The into Enj ES. >d translations THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES actness, and esides numer- :ecuted by the an twenty un- gate is accom- xmtains a con- devoted, at they offer a ion. Such ob- edical centers; ears of routine cs these books ilete and con- rk, interpreted profession has works because which i cheapr Eac ous illu: most s\ pressior panied 1 densed Oik ready i servatic and ev< hospita will be venient by the WI heretofuic uccn p.cvv....^..^ r — of their extremely high price, made necessary by a limited sale and an enormous expense of production. Now, however, by reason of their pro- jected universal translation and reproduction, affording international dis- tribution, the publishers have been enabled to secure for these atlases the best artistic and professional talent, to produce them in the most elegant style, and yet to offer them at a price heretofore unapproached in cheapness. The great success of the undertaking is demonstrated by the fact that the volumes have already appeared in thirteen different languages-German, English, French, Italian, Russian, Spanish, Dutch, Japanese, Danish, Swedish, Roumanian, Bohemian, and Hungarian. The same careful and competent editorial supervision has been secured in 'he English edition as in the originals. The translations have been edited by the leading American specialists in the different sub- jects. The volumes are of a uniform and convenient size (5 x 7^ inches), and are substantially bound in cloth. (For List of Books, Prices, etc., see back cover and Hy-Ieaf ) Pamphlet containing specimens of the Colored Plates sent free on application ATLAS AND EPITOME OF OPERATIVE OPHTHALMOLOGY BY PROF. DR. O. HAAB of Zurich AUTHORIZED TRANSLATION FROM THE GERMAN WITH EDITORIAL NOTES AND ADDITIONS EDITED BY G. E. DE SCHWEINITZ, A.M., M.D. Professor of Ophthalmology in the University of Pennsylvania Ophthalmic Surgeon to the Philadelphia Hospital ; Ophthalmologist to the Orthopedic Hospital and Infirmary for Nervous Diseases With 30 Colored Lithographic Plates and J54 Text-cuts PHILADELPHIA— NEW YORK— LONDON W. B. SAUNDERS AND COMPANY 1905 Copyright, 1905, by W. B. Saunders & Company. Registered at Stationers' Hall, London, England. ELECTROTYPED BY PRESS OF WESTCOTT & THOMSON, PHILADA. W. B SAUNDERS & COMPAC EDITOR'S PREFACE. This volume forms a natural and admirable conclusion of the series of Atlases which Professor Haab has pre- pared and published. Beginning with a thorough discus- sion of the proper construction of operation-rooms, narcosis both general and local, sterilization as it is applied to ophthalmic instruments, and the theory and practice of disinfection, the main operations upon the eye and its appendages are described with characteristic fidelity and clearness. The thirty colored lithographic plates portray in a far more satisfactory way than words can the steps of an operation. Next to seeing an operation itself, these are of value, and in most instances give a view of lifelike accuracy. What is omitted in the colored plates is sup- plied in the text illustrations, of which there are one hun- dred and fifty. As in the previous volumes of this series, one is im- pressed with Dr. Haab's wide experience, admirable technic, and sound judgment. The editor, as in the pre- vious books of this series, has compared the translation with the original, and believes that it conveys with faith- fulness the author's meaning. Editorial comments are 5 6 EDITOR'S PREFACE. placed in brackets, and a few operations not described by Professor Haab have been inserted. This book should prove useful not only to students of ophthalmology who may not have the opportunity of witnessing frequently operations upon the eye, but also to those whose daily work is concerned with the operative side of ophthalmic work. January, 1905. PREFACE. The great abundance of material made it necessary to exercise a certain selection in this Atlas and Epitome of Operative Ophthalmology. I was guided in my selection chiefly by my own practical experience, which covers a period of almost thirty years ; but let me say at once that I am not familiar with all the methods of operations de- scribed in this work from personal experience with them. In the case of most of them, however, I have determined their advantages by testing them myself. In doing so I found out that it is not only necessary, but also most in- teresting, for the operator to resort from time to time to other methods besides those on which he was, so to speak, brought up, and which have become a part of him. I have, therefore, endeavored in this work to describe the various operative interventions in such a way as to enable my colleagues to vary their operative procedures as I myself have done. As a rule, mere verbal description does not suffice to give a clear idea of operative procedures, and pictorial, illustration is therefore indispensable in this kind of work ; for which reason a copiously illustrated Atlas is most desir- able. 8 PREFACE. The text, which has been condensed until it contains only what is indispensable, is intended as a guide to stu- dents, practitioners, and ophthalmologists in the technic of operations on the eve and their various modifications ; and I imagine that assistants who have to prepare an operation will welcome the book because it enables them, without loss of time, to get a general idea of the plan of an oper- ation and the instruments necessary for its performance. In order to demonstrate the usefulness of a special method of operation I have thought it advisable to give the pictures of cases after recovery. On the other hand, I have omitted many geometric drawings of plastic oper- ations which usually embellish the chapter on Blepharo- plastic Operations in most of the current works and text- books, but which are more likely to have seen the light of day at the desk than on the operating-table, and are therefore of questionable usefulness, especially since the introduction of Thiersch's method of skin-grafting has made so many changes in this branch of surgery. The illustrations of the instruments in this work were obtained by reproducing the photographs made under my direction by Messrs. H. and E. Butcher, of Zurich, after reducing them one-tenth ; except in two groups, those for Krönlein's operation, for which, on account of the size of the instruments, a reduction of one-half was found to be necessary. The instruments which are here represented were obtained in the course of years from the following PREFACE. 9 firms : Weiss & Son, 287 Oxford street, London, W. ; H. Windler, Friedrichstrasse 133 a, Berlin ; H. Wulfing- Liier, 6 Rue Antoine-Dubois, Paris ; G. Tiemann & Co., New York ; and Chambers, Inskeep & Co., Chicago ; but I do not pretend to say that other instrument-makers do not also furnish very good instruments of the kind. I am indebted to the artist, Mr. J. Fink, for the prepa- ration of the remaining pictures, many of which presented considerable difficulties. I am also indebted to the publisher, Mr. Lehmann, for his efforts in connection with the preparation of this Atlas. 0. HAAB. LIST OF LITHOGRAPHIC PLATES. Plate 1. — Introduction of a Pencil of Iodoform into the Anterior Chamber in a Case of Infection by a Foreign Body. Plate 2. — Operation for Senile Cataract. Plate 3. — Reposition of the Iris with the Spatula at the End of an Operation for Senile Cataract. Plate 4. — Operation for Secondary Cataract, after Bowman, with Two Needles. Plate 5. — Operation for Secondary Cataract with Knapp's knife in- troduced through the Sclera. Plate 6. — Iridectomy in Glaucoma. Plate 7. — Inferior Sclerotomy. Plate 8. — Advancement of the Right Interims in Divergent Strabismus, after Prince. Plate 9. — Enucleation of the Eyeball. Plate 10. — Opening of the Orbit after Krönlein. Plate 11. — Opening of the Orbit after Krönlein. Plate 12. — Destruction of the Orbit by Carcinoma (Rodent Ulcer). Plate 13. — Fig. 1. — Pagenstecher's Ptosis Operation. Fig. 2. — Gaillard's Suture in Spastic Entropion. Plate 14. — Fig. 1. — Blepharophimosis. Fig. 2.— Canthoplastic Operation. Plate 15. — Fig. 1. — Ectropion due to Facial Paralysis in the Second Year of Life. Fig. 2.— The Same Eye after Six Months, after Median Tar- sorrhaphy with Szymanowsky's Modification. Plate 16.— Senile Ectropion with Senile Cataract (see Plate 17). Plate 17. — Fig. 1.— Kuhnt's Ectropion Operation in Same Patient. Fig. 2. — Same Eye Three Months after the Operation and One Month after Cataract Operation without Iri- dectomy. Plate 18.— Fig. 1.— Senile Ectropion. Fig. 2.— Same Eye Immediately after Kuhnt's Ectropion Operation with L. Mailer's Modification. Fig. 3.— Same Eye Three Weeks Later, after Recovery. 11 12 LIST OF LITHOGRAPHIC PLATES. Plate 19.— Fig. 1.— Severe Cicatricial Ectropion. Fig. 2. — The Same Eye Six Months Later. Plate 20. — Fig. 1. — Cicatricial Ectropion. Fig, 2. — Showing the Wound before the Skin-grafting. Plate 21. — The Same Eye Two Weeks Later, after Uninterrupted Re- covery. Plate 22. — Enormous Cicatricial Ectropion. Plate 23.— The Same Eye Three Months after the Last Operation. Plate 24.— Fig. 1.— Cicatricial Ectropion after a Dog-bite. Fig. 2.— Condition of the Eye Fifteen Months Later. Plate 25. — Fig. 1.— Complete Symblepharon and almost Complete Ankyl- oblepharon. Fig. 2.— Eecent Burn on the Lower Portion of the Conjunc- tival Sac. Plate 26.— Figs. 1, 2.— The Symblepharon which had Meanwhile Devel- oped was Treated by Operation. Plate 27. — Large Carcinoma. Plate 28.— Shows the Patient's Condition when Discharged. Plate 29.— The Same Patient after the Carcinoma had Recurred and had again been Removed. Plate 30.— Fig. 1.— Extirpation of the Tear Sac. Fig. 2.— The Extirpated Tear Sac, which had probably not been Reached by the Incision and Curettage Re- ferred to. CONTENTS. PAGE General Considerations 1? Hospital Wards and Operating Rooms 18 Anesthetization 25 Local Anesthesia 26 Sterilization, Antiseptics, and Asepsis 33 Bandaging 45 Salivary Infection . . . . 59 Disinfection ... 68 Instruments 76 Operations on the Globe 81 Operation for Cataract 81 Indications , 85 for Removal of Total Juvenile Cataract 102 for Total Soft Cataract of Adults 108 for Traumatic Cataract 108 for Partial Stationary Cataract 112 for Seuile Cataract 118 Preparatory Treatment 124 with Iridectomy 136 without Iridectomy 142 Modifications 148 Accidents and Mistakes 154 Method of Applying Dressing and After-treatment .... 162 Accidents Interfering with Healing of Wound After . . 163 for Secondary Cataract 166 Treatment of Operation for Senile Cataract by Couching and Depression 174 Operative Treatment of Dislocation of the Lens 175 Removal of the Lens in High Myopia 176 Iridectomy 179 Optical Iridectomy 180 For Relief of Increased Tension 186 Sclerotomy 196 13 14 CONTENTS. PAGE Operations on the Cornea, Sclera, and Conjunctiva 202 Eeruoval of Foreign Bodies from Cornea 202 Puncturing the Cornea 206 Operation for Pterygium 208 The Utilization of the Conjunctiva to Cover Defects in the Cornea 210 Tattooing of the Cornea 210 Eemoval of Dermoids . 212 Staphyloma of Cornea . 213 Operations in the Anterior Chamber 215 Separation of Anterior Synechias 215 Separation of Posterior Synechia? 216 Removal of Foreign Bodies from the Interior of the Eye .... 216 Eemoval of Spicules of Iron from the Eye (Magnet Opera- tion) 216 Eemoval of Foreign Bodies not consisting of Iron . . . 237 Operations Outside of the Eyeball .... 239 Operations on the Ocular Muscles 239 Strabismus 239 Tenotomy after von Gräfe 242 Tenotomy after Arlt 245 Tenotomy after Snellen 246 Operations on the Antagonist of the Squinting Muscle . . . 249 Knapp's Method 249 Weber's Method 249 de Wecker's Method 250 Landolt's Advancement 252 Prince's Operation 253 Verhoeff's Operation 254 Worth's Method 255 Capsular Advancement after de Wecker 256 Knapp's Method 257 Todd's Method 258 Brand's Method 258 Schweigger's Method 258 Roster's Method 259 Miiller's Method 259 Enucleation of the Globe 265 Eesection of the Optic Nerve 274 Exenteration or Evisceration of the Globe 275 Artificial Glass Eyes 278 CONTENTS. 15 PAG E Operations on the Orbit 279 The Eemoval of Tumors from the Orbit 281 Krönlein's Operation 284 Exenteration of the Orbit 291 Operations on the Lids and in the Conjunctival Sac 295 Operation for Ptosis 295 Pagenstecher' s 297 de Wecker* s 297 Dransarfs 297 Hess' 298 Pana's 300 Motais' 300 Eversbusch's 302 Snellen's 303 Wolff's 304 Lapersonne's 305 Elschnig's 306 Gillett de Grandmont's 307 Operations for Entropion 308 Gaillard's Suture 309 Destroying Roots of Cilia by Electrolysis ........ 309 Spencer Watson's 311 Hotz's 311 Entropion Operation with Advancement of the Levator Tendon 314 Streatfield's 316 Snellen's 317 Hotz's Tarsus Excision for Trichiasis of Upper Lid ... 317 Division of the Tarsus after Panas 318 Pfalz's 319 Ablation of Ciliary Border after Flarer 320 Displacement of Ciliary Border after Jasche-Arlt .... 320 Operation for Blepharophimosis 321 Canthoplastic Operations 321 Tarsorrhaphy 302 Operations for Ectropion 323 Snellen's Suture 324 Szymanowsky's m 304 Kuhnt's Operation 325 Blepharoplastic Operations 328 Fricke's 329 16 CONTENTS. PAGE Dieffenbach's 331 Thiersch's Method of Skin-grafting 332 Operation for Symblepharon 337 Operations on the Conjunctiva 345 Operations on the Lacrimal Organs 347 Simple Eversion of the Lower Lacrimal Punctum . . . 348 Dacryostenosis 350 Dilation of the Nasal Duct by Means of Sounds ... 353 Extirpation of the Tear Sac . 357 Literature 361 Index OPERATIVE OPHTHALMOLOGY. GENERAL CONSIDERATIONS. Since upon the .success of an ophthalmic operation, especially an operation for cataract or glaucoma, depends not only the sight of the affected eye, but also that of its fellow, because any operation in which the globe is opened may be followed by sympathetic disease of the other eye — for these considerations an operation on the organ of sight is fraught with great responsibility and should not be lightly undertaken. For most people blind- ness is as bad as death, and for many it is even worse. As an operation on the eye may often be exceedingly difficult and call for the greatest care and skill on the part of the operator, I fully agree with Snellen when he says : " Although it is true that the operative field in ophthalmology is limited and most of the operations are not formidable, it is nevertheless a mistake to regard operative ophthalmology merely as a part of minor surgery and within the scope of every practitioner, as there appears to be a tendency to do from time to time. When an opera- tion on the eye fails to realize the patient's hopes, the eifect is often more tragic than death itself." In operations on the eye a surgeon must be cool, de- liberate, and experienced, or an accident is very likely to happen to him or, rather, to his patient. He must also have well-drilled assistants of the right kind. The most important operations on the eye, particularly those for cataract and glaucoma, arc peculiar in that they must be performed in a short space of time ; and if the 2 17 18 GENERAL CONSIDERATIONS. operator has made a slight mistake, as, for example, in the size or position of his incision, it is often difficult for him to rectify it. Besides, the surgeon is very much de- pendent on the patient's behavior, which frequently spoils the most beautifully planned operation. In such cases nothing but promptness on the part of the operator to do the right thing and the greatest presence of mind will avert disaster. At the same time the entire operative field must be kept constantly in mind during the entire operation — not only the spot where he happens to be busy with his instruments. It. may be asserted with confidence and with entire honesty that an ophthalmic surgeon, be he ever so experienced, never is certain when he begins an uncomplicated operation for cataract how it will end. This feature lends a special character to this operation, which is one of the most important that can be performed on the human subject. Not only the operation itself, but the after-treatment, the subsequent course, and the question of recovery are very much influenced by the patient's behavior. In the same way the nursing and medical treatment which he receives are important features in bringing about the ultimate result. Hospital Wards and Operating Rooms. The question of efficient nursing and treatment is much simplified if the operating room and the wards in which the patients spend their convalescence are properly ar- ranged. By exercising great care and deliberation in the treatment of the eye, from the time of operation until recovery, excellent results may be achieved even under unfavorable external conditions in hospitals and operating rooms which fail to come up to the most modern require- ments. Of course, the man who can give his patients the benefit of the scrupulous cleanliness of a modern hospital will have an easier conscience during the operation, and, on the average, more satisfactory results afterward, pro- HOSPITAL WARDS AND OPERATING ROOMS. 19 vided the nurses and assistants are thoroughly imbued with the principles of modern hospital nursing and the modern treatment of wounds and act according to these principles. The condition of the walls and of the floors has no special bearing in ophthalmic surgery ; but the hands of the nurses who take care of the patients are of the utmost importance. For that reason I should like to mention — aside from the well-known architectural ad- vances of the last decades, which ought to be found in every hospital — the fitting up of every room with running hot water as a chief requisite or at least a great advantage for an eye dispensary of any considerable patronage. If hot water and soap are readily accessible, the attendants will have no objection to cleansing their hands at frequent intervals, and this alone is of value. It has also been found desirable in our clinic at the University, which has now been in operation seven years, to have two rooms adjoining the operating room for patients that have just undergone operation, especially for cataract, one for males and the other for females. The patient's bed is rolled into the operating room, the opera- tion performed while he is in bed, and he is then taken back to his room, so that there is no necessity of lift- ing him from his bed to the operating table, and from the latter back to his bed. I have no doubt that patients who have been operated upon for cataract or glau- coma may be allowed to walk about and go to their rooms, as is the custom in some hospitals, without any great danger of harm arising therefrom ; but it is per- fectly evident that complete rest in a recumbent posture immediately after the operation is not only more agreeable to the patient, but also better for the wound, and that in any large hospital it is more convenient simply to transfer the patient in his bed from the operating room to the ward or private room. Since it is of the greatest im- portance in the case of all wounds that involve division of the capsule of the globe to get primary union, if pos- sible, during the first twenty-four hours after operation, 20 G FNE BAL CONSIDERATIONS. complete rest during the first day is desirable. The patient himself will realize the importance of such pre- caution better if the rest begins immediately after the operation and he is not allowed to walk about for a time before he begins his rest in bed. In my private clinic cataract extraction and iridectomy are invariably per- formed in the patient's own room, and subsequently the latter remains quietly in his bed. This was also the practice of my esteemed master, Horner, both in his clinic and private work. It is possible that this practice is in part responsible for the fact, which has always been a source of personal gratification, that during the twenty- seven years of operative experience (including the time when I was an assistant to Horner) I have had but 1 case — two years ago — of that frightful intra-ocular hem- orrhage, which so treacherously destroys the eye imme- diately or soon after cataract operations. [An operating chair or table, the height or inclination of which can be altered to suit conditions, and the imme- diate surroundings of which can be maintained in surgical cleanliness, is preferred by the majority of surgeons. From it the patient can be lifted readily to the bed he afterward occupies without deleterious effort on his part. —Ed.] It is not necessary to darken the room of a patient recently operated upon. All that is necessary is to arrange the shutters so as to bar out any glaring light that would be equally unpleasant to the normal eye. It is important, however, to see that the ventilation in the rooms is ade- quate, because the patients are often old and their respira- tion is insufficient, so that oxygenation and metabolism are incompletely performed. The enforced rest during the first period should be made more bearable to a patient who has been through an operation for cataract or glaucoma by giving him an electric bell to hold in his hand ; in this way we may guard against fright, which in many cases is, perhaps, the precursor of post-operative delirium, especially when HOSPITAL WARDS ÄND OPERATING ROOMS. 21 both eyes are bandaged. It is possible my habit of impressing my patients with the advantage of the bell, as Horner was in the habit of doing, is responsible for the fact that this complication (aside from delirium tremens) has so far never occurred in my practice. It has the additional advantage of making it very much easier for the patient to remain strictly quiet during the first twenty-four hours after the operation. If a patient becomes excited, in spite of the fact that both eyes are bandaged, the bandage must be removed from the other eye and, in the case of one-eyed persons, from the operated eye also, a wire screen being applied for protection. In the arrangement and illumination of the operating room the same rule- are to be observed as for operat- ing rooms in general. It is a debatable point whether the color of the walls should be as bright as possible, in accordance with modern ideas on hospital arrange- ments, <>r dark ; because in the latter case the amount of lateral illumination is diminished and the operator thus secures a light that is free from reflexes and more agreeable to the eye, as well as better adapted for cer- tain ophthalmic operations. Snellen, after a number of experiments and years of experience, recommends for the walls, floor, and ceiling a dark, dull-black background enlivened with a dark-gray pattern, for the purpose of making a more agreeable impression (a point which I consider of some importance). The north window in the room Snellen has provided with four parallel shades, by means of which the entire window or only a part of it can be darkened. I have also tested this point by way of experiment and operated in a room with black walls, which was generally used for ophthalmoscopy. It is not to be denied that any operations in which the corneal reflex is an important factor and which require the operator's fullest visual acuity such an illumination of the operative field is most desirable and at the same time grateful to the eyes, both of the operator and of 22 GENERAL CONSIDERATIONS. the patient. To be consistent, however, the assistants and other attendants must either wear black gowns or choose their positions so that their white gowns will not reflect the light, But as we also have to perform operations in which a good light from all directions — such as surgeons prefer in their operating rooms — is desirable ; that is to say, opera- tions on the adnexse of the globe, especially plastic opera- tions, extirpation of the lachrymal sac, Krönlein's opera- tion, etc., it is wiser to steer a middle course and arrange the operating room somewhat in the fashion that I have adopted. The walls should be a light gray, not entirely white ; the floor a gray terrazo, and the ceiling white. There should be a large double window, provided with two wooden roller-shades attached outside of the window, by means of which it may be rapidly darkened more or less to suit the exigencies of the moment. Since the amount of light that enters through the window is dimin- ished, the brightness of the walls also diminishes ; while at the same time sufficient light falls on the patient and, if the patient's bed is moved sufficiently close to the window, enough light will fall on the eye from the side. With regard to the proper exposure for the operating room, I find a western light, which circumstances happen to make the only one available, very satisfactory, because, like all my colleagues, I nearly always operate in the forenoon. In cloudy weather this gives a better light than if the room faced the north. [In many American hospitals operations are performed late in the afternoon, hence western light would often not be satisfactory. Practically, however, the lighting by daylight of ophthal- mic operating rooms is unimportant if they are provided, as all should be, with suitable stationary as well as port- able electric lights, and with shades for darkening the windows, as may be needed. — Ed.] Another expedient that I have resorted to for years and w T hich, I believe, is also employed in many other clinics and eye hospitals, is to perform operations which require HOSPITAL WARDS AND OPERATING ROOMS. 23 an especially good light and as accurate vision as possible exclusively with electric illumination to the total exclusion of daylight ; this also enables one to control the position of the corneal reflex and to keep everything dark except the small operative field, so as to obtain a maximum visual acuity on the part of the operator and a maximum of light on the operative field. The small incandescent lamp surrounded by a metal tube concentrates its light, which passes through a strong convex lens on a small, clearly and intensely illuminated spot, and, as the lamp is provided with a suitable handle and receives its current from a portable accumulator, the light is thrown on the operative field in such a way as to obviate any disturbance by the corneal reflex. The attendant who looks after the light must, however, pay special attention to one point : the lamp unfortunately soon becomes hot, and if he brings it in contact with the patient's face, as the nose, for in- stance, he may suddenly start and thus endanger the suc- cess of the operation. In some instances it is therefore better to have the lamp fastened to the forehead, as prac- tised and recommended by Czermak. It is not desirable to be without artificial illumination in secondary operations for cataract and other difficult cataract performances. To provide against the accidental failure of the electric light, I use a gas or petroleum lamp and a large convex lens to concentrate the light on the operative field, as I did many years ago, before electricity came into use. Suitable illumination is so very necessary in many opera- tions on the eye, and particularly in the most important ones, that the operator must never neglect it under any circumstances. In support of this fact, only one example will be mentioned. It not infrequently happens in opera- tions for cataract that, immediately after the capsule of the lens has been opened, a considerable quantity of soft, cortical material from the cataract escapes through the in- cision. In these cases the compact nucleus of the cataract is small, and does not present so readily in the wound as a large nucleus when the attempt is made to deliver it. 24 GENERAL CONSIDERATIONS. It may even rotate about its transverse axis, and in the attempt to force the delivery by carrying a suitable instrument (scoop) from below over the cornea, with a certain amount of pressure, it not infrequently happens that the nucleus slips by the wound and lodges against the upper ciliary body. If the operator fails to notice this unfavorable position of the nucleus and continues the delivery of the cataract, the nucleus slips on into the upper part of the vitreous, and can not be brought out again even with the aid of a wire loop, the opera- tion is a failure, and the trouble can not be very easily remedied even by a secondary operation. On the other hand, if the operator notices in time this tendency on the part of the nucleus to slip behind the wound — and to do so requires good vision — he can correct it by pushing the nucleus down again with the knife (fleam), and as soon as the upper edge is exactly behind the wound, he can effect the delivery by exerting pressure on the cornea. In regard to the operating table, it is important that it should be possible to lower the head and raise the foot rapidly, because, in my experience, this is one of the most important procedures when there is trouble with the anesthetization. In other respects the table may be constructed in any way that suits the operator's conveni- ence. It should be made entirely of iron and without any upholstering, both for the sake of convenience and to save time in cleansing it. This feature, however, is im- material so far as the healing of the operative wound is concerned, and sensitive patients find these hard tables, which so much resemble a machine, both physically and psychically, most unpleasant — another reason why I fre- quently operate on a patient in bed, but I shall never perform an operation under general anesthesia in bed, unless under very exceptional circumstances. [So many operating tables and operating chairs are now manufact- ured, adapted to all the exigencies of ophthalmic surgery, that operations performed on the patient's bed, except ANESTHETIZATION. 25 when done in private houses, would not seem to many sur- ge« >ns commendable. — Ed.] Anesthetization. My experience with this important subject is that the ophthalmic surgeon will do well to restrict him- self as much as possible in the use of general anesthesia with chloroform, ether, bromethyl, or ethyl chloric!. These anesthetics are all dangerous, whatever may be their names, and especially chloroform and ether, the latter perhaps a little less so than the former. [See editorial note on page 28. — Ed.] Chloroform particularly may in certain individuals cause death with lightning ra- pidity, even at the very beginning of narcosis, and there is no way of recognizing the danger beforehand. As Laqueur recently pointed out in connection with a ease of death from chloroform anesthesia, persons with a large thymus gland are particularly predisposed, and it is well known that such persons may die suddenly from other causes, which in some cases are quite trivial, such as a fall into cold water, or even in the absence of any recognizable cause. Unfortunately, enlargement of the thymus gland can not be diagnosed with certainty ; but Laqueur points out that the same individuals often present hyperplasia of the lymphatic apparatus in the pharynx from enlargement of the follicles at the base of the tongue and of the tonsils. The presence of such enlargements has* a more serious bearing on anesthetization even than a valvular heart- lesion. Another feature that renders anesthetization more dan- gerous in operations on the eye, so that a normal patient is in constant danger, even when narcosis is properly carried out, is the fact that the eye is so slow to lose its sensibility. [The eye may be anesthetized with coeain. — Ed.] The general surgeon can operate on the trunk and extremities long before the ophthalmic surgeon may begin to cut — if he really wishes to operate under total and not 26 GENERAL CONSIDERATIONS. under partial anesthesia. For that reason many ophthalmic surgeons operate under partial anesthesia, although they may not be quite conscious of the fact. In my experience even etherization is not without danger if carried to the point of actual, profound anesthesia. I have witnessed the most dangerous collapse from ether in the case of two women : One of them had a moderate goiter and was menstruating at the time of the operation ; in the other I could not find any reason for the accident, which almost ended fatally. In both, the pulse and the breathing be- came worse and worse during the operation, and the most vigorous measures for resuscitation were repeatedly em- ployed to avert a fatal issue. I have repeatedly seen similar grave accidents from cardiac weakness in chloro- form anesthesia. In several cases of chloroform and ether anesthesia cardiac weakness did not develop until after the anesthetization was completed and the patient had partially regained consciousness ; the attendants were compelled to continue their efforts at resuscitation for from one-half to one hour. For this reason I always have the pulse and respiration carefully watched after the operation when a patient has had a general anesthetic. Furthermore, in cases of enucleation I avoid cutting the optic and ciliary nerves while the patient is in pro- found anesthesia, and prefer not to take this final step until the patient begins to show some reaction. For fre- quently severe collapse has occurred, evidently brought on by the shock which immediately followed the snip of the scissors. In reviving a patient who has gone into collapse I have found it useful : (1) To lower the head and trunk as soon as possible ; (2) to draw the tongue forward ; and (3) to begin artificial respiration. In addition, to use at the same time, (4) heart massage (vigorous rhythmical pressure on the precordial region in time with the heart beat) ; also occasionally to employ injections of camphor oil. In several cases of severe cardiac collapse I obtained very favorable results by (5) completely inverting the ANESTHETIZATION. 27 patient so as to place him as nearly as possible on his head. In two cases of this kind, in which artificial respira- tion and the other measures referred to had failed to give satisfactory results, it was demonstrated with the accuracy of a physiologic experiment, that inversion of the patient was followed by return of the pulse and respiration ; while as soon as he was laid down again and the operation resumed, collapse recurred, which again subsided as soon as the patient was inverted, and so on, several times in succession. In the end both patients were saved, and so far, although I have performed many operations under gen- eral anesthesia — fortunately without a death occurring — I am becoming more and more cautious, because in the course of years some very sad cases have come to my knowledge, even cases in which young persons died from anesthesia in simple operations for strabismus. I there- fore still hold to the opinion given by me publicly years ago — namely, that it is not permissible, for the sake of such a trivial operation as that for strabismus, to risk a patient's life by total anesthetization. After writing this I once allowed myself to be persuaded by a young woman, against my own injunction — although it is true that this particular operation for strabismus was a com- plicated one (tenotomy and advancement) — to use a general anesthetic (chloroform), and this same young girl barely escaped dying under the anesthetic. Although of a blooming appearance and possessed of perfectly normal heart and lungs, she developed a very bad cardiac weak- ness which required an hour of most energetic treatment. It is my rule never to employ total anesthesia un- less attended by at least two assistants, so that every resuscitating procedure may be performed correctly, vigor- ously, and persistently without fatigue on the part of the operator. I formerly used bromethyl [ethyl bromid] occasionally because, owing to its rapid and brief action, it is very convenient for many cases ; but gave it up entirely after 28 GENERAL CONSIDERATIONS. witnessing a person who is very near to me develop grave cardiac weakness lasting thirty-six hours (so that for some time the pulse could hardly be felt), after anesthetization with bromethyl for the purpose of extracting a tooth (at which I assisted). The attack in this case must have been due to bromethyl anesthetization and could not be at- tributed to anything else; possibly the patient may have had an idiosyncrasy for the drug. Ethyl chlorid possibly has some advantages over bromethyl ; but I have never had any experience with it in operations on the eye. For short operations of this kind primary ether anes- thesia has been recommended and when successful is very convenient. The patient is made to take ten to fifteen deep inspirations of ether, after which short operations can be carried out without giving pain — as I have often convinced myself — and the patient feels as well as before as soon as the operation is over. [Ether is far safer than chloroform. According to H. A. Hare, the mortality due to etherization is about 1 in 20,000, or, according to the combined statistics of Julliard and Ormsby, in 407,553 cases there were 25 deaths, or 1 in 16,302. Again, to quote Hare, compared with this statement, the record of chloroform is as fol- lows : The mortality based upon many tens of thousands of cases in which chloroform has been used is about 1 in 2039 (Gurlt) ; or, according to the combined statistics of Jul- liard and Ormsby, in 676,767 administrations there were 214 deaths = 1 in 3162. Chloroform is, therefore, fully five times more dangerous than ether. The practice of beginning an anesthesia with nitrous oxid which is to be continued with ether or chloroform obviously possesses many advantages. The same remark applies to primary inhalation of ethyl chlorid. — Ed.] I/OCal Anesthesia. — In view of what has been said I have endeavored, since the introduction of cocain, to substitute local for general anesthesia as much as possible in operating on the eye. For a slight operation on the conjunctiva and cornea ANESTHETIZATION. 29 the installation of a 1 to 2 per cent, watery solution of cocain for from five to ten minutes is quite sufficient ; but for excision of the iris, if the anesthetizing action is to penetrate as far as that membrane, the instillation of a 5 per cent, solution for a half hour, every three minutes, is required, and the eyes should be firmly closed during the intervals between installations, so as to prevent the cornea from being roughened bv the action of the cocain and thus having its transparency impaired. When the iris is inflamed, even this protracted instillation is not quite enough ; of this more will be said presently. In order to perform a really painless operation for strabismus, it is necessary to inject a few drops of a 3 to 5 per cent, solu- tion under the conjunctiva at the spot where the tendon is to be removed or advanced. After that, however, the operator must wait live minutes before beginning, and it is well to employ this time in distributing the fluid by gentle massage of the lid, so as to prevent its bringing about any changes in the operative field and thus rendering the operation more difficult. Ever since the year 188b* I have used this subcon- junctival injection of cocain in operations for strabismus and have never had bad results. At the worst, the opera- tion is occasionally followed by a little vomiting in the case of sensitive patients. The small quantity of cocain is amply sufficient to render the tenotomy and advance- ment painless. Whenever cocain is injected, however, especially when a little extra quantity is required, it must be remembered that even cocain may be dangerous if too great a dose is employed. In no case should more than 0.05 gm. be used altogether in operations about the head ; if possible, one should try to get along with less. We should always remember the sad case which occurred when cocain first came into use, and when its dangers were too little known. A surgeon injected cocain for a trivial operation that he was about to perform : the patient immediately died, and the doch >r, overcome by the calamity, sent a bullet through his brain. 30 GENERAL CONSIDERATIONS. For some time I have even performed enucleation in suitable eases — that is, in non-inflammatory cases, when there is no reason to suspect adhesion of the bulb to Tenon's capsule — practically without pain after the injec- tion of a weak cocain solution : First inject a consider- able quantity of the fluid at the four insertions of the rectic muscles, and, after the tendons have been cut, make an injection with a curved needle at the posterior pole of the eye. During recent years a weak mixture of cocain and eucain has been used for this purpose, and the quan- tity injected is large enough to give the concomitant effect of infiltration — anesthesia after Schleich. 1 This method is even better and less dangerous, especi- ally when it is possible to inject some of the fluid into Tenon's space. With this method, also, the operator must wait five minutes before beginning. This local anestheti- zation in enucleation is particularly useful in the numerous cases in which the operation is performed on account of hemorrhagic or some other form of advanced glaucoma ; for such patients, as a rule, have diseased blood-vessels and a diseased heart — that is, defective circulation, and are often of advanced age. For the enucleation of an eye that is giving pain, Snellen recommends the injection of cocain with a Pravaz syringe into the vitreous body through the sclera, and asserts that this materially dimin- ishes the sensibility of the eye. When the eyes are soft, as, for instance, after cyclitis, the procedure at the same time raises the tension of the eye-ball and thus facilitates the operation. For the removal of the lachrymal sac, a preliminary injection of the cocain and eucain mixture may also be recommended, providing the operation can be performed in a non-inflammatory region. The fluid must be injected slowly and a considerable quantity must be used. 1 Schleich uses a stock solution of eucain ß and cocain hydro- chlorate, ää 0.5 gm. (gr. viij), absolute alcohol 4 gm. (3,j), distilled water 16 c.c. (^ss). Two parts of this solution are mixed with eight parts of freshly boiled water in a graduated pipet. ANESTHETIZATION. 31 Local anesthesia is considerably more difficult in acute glaucoma or acutely inflamed eyes in which iridectomy is to be performed. In such cases the iris is extremely sen- sitive, and even the previous injection of cocain solution under the conjunctiva at the spot where the keratome is to be introduced into the anterior chamber, as recommended by Koller, has not always proved sufficient in my experi- ence to enable the operator to seize and excise the iris without giving pain and causing the patient to move. In such cases I have for years resorted to the expedient of using pure cocain, taken directly out of alcohol and allowed to crystallize, so that it is perfectly sterile, using a German silver spatula for the purpose of introducing it into the anterior chamber, and applying it directly to the iris after I have made the incision. In that way the pain may, as a rule, be greatly diminished and in many, although not in all, cases entirely abolished. Total anesthesia, which in such cases of acute glaucoma appears to be very much indicated, and is, in fact, regularly employed by some operators, if only to enable them to carry out the opera- tion quickly and methodically, does not always facilitate iridectomy — which in such cases should be made above the pupil whenever it is possible — as much as is desirable, be- cause of the upward rotation of the globe. Besides, it is, as has been said, dangerous in glaucomatous patients. The application of a thin layer of cocain in crystals is a method that I have employed for some years, even in slight operations on the lids and on the globe, in which the incision is made through the conjunctiva (removal of chalazion). During recent years cocain has gained an ally in the extract of the adrenal gland, one of the constituents of which, when the solution is applied to a mucous mem- brane, causes vigorous contraction of the blood-vessels in a very short time. This prompt constricting action is possessed in a remarkable degree by adrenalin (Solutio adrenalini hydrochlorici), which is prepared by Dr. Taka- mine, in America, and sold by Parke, Davis & Co., in 32 GENERAL CONSIDERATIONS. New York and London. This preparation also has the advantage of being stable and clean, and a very weak solution of it possesses a marked action, as I discovered long ago. By instilling a very few drops of adrenalin at in- tervals of a few moments, the redness can be made to dis- appear temporarily, if not wholly at least in part, from inflammatory or hyperemic eyes. After this has been done, the cocain, as a rale, develops its action more readily. Whether in glaucoma the action of cocain on the iris can be rendered sufficiently powerful with the aid of adrenalin I cannot say, as I have not had sufficient experience in the matter. That adrenalin is very valuable as a hemo- static I can confirm from my own experience. Ophthalmic surgeons have, however, long been familiar with artificial anemia as produced by clamping the lids with the instru- ments devised by Desmarres, Snellen, and Knapp, and the method is used to great advantage in many operations on the lids. But when these clamps can not be applied to the lids, as in extirpation of the lachrymal sac, and sometimes in operations for strabismus, etc., the use of adrenalin offers distinct advantages, for the lids and surrounding tissues are extremely vascular, so that hemorrhage is often very profuse and interferes with the operation. My experience in this matter has taught me that by adding to the fluid (cocain, cocain-eucain) which is injected in the tissues underneath the conjunctiva, etc., for the purpose of inducing local anesthesia, a very small quantity (1-2 drops of adrenalin solution), it is usually possible to re- duce the hemorrhage, especially the capillary hemorrhage, in the most welcome manner. Sometimes it is possible to render the tissue practically bloodless, as, for example, in Kuhnt's operation for ectropion. It is well to be cautious with the dose of adrenalin and to confine one's self to the minimum that is required. Adrenalin chlorid solution (Takamine) directly mixed with more or less of a 1 to 2 per cent, solution of cocain is generally used. [Very satisfactory local anesthesia can be produced with beta-eucain and adrenalin chlorid. Professor Arthur STERILIZATION, ANTISEPSIS, AXD ASEPSIS. 33 E. J. Barker has recently recommended the following solution : Pure chlorid of sodium 0.8 gm. Beta-eucain 0.2 " Adrenalin chlorid 0.001 " Distilled water 100. " If as much as 50 c.c. of such a solution were injected, only 1J grains of beta-eucain and 1 mg. of adrenalin chlorid would have been employed. In many operations around the eye a much smaller quantity would suffice. It is necessary to wait from fifteen to twenty minutes after the injection before the edema disappears and the full effect of the adrenalin chlorid has asserted itself. Professor H. C. Wood suggests that the efficiency of these solutions might be increased by adding to them not only beta-eucain, but also cocain. — Ed.] Whenever the capillary bleeding is severe enough to be troublesome in work on the lids, plastic operations in the neighborhood of the eyes, extirpation of the lachrymal sac, and the like, it is a good plan, while operating, to apply small pledgets of cotton saturated with adrenalin cocain to the bleeding points from time to time, with moderate pressure. In this way the preliminary injection of the hemostatic fluid into the tissue can be supplemented and less adrenalin will be required. One of the most important and most difficult tasks of the ophthalmic surgeon is the proper management of Sterilization, Antisepsis, and Asepsis. The battle with the micro-organisms which interfere with the healing of wounds must be carried on with the same weapons in operations on the eye as in other surgical procedures on the human subject ; and, although vigorous measures are required, they must be undertaken with due caution, owing to the delicate structure of the organ. It is most important to fight the micro-organisms at the right 3 34 GENERAL CONSIDERATIONS. spot and at the right moment ; it Mould be wrong to rely on the asepsis of the operating room, the sterilization of instruments, and the like, and overlook individual local peculiarities of the operative field and the dangers incident thereto. In cases involving the opening of the capsule of the globe (cataract extraction, iridectomy, etc.), more than in any other, the surgeon must carefully determine beforehand what is the proper thing to do in any indi- vidual case — whether the aseptic or the antiseptic method is to be used. While the surgeon must practically become a pedant in the observance of aseptic and antiseptic pre- cautions, it is equally important, on the other hand, to guard against becoming a slave to routine. For example, it would be quite wrong to assume that the rules followed when dealing witli a cutaneous region, which is so cleansed that the entire operative field remains aseptic, can be directly applied to operations on the eye and will result in aseptic healing of the wound. Such an assumption is wrong, for the simple reason that, as will be explained more in detail, the ophthalmic surgeon is never certain that he is operating in a sterile field. Plence, al- though he may have taken every precaution dictated by a scrupulous aseptic technic, he will occasionally have trouble with the healing of his wound and will soon realize that the eye is a peculiar region as regards operations. It is true that even before the period of asepsis, when nothing was known of the methods of fighting microbes — that is, by antisepsis and asepsis, and even prior to the dissemination of a clear idea of the elementary principles of cleanliness in operations on the eye, many such procedures, as hundreds of observers could testify, turned out remark- ably well. Nevertheless, however, as large a proportion as twenty or even thirty out of every hundred eyes per- formed on for cataract went blind from purulent or non- purulent inflammation before the advent of antisepsis ; although the eye has fortunately exhibited a marked tendency toward recovery after operative and traumatic wounds. STERILIZATION, ANTISEPSIS, AND ASEPSIS. 35 On the other hand, even the most scrupulous cleanliness and the observance of all the rules that have been set up by the doctrine of sterilization and asepsis in the treat- ment of wounds, do not always suffice to guarantee, as it were, an uncomplicated healing and completely to make good the loss of tissue in the same way as is now possible in many operations which are much more dangerous and extensive and were never even attempted before the period of antisepsis. We have, undoubtedly, reduced the per- centage of losses in cataract operations in the most grati- fying manner, from 20-30 per cent, to 1-2 per cent., by adopting the modern treatment of wounds in surgical pro- cedures on the eye ; but we have not yet succeeded in bringing about what ought to be the aim of every oph- thalmologist — namely, to reduce it to zero with absolute certain tv. To judge from the publications found in modem literature bearing on this point, it might almost be supposed that failures in surgical treatment for cataract are a thins: of the past. This optimistic presenta- tion of actual conditions is partly explained by the fact that an operator nowadays may easily perform at least 100 or even 200 successful opera- tions for cataract without losing an eye, and, if he makes up his statistics from such a favorable series, he will not have any failures. An experienced ophthalmologist will in this respect, however, hold to the dictum of Knapp that " If the statistics are large enough, every- thing is possible" — r". r. Sidler-Huguenin, who has so far exclusively attended to their preparation ; for it is obvious that every precaution must be observed in the preparation of this material. J. Bernheim demonstrated by certain investigations carried out in our laboratory that iodoform maybe polluted with microbes, and with pathogenic microbes at that. Sidler-Huguenin, who has fre- quently washed iodoform out in a 3 per cent, solution of carbolic acid, often found unorganized particles of matter, splinters of wood and the like, which would be capable of causing irritation in the interior of the eye. As the number of microbes that we have to combat is always an important feature in disinfection, their number must not be still more increased by the introduction of the iodoform into the interior of the eye. For this reason the iodoform preparations must be sterile and must be kept sterile. In removing them from the glass tubes in which they are put up by the trade, 1 a sterilized forceps should be used, which must be absolutely dry, else the pencils will break up as soon as they are within the grasp of the forceps. 1 This is done by the Apotheke zur Post, Kreuzplatz, Zurich V. 72 GENERAL CONSIDERATIONS. Plate i. Introduction of a pencil of iodoform into the anterior chamber case of infection by a foreign body. The iodoform pencils may be introduced either through the already existing wound or through an incision. One pencil is usually enough for the anterior chamber ; but under certain circumstances it may be advisable to intro- duce two or three into the vitreous, depending on the extent of the infectious inflammation. The method of introducing the pencil into the anterior chamber is shown in Plate 1, illustrating a case in which, after the removal of a spicule of iron with the aid of my large magnet, signs of infection developed, with the accu- mulation of pus in the anterior chamber. As in this case the wound from which the foreign body had been ex- tracted was already closed, an incision was made into the temporal half of the cornea with a Gräfe cataract-knife, and the pencil, which was held with a curved iridectomy forceps with serrated jaws, rapidly introduced through this incision. Jt is important to see that no aqueous humor escapes during the incision. The accident can easily be avoided if the eye is well cocainized and the knife is sharp. The introduction should be effected rapidly, to guard against premature melting of the iodo- form pencil. Finally, in order to prevent the pencil from slipping out of the anterior chamber, great care must be taken to see that it is introduced rapidly and that all of it enters the chamber. This is best accomplished by first introducing it as far as possible with the forceps, then releasing it for a moment and pushing it in the rest of the way with the closed forceps, which is therefore used like a delicate probe. In this way the freely movable pencil can be properly placed in the anterior chamber. If there already is a large wound in the cornea or in the sclera, the jaws of the introducing forceps should not be released until the pencil is completely within the anterior chamber or vitreous body. V y%8ii ' "^ DISINFECTION. 73 The incision should be no larger than absolutely neces- sary, but it should not be too small — that is to say, for pencils 1 mm. in diameter the incision should be made with a narrow Gräfe knife, and not with a keratome, be- cause with the former instrument the internal wound (in Descemet's membrane) can be made as large as the ex- ternal wound, and the wound canal in the cornea therefore does not become narrow as it approaches the anterior chamber. Another advantage of the narrow Gräfe knife is that it is better adapted for puncturing and cutting than the keratome. The same considerations obtain for incision of the sclera. If that procedure becomes neces- sary, the coat must first be properly exposed by incising the conjunctiva and Tenon's capsule so that the subse- quent incision of the membrane may remain constantly exposed to view. If the conjunctiva and sclera are incised at the same time, the rapid introduction of the pencil may be impossible because the sclera wound may be missed. That iodoform is well borne by the anterior chamber I learned from my earliest experiences in the year 1892, when I treated tuberculosis of the iris and suspicious cases of tuberculous iritis with deposits by the introduction of iodoform pencils. From that it was a natural step to employ the remedy against a purulent infection, because I had always considered iodoform a useful antiseptic and had used it in the treatment of the wound after a cataract operation. It is, however, to be observed that when there is intense infectious inflammation in the anterior chamber, a fairly heavy opacity sometimes develops in the cornea at the point where the iodoform is placed, and it occasionally happens that the corneal opacity does not disappear altogether. It is therefore advisable not to place the iodoform immediately in front of the pupil, whenever that can be avoided. It appears that the toxins generated by the inflammatory process, acting together with the iodo- form, are capable of injuring the endothelium of Descemet's mem- brane. Nevertheless, in eyes that have gradually become free from inflammation, remains of iodoform may be seen even on the lens with- out producing any opacity. The iodoform is gradually removed from the anterior chamber by absorption, and I have often seen it remain there without producing any irritation after the inflamma- 74 GENERAL CONSIDERATIONS. tion (for the removal of which its use was necessary) had long ago disappeared. Iodoform is also well tolerated by the vitreous body, from which it also gradually disappears. Disinfection of the vitreous, however, may obviously be a most difficult task, as the germs may spread over such a large area that they can not be reached and controlled with iodoform. In disinfecting with iodoform, as with any other disinfectant, the generally familiar observation is made that the sooner disinfection is begun, and the milder the infectious process, the more probably will our eiforts at disinfection be crowned with success. The virulence of the infectious process depends not only on the relation between the ac- tivity of the microbes on the one hand, and that of the tissue attacked on the other, but also on the kind of germs that are present. It appears that in the case of certain varieties of bacilli, which are extremely pathogenic for the eye, and which most frequently effect an entrance along with splinters from a hoe, are too virulent for iodo- form disinfection, and in these cases the method is apt to prove futile. I named these organisms panophthalmia bacilli and they were later recognized by Silberschmidt and Römer as belonging to the group of hay bacilli. The method may, of course, prove a failure with other mi- crobes, especially if the drug is not brought into suffi- ciently close contact with the germs, or the latter can not for some reason be brought sufficiently within its influence. Thus, even Descemets membrane is sufficient to prevent a purulent ulcer of the cornea from being adequately in- fluenced by iodoform introduced into the anterior chamber, and for this reason the treatment of ulcus serpens by in- troducing iodoform into the anterior chamber is not a suitable one. Iodoform acts slowly and, therefore, does not injure the tissues with which it comes in contact, and if it can be confined within a narrow space along with the pathogenic germs that have entered the eye, and the tissues are en- abled to develop their normal power of resistance, the DISINFECTION. 75 attempt to render the microbes innocuous may be success- ful ; for it is not necessary to kill the germs, if only they are prevented from multiplying. That is why intra-ocular disinfection with iodoform quite often yields very favorable results if the method is adopted early and carried out properly. On the other hand, it is practically incapable of doing any harm, so far as my experience has gone. This method of treating the interior of the eye with iodoform is specially adapted for the treatment of infected traumatic or operative wounds that have penetrated deep into the eye, as, for example, wounds due to the entrance of foreign bodies or any large pointed or cutting objects. It can also be used to advantage after cataract operations that do not heal kindly, especially if an insidious irido- cyclitis with deposits persists for some time and keeps the eye from quieting down. I have observed very favorable results in scars that have suppurated after operation, and which have become very angry. Superficial wounds that show r signs of infection may also be disinfected by means of heat, either with the galvanic- electric platinum loop or Pacquelin's benzin cautery. If the effect of heat is desired in the depth of the wound, the latter method alone is to be recommended, because, when the galvanic-electric loop is introduced into a moist tissue, the current is short-circuited by the moisture of the tissues and the loop at once begins to cool. When Pacquelin's cautery is used for the eye, it should be fitted with a specially fine point. Disinfection by cauterization is al- ways attended by the disadvantage that the dead tissue may become the seat of further bacterial growth. There is also danger, if the cauterization in the deeper portions of the eye is thorough, that the destruction may be so great as to cause marked cicatricial contraction and ret- inal detachment. [The editor can substantiate the author's statements in regard to iodoform under the circumstances detailed. Opening of the wound and daily drainage of the anterior chamber is, according to Knapp, the most efficient 76 GENERAL CONSIDERATIONS. method of combatting infections of the eye after cataract extraction. For certain infections, limited to the anterior portion of the eye, and nnassociated with the formation of ring abscess in the cornea, but with fibrinous exudate in the anterior chamber, dionin in 5 per cent, solution has an excellent effect ; the same is true of a 25 per cent, solution of argyrol. — Ed.] Instruments. A few remarks about instruments may not come amiss. It is evident that operations on such an important organ as the eye call for instruments which must be of the very best make and in absolutely perfect condition. The success of an ophthalmic operation is often entirely dependent on the excellence and proper construction of the instruments used. Above all, the cutting and puncturing instruments with which the capsule of the bulb is opened — that is, cataract knives, needles, capsule knives, discission needles, and the like, must be as perfect, with regard to their edges and points, as it is possible to make them. For this reason an instrument of this kind can not be used any length of time, no matter how careful the opera- tor may be, without being reground. The cornea and sclera are tough and hard to cut ; hence, only properly constructed and properly sharpened instru- ments are capable of making a smooth incision. The smoother the incision, the more easily and the more quickly will union of the wound and healing take place. When the edges of the wound are bruised and torn they are covered with partially or totally contused and dead particles of tissue which must first be cast off or absorbed before healing can take place. Such tissue elements, which have been destroyed by the incision, are also quite capable of becoming culture media for pathogenic micro- organisms. The sooner union and healing take place in the wound, the better is the prospect of preventing the growth of bacteria, in other words, secondary wound in- INSTRUMENTS. 77 fection. Secondary — i. e., post-operative — infection is a special danger in wounds of the eye because the operative field can not be rendered or maintained absolutely sterile. For this reason a smooth incision, made with a sharp in- strument, and with as little contusion of the edges of the wound as possible, is a strung guarantee of a smooth re- covery. Properly constructed instruments and proper care in keeping them in order are, therefore, two impor- tant factors influencing the result of operations on the eye. A good polish is very important for knives, needles, and scissors. In the first place it has much to do with the smoothness of the incision and the absence of con- tusion of the wound edges. In the second place, an in- strument that is perfectly polished is less apt to become soiled, and is much more easily cleansed ; and for this reason all instruments, whether cutting or non-cutting (strabismus hooks, spatulas, specula, and the like), should always be as smooth and bright as possible. Good polish and smooth finish are strong guarantees of asepsis. It has been proved that a well-polished instrument may be rendered germ free or nearly so by simple mechanical rubbing. If, in addition, the precaution is taken to see that an instrument is never very badly soiled by allowing shreds of tissue from the wound to adhere to the blade, I find by years of experience that knives, keratomes, dis- cission needles and the like can be disinfected or kept aseptic with the least degree of injury to the cutting edge by placing them for ten minutes in a 3 per cent, solution of carbolic acid and rubbing them well with sterile gauze or cotton while in the solution. In the twenty-five years that I have used this method in my private institu- tion I have never had a single case of primary wound- infection after an operation for cataract, and altogether only 1 case of suppuration, which began on the fifth day after operation, and could, therefore, hardly have been caused by the instrument. If it is desired to boil cutting and puncturing instru- 78 GENERAL CONSIDERATIONS. ments, great care must be taken to guard both edge and polish against injury. Boiling for ten minutes in a 1 per cent, solution of sodium carbonate renders them sterile, at least as regards the ordinary pathogenic germs. The coating of soda which adheres to the instruments after boiling and spoils the polish must be removed at once, and this is best effected by transferring the instruments, or the vessel containing them, from the boiling water into sterilized water or sterilized salt solution. Great caution must be observed, however, to see that the sterilized fluids really are sterile. Instruments with ivory handles may also be boiled ; but after a time the ivory deteriorates and becomes rough, so that perfectly smooth handles made of metal and well nickel-plated are to be preferred. The cross-pieces with which some instrument makers provide the metal handles are undesirable and, in fact, useless. In a large clinic service there is no doubt that the most convenient and safest method of sterilizing that has yet been devised is by boiling at least all non-cutting instru- ments ; and treating cutting and puncturing instruments with the previously mentioned precautions. Keeping the instruments constantly moist during the operation, by returning them to a sterilized fluid every time they are used, has the great advantage that it pre- vents pieces of tissue adhering and renders them easier to cleanse. The cleansing should be done soon after the operation, because, if the instruments are left in the fluid any length of time, both the polish and the edge suffer. It was formerly customary, when necessary to use two instruments in rapid succession, as, for example, the cystotome and a curet, to attach them to the same handle ; and this is still sometimes done (Fig. 29). But it is not to be recommended, nor is it necessary, since we know that rapidity during the operation is not an important factor. The danger is that in using such an instrument the end which is turned away from the eye — for example, the curet-end — may be soiled by coming in contact with some other object while the cystotome is being used, for it INSTRUMENTS. 79 is impossible to watch both ends of* an instrument and at the same time the entire operative field. An Instrumentarium for operations on the eye which shall contain the most necessary instrument- is composed as follows : 2 Desmarres' eye specula, 1 Spring- speculum after Bowman, Snowden, etc., 1 Desmarres' lid clamp or entropion forceps, 2 Knapp or Snellen lid clamps, 1 Jäger horn spatula, 1 Cilia forceps, 1 Fixation forceps, with catch, 1 Fixation forceps, without catch, 1 Curved fixation forceps, 1 Heavy straight fixation forceps, 1 Fine straight conjunctival forceps, 1 Curved iris forceps, with hooks, 1 Curved and serated iris forceps, 1 Heavy curved Cooper scissors, 1 Large heavy scissors, 1 Small straight sharp-pointed scissors, 1 Curved strabismus scissors, with blunt ends, 1 Curved sharp iridectomy scissors, 1 Wecker's scissors, 5 Grate's cataract-knives, 5 Keratomes of various widths, 2 Bowman discission needles, 2 Knapp's capsule knives, 3 Large and small scalpels, 1 Weber's knife for splitting the canaliculi, straight, 1 Weber's knife for splitting the canaliculi, curved, 1 Gräfe's cystotome, 1 Schweigger's cystotome, 1 Daviel lens-scoop, 1 Hard-rubber or glass scoop for delivering the cataract, 1 Critchett's scoop, 1 Broad wire loop, after Weber, 1 Xarrow wire loop, after Snellen, 80 GENERAL CONSIDERATIONS. 1 German silver spatula for replacing the iris, 2 Strabismus hooks, large and small, 1 Double Wecker hook or Prince forceps (angular), for muscle advancement, 2 Large double hooks, 2 Small double hooks, 1 Single small hook, 1 Pointed iris hook, 1 Blunt iris hook, 6 Pean or Langenbeck hemostats, 12 Best curved needles, large and small, 1 Needle-holder, 1 Myrtle-leaf probe. 4 Bowman's lacrimal probes, 1 Conical probe, 2 Glass syringes. The possession of the following instruments is also desirable : Desmarres' capsule forceps, 1 Couching needle, 1 Beer cataract-knife, 1 Straight cataract-knife (Beer), 1 Blunt Desmarres' knife, Knapp's curved knife-needles (curet-hook), Lang's knives for separating anterior synechia?, Pellier's eye speculum, Müller's retractors for extirpating the lacrimal sac. Instrumentarium for Krönlein's operation : Galvanocautery and large moist cell, Pacquelin's thermocautery, Giant magnet, Small magnet, Illuminating apparatus for the removal of foreign bodies from the cornea, after Sidler-Huguenin. OPERATION FOR CATARACT. 81 OPERATIONS ON THE EYE. (A) OPERATIONS ON THE GLOBE. 1. OPERATION FOR CATARACT. The removal of an opaque lens is one of the most important and most difficult tasks that falls to the lot of the ophthalmic surgeon ; for in this operation, more than in any other, the eve is exposed to the danger of infection and therefore to rapid, purulent inflammation or slow and insidious cyclitis, which may even eventually cause blind- ness of the other eye. The operation for cataract, espe- cially for senile cataract, therefore furnishes a touchstone for the ophthalmic surgeon's efficiency, both as to his operative technic and the prevention of surgical compli- cations. As cataract is much more common in later life than in youth, so-called senile cataract forms the largest and most important group. It should be mentioned, however, that age merely constitutes a predisposing factor and that the true cause of cataract, so far as it is known at all, lies in disease and weakness of the entire body, or of important organs, or of the eye itself. The division into juvenile and senile cataract was sug- gested by operative considerations. Up to the age of thirty the lens is uniformly soft ; after that period, how- ever, the central fibers of the lens, owing to the physio- logic hardening of the tissues, contract, and a hard nucleus is formed, which in the course of years con- stantly increases in size and hardness. As this nucleus grows, the soft cortex naturally diminishes more and more, and by the sixtieth year of life the sclerosis has usually spread to the capsule of the lens. Physiologic sclerosis (the cause of diminution of the power of accommodation and presbyopia) has nothing directly to do with the formation of cataract ; but it is an 82 OPERATIONS ON THE EYE. important factor in the cataractous process because the hardened nucleus for the most part resists the degenera- tion which involves the rest of the cataract and, forming a solid body, plays an important part at the operation. When, on the other hand, as is the case in the juvenile eye, no nucleus has been formed, the entire lens, as it softens, is converted into a semifluid mass which does not contain a hard nucleus. Sometimes clouding of the nucleus is prevented by the same process of sclerosis, and after the cataract has matured a fairly clear nucleus, which, as a rule, has a yel- lowish color, is found surrounded by the grayish, abso- lutely opaque and glue-like cortical substance. In such a case we have to deal with a senile, cortical cataract. The development of cortical cataract begins with the appear- ance in the cortex of striae and rows of punctate opaci- ties, which gradually increase in number and radiate toward the center, followed by the appearance of gray wedges, while the nucleus retains its transparency for some time. As the process goes on, the nucleus may also lose some of its transparency, but the haziness chiefly affects the cortex. Sometimes, but on the whole less frequently, the cata- ract begins in the nucleus and immediately contiguous surrounding zone of cortex. In such a case we speak of nuclear cataract. The haziness of the cortex in these cases varies both as regards intensity and rapidity of development. It sometimes happens that complete opacity does not develop until the individual has reached an advanced age, although the sclerosis gradually becomes more firm. In nuclear cataract the visual disturbance appears ear- lier and is more intense than is the case in cortical cata- ract ; unless the latter begins with an anterior or poste- rior polar opacity, and not, as is usually the case, at the equator of the lens. The term capsular cataract, finally, is applied to opaci- ties formed by proliferation of the epithelial cells in the OPERATION FOR CATARACT. 83 capsule of the lens. The entire posterior aspect of the anterior lens capsule is covered by a single layer of cap- sular epithelium. In cataract formation this epithelium, as a rule, begins to proliferate at the center, opposite the anterior pole ; but not until the cataract has existed for some time and has become over-ripe ; so that anterior capsular cataract is an important sign of " over-ripeness " of the cataract. These proliferations of capsular epithe- lium are recognized by the white color in contrast to the opaque cortex, which is more gray or grayish white, and by the fact that they form at the anterior pole a circular or irregular patch which gradually increases in size and often appears as a distinct thickening on the cortical opacity. In those cases in which cataract is produced by some grave disease of the eye — complicated cataract — anterior capsular cataract is sometimes found, as, for example, when cyclitis or retinal detachment has been followed by profound disorganization of the eye, with cataract. Ante- rior polar or pyramidal cataract, which occurs in earlier life as a result of ulcerative perforation of the cornea, is another form of capsular cataract. It follows from what has been said that the lens varies in accordance with age, and that the structure of the cataract and its condition greatly influences the sur- geon in his choice of operative procedures for its re- moval. There are various methods of removing the lens from the eye. 1. We require with lenses, which as yet have no firm nucleus, simply to open the anterior capsule, and then to leave the absorption of their entire contents to the eye alone. During this process the lenticular masses, which may be perfectly clear or more or less completely opaque, gradually enter the anterior chamber and are there absorbed. The process of absorption may, if neces- sary, be shortened by puncturing the anterior chamber and thus evacuating the semifluid lenticular masses. If the lens is completely opaque at the time the capsule is 84 OPERATIONS ON THE EYE. opened — as, for example, as the result of total congenital cataract or cataract developing early in life — absorption may take place without anything further. If, on the other hand, the lens is only partially opaque when the capsule is opened, as, for example, in lamellar or zonular cataract, the non-opaque cortical and nuclear masses must first become cataractous by imbibition of aqueous humor, which causes them to swell and protrude into the anterior chamber, where they then undergo absorption. If the lens shows no haziness whatever when the capsule is opened, as, for example, in stab-wounds or in the operation for myopia, the entire lenticular mass, before it can be absorbed or evacuated by puncture, must be gradu- ally saturated and distended with aqueous humor, so as to become cataractous and disintegrate. The above-described method of removing the lens therefore implies the following requisites: («) Good absorbing power in the eye, which is great- est in youth and diminishes with advancing age. (6) Little tendency to increased tension (glaucoma), which, as we know, is an almost certain result of trau- matic cataract. The tendency to glaucoma is less in youth than in old age. (c) The lens must be one that does not contain a hard nucleus, because the latter could not readily be absorbed in the anterior chamber, but would cause irritation and under the most favorable circumstances would require a long time to undergo absorption. Simple laceration or discission of the anterior capsule, with or without subsequent puncture of the anterior chamber, is therefore applicable only to young eyes up to the age of thirty to thirty-five — L e., before any marked nucleus formation lias taken place, and it makes no dif- ference how great the haziness of the lens at the time of operation ; for the hazier, the more readily it will be removed from the eye, either by simple absorption or with the aid of puncture of the anterior chamber, as the evacu- ation brought about by that procedure is the more com- OPERATION FOR CATARACT. 85 plete, the greater the capacity and consequently the dis- integration of the lens. 2. It is obvious from the foregoing that when there is marked nucleus formation — that is, after the thirtieth to the thirty-fifth year of life — a different method must be adopted for the removal of the cataract. Assuming that the conditions for cataract operation are present, we must turn our thoughts as much as possible to the nucleus; and we will not succeed any longer, after the capsule has been opened, with mere puncture of the anterior cham- ber — that is, with an incision from 3 to 5 mm. in length — but need a cataract incision so large that this nucleus can readily escape. This incision need not be so large in patients of thirty-five to forty-five years as at a later period of life. Indications. — As with advancing years the absorp- tive power of the eye diminishes and the tendency to glaucoma increases, the indications for operation are also subject to variation. It is important to reduce to a minimum the cataractous masses to be absorbed after a cataract operation, if rapid recovery is desired. When- ever it is possible, the entire contents öf the capsule must be removed at the operation. If we proceed properly the nucleus is readily expelled ; but the same can not be said of the cortex, parts of which often adhere to the capsule, especially when it is not opaque. In such a case the cor- tical substance becomes hazy after the operation, through the entrance into it of aqueous humor, and has to be ab- sorbed by the eye. These cortical remains often interfere for a long time with vision. They sometimes encroach upon and irritate the iris, and — most important of all — conjure up the danger of glaucoma. 1. For this reason it is always best in cases of cataract during the later decades of life to wait for complete opacity of the cortex — maturity of the cataract — before operating ; in other words, until the conditions are such that the cortical substance, having undergone total cata- ractous disintegration, separates completely from the cap- 86 OPERATIONS ON THE EYE. sule after the anterior capsule is opened and slips out of the wound, either bringing the nucleus with it or following immediately after the nucleus which slips out ahead. It is not always altogether easy to determine whether a cataract is ripe in this sense. In the great majority of senile cataracts conditions are such that, as soon as the third stage has been reached, operation gives the best prospect of speedy success. By the first stage is meant the beginning of cataract, Cataracta in- cipiens ; the second stage is that of swelling, because as the cloudiness increases the lens begins to swell, as may be determined by noting the diminution in the depth of the anterior chamber. During the second stage the cloudiness of the cortical substance is still incomplete, and on examination with lateral illumination an interval can be made out be- tween the lenticular cloudiness and the edge of the pupil, the latter throwing a faint shadow on the cloudy lens, which is situated some little distance behind it. During the third stage, that of operative maturity, the cloudiness of the lens has extended to the capsule and therefore as far as the pupillary margin, so that the shadow of the latter is no longer seen. At the same time the swelling of the cloudy lens diminishes during this stage and the original depth of the anterior chamber is restored. • During the fourth stage, that of over-ripeness, the cataract is seen gradually to contract ; the depth of the anterior chamber is therefore still further increased, the radiating striatum disappears on account of the continued disintegration of the cortex and is replaced by the pale, dotted appearance of capsulary cataract which begins in the middle, at the anterior pole. Eventually the cortex may liquefy and allow the nucleus to sink to the bottom of the resulting fluid. This is known as a Morgagnian cataract and is not a very common occurrence. In most cases the cataract contracts to form a flat tenacious disc, which does not separate so readily from the capsule as is the case during the third stage. During the stage of over-ripeness a process begins which is of grave import from the operative standpoint ; the suspensory ligament of the lens, zonule of Zinn, atrophies, and tremulousness of the over- ripe cataract results — that is, the cataract trembles with every move- ment of the eye. Or the friable character of the zonule in an over- ripe cataract of this kind may not be recognized until it tears during the operation and allows the vitreous to enter the wound. It follows, therefore, that over-ripeness of the cataract diminishes the favorable conditions for a formal operation for cataract and a smooth recovery. Although the stage of maturity is the best for opera- tion, the surgeon is often compelled to operate before this desirable condition is present because the patient wishes OPERATION FOP, CATARACT. 8? to recover his sight as soon as possible in order to guard against any accident that might arise on account of his defective vision. It is especially when cataract develops in the remaining useful eye that an early operation of this kind may be absolutely demanded. Premature operation may also become necessary when both cataracts develop at the same time and with equal intensity, although in most cases of double cataract the development is un- equal and the process progresses more rapidly in one eye than in the other. Fortunately, in some eases the im- maturity, which at first arouses serious anxiety in the surgeon, is only apparent — that is to say, although some portions of the cortex have not become hazy, the result of the cataract operation is nevertheless a favorable one. (a) It occasionally happens, mostly in the ease of old persons, that the haziness of the cortex is very slightly or not at all pronounced. The cataract is a dull-yellow or brownish color, or the pupillary region may appear perfectly black — black cataract (Cataracta nigra). When the eyes are examined with the ophthalmoscope, however, it is found that the transparency of the lens is greatly impaired and the eyeground can only be seen very indis- tinctly. The darker the pupil appears with lateral illumi- nation, the darker and more blurred will be the veiled background of the eye. As a rule, eyes of this kind possess better vision than those with the ordinary gray cataract. A lens with the latter variety of cataract trans- mits the rays of light better in both directions than is the case in the former variety of cataract, so that, on the one hand, the examiner is able to see the eyeground with some degree of accuracy, and the patient, on the other hand, retains the power of recognizing larger objects. Never- theless, the impairment of vision is usually sufficient to cause a serious disability and menace to the patient. It would be very bad practice to wait for the develop- ment of gray discoloration of the anterior cortex and blindness before operating on cataracts of this kind. These lenses never become gray or entirely opaque like 88 OPERATIONS ON THE EYE. other lenses, because they have no cortex to become gray. The lenticular sclerosis in these cases extends as far as the capsule, either prematurely or at the normal time — that is, after the sixtieth year — and this hardening change protects the lenticular mass from disintegrating into a gray, semi- fluid material, just as in the case of the physiologic hard- ening process of senility which prevents disintegration, so that the cataractous lens always contains a nucleus which may vary in size. The size of the nucleus must deter- mine the size of the incision necessary for its escape at the operation. To be exact, the condition in these cases is not a cataract formation, but merely a hardening. When an eye of this kind is operated upon, the opening of the capsule is immediately followed by the escape of the entire contents in toto in the form of a large, hard, amber colored or brown cataract ; and if the wound has not been made large enough the delivery of the cataract may cause great difficulties. After the escape of the cataract the pupillary region may be perfectly clean and without a trace of opacity. A cataract of this kind is, therefore, mature or operable even before it has become entirely opaque and gray. (b) Occasionaly in individuals who are not very old and in cases of myopia there may be an incomplete haziness of the lens, made up of a number of striae, usually radiating toward the center, and narrow wedges interspersed with dots and small patches, chiefly affecting the cortical portion. But the nucleus also frequently presents delicate punctate and striate opacities. The patients see as through a screen and vision is usually imperfect, and although they are still able to find their way, they are in danger of occasionally breaking a limb. Sometimes they are still able to read coarse print, and on examination with the ophthalmoscope the eyeground can still be seen indistinctly. This variety of cataract is also operable if the opaque striae, dots, and patches extend all the way to the capsule of the lens ; for in that case the cortex comes away al- most completely from the capsule at the operation. It is OPERATION FOR CATARACT. 89 possible for some of the cortex to remain behind ; but, as a rule, it would be useless in these cases to wait for com- plete haziness of the lens to develop. (c) There is another group of cataracts susceptible of operation, although the cortex is only partially and insuf- ficiently cloudy. They are the cases of cataract in which the hardening process of age comes to our aid, that is, cataracts occurring after the sixtieth year, in which the cortex also is involved in the sclerosis and has, therefore, attained a consistency which enables it to escape from the capsules without adhering to it. As a matter of fact, most lenses might be extracted without any more ado after the sixtieth year, depending only on the degree of hardening. It has been found, however, that the cata- ractous process often spoils our calculations by interfering with the normal hardening of the cortex and, therefore, with its separation from the capsule. The cortex re- mains semitransparent and does not undergo cataractous degeneration ; nor does it harden properly, or at least the hardening is only partial, and when cataracts of this kind are extracted, a considerable portion of the cortex often remains behind. In spite of this fact, however, the period of disability is less than it would be if operation were deferred until perfect maturity, which in these cases often occurs very late, even though it may take weeks or even months before the patient regains his eyesight. Although it is always a serious matter to leave remains of the cortex behind when operating on cataract in old persons, the danger in this respect has nevertheless been diminished by the adoption of antiseptic and aseptic methods. For my part I am convinced that if we can succeed in protecting the wound from inflammation, in other words, keep it aseptic, the eye will tolerate a con- siderable quantity of cataractous material that has been left behind, and the latter will eventually be absorbed, pro- viding the eye is kept under careful supervision and the pupillary action, as well as any changes in pressure, can be controlled with suitable drugs. On the other hand, if 90 OPERATIONS ON THE EYE. the anterior chamber has become infected in the operation, even if the infection is not a very virulent one, the situa- tion at once becomes much more dangerons in the pres- ence of any cataractous remains, because the latter afford a good culture medium for the infectious germs. The modern treatment of wounds has rendered the outlook in operations on unripe cataracts much more favorable. Attempts to render unripe cataracts operable by arti- ficial maturation have been in vogue for some time. At one time this was done by making one or several small, preparatory discissions or punctures in the anterior cap- sule, because it is a matter of common observation that slight injuries of the lens, as, for example, by a foreign body, may gradually produce complete traumatic cataract. The procedure, however, fell into disrepute, and there is no doubt that it was formerly a dangerous one, and often followed by an undesirable degree of irritation, glaucoma, or even grave inflammation. It has been again recom- mended in more recent times, and perhaps this is another illustration of asepsis rendering possible a procedure which before its advent was proscribed ; but so far I have had no personal experience in this matter. A much more harmless method of inducing maturity artificially is that suggested by Foerster. He advises massage of the cataract, after a preliminary iridectomy, using a suitable blunt instrument, such as a strabismus hook or curet, with which the center of the cornea is to be rubbed, and asserts that the procedure is followed in a few days by the development of complete opacity. The method is suitable in many cases and quite worthy of commendation, but I have often found that in slowly maturing cataracts this massage of the lens fails to hasten the development of opacity sufficiently. [More effectual than Foerster's method of artificially ripening cataract is paracentesis of the cornea and internal massage directly on the anterior capsule of the lens with a small spatula, a method which Knapp, following the recommendations of OPERATION FOR CATARACT. 91 Ricaldi and Bettmann, has recently advocated. Simple paracentesis of the cornea with external massage, as recom- mended by T. R. Pooley and J. R. White, is said to be effectual. Should cortical remnants be found after the extraction of unripe cataract, they may be removed with the help of a syringe, as has been specially recommended by McKeown, Lippincott, and others. The editor has not, however, been pleased with this form of irrigation, al- though in the hands of experienced colleagues it finds much favor. He believes that the lens may be safely extracted even if it is in part unclouded, certainly after the sixtieth year, and prefers extracting an unripe cata- ract to performing a ripening operation. — Ed.] Snellen, Horner, and others long ago emphasized the fact that an iridectomy usually hastens the ripening of a cataract and that this is, therefore, one of the most important reasons for resorting to prdiminwy iridectomy — that is, an iridectomy performed a few weeks before extraction of the cataract. It also increases the chances of success by the fact that a major operation is divided into two minor operations, each of which is less dangerous by itself. Another considera- tion is that the preliminary operation has a desirable edu- cational effect on the patient and enables the operator to determine how he acts under the knife, information which he will find useful to guide him at the subsequent extrac- tion. The preliminary operation is also the best one to combat any disposition there may be to glaucoma, which sometimes develops in a most unpleasant way after a cataract extraction, even when no part of the cataract has been left behind. Preliminary iridectomy is unquestionably most desir- able in many cases and is especially indicated when com- plications threaten, either during or after the operation, aside from insufficient ripeness — be it that the eye is not entirely normal, as, for example^ in high myopia, or the patient's strength and general condition necessitate the greatest caution. A preliminary iridectomy is also, as a rule, necessary in cases of true complicated cataract — 92 OPERATIONS ON THE EYE. that is, cases in which there has been iritis, choroiditis, and disease of the vitreous. As in all these cases a secondary operation for cataract is usually necessary, it is true that three operations in all have to be performed. But why, when so much is at stake, should not this course be pursued, even if it be somewhat slower, since it offers greater security and free- dom from risk, particularly as each of the three operations necessitates only a short period in bed and is practically painless. The diagnosis of maturity — that is, the condition in w T hich the lens is suitable for operation — is evidently not a simple matter and, as we have seen, depends on other factors besides clouding of the anterior cortex. Complete opacity of the lens is also more difficult to recognize posi- tively because it is impossible to make sure that the pos- terior cortex has undergone cataractous disintegration and will separate readily from the capsule. It is true that in most cases the condition of the posterior cortex, as regards the degree of opacity, is the same as that of the anterior cortex, but there are exceptions. Thus, it may happen that after the extraction of a cataract which seems to be entirely opaque, the operator is surprised to find that a good deal of the cataractous material has remained behind. It has also happened when the anterior cortex presented Foerster's maturity that the posterior was not in the same condition. In addition to careful inspection of the lens with the aid of a magnifying glass after dilatation of the pnpil, 1 and the other factors already mentioned, such as the depth of the anterior chamber, the change in the shadow of the iris, etc., the functional state of the eye affords some information as to the degree of ripeness. But from 1 1 wish to emphasize particularly a caution which ought not need to be mentioned. It is that atropin must never be used under these cir- cumstances to dilate the pupil, because cataractous eyes, aside from their age, are naturally prone to develop glaucoma, especially while the cataract is swelling; for this reason homatropin [or euphthalmin — Ed.] should always be preferred. OPERATION FOR CATARACT. 93 what has already been said it would evidently be wrong to judge of the operability of a cataract solely by the con- dition of the eyesight and to wait until the affected eye becomes totally blind. 2. Function. — Among the conditions affecting the suc- cess of the operation must be mentioned, in addition to ripeness of the cataract, the functional condition of the affected eye— that is to say, the health of the eye— espe- cially as regards the deeper portions which escape inspec- tion in advanced stages of cataract, and are, therefore, judged only by investigating the function. A case of cataract can not be regarded as operable unless the eye still possesses a certain degree of vision, at least for move- ments of the hands at 0.25 to 0.05 m. ; it is impossible to give accurate numbers. Whether the retina still retains some central vision may be roughly determined by noting whether the patient is still able to perceive movements of the hands or the flame of a candle in the dark at a distance of 6 m. The latter test, however, in the case of cataract includes much more than the center of the retina, because an opaque lens acts much like a piece of ground glass held before the eye, which diffuses the light from the candle over the entire retina, so that the flame can be perceived even when a central scotoma is present. [The function of the center of the retina should be tested by means of two small flames, which under normal conditions should be readily recognized as such by the patient. — Ed.] However, the candle-test also reveals the light sense of the retina and is useful on that account. The degree of peripheral vision is determined by means of the so-called projection-test, a kind of measuring of the visual field by means of a coarse stimulus capable of affecting the cornea through the cataract. The patient is taken into a dark room, the other eye is bandaged, and his ability to localize with the cataractous eye a candle flame in various portions of the visual field is tested, the examiner covering the patient's eye with his hand while 94 OPERATIONS ON THE EYE. the light is being placed at the desired spot — above, below, to the right, to the left, etc. As soon as the eye is uncov- ered the patient should be able to point to the light with his finger at once and unerringly. With unintelligent patients this test must be repeated, if it is unsatisfactory the first time, until the patient learns what is expected of him. Many patients also believe that they will not be operated upon unless they have lost their vision com- pletely and therefore give incorrect answers in order to be sent home without operation. The projection-test enables us to determine whether the retina is the seat of a gross lesion, such as detachment, occlusion of its vessels, etc. ; or if, for example, a tumor of the choroid is present. The function of the retina and of the optic nerve is further determined by testing the pupillary reaction, which incidentally shows whether any synechia are present. Although the latter do not render the operation impos- sible, they diminish the chances for success because they are often associated with disease of the vitreous. As it is impossible in most cases, if the cataract is com- plete before the patient is seen, to find out whether the posterior segment of the eye is in good condition — as it ought to be if the cataract operation is to be successful — it is very important that the practising physician who recognizes, or at least suspects, beginning cataract should send his patient at once to the oculist who is to operate later on, so as to enable the latter to satisfy himself that the lens is still tolerably transparent, that the eye is sound, and, in short, to enable him to get better acquainted with the eye. This is often of the utmost value. I wish to state emphatically, however, that it is both inhuman and unwise for either a general practitioner or a specialist to mention cataract and operation to a patient before the cataract has reached the stage when an opera- tion will soon be required ; for nobody likes to be told that he has a cataract (our excellent statistics notwith- standing), and most people are greatly alarmed by the information. Besides, if the individual is very old and OPERATION FOR CATARACT. 95 dies before operation becomes necessary, the physician will have embittered his declining days unnecessarily by the premature announcement. In the same way it is bad practice to mention the question of operation until it has been definitely determined that the cataract can be suc- cessfully extracted. 3. Bodily (General) Condition of the Patient. — Another important condition for a successful operation is that the general bodily condition of the patient be satisfactory. Extreme age is no contra-indication to a cataract opera- tion if the patient's strength is fairly good, although patients and their friends usually think otherwise. Idiocy, minor degrees of epilepsy, and deaf-mutism do not con- tra-indicate the operation ; on the contrary, those afflicted with the latter misfortune should be operated upon as early as possible, and are usually most grateful for the improvement in their general condition thus brought about. The operation is not rendered impossible by diabetes and albuminuria, unless the diseases mentioned are far advanced ; but under such circumstances special caution is required and the diet must be suitably regulated in some cases for some time before the operation. On the other hand, suppurating processes of any kind in the body — leg ulcers, eczema, and the like — must be regarded as strict contra-indications so long as they are present. If they can not be cured, the diseased portion must at least be rendered innocuous by covering it with an antiseptic bandage during the entire time the eyes are under treatment. It is absolutely indispensable to sur- round the eye with special care before and after the operation in such cases. The conditions for a cataract operation, so far as the eye itself is concerned, can be deduced in part from what has been said and in part will be discussed in con- nection with methods of operation. If both eyes are the seat of cataracts that have reached maturity, it is not advisable to operate on both cataracts 96 OPERATIONS ON THE EYE. at the same time, because if any unfortunate complication, such as wound-infection during the operation, delirium tremens, diphtheria or erysipelas should ensue, both eyes might be lost. It is better to defer operation on the second eye until after the wound in the first has healed, and, in the case of old persons, until after the patient has completely recovered from the first operation. Is it proper to operate on an eye with a ripe cataract when vision is perfectly good in the other eye? The answer to this question is that it is proper to remove cataract of this kind only when it has become completely ripe and is in no danger of becoming over-ripe. Under such circumstances, however, the patient often exhibits very little gratitude for having obtained vision Avith his cataractous eye, and occasionally he even complains that the vision of the operated eye disturbs that of the sound eye. It is therefore well to explain the state of the case to him carefully beforehand and to tell him that the eye which is to be operated upon will only be used to a moderate degree, and, in a sense, represents a reserve eye in case the other should at any time become blind from cataract. He should be told that he really would not need cataract glasses after recovery ; but practically it is better to give him cataract glasses nevertheless, in order to enable him to convince himself that he can see with the eye ; otherwise he will think the operation has been unsuccessful. The important and often difficult question, when may or shall a cataract be operated upon before it is ripe has been largely answered in the foregoing pages. It may be well, however, ,to recapitulate. There is no doubt that nowadays, thanks to the improvement in the treatment of wounds, we need not hesitate as much as formerly to operate on unripe cataracts when it is necessary. It would not be right to adhere to the former practice, which at that time was perfectly justifiable, to make patients wait, sometimes until they depart for a better world, for com- plete ripening of the cataract and operation. It must OPERATION FOR CATARACT. 97 always be clearly kept in mind that an operation on a cataract which is actually — not only apparently — unripe involves certain dangers, the least of which is a tedious recovery. The last-mentioned fact must be clearly placed before anyone with a cataract of this kind, and it must be explained to him beforehand that a secondary opera- tion will probably have to be performed. If in the end it turns out that the latter is unnecessary, it is all the better. My experience has not taught me that cataract, whether completely or only partially opaque, can be extraced with the same success after the sixtieth year of life. When the opacity of the cataract is incomplete, it often requires weeks or even months for the remains to be absorbed. It is true that even in these cases vision may eventually be quite good ; a question that will be referred to later. When shall an operation for cataract be preceded by an iridectomy ? This question, which will be touched upon again in the course of this work, may be answered in a general way by saying that on general principles iridectomy is to be avoided in operating on cataract and is to be resorted to only when there are strong reasons for doing so. It will probably be generally conceded at the present time that in all cases of juvenile cataract, including the lamellar form, and in all cases up to the fortieth or forty- fifth year of life, especially in female patients, iridectomy can in almost every instance be avoided and must be avoided. Even if the tension increases while a cataract of this kind is under treatment, iridectomy is not always necessary at this age ; for the increased tension may be corrected by corneal puncture or possibly by a sclerotomy. At this time of life the question of appearance must be considered by the operator, because at this age the eyes are generally held wide open, while in old persons, owing to the loss of fat in the orbit, the upper lid usually hangs down over and, as a rule, covers the upper half of the cornea, so that one has to raise the eyelid with the finger 7 98 OPERATIONS ON THE EYE. in old people to find out whether an iridectomy has been performed. Another reason why iridectomy is less urgent in earlier life, up to the age of forty or forty-five, is that the nucleus of the cataract is not so large ; hence its delivery is easier and not so severe on the iris, as is the case later on. Opinions differ as to whether in the case of true senile cataract the operation should or should not be preceded by iridectomy. It may be remarked in general that, although an operator may on principle avoid iridectomy, he will nevertheless be compelled from time to time to resort to the operation, and that it is better to do so when- ever the iris is at all slow to return to the anterior cham- ber after the delivery of the cataract, and there is corre- sponding failure of the pupil to contract. It is impossible to know beforehand how the iris Mill act. Individuals differ in this respect, and it has often been observed that if the iris returns readily in one eye it will do the same in the other if the latter is operated upon later ; and, con- versely, if the iris shows flaccidity in the first eye, it will do the same thing in the second eye. It is not advisable to bring about contraction of the pupil beforehand by in- stilling physostigmin, because the contraction of the pupil may interfere with the ready escape of the cataract, with the result that a good deal of cortical matter is stripped off and remains behind the iris. In the case of old and feeble persons who must not be kept in bed for any length of time, because they would lose their appetite altogether and might develop hypostatic pneumonia from the continued recumbent posture, it is more advisable, as a rule, to excise the iris, for by doing so it is quite possible to allow the patient to get up and walk about twenty-four hours after the operation, without the danger of prolapse of the iris. In another class of patients, who, for other reasons, such as, for example, occasional severe attacks of cough- ing or sneezing, great nervous excitement, nervous dis- tress on account of heart trouble and the like, are not OPERATION FOR CATARACT. 99 likely to keep quiet for twenty-four to forty-eight hours, it is advisable to perform an iridectomy before extracting the cataract. In many cases of this kind and whenever a complication before or after the operation is imminent, such, for example, as an escape of vitreous by reason of the patient's unmanageableness or idiocy, abnormal con- ditions of the eye — such as liquefaction of the vitreous from myopia and the like — it is always well to have a pre- liminary iridectomy. In weighing the reasons for and against iridectomy in operations for senile cataract it should be mentioned that it is of no importance whatever, so far as the patient's ultimate visual power is concerned, whether the pupil remains round or not. In either case vision may be nor- mal or practically normal, provided the pupillary region is free from the remains of cataract. Owing to this necessity of keeping the pupillary region absolutely clear, secondary cataract operations are somewhat more fre- quently required after the simple one, that is, one with- out iridectomy, than after an operation combined with iri- dectomy, because the remains of the cataract can be better stripped out in the latter case than when the iris remains intact and therefore hinders the escape of the soft cortical masses. This is not a very important factor, however, because secondary operations have to be resorted to often enough after combined extraction if the operator hopes to secure perfect vision. It has been objected to by those who advocate the simple operation that the increased amount of light admitted to the eye, as the result of the iridectomy, may be a disturbing factor. It is to be remarked, however, that in the case of old persons the upper lid generally covers the iridectomy and prevents the light from enter- ing through the coloboma. On the other hand, when the upper lid does not hang so low, as, for example, when the eyes are somewhat more prominent, it is quite true that the iridectomy-gap is not screened against the excess of light, and that an increased amount of light enters the 100 OPERATIONS ON THE EYE. eye and may blind the patient and cause him to see red — erythropsia. The latter phenomenon is due to the fact that when an eye, particularly one that is deprived of its lens, is exposed to strong light for some time, the retina gets into a condition of excessive irritation ; and when the patient enters a dark place all bright objects for a time appear to be colored a bright red, which greatly frightens the patient and causes him to think that a hem- orrhage has occurred. It appears from the investigations of Fuchs and others that the ultraviolet light rays are chiefly concerned in producing this effect on the retina and that they may cause erythropsia in the normal eye, as, for example, after a long period of snow-blindness on high mountains. As the lens has a high absorption for chemical light rays and keeps them away from the retina, eyes with aphakia are more liable to erythropsia than those which still possess a lens. If, therefore, the upper part of the iris is not covered by the lid, it is better to leave the iris intact when opera- ting for cataract. It is not true, however, that simple cataract extraction without iridectomy is less dangerous and less apt to be followed by wound infection because the traumatism to the eye is somewhat less extensive. First of all, the simple operation has the disadvantage that if, during the night after the operation or even later, the wound suddenly opens, the iris may be washed into the wound by the aqueous humor and a prolapse of the iris may thus be produced, causing distortion of the pupil upward and disfiguring the eye and interfering with the regular progress of recovery. It is anything but pleasant under such circumstances to be forced to operate again ; for there is no choice and the prolapsed portion of the iris must be removed absolutely. This point will be referred to later. On the other hand, it is possible, even when the opera- tion for cataract is preceded by iridectomy and especially if the wound is slow to heal and frequently reopens, for OPERATION FOR CATARACT. . 101 the iris to slip into the wound or to be washed into it by the aqueous humor. As a rule this happens only on one side of the coloboma. But the accident is not often observed and is usually mild in degree. It will be well, on the whole, to decide this question of iridectomy chiefly by individual conditions and to avoid routine methods. Under what circumstances may general anesthesia be employed for cataract operation ? In answering this question it is to be remembered that the eyeball is, as a rule, rotated upward during the anes- thesia, especially if it is not very profound, and thus makes it difficult to place the incision at the upper border of the cornea, which is justly considered the preferable site. It is not always easy in general anesthesia to rotate the eyeball downward with the forceps without causing a dangerous gaping of the wound. Another disadvantage of general anesthesia is the vom- iting that frequently follows, as it is apt to interfere with closure of the wound, and in old persons with friable vessels may cause intra-ocular hemorrhage. Finally, general anesthesia always implies a certain degree of danger to life. Cataract operations, to begin with, are not very painful, and with the proper use of cocain can be rendered bear- able even to the most sensitive patient, so that, for these reasons and the above considerations as well, general anes- thesia should be practically abandoned in the case of old persons, and if employed at all should be reserved for patients who, on account of idiocy or absolute inability to control themselves, offer no guarantee that they will conduct themselves properly during the operation. In such cases it may be advisable to extract the cataract from below if the upward rotation of the eyes is very marked. In operating on children, chloroform is always necessary if, owing to great restlessness and excitement on the part of the little patient, it is impossible to perform the opera- tion properly, and especially when there is danger of tear- 102 OPERATIONS ON THE EYE. ing the zonule of Zinn and thus allowing the vitreous to enter the wound. In the ease of very small children only a small quantity of chloroform is required to keep them quiet during the brief time occupied. It is often possible by speaking to the child kindly, and, especially if one has good assistants, to control the situation with cocain. Having thus discussed in a general way the necessary conditions for a cataract operation and the preliminary examinations, I shall turn my attention to the operation itself as it is to be performed in the various forms of cataract, and shall incidentally discuss various special aspects of the question, including the after-treatment. Beginning with the simpler procedure which suffices for removing a cataract in the case of children, we proceed to discuss (a) The Operation for the Removal of Total Juvenile Cataract. By this term is meant a cataract which is noticed soon after birth or perhaps somewhat later, and is usually brought to the physician for treatment early because the gray color in the pupil is noticed by the patient's family. This form of cataract is usually bilateral and much more rare than senile cataract. Juvenile cataract is especially amenable to treatment by simple discission, a method which, owing to its simplicity, can be used with little children. The indication is to re- move these cataracts as early as possible, so as to enable the retina to receive distinct images as soon as the child begins to use its eyes, and thus prevent the development of the form of defective vision which has been attributed to fail- ure to use the retina during the period of development (amblyopia exanopsia), and which may give rise to nystag- mus — i. e.j irregular action of the eye-muscles — explain- able on the assumption that the complicated mechanism of the ocular muscles is not properly regulated by the forma- tion of distinct retinal images, and therefore fails to de- velop properly. REMOVAL OF TOTAL JUVENILE CATARACT. 103 Nevertheless it is not advisable to operate on these cata- racts too early — i. e., before the end of the first or second year of life — because it sometimes happens that, owing to prolapse of the cataract into the anterior chamber, incision of the cornea and the removal of part of the cataractized masses become necessary after discission has been per- formed. This complicates the operative treatment and requires bandages and sometimes rest, measures that are difficult to carry out in the case of a very small child. On the other hand, the operation must not be delayed too long, because otherwise a cataract of this kind becomes over-ripe, contracts, and then requires the same treatment as a senile, membranous cataract, which is similar to the treatment of dense secondary cataract (to be discussed later), and which may be attended with some difficulties. Before beginning the operation, a careful examination must be made to determine whether the cataract is simple or complicated, and particularly whether there are any synechia? — i. c, traces of an antecedent or still active iritis. If there are synechia? — which may not be dis- tinctly visible until the pupil has been dilated with horno- tropin or atropin — the prognosis is dubious, because these are generally cases of congenital syphilis. This fact should be made clear to the family beforehand, for the reason that in this disease other alterations are often present in the deeper structures of the eye or may make their appearance after the operation and endanger the eye- sight. On general principles it is wiser in the case of cataract in very small children, even when they are not complicated, to maintain a certain reserve in regard to the result of the operation. There are cases which never attain more than a moderate visual power, even when re- sulting successfully, a condition for which it is sometimes impossible to discover a cause. The preparations for discission are simple. As the operative wound is a mere perforation and is therefore a comparatively trivial interference, the cleansing of the operative field need not be so rigorous. After the pupil 104 OPERATIONS ON THE EYE. has been dilated with atropin and a few drops of a 3 per cent, solution of cocain have been introduced into the eye, the skin of the lids and surrounding portions is cleansed with soap and warm water, and then with bichlorid solu- tion of 1 : 1000, after which the conjunctival sac is washed out with a bichlorid solution of 1 : 5000 or with sterile salt solution. The operation is usually performed without anesthesia. The speculum (Fig. 10), is introduced or an assistant holds the lids apart, the operator seizes the bulb with the fixation forceps (Fig. 21) at a point to the nasal side of the cornea, and with a discission needle (Fig. 56) or a capsule knife (Fig. 58) pierces the cornea at a point a little below the horizontal meridian and 3 mm. from the Fig. 3.— Division of the anterior capsule of the lens with Bowman's dis- cission needle. Fig. 4.— Linear incision through the cornea with the keratome. Fig. 5.— Flat curved incision. temporal border of the membrane, carrying the instru- ment a little beyond the center of the pupil. [The needle may be entered just external to the limbus. — Ed.] After the lens has been entered, an opening is made with the point of the needle in the capsule of the lens, 4 to 5 mm. in length, and running from above downward (Fig. 3) ; the needle is then rotated about its long axis and at the same time slightly withdrawn, a short transverse incision is made, and, after the needle has been rotated back into its original position, it is quickly removed, so as to prevent the escape of any aqueous humor. A little cotton and a few strips of adhesive plaster are always necessary for a dress- ing, and during the first two days the child's arms must, REMOVAL OF TOTAL JUVENILE CATARACT. 105 as a rule, be bound to its sides to prevent its handling the dressings. The after-treatment consists in carefully looking after the dressing and keeping the pupil dilated by instilling from 1 to 2 drops of atropin solution per day. The eye must be kept under close supervision on account of the danger of increased tension, which would manifest itself by haziness of the surface of the cornea. If the child cries out and cL >ses the eyes forcibly when an attempt is made to determine th'e intra-ocular tension by palpation, it must be brought slightly under the influence of an anesthetic. If the tension rises on account of prolapse of cataractous ma- terial the first thing to do is to diminish the atropin, and, if that fails to correct the trouble, an incision is made in the anterior chamber, under full anesthesia, if the child is unruly. For this purpose a keratome instead of a needle is in- troduced into the anterior chamber in the same way as for discission. The instrument is best introduced in the temporal portion of the cornea, between the margin and the center, so as to make a vertical incision from 4 to 6 mm. in length, the extremities being at equal distances from the center of the cornea (Fig. 4). After the lens has been withdrawn, the periphery of the wound is depressed some- what with the spatula (Fig. 30), so as to make the wound gape and cause the escape of the cataractous mass. If the latter is tough and slow to escape, the spatula is intro- duced a distance of 4 to 5 mm. into the anterior chamber and into the cataractous mass, the periphery of the w T ound is pushed back, and the spatula rotated around the long axis of its handle from one side to the other to stir up the cataractous masses. By the aid of this manouver it is possible to evacuate a considerable quantity of lenticular masses without doing any injury, even when they are quite tough. If necessary, the evacuation may be assisted by exerting moderate pressure on the globe at the same time with the fixation-forceps. The anterior chamber may also be opened at the tern- 106 OPERATIONS ON THE EYE. poral, lower, or upper border of the cornea instead of between the border and the center (Fig. 5). If during the evacuation of the cataract the iris is forced into the wound, the surgeon must take care not to leave it there, but must replace it with the aid of the spatula. The operation of opening the anterior chamber by means of the incisions shown in Figs. 4 and 5 is also called simple linear extraction, bnt the term is not appropriate for most of these incisions. A true linear incision through the cornea must occupy the plane of one of its meridians — that is, a plane which passes through the center of the curvature of the cornea. Such an incision would necessitate intro- ducing the keratome practically at a right angle and aiming directly at the said center of curvature. But such a method of introducing the lancet would endanger the posterior capsule of the lens. A linear incision might resemble the flat-curved incision shown in Fig. 4 ; the line shown in Fig. 5 passing transversely over the cornea would also represent a linear incision. As a rule, however, the keratome is intro- duced into the anterior chamber in such a way that the wound coin- cides with a parallel of the cornea, and therefore represents a flat incision or curved incision with variable degrees of convexity, as, for example, the incision at the lower border of the cornea shown in Fig. 5. This method of removing portions of the cataract also requires great care to prevent rupture of the zonula or laceration of the posterior capsule and the escape of vitreous into the wound. This unfortunate accident may- even folloAV primary incision if the operator is not careful to avoid lateral traction of the lens in performing the operation. If the vitreous appears in the corneal wound in the form of a transparent bead, the operation must be terminated at once and a dressing applied. If this is done, a small quantity of vitreous may return of its own accord. After the cataract has been removed in this way a heavy dressing of cotton, adhesive-plaster strips, and a roller bandage, usually a double one, must be worn for two days. At the end of every twenty-four hours the surgeon must determine whether atropin is necessary to keep the pupil dilated, and how much is required. In children, who always try to rub their eyes, the eye that has been operated upon must be kept well bandaged for at least a week. REMOVAL OF TOTAL JUVENILE CATARACT. 107 If the child is somewhat older and has the sense to submit to rest and the application of a bandage, the treat- ment by discission may be abandoned in favor of the senile linear extraction — i. e. } extraction of the cataract through an incision like those shown in Figs. 4 and 5. Without previous dilatation of the pupil by atropin the eye is cocainized, the lids and surrounding skin cleansed with soap and bichlorid solution, and, after the conjunctival sac has been flushed out with a 1 : 5000 solu- tion of bichlorid or with sterile salt solution, the stop- speculum is applied and the cornea at once opened by means of one or the other above-mentioned incisions. The keratome may also be introduced from above ; but as a rule it will be found most convenient to introduce the instrument on the temporal side, as shown in Fig. 4, the globe being steadied by seizing the conjunctiva with the fixation-forceps near the corneal margin, at a point oppo- site the entrance to the wound, as shown in Plate 6. In carrying the keratome forward the point must always be directed toward the axis of the eye. The opening of the anterior capsule may be effected by introducing the kera- tome into the lens at once or, better, by withdrawing the instrument after the corneal incision, which should be 5 to 6 mm. in length, has been made, and afterward opening the capsule by a fairly liberal incision with a cystotome (Fig. 40), as will be more accurately described later in connection with operations on senile cataracts. In this procedure also great care must be exercised to avoid lateral dislocation of the lens, so as not to lacerate the zonule of Zinn. As a rule, the opening of the anterior capsule is at once followed by the escape of part of the cataract into the anterior chamber. The next step consists in evacuating the entire cataractous mass with the spatula, as has already been explained. Small remnants may be left to be absorbed. The after-treatment is the same as that of incision following discission. 108 OPERATIONS ON THE EYE. (b) Operation for Total Soft Cataract of Adults. The cataract is removed in the manner just described by means of a corneal incision (" simple linear extrac- tion ") whenever the age of the patient and the appear- ance of the cataract are such as to make it probable that the cataract does not contain a nucleus or a small one. The presence of a nucleus can sometimes be recognized under strong lateral illumination by the presence of a denser opacity in the central portion of the lens, particu- larly in patients over thirty-five years of age. If the presence of a nucleus is demonstrated, or the age of the patient is such as to render its presence probable, a curved, and correspondingly larger, incision is made at the edge of the cornea, either with a keratome or with a Gräfe cataract-knife. The operation is exactly like that for senile cataract without iridectomy, to which the reader is accordingly referred. Soft cataracts in middle-aged patients, particularly in women, are sometimes complicated with iritic deposits on the posterior wall of the cornea, with synechiae, and without the eye exhibiting any other dis- ease — no redness or irritation. Such a condition is, according to my experience, no contra-indication to the operation. As a rule the deposits disappear after the operation. (c) Operation for Traumatic Cataract. Up to the age of thirty-five to forty years, the period when nucleus-formation begins to be marked, this opera- tion is also performed according to the method described in the preceding paragraph — i.e., the cataract is removed through a corneal incision of varying size. If the anterior capsule has been opened by the injury and the wound lias failed to close, causing the escape of cataractous masses, exactly as after a discission when the operation is performed on a lens that is not opaque or only partially so, nothing more is required except an incision to the anterior chamber. If, on the other hand, the anterior capsule lias only sustained a slight injury and the wound has closed, a form of cataract in every respect OPERATION FOR TRAUMATIC CATARACT. 109 resembling ordinary spontaneous cataract may develop, and the operator will be forced to open the anterior capsule. The same thing often happens when a small foreign body perforates the lens completely or becomes embedded in the posterior capsule without injuring the structure. When a splinter has passed completely through the lens, as not infrequently happens, total cataract, as a rule, develops sooner or later. In very rare instances — I have personally observed such a case — the lens remains clear. In operating on such a lens after it has become completely opaque, much greater care is required than in cases in which the posterior capsule is intact ; for the wound of the posterior capsule, even though it may be small and may have existed for some time, so as to make it probable that cicatrization has taken place, is apt to re-open — ac- cording to my experience — and allow the vitreous to escape into the wound, thus bringing about a most unde- sirable complication. It seems that under certain circum- stances the wound in the posterior capsule enlarges, and even when the original opening is small, the prolapse of vitreous may be quite considerable. In order to minimize this danger it is advisable to keep the eye under the influence of cocain for some time before the operation — that is, to instill 1 drop of a 3 per cent, solution of cocain every five minutes for one-half hour, because the intra-ocular tension is thereby diminished. It is also advisable, as in every case when an escape of vitreous is to be feared, to tell the patient, during the operation, to keep his eye directed straight forward — that is, in the primary position, and to rotate it as little as possible to the side or upward, because rotation of the eye, by increasing the pressure of the external eye-muscles which are put on the stretch, causes an increase in the intra-ocular tension and brings with it the danger of escape of the vitreous. For this reason a cataract of this kind is best extracted through an incision in the temporal or lower half of the cornea. 110 OPERATIONS ON THE EYE. In these cases there is also a special indication for the strict observance of every rule of antisepsis and asepsis before, during, and after the operation. If a foreign body, after passing through the lens, becomes embedded in the back of the eye and can not be removed, and the eye remains free from inflammation, the removal of such a traumatic cataract is indicated in spite of the existing complication, not so much for the purpose of restoring the eyesight, as to avoid any evil conse- quences that a cataract of this kind may give rise to by becoming over-ripe (dislocation into the anterior chamber or into the vitreous). It is to be remembered that by removing a cataract the eyesight may be restored to a considerable degree even when the splinter, which may be a particle of copper or of iron, remains embedded in the eye ; and if the foreign body becomes well encysted, vision may be preserved for some years. If, as rarely happens, a particle of copper or stone becomes embedded in the lens, it should be allowed to stay there if it is well tolerated until the lens has become completely opaque, when the foreign body is removed along with the cataract. But if the foreign body in the lens is of iron, it is better to extract it as soon as possible with the large magnet (see Magnet-operation) and to operate on the cataract later. Traumatic cataract may also be produced by a severe blow on the eye lacerating the capsule of the lens. The laceration usually occurs in the equatorial region of the lens. This also, as a rule, leads to total cataract ; at the same time, however, the neighboring zonule of Zinn is also torn. This complication, which has a very import- ant bearing on the operation, is not always easy to recog- nize ; but it may manifest itself by the appearance of a small portion of vitreous making its way from behind the iris into the pupil, which is often somewhat distorted, and this prolapse of the vitreous can be recognized under strong lateral illumination and, if necessary, with the aid OPERATION FOR TRAUMATIC CATARACT. Ill of a lens. The iris is forced away from the lens at the corresponding point. Laceration of the zonule of Zinn, when of considerable size, often manifests itself by slight tremor of the lens, which at the same time may be some- what decentered — i. e., displaced toward the side opposite the laceration. Finally, there are cases in which the iris is torn from its ciliary attachment before laceration of the zonule of Zinn takes place, so that the absence of the zonule can be seen directly through the black opening formed by the iridodialysis, it being impossible to see the fine radiating fibers of the structure, either with the ophthalmoscope or under lateral illumination with a mag- nifying lens. Whether laceration of the zonule is diagnosticated or only surmised, the danger of prolapse of the vitreous, which infallibly forces its way into the corneal incision, must be kept constantly in mind when operating on a traumatic cataract produced by the violent impact of a blunt body. A cataract of this kind should therefore, whenever possible, be extracted by the operation of discis- sion with two needles, without making any corneal incis- ion. The discission wound in the capsule should be very small, so as to prevent the escape of a large quan- tity of lenticular material into the anterior chamber and the development of glaucoma. If, owing to the small size of the capsular opening, absorption is interrupted because the cells of capsular epithelium sometimes cover up the gap, a second or third discission through the same opening in the capsule may be cautiously performed to remedy the trouble. Although this method is slow, it is very much safer than any other and is to be recommended above all others in these cases. Whether the cause of a traumatic cataract be one or the other of the above-mentioned factors, it may be par- tial and may never become total. If the partial cataract interferes with vision, as is sometimes the case, for exam- ple, when it forms a figure like a rosette at the posterior pole, and if the vision of the other eye is feeble and it 112 OPE BÄTIONS ON THE EYE. becomes necessary to restore the vision of the injured eye, the procedures to be described in the following section are to be adopted. (d) Operation for Partial Stationary Cataract. Partial cataract, which does not go on to complete clouding of the lens, is usually treated while the patient is still young. lamellar Cataract. — This is the most frequent and therefore the most important example of the class. It develops chiefly in children suffering from convulsions and rachitis and is almost always bilateral. The charac- teristic features are an anterior and posterior layer of opacity surrounding a nucleus of variable size, which is either clear or only slightly opaque. When the nucleus is large, the opaque layers are near the capsule of the lens ; when it is small, the capsule is separated from the opaque portions by a broad layer of clear cortical matter. The opacity of the two layers, the edges of which may overlap like segments of a sphere, may be of a variable degree of intensity. When the opacity is only slight, the eye is not impervious to direct light and the individual's vision is only moderately reduced. There are cases in which the opacity is so slight as practically not to inter- fere with vision at all ; in such cases we may speak of a rudimentary lamellar cataract. As a rule, however, the opacity is such as to impair the visual power, especially if the child is going to school and there is a considerable demand on the eyes ; for this reason children with lamel- lar cataracts present themselves for treatment during the school years. The best treatment, as a rule, consists in removal of the lens, because optic iridectomy, which will be mentioned later, frequently leaves the eye with incomplete vision, and the success of the procedure under certain circum- stances may be diminished by the fact that later, as the patient becomes older, the cortical layer, which up to that OPERA TION FOR PA R TIA L STA TION. 1 R Y CA TA RA CT. 1 1 3 time had remained unaffected and which through the iridectomy becomes accessible to the rays of light that enter the eye, gradually becomes more and more opaque ; although, as a rule, the opacity in this variety of cataract remains stationary until extreme old age and is limited to the zone between the nucleus and the cortex. Iridectomy, however, can only be performed in a comparatively small group of cases, in which the lamellar cataract is small enough to leave room for the rays of light to enter the eye after the iridectomy has been performed. In the great majority of perinuclear cataracts radical operation by re- moval of the lens is indicated. This operation can be performed in one of two way- : either by discission followed by a short incision of the cornea, or by immediate removal through a large curved incision. The latter method is adapted only for old per- sons in whom a hard nucleus has already formed. These cataract patients retain fairly good vision long after they have passed middle age ; gradually, however, the opacity of the lamellar cataract or that of the nucleus increases and the patient is unable to work. The cortical layer, unless it has become cloudy from senile cataract, adheres to the capsule and has to be absorbed later. In child- hood, on the other hand, which is the time when most lamellar cataracts are removed, the proper treatment is discission, because it at once induces opacity and softening of the cortical layer and of the nucleus and thus permits absorption to take place. In most cases, however, the swelling of the cortical masses forces the nucleus, after it has become more or less cloudy as the result of the discis- sion, through the opening in the anterior capsule either as a whole or in fragments, so that the latter occupy the anterior chamber, and it is then advisable to make an incision in the cornea and evacuate the cataractous mass in order to shorten convalescence. In very small children and in larger children who are unmanageable it is of course wiser to avoid a corneal incision as much as pos- sible and, whenever it is feasible, to be content with mere 114 OPERATIONS ON THE EYE. incision and absorption. If, however, it becomes neces- sary to relieve the tension in the anterior chamber by evacuating its contents, it is best to make a short incision not more than 5 to 6 mm. in length between the edge and the center of the cornea. The individual steps of this procedure have already been described, and it is evident that they must be carried out with due observance of antiseptic precautions. Whenever in the case of older children it becomes necessary to remove the lamellar cataract without loss of time, as for example, in order not to keep the child out of school too long, it is advisable to divide the anterior capsule along with the anterior cortical layer by a liberal incision, which should even be carried into the nucleus so as to admit the aqueous humor. This is a better pro- cedure in such cases than discission, performed with one needle in the manner already described, and is done with two Bowman's discission needles (Fig. 56). The two needles are inserted opposite the peripheral portion of the cornea, as shown in Plate 4, for the secondary operation on cataract ; the points of the needles are then brought close together and introduced into the lens and then separated again, at first in a horizontal, and then in a vertical direction, so as to make quite a large and deep crucial incision. The object of using two needles is to avoid dragging the lens about and thus tearing the zonule. For the sake of greater security, if the child has not been chloroformed, which is as a rule an unnecessary pre- caution, it is advisable to have an assistant to steady the eye with a fixation-forceps in order to guard against any laceration through sudden movements of the globe. This is not shown in Plate 4. In performing discission with Bowman's needles it is very important to see that the needles are properly constructed. Nowadays needles are manufactured which do not possess the chief advantage of Bow- man's needles — namely, that of preventing the escape of aqueous humor during the operation. This is accomplished by making the needle thick enough so that the part immediately behind the point com- pletely occludes the wound as the needle is thrust through the cornea. OPERA TION FOR PA R TIA L STA TIOXAR Y CA TARA CT 115 Even if the latter is not introduced as far as the stop (Fig. 6 (a) 2), the wound is supposed to be closed not by the stop, but by the shaft between it and the point, which must be thicker than the point at its greatest width. As soon as the point has penetrated the cornea, the shaft (between 1 and 2) should at once com- pletely occlude the wound. For in the case of children it may happen that the needle can not be inserted as far as the stop in this operation, and the stop can not therefore be used as an obturator. If the wound is prop- erly occluded by the needle,the normal depth i if the anterior chamber is preserved and the distance between the lens and the cornea does not change during the operation. But if the needle is not properly constructed, as shown in Fig. 6 (b), the large wound made by such a lance-shaped instrument will not be occluded by the posterior portion of the needle, the aqueous humor escapes along the shaft as soon as the edge of the needle has passed the cornea, and the lens at once approaches the cornea. Under such cir- cumstances it is quite impossible to intro- duce the needle as far as the stop, so as to use it to occlude the wound, because by doing so the needle would be thrust too far into the lens. The aqueous humor accord- ingly continues to escape and, if discission is performed under such circumstances, there is great dancer of tearing the pos- terior capsule also, because the lens rapidly advances toward the cornea, especially if the child begins to cry. An injury to the posterior capsule is a very serious blunder in this operation and brings its own pun- ishment when the operator is later obliged to puncture the anterior chamber; for some of the vitreous is sure to force its way into the wound, which can not be regarded as anything but a very grave complication. When instead of Bowman's needles a capsular knife is used for this operation, as for example, Knapp's knife (Fig. 58), the knife must be constantly tested on the chamois to determine whether the shaft occludes the incision. (I Fig. 6.— a, Discission needle properly constructed to occlude the wound; ft, one that does not occlude the wound (greatly magni- fied). As soon as the capsule and the lens substance have thus been freely laid open, the lenticular material begins to become cloudy and rapidly swells. But by keeping the pupil dilated so as to prevent the formation of synechia? 116 OPERATIONS ON THE EYE. it is quite safe to wait until either the tension increases or a considerable quantity of gray cataract material has entered the anterior chamber, including within it the more or less fragmented and opaque nuclear portion. The more the anterior chamber becomes filled with this grayish, translucent mass, which resembles glue, the more easy will be evacuation with a keratome incision as sketched in Fig. 4. If necessary the puncture may be repeated if the first does not suffice to clean up the pupillary region. If the tension becomes increased during the course of the treatment, the condition may be corrected by making a small puncture of the cornea with a narrow keratome or linear knife and, if necessary, repeating the operation. A rise in tension should never be regarded as an imme- diate indication for iridectomy. In fact, iridectomy, as has already been intimated, is to be excluded on general principles in the case of young patients. If the iris glides into the wound after incision of the anterior cham- ber, it must be at once replaced with a spatula and con- traction of the pupil brought about by instilling physo- stigmin. If an anterior synechia forms in the corneal opening it can be divided later in the manner to be described. Finally, it is necessary in most cases, in order to obtain as good vision as possible, to perform discission on the posterior capsule and any remaining cataractous material ; this is done in the same way as a secondary operation for cataract, which will be described. The entire duration of the treatment when discission, combined with corneal incision, is used may be from six to eight weeks. If discission is used alone, without punct- ure, the treatment may last even longer; but the most important consideration in these cases is to choose the safest and not the shortest method, especially as most of the children have plenty of time and the danger of pro- lapse of the vitreous into the wound must be specially guarded against, because in children it is usually followed by bad recovery with iritis, cyclitis, and distortion and OPERA TION FOR PA R TIA L STA TIONAR Y CA TARA CT. 117 occlusion of the pupil. The different operations must not be performed in too rapid succession, else there will be danger of iridocyclitis. It is also advisable not to operate on both eyes at the same time, because, if the child should be unfortunate enough to contract a disease — such as scarlet fever or diphtheria — accidentally, or the wound should become infected, both eyes might be destroyed. It is most important in these cases of lamellar cataract to secure smooth recovery, with a round, perfectly mov- able, clean pupil in correct position for the reason, even when recovery is ideal, the visual power quite frequently turns out to be only moderately good (from ^ to f), although there does not seem to be any cause for this want of success. Ultimate vision of \- constitutes a disability. If before the operation the patient had a visual acuity of J, and it is not increased by the operation, the removal of the lens has been of no benefit to him ; for he has been deprived of his accommodation and will require a thick convex glass (cataract glass) for distinct near vision, and most patients who have to be operated on for cataract find this very unpleasant. If, therefore, in a case of lamellar cataract the indi- vidual still has a visual acuity of J to J-, an operation is permissible only if there is some certainty that it will be followed by an uninterrupted recovery and a fairly good result ; otherwise it would be better not to operate, for there is always a possibility of more favorable conditions for its removal developing later. As a rule the opacity of a lamellar cataract and the reduction of vision are nearly the same on the two sides, but in some cases there is a difference. In such cases it is well to operate on the worst eye, and not to interfere with the other if near vision is still fairly good, so that, if the patient happens to loose his reading glasses, he is not entirely helpless so far as near vision is concerned. The same treatment as for lamellar cataract is indicated for other stationary, partial cataracts in young individuals, such as spindle cataract, anterior and posterior polar cata- 118 OPERATIONS ON THE EYE. ract, etc. These forms rarely come to operation. With regard to anterior polar cataract, which occasionally pro- duces a distinct increase of the white discoloration at the anterior pole in the form of a pyramidal cataract, it is evi- dent from what has been said about capsular cataract that it can not be removed by itself, as by scraping, for example, because it is a capsular cataract and is therefore under- neath the capsule. Small opacities of this kind do not interfere with vision enough to require operation ; large anterior capsular cataracts, which obstruct the greater portion of the pupillary region, must be treated either by doing a small optical iridectomy or by discission — i. e., they must be removed along with the entire lens. Opacities on the posterior pole of the lens, on the other hand, cause a much greater disturbance of vision. They are occasionally met in youthful individuals who present no other disease of the eyes. Strictly speaking, this form of opacity usually belongs to the progressive varieties, but it sometimes increases so slowly that it is impossible to wait for total clouding of the lens to take place. It is better to follow the same line as in lamellar cataract, pro- viding there are no complications, such as iritis, vitreous opacities, choroiditis, or retinitis, to contra-indicate such a procedure. (e) Operation for Senile Cataract. The following points in the interesting history of operation for senile cataract are worthy of notice : Until the year 1745, when Jaques Daviel (1696-1762) first removed a cataract from the eye, an operation for cataract consisted not in removing the cloudy lens from the eye, but merely in getting it out of the way, either by means of the so-called cataract puncture, by which it was pushed down into the vitreous (depression) or turned over back- ward ( reclination, couching). This comparatively simple operation was usually performed by itinerant "cataract-stickers." If the operation was successful the patient, who before had been blind, at once was able to see with the aid of a cataract lens. Unfortunately, however, there were many cases in which the patient did not long enjoy this happiness. It often happened that the lens, after a short time, was again displaced by the vitreous body assuming its original position and again obstructing the view, and still more frequently it happened that the operation was OPERATION FOR SEXILE CATARACT. 119 followed by infection or glaucoma with more or less pain and, ulti- mately, blindness. Glaucoma was frequently responsible for the destruction of eyes that had been treated in this way. Nevertheless this rude method of puncturing cataracts was carried on in many parts of Europe until well into the nineteenth century, and is still practised by the natives of India, where cataract is so common. For cataract extraction is a much more difficult and circumstantial operation and took some time to make its way in practice. Daviel extracted the cataract through a corneal incision which took in from one-half to two-thirds of the lower circumference of the cornea, thus forming a large flap as wide as one-half the diameter of the cornea. Wenzel— both father and son — on the other hand, used a flap directed inward and upward. Gottlob August Richter, in Göttingen ( 1742-1812), and Beer, in Vienna 1 1763-1821 ), again made their incis- ion at the lower border of the cornea with a somewhat smaller flap, although Richter raised the question whether it would not be better to make the incision above. The lower incision was, however, unques- tionably easier of execution, because during the operation the eye is reflexly rotated upward as soon as the pain begins. For this reason Fig. 7.— Flap incision (after Beer) : a, b, Fig. 8.— von Gräfe's Horizontal diameter of the cornea. The linear incision, dotted curved line indicates the inner wound; the solid line, the outer wound. most operators made the flap incision below until A. von Gräfe's time (see Fig. 7). For the sake of greater security and to obtain a smooth incision special knives were devised. That of Beer had the form of a flat triangle (see Fi#. 119). After the incision had been made, the rest of the operation consisted merely in opening the capsule of the lens and delivering the cataract, with gentle pressure, through the capsular opening, the pupil, and the corneal wound. As it was customary, in order to obtain a better view of the cataract and assist in its escape, to dilate the pupil with bella- donna, prolapse of the iris into the large corneal wound — an accident that is very apt to happen with this incision — was still further facili- tated and frequently developed even after the operation. This increased the danger of wound infection, caused a faulty position of the pupil, disturbed the curvature of the cornea and, finally, left the eye with a tendency to glaucoma. It also happened quite frequently that the large corneal flap, either during or after the operation, would be turned over 120 OPERATIONS ON THE EYE. Fig. 9. — Noyes' stop-speculum. Fig. 10. — Clark's (Weiss) stop-speculum. Fig. 11. — Weiss' stop-speculum. Fig. 12. — Roster's stop-speculum. Fig. 13.— Mellinger's stop-speculum. The stop-specula shown in this and the following figure-plates (Figs. 14, 24, 33, 34) are intended to illustrate the most important models among the numerous instruments of this kind, both as regards the stop- mechanism, which in most of them consists of a screw, and in others of a ratchet (Figs. 12, 13, 34), and as regards the curvature and the con- struction of the arms of the instruments, which are introduced under- neath the lids. In a number of the specula the latter are provided with a wire (Figs. 9 and 12) or a solid plate (Figs. 11, 14. 33) for protection against the lashes. A solid plate, however, takes up too much room unless it is curved, as in Lang's newest model (Fig. 33). One of the first requisites of a good speculum is that it shall be possible to close it quickly and surely, so that it can be removed from the eye without difficulty. backward by spasmodic closure of the lids, and the bruising to which it was thus subjected also gave rise to infection and suppuration. In fact, suppuration was not at all rare after the operation, occurring in 5 to 10 per cent, and more of the cases. It was a complication that was spe- cially dreaded, and thoughtful operators attributed it chiefly to the large size of the flap and to the fact of its occupying a tissue poorly supplied with blood-vessels and therefore unfavorably situated for nutri- tion, as it was not difficult to show that similar but smaller incisions, as, for example, in iridectomy, showed much less tendency to suppuration. The result of this reasoning was that Jacobson gave up the large corneal incision and instead incised the lower border of the sclera ; this, however, increased the danger of escape of the vitreous to such a degree that the operation was found to be impossible except under pro- found anesthesia. Albrecht von Gräfe (1828-1870), of Berlin, who brought about a complete revolution in the method of treating a cataract, not only transferred the incision to the sclera, but reduced its size as much as possible, which, of course, made the escape of the cataract more diffi- cult. He also tried to avoid the formation of a flap altogether by placing his incision as much as possible in the meridian of the globe, so that, when viewing the meridian from above, the incision formed a straight line. Hence, von Gräfe's incision was called the " linear incision," and his method the "linear extraction" and, in contradis- tinction to the already mentioned simple operation, the "modified linear extraction." As the incision was so very near the periphery, and, owing to the small size of the wound, the iris got in the way of the escaping cataract and suffered more or less contusion, depending on the size of the hard nucleus, von Gräfe added iridectomy to the cataract incision ; and in order to minimize the disadvantage of allowing so much light to enter the eye, as well as to avoid disfigurement, he placed 121 122 OPERATIONS ON THE EYE. Fig. 14. — Gaupillat stop-speculum with jointed blades and movable end-plates. Figs. 15, 16. — Desmarres' speculum, Fig. 17. — Simple wire-speculum, showing at the other end Jager's horn spatula for operations on the lid. Fig. 18. — Noyes' speculum. the incision for extraction above, so that the iridectomy (coloboma) was covered by the upper lid. To insure greater accuracy in making the incision he devised a special, narrow knife, resembling a spear of grass (see Fig. 26). A narrow blade of this kind was, it is true, the best instrument for making this somewhat difficult linear incision, which was bounded at the extremities by the two lateral tangents of the cornea (Fig. 8) ; but even with Griife's knife it was a difficult feat, after entering at a and advancing the point toward the middle of the pupil, to make the wound of exit correctly at b. In his desire to make the wound large enough the operator was apt to bring the point of the knife out at a point too far away from the corneal margin, thus getting into the dangerous region of the ciliary body ; or, in his anxiety to avoid the ciliary body, he would bring out the knife at a point too near the corneal margin, and thus make too small an incision, through which it was difficult to deliver the cataract, even after the iris had been excised and the cap- sule opened with the knife (Fig. 29) introduced by von Gräfe. Thus the escape of the lens had to be assisted with spoons, and a good deal of the cortical matter was thus scraped off and remained in the eye, to be either curetted out or "milked out" with the lower lid — that is, the operator, after removing the speculum and fixation-forceps, kept up a kind of massage of the lid for some time, exerting more or less pressure on the lid with the finger, and pushing it from below upward over the cornea in order to express the remains of the cataract through the wound, which would gape of its own accord. Personally I have no doubt whatever that this milking movement, by expressing the contents of the glands in the lower border of the lid, was often a source of in- fection ; for we know that the edges of the lids are very frequently the most infected part of the eye. Sometimes, when this method of milk- ing was resorted to, the operation would terminate most disastrously in prolapse of the vitreous, for the peripheral wound was uncomfortably near the vitreous. As the incision was also very near the ciliary body, inflammation of the wound was very apt to be followed by dangerous cyclitis, causing not only blindness in the operated eye, but not infrequently destroying the other eye as well, through sympathetic inflammation. However, postoperative suppuration diminished, and the fact that iridectomy had to be accepted in this method was less objectionable, because the defect was covered by the upper lid. Owing to the dimin- ished curvature of the incision, the wound healing more rapidly, and the shortened length of the incision were probably chiefly responsible for the better results that were obtained ; for, as we now know, it was a 18 123 124 OPERATIONS ON THE EYE. mistake to suppose that iridectomy diminishes the danger of postoper- ative inflammation. Nevertheless the danger of this incision caused even a partial return to the corneal margin, even among many of von Gräfe' s followers, thus giving the incision a certain degree of curvature. Iridectomy, how- ever, was retained. During the seventh and eighth decades of the last century, when the knowledge of antisepsis and asepsis and of the use of miotics and of cocain was gained, there was a growing tendency to return more and more to the old flap incision and to suppress iridec- tomy whenever possible. As the true causes and correct method of combating suppuration became better known the dread of such a compli- cation diminished correspondingly. Prolapse of the iris, it was found, could be combated by means of the miotics, especially physostigmin, and it became possible to retain the upper incision because the pain of the operation was practically reduced to zero by the use of cocain. Incidentally it was also found that it is easier to get along without iridectomy if the incision is so large that it takes in nearly, if not quite, one-half of the cornea, and it was also found that the incision may safely be quite near the periphery, although it might be supposed a priori that these two factors would favor prolapse of the iris. The reason is that when the incision is large and near the periphery the cataract can escape much more easily without any contusion of the iris. It is true that the iris is momentarily subjected to great disten- tion as the cataract escapes through the pupil ; but if it has not been previously paralyzed by atropin it usually contracts again vigorously and returns into the anterior chamber to its proper position, which it will retain if the patient afterward remains quiet until the wound has united. Reopening of the wound, however, may at any time be fol- lowed by prolapse of the iris, because the aqueous humor washes the iris into the wound. It is therefore wise to assist rapid closure of the wound by making a conjunctival flap. Preparatory Treatment for Operation on Senile Cataract. — All preliminary procedures, including exami- nations, must be carefully carried out with due regard both to the patient's general health and the condition of the eye, as well as its functions. With regard to the functional examination, especially that of the macula lutea, the following should be borne in mind : In the case of a cataract that has not become completely opaque, although operable, central vision (according to Pagenstecher) may be tested by dilating the pupil and examining the patient with the stenopeic slit-hole and a strong convex lens, moving it back and forth in front of the dilated pupil until the patient finds the clearest spot in the lens. The size of the finest print that the patient is able to read will serve to indicate the visual power of the macula. This method of examination is useful when it is possible to see changes in the macula through the opaque lens, and there is a doubt in the examiner's mind whether the condition of the macula is still good enough to justify operation on the cataract. OPERATION FOR SENILE CATARACT. 125 If the patient is intelligent, Pagenstecher believes that the behavior of Purkinje'* vascular figure will indicate the functional condition of the macula, even when the lens is completely opaque. As regards the general condition, it is, above all, im- portant to examine the urine once or twice for albumin, taking a specimen of the urine passed between 10 and 12 o'clock in the morning, as well as for sugar, taking for the latter purpose a specimen of urine passed between 3 and 4 o'clock in the afternoon, after a meal containing carbohydrate and sugar. Fever, even of a very slight degree, is a contra-indica- tion. It is especially important to examine a patient with a cataract for the presence of suppuration in any part of the body (leg-ulcer, eczema, fistula of any kind), and for any spot on the skin that may become the starting-point of erysipelas (fissures behind the ears and at the nose, etc.). All such sources of wound-infection must be rendered innocuous, either by curing them or covering them with an antiseptic dressing before the operation is undertaken. The most dangerous form of suppuration for a cataract patient is suppuration in the lacrimal sac. Even a mere purulent catarrh in its structures suffices to cause a most destructive infection of the cataract wound. Mere external inspection of the eye and pressure on the lacri- mal sac are not sufficiently accurate methods of determin- ing whether the lacrimal passages are normal ; it is much better in every case to inject fluid into the lacri- monasal duct, as explained on - p. 56, and to carry out the other procedures advised at that place. This injection of the lacrimonasal duct (the technic of which will be more accurately described in the section devoted to Opera- tions on the Lacrimal Apparatus) may be performed the evening preceding the operation or in the morning, imme- diately before beginning the operation. The conjunctiva also must be carefully examined, as conjunctival catarrh may be quite as dangerous as catarrh of the lacrimal sac. Conjunctival catarrh, to which old 126 OPERATIONS ON THE EYE. persons are so predisposed, must first be removed. If the conjunctiva merely appears somewhat suspicious it should be treated prophylactically, at intervals of twenty- four hours, with a 1 per cent, solution of silver nitrate, especially if the dressing (presently to be mentioned) shows the presence of some secretion. [A 25 per cent, solution of argyrol, or 20 per cent, solution of protargol is even more valuable. — Ed.] Blepharitis is also a contra-indication ; when it is only moderate, however, the operation may be performed, pro- vided an ichthyol dressing is used. The operator must never forget to test the intra-ocular tension several times in every case of cataract. If the tension is found to be heightened from time to time, even if the increase is only small, iridectomy should be per- formed first, and the treatmeut with miotics kept up until the tension has become normal, for glaucoma following an operation for cataract is a grave condition that is often difficult to correct. Examination must also include the other eye in every case. If it shows signs of disease, especially of iridocy- clitis or glaucoma, such conditions must first be removed. If it is phthisical and sensitive to pressure it is better to perform enucleation first, especially if the phthisis has followed an injury or operation. An eye which, owing to cyclitis, is in danger of producing sympathetic disease of the eye needing operation, or lias already produced such sympathetic disease, or only sympathetic irritation, ought to be enucleated before the other eye is operated upon, if it is blind or has defective projection ; and enu- cleation should take place about six to eight weeks before the cataract extraction. This is because the cataract operation may convert a mere sympathetic irritation into sympathetic inflammation. In addition there are certain other preliminaries to be observed before an operation for cataract : 1. A bath for cleansing purposes, or even several, if necessary, in the case of dirty patients. OPERATION FOR SESILE CATARACT. 127 2. The eyelashes should be carefully cut off without injuring the skin of the eyelid, and the eyebrows must be either trimmed or shaved ; the latter especially in the case of dirty persons. This should be done an hour — or imme- diately — before operat i ng. 3. On the evening preceding the day of operation the eye to be treated should be bandaged, and the bandage must remain in place until the operating period, being moistened from time to time with a 1 : 5000 solution of bichlorid of mercury. This preparatory bandage has the following advantages: The patient's sensitiveness to bichlorid of mercury is determined ; for it is well known that there are individuals in whom even a small quantity of very weak bichlorid-of-mercury solution produces a dermatitis, which often discharges for days in a most unpleasant manner, even if the use of the remedy is at once discontinued. A dermatitis of this kind, surround- ing an eye from which a cataract has been extracted, is capable of seriously endangering recovery. If on the morning after the moist bichlorid bandage has been applied the skin appears in the least reddened, operation must be delayed until the skin has become normal ; and in such a case the use of bichlorid of mercury must be avoided, both before and after the operation, simple sterilized water being substituted in its stead. The trial bandage also shows whether there is any con- junctival secretion, which, if present, will be found on the cotton pad that covers the eye. In such a case the operation is also postponed until the catarrh has been cured ; or at least, if the conjunctiva shows but little catarrhal change, it is painted once or twice with a 1 per cent, solution of silver nitrate as a matter of precaution. [Argyrol or protargol may be used. — Ed.] The chief advantage of the preliminary bandage is that it makes it easier to secure thorough cleanliness of the skin of the lids and surrounding parts before the operation, because these parts are softened by the moisture of the bandage. 128 OPERATIONS ON THE EYE. Fig. 19. — Pamard's instrument for fixing the eyeball. Fig. 20. — Dujardin's forceps for the same purpose, provided with a lock. Fig. 21. — Fixation-forceps without a lock. Fig. 22. — Noyes' curved fixation-forceps with a lock. Fig. 23. — Fine-toothed forceps. Fixation-forceps should be broad in front and provided with teeth, which should not be too sharp, so as not to tear through the conjunctiva, and thus defeat their purpose. If the conjunctiva is friable, the instru- ments illustrated in Fig. 19 or 20 may be used. [The editor doubts the necessity and even the wisdom of a preparatory bandage as described. It is apt to dis- turb the rest so much needed during the night prior to the day of operation, and tends to encourage hyperemia of the conjunctiva. If it is used the pad should be soaked in boric-acid solution or sterile water, because many patients will not tolerate a sublimate solution. — Ed.] 4. The bandage having been removed immediately be- fore the operation, cocain is instilled into both eyes to guard against the disturbing accident of reflex closure of the lid, in case a drop of fluid of any kind accidentally gets into the other eye during the operation. All that is necessary, as a rule, is to instil 5 drops of a freshly boiled 3 per cent, solution of cocain at intervals of three minutes, [or 3 drops of a 4 per cent, solution of cocain at intervals of five minutes. Some operators prefer a 1 per cent, solu- tion of holocain. — Ed.] In the case of patients with little self-control, and in cases in which, owing to marked my- opia, for example, prolapse of the vitreous is to be feared, it is well to instil a drop of a 3 to 5 per cent, solution of cocain every three minutes for one-half hour. To pre- vent the cornea from getting dull and opaque, the eyCis covered with wet cotton while the cocain is being instilled. [The editor prefers not to make such frequent instilla- tions of cocain ; in spite of all precautions they tend to cause opacity of the corneal epithelium, and encourage subsequent collapse of the cornea. — Ed.] 5. All the attendants whose fingers come in contact with 129 130 OPERATIONS ON THE EYE. the operative field should disinfect their hands with soap, hot water, a sterilized brush, 60 per cent, alcohol, and, finally, bichlorid of mercury and trichlorid of iodin in the strength of 1 : 1000. As, however, it is not always possible to be quite certain that the hands are sterile, it is always best to adopt the rule not to touch the operative field with the fingers, but only with sterile instruments, and not only during and after the operation but also be- fore the operation, while cleansing the parts in the manner now to be described. 6. The next step is the cleansing of the operative field : (a) All the external skin covering the forehead, cheek, and nose, as far as the edges of the lids, to be washed first with the tincture of soap and hot water, then with alcohol, and finally with a 1 : 1000 solution of bichlorid of mercury, the cleansing with all these materials being done with cotton pledgets. The preliminary softening of the skin by the wet bandage materially facilitates this laving process. The cleansing of the edges of the lids, which must be performed cautiously but thoroughly, is of the utmost importance. (6) Next the conjunctival sac is thoroughly flushed out by pouring a 1 : 5000 solution of bichlorid of mercury or carefully sterilized saline solution from a suitable vessel on the everted lids and transition folds, rubbing the parts at the same time with small pledgets of sterilized gauze ; or glass rods tipped with cotton may be kept ready for use as sterile sponges, and these may also be used for cleansing the conjunctiva by thoroughly wiping all the folds of the membrane. After the lids have been re- placed, the bulbar conjunctiva, the inner canthus^nd especially the region where the cataract incision isrto be made, should also be gently wiped off and irrigated. The edges of the lids must be once more carefully wiped off, because the manipulation during eversion may have ex- pressed some of the contents of the Meibomian and other glands in the edge of the lid. OPERATION FOR SENILE CATARACT. 131 If there is a dacryostenosis without so much secretion as would necessitate extirpation, the upper and lower lacrimal canaliculi must be closed with the galvano- cautery, as described on page 58, after which the inner canthus is once more flushed out. It is important to begin the operation immediately after the cleansing has been completed, because the cocain anesthesia soon disappears. As the cleansing of the conjunctival sac produces some reddening of the mucous membrane, the anesthesia rapidly disappears and can not be maintained by the further addi- tion of cocain unless adrenalin is instilled at the same time. The patient's head, especially the hairy scalp, having been covered with sterilized gauze so as to leave only the eye and its immediate neighborhood exposed, and the operator, having satisfied himself that the light falls on the operative field from the right direction, and that the electric light is ready for any emergency — the latter being the exclusive source of illumination on dull days — each attendant takes up his proper position and begins his duties, and all is then in readiness. As regards the posi- tion of the operator and his assistants, it is. obvious that the operator, who always stands at the patient's head and operates on the right eye with the right hand and on the left eye with the left hand, must have the most comfort- able position. If he is not ambidexter he will have to stand to the left of the patient when operating on the left eye. One practised assistant is indispensable, and a second is much to be desired. The former, who stands facing the operator, manages the lids and, if an iridectomy is to be performed, steadies the bulb. The larger the corneal incision and the more it resem- bles a flap incision, the more important it is to hold the lids well apart. If a stop-speculum, like those illustrated in Figs. 9-13, is used, the assistant must hold it tightly by its peripheral extremity so long as it remains in the eye, and keep it away from the globe so that, if the patient winks, the lids will be unable to exert injurious 132 OPERATIONS ON THE EYE. Figs. 24-31. — Instruments required for an operation on senile cataract. Other instruments of the same kind may, of course, also be used. Fig. 24. — von Gräfe speculum. Fig. 25. — von Gräfe fixation-forceps with lock. Fig. 26. — von Gräfe cataract-knife. Fig. 27. — Iridectomy forceps. Fig. 28. — Iris scissors, curved. Fig. 29. — von Gräfe cystotome. The other end of the instrument is provided with a metal scoop, to assist in the escape of the cataract. Fig. 30. — German-silver spatula for replacing the iris, etc. Fig. 31. — Weber wire-loop. Even when the operator intends to extract without performing an iridectomy, the iridectomy instruments — forceps and scissors — must be kept in readiness. The combination of cystotome and scoop is not to be advised, because in using the cystotome the operator is apt to touch something with the scoop end. It is better to use the cystotome (Fig. 40) and the scoop (Fig. 35) separately. The wire-loop should be laid out ready for use at every operation. pressure on the eye. Many operators prefer to have the lids held apart with single specula or retractors, as, for example, Pellier's instrument (Fig. 32), especially when they operate without iridectomy. Others merely have the assistant draw the lids apart. In that case the assistant should cover the fingers that he uses for that purpose with sterile gauze, to enable him to get a firm grip of the lids. Unless his fingers are very slim, however, they are apt to be in the way, and, as a rule, a properly handled lid- speculum is to be preferred. If the assistant is to hold the speculum in the way that I have described he must pay attention to the following points: He must not go too far in his effort to hold the speculum away from the eye, to protect the organ from injurious pressure by the eyelids when the patient shuts his eyes tightly, for fear of the instrument suddenly and' entirely slipping out from under the lids, especially when the lids are rather long and flaccid, as such an accident would be followed by unpleasant consequences. .Again, during the delivery of the cataract, when slight pressure on the globe may under certain circumstances be desirable, he must relax his hold on the speculum, but not relinquish 133 134 OPERATIONS ON THE EYE. it. In order to be able to do do all these things properly the assistant who is charged with this duty must have a firm footing — for the work he has to do is of a most par- ticular kind. The second assistant, who stands by the side of the operator, hands him the instruments, taking great care to avoid contaminating any. If necessary, he also looks after the electric light ; although it is better to have this duty attended to by some one else. Finally, some one must hold the patient's head, taking care, of course, to keep his or her hands under the gauze covering. Instruments, sponges, dressing-material, etc., should be laid on a small operating table, close to the patient's head. During the entire operation water should be boiling in the immediate neighborhood, so that an instrument may be plunged into it at any time, if necessary ; for, in spite of the utmost precaution, it may happen to come in contact with something outside of the sterile operative field and have to be at once sterilized again. The patient lies on his back, either on the operating table or on his bed, with his head slightly raised and in as comfortable a position as possible. The operator, having provided himself with a mouth-mask, which I have now used for two years, gives him the necessary instructions, telling him specially not to hold his breath during the operation and not to bear down. The mouth-mask makes it possible to talk to the patient quietly ; and if the latter, as is usually the case, is excited, this has a very quieting effect, providing the physician himself is cool. By judicious encouragement it is very often possible to quiet the patient's fears and remove all dread of the operation. Nobody but the operator should talk or give the patient^ any instructions, as it would only confuse him. [Professor Haab's directions are so explicit, in so far as the preparation of the region of operation and instru- ments are concerned, that additional comments may seem superfluous, but the editor feels that the method used by himself and many colleagues is worthy of record here. Referring especially to the preparation of the eye itself OPERATION FOR SENILE CATARACT. 135 for some days previous to the operation, the editor be- lieves, with Knapp, that it should be protected from any- thing which may produce congestion, and that the patient should remain in the hospital, perfectly resting his eyes and body, and frequently washing his face and the surface and margins of the eyelids with soap and water. If there should be any discharge from the conjunctiva and a tendency of secretion to gather at the commissural angles, an instillation of a 25 per cent, solution of argyrol, two or three times a day, is of great advantage. During these days scrupulous attention should be given to the naso- pharynx. In recent years the editor, following a sugges- tion of J. A. Lippincott, has been accustomed to spray the nasopharynx three times daily with a solution of permanganate of potassium (1 : 5000) with gratifying results. In the preparation of the skin of the region of opera- tion the following plan is pursued : The skin is treated first with soap and water, then with alcohol, and finally with corrosive sublimate (1 : 2000). These irritating sub- stances are not allowed to enter the conjunctival sac, but the face, surface of the closed lids, eyebrows, brow, and scalp above the brow are thus prepared : The ciliary margins are cleansed with soap and water, followed by bichlorid of mercury (1 : 5000). The parts are kept covered with a compress of lint soaked in a bichlorid solution (1 : 5000) or in boric-acid solution for at least an hour prior to the operation and after the preparation just described has been completed. Just preceding the operation, the preparatory bandage is removed, the ciliary margins again cleansed with bichlorid of mercury (1 : 5000) with the same precautions previously described. Next the conjunctival cul-de-sac is flushed with a tepid solution of boric acid, applied with some force, or with a sterile physiologic salt solution. During these irrigations, pressure should be made over the lacrimal sac in order to be sure that no deleterious secretion is contained within it; or its condition may have 136 OPERATIONS ON THE EYE. Plate 2. Operation for Senile Cataract : The cataract-knife has been carried through the anterior chamber, and the incision is now being made upward. been ascertained previously by injecting it with an Anel syringe, in the manner described by Dr. Haab. The lids are then everted, the tarsal conjunctiva and the region of the inner canthus wiped with a pledget of cotton moistened in boric-acid solution. If there is any suspicious redness in the region of the caruncle at the conclusion of the operation and before the bandage is applied, this is dusted with sterile iodoform powder. — Ed.] Cataract Extraction with Iridectomy. — For this procedure the instruments illustrated in Figs. 24-31 are required. The speculum having been introduced and locked, so as to make it impossible for the lids to close, the globe is seized with the fixation-forceps immediately below the cornea, utilizing a fold of the conjunctiva (see Plate 2), and the knife, held with the edge upward, is introduced into the upper part of the anterior chamber, making a corneal incision, the size of which is gauged by the size of the nucleus of the cataract and the size of the cornea. The darker and more yellow the nucleus appears through the small quantity of cortical matter, the larger it will be. If, on the other hand, the cortical material represents a thick layer surrounding the nucleus, as, for example, in young individuals, such a condition betrays itself by the fact that the grayish, translucent, rather milky coloration extends deep into the cataract. The diameter of the cornea also may be quite variable. The, cornea may be small without the cataract behind it neces- sarily being small also, and in such cases it is specially important not to make the incision too small. The height of the flap must be increased, and the incision must, if possible, lie entirely within the scleral border. If the cornea is large, as is sometimes the case in myopic eyes, the flap need not be so high as shown in Plate 2, espe- OPERATION FOR SENILE CATARACT. 137 cially if marked myopia is actually present. In a myopic eye of this kind it is important to guard against the loss of any vitreous material, the danger of which is greater when the incision lies within the scleral border. It is therefore advisable in these cases to keep the incision entirely within the cornea. It appears, therefore, that in making the incision for cataract extraction it is necessary to individualize ; but it is always better to make the incision somewhat too large than too small. Having carefully noted the points where the instrument is to enter and to emerge, the knife (which is held like a coffee spoon) is rapidly carried through the anterior cham- ber, in doing which the operator must not bear heavily with his hand on the patient's head and, if possible, should not support his hand at all. The incision is then com- pleted by drawing the knife backward and forward — that is, by a sawing movement, closely following the corneal border. Beginners, in making these incisions, often make the mistake of bearing too hard on the edge, and not drawing the knife backward and forward enough. The more the edge of the knife is drawn backward and for- ward against the object to be divided, the better the knife will cut. This is specially true of hard tough objects, of which the cornea is a very good example ; for it does not belie its name. Only soft substances, like butter, or semi- solid material of uniform consistence, like paraffin, can be divided or crushed apart by direct pressure on the edge — that is, by using the knife like a chisel. But in drawing the knife backward and forward there is danger in the case of deep-set eyes of injuring the inner canthus, or the upper margins of the lids, which are not rendered insen- sitive by the cocain. This causes the patient to jerk and wink, and in that way escape of the vitreous immediately after the incision has been made becomes possible. [The wound margins will be smoother if, after puncture and counter-puncture, the knife is pushed steadily onward as far as possible, with an upward tendency, and the incision is completed by a free cutting, not a sawing or dragging 138 OPERATIONS ON THE EYE. movement, keeping the knife in the same plane through- out the procedure. — Ed.] From this we deduce the important rule that, in mak- ing the incision, the operator must keep his eve not only on the edge of the knife, but also on the point. The other hand, which holds the fixation-forceps, must also be carefully controlled by the operator. If, as the begin- ner in operative work is apt to do, the surgeon directs his attention exclusively to the cutting hand, he is in danger of unconsciously exerting a most injurious pressure on the globe with the forceps, " by way of emphasis," and as a result the knife, as it completes the incision, may be followed by the sudden escape of vitreous. For this reason it is a good plan to support the hand which holds the fixation-forceps (even when that duty is entrusted to the assistant) on the patient's upper jaw as the globe is seized and held fast, so that once the proper position for fixation has been taken, any pressure on the point of the forceps becomes absolutely impossible, because the hand or the tips of the fingers rest against the patient's jaw. Another reason for making the incision slowly is that the aqueous humor ought not to escape through the ante- rior chamber too rapidly, because a sudden lowering of the pressure favors the occurrence of intra-ocular hemor- rhage. It must not be made too slowly, however, because in that case all of the aqueous humor escapes, carrying the iris with it and bringing it in front of the knife ; although, if such an accident happens, the incision should be quickly completed, for the iridectomy will then be per- formed at the same time, although not in the regular way. When it is necessary to make a conjunctival flap, the customary upward rotation of the edge of the knife, which is performed as the last fibers of the membrane are divided, so as to bring the knife out of the tissue before leaving the cornea, is omitted and the incision is continued a little farther in the direction of the sclera, under the conjunctiva, which is loosely attached to that membrane. The knife is thus carried some little distance under the OPERATION FOR SENILE CATARACT. 139 conjunctiva before it is rotated upward and brought out of the tissue. In order to prevent the conjunctival flap from becoming a disturbing factor in the iridectomy, it should be at once turned back over the cornea with the point of the knife, as otherwise it is apt to be cut off along with the iris. The next step is the iridectomy. The fixation-forceps is handed over to the assistant, who gently rotates the globe downward, enabling the operator to introduce the curved iris-forceps and seize the membrane. The forceps is introduced closed and carried near the edge of the pupil ; it is then opened a little, gently inserted into the iris, closed again, and drawn out of the wound, so that the iris can be cut off with a single snip of the scissors, the curved blades of the iridectomy-scissors being pressed firmly against the wound. It is not necessary to excise a large section of the iris in operating for cataract. After the iridectomy the capsule of the lens is opened. The cystotome, with the blunt part foremost, having been introduced into the pupillary region, lacerations are made with the sharp point of the instrument from the lower edge of the pupil upward almost to the wound, as well as crosswise, so as to lacerate the capsule. The knife should not be introduced deep into the lenticular substance, so as to touch the nucleus and displace it. The instrument must be sharp, in order not to catch in the capsule and cause luxation of the entire cataract when traction is made on the instrument. It must not act like a blunt hook, pulling on the capsule and tearing the zonule of Zinn, thus producing a prolapse of the vitreous. Whenever, therefore, as happens in the case of over- ripe or complicated cataracts, the anterior capsule is thickened at its center and shows the senile capsular cata- ract, which is recognized by a paler or even a white dis- coloration, it is better, in opening the capsule, to cut around the thickened capsule with the knife, completing its removal with the forceps before proceeding with the delivery of the cataract. The thickened capsule may 140 OPERATIONS ON THE EYE. Plate 3. Reposition of the iris with the spatula at the end of an operation for senile cataract. The gauze with which the parts around the eye are covered is not shown in the picture. also be seized and lifted out with specially devised cap- sule-forceps (Figs. 44 and 46). In fact, some operators prefer to open the capsule with the capsule-forceps in every case, because a large piece of the anterior capsule is thus entirely removed, and the cause of secondary cata- ract is in part obviated. Unless the forceps is very well made, however, and is delicately and ably handled, the operator is very apt to tear the zonule of Zinn, either by pressing on the cataract as he seizes the capsule, or by dragging on the capsule as he tears it out, and thus cause prolapse of the vitreous. After the capsule has been opened, the delivery of the cataract is a comparatively simple matter. The operator, who has resumed the fixation-forceps after completing the iridectomy, exerts moderate pressure on the globe with the instrument and thus forces the lower edge of the cata- ract somewhat backward. As a result the upper border is tilted slightly forward and enters the corneal wound. To complete the delivery of the cataract the operator resorts to a suitable, curved, spoon-like instrument (Fig. 29), preferably made of glass (Fig. 35), which he carries across the cornea from below upward, exerting more or less pressure, and thus stripping out the cataract. Usu- ally part of the soft cortical matter escapes first, the nucleus then presents and slips out, followed by remains of the cataract consisting of cortical matter ; or fragments of the nucleus are stripped out in a similar manner until the pupillary region appears to be as clean as possible — that is, black. This, however, does not end the operation. The iris, which is usually pushed into the wound during the delivery of the cataract, must be freed, and replaced as nearly as possible in its normal position. The iris must j OPERATION FOR SENILE CATARACT. 141 never be allowed to stay in the wound during an opera- tion, and this principle applies to operations on cataract also. With the spatula (Fig. 30), therefore, the iris, which lies in the angles of the wound, is carefully replaced by carrying the instrument cautiously from the angle of the wound toward the center and slightly inward toward the pupil (see Plate 3), so that the corners of the sphinc- ter occupy their normal positions. Allowing the iris to remain within the wound also, has the following disadvantages : (1) The pupil is too high, which is undesirable, because only the central portion of the cornea possesses the curvature necessary to form a sharp retinal image. (2) Astigmatism increases after the operation, because the iris is caught in the scar and pre- vents the cornea from regaining its normal curvature, which is for a time impaired by the cataract incision. (3) The possibility of iritis following the operation is greater when the iris is caught in the scar. (4) The ten- dency to increased intra-ocular tension (glaucoma) is greater for all time in an eye of this kind. (5) If the adhesion of the iris is large, as is apt to be the case, and increases as healing progresses, it becomes a permanent disability, because a scar that contains a portion of the iris may become the port of entry for an infection, which in a short time may lead to panophthalmia, and therefore to loss of the eye, unless the infection can be removed with iodoform, as has been mentioned elsewhere in this work. If some tissue remains behind after the escape of the cataract, especially in the region of the pupil, an attempt may be made to strip it out, not as was formerly done with the aid of the lower lid, because the edge of the lid is apt to cause infection of the wound, but with the same instrument that is used for the delivery — namely, a glass spatula (Fig. 35), hard-rubber or metal spoon (Figs. 29 and 39), or the like. The remains of these lenticular masses must, however, not be scraped out too energetically, because there is danger of injuring the cornea and espe- 142 OPERATIONS ON THE EYE, dally of causing prolapse of the vitreous. Whatever can not be removed with this method without using undue force had better be allowed to remain. Such material often consists of sticky portions of the cortex, which ad- here to the capsule and can only be driven out by using injudicious pressure ; besides, they readily undergo ab- sorption later, if the eye is not inflamed. Now that we are not afraid of making a large incision for the extraction, the stripping out of cataractous remains is not as important a matter as it was during the period when Gräfe's short incision was in vogue. In concluding the operation the corners of the iris are once more inspected and, if necessary, the iris is once more replaced, and finally, the operative field is thoroughly cleansed of blood and the remains of the cataract. The blood, which is usually clotted and adheres to the wound in shreds, should be removed with the iris-forceps (Fig. 27). In doing so the operator sees that the conjunctival flap, if he has made one, is in the proper position and, if necessary, replaces it with the spatula ; for the flap must not be turned back and lie in the wound at any point. The eye is then bandaged and the after-treatment, which will be mentioned again, begins. Operation for Senile Cataract without Iridec- tomy. — This is also called the simple cataract operation, and the same instruments are required ; for the iridectomy- forceps and scissors must always be ready at hand when this method is employed, because the operator is never certain that excision of the iris will not be necessary. A good many operators prefer to use a single speculum in- stead of the stop-speculum in this method of extracting the cataract, especially a Pellier (Fig. 32) or a Noyes speculum (Fig. 18), which take up less space. Or they merely ask the assistant to hold the lids apart with the fingers, protected with gauze. If a stop-speculum is used with this operation, the assistant must exercise great care to keep the blade under the upper lid slightly away from the globe whenever the patient tries to wink. This is OPERATION FOR SENILE CATARACT. 143 particularly necessary after the incision has been made, when the danger of prolapse of the vitreous begins. If the stop-speculum is properly managed it is, according to my ex- perience, practically impossible for the patient to produce prolapse of the vitreous by compressing the lids, both when iridectomy is used and when the cataract is extracted without iridectomy ; it is even possible to use stop-specula which are held open by means of a screw (Figs. 9-13). If the assistant possesses the necessary skill he will, as a rule, have plenty of time to remove this instrument from the eye. Certain in- genious mechanisms have been devised in the construction of the instru- ment for the purpose of making it possible to remove it suddenly from the eye in case of threatening prolapse of the vitreous. Instead of a screw, Landolt has a small lever (Fig. 34) which can be pushed back and forth with the finger. This locks the speculum when it is dropped into a small ratchet, and allows it to open again when it is raised. Mellinger's (Fig. 13) and Roster's (Fig. 12) instruments are even more simple in their construction ; for, while closure of the eyes is rendered impossible, although there is no stop-screw, the instrument can be at once closed and removed simply by compressing the handles and thus approximating the arms of the speculum. Unfortunately, these two specula sometimes draw the lids farther apart than is necessary. In using a stop-speculum the assistant should stand on the same side of the patient as the eye to be operated upon ; but if the lids are held apart with Pellier's hooks or with the fingers, the assistant should stand on the opposite side. In the former case his position is also the best in case an iridectomy becomes necessary. If the operator takes up his position on the patient's left side while he is operating on the left eye, the assistant must stand at the patient's head. This arrangement should ;ilso he adopted for extraction with iridectomy. The assistant should grasp the peiipheral end of the speculum firmly with the thumb, second, and third fingers of the right hand, and keep it slightly away from the globe. At the same time he must take care not to hold it too far away ; otherwise, if the lids are flaccid and long, the arms of the instrument may suddenly slip out from under them. As the arms are usually curved, the hand in which the speculum is held can be kept to one side of the patient's head so as not to interfere with the operator. The simple operation is performed in the same way as when iridectomy is also used, except that the flap is made somewhat larger by inserting the instrument into the cornea and emerging again near the horizontal meridian of the membrane — i. e., when the lens is extracted from above, a little deeper than shown in Plate 2. When this method is used, the cataract can, of course, also be ex- tracted from below, and the latter method would be easier in the case of patients wdio find it hard to look down. 144 OPERATIONS ON THE ÜYE. Fig. 32.— Pellier speculum. Fig. 33. — Laug speculum. Fig. 34. — Landolt speculum. Fig. 35. — Pagenstecher glass spatula (manufactured by Müller, Wies- baden). Fig. 36. — Desmarres knife with a blunt point for the cataract in- cision. Fig. 37. — Narrow wire-loop, after Snellen. Fig. 38. — Broad wire-loop, after Weber. But as one can never know for certain that an iridectomy will not be necessary, it is customary to make the incision above, because an upper incision is protected by the upper lid and during the period of healing is not quite so near the palpebral margin, which is never above the suspicion of infection. The size of the flap must, however, be gauged more or less by the probable size of the nucleus and that of the cornea. If the latter is small, the flap must include one- half the membrane, the incision coinciding with the scleral border; if the cornea is large, or the nucleus which is to be expected is small, the base of the flap may be a little above the center of the pupil and the curved incision just within the corneal tissue. It is specially important and desirable when operating without iridec- tomy to make the wound rather too large than too small. For if the cataract escapes easily, without crushing the iris and forcing it into the wound, there is a reasonable expectation that no prolapse of the iris will take place. After seizing the globe with the fixation-forceps near the lower border of the cornea (see Plate 2), the operator quickly makes a mental note of the point of entrance and exit for the knife. To impress these points on his mind, especially if he has not had a great deal of experienc, he should lay the cataract knife for an instant across the cornea so that the back of the knife is just in front of the horizontal diameter. He may also utilize this moment to make sure that the edge of the knife is directed upward and not downward, a mistake that is easily made, because the knife has such a narrow blade. 35 10 145 146 OPERATIONS ON THE EYE. When a large flap incision of this kind is made the operator must be particularly careful to draw the knife backward and forward, and not exert too much pressure on the edge while completing his incision. Or he should follow the edge of the cornea, and keep as much as pos- sible in the same plane of section, and when he reaches the upper margin he should cut a moderately large con- junctival flap. To do this the edge of the knife, instead of being turned sharply forward, is allowed to enter the sclera, and the incision continued a little longer, so that the edge emerges under the conjunctiva, which in old persons is not so firmly adherent to the sclera and, as a rule, is lifted up by the knife. It is then carried a little farther in the same direction, depending on the width of the flap which it is desired to make, and turned sharply upward so as quickly to divide the conjunctiva. Most of the adherents of the simple extraction lay a great deal of stress on the conjunctival flap, on the ground that it favors rapid union of the wound and thus helps to prevent subsequent prolapse of the iris. Some operators also praise it as being a protection against infection. In my own opinion it is best not to place too much dependence upon its advantages, although it can not be denied that they are altogether lack- ing when a conjunctival flap is made ; but any favorable influence it may have on the healing process should be regarded only as one of the factors in bringing about smooth recovery. A. von Gräfe, who also used this flap in his modified linear extraction, carefully investigated its value and advised against making a broad flap. Czermak's comprehensive critical review also shows that a broad conjunctival flap may interfere with rapid union of the corneoscleral edges of the wound; for the bridging of the tissue by the conjunctival flap destroys the marginal layer of epithelial cells, which, as we know, rapidly fills in the gap in a corneal or corneoscleral wound, and therefore materially aids in bring- ing about primary union. Instead, the marginal zone of epithelium lies farther back, at the edge of the flap. " At first, closure of the wound is effected solely by adhesion between the edges of this flap, until the combined corneoscleral wound has been closed by cicatricial tissue, which bridges it over and then contracts it ; but the latter process does not begin until the fourth day." It is therefore better, if a con- junctival flap is to be used at all, not to make it more than 2 to 3 mm. wide. After the cataract incision has been made, instead of doing an iridectomy, the operator at once opens the cap- sule with Gräfe's knife or some other cystotome, making OPERATION FOR SENILE CATARACT. 147 a thorough crucial or Y-shaped incision, at the same time being careful not to tear the zonule or displace the nucleus. [Peripheral opening of the capsule is preferred by some operators, as such a procedure lessens the danger of the formation of posterior synechia?. Practically always a subsequent laceration of the capsule — discission — will be required. — Ed.] After capsulotomy the cataract is delivered in the same way as in the operation with iridectomy, except that, as the cataract passes through the pupil, the iris is also pushed forward more or less ; but unless it has been firmly pressed into the wound it usually drops back into its normal position, sometimes not without slight assist- ance with the spatula. If it fails to return, so that the pupil is no longer circular and is not at the right place, a delicate sound (Fig. 82) must be introduced into the wound, and the iris carefully freed and enabled completely to return to its normal position. If this attempt fails, and the pupil remains eccentrically displaced upward, it is better to make a secondary iridectomy. As regards stripping out the cataractous remains sur- rounding the hard nucleus, it is best to do so rapidly and immediately after the escape of the nucleus, so that the iris will not remain long in the wound. Generally speak- ing this can not be done so thoroughly when no iridectomy is performed, because the iris gets in the way. If the remaining tissue is very small in amount it is better to leave it alone ; if the fragments are large an attempt may be made to remove them with a Critchett scoop (Figs. 48 and 49) ; but if in the end any considerable quantity of material remains behind, it is better to do a secondary iridectomy, when the remains may be removed by expres- sion or with the scoop. Quite recently flushing the anterior chamber and capsular sac, which was in vogue during the eighteenth century, but was later given up again as being too dangerous (Guerin, 1773, see Magnus), has again been recommended as a painless and effective method of removing cataractous remains from the eye. M'Keown, Lippincott, Schiess, and Mellinger (according to Rothlisberger's and Erb's communications) 148 OPERATIONS ON THE EYE. have recently given much attention to the technic of this method, using it in a considerable number of cataract operations. M'Keown's method was recently used by R. H. Elliott, in Madras, on 800 cases, and he warmly recommends it. In this method the irrigating fluid is contained in a glass bottle with a double bulb, and is forced through a short rubber tube into a glass point attached to the latter. In his book, M'Keown gives an accurate description of the method that developed, especially for the operation on unripe cataracts, and used in 148 cases. Lippincott reports 100 operations of this kind. He uses a glass irri- gator, which is simply raised to get the action of gravity, the fluid being conducted through a glass point. In the 238 cases reported by Röthlisberger, Schiess used a Wicherkiewicz " undine," modified by Uhle; and, finally, Erb constructed a glass syringe, which has the advantage of being more readily sterilized. It is needless to say that these irrigating instruments must all be absolutely free from germs, a point insisted upon also by M'Keown. His apparatus, which may be obtained from John Clarke & Company, Belfast, Dublin, can also be completely sterilized by boiling. With regard to the fluids that may be employed in this method of irrigating the anterior chamber, it fol- lows from what has been said on p. (59, that any solution in the least injurious to the tissues, particularly bichlorid of mercury, or carbolic acid, and the like, and even distilled water, must be avoided ; for even distilled water is slightly injurious to the endothelium of Descemet's membrane. It has been found, however, as the result of accurate investigations made by Mellinger, and of innumerable clinical observa- tions, that simple physiologic saline solution, or a 3 to 4 per cent, solu- tion of boric acid is very well borne by the anterior chamber. All the authors cited agree that this method of flushing out the anterior cham- ber is the least injurious, and the best means of removing cataractous remains from the eye. It is also said to facilitate reposition of the iris, both after iridectomy and after operation without iridectomy. Irriga- tion may also be a" great advantage in cases of traumatic cataract. Suction has also been employed for the removal of soft cataractous masses through a small corneal wound ; this procedure is not free from danger, and may only be employed with a syringe that can be well sterilized, as for example, Lang's syringe, made for this special purpose by Bowman, and obtainable from Weiss in London. Modifications of the Operation for Senile Cata- ract. — Modifications have been introduced at various stages of the operation for cataract extraction to insure a better subsequent course and a smoother recovery, as well as for the purpose of adapting one's self to individual variations, either in the eye or in the patient. 1. English operators in India, who practise largely on cataracts, among them Elliot and Pope, prefer to open the capsule before making the corneal incision. The capsule OPERATION FOR SENILE CATARACT. 149 is opened with Bowman's needles, which are inserted at the scleral margin in order to prevent as much as possible the escape of aqueous humor. They dwell on the advan- tage possessed by this procedure of enabling the operator to see accurately what he is doing, unhindered by any flow of blood, which often renders opening of the capsule difficult. At the same time this method enables the operator, before he makes the incision, to determine the structure of the cataract, the size of the nucleus, and the condition of the cortex, whether it be soft or flabby. During a period covering a number of years I have occasionally employed this method in the case of juvenile cataracts in order to find out whether a small (line) or large (curved) incision would be required to remove the cataract, and it is quite true that in the case of senile cataract also the method does possess the advantages which have been claimed for it. 2. Some operators, particularly the French, open the capsule with the point of the knife as they carry it through the anterior chamber. This procedure has a certain value in cases in which it is desirable to terminate the operation as rapidly as possible. 3. Many operators prefer to tear out a piece in the pupillary region with the so-called capsule-forceps (Figs. 44 and 46) when they open the lens capsule. The instru- ment, which is very much like an iris-forceps, must be armed with teeth set obliquely and with the points down- ward. When the forceps is applied to the lens with gentle pressure, in the same way as when the iris is seized prior to iridectomy, the teeth bury themselves some dis- tance in the tissue of the lens and, as the forceps is closed, the capsule is caught by the teeth and torn out and may be completely removed, so that afterward there is nothing left of the capsule and its epithelial cells in the pupillary region, and these structures can not, therefore, help to cause a secondary cataract. This procedure requires a very steady hand and a pair of forceps of perfect workmanship, if it is to be carried 150 OPERATIONS ON THE EYE. Fig. 39. — v. Gräfe cystotome with hard-rubber scoop. Fig. 40. — v. Gräfe cystotome without the scoop, better than the above combination. Fig. 41. — Cataract needle, without stop, for cystotomy, secondary cataract operations, etc. Fig. 42. — Schweigger cystotome. Fig. 43. — Cystotome of Weiss, London. Fig. 44. — Wicherkiewicz capsule-forceps. Fig. 45. — Couper capsule-forceps. Fig. 46. — Treacher Collins capsule-forceps. out correctly and without doing any damage ; otherwise the zonule is apt to be torn and cause subsequent prolapse of the vitreous. If the anterior capsule is thickened at the center, as occurs in cataracts that are somewhat over-ripe, the removal of the thickened portion may be a distinct advan- tage, if it can be effected without dislocating the entire lens. A more cautious procedure, however, is to make a circular incision around the thickened portion before lifting it out. For this procedure Snellen recommends a fine, round needle, the extreme point of which is bent over at an angle of 90°. With such an instrument he claims it is possible to scratch and divide the capsule in every direction, while Gräfe's cystotome permits the operator only to cut upward and downward. When Snellen uses this instrument to make the ordinary crucial incision for opening the capsule, he makes a vertical incis- ion from above downward, so as not to displace the nucleus upward and thus draw it behind the wound. When there is some difficulty about opening the capsule, because the cataract is over-ripe and shrunken and the thickened capsule adheres with abnormal tenacity to its contents, it is better to extract the cataract along with the capsule, and not attempt to open the latter at all. 4. Extraction of the cataract with the capsule, a method which has been chiefly developed and successfully used by A. and H. Pagenstecher, is specially adapted for over-ripe cataract, which possesses an atrophic zonule of Zinn (see p. 86), so that the cataract is apt to become separated 39 40 151 152 OPERATIONS ON THE EYE. in toto from its suspensory ligament. Atrophy of the zonule is also observed in Morgagnian cataract and in cataracts that have already contracted. Dislocated and calcified cataracts are also best removed without opening the capsule. Ordinarily, the fact of a cataract being over-ripe is recognized, aside from the possible presence of a capsular cataract, by the uniform gray or grayish-yellow cloudiness of the anterior cortical layer, it being impossible, even with oblique illumination, to make out any sharply defined markings. The great advantage of this method of operating is that the entire lens is removed from the eye clean, without leaving any remains, while its disadvantage, which must not be overlooked, is that more or less vitreous is always lost ; for such a loss is apt to occur, or at least threatens to occur, in most cases. By thorough cocainization this accident can, however, be confined within narrow limits. As this operation is never performed without at least opening the vitreous space, it is particularly important to make sure of as perfect asepsis as possible. The incision (according to A. Pagenstecher) must always be made at the corneoscleral margin, and the conjunctival flap must not be omitted. The incision must be just large enough to make it possible to remove the lens in the given case without any special difficulty ; the smaller the better; but not too small and not larger than one-third of the circum- ference of the cornea. Cataracts that have a large amount of soft and semifluid cortical matter may be removed through smaller incisions than cataracts with a large firm nucleus (Cataracta nigra). Iridectomy should always be performed, and the two edges of the iris section freed from the corners of the wound and replaced as shown in Plate 3. Pagen stech er's curet (Fig. 51) is introduced be- hind the upper border of the lens, at first in a vertical direction ; the handle is then depressed, and the instru- ment carried forward a little farther, but never beyond the posterior pole of the lens. The assistant makes gentle OPERATION FOR SENILE CATARACT. 153 pressure on the lower border of the cornea with a glass spatula (Fig. 35), and gently and steadily pushes the lens upward until it presents in the wound. This operation is not adapted to cases in which the ten- sion of the vitreous body after the incision and the iridec- tomy continues high, nor when the patient is very rest- less. 5. Subconjunctival extraction, which was practised at the beginning, middle, and end of the last century by a few operators (Alexander, 1825; Desmarres, 1851 ; von Hasner, 1873; Pansier and Vacher, 1899), has been recommended lately by Czermak for cases in which there is danger of loss of the vitreous, either during the opera- tion, owing to dementia, excitement, dislocation of the lens into the anterior chamber, over-ripeness, and the like ; or after the operation from gaping of the wound (great restlessness, epilepsy, violent paroxysms of coughing, etc.). The procedure consists in making a broad conjunctival flap with the base above, which is not divided posteriorly, so that the edge of the corneal wound is connected with the equatorial conjunctiva by a broad bridge of conjunc- tival tissue. This makes it impossible for the wound to gape ; at the same time, however, it is more difficult to excise the cataract under the conjunctival bridge. The latter should be made before the anterior chamber is in- cised, but, owing to the greater difficulty of extracting the cataract through an upper incision, iridectomy is absolutely indispensable. If it is desired to retain the circular form of the pupil, it is better to extract from below. In order to avoid, as much as possible, hemorrhage from the flap into the anterior chamber during the operation, adrenalin is first instilled into the eye. 6. AVenzel's operation is a very good procedure when the iris is adherent to the cataract (Cataracta accreta), with or without inflammatory exudate formation behind the iris, and when there is anterior dislocation of the lens from glaucomatous increase of the intra-ocular tension, provided the other necessary conditions for operation are 154 OPERATIONS ON THE EYE. Fig. 47. — A sickle-shaped cystotome and Daviel's scoop. Fig. 48. — Bowman's scoop, rough at the point; and Critchett's, slightly bent over at the end, seen from the side. Fig. 49. — The same instrument, front view. Fig. 50. — Waldau's scoop. Fig. 51. — Pagenstecher's scoop. Fig. 52. — Weber's scoop. The scoops shown in Figs. 48-51 are made of German silver; Weber's scoop is made of tortoise-shell. present. The cataract knife is inserted not only through the cornea but also through the iris, and carried behind the curtain ; it is then brought out again through the iris and the cornea, the blade at the same time cutting the cat- aract, so that a curved incision is also made in the cap- sule, as the incision is completed in the usual way, either upward or downward. The iris is then excised as well as possible, just as in the case of an optical iridectomy. If the pupil is densely adherent, and a mass of exudate is also present behind the iris, it will be impossible to draw the membrane out of the anterior chamber, and the scis- sors will have to be introduced into the chamber. Weck- er's scissors are useful for this purpose (Fig. 53). The cataract usually escapes without any difficulty. Accidents and Mistakes in the Operation for Cataract. 1. When the conjunctiva is so friable in old persons that the tissue tears through every time it is seized with fixation-forceps, Pamard's spear (Fig. 19) or Schweigger's fixation-forceps may be used for steadying the globe. 2. In old persons with rigid sclera, especially when much cocain has been instilled, blood or air, or both, may enter the anterior chamber immediately after the incision (see p. 70). In itself this accident is of no great im- portance ; but the blood may interfere with opening the anterior capsule, while a bubble of air, on the other hand, if anything, makes the opening of the capsule more dis- tinct. In this class of patients the delivery of the lens requires 47 48 f 49 § § 50 51 52 155 156 OPERATIONS ON THE EYE. somewhat heavier pressure with the glass spatula or the spoon because intra-ocular tension is so low. After the lens has been delivered, the marked negative pressure, brought about by the diminution in the contents of the globe, causes depression of the cornea, which often forms a deep pit ; but although it looks queer it is not followed by any bad consequences except that in such cases cata- ractous matter that has remained behind can not be stripped out, and must be allowed to stay or be flushed out. In these cases the first bandage must be applied somewhat more loosely, so as to allow the aqueous humor to collect again and bring the cornea back to its original position. 3. Several mistakes are possible in making the corneal incision. In the first place the knife may be held with the edge directed downward instead of upw T ard as it is carried through the anterior chamber. If such a mistake has been made it is best to withdraw it rapidly, if possible without allowing the aqueous humor to escape, and reinsert it in the proper way through the first wound if possible, if not, alongside of it. In the second place the knife may be wielded with an excited and trembling: hand as the in- cision is made, which is apt to cause premature escape of the aqueous humor and allow the iris to get in front of the knife. It is best under such circumstances to continue the incision quietly, cutting the iris at the same time, although, of course, the resulting iridectomy will be irreg- ular or too small. That, however, can be remedied after- ward with forceps and scissors. A third and more serious mistake is to make the incision too small, especially when the nucleus is large. The incision in that case must be cautiously enlarged either with Desmarres' blunt-pointed knife (Fig. 36) or Wecker's (Fig. 53) or Stevens' scissors (Fig. 92). If a hard nucleus sticks fast in the wound it can be rolled out with a Gräfe's cystotome by hooking it into the side of the nucleus along the equator. 4. If the patient bears down while the incision is being made, the aqueous humor is rapidly forced into the wound ACCIDENTS IN OPERATION FOR CATARACT. 157 and brings the iris with it. In such a case the prolapsed portion of the iris is seized transversely — that is, in a line parallel to the corneal margin, gentle pressure being made on the iris while the iridectomy is being performed. 5. If, owing to abnornal toughness or thickening, the opening in the capsule turns out too small or can not be effected at all, which may also be due in part to a dull cystotome or interference with its action by blood getting into the anterior chamber and obscuring the held, the operator must carefully guard against trying to force the delivery by excessive pressure, as that would result in escape of the vitreous instead of the cataract. The thing to do is to take a cystotome and improve the opening. If the wound gapes during the attempt to deliver the lens, without any part of the cataract being seen, it should at once suggest that the capsule may not have been properly opened. 6. A more serious accident is failure of the nucleus to present in the wound, with the tendency to glide toward the upper ciliary body, an accident which has already been referred to for the purpose of illustrating the great importance of good illumination in cataract operation. As soon as it is noticed that the upper border of the nucleus fails to present in the wound, although cortical matter has escaped, this possibility must at once be thought of and lead to a careful examination of the state of affairs. This requires a very good light. With a cystotome the nucleus, if it has moved too far upward, may be pushed down again until the upper border is behind the wound, when quick, firm pressure on the lower border of the cornea will cause it to present in the wound. 7. A very grave and very important accident is pro- lapse of the vitreous. It should, by all means, be avoided, for it may have evil consequences not only immediately after the operation, in the form of opacities in the vitreous, infection of the vitreous and retinal detachment, but also at some later period. When there is myopia especially, retinal detachments may develop and end in blindness. 158 OPERATIONS ON THE EYE. As a rule, prolapse of the vitreous injures the shape of the pupil, because it is impossible to replace the iris which has been forced into the wound. This gives rise to the disadvantages which have been discussed on p. 141. As a normal vitreous body, after prolapse, remains some time in the cataract wound, closure is delayed by from one to two weeks, and during all this time infection of the interior of the eye is possible. Fortunately every loss of vitreous is not followed by loss of eyesight or of the eye, especially when only the anterior portion of the vitreous, which occasionally is partially liquefied in cataractous eyes, escapes at -the operation ; but it should be an in- violable principle with an ophthalmic surgeon to leave the vitreous unhurt and untouched, whether the operation is performed for cataract or for any other purpose. The appearance of the eye after an escape of vitreous at an operation for cataract differs according as the vitreous is normal or liquefied. In the former case it may be so watery as to be barely distiguishable from aqueous humor. Unless the operator is careful, a large quantity may escape during the operation, leaving the globe collapsed. This is, therefore, an important caution in the case of eyes in which the vitreous is probably liquefied (in myopia after iridochoroiditis). Liquefaction of the vitreous is recog- nized by the fact that it can be drawn out in threads. When normal vitreous escapes through the cataract wound, the edges are forced apart momentarily by the escape of a large transparent prolapse of a substance resembling fresh white of egg. The dark cavity of the interior of the eye shines through most uncannily in the depths of the transparent mass. If the proper thing is done and done at once — that is, the speculum removed, pressure on the eye diminished, and the patient quieted down — it may occasionally be possible to prevent the escape of normal vitreous after it has entered the wound. When the zonule is torn, however, or the hyaloid membrane has been split, it is the rule for a variable quantity to escape from the wound. ACCIDENTS IN OPERATION FOR CATARACT 159 Prolapse of the vitreous may be favored or caused by some morbid condition of the eye or, rather, of the zonule, which may be atrophied or partially lacerated and therefore fail to prevent the escape of the vitreous. Ab- normality of the zonule is specially apt to be present in extreme myopia, in over-ripe cataract, and after chronic uveitis and other varieties of degeneration of the vitreous. Sometimes the watery nature of the vitreous betrays itself before the operation by tremor of the lens during rapid movements of the eye. In non-congenital lateral dislo- cation of the lens and in pure luxation of the lens pro- lapse of the vitreous is almost unavoidable at the opera- tion. In the normal eye prolapse of the vitreous may be brought about by a faulty behavior on the part of the patient. At the slightest sensation of pain, and sometimes even when there is no pain, some patients compress the eye so that the contraction of the external muscles and of the lids forces the vitreous into the wound, even when the operation is faultlessly carried out. Finally, a number of errors that are apt to be com- mitted at the operation are capable of causing this unfor- tunate accident. The danger of excessive pressure with the fixation-forceps and wounding of the inner angle in this respect has already been referred to. When the opening in the capsule is insufficient, or no opening at all has been made, forcible manipulation for the purpose of expelling the lens may cause the vitreous to escape even before the lens. The accident most frequently occurs during and after the delivery of the cataract, while remains of the same or even some portions of the capsule are being removed. When this is attempted with the forceps, even though it be with the greatest caution, prolapse of the vitreous almost always ensues, hence the operator should never yield to the temptation of resorting to this pro- cedure when he finds thickened pieces of capsule with or without adhering cortical matter. In regard to cataractous remains in general, the rule to expel and express only 160 OPERATIONS ON THE EYE. what comes away readily and without too great expendi- ture of force should never be transgressed, nor should it he forgotten that the introduction of an instrument into the anterior chamber after the delivery of the cataract is always apt to be followed by injury and escape of the vitreous. The earlier the prolapse of the vitreous takes place during the operation, the more complicated will be the situation and the more difficult will it be to finish the operation. If it appears immediately after incision of the globe, the iris, which has usually been carried into the wound, must at once be trimmed off with the scissors and a snare (wire loop) introduced to bring out the cataract, Avhich otherwise sinks into the depths of the eye. During this procedure, which must be carried out as rapidly as possible, pressure on the bulb with the instrument or speculum must be avoided with the greatest care. The snare (Fig. 31) must be broad enough to take a firm hold of the cataract. It is introduced vertically around the upper edge of the cataract and the handle is depressed so as to seize the cataract from behind ; the instrument is then carefully withdrawn, forcing the cataract slightly against the iris and cornea to prevent its escaping laterally from the loop. As soon as the cataract has been ex- tracted the patient is told to close his eyes, and the bandage is applied. It is usually impossible to replace the iris, nor is the attempt to do so advisable, because it would only be attended by further escape of the vitreous. If the cataract sinks farther into the depths of the vitreous, and can not be removed with the snare, the operation should be suspended, the bandage applied, and the patient let alone until the next day, when there is a possibility of finding the cataract at its proper place and being able to remove it with the snare. As the necessity of using the snare may arise at any cataract operation with a flap-incis- ion, it is always well to have the instrument ready at hand. Often prolapse of the vitreous takes place because the cataract incision is too small and it requires too much force ACCIDENTS IN OPERATION FOR CATARACT 161 to deliver the lens, thus endangering the integrity of the zonule. The more peripheral the incision — that is, the farther away from the edge of the cornea — the greater will be the danger of prolapse of the vitreous when other favoring conditions are present. Hence, in operating on an eye in which prolapse of the vitreous is to be feared, the incision should lie entirely within the cornea. Sometimes the way is paved for the escape of the vitre- ous by careless manipulation, causing injury to the zonule, especially by beginners ; either excessive pressure upward may be made in applying the forceps for iridectomy, or the lens may be drawn from side to side and severely pressed upon during cystotomy. [If vitreous escapes after the lens has been extracted, the wound should be cleaned of protruding vitreous as gently and rapidly as possible and a bandage applied. If the escape of vitreous has been great, particularly if the vitreous is thin and there is a tendency for the eyeball to collapse, a tepid sterile physiologic salt solution should be injected into the vitreous chamber until the globe assumes its proper con- tour, as has been recommended (a recommendation which the editor can heartily endorse) by J. A. Andrews and H. Knapp. — Ed.] 8. The gravest complication during the operation is hemorrhage from the choroid. The patient feels a sudden agonizing pain, and a profuse hemorrhage takes place in the deeper layers of the eye, the rush of blood forcing the vitreouV retina, and choroid into the wound and partly through it, destroying the eye. This grave accident may not appear until after the operation, when it is recognized by the occurrence of severe pain and saturation of the dressings with blood. Immediate enucleation is the best plan in such cases. [An attempt may be made to stop the hemorrhage without resort to enucleation : upright position, hypoder- mics of morphin, and full, firmly applied antiseptic dress- ing. — Ed.] 11 162 OPERATIONS ON THE EYE. The best safeguards against the occurrence of a fatal hemorrhage of this kind are perfect rest after the opera- tion, and, in the case of arteriosclerotic patients, measures to guard against sudden changes of pressure in the vascular system of the head and eye ; as by cough and the like. Finally, in making the cataract incision the operator must be careful to cut slowly in order not to diminish the intra- ocular pressure too rapidly, and thus cause rupture of the vessels in the interior of the eye. Method of Applying Dressing and After-treatment. Whatever dressing may be used, and whether the eye is bandaged or not, the chief object under all circumstances is to induce as rapid union of the wound as possible, because it is the strongest precaution against secondary infection. Most ophthalmologists at the present time keep the operated eye bandaged at least for several days, and have the bandage changed every twenty-four hours. It is my custom to keep both eyes bandaged for twenty-four hours, changing the dressing once or twice, then to keep the operated eye bandaged day and night for from three to six days, and at night only for two weeks longer. For restless patients who, especially at night, are apt to injure the eye by rubbing or striking against it, Snellen's alumi- num disc should be incorporated in the dressing, or a screen should be applied. If no bandage is to be used the eye must at least be protected by a screen. Twenty-four hours after the operation the eye should be examined ; but in most cases inspection of the lower part of the cornea and the anterior chamber is sufficient, the wound remaining covered by the upper lid. After an experience of many years H. Pagenstecher again recommends von Hoffmann's ichthyol dressing, and the excellent results he has obtained with that procedure speak strongly in its favor. Pure ichthyol (from the Ichthyol Company, Cordes, Hermanni & Co., Hamburg) is spread on a piece of gauze ACCIDENTS INTERFERING WITH HEALING. 163 saturated with liquid paraffin, and laid on the eye. Both eyes are then covered with cotton, which is held in place by wire-screen spectacles to protect the eyes against injury. On the second, third, or fourth day the ichthyol dressing is removed from the eye that has been operated upon and only applied at night ; this is kept up for several nights. This dressing, with which I have also had practical experience for a year, and which I find very useful, is also justified on theoretic grounds. It has already been stated (p. 58) that the edges of the lids are most liable to cause infection, and should therefore be cleansed as scrup- ulously as possible. Both the ichthyol and the paraffin at least have the property of mechanically preventing any microbes that may happen to be on the edges of the lids from escaping into the conjunctival sac. It is also prob- able that the ichthyol has some disinfecting action. Rest in bed should be insisted upon for at least twenty- four hours, and in most cases for several days, especially when the operation has been performed without iridectomy. In the latter case complete rest on the part of the patient is particularly necessary, and the eye must be protected against a blow or rubbing during the night ; Knapp there- fore advises that these patients should have their arms tied. To avoid chewing movements the diet should be liquid for the first three days. If iridectomy has been performed, however, the patient may, after the third day, spend the greater part of the day out of bed. The rule should be that the older the patient the shorter should be the period of confinement in bed, because otherwise the digestion suffers, with resultant loss of strength. It is not advisable to discharge a patient who has been operated upon for cataract before the sixteenth day (see p. 44). Accidents Interfering with the Healing of the Wound after Operations for Cataract. Delayed closure of the wound and failure of the an- terior chamber to regain its normal condition for several 164 OPERATIONS ON THE EYE. days calls for careful bandaging of the eye without undue pressure, or simply the use of the screen. Delayed closure is observed chiefly in weak, ill-nourished and decrepit patients. Iritis and iridocyclitis as sequels after an operation for cataract are less frequent than during the pre-anesthetic period. These conditions not only delay recovery and keep up the redness and irritation of the eye an abnor- mally long time, but may be the cause of true secondary cataract — that is, a more or less robust membrane in the pupillary region, formed by the posterior capsule, the re- mains of the anterior capsule, and inflammatory iritic exudate. Severe iritis may lead to the formation of a dense " plate," everywhere adherent to the pupillary margin. An unpleasant complication is slow iridocyclitis with punctate deposits. Sometimes the latter are few in num- ber; but when an eye that has been operated upon for cataract continues to present ciliary redness for more than three weeks, such deposits are usually found when the eye is carefully examined with a lens. The inflammation may last weeks and months, bringing with it the danger of sympathetic disease of the other eye. It probably de- pends on some form of infection, the exact nature of which is as yet unknown (see p. 66). It requires careful supervision, atropin, great rest for the eyes and a subdued light, and if it fails to disappear under such treatment, and the introduction of an iodoform pencil into the anterior chamber also fails to bring about recovery, as I have often seen it do, enucleation is indi- cated. [Dionin, in 1 to 5 per cent, solution, combined with atropin, is of great service in postoperative iritis. In- ternally, salicylates, in full doses, are useful, and, if the patient's constitution can bear it, diaphoretic doses of hydrochlorate of pilocarpin (gr. -|- to \). Subconjunctival injections of saline solution and of cyanid of mercury are also to be considered. — Ed.] ACCIDENTS INTERFERING WITH HEALING. 165 Such patients, with slightly reddened eyes, deposits on the posterior wall of the cornea, and a tendency to lacri- mation, are just the ones who are apt to return with sym- pathetic disease of the other eye, if the surgeon yields to their importunities and allows them to go home before the eye has become completely quiescent and white. Sym- pathetic disease after operation for cataract has also become less frequent during recent decades ; but whenever the operation causes cyclitis, especially if the wound extends into the scleral border, the possibility of that horrible dis- ease attacking the other eye must be borne in mind. Purulent infection of the eye during and after the operation for cataract is a very grave complication and, as a rule, very difficult to combat successfully. It may lead to purulent infiltration of the edges of the wound and diffuse cloudy discoloration of the cornea within twenty- four hours after the operation and, as a rule, goes on irre- sistibly to total purulent infiltration and breaking down of the cornea, with more or less inflammatory edema of the bulbar conjunctiva. Often the inflammation spreads rapidly into the deeper layers and causes protrusion of the globe and ultimately panophthalmia. A purulent infection may develop after the first day and, in fact, at any time until the wound is firmly closed ; but it is most to be feared on the first and second days. As it is usually heralded by pain, it is absolutely necessary to examine the eye at once if the patient complains, as the process may possibly be arrested or at least kept within ^~ bounds if discovered at the very beginning. The eye must then be disinfected in the manner previously de- scribed (see p. 68). A harmless accident after an operation for cataract is the draining of the aqueous humor underneath the choroid after the wound has healed and the anterior chamber has been restored. The latter sud- denly becomes shallow, and when the interior of the eye is examined, the choroid is discovered as a tumor-like prominence of grayish or gray- ish-brown color, protruding into the aqueous and forming a pseudotumor, which, however, need not alarm the surgeon. Fuchs has observed a comparatively large number of cases in which the aqueous humor 166 OPERATIONS ON THE EYE. Plate 4. Operation for secondary cataract, after Bowman, with two needles. escaped in this way without producing any harm. The fluid makes its way through a tear in the root of the iris. Glaucoma is a most unpleasant, although, fortunately, not very fre- quent, complication after operations for cataract. Since we know, that when the cataract wound is slow to close the epithelium of the cornea and of the conjunctiva may proliferate into the anterior chamber and form a complete lining for it as well as for the iris and the angles of the chamber, we understand why glaucoma after the operation for cataract sometimes defies every form of treatment. Occasionally something else besides iritis and deposits on the cornea is the cause of protracted reddening and irritation of the eye ; it may be a capillary fistula in the scar of the wound. This also is usually due to delayed healing of the wound, the epithelium in places bridging over the wound-edges and thus making it possible for a small fistula of the anterior chamber to develop. The eye under such circumstances often frightens a surgeon, because of the minus pressure which suggests a cyclitis. On examining the scar and at the same time exerting a gentle pressure on the eye, a little fluid will be seen to work out at a certain spot. As a rule cauterization with the galvanocautery is speedily followed by recovery. Operation for Secondary Cataract. Since the introduction of modern methods of treating wounds, this operation, which was formerly a much- dreaded one, in spite of its apparently trifling character, is, when properly performed, practically harmless and at the same time a most satisfactory procedure. In many cases vision is not permanently restored until it has been performed. Its object is to perforate the membrane which remains behind in the pupillary region after a cataract operation, or makes its appearance later, becomes thick- ened and interferes with vision, so that the center of the pupil finally is freed of everything capable of obstructing the light. Even the posterior capsule alone, if it forms wrinkles or possesses or develops areas of thickening, may prove a serious obstacle to vision, and, if to this are super- added remains of the anterior capsule, epithelial prolifera- tions of the latter, causing still further thickening, and remains of cortical material, the result is often a con- tinuous, thin, grayish membrane, which may easily reduce OPERATION FOR SECONDARY CATARACT. 167 vision to \ or \, even when there is no inflammation in the case. If the operation is followed by iritis, the sec- ondary cataract may be even thicker. In myopic individuals more or less secondary cataract is the rule. The persistence of large remains of cortical matter does not always produce a secondary cataract. A very clear pupil may be formed in spite of them, even though it takes some time, provided only there is no inflammation. This is probably explained by the fact that the cortical remains keep the anterior capsule and its proliferating capsular cells away from the posterior capsule for some time and hold the edges of the tear in the anterior chamber apart, so that the capsular cells are unable to form deposits on the posterior capsule, and after the remains have been absorbed the posterior capsule remains perfectly clean. The indication for discission of a secondary cataract or of a w r rinkled posterior capsule depends on the accuracy of vision that is necessary in any individual case. If the patient's work is such as to require accurate vision, a sec- ondary one will be necessary, even if he has a visual acuity of one-half. When a cataract operation is followed by a normal re- covery, the one for secondary cataract may be undertaken as early as two or three weeks later. It is better to avoid delay, because even a thin secondary membrane becomes more rigid and harder with time. It is therefore easier to divide them early, especially if the finest portion of the membrane is selected for discission. However, the eye ought to have lost every sign of redness before it is at- tempted, and the general rule wdiich has been given above, that inflamed eyes must not be operated upon, applies particularly to these cases, barring only the exceptions noted on p. 68. Discission of a secondary cataract can be performed equally well four to eight w r eeks after the primary one. In this operation it is always to be remembered that it is free from danger only when strict antiseptic precautions 168 OPERATIONS ON THE EYE. Figs. 53-59. — Instruments for secondary cataract operation. Fig. 53. — von Wecker' s scissors-forceps. Fig. 54. — Desmarres' capsule- forceps. Fig. 55. — Desmarres' capsule-forceps, modified by Liier. Fig. 56. — Bowman's discission-needle. Fig. 57. — Knapp' s capsule-knife. Fig. 58. — Knapp' s capsule-knife. Fig. 59. — Weiss' cataract needle with one cutting edge. are observed. Formerly it was almost as dangerous as the cataract operation itself. Surgeons did not like to resort to it because it was also apt to be followed by severe purulent inflammation and sympathetic disease of the other eye. In fact, a case was reported recently in which, in spite of modern antiseptic precautions — although it was in a walk- ing patient — the eye was lost through panophthalmia. It follows, therefore, that the eye must be prepared quite as carefully for a secondary, as for a primary cataract operation. It is also advisable, before entering the ante- rior chamber, to flood the operative field with a 1 : 5000 solution of bichlorid of mercury, so that the needle or needling knife makes its way through a thin layer of the antiseptic fluid. It is also important not to touch anything with the needle first (Fig. 1). The small puncture will heal more quickly if it is placed under the conjunctiva, at the scleral border, after the method of Kuhnt, because it is in a vascular tissue and there is less danger of the wound filling with vitreous. A prolapse of the vitreous into the wound may also take place in this operation if the wound is in the cornea, even though it be a small one. For the vitreous material protrudes through the wound like thread, at first clear, and later of a grayish color, and endangers and interferes with recovery. It forms a bridge by which infection may reach the interior of the eye. At the best it delays healing and annoys the patient by the irritation that is set up. Sometimes these threads consist merely of the so-called filamentous keratitis, a less dangerous but equally tedious complication. A poor needle — as, for example, one of the wrong width (see Fig. 11 56 59 57 58 169 170 OPERATIONS ON THE EYE. 6, b) — favors the occurrence of prolapse of the vitreous. Needles that have been ground too often, and have there- fore become too narrow at the cutting edge, also predispose to this accident, because, as the needle advances, the handle also pushes the wound edges apart and makes a roundish hole, which is slow to close and sometimes permits the vitreous to escape. Needling knives that are not of the proper construction may produce similar results. Instruments suitable for this purpose are sharp discission needles of various shapes (Figs. 41, 43, 56), or needling knives as designed by Knapp (Figs. 57, 58) and Kuhnt (like Knapp's instruments, but bent over). With good instruments of this kind it is also possible to enter the cornea (Knapp) and in that way attain more freedom of movement with the instrument. The steps of the operation depend on the kind of sec- ondary cataract present. First of all, the eye must be carefully examined under good lateral illumination with the magnifying lens to determine the nature of the cata- ract and the location of the blackest, that is, the thinnest, spots. The spots which lie nearest the center of the pupil are first utilized for making the opening. A bright light is indispensable for the proper perform- ance of a secondary cataract operation ; electric light is the best. The eye, having been dilated with atropin and cocain- ized and the speculum introduced, the globe is seized with the fixation-forceps opposite the point where the needle or knife is to be introduced at the scleral border. This spot is chosen where the introduction of the blade will most easily enable the operator to make a free incision in the membrane with the first movement of his hand, as indi- cated by the arrow in Fig. 3. The needle or knife is introduced at a point 2 to 3 mm. from the corneal border, through the conjunctiva and sclera, into the anterior cham- ber, so that the instrument enters just in front of the iris, and is introduced along the iris until the desired thin spot in the secondary cataract has been reached (see Plate 5). OPERATION FOR SECONDARY CATARACT. 171 After the first incision has been completed, a second one is made vertically or obliquely to the first, either by rotating the needle or knife through 90° around its long axis, or by introducing it a second time at some other ap- propriate point on the scleral border. It is better not to attempt to divide thick areas and threads and cords in a secondary cataract, because the attempt is usually not suc- cessful with this method. The instruments should never be thrust deep into the vitreous body. No aqueous humor should escape — an accident which can readily be avoided with this method of introducing the instrument if the needle or the knife has a good point and a good edge. When the secondary cataract is somewhat thicker and does not present any thin areas, the capsule-knife is intro- duced more nearly at a right angle — i. e., through the cornea about 2 to 3 mm. from the border ; the operation is then completed in a similar manner, the edge of the knife being brought into action as much as possible. Or the operation may be performed with two needles, after Bow- man, which is more a lacerating than a cutting procedure. According to my experience this operation, which, until recently, I used almost exclusively, or at least in a large number of cases, has many advantages and, if properly performed, is quite free from danger to the eye. Cor- rect technic consists in introducing the two needles as shown in Plate 4, one after the other or at the same time, at a point about 2 taiLmm. from the corneal border and at directly opposite points, and bringing them out . again through the secondary cataract at the same point in the center of the pupil. By separating the points of the needles with a symmetrical movement, a short horizontal tear is effected without the traction being communicated to the periphery ; the tear is then increased in a vertical direction by separating the points of the needles from one another from above dowmvard. The two movements may have to be repeated once more with somewhat larger ex- cursions, and, as a rule, the resulting gap is then large enough, even if the secondary cataract is quite thick and 172 OPERATIONS ON THE EYE. rigid. It is even possible with the needling operation to divide any small cords that may accidentally be found at the center of the cataract. This is done by crossing the needles slightly as they are introduced into the membrane. When a thickened portion is found at the center of an otherwise rather thin secondary cataract, it can be removed with Desmarres' spe- cially constructed capsule-forceps (Fig. 54) or with Lüer's modification of the instrument (Fig. 55). A Gräfe knife or some other narrow- bladed knife (Figs. 76 and 78) is introduced through the cornea or even, if there is an appropriate spot, directly through the secondary cataract, which is then seized with a small capsule-forceps. The instrument shown in Fig. 55 may also be thrust directly through both the cornea and the secondary cataract. The method is somewhat more radical than those mentioned above, but it can nevertheless be employed with- out doing any injury to the vitreous or causing it to enter the corneal wound. When the secondary cataract consists of thick, compli- cated masses of tissue everywhere adherent to the pupil, or when there has been complete upward displacement of the pupil after a bad recovery, and the iris is usually cov- ered on the posterior aspect with a membrane consisting of inflammatory exudate and masses of secondary cataract, it is often a very difficult task to make an opening in this diaphragm. After traumatic cataract, when convalescence has been complicated with inflammation and after com- plete distortion of the pupil, we often find ourselves in the same predicament. The most important rule is not to operate until the eye has been free from inflammation for from six months to one year, as otherwise the operative wound closes again in a very short time. The least severe operation in these cases consists in the following procedure : Two of Bowman's needles are intro- duced, one after the other, from the temporal side, through the cornea and iris, near the edge of the former, parallel to each other and 3 mm. apart, and the two needles are then advanced almost to the other side of the iris. The needles are then held by an assistant, who at the same time fixes the globe with the forceps. Their purpose is to prevent the thickened iris from slipping backward as OPERATION FOR SECONDARY CATARACT. 173 the diaphragm is divided between the two needles. To accomplish this a Knapp's capsule-knife is introduced opposite the points where the needles have entered — that is to say, near the nasal edge of the cornea and in the horizontal meridian, introducing it into the anterior cham- ber almost as far as the point of entrance of the two needles. The edge is then directed backward, and the iris divided as completely as possible between the needles. As a rule, the incision becomes sufficiently stretched by the prolapsing vitreous body. No vitreous is lost in this procedure be- cause only three small punctures are made. A more radical operation, because combined with more or less escape of the vitreous, and a more useful one for many cases, is that of de Wecker, which is performed with the excellent scissors-forceps (Fig. 53) designed by him. With a narrow keratome or knife, as in the case of linear extraction, access to the iris is obtained, and at the same time the knife is also introduced into the thickened iris. The corneal incision should only be large enough to permit of the introduction of the closed scissors-forceps. The scissors are then opened in the anterior chamber ; one of the blades introduced through the wound and placed behind the membrane consisting of secondary cataract and iris, while the other blade is pushed as far in front of the iris as possible, when the intervening tissues are divided with one snip, leaving a widely gaping cleft. If neces- sary, a second incision carTbe made so as to form a V-shaped wound. The remaining tag usually retracts. A variety of other methods have been recommended for the excision of pieces from the center of an iris compli- cated by thickenings of the capsule, but the loss of vitreous at the operation is sometimes greater than is quite justi- fiable. Not infrequently the loss of vitreous is too great, even with the small incision necessary for the introduction of Wecker' s scissors. Dressing and after-treatment must be as scrupulously attended to after an operation for secondary cataract as after a primary operation. 174 OPERATIONS ON THE EYE. Treatment of Operation for Senile Cataract by Couching and Depression. These antiquated methods, which were practised before cataract extraction came into vogue, are not used by sci- entific physicians except in very rare cases. In India, on the other hand, and possibly among other distant peoples, the method is still practised by the native lay doctors. For reasons referred to previously (p. 118) the procedure ends in failure in 40 per cent, of the cases. It might pos- sibly be indicated when the vitreous is liquefied, especially in cases of marked myopia when a corneal incision would cause the escape of almost all of the vitreous, which would be followed by a retinal detachment. In such a case couching, with scleroticonyxis — that is, puncture through the sclera — may be advisable, as the operation through the cornea (keratonyxis) is more difficult and less reliable. According to Scarpa's method the operation consists in turning the cataract over backward and upward with a couching needle (resembling the needle shown in Fig. 41, except that it is bent on the flat). The eye having been prepared in the same way as for a cataract operation, the globe is seized with a fixation-forceps, immediately under the cornea, and steadied while the needle is intro- duced into the sclera 3 to 4 mm. from the corneal margin and slightly underneath the horizontal meridian, as though it were to be carried toward the center of the vitreous. The edge of the needle should lie in the horizontal plane, the convex surface directed upward. After the needle has penetrated the globe to a distance of about 0.5 cm., it is rotated around its axis until the convex surface is directed forward. The point is now directed forward and pushed in between the iris and the lens. After it has en- tered the pupil as far as the pupillary margin of the oppo- site side, the shaft of the needle is elevated in front, thus imparting a lever-like action to the needle and depressing the lens downward and outward. The cataract must be maintained for a few moments in this new position until it becomes completely surrounded by the vitreous, after OPERATIVE TREATMENT OF DISLOCATED LEXS. 175 which the needle is withdrawn in the same way as it was introduced. The cataract may rise again and return to its original position. If it is soft, it usually breaks up without being depressed. As a rule the capsule is opened in this pro- cedure. Sometimes the cataract would get into the anterior chamber. The operation is not such a very simple one. Depression — that is, pushing the cataract directly down- ward — is still less to be recommended. The Operative Treatment of Dislocation of the Lens. The lens, whether clear or cloudy, may be dislocated spontaneously, especially in myopic eyes and after chronic iridochoroiditis, or as a result of traumatism — a blow or a fall and the like. The dislocation takes place either into the vitreous or into the anterior chamber, and is due to atrophy or laceration of the zonule of Zinn. In either case the dislocation is apt to produce glaucoma. The operative removal of a dislocated lens from the eye is a most precarious and ungrateful undertaking for the sur- geon, and should not be resorted to until after rest, miotics, etc., have failed to bring about the desired result. For, as the lens has become loosened from its suspensory ligament, its removal is always followed by the escape of much vitreous and its evil consequences, even though the operation be performed under anesthesia. It is to be remembered that in dislocation of the lens into the vitreous it is often very difficult to get a firm hold of the lens with a snare and to remove it rapidly. It is apt to slip to one side and escape from the snare. In any case the corneal incision must be large enough, otherwise the lens can not be removed from the globe at all. When dislocation of the lens is the result of inflamma- tory degeneration, it is best to enucleate the eye, because recovery after extraction of the lens is doubtful, and the operation is apt to produce sympathetic disease of the other eye. In fact, I have seen that develop after extrac- tion of the lens in the case of traumatic dislocation. 176 OPERATIONS ON THE EYE. Plate 5. Operation fur secondary cataract with Knapp's knife introduced through the sclera. In partial dislocation, when the lens is merely displaced to one side and is still held by the zonule of Zinn on the other, discission is the best operation, especially in youth- ful patients. If the operation is performed with skill, it is usually possible to spear the lens with one of the dis- cission-needles, and tear the capsule with the other needle, making only a moderately large opening, so that the swelling of the lens will not be too great and the pro- lapsing mass of lenticular material is at once absorbed. Puncture of the cornea must be avoided in such cases, because it would be followed by immediate prolapse of the vitreous. If absorption is interrupted a needle is intro- duced into the opening in the capsule, and the lenticular substance stirred up, or the opening may be enlarged with both needles. Increased intra-ocular tension is treated with rest in bed and miotics. Although this method is somewhat slow, it is reliable and yields beautiful results. It is also suitable for cases of congenital ectopia of the lens in young persons, when the tremor of the lens is so great as to increase the intra- ocular tension or threaten dislocation. According to my experience extraction of the lens in these cases is less advisable. Removal of the Lens in Cases of High Myopia. It was pointed out by Beer, in 1817, and by Mauthner, in 1876, as well as by others, that a very high grade of myopia can be improved by removing the lens. The relief thus effected is more urgently indicated, as it is im- possible to wear glasses strong enough to secure good vis- ion, because the eyes will not tolerate them. The operation for myopia was first performed by Ad. Weber in 1858, but was not accepted by the operators of his time, chiefly on the ground of its danger, and, indeed, fi^V^ M REMOVAL OF LESS IN CASES OF HIGH MYOPIA. 177 it was quite right to put it off until our own time. It needs the extra precaution of antisepsis and asepsis to justify this grave interference in cases which for years have been regarded as dubious from the operative point of view, and which formerly were quite rightly regarded as noli me längere. Fukala returned to the method thirty years after Weber's time, and wrote about it in 1889. He was followed soon after by Yacher, in France. The operation has been taken up with great enthusiasm, per- haps with excessive enthusiasm. On the strength of my own experience with 100 operations of this kind I feel impelled to counsel caution, not only in the operation itself but also in the selection of cases. It is not true that disease of the macula, which is such a serious menace to the eyesight, does not occur after this operation, or is brought to a standstill. If such eyes are used, macular disease often develops, and is quite as severe as in eyes that have not been operated upon. The more intellectual among these patients, who wish to make extensive use of their improved vision, often live to be cruelly disappointed, either because the eyesight again becomes irreparably im- paired, or the physician keeps on repeating the old caution against excessive use of the eyes. It is also probable that those who have been operated upon for myopia are in greater danger of having a retinal detachment than those who have not. Unless the entrance of vitreous into the wound during the operation is scrupu- lously avoided — which requires the greatest care — or if the vitreous is injured at the final discission of the pos- terior capsule, the predisposing factors for a retinal de- tachment are furnished. It is not right to assume, when a retinal detachment does not occur until one or two years later, that it can not be due to the operation. Moderate or very slight injuries to the vitreous are often followed by a retinal detachment many years later. Since the primary failures alone with this operation in the hands of individual operators amount to 10 to 14 per cent., which does not include subsequent deterioration or 12 178 OPERATIONS ON THE EYE. loss of vision, the greatest caution is absolutely indis- pensable. It is much more important in this operation than in any other to prevent the entrance of vitreous into the wound, whether the latter be large or small. Indi- viduals with high myopia are naturally prone to retinal detachment. In the second place infection of any kind must be scrupulously guarded against. Finally, unless the operation is correctly performed in every particular, such eyes are exposed to the danger of severe glaucoma, and the literature shows that many an eye has become blind from that cause. To escape the patient's reproaches and a great deal of trouble the operator should select only cases in which the macula is still in a fairly good condition, the myopia 20 D. or more, and the patient young. Moreover, he should choose the method of operating with which he is least likely to see anything of the vitreous — that is, dis- cission — and make as small a puncture of the anterior chamber as he can get along with. In children discission alone and absorption suffice. It is better, if possible, to omit the final discission of the posterior capsule ; at least it should never be done earlier than six mouths after the operation and after the eye has had complete rest and is free from irritation. Scrupulous care and the strongest possible light are indispensable, even for the first discission of the ante- rior capsule, in order to guard against laceration of the zonule. Such eyes naturally possess a weakened, delicate zonule, which may quite easily be injured at the first opening of the capsule. If the zonule tears, the initial puncture or linear extraction will be attended by the entrance of vitreous into the wound, and the evacuation of the catar- actous masses must at once be interrupted. The cataract continues to swell, the tension is increased, a second puncture is required, vitreous again escapes with but a small quantity of lenticular substance, and the condition ends in glaucoma, with which the surgeon will have to IRIDECTOMY. 179 contend fur months without satisfactory treatment and without success. It therefore follows that, when the capsule is first opened, the lens must not be pulled to and fro even the width of a hair, nor pushed backward. In order to evacuate a swollen lenticular mass after the discission, a fairly large corneal incision is necessary ; for when the lens is not cloudy the cataractous masses are exceedingly tenacious. Some operators prefer to remove a clear lens, even in youthful individuals, by the same operation as that which is employed for senile cataract — that is to say, a large incision at the corneal border, opening of the anterior chamber without preliminary iridectomy, and expression of the lens. The ultimate effects of this procedure have not been reported in sufficient numbers to make it pos- sible to form a judgment, but it can not help being followed more frequently by injury of the vitreous than cautious discission. In most cases it is advisable to operate only on one eye, so that the other eye will at least be useful for near-sight and, in case of accident, the patient does not become totally blind. The man who operates on a myopia of less than 15 D. brings the method into ill-repute. The patients simply exchange their minus glass for far-sight for a plus glass of equal strength, and lose their good near-vision without spectacles, of which they are often quite proud. After the operation they have to wear a heavy cataract lens of 8 D. or more for near work. II. IRIDECTOMY. Iridectomy as an independent operation is performed chiefly for two reasons. First, as optical iridectomy to afford the rays of light access into the interior of the eye when the normal pupil is displaced laterally or anteriorly by inflammatory exudate or distortion, or completely cov- 180 OPERATIONS ON THE EYE. Figs. 60-66. — Instruments for iridectomy. Fig. 60. — Von Grate's stop-speculum. Fig. 61. — Curved keratome, seen from above. Fig. 62. — Curved keratome, seen from the side. Fig. 63. — Fixation-forceps. Fig. 64. — Curved iridectomy-scissors. Fig. 65. — Iris-forceps. Fig. 66. — Spatula for replacing the iris. Of course, instead of these instruments, others that serve the same purpose may be used. ered by a thick central corneal opacity. The operation may also be considered when there is a stationary central opacity of the lens (see p. 112). Second, another and much more important reason for performing iridectomy is to reduce morbidly increased intra-ocular tension in glaucoma. i. Optical Iridectomy. This operation, which originated in the eighteenth cen- tury, is now, as a rule, performed after the manner pro- posed by Beer at the beginning of the nineteenth century. The value of the newly formed pupil is often greatly diminished by the fact that the lateral portions of the cornea and of the lens, which correspond to the new pupil, are not possessed of as equally good refracting power as the central portion. The more peripheral the location of the new pupil the less distinct will be the retinal image that it makes possible; although its distinct- ness may be increased by means of a cylindric lens. Hence, the optical result of the measure is, as a rule, most satisfactory when the pupil has to be only slightly displaced to one side, for which purpose it is enough to cut a small piece out of the iris near the pupil. It must never be forgotten that iridectomy, unless it is covered by the upper lid, may distress the patient by ad- mitting too much light, especially in cases of corneal opacity. For, if the pupil is not adherent to the lens, and therefore possesses its normal mobility— as, for ex- ample, when iridectomy is performed solely on account of a corneal opacity— the pupil will remain permanently 182 OPERATIONS ON THE EYE. dilated, because a piece of the sphincter has been removed, and the normal power of contraction has therefore been impaired. Corneal opacities often produce marked blind- ing, because they act like a ground-glass and diffuse the light into the eye. The annoyance is, of course, greater in proportion to the size of the pupil and the degree of translucency of the opacities. In such cases it is some- times necessary to blacken the central corneal opacity by tattooing, in order to diminish the patient's discomfort. It is altogether wrong to make an optical coloboma behind an opaque cornea, even when the opacity is only slight. The vision is not materially improved thereby, while the patient is annoyed by the troublesome blinding effect. If optical iridectomy is to accomplish its purpose, it must be wholly or at least partly within the region of the palpebral fissure. If the greater part of the cornea is opaque, the location of the iridectomy will, of course, have to be determined by the remaining clear tissue. A clear spot may be tested for the remaining degree of function by dilating the pupil and holding a disc of lead with a slit in it in front of the eye, in various meridians, until the position is found where vision is best, which will correspond to the most favorable corneal meridian. Some- times it may be necessary to give the patient a convex or concave lens in performing the test. The iridectomy should then be placed in this meridian, care being observed to excise a narrow piece of the curtain, so that the opening will be cleft-like in form. A diaphragm with a small and narrow opening yields more distinct images than one with a large opening. The instruments necessary for this form of iridectomy are shown in Figs. 60-66. After the eye has been well cleansed and cocainized, the speculum is introduced, and the operation is usually performed with a narrow, or only moderately broad, curved keratome (Figs. 61 and 62). In cutting, the operator may carry the instrument away from his body, OPTICAL IB IDECTO MY. 183 or he may carry it toward it ; but in the latter case he will have to change his position with relation to the patient. For example, in doing an iridectomy on the left eye at the inner and lower angle, which is often selected for optical iridectomy, the operator, if he wishes to cut toward his body, stands to the right side of the patient ; and if he wishes to cut away from his body, to the left of the patient. For excising a small segment of the iris, the knives shown in Figs. 76 and 78 may also be used to ad- vantage. With these instruments a small wound is made in the cornea which, however, must not be too narrow on the side toward the anterior chamber, so that there may not be much difference between the inner and the outer wound. It should also be remembered that instead of an iris-forceps (Fig. 65) a blunt iris-hook (Figs. 67 and 68) is also quite useful in optical iridectomy, especially when it is desired to seize only a small piece near the pupil. It requires only a small incision in the cornea to introduce the hook into the anterior chamber, and, as it is blunt, there is no danger of injuring the lens. Besides, seizing the iris with the hook is a painless procedure (Axenfeld), which makes it easier to place the iridectomy correctly. The instrument is introduced flat over the iris, then slightly rotated to seize the edge of the pupil, and drawn out again flat. It has the advantage of permitting the incision to be made at the limbus of the sclera, leaving the cornea free from any incision, and therefore obviating any danger of a consequent permanent opacity, which sometimes partially interferes with the newly formed coloboma. The globe is fixed opposite the point where the keratome is introduced. After the assistant has taken charge of the fixation-forceps, the operator introduces the finely serrated iridectomy-forceps (closed), seizes the iris near the edge of the pupil, draws it out in front of the wound, and snips off the fragment with the bent iridectomy-scissors. When a narrow iridectomy is desired, the iris, after it has been drawn out through the wound, is excised in a radial 184 OPERATIONS ON TUE EYE. Fig. 67.— Blunt iris-hook. Fig. 68.— Blunt iris-hook. Fig. 69. — Sharp iris-hook. Fig. 70. — Sharp iris-hook. Fig. 71.— Single hook. Fig. 72.— Double hook. direction. If, on the other hand, it is desired to have the coloboma reach as far as the periphery, the curtain is cut off along a line parallel to the wound. Instead of the usual iridectomy-scissors, Wecker's scissors may also be used. After the excision, the iris is carefully replaced with the spatula (Fig. 66). The same thing must be done when the iris has been seized with a hook in making a coloboma. A single bandage must be worn for from five to six days, and the patient remains in bed twenty-four hours. He should be kept under supervision for from eight to ten days, when recovery will have taken place. As a rule, there is no complicating inflammation. Forming the transition from optical iridectomy to iridec- tomy performed for the relief of tension there is the opera- tion performed for the purpose of preventing secondary glaucoma. When the pupil is adherent around the entire periphery, or there is only a small gap left in the circular synechia, it is better not to wait until the tension has actually increased and irritation and sensitiveness have made their appearance ; it is much better to take advan- tage of the time when the eye is at rest to make an open- ing in the iris for the purpose of restoring communication between the space behind the iris (the posterior chamber) and the anterior chamber, as sooner or later there is danger of bulging of the iris from an accumulation of aqueous humor behind it, producing an increase of tension. In this form of iridectomy the upper segment of the eye is usually selected. The excised portion need not be broad. A moderately broad keratome is introduced at the scleral border. After the iris has been seized with the forceps it is slowly drawn out, because the adhesion be- r 1 69 JO 71 185 186 OPERATIONS ON THE EYE. tween the piece of iris and the lens has to be separated. In some cases, if the adhesion is very dense, the edge of the pupil remains behind on the lens, where it should then be allowed to remain. Even in case of an extensive anterior synechia — that is, an adhesion between the iris and the cornea as a result of perforation, with ulcer or injury of the latter — it is often advisable not to wait for secondary glaucoma, which is so apt to follow this condition, but to relieve the pressure on the iris by iridectomy as soon as the eye has been quiescent for some time. 2. Iridectomy for the Relief of Increased Tension. As the object is not to improve vision, the iridectomy should, whenever possible, be covered by the upper lid, and a broad piece of the iris extending to the periphery should be removed. The discovery that iridectomy cures glaucoma is the immortal achievement of Albr. von Gräfe (1856). Before his discovery, all eyes affected with glaucoma, without exception, went blind after a longer or shorter space of time. The fifty years that have elapsed since then have shown that iridectomy, when performed in time, is the best method of treating glaucoma, but that in advanced and chronic cases the cure effected by this means is not certain nor always permanent ; for relapses occur even when the operation has been correctly performed. In hemorrhagic glaucoma, iridectomy usually fails to have the desired effect and may indeed do more harm than good. As in old cases of ordinary glaucoma iridectomy may make matters worse, the chief indications for iridec- tomy in cases belonging to the group of primary glaucoma are acute and subacute glaucoma, and simple glaucoma when not too far advanced — that is, when there is not much narrowing of the visual field from the nasal side. In childhood, if the child is not very young and the glaucoma not very far advanced, iridectomy may be tried ; IRIDECTOMY FOR RELIEF OF INCREASED TENSION. 187 but in all other cases of infantile glaucoma sclerotomy is to be preferred. The latter operation is more advisable also in advanced cases of simple glaucoma and hemor- rhagic glaucoma, although it sometimes has to be repeated several times. In secondary glaucoma, iridectomy is indicated when there is a circular synechia. In the remaining varieties of secondary glaucoma, sclerotomy or puncture of the cornea usually suffice. The eye should be prepared for a glaucoma iridectomy by the instillation of miotics (physostigmin and pilocar- pi), and this preparatory treatment is the more necessary the shallower the anterior chamber, because it enables the operator to carry out the operation correctly. The deeper the anterior chamber and the narrower the pupil — two conditions that are brought about or favored by the use of miotics — the easier it is to introduce the keratome cor- rectly, and the more effective will be the excision of the iris. Other preparatory measures include rest in bed and judicious use of morphin to induce as much sleep as pos- sible ; for sleep has a favorable effect on the intraocular tension. It is not wise, however, to spend more than twelve to twenty-four hours in preparing a patient for operation in cases of acute glaucoma. If by that time the anterior chamber has not become deep enough, either a preparatory sclerotomy should be performed or an iri- dectomy should be effected with a narrow knife or by in- cising from without. Preliminary local anesthesia with cocain and adrenalin is most important. [In acute glaucoma, when not contra- indicated by physical conditions, general anesthesia is preferable. — Ed.] What was said above on p. 31 ap- plies to these cases. It is also necessary to instil physos- tigmin (eserin) into the other eye for some time before operating, in order to guard it against an attack of glau- coma from the excitement of the operation. [Eserin should be used on the unoperated eye during the conva- lescence from the iridectomy. Both eyes should be band- 188 OPERATIONS ON THE EYE. Plate 6. Iridectomy in glaucoma. aged until the iridectomy wound has healed and the anterior chamber is restored. — Ed.] It is more important in this instance than in any other to see that the patient is in a proper position. If the operation is painful, an unduly soft and yielding pillow will permit the patient to draw the head back, and thus greatly endanger the success of the procedure. The head should therefore be placed on some hard substance and held very firmly, so as to keep it absolutely immovable during the painful process of drawing out and cutting off the iris. The light for this form of iridectomy must be at least as good as for a cataract operation. (a) In the great majority of cases the keratome is to be preferred for iridectomy, because the wound which it makes, as a rule, heals more quickly and more kindly than a wound made with a narrow knife. It is true that the latter is easier to handle and, perhaps, would be better for a beginner to use instead of the keratome, which is often very difficult to manage when the anterior chamber is narrow, and always places the lens in some danger. After the conjunctival sac has been lightly flushed out, or, if the irritation is severe, without that preliminary precaution, the stop-speculum is inserted, the globe firmly held below with the fixation-forceps, and the keratome introduced from above into the anterior chamber, either as shown in Plate 6 — that is, the operator stands at the patient's head and pushes the keratome away from his body — or he stands by the side of the patient and, after introducing the keratome, pushes it toward his body. The keratome is introduced 2 mm. from the transparent edge of the cornea and advanced in such a way as to make the incision parallel with the corneal border. In old persons with deep-set eyes it is often necessary, in order t<> sref at the eve, to draw the flaccid skin of the X IRIDECTOMY FOR RELIEF OF INCREASED TENSION. 189 upper lid upward with the fourth finger (see Plate 6). The keratome should be introduced as far as possible, without, however, injuring Descemets membrane with the point. It is also necessary in introducing it to avoid pricking the iris or even the lens. In the same way, when the instrument is withdrawn, the operator must be careful not to scratch the lens with the point. It is therefore better to depress the handle toward the patient's brow, and to bring out the point along the posterior surface of the cornea, but without touching the membrane. If the anterior chamber is shallow and it is impossible to advance the keratome far enough, the incision may be enlarged to one side as the instrument is withdrawn by turning the point in that direction and cutting as it is withdrawn. It is always well to press the keratome against the iris, in order to prevent prolapse of the latter from the wound. The excision of the iris, which now follows, requires a good assistant and perfect fixation of the patient's head, if the eye is sensitive. If the iris remains in the anterior chamber, as is best for a regular iridectomy, the curved iris-forceps (Fig. 65) is introduced (closed) nearly as far as the pupillary border; it is then opened about 3 to 4 mm., and the iris is seized. The assistant, to whom the oper- ator has given the fixation-forceps after completing the incision, now has the important task of holding the globe rigidly and preventing it from rotating tip ward, because as soon as the sensitive iris has been seized with the forceps and drawn out the patient reflexiv rotates the eyeball upward in proportion to the severity of the pain. This upward rotation makes it difficult or even impossible to draw the iris forward properly and cut it off as it should be done. But the assistant must not depend solely on the conjunctiva, in the grasp of the forceps, to draw the globe downward, because, as this operation is frequently performed on old persons with friable conjunctiva?, the membrane would simply tear, and fixation would be at an end. He must, on the contrary, utilize the sharp corners 190 OPERATIONS ON THE EYE. of the forceps for fixation by pressing them into the sclera, and thus strengthening his hold on the globe. For that purpose the forceps must, of course, be brought into a more vertical position in relation to the globe than as shown in Plate 6 ; and if the globe shows a tendency to escape upward, it must be pushed, rather than drawn, downward. After the operator has drawn the iris out about 5 to 6 mm. from the anterior chamber he holds the curved iri- dectomy-scissors with the convex surface against the globe, seizes the extracted iris between its blades, and cuts off the membrane with one snip of the scissors, mak- ing slight traction on the iris at the same time ; or he first cuts off half of the drawn-out iris and then the other, again making vigorous traction on the membrane. For it is necessary to excise a broad piece of the iris, extending as far as the peripheral insertion of the membrane, so as not to leave any more of the iris at the angle of the chamber than is absolutely unavoidable. For that reason it is indispensable to hold the scissors firmly against the globe while cutting. Wecker' s forceps-scissors (Fig. 53) are also an excellent instrument for cutting off the iris. If the iris prolapses in front of the wound as the kera- tome is withdrawn, it should be seized transversely and cut off as described. In this operation also it is necessary to replace the iris with the spatula (Fig. 6ti) after the excision has been completed (see Plate 3). Indeed, to leave the iris in the angles of the wound would be particularly dangerous in glaucoma, because it would be followed by an increase in the tension. The corners of the sphincter must be re- placed in such a way as to correspond with the normal border of the pupil, so that the latter, with the coloboma, resembles an inverted keyhole. It is well to have the coloboma somewhat wider above — that is, at the periphery of the iris — than at the edge of the pupil (Fig. 8). Quite frequently in iridectomies for glaucoma the iris, which has been paralyzed by the increased tension, is slow to IRIDECTOMY FOR RELIEF OF INCREASED TENSION. 191 return to it* normal position. This may be expected when the pupil refuses to contract in ,-pite of appropriate preparatory treatment, and the iridectomy has to be per- formed with a dilated pupil. Often the dilatation of the pupil in glaucoma is greatest at its upper portion, and only a narrow hem of iris re- mains for excision. This disturbing factor and a deep position of the eyeball, with a- tendency to rotate upward, which is often present in glaucomatous patients, who are usually advanced in years, sometimes render it advisable to place the iridectomy along the temporal or lower por- tion of the curtain instead of above, particularly in cases of advanced glaucoma, in which the operation is per- formed more for the purpose of relieving pain and saving the globe than to improve vision. In every iridectomy, and particularly when it is performed for glaucoma, it is important to avoid the error of introducing the keratome at too great an angle through the cornea (Fig. 72r/, ), as that would bring the inner wound too far away from the outer wound, and therefore too near the center. The wound should be as near as possible to the angle of the chamber ( ), because that is the only way that ade- quate incision of the iris is possible. It is obvious from Fig. 72a that the correct incision would come into col- lision with the iris. Hence, after the keratome has been advanced in the direction of this line as far as the iris will permit, the handle must be gradually depressed in order that the point may miss the iris and anterior pole of the lens. The figure also shows that the sclera ^S^ST^^yä- overlaps the cornea somewhat at the cision for iridectomy. corneal border. Hence an incision 2 to 3 mm. from the corneal border will encroach upon the cornea with its inner edge (which lies in Descemet's mem- brane) or, in other words, if the inner edge of the wound is to be placed within the corneal border — or angle of the 192 OPERATIONS ON THE EYE. chamber — the outer wound must lie within the sclera, 2 to 3 mm. from the edge of the cornea. (6) When iridectomy is performed with Grafts cataract knife, there is less danger of pricking the lens, and the mistake just referred to is, therefore, more readily avoided ; but an incision made with this instrument, as a rule, does not close so easily, and the operator is apt to fall into the error of coming out too near the periphery, and having a prolapse of the lens, either during or after the operation, as the lens may be forced out by the intra-ocular tension if the latter does not rapidly diminish after the operation. Occasionally it takes several days for this to occur. Hence, although the length of the wound, which should be from 6 to 7 mm., has a most favorable effect in curing the glau- coma, too large a wound must, for the reasons given, be avoided. The Gräfe knife, which should be very narrow, is car- ried through the anterior chamber, as in an operation for cataract, except that the point of entrance and point of exit should not be more than 6 to 8 mm. apart. The in- cision, which should be at the scleral border, should be about 2 mm. from the edge of the cornea at every point along its entire length. With this instrument also it is often difficult, on account of insufficient depth of the an- terior chamber, to get through between the cornea and the iris, and succeed in making a sufficiently long in- cision. Excision of the iris and replacement are performed in the same way as before described. (c) Iridectomy by incision with scalpel or scarifier (Gay et, Schöler). Whereas, when the incision is made with the Gräfe knife, as just described, the anterior chamber is opened from within outward, it may also be opened from without inward, either with the same knife or, still better, with a broader-bellied knife, as, for ex- ample, the scarifier mentioned, or a very sharp scalpel. This method is advisable when there is little or no room between the cornea and the iris because the curtain has IRIDECTOMY FOR RELIEF OF INCREASED TENSION. 193 been pushed too far forward, either owing to severe primary glaucoma or, very frequently, from secondary glaucoma, with bulging of the iris, as a result of a cir- cular, or a large anterior, synechia (for example, after a large central perforating ulcer). In such a case the in- cision is made cautiously from without inward along the corneal or, better, the scleral, border. The incision by which the anterior chamber is opened is first made short and then enlarged with suitable scissors, [de Wecker's (Fig. 53), Stevens' (Fig. 92), or Desmarres' (Fig. 36),] the instrument being brought into play at the angle of the chamber between the cornea and the iris. So far we have succeeded no better in explaining the effect of iridectomy in primary glaucoma than we have in explaining this form of glaucoma itself. The thought naturally suggests itself that incision of the capsule of the globe is followed by increased seepage of aqueous humor from the anterior chamber — in other words, a so- called filtration -scar is produced and furnishes a kind of safety-valve, protecting the eye from excessive pressure. On these grounds de Wecker recommended simple in- cision at the corneoscleral border without iridectomy, under the name of sclerotomy, and used it in the treat- ment of glaucoma. It was found, however, that the effect of this procedure was not as great as that of iridec- tomy, and that excision of a piece of iris reduced the excessive tension better than more incision, at least during the initial stage of the process. It can not be denied that sclerotomy acts well in the later stage of glaucoma and in children, and that it is possible, therefore, that part of the effect of an iridectomy is to be attributed to the increased seepage (filtration). Since it appears, from the investigations of Knies and Ad. Weber, that obliteration of the angle of the anterior chamber (Fontana's space) plays an important part in the causation of glaucoma, and has even been considered the primary cause of the disease, the good effect of ex- cising a piece of the iris has been explained by the open- 13 194 OPERATIONS ON THE EYE. ing up of the angle of the anterior chamber so far as it falls within the influence of the iridectomy. As a matter of fact, however, the angle is opened up only when the iris is extirpated as far as its root, which, as appears from the anatomical investigations of Treacher Collins, is not the case as a rule. In 23 eyes which had been iridec- tomized for glaucoma he found that in only 2 the oper- ative scar extended near enough to the periphery for the incision to have involved the ligamentum pectinatum. In 3 cases, in which the incision had been carried very near the periphery, the increase in tension had returned. Nevertheless, it may be assumed that the removal of a piece of iris renders the angle of the chamber more access- ible, and thus improves the drainage. Priestley Smith's theory that the way is prepared for glaucoma chiefly by the physiologic increase in the size of the lens — which occurs in advanced age — furnishes another possible explanation of the favorable eifect of iridectomy and sclerotomy. As the lens increases, the space between it and the ciliary body diminishes, and if the ciliary processes become engorged with blood, the edge of the lens and the ciliary process may force the root of the iris forward, thus narrowing or even occluding the angle of the anterior chamber. This mechanism would render the effect of iridectomy intelligible, because the iris, at all events, could not be pushed forward at the site of the iridectomy ; and there is another factor — for Snellen ob- served that every successful operation is followed by quite a considerable flattening of the cornea in the direction toward the operative wound. This flattening is neces- sarily accompanied by a certain dilatation of the bulbar wall in the ciliary region, and in that way there is pro- duced a dilatation of the perilenticular space, which, ac- cording to Priestley Smith's theory, must have a favorable effect on the circulatory conditions in that region. The after-treatment of a glaucoma iridectomy requires, first of all, a few days' rest in bed, which has a favorable effect on intra-ocular tension. The use of miotics is in- IRIDECTOMY FOR RELIEF OF INCREASED TENSION. 195 dicated very soon after the operation, sometimes even on the first day. Pilocarpin, 2 to 3 per cent, solution, five to six times a day, if necessary, is to be preferred for post- operative use, as it is less irritating than physostigmin (eserin). Iridectomy wounds also must be kept clean, to guard against iritis. Even sympathetic disease of the other eye has been known to occur after an iridectomy for glaucoma. The most important complication during convalescence is failure of the wound to close, because the tension fails to diminish after the operation. In such unfavorable cases, posterior sclerotomy has been recommended, com- bined, if necessary, with Weber's procedure (see Scle- rotomy). Total escape of the lens, which sometimes does not take place until after the operation, and occurs when the in- cision is too near the periphery, or too large, is undesirable, but is better than mere prolapse of the lens into the wound, which causes renewed increase of tension. Hence, the accident may have a favorable effect. Retinal hemorrhages occurring after the operation pos- sess little significance and are probably caused, as a rule, by the introduction of the intra-ocular tension which fol- lows incision of the globe, and brings about rapid change of pressure in the retinal vessels. Such a hemorrhage is not a sign that the glaucoma belongs to the hemorrhagic form. But if the hemorrhage takes place before the operation, it is a sign of hemorrhagic glaucoma. In addition to the two above-mentioned principal indi- cations for iridectomy, and iridectomy as a preliminary operation for cataract extraction, which has been referred to, certain less frequent indications should be mentioned. 3. Iridectomy in chronic iritis to prevent relapses and clear up the vitreous. This operation has lost much of its former popularity, at least among those who only per- form necessary operations. At any rate it must be per- formed only during an interval of entire freedom from inflammation, and even then the gap in the iris closes up 196 OPERATIONS ON THE EYE. again, usually after a large hemorrhage, which more or less completely fills the anterior chamber. In the same way the relief obtained by iridectomy in cases of obstinate and troublesome flocculi in the vitreous is often but slight. It is an absolute mistake to operate on account of a few synechia?. The view which was held several decades ago, that synechia? produce a fresh iritis, has lost weight since we know that iritis is usually due to a constitutional cause. 4. In cases of ectatic scars of the cornea and staphy- loma-formation, iridectomy is perfectly justifiable and, as a rule, reduces the bulging in both of these conditions. 5. Iridectomy may be tried for the purpose of removing very small sarcomatous nodules on the iris. According to my experience the best procedure in such cases is, first, to make a large incision at the corneal border, equivalent to ^ or ^ of the circumference of the membrane, if neces- sary, with the scissors, and then to perform an iridectomy to the right and left of the nodule. In that way the piece of iris containing the tumor may be completely rolled out of the anterior chamber and removed, to the very root of the iris. In the case of tuberculous proliferations it is better not to extirpate, but to treat them either by introducing iodo- form into the anterior chamber or by tuberculin injections or enucleation. III. SCLEROTOMY. As has been mentioned, anterior sclerotomy — that is, sclerotomy performed at the corneal margin, represents one-half, and under certain circumstances the better one- half, of iridectomy ; for it is always a less dangerous pro- cedure, although not quite so effective as iridectomy ; but it can be repeated as often as may be desirable. In infan- tile glaucoma, in advanced cases of glaucoma, and in hem- orrhagic glaucoma I believe, from my experience, 1 that it 1 Up to June, 1900, I had performed 570 operations on 303 adults suffering from glaucoma — 279 iridectomies and 291 sclerotomies; up to November, 1899, I had performed 104 sclerotomies on 84 children affected with glaucoma. SCLEROTOMY. 197 is preferable to iridectomy, and in the remaining forms of glaucoma it is often a useful accessory or complementary operation ; for in many of the cases of glaucoma that pre- sent themselves late for treatment iridectomy fails to effect a permanent cure, and sooner or later a secondary operation becomes necessary. In the presence of iridocyclitis with deposits, causing increased tension, sclerotomy is the proper operation and iridectomy would be altogether out of place. In kerato- conus, repeated sclerotomy is indicated — to arrest the prog- ress of the disease. Sclerotomy may be performed either with the keratome (Quaglino, Snellen) or with the cataract-knife. The latter method, proposed by Wecker, makes it possible to avoid a prolapse of the iris, which is always apt to occur when the keratome is used. The Gräfe knife is introduced much in the same way as in the operation for cataract (see Plate 7), except that the points of entrance and exit lie farther out on the sclera ; the knife is drawn to and fro with a sawing movement, as though for the purpose of making a curved incision in the corresponding direction (below in Plate 7) ; but after the entrance and exit wounds have been enlarged to about 3 mm., a broad bridge of sclera is allowed to stand, the point of the knife as it is withdrawn being carried over the inner surface of the sclera in the angle of the anterior chamber. But in thus incising the inner angle of the chamber, as recommended by de Vincentiis and Taylor, and extending the incision from the angle of the chamber into the sclera at the level of the iris, the knife must not be inserted too deeply, as, otherwise, the iris afterward gradually slips into the in- cision and causes a corresponding distortion of the pupil. In order to make this incision correctly, it is necessary to apply the fixation-forceps midway between the wounds of entrance and exit (see Plate 7). This is an important point, as it enables the operator to make this incision with such certainty and precision that little or no aqueous humor escapes, and, if necessary, it also enables him to 198 OPERATIONS ON THE EYE. Fig. 73.— Small knife, after Lang, for incising the cornea preparatory to the introduction of the blunt knife, shown in Fig. 74, for the purpose of separating anterior synechise. Fig. 75. — Steel spatula, after Lang, to be used in connection with a large magnet for drawing small particles of iron from behind the iris. Fig. 76.— Curved broad needle (keratome) for incising the cornea (the needle is angular rather than curved). Figs. 77 and 78.— Broad needles for incising the cornea for a narrow iridectomy, etc. make a secondary sclerotomy immediately after the first, which enhances the effect. Preparatory treatment with miotics is also necessary for sclerotomy, to guard against prolapse of the iris into the wound. Under the name of posterior sclerotomy an operation for glaucoma has been recommended. It consists in making a short incision of the sclera with a Gräfe knife farther backward, in the equatorial region of the globe, and at the same time incising the vitreous to a considerable depth. This procedure is said to facilitate a subsequent iridec- tomy or to enhance the effect of the operation when it is insufficient. The patient is told to look toward the nasal side, the conjunctiva is seized with the fixation- forceps near the horizontal meridian and drawn slightly down- ward. With a Gräfe knife, the back of which is directed toward the cornea, the sclera is then punctured in the horizontal meridian at least 5 mm. behind the corneal margin, and the knife is advanced about 10 mm. in the direction toward the center of the globe. As it is with- drawn it is slightly turned on its axis, so as to make the wound gape and permit some of the fluid to escape. In- fection is guarded against by displacing or drawing the conjunctiva to one side as the knife is introduced and by observing cleanliness. Priestley Smith only saw hemor- rhage twice after this method of sclerotomy in 60 oper- ations. If, in from ten to twenty days after an iridectomy, the anterior chamber is not restored and malignant glaucoma manifests itself, Ad. Weber's procedure may be tried as 73 74 III 75 II 76 199 200 OPERATIONS ON THE EYE. Plate 7. Inferior sclerotomy in a case in which iridectomy had previously been performed on account of glaucoma. a last resort. This operation is performed as follows : During a posterior sclerotomy, such as has just been de- scribed, with an incision of 8-10 mm. out from the corneal margin, and while the wound is being made to gape by rotating the knife through J of the circumference, the operator exerts pressure on the cornea for about two minutes by means of the upper lid. The pressure exerted must be slight at first and increased gradually, and must act in a direction perpendicular to the surface of the coloboma, as that is the direction toward which the dislo- cation of the lens is usually greatest. The object of this procedure is to force the lens back when it has prolapsed in front of the ciliary processes. When the greatest degree of pressure has been obtained it should be kept up for from one to one and one-half minutes in order to give time for the accumulation of aqueous humor. (As regards resection of the sympathetic, which has been recommended for the cure of glaucoma, it is not quite clear as yet whether the opera- tion has any great value or is even permanent in its effect, and whether the benefit derived is in proportion to the severity of the operative in- tervention ; for we do not even know accurately whether it may not do harm in some other direction. ) An operation very much like the above-described pos- terior sclerotomy is puncture of the sclera as recommended by Deutschmann for the cure of retinal detachment. A double puncture is made and the knife is carried around the periphery instead of being introduced in a vertical direction. The procedure is most adapted to cases of some standing, in which the detachment has already gravi- tated downward. After the instillation of atropin, the patient is directed to look up and a bayonet-shaped two- edged knife is introduced in the lower fornix, as near as possible to the equator, and carried transversely across the lowest portion of the globe, so that the knife traverses the subretinal space, the retina, and the preretinal space, and r J^ Ml I SCLEROTOMY. 201 perforates the sclera at the inner and lower side of the globe, but does not perforate the conjunctiva. The knife i> then slightly rotated and withdrawn, so as to permit subretinal and preretinal fluid to escape. Puncture from below upward is not to be recommended. If necessary, the procedure may be repeated several times at short in- tervals or, in some cases, after an interval of several months. If the condition still does not improve, the in- jection of vitreous from a rabbit should be tried. The vitreous is taken from a rabbit about three months old, and thoroughly stirred up, either pure or with the addition of saline solution. The subretinal fluid having been drained off by means of the above-described incision, the vitreous material is injected into the preretinal space — I. c, between retina and vitreous. As the rabbit vitreous is stirred, gray . floeculi form, which gradually sink to the bottom. The more of these floeculi that are injected, with strict antiseptic precautions, of course, the more severe will be the inflammatory action. This procedure is only adapted in cases in which all other hope of pre- serving the eyesight has been lost. L. Müller recently recommended an operative procedure for the cure of retinal detachment. It consists in the exri.r with spoon-shaped extremities is preferable to a conjunc- tival forceps. Knapp's hollow hook is sometimes quite serviceable. "When the splinter is wedged fast in the groove between the iris and cornea, usually the lower portion, I have found by experience that it is best to make a large cor- neal flap-incision at the corneal border, and, after raising the latter with a double hook (Fig. 72), have an assistant hold the iris in position with a spatula — as otherwise the curtain falls over the foreign body and covers it up — and carefully pick out the splinter with a suitable instrument. Forceps should be avoided altogether in such cases, because the foreign body, which may be partially embedded in the iris, is apt to be pushed all the way through the curtain and pass entirely out of reach. For the same 238 OPERATIONS ON THE EYE. reason care must be exercised in making the flap not to exert any pressure on the splinter. Turning back the cornea, a procedure which has also been recommended by Knapp and Gayet, offers the readiest access to the ante- rior chamber without injuring the membrane. Foreign bodies in the lens, consisting of some material other than iron, are to be treated as described on p. 110. The presence of a splinter of this kind in the vitreous constitutes a much more serious injury than does the pres- ence of an iron spicule ; for its removal presents great difficulties and, as a rule, necessitates going in from the side through the sclera — that is to say, in most cases, an incision, through which an attempt must be made to extract the foreign body. It is not usually possible to seize the body with forceps, unless it is embedded in exu- date which offers a hold for the jaws of the forceps. I once extracted a cartridge splinter through a scleral inci- sion, four and one-half days after it had entered the eye, by obtaining a hold on the thin exudate by which it was surrounded. Recovery ensued with normal vision, but four years later a retinal detachment developed. I adopted a somewhat different plan in another case of a percussion-cap explosion, in which a smooth piece of copper had entered the vitreous, and the other eye had also been injured by the same explosion. A small inci- sion was made in the sclera with a Gräfe knife, and, with the aid of a head mirror, with which the splinter can be readily seen, the pupil was dilated, a Desmarres' capsule forceps (Fig. 54) introduced and, after the delicate forceps had been opened and closed a number of times by means of the lever attached to the handle, I finally succeeded in seizing the elusive splinter and extracted it without any of the vitreous escaping through the small incision, which was completely stopped by the instrument during my attempts at seizing the foreign body, and without the instrument causing any considerable destruction in the vitreous. This operation convinced me how difficult it is to get hold of a foreign body in the vitreous, even when OPERATIONS ON THE OCULAR MUSCLES. 239 both it and the instrument can be kept constantly in plain view. I may recommend Desmarres' forceps for suitable cases as one of the least destructive instruments. Knapp's hollow hook can also be used for extracting splinters of this kind. B. OPERATIONS OUTSIDE OF THE EYEBALL. I. OPERATIONS ON THE OCULAR MUSCLES. Strabismus. The correction of strabismus, whether it be paralytic or of the more frequent concomitant variety, often, but not always, requires operative intervention. Operative procedures should always be based on accurate examina- tion. The question which of the two varieties of strabis- mus is present must be accurately determined (see my Atlas and Epitome of External Diseases of the Eye, second edition, p. 73), and in the case of concomitant squint it must also be determined whether it is convergent or divergent, with or without simultaneous upward devia- tion, whether the squint occurs only periodically or is constant, whether it is unilateral or alternating (now on the right and now on the left side), the magnitude of the squint angle, the condition of visual acuity and the refrac- tion of both eyes (either in the erect image or with the shadow test), and the movability of the globes (as regards abduction, convergence, etc.). It is an important principle in the treatment of strabis- mus never to operate until every other mode of treatment has failed — i. e., in case of paralytic squint, causal treat- ment ; and in case of convergent squint, suitable exercises and the necessary correcting glasses. In concomitant, divergent squint, operation, it is true, is the only effective treatment ; something, however, can be done for this variety of squint, which in many cases is combined with myopia, by ordering the necessary concave lenses. Con- 240 OP ERAT 10 SS ON THE EYE. vergent strabismus, on the other hand, which occurs more commonly in hypermetropia, and in many cases is prob- ably enhanced by increased accommodation and the asso- ciated increased convergence, is often favorably influenced by convex lenses which neutralize the refractive error. In both varieties of strabismus, astigmatism must be cor- rected at the same time, so as to give both eyes the best possible far and near vision and thereby render binocular vision as perfect as possible. If this treatment fails and operation has to be resorted to, the operator must never overlook this important rule : The operation must be such as not to diminish the mo- bility of the globe in the domain of the corrected muscles. The fundamental principle of a strabismus operation consists in advancing the muscle, if its action is to be in- creased, and moving it back if its action, on the other hand, is to be limited. The procedure is confined abso- lutely to the tendinous insertions and their immediate neighborhood. Division of the muscle, which was recom- mended by Strohmeyer, and first performed by DieiFenbach in 1839, was incorrect because it put the muscles out of action. It was this method that brought discredit upon strabismus operations until Bonnet, Böhm, Guerin, and especially A. von Gräfe, later also Critchett, A. Weber and others established the operations of tenotomy and advancement on a correct basis in harmony with the ana- tomic conditions. Even now, however, the operation for the correction of strabismus, taken in connection with the entire treatment of squint, is the subject which is most hotly discussed, and, if only the permanent results are taken into consideration, it is the least satisfactory of all operative procedures on the eye. The treatment is far from being simple, either in principle or in execution, as was formerly supposed when tenotomy, the simplicity of which can not be denied, was almost exclusively practised, and there is no doubt whatever that advancement, although more difficult and more unpleasant to the patient, deserves more consideration than it has so far received. In the OPERATIONS ON THE OCULAR MUSCLES. 241 same way greater attention should be given to the sug- gestions of Javal, Priestley Smith and Worth, that stra- bismus be treated in early childhood with suitable correcting lenses and exercises, in order to maintain or restore cen- tral, so-called binocular, vision, and as a preparation for the permanent restoration to the normal, with or without operation. With regard to the anatomic relations of the tendinous insertions of the muscles in the globe, the following is worth remembering: The internal and external rectus end in a slightly curved line (with a con- vexity toward the cornea) ; the inferior and superior rectus end some- what obliquely in an irregular line, so that the distance between the insertion line from the cornea varies according to the point where it is measured. For example, in the case of the superior rectus the nasal end of the tendinousjnsertion is 6.5mm., and the temporal end 11 mm., from the cornea, according to Motais 'inferior, nasal 5.5; temporal 8). For practical purposes the following numbers, which ;tre easy to re- member, will sumce : right internal rectus 5 mm., inferior rectus ö mm., external rectus 7 mm., superior rectus 8 mm., measured at about the center of the tendon. It is also important that the tendons of the four straight muscles of the eye should not only be adherent to the sclera along the above-men- tioned insertion line from 9 to 11 mm. in length ; they must also be laterally in relation with Tenon's capsule, so that, when a tendon is only separated in front at its scleral insertion.it retracts only a short distance, say 4 to 5 mm., because of the above-mentioned attachment to Tenon's capsule, and the reduction in the power of the muscle is there- fore correspondingly moderate, and the gain to the antagonist corre- spondingly small, if the latter possesses the strength to rotate the bulb a corresponding distance over to its own side. The effect of separating the tendons on the position of the eye, therefore, depends very largely on the contractile power of the antagonistic muscle. The retracting tendon then forms a fresh adhesion with the sclera. The preparations for a strabismus operation consist in cleansing, local anesthesia by the injection of 2 drops of a 2 per cent, cocain solution with a drop of adrenalin under the conjunctiva (if necessary general anesthesia, see p. 26), and a delay of five to ten minutes, during which the eyeball is subjected to gentle massage. There is no ground for the objection that has been made against injecting cocain in this ^vay — that it greatly disturbs the topography of the operative field ; while, on the other hand, it is most agreeable for the patient, espe- 16 242 OPERATIONS ON THE EYE. Figs. 87-93. — Instruments for tenotomy : Fig. 87. — Clark's eye-speculum (Weiss, London). Fig. 88. — Straight conjunctival forceps. Fig. 89. — Strabismus-hook, large. Fig. 90. — Strabismus-hook, small (Stevens). Fig. 91. — Strabismus-scissors, bent, with the blunt ends. Fig. 92. — Strabismus-scissors, straight (Stevens). Fig. 93.— Needle-holder (Sands). cially in the case of children, and, as it prevents all the struggles that are otherwise apt to take place, it is an im- portant aid in guarding against any interruption of the operation. In the case of excitable children,^ who some- times become unmanageable, even when they do not suffer pain, it is well to have the bent forceps (Fig. 22) ready, so that, if necessary, the assistant may rotate the globe toward the proper side and, especially in tenotomy of the internus, provide easy access to the insertion of the tendon. For the rest, the instruments shown in Figs. 87 to 93 are necessary or, at least, desirable for the operation. It is most important never to use sharp scissors for tenotomy, on account of the danger of injuring the sclera. It must also be borne in mind that the sclera underneath the muscular tendons may not be more than 0.2 mm. in thickness. The operator takes up his position in such a way that the insertion of the tendon which is to be cut is opposite his right hand — that is, when the left internal rectus is to be cut, he stands to the left of the patient. (1) Tenotomy after von Gräfe. — A vertical incision 5 to 6 mm. in length is made in the conjunctiva between the cornea and the insertion of the tendon, the cornea is picked up with a sharp forceps (Fig. 88), and a vertical incision is made between the cornea and the tendon. The membrane is then thoroughly undermined with the scissors in the direction of the muscles. This is particularly neces- sary in case of tenotomy of the internal rectus, to guard against the cornea being subsequently drawn back by the retracting muscle and causing a disfiguring deepening of 244 OPERATIONS ON THE EYE. the inner canthus. The conjunctiva should be well un- dermined with the scissors as far as the caruncle. It must also be undermined in the direction in which the strabisin us-hook is to be introduced under the muscle — that is, in the case of the left internal rectus, above the tendon, so as to make room for the hook — the peripheral edge of the conjunctival wound being constantly elevated with the forceps, which is also kept up while the strabis- mus-hook (Fig. 89) is introduced. To make sure that the hook gets under the tendon, it is first pushed under the conjunctiva with the point away from the tendon — for example, in tenotomy of the left internal rectus it is directed toward the forehead. It is then rotated so that the point is pressed somewhat vigorously against the globe and thus glides under the tendon, at the same time transfixing Tenon's capsule to one side of the tendon. This is the most important step in the operation. It is more likely to succeed if the bulb is rotated toward the side of the antagonistic muscle, either in response to com- mand or passively by the curved forceps in the assistant's hand. If the hook has seized the tendon properly, some resistance is felt as the instrument is drawn forward. The handle is then changed from the right to the left hand, after the forceps has been laid down ; and with the strabismus-scissors the tendon is then divided in a manner similar to that shown in Plate 8, except that in that illus- tration the instrument is a double hook and the wound is larger than in the case of tenotomy. With the same hook or with a smaller one (as for example, Stevens', Fig. 90) the operator makes sure that he has not left either above or below, at the insertion in the tendon, a small portion of tendon fibers ; if any are found, they are, of course, to be divided. He also makes sure that the tendon does not possess a second, less perfectly developed, attachment to the sclera farther back, formed by a few fibers of con- nective tissue passing through the lower surface of the tendon to the sclera. These, if they are present, must also be divided, otherwise the operation is unsuccessful. OPERATIONS ON THE OCULAR MUSCLES. 245 It may also appear, when the effect is tested — which must be clone immediately after the operation — that the separation has been incomplete. The mobility of the eye is examined. If it is found that the excursion toward the side of the tenotomized muscle is as great as it was before, the wound should be examined to determine whether some portions of the tendon have escaped divi- sion. If the operation has been properly performed, a moderate diminution in the mobility, proportionate to the tenotomy, is observed. This reduction must not be too great, however. After tenotomy of the internal rectus the patient should have sufficient convergence to enable him to see the operator's finger, held in front of him at a distance of about 12 cm., with both eyes. If too much of the tendon has been separated from its lateral connec- tions with Tenon's capsule, as may happen if the hook is handled too roughly or the lateral connections of the tendon are separated with the scissors — resulting in a faulty reduction of mobility — the effect of the tenotomy should at once be counteracted by inserting a restraining suture through the side of the tendon and including Tenon's capsule, drawing the latter, as well as the tendon, forward. The gaping wound in the conjunctiva is now closed merely with a superficial suture, as at the end of a regular operation. The suture may be rendered still more effective by introducing two needles, one above and the other below the tendon, through conjunctiva and Tenon's capsule and then through the zone of conjunc- tiva, between the cornea and the wound ; the needles are then removed and the suture tied. A single bandage and a few hours' rest are indicated, although, if necessary, the operation may be performed on walking patients. [The editor believes that both eyes should be bandaged ; or better, if possible, the correcting glasses should be worn without a bandage immediately after the operation. — Ed.] (2) Tenotomy after Arlt is performed as follows : The eyeball having been rotated toward the side of the 246 OPERATIONS ON THE EYE. Fig. 94. — de Wecker's hooks for muscle advancement. Fig. 95. — Prince's forceps for muscle advancement. Fig. 96. — Angular (raven-beak) scissors for dividing the tendon (Lan- dolt). Fig. 97.— Needle-holder (Weiss, London). antagonist, the conjunctiva is seized with a sharp conjunc- tival forceps, a little to the corneal side of the insertion of the corresponding tendon, and drawn slightly away from the globe. The fold thus produced is then nicked with stra- bismus-scissors, and the opening enlarged upward and downward, so as to make a vertical wound from 8 to 10 mm. in length ; from this wound the conjunctiva is then undermined in the direction of the tendon. The tendon is then seized with the same sharp forceps, which is held perpendicularly to the globe. The tendon is also lifted slightly away from the globe and divided with the scis- sors close to its insertion. The strabismus-hook is then introduced to make sure that none of the fibers of the tendon has escaped. The effect of the operation is then tested and, if necessary, corrected as in the foregoing operation ; or the operation is terminated at once. A suture is inserted in the conjunctiva, and the after-treat- ment is the same as in the foregoing operation. (3) Tenotomy after Snellen is similar to the fore- going. Snellen makes a horizontal incision in the cornea, over the center of the tendon (as von Gräfe occasionally did and advised) ; undermines the mucous membrane laterally on both sides and in the direction of the tendon (in the case of the internus as far as the caruncle), seizes the tendon with the conjunctival forceps ; and first makes a small opening at the center of its insertion. Introducing the scissors through this opening, he then gently pushes the instrument well under the insertion of the tendon, both above and below, so as to divide the tendon with the least amount of damage and without distorting or dis- placing it. The after-treatment is the same as in the fore- going operation. Tenotomy, which restricts the sphere of action of the 247 248 OPERATIONS ON THE EYE. muscle, often needs to be combined with an operation to increase the action of the corresponding antagonist. Thus, in severe cases of divergent squint, unilateral or bilateral tenotomy of the externus would not accomplish the desired result if one or both inward rotators were not also util- ized to correct the condition, and the same is true of the outward rotators in the case of severe convergent squint. Such an operation to increase the action of a muscle is indicated specially in paralytic squint and when, as a result of strabismus of long standing, the action of the antagonist of the squinting muscle, abduction in conver- gent squint, has become very deficient. The corrective operation may also become necessary to advance a muscle that has receded too far after tenotomy or myotomy, and to strengthen its action. This latter indication led to the development of advancement of tendons, which was performed in the early days of strabismus opera- tions to correct the movements of an eye that had been damaged by myotomy (instead of tenotomy) and had developed strabismus of the opposite type. Dieffenbach treated this secondary form of strabismus by searching for the retracted muscle and fastening it, by means of a suture, to the anterior portion of the globe after it had been rotated inward; or, by freshening the edges, united the muscle with a fine suture — that is to say, he attached the abnormally retracted muscle to its tendon. Guerin in 1849 and, later, von Gräfe, brought the retracted muscle forward by searching for it and separating it from the globe. The eye was then rotated toward the muscle which was to be advanced until the insertion corresponded with the cornea — that is to say, it was advanced beyond the true insertion. Rotation was effected by means of a suture in the manner already practised by Dieffenbach, GueYin passing the suture through the conjunctiva to the temporal side of the cornea, while von Gräfe did a tenotomy on the abducens and attached the suture to the tendon stump. By means of this suture, which was fastened to the root of the nose w r ith adhesive plaster, or, in the case of abduction, to the cheek, the eye was maintained in the forced position for several days, during which a bandage was applied in order to compel the retracting muscle to form a new insertion in front. But as, like every other muscle, it was apt to contract, it sometimes grew fast too far back on the globe, in spite of this precaution. This operation, which causes the patient pain and compels him to keep quiet for several days, was known as the suture operation. It was compelled to yield the floor to actual advancement and suturing of the tendon, which was first per- formed by Dieffenbach and then elaborated by Critchett, von Gräfe, OPERATIONS ON THE OCULAR MUSCLES. 249 Knapp, AVeber, de Wecker, and many others. Critchett suggested as an improvement the introduction of 3 sutures. He made a vertical incision in the conjunctiva, between the cornea and the tendinous inser- tion, and through it introduced a strabismus-hook behind the tendon, thus separating it from the sclera. He then cut away a strip from the peripheral edge of the wound and united it by means of 3 sutures introduced in a horizontal direction above, at the center and below, including the piece of conjunctiva remaining at the corneal margin and taking a deep hold on the peripheral ^d^e of the wound. When the three sutures were tied the tendon was drawn forward almost as far as the corneal margin. Operations on the Antagonist of the Squinting Muscle. 1. Knapp's Method. — In order to make sure of the effect of the advancement, Knapp does a thorough tenot- omy on the squinting muscle, and then introduces the sutures toward the equator, through the tendon and con- junctiva. He inserts 4 to 6 sutures through the conjunc- tiva, the subconjunctival, and part of the scleral tissue, the intermediate ones near the horizontal meridian, and the upper and lower ones to one side and above and below, respectively, near the vertical meridian of the eye. 2. Weber's Method. — Ad. Weber, in his advance- ment method (1873), followed the principle of drawing the tendon forward toward the cornea in a perfectly uni- form manner, avoiding any irregular traction of the sutures and, therefore, any upward and downward dis- placement of the tendon. After making a vertical incision in the conjunctiva in front of the line of insertion of the muscle to be advanced (between the line of insertion and the cornea), and undermining the conjunctiva to a point beyond the tendon, he separated the latter from the sclera by seizing it with forceps and holding it while the suture was passed through the center of the tendon, going in from the scleral side. A long suture provided with a curved needle at each end is folded in the middle and passed double through a third needle. By means of the third needle the thread is introduced into the tendon and, a little farther back, through the conjunctiva as well (Fig. 98, a). While the loop, which thus comes to the surface, 250 OPERATIONS ON THE EYE. Fig. 98. — Methods of advancement : (a) After Ad. Weber. (6) After de Wecker. (c) After Prince (see Plate 8). (d) After Verhoeff. (e) After Verhoeff. (/) After Worth. Whenever the suture is covered by tissue it is indicated in the schem- atic drawings by dotted lines. is secured by the assistant, and, after the needle has been removed, the operator carries the lower end of the suture between the conjunctiva and the sclera as far as the verti- cal diameter of the cornea and far enough (2 to 3 mm.) from the corneal margin so that the thread, when it is stretched, will not touch the cornea. The same thing is then done with the upper half of the suture. The two ends of the suture are then passed through the loop in the tendon, drawn tight, and ligated after the tendon has been drawn forward as far as necessary. But the knot must not slip through the loop, else the entire suture comes out. It is, therefore, better to modify Weber's method by pass- ing the two ends of the suture in opposite directions through the loop, so as to tie the loop in with the knot. I saw Horner perform this modification in 1877, and Fröhlich, who very frequently used this method of ad- vancement — with a few additional modifications (horizontal incision in the cornea, stretching of the muscles — also ligated the sutures in this way. He thinks very highly of this operation on account of its simplicity, its practi- cally uniform success, and its wide range of applicability. 3. de Weckens method of advancement is similar to that of Weber. The double hook which he designed (Fig. 94) is very useful, both for his own and for other methods of advancement. By means of it the tendon can be securely held, and it is possible, by holding the tendon away from the globe after it has been separated, to insert a needle through the lower side at any desired distance from the anterior extremity of the tendon, de Wecker introduces the needle in this direction after threading it ® M°) 252 OPERATIONS ON THE EYE. with a single suture (Fig. 98, 6) and drawing it halfway through, so that the needle is at the center of the suture. The ends of the suture are then again provided with needles. After the middle suture has been introduced through the tendon and the conjunctiva from the scleral side, the needle is cut away so that, instead of Weber's loop, there are left two free ends emerging from the ten- don and conjunctiva. These two ends are then tied with the other ends of the suture, which have been passed through the conjunctiva, above and below the cornea, in the same way as in Weber's operation. The operator must be careful to make equal traction on the two sutures, otherwise the muscle will be displaced upward or down- ward. 4. I^andolt's advancement resembles de Wecker's in so far as a suture is passed through the tendon from in front, above and below the cornea ; but each suture is introduced separately (Fig. 99). After making a large conjunctival flap, so that the wound extends almost to the cornea, the apex of the flap is trimmed off and an incision is made in Tenon's capsule, close to the tendon, through which the hook is introduced and pushed underneath the tendon. Two sutures are then introduced through the tendon, as shown in Fig. 99, the exact site being deter- mined by the degree of advancement that is desired. If the sutures are introduced as far back as shown in Fig. 99, the tendon is divided at a point slightly in front of the suture (Landolt uses the scissors shown in Fig. 96), and the piece of tendon is then cut away as far as the insertion — that is to say, the tendon is shortened by 3 to 5 mm. In order to be able to attach it in front, the conjunctiva and subconjunctival tissue are then seized with the con- junctival forceps in the direction of a to 6, and the needle of the corresponding end of suture is introduced as deeply as possible through the fold thus formed, making it pene- trate into the episcleral tissue. The introduction of the suture is slightly facilitated by the fact that the conjunctival forceps has oblique serrations w T hich project beyond the OPERATIONS OX TUE OCULAR MUSCLES. 253 point and therefore takes a better hold on the tissues. If it appear that the suture has not a deep-enough hold on the tissue, matters may be improved by seizing another fold of conjunctiva and episcleral tissue in a direction per- pendicular to a to b, and again introducing the needle. When these sutures have been placed, the assistant rotates the bulb toward the side of the muscles to be advanced, using a fixation-forceps ; whereupon the sutures are tied Fig. 99.— Advancement of the abdurens after Landolt : The tendon has been slightly raised with a simple hook. The needles are later introduced from a toward b (see the text). without any traction having been made on the tendon or on the conjunctival sutures. In the following methods of advancement the object is to make the approximation of the tendon to its new place of insertion somewhat more certain than in those described so far ; the sutures are not introduced blindly, and the operator is not obliged to grope his way, more or less, in the dark underneath the conjunctiva. 5. Prince's operation is performed as follows : A 254 OPERATIONS ON THE EYE. Plate 8. Advancement of the right internus in divergent strabismus, after Prince. The suture in the sclera, to which the tendon is afterward fast- ened, is seen lying along the corneal margin. The tendon has been seized de with a Wecker's double hook, and the operator is about to separate it from the sclera. suture, armed with a sharp needle, is introduced at the corneal margin, transfixing the conjunctiva, subconjunctival tissue, and superficial layer of the sclera (see Plate 8), while the globe is prevented from rotating with a broad fixation-forceps. To this suture the tendon is afterward attached. The latter is exposed, by means of a vertical incision in the conjunctiva, and grasped, either with a Prince's forceps or, as shown in Plate 8, with a de Wecker's double hook, and divided, after which the tendon is seized with a suture, armed with two needles. Each of these needles is then introduced from below upward at some point on the posterior portion of the globe, taking in tendon, capsule, and conjunctiva, one on each side of the median line of the tendon and about 4 mm. apart. One of the ends of the suture is then laid square across the cornea, so as to cross the suture which has been introduced at the corneal margin, and which is then tied over the other suture (Fig. 98, c). The other end of the suture, which passes through the tendon, is then laid over the former and tied, drawing the tendon and, with it, the conjunctiva for- ward as far as the fixation-suture. I have used this method of Prince's almost exclusively for many years whenever I have had to do an advancement, and have always had good results with it. Occasionally I modify the ligation of the sutures by simply tying the two ends of the suture which passes through the tendon with the two ends of the fixation-suture, the operator and the assistant making uniform traction on the sutures. In this way the tendon is spread out a little more as it is drawn forward. 6. In Verhoeff 'S operation, which results in a very strong attachment, a vertical incision is made in the con- junctiva at a distance of 3.5 mm. from the cornea; the conjunctiva is undermined as far as the cornea ; the tendon is sought for, divided from its lateral attachments with the OPERATIONS ON THE OCULAR MUSCLES. 255 capsule, and grasped with a Prince's forceps (Fig. 98, c). If necessary, the squinting muscle may then be tenotomized. The edge of the conjunctiva remaining along the cornea is dissected back as far as the latter membrane, and a suture with a needle at each end is then introduced vertically a distance of 6 to 8 mm. through the superficial layer of the sclera, at a distance of about 1 mm. from the corneal margin, in the portion of the sclera which has been ex- posed by the dissection. The needle is to be reintroduced at the point of exit and carried a short distance in a hori- zontal direction. The same thing is then repeated at the point of entrance with the second needle. The two needles having been passed through the tendon at some point be- hind the scleral side, the assistant grasps it with a clamp and draws it forward as far as necessary to bring the desired part on the scleral suture, which is then tied (Fig. 98, e). The piece of tendon contained within the clamp is then resected, the remainder — between the suture and the cornea — is pushed under the conjunctiva, and the mem- brane united over the suture. The conjunctival suture may be remove after four days, the one in the tendon after seven days. The needles used for introducing the suture into the sclera should not be too long and not too sharply curved at the point. The suture must not be too thick. 7. With Worth's method of advancement, that por- tion of the suture with which the tendon is seized is secured as firmly as possible by including the adjoining Tenon's capsule along with the tendon (Fig. 98,/), access having been obtained to the insertion of the tendon through a vertical incision in the cornea about 10 mm. in length. A Prince's clamp is applied behind the insertion in such a way as to include Tenon's capsule and the conjunctiva over the tendon. After the tendon has been divided from the scleral side, it may be raised sufficiently, by means of the clamp, to permit of the introduction from within out- ward of a suture through conjunctiva, capsule and tendon, which is made to emerge at b ; the other edge of the tendon is seized in the same way and the suture (cd) is tied. 2o6 OPERATIONS ON THE EYE. Hence, one of the sutures hanging from the knot is with- out a needle, while the other has one. The latter is then introduced a little behind the knot at e, from without in- ward, and passing through conjunctiva, capsule and tendon, carried forward underneath the tendon toward the cornea, and made to emerge at g, after passing through the edge of conjunctiva and the subconjunctival tissue. The same thing is done with the suture at the other edge of the muscle. The two sutures — that which has been left hang- ing from the knot in the tendon and that which has passed forward through the limbus of the sclera — are then tied. Worth attaches a great deal of importance to the quality of the thread, which must not be too thin, and which he prepares very carefully by drawing it through a boiling mixture of beeswax (3 parts) and white vaselin (5 parts), and keeps in a sterile vessel. One sometimes has the unpleasant experience in doing an advancement of having the suture cut through the tendon or through the conjunctiva in front. Often the tendon of a muscle which is to be advanced is atrophic, thin and narrow, and does not afford sufficient hold for the suture, especially when the latter is merely passed through the body of it. The conjunctiva and the epi- scleral tissue also may not always be sufficiently robust to resist the constant traction exerted by the muscles on the suture. If the stitch cuts through, the result, unfortu- nately, is that the advancement becomes converted into a condition of more or less marked retraction. These considerations suggested different methods to secure the same result as were obtained by advancement, which are : (1) making a fold in the muscle or tendon, with- out separating the latter from its insertion ; (2) resection and actual suturing of the tendon, thereby also effecting a shortening of the tendon or of the muscle. 8. Capsular Advancement after de Wecker. — In this operation the tendon is folded as described above, and Tenon's capsule is drawn forward. Since 1888 the originator has used this method exclusively instead of his OPERATIONS ON THE OCULAR MUSCLES. 257 muscle advancement (described on p. 250). Instead of a vertical, a curved incision is made about 10 to 12 mm. in length in the conjunctiva, running parallel to the cornea and a few millimeters from its margin. When it is de- sired to obtain a very marked effect, a crescentic piece of conjunctiva is excised by means of a second curved in- cision. A vertical slit, a few millimeters in length, is then made in the capsule, both above and below the tendon and in the direct prolongation of the line of insertion. Through these two openings the capsule, as well as the tendon, is undermined with closed scissors, and any adhesions between the latter and the sclera are divided. Through these open- ings in the capsule the sutures are then introduced, one of the two needles of a doubly armed suture being introduced in the upper, and one in the lower, opening and brought out underneath the tendon, 5 to 8 mm. behind the inser- tion, transfixing the tendon and conjunctiva. The two stitches should be 3 mm. from the edge of the tendon and 3 mm. apart. The other needle is introduced into the aforesaid opening in the capsule and carried forward, under the conjunctiva, in the superficial tissue of the sclera as far as shown in Fig. 98, b. The upper and the lower sutures are then tied, while at the same time that portion of the tendon which is transfixed by the two fast- enings is drawn forward along with the capsule and the conjunctiva. In other words, a fold is made in the tendon, since the original insertion is retained. The operation is in every way analogous to de Wecker' s method of advance- ment, which has been mentioned, except that the tendon is not separated from the conjunctiva. 9. Knapp's Method. — Knapp modified his method of advancement (see p. 249) in a similar manner — that is, he introduced the sutures in almost the same manner, but does not separate the tendon, so that he also makes a fold in the tendon and in the capsule, since the posterior por- tion of the tendon, which is seized by the stitches, is drawn forward over the insertion. 17 258 OPERATIONS ON THE EYE. 10. Certain American authors are even more radical in their efforts to bring about a dnplicature of the tendon. Thus, Todd, for example, after freely exposing a consid- erable portion of the tendon by means of a flap incision through conjunctiva and capsule, performs an actual fold- ing over by means of a fork-shaped instrument and fixes the dnplicature with two catgut sutures. The " tendon folder " is so constructed that the two arms can be approx- imated by means of a screw, and its action may be com- pared to that of a two-tined fork, one tine of which would be placed on the tendon near the insertion, while the other is placed underneath the tendon behind it. If the fork were turned about its long axis, the posterior portion of the tendon would come to lie on the anterior portion. After tying the two catgut sutures, Todd further secures the duplicature with two silk sutures, which include the conjunctival flap, and are brought out in front, a little to one side of the cornea, in a manner similar to that em- ployed in de Wecker' s advancement. 11. Brand adopted yet another method of making a duplicature. After freely exposing the tendon between two ordinary strabismus-hooks, he inserts a particularly heavy strabismus-hook (2 to 2.5 mm. in thickness) under- neath the tendon, between the other two hooks, and intro- duces sutures underneath the large hook, so that the tendon is shortened by an amount equal to the part that has been elevated with the large hook. 12. Schweigger's Method. — Resection of a stretch of tendon as long as the necessities of the case require, followed by suturing of the ends is a method that has been chiefly cultivated by Schweigger. His operation for " advancement " is performed as follows : After tenotomy of the squinting muscle, the conjunctiva is incised directly over the tendon of the antagonist in a line parallel to the tendon, the incision being carried through the tissues of Tenon's capsule. An unprotected hook, curved on the flat, is then pushed under the muscle, and the latter ele- vated. Tenon's capsule, which is usually raised at the OPERATIONS ON THE OCULAR MUSCLES. 259 same time at the edge of the muscle, is first transfixed with a hook and then dissected away until the entire tendon lies free on the hook. To make sure of this, it is better to introduce a second hook under the muscle in the opposite direction. While one hook is left under the tendon, the other is pushed along the muscle to the point where the sutures are to be introduced. Hence the tendon and the muscle are completely laid bare for a distance of from 3 to 10 mm. With the aid of a scale, with which the length of the piece to be excised is determined, the catgut sutures are placed in such a way that one of the needles is introduced at the point that has been measured, from underneath the upper edge of the muscle, carried forward from the posterior to the anterior side and brought out below the middle of the muscle. The entire muscle is thus ligated and divided in front of the sutures. Each suture has two needles, the second of which is used to fasten the divided muscle in front to the tendinous insertion or to the tendon-stump that has been left at the insertion. A piece may be ex- cised from the muscle that is to be advanced if the muscle has been ligated at some distance behind the tendon ; for it is not necessary to leave more of the muscle on the tendon than is required to furnish a good hold for the suture. As a rule, the excision of a piece of muscle is unnecessary. 13. Kostens method of advancing the tendon is quite similar to Schweigger's, except that he does not divide it. He thus effects a duplicative of the tendon. 14. On the other hand, Iy. Müller recommends actual myectomy, like the operation of suturing tendons per- formed by the surgeons, but accompanied by tenotomy of the squinting muscle ; while Vieusse and Xoyes-(Detroit), who were the first to practise excision of a piece of the tendon, do not correct the squinting muscle. Müller points out that advancement of the muscle is a very im- perfect operation and has no analogue in general surgery. He says it is impossible to tell how much the movable 260 OPERATIONS ON TUE EYE. conjunctiva will yield to the tonic pull of the distended muscle during the hours immediately succeeding the opera- tion, and that is why the operator always tries to get a much greater effect than he ultimately wants, because he does not know how much of the primary effect will be lost. He also thinks it is very important to leave the insertion of the tendon in the bulb intact, so as to avoid displacement of the tendinous insertion if the line of union turns out crooked ; such a dislocation is very easily pro- duced during the operation for advancement and may cause upward or downward deviation of the globe. The operation should be performed under anesthesia, so that the muscles may be relaxed. A vertical incision is made in the conjunctiva, 4 mm. from the cornea, and the mucous membrane dissected away sufficiently to leave the muscle fully exposed. A strabismus-hook is then placed underneath the muscle, and its lateral connection with Tenon's capsule divided with scissors as far back as the length of the piece of muscle that is to be excised, which in divergent squint may be 6 mm. in length and equiva- lent to the degree of deviation — in divergent squint, 1 to 2 mm. greater; and in convergent squint, 1 mm. less. This length is laid off on the muscle with a pair of dividers, taking care to leave a piece 2 mm. in length attached to the sclera in front. Behind the piece that is to be excised a moderately heavy silk suture is introduced at the upper, and another at the lower, edge of the muscle, taking in about \, and tied with a surgical knot to prevent slipping. Hence, there are two free ends at the upper and two at the lower edge of the muscle ; and of each pair one is cut off close to the knot. The muscle is then divided in front of the sutures and the anterior piece amputated, all but the above-mentioned stump, which is 2 mm. wide. Two corresponding sutures are then intro- duced into this stump in the same way as in the muscle ; and the two upper, and then the .two lower, ones tied with surgical knots. Whenever the tension is found to be very great — when the stitches in the tendon are brought OPERATIONS ON THE OCULAR MUSCLES. 261 together — Müller adds an ordinary tendon-suture, after Wölfler, through the middle portion of the muscle. The conjunctiva is then closed over all by means of two sutures. The tendon-muscle sutures heal into the wound and are not removed. Both eyes must be bandaged for three days. Both operation and after-treatment must be conducted according to aseptic principles in all these procedures of advancement, duplicature or resection ; special attention should be given to the sterilization of the suture material. But no matter how perfect the sterilization, a suture should never be passed completely through the sclera to the corneal margin, for after a few days the operative field ceases to be sterile, and there is every possibility of infec- tion spreading along such a suture into the interior of the globe and doing a great deal of damage. A good many operators recommend general anesthesia in cases of advancement. In regard to this point I adhere to the opinion which I expressed emphatically on page 27, and I may add that I have performed a large number of advancements with nothing more than cocain anesthesia during the last twenty years, and do not believe that I have had any worse results by so doing. An operation for advancement is followed by a good deal of pain, which persists for several hours, and should be relieved by an injection of morphin. Another unpleasant feature about this operation on the antagonistic muscles is the necessitv of wearing a double bandage for several days to insure healing. In cases of advancement such a bandage must be worn for six to eight days ; in duplicature or resection a few days less. The redness and swelling which persist for some time after the advancement and duplicature always subside in the end. On the other hand, one can never be certain whether the sutures that have been left will become encysted or will be extruded after a period of weeks or months ; an occurrence which the patient usually finds most unpleasant. 262 OPERATIONS ON THE EYE. Müller has pointed out that the only effect of advancement is to shorten the muscle ; for the advanced muscle probably grows fast to the bulb, along the entire interval between the side of the wound and that of the old insertion, and does not unwrap itself from the globe even in extreme rotation. Hence, the advanced muscle is practically inserted at the side of the original tendinous insertion. Later, it was actually proved by Fröhlich that such is actually the case. Five weeks after advancement, to a point in front of the original (normal) insertion of the corresponding advanced muscle, he cut down vertically as far as the sclera, so that that portion which had been advanced beyond the original insertion was completely separated from the rest of the muscle. But the effect of the operation was in nowise impaired, nor did he find a free space between the advanced terminal portion of the muscle and the globe. With regard to the indications for the different kinds of operations performed for the correction of strabismus, it may be said that the divergence of opinion is still very- great. Opinions differ widely even with regard to the age at which they may be undertaken. As convergent squint in children occasionally disappears as they grow older, many operators maintain that no operation should be performed for the correction of this variety of strabis- mus before the fourteenth to the sixteenth year. Others recommend an early one in order that binocular vision may be established as soon as possible. There is no doubt that in cases of convergent squint in children one has to be very careful not to overcorrect the error and cause subsequent divergent squint, which is quite apt to develop in cases of this kind, especially when the tenotomy has been radical. Earlier than the fifth or the sixth year surgical aid for the correction of convergent strabismus is not to be recommended, in my opinion ; after that year one must be guided by individual conditions and by the severity and character of the anomaly. In general it may be said that the older the patient, the more radical may be the treatment. Especially in adults with marked stra- bismus no satisfactory result can be hoped for without thorough advancement. In regard to the choice of operation in any given case of strabismus there is a similar difference of opinion, and theory and practice are also at variance. Most of the OPERATIONS ON THE OCULAR MUSCLES. 263 procedures by which the antagonist of the squinting mus- cle is corrected by advancement, duplicative and the like, and which I have not by any means exhausted in the above list of 14, show that the task is not an easy one and that its solution does not always satisfy the operator. This is largely because all the sutures have to be intro- duced in soft, yielding tissue, and cut through, more or less, on account of the steady pull of the muscle. The firmer the anterior fixation of the suture, the more will the tendinous portion be endangered ; and vice versa. To be moderately sure of a good result, both eyes must be completely immobilized for six or seven days, and this subjection to the discomfort of a double bandage is a very unpleasant concomitant of the operation. As the pull of the muscle is weakened by adding tenotomy of the squinting muscle to the advancement operation, the former is specially to be recommended whenever a marked degree of strabismus is to be corrected. Simple advancement without tenotomy, sometimes on both sides, has been chiefly recommended by Landolt for convergent squint in youthful individuals. It is quite conceivable that in this way there is less danger of overcorrection, and that mobility is better than when tenotomy is performed. On the other hand, I have seen exophthalmos develop after radical advancement without tenotomy of the squinting muscle, and the cosmetic effect was very bad. As regards mobility, it should always be borne in mind that tenotomy must be performed with due caution and in such a way as not to impair the mobility of the globe in the domain of the tenotomized muscle ; hence, the lat- eral attachments of the tendon with the capsule must not be injured. Too thorough correction should not be attempted with a single operation ; it is better in cases of severe strabismus to distribute the effect over the two eyes. If the squinting persists, it is not advisable to subject the same muscle to a second tenotomy ; in such a case one should always resort to advancement. It has also been objected that tenotomy is followed by 264 OPERATIONS ON THE EYE. protrusion of the eye and, when the internus has been cut, to disfiguring retraction of the inner canthus. So far as the last-mentioned disfigurement is concerned, it can be avoided by undermining the conjunctiva, as far as the caruncle, before doing the tenotomy and dividing it so as to separate its connections with the muscle, which may be expected to retract after it has been cut. The conjunc- tival wound must also be carefully united after the opera- tion. If there is staring of the eyeball after tenotomy, it is a sign that the tendon has been too freely separated. It is very difficult to know in advance how many operations will be required to correct a case of strabismus, and it is practically impossible to predict exactly what the ultimate effect will be. This is dependent not only upon how much of the tendon is separated from the globe, but even more on the strength of the antagonist and its ability to rotate the globe to its own side. But even with the most ingenious method of examination it is impossible to predict what the permanent strength of the antagonist will be, because in all these examinations it is only the momentary contracting power of the muscle that is tested, and a tenotomy or an advancement not infrequently in the end produces quite a different effect from the one that had been expected. The treatment is most successful when it is conducted upon the same lines as orthopedic treatment, the correction being kept up cautiously until a satisfactory result is obtained. The operator should never allow himself to be beguiled into making any definite statement beforehand about the duration of treatment and the kind and number of operations that will be required. In severe degrees of strabismus, especially in the diver- gent form, in which there is less danger of overcorrection or of the condition later changing to convergence, it is well not to separate too much of the tendon from the globe, and to combine tenotomy with advancement, making the latter as radical as possible. In most cases of convergent, as well as divergent, squint the ultimate effect is insufficient, ENUCLEATION OF THE GLOBE. 265 and the anomaly can, as a rule, be fairly well corrected by means of a tenotomy on the other eye. The operative treatment must be combined with the proper use of lenses and stereoscopic exercises. If, after tenotomy and advancement have been done on the eye, there is only a slight deviation, and it is to be feared that a second tenotomy might produce an excessive effect, especially in cases of convergent squint, the primary operation may be supplemented by Verhoeff 's oper- ation for lengthening the tendon, which is only moderate in its effect. In this the tendon is lengthened, by means of incisions, without sepa- rating it from the globe (Fig. 100). Whether the result of this process is more permanent than that produced by partial tenotomies, which were formerly proposed and carried out by various authors, will have to be shown by future experience. Fig. 100.— Verhoeff' s operation for lengthening a tendon. While the substitution of tenotomy for advancement would be a most welcome change, the difficulties in the way of its accomplishment, especially in children, are very great. In any case a tenotomy, if undertaken at all, should be performed in such a way as not to disturb the mobility of the globe. The weaker the muscle the more urgently is advancement indicated. For cases of paralytic squint it is the most important method. ENUCLEATION OF THE GLOBE. Complete removal of the eyeball from Tenon's capsule was first proposed by Bonnet, of Lyons, in 1841. It is based on his anatomic studies of the connective-tissue capsule of the eye, for which reason Tenon's capsule is also known as Bonnet's capsule. When the eyeball is removed along with some of the appendages (as, for example, in the case of a tumor of the globe that has ruptured externally), the operation is called extirpation of the globe. When it is still more com pre- 266 OPERATIONS ON THE EYE. Figs. 101-105. — Instruments used in enucleation: Fig. 101. — Straight conjunctival forceps. Fig. 102. — Blunt, curved strabismus-scissors; a seen from the side. Fig. 103.— Strabismus-hook. Fig. 104. — Heavy fixation-forceps for seizing the globe. Fig. 105.— Heavy, curved scissors for dividing the optic nerve ; a seen from the side. hensive and affects the entire orbit, it is known as exenter- ation of the orbit. In cases in which the eyeball is greatly inflamed or adherent to its surroundings as a result of former inflam- mation or of subconjunctival injections of bichlorid, the preliminary treatment for enucleation includes whatever is necessary as a preparation for general anesthesia. (For the treatment in other cases the reader is referred to page 30.) The instruments necessary for the operation will be found under Figs. 101-105. If Arlt's operation is selected, the strabismus-hook (Fig. 103) is not necessary ; while, on the other hand, a heavy, straight pair of scissors, like that shown in Fig. 108, is required. Desmarres' retractors, as shown on Plate 9, are specially recommended to begin- ners, because an inexperienced operator is in great danger of cutting the lids in this operation ; but specula like those shown in Figs. 14 and 33 can also be used. Before beginning, especially if a general anesthetic has been given, the operator must carefully notice once more which eye is to be enucleated, to guard against the accident of removing the wrong one, which has happened more than once. The mistake is specially apt to happen when the eyes present the same external appearance, as when both are normal so far as external appearances go, or equally inflamed, as, for example, in sympathetic disease. Sometimes the mistake is due to the fact that the operator takes his position at the patient \s head. Beginners ought to make it a rule to have the sound eye covered for some time before the operation with an occlusive bandage. [A mark with an anilin pencil should be made on the brow, over the eye to be removed. — Ed.] 268 OPERATIONS ON THE EYE. Plate 9. Enucleation of the eyeball. The globe has been rotated to the extreme right aud the optic nerve is being divided with the scissors. It is hardly necessary to say that the parts around the eye and the conjunctival sac must first be cleansed and the instruments boiled. It is not necessary to cut off the eyelashes or shave the eyebrow. If the operation is performed under local anesthesia, a strabismus-hook for finding the muscle tendons should be used, the operator proceeding as follows : In enucleation of the right eye he takes up his position on the right side of the patient, who lies on the operating table ; in case of a left enucleation he stands at the patient's head. If the eye is enlarged from the presence of a staphyloma or buphthalmos, the external canthus is laid wide open with a pair of straight scissors (Fig. 108) ; the blunt blade of which is inserted under the outer commissure, which is then divided with one or two snips of the scissors. With a pair of curved strabismus-scissors (Fig. 102) the operator then divides the cornea and, close to it, the conjunctiva, picking up the latter with a straight conjunc- tival forceps (Fig. 101) and slightly stretching it, so that it retracts ; it is then divided and undermined. The undermining is then continued around the entire eyeball beyond the insertion of the muscles ; when there are many old adhesions, this as well as the separation of the tendons is often a somewhat troublesome procedure. The four straight ocular muscles are then divided in the same way as in the operation for strabismus, each tendon being picked up with the hook. In this way the quadruple tenotomy can be performed without inflicting much damage and with- out giving pain by pulling and twisting the globe. It is best to begin with the external rectus, then, after the capsule has thus been opened, the superior is attacked with scissors and hook ; next the inferior, and, finally, the internus, are separated from the globe, the latter being divided behind the hook — not between the hook and the ENUCLEATION OF THE GLOBE. 269 sclera — in order to leave a somewhat longer stump (3 to 4 mm.) by which to hold and abduct the eyeball. For the latter purpose the heavy fixation-forceps shown in Fig. 104 is used, and at this point of the operation the surgeon takes up the heavy, curved scissors | Fig. 105), the better and more surely to perform the last act of the operation. With the globe in extreme outward rotation, the surrounding tissues are carefully dissected away with the scissors, and the optic nerve is found by palpating carefully with the closed scissors. It is very important to see that the globe is accurately rotated outward — that is, brought into a position of >imple abduction without either elevation or depression (Plate 9), and if this has been care- fully attend to the optic nerve is found without any trouble. The operator then opens the scissors so that the nerve slips between the two blades, and cuts it off short at the globe with one snip. The eyeball at once advances, the two oblique muscles are divided, and the mass is gradually removed from the orbit. In cases of enucleation for glioma of the retina as long a -tump as possible is left in dividing the optic nerve — that is, the scissors are carried away from the globe and the optic nerve divided farther back. When the operation is performed, under general anes- thesia, it is not so necessary to avoid pressure and traction on the globe, and Arlt's method may be recommended on account of its simplicity. When the globe is held fast by dense adhesions, however, the operation is somewhat more difficult ; it is not to be recommended when the globe is soft. If the operator, as is usually the case, handles the scissors with the right hand, he should stand to the right of the patient. In enucleating the right eye he divides the optic nerve from the nasal side, as shown in Plate 9 ; and in the case of the left eye, from the temporal side. In the latter case the globe is, of course, rotated toward the nasal side. With a heavy, straight fixation-forceps (Fig. 104) the operator then seizes the conjunctiva near the corneal margin, in front of the internus, on the right 270 OPERATIONS ON THE EYE. side, and in front of the abdncens on the left ; makes a vertical incision with the heavy straight scissors ; pro- longs the cut through the cornea, first downward and then upward along the cornea, as far as the opposite border ; seizes the internus with the forceps in the same way as the tendon is seized in Arlt's method of tenotomy (in the case of the left eye the externus) ; and divides the tendon as in a strabismus operation, except that the divi- sion is made farther back, so as to leave a stump of tendon for the further manipulation of the globe. From this point the blunt blade of the same (straight) scissors, with the edge directed forward — that is, held flat and close to the sclera, is carried to a point behind the insertion of the inferior, where the tendon of that muscle is divided close to the bulb ; after which the superior is divided in the same way. The globe is then rotated to the left side, and the oblique muscles, and finally the externus or internus, are divided with the same scissors, close to the globe. When, owing to great enlargement of the eye — especially posterior enlargement — or to a relatively deep position of a high nasal bridge, the optic nerve is not so accessible, a pair of curved scissors (Fig. 105) should be used. The same instrument should be selected in cases of glioma of the retina in which the optic nerve must be divided farther back than 1 to 2 mm. behind the sclera. Landolt designed two kinds of scissors, curved both on the flat and over the edge, one to the right and one to the left, which can be readily introduced underneath the tendons. Landolt operates in the same way as Arlt, but always separates the externus first and then the inferior oblique, after which he always divides the optic nerve from the temporal side. In arteriosclerotic individuals the hemorrhage during and after the operation may be quite severe, but it never requires ligation of the vessels. In most cases it is well, after thoroughly washing out the wound with cold bi- chlorid solution, 1 : 5000, to lay cotton plentifully on the cavity when the dressing is applied, for the purpose of ENUCLEATION OF THE GLOBE. 271 compression. If this fails to arrest the hemorrhage, the cavity must be packed with cotton, iodoform gauze, or even gauze saturated with adrenalin. Sometimes all that is necessary is to turn out the large clot that forms after the operation, after which the hemorrhage usually ceases. Some operators terminate the procedure by closing the conjunctiva with a tobacco-pouch suture, or they may unite the upper edge of the bulbar conjunctiva with the lower, or attach each muscle individually to the con- junctiva, so as to get a more movable stump. I have had jio personal experience with these different methods. I have always seen the cases end in normal recovery within six to seven days even without a tobacco-pouch suture, and only in very rare cases have I seen a mass of granu- lations result. In fact, the tendency to healing in enucleation is very great, abnormal healing being quite rare. The patient is usually in a condition to be discharged in six or seven days. Incising or puncturing the globe during the operation is an error in technic which must be specially guarded against. To avoid puncture one should dispense with sharp scissors. The accident of incising the globe, which usually occurs as the optic nerve is divided, is to be feared particularly in eyes that have become soft from cyclitis or injury, and have lost part of their contents. Hence it is well in such a case to fill up the eye before the operation by injecting cocain (see p. 15). Large traumatic wounds should, if possible, be allowed to close up partially before enucleation in order to increase the chances of successful operation, because pressure on the globe must be scrupu- lously avoided. The result may be a failure if the operator, before dividing the optic nerve, fails to rotate the globe properly — that is, fails to keep it in the plane which passes through the internal rectus, external rectus, and the insertion of the optic nerve. The latter is thereby displaced either upward or downward, and the scissors, failing to find the 272 OPERATIONS ON THE EYE. optic nerve, cut alongside and usually produce a large hemorrhage, which will make an inexperienced surgeon lose his head. Under such circumstances it is best to withdraw the scissors, let go of the globe altogether, then take a fresh hold and rotate it correctly, when the nerve may again be attacked with the scissors. The introduction of a retractor behind the globe, to displace it forward, sometimes proves dangerous, and is not to be recom- mended, because, although one is less likely to miss the optic nerve, it is thereby subjected to undue tension. Spoon-shaped instruments have also been constructed which are to be pushed behind the globe to facilitate the division of the optic nerve ; but these instruments can be dispensed with. If the outer commissure has not been divided, the globe may fail to emerge from the orbit even if the optic nerve has been properly cut, because the eyeball is too large or the palpebral fissure too small. In such a case the com- missure must be split secondarily. The indications for the operation are : 1. Malignant tumors. 2. Injuries in which enucleation becomes necessary, either primarily, on account of the great destruction of the globe ; or, secondarily, because of failure to heal and the danger of sympathetic disease of the other eye. The latter is particularly apt to develop from retracted scars in the ciliary region (also postoperative scars), contracted globes with sensitiveness to pressure, and slowly progress- ing post-traumatic or postoperative cyclitis. 3. Uncontrollable pain in blind eyes, especially from glaucoma, either primary or secondary. 4. Staphylomatous degeneration of the eye. 5. Opinions differ in regard to panophthalmia and acute purulent inflammation of the interior of the eye, as death from meningitis was formerly observed after enucleating in cases of this kind. Many authorities to this day regard the presence of such inflammatory conditions as a contra- indication, although the number of those who consider the ENUCLEATION OF THE GLOBE. 273 operation justifiable is increasing. Personally, I have always regarded both mere intra-ocular suppuration and panophthalmia — that is, the extension of the inflammation to the tissues around the globe with protrusion, etc., as indications for enucleation, and have operated on a number of cases of that kind without any bad results. 1 Even in these cases recovery is usually smooth and remarkably prompt. The operation is a blessing to these unfortunate patients, because it not only shortens their sufferings, but to a great extent, also, their disability. The fact that I have observed uninterrupted recovery occur in many cases of the severest panophthalmia with protrusion, immobility of the globe, and marked edema of the palpebral conjunc- tiva is explained in part by the modern treatment of wounds ; but it is, no doubt, due in part to the fact that microbes capable of producing inflammation (in these cases they were usually bacilli) had settled, or, at least, were demonstrated, only in a small portion of the interior of the eyeball, as has been proved by a number of micro- scopic examinations. The frightful inflammation to which they give rise and which spreads into the orbit was to be attributed solely to the spread of their toxins. Similar conditions may be present in many cases of this kind ; and in this connection the observation made by Silber- schmidt — that certain bacilli belonging to the group of the hay bacilli are responsible for some cases of panoph- thalmia — can only be demonstrated in the globe for a short time (they evidently die), although the inflammation does not subside at once. As regards the antiseptic precautions necessary in these cases, one should, above all, guard against incising or puncturing the globe, and, if there is a large wound that has united, care must be exercised not to reopen it. Thorough flushing of the cavity, with a bichlorid solution of 1 : 1000, while the wound is held wide open with the lid specula is also indicated. In these cases a few disks 1 Dr. C. Bauer has reported 53 cases from the years 1886 to 1900 {Korrespondenzblatt f. Schweizer Aerzte, 1901, p. 577.) 18 274 OPERATIONS ON THE EYE. of iodoform and a little iodoform gauze should also be placed in the wound, and in cases of intense panophthal- mia, drainage should be provided by means of a small rubber tube or a strip of iodoform gauze inserted between the lids and brought out at the outer or inner canthus. The lids are also to be covered with iodoform gauze, and the patient, in order to facilitate the escape of the secre- tions from the orbit, should lie on the side on which the drainage tube or gauze strip emerges. It is needless to say that in all cases of purulent inflam- mation tobacco-pouch sutures and other kinds of sutures of the conjunctiva should be avoided. In my opinion these methods of suturing are in themselves bad surgery and, except in wounds in which the asepsis is perfect, un- justifiable. [It is evident that suppuration within the globe should not be permitted to continue without interference, and the surgeon must decide between enucleation and eviscer- ation. Although the risk of meningitis or of a fatal termination from any cause after enucleation for any pathologic process within the globe is exceedingly rare — being about 1 in 1 600 operations — it must be remembered that in the majority of cases the lethal issue has occurred when the pathologic condition of the eyeball at the time of the enucleation was one of partial or complete suppu- ration. Now, while it was not always possible to connect the meningitis directly with the operation, in some instances this connection was definitely established ; hence the claims of evisceration must be considered. See a paper by the editor on " The Comparative Value of Enucleation and the Operations which have been Substituted for it. — XIII. International Congress of Medicine, Paris, 1900. Section on Ophthalmology. — Ed.] Other operations have been suggested in the place of enucleation, the latter leaving a bad deformity. 1. Resection of the optic nerve {Neurectomia Opticociliaris) was suggested by Schweigger, to take the place of simple division of the optic nerve, which had been used before his time. He recommended ENUCLEATION OF THE GLOBE. 275 and adopted the following procedure : An incision is made in the con- junctiva and Tenon's capsule, 3 mm. behind the insertion of the right internus; the muscle is exposed, and a blunt strabismus-hook (not guarded) curved on the flat, and then another, are introduced under- neath the muscle. As the two hooks are drawn in opposite directions, one of them catches on the angle at the insertion and rotates the eye nut ward, while the other draws the muscle up out of the orbit. Under- neath the second hook a needle, threaded with catgut, is passed through muscle and conjunctiva, reinserted close to the point of exit, and brought back again through conjunctiva and muscle. The muscle is then divided 5 mm. behind the insertion, and the suture is tied. A second similar suture is introduced through the tendon and conjunctiva and tied at the anterior extremity of the muscle. The wound is then enlarged in the direction of the superior and inferior recti, a small, sharp double hook (Fig. 72) is inserted into the sclera as far back as possible, and the eye is drawn forward and outward. A pair of flat scissors are then intro- duced along the globe until the orbit is reached, the optic nerve is sought for and divided as near as possible to the optic foramen. "With the aid of the double hook the posterior portion of the periphery of the eye is rolled forward, and the tendon stump adherent to the globe is cut off close to the scleral insertion ; finally the eye is replaced and the wound is closed with the sutures that have been introduced at the beginning of the operation. As a last step the palpebral margin is also closed with a few silk sutures. Three sutures are quite enough to con- trol the bleeding and exophthalmos ; but if this precaution is neglected the hemorrhage may prove most unpleasant. After about four days this danger is obviated and the sutures, which by that time have usually cut through the skin of the upper and the lower lid, are removed. de Wecker simplifies the operation of resection by confining it to the optic nerve, from which he excises merely a section from 5 to 6 mm. in length. He also devised a hook for seizing the optic nerve, and a pair of scissors with which the nerve can be compressed after it has been divided ; in that way he claims to diminish the hemorrhage. Resection, which I have, so far, never performed myself, may be suitable for isolated cases in which one has to contend with severe pain accompanied by blindness, as, for example, in glaucomatous degenera- tion. But the method is not a sure preventive of sympathetic ophthal- mia, for the disease has been known to occur even after resection had been performed. 2. Exenteration or evisceration of the globe is another operation that has been recommended as a substitute for enucleation, and is quite frequently performed. The object is to remove the entire contents of the globe through a circular incision in the sclera behind the cornea, after which the sclera is closed in front. It is claimed that in this way a larger and more movable stump is obtained, affording a better hold and greater mobility for the artificial eye. Alfr. Gräfe and Bunge proceed as follows : After thoroughly disinfecting the operative field, the sclera is divided by a circular incision immediately behind the cornea, the operator seiz- ing the palpebral conjunctiva close to the corneal margin to his right 276 OPERATIONS ON THE EYE. side with conjunctival forceps, while his assistant at the same time grasps the conjunctiva at a point 5 mm. farther back, but in the same meridian. Between the two forceps, close to the anterior forceps, the sclera is then carefully incised, layer by layer, with a broad scalpel, until the dark ciliary body appears in the wound. With straight scissors, the blades of which are not too thick, and must be blunt at the points (Stevens' scissors shown in Fig. 92 are suitable), the incision is then enlarged, while the sclera is held fast with the two forceps, one blade of the scis- sors being pushed forward between the ciliary body and the sclera. After each snip of the scissors the two forceps take a new hold on the sclera where the incision ends. After the incision has thus been enlarged around the upper half of the cornea, the same thing is done around the lower half, keeping constantly close to the corneal margin. By means of Bunge's scoop the entire contents of the globe is then removed, if possible in Mo, and if not, piece by piece. After the cavity of the scleral cut has been thoroughly cleansed by scraping with scissors and forceps, or rubbing with gauze, and has been washed out with a disinfectant, the opening in the scleral cavity is brought together with 3 to 5 sutures, which include the conjunctiva, the wound being then closed in a hori- zontal direction ; or a tobacco-pouch suture may be introduced. The after-treatment in this operation is much more distressing to the patient than in the case of enucleation. The other eye should also be bandaged for from two to four days. Severe ciliary pain often develops and has to be relieved with morphin. The sutures are removed on the fifth day. In from eight to ten days, if everything goes well, recovery is complete. Possible complications are orbital cellulitis, intense unilateral headache, and slight febrile movements. Occasionally the operation needs to be followed by a sec- ondary enucleation. If the scleral cavity fills with blood and granula- tion grow in it afterward, the resulting stump may be primarily quite small, not much larger than after enucleation. Sometimes the stump becomes small secondarily because shrinking continues for months and even years, so that the result is not worth the trouble and distress to the patient. This consideration suggested the attempt to cause a spherical body of glass (Mules), celluloid (Lang), silver (Kuhnt), etc. [gold-plated balls are very satisfactory — Ed.], to heal into the scleral capsule. The same thing was done by Frost and Lang after enucleation, with the object of getting the foundation for the artificial eye to heal into Tenon's capsule. Unfortunately, these balls of glass and other materia Is are usually extruded after a time. Exenteration is not a suitable procedure in cases of malignant tumor, because one can never be sure that the inside of the sclera has not been attacked. In cases of purulent inflammation, also, I do not believe that the procedure is sufficiently radical to insure perfect removal of all the elements that are responsible for the inflammation. In fact, I consider that this operation is bad surgery, because it leaves a cavity with rigid walls, with a possibility of noxious material being retained in it. Robust as the sclera is, it nevertheless consists of living tissue, and it has been shown by microscopic investigations (S. Huge) that it is very difficult ENUCLEATION OF THE GLOBE. 277 to render the inside of the scleral cup absolutely free from cells or microbes. It is, therefore, doubtful whether exenteration affords suffi- cient protection against sympathetic disease. [Professor Haab's statement that the artificial vitreous (glass or gold globes) used in Mules' operation " are usually extruded after a time" would not seem to be entirely sub- stantiated by statistical information. In 1900, before the Thirteenth International Congress of Ophthalmology, the editor read a paper in which 317 operations of this char- acter were analyzed, and in only 17 per cent, was there escape of the artificial vitreous. In more carefully per- formed series of similar operations this percentage is re- duced to 8. The operation should be performed as fol- lows : After general anesthesia a stop speculum is introduced, and the conjunctiva dissected from the corneoscleral at- tachment, in all directions to the equator of the ball, without disturbing the muscles. The cornea and 1 mm. of the scleral margin are removed in the manner described under Evisceration. Next, the contents of the globe are emptied by any convenient method, a small evisceration scoop being a satisfactory instrument. Great care must be taken to remove the entire contents, leaving a perfectly clean, white sclera. Hemorrhage is controlled by packing the scleral cavity with sterilized gauze, and by frequently irrigating it with a tepid solution of bichlorid of mercury, 1 : 5000. A glass or gold sphere of such size that it may be introduced within the scleral cup without difficulty is selected, its introduction being facilitated by splitting the sclera vertically for about 4 mm. at the upper and lower margins of the opening. The introduction of the glass sphere is further facilitated by the use of an instrument specially devised by Mules for this purpose. The con- cluding steps of the operation consist in stitching the sclera vertically, the conjunctiva horizontally, and apply- ing a full antiseptic dressing. The greatest care should be exercised to secure absolute asepsis during the opera- tion and at the subsequent dressings. The patient should 278 OPERATIONS ON THE EYE. be confined to bed for at least four or five days. Con- siderable reaction and marked Chemosis of the conjunctiva may follow. This may be controlled by the continuous application of cold, and probably be avoided by not re- moving the bandage for forty-eight or even seventy-two hours. Mules recommends that the sutures should be of catgut ; the editor prefers silk sutures. Implantation of an artificial globe in Tenon's capsule after removal of the eyeball is performed as follows : The eyeball is enucleated in the ordinary manner, and, after all bleeding has been checked, a gold or glass sphere is inserted within Tenon's capsule. The capsule and conjunctiva are next sutured over the artificial globe with silk, the tendons of the ocular muscles having pre- viously been secured by one of the methods described under Enucleation. The subsequent treatment is the same as that suited to Mules' operation. — Ed.] Artificial Glass Eyes. The improvement in artificial eyes, which was stimu- lated a few years ago by Snellen, has greatly diminished the importance of the two operations that are performed instead of enucleation, and they are therefore even less justifiable than they were formerly. The artificial eye which had been used until that time consisted of a com- paratively thin glass shell, and was originally intended only to be worn over a more or less phthisical globe. Snellen then induced the firm of Müller Söhne, in Wies- baden, to manufacture eyes consisting of a double shell, which possess the advantage that they fill out the orbital cavity more completely and have smoother edges. After much trouble the firm succeeded in turning out artificial eyes of the proper form and workmanship, which they call " reform-eyes." One of the great advantages is that they prevent the collapse of the upper lid, which occurs when the old form of artificial eyes is worn, and spoils the ex- pression. Snellen is quite right in saying that it is more important that an artificial eye should fill the orbital OPERATIONS ON THE ORBIT. 27 '9 cavity completely than that it should have a wide range of movement. A great many people hardly rotate their eyes at all and get along by moving the head. In any case it is better to advise the patient who is forced to wear an artificial eye to move his head instead of his eyes. The following rules should be observed : It should be impressed upon the patient to get a new glass eye at in- tervals of eighteen months to two years, because the glass becomes rough and may produce irritation and a discharge of mucus, followed by cicatrization and shrinking of the cavity, which ultimately contracts to such a degree that it becomes difficult or even impossible to wear the artificial eye. This is particularly apt to happen with the old style with narrow edges. Abrasion and cicatrization may also occur if one has made the mistake of wearing one too large in order to make sure of completely filling the cavity. One should never order an artificial eye so large that the lids can not completely close over it. In the case of phthisis of the eyeball, the patient should not be allowed to use an artificial eye unless it is perfectly comfortable. A glass eye should be removed at night in order to prevent it from getting rough. It should not be placed in water, but merely cleansed and then laid away dry. The patients soon learn how to insert it : first under the upper, and then under the lower lid. Removal is best accomplished by means of a glass-headed pin ; this is in- serted under the lower edge of the artificial eye, which is then drawn forward. OPERATIONS ON THE ORBIT. Opening an abscess in the anterior portion of the orbit is a comparatively simple operation, as the abscess usually starts in the bone or the periosteum of the orbit or in the adjoining bony cavities. A broad incision is made as close to the bone as possible, taking care, above all, not to injure the levator palpebral superioris. 280 OPERATIONS ON THE EYE. When the pus is in a deeper situation, as when it has its origin in one of the accessory sinuses of the orbit, par- ticularly the ethmoidal and sphenoidal cells, a so-called orbital phlegmon often results. This is a dangerous and often a violent inflammatory process, which not only soon destroys the optic nerve and the patient's eyesight, but may also threaten his life. Immediate operative relief is imperative. Free drainage must be provided for the inflammatory products (edema, pus, etc.) contained in the orbit, in order to rescue the tissues from compression and intoxication. For this purpose a large incision is made at that portion of the orbital margin opposite which the greatest degree of inflammation and swelling is discovered in the depths of the tissues — that is, for example, above and to the nasal side when the protruding globe is dis- placed downward into the temporal side. The patient is anesthetized and a curved incision, 4 to 5 cm. in length, is made directly over the orbital edge, dividing the periosteum. The latter is then separated from the bone with an elevator (Fig. 112) to a depth of 3 to 4 cm. By keeping between the bone and the perios- teum all danger of wounding the levator, the trochlear nerve, or the lacrimal gland is avoided. Separation of the periosteum is often followed by a flow of pus from below, or, if not, the wound is held open with hooks and the periosteum is incised in the depths of the orbit when pus is suspected. By cutting from behind forward it is not difficult to avoid the eye muscles. Even if no pus is found, but only inflammatory edema, the incision does good and is absolutely required to preserve the integrity of the optic nerve. Afterward iodoform gauze or a drainage tube is introduced as far as possible into the wound to facilitate the escape of the secretions. At the same time, the diseased accessory cavity which contains the source of the process must be subjected to vigorous treatment. THE REMOVAL OF TUMORS FROM THE ORBIT 281 THE REMOVAL OF TUMORS FROM THE ORBIT. Tumors in the anterior portion of the orbit can usually be removed without much difficulty by a curved incision running parallel to the orbital margin, or they may be peeled out or dissected out by going in through the con- junctiva. Among such are cysts, which are fairly common (see Atlas of External Diseases of the Eye, PI. 12, Fig. c). The operator must be careful to remove every portion of the cyst, and this is not always an easy matter, because they may extend far into the depths of the tissue. It will be easier to remove the posterior portion without injuring the globe and without leaving anything behind if the cyst is first incised at some convenient point on the anterior wall, and part of the contents evacuated ; the small incision must, however, be closed with a ligature, so that the poste- rior wall may still retain some of its rigidity. Non-encapsulated angiomata in the anterior portion of the orbit and often extending into the lids are usually congenital and of slow growth. These tumors, according to Knapp, may be best extirpated by inserting the horn handle of an ordinary lid speculum (Fig. 17) into the conjunctival sac underneath the lid in order to avoid a profuse hemorrhage into the operative field. The instru- ment is pushed back under the tumor as far as the wall of the orbit, and the flow of blood to the angioma is thus con- trolled by pressure. The tumor is turned out through the skin, avoiding the levator palpebrarum if the tumor occupies the upper lid. Small remnants that have ex- tended to the skin of the lids or as far as the palpebral margin, or even to the back of the posterior surface of the lid, may be left behind ; according to Knapp, they disappear after the main tumor has been removed. For the removal of small palpebral angiomata the lid- clamps designed by Knapp, Desmarres or Snellen (Figs. 120, 122, 124) are extremely useful. With this instru- ment the operation practically becomes bloodless. Retrobulbar automata and cavernomata are extirpated 282 OPERATIONS ON THE EYE. Figs. 106-112. — Instruments for Krönlein's operation (half-size) : Fig. 106.— Scalpel. Fig. 107. — Stout curved scissors, after Cooper. Fig. 108. — Heavy straight scissors with protected points. Fig. 109.— Forceps. Figs. 110, 111.— Tenacula. Fig. 112.— Elevator. in the same way as other retrobulbar tumors ; the method will be discussed later. Whenever the whole or the greater part of a tumor spreads out behind the globe, a more radical operation is required for .its removal. Up to the time when Knapp (1874), and especially Krönlein (1889), described their methods of operation, retrobulbar tumors, with few excep- tions, were treated by enucleation of the globe. If the globe has been displaced far forward by a tumor situated at the back of the orbit and frequently beginning in the optic nerve, especially a myxosarcoma or fibrosar- coma, it may be possible, on account of the anterior dis- placement, to remove it from in front without sacrificing the globe, after Knapp's method ; but the limited amount of room and the inaccessibility of the tumor are distinct disadvantages which increase with the size of the tumor and the number of adhesions to the surrounding tissue. Krönlein's operation permits much easier access to the operative field. In Knapp and Lagrange's operation for the removal of retrobulbar tumors without sacrificing the globe, a method which is best adapted for the optic nerve, access is gained to the retrobulbar space through a large conjunctival incision, either from the nasal or from the temporal side, depending on the position of the tumor. If necessary the extern us or internus, and sometimes a second muscle, is divided after having been secured with a suture, which is afterward used to unite the two divided ends. By this method the globe can be drawn farther to one side, and better access is obtained to the deeper portions, so that the tissues can be dissected out with the finger or the hollow 283 284 OPERATIONS ON THE EYE. Figs. 113-116.— Instruments for Krönlein's operation (half-size) : Fig. 113.— Spatula for keeping back orbital congestion. Fig. 114.— Chisel. Fig. 115.— Mallet. Fig. 116. — Electric circular saw. probe until the tumor is reached. At this point a ligature may be passed around the posterior portion of the optic nerve with an aneurism-needle and the structure tied off; the nerve is then divided as close as possible to the optic foramen, and the tumor turned out after the globe has been turned completely around. Next the optic nerve is cut off close to the globe ; the latter is replaced ; and the muscles and conjunctiva are reunited by sutures. If pro- fuse hemorrhage from the deeper tissues takes place, an attempt may be made to control the exophthalmos by closing the palpebral fissure. It is evident that under certain circumstances it may be difficult with this method to remove all the posterior portion of a tumor and leave a clean surface. Fortunately, primary tumors of the optic nerve are often benign myxo- sareomata, which represent the majority of all optic-nerve tumors ; and, although the posterior portion of such a tumor may remain in the optic canal, it will not proliferate (Salzmann). In the case of sarcoma and endothelioma complete extirpation is unavoidable. Krönlein's Operation. This represents a distinct advance in orbital surgery. It possesses the immense advantage that the operative field, the retrobulbar space, is much more freely exposed, so that the surgeon can see what he is doing, and is therefore able to operate without doing so much harm. The instruments which my colleague, Krönlein, uses for this operation and which I obtained from him for the artist's use (and I wish to mention here that I am also indebted to his kindly help for the authentic illustrations on Plates 10 and 11 as well 285 286 OPERATIONS ON THE EYE. Plate io. Opening of the orbit after Krönlein. The skin-muscle-bone flap has been reflected forward and shows a large portion of the periorbita. The latter is then incised from behind forward, producing the picture shown on the next Plate. as for Fig. 117), are illustrated in Figs. 106-116. Axen- feld lias devised for this operation special blunt hooks and holders or retractors, in the form of round plates attached to an angulated handle, for holding the orbital tissues apart. (This may be obtained from Windier, in Berlin.) ..... Fig. 117.— Skin incision (curved line) and bone incisions (heavy lines) in Krönlein's operation. Independently of Wagner, who suggested in 1886 that it might be advisable under certain circumstances, espe- cially for the removal of foreign bodies, to make a tem- porary resection of a wedge-shaped piece of the orbital edge, Krönlein, in the same year, performed his first operation of this kind, after he had tried it on a cadaver and had developed a definite plan of operation. THE REMOVAL OF TUMORS FROM THE ORBIT 287 Technic. — The operation is performed under anes- thesia. The eyebrows and hair having been shaved from the entire temporal region, an assistant rotates the patient's head slightly toward the sound side, and the operator takes his position at the patient's head or to one side, under lateral illumination. The first step of the opera- tion consists in dividing the soft parts with a curved inci- sion, as shown in Fig. 117. The incision begins above, at the point where the linea semicircularis of the frontal bone, which is readily felt, intersects a horizontal line running 1 cm. above and parallel to the supra-orbital margin, and is carried downward in a gentle curve along the temporal edge of the orbit to the level of the upper edge of the zygoma, where it makes a bend backward and ends at the center of the zygoma. The center of the curved incision bisects a horizontal line which connects the outer canthus with the outer orbital margin. In this interme- diate portion the incision should be carried down to the opening, while at the upper and lower portions of the orbit the knife should divide only the skin, fascia, and muscular layer. The length of this incision in adults should be from 6 to 7 cm., and in children two to seven years old about 4 cm. It is important not to make the incision too small and to make it exactly as described above. Above all it should not be near the temporal side, but slightly to the nasal side of the temporal margin, in order that the latter may remain well covered by its soft parts. At the central portion of the skin incision, where it is carried down to the bone, a sharply bent elevator (Fig. 112) is introduced, and the periorbita is separated as a whole from the external orbital wall upward to a point about 1 cm. above the zygomatieo-frontal suture, down- ward to the anterior orbital fissure, while the depth should carry it well behind the zygomatieo-sphenoidal suture. The point of the elevator is then carried vertically down- ward as far as the anterior orbital fissure, in order to determine the point where the open incisions presently to be made are to converge. The elevator should not be 288 OPERATIONS ON THE EYE. Plate ii. Opening the orbit after Krönlein. After the periorbita has been divided, the deeper tissues are dissected out so as to bring the posterior portion of the globe and the optic nerve clearly into view. The large wedge of bone that has been chiselled out is also distinctly recognizable from its orbital side as far as its apex. introduced into the fissure with too much force, so as not to injure the infra-orbital nerve. ■ The bone incisions (see Fig. 117), which are now in order, must mobilize the piece of bone which is to be tem- porarily removed, consisting of a wedge, the base of which is formed by the outer orbital margin, zygomatic processes, frontal bone, and frontal processes of the zygoma, while the apex lies behind the anterior extremity of the anterior orbital fissure. The soft parts having been pushed to one side, and the periosteum divided down to the bone in the line of the bone incision, the zygomatic process of the frontal bone is cut through transversely with the chisel above the zygomatico-frontal suture, which is readily felt, or with an electric circular saw (Fig. 116). This bone incision must not be placed too high, to avoid open- ing the cranial cavity. Beginning at this horizontal upper incision the bone is divided with a sharp chisel (in order not to splinter the bone) in a straight line running obliquely through the lateral wall of the orbit to the ele- vator, which is fixed in the anterior orbital fissure — i. e., to a point 1 cm. behind the anterior extremity of the fis- sure ; at the same time the orbital contents are gently pressed toward the nasal side with the elevator. The next step consists in a horizontal division with a chisel or a saw of the frontal process of the zygoma, close to its base ; this is also continued into the fissure. The piece of bone is now movable and may be reflected outward along with the skin-fascia-muscle flap of the temporal region far enough to give free access to the orbit, which is still half-covered by the periorbita (Plate 10). The latter must be split from before backward with the blunt scis- THE REMOVAL OF TUMORS FROM THE ORBIT. 289 sors (Fig. 108), and held apart with tenacula applied above and below (Plate 11), whereby free access to the retrobulbar -pace is obtained. Superficially lies the right external rectus muscle, which, if necessary, is divided near its tendinous insertion, after sutures have been intro- duced, so as to make it possible to unite the divided ends. Or the abducens may be merely drawn to one side, and the dissection continued along the optic nerve with Cooper's scissors (Fig. 107). As the wound gradually becomes quite deep, good illumination is absolutely neces- sary, especially when the operator has to advance to the apex of the orbital funnel or as far as the nasal portion of the orbit. During the operation the globe may be pushed slightly forward and inward with a blunt hook, and the orbital fat pushed aside with the instruments shown in Fig. 113, or with Axenfekrs plates. After the retrobulbar operation has been completed, the eye muscles that have been divided are reunited ; the skin-muscle-bone flap replaced ; the periosteum secured with a few silk sutures ; and, finally, the soft parts are carefully sutured with silk. A drainage tube or iodoform wick is placed in the upper portion of the wound, but can, as a rule, soon be removed. An aseptic and occlusive bandage, covering the entire eye, is applied. The globe should be carefully covered by the lids, especially in cases in which the cornea i^ anesthetic, so that if there is no ptosis it may sometimes be advisable to close the palpebral fissure with sutures (Axenfeld), a procedure which is also valuable for controlling a postoperative retrobulbar hem- orrhage (Braunschweig, Ellinger). As in many cases this method has been found to possess the disadvantage of leaving the eyeball with defective power of abduction, it is important in this operation to avoid injuring the abducens, not only when the periosteum is opened, but also later on ; in fact, during the entire operation the tissues should be dissected away with much caution, to avoid injuring the nerves and the rest of the orbital tissues. 19 290 OPERATIONS ON THE EYE. There is no special advantage in making the bone incisions with a Gigli wire saw from within outward or from behind forward (Schuchardt, Torek). My colleague, Krönlein, was kind enough to tell me that he gave up this method because the introduction of the wire is not by any means such a simple operation, especially if, as Torek advises, the outer orbital wall is first perforated for the upper oblique incision. Czermak, after experimenting on cadavers, proposed a modification of Krönlein's operation, having for its object to obtain still better access to the orbit. He resected with a chain saw not only the outer, but also a small portion of the lower, wall of the orbit. Domela-Nieuwenhuis, in his exhaustive monograph on Krönlein's operation, offers a criticism of this procedure, based on careful tests performed by himself, and con- cludes that Czermak's operation is so complicated as to belong rather to the province of the surgeon, while Krönlein's operation can easily be performed by an oculist. Besides, he says, Czermak's operation, al- though much more difficult, affords but little better access to the orbital cavity than is obtained by means of Krönlein's operation ; and finally it is to be remembered that the latter usually gives room enough if it is properly carried out. Another modification of Krönlein's operation was proposed by Parinaud and Roche. In order to avoid a scar near the outer canthus of the eye, with the possibility of distortion in that direction, they made the base of the skin-flap at the orbital edge and reflected it for- ward. From the temporal portion of the eyebrow a horizontal incision is carried 5 cm. backward, then 5 cm. upward, and finally 5 cm. for- ward, making a four-cornered flap which is reflected forward. The rest of the operation is the same as Krönlein's. Although the case reported by the authors made a good recovery, the nutrition of the bone is in much greater danger in this operation than in Krönlein's, 1 since it is attached only by the temporal fascia and temporal muscle. Under the name of malar orbitotomy Rollet recommended temporal incision of the body of the zygoma and performed it in a case of exophthalmos. He exposed the bone by a curved incision along the outer and lower edge of the orbit, to which he joined short incisionsat the upper and lower extremity, forming right angles with the first in- cisions ; chiselled through the frontal process, the temporal process of the zygoma, and the insertion of the latter in the upper jaw, after which he bent the zygoma outward and downward with the finger. Later the bone is raised and returned to its original position. 2 Entering the orbit from above, as proposed by Cahen arid Franke, is a much more difficult and complicated undertaking. Cahen, in an operation for the total extirpation of the supra-orbital nerve, chiselled away the entire orbital wall for good, after he had gained access by 1 These authors evidently misunderstood Krönlein's method, for they speak of a vertical skin incision 6 to 7 cm. in length, which, they imply, was improved upon by Jonnesco's adding horizontal incisions. 2 Rollet also is not sufficiently acquainted with Krönlein's procedure ; as appears from his criticism that it involves fracture of the outer orbital wall, which might extend into the sphenoidal bone. THE REMOVAL OF TUMORS FROM THE ORBIT. 291 temporary resection of a piece of the frontal bone and pushed the dura mater aside with the bone. Cahen believes this method to be suitable for regular orbital operations. Franke, after experiments on cadavers, proposed to expose the upper portion of the orbit by temporarily resecting the upper edge of the cavity and reflecting it downward along with the skin. In this way, he says, it is possible to reach the optic foramen. The two methods devised by Gussenbauer, and consisting in tem- porary resection of the framework of the nose, to expose the two orbital cavities, and the frontal, ethmoidal and sphenoidal sinuses, sometimes on both sides of the head, may be tried in orbital cases with simul- taneous diseases of the ethmoidal and sphenoidal cavities, especially in the presence of bilateral retrobulbar disease. The operations of the three latter-named authors are very much more complicated than that of Krönlein, and in my opinion belong to the province of the general surgeon. It appears from Domela's comprehensive collection of cases, and other contributions to the literature that have appeared since then, that the indications for Krönlein's operation are: 1. Cyst, particularly retrobulbar cyst, in- cluding echinococci and cysticerci (the latter are rarely found in the orbit). 2. Tumors of the optic nerve and of its sheath. 3. Retrobulbar cavernous angioma, lymph- angioma, and other retrobulbar tumors, also aneurisms, and varicose dilations of the orbital veins. 4. Retro- bulbar injuries, particularly foreign bodies in the orbit. 5. Orbital abscesses (phlegmon). 6. Any operations on the deeper portions of the eyes (removal of a subretinal Cysticercus in the macular region, opening the sheath of the optic nerve in choked disk, Midler's operation for retinal detachment, etc.). 7. Finally the operation is also perfectly justifiable for purposes of diagnosis in doubtful cases (Franke, Braunschweig), because it is absolutely free from danger, and is often the only means of arriving at an accurate diagnosis of a retrobulbar process. Exenteration of the Orbit. The object in evacuation of the orbital cavity is to remove not only the globe, but all the remaining contents of the orbit, as completely as possible. It is usually necessitated by malignant tumors, be it that a neoplasm 292 OPERATIONS ON THE EYE. has advanced from the interior of the globe into the orbit, or that the latter is the primary site of the sarcoma, etc. Exenteration may sometimes have to be performed after enucleation if, after the globe has been removed, it is found to be ruptured and permits portions of the tumor (sarcoma or glioma) to escape ; the perforation may be quite small. This operation also requires a general anesthetic. The first step consists in dividing the outer angle of the lid in a line coinciding with the prolongation of the palpebral fissure, with heavy straight scissors (Fig. 108), carrying the incision a good centimeter beyond the edge of the orbit. Beginning at the outer orbital edge, which has thus been exposed, an incision is made through the soft parts around the orbital cavity from the conjunctival sac to the bone, the lids being held well apart with retractors. This incision is made with the scalpel (Fig. 106), which must be kept close to the orbital margin. As this incision at the same time divides the periosteum along the edge of the cavity, it is usually easy by means of the elevator (Fig. 112), which is introduced at the outer angle between the orbital margin and the periosteum, to separate the periosteum from the bone in every portion of the orbit, passing carefully over the thin parts of the bone, particu- larly the inner orbital wall (lamina papyracea of the ethmoidal bone, and lacrimal bone), so as not to perforate the bone. Wherever the elevator meets with greater re- sistance the tissues are divided with the scissors. The attachment of the posterior limb of the inner palpebral ligament and the capsular tag of the internal rectus, par- ticularly, will have to be divided with the scissors. After the periorbita has thus been removed from the entire orbital funnel as far as the apex, so that the wedge- shaped contents of the cavity are held merely by the pedicle formed by the optic and remaining nerves, the blood-vessels, the insertions of the muscles, and the periosteum, these tissues are divided with large Cooper scissors (Fig. 105), which are introduced along the outer THE REMOVAL OF TUMORS FROM THE ORBIT. 293 orbital wall. In this way the entire contents, surrounded on all sides by periosteum, can be removed. The hemor- rhage from the large orbital vessels which follows can, as a rule, be controlled by packing with iodoform gauze ; if it is very profuse the place may be cauterized with a Paquelin cautery. The cavity should be packed with a long strip of iodoform, which can afterward be removed gradually, a piece at a time. In any case the iodoform gauze must project in front between the lids, which are not closed, and must communicate with the gauze in the dressing, so as to enable the secretions to escape from the cavity. Czermak suggests that the entire orbital cavity be filled with a large round piece of iodoform gauze, to the center of which a ligature has been attached ; this is stuffed into the cavity like a pocket and filled with strips of iodoform gauze, some of the latter remaining between the lids, which are held open. In the cavity the gauze should not be packed too tightly. When the dressing is changed the contents of the pocket are removed before the latter is withdrawn by means of the suture attached to its center. Since, after exenteration of the orbit, the lids retract into the orbit as healing takes place, it is impossible to wear a false eye after this operation. It is therefore necessary to do something to correct the ugly deformity which would be produced by an empty orbital cavity. The indication for this is particularly strong when one or the other of the lids, or both, have been removed at the operation because they are involved in the neoplasm. Another reason for covering the large wound in the case assumed is that the period of healing is greatly shortened by such a procedure. If both lids have been removed at the operation, or if, as in the case shown in Plate 12, they have been destroyed by the neoplasm (carcinoma), the procedure which was customary in von Langenbeck's clinic (Krönlein, namely, covering the defect with a large skin flap obtained from the neighborhood, as, for example, the forehead, will give the best results. The skin flap 294 OPERATIONS ON THE EYE. Plate 12. Destruction of the orbit by Carcinoma (rodent ulcer). Destruction of the lids and globe, leaving only a small, roundish, shrunken remainder in the large cavity, the deepest portion of which communicates with the ethmoidal cells (dark spot in the picture), and laterally with the nasal cavity. It is probable that the carcinoma started in the lids. The result, after extirpation of the neoplasm, which was performed by my colleague, Krönlein, is seen in Figure 118 (p. 296). required for occluding the exenterated orbit must have a pedicle, and may be obtained, depending on the necessities of the individual case, either from the skin of the cheek, as in the two cases cited by Krönlein, or from the skin over the temporal and frontal regions. (Information kindly imparted to me by my colleague, Krönlein.) Küs- ter also recommended covering the wound. The operation may be performed as shown in Figure 118, which repre- sents a picture of the woman, taken eight weeks after the operation by my colleague, Krönlein, for a carcinoma which had penetrated far into the orbit, as shown in Plate 12. The entire cavity of the wound was closed with a large flap taken from the forehead, the edges of the flap being carefully united to the edges of the large wound with sutures ; after which the denuded area in the fore- head was at once covered with skin grafts, after the Thiersch method. Both the latter, as well as the large pedunculated flap, healed perfectly, nor was there much retraction later, because the orbit became filled with a thick, fibrous tissue, formed by proliferating granulations. When exenteration of the orbit is performed without sacrificing the lids, Küster' s suggestion may be adopted, and more rapid healing induced by freshening up the edges of the lids and uniting them with sutures. The follicles of the lashes and the entire conjunctiva are re- moved, and the palpebral fissure is closed with sutures, all but one-quarter for the escape of the iodoform tampon with which the cavity is filled, and which, after a few days, can be replaced by a short drainage tube. A light- pressure bandage is then applied, and if no infection takes I g I / M OPERATIONS ON LWS ÄND CONJUNCTIVAL SAC. 295 place, complete healing occurs within one to two weeks, although the united lids become somewhat retracted, but only form a shallow depression. If one eyelid has been sacrificed, the remaining one is utilized in the manner de- scribed above to cover the cavity with a skin flap. It has also been advised to line the entire cavity with skin grafts, after the Thiersch method, after exenteration of the orbit without sacrificing the lids. C. OPERATIONS ON THE LIDS AND IN THE CONJUNCTIVAL SAC. I. OPERATION FOR PTOSIS. Ptosis may be congenital (usually bilateral) or acquired, and in the latter case it may be unilateral or bilateral, from paralysis of the nerves (oculomotor or sympathetic), or from muscular anomalies from disease or after an injury. The operative procedures vary according to the cause and character of the ptosis. If, as is often the case in the congenital form, the levator is practically inactive or en- tirely absent, either functionally or structurally, an effort must be made to secure elevation of the lid through other muscles, either of the occipitofrontalis or the superior rec- tus of the eyeball. People with ptosis, as a rule, use the frontal muscle of their own accord for drawing the lid upward, and therefore present the characteristic deep wrinkles in the brow (see my Atlas on External Diseases of the Eye, Plate 9). If the ptosis is very great, such patients also find themselves obliged to throw the head backward, so as to bring the pupil into the palpebral fis- sure. To determine what part in the elevation of the eye is played by the frontal muscle in a patient of this kind, pressure should be made with the flat of the hand on the forehead, which causes him to close the eyes. He is then requested to open the eyes wide and look straight ahead or slightly upward. As the action of the frontal muscle 296 OPERATIONS ON THE EYE. is then excluded by the operator's hand, any elevation of the lid that takes place must be effected by the levator. Fig. 118.— This is the same patient as the one shown in Plate 12. The large wound cavity remaining after the operation is here seen to be covered with pedunculated flaps taken from the forehead, while the wound in the forehead has been covered with flaps, after the method of Thiersch. The operation was performed by Krönlein. This picture was taken eight weeks after the operation. There are a number of operations having for their object to increase the elevation of the lid in ptosis by means of the frontal muscle, chiefly bv means of cicatricial bands OPERATIONS ON LIDS AND CONJUNCTIVAL SAC 297 attaching the upper border of the lid to the region of the eyebrow. Among these operations are : 1. Pagenstecher's Ptosis Operation. — This is per- formed with either one or two sutures, each of which is armed with two needles. One needle is introduced under the skin of the upper lid, at a point 1 to 2 mm. from the palpebral margin, and running parallel with it ; it is then reinserted exactly at the point of exit, and carried upward between the tarsus and the skin of the lid and brought out above the eyebrow (Plate 13, Fig. 1). The second needle is then introduced at the same point as the first, and also carried upward and brought out alongside of the suture of the other needle, above the eyebrow — after which the two sutures are tied. The suture is therefore entirely subcutaneous, and, if desired, a second one may be intro- duced. The sutures are allowed to remain in place for a variable length of time, and may be gradually pulled out and retied until they cut through the tissue, thus increasing the scar-formation. 2. de Wecker' s Operation. — de Wecker combined the old ptosis operation by von Gräfe (excision of a semi- lunar piece of skin with the underlying orbicularis muscle from the upper lid) with Pagenstecher' s suture. Hence, by mentally supplying this excision, Plate 13, Fig. 1 may be taken as an illustration of de Wecker' s operation. The object in excising the orbicularis muscle in von Gräfe's and de Wecker' s operation is to weaken the antag- onist of the levator. In cases in which the upper lid is thickened after trauma, inflammation, etc., excision of the skin also has the advantage of diminishing the weight of the lid and thus making it easier for the frontal muscle to elevate the lid, because it is less apt to elevate only the yielding skin instead of the lid itself. 3. Dransart has advised an operation similar to that of Pagenstecher's, except that his suture does not extend as far as the edge of the lid, but only as far as the upper border of the tarsus. He also brings his three sutures, each of which is armed with two needles, out above the 298 OPERATIONS ON THE EYE. Figs. 119-124. — Instruments for operations on the lid : Fig. 119.— Beer's knife. Fig. 120. — Knapp' s lid clamp. Fig. 121. — Jäger's horn plate. Fig. 122. — Desmarres' clamp. Fig. 123.— Wilder' s double knife. Fig. 124.— Snellen's lid clamp. eyebrow and ties them there. The short horizontal por- tion of the suture within the lid passes through the upper part of the tarsus (instead of through the skin of the pal- pebral margin, as in Pagenstecher's operation). By drawing the sutures more or less tightly the effect can be increased or diminished at will. 4. The operation of Hess is a marked improvement on that of Dransart. The eyebrow having been shaved, an incision is made running the entire length of the brow through the skin and the subcutaneous tissue. Through this incision the skin of the eyelid is dissected away from the subjacent layer of orbicularis muscle with a scalpel. After the hemorrhage, which is usually not marked, has been controlled, three sutures with two needles each are introduced from without inward through the upper por- tion of the dissected skin of the lid, so that when the sutures are drawn tight they form a fold in the skin, resembling as nearly as possible a corresponding fold in the normal eye. The sutures are carried upward under- neath the skin, somewhat as shown in Plate 13, Fig. 1, and the needles are brought out above the incision ; that is, at about the same point as in Pagenstecher' s operation. There they are tied, and then allowed to remain in place for from a week to ten days. If necessary, they may be tightened from time to time. The wound in the eyebrow is closed with a continuous suture. The important feat- ure of the operation is the formation of an extensive wound surface, the cicatrization of which permanently fixes the artificial fold in the upper lid. Another feature is that the sutures are carried upward, bringing the upper dome of the fold, which also belongs to the wound sur- " 119 300 OPERATIONS ON THE EYE. Plate 13. Fig. 1. — Pagenstecher' s ptosis operation in a young girl with congeni- tal ptosis. Fig. 2. — Gaillard's suture in an old man with spastic entropion. face, into intimate union with the lower extremities of the muscle bundles of the frontal muscle, and thus enabling the latter to transfer much of its action to the lid. 5. In Panas' operation the lid is fastened to the frontal muscle by forming a skin flap about 8 mm. wide and 5 to 6 mm. high in the lid, undermining it carefully and directing it upward. This flap is then drawn up under the skin covering the region of the eyebrows. For this purpose a horizontal incision 3 mm. long is made immediately above the eyebrow and parallel with it ; through this incision the skin between the eyebrow and eyelid is undermined, so that the lid flap can be drawn under this bridge of skin with sutures and fastened in place. The operation is very effective, but leaves unsightly scars in the upper portion of the lid. 6. Motais* Operation. — Instead of the frontal mus- cle, the rectus superior may also be utilized to assist in the elevation of the upper lid. This very useful and original operation of Motais is particularly adapted to cases of ptosis (especially bilateral cases), in which the levator muscle is entirely wanting. To secure good access to the operative field, the eye is first rotated down- ward with the single or double hooks, and the upper lid, after being everted, is drawn upward (Fig. 125). Liga- tures may be used instead of hooks. A horizontal inci- sion is then made in the bulbar conjunctiva and in Tenon's capsule, and the tendon of the superior rectus searched for. A tongue is then excised from the middle of the tendon, running as far as the insertion. A suture with two needles is passed through this tongue (Fig. 126), which is then, by means of this suture, inserted between the tarsus and the skin of the upper lid. For that pur- pose an opening is made with the scissors in the conjunc- er* '*x8jhj OPERATIONS ON LIDS AND CONJUNCTIVAL SAC. 301 Fig. 125. Fig. 127. Fig. 126. Fig. 128. Figs. 125-128.— Motais' ptosis operation (see text). tiva, and in the levator tendon at the posterior extremity of the inverted lid ; that is, at the upper border of the tarsus (Fig. 127). Through this opening a pouch is 302 OPERATIONS ON THE EYE. made between the tarsus and the orbicularis muscle, extending to within 2 mm. of the edge of the lid, into which the suture with the two needles, and bringing with it the tongue-like piece of tendon from the superior rectus, is introduced (Fig. 128). The two needles are then brought out through the tarsus and the skin, at a distance of 4 mm. from one another, and the sutures tied on the outer side of the lid. Thus the tongue of tendon lies on the outer side of the upper tarsus. Postoperative depression of the eyeball, with corresponding vertical diplopia, which sometimes follows the operation, has always disappeared after a period varying from two weeks to five months at the latest in all the operations of this kind that have so far been reported. Among the modifications of Motais' operation (for it also has already been modified) I may name that of Cannas, who stitches the tendon of the levator to the belly of the superior rectus muscle. A vertical inci sion extending over the entire lid is made for the purpose of finding the tendon of the levator palpebrarum superior ; this is dissected away from the tarsus for a distance of 5 to 6 mm. ; and at the same distance from the tarsus a catgut suture is passed through the tendon and the latter divided above the suture. The superior rectus is then exposed, and the peripheral ends of the levator approximated to the rectus by means of the catgut suture. When the function of the levator is impaired without being entirely deficient, a very different method may be pursued. This is the case in many congenital or acquired forms of moderately severe ptosis with considerable cos- metic or functional disturbance. In such cases the muscle or the tendon may be shortened or the insertion may be placed more deeply ; in other words, a kind of advance- ment may be made, a procedure which is quite out of the question when the muscle is entirely paralyzed or defi- cient. Among the many procedures of this kind the fol- lowing may be mentioned : 7. Ptosis Operation of Eversbusch. — The patient having been anesthetized, Snellen's lid clamp (Fig. 124) is applied, pushed well up behind the affected lid. Before the clamp is closed the skin of the lid should be drawn OPERATIONS ON LIDS AND CONJUNCTIVAL SAC, 303 down as much as possible toward the palpebral margin, so that after the screw has been closed the prolongation of the lid (transitional fold and skin beneath the eyebrow) may be caught in the instrument. Midway between the edge of the lid and the eyebrow an incision is now made between the skin and the orbicularis layer, parallel to the palpebral margin ; the skin with the subjacent muscle is then dissected away upward and downward to a distance of 4 mm. both ways, and loosened from its foundation, so that the upper transitional fold and the insertion of the levator at the tarsal plate of the lid can be exposed. The levator tendon is then drawn down by means of three vertical double sutures, or folded, so to -peak. At the center of the tendon, above its insertion in the tarsus, a suture witli two needles is inserted horizontally across, so that the points of entrance and exit through the tendon are about 2.5 mm. apart. Two needles are then carried outward on the tarsus — i. e., between the tarsus and the orbicularis ; brought out at the free border of the lids, also at a distance of about 2.5 mm., and tied over a glass bead in order to prevent them from cutting into the tis- sues. The two other sutures are introduced in the same way to the right and to the left of the central suture, in the temporal and nasal portions of the levator tendon, and carried downward, so that the tendon is drawn forward and outward by three separate loops. The skin wound is then closed, and a double bandage must be worn for several days. Later, Eversbusch modified the operation in cases of paretic or paralytic ptosis by the addition of partial re- section of the adjoining orbicularis muscle, after drawing the levator tendon to the upper edge of the tarsus. The advancing sutures were carried through the skin, frontal muscle, levator tendon, superior tarso-orbital fascia, orbic- ularis muscle, and the skin of the lid, and tied outside on the skin, over glass beads. 8. Snellen shortens the levator muscles by excising a horizontal oval piece. He makes a skin incision over the entire breadth of the lid, making it coincide as nearly as 304 OPERATIONS ON THE EYE. possible with a fold in the skin. The orbicularis is divided and drawn apart. A little above the upper edge of the tarsus the orbitotarsal fascia is incised. The globe mean- while is protected by a Jäger plate; the eyelid is drawn well downward, and from 2 to 5 curved needles with sutures are introduced in a fan-shaped arrangement through the levator muscle and tendon in the direction from muscle to tarsus ; and on the needles an oval piece, with the long axis running transversely, is excised. The needles are then drawn through and the sutures tied. Later, Snellen merely introduced the sutures and tied them without excis- ing the muscle and tendon. In mild cases he thinks the suture alone, without any skin wound, is sufficient. Both ends of the doubly armed suture are passed through the thickness of the lid, beginning at the fornix of the con- junctiva, one end as far back as possible through the conjunctiva and the muscle, and the other end through the broad edge of the tarsus; while the points of exit on the outside of the lid are brought close together and the sutures tied over beads. 9. Two other methods of shortening the levator or advancing it were suggested by H. Wolff. By making a careful anatomic investigation of the insertion of the levator in the tarsus he discovered that the upper part of the tendon is inserted in the anterior surface of the tarsus, about midway between the upper and lower margins, along a line of insertion running horizon- tally and approximately parallel to the free border of the lid. This line of insertion is about 5 mm. distant from the free border of the lids at every point. The tendon is as strong and firm as that of one of the recti. The surface of the tendon gives rise to numerous connective- tissue plates running outward and forward between the bundles of orbic- ularis muscle (Schwalbe) and ultimately inserted into the skin. The upper border of the tarsus also gives insertion to the superior palpebral muscle of Heinrich Müller, which in an anatomic sense is also to be regarded as one of the tendons of the levator. This insertion line on the tarsus, which Wolff discovered, makes it possible to use a shortening operation on the tendon like that performed by Schweigger on the recti muscles — i. e., leaving the normal insertion and advancing the tendon by means of securely holding sutures. — Elschnig, however, whose procedure will be described later, denies the existence of this insertion as described by Wolff, on the strength of a great many anatomic preparations. OPERATIONS ON LIDS AND CONJUNCTIVAL SAC. 305 In one method Wolff exposes the levator tendon dis- covered by him in front of the upper portion of the tarsus, to a breadth (horizontally) of about 1 cm., by mean- of the two strabismus hooks, and shortens the tendon by re- section in the same way as in Schweigger's operation for strabismus (p. 258). In his second method Wolff, after everting the lid twice, goes in after the muscle from the conjunctival side by dividing the conjunctiva horizontally. Fig. 129.— Lapersonne's ptosis operation. The intermediate isolated portion of the muscle is also seized with two strabismus hooks of a measuring spatula and secured in the same way with catgut sutures, after which it is resected as in the above-mentioned procedures. Later, Wolff added a skin incision for the purpose of draining the wound and preventing swelling. 10. Recently, I^apersonne advised the following oper- ation (see Fig. 129) : Incision through the skin and 20 306 OPERATIONS ON THE EYE. orbicularis, 4 to 5 mm. above the edge of the lid, exposing the tendon of the levator ; two vertical incisions as far as the conjunctiva, to permit the introduction of a strabis- mus hook ; introduction of sutures armed with two needles, one in the nasal and the other in the temporal portion of the tendon. After the tendon has thus been secured it is divided below the suture and, if necessary, a piece may be excised. The sutures are then passed through the tarsus, at a distance of 2 to 3 mm. toward the edge of the lid, and each suture is tied. In most cases it is better to excise a section from the skin of the lid as well as from the orbicularis. The skin wound is then closed. 11. Elschnig, in his operation for advancement of the levator to correct cases of incomplete ptosis, adopts yet another method : Skin incision parallel to the free edge of the lid and 3 to 4 mm. above it along the entire extent of the eyelid. The upper part of the skin of the lid is then dissected away in such a way that the greater part of the orbicularis remains bound to it, and is then drawn upward, whereby the lower half of the tarso-orbital fascia is exposed. The lid having been well drawn down to render the fascia tense, the latter is then incised about 10 mm. above the palpable convex border of the tarsus along its entire extent, in a line parallel to the edge of the lid. Immediately underneath the tarso-orbital fascia is the thin layer of the levator, which is exposed by gently pushing back the fascia. The levator is now seized at a distance of from 5 to 10 mm. above the convex border of the tarsus with a loop running perpendicularly to the axis of the fibers, and divided immediately below for a distance of from 3 to 4 mm., after which the division of the muscular layer along the entire extent of the lid is completed with scissors in a line parallel to the edge of the palpebral margin. The peripheral portion of the divided tarso-orbital fascia is then undermined with scissors as far as the middle of the tarsus, or, rather, to the lower edge of the skin wound, so as to form a pocket, and entirely isolated OPERATIONS ON LIDS AND CONJUNCTIVAL SAC 307 from the surface of the tarsus, so that the cartilage can be exposed by drawing up the bridge of fascia, which is only fixed to the two sides of the lid. The advancement of the muscular layer is effected by seizing the free proximal border with three doubly armed sutures, passing each suture through the bridge of fascia in a direction per- pendicular to the edge of the lid, then introducing each needle vertically through the tarsus and conjunctiva along the lower edge of the skin wound and bringing it out in the same way 2 mm. above the free edge of the lid — i. e., about 2 mm. from the line of the lashes, through the con- junctiva, tarsus, and skin, or, in other words, through the entire thickness of the lid from behind forward. Great care must be exercised to see that all the sutures are car- ried vertically through the lid. Each pair of sutures is passed through the lid, in the manner described, at a dis- tance of about 3 mm. from the next, so as to draw the muscular layer down to the middle of the tarsus. The tarso-orbital fascia is then united again with two catgut sutures (it is best to introduce these sutures at the very beginning, when the fascia is divided), and finally, after the skin incision has been closed, the muscle sutures are also tied over sterile pledgets of cotton. Instead of excising a piece from the tendon, some operators excise from the tarsus. The first of these was Boucheron, who excised a strip of tarsus along with the orbicularis, cutting in through the conjunctiva in order to avoid any scar in the skin. Similar procedures are recom- mended by Nicati, Heisrath, and Gillet de Grandmont. Later, Gruening again discovered this method of excising the tarsus and practised it to some extent. Marple had very good results with it in cases of traumatic ptosis. 12. Gillet de Grandmont, after applying a Snellen's clamp, incises the skin along a line parallel to the edge of the lid, 3 to 4 mm. away from it, making an incision about 2 to 5 cm. in length. The tarsus is thus completely ex- posed, and from it he excises a crescent-shaped piece, the lower border of which is 2 cm. long and runs parallel to 308 OPERATIONS ON THE EYE. the edge of the lids, at a distance of 2 to 4 mm. from the same, while the upper curved incision is placed as far away from the lower incision as is necessary for the proper elevation of the lid. The conjunctiva is excised along with it. The edges of the tarsus are then united with three fine catgut sutures. It is not necessary to suture the skin. Finally, it may be mentioned that there are cases of traumatic ptosis in which the tendon of the levator pal- pebrarum superior is torn and turned away from the tarsus and must be picked up and reunited to the tarsus with sutures. Green, in 1871, adopted this procedure with good success in a case in which complete ptosis had been produced by a blow from a cow's horn, the levator tendon having been completely torn away. In making a choice between the various methods in an operation for ptosis, it must always be borne in mind that closure of the lid must not be rendered impossible. It is needless to say, also, that the operation selected must be adapted to the particular form of ptosis in each case. When the levator is completely paralyzed or absent, the only operation to be considered is one in which the frontal or superior rectus muscle is utilized. On the other hand, if the levator is only weakened, advancement or shortening of the tendon or of the tarsus is a perfectly proper operation. If the lid is lengthened and the tissues are thick, excision is especially indicated for the purpose of reducing the size and weight. II. OPERATIONS FOR ENTROPION. Spastic entropion is usually temporary and confined to the lower lid in old persons, especially after an oc- clusive bandage has been applied (after an operation or for keratitis). Aside from flaccidity of the skin and de- pression of the globe, the chief predisposing factor is blepharophimosis (Plate 4, Fig. 17), and the condition is best corrected by means of a Gaillard suture. OPERATIONS FOR ENTROPION. 309 In some cases the condition, which is especially apt to be unpleasant in patients who have been operated upon for cataract, can be controlled by applying strips of ad- hesive plaster in such a way as to draw the skin of the lower lid away from the palpebral margin and toward the cheek : 1. By means of Gaillard's suture the skin of the lid is temporarily shortened, a fold being caught in one or two sutures. With the thumb and index finger of the left hand a horizontal fold of the skin of the lower lid is picked up and its base transfixed with the two needles of a doubly armed suture, entering about 3 mm. from the palpebral margin and emerging about 15 mm. below it. The second needle is introduced in the same way as the first, at a distance of 3 mm. from it, and carried down- ward. The sutures are then tied over a small piece of rubber tube or cotton pledget (Plate 13, Fig. 2). If de- sired, a second suture can be introduced in the same way. The sutures are removed after two or three days. The fold smoothes out again later, but in the meantime the irritation, which was responsible for the blepharospasm, as a rule, disappears. If the entropion recurs the skin may be permanently shortened by excising a piece, the shape of a myrtle leaf, from the lower lid, quite near the edge, along with the subjacent orbicularis muscle, and closing the wound with a few sutures. A still better operation in these cases is that devised by Hotz (see p. 311). The condition known as partial trichiasis, in w T hich a limited number of cilia are turned inward and rub against the globe, is usually caused by small scars remaining after hordeolum, diphtheria, burns, or operations on the inner side of the lid. 2. The best treatment consists in destroying the roots of the cilia by electrolysis, as extraction of the mis- placed cilia brings but temporary relief from the condi- tion, which is often followed by corneal disease, or, at least, corneal irritation, for the cilia grow again in a short 310 OPERATIONS ON THE EYE. time. Electrolysis is effected by means of a small sharp needle fixed in a holder, through which an electric current of about 2 milliamperes from a constant battery of the necessary number of elements is passed into the needle. The latter forms the negative pole ; while the positive pole, an ordinary flat electrode, after having been well moistened, is applied to the patient's temple or placed in his hand. It is well to inject a little cocain solution sub- cutaneously at the affected area of the palpebral margin, ^ vuuUuJj^ ft, Fig. 130.— Trichiasis operation by Spencer Watson. because, after the needle has been introduced into the follicle close to the eyelash, the closure of the electric current causes rather severe pain. After from five to ten seconds, during which small bubbles of hydrogen emerge from the tissue around the needle, the follicle will be destroyed, as appears from the fact that the eyelash either follows the needle as it is withdrawn or is removed by a very slight pull with the forceps; if it has not been destroyed the procedure must be repeated. OPERATIONS FOR ENTROPION. 311 When the trichiasis extends over a larger area and in- cludes, say, the outer or inner half of the palpebral mar- gin, Spencer Watson's operation is indicated. 8. Spencer Watson's operation consists in trans- plantation of the misplaced cilia by displacing a flap (Fig. 130). An assistant having introduced a horn plate, the entire portion of the skin affected with entropion is loos- ened. With the thumb of the left hand the skin of the upper lid is drawn slightly upward, and the eyelid is then divided into a main anterior layer bearing the cilia, and a posterior layer composed of tarsus and conjunctiva, mak- ing the division as deep as may be required for the lower flap, a. This part of the operation is best performed with an iridectomy knife or a Beer's cataract knife (Fig. 119). Above this the main flap, b, is formed, and then the two are made to change places, so that a lies above, and the cilia are drawn away from the globe. Complete (general) trichiasis, or extensive inward dis- placement of the cilia along the entire palpebral margin, requires an operation by which the position of the entire ciliary soil is altered. One of the best of the numerous operations that have been recommended for this purpose is known as 4. Hots's Operation for Entropion. — The main objects of this operation are to draw away the skin from the cilia with the edge of the lid and fasten the latter to the tarsus and tarso-orbital fascia. It can be performed both on the upper and on the lower lid. In the former case the lid is drawn down over a horn plate, which may have to be dispensed with, and a horizontal incision is carried right across the lid. This incision should follow the curved line of the upper edge of the tarsus, the breadth of which is subject to individual variations. When the eye is closed the edge of the tarsus is readily recognized by a delicate wrinkle in the skin, beginning about 2 mm. above the inner canthus and rising gently to the middle of the lid, and from that point falling gradually to the external can- thus. As it is difficult, owing to the extreme looseness of 312 OPERATIONS ON THE EYE. the skin of the upper lid, to follow this curve with a knife, it is better to draw the lid well down in the manner described, as it has the effect of converting the curved into a straight line, which can easily be followed with the knife on the tense lid. This incision is carried from a point 2 mm. above the inner angle of the lid to a point 2 mm. above the outer angle. As soon as the skin has been divided the upper edge of the wound retracts (Fig. 131). The orbicularis is now cautiously divided exactly along \^ Fig. 131.— Hotz's entropion operation. the lower edge of the wound until the yellowish-red color of the tarsus becomes apparent. The upper edge of the tarsus is readily recognized by the marked contrast between the yellowish tendinous color and the grayish-red color which shines through the tarso-orbital fascia at this point. The latter must not be wounded during this operation. After the palpebral portion of the orbicularis has been separated in this way from the orbital portion throughout the entire width of the lid, and has been loosened from the tarsus along with the skin, the operator lets go the lid, OPERATIONS FOR ENTROPION. 313 whereupon the wound at once ceases to gape and the in- cision exactly coincides with the curve, with the above- mentioned wrinkle in the skin. The assistant now turns the skin slightly backward at the center of the lower edge of the wound, so as to bring the orbicularis into view. The operator then seizes the muscle fibers nearest the edge of the skin with a delicate pair of forceps, and dissects away a strip about 3 mm. broad from the center of the edge of the skin to each angle. The edge of the skin and the upper portion of the tarsus must be absolutely free from muscle fibers. In applying the sutures the needle is introduced first through the lower lip of the wound, 2 mm. from the edge, while the assistant pushes the upper lip of the wound upward with his index finger and the operator draws the lower one down. The needle is introduced 2 mm. above the upper edge of the tarsus, through the aponeurosis, passes upward along the tarsus, and made to emerge about 2 cm. above it through the tarso-orbital fascia. Finally, it is introduced through the corresponding point on the upper edge of the skin, care being taken that the sutures contain nothing but skin, and avoids the orbicularis fibers. Three or four such sutures are required, and care must be exer- cised to see that the skin edges are accurately approxi- mated. The eye is dressed with iodoform gauze and cotton, and the bandage may be dispensed with after from two to three days, when the sutures may also be removed. The same procedure is recommended for the lower lid. When the skin is long and loose, especially in old people, the operator must be careful not to make the skin incision too far from the edge of the lid, so as to make sure that the skin is sufficiently put on the stretch on the tarsus. At the same time it may be advisable to excise a narrow portion of skin. Should this operation prove not quite adequate in very marked cases, other auxiliary measures may be resorted to, as, for example, the secondary excision of a narrow 314 OPERATIONS ON THE EYE. horizontal strip of skin near the edge of the lid. Or, when the inward inclination of the cilia is extreme, the condition may be corrected by splitting the free edge of the lid along its entire extent and separating the cilia-bear- ing portion from the tarsus, and then filling the cleft with a piece of skin from 2 to 3 mm. wide, taken from some hairless portion of the head where the skin is thin, prefer- ably behind the ear, with Wilder's double knife (Fig. 123). I have had occasion to convince myself that this method of transplantation is very generally successful and pro- duces a widening of the palpebral edge, as the transplanted strip of skin fits in between the cilia and the globe. It is possible to combine with Hotz's operation excision of a narrow piece of the tarsus running parallel to the edge of the lid, in case it seems desirable to straighten the cartilage. Wilder's knife is convenient for this excision also. Hotz's operation had a predecessor in the form of a sim- ilar procedure devised by Anagnostakis (1857), which, however, did not attract much attention. Anagnostakis placed the incision (in the upper lid) 3 mm. above and running parallel with the edge of the lid (that is to say, much nearer than Hotz's incision), removed the muscle fibers covering the upper third of the tarsus with forceps and scissors, and then secured the lower lip of the wound to the upper edge of the tarsus by means of sutures, which were allowed to slough out. This method of allowing the sutures to come away by suppuration is less commendable than the more accurate suturing advised by Hotz, followed by removal of the sutures after two or three days, as dis- figuring vertical scars are produced by the process of sup- puration. 5. Entropion Operation with Advancement of the levator Tendon. — After Pagenstecher began to use Hotz's operation he soon expanded it into his own entropion operation with advancement of the levator tendon. In this operation the surgeon stands at the patient's OPERATIONS FOR ENTROPION. 315 head and finds the upper edge of the tarsus with the index finger of his left hand, which is an easy matter in most cases of entropion, because the tarsus is always more or less thickened. A short skin incision is made about 1.5 mm. below the upper edge of the tarsus as a land- mark. The lid clamp is then introduced, taking care to clamp the lid straight, and a horizontal incision is made in the skin parallel to the edge of the palpebral margin at the point previously marked. This incision penetrates as far as the tarsus at the center, but on the two sides divides only the skin and extends exactly as far as the arms of the clamp. While an assistant depresses the lower lip of the incision downward at the center of the lid with a small pair of forceps, which he keeps closed, the operator, using the tip of the left index finger, pushes the upper lip of the wound upward at a corresponding point, so that the yellowish, tense tarsal tissue is brought into view. Next the upper half of the tarsus, and particularly the tarso-orbital fascia, must be exposed. The assistant pushes the bundles of orbicularis fibers downward while the operator pushes them upward, and the latter dissects away all the bundles lying above the incision — L e., the outermost curved fibers of the palpebral portion and the orbital portion of the orbicularis muscle — pushes them up with the tip of the index finger, and thus gradually cleanses the upper tarsus throughout its entire extent, and exposes the tarso-orbital fascia, the white color of which contrasts sharply with the yellowish tint of the tarsus, for a dis- tance of 3 to 4 mm. above the center of the upper edge of the tarsus. Next comes the most difficult part of the operation, namely, the introduction of the sutures. First a moder- ately curved needle with a medium-sized silk suture is carried through the skin and muscular tissue about 1 mm. above the edge of the lid and brought out on the inner surface of the lower edge of the wound, which has been picked up with the forceps. While the assistant draws the upper lip of the wound as far up as possible, 316 OPERATIONS ON THE EYE. the operator, with a delicate rat-tooth forceps, takes firm hold of the tarso-orbital fascia about 2 to 3 mm. above the upper edge of the tarsus, and at the same time raises a fold of the tendon of the levator palpebrarum, which lies immediately underneath. The needle is then passed through the upper edge of the tarsus itself and the entire thickness of the fold of the levator tendon as it is vigor- ously drawn up, after which the needle is brought out through the upper edge of the skin wound. Two other sutures are then introduced in the same way, one on each side of the first, and, first, the central suture, and imme- diately afterward, the two lateral ones are tied as tightly as possible and the lid forceps removed. Double band- age ; rest in bed ; first change of dressing on the third day. On the fifth or sixth day the sutures are removed and no more dressing is applied. This method, therefore, differs from that devised by Hotz in that no muscle bundles are removed, and the same cicatricial union is achieved between the orbicularis fibers on the one hand, and the upper edge of the tarsus with the fascia and the levator tendon on the other hand, the tendon being advanced and the direction of its action changed. In other operative methods entropion is combated by altering the shape of the tarsus — tarsoplastic operation. This is effected by dividing the cartilage horizontally, or excising a horizontal wedge-shaped strip, thus causing outward rotation of the lower edge of the tarsus. Such an operation on the tarsus, however, is justified only in those cases in which, usually owing to trachoma, there is already such extensive disease of the tarsus that the Meibomian glands have all been destroyed, as the latter would otherwise be greatly injured by the procedure. The operation is especially adapted to the upper lid. 6. Streatfield's entropion operation includes exci- sion of a prism-shaped piece from the cartilage, and should be mentioned first among these methods (1858). To control hemorrhage and keep the parts in the proper OPERATIONS FOR ENTROPION. 317 position he used a Desmarres' clamp (Fig. 122), and car- ried an incision 2 to 3 mm. above the cilia along the pal- pebral margin oVer the entire width of the eyelid as far as the cartilage, without injuring the follicles. He then made a second incision parallel to the first and 3 mm. higher, which, by tracing a slight curve, was made to unite with the first at the temporal and nasal extremities. The two incisions are then continued into the tarsus until they meet, and in this way a long prismatic or wedge-shaped strip is excised, which is then dissected out along with the superimposed muscle and cutaneous layer with scissors and scalpel. In certain cases of simple entropion the knife must be handled very carefully, so as not to cut through the tarsus and the ducts of the Meibomian glands. Although this was laid down as a necessary condition of the operation, it is a condition that is not easily fulfilled. Xo sutures were introduced after the operation. 7. Snellen's entropion operation with excision of the tarsus was developed as a modification of Streatfield's. Snellen used his own lid clamp (Fig. 124), made an incision extending over the entire breadth of the eyelid, between 2 and 3 mm. above the cilia, and with the scissors excised the underlying muscle bundles. The wedge-shaped strip of tarsus was then excised by means of two oblique inci- sions extending almost to the posterior surface of the tarsus, and the wound was finally closed with three doubly armed silver sutures (sterilized silk is just as good). One needle is introduced through the upper portion of the tarsus, the second 3 mm. horizontally alongside of it, also through the tarsus, after which the needles are carried from the lower lip of the wound underneath the skin at the palpe- bral margin and brought out immediately above the cilia. Here the corresponding sutures are securely tied over a glass bead to prevent their cutting into the tissue. The skin incision requires no sutures. 8. Hots himself, for certain cases of trichiasis of the upper lid, supplemented his above-described operation with a tarsus excision. This he did in cases in which 318 OPERATIONS ON THE EYE. the free edge of the lid is rotated inward, owing to con- traction of the conjunctiva and posterior portion of the tarsus, and lie in the same plane as the conjunctiva of the lid, so that the conjunctiva appeared to reach to the eye- lashes. The inward rotation of the palpebral margin is accompanied by a similar inclination of the cilia toward the globe, with which they ultimately come in contact. In these cases Hotz restores the proper position of the palpebral margin by combining his above-described opera- tion with excision of an oblique wedge near the edge of the lid. The first, lower, incision is carried vertically through the tarsus immediately above the follicles of the cilia ; the second, above, running obliquely outward. The incisions meet in the posterior portion of the tarsus, about 3 mm. above the edge, in a line corresponding to the posterior edge of the inverted palpebral margin. After removal of the strip of tarsus the anterior edge of the lid may return to its normal position and the cilia resume their normal position perpendicular to the globe. After the hemorrhage has been controlled, 3 or 4 sutures are carried through the lower edge of the tarsus and ultimately through the upper edge of the skin wound. 9. Division of the tarsus after Panas is the method employed by the latter chiefly for cases of severe and obstinate trichiasis with entropion occurring in trachoma- tous subjects. He prefers Jäger's horn plate (Fig. 121), and makes his incision horizontally, 3 mm. above the row of cilia and extending over the entire lid to the tarsus. The latter is then completely exposed, both above and below, by dissecting away the orbicularis muscle with knife and forceps, but the cartilage is not excised. Below, the edge of the skin-muscle wound is undermined only as far as the cilia. If the tarsus is not abnormal it is allowed to remain intact ; but if it is bent and thickened the entire structure, including the conjunctiva (that is, as far as the horn plate), must be divided in a direction perpendicular to its surface (Fig. 132). The needles are so introduced as first to seize the aponeurosis and the upper edge of the OPERATIONS FOR ENTROPION. 319 tarsus ; they are then passed underneath the lower lip of the wound and brought out immediately behind the eilia. Although the upper lip of the skin wound is not included in the suture, the wound closes, nevertheless, and after the sutures have been tied they are not cut off, but are drawn together in a bundle and fastened to the forehead, above the eyebrows. The sutures are removed after three to four days, and an occlusive bandage is worn a few days longer. 10. The entropion operation devised by Pfals is related both to that of Snellen and that of Panas, and is Fig. 132.— Entropion operation by Panas. suitable for severe cases. The entire width of the lid is excised immediately above the lowest row of eyelashes, the edge of the knife being directed slightly upward and backward. By means of a second incision, running 3.5 mm. above and parallel to the first, a narrow flap of skin is outlined and then excised. The orbicularis may be excised in the entire operative field ; the orbicularis is then also excised in the entire extent of the wound, and the tarsus having thus been exposed, a wedge-shaped piece about 2 mm. wide is excised from the base, the rounded apex corresponding to the point of greatest curvature of the tarsus. The conjunctiva is then also excised in a horizontal 320 OPERATIONS ON THE EYE. line a distance of about 6 mm. along the middle of the flap, in order to increase the mobility of the palpebral margin. The needle is introduced from above through the skin and muscle, passes through the upper portion of the tarsus and the lower portion of the tarsus, and is brought out behind the last rows of eyelashes. Five sutures are used, which are also to be fastened to the fore- head. Snellen's suture is used for spastic entropion. The two needles of a doubly armed suture are brought out through the lid from the transitional fold, are then reintroduced through the point of exit, carried upward under the skin of the lid, brought out near the anterior palpebral margin and tied. Two or three such sutures are required. This procedure sometimes fails of any permanent effects, and is suitable only for the lower lid. Ablation of the ciliary border after Flarer and the improvement on the operation by Stellwag, who ablated the ciliary border and, after rotating it through 180 degrees, replaced it in the wound (plastic operation on the pal- pebral margin), are hardly as good as the above-described methods, and are certainly suitable only for the lower lid. Displacement of the ciliary border after Jasche- Arlt is performed as follows : An intermarginal incision is made and the cilia-bearing edge of the lid is undermined a distance of 4 to 5 mm. A crescen tic-shaped piece is then excised from the skin of the lid, which has the eifect of drawing the skin along with the cilia away from the palpebral margin and leaving the latter freely exposed for the formation of granulations ; or, according to Waldhauer, the palpebral margin is covered with the excised piece of skin (non-peclunculated transplantation). This operation is no better, and often does less good, than the above- mentioned procedures. It was first proposed by Aetius and Paul of .ZEgina. OPERATION FOR BLEPHAROPHIMOSIS. 321 III. OPERATION FOR BLEPHAROPHIMOSIS. Canthoplastic Operations. Entropion is not infrequently produced or favored by blepharophimosis (Plate 14, Fig. 1), which consists in a vertical fold of skin covering the external canthus and, therefore, apparently shortening the palpebral fissure ; although, when the fold is displaced toward the temple, the external canthus is seen to be intact (while ankylo- blepharon is caused by cohesion of the palpebral margins). Blepharophimosis is usually caused by shortening of the skin at the outer canthus in a horizontal direction, as in chronic conjunctivitis, the skin becoming excoriated from contact with the lacrimal fluid and other secretions, and ultimately undergoing contraction. The process is aggra- vated by periodic blepharophimosis and senility. Operation. — The anomaly is corrected by dividing the external canthus in a horizontal direction. The lids are first well separated and at the same time drawn ten.-e toward the nasal side, and the external canthus is divided horizontally with one snip of a heavy pair of scissors, after which the conjunctiva is stitched into the wound (Plate 14, Fig. 2), so as to cover it, as otherwise the edges of the wound would rapidly grow together again. The needle is inserted first into the conjunctiva. The first suture is placed in a horizontal direction, and the two others in a direction outward and upward and outward and downward through the skin and then tied, whereby the conjunctiva is drawn into the wound. A bandage should be worn for several days. Simple division of the external canthus without intro- ducing sutures — provisional canthoplastic operation — is done in cases of blepharospasm leading to entropion and in gonorrheal conjunctivitis of adults to diminish the press- ure exerted by the overstretched lids on the cornea ; also' in enucleation and exenteration of the orbit, as has been mentioned. 21 322 OPERATIONS ON THE EYE. Plate 14. Fig. 1. — Blepharophimosis in an old man : Vertical fold of skin in front of the outer canthus. Fig. 2. — Canthoplastic operation : Enlarging the outer canthus. IV. TARSORRHAPHY. The outer or inner canthus may be united with sutures for exactly the opposite purpose as that for which the operation just referred to is performed, namely, to shorten the palpebral fissure in a horizontal direction. Fig. 133.— a, Tarsorrhaphy after von Gräfe; b, tarsorrhaphy after Fuchs. This operation is indicated in ectropion and in lagoph- thalmos ; in the former for the purpose of raising the lid f i>erationslehre. 361 362 LITERATURE. 15. Marthen, Experimentelle Untersuchungen über Antisepsis bei Augenoperationen und die Bakteriologie des Konjunktival- sackes. Ebenda. 2. Bd. 1893. 16. Bach, lieber den Keimgehalt des Bindehautsackes, etc. A. f. O. 40. Bd. 3. 1894. 17. Helleberg, Zur Frage der bakterientötenden Wirkung der Tränen. Hygiea 1900 und Mitteilungen aus der Augenklinik zu Stock- hohn. 3. Heft. 1901. 18. Franke, Untersuchungen über die Desinfektion des Bindehaut- sackes etc. A. f. O. 39. 3. 1893. — — , Weitere Untersuchungen über Asepsis und Antisepsis in der Augenchirurgie. A. f. O. 43. 1. 1897. 19. Bach, Experimentelle Untersuchungen über die Infektionsgefahr penetrierender Bulbusverletzungen etc. A. f. A. 30. 1895. — — , Antisepsis oder Asepsis bei Bulbusoperationen? A. f. A. Bd. 33. 1896. 20. Dalen, Experimentelle Untersuchungen über die Desinfektion des Bindehautsackes. Mitteilungen aus der Augenklinik zu Stock- holm von Widmark. 1. Heft. 1898. 21. Haab, Bemerkungen zur Staaroperation. Beiträge z. Augenheilk. v. Deutschmann. 1. Bd. p. 252. 1891. 22. v. Pflugk, Ueber die Vorbereitung des Lidrandes und der Cilien für Bulbusoperationen. A. f. A. 45. Bd. p. 176. 1902. 23. Eversbusch, Ueber die Anwendung der Antimycotica in der Augenheilkunde. Zentralbl. f. A. 1890. p. 354. 24. Sidler-Huguenin, Ueber die Einwirkung der Sterilisationsver- fahren auf Kokainlösungen und über die beste Methode Cocain- und Atropinlösungen steril aufzubewahren. Korresp. ■ Bl. f. Schweiz. Aerzte. 1900. 25. Brunner, Konrad, Erfahrungen und Studien über Wundinfektion und Wundbehandlung. Frauenfeld. 1899. 26. Schirmer O., Ueber benigne postoperative Cvclitis auf infektiöser Basis. IX. Int. Ophthal. Kongress in Utrecht 1899. Bericht p. 402. 27. Gräfe, Alf. , Fortgesetzter Bericht über die mittelst antisept. Wund- behandlung erzielten Erfolge der Staaroperation. A. f. O. 35. 3. 1889. 28. Bunge, Ueber schädliche Wirkungen des Cocains auf die Horn- haut. Monbl. f. Augenheilk. 1885. p. 402. 29. Haab, Ueber intraoculare Desinfection. IX. Congres int. Utrecht 1899. Bericht p. 425. 30. Sidler-Huguenin, Herstellungsweise der Jodoformstäbchen und -Plättchen für die intraokuläre Desinfektion. Zeitschr. f. A. Bd. X. p. 108. 1903. 31. Haab, Weitere Mitteilungen über Panophthalmie-Bazillen. Fort- schritte der Medizin. Okt. 1891. 32. Silberschmidt und Baenziger, Zur Aetiologie der Panophthalmie nach Hackensplitterverletzungen. Bericht der Ophth. Ge- sellsch. Heidelberg. 1902. 33. Römer, Zur Frage der Jodoformwirkung bei intraocularen Infek LITERATURE. 363 tionen. Bericht der Ophthal. Gesellsch. Heidelberg. 1901. p. 209. 34. Foerster, R.. Künstliche Keifung des Staares. Bericht der Ophthal. Gesellseh. Heidelberg. 1881. 35. Fuchs, E., Ueber Eiythropsie. A. f. O. Bd. 42. 4. 207. 1896. 36. Pagenstecher Ad. H., Ueber Staaroperation mit besond. Berück- sichtigung der Xachstaaroperation. Ztschr. f. A. Bd. X., p. 206. 1903. 37. v. Gräfe, Nachträgliche Bemerkungen über die modifizierte Linear- extraktion. A. f. O. 12 Bd. 1. p. 161. 1866. 38. Czermak, Die Augenärztlichen Operationen p. 596. 1896. 39. Magnus, Zur histor. Kenntnis der Vorderkammer-Auswaschungen. A. f. O. Bd. 34. 2. p. 167. 1888. 40. M'Keown, A treatise on unripe cataract. London, 1898. 41. Lippincott, J. A., Routine Syringing Out of Cortical Matters in Cat- aract Extraction, as Illustrated by One Hundred Cases. Transact. Americ. Ophth. Soc. 1891*. 42. Röthlisberger, Ueber die Ausspühlungen der vorderen Augenkam- mer bei der Staarextraktion an der Basler ophth. Klinik. Diss. 1893. 43. Erb, Ein neues aseptisches Instrument zur Ausspühlung der vord. Kammer bei der Staarextraktion. Ztschr. f. A. Bd. 8. p. 303. 1902. 44. Elliot, R. H., M'Keown's Method of Irrigation in Cataract Opera- tion. The Indian Medical Gazette, Vol. 38. 1903. 45. Pope, T. H., On Cataract and its Extraction in the Government Ophthalmic Hospital, Madras. The Indian Medical Gazette. Vol. 36. 1901. 46. Pagenstecher H., Ueber Staarextraktionen mit und ohne Entfer- nung der Kapsel. A. f. O. 34. 2. p. 144. 1888. 47. Knapp, H. , Operations Usually Performed in Eye Surgery. System of Diseases of the Eye, by Xorris and Oliver. Vol. III. 1898. 48. Taylor, L. H., A Case of Acute Panophthalmitis following Discis- sion of the Capsule. Trans. American Ophth. Soc. 1903. 49. Kuhnt, L'eber Xachstaaroperation. Ztschr. f. A. 1. Bd. p. 151. 1899. 50. Axenfeld, Die Technik der optischen Iridektomie. Verhandlung. der Ophthalmolog. Gesellsch. in Heidelberg 1903, Monatsbl. f. A. 903. 11. 253. 51. Treacher Collins, On the Operative Treatment of Glaucoma. Ophth. Hosp. Rep. XIII. p, 166. 1891. 52. Priestley Smith, Glaucoma : Pathogenesis, Symptoms, Course, and Treatment. System of Diseases of the Eve, edited bv Xorris and Oliver, vol. III. p. 629. 1898. 53. Weber Ad., Die Ursache des Glaukoms. A. f. O. 23. 1. p. 1. 1877. 54. Deutschmann, Weitere Mitteilungen über mein Heilverfahren bei Xetzhautablösung etc. Beitr. z. Augenhlk. v. Deutschmann. 40. Heft. 1899 und Verhandl. der Ophthal. Gesellsch. in Heidelberg 1903. 55. Müller L., Ein neues Operationsverfahren zur Heilung der Xetz- 364 LITERATURE. hautabhebung. Münchener. Mediz. Wochenschr. 1903. p. 977. 56. Knapp H., Ueber einige neue namentl. plastische Konjunktival- operationen. A. f. O. 14. Bd. 1. p. 267. 1868. 57. McReynolds, The Nature and Treatment of Pterygia. Jour. Americ. Med. Assoc. Aug. 9, 1902 et Annals of O. 1902, p. 754. 58. Kulmt, Ueber die Verwendbarkeit der Bindehaut in der praktischen und operativen Augenheilkunde. Wiesbaden 1898. 59. Cofler, II tatuaggio della Cornea con speciale riguardo a quello variopinto ed a quello delle palpebre. Annali di Ottalm. 1902 p. 169. 60. de Wecker, Die Tättowirung als Ersatz der Prothese. Monatbl. f. A. 1902. I. p. 374. 61. Nieden, Ueber eine neue Tätowirmethode u. die Benutzung eines neuen Tätowirmaterials. Ber. d. Ophthal. Gesellsch. in 9 Heidelb. 1901. p. 249. 62. Weidmann, Ueber die Verletzungen des Auges durch Fremdkörper, Diss. Zürich. 1888. 63. Hirschberg, Die Magnetoperation in der Augenheilkunde, 2. Aufl. 1899. 64. Pooley, Der Nachweis und die Lokalisation von Stahl- und Eisen- partikeln im Auge durch die Indikationen der Magnetnadel. A. f. A. 10. Bd. p. 9 u p. 315. 1881. 65. Asmus, Das Sideroscop. A. f. O. 40. Bd. p. 280. 1894. u. A. f. A. 29. Bd. 1894. 06. , Meine Erfahrungen mit dem Sideroskop seit Einführung der elektrischen Strassenbahn in Düsseldorf. Monatbl. f. A. 1901 p. 423. 67. Knies, Extraktion eines nicht sichtbaren Fremdkörpers aus dem Auge mit Hülfe eines Elektromagneten. Monbl. f. A. Bd. 19. p. 30. 1881. 68. Haab, Die Verwendung sehr starker Magnete zur Entfernung von Eisensplittern aus dem Auge. Bericht der 22. Versamml. d. Ophthal. Gesellsch. in Heidelb. 1892, p. 163. 69. Grüning, Wounds and Injuries of the Eyeball, etc. System of Diseases of the Eye ed. b. Norris and Oliver, vol. Ill, p. 705. 70. Lang, W., A Note on the Use of Haab's Magnet. O. Hosp. Rep. Vol. XV., p. 296, 1903. 71. Haab, Ueber die Anwendung des grossen Magneten bei der Ausziehung von Eisensplittern aus dem Auge. Ztschr. f. A. VIII, p. 587. 1902. 72. Knapp, H, Die Entfernung von Fremdkörpern aus dem Innern des Auges. A. f. A. 8. p. 71, 1879. 73. Gayet, De la conduite ä tenir dans les cas de penetration dans la chambre anterieure de l'oeil de certains corps etrangers (Sta- cheln von Kastanienschalen). Arch. d'Ophtal. 19. p. 454. 1899. 74. Javal, Manuel du Strabisme. Paris, 1896. 75. Priestley Smith, On the Etiology and Educative Treatment of Con- vergent Strabismus. Bowman lecture. Trans, o. soc. unit, kingd. Vol. 18 p. 17. 1898. LITERATURE. 365 76. Worth Claude, Squint : Its Causes, Pathology, and Treatment. London, 1903. 77. Arlt, Handbuch der gesamten Augenheilkunde von Gräfe und Saemisch Bd. III. p. 398. 1874. 78. Snellen, Klin. Monbl. f. A. 1870, p. 26. 79. Knapp, H., Erzielung grösserer Wirkung bei der Schiel-operation. Monbl. f. A. 1865, p. 346. 80. Fröhlich, C, Ueber die Muskelvorlagerung als Schiel-operation. Monbl. f. A. 1900, p. 369. 81. de Wecker, De 1' avancement musculaire au rnoyen du double fil. Ann. d'Ocul. Bd. 70. 1873. p. 225. 82. Landolt, La technique de Pavancement musculaire. Arch. d'Opht. Bd. 21. p. 369. 1901. 83. Prince A. EL, The Pulley Method of Advancing the Rectus with Indications for its Employment. Ophthalmic Review, 1887, and St. Louis Med. and Surg. Jour. 1888. 84. Verhoeff F. H., A Secure Stitch for Advancement Operations. The Ophthal. Record, 1901. 85. de Wecker, Sur Population du strabisnie au moyen de Pavancement capsulaire. Ann d'ocul. T. 90 p. 188. 1883 u. Arch. d'Opht. T. 13. p. 1. 1893 86. Todd, A Secure Advancement Operation Performed with the Aid of a New Tendon Tucker. The Ophth. Record, Vol. XL, p. 73, 1902. 87. Brand, Ueber Muskel vorlagerung. A. f. A. 1902. 88. Schweigger, Die Erfolge der Schieloperation. A. f. A. 29. p. 165. 1894 89. Koster, Muskelverkürzung. Versamml. der Niederl. Ophthal. Gesellsch. Dec. 1901 und van der Hoeve, Beiträge zur Lehre vom Schielen. A. f. A. 46. p. 204. 1902. 90. Müller, L., Die Muskelausschneidung als Schieloperation. Monbl. f. A. 1893. p. 118. 91. Verhoeff F. H., Eine graduelle plastische Tenotomie. Monbl. f. A. Bd. 41. 1903. 92. Schweigger, Ueber Resektion der Sehnerven. A. f. A. 15. p. 50. 1885. 93. de Wecker, Le traitement de Pophthalmie sympathique. Annales d'Ocul. _ T. 104. p. 209. 1890. 94. Knapp, Exstirpation einer Schnervengeschwulst mit Erhaltung des Augapfels, Monatsbl. f. A. 1874. p. 439., sowie Operationslehre in Xorris und Oliver (1. cit). 95. Lagrange, De la conservation du globe de l'oeil dans l'extirpation des tumeurs du nerf optique. Congres francais de Chirurgie, Paris 1892. 96. Krönlein, Zur Pathologie und operativen Behandlung der Der- moidcysten der Orbita. 1. Das Zwerchsackdermoid der Orbita. 2. Die osteoplastische Resektion der äusseren Orbitalwand als Vorakt für die Exstirpation von tiefsitzenden latenten Orbital- tumoren, insbesondere von Orbitalclermoiden. Beitr. z. klin. Chirurgie herausg. von v. Bruns Bd. 4 p. 149. 1889. 366 LITERATURE. 97. Schuchardt, Krönleins Operation, Osteom des Orbital daches. Berlin Hin. Woch. 1897 S. 594. 98. Torek. Krönleins Operation, Tumor der Tränendrüse, New Yorker Med. Monatsschrift 1902. p. 32. 99. Domela — Nieuwenhuis, Ueber die retrobulbäre Chirurgie der Orbita. Beitr. z. klin. Chirurgie von v. Bruns Bd. 27. 1900. 100. Parinaud et Roche, Angio-fibrome de l'orbite, »modification au procede de Krönlein. Ann. d'Ocul. Bd. 126 p. 241. 1901. 101. Rollet, Exophthalmie guerie par Orbitotomie malaire. Ann. d'Ocul. Bd. 126. p. 370. 1901. 102. Cahan, (Resektion des Orbitaldaches) Zentralbl. f. Chirurg. 1897. S. 737. 103. Franke, Eine neue Methode der osteoplastischen Freilegung der Orbita. Dtsche. Ztschrift f. Chirurg. Bd. 59. 1901 % 104. Gussenbauer, (Resektion der äusseren Orbitalwand). Wiener klin. Wochensch. 1895. 105. Krönlein, Die v. Langenbeck'sche Klinik und Poliklinik zu Berlin während der Zeit vom 1. Mai 1875 bis 31. Juli 1876. Berlin 1877. S. 72 u. 73. (Fälle 34 u. 35 der Tabelle.) 106. Küster, Die Deckung der Augenhöhle nach Ausräumung derselben. Centralb. f. Chirurg. 1890. und Peren (gleicher Titel) Inaug. Diss. Marburg 1891. 107. Pagenstecher, FL, Ein neues Operations verfahren zur Heilung der Ptosis. Transact, of the int. med. Congr. London, p. 108. 1801. 108. de Wecker, Une nouvelle operation du ptosis. Ann. d'ocul. Bd. 88. p. 29. 1882. 109. Dransart, Ouerison du ptosis par des procedes operatoires speciaux. Ann. d'Ocul. Bd. 88 p. 147. 1882. 110. Hess, Eine Operationsmethode gegen Ptosis. A. f. A. Bd. 28. p. 22. 1894. 111. Panas, D'un nouveau procede operatoire applicable au ptosis con- genital et au ptosis paralytique. Arch. d'Ophtal. Bd. 6. p. 1. 1887. 112. Motais, La methode operatoire du ptosis par la suppliance du M. droit superieur. Communication ä l'Acad. de Med. Seance du 24. Mars 1903. 113. Cannas, N., Operazione della ptosis median te la sutura del mus- culo elevatore della palpebra al muscolo retto superiore. Torins S. A. 114. Eversbusch, Zur Operation der congenita len Blepharoptosis. Monb. f. A. 1883 p. 100. 115. — (Ptosisoperation) Monb. f. A. 1893. Bericht über die Ver- samml. i. Heidelb. p. 146. 116. Snellen, (Ptosisoperation) Monb. f. A. 1893. Ber. über die Ver- sammi. i. Heidelb. p. 150. u. Trans, of the Ophthal, soc. of the unit. Kingd. Vol. X p. 208. 1889. 117. Wolff, Hugo, Die Vorlagerung des Muse, levator palp. sup. mit Durchtrennung der Insertion. Zwei neue Methoden gegen Ptosis congenita. A. f. A. Bd. 33. p. 125. 1896. (Literatur der Ptosisoperation.) LITERATURE. 367 118. Lapersonne, Sur quelques modifications dans les operations du ptosis. Arch. d'Opht. Bd. 23. p. 479. 1903. 119. Elschnig, Ptosisope ration. Wiener Medic. Wochenschrift 1903. No. 51. 120. Boucheron, Operation du ptosis. La tarsectomie aver avancement du muscle rcleveur de la paupiere. Arch. d'Opht. Bd. 8. p. 229. 1888. 121. Gillet de Grandmont, Xouvelle Operation du ptosis congenital. Recueil d' Opht. 1891. p. 267 und Ann. d'Ocul. Bd. 105. p. 237. 1891. 122. Gruening, E. C, The Value of Partial Resection of the Tarsal Cartilage in the Operative Treatment of Congenital Ptosis. Trans. Americ. Ophth. Soc. 1902. p. 574. 123. Marple W. P., Case of Traumatic Ptosis of the Left Eye < »perated upon, with Most Satisfactory Result, According to the Method of Dr. Gruening or Gillet de Grandmont. The Ophthal. Record. Bd. 12. p. 493. 1903. 124. Green, J., Case of Readjustment of the Levator Muscle of the Upper Lid. Trans. American Ophthal. Soc. 1871. p. 134. 125. Spencer, Watson, On the Treatment of Trichiasis and Distichiasis by a Plastic Operation. Med. Times and Gaz. Vol. 49. 1874. — On a new Operation for Distichiasis, with a Successful Case. Ophth. Hosp. Rep. VIL 1873. 126. Hotz, Eine neue Operation für Entropium und Trichiasis. A. f. A. 9. Bd. p. 68. 1880 und Eine Entropiumoperation am unteren Augenlid, besonders bei alten Leuten, Monbl. f. A. 18. Jahr- gang, p. 49. 1800. 127. Anagnostakis, (Entropium-Operation). Annales d'Ocul. Bd. 38. p. 5. 1857. 128. Pagenstecher H., Ueber Vorlagerung der Levatorsehne. Ein neues Operationsverfahren von Prof. Dr. H. Pagenstecher für Ektro- pium u. Trichiasis des Oberlids, v. O. Scheffels. A. f. O. Bd. 36. 4. p. 265. 1890. 129. Streatfield, On Grooving the Fibrocartilage of the Lid in Cases of Entropium and Trichiasis. Ophth. Hosp. Rep. Vol. 1, p. 121. 1858. 130. Snellen, Beiträge zur Behandlung gewisser Krankheiten der Aug- enlider von van Gils, Inaug. Diss, und 11. Jahresbericht über die Leistungen des Nederlandsch. Gasthuis voor Ooglijders in Utrecht. 1870. 131. Hotz, Die Reposition des Lidrandes bei Trichiasis des oberen Lides. Monatsbl. f. A. 26. Jahrgang p. 98. 1888. 132. Panas, P/une modification apportee au procede dit de Transplanta- tion du sol. ciliare. Arch. d'Ophtal. Bd, IL 1882 und Traite des maladies des yeux 2. Bd. p. 152. 1894. 133. Pfalz, Leber ein Operationsverfahren gegen Entropium und Trich- iasis. A. f. O. Bd. 33. 3. p. 165. 1887. 134. v. Arlt, Operationslehre. 1. cit. Xr. 77. 135. Kuhnt. Ektropiumoperatlon. Beiträge zur operativen Augenheil- kunde. Jena 1883. 368 LITERATURE. 136. v. Siklösy, Zur Blepharoplastik. Monatsbl. f. A. Jahrg. 12 p. 228. 1874. 137. Müller L., Beitr. z. operat. Augenheilkunde. Monatsbl. f. A. 31. Bd. p. 113. 1898. 138. Fricke, Bildung neuer Augenlider (Blepharoplastik) nach Zer- störung und dadurch hervorgebrachter Auswärtswendung der- selben. Hamburg 1829. 139. Dieffenbach, Einige Bemerkungen aus und über Paris. Caspers Wochenschrift 1835. 140. Szymanowsky, Handbuch der operativen Chirurgie. Braun- schweig 1870. 141. Thiersch (Hauptpfropfung) 15 Kongress der deutschen Gesell- schaft für Chirurgie 1886 und über Hauptverpflanzung. Zen- tral, f. Chir. No. 24 p. 17. 142. Kuhnt, Ueber den Wert der Lidbildung mittelst Uebertragung stielloser Hautteile. Ztschr. f. A. 7 Bd. p. 19. 1902. 143. Sachs, Bemerkungen zur Lidplastik. Ebenda p. 44. 144. Axenfeld, Plastische Wiederherstellung des ganzen Konjunktival- sackes in einem Falle von Symblepharon et Ankyloblepharon cicatriceum totale. Monbl. f. A. 1900. p. 845. 145. Hotz, Case of Symblepharon of the Lower Lid Relieved by Skin Grafting. Chicago Med. Soc. Nov. 1901. The Chicago Med. Eec order. 146. May Ch., Wiederherstellung des Konjunktivalsackes in einem Falle von totalem Symblepharon mit Hilfe Thiersch'scher Hautläppchen. Archives of Ophthal. 28. Bd. u. A. f. A. 40. p. 358 (Uebersetzung) 1900. 147. Landström, Ueber Operation von Symblepharon nach May, Mit- teilungen aus der Augenklinik des Carol. Med. Chir. Instit. zu Stockholm, herausg. v. Widmark. 4. Heft, 1902. 148. Eversbusch, Ueber die Verwendung von Epidermistransplanta- tionen bei den plastischen Operationen an den Lidern und an der Konjunktiva, Münch. Med. Wochenschr. 1887. No. 1. u 2. 149. Landolt, Nouveau procede de blepharoplastie und Un nouveau cas de blepharoplastie. Arch. d'Opht. 1. Bd. p. 9 et p. 111. 1881. 150. De quelques operations pratiquees sur les paupieres. Ebenna. 5 Bd. p. 489. 1885. 151. Knapp, Demonstration of a Roller-forceps Constructed According to the Mangle Principle for Pressing Out Trachoma Granula- tions, with Remarks. Trans. Americ. Ophth. Soc. 1891. p. 148 und A. f. A. 25 Bd. p. 177. 1892. 152. Berlin, Ueber Exstirpation des Tränensackes. Sitz.-Bericht der Ophthal. Gesellsch. in Heidelberg. 1868. NDEX Ablation after Arlt for pterygium, 208 Abscess of orbit, 279 Accidents and mistakes in opera- tion for cataract, 154 interfering with healing of wound after operations for cataract, 163 Adrenalin anesthesia, 31 cocain for hemorrhage, 33 for hemorrhage, 32 Advancement, Brand's method. 258 capsular, de Wecker' s method, 256 de Wecker's method, 250 Knapp's method, 249, 257 Roster's method, 259 Landolt's method, 252 Mailer's myectomy for, 259 Prince's method, 253 Schweiggers method, 258 Todd's method, 258 Yerhoeff 's method, 254 Weber's method, 24'.' Worth's method, 255 Anagnostakis' operation for entro- pion, 314 Anesthesia, 25 adrenalin, 31 beta-eucain and adrenalin chlo- rid, 32 bromethyl, 27 chloroform, 25 mortality due to, 28 cocain, 29 in enucleation, 30 in iridectomy, 31 in removal of lacrimal sac, 30 in strabismus, 29 24 Anesthesia, collapse during, treat- ment of, 26 enucleation during, 26 ether, 26, 28 mortality due to, 28 ethyl bromid, 27 chlorid, 28 in operation for cataract, 101 local, 28 Schleich's, in enucleation, 30 Anesthetization, 25 Angioma of orbit. 281 Anterior chamber, blood in, punct- ure of cornea for, 206 Operations in. 215 polar cataract, 83 synechia?, separation of, 215 Antisepsis, 33 Antvllus' operation for ectropion, 325 Arlt's method of nasal tarsorrhaphy, 323 operation for pterygium, 208 tenotomy for strabismus, 245 Artificial glass eye-. 27s globe, implantation of, in Tenon's capsule, 278 Asepsis, 33 Asm us' sideroscope, 219 Atropin in cataract, danger from, 92 Bacilli, panophthalmia, 74 Bandage, mouth-, during operation, 59, 60 Bandaging, 45 Beer's flap incision, 119 Beta-eucain and adrenalin chlorid anesthesia, 32 369 370 INDEX. Black cataract, 87 Blepharophimosis, operation for, 321 canthoplastic, 321 BJepharoplastic operation, 328 Dieflenbach's, 331 Eversbusch's, 343 Fricke' s, 329, 330 Landolt's, 343 Blood in anterior chamber, punct- ure of cornea for, 206 Brand's method of advancement, 258 Bromethyl anesthesia, 27 Canna's modification of Motais' operation for ptosis, 302 Canthoplastic operations for bleph- arophimosis, 321 Capillary fistula in scar of wound after operation for cataract, 166 Capsular advancement after de Wecker, 256 cataract, 82 Capsule, Tenon's, implantation of artificial globe in, 278 Carcinomatous growths of conjunc- tiva, 213 Cataract, accidents and mistakes in operation for, 154 anterior polar, 83 atropin in, danger from, 92 black, 87 capsular, 82 complicated, 83 first stage of, 86 fourth stage of, 86 juvenile, 81 discission for, 102 after-treatment, 105 preparations, 103 operation for, 102 simple linear extraction of, 106 lamellar, operation for, 112 maturity of, 85 diagnosis, 92 methods of inducing, 90 preliminary iridectomy for in- ducing, 91 Cataract, Morgagnian, 86 nuclear, 82 operation for, 81 accidents and mistakes in, 154 interfering with healing of wounds after, 163 after-treatment, 1 62 anesthesia in, 101 bodily condition of patient in, 95 capillary fistula in scar of wound after, 166 central vision in, 93 function in, 93 general condition of patient in, 95 glaucoma after, 166 hemorrhage from choroid in, 161 indications, 85 iridectomy preceding, 97 iridocyclitis after, 164 iritis after, 164 maturity of cataract in, 85 method of applying dressings, 162 peripheral vision in, 93 projection-test for deter- mining, 93 prolapse of vitreous in, 157 pupillary reaction in, 94 purulent infection after, 165 subconjunctival, 153 suppurating processes in, 95 over-ripeness of, 83, 86 partial stationary, operation for, 112 percentages of losses in, 35 pyramidal, 83 removal of lashes and eyebrows before operation for, 55 second stage of, 86 secondary operation for, 166 de Wecker's method, 173 senile, 81 cortical, 82 operation for, 118 couching and depression in, 174 INDEX. 371 Cataract, senile, operation for, func- tional examination in, 124 preparatory treatment, 124 Wenzel's, 153 with capsule, 150 with iridectomy, 136 without iridectomy, 142 soft, operation for, 108 third stage of, 86 traumatic, operation for, 108 Cataracta incipiens, 86 nigra, 87 ( autery, Paequelin's, 75 ( 'hair, operating, 20 Chloroform anesthesia, 25 mortality due to, 28 Choroid, hemorrhage from, in ope- ration for cataract, 161 Cicatricial ectropion, 327 Thiersch's method of skin- grafting in, 332 Cocain, adrenalin, for hemorrhage, 33 anesthesia, 29 in enucleation, 30 in iridectomy, 31 in removal of lacrimal sac, 30 in strabismus, 29 in operation for strabismus, 241 Collapse during anesthesia, treat- ment of, 26 Conjunctiva, carcinomatous growths of, 213 operations on, 202, 345 papilloma of, 213 polyps of, 213 sarcomatous growths of, 213 utilization of, to cover defects in cornea, 210 Conjunctiva] sac, operations in, 295 Cornea, defects in, utilization of conjunctiva to cover, 210 dermoids of, removal of, 212 ectatic scars of, iridectomy for, 196 foreign bodies in. removal of, 202 operations on, 202 puncture of, 206 for blood in anterior chamber, 206 Cornea, puncture of, for deep cor- neal ulcer-, 207 staphyloma of, 213 staphyloma-formation of, iridec- tomy for, 196 tattooing of, 210 ulcers of, deep, paracentesis of cornea for, 207 Cortical cataract, senile, 82 Couching and depression in opera- tion for senile cataract, 174 Da< ry( )stkx< ..-is, 350 de Weckers method of advance- ment, 250 of capsular advancement, 256 operation for secondary cataract, 173 ptosis operation, 297 Dermoids of cornea, removal of, 212 Desmarres' transplantation opera- tion for pterygium, 209 Detachment of retina, excision of myrtle-shaped piece of sclera for, 201 puncture of sclera for, 200 Dieffenbach's blepharoplastic ope- ration, 331 Dilation of nasal duct with sounds, 353 Dimmer's modification of Kuhnt's operation for ectropion, 327 Disinfection, 68 Dislocation of lens, operation for, 175 Dransart's ptosis operation, 297 Dropping bottle, 62. 64 Sidler's, 64 Duct, lacrimonasal, irrigation of, 350 _ nasal, dilation of, with sounds, 353 Ectropion, cicatricial, 327 Thiersch's method of skin- grafting in, 332 operation for, 323 Antvllus', 325 Kuhnt's, 325 372 INDEX. Ectropion, operation for, Kuhnt's, Dimmer's modification of, 327 Müller' s modification of, 326 Szymanowsky's, 324 senile, 325 Snellen's suture in, 324 Electric bell for patients after ope- ration, 20 Electromagnet for removal of for- eign bodies, 216 Elschnig's ptosis operation, 306 Entropion, operation for, 308 Anagnostakis', 314 by destroying roots of cilia by electrolysis, 309 Flarer's, 320 ( raillard's suture, 309 Hotz's, 311 with tarsus excision, 317 Jasche-Arlt, 320 Pagenstechers, with advance- ment of levator tendon, 314 Panas', 318 Pfalz's, 319 Snellen's, 317 Spencer Watson's. 311 Streatfield's, 316 tarsi »plastic, 316 with advancement of levator tendon, 314 Snellen's suture for, 320 Enucleation, cocain anesthesia in, 30 during anesthesia, 26 of eyeball, 265 hemorrhage in, 270 implantation of artificial globe in Tenon's capsule after, 278 _ indications for, 272 operations substituted for, 274 suppuration in, 274 of globe, 265 Schleich's anesthesia in, 30 Ervthropsia, 100 Ether anesthesia, 26, 28 mortality due to, 28 Ethyl bromid anesthesia, 27 chlorid anesthesia, 28 Eversbusch's blepharoplastic ope- ration, 343 ptosis operation, 302 Eversion, simple, of lower lacrimal punctum, 348 Evisceration of eyeball, 275 Excision of myrtle-shaped piece of sclera for retinal detach- ment, 201 Exenteration of eyeball, 275 of orbit, 291 Extirpation of tear sac, 357 Eyeball, enucleation of, 265 hemorrhage in, 270 indications for, 272 operations substituted for, 274 suppuration in, 274 evisceration of, 275 exenteration of, 275 outside of, operations on, 239 Eyelids, operations on, 295 Fistula, capillary, in scar of wound after operation for cataract, 166 Flarer's operation for entropion, 320 Eoeister's method of inducing ma- turity of cataract, 90 Foreign bodies in cornea, removal of, 202 in interior of eye not consisting of iron, removal of, 237 removal of, 216 Röntgen ravs in diagnosis of, 229 in lens, 238 in sclera, removal of, 206 in vitreous humor, 238 Fricke's blepharoplastic operation, 329, 330 Gaillard's suture operation for entropion, 309 Ganglion, sympathetic, resection of, for glaucoma, 200 Gillet de Grandmont's ptosis opera- tion, 307 Glass eyes, 278 INDEX. 373 Glaucoma after operation for catar- act, 166 iridectomy for, 186 retinal hemorrhages after, 195 with Grate's cataract knife, 192 with keratome, 188 with scalpel or scarifier, 192 malignant, Weber's operation for, 198, 199 posterior sclerotomy for,l98 resection of sympathetic for, 200 secondary, iridectomy for pre- venting, 184 Globe, artificial, implantation of, in Tenon's capsule, 278 enucleation of, 265 operations on, 81 Gräfe's cataract knife, iridectomy for glaucoma with, 192 linear incision, 119 tenotomy for strabismus, 242 Grandmont's ptosis operation, 307 Hemorrhage, adrenalin cocain for. 33 adrenalin for, 32 from choroid in operation for cataract, 161 retinal, after iridectomy for glaucoma, 195 Hess' ptosis operation, 298 Hirschberg's iron-searcher, 219 Hospital wards, 18 Hotz's lead plate, 341 operation for entropion, 311 with tarsus excision, 317 Humor, vitreous, foreign body in, 238 Illumination of operating room, 21 Implantation of artificial globe in Tenon's capsule. 278 Instruments, 60, 76 Iodoform, 54, 70 pencil, method of introducing into anterior chamber, 72 Iridectomy, 179 cocain anesthesia in, 31 Iridectomy for ectatic scars of cor- nea and staph vloma-forma- tion, 196 for glaucoma, 186 retinal hemorrhages after, 195 with Gräfe's cataract knife, 192 with keratome, 188 with scalpel or scarifier, 192 for preventing secondary glau- coma, 184 for relief of increased tension, 186 for sarcomatous nodules on iris, 196 ^ in chronic iritis, to prevent re- lapses and clear up vitreous, 195 optical, 180 preceding operation for cataract, 97 preliminary, for inducing ma- turity of cataract, 91 senile cataract extraction with, 136 without, 142 Iridocyclitis after operation for cat- aract, It '»4 Iris, sarcomatous nodules on, iri- dectomy for, 196 Iritis after operation for cataract, 164 chronic, iridectomy in, to prevent relapses and clear up vitre- ous, 195 Iron in eye, magnet operation for, 216 magnetic needles for, 218 removal of, 216 Iron-searcher of Hii-schberg, 219 Irrigation of lacrimonasal duct, 350 Jasche-Arlt operation for entro- pion, 320 Juvenile cataract, 81 discission for, 102 after-treatment, 105 preparations, 103 operation for, 102 simple linear extraction of, 106 874 INDEX. Keratome, iridectomy for glau- coma with, 188 Knapp's method of advancement, 249, 257 operation for broad pterygium, 209 for retrobulbar tumors, 282 Roster's method of advancement, 259 Krönlein's operation, 284 indications for, 291 technic of, 287 Kuhnt's ectropion operation, 325 Dimmer's modification of, 327 Müllers modification of, 326 Lacrimal fluid, bactericidal quality of, 41 organs, operations on, 347 punctum, lower, simple eversion of, 348 sac, removal of, cocain anesthesia in, 30 Lacrimonasal duct, irrigation of, 350 Lagrange's operation for retrobul- bar tumors, 282 Lamellar cataract, operation for, 112 Landolt's blepharoplastic opera- tion, 343 method of advancement, 252 Lapersonne's ptosis operation, 305 Lens, dislocation of, operation for, 175 foreign bodies in, 238 removal of, in high myopia, 176 Light in operating room, 21, 22 of room after operation, 20 Linear extraction, simple, of ju- venile cataract, 106 of soft cataract, 108 incision, von Gräfe' s, 119 Literature, 361 Magnet operation for iron in eye, 216 Magnetic needles for iron in eye, 218 Malignant glaucoma, Weber's ope- ration for, 198, 199 Mask, mouth-, during operation, 59, 60 Maturity of cataract, 85 diagnosis of, 92 methods of inducing, 90 preliminary iridectomy for in- ducing, 91 May's glass plate, 341 McReynold's modification of Des marre's operation for ptery- gium, 209 Morgagnian cataract, 86 Motais' ptosis operation, 300 Gannas' modification of, 302 Mouth-bandage during operation, 59, 60 Mouth-mask during operation, 59, 60 Muller's modification of Kuhnt's operation for ectropion, 326 myectomy for advancement in strabismus, 259 operation for retinal detachment, 201 Muscle, squinting, antagonist of, operations on, 249 Muscles, ocular, operations on, 239 Myectomy, Muller's, for advance- ment in strabismus, 259 Myopia, high, removal of lens in, 176 Nasal, duct, dilation of, with sounds, 353 tarsorrhaphy, 323 Nerve, optic, resection of, 274 Neurectomia opticociliaris, 274 Nodules, sarcomatous, on iris, iri- dectomy for, 1 96 Nuclear cataract, 82 Ocular muscles, operations on, 239 Operating chair, 20 rooms, 18 arrangement of, 21 illumination of, 21 table, 20, 24 INDEX. 375 Operation, care after, 42 electric bell for patient after, 20 light of room after, 20 mouth-bandage during, 59, 60 mouth-mask during, 59, 60 pollution after, avoidance of, 59 salivary infection during, 59 ventilation of room after, 20 Operations, 81 Optic nerve, resection of, 274 Optical iridectomy, 180 Orbit, abscess of, 279 angioma of, 281 exenteration of, 291 operations on, 279 tumors of, Kronlein's operation for, 284 removal, 281 Orbital phlegmon, 280 Pacquelin's cautery, 75 Pagenstecher's operation for en- tropion with advancement of levator tendon, 314 ptosis operation, 297 Panas' entropion operation, 318 ptosis operation, 300 Panophthalmia bacilli, 74 Papilloma of conjunctiva, 213 Paraffin, filling tear sac with, 359 Partial stationarv cataract, opera- tion for, 112 Peripheral vision in operation for cataract, 93 projection-test for deter- mining, 93 Pfalz's operation for entropion, 319 Phlegmon, orbital, 280 Polyps of conjunctiva, 213 Posterior svnechia?, separation of, 216 Prince's method of advancement, 253 Projection-test for determining peripheral vision in catar- act, 93 Prolapse of vitreous in operation for cataract, 157 Pterygium, operation for, 208 ablation after Arlt, 208 Pterygium, operation for, trans- plantation, 209 Ptosis, operation for, 295 de Weeker's, 297 Dransart's, 297 Elschnig's, 306 Eversbusch's, 302 Gillet de Grandmont's, 307 Hess', 298 Lapersonne's, 305 Motais', 300 Cannas' modification of, 302 Pagenstechcr'b, 297 Panas', 300 Snellen's, 303 Wolff's, 304 traumatic, 308 Puncture of cornea, 206 for blood in anterior chamber, 206 for deep corneal ulcers, 20*3 of sclera for retinal detachment, 200 Pupillary reaction in operation for cataract, 94 Purulent infection after operation for cataract, 165 Pyramidal cataract, 83 Resection of optic nerve, 274 of svmpathetic for glaucoma, 200 Retina, detachment of, excision of myrtle-shaped piece of sclera for, 201 puncture of sclera for, 200 Retinal hemorrhag'es after iridec- tomy for glaucoma, 195 Röntgen rays in diagnosis of foreign bodies in interior of eye, 22'.» Room, light of, after operation, 20 operating, 18 arrangement of, 21 illumination of, 21 ventilation of, after operation, 20 Salivary infection during opera- tion, 59 Sarcomatous growths of conjunc- tiva, 213 :J76 INDEX. Sarcomatous nodules on iris, iridec- tomy for, 196 Scars, ectatic, of cornea, iridectomy for, 196 Schleich'» anesthesia in enuclea- tion, 30 Schweigger's method of advance- ment, 258 Sclera, excision of myrtle-shaped piece of, for retinal detach- ment, 201 foreign bodies in, removal of, 206 operations on, 202 puncture of, for retinal detach- ment, 200 Sclerotomy, 196 anterior, 196 posterior, for glaucoma, 198 Secondarv cataract, operation for, 166 de Wecker? s method, 173 glaucoma, iridectomy for pre- venting, 184 Senile cataract, 81 cortical, 82 operation for, 118 couching and depression in, 174 functional examination in, 124 modifications of, 148 preparatory treatment, 124 subconjunctival, 153 Wenzel's, 153 with capsule, 150 with iridectomy, 136 without iridectomy, 142 cortical cataract, 82 ectropion, 325 Separation of anterior synechia?, 215 of posterior synechia, 216 Sideroscope, Asmus', 219 Sidler's dropping bottle, 64 Skin-grafting, Thiersch's method of, in cicatricial ectropion, 332 Snellen's entropion operation, 317 ptosis operation, 303 suture in ectropion, 324 Snellen's suture in entropion, 320 tenotomy for strabismus, 246 Soft cataract, operation for, 108 Sounds, dilation of nasal duct with, 353 Spencer Watson's operation for en- tropion, oil Squinting muscle, antagonist of, operations on, 249 Staphyloma of cornea, 213 Staphyloma-formation of cornea, iridectomy for, 196 Sterilization, 33 Strabismus, 239 advancement in, Brand's method, 258 capsular, de Wecker's method, 256 de Wecker's method, 250 Knapp's method, 249, 257 Roster's method, 259 Landolt's method, 252 Midler's myectomy for, 259 Prince's method, 253 Schweigger's method, 258 Todd's method, 258 VerhoefFs method, 254 Weber's method, 249 Worth's method, 255 cocain anesthesia in, 29 in operation for, 241 tenotomy after Arlt for, 245 after Snellen for, 246 after von Gräfe for, 242 Streatfield's entropion operation, 316 Subconjunctival extraction of senile cataract, 153 Suppurating processes in operations for cataract, 95 Suppuration in enucleation of eve- ball, 274 Suture, Gaillard's, in entropion, 309 Snellen's, in ectropion, 324 in entropion, 320 Symblepharon, operation for, 337 Sympathetic ganglion, resection of, for glaucoma, 200 Synechia 1 , anterior, separation of, 215 INDEX. 377 Synechie, posterior, separation of, 216 Szvmanowskv's operation for ectro- pion, 324 Table, « >}»evating. 20, 24 Tarsoplastic operation for entro- pion, 316 Tarsorrhaphy, 322 nasal, 323 Tattooing of cornea. 210 Tear sac, extirpation of, 357 filling of, with paraffin, 359 Tenon's capsule, implantation of artificial globe in, 27- Tenotomy after Arlt for strabis- mus, 245 after Snellen for strabismus, 246 after von < j nit'e for strabismus, 242 Tension, increased, iridectomy for relief of, 186 Test, projection-, for determining peripheral vision in cataract, 93 Thiersch's method of skin-grafting in cicatricial ectropion, 332 Todd's method of advancement, 258 Trachoma, operation for, 345 Transplantation operation for pterygium, 209 Traumatic cataract, operation for, 108 ptosis, 308 Trichiasis, complete, 311 partial, 309 Tumors of orbit, Krönlein'g opera- tion for, 284 removal of, 281 Ulcers of cornea, deep, paracen- tesis of cornea for, 207 Ventilation of room after opera- tion, 20 VerhoefPs method of advancement, 254 Vitreous humor, foreign body in. 238 prolapse of, in operation for cat- aract, 157 Von A i It's method of nasal tarsor- rhaphy, 323 operation for pterygium, 208 tenotomy for strabismus. 245 Von (frafe's cataract knife, iridec- tomy for glaucoma with, 192 linear incision, 119 tenotomy for strabismus, 242 Ward«, hospital, 18 Watson's operation for entropion, 311 Weber's method of advancement, 24'.' operation for malignant glau- coma, 198, 199 Wecker' s method of advancement, 250 of capsular advancement, 256 operation for secondary cataract, 173 ptosis operation, 297 Wenzel's operation for senile cata- ract, 153 Wolff's ptosis operations, 304 Worth's method of advancement, 255 SAUNDERS' MEDICAL HAND-ATLASES A SERIES OF BOOKS OFFERING A SATISFACTORY SUBSTITUTE FOR ACTUAL CLINICAL WORK SPECIAL OFFER A S it is impossible to realize the beauty and cheap- * • ness of these atlases without an opportunity to ex- amine them, we make the following offer : Any one of these books will be sent to physicians, carriage prepaid, upon request. If you want the book, you have mere- ly to remit the price ; if not, return the book by mail. A Descriptive Catalogue of all our Publications Sent on Request W. B. SAUNDERS 6 COMPANY 925 Walnut Street Philadelphia NEW YORK LONDON Fuller Building', 5th Ave. and 23d St. 9. Henrietta St., Covent Garden 2 SAUNDERS' MEDICAL HAND-ATLASES saunders' Medical Hand-Atlases ¥N planning this series of books arrangements were made with representative publishers in the chief medical centers of the world for the publication of translations of the atlases in thir- teen different languages, the lithographic plates for all being made in Germany, where work of this kind has been brought to the greatest perfection. The enormous ex- pense of making the plates being shared by the various publishers, the cost to each one was reduced approximately to one-tenth. Moderate Price Thus, by reason of their universal translation and reproduction, affording international distribution, tne publishers have been enabled to secure for these atlases the best artistic and profes= sional talent, to produce them in the most elegant style, and yet to offer them at a price heretofore unapproached in cheapness. One of the most valuable features of these Substitute for Clinical Observation atlases is that they offer a ready and satis= factory substitute for clinical observation. Such observation, of course, is available only to the residents in large medical centers ; and even then the requisite variety is seen only after long years of routine hospital work. To those unable to attend important clinics these books will be absolutely indispensable, as presenting in a complete and convenient form the most accurate reproduc- tions of clinical work, interpreted by the most competent of clinical teachers. Adopted by U. S. Army As an indication of the great practical value of the atlases and of the immense favor with which they have been received, it should be noted that the Medical Department of the U. S. Army has adopted the "Atlas of Operative Surgery " as its standard, and has ordered the book in large quantities for distribution to the various regi- ments and army posts. SALWDEKS' MEDICAL HAND-ATLASES Sobotta and Huber's Human Histology Atlas and Epitome of Human Histology. By Privat- docext Dr. J. Sobotta, of Würzburg. Edited, with additions, by G. Carl Huber, M. D., Professor of Histology and Em- bryology, and Director of the Histological Laboratory, Uni- versity of Michigan, Ann Arbor. With 214 colored figures on 80 plates, 68 text-cuts, and 248 pages of text. Cloth, 34.50 net. INCLUDING MICROSCOPIC ANATOMY This work combines an abundance of well-chosen and most accurate illustrations with a concise text, and in such a manner as to make it both atlas and text-book. The great majority of the illustrations were made from sections prepared from human tissues, and always from fresh and in every respect normal specimens. The colored lithographic plates have been pro- duced with the aid of over thirty colors, and particular care was taken to avoid distortion and assure exactness of magnification. The text is as brief as possible ; clearness, however, not being sacrificed to brevity. The editor of the English translation has annotated and altered very freely certain por- tions of the sections on the adenoid tissues, blood and the blood-forming organs, muscular tissues, special sense organs, and peripheral nerve distri- butions, in order to make these parts of the work conform to the latest advances in the study of these tissues. OPINIONS OF THE MEDICAL PRESS Boston Medical and Surgical Journal " In color and proportion they are characterized by gratifying accuracy and litho- graphic beauty. . . . May be highly recommended to those who are without access to histological collections." Bulletin Johns Hopkins Hospital " A ready means of getting a good idea of the appearance of normal human tissues, hardened, sectioned, and stained. . . . The additions which the editor of the translation has made are of such value that one wishes he had used his hand more freely." Unsurpassed for accuracy, pictorial beauty, completeness, cheapness SAUNDERS' MEDICAL HAND-ATLASES Grünwald and Newcomb's Mouth, Pharynx, Nose Atlas and Epitome of Diseases of the Mouth, Phar- ynx, and Nose. By Dr. L. Grünwald, of Munich. From the Second Revised and Enlarged German Edition. Edited, with additions, by James E. Newcomb, M. D., Instructor in Laryngology, Cornell University Medical School ; Attending Laryngologist to the Roosevelt Hospital, Out-Patient Depart- ment. With 1 02 illustrations on 42 colored lithographic plates, 41 text-cuts, and 219 pages of text. Cloth, $3.00 net. INCLUDING ANATOMY AND PHYSIOLOGY In designing this atlas the needs of both student and practitioner were kept constantly in mind, and as far as possible typical cases of the various diseases were selected. The illustrations are described in the text in exactly the same way as a practised examiner would demonstrate the objective find- ings to his class, the book thus serving as a substitute for actual clinical work. The illustrations themselves are numerous and exceedingly well executed, portraying the conditions so strikingly that their study is almost equal to examination of the actual specimens. The editor has incorporated his own valuable experience, including notes on the use of the active prin- ciple of the suprarenal bodies. OPINIONS OF THE MEDICAL PRESS American Medicine " Its conciseness without sacrifice of clearness and thoroughness, as well as the excel- lence of text and illustration are commendable." Journal of Ophthalmology, Otology, and Laryngology " A collection of the most naturally colored lithographic plates that has been pub- lished in any book in the English language. . . . Very valuable alike to the student, the practitioner, and the specialist." Each volume contains from 50 to 100 colored plates SAUNDERS' MEDICAL HA XD- ATLASES Helferich and Bloodg'ood's Fractures and Dislocations Atlas and Epitome of Traumatic Fractures and Dis- locations. By Professor Dr. H. Helferich, Professor of Surgery at the Royal University, Greifswald, Prussia. Edited, with additions, by Joseph C. Bloodgood, M. D., Associate in Surgery, Johns Hopkins University, Baltimore. From the Fifth Revised and Enlarged German Edition. With 216 colored illustrations on 64 lithographic plates, 190 text-cuts, and 353 pages of text. Cloth, $3.00 net. SHOWING DEFORMITY, X-RAY SHADOW, AND TREATMENT This department of medicine being one in which, from lack of practical knowledge, much harm can be done, and in which in recent years great importance has obtained, a book, accurately portraying the anatomic rela- tions of the fractured parts, together with the diagnosis and treatment of the condition, becomes an absolute necessity. This present work fully meets all requirements. As complete a view as possible of each case has been presented, thus equipping the physician for the manifold appearances that he will meet with in practice. The illustrations show the visible external deformity, the X-ray shadow, the anatomic preparation, and the method of treatment. OPINIONS OF THE MEDICAL PRESS Medical News, New York " This compact and exceedingly attractive little volume will be most welcome to all who are interested in the practical application of anatomy. The author and editor have made a most successful effort to arrange the illustrations that the interpretation of what they are intended to present is exceedingly easy." Brooklyn Medical Journal " There are few books publish than this work of Professor Helfe result of much labor and thought. " There are few books published that better answer the requirements for illustration than this work of Professor Helferich. . . . Such a collection of illustrations must je the They are Satisfactory Substitutes for Clinical Observation SAUNDERS' MEDICAL HAND-ATLASES Sultan and Coley's Abdominal Hernias Atlas and Epitome of Abdominal Hernias. By Privat- docent Dr. Georg Sultan, of Göttingen. Edited, with addi- tions, by William B. Coley, M. D., Clinical Lecturer on Sur- gery, Columbia University (College of Physicians and Surgeons), New York. With 119 illustrations, 36 of them in colors, and 277 pages of text. Cloth, $3.00 net. DEALING WITH THE SURGICAL ASPECT This new atlas covers one of the most important subjects in the entire domain of medical teaching, since these hernias are not only exceedingly common, but the frequent occurrence of strangulation demands extraordi- narily quick and energetic surgical intervention. During the last decade the operative side of this subject has been steadily growing in importance, until now it is absolutely essential to have a book treating of its surgical aspect. This present atlas does this to an admirable degree. The illustrations are not only very numerous, but they excel, in the accuracy of the portrayal of the conditions represented, those of any other work upon abdominal hernias with which we are familiar. The work will be found a worthy exponent of our present knowledge of the subject of which it treats. PERSONAL AND PRESS OPINIONS Robert H. M. Dawbarn, M. D., Professor of Surgery and Surgical Anatomy, New York Polyclinic. " I have spent several interested hours over it to-day, and shall willingly recommend it to my classes at the Polyclinic College and elsewhere." Boston Medical and Surgical Journal " For the general practitioner and the surgeon it will be a very useful book for reference. The book's value is increased by the editorial notes of Dr. Coley." They have already appeared in thirteen different languages SA CYDERS' MEDICAL HAND-ATLASES 7 Brühl, Politzer, and MacCuen Smith's Otology Atlas and Epitome of Otology. By Gustav Brühl, M. D., of Berlin, with the collaboration of Professor Dr. A. Politzer, of Vienna. Edited, with additions, by S. MacCuen Smith, M. D., Clinical Professor of Otology, Jefferson Medical Col- lege, Philadelphia. With 244 colored figures on 39 lithographic plates, 99 text-illustrations, and 292 pages of text. Cloth, $3.00 net. INCLUDING ANATOMY AND PHYSIOLOGY This excellent volume is the first attempt to supply in English an illus- trated clinical handbook to act as a worthy substitute for personal instruction in a specialized clinic. This work is both didactic and clinical in its teach- ing, the latter aspect being especially adapted to the student's wants. A special feature is the very complete exposition of the minute anatomy of the ear, a working knowledge of which is so essential to an intelligent concep- tion of the science of otology. The illustrations are beautifully executed in colors, and illuminate the text in a singularly lucid manner, portraying patho- logic changes with such striking exactness that the student should receive a deeper and more lasting impression than the most elaborate description could produce. Further, the association of Professor Politzer in the prepa- ration of the work, and the use of so many valuable specimens from his notably rich collection especially enhance the value of the work. The text contains everything of importance in the elementary study of otology. PERSONAL AND PRESS OPINIONS Clarence J. Blake, M. D., Professor of Otology, Harvard University Medical School, Boston. " The most complete work of its kind as yet published, and one commending itself to both the student and teacher in the character and scope of its illustrations." Boston Medical and Surgical Journal 'Contains what is probably the best collection of colored plates of the ear, both of normal and pathological conditions, of any hand-book published in the English language. In addition to this the text is presented in an unusually clear and direct manner." They are offered at a price heretofore unapproached in cheapness ! SAUNDERS' MEDICAL HAND-ATLASES Lehmann, Neumann, and Weaver's Bacteriology Atlas and Epitome of Bacteriology : including a Text- Book of Special Bacteriologic Diagnosis. By Prof. Dr. K. B. Lehmann and Dr. R. 0. Neumann, of Würzburg. From the Second Revised and Enlarged German Edition. Edited, with additions, by G. H. Weaver, M. D., Assistant Professor of Pathology and Bacteriology, Rush Medical College, Chicago. In two parts. Part I. — 632 colored figures on 69 lithographic plates. Part II. — 511 pages of text, illustrated. Per part: Cloth, $2.50 net. INCLUDING SPECIAL BACTERIOLOGIC DIAGNOSIS This work furnishes a survey of the properties of bacteria, together with the causes of disease, disposition, and immunity, reference being constantly made to an appendix of bacteriologic technic. The special part gives a complete description of the important varieties, the less important ones being mentioned when worthy of notice. The lithographic plates, as in all this series, are accurate representations of the conditions as actually seen, and this collection, if anything, is more handsome than any of its predecessors. As an aid in original investigation the work is invaluable. OPINIONS OF THE MEDICAL PRESS American Journal of the Medical Sciences " Practically all the important organisms are represented, and in such a variety of forms and cultures that any other atlas would rarely be needed in the ordinary hospital laboratory." The Lancet, London " We have found the work a more trustworthy guide for the recognition of unfamiliar species than any with which we are acquainted." There have been 82,000 copies imported since publication SAUNDERS' MEDICAL HAND-ATLASES Zuckerkandl and DaCosta's Operative Surgery Second Edition, Revised and Greatly Enlarged Atlas and Epitome of Operative Surgery. By Dr. 0. Zuckerkandl, of Vienna. Edited, with additions, by J. Chal- mers DaCosta, M. D., Professor of the Principles of Surgery and Clinical Surgery, Jefferson Medical College, Philadelphia. With 40 colored plates, 278 text-cuts, and 410 pages of text. Cloth, $3.50 net. ADOPTED BY THE U. S. ARMY In this new edition the work has been brought precisely down to date. The revision has not been casual, but thorough and exhaustive, the entire text having been subjected to a careful scrutiny, and many improvements and additions made. A number of chapters have been practically rewritten, and of the newer operations, all those of special value have been described. The number of illustrations has also been materially increased. Sixteen valuable lithographic plates in colors and sixty-one text-figures have been added, thus greatly enhancing the value of the work. There is no doubt that the volume in its new edition will still maintain its leading position as a substitute for clinical instruction. OPINIONS OF THE MEDICAL PRESS Philadelphia Medical Journal " The names of Zuckerkandl and DaCosta, the fact that the book has been translated into 13 different languages, together with the knowledge that it is used in the United States Army and Navy, would be sufficient recommendation for most of us." Munchener Medicinische Wochenschrift "We know of no other work that combines such a wealth of beautiful illustrations with clearness and conciseness of language, that is so entirely abreast of the latest achievements, and so useful both for the beginner and for one who wishes to increase his knowledge of operative surgery." Each volume b edited, with additions, by a leading specialist IO SAUNDERS' MEDICAL HAND-ATLASES Dtirck and Hektoen's General Pathologic Histology Atlas and Epitome of General Pathologic Histology. By Pr. Dr. H. Dürck, of Munich. Edited, with additions, by Ludvig Hektoen, M. D., Professor of Pathology, Rush Medical College, Chicago. 172 colored figures on 77 lithographic plates, 36 text-cuts, many in colors, and 350 pages of text. JUST ISSUED This new atlas gives the accepted views in regard to the significance of pathologic processes. All the illustrations have been made from original specimens without combining different microscopic fields. Extraordinary care has been taken to reproduce them as near perfection as possible, in many cases twenty-six colors being required. Dürck and Hektoen's Special Pathologic Histology Atlas and Epitome of Special Pathologic Histology. By Dr. H. Dürck, of Munich. Edited, with additions, by Ludvig Hektoen, M. D., Professor of Pathology, Rush Medical College, Chicago. In Two Parts. Part I. — Circulatory, Respira- tory, and Gastro-intestinal Tracts. Part II. — Liver, Urinary and Sexual Organs, Nervous System, Skin, Muscles, and Bones. 243 colored figures on 122 plates, and 350 pages of text. Per part: Cloth, $3,00 net. William H.Welch, M.D., Professor of Pathology, Johns Hopkins University, Baltimore. " I consider Diirck's 'Atlas of Special Pathologic Histology,' edited by Hektoen, a very useful book for students and others The plates are admirable." They represent the best artistic and professional talent SAUA'DEJiS' MEDICAL HAND-ATLASES Haab and deSchweinitz's Ophthalmoscopy Atlas and Epitome of Ophthalmoscopy and Ophthal» moscopic Diagnosis. By Dr. O. Haab, of Zürich. From the Third Revised and Enlarged German Edition. Edited, with additions, by G. E. deSchweinitz, M. D., Professor of Oph- thalmology, University of Pennsylvania. With 152 colored lithographic illustrations; 85 pages of text. Cloth, $3.00 net. Not only is the student made acquainted with carefully prepared oph- thalmoscopic drawings done into well-executed lithographs of the most important fundus changes, but, in many instances, plates of the microscopic lesions are added. It furnishes a manual of the greatest possible service. The Lancet, London " We recommend it as a work that should be in the ophthalmic wards or in the library of every hospital into which ophthalmic cases are received." Haab and deSchweinitz's External Diseases of Eye Atlas and Epitome of External Diseases of the Eye. By Dr. O. Haab, of Zürich. Edited, with additions, by G. E. deSchweinitz, M. D., Professor of Ophthalmology, University of Pennsylvania. 98 colored illustrations on 48 lithographic plates and 232 pages of text. Cloth, $3.00 net. SECOND REVISED EDITION-JUST ISSUED. In this thorough revision the text has been brought up to date by the addi- tion of new matter, including references to some of the modern therapeutic agents. There have also been added eight Chromolithographie plates. The Medical Record, New York " The work is excellently suited to the student of ophthalmology and to the practising physician. It cannot fail to attain a well-deserved popularity." (Review of previous ed.) They are convenient in size and uniformly bound 12 SAUNDERS' MEDICAL HAND-ATLASES Schäffer arid Edgar's Labora/id Operative Obstetrics Atlas and Epitome of Labor and Operative Obstetrics. By Dr. 0. Schäffer, of Heidelberg. From the Fifth Revised and Fnlarged Germa?i Edition. Edited, with additions, by J. Clifton Edgar, M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University Medical School. 14 lithographic plates in colors; 139 other cuts ; in pages of text. $2.00 net. The book presents the act of parturition and the various obstetric opera- tions in a series of easily understood illustrations. These are accompanied by a text that treats the subject from a practical standpoint. Dublin Journal of Medical Science, Dublin " One fault Professor Schäffer's Atlases possess. Their name, and the extent and number of the illustrations, are apt to lead one to suppose that they are merely ' atlases,' whereas the truth really is they are also concise and modern epitomes of obstetrics." Schäffer & Edgar's Obstetric Diagnosis and Treatment Atlas and Epitome of Obstetric Diagnosis and Treat- ment. By Dr. O. Schäffer, of Heidelberg. From the Sec- ond Revised German Edition. Edited, with additions, by J. Clifton Edgar, M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University Medical School. 122 colored fig- ures on 56 plates; 38 other cuts; 315 pages of text. $3.00 net. This book treats particularly of obstetric operations, and, besides the wealth of beautiful lithographic illustrations, contains an extensive text of great value. This text deals with the practical, clinical side of the subject. New York Medical Journal " The illustrations are admirably executed, as they are in all of these atlases, and the text can safely be commended, not only as elucidatory of the plates, but as expounding the scientific midwifery of to-day." These are the famous " Lehmann medicinische Handatlanten " SAUNDERS' MEDICAL HAND-ATLASES 13 Mracek and Stelwag'on's Skin Atlas and Epitome of Diseases of the Skin. By Prof. Dr. Fraxz Mracek, of Vienna. Edited, with additions, by Henry W. Stelwagon, M. D., Professor of Dermatology in the Jefferson Medical College, Philadelphia. With 63 colored plates, 39 half-tone illustrations, and 200 pages of text. Cloth, $3.50 net. This volume, the outcome of years of scientific and artistic work, con- tains, together with colored plates of unusual beauty, numerous illustrations in black, and a text comprehending the entire field of dermatology. The illustrations are all original and prepared from actual cases in Mracek' s clinic. American Journal of the Medical Sciences " The advantages which we see in this book and which recommend it to our minds are : First, its handiness; secondly, the plates, which are excellent as regards drawing, color, and the diagnostic points which they bring out. We most heartily recommend it." Mracek and Bang's Syphilis and Venereal Diseases Atlas and Epitome of Syphilis and the Venereal Dis= eases. By Prof. Dr. Fraxz Mracek, of Vienna. Edited, with additions, by L. Bolton Bangs, M. D., late Prof, of Genito- urinary Surgery, University and Bellevue Hospital Medical College, New York. With 71 colored plates and 122 pages of text. Cloth, S3. 50 net. According to the unanimous opinion of numerous authorities, to whom the original illustrations of this book were presented, they surpass in beauty anything of the kind that has been produced in this field, not only in Ger- many, but throughout the literature of the world. Robert L. Dickinson, M. D., Art Editor of " The American Text-Book of Obstetrics." *" The book that appeals instantly to me for the strikingly successful, valuable, and graphic character of its illustrations is the ' Atlas of Syphilis and the Venereal Diseases.' I know of nothing in this country that can compare with it." The lithographs, all made in Germany, are unrivalled 14 SAUNDERS' MEDICAL HAND-ATLASES Schäffer and Webster's Operative Gynecology Atlas and Epitome of Operative Gynecology. By Dr. O. Schäffer, of Heidelberg. Edited, with additions, by J. Clarence Webster, M. D. (Edin.), F. R. C. P. E., Professor of Obstetrics and Gynecology in the Rush Medical College, in affili- ation with the University of Chicago. With 42 lithographic plates in colors, many text-cuts, a number in colors, and 138 pages of text. Cloth, $3.00 net. JUST ISSUED The excellence of the lithographic plates and the many other illustrations in this atlas render it of the greatest value in obtaining a sound and practical knowledge of operative gynecology. Indeed, the artist, the author, and the lithographer have expended much patient endeavor in the preparation of the water-colors and drawings. They are based on hundreds of photographs taken from nature, and they reproduce faithfully and instructively the various situations. The text closely follows the illustrations, and is fully as accurae. Shaffer and Norris' Gynecology Atlas and Epitome of Gynecology. By Dr. O. Shaffer, of Heidelberg. From the Second Revised and Enlarged German Edition. Edited, with additions, by Richard C. Norris, A. M., M. D., Gynecologist to Methodist-Episcopal and Philadelphia Hospitals. With 207 colored figures on 90 plates, 65 text-cuts, and 308 pages of text. Cloth, $3.50 net. The value of this atlas will be found not only in the concise explanatory text, but especially in the illustrations. The large number of colored plates, reproducing the appearance of fresh specimens, will give the student a knowl- edge of the changes induced by disease that cannot be obtained from mere description. Bulletin of Johns Hopkins Hospital, Baltimore " The book contains much valuable material. Rarely have we seen such a valuable collection of gynecological plates." These books are next best to actual clinical work SAUNDERS' MEDICAL HAND-ATLASES 15 Jakob and Eshner's Internal Medicine & Diagnosis Atlas and Epitome of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited, with additions, by Augustus A. Eshner, M. D., Professor of Clin- ical Medicine in the Philadelphia Polyclinic. With 182 colored figures on 68 plates, 64 illustrations in black and white, and 259 pages of text. Cloth, $3.00 net. In addition to an admirable atlas of clinical microscopy, this volume describes the physical signs of all internal diseases in an instructive manner by means of fifty colored schematic diagrams. As a means of instruction its value is very great ; as a reference handbook it is admirable. British Medical Journal " Dr. Jakob's work deserves nothing but praise. The information is accurate and up to present-day requirements." Grünwald and Grayson's Diseases of the Larynx Atlas and Epitome of Diseases of the Larynx. By Dr. L. Grünwald, of Munich. Edited, with additions, by Charles P. Grayson, M. D., Physician-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania. With 107 colored figures on 44 plates, 25 text-illustrations, and 103 pages of text. Cloth, $2.50 net. This atlas exemplifies a happy blending of the didactic and clinical, such as is not to be found in any other volume upon this subject. The author has given special attention to the clinical portion of the work, the sections on diagnosis and treatment being particularly full. The Medical Record, New York " This is a good work of reference, being both practical and concise. ... It is a valu- able addition to existing laryngeal text-books." For " Special Offer " regarding these atlases see page I l6 SAUNDERS' MEDICAL HAND-ATLASES Hofmann and Peterson's Legal Medicine Atlas of Legal Medicine. By Dr. E. von Hofmann, of Vienna. Edited by Frederick Peterson, M. D., Professor of Psychiatry, College of Physicians and Surgeons, N. Y. 120 colored figures on 56 plates, 193 half-tone illustrations. Cloth, $3.50 net. The Practitioner, London " The illustrations appear to be the best that have ever been published in connection with this department of medicine, and they cannot fail to be useful alike to the medical jurist and to the student of forensic medicine." Jakob and Fisher's Nervous System and its Diseases Atlas and Epitome of the Nervous System and its Diseases. By Prof. Dr. Chr. Jakob, of Erlangen. From the Second Revised German Edition. Edited, with additions, by Edward D. Fisher, M. D., Professor of Diseases of the Nervous System, University and Bellevue Hospital Medical College, N. Y. S3 plates and copious text. Cloth, $3.50 net. Philadelphia Medical Journal "We know of no one work of anything like equal size which covers this important and complicated field with the clearness and scientific fidelity of this hand-atlas." Golebiewski and Bailey's Accident Diseases Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed. Golebiewski, of Berlin. Edited, with additions, by Pearce Bailey, M. D., Consulting Neurologist to St. Luke's Hospital and Orthopedic Hospital, N. Y. 7 1, colored illustrations on 40 plates, 143 text-cuts, 549 pages of text. Cloth, $4.00 net. Medical Examiner and Practitioner " It is a useful addition to life-insurance libraries, for lawyers, physicians, and for every one who is brought in contact with the treatment or consideration of accidents or diseases growing out of them, or legal complications flowing from them. The "Atlas of Operative Surgery" has been adopted by U. S. Army Atlas and Epitome of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited, with additions, by G. E. DE Schweinitz, M.D., Professor of Ophthalmology in the University of Penn- sylvania. Second Revised Edition. With 98 colored illustrations on 48 plates and 232 pages of text. Cloth, $3.00 net. " The work is well done, and is valuable to physicians in general, as well as to ophthal- mologists. I shall take pleasure in recommending it." — John E. Weeks, M.D.. Clinical Professor 0/ Ophthalmology, University of Bellevue Hospital Medical School, N. Y Atlas and Epitome of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited, with addi- tions, by Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic. With 179 colored figures on 68 plates and 259 pages of text. Cloth, $3.00 net. " Dr. Jakob's work deserves nothing but praise. The information is accurate and up to present-day requirements." — British Medical fournal. Atlas of Legal Medicine. By Dr. E. von Hofmann, of Vienna. Edited, with additions, by Frederick Peterson, M.D., Professor of Psychiatry, College of Physicians and Surgeons, New York. With 120 colored figures on 56 plates and 1 93 half-tone illustrations. Cloth, $3.50 net. " It is rare indeed that so large a series of illustrations are found which demonstrate so well and so accurately the conditions which they are supposed to represent." — Boston Medical and Surgical Journal Atlas and Epitome of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited, with additions, by Charles P. Grayson, M.D., Physician-in- Charge, Throat and Nose Department, Hospital of the University of Pennsylvania. With 107 colored figures on 44 plates, 25 text-illustrations, and 103 pages of text. Cloth, $2. 50 net. " Excels everything we have hitherto seen in the way of colored illustrations of diseases of the larynx." — British Medical Journal. Atlas and Epitome of Operative Surgery. By Dr. 0. ZuCKERKANDL, of Vienna. From the Second Revised and Enlarged Ger- man Edition. Edited, with additions, by J. Chalmers DaCosta, M.D., Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College, Philadelphia. Second Edition, Revised and Greatly En- larged. With 40 colored plates, 278 text-cuts, and 410 pages of text. Cloth, $3.50 net. " It may be said that few, if any, books of this description are so comprehensive in their scope." — Philadelphia Medical Journal. Atlas and Epitome of Syphilis and the Venereal Dis- eases. By Prof. Dr. Franz Mracek, of Vienna. Edited, with ad- ditions, by L. Bolton Bangs, M.D., late Professor of Genito-Urinary Sur- gery, University and Bellevue Hospital Medical College, New York. With 71 colored plates and 122 pages of text. Cloth, #3.50 net. "A glance through the book is almost like actual attendance upon a famous clinic." — Journal of the American Medical Association. Atlas and Epitome of Skin Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited, with additions, by Henry W. Stei wagon, M.D., Professor of Dermatology in the Jefferson Medical College, Philadelphia. With 63 colored plates, 39 half-tone illustrations, and 200 pages of text. Cloth, $3.50 net. " The illustrations are very well executed, and the coloring remarkably accurate ; they will serve as substitutes for clinical observation." — Medical Record, New York. Atlas of Bacteriology and Text-Book of Special Bac- teriologic Diagnosis. By Prof. Dr. K. B. Lehmann and Dr. R. O. Neumann, of Würzburg. Fro?n the Second Revised aud Enlarged German Edition. Edited, with additions, by G. H. Weaver, M.D., As- sistant Professor of Pathology and Bacteriology, Rush Medical College, Chicago. Two volumes. Part I. — 632 colored figures on 69 plates. Part UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. by E. D. Fisher, M.D., Professor of Diseases of the Nervous System, University and Bellevue Hospital Medical College, New York. 83 plates ; 215 pages of text. $3. 50 net. " Represents with wonderful accuracy the macroscopic and microscopic anatomy of the nervous tissues as found in normal and pathologic conditions." — American Medicine. Atlas and Epitome of Ophthalmoscopy and Ophthal- moscopic Diagnosis. By Dr. O. Haab, of Zurich. From the Third Revised and Enlarged German Edition. Edited, with additions, by G. E. de Schweinitz, M.D., Professor of Ophthalmology in the Uni- versity of Pennsylvania. With 152 colored figures; 82 pages of text. Cloth, #3.00 net. SAUNDERS' MEDICAL HAND-ATLASES Atlas and Epitome of Otology. By G. Brühl, M.D., of Ber- lin, with the collaboration of Prof. Dr. A. Politzer, of Vienna. Edited, with additions, by S. MacCuen Smith, M.D., Professor of Otology in the Jefferson Medical College, Philadelphia. 244 colored figures on 39 lithographic plates, 99 text-cuts, and 292 pages of text. Cloth, $3.00 net. "The most complete of its kind as yet published." — Clarence J. Blake. M.D., Pro- fessor 0/ Oto'o^y, Harvard Medical School, Boston. Atlas and Epitome of Abdominal Hernias. By Privatdo- cent Dr. Georg Sultan, of Göttingen. Edited, with additions, by Wil- liam B. Coley, M.D., Clinical Lecturer on Surgery, Columbia Univer- sity, N. Y. 119 illustrations, 36 in colors ; 277 pages of text. Cloth, $3.00 net. " For the general practitioner and the surgeon it will be a very useful book for refer- ence. The book's value is increased by the editorial notes of Dr. Coley." — Boston Medical and Surgical Journal. Atlas and Epitome of Traumatic Fractures and Dislo- cations. By Prof. Dr. H. Helferich, of Greifswald. Edited, with additions, by Joseph C. Bloodgood, M.D., Associate in Surgery, Johns Hopkins University, Baltimore. With 216 colored figures on 64 litho- graphic plates, 190 text-cuts, and 353 pages of text. Cloth, $3.00 net. " The author has given the anatomy of fractures his special attention. ... It is this feature of the work which gives it special value." — University 0/ Pennsylvania Medical Bulletin. Atlas and Epitome of Diseases of the Mouth, Pharynx, and Nose. By Dr. L. Grünwald, of Munich. From the Second Revised and Enlarged German Edition. Edited, with additions, by James E. Newcomb, M.D., Clinical Instructor in Laryngology, Cornell University Medical School. With 102 colored figures on 42 lithographic plates, 41 text-cuts, and 219 pages of text. Cloth, $3.00 net. "A distinct and valuable addition to the armamentarium of the worker in rhinologic fields..' — American Medicine. Atlas and Epitome of Human Histology and Micro- scopic Anatomy. By Pr. Dr. J. Sobotta, of Würzburg. Edited, with additions, by G. Carl Huber, M.D., Professor of Histology and Embryology, University of Michigan, Ann Arbor. With 214 colored figures on 80 plates, 68 text-cuts, and 248 pages of text. Cloth, $4.50 net. " The 200 or more colored plates are, above all things, natural, and just as one would see them under the microscope." — Indian Lancet, India. Atlas and Epitome of Operative Gynecology. By Dr. O. Schaffer, of Heidelberg. Edited, with additions, by J. Clarence Web- ster, M.D. (Edin.), F.R.C.P.E., Professor of Obstetrics and Gyne- cology, Rush Medical College, in affiliation with the University of Chicago. With 43 colored figures on 42 lithographic plates, 21 text figures, many in colors, and 138 pages of text. £3.00 net. Just issued. Atlas and Epitome of General Pathologic Histology. By Pr. Dr. Hermann Durck, of Munich. Edited, with additions, by Ludvig Hektoen, M.D., Professor of Pathology, Rush Medical College, in affiliation with the University of Chicago. With 172 colored figures on 77 lithographic plates, 36 text-figures, many in colors, and about 450 pages of text. Ready Shortly.