his announcement, and one of the mem- bers — Duverney — advised him to keep his discovery to himself, and not to make himself the laughing-stock of the Academy. Brisseau's silent resolve was, further investigation, on which to base his opinion. In 1707 he op- erated a hard cataract; this split into pieces, and thus he was convinced that it could not be a membrane, but must have its seat in the lens. "Maitre Jean ^^ tells us that he had arrived at the same conclusion as early as 1682. Later on. he examined the eyes of a corpse, which were cat- aractous, and saw plainly that the cloudiness was in the lens." "One of the greatest learned men of his time, who took up the new teaching in a positive manner, and who with untiring efforts defended it against many disbelievers, even after the French Academy had given in, was Prof. Lorenz Heister, Professor at Altdorf and Helmstedt. In his 'Tractus de Cataracta glaucomate et amaurosi,' Altdorf, 1812, he writes, "duo industrii galii post multa experimenta sedem cataractae exhumore aqueo penitus in humorem crystallinum transtulerunt.^ " "The discussions of the French Academy from 1705 to 1708, caused by Brisseau and Maitre Jean, show the views of the corporate body of medi- cine of that time. At that time, cataract was held to be a small, somewhat thickened membrane situated in the pupil, and which had formed in the aqueous humour, and which could, by means of a needle, be successfully rolled up and depressed into the deptlis of the eye. Even at that time, glau- coma was held to be an opacity of the lens, said to be incurable, in contra- 13 Traite des Maladies de I'oell Troyes. 1707. io8 distinction to cataract. At first the Acadeni}" took a stand on the authority of Galen, then again it held an opposite view, that an eye without a lens could not see; then they permitted Littre to appear before the Academy and demonstrate an iritic memhrane as a true cataract. Finally, however, it entered upon the road of investigation itself, in that the Academy had eyes dissected before it, which had been operated on for cataract by Mery. Naturally, since it was impossible to be otherwise, these investigations finally demonstrated the truth of the fact which had been so hotly con- tested. In the year 1808, the Academy began its acknowledgement with the following memorable words: "La verite coiumeuee a se deeouvrir sur la question des Cataractes," and a few lines further down continues: "M. Brisseau, medeein de Touruai et M. Antoine, tons deux inventeurs en nieme temps ou plutot restaurateurs, sans le scavoir, du nouveau sisteme de feu M. Rohault, qui confondoit le Glaucoma et la Cataracte. soutenoient et par uns suite de ce sisteme el par des experiences dont ils etaient convaincus, que Ton pent voir sans cristallin, c'est a dire, sans ce qui a toujours passe pour le principal instrument de la vision. Quelque etrange que soit ce Paradoxe. I'Academie en avoit des I'annee precedente ap- percu la possibilite, mais enlin il est devenu un fait constant I'Academie a vu >un Cristallin que Ion avoit tire a un Pretre en presence de Mery et elle a vu ce meme Pretre lire du meme oeil avec une forte loupe ces gros Cataractes, que les Imprimeurs appellent Parangon." 14 "The proceedings of the Academy during the years 1705-1708 are in other respects very important to opthalmology. They contain the views, concerning the new teachings, contained in a series of optical studies by De la Hire, father and son, by whom it was shown that the aqueous and vitreous humour have the same index of refraction, and in which for the first time the dioptric conditions of the aphakic eye were properly pre- sented." "Though the new ideas were accepted by the Academy in the most enthusiastic manner and were taken up by the learned world of France and the neighboring countries, those were not wanting who violently opposed them. The most stubborn opponent was Woolhouse, an English physician resident in Paris. The many discussions between him and Heister are, even at the present day. worthy of being read. Later on, the conception of cataract was changed by Gunz, (Schnitzlein, praes Gunz, diss de suffus- sionis natura et curatione), who describes as cataract every dark body situated between cornea and vitreous, which impeded vision, or it was said that cataract was eveiy cloudiness between cornea and vitreous, (Macken- 14 Hist, de TAcad. Royale des Sciences. Annee, 1708. p. 39. I09 zie), until finally Vclpeau ^■'' defined cataract as "une opacite centre nature dun des millieux tran.sparencs de I'oeil, (pie tiaversent habiluellement des rayons lumineux pour arriver a la retine.' Other authoritis, like Wardrop, went a step further and defined every perceptible disease in the pupil which disturbed vision as a cataract, and used as synonyms the following ex- pressions: Cataracla nigra, guff a serena, black cataract and amaurosis." ''Beyond all doubt, the word 'cataracta' is of Greek origin, xaTapprjyv/xi[HaTappa.GGOL>)^ and hence was often written 'catarrhacta.' It was never used by the ancients to describe a disease of the eye. The first time it is found used in the literature of this subject, is in the above given definition by the Salernian physician, Platerius, 1150,^^ and here it is used to express the same idea as suffusio or hypochysis. In Mackenzie's work,^^ the opinion is expressed that ,tlie Arabs — who, as is well known, in scien- tific aft'airs, especially medical, depended entirely on the teachings of Galen — found this expression, L';ro;j;f(TzS', and translated it literally, and then later on, when the Salernian translated the works of iVlbulcasis and Avicenna into Latin, this expression, which had come into general use, was retained, and thus the neiv word "cataract' was coined. In the translation of Albulcasis by Gerard de Cremona, (1114), the subject of the twenty-third chapter reads, 'De cura aquae quae descendit in oculo vel cataracta.' The time when the passage was written corresponds about to the time of Platearius, and the original sense in which the word 'cataract' wa^ used was to convey the idea of 'a flowing down of water,' 'a water fall.' As a matter of fact, in Avicenna,^^ the Arabic expression given for grey cataract is 'nuzul el ma,' which, literally translated, also means, 'a flowing down of water.' There can, therefore, be no doubt but that Mackenzie's idea is the correct one. This is all the more striking, since the literal meaning of the word, used to designate the grey cataract became the accepted view of the nature of the disease by later authorities. Thus, x\mbrose Parre, (bom in 1517), translating the word 'cataract' into French, uses the word 'coulisse/ or 'curtain,' and. he declares, 'C'est en effet du sens de cloture de coulisse qui ferme, que la mot cataracte a passe au sens d'opacite du cristallin.' Antonie Furetiere (1690) gives the same definition in his 'Dictionaire Universal;' he however quotes Parre. This proof is all the more important, since Parre was looked upon as the first doctor who wrote in French. Only after the decree of King Francis I., 1523 and 1529, and the edicts of Villers-Cot- isClinique Chirurg., 1840, p. 517. 16 Hirsch Klin. Monatsblatter. 1S. 18 Lib. Ill, Faun III, Tract IV, Cap. 18. no terets (1539) was the court, compelled to carry on its proceedings in the French language. As is well known, Calvin originally wrote his 'Insti- tutio religionio Christianae' in Latin; and first in 1536, when filled witli hatred against the language of the Pope and its traditions, and when he found himself compelled to turn to the people, he concluded to translate his principal work into his native tongue. As a like proceeding does not occur in all scientific writings up to this time, Ambrose PaiTe, who wrote in the forties of the sixteenth century, is therefore to be presumed was the first to have the written, 'catarada,' as a French word. So far had the etymology of the word been lost, that the Academy, in its discussions with Brisseau, did not hesitate to state as a fact, that the word 'cataract' meant a membrane before the pupil, and used this as an argument against the new teaching. 'Les cataractes des yeux ont este ainsi appellees dun mot Grec qui signifie une Porte gu'on laisse tomber de haut en has comme une Sarrasine, el en efi'et ce sont des especes de Ports, gui ferment I'oeil aux rayons de la lumiere.^^ To quote but a single passage from the literature of foreign countries, taken from the writings of Laurentius Heisterus, (31, p 1), 'Vulgo autem el notiori inter medicos vocabule ratarada vocatur, quae vox, teste Livio (XXVII., 28) portas pendulas et recidentes, quae ad ingressum urbium, praecipue munitarum, conspiciunter, significat, quibus recidentibus vel demissis liber prohibetur transitus et vernaculo sermone Fall Gattern appellantur. N"otat etiam cataract a pessulum vel obicem, quo porta obfirmi solet. Belgae quoque cataractas vocant robustissimas illas valvas, quibus aquarum iiTuentium vim cohibent, ne plus, quam par est, aquae in oppida veb campos influat, et ab iis vernacula sua Slui/sen nonima- tur.' " 'It is evident that this erroneous idea was evolved after the word 'catai-act' had come into use, and the historical development of the word had been entirely forgotten. The true meaning of the word 'trap- door' or 'sluiceway,' as used by the ancients, had become entirely changed to that of a waterfall, this coinciding more nearly with the prevailing idea as to the anatomical conditions of a cataract." "The German word 'staar,' likewise the compound word 'staar-blind,' are very old. In the Keronishe Glossen of the eighth century one finds the following: 'Hyerna bestia staraplint (Reichenauer Ausgabe; hyaena stara bestia plint) cujus pupillae lapideae sunt des seha augono stani sint.' This passage is copied in Graft's Diutiska, I., 339.20 Weigand 21 says, 'AI3 19 Hist. <1<'1 A<:i(l. K<..v (les Sc. 17<»;. p. 12. 20 See also Crnffs AIUkk-Ii 1 >rulsclier Spr:iclis<-li:it/. Ml. S.. -Jii:'.. 21 Deutsclits Woitcil.uili. II. S.. TT'.t. Ill Wurzelvorbuin i.st aufziistelleii ein gotli. stairan, ahd, stoian unbeweglich stelien, woven ahd, staren, mhd, stem = die Augen unbeweglich auf etwas richtet, starren.' Therefore, 'staar' signifies, a staring look. I have not been able to discover, where it was that the word first came into use." "Since the word 'staar' was originally used to denote a symptom of an eye disease, namely, the staring look, one can easily see how gradually it began to be used to designate various diseases of the eye. As we began to discern differences, it began to be used in connection with other words to designate the variety as the grey, the black, etc., and these expressions are in use at the present day. They were, however, in former times a great variety of other forms in use, which have since been set aside. Thus George Bartisch of Kocnigsbruck, citizen, oculist and Surgeon to the King's City of Dresden, in his work on opthalmology, published in 1583, speaks of the green, the white, the yellow and the blue 'staar.' At the pres- ent day the word 'staar' used alone, without the prefix 'grey,' will be synonymous with cataract, meaning a cloudiness of the lens. ''The knowledge of the original meaning of the word, seems grad- ually to have been lost, both by the physician and the general public. This very same Bartisch writes, (1. c, p. 42), 'I have not been able to discover, why this is called "staar," or where the word originated. The word is so well known and in such common use, that it is equally often used by citizen or farmer, the educated or ignorant. For whether they speak of, see, or hear of a blind person, they know of nothing further to say than that it must be a "staar," and they say — "he is staar-hlind." ' In his very next statement, however, he says, "that it is no wonder that the word "staar" has been used to designate a disease of the eye, since there are other infirmities, defects, and ills of man which have been named after anianals and other things, such as krebs, lupus, carfunkel and ranula." On the next page, he goes on to state, that there are people who imagine that this defect is due to the starling, a bird, for if we eat it frequently, or drink from the same water of which the bird has partaken, or in which it has taken a bath, (we become staar-bHnd)(?) This, however, is a superstition and a false delusion. Luther spelled the word 'starr'; Bartisch, as we have seen, 'star.' In Andersen,-^ I find, 'Im mhd bedeutet star, also subst sturnus, als adj rigidus, di nach gewohnlicher Schreibweise im mhd staar uud starr. Seit dem aber das ahd staraplint statt durch starr-blind, wie es hatte lauten sollon (vgl austarren, stieren) viel mehr durch staar- blind weidergegeben wurde und ein subst, staar (augenstarre hin zugetreten ist, gerieth man spater auf dem gedanken den vogelnahmen stahr zu 22 Deutsche Orthographie, S.. p. 18. 112 schrieben. Leicht ist es einziisehen, class, wofern nieht, was unstreitig das einfachste ware, die mhd, form fur beide worter verbleiben kann, mindestens das eine der verbaldehung lieber eintriethe, weil da durch der zusammenhang mit starr desto deutlicher hervortrete.' This also answers Strieker's question (Star or starr ?).23 The work of Lichtman mentioned by him (Nuremburg, 1720), contains the above-given passage of Bartisch." "Later on, the word 'staar,' was used with an entirely different mean- ing, (though seldom so applied), to signify the pupil ('augenstern'), as per example, by Baggensen and Matthison. The word 'augenstern' could be used to signify a pupil containing a 'star," or cataractous formation, but not in the opposite sense. Though one does meet with the expression in Rabener's work, (IV., 36), 'I have a star (stern — a star in the firma- ment) on the one eye," this does not give us a clue to the derivation of the word, nor is this suggestive that the word is derived from 'stern,' (a star in the firmament), or even derived from the English word 'star,' (a deriva- tion which has been hinted at). Opposed to all this, is the fact that the English, as well as the French and Italians, have for a long time never used any other term for 'staar' than ^cataract.' CATAEACTA VERA AND SPURIA. Several authors differentiate between true and false cataracts. In eataracta spuria we find a deposit on the anterior surface of the anterior capsule, be this a pigmented exudate following an iritis, or an organized tissue, the result of an inflammatory deposit. (See page 99). After a corneal perforation, if the lens comes in contact with the corneal surface, and subsequently on closure of the perforation, the lens on returning to its normal position, may take with it some of the cicatrical tissue adherent to the anterior capsule, eataracta cap- sularis anterior spuria. Exudates due to iritis may almost fill the anterior chamber without leaving a permanent trace on the anterior capsule of tho lens. More frequently an organized membrane remains partly adherent to the iris and partly to the capsule of the lens. These adhesions are not to be classed as eataracta spuria. Still, they are an etiological factor in the development of true cataract. "THE VARIOUS FORMS OF TRUE CATARACTS. Anatomically considered, true cataracts are divided into capsular and lenticular, eataracta capsularis and eataracta Unticularis. The latter is again divided into cortical and nuclear, eataracta lenticuJaris corticalis and eataracta Untic- ularis nuclearis. If both nucleus and cortex are cloudy, one speaks of eataracta Unticularis totalis: if there is both capsular and lenticular cata- 23 Walter von .Viiunoti. .Touiiuil fm- ('hifurs.M»' und Aujit'iiluMlkuiulf Neuo Folge. Bd. VI. 1S4T. "3 ract, this is desigTiatotl as cafarada capsulo-hnticularis. Where tlie chjudi- ness is in the axis of the lens, one speaks of a central cataract, or catarada ceniralis: a better name, however, is axial cataract, catarada axialis. De- pending on the part of the axis in which the cloudiness is located, one dif- ferentiates between a catarada centralis lenticular is, the seat of the cloudi- ness being in the centre of the lens, from a catarada centralis anterior or posterior. Here again a separation ought to be made between catarada centralis capsularis anterior and posterior and catarada corticalis anterior and posterior. Equatorial and meridional cataracts are also spoken of." "At times we meet with opacities of the lens which are partial; then again, others which are complete. But since every complete opacity must at the time of its development have been partial, the name partial cataract has been applied to those cases which clinical experience has proven to re- main stationary during the whole of life, or at least during a great many years. On this account, the following expressions, cataracta partialis and cataracta stationare; also, catarada totalis and cataracta progressiva have come into use." "The former are often the result of errors in the original formation, hence congenital. There are, however, congenital cataracts which are not partial, cataracta congenita and acquisita." "The grey cataract may develop at any time of life. It is, however, more frequently met with in children and the aged, than in people in the middle period of life — cataracta jnvenum and cataracta senilis. Cataracts occurring in children are usually classed with the cataracta congenita." This separation is of practical value, since the consistency of the cata- ract to a large degree depends on the age of the individual. Cataracts of the young as a rule are soft; in the aged they are either hard or of a mixed consistency; in the latter, where the nucleus is hard and the cortex soft — catarada mollis, dura and mixta. The extremes of these varieties are called cataracta fiuida, cataracta ladea, cataracta lapida, calcarea, ossea and cataracta Morgagni. Some of these expressions will be met with again, when we come to consider and divide forms of cataract due to the products of chemical disintegration, or new formation — cataracta gypsea. calcarea, ossea, putrida idioreni tenens." "Though there are good grounds for considering eyes in which cata- ract develops, as otherwise diseased, still in most cases, aside from the cataract one is not able to discover any special disease. In these cases the cloudiness develops primarily. There are, however, certain diseases of the eye to which frequently or at certain stages the grey cataract is secondarily added; this form, together with all cataracts which are due to constitu- tional diseases or diatheses are today designated as consecutive cataracts. 114 (See page 99). This avoids the confusion which formerly existed, since formerly the consecutive cataracts were designated as secondar}' — together with the ''nachstaar/ the cataract which develops subsequent to a cataract extraction, and which today are considered as true catarada secundaria.'' "The conception of the complicated cataracts is somewhat more gen- eral. Every consecutive cataract is also a complicated one, since it is a complication of the underlying causes which have led to the formation of a cataract. The cataract may, however, develop, without depending on any general disease, in an eye which is diseased and in such a manner as to in- fluence the result of an operation or the probability of a cure. In such d case we are dealing with a complicated cataract, which, however, is truly a primary formation, cataracta complicata. Thus, in consequence of glau- coma, a cataract may develop, cataracta glaucomatosa; and this, though a secondary cataract, would also be a complicated one. Where glaucoma develops in an eye previously, simultaneously, or after the grey cataract has developed, independently of the cataract. This should be designated as cataracta in oculo glaucomate afferto, and ought to be considered as :i primaiy cataract, but complicated." ''. 'i'o detoriiiiiu' this, it is nocessarv to cstitnatc the (l.'.urc.' of li-lit perception. lu former limes, one was satislied to simply estimate the .sensitiveness of the retina hy watehin^- the reaction of the pupil when an eye was exposed to various stren.uths of light. Another metliod was. to have the patient rap- idly open aud close his eyelids and thus watch the pupillary reaction, thereby gaining an estimate as to the sensit iveiu-ss of the ivtina. This metliod may he advised. Xot withstanding the ingenuity of the construction of this a[)paratns. owing to its cost and because it is an inconvenient instrunicMit to handle it has not come into genenil use. l"'or [iractical purjxises it suflices to examim' the light sense of all cataract |)atients with a light which has a known degree of intensity. A lamj) has the advantage, that one may increase or diminish the intensity of the source of light by turning it on full or turning it down. By prac- tice, one finally gets in a ])osition to be able to make a useful estimate. This, however, can not be expressed in figures. At the ])resent day the argand burner light, as used in making opthalmoscopic examinations, is used, and gradually turned lower and lower until light ]»ei-eeption no longer exists. 132 The lowest degree of liylit still discernible is registered as smallest lamp- light, medium, or bright light. As indicated above, the whole examination is only then of value when vision has diminished to such a degree that the patient can no longer count fingers. In certain forms of total cataract, this in fact nevei- occurs. The greater a nucleus in a senile cataract, the thinner consequently must be the amount of cortical substance, and the farther will the light of ,a candle llame be recognized. The character of the cloudiness of the cortical substance likewise has its influence. If this has developed slowly so that the general cloudiness and radial striations are very fine, they will permit more light to penetrate, than the rapidly developing, cloudy, mother-of-pearl or silky, glistening bluish-white, wide- ly-striated cortical substance. In such forms of cataract the distance at which a light is recognized varies from 20 to 30 feet. In fully-developed soft cataracts, in which, owing to youth, a real nucleus is not present, as a rule the light sense is not so distinct. In this form, one should not at once judge a complication on the part of the retina to be present, even if the light be only recognized at 16 to 18 feet. In the forms of fluid or emulsion cataracts, as well as in the cataracta Morgagni of the aged, as in the cata- raeta lactea of youth, it may happen, that the light disappears at 8 to 10 feet, whereas the retina is found intact after an operation. If in over- ripe cataracts, after a time the swollen cortical substance thickens again and becomes more homogenous, the distance at which the candle can be seen, may again increase. Under certain circumstances this becomes a symptom of an over-ripe cataract. In exceptional cases it may even reacli the point where fingers can again be counted. Naturally, calcareous lenses do not permit the passage of any light. All light which reaches the retina must pass to the side of the cataract, consequently must penetrate through the sclerotic. Even though the retina were still capable of performing its function, its perception to light would necessarily be of a very low degree. But cataracta gypsea and cakarea are almost exclusively found in amaurotic eyes. Von Graefe drew attention to the fact, that occasionally the refraction of the eye exerts an influence (ui tlie results of these tests. High grades of myopia, when equip])ed with concave glasses, not infrequently give the differences be- tween light and darkness at a much greater distance than without them; likewise, the hypero])ic with convex glasses. The more inexact the focus of the various rays of light, the weaker will be the illumination of any particular part of the retina. Eye* which are affected with non-complicated cataracts, can decide the color of the light, even when there is a total cataract. The perce])tion of color, however, is influenced bv the color of the muleiis. if the nucleus 133 is }-ello\v or hiowii. llif pcrcciMioii (if cDlor will he ilic siiiiic as in a healthy ove lookiiiii' llirmiii'li vclhiw nr hiow ii i;lass. Tlic iiioi-c intense the color of the nucleus the nioi'c hlnr li-lit will l»r ahsoi-licd. 'riicivrorc, if a cataract ])alicnt look> lliioiiuli a eohall-hluc ulass. a t'andie tiame will appear as violet. ..!• even red. The same will follow to a lesser derive if the patients look ihi'onuli a hhie .ulass at a white clond. i')Ul hy nsiiifi- glasses of other colors, the iiilluenee of the yellow nuelens heconies manifest. A bluisli- i^reen ulass appears yellowish-^reen to him. a rv(\ .iilass assumes great bril- liancy. If one shows to a cataract patient, sheets of variously colored paper, (I'ach of a, siiiiih' coloi-). every answer will uo to ]trove. that he sees it as thonuh lookin.u' throu^'h a yellow .ulass. Tlierefore. a cataraetous eye, as one is wont to e.\i)rcss it. lias not only (luan- litaTiyc lijjlit sense, but is also, as we liaye seen, uot without perception for • inalit.v of incident ra.vs of light. Tlie commonly used expression. quulHative perception of lif/ht; that is. the recognition of objects by their contour, in contra- distinction to quantitative percejition of light used to designate the proper exer- cise of Judgment dei)ending on Tlie amount of light which penetrate the eye, should hv dropped, since it not only gives rise to a misapprehension, but aside from this is incorrect. Jf one will nu)ye his hand from aboye downward before a cataraetous eye, ^yhicll no longer can recognize an object, if no complication is present, in nearly every case the patient will be able to perceive the direction of the motion. This will at once be evidenced by the eye following the hand. If, instead of the hand, a lighted candle is used, the direction will always be correctly given. The examination becomes more accurate, if, in moving the light from one ])osition to another, one covers it with the hand, be- cause where the perception is incomplete, the gradual transition from one ])lace to another leads to conclusions, whereas the perception is more inde- pendent (for each jiortion of the field) where the light appears fir.st in one direction, tlren in anothei-. For the same reason, the most accurate results ai-e obtained w hen the light is reflected fi'oni the various directions by means of the opthalmoscopic mirror. It then liecomes impossible for the patient to follow the light from one position to another. From this experiment it beconjes evident, that the i)ower of projection of light of the eye and the retina is not impaired by the cataract. This is explained by the fact that the cataraetous lens does not become non-tran.s- ])arent, but remains translucent, for notwithstanding the fact that to our eye there appears to l)e a com|)lete (doudiness. '•moleeidar i)aths" of lens substance still remain, through whi(h the refracted light can regularly pass. ITence the cataraetous lens still acts as a collecting lens, does not light \\p the interioi' of the eve unifoi-ndv. l)ut concenirates the incident 134 rays of light. (depeii(liii<;- on the ])()siti()ii of tlu- source of light), on a par- ticular part of the retina. Attention wa:- drawn above to the fact, that this occurred with greater accuracy the more the distance of the source of light coincided with the refractive conditions of the eye. If now, on making such an examination with the candle, one finds that the patient fails to locate the ])osition of the light in some particular portion of the field, or if lie tails to locate it proj)erly in any portion of the field, one concludes, that the ])articular ])ortion. or the entire retina no longer perceive the light. On can, therefore, notwithstanding the presence of a cataract, diagnosticate contractions or defects in the field of vision. On making a very careful examination, it becomes possible, and \vith a con- siderable degree of accuracy, to map out the form of the defect or con- traction, so that it further becomes possible to determine whether we are dealing with a case of glaucoma or a detachment of the retina. As a rule, one is satisfied to determine whether the peripljeiy of the retina has suffered, since this complication is the most frequent. How^ever, if one fails to examine for the presence of central defects, this may lead to unpleasant disappointment, when, after a successful operation, one finally comes to test the, vision. In the year 1871. I (Becker) operated the prioress of a convent. Her eye had the myopic build, and she said that she had always been myopic. On the left eye I found a diffuse posterior cortical cataract, on the right a catanicto (iccreta. The examination of the light sense and projection left nothing to be desii'ed. After a preliminary iridectomie. I made a successful extraction. Nevertheless, the patient could not read. Opthalmoscopic examination disclosed a large de- fect of the retina and choroid, wliich undoubtedly was due to a previous hemor- rhage. A special examination in regard to tliis condition would undoubtedly have led to its detection before the operation. In order to obtain some idea as to the size of the snuillest defect which it would be possible to detect, notwithstanding the presence of a cataract. Becker attemjited to see if cataract patients could hi' made aware of the presence of Mariottes' spot. This was shown to be an im])ossibility — hence ii demonstratablc defect must be larger than tlu' entrance of the optic nerve, 'i'he expei'inient can also l)e successfully [tracticed. by testing the distance at which the fiames of two candles will heconie fused into one. If these examinations are always carried out with the candles at a certain distance from the eye. one can obtain (\\uiv accural c results regarding tlu> extreme delicacy of the perception of the retiiui. ••When, after the above method.-. Ihci-e i> >lill a doubt renuiining as 1o the light sense, oiu' can determine h\ the occasional appearance of phosplu'nes ariuind the entrance of the optic iier\t'. (more detinitt'ly. how- •35 ovci-, l)y llic |)i'c^ciic(' (.r |.li(.>|)liciM's as sii<:,i:c>t(Ml l)y ScMc> .!(■ I'zeo), if there is aiiv sensitiveness of the retina reinaininy or not. 'I'his matter, however, can never ,uain any pai'tieular oi- praetieal valne." ^^ AETI()L()(i^' Ol'' ('A'r.\l.'.\("l\ In the previous chapters, taking senile cataract as I lie prototype, we liave cited all those factors which lead to tlu' foi-niation of ealaraet. We have seen (pag.' oO) that the initial o))a('ities are due to ehenneal changes in the stagnant fluid which occupies tlie inters|)aces. tlie lihres secondarily becoming cloudy, due to their chem- ical decomposition and niechatncal disintegi-ation. The formation of these interspaces being i\\w (page Id) to interference with the regular sclerosis of the lens and to mechanical causes. "Where both lenses become cloudy, one at'tei- tlie other, we may con- clude that this is the result of constitutional disease. Generally speaking, one nuiy assume that the fonnation of cataract is influenced by a consti- tutional disease or diathesis, especially since we know that these diseases may lead to other diseases of the eye, which in their turn lead to cataract, as occurs in diabetes, albuminuria and syidiilis. However. I do -not wish to be misunderstood as stating that every disease of the eye due to constitu- tional disease will eventually lead to cataract. In his "Pathologic and Therapie," page 2'H, Becker states, that, strictly speaking, there is no such thing as a primai-y cataract, the expression "primary" simply hiding our ignorance. If at this time he tried to locate the cause in the eye, at the present day, though we still seek it in the eye, we do so, in an altered chem- ical constitution of the vitreous, which influences the nutrition of the lens. It is es])ecially worthy of note to observe whether the cataract occurs in both eyes or not. Where the disease occurs only on one eye, the as- sumption is a perfectly natural one, that this is due to a local cause. But in those cases where the cataract occurs in both eyes we must seek for some causative factor in the general system, even for the cases in which the eye dist-ase influences the nutrition of the lens. A very pregnant ex- ample is the cataract which develops in retinitis pigmento.sa. The occur- rence of this disease in several members of the same family, seems decid- edly to favor this hypothesis. Under these conditions, it does not seem to be going too far, to assume a like cause for all cases of cataract which occur in both eye.s, or in one shortly after the other, and in which age, togethei- with other iieculiarities of the entire organism, play a ])r()niinent part. "This idea, whether t'onsciously oi- unconscionsly. has been prevalent 36Vgl. v. Graefe, Klinisohe Monatsblatter, 1865, S. 140. 136 for the past thirty years. Whereas Sichel, Vemeuil ^" and Tesnier ^s con- fine their remarks to attributing their poor results after extraction to con- stitutional peculiarities; others, following Mooren/9 have attempted to find the cause in a previous or general disease existing at the time of its de- velopment. ]?ominee *^ records 44 cases of cataract on both eyes in youth- ful individuals, their average age being thirty years, 31 women and 13 men); these were preceded by typhus 17 times, variola 3, chlorosis and loss of blood T; purulent discharges, rickets and heart disease 10. These few cases do not give these causes any jjarticular weight. In most of these cases the history fails to state whether or not the cataract had, or had not been preceded by another eye disease, which in its turn might have led to the cataractous formation. Kominee designated these cataracts as "cat pointilee"; in several cases as "demi molle.'' In that he makes the following statement, "gu'une maladie dibilitant I'organisme pent prodnire la cataracte," he goes a step further than Foerster, who states,*^ "IF a cloudiness of the lens is just beginning, very severe bodily ailment may hasten the development of the cloudiness. Dor^^ declares that all cata- racts of youthful individuals (occurring in both eyes) are due to a diathesis. In eight cases he found phosphaturia seven times. I am aware that the opinions on this subject are very conflicting, and it is quoted here, sinii)ly to show the existing desire to prove that cataract formation is dependent ou constitutional causes. Lately, Deutschman has attempted to demonstrate an actiological connection between chronic nephritis and senile cataract." The constitutional disease manifests itself in its action on the lens in such a manner, that it either first causes disease of other portions of the rifj, therehy leading to a pathological changed vitreous, which, in its turn leads to a disease of the lens and ratanut formation, or the hjnipJi of the rn/ire organism heconies changed, llrus leading to cataract formation irlllioul any other disease of the eye having .preciously existed. "The term complicated cataract," in its more restrii-ted sense, is used 37 Note sur rOperiition do l.i ('ntMiacto cliez les l>iabtni(iii<"s. Kcviie tie Med. et Chir., 1877, No. 7. 38 De la Phosphaturie a Forme Diabotique el de son InHuonce sur le Resultat de quel ques Operations de Cataracte. These de T^yoii. 39 0pthalniiatr. Beobaelitungen. Berlin. l.S(;7. 40 Cataractes ('onsecutives a la tievre Typhoid*' el .i la \ariole. Recuell d'Opthal.. 1S7J). p. .'S(;. 41 Beziehunjien dcr AMiicinciii-Lcidcn mid < )r.uaM-i:ikr;mmiii,m-ii y.n ^•rI•.•lIlder- unjren nnd Kraid a detaeliiiieiU oL" the retina, absolute o-laucoma. iiit niotulai' tumor or cv.M icei-cus. Here also ])eloni£ tliose cases in which the iris has hccoine attached to the capsuh- of the lens, or where. I'ollowini: an irido-cvcliti>. a lu'u -I'oi lueij mehrane i)econle^ attached to the ])()stei'ioi- surface o\ the len>. In all the>e caM'> ahiiornial eirculatory con- dition.- are developed. 'The processes of secretion and assiinihition take l)hu'e uiuler cliano-ed condition,-. The local cause is attested hy the fact of the catai-act reniainiiii;- limited to the one eye. Of all the forms of cataract, those easiest to understand are those dm; to ti-auma. This seldom occurs where there has been a simple concussion of the eye without luptui'e of the capsule and consequent jjathological entrance of the fluids of the eye. Perhaps these exceptional cases can be explained in this way. that the epithelial lininp- becomes separated from the capsule and fails to become adherent a^ain. If the suspensory ligament tears, the lens l)ecomes luxated and comes into ditferent relations to sur- rounding- parts. The capsule coming in contact with solid parts, the nutri- tive ])rocesses are interru])ted. A perfectly analogous result follows wheri .spontaneous luxation of perfectly transparent lenses occitrs. This last con- dition, however, is the result of some previous disease. If the capsule is ruptured, the dissolving action of the aqueous and vitreous is made luanifes-t at once by the cloudiness, the swelling and the processes of absorption of lens substance. CHAPTER II. A SYSTEMATIC CONSIDEEATIOX OF THE YAEIETIES OF CATARACT. THE MALFORMATIONS OF THE LEWS. If, as formerly, we were to state that all anomalies of the lens w^hich are present at birth are congenital, and all those w'hich develop after birth are ac([uired, we would simply be ignoring the underlying causes of these conditions. A portion of the abnormalities can be traced to anomalies in the develo})ment of the lens and the eye: another portion arises after the lens has been fully developed; that is, during the foetal period of growth in a manner similar to analogous diseased conditions which occur in extra- uterine life, in consequence of pathological conditions of the entire organ- ism, or especially in the eye. There is simply this difference, that in the former we must conclude from the residue and consequences, whereas in the latter case we are in a position to make direct observation and to follow their course. Thougli they are congenital, they do not belong to the mal- fomiations. All malformations are congenital, but all congenital diseases of the lens arc not malfoi-mations. Hence the congenital diseases will be considci'cd along with the analogous dist-ases which occm- in cxtra-ntcrine life. MALFORMATIONS OF THh: LENS SYS'iM<:M WHICH ARE AS- SOCIATED WITH ANOMALIES OF THE HYALOID AE- TERY OR THE VASCULAR CAPSULE OF THE LENS. Owing to the important role whii-h the lens takes in the formation of the entire eyeball, the mntnal action which lens and globe c^xert one on the other cannot be surprising. In a whole series of anomalies it is ver^- difli- cult to decide whether the abnormal process in the development of the lens influenced the formation of the eye, or whether the interference with the development of the eye influenced the formations of the lens. Anatomical examinations of congenital cataracts have for some time past caused attention to be directed to the fact that certain forms are com- bined with an interrupted retrograde change of the Avascular capsule of the lens. The eolombata of the eye, in whicli most pecrdiar anomalies in the formation of the lens have been observed, are Hkewise attributed to abnor- mal conditions, those of the arteria hyaloidae and vitreous playing an im- portant role. We are indebted to Manz ^ for a very thorough and complete investigation of the conditions which lead to these anomalies. From these investigations we learn that the invagination of the epithelial plate into the hollow space of the secondary vesicle may give rise to interference with the proper closure of the fissure of the eye. With the closure of this fissure follows a complete severence of tlie communication between vitreous and the surrounding ''head jilate." a process which may be l)iit illy accom- plished, owing to the advanced stage of development of the pedicle. Above all, Manz reminds us of the blood vessels which gain entrance along this foetal fissure and which are found so iibundantly develojx'd in the foetal eye. This is attested by the conditions found in the (ow cases of colohoma hulbi so far accurately examined, and in which the viiscular system of the vi'treous still contained the branches of the arteria hyaloidea extending from the walls of the globe to the capsule of the lens. Whereas, as we see, ^Manz seeks the primary (au>e in an excessive vas- 1 "Die Missl)ilt. Klin- ische :M()natsl)latter. XIX. p. 101. 4 "Mickroptlialmus und Colobouiaiii Kaninclieii." Ai' the very prominent snout. The eye was almost globular in shape, and had a diameter of 22 mm. The, almond-shaped lid fissure was about 27 mm. wide. It was impossible to detect a line along which there had taken place a fusion of tli<> lids. Puncta lachrymalis wanting. The cornea was transversely oval, and disclosed a slight depression in tlie center, likewise above and below the edges. These indrawn places were con- nected by a very fine vertical line, so as to give the impression that along this line the two cornea had joined. Both halves were of equal size; their total di- ameter equal to 17 mm. Otlierwise, one tinds no signs suggestive of two eyes being joined togetlier. On dissecting the eye, find but a single optic nerve, and transverse serial sections appear normal. The retina is detached, but shows no evidence of separation into tAvo halves. In the anterior half of the eye the con- ditions are somewhat more complicated, owing to the presence of tiro letifies. One finds two perfectly developed lenses, situated about 4 mm. from each other. liaterally, from each is a normal ciliary body, and a normally developed iris. Corresponding to the vertical tine line on tlie external surface of the cornea there appears on its posterior surface a T formed iirouiinence, looking upward and downward. This prominence is smallest at the center: tlius form- ing for each lens a pupil of about normal size. These prominences consist partly of vascular connective tissue. p;utly of nonstriated vascul.ir tibres. like those found in the ciliary body. The prominence which extends backward is covered Avith a thick pigment layer of epithelial cells, as seen on the p.irs ciliaris retinae. Tlie anatomical conditions of the brain were especially interesting. On re- moving the calvarium. the cerebellum and corpora quadrigemina were found to be normal. At the anterior end of the brain the cerebrum appeared as an un- divided mass, filling up the anterior fossa completely, but only altout one renini into tw(» iicuiis- l»iieres. Tlie exact condition of the olfactory nerve could not Ite «h-linitely de- termined. Accordins;ly. the posterior and middle portions of Die liraiii were normally develoi)ed; whereas, the cerebrnm and all tiie parts wiruii sulc of normal thick- ness and transparency: also a well-preserved single layer of epithelial cell-: aside from these, very regularly arranged lihre-like cells extending from be- hind forward, showing beautifid nuclei, in the at^piatorial region in the situation of the lens whorl were found disintegrated masses. On the ex- 12 Congenital diseases and malformations of tlie dioi)tr. media. iMinlin's Quarterly Journal, No. 61, IStil. 144 ternal surface of the posterior tapsule were found numerous patent l)loo(l vessels. These conditions are exceedingly interesting, because they indi- cate that the cause of the disease could not have exerted its influence long after the beginning of the third period of foetal development. This must coincide with about the second month of foetal life." (See Manz. page 82). The persistence of the hyaloid artery places this malformation, which may "be designated as a failure of the lens to undergo further develoi)ment after having reached a certain stage of development, in the category of the above- described sequelae of coloboma formations. A\'. von (Irollman ^" describes a case in which the posterior capsule was wanting, the hyaloid artery had grown into the lens, which was filled with connective tissue, blood vessels and a few lens fibres. The fact, that branches of the hyaloid artery still containing l)lood are found on the posterior surface of a certain class of congenital mem- branous cataracts, indicates, since the hyaloid artery has no accompanying vein, that a number of venous branches of the vascular capsule also re- main. And, as a fact, in this form of cataract one does frequently find that a connection between the capsule and the iris still exists. Hence this form is also designated as rahinicfd niniihrdiHircn roitjcin'la acciria, in that this connection is looked \\\)nu as a jiosterior synechia, the result of a foetal iritis. Further anatomical examinations of entire eyes containing cataracta membranacea .accreta are necessary in order to show whether there are other remains of a foetal iritis. This touches on the question of the cause of the membrana pupiUaris perseverans and the deposits on the outer sur- face of the anterior capsule which thus leads to the cafarada capsularis an- terior s/niria. It ispossiblethata disturbance in the retrogressive change in the vascular capsule is to be sought in an inflammatory proct'ss in this capsule. This would also explain the genesis of the cahiniclti /xilnris posterior spuria. All the cases so far described are deposits on the outer surface of the posterior capsule and usually are found in the region of the posterior ]iole of the lens. They are chai'acterized by the white shining color which this form of cataract reflects. It is seldom very small, often the size of a hemp or poppy s(>ed, and fre(piently by focal illumination one can see that an- teriorly it is concave and smooth as a mirror. On using the oi»tlialmoscopc it can be seen to taper toward the xitreous. (ieiu'i'ally its contnur is round, though in the individual case it may show a few pointed striations. It might possibly he mistaken for a posterior cortical cataract such as occurs in choroidal disease and disease of the vitreous, more particularly 13 "Uber Mickropllialiims mu\ (':itiii:ictM ('(Hiycnil;! VMseulosM." (Jraef Arch. Vol. XXXV. B. 314. ISS'J. '45 (lie form .K-ciiiTin,<:- in ivtiiiili- |)i.-inciU..~ii. It i^. Ik-wcx .t. ikiI (lilli.-ull lu (lii1\Mviitialc. since- in [...stciior cnrticnl calai.iri tlio glistening white color and niirror-likc sniootlnu'ss arr wantinp-. and llir latter form generally goes over into the general eortieal eatarael wliih' under ohservation. The presence of radiating sti-iae favors the diagnosis of posterior conical cata- ract, on till- ontei' >urfa(H' td' the ])o>terior capsule. A'on Amnion'^ \\a> the lii'st lo draw attention to the fact, that ab- normalities at the posterior capsule could he traced to disease of tlie hya- loid, in the eve of a rahhit hoin hiin.l, lu' f.umd the ol)literated central artery, logetlu'r with a ceiiti-al ojjacity of the posterior wall of the capsule, lie gives an illustration (Fig. Ti. Plate 15) of a ease of congenital thick- ening of the hyaloid artery and a resulting cataraeta centralis, showing a portion of the artery attached ])osteriorly to the conical lens, through the axis of which an opacity exists. \'on Amnion diagnosed opacities in the posterior portion of the lenses of living men, which he ascribed to early (d)literation of the centi'al arteiT.^'' 11. Muller (I. c. p. SC.) described such a posterior i)olar catarat-ta in both eyes of a goat. l>oth lenses showed a two-fold cloudiness. He also observed a case in which there was a greyish opacity in the centre of the lens, [rataracla centralis), together with a flat- tened cone at the po.sterior surface, yellowish in its centre, yellowish white at the periphery and ])rotrnding backward through the vitreous to the papilla: from the ci'Utre of this cone the hyaloid artery could be seen. The eyes, though of normal shape, showed the evidences of a |»revious iii- flanunatory infiltration. The central artery was sui'rounded hy iidlam- niatory jn'oducts and could be distinctly seen to pass between the nodule and the lens substance. Therefore, the opaque mass had its seat at and in the remains of the embryonal capsule of blood vessels, and it can scarcely be doubted that this peculiar formation is due to an interference with the embryonal development of the oi'gan. Finally, we are indebted to Berthold ^'' for the exact exannnation of such a cataract, obtained from a congenital buphthaliuus. and the origin of which he likewise traced to a persistent arteria ca])sidaris. Jle found beautiful e])ithelial cells ahmg the posterior cap.sule, the lens otherwise being jierfectly noi'inal. lie adds. "It is remarkable, that this epithelium which is found alongthe po>ti'rior cajisule dm-ing foetal life should not have entirely disappeared," but. according to our understiinding of the subject today, this e])ithe]iiim must have been 14 Klin. Darstollun?-. III. p. (u. l->8ee also Recli. "Do ("atarada ("cnli-.ili." Iiimul;-. Dissert. Lips. 18.".0. 16 "Beitraji- znr Pathol(),s.nscli(" Anaroiiiie «les Au.-e." (Jraefe Arch., Bd. XVII, 1) 174, 1871. 146 newly funned. Thif^ would then bo tlie first and only case in which such a newly formed epitlioliuni was found in a transparent, non-eataractous lens. Berthold's observations become still more interesting since Becker (Anatomic, p. TO) observed a like condition in both lenses of a dog, but he is nnable to give a satisfactory ex])lanation. A later observation and ex- amination l)y Oeller,!'^ in the case of a boy, also one in the eye of a pig, here noted, are certainly worthy of being read. Since attention has been directed to this subject, the opthalmoscopic examination lias disclosed very fine foetal remains of the hyaloid and its brandies, sucli as cause no interference with sight and which ordinarily Mould have been overlooked. Cww Report. Miss K. S., aged 18, came to have her eyes tested iu November. 1895. Opthalniosoopic examination of fundus disclosed a somewhat irregular heart sliaped choroidal atrophic area to the upper and slightly to the nasal side of the papilla. This area is snow wliite. surrounded by a deeply pigmented margin, and about the size of the papilla. During, the examination a peculiar striafion seemed to veil the distinct view of the fundus, but on gradually adding plus glasses, until the posterior surface of the lens was accurately focused (plus 10 D). these striations gradually became distinctly visible as black lines. They take their origin from a knob-like protuberance, Avhich curves backward into the vitreous. It passes on to the lens and gradually spreads out fan-shaped, taking in a section of about 30 degrees. Directly below this, leaving an inter- vening space of about 2 mm., another similar figure begins, but soon disappears. These undouljtedly are tlie remains of tlie hyaloid, which during foetal life were present on the posterior surface of the lens. In a monograph by Dr. David DeBeck,!^ all the literature on this sub- ject was compiled, and in his classification he speaks of (I) strands attached to the lens alone; (J) posterior capsidar cataracts: (K) striae on the posterior lens capsule. CHAPTER III. MALFOinrATTOXS OF THE LEN8 IX CONSEQrENCE OF UX- SY:\lMK'riU('AL DEVELOPMEXT OF THE ZOXULA ZIXII. COLOBO^F.V LEXTI8. (Aril). One of the causes of this malfoima- tion of the lens, which is due to an unsymmetrical ligament, is sought in the late closure of the ocidar fissure, as is at times seen in cases of coloboma iridis. 'I'his is nearly always combined with a slight malfonnation of the orbicularis ciliaris, in that at the point where the ocular fissure closed one or more ciliary processes are wanting and the ciliary body is sim])ly indi- cated. In consequence, tlic zonula, if present at all, is less tense, though iu nZur Aetiologie der Cataracta Polaris Posterior. Dissert Munchen. 1878. 18 "Persistent remains of the F()(>tal Hyaloid Artery." Cincinnati. 1800. '47 all pr()l)i)l)ili;.v it is wantiii- ;il lliis |.<.inl. .\> a loiill of tlii> ivductioii of tension, on (i|)tlialiii<)<(o|iic cxaininat ion tlif line of this dcrcct is marked by a black line, ihc lens ai)|)car> notclicd al it> cd.uc. iiiid tlu'iv i< an indent- in(? of till' contour as a result of inc ii'a>cd rctlcxioii. IlcyP develoix'd llir in-viiioii> liieorv. thai llii- iiial formal ion is due to a lack of nutrition. <\uv to a dcl'ccl in the anlci-ioi' 1. randies of the hya- loid. This surely can not have much in it> favoi'. '{'readier Collins i:ives (luile a diirerent e\|ilanatiou foi- the occur- rence of this malformatiiU). a> ha> already been fully explained .m ])ages 2U ami : I. Accoi'din,^- to the latest woi'k on thi> Mihjecl hy Di'. K. I'.ock.- con- oenital malformations of the lens hclon.i:- to the rarest of ocular findings. The author reports six cases of his own ami forty->ix other cases occurring in thirty-eight: person^ reported in literal ui'e. At the nu'cting of the Amei'ican ( )pthalmological S(.dety. is'.ll. Dr. C. F. Clark. Columhus. Ohio, reported a case of hinocular colohoma leiitis in which the accommodative powei' was i-eiained. THE OKXESJS OK COl.Ol'.OMA LKNTIS. I'.adi seek> the cause in a delayed closure of the ociilai- li>sure. The pi'ocess of mesodermal tissue which extends as a process against the v(](ye of the lens, acts as a mechanical obstruction at the respective point. .\s a result of this ])ressure along the foetal fissure, the lens sul)stance deteriorates, is altered in its constitution, and may simply assume a cloudy as]>ect: or the more actively affected ]ior- tion may disintegrate and he absorbed, aiul along this liiu' one will observe a vacant siiace or fissnre. Bach accei)ts this explanation, but goe> still further, stating that the fundamental cause is to be sought in an ahiiormally developed lens, which in early foetal life o])poses the advancing mesoblast. which in its turn presses against the gi-adually enlarging lens, or vice versa. Further, if the adhesions between the vascular capsule of the lens and the mesoblast do not dissolve along the entire equatorial region, this must lead to a transient tension at the respective ])oint where this attachment persists, which in its turn leads to a disintegration, evi'utually to a desti-uction of lens >ubstance. The capsule may even he pushed aside from the region of stu-h a lenticular defect, or the defect may he covered by this membrane. Sim-(> the forma- tion of the caiisule of the lens is now proven to be the ]iroduct of the cap- sular cells, and since nucleated lens fibres must still be ]M'esent in the neigh- 1 Coloboma Lentls. Report of Fiftli luteiiiational Optli. Congress, 1877. p. 16. Annal (VOculist. 1877. p. LMlf.. 2 IMe Anti-elH.r.'ncn ("ololx.nie des .\ui:upfels Wieii. IS'.i:^,. 148 borhood of the suiic lu'iu-c one iiuiy roadily ^mdcrstand liow the capsule may subse normal. Xothing special is known concerning the cause of the unequal length of the zonular fibres. Here, once umre, attention is drawn to Treacher ('ollins' explanation, i)age '\\. Since the displacement in both eyes is almost invarial)ly synnnetrically upward; either directly upward, or nj)ward and to one side, it does not seem difficult to assume, that here likewise, closure of the ocular fissure plays an im- portant role. Attention is first directed to this condition from the fact, that the patient sees very poorly, and that vision can not be improved with glasses. Vision can only be improved by the use of strong concave glasses. A prac- ticed eye at once perceives that the anterior cluunher is of uniMpial depth, in that one portion of the iris is situated more anteriorly than the diher. The uiore deeply seated portion trend)les on moving the eye. On opt halnioscopic examination, one will see at once, or possibly only aftei' dilating the pu|iil.the edge of tlie lens passing through the pupil, as the segment df a black ring along the liiu' wliei'e the iris li(\s dee])est. If the attempt is now made to get a \iew (d' tlie fundus, this can be accomplished in a two-fold manner. if one looks tlirctugh tlu' lens, using the corrccli(Ui f(ii- a myopic eye. one nhtains a. view of the ])apilla. and on looking to the side of the lens, using the a])hakic correction, one gets another \ie\\ of the papilla, ff we now inake tests for vision, the presence of this condition can he ]iroven f(n- dis- tance, by concave glasses, where the patient looks through the crystalline lens: the same result, howevei-. may he ohtained hy using catai-act glasses, the j)atieiif looking to the side of the leu>. If hy the one method or the 149 other the ;in(iiii;ilic of rctVacI ion is iiciit i-;ili/,('il, llic >crT)n(l ]io.i>il)ilit y will iiitert'ci'c 1)111 lilllc. Ilowcvci-. witlKMil ;i ciiiivcl imi ;i tnic iiioiioeiilai' diplopia will (k-cui'. This (■(•iidiiioii can nt)t always Ix- niadr apparrnl to the paticnt^ at ouvv. It (Icjx'IhI.- upon the distance at wliicli tlit; li^dil is i\'iii()\c(l I'nini tlic patient, wlidlicr hotli iniaiic^ will liccdinc ap|>arcnt Of wlit'tlici- one will l)(' suppressed. IF one liad pi'exionsly delerniiiied botii (•(inditi.in> of refraction, one can easily lind llie distance at wliii-h botli iiuayes iiinst. become appai'ent. .\t this |)oint. as a rule, the patient will see both images at once. The inia;.:e which is foi'uu'il without the aid of the crystalline lens i> projected correctly, whereas the crystalline lens acts as a pi'isni. Hence the iiua^x' which passes tbrou(,di the crystalline lens is projected falsely and in exactly the op[)osile direction to that in which the lens is Inxated. 'I'his knowlcdr.) 1 :nn acquainted witli a t'ainily. in which a brother and sister show in both eyes a syiniiietrical eetopi.i lent is. Ten years ago both could overcome the interference witli vision l)y cylindiical glasses. At present this is no longer possible. 'I'lie cliildren ot tlie sister, a boy and a girl, both are astygniatic, and Avere eorreeted tour yeai-s ngo by cylinders. .Vt tliat time. I measured the cornea with the oi)thalnionietei-. and could not discover any asynietry. On dilating the pupils of botli children oih' could see downward and inward a dark spot at the edge of the lens, which 1 i)ronouneed a congenital partial cataract. Now the c.vlindrical glasses are no longer of use. and the trouble is continually becoming more pronounced, as a luxation of the lens, rndoubtedly the zonula first began to give downward and inward, and is gradually lieeonnng elongated. \'on (iraefc'^ was the lii'st to accui-atelv desciibe a case of ccuicenital Arch, fur Qpth., I, S. 343. I50 luxation of the lens. The pecnliarities of vision in these eases are hero found accurately described; he, however, failed to state whether this is a congenital condition or not. He seemed to believe that the cause is a Huidity of the vitreous, and a, defect in the natural partition wall, though, on using the o])tlialni()scope. he could not discover the slightest trace of a flaky or membranous cloudiness in the vitreous, and the fundus appeared perfectly normal. In the sime year (18r)4) E. Yaeger descnbed a case, which bore a close resemblance to the one mentioned above, and he de- scribed it as a case of congenital displacement of the lens system. Stell- wag ^ was tlie first to describe an abnormally small lens as a congenital anomaly, and to use the word "ectopic" in the sense we use it today. From now on. the reports of cases of luxation of the lens began to increase; also explanations as to its cause. Dixon, the Englishman, as the result of a re- port of a large number of cases, added much to the methods of diagnosing congenital luxation of tlu' lens. Hippel ^ finally took the last step, when he said that '"sponfdiieoiis Iii.niiiun" and "ectopia hntis^' are two entirely different conditions, in that the former is due to diseased conditions in the eye, whereas -the latter is a malformation. CHAPTER IV. ACQUIRED AXOMALIES IX THE POSITIOX OE THE LENS. XOT DUE TO MALE()1«LVT10X8. LUXATIO LEXTIS— LUXATIOX OF THE LEXS. Anatomically considered, the accpiired anomalies of position of the lens, can not in any sense be considered as malformations. Xevertheless, owing to the great similarity of the symptoms, both subjective and ob- jective, they will be considered at this point. The tei-m ''lu.valio lenlis'' embraces not only the cases of spontaneous displacement of the lens, originally in their normal position, but those cases which occur in consequence of violence which causes the lens to par- tially or totally leave the fossa patellai'is. l^lodigo suggested that we use the tei-m ''(Jislocalii).'' instead of "luxalio lentis." and this nauie might with givat. |ti'opriety be used in cases of secondary luxation. SPOXTAXEOUS Ll'XA^JTOX OF ^JTIE LEXS. EUXATIO LEX- TIS SPOX^WXE. DEPLACE^rEXT SPOX^JWXE. We are indebted to 4 Wiener Med. Woclicuhlatt. 1S.->(i. 5 "Die si)oiitiiii(' Inx.itidu dcr liiise >unl ilire .•inucltoreiie ectopie." .Marburg. 151 SiclK'P for the first accurate descriptions of sponiaiiL-ou.^ displacement of the lens. This can only occur when the zonula zinii has been partially or totally destroyed. IF such a defect in the zonula takes place to the side of, or below the lens, a chancre in the position of the lens does not necessarily follow at once. Tvuv. ..wino- to the specific weio^hi cf the lcii>. on niovins? the eyes, even after they have aoain come to rest, tlu' lens will continue to make movements. In e(.ii^e(|uence of these oseilatiii-r movements, the lens may become turned on its axis, so that its one edge may come nearer to the cornea than the other: but a real displacement to the one side or down- ward will not oeeiir as long as the portion of the zonula zinii above, remains intact. As soon as this becomes affected the weight of the lens will begin to exert its influence, and as a result, the lens will begin to sink downward. Xo matter where the zonula has l)eeii afl'eeted. owing to the oscillation of the lens, in eourse of time the zonula will give above, and the lens will becMime displaced downward. It will then depend upon the conditions of the latteral portions of the zonula whether this sinking will take place exactly downward, or downward aiul inward, or downward and outward. This is a very important fact, since a lens can iu'\er l)e .ywntaneoush/ lux- ated exactly upward. The cause of this spontaneous displacement lies either in the condition of the vitreous and the zonula, or in the lens system itself. The disease which is considered to be most frequently followed by a spontaneous luxation is a general fluidity of the vitreous. (Sijnchysis corporis vitrei. Aside from the fact that the clinical picture of this disease is by no mean> a definite one. it is impossible for the lens to sink down without the zonula zinii suffering in its continuity. Although up to the present time it has never been quite clear in wlwit nuinner a fluidity of the vitreous could affect the zonula, especially since there is no rediution in volume of the vitreous when it is in a fluid state, we are entitled to make the assum])tion: since, as we have seen, the zonula is of mesoderniic origin, as is also the vitreous: hence the same causes which lead to fluidity of the vitreous, may at the same time dissolve the zonula fibres. Hence, in cases of spontaneous luxation, we are not dealing with a tearing, but with a dissohiiion of the zonuta. However, when we say this, we are only saying that the same cause, of which we are as yet ignorant, causes a like change in both vitreous and zonula. A spontaneous luxation nuiy as well lake place when the lens is per- fectly transparent, as when it is cataractous. Further along, a different factor will be shown to be at work in influencing the spontaneous luxation 1 Oppenheiru's Zeitsehrift, XXX, 3 Heft. 152 of a cataractous Jens, which factor has nothing to do with the above-men- tioned manner of occurrence, since in these latter cases there is no fiuidit} of the vitreous. The symptoms of spontaneous luxation necessarily vary, depending on the fact, whether the U-ns is transparent or not. In cases of transparent lenses, tlu' symptoms are very much like those of ectopia lentis: tlicy (lilVcr. liowcvcr. from these, in that the symptoms develop in a proportionately shorter time. 'Vvml', as a rule, this sinking dovt^n takes place slowly, though always more rapidly than in the cases described under congenital ectopia lentis. In onh'r to make a differential diagnosis, it is of great importance to be able to determine, if for a certain period of life, vision has been normal. In just such cases, where fonuerly vision was perfectly normal, tlie ]iatient will become aware of the change, vision is not so sliarp, and iu trying to see accurately, objects seem to oscillate. The lens begins to move about behind the iris, and in consequence the iris begins to tremble. Examination of the refraction discloses the fact that the far point has come nearer to the eye. If the lens has sunk down so far that a part of the pupil is free, a double refractive condition will result, together with true monocular diplopia, as in ectopia lentis. A further striking symptom is now added, since vision changes with each change in the position of the head, for on bending the head forward the lens comes up close to the iris, whereas on bending the head backward, the lens falls back into the vitreous. In the first case the already unequally deep chamber becomes shallower, whereas in the latter it becomes much deeper. Where there is a great mobility, symptoms of irritation on the part of the iris and choroid may develop. This is preceded by a variety of ectopic phenomena. The patient beconu's aware of the presence of the lens as a grey disc, or as a similarly colored segment of a circle, and at the same time he begins to see flashes of light and tlauu' like figures; likewise, irritability to light, tearing, and pain may be added. If the zonula zinii lias been entirely dissolved, the slightest jar mav cause the lens to fall into the antci'inr cliauihcr. In coui'se of time, lenticular and capsular cataracts always follow in cases where there ha> taken place a luxatitui of the lens system. '^rhe >| laneous luxation of the riila nnhiiis lens is ])rodui-ed in an en- tirely dilTerenl manner. Tlii> is not true of all cataracts which spon- taneously leave (he |»upillaiy area, for it is possible for the vitreous to be- come 11 u id in case> of cataract: without taking into consideratiiui those cases, in wliich tlu' displacement i> of Mich a slight degree that it ha> l)een 153 overlooked, but neverthek'.r(|iicn(c ..f uliidi the lens has l)Coome cataractoiis. It has long been known, as an rslal)lislie(l fact, that after a rnlly-dt-- vch.pod senile cataract has existed lor a Inn-- linif. llic cataract may spon- taneously leave the pupillary area. Bei'ure this can occur, it is necessary that ii looseninfr take place, between the zonula zinii and the lens on the one liand. and hctwcon llic i)o>tcrior and ilic concave vitreous depression on the other. Wenzel. i'.eer. and others liave reported that not infre- quently, on niakin-i- a (lap incision, tlie lens, together witli its cap>ule, would i)op out of the eye with considerable force. This can oidy l)e ex- plained. l)y assunnng that the tension on the zonula zinii, and perhaps also the sudden change in the position and form which takes place in the lens, the nionient the aqueous is evacuated; and also due to the pressure the vitreous exerts anteriorly, is sufficient to tear the lens from its con- nt'ctions. It must have been these observations which led to the develop- ment of those methods which had as their object the removal of the U'ns together with its capsule. The anatomical cause of such a loosening of tlie lens from its attach- ments is not to be sought in a fluid vitreous. Xot only are we in possession of reports of cases in which the removal of the lens in its capsule was not followed by an evacuation of vitreous, operators know only too well, that a fluid vitreous has a tendency to get in front of the lens and cause the lens to fall backward into the vitreous. However, one must not lose sight of those senile changes in the zonula fibres already described, which makes them stifl'er and more brittle, so that they are less able to resist a sudden force acting on them. However, the greatest stress must be laid on the condition of the anterior capsule. If our conception regarding the forma- tion of capsular cataract is correct, the formative stage is foHowed by the stage of shrinkage, just as we see it in cicatrical tissue. Since we know that the capsular cataract does reach its linut. in that it does not grow in the periphery, as it does in thickness ad libitum, it must necessarily finally be- come reduced in volume after it has reached its maximum growth. Further, since it is formed on the concave side of the anterior capsule on shrinking, it has the tendency of becoming tense like the string on a bow. and hence exerts a certain amcmnt of tension on \hv capsule. .\s a i-esuit of tlvs tension, capsular cataracts of long standing appear folded. Ji. .Muller, 1. c, pp. 281 and 284). This has been looked upon as one of the causes of pyramidal cataract. Such shrinkage likewise becomes a very im]iortanr, factor in the production of the various forms which secondary cataracts assume. The greater the amount of lens substance al)sorbed, the greater will be the eft'ect on the -ha])e of the eiitii-e len>. in cases in which the cap- 154 sule lias not l)eeii injured. The development of cataracta frpunila. natalis and elastica will now he more easily understood, since these are principally {•apsnlar cataracts. The s])ontaneous luxation of senile cataract is undouhtedly favored l)y changes in the zonula fibres, and could with difficulty occur without the intervention of some form of accidental traumatic cause, such as vomiting, convulsions or concussion of the entire body and the eye; this is, however, always preceded by the formation of a capsular cataract. The tension which is exerted on the anterior capsule during the process of shrinkage must all the more assist in severing this connection between the anterior capsule and the fibres of the zonula zinii, because this shrinking capsular cataract extends just to the peripheric endings where the zonula fibres are inserted into the anterior capsule. This view is strengthened by the fact, that in cases of spontaneous lux- ation of senile cataract, as a rule, one finds extensive capsular cataract; further, that not only in spontaneously luxated lenses, but also in cases where at the extraction, the lens in its ca])sule escapes by itself, one can never discover any remains of zonular fil^res on the capsule. This also shows that the connection is severed at the capsule and not along the length of the zonular fibres. a. LTJXATIO LENTIS TKAHMATICA— TRAVMATIC LUXATTOX. Traumas, which may cause the lens to leave its normal position, are either contusions of the eyeball in which the coats of the eyeball may or may not be opened, or the zonula is ruptured by the direct action of a foreign body which has penetrated the eyeball. In the latter case tho foreign body may eitlioi- remain within or again leave the eyeball. If a foreign body penetrates the eyeball in such a manner as to sever the zonula zinii in only a circumscribed area, it goes without saying thgt besides the zonula, cornea, iris, and also the vitreous are always involved. If the in- jury is caused by a pointed instrument, (such as a needle, the shoemaker's awl, a steel ])en, or a pointed knife-blade), this will again leave the eye and the injury may heal in a few days without any special reaction. Fre- quently the case comes under observation only after the wound has healed. The statements of the patient then lead us to make a very careful examina- tion. Here we find a cicatrix in the cornea, a hole in the iris, through which, when properly examined, light can be reflected from \hv fundus. If the hole in the iris is larger and extends perpendicularly to the radiating striations of the iris, the pupil at this point will not be so wide, and conse- quently not perfectly circular. Tossibly one can detect a numluT of flakes ill the vitreous. .\sj(le from (list urhaiices of vision due to opacities in the ■55 vitreous, iiiaeciiracy of vision may develop as the ri'suli of a>ly<:iiiali.-iii. At the ])oint wliere llie Zonula has lieeii -evered. it will e\erl less prcssur-^ on the lens. At this puini the len> l.e((Mnes thicker, aiul in this meridian, the eve will heeouie myopic. Attempts at cylindrical c(,iTeclion are as a rule attended with Itnt >li-hl >ueeess. .ince the entire meridian does not alter its relVaclioii. the .ippixition end of tlu' respective meridian remain- ing fastened in its noiuial cdndiliou. The ivsuh n\' >uch an injury, there- fore, is a ])ei'manent reduction of vision. .\s to whether or not an iri> pro- hipse follows the injuiw depends entirely on tlie size of the corneal wouml. If this occurs, undei- cei'tain comlitions this must he exercised. It may necessitate an iridectomie. If, aside from the above-mentioned tissues, the lens and corpus ciliars are injured, the process of healing hecomes proportionately nujre compli- cated, and the sequehie for sight — in fact, for the whole eye; indeed, the second eye, since this may he sympathetically alTected — nuiy he of the very worst kind. Hence injuries of these parts are of the very greatest importance, and mention is made of this here so tluU it need not be referred to again. Though it clearly is not within the province of this work to enter into the sul)ject of SY:\IPATHETIC OPTHAmilA, still it seems but proper to state that most authorities today aekm)wledge that this disease is clearly an infection. Where a foreign body, as indicated above, penetrates the eyeball and is retained, be this a minute spicule of iron, steel, lead, copper, glass oi- stone, it may re- main free in the vitreous or stick fast in the [)osterior wall of the eye; and, if asce])tic. it may become encapsulated and remain latent for years. However, it nuiy be here stated that even these capsules lead to tension on the vitreous and eventually to loss of the eye, notwithstanding the isolated cases reported in literature in which this result did not follow. Leher,2 as the result of eleven years of experimental investigation with every conceivable substam-e, studying its action on the interior of the eye, states, that all the metals, even gold and silver, glass, etc.. are gradually acted on by the fluid media of the eye. minute quantities gradually dis- solved off, and thus act as an irritant causing a purulent inflammation wliich may be dsrcplir in its nature. The recognition of asceptic pus chem- ically i)roduct'd, he regards as of the greatest therapeutic value. lUit where micro-organisms are carried into the eye with the foreign body the condi- tions are different and the occurrence of sympathetic opthalmia becomes a 2 Die Enstehun^ der Kntzundunjr nrul die -wirkmri: iter I'nTziniduiiirs ere- gende Schadlichkeiteu. Leijjsi;:-. IWtl. 156 possibility, if not a i»n>l)aljility. Weckcv coiiddcrcd tin? subject of such great inipoi'tancc that he .levotcd an entire chapter to its discussion.^ He critically analyzed some twenty-two cases, and finally concluded that the tension of cicatrical bands on the ciliary body led to chronic irritation and sympathetic opthalniia. Many of these earlier experiences, read in the light of our present imderstanding of the subject, are clearly an infection. "On New Year eve, 1870. a piece of a percussion cap flew into tbe eye of a twelve-year-old boy in the neighboring county of K. I (Beclier) found, down- ward and inward from the edge of the cornea, two millimeters distant from its transparent edge, a wound about three millimeters long, into which the iris had prolapsed. After excising the prolapse, a coloboma was found extending to the perii)hery. After the Avound was healed, on looking through this colo- boma. one could see a distinct indentation of the edge of the lens. Colobortw Laitix Artificink', and this also caused astygmatism. This piece of percussion cap became encapsulated without in.iury to tlie eye. and after a lapse of five years the eye still performs its function." If. aside from cornea, iris, zonula and vitreous, fhc Iciis and cUiari/ bochi are involved, the prognosis and the duration of the trouble will materiallv depend on the extent of the injury to the parts. It then would certainly be advisable to cut short a long and painful stage of healing and forestall a possible sympathetic affection of the other eye by an immediate enuclea- tion. A contusion of the eyeball is frequently followed, without the coats of the eyeball being ruptured at any point, by a stretching and final separa- tion of the fibres of the zonula zinii, and as a consequence, exerting a tem- porary or pernument influence, on the form and position of the lens. It is questionable, and has not as yet been proven, whether or not the individual fibres of the zonula possess the property of elongation or distension. It is stated that where the anterioi- chamber is evacuated, the anterior capsule of the lens comes in contact with the cornea, and that this could not possibly occur without the elongation of the zonula fibres. It is only certain that the zonula fibres do not tear, otherwise the lens could not retain its normal position with a complete retention of its normal functions. Instead of an elongation of the zonula fibres, such a consider- able moving forward of the lens (about -2:] mm.) could be caused by an an- tei'ioi' movement of ibie ciliary body, togethei- with tbe ii'is. and the in- creased convi'xily of the anlerioi- sui-face of tbe lens. "It would not h.-ivc been n(M-essjiry (o luenlion tliis elongation of tlic zonular fibres, if it were not for a case reimrted by Aub.4 whicli he tried to explain by 3 Pathologie and Tlieraiiie des I>insensystems, p. 4 Arch. f. A. und ().. II. I. p. !.••">'.». '57 usiu;;- this liyiioihcsis: A in:in. ."..'. yr.-irs of nuc w liilr uiii liuiiiiiiv^ w.-is siruck oil tlu' (\v('lt;ill by :i slioi fnnii ;i sIkiIlmiii. A single slioi \v:is inudvcil from iho oiitcr iiortioii of tlic (•oii.jiiiictiv.-i tlic next roven that the zonula is elastic, and further, that a partial ]>aralysis of tlie ciliary muscle, at the point where tlie shot struck the eye. would explain all tlie iihenomeiia which he reports." TJ^AIMATIC LUXATION is always the result of a tearing of the zonula zinii without an injury of the lens capsule. Since it can not be as- sumed that tears in the zonttla can heal, we are justified in making a diag- nosis of a partial tear of the zonula, in all cases in which, in conseqtience of a eontusi(jn. the [ilienomena of a dislocation of the lens system appear and do not retrogress. In the beginning, these phenomena are the devel- opment of a myopia and the gradtial shortening of the distance of the far point of the eye. If the tension which the zonula e.\erts on the crystalline lens is abolished, owing to an extensive or jiossihle total tear, the equa- torial diameter will be diminished and the axial diameter will be increased. Owing to this change in the form of the h'lis. the far ])oint will approach closer to the eye. lUit where there is a total, or even a very extensive tear- ing of the zonula, accommodation beconu^s imi)ossible. and there will be but one point, which will neither coincide with the former far or near point, at which it will be possible to see distinctly. The former symptom will, however, only then become Aaluable for differential diagnosis, where 5 L'ber die Verletzimgen des Auges in (Jerichtsarztlicher Zeziehung. Wiener Med. Wochenschrift. 1.S74, No. 15. S. 200. 158 we know, what the refraction of the eye was previous to the accident. In manv cases, liowever. by conipai'ing tlie eye with tlie uninjured one, we can, with a considerable dej^rcc of certainty, form an estimate. (It must, however, not be forgotten that not infrequently the refractive conditions of the two eyes are not alike; hence it can never give more than an ap- proximate resnlt.) If the lens is not held equally tense in all directions by the zonula fibres and lield fast in its connection with the ciliary processes, on moving the eye, the lens will begin to make independent movements, in which the iris will participate. (Trembling of the iris — iridodnnesis). However, this symptom alone does not decide anything as long as the lens is trans- parent. For the iris may independently make such movements if the pupillary margin is free and an abnormal amount of aqueous is behind it. In exceptional cases, this can be observed: as, per example, where there is a large cornea and a relatively small lens, in cases of myopia with relatively deep anterior chamber, in eases of buphthalmus, and in cases of synchisis corporis vitrei, where the lens lies deeper than the normal. b. SUBLUXATION OF THE LEXS. In cases in which there is a partial tearing of the zonida, the lens may retain its position unchanged in the concare hollow of the vitreous for an indefinite length of time. In most cases, liowever, after a time the lens in a two-fold manner changes its position, in that it not only turns on its equatorial diameter, but also moves toward the side where the zonula is still intact. Due to this oblique position or turning of the lens, the iris is pressed forward at one point, and consequently the anterior chamber at that point is shallower. The opposite edge of the lens approaches the axis, and on using the opthalmoscope it may be seen when the pupil is small, and must appear when the pupil is dilated as a black segment of a circle. However small this segment of a circle may be, by means of this, we can definitely determine the position of the lens and the kind of transposition we have before us. 'I'Ir' edge may even become visible to the patient, as a black ring. If the edge of the lens passes tlii-ougii a impil of normal size, naturally, everything will be seen double. The iinportaucc of a subluxation ri'sts on the fact, that uiuler all circumstances thcj-e will be ])ermanent interference with vision. Aside from this, experience has taught us. that in. nearly all cases, if the patient lives long enough, a total luxation will finally result. Further, in course of time the lens will always become cataractous. This frequently happens before the zonula is completely torn. The latter must naturally follow, Ihitin.u- of the Ici 1>. (Ml Mlii\ •ill- tl end to ail ahiioriii; 111 tension (111 tile V iiiav (iiialU lca( 1 1(1 cvcliti ^. cll.-l 159 'ad ai id the lin iii.-i- zonula i> ; ind syiiip- lih res as the -!"■ ik of n since the constant o eyes, necessarily niiis fibres. The same ca tonis of glaucoma. As has already been stated, a rcsiitnti( result of liealing is not to he expected. li( therapie tor subluxation. In some special eases ilie attempt may he made to give aid, by the use of glasses. (Mtlier by looking through the dislocated lens, or to the side of it. II' the lens has become catanictous, the attempt may be made to give assistanci' by an irideetomie or by an extraction. The mechanism by means of which a tearing of the zonula is brought about, is as little understood, as is the mechanism oi all other internal in- juries of the eye, which result from a conhisio hulbi. Jt appears most prob- able, that the globe, owing to its peculiar situation in the orbit, can only be struck in its anterior position, by a, blunt force, and most frequently is flattened in a direction from in front, below and outward. l>ackward, upward and inward. Such a flattening, owing to the inconipressibility of the media of the eye and the relatively slight elasticity of its coats, can not occur unless the globe is distended in the eqautorial region. If the cornea is the part compressed the distension will take place at the sclero-corneal ring. By this means we can most easily explain, why it is that choroidal ruptures occur most frequently in the equatorial region and very nearly concentric and opposite the place to which the force was applied. This also explains the relatively frequent occurrence of iridodialysis and tears of the zonula. Relative to the latter, we must also consider that in every case of concussion of the eyeball, the lens, owing to its greater specific weight, tries to make more extensive movements and hence pulls on the zonula, which tears when a certain degree of tension is brought to bear on it.*^ The lens may retain its position in the fossa jiatellaris in cases in which there is a partial, as well as when there is a total tearing of the zonula. In most cases instantly, in other cases after a certain length of time, the lens changes its ])osition, remaining in contact with the patellar fossa or leaving it altogether. Thv first condition occurs most ri-e(piently and will continue longer wlu-re the zonula is hut partially torn. This may be designated as a suh-lti.nilioii. (Arit). in contradistinction to a liLniliaii. in which the crystalline body has entirely h'ft the hollow grove of the vitre- ous, and is found t'ither in the anterior chamber or wedged in tlie ])upii 6 Yoral. Arlt. Wiener INIed. Woclienschrlft. 1874, No. 12. p. 2.''.1. i6o or in tlie vitreous, oi-. liimlly. iliai it lia> Ix-eii (li'a^-pod entirely out of the evel)all. Tlu^ force wliifl) eause.s a ronliisia hull I, as a rule strikes the eve in a direct manner. Tlie body eoming in contact with the eye may 1)e rela- tively lartje as com])ared with the size of the eye. and have considerable thickness, or have a blunted end on a rounded ])i'oininence: and this, aside from causino- ;i o-eneral tlatteninii' of the ulobe. may cause a locally deeper impression without peneti'atinii' the coats of the eyeball. I)Ut il is nor necessary that the foi-ce >ti'ike the eye in a direct manner. Thrusts, blows, gunshot wounds which >tiikt' the neighborinp; bones, may likewise cause a concnssion of the eyeball. Fimilly. it may be mentioned that projectiles flying ])ast, close to the eye, may cause a roimnotio h>ilhi. During the war of "lt)-71. 1 (Becker) saw two cases of injury of the eye wh.ich were caused in this manner. True, both cases were ruptures of the choroid, not teaj-s of the zontda. but since the former did occur, it can not be doubted that the latter is a piossibility. e. TOTAL LUXATIOX OF THE LENS. Everything which has been said regarding the manner in which sub- luxation may be caused, is also true in this instance. A trauma of greater intensity, instead of causing a subluxation, causes a luxation. .\s a rule, a total luxation is preceded by the entire tearing of the zonu.la ziidi: how- ever, one can understand, that a few fibres may remain intact, though the lens l)e entirely removed from the fossa patellaris. On which factor, the direction of the luxation of the lens (U'])en(ls, is not known: the symjitoms naturally vary and dept'nd entirely on the posi- tion of the lens. 117/f/; llie Inxatal lens is found in llir anfcrinr chnnihrr. as the direct result of a trauma, we see a round body, with an ahnost golden colored ring which lies concentric to the l)ase of the cornea, and it has a very (lece|ttive similarity to a di'op of oil. Thi> body does not entirt'ly fill the anterior chandx'i'. but the ii'is is not visible, sim-e it has been inverted. Aside from this phenomenon of total refit'ctiou of the edge of the lens, one can see, on focal ilbnuination. in the ti-aiisparenl body, radiating >n'iations and splits, which can be traced to the lens. If such an eye is examined shoi'tly after the injni-y. one sees the results of the action of the direct trauma, in the neighborhood of the eye. whereas the eye itself is free from any ii-rilation. Lalei-. howcvei-. (in most ea,-es. aftei' a few (hiys). ciliary injection and even swelling of the conjunctiva bull)i sei> in. and the globe becomes glancomatose and exceedingly ])ainfid. Then ihe cornea becomes «lond\ at the point whei-e the lens is in contact with il. and linally. as the i6i subjective sympldin a.nl infill ra lion t;() on inci-easing. per foration take> place. The liinil re- nil i.- ;, escape ■ of 1 he lens and pnrnleni | .hlhisis of the glol)e. The lens docs not, : d\\ay> ( ■oniplctely enlei- ihc anlei rior chamber, o\viii,i;' to I lie spaslic conn •aclion ( if the sphincler iridis. I'oi- ji list as the lens is ]»;issiii,u' t liroiiuli 1 1... ,, mpil. il nia\' become lixcd. llere the picture is highly cliai-actci'isiic and can not be mistaken. Nearly alwa; ^s do we see a more or less transp; u'cnt , ronml and tlatteniMl body exteiK ling ol)li(iuely into the anterior chamber, ami at its edge can be seen the \vell-k]U)\vn shin- ing, reflected ring. In most cases, such a condition is transitory. If the spasm coidiiuies. pain will be added to the iiitert'erence witli vision. The patient seeks relief, which can be given him by the energetic use ol:' atropine. If this is not done, glaucoma will follow, and finally, as the result of ulceration, the eye will becouu' phthisical. It appears, that ex- ceptionally this condition uuiy be tolerated for a considerable length of time. 13ader' describes an eye, which is in the museum at Moor- fielcTs Hospital, London, .showing a lens in its ca])sule. tixed in the pupil, and which had takeu on ])ermanently a biscuit form, lie fails, however, to state whether the lens attained this position as the direct result of a traunui. or whether this was simi)ly the result of a change of position of a freely nu)vable lens, M'hich had become wedged in the ]ni]nllary area. The lens is most frequently luxated into the vitreous. Since it has a heavier specific weight, hence after a tinu'. if not at once, we may seek il in the lower portion of the vitreous space. It will now depend largely on the condition— that is, the consistence — of the viti'eous. and most probably also, whether or not a portion of the zonula fibres have remained uninjured, if the lens, on nu)ving the eyes, will remain ([uiet, relatively s])eaking, or if it make very wide excursions. We must also renunnber, that, owing to these active movements of the lens, the vitreous must gradually become diseased; that is, fluid. The lens, enclosed in its capsule, may remain transparent for a long time; it will, lunvevei'. finally become cataractous. Though the capsule ]»reveuts the lens from being absorbed, it will neverthe- less, gradually beconu' smaller. It is not known whether the intracapsular cells will undergo a hyperplasia where a normal lens sinks into the vitre- ous, as the result of a trauma. TiUxated lenses examined showed incipient capsular cataracts. However, it could not be determined whether this was the result of. or had existed previous to, the luxation. This is mentioned simply to draw the attention of my colleagues to this question, owing to its great importance. 7 The natural and morbid chanfros of the human eye. etc. London, 1868, p. 260. I 62 ,1. K1M-:K1.V .McnKAl'.LK I.KXSES. I'lulci- this name, a condition lias been described and illustrated by innumerable ease re])orts. whieh may result just, as well from congenital ectopia lentis, as in conse([uence of -pontaneous or traumatic luxation. This name was introduced by TTeyman. The cases belonging to this category date back a very long tinu'. The common symptom of all these cases is, that the lens, no matter what the position of the head or eye, always takes a position relative to its weight. This does not only refer to a change of ])osition in the vitreous. I»ut the lens may also become wedged in the pupil- lary area, oi* evi'U get into the ai";terior chaml)er. In cases of congenital ectopia we must assume that the zonula fibres have an abnormal length. As a result, the lens may slijt into the anterior chamber or fall back again into the vitreous. ""Such a case, I (Becker) saw at Arlt's clinic, where a boy. eight years of age. could easily accom- plish this change. Since, when this small lens was in the anterior chamber, fine indentations were observed all around the periphery of the lens, which undoubtedly were due to the tightened, tense zonula fibres: hence this case served to reiiioxe any doubts in my mind, that there are cases of freely movable lenses in which the zonula is not lorn." The symptoms which such a freely movable lens cause, are in part piirely optical in their natui-e: in ])art pathological, since they cause pain, and other sul)jective syni]»toms which give rise to the necessity for opera- tive interference if we desire to prevent total destruction of the eye. Arlt reported a case.s illustrating the first mentioned symptom. A carpenter, 48 years of age, who had always been in perfect health, and wlio durins; his school days had had good vision, gradually later on became nearsighted. In his 45th year he suddenly developed monocular diplopia in both eyes. At the end of one year the double sight disappeared again. If lie lay on liis back he imagined that he saw in front of each eye a round iiiiid tlie iris, in tlie i)Ui)illary area, and llius he was en- abled to road. 'I'lic following case is reported by .Noyes.i' A man 4.''> years of age was struck ill tlic left i'\v \\y tlic list of .-inother. Three weeks later the diiigiictsis of lux- Mtioii (lowiiw.-ird into ihe vitreous w:is lu.-ide. His ref ruction was that of aphakia. A wee]< later tlie ii.-itieiit reiH.rted tli:il he saw good .-igjiiii. Tlie crystal- Die Kr: lllklieiteli .les \iige> c. III. p. .-.. ls.-,(; .\ll( •]i. r iir .\ngeii 1111(1 Olire 11. ileilkun.le. I '63 liut> U>us, as coultl oasil.v he (Icicriniiicd liy llic coiidilioii of Die iris, wliich was pressed I)ack\var(l, and by liif li.ylil cdjic of tiic Iciis. liad sliiyjird iiito tlic an- tfi-ioi- cliandtcr. It was still in its capsnlc. and iiad a I'ainl aniltcr colm-, l)ut at)- .solutely transitarenl. roiicspondinu 1(. the :\iXi- of ilir patient. 'Piie eiiaiijj:e of position was l>rou.i;lit :il»ont l>y tiie patient snee/in.i; violently after takin>r a piuoli of sntiff ou leavin.t;- the clinic, where his pni)il had been widely dilated by atropine. Innnedlately thereafter lie noticed that vision was imi)roved. Ex- amiuation of his refraction disclosed II ni. (Mjual to I-IS; \'. equal to 20-40 on his rijiht eye: liis left in.iur(>d eye M. equal to 1-0. As. ni. :24. \. 20-50. The myopia is explained by the advance of the nodal point, also as a result of the increase convexity of the lens, wliich had been loosened from the zonula attachment. Noyes states tliat tin- astysmatism is due to the fact that since the lens does not completely till out the anterior chamber, it sinks down; hence, its axis and that of the cornea do not coincide, btit that of the lens lies somewhat deeper. There are. however, most certainly other factors at work which cause the lens to suffer in its symmetrical form. Tlie presence of the lens in the anterior chamber may Ix; l)orn for a long time without destruxing tlio eye; in fact, for yeai's. Jl is hardlv pos- sible foi- the condition to exist without disturbing the functions of the eye. The pathological changes which follow affect the cornea, which be- comes cloudy when the lens comes in contact with it; tlie iris becomes hyperacmic and loses its color, and cyclitis is developed. \Vith()ut the de- velopment of an exudate — that is. tlie development of true iritis, a severe ciliary injection develops, and to this chemosis may be added. At the same time, the glol>e becomes tense and hard, and the other symptoms of sec- ondary glaucoma develop. In some cases, in a proportionately short space of time, the globe changes its f(u-m, the area of the sclerosis close to the cornea becomes bluish in color, and a staj)hyloina intercalare develops. The globe l)t'comes i)ear-slia])ed and the axis of the globe may become enor- mously t'longated. The inHammatni'y symptoms increase and finally either lead to ulceration of the cornea, with loss of the lens, so that phlMsis lulhi results, or the inflammatory syinpioins gradually subside, leaving an amaurotic t'ctatic globe, which gives rise to no furtlier trouble. In such a case one will find the lens considerably diminished in size, adherent to the coriu^a. It appears, that in cases in which tlie zonula is intact, the permanent presence of the lens in the aiHerior chamhei- (free niol)ilily of the lens, owing to congenital lengthening of the /oniila) will niiieh sooner lead to intense symjitoms of reaction, than in cases in which the lens is perfectly free from its suspensory ligaments. It is most probable, that the great danger of a partial luxation, is due to the constant tension which the re- maining ])()rtiou of the zonula exerts on the ciliary body (Von Graefe). 1 64 Heuce the lens, which is luxated into the anterior chamber, may involve the cornea and iris, o\vin<>- to direct contact, and the ciliary body as the result of tension of the zonular fibres. As long ago as ISriO Arlt lo described such oases of persistent luxation of the lens into the anterior chamber. The occurrence of growing together of lens and cornea was noted by von Graefe (Arch, fur Opthal., XV. 3, 158). and he states that such cases are the result of dislocation of the lens in the early years of life. Such lenses can be successfully extracted. As regards vision, we can only expect good results before staphyloma intercalare has developed. I (Becker) have been given the accurate history of a case and the operative result, through the kindness of Prof. Mauthner. The nine-year-old N. .\. is said to have seen well lip to her eighth year. From this time on her vision began to diminish, said to have resulted from a fever. In the left eye the iris, in its upper half, is more anteriorly situated than in its lower half. The pupil is black, and somewhat displaced upwards, irido-donesis. The refractive media are clear. The eye is highly myopic, irregularly astygmatic. but shows no staphyloma. With — y^ vision can be improved to Ag. On use of atropine, full dilation of the pupil is obtained, but the lower margin of the lens can not be seen. The right eye shows a normal conjunctiva and cornea; no ciliary injection. Near the high- est point of the anterior chamber is located the greyish white and cloudy lens. It is closely adherent to the posterior surface of the cornea, and is immovable. It is smaller in all its diameters, and is shrunken to about two-thirds its normal size. The iris, as far as can be judged, shows no abnormality. The pupil, which can not be dilated by use of atropine, is completely covered by the lens. On May 23, 1870, Mauthner extracted the lens of the right eye by means of a peri- pheric linear incision. The Graefe knife passed through the Aequator Lentis, and the part' of the iris which was pressed forward was excised. The lens, which oil, pressure did not come out, was finally removed with a Yaeger's cir- cular spoon. Nevertheless, a portion of the lens remained adherent to the pos- terior wall of the cornea. A portion of this was removed with a Daviel's spoon, without, however, causing the cornea to give up its non-transparent and cloudy appearance. No special reaction followed the operation. At the end of five days a severe episcleral injection developed; on the seventh new vessels became vis- ible, extending from the line of the corneal incision up to the part where the cloudiness existed in the posterior portion of the cornea. The lower half of the pupillary margin is adherent to the cloudy corneal tissue. In about one week the episcleral injection and new formed vessels disappeared. By means of a broad iridectomie doAvnward, made on the 22d of June, vision was increased to fg by use of -|-l-4. equal to -|-10 D. The pathological and anatomical conditions of the case may be explained by the examination of an eye, which. I am sorry to say. was sent to me (Becker) without a history by Dr. Schmidt, of Odessa. It is exceedingly pear-shaped, 10 Die Krankheiten des Auges, II, 274. '65 lias a deep cxca vatidii (if llic ()i)tir' nerve, aiul sliows a (letai-liiiieiit of tlie vitre- ous, ciliai-y stapliyloiiia. and in its anlerioi- cliainlx'f. almost at liie anterioi- pole, is a lens .•'.'o mm. in tliickness. and 4'-.. mm. in widtii. Tlie lens is ench.sed in its capsule. wiii<-li is slu'nni mm. behind the pole of the cornea). The cornea is thicker in the center than at its periphery. The Corpufi CU'utre is exceedingly atrophic, the ciliary processes ap- pearing as thin ridges. .V most exact description of the case, together with the illustrations, can be found in the second edition of Becker's Atlas (Die Pathologische Topographie des Auges), Plate XYIII. This case differs from Mauthner's. in that in the former a ciliary staplyoma had not as yet developed, and consequently one could expect an improvement in- vision. The phenomena which were observed during and after the operation at the line of attachment, especially the persistence of the cloudiness at the point and the development of vessels and their disappearance again, are fully explained by the foregoing examination. Where violent symptoms of reaction begin to develop, both in cases of spontaneous luxation, as well as traumatic luxations in the anterior chamber, a threatened ulceration of the cornea, ending in l)hthisis. and a total loss of vision, dtie to secondary glaucoma, can only be averted by an early extraction. Hence. Arlt advised the use of a small Beer's knife, and in e.icli case he decides according to the special features of the case, whether or not the capsule should be opened at the same time. If we desire to excise the iris after the lens has been extracted, this can be grasped by a hook. It will scarcely be possible to avoid escape of vitreous. In order to avoid a possible ihoroidal hemorrhage, it is advisable to first induce deep narcosis. If the operation is made before the development of glaucoma, the result will be better. The peculiar features which may develop during the process of healing, where glaucoma has already set in, are Illustrated by the following case: The seventy-three-year-old wife of a gardener, while chopping wood, struck herself in the right eye. In the beginning the pain was not severe; she could see, "only different." as she expressed it. On the third day the pain became i66 very violent, and vision was almost totally abolished. On being called, I found the lens in the anterior chamber, the iris pushed bade and the entire eyeball red and hard. She could still count fingers. On the eleventh day I made the extraction upward by means of a flap incision. The lens escaped easily without loss of vitreous, and the iris was not excised. Pain ceased at once, the wound healed very quickly, and the patient was ready to be discharged on the tenth day. Since she could not receive proper attention at home she remained at the- clinic. I made a trip, and to my astonishment on my return, after an ab- sence of three weeks, found her still at the clinic. Owing to increased intra- ocular tension, the wound which had healed so quickly commenced to give, and "Without a perforation having ever taken place, or the iris cicatrized in the wound, I found an ectatic condition of the cicatrix. Notwithstanding the most intense pain the patient would not permit me to enucleate. Therefore, I made an incision through the cicatrix, and permitted sufficient vitreous to escape, so that phthisis bulbi followed. If, at the time of the trauma the kixated lens is already cataractous, the diagnosis is easy. Owing to its cloudiness, no matter where located, the lens can be found. The subjective symptoms are subject to change, inso- much, that the lost vision may be restored. Eespecting the aetiology, one must only be reminded of cases of long standing cataract, where, owing to the shrinkage of new formations on the inner surface of the anterior cap- sule, the connection between the capsule and the zonula are loosened, and in these cases a contusion of the eyeball, or a concussion of the entire body may be the exciting cause to bring about the condition. Here the luxa- tion is really not spontaneous, but one must assume that if the accidental cause had not taken place, the same result would nevertheless have occurred in course of time. The operative procedure of reclination must also be looked upon as a cause of luxation. The occurrence of luxation into the anterior chamber dviring the operation of reclination became a matter of great importance in the history of opthalmology. Even in extraction, luxa- tion of the cataract plays a prominent part. A fi-eely movable cataractous lens is also desi'ril)e_d. especially the cal- careous cataract. As vision, as a rule, is totally lost in cases of calcareous lenses, it is simply a question of removing a calcareous lens which has fallen into the anterior chamber, or become wedged in the pupil, either for cosmetic purpose, since the white or yellow amber-colored, wrinkled body disfigures the eye very much: or one opcrntod on iUHount of tlie pain or inter-current inflammation. In sucli oixTations one must l)c prepared, not only for the escape of vitreous, l)ut lor large choroidal hemorrhages. For this reason, the prognosis as tlie result of an operation is exceedingly dubious. If. Ml 1lic lime of the contusion of Ihe ulobe. the sclera is rnnlurcfl. i67 in iK'aHy vwvy ease llio lens will he i-eiiiovcd from il> iioi-mal prisilion. It ma}' I'oinaiii in the eye, and thus heeoiiie a new soiiree of danger, for in nearly every ease the capsule is opened. The proiiiiosis. however, does not entirely dojiend on the lens: liciicc we need mil consider these cases any further. It is. howe\er. nol an inrre([neiil occurrence I'oi- the lens to be forced out of the eyi' at the time of the accident. The scleiotic is nearly always ruptnred. in a directi(ui which is ciuu-enti'ic to the base of the cornea, at about 3 (at inost. 4) mm. distance from the hase of the cornea, most frequently upward, aiul upward and inward: oidy isolated eases have been reported where such a I'upture has taken place downward. Whether the conjunctiva ru])tures at the time or not, depends on the f(u-ce of the hlow. In the tirst case, the lens will be found in the conjunctival sac, or it is never found. Iris and corpus ciliare, as well as a good portion of the vit- reous, prolapse from the wound, and the entire globe collapses. iUood is found in the anterior chamher and. as can be seen in cases which heal, the vitreous is permeated with large clots of blood. Treatment consists in ex- cising the ])rolapsed uvea and vitreous and applying an asceptic dressing to the eye. The application of cold, especially ice compresses seem to be of great benefit. If the conjunctiva has not been ruptured we will find under a vesicle-like elevation of the conjunctiva, the lens in its capsule, appear- ing like a round, transparent body, which on focal illumination gives the well-known shining circle. In this location, the lens may retain its trans- parency for weeks, so that the rupture of the sclerotic, through which the lens escaped, may become entirely healed. It is a striking fact, that in these cases of luxation under the conjunctiva, neither iris nor vitreous prolapse from the wound. The iris, however, is frequently inverted at this point, and simulates a coloboma. Where the sclerotic closes again before the lens is removed, tlie process of healing is a much simpler one. the conjunctiva acting as a barrier against infection. SKCONDAKY LUXATION OF THE LEXS. DISLOCATIO LEXTIS. Among those pathological conditions of a com})licated character, Avhich lead secondarily to a luxation of the lens, those which lead to staphy- lomatous formations occupy the first position. If, owing to the perforation of a corneal ulcer, the aqueous escapes, or if as the result of a trauma, the anterior chamber is opened, the iris and lens will apply themselves to the posterior surface of the cornea. If the opening closes again, so that no more aqueous escapes, under certain con- ditions both iris and lens will return to their normal position. But just as 1 68 the iris, owing to an antiTior .synechia, may he held in ilie wound, tlie lens may likewise, with oi' witliont a previous opening of the capsule, be held fast by new-formed cicatrical tissue and thus he prevented from fullv re- turning to its normal position. It is well known that cases of large perforating wounds of the cornea lead to partial or total corneal staplyloma. The influence which this exerts on the position of the lens depends entirely on the fact whether the entire lens escaped at the corneal perforation or whether the capsule was simply opened, and a portion of the lens was evacuated, or whether the lens, either intact or opened, has become cicatrized to the bulging cornea: and, finally, where all these conditions are not present, whether the corneal staplyloma does not secondarily lead to a dilation of the annuhis ciliaris, and thus cause a partial or total teai'ing of the zonula zinii. Accordingly, we may find in the staphyloma either no lens at all. or a calaracfa .■^rriindaria. or the lens is adherent in front, or it may he perfectly unchanged in its normal ])osition, or it may finally he found floating in the vitreous, still attached to the remains of the zonula. In cases of buphthalmus. just as in cases af staphyloma intercalare, the zonula finally tears, and the lens is luxated. If the pus, in case of panopthalmitis, or purulent hyalitis and choroid- itis, forces its way out of the eye, in the majority of cases it will do so, so close to the perijdiery of the cornea as to partially distroy the zonula. The lens will he displaced and inil)e(lded in a puruU'ut mass, which is partially derived from tlie vitreous and ciliary hody. partially from the iris. In these cases, the lens assumes the most peculiar shapes, which no doubt result (being preceded by softening) from an unequal pressure exerted in a purely mechanical way. Finally, new formations which originate in the retina and choroid, as soon as they come in contact with the lens, force the lens from its normal position, and can cause it to assume the most won- derful shajies. A liijdrops raiiicrdc nnlcrious will press the lens backward; a rhdniidHis srrosd or (jhuicoiiKt will force it forward. In a case of spon- taneous abscess of the vitreous which followed years after an operation for glaucoma, I observed how the lens M'as pressed forward until it touched the posterior surface of the conu'a, even before a change in the shape of the eye occurred. i69 CHAPTER V. MALFORMATJOXS OF TUK LKXS W I'lIIOl'T DEMOXSTRATA- BLE PuVTHOLOUlCAL CHANGP^S IN THE OTHER PORTIOXS OF THE EYE. IXDEXTED OR XOTCIIKI) LKXS. Owin^- to their great rarity, anomalies in form of tlie lens in otherwise healthy eyes are exceedingly interesting. The case which Becker describes in both his works is evi- dently one and the same. In his Anatomy, he states that it occurred in a syphilitic child a few weeks old, whereas in his "Pathology and Therapy," where the case is fully described, he says that it occurred in a boy eight years of age. Both cases are referred to in the same illustrations. (See Becker's Tafl., XII., Fig. 3, 4. o). "I (Becker) am in possession of Imtli eyes of a boy 8 years of age. wlio liad congenital syphilis, and who died in the hospital of Vienna in 1866. The eyes were sent to me because, during life, the boy had seen very poorly, without any outward cause being discernible. The lenses in botli eyes were found to be of normal size, the anterior capsule of normal thickness and curvature. On the posterior surface, however, 1.25 mm. from the edge, there existed a horse-shoe like indentation open toward the bottom. As preparations of Dr. Goldzieher disclosed, the course of the fibres in the interior of the lens was an anomalous one, and thus accounted for the external appearance." Knies ^ believed that he had seen a similar case, because he observed peculiar shadows on making an opthalnu)scopic examination. The anatomical connection between this anomalie and central cataract, spindle cataract and zonular cataract will he referred to further along, when these various forms come under consideration. A particularly in- structive case (i)age 18()) has been anatomically considered by Schirmer. which illustrates the possibility of its production in a manner analogous to that of a spindle cataract. This has likewise been referred to by Knies (quoted above). LENTICOXUS. CRYSTALLOKOXUS. ANTERIOR ET POSTERIOR. The entire literature on this subject comprises but sixteen cases, hence it will be seen how extremely rare is its occurrence. The first case was described by Webster ^ as one of hnticonus, and the 1 Tiber den Spindelstaar und die Accommodation bei demselben. Arch. f. Opth., Bd. XXIII. 1. p. 219. 2 Ein Fall von Lenticonus aus der Prexis der Dr. C. R. Agnew, Arch, fur Augen und Ohren. Knapp, Moos B. lY, 1874, p. 262. ''j^M^SCVKbin Kttr 0!y ff'!«r'.*r'i4faa» W '^^ v»S#1j rTif 'feai-^wsi 3*«HK- :afe.-». te- aft- «< ae •*«»* a ^t^t^Mift. sai&SHr ;a»eiBftc aganet. ■ iiii'iii— fii . -._;_-:- - ■ ^ - .'.-:11c - - ^ * a _:• - - , -<«tr. ■ ■ ^ - -. ■ r Si rir^ iC^ :i0^2;;:^2^ :i«jLtniur-u^ \_U;i -;_!iO ^St 172 large. This latter, however, is not sharply detined, and aside from this are numerous fine punctate opacities. On moving the eye the opacities undergo such a high degree of parallactic transposition in the opposite direction that one must secure very slight move- ments to prevent entire loss of these opacities out of the pupillary area. These movements are decidedly more marked than we are accustomed to note them, when there are opacities at the posterior pole of the lens, and hence permit of our drawing conclusions as to the probable seat of these opacities. One can safely say these opacities are further back than is the usual position of the posterior surface of the lens. The Purkinje-Sanson pictures are present. The one belonging to the pos- ttrior surface of the lens makes very rapid movements on changing the position of the lamp. On focal illumination we at once see the cause of the peculiar pictures noted above. One sees a funnel-shaped Iwdy deep in the sagittal axis of the eye. which reflects the light. The base of the body, as far as on can judge, is at the pos- terior surface of the lens, and from here it projects backward into the vitreous. This funnel-shaped body is perfectly transparent, and is continuous with the otherwise totally transparent substance of the lens, and its limiting surfaces show the same spots observed with the nairrot", only where they were dark they now appear white, strongly reflecting the light, .ttie one "first described above appearing almost exactly at the tip of the funnel. Hence there can be, no doubt as to the diagnosis of lenticonus posterior. Opthalmoscopic examination in the direct method, to the side of the funnel, permits a good examination of the fundus, which shows nothing abnormal. In the direct method only the periphery of the fundus can be examined, and shows Em. It is impossible to gain a sharp image of the papilla; the best can be obtained by a 12 D or 13 D. The large opacity at the tip of the funnel is best seen with a -|- 28 D. That lenticonus posterior is neither a formative nor a developmental anom- alie, but rather a patliological process, seems to be attested by the fact that opacities were present ou the posterior capsule. One could then compare this condition to that of keratoconus, where, as a result of softening and tliinning of the capsule, less resistance is offered to the presence of the growing lens. I'rof. Knapp^ reported a ca^ie in ISJll. He consider? the conus con- genital and stationary, and suuocsted tlic tcnii "ccfasic" or ••twravation of the posterior pole of the lens. Since tlicn. hut three eases liave been re- ported, one by J. Mitvalsky,^ one by Eisaeh,' and one by Dr. Gullstrand.* 5 Knapp's Arch.. Vol. XXII. p. 28, 1891. fi Eiu Xener Fall von Lenticonus Posterior niit tlieilweiser persistence der Arteria Ilyaloidea. Centralltlatt fur pi-.-ik Augenlieilkunde. Mars, 1802. 7 Eiu Fall von Leiiliconus Posterior. Zclieiidcrs Klin. Monatshlatt. March. 1892. 8Ein Fall von Lenticonus I'oslerior. .Nonlisk Oi.th. 'IMdskrirt. V. 1. Ceutral- blatt, p. 377. 1892. 173 In a recent |).i|»i'r Ity L. fJiicli.-' the ciitiic snhjcft of lenticoniis poste- rior is reviewed. He states: "'I'l) to the [)reseiit time. \m\ sixteen oljservations of len- ticonns posterior have been Tiuule, and iccently hut three aiiatotnical ex- aminations." 1" Clinical oI)svrvati()ns (lisciosed the I'aet. that this nialforniation oc- curred in twelve cases; eight times on one eye, four times on both. In the eight cases, the other eye was pronounced normal seven times. In the four cases, the statement is made that one case is, positively, and the other three cases, in all probability, congenital. ]n eight cases a cataracta polaris posterior is said to have been present, together with the lentieonus posterior. Jn two cases, other opacities of the lens were present. Jn two easfs. remains of the hyaloid artery were found, and in one, a rudimentary persistent i)upillary membrane on the other eye. Bach examined two cases occui-ring on two rabbits, and, as a result of his anatomical examinations, draws the following conclusions: — "A disturbance in the development of the eye is the cause of lentieonus posterior. Sutficient facts are at hand to Justify us in asserting that during the development of such eyes, there .is an anomalous formation of tlie lens, possibly a slight disintegration at the posterior pole, together with a per- sistence of the vascular capsule of the lens, which latter rema'.ns in contact with a foetal vitreous strand. Then, as the eye increases in size, this strand exerts tension on the posterior capsule, drawing it out. and finally ruptur- ing the sanu>: at the same time the posterior cortical substance, following the direction of least resistance, diffuses itself posteriorly, and forms the lentieonus. Fnrtlier. tlie lens substance may swell up, and tl-.us lead to ruptitre of the ea])su]e. There seems to be no doubt that lentieonus posterior is due to tension exerted on the posterior capsule by the con- nective tissue strand, which runs through the center of the vitrecxis. Dis- turbance in the i-etrogressiv(> ehanges in the hyaloid artery, is cervainly an aetiological factor in the genesis of lentieonus posterior." 9 Path. Auntomische Studien uber Verscliiedenp Missbiklnnsen des Aiiges. Graefe Arcli.. Vol. XLV. Part I. 189S. 10 Perjieus Ed. Huphthalmus niit Leuticonus Posterior. \vch. f. Auponheilk. XXXV, 1 Heft, S. 1; Hess C. Path. Anat. Studien. etc. (Jraefe Arcli.. Vol. XLH. Part III, p. 214. CHAPTER VI. PAKTIAL CATAKAOTS. A. AXIAL CATAEACT. CATAEACTA AXIALIS. Only such cataracts should be considered as partial, which have re- mained as such for many years or during the whole of life; hence they are also stationary. All partdal or stationary cataracts which are not the result of a trauma, are congenital or develop during the years the lens is grow- ing (zonular cataract). The forms of partial cataract which occur most frequently are found on a line connecting the two poles of the lens. Hence they are called axial cataracts. Formerly they were called cataracta cen- tralis, without regard to the fact, whether they were in the centre of the lens, or at its anterior or posterior pole; the centre of the pupil and the centre of the lens being looked upon as identical points. But as long ago as 1814, Benedict ^ drew attention to the uselessness of such a nomen- clature, and he proposed that centralis should be applied, only to those rare cases in which an opacity of foetal origin, and confined to the nucleus of the lens remained. Those opacities due to inflammation of the capsule of the lens and located at the anterior pole are designated as cataracta capsularis punctata. The axial cataracts are situated either in the centre of the lens, or at its anterior or posterior pole. 1. CATAEACTA CENTEALIS (LENTIS). congp:nital, centeal lens CATAEACT. During life the central cataract appears as a siiiall. white, globular opacity in the nucleus of the lens, exactly in that place, where genetically one would expect to find the oldest fibres. The glaring white hght which the central cataract reflects gives evidence of the intensity of the opacity at that point. Such central cataracts have repeatedly been observed at birth, hence they are most certainly congenital. There are, however, cases (as will be shown fmilicr along) in wliich tlie opacity of a zonulai- calaract is so in- tense as to simulate a central cataract. Tlie reniiiinder of the lens may l>e |»ei-i'ectly trans])arent. and vision excellent. From this we may also conclude, that the curvature of the an- terior and posterior capsule is normal. In such cases the central cataract iMonographie des Grauen Staar's. Breslau. 175 is often discovered by the merest chaiKH': often not until very advanced life. More frequently, however, this form of ciitaract is complicated by other forms, togetlier witli inishujiinis. Ifcnic- hclicvc^ iliat ilic nystagmus is iuit due to tlu' calaract alone, hut to M)iHe di.-ease of the muscles or nt'rve inervation. Tlu' seat of this form of calaract must be situated where, according to the development of the lens, one would expect to find the oldest lens fibres; those which had grown in a saggital direction; hence, we mnst come to the conclusion, that it was the fate of the lens fibres which belong to the second })eriod of foetal development to form tliis varit-ty of cataract. In very tliin meridional sections of hunum Icjises taken from tlie end of foetal life and the beginning of extra-uterine life, one can recognize these fibres enclosed in the concentric lamellae. It is especially worthy of note that in the sheep during the second period of development there is at times an en- tirely perverse position and unequal growth of the proximal cells. Though we can not conclude from this, that the cloudiness is the result of the ab- normal position, nevertheless, the observation has shown, that at times the abnormal changes do take place. If, however, one is not inclined to believe that subsequently there is cloudiness of this conglomeration of cells, one can conceive of a condition here, as it occurs in lamellar«'cataract, where, over a mass of lens cells which have become cloudy, new lamellae of lens fibres are deposited, which have abnormal shape, position and transpa- rency. This always presupposes that the productive viability of the epi- thelium of the anterior capsule and along the whorl has not been disturbed by the formation, of the central cataract. The time of development of this form of cataract is placed during the second period of development of the lens; hence, about the sixth or seventh week of foetal life of the human embryo. Arnold's idea,^ that the lens is originally cloudy and later clears up fiom the periphery, must be dropped. For, as has been shown on page 51, this central cloudiness which Fr. Arnold found in the central portion of the lenses of young animals is due to the presence of a fatty substance which melts at a low degree of temperature, and this snl)stance is only found in the centre of young lenses where the temperature is reduced; this coagulates, and the centre of the lens becomes cloudy; whereas, on heating to the temperature of the body, the lens clears up again, the substance re- turning to the fluid state. 2 Walter von Amraou's .Tournal. f. d. Chir. and Auficnlioilknndp. XXXII, p. 524. 3 Untersuchuugen uber des Aujio des Mcuschen. lS.",-_'. p. 1.j4. 176 H. Muller ^ described a case occurring in a young goat, with cataracta polaris posterior and persistent hyaloid. But he was so taken up with the description of the posterior polar cataract, that he simply mentioned the presence of the cataracta centralis lentis. Carl Hess reports an exceedingly interesting congenital anomaly in a chick 150 hours old.° The essential features of this malformation con- sisted in a delayed and incomplete closure of the lens vesicle, as it is derived from the epithelial plate. In consequence of this incomplete closure, the lens fibres were not held in by the enclosing capsule, and, undergoing hyperplasia, found an exit through the opening in the ampulla: as a result, the normal nutritive conditions were markedly disturbed, and a diffuse disintegration of the elongated fibre followed. This description is exceedingly interesting, since it offers us an ex- planation as to the cause of certain forn^s of congenital cataracts, which up to this time has been ])urely speculative. It is possible, if the develop- ment of the chick had not been interfered with, that later on this lens vesicle might have become constricted and closed, after those fibres which had grown out of the ampulla had totally disintegrated, and a hindrance to a closure which they offered had been totally removed. The fibres within the ampulla (those which later on would have formed the nucleus), would also have disintegrated. If now, later on, new fibres had developed in a perfectly normal manner, a normal cortex would have formed around a diseased nucleus, thus giving us the picture of a true congenital central (nuclear) cataract. Hess further suggests the intimate connection between this form of cataract and zonular cataract, and he further states that an- terior polar cataract could easily be explained as the result of a delayed closure of the lens vesicle. Spindle cataracts could be explained in a like manner. 2. CATARACTA POLARIS ANTERIOR. CATARACTA CENTRALIS CAPSULARIS ANTERIOR. CATARACTA CAPSULARIS PUNCTATA. ANTERIOR CENTRAL CATARACT. CATARACTA PYRAIMIDALIS. CATA- ■ PACTA PYRAMIDATA. Frequently we find a small, glistening, white, and (as a rule) round opacity at the anterior pole, which reflects the light. This opacity varies in size from that which is Just perceptible, up to one having a diameter 4 Gesamruelto Und Ilintorlassono Schrifton Hornusgegeben von O. Becker, 1872, Bd. 1. 5"Zur Pathology und ratliologisclu'ii Anatoinic Verschiedener Staaar For- men." Graefe Aicli.. XXXIX. 18SK3. B. 1. p. 183. 177 of from 2 to 3| mm. At times tliis wliitf spot is smooth on tlie surface; again, it may extend out into the anterior chamber the distance of a milo- metre. AVhen the pupil is contracted, it touches this on all sides, whereas when the pupil is enlarged it always remains situated in the centre of the same. In the ''flat varieties," if they are not too small, we can at times demonstrate l)y focal illumination a slight folding of the adjacent parts of the capsule. Those which extend into the interior chamber are known as ratarada pyrarnidalis or pi/nimiddhi. Vwy nftcn the cataractM pyramid- alis is the only anomaly of the eye. In such cases the amount of vision de- l)ends largely on the size of the cataract, and the conditions of its adjacent parts of the capsule. Cases have been repeatedly observed in which vision was perfectly normal. More frequently, however, it is associated with the opacities of the lens, such as cataracta centralis. Tn all such cases, atten- tion should be directed to the transparency of the cornea; also, careful in- vestigation for remains of a pupillary membrane should be made. In his "Anatomic," Becker divides anterior polar cataracts into three groups — the congenital, the acqnii'ed. and those due to adhesions between capsule and iris. a. CATAKACTA POLARIS ANTKKIOR (PYRAMIDALIS) CON- (;enita. All the varieties of cataract noted at this point are capsulojr cataracts. In all cases of congenital anterior polar cataract, the lens is otherwise nor- mally constructed. Hence the cataract must have developed after the con- centric formation of the lens had begun; hence in the third period of foetal development, possibly at the close of the second. In the foregoing division, attention is drawn to a case observed by Hess, and the possibility of a late closure of the lens vesicle ])eing the cause of an anterior polar cataract. Jt appears that iieither these congenital anterior polar cataracts, nor the acquired forms seem to interfere with the further growth of the lens, and, finally, since the growth of the lens follows as a result of indirect cell division of the anterior epithelium, a partial loss of this epithelium can not interfere with the further growth of the lens. The histological structure of these capsular catai'acts (litTci- in no wny from capsnlar cataract as already described. The capsule itself is nol diinvn out as a rcgulai- one. hut seems rather to be folded, and on section shows vcit pretty jjictures. Frequently the base of the pyramidal cataract is lound, and extends for sonu^ distance into the lens substance; in fact, the central portion sci'ms to extend a little deeper, so that its edge appears curved and distinc-t again.st the surround- ing transparent lens substaiu-e. Whov there is a constriction near the 178 anterior capsule, this curvature becomes especially marked, and it appears as though this constriction were the cause for the curvature of the deeper layers of fibres. At times one observes that the pyramidal cataract, as well as the flat ones, are continuous with a sharp process, which extends back- ward into the lens substance. Such forms are the transitional step to the formation of the spindle cataracts. h. CATAEACTA POLARIS ANTERIOR. (ACQUISITA). ACQUIRED ANTERIOR CENTRAL CAPSULAR CATARACT. The aetiology of the acquired form of central capsular cataract has been the subject of a great deal of study and investigation. According to Arlt, it develops in children, seldom in adults, as a result of a perforating central corneal ulcer. He was of the opinion that a portion of the exudate remained adherent to the capsule. It is not to be denied that this can occur. The oases of cataracta pyramidalis in which a shred of scar tissue extends from the cornea to the capsule, and thus, by this means, draws the lens and iris forward and holds them in this position, demonstrates that scar tissue which is formed by cornea and iris can take part in the formation of the pyramidal cataract. This, however, is not necessary. Schweigger convinced liimself,that corneal ulcers which are not situated in the centre of the cornea and perforate may give rise to central capsular cataract. Hulke (O. H. R., p. 189) does not consider it necessary that a perforation should occur in order to give rise to a central capsular cataract. Owing to the extreme shallowness of the anterior chamber in the child's eye, especially in the new-born, a simple swelling of the corneal tissue during an inflam- matory process (as, per example, in bl. neonatorum), is sufficient to bring the lens and cornea in contact (Mackenzie, Ed. IV., p. 469). In both cases — either where the aqueous is drained off', or where the inflammatory ir- ritation causes a contraction of the pupil — only the centre of the anterior capsule is permitted to come in contact with the inner surface of the cor- nea, and it appears, if this takes place for a sufficient length of time, it will induce a hyperplasia of the capsular epithelium. According to Knies," but a few days of actual contact of the ])upillary iH)rtion of the capsule of tlu! lens with the surface of a corneal ulcer are sufficient to t'ause a hyper- plasia of the e|)ithclium on its inner surface. Knies succeeded in examining this hyperplasia at such an early stage that the cloudiness only sel in dur- ing the hardening process. Deutschman's statements are of eciual im- portance. He observed that in acute imiulcnt processes of the anterior 6C. P. Anterior und ('. Mor,s:ii;ni. /flu'iidtM-s Klin. M..n:itsblattt'r. ISSO. Bd. XVIII, p. 181. 179 segment of the gl()])e, only the [joriioii <>[' the «r|obe corresponding' to the free pupilhirv area was affected by ilic pus. the posterior surface of the iris protecting the remaining portion of the capsule for a long time, un- doubtedly because, as a result of i litis, the posterior surface of the iris be- came adherent to the capsule. Deutsclinuin further ob.served that the pro- duction of a chronic inflammation of the vitreous likewise caused a hyper- phisia of the anterior capsular epitheliun\. leading 1o the formation of a true capsular cataract. 'J'lu' local and circumscribed area of development of the capsular cat- aract, all favor the local and the temporary action of the cause, and this is to be found in the contact of the anterior capsule with the pathological products of the corneal ulcer. As a result of direct contact of the cap- side with the vascular pupillary margin of the inflamed iris, and with the inflamed and vascularized cornea, a portion of the lens .receives its nour- ishment as it did in foetal life; namely, by means of the vascular capsule. Here, again, the epithelial cells receive their nutriment directly through the capsule, and as a result there will be an increased production of cells; which, since it will be in excess of the regular development of fibres at the whorl and the gradual movement of the entire epithelium, will naturally lead to a local hyperplasia, which becomes changed into a capsular cataract; which, as a result of its owai products, limits its own growth. The various forms of punctate, flat, pyramidal, congenital and acquired central" cap- sular cataracts, are but ditjerently developed products, of the same process. Sight must not be lost of Hulke's observations, that during foetal life, in which a tnie anterior chamber does not exist, every affection of the cor- nea leading to swelling, would be sufficient cause, to excite that portion of the lenticular epithelium lying in the pupillary area to undergo a hyper- plasia. Hence Becker states that he "'inclines more and more to the belief, that both the congenital and the acquired capsular cataracts are due to the same cause." Though it is the rule that congenital central capsular cataract is pres- ent on both eyes, this is not necessarily always the case. c. CATA1?ACTA CAPSULAR] S AXTEinOlJ. (ACCKKTA.) There is a variety of circumscribed capsular cataract, which occasion- ally comes under observation, which results from permanent adhesions between capsule and iris. True simple synechia seldom lead to the forma- tion of capsular cataracts, which are occasionally observ^ed at the point where the remains of a persistent pupillaf}' membi'ane is still adherent to the capsule, the lens being perfectly transparent. x8o 3. CATARACTA POLARIS POSTERIOR-VERA. The differentia] diagnosis between this form and the spuria, was given on i)age 144. Jn reality, the diagnosis was made between the latter and posterior cortical cataracts, as observed in retinitis pigmentosa and cho- roidal disease. The posterior cortical catarai-ts will be considered further along. Becker states, (Anatomy, p. 123), "that, based on his examination of preparations of posterior cortical cataract, he considers that he has shown that a true posterior polar cataract may result from a stagnation, (possibly a coagulation), of the tissue fluids, even at the temperature of the blood. (Page 20(5.) He also reports the case of a dcg. where the diagnosis of posterior polai- cataract was made. In both eyes, on examination, the foetal fissures w^ere found filled with Morgagni's globules. These, he states, one would not assume were albuminous globules originating from partially destroyed lens fibres, since these ended in the well-known man- ner, with broadened ends. To his surprise, as far as the fissures touched the capsule, this was covered with a beautiful epithelium, which he suggests might be an anomaly or a malformation." Knies describes a true posterior polar cataract in connection with a spindle cataract. Becker states that "the formation of a true posterior polar cataract in man would undoubtedly originate during the third period of foetal development. Where due to some unknown cause, the saggital fibres of the second period remain in contact with the capsule and poste- riorly prevent the new fibres of the third period from coming together from opposite directions, and pressing these saggital fibres toward the cen- tre, we have the ideal example of a cataracta polaris posterior vera. Such a case has been anatomically examined by Schirmer, and will be fully de- scribed along with the lamellar catai'acts. (Page 186.) CATARACTA FUSIFORMIS. SPINDLE CATARACT. .\ssociated with one or more forms of axial cataract, a form of cloudi- ness occurs, which extends through the entire length of the axis of the lens. Amnion mentioned this form. Pilz ^ was the first to give it a more accu- rate description and name. h\ the eye of a boy who had suffered from a scrofulous conjunctival disease, he found an anterior polar cataract about the size of a pin-head, and going out from this a cloudiness which extended backward exactly in the axis of the lens, simulating very murh a thread having a smoky or topaz color. Whereas tlic cax' of I'ilz was most ])i'ol)ab'ly an acniii-cd I'oi'in. Hecker 7 Pathology des Krystallinsen System. Prag. Viertelyahrschr.. 1850. 1 S.. 33. i8r observed a ease, in botli eyes of a vdimji- man. in uliieU a ((iiiiplicated eon- genital spindle eataraet existed.** This extended t'loni iIk^ posterior sur- face of the anterior capsule, exactly in the pole of the lens, as a .solid, and by focal illumination, as a bluish white, non-transparent process, which gradually widened into a bluish white, very delicate and veil-like transpa- rent bubble, enclosinti' the innermost portion of tlu' nnch'ns. and this, con- tinuing again beyond tile bu!)b]e in the axis of tlie lens, a^^ain hecomes a solid strand, whicii finally attached itself to tlu' posterioi' (■a|)snle. Within this transparent bubble, separated from it by transparent lens substance, was a characteristic cataracta centralis. Previously, E. Mueller had illustrated and described cas<.'s in which both spindle cataract and zonular cataract were )>resent at the same time. He obsei'ved a case where three sisters, the mother of whom likewise had a very high degree of reduced vision, had ton alar cataract, and in three eyes there was also a spindle cataract present, 'i'he second eye of the youngest also had a posterior polar cataract which he attributed to an obliterated central artery. It is characteristic to find a central cataract fused with an anterior and posterior polar cataract, as in the ease described aljove. At tinu's. in con- nection with the globular cloudiness, there may be a number of cloudy lamellae situated moi-e peripherically. Knies has described the spindle cataracts with especial care, and it is interesting to note that in the mother of the children who had this affection he found incomplete zonular cataract on both eyes, whereas the father had become blind as the result of consecu- iire cataract. (Eight eye, cataracta tremula: left, cataracta accreta). Since the eyes which have been examined show no signs of foetal disease, the anomaly can only be ascribed to an anomaly in the development of the lens. Above all, heredity seems to favor this view. Cases in whicli the spindle-formed cloudiness gradually goes over into a central cataract are explainable on the theory, that at the time when the concentric arrange- ment of the lamellae begins (third period of development) the product of the second period (which does not clear up, or which possibly only later on becomes cloudy) remains adherent to both poles of the lens capsule, so that it becomes impossible for the new lens fibres to conu' in apposition at the anterior and posterior pole, but remain separated l)y this cloudy strand. Leber has described a spindle cataract, which he produced experiment- ally by injuring the capsule of the lens.^ His investigations con-oborate to a certain degree Knies' views in reference to its formation. 8 Berichte der Wiener Auffenlvlinik. S. 9JM). 9 Kernstaarartige Trubung der liinse nach Verletzung ihre Kapsel nebst Bemerkuugeu uber die Entsteluuig des Stationaren Kern und Schihtstaar's Uberhaupt. Arcb. f. Optli., Bd. XXVI, 1. p. 28(;-289. 1 82 B. LA^IELLAR CATAKACT. (WTARACTA PERI NUCLBARTS. ( ATA HACTA ZONULARIS. Ed. von Yager ^" ])re.<('iitefstive treatise. He jiointed out the fact that lameJJar cataract, as it is now known, is, of all the varieties of c-ataract, the one which develops most frequently in childhood. Since that time, the number of observers of lamellar cataract has greatly increased, so that we are now in a position to divide them into three classes.^^ After the use of atropine, one observes behind the pupil, a faintly sat- urated cloudiness, which has a sharply defined line of demarcation from the adjacent transparent peripheral lens substance, and has a diameter varying from 5 to 8 mm. The degree of saturation of tliis cloudiness gradually diminishes as it proceeds toward the centre of the lens. By this means the zonular cataract is most markedly differentiated from a nuclear cataract. In the latter, the cloudiness becomes more saturated as it proceeds toward the centre. On opthalmoscopic examination, the entire cloudiness gives a dark retiex and is sharply defined: whereas, on focal ilhuuinaticui. it ap- pears grey, and the centre of the lens gives a l)r()\vnisli red retiex. The cloudiness is not ('(pially dilfiise in all cases, and made up of scarcely rec- ognizable punctate opacities; but there may he two hinicHac (uu- in fi'ont of, the other behind the nucleus, mach' up of a variahK' uuinhcr of radiallv placed cloudy striations. Under such coiuliticnis, the lanu-lJar cataract bears 10 Staar und Staaroijeraiioiu'ii. isr.4. S. 17. 11 Arch. Opth., I. 2. 'I'M. 12 Vrv'^U Licl.rcicli. 1. c. \K 4S(l. I S3 a very close rcseiiiblaneo lo some foniis of incipient senile ciitaraet, only in the latter these radially placed striations are more peripheric. But since transparent lens substance is found between these striations, they ])ermit of a clear insight into the formation of this variety of cataract. One is enaibled to see through the anterior convex cloudiness into the concave side of the cataract behind the nucleus. The number of lamellae involved and the density of the opacity may vary, so that one may meet with all gradations, from the scarcely recog- nizable smoky cloudiness to the complete opacity. This latter form was first illustrated by Von Amnion.i:! and also descrilied by AVeniek.iSa Arlt described this as a form of stationary nuclear <'ataraots of youth.14 Von Graefe was the first to apply V. Yager's anatomical data to Arlt's stationary niuleaivcataiact and since tlien the existence of a stationary solid nu- clear cloudiness has been described. So that even Tetzer's compendium of Arlt's Aegide, places these two forms together. Only Hasner still contended that an independent stationary nuclear form could occur. Becker draws attention to the fact tliat the density of the cloudiness may be so great as lo make it im- possible lo decide wliether or not transparent lens substance is enclosed in the center of the lens. This has since been shown to be true, as the result of the anatomical pathological investigations of Schirmer, presently to be quoted. Von Graefe, Sichel and Ed. Muller were the first to describe a douhle lamellar cataract, the last named even a triple one. It is seldom observed fully formed. It can only be diagnosticated, when the outer cloudy lamella is still transparent. Frequently, however, we observe how around a well developed lamellar cata- ract, a second one is beginning to develop. The latter is evidenced by the fact that between the lamellar cataract and the equator of the lens, we find isolated, delicate, fork-like, cloudy striations ))eginning to penetrate the anterior and pos- terior cortical substance. On focal illumination, one observes that these fork- like striations seem to ride on the lamellar cataract; hence they have also re- ceived the name of "ffirfers." Such p:ir1i:illy cloudy, more peripherically situ- ated, lamellae may likewise remain stati(»nary in this condition. ■Liebreich has illustrated such a case. These riders, however, only appear later on, and are significant, in tliat tliey foretell that the stationary cataract is about to become a total one. Finally, Liebreich drew attention to the fad. ihat the lens is less de- veloped in volume in cases of lamellar cataract. Lamellar cataract nearly always occurs simultaneously in both eyes. Where trauma leads to the development of lamellar cataract on one eye, this is not the case. Becker states that a case of monolateral lamellar cat- iSaAmmon Zeitschrift, III. p. 480. 13 Yager's Atlas, III, Taf. XIV. Fig. 114. 14 Die Kraukheiten des Auge. II, S. 2.50. i84 aract. the other eye remain iiio- perfectly normal, has never been observed, Schirmer ^^ reports a case which is especially interesting, since the cataract was only present on one eye: further, while under observation, the cloudi- ness of \\\v inner zone increased, the originally transparent zonular cataract being changcil to an opacjue one, {"nuclear catnracf'), and because there could be no doubt as to the late development of the outer cataractous zone, this having developed after the seventh year, and while under observation. The originally healthy eye remained so. Scfiinnrr's Case Xo. T'.-C'o,se Report. Heinrieh Erust, aged 14 years, was first seen in this clinic in his seventh year, October 14. 1884. At that time the diag- nosis of zonuhir cataract on his right eye was made. This was of moderate size, sharply defined, and permitted the transmission of light through the center. V— fingers at 1 mm. The left e.ve was not cataractous. In early life the patient had suffered from rachitis, and at the time changes could be observed in the cartilaginous portions of the ribs; also the characteristic anaraolies of the teeth. An iridectomy was made downward and inward. Vision was not improved. The boy was seen again June 7, 1891. There is still present on the one eye a double zonular cataract, the inner of w^hich is totally opaque, and according to the usual nomenclature this would be designated as a nuclear cataract. The lens is moderately shrunken. The outer not very opaque zonular cataract has a diameter of about 7% mm.: the inner at 41/0 mm. Both are sharply defined, but their contours are not perfectly circular, but more or less wavy or protrud- ing. July 8. 1891. Extraction was made through the old coloboma. after a piece of the capsule had been extrat>ted. On exerting but slight pressure almost the entire lens was successfully extracted w^ithout the loss of vitreous. The cataract, which was extremely soft, was carefully cut in halves, and the one half at once placed in a 60 per cent, alcohol solution: the other half was examined in the fresh state. On transverse section one at once recognized the cloudy rings, and that which is still more important, is that one sees at a glance the center of the lens is perfectly clear and transparent. Hence, this is not a nuclear cataract, notwithstanding the opaque condition 'of the inner zone. In the fresh sections one finds the droplets between the fibres, the num- ber and size varying, according to the location from which the section is made. They are very numerous in particles taken from the cloudy zone, very few In the trans|»arent zone between the two cloudy zones, and still less so in the nucleus. The fibres are everywhere smooth, and in places where there are many droplets they are wavy and swollen, but nowhere are they serrated. The hardened portion was cut in sections. Thick sections show the two cloudy zones very distinctly, with the transparent interspace between them, also the clear nneleus. Under the microscope one finds both made up of numer- l5Zur Pathologische Anatomic und Pathogenese des Centralstaars, Graefe Arch,, XXXVIII, B. 4, 1891. 1 85 ous minute drops lyiiiR betwoon tlic fibres, and tlit'Sf aro markedly mon- nuiner- ous and smaller in the inner zone. (».(K»iri to 0.(MK{ mm., whereas in the outer zone, they range from 0.00<> to O.OO;^ mm. Externally the rings are sharply de- fined, whereas inward the number of drops is markedly decreased. The char- acteristic changes are noted to a less degree in the nucleus in the zone between the two zonular cataracts, they are somewhat more numerous. ScliiriHor reports a similar case, which, owing- to the rarity of tliis con- dition, likewise deserves mention. Case No. VI. Anna Durch. aged 17 years, presented herself at the clinic with a double zonular cataract in the right eye. The outer zone was ex- tremely delicate and transparent, but showed no defect at any point. This surrounds very closely a large disc 6 mm. in diameter, which is totally opaque. The patient had had convulsions in childhood, and her teeth showed the anam- olies described by Horner. The clinic records show that this patient had been examined twelve years previously, and the diagnosis reads: ••Simple zonular cataract/' At that time a discission was done on tlie left eye, and at present a delicate secondar.v cataract exists. Ill this same paper, Schirmer reports another case equally important, because it throws light on the aetiology, not only of central cataract, but also of true posterior polar cataract; the conditions present coinciding en- tirely with those described by Arlt ^^^ and Tetzer ^^ as the n.?iial ones for the formation of a central cataract: namely, associated with congenital anomalies — in this case, a micropthalmus. The anatomical basis for the nuclear cloudiness consisted of tine drops which so completely filled the centre of the lens, that the cloudiness of the fibres could be made out with difficulty. "They are equally dispersed throughout the cloudy area; external to this, they suddenly cease to ap- pear. The fibres are greatly changed and transformed in the most pe- culiar manner. The physiological changes which one would expect to find in a patient ol years of age did not apjiear. The minute droplets are ar- ranged as described in previous cases, only in this case, owing to the push- ing aside of the central cloudiness, they follow a .somewhat irregular course. The interspace between this zone and the central cloudiness shows but slight changes. Hence here we find enclosed in a zonular cataract a nuclear cataract, an intense equally difTu.se cloudiness of the centre of the lens, the anatomical construction of which is analogous to the changes noted in the cataractous zone of a zonular cataract. Xotwithstanding the ])cculiar position of the cloudiness, this is a cen- tral cataract. Anatomical examination showed that the oldest lamellae of 16 Arlt-Krankheiten des Auge. Bd. IT. p. 2.">0. Prag., 18.54. 17 Compendium der Augenlieilkunde. 4 Aufl., S. 282. Wien. 1887. 1 86 the lens were alYected bv tlie cataractous process, and its adlierenee to the posterior capsule explains its dislocation posteriorly. This process is anal- ogous to the one found in spindle cataracts, and this latter form is found associated with zonular cataract. In this case the abnoi-nial adhesions did not lead to a drawing out of this to a thread, since this adhesion only ex- isted at the posterior capsule; hence, as the leaves of the capsule continued to separate farther and farther from each other, there was not sufficient tension exerted, and the posterior ends of the fibres, which should have pushed themselves in between the posterior and the central cataract, were apparently not strong enough to stretch this adhesion, which seems to be a possibility where the adhesion is narrower, as shown by Knies.^^ Schirmcr'f^ Case Xo. IT. George Xaujoks. .".(» years of age. born of healthy parents: all of his brothers and sisters, except a stepsister, died in early child- hood of diseases unknown to him. This sister, since early childhood, can only see objects which are in close proximity. WJietliei; tl«^ is due to myopia or interference in the refracting media, am unable to learn. Patient states that he never had convulsions. Since early childhood he has only seen sufficiently to grope his way about. In his twentieth year iridectomy was done on both his eyes, and vision was thus somewhat improved. The left eye remained in this condition foi- many years, and only lately has \ ision diminished. Several years after the operation the right eye became totally blind. March 10. 1891. Active horizontal nystagmus on both eyes; pronounced mi- cropthalmus. Right eye, artificial coloboma, downward and inward, in the middle of which one can see the edge of the shrunken lens. Left eye. the cortical substance is totally transparent, with the exception of a delicate cloudi- ness downward and inward. One can easily discern a central cloudiness of the lens, which appears to be markedly posterior to the plane of the iris. This can be separated into a central yellowish white small portion, surrounded by a 3 mm. in size Avhitish lamella, which everywhere surrounds the edge of the Internal cloudy portion. Both are sharply defined; their contours are not en- tirely circular, but here and there show slight projections. No distinct pictures of the fundus can be obtained, though a red reflex of the fundus can be ob- tained tln-ough the periphery of the lens. There is also a very delicate diffuse cloudiness of the cornea. A'.— fingers at 2V2 meters. Right eye. Conditions altouT the sMiiie. with ;il>s(.lu1e .•uiiaun.sis. subse.nient to a very active chorio-retinitis. May 22, 1891. Left Eye. A discisioii w.is doii.'. Veiy slight tumescenes and slow cloudiness of the cortical layers followed. Siiin. Arch, fur Opth. XXIII. 1, S. 217. i87 piece of llie capsule; tile si><)oii was iiit rodiiced, and the cloudy n\icleus, together Willi liie cortex, feiiioved: and the i-eiiiaiiis largely removed by massage. By .hiiie IS. l.SDl. the cortical reiiiaius were lotalLy resorlied. so that the impillary area was perfectly free hack to the posterior c:ipsule. On this <-ouhl be seen (lisliiiclly. ceiitr.ally located and intensely whit.-, a sni:ill posterior capsular cataract, which had been observed shortly stibse.nient to the extraction; like- wise, the two Maps which lie closely to the coloiionia appear greyish white. Vision with +12 1». ling.'fs at three meters. This tliickeiiing of Ih.- ca])snle ^vas extracted with but slight loss of vitreous. .Inly 15. 1891. Course of healing normal, l.arge. sule of the lens, and re- mained adherent to it at the time of the extraction, .lud assumed this peculiar change as a result of its contact Avith the aqueous. The capsule was stained, imbedded, and cut into. sections. Sagittal sections showed that between the above spoken of remains and the c:ipsule. true non-i)igniente(l capsular cata- ract tissue existed. The two flaps likewise contained capsular cataracts, and the pigment undoubtedly was derived from the iris. From this it follows that the pigment only entered subsequent to the extraction. The extracted lens was cut in half in the fresh state; on section it disclosed an almost globular, intense cloudiness, I'l- mm. Avide and 1 mm. thick, which borders posteriorly at the posterior pole, at the point where the piece of cap- sule Avas extracted. It gives one the impression :is though the nucleus had been forcibly pressed backward. This cloudiness is further sui-rounded by a second cloudy zone, Avhich anteriorly is separated from the former by a trans- parent zone, whereas laterally it is directly in contact with, and posteriorly entirely Avanting. The other portion w;is imbedded and cut intij sections. The microscopical examination offers the s.-uiie expl.-mation for the striking position of the central cataract. In fact, the entire nucleus has been dislocated jiosteriorly. The anterior cortical layers are es]»eci;illy thick, whereas posteriorly they are very thin, and ce:ise at a certain distance from the posterior pole, so that at that point the nucleus lies entirely free. The study of the etjuatorial region. Avhere the fibres turn, is especially instructive and conclusive for this condition. The fibres do not lie as in the normal lens, in a plane which is slightly bent back- ward, but they ouly follow their normal position in the periphery; the older the fibres the more centrally they lie, and the farther back their point of bend- ing is placed, and finally they border on tlio equator of the nucleus. A plane drawn through all the points of curvature would assume posteriorly a very de- cided funnel-shape, facing posteriorly, as though the nucleus had been exerting traction backward. As has already been stated, the posterior surface of the nucleus is centrally perfectly free, simply covered by an albuminous film, and here the fibres have not the concentric arrangement, but are arranged vertically or almost so, and are torn in a jagged line, along which are numerous sharp points. This in connection with the posterior polar cataract, gives us the ex- planation for the position of the nucleus. TJiere was an adhesion between the oldest fibres and the posterior capsule of the lens, which at this point held the nu- cleus fast, and offered an insurmountable obstacle to new forming lamellae, so that these could derelop normally only in the anterior half of the lens. Otherwise, the examination disclosed nothing other than has already been observed in teased sections. The zonular cataract shows the same small drop- lets coalescing to form larger ones in the interspaces. The apparently clear zone between the cloudy zone and the central cloudiness, likewise shows sim- ilar formations. The outer cortical lamellae are normal in appearance, the inner show signs of advancing age. Where the discission had been done the fibres show signs of disintegration. The amount of vision depends on the density of the cloudiness, and the equatorial diameter of the cloudy lamellae. It may occur that children with douhle lamellar cataract may go through school without suffering any material interference during their entire school life. Becker operated a married woman, in whom a lamellar cataract had become progressive, and a man 24 years of age was taken up in the clinic for the same reason. The rule, however, is that the defect becomes noticeable when the studies begin to make greater demands on the eye. Hence most cataracts come under ob- servation between the tenth and twelfth year. If the cloudy lamellae are very centrally located, hence especially small, the eye, where there is a moderately wide pupil, can see past the cataract, and the degree of vision may be relatively high. Becker very carefully examined a series of such cases, three at Vienna, and in all of them, found a slight degree of myopia. Owing to the reduced vision, such an examination offers great difficulties. Nevertheless, eliminating all source of error as much as is possible, it is still possible to estimate the refraction. On using atropine, a case which at first was myopic was found to be hyperopic. Nearly always, the condition of refraction is found to be a slight myopia, and the width of accommodation is exceedingly narrow. "With the exception of the three Vienna cases which I examined, being as- sisted by Dr. Schulek, the utmost care was used to eliminate every source of 1 89 error. All the estimates of refraetion were made with the opthalmoscope. As a rule, no staphyloma was found at llie ent ranee of the opiie nerve. l»ui slight evidences of choroidal atrophy were observed. Aside from this nothin-; abnormal was found in the fundus. The overwhelming occurrence of slight myopia with- out the opthalmoscopic evidences of a myopic eye, can be explained by the spherical aberration of the lens, since all the rays of light whicli pass near the (•enter of the lens are detiected." "Xevertheless. the myopia may be acquired in ilie usii.-il way. since, owing to tlie i)oor vision, objects are brought closer to the eye. In tlie eases examined vision varied from ^ to j^^j, and was lowest in liypermetropic eyes. With- out exception, tlie width of accommodation is reduced in eyes having lamellar cataract. This is not surprising, since one does not have to go far to under- stand that in cataractous lenses, even where the cataract is partial, that but few eyes are suitable for the observation of processes of accommodation, es- pecially where the iridectomy is made for lamellar cataract: hence, the results of the investigations of Coccius 19 are to be critically examined, since they were made on just such eyes." Lamellar cataract occurs almost exclusively on both eyes. This of itself seems to indicate that the causative element is present in the general condition of the patient. This belief is .strengthened by the fact, that fre- quently there seems to be an hereditary influence. Hence until lately it re- mained an undecided question as to whether lamellar cataract is congenital. Just during the time Becker was occupied in studying this subject, a child fifteen weeks old was brought to liim, which had, in both eyes, a small, but not to be mistaken, lamellar cataract, which the parents observed the day the child was born. According to the general opinion, however. lamellar cataract does not develop until after birth. Von Graefe considered it a fact, that during the first years of life this cloudiness continued to increase in .saturation, only later on to remain sta- tionary. Hence so many lamellar cataracts are overlooked during the earlv years of life. Great credit should be given to Arlt, who was the first to formulate our ideas as to the aetiology of lamellar cataracts, and he was the first to direct our attention to the frequent occurrence of lamellar cataract in in- dividuals who had suffered from convulsions in infancy. Horner also noted this fact, but added, that many also suffered from deformities of the teeth, of the cranial bones, and were mentally weak. In the ()5 cases recorded by Arlt and Horner, in 48 cases the coincidence of lamellar cataract and con- vulsions were noted. Horner's 36 cases showed deformities of the teeth in 25 cases, in 16 cas«s anomalies of the cranial bones, and 4 were mentally 19 Der Mechanis mus der Accommodation des Menschliehen Auges. Leip- sig, 18G8. 190 deficient. In 1883 Max von Aix 20 reported 189 cases of zonular cataract, observed between 18(i.j and 188;), in the i)rivate clinic of Prof. Horner. Of these, 107 (56.61 per cent.) had had convulsions in earliest youth; 111, (66.07 per cent.) which in 1865 were designated as having rachitic teeth, 60 (31.76 per cent.) showed malformations of the bones of the skull, con- sisting of more or less assvmetry; 40 (21.16 per cent.) showed marked signs of rachitic deformities of the extremities. In 153 cases (80.42 per cent.) the patients showed at least one. usually two or more, s3'mptoms of consti- tutional disease, whereas but 37 showed absolutely no signs of rachitis. In the entire statistical table, there is not a single case recorded in which the characteristic uveal disease, or interstitial keratitis diffusa, was noted; hence in all probability zonular cataract is the result of rachitis, and not syphilis." The cases of multiple lamellar cataract are not less important aetio- logically than the above, since they show, owing to the presence of the cloudiness in more than one lamella, that the cause of the disease must be of a remittant and recurring nature. Arlt did not consider lamellar cataract as congenital, but imagined that the shock which the eye received during a convulsion was sufficient to cause a sliding past each other, as it were, of the elements of the lens, just at the point where the most compact and heavy nucleus came in con- tact with the softer and more delicate cortical substance. This change in position he considered sufficient to cause a cloudiness of the lamellae which lay next to the nucleus. Becker likewise, basing his conclusions on Von Graefe's three cases, where, following an injury to the eye, the lens was dislocated and gradually a lamellar cataract developed, and one of his own in which a lamelhir cataract developed after a trauma, came to the con- clusion that this form of cataract may be due to trauma, as well as con- vulsions, the lamellae nearest the capsule being disturbed in their nutri- tion, and in consequence of this, becoming cloudy. Then, again, the occur- rence of a number of lamellar cataracts could be brought in connection with the intermittent cliaracter of the convulsions. The inner lamellae being the oldest, depending on the size of the cloudy zone, one could to a certain extent, determine at what time of life the convulsions occurred. Horner laid great weight on the fact that, aside from the convulsions, other signs of rachitis could be found. It was mainly the result of his ob- servation that attention was first drawn to the rachitic form of teeth found in these eases. Owing to the great imi)()rtance which attaches to the simul- taneous presence of this ronii of teeth i\iu\ this fonu of cntai-aet. 1 (piote his description. 20"Zur ratholojjie de.s Schkht Sraars." InauK- Dissert, unter Horner. 191 "On close exaniinatlon of jin incistT tooth one will observe, in a perfect specimen, that the enamel gradually tliins off toward the neck. The enamel is shininjr and smootli. and on focal illumination has a satiny gloss. This satiny appearance is due to a system of transverse furrows, wliicli encircle the crown of the tooth. The less completely a tooth is foriiieil, liie less lliis toolli will show this wavy finish, and by close observation one can sec tluit tliis is due to the greater distance at wliich tliesc furrows are one from anotlier. Tliese fur- rows may be exceedingly delicate, and so closely packed together as to require a magnifying glass 1o see tliem; and again, they may become gradually more distinct and coarser, so as to l)cconie visil)le to an olsserving eye. Now, in rachitis an anoiiiiily |>rcsciits itself wiiieli is easily recognizable. The teeth are plump and thicker. Instead of the elegant chisel-shaped teeth we find them cubical or ill-shapen. Nevertheless, the form as a wiiole may resemble the ideal. The most interesting feature, however, is the departure from the normal of the surface of tlie tootli; the enamel instead of gradually disappearing to- ward the neck, nearly always ends suddenly in a tliickening. The above men- tioned furrows are heajied up t(t an enormous height; sometimes we find, es- pecially toward the cutting edge, instead of a furrow, in the same place, a row of round holes, as though they had been gouged out with an awl. Toward the cutting i^d'^e the body of the tooth terminates with a convex edge. The union of the lingual and the labial plates of enamel are joined over the body of the tooth in irregular or .ingSfd lamellae. In extreme cases, at some points, the enamel may be entirely wanting, and mostly in such a manner that the base of the denuded spot coincides with a very large transverse furrow; while in other places it is heaped up wave-like; whereas again, at the cutting edge, it seems to be washed away. The denuded bone of the tooth then, as the result of the action .of the damp warm air in the mouth, turns brown, in striking con- trast to the white enamel. Only individual teeth seem to suffer in a character- istic manner from this anamoly, and these seem to be aft'ected only to a certain degree. '•In contradistinction to this anamoly stands the one due to hereditary syph- ilis, and which occurs almost exchisively on tlie ujtper incisors, and appears even in the permanent teeth. "The upper teetli are short, narrow, their angles rounded off. and their edges exhibiting a broad, shallow notch. Usually one or two teerh converge toward each other; in other cases they stand apart with an interspace, or they diverge. The simple broad notch of greater or less degree of depth, is hardly ever wanting. The teeth are almost always of bad color. They may, however, in some instances, be of very fair whiteness. On looking carefully at the sur- face of the notch, there is almost .always the evidence of wearing: that is. the enamel is not perfect in the scooped out border of the tooth." 21 Hence, these teeth seem to be wanting in .iust the most characteristic point in differential 21 Hutchlnson-Trans. of Pathological Society of London. Vol. X, p. 294. 192 diagnosis, for in rachitic teeth we tind the heaping up and ridge-lilie formation, ami in places the total absence of the enamel. This enamel, like the lens, is of epithelial origin, anil it niiifit certainly appear as an astonishing fact that both should show a zonular nhnonnaJUy. Previous to this time, II. Schmidt had drawn attention to the fact, that in youthful individuals, in affections of the teeth in whicli there was irritation of the alveolar branches of the trigeminus, not infrequently the near point became further removed and the width of accommodation nar- rowed. He looked upon this as due to a reflex increase of intraocular ten- sion. Lately, he has attempted to explain lamellar cataract by referring to an interference with the nutrition of the lens .'system, due to teetliing, and he also pointed out the fact, that during the progress of glaucoma, opacities invariably develop in the lens. He considered himself justified in drawing the following conclusions; namely, that the branches of the alveolar nerves reflexly interfere with the processes of nutrition in the eye during the time of teething, and in some individuals this interference may lead to the formation of cloudiness of some of the lamellae. Thus Schmidt attempts to connect the formation of lamellar cataract with the development of the teeth. In reference to this matter, the investigations of Arnold have led to a most surprising discovery, and supported in a most unexpected manner the views held by Horner; proving that the simultaneous occurrence of lamellar cataract and rachitic tooth formation is something more than a coincidence. Both abnormalities have a common cause — ricketts; and it can be no longer a matter of surprise that other sequelae of this disease, such as abnormalities in the formation of cranial bones, convulsions, etc., occur in the cases in which we find lamellar cataract. Further, we will no longer consider convulsions as a necessiiry step between ricketts and lamellar cataract. It is also, worth noting, that the time of the development of the enamel of the second, or permanent, teeth is coincident with the formation of those layers of the lens which become cloudy where lamellar catai-act toiins. The permanent teeth alread exist, fully formed at birth, and gain continuously during the next few years their later shape. There- fore, during the time of their greatest development, they are exposed to the action of the same noxious influence. Up to 1888, Horner's theory, which was coincided in hv Leber,22 was in vogue. .\t that time, Beselin 2:^ ])ublished the results of his microscop- 22 "Kernstar-artige Trubiuig der Linse naeh Verletzung ihre Kapsel." etc. (iraefe Arch.. XXVI, B. 1. p. 283, 1880. 23 "Kin Fall von e.xtralnrtern und microscopisch uutersiu'ht«Mn Scliichstaar einer Krwaehsenen." Arch, fur Augenh., Bd. XVIII, p. 71, 1888. 193 ical-aiiatomical-pathological cxainiiiatiori of a case of lamellar cataract, in which he claimed that it was formed just as in the senile cataract. Jlc states that he not only found fine continuous splits between nucleus and cortex, which he considered the anatomical substratum of lanu'Uar cata- ract, but also changes in the nucleus, which was hlled with a great number of minute splits and interspaces, all of which were filled with granular mat- ter. Though he considered the changes in the nucleus of post mortem origin — whereas he looked upon the large concentric splits as having oc- curred during life — from this he believes that he can positively conclude that they are due to the chemical change of the nucleus tvhich leads to its more active shrinkage. The new-formed outer lamellae can not follow the con- tracting nucleus, but separate from this, hence the development of the interspaces between the two — and these interspaces are the expression of what is known as zonular cataract. The essentially new part of JBeselin's theory is the assumption, that the detrimental cause, at the time it is exerting its influence, affects a fully formed lens; and, secondly, that the cloudy zone is not the imme- diate result of the detrimental cause nor produced at the time of its action, but only follows later on, as the result of the shrinkage of the nucleus. This is not in keeping with Deutschman's statements,^* who found the nucleus unchanged, and who likewise coincided with Horner's theory. Lawford,^^ who examined three cases, likewise states that he found the nucleus changed and found splits and interspaces. He does not state that he agrees with Beselin's theory, but states that he looks upon the forma- tion of tine splits running concentrically to the surface of the lens, and between the nucleus and cortex, as the cause of lamellar cataract. As the result of his examinations, Schirmer -*' states that in four cases which he examined he found three constant conditions: First, a totally, or almost totall)', normal cortical substance; second, beneath this, what microscopically appeared as a cloudy ring running parallel to the surface of the lens, a layer of compactly arranged minute interspaces, and, finally, similar, but larger and less frequently distributed interspaces throughout the nucleus. Microscopically, a sharp line of demarcation did not exist, but the transition from the large to the minute interspaces is quite rapid. In this work of Schirmer's and the one quoted above, and frotn whicli 24 "Pathologische Anatomische Untersuchnngren eines Menschlichen Schicht- staars." V. Graefe's Arch., XXXII, B. 2, p. 295, 188G. 25 On the Pathological Anatomy of Lamellar Cataract or Zonula. Royal London Hospital Reports. Vol. XII. Part II. p. 184. 1888. 26 "Zur Pathologischen Anatomie uud Pathogenese des Schiclitstaars." Graefe Arch., Vol. XXXV, B. 3, 1889. 194 the east' rtixuls are lakcii, ilic \\\n>\ inddcrn views (•(»iiccriiin fniin of cataracl and il.- rehition to central cataract are expressed. A iiiiinlxT tif later iiivesti.iiatois. Bernhard Duh,^^ Carl Hess,28 and Albert I'eters."' though ditTei-iiig with him in some minute details, essentially agi'ee with him — hence Schirmer's views e.\[)ressed in his later work.*' are (pioted in Jidl. "In accord with Iloiiier"s iheorv. 1 conceive that a zonular cataract is due to the action of a passing noxious pi'iiiciph' whicli manifests itself hy the formation of little dro])lets in the lens as it exists at that particular time. The droj)lets appear in greatest numhers in the youngest lens fibres and lamellae, so that '-linically we lind a demoiist rahle cloudiness; whereas the oldest fibres, in which less interchange of products is going on, are but slightly affected, and microscopically these latter show no change. The fibres which form later do not suffer in their normal transparency. This explains in a ])erfectly rationally manner, why it is that the cloudy zone in lamellar cataract has the foiiii of the lens, that the intense cloudiness is confined to one sheath (as it wvw). and show but slight changes in the nucleus. In very early foetal life the lens is not only smaller, but much more globular than at birth. Tfence a zonular cataract which forms very early in life will not only be smaller, but must be nuire globular, than where formed in extra-uterine life. At such an early period of development the fibres throughout the entire lens possess an equal amount of life, and all demand an equal amount of nutrition: at this time, they do not as yet exist as fibres, which are changed, shrunken and removed from the action of the nutritive processes. This same noxious principle, which later on simply affects the youngest lamellae, causing these to beconu' cloudy and only slightly affects the central portion of the lens, which is I'emoved from the influence of the nutritive processes, here affects the entire lens, leads to a foetal total cataract, over which gradually new transparent lamellae are deposited, and thus in time a central lens cataract is formed." Hence the theory of the pathogenesis of zonidar cataract can. without further discussion, be adopted for central cataract, ami the following state- ments apply to both forms: '^\ny noxious principle, the exact miture of which is as yet uid. IS;'.. lSostfrior lo the orra scrrata. to the temporal side, osseous tissue is developing. The entire atrophic retina is detached, and near the pa- pilla shows numerous folds. These partly cover a deep excavation of the pa- pilla, which is distinctly visible in the sections. Both the flat space between the choroid and retina, as w^ell as the entire vitreous space, Petit's Canal in- cluded, and the posterior chamber, is filled with a fluid which has coagulated in the MuUer's fluid. This undotibtedly chemically changed fluid in the eye lead to such a complete imbedding of the lens, that after the lens had been cut in four parts and imbedded in stearin, it was possible to make fine sections (Kuhnt liUdwig). The other half of the lens was put up in calabar substance, and then cut (Dr. Pinto). From the description it follows that the lens was held fast in the pupillary area and its immediate nighborhood, and that it was connected with vascularized tissue, and was further imbedded on all sides by pathological liumor aqueous and vitreous. The changes in the lens are highly interesting, and fit in exactly with those already above mentioned in the case of the granulom of the iris. A capsular cataract, 8 mm. long and 0.4 mm. thick, occupies the pupillary area. This shows all the attributes of a conglomeration of cells without the presence of intercellular substance; hence, this in the first stage of develop- ment. In the equatorial region are vesicular cells. The inner surface of the posterior capsule is clothed with epithelium, which is undergoing hyperphasia. Tlie lens whorl is liut partially recognizable. The ch;inges in the fibrous portion of the lens are likewise characteristic; separated lamellae, between which are highly light-reflecting globules of coagulated albuminous fluid, and the presence of innumerable vacuoles in the peripheric fibres all indicate that this cloudiness, of the lens has developed rapidly. This agrees with Dr. Pauli's statement. In .Tune. 1877, the iris trembled, the pupil was free, and the lens transparent. In October the first signs of changes in the eye were noted, which lead to the formation of the cataract. As the immediate cause of the same, one must designate the local adhesions which the vascular pseudo membrane in the pupil and tlie i)atli()l()gieal nutritive siii)i»ly on the part of the vitreous. CATAKACTA CAI'SULO-LP^XTICULAHIS COMPLICAT.V (I)l<:TA(MniENT OP THE RETINA). Mrs. K., .-ibont 4(» years of age. was treated by Steffan, to whom 1 am in- debted for this eye. I take the following from his notes: October, ]S7:'., s1ai)ly()iiia posticum progress. Choroiditis dissemin:it;i. Cat- aract polaris posterior. Inner half of field of vision wanting. Externally she still counts fing«'rs at 1..".. Right eye. Irido-choniiditis, .aiarMcia ••apsularis accreta. Ciliary irritation. Amaurosis. This eye was enucleated October 7, 1873. Two years later, October 7, 1895. the eye was opene;icf lictufcn tiiis ;iii to Ix- attested hy (ho fact, that in all three eases in which we examined ihc cataract in the eye, the vitreous showed marked chaii-ics. in hoth the lases, Buttmann and Merz, the vitreous was permeated hy pr<)lifcratii.t>- cells, whicii frequently showed ]on<;, swollen processes. In the case of i.rna Srliaiih. the colls were more sparsely distributed, but all showed uuinerous and dilated processes. Besides this, the fact is especially worthy of note, that in all these cases so far e.vaniined. the eyes showed no other signs of an inflammatory process. In oi-der to be perfectly certain in this matter, I examined the vitreous of a large number of eyes taken from the new-born and very young children, and though I always found in this fluid an increased num- ber of cellular elements, as compared with the vitreous of the adult, in not a single case did I find those forms which justify iis in stating that there is an inflanmiatory irritation of the vitreous. From this, one may conclude that where the vitreous shows the evidence of an active cellular prolifera- tion, by the presence of large numbers of cells, the vitreous fluid is chem- ically altered, and hence supplies to the lens an abnormally constituted nutritive ni'aterial. J! ad the .second and third cases coincided entirely with the first, one might form an idea as to the point where the first pathological changes begin in such a case. The absence of epithelial cells along the posterior capsule and the pre>eni-e of the peculiar hyperplasias of cells along the whorl — hence there, where, under normal conditions, the nutritive stream gains entrance to the lens — indicate very strongly that it is just at those places where the initial changes begin, making it impossible foj- new fibres to form, and prevent the further surface advanee of the dividing epithelial cells, so that the new-formed cells are piled up on top of each other, and finally lead to the formation of a capsular cataract. The difference in the ease, Jferz, may be explained as due to a less intense action along the whorl, so that, though the formation of new hms fil)res was ])revented. it was not so wdth the further advancement and formation of new epithelial cells. In the case. Lena Srliauh. since no perceptible changes were found along the whorl, this explanation could not be accepted without furthei- ex])lanation. It appears that in the above-des<-ribed cases, in which neithei- remains of the hyaloid artery, nor the vascular capsule of the lens, nor a foetal iritis are present, the genesis of all those cases of congenital or total cataract occurring on both eyes during the first years of life is given. This is true as well of those in which a portion of the lens is still present as in those which simply consist of capsule, hyperplasia of ca^jsulai' cell- and fluid. which latter we have been in the hal)it of designating a> shrunken cata- racts. It is possible, in course of tinu'. according to the mode of devel- 214 opment, for shrunken cataracts to form. Nor can it be denied that where such a cataract is not operated and remains in situ to very advanced age, the fluid in the capsule may be absorbed, and then appears as a mem- branous cataract (cataracta menibranacea). Only diifering from catarada memhranacea, are those forms which, on account of their similarity to fruits dried in the pod, have been given the name, cataracta arida siliquata, by Adam Schmidt. Sucli a cataract, including its capsule, seems to have a thickness of 2 to 3 mm., is a perfectly opaque, yellowish white, caky mass, and appears to be composed principally of dried-up lens substance. Fre- quently one obsei-ves, associated with such a cataract, a more or less ex- tensive tearing of the zonula zinii, and then it trembles with every move- ment of the eye; and it is then called a tremWing or floating cataract. {Cataracta tremula vel natatilis). Arlt drew attention to the fact that such "^dried-pod" cataracts, as well as the membranous, seem to adhere to one or more places in the periphery, and hence, where repeated attempts are made to depress them into the vitreous, they always seem to rise up again. (Cataracta elastica). This, however, can be partially explained by the fact, that both of the forms, owing to their being so dry, are specifically lighter than the vitreo^us. Here at least the suggestion of Pauli may be adopted, to perform reclination upward. ~Wliere the contents of the cataracta tremula or natatilis is fluid, this cataract will assume the shape of an almost globu- lar relaxed bladder (cataracta cystica). This capsule filled with fluid ap- pears always to seek its equilibrium. In his ''Pathology and Therapie," page 249, Becker describes the following interesting case: In 1874 I extracted from the eyes of a woman, 36 years of age, two con- genital, shrunken, membranous cataracts, which w'ere not adherent to the iris. Her statement that these cataracts had existed since birth was worthy of be- lief, since she also had nystagmus. The question as to whether both these cat- aracts were shrunken, or whether they were soft cataracts which had subse- quently during extra-uterine life become membranous, may be set aside. Both cataracts answered the above anatomical description exquisitely. Especially well shown were the cellular elements in the fibrous tissue. I do not doubt but that the entire cataract took its origin from the capsule cells. Dr. Raab made the examinatio. (N. B.— This same case is cited in Becker's Anatoniie, p. 40, Figure 22, as "Cataracta Capsularis Congenita." The operation was done as follows: First an iridectomy was made: the cat- aracta membranacea was then grasped by forcing one branch of the forceps through the zonula, so tliat it passed behind the cataract and into ilic vitreous, and then by slow and steady traction the cataract was gradually extracted. After an interval of several months, when the patient again presented herself, a most peculiar condition Avas present. After dilating the pupil the zonula of zinii came into view. Tliis had remained in i)ositi<)n. liad a faint grey color. 215 and presented the appearance of a striated till for tli.- uvrk. Tliis liad a per- fectly circular central hole about the size of a moderately dilated pupil, and on moving the eye no motion of its own could be detected. Consequently the zonula had not retracted. That this was so plainly visible is no doubt due to a pathological thickening which took place at the time the shrinking process of the cataract was going on. Finally, the cases Buttmann and Mrrz offer an explanation for a large num- ber of clinical observations, which formerly were designated as Cataracta Mor- gagnUina in Children. Both Janin and Arlt have reported cases in which they have operated for cataract, where on opening the capsule a cloudy, milky or blueish fluid escaped, a transparent nucleus remaining behind, which later on became cloudy. A cataract, as observed in the case Merz, might take such a course, if one will assume that the nucleus, as far as this still exists, permits to a degree the transmission of light. CONGENITAL HAED NUCLEAR CATARACT. Graefe's Cases, 1 to 3, have awakened another train of thought which I would fain express here. In the year 1879, Alfred Graefe drew attention to a form of congen- ital cataract which up to this time had seldom heen recognized/ but which previously had heen recognized by Mooren.^ This form was characterized by its excessively hard, wax-like consistency. This form always occurs on both eyes as a total cataract, and the volume is always equal to that of the physiological lens. The cloudiness is more homogenous, or possibly in- creases, toward the centre. It is a greyish white, or perfectly grey in color. It has no tendency to shrink or to complications. Capsular cataracts do not occur. Since discissions are of no avail, extraction must be done. Just * corroborates these ataitements, and reports seven extractions done on four children, all between the seventh and the fifteenth month. In all these cases, according to the statements of the parents, the cloudiness in the lens did not develop until after birth. , In two of the cases the thickened capsule was subsequently removed with the forceps. Just's cases differ from Von Graefe's insomuch that the former reports the presence of capsular cataract. •Just was kind enough to send me four of the cataracts and the two capsules for microscopical investigation. The latter showed capsular cataracts, without the presence of much intercellular substance. Unfortunately the nuclei were too friable to permit of making of tine sections. In teased specimens no ab- normal formation of the lens could be detected. Hence, the examinations gave but a negative result. These Graefe-Just congenital nuclear cataracts can scarcely be looked 4 Uber Congenitalen harten Kernstaar Sitzungs Bericht der Heidelborger Congress, 1879, p. 25. 5 Opthalraiatr. Beobaehtungen, Berlin, p. 209. 1807. 6 Kernstaare im Kindesalter. Ceutralblatt fur Aug., .January. 1880. 2l6 upon as anything otlior llian cataraols agreeing- with the type, Buttmann. If one will assume that a lens which has become adherent to the anterior capsule by means of a capsular calaract, is not reabsorbed, but persists and becomes saturated with a fluid wliich coagulates easily, one can easily un- derstand how this will become changed in a more homogenous waxy mass, and then we have before us the congenital hard nuclear cataract. If, on the other hand, the nucleus is not fixed, one can further assume, as in cases, Merz, Scliauh and Flesch, that this will gradually be dissolved and re- sorbed. T'hus. in congenital total cataract, we would have a two-fold final stage, one corresponding to the cataracta huperniatnra reducta, and the other to the cataracta Morgagnian a. CATARACTS OF SI'DDEN DEVELOPMENT. In one of Just's cases, the mother saw the cataract develop during the time the child had a convulsion. He cites another case, according to which the mother likewise s! rictcd chiciilal ion of lln- \arion> controversies existing ooncerninL;' the .izcncsis of dialx'tic- catai-acl will aid us in I'orinnlat- ing an opinion as to the maniuT in wliieh conslii utional calai-act dcNclops. Case. R. W., 19 years of age. from H.. a blonde, poorly nourished jrlrl. with a dry skin, suffered from diabetes. Two days after an extraetion had been done on the left eye, and a preliminary irideetomy on the right, she died of diabetic coma. The eye, which was removed twenty-three hours after death, remained in MuUer's fluid seven years before it was examined. {PMgvu-es 24, 25, 26 and Plates V and VI were made from the sections.) The corneal epithelium was plainly preserved, notwithstanding the long time the specimen had been in Muller's fluid, and showed perfectly distinctlj' the nuclei under- going division. The epithelium had begun to grow down into the iridectomy wound. The stump of the iris, as well as the posterior surface of the same, .show an enormous tumescence of the pigment cells. These are so large that one can easily see the nuclei, a thing whicli under normal conditions is very difficult. Lilvewise the portion of the iris on which the pigment rests is oede- matously swollen. Around the periphery of the iris there is a pigment ring, which is raised to an almost veritable swelling, as the result of an infiltration with an amorphous fluid. There must have been pathological changes in the posterior segment of the eye previous to the operation, for immediately behind the lens traces of blood can be found in the vitreous. I have not been able to decide from which vessels this has come. We are, liowever, interested more espetially in tlie conditions of tlie lens. This has an equatorial diameter of 8-2 mm. and a sagittal of 4-8 mm. This almost globular form is due to the excessive taking up of water inside the cap- sule, Avhicli is partly situated between the lamellae and lens fibres, and partly in larger (luantity between the lens proper and its anterior and posterior cap- side. Anteriorly this layer equals 0.53 mm. in thickness, posteriorly, 0.0.") mm. Only along the equator do we find the nuclear zone and whorl still in contact with the capsule. This fluid, which has been taken up in the capsule, is firmly coagulated: hence, has not fallen out of the finer sections. At the anterior pole the capsule has a thickness of O.Oltt nun., at tlie posterior. 0.008 mm. If one examine carefully with a high power the epithelium of the anterior capsule, one will find it undergoing a hyperplasia at the ant(>ri(>r i)ole. As yet. neither pearls nor large accumulations of cells iiave formed, ttut at numerous points several layers of cells can be found. Iniernal to tlie I.iyer of cells is a regular layer of albuminous globules. Towai'd the e(|uator the etiithelium is beauti- fully and regularly arranged, and the whorl is of extraordinary beauty. A num- ber of sections show, immediately posterior to the whorl, an extensive forma- tion of large vesicular cells. Toward the center of the lens the fibres and la- mellae of the lens .-ire separaled fioni each other, and as a result large spaces 2l8 have formed, which are filled with coagulated fluid. This has a tendency to form globules similar to the tissue fluid of the lens. Whereas the normal width of the lens fibres equaled 0.010 mm., the smallest diameter found equaled 0.019 mm. Only in the peripheric fibres did I find any signs of deterioration, disintegration of the lens fibres, formation of vacuoles, or punctate cloudy spots. The reaction of the various stains on the lens was especially interesting. Alum carmin. which otherwise is exceedingly good for staining nuclei, stains the entire specimen equally, but does not show the nuclei with any prominence. Likewise haemotoxylin. But beautiful and useful specimens are derived by the use of double stain haemotoxylin eosin. But even in these the nuclei at times hardly take up sufficient stain to make useful specimens. This is very re- markable, since only here and there over the entire capsule, certain nuclei take the stain more intensely and appear larger. The number of these darkly stained nuclei increase toward the equator. At the whorl, however, all are pale, show- ing the various stages of degeneration to veritable death of the nuclei. As a result of this double stain, we discern delicate chemical differences, which would not otherwise have been discovered. Thus we find in all peripheral sec- tions, which have not been extensively fissured, dark blue dots and spots, which have a great resemblance to the fat drops observed in youthful lenses. Like- wise, the spindle-shaped bodies or interspaces appear blue. But it must as yet remain undecided whether or not this is the result of sugar contained in the tissues, or whether this is simply the result of the action of the hardening ma- terial. But in applying the results of the anatomical examination to tlie clinical observations made on the living eye, one must not forget that this was a cadaverous eye, which had been preserved seven years in MuUer's fluid. The girl died January 11. 1874, at 1:45 p. m.. and t he post-mortem examination was made the following day at 12 o'clock. Notwithstanding the low temperature during the month of January, sufficient time has elapsed to allow the forma- tion of Morgagni's globules on the inner surface of the epithelium: nevertheless, the time was certainly too short to permit of so large an amount of water being taken up in the capsule. Nevertheless, hundreds of specimens which have been preserved in like manner do not show such a condition. Hence, we may assume that the hydropsia occurred during life. Cssowidzki "' collected all the historical notes relating to the occurrence of grey cataract in patients suffering with diabetes mellitus. From the more recent literature, I will only quote that which seems to be most im- portant. 1. Eeports vary greatly concerning the frequency of cataract in dia- 7 Uber die bei der Zuckerrulu- Vurkommenden Augenkrankheiten. Berlin, 219 betic patients. Fauc()iinc;iii-I)iiric>iic ' loiind tliciii in O.r; per cent.. J. Mayer ^ in 3 per cent., Seegen ^"^ in 4 \)vr cent.; whereas. Von Graefe esti- mated its occurrence in as high as 25 per cent, of cases.^^ In 14| years, I (Becker) have treated (50,000 eye i)atients, and among these I found twelve cataracts in six diabetic patients; on five of these patients I made seven ex- tractions during this time. Hirschberg ^- claims to operate six to eight diabetic cataracts yearly, and among the last 150 cataract patients consult- ing him in private practice, six had diabetes. 2. The diabetic gi'ey cataract may occur at any period of life; it is stated, however, to occur most frequently in youth. The youngest patient with cataract reported is a girl twelve years of age. (Seegen, No. 23). My (Becker's) patients were, respectively, 19, 27, 38, 40, 62, and 63 years of age, whereas I recollect that formerly I operated a number between the ages of 18 and 35, and some of these were blood relations. Seegen's six diabetic cataract patients were, respectively, 12, 39, 47, 53, 56, and 64 years of age. 3. More women seem affected than men. Among Seegen's cases, four were women, two men. In my cases, the number was equal. 4. In diabetes more frequently than in other conditions, the cataract develops simultaneously in both eyes, or only a very short interval inter- venes before its development on the second eye. Seegen's twelve year old girl is said to have had cataract only on her left eye, but it appears that she remained under observation but a short time. 5. Usually one finds large quantities of sugar in the urine, and the general condition of the body very much reduced. The cases in which this is not found to hold true, is in older people; Seegen, 53; Foerster, 52; my own cases, 62 and 63 years. 6. The form of cataract which develops in a diabetic patient, as a rule, depends on the age of the patient at the time of its development. In his "Pathology and Therapie," page 270, Becker states, "Since the causative disease is not limited to any particular period of life, hence the cataract may develop in different varieties; in young individuals as a total soft cataract, in the aged as a mixed cataract. Hence, from its general 8 Leber. Uber die Erkraiikungon des Auges lw\ Diabetes Mellitus. Arch, f. Opth., Bd. XXI, 3. 9 Uber die Wirlvsamkeit vou Karlsbad, Diabetes Mellitus. Berlin Klin. Woehea., 1879. 10 Der Diabetes Mellitus. Leipsig, 1870. 11 Foerster-Beziehungen der Algemein-I^'iden und Organ Erkrankungen zu Verandenmgen unf Krankheiten des Sehorgans Graefe Saemisch, Bd. VII. Cap. XIII, p. 219. 12 Uber Staar Operationen und Diabetisch C. Deutsch. Med. Wocheuschrift, No. 37. 1889. 220 appearanet'. one is not ciiahltMl to make the diagnosis of diabetic cataract. One does, however, frequently observe tendency to a rapid retrogressive metamorphosis." ]-\)erster states, "that in the great majority of eases in old people, the cataract develops just as it would in the senile form. There are, however, cases in which the cataract develops in an entirely different manner. This foi-m of diabetic cataract may be recognized, and has some- thing peculiar in its formation. First, the cortical lamellae immediately beneath the capsule become cloudy: a thin, bluish grey film permeates the entire anterior surface of the lens, and its position immediately behind the edge of the pupil demonstrates that the most external layers of the cortex are involved. Its color, so far as it is confined to the sections of the super- ficial lamellae, is homogenous. Whereas in other cases this facetting of the sectors of the superficial layers of the lens is one of the last acts in the formation of cataract, it is here noted as one of the first. The nucleus and the deep lamellae are not entirely transparent, as can be seen by focal illumination. In the course of a few weeks, the deep layers are involved, and finally a bluish, soft, non-nuclear cataract results, which can not be difl'erentiated from the cataracta of youthful individuals. This always occurs simultaneously on both eyes. I have only observed this form in young individuals up to the twentieth year, and at the very beginning the appearance of the lens is so characteristic, that from this alone on several occasions I have predicted sugar in the urine. As my (Becker's) observations do not agree with the above description, and as we shall see that other authors likewise lay great stress on the appear- ance of the cataract, I will give the description of all my cases. Case No. 1. R. W., of H., aged 9 years, was the youngest individual. The cataract on the left eye was extracted January 8. 1874. and had the appearance of a lens w^hich had become cloudy very rapidly, was a tumescent, bluish white soft cataract. Tlie iris shadow was very pronounced. Examination for sugar was not made. On December 4. 1873, the right eye was noted as cataracta cor- ticalis posterior. At the time of the extraction of the tirst the second had ma- terially increased; nevertheless, she still counted fingers at 5-6 feet. Case No. 2. A. S., a farmer from W., aged 27 years, has had diabetes for a long time. At times 8^4 per cent, sugar in llie urine. In 1882 he noticed that the siglit of the right eye was f;iiling. .-inil on Dcfcmlx'i' ir.tli he eonld only recognize tin- movements of llie lumd. rro.jeetion good. '[Iw cMtarjiet had a mother of pearl appearance, tumeseeni. .md the lens star is darker and seems to stand out from the cloudy tibres. The iris shadow is well marked. The left eye has .-i, M. :'.. \-. e(in:ils .*=, T.ens is cle.-ir. M;ircli 1'Mh. three months later, the patient \v;is ex.-niiined again. On tlie right eye the cntjifnct was somew'hat .shrunken, .\titefiof eii.-i tuber (h-ej). Iris siiadow ni.-irked. 'i'iie dark grey lens could otily l)e dete.'ted hy ol)ii(Hie illiiiniii:! lioti. 'I'lie snbstMiiee of tile lens shows 221 tin«' nidiatiiif; striations. Ht'tw.'cii ilicsr sirialioiis arc wliiic piiiK'talc duts. Vision is not materially altetvd. I-ft't cyr. ilic anterior eliainlK-r is of normal deptli. In the pupillary plane on focal illimiination one notes a veil like hlueish- irrey cloudiness, as though the lens had been breathed on. The lens star shows a somewhat more saturated greyish white color. TIh" nucleus is transparent. On dilating the pupil with atropine. Hud tlial the e(iu:ii()rini /(inc ot tin- It'US is cloudy in a broad zone. Vision reduced to ..\. Case No. 3. A. E., a farmer, 38 years of age. came under olis.-rv.itioii Maich 0, 1S73. The left lens showed signs of an immature soft (•.ilar.icl. Tiic an- terior corticiilis was still soft. Counts lingers at 4-5 feet. Right lens. Cataracta incipiens II 2 \=,i,; urine. S. C. Itt42. .Noveinber 27. IST:;, could only recog- nize movements of the hand. S. (J.. lo:',:'>. Tlie lens w;is extracted November 28th. Owing to a slight iritis during the process of liealing, a preliminary iri- dectomie was made on the left eye January .5. 1874. and February 27, 1874. the extraction followed. Discharged with O. 1 >. V.=?. O. S. \.^j\,. Kuhne. who examined both lenses for the presence of su.gar. found the same i)resent. (Pathologie uud Therapie des Linsen System, p. 271.) Case No. 4. J. S., a day laborer, 40 years of age. Sight began to fail in 1880. Since December can only count lingers. Was taken up at the clinic March 7, 1881, at which time he could only recognize movements of the hand. Lens is completely cloudy; exceedingly tumescent. Anterior chamber shallow. Urine acid. S. G. 1030. Quantity passed in twenty-four hours equaled t!72(t cm.; contains 6.7 per cent, sugar, equal to about 450.2 grms. Extraction was made on the right eye March 9th; left eye March 29th. Healing perfectly. N'ision equalled to ^ The daily amount of sugar varied. On tlie day of his arrival, owing to the journey and poor noiu-ishnient, tlie (luantity of sugar was 450.2 grms.. whereas the usual quantity was from 200 to 300 grms. On the day be- fore the first operation, failed to estimate the amount of sugar. The amount of urine passed was 2780 and 1080 ccm. In the next few days the quantity of sugar fell to 80.98 and 86 grms., but rose again during the following ninety days to 161.3 grms.; sank once more, but rose again during the last few days before the second operation to 173.3 grms. After this there was again a de- • crease. These results are interesting because they indicate the influence of diet during his trip and the first few days after the operation, and in the days previous to the second extraction, during which time the patient was given a mixed diet, in order to strengthen him. In both cataracts sugar was found. (See pagt' (;7 of text.) Case No. 5. ^Irs. B.. of W.. aged 62 years, for the past three years has suffered from a very intense degree of diabetes, with never more than 0.9 per cent, sugar in the urine. She has repeatdly been to Carlsbad. For a year past has noted the decrease of vision in both eyes. Was seen for the first time November, 1882. O. D. cataracta incipiens: O. S. cataracta nondum matura. In both eyes found the posterior cortical substance and the equatorial zone very cloudy, and the nucleus highly refracting the light. Riglit «>ye counts fingers at 2.3 m.; left eve at 1 m. In 1S83 tlie c-itaract on tlie left eye liad advanced so 222 far that the radii could be seen when the pupil was dilated. Extraction was done under narcosis March 7th. Process of healing uneventful. During the operation the aqueous was aspirated with a pipette from the conjunctival sac, and together witli the lens was examined by Kuhne and found to be free from sugar. The amount of urine passed, the specific weight and the amount of sugar, especially the latter, during these days, though slight was at no time very great. March 7th, amount of urine =1110; S. G.=-1020; sugar -0.22 per cent. March 8th, 1860, 1018. and 0.3 per cent. March 9th, 1250, 1013, 0.1. From this time on the urine was free from sugar (March 15th), only on March 17th. 22 per cent, did the urine show signs of sugar. Case No. 6. Mrs. J. D., of Z., a wealthy woman 63 years of age, was oper- ated on by me November 16, 1871. According to appearances this was a cata- ract senilis simplex. Left eye shows a cataract incipiens. This lady has had diabetes for a number of years. Quantity of sugar not estimated. V. =j^. Opthalmoscope revealed a retinitis diabetica. Kuhne. who examined the lens, found no sugar. (P. and Th., p. 271.) Jany ^^ gives lis a very accurate description, in which he especially emphasises the fissiiring of the cortical substance, which gives it the ap- pearance as though discission had been practiced. In both his cases the anterior cortical substance was but slightly cloudy, whereas posteriorly there existed exquisite choroideal cataract. "The entire posterior corticalis simulates "the pod of a fruit," in which the peculiar asbestos gloss was particularly noteworthy. Owjng to the scarcity of personal observations, I have called on my colleagues. Horner writes, "I find cataracta punctata, especially posterior cortical cataract, equatorial cataract and anterior cor- tical cataract. The age of the patient appears to influence varieties. In young diabetic individuals there appears to be a more rapid disintegration of the anterior corticalis, whereas in older people (and in fact, in very severe cases) the posterior corticalis may first be affected. According to my ob- servations, there is no particular rule." Leber lays stress on the same picture \\hich is observed in youthful diabetic patients and in other rapidly developing cataracts occurring in youthful individuals. "The cloudiness is close 'to the capsule and there is always a tumescence and shallowness of the anterior chamber, but I do not find that the anterior corticahs is always first involved." Concerning the cataract of a young woman at present under observation (about 4.000 cm. urine, with 10 per cent, sugar) and suffering with a high degree of diabetes, Leber writes, "In the right eye the cloudiness exists just as Horner ha.s described it, consisting of broad, bluish, wavy sectors; which, if not immediately beneath, are at least close to the capsule. Through this cloud- iness one can plainly see the cloudy striations in the posterior corticalis. iSZwei Fallo von Roidor Seitigo Cntaractn Diabetica. Arch. f. Augen. Bd. VIII. 223 On the left eye the anterior corlicalis is a.? good as totally iraiispareiit; whereas the posterior shows the shell-like cloudiness, disclosing the deli- cate, moderately broad striations of which it is made up." Dr. JMax Perles ^* reports the following remarkable case. In a patient sixty-two years of age, he discovered a very peculiar change in the lens. By daylight the pupils give back a peculiar greenish-black reflex. On focai illumination and examination with the corneal loup, the anterior corticaHs and the nucleus are found to be clear. In both eyes, however, the temporal portion of the posterior substance discloses an almost completely symmet- rical deposit of rust-brown coloring matter, which is arranged like a closely woven network of mycelium. This deposit is located immediately beneath the capsule, is most dense along the temporal edge, becomes thinner toward the middle, and finally is lost in the finest threads. In this network these dark brown granules are deposited. Neither vesicles nor droplets, as is usual in beginning cataract, can be seen. The vitreous is free from cloudi- ness; both eyes are emmetropic. View of the fundus is difficult, but shows no visible change. There is no albumen in the urine, but about 7 per cent, of sugar; no abnormal pigmentation of the skin. Microscopical examina- tion of the. blood shows the haemoglobin normal. This pigmentation of the lens positively only set in after the diabetes had existed in this severe form for several years. Perles concludes: "These changes, in all probabil- ity, are due to the diabetes, since a like pigmentation of the skin in this form of disease is not unusual. However, an expression of opinion as to the nature and source of this pigmentation can not be made until anatom- ical examinations have thrown some light on the subject." Eegarding the presence of sugar in non-eataractous lenses of diabetic patients, we possess but a single observation made by Deutschman.^^ j^ the lens of a ten year old girl who had died of diabetes, he could not dis- cover any sugar in the lens, whereas the urine contained 0.5 per cent. From the folloAving it will be seen how important it would be to make a large number of analyses in analogous cases. In the following table, arranged according to their age, will be found a report of all the accessible cases of diabetic cataract in which the lens was examined for sugar after the extraction. Assuming that the table repre- sents all the reported cases of diabetic cataract extracted and examined for sugar, one finds that in the great majority of cases sugar was found present. In^bo'th of the senile cataracts extracted by me November 30 and 31, no sugar was found. Since negative results are reported for all ages, one is 'justified in assuming, that the presence of sugar in cataract has nothing to do with the age of the patient, and since at times in the soft, rapidly 14 Pi^uentstaar bei Diabetes. Hirschberg's Centralblatt. p. 171. 1892. 15 Uutersuchun^ zur Pathogenese der Kataract. Arch. f. Opth.. XXIII, 3, 1, 143. 2 24 clouding and iuinescent cataract, pugar was not found at other times; hence the variety of the cataract can not be looked upon as indicating the pres- ence of sugar in the lens. In all the positive results, there has been a high percentage of sugar in the urine, and in the negative a low percentage. If one will stop to consider the large quantity of sugar voided the day of, or the last few days previous to the operation, as an indication of the quantity present in the blood and tissue fluids; also, as has been observed time and again, that the cataract formation only occurs w-here there is a large excretion of sugar, hence one will understand that in these cases, sugar will be found in the lens. From this it would also follow that sugar will not be constantly present in the lens, but will vary, depending on the general condition. This fact is particularly demonstrated in Case 4, No. 25 and 20 of the table, in w'hich special attention was given to this fact: Urin. f] Name of Name of Examiner. 1 Opera- tor. < Kind of Cataract. S. G. Percentage of Sugar. a I Schmidt. Zincke. 15 F. Cataract hypermatura re- ducta. Much Urine. Large quanti- ^ - 2 15 F. Cataract hypermatura re- ducta. Much Urine. ty of sugar. Large quanti- I? 3 Viol. 16 F. Cataract hypermatura re- ty of sugar. i?i ducta. 1040 Large quanti- 4 16 F. Cataract hypermatura re- ducta. 1041 ty of sugar. Large quanti- ty of sugar. ' 5 Jatiy. Buchwald. 17 M. Ant cortical delicate, post cortical dense cloudiness, nuclear clear. 0.7-5.61 in the days of the 6 Muller. 17 M. Lens densely tumescent, thick cloudiness of cortex. oper 2.0. J y Viol. 18 1042 1 8 20 1045 9 Stober. Hepp. 21 F. White, cloudy, soft, tume- I scent cataract. 1041 4,807 I 10 Jany. Muller. 22 22 F. F. Tumescent milky. Anterior corticalis delicately 1040 0.15-8.6 K 1 clouded, posterior cortica- lis shell-like cloudiness, 1 nuclear clear. 1034 0.15-8.6 3"^ •c _ Hepp. 23 F. I I n 12 Stober. 23 F. Soft, milky. 1052 8.8-9.7 I n 13 14 Teillais. Cariiis. 23 25 F. M. Greyish white opalesence to 1052 8.8^.7 J ° 15 Knapp. 25 M. yellow. 0.5. Cataract hyi)ermatura re- 1052 8.9 , a 16 ducta. 1052 8.9 I n 28 1052 < 17 Viol. Klinger. 31 M. Catar. nondum matura o. w. 1052 7.8 ] 18 Berlin. 31 M. Catar. nondum matura o. w. 1052 7-8 I n 19 0. I^iebreich. 34 F. Catar. mollis matura o. w. 1040 8.6 I 20 Schmidt. 34 F. Catar. mollis matura o. w. 1040 8.6 ^ 35 M. 1040 8.6 I 22 Nagel. Kuhne. 38 M. Both eyes, soft tumescent I 23 Becker. cataract. 1040 8.6 I 38 M. Cataract. 1040 8.6 -4 40 M. Both eyes, .soft tumescent [ I 2.S 40 cataract. M. Both eyes, .soft tumescent 1040 6-7 I 2f> " ! cataract. 1040 6.7 Berlin. 1-chling. 40 Moderately soft cataract, with clear nucleu.s. 1040 6.7 J 28 l.tber. 53 F. Rapidly developed, double, .soft cat., not entirely ripe. Broad mother of pearl stria- ,.,40 4-7 ' 29 53 F- I tions. 1040 4-7 30 Becker. Kuhne. 62 F. Cataract senilis matura. 1040 4-7 I 63 F. Cat. .senilis non dum matura. 1040 0.1-0.9 1 225 'riirl-cf. )i-c, t(» -i|iiiiiiiii-i/.(' all tl hal li as liccii said ; is the r< ■>ull (d' personal )l)S('r\ati(iii and till- ol)sci-\ati (III (1 r ..tl icrs. one Wdll Id >a.v t hat in youthful iudividiials ihc diahi'lic calai ■act ( level ops al)(iiil as r..ll..\\>. First there is a cloudiness in the equatorial zone in most cases followed hy a cloudiness in the posterior cortical suhstancc and after this had developed tlie anterior corticalis is attacked. This rapidly progresses to form a soft cataract, at first attacking the lamellae immediately beneath the ca])sule. At this time there is neither a tumescence nor a shrinkage of the lens system, but it i? true that very soon the star figure is developed. This latter symptom, as in all other soft cataracts, I look upon as the first indication of the taking up of water. The tumescence goes on rapidly and steadily, as the result of the taking up of water in the capsule, and at the same time the lens is fissured and split into sectors. The tumescent lens always shows a vers- marked iris shadow, because there is a very perceptible layer of fluid be- tween capsule and lens. This condition may last one or two months. At the end of this time the volume is reduced, but the iris reflex may remain. The silky gloss is lost and a new picture, (that of the cataracta hyperma- tura reducta of senile cataract), is developed. The entire lens system is reduced. Schmidt-Eimpler extracted and measured such lenses. Both lenses, Nos. 1 and 2 of the above table had an equatorial diameter of 8.5 mm.; the right a saggital diameter of 2.5 mm., the left of 2.0 nmi. (See Becker, Case No. 2). From personal observation, I can not state, nor have I been able to find any statements in literature, as to whether the diabetic soft cataracts of youth can become entirely fluid; whether capsular cataracts may be added to these, or whether calcareous deposits can take place. Ber- lin writes to me that he operated a diabetic patient for a cataracta Mor- gagniana; who. however, during the days of the operation haarate the anoniahuis substance in the nutritive supply. 2 26 THE AETIOLOGY OF THE SO-OALLED DIABETIC CATARACT. Owing to the fact tliat sugar lias been found in all the tissue fluids of the body, and since the now famed experiments of Kunde for the expeii- mental production of cloudiness of the lens, entire series of methods have been devised to ex])lain the cloudiness of the lens which develops in dia- betes. After Leber 1^ had expressed the hope, that our knowledge concerning the development of diabetic cataract would be furthered, by experimental investigation, Deutschmann ^"^ and Heubel ^^ entered on this task most fully. Xotwithstanding the difference and the relative values of the methods em})loyed in making these experiments, and aside from the animated dis- cussions which arose between Deutschman and He'ubel, it becomes a matter of general interest to note, that both experimenters are in accord in stating that the so-called salt, or sugar, cataracts are produced by the process of diffusion, between the salt or sugar containing aqueous (or vitreous) on the one hand, and the lens on the other; in consequence of which water and albumen diffuse in the aqueous, and the nacl, respectively the sugar, into the capsule of the lens. According to my (Becker's) judgment, Deutschman's conclusions prove nothing. He placed a human eye, taken from a corpse, in a 5 per cent, sugar solution and after fourteen hours the lens became cloudy, whereas in a highly diabetic girl in whom there was no cataract, sugar was formed in the fluid media of the eye not in excess of 0.5 per cent.; hence he denies that the cataract can result from the extraction of water by means of a large quantity of sugar present in the fl'iiid media of the eye. Though no weight is placed on Heubel's objection that experiments made on enucle- ated lenses can not be applied to the living eye, he nevertheless is correct, beyond a doubt, when he draws attention to the fact, that smaller quantities of sugar solution acting for a relatively longer time, may cause even more ifi UlHT die Erkrankun^vn dor Augeii bei Diabetes Mellitus. Arcli. f. Opth., Bd. XXI, 3. 17 (1) Untersuchungen zur Tathogenese der Cataract. Areb. f. O.. 3. 1, (2) Zur Wirkung wasser entziehender Stoffe auf die Krystallinse. Arch. f. d ges Phys., Bd. XX. (3) Entsteh die Diab Kataraot brim Meuschen in Folge von wasserentziehung der Linse seiteus zucker lialtiger AugcntlussigkeitV Eiue Ent- gegnuug an Prof. Heubel in Kiew. Arch. f. d ges Phys., Bd. XXII. 18 (1) Uber die Wirkung Wasserentzicliender Stoffe insbesondere auf die Krystallinse. Arch. f. d ges Physiol.. Bd. XX, p. 111-118. II Bemerkungen zu Dentschmann's Aufsatz. (2) Arch. f. des Physiol., Bd. XXI, p. 153-176. (3) Ant- wort auf Dr. Deutsc Innann's Entgegung. Arcli. f. d. ges Physiol.. Bd. XXII, p. 580-590. 227 extensive changes, than large quantities acting for a short time. The lesser quantity of the active substance is compensated for by the longer time it is active. "With all due respect to Heubel's talent, both as an experimental in- vestigator and critic, I feel called upon to raise a few objections from a clinical standpoint, to the application of his experimental results to cataract as observed in diabetic patients." "In his first critical essay, in reply to Deutschmann, (2, above p. 175), he sums up his views, stating that, "in the formation of the true diabetic cataract, the sugar contained in the aqueous and vitreous (be it as such or in Combination with Na. CI.), is of the very greatest importance, and the first and most important change which the lens undergoes is the withdrawal of water as the result of the action of the sugar." "The genu- ine diabetic cataract develops in an unusual and in a peculiar, entirely dif- ferent manner, and in this mode of development the aqueous positively ex- erts an influence in producing this cloudiness." "There is a complete analogy between the mode of development of the diabetic cataract and those cataracts which are experimentally produced by the dehydrating action of sugar and salt solutions. This cloudiness always involves, first, the external cortical layers; at the beginning the nucleus remains clear and the surface of the lens shows the sector-like facetts." "Competent observ- ers have stated that with proper diathetic and therapeutic treatment, by which the amount of sugar can be considerably reduced, the lens may be made to almost completely clear up again, a condition which has hardly ever been observed in other forms of cataract. There, also, do we find an- other remarkable coincidence between diabetic cataract and those experi- mentally produced by the dehydrating action of the sugar and salt solu- tions." "One must here note that Heubel lays particular stress on the expres- sion, 'genuine dialeiic cataract.' By this he can only have reference to the diabetic cataract of youth as described by Foerster. Heubel possibly unconsciously has given up complete agreement with Foerster, for he states that sugar in the vitreous may also lead to cataract formation. (Cited above, p. 187.) He describes an experiment in which, if the aqueous is permitted to escape, the cloudiness only appears at the posterior pole. But, aside from this, I believe that I have shown above that "genuine diabetic cata- ract," as a special variety, does not exist, but coincides in form with the majority of cataracts developing in youthful individuals, as rapidly devel- oping soft cataracts, also as to their course and final end. Heubel's argu- ments, based on the experimentally produced cataracts and their subsequent clearing up, is even on a weaker basis. The cases on which Heubel bases his 2?S arguinents (cited above Xo. 1, p. 176, II, 17(5), Becker reported years ago.^^ Seegen's case ^^* occurred in a man 39 years, of age; Gerhardt's in a woman 56 years; and, according to Foerster's statement, these could not have been eases of genuine diabetes, since they do not occur past the middle of the twenties. Ileubel himself states that "hardly ever" has a non-diabetic cataract been known t(^ clear up. "Will anyone think hard of it, if oculists refuse to accept this fact as .proven? I hardly doubt that both Gerhardt and Seegen will aclaiowledge the possibility of their having made a mis- take. At the same time, one must not doubt but that vision was improved by Carlsbad salts. It has simply not been proven that a disappearance of cloudiness of the lens bettered vision. It is far more probable that this was due to a clearing up of the vitreous and the improvement of a case of retinitis: causes which ought not to be set aside." lu his reply Heubel drew attention to two other possibilities. Zehender's remarks did not escape him, namely, that the soft, tumescent condition of most diabetic cataracts seemed to refute the idea that there is a withdrawal of water from the lens. This thought, later taken up by Jany and myself, was answered by Heubel (one cited above), by his drawing attention to the fact "that in beginning cloudiness and in new cases the dehyration is but partial, is re- stricted to a small portion of the lens; whereas, the remainder of the lens sub- stance i-etaius its normal or possibly a reduced consistency." Heubel considers it as more than probable, that as tlie result of the withdrawal of water the changed, cloudy (ov shrunken) "lensrads," after the lapse of a certain length of time, even where there is abundant addition of water, can not be cleared up again; and after diabetic cataract has existed for a certain length of time, such manifold changes do not set in as can easily lead to a soft and watery con- sistence of the cloudy lens substance." As a fact, one must acknowledge that in soft diabetic cataract, as in any other spontaneously developing cataract, the tumescence is the first stage of cataract formation. In his first essay on this subject Deutschman pointed out tlie fact that the microscopical conditions noted in the experimentally produced salt and sugar cataracts does not coincide with those of the true diabetic cataract. True, at that time he only had for comparison the short comiuunication of Knapp 20 concerning the condition of extracted diabetic cataract. Here I must again agree with Heubel (two above). "We can scarcely form an idea as to the man- ner in which diabetic cataract develops by examining a diabetic cataract in its latter stages." There is always this difference, the experimentally produced diabetic cataract develops acutely, whereas the diabetic cataract develops in 19 Pathologic and Therapie, p. 272. 19a Der Diabetes :Mellitus. Leipsig. 1870. p. 212. 20Bericht uber ein siebentes hundert Staar oxtractionon. Arch. f. Opthal., Bd. XII, p. 49. 229 a chronic manuer; hence, it seems que^^tiouJlble to lue, though it would he pos- j^ible to examine microscopically a developing diabetic cataract in its capsule, whether one would even be able to formulate a theory which could not be attacked. Our science is certainly deeply indebted to Heubel for the thorough and objective criticism, and the manner in which he refuted Claude Bernard's hypothesis, that cataracta Aiahctica is solely and alone due to the increased amount of sugar in the blood. In 1887, Deutschman again took up this siibject,^! and formulated the following hypothesis as to the genesis of 'this form of cataract. He states, ''Owing to the dyscrasia, the lens, which is an epithelial structure, is subject to the same disintegration as other epithelium. The lens fibres undergo the same local death as does the epithehum of the kidney, and with this death of the cells begins the anomalous process of diffusion; but the moment the lens iibres begin to die, just as in the cadaverous lens, changes follow in consequence of the processes of diffusion, and cloudiness and tumescence of the lens follows. Hence I assume a primaiy death of the lens, which is an epithelial structure, in diabetic cataract. This must not necessarily be a total death; a partial death is sufficient to permit of a change in the process of diffusion. I am opposed to the theory of "the withdrawal of water from the lens." Likewise, Leber, by demonstrating that the fluid media in diabetes have an alkaline reaction, has refuted Lohmeyer's hypothesis,^^ that sugar in the aqueous and vitreous becomes changed into lactic acid, and the action of this leads to the cloudiness of the lens, hence we are as far today as ever from finding the intermediate link between the pathological condi- tion in which sugar is found in the nutritive fluid and the cloudiness of the lens. In the case of the diabetic cataract, we are no fai-ther than in other forms of constitutional cataract. There is an entire series of constitutional diseases, in which the con- stitution of the blood and lymph is altered, hence in which the lens receives an abnormally constituted nutritive material, which in some cases leads to cataract formation. Diabetes mellitus belongs to this class of diseases. PROGNOSIS OF CATARACT OPERATIONS IN DIABETES. •'•Even at the present day some operators look upon operations for cataract in diabetic patients as offering a poor prognosis. This is evident from the oft- 21 Pathologisch-Anatomische Untersuchungen Augen von Diabetikern, nebst Bemerkungen uber die Pathogenese der Diabetischen Cataract. Graef Arch., XXXIII, Bd. 2. 1887. 22 Beitrag zur Histologie und Aetiologie der Erworbenen Linsenstaare. Zeit- schrift fur Rationale Medicin., N. F.. Bd. V. p. 99. 1854. 2 30 repeated printed statement, "Luckih- operated." As is well known, Von Graefe was very guarded in his statements, and though others, as well as myself, have pointed out the fact that the incision even in very emaciated diabetic patients, heals very kindly, nevertheless, Jany advises, after a peripheral incision, the extraction he made by suction subsequent to a pre- liminary discission. But if any one will read Jany's description of his four cases operated in this manner, he can only conclude that eyes which can undergo such manipulations are really less vulnerable than healthy eyes in which an ordinary senile cataract has developed. From a large number of experienced operators, I have been privately informed that, just in diabetes, an unusually good process of healing follows. It is possible that the presence of sugar in the lymph causes the edges of the wound to be- come rapidly agglutinated. The only possible complication (where the operation is correctly done) is an iritis. This has occurred once to me; also to Horner, and likewise to Leber. Snellen writes to me, "I often find the pigment at the edge of the pupil very loose, as in macerated eyes." I (Becker, "Pathologie and Therapie," p. 272) before this time had drawn attention to this fact, namely, that in cases of tumescent diabetic cataract, the pigment around the edge of the pupil is very broad, and that even after an iridectomie the same condition is noted along the edges of the colo- boma. This peculiar condition of the iris, and the hemorrhages into the vitreous, even though extremely slight, indicate that a diabetic cataractous eye is not only a diseased eye, but possibly also explains the occasional occurrence of iritis after an extraction." There is another circumstance to which I desire to call attention. In the literature on this subject I find four cases reported, in which a few days after a cataract extraction, the patient died of diabetic coma. One ought to tell the relatives, as well as the patient, of the possibility of such a termin- ation, in consequence of the excitement incident to an operation and the dietary restrictions which become necessary. E. CATARACTA SENILIS PEAEMATURA. Between the soft cataracts of youth and the senile cataract, a form of cataract develops which occupies a mediam place between the two forms, both as to the time of its development and its seat in the middle of the lens. The aetiology seems to be closely linked with a general reduction of the nutrition of the body. Foerster considers the cause of the cataract formation to be a premature marasmus of the body. He also draws atten- tion to Hogg's statement of the frequent coincidence of urethral stricture and hypertrophy of the prostrate with the marasmus praematuris, 231 (among 50 patients, he found IT cataract cases). However, this does not prove an exact relationship between the two. There is, likewise, a total absence of symptoms by means of which one may with certainty recognize tlie premature marasmus or premature senility. Up to this time, it has not been possible to do more than make some general statements. Never- theless, Becker states, he has attempted to make a diagnosis of such a cata- ract from the manner of its development. CATARACTA (SKNIIJS PKAEMATUEA) NUCLEATMS. This form of cataract characterizes itself by^ developing in the nucleus of the lens, between the fortieth and fiftieth year, a time of life when the sclerosis of the nucleus of the lens is already far advanced; and this cloudi- ness gradually extends into the transparent cortical substance. It has a peculiar white, almost milky, color. This cataract, at an exceedingly slow rate, finally becomes a total cataract. The individuals show in their gen- eral appearance that their health has been disturbed for a long time. They are people who have been reduced by general marasmus, disease, excessive bodily exertion, many and difficult labors, material want, grief, and care; and frequently the clinical history shows that the patients (women) have suffered from hysterical convulsions. Becker states that he has only been enabled to examine teased speci- mens of extracted cataracts of this form, but has not been able" to discover any distinctive peculiarity. A positive judgment must be withheld until a complete eye containing such a cataract can be examined. In his "Path- ology and Therapie," ^3 he suggested, that possibly a chemical examina- tion might throw some light on the subject. He further suggests ^^ the possibility that, in contradistinction to all other conditions, there has never been a true formation of a nucleus in a lens which becomes diseased in this manner. It would, then, not be a 'difficult matter to understand how, owing to this exceptional condition of the lens, there should follow a peculiar cataract formation. Without in such cases being able to demonstrate a diseased condition of the nutritive fluids of the entire body, (since we find neither albumen nor sugar in the urine), we might look upon the general marasmus of the en- tire body as the cause of a failure to form the nucleus. The subjective symptoms are those of so-called nuclear cataract. The prognosis is not as good as in simple senile cataract. It is not dependent, even partially, on the general condition of the individual, nor on the general tendency of 23 S. 73, p. 270. 24 S. 73, p. 270. 232 the healing of wounds; but on the fact that the outer non-cloudy lamellae of cortical substance necessarily remain behind in the eye, or are reinoved with difficulty. In no other form would Von Mutter's proposal— to punc- ture the capsule, so as to hasten ripening of the cataract — be as applicable as in this form. In such cases it would be worth the attempt, in advanced cases, to practice discission. At the present day, no doubt, artificial matura- tion would be practiced. SENILE CATARACT. CATARACTA SENILIS. As the name indicates, this form of cataract occurs in the aged, and as a rule one should hesitate to designate a cataract as senile if the patient has not passed the fiftieth year. It is not correct to state that an earlier ageing of the entire body would predispose to senile cataract. There are no observations reported where in so-called "youthful aged ones" an earlier sclerosis of the lens occurred or developed more rapidly than under normal conditions. Just as far as the sclerosis of the lens extended at the time the cataract formation began, just so far will the lens remain as good as unchanged dur- ing the entire time those processes take place which are associated with and take place during cataract formation. In consequence, after extraction we find, even in the most varied forms of senile cataract, that the nucleus is bi-eonvex, more or less intensely yellow, or even red; always transparent, but not eataractous. Both Malgaigne and Foerster pointed out the fact that in senile cataract the cloudiness develops first in the cortical substance, but this did not receive the deserved recognition. In the second part of this work, the pathology and the most important forms of senile cataract were so exhaustively considered that a short resume of the clinical data at this point will suffice. The very first recognizable signs during life, of a beginning senile cat- aract, are the very delicate fissures in the deeper portions of the cortical substance, which totally reflect the light. These are followed by the '"riders," which develop in the equatorial region. These cloudy striations are due to the presence of a chemically changed fluid which accumulates in the interspaces as the result of processes of diffusion going on between this fluid and the lens fibres. This fluid had an index of refraction differ- ing from that of the neighboring lamellae. The cause of this, formation of interspaces is to be found in the pathological shrinkage of the nucleus, which seems to be a preparatory condition to the formation of catiiract. As a rule these interspaces make their first appearance in the cortical sub- stance, in the equatorial region, because in the region of the poles both 233 capsule and corlc.x oin more casil) follow ilic shiMiikino- nucleus than along the equatorial zone, ulicic the zoinil.i of zinii exerts traction in an opposite direction. As a result of (lilTii.-ioti between tliese spaces and the contents of the fihres, the latter >iinci- changes which lead to molecular disintegra- tion. During the lime these processes are going on, pos>il)ly cvi'u preceding them, without exception, hyperplasia of the capsular epithelium is pro- gressing, which is looked npon as an atrophic liyperplasia. The general picture which these striated opacities in the cortical sub- stance present at this time, whether observed by the direct illumination with the mirror or by focal illumination, is always that of the well-known arrangement of the lens fibres. The careful observation of this gradually developing total opacity of the cortical substance which surrounds the sclerosed nucleus, has led oculists to a series of names which designate the condition of the cataract. As long as the above anatomically described condition persists and but few cloudy striations appear in the periphery, either in front of or behind the nucleus, one speaks of a beginning cataract (rafaracla incipiens). Where this cloudiness has advanced further, we use the expression, "unripe cata- ract," (caiaracta noncluin mainra). Although there can be no sharp line of demarcation between these two stages, nevertheless they can be kepi apart by speaking of caiaracta incipiens as long as the greater portion of the cortical substance is not cloudy. When the entire cortical substance has become totally cloiuly. we speak of caiaracta matura. At times, a further distinction is made: a stage immediately preceding that of ripe- ness is described as cataracta maturesrcns. The molecular disintegration of the lens fibres is accompanied by a tumescence or swelling of the lens, due to the taking up of water, and this process may go on more or less rapidly. This may proceed so rapidly and the polar diameter of the lens so increase, as to become evident to the naked eye; and press the iris for- ward, so as to lessen the depth of the anterior chamber. This taking up of water is followed by a giving ofT of the same: the tumescence, by a reduction in volume. If from the depth of the anterior chamber one can judge that the size of the lens is etjual to that of a normal lens we call this a caiaracta waliira. when this has fallen below the normal volume we speak of an over-ripe cataract, caiaracta hi/pennalttra. The stage of ripeness is recognized, on focal illumination, by the sign-, that one can no longer recognize dark sectors: and on using the op- thalmoscope. even when the pupil is dilated, we no longer get a red reflex from the fundus. One must, however, direct attention to the most anterior lamellae, since these are of the greatest importance. Owing 334 to the extreme thinness of the capsule of the lens, the pigmented edge of the iris will seem to lie in contact with the lens when the cortical substance is totaJly opaque. If transparent cortical substance is still present behind the iris, on focal illumination a black interspace will appear between the pupillary edge of the iris, and the most anterior lamellae which reflect the light. This is known as the projected iris shadow, and by this means one can determine how much cortical substance still remains non-cloudy. The ancient operators observed, that where the lens had become completely cloudy, it would, comparatively speaking, be as easily removed from its cap- sule as a ripe fruit be shelled out of its pod; hence the expression, "ripe cata- ract. And this is found in the writings of Baron Wenzel, the father (1. c, p. 14); also of Percival Pott, 1779 (Morgagni, XIII, 18). It appears after the expres- sion "ripe cataract" had for a time fallen into discredit, it again came into jgeneral use, and in reality there can be no objection raised to its use, if we associate its use with a well defined condition, such as was described, and for which we are indebted to Arlt (1. c, p. 260). Our knowledge concerning senile cataract has advanced in more ways than one. We are indebted to Priestly Smith for one important step for- ward. He succeeded in demonstrating that the cloudiness in the senile lens is preceded by a reduction in its volume. This shrinkage of the nucleus, which I had looked upon as proceeding to a like degree in all sim- ilar lenses, and which I had utilized to explain the occurrence of the first fissures and splits in the equatorial region as the result of the fixed position of the equatorial region in consequence of the zonula zinii, is now shown to he developed to a greater degree in those lenses which later on lecome cata- radous, than in those which remain clear. ' On pages 66, 67 it has been shown that the nucleus of a senile cataract has a different chemical constitution, than the senile nucleus of the non- cataractous lens. Hence one might assume that the cause of the increased shrinkage of the nucleus is due to its abnormal chemical constitution. But since this has only been proven in the case of cholesterine and only as ex- ceedingly probable for albumen, (Cahn, Knies); hence it yet remains, to make the same chemical analyses of the nuclei of senile non-cataractous lenses, so as to compare the two. "According to Jaeobson and Cahn, we may assume that both the cho- lesterine and the modified albuminous substance are not carried into the lens from without by the nutritive stream, but are developed from the albuminous substances which are normally present in the lens. Since the changes which take place begin in the nucleus of the lens (hence in its oldest and inmost lamellae), and no doubt proceed, just as do the normal processes of sclerosis, very slowly; hence we may draw the surprising con- 235 elusion that the preparation for the formation of senile cataract has been going on for a long time. That is, the beginning of the abnormal chemical changes in the nucleus of the lens, which are a departure from the normal sclerosis of the ageing lens, and ivhich lead to the senile cloudiness of the lens, do not coincide in time, to the period when we observe the first cloudiness at the border line between nucleus and cortex, but precede this by many years. Whether or not a person shall become affected with cataract in his sixtieth year, in all probability is dercided at forty. Stress has already been laid on the fact, that senile cataract always occurs on both eyes, though one lens may be affected somewhat later than the other. The cause of this must be sought in an altered constitution of the nutritive fluids of the entire organism. True, we do not as yet know what this something is. This is probably to be explained by the fact, that we have not as yet sought at the proper time or place, when this preparation for the future cataract forma- tion is going on. It is just possible that these departures from the normal, which later on lead to cataract formation, might be found in the lenses of persons just reaching the age in life when presbyopic functional symp- toms manifest themselves, and just in those lenses which apparently one would suppose would remain perfectly clear, even in very advanced old age. It is certainly more than a mere coincidence that just those processes, which take place in the nucleus of a premature senile cataract, and which differ- entiates it from the senile cataract, should occur just in these years, when we suppose this preparation for the formation of a senile cataract is taking place." The question of hereditary predisposition to cataract, might likewise be elucidated, if we would try to discover a common constitutional pe- culiarity. If one finds a family, as I have, in which the grandmother de- veloped double senile cataract without any known complication, at 57 years, the father at 48 years, and the son at 26 years, one can not help thinking that there must be some hereditar}' constitution cause. The subsequent taking up of water is not inconsistent with Priestly. Smith's assertion. The taking up, is to be looked upon as a process of diffusion going on between the fluid media of the eye and the already partially cloudy, hence chemically changed, lens. This is looked upon as the second stage of senile cataract formation. THE AETIOLOGY OF SENILE CATARACT. As we have seen, there is a chemical and a physical difference between the nucleus of a sim- ple senile lens and the nucleus of a senile cataract. As a result of this chemical difference, as Priestly Smith has shown, there is an increased shrinkage of the nucleus of the lens, which later on is to be attacked by cataract, and this, on the other hand, has given additional support to Becker's 236 theory. The anatouiieal proof of the hyperplnsia of the intracapsular cells which invariably accompanies the formation of senile cataract, aside from the above, is in accord with the theory of shrinkage. ALBUMIN URJ A AS A CAUSE OF SENILE CATARACT. "Deutschman, since he found albumen in the urine of a large pei'cont- age (33 per cent.) of patients suffering from senile cataract, attempted to set up a s])ecial form of cataract — cataracta nephrUica. After attention was drawn to this fact, the percentage in my clinic also rose; thus, in 1881 it was 2 per cent., whereas in 1882 it was 18.8 per cent. Though chronic nephritis does occur frequently in old people, this does not by any means prove that there is a causative relationship between the two. And if the above explanation, as to the time when the basis is laid for the later devel- oping cataract, is not totally erroneous, the mere fact that both these dis- eases are present at the same time, does not by any means prove a causative relationship between the two." "Although chronic nephritis and albuminuria belong to the constitu- tional diseases, which, as we know, may at times lead to deep-seated antl almost always, disease of both eyes, and which may easily affect the consti- tution of the vitreous, for the present, at least, the causative relation be- tween chronic nephritis and cataract can not be looked upon as proven." ATHEROMA OF THE C'AKOTID AS A CAUSE OF CATARACT. "Michel's statement,-^ "that atheroma of the carotid is a very intimate causative factor in the production of senile cataract, as well as in the pro- duction of cataract in one eye," seems to find but slight support, in fact. Based on a collection of the cases reported, and a few experiments of his own and clinical histories, some with, some without, post mortem exam- ination, Michel assumes as proven, that pronounced interference with the circulation in the carotid may cause very great interference in the eye on the same side; and he further believes that where the circulation in both carotids is interfered with for a long time, this will gradually lead to an increase of those pathological processes which characterize themselves by interference with the nutrition of the eye. Michel says atheroma of the carotid is such a disease, and such a nutritive disturbance leads to cataract." "Michel goes on to state, "owing to the rigid walls of the arteries, the pulse waves are not carried sufficiently far, and in consequence of the loss 25 Das verbalten dcs Auges bei storungon ini Circulationsgebiot der Carotis in Beitrago zur OitTli.-iliiioloiiif .-ils F('st;ia1i(' fur I-'ricdi-idi HonitT. Wifslcidoii, ;881. 1 237 of elasticity, the column of blood is not propelled onward. Hence, a certain slowing vp of the niorenienf of the hlood foUoirs, and, as a result, changes of nutrition follow. It is easily seen, that the explanation is based on a false premesis, for ceteris paribus, a column of fluid will rise, not slower, but more quickly in a rigid tube; but when fhe propelling force acts periodically, the column will not ascend continuously, but intermittently. When fluid is forced into a tube periodically it will also flow out periodically, since the same amount of fluid must flow out at the one end of a tube as is forced in at the other end, under a certain degree of pressure.^^ However, in rigid tubes, the changes in the degree of pressure is greater than in elastic tubes. Where the outflow is not a free one, the conditions are not the same. Where the interference is very great, the advancement of the column of blood is slowed, and the blood in the left heart is under heavier pressure. In atheroma, owing to the diminution of the lumen of the smaller arteries and capillaries, this resistance is increased. Whereas an atheromatous degeneration of the vessels of the eye, whether this be combined with an atheroma of the caro- tid or not, would influence the nutrition of the eye, more especially the lens. ''However, notwithstanding the want of a proper explanation, the con- nection between atheroma of the carotid and cataract is still pointed out, hence I have had the last fifty-three patients taken up at the clinic for spontaneously developed cataract examined in tliis regard in order to test Michel's statements. I was all the more induced to do this, owing to an experiment known to me which appeared to have some direct bearing on the connection between one-sided atheroma and cataract on the same side, and which seems entirely to have escaped Michel's notice. Heubel ^^ writes: "One can easily bring about a cloudiness of the lens, truly only after the death of the rabbit, if one injects a concentrated sugar solution in the peripheral end of the common carotid. Death nearly always follows im- mediately after the injection, but simultaneously or a few minutes later one always observes the lens on the same side assume at first a faint, grad- ually-increasing cloudiness, and hence one may assume that this form of cataract develops just as it do€S in the rabbit." "Perhaps I would not have decided to place my negative results oppo- site the positive results of Michel were it not for the recent publication of a dissertation by Marion von Karwat, written under ^lichel's direction,-* and which indicates that even at the present day he holds fast to his conclu- 26 See RoUet, Physiologie der Blutbewegunjr in Herman. Handbuch der Physiologie. IV. 1. p. 177. 27 Quoted above. 1, p. 164. 28 Beitrage zur Erkrankung des Auges bei Carotis atheroai. Wurzburg. 18S3. 238 sions, and if according to an observation of Mooren's he did not look upon this as a proven fact. In his "Funf Lnstren Opthalmologischer Wirk- samkeit" he says (page 197): ''Michel's beautiful experiments have proven to us the connection between the development of cloudiness of the lens and sclerotic (atheromatous) changes in the walls of the carotid." Such a thoughtless assent on the part of Mooren becomes all the more con- spicuous, because Mooren^s gtates that atheroma of the carotid is the cause of senile cataract. Michel, however (p. 45), purposely avoids stating that the condition of affairs are such, but that there is a direct connection be- tween cloudiness of the lens and atheroma of the carotid, but not that where this condition exists, there is also a like change in the vessels of the choroid. But he distinctly states: "In not a single case where it was pos- sible to make an opthalmoscopic examination after an extraction could changes be found in the arterial vessels of the retina." He further points out the fact that if this were the case, the functions of the eye would suffer more frequently than is the case. In order that this examination should be conducted in the most per- fect and reliable manner, I begged of Prof. Adolf Weil to conduct the same. He was kind enough to do this with the greatest conscientiousness, and has permitted me to publish the results, together with his views on the subject. •'Michel's ideas have awaliened a number of priori thoughts. In the first place, it is difficult to understand how, with the existing anastomosis between the two carotids and the vertebral arteries, an atheromatous change in one car- otid artery, the vessels of the eye itself being normal— and such he expressly states to be the case— could bring about disturbance in the lens. It is also remarkable that though he continually speaks of a connection between cloudi- ness of the lens and sclerosis of the carotid, he fails to state whether he has reference to the common carotid, the internal or external. The internal carotid, even in thin people, is not accessible to palpation; hence, we must assume that his remarks refer to the carotis communis, or the external. The relative fre- quency of atheroma in young people, the isolated, more especially the involve- ment of the carotid, the occurrence of arteriosclerosis on one side, the absence of all other symptoms which would point to atheroma of the carotid in which we find true aneurysmal formation. It is, however, as unknown for an aneu- rism of the carotid to bring on a cataract. Notwithstanding these objections, it nevertheless seemed proper to determine by renewed investigation whether these two conditions really existed at the same time, though no direct connection between the two could be proven. For this purpose the circulatory system of fifty-three cataract patients was examined, without the examiner knowing any- 29 0pthalmish Beobachtungen. Berlin, 1867. 239 thing concerning the special condition of the cataract. (As to wiiich side the cataract was confined, whether it was on one or botii sides, etc.) Examination was made of the heart, the brachial and the radial arteries, and the portion of the carotis communis and externa which were accessible to palpitation, to de- termine whetlier the carotids were atlieromatous or not. This palpitation, how- ever, is much more difficult than in the case of the radial or brachial arteries, which can be more easily encompassed and compressed. Judgment as to whether the carotid is more or less tortuous, or whetlier the pulsations are more marked, must surely be more uncertain, unless the degree of change is very great or unless comparison between the right and left offers a very great difference. It must, however, not be forgotten that even under normal circum- stances the right carotid communis is often thicker than the left. And a moder- ate dilation of the upper end of the common carotid— a sort of bulb— according to the general opinion of anatomists must not be looked upon as pathological. Every experienced examiner will agree with me when I state that the width and the tension in the arterial tube, as well as the height of the pulse wave, not only in different individuals, but even in the same individual, varies greatly at different times. Hence, one will only be able to diagnose with certainty changes in the walls of the arteries (thickening and rigidity), when the anom- alie of width and tension of the arterial tube, as well as the pulse wave, ex- ceed a certain degree." The following table gives the results of Weil's Examinations: Atheroma of the Atheroma of the it Carotid without Carotid with Heart td Heart Disease. Heart Disease. < Disease u < < ^E = ^ without Age. z On the side Not on the On the side Not on the SS Athero- ft, :- ^8 of the first side of the of the first side of the ^5 ma OF the diseased first dis- diseased first dis- Carotid. lens. eased lens. lens. eased lens. 1-10 1* 2* 3 3 11-20 2 2 •2 21-30 1* 1* 2 2 31-40 1 1 1 41-50 2 3 5 3 1 1 51-60 6 8 14 11 2 1 Hl-70 8 9 17 8 2 4 1 2 71-81 1 7 8 2 2 1 1 2 81-90 1 1 1 Total... 22 31 53 32 6 7 2 1 5 1. The asterisk marks the four cataracts which occurred only on one eye. 2. Both of the boys' eyes eleven and twenty years, had zonular cataract. 3. The man of thirty-eight had albuminuria. 4. Of the five patients between forty and fifty years, three had nuclear cata- ract (Becker), one had albumen in the urine. One was a rapidly developing tumescent cortical cataract, without the presence of sugar in albumen. 240 "Hence, in but sixteen cases was there any disease of the carotid to be found, whereas in thirty-seven cases this was not the case. Of the sixteen, but six had atheroma on the side of the lens which first became cloudy; in ten this was not the case. This, however, only occurred in individuals who had passed the fortieth year. In the four cases with cataract on one eye, the condition of the circulatory apparatus, especially of the carotid, was found to be normal. It would hardly seem necessary to examine into this table any further. This much, however, must be patent to every unbiased reader; namely, that both Michel and Mooren have gone too far. in that the former assures us that there is an aetiological connection be- tween the so-called senile cataract and the one-sided cataract of unknown aetiology, and that atheroma of the carotid offers a satisfactory explanation for this cloudiness of the lens, and the latter in giving assent to the utter- ance." "Hence, I find myself placed in the peculiar position of defending my position against Mooren by Mooren's own statements made many years ago, and in which he expressed the correct views concerning the aetiology of cataract (1867)." "In the above I have given my reasons which prevent me from accept- ing the views of Deutschman and Michel concerning the genesis of certain forms of cataract. There is possibly some basis of truth in both, for chronic nephritis is frequently accompanied by disease of the smaller blood-vessels and capillaries. According to some authorities this disease of the blood vessels is the cause of the nephritis. Likewise, even though Michel can not convince himself of the fact, we may assume that w^here there is ather- oma of the carotid there is likewise disease of the smaller arteries, especiallv the smaller branches of the opthalmic. This pathological condition of the vessels of the uvea would then offer us the intermediate link in the chain between cloudiness of the lens on the one hand, and nephritis' and atheroma of the carotid on the other. As I have already shown, both diseases may then be utilized to explain the occurrence of cataract even on the one eye, if statistics made on a large scale once demonstrate the more frequent occurence of either two. And here it is proper to point out the important fact, that in the microscopical examination of cataractous eyes more atten- tion might be given to the condition of tlio choroidal vessels." In his Pathology and Therapy (Sec. G7, p. 261) Becker draws attention to some interesting points concerning the aetiology of senile cataracts. He quotes Walter and Arlt, who claim that eyes with a blue iris are more frequently af- fected than those with a brown iris, for, says Arlt: "the pigment in the iris prevents the lens from being acted on to sO great a degree by the light.'" Though Yager, Arlt. and llasner conclude that more men are affected than women, in 241 proportion of 4.3, Beekor .oiicliKlfs that ilioujili this iii;i.v appiirciiil.v he ;i I'.ict, lie govs on 1o state: "Mmiiv of iIm- ii;iii«'nts taken np in clinics come a long distance to be operati'd. Tlic most ol tliese are poor people, so that the ex- penses of such a journey are met under great difficulties. Hence, since vision to n)an is of greater valtie tlian to won)an. since lie must carry on his o<-cupation. in order to earn money to supply the necessities of life; hence, this fact alone will exi»lain why it is that more men are operated than women. It has already heen stated that cataract occurs with greatest frequency in the young and in the aged, and it is worthy of note that after the seventieth year there is a very marked decrease in the proportion of frequency. In 882 cataracts occurring between 25 and 85 years. 626 occurred between 45 and 70 years (Arlt). The majority of senile cataracts occurred between the 50th and 70th year. Station and occupation do not appear to exert much of an influence. Cata- ract has been observed in the English royal family. It is probable that King Wenzel of Bohemia had a cataract. King Don Juan of Aragon was operated by Rabbi Akiabar. of Lerida, for cataract in 146829a Gladstone, the great English Premier, was successfidly operated in 1895 by Nettleship. But if senile cataract occurs but seldom among the rich and notable, this may be explained by the fact that this class forms but a small percentage of the entire population. Dr. Meyerhoefer30 draws attention to the fact that cataract develops in glass makers. In an examination of 5(X) persons he found opacities in the lenses of 59, and 4 had total cataract. This he attributes to the excessive heat of the oven, and the exceedingly profuse perspiration, which withdi-aws large quantities of fluid from the body. The subject of heredity had already been touched upon. A long list of ob- servers could be mentioned who have recorded cases proving that heredity plays an important role. Among these we find the names of Beer, Richter, Arlt, Dupuytren, Sanson. Streatfield, Susardi, Dyer, Roux, Maunoir. Sichel, Ullmann, Bartard, Hirschberg, Armaignac. Galezowski and others. Carreas y Argo 31 has given us a complete review of this subject, and concludes, that the liereditary cataracts by preference attack individuals belonging to the same sex, as the one so first affected; further, that the cataracts do not always, as many authorities contend, develop at the same time of life as in the previous generation, but quite the contrary at an earlier date, and may even develop at birth. Galeowski places the hereditary percentage at from four to tive per cent. It is also noteworthy that the heredity is not always continuous; it may skip a generation. Galeowski,32 in the course of nineteen years among 128.000 patients, noted 29a I'llersperger A. F. ()., 2, p. 272. 30 Zur Aetiologie des (Jrauen Staares .Tugendliclier Iiidividuen bei Glass macher. Zehender's Monatsblatt, 1880. 31 Hirschberg's Centralblatt. August, 1884. p. 406. -Von der Erblichen Cata- racten und ihrer Ubertragung auf Individuen des gleichen Geschlectes." 32 De la marche el du prog des Cataract. Reciveil d'Opth, May, 1885. 242 4.77G cataracts (1,646 senile, 199 traumatic, 1,680 cortical, 231 congenital. 130 capsular, 94 diabetic. 128 choroidal). He ascribes the principal aetiological fac- tors, aside from trauma, to heridity, gout, age and the various diseases of the choroid. G. CATAEACTA HYPEEMATURA. Subsequent to the stage of ripeness of senile cataract, one of two dia- metrically opposite changes may take place. Either as a result of the giving off of water the cataractous mass may become smaller and inspisated — cataracta liypermatura reduda — or the cloudy substance becomes fluid and the nucleus sinks to the bottom of the sac, during which process chol- estearin, and possibly fat, are formed, without great development of drusen, capsular cataract, cataracta Morgagniana. 1. CATAEACTA HYPEEMATUEA EEDUCTA. It appears that in a large number of cataracts which have passed the stage or ripeness, the giving off of water continues, and the inspisated cat- aractous mass consists of degenerated lens fibres. The cataract has the appearance of a drop of dried carpenter's glue, and though the radiating striations do not entirely disappear, these are now associated with a number of quite regularly arranged transverse striations. When the pupil is di- lated the appearance is very similar to that of a spiderweb. About this time the cortical substance, and with it the entire cataract, may again be- come transparent. We may assume this, since at times patients who are waiting for the second eye to become blind before coming for operation, observe that they are again beginning to see something with the first af- fected eye (Arlt 1, c. p. 260.) The lens may remain in this condition for years. In course of time, however, a capsular cataracta develops. These are the cases of true phako scleroma. As far as microscopical examination goes this has shown the presence of fatty drops, so-called myeUn, cholestearin plaques, calcareous granules and pieces of lens fibres. 2. CATAEACTA HYPEEMATUEA FLUIDA. C ATE ACT A MOEGAGNIAXA. In another series of cases we find that though the volume of the tumescent cataract is reduced below that of the normal volume of a senile lens, it does not become inspisated, but becomes even more fluid than it was during the stage of tumescence. Under these conditions it becomes exceedingly difficult, and in. some cases it is impossible, to get anything 243 like a distinct reflex of the nucleus on focal illumination. The cataract has a greyish yellow color, and one can no longer detect any striations. A different picture can be produced by having the patient bend his head for- ward for a time. After a time one will then be enabled to observe a brown- ish, more or less circular disc, which will disappear if he bends his head backward. These changes are due to the fact that the nucleus is floating in a fluid cataractous mass, and hence can. change its position. Being specifically heavier, it sinks to the floor when the head is in the upright position, and changes its position with the relative position of the head. Such nuclei have a very similar likeness to a lentil, are perfectly smooth and transparent. Pathologie and Therapie, Sec. 68. p. 204. H. Mullcr (1. c, p. 263) had the opportunity of making an anatomical e-xamination. He says: "On opening the capsule, a thin, yellowish pus-like fluid escaped, which seemed to contain only very delicate pale molecules. A dense cloudiness followed the addition of acetic acid, and in excess this cloudiness again disappeared, a few flakes remaining. Under the microscope this pasty fluid was found to contain myelin, fat and cholestearin. Page 265. I have not been able to positively determine the name of him, or for which particular variety the name C. Morgaoniana was first used. Mor- gagni (1. c, Epis. 63, 6) described a case which may have led to the use of this name. He gives the following description of the eye of a man 40 years of age who in youth had had smallpox, and who acquired a corneal cicatrix, in con- sequence of which he was nearly blind. "Scleroticam igitur cuma tergo vix incidere coepissem: limpida aqua statim effluxit, it quam pass magna vitrei humoris videri poterat al)iisse, cum pass reliqua, natural! quadantenus similis, annexa, ut solet, crystallino humori restitisset qui illam cum retrosum traherem, secutus est. Is parvus erat secundum om nes dimensioues. crassit autem vel paulo minor quam ejusmodi oculo conveniret. Facie anteriore in medio cral albus, siucti per corneam transpexeram, caetera albidus; et cum inter digi- tos leviter comprimerem, mollis. Cumvero ejus tunican incidere coeppisem; continuo apua erupit. nihil purulenti habens, imo pura, el limpida, eague copia pro parvitate crystallini. ut hie statim ad multo minorem crassitudinem redig- eretur. Quidquid de substantia ipsius reliqum fuit. lentls pristinam figuram re- tinuit; el cum per diametrum disse cuissem; utraque sectio quandam quasi seriem mimarum nigrescentiam particularum ostendit. quae per medium recta ab uno ad alterum sectionio ducelxatur. cum ubrique alibi color absolete albidus appareret." Aside from the fact that this is the first report of a case of detachment of the vitreous, one could call this a case of cataracta Morgagnia, as we understand it today. Here we find a capsular cataract, a fluid corticalis, and within a regularly floating nucleus. In one point only does it not tally: the fluid which escaped was clear not cloudy. I could find no reference to this case by authors 244 whicli would tend to show that they based their writings on tlie above case. Jamin (1. c, p. 243 and 264) describes two cases, in one of which the nucleus was found floating in a milkj' cortical substance, the nucleus being a regular brown, the other showed a greyish blue, slimy corticalis. after the evacuation of which a perfectly transparent nucleus remained, by means of which tlie patient is said to have been able to read and see small objects without the use of glasses. In a foot note, speaking of the first ease, Jamin says (1. c, p. 244) that the cloudy fluid was simply altered humor Morgagni. and that in the sec- ond case the humor Morgagni was simply cloudy. The statements of Morgagni in reference to this matter are found in his "Adversaria Anatomica Sexta Anima Adversa, LXXI," and reads as follows: "Deinde eadem tunicam in vitulis etiam. bobus(iue sive recens, sive non ita recens, occisis perforata plures auimadverti illico humorem (|uendam aqiieum prodire; quodet et in homine observare visus sum." Himly (1. c, p. 229) bases his statements on the writings of Jamin, and is of the opinion that Morgagni was the first to differentiate between Morgagni*s cataract and milk cataract, and also accepts the name for the second condition. Beer (1. c, p. 292) likewise uses the one name for both varieties. Notwithstanding this I would have doubted the exist- ence of such a condition had not Arlt (1. c, II. p. 257) described a case belong- ing to this variety. Owing to its rarity I will give an abbreviated quotation. A girl 9 years of age had cataract on both eyes, and these had developed six to eight weeks subsequent to birth. The cataracts, which were yellowish grey in color, with here and there greyish opacities, were about 1 mm. removed from the iris, and the patient saw sufficiently to get about. On dilating the pupils a milky fluid was disclosed in both capsules surrounding both nuclei, not unlike a hypopyon. The nuclei changed their position with every movement of the head. For two years the amount of vision remained unchanged. In the eleventh year the discission was made. After incision of the capsule a quantity of cloudy fluid escaped, and the pupils appeared black. The child could now recognize the fingers of the hand, a handkerchief, etc. On the twelfth day a decided reaction set in— hydro meningitis. The lens gradually became cloudier and more voluminous, and after three months was totally resolved. Arlt spe- cifically designated this as a cataract Morgagni, though his description is ex- actly that of a cataract Morgagni. as we have described it in the aged. All the late authorities use the name only for those cases where the cortical substance becomes fluid in advanced life, and the hard nucleus sinks to the bottom of the sac. If we wish to do justice to both varieties, one is compelled to include under the name cataract Morgagni all those ca.ses in which the cortex is fluid and the nucleus hard, aside from the color of the nucleus, which in age is sclerosed, whereas in youth this is soft and transparent. A later examination is by Knies, (p. 182), wlio examined a case in which Horner had made the extraction; the case of a woman forty-three years of age. "The entire -anterior capsular epithelium was normal: in tV.e equatorial region there was an excessive prnlifcralioii and many of the well- 245 known large, romul vesicles, partly eonlainiiig nuelei. other new formations, sueli as we are accustomed to find in the so-called crystalline pearls. As yet we can not state whether we are to seek the cause of the Morgagni's cata- ract in a perverted crystalline pearl formation in which the epithelial cells have undergone a mucoid or si miliar change. "The nucleus shows no change different from that observed in other cataxacts; the fluid between it and the capsule was coagulated by the hardening fluid, (alcohol and Mul- lers fluid) ,and consisted largely of myelin globules and detritus, in which nothing special could he recognized." If we will designate every cataract in which the cortical substance has become fluid as a catarada Moryagtiiana, we will meet with it at every period of life, even congenitally. Only, the fluid cataracts of youthful in- dividuals do not possess a nucleus. However, in these cases one frequently finds present in the fluid an unusually large quantity of carcareous, finely granular matter, and crystals. If the eye is kept perfectly quiet for a time the calcareous matter gravitates to the bottom; whereas above, there will be, relatively speaking, a clear fluid. If the eye is moved about, the cataract assumes a milky hue. In the few cases of catarada ladea examined, just as in the firm cataracta calearea, the epithelium of the anterior capsule was found practically destroyed. In older individuals one always finds a nucleus in the fluid cortical substance. The volume of the nucleus depends on the age of the indi- vidual; the younger the individual, the smaller the nucleus. N'evertheless, the age of the cataract must be taken into consideration as a factor; for at times one does flnd a very small nucleus in old people; so that one must assume that the decrease in the volume of the nucleus is the result of maceration in the fluid corticalis. The smallest nucleus Becker extracted Avas obtained from a man fifty-seven years, and it weighed in its fresh state 0.07 grm. The normal weight of a lens of the same age is 0.24 grni., and the weight of a large nucleus of a mature cataract about 0.13 grm., so that the supposed melting away of the nucleus must have equaled about one- half in its weight. I have frequently examined the coi-tical mass, and have always found cholesterine and fat. THE CONDITION OF THE INTKACAPSULAR CELLS IN OVER- RIPE CATARACTS. Almost without exception, in cases of catarada hypermattira reduda; less frequently in cases of cataracta Mon/agniaua which have existed for any length of time, we find capsular cataracts developing. All the various 246 stages \vhieh have been described in the earlier part of this work are met uath here. I desire, however, to draw attention to a point in the genesis of capsular cataract, which was probably not sutficiently dwelt upon. If after the volume of the lens is reduced; during the time of prep- aration for the cataract formation is going on, and the epithelial cells, which have not lost their formative power, are incited to reproduction; the question might be asked, why it is, that the former method of formation of lens fibres at the whorl does not continue and proceed to the laying dawn of new lens fibres and lamellae. Undoubtedly the epithelium must have undergone a change ivhich prevents this. A normal increase is only pos- sible where the formation of new cells is distributed over the entire epi- thelial surface and where, as a result of indirect nuclear division, the new cells force themselves in between the old, and thus cause a gradual move- ment toward the equator. If we will now assume that this power to move along the inner surface of the capsule is lost to the cells, which have fallen a prey to the simple senile atrophy; hence the new-fonned cells will like- wise be retarded in this power of locomotion, and will form, at the place where they are developed, heaps of cells which in the further course of changes, gradually go over to form a capsular cataract. This loss of power of locomotion hence becomes an essential factor in the formation of a capsular cataract. This assumption is supported by the fact, that along the posterior capsule, where the hindrance does not exist, one so frequently finds a com- plete epithelial covering developing from the cells along the equator. As Knies and Muller have stated, in Morgagni's cataract one fre- quently finds the epithelium as well preserved as in other unripe cataracts. In all the cases which I examined, as well as in the cases of Kniess and Muller, the vesicular cells in the equatorial region were excessively devel- oped. It appears that, whereas Knies observed their development ex- clusively in the equatorial region of the lens, Muller claims to have seen them develop in different ways, as did Wedl, from other epithelial hyper- plasias and formations along the posterior capsule. These vesicular formations are a constant production in all cataract formations. Knies was the first who gave utterance to, or more properly speaking, recorded in literature, this thought, which is worthy of respect. Notwithstanding our total ignorance as to the cause, why it is that in one case the corticalis of over-ripe cataract becomes inspisated; in another, notwithstanding the giving off of fluid, it becomes fluid; I can not refrain from expressing the thought, as to whether it is not possible in cases where we find such excessive formation of vesicular cells, for these later on "to flow together," and thus form the anatomical basis for a Mor- gagni's cataract. 247 CATARACTA NIGRA. "The name of this form of cataract, as well as its existence, has been both variously applied and understood. Wenzel (1. c, p. 38) describes the extraction of a lens taken from an eye in which vision was very much re- duced, the pupil of which did not appear grey; so the existence of the cat- aract was doubted. A large dark-brown lens escaped from the wound. The wound healed, and vision was restored. This form of cataract he called catarada nigra. The entire description showed that he was dealing with a lens in which the formation of the nucleus extended up to the capsule without the process ever having come to a standstill. Such exquisite ex- amples, in which no cortex remains,, are but seldom encountered. They might also be called catarada hrunescens." "It would be proper to translate catarada nigra as the 'black grey cataract,' but not as "black cataract," since this latter term, even today, is used to define absolute amaurosis. It is interesting to note that in former times both the English and the French used the expression cataracta nigra synonymously with gutta serena and paralysis (?) of the optic nerve. I find it is so used by Pereival Pott;33 also by Morgagni.34 in a dissertation by Von Warnatz (Cata- racta Nigra, 1832) is found a very complete compilation of the literature on this subject. In later times Von Graefe 35 accepts the name of cataracta nigra for those cataracts in which pigment is found inside the capsule, which he consid- ers as coming from the haematin which has passed through an uninjured cap- sule. Cases belonging to this class have also been described by Von Beck. Should it become an established fact that pigment does pass through the cap- sule, it certainly would be proper to call these cataracta pigmentaire, or cata- racta hemorrhagica, rather than cataracta nigra. I can not understand how men can be such blind followers of Von Graefe as to persist in writing about the frequent occurrence of cataracts containing haematin." Since it has been shown that the nucleus of a senile cataractous lens differs chemically from the simple sclerosis of old age, the cataracta nigra must be looked upon as a senile cataract, which, in consequence of the regularly progressing sclerosis up to the periphery, is not accompanied by the formation of splits and fissures, in the most peripheric cortical lamellae. The most essential points in the senile sclerosis, as well as in the senen- scence of the lens are the following; the oldest fibres in the centre of the lens lose the serrations which they had attained during the growth of the entire 33 Remarques sur la Cataracte, Traduit de la Auglaisse par Lemoine, 1779, p. 501. 34 Epist., XIII. 13. 14. 17(;2. 35 Arch., I. p. 1.33. 248 organism, and with tlie steady increase in the index of refraction and tlie taking on of a more saturated yellow color, until finally an almost homo- genous mass is formed, in which the individual elements are scarcely recog- nizable, or not at all; and. as age advances, this process slowly, but surely, extends toward the periphery. At the same time, the processes at the whorl and along the nuclear zone become less active and consist of but few ele- ments containing nuclei. The epithelial cells become fat, and in many the chromatic substance and the nuclei are greatly reduced. The capsule becomes thicker and tougher. The farther this process extends, the more light will be absorbed, and the poorer will the vision be. where there is a moderate degree of illumination. This explains one of the causes for the reduction of vision in the aged." "It may, however, happen that, even in very advanced age, not even an equatorial cloudiness may exist — gerontoxon lentis — and the individuals have good vision. Thus I have had the opportunity of examining the lens of a man ninety-four years of age, and on focal illumination found but a scarcely recognizable yellowish reflex; whereas, on opthalmoscopic examina- tion, the lens was perfectly clear, and with a convex glass of 3 D on both eyes, ^=1% to |. "Then, again, tliere are people who see much more poorly at an earlier age — thus I have examined people who, as early as the fifties, could scarcely count fingers at one or two metres; without any cloudiness of the lens being discernable with the mirror; whereas, on focal illumination, there is a deep brownish-red reflex from the lens. Therefore, this remarkable difference in the conditions of the lens, noted during life, is due to the pathological sclerosis and saturated color of the nucleus in cataracta nigra. I have examined anatomically two lenses extracted in their capsules, and sent to me by Dr. Mittelstadt and Dr. Marckwort, of Antwerp, the diagnosis being cataractae fere nigrae. Very fine micj-oscopical sections, made with the microtome, show that the entire lens up to the capsule are regularly changed to nucleus. The whirl and nuclear zone consist of but few cells. On trans- verse sections only the nuclei appear on the inner surface of the capsule, the protoplasm of tlie cells l)eing so greatly reduced. One finds no pictures of splits or fissures in the sections. It is especially worthy of note that there is not a trace of cortical substance between capsule and nucleus. The only dif- ference between this lens and the senile lenses of the same age would be the sparse and frequently interrupted distribution of vesicular cells in the equa- torial region. Teased preparations show nothing differing from that formed in normal lenses. There was no particular avidity to the stain. About the same conditions were found in another lens received from Sam- melsohn. In the equatorial region, however, were large nests of vesicular cells. 'J'lierct'drc. ciitaracla nigra is a snccial variety of senile cataract, but 249 differs froiii the o]-(liii;irv senile lens of the <;niie ;i:ie in the patliological miclear sclerosis, which, as we have seen in the underlying basis in the de- velopment of senile cataract. TTence, the same reasons likewise apply here, which lead lis to coiisi(h'r senile calni'act as a consl ii ntional (;ataracl. CATAlfACTA CAl'STLAinS. CAFSl'LAi: CATAKACT. As we have seen, capsular cataract is most fretjiiently a sequelae of the over-ripe cataract. Jf we only waited long enough, we would find that to every lenticular cataract finally would be added a capsular cataract. The variety generally observed by the oculist is seated at the anterior pole. In the non-complicated, over-ripe senile cataract, it usually ac(|uires about the size of a medium-sized pupil. It then, as a rule, has sharply de- fined, jagged edges, and it is generally accepted that these jagged edges mark the line of insertion of the zonular fibres into the capsule. Fre- quently the capsule is folded in the portions which cover the capsular cat- aract, and in cases of pyramidal cataract, this frequently reaches the height of a millometre. These folds are a proof that this new-formed tissue has a tendency to shrink, and in this shrinkage is to be found the reason for the loosening of the connection between the capsule and its suspensory liga- ment, and this may lead to cases of spontaneous luxation of over-ripe cata- racts. This also makes possible the operation where the lens is extracted in its capsule. There are many exceptions to the restriction of the capsular cataract to the pupillary area. This is especially true of the consecutive cataracts, for it may extend over the entire inner surface of the anterior capsule, and may even extend over the posterior capsule. It is especially in these forms of capsular cataract that we so fi-C(iucntly iind tiie calcareous de- posits. The capsular cataract may remain unassociated with any other form of cataract for many years. When a capsular cataract de-. velops in advanced age, the lenticular cataract will soon follow. The pri- mary development of a capsular cataract is the purest example of what might be technically designated as an inflammation of the lens, (or hyper- plasia of epithelial cells), a true phakitis; but where this occurs, the eye is otherwise diseased, even though its exact nature be indefinite. The mere presence of a primary capsular cataract should arouse our suspicions of other complications. If Leber's theory is correct, that these epithelial cells have the function of giving the nutritive fluids their specific chemical constitution, it certainly must be evident that a diseased epithelium must of necessity finally be followed by a lenticular cataract, and likewise it must 250 not be forgotten that a diseased nutritive material (aqueous or vitreous) can stimulate the capsular cells to proliferation. , True capsular cataract does not only occur congenitally as an anterior polar cataract, but it may be acquired primarily at any age of life. CHAPTER XI. TRAUMATIC CATARACT. CATARACTA TRAUMATICA. Mechanical disturbances may lead to an injury of the lens, and thus secondarily lead to the development of traumatic cataract. This may be due to the action of a blunt force, as a concussion, or as the result of a puncture, accidentally; or of an incision, intentionally produced, as where discission is practiced. A. CATARACTA EX CONTUSIONE. Here, as a rule, the capsule of the lens is ruptured, and the lens becomes cloudy, in consequence of com- ing in contact with the fluid media of the eye. In exceptional cases the lens substance becomes cloudy, even when the capsule has not been rup- tured. Thus Arlt^ states, "though we do not as yet possess any reliable reports of cases in which a concussion of the eyeball, in which neither a rupture of the capsule nor a simple tearing of the capsule has taken place, lead to a cloudiness of the lens; still, as a rule, we must acknowledge the possibility of its occurrence." The truth of this statement seems to be proven by the fact, that Berlin ^ produced a cloudiness of the anterior cortical substance by gently tapping the eyes of rabbits with an elastic rod. Becker reports the following case, in which, as the result of a con- cussion of the eyeball, without a tearing of either the zonula or capsule, cloudiness of the lens followed: During the winter of 1870-72, a policeman, stationed at tlie railway tunnel running under the Heidelberger Schloss, while engaged in removing large icicles which had formed at the entrance of the tunnel, was struck by one of these in his right eye. The pain was not very severe, but vision at once became cloudy. Several days later he presentd himself at the clinic, and vision was found to equal ^g. There was no sign of an external injury, luxation or tear of the capsule, but we found a rupture of the choroid. This latter was quite centrally located, but not very large. From time to time he presented himself at the clinic, so that we had the opportunity of carefully observing the gradual development, from the third week on, of an anterior polar cortical cataract, lUber die Verletzungen des Auges in Gerichtsartzlicher Beziegung, 1. c, p. 296. 2Zur Sogen Commotio Retinae. Monatsblatt, 1873, p. 47. 251 which assumed the same form as a posterior cortical cataract, after an injury of the periphery of the lens. After it had developed to about one-half the size of a medium dilated pupil it became stationary. After a year the railway com- pany gave him an easier position, so that he passed from observation. Whenever a unilateral cataract is met with an indefinite time after a contusion of the eye, one should not forget that the cataract may be the result of an injury to the eye other than a lesion of the capsule or zonula. It is only of too frequent occurrence that months pass before the lens be- comes cloudy, and then the cataract is to be looked upon as consecutive. However, there must not always be a rupture of the choroid; hemorrhage into the vitreous, with secondary detachment of the retina; but a con- secutive cataract may develop, when the only demonstratable sign is a paralysis of the ciliary body, together with an apparent myopia. Hence, great care should be practiced in making a prognosis, even in apparently slight contusions of the eyeball, and this should be especially remembered as a point in medical jurisprudence. Euptures of the capsule, independent of a tear in the coats of the eye- ball or of the zonula, have been but rarely reported. Isolated cases of tear- ing of the posterior capsule have been reported by Knapp and Aub.^ John R., aged 20 years, the son of a farmer living at Kuhbergershof, while chopping branches from a tree, was struck in the eye by a twig. Vision at once was impaired, without any visible sign of injury. Two weeks later, since vision did not improve, he was brought to the clinic. It was impossible to detect the slightest trace of an injury, either in the lids, conjunctiva or cornea. The conjunctiva bulbae was pale, and there was absolutely no ciliary injection present. Cloudy lens substance was being extended through the narrow pupil into the anterior chamber. Tension was normal. Field of vision intact, and he could count fingers at one foot. He had no pain; there was no irritability to light, no increased secretion of tears. On use of atropine the pupil dilated and disclosed no synechia. Though the patient was repeatedly examined later on, and notwithstanding every possible effort, no trace of an injury, more es- pecially of tlie cornea, could be detected. And since on dilating the pupil a change of position of the lens system could be absolutely excluded, hence the diagnosis of a simple rupture of the capsule of the lens as the result of a con- tusion was justified. The progress of the case was an exceptionally favorable one, and the lens was totally resorbed without the occurrence of any com- plications. B. Frequently a simultaneous luxation takes place — that is, a tearing of the zonula zinii and a rupture of the capsule. All these cases, in which one is able to demonstrate a subluxation of the lens, and to which already in 3 Arch, fur Augen und Ohren, I, 1, p. 20 and II, 1, p. 256. 252 the first few days, a cloudiness of tlie lens-is added; beloii;^ to tliis class. In most of these cases the lesion in the capsule is in the equatorial region be- tween the insertion of the zonula and its anterior and posterior attach- ments. All clinical observations show that the cloudiness begins in the tMiuatorial region. c. INJURIES CAUSED BY CUTTING Oil POINTED INSTRU- MENTS NEARER aifect the lens alone. The symptoms, the course and prognosis depend entirely on the size of the capsular wound, the depth to which the instrument penetrates the lens, the kind and extent of the in- jury, which at the same time affects other parts of the eye, and also as to whether the body which causes the injury remains partially or entirely within the eye. Should the body which causes the injury only penetrate the cornea and the lens, and do no other injury, we will have a condition to deal with similar to a discissio per corneam. If the corneal wound is a large one, some of the lens substance may be extruded, and hence the ab- sorption hastened, but just such wounds later on materially interfere with vision. If, besides cornea and lens, other portions of the eye are involved — the iris, the sclera, and corpvs ciliare, the vitreous, etc. — the prognosis largely depends on the extent of the injuries. Penetrating wounds which at first appear trivial, owing to infection, may become the most serious. Where the foreign body penetrates through the periphery of the cor- nea and the ciliary portion of the iris into the lens, so that the lens is struck near the equator, it very curiously indeed happens that, aside from the cloudiness in the neighl)orhood of the point of entrance, the posterior cor- tical substance is clouded earlier than anywhere else. On dilating the pupil, it is possible to follow the entire course of the penetrating instrument through the lens, and the same cloudy lens star develops. If the wound is not large it may close again, and the opacity remain restricted to the poste- rior coriical substance, or eventually clear up again.'' If small foreign bodies eulor the lens, they may either still stick fast in the cornea by the other end. ])pnetrate the iris or extend into the pupil and anterior chamber, and be recognized l)y the naked eye; or they may be entirely enclosed in the lens capsule; or, finally, they may pass througli the lens and be found sticking fast in the })osterior wall of tlie eye, or be found lying free in the vitreous. As long as the lens remains transparent, one can get a view of these foreign bodies by means of the opthalmoscope. The diagnosis is easy, where it is possible to see tlie foreign body in 4 Vergl die Berichte der Wiener Clinic, p. 87 and No. 7G. 253 the cornea or iris alone, or in both, and penetrating the lens. That the lens is involved becomes evident, owing to the more or less diffuse cloudi- ness which in such cases is never wanting. It is more difficult at times to demonstrate the presence of a foreign body which is entirely enclosed in lens substance, especially when the lens has secondarily become totally cloudy. It then depends entirely on the color of the foreign body whether or not one can still see it. However, it is not necessary, nor does it always occur, that the entire lens becomes cloudy. One then sees, either in the anterior cortical substance a circumscribed white cloudiness, with its cor- responding capsular wound; or, if the cloudiness lies deeper, we see between it and the capsule a linear cloudy path which indicates the course of the foreign body. If the reports of some authors are to be believed, we can at times recognize the foreign body. Many observers attest the fact, that the capsule may close again after the entrance of a small foreign body, and this be retained in the lens. Especially where the wound is in' the region of the iris, this may form a primary object of closure. When the wounds are in the centre of the pupil, the iris can be of no assistance, and still it is possible for the wound to heal without any lens substance ever having been extruded — a true sanatio per primam intentionem. More frequently, the wound only heals after a flake of greater or less size has been extruded and been absorbed. In the vicinity of the wound the capsule is always folded. Becker states that, from his own experience, he knows that grains of powder may become encapsulated in the lens without causing a total cloudi- ness of the lens. This, however, is the exception; the rule being that for- eign bodies will lead to a complete cloudiness, even where the cloudiness remained partial for a long time. This condition seems to be analogous to the congenital partial cataracts. Hence one must not be astonished if, after an extraction, one finds that the cataract which we considered as an ordinary senile cataract, should be found to contain a foreign body. Work- ers in metals, who are so accustomed to have particles of metal fly into their eyes, overlook the entrance of such a foreign body into the lens, since the aqueous is not necessarily evacuated, and the reaction must not neces- sarily be any greater than when a particle is imbedded in the cornea. If now the lens should cloud up but slightly, and in fact, very slowly, the oc- currence of the injury will in all probability be forgotten before the dis- turbance of vision is noticed. One most frequently observes the retention of a foreign body where it is very small and not too heavy. In these cases, most probably, the scler- osed nucleus holds the foreign body fast. The case of Parnard, in which he 254 was enabled to see, and later extract, a grain of shot out of the lens,^ de- sen^es to be classed as a great curiosity. It occurs much more frequently, that the foreign body which pene- trates, passes through the lens. Even in such cases, the openings in both capsules may close again. This occurs most frequently when both point of entrance and of exit are in the periphery of the lens, the healing of the anterior capsule being again aided by the iris. The posterior wound, however, is under more favorable conditions, since the vitreous has less tendency to dissolve the lens fibres. Where the penetrating body is of considerable size, or where by chance the capsular wound happens to be a large one, the lens becomes cloudy in proportion to the area which comes in contact with the fluid media of the eye; and it depends largely on the amount of general injury which the eye has received whether the lens will be partially or totally resorbed, and whether the eye will be destroyed by iridocyclitis, choroiditis or panopthal- mitis. No case has been observed where, following the entrance of a foreign body into the lens, and its remaining in situ, or after its passage through the lens, the lens either spontaneously cleared up again, or remained en- tirely transparent from the beginning. Hence the cases reported by Desmarres tils ^ can only be looked upon with doubt, as to their correct observation. Opening of the capsule, in consequence of a perforating corneal ulcer, is likewise to be looked upon as an injury of the lens. The sequelae, as far as the lens is concerned, depend on how much of its substance is lost, or is later on absorbed by the aqueous. Sometimes the shrunken lens re- mains adherent to the cornea and iris, owing to new-formed cicatrical tis- sue; again, it returns, in a greater or less degree, to its normal position. Aside from the fact that the lens, together with its capsule, may entirely leave the eye, at times the only remains is a cataracta secundaria. The appearance of a traumatic cataract is that of a soft cortical cata- ract. The rapidity with which the lens becomes cloudy depends on the extent of the injury and the age of the individual. Since young people are more exposed to such injuries than older, hence in this we find a further reason why the traumatic cataract as a rule is soft. The chemical constitu- tion of the foreign body \nll affect the color of the cataract, and whenever the well-known color is wanting the suspicion of a foreign body in the lens ought to be aroused. BAnnal d'Oeulistic. 43, 23. 6 Le cons Cliniques sur la Cliirurgie Oculaire, p. 90. 255 It is a well-known fact, that traumatic cat;u;ied in both eyes of a woman 45 years of age. Setons were put on both arms and laxatives were administered at the same time, and at intervals ctips were also applied. After a duration of five years the yellowish white cataract became more cloudy in both eyes: did not. however, become resorbed from the periphery to the center, but had a fractured and divided ap- pearance, a stariike configuration, almost like the figures seen after a kerato- nyii*. Resorption progres.aed so rapidly that at the end of six months both pupiLs were pure Wack. and every cataractous di-scoloration of the lens had disappeared- This patient used spectacles. iWamatz.» ^Likewise a cataracta MorgagnianL) To these case*, taken from the pre-opthalmoscopic literature. Becker adds the clinical report of a case kindly given to him by bis friend. Dr. Brettauer, of Triest which may serve to put these observations of Wamatz in their proper light, and serve to plac-e the possibility of a lens being spontaneously resorbed within its capsnle in its proper light. March 20. 1862. Mr. Z., aged 35 years. <^ame to me for treatment. Ou the right eye he bad a ripe cataract, a milky white corticalis, presenting no special features. Beneath the capsule were a few white chalky nodules, about one-half the size of the bead of a pin: and the nacletis could be differentiated. On the 2fjih of >Iarcb the right eye was operated bj a flap extraction downward, with- 1 Walter and Ammon Journal. XXXII. p. 219. out an iridectomie. Imm^luitelT after introduction of the cy^totome the vitre- ous prolapksed. At the same moment the cataract disappeared out of the pupil- h^.ry area. Whether the entire t-ataraft was llui^L or whether the Tirre^.us caused the nucleus to be dragged out of the eye. could not be determined, as the accident reiiuired mv undivided attention. We hunted for the cataract on the bed and on the floor, but it could not be found. During the healing pro- cess blood filled the pupillary area for a long time, and the iris cicatrised in the wound. August 4th. with a — «- the patient could read Yager No. S. and with a — '6 the numbers of the houses across the street. The restilt was perma- nent, since with this one eye he was enaMed to follow his occupation, that of a hat maker, and at the end of twelve years "March. 1ST4», with ~- i^ V = f,. When he came again, in ISTI. to have his glasses changed. Dr. Brettauer. who had not seen the patient since the operation, noticed a trembling aini discolora- tion of the left iris, which was, however, round aiHl reacted to light. In the center of the pupil was an irregttlar star-shaped meml»rane. This disc4iTc?ed. on dilating the pupil, going out from the central-shaped membrane correspond- ing with the sectors of the lens; a grtatinous mass, hanging from which are an innumerable number of cholesterine crystals. resemWing the golden tinsel on a Christmas tree. Between these various sectors of gelatiiK>«s stibstances, we can get a red reflex from the fundus by means of the opthAlmoscope. ♦Beck- er saw this case in 1S72.> March 2. 1S74. this trembling of the iris had ii»- creased: the gelatinous mass as a whole had grown less, likewise the number of crystals. Downward and outwaril a sector of gelatinous substaiKV seemed to lie anterior to the plane of the central membrane. Immediately posterior to the leas one could see a number of easily movable and quite large vitreous membranes, all in the anterior portion of the vitreous. The [«apilla was slightly hyperaemic. and on the outer side a small conus about one-sixth the diameter of the papilla. With + **, vision equaled nearly |J. The slightest change in the position of the glass impaired vision: hence, there is no sign of accv^mmo- dation. How long vision has been improving on this eye Z. is m-»t aWe to state. During the past two years this absorption and diminution of the crystals has materially decreased. Z. denies ever having receive*! a trauma, and it is not possible to demonstrate, either on the cornea or iris nor on the capsule, a cica- trix, a tear or anything resembling it. Since the patient reqtiired on this eye « glass of the same strength as he did on the operated eye. there can l>e no doubt but that this is a case of Sfmmtnmrtiti* .>«.. rr, ., , - ,i ,■,7^^o,. r v-t,.. t\^ caf^ttlf *«* not hrem rmfttmrri. «Bretthauer.^ Gilson ip. 722"* has reportcil a case wherx* a ^^nli;^•n.;u v-s:.-iracu-^ lavua ".-is resorlH-»d. as the result of a blow on the eye. which ruptured the capsule without catising any other injury to the coats of the eye. Finally, all these oases belong to this class, in which, following a sjx^n- taner>us sinking of the cataracious lens, vision is restored. Literature is full of the reiH>rts of such cases. The oUlt^t reiH>rts are by St. Yves, and Janin re- ports two oases, 'Ono of these had a cataract fn^m early youth, SicN^K! and 264 Himly (Opthal. Bibl.. I. 187. 1801), in the reports of their cases, seem to have come to similar conclusions, in that pre-supposing that a subluxation had oc- curred, they gave the patient suffering from a "trembling cataract" the advice to take jumping exercises, in order to bring about a total luxation. Later on it became fashionable to apply electricity or to give large doses of strychnia, so as to bring on a separation of the lens from its connection as a result of muscular contraction. Sperino attempted to clear up a beginning or even fully developed cataract by operative means, though not by a true cataract operation. After Hoquet, in 1729,and Les Col. de A'^lllars. in 1740. had suggested that the attempt be made by means of repeated punctures of the anterior chamber to influence the de- velopment of cataract (the experiments of Dietrich also being here), Sperino took up his experiments in a more extensive manner, in that he did not restrict his experiments to cataract alone. His results were excellent. A woman who could no longer find her way about was so much improved by this method that she could read Yager No. 3 without spectacles, and vision was permanently improved. In forty other cataract cases vision was more or less improved. It is definitely recorded that the clearing up was determined by opthalmoscopic examination. These experiments were repeated, especially by Sperino's coun- trymen. Borelli.2 in twenty-one cases, had little or no result. Torresini (ilid) even noticed a rapid increase in the cataractous cloudiness. Rivaud Laudran reported a case without any results at the Congress held in Paris in 1863.3 Since that time nothing further has been heard concerning Sperino's sugges- tions. I do not know whether this subject has received any further attention. Good results were certainly not attained, otherwise we would have heard of them. The great attention which the experiments of Sperino attracted is ex- plained by the fact that the possibility of the nutrition of the lens being af- fected by the repeated punctures of the anterior chamber, could not a priori be denied. It can not be doubted but that by the repeated evacuation of the aqueous, the chemical formation of the same is altered. We know that by means of puncture of the anterior chamber in cases of traumatic cataract, and after discission, we can hasten the absorption of the swollen up lens substance. Aside from this, every time the anterior chamber is punctured, the lens changes its position, which does not take place without at the same time the lens chang- ing its shape, and consequently the lamellae are pushed past each other. If it is correct that there are always, or at least often, a splitting up of the lens during cataract formation, hence such an abnormal change in the form of the lens, as occurs when the aqueous is evacuated, can not but influence the for- mation of a cataract. One should at least incline more to the opinion, as Tor- resini observed, that the cataract formation is hastened by the repeated punc- tures. This would be in accord with Snellen's verbal statement to me (Becker), that the making of a preliminary iridectomie will ripen an unripe cataract. 2 Gionale d Ottalmologia Italiano, 18G2. " 3 Comptes Rendus, 155. See the discussions in which Raymond. Desmares, Testelin, Borreli, Dor, Ricardo-Secondi Quaglino took part. 265 CHAPTER II. THE OPERATIONS FOR CATARACT. The true operations start out with an essentially different purpose. By their means the cloudiness of the lens is not expected to be cured, but rather the detriment«c and i^'jztoj punctio corneae). How the method of discission developed from this suggestion, I will explain more fully when we come to the subject of leratonyxis cum depressione cataraciae. THE DEPRESSIO CATARACTAE is the only method of which a complete and lucid description has been handed down to us from ancient times. This is found in Celsius (Lib. VII., c. VIII., 14). Owing to the extreme importance which this bears to the history of opthalmology, I will quote it here in full: "Igitur vel ex ictu ooncresit humor sub djuabis tunicis (/ft/Mirof/fW/C et h«/jwfMw), qua locum vacuum esese proposul; isque paulatim indurescens interior! po- tentiae se oppouit. Vitiique ejus plures sunt species; quaedam sanabiles, quae- dam quae curationem non admittunt. Nam si exigua effusio est. si immobilis, colorem vero habet marinae aquae, vel ferri nitentis, et a latere sensum aliquem fulgoris relinquit, spes superest. Si magna est. si nigra pars oculi. amissa nat- urali figura, in aliam vertitur, si suffusioni color caeruleus est, aut auro similis, si labat, et hac atque iliac moyetur, vix unquam succurritur. F:ere vero pejor est, quo ex graviore morbo majoribusve capitis doloribus. vel ictu vehementiore orta est. Neque idouea curationi senilis aetas est, quae sine novo vitio. tamen aeiem hebetem habet: ac ne puorilis quidem; sed inter has media. Ooulus quoque curationi neque exiguus, nt-que coucavus. satis opportunus est. At que ipsius suffusionis quaedam maturitas est. Expectandum igitur est. donee jam non tluero. sed duritie quadam eoncrevisse videatur. Ante curationem autem modico dbo uti, bibere aquam triduo debet: jtridio ab omnibus abstinere. Post haec in adv«'rso sedili collocandus est loco liicido. luiiiinc :idv(M-so sic. ut contra medicus paulo altius sedeat: a posteriorc aiitfiii i>artc c-ipnt ejus min- ister contineat. ut immobile it praestet; nam levi motu eiipi ades in perpetuum potest. Quin etiam ipse oculus immobilior faciendus est, super alterum lana imposita et deligata. Curari vero sinister oculus dextra manu. dexter sinister debet. Turn acus adinovenda est acuta ut foret, sed non ninium tenuis; eaque 267 deuiittencla recta est per suiiinwis diias tuniciis iiifdiu loco inter oeiili nigrum et augulum tempori propioreui. e regioue inetliae siift'usionis sic, ne qua vena laedatur. Neque taineii timide demitteuda est. »iuia inani loco excipitur. Ad qiiem qiium ventnni est, ne mediocriter quideni peritus falli potest: quia pre- meuti nihil reuititur. Ubi eo veutum est, iucliuanda acus ad ipsani suffusionem est, leniterque ibi verti, et paulatiin earn deducere infra regionem pupillae debet; ubi delude earn trausiit, veheuientius iuiprimi, ut inferiori parti insidat. Si haesit. curatio expleta est: si subinde redit. eadeni acu concideuda et in plures partes dissipanda est: quae siugulae ea facillus conduntur, et minus late offici- wnt. Postea educenda recta acus est, inipouenduni(iuc i.iii.i niolli exceptum ovi album, et supra quod iuflammatlout'in coerceat, atqui- ila di'viucienduni. Post haec opus est quiete, abstinentia, leniura medlcamentorum inunctionibus, cibo, qui poster© die satis mature datur, primum liquido, ne maxillae laborent; deinde, inflammatione tinita, tali, qualis in vulneribus propositus est. Quibus ut aqua quoque diutius bibatur, necessario accedit." From the above one sees that even Celsius (liftereiiiiated between the trau- matic cataract and the one due to internal causes, and that he considered all cataracts not the result of trauma as due to some disease. He was even then of the opinion to which we are all now returning: namely, that all cataracts are secondary in their nature. He also recognized the importance which the color of the cataract bears to the prognosis. In that he separated the curable from the incurable. He acknowledged that there is hope of a cure when there is still perception of light. We meet with the expression "ripeness of the cat- aract," and also learn that a preparatory treatment was practiced, and that at the time of the operation, the patient was placed in a position similar to that customary up to a few years ago. (The patient in a low chair, the physician somew^hat higher. Desmarres, 1252, p. !"►.) An assistant held the head; the other eye was covered Avith a bandage, in order that the eye to be operated on might remain quiet. The doctor should be ambidextrous. After the operation the patient received only fluid nourishment, "net maxillae laborent." If we look at the very exact description of the operation, one really can not tell at what one shall be most astonished; that Celsius shoiild have had such a com- plete understanding of the operation of depression, which up to a few years ago was so frequently made, or that this method should not have materially improved until after the discovery of the extraction, which robbed it of its supremacy and caused it to be almost entirely abandoned. The only change from the methods of Celsius in ancient times, is con- fined to the instruments. Instead of the round-pointed needle of Celsius, we gradually came to use the myrtle-leaf -shaped needle of Brisseau. This change was first suggested by Giinz (1750) and was first carried out by Willburg (1785), and was the cause of the introduction of llic naiiio irclina- tion. The lateral displacement of the lens (drprc^sio latcnilis. 1801) was first suggested by Bell and was (iist introduced into practice by Scarpa, and this was greatly facilitated by the use of a eatai-act needle, which was mod- erately cun-ed on the flat at its point, and even today this needle bears Scarpa's name. The suggestion of Pauli, 1858, (450) is to be looked upon as an error — suUalio catarade, reUvement de la catarade. The words of Celsius may be interpreted to mean that the needle .should be so introduced from the beginning, that the point, by being simply pushed forward, will reach the upper edge of lens. Later on, we diverged from this, in that the needle was introduced perpendicularly through the coats of the eye, and the attempt was made, by Just touching the upper edge of the lens, to reach the posterior chamber. If by this means the certainty of depressing the lens was increased, the amount of damage to the interior of the eye must likewise have increased, owing to the movements of the needle. The methods of Willburg and Scarpa must likewise have led to more extensive destruction of the vitreous, than where the typical opera- tion of Celsius was practiced. If, owing to the lens rising up again, they were compelled to break the lens into a number of pieces ("eadem acu con- cidende et in plures partes dissipanda, Celsius") the destruction of the vitreous could surely not have been less extensive, even where this method was practiced. Since the time of Buchhorn's suggestion, depressio per corneam has also been practiced, (depressio per corneam, per keratonyxim). It appears however, that this method is of earlier date. For it is said, that among nations " which are somewhat removed from our civilization (as, for in- stance, in Koumania) skilled women who are not physicians, even today, practice this method (depressio per corneam) by means of thorns of the Lycium Europaeum which have been hardened by fire. Who will fail call- ing to mind the fable of the goats? Tradition tells us that the ancients ascribed the discovery of reclination to observations which were made on goats. It is really worth while stopping and critically examining this story. Pliuiusi tells: "Oculos subfusos cnpra iinici puncto sanguine exonerat caper rubi." It is not difficult to form an UW:i how the sentence came to be written. No doubt goats were observed which liad wounded themselves with a thorn, and they must have had a subconjunctival hemorrhage, and at the same time a i^ suffusione male liabens. Jiinco Mciileati) in octilum impacto, visum receperit." Here a cataract operation is spolien of. and since we do not possess any positive evidence that any operation other tlian depression was known during the time of Galen, hence we may apply these remarks directly to the operation of reclination. It is perfectly natural that such an operation should have been made, and by this means the reasons on which the operation of discission is based were finally arrived at. It must certainly strike every one as a curious fact, that the ancients who displayed siuli great talent in making observations, and vrho had every opportunity of observing the fre- quently occurring cases of traumatic cataract, slioidd not iiave come upon the idea of purposely bringing about the process of spontaneous resorption as it occurs in traumatic cataract. However, this is easily explained if we will call to mind, that in most of the cases of cataract in which reclination was practiced, the cataract only becaaie partially resorbed, and in many cases of reclination vision was restored only after the remains of the lens wliicli occupied the pu- pillary area were gradually resorbed. and that frequently, instead of making a reclination. in reality a discission was made. (See Celsius.) I can not refrain from again most particularly drawing attention to the fact, that this book is only ascribed to Galen; the period when it was written is not fixed. I also desire to quote a passage from Aelian.2 which has been translated by Schneider: "Caliginem oculorum. quam suffusionem medici vocant. caprinum pecus probe curare scit; et ab ipsa remedium ejusdem homines quoque mutati dicuntur, idque hujusmodi est. Cum conturbatum oculum sentit. cam ad rubi spinam et admovet, et reserandam permittit: haes ut pupugit. i)ituita statim evocatur, nuUaque pupillae laesione facta, viveudi usum recuperat: neque sane hominuum sapientia adfaciendam sibi meilicinam egel." Tliis sliows tliat the fable has been perfected pretty well. According to Scott.3 the Brahmids of East India depressed the cataract by means of a small cotton tipped probe, which is inserted through an opening in the sclera, after a considerable amount of the vitreous had been evacuated. 2 De Natura Animalium. Lib. VII. Cap. 14. Ed. Sdineider. Leipsig. 1784. p. 230. 3 Journal of Sciences and Arts. Tendon. ISIG. No. 3. pi. II. A. B.. and Himly's Krankheiten und Missbildungen, Bd. II. p. 297. 270 According to Engel 4 the same procedure is successfully practiced in Turkey, the Moldan and AA^allaehei of Laien (Stellwag, 1. c. 1, p. 771). The reports de- serve to be recorded here, not only because, as Stellwag has pointed out, they teach us how mucli an eye can withstand without being totally destroyed, but because they teach us that in every country the autochthon cataract operation was the depressio cataractue in some modified form. B. EXTE ACTIO CATAEACTAE. (PEE KEEATOTOMIAM AUT PEE SCLEEOTOTOMIAM). "Extraction" was the expression used to designate every operative metliod, by means of which a lens of normal size, shrunken, transparent or opaque, with or without its capsule, was entirely or partially removed from the eye through an incised or thrust wound through the outer coats of the eye, (cornea and sclera) and through the (anterior or posterior) capsule, proportionate to the size and consistence of the crystalline body or portion of the same to be removed. According to the position of the incision, the differentiation was established between a corneal, a scleral, and a corneo- scleral extraction, and depending on the form of the incision, as a flap, semi- circular (Bogen) and linear extraction. "As a rule, extraction is only practiced wliere we desire to remove a cata- ractous lens from the eye. In moi-e recent times we have extracted perfectly clear lenses where particular indications presented themselves, as where sym- pathetic opthalmia of the second eye had set in (obsolete), or where we desire to reach a cysticercus in the vitreous, or behind the retina. And finally it has been suggested that we i-emove a normal lens to overcome a high degree of myopia, (Bonders. 1. c. p. 351). (Fukula.4a) To make an extraction by means of an incision behind the ciliary body, as was suggested and often practiced by Freitag, Bell, Butter, Earlie (263), Quadii, Loebenstein-Loebell and Ritterich, has been entirely abandoned, so that I need pay no further attention to this procedure. However, in the last few years (1876) this scleral incision has again come into vogue, in removing foreign bodies from the vitreous, also subretinal cysticercii; hence, this scleral incision is at least worthy of being mentioned at this place.5 It is not at all improbable that the operation of extraction was known to the ancients. Tlie passage quoted from Plinius (1. c, XXIX, 1, 8) to sustain this assertion, reads as follows: "Ne avaritiam quidem arguam, rapacesque nundinas pendentibus fatis. et dolorum indicaturam. ac mortio arrham. aul iinaiia itraeceptii. S(|uamani in oculis emovendam jxtlius (piam extraliend.-un: per (lu.ic rtfCctiiiii est. ut iiiliil 4Gaz. Med. de Paris, 1S4(). 4a Operative Hcliandluiig iKtclistgradiger Myopic durch .\phakie. Graefe's Arch.. Vol. XXXVI. 2 P.. p. 2.",(). 1800. 5 See O. Becker, in Mauther's Opthalmoskopie, p. 467-4()8. 271 magis prodosso vidci-ctui-. (|u;iiii iiiuhiliiilo .i;r:iss;iiiliiiiii. NCipir iiiiiii pudor, sed at'inuli i>r('ti:i sniimiit t mil." I'.ut tlicrc is imtliinu- lo show ili.-it the word "squama," as used by the aiiciciits, was iist-d to dcsii^'nati- a cataract (S. Hirseh., p. 285). Then Galou woidd lie the liist in whoso works I liiid tiic extraction mentioned. In "Methodi Medendi, l.XIA', c. 13, Ed. Kuhn. Tom. X, p. 986," Is written: " "'Efinalw rV loi; I-tt) tuv rnoxofinrM' (iTTmr'tTTTnvTEC riw np('.)Tov OKorror ffpof FTcpov ayo/iev al'T(i rii-oi- nKvpuTEpni'. 'Kvioi (U Kai Tavrn kfvoih' tTrtXEipV^nv, (jf Iv ro7f jfy/joiy^yojyuvo/f t/KJ." "The extraction is again mentioned in the Continens of Rhazes, who lived in the ninth century. In tlio Venetian edition of 150<> (Lib. II, Fol. 3, B. 40), we find in 'Latyrion dixit cum chiruigicus vult extrahere cataractam ferro debemus tenere instrumentuni super cataractam per magna m horam in loco ubi ponitur illud,' and at another place far from this one we tiud: 'Dixit Antilus et aliqui opererunt sub pupilla.et extraxerunt cataractam et potest esse cum cataracta est subtilius; et cum est grossa, non potnet extrahi, qui humor egrederetur cum ea.' Both of these passages, since their discovery by Albr.echt von Haller, have been quoted in all text-books, and have given rise to a great many false conceptions, in that they have led us to arbitrarily place the time of Latryion's life in the first century after Christ; whereas, tlie text simply states that he must have lived before the ninth century, and we have likewise brought Latryion in per- sonal relationship with Antilus, Avho lived in the third or the beginning of the fourth century." (Hirseh.) In the eleventh century, it is Avicenna g wlio again takes up tlio subject of extraction. "There are various instrumental methods of treating cataract, thus there is one iu which we sever the lower portion of the cornea, and then pull out the cataract; but this is dangerous, for with the cataract, if it is thick, (agua quado est grossa), the vitreous also escapes." It is worthy of note, and Hirseh drew attention to it, that there is not a single passage extant, which could prove to us that any one of the well-known ancient physcians ever really made an extraction. All reports, taken from that time forward, and on which any reliance can be placed, simply go to show, that the cases which they report are simply hearsay, and others coming after tliem, have simply quoted their writings. Avenzor, who lived in the twelfth century, mentioned the extraction, but declares that it is a simple impossibility. He writes (Lib. I, Tract 8, Cap. 19, Fol. 149): "The cataract must not be pulled oiit until it is fully ripe; if removed sooner it will return, . And when I say pulled out (extrahere), I desire you to understand that this is not possible, as so many believe, but that I push the .cataract down into the depths of the eye by means of a needle, and when I have done this I draw the needle out again." All other evidence of ancient times and tlie middle ages is not relevant to the operation of extraction. From the time of Avenzor until the close of the seventeenth century, all writers are so completely silent on this subject that we must come to the conclusion that it had fallen entirely into oblivion. Hence, 6 Ed. Venetio, 1544, Fol. 237. Buch 3, Fen. 3, Tract 4, Cap. 20. 272 we are placed in a position wliere we can follow closely, even in its preparatory stages, the discovery of the corneal extraction by Davlel. In his dissertation (De Cataracta Argentorum). which appeared in 1721, Henrieus Freitag tells us, that in 1G94 his father, John Conrad Freitag, removed through the sclerotic. by means of a hook-shaped needle, two cataracts which had again "risen up" after reclination. According to the statements of Albini. in Goskey's disserta- tion (15), about this time, in 1695, men traveled from place to place (cataract cutters— staarstecher) who practiced extraction through the cornea. Gosky described an instrument something like a pair of forceps, which was used to extract the grey cataract. He gives an illustration of this instrument in his dissertation. These facts were unknown to the French, to whom we are really indebted for the method of extraction. At the same time that Brisseau made his dis- covery as to the seat of cataract, St. Yves (1707), Du Petit (1708) and Duddell (1729), extracted, per corneal incision, cataracts which had fallen into the an- terior chamber during reclination. In 1745 Jacques Daviel found himself called upon to practice this same procedure which Petit had practiced, being compelled to remove, per corneal incision, a cataract which liad fallen into the anterior chamber while making a reclination. Jacques Daviel was born in La Barre. Normandy. August 11, 1696. He studied at Rouen, and served at the Hotel Dieu, in Paris. In 1719 he was sent as "plague physician" to Provence, and for the services there rendered he was appointed Surgeon to the City of Marseilles. There he became Professor of Anatomy and Surgery, but from 1728 he employed his time exclusively in the treatment of eye diseases, ^nd he became so renowned that he was repeatedly called to Portugal and to Italy. In 1746 he settled in Paris, and in 1749 he received the appointment of Surgeon Oculist to the King. In 1750 he was called to attend the Kurfurstin at Mannheim; in 1754 to Ferdinand VI. of Spain, and later he was once more called to see the Princess Clemens of Bavaria. To restore his shattered health he went to Bourbon and to Geneva, to take the baths, at which latter place he died in 1762. A hermit of Aiguilles, in Provence, was operated on the right eye without result, and came to Marseilles, where Daviel was at that time residing, to be operated on his left eye by him. But Daviel had no greater success. A num- ber of pieces of tlie lens fell into the .'interior chnuilx'r. whieli :il the same time became filled witli blood. Daviel then punctured the cornea Avith a bent needle, and enlai'ged the opening with a pair of curved scissors. The pupil cleared up and the patient saw. Two days later, however, purulent iutlammation set in. and the eye was lost. Nevertheless. Daviel advanced a step farther, and made the attempt to reach the lens in its capsule by inc-ins of an incision in the cornea, and then to permit the lens to enter \Uv miterior chamber through the pupil, and from here to draw (tirer) it out of the eyi". He did this operation the first time on a woman. He tells us: ".louveris la <-ornt'e coniuie .ie I'ai ex- 273 pliqiu' cusuito fii i)()rl:ni1 la iM'til spamlr iateineiit i^ made, thai imlliine remains J.vt the knife." (iraefe's life ha.s borne fruit tn the eatai-act (iperation. and certainly has led to the develoi)ment of new ideas. His metho.l reduced the percent- age of losses, even in the hands of those who have >inee changed his tech- nique. His intlnenee may l)e com[)ared to that of J.ister, \vho.se fame will live on. h)ng aftei- his iiK'as liave been set aside hy the advancement of science. True, time has shown that the principle of the linear incision is not as essential as- Yon Graefe originally thought. Where not accurately made, the linear incision is often too small, and places difficulties in the way of the deHvery of the lens, and leads to escape of vitreous. In the hands of a novice the linear incision may he too peripheric, .and as a con- sequence leads to cicatrization of the iris in the wound, and this to sympa- thetic o])thalmia — an almost unheard-of complication during the time of the classical flap operation. The new method had the advantage, that the U'lis no longer had to be forced through a small — in old people, often rigid — sphincter, which can scarcely be dilated, and which now could easily come forward through the sht in the iris, and. further, that cortical remains could easily be removed by simple massage without going into the eye with a spoon. And thus a sort of compromise procedure has developed, which bears the name of no operator, which is very like the Graefe procedure; has ac- cepted all its advantages, and tries to avoid all the recognized dangers, and has received the name of the one-thixd circumference incision}^ The incision should always be of sufficient size to permit the largest lens system, though it be hard. 'to pass easily. This can he done where the incision equals one- third of the corneal circumference. In the centre of the incision a section of the iris is removed, then the cystotomie and delivery of the lens follows by simply applying moderate pressure to the lower part of the cornea. Jacobson (cited above) sums up the subject with the statement that a great many opthalmologists have gone over from the Graefe operation to the peripheric ftap incision in the corneal margin — hut not to the Dariel fiap. So that the incision is the one originall suggested by Jacobson in 1863. He states: '".-l large incision in /lie si Irm-cornenl man/in heats l)elter than a Daviel's flap or the so-called lornenl linear Imision. niDDe Wecker— Annales d Oculistiquo. 1884. 92. p. 207. and 188.1. p. 29. (2) Hirschbers's Deutsche Zeitsclirift fur IMak. Med. 1887. Beitrag zur Augen- beilkunde Heft., HI. 1878. p. 77. 28o Jacobson summarizes the value of both Von (Iraefe's and Daviel's work, as follows: *'It will always remain as the undeniable work of Von Graefe, that he did not, as most of his predecessors, content himself with attempts to stop suppuration of the cornea, but after long and systematic attempts, became the originator of a new method of extraction, in which the dangers of wound infection were reduced to a minimum. Though the theoretical premises may have been ever so wrong, still, as a result of this method of extraction, losses by suppuration were reduced from 10 and 12 per cent, down to 3 and 4 per cent., and poor results from 10 or 15 per cent, to about 6 per cent." "To Daviel belongs the honor of having devised the bold procedure, by means of which all the forms of later times have been made possible, and which totally set aside reclination, depression, and simiiaf' methods, which in their old form will never return. It is not the great practical service of having reduced the 25 per cent, of losses down to 10 or 12 per cent., which will make Daviel's name immortal in the history of our science, but rather his clear insight, which showed him the way to the only safe means of extracting the cataract from the eye, and to a perfect method of healing. His boldness, which permitted him to make such an extended separation of the cornea without fear of injury to the eye, his great surgical genius, which lead him to devise from its very beginning the compKcated technique of this operation, all pronounce him the father of this operation, whereas to Von Graefe belongs the credit of having removed its most serious dangers by means of his new operation." C. DISCISSIO CATAEACTAE. BROIMENT DE LA CATARACTE. DISCISSIO CATAEACTAE PEE KEEATONYXIM AUT PEE SCLEE- OTICONYXIM. Where a discission is made, {discissio capsulae Icntis, incising of the capsule), the intention is, by means of a needle, which is pushed through the cornea or sclera, to open the anterior, also the posterior capsule, so as to bring the lens substance in direct contact with the aqueous humor, or the vitreous, so that it may be absorbed, and also that the anterior capsule may draw back out of the pupillary area. "Discission is tlic latest of the three principal cataract operations. It is also, so to say. a daujiliter of depression. Amonp the writings of the ancients (Galeuus. de Methodis Medendi. XIV. edition Kuhn. torn. X. p. 1019). we find but a single passage which seems to refer to this operation of discission. The 28l translation of this passage, wliidi Aiia^xnostakis (12MJM made, seems to liavo been made with a purpose. Learned philologists whom 1 have consulted regard- ing this passage are not at all satisfied with his translation. The whole matter appears to have reduced itself to this, namely; and this we also Ijnow from other sources, that the ancients did puncture the cornea. Since all the more exact points of differential diagnosis were wanting for all those diseases which lead to a cloudiness posterior to the pupil, to adhesions and indistinctness of the same, I am no longer in doubt, after a somewhat thorough investigation of the literature that the great confusion wliich existed concerning these named processes, was the result of the continual confounding of glaucoma, occlusion of the pupil, and liypopyon, one with anotiier. To say the least, it would be exceedingly strange if discission had been known to Galen, and that the knowl- edge of this would have been completely lost again for hundreds of years." It must certainly have occurred frequently during the act of making a depression; and, in fact, it must of necessity have occurred in all cases of cataract, that large portions of the same strayed into the pupillary area and protruded into the anterior chamber, or remained in the patellar fossa or in the vitreous itself. Even in Malgaigne's time, where contro- versies concerning the existence of capsular cataract were going on, such remains of lens substance were looked upon as pieces of thickened capsule. But from these numerous clinical histories, in which we find such accurate descriptions of how these capsules were gradually absorbed, it fdllows, that they could only have been remains of lens substance. Henkel (1770) was the first, to whom this common occurrence suggested the founding of a new operative procedure. The statements of Percival Pott (1781) are much more exact. He stuck a needle through the sclerotic; with this he im- paled the lens, and tried by repeatedly turning the instrument to destroy, as much as possible, the capsule and the lens, so as to prepare it for resorp- tion. This new method found many followers, especially among Pott's countrymen. Hey, Saunders, Adams; and by the latter was improved. The Englishmen, and not without right, claim the honor of inventing this method of breaking up the lens through the sclerotic. However, if we acknowledge Pott as the founder of this method, this is not exactly cor- rect, since when we use the word ^'discission" today it also carries with it the thought of keratonyxis; and, furthermore, the expression, "discissio cataradae, as can be proven, was not used until 1824. Hence, Pott's opera- tion should be designated as a breaking into pieces, {''dislaceratio"), if we do not wish to take up Himly's suggestion, which will be referred to again.'' "Discission through the cornea {keratotiy.rtfi cum disciftsio cataractae) is even of later date. This likewise has its previous history. Wenzel and Gleize, in their writings, state that cataracts after the opening of their capsules have been gradually resorbed in the anterior chamber. Conradi and Beer attempted 282 to cut the anterior capsule in a methodical manner. Their results, possibly due to a laclc of method, were not favorable, and they gave it up again. In 1800 Buchhorn published the results of experiments made by him, at the insti- gation of his teacher Reil, in which he incised the anterior capsule of the lens through to cornea (here originates the word keratonyxis), in the eyes of corpses and animals. "Langenbeck, to whom he sent a copy of his dissertation, then carried out in operative practice, keratonyxis; that is, incising through the cornea and the capsule of the lens. Of all the innumerable writings with which literature is replete concerning this operation of keratonyxis. it is only necessary to men- tion here the dissertation of Hulverding (Wien, 1824), because it was through him that the word discissio (it is to be written with two ss, not one. It is de- rived from discindere, to split up, to tear to pieces), was introduced into opthal- mology. However, we must not lose sight of the fact, that as far as Buchhorn and Langenbeck were concerned, they did not in the beginning look upo& it as a new method by which without injury to the posterior capsule, the contents of the capsule, was by means of the aqueous to be resorbed. but they rather looked upon it as a new method in which,by means of a corneal puncture,the lens could either be depressed, as was done by Celsius, or be broken up, as was done by Pott. Only gradually, without any particular person being deserving of the honor, out of this suggestion of Buchhorn, tlie discissio cataractae s. capsulae lentis, as we know it today, was evolved. It would not be out of place to accept Himly's suggestion, and use synonymously with our discissio, punctio capstilaris, the word dislaceratio with discissio. One can hardly refrain from expressing the greatest astonishment that it should have taken so long to come upon a method which we so frequently see clinically exemplified in cases of injury, following which the lens is absorbed. One must not fail to supplement the above by the suction niefhod, a method which Sichel shows us, was known to the ancients, and states that the Arabs learned it from the Persians. In our time, it has been re-invented by Laugier, and, as literature attests, is practiced today. " By means of a trocar, which is pushed through the cornea into the lens, the soft and fluid portions of the lens may be aspirated through a canula, and thus an entire cataract may be removed from the eye, just as where an extraction is made. Taking into consideration the manner of procedure, and the size of the wound, this method approaches that of discission. Since today we are in a position in most cases to diagnosticate a soft cataract, it is to be supposed that this iiiotlidd will remain in use for special cases. 283 CHAPTER III. THE PKOC'EDUHES AND CILVNGES JN THE EYE DURING AND SUBSEQUENT TO CATARACT OPERATIONS. In order that we may understand, and become fully acquainted with the injuries which an eye necessarily receives while undergoing a cataract operation, and that we may become familiar with those setinelae which do follow, and others which, under certain conditions, are sure to be added, we may follow a variety of plans. Where one possesses an accurate knowledge of the anatomy of the eye, and of the operative procedures,' though he may have no clinical experience, he certainly can attain a very clear theoretical conception of all these procedures. Thus, in 1733, Frances Petit, in his published "Reflexions," exerted an influence on practical opthalmology, in that among other things he showed that tlie iris is not vaulted, as it appears to be when seen through the cornea. The physician finds a second method of observation in watching the. healing process of the operated eye. For this, we are indebted to Von Jacobson, who did this in a methodical manner, beginning with the first hour after the operation. His writings concerning this matter are truly classical. Finally, here, just as in General Medicine, the study of the pathological anatomy— that is, the anatomical examination of eyes which had been operated on for cataract— teaches us the reasons for our clinical observa- tions, and assists us in drawing conclusions, by means of which the ill results may in the future be avoided or controlled. Both branches of path- ological anatomy are here of equal importance; the experimental, as well as the descriptive pathological anatomy. Along these three lines, all these processes which occur in eyes which have been operated for cataract shall be studied and enumerated, going over, first, briefly, the methods of healing and the sequelae, as observed in reclination and discission. But, since reclination is but little practiced at the present day; hence our personal observations are but limited. Many of the evil sequelae of discission fall in the same category with those of reclination; in part they lead to the same final results, as have been ob- served when a large portion of lens substance remains after a cataract ex- traction. In fact, as we shall see further along, there are certain clinical pictures which develop in almost exactly the same manner, no matter which method is practiced. Owing to their great importance, the attempt will be made to give an exhaustive account of our present position and knowledge of the changes which take place subsequent to a cataract operation. First of all, the reader is reminded of the far-reaching and beneficial 284 effects which the study of bacteriology has had, not only on general sur- gery, but also on this particular branch of the same. In no other depart- ment is such painstaking care requisite to prevent infection. Not only must the eye and its adnexa be absolutely free of infection before an opera- tion is undertaken, but the same care and attention must be given to the instruments, the bandage and the eye water used during and after the operation and during ihe processes of healing. Truly, to prevent infection, here, if anytvhere, the price of success is eternal vigilance. This one factor, "infection," is responsible for more poor results than all the others com- bined, and its occurrence will explain many of the pathological conditions to be enumerated. He who ivill read between the lines, will, in the follow- ing pages, note the effect of infection. A. EECLINATION. The operative procedures, by means of which a displacement of the lens is purposely and skillfully brought about, differ from each other, as we have seen, in more ways than one, depending on whether the needle- like instrument which we employ is pushed through the cornea, or the sclera, and also upon the position in the eye, into which the cataract is to be brought. The thrust wound through the cornea which is made in kera- tonyxis is, as a rule, followed by but slight consequences; but, nevertheless, we meet with cases in which the reaction has been very great, and the operation followed by iritis and cyclitis. If the needle is poorly con- structed, so that during the operation the aqueous is evacuated, there will be added to the injury of the eye, which must necessarily tak6 place during the act of tilting the lens over, an entire transposition, equal to the depth of the anterior chamber, of the contents of the eyeball, and this transposi- tion, during discission, not infrequently complicates the surgical procedure in a most detrimental manner; however, during extraction, this can never be avoided. In making a sclerotonyxis, the needle wounds the conjunctiva, the sheath of the ninsele, rccfuf<, e.vternvs. or the musck' itself; the sclerotic, tlie choroid, and the ciliary portion of the retina. It then reaches the vitreous, and then the danger arises of puncturing one of the ciliary processes, and finally it passes through the zonula zinii. Thereupon, it either enters the lens behind the aequator and leaves it again in the periphery of the anterior capsule, and finally comes in contact with the iris; or, without touching it, makes its appearance in the pupil, with its surface in contact with the anterior capsule, (Willburg, Scarpa): or it grasps the 285 lens at its upper edge, in order to depres> it. in whicli ;in iiijui'v to the lens before the act, is not always necessary. (CcLsiiis). Hence the injury, on making a sclerotonyxis; the simi)lc' piiiuture with the needle, is a more serious procedure, and differs further from the keratonyxis, in that the channel of the wound through vascular tissues and the possibility of punc- turing a choroidal vessel (Celsius), or a ciliary ])rocess exists, and of thus causing an internal hemorrhage. Nevertheless, experience has taught, thai even this method of ])uncture is frequently tolerated without evil conse- quences. Where, after reclination in any particular case, infiammatorv symptoms develop^ we are not able to exclude the fact, that the peculiar nature of the channel of the puncture is in all probability responsible for the trouble. (Infection.) Arlt (operations lehre, p. 255) considers it as the usual oeciirrence, where we operate after Scarpa, that the needle passes througli rhe -?dge of the lens and the anterior capsule, and on raising the handle of the instrument, the anterior capsule bursts; and if the cataract is hard enough, it will be forced into the vitreous through the previously torn posterior capsule. Hence, in making a dislocation of the lens, we either cause a rupture of the posterior and anterior capsule; or, at times, a partial, at times, a complete detachment of the lens in its capsule from the zonula zinii; with or without at the same time injuring the capsule. Hence the hyaloidea in the hollow groove of the vitreous must be torn, and the tissue of the vitreous forced asunder, in order to permit of the lens occu- pying a certain amount of space. In which part of the vitreous the lens will finally come to rest, and the manner in which its surface will lie, de- pends on the method pursued. It stands to reason, that it is impossible for the eajtsule to be torn, or for the lens to become detached from the zonula zinii, or for the hyaloidea to be ruptured without at the time exerting a certain amount of traction on the corpus ciliare and the parse ciliaris retinae. The force and influ- ence which the traction will exert on the future welfare of the case depends partially on the certainty and the delicacy with which the operation is made, and partly also on the intimacy which exists between the lens and its sus- pensory ligament. As we have already seen, this connection becomes looser as age advances; more particularly so, where a shrinking capsular cataract has developed. The performance of the operation and the nature of the cataract, influence the extent of the injury whicli the vitreous must re- ceive. There will be but slight resistance to the dislocation of a hard, !:hrunken lens, whereas the traction on the ciliary body will certainly be greater, where a cataract is but partially cloudy, or where the cataract is •oft. When the entire lens system has been reclinated, there is less danger for it to mount up again, whereas in cataracts which have a less tough con- 286 sisteiiee, the capsule is torn in the greatest variety of ways, and a portion of its shreds will remain in connection with the reclinated lens. On this account, in the latter cases, the reclinated cataract more frequently mounts up again, thus necessitating a repetition of the steps of reclination, and thereby increasing the injury to and destruction of the vitreous. The result of the operation depends greatly on the consistence of the vitreous. If it is normal, it will naturally offer greater resistance to the sinking of the cataract; but, at the same time, if the foreign body has once been taken up. it will be held all the firmer, since both its point of entrance and the channel which it made for itself will close up and heal all the sooner. A fluid ^dtreous will offer but little resistance to the cataract, as we see it in cases of spontaneous luxation of the lens, but on the other hand it will offer no resistance to the independent movements which the foreign body may make. As we shall see further on, fluidity of the vitreous may be a result of reclination, hence this will explain how it happens, that cataracts which have not been fully resorbed may after many years spontaneously mount up again. Further, it depends on the nature of the cataract, especially its con- sistency, whether it will be necessary to go through the movements of reclination a number of times, and it depends largely on the factor whether or not the lens will be depressed in the vitreous as a single mass, or divided into a number of pieces. This certainly must exert an influence on the pathological processes which take place in the eye after an operation. From that which has been said, it must become evident, that in this method of operating more than in any other which we will consider, great differences will be found in the results, even of operations which have been most suc- cessfully executed. (Stellwag, 1. c, p. 771). In considering the processes of healing, it does not suffice to eliminate the operative procedure; but, owing to the reaction of the lens in the eye, pathological conditions are produced which under certain conditions may require weeks, months and even years to subside. The dislocated lens is to be looked upon as a foreign body which possesses the peculiarity that it may be dissolved and absorbed, and this pathological condition may only be looked upon as ended when the above conditions have been fulfilled. But since in these cases such a complete resorption never takes place, hence Just such eyes never become free of this diseased condition. If, by means of these lever-like movements, the lens is successfully re- moved from the pupillary area, so that it does not mount up again, and no signs of reaction follow, one might almost say that the immediate result of the operative procedure is wonderful. Truly, one must have been pres- ent and witnessed snch a procedure — something wliieh is hardly vouchsafed 2,S7 the yoiino-er generation of oculists — to fonii any idea of the impression which the sudrlenl_y-attained bhick pupil makes, ami to witness tlic radiant joy of tlie patient who has had his sight suddenly restored to liim. And. in fact, such cases were not of infretpient occurrence. A reclination which is made without a mishap is often followed by no reaction whatever. The eye remain- pci-rccily ])alc. the lens does not mount up again, and in the course of a week the patient is permitted to use liis eye. In other cases the conjunctiva becomes reddened, the eye irri- table to light and tears a few days; this, however, soon subsides, and the use of the eye is delayed a few days. If ciliary injection sets in, one must decide if this is partial, or if the entire cornea is encircled. Even in tlie lirst condition t!ie conjunctiva be- ,gins to swell up; there is considerable secretion, the iris becomes discolored, vascularization becom.es distinct and leads to exudation. After a time this abates, leaving a few synechia. iVfter all these inflammatory symptoms cease, we find the pupil drawn in the direction in which the lens was re- clinated, and a secondary cataract of greater or less thickness can be seen. The usefulness of the eye will depend on the thickness of this latter cata- ract. If the ciliary injection is not restricted to th? neighborhood of the point of puncture, the conjunctiva will become chemotic, iritis develops, and one can discern through the pupil that the capsule is involved in the inflammatory process. This disease lasts longer, and not infrequently leads to total occlusion of the pupil. How much of a result can be obtained by a subsequent operation in such a case, to increase vision, I can not state from personal observation, nor have I been able to find any reports in liter- ature. It appears that the so-called subsequent operations have but lately been adopted (1876). If the pupil is not entirely occluded, a greater or less amount of vision may still be oljtained. If these symptoms increase, hypopyon develops, and then the pupil will give a yellowish reflex. These cases may terminate in one of two ways. During the gradual resorption of the hypopyon and total occlusion of the pupil, phthisis hulbi gradually develops; this process takes months, and is accompanied from time to time by pain; sensibility to light is totally abohshed, or may for a time still be present. Or the pus is not resorbed. but evacuates itself at some point, most frequently in the neighborhood of tlie point of puncture, finding its way outward through the sclerotic. But seldom has .ulceration of the cornea been observed. (Daviel). (This is the picture of an infection). The above-named forms of disease may be complicated by portions of the lens remaining in the pupil, floating about in the vitreous, or getting into the anterior chaml)er. Before a useful amount of vision can be at- 288 tained these must first be resorbed and eliminated from tlu'ii- respective positions. These processes may not develop at once in the manner described, but may develop suddenly in an entirely imexpected manner after the lapse of monihs or years in cases which had apparently terminated most success- fully. There are also cases in which, without any premonitory symptoms, or without any outward signs, a serous choroiditis develops, leading to glaucoma and amaurosis. Finally, cases are reported from the remotest antiquity, in which lenses which had been reclinated for thirty years, sud- denly mounted up again in a vitreous which had become fluid, and began moA-ing about freely, and for a time return to occupy their former position in the pupil, or by accident getting into the anterior chamber, thus causing secondary glaucoma. "The anatomical examination of eyes on which the operation of reclination has been practiced has explained to us the reasons for the various clinical pic- tures that have been described. The literature which reports the examination of eyes on which reclination had been practiced is considerable. The epoch- making examination of Brisseau was made on an eye, on which this operation had been made after death. Maitre .Jean, Heister, Morgagni and others corrob- orated by their post-mortem examinations on non-operated corpses the ana- tomical nature of grey cataract; these, however, were soon followed by a num- ber of others, Deider, Henkel, Boerhaven, Hein, Pott, Scarpa. Acrel. Earl and Hesselbach, and these again by Soemmering and Textor, who were almost ex- clusively interested in the fate of the torn capsule after reclination, and also of the reclinated lens; and only in a passing way paid attention to other changes which they found in the eyes. The first accurate examination of an eye on which reclination had been practiced, and which was obtained for patho- logical examination during the period of reaction, was made by Rienker, in the year 1834. This was followed by examinations made by Von Graefe, Iwan- off and Pagenstecher, so that today we possess quite accurate anatomical in- formation regarding the more important processes, even those which occur in the most serious cases after reclination. A short time after scleronyxis it is often impossible to find the cicatrix of the puncture. Nevertheless, in one case Soemmering was able to recognize the point of puncture thirteen months after the operation; in another, eight and a half years later. This was recognized as a dark spot, one and a half lines from the cornea, and appeared somewhat more transparent than the rest of the sclera. Within, it was hardly a line from the edge of the retina, but on the folded edge of the cornea it could not be i-fognized. Puncture wounds of tlie cornea will be presently considered." 'I'lic ( li.uigcs wliich ihc capsule undergoes after reclination. v;iry greatly. If ihc lens, fogctlici- with its capsule, has been reclinated. naturally no trace of Ihc lattci- will be foniid in the ])iii(ill:iry area. Tlie t'uttire cdnditioii of the eye 2S9 then (Icix'uds on the I'jict, wlictlici- or not any considerable inflammatory symp- toms follow tlio operation. In Sonimerin>i's tiftli ()i)eration he fonnd tlie cap- sule free from its litiainent and its entire (•ir<-uniference except at tiie lower edge, where it was still attached to the zonula. Sommerint; leaves tlie (piestiou an open one, as to whether the capsule was separated and depressed without tearing, or if there was originally a small tear which had closi'd again. Opinions differ greatly regarding the frequency with which the lens, to- gether with its capsule, is reclinated. Stellwag (1. c, p. 614) declares as the result of his investigations that cases of primary cataract dislocation in the capsule are an exceedingly rare occurrence. Hence, the statement of Beer (1. c, II. p. 364). who in former years found reclinated lenses in their capsules, as also did Richter (Chir. Hiblioth., II, 322) and Szokalski (Prager Viertel Yah- resschrift). are all the more important, since both after the lapse of many years extracted cataracts which had mounted up again, and were enabled to deter- mine that they were enclosed in their capsules. Stellway states that it is pos- sible to find the "dry pod cataracts." If the capsule in its entirety, or even a portion of it. remains in direct con tinuity with the zonula, it is impossible to perform reclination. unless at least the posterior capsule is torn. Five years after reclination Von Grate found in an eye which he examined the anterior capsule intact; whereas, in the pos- terior there was a circular opening 2.5 inches in diameter. Hence, the point of the needle used did not touch the anterior capsule, but remained imbedded in the lens substance. Stellwag (1. c, p. 608) stated that such a thing is pos- sible, and Ritter (91"). p. 9) proved it experimentally. The opening in the pos- terior capsule is not always regular. Stellwag found in post-mortems made on cholera patients, that the capsule was torn in many directions. Sometimes the central portion was missing. But even in these cases the peripheral por- tions" adhere to the anterior capsule. If death had followed shortly after theit reclination. they were to be recognized as floating slireds. But if tlie patient lived many years after operation these shreds were always found drawn back, and forming either a part of the crystalline pearl (Wulst). or as the posterior portion of a tattered secondary cataract, resembling in form a cataraeia sili- qtiata; or they were even found together with the anterior capsule somewhere in the eye rolled up like a ball. Tlie anterior capsule either dischised a simple hole, or a piece had Iteen torn out. These shreds whicli had been torn loose resembling a clotli wliich liad been rolled up. were found folded together in tlie vitreous: tliey were, liowever. adherent to the nucleus of the lens, and were fiirtlKT. still in coiiueciion with the uninjured portion of the zonula, and in this manner with the corresponding ciliary processes. In other cases the anterior capsule was partially loosened from the zonula, and floated in the aqueous humor of the posterior chamber, either alone or in connection with the remains of the posterior capsule. Stell- 290 wag described a case in Avliich recliuation nart been performed according to tlie rules laid do%vn. and the anterior capsule was found adherent to the zonula only below, and was floating in the vitreous as a conglomerated folded mass. In every case in which it was shown that the anterior capsule had simply l)een torn, but that its connection with the zonula had not been disturbed, a so- called crystalline pearl or wulst had formed. This was first accurately de- scribed and defined by Soemmering, and dependent on conditions found in eyes on whicli recliuation had been practiced. The formation and the anatomy of the co-called crystalline pearl has already been described under secondary cat- aract. After the lens has been forced out of its capsule into the vitreous, the latter must take the place of the former. Hence, th vitrous will cause the capsule to bulge out anteriorly. But along with the gradual shrinkage and resorption of the reclinated lens, an increased secretion of aqueous takes place, and to- gether with the formation of the secondary cataract, the two halves of the capsule approach each other so as to lie almost in an even plane. This is found in nearly all post-mortem examinations. Earl alone states that after a lapse of five months he still found the space formerly occupied by the cataract filled with transparent fluid vitreous. Whereas, Soemmering states that at the end of thirteen months he found a perfectly even partition wall, made up of the remains of a torn lens capsule, which separated the aqueous from the vitreous. According to Soemmering and Textor d. c. p. 32) the opening in the pos- terior capsule is at times filled out by a very delicate, transparent membrane, which then forms the partition wall between aqueous and vitreous. This can be nothing more than the hyaloidea. concerning the wounds of which Stellwag has observed that they can heal without leaving a cicatrix. It is to be re- gretted that just in this fifth observation of Soemmering he makes no men- tion of the relation which he found existing between aqueous and vitreous. The few statements which report that after the close of the process, the vitreous is found bulging anteriorly, are of earlier date. Even in eyes which had very good vision, an abnormal adhesion was found between the periphery of the posterior capsule and the zonula, without the presence of any synechia. Such thickenings of the zonula coming on after a cyclitis are not of such rare occur- rence (v. Graeffe). Nearly all investigators seem to have interested tliemst'lv<'s mostly with the fate of the reclinated lens. The position which a reclinated lens will occupy must necessarily depend on the method which is practiced,, if the operation has been done in a perfect manner, and further depends on whether the lens does or does not completely or partially mount up again. Examination has shown that the reclinated lens comes to lie directly over the insertion of the R. inferior (Soemmering. 1. <■.. ]>. HO), at times downward and outward in the vitreous (Soemmering. Phitc I. Fig. 1 and 2. 4. IMate II. Fig. 5. Textor. Fig. 'J. 3. 4). In cases of incoinph'tc rccliiuition. and following partial resorption, tlie nucleus I 291 of the lens may agniu bet-oiiio so displaced as to get back into the capsule, sink to the bottom, and simulate a Morgagniani's cataract (Textor, Fig. 1). The opportunity has been but seldom oflfered to accurately determine, at an early date, the position of the surfaces of the lens. Hence, it may be a matter of great interest to state that I (Becker) have been given n specimen by Dr. Manz (scleronyxls). in which the lens lies somewhat below and inward, almost touch- ing the lower edge of the torn capsule, and with its anterior surface turned upward. In Soemmering's fifth case the lens must have occupied a somewhat similar position, and four and five years after a reelination v. Graeflfe could determine the anterior (less convex) surface of the lens turned backward and somewhat upward, the posterior surface somewhat forward and downward. The illustrations of Soemmering and Textor give us a very good idea of the position in which the lens finally becomes fixed. It is also very noticeable that in Soemmering's illustrations we find the lens lying further back than in Textor's illustrations. This is probably due to the fact that Soemmering recli- uated through the sclera, whereas Textor did so through the cornea. One can. however, only then form a correct estimate of the position of the lens lies. If we bear in mind the position of the center of the lens, for since the lens shrinks in the vitreous; hence, in order to judge how far the lens is removed from the I'Qterior or posterior portion of the eye, one must not forget that this depends on the degree of shrinkage. In Textor's cases the center of the lens lies on the folded portion of the corpus ciliare, whereas, in Soemmerlng's they lie on the flat portion, so that before resorption his lenses must have been partially en the retina. All reports agree in showing that the post mortem examinations showed tbo volume of the reclinated lenses to be diminished. It is only in the fifth .-(•pert of Soemmering that he emphatically states that though years had elapsed since reelination. the darkened and hardened lens in its capsule was not re- duced in volume. Likewise in Manz's case, no reduction in volume could be found. (I regret that I can not give the exact date of the operation.) In all other cases I find it mentioned how great the reduction in volume was. or if the lens had entirely disappeared without leaving a trace. The number of the latter observations, however, is not very great. Such cases have been described by Deider. Acrel. Hoin, Earl. Soemmering, Arlt and Iwanoff. However, it must be stated that in the eyes operated by Soemmering and Iwanoff vision was de- stroyed as the result of very severe inflammation, so that it is very likely that the lenses were destroyed by the purulent inflammation. Hence, with the ex- ception of Arlt's cases, all those reports of cases in which good vision existed after reelination with total resorption of the lens are of earlier date. However, both Acrel and Arlt make very positive statements. The former says (1. c, p. 109): "I examined the eye on which the patient had good vision subsequent to the operation, and I find that the depressed lens had been totally dissolved and absorbed." Arlt says (p. 346): "In a specimen taken from an insane pa- tient, who had been operated nine years previously, not a trace of the nucleus 292 of the lens could be found, either in the vitreous or on the retina." The volume of the remains of the lens varies greatly, from the scarcely perceptible pieces to pieces the size of millet seeds— greyish white bodies. (Soemmering, Beob. l.,» Beyond a doubt the result is greatly influenced by the consistence of the cata- ract, and dependent on the fact whethei*. during the operation, a great deal of cortical substance is stripped off; also, whether the capsule is also reclinated. Time does not seem to be the only factor requisite to bring about resorption of a cataract. Beer says (1. c p. 364): "In fact, I have never yet seen a cat- aract which, being held but partially fast, could be entirely dissolved and re- sorbed, and before I will believe that this can occur, I must personally see a depressed, solid, hard cataract really dissolved and resorbed, which I am sorry to state I have never as yet been able to see." In a case which Hesselbach examined, a lens which had been depressed for forty-four years was not en- tirely resorbed. However, in these cases of such long standing, examined by Hesselabch and others, deposits of lime salts were found in the remains of the lenses. Ritter described the processes of resorption of the lens in the vitreous as similar to those which take place in the aqueous. The fibres lose their close and compact arrangement, so that the reclinated lens may later on separate into a number of pieces. The fibres shrink, and whereas the fibres break up and become tumescent, and finally absorbed, the membrane most probably remains unchanged. Opinions differ greatly as to what becomes of portions of the capsule which get into the vitreous during reclination. Stellwag states (1. c, p. 615) that he frequetnly was not able to find pieces of capsule which had been torn away and fallen into the vitreous. Likewise, he frequently found edges of the posterior capsule which were still connected with the an- terior capsule much reduced in size. Where the edge of the posterior capsule was wanting, one could never find any remains of the posterior. The portions of the latter which were found imbedded in the crystalline peai-1 was never as large as those shreds which were found adherent to the edge of the anterior capsule, when the eyes were examined shortly after the opej;ation. From this •we can assume that not only dislocated pieces of the anterior aud posterior cap- sule and those which are torn out may be absorbed, but also those which are still adherent. Stellwag himself seems to acknowledge that the whole capsule or large pieces of the same are not only not absorbed, but offer great resistance to the resorption of the enclosed lens substance. This general principle of Stellwag's, which is also met with at other plnc(>s, T desire to contrast with the fact, that at that time the methods of nii( r()S(<)i)i(al investigation were not developed sufficiently to distinguish Avhother ur not very fine and delicate shreds of the capsule were still present in tlie eye. Evt'u in cases wliere the entire eye is destroyed by purulent inflammation, the In/dliiir IinncJUic of thr rlmroid withstand solution, as does also the iiiciuhnind liniihnis of the niiiKu: even when nothing else remains of these structures. The same is true of iiienibnina dcsccmrtl and of tlie ('(ipsidc of the lens, in cases of traumatic cataract. Dr. Gold- 293 zieher found, one year after tlic coiiiplctioii of a raiaran ..jici ation. a jtiocc of the capsule entirely undiauyed. enclotsetl in ilic former are gradually acted on by the vitreous dissolved oft', and even in the miinitest quantities like chemicals exert an irri- tjiting iiitiuence. .lud give rise t(t inflammation of ascei)tic or chemically pro- duced pus. 'I'his inflammation may be of a very low grade and chronic variety, and gradually lead to destruction of the vitreous. The compar.atively frequent observation, namely, that in successful cases of reclination. the reclinated lens is found still held in connection with the lower portion of tlie zonula, will exjtlain why this detrimental pressure on the retina and corpus ciliare does not so often overstep tlie limit of endurance. 294 The zonula fibres act like an elastic spring, counteracting the pressure which the lens would otherwise exert. The elasticity of this membrane, and with perfect right, has been enumerated as one of the causes for the mounting up again of the lens. This, however, is not the only cause. Time and again post mortem examinations have shown the vitreous to be fluid (Soemmering, Acrel and others). A synchisis before the operation would necessarily defeat the results of an operation. Just as a fluidity of the vitreous is to be looked upon as a cause of spontaneous luxation, it must likewise favor a reclination of tlie lens: but it will also prevent a permanent result. If the fluid- ity is a result of the iccliiiation. it will depend on tlie kind of adhesion whether or not the lens will become freely movable in the vitreous. Various observers have found the reduced lens floating freely in the vitreous. Stellwag (1. c, p. 618) describes a peculiar form of fluidity of the vitreous, ■which seems only to affect the anterior and middle portion; but with this I am neither familiar from personal observation, nor from the statements of others. He says: "Very frequently he finds the vitreous reduced to such a degree that, aside from the portion which is applied to the retina, there is a space anteriorly which is filled wltli watery fluid." And he adds (with perfect right): "and when the portion of the vitreous in contact with the nucleus of the cataract becomes fluid, the position of the latter in the future will be deter- mined by its speciflc weight. On moving the eye about we can then see it dancing about inside the globe, and it may possibly get into the anterior chamber. Such a fluidity of the vitreous, coming on long after an operation, has for a long time been looked upon as the cause of amaurosis without cloudiness of the transparent media, or without detachment of the retina. (Secretion glau- coma of V. Graefe). This was first described by Beck and later again by V. Graefe. The connective tissue threads, which in cases wliieh take a favorable course totally surround the lens and hold it in its position, can be most easily de- scribed as the products of a circumscribed cyclitis, and of that particular va- riety which by preference originates in the pars ciliaris retinae. The amount of new formed tissue permits us to estimate the intensity of the cyclitis. and Soemmering has described and illustrated stages of development of this pro- cess. We possess the reports of more eXact examinations made by Rieneker, V. Graefe and Iwanoff, in which vision had been totally destroyed as the result of cyclitis and its various complications subsequent to reclination. Rieneker examined an eye on which keratonyxis had been practiced eleven days pre- viously by means of a Scarpa's needle. Violent inflammation followed, intense chemosis, hypopyon and ji yellow reflex from the pupil was noted. The eye became amaui'otic on the fourth day; the light sense remained nihl, but the inflammatory symptoms subsided a few days before death. On post mortem examination the point of puncture could only be found existing as a fine cica- trix. At the lower portion of the anterior chand)er exudate was still present 295 (liyi)Oi».von». wliich liimly .-mIIi. M-fd to ih,- ntnw.i .-nul iris. Tlic tii.|.cr half of the iris bad a gioeiiish disouloratiou. and in the neifihborhood of the hypopyon were small echynioses. The moderately dilated pupil was in about two-thirds of its area filled with exudate. The retina was loosened up and of a grey color; the choroid was of a brownish red color. Extravasated blood lay between the retina and the vitreous. The vitreous was very consistent, and of a greenish color. To the temporal side was a mass of pus about the size of a beau. In front of this, to the outer and lower side of the uvea lay the lens, on the ciliary baud, between hyaloidea and nervea. Close to the lens was an ecchymosis. The lens was swollen, externally soft and flaky, internally hard. In the neighborhood of the lens the sclerotic seemed to be normal. This is the only case, which I have been able to find in literature, in wliich the sequelae follow- ing reclination and acute purulent irido choroiditis, has been described in a perfectly clear and comprehensive manner, taking into consideration the time when it was written. (No doubt bacteriological investigation would have dem- onstrated the presence of staplylococci and streptococci). It appears that Iwan- off must have examined a similar case. In the eye which Moren examined (1. c. p. 35) the globe had retained its form and size, retina and choroid were in their normal position, the vitreous, however, was drawn forward, so that its anterior posterior chamber measured but 8 mm. Downward and outward, where in Rienelcer's case the lens lay, there was found an abscess in the stage of inspisation. The only remains of the lens was a crystalline pearl. This was everywhere enclosed in a thickened, new formed tissue, which posteriorly gradually disappeared in the vitreous, and anteriorly bound this crystalline pearl tightly to the iris. The pathological conditions were .iust as intimate with the ciliary body, which had likewise been changed by inflammatory prod- ucts. Both retina and choiroid showed increase of tissue change, more an- teriorly than posteriorly. Anteriorly the former showed many spaces filled with fluid, and many round cells, and the latter a more intimate connection of the various lamellae could be made out, especially between the pigment epithelium and the vitreous lamellae of the choroid. We recognize the description as that of a typical case of irido-eyelitis. Von Graefe examined a blind eye four or five years after reclination had been practiced. During life one could not de- termine any other diseased condition than a rigidity of a moderate sized pupil, in the center of which one could see a secondary cataract. Post mortem exami- nation showed that the iris was not adherent to the secondary cataract. The latter, however, was held adherent to the zonula by means of an exudate, and by means of this also with the ciliary processes. In the retina could be seen countless small and large whitish granules and nodule.s. and part of these ex- tended into the choroid. At some places they formed large i>laques. On micro- scopical examination all of these were found to form a continuous sheet be- tween retina and choroid, which at the orrata serrata became continuous with both membranes in their entirety. In the vitreous the direction which the lens had taken could be followed by means of a new formed connective tissue mass, 296 which h'jul to ;i im^inbriinous jKxket in the vitreous, and was located dowmvard and outward. In the neljrhborhood of this pocket, very tine whitish, cloudy nieuibranes in tiie otherwise colorless vitreous. A considerable amount of carbonate of lime was found between the choroid and retina, as also on the inner surface of the ciliary body, just as in the above mentioned case, ^'on Graefe draws attention to this diffuse process, extending from the ciliary pro- cesses over the entire choroid. Owing to the fact that the new formed con- nective tissue was in the vitreous, and tlie iris was not involved, this should be designated as a chorio-cyclitis. Tlic case of A'on Graefe. which was ex- amined by Iwanoff, was an atrophied eye. as a result of reclination. Here it ap- pears the reclinated portion of the lens was resorbed. The entire vitreous had been clianged into a new connective tissue mass and was drawn forward. Only here and there could the various layers be distinguished in the detached retina, which seemed to be made up of hyiiertrophied. radiating fibres. The entire choroid was folded, and between this and the retina anteriorly was a thin lamellae of bone. Even in flue sections small abscesses could be detected in the vitreous. The sheath of connective tissue which surrounded the lens seemed to be very tough, and at some places enclosed deposits of lime salts. This advanced calcitication seemed remarkable, considering that the reclina- tion had been practiced but nine months previously. The processes which lead to these changes is to be designated as an irido-clioroiditis. B. DISCISSION. As a rule, but slight reaction follows discission through the cornea; there are, however, exceptions to the rule. The kind of instrument used to puncture the cornea, and to open the capsule, is not without its influence. The English discission needle which is now in general use, only became so graduall}'. This is straight, anteriorly two-edged, and its neck has everywhere an equal thickneSvS, so that, when during the operation the needle is either pressed forward or drawn backward, it always completely fills out the channel of the wound; and, since the wound made by the double edge is just equal to the diam- eter of the neck, hence it is impossible for the aqueous to escape, during the operation. The older instruments, especially those which, even until re- cently, were recommended by some Eliglish physicians, arc conical and increase in thickness. This instrument not only interferes with the free movement in the channel of the wound, but its use certainly favors the bruis- ing of the edges of the wound. Such a waund will leave a cicatrix, which will be visible for a much longer time. In exceptional cases, the edges of the wound have been observed to swell up and assuuu^ a bubble-like promi- nence. If we will only stop to consider, how kindly frequently repeated 29 T punctures of the anterior clianiber are borne, (.Sperino), we can not assume that the occasional unfortunate mishap?;, are entirely the result of the cor- neal wound. Here again, the effect of an infection, either direct, by ui^e of a non-sterile instrunient. or the siibse(|uent infection of the wound from conjunctival secretion, is to be l)orne in mind. If. during or after the operation, the a(pit'()us is partially or com- pletely evacuated, the entire lens system must move forward. All the se- quelae of this occurrence, the release of the blood vessels from the intra- ocular pressure, and the consequent hyperaemia, in all the vascular portions of the eye, as well as the tension which is exerted on the ciliarv bodv in consequence of this moving forward of the lens, must be looked upon under certain circumstances as replete with injurious effects. It is well known, that puncture of the anterior chamber during the course of inflammatory affections of the eye. is accompanied by great pain. The moving forward of the entire lens system depends on the extent of the wound in the capsule, the depth to which the needle penetrates the lens substance, the consistence and, more especially, the compactness of the cataract. If one may so ex- press it. the normal process of absorption of the lens, after opening the capsule, has already been fully described in the general consideration of traumatic cataract. But discission does not always follow the normal course there depicted, for symptoms of a violent reaction may develop. The pupil contracts, and, in spite of the free use of atropine, will not dilate. The iris becomes discolored, and, owing to the rapid swelling up of the entire lens, is pushed forward, or a large amount of lens substance enters the an- terior chamber and also presses the iris forward. The peri-corneal in- fection which develops at once, gradually leads to an oedema of the con- junctiva bulbi; the ej-es become hard, and the field of vision contracted to the nasal side. At the same time, the patient complains of irritability to light, and intense pain radiating along the branches of the trigeminus. The picture of secondary glaucoma is complete. It has been supposed that these phenomena are the result of opening the capsule too widely, and of permitting the needle to sink too deeply into the lens substance; nevertheless, they have occurred after the most care- ful opening of the capsule. Hence, either the eye must be too sensitive or ■ the cataract peculiarly constituted chemically, so as to exert such a detri- mental influence. But the increased tension is always brought on by the rapid swelling up of the lens; this leads to the circulatory disturbances, the contraction of the field of vision, the irritability to light and the ciliary pain. "All these changes are almost exclusively obseived in the eyes of youthful individuals, except in cases in which we are dealing with exten- 29S sive injury. In older persons the opening of the anterior capsule likewise leads to a swelling up of the cortical substance, but if this does not exceed reasonable bounds, it will not lead to a pressing forward of the entire len- ticular mass, which does not seem to take place unless the nucleus likewise swells vip.'' These words of Von (Iraefe^ explain why injuries of the lens in older individuals have a better prognosis than in younger individuals; and also why in the latter days of his activity he became more careful in the selec- tion of cases, in which he practiced discission. If we are to look upon the great swelling of the cataract as the cause of the increased intra-ocular ten- sion and its evil consequences, it must become evident, that if the swollen lens, even in its entirety or partially, is extracted at the proper time, the pain, as a rule, will cease at once, the chemosis will gradually subside, and the resorption of any portion left behind will take a regularly normal course. It must, however, become evident, that under just such circum- stances a thick secondary cataract will develop, and that this can hardly take place without the formation of synechia. The spastic contraction of the pupil following discission is caused by a swelling up of the lens, which condition likewise leads to increased ten- sion, owing to the interference with the evacuation of the swollen lens sub- stance into the anterior chamber. The increase of tension is also due to increased secretion within the eye, due to the injury to the lens. Hence the healing influence which an iridectomie, made either at the time of discission or previous to it, exerts on the course of the discission, can be explained in two ways. Owing to the incision in the sphincter pupillae, the iris loses its power of contraction, and, aside from this, the excision of the pieces of the iris, acts just as it does in true glaucoma. Hence it is most advisable to make the extraction of a swollen lens through a linear incision, at the same +ime making an iridectomie In his -ast publication on cataract. Von Graefe spoke in the highest terms of praise of this method of treatment, and I (Becker) have repeatedly drawn attention to the same fact If the operation made during the stadium glaucomatosum is not made according to this method, advised above, in most cases a very painful, "sneaking" iridocyclitis will follow, leading to occlusion of the pupil and phthisis bitlhi. In such cases the detachment of the retina usually comes on at a later date. For a long time, a part of the sensitiveness to light remains, even in eyes in which intra-ocular tension is reduced. There may also develop primarily, as well as following a status glaii- 1 A. f. O.. I. 2. p. 238. 299 coiinilosiis. a su[»|)uriilivc' irido-c-lioroitlili.-. ))aii(i|tllialiiiit i>, willi purulent destruction of the eye. Where a discissio per scleroticam is made, the amount of vision at- tained should equal that attained where a soft lens is reelinated. Hence it will be unnecessary to again consider those processes which have already been described, and which make the results of such an operation question- able. The pathological ])rocesses wliich iolluw a discission have been prac- tically considered under the head of traumatic cataract. Here we must again refer to the experimental investigations of Dietrich and Ritter. How- ever, to give a synopsis of their work, wouhl l)o Init to repeat many facts which have already been quoted. Swanzy (Diseases of the Eye. London, 189-^, p. 360) states. ''This method is applicable to all complete cataracts up to the twenty-fifth year, and to those lamellar cataracts in which the opacity approaches so close to the periphery of the lens, that nothing can be gained by an irideetomie. After the above age, the increasing hardness of the nucleus, and the in- creasing irritability of the iris render the method unsuitable." "Discission is a safe procedure when used with the above indications and precautions. The danger chiefly to be feared is iritis, from pressure of the swelling lens, masses on the iris. When this occurs, or is threatened, removal of the cataract by linear incision in the cornea should be at once performed. Another danger consists in the glaucouuitous increase of ten- sion (secondary glaucoma): here, likewise, removal by a linear incision is at once indicated." C. EXTRACTION. As we have seen, tlu- original Daviel extraction consisted of a corneal ■flap ((h)iritirard), taking in tiro-thirds of the corneal circumference, and without an irideetomie. The only change up to the time of Von Graefe consisted in the position of the wound (Yaeger, iijiironl: W'enzel. oiilirard). But the principal objection to this operation always had been, the rela- tively large percentage of losses as the result of suppuration. Yon Graefe early recognized that this was due to the. at times, unnecessary gaping of the wound, to overcome which lu' iiitidduced what i> known as the linear incision. Such an incision can only he done, when the inc-ision is made in the "largest circle"* of the s])herical surface of the eye. because the shortest distance between points u])on the surface of the sphere, i. e., the line which is most nearly straight falls in the largest circle. The largest circle which passes through two points on the surface of a sphere, is situated in a plane 300 passing through tliese points and the centre of the sphere. In order to make this incision, a much narrower knife was necessary', and this Graefe likewise invented, and this today bears his name. This incision was like- wise made in the cornea, but in order to allow the lens to escape easily the preparatory iriiieciomie was made. Jacobson made his incision in the sdero-corneal mar(/in, and this suggestion was adopted by Von (Jraefe add- ing to this an ocular conjunctival flap which acted as a provisional band- age. 'J'his is known as his peripheral linear incision, and was in vogue dur- ing his lifetime. After his death, however, operators gi*adually departed from this operation, going back to the flap extraction, one set of operators making what is known as the scleral flap extraction. In this operation, the puncture and counter-puncture are made in the sclera one-half mm. from the corneal margin, and in such a manner that a straight line connecting these two points would separate the upper foui-fh from the lower three- tonrths of the' corneal circumference. After the counter-puncture is made, the incision lies close behind the limbus. As soon as the sclera is severed, the edge of the blade is turned slightly backward, so as to form a conjunc- tival flap, about 2 mm. in width. The irid£ctomie, capsulotomy, and ex- traction of the lens follows. The great advantage of this operation lies in the fact, that the incision lies under the conjunctiva, which latter also forms a tla]). which soon closes over the wound again, and thus prevents s uhseqiient infection . A second form of operation is the corneal flap extraction, (Wecker, Stellwag). Here the entire incision is made in the corneal limbus and in such a manner that one-third of the cornea is separated from the sclera. In this operation no conjunctival flap is obtained; or, if any, but a very slight one. llie iridectoniie may or need not he made, depending on the desire of the operator. Fuchs says, (Lehrbuch, 1891, p. T59), "Since this incision is less peripheric, i)rolapse of the iris is less apt to occur, than where a scleral incision is made. Whereas, when no iridectomie is made, the patient has the advantage of a round and movable pupil, it also brings with it its disadvantages: First, the delivery of the lens without an iridectomie is more diflficult, since it must be forced througli a narrow pupil, which procedure requires considerable pressure. Hence, this method is not indi- cated in cases which depend on a very delicate delivery of the lens, as, per example, whore the lens trembles and every increase of pressure is apt to lead 1(1 tearing (»!' tlie zonula and the liyaloi(h'a. and at the same time lead to a prolapse of the vitreous. Second, extraction without iridectomie is not advisable in complicated cataracts, in which synechia exist between lens and iris. Third, notwithstanding the use of eserine, prolapse of the iris niav ot( iii' in the first few days after an operation. Under such cir- 30I cumstances the prolapsed iris u\u>t ho excised. Ilenee, extraction without iridectomie is not indicated in cases wliicli show a tendency to prolapse of the iris, or where the patient is restless. Hence, one may conclude that the corneal flap extraction, where the conditions ar. favorable, gives the most satisfactory results; it is. liowever. not adapted to all cases, nor does it insure those almost positive results, as does the scleral extraction with iri- dectomie." Swanzy (Handbook. Fourth Edition, 181) Yrs. Yrs. Yr.s. Yrs. Yrs. Yrs. Yrs. Yrs. Yrs. Yrs Yrs. Yr.s. ■ 5-5-60 I , I 2 I 6=2 f* 6.5-7 5 4 7 10 13 23 21 14 II 2 110=2254 3 mm. 7-5-8 3 4 16 38 47 71 76 35 21 5 5 320-64 ^i &5-9 3 2 5 6 15 12 5 Iff the capsule 3 2 I 3 ' 5 2 ^ "1,.: 4 mm. Hirschberg (quoted above) states, "In order to attain good results in cataract extraction, three things are necessai7; care before the operation, care during the operation, care after the operation. The two greatest at- tainments of modern surgery, namely, anaesthesia and antisepsis (new, asepsis), have not failed to bear fruit in opthalmology."' The patient should never be operated on the day of his admission to the hospital. One day of preparation is sufficient; to wait longer, causes the patient to become impatient, and this is detrimental. The day previous to operation the patient receives a dose of oleum ricini (or some other luxative) and in the evening a light repast. The day of the operation, three hours previous to the same, a cup of coffee (or milk; without bread; and, subsequent to the operation, during the first few days, a bland diet which does not require much mastication and produces but little faecal matter; hence, during the first four or five days during which the patient is confined to bed, there is seldom a desire to empty the recium. Finally, the evening previous to the o])eration, the patient receives a luke- warm bath, especial attention being given to a thorough washing of the head. The operation is to be done in a well-lighted room, the best light being the north light. The operatoj-"s hands are to be thoroughly washed with soap and water, washed in subhmate 1:1000 and alcohol, and the finger nails cleaned with nail brush and file. The instruments are to be tested by the operator himself. All instru- ments which enter the eye must be made thoroughly aseptic. Boiling water destroys the pns- form rrs, so that instruments which are kept clean may be considered sterile, after being ])hu-e(l in l)()iliiig water for one-half to one minute. All glass or porcelain utensils are to be previously cleansed in a 1:1000 sublimate sol. All glasses, dishes and droppers are previously 305 placed in a 1:1000 sublimate sol., and jjiepared fresh for each patient, and just previous to the operation are washed out in a warm 1:5000 sublimate sol. The three fluids (absolute alcohol. IXii jxt cent.; sublimate water, 1:1000, and sublimate water, 1:5000) are kept in well-stopped bottles. A small bottle of a 5 per cent, cocaine sol. is prepared fresh, just prior to the operation. The operations arc always done early in the inornin«i-, for to do such delicate operating the operator should feel fresh. Knapi),^* however, be- lieves it better for tlie patient to be operated in the afternoon, because the usual five or six hours of smarting will then be followed by an undisturbed sleep, during which the union of tlie wound has the best chance to take place and become permanent. With a sterilized dropper, at intervals of five minutes cocaine is dropped into the eye three or four times. (When the iridectomie is made, four times is sufficient: tlie touching of the iris with the forceps will scarcely be felt). During the intervals in which the cocaine is being dropped into the eye, the lids should remain closed. Immediately after the last drop has been dropped into the eye, the lids and conjunctiva are to be carefully washed with absorbent cotton and fresh subhmate water, and then dried. The patient is then placed horizontally on the operating table, with the head slightly raised. An assistant holds the head, his one hand on the temple on the side opposite the operator, and tlie other on the forehead. (A nurse usually liolds the patient's hands.) The eye which is to be operated, is placed toward the window. The operator, who always operates with his right hand, sits behind the patient when operating the i-ight eye, and in front of the patient when operating his left. A short speculum, one which separates the lids v>idely and keeps them at a good distance from the eye, but which opens and closes easily, is then introduced; the screw, however, should never be clo.^ed, .«o that it may be removed quickly by a single movement at any time; ;.nd which, as a rule, is done immediately after cystotomie, and in exceptional cases where the patient presses very hard, even before the iridectomit . With the left hand, the operator now takes a short pair of fixation for- ceps with a spring to close tlu'ni. and with tliese grasos a fold of the ocular conjunctiva just below the horizontal meridian. In his right hand he takes his cataract knife, which is li mm. in width: this k delicately held, like a pen, the cutting edge naturally upward, toward the ujipcr corneal margin. 3a N orris and Oliver System of Diseases of Eye. Vol. III. p. Tfn 3o6 In this manner, the anterior chamber is punctured, s > that the back of the knife separates one-third of the corneal circumference. (The pulling down- ward of the e5'eball by means of the fixation forceps, as well as the pointing of the knife toward the centre of the pupil, as advised by Von Graefe, are unnecessary, and. if anything, detrimental.) The cocainized eye is com- pletely toleran^ to the fixation forceps, so that one may at once make punc- ture with the cataract knife. The practiced eye will at once see at a glance whether the width of the pupil is equal to one-fourth or one-third of the heiglit ot the cornea, (3 or 4 mm.); hence, whether the edge of the knife should be tangent to the upper edge of the pupil or a mm. below this; and • along this line the knife reaches the symmetrical point opposite to that of its entrance into the anterior chamber, in order to gain the correct point of contra-puncture; the handle of the knife is depressed slightly toward the temple, and then the point of the knife is pushed forward a few milometres. The handle of the knife is then made to make a quarter turn on its axis, so that the cutting edge comes against the posterior surface of the cornea, and then, by means of a slight sawing motion, the corneal incision is completed, the line of the incision falling close to the limbus. The assistant,, who sits or stands on the opposite side of the operator, takes the fixation forceps out of the operator's hand from beneath the operator's hand, and holds them. The operator lays his cataract knife on the porcelain plate at his side, and takes up the curved iris forceps with his left hand, the scissors with his right. (The instruments are often handed to the operator by an assistant). The iris almost never prolapses, but in the exceptional cases it is first carefully replaced, after waiting a few moments to see if it does not do so itself. The curved iris forceps is then introduced, dosed, at the centre of the incision in a radial direction, and opened a few milometres from the edge of the sphincter; and iris fold is grasped, withdrawn, and cut off by a single clip of the scissors. Since the introduction of cocaine, bleeding from the iris almost never occurs; the in- cision in the globe likewise never bleeds, since it is made entirely in the cornea, and the conjunctival flap given up. As a rule, the coloboma is small, with converging or parallel edges; its definite form, however, is de- ]>endent on the exit of the lens. The assistant now carefully opens the spring on the fixation forceps; at the same time, the speculum is gently closed, and while the patient is being told to slowly look downward, these are also removed. The assistant now gently holds the lids apart, far enough to expose the entire cornea. Thereupon, the operator again clasps the ocular conjunctiva exactly the vertical meridian, with a pair of forceps held in the left hand, while in his rjtrht hand he takes the cvstitome (the hook of which is lon.o;tM- and sharper 307 llian in the original (iniclV niodci. wlici'cas the straijilit portion is sliorter). With this, a T-shapod incision is made in the capsule; the horizontal por- tion first, and this is made to lie in the coloboma. Finally, the operator re- verses the instrument, and with the convex surface of the rubber spoon (or metal), makes gentle pressure on the external lower portion of the cornea, whereupon the lens rises up, during which time the spoon slowly follows, until the lens is totally dehvered. The patient is lold to close his eyes, and the operation is practically completed. Where the operaiion is made withoiil the ivideetoniy, Knapp lays par- ticular sii'css on the mannci' in wliicli ihc cajtsule is to be opened. He says: "The cvvtotome so advaiucs I hat the tip goes underneath the upper part of the iris, turn.- it, . T'.ts. b Modern operators apply a simple broad dressing, held in plaee by strips of eourt-plMsler. 3o8 first and second days, a dose of chloral hydrate Is given, and tlie nurse is especially watchful. The bandage is renewea each day until the twelfth day, but the patient is not permitted to touch the eye. At each removal of the dressing, the lids are first gently washed with pledgets of cotton dipped in sublimate water. Atropine is not used before the first day, and, in faci. only then when there are cortical remains or irritability of the iris.^" •'Reaction seldom follows. The two principal forms are iritis, due to swelling up of cortical remains, and septic infection, which nearly always leads to destruction of the operated eye, and can but seldom be stayed." •'THE LIXEA'E EXTRACTIOX is only adapted to soft and fluid cataracts in young persons. Here the incision is made with a l)road lance- shaped iridectomie knife, either in the outer horizontal or the lower outer quadrant. The knife penetrates about 4 mm. from the corneal margin, and is pressed forw^ard in the plane of the iris, until the corneal incision ha? attained a width of G or 7 mm. The point of the knife being now laid close to the posterior surface of the cornea — in order that no injury may be done to the iris or lens, when the aqueous humour commences to flow ojffi — the instrument is very slowly withdrawn, so that the aqueous humour may come away gradually without causing prolapse of th'^ iris. In withdrawing the knife, it is well to enlarge the inner aspect of one or the other end of the wound, by suitable motion of the instrument in thai, direction. The knife being now put aside, the cystitome is passed into the an- terior chamber as far as the opposite pupillary margin, care being taken, by keeping the sharp point of the instrument directed either up or down, not to entangle it in the wound or in the iris. The point is now turned directly en the anterior capsule, and by withdrawing the cystotome toward the corneal incision, an opening in the capsule of the width of the ])upil is produced. The cystotome is then removed from the anterior chamber with the same precaution as on its entrance. The edge of the spoon is then placed on the outer lip of the corneal incision, and the latter is made to gape somewhat, gentle pressure being at the same time applied to the inner aspect of the eye by the fixation forceps and in lliis way tlie lens is evacuated. When the ])ui)il has become quite black, the operation is concluded. If pressure does not at first clear the ])upil completely, the s{)eculum should l)e removed, the eyelids closed, a compress applied, and a few minutes allowed to elapse, in order that some aqueous be secreted. A renewal of the eH'ort to clear the pupil will prob- ably now be successful; if not, another pause may be made, and then fresh attempts employed, until the pupil is quite clear. It is unwise to insert the spoon into the eye to withdiaw tlie frn.aineiits: and. if some of these should 309 be left bcliiiul. iio ill I'cstilts need iicccssaiily follow, iill lioii^Mi iritis is more apt to supervctu' than il' the lens he thoi'oucrlily evacuaicd. l-'rag- inents left behind beioin'j absorbed. If there he a, prolapse of the iris which can not be reposed, it must be abscised." (Swanzy, p. 33(5.) This same operation is applicable to nienibranous cataracts, with a sharp-pointed hook or forceps, which is ])assed through the wound; the membrane is grasped and withdrawn. The advantages of this incision consist in its relatively small size, and the readiness with which it closes. Xo iridectomie is necessary. Tmt, owing to the size of the corneal incision, this operation is only applicable to the membranous and soft cataracts; that is, in those which do not possi'ss a nucleus. By increasing the size of this original linear incision, moving it back farther, and making it above and combining it Avith an iridectomie, Von Graefe originated his peripheral linear incisiov. But this incision was often too small, so that Jacobson moved it still further back into the sclera. He, however, abandoned the linear incision, and made a Ha]i incision and the iridectomie. (iraefe made his opening in the capsule with the cystitome. others with a discission needle or a small, sharp hook. A decided improvement has been the introduction of the capsular forceps. By means of this in- strument, not only is the capsule opened, but a piece of the anterior cap- sule is withdrawn from the eye. This prevents a rapid closure of the cap- sule and permits of a greater resorption of retained lens substance. This procedure has lessened the number of secondary cataracts. It has. how- ever, one objectionable feature; namely, it is possible, in tearing the capsule, that the rent will be too extensive, extend too far into the equatorial region, even into the posterior capsule, and thus produce conditions favor- able to prolapse of the vitreous. During the sitting of the Seventh International Optlialmological C'on- gress, held at Heidelberg, in 1888, Schweigger wrote the following sen- tence on the blackboard: "The bad results are not dependent on the posi- tion or the size of the incision." Since the application of antiseptic and aseptic methods to eye surgery, most of the complications occurring subse- quent to a cataract extraction have ceased to exist; namely, the wdiole train of diseases due to septic infection. It seems rather a sad commentary that all the efforts of Yon Graefe and his school should have passed away and have been set aside. Still, to him remains the credit of having greatly re- duced the ])ercentage of losses in the pre-antiseptic days. In considering the changes which the lens undergoes during an ex- traction, we must differentiate between those of the capsule, of the intra- capsular cells, and of the true lens substance. The size of the wound in the 3IO capsule has but an indirect influence on the process of healing. This mem- brane, aside from rolling and folding itself up, remains perfectly indifferent to the changes in its vicinity. The intracapsular cells, the so-called single layers of epithelial cells which line the inner surface of the anterior cap- sule, as also the cellular structures along the equator, on opening of the capsule and extrusion of the lens, are disturbed in their regular continuity and brought in contact with a heretofore foreign fluid. The manner in which they react has already been considered under "Secondary Cataract" and the "Crystalline Pearl.'' Only exceptionally is the lens removed in its entirety. As to what will remain in the capsule depends largely on the consistence of the cataract. Everything of which the lens is made up may be found — normal lens fibres, whole or broken cataractous lens fibres, myelin globviles, fat, cholestearine crystals, and lime salts; all of which are incapable of further development, hence they act as a foreign body. As we have seen, the lens fibres* possess the peculiar quality of swelling up to an enormous size, so that their pres- ence may greatly endanger the further existence of the eye. Aside from this, not infrequently after an operation, this capsular epithelium begins to undergo a hyperplasia, and then take an active part in the formation of the secondary cataract and the crystalline pearl. If the extraction is made so as to remove the lens in its capsule from the eye, as Sharp and Mohrenheim attempted to do, and as Pagenstecher did, the injury will be of a different character. The lens (like an amputated member of the eye) can no longer enter into the .onsideration of the pro- cesses of healing; one must, however, not forget, that the lens could not have escaped from the eye without tearing every single fibre of the zonula zinii. This operation has been practiced by Beer, Eichter, Sperino Mac- namara and Andrews. (Tiber Staar Extractionen mit und ohne Entfernung der Kapsel von Herman Pagenstecher, Graefe, Arch., Vol. "XXXIV., B. 2, 1888). After completing the corneal incision, owing to the evacuation of the aqueous and the loss of the greater portion of the contents of the capsule, or of the lens, together with its capsule, the globe loses from 2t to 14 of its volume. Notwithstanding this, as a rule the eye does not become lessened in size, nor does it collapse. By what means is tliis prevented? It is evi- dent that, whereas in the beginning, aqueous, iris, lens, and vitreous fill out the space, after the operation, this same space is simply occupied by iris and vitreous, where formerly was aqueous and lens. The change of posi- tion to which these parts must be subjected, must be considerable. The ins moves forward the depth of the anterior chamber, equal to a distance of three-quarters of a uim. 'I'lie fossa patellaris, which is still separated 3" from the anterior chamber by the posterior capsule, moves forward J mm. Such a great transposition of the individual structures can not possibly take place without materially drawing on the structural elements of the iris and corpus, ciliare, and, more especially, on the nerves which traverse them. But it is impossible for the vitreous to move forward without the space which it vacates becoming filled in some other way. In eyes in which the coats are still elastic, these will contract and re- duce the volume to a degree equal to the previous tension of the globe. By this means, the most essential portion is compensated for. Hence it follows that where the sclera has lost its elasticity, the cornea becomes wrinkled; or, owing to atmospheric pressure, is pressed, funnel-like, inward. This, however, is not the only compensation. When the aqueous is evacuated, and, still more so, on evacuation of the lens, the pressure of the blood vessels in the eye must be reduced, to a degree propoi-tionate to that which they were under before the above parts were pressed out, and de- pendent on the tension of the eye itself. Hence, just at this moment there must take place a sudden and great dilation of all the blood vessels in the eye. It has been a well-known fact for a long time, that in cases in which there existed a pathological increase of intra-ocular pressure, the sudden reduction of this pressure, on opening the anterioi cliaiiiber, has not infre- quently led to the occurrence of hemorrhages into the interior of the eye. In a case, in which I (Becker) punctured the anterior chamber for an em- bolus of the arteria retinae centralis, with the hope of thereby causing the embolus to change its position, I observed the occurrence of innumerable retinal ecchymoses, though the intra-ocular pressure had previously not been increased. Hence there appears to be no doubt, but that retinal hemorrhages may occur when an extraction is made From opthalmoscopic examination, we know that where the intra- ocular })ressure is reduced, on the use of atropine, hypei-aemia of the retina and choroid does take place, together with a dilation of the blood vessels. In favorable cases, one may observe this hyperaemia with the naked eye, by simply watching the change in color w^hich a slightly pigmented iris assumes during an extraction. Finally, IwanofE's experiments have proven it to be not at all improbable that even in cases o-f normal extraction, prob- ably during the same, a detachment of the vitreous takes place, so that when the vitreous moves forward a vacuum is produced at the posterior pole, if this is not prevented by an instantaneous transudation. That which has so far been described, can and must occur when an extraction is made, even though an eye speculum is not used, non-fixation of the eye practiced, when a lens is removed, and no special maneuvers are required to bring this about. 312 Thougli the greatest care is exercised in inserting and removing the specuhini, we do not always succeed in avoiding injury of the cornea. If attention were only directed to this point, frequently after cataract extrac- tion, extensive loss of epithelium would be found. Owing to the great im- portance which such epithelial losses assume, where infectuous conjunctival secretion is present, it certainly ought to receive the most serious attention. The iris may be involved in a variety of ways. In every case, the moment the aqueous is evacuated it contracts spasmodically, so that where the pupil is forcibly distended by the passage of the cataract, it must suffer a ven' considerable bruising and transposition, and not infrequently we find iris pigment adherent to the extracted cataract. Even where the operation proceeds in a perfectly normal manner, the iris is easily pressed into the wound, and then either draws itself back by means of contraction of the sphincter, or the sphincter must be irritated to contract by means of rubbing the lids; or, finally, the iris must be returned to its normal posi- tion by means of instruments. It is entirely irrelevant whether or not we grasp the conjunctiva bulbi alone or together with the tendon of the rectus inferior, in order to fix the eye. Notwithstanding this, not seldom a demonstratable injury is pro- duced. Even where the fixation forceps are used with the greatest care, for days afterward, the points where they grasp the conjunctiva are mark- ed by a suffusion. If the teeth of tlie forceps are vei-y sharp, and the con- junctiva (as it frequently is in old people) friable, this will lead to hemor- rhage, and even to tearing of the tissues. Later on, it will be shown how the sudden occurrence of ciliary injection on fixation may be utilized in determining, whether one should risk or put off the extraction in a case in which cyclitis had supervened after traumatic cataract. In such cases, the simple fixation, in eyes which were previously pale, is sufficient to bring on ciliary injection, and proves that this grasping of the conjunctiva with the forceps, is not such an innocent pi'ocedure as one is wont to suppose. (S. Liebreieh, 1219). Tliat which has just been said bt'i-ouies of tncn jiroater importance Avhen the lixation is contiuuod after tlie eyeball has been opened, and even more so when tlie opei-ator. after making tlie (.-orneal incision, iu order to be able to ex- cise the iris, leaves the fixation forceps in charge of his assistants, and later again takes charge of them. Since the eye involuntarily rolls upward, a certain amoiint of force must necessarily be exerted in order to bring the wound into an accessible position. Even in the hands of the most expert operators the tension between the point of fixation and the corneal wound is undoubtedly greater wheie the closed forceps hanging to the eye is handed over to an assistant. In such cases the cornea will gap wide open, and even fold itself vertically. Just such traction on the cornea, the corpus ciliare and iris becomes the most detri- 3>3 iiU'Ufal factor of an cxlraction. I »»'iicii(liii;; on tlic dciiicc to wliicli this second pernicious occurrence is avoided will he found the secret of tlie j^reat differences in the results of the various skilled operators. Every method and «'very sup- j^estion which will aid us in lessening this portion of the operative procedure is deservins: of the most earnest eonsideration. Hence, one should «-hoose a pair of forceps which are not too sharp, rather. re it follows as the result of a strong muscular contraction on the part of the patient. The escape of vitreous, previous to the delivery of the lens, since it necessitates our going into the eye with instruments, is to be looked upon ns a verv i-cvcre complication. i 315 Ever siuee the iutrodiK-tioii of Daviel's method, the escape of vitreous, as a novel occurrence during cataract extraction, has naturally excited the atten- tion of operators (it even occurred to Daviel and he in<'ntioncd iti. and has therefore, since that time, been frequently anw he could foretell the occurrence of such hemorrhages. Arlt was of the opinion that this occurrence could be prevented, if we would refuse to operate an eye, which showed any evidence of increased intra-ocular ten- sion, without having made an iridectomie at least one week in advance. The cause of such a hemorrhage might, however, be ^ound in the condition of the blood vessel ivalls. Becker states that in 1864 he was a witness to an operation which Arlt made on an amaurotic eye, in which he extracted a calcareous lens which had fallen into the anterior chamber. Immediately on completion of the corneal incision, an enormous hemorrhage took place from the interior of the eye, so that the blood trickled from the corneal wound. It did not come from the iris, but rather from the corpus ciliare. from the retina or choroid, for after the hemorrhage was controlled, one could see a clot protruding from the pupil. In the following few days, this hemorrhage repeated itself, and caused the corneal wounds to reopen again. The eye, however, was saved, and retained its form. This case was a particularly interesting one, because the patient had a very extensive flat teleangiektasie on the whole half of the face. Hence, it is to be presumed that the blood vessels in tlie eye were likewise varicose. 3i6 There are but few cases reported in literature iu wliieh, during the oper- ation or immediately following it, an extensive hemorrhage took place from the choroid, and thus instantly and forever destroyed the function of the eye; possibly this is due to the fact that but few men care to report their poor re- sults. As has, however, been personally communicated to me by a colleague, and who by the way is a very busy man, this does occur. He operated an aged physician for cataract, ■who since early youtli had been myopic to a high de- gree. Immediately following the delivery of the lens. Avhich took place with- out the occurrence of any mishap, the vitreous, accompanied by a dazzling sen- sation and violent pain, Avas extruded through the wound as a globule. The hyaloidea did not rupture, though blood did not escape from the eye, it could be seen through the vitreous. At the same time the eye became as hard as stone, and the sensation to light was instantly abolished. The protruding vitre- ous was cut off. Phthisis bulbi followed without a corneal ulceration. Even in such cases the cause of the hcnwrrhaye is iiu doiiht dur to a diseased condition of the vessel walls of the choroid. Dr. J. A. Spaulding ^ reported such a case, together with a very com- plete literary review of this subject, but has evidently overlooked the above remarks of Becker, which appeared almost twenty years ago. Practically, his statements agree with those of Becker. He states, "In conclusion, it would seem that hemorrhage from the choroid after extraction, and occa- sionally after iridectomie, is by no means so rare a complication as one Avould think. Numerous cases have been reported, and there can hardly be a doubt that many remain unpublished in the dread of publishing what may seem to be a badly performed operation. But where we read the names of the surgeons to whom the accident has occurred, it is plain that the mis- fortune is due solely to a diathesis of the patient. This being once estab- lished, we shall probably hear in the future of many more interesting cases of the sort. The chief cause is undoubtedly atheromatous condition of the vessels, and an abnormal tension of the eyeball suddenly reduced by the incision in the cornea and the outflow of aqueous. When it occurs, the best treatment is to raise the patient's head: to relieve the pain, and to watch the eye carefully, prepared to perform enucleation at the soonest possible moment. Where the accident has occurred in one eye. it is likely to occur in the otlier, and pressure on the carotids and ergotine is indi- cated. It does not appear that extraction with iridectomy is more fre- quently followed by choroidal hemorrhage than simple extraction. The accident can not be foreseen, but may be looked for witli increased tension; also in the decrepid and those advanced in years." In this same paper he reports the statement of Da Gama Pinto (Keviio dc ({eneral d'Opth.. 1884, p. 97), who witnessed two such occurrences in Becker's clinic. 4 A case of Choroidal Hemorrhage following Extraction. Archives of Opthal- mology, January, 1896, p. 92. 317 Sattlei-« has flrawn attention to llic fact that the hiv^oA nunibcr of cases of retro-choroidal hemorrhage have been reported sinee coeain lias come into use. He has attempted to explain this by the assumption, that after the effect of the cocaine, which causes c(uitraction of the vessels, has worn ofl'. an excessive dilatation follows, wliich in cases where a predispo- sition exists, is followed by rupture. In a recent imhlication, Salina lilooni '' critically analy/.o all the views held as to the cause of this baneful occurrence. In succession are set aside as causes, the loss of vitreous, separation of choroid from sclera, predispo- sition to hemorrhao;e, sudden reduction of intra-ocular pressure and its effect on arterial vessels, arterio-sclerosis, increase of arterial blood pressure, as result of psychic excitement, vomiting, coughing, etc.. condition of pos- terior ciliary arteries. "Anatomical examination has shown that the hem- on-hage is always intra-choroidal, and that the predisposing cause is a phle- hifis or peri-pJilebitis of the choroidal reins. Depending on the degree and stage of this inflammatory process, and the time when the intra-vascular pressure occurs, it is evident why this deplorable disaster may take place in persons apparently healthy — may occur in one eye and not the other." VII. HEiMOEimAGES WHICH AEE RESTRICTED TO THE ANTERIOR CHAMBER have an entirely different significance. As a lule, they only occur where an iridectomie is made at the time of the extraction. They occur, however, more seldom than one would imagine. One must rather w^onder, that on making such an extensive wound in the iris, that there is not always sufficient blood lost to make it perceptible to the naked eye. The causes here are tlie same as where a siiuph- iridectomie is made. Just as we observe that there, where the instantaneous contraction of tlie blood ves- sels at the surface of a wound j)revents a large escape of blood, likewise here, if the iris is healthy and moves so far forward as to touch the posterior surface of the cornea. But if the globe has suffered in its elasticity, so that a reduction of pressure exists in the anterior chamber, this may become filled with air or blood. As a rule the blood comes from the Vessels of the iris. But the simul- taneous presence of air would lead one to believe tliat the blood had been aspi- rated from the conjunctiva, and is derived from the conjunctival vessels cut during the operation. Such a hemorrhage may greatly increase the difficulties of the completion of the extraction, because one is not always successful in re- moving the blood. The operator finds himself necessi.tated to open the capsule and deliver tlie lens, so to say. in th«> dark. The presen<-e of blood in the an- terior chamber does not. however. i)rcjudicc tlie prognosis for the worse. a Beriche uber die 2.1th Versamulung der Opthalmogischen Congress in Hei- delberg. 1896. p. 211. b rbcr die Itctro-clioioidcalblunuig iiacli Staar extraction. CJraef Arch.. Vol. XLVI. Part. I. p. 1S4. 1898. 3i8 The same may be said of the presence of air bubbles in the anterior cham- ber. Only theoretical considerations could have lead so experienced a practi- tioner as Beer to take the position that the mere contact of the iris with air is to be looked upon as dangerous. Finally, one must draw attention to the influence which is exerted on the entire surgical procedure by the insertion of instruments into the eye. especially such as are used for pulling or exerting tension. Since the use of sterile instruments the fears which formerly existed in the minds of even the best operators, regarding the evil effects of the introduction of instruments into the interior of the eye, such as the mere entrance of a cataract knife, the use of the cystotome or the entrance of the iris forceps, are of but historical interest. It is interesting to note, however, that in the sixties Luer (the instrument maker) advised that a cataract knife should never be used immediately after testing it on the drum leather. He believed that some deleterious matter con- tained in the alum tanned leather might cling to the knife, and thus be brought into the eye. Attention was also drawn to fine threads of linen which might be carried into the eye by the iris forceps or cystitome. Hence, all instruments should be held up to the light and carefully examined before using them, to see that no linen threads derived from the cloth on which the instruments are wiped, are not still adherent. The dangers are greatly increased where one is necessitated to deliver the lens, by getting in behind it with some variety of spoon, Weber's loop or hook (Pagenstecher). It is more apt to occur, since where it is indicated there is already a prolapsus corporis ritrei, and it is impossible to avoid destruction of the vitreous, bruizing of the iris, and rough contact with the posterior surface of the cornea. If by simply using the cystotome or iris forceps Ave are apt to produce a traumatic irritation of the endothelium of the descemetis, how much greater must be this injury where the lens is pressed against the descemetis by a constant pressure from behind the lens. Irrigation of the anterior chamber, or intra-capsular injection, is a method which has been practiced by various operators. -But it does not appear to be entirely free from danger. In an exceedingly interesting paper on this subject Dr. Hugo Magnus ^ gives us a complete historical review of this subject. He tells us that the ancients considered the aque- ous as the only nutritive fluid of the eye that once lost it could not be renewed, and that its loss was followed by blindness. This theory was in vogue until the seventeenth century, when it was refuted by Haller,^ who reviewed all the ancient history. St. Yves was the first to practice irriga- tion. It was not only used after cataract extraction to remove cortical re- 5 Zur Historischen Kentniss der Voder Kammer Auswashungen. Graef Arch., XXXIV, Vol. 2, 1888. 6 Elementa Physiologiae Corporis Hunmni. Lausanne. 1763, Tom. V. 3'9 mains, l)ut to remove intlMiiimatury produets in the anterior cliamher. ;m(l also to press the cornea back into shape, and give it its former curvature after it had collapsed subsequent to an extraction. Its application to cataract dates back to the latter part of the eighteenth century. In the beginning an ordinary syringe was used, and a stream of water forced into the anterior chamber. Florenze was the first to attemi)t to impiove tliis method.^ He used an Anel's Syringe. Mannoir and St. Yves simply put luke-warm water in the conjunctiva, held the wound oix-ii. and allowed the fluid to enter the anterior chamber. C'assamanta tells us how Feller^ washed out the anterior chamber with water and spiritus after cataract extraction. Beer, however, who lived in the early part of the nineteenth century, does not mention this method. It was again recommended by B. Benedict.^ Pauli ^^ considers this procedure "an insult to the eye," and Himly ^^ calls it "poor practice." This method was dropped during the middle half of the century, and has been totally ignored by the greatest authorities. It has, however, been recommended by McKeown,^^ Wiecher- kiewiez and Pannas.^^ Pannas claims that "strict aseptic practice has set the dangers of this method aside," and after removing all blood, pigment, capsular shreds and air from the anterior chamber, he washes out the anterior chamber with a 0.005 per cent, solution of biniodide of mercury. This method, however, has not found general favor, and is but seldom practiced. Sterile 1-10.000 sublimate solution of atropine or eserine are well borne in the eye. THE EESULTS OF CLINICAL OBSERVATION. Beer laid down the rule that nature alone would heal simple wounds made with a clean, sharp knife more quickly and more securely than with the assistance of the surgeon; hence, he criticized every ingenious effort made to assist the healing of a corneal wound. All the surgeon has to do is to remove every obstacle in the way of a normal process of healing. 7 Observations sur une Cataracte, ete. Actes de la Societe de Medicine Clii- rurgie et Pliarmacie etablie a Brussels. Tom Primier Deuxiene Partie, p. 11. Brussels, 1799. 8 1)0 .Metliodis suffusioiicui (iculoniiii cin-aiKli a ("assaiiiala el Siiudiii cultis. Lipsiae, 1782. 9 Handbucli der Pralctische Augeuheillauide. Leipsis. 1824. B. 4. p. 231. 10 I'ber den (Jrauen Star, etc. Stuttjiart. 1S24. i). i:!7. 11 Die Kranlvbeiten und Missbildungen des Auges und derer Heiliinsr. Zweiter Theil, Berlin, 1843, p. 280. 12 British Medical Journal. January 28, 1888. 13 Des Denier progres realises dans operation de la catarael i)ar cxlraeiion. January 5-11. 1886. In all that has heeii previously slated, the endeavor has heen made to demonstrate that the extraction does not consist solely of a corneal wound, but that even in the most favorable cases in which, after an ex- traction, no signs of reaction set in, this simply goes to show that under certain conditions; absolute cleanliness, rest, absence of light, and all ex- ternal i)ernici()iis influences; even so complicated an injury will heal. Naturally, as long as the eyes were kept bandaged for days, the external l)heuomeua which are the result of the process of healing could not be observed. Beer, who in the beginning only removed the bandage on the eighth day, finally shortened the time to four days. After his time the old custom again came into u.se. and though Arlt and Vou (iraefe gradually returned to five days, and even three days, they both for a long time warned against doing this earlier than the third day. Jacobson was the first who had the courage to overcome tliis preju- dice, for he not only removed the bandage at the end of the first day. but even from tliat time on did so every twelve hours, and by focal illumination examined the siu-face of the wound. As a result of his observations and those of othei'S we have finally gained a knowledge of those changes which can be observed with the naked eye. and which take place in cases where everything jn-ogresses in a perfectly normal manner. It must, however, be stated that Kowuian had previously very carefidly studied on the living all these cliauges. since In his lectures (p. 28) Ave find a true description of all those changes which take place during the healing process of a corneal wound, and in such a way as could only have been the result of personal observation. True, ample opportunity is given to study all these processes, in cases of discission, paracentesis of the anterior chamber and simple iridectomies, and cases of non-complicated punc- tured and incised wounds. a. If we examine a punctured wound of the cornea a few minute>i after a discission, it will appear as a sharply-defined, grey round spot. In the course of a few hours this saturated round spot is less sharply defined externally, and gradually becomes fainter, and is lost in the surrounding tissue, usually about 1-1^ mm. from the periphery. If the wound is aseptic, no more violent reaction follows, and in the course of a few days all that will remain will be a grey spot marking the point of puncture. Its diam- eter will always be equal to about twice the diameter of the instrument used, and can often be found unchanged years afterward, by focal illumi- nation. h. AVhere a .simple iridectomie or a simple linear extraction is made, the edges of the wound will become agglutinated more quickly, the more the line of incision falls in the radii of the circle of the corucal surface. The anterior chamber may be restored before sufficient tinu' has elapsed to apply a dressing. In such a case, a grey line mai-ks the site of the Avound, and by the time of the evening visit thie will be fouiul to have become wider. Where no infection takes place the reactiiui will be ex- tremely slight, oi- the viVj^v^. of the wound may swell u]i slightly. In more 321 severe cases a guttfr-like depression may devcloi.. tin- nunk' of licalinjr o£ which will be presently described. c. The condition of flap wounds located in the cornea has been ex- perimentally studied by E. Neese.^^ He states tliat it was immaterial whether a Graefe's knife or a Beer's knife was used. Jn his examination, made on rabbits, he found duriiir -ivnlcr ..r l(>>s dcpili. Tn exaggerated cases the peak of tlie (((riica will l)c depivssed fiinuel-like, so as to become the deepest point of llio cdriiciil surface, whereas the periphery is still supported bv tlic \r\>. In >ii(li a case, if the lens is now removed, not only the entire e(.niea, beginning at the limbus. but also the iris sinks back- ward inlo the fossa patellaris. In the less serious cases, the curvature of the cornea will be restored ; by the accumulation of tbe a(|ue()iis. without any furtlier sequelae. The formerly depressed place will still remain visible for a few hours, owing to the increased reflex. (Jacobson.) Whereas, a complete collapse will leave for days a faint grey cloudiness, intersected by many fun-ows, which will correspond to the previous folds. It is not at all an infrequent occur- rence tliat the cornea will remain (kq)ressed funnel-like for hours, and I (Becker) have observed a case where this condition persisted throughout the second day. The cornea remains deprived of its natural glos-siness for several days, the cloudiness of its substance lasts longer, without the case taking an unfavorable turn. Subsequent to an injury with extensive loss of vitreous, we not infrequently meet with this condition; likewise in cases in which prolapse of the vitreous takes place during an extraction. The cause for this greater or less degree of collapse of the cornea is not to be sought alone, in the pecuHar condition of the same. The fold- ing and collapse always occur to a greater extent where, on evacuation of the aqueous, and the removal of the lens, the space thus evacuated is not at once compensated for by an increased fullness of the vessels, and a moving forward of the vitreous. But as has already been explained, the latter can only occur where the sclerotic, owing to its inherent elasticity, is able to draw itself together to a smaller volume, and the vitreous is not obstructed in its forward movement by a pathological diaphragm, taking its origin from the ciliary body. Hence, the coniea will always sink in- ward, when the sclera has lost its elasticity, and becomes ^gid, or where the vitreous is held fast by cyclitic bands. If the cornea is not supported from behind, it is not able lo withstand the atmospheric pressure. From this collapse we can not conclude that there is a general marasmus of the eye, but rather that the sclera is rigid, or that adhesions have formed be- tween the iris and the capsule of the lens, together with the formation of cyclitic bands. Since the pressure of the external muscles of the eye and the orbicu- laris act in the same sense as does the elasticity of the sclera, they may, to a certain extent, replace the latter, and this will explain how tliey facili- tate the pressing forward of the vitreous, the moment the anterior chamber is opened and the lens extruded: whereas, when this factor is eliminated 326 by chlorofonn narcosis, we more frequently meet with a collapse of the cornea. As has already been pointed ont, the same causes which lead to the collapse of the cornea, also lead to the entrance of blood and air into the anterior chamber from the conjunctival sac. The attempt has been made to explain these two occurrences by saying that they result "ex vacuo." This wrinkling up and collapse of the cornea does not only occur after a flap or Graefe's extraction, but even after a simple linear extraction or an iridectomie. If one were to choose the proper case, one would find that after a paracentesis the aqueous would not escape without the appli- cation of some pressure to the eye. The difficulty experienced in removing blood from the anterior chamber is due to this lack of vis a tergo. This view of the subject is further supported, as even Jacobson ob- serves, by the fact that coUapsus corneae, in all its various gradations, occur more frequently where the operation is done under chloroform narcosis. It is well known that an eye which is normally distended will become re- laxed, after the mere entrance of the knife or lance, so as to very much increase the difficulties of the operation. Hence I (Becker) do not entirely agree with the views of Jacobson or Arlt. "Frequently tlie vieAV is met with, tliat there must be a peculiar formation of the cornea, an abnormal thinness, a senile marasmus of the same, which is the only or important cause of the coUapsns corneae, and the attempt is often made to explain the loss of an eye as the result of a really observed or sup- posed collapse of the cornea. They even went so far as to declare that a tender and finely folded skin on the hands and chin would indicate a similar condition of tlie cornea, and owing to this condition make a bad prognosis. I will not deny that in old people the cornea may deviate from the normal and have a reduced thickness. Just as we may determine the thickness of the skin by the thinness or thickness of its creases or folds, so likewise can we observe that the thickness of the folds in the cornea vary, and hence are justified in reaching a similar conclusion, just as in respect to the skin. Becker has found by direct measurement that there may be a reduction from the normal equal to 0.25 mm. In specially selected cases, which have for a long time been subjected to in- creased intra-ocular tension, not only the cornea but also the sclera is thinned. As a matter of course, a thin, marasmic cornea would be less able to withstand the atmospheric pressure. Hence, when there is an abnormal cornea a collapse would naturally follow much easier. In other cases, where the surface of the cornea has its normal curvature, we do see some cases in which air enters the anterior chamber. Here undoubtedly the extei'nal and internal pressure acting on the cornea must be equal, and the bubble of air which enters the anterior chamber fills up the vacuum, and thus prevents the collapse of the <'ornea. It is also possible for blood instead of air to occupy this space. "Though I do not believe that collapse of the cornea is something to be wished for, still I do believe that its dangers have been greatly overrated. It 327 is not because the cornea is niarasniic. and but poorly disposed to such ac- tivity, as is required for the formation of a cicatrix; tliat tlie collapse of the cornea is followed by such evil consequences, but oiif imist lather look upon these folds and creases of tlie individual tissue elements .is an additional com- plication of tlie trauma produced by the \V(mii(i. 'I'iiat a collapse of the cornea may last for ijuite a long time without caiisiuij; any evil results is attested by the fact that I (Hecker) once observed a ease in whicli tlie cornea remained depressed funnel-like for three days without the slightest sign of an iritis, and went on to perfect restitution." ABNORMAL COXDITIOXS DEVKl A ) P i: I ) 1 ) IJ IM N' ( i 'V} 1 1-: PJtOCESS or HEALING. Clinical observation teaches us that the healing of a ^^clero-eorneal wound may take an abnormal course in a three-fold manner, in that either the cicatrical tissue which binds together the edges of the wound gives way before the intra-oeular pressure, and in this manner brings about the so-called cystoid cicatrix, or the iris, or a tag of the capsule, becomes im- bedded in the wound, and is held fast in the cicatrix. a. CYSTOID CICATRIZATION. Whereas, as a rule, subsequent to a linear incision made with a lance or Graefe's knife, a narrow, dense, homogenous cicatrix follows, in exceptional cases it does occur, that the apparently reunited edges of the wound separate again from each other, and in the connective tissue which thus remains loosely connected for a long time, is developed an ectatic condition. In the beginning the process of healing may go on so devoid of all irritation, that one does not observe the split in the wound, through the conjunctiva. But if the examination is made Avith a magnifying glass, one mil observe that though a number of dense strands of connective tissue do cross the wound transversely, still between the strands one will see only a very thin transparent membranous substance filling out the wound. At these points, possibly in a few days, in other cases after a week or two, the wound begins to give to the intra-ocular pressure. It occurs at times that the process develops gradually, after the patient has been discharged from the hospital. The thin, transparent, membranous substance which closes up the interspaces between the strands is pressed forward; hence, the situ- ation of the wound seems to be filled up with a number of transparent vesicular prominences. Generally this interstitial substance ruptures, and in this manner the aqueous humor is permitted to escape beneath the conjunctiva, which then seems to be raised up by a serous fluid from the sclera. This may take place many months, even years after the operation. The above has been taken almost verbatim from Graefe's description of 328 cystoid cicatrization, in his first report of sequelae of slancoma operations, and it is quoted here because later on he declared, that all that he had there said was also true of the scleral extraction. The vesicular prominences, which are the result of the cystoid cica- trization, may, under certain conditions, attain the size of a pea. The opening which forms the point of communication hetween the anterior chamber and the vesicle is always very small. When they have existed for a long lime, they widen at their base so as to extend over on to the cornea as well as into the episclera, so that it no longer can be looked upon as an almost closed vesicle with a very tine stem, but rather as one situated over a wide opening, which is simply covered by the most superficial layers of the corneal tissue, which undoubtedly takes its origin at the limbus. in the conjunctiva and episcleral tissue. A cystoid cicatrix does not occur when a clean corneal incision is made, and in fact has only been known to occur since Graefe commenced treating glaucoma by making the iridectomie incision in the limbus. Jacob- son never observed this occurrence when he made his incision for an ex- traction at the edge of the sclera, and Graefe mentioned its occurrence for the first time in his second treatise concerning the modified linear ex- traction. In this Graefe says: "The injury at the edge of the sclera only then leads to cystoid cicatrization when the intra-ocular pressure is in- creased. This abnormal healing of the wound has lately been used as a weapon against this operation, especially by the French opponents of the Graefe operation. (Fano, 1259.)" Becker says: "From my own experience I can support Graefe's view, as I only had a cj'stoid cicatrix follow in a single case, and in this case I made the operation when Basedow's disease was present. All the other eases which are known to me are taken from Arlt's practice, and that of my predecessor Knapp, and in none of these did intra-ocular tension exist before the operation. By this I do not wish to deny that it is possible for an increased intra-ocular pressure to have existed and still have been overlooked." "Though Graefe does state, lliat where cystoid cicatrization is pres- ent, and the anterior chamber has been restored, the globe is always soft, hence he assumes that the aqueous humor must escape possibly through the membraiu'. ]\Iy cxporience has Ih'cu (|uile the contrary, at least in long-standing cases, for I have always tnuiul the glohe to he quite tense. Here I will not entirely overlook the fact that sucli a cvstoid cicatrix may for many years rupture periodically." h. CICATRIZATTOX OF TIIK Ib'IS 1 V TIIK WOUND. Very probably Yon Graefe sei)iirated the cystoid ciciiirix fronrall those anoma- 329 loiis changes which arise in conse.iuence of incarceration of tlic iris in the wound. Just as in any iridectomies some of the iris piuiiient may he hrushed ofE and remain in the wound. Sucli a pigmented cicatrix is frequently seen after an iridectomie, more frequently where the punctiire is made more peripheric, in the limbus or beyond it. The more peripheric the wound, the easier does the prolapse of the iris follow, and owing to the involvement of the conjunctiva the channel of the wound is deeper, and consequently pigment is more easily contained in the cicatrix. Hence, we can under- stand how it happens that, after an extraction at the sclero-corneal edge, the cicatrix so much more frequently is pigmented. This can be avoided where the wound is carefully cleansed; the enclosure of pigment, however, is not detrimental in any way. Especially during the first few years after Graefe introduced his oper- ation, it frequently happened to him and to other operators, that the iris prolapsed into the wound, and became fixed there during the process of healing. During the process of healing one would then observe in one or both angles of the wound, a small blueish-black spot, which either lay exactly on a level with the cicatrix and remained there, or it gradually became prominent, like a small button, and at times protruded as a vesicle of not inconsiderable dimensions. Hence, even in favorable cases, the pro- cess of heahng was considerably prolonged. After the cessation of all signs of irritation, we had before us a picture such as we are wont to see after glaucoma operations, especially where the operation was made for acute glaucoma. Naturally, the peripheric position of the incision favored the prolapse of the iris; hence, Graefe advised that the excision of the iris should be made without going into the anterior chamber with the iris forceps, but simply to grasp the prolapsed portion of the iris, and where a ])rolapse did not occur, this w^as to be induced by pressing on the sclerotic with the forceps. He lays down the rule that, we should only cut off as much as has prolapsed, and to desist from any effort to draw the iris out of the wound, and that that which does not easily fall forward into the wound will easily draw back again, but for my part (Becker) T will admit this to hold good only in cases where there is reduced, or at least no increased intra-ocular tension. In such eyes, in which the corneal incision is fol- lowed by a sinking in of the cornea, a cicatrization of the iris in the wound never follows. If the eye luis a shining, tense appearance after the oper- ation, so that the iris is pushed against the posterior surface of the cornea with a certain amount of force, or if increased intra-ocular tension was diagnosticated before the operation, one may surely count on the iris heal- 33° ing in the wound, if one does not carefully excise it along the entire length of the wound. One can choose but one alternative in such a case, either to make a wide colohoma, or to find the iris cicatrized in the wound. Aside from the already mentioned prolongation of the period of healing, a cicat- rization of the iris in the wound, has the further injurious effect of caus- ing not only a greater or less disfigurement, hut it becomes a source of continuous irritation, the extent of which will l)e proportionate to the extent of the prolapse. Though no prominent iris vesicle may form, the simple fixation of the iris in the cicatrix is sufficient to cause the pupil to be drawn towai-d the wound. Further, one will, from the contour of the pupil, where one can not detect both edges of the cut sphincter of the iris, by this condition alone determine that there is a cicatrization of the iris in the wound, even where this can not be determined externally. As a matter of course, the cicatrization of the iris in the wound must exert an influence on the curA^ature of the neighboring corneal tissue, and hence influence the amount of \ision after such an operation. Since a pupil which is drawn to the periphery falls in the area of a less regularly curved portion of the cornea, and hence is less favorably situated for good vision, hence, under all circumstances the cicatrization of the iris in the wound must be looked upon as detrimental to the sight on the oper- ated eye. Owing to the more peripheric position of both Jacobson's and Von Graefe's incision, the almost unavoidable occurrence of an iris prolapse lead these oper- ators to make the excision of the iris, before opening the capsule, one of the integral steps of the operation of extraction. Even in the old flap operation, if the incision lay too far in the periphery, or even where only a part of it was so located, or where the globe was too tense, not infrequently prolapsus iridis fol- lowed. Already Wenzel incised the iris, starting from the pupillary edge, where the escape of the cataract through the pupillary area was connected with great difQculty. Maunoir incised the iris vertically in cases which he found it im- possible to replace the prolapse, and by this means found that it drew back of its own accord. In cases in which the lens pushed the iris pouch-like before it, Pourfoor du Petit, and later Carron de Yillards, excised a piece of the iris with a scissors, and thus made an artificial opening for the escape of the lens. The occasional excision of the iris after the extraction of the lens was practiced by Von Graefe and .Tacobson. In all these cases the iris lays itself with its surface in contact with the wound, so that the iri.s, like :i dolli. is plugged into the wound from within. Under certain conditions tlie .Kiufous continues to press it more and more into the wound, until finally it cxlciids beyond tlic external level of tlic w<)\iii(i. It iiijiy. hoAvevcr. beeonie tixcd :it ;iny point .-ilong the channel of tlie wo\in notice, that it begins to exert its influ- ence again, and even then not along the entire extent of the old pupil and' its coloboiiia. Tlie two sides of the coloboma seem to offer the greatest resistance. In t'avoinbly ])i-ogressing cases, we notice, on making our even- ing visit or ilic following morning, that the jnipil and coloboma are dilated regularly. In other cases adhesions an- noted. This can onlv occur where 333 the capsule of the lens and the ed-es of the iMi|.il l..n.l, cm.Ii -ith.-r. Hence, the less complete the cvaciialion of the lens has been, and the longer the time elapsed hefore the anterior diaiuher is restored, the more easily will this occur. These ohservations indicat.' tliat l)ut a very short time subse- quent to the operation is sufhcieut foi- an adhesive iiitis to develop along' the ed^es of the wound, in the new pupil, and at >in-lc pnint> along the old, and this manifests itselt by the early adhesions between the wounded iris surface and its closest neighborino- tissue (be this a .^^hred of the capsule or minute intra-capsular reiuains or blood clots). (Jacohson.) If we desire to prevent seclusion of the pupil, active u.«e of atropine is indicated. Such synechia, if once forjned along the edges of the new pupil, can not, in most cases, be broken up again. e. PLiVSTIC IKITIS is to he dill'erentiated from the adhesive variety. This likewise sets in soon after the extraction, often with but slight sub- jective symptoius. even when the tlaj) wound has healed normally, and characterizes itself in that, to begin witli. there is little clotidy aqueous, yellowish flakes appear in the pupillary area which do not sink to the floor, but retain their original position, and very soon form adhesions with the edges of the pupil, and later on also f(»rm demonstrable attachments behind the iris. Stich yellowish (le])()sits may develop inside of twenty- four hours on the anterior surface of the iris, and in the aqueous without the formation of a fluid ]uis. (Jacohson.) Occasionally one observes a jelly-like, yellowish exudate, like the spawn of frogs, which tirst appears l>etween the edges of the wound, and finally gets into the anterior chamber. It may accumulate to such a de- gree as to fill out the entire anterior chamber, at the same time showing such a slight cloudiness as to still permit one to distinguish tho finer lines on the surface of the iris, so that one inclines more to the belief that one is dealing with a very faint cloudiness of the cornea, rather than an exu- date on the iris. Only when this begins to contract, and the peripheiT of the iris becomes clear, does it become evident as to just what we are deal- ing with. This jelly-like mass continues gradually to contract more toward the edges of the artificial pupil, and at times is so completely resorbed that aside from a perfectly transi)arent mem1)rane in the pujiil (t-a])sidar thickening), and a few synechia, nothing remains. Becker states that he observed this form of ])lastic iritis twice in dia- betic patients, and in fact only where the cataract was tumescent. It seems most probable that the intensely swollen condition of the lens is the main cause of the chronic irritation of the iris and the ii'itis. ("hemosis and swelling of the lids is still to be mentioned as occasional occurrences, but to only a moderate degree: but true ciliary ])ain and purulent conjunc- 334 tival secretion are entirely wanting. In these cases a true hypopyon never occurs (when it does the diagnosis is infection). f. After the original sclero-corneal wound lias closed, after the second or third week, a form of iritis may still develo]). which is character- ized by its persistence and relapses. Tp to this time the process of heal- ing may have appeared, to be perfectly normal. The only change seems to be, that the eye appears injected, and the iris assumes a darker color or a slight discoloration. Without any change in the form of the pupil, ciliary injection sets in, together with irritability to light, tearing and pain. It is not necessary for vision to be reduced, and we suddenly find a slight hypopyon, which at times disappears and suddenly appears again. If the patient lies on his back, the hypopyon disappears, whereas, as soon as he moves about it develops again. This may continue for days, even months. This peculiar fonu has been observed in cases in which the capsule was removed, together with the lens. The final result may be a perfectly good one. Owing: to the fact that the iris shows no visible changes, that the hypopyon disappears when the patient lies on his back and develops again when he moves about; and finally, that it develops even when the eai*sule is wanting, and also owing to the pain in the ciliary region, it is possible that the ciliary body is involved; hence, it would probably be more correct to designate this form as a relapsing irido-cyclitis. All therapy seems to be useless. The above description is undoubtedly that of an infection. g. A few hours after an operation one may perceive changes in the pupillary area, which will indicate if at the completion of the procedure we will get a black pupil or not. Xot infrequently it happens, that though at the close of the operation the pupillary area appears perfectly black, we are surprised at our evening visit to find the ]uipillary area "filled with a considerable amount of cloudy cataractous remains." Though Ihe pupil appears black at the close of the operation, this does not indicate that the entire lens has been removed. If the examination made previous to the operation proved the anterior lamellae of the lens to be still transparent, these will remain adherent to the capsule at the time of the operation, and later on became cloudy. But it is likewise possible, though all the anterior layers be cloudy, for some of the posterior to have been transparent, and these will ivuiain adh(>reiil and uuiu^ticed after an extraction. True we term as catarada maiura, a lens system which has become completely cloudy, and this cloudim^ss has extended to the anterior chamber. Just as it is possible for the posterior cortical substance to remain cloudy for years, in the so-called choroideal cataracl, the anterior portion reiuaining clear, likewise, it is possible for the same condition to occur in just oppo- 335 site form. However, we do not as yet possess the means of making a diag- nosis of such a condition. This condition does exist, for in a number of eases Becker found tlie regular radiating arraugemoiit of the cloudy re- mains of lens substance when the cxiiniination was made at the evening visit. Frequently cataraclous remains came into view, which at the time of the oi)eration were hidden behind the iris. After the wound is closed and the anterior chamber restored they may, owing to their tumescence, appear in the pupillary area, or where an iridectomie has been made in the area of the coloboma. Not infrequently it is impossible to get the pupil entirely clear. Even in these cases, on making the first visit, the quantity of cataractous mass remaining seems increased, undoubtedly due to the action of the aqueous in causing it to swell up. The general course of the operation largely depends on the amount of cataractous substance retained. Nevertheless, it is very difficult to de- termine jnst how much cataractous mass, if left behind, can become an element of danger. Hence, one of the principal objects in every extraction must always be to remove as much lens substance as possible. According to many operators, the condition of the cataract is not entirely without its influence. At times a certain variety, a sticky (pasty) consisd;ence of the cortical substance in cataracta nondum matura, at times the pasty mass of an overripe cataract, is said to be especially dangerous. There does not appear to be a uniform agreement of opinion on this point. But as there is un- doubtedly a chemical action, taking place in the secondary disintegration of the cataractous mass; hence, a priori we must admit, that the remains of an overripe cataract may act in a detrimental way, owing to its chemical constitution. As a rule, cataractous remains, even when present in considerable amounts, in and of themselves do not cause a reaction which will end dis- astrously to the eye. The main danger undoubtedly lies in the fact, that these cataractous remains may become a very detrimental complicating factor, where other portions of the eye are not well disposed. In this manner the attempt has been made to explain the bad prognosis in cases of unripe, especially tumescent cataracts. In these ^ases, even before the operation, the iris is irritated by llie swollen lens, and from this, the active reaction sets in. Undoubtedly the most freciuent sequelae of cataractous remains are posterior synechia. Aside from these a cataracta secundaria nearly always develops. Cases do occur in which the ])upil remains free and totally black, and in which after complete healing, even on focal illumination, one can 336 only detect a somewhat ()])alt'seent incmhrane. the posterior capsule, but they are exceedingly rare. They can only l)e exphiined by supposing that immediately after an opei-ation,' the edges of the capsule draw back far into the periphery, so that only the posterior capsule, entirely free of lens sub- stance, remains in the pupillary area. The remains of lens substance left in the equatorial region, are at once shut oti'. hence, can not swell up and therefore give rise to no further troul)l('. //. If one waits a certain length of time before applying the bandage, or if from any cause it becomes nec<'ssary to remove it. one will at times note how very quickly the anterior chamber is restored. For this to occur the entire length of the wound must become agglutinated, and further, to have attained a certain amount of security. If at the next visit the con- dition has remained unchanged, it becomes \''ery probable that this closure following the operation will remain a permanent one. Paracentesis of the anterior chamber has taught us. that a very few minittes are sufficient to permit the accumulation of a requisite amount of aqueous. If the anterior chamber is punctured so as to evacuate the aque- ous at regular intervals, so as to ease pain in the eye, it will be found necessary to repeat this procedure every four or five minutes. In most cases this closure of the wound does not follow so quickly ' subsequent to an extraction, or at least is not of a permanent character. Though we do frequently find the anterior chamber restored on making ' our evening visit, still one may expect it to open again several times before it finally becomes securely closed. Patients state that after they have ex- perienced a slight increase of tension in the eye, they suddenly experience a stinging pain, following which the pressure seems to be removed, and ■ at the same time they experience a feeling as though something were flow- ing out of tlieye. The aqueous which reaccumulates must reestablish the intra-ocular pressure, and unless the wound closes securely, must neces- sarily rupture it again. As has been said, in exceptional cases the wound does not close on the first day, so that on making our visit we still find the anterior chamber abolished. I have seen such a condition, which is generally recognized as following glaucoma operations, follow a cataract extraction, and continue for four or five days, and in cases where everything seemed to be pro- gressing in a perfectly normal manner. .lacob.-on rejtorted c:\ siu'iis of an iritis 338 or swollen up remains of lens substance. The aqueous is found to be especially cloudy. The anterior chamber is not narrow because the aque- ous is being constantly evacuated, but because the iris and tbe capsule of the lens are pressed forward. On tbe other hand, an unusually dee}* anterior chamber may develop shortly after an operation. The aqueous may remain perfectly clear, the iris lie somewhat deep and tremble markedly. Focal illumination will then show a very considerable space existing between capsule and iris. Such eyes heal without any posterior synechia, and good vision is obtained. In old people, on whom flap operations are made without iridectomie, in most cases the pupil is narrow, perfectly round, and only the practiced eye can distinguish the trembling of the iris, which lies deeply and in a per- fect plane behind the cornea, and owing to the fresh, clear appearance of the eye, recognize that he is not dealing with a case of luxation of the lens, but with a case of aphakia, following extraction. If the iris lies deep, the pupil wide, and the aqueous from the beginning abundant and cloudy, one will observe movable opacities in the anterior portion of the vitreous, and a characteristic blueish red peri-corneal injection. At the same time the globe is tense. Jacobson observed this condition in hydropthal- mic eyes. This is explained by, the fact that owing to the altered conditions of intra-ocular tension subsequent to extraction, a profuse exudate follows from the dilated vessels of the distended anterior segment of the eyeball. Such a hypersecretion of humor aqueous is said to interfere more with the firm healing of a flap wound than with the tinal general result. Puncture of the anterior chamber would eveTitually \)v indicated in such a case. PROCESSES OF hp:aling with incompeete resuets. Since the object of an extraction is to remove the interference with sight, which is located in the cloudy lens, hence, all tinal results which interfere with the perfect attainment of this end must be designated as incomplete results. We must, however, differentiate between those cases which are improved by a second operation and those which are to be looked npon as lost, so far as sight on the eye is concerned. In such cases the second operation is always made for secondary cataract (ratararfn secun- daria). Such a cataract may exist without a complication, or // is adherent io the iris: hence, at the same time a cataracla accreta. A secondary cata- ract may be complicated by other changes which may occur after an oper- ation, such as the formation of cyclitic bands and detachment of the vitre- ous. But since operations made on these (•om))licated cases, as a rule, are not followed by good results, hence it is advisable not to count these cases in with those of secondary cataract: so that in speaking of secondary cata- ract (Xachstaar). only those cases iwv iiichuh'd wliicli ai'c op('riii)lr. 339 a. Thv jMire siveiidaiy cataract is only the result of the sequence of chanoes which tak.'s place' (h.rin- and after an extraction within the cap- sule of the le.i>. an.l is confined to those portions of the lens substance whi.h are not evacuated. Hence, if one may so express it, this is the product of a pure phakitis. Every one can observe how the lens substance which escapes from the ir.lerior of tbe capsule, but is retained within the anterior chamber, swells up and is absorbed. Every oculist should see to it that the iris is well dilated, so as to prevent the possible formation of synechia. If they are not formed, one will be enabled to see at a recognizable distance behind the pui>il, a grey, nuMnhraiious-like cloudiness, which is more or less trans- parent, and dependent on the degree of its non-transparency vision will be pr()i)()rtionately impaired. If the pupil is dilated one can easily see that this cloudiness increases toward the periphery: hence, the portion which is hidden behind the iris is more saturated than the portion in the pupillary area. The secondary cataract is thickest in the equatorial region of the lens. (Tlie reason for this has been explained in the third part of this work.) In llie i)upillary area this thickness is a variable quantity. In iso- lated spots this secondary cataract may be entirely wanting. At times such u small opening is sufficient to enable one to obtain sufficient vision. The changeable appearance of the secondary, cataract in the ])upillary area is eharacteristic of the pathological changes which take ])lace in the remains of the lens substance. The duration of the phakitis is variable. True, we discharge a cata- ract patient as well, when the eye looks pale and the pupil relatively clear. Weeks or months later tlu- patient returns, and we find the pupil occulated by a thick secondary cataract. Years may elapse without any change tak- ing place in the degree of vision, without our being in a position to deter- mine whether or not any change has taken place in the secondary cataract. Then suddenly the patient notices a gradual diminution in the amount of vision, whereas the accompanying symptoms, the irritabihty to light, the pain, the tearing and ciliary injection, may be so slight as to be scarcely noted by the patient. If such a patient comes under observation at this time, one can see a punctate, striated, or spotted cloudiness gradually de- veloping in tlie ])upil. As a rule, this cloudiness begins near the point of incision, and gradually extends toward the center At the s^me time the iris may ap])arently be uninvolved. (This is the picture of the tension of the cicatrized iris or capsule in the wound, possibly a secondary infection along a fistulous tract.) There is a peculiar form of "di-usige" hyaline thickening of the origi- nally clear ca])snle, which can lead to a very material reduction of vision. 340 On use of the refracting opthalmoscope one can discern these warty ex- cressences,, and on moving the mirror they give a sliiny reflex, but are otherwise transparent. Eepeated examination will show that these exist in numbers. These conglomerations cause considerable interference with vision, but Becker states that he has never seen them change to total opaci- ties. That the processes which take place in a pure secondary- cataract are confined to the capsule of the lens and those lens cells which remain behind, is attested by the fact that the neighboring tissues are not involved in this inflammatory (?) process. A secondary cataract always forms where the capsule is not extracted. The slightest folds in the capsule cause reflexes, hence, it becomes seK- evident, that there must nearly always be an improvement in vision where the cause of these reflexes is removed. But whether a patient will desire a second operation will depend largely on how much he will need his eyes. The amount of vision which ought to be attained will be considered later on. Speaking in a general way a secondary operation is indicated when vision is reduced to 6-60. If during extraction the vitreous puncture (Hass- ner) is made, and no reaction follows, vision will not only be good, but seldom will this hter be diminished. COMPLICATED CATAEACT. PHTHISIS BULBI AXD PANOPTHALMITIS. These are conditions which are but 'rarely me: with at the present day, and only occur when an infection takes place. A complicated cataract may be the result of an iritis. As has already been mentioned, its slightest foi-ms occur very frequently, and do not always lead to a secondary operation. But the more intense the reaction, the thicker will be the secondary cataract. Just as soon, however, as the symptoms of wound reaction set in, at the sclero-corneal wound, on the iris, in the pouch of the capsule or in the ciliary body, the active develop- ment of a secondary cataract will go on, and finally lead to occhisio pupillae. According to the extent of the general reaction this can be divided into a number of clinical forms of disease. However, where this process reaches a certain intensity, all those tissues which were involved in the incision will be affected. Depending on the extent of the general reaction, this will lead to an iritis wifh orrlusion of fhfi pupil, an iridocyditis with occlu- sion of the pupil, toiicllicr irllli llir ^uhscijiiciil sliriiil-di/e of ])ands of connective tissue in the vitreous, a piinilciil iufloiiinnitinn of the vitreous, euding in phthisis t)iitl)i, and llnally. i,i /»o7ioplli(ilorilis. ilic gi-atly feared total loss of the entire eyeball, or a siippnrotiou of the rorurn. 341 ^ 1. lA't US iirsl cxjimiiic the rli:iii-(- which l;ik-' phicc in th.- <-<.i-ii<'a. All tlic processes of woniid iviiclion (h'-crihcd ;ihove are inteiisilled, and we liiul tlie tMl,a-es of the wound >u|i|iui-;it m-. While snft'erinjr from tetir- ino- and irritability lo li^hl. the patient coniplain> of pain, the eoiijuiietiva in the neiuhhorhood of the wound, and the vi\izv< oi' the W(»und tliemselves swell up. From the second day on. the ,urey striations in ihe eoi-nea in- creasi', assume a more yellow color, and linally either a circunisci-ihed por- tion or the entire length of the wound heciunes inllllrateil with pii-. Hav- ing reached this stage of developnu'iit. thi.s process may come to a stand- still on the third oi- rouitli day. gradually retrogressing again, and leave the gi'eater poi'lion (d' the cornea t i-anspareiil. Ileiv we always (iiul the iris, the capsule sac. and very ol'len, also, tlu' coi-piis eiliare in the neigh- borhood of the wound involved, liepending on the degrei; of the process Ave always assume the involvement of the above sti-uctures: this, however, can never be determined imtil the coi'iu'a has coiumenced to clear up. To combat this sup])ni'ation the best method is to immediately cauterize the corneal wound along its entire extent with a galvano caiitery. The an- terior i-hand)ei- should, if not completely open, be reopened and washed out with a corrosive sublimate solution. As a linal i-esult, one always finds the sclero corneal cicatrix drawn in. and a thick secondary cataract, which in its entire extent, is everywhere adherent to the periphery of the iris. Owing to the gradual shrinkage of this secondary cataract, which is con- nected with the cicatrix of the wound, the iris is gi-adually drawn toward it. As the pupil now gradually becomes smaller at the sides, the secon- dary cataract likewise appears to gi-ow smallei'. and shows vertical stri- ations, which seem to be continuous with the sli-iations of the iris, giving us the picture resendjling the ai-rangement of the ribs in a large palm-leaf fan. The iris presents in nnniature the ])icture of the so commonly Used Japanese fan. "Weeks and months may ]iass before this process has run its course. All this time, howevt'r. the tension of the globe remains normal. 2. If the corneal infiltration does not remain I'estricted to the imme- diate vicinity of the wound, on the second or third day one will o1)serve an extension of this striated keratitis, until the entire coi'uea may finally become infiltrated in a tongue-like manner. There can be no doubt now as to the involvement of the intu'i' portions of the eye. 'I'his can be deter- mined by the extensive chemosis and the ])lastic oedematous swelhng of the entire conjunctiva bulbi. The subjective pluMiomena are also very much increased. It is not necessary that this should lead to complete suppurati(m of the globe, but it always leads to the formation of an opaque corneal cicatrix, which is intimatelv connected with the ii'is. and to a 342 thick cyclitic meinbianoiis cataract. If after months the process finally becomes quiescent, the globe may retain its general form, bnt its intra- ocular tension will be found to be reduced. Notwithstanding the fact that the light sense may still be present, this flattening of the cornea, phthisis corneoe, will cause everj- operation to be without result. 3. This tongue-like infiltration of the corne-a seldom leads to suppu- ration of the same. But one must always be prepared for such an occur- rence, and on the third or fourth day there may develop. ^ mm. removed from the corneal edge and concentric to the same, a saturated yellow ring- like cloudiness which is very pronounced (ring abcess of Yon Graefe). Such a picture seldom develops without causing a necrosis of the entire cornea, and the much feared panopthalmitis. An ill omen which appears at the same time, together with a flabby oedematous swelling of the con- junctiva, is a very profuse blenorrhoeic secretion from the same. Naturally, such a profuse purulent infiltration of the cornea is from the very be- ginning associated with a purulent inflammation of the iris, the corpus ciliare, the choroid, the retina, the vitreous, and evei. the sclerotic. We, how- ever, only make a diagnosis of panopthalmitis, when a protrusio hdbi, a slight exopthalmus is added. This latter condition is the symptom .which tells us, that the purulent inflammation has extended beyond the borders of the 'eyeball, and that it has invaded the lymph sac of Tenon's capsule, and possibly has extended into the orbital tissue. Von Graefe (1. c, p. 189) has given us the foUowins classical description of the symptoms which a case of panopthalmitis presents: "After a more or less indifferent course of twelve to eighteen hours, seldom thirty hours, a gradually increasing SAvelling of the upper lid. togetlier with the formation of a consider- able quantity of thin, dirty, yellowish pus develops. This latter consists less of the secretion of the tear glands than of a transudation from the conjunctival .surface, which, together with the epithelial detritus and pus cells, forms a some- what even emulsion. There may be but little pain at this time.and this may depend on the faint reduction (tf Ihc general s('nsil)ility in such i»a1ients. If one separates the lids at the vei-y lieginning of the disease, a jiortion of tlie secretion which was hidden beneath the lids will well forlli. At tliis time neither corneal wound nor pupil sliow any i>ar(icuhir .-inonialy. However, the entire anterior surfjice of tiie eye lias a most ]>eculiar yellowish <-o!oi-. d\ie to the excessive hlling of tlie lymph sp.-ices in ItoIJi conjunctiva and coi'nea. The general swelling of tlie former, and tlu' adhei-ence of tlie ••li(iui(l mass" (o its surface, gives the eye the ominous '"waslied out" appearance. The yellowish discoloration of the cornea is due to tlie tilling up of its lymph spaces with a yellowish material. Although these "tubes" seem to lie liiled with purulent matter in the most pregnant manner, nevertlieless. in tlie beginning this is a very lliin layer, so tluit on tlirowing the light on the conie.-i. this lias .-i "steam- 343 in,:;" appearaneo. Even with tliis condition present tlie anterior chamber may be fully restored, for truly this is usually the case; but tliere may still be a fistulous openinjr. Wlietlier tlie on<' or tlic other condition is present depends largely on the intra-ocular pressure; partly, also, on the condition of the surface of the wound; Where tliis infiltration develops suddenly and intensely on the edges of the sclero-eorneal wound, iind also in tin- subconjunctival portion, this will lead more easily to closure of tiie iintnior (Miaiuber: whereas, if the process spreads more rapidly along the surface, ilie anterior chamber will not be so easily resored. and will soon lead to a culminating point." 4. At times one can di&eover important phenomena on the iris before the cornea is involved, or shows any signs of cloudiness. In the beginning the aqueous is cloudy, the iris discolored, and shows signs here and there of yellowish spots, and tinally hypopyon develops, a true acute suppurative iritis. Later on the cornea becomes cloudy in its entire extent, but ne- crosis of the same seldom follow^s. Frequently the wound which has closed opens up again, and a drop or two of pus will be found exuding from the wound. It is possible for a case of suppurative iritis to heal with a perfect retention of form, normal tension of the globe, light sense retained and good projection. But nearly always there is developed a thick secondary cataract, in the fonnation of which the ciliary body participates; still, I have seen cases attain perfect restitution of sight without undergoing a second operation. It goes without saying that the capsule plays a very important role in the entire process. It depends entirely to how great a degree the cihary body is involved, how thick the cyclitic bfjids behind the lens are. whether the vessels in the same will become obliterated, and whether the vitreous body will shrink, what degree of benefit operative interference would give to the patient. An estimate concerning these concUtions in an eye may be formed by testing the tension of the globe. Whether nn eye can be made to see or not, depends on these factors. ■"). Cyclitis assumes an important role, and in the cases in whit-h kera- titis and iritis ai-e most pronounced, the prognosis largely depends on the development of this complication, l^ut cyclitis may disclose itself as the primary and most important sym]itom, and in a very severe form. In such a case, during the first few days, neither cornea, iris or pupil will show any suspicious signs. It is only after one believes that all the danger is past, that on the fourth or fifth day the eye becomes reddened. Whereas the cornea appears clear, the iris begins to take on a darker color, and the pupil begins to show a tendency not heretofore observed to cata- ract, and the subjective symptoms irritability to liglit. spontaneous pain 344 and tendiTiiess to pressure beoin to develo]). Tu t\m may be added a gradual liyperplasia of the cells m the capsule, and even to a greater for- mation of flakes in the vitreous; likewise, an exudation in the anterior chamber, as well as a simple cloudiness of its contents, to which may be added pus and 1)lood. The characteristic feature of this process is its exceptional olistinacy. Notwithstanding all this, it may cease after uu)nths. leaving but a very delicate secondary cataract, which even in a case where exceptional require- ments are made of the eye, would not require a subsequent secondary cata- ract. On the other hand, it may lead to a thick secondary cataract, ad- herent to the iris and cyclitic bands, and even finally result in phthisis hulhi. This latter condition even develops very late. Such a result is to be feared where tenderness to pressure will not cease. This process may be complicated by detachment of the retina and internal hemorrhages, thus finally necessitating enucleation. G. The vitreous body may become primarily afl'ected without either iris or cornea being primarily affected. This, as a rule, occurs when there has taken place a prolapse of tlie vitreous. Becker states that this has occurred in cases in wliich the hyah)idea had not ruptured, and the -vitre- ous had simply been exposed as a vesicle in the wound. Such a heimia corporis vitrei can only occur where a tear in the zonula has taken place. On the second day one can see yellowish grey shreds extending from the pupil into the vitreous. The wound gaps and flakes of pus exude. In a short time the entire pupil is filled with pus, the iris discolored is pressed forward, and the conjunctiva is chemotic. It is a very noteworthy fact, that though the cornea may be pressed forward to such an extent, by the pus in the anterior (•haml)er as to form a perfect angle, it nevertheless retains its trans])arency except along a narrow edge, along the line of the incision, so that it is possible to observe accurately and follow up the gradual vascularization of the pupillary edge of the iris, and also the de- velopment of blood vessels in the purulent mass in the pu])illary area. Naturally, swelling up of the lids and plastic chemosis are ])resent. but only to a inodei'ate degree. The globe, however, under all circumstances, retains ils niol)ility, and a prolrvsio huttn never occurs. Sensation to light may be relained for a few days, but disa])pears on the fourth or fifth day. It is possible for sncli a ])urulent inflammation of the vitreous to be followed by total retention of the form of the glob? of sensation to light. and even normal tension. In these cases the wound clpses toward the end of the second week witliont the develo])ment of increased intra-ocular tension. In llicsc cases one is justified in the belief that the process wa.s I 345 restricted to the anterior half of the vitreous. As a rule, in course of time diminished intra-ocular tension develops. If this discharge of pus continues for any lenoth of time, sensation to lio-ht will be totallv abolished, even before the wound closes, more fre- quentiy, however, after it has closed. During this time the eye has a hard peculiar increased resistance to the touch. It does not feel hard, but gives one the impression that its coats hdve lost all their elasticity. The further course continues but slowly. The pains, which have never been severe, after the wound closes become markedly increased. As a consequence, the general health of the patient does not suffer, and the absence of pain helps to keep up his hope. When the last exacerbation of pain ceases, the swelling of the lids disappears. The infiltration of the conjunctiva continues, although the oedema disappears. Gradually the anterior chamber is restored, the vessels of the iris and pupillary area are no longer visible, the tissue which occludes the pupil gradually assumes a grey color, and is reduced to a small, vertical band. From now on the tension of the globe gradually diminishes, and phthisis corneae and hulbi develop. Six to eight weeks elapse before the recti muscles begin to leave their impress, and months pass before the process of shrinkage comes to a close. During all this timethe eye is moderately sensitive, the conjunctiva especially around the cornea is 'deeply injected, and as a rule the palpebral fissure is kept closed. 7. Hemorrhages which occur during the process of healing are to be differentiated from those which have already been mentioned. They have never been observed following a flap extraction unless associated with a rupture of the wound or due to a trauma. Hence it seems we must seek their cause in the peripheric position of the incision and the iridectomie. This same occurrence has been noted where a simple iridectomie is made. Not unfrequently they pass off without any evil consequences, especially when the hemorrhage has been a slight one, but where this has been severe it is nearly always followed by iritis (Snellen). But if hemorrhages which appear to be very severe recur, they may lead to very unpleasant results. As a rule, these hemon-hages take place in ihe anterior chamber, much less frequently do they occur as minute or large ones into the ritre- ous. The prognosis becomes all the -worse, the more reason one finds for their not being the result of trauma. It can not be doubted, that especially during sleep, patients unconsciously rub the healing eye. At times they admit it. If we will eliminate these eases, the following cause may be enumerated with more or less certainty: (1) Eepeatedly have such hemorrhages been observed where the an- terior chamber was suddenly restored, after having been abolished for a 346 considerable length of time. The hemorrhages were never great, and never were followed by evil conseqnences. It seems probable that the tension which is exerted on the iris, where, owing to the accumulation of aqueous, it is forcibly pressed backward, one of the new formed blood vessels is ruptured, and thus gives rise to the hemorrhage. The patients always state that they felt a sudden pain. (3) If at times, or shortly after the hemorrhage, an iritis develops, it is more than likely that the hemorrhage is the result of a previous hyper- aemia of the iris, especially since cases of iritis have been observed in which hemorrhages did occur when no operation had been made. Owing to the great rarity of spontaneous hemorrhage in iritis following extraction, one must assume as a second cause diseased friability of the blood vessels of the iris. (3) Together with Knapp (A. f. A. and 0., I. p. 54) Becker considered a predisposition to hemorrhage as the main cause of those hemorrhages which are restricted to the anterior chamber, and which become danger- ous, owing to their recun-ence, and which may likewise take place in the vitreous. Those cases of cloudiness of the vitreovis reported by Knapp (1. c, p. 57). are most easily accounted for in this manner. According to Knapp such hemorrhages offer a veij had prognosis. The cause, most certainly, is a diseased condition of the vessels which existed before the operation, and this can not always be diagnosticated. The final result need not always be a sad one, as was demonstrated to me (Becker) in a case in which, on the fourth day, a large hemorrhage took place in the vitreous and in the onierior chamber, accompanied by the most violent pains, without a rupture of the wound taking place, and only a quanti- tative perception of light remained. The blood in the anterior chamber soon disappeared, though the resorption of the blood in the vitreous re- quired months; nevertheless, finally a very satisfactory amount of vision was restored. In operating on the second, a preliminary iridectomie was made, and the eye healed without an accident. The opinion lias been expressed personally to me (Becker), that the venous plexus of Leber is incised during the operation, and that the hemorrhage may arise from this cause. However. I have never found such a condition present as would warrant such a conclusion in the innumerable microscopical sections which I have examined. 8. The relative frf-quency of the above described processes of healing, especially those in wliicli a good result is not attained, is dependent to a large degree on the manner of procedure during the operation: hence, to speak more plainly, on the operator himself. In no department of opthal- mology docs the difference between the master and the novice become more 347 apparent than in .be operative, and here, above all. m the ,K.rfornmnce of a cataract extraction. But even in the hands of the most skillful all cases which have apparently had a similar result, after being operated accord- ing to the same method, do not attain a simila.- final result. Different individuals after undergoing a simi^lar operation react differently. This idea has already been expressed. \\ here it became necessary to separate the simple from the complicated cataracts. Likewise, the fact deserves men- tion here, that the second affected eye offers a bettei- prognosis than the first affected. In many cases the individuahty of the operated eye is re- sponsible for a poor result. Becker, as the result of the microscopical examination of human eyes which had been operated on for cataract, and also of pigs' eyes, on which he had experimentally operated, makes the following important obser- vations: Accurate measurements regarding the position of the various forms of incision in the edge of the cornea have shown very interesting differ- ences between the Daviel and the Graefe's incision. In making a flap ex- iraction, the outer edge of the wound should not touch the limbus. In three eyes examined the wound lay 1 mm. from the limbus; the inner edge of the wound, therefore, lay 2-2.35 mm. distant from the insertion of the iris. This is ahout the condition which should exist where the operation is made according to the rule laid down. In the Graefe extraction, where the outer edge of the wound falls in the limbus, one is less in a position to measure its distance from the edge of the cornea. The mean distance of the inner edge of the wound from the iris is equal to about 1.25 mm. If a so-called negative incision is made, it is found to lie anterior to the limbus, in the cornea, and in carrying out this method the inner edge of the wound is farther removed from the insertion of the iris. Frequently a glance at the corneal cicatrix will sufhce to show us the method which was employed in operating. A flap extraction made with a Beer knife goes through a line which forms an angle, of varying degree, with the radius of the cornea, hence has an oblique direction, and is con- siderably broader than the thickness of the cornea. It lies in a single plane, and in transverse section shows lliat it does not change its direction. However, in the Graefe operation, after making the eontra-punctiire, the knife must be turned so that the cutting edge looks antei-inrly. In doing this it is not always possible to do so without changing the direction of the cutting edge of the knife several times. On section we get an angular cicatrix, if the section is taken from the point where puncture or counter- puncture was made. But we can even recognize a Graefe incision in the 348 section, where this is taken from the center of the line of incision, because this is always more perpendicular to the surface of the cornea. An angular condition of the incision must, under certain conditions, act as a hindrance to an exact adaptation of the two surfaces of the wound. The tendency of a corneal wound to open again is dependent on the height of the flap. This tendency, however, is increased by the fact that the two surfaces where these lie in a single plane glide past each other more easily, and give more easily to the intra-ocular pressure than where the two surfaces fit into each other by means of an angle. This tendency of the corneal portion to glide past the scleral, exists both in practicing the Daviel, and the Graefe method of eairaction. But under like conditions this gliding past each otlier seems to be greater where the flap extraction is made, than where a peripheral linear incision is made. According to measurements, this difi'erence varies from 0.12 to 0.30 mm. The younger the individual, and the more recent the cicatrix, the greater will be the dislocation; but it appears that in course of time, this may equalize itself again. The astygmatism which develops after an extraction depends partly on this fact. But the most inconsiderable thickening of the corneal tissue along the line of the wound is not without its influence. Both have a ten- dency to grow less in the course of a few months. In cases where the capsule of the lens, or the iris, cicatrize in the wound, the corneal tissite undergoes greater reaction, and the curvature of the cornea may be con- siderably altered. lEREGULAR HEALING OF THE WOUNDS. The normal pro- cesses of healing of a corneal wound, may be modified or interfered with by the entrance of foreign substances between the surfaces of the wound. This is aided by the peripheral position of the wound, and the combining of the operation of iridectomie with that of extraction. As a rule, such a wound heals slower, and though the final amount of vision- may be good, still during the first few months this acquired asymetry of the cornea will make itself very evident to the patient by its interference with sight. In such a cicatrix we must seek for the causes w^hich produce signs of irrita- tion, which may not begin to manifest themselves until long afterward, and which, together with other pathological conditions which may follow in their track, may finally become fatal to the existence of the eye, and even threaten the other eye. ]. PigiriPfilntiov of the Cicatrix. In every case where an iridectomie is made, in drawing cut tlio iris and cutting it ofl", some of the pigment is brushed off in the wound, cicatrized there, and these pigment cells begin to undergo a liyper])lasia. Even where n flap extraction without iri- 349 dectomie i. made, tlie iris may iirolaps,-. thus reccssitating its rq.la.-cneiit, hence the pigmentation whore no iridccl.Miiie lias heen made. Where the process is in other respects pn-fctly n..rnial. the pigment is found as small, black granules in the cieatrix; not ..nly in the intra- cellular substance, but within the cells tlieniselves. Hence, it can not be surprising if isolated granules, carried hy the lynipli stream, are found in the corneal substance itself. This i)igiuent does not in any way interfere with the perfect healing of the wound. 2. Cicatrization of the iris in the wound. The more peripheric the incision, the more apt is this to occur. Becker states that in seventeen anatomical examinations of eyes operated by the flap method, the iris was held in connection with the cicatrical tissue of the cornea but three times, whereas in fifteen peripheral linear extractions, this condition was met with ten times. The manner of its enclosure may be a three-fold one. In both methods it is possible for the iris to prolapse into the wound and cicatrize there. It will then depend on the extent of the enclosure and the depth to which the iris fills out the wound, how great the inter- ference with the normal processes of healing, and how great will become the density of the new-formed interstital tissue. Ever since extraction has been practiced, has the attempt been made, to avoid the formation of staphylomata. Hence the necessity for making a clean-cut excision of the iris; a care to prevent this cicatrization of the iris in the. wound. The fre- quency of this latter condition is shown by anatomical examination to be very great. CONDITIONS OF THE CAPSULE. Immediately after an extrac- tion, the incised anterior capsule, in the pupillary area, is in contact with the posterior surface of the cornea, whereas in the peripher}- it is in con- tact with the posterior surface of the iris. Being separated only from the anterior capsule by the lens substance which has remained behind, the posterior capsule is forced against the anterior, by the vitreous which presses forward. The posterior capsule, which formerly was convex on its posterior surface, now is convex anteriorly. This must likewise be the case with the hyaloidea. In place of a fossn patellaris. we now have a coUiciilvs. From now on, the radius of curvature coincides almost with that of the posterior surface of the cornea. These conditions are all changed as soon as the coi'neal wound heals, for the aqueous, as it accumulates, pushes the iris and capsule backward again. If finally, in the strict sense of tlie word, a sim])le secondary cata- ract (see page 389) forms, this will he found removed al)oni 1 mm. pos- teriorly from the posterior surface of the iris. The catisule of the lens 350 owing to the loss of its contents, and which 'gave it support, will appear folded. Owing to the insertion of the zonula fibres, the so-called fixed points can not alter their position; or if they do this, they approach each other and cause folds. This folding will be more apparent in the pupillary area than in the region of the crystalline pearls. Owing to the incision of the anterior capsule, its condition is a com- plicated one. This condition assumes great importance when we bear in mind that a piece of the anterior capsule may cicatrize in the corneal wound. In order to prevent this, some idea should be had as to the proper position of incising the capsule, which is only reached under difficulties. Gayet attempted to solve this question in an experimental way, and Becker states, since he could not obtain a copy of this work he made similar ex- periments, using pigs' eyes (as fresh as possible). Extractions were made according to the various methods, and using various instruments to open the capsule. The eyes were then hardened in Muller's fluid and then ex- amined. All varieties of the cystotome were used, and on making a simple movement, merely a jagged angular wound was made, the base of wliich is perpendicular to the j)osition in which we permit the instrument to act on the capsule. Per example — If the instrument is passed through the corneal incision directly to the opposite side of the pupil, and the incisions made exactly upward, we will find that we obtained a triangular flap with its base horizontally placed. If the lens is now extruded through this three- cornered opening, the base will become enlarged, the flap turns over outwardly and is in great danger of remaining in the wound. If, on the contrary, the instrument is passed horizontally across the capsule, we get a three-cornered flap with its base vertically placed. If .the lens is now extruded, the capsule will be torn vertically to the corneal incision, conse- quently this flap will be pushed to one side and will not be able to get into the wound. One can judge how much depends on the sharpness of the cystotome from the fact that it can be felt to take hold and let go of the capsule several times before it finally penetrates and tears it. From such incisions and tears as have been described, one can easily see that these flaps have a tendency to turn over outwardly. If. instead of a single incision or tear, a number are made, these can, without difficulty, be brought in ooniu'cliou witli the numlier. form and condition of the flaps. In general, liowevei-. tlie I'elationsliip is the same; the flaps are turned outwardly and show rre(|nenl iiiid irregular folds. 351 All the staleiiu'iits n-anling tlie cicalri/.alion of the capsule in the wound were substantiated l.y the exi.erinu.ntal investi-aticns made on pigs' eyes. Adam Weber's and A. \V."s experiments are to he mentioned here. They removed entire pieces of the anterior capsule from the eye, before delivering the lens. In cases of so-called thickened capsule, this can be done without any gr.-at ditruulty. At limes this will lead to the desired end.18 THE COMPLICATED SECONDAKY CATARACT. (CATARACTA SECUNDARIA ACCRETA.) Strictly speaking, a single synechia between the edge of the pupil or the side of the coloboma, and the secondan^ cataract, is sufficient to bring the latter within this class, though in every other respect this is a simple secondary cataract so far as the processes within the capsule are concerned. Such a synechia may influence the position and the form of the secondary cataract. The frequency of the adhesion between iris and capsule is well known to all observers. As has already been repeatedly stated, frequently the capsule cicatrizes :n the corneal wound, and thus complicates not only the wound, but the cataract. In most of these cases, the stump of the iris is likewise involved, and in these cases the enclosure of iris and capsule are responsible for the increased reaction which leads to the formation of a cicatrical secondary cataract, which takes its origin either in the cqmea or iris. In some cases the ciliary body is likewise involved in this low grade inflammation, which leads to the formation of connective tissue bands, which are stretched across the eye posteriorly to the posterior cap- sule and connected with the same. Owing to the involvement of the cornea, iris, ciliary body and the capsule of the lens, in such a secondary cataract, one can easily comprehend why it is that such an inflammatory process will only cease after weeks, or even months. The more complicated the structure which takes part in the formation of the cicatrix, the more intense will be the shrinkage which Mall follow, and it is possible for the secondary cataract which is cicatrized in the wound, to be drawn in toto to the side of the wound, so that "Petit's Canal" may be widened to an extreme degree on the side directly opposite the wound. This will explain the fact, why it hap])ens, that at times, where a complete occlusion of the pupil, following a cataract ex- traction, exists, and a coloboma is made diametrically opposite the original incision, a space will be found which is entirely free of the secondary eataxact. 18 Nagel's Yahresberieht, 1870, p. 393. 352 Histologically, these complicated secondary cataracts are made up, not only of the products of lens substance, but of those of iritis, cyclitis and keratitis. Hence it is evident, why in. such secondary cicatrical cataracts, aside from the elements described as occun-ing in simple secondary cata- ract, we here find connective tissue, pigment, blood vessels, even new- formed bone. SEQUELAE OF TENSION AND SHEINKAGE OF THE CATA- EACTA SECUNDAEIA ACCEETA. The evil results of a secondary cataract, which is attached to neighboring structures, are not alone confined to interference with vision. Only too often do we find, in this attachment, and shrinkage of this cicatrical tissue, which in course of time must follow, the destructive element which in course of weeks not only threatens to destroy the pe]-ception of light, but which leads to recurring infiammation which may finally totally destroy the shape of the eyeball. And, what is still worse, the painful signs of irritation which are the result of the shrink- age of the secondary cataract, which may lead to sympathetic irritation of the second eye. A single simple posterior synechia changes the normal position of the secondary cataract, in that it is drawn forward. In its turn, this causes the formerly perfectly flat anterior surface of the vitreous to become more or less convex. The vitreous, however, may form a slight convexity in the fossa patellaris, even where no adhesions have formed, and in cases in which the crystalline pearl is very thick. If the secondary cataract is very thick and posterior synechia exist, the iris may be drawn, funnel-like, backward — a condition which is met with at times. The greater the amount of new-formed tissue in this secondary cata- ract, the greater will be the extent of its shrinkage, and the longer will the irritation continue, which will be exerted on the ciliary body. In the few- est cases will this irritation be ended at the time the patient is discharged from the physician's care. Though accommodation no longer exists after a cataract extraction, nevertheless, the muscular contractions of the ciliary body undoubtedly go on, when an attempt is made to see objects distinctly w'hich are close by; hence this will also explain the evil results which may be exerted as a result of stopping the use of atropine too soon; likewise, by permitting the patient to use his cataract glasses too soon. In complicated cataracts, the conditions are still more unfavorable, since the ciliary lody noi only draws on iho corneal cicatrix, through the medium of the zonula, but also by means of the iris attached to the cap- sule. Hence in such cases the indications are to leave the eye at rest as long as possible. 353 CYCLITIS. Th.- products have already Ix'cn considered in speaking of complicated cataracts. Here we must difi'erentiate between the direct in- fluence of those lighter forms involved in the formation of secondary cata- ract and those severe forms due to infection which U.ul to purulent degen- eration of the vitreous and panopthalmitis; and, further, those changes which are due to the shrinkage of these cyclitic products and lead to detach- ment of the ciliary body and detachment of the retina. DETACHMENT OF THE VITREOUS. This may occiir in a two- fold manner; it may he acute or primary, chronic or secondary. Iwanoff found in quite a number of cases which seemed to have healed under per- fectly normal conditions, twelve to twenty days after extraction, a detach- ment of the vitreous from the retina equal to several millometres in the region of the postenor pole. It seems easy to attribute this to the sudden escape of aqueous and lens, at the time of extraction. This detachment was found to be greatest in eyes examined soon after the extraction. If this detachment occurred at the moment of extraction, one can not very well understand why a hemorrhage did not occur more easily; since, how- ever, this did not occur, it is more probable that the detachment resulted from the gradual contraction of the vitreous, which was greatly distended at the time aqueous and lens Avere evacuated. A great deal more is known concerning the cause of detachment of the vitreous, as a result of the contraction of new formed cicatrical tissue and blood vessels wdiich are found in the anterior half of the vitreous. Here, again, we are dealing with the results of tlie contraction of the infiltrated vitreous, subsequent to inflammatory processes.^^ DETACHMENT OF THE CILIARY BODY. This likewise is due to the contraction of the cychtic bands, which extend across the eye from side to side posterior to the capsnle. DETACHMENT OF THE RETINA. It has been abundantly proven that these cychtic bands likewise lead to detachment of the retina.^^* GLAUCOMA. Cases of glaucoma may develop immediately after a cataract extrac- tion, during the healing of the operative wound, and it is not possible in every case to give a satisfactory explanation as to its cause. Rumsche- witsch 20 states that these cases are not as rare as one would suppose, and he reports three cases, in one of which the lens was removed in its cap- 19 See Iwanofe Arch. f. Opth., XY. 2. p. 59-60. 19a Erik Nordenson. Die Netzliaut ablosuns- Wiesbaden, 1887. 20 Zur Casuistick des Glaucoma nach Staar Operationen. Zehender's Monats- blatter, June, 1896. 354 sule. H. Pagen steelier 21 states that this eonditioii usually follows in the first few days, subsequent to the use of atropine; henee great care in the use of this mydriatic is indicated. Such eyes may never have shown signs of hypertonia, but fyequevlUj in eijes irhirli hare hod foniier aftacls of glaucoma. It may occur in eyes which up to the third or fourth week have shown no sign of hypertonia. Here the swelling of the cortical remains may be the cause, but even this condition has been shown to follow when the lens has been extracted in its capsule. As we have seen, as long ago as 18G9 Von Graefe observed cases of acute glaucoma supervene after a discission. Here the swollen lens sub- stance pressed the iris against the filtrating angle, thus closing it off. Priestly Smith 22 reports the case of a child in which, seven years subse- quent to a discission, high tension developed. This was found to be due to an annular synechia, which had united the pupillary margin of the iris with the capsule, locked up the posterior chamber, and thus caused a bulging of the iris, with closure of the filtrating angle. A small iridec- tomie gave exit to the fluid retained behind the iris; the iris retired, from the cornea; the eye recovered with normal tension. He shows that not infrequently the pupillary margin is adherent throughout to the remains of the lens-periphery. The pupil may not appear to be blocked by any visible false membrane, still this membrane opposes the free escape of fluid from behind the iris. Priestly Smith states (page 59): "High tension may set in 3'ears after a good result. JSTatason (Uber Glaucom im Aphaldschen Augen. Mattieson. Dorpat, 1889) showed that immunity from subsequent glaucomatous complication is not insured by any particular operation. Glaucoma may occur after the flap operation without iridectomie, after iridectomie with variously placed incisions, after an extraction preceded by a preliminary iridectomie, and after extraction in the capsule. They show that in the majority of cases there was some visible complication involving the iris or the capsule, or both, namely, iritis or irido-cycltis, with occlusion of tlie pupil, prolapse or adhesion of the iris at the wound, or a similar entanglement of the capsule. This cicatrization of the iris or the capsule of the lens in the wound was likewise demonstrated by Stolt- ing23 aii(] liosch.2'''a In some cases, on the other hand, the eye appeared 21Gl:ni(oin nncli Staar Extraction. Zolipiidcr's Klin. Monatshlalter. May, 1895. 22 The ratiiolouy and Trcatiut'nt of (ilaucoma. London. 1S!»1. p. 57. 23 Glaucom nach Linear Extraction. Graofe Arcli.. Vol. XXXIII. B. -2. 1SS7. 23a(^lanconiatoso nnd .\troi)hisclio Excavation in oincni aphalviclicn Anuc. Anil, fur An!,'('nh.. XXVIIT, ;i."S. ."ill. 355 to be quite free fi'oni any cuiniilicaiioii of the kind. -This negative evi- dence is, however, not quite conclusive, for slight adhesions of the kind in question may he quite undiscoverable in the living eye, and that they are frequent, even in satisfactory cases, has been proven by Becker. Becker examined wiili the inicrosfopo thirty-eight eyes from which cataracts had been extracted, and in only oiif-tbird of these was the iris free from the scar, although thirty-two of the thirty-eight eyes were removed, not on account of any trouble during life, but after the death of the patient. He expressly slates that minute adhesions of the iris or capsule may be quite invisible in the living eye. "It is obvious that an entanglement of the iris or the lens capsule in the wound may lead to a closure of the filtrating angle in its immediate neighborhood, but this does not suffice to explain the occurrence of glau- coma. We can not assume that obstniction of the filtrating angle, confined to a small part of the circle, is sufficient to cause high tension; on the con- trar}', we know tliat such entanglements after cataract extraction are com- mon, while glaucoma is rare." "Treacher Collins' microscopical examinations-* give more positive evidence as to the cause of the glaucoma. In nine of the ten eyes exam- ined by him the capsule was adherent to the scar; in the remaining one from which the lens had been removed in its capsule, the hyaloid was adherent in the same manner. The filtrating angle was closed in the neighborhood of the scar in every case; moreover, it was closed at the oppo- site side of the eye also, and probably throughout the whole of the circle, in seven out of the eight cases; and in those in which it was not closed by apposition of the iris and cornea, it was blocked by exudation." "In the living eye, also, we can sometimes, I think, make out the cause of a glaucomatous complication after cataract extraction. In some cases the iris and posterior capsule, being united and coated by inflamma- tory exudation, appear to form an impermeable or insufficiently permeable diaphragm across the eye, which checks the passage of fluid from the ciliary processes into the aqueous chamber. An excess of fluid becomes imprisoned behind this diaphragm. This may happen although a good iridectomie has been made. In a case of this kind, on the eighth day after extraction, and in the presence of acute iritis, with free exudation into the aqueous chamber and very high tension, which had twice rapidly re- turned after paracentesis of the aqueous chamber, I made an iridectomie downward, tearing completely through the adhering membranes, and ob- 24 Trans, of Opth. Society of the United Kiiiirdom. Vol. X. p. 108. 356 taining for tlu' nionu'iii a Jet hlack [)ii])il. ''J'ho L^yo recovered normal ten- sion and good vision, which are still retained after thirteen years." "It is not eas3% even with the help of pathological specimens, to explain the occurrence of glaucoma after a long interval of time, during which the eye has enjoyed useful vision. It appears probable, however, that a transparent membrane, stretching across from the ciliary processes on the one side to the cicatrix on the other, may in course of time undergo some slight contraction, which draws the processes forward so as to com- press the filtrating angle. Or such a membrane may become less permeable than at first. In this way, or perhaps through some change in the intra- ocular fluid itself, filtration from the vitreous to the aqueous itself is checked. This is not mere conjecture. In an elderly lady I performed a preliminary iridectomie, and later an extraction, apparently with com- plete success. A few months later an insidious glaucoma began, which at first yielded to eserine, but later became persistent. The field contracted, the disc became cupped. Sclerotomy with a Graefe knife was performed in the region of the extraction wound. On the withdrawal of the knife, hardly any fluid escaped, and the iris applied itself closely to the cornea, showing that fluid was imprisoned behind the aqueous chamber. The point of the knife was then passed in again through the same wound, and through the coloboma into the vitreous. A gush of fluid escaped, the iris retired from the cornea and the globe became slack. The eye recovered with normal tension. Curiously enough, I operated later on the fellow eye of the same patient, and encountered almost exactly the same sequence of events. In some cases of this kind the high tension may be banished by passing a cutting needle through the area of the pupil, so as to divide the ]josterior capsule and the anterior of the vitreous.'' "With regard to glaucoma following cataract extraction, we can, there- fore, assert that there is usually a closure or blockage of the filtrating angle, although we can not in every case ascertain the precise manner of its production. The ])oint of practical importance is, that such an ob- struction can be remedied only while it is recent: and wlieii the base oi the iris has become adherent tlirouglioiit to the uoriphery of the cornea, the glaucoma is incurable." The warning can not be stated too emphatically to beware of matur- ing posterior cortical cataracts, and then extracting, without first investi- gating as to tlic [)robal)le cause of tliis couditiou. 'i'lu'sc cases are always secondai'v to disease of tin- uveal tract, and the i)ossil)iliiy of a secoud at- tack of glaucouia sul)se(|Ui'nl to exti'aeliou should nol he forgotteu. Fiually, I he fact can not eutii-ely he sel aside, llial the arthritic or goutv diathesis may he Hie pi'luu' causative factor in ihe |iro(lu(iiou of glau- 357 coma in an apliakic fvi\ \\1iieli in tliis case is inih'pcndcnt of any patlio- logical clian.i^cs atlrihulahlc Id the opci-aiion. Di-. David Dcr'x-ck lias re- cently illustiMtcd tlu'sc facts by xmic xcry iii-t riictivi' cax- rcjxtrts. (Tlio Ohio Medical .luunial. \'..l. IX. X..s. 1 and !i. ISIKS.) CHAPTER IV. Paradoxical as it may seem, the after treatment beo^ins before the operation, and is not finished when the patient is dismissed from the hos- pital or the personal care of the physician. THE MATFEATION OF CATARACT. TTIK ATrriFTCTAL h'JPEX- IXG OF CATARACT. Formerly months and even years were required before a cataract was considered as operable. Owing to a large c^nantity of cortical substance which remains behind when a cataract is operated before it is ripe, and the detrimental influence which a large quantity of cortex may cause, oper- ators have always been fearful of extracting an unripe cataract. One can only understand what a ripe cataract is where we take into consideration how it has develojaed. Celseus was the first to give a more exact description. "One must wait (before operating) for a kind of ripening of tlie cataract (maturitas), until it is no longer fluid, but has rather acquired a certain hardness as a result of coagulation." According to Beer,^ a grey cataract is ripe when it is not possible for it to undergo further development. The expression "ripe cataract" has been handed down to us; but our understanding of the pathological changes has been radically changed, and has been fully con- sidered in the second part of this work. It certainly does not appear wise nor humane to cause a person af- flicted with cataract to pass an indefinite period, waiting for the cataract to reach maturity. Where there is disease of the one eye, the other still having good vision, we may leave it to the discretion of the patient, as to whether he will undergo an operation or not. But where the other eye is also affected, and the patient can no longer follow his vocation, it certainly seems no more than proper that we should do all in our power to both assist him in regaining his sight and luisten the i-ipening of the cataract. We certainly would err greatly if we would permit those advanced in years to pass the few remaining years of their life in the useless waiting for a cataract to ripen, simply because the ancients imagined that cataract was an excretion, or to wait for the cataract to harden. At the present day we know that a ripe cataract can easily be ex- 1 Ansonkrankheiton II. ."110. Wien.. 1S17. 358 tracted from its capsule. Professor Schweigger - does not believe that it is necessary to cause an artificial ripening, after the time when physiolog- ical changes in the lens have done away with the act of accommodation; that is, toward the fifties and surely after the sixtieth year. He beheves that every cataract may be extracted as soon as the interference of sight demands the operation, even if the greater portion of the lens is still clear. "An equal degree of cloudiness in a young individual would designate an unripe cataract. In a young individual, accommodation is still present, the cortex of the lens still consists of a tenacious sticking mass, which ad- heres to the capsule, and if now such. a lens extraction is made the nucleus still escapes, but the cortex remains behind adherent to the capsule. Though the pupil appear black in the beginning, it will soon become cloudy, owing to the saturation with aqueous; the changes here are simply those following discission. Generally speaking, after the fortieth year, every human lens contains a hard nucleus. If the corneal wound is of sufficient size, and the capsule is properly opened, the cataract can be delivered on the slight- est pressure, and it is immaterial whether it is ripe, partially ripe, entirely ripe, or over-ripe. Alfred von Graefe ^ certainly did a great thing when he declared operable the brown, posterior cortical, and the punctate stri- ated cataract." Schweigger declares that for some years past he has handled the subject in a purely practical manner. He operates all patients past the fiftieth year as soon as the senile cataract interferes greatly with the patient's vision, "so that life ceases to be a pleasure to him, and he becomes unable to be self-sustaining, and. the doctor may hope that by the removal of the lens \dsion may be materially improved. It is immaterial whether a greater or less portion of the lens is still clear." Schweigger seems to believe that all methods of artificial ripening of hard cataract, which have as their object the shortening of the time of blindness, can be dispensed with. He considers them purposeless. He states: "To my mind it is antiquated to teach the practicing phy- sician how to diagnose a ripe cataract. It is useless to make four operations on one eye. (1) The preparatory iridectomie; (3) The trituration; (3) The extraction through a small opening; (4) A subsequent secondary operation. By a single operation we not only reach the same end. but do it more quickly and better." It had been observed long since, that where the capsule of the lens was accidentally touched; during an operation either on the iris or opening of the anterior chamber, that a subsequent cloudiness of the lens followed. 2 The Extraction of Unripe Cataract, Berlin Med. Society, July 2, 1890, Hirschberg's Centralblatt, p. 206. 3 A. f. O., XXX, 4, 22.5. 1884. 359 It was supposed tliat here tlie .onlmt In'twcrn the instruinonl and the capsule of the lens caused a disturbance,, either in the epithelial cells lin- ing the capsule, or a dislocation of the fibres innnrdiatoly beneath the epi- thelial cell; as a consequence, interference with ihe proper . utrition and the regular arrangement of the lens filn-es followed, with the further result of cataract formation. Foerster believed that there was a mechanical de- struction of the lamellae between capsule and nucleus, and to him is due' the credit of having first utilized this fact in hastening the ripening of cataract. He originally made the preparatory iridectomie, and then gently massaged the external corneal surface by means of a strabismus hook, and in the course of four to eight weeks the cataract wf.s ready for extractidn. The difficulty in doing this operation has always depended on estimating the requisite amount of pressure to be applied; since if this be excessive the zonula is easily ruptured, and with the result o^ loss of vitreous at the time of the extraction. This method of ripening has been widely em- ployed. Some bolder operators of the present day even entering the an- terior chamber with a small spatula, and triturating the lens direct. The artificial ripening of cataract has been the subject of considerable experimental investigation by Hellferich,* Oettinger 5 and finally by Schir- mer.6 Schirmer experimented on fifty-two rahbits in exactly the same manner as Foerster did, Avithout, however, making an iridectomie. He found that the earliest cloudiness set in in one or two hours after tritu- ration, which could be defined as a series of very fine striations on focal illumination. In the course of a few hours this had advanced toward the equator until a circumference of this cloudy area about the size of a moder- ately dilated pupil. In forty-six cases a decided cloudiness followed; in ten a total cataract. On microscopical examination he found that as the result of mechanical pressure of the strabismus hook, the capsular epithelial cells undoubtedly degenerate. The nuclei of the cells show considerable re- sistance, with at first formation of vacuoles, until finally these were pressed out of the shrinking chromatin net-work, which forms a l)iMght halo around them. The chromatin finally splits up in fine granules. Immediately after the operation the superficial fibres are separated from each other, and spindle-shaped interspaces are formed. These spaces soon increase and are filled with granular substance. The fibres of the superficial layers swell up into vesicles, burst, and their contents exude under the capsule This disintegration is undoubtedly hastened by the 4 Uber kunstliclie reifung des staare. Sitzungs Berlchte dor Wurtzburger Phys, Med. Gellschaft. 1884. p. 115. 5 Uber kunstliclie reifung des staares. Inaugural Dissertation. Breslau. 1885. 6 Experimentelle Studie uber die Forstersche Maturation der Cataract. Von Dr. Otto Schirmer Graefe. Vol. XXXIV. B. 1, 180.3. 36o entrance of acjueous^ into the capsular sac. As a result of this disintegra- tion of lens fibres, the processes of diffusion set in between the lens and humor aqueous, just as in other forms of cataract, and since the fibres possess a different coefficient of refraction, this zone becomes non- transparent to rays of light, and hence will appear white. But if the fibres disintegrate, and a more homogenous mass is formed, the substance may be carried out of the capsule to such an extent as to cause small indenta- tions on the surface of the anterior capsule. ;Meanwhile, the lens con- tinues to grow at the equator, and the new fibres extend immediately be- neath the epithelium toward the pole, so that the entire detritus may be surrounded by new formed lens fibres. In ever}^ case where we expect a successful maturation the massage must be exerted to an 'i-qual degree on all fibres, in order that we may ju-o- duce an equal destruction, and thus lead to a total cataract. The fibres can only be destroyed where the tension within the capsule is increased. "This pressure causes a dislocation of the various lamellae, and the for- mation of interspaces in which fluid stagnates, thus setting up an abnor- mal process of diffusion and a subsequent disintegration of the lens fibres." THE AFTER TREATMENT. Sufficient has already been said concerning the preparatory treatment. If necessary the patient's general health should be cared for, examination of the lungs, the presence of an aggravated bronchitis, should be allevi- ated as much as possible, in order to prevent coughing spells during the time the patient must be quietly on the back, and the urine should always be examined, and finally, the bowels should always be thorcnighly evacu- ated before the operation. The conjunctiva should b^ thoroughly cleansed with antiseptic solutions before the operation. At the present day neither atropine nor eserine are used previous to an operation. Becker, however, gives us special indications for their use, which are likewise applicable today. He tells us. "In i)erforming the flap operation the right eye was brought fully under the influence of atropine. The idea being to lessen the chances of the iris eoming in contact with the knife, and at the siune time facilitating the exit of t he lens." We believe the observation is correct, for though tlu' itupil conliMcls the nioiuent the aqueous is evacuated, the iris is more t'asily dilated by the h'us after open- ing the capsule of the lens, when tlie eye has been previ(.u>ly atropized. For the time being, the action of the atropint' is overeonu' by the induced spastic contraction of the sphincter, without this action being of a lasting character. In the course of a normal healing, one will lind that the im[)il \ 361 which at the time of tlie operation was t-ontracted. will in the conrse of a few hours become fully dilated again. Likewise, in the beginning atropine was used in the Graefe operation. Eduard :Nreyer, however, suggested that its use previous to the operation be abandoned, and this suggestion has found general favor. The belief was expressed that cicatrization of the iris could be avoided in many cases, since, if we did not paralyze the sphincter previous to the operation, the iris Avould contract after the escape of aqueous, and thus permit the iris from becoming involved in the wound." For the same reason DeWecker, in making his operation without ex- cision of a piece of the iris, goes a step further, in that, at the conclusion of the operation, he drops a drop of sulphate of eserine (| per cent, so- lution) into the eye, and thus by contraction of the pupil draws the iris out of the wound. Instead of a mydriatic he uses a myotic. It is a matter of special importance to carefully examine and watch the conjunctiva before the operation. A host of observers have shown us the effect of an infected lachrymal secretion. The deleterious effects of a tear sac blenorrhoea have been recognized for a long time; and one would hardly expect to find an operator at the present day who would perform an operation without first healing the latter condition. The same is true, though to a lesser degree, of all forms of conjunc- tival disease. A chronic catarrh should be suppressed as much as possible, and one should not forget that after an operation, owing to pressure of a bandage, the secretion may rapidly increase again. This should diligently be watched, the conjunctival sac kept clean, and thus the accumulation of the secretion prevented. It is a peculiar tiroumstance that trachoma, granular conjunctivitis (chronic blenorrhoea of Arlt. opthal aegyptica), is not to be looked upon as a contra- indication to the performance of an extraction. At least this is true where pannus has developed, for the vessels in the cornea lead to a rapid and fortu- nate healing of the corneal wound. THE AFTEE TREATMENT. Von Graefe Avarned us against a cer- tain indifference which even men of the greatest ability have been guilty of, as soon as the process of healing takes an anomalous course. He says: "True, owing to inability to explain in every case the cause of the intense reaction, one easily falls into the fatal error of simply laying one's hand in one's lap just as soon as the pain, active secretion, redness and swelling of the conjunctiva, uncleanness of the wound, cloudiness of the cornea, hypopyon, or hemorrhage into the anterior chamber set in. True, at the suggestion of a more experienced colleague, one tries oiu^ thing then another, but since n<. one method seems to avail in a-ll cases which present 362 ilie same symptoms, we become dissatislied. and at times desist from any further attempts. Thus we turn from one mode of treatment to another, and finally we become completely skeptical, since no form of treatment is uniforndy followed by favorable results." This was written before the study of bacteriology had assumed its present important position, and 1)efore the full extent of the action of micro-organisms, in the production of inflammation was recognized. Today we know that all pathogenic germs may and do lead to destruction of the eye. Prevention of an infection is the watchword, for after the in- terior of the eye is once invaded, we may as well stand by, for we are helpless to stay the inflammation. All we can do is to alleviate the pain, meet complications as they arise, and eventually enucleate to prevent in- fection of the other eye. The first symptom which demands attention is pain. Since the nor- mal course of healing is accompanied by pain, it would certainly seem im- portant to fix a border line where this becomes pathological. This, how- ever, is impossible, since some patients are more sensitive than others. This pain is usually described as a burning pain. This never increases, but usually continues during the first few hours, gradually growing less. After five or six hours there should no longer be a continuous pain. From time to time the patient experiences a slight sensation of pressure. This is followed by a short, pricking sensation, followed by a sensation as though something were flowing from the eye. This sensation is due either to the accumulation of tears in the conjunctival sac, which in cases where the margins of the lids have become agglutinated together, can only escape when the pressure of the accumulated tears forces the Ms apart. Or the pressure and the pricking pains are due to the accumulated aqueous forcing the edges apart, and thus escaping, either beneath conjunctiva or into the conjunctival sac, and then finally escaping, between the edges of the lids. These sensations can not be included with those of active reaction. As soon as the pain becomes paroxysmal, or changed from a burning to a tearing, lancinating, boring or thumping, it is to be alleviated by any method possible. The bandage should be removed, the wound carefully t'xamined and carefully cleansed. If the pain continues, cold applications and a hypo- dermic injection of morphia are indicated. Under all circumstances the patient should have a good night's rest. If necessary bromide of potash and chloral are indicated. In normal cases, all signs of wound reaction disapjioar l)otween twelve and twenty-four hours. Becker warns us that the very worst forms of disease begin to manifest themselves toward the close of the first night. The bandage should at once be removed and the wound oxaniinod. and if 363 there is no tearing or swelling of tlie li(i.s, the simple application of a fresli dressing, together with the usual washing off of the edges of the lid, will he sufficient. If, however, the linen paa which covers the eye is wet and covered with purulent secretion, we know that we are dealing with an infection. Von Graefe advised, after carefully cleansing the lids, that we touch the entire surface with nitrate of silver and then thoroughly neutralize the same. In rohust individuals he even practiced venesection. Today use of antiseptics is called for. and as has already been stated, many operators cauterize the edges of the wound; and the anterior chamber is wa>een how the shrinkage of the complicated secondary cataract may become the cause of long-continued signs of irritation on the operated eye, and how this condition may induce sympathetic irritation; so likewise, the early use of cataract glasses, owing to their inducing efforts at accommodation in the opei-ated eye, are only too often the indirect cause of iritis and cyclitic irrita- tion wliich develops later on. Many a case of cicatrization of the iris and ca])sul('. which would not have given rise to any trjuble, take a fatal ter- mination as the result of the early use of glasses. It is not an easy matter to make a general statement as to tlie time after which the use of glasses can no longer be looked upon as detrimental. This depends on the mode of healing. The older physicians were correct when they laid down the rule that cataract glasses should not be used until months after an extraction. THE SECONDx\KY OPERATIONS. In the broad sense of the term, these ought to be considered a part of the after treatment, since both the simple and complicated secondary cataracts may give rise to occasion for practicing these secondary operations. Whether the amount of vision obtained after a cataract operation will be sufficiem or not does not alone depend on the degree of vision attained, but also on the demands which the patient makes on his eye. A farmer or a day laborer will be well satisfied if he can read medium-sized print; whereas, one who follows intellectual pursuits will require more vision, and request a secondary oper- ation. Since a secondary cataract may also result from injuries of the lens system, and since the difference between secondary cataract subsequent to an operation for cataract and traumatic cataract is really only one of de- gree, hence the treatment of both will be considered together. The therapy of injuries of the lens, and of traumatic cataract, as well as the prognosis of these injuries, and the character of operation to be made, depends entirely on which other portions of the eye were injured, and what the condition of the eye is after the injury has healed. TREATMENT 0¥ RECENT INJURIES. Traumatic cataracts, in which there has been no injury other than of the capsule, do not re(}uire, during the period of their formation, any other treatnuMit than tliat which any other disease process present at the time may require. Use of atropine prevents iritis and breaks up any possible synechia already present. It is dependent on other circumstances whether the cataract will remain partial or become complete. If only the capsule of the lens has been involved, and no foicign body has remained in the lens, which is only possible where the wound in the 366 capsule is a small one, the pupil is to be widely dilated by atropine, and then await developments and see whether the wound in the capsule heals, or if the tumescent lens substance is extruded into the anterior chamber. If the corneal wound heals, and no signs of a violent reaction develop during the lirst few days, which may result from the most trivial solutions of continuity, owing to increased tension in the eye, the same regulations are to be followed as in cases of discission. Simultaneous injury of the iris will not call for any special therapeutic procedure. Often the involve- ment of the iris is the cause of a more rapid healing of the wound in the capsule. Under certain circumstances a cut in the sphincter of the iris may assume the role of a prophylactic iridectomie. One of the evil results of the above conditions may be a swelling up of the lens substance. As a result of his painstaking observations of trau- matic discissions, A'on Graefe restricted the indications for discission to the young. This swelling lens substance may lead to secondary glaucoma in the aged, and at times even in the young. In younger eyes the elasticity of the outer coats is greater; hence, a passing intra-ocular tension is more easily borne, until finally disturbance in the circulation sets in, and per- manent increase of tension ^ets in. Hence, in the aged, owing to the greater rigidity of its walls, glaucoma and excavation of the papilla set in much sooner, the conditions being the same. Kot infrequently we see the eyes of children under the influence of traumatic cataract for weeks and months, and in a condition of increased intra-ocular tension, without the optic nerve suffering in any way. Whereas, in old people we find the most insignificant swelling of isolated pieces of lens substance lead to glau- coma. This has been shown to be due to pressure on the root of the iris. This presses against the filtrating angle in the anterior chamber, and thus excluding a part of the filtrating angle, leads to interference with the out- flow of fluid, and thus causes glaucoma. If it is evident that glaucoma is about to set in, or if it is ali-eady present, one should not delay. The pressure phosphenes are especially valuable in testing the field of vision, since the tumescent lens substance materially afi'ects, owing to the diffusion of liglit, all tests for projection. The indications seem to he divided between simi)le iridectomie, cataract extraction, or a combination of both methods, t,) young children one would make an extraction of tlic lens by a simple linear extraction, or by modified extraction in use today. If violent synij)toms hav(> developed, and call for interference, the lens will always be found to hv so intensely swollen as to escape at once on making the incision. If the individual is older, and the increased intra-ocular tension is due to but slight swelling which is pi-essing on the posterior surface of the iris, the entire lens not being swollen, a simple iridectomie at tlio ])lac-(' where the pressure is ex- erted, would give by far the best results, and if necessary one would later on make a much better cataract extraction. If the patient is past the years of adolescence, and the lens is swelling, one will find the greatest relief follow a linear incision. In the above described cases it frecjucntly happens that the injury to the lens is the smallest part of the injury to the eye. This is always the case when the corpus ciliare is injured, be this ever so slight. The fatal influence which a shrinking cicatrix of the ciliar}- body exerts, not only on the injured but on the second eye, is too well known. Likewise, where a foreign body is in the vitreous, be it ever so small, the injury to the lens becomes a matter of secondary- consideration. Very broad incised or punctured wounds, as well as total destruction of the form of the globe are, as a matter of course, coraphcated by injuries to the lens. After the signs, of inflammation have disappeared, one must take into consideration the volume of the traumatic cataract before deciding on the , method to be employed. If the diiference of volume from u normal lens is but slight, one will be called upon to make a regular operation. The more the volume is reduced the hiore nearly will the cataract come under the same variety as the secondary cataracts. TEUP: TEAUMATIC CATAEACT. if the traumatic cataract differs but little in volume from the normal lens, vision may be totally restored by performing a technical cataract operation. And since such traumatic cataracts usually develop as soft cataracts, a linear extraction is indicated. JSTotM'ithstanding the fact that synechia are frequently present the per- formance of the extraction is not, as a rule, connected with any diificulty; the results, however, are not very encouraging, depending largely on the further injury to other parts of the eye at the time of the accident, and the possible infection at that time. In all these cases one should not forget, before operating, to test the light sense and the projection. As has already been said, the operation offers no special difficulties. It is only where there is a capsular cataract present, or where the capsule has cicatrized in the cornea, iris, or ciliary hody. that it does not give easily to slight traction; hence, one should not attempt to draw it out of the eye by force, though it does interfere with sight. Violent trad ion, es- pecialJ;/ on the ciliary hody, will he folloirrrl hij the most detrimental re- sults. Even where such difficulties aix' nol encountered, frequently the most violent reaction follows. The ojK'rativc ])r<)(H-dnre leads to a recur- rence of the cvclitis, which had Inn recently subsided. 368 Naturally the irritability of the eye decreases, the longer the time elapsed since the accident, and we may assume that a period is reached in every eye, at which time no evil consequences as a result of the accident wall exert their influence on the proper healing of the operative procedure. Hence, it would be advantageous to fix a time when it would be well to interfere. It has been said that a traumatic cataract should not be oper- ated earlier than the sixth or eighth week. Such a rule has no value, since tinder strict asceptie precautions the operation can not of itself induce any further injury to the eye. But where the case is complicated by iritis, cyclitis or choroiditis, it certainly would not be wise to undertake an oper- ation. During this time Becker laid great stress on the circumcorneal injection, and laid down the rule, that the time for operating had arrived as soon as the pericorneal injection ceased to appear in grasping the con- junctiva with the forceps. Seldom do we meet with a membranous cataract {catarada inem- hranacea), or a secondary cataract {catarada secundaria), without finding the iris bound down to the capsule in one or more places. Especially in cases of traumatic cataracts do we find broad adhesions. This is explained by the fact that during the period of swelling or immediately following the operation, the iris, for a considerable period of time, remains in contact with the capsule. P^requently. however, the iris receives a direct injury, or at least is irritated. Thus, depending on the character of the injury or the processes which have taken place subsequently, will we find a simple ad- hesion, a broad adhesion, or a proliferation of cells from the iris into the capsule. A deep anterior chamber, the irregular form of the pupillary edge of the iris which is adherent, the processes of an opaque membrane in the pupil, pigmented here and there, possibly vascularized, are all land- marks for the diagnosis of the above condition. If a piece of the iris has been excised at the time of the o]jeration, one can also observe how the cloudy membrane gradually is lost in the cicatrix after the operation. In such a case, the secondary cataract usually lies far forward, adherent to the iris, or the cicatrical tissue in the cornea. In the simple non-complicated secondary cataracts a disnsfoon with one or two needles will bring about llu' desired result, and with a higli de- gree of safety and efficiency. This operation of discission aftei- extraction is not without its dangers, which, according to Knapp,^ causes glaucoma in from !-•<; per cent, of aphakic eyes. He believes that tlie charader of the secondary cataract, and the itniiinrr »f ofhn-kiinj the >aiue. are the main 1 Archives of ()plli:il.. \(.l. XX VII. Xo. o. I I 369 factors. The reac-lion — i- due l<» the traction on the cicatricial bands stretching to the ciliary l)ody. If the secondary cataract is fixed in the wound by cicatrical tissue, one frequently meets with success by making an iridectomie in the oppo- site direction, and thus regain a satisfactory amount of vision; since in such cases the greatest portion of tlie scconchuy cataract is drawn toward the wound. Frequently, however, tlic hirgest pupil tills uj) again, so that even a second iridectomie is without result. This usually is tlie case where the vitreous is detached and changed to connective tissue, and takes part in the formation of cicatrical bands. Such a result can not be foretold with certainty before an operation, but its occurrence is to be feared in all cases in which the cicatrix is drawn inward, and the tension is reduced, when the iris is discolored, and the membrane in the ])upil appears to be vascularized. Both of the last symptoms ai'e indicative of abnormal circu- latory conditions. Jn consequence, dui'ing the operation, the anterior chamber becomes fdled with blood, which is only absorbed after many days or weeks. When one finally^ does get a good view of the conditions present, one finds the pupil, which had again been made, filled up with new formed tissue. The operative procedure has awakened anew the for- mation of the cyclitic bands, and the momentary result of the operation has been brought to naught. For this reason other operative procedures have been introduced to take the place of the iridectomie. It was advised that the cornea be severed by a 3 mm. wide two-edged knife; then go in with a pair of forceps and cut out a large piece of the iris, so as to lessen the chances of the space filling up again. (Agnew A. Weber.) Later on DeWecker favored the iridectomy (Annal. d'Ocul., Tom. LXX, ]). 1-^3). The advantages of the iridectomie which he makes with the lance-knife, and his '-Pince-Ciseaux." lie in the fact that his operative procedure does far less injury, because the iris is not drawn out to be excised; but since it is held tense, he simply incises it and allows it to retract. Mooren followed this suggestion. Kruger advised cutting out a piece of tlie membrane witli a scissors-like i)unch (Klin. Monatsblatt, 1874, p. 4'^9). Owing to the influence which everything wliicli causes tension on the ciliary body exerts in causing cyclitis, it must be ai)parent that a secondaiy operation will be more certain of bringing about a good result, the nu)re the above circumstances are avoided. With this object in view the two following operations were introduced: BOWMAN'S METHOD. Two discission needles are employed: one is passed through the inner ([uadrant of the cornea and thi'ough the center 370 of the opacity: the second needle is passed throngli tlie onter qnadrant of the cornea, and into the opaeit}' close to the first. The points are then separated, and tlins a hole is made in the membrane. NO YES' METHOD. A puncture and counter ])nnctur(' is made with a Graefe knife in the horizontal meridian of the cornea, and as the knife is withdrawn it is made to puncture the secondarv cataract. Two blunt hooks are now entered through the original corneal punctures,, and the points passed through the openings in the membrane. By traction the opening is enlarged without any di'agging on the iris or cilian' body. THE THERAPY OF LUXATION OF THE LENS. The treatment of luxation of the lens, just as that of cataract, be this of traumatic, spontaneous or consecutive origin, can only be considered prophylaetically. This, however, has but little practical value, owing to the rarity of traumatic luxation, and because it occurs, even less frequently as the result of certain occupations than the traumatic cataract, which is the result of accidental or designed injury of the eye. The attempt was made a few times (Hornig, llGOa) to replace in the fossa patellaris a loosened or even a partially or totally dislocated lens by therapeutic measures, and thus to bring it back into its normal position. Eduard Meyer (1160b) reports a case in which a len.;; which was dislocated upward and inward returned again to its proper position in the pupil, not- withstanding the dislocation on the other eye increased. However, it did Dot remain fixed in its position, but moved about when the eye was moved about violently. Xo cases are reported in wliich it has been ])ossible to stop this in- creasing ectopia. Here, just as in cases of spontaneous sinking down of the lens, one can not ho])e for relief until we have discovered the cause. For though we accept Schirmer's idea, that the failure of the lens to grow during the time the remaider of the eye is :::rowing, as the cause of the increasing dislocation in cases of ectopia, still one can not understand how the lens is to be urged on, or the remainder of the eye retarded in its growth. Similar reasons are given for the cases of spontaneous luxation following fluidity of the vitreous. If the dislocated lens is still ])artially in the pu])inary area and trans- parent, either myopic astygmatism or double refraction will ensue. The interference with sight may then be partially or totally relieved by glasses. If, however, the lens is cataractous. the interference with vision may be overcome by an iridectomie. ver}' nuuii in the same niannei' as has been advised in cases of zonular cataract. Kiiapp was the first (!)().")) to advise iridectomie in cases of luxated cataractous lenses, which still occupied the pupillary area. Naturally, a pei'manent result only is to be expected, where 371 the dislocated cataract lias become lixod. Knapp's case was a dislocated traumatic cataract which had formed adhesions with the iris. Since in cases of shrunken traumatic cataract, the zonula zinii is frequently drawn to one side, and the interspace found considerably wider; so an iridectomie properly made will aid us in restoring a very considerable degree of vision. Von Graefe was the first to practice iridectomie in cases of zonular cataract in 185.5. Though we might look upon the spontaneous sinking of the cataractous lens out of the pupillaiy area as an auto-cure, it may, nevertheless, if it is free in the eye, at any time give rise to secondarj' glaucoma. This is more apt to occur when a freely moveable transpai'ent or cloudy lens gets in the anterior chamber. The extraction becomes a necessitv in both cases. PART V. THE APHAKIC P:YE. DEFINITION AND DIAGNOSIS OF APHAKIA. According to the suggestion of Donders (Ametropie en hare gevolgen, Suermann en Donders, 1860, p. 8T), we designate that condition in which the lens is absent from tlie dioptric system of the eye by the term Aphal-'ia (a ])ri- vativum and tpax^ the lens or bean). Aphakia may be produced by different causes. It occurs most fre- quently as a result of operation for cataract or of an injury. In both ways the lens may either be removed from the eye at once, or after opening of the capsule be resorbed in the eye, or simply be depressed in the vitreous. Under the latter condition the lens is still in the eye, and may even remain transparent for a long time. We are, however, justified in designating this condition as aphakia, since the lens can no longer iniluence the direction of the rays of light. Tn cases of incomplete luxation (be this traumatic in its nature or spontaneous, or as in cases of ectopia lentis, in which not in- frequently part of the pupil is free, whereas in the other portion of the pupil the rays of light as they enter are acted on by the lens), there exists a double condition of refraction. As a rule, myopia and hypermetropia are present at the same time, and we have before us a case of monocular diplopia. The myopia is due to the increased curvature of the surface of the luxated lens, and hence in an emmetropic eye tliis does not become very great. Whereas, the hyperopia differs in no way from the refractive condition of a completely aphakic eye. It is not always an easy matter to determine the presence of aphakia at first sight. The appearance of the eye depends largely on the method of operation employed, the kind of injury produced, and the manner in which the process of healing progressed. In the foregoing chapters all those symptoms have been enumerated which could serve to aid us in making the diagnosis in every ])ossil)le case. Whether the operation or tlie injury has been followed l)y an occlusion of the pupil, one can judge by the external ap])earance of the eye. Where the operation was combined with an iridectomie, or the lens has escaped from the eye, in consequence of a rn])turi' of the sclera, the coloboma of the iris, or the displaced pu))il, will lead us to investigate the coiulition, and lead us to dctcrniinc wliclhcr or not the lens is urescnt. I>\it if wc are ,-..ssfi in. 373 1 was made without an at ion or a spontaneou.s SCISSI r the eye. the aphakia will be character- he presence oi' iridodonesis, the absence and hy the liii^h decree of hyperopia. aiilei'ior ehaiidiei' will he all the more iilly Ihe shallower the an- eases of luxation (d' the i>e(|i [•a ted ey )tl ..f Ih which dealing with a ease in which a iridectoniie. or a case of siiupl( sinking of the lens in the depth ized by a deep antei'ioi' chaiid)e of the I'urkinj.' Iigure> of the le ^rhis ahnoriual depth of t apparent the oldei' the individii terior chandler on the non-op lens, or e( topia. it is the une(|ual d( directs our attention to the i)ro])ei' diagnosis. Iridodonesis aloiU' is not positive evidence of the absence of the lens, since jieripheric t reniulonsness of the iris has lieen observeTICAL SYSTEM IN APHAKIx\. "Owing to the removal of the lens, the complicated dioptric system which exists under normal conditions in the eye, now becomes the simplest of which it is possible for us to conceive. Notwithstanding its difl'erent histological structure, we may look upon the cornea as having an index of refracting about the same as that of the aqueous humor. The very slight difference which was found in the coefficient of refraction, was determined by measurements made on the dead cornea. If we examine a living cornea in the aqueous, as is well known, differences will only begin to manifest themselves after a time, and these are to be looked upon as due to a gradual death of the ti^ue. Hence, during life the cornea is not only to be looked upon as homogenous, but as optically like the aqueous." "Likewise, there is scarcely any optical difference between humour aqueous and corpus rifreum. Already the younger De la Hire found (1707), at the time he was called upon by the Akademie to answer the new teachings of Brisseau, contrary to what he had believed, that a mixture of aqueous and vitreous, taken from a pig's eye, remained perfectly clear, and thus proved that these two fluids neither exerted any chemical change on each other, nor did they have a different coefficient of refraction. All later investigations have simply further proven, that both not only possess the same index of refraction, but that this is the same as that of distilled water." a In order to translate the inch scale to the Dioptr»\ innltijily the traction by forty. Thus, \ X 40= Y== 10 T). i 375 "If we will simply consider the results of the luvestifiations of the four last investigators, TIelmholtz, C'yon, Fleischer, and Ilirschberg, we will see that they respectively place the coefficient of refraction at 1.3;5G5_, 1.33532, 1.33T3, 1.337 1, and that of the vitreous at 1.3383, 1.33566, 1.3369, 1.3360, and we will further see that all thos<^ figures only differ in the third decimal place. And further, if we will take into consideration that Cyon made his calculations on the ox's eye, and that though Helmholtz and Hirschberg have found difl'erences between aqueous and vitreous, which ex- ceed somewhat 0.001, which ho\vover,may be ignored, we certainly can not go amiss if we accept as a l)asis for our work the figure attained by Fleischer. But since Fleischer has drawn attention to the fact, that owing to the increased temperature of the blood in the living eye, we will have to reduce the refracting indices of aqueous and vitreous about C. 0.001; hence, since our calculations are to be made for the living eye, we may place the index of refraction of the fluid media of the eye in aphakia— 1.3360, which agrees almost exactly with the index of refraction of distilled water as determined by Brewster— 1.3358." ''According to Listing it is not the surface of the cornea but rather a capillary surface of tears which is to be looked upon as the refracting sur- face. Hence, Hirschberg had a happy thought when he determined to estimate the index of refraction of the tears. This equals 1.33705, and hence only differs in the third decimal place. Hence the cornea, the center of which only comes under consideration here, is to be looked upon as a perfectly parallel surface, placed between two fluids of equal indices of refraction, and hence it can not exert any dioptric influence." The same may be said of the capsule when this has been retained In the eye after a cataract operation. It may be folded, and reflect the light and coniain cloudy masses here and there, absorb the light and cause dispersion, but it can never act as a refracting medium. ^ "This capillary sheath of tears, which fills out all the uneven places on the corneal surface, and which is to bo looked upon as the true refract- ing surface, is dependent for its form, as a matter of course, on its under- lying structure, the cornea. Its curvature is determined by its catoptric effect; that is, by the size of its images, and its power of refraction depends on this curvature and the coefficient of refraction (1.336) of the transpar- ent media. Though the cornea is not spherical, but has rather an ellip- soidal cuiwafure, one may ignore this departure from tlie globular form; since in the first place, at that point in the center of the cornea where the visual Hne cuts the same, this departure in a single meridian is exceeilingly slight; and secondly, because in making the optometric examination of the refractive condition of the aphakic eye, in order to prescribe cataract glasses, we only make use of spherical glasses, and the choice of the same is nearly always confined to the condition of the refraction of ihe horizontal 376 meridian. Hence, for the ])resent we will not consider a congenital or ac- quired asymetrie in the curvature of the cornea. (Ast5'gmatism.)" "The simple dioptric system of the aphakic eye, which we shall take as our model for all our future considerations, consists of a spherically- curved refracting surface and two refracting media, the atmosphere which has an index of refraction 1.000. and the thiid media of the eye. which have a refractive index 1.33()." "If we now also know the radius of curvature of the refracting sur- face, we can easily determine the cardinal points of the system, according to Helmholtz's simplified formula of Gauss, and we can easily determine the interesting equations as to the length of the axis of an aphakic eye of known refractive condition, and vice veisa, given the length of the axis; also concerning the size of the images at a given distance, and vice versa; also concerning the enlargement on combining the cataract glasses \Wth the aphakic eye." Owing to the great simplicity of sucli a formula, as compared witli that of the complicated system of a complete eye. Listing came upon the idea of sub- stituting the dioptric strength of his average schematic eye by a refracting sur- face: however, retaining the position of the posterior nodal poiut. and thus he constructed his so-called reduced eye. "However, notwithstanding the analogy which exists between the reduced and the aphakic eye, they differ in that in the latte^ case we are always in a position to measure the curvature of the cornea with the opthal- mometer, so that we are no longer dealing in the abstract, but are met by a condition of affairs which really exists." "Hence, in arriving at the following general formulas we need not confine ourselves to the computations of Listing and Helmholtz in their schematic eyes. This is the result of the work of Bonders (1. c, p. 208. Eup. Translation, 1864, p. 310), in that he does not use the average radius of curvature of the ccrnea of the aphakic eye. as computed by Listing and Helmholtz, 8 mm., but he uses the results of his own measurements, made on eyes of old men, the average of which he placed at 7.7 mm." "Under these conditions the average measurement* of the ajdinkic eye will be as follows: Corneal radius, 7.7 iniu.: index of refraction of the media of the eye. 1.33()0. The antorioi- focal distance,^^ = '^"^.!>l ]nin. The posterior focal distance, teimine the length of the visual axis, when tlie focal distance of the glass which corrects the hyperme- tropia and its distance from the center of the cornea are known. Accordingly, as this glass is held at a greater or less distance from the eye. eyes with vary- ing lengths of the visual axis can see in the distance." EMMETROPIC APHAKIA. "The finding of tlie proper glass with which an aphakic eye can see in the distance is practically a matter of experiment. In order to do thi.s, we either follow the suggestion of Bond- ers, using a luminous point; or we use the Snellen's test types, such as are usually employed in testing cases of refraction. By this means we at the same time gain an idea as to the acuity of vision." E.\])erience has taught us tliat a glass which has a focal length of more than 3.5" (+11 D), will be required in order to see distinctly in the distance. In the last hundred ca.'ses operated, thirty - five received glasses of ^, (+ 11 D); fifty-two glasses ranging between ^ (+10 D) and ^ (+ 11 D). Aside from this' twenty-four glasses No. ^ ( + 10 D); so that by adding these together, we find that seventy-six, about three-quarters of all those, received cataract glasses of ^ to -^. Only eight patients saw distinctly in the distance with stronger glasses, and sixteen with weaker glasses. The weakest glass which I ordered was for y^, the strongest ^ This agrees with Snellen's statements, who gave a glass of ~ in 65 per cent, of cases; in 11 per cent, stronger, and in 24 per cent, weaker glasses. (If Westhofi" doubts these figures for acquired H, this must evidently be a clerical error for Bonders, from whose reports the above statements are taken, is likewise of the opinion that in the majority of cases a glass of ^ to ^ (+10D to+ 11 I)) will he necessary to see distinctly in tlie dis- tance.) The conditions are confirmed by all rejjorts. "If we assume the average distance at which a cataract glass is placed from the cornea, equal to 0.5", we would still find, taking into con.sider- ation the distance of the nodal point from the cornea, in the majority of cases after the cataract operation, the ac(|uired H would equal Ji ,\r- the radius of cornea being 7.7 mm; the length of the ojitical axis being 23.86 (7) mm." 378 "(In the case of the schematic eye, the radius of the cornea would be 8 mm., and the length of the optic axis would be 24.5 mm., which would be more than above.) Hence such an eye, haA'ing a corneal radius of 7.7 mm., an index of refraction of 1.3360, and an optical axis of 23.86 (7) mm., may be looked upon as an enmieti-opic eye. We therefore call it the emme- tropic-aphal-ic eye.'" "Very frequently, however, the distance of the center of the glass is farther removed from the center of the cornea than 0.5". Where the distance of the glass is 0.75", the length of the optic axis is reduced (7.7 mm. radius) to 23.39 mm. Hence, it is still considerably greater than is the case in Helm- holtz's schematic eye (22.23). If we will now assume that most cases of senile cataract occur in eyes Avhich were emmetropic before they became cataractous, and became affected with senile hypermetropia, we come upon a contradiction between tlie average length of the optical axis as determined by Helmholtz, and ourselves, after cataract operations, aud a-ecording to optometric exami- nations." In any special case, we need not satisfy ourselves with the average length of the radius of the cornea after a cataract operation, for we can obtain this accurately by measurements made with the opthalmometer. Here assuming that the index of refraction of the vitreous has not changed, we can obtain the exact length of the axis. In the following table I have taken those in which the corneal radius was measured in the horizontal meridian with the opthalmometer before the operation by Eeuss and Woinow. Since the distance from the eye is not stated, I have taken this to be in one case 0.5"; in another as 0.75". From these tables it also be- comes evident, that the average length of the axis, without exception, is greater than is the schematic eye." Hence, it follows, that not only the corneal radius given is too great, but that also the refractive strength of the lens, be this the result of im- proper position or a too great absolute strength, has been assumed too great. 379 T ABLE VII. XAME- ,/.. Focal Distance of the Glasses Ordered for Distance. y;-=- H aph. Length of the Visual Axi.s /// - // aph. Length of Axis Pischinger . . Nitsch .... Werhotta . . . Pohlhammer . Donabaum . . Furtlehmer . . 8 0780 7.9275 7.7282 7.4964 8.1794 7.8976 7.6108 9.^^5 6.00 4.5 3.75 3.5 3.25 3.00 9.^^00 5.5 4.0 3.25 3.00 2.75 2.5 1 8.H6 1 0.15 1 3.65 1 2.90 1 •2.65 " 2.40 1 2.1.-) 29'^ 33 27.10 25.20 24.84 24.86 24.20 23.71 23.05 23.68 23.07 21.93 8. ^'7 5.25 3.76 3-00 2.75 2.5 2.25 H.-IO 1 4.iliJ 1 3.40 2.6.=p 1 2.40 2.15 1 1.90 26.' '80 26.66 25.70 24.36 24.34 23.70 23.04 7.4155 22.60 Dolak . . . 7.8740 23.17 3Iatcheky . . . 7.5862 7.3644 22.54 21.34 i*h= Radius of horizontal meridian of cornea ; /, as in formula on page 376. H. aph, aphakic hypermetropia ; /, as given on page 376,/ determined length of axis. MYOPIC AND HYPEEMETEOPIC APHAKIA. 'If the eve was mj-opic previous to the operation, it will require weaker glasses after the operation. And likewise, where an eye requires a weaker glass after oper- ation to see in the distance, we conclude that the eye must have heen myopic. We can then also approximately judge the degree of myo]iia. Donders repoi-ts a case in which an aphakic eye was not improved, either by use of a plus or minus glass. In this case the casual axis of an eye which had become emmetropic by aphakia, must have had a length of 30 mm., and from this we may draw the deduction that as long as the lens was present in the eye there must have existed a myopia of al)out ^ ( — 10 to — 11 D). A glass of \ (+ o D) or less is now .sufficient to see in the distance, and not in- frequently patients state that they now see better witli a +4 D, or + 5 D,or less, than they formerly did with the inyojiia of i ( — 8 D) or more." "Donders, who drew attention to the fact that zonular cataract, as a rule, is associated with myopia, was given the opi)ortunity to measure the radius of curvature of the cornea in three cases, which were myopic before 38o and hypertropic after the operation, and from this lie determined the length of the optic axis. Table VIII shows their length. It happens that in the first case the axis of curvature of the cornea is somewhat shorter, and in the two latter somewhat longer than usual. Hence, from the length of the visual axis one can determine the degree of myopia." TABLE VIII. AMETROPIA. Curvature Radius of Cornea. Calculated Length ok Before the Operation. After the Operation. THE Visual Axis. M=l:6 M=l:8.5 M=l:24 H=l:5.12 H=l:4.5 H=l:3.2 7.6 7.92 8.04 25.96 26.39 25.02 ''We find that congenital hyperopia acts in exactly the opposite man- ner. However, Bonders declares that one seldom finds an aphakic H > 1:2.5. 1 do not remember that I even prescribed a stronger convex glass than |. In the two hundred cases reported by Snellen, I find only two cases in which 2^ was prescribed. One of these cases had been previously operated on (iridectomie) for glaucoma, and with success." AVERAGE MEASUREMENTS OF THE EMMETROPIC EYE. "Based on the values given for the emmetropic eye in the foregoing para- graph, we can construct an absolutely emmetropic average eye, if we will reconstruct the lens within the same. Of this lens we neither know its focal distance nor the position of its principal points; however, we do know, that it must fulfill certain conditions, namely, to cause rays of light which enter the aqueous converging, so as to meet at 30, (>! mm. behind the cornea, to so alter their course as to come to a point at 28.36 mm. To this problem there are an indefinite number of solutions, in that the focal dis- tance of the lens is dependent on the position of the principal points, and vice versa. The calculation has shown, that a lens having the focal dis- tance, as in the schematic eye (43.707 mm.), answers the above condition when its conjoined principal point is 9.754 mm. posterior to the cornea. According to our anatomical knowledge such a position of the lens is an impossibility. However, if wc will calculate tlie focal distance of a crystal- line lens, the o])tical center of wliich shall be in tlie uodal point of the aphakic eye (7.7 mm. behind the center of the coi'nea). and which shall answer the ahovc conditions, we will obtain a value of 54. S4 nun. Such a position of the lens is a po.ssibility, though it has not heen anatomically proven. Since following an operation we desire to calculate for the aphakic eye what the previous i-cfi'activc condition was. wc must dctci-uiiuc. asjias 38i already been explained, what tlie true conditions are in the emmetropic eye, and to do this the schematic eye does not suffice; hence, 1 jjive below the calculation made for an average emmetropic eye." r=7.7 mm., ^^^ 1.3360, /"j =23.86 mm., focal distance of the lens=54 84 mm. and position of the 8ame=7.7 mm., i^i=16.15 mm., i''2=:21 59 mm. Position of //i=2.25 mm., H^=2.28 mm., A"i=:7. 68 mm., 7^2=7.71 and finally the position of i'\=— (16.16 — 2.25)=: — 13.90 mm., and the position of ^2 =23. 87 mm. P'inally, it is interesting to note that according to Helmlwltz the focal distance in ihe air of the lens in his schematic eye is 8.9 mm.; whereas, ac- cording to ours this has fallen to 11. 1(5 mm." "In the constructicn of our average emmetropic eye we have made two assumptions. It is only an assumption, and has not been proven that an aphakic eye, which has its H. neutralized by a lens of 3.5" focal distance, placed at 0.5" distance from the centre of the cornea, must have been emmetropic before the operation. Owing to the very great importance of the propositions which must follow, it is a matter of the greatest im- ])()rtance, and its value can hardly be estimated, if it were to become pos- sil)le to determine the aphakic H. exactly, in eyes in which the condition of refraction is known. The second assumed factor is the position of the the lens. If it should ever happen that we should be enabled to make an extraction on an eye wdiich, before becoming diseased, had been under ob- servation, and in which we had estimated the refraction, the corneal curva- ture, the depth of the anterior chamber, and the curvature of the anterior surface of the lens; and again, after the extraction, estimate its refraction and its corneal curvature, this would certainly materially aid us in our estimates, concerning our knowledge of the lens system in the living human eye. As this w^ould also aid us in determining the index of refraction of the lens and its individual lamella, the only fact still remaining unknown would be the form of the posterior surface of the lens, and on which the thickness of the lens depends. Under these existing conditions it seems proper that the following figures should be stated as having a direct bear- ing on the question. TABLE IX. Name. Age. Non-Operated. Oper.\ted. EVE. R. ,.. Eve Operation. // a//i. pA. I^ENGTH OF Axis. Schweller . . Weiss Hilbert Kircher . . . 11 11 40 83 L. L. R. 36~ ""36- !_ + -4 7.74 7.37 7.fi414 7.2828 R. R. L. R. Discission ( Discissio mo- 1 dificalo Graefe's Ext. , 7.526 23.086 2.4 1 3.17 1 4.22 7.247 24.456 ''The above table contains a series of figures bearing on the condition 382 found existing in four individuals, in each of whom an eye had been oper- ated on for cataract; whereas the other eye still had a transparent lens, and in which the refractive condition could be estimated by the test types and the opthalmoscope. An exact inquiry into the liistory of the case showed that previous to the disease the patient had seen equally good with both eyes. In order to determine the length of the axis of the aphakic eye, the distance between the glass and the cornea, was estimated as nearly as pos- sible. Though the radius of the cornea may be diminished in its horizontal meridian as a result of the operation, this will not shorten the length of the axis of the eye. Hence, one may safely transfer the investigation of this point to the sound eye. In the fourth case the length of the axis ap- pears relatively short, owing to the abnormally increased corneal curva- ture; especially if one will compare this case with an analogous one, case 2, in table VIII. In that case the corneal radius was abnormally large, here it is abnormally small. The minimum measurement, according to Bon- ders, of 7.28 mm., coincides exactly with the radius of Kircher's case. A portion of the myopia hence is dependent on the cornea, and in this case we are dealing with one of corneal myopia.'" "Conditions which exist between aphakic H., length of the optic axis, and also the E. previous to the operation. In preparing the following table, which shall serve to illustrate the mutual dependence between the degree of .H. aphakia and the length of the optical axis, I have started with the express value of F. The value of f . was obtained from the well known formula,/,=^j~ and according to which this table has been estimated. On these values, taking into consideration the distance of the glass from the center of the cornea and the nodal point in the aphakic eye, the values of the correcting glass and the aphakic H. are dependent." TABI.E X. 383 /„=Mm. ^- // acgtiisita. (Distance from K=7 7.) Correcting Glass when Distance from Eye. R. Mm. p. z. 13.54 Mm.= 5P- J0.31 Mm.=== 05 P. 30.61 00 CO 1 00 1 2.5 2'J.m (549.1)2 24 1 23.65 1 •24.5 1 24.75 3 28.58 324.(55 12 11.65 1 ia.5 1 12.75 1 3.5 27.24 21(5.(54 8 1 7.65 1 8.5 1 8.75 _ 1 4.0 2(5.81 1(53.48 « 1 5.65 1 6.5 1 6.75 1 5.7 20.1(5 135.30 5 1 4.65 1 5.5 1 5.75 1 6.4 25.75 121.8(5 4.5 1 4.15 1 5 1 5.25 _ 1 7.6 25.25 108.32 4 1 3.65 1 4.5 .J 1 4.75 _ 1 10.0 24.(53 04.78 3.5 1 3.15 1 ,4 1' 4.25 _ 1 1.75 23.8(5 81.24 3 ITto 1 3.5 3.75 1 . 00 23.40 74.47 2.75 1I40 1 3.25 35 27.7 22.87 67.47 2.5 Tl5 3, 111 3.25 + , 1 . 12.0 22.24 (50.i»3 2.25 1 1.90 2.75 1 3 - -7V 21.51 54.16 2.0 1 1.56 1 2.5 1 2.75 4.6 The last column of figures requires an explanation. It is desic^nated IJ. (refraction). The reciprocal values which th(?y represent are, according to Zehender's suggestion, the various grades of iiypermetropia where they are minus, and the various grades of myopia when they are positive, and emmetropia is designated by 1. All these values have been estimated ac- cording to the formula: f^ — F,= /< '''>< 0. Helmholtz, 1. p. 49, 7*, fii — ■f' II r } Since f, — P. represents the difference of position between the retina of the emmetropic and the ametropic eye, lience it became necessaiy in the foregoing paragi-aph to determine for the emmetropic eye the length of its axis, and for this reason it was given in the one table as 23.86 mm." "As a matter of course, this table only contains the average values. A comparison of this table with the foregoing one will serve to clear up all the causes of all individual differences." 384 ACCOMMODATION OF THE APHAKIC EYE. "The eye does not desist from making accommodation efforts after the loss of the lens. The subjective sensation of accommodative effort on which Bonders, and so correctly, lays such great stress, is very evidently present. Not only do patients who have been operated on one eye or both, without any knowl- edge of the subject, express themselves very plainly, stating, that notwith- standing every effort, they are not al)le to see; but in those cases where the one eye is aphakic while the other is still in possession of its accommo- dation, intelligent patients state, that they are made aware of the well- known sensation in the operated eye." "Under like conditions, in cases where no iridectomie has been made. and in which no muscular insufficiency is present, the aphakic eye will follow the accommodative effort of the other eye, by making the corre- spondent movement of convergence, and likewise the pupil will undergo contraction or dilation. Hence, there can be no doubt, that in both eyes the muscle of accommodation has a similar innervation, and is likewise incited to contract. This view is further strengthened by a series of patho- logical experiences which have already been referred to. These accommo- dative efforts, however, have no result. WitJi. the lo.'^s of the lens everj/ trace of accommodative power passes away. Bonders has given us the proof of this axiom." 1. "A youthful individual was successfully operated on both eyes for congevifnl caiaract. By using glasses ^ (+7.5 D), 5" from the eye. he saw a luminous point, perfectly round and sharply defined. A screen was placed between the one eye and the luminous point, and now in converging so as to cause the visual axis of both eyes to be directed to this screen, this luminous point still appeared unchanged, or at most somewhat smaller and more sharply defined. If now this lens before the eye was only moved forward, (10 mm.), this luminous point in distance ceased to be so shaiTily defined, and seemed to be elongated in the opposite, direction. This visual line became slightly shorter on converging, without, however, becoming merged into a single point. This shortening, as well as the diminution in size of the point which had been so sharply defined, seemed to depend on the narrowing of the pupil during the act of convergence. 2. In a second cataract operation, made on a very intelligent young man, Bonders Avas further enabled to determine, that Avhere a point of light could be sharply seon by using a certain lens, the addition of n lens of light could be sharply seen by using a certain lens, the addition of alensof +_j^or — y^ would materially change 1he sbariinoss of the image. In a third cage this difference was noticeable on the addition of a + ■o"i7- I'^" variably the patients state, by the addition of a +^-^, the image becomes 385 drawn out vertically, nnd by the use of a —jl^ in the liorizoiital diroetion. Whereas, by conver^in«i- of the visual line in making his experiment, so as to see near, was not followed by tlif slightest effect on the form of the images. If one will make an t'xaet examination of the amount of vision (V=0) in an ai)hakic eye, foi- some pai'ticidar point, for which the eye is ec^uipped with a certain glass, and will then further examine the anunint of vision which the eye possesses for point> lying either in front of or be- hind the selected point, one will find the vision becomes reduced in botii directions. From thi- it must follow, that the eye does not possess any accommodation, for if it did the amount of vision would either remain the same, or in cases of ])ositive accommodation, owing to the object being brought closer to the eye, and the moving forward of the second nodal point, even became somewhat greater (Coert over de scynbare accommo- datie by aphakic). The truth of these experiments, undertaken at the suggestion of Bonders, became all tlie greater, since it was furtlier shown that the circles of dispersion, the pupils being of equal size, b'^came larger instead of smaller in cases in which there was an aphakic dioptric system." "During the previous century, this question of the reeommodation of the aphakic eye (see Bonders, 1526) was the subject of vei'y extensive investigations, carried on especially by English physicians and investigators in natural sciences. Hunter attempted to prove the correctness of the tiieory which had been ac- cepted since the time of Leeuwenhoek. namely, that tlie lens was made up of muscular fibres, and that by means of their contraction and relaxation we were enabled to accommodate for various distances. His successor. Home, hit upon the lucky idea of deciding this question of accommodation by making his inves- tigations on the aphakic eye. In this work he sought the assistance of Rams- den, and both came to the conclusion that even without a crystalline lens there existed considerable accommodation. They, however, made no further investi- gations after they found that Benjamin Clark, who had been operated on for cataract, and on whom they made their investigations, could read at different distances with the same glass. Home tiit-u (•(inecivcd the idea th;it the cornea changed its form during the act of acconiniodatidu. In investigations made in this direction, they distinctly saw tlie cornea advance further forward, and from this they concluded that tlie coi-iiea became more convex on accommo- dating for near. On November 27. isoo. Thomas Young appeared before the Royal Society, and ()pi>()sed botli of these statements of IlamsdcMi .-iiid Home, and proved in the most convincing manner lliat in seeing near ol).iects neitlier the cornea became more convex nor did the visual axis become elongated, and aside from this he proved, not only by exclusion, but by the most positive facts, that the seat of accommodation could only be found in the lens itself. "Assisted by his friend Ware, he likewise examined a series of cases of aphakia. In doing tliis lie employed I'orterfield's optomc^ter. wliicli is based on 386 the principle of Sclieiner's experiments, and lie convinced himself that the points of intersection of the threads across the image always are seen exactly in the same position. Wherever a slight difference occurred, he could always find that a corresponding change in distance between the eye and the glass was to blame. Young further found that in making the Scheiner's experiment, if small objects were seen double the patients were not able, by exerting any degree of effort, to bring the objects closer together. Though he stated that his results were only "tolerably satisfactory," nevertheless this seems really to have settled the question. It is a well known fact that these investigations of Thomas Young, "On the Mechanism of the Ej^e," had long been forgotten; hence, it can not be so much of a surprise to find such men as Arlt and others ascribing to the aphakic eye a slight degree of power to adapt itself to various distances. The question again became an important one after Kramer, in 1852, had given us the direct proof that the lens becomes more convex during the act of accommodation. Since it was exceedingly difficult to prove that these images on the lens diminished in size to a degree proportionate to the extent of accommodation as measured by the optometer, hence they tried to positively settle the question by determining whetlier a trace of accommodation still re- mained after loss of the crystalline lens. The first investigations made in this direction by Von Graefe did not clear up this subject. (Beobachtungen uber die Accommodation bei Linsen defect u. s. w. Arch, fur Opthal., II, 1. p. 187. 1855). Graefe verified Ramsden's expei'iments. "Only lately I examined a patient who had undergone an operation for cataract on both eyes but four weeks previously, and he could read medium sized print (No. 77 Yager's test types) with a -|-3 con- vex, at a distance of 6" to 20". But since only a short time previous to this he himself had explained why eyes with high degrees of hypermetropia are better able to distinguisli small objects, notwithstanding the increased size of the circles of dispersion, when they bring the object much closer to the eye: hence, he was admonished to lie careful, and thus was enabled to express the opinion, 'that shortly after a cataract operation there was either none whatever or pos- sibly only a trace of accommodation left. And where he says that the amount of adaptability in the operated eye, as compared with that existing under nor- mal conditions is exceedingly slight, his doubt as to the remnant of accommo- dation left is of such a character, that he sought for a means to explain this." "The cause for these unsatisfactory results was owing to the fact that the idea of 'width of accommodation' and 'amount of vision' had not yet been so accurately determined. After Helmholtz liad expressed himself, 'in order to prove that accommodation is still present, the patient must be able to distin- guish an object at a given distance distinctly or indistinctly, even after he has attempted to see an object at the same or at a greater distance.' it still re- mained for Bonders to give us the accui'ate proof, that an aphakic eye possessed absolutely no power of accommodation. (See text.) Hence, it will ho a matter of the greatest surprise to learn that in 1872 Foerster (Klin. Monatl)liitt. p. 39. Accommodations verniogen l)ei .\plinkiel expressed liiiuself. tliat aceoiniiiDdation .^87 was present in eyes devoid of a lens. Foersiei- lias iiotliiny lurtlier to offer us than the lIonie-TtaTusden experiments, and he even iieKleeted in the sinj?le ease which he examined to make an accurate test of I lie refract' on, to give the amount of vision for distance, the size of the test type used, and to inform us whether or not care was taken to see that the lenses were properly centered, so as to coincide with the visual axis. Hence, it seemed hardly necessary To reply to his paper. Nevertheless, it called forfli a mass of refutations. Mannhard re- i-t'i)c:itiMl !{;ins(len"s cxpcriiiiciiis. usiii^i the Siieilcii test lyiie and P.urghardt's dotted tests. Tlie more delicate tlie oli.jcct used tlie more delicate these tests for amount of vision and (lis(ance became: tlie more this apparent width of ac- commodation shrank together. I Avas enabled to get the same mentioned col- league and make these experiments on him, and I also used the rodoptometer, the apparent width of accommodation equaled with -f-i/^ and Sn No. 1% about 2*0. with Hurgliardfs dotted tests No. 3, less than .}^ and with tlie rodopto- meter. less than ^i^ The use of this rodoptometer, which was not used by Foerster. appears to me to be the most conclusive of all the tests for vision. Above all. to make these tests properly, the patient should be a scientifically educated as well as an honest man. Above I have already mentioned the in- vestigations of Coert, made under the supervision of Bonders. Woinow sided with Foerster to a certain degree. He placed a piece of cobalt glass in a slit and illuminated this from the rear, and then found that in his own atroi)ized eye. simply moving the instrument 2-3 mm. nearer to his eye was sufficient to cause the edges of the split to be bordered with colors. He however found that those who had undergone cataract operation could see this slit at a more vari- able distance without the appearance of this border, so that in intelligent pa- tients with a vision equal to or less than two-thirds, he could find a remnant of accommodation of about ^l. THE ACITTENESS OF VISION IN APHAKIA. ^'Strictly speak- ing, every cataract operation has attained an optical result, in which vision is better after, than it was before an operation." Eor example, if fingers could no longer be counted before the operation, and if this has become possible afterward; or if fingers can be counted at a greater distance than before the operation, one surely would not say that the eyesight has not been improved by the operation. However, neither patient nor physician would be satisfied with such a result. Both have acceded to the operation with the hope, that a useful degree of vision would be restored, and only if this is attained, as compared with an insufficient or partial restoration, can one speak of a satisfactory result." "Since one meets with every degree of vision, from counting of fingers up to |§. hence repeatedly in compiling statistics, the want of a sharp line to guide onr rcstilts has made itself ai)])arcnt: but sueli docs not exist. In special cases this depends entirely on the requiretnents which the patient demands from his eyes." 388 "But seldom does the acuteness of vision of the aphakic eye equal that of the normal eye. This is determined by the Snellen type, always, however, bearing in mind the age of the patient. Howevor, as Bonders pointed out, owing to the magnifying power of the cataract glasses, we must make a slight correction." "Owing to the fact, that either convex glasses of varying strength are required to see at the various distances, or the glasses must be adjusted at varying distances from the eye; hence, the acuity of vision, where this is simply determined by convex glasses, will show great differences for the various distances. Equal values can only be attained, if one will multiply these with the corresponding so-called (verkleinerungs zahlen) reduced figures." "If we will now consider those cases of aphakia which have been cor- rected for distance by spherical glasses, we must look upon the attainment of an acuity of vision of 20-70 as the average amount following a successful cataract operation. But in many cases y=^% or ,Yff ^^^ distance, an- swers all requirements, which are needed for near work. If one will no-w classify the results following the operation into losses, partial and total good results, we must look upon all as belonging to the first class, in which vision is less than iV at twenty feet. And all belong to the third class, in which vision is ise:ises of tl>e Eye. \(.l. III., pa.ire 818. 389 TTON. 'IMial noniial vision, jiccoi'dinii' lo llic Snellen iden, is so seldom attained iil'ter a cataract operation. >o lon^' as we coiiline ourselves to the use of sjiherical fjlasscs. vieniands an ex])lanation, especially since Weber has definitely stated that "tlie moving- I'oi'ward of the nodal ])oints. should justify us in theoretically e.\pectinion much <,M-eater than normal, after a catai'act o])eration.' " "Let us only considei- the senile cataract, and we will tiiul one cause for this at once in the fact, that according to the investigations of DeHaan, in the sixtieth year vision sinks to |-J; that is, to -^. Aside from this opacities in the ]iii])illary area are su])posed to be the main cause of the reduction in the vision. Sui'ely we have already dwelt sufficiently on the fact that even in cases of simple secondary cataract, the folds in the cap- sule, and the slight cloudy spots in the same, give us the anatomical basis lor the increased reflection and dispersion of light. In consequence of this, not only are the retinal images less brightly illuminated, but likewise, as a result of the dispersion of light, the images are less shar]dy defined. The influence of a secondaiy cataract, becomes most evident, for in cases of a very dense secondary cataract, vision may be exceedingly good, if there is but a small opening, and at times this is proven by the extraordinary influence which a discission of a secondary cataract exerts on vision. But even after such a. procedure, or after the extraction of a cataract in its capsule, even after making a vitreous puncture, we but seldom attain a result in which vision equals ||. Since the curvature of the surface which separates the vitreous from the aqueous has no influence on the sharpness of the retinal images, and since an immovable pupil or even a large coloboma (at least as it is associated with direct seeing) is without influence on the acuity of vision, hence the main cause for the diminution of vision in the successful cases of cataract operation must be sought in ihe rhnnried ciirva- tvre of the cornea, which is the most important of all the refractive sur- faces." '■Ponders (Enjr. Edit.. 1864. p. 315) in 1864 drew attf-ntion to this fact. It appears tliat .Taval (Klin. Mouatsblatt., 1865. p. 339) was the first to really measure the amount of astyyinatism in those who had underj^ono cataract operation. In one case, by usinjj a cylinder of ,'„. the acuity of vision was increased from % to ^: whereas, by the most careful selection of a proper spherical glass, this could only be increased to H>. Oraefe likewise expressed himself, that the cause of this astygmatism which appears after cataract, oper- ations in a good many eases, is due to a less perfect cicatrization, which leads to this cylindrical curvature of the cornea. But if vision was normal before the formation of the cataract, and if after tlie operation vision is very materi- ally improved by the use of a cylindrical glass, this could be explained by as- 390 suming that in the former integrity of the lens system the degree of corneal and lens astygmatism exactly compensated each other, and later on when aphakia had set in. the corneal astygmatism still remained. Whereas, in such cases tlie conditions remain totally stabil; still, under the first named condi- tions these gradually become changed to the advantage of ihe patient. Haase (Wiesbaden Klin. Beobachtungen. III. p. IKJt then more fully examined into the causation of this astygmatism which develops after cataract operations. He found that in cases in Avhich the incision was made exactly in the hori- zontal meridian, one would always find the meridian which refracts most strongly exactly horizontal. If the direction of the incision was slightly changed, then likewise also the direction of the most strongly refracting meridian. Dur- ing the process of healing of a flap incision, the intra-ocular pressure will con- stantly press the edge of the wound, which still gives apart. By this means the curvature of the cornea becomes flattened in its vertical meridian; whereas, the curvature of its horizontal meridian will be increased. In cases of abnormal healing, as in prolapsus iridis, the astygmatism is so irregular that a good cor- rection can not be obtained by use of cylinders. In the six cases of flap extrac- tion which he reports, the astygmatism varied from Ye to % ." '•Eeus and Woiiiow (1167) have collected the largest amount of ma- terial having a bearing on this subject. They were enabled to make opthal- mometric examinations in thirty-one patients who had been operated for cataracts. Of these twenty-three had been measured before the operation. From this they were enabled to determine how much of the astygmatism had developed in consequence of the operation. If we will now consider those twelve cases (1, 3, 5, 8, 10, 13, 15, 17, 18, 24, 28 and 31) in wliieh the principal meridian was exactly vertical and horizontal, both before and after the operation, we find in only eleven cases an increase in the curva- ture; that is, a shortening of the corneal radius in the horizontal, and only in ten cases is there a diminution of curvature; that is, an increase of the corneal radius in the vertical meridian. In the other cases the result was directly opposite. And in fact, both forms 'occur as well after flap ex- tractions as after the corneal extraction." "Hence, it seems quite evident that the degree of astygmatism after an operation depends very materially on the degree present before the operation, and also on the direction of the same. One can not, however, in any given case, determine from the degree of astygmatism pres- ent after an operation wliich method of operation would have given the best result." "This much, however, is certain, that in the twelve mentioned cases, the particular condition was produced by the operation. Reuss is very careful in making his statement, and merely says, that the astygmatism is caused by the cicatrix, and its degree is largely dependent on the more 391 or less perfect processes of lu'iilin>i-. More cxactlv stated, always depend- ent on the kind of astyjrniatism present Ix't'orr tlir opei'aiion. The direc- tion of the aecpiired astygniatisni is always (Icpeiidcnt on the position of the incision, its extent, on the perfect liealin-. and it> n-iilarity dei)ends on wliether or no! tlie iris and capsule Ixn-onie cicatrized in the wound." "Althoii.ali we must aeknowled^a' tiiat we do not as yet possess any positive amitoniical exjdanations for those cases in which the vertical me- ridian has an increased curvature, and the horizo'ital a diminished curva- ture after the operation; nevertlieless, in all of the ihii1y-one eases nu'as- iired hy Eeuss and Woinow the corneal astygniatism was changed as the result of the operation. Hence, Eeuss is correct when he considers the above second explanation of Yon Graefe as only correct for those eyes which were operated hy discission or reclination, hut not for those in which the lens was removed from the eye hy an excision. jSTow, in wdiat manner does this cicatrix bring about this acquired astygmatism? Concerning this point, up to the present time there have existed but suppositions. After such data as can be gleaned from our knowledge concerning the cicatrix following cataract extraction, and according to the facts which have been ^iven us as a result of the experimental investigations of Gussenbauer and Guterboek, there can scarcely arise any question as to the influence of an intercalar substance in cases of perfect cicatrization, since this was found to be but 0.02 mm. in width. However, the inelosi;re of foreign substance, especially of the capsule or the iris, where this has taken place to. a large degree, must exert an influence on the conditions of curvature of the cornea. Even in cases in which a perfect cicatrization has taken place, it does occur that the lip of the corneal wound becomes displaced toward the sclera, and in five cases I (Becker) have been able to measure this exactly. This varied from 0.12 mm. to 0.3 mm. It appears (if the number of these observations can be looked upon as sufficient from which to draw conclusions) i o be larger after flap extraction, ceteris paribus, than after the scleral extraction, and aside from this is favored by the enclosure of foreign substance in the cicatrical tissue. And finally I (Becker) was enabled to prove that the portions of corneal and scleral tissue close to the cicatrix were very much increased in thickness, in abnormal cases as much as 0.5 mm. Beyond a doubt -this is due to infiltration and oedematous swelling of the tissue, and hence can not be considered as an increase in the amount of tissue laid down in the direction of the corneal lamellae, that is perpendicular to the direction of the wound, without a simultaneous swelling being present."' "We must, however, call attention to another factor which gives rise to change in the corneal curvature. The clinician, and rightly, too. knows 392 but too well thai tlie drawing in of the extraction cicatrix is but a much- feared symptom of beginning phthisis bulbi. Aside from this I have re- peatedly drawn attention to the great tension which the contraction of secondary cataracts, which have cicatrized in the wounds, exert while shrinking, on the corpus ciliare, the vitreous, etc. Now, there can be no doubt but that even where this exists to a slight degree in eyes which can see, the shrinking of this secondary cataract by its tension will draw the cornea backward. By this means the curvature of the cornea will become increased vertically to the direction of the incision; and hence, the cornea is given a more cylindrical shape, and the curvature of the horizontal me- ridian will become diminished." "For the present I must leave unanswered the question as to whether this tension of a secondary cataract can act in just the opposite way, caus- ing an increase of the horizontal and a diminution of the vertical meridian." "This influence, which the various methods of cicatrization of wound exerts on the condition of the curvature of the cornea, must be entirely diiferent, and makes its effect felt in just the opposite way where the in- cision is made vertically or obliquely. The pushing more anteriorly of the edge of the corneal wound must necessarily have as its result a diminution of the curvature of the cornea, vertical to the direction of the wound. But if no sliding past each other of the edges of the wound has taken place, and if one can everywhere see the scleral edge of the wound and the under- lying edge of the cornea, the swelling of the substance which hes between the edges of the wound, must cause the increase in the curvature of the cornea in the vertical meridian. For if we attempt to introduce the seg- ment of a circle between two fixed points of a segment, of another circle, this can only be accomplished by increasing the radius of curvature of the latter." "The action of a connective tissue mass between the edges of the wound acts differently, depending on whether a sliding past each other of the edges of the wound has taken place or not. If the outer edges of the w^ound are in exact apposition, owing to the presence of this connect- ive tissue mass, the curvature likewise must become greater. If at the same time this mass causes a forw'ard displacement of the edges of the wound, this flattening action of the cicatrix must be increased. If the incision is made perpendicular to the surface of the cornea, as it is in the ideal Cxraefe's extraction, such a displacement forward can not occiu* so easily, and therefore is not so frequently obsei-ved as after the flap extrac- tion, in which the incision is made perpendicular to the visual line. In the flap operation there is a greater tendency for the edges of tlic wound to gaj). and this is in accord with the greater frequeiu-y and the greater 393 degree of disphuonu'iit forward. Jlased on measurements made l)y me, the amount of flattening which the cornea siifl'ers as a result of displacement after fia]) extraction can be measured/" "vStartiuj: out with the assumption that the ooruea lias a sphorical curva- ture, a vertical section of the same would he represented by the segment of a circle, the chord of which would be equal to the distance from the upper to the lower edge of the cornea. The length of this seguient is calculated by the for- mula: '^^"i'" . when n° is eciual to the angle which tlie segment of the 360° ' circle subtends, the radius (R.)— 7.7 mm., and the distance from the upper to the lower edge of the cornea equals 10 mm., then the length of this segment of the circle (P.) equals 10.8834 mm." "The direction which the edge of the corneal wound takes as it moves forward, is determined by the direction of the original incision. If this falls in that of the ideal linear incision, in the direction of its greatest circle, the anterior movement will take place in a line that is along the radius drawn from the center of the circle toward the upper edge of the cornea. The segment of the circle will remain the same, but the chord which it subtends will have grown larger. If this forward movement equals respectively, 0.12, and 0.15, and 0.3 mm., the radius will be, respectively, 8.0798, 8.1TT-"), and 8.7638 mm. Starting out with the assumption that previous to the operation both the vertical and the horizontal meridian had a radius of 7.T mm., they will now have a radius respestlvely of jf^, , '_, and ^ L< • III making this calculation, the further hypothesis was 14.4/' 0.9t)4 ^ ' ' '■ drawn that this flattening of the corneal surface was equally distributed over the entire vertical meridian. However, in doing this no attention was paid to the fact, and the same was done in the calculation of Eeuss and Woinow, that simultaneously with this flattening in the vertical meridian, an increased curvature manifests itself in the horizontal." "Notwithstanding this, the calculations of Dr. AVeiss show, that the average measurement as used by me is sufficient to explain the degree of astygmatism found after an extraction. This increased curvature of the horizontal meridian, which for the time had been neglected, may be as- sumed to correct the astygmatism which had previously existed in the opposite direction." "Various observers have noted, that the astygmatism wliicli develops after cataract extraction becomes less as time goes on. This can be ex- plained anatomically by the gradual diminution of the infiltration, and swollen conditions of the area surrounding tlie wound, and by the gradual contraction to a smaller volume of the connective tissue mass when pres- ent, and also by the gradual return of the flap to its normal niveau, where this has glided i)ast its fellow, owing to the tense drawing together of the 394 interstitial tissue. This can not be absolutely proven, since it is not pos- sible to make anatomical examinations of the same eye at various periods. But these conclusions are justified, and may be as>uuied to be facts, as the result of anatomical examinations of various eyes made at different periods after operations. Hence, the astygmatism must graduallx diminish in both directions." •'I (Becker) owe special thanks to Dr. Roder, of Strassbury-. for the personal eomnnmication of a case which clinically is of the very greatest interest. He noted that the astygmatism following an operation suddenly became less after the. making of an iridectomie for secondary cataract. The horizontal incision made Avith the lance, made to relieve the secondary cataract, must for the time have relieved the tension which this exerted at the sight of the original wound. Hence, if the curvature of the cornea perpendicular to the direction of the "incision before the irdectomie was greater, one must certainly be able to see that the cutting through of the capsule would have released and equal- ized this; but since likewise a less degree of curvature in the vertical and an increased degree in the horizontal should likewise be abolished by an iridec- tomie. Ave must also seek part of the explanation for this in the vertical in- cision of the capsule, made Avith the pinceciseaux. But since this fact has not as yet been as well proven as could be desired, it would hardly seem neces- sary to seek for an anatomical basis for the same as yet. But if tiiis should be proven to be true, it certainly would become a matter of vmusual interest. There Avould then ajtpear to be a way in Avhich to cure, by oi)erative means, astygmatism Avliicli results from oiteration." "Although tlie measurements of Reuss and WoinoAV made on the living, and my (Becker) measurements made on anatomical preimnjtion. coincide ex- actly Avith the results obtained by Haase, namely, that corneal astygmatism is greater after the flap extraction than aftei- the linear extraotion. one must never- theless be careful and not accept this as an absolutely established fact, llaase undoubtedly picked out the most pronounced cases, since during an entire year he only measured the astygmatism in six cases of all those operated by Pagon- stecher; whereas, among Reuss' and WoinoAv's thirty-one cases, tliere are but live flap extractions, and of tliese but in tluec cases Avas tlie cornea measui'ed before. In addition to this, I tind tiial the greatest degi-ee of astygmatism noted, ' did not occur after a flap onei-ation. but .-iftcr a liuear extraction. .T.n'i Nevertheless, tlie subject is certainly deserving of every cousiderMtiou, and as early as 1S<;T W'elier drew attention to the fact, liiai the various operations exerted a varying iufhieuce on tlie inetliods of healing and the sul>se(|uent as- tygmatism. .\ii(l it c.-in not be denied, that if it sliould liually lie shown rhat one operation is more I'csiKiusihle for this couilitiou than die dtlier. this factor Avould certainly weigh heavy in tlie lialaiice against it. 1 >r. Weiss has lately taken up these investigations .-igaiii. and I may state, that live cases which Avere measured ])ef<)re and after operation by the Weber s inetliod. in three 395 cases chanjro iu form were t.4, 1:L'T.:?: wliciviis, iu two cast's wiiicli ucro f)|)«*nitt*d by Weber, the astvjiniatisin was U and 1 — . Tlir iiilliu'iicc which the subse- ^ 9.(13 quent corivctiou of tlic a<-(iuinHl astyjiinatisni followin^i cataract (>.vtraction has on the acuity of vision of tiu' a|)liakic cyt'. is shown by tlic followiufr iuvt^sti- gations of Keuss and Woiuow. In twcnty-nino ryi-s which wore subjected to a thorough examination by tlie use of si)herical glasses, four acquired V=^ four V -- ,y„, thirteen. V rfj, six. V= V^, two, V= ?fj. But where these same eyes were corrected l)y ii coinbinatimi of sjiherical and cylindrical glasses, there was but a single case in wliich \' j-',;,, i. wiiich could not be improved. In the others, however, vision was raised four times to V = |g, three times to 2j? seven times to f^ ten times to fg .^nfi f„„r times to fg. The last tigures are especially interesting, liecause once vision of ,2gOj, twice vision of ?;|, and once vision of ||; was raised to this iiigli degree." The above statements liavc been verified 1)\ .Vdolpli (). Ffingst. He draws attention to the literature on this subject. La([iier.2 ('hintemi,2a Bumett.3 He states: "AVe know that in tbe majority of cases tlie addition of a cylinder to the spherical lens improves the vision. As the cornea grad- ually assumes its original or almost original shape by the contraction of the cicatrix, the cylinder glass frequently ceases to be of benefit. To avoid the expense of a new glass after this contraction has taken place, we are, and especially in hospital practice, often called upon to prescribe at once the lens which we consider best for ultimate use." He gives the following interesting; tables: J.— CASES WITH COMPLICATED HEALIXG OE WOI^XD. Extraction of Iridectomy. W. R.— with the Rule. Ag. R.— against the Rule. d Astig. before operation. Astig. 2 wks. after opera. Astig. 6-10 ; Astig. 4-6 Astig. 6-10 weeks after months months operation, afteropera. afteropera 1 REMARKS. I 1.0 D. W. R. 9..S D. Ag. R. 6 weeks, 356 mon., 2.5 D. ag. R. ag. R Slight incarceration of iris in middle of section. 2 I.o D. W. R. lO.O 4^4 month. 20 ag. R. Iris drawn upward, and slight a d hesion to middle of section. 3 18.0 Prolapse of iris, abscised 14 hours later. 4 13.0 Prolapse of small head of vitreous. Small incarceration ot iris. 3 1,75 D. W. R. 12.0 Patient ruptured wound 3 times. .\dhesion of iris to middle of sec. 6 '"•" • 6 weeks. 1.90 ag. R. Large incarceration of iris in mid- dle of section. 7 0.75 D. Ag. R. 6.0 8 weeks. 6.5 ag. R. Prolapse of iris, abscised 8 hours later. 8 0.5 D. W. R. 12 Iris adherent to middle of section. 9 22.0 Iris adherent to section in its entire extent. lo 0.5 D. W. R, 1 Incarceration of column or iris in 11 7.0 6 month 6.oi ag. R. j wound, on nasal side. Prolapse of iris, ab.scised 12 hours 12.0 •' 1 later. 12 i Adhesion of iris in entire length 17.0 of wound. 155-5 Average, 12.9 D. 2 Arch, fur Opthalmol., XXX.. 1884. 2a Annales di Ottal., 1890. 3 A Treatise on Astygmatism. p. 120. 396 B.— CASES AVITH UNCOMPLICATED HEALING OF WOUND. No. Astig. Before Operation. Two Weeks After Operation. 6-10 Weeks After Operation. 4-6 Months After Operation. 6-10 Months After Operation. REMARKS. 13 14 0.5 D W. R. 7.oD.Ag. R. 2.5 iowks.,3.oAg.R. 6 " 2.0 6 mo., i.sD^.R. iomo.,i.5Ag.R. 10 " 1.75 W.R. 15 Em. 6.0 9 " 20 " |4 " 12.5 Ag. R. 6h " 1.25 Ag.R. 16 0.75 W. R. 4-5 8 " 2.0 " 5 " 1.5 7 "1-5 17 3-5 8 •' 1.25 •• 16 " E. 18 11. 7 " 3.0 " 6 " i.o Ag. R. 19 3.5 9 " 2.5 " 6 " 1.75 20 0.5 W. R. 8.0 6 " 2.5 " 4I " 2.0 21 1.0 W. R. 3-5 " 22 Em. 7-5 10 " 3.0 ■' 4i-' 3.0 2? 0.5 W. R. 7-5 6 '• 2.0 •• 4 " 0.75 24 7-5 8 " 3.0 " ,4 " 1.75 25 0.75 W. R I5-0 6 " 3.5 " \4 " 2.0 26 0.75 W. R. 3-75 " 6 " 2.0 27 8.5 7 '■ 1.0 " 4 •• 0.5 W. R. 28 5-0 8 " 2.0 '■ 29 5-5 6 " 2.5 " 5 • 2.25 Ag.R. 30 1-75 10 " 1.75 W.R. 31 0.5 Ag. R. 6.5 •■ 6 " 2.oAg.R. 32 9.0 9 " 2.25 " 8 •' 1.25 " 33 l.o W. R. 7.0 34 4.5 W. R. 8.0 5 •• 6.0 " 35 lo.o " 6 ■• 2.25 " 36 lO.O " 9 " 2.25 " 37 1-75 10 •• 1.75W.R. . 38 Em. 13.0 6 - 7.oAg.R. 39 6.0 8 " 2.5 " 40 0.75 Ag. R. 2-5 8 " 1.25 " 41 42-59 Em. .M '■■ 6 " 2.0 Bciiresenta 17 c«8e«, which were only ex- itmiDed once. 29975 i Average, 6.40 D. Total number of ca.ses, 59. Total astygmatism, 455.25 D. Averagt- of astygmatism, 7.7 D. From these he draws the following conclusions: "Briefly recapitulating, we see: (1) That two weeks after the flap ex- traction of cataract, there is corneal astygmatism, varying from 1.75 D with rule, to 20.0 D, against rule. (2) That the greatest amount of tliis astygmatism disappears in the following four to six weeks. (3) That it is ahsolutely reduced in six months, aftci- wliieh it seems there are no further changes." "Bearing these facts in mind it is evident that an accurate estimation of the ultimate glasses can not he made at the end of two weeks. The rule among opthalmologists is to give a temporary glass for three to four months, and allow cicatrical contraction to take place hefore deciding on the final glass. But even in selecting this temporary gla.. 192 and 193), moves in front of the nodal point of the aphalir, and tlierefore, also in front of the second nodal point of the emmetropic eye. Hence, the retinal images of objects observed at equal distance, are to each other, as the distance of the second nodal point of both systems from the plane of tlio image, wliich. when seen distinctly, exactly coincides with the retina. Hence we may place them in relation with the distance, instead of the si/.e of the image. (See Manth- ner, 1. c, p. 175.)" "Above it was stated, that in a case of hyperopic aphakia, it would be impossible to obtain a sharply-defined image without a correction. There is a single exception when the retina lies in the .second princii)al focal plane of the aphakic system. If an aphakic eye is 30.61 mm. long, then parallel rays of light will come to a point exactly on the retina; that is, will form sharply-defined images of objects placed at infinity. This image will be, as compared with an emmetropic eye .very much enlarged. If we will 398 now designate the size of the image of an accurately seeing aphakic eye by Bj, that of the emmetropic eye as B, further the distance of the nodai point from the retina in the former by K2n' ^in^^ of ^^^^ latter by Kn, hence the relation will be Bj : B^K^,,: K„. If we will now substitute for the second side of the equation their values, it will be B2 : B=30.61— 7.7:23.86— 7,7. =22.91:16 16. =1.417:1. and it will then be 1:1, 417=0, 705:1; hence, B2=1.417B, and the amount of vision thus obtained by the optometric measurement of the aphakic eye is to be multiphed by 0.70."), so as to be comparable with the emme- tropic eye.'" Thus, if we found that vision in an aphakic eye 30.61 mm. long was equal to f^ we would have to multiply this result by 0.70,5 in order to obtain the actual degree of vision, as compared with retinal image of equal size, or expressed differently V=f|- would be the apparent degree of vision, and Y=^^xQ.705=Y=^4^ , or V=-^ would be the actual acuity of vision in an aphakic eye 30.61 mm. long, without any correction for the distance. If we will now plaiie before the aphakic eye a convex lens of yV at a distance of 0.5" from the cornea, and make the calculations for this combined system, we will find that K2n=29.58 mm. Comparing this with the emmetropic eye, we will find that the increase = 29.58:16.16 = 1.830; whereas the diminution equals 0.546. From this it follows that this ejilargement is must greater, when, as in the case where a convex glass of yV is placed before the eye, "the eye is accommodated for a distance equal to 10.5." The apparent acuity of vision is determined by the following: Vl^XJf?-!^ 1-290=^, and this in its turn again, multiplied by the amount of diminution 0.546, give us the actual degree of acuity of vision." "=15:50" >< ^- ^^^=^iiM ' •'In this single instance, in wliich. aii aphakic eye is enabled to see images perfectly distinctly, we can compare the acuity of vision of the aphakic eye for near and far. The figure re|)resenting the enlargefiient of the image, v/here we artificially ])roduce accommodation for 10.5" distance equals 29.58:22.91=1.290. By this means, just as for near V=|^Xl.290=-j|^. "Tlie enlargement or tlie apparent acuity of vision is dei)end- ent wliere the focal sti'eiigth of the convex lens n^ninins the same, on its (hslanec from the eve, and where llie distance fr(»ni the eyo 399 remains the same, on the focal strength of the glass chosen. If one will at the same time so change both factors, so that the focal strength of the glass, less the distance (f-x) always remains the same, there will likewise take place a very considerable movement anterior to the second nodal point. All three metliods ajv iiuporljinl in general practice. T^y means of the last mentione3 27.84 27.44 27.18 26.86 26.63 26.L9 23.86 22.82 22.24 21.49 20.64 19 56 -1.22 -1.41 -1.62 -1.66 -1.81 -.■.00 -3.97 -4.58 -4.94 -5.37 -6.89 -(:.64 -2.75 -3.17 -3.42 -3.72 -4.08 -4.54 6.78 5.45 5.32 6.09 4.87 4.56 3.03 2.28 1.90 1.37 0.79 0.02 20 84 21.59 21.97 22.50 23.08 23.85 16.1H " " " " " 1.298 1.347 1.363 1.392 1.422 1.475 0.775 0.742 0.739 0.711 0.703 0.677 }» 562.91 369.29 249 79 184.64 139.75 20.7 13.6 9.2 68 5.1 In table XII the glass of -^ has been removed from the eye from ^ to 4" up to 2 '. But even by bringing about the furtherest possible distance from the eye, the artificially produced near point could only be brought up to 13" from the eye. JSTevertheless, the enlargement grows until it has doubled itself. In table XIII the various glasses,^, -^,-^j-^,^aTe all placed at an equal distance. On using -^ the aphakic near point reaches 9" distant from the eye. With | the eye can see distinctly at 5". Whereas, by such an excessive {Accommodation, the enlargement only becomes one and one-half times enlarged. THE SELECTIOX OF SPHEEICAL GLASSES. "In practice, as a rule, we begin to seek the proper correction for distance by use of a +\ (4-10 I)), and where we do not get the requisite amount of vision we move the glass either a little nearer or a little further away from the eye. If in the latter position sight is improved, we take a stronger glass and continue this procedure. In this manner we soon arrive at the glass which gives the best result. In the other case we go f roni ^, i, |-, etc. After having in this manner arrived at the proper glass for distance, we can in like manner arrive at tha proper correction for reading. However, one will save time if one will bear in mind, that to the glass which gives a proper correction for an infinte distance, sliould l)e added the glass having the reciprocal value for a distance; thus, if the correction for infinity is -^ to accommo- date for a distance of 20", we would have -^-j-~=^ (exactly -^V)' ^^^ 10.5" would be -^-^^Xj^=z-^ (exactly ^V)' ^^^- Naturally, one does not have all the lenses corresponding to these fractional figures the result of calculation, so one uses the lens which comes nearest to it in the test case, and we correct the slight difference bv the distance at which the glass is 403 placed fi'oni the vyv. Any one who iiiiir^t frequently prescribe strong glasses for distance, soon learns to give the proper correction for near." ''The dioptric system now being in use, having once found the cor- rection for distance, the glass for near is very easily found by adding to this the glass which would re])resent the amplitude of accommodation up to the j)oint at which the patient wishes to read. ''JMuis. if this be 25 cm. j%V -iJ)- tlien if glass re(|uired for distance is KH) for near, 10 -j- 4 D = 14D would 1)1' rc((uiir(l: if this is 1 "i 1 ) for near, l".^ - - 1 D-inD would be required." In order to see a point distinctly, wliidi is at a distance Y removed from the lens, the rays of light wliicli emanate from it. after they have passed through a lens having a focal lengtii of F^, which is accommodated for near, must con- verge tf» the same point, as do parellel rays after they h»«e been deflected by a lens F,, which is tlie proper corrpctton for distance. This mutual dependence of Y and F'2 is expressed then -L =_L4-J.=li^__L. F^ 1« ' 3.5 28 •i.43 Hence, one would see distinctlv at a distance of 10, 5" Avith a lens JL at 2.59 a distance of ().."►" from the eye. and distinct vision at S.r>" with a lens l 2 43, 0.5^' from the eye. Since both of tliese glasses are not found in the test case, one chooses the nearest glass, J-, and if the distance of the glass before the eye is not changed, accurate vision will l)e attained, at S."/' from the glass, 9.25''' from the cornea and at •.t.tio" from the nodal point of the eye. "N'ow. if one will look iti table XI 11 and tiiul the distance for which an aphakic eye is focus when armed with a convex glass of ^ focal dis- tance, placed at o.")'' distance, one will find that this is given in the fifth column as ^^ which coincides with our M'cond value. 9.25. At the same time we discover that the degree of vision for near objects is much greater than for distance would have led us to e.\|)ect. The reason for this is, as has already been indicated, due to the inc •rea>e in size, owing to the strength of the convex glass used." 404 If the degree of vision attained is not sufficient to answer the require- ments of the patient, we have another means at our disposal to enlarge the retinal images, and thus to increase the apparent degree of vision, one eitlier removes tlie glass furtlier from the eye or one uses a stronger glass. But in hoth cases, as can be seen from tables XII and XIII, the object must be brought nearer to the eye. The patient then sees, if one may use the expression, as if he were looking through a Galileo's telescope, or is using a lens to enlarge images. From all that has been said it will be seen, that no statistical results are of any value, in which simply the number of the Snellen or Yager's test t}'pe read are given, only then do they give a correct idea as to the degree of vision attained, when, at the same time, the distance at which they are read is also stated. But even then the most tiresome calculations are necessary, since the smallest test type of Yager and Snellen, in cases of normal vision, must be read at a much greater distance than is the usual reading distance." THE CYLIXDEICAL CORRECTION. "Just as soon as one finds that the amount of vision attained for either distance or near does not equal the a^^rage degree which ought to be attained by the use of spher- ical glasses, the attempt fih-euld be made to improve this by the use of cylinders. Reuss and Woinow have demonstrated to us, that in most cases this procedure will be successful, if there is not a very large secondary cataract present. If we have found the cylindrical correction for distance, we simply add this to the spherical combination for near." "The above named authorities claim to have found, that in the aphakic eye, at times when looking at near objects, the degree and position of the meridian in which the astygmatism lies is changed; however, this observa- tion has never been corroberated by any other observers." "As a rule, the number of the cylindrical glass is found by experiment, but in order to save time one may start out with the average degree (iV fo yV). and place it in the well-known direction of least curvature which appears after cataract operations. A very valuable control experiment is that of measuring the corneal curvature with the opthalmometre. Since when we have arrived at the corneal astygmatism, we have at the same time arrived at the total astygmatism of the entire eye." "Reuss and Woinow have advised the use of a cylinder, as found by opthalmometric examination; but still, since following this examina- tion,, one must still test to see how much vision is attained, one can not see why this procedure is to be preferred." "Thomas Young showed that by placing a spherical convex lens obliquely, the homoccntric rays of light which fall on it do not exactly come to a point, but come together in two lines placed vertical to each 405 other. s(i that we i.m pnxhu-c a similar cH'cct liy |>la(iii;^- the ^ilass sonu'what ()l)li(|n("ly t-- the Wiw of vision, tliii- pi-odiiciiin- an •■llV'tt anah)^ous to the combination of a spherical and cylindrical lens. And it is well known that those who wear glasses often unconsciously correct slight degrees of astygniatisni by bending, moving forward, or displacing their spectacle frame." "We often find patients who have undergone cataract operation place their glasses in aJi.obli(iue position. Every beginner often is very much confused to find the patient state that at times he sees better, at times worse with the same glass, or is unable to explain this condition satisfac- torily to himself; or in other words, that he can see better with his spec- tacles than he can with a glass of the same focal strength, which the phy- sician places in front of his eye. Both conditions are explained by the cylindrical action of a glass held obliquely. That which the patient often does unconsciously is often a valuable aid in the hand of the physician, who in this simi)le manner can increase the degree of vision. Donders drew attention to the fact in 1864, and Java! used it in 1865, and I belieye that in many cases one can avoid giving a cylindrical correction by employ- ing this means. Unfortunately as yet we have no scientific explanation for this practical and important subject." THE INFLUENCE WHICH GLASSES EXEKT ON THE VISION OF APHAKIC EYES. a. CONTRACTION OF THE FIELD OF VISION. From time immemorial it has been customary to prescribe large round glasses for cataract glasses. It was supposed that by this means we could increase the size of the field of vision. Many patients, however, remonstrated against such glasses, because the weight often became a burden, and fre- quently the patients would go and have them cut oval. By doing this they did the proper thing in more ways than one." "Already Thomas Young had shown that rays of light passing through a bi-convex lens placed obliquely, did not come together at a single point, but in two focal lines at a certain focal distance. This departure from the regular refraction increases with the size of the exposed surface of the glass, and with the angle at which the glass is placed, and with its curva- ture. As a result, when looking through convex glasses, objects in the periphery of the field of vision look distorted. To overcome this exi\ effect Wollaston constructed his periscopic glasses: whereas several practical opticians of his time advised glasses of a smaller diameter, since they started out with the assumption, that the outer portion of the retina is less sensi- tive, hence, could well get along without an optical correction without any evil effects. The advantage which Wollaston hoped to get from periscopic 4o6 glasses has not been practically realized, at least for convex glasses. Since it was shown that the so-called prismatic displacement, at least for the periscopic glasses, is just as great as it is with bi-convex or plain convex glasses." "When weak convex glasses are ns«l, tliis disturbance, so far as the excentric vision is concerned, is not very great. But if, as is the case with those who liave undergone a cataract operation, strong convex glasses are exclusively used, we find, as Berlin showed, that it is not a matter of dis- tortion, but a zonular, concentrically-defined defect in the periphery of the field of vision. Even when the large round circular cataract glasses are used, the outer periphery of the retina receives its light direct, without passing through the cataract glasses. Owing to the highly prismatic action of the edges of the cataract glasses, light does not reach the pupil from a not inconsiderable zone of the field of vision. And since a total reflection also takes place from the edges of the cataract glasses, Berlin especially draws attention to the fact, that this zone is not sharply outlined in any direction as a result of the action of this total reflection. Since the outer limits of the field of vision are more dependent on the size of the glass, by making tlwse smaller we can at least limit this eccentric loss of the peripheric field of vision. Hence, I see no reason why we should prescribe large, heavy, and therefore very uncomfortable cataract glasses instead of the oval glasses, when at the same time we desire the benefit of a diminu- tion of the peripheric distortion, and loss of the excentric portion of the field, especially above and below."" 'Tor the upper half of the field, the advantage certainly would not be of any great importance, but when glancing downward the condition of affairs certainly assumes great importance. Only too often do cataract patients complain of defective ability to exactly locate objects. In walking, especially in going up or down stairs, they are frequently inipeded, so that many, especially when they have a slight myopia, prefer to walk about without their glasses. On using the oval glasses this defective power of locating objects is at once corrected. Undoubtedly the patients receive inaccurate images of the floor on which they are walking, but at the same time they do not receive interrupted or distorted ictinal images."" "Owing to the highly prismatic deflection which all the rays of light receive, except those which traverse the rvuiw especially careful to i^ec that in cases where hot the glasses are perfectly ceiitei'ed. Oiheiwise. asthenopic trouble will arise."" "If only the one eye has been o])i'rate(l. an be used to see with, the glasses foi- distance an )!' 1 he glas s. we nnist be e\e s have hecn operated. ■|-y annoying di] tlopia or th. ■ other can ti lo longer ne; ir may \)V pi: it in one 407 frame, with a neutral nose piece, if n liiio on the no?e doe? not veto such a procedure." "Hence, tlie field of vision of the aphakic eye extends over ns much space as does a complete eye. Only the former can not see so well, in tlie periphery as in the center, even wlu-ii provided willi j,dasses, owing to the distortion of the images. And this incc.nvcnience is increased hy the cata- ract glasses. This contraction of ihc field, as a result of the ust> of the convex glasses, becomes increased when the distance of the glasses from the eyes is increased. Hence, owing to these conditions, accommodation can be accomplished by the use of stronger glasses. Naturally, the increase in the apparent acuity of vision for distance suffers also where there is a very large contraction of the field of vision. Hence, it is almost impossible to wear continuously in front of both eyes glasses far removed, notwithstanding the pleasure which such patients may derive from wearing their simple opera glasses." EXACT CENTERING. -Jn the selection of cataract glasses more depends on the selection of a proper frame than on any other condition in which glasses are required, for on this is dependent the fact whether the eye and the glass will be properly centered. For instance, the prismatic deflection when using a +^ at 1 mm. distance from the center is as great as in a +1^ at 3 mm. distance from the center (1° 15'). By this means not only is there a very perceptible distortion of objects, and the arrangement of the same, brought about in the periphery of the field of vision, but light is broken up into its various colors, which becomes very annoying to the patient. Hence, no one who is necessitated to wear glasses, worries himself so long and so persistently, so as to get them in a proper position in front of his eyes, as does the patient operated on for cataract." •'As long as only one eye has been operated on, we may permit the patient to worry himself in getting his glass properly centered. But in prescribing cataract glasses for both eyes, other factors come into play, such as the occurrence of diplopia, and we must take into consideration the muscular condition of the eyes, and then it becomes the physician's duty to see that the glasses have a proper ]iosition, in their relation to the eyes, according to the general fundamental rules. If, as i? usually the case under such circumstances, we prescribe separate glasses for distance and near work, we must at least approximately take into account for each special case, the iingle which the lines of vision must make with each other, and aside from this we must see to it that the glasses are so bent as to form an obtuse angle, open anteriorly." 4o8 FEW PECULIARITIES OF APHAKIC VISION. a. Entopic Vision. It vvould hardly seem necessary to state, that in consequence of loss of the lens, all entopic phenomena which arise in the lens system are wanting, if it were not, that at times during the formation of a cataract, these ])henomena force themselves to the attention of the patient in the most disturbing manner. In aphakia the patient becomes aware of opacities in the vitreous under entirely changed optical conditions. Since the entire vitreous has moved perceptibly away from the focal ]ihine: lience, where no cataract glass is used, every cloudiness in the same must cast a shadow on the retina, and since the power of accommodation is wanting, hence all vitreous opaci- ties will at once be recognized, as soon as an eye equipped with cataract glasses directs its attention to any object which is at a distance equal to that for which the glass is intended. ERYTHEOPSIA. A peculiar sul)jective phenomenon of the aphakic eye is the sudden occurrence of red vision, of which the patients not infre- quently complain, and which frightens them greatly the first time it occurs. It occurs suddenly; at times it lasts but a few minutes; in other cases, hours and even days. It always disappears gradually. Since all patients who observe this are sure to relate it to their physicians, hence it can be stated with certainty that it occurs in from 3 to 5 per cent, of all cases. Since no evil results luive ever been observed following its occur- rence, one is justified in quieting the fears of the patient by making a good prognosis. Becker had the oi)i)ortunity repeatedly to examine, wdth the opthahnoscope, such a patient during an attack, and believed that he might safely state, that he did not observe a hyperaemia, either of the retina or the optic nerve. Erythropsia has been the subject of considerable investigation by Hirschler, Dimmer, Purtscher, Meyerhauser, Steiner, Benson and many others. Dr. Hirschler has been the subject of this peculiar phenomena him- self, and has given us a graphic description of his sensations. He states 4 tiiat he had always been very near sighted (M. 1-10. suffered from mouehes volaiites. and frequently scotoma scintillans fu^ax). Strong- lijiht al- ways caused trouble, and frequently caused "nachbilder." In 1878 his left eye became diseased, and in 1880 cataract developed in liis right. In 1882 a Von Graefe extraction with a broad coloboraa. With the exception of micropsie. the process of healing and convalescence was perfect. Notwithstanding astygma- tlsm with a 4 5i/. V •^1], and with a + .">^',. read Y 1. Tlie r)eculiar phenomena 4Zum Uothselien dcr .\piialviselicn. Welncr Med. Wochcnsclu-ift, 4. 6. 1883. 409 of orythropsia bi'^iau the tiftli month after the oi)eration. As soon as evening approached the entire tirniauient appeared red. wliereas all tern'strial oltjects were red throngh the reflection of tlie red light from above. This phenomenon was also present indoors, but only on looking toward the windows. This continued regularly for about one hour, gradually disappearing. During the continuance of this phenomenon the acuity of vision was not reduced. Even on cloudy days this red discoloration of the tirmament did not fail to appear, even if the rain was coming down in torrents. This phenomenon never oc<-urr^d during the day. However, if the eyelids were brought sufficiently close together this red discol- oration could be made to disappear during the evening. However, closure of the right cataractous eye did not exert the slightest influence on this phe- nomenon. Towards the fall of the year tlie erythropsia disappeared just as suddenly as it had come. He .seeks the cause in the large iris colobom. not as a result of the colored rays of dispersion, but rather as a result of the intensity of the light which, falling on the peripheric portions of the retina, caused there an unusual degree of irritation. This excessive irritation is followed by exhaus- tion. In this ease, the peripheral portion of the retina being so exhausted that light at twilight was not strong enough to arouse sensation to its fullest de- gree. This exhaustion must manifest itself for rays of light which have higher indices of refraction, whereas the sensitiveness for the red rays is still present, as a result of which the field is colored red. The results of experiments with stenopaic glasses verifies this. Piirt8cher° investigated this subject, (Irawing the followiiii-- coiiehision: 1. That eri/thropsia is not an optical phcnomoion. Dispersion of colors could not be thought of, becaii.se then only tlie edges of objects would be colored. Two causes might be thought of, cloudiness of media or hemorrhages in the vitreous, but both can be set aside because if present they could be detected with the opthalmoscope. Further, there is no reduction of acuity of vision during the time everything appears red to the patient. 2. The orcurrence of erythropsia in aphhia is not dependent on the pres- ence of a coloboma. In his own ca.se of traumatic cataract, likewise in Dim- mer's case, there was no coloboma. S. An explanation on the basis of tonlrast in colors can nol he linnii/ht in accordance with the facts. I'hough it has been supposed that after re- maining for a long time where everything is green, the complimentary color red will appear. One fact mitigates greatly against this a.^suniption, for in many ca.ses the red appeared at (uice on waking in the morning. 5Zur Frage Krythropsia. Centi-.-illilntt fur Prakrischer Augenheilkunde, .luni. ISS;?. 4IO 4. Hirschhr's e.rplanalion has a pln/sioJoyicnl basis for it. He explains ilie eryihropsia as dve to fatigue of the retina, tvhich becomes most evident in the evenin(/. and manifests itself mostlij for the more hiqhlii reflective rays, whereas, the rays of less refractive power can still art. Aubert ^ states that sensitiveness for blue or green is lost in ten min- utes, when dark blue or dark green glasses are worn; whereas, red can still be seen after several hours. One might suppose that a retina which be- comes fatigued 'very rapidly (for colors), would lose its sensitiveness for refractive rays of diffuse light much sooner than its sensitiveness for the less highly refractive red rays. Further, one ought not forget the fact that among pigments red can still be recognized where the intensity of the light is reduced, after all other colors can no longer be seen. Hence, it would seem that the Conditions for the recognition of red rays are more favorable when the iMensity of the illumination is reduced. This fact becomes still more important where, in a fatigued eye, hemeralopia also is present (as Hirschler states of his own case), and which he assumes to occur generally in aphakics, where coloboma has been made. 5. This phenomenon of seeing everything red is purely a subjective one, and has its- seat in the sensitive apparatus ivhich receives the rays of light. It is partly direct, partly indirect, depending on nervous influences. For the former, one can assume, that a retina which had been shielded for a long time from the more intense impression of light by a developing cataract, would certainly be more sensitive to the action of light after the obstacle had been suddenly removed. Likewise, the tendency to fatigue would be greater. He gives a series of cases and further investigations," and after review- ing all the literature, reasserts all the above, and finally concludes: "This ]jhenomenon of seeing red is purely a subjective one. due to irritation, or finally, a fatigue of the visual apparatus — the result of partly direct, partly indirect, nervous, special and vaso-motor influence. Indi- viduals of a naturally nervous disposition and aphakic — possibly more cor- rectly, those who have suffered from cataract — are predisposed. This pre- disposition is, in all probability, heightened by coloboma." Immediately after delivery of the lens, patients not infi-equently see everything in a color other than normal, as jier e.\am])le. the finger looks 6Graefe Saenisch H.. II. 2. S. "mT. 7 Foer.ster Koitrajio zur Fni^o dcr Kiytluojtsic. o. I'urtsclun- Contralblatt fur AuK«'nlicilknii(l.'. FchniMrv .mikI .March. 1SS4. 411 blue. One lookod upon I his ns a coiit ra-1 action: for as we stalled, an inu-nso yellow color of the nucleus influenced llie jxTception of colors in the cata- ract patient. Fnder such circumstances we would expect this phenomenon to disappear a certain length of time after delivery of the lens, and ought to be entirely wanting in soft cataracts, which have a yellow nucleus. Roth, however, are not true: it can. however, be shown ihat this phenomenon is due to particles of lens substance left behind in the aqueous, and to very finely diffused blood. This blue discoloration always disappears as so(ui as the lens substance is absorbed. At times simi)ly permitting the aqueous to be evacuated a number of times by separating the edges of the wound, is sufficient to cause the finger held before the eye to again assume its normal color. Fuchs*^ has given us the most exhaustive exposition on this s\ibject, and has shown that erythropsia may occur in normal eyes, lie came to the conclusion that the cause must be sought in some dii-ection other tiuin in the illuminated field. He found that erythropsia ensued even when colored glasses were used, and concluded that the erythropsia is entirely independ- ent of the color of the light. Finally, he sought its origin in the color of the visual purj^le of ihe retina, which begins to regenerate every time the eye is removed from the influence of the light. He, however, indicates that he can not explain why at times the red seeing is preceded by green. Snellen ^ believes that this is a contrast phenomenon. The portion of the eye which had been exposed to the bright light will appear red, whereas the portion which has been protected (being in the shadow), by contra.st will appear green. Finally, he points to the fact that a very thin, transparent lid, owing to its great vascularity, a strong light })assing through it into the eye, on trans-illumination, will appear of a purple color. f). OPTHALMOSCOPICAL EXAMINATION. "As is well known, jn the emmetropic eye, the entire curvature of the retina lies in the focal plane of the dioptric system. According to Thomas Young this is sup- posed to be due to the lamellar formation ..f the lens Hebnlioltz agrees with the idea, and mere recently, owing to this pi-oi)erty of the concentric arrangement in layers of lenses, Ludimar Henna: has applied to them in a somewhat different sense the name "])eriscopic,'' It is a fact, that m making the direct examination, even those points in the perii)hery. even where it is still possil)le to get a view of the fundus, do not give us dis- torted pictures. But I can not agree with Donders when be states that we can see the various portions of the retina without changing our accom- modation. The former is caused by the lens, which seems to be shown with aT'ber Erythropsie. (Jriiefe's Arch.. XLH.. Part 4. IWH. b Er.vtliroi)s!e. Oraef.'-s .\nli.. XIJV.. Pari I. ISitT. 412 a certain degree of certaint}- by the fact, that in aphakia we can onl}- recog- nize the periphery of the fundus in variously distorted pictures. However, we can not draw any certain conclusion from this, because on the one hand we know that the curvature of the cornea suffers, as a result of the operation, and because on the other hand the capsule w^hich is folded and left beliind under all circumstances, causes an irregular astygmatism. which becomes more manifest in the periphery than m the center.'' "Donders quite to the contrary saw the periphery of the fundus niucli more distinctly when the lens was absent than when it was present. And since, in the former ease, the peripheral images are also properly projected, he assumes that in aphakia the indirect examination is so changed, that the form of objects in the retinal pictures are now better seen with the opthalmoscope. and hence are less properly projected by the eye." c. BINOCULAR VLSION IN APHAKIC EYES. "Up to the pres- ent time binocular vision in aphakic eyes has not been adequately investi- gated. For the little which we do know we are indebted to Von Graefe (807). The question becomes pre-eminently a practical one, where we are to decide whether or not we shall operate when a cataract is present on only one eye. The question must be answered variously, depending on the fact whether the other eye is still intact, hence able to see, or whether the second eye is already attacked by cataract but is still in a condition to see. Aside from this, we must take into consideration whether or not the eye to be operated on promises a satisfacton,' result as to vision. If this is not the case, the operation is to be made for cosmetic reasons, and it would seem hardly necessary to state here, that everything depends on whether it would be i)ractical to operate or not under such conditions. "In those cases in which the second eye is already afPe<;ted, it is not difficult to come to a decision. Nevertheless, experience has taught, that where two eyes see under such different conditions, they disturb each other verv mucli during the f.ct of seeing. Each eye blends the other. As long as the non-operated eye answers all the special demands for seeing on the part of the patient, he prefers to use the non-operated eye, especially for near work; and at times even when the degree of vision on the operated eye is greater. This is explained by the fact, that in the operated eye much illy-refracted light enters the eye, which blends the distinct picture of the other eye. always assuming that \hv secondary eataraet is woi a large one, causing an enlarged retinal image, wliieh without a correction is a very indistinct one; and lience, the patient finds liinisell' in a position similar to that of aiiisonieti-o|)ie. howeviT. I'eceiving i-athcr less dilViisi'd light than tlie non-opei';itc(l eye."" •'ir ihr non-o|icr;it('(l r\v no longer sulliees for seeing, this over-hleiul- 4i3 ing will still take place. But it loses its dislurbinfj qualities the more the cataract progresses. Hence, we can often answer complaints with this con- solation, if we do not prefer to cut otT' the eye entirely from the act of see- ing by placing an opaqne disc before it. Notwithstanding all these draw- backs, no one should ever hesitate to operate a ripe cataract because the otiier is not yet ripe. And indeed lite Hiiir for (in opcntUmi has (im'red, irlicii ihe second affected eye hcj/iits lo fail in ils scrricc. Ili'iicc. we save the patient, short as this might be, time of enforced idleness. One ought, with Graefe, to wish every person without exception, who is affected with cataract, a successive development of the trouble on both eyes." "If we are dealing with a cataract on the one eye, where the other eye shows no sign of becoming atfected in tlie s;nne way. as in a case of cataracta iraumatica or canrpUcata, one must consider, that pfter even a successful o])eration, the patient will have a high degree of anisometropia during the rest of his Lfe. In a certain proportion of these cases of acquired anisome- tropia, and as it occurs in congenital cases, the image on the operated eye is suppressed. As a result no absolutely sharp fixi.tion on the operated eye takes place during the act of accommodation and the associated movements. Likewise, by the use ci prisms, one can neither bring about the perception of double images nor a deviation of the visual line. (V. Graefe.) Investi- gations have not as yet been made to lind out whether or not these occur in eyes which before the cataract operation had perfect binocular vision. In another percentage of cases Von Graefe found that true binocular vision did occur, without causing the patient any particular annoyance, notwith- standing the enormous difference in the refractive condition of the two eyes. If the fixation is absolutely correct, the eye will turn inward in using an adducting prism, and it will turn outward behind an abducting prism. Stereoscopic vision is present, and distance can be properly judged." •"Up to the present time I have only had one patient under observa- tion who could be used for making these experiments — the young colleague whom I have so repeatedly mentioned. I can positively assert, that during complete and accurate fixation he was not disturbed in the least by the difference in the size of tlu' images. The use of prism gave the same results, and he was not aware of any difference in his ability to Judge distances and in looking at stereoscopic pictures. I regret, however, that I have not been enabled to make any more exact experiments. Hence, thio very inter- esting subject is still to be investigated." "Though such successful eases are to he looked upon as exceptional. one must nevertheless? emphasize the fact, that no Y()(>lhouse. Jena. (Handelt besonders vom Staar.) 1717. 49. \Yoolhouse. J. Th.. Dissertations scavantes et criti(iues sur la cata- racte et le glaucome de plusieurs modernes. Frankfurt, 1717 u. 1730. Lateinisch von Christ, le Cerf u. d. T.. Dissertationes de cataracta et glaucomate contra, systeraa Brissaei. Antonii et Heis- teri. Francof, 1719. 1718. .50. Woolhouse. J. Tli.. Observation sur des cataractes nHMiihrancuses. Memoires de Paris. 51. Gastaldus. J. B.. An cataract.-i vitium lentis. Avignon. 1719. 52. . Quaestio medica. an cataracta a vitio hniiioris a(inei vel crys- tallini oriatur, an a glaucomate diffciat et .ilitcr 55. LeCerf, Chr„ An Llcht besehener Staar odcr i.as(iMillantisther Criti- cus Sincerus F'dolis. Leipzig. 56. Wiedeniaii, Fr.. Borlclil vom Stein aiuli Bnulu-u zu sclmcidt'ii nud Staar zu steelien. Augsburg. 1720. 57. Bianelii, O. S. oder Plancus. L«>ttera intorno alia f-ataratta. Rimini. 58. Lichtnianu. .7. M.. Besobreibung des Staars. Nurnberg. 1721. 51>. — . Geschiekter Augenarzt. H«>schrt'il>ung (l«'s Staars niid Mini- fells. Xurnberg. 60. Freitag. J. II.. Dissert, medica de cataracta. Argentorati. Auch in Haller. Disp. Cbirurg. sel. torn. 2. Lausannae, 1755. 01. Coccbi. A. <;.. Epistola ad Morgagnum de lente crystalliua oc-uli hu- mani, vera suusiouis sede. Romae. 1722. 62. Bianebi. Lettera esaminando una lettera del Coechi gli nioustra al- cuni errori; tragli altri esser falso che Tumor cristallino sia sem- pre la vera sede della suffusione. Rimiui. 63. Benevoli, Ant., Lettere sopra due osservazioni fatte intoruo alia cata- ratta. Fii*enze. 64. , lu Ephemerid, naturae curios, cent. II, IV u. VII. Beobachtun- gen von Heister. Thomasius und Sproegel. 65. St. Yves, Traite des maladies des yeux. Paris. 66. Roberg, L., Disp. de cataracta. Upsal. 67. Pinson, Observations sur la cataracte et le glaucoma. Dictees a Mr. de Woolbouse. Jom-n. des Scavauts. .luillet. p. 42. 68. Deidier, Lettre ecrite a Mons. Woolhouse, ibidem, p. 80. (Beschreibt darin eine cataracta membranacea accreta.) 69. Sauveur Morand. Observations sur la cataracte des yeux. .Mem. dc Paris. 1724. 70. Antonio Benevoli. Nuova proposiione intorno alia canincnla dell" Uretra e della catai-atta glaucomatose. Firenzi. 71. Molineux. Sectio oculorum duorum cataracta aftectiDUum. IMiilits. Transact.. 1724. 72. John Rauby, On occount of tlie dissection of an eye witli a cataract. Philos. Transact., 1724. 1725. 7o. "Woolhouse, Th.. Disp. de cataracta. Trivult. 74. Francois Pourfonr du Petit, Dissertation sur Toperation di- la cata- racte. Memoires de Paris. 1720. 75. , Menioire dans lequel on determine Tcndroit, on 11 faut piquer I'oeil dans I'operation de la cataracte. Memoires de Paris. 4i8 1727. 7t). Doebel von I)ot>l)t"lii. J. .Inc.. l>e t-ataracta natura et cura. I.ordir. 77. Petit, Diss, siir une uom'elle metliode de faire I'operatioii de la cata- racte. Mem. de Lit. et du P. des Molets, III. Paris. 78. Wigeliiis, Canutiis. Disi). de cataracta. T'i)sal. 79. Ribe. Diss, de ( atai-acta. Tpsal. 1728. 80. Grateloup, B. Fr.. De cataracta. Tlieses medico-miscellaneae. Argent. 81. LeIMoine, Auton. Quaestio nied.-chir.. an depriniendae cataractae ex- spectanda nianirntio. Pai-is. und in Hallcr l>ispnT. cliinirg. sel. 2, 1755. 1729. 82. Dnddel, Treatise on diseases of liorny coat. eto. London. 83. Hofmann. Fr.. Disp. de cataracta. Hallae. 84. Henrici, M. H.. Disp. de cataracta. Leidae. 85. Hecquet. P. H., Lettre sur Tabus des purgatifs et des aniers. Paris. Yon demselben. 1730, 5 Brief e uber den grauen Staar. 8R. Petit, Fr., Lettre. dans laqnelle il demontre, que le crystallin est fort pres de I'T'vee et i-apporte de nouvelles pruves. qui concernent I'operation de la cataracte. Paris. Halleri Disp. chir. sel.. V. 370. 1730. 87. Adam, Aeg. et L. P. Lehoc. Ergo praecavendae cataractae oculi par- acentesis. Paris. 1731. 88. Fizes. Ant., Disp. de cataracta. Monsp. 89. Magnol. Ant. et Laulanie. An cataractae confirmatae oi)eratio chi- rurgica unicum remedium. Monsp. 1732. 90. Ferrein, Ant., Qiiaestio medica. quinam sint praecipui. quomodo ex- plicentur et curentur lentis crystallinae morbi. quae est duo- decima quaestio inter eas, (luas defendit. ]Monspelii. 91. Benevoli Anton, Manifesto sopra alcune accuse contenute in uuo certo Parare del S. Pietro Paoli. Firenz. 92. , Giustifieazione delle replicati accuse del S. Pietro Paoli. Firenz. (Beide Scliriften beziehen sich auf den grauen Staar.) V)3. Petit. Fr., Reflexions sur ce (pie Mr. Hecquet a fait imprinier sur les maladies des j-eux. Paris. 94. , Lettre contenaut des reflexions sur les decouvertes faites sur les yeux. Paris. (Beide Schriften liandeln vom grauen Staar.) 1733. 95. Franken. .T. H.. Over het stryken van verscliiedene cataracten. Amsterd. 17.30. 90. Taylor, .7.. New treatise on the diseases of (lie crystalline luuuor of the eye. or of the cataract ;iud glaucoma. London. 1738. 97. .Tucli, H. P.. Disp. de suffusione. Giford. 1739. 98. Vallisnieri, Historic von der lOrzeugung der Mensclicii. Lcnigo. p. 297. Doi)i)elt(' Linse in einien Augc. 1740. 99. Col. de A'ilhirs. A. )■'. L»'o et Lc Hoc, \u oculi pundio cataractani l)raec;iveat. Diss. Parisiis nnd in Ilallcr. Disp. Cliirurg. si^lcctae. Tom., H. I(t0. Roscius. .1. .r., Dc vera c-il.'ir.-icl:! rrystallina ladea. Rcginni. 419 1741. 101. l>f l;i Fa.vt". (J.. Ki-,u;<) v.-ni cMtMiactac st'.Ics in Icnte. Paris. 1742. 102. Elias Col. do Villars, Erjio vera catanictac sodi's in lonte. Taris. 174.3. lOo. Do la Souo. J. M. Fr. et Arcelin. Disp. stan-no potest vislo absque fi'j'stallino. Paris. 1744. 104. Ilcnolvcl. J. F.. Diss, iiiedioa do cataracta < lystalliiia vera. Francof. u. Ilallori Disp. Chir. sel., II, p. S.".. 1745. U»5. Anonym., 'I'roatise on cataraot and lilauconia. London. Aueh in Ilallor. lUhliotli. Chir.. IT. p. l!7S. iVon ..inoni Sdiuler Wool- lious<''s.l 100. Trow. Chr. .lac. Do oataiacla. In ((.niniorcio littorario. Norici, I, 1. •',(;. 1748. 107. Daviol. .Ia<'(iiios, Snr unc nouvollc niolhodo do gnorison de la cata- racto ]>ar !."► o.xtracTion. lAndi in .Monioiro do I'Aoad. do Chirurg. II. p. :!:'.7. isr»:{.l .Morcnro do Franco. 174S. (Vi 108. I.a Fayo. Il>idoni. p. r,^^?,. 100. (^uolmalz. S. Tli., Pi-oiir. dopositiouis cataraetae eflfeetus exponens. Lipsiao. 110. De la Faye, (!., Monioire pour servir a porfeotionner la nouvelle niethode de faire I'operation de la cataracte. Mem. d'Acad. de Chir., II, p. 563. 111. Koscius, J. Jac, Diss, de vera cataracta lactea crystallina. Regiom. 112. Nannoui. Angelo, Delia cataratta. lu dessen dissertazioni chiriir- giche. Parigi. Andere Ausgabe. Firenz. 1751. 1749. 113. Reglielliui, .launs. Lettera cliirurgica sopra Toffesa della vista In nuii donna, consistente nel raddoppiameuto degli oggetti. segnito dopo la depressione delle cataratta. Venezia. 1750. 114. O'Halloran. S., A new treatise on the glaucoma or cataract. Dublin, und Ilaller, Bibl. Chir., II, 345. 115. Palucci, Histoire de I'operation de la cataracte faite a six soldats invalides. Paris. 116. . Description d'un nonvol instrument, propie a abaisser la cata- racte avec tout lo succos possible. Paris. (Beide Schriften Deutsch. u. d. '1\ Beschreibung eines neuen instruments, den Staar mit alleni nur moglichen Erfolg niederzudrucken, nebst einer Nachricht von den Operationen, welche damit bei 6 Inval- iden u Paris unternomnien worden. von dem II. Palucci. Leiji- zig. 17.52. :\Iit Kupfer.) 117. Guntz, J. (}., Animadversiones de siiflfusionis natura et curationo. Lipsiae und Haller, Disp. Chir., sel. II. p. 105. 1751. 118. De Yermale. L<^ttre sur I'extraction du cristallin hors du globe de I'oeil. imaginee par Daviel. Paris. .Tourn. de Med., II, p. 418. 110. Andre. Lettre sur I'extraction du cristallin hors du globe de roeil. nouvelle operation imaginoo par Mr. Daviel. 120. Palucci. Pi'ocis do la ni(>1hodo d'abnttro la cataracte. M(>m. de Paris. 121. liathljnnv. .1. I'.. Traito do l;i cat.-irMcto. Anst. 420 1752. 122. . ^■^'^h;lunr.v, Lettro addressee a Mess, les auteurs du Journal des Scaviins sur les advantajjes de I'extraetio de la cataracte. Nou- vell(> iiii'thode inventee ])nr Mi-. Daviel. Journ. dos Scav. Fev- rier. p. -MTk 140. "\VahllK)Ui, J. (}.. Heiuerkunjien uber das st.iiirstechen. Abliandlun- fien der Sclnvedischen Akademie. 17."7. 141. Acrell. Olaus. YergleicluiniL!: zwischen den vortheilen und unbequem- lichkeiten. welclie jeder art des staarstechens begleiten, durch eigene versnclie und benierkungen unterstutze. K. Sw. Wet. Acad. Tiini.. Ill; anch in Seliriftwaxling om alle brukelige satt at operum Staaren pa agonen. Stockholm, 1766. 142. Tenon. Tlieses ex anatomic et cliirurgia de cataracta. Paris. 1758. 143. Tlieronde de Vallnn. ('. F. A. .T.. Descemet. Non E. sola lens cata- ractae crystallinae sedes. Paris. 144. Lander, Diss, de cataracta. Edinburg. 1759. 145. Sabatier, B. R. et Martin, P. D., Tlieses de variis cataractam extra- liendi methodis. Parisiis. 146. Daviel, Jacques, Yon zwei angebornen Staaren, welche er auszog. Koningl. Swel. AVet. Acad. Trim., I. 147. Morand, J. Fr. CI., Lettre conceruant quelques observations sur divereses especes de cataractes. Mercure de France. Aout. 148. Hoin, J. J. L.. Lettre concernant quelques observations sur diverses especes de cataractes. :Merc. de France. Aout; auch in Janin, p. ]G9. 1760. 149. (on Morand). Seconde lettre a Mr. Daviel sur la cataracte radiee. la convexite du cliaton du cristallin apres I'extraction de celui-ei, et une cataracte fenetree. Merc, de France. Mars. 150. Scliurer, J. L., Quaestio, num in curatione suffusionis lentis crystal- linae extractio depressioui sit praeferenda. Argentorum. 151. Daviel, Jacques, Mercure des France. Janier. Antwort auf einen Brief von Hoin. 1761. 152. Ten Ilaaf, G., Korte verhandeling uspens de nieuwe wyze van de cataracta to geneezen door middel van bet crystalline vocht nyt het oog te neenien. Rotterdam. 1762. 153. Demours, Petrus, Sur une maladie des yeux on Ton indique la veri- table cause des accidents qui surviennent a I'operation bien falte de la cataracte par extraction et Ton propose un moyen pour y remedier. 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Bech, Dissert, de cataracta centrali: Lips. 403. Ammon, v., Ueber den krankhaften consens der Hornhaut, der krys- tallinse und ihrer Kapsel. Z, f. d. O., I, p. 119. 1831. 404. Schmidt, J. A., A' on der cataracta y. Amnion's Z. f. d. O. I, p. 350. 405. Schon, Ueber den marasmus senilis der kapsel und linse im mensch- licben auge. Ibid. 406. Lochia, Wutzer, Jahn, Ueber Coloboma iridis mit gleichzeitiger cat- aracta lenticularis und uber die Genesis der Irisspaltung. Z. f. d. O. I., p. 253. 407. Ammon. v., Spontaner Yorfall einer Krystallinse in die vodere augenkammer. Z. f. d. O. I., p. 260. 408. Gescheidt, Colobomo iridis mit Partialtnibung der Linse (c. I. cen- tralis). Z. f. d. O. I., p. 549. 1832. 409. Warnatz, Dissert, de cataracta nigra. Lips. 410, , Die schwarz gefarbte anderen ahnlichen augenkrankheiten. Z. f. d. O. II, p. 295. 411, Ullmann. Spontaner Yorfall einer Augenkammer und entfernung derselbe durch die extraction. Z. f. d. O. II, p. 129. 412, Ammon, v., Zur pathol. Anatomic der Fossa hyaloidea im meusch- lichen Auge. Z. f. d. O. II, p. 388. 41.'>. . Prof. Rosas' Ansichten uber die Sehversuchi' gleich uach voll- zogener Extraction des Staares. Z. F.. d. o., p. 4(KI. 414. Dupuytreu, Bemerkungen uber den grauen Staar. Mitgetheilt von Behr. Z. f. d. O. II, p. 460. 415. Arnold, F., Anatom. Untersucliungeu uber das Auge des Menschen. 416. Schmidt, Aemil, Diss, de Keratotomia sursum vorgente secundum Jaegeri methodum. Berol. 417. Carron du Villards, Ch. J. F.. Lettre a Mr. Mauuoir sur un nouvel instrument destine a rectifier ou aggrandir I'incision de la cornee dans I'operation de la cataracte par extraction. Paris. Graefe u. Walther .Tourn.. Vol. XXIII. 1835. 434 1832. 418. Amniou. v.. Venlickunj; und Verwachsunjr thn- Art. centralis orliaupt. Z. f. d. ()., p. 485. 1833. 419. Beck. De ociilorum miitationibus, quae cataractae operationem se- quuntur. observatio. aduexis corollariis. Freib. Deutsch von Be- ger in von Amnion's ZeitscLr.. f. d. O., Bd. 4. 42(t. Amnion, v.. Der angeborene Staar in path., anat.. in pathogen, und in operativer Hinsicht. Z. f. d. O. Ill, 70. 421. , Operation des grauen Staars an einciii Alttiiio. Z. f. d. O. Ill, p. 116. 422. Beger. Ueber die Ver-vvundbarkeit (h's Auges und seiner Haute. Z. f. d. O. III. p. 145. 423. Heidenreich. Schwarze cataracte niit weissem exsudate auf der kapsel. Z. f. d. O. II, p. 205. 424. Werueck. Zur Aetiologie und Genesis des grauen Staars. Z. f. d. O. Ill, p. 473. 425. Mannoir. Th.. Essai sur quehiues p(»ints de IMiistoire de la cataracte. These. Paris. 42G. Rast. De variis cataractae opera ndae methodis. Solinb. 427. Bergeon. G. C, De la reclinatiou capsulo-lenticulaire. ou nouveau precede d'abaissenient de la cataracte avec aiguille nouvelle. These. Paris. 428. Lattier de la Roche, Mem. sur la cataracte et guerison de cette mal- adie sans operation chirurgicale. Paris. 1834. 429. Deutsch. u. d. T., Beobachtungen und Erfahrungen uber die Heilung des grauen Staars ohne chirurg. operation, etc. IlmeDau. 1834. 430. Carron du Villa rds, Recherches pratiques sur les causes qui font echouer l"operation de la cataracte suivant les divers procedes. Paris. 431. Kyll, Geschichte einer freiwilligen Zerreissung der Cornea und He- raustreten der Linse. Z. f. d. O. IV, p. 157. 432. Starrhetti, Partieller Vorfall einer durchsichtigen Krystallinse. Z. f. d. O. IV, p. 463. 433. Dupuytren, G.. Von der Cataracta. Kliniscli-cliirurg. Vortrage fur Deutschland bearbeitet von Beck u. Leonhardt. Bd. 1. Leipzig. 434. Rineclier, Fr., Entzundung der Gefass, Xerven und Glasliaut des Auges und ihr Ausgang in das hintere Eiterauge, in Folge der Niederdruckung des Staars. Inaug. Wurzburg. Anch. Z. f. d. O. V, p. 358. 1835. 435. Warnatz, Resorptio citarMctae spontanae. V. .Vniiiu.n's Z. f. d. O.. V. p. 49. 436. liorcli. Von «'inigen durcli Naturlmlt'e gelioheiieii .\ugenkrankheiten. Z. f. d. (). IV. p. 3S. 437. Schon. .Marasmus senilis dei- Kapsel und der Linse. W Animon's Z. f. d. U. IV. p. 73. 435 1830. 4;kS. Koll.ir, .1., I»iss. dc praccipiiis iiioil)is pcist cMtiiracta openitionem sfc-iidariis. \ratislav. 4;;!>. Kcfkcr. Tli., A. 1'.. Diss. . V. \). :\7,s. 443. Comperet. These svir la eatanicte, I'aris. 444. Unger, Operation einer Cataract bci glwcli zeitig bestehender Harn- rulir. 7.. t'., d. (). v., p. 356. 1837. 445. Siehel. Traite de ropthalniie. la cataraete et Tauianrose. Paris, in So. p. 7,-»(). 44<;. Carron dn Ylllards. Keeherches medico-eliirurgicales sur I'operation de la cataraete, les luoyeus de la rendre plus sure et sur I'inutilite des traitements medicaux pour la guerir sans operation. Paris, in 8o, p. 423. 1838. 447. Burkhardt, Appreciation physiologique de deux cas de luxation du cristallin. Ber. der Xaturf. (ies. in Basel u. Ann. d'Ocul.. XXX. p. 114. 448. Onsenoort, van Geseli, der Augenh. als enleitung in d. Studium der- selben. Deutscli von Wutzer. 44;». Pauli. F., Sublatio cataractae, eine neue luetliode den grauen Staar zu operiren. V. Ammon, Monatssclir.. I, p. 97. 4.50. Benedict. Bemerkungen uber einige neuere Enclieiresen znr Erleich- terung der Staar operation. Y. Ammon. Monassclir.. I, p. 198. 451. Pauli, F., Ueber den grauen Staar und die Verkrummungen und eine neue Hellart dieser Krankheit. Stuttg., in So, p. 439. 4.52. Beck, Ueber die entstebuug der cat. caps, anterior. V. Ammon, Mo- natssclir. f. INIedicin, Augenheilk. u. Cbirurg., t. II. 453. Stoeber. Observations des cataractes traumatiques, addressees a I'Acad. Roy. de Med. de Paris. Ann. d'Ocul., III. p. (54. 4.54. Loewenhardt, Resorption d'une cataract au moyen d'un seton passe a travers le sristallin opacpie. Ann. d'Ocul., I, p. 20. 455. Cunier, Du displacement spontane du cristallui. Ann. d'Ocul.. I, p. 59. 4.50, Carron du Villa rds. Du deplacement du cristallin. Ibid., t. I, p. 74. 457, Petrequin, Nouvelles remarques sur Toperation de la cataraete par I'abaissement, Ibid,, I, d. 157. 1839. 4.58. Lombard, Considerations et observations sur la guerlson des cata- ractes et des effections de la cornee transparente par une methode resolutive, etc. Paris, in So. p. SO. 436 1839. 459. Furnari, Essai sur uue uouvelle methode d'operer la cataracte par rextraclion par la sclerotique. Paris, in 8o, p. 16. 460. Bron, Traitement homoeopath ique de la cataracte. Ann. d'Ocul., II, p. 218. 4(;i. . Cataracte leuticulaire gueric iKir le cannabis sativa. Ibid., p. 181. 462. Pauli, Ein beitrag zur Lehre von der Heprodnction der Linse. V. Ammon, Monatsschr., II, p. 84. 463. Averdam, B. H. J.. Diss, de cataracte. Berol. 464. M. X., Quelle est I'influence qu' exerce I'operation de la cataracte sur la vie de ceux pui la subissent. Ann. d'Ocul., H., p. 57. 465. Onsenoort, van, Deplacement du cristallin suite d'une lesion re- marquable'de Toeil. Ann. d'Ocul., II, p. 138. 1840. 466. Stocher, A^,Observations de cataractes traumatiques. Ann. d'Ocul., T. 3. 467. Drouot, F., Nouveau traite des cataractes, causes, symptomes, com- plications et traitement des alterations du cristallin et de la cap- sule sans operations chirurgicales. Bordeaux. 468. Sichel, Methode simple et facile de faire des cataractes artificielles. Ann. d'Ocul., IV, p. 147. 4»59. Tyrell, A praTctical wwk on the diseases of the eye and their treat- ment medically, topically and by operation. London, in 8o, Vol. II, p. 556. 1841. 470. Hoeriug, G., Ueber die Dislaceratio capsulae. nach .Tager. Wurtemb. Med. Corresp., B. 1, No. 8. 471. Dittrich, Dissert, sistens couspectum cataractarum, in clinico et con- • signatione opthalmiatrica operatorum. Pragae. in 8o. 472. Sichel, De la cataracte glaucomateuse. de I'inutilite et des suites facheuses de son operation. .\nn. d'Ocul., V, p. 232. 473. Malgaigne, Opinion sur la nature et le siege de la cataracte. Ibid., VI, p. 62. 474. Lerche, Ueber die Heilwirliuug des Galvanismus in einigen organ- ischen Augenkranliheiten (Cataracta). Zeitschr., d. V. f. Heil- kunde, in Preussen, No. 24. 475. Ounier, Comptc rendu. XXII. Cataracte verte. "Ann. d'Ocul., V, p. 249. 476. Fahl, G. R. J., Diss, de praecipuis morbis. . Mackenzie, W.. Cataracte lenticulaire, operee par extraction. Section de la cornee au uioyen du couteau-aiguille. Remarques sur les couteaux-aiguilles. Ann. d'Ocul.. X. p. 209. 496. Sichel, Lettre sur la nature et le siege de la cataracte. Ann. d'Ocul., VI, p. 64. 497. Leroy D'Etiolles. Lettre sur la nature et le siegr de la cataracte. Ann. d'Ocul., VI, p. 70. 498. Heyfelder, Das chirurgische und augenkranken-klinicum der Uni- versitat Erlangen. vom 1 Oct., 1841. bis 30 Sept.. 1842. Heidel- berger Medic. Annalen, 1842. 1843. 499. Vallin. Le succes de toute operation cliirurg depend autant des soins qui la precedent et de ceux qui la suivent que de I'operation elle- meme; application de ce princii)e a la guerison de la cataracte. Paris. 438 184:?. r»(H». Duval ((rAr.uciitoiii. Considcnitions ■.MiicrMlcs sur In rnlnractp. Ann. d'Ocul., IX, p. ()1. 501. (tuIz. Velpeau's extraction des grauen Staars am leehten auge. Oesterr. Mod. Wochensclir., No. 39. ."502. Quadri. MonoKraphie de la double depression destinee a detruire la cataraete. Paris. .")03. :Magne, De la cataraete noire. Ann. d'Ocul., IX, p. 244. ,104. Gerhardt, Ueber den Vorfall der Krystallinse im mensehlichen auge. Heidelb. Med. Annalen.. IX. r.05. Barbarotta. Guarigione spontanea di cataratta. Osservatore Med.. No. 5. .")06. Valentin, Mikroscop. Untersucliungen zweier wiederzeugter Kryslal- linsen des Auges. Henle u. Pleuffer's Zeitschr., f. Rat. Med., I. 507. Travignot, Memoire sur les eataractes secondaires. Paris. .'.08. Rente. Zur Genese der Cataract und des Nystagmus. V. Walther's und V. Ammon's Joiirn., II. St. 4. 509. Fronmuller, Sonderbare Eutstebung einer Cataract. Ibid., St. 2. .jlO. .Tans. Cataraete operee avec sueces chez une femme aveugle depuis Aingt cinq ans. Ann. d'Ocul., X, p. 128. 511. Stafford, Cataraete congenitale, operee chez un sujet de 23 ans. Ann. d'OsHd., X, p. 143. 512. Mackenzie, Cataraete lenticulaire, operee par extraction. Section de la cornee au moyen d'un couteau-aigullle. reniarques sur les cou- teaux-aiguilles. Ann. d'Ocul., X, p. 209. 513. Rigler. Note sur I'anatomie pathologique de la cataraete. a propos de la discussion survenue entre Mons. Guepin et Szokalski. Ann. d'Ocul., X, p. 220. 514. Boling. Cataraete operee avec sueces sur un vieillard de 110 ans. American Jotirnal. 515. :Mannoir. Mem. sur les causes de non-succes dans I'operation de la cataraete par extraction et des moyens d'y remedier. Ann. d'Ocul., II. 510. Boulogne, A., Mem. sur deux instruments nouveaux, destines a Tex- traction et a I'abaissement de la cataraete. Marseille. 517. Sichel, .T., Etudes eliniques et anatomiques sur quelques especes peu connues de la cataraete lenticulaire. Ann. d'Ocul.. VIII. p. 109. (Fortsetzung.) .518. Drauot, Des erreurs des oculistes sur la cataraete. I'amaurose et les traitemens opposes a les affections. Paris. 1843. 519. Gluge, Note sur rossifleation du cristalliu. Ann. d'Ocul.. X. p. 220. .520. Bonehaeourt. Observations sur les concretions calcaires dans roeil. Cont. les petrifactions de la lentille. Ann. d'Ocul.. X, p. 250. 521. Guepin. Quelle conduite faut-il tenir dans les catanictes etroites. eongenitales ou autres'/ I>\MUl-il dans I'operation de la cataraete presser sur I'oeil pour la ire sortir le cristallin? Response a la lettre de Mons. le Doct. Rigler. Ann. d'O.ul.. X, p. 291. 439 1844. 522. Hooriu^-, (!.. FoIht .leu Sit/, un.l .li.- nalur d.-s ^Mnvion Staars. Eine von der Redactiou dor Annali's d'Oculistiquf (;«'kront.' Prelss- schrift. Hoilbronu. 1844. .-)2:;. Duval (d-AKontan). De la t-ataracto srcondaiic Ann. d'() ('arlsba. Landrun. .1. F. P., De la kistotomie posterieure on dechirement de la crystalloide posterieure apres I'extraction. comme moyen de s'opposer aux cataractes membraneuses secondaires. Paris. 5.W. Pamard. Memoires de chirurgie pratique, conten. la cataracte. I'iritis et les fractures du col de Temur. Paris. ->?,!. Duesing, Das Krystalliusensystem des-menschlichen auges in physi- ologischer und pathologischer Hinsicht. Berlin. 532. Pamard, De la cataracte et son extraction par un procede particulier. Ann. d'Ocul., XII, pp. 149, 191. 5.33. Guepin. A., De la refraction de la lumiere dans Toeil apres I'oper- ation de la cataracte par extraction. Ann. d'Ocul., VI, p. 12. 5.34. Guthrie, Observations cliniques sur la cataracte. Med. Times, Oct. et Dec. 535. A. de Grand-Boulogne. Memoire sur deux instruments nouveaux destines a I'extraction et a I'abaissement de la cataracte. Ann. d'Ocul., XI, p. 56. 536. Blasius, Sur une nouvelle modification apportee an couteau-aiguille pom- I'extraction de la cataracte. Ann. d'Ocul., XI, p. 135. 537. Lusardi (pere). Response a cette question: Quelle est I'influence qu' exerce I'operation de la cataracte su- la vie de ceux (pii la subis- sent. Ann. dOcul., XI, p. 145. 538. Berard. De I'operation de la cataracte faite sur un seul oeil. sans attendre que la cataracte soit formee dans I'oeil opposee. Ann. d'Ocul.. XI. p. 179. 539. Sichel, Cas rare d'ossification de la capsule cristalliue dans une cataract traumatique. Ann. d'Ocul.. XT. p. 223. 540. Szokalski. Operation de cataracte sur uii vicillard de 103 ans. Ann. d'Ocul.. XI. p. 272. 440 1844. 541. Abren. Cristalliu remonte et passe dans la chambre anterieure, 22 mois apres la depression de la cataraete. Ann. d'Ocul., XII, p. 36. .".42. Tilanus. Observation d'iridereniie eongenitale. eompliquee de cata- raete. Ann. d'Ocnl., XII, p. 43. 543. Abren. Diss, snr un nouveau procede pour la reclinaison depression de la cataraete et snr les resultats obtenus dans cette operation, a I'institut opthalmique a Bruxelles. Ann. «.'Ocul., XII, p. 53. 544. Turnbnll. Nouveau traitement de la cataraete et le quelques autres maladies des yeux sans operations chirurgrieales. Traduit de I'an- glais par lusardi (pere) et Paul Bernard. 54.5. Textor. De I'operation de la cataraete par keratouyxio. Ann. d'Ocul. XII. p. 212. 54<'.. Fischer. Eclaircissements sur la relation qu' faite Cheselden au sujet d'un jeune aveugle de 14 ans qu'il opera il y a pres de 120 ans. Bericht uber die Verhandl. der naturf. Gesellsehaft zu Basel. 1844. VI. p. 111. Ann. d'Ocul.. XXX. p. l-tt. 1845. .547. Strieker. Die krankhelten des Linsensysteuis nach physiol. Gund- satzen, Frankfurt. 548. Frerichs, Path. Anatom. und Chemische Untersuchungen uber Lin- senstaare. Hann. Ann., Nov. u. Dec. 549. Desniarres, De la cataraete pigmenteuse ou uveenne et son diag- nostic differential. .Tourn. de Chirurg. de Malgaigne et Ann. d'Oc, XIII, p. 132. 550. Arlt, Zur Nosogenic der catar. caps. cent, anterior und der catar. pyramidalis. Oesterr. Med. Wochenschr., No. 10 u. 11. 551. Furnari, De la pretendue inflxience des climats sur la production de cataraete et de I'iunocuite de la reverberation directe et de la lumiere sur les uiilieux refringents de Toeil. Ann. d'Oc. XIII. p. 158. 552. Christiaen, De I'extraction simultanee du cristallin et de sa capsule. Ibid., p. 181. 553. Guthrie. On cataract and its appropriate treatment by the operation adapted for each peculiar case. London. 5.54. Sichel, Considerations praticiues sur I'extraction des corps etrangers inipl.'intes dans le cristallin. Ann. d'Oc, XIII, p. 193. 555. . Etudes diniques sur I'operation de la cataraete. Gaz. des Hopitaux et Ann. d'Oc, XIV, p]>. 75. Ill, 155. 5.50. Boux, Generalities snr les deux procedes (r<)i)eration de la cataraete. Ibid., XIV, p. 177. 557. Serre (de Monlpellieri. Oi>eration de la cataraete selon la methode par deplacement. faite avec succes apres soixante ans de cecite. Ann. d'Oc, XIV, p. 224. 558. Dubois (de Neufchatel). Operation de la catarai'te datant de 44 ans. suivie de retablissenient de la vue. (iaz. Med. et Ann. d'Oc, XIV, p. 229. k 441 1845. 559. Gerold. Ueber cataracta uatatllis uud lui. Moifiasiii. /eitschr. des Vereins fur Heilkunde in Preussen, No. 25. 560. Coopor, Remarques siir Textraction de la oataracte. Pro v. Journ, .Tuin. 5(il. Hervez de Chegoin, De I'operatioii de l:i eataracte par <'levation. Ann. d'Oc, XIII. p. 37. 562. Pamard, Memoires de ehirurgie pratique, compr. la eataracte, I'iritis et les fractures du col de femur. Paris. Ann. d'Oc, XIII. p. 83. (Fortsetzung.) 563. Duval, Quelques reflexions sur les premieres impressions d"un aveugle ne rendu clairvoyant: suivies de considerations soramaires sur la maniere d'operer les cataractes de naissance de differentes . ages. Ann. d'Oc, XIII, pp. 07 and 241. 564. Heyfelder, De I'influence de la commotion sur I'oeil. Ann. d'Oc, XIII, p. 145. 565. Vinella, Ossification de la capsule du cristalliu. Ann. d'Oc, XIII, p. 279. 566. Vogel, Examen niicroscopi8M. FronmuUer. AViedtM-erzouKUHJ? lUn- Krystnlliiisi'. Ibid., VI, H. 2. r>81. Bartes, D(» la eataracte. Ia\ Clinique de Montpellier. Fevr. et Aout. riS2. Soidl mid Kanka. Bericlit uber die AViener Augenklinik und die ruit ilir verbiindeue Abtheilunj;: des AII.2;. Krankenhouses. Oestr. Jahrb., 1840. 583. France, J., Cas dossiticalion el de deplacenieut de la leutille cristal- line. Gaz. Med. de Paris, No. 4. 184G, et Ann. d'Oc, XV, p. 38. 584. Miguel, Cristallin passe dans la cli.-uubre anterieure depuis un an. Emploi de la pomade df (Jondret. Resorption. Bulletin Gener. et Therapeutique. Ann. d'Oc. XIV. p.>125. 585. Sichel, De quelques accidents consecutifs a 'extraction de la eata- racte et en particulier de la fonte puruleute de la cornee et du globe oculaire: des moyens de prevenir ces accideilts. Bull. Gener. de Therap. Ann. d'Oc. XV, p. 128, ISO-; X-X, p. 112. 586. Guerneiro, Compte rendu de la clin. opthal. de M. Ansiaux, pour I'annee, 1845. Ann. d'Oc, XIV, p. 145. 587. Gerster. Reascension d'une eataracte depriniee. Medic. Corresp. B. 1. Bayrischer Aerzte. Ann. d'Oc, XVI. p. 91. 588. Sichel, Double extraction de eataracte. suivie de non succes complet; phthisic de I'oeil droit et atrophic connuencente de I'oeil avec obliteration de la pupille. Iridodialysis pratique a trois reprises, chaque fois avec succes immediate sous le i-apport de la ma- noeuvre, non-retablissement de la vision. Atrophic complete de I'oeil un a deux and apres roporation. Ann. d'Oc, XA'I, p. 388. 1847. 581). Strieker. Staar oder Starr. A'. Walther's u. v. Amnion's Journ., t. A'l. 590. Guepin (de Nantes). Notes sur les resultats comparatifs de I'abalsse- ment et de I'extraction dans I'operation de la eataracte. Ann. d'Oc, XVII, p. 39. 591. Laugier. Nouvelle methode d'operer de la c.-itaracte on methode par aspiration. Ibid., p. 29. 592. Armati. De I'operation de hi eataracte par aspiration. Revendication de priorite en faveur de M. le prof. Pecchioni de Sienne. Ibid., p. 79. 593. Cunier. Nore pour servir ;i I'liistoric de la succion de la eataracte. Ibid., p. 85. 594. Sichel. Recherches histoi'i(iucs sur ri.pt'nilioii par succion ou aspi ration. Ibid., p. 104. 595. Magne, Note sur un couteau-aiguille. uouvfl instninicnt pour I'oper- ati(m de la eataracte. Ibid., p. 111. 59(i. Behn et Auimon. Zur path, anatomie des piol.ipsus leutis traum. und hydroiis tunic-ie Jaeobi. \. AValtlier's u. v. .Viiiiuoirs .lourn.. A'll. H. 2. 597. Lagoguey. l>u IriiilciiuMil i\v cnlnnicles hiileiises par succion. Gaz. Med. d.' I'aris. .No. 47. 443 1847. r>OX. Pri(li:ii. Kuhrlcn. HeimTkuiifron iilx-r die (•.itanicla e la valeur. de roperation de la .-ataraote par aspiration. Ann. d"()e.. XVIII, p. 38. 604. Blancliet. Operation de la cataracte par su(. Ann. d'Oc, XVIII, p. 127. 607. Heylen. Xouvelles observations tendant a prouver retticacite de la salivation niercnrielle. corume moyen de prevenir rinflanimation consecutive a I'oix'ration de la cataracte. Ann. d'Oc. XVIII, p. 244. 608. :Magne. Cataracte capsulaire ossifiee. passee dans la chainbre ante- rieure: extraction. Ann. d'Oc, XVIII. p. 271. 609. Velpeau, Emploi de la belladonne apres lOperation de la cataracte. Ann. d'Oc, XVIII, p. 270. 610. Brett, On cataract, artificial pupil and strabismus. London. 611. Malfatti. Xeue Heilversuche. I. Gelungene Vertilgung des grauen Staars duicli eine aussere Ileilmethode. Wien. 1848. 612. Ran. T'el»er die Beliundlung des .irrauen Staars durcli Pliarm. Mittel. V. Waltlier's n. \'. Amnion's .Tonrn.. 1. VIII. H. 3. 613. Xeil, On tlie cure of cataract, witli a prjulical suniniary of tlie best modes of operating. Liverpool. 614. Rivaud-Landrau, De la kystotoniie posterieure. on decliirement de la cristalloide post, apres I'operation de la cataracte par extraction, conime moyen d'eviter la formation des cataractes (•a!)sulaires consecutives. Ann. d'Oc. XIX. p. 7A. 61.5. Marcus, Ueber die Naclibehandhui- b.M Staan.perationen. Casper's Wochenschrift. No. 49. 6ir,. Sichel. Des principes rationels et des limites de la curabilites des cataractes sans operation. Bullet, de Therap. et Ann. d'Oc, XX, p. 76. 444 1848. 617. Ceroid, Elementa pliotoinetri ad curam cataraetao seciind. adhibendi, etc. Madgeburg. G18. Malgaigne, Des divers espeees de cataracte. Ann. d'Oc, XXI. p. 234. Meliori, Cataracta centr. eapsul. als Bilduugsfeliler mit auffalender Klein- heit des Auges und aller seiner Theille. Oesterr. Med. Woch- enschr., No. 12. r>20. Nelatou, Displacement irauniatifjue du cristallln. Gaz. des Hop., No. 32. 621. Leuw, de. Versteineruug der Liuse nnd ilirer Kapsel. Zeitschi*. d. V. f. Heillv. in Preussen, No. 36. 622. Ran, W., Ueber die Behundlung des graueu Staars durch Pharm. Mittel V. Walther's n. v. Amnion's Journ., t. YIII, H. 3. 623. Guepin, Notes sur des operations de cataracte snivies de phenomenes remarquables. Ann. d'Oc, XIX, p. 116. 624. Tletzins, Du galvanisme comme moyeu du traitement de la cataracte. Ann. d'Oc, XIX. p. 123. 625. Langier, Nouvel essai de I'operation de la cataracte par aspiration on succion. Ann. d'Oc, XX, p. 28. 626. Boyer, Entrainement des parties anterieures du corps vitre, pendant I'operation de la cataracte par abaissement. Gaz. Med. de Paris; Ann. d'Oc, XX, p. 61. 627. Sichel, Des principes rationels et des limites de la curabilite des cata- ractes sons operation. Bullet, general de Therapeutique; Ann. d'Oc. XX, p. 76. 628. , De la .sortie du corps vitre pendant ou apres I'operation de la cataracte. Bull. Gen. de Therap.; Ann. d'Oc, XX, p. 182. 629. , Lettre a Mns. Malgaigne en refutation de quelques assertions emises dans I'artide qui precede. Ann. d'Oc. XX, p. 242. •1849. 630. Paiili, Aus der Praxis und am Schreibtisclie. Med. Corresp., Bl. Bayrischer Aerzte. No. 42. 631. Bowman. Lectures on the parts concerned in the operations on the eye, etc London, 1849. Auch in London Medical Gazette, 1847 u. 4S. und Ann. d'Oc, XXIX-XXXXII. 632. Buzzi. Aiguille pour la cataracte laiteuse. Bolletione delle Scienze Mediche, et Ann. d'Oc, XXI. p. 261. 633. Boyer, Lucien, Deux operations de cataracte executees par un nou- veau procede d'abaissement (re))ulsion anguleuse du cristallln). Ann. d'Oc, XXII. p. 21. 634. Langenbeck, Max. Klinische Beitrage aus dem Gebiete der Chirurgie und Opthalmologie. Gottiugen. 635. WerdmuUer. Einige kurze Bemerkungon \iber die Natur. und Entste- hungsweise des acijuirirten graueu Staars. Sclnveiz. Centr. Zeit- schrift. Y. 1, u. Ann. d'Oc, XXX, 103. 636. Pricliard. Man«|U(" cdngenital du cristJiUin. Prov. Journ.. No. 8. 445 1849. 637. Bayard, Do la luaturite dcs cMtaiaetes et des cataractos sot-ondaires. Gaz. des Hop., .\(». ST el ll,"). 638. Ilasner. d'Arth.-i CoUodium a!s VcilyMiKliuiiicl ii.hIi <1. Trincliint'tti. Olisci-v.-itioiis siii- Ics premieres iiiipi-essioiis visuelles percues par deux aveuglos do naissanfo, apros roi^eration de la eataracte. Gionialo del Instituto Lombardo, 1847. Ann. d'Oc, XXI, p. 259. 640. Duval, Coup d'oeil sur la iiiemoii-o inibliee par Liiclou Boyor sous titre: De I'entrainenient des parties anterieures du corps vitre, pendant I'operation do la oataracte par abaissement. Ann. d'Oc, XXII, p. 75. 641. Boj-er, I^ttre eu response aux obsorvations criticiuos qui prooedent. Ibid., p. 82. 642. Sauveux-, Statistique d»'S sourds-muets et des aveuglos de la Bel- gique. Ann. d'Oc., XXII, p. 86. 643. Tavignot. De I'hydropsia de la capsule du cristallin. Ann. d'Oc, XXII, p. 07. 1850. 644. Nelatou, I'arallelle des divers uiodos operatoiros dans lo traitement de la eataracte. These de Coucours. 7. Fevr. Paris u. Onn. d'Oc, XXIV. p. 127. 645. I'ilz. Zur I'.ithologie des Krystallius(>nsystenis des mouschllchen Angos nebst praktischen Benierkungeu nbor Staaroperation. Prag. :Med. Viertol.iahrschrift. Jahrg., VII. 646. Brodliurst, On the cristalline lens and cataract. I.ondou. 647. Cornaz, E.. Quelques observations d'abnormites congeniales des yeux. Ann. d'Oc, XXIII, p. 47. (Mikropthalmus mit Cataract.) 648. FronmuUer, Beobachtungen aus dem Gebiete der Augenheilkunde. Furth. 649. Rivaud-I.andrau. Cataiaete eapsulo-leiitieiilairo prodiiite par la foudre un mod. 650. Gossolin, Deplacenient sul)it des capsules deniourees dans champ de la vision lors de I'abaissement de cataractes. Arch. Gen. de Med. .luiu. u. Ann. d'Oc, XXXV, p. 192. 651. Desniarres, Operation de la eataracte et de la pupille articielle dans un cas de micropthalmos double. Gaz. des Hop., No. 4, u. Ann. d'Oc, XXIII, p. 18. 652. Dyei*. Sam., Cataracte hereditaire. Prov. .Touru.. No. 4. 653. Walton. Cataracte capsulaire. Medical Times, January. 654. Buhrig, tleber die operation der cataracta. Deutsche Klinik. No. 38. 655. Dieterich, v.. Operation der mit dem ganzen umfange der iris ver- wachsenen cataracta durch centrale Durchbohrung. Med. Zeitung Russland's, No. 20. 650. Wilde. Ciseaux pour eulever la crislalloide opaiiue et des fausses membranes. Med. Times, Dec 446 1S50. 0.">7. Hivaud-Laiulrau. Cat. capsnlo-lcnticiilaiic iinxliiito par la foudre. Ann. iVOc. XXXV. p. ISS. 658. Junjrkeu. Ueber Staaroperationcii. Dciitsclif Klinik. No. S. 1850, u. Ann. d-Oc, XXXV. p. ISO. 659. Beauclair. Recherches et cxperioiK-eis sur la eataraete uoire et sur son diagnostic. Ann. d'Oc, XXIII, p. 130. 660. Petrequin. Recherche sur la eataraete noir et sur son diagnostic differentiel. Ann. d"Oc.. XXIII. p. 172. 661. Algnie. Tentative de guerison de la eataraete sans operation. Revue Therapeut. du Midi. u. Ann. d'Oc. XXIII. p. 177. 662. Prichard, Absence eongenitale du cristallin. Ann. dOc. XXIII. p. 74. 663. Rivaud-Landrau, De la luxation et du deplacement du cristallin par une cause traumatique. Ann. d'Oc. XXIV, p. 74. 664. Barrier, (iuelques faits intercessants de clinique opthalniologique (Linsenluxation). Ann. d'Oc, XXIV, p. 83. 1851. 665. FoUin. Examen d'un oeil opere de la eataraete par extraction, quiuze ans avant leniort du nialade. Ann. d'Oc. XXV. p. 14."">1. 666. Hassner, d'A.. Ueber aetiologie der cataract. Prager Vierteljahr- schrift, Jahrg. VIII. (-,67. , T'eber das anatoiiiische verlialtniss der linsenkapsel zum glas- korper. Deutsche Klinik.. No. 12. 668. Gerhard. Peut-on preveuir la foi-mation d'une eataraete secondaire dans Toperation par scleroticonyxie? Ann. d'Oc. XXV. p. 1851. 669. Coursserant. De la pre-eminence de I'extraction sur I'abaissement de la eataraete. Avantage de la keratotomie snperieure. Ibid. XXVI. p. 160. 670. Ammon. v.. Optlialm. Skizzen. Verdunkelung ues Orbiculus capsulo- ciliails: seine Bedeutung fur die cataractologie. Deutsche Klinik, No. 4o; Ann, d'Oc. XXVII. p. 26. 1852. 671. Lebert, Anatomic pathologi(iue et curabilite de la eataraete. Un. Med. et Ann. d'Oc, XVI. p. 102. 672. Gihon. H.. On the cataract. The Philadelphia Lancet. No. 1. .January. 673. Balfour. C. W.. De la luxation spontanee du cristallin. Med. Times. March. 674. Jaeger. K.. Neuer Optlialmostat. Wien. Zeitschr.. No. 6. 675. Jacob. De la cat^u-acte. Dubl. Med. Press.. Juill et Aout. 676. Rivaud-Landrau. Cataracte pierreuse luxee dans la chambre ante- rieure. Gaz. des Hop.. No. 118. 677. White. Cooper. Cataract operation an ciiiein Haren. Med. Times. 1850, u. Ann. d'Oc. XXV. p. 86. 678. TJllmann, Aeusserst spat eingetretene Autsaugung der Theille einer durcli Staaroperation zerstuckelten linse. ^led. Zeitschr., I. 44. 679. Ansiarix. Cliniciue du dispeusain* opthalmique de Liege, pendant I'anuee. 1850. Cataractes. cat. capsulaire secondaire— emploi de la serre-tele de Desmarres; eat. congenitaes; cat. traumatique; cristallin pierreux. Ann. d'Oc. XXV. j). 63. 447 1851. 080. I>!U-n'.v. Lux.ilion du ciishiHin (l.-in.-inv tniiispMn'iit. Ami. dOc. XX Y. p. ITC. 681. Robert. Lesions tnuiiiKit i(|m's .lu cristMlliii ft dc sm cjipsulc. Ann. d'Oc. XXV. p. 1!)4. (582. Xelaton. Extr:uti(>n df la caliiiaclc i.ar la keiatctciiu.- superieure. Gaz. des Hop., u. Ann. d'Oc. XX\'. p. 1!our rc.vtraction sch'roticalc des cata- ractcs capsidairt's (>t dcs fausscs nicinbrancs. Ann. d'Oo., XXV. p. 142. 685. Fnrnari, Nouvelle invention d'nu instrument pour I'operation do la cataracte et la pupille artitielelle. Ibid, p. 144. 686. Stellwag, von Carion. Statistisc-he Beitrage zur Lelire vom Staar u. s. w. Zeitschr. d. Wiener. April. Mai, .luni. 687. Blot. Anat. pathol. de la cataracte noire. (Jaz. Med. Padis. No. 2r,. u. Ann. d'Oc., XXXV, p. 188. 688. Davaine. Exanien microscop. de deux cataractes lenticulaires. Gaz. Med. Paris, No. 49, u. Ann. d'Oc, XXXV, p. 188. 689. Aminon. v., Zur genesis der catar. centr. pyramid, naeh st^otions re- sultaten. Deutsche Klinik. No. 9. 690. Laugier. Nouvelle Aiguille a lance mobile pour I'abaissement de la cataracte. Keratotome cache termine par une lance mobile ar- ticulee pour Textraction . Kirk. Depots osseux dans la nieiubrane vit reuse et le cristallin. Montli. Journ., Novembei-. 72G. AValtou. Haynes. Diagnostic des cataractes commencantes chez les persounes agees. Med. Times and Gaz., October. 727. Gros, Du cristallin et de sa capsule. Ann. d'Oc, XXIX. p. 22. 728. Chassaignac, Catar. corticalis. Extraction, AnAvendung der Kalte u. des Eises. schnelle Heilung. Gaz. des Hop., 109. 729. Canton, Ossification du cristallin et de la capsule. Lancet u. Ann. d'Oc, XXIX, p. 51. 730. FoUin, Untersucliung der retina uud der lirystallinse mittelst eines neuen optischen instrumentes. Rapport daruber von Chassaignac. Memoire de la Soeiete de Chirurgie, III, 4. 731. Jacob, A., De I'operatiou de la cataracte pratfque a I'aide d'un fine aiguille a coudre introduite a travers la cornee. Ann. d'Oc. XXIX. p. 172. 732. Laugier, Nadel zur suction der cataract. LTnion, 110, u. Ann. d'Oc. XXXIV, p. 36. 73.3. FoUiu. Luxation sous-conjonctivale du cristallin. Arcli. Gener. de Medicine, p. 210; Ann. d'Oc. XXXIV. p. 39. 734. Trexler, Reascensiou de cataractes operees a I'aiguille. Ann. d'Oc, XXX, p. 100. 735. Guepin. Connai.sons nous bien les fonctions du cristallin? Ann. d'Oc, XXIX, p. 147. 736. Trettenbacher, Statistique de I'hospital optlialmique de Moscou, 1850-53. Ann. d' Oc, XXX, p. 129. 737. Quadri, Intorno all' ernia iride consecutiva all' estrazione anteriore del cristallino. 738. Bosch. De I'opacite de la capsule cristalline. Ann. d'Oc. XXX, p. 225. 739. Alessie. Opthalmostat du Prof. Jaeger modifie. Ann. d'Oc. XXX, p. 229. Nouveau kystitome. Ibid. p. 230. 450 1853. T-K). H.Tvicz. Uvww (.ptlialniolojiicinc du s.Tvicf de ,M. I'.-ticinin. Cata- racte, cataracte noire. Ann. d'Oc, XXX. p. 24;». 741. Burdach. Ueber die Verfettuns vou proteinlialtiji-eu snbstanzen in der peritonealhohle lebendtT Thiore. Aircli. Aixh.. YI, p. 103. (Dorthin f-ebrachte linsen-verfettetcn.i 742. White, Cooper. Du changemeut de la vue comme signe precurseur de cataractes dures. Associat. Medical .Tourual. November. 1853. 743. Kletzinsky, Vergleicbung der /usanmieusetzung der krystallinse unci getrockneter eataracten. Zeller's Anli. f. riiysiol. u. Tathol. Chemie, isr>3. p. '27>i;. 1854. 744. Bo\A-man. Leeous .sur les ])arties iiiteicssces dans Ics operations pu'on pratique sur I'oeil. Aim. d'Oc. XXXI. p. 7. 745. I>ohmeyer, Beitrage zur Histologie nnd Aetiulogle der erworbenen I.insenstaare. Zeitschr. f. Rat. Med.. Y. II.. 1 u. 2. 740. Bonders, Entzundliche cataract. XNederl. Lancet, No. t>. 747. Broca, Memoire sur la cataracte capsulaire, etc. Arch. d'Optb. de Jamain, H., p. 18-i. 748. Graefe. A. v., Ueber Staaroperationen. Deutsclie Kliiiik.. Nos. 1, 2, 4 u. 6; Arch. f. Opthal., Bd. I, 1, p. 323-325. 74Sa. , Cataract niit doppelteni biconvexem linsenkern. A. f. O., I, 1, p. 323. 74Sb. .Extraction einer liCi .Jahrc reifen cataract. Ibidem, p. 326. 74Sc. , Cataract aus phosphorsauer kalkerde bestehend. Ilndem. p. 330. 74,Sd. . Falle von cataracta nigra, mikroscopische untersuehung einer solchen. Ibidem, p. 333. 74Se. , Zwei falle von linsenluxationen. Ibidem, p. 3.''. la facilite d<' roxtr.i.tioii dr la cataractf dans certains (•as de pupillo artitieielle. Lancot. 25 Juin, et Gaz. des Hop., No.115. SOS. Desmari-es et Kobin. Ch.. Stnieture de la cataracte ponotuee. Gaz. des Hop., No. 64. 800. Desniarres. Extracti(»n liiieairc dune eataraete traumaticiue chez nn enfant. Guerison en 24 lieures. Ibid, No. 70. 810. Salomon. Vose, Extraction des cataractes traumatiques recentes comme moyen de diagnostic. Assoc. Journ., Avril. 811. — r-, D'un signe caracteristique des cataractes dures. Ibid. Juln. 812. Stellwag. v. Carion. Ein fall von ectopia der normwidrig kleinen krystallinse. Wien. Wochenbl., No. 49 et 50. 813. Pernzzi, Cataracte capsnlaire gnerie par un traitemeut inercuriel. Raccogl. di Fano u. Ann. d'Oc, XLIII, p. 53. 814. Tavigot, Nouvelle methode operation de la cataracte par debride- ment. Academic des Sciences. 19 Mai, 1856. 1857. 815. Prichard, Anatomic, physiologic et maladies de la membrane pupil- laire. Etiologie de la cataracte capsulaire r-entrale. Iraduit de I'anglais par M. Doumic. Union Med., No. 126 et 128. 816. MuUer, H.. Ueber die anatomischen verlialtnisse des kapsolstaare. Arch. f. Opth.. Bd. Ill, A. 1. p. 55. 817. . Ueber den Sitz des Kapselstaars und Mittheilung neuer Falle. Yerhandl. d. Phys. Med. Gesellsch. zu Wiirzb., t. VIII. 818. . Untersuchiingen uber die Glashaute des Auges, insbesondere die Glaslamelle der Choroidea und ihre senilen veranderungen. A. f. O., II, 2, p. 1 und loco, p. 2.31. 818a. Forster. Zur pathologischen anatomic der cataract. A. f. O., Ill, 2. p. 187. 819. .Tordan. F.. Fiirneaux. Rapports de la cataracte avec les maladies du coeur. Brit. Rev., Avril. 819a. Graefe, Ueber verkleinerung des linsensystems mit erlialtung der transparenz. A. f. O.. Ill, 2, p. 576. 819b. . Notiz liber entstelning des schichtstaars an dislocirten linsen. Ibidem, p. 372. 819c. . Beobachtung einer partiellen dislocation der linse unter die con.innctiva durch ein trauma. Ibidem, p. 365. 820. Nelaton. Cataracte double (tremulante). Un. Med., No. 78. 821. Taylor. R.. De la catai-acte suivi de remarques sur ranatomie et la physiologic du cristallin. Med. Times and Gaz. Mai. 822. Williams. De la cataracte zonulaire. Americ. Med. Chir. Rev. Sept. 823. Castorani. De I'etiologie de la cataracte. Gaz. des Hop., No, 82 et Gaz. Ilebdom.. No. .36. 454 1857. 824. Desmnrn's. Operation dcs cataractt's capsulo-leiiticulaires adher- entes. Gaz. ties Hop., No. 106. 825. Valez. l)es eataractes artificielles. .Touru. tie Brux., Juin. 826. Kuntie, Ueber kunstliche cataract. Zeitsclirift fur Wissenscli. Zoolo- gie, YIII, p. 466. 827. Streitfeiltl, Statistics of cataract. K. I>. O. II. Optlialm. Hosp. Rep. I. 828. BatJer. Ibiti, p. 43, 142. 829. Dixon, Abnormal position of tlie crystalline lens occurring In four members of the same family. Opth. Hosp. Rep., I. 830. Streatfeild, Six cases of cataract in one family. O. H. R. I., p. 104. 831. Martin, On the operations for cataract among the natives of India. O. H. R. I., p. 161. 832. Hulke, Observations on the growth of the crystalline lens, and on the formation of capsular opacities. O. H. R. I., p. 182. 833. Valenciennes et Fremy, Recherches sur la nature du eristallin dans la serie animale. Bull, de I'Acad. des Sciences. Juin, 1857. 1858. 834. Cooper, White. Des luxations du eristallin. Med. Times and Gaz., 2 Janv. 835. Sichel et Robin, De la cataracte noire. Gaz. Med. de Paris, No. 51. 836. Fenner. C. S., De la cataracte. Amer. Med. Chir. Rev. Janv. 836a. Graefe, Ueber die iridectomie bei spaterer verschiebung der krystal- linse. A. f. O., IV, 2, p. 211. 836b. , Ueber die mit diabetes mellitus vorkommenden sehstorungen. Ibidem, p. 230. 836c. , Verklebung der vordern linsenkapsel mit membrane desce- metii und bemerkungen uber gewisse formen von nachstaar. Ibidem, p. 241. 837. Koeberle, de la cataracte pyramidale. Gaz. de Strasb., No. 5, et Ann. d'Oc. XLIII, p. 192. 838. Mahieux, Luxation spontanee du eristallin, utilite de I'atropiue pour le reduire. Monit. des Hop., Avril, et Bullet, de Therap., Juin. 839. Salomon. Vose, Gas de eataractes unilaterales, influence de I'opera- tion sur la vision. Brit. Med. Journ., April 17. 840. Geissler, Zur lehre vom grauen staar. Schmidt's Jahrb., t. C, p. 249. 841. Kuhnhorn, De cataractae aquae inopia effecta. Gyrphiae. 1858. 842. Streatfeild, Cataract first affects the right eye or left eye. O. H. R. I. p. 214. 843. Salomon, Vose, The reclination of cataract with two needles. O. H. R., I, p. 218. 1859. 844. France, The cataract in association with diabetes. Opth. Hosp. Rep., I, p. 272. 845. , On the use of forceps in extraction of cataract. Ibid, II, p. 20. 846. Hulke, Rupture of the eyeball, with escape of the lens, etc. Ibid, I, p. 292. 455 1859. 847. Arlt, Ueber cataraeta. Spitalzeitung. No. 1. 848. Cafife, Traiteinent inodical de la cataracte. (iaz. des Hop., No. 8. 849. GiU'pin, Traitement medical de la cataracte. Bull, de Therap., Fevr. 850. Laurence, Z., Luxation traumatique du eristallln. Med. Times and Gaz., 5 Mars. 851. Rolirer, J. S., Cataracte eonticiiifalc; opcfMlloii; fi"»-'i'i«<>u- Amer. IMed. Chir. Rev., Jan. 852. Robin, Ch., De I'anatomie de diverses lorincs de cataracte. Bull. de I'Acad.. XXIV. ]). 84.S. u. Ann. d'Oc. XLIII. p. 10.';. 853. Weber, C. O.. Vorfall der linse und einhellung eines wimperhaares in der vordere augenkammer. Med. Centr. Zeit., No. 5. 854. Bonat'os-Lazermes, De la catarncte. .Tourn. de Toulouse. Juill. 855. Van Doninielen. (Juerison niedicale de la cataracte. Nederl. Tljdsch., .luin. 850. Hildige. J. H., lleinorrli.ijiie apres I'operation de la cataracte. Lan- cet, 12 Sept. 857. Jager, E., Fall von cataract. Wien Zeitsclir.. No. ol. 858. Bayard. Traitement de la cataracte par la galvanocaustique. Gaz. des Hop., No. 149. 859. Dechambre. De la cataracte diabetique. Gaz. Hebd., No. 51. 860. Desmarres, Curec avec cystotome pour I'extraction lineaire de la cataracte. Gaz. des Hop., No. 121. 861. Joseph. G.. Dislocation eines cataractoseu linsensystems in folge V' II einwirkun2' vo'' at •pln-eintraufehmg. Gunzb. Zeitsobr., No. 5 u. 6. 862. Waldhauer, Cataracta centralis. Rigaer Beitr. z. Heilk.. IV, p. 100. 863. Walton, Cataracte; position abnormale de I'iris et du eristallln. dla- bete, operation, succes. Med. Times and Gaz., 12 Nov. 864. Graefe, v., Ueber sehstorung be! diabetes. Deutsche Klinik. 1859, p. 104. 865.Caussade, Recherches pour servir a I'histoire pathologique de la cata- racte et de son traitement. These. Montpellier. 866. Lowenhardt, Procede pour I'extraction de la cataracte. Gaz. Hebd.. No. 7, u. Ann. d'Oc, XLIV. p. 53. 867. Chassaignac, Resorption de I'iris du eristallln. France Medicale u. Ann. d'Oc. XLIV, p. 5.".. 868. Zepernik. Meletemata de cataracta. Diss. Dorpat. 1860. 869. Gosselin, Repos absolu des paupieres et du globe de I'oeil apres I'operation de la cataracte. Gaz. des Hop., No. 165. 870. Weber, C. O.. Ueber den ban des glaskorpers und die pathologischen, namentlicb entzundlichen verwundungen desselben. Virchow's Arch., XIX, p. 367. 871. Leport. Guide pratique pour bien executer, bien reussir et mener a bonne fin I'operation de la cataracte par extraction superieure. Paris, u. Ann. d'Oc. XLIII, p. 200. 456 872. Viol. Ziu-kersc'halt (U's grauon staars bei diabetes. yWd. Centr. Zig., No. 51. 873.Wilson. Disloeatiou of the lens. Opth. Hosp.. No. Ill, p. 65. 874. Graefe, A. v., et Schweiger, Cataracta traumatica u. clironische cho- rioiditis durch eineu fromden korper iu der linse bedingt. Arch. f. Opth. Bd. VI, p. 134, und ectatische chorioditis mit scleralstaphylom, linseudislocation und excavation des sclmerven. Ibid, p. 150. 875. MuUer, H., Nachtrage zuni kapselstaar. Verhandl. d. Win-zb. Phys. Med. Gesellsch.. t. X. 876. Hesser, Faserschichteustaar. Zeitschr. d. Ges. d. Aerzte z. Wien, No. 23. 877. Mitchell, De la cataracte diabetique, experiences physiologiques. Gaz. Hebd., No. 48. 878. . On the production of cataract. Amer. Journ. of Med. Science. 879. Just, Eigenthumlicher kapselstaar, etc., und hinterer polarstaar. Oesterr. Zeitschr. f. Prakt. Heilk., No. 30. 880. Schuft, Die Ausloffelung des Staares. Ein neues verfahren. Berlin in 8o. u. Ann. d"Oc., XLIV, p. 151. 881. Sichel. Extraction de la cataracte. Gaz. des Hop.. No. 20 et 32. 882. Graefe. A. v.,Ueber die vorsuge eines von Dr. Schuft, erfundenen loffels bei der linearextraction. Arch. f. Opth., Bd. VI, A. 2, p. 155. 883. Mitchell. Cataract bildung durch injection von zuckerlosung ins subcutane zellgewebe. Oesterr. Zeitschr. fur Prakt. Heilk., No. 39. The Amer. Journ. of Med. Sciences, January, 1860. Gaz. Hebdom., No. 48; Ann. d'Oc, XLV, p. 79. 884. Richardson, Ueber kunstliche cataractbildung. Oesterr. Zeitschr. f. Prakt, Heilk., No. 45. 885. , Synthesis de la cataracte. Journ. de Physiol., Oct., p. 645. 886. Bouisson, Histoire d'un aliene aveugle qui, apres avoir subi I'opera- tion de la cataracte, a recouvre a la fois le vue et la raison. Mont- pellier Med., Nov.; Ann. d'Oc, XXXIV, p. 246. 887. Schartow, E.. Historia operationum ad cataractae lenticularis san- ationem spectantium. Gryphiae, 1800. Dissert. 888. Bader, Report on cases of cataract treated by "linea'r extraction," at R. L. O. H., from April, 1857, to May, 1860. O. H. R., II, p. 346. 889. Ammon, v., Acyclia, irideremia et hemiphakia congenita. Nova acta Acad. Caes. Leop. Carol., t. XXVII, u. Ann. d'Oc. XLIII, p. 282. 890. Coruuty, De la paracentese de I'oeil, 6, Phlegmon de I'oeil a la suite des operations de cataracte. Ann. d'Oc, XLIV, p. 92. 891. Oeil atteint de cataracte double, dite polaire, developpee dans la capsule anterieure, et de cataracte du centre de la lentille cristal- line, avec rayonnement sur la face posterieure du crystallin. Gaz. des Hop., p. 322, u. Ann. d'Oc, XLIV, p. 146. 892. Sichel. Du cephalostat, appareil servant a tixer la tete pendant les operations de cataracte qu'on pratique chez les enf;'.nts. Bull, de Ther.. LTX. p. 141. u. Anu. d'Oc. LIV. p. 149. 457 1860. 89:'.. Courss.'iant. Catjir.i(t.>; nouvciu phmimI." .r.-xtraclion. Soc. fie Med. Prat., 7 Juin, u. Ann. d'Oc. XXXIY. p. 240. 894. Leport, Fmn-che a deux branches pour la fixation dc I'ooil dans les operations qu'on pratitiuo sur cet orfiane. in "Guide pratique pour bien executer I'oper. de oat. par extraction." Paris et Rouen. Ann. d'Oc, XLIV, p. 247. 895. Quagliuo, Taixation spontanee du crislalliu. etc. (Jioru. d'Oiithalm. Ital. et Bull, de Therap., Avril. 89(;. Desmarres, Extraction voluiuinosor cataracten durcli den linear- schnitt. Allg. Wien. Med. Zeitg., No. 27. 897. Hogg, J., Luxation du cristallin dans la chambre anterioure par suite d'un eternument prolonge. extraction guerison Lancet. June. 898. Teisser, Luxation du cristallin dans la chambre anterieure a la suite d'une operation. Rev. de Therap. Med. Chir., No. 11. 899. Blanc, Questions cliniques relatives a la cataracte. (Jaz. Hebd., No. 30. 900. Kuchler, H., Die umlegung des grauen staars durch die sehnenhaut, ihre gefahren und die mittel denselben vorzubeugen. Deutsch. Klin., No. 31, 33. 901. Fano, Luxation sous-eonjonctivale du cristallin. Oaz. des Hop., No. 152. 902. Squere, W. J., De la cataracte et de son traitement chirurgical. Brit. Med. Journ., Sept. 15, 22. 903. Desiuarres, Fils, amblyopic avec signes do nyctalopie par agenesia incomplete du cristallin, observee chez trois freres. Mon. des Sc. Med., 1138, u. Ann. d'Oc, XLV, p. 196. 1861. 904. Critchett, Practical observations upon congenital cataract. Opth. Hosp. Rep., Ill, p. 137 and 183. 905. Pagenstecher, Die verlagerung der pupille durch iridodesis. Arch. f. Opth., t. VIII, A. 1, p. 192. 906. MuUer, E.. Rcitrag zur kehre der spontanea llnsenluxation. Ibid, p. 166. 907. Schweigger. Ueber entstehung des kapselstaars. Ibid, p. 227. 908. Heddaeus. Partieller schichtstaar. Ibid, p. 315. 909. Wilde. Congenital diseases and malformations of the dioptric media. Dubl. Quart. Journ.. No. 01. February. 910. Hulke. Cases of congenital cataract treated i)y iridodesis. Opth. Hosp. Rep., III. p. 339. 911. Poland, On the use of forceps in extraction of cataract; France's method. Opth. Hosp. Rep., Ill, p. 268. 912. Swain, Case of cataract and diabetes. Optli. Hosp. Rep., Ill, p. 331. 913. Ritter, Folger de reclination und discission. A. f. O.. VIII, 1, u. Ann. d'Oc, p. 323. 914. Lecorche. De la cataracte diabetique. Arch. Gener. de Med., Mai; Ann. d'Oc. XLVIII. p. 100. 458 1861. 915. .laser, E. v., Spontaue beiluus- von tnibungeu in (Ut niensfhlichen linse. Ot'sterr. Zeitschr. f. Prakt. Ileilk., No. 31 u. 32. 916. Tedesclii, Nonveau precede pour operer I'extraotion de la cataracte. Un. Med., Avril; Ann. d'Oc, XLV, p. 280. 917. Heymann, Spoutaue freibeweglichkeit der linse. Zeitsch. der Ge- sellsch. f. Natur. uud Heilkunde. Dresden, w. Ann. d'Oc, XLVIII, p. 189. 918. Fischer, De la luxation spontanee du cristallin. Arcb. Gen. de Med., Janv.. u. Ann. d'Oc, XLVI, p. 83. 919. Quadri, A., Note sur un cas de traitement de la cataracte sans oper- ation. Ann. d'Oc, XLIV, p. 202. 920. Fa no, Sur la sortie premature du niyeau du cristallin dans la cata- racta moUe operee par extraction. Gaz. des Hop., p. 391, u, Ann. d'Oc, XLVI, p. 220. 921. Rivaud-Landrau, Statistique d'operations de cataracte. Gaz. Med. de Lyon, p. 450. 922. Zehender, Die Icrankheiten des linsensystems. Handbuch der Augen- heilkunde. Erlangen. 923. Saemisch, Zur operation der cataract. Wurzb. Med. Zeitschr.. II, p. 272. 924. France, Observations de cataracte diabetique. Med. Times and Gaz., 9 Mars. 925. Cade, Am., Cataract congenitale double operee a Tage de 18 ans. Bullet, de Therap., Juin. 926. Demarquay, Keratotomie superieure, procede sous-coujonctival, keratotomie superieure et iridectomie. Gaz. des Hop., No. 53. 927. Peachy, H. D., Guerison spontanee d'une cataracte. Amer. Med. Chir.urg. Rev., Mars., p. 317. 928 Gouriet, Resorption lente ot progressive du cristallin; daltonisme; des diverses methodes de scleronyxis. Gaz. des Hop., No. 113, u. Ann. d'Oc. XLV, p. 166. 930. Giraud-Teulon, Des mouvements de concentration lateral de I'appa- reil cristallinien pour satisfaire a I'unite de la vision binoculaire, fant lors de I'intervontion des prisraes ou des lunettes que dans certains cas pathologiques. Ann. d'Oc, XLV, p. 113. 931. Slchel, Materiaux pour servir a I'etude anatamique de I'opthalmle periodique et de la cataracte de cheval. Ann. d'Oc. XLVI, p. 181. 9.32. Prault, Operation des grauen stanrs bei einem r2 jagrigen knaben. Allg. Wien. Med. Ztg., No. 37. 933. Serres, Operation modiee de la cataracte. Gaz. Hebd.,.No. 38. 1862. 934. Meyer, Ignaz, Die kriebel-kraukheit als ursaclie der staarbildung. Wien. Wochenschr., No. 47, 1861, u. Arch. f. Opth.. VIII, A. 2, p. 120. dSn. Sperino, Etudes cliniques sur I'evacuation repetee de Thumeur aqneuse, etc Turin, in 8o. 459 1862. U'\r>. Swain. Caso of cilanict and (liah.-tcs. (}\>\U. IIosp. ilvp.. No. 17, p. 331. 937. Graefe, A. v., Cystoido vt-rnaihun^' b.-i iridrctomie wej.'on glaucom. A. f. O., VIII, 2, p. 263. 938. Alessi. Cause de la cataracte cliez les paysu'-s des l)ords du Don. Ann. d'Oc, XLVII, p. 30. 93J>. Mooren, Die vermindorteu gefahren ciiifr llornhautvereitcrung bel der Staarextractiou. Berlin, in So. 940. Jamin, A., Du broiemont de la cataracte. Gaz. des Hop.. No. 18. 941. Smith, G., De I'abaissenu'nt de la cataracte aux Indes. Edinb. Med. Journ., p. 101. Fevr. 942. Walton, H., Operation pour la resorption de la cataracte dure. Lan- cet, 14 Avril. 943. . , De la discission de la cataracte. Brit. Med. Journ., 7 .Tuin. 944. Browne, Observation de cataracte. Dubl. Jouin. :Mai 945. , Cataracte congenitale. Ibid. November. 946. Stoeber, Cataracte dlabetique. extraction lineaire. Gaz. de Strasb., No. 5 et 6. 947. Chausit, A., Luxation sous-eonjonctivale du cristalUn. Gaz. des Hop., No. 101. 948. Gerardi, Ueber Staaroperatlom-ii auf deni I.ande. Wien. Med. Halle, No. 40. 949. Hart. E., Deux cas de cataracte et extraction par la section iferieure, etc. Lancet, 5, Avril, Oct. et Nov. 950. Tetzer, Max, Ueber cataracta. Allg. Wien. Med. Zeitg., No. 1-4. 951. Alessi, Kesultats des operations de cataracte et relation d'un cas d'extraction, dans lequol la pointe du keratome s'est brisee dans la cornee. 952. Rivaud-Landrau, Statistiquo d'operatious de cataractes (2317). Ann. d'Oc, XLVII, p. 65. 953. Alessi, Un aveugle-ne sourd-muet, gueri de la cecite congenitale. Ann. d'Oc, XLVII, p. 112. 954. Lanne, Pince-aiguille a cataracte. Gaz. des Hop., P'evr., u. Ann. d'Oc, XLVII, p. 109. 955. Coursserant, Incision de I'iris dans la keratotomie superieure. Gaz. des Hop., No. 132. 956. Desormeaux. Blessure du cristallin. Ibid. 957. Ilulme, Luxation du cristallin, avec transformation cataracteuse Chez neuf membres d'une famille. Lancet, 23 Dec. 958. Nelaton, Cataracte double, extraction lineaire. Gaz. des Hop., No.l45. 1863. 959. .Tacobson. Ein ncnies gefahrloses operations verfahrcn zur hellung des grauen Staars. Berlin, in 8o. 960. Boiling, A. Pope, A case of laminar cataract. Opth. Hosp. Rep., IV, p. 79. 46o 1863. 961. Boiiissou, D'lm t-as partirulier ile diabet«' avec cataracte double. Montpellier Med., Janv. 962. Wecker. Iridesis in einem falle von doppelter linsenluxation. Klin. Monatsbl., Maiz, xi. Gaz. des Hop., No. 22. Ann. d'Oc, XLIX, p. 159. 963. Knapp. Erfolgreiehe pupillenbilduug bei eiuer durcli einen Stoss dis- locirten linse. Ibid. Avril. 964. Graefe, A. v., Extraction bei maiastisflieui auge, uinscbriebene sup- puration. Ibid. Avril, Juin. 965. Hays, Remarks on cataract. Aiuer. Journ. of Med. Science. .Juillet. 966. Sichel, Sur une espece particuliere de delire senile, qui survient quelquefois apres I'extraction de la cataracte. Un. Med., Janv. 967. Borelli, Nouveau cas de delire nostalgique consecutif a Toperation de la cataracte. Giorno d'Opth. Ital. 968. Becker, F. S. v., Untersuchungen uber den bau der linse bei den Meuscbeu. und Wirbelthieren. Arch. f. Opth., IX, A. 2, p. 1. 968. Graefe, A. v., Ueber die zweckmassigkeit einer breiten discissions- nadel bei operation flussiger cataracten. Ibid, p. 43. 969a. ,Extraction fremder Korper, reclinirter linsen und entozoen aus dem glaskorperraum. Ibid, p. 79. 970. Knapp, Beiderseitige linearextractiou eines d'abetischen Staars. Ze- heuder Klin. Monats., 168, u. Ann. d'Oc, LI, p. 50. 971. Graefe, A. v., Ueber den druckverband bei augenkrankheiten. Ibid, p. ni. 972. Hildrige. Sur le traitemeut de la cataracte par Tevacuation frequente de I'humeur aqjieuse. Gaz. Med. de Paris, p. 507. 973. Quaglino, Sulla cura medica della cataratta et sugli effecti della paracentesi corneale repetuta, etc. Ann. Univ. di Med. Milano, 181. 974. Masen, Cataracte trauma tiqne. e tc. Bull, de la Societe Medic, de Gand. Mars. 975. INIauduy, De I'operation de la cataracte par extraction lineaire. These, de Paris. 976. Eberhardt, Memoire sur la cataracte lamellaire. Nantes, in 8o, p. 15, Gaz. des Hop., No. 64. 977. Froebelius. Cataractbildung durch vier geueratiouen einer familie hindurch. Petersb. Med. Zeitschr., No. 8 u. 9. 978. Hart, E., Gas d'extraction et de discission de cataracte. Lancet II, 13 Mars et 16 Avril. 979. Scliirmer. Uelier spontaue luxation durchsichtiger linsen. Greifs- walder Beitr., I, p. 77. 980. Lanne. Delire nerveux a la suite de l'(>i)erati(»n di' la cal.ir.u'te. Gaz. des Hop., No. 57. 981. Magne, Delire apres I'operation de la cataracte. Bull, de Therap., 30 Mai. 46 1 1863. 082. Lausier. Luxation du (rist:illiii diiiis l.i .liMiiilur .inlci-ieiiro. Gaz. (los Hop., No. ST. OSa. Carter. Rob, T^es nouvcnux |.i(m(mIcs (Icxtr.iclioii dc oatnracto. Med. Times and Gaz.. 24 Oct. 984. Beelver. O.. Function dor ciliarlortsatze. AVifUcr Med. .lalirbucher. 985. Laurence, Irri.aalions apres I'extraction de la cataracte. Brit. Med. Jouru. .luillel. 986. Saint-IIdepliont. 'ri'.-iilcniciit dc hi <-:it:ir;ici.' smiis (.iteration. Revue de Tlier.. No. Xo, 402. 987. Warlomont, Cas de mort ;i la suite d iiiie (.i.er;iti luxation de lins.' niit cataractbildung. Ibid, p. 164. 1039. Berlin, Zur statistik der Jacobson's cheu extractions-methode. Wur- temberg. Corresp., B. 1, No. 19. 1040. Critchett, On the removal of cataract by the scoop-method, or the method by ti-action. Opth. Hosp. Rep.. IV, p. 315. 1041. Bowman. On extraction of cataract by a traction instrument with iridectomy; with remarks of capsular obstructions and their treat- ment. Ibid, p. 332. 1042. Kruse, II., Ueber cataractbildung. Zeitschr., f. Rat. Medic, XXIV, p. 261. 1043. Salomon, A'ose. Annular synechia and cataract, etc. Opth. Rev., No. 5, p. 28. 1044. Graefe, A. v.. Remarks on traumatic cataract. Berl. Klin. Woch- enschr., u. Opth. Rev., No. 6, p. 37. Ann. d'Oc, LIV, p. 270. 1045. Kuchler, Ueber die form der staarmesser; uber nachbehamllung nacb der staaroporation. Deutsch. Klin., Nos. 39, 40 u. 43. 1046. Moon, Observations sur I'extraction linealre de cataracte molle, suivie d'un decoUement de la retine. Ann. d'Oc, LIII, p. 250. 1047. Taylor, Cinq cas de cataractes traites par "'extraction suivant la methode de Mooren. Ann. d'Oc, LIII, p. 2.58. 1048. Holmes, Observations de cataract pyramidal. Anier. Journ. of Opth., II, 14. 1049. Szolvalsky, Cristallin luxe sous la ron.jonclivc. Ann. d'Oc, LIV, p. 212. 1050. Wecker. Luxation du < rist.-illin et c.itaractes reconnues, malgre I'obliteration de la impille ii travers I'iris atroithie. Gaz. des Hop., 8, 29. Ann. d'Oc \.\\. ]>. 125. 1051. Lawson, F.. A case of dislocation of tiie lens into the anterior chamber; excessive pain two yea is after the in.iury and loss of sight; extraction of t lie lens foUowed by immediate posterior hemorrhage. Opth. IIosp. Rev.. IV, p. .379. 464 1865. 1052. Prie, Obscrva lions de oataracte. I*aris, iu 80, p. 11. 1053. Graefe, A. v.. T'elK-r nioililiciite lluoarextraotion. Arch. f. Opth., X, A. 3, p. 1. 1054. Ullersperger. Kleiue mittln'iluny fur die ^'oscliitlitc der operation des graiien staars. Ibid. XI. A. 2, p. 2tJ2. 1806. 1055. Adams, Math., The modern methods of dealing with cataract. Brit. Med. Journ., 13 Janv. 1056. Monte, Michele de. Note sul" inrtiuinnatione del cristallino e della sua eapsula, 11. Morgagni. I. 1057. Follin, Des diverses methodes operatoires de la f-ataracte. Arch. Gener. de Med., Fevr., p. 212. 1058. , Luxation congenitale du eristallin. Gaz. dez Hop., No. 20. 1055. Martin, E., De I'extraction de la calaracte duie au moyen de la eurette-erigne. Gaz. des Hop., No. 9. 1060. Paikrt. A.. liUxation u. fractur der linse in folge von verletzung. AUg. Milit. Arztl. Ztg., No. 4. 1061. Hart, E., Clinical lectures on cataract, with reference to improved methods of diagnosis and treatment. Lancet, 21 May. 1062. Hasner, d'A., Klinische vortrage uber augenheilkunde. 3, Abtb. Die krankheiten des linsensystems. Prag, in So, )>. 106. 1063. Lnca. Dom., De I'extraction de la cataracte capsulaire et capsulo- lenticulaire. II. Morgagni, No. 2 et 3. 1064. Bowman. Cases of malformed, misplaced and dislocated lenses, in some of which glaucomatous symptoms were developed. Opth. Hosp. Rev., y, p. 1. 1065. Samelson, A.. A case of pyramidal cataract, with microscopic ex- amination (by Prof. C. Schweiggei'l of the lens after extraction. Ibid, p. 48. 1066. Cowell. G., Two cases of traumatic cataract, possessing some inter- esting points of diagnosis. Ibid, p. 131. 1067. Meckeand, Extraction des cataracte moUes par succion. Brit. Med. Journ., 30 Juin. 1068. Testelin, Luxation sous-conjouctivale du eristallin. Gaz. des Hebd., No. 31. 1069. Arlt, Ueber v. Graefe's linearextraction der cataracte. Wien. ISIed. Wochenschr., No. 24. 1070. Samelson, A., v. Graefe's modilicirte linear extraction. Deutsch. Klin., No. 7. 1071. Kuchler, Ueber extraction des staars. Ibid, 37-39. 1072. Classen, I'eber staaroperatiou. Ibid, No. 43. 1073. Fano, De I'operation de la cataracte. Gaz. des Hop., No. 124. 1074. Sichel. Du mode operatoire qui convient le mieux aux cataractes (•.•il)suhiires centrales et capsul.-iires-lenticulaires centrales, etc. Bull, (le Therap., 15 Sept. 465 18G«;. 1075. Pafit'iislccluT, rclu-r (lit- cxtniclion d.s -r.-mcii suiiirs bei uneroff- notcr kapsel (lurch tlcu sclcnilschiiil t. Kliii. licohacht. aus der ausonluMlanstalt zu Wicsbadt-ii. Ill, p. 1. 1076. Iwanofl". Bcltras zur patliolouisdu'ii anatomic dcs hornhaut und liuseiu'pithcls. Pagcustcchci-. Kliii. Hcobaclil., Ill, p. 126. 1077. Matrion, G.. Des iudlcatious dc ropcialiou de la cataracte et du choix de la methodc opcratolrc. These, dc Paris, in 4o, p. 70. 1078. Vitrac, E.. Etude sur le traitcnicnt de la cataracte par discission. TlU'S«'. de I'aris. in 4o. p. .">:>. 1079. Arguillo. Marcello. De I'operation de la cataracte par ''extraction lineaire. These, de Paris, in 4o. p. 3»!. 1080. Keand. M.. Case of extraction of soft cataract in both eyes by suc- tion. Brit. Med. Journ., .30 ,Tuin. 1081. Hutchinsin, Cataracts in childhood fully developed in one eye. Operation on one eye at the age of fifteen. No sight obtained, owing to atrophic changes in optic nerve. Pupil of this eye very active. Opth. Hosp. Rep., V, p. 216. 1082. Nermann, Spontaneous rupture of film of cai)sule three months after extraction of lens. Opth. Hosp. Rep., V, p. 223. 1083. Hutchinson, Operations for solution of senile cataracts commenced at an early period, without allowing the cataract to ripen. Opth. Hosp. Rep.. V, p. 329. 1084. Walton. Haynes, Black cataract. Brit. Med. Journ.. 27 January. 1085. Bouyer, Cataracte trauniatique avec synechia posterieure. Gaz. des Hop., No. 118. 1086. Desmarres, A., Des applications de Tiridectomie au traitement de la cataracte. These, de Paris, in 4o, p. 95. 1087. Tillaux, Luxation sous-con jonctivale du cristallin. Gaz. des Hop., No. 127. 1088. Wells, Lectures on cataracts and the modern operations for its treatment. Med. Times et Gaz., 17 Oct., 10 Nov., S Dec. u. 22 Dec. 1089. Graefe, v., Nachtragliche bemerkungen uber die modificirte linear extraction. Arch. f. Opth., XH, A. 1. p. 150. 1090. , Cysticercus in der linse. Ibid. XII, A. 2, p. 191. 1091. Windsor and Little. Th., Cases of flap extraction of cataract under chloroform. Opth. Rev., No. 8, p. 305. 1093. Dyer, Fracture of the lens of one eye and of the anterior capsule of both eyes from death by violent hanging. Trans, of the Amer. Soc, Boston. Juin. 1094. Hirschmann, Luxatio lentis spontanea. Klin. Monatsbl., IV, p. 98. 1095. Borelli, Osservazione di doppia cataratta molle risanta i-apidamente coir estrazione lineare. Giorno d'Oft. Ital., IX, p. 180. 1867. 1096. Milliot, Memoire sur la regeneration du cristallin. Bull, de I'Acad. des Sciences. 28 Janv.. et Gaz. des Hop.. No. O. 1097. Knapp. Metastatische clioroiditis. A. f. ()., XIII. I 466 1867. 1098. Gouriet. Cas reuiarquable de luxation spoutauee du cristalliu et de sa capsule dans la chanibre anterieure. C4az. des Hop., No. 43. 1099. Monoyer. Une extraction de la cataracte dans un cas de luxation spontanee et d'opacitication du cristallin, etc. Gaz. Med. de Strasb.. No. 14. 1100. Paoli. Cesare, Del metodo operative pr<'feri»)ili in vari casi di cata- ratte. Firenze, in 8o. 1101. Simi, A., Supra uno scritto des c. s. Prof. Cesare Paoli intitulata sul methodo operatorio preferibile nel vari casi di cataratta. Lucca, in So, p. 9. 1102. Taviguot, Traitement df la cataracte par I'extraction directe. Nou- veau precede. Abeille Med.. No. 48. 1013. Walton. H., Extraction de la capsule opaque apres la perte du cris- tallin. Brit. Medv Journ., 2 Fevr. 1104. Stepban, Erfahrungen mit studieu ubcr die staaroperation. Er- langeu. in 8o, p. 62. 1105. Rydel u. Becker, Spontane aufhellung der catar. traumat.; cataract. caps, centr. anter. mit cat. nuclearis; zwei seltene staarformen. Voy. Ber. uber die Augenkliu. d. Wien. Univers. Vienne, In So. 1106. Macnamara, linear extraction of t be lens. Opth. Rev., No. 11, p.371. 1107. Windsor. Tb., A new, operation for cataract. Ibid. p. 251. 1108. Quaglino, On scleronyxis. Ibid. No. 12. p. 371. 1109. Little. Cases of flap extraction, etc. Ibid, p. 398. 1110. Williams, II. AV., Remarks on tbe use of suture to close tbe corneal ■wound after removal of cataract by flap extraction. Opth. Hosp. Rep., \I. p. 28. 1111. Businelli. Caduta del nucleo del cristallino nella camera anteriore sette anni dopo I'operatione di cataratta per abassamento. etc. Giorno d'Oftal. Ital.. X. p. 153. 1112. Liebeich. Du diagnostic de la cataracte et de I'appreciation des methodes operatoires applicables a ses differentes formes. Nou- veau Diction, de Med., VI; Ann. d'Oc. LVIII. p. 103. 1113. Pires, De I'operation de la cataracte par extraction lineaire sderot- icale. These, de Paris, in 8o, p. 86. 1114. Knapp. Bericht uber hundert staarextractionen nach der neucn v. Graefe'schen mcthode ausgcfulirt. An-h. f. Opth., XIII. A. 1, p. 85. 1115. Weber, A.. Die uormale linsenentbindung der modiflcirten linear extraction geAvidmet. Ibid, p. 540. 1116. Bergmann. Ueber entfernung des giauen staais mit der kapsei. Ibid. XIII. A. 2, p. 383. 1117. Graefe. v.. Noli/ uber die linsenentbindung bei der modificirtea linear extraction und vereinzelte bemerkungen uber das ver- fahreii. Il)id. p. .".49. 467 1867. ins. K.-iinpf, 'rrauiuati.scbe cataract*' mit fremdon korpcr in dcr liuse. Oestcir. Zoitschr. f. Pract. Ilcilk., No. 9. 1119. Kuchler, Ueber die qnerextraction des staars. Memorabllien, XII, 1. 1120. Magni, I>e la cataractc. son diagnostic et son traitement. Rlv. Clin., VI, 2. 1121. Wells. Soelbei-fi. Lt'ctun-s on cataract and the modern operation for its treatment. .Med. Times et Gaz., 23 et 30 March. 1122. Watson, Spenser, Cas de cataraete traumatique. Ibid, 11 Mai. 1123. Iloerinfr, F.. Die modifircte Graefe'sche linearextraction. Wurtem- bi'rg ]Med. Corresp., B. 1, No. 24. 1124. Leiidiger-Formentel, Cataraete donble chez un enfant de 4 ans, e tc. Union Med., No. 66. 1125. Meyer. Ed., Du noiiveau ,procede de M. de Graefe pour I'extraction de la cataraete. Ibid, No. 99, et 101. 112G. Terson, De la cataraete. Analyze critique et indications des anciens et nouveaux precedes operatoires. Toulouse, in 8o, p. 79. 1868. 1127. Ilasner, d'Artlia, Dir neue phase der staaroperation. Prag., in 8o, p. 15. 112S. Graefe, v.. Ueber v. Ilasner's kritik der linejirextraction. Klin. Monatsbl.. VI. p. 1. 1129. Ritter, Anatoniie du cristallin. Wecker, Traite des ^laladies des Yeux, 2 e d.. II, p. 1. 1130. Mauthner, liClirbuch der Opthalmologie. Wien. 1131. Schumann, Ueber den mechanismus der accommodation des menschlichen auges. Dresden. 1132. Coccius, Der mechanismus der accommodation des menschlichen Auges. Leipzig. 1133. Rothmund, Ueber c.-itaracten in verbindung mlfc einer eigenthum- lichen hautdegeneration. A. f. O., XIV, 1. p. 1.59. 1134. Knapp, Bericht uber ein Ilundert staaroperation, etc. Ibid, p. 285. 1135. Foucher. Lecons sur la cataraete, in 8o, p. 287. 1136. Kuchler. Die qnerextraction des grauen staars der erwachsenen. Erlangen, in 8o. p. .•>7. 1137. Wolfe, J. R., On imiirnvcd metliods of extraction of the cataract. I>ancet, 11 April. 11.38. Weclcer, Des nouveaux iJi-ocedes operatoires de la cataraete; para- lete et criti(iue. Ann. d'Oc, LIX. Mars et Avril. Paris, in 8o, p. 49. 11.39. Gnu'fe. A. v.. Uel)er das verfahren des peripheren linearschnittes. A. f. ().. XIA'. .'!. p. 10(i. ISCS. 1140. Ileymann. Velnn- liuearextra. 2S'_'. 469 1869. IKm. KiiMpi). St:iiin>iK'r:ili()iH'ii ii.-n-h dcr iH-riplH-i-liiif.-ircn oxi motion. A. f. A., u. O., I, 1, V. 44. HOG. Noyt's. Linseuluxatlon in dm jil;isl<(iiiitr luid daiauf in die vordere Kammer. Ibid, p. ir.4. 1167. Reuss u. Woinow. I'i'Iht corneal-astifrinatisnnis nacli staaropera- tionen. Wien.. Braunuillcr. 1168. Williams, Ueber staarcxtraction. A. f. A. u. ()., I. 1, p. 91. 1169. Stophan. Weitere erfahruugeu und Studien der Jahre, 1867-69. 1170. Wolfo. Tebor cataractoxtraction. Olasfiow Med. Jonrn.. S. II, 1, p. 82. 1171. Monte. Micliele del., Feber operation s liartcn staars durch ex- traction. Morgagni, XI, p. 824. 1172. Noyes, Cataraetmesser. Transact, of tlie Anier. Optb. Soc, p. 51. 1173. Oglesby, Entfernung der ganzen iris bei einer staaroperation. O. II. R.. YI, p. 269. 1174. Williams. Remarks on the use of the suture to close the corneal wound after removal of the cataract by flap extraction. O. H. R., VI, p. 28. 1174a. Hutchinson, Clinical notes on pyramidaj cataracts, with specula- tions as to their cause. O. H. R., VI, p. 136. 1870. 1175. Perrin, P\alle von cataract bei diabetikern. Gaz. des Hop., p. 63 u. 70. 1176. Walton, Haynes. Vorlesungen uber cataract. Med. Times e t Gaz., p. 15 u. 26. 1177.Charteris. Falle von staaroperationen. (ilasgow Med. Journ., II, 3, p. 481. 1178. Coppee, Doppelseitige cataract operirt mittelst der modificirten lin- earextraction. Presse Medic, XXII, 14. 1179. Giraud-Teulon. Ueber staaroperationen. Gaz. des Hop., p. 159. 1180. Graefe, A. v.. Feber den peripheren linearschnitt. Klin. Monatsbl., VIII, p. 1. 1181. Mourton, Ueber luxation der linse unter die conjunctiva. Recueil de Mem. de Med. Milit.. 3 Serie, XXIV, p. 414. 1182. Zereissung des augapfels; verlust der linse und iris; erhaltung des sehvermogens. Rrit. :Med. .Tourn., p. 40. 1183. Stilling. Aphorismus uber den erfolg der neueren staaroperations methoden. Klin. Monatsbl.. VIII, p. 97. 1184. Taylor. Ueber staaroperation. Lancet, .\pril. Brit. Med. .Tournal, March. 1185. Wilson, Henry. Ueber extracliou des staars dunh (Jraefe's peri- pliercn linearsclmitt. Dubl. .Tourn.. XLIX. May. 1180. Coccius. und Wilhelmi. Die Heilaustalt fur arnie augeukranke zu liCipzig 7AU- /.('it ihres ."(• jnlii'iucn besiehens. 1187. Blodig. Karl. Feber die dislocation der linse. Wien. .Med. Presse, XI. 44. 470 1870. 1188. Thiry, Ueber die modificirte lint'nr.'xtration dos staars. Presse Med., XXII, 4. 1189. Delagarde. Philip Cliilwfll. lU'lun- cataractextraetioneu. St. Bartli. Hosp. Rep., \I, p. 5<'. 1190. Forster, Ueber den peripheren liuearsclinitt bei staaroperation. 27. .Tahresbericht der schles. Gesellscli. fnr Yaterl. Cultur., p. 220. 1191. Ritter, Fall von acuter oataractbildnnfr. Klin. Monatsbl.,VIII, p. 256. 1192. Stellwag. von Carion, Lohrbnch der prakt. Augenheilkunde. 4. Aufl. 1871. 1193. Knapp. Ueber staarextraetion. Transactions of the American Opthalmological Society. Seventh Annual Meeting. July, 1870. 1194. Hasner, Ueber die staarextraetion. Prag. Yierteljahrschr. C. X, p. 73. 1195. Knapp, Ueber knoclienbildung im auge. A. f. A., u. O.. II, p. 133. 1196. Lindner, Luxation de linse zwischen sclera und bindehautsack. Oesterr. Zeitschr. f. Prakt. Heilk.. XXIV, 2. 1197. Aub. Beitrage yaw kenntniss der vorletzungen des auges und seiner umgebungen. A. f. A. u. O., II, 1, p. 2.">2. 1198. Berthold, Cataracta congenita capsularis posterior. A. f. O., XVII. 1, p. 169. 1199. Canstatt, v., Zur operativen heilung des grauen staars, nebst Nach- schrift von Zehender. Klin. Monatsbl.. IX. p. 1.31. 1200. Galezowski. Ueber ein neues verfahren zur cataractextraction. Gaz. des Hop., 36. 1201. Naquard, Etude sur les luxations du cristallin. These, de Paris. 1202. Iwanoff. Glaskorper. Strieker's Gewebelehre. p. 1071. 1203. Ba1)ucliin. Linse. Ibid. p. 1030. 1204. Gussenbauer. Ueber die heilung per ])rimain intentionem. Arch. f. Chirurgie, XII, p. 791. 1204a. Guberboch,Studien ubei- die feineren vorgange bei der wundheil- ung per primam intentionem an der cornea. O. Q. Jj. Hft., 4. 1204b. Westlioff. De operatic de senile cataract, Utrecht. " 1205. Schiess-(;emuseus. Angel)orener linsendefect. Klin. M. 12t;. 47 X 1871. 1211. Perriii. V.M-fahii'ii /ur z.'isl.iniim dt-r kai.s.I l.ci .Icr cntarnotoptT- ation. Giiz. ties Hop., p. 54:'. 1212. Taylor, Ueber cataractoperation inittelst ciues sdmittcs an tier periplierie der iris ohno veiictzung dor pupille. Lancet, II, 19. 1213. Tweedy, Ueber eine sit-htbare streifuiig der normalen krystallinse. Lancet, II, 19. 1214. Critchett, G., Ueber behaiidluim der f-ataracte. Tresse Med.. XXIV, p. 60. 1872. 1215. Midler, Heinrich, Gesamelte uud hiuterlassene sehrifteu zur anato- mie und Physiologie des Auges. Bd. 1216. Berthold, I'eber verknocherung der krystallinse des nieuschliehen auges. A. f. ()., XVIII, p. 104. 1217. Salomon. Max. Dir kraukheiten des linsensysteras. Braunschweig. 1218. Loring, Eduard G., Astigniat. (ilas fur starrkranke, nebst bemerk- ungen uber die statistik des sehvei-mogens nach cataractopera- tionen. Transactions of the American Opth. Society. Eighth An- nual Meeting. .July. 1872. 1219. Liebreich, Eine neue methode der cataractextraction. Berlin. 1872. St. Thomas Hosp. Rep.', II. p. 259. 1220. Milliot. Benjamin. Ueber regeneration der krystallinse bei einigen saugetheiren. .Tourn. de I'Anatomie et de la Phys., VIII, 1, p. 1. 1221. Rothmund, A., Die neueren methoden der staaroperation, mitget- heilt von Berger. Bhitter fur Heilwissenschaft, III, 1 u. 2. 1222. Wolfe. J. P., Ueber traumat. cataracte und deren operation. Brit. Med. .Tourn., .Tan. u. March. 1223. Coates, Traumat. cataracte. Operation. Lancet. I. 23. 1224. Forster, Accommodationsvermogen bei aphakie. Ivlin. Monatsbl., X, p. 39. 1225. .Teaffreson, Schichtstaar. Iridectoniie. Brit. :Med. .Tourn.. p. 612. 1226. Panus, Ueber cataractoperation. Gaz. des Hop., p. 4,52. 1227. Taylor, Bribosia, Hansen. Discussion uber sl:iaroperatiou. Klin. Monatsbl.. X. Sept. 1228. Wolfe, Traumat. cataract. Ibidem. 1229. Cowell, George. Entzundung des uvealtractus bei vater und 3 Sohnen: anfaugliche affection des rechten auges bei alien, darauf folgende affection des linken auges bei 2: catai'actose linse in 4 augen; congenitale citaract bei der Mutter. Opth. Hosp. Rep.. VII, 3, p. 3.33. 1230. Harlan George C. Xucleai-cntaracte. Pliil.i. Med. Times. II, 4.'^.. 47. 1231. Jacobson, Widerlegung der neiiesten augritTe gegen v. Graefe's linearextraction. A. f. O., XVI II. 1. p. 297. 1232. Streatfeild, Ueber die vortheile der anweiidting scharfer li.-iken bei der cataractoperation. Lancet. II. 2. 12.33. Driver, Bericht uber .50 staarextractiouen nacli der A. Weber'sc hen methode. .\. f. ().. XVIII. 2. p. 2P. H- Report of one Imndn-.l muI f..urt('.'ii ...xtraftions of cata- ract. Transact. Amcr. Opth. Soc, p. 5()-54. 1289. Kostecki, Z., Ueber v. Graefe's liueaire methodc nnd dorcii crlolge. Gazeta Lekarska, No. 'J*',. 129<\ Leber, Stiidien nlier den Flussmkcitswccks.-l im Auro. A. f. O.. XIX, 2, p. 87. 1291. Lebriin. Nouvelle metliodc .rcxtraction d.- la .atara.tc par un pro- cede a lambeau median splH>ro-.ylindri.iuc. Congres de T.ondres. Compte-Kendu, 21.J-227. 1292. Lefort, Leon, Snr la valeur des differentes methodes d'extractlon de la cataraete. Soc. de Chir., 30 Avril. Gaz. des Hop., p. 565-581. 1293. Lindner, Sigmund. Ein fall von linsendislocation niit vollstandiger resorption der linse. Allg. Wien. Med. Z^g., No. 15. p. 237. 1294. Little, David, Tabular report and remarks on 200 cases of extrac- tion of cataract by Graefe's modified linear section. Mod. Chir. Review, .January, p. 19C.. 1295. Logetschnikoff, Ueber die von ihm im Jahre, 1872 und 1873, nach der Graefe-schen methode gemachten linearextractionen. Opth. Ges. Klin. Monatsbl. f. Augenb., p. 483-486. 1296. 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Twenty-third Meeting of American Opth. Society. 1887. 2429. Kipp, Case of spontaneous absorption of senile cataract without injury to the capsule of the lens; restoration of excellent vision. American Journal of Opth. June. 2430. Ijagner, Case of Recklinghausen in Nineteenth Opth. Congress. Heidelberger. 527 18K7. 2431. Ix?c, On the extraction of soft c:itjir:ift by injections. Brit. Med. Journal. January. 2432. Mn?:nus, Therepeautisclior Monatsclirift. October. Ub;-r einfln.'! »le.s napthalin auf dem sehorgau. 2433. Meyer, Paul, Die spontane aufsugnng cataracta senilis. Graefe, XXXIII, B. 1. 2434. Moeller, Ca.suistisclio niiltlu'iliiii;; uber das vorkoniiueu unci die operative behandlnng des .sranen staars l)eini Ininde. Zeitselirift fur Augenlieillvunde. 2435. Mules, Cataract extraction. .\ new method ol treatinj; an old com^ plication. British Medical .loiiiii.il. .inne 11. 243(5. Mathiossen. Ludwig. Beltrag zur dioptrie der krystallinse. Berlin. Everbusch Zeitschr. fur Verg. 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Boston Med. and Surgical .loiirnal. CXYIII, 8. p. 189. 2492. Doyne, A peculiar degeneration of the lens. Opth. Soc, Dec. 13. 2493. Eoliver, Belt, Bericht uber 100 staaroperation. Knapp Arch.. Vol. XIX. B. 2. 2494. Fuchs. I'ber traumatisclie. Klinisclie Woclienschrift. Xo. 3 and 4. 2495. Falchi, Microptlialmns Congenita. .Viuiali di Optlialmologi. XIII. 530 1888. 2496. F. Me^er, Ein Fall von Lonticouiis iiosterior. Arch, fur Prakt. Augenheilkiuulo; Febry.. 1888. 2497. Flenzal, Discission mit dem Lanzenmesser bei den verschiedent-u Arten von Angeboreuer Cataract. Societe Francaise d'Opth., May 9, 1888. 2498. Freyer, B. E., Excessive hemorrhage of several hours' duration after cataract extraction (senile), d case). American .Tournal of Opth.. February. 2499. Fischer, F., Bericht uber ein acht yuliriges kind mit augeborener totaler cataract und dessen verhalten wahrend der Ersten Wochen 2500. G. A. 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Eiii fall von h-n1iconns posterior. Arch. f. Augonhell- kunde, XXII, B. I. , Uber extractioi f. Augenheilkunde. XXII, Heft. 2. Uber extraction in dcr .ulaskorpor dislocirton linsen. Arch. 2686. , Bericht uber ein drittes hundert .■xlr.Htions olnu- iridectomie. Arch. f. Augenheilkunde, Heft. 2. 2687. Keyser, Soft cataract. Times and Register. XXI. 20, p. 257. 2688. Iwan M. Burnett, Regular astygmatism following cataract extrac- tion. American Journal Opth. 1889. 2689. Lucanus. Ein fall von monocularem doppelseheu. Klin. Mon. Bl. f. A.. XXVIII, S. 282. 2690. Magnus. Hugo, Experimentelle studien der ernahrung der krystal- linse und uber cataractbildung. Graefe Arch., Vol. XXXVI, B. 4. 2691. McHardy. Artificial maturation of immature senile cataract by trituration. Opth. Society of United Kingdom. Arch. f. Augenh.. P, 274. 2692. Straub, M., Die concavitate des vodern zonula blattes nach vorn. Arch. f. Augenheilkunde. Heft. 2. •2tU»:{ McKeown, Cataract operations. Brit. Med. Journal, 1890, No. 1560, p. 1186. 2694. Mario w, J. W., Preliminary capsulotomy in the extraction of cata- ract. New York Med. Journal, LH, No. 13, p. 357. 2695. Parinaud, Du delire apres I'operation de la cataracte. Societe Francaise d'Opthal. Arch. f. Prakt. Augenheilkunde, p. 334. 2696. Rolland. Mayens tres practiques et asepsis pour la cataract. Re- cueil d'Opth., March and February, 1890. De la operation de la catracte chez la maladies ambulants et de la responsabilite modi- cale quelle entraine. Recueil d'Opth., April. 2697. Kerschbaumer, Rosa, Bericht uber 200 cataract extractions. Arch. f. Augenheilkunde, XXII, Heft. 2. 2698. Kalisch, Richard. The arrest and partial resorption of immature cataract, with restoration of reading power. Medical Record. March 29. 2699. Schoen, Bericht zu Prof. Magnus Aufsatz. Graefe Arch., XXXVI, B. 1. 2700. Schweiggger, Uber die operation unrifer stare. Berliner Med. Ge- sellschaft. Hirschberg's C. Blat., 206. 2701. Schnabel, Uber cataract operationen. Wiener Med. Presse. No. 19. 2702. Schirmer, R., Uber indirecte verletzung der voderen linsenkapsel und des sphincter iridis. Zehender's Klin. Monatsch. May. 1890. 2703. Scimeni. Sull modificaziono della curvatura della cornea in segulta ad estraziono di cataratta. Annnl. d'Opth.. XIX. 3. 4. p. 209. 540 1890. 2704. ShioMs, Cha.s., Wlion shall we oporate cataract and strabismus in children V New York Med. Journal, LII. p. 384. 2705. SAvanzy. Series of 100 cataract extractions. New York Medical Journal, IJI. p. 146. Remarks on cataract extraction. British Medical Journal, No. 1528. 1890. 2706. Treacher Collins, Glauoma after cataract extraction. Opth. Soc. of the United Kingdom. British Med. Journal, February 8, 1890. 2707. Trousseau, Les maladies generales et I'operation de la cataracte. Recueil d'Opth. March. 2708. ^Tyner. T. J.. Preliminary capsulotoniy in the extraction of cataract. Optli. Review, IX. 108. p. ;i20. 27t»Jt. Vetrcl). Uber das Rothsehen (3 cases). Corresp. Bl. f. Schweizer Aerzte. 1889. 2710. Valk, Francis, Operation of cataract without iridectomy. N. Y. Med. Journal, LI, 16, p. 431. 2711. Yalude, Accidents centraux consecutive a I'operation de la cataract. Soc. Franc. Opth. 1890. 2712. Wood. Hiram, Intraocular lieniorrliage, consecutive to cataract ex- traction. Med. Record. May .31. 2713. Webster. Traumatic dislocation of the lens. N. Y. Med. Record, LII, p. 11 and 295. 2714. , Fatal meningitis subsequent to panopthalmitis after extrac- tion. Arch. f. Augenheilkunde. XXI. 2. S. 191. 2715. Ci-osz, Emil, Cataracta partiales trniiniati<-a. (Szenieszet. No. 1.) Arch. f. Frakt. Aug.. p. 316. 2716. leweski, F. O., Cataract and xerosis conjunctivae bei den arbeitern der Glasfabriken Wjestnik Opth. ;May and June. 2717. (xuaita. Panopthalmitis six monat nach staar operation. Italien- isches Congress. Pis«?., 180. Hirscliberg's Centralblatt. p. 558. 2718. , Experimenteli reifung des staares. 1891. 2719. Berry. Unusual itsuIIs of cataract extraction. Opth. Society of United Kingdom. Janu.-iry. 1N01. Briiisli .Med. Journ., Feb. 7,1891. 2720. Czermak, W.. Di-ei fallc von iiili-acai»sii];;rer aurs.-iugung ih's alter- staars. Zeheiidcr's Klin. Monalsldal Icr. A|)iil. ISI'l. 2721. Chibret, A prospus du niccliaiiisiiie de rinlcctic.n aiircs I'operation de cat:iract. Revue (JeiicMal .i"()i)(li.. January. 18M. 2722. Bernh.'ird. Dub.. Beit rag zur keiitniss der cataract zouularis. (Jr.-iefe Arcli.. ^•(.l. XXXVII. B. 4. 2723. Dimiiier. I'.. Yaiv glasc r correction lici aplialvic Zeliendt-r's Klin. .Moiiatsblatter. I'\-I.ruaiy. ISOI. 2724. Fischei-. Kicii.. Sticli verlctzung cines jinges. Walirscheinlicli unge- (Iciintc /.cireissung der vodcicn liiiscn]S5. 2808. Il.u-lMii. 11.. Sucfcssful ciiliiraci rxtractioii ISC of adavanced retinitis i,i.';im>nt..sa. Mar.vlaii.l Mr.l. .louri... XXIV. p. 2C,r,. Bal- timore. lS'.tl-!»1. 2800. . Eiu fall vou iris prolaps am 3. Tagc nacli ciiu'r katarakt ex- traktion oliue iridoktomie. Trolaps rcponiorl; Hoihing. Arch. f. Augenheilk., XXIV. S. 50. 2810. , Case of hernia of iris occurring ou tiiinl day after cataract extraction without iridectomy; liernia replaced: recovery. Arch. Opth., XX. p. 81. 2811. Hjort. rel.er katarakt extraktioii ..line iridcktmnic Xm-sk. .Magaz.. p. (543. 2812. Holmes. Spiccr. llennirrliagc following extraclion of a black cata- ract in a highly myopic eye. probably associated with choroidal changes; enucleation. .lourn. Amer. Med. Assoc. XYI. p. 83. Chicago. 2Si;!. Jacqiiin, Pressure on the globe after cataract extraction. Ibid. XVI. p. 331. 2814. . The simple extraction of cataract. ^Maryland Med .lourn.. X.\I, p. 67. Baltimore. 1801-92. 281.5. .Tohannson. E.. Katarakt operatiouen in ausserklinischer beliaud- lung. (Livlandischer Aerztetag.) Walk. September. 1801. (St. Petersburger ^led. Wochenschr.i 281(). Kerschbaumer, Rosa, Report of two hundred cataract extractions. •Translated by Dr. C. A. Wood. Arch. Opth.. XX, p. 3-19. 2817. Knapp, H.. Ein fall von glaskorperblutung nach einer staar extrac- traktion. Arch. f. Augenheilk., XXIII, S. 272. 2818. . The occurrence, prevention and management of prolapse of the iris in simple extraction of cataract. Trans, of the Amer. Opth. Soc. 27th Meeting, p. 80. 2819. , Die behandlung der kapsel wahreud und nach der staar ex traktion. Verh. des X. Interuat. Med. Congresses, Bd. IV. 4. S. 1. 28'20. Kollock. C. X., Report of cataract cases. Trans. South Carolina Med. Assoc, p. 107. Charleston. 2821. Eacqueur. Teber den gegenwartigen stand der lelnv von der staar operation. Deutsche .Med. Wochenschr.. Xo. n. (Xaturwissensch. Med. A'erein in Strassburg. Sitzung vom 20. Xovember. 1890.) 2822. Landolt. Presentation; de quelques instruments ayant trait a I'oper- ation de cataracte. (Societe Francaise d'Opthalmologie.i Arch. d-Opth.. XI. p. 4G3, 545, et XII. p. 323. et Annal. d'Oculist. T. C\. 546 1891. 2823. Lerebzenicowa. E., Bericht uber 300 katarakt operationen. Wjest- nik Opth., VIII, 1, p. 32. 2824. Lippincott, J. A., Routine syringing out of cortical matter in cata- ract extraction, as illustrated by 100 cases. Trans, of the Amer. Opth. Soc, 27th Meeting, p. 85. 2825. Logetschnikow, S., Eiue staar extraktion bei morbus basedowii. Klin. Monatsbl. f. Augenheilk., S. 277. 2826. , Staarextraction bei einer krauken mit morbus basedowii. (Slutschij i swletschenja katakakti, osloschnjonnoj bolesnju base- dowa.) Westnik Opth., Ill, p. 219. 2827. Martin, G., Une complication post-operatoire de la cataracte de Morgagni. Societe d'Opth. de Paris, November 3. 2828. Mellinger, C, Experimentelle untersuehungen uber die entstehung der in letzter zeit bekannt gewordenen trubungen der hornhaut nach staar extraktion. V. Graefe's Arch. f. Opth., XXXVII. 4, S. 159. 2829. Millee, E., Extraction du cristallin a la curette. Nouvelle anse fenetree. Annal. d'Oculist, T. CVI, p. 2. (Durch einen in der Mitte verlaufenden Langsleisten gefenstert.) 2830. Minor, J. L., A report of twenty-five cataract extractions. Arch. Opth., XX, p. 69 2831. Murrell, T. E., To what extent are personal restraints essential during healing of corneal wounds? Journ. Amer. Med. Assoc, XVII, p. 333. 2832. Neuschuler, De I'astigmatisme post-operatoire. Recueil d'Opth., p. 515. 2833. Nikoljukin, J., Bericht uber 97 staar operationen in der Land (Sems- two) Praxis. (Ottschjot o 97 operatijach katarakti w semskoj praktike.) Wjestnik Opth., VIII, 3, p. 226. 2834. Nuel, Sur la prophylaxie de la suppuration apres I'operation de la cataracte. (Societe Fraucaise d'Opthalmologie.) Arch. d'Opth., XI, p. 463, 545, et Annal. d'Oculist, T. CV, p. 227. 2835. Norrie, G., Die katarakt operation in Skandinavian in der letzten Halfte des Jahrhunderts. Nord. Opth. Tidsskr., IV, p. 1. 2836. Ostwalt, F., Einige Worte uber glaserkorrektion bei aphakie. Klin. Monatsbl. f. Augenheilk., S. 283. 2837. Parinaud, H.. Le prolapsus de I'iris dans I'extraction simple de la cataracte. Recueil d'Opth., p. 321. 2838. , L'enclavement de I'iris dans I'extraction de la cataracte. (Societe Francaise d'Opthalmologie.) Arch, d' Opth., XI, p. 463, 545, et XII, p. 323, et Annal. d'Oculist, T. CV, p. 227. 2839. , II prolasso dell iride nella estrazione della catei-atta. Boll. d'Ocul., XIII, 10. 547 1891. 2840. I'itts. B.. CiitanKl cxtrjK lion. 'I'niiis. .M("(li<;il Assoc, X.XXIII, p. 64. 2841. Pooley. T. li., Operation lor srcoiulary cataracl. followed by irido- cyclitis and consecutive glaucoma. Anicr. Journal of Dptli.. p. 'Ml. 2842. Kider. W.. Report of a case of fatal in«'ninj,'itis following suppura- tion of tile i-ornea after cataract operation. 'I'rans. Med. Society New York, p .402. I'biladulpliia. 2843. Roosa, The results of various methods of extraction of cataract, illustrated by 206 cases. Arch, of Opth., XX, No. 2, p. 207. 2844. Santos, Fernandez, Extraction du cristallin dans myopie. Compte rendu de la section opthalmologiiiue du Congress Medic, de Val- ence. Revue Generale d'Opth., p. 352. 2845. . I'n accident possible, mais remediable dans la keratotomie. Revue Generale d'Opth., X. 3. 284G. Schnabel, Entwickelung der staaroperationeu. Allg. Wien. Med. Zeitg.. XXXVI, S. 425. 2847. Serebrennikowa. E.. Bericht uber 30 staaroperationeu. (Ottschjot o 300 staaroperatij katarakti.) Wjestnik Opth., VIII, 1, p. 32. 2848. Smith. E., Staar. Wie sollen wir uns zur kapsel verhalten? Neue Cystotompincette. Journ. Amer. Med. Assoc, November 5. 2849. Suarez de Mendoza, La suture de la cornee dans I'extraction de la cataracte. Recueil d'Opth., p. 577. 2850. . Nouveaux faits a I'appui des avantages de la suture de la cornee. dans I'operation de la cataracte. (Societe Francaise d'Opthalmologie.) Arch. d'Opth., XI, p. 463, 545, et XII. p. 32.3, et Annal. d'Oculist, T. CV, p. 265. 2851. Thomas. A report of 50 cases of cataract extraction. .Tourn. Opth. Otol. and Laryngol., p. 8. 28.52. Valude, L'operation de la cataracte et son pansement. Ann. de Therap. Med. Chir., VI, p. 269. Paris, 1890. 2S53. VanDuyse. De I'hemorrhagie choroidienne grave dans Textraction du cristallin cataracte. Annal. d'Oculist, T. CV, p. 112. 2854. Vignes, Algunas palabras sobre las cataractas secundarias. Rev. Esp. de Oftal.. Dermat., Sif., etc., XV, p. 289. Madrid, 1891. 2855. , Quelques mots sur les cataractes secondaires. Recueil d'Opth.. p. 65. 2856. Wageninann. A.. Zur anatomic des dunnhautigen nachstaars, nebst benierkuiigen uber die heilung von Wunden der Descemet'scheu Membran. V. Graefe's Arch. f. Opth., XXXVII, 2, S. 21. 28.57. Wahlfors. K. R.. Bericht uber 150 staarextraktionen. Finska La- karesallsk. llandl.. XXXIII, p. 333. 2858. Webster, D., Notes of a case of diabetic cataract operated upon by Dr. C. R. Agnew. Amer. .Journ. of Opth., p. 131. 2859. , Report of 136 cases of cataract extraction. Trans, of the Amer. Opth. Soc, 27tli Meeting, p. 75. 548 1891. 2860. , Improved eye-pads for the after dressing in cataract oper- ations. Med. News, March 28. 2801. DeWecker. Ablation de la capsule anterieure. Paris, Lecrosnier et Babe. 2862. — — . Nouvean procede operatoire de cataracte secondaire. (So- ciete Francaise d'Opthalmologie.) Arch. d'Opth.. XI. p. 463, 545. et XII, 323, et Annal. d'Oculist, T. CV, p. 227. 2863. Wlckerkiewicz, Ein nngewohnliches ereiguis bei einer normal aus- gefuhrten alterstaar extraktion. (Polnisch.) S. A. aus Przeglada Lekarsk. Nr. 38. 2864. Wolkow, M., Zur frage der staarextraktion ohne Iridektomie. (Kwoprosu ob extraktii katarakti bes Iridektomii.) Wjestnik Opth., VIII. 2, p. 99, und Tagebl., d. IV, Kongresses d. Russ. Aerzte. Nr. 10. 2864a. Knaggs, On lenticomus. Lancet. 1891. 1892. 2865. Abadie, Nouvelle methode de traitement des luxations completes du cristallin. Soc. d'Opth. de Paris. July 5. 2866. Alt, A.. A case of acquired anterior polar cataract. Amer. Journ. of Opth., IX, 11, p. 357. 2867. Arnold. Th., Mittheilungen uber 4000 staaroperationen, ausgefuhrt von Prof. O. Haab. Arch. f. Augehheilk.. XXV, 1-2, S. 41. 2868. Audibert, Procede nouveau pour I'aspiration, en un seul temps, des eataractes liquides et demi-molles; description d'une aiguille kera- totome ci-euse speciale. Ann. d'Ocul.. CVIII, 2. p. 100. 2869. Aiisin, Johann, Das eisen in der linse. Dorpat, 1891. 2870. Baker, A. R., The pathology and treatment of infantile cataract. Amer. Med. Assoc, Detroit, June. 7-10. 2871. Baker. A., Infantile cataract. Amer. Journ. of Opth.. IX, 11. p. 350. 2872. Barsanti. Cataracte traumatique developpe soudainement a la suite d'une commotion du cristallin. Rec. d'Opth., No. 1, p. 1. 2873. Beaumont. W. M., Aphakial erythropsia. Opth. Rev. No. 125, p. 72. 2874. Bettman, B., A new operation for the speedy ripening of imma- ture cataract. Chicago Medical Recorder, April. 2875. Bribosia, Guerison d'lm aveugle de naissance; operation de cata- racte congenitale double; chez un sujet de 15 ans. Arch. d'Opth., XII, 2, p. 88. 2876. Cant, W. J., On the management of prolapse of the iris after sim- ple cataract extraction. Brit. Med. Journ., No. 1659, p. 834. 2877. Chisholni, J., The dislocation of :in opaciue lens. Amer. Journ. of Opth., IX, 4, p. 101. 2878. Colline, E. T., On the minute anatomy of pynmiidal cataract. Trans. Opth. Soc, XII, p. 89. 2879. Colline, E. T., and Richardson Cross, Two cases of epithelial im- plnnt.-ition cysts in the anterior chamber after extraction of cata- ract. Trans. Ojith. Soc. Nil. ii. 17.". 549 18t»2. 2SS0. l»t'srliiiiiii)s. A piosjx.s d'nii c.-is dc lii.xMt ion sponlaiifc dcs deux cristallins. Aiiual. (rociil., CNIH. .'.. ]). .117. 2881. Dimmer, J., Noch einnial die ^.dascicnirrclioii l)ci ai)liakie. Klin. jNIon. BL, XXX, S. 7:5. 2SS2. Dittmer, J.. Beitra^- zur stalisdk dn- iiiodilicirl<-ii linear fMi-Mction. In. Diss. Kiel. 2883. Dolschenkow, W., P.ei-iciii idicr cinlinndcri raiaiad oiicnitionen. Wjestnik Optli., IX. 1. S. -jr,. 2884. Dor, Sur le traitement de la ealaiaete congenitale. Conyr. Franc. d'Opth., May 2. Rapport sur le traitement de la cataiacte con- genitale. Compte Rend, de la Soc. Franc. d'Optli.. .May 2. 2885. Eiseck. Eln fall von Icnticonus postiTidi-. Klin. Mon. I'd.. XXX, S. 110. 2880. Erwin. Treatment of incipient eataraet. .Vnicr. .Med. Assoc., De- troit, June 7-10. 2887. Friebis, G., A ease of congenital ectopia leutis. Ebenda. 2888. Galezowski, Sur un nouveau procede operatolre d'extraction des cataractes incompletes. Congr. Franc. d'Opth., May 2. 2889. , Nouveau procede operatoire d'extraction de cataractes in- completes par incision semielliptique de la cornee avec sphinc- terotomie. Rec. d'Opth., No. 5, p. 262. 2S90. Gardner. C. R., Absorption of opacities in a case of senile cataract. Opth. Rec. I, 12, p. 111. 2891. (Jayet. En eas de luxation double du eristallin. La Province Med.. No. 31. 2892. Hansen, H. .1.. The extraction of double congenital cataract: sym- pathetic inliammatiou after second ojjeration; recovery. Ann. of Opth. and Otol., I. 2, p. 137. 2893. Higgens, Ch., Spontaneous cure of cataract. Oi)th. Soc. of the United Kingdom. Case of spontaneous disappearance of cata- ract. Trans. Soc, XII, p. 107. 2894. Hilbert R., Zur geschichte der kyanopie. Arch. f. .Vugenheilk. XXIV, 3, S. 240. 2895. Hirsehberg, Ueber kernstaar— Ausziehung. Berlin. Klin. Woch.. No. 20. 2890. Knapp, The methods and results of simple cataract extraction. Amer. Med. Assoc, Detroit, June 7-10. 2S97. Kortnew, A., Ueber die rachitiscbe cataract. Wjestnik Opth.. IX. 2, S. 114. 2898. Landolt. L'operation de la cataracte de nos Jours. .\rch. d'Opth.. XII, 9, p. 529. 2899. Lapersonne. De Topportuuite dc liiitervention dans les cataractes traumatiques. Congr. Franc. d'Opth., May 2. 29(H). Logetschuikow, S., Einige benierkungen uber die cataract extrac- tionen nach Dr. Wolkow. Wjestnik ()i»tli.. IX. 4. S. .3.'.S. 550 1892. 2901. Majinus. H.. Dio entwiekeluns ties alterstaares. Augenarztliche unteiTichtstafelii fur deu academischen und selbstimtericht. Heft. II. Breslau. 2iM)2. Milliken. lujufy of the lens, with cases. Amer. Med. Assoc. De- troit. June 7-10. 200.",. Mitvalsljy, J., Ein neuer fall von lenticonus posterior niit theil- Aveiser persistenz der arteria hyaloidea. Centralbl. f. Prakt. Augenheilk., S. 05. 2;)04. . Zur kentniss der spontanheilung des senilen totalstaars ver- mittelst der intraeapsularen resorption nebs. 2unn. ... Thre. .as.s ... .lislo.a.iou of the h-ns o..cumo. in cata- ract extraction; showing three of the positions the lens may as- sume: question as to the regeneration of the vitreous. Ann. Opth. and Otol., II. p. 250. St. Louis. 09^9 , The cataract knife. New York Med. Record, p. GOO. Veo' . Extraction of part of the capsule as an operative procedure in certain cases of secondary cataract. Arch. Opth., XXII, p. 344. New York. , . , , 00,1 Evorsbusch. Kin fnll von ektopia lentis congenita binoculans bei "^ ' ..inen. IT .inhre alt. n.anne. Versa.nuH.lunu- Deutscher Natur- forscher u. Aerxte. Nurnberg. ISO.-.. 29(52. Fage, Hemorrhagic intra-oculaire grave apres une extraction de cataracte. Annal. d'Oculist, T. CIX, p. 266. 2968. Faravelli. Sulla cataratta naftalinica. Annali di Ottalm., XXU. 2964. FreeLd, Fergus. On ten years" experience of cataract operations. Brit. Med. .Tourn., May 13. 2965. Froniaget, Cataractes congenitales hereditaires pendant six gene- rations. Ibid., No. 31. 2966 Fuchs, Die neuen methoden der staar operationen. Vortrag Ge- halten in der sitzung der k. k. Gesellschaft der Aerzte in Wien, December 2, 1892. Wien. Klin. Wochenschrift. No. 2. 29(i7. Galezowski, Extraction de la cataracte sans iridectomie. Ses avantages et ses egueils. Recueil d'Opth. May. 2968. GiUet de Grandmont, Observations de cataracte noire. Extraction. Analyze spectroscopique. Progres Medical, No. 17. 2969. Grosz,"E., A szurke halyog operalasarol. (Operation des grauen staars.) Szemeszet, p. 29. 9970 Gullstrand, A., Ein fall von lenticonus posterior. Nordisk Opthal- mologisch Tidsschrift. Vol I. (Typischer Fall von linksseitigem lenticonus posterior bei einem 30 jahringen Maim.. 2971 Heucke. A.. Beitrag zur lehre von der aetiologie uu.l behandlung der luxationen der krystallinse. Inaug. Diss. Strassburg. 2972. Hisigens, C. Extraction of cataract. Lancet. II. p. 1180. 2973. Hippel, E. v. sen., Ueber den gegenwartigen stand der staar oper- ation. Munch. Med. Wochenschr.. S. 669. 2974. Hirschberg, J.. Ueber schichtstaar bei altereu luenschen. Cen- tralbl. f. Prakt. Augenheilk., August. S. 225. •2975. . Heilung der kurzsiclitigen netzliautablosunjr nach auszei- hung der getrubten linse. Ebd. Marz. 2976. Howe, L., On the removal of hard cataract by s...tiun. 'I>ans. of the Amer. Opth. Soc. 29th Meeting, p. 594. 0977 .Tackson, E.. When cataract is ready for operativ(> treatment. Trans. Med. Soc. Pennsylvania. XXIV. p. 97. TMula.lelphia. 554 1893. 2978. Jackson. E., Indirect massage of the lens for the artificial ripening of cataract. Trans, of the Amer. Opth. Soc, 29th Meeting, p. 523. 2979. Kayser, Fritz, Iridectomy necessary twelve and fourteen days after normal extraction of cataract. Opth. Record, Nashville. 1892-93, p. 353. 2970a. Hess, Zur Pathologie und Pathologischen Anat. verschieden Staar formen. Graefe Hich. f. Opth.. XXXIX, 1. 1893. 2980. Korschenewsky, S., Kurzer bericht uber das zweite hundert von katarakt extractionen in der land praxis. (Kratkij ottschott o •wtoroj sotne iswletschenij katarakti w semskoj praktike.) Ibid., XL, p. 483. 2981. Krukow, A., Ein fall von pyramidal katarakt. Sitzungsberichte des Moskauer Opth. Vereines. 1892. 2982. Kusehew, N., Kurzer bericht uber das zweite hundert von kata- extraktionen (Kratkij ottschott o perwoj totne iswletschenij kata- rakti). Wjestnik Opth., X, p. 510. 2983. Landolt, Un couteau destine a la discission. Arch. d'Opth., XIII. p. 529. 2984. Logetschnikow, S., Eine eigenartige katarakt mit sequester. Sitz- ungsberichte des Moskauer Opth. Vereins. 1892. 2985. , Eine seltene anomalie von linsenstaar (Redkaja anomalia katarakti). Chirurgitscheskaja Lepotis, III, No. 4. 2986. Maschek, O operacyi zacmy bez woyciecia teczowki. (Uber staar operation ohne iridektomie.) S. A. aus Przeglad Lekarski. 2987. Magnus, H., Ueber das verhalten von fremdkoipern in der linsc. Centralbl. f. Prakt. Augenheilk.. November S. 327. 2988. Manolescu, A propos de Textraction simple de la cataracte. Rou- manie Med. Mars. 2989. Mastrocinque, Massagio diretto sul cristallino per la maturazziont- artiflciale della cataratta con un nuovo instrumento. (Rend, del XIII. Congr. della Assoc. Oftalm. Ital.) Annali di Ottalm., XXII. p. 45. (Empfehlung der direkten linsen massage mit eihem eige- nen sondenartigen instrument.) 2990. McCoy, T. J., A new shield for the protection of eyes after cata- ract operations. Med. Record, New York, 1892, XII, p. (;04. and South. Californa Pract., Los Angeles, 1892, VII, p. 8. 2991. Meyer, E., Malformation du cristallin. Revue Generale d'Opth.. p. 1. 2992. Mitvalsky, Microphakie und deren klini.sche bedeutung. Klin. Monatsbl. f. Augenheilk., S. 323. 2993. Moerner, C. Th., Untersuchung der proteinsubstanzen in den licht- brechenden medien des auges. (3) Mitt. Zeltschr. f. Phys. Cheni.. XVIII, S. 61. 555 2JHM. Moore, W. O.. The after ticiitiiicut of cataiacl ixiia<-tlon. Med. News, Philadelphia, p. '2'>:',. 2995. Mooren, Die iiidikationsjin-iizeu der caL-iract discission. Deutsche Med. Wochenschr., S. 857. 291)(;. Moorehead. G. C, Cataract operations, .lourn. .\nier. .M«'d. Assoc, Chicago, XX, p. 437. 29J>7. Mules, Pyramidal cktaract. lOptli. Soc of the United Kiuj^dom.) Opth. Review, p. W9. 2!>5>8. Murell, T. E.. The simple dressing after cataract extraction. Opth. Record, Nashville, 1893-4, III, p. 121. 2999. Neuburger, Ueber die hauflgkeit der staarbildung in den vehschie- denen lebensaltern. Centralbl. f. Prakt. Augenheilk.. September, S. 2(!3. Beitrag zur entwickelung der katarakt. Ebd., S. 165. 3000. Nicati, La pointe couteaux a cataracte. Facheuse routine a dera- ciner. Arch. d'Opth., XVII, p. 136. .3001. Nickelsburg. Leopold, Weitere beitrage zur aetiologie der cataracta senilis. Inaug. Diss. Wurzburg, 1892. .3002. Panas, Prophylaxie des accidents infectieux consecutifs a I'oper- ation de la cataracte. Arch. dOpth., XIII. p. 593. 3003. , L'operation des cataractes congeni tales. Progres Med., No. 7. 3004. Parinaud, Le prolapsus de I'iris dans I'extraction simple de la cata- racte. Soc. d'Opth. de Paris. April, 1893. 3005. Peters. A., Ueber die entstehung des schichtstaars und verwandter staarformen. V. Graefe's Arch., XXXIX, 1, S. 221. 3006. Piechaud, A.. Cataracte congenitale demi-pierreuse. Recueil d'Opth. p. .552. 3007. Reche. A., Ein beitrag zur entwickelung der katarakt. Centralbl. fur Prakt. Augenheilk., May. S. 129. .•{008. -. Ein fernerer beitrag zur entwickelung der katarakt. Ebd. December. S. 963. 3009. Rivers. E. C. Cataract extraction. New York Med. .lourn., p. 301. 3010. Roethlisberger. 1*.. Ueber die ansspulungen der vorderen kammer bei der staarextraktion an der Easier Opth. Klinik. Inaug. Diss. Basel. 3011. Roosa, .John, A series of cataract operations. Post Graduate, New York, VIIL p. 271. 3012. Rudall, J. T.. Spontaneous rupture of capsule after iridectomy pre- liminary to cataract extraction. (Opth. Soc. of tlie United King- dom.) Opth. Review, p. 347. 3013. Santos Fernandez. .1.. Conducta que debe observarse con las cata- ractas invalidas de glaucoma. Cron. Med. Quir. de la Habana, 1892, XVIII, p. 740. 3014. , Hernia voluminosa del iris despues de la extraccion simply de la cataracta. Ibid., p. 0. 556 1893. 3015. Sbordoms Osservazioni pratiche sulla operazione della cataratta col processo a lembo seuza iridectomia. (Rend, del XIII. Con- gresso della Assoc. Oftalm. Ital.) Annali di Ottalm., XXII, p. .^rjJ). (Siehe diesf'n Rev. pro 1802. > 3016. Schantz, Fritz-Jena. Ueber deu eiufluss der pupillaroffuimg- auf das sehen aphakischer. Verhandlungen der Gesellschaft Deutscher Naturforscher u. Aerzte. Halle, 1891. 8017. Schlosser, Ueber akkommodation aphakischer augen. (Gesellsch. f. Morphol. und Physiol.) Munch. Med. Wochenschr., S. 291. 3018. Schoen, W., Die anfange und ursachen der stare. Deutsche Revue. Breslau u. Berlin. XYIII, S. 115. 3019. Die funktionskrankheiten d. auges. Wiesbaden. J. F. Berg- man. 3020. Schreiber, P.. Elfter jahresbericht meiner augenklinik. .Tahrg. 1893. 3021. Schweigger, Operative beseitigung hochgradigre myopic. Deutsche Med. Wochenschr., No. 20. .3022. Smith, and Travis, B. F., Report of a case of extraction of cata- ract in a negro said to be 116 years old. Journ. Amer. Assoc, Chicago, XXI, p. 684. 3023. Snell, S., Case presenting unusual appearances after extraction; simulating cyst, but really due to a distended capsule. Opth. Review, p. 345. Die ausgedehnte eine cyste vortauschende linsen kapsel bei einer vor 7 jahre staaroperierten. Frau entheilt Zer- fallsprodukte der linse selbs. 3024. Sous, De I'uree apres les operations de cataracte. .Journ. de Med. de Bordeaux, September 17. 3025. Stafford, H. E., Extraction of senile cataract. New York Poly- clinic, I, p. 142. 3026. Swanzy, On the combined method of cataract extraction. (Opth. Soc. of the United Kingdom.) Opth. Review, p. 213. 3027. Teale, T. P., Bowman lecture on the abandonment of iridectomy in the extraction of hard cataract. .Journ. Amer. Med. Assoc, Chicago, XXI, p. 684. 3028. Theobald, S., Exhibition of patient with zonular cataracts. John Hopkins Hospital Bull., Baltimore. IV, p. 55. 3029. Thier, Die operative behandlung hochstgradiger myopie durch dis- cission der linse. Deutsche Med. Wochenschr., XIX, S. 717. 3030. Trousseau, Le pterygion et I'operation de la cataracte. Annal d'Oculist, T. CIX, p. 146. (Verf. glaubt versichern zu mussen, dass ein vorhandenes pterygium nicht die Gefahr der Eiterung nach einer staaroperation erhohe.) 3031. Vacher, M., Nouvolle technique operatoire de la capsulotomie dans I'operation, de la. cataracte. Societe d'Opth. de Paris. Seance du 7 Novembre, 1893. 557 18it:{ 30812. Yolhagen. C Kiii scll. K.Miiscliniann's Beitrage zur Augenhoilkunde. IX. Heft. 3030. Warner. A. (",.. Dislocation of tlie lens and subs(>quent cataract by a sliot from an air gun. .louni. Optli. otol. and Laryngol., V, p. 88. 3037. Webster. D.. A case of congenital cataract; both lenses removed by operation. Arch. Pediat., New York, X, p. 929. 3038. DeWecker. Reminiscences historiques concernant I'extraction de la cataracte. Arch. d'Opth., XIII. p. 212. 3039. — . T.a section de Daviel. Ibid. p. 2tn. 3040. , INIodifications apportees par Daviel a la section. Ibid, p. 401. 3041. — , L'extraction a lambeau triangulaire ou ogival. Ibid, p. 412. 3042. Wescott, An unusual case of dislocation of the lens. Annal. of Opth. and Otol., January. 3043. Wintersteiner. Ein fall von eiuseitigen, doppelten schichstaar. Klin. Monatsbl. f. Augenheilkunde. S. 300. 3044. — . Angularer aequatorialstaar. Ebd., S. 333. 3045. White, J. A., Cataract; report of 100 operations. Virginia Medical Monthly. Richmond, 1892-93. XIX, p. 731. 3046 Zimmermann, C, Dislocation of the lens into the anterior cham- ber with iridodialysis; extraction; recovery. Congenital unilat- eral anopthalmus. Arch, of Opth., XXII, No. 3. 1894. 3047. Adelheim, Ein fall von colobomallentis. Wjest. Opth., XI, 2, S. 191. 3048. Ahlstrom. G., Redogonelse for 100 staaroperationer. Goteborg's Lakar. Forh., N. I. 3049. Birnbacher, Ein neues verfahren der kapselentfernung bel staar- operationen. C. f. Pr., A., S. 65. 3050. Bitzos, G.. Le point noir de I'operation de la cataracte par l'ex- traction. Ann. d'Ocul., CXI, 4, p. 247. 3051. Brose. L. D.. Two cases of double-sided ectopia lentis. Opth. Rec. IV, 1, p. 24. 3052. Cheatham, W., Cataract extraction an office extraction. Ibid, IV, 2, p. 62. 3053. Chisolm, .1. J., Hoav cataract patients eyes are dressed at the Pres- byterian Eye, Ear and Throat Charity Hospital of Baltimore, Ann. of Opth. and Otol.. Ill, 1, p. 5. 3054. Chodin. Ueber eine merkwurdige comiilication bei der cataract ex- extraction. Wjest. Opth., XI, S. 78. 30.55. Christen. Th.. Drei falle von angeborenen\ linsen colobom. Arch. f. .\ugeiilieilk.. XXIX, S. 233. 558 1894. 3056. Clark. C. F., A case of binocular colobonia of the lens with accom- modative power retained. Trans, of tlie Anier. ()i)tli. Soc. p. 999. Dislocation of both crystalline lenses. ll)id. p. '2'AU. 3057. Collins. Treacher. The association of lamellar cataracts and il( kets. Opth. Soc. of the United Kin.udom. November 4. 30.58. Czermak. \V.. rel)er druckende verbandc nnd wundsprengung nach staar extraction. Wiener Klin. Woclienschr.. VII. No. 27. S. 506. Ueber extraction ohne iridectomie. Ibid, No. 27. 3059. Dalganow. T'el)er den astigmatismns der liornhant nach cataract extraction. W.1est. Optli., NI, 1. S. IS. 3060. Dehn. E., Ein beitrag zur kentuiss der luxtaio lentis. A. f. O.. XL. S. 237. 3061. Derby. Hasket, Hipts concerning the performance of the operation for the extraction of senile cataract, being a record of personal experience. Boston Med. and Surg. Journ., CXXXII. No. 5. p. 97. 3062. Dimmer, Das opthalmoscopische aussehen des linsenrandes. Wien. Klin. Wochenschr., No. 46-47. 3063. Dolard. Considerations generales sur I'operation de la cataracte ches enfants. Rec. d'Opth., No. 8, p. 468. 3064. Dolganoff, W., Ueber die veranderungen des wudastigmatismus der hornhaut nach der cataract extraction. Arch. f. Augenheilkunde. XXIX, S. 13. 3065. Dolganow, Ueber corneal astigmatismns nach staar operation. Wjest. Opth., No. 4, S. 388. 3066. Erwin, A. J., Two lenses extracted from one eye at the same sitting. Opth. Rec. Ill, 11, p. 433. 3067. Page, Le, Le nettoyage secondaire de la pupille dans les operations de la cataracte trauma tique. Inter. Med. Congr.. XL L'extrac- tion simple de la cataracte sur les yeux atropinisees. Soc. Franc. d'Opth. 3068. Field le Mond. R.. Cataract operation and office operation. Opth. Rec, IV. 2, p. 72. 3069. Fox. L. W.. Immediate capsulotomy following the removal of cata- ract. Journ. Amer. Med. Assoc, June 2. 3070. Oasperini. E., Emmoragia consecutiva ad ablazione di cataratta e successiva guarigione sponatanea di ambo gli occhi. Annal. di Ottal., XXIII, p. 270. 3071. Gifford, IL, The shield dressing for cataract extraction. Ann. of Opth. and Otol., Ill, 2, p. 141. 3072. Goerlitz. M.. Beitrage zur pathologischen anatomic der cataracta diabetica. In. Diss. Freiburg. 3073. Graddy. L. B.. The prevention or modification of astigmatism after cataract extraction. Opth. Rec, IV, 1. p. 1. 3074. Ilaltenhoff, Traitement de cataractes traumMti(iues. Soc. Franc. d'Optli. 559 18!»4. aoir,. Mc-llardy. Tlu- :.r1ilil ..Id. Opth. Ki'C, 111. 11. !•• 4:{1. 3077. noc'(inart. K.. D.^rnniiatioiis nH'(liaiii.iii«'s \vinj; .alara.-l .-xtraction. Ann. of Opth. and Otol., 111. 1. i'. '••■ 3079. .Tolks. L. B.. Report of cataract op.-ralion in tli.- .-is.- .>f three sis- teis. Opth. Rec, IV. 2. p. CS. 3080. Kalt. De la suture corneenne aprcs rcxna.ii.>ii .h' la (ataraete. Arch, of Opth.. XIV. 10. p. r,:\U. lUe coruealnaht na.h extra, tion des cataract. Arch. f. Au.iienli.. XXX, S. 15. 3081. Kessler. 11. M. V.. Tranniatischc spli.jtinu (Wv lens. Oogh. Versl. Utrecht. 3082. Knapp, II.. Remarks on the extraction of cataract, based on the results of the operations of tiOO consecutive cases. Trans. Intern. Opth. Congr., p. 14. .3083. Lawford. .1. B.. Peculiar cataracts of lamellar ty|.es. Trans. Opth. Soc. XIV, p. 138. .3084. Lippencott, J. A., Unusually large loss of vitreous in cataract ox- traction; recovery with useful vision. Trans, of the Amer. Opth. Soc, p. 252. 3085. Little. D.. Extraction of senile cataract, with and without iridec- tomy; live years" hospital experience. Trans. Internat. ()i>tli. Congr., p. 25. 3086. Logetschuikow, Ueber die einfache extraction des cataract anf dem atropinisirten auge. Wjest. Opth. XI. 2, p. 103. 3087. Lowe, J. W. C Cataract extraction an otfice operation. Opth. Rec. IV, 6, p. 213. 3088. Marple, V^'. B.. Coloboma lentis. .\ew York Eye and Ear Intirmary Rep., Vol. II. p. 30. 3089. Millingen, van. Ni'ue versuch«- ul)er die kt'ratoplastik und nber die massregein, um den irisvorfall nacli der einfaclien cataract oper- ation zu vermeiden. Intern. Med. Congr.. XI. 3090. Mitchell. S.. Cataract extraction an otfice .)peration. Opth. Rec. IV, 1, p. 7. 3091. Mooren. A.. Die operative behandlung der natmich und kunstlich gereiften staarformen. Wiesbaden. Bergniann. 3092. Moores Ball, J., Two cases of traumatic cataract in .hildren. Ther. Gazette. XVIII, 10, p. 013. 56o 1894. 3093. Mullcr. L., Hat der lenticoiius sfiiu'u .liiuiul in cinci- aiKjiii.ilie der hinteron linsenflache? Klin. Mon. Bl., XXXII, S. 173. 3094. Nicati, M., Discissions cristaliniennes et iritomies ou couteau. Ann. d'Ocul.. CXII, p. 398. 3095. Nicolulvin, Berieht uber 204 cataract operationeu in der land praxis. Wjest. Opth., XI, 3. p. 245. 3096. Pagensteclier, H.. Practisclie rathschlago zur staar operation fur angehende angeuarzte. Klin. Mon. f. Augenh., XXXII, S. 339. 3097. Peters, A., Ueber die entstehung des schichtstaares. A. f. O., LXX, 3, p. 283. 3098. Purtscher, O.. Casuistischer beitrag zur leliro vom schielitstaar. C. f. Pr., A.. February, S. 33. 3099. Risley, S. D., Destructive hemorrhage during extraction of cata- ract. Ann. of Opth. and Otol., Ill, 1, p. 16. 3100. Schramm. F., Spontane aufsaugnng eines alterstaares bel unver- letzter linsenkapsel. Wiener Klin. Wochenschr., No. 37. 3101. Schweinitz. Jackson, Risley, Complications of cataract extractions and subsequent healing. Opth. Rec. Ill, 1, p. 421. 3102. Schweinitz, G. E., A case of intraocular hemorrhage after extrac- tion of cataract. Ann. of Opth.. January. April. 3103. Snell, S.. Case presenting unusual appearances after extraction of cataract. Trans. Opth. Soc, XIY. p. 135. 3104. Tenant, F., L'operation de la cataracte simplifiee procede du Dr. A. Trousseaux. These, de Paris. 3105. Theobald, S., A case of panopthalmitis .suppurativa following dis- cission of a capsular opacity. Amer. Jouru. of Opth., XI, 7, p. 193. 3106. Terson, A., Sur la pathogenie et la prophylaxie de I'hemorrhagie expulsive apres I'extraction de la cataracte. Arch. d'Opth.. XIV, 2, p. 110. 3107. Thompson. L., Observations on some phases of opacity and lux- ation of the crystalline lens. Brit. Med. .Tourn.. No. 1759, p. 589. 3108. Vullers. H.. Angeborene cataract beider augen niit perforation der linsenkapsel beim kaninchera. A. f. O.. XL, .">, S. 190. 3109. Weeks, J. E., A case of lenticonus posterior, witli remarks. Arch. of Opth., XX, 2, p. 260. 3110. Wiclierkiewicz, Febfler die behandlung intraocularer eiterung nach staar operationen. Wiener Klin. Wochenschr.. No. 46-47. 3111. Wolkow, 1st die kapsulotomie bei der extraction seniler cataracte nothwendig? Ibid., No. 4. S. 36(>. 3112. Abadie, Rapport sur un travail de M. Ic Dr. Bistls (de Constanti- nople), intitule de la cataracte par rajtport aux convulsions. Un cas de tclanie avec cataracte mollc. Societe d'Opth. de Paris. Marcli. 56 1 1894:. 3113. Albraud. W.. Report of ~)4\) futaracts oitci-atcd at I'rof. Scboclcr's eye clinic in Berlin. Arch, of Oplli.. XXTII. i.. 1.V'.. Oki. (sicbe diesen), Ber.. 1898, S. 292. 3114. Ball. J. M., Two cases of traumatic cataract in ciiildrcn; siucess- fiil results. Therap. Gaz., Detroit, X. p. G61. 3115. Barrett, J. W., Foreign body in lens; traumatic cataract; extrac- tion of foreign body and lens in globe. Austral. Med. Journ., Mel- bourne, XVI, p. 157. 3116. , A case of couching for catarad: pfrfcct vision tliirteen years afterwards. Ibid, p. 381. 3117. Bei'ceot, H., Quelques considerations sur le traitement des cata- ractes secondaires. Tliese. de Pari.^;. (Bringt Bekanntes.) 3118. , A propos de I'operation de Daviel. Ibid. p. 2.57. 3119. Bourgeois, Lunettes pour operes de cataracte. (Societe Francaise d'Opth.) Recueil d'Opth., p. 39(i. 3120. . Procede simple pour certaines extractions dans la chanibre anterieure. Ibid, p. 286. 3121. Chand, M., Spontaneous falling down of cataract into the posterior chamber; restoration of sight. Med. Reporter, Calcutta, IV, p. 140. 3122. Chibret. Un cas de correction astigmatique du crlstallin. Arch. d'Opth., XIV, p. 275. ■ 3123. , On the good effects of dressing one eye only after cataract extractions. Brit. Med. Assoc, 62d Meeting. Bristol. 3124. Cirincione, Cataratta lussata nella camera anteriore e glaucoma consecutivo. Riforma Med., Napoli, II. p. 220. 3125. Collins, W. J., Note on non-pathological cataracts. Lancet, I, p. 1493. 3126. , Ueber druckende verbande und wundsprengung nach staar- extraktion. Bbd., p. 506. 3127. Schweinitz, de, A case of intraocular hemorrliage after extraction of cataract. Amer. Opth. and Otol., St. Louis, III, p. 12. 3128. , The treatment of immature cataract, and when to operate for cataract. Journ. Amer. Med. Assoc, Chicago, XXII, p. 105. 3129. Danesi, G., La medicatura antisettica nella chirurgia oculare. Boll. d'OcuL, XVI, 13. 3130. Dolard, De la cataracte chez les jeunes sujets. These, de Paris. 3131. Donberg. G., Ueber aseptik bei augen operationen. (Ob aseptike pri glasnich operatijaeh.) (V. Kongr. d. Russ. Aerzte in St. Peters- burg.) Wjestnik Opth., XI, i». 7H. 3132. Dujardin, A propos de I'operation de Daviel. Annal. d'Oculist, T. CXI, p. 258. 3133. Dunn, Vacuoles de crlstallin. Virginia Med. Monthly. August. 3134. Egappa, T. A., A modified operation for extraction of cataract se- nilis. Indian Med. Record, Calcutta. 1893, V. p. 313. 562 1894. 3135. E]gbert. J. H.. The absorption of immature cataract with restoration of vision. Paoitic Med. and Surg. Record, San Francisco. 1893-94, VIII. p. 147. 3136. Erwin, Two lenses extracted from the same eye at the same sitting. Opth. Record, May. 3137. , Soixante-dix extractions de cataraete; operations secon- daires. Gaz. Med. de Picardie, Amiens. XII, p. 43. 313S. Fergus. Patients upon whom the operations of extraction of the lens had been performed for high degrees of myopia. Olasgow Med. Journal. XII. ]). 14(1. 31.30. Ferguson. Lindo H.. A new form of capsular scissors. Optli. Re- view, p. 58. 3140. Fukala. Beitrag zur geschichte des operativen beliandlung der my- opia. Arch. f. Augenheilk.. XXIX. S. 42. 3141. . Correction hochgrider myopie durch aphakic. Wahl des operations verfahrens. mit rucksicht auf die path, anatoralschen veranderungen der choroidea. Trans, of the Seventh Internat. Opth. Congress. Edinburgh, p. 181. 3142. Ilefiebower. Foreign bodies in the crystalline lens. Cincinnati Lancet-Clinic. February 10.1 3143. Heuse, Einiges uber die ausziehung des alterstaares. Festschr. z. Feier des 50 jahr. Jubilaums des Vereins d. Aerzte des Reg. Bezirkes Dusseldorf, S. 302. 3144. Hippel, A. v.. Ueber die operative behandluug hochgradiger kurz- sichtigkeit. (Naturhistor. Med. Vereiu zu Heidelberg.) Munch. Med. Wochensehr.. S. 157 u. 660. .3145. Hirschberg. Remarques sur I'historique de I'operation de Daviel. Arch. d'Opth., XIV. p. 208. 3146. , Ueber den staarstich der Inder. Centralbl. f. Prakt. Augenh., February, S. 48. 31^". . On the cataract pricking of the Hindus. Indian Med. Gaz.. Calcutta, XXIX, p. 211. 3148. Hori, M., Beitrag zur operativen behaudlung der hochgradigen my- opie. Arch. f. Augenheilk., XXIX, S. 142. 3149. , Indirect massage of the lens for the artificial ripening of cataract. Therap. Gaz.. January. 3150. Jackson, E., and Risley. S. D.. Complication of cataract extraction and subsequent li(>aling. Opth. R(>cord, Nashville, 1893-94. Ill, p. 421. 3151. Jennings. L. K., Report of a cataract operation in tlie case of three sisters. Opth. Record, Nashville, 1894-95, IV, p. 68. 3152. Jennings, J. E., Remarks on the treatment of two cases of lamellar cataract. Med. Review, St. Louis. XXIX. p. 285. 563 18t)4. 3153. . On tlu' foriiciil siituic in cMtMiacl .'X tract ion. TraDslatcd J).v II. KnaiH). Arch, of Upth.. XXIII, p. 421. 3154. Keiper, G. F., Imniediato eapsulotomy following,' the removal of cataract. Annal. Opth. and Otol., St. Louis, III, p. 420. 3155. Kirk. R., Extraction of a cataract in a niyxoedematous subject aged 72 years. Lancet, II. p. 794. 315(!. Knapp. Ueber glaucom nacli discission des naclistaars nnd seine heilung. Arch. f. Augenheilli., XXX, S. 1. 3157. Lang, Krystallbildung in d.M- linse. Optli. Soc. of tiie United King- dom, November. 3158. Langenecker, D. F.. lleuiorrliage after cataract extraction, and some thoughts as to cause. Proceedings Kansas Med. Soc. To- peka, p. 291. 3159. Ljubornudrow, 14 augenoperationen, im lokallazaretii zu Lurzk, in den .Tahren 1892-93 ausgefuhrt. Wojenno. Med. .Tourn.. April. (14 extraktionen. 1 Verlust durch Panopthalmie.) 3160. Manz, Ueber operative behandlung hochgradiger myopie. (Verein Freiburger Aerzte.) Munch. Med. Wochenschr.. S. 1044. 3161. Martin, G., Sur le delire consecutif a I'operation de la cataracte. 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November. 1895. 572 1896. 3295. Prel'ontaine. L. A., Summnry of operations for cataract done at the New York Eye and Ear Infirmary from October 1, 1894, to Oc- tober 1, 1895. New York Eye and Ear Infirmary Reports. Vol. IV, part I. p. 55. ,'>296. Plettinck-Bauchau, Des iucouvenienls de I'operation de la cataracte avec iridectoniie compares aux advantages de I'extraction simple avec le lambeau semielliptique de Galezowski pratiquee a I'in- stitut opthalmique de Bruges. Recneil d'Opthalm., 18, annee, No. S, p. 449. ."•297. ruecli. Cataractes traumatiques. Recueil d'Opthalm., 18. annee. No. 8, p. 466. 3298. Pinto, J. da Gama. Ein beitrag zur uachstaar operationen. Klin. IMonatsbl. f. Augenheilk., XXXIV. p. 295. 3299. Rumschewitsch, K., Zur casuistik des glaukoms nacb staar oper- ationen. Klin. Monatsbl. f. Augenheilk., XXXIV, p. 191. 3300. Steiner, L., Persistence du canal de Cloquet et cataracte polaire posterieure compliquee de chorioretinite speciflque; depots de pig- ment dans les parois du canal. Ann. d'Oeulist. T. CXV. Livr. 1, p. 41. 3201. Story, John B., One hundred consecutive operations for senile cata- ract, complicated and uncomplicated. Transactions of the Royal Academy of Medicine in Ireland, Vol. XIII. 3302. Segal, L., Opthalmologische beobachtungen. Zur frage der pupillen bildung bei occlusio pupillae nach katarakt extraction. Bd. XIII. Heft. 1, p. 31. 1896. .3303. Schreiber. .Julius. Zur lehre vom schichtstaar. Inaug. Dissert. Kiel, 1896. 3304. Sanford, Arthur. England. Opthalmological Society of the United Kingdom. October 15, 1896. Cataract extraction in an Albino. Brit. Med. Journ., No. 1869, p. 1231. 3305. Schoen, Wilhelm, Die staarkrankheit, ihre ursache und verhutung. Wiener Klin. Rundschau, 1896, Nos. 19, 20, 21, 23, 24, 25, 26. 28. 29, 30, 31. 3306. Topolanski, Alfred, Ueber kapselabhebungen. A. v. Graefe's Arch. f. Opthalm., XLI, 3, p. 198. :!;i07. Thomas, Wilhelm, Beitrag zur lehre von der cataracta diabetica. Inaug. Dissert. Kiel, 1896. 3308. Trotow, Otto, Operazione delle cataratte incomplete. Ann. di Ottalm., XXIV, fasc. 6, p. 580. Siehe auch Italia, XIV. Con- gresso deir Associazione Oftalmologica Italiana. teuuto in Ve- nezin, dal 26 al 29 Agosto. 1895. Ann. di Ottalm.. nniio XXIV. supplcinciito Ml fasc. 4. •i.'lc I'lancaiso d'Opthal- 7 .M.i i. l.SfK;. De l-extrac- (lyrll l(n)])liy lacticiut; de 1896. 3310. Yacher, Fraukroicb. ( 'oiij^'rcss df la niolojiio. Soction tciiiie a I'iiris dii 4 tion du crisfalliu transparent coiiiiii la myopie forte, progressive et dn dccollemeut de la retine. 3311. Watson. W. Spencer, and W. J. Collins. A case of traumatic cata- ract with a foreign body imbedded in the lens snccessfully treated by operation. Transactions of the Opthalmological Society of the United Kingdom, Vol. XV, p. 115. London, 1895. .T. and A. Churchill. 3312. Wood, Casey A., The after treatment of normal cataract extrac- tion; a lecture delivered at the post-graduate medical school. Therap. Gaz., Vol. XX, No. 2, p. 77 3313. Wecker, L. de. L'extraction de la cataracte en 1952. Ann. d'Oculist, T. CXV, Livr. 4, p. 275. 3314. Weill, George, Aiguilles lancettes pour U'.s opcnilions de cataracte secondaire. Revue Gen. d'Opthal., No. 8, p. 338. 3315. Abadie, Ch., Etude clinique et pathogonique d'uno complication pen connue consecutive a l'extraction de la cataracte avec iri- dectomie. Ann. d'Oculist, T. CXVI, Livr. 1, p. 45. 3316. Albrand, Walter, Bericht uber 295 staar operationen der Scholer's Chen Augenklinik in Berlin. Arch. f. Augenheilk.. Bd. XXXIII, Heft. 1, p. 71. 3317. Darier, Frankreioh. Cougres de la Societe Francaise d'Optlialmol ogie. Section tenue a Paris du 4 au 7 Mai, 1896. Nouveau pro cede de keratotomie pour pratiquer I'iridectomie ou 'extraction de la cataracte dans les cas d'effacement complet de la chambre anterieure. 3318. Davis, A. Edward. The report of a case of double senile cataract, with leucoma as a complication in each eye. Extractions after preliminary iridectomies. New York. Manhattan Eye and Ear Hospital Reports, Vol. Ill, p. 37. January, 1896. 3319. Hennicke, Ein fall von katarakt, veranlasst durch entozoen (?). Klin. Monatsbl. f. Augenheilkunde, XXXIV. p. 423. 3320. Schweinitz. G. de. Concerning the extraction of immature cataract. with the report of cases. Phila. Polyclinic, Vol. V. April, 1890. 3321. Stadfeldt, A. E., Die veranderung der linse bei traction der zonula. Klin. Monatsbl. f. Augenheilk., XXXIV, p. 429. 3322. Vignes, Frankreich. Societe d'Opthalmologie, November, 1896. Re- tard de cicatrisation chez les operes de cataracte. 1897. 3323. Augstein und Ginsberg, Ueber die resorption der linso und der lin- seukapsel bei luxation in den glaskorper. Centralbl. f. Prakt. Augenheilk., p. 356. November. 3324. Antonelli, Albert, Le croissant lineaire du cristallin, dans certalne.'^ formes de cataracte; confirmation anatomo-pathologique. Ann. d'Oculist, T. CXVIII, Livr. 2, p. 17. 574 3325. Angelucci, A.. Una modificazione al proeesso di estrazione sempli- fic-nta della cataratta. Arch, di Ottalm.. Vol. V, fasc. 3 u. 4. p. 71. 3326. Bert, Ellis. Penetrating wounds of the lens: report of four cases. Opthalm. Record, Vol. VI, No. 3, p. 131. 3327. Bach, L., Histologische und klinische mittheihmgen ubcr spindel- staar und kapselstaar. nebst bemerkungen zur Genese dleser staarformen. A. v. Graefe's Arch. f. Opthalm., Bd. XLIII, abth. 3. p. 663. 3328. Barck, Carl. On retarded closure of the wound, and some rare acci- dents and sequelae of cataract extraction. Amer. Journ. of Opth., Vol. XIV. No. 9. p. 281. 3329. Bullard. W. L.. A case of sympathetic optlialmia following a suc- cessful cataract extraction. Opthalm. Record, Vol. VI, No. 10. p. 518. October. 3330. Crzellitzer, Zonularspannung und linsenform. Heidelberg. Bericht uber die XXV. Versammlung der opthalmologischen Gesellschaft Heidelberg, 1896. Unter mitwirkung von E. V. Hippel und A. Wagenmann, redigirt durch W. Hess und Th. Leber. Wiesbaden, 1897. J. F. Bergmann. Page 48. 3331. Cartwright, E. H., Congenital post-lental opacity with remains of hyaloid artery; irregular development of suspensory ligament and coloboma lentis. Transactions of the Opthalmological Society of the ITnited Kingdom. Session 1895-96, Vol. XVI, p. 186. London, 1896. J. and A. Churchill. 3332. Critchett, Anderson, Extraction of dislocated lens with good result. Transactions of the Opthalmological Society of the United King- dom, Session 1895-96, Vol. XVI, p. 62. London. 1896. J. and A. Churchill. 3333. Coover, David. An interesting but disastrous termination of a cata- ract operation. Opthalm. Record, Vol. VI, No. 3, p. 126. 3334. Coleman. W. Franklin, Preliminary iridectomy in the extraction of senile cataract. Ann. of Opthalm., Vol. VI, No. 2, p. 218. 3335. Dimmer, F., Beitrage zur opthalmoskopie. Der Rand geschrumpter Oder theilweise getrubter linsen. A. v. Graefe's Arch. f. Opthal., Bd. XLIIL abth. 1, p. 1. 3336. DuBarry, Operation de cataracte suivie de suppuration guerie par les injections sous-conjunctivales de sublime a 1-1000. Clinique Opthalm., No. 13, p. 154. 3337. Damianos, Nikolaus, Zwei falle von extopia pnpillae o1 lentis. Bei- trage z. Augenheilkunde. heft. XXIX, p. 812. 3338. Elschnig, Anton, Ueber die discission. Wiener Klin.. Wochenschr., 1896, No. 53. 575 r\\ (iiifii 1 1 l.th. Ass.>ci:ili( Ill licid ill St. .l<. iinia il .>l ■ (»|itli; III m. . Vol. XIV. all •li.lc ( "liiii) Complicated cataracts, tlieir iiiitiii-c and results. .loin-n. Auier. .Med. Assoc.. .Ian. S. 1898. 579 1898. 3405. Kreiwitz, Corneal astyginatism after iridectomy ana simple linear extraction. Inaiig. Dissert. St. Petersburg, 1897. 3406. Lopez, Fernando, Expulsive hemorrhage after cataract extraction. Ann. d'Opth., No. 1, p. 2. 1898. 3407. Meyer, O., Beitrag zur pathologie und pathologische anatomle des schicht und kapsel staars. Bd. XLV, Part III, p. 540. 3408. Muttermilch, Notes on cataract operation. Ann. d'Ocul., XVIII. p. 408. 8409. Milbury, Report on 70 cases of cataract extraction. Journal of Amer. Med. Assoc, April 17, 1897. 3410. Mitvalsky, Remarks on subconjunctival luxation of the lens. Arch. d'Opthal., XVII, p. 337. 3411. Mittendorf, W. F., Some of the earlier symptoms of senile cataract. Report of Trans. Amer. Opth. Soc, 1898. Arch, of Opthal., Vol. XXVII, 4, p. 447. 3412. Mulder, Anatomical examination of a case of lenticonus posterior. Zehender's Klin. Monatsbl., XXXV, p. 409. 3413. Oliver, Clinical history of a case of subconjunctival dislocation of the lens. Opth. Record, June, 1897. 3414. Puccioni, A case of spontaneous luxation of both lenses. Boll. d'Ocul., XVIII, 14-15, p. 108. 3415. Pfluger, Prevention of prolapse of the iris in extraction of the senile cataract. Proceedings of Moscow International Congress. Arch, of Opthal., Vol. XXVII, Part I, p. 95. Zehender's Klin. Monatsbl., XXXV, p. 332. 3416. Purtscher, Congenital cataract as a family affection. Centralbl. fur Augenh., Vol. XXI, p. 198. 3417. Purtscher, Choroidal hemorrhage after extraction. Centralbl. fur Augenh., XXI, p. 193. 3418. Rogmann, A new contribution to the study of the congenital anom- alies of the lens. Colobomas situated in direction not correspond- ing to the foetal cleft. General conclusions on the genesis of len- ticular colobomas. Arch, fur Opth., XVII, p. 427. 3419. Rauschenbach, A contribution to the pathology and therapy of traumatic cataract. Inaug. Dissert. Basle, 1897. 3420. Sattler, H., Zuzatz zur Bloom'schen Arbeit. Uber die retro-cho- roideal blutungen nach staar extractionen. Graefe's Arch.. Bd. XLVI, Part I, p. 184. 3421. Schweigger, C, Simple extraction downward. Arch, of Opth., Vol. XXVII, No. 3, p. 255. Ann. of Opth., Vol. VII, No. 2, p. 240. 3422. Schantz, A family with juvenile cataract. Centralbl. fur Augenh.. Vol. XXI, p. 264. 3423. Schoen, Cataract following convulsions. Wiener Med. Wochenschr.. No. 17. 1897. 58o 1898. 3424. Sattler. On tlie operative treatment of ectopia lentis. Arch, fur Augenh., XXXV, 4, p. 355. 3425. Sourdille, Daviel's section, accordiu.s, to authoritative texts. Arch. f. Optla., XA^I, p. 657. 3420. Scliiotz, Cataract statistics. Nord. Mag. f. Lageridsk. F'orhaudl. Christiana, 1897, p. 159. 3427. Schumway, E. A., Summary of operations for cataract, done at New Yorli Eye and Ear Infirmary, October. 1895, to October, 1896. January, 1897. 3428. Trousseau, Treatment of hemorrhage after extraction of cataract by corneal suture. Arch. f. Opth., XVII, 2, p. 106. 3429. Trocavo, Uribe, Delay in the past operative formation of the an- terior chamber. Ann. d'Opth., Vol. I, No. 1. July, 1898. 3430. Valois, G., Delay in cicatrization after cataract operation. Recueil d'Opth., January, 1898. 3431. Velhagen, A case of pseudo-neoplasm in the interior of the eye after cataract extraction. Centralbl. fur Augenh., XXI, p. 363. 3432. Wettendorfer, A contribution of the aetiology of juvenile total cat- aract. Wiener Med. Wochenschrift, 1897, Nos. 11 and 12. 3433. Wilson, F. M., Senile cataract. Trans. Conn. Med. Soc. 1895. INDEX, ACCOMMODATION— Abolition of (Traumatic Lux- ation) 157 Aphakia in 364 Artificial (in Aphakia) 400 Beirinning of 3(5, 97 Diminution of 49 Developing cataract in l'^6 Effort at, after Extraction, (its consequences) 364 History of Subject 384 Eelation to Shape of Lens. . . 36 AETIOLOGY OF CATARACT. 135 (See also C. Senilis.) ALBUMEN— Increased Amount in Cataract 72 Modification of 65 Normal Amount of, in nor- mal lens 63 Kali-A 62 Serum-A 62 ALBUMINOUS SUBSTANCES— (In the Lens) 64 Quantitative Estimate 65 ALBUMINURIA— (A Cause of Senile Cataract) . . 236 AMBLYOPIA ex ANOPSIA. . . 414 ANOMALIES (of the I^ns)— Cause- of 138, 148 ANOPTHALMUS— Aetiology 139 Condition of Lens in 140 APHAKIA— Accommodation in 384 Artificial Ace 400 Astygmatism in 388 Average ^Measurements in Em- etropic Eye 380 Cause of 372 Definition, Diagnosis 372 Dioptric Sytem in 376 Emetropic 377 Glasses in — Cylindrical 404 Influence of 405 Spherical 402 Hyperopic • • • • 376, 379 Myopic 379 Optical System in 374 Peculiarities 408 Pupil, appearance of 338 Vision in Acuity of (Real and Apparent) 397 Acuteness of 387 Diminution of, (cause) 388 APHAKIC EYE— Appearance of 338 ARTIFICIAL RIPENING OF CATARACT 264, 357 ASHES— Normanl Lens 64 ASTYGMATISM— After operation, cause of .348, 392 After partial rupture of Zon- ula 155 Degree and effect of 389 Influence of operation on de- grees ^^"* Irregular, cause of 314 ATHEROMA of the CAROTID— Cause of Senile 236 Choroidal Vessels 240 582 INDEX— Continued. ATEOPINE- After Extncction 332 Danger of Glaucoma. 354 During Extraction 352, 361 Histon- of 116 Physiological action 311 Use of C. Incipiens 127 AQUEOUS— Albumen in 71 Albumen during cataract for- mation 72 Chemistr}' of 69 Evacuation of, Effect on con- tour of the lens 36 Effect of repeated puncture on chemical, constitution of . . . 264 Effect on position of the lens. 297 Historical review 108 Index of Eefraction 70, 374 Nutritive fluid of Eye 318 Ee-accumulation of 336 Sugar in 71 BACTEEIOLOGY— Importance in operating 362 BUPHTHALMUS— Influence on the Lens 168 CAPSULA LENTIS— Condition of (after Extrac- tion) 349 Corpuscles 45 Construction of 45 Contraction of 98 Development of, (Time of). 25, 27 Dioptric influence 375 Elasticity of 46 Function 26, 27 Growth 43 Injuries of, by cutting instru- ments 252 Lamellae, (Zonular) 44 Ledges 40 Measurements 43 Origin, (experimental investi- gations) 44 Perforation, result of traction of cyclitic bands 203 Physical properties 45 Pores 55 Pressure, (Intracapsular) — Fall of 98 Limiting formation of fibres 97 Puncture of, (closure) 253 Eeaction of — Capsule after operation ... . 309 Contents of capsule after. . 309 Eupture of 251 Et Zonula Zinii 251 Stomata 94, 256 Swelling of 56 CAPSULAE CICATEICES— Development 44 Foreign Substances enclosed. 94 Growth 45 Pathology 90 CAPSULAE FOECEPS— Value of 309 CAPSULOTOMIE. (CYSTO- TOMIE) 309 Mode of procedure. .306, 307, 350 Dangers of 309 CATAEACTA. CATAEACT— Origin of word 109 (N. B. — For all general con- siderations see, Cataracta Senilis — Senile Cataract.) C. ACCEETA 114, 198 (See C. Complicata.) C. ADVEESA 115 C. ACQUISITA 113 C. AEBOEESENCE 116 C. AEIDO SILIQUATA 114 Aetiology, Genesis 213, 214 583 INDEX— Continued. C x\XIALI3- "'" C. CAPSULARIS CUM BUR- ""'' Definition 113 SA ICHOREM CONTI- C. AXIALIS ANTERIOR— NENTE ••••••••••• — • ^'^ (See C. Pyramidalis.) C. CAPSULARIS LENTICU- Definition 174 LARIS 113 C. BEUNESEn'ce: ■.;;;'.'.;;■.'. 84? C. C APSULAEIS NATAUS . . 115 (See C. Nigra.) C. CAPSULARIS PUNC- • TATA 174 C. CALCAREA— Anatomical description 201 C. CENTRALIS— CUnical History 166 Definition 113, 174 Definition 113 Description, Genesis 175, 185 Perception of Light 132 Pathology 194 C C \PSUI ARIS- ^^'^ ^- 2°^^^^^^^-) l.LArbUi.AKife C. CENTRALIS ANTERIOR'.. 113 Chemical constitution.... 92 ^ CENTRALIS CAPSU- Chmcal descnption . . . 249, 258 ^^^^^ POSTERIOR 113 Contraction o , leading to ^ CENTRALIS LENTICU- spontaneous luxation 15d t at?TS 113 ^®^"^'*^°^ ;••••• ^^^ C. CENTRALIS POSTERIOR. 113 Foreign substances enclosed — (Clacoxeous depoeits) 94 C. CHOROIDEALIS- Cholerterine) - Climeal m.tory 304, 206 Generis of 246. 258 DiffcT«itiation from C. Po- Hyaline Thickening .339 ^^^\^- ??»"») 1** Localized growth, can» of. . . 101 Nntnt.ve Di^urbances 207 General consideration 89 (^^^ C. Punctata.) Genesis - Historical Re- C. COMPLICATA- Tiew 89, 246 Aetiology 136 , Primary development 249 Anatomical Examinations. ... 199 Petrifaction 103 Clinical History and Sequel- Presence in Senile Cataract. . . 233 l^e C. CAPSULARIS ANTERIOR Definition 114, 136. 198, 340 CENTRALIS 113 Operative interference 204 (See C. Polaris Anterior. Con- C. COMPLETA 115 genitaetAcquisita.) C. COMPOSITA CRYSTAL- C. CAPSULARIS ANTERIOR LINAE 115 SPURIA— (See C. Capsularis.) Aetiology 144 C. CONGENIT A- Definition 112 Definition 113 C. CAPSULARIS ARIDA SII^ C. CONGENITA NUCLEARIS IQUATA 115 DURA 215 584 INDEX— Continued. Description, Operations Path- ogenesis 216 C. CONGENITA TOTALIS OCULI UNTEIUSQUE— Aetiology 213 Anatomical Examination . 207, 211 Genesis 209, 213 Time of occurrence 213 Varieties 207 C. CONSECUTIVA, (Constitu- tional Cataract) — . Changes incipient 59 Definition 99, 113, 205 Pathogenesis 99 C. CONSECUTIVA P A E - TIALIS. (See C. Axialis.) C. COETICALIS— Anterior, Posterior 113 C. CYSTICA— Definition 115, 214 C. DIABETICA— Aetiology 226, 240 Anatomical Examinations. . . 217 Chemistry of 67, 223, 227 Clinical description.. 219, 220, 225 Development, Period of 219 Diabetic Coma 230 Experimental production of. . 237 Frequency of 218 General condition of patient.. 219 Genesis 82, 229 General consideration. . .216, 225 Pathology of 80, 220, 222 Pathogenesis . . .99, 216, 222, 225 Pigmentation 223 Prognosis of operations 229 Eelation of cataract forma- tion to quantity of sugar in the urine 223 Sex affected 219 Varieties 319 C. DURA— Definition 113 C. EIvASTICA— Cause of 154 Definition, Description 214 C. EX CONTUSIONE 250 C. FLUID A- Definition 113 Perception of light in 132 C. FUSIFOEMIS. (Spindle Cat- aract) — Clinical description and his- tory 180 Genesis 176, 181 C. GLAUCOMATOSA— Definition 114 C. GYPSEA— Definition 113, 202 Perception of Light 132 C. HEMOEEHAGICA 247 C. HYPEEMATUEA— Clinical Data 233 Definition 114 Sequellae 342 C. HYPEEMATUEA FLUIDA 242 (See C. Morgagniana.) C. HYPEEMATUEA EEDUC- TA— Aetiology and Clinical De- scription 242 C. ICHOEEM TENENS— Definition 113 C. INCIPIENS— Definition 11 x, 115, 233 Pathology 80 C. INANITION 207 C. JUVENUM— Calcareous Deposits in 82 Changes . 59 Definition 113 Genesis, Pathology 80 INDEX— C. LACTEA— Definition 113, 114 Description and difl'erential diagnosis 202, 24o C. LAPIDA- Dofinition 113 C. LA:\IELLAE. (See C. Zon- ula ris.) C. LEXTICUEAT^TS— Definition 112 History 116 C. LENTICULAIJIS COinT- CALIS 112 C. LENTICULARIS NUCLE. AT?IS 112 C.LEXTICULAEIS TOTALIS 113 C. MATURA— Clinical Data 233 Definition 114. 233 Pathology 79 C. MATURESENCE— . Definition 114, 233 C. MEMBRArACEA— Definition 114 Diagnosis 368 Genesis 213, 258 Pathology 102 Treatment 367 C. MEMBRANACEA CON- GENITA— Aetiology 214 C. MEMBRANACEA CON- GENITA ACCRETA— Description, Pathology, and Aetiology 143 C. MOLLIS— Definition 113 C. MOLLIS EX CHOROID- ITIDE 204 C. MOLLIS JUVENUM. (See C. Diabetica.) 585 CONTINI'ED. C. MOWGAGNIANA— Anatomical Examination. . . . 243 Cause of 1 1 r,, 245, 246 Clinical description 242 DefiniHon 113, 115, 245 Genesis 246 History 243 Nucleus 245 Pathology 80, 89 Perception of Light 132 C. MIXTA— Definition 113. 115 C. NATALIS. (Natans.)— Cause : 153 Description 214 Definition 114, 115 C. NIGRA— Anatomical P]xamination .... 248 Chemistry of 69 Clinical description 248 Definition 114, 249 Genesis 247 Historical 115, 247 Pathology 79, 247 Spectroscopic Analysis 69 Varieties 67, 79 C. NONDUj\I MATURA— Definition 114, 233 C. NUCLEARIS— Anatomical Basis 80, 185 Differentiation from C. Zon- ularis 182 C. NUCLEARIS CONGENITA DURA— Description and Genesis 215 C. OSSEA— Definition 113, 203 C. PARTIALIS. (See C. Ax- ialis.) Definition 113, 174 Effect on Vision 124 Varieties 196 586 INDEX— Continued. PAGE C. PIGMENTAIEE 223 C. POLARIS ANTERIOR (Pyramidal) s) — Cause of 153 Definition and description. . . 176 Pathogenesis 100, 176 Varieties and identity lOl C. POLARIS ANTERIOR AC- CRETA 179 C. POLARIS ANTERIOR AC- QUISITA— G-enesis 178 C. POLARIS ANTERIOR CONGENITA— Description and Genesis 177 C. POLARIS POSTERIOR in RETINITIS PIGMENT- OSA— Anatomy, Description, Gene- sis and Diagnosis 205, 206 Nutrition of 207 C. POLARIS POSTERIOR SPURIA— Description and Genesis 144 C. POLARIS POSTERIOR VERA— Diagnosis and Genesis. . .180, 185 C. PROGRESSIVA— Definition 113 C. PUNCTATA— Cause of 39 Description and Pathogenesis. 196 Varieties 197 C. PUTRIDA— Definition 113 C. STATIONAIRE— Definition 113 C. SECUNDARIA, (Acute In- flammatory) 99 C. SECUNDARIA, (Simplex)— Cause of 310. 335, 364 Definition 114, 339, 257 Genesis 98, 339 Origin 99 Presence of Vesicles 88 Varieties 99 0. SECUNDARIA ACCRETA COMPLICATA— Cause of 340 Course, Definition, Clinical Histor}' 258 Interference with Vision, cause of 258 Operation 351 Pathology 352 Sequellae 352 C. SENILIS. (Senile Grey C.)— Aetiology 59, 76, 81, 96, 135, 234, 240, and 241 Albumen, Increase 72 Cataract, (Origin of Word) . . 109 Changes Incipient 77 Classification 113 Clearing up of 261 Clinical Data 232 Colors, perception of 132 Definition. . .17, 59, 104, 113, 232 Diagnostic features 116 Facial Appearance of Patient. . . 125 Genesis 78, 96, 234 His/tor}^ of .104, 116 Influence of Refractive Con- ditions 132 Light, perception of 131 Luxation Spontaneous 153 Measurements of 304 Microscopical changes. 80, 97, 232 Myopia during cataract for- mation 61, 126 Opacities, frequency of 205 Opacities, increased by punc- ture of Anterior Chamber.. 264 Pathology 75, 76, 79, 332 INDEX — Continued. 587 Pathogenesis 99 Predisposition to Heredit- ary 835, 341 Prognosis to second affected eye 347 Refractive Conditions. . .126, 133 Resorption Spontaneous 262 Ripeness of '^^, 833 Symptoms, Subjective 123 Varieties 113 Vision, interference witli.125, 129 Volume, reduction of "9 C. SENILIS PRAEMATURA— Aetiology 830 C. SENILIS PRAEMATURA NUCLEARIS— (See also C. Nuclearis). Clinical History. Course, Gen- esis, Prognosis 231 C. SENILIS PRAEMATURA PUNCTATA (See C. Punctata.) C. SPURIA— Definition .112, C. SPURIA ANTERIOR— Cause of C. SPURIA POSTERIOR— Cause of C. STATIONAIRE— Definition 113 C. STELLATA 116, 198 C. of SUDDEN DEVELOP- MENT 216 C. TOTALIS— Definition 113 Refraction 185 Vision 125 C. TRABECULARIS 115 C. TRAUMATICA— Aetiology 81, 137, 250 Clinical Description 250, 254 196 115 144 144 Color of 254 Complications 252 Definition 115, 250 Pathology 81. 255 Prognoas 298 Treatment 367, 365 C. TREMULA. (Vel Natalitis)— Aetiology 153, 214 Definition 115 C. VERA— Deiinition 112, 115 C. ZONULARIS, (Lamellar C.)— Aetiology 189 Anatomical Examination 184 Clinical Histon' and Descrip- tion 182 Differentiation from — Nuclear Cataract 182 Senile Cataract 183 Lamellae, number of involved 183 Nystagmus 185 Occurrence in both eyes. . 183, 189 Pathogenesis 38, 192 Transition to Senile C 183, 188 Time of Development 195 Vision, degree of 125, 188 Volume 183 CATARACTOUS REMAINS— Effect on Vision 334 Element of Danger 335 Sequelae 336 CENTRAL PLANES 39 CHOLESTERINE— Amount in — Normal Lens 62, 63 Cataractous I^ens 66, 123 All ages of life 66 CHOROIDITIS SEROSA— Effect on Position of the Lens 168 CILIARY BODY— Contraction after Extraction. 364 Detachment of 353 588 INDEX— Continued. Function 36 CYCLOPS— Injury of 155 Description, Aetiology. . .142, 143 Irritation 352 CYSTOID CICATRIZATION. 331 Tension on 352 DAVIEL, JACQUES— Violent traction on, during Sketch of his life.— Value of Extraction 367 368 his work 272, 280 COETEX 49 DIAPHRAGM— COCAINE— Use in diagnosis of 128 Effect of its use during Ex- DIPLOPIA— traction 317, 324 After Cataract Extraction . . . 413 Histon^ of 116 Monocular Luxatio Lentis. . . 153 COLOBOMA LENTIS— Mono.cular Ectopia Lentis. . . 148 Genesis and Description 146 DISCHARGE of natient from COLOBOMA TOTALI OCULI- _ physician's care 363 Causation of 138, 140 DISLOCATIO LENTIS. (See COMA DIABETIC 230 Luxatio.) CONCUSSION OF EYE- DISCISSION. (See Operations.) BALL— DRUSEN— Effect on cataract forma- Genesis 83, 84, 101, 339 tion 160, 251 ECTOPIA LENTIS— CONJUNCTIVA BULBI— Genesis Involvement in operation .... 312 General Consideration, His^ CORNEA— tory, Ohjective, Symptoms, (See Operations.) Symptomatology 148, 150 Ulceration Secondary to Glau- Free movement of Lens 162 coma after Luxation 165 ELECTRICAL TREATMENT Varying thickness of 326 FOR CATARACT 260 CORNEAL CURVATURE— ENTOPTIC OBJECTS... 127, 408 After Extraction Astygmatism In Luxatio Lentis 152 IiTCgular 348 391 ENZYM 95 Astygmatism Regular EPITHELIUM of ANTERIOR Radius of Curvature 375, 377 CAPSULE— CORNEAL MICROSCOPE. . .. 122 Changes due to age. . 51 CRYSTALLOCONUS. (See Foetal Origin 19 Lenticonus.) Foetal Development 21 , 22 CRYSTALLINE PEARL. (See Formative cells 86 also Sommering's C. P.) Function of 249 Occurrence after Reclination. 290 Genesis of new cellular for- Pathology of 88, 98 mations 97, 98 CYCLITIS— Histology of 52 After Luxation 158, 159 Hyperplasia 59, 85, 96, 310 After Operation 353 Karyokinetic changes 42 INDEX— Continued. 589 Patlio«i-enesis of restricted re- production 103 Pathological changes — Atrophic nev\^ cellular for- mations 84, 101 Degenerative 83 Hyperpalsia 100 Perverse 98 Progressive 96, 100 Eegenerative 84, 161 Retrogressive 103 Reaction, after opening the Capsule 309 Sizeof 41, 53, 85 EPITHELIUM of the POS- TERIOR CAPSULE— Genesis 85, 86 Pathology 85 Pseudo Epithelium 87 ERYTHROPSIA 408 ESERINE— Use of 300, 302, 361 Value of 301 EXTRACTION. (See opera- tions.) FAT in Senile Lenses — Ox Lens 63, 66 FOCAL ILLUMINATION. ... 117 FIBRES LENS— Abnormalities 38 Arrangement — Foetal 20, 23 Extra-uterine 35 Attachment, mode of. .33, 36, 39 Development of — Foetal 21 Second period 31 Third period 33 Distal 30 Focal illumination 11''' Formation of new fibres 41 Formation, limitation of by Intracapsular pressure 97 Grow til — Pktra-uterino 37, 38 Foetal 22, 33 Irregularities of 38 Length of extra-uterine. . .25, 35, 36, 37, and 42 Length of foetal 33 Morphological changes 49 Nuclei of. (See Nuclei.) Origin, line of 35 Physical changes 50 Proximal 30 Proximal, transition of 31 Refraction, index of, in- crease 50, 60 Retrogressive changes 103 Serrated . . . .' 49 Vascuoles 83 Vitreous, action of , on 354 FIELD OF VISION— Contraction of, in Aphakia... 405 Defects 134 Importance of determining oefore operation 134 FOCAL ILLUMINATION.... 117 Edge of Lens 119 FORMATIVE CELLS 43, 86 GERONTOXON LENTIS. .77, 361 GLASSES, CATARACT— Centering exact 407 Cylindrical correction 404 Influence of 405 Selection of proper 377 Spherical correction 403 Time to begin use of 353, 364 GLOBULINE 63 GLAUCOMA— Idiopathic 356 Influence on Position of the Lens 168 Producing opacities of Lens . . 192 Secondary to Atropine. Use of 354 59° INDEX— Continued. Cystoid Cicatrization 328, 354 Depression 288, 294 Discission 297, 368 Extraction 310, 353 Healing of Wound 165 Injuries of the Lens 366, 368 Luxation of Lens into ante- rior chamber. 160, 161, 163, 165 Spontaneous sinking of a Cat- aractous Lens 371 Symptom of, and prevention of 337 Subluxation 158, 159 GEAEFE, VON— Historical notes 276 Estimate of his work 279, 280 HAEMATIN in the Lens 122 HEAT— Influence of, on the Lens. ... 51 HEMOERHAGE INTRAOCU- LAR— Choroidal, avoidance of 165 Concussion et Contusione. . . . 251 Cause of 311 During Extraction 315 During Extraction of freely movable lenses 166 During healing process 345 Retinal 311 Seleronyxis 285 Iris from 306, 317 Intra-Choroidal 315 HISTOLYSE 96, 256 HYALINE DEPOSITS 40 HYALINE EXCRESCENCE . . 83 Genesis of 84 HYALOID ARTERY— Influence on Cataracta Mem- branacea Congenita Ac- creta 143 Malformations of Lens Sys- tem ". . 138 HYDROPTHALMUS 338 HYDROPSICAL CELLS 88 (See Wedl's Cells.) Genesis of 103 HYPERMETROPIA— Acquired 17 INTRACAPSULAR P R E S - SURE— Limitations of 97 INDENTED LENS. (See Notched Lens.) INJURIES of Lens, Recent— (See also C. Traumatica.) Treatment 365 INTERFIBRILAR SPACES.. 39 IRIS— Differentiation of Cicatriza- tion of stump 331 Hemorrhage from 306, 317 Hyperaemia of 333 Involvement in Simple Ex- traction 312 Prolapse of, cause an sequel- lae 301, 332 Shadow in Senile Cataract. ... 234 Tension, effect of, on 330, 331 IRITIS— Plastic, (after operation) 333 Relapsing 334 Suppurative 343 Secondary to Lens in the An- terior Chamber 163 Traumatic, (Simple) 332 IRIS SHADOW 233 IRIDECTOMIE— Advantages vs. disadvantages of 275,279,300, 301,-312 Aesthetic objections to 302 History of, (in Extraction) . . . 330 Indications for 300 Secondary Cataract, position of in . ". 368 Size of 302, 306 INDEX— Continued. 59' IRIDO-CYCLITIS— Eelapsing form 334 lEIDONESIS— Luxation Traumatic 158 Value in Diagnosis of Apha- kia 372 KERATINE 65 KERATITIS— (Rand K.) Striated 322 LECITHIN— Amount in normal Lens. .62, 63, and 64 LEDGES 40 LENS— Adherence to Cornea 164 Absence of, Total 140, 141 Analysis of Chemical 62 Analysis of Quantitative 64 Calcareous Deposits in 82 Calcification of 201, 296 Changes — Physical 58 Progressive 57 Chemical difference between inner and outer portion of 50, 51 Chemistry of 61 Color, loss of 58 , Cortex of 49 Development of — First Period 19 Second Period 20 Completed 21 Third Period 22 Completed 24 Relation between develop- ment of Eye and Lens 138, 141 Dimensions, Equatorial Sag- ittal 31, 33, 34 Dryness of 58 Displacement of — (See Ectopia Lentis) (See Luxation Lentis) Focal illumination of Foreign Bodies in the — Clinical History and Diag- nosis of Foreign Bodies which penetrate. . . .253, Chemical tests for Reaction to Sequelae of Spontaneous clearing up, after Form of — Attained, Time of 22, Change at Birth Effect of Aqueous Effect on Accommodation. . Growth — Developmental Intra and Extra-uterine . 30, Rapidity of Intra and Ex- tra-uterine 34, Hardness Index of Refraction Injuries of 250, Peripher}- Subsequent Clearing up of . Treatment of Lamellae Lymph spaces Luxation of. (See Luxatio Lentis.) Malformations of Morphological changes Nucleus of. (See Nucleus.) Nutrition- Effect of repeated puncture of Anterior Chamber. 71, Interference with Mode of Theories, Experiments. .53, 58, and 148 150 117 254 257 257 254 254 30 36 36 36 23 31 38 59 59 252 252 254 365 38 57 137 49 264 58 53 71 592 INDEX— Continued. Opthalmoscopic P]xaniination. 118 Oscillation of 151 Ossification of 202 Pathology of 75 Petrifaction of 103 Ph3'siology of 53 Pliysical changes 58 Position of, in fishes 35 Pus in the 94, 95 Refractive medium 3G Relation of Diameter of the Lens to the Diameter of the Eye-ball 33 Retrogression, Physiological.. 48 Role of, in formation of Eye- ball 138, 141 Sclerosis of 79 Specific Gravity 31 Structure of 23 Temperature of 63 Two lenses in one eye 142 Tumors of 102 Vascular Capsule of 138 Volume of 31, 58, 97 Weight and Volume of Cata- ractous Lenses 58, 64, 97 ' Of Foetal Lenses 31, 58 LENTO ALBUMEN— Globuline 62 LENTICONUS— Anterior 169 Posterior 170 Diagnosis, History, Clinical Description 169 Aetiology 173 LENS WHORL 25 TJOHT— Distance at which recognized in Cataract 132 Influence of 35 Perception of Qualitative. . , . 133 Quantitative 130, 132 Prismatic Deflection 129 Projection 133 LIGHT SENSE— Determination of in Cataract . 131 LINSENWIRBEL 25 (See Lens Whorl.) LIQUOR MORGAGNI 115 LITERATURE 415 LUXATIO LENTIS— Acquired; AnomaHes of posi- tion 150 Freely movable lenses 162, 165 Spontaneous — Cause of 74, 152, 166, 249 DescriptionyClinical History, Symptoms.150, 152, 154,' 266 In Cataractous Lens 266 Therapy 370 Subluxatio — Aetiology 160 Prognosis, Symptoms and Treatment 158 Dangers 163 Totalis— Adherent to Cornea 164 Causation, Symptoms, Di- agnosis, Various Posi- tions 166, 167 Treatment 160, 167 Into Vitreous 161 Into Anterior Chamber... . 163 Traumatica — Causes, Results.. .154, 157, 166 Secondary 167 MATURATION OF CATA- RACT 264, 357 MEMBRANC CAPSULO PU- PILLARIS— Origin of 28 MENTAL DERANGEMENTS after Operation 363 MICROPTHALMUS— Aetiology 139, 140, 141 Condition of Lens in 140 INDEX— Continued. 593 MORGAGNI'S GLOBULES— 39, 40, and 80 MOTHER CELLS 42 MOUSCHES VOLAXTES. ... 128 NAPTHALIN E X P E R I - MENTS 57 NOTCHED LENS 169 NUCLEI OF FIBRES— Death of 41, 50 Diminution of 51 Increase of 41 Position of Extra-uterine . . 25, 37 Position of Intra-uterine. ... 20 Size of 41, 85 NUCLEUS— Chemical Constitution . 50, 66, 334 Color Embryonal . . Influence on tion Role in Cataract tion 49 133 232 .22, 30, Percep- .. .132. Forma- 80, Softening in Cataract Forma- tion 82 Weight and Volume 245 NUCLEAR CURVE 25 NUCLEAR ZONE 25, 37, 51 NYSTAGMUS 125, 129, 175 OPEEATIONS. DISLOCATIO, (Depression, Reclination) — Anatomical conditions pro- duced by 285 Anatomical examination of operated eye 288 Capsular changes 288 Resorption of 292 Zonular connections 289 Conditions affecting results of operation 286 Definition 265 Historical review of the opera- tion 266, 274 Per K eratonyxis — Derivation of word Definition Effect of History and legends 268, Lens — Calcification of Enclosure in new C. T.. ..293, Fate of Path which Lens takes Position of 290, Resorption of Secondary mounting up of . . . 285, Volume of Vitreous — Reaction to Fuidity of Effect on Lens Per Scleronyxis — Definition Structures involved Value of the operation Scleronyxis Cum Discissio — Evil effects of Results, conditions bearing on final results Complications Incomplete Secondary mounting up of the Lens 288, A'arious Methods 265. DISCISSIO, CATARACTAE— (Discission.) Definition History of Instruments used Indications for 215. Patholocfical processes subse- quent to operation Prognosis, Treatment Results of Discission Spastic contraction of pupil . . Sequelae 281 26(i 284 282 296 294 290 293 294 292 294 291 293 294 286 266 284 268 285 287 287 287 294 267 280 269 296 299 299 298 297 298 298 594 INDEX — Continued. Discissio C. Cnm Keratonyxis- History of •2 8 -3 EXTRACTION— Definition 270 Length of time of operation . . 307 Steps of operation 304 Cystotomie — Mode of procedure. .306, 307, 350 Globe — Condition of. After Ex- traction — Anterior Chamber, introduc- tion of air or blood .... 313, 318, and 326 Cornea, creasing of; funnel- shaped depression 312 Conjunctiva Bulbi, involve- ment of 312 Contents of; change in rela- tive portion 310 Effect of constant fixation of. 312 Elasticity of Coats of Eye-ball. 311 Iris, involvement of 312 Pressure on, Effect of 311, 313 Vitreous, detachment of 311 Volume 310 Healing Process. — Abnormal Conditions Developed — Anterior Chamber, restora- tion of 336 Depth of 337 Cataractous remains — Effect of 334 Element of danger of 335 Sequelae of 335 Corneal Phthisis 341 Cystoid Cicatrization, Causa- tion and Clinical History of. Iris in Wound 327 Capsule in the wound 327 G-laucoma 337 Iritis 331 Adhesive 332 Hyperaemia of 332 Plastic 333 Relapsing 334 Irido Cyclitis 331, 334 Stump of Iris in the wound. . 331 Sympathetic Opthalmia. .155, 315 Sympathetic Irritation 352 Wound — Late closure, cause of 337 Permanent closure 302, 336 Time of healing 336, 364 Incomplete Results 338 Cataracta Secundaria, forma- tion of 338, 339 Cataracta Complicata, forma- tion of 340 Cornea — Infection, Clinical History and Treatment 341 Phthisis; Clinical History and Treatment 341 Cyclitis; Clinical Histor}^ and Treatment 343, 353 Hemori'hages; Causation and Clinical History 345 Iritis Suppurative 343 Panopthalmitis 342 Phthisis Bulbi 344 Tension of Cicatrized Iris, Capsule in the Wound .... 349 Vitreous, infection of, and se- quelae 344 JDetachment of 353 Incision — Corneal Flap,(Daviel Incision) — Character and form of the wound 273, 274, 299, 303 Description of and varie- ties 273, 277, 299 History of 270 Incision, size and rationale of 303 INDEX — Continued. 595 InstrumeiTts upcd 274 Objections to 299 Position sjid Measuromonts. 347 Peripheric Flap 279 Corneal Flap. (Sfrlhrnr/ de Weclcer) .300 Definition and description of 279. 300 Tendency of wound to <::ap. 348 Value of operation? 301 Varieties 270 Scleral Flap — Character of 300 Posterior scleral 270 Jarohson Flap — Character of 300 Linear — Applicahility of 300 Description of 308 Dangers of 308 Historical Importance 309 Linear, Simple. (Van Graefe) — Advantages of 303 Character of 278, 299 Graefe Knife 300 Indications for 299 Size and rationale of... 277. 303 Linear Peripherir. (Von Graefe) — Advantasres of 275, 328 Character of 300 Dangers of 279 HistOTv of 275, 277 Incision, principle of 278 Position and measure- ments 347 Tendency to gap 348 Losses, percentage of 278 Infection 283 Iridectomie — Aesthetic objection to 302 Advantages versus disadvan- tages. . .275, 279, 300, 302. 312 Preparatory — Its advantage and histor\'. . 275, 277 History of 330 Reasons for broad Coloboma 330 Size of 306 Irrigation — y\nterior chamber and intra- capsular injection; histor- ical review and method of procedure 318 ^latu ration — Indications for 357 Also in Cataracta Senilis Praematura 232 Operation — General Statement 18 After-treatment 307, 3fil Air in the anterior chamber. . 318 Capsule — Eeaction of 310 Incarceration 314 Cataractous Remains, reten- tion of 314 Hemon-hages. restricted to anterior chamber 317 Intraocular 315 Incision, too large or small . . . 313 Infection 313 Iris, Prolaj)S(' and Cicatriza- tion 314 Personal Equation of Op- erator 346 Of Patient 347 Pain, significance of 362 Purpose of 265 Preparations for 204, 360 Reaction 307. 362 Steps of... 304 Sterilization of instrument and Evewater 304, 318, 319, and 331 596 INDEX— Continued. Success, conditions for... 304, 309, 34G, and Time for 307, 357, Vitreous-Prolapse Procedures and Changes during and. subsequent to cataract ex- traction \Vound, (Corneal) — Cicatrix, formation of Cloudiness after extraction . . . Depression and cause of Epithelium, erosions of. .313, Irregular Healing — Irritation due to pigmenta- tion of cicatrix Cicatrization of Iris in the wound Sequelae of Keratitis, various forms. .322, Late closure, cause of Observations of the regular healing of Cornea; com- plicated character of . . . . a. Puncture b. Linear c. Flap Permanent closure Eemoval of first dressing Sclero-Corneal Time of healing of wound . . . 336, PAGENSTECHEE'S OPEEAl TION, (in the Capsule)... 73, 276, Genetic Basis for PiECLINATION— Indications for in Cataracta Membranacea (upward).. . . (See Dislocatio.) SUCTION OPERATIONS, (SECOND- APY) TndicMiJons ;mo 361 414 314 283 321 324 325 323 348 349 352 323 337 320 320 320 321 336 320 322 364 310 257 214 282 365 365 O]iorations — Cataracta Secundaria 367 Iridectomie 368 Agnew; Weber; Do Weeker; Mooren; Kruger; Bowman. 369 Noyes 370 Treatment — Pecent injuries 365 True Traumatic Cataract. . 367 OPTHALMOSCOPE 77 Diagnostic value 118 Histor}^ of 116 Refracting Opthalmoscope. . . 119 Use of in — Aphakia 412 Diagnosing Cataract 77 Diagnosing opacities in me- dia 120 OPTIC VESICLE— Primary cause of formation. 141 OP lUTAL CYSTS— Aetiology 139 Description 140 OSSIFICATION OF LENS. . . 202 PAIN— Significance of, in healing of corneal wound 362 PAGENSTECHEE. (See Ope- rations.) PANOPTHALMITIS 315 Effect on Lens 168 Clinical History, Causation, Symptoms 340, 342 PATHOLOGY of Lenticular Cataract 75 History of 75 Microscopical changes 80 PETIT'S CANAL 47 Operations, value of, in Sec- ondary Cataract 351, 369 PETPIFACTION OF LENS. . 103, 201 INDEX— C PAOF, I'lIAKJTTS— Duration, Clinical History and Description 240. 339 PHAK(VSrDKl?OM •? I? PHOTOMETER 131 PHTHISIS BULBI— Clinical History and Cause . . . 1G3, 340 POLYOPIA MONOCULAETS. 128 PORES in CAPSULE 55 PRESBYOPIA 17 PRESSURE, INTRACAPSU- LAR 97 PURKINJE ARTERIAL pic- tures 130 PURKINJE, SANSON, figures. 121 Value in diagnosing Aphakia. 373 PUPIL APHAKIC— Conditions in 372 Conditions of. in cicatrization of Iris in the wound 330 Occlusion of 340 Position of in Secondary Cat- aract ' 341 Seclusion of 333, 341 PUPIL— Value of consensual reaction during cataract formation.. 131 REFRACTION, INDEX OF IN THE LENS 59 Development of Myopia, in cataract formation GO, 61 RETINA— Determination of perception of light 132 Importance of 13 1 RETROGRESSION, PHYSIO- LOGICAL, of the Lens .... 31 RESORPTION OF CATA- RACT— Spontaneous 262 SYMPATHETIC OPTHAT^ MIA 155, 315 597 ONTINUED. VMiK RIPE CATARACT— Origin of expression 234 RIPENING OF CATARACT. . 264 Senile Sclerosis 17 S F.AM 8— Definition and I'or- mation 21, 23, 25 SKIN — Condition during cat- aract formation 326 SOEMMERING'S CRYSTAL- LINE PEARL 88, 98, 258 STAAR— (See Cataract.) ST A A R-FIG URE— Arrange- ment of (Tri-star, or three rays) ^:^. '^^ Cause of 24, 37 Complicated figure 34, 37 Significance of 24 Types '^-^ SCLERA— Rupture and Results 166 STAPLYOMA, Corneal 332 (See Cystoid Cicatrization.) STAPHYLOMA— INTER-CALARE,due to Len< in anterior chamher K'3 EfPect on Lens Ki'"^ STAPHYLOMATOUS VESI- CLES— Treatment -^32 STRABISMUS— (After operations) 413 SUBLIMATE— Use in operating 324 SUBLUXATIO LENTIS— Aetiology, Prognosis, Symp- toms, Treatment 158 SUGAR IN AQUEOUS—. ... 71 Tvcns, Chemistry of 67 Vitreous 71 SYMPATHETIC IRRITA- TION 353 598 INDEX— C TAGE SYNCHISIS CORPORIS VIT- REI t^, 151 TEARS, INDEX OF REFRAC- TION 375 TEETH— Hutcliinsou, Rachitic 191 TE.MPERATURE WITHIN THE EYE-BALL 62 THERAPEUTIC Value of Heat 63 THERAPY OF DISEASES OF THE LENS— Medicinal 260 Prophylactic 261 Spontaneous 261 TUMORS— Pathogenesis of 102 VACUOLES in the Lens Fibres. 82 VASCULAR CAPSULE of the Lens; Importance in Mal- formations of Lens System. 138 VESICLE, Primary Indenting.. 141 VESICULAR CELLS— Genesis 85, 87, 98 Retrogressive changes. .. 103, 246 VISION— Age-advancing 248 Acuity of, in Aphakia 387 Binocular, in Aphakia 412 Cataractous Remains 334 Cicatrization of Iris in wound. 330 Diminution in Aphakia. .330, 339, 348, and 388 Disturbances of 123 Glasses, effect of 405 In Aphakia 365 In Cataract 127, 130 Piirtial Cataract 124 ONTINUED. PAGE VITREOUS— Action in Lens Fibres 254 Albumen in 71 Chemistry of 69 Destruction of, by action of foreign bodies 161, 203, 285 Detachment 311, 353 Effect on, in Reclination.286, 294 Examination of, in young Fluidity of 151, 286 children 213 Infection of 344 Opacities noted in cataract formation 205 Prolapse of, in Capsulotomie . . 309 During Operation. 165, 166, 314 Historical notes 315 Refraction, index of 70, 374 History of 108 Sugar in 71 VORTICES LENTIS 35 W^ATER— Amount in Normal Lens. .62, 63 Amount in Cataractous Lens . 63, 8'^ WBDL'S VESICULAR CELLS, 87 Characteristics 88 Differentiation 40, 52, 59 Genesis and development. ... 87 WHORL 25 ZONULA ZINII— Anomalies of formation 74 Atrophy of 73 Action of Aqueous on 36 Development of 27. 'Id Elongation and Distention . . . 15() Focal Illumination 117 Function of 3(;, 18 Genesis of 47 599 INDEX— Continued. i'Ai;i; VAi.i: Historical T?evie\v 27 Scmicsciuh' of 7)}. lo3 Hypertropliy of 73 Tears of — Influence of, on Lens fibres. . 30 During depres^sion 389 Lcngtlieninp^ of, Congenita!. . 1(!3 ]\l('clianism of 1-59, 108 Malformation, result of 146 Partial 157, 158 Origin and insertion of 47 Tears of Zonula et Capsule... 251 Pathology of 73 Thickening of 214 Results of 150, 154 Varieties of Fibres 48 Solution of Continuity. ...74, 149, and 151 mm ' M.;JS 5 , f>-if f" t